Survival and Quality of Life among Patients with Severe Lower Extremity Peripheral Arterial Disease

Lower extremity peripheral arterial disease (PAD) is associated with decreased functional status, diminished quality of life (QoL), amputation, myocardial infarction, stroke, and death. Nevertheless, public awareness of PAD as a morbid and mortal disease is low. The aim of this study was to assess the incidence of major lower extremity amputation due to PAD, the extent of reamputations, and survival after major lower extremity amputation (LEA) in a population based PAD patient cohort. Furthermore, the aim was to assess the functional capacity in patients with LEA, and the QoL after lower extremity revascularization and major amputation. All 210 amputees due to PAD in 1998–2002 and all 519 revascularized patients in 1998–2003 were explored. 59 amputees alive in 2004 were interviewed using a structured questionnaire of QoL. Two of each amputee age-, gender- and domicile-matched controls filled in and returned postal self-administered QoL questionnaire as well as 231 revascularized PAD patients (the amount of these patients who engaged themselves to the study), and one control person for each patient completed postal self-administered QoL questionnaire. The incidence rate of major LEA was 24.1/100 000 person-years and it was considerably high during the years studied. The one-month mortality rate was 21%, 52% at one-year, and the overall mortality rate was 80%. When comparing the one-year mortality risk of amputees, LEAs were associated with a 7.4-fold annual mortality risk compared with the reference population in Turku. Twenty-two patients (10%) had ipsilateral transversions from BK to AK amputation. Fifty patients (24%) ended up with a contralateral major LEA within two to four amputation operations. Three bilateral amputations were performed at the first major LEA operation. Of the 51 survivors returning home after their first major LEA, 36 (71%) received a prosthesis; (16/36, 44%) and were able to walk both in- and outdoors. Of the 68 patients who were discharged to institutional care, three (4%) had a prosthesis one year after LEA. Both amputees and revascularized patients had poor physical functioning and significantly more depressive symptoms than their controls. Depressive symptoms were more common in the institutionalized amputees than the home-dwelling amputees. The surviving amputees and their controls had similar life satisfaction. The amputees felt themselves satisfied and contented, whether or not they lived in long-term care or at home. PAD patients who had undergone revascularizations had poorer QoL than their controls. The revascularized patients’ responses on their perceived physical functioning gave an impression that these patients are in a declining life cycle and that revascularizations, even when successful, may not be sufficient to improve the overall function. It is possible that addressing rehabilitation issues earlier in the care may produce a more positive functional outcome. Depressive symptoms should be recognized and thoroughly considered at the same time the patients are recovering from their revascularization operation. Also primary care should develop proper follow-up, and community organizations should have exercise groups for those who are able to return home, since they very often live alone. In rehabilitation programs we should consider not only physical disability assessment but also QoL.

