| 1. |
- Adamiak, Grazyna Teresa, 1956-
(författare)
-
Påverkan av organisatoriska och miljömässiga faktorer på tillgänglighet till akutsjukvården
- 2004
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The settings investigated were departments of internal medicine (IM), orthopaedics and surgery in acute care hospitals in Sweden. The objective was to identify exogenous and endogenous determinants of accessibility of health care. Both qualitative and quantitative analysis of utilisation was performed on national and regional level of data aggregation. The study proposes that accessibility to acute health services is influenced by exogenous factors, partly outside the control of health care professionals, such as season, physical proximity and overall supply. Organisational properties such as availability of inpatient beds, hospital and physician specialisation and the degree of system integration between provides of emergency care have effects on the quality of care. The novel finding is the strong association between acute readmissions and remaining inpatient utilisation indicating effects of bed supply on global use within IM. These conclusions follow:§ structural changes on system level work as a method of prioritisation between patient groups by changes in criteria of accessibility;§ the natural and organisational environments determine waiting times in EDs in hospitals by fluctuations of demand;§ geographical accessibility coincides with the supply in terms of over- or underutilisation mirrored in the outcome of medical care;§ effective access is determined by the divide of resources between inpatient and outpatient care and the total supply of inpatient care;§ increasing demands on inpatient care in IM may be derived from deficiencies in the care of chronically ill, elderly patients;§ transition of information and communication among care givers and patients varies in efficiency depending on vehicles for coordination and system integration;§ the level of training of the admitting physician has effects on effective accessibility to inpatient care.There are conflicts between accessibility, efficiency and appropriateness of settings calling for attention to capacity to benefit in addition to needs as priority criteria.
|
|
| 2. |
- Albinsson, Lars, 1944-
(författare)
-
A Palliative Approach to Dementia Care : Leadership and organisation, existential issues and family support
- 2002
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The main purpose of this thesis was to apply the WHO and NHS palliative care approach to dementia care. Thirty-one staff-members in mid-Sweden (studies I and II) and 20 next-of- kin (study IV) were interviewed. In study III, 316 staff-members from dementia care and 121 staff-members from palliative cancer care responded to a questionnaire about family support. The interviews were tape-recorded and analysed with a qualitative phenomenographic (I and II) and a hermeneutic approach (IV). The questionnaires (III) were analysed using qualitative and quantitative content analysis.The staff-members stated almost unanimously that daily leadership was lacking, and consequently clear goal formulations and care planning were rare (I). Proper teamwork between the doctor and the staff who worked on a daily basis with the patients was absent (I). With respect to existential issues, education and staff discussions were lacking (II). The staff were at a loss concerning how to deal with these issues. Nevertheless, these issues are central to family-members who have to deal with an existential crisis (IV). Important questions emerged about obligation and guilt, faithfulness, responsibility, and paying back what you once received. Existential isolation could be identified e.g. in the reversal of roles experienced as "being a parent to your parent" and in the burden of "visiting a living dead person". There were no routines for bereavement visits. The type of support suggested for dementia family members is partly similar to support in palliative cancer care, but it also differs in other respects such as feelings of guilt because the early signs of the disease are misunderstood, the need for respite because of the long trajectory of dementia diseases, and the occurrence of anticipatory grief because in the late phase family members can no longer make any contact at all with the patient (III).A palliative approach can improve the quality of life for the dementia patient and for the family. It can be used as a basis for a clear goal formulation. Some of the suggestions listed in this thesis for improving the quality of care are more a reflection of the need for a change in attitudes rather than the need for substantial budget increases.
