| 61. |
- Deyessa Kabeta, Negussie, 1966-
(författare)
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Intimate partner violence and depression among women in rural Ethiopia
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Several studies have reported socioeconomic, socio-demographic factors, including violence against women to be associated with depression among women, but knowledge in the area among women living under extreme poverty in developing countries remains scarce. Relationship between intimate partner violence and women’s literacy in societies where violence is normative is complex, there are only limited data describing this difference in the distribution of violence exposure by residency and literacy. Few studies have addressed consequences of maternal depression and experiencing violence among women on children’s survival. Objective: The aim of this thesis is to determine prevalence of depressive episode and examine its association with violence by intimate partner and socioeconomic status It also assesses contribution of residency and literacy of women on vulnerability to physical violence by intimate partner, and independent effect of intimate partner violence and maternal depression on the risk of child death in rural Ethiopia. Methods: A community-based cross-sectional study was undertaken among 3016 randomly selected women in the age group between 15-49 years conducted from January to December 2002. A cohort study was done through following up women who gave birth to a live child within a year of the survey, in rural Ethiopia. Analysis was made using all the 3016 women, 1994 of the married women and 561 of women who gave birth within a year of the data collection time. Cases of depression were identified using the Amharic version of the Composite International Diagnostic Interview, experience of physical, sexual and emotional violence by intimate partner was made using the WHO multi-country study on women’s life events, and child death was measured by continuous demographic surveillance data from the Butajira Rural Health Program. Result: The twelve-month prevalence of depression was estimated to be 4.4%. In the analyses being currently married, divorced and widowed women, living in rural villages, having frequent khat chewing habit, having seasonal job and living in extreme poverty were factors independently associated with depression. Similarly, among the married women, experiencing physical violence, childhood sexual abuse, emotional violence and spousal control were factors independently associated with depressive episode. Women in the overall study area had beliefs and norms permissive towards violence against women. Violence against women was more prevalent in rural communities, in particular, among rural literate women and rural women who married a literate spouse. In this study, maternal depression was associated with under five child death. Although no association was seen between experiencing violence and child death, the risk of child death increases when maternal depression is combined with physical and emotional violence. Conclusion: Prevalence of depression among women was still in the lower range as compared to studies from high-income countries. Though depression is associated with socio-demographic factors and extreme poverty, the association is complex. The high prevalence of violence against women could be a contributing factor for preponderance of depression among women than in men. Urbanization and literacy are thought to promote changes in attitudes and norms against intimate partner violence. However, literacy within rural community might expose women to the higher risk of violence. Improving awareness of clinicians and public health workers on the devastating consequences of violence against women and depression is essential in order to identify and take measure when violence and maternal depression co-occurred.
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| 62. |
- Diamant, Ulla-Britt, 1955-
(författare)
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Long QT syndrome : studies of diagnostic methods
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The Long QT Syndrome (LQTS) is a hereditary heart disease with risk of malignant ventricular arrhythmia and sudden cardiac death. Despite our increased knowledge about genotype and phenotype correlation we still rely on the 12-lead ECG for assessment of the QT interval and the T-wave morphology for diagnosis and risk stratification. Intra- and -inter individual variability in manually QT measurement and, e.g., difficulties in defining the end of the T-wave may impair the diagnosis of LQTS. Increased heterogeneity in ventricular repolarization (VR) may be an important factor in the arrhythmogenicity in cases of LQTS. In a LQTS founder population the same mutation is carried by numerous individuals in many families which provide a unique opportunity to study diagnostic methods, risk assessment, VR and the correlation between genotype and phenotype.Methods: Resting 12-lead ECG and vectorcardiogram (VCG) were recorded in 134 LQTS mutation carriers and 121 healthy controls, to investigate the capability and precision in measuring the QT interval. For assessment of the VR, VCG was compared in individuals with mutations in the KCNQ1 and KCNH2 gene. Genealogical and geographic studies were performed in 37 index cases and their relatives to determine if Swedish carriers of the Y111C mutation in the KCNQ1 gene constitute a founder population. To confirm kinship, haplotype analysis was performed in 26 of the 37 index cases. The age and prevalence of the Y111C mutation were calculated in families sharing a common haplotype.Results: VCG by automatic measurement of the QT interval provided the best combination of sensitivity (90%) and specificity (89%) in the diagnosis of LQTS. VCG showed no consistent pattern of increased VR heterogeneity among KCNQ1 and KCNH2 mutation carriers. Living carriers of the Y111C mutation shared a common genetic (haplotype), genealogic and geographic origin. The age of the Y111C mutation was approximately 600 years. The prevalence of living carriers of the Y111C mutation in the mid-northern Sweden was estimated to 1:1,500-3,000.Conclusion: We have shown that VCG provides a valuable contribution to the diagnosis and risk assessment of LQTS in adults and children. No consistent pattern of increased VR heterogeneity was found among the LQTS mutation carriers. The identified Swedish LQTS founder population will be a valuable source to future LQTS research and may contribute to increase our understanding of LQTS and the correlation of phenotype, genotype and modifying factors.