Geochemistry and water quality of Lake Qarun, Egypt

Water geochemistry is a very important tool for studying the water quality in a given area. Geology and climate are the major natural factors controlling the chemistry of most natural waters. Anthropogenic impacts are the secondary sources of contamination in natural waters. This study presents the first integrative approach to the geochemistry and water quality of surface waters and Lake Qarun in the Fayoum catchment, Egypt. Moreover, geochemical modeling of Lake Qarun was firstly presented. The Nile River is the main source of water to the Fayoum watershed. To investigate the quality and geochemistry of this water, water samples from irrigation canals, drains and Lake Qarun were collected during the period 2010‒2013 from the whole Fayoum drainage basin to address the major processes and factors governing the evolution of water chemistry in the investigation area. About 34 physicochemical quality parameters, including major ions, oxygen isotopes, trace elements, nutrients and microbiological parameters were investigated in the water samples. Multivariable statistical analysis was used to interpret the interrelationship between the different studied parameters. Geochemical modeling of Lake Qarun was carried out using Hardie and Eugster’s evolutionary model and a model simulated by PHREEQC software. The crystallization sequence during evaporation of Lake Qarun brine was also studied using a Jänecke phase diagram involving the system Na‒K‒Mg‒ Cl‒SO4‒H2O. The results show that the chemistry of surface water in the Fayoum catchment evolves from Ca- Mg-HCO3 at the head waters to Ca‒Mg‒Cl‒SO4 and eventually to Na‒Cl downstream and at Lake Qarun. The main processes behind the high levels of Na, SO4 and Cl in downstream waters and in Lake Qarun are dissolution of evaporites from Fayoum soils followed by evapoconcentration. This was confirmed by binary plots between the different ions, Piper plot, Gibb’s plot and δ18O results. The modeled data proved that Lake Qarun brine evolves from drainage waters via an evaporation‒crystallization process. Through the precipitation of calcite and gypsum, the solution should reach the final composition "Na–Mg–SO4–Cl". As simulated by PHREEQC, further evaporation of lake brine can drive halite to precipitate in the final stages of evaporation. Significantly, the crystallization sequence during evaporation of the lake brine at the concentration ponds of the Egyptian Salts and Minerals Company (EMISAL) reflected the findings from both Hardie and Eugster’s evolutionary model and the PHREEQC simulated model. After crystallization of halite at the EMISAL ponds, the crystallization sequence during evaporation of the residual brine (bittern) was investigated using a Jänecke phase diagram at 35 °C. This diagram was more useful than PHREEQC for predicting the evaporation path especially in the case of this highly concentrated brine (bittern). The predicted crystallization path using a Jänecke phase diagram at 35 °C showed that halite, hexahydrite, kainite and kieserite should appear during bittern evaporation. Yet the actual crystallized mineral salts were only halite and hexahydrite. The absence of kainite was due to its metastability while the absence of kieserite was due to opposed relative humidity. The presence of a specific MgSO4.nH2O phase in ancient evaporite deposits can be used as a paleoclimatic indicator. Evaluation of surface water quality for agricultural purposes shows that some irrigation waters and all drainage waters have high salinities and therefore cannot be used for irrigation. Waters from irrigation canals used as a drinking water supply show higher concentrations of Al and suffer from high levels of total coliform (TC), fecal coliform (FC) and fecal streptococcus (FS). These waters cannot be used for drinking or agricultural purposes without treatment, because of their high health risk. Therefore it is crucial that environmental protection agencies and the media increase public awareness of this issue, especially in rural areas.

Co-opetition: Coexistence of cooperation and competition in public sector – A case study in one city’s public companies

Business actions do not take place in isolation. Complementary competencies and capabilities are the most important resources in the exponential knowledge growth. These resources are partially accessed via business partners. A company needs partners and the capability to cooperate, but also the awareness of the competitive tension, when operating in the market with multiple actors. The co-opetition research studies the occurrence and the forms of simultaneous cooperation and competition between companies or their units. Public sector’s governmental and municipal organs have been transformed into companies over the past years. Despite of their non-profit nature, public sector and public companies are adopting business doctrines from private sector towards efficient business operations. This case study aims to show, how co-opetition concept can be observed within public sector companies and in their operations with others, how public companies cooperate but also compete with others and why this happens. This thesis also explicates advantages and disadvantages of the co-opetition phenomenon.

Public-Private Partnerships: Managing organizational change for acquiring value creative capabilities

The objective of the dissertation is to examine organizational responses of public actors to customer requirements which drive the transformation of value networks and promote public-private partnership in the electricity distribution industry and elderly care sectors. The research bridges the concept of offering to value networks where capabilities can be acquired for novel product concepts. The research contributes to recent literature, re-examining theories on interactions of customer requirements and supply management. A critical realist case study approach is applied to this abductive the research which directs to describe causalities in the analyzed phenomena. The presented evidence is based on three sources, which are in-depth interviews, archival analysis and the Delphi method. Service provision requires awareness on technology and functionalities of offering. Moreover, service provision includes interactions of multiple partners, which suggests the importance of the co-operative orientation of actors. According to the findings,portfolio management has a key role when intelligent solutions are implemented in public service provision because its concepts involve a variety of resources from multiple suppliers. However, emergent networks are not functional if they lack leaders who have access to the customer interface, have power to steer networks and a capability to build offerings. Public procurement policies were recognized to focus on a narrow scope in which price is a key factor in decisions. In the future, the public sector has to implement technology strategies and portfolio management, which mean longterm platform development and commitment to partnerships. On the other hand, the service providers should also be more aware of offerings into which their products will be integrated in the future. This requires making the customer’s voice in product development and co-operation in order to increase the interconnectivity of products.