|
|
| 3. |
- Andershed, Birgitta
(författare)
-
Att vara nära anhörig i livets slut : Delaktighet i ljuset - delaktighet i mörkret
- 1998
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aims of the present dissertation were: 1. To describe how the establishment of an inpatient hospice ward affected dying cancer patients' utilisation of care at a Medical Centre Hospital; 2. To analyse the involvement of the relative in the care of gravely ill cancer patients in different care cultures; 3. To analyse obstacles to and possibilities for relatives' involvement: 4. To develop a theoretical framework of understanding concerning the involvement of relatives. For the first aim, data was collected via register studies. The basic research design for the other aims was the hermeneutic method.The results show that during the first three years 315 patients died at the newly opened hospice ward. The year before the ward opened 82% of the cancer patients died in acute care compared with 59% during the third year of the hospice ward.The involvement of relatives in the patients' care was categorised into three main categories: "to know", " to be" and "to do". The studies show that the involvement can be described either as involvement in the light or involvement in the dark. Involvement in the light and in the dark illustrates relatives' understanding of the situation, their possibilities for involvement, and the attitude of the staff toward the relatives. Factors that promoted involvement in the light were a humanistic attitude of the staff, a stronger sense of coherence of relatives, an appropriate course of illness, and other available resources such as other relatives and one's own health.A surprising result was that the time between diagnosis and death was three months or less for 49% of 67 patients. In those cases where the course of illness was short there was no time to lose, and it was important that caring delays were avoided.The results from the substudies were summarised in five statements, which together form a theoretical framework of understanding for the involvement of relatives.
|
|
| 4. |
- Frid, Christina, 1952-
(författare)
-
Children with Down syndrome - : an epidemiological study with special focus on congenital heart defects
- 2002
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- To assess the impact of congenital malformations in Down syndrome (DS) on morbidity, mortality and outcome at birth, information on all children with DS born in the northern part of Sweden in 1973-80 (n=211) and 1995-98 (n=88) was collected. Most common were congenital heart defects (CHD), dominated by atrioventricular septal defects (AVSD). Up to age 10 years, morbidity and mortality were more than 10 times higher in DS children with CHD than in healthy DS children. The DS children seemed more vulnerable at birth than Swedish children in general: they had increased frequencies of Cesarean sections, premature birth, asphyxia, and low birthweight, and higher proportions of children small for gestational age, regardless of the presence of CHD. Infant mortality decreased from 14.2% to 2.3% between the two periods.All children with AVSD with and without DS born in Sweden 1973-1997 (n=801) were followed up retrospectively to 2001. Children with isolated AVSD without complex additional CHDs were studied more closely (n=502). A reduction in age at operation and postoperative mortality (from 28 to 1%) was observed. No significant difference in 5-year postoperative mortality between genders or between DS and non-DS children was found. The 5-year postoperative mortality in DS decreased from 35% in 1973-77 to about 10% in 1993-97. CHD had a major influence on morbidity, infectionrate and mortality in DS, but not on DS birth variables. The formerly high mortality in CHD is now reduced. In isolated AVSD measures seem equally successful in DS and non-DS children. Mortality is still 3 times higher in DS children with isolated AVSD than in healthy DS children.
|
|
| 5. |
- Frost, Britt-Marie
(författare)
-
Chemotherapy in Childhood Acute Lymphoblastic Leukemia : In vitro cellular drug resistance and pharmacokinetics
- 2002
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aims of the studies described in this thesis were to investigate the pharmacokinetics of and cellular resistance to chemotherapy as causes of treatment failure in childhood acute lymphoblastic leukemia (ALL).Leukemic cells from 370 children with newly diagnosed ALL were tested by the Fluorometric Microculture Cytotoxicity Assay to measure their resistance to each of ten standard cytotoxic drugs. In the high-risk group, increased in vitro resistance to each of the drugs dexamethasone, etoposide and doxorubicin was associated with a worse clinical outcome. Combining the results for these drugs yielded a drug resistance score, showing a relative risk of relapse in the most resistant group that was 9.8 times higher than in the most sensitive group. In the standard-risk and intermediate-risk groups, final evaluation must await longer follow-up.The new cytotoxic agent CHS 828 was equally active in vitro in samples from children with acute myeloblastic leukemia (AML) and ALL, with 50% cell kill at concentrations achievable in vivo. In AML samples CHS 828 also displayed high frequencies of synergistic interactions with four standard drugs. The well-known differences in clinical outcome between Down´s syndrome (DS) and non-DS children with acute leukemia may partly be explained by our finding of differences in drug resistance at the cellular level.Pharmacokinetic studies were performed at the start of induction treatment of ALL. Doxorubicin was assayed by reversed-phase liquid chromatography with fluorometric detection, and vincristine by high performance liquid chromatography with electrochemical detection. Plasma doxorubicin concentrations were measured in 107 children after 23 h of a 24-h infusion. The median steady-state concentration in children 4-6 years old, a group known to have a favorable outcome of treatment, was about 50% higher than in those 1-2 and >6 years old Vincristine pharmacokinetics was evaluated in 98 children. There was no correlation between age and total body clearance or any other pharmacokinetic parameters.In vitro testing of cellular drug resistance might be useful in predicting the outcome in high-risk ALL. The further exploration of CHS 828 in childhood leukemia seems warranted. There is no pharmacokinetic rationale for the common practice of administering relatively lower doses of vincristine to adolescents than to younger children.