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| 63. |
- Ding, Wenhong, 1968-
(författare)
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Survival and functional recovery following valve replacement in patients with severe aortic stenosis
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Aortic stenosis (AS) is the most common heart valve disease in Europe and North America. Age-related calcification of the valve is the commonest cause of acquired AS, especially in patients older than 70 years.Conventional surgical aortic valve replacement (SAVR) and the novel, minimally invasive transcatheter aortic valve implantation (TAVI), effectively preserve left ventricular (LV) function, relieve symptoms and improve survival in patients with severe symptomatic AS. However, patients with impaired LV function may carry significant operative risk, and long recovery time. In addition, such patients might have other comorbidities, and hence adding another challenge. Thus evaluation of ventricular function before and after AVR, as well as critical evaluation of TAVI patients should contribute to better clinical outcome.Methods: We studied LV function by conventional echocardiography before and after SAVR in the following groups; (I) 86 patients (aged 71±10 years) with severe AS and LV dysfunction; (II) 112 consecutive elderly AS patients (aged 77±2 years) and compared them with 72 younger patients (aged 60±1 years); (III)66 patients (age 70±2 years, 53 male) who underwent AVR for severe AS with concurrent LV dysfunction; (IV) 89 consecutive patients with symptomatic severeAS who underwent successful TAVI, 45 of whom received trans-apical TAVI (TA)(age 80.8±4.9 year, 26 male) and 44 trans-femoral TAVI (TF) (age 82.9±5.8 year,22 male).The conventional echocardiographic measurements were made according to the guidelines. Severe AS was identified by aortic valve mean pressure gradient >40mmHg or valve area <1.0 cm2. LV systolic dysfunction was identified as ejection fraction (EF) <50%. LV long-axis function was presented by mitral annular plane systolic excursion ( MAPSE ) at lateral wall and septal wall, which were measured from apical four-chamber view. Also from the same view, LV septal and lateral wall deformation using STE as well as global longitudinal systolic strain. The LV systolic twist as the net difference between apical rotation and basal rotation was measured from the parasternal apical and basal short-axis views in the TAVI patients.Results: Study I: In the low flow and high gradient group, operative (30-day) mortality was 10%, and peri-operative mortality was associated with lower mean LVEF, higher mitral E:A ratio, peak systolic pulmonary artery pressure (PSPAP), and higher serum creatinine (all p<0.001), NYHA class III–IV, concomitant coronary artery bypass graft (CABG), urgent surgery, and longer bypass-time (all p< 0.05). Mortality at 4 years was 17%. Univariate predictors of 4-year mortality were: lower EF (p<0.001), presence of restrictive LV filling (p<0.001), raised PSPAP (p<0.001) and CABG (p=0.037). However, only EF<40 % (p=0.03), the presence of restrictive LV filling (p=0.033) and raised PSPAP (p<0.01)independently predicted mortality in this group.Study II: Elderly patients had higher NYHA class, more frequent atrial fibrillation (AF), coronary artery disease (CAD), emergency operation and use of bioprosthetic valves. They also had shorter E-wave deceleration time (DT) and larger left atria (LA) (p<0.05 for all). 30-day mortality was 12% vs 4 % (Log Rank x2=3.02, p=0.08) and long term mortality was 18% vs 7% (Log Rank x2=4.38,p=0.04) in the two groups, respectively. Age was not related to mortality after adjustment for other variables. Among all variables, anemia (OR 4.20, CI:1.02–6.86, p=0.04), cardiopulmonary bypass (CPB) time (OR 1.02, CI 1.01–1.04,p<0.01), significant patient prosthesis mismatch (PPM) (OR 5.43, CI 1.04–18.40,p<0.05) were associated with 30-day mortality in elderly patients. Their long-term mortality was related to CBP time (OR 1.02, CI 1.00–1.05, p=0.04),PPM (OR 4.64, CI 1.33–16.11, p=0.02) and raised LA pressure: DT (OR 0.94, CI0.84–0.99, p=0.03) and pulmonary artery systolic pressure (PASP) (OR 1.12, CI1.03–1.19, p<0.001).STUDY III: Following SAVR peak aortic pressure gradient (AOPG) decreased and indexed valve area increased (64±3 to 19±1 mmHg and 0.30±0.01 to 0.89±0.03 cm2/m2, p<0.001 for both). LVEF increased (from 45±1 to 54±2%;p<0.001), LV end diastolic and end-systolic dimensions fell (LVEDD index: from 33±1 to 30±1 mm/m2; and LVESD index: from 27±1 to 20±1 mm/m2; (p<0.01 forboth). LV diastolic dysfunction improved as evidenced by the fall in E/A ratio (from 2.6±0.2 to 1.9±0.4) and prolongation of total filling time; (from 29.2±0.6 to31.4±0.5 s/min, p=0.01 for both). Among all echocardiographic variables, LV dimensions (LVEDD index, OR 0.70, CI 0.52–0.97, p<0.05; LVESD index, OR 0.57, CI 0.40–0.85, p=0.005) were the two independent predictors of post-operative LV functional recovery on multivariate analysis. A cut-off value ofpre-operative LVESD index<=27.5 mm/m2 was 85% sensitive and 72% specific inpredicting intermediate-term recovery of LV function after AVR (AUC, 0.72, p=0.002). STUDY IV: Before TAVI, there was no difference between the two patient groups in gender, age, body surface area (BSA) and baseline LV function. However, left ventricular mass index (LVMi), left atrial volume index (LAVi) and tricuspid regurgitation pressure drop (TRPdrop) were increased in the TA group (p<0.05).One week after TAVI, aortic pressure gradient (AOPG) markedly dropped in thetwo groups (both p<0.001), LVEDD index and LVESD index fell but EF andmyocardial strain remained unchanged. Overall cavity twist reduced (p<0.048).Significant LVESD index reduction was only seen in TF group (p=0.02) with a slight increase in LVEF (p=0.04). Lateral MAPSE increased only in the TF group(p=0.02). LV longitudinal systolic strain remained unchanged in TA patients while apical lateral strain increased in TF group. LV apical rotation fell in the two groups but basal rotation increased only in the TA patients (p=0.02). LAVi reduced in bothgroups and to a greater extent in TF TAVI (p=0.006), as did TRPdrop (p<0.001).Conclusion: SAVR and TAVI are two effective treatments for severe AS patients.The severity of pre-operative systolic and diastolic LV dysfunction is the major predictor of mortality following SAVR for low-flow and high gradient AS.Peri-operative AVR survival is encouraging in the elderly. Long term mortality in the elderly is related to PPM, LV diastolic dysfunction and secondary pulmonary hypertension. LV functional recovery was evident in most patients with LV dysfunction after SAVR. A lower prevalence of LV functional recovery in patients with large pre-operative LVESD index might signify the loss of contractile reserveand thus predict post-operative functional recovery. TAVI results in significant early improvement of segmental and overall ventricular function, particularly in patients receiving the trans-femoral approach. The delayed recovery of the trans-apical TAVI group, we studied, might reflect worse pre-procedural diastolic cavity function.