|
|
| 6. |
- Hagelin, Elisabet
(författare)
-
Barnhälsovårdsjournalen som kunskapskälla : En analys av fullständighet, instruktionsenlighet och tillförlitlighet : [an analysis of completeness, reliability and accuracy of recording]
- 1998
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Information contained in medical records is increasingly used for the evaluation of the process of care and to study the health status of individuals. Hence, if recorded information were accurate and reliable, records would be a valuable data source in quality assessment and research.The main objectives of this thesis were to determine (a) the extent to which information about preschool children's living conditions, health and development and provision of care was completely recorded in Child Health (CH) records; (b) whether information was recorded in accordance with recommendations; (c) whether information was in agreement with other sources and with the care actually provided; and (d) whether information could be reliably transferred to a structured protocol. Three sample records were reviewed and parent-child consultations were observed.The results demonstrated that different types of information were recorded with varying degrees of completeness and concordance. There was low agreement between record information and information from other sources. Moreover, the observations of health consultations indicated that the care actually provided was more extensive in relation to recorded care. Most types of information in CH records could be reliably transferred to coding protocols.To increase the quality of medical record data, the CHS staff need to be reminded of the importance of exhaustive documentation of central tasks in CHS. Finally, the arrangement of national instructions for record keeping and a classification system for children's health problems are recommended.
|
|
| 7. |
- Hägglund, Doris
(författare)
-
Att leva med urinläckage : En longitudinell populationsstudie om livskvalitet hos kvinnor och hur de hanterar sitt urinläckage
- 2002
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Urinary incontinence is a prevalent condition; nevertheless few women seek professional help. One aim of this study was to investigate all women aged 18-70 years in a Swedish community regarding (a) the prevalence rate and risk factors of urine leakage and (b) the quality of life for women with and without urine leakage, for women with stress incontinence versus urge incontinence, and for women with urine leakage who had or had not sought help. A second aim was to study all women aged 18-46 years from the same population four years later regarding (a) the quality of life and natural history of urine leakage, (b) why some women with persistent urine leakage seek help and others do not, and (c) how they deal with their urine leakage.Every fourth woman aged 18-70 years was found to have urine leakage. The number of women with urine leakage increased with increasing age, the number of deliveries, the presence of urinary tract infection, and the use of oestrogen substitutions. Women with urine leakage had a lower quality of life in all eight dimensions of the SF-36 as compared with women without urine leakage. Furthermore, in women with urge incontinence the quality of life was lower compared with women with stress incontinence in all dimensions of the SF-36. Women with urine leakage who had sought help had lower quality of life in seven of eight SF-36 dimensions as compared with women with urine leakage who had not sought help.At the four-year follow-up the quality of life had deteriorated in five of eight SF-36 dimensions in women aged 18-46 years with persistent urine leakage as compared with women with persistent continence. The mean annual incidence and remission rates of urine leakage were on the same low level (4%). Most women with slight or moderate long-term urine leakage had not sought professional help, largely because they considered their leakage a minor problem. Pelvic floor exercises was the most commonly used management method for all participants.