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| 64. |
- Edmundsson, David, 1956-
(författare)
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Chronic exertional compartment syndrome of the lower leg : a novel diagnosis in diabetes mellitus: a clinical and morphological study of diabetic and non-diabetic patients
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Chronic exertional compartment syndrome (CECS) of the lower leg, defined as a condition with exercise-induced pain due to increased intramuscular pressure (IMP), has previously mainly been described in running athletes, and etiologic factors are poorly described. CECS has not been reported to occur together with other diseases and information about consequences on muscles morphology after treatment with fasciotomy is largely unknown. We investigated etiologic and pathophysiologic aspects to CECS in a consecutive series of 63 patients with exercise-related leg pain and in 17 diabetic patients with symptoms of intermittent claudication but no circulatory insufficiency. Clinical examination, radiography, scintigraphy and IMP measurements at rest and after reproduction of symptoms were done. Patients with CECS were recommended treatment with fasciotomy. Biopsies were taken from the tibialis anterior muscle at time of fasciotomy and at follow-up 1 year later. For comparison muscle samples were taken from normal controls. Enzyme- and immunohistochemical and morphometric methods were used for analysis of muscle fiber morphology/pathology, fiber phenotype composition, mitochondrial oxidative capacity and capillary supply. Thirty-six of the 63 patients fulfilled the criteria for diagnosis of CECS in the anterior tibial compartment. The CECS patients could be divided into different etiologic groups: 18 healthy, 10 with history of trauma against the lower leg, 4 diabetic patients and 4 others. Only 5 of 36 CECS patients were athletes. The results after fasciotomy were good or excellent in 41 of 57 treated legs. Sixteen of the 17 diabetic patients were diagnosed with CECS, 11 with diabetes type 1 and 5 with type 2. The diabetic patients differed from the other groups with longer symptom-duration, shorter pain-free walking distance, firm and tender lower leg muscles and higher IMP. The postoperative outcome was good or excellent in 15 of 18 treated legs. The muscle biopsies taken at fasciotomy showed frequent histopathological changes including small and large sized fibers, fiber atrophy, internal myonuclei, split fibers, fibrosis, disorganization of mitochondria in contrast to healthy CECS subjects having low muscle capillarization as the main finding. Muscular abnormalities were generally more complex, severe and widespread in diabetic patients. After 1 year, the majority of CECS patients could return to unrestricted physical activity and the histopathological muscle changes were clearly reduced. The muscle fiber size was larger and the muscles contained signs of regeneration and repair. Remaining muscle abnormalities were present mainly in diabetic patients. CECS is a new differential-diagnosis in diabetic patients with symptoms of claudication without signs of vascular disease. A low ability for physical activity, reflected by the signs of both myopathy and neuropathy, indicates that high IMP and circulatory impairment has deleterious effects for the involved muscles. Increased physical activity and normalization of muscle morphology 1 year after treatment shows the benefit of fasciotomy. The more severe clinical and morphological findings in diabetic compared to healthy subjects with CECS indicate differences in the pathogenesis. The unrestricted physical ability after treatment is very important for diabetic patients, since physical activity is an essential part of the therapy of the disease.
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| 65. |
- Edvardsson, Kristina, 1973-
(författare)
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Health promotion in pregnancy and early parenthood : the challenge of innovation, implementation and change within the Salut Programme
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: In 2005, the Västerbotten County Council launched a child health promotion programme, “the Salut Programme”, in response to an alarming prevalence of overweight and obesity, and trends of increased dental caries, among young county citizens. The programme, initially developed in four pilot areas, is built on multidisciplinary and cross-sectoral collaboration and aims to support and strengthen health promotion activities in health care, social services and school settings. It targets children and adolescents (0-18 years of age) and their parents, and starts during pregnancy. This thesis focuses on interventions provided by antenatal care, child health care, dental services, and open pre-schools, directed to expectant parents and families with children aged 0-1 ½ years. Within the programme context, the aim was to explore socio-demographic patterns of overweight and obesity in expectant parents (Paper I), firsttime parents’ experiences of health promotion and lifestyle change during pregnancy and early parenthood (Paper II), professionals’ experiences of factors influencing programme implementation and sustainability (Paper III and IV), and early programme outcomes on professionals’ health promotion practices and collaboration following countywide dissemination and implementation (Paper IV). Methods and results: A population based cross-sectional study among expectant parents showed overweight and obesity in 29% of women (pre-pregnancy) and in 53% of men (n=4,352♀, 3,949♂). The likelihood for obesity was higher in expectant parents with lower levels of education, among those unemployed or on sick leave, and those living in rural areas. In 62% of couples, at least one of the partners was overweight or obese; a positive partner correlation was also found for BMI (I). An interview study with 24 first-time parents (n=12♀, 12♂) revealed that they primarily undertook lifestyle changes to secure the health of the fetus in pregnancy, and to provide a healthy environment in childhood. Parents described themselves as highly receptive to information about how their lifestyle could influence fetal health, and they frequently discussed pregnancy risks related to tobacco and alcohol, as well as toxins and infectious agents in foods. However, parents did not seem inclined to make lifestyle changes primarily to promote their own health. The antenatal and child health care services were perceived as being mainly directed towards women, and parents described a lack of a holistic view of the family which included experiences of fathers being treated as less important (II). An interview study undertaken with professionals (n=23) in the Salut Programme pilot areas indicated programme sustainability at most sites, two years after implementation, although less adherence was described within child health care. Factors influencing programme sustainability, as described by professionals, were identified at multiple organisational levels (III). A before-and-after survey among professionals (n=144) measured outcomes of the county-wide implementation of the Salut Programme in 13 out of 15 county municipalities. Results showed significant improvements in professionals’ health promotion practices and collaboration across sectors. A number of important implementation facilitators and barriers, acting at different organizational levels, were also identified via a survey comprised of open-ended questions (IV). Conclusion: The Salut Programme, developed with high involvement of professionals, and strongly integrated in existing organisational structures and practices, shows potential for improving health promotion practices and cross-sectoral collaboration. The findings can inform further development of the Salut Programme.as well as new health promotion initiatives, and inform policy practice and future research. These aspects include approaches in health promotion and prevention, father involvement during pregnancy and early parenthood, and factors influencing implementation and sustainability of cross-sectoral health promotion programmes.
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| 66. |
- Ekblom, Kim, 1970-
(författare)
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Oxidants and antioxidants in cardiovascular disease
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Cardiovascular diseases, including myocardial infarction and stroke, are the main reason of death in Sweden and Western Europe. High iron stores are believed to produce oxygen radicals, which is the presumed putative mechanism behind lipid peroxidation, atherosclerosis and subsequent cardiovascular disease. Iron levels are associated with the hemochromatosis associated HFE single nucleotide polymorphisms C282Y and H63D. Bilirubin is an antioxidant present in relatively high levels in the human body. Several previous studies have found an association between high bilirubin levels and a lower risk for cardiovascular disease. Bilirubin levels are highly influenced by the common promoter polymorphism TA-insertion UGT1A1*28, the main reason for benign hyperbilirubinemia in Caucasians. There is a lack of prospective studies on both the association of iron and bilirubin levels, and the risk for myocardial infarction and ischemic stroke. Material and methods Iron, transferrin iron saturation, TIBC, ferritin and bilirubin were analyzed and HFE C282Y, HFE H63D and UGT1A1*28 were determined in myocardial infarction and stroke cases, and their double matched referents within the Northern Sweden Health and Disease Study Cohort. Results There were no associations between iron levels in the upper normal range and risk for myocardial infarction or stroke. No associations were seen for HFE-genotypes, except for a near fivefold increase in risk for myocardial infarction in HFE H63D homozygous women. Plasma bilirubin was lower in cases vs. referents both in the myocardial infarction and the stroke cohort. Despite a strong gene-dosage effect on bilirubin levels in both cases and referents, the UGT1A1*28 polymorphism did not influence the risk for myocardial infarction or stroke. Conclusion High iron stores are not associated with increased risk for neither myocardial infarction, nor stroke. There was no association between UGT1A1*28 and the risk for myocardial infarction or stroke. Consequently data suggests that other factors, which also may lower bilirubin, are responsible for the elevated risk observed in conjunction with lower bilirubin levels.
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| 67. |
- Ekman, Urban, 1968-
(författare)
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Functional brain imaging of cognitive status in Parkinson's disease
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Parkinson’s disease (PD) is next to Alzheimer’s disease (AD) the second most common neurodegenerative disease. PD has traditionally been characterised as a motor disorder, but more recent research has revealed that cognitive impairments are frequent. Cognitive impairments in executive functions, attention, and working memory with reliance on dopaminergic transmission, are often described as dominating the cognitive profile in early-phase PD. However, although knowledge about the neuropathology that underlies the cognitive impairments in PD has increased, its features are complex and knowledge remains insufficient. Therefore, the aim of the current thesis was to improve the understanding of how task-evoked brain responses relate to cognitive status in patients with PD, with and without mild cognitive impairment (MCI), and to evaluate the predictive value of PD-MCI in respect of prodromal Parkinson’s disease dementia (PDD). This was conducted within the “new Parkinsonism in Umeå” (NYPUM) project, which is a prospective cohort study. Patients with idiopathic PD were included in this thesis, and the patients were examined with a comprehensive neuropsychological battery and with a functional MRI (fMRI) working memory protocol. During scanning, patients conducted a verbal two-back task in which they needed to maintain and actively update relevant information, and the primary outcome measure was blood-oxygen-level-dependent (BOLD) signal. This thesis shows that patients with PD-MCI had significantly lower BOLD signal responses than patients without MCI in frontal (anterior cingulate cortex) and striatal (right caudate) regions (Study I). The altered BOLD response in the right caudate was associated with altered presynaptic dopamine binding. The fronto-striatal alterations persisted across time but without any additional change. However, decreased posterior cortical (right fusiform gyrus) BOLD signal responses were observed in patients with PD-MCI relative to patients without MCI across time (Study II). Finally, PD-MCI at baseline examination is highly predictive for prodromal PDD with a six-fold increased risk. Cognitive tests with a posterior cortical basis, to a greater extent, are predictive for prodromal PDD than tests with a fronto-striatal basis. The observed working memory related alterations in patients with PD-MCI suggest that early cognitive impairments in PD are linked to fronto-striatal dopaminergic dysfunction. The longitudinal development of cognitive impairment in PD reflects additional posterior cortical dysfunction. This might reflect a dual syndrome, with dopamine-depleted fronto-striatal alterations that characterise PD-MCI in general, whereas additional posterior cortical cognitive alterations with a non-dopaminergic basis to a greater extent characterise prodromal PDD. If, and how, the two potential syndromes interact, is still unclear. Thus, this thesis provides information on cognitive neuropathological changes in PD that might contribute to more relevant choices of pharmacotherapy and diagnostic accuracy in respect of PDD. However, additional large-scale longitudinal imaging studies are needed to further clarify the neuropatholgogical features of PD-MCI in respect of prodromal PDD.