|
|
| 8. |
- Magnusson, Margaretha
(författare)
-
Barnhälsovård : Studier av effektivitet och föräldratillfredsställelse
- 1999
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The research examined the role of the Swedish health surveillance program in identifying health problems and the degree to which Child Health Centers (CHC) respond to parents' expectations. The five studies were based on populations of pre-school children in Uppsala county.Analysis of the surveillance program showed a very low yield of newly detected health problems from about 3500 physician examinations of children at 2, 6, 12 and 18 months. About 2.5% of the children had newly detected problems, but most were minor or moderate. Only four severe problems were detected during the 14000 examinations by CHC physicians.Retrospective analysis of records for children with severe disabilities and diseases showed that 63% were detected neonatally. Only 20% were detected at the CHC, and less than half of these were found during scheduled examinations.A screening program for communication disorders was analyzed in a case-control study. Sensitivity for the screening was only 25%, and specificity was 61%.Two studies measured parental satisfaction in 1970, 1988 and 1993. In 1988, child health service was the responsibility of district nurses serving the general population, while in 1970 and 1993 it was handled by nurses working primarily with children. A significantly greater proportion of parents who perceived their infants as having behavior or feeding problems sought help from the CHC and were more satisfied with the advise received in 1970 and 1993 than 1988. General parental assessment of the service showed the same pattern.The results raise questions about the rationality of regular physician examinations for all infants, the respective roles of nurses and physicians in health surveillance, and the impact of organization and other factors on parental satisfaction with child health services.
|
|
| 9. |
|
|
| 10. |
- Walker-Engström, Marie-Louise, 1952-
(författare)
-
Treatment effects with a mandibular advancement appliance and uvulopalatopharyngoplasty in obstructive sleep apnea -randomised controlled trials-
- 2003
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Enthusiasm for uvulopalatopharyngoplasty (UPPP) in the treatment of mild-to-moderate obstructive sleep apnea syndrome (OSAS) has declined in recent years, partly because of a lower success rate over time and partly because of adverse effects. In more severe cases, the patients are generally treated with nasal continuous positive airway pressure (CPAP). However, many patients do not satisfactorily tolerate CPAP as a result of frequent side-effects. Consequently, there is a need for an alternative treatment. Reports on the beneficial effects of mandibular advancement appliances in the treatment of mild-to-moderate OSA exist in the form of short–term evaluations.One of the aims of the present thesis was to compare treatment effects with a mandibular advancement appliance and UPPP in patients with OSA with follow-up after one and four years. Ninety-five male patients with confirmed mild-to-moderate OSA (apnea index, AI >5 and <25) were randomised to treatment with a dental appliance or UPPP. Sleep studies were performed before and one and four years after intervention. According to the criteria for normalisation (AI<5 and apnea hypopnea index, AHI<10), 78% of the patients in the dental appliance group and 51% of the patients in the UPPP group had normalised after one year (p<0.05). Still after four years of treatment, 63% of the patients in the dental appliance group and 33% of the patients in the UPPP group were normalised. The dental appliance group had a higher normalisation rate than the UPPP group, but the efficacy was partly invalidated by the compliance rate of 62%.Quality of life assessments in the dimensions of vitality, contentment and sleep improved in both groups at the one-year follow-up after treatment. There was no difference between the groups in terms of vitality and sleep. The UPPP group, however, reported a higher degree of contentment than the dental appliance group, even though the somnographic values were superior in the latter group. Another aim was to conduct a randomised study to test the hypothesis that severe OSA patients will benefit from more pronounced mandibular advancement (MA) compared with a shorter advancement. Eighty-six males with severe OSA (AI>20) were randomly allocated to either 75% or 50% MA for a six-month treatment period. Treatment with a more pronounced mandibular advancement yielded a 20% higher normalisation rate than a shorter advancement. A mean normalisation rate of 45% was found for patients in this category with few side-effects, good patient satisfaction and a compliance of 92% after 6 months. The overall conclusion is that dental appliance treatment is effective in patients with mild to moderate OSA and even for patients with severe OSA. The efficacy in terms of normalisation in patients with mild to moderate OSA was higher after the dental appliance treatment with a 50% degree of advancement than after the UPPP treatment. However, severe OSA patients might benefit from more pronounced advancement (75%) compared with a shorter degree of advancement (50%). QOL improved significantly after both dental appliance and UPPP treatment.
|
|