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| 68. |
- Elcadi, Guilherme H.
(författare)
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Near infrared spectroscopy for assessing oxygenation and hemodynamics in the upper extremities of healthy subjects and patients with work-related muscle pain
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The prevalence of work-related muscle pain (WRMP) is large in the general population in the industrialized world. Despite significant advances over recent years in some research areas, the mechanisms of why WRMP occurs and the pathophysiological mechanisms behind the disorders are still unclear. One suggested explanation is that WRMP is caused initially by a limitation of the local muscle circulation and oxidative metabolism. There is a lack of objective methods to gauge the development and diagnosis of WRMP. Near infrared spectroscopy (NIRS) is a non-invasive technique that allows for determinations of oxygenation and blood flow. The purpose of this thesis was to evaluate NIRS (1) as a method for measuring muscle oxygenation and hemodynamics for the extensor carpi radialis (ECR) and trapezius descendens muscles (TD), and (2) to investigate whether variables measured by NIRS differed between patients diagnosed with WRMP and healthy subjects. Several variables of NIRS were produced and investigated. These included muscle oxygenation (StO2%), changes during contractions (∆StO2%) and StO2% recovery (Rslope), total hemoglobin (HbT) as an indication of blood volume and its changes during contractions (∆HbT). In addition, for the ECR, by applying an upper arm venous occlusion (VO) HbTslope increase as a surrogate of blood flow, and for both VO and arterial occlusion (AO) HHbslope increase (i.e. deoxyhemoglobin slope) as a surrogate of oxygen consumption were variables of interest. A first objective was to determine how StO2% and HbT responded to various contraction forces and how it related to muscle activation measured by electromyography (EMG). For both muscles isometric contractions of 10, 30, 50 and 70% of maximal voluntary contraction (MVC) were maintained for 20 s each by healthy males and females; additionally a 10% MVC contraction was sustained for 5 min. For the different contraction levels, predictable relationships were seen between ∆StO2% and force, and between ∆StO2% and EMG RMS amplitude. The general trend was a decrease in ∆StO2% with increasing force and increasing EMG. Females showed a tendency for a higher oxygen use (i.e., drop in StO2%) for the ECR over force levels than males and a higher RMS% MVC for the TD. For the 10% MVC contraction sustained for 5 min gender specific changes over time for HbT and RMS for the ECR, and for StO2% for the TD muscle were seen. A second objective was to determine the day-to-day reliability of NIRS variables for the ECR and TD muscles at group level (Pooled data) and at gender level (males and females). Measurements were performed on two occasions separated by 4-6 days and intraclass correlation coefficients (ICC) and limits of agreement (LOA) were determined as reliability and reproducibility indicators, respectively. Variables tested were ∆StO2% during submaximal isometric contractions of 10, 30, 50 and 70% MVC and StO2% recovery (Rslope) after contractions and after AO. For the ECR, HbTslope as an indication of blood flow (using VO) and HHbslope as a surrogate of oxygen consumption for both VO and AO were computed. For ∆StO2% for the ECR the highest ICC was at 30% MVC for both the pooled data and at gender level. For the TD ICCs were comparably high for 30, 50, 70 % MVC (for both muscles the ∆StO2% at 10% MVC showed the lowest ICC). Further, females showed a higher ICC than males for contraction levels of 50 and 70% MVC. For both muscles, LOA for ∆StO2% was lowest at 10% and highest at 50 and 70% MVC. For the ECR Rslope ICCs were high for all contraction levels, but was lower for AO; LOA was lowest at 70% MVC. For the TD, Rslope ICCs were also high for all contraction levels and LOA was lowest at 30 % MVC. ICC for HbTslope was the lowest of all variables tested. For HHbslope ICC was higher for AO than for VO, and LOA was lower for AO. A third objective was to determine if there were differences between healthy subjects and patients diagnosed with WRMP in ∆StO2% and ∆HbT responses during varying submaximal contractions (10, 30, 50 and 70% MVC), and StO2% recovery (Rslope) immediately after contractions and AO. Additional variables tested in the ECR at rest were HHbslope to indicate oxygen consumption (using AO) and HbTslope as an indication of blood flow. There were no differences between groups in ∆StO2% and ∆HbT variables during the contractions or Rslope in the recovery after contractions or AO. Furthermore, HbTslope was not different between groups However, oxygen consumption for the ECR and StO2% for the TD at rest were significantly greater for healthy subjects compared to patients. A fourth objective was to determine if there were differences in StO2% and HbT between healthy subjects and WRMP patients during a 12 min sustained contraction of 15 % MVC. In addition, the protocol included a recovery period of 30 min. Prior to contraction, as well as during the recovery period, HbTslope as a surrogate of blood flow was determined for the ECR. Neither the ECR nor the TD exhibited significant differences between groups for StO2% and HbT during the contraction. For the TD patients showed a lower StO2% value at rest and throughout the contraction than healthy subjects. For the ECR HbT during the sustained contraction the general trend was an initial decrease with gradual increase throughout the contraction for both groups. For HbTslope no differences were seen between patients and healthy subjects before the sustained contraction and during the recovery period for both muscles.NIRS is deemed a suitable technique for assessing physiological measurements of the upper extremity, including for day-to-day testing.NIRS was not able to distinguish between the patients with WRMP and controls. A concern in the thesis is the characteristics of the patient group in being equally active in recreational sports, actively working, and similar in muscle strength as controls. Thus, applying NIRS for studying a more severe patient group could yield different results.
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| 69. |
- Enarsson, Per, 1962-
(författare)
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Mellan frihet och trygghet : personalgemensamt förhållningssätt i psykiatrisk omvårdnad
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: The common staff approach in psychiatric care has not been studied explicitly before. Earlier studies in related areas of social processes in psychiatric care highlight the importance of the interaction between the patient and the carer to understanding communication patterns and attitudes. Other studies on social order and power in psychiatric care shows carers and patients as taking part in a hierarchical system in which patients are subordinate to carers. Aim: The overall aim of this thesis is to study the phenomenon of the common staff approach in psychiatric care, how it emerges, and how it is used and experienced by both carers and patients. Method: In the first study, grounded theory was applied to data from observations and interviews carried out with carers and clients in two psychiatric care group dwellings. In the second and third studies, a phenomenological hermeneutic method was used to analyse narrative interviews conducted with nine careers working on psychiatric wards and nine patients with experience of psychiatric in-care, respectively. In the fourth study, qualitative content analysis was used to analyse data obtained by a vignette method from interviews with 13 carers with experience of working in psychiatric in-care. Results: A common staff approach can be understood as a social process in municipality-level group dwellings and psychiatric in-care, imposed by carers on clients or patients with the aim of restoring a predetermined order desired by the carers. When the order is disturbed the carers try to restore it by adopting a common and consistent approach towards the single patient perceived as the threat to order. Barriers to the success of a common staff approach, from the point of view of the carers, include the likelihood that colleagues will interpret situations differently, the chance that patients might succeed in dividing carers into “good” and “bad” camps, and the knowledge that the patient suffers under a common staff approach. The patients’ experiences partly confirm those of the carers – the dominant picture is that the patient feels persecuted and suffers under a common staff approach. However in some situations, patients can perceived the common approach as supportive and aimed to promote their recovery. Carers’ ethical reasoning about the common staff approach is usually applied on an individual basis; it can change depending upon the patient, the situation, and the proposed approach, as well as upon how the approach might affect other patients, staff members, or the carers themselves. Conclusions: The overall results from the four studies show that the common staff approach may meet carers’ needs, which under the approach take precedence over those of patients, but that the approach is more an exercise in asserting power and maintaining control than it is a therapeutic technique; that it is a difficult choice for the single carer to choose between the interests of the patient and the approval of colleagues; that the patient often suffers when a common staff approach is used; and that carers are seldom aware of the suffering experienced by the patient being managed by such an approach. A common staff approach has no part in a care-strategy; it is not an intentional care-plan; instead it appears to be a way for carers who feel vulnerable and under pressure to maintain order by controlling particular patients.
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- Eriksson, Catharina, 1955-
(författare)
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Immunological mechanisms in systemic autoimmunity : autoantibodies and chemokines in systemic lupus erythematosus and during treatment with TNF inhibitors in rheumatoid arthritis
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background. Rheumatoid Arthritis (RA) is an autoimmune inflammatory disease that, without powerful treatment, may lead to irreversible joint damage. During the past decade, anti-cytokine therapy has become available, e.g., infliximab, a chimeric antibody targeting the pro-inflammatory cytokine TNF that has a central role in the inflammatory process in RA patients. Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease that may affect all organs and is characterized by a massive antibody production. Chemokines, chemokine receptors and lipoprotein receptor-related protein 1(CD91) are regulators of inflammation in autoimmune diseases and T-cell migration. Objectives. The aim of this study was to get a deeper understanding how TNF blocking treatment influences inflammatory mechanisms and autoantibody formation in RA with special reference to similarities and differences with SLE. Methods. In patients with RA treated with anti-TNF, and in SLE patients (ACR criteria) clinical evaluation was performed and blood samples analyzed. Autoantibodies were analyzed using indirect immunofluorescence, ELISA and multiplex flow cytometry in samples from anti-TNF treated RA patients (n=59) followed longitudinally for 54 weeks, in pre-diseased samples from SLE patients (n=38) and matched population-based controls (n=152). T-cell expression of chemokine receptors and CD91 was analyzed by flow cytometry, whilst serum levels of chemokines were determined using ELISA in anti-TNF treated RA-patients (n=24) followed longitudinally (30 weeks), and cross-sectionally in SLE-patients (n=23). Expression of mRNA for chemokines was analyzed in T-cells from SLE-patients (n=10) using PCR. Results. After treatment with infliximab, RA patients produced ANA, anti-dsDNA and anti-nucleosome antibodies, but not anti-ENA antibodies. Although these antibodies are considered typical for SLE only one patient developed a transient lupus-syndrome. Antibodies against cell nuclear antigens, including ENA, were detected several years before the first clinical symptom of SLE; anti-SSA was the earliest detectable antibody. In RA-patients before infliximab treatment, the T-cell expression of several chemokine receptors was elevated compared with healthy controls. In contrast, only one soluble chemokine, IP-10 was elevated. After treatment the levels of soluble MIP-1β, MCP-1 and IP-10, and the T-cell expression of CCR2 were decreased. In SLE-patients MIP-1β, MCP-1, SDF-1, IP-10 and RANTES in blood were elevated, whilst expression of CXCR5 and CCR6 on T-cells was lower than in healthy controls. T-cell expression of CXCR2 and CCR1 was elevated in active disease (measured as SLEDAI index), whereas the CXCR5 and CCR2 expression was lower in inactive SLE. In SLE patients with nephritis IP-10 was lower and T-cell expression of CXCR3 and CCR3 elevated compared with patients without nephritis. The expression of CD91 was higher on T-cells from patients not responsive to infliximab treatment compared with responders. Conclusion. These findings indicate that anti-TNF (infliximab) treatment in RA-patients has a major impact on the production of autoantibodies and chemokines. The autoantibody profile in infliximab-treated patients was similar to that predating disease onset in SLE patients with the exception of anti-ENA being detectable in SLE, but the development of lupus-syndromes was rare. The expression of CD91 on T-cells may predict responsiveness to infliximab. The expression of chemokine receptors in SLE- patients seemed to be related to disease activity. Anti-nuclear antibodies were detectable years before clinical disease onset in patients who developed SLE suggesting a gradual pathogenic process.
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