| 1. |
- Borendal Wodlin, Ninnie
(författare)
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Fast track abdominal hysterectomy : On the mode of anesthesia, postoperative recovery and health economics
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Hysterectomy is the most common major gynecological operation in the Western World and approximately 5000 benign hysterectomies are performed in Sweden every year. Consequently it is a surgical procedure that affects many women. The procedure comprises challenges concerning perioperative health care, perceived postoperative symptoms, quality of life aspects and health economics. The concept of fast track is a multimodal strategy to reduce hormonal surgical stress response and achieve an enhanced postoperative recovery and is today considered to be evidence based in relation to colorectal surgery. Spinal anesthesia, as an important part of fast track, provides benefits of extended effect on analgesia and reduced postoperative morbidity. It is reasonable to believe that employing the strategies of fast track including spinal anesthesia could also provide substantial benefits for women requiring surgical removal of the uterus.Aims: To determine whether duration of hospital stay, presence and intensity of postoperative symptoms, duration of sick leave and cost-effectiveness differ between women undergoing benign fast track abdominal hysterectomy in spinal anesthesia with intrathecal morphine (SA) and in standard general anesthesia (GA).Material & Methods: 180 women participated in this open randomized multicenter study with five participating hospitals in the southeast region of Sweden. One hundred and sixty two completed the study; 82 women were randomized to SA and 80 to GA. A fast track model comprising premedication without sedatives, intravenous fluid regulation, analgesics based on non-opioids, pre-emptive antiemetic therapy, early enteral nutrition and mobilization and standard criteria for discharge were used. End points were duration of hospital stay, use of analgesics, perceived postoperative symptoms, occurrence of postoperative complications, duration of sick leave and health economic evaluations.Results: Duration of hospital stay did not differ between the two modes of anesthesia. Vomiting and pruritus occurred significantly more often after SA. Complication rates did not differ between groups. Women with SA experienced less overall discomfort and had a reduced need for opioids postoperatively. Abdominal pain, drowsiness and fatigue occurred less often and with lower intensity among the women in the SA group. Health related quality of life improved faster and the duration of sick leave was shorter in women after SA. Total costs (hospital costs plus costs for productivity loss) were lower for the SA group. Within the first 29 days after hysterectomy the women in the SA group gained more QALYs than women in the GA group.Conclusions: The duration of hospitalisation after fast track abdominal hysterectomy was less than 50 hours and mode of anesthesia did not influence this. SA displayed considerable advantages regarding postoperative symptoms and recovery. SA was considered cost-effective in comparison with GA due to lower total costs and more QALYs gained. Our study indicates that SA should be recommended as the first choice of anesthesia in benign abdominal hysterectomy.
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| 2. |
- Borgström, Sara, 1977-
(författare)
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Urban shades of green : Current patterns and future prospects of nature conservation in urban landscapes
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Urban nature provides local ecosystem services such as absorption of air pollutants, reduction of noise, and provision of places for recreation, and is therefore crucial to urban sustainable development. Nature conservation in cities is also part of the global effort to halt biodiversity decline. Urban landscapes, however, display distinguishing social and ecological characteristics and therefore the implementation of nature conservation frameworks into cities, requires reconsideration of what nature to preserve, for whom and where. The aim of this thesis was to examine the current urban nature conservation with special focus on formally protected areas, and discuss their future role in the urban landscape. A social-ecological systems approach was used as framework and both quantitative and qualitative methods were applied. The studies were performed at local to regional scales in the southern part of Sweden. Four key questions were addressed: i) What are the characteristics of nature conservation in urban landscapes? ii) How does establishment of nature conservation areas affect the surrounding urban landscape? iii) In what ways are spatial and temporal scales recognized in practical management of nature conservation areas? and iv) How can the dichotomy of built up and nature conservation areas be overcome in urban planning? Nature reserves in urban, compared to rural landscapes were in general fewer, but larger and included a higher diversity of land covers. They were also based on a higher number and different kinds of objectives than rural nature reserves. Urbanisation adjacent to nature reserves followed the general urbanisation patterns in the cities and no additional increase in urban settlements could be detected. In general, there was a lack of social and ecological linkages between the nature conservation areas and the urban landscape and practical management showed a limited recognition of cross-scale interactions and meso-scales. Such conceptual and physical isolation risks decreasing the public support for nature conservation, cause biodiversity decline, and hence impact the generation of ecosystem services. A major future challenge is therefore to transform current conservation strategies to become a tool where urban nature is perceived, planned and managed as valuable and integrated parts of the city. To enable social-ecological synergies, future urban planning should address proactive approaches together with key components like active enhancement of multifunctional landscapes, cross-scale strategies and border zone management.
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| 3. |
- Dietrich, Anna L., 1979-
(författare)
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Use of phytometers for evaluating ecological restoration
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The increase in ecological restoration can be attributed to valuation of healthyecosystems and concerns for future climate changes. Freshwaters belong among theglobally most altered ecosystems and are restored to counteract human impacts.Many Swedish streams that were channelized to facilitate timber floating have beenrestored by returning boulders and reconnecting riparian with instream habitats.Evaluation of restoration lacks reliable indicators of organism performance, possiblydue to the complexity of ecosystem responses. Phytometers, i.e. standardized plantstransplanted to different environments, are important indicators of restorationsuccess. Phytometers integrate multiple environmental factors and measureecosystem functions directly. This thesis combines a literature review with threeexperiments and focuses on phytometer use for evaluating ecological restoration. Werecommend using different phytometer species, life-forms and life-stages and longexperiments (>1 year) to obtain high resolution and generality (I). In greenhouse andfield experiments we investigated the effect of restoring channelized rivers onphytometers and abiotic variables in the riparian zone. We hypothesized thatphytometer performance varies with stream size and climate. In the greenhouse, weanalysed differences in fertility between channelized and restored reaches by growingphytometers on soils from experimental sites (II). Phytometers grew better on soilsfrom restored sites in small streams, indicating a positive effect of restoration on soil.We detected this effect already 3-7 years after restoration, suggesting a fasterrecovery than predicted. In a short-term field experiment focusing on germinationand establishment of sunflowers, seedling survival, substrate availability, and soilnutrient content in large streams were enhanced by restoration (III). Overall,phytometers performed best at high altitudes and short growing seasons. The use ofMolinia caerulea and Filipendula ulmaria as phytometers in a long-term fieldexperiment (IV) revealed a better performance at restored sites. One reason was thatsummer flow-variability was higher, particularly in medium-sized streams. Sincephytometers allocated more biomass to belowground parts at restored compared tochannelized sites, it seems important to separate above- and belowground biomass inrestoration evaluation. Restoration outcomes vary with location in the catchment.Knowing such potentially different responses could guide restorationists in where tolocate restoration to be effective or successful. We suggest that small streams reactparticularly fast to restoration. Given that the proportion of small streams is high andthat restoration success in headwaters may favour downstream reaches, werecommend restoration to begin in tributaries to larger rivers. It is not always knownwhy phytometers react the way they do. Greenhouse experiments can disentangle thecauses of phytometer responses in the field by focusing on single environmentalfactors. We demonstrate that phytometers integrate ecosystem responses torestoration by reflecting how environmental factors affect plants under fieldconditions. Further studies are needed to better understand the underlyingmechanisms.
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| 4. |
- Ekdahl, Christer, 1962-
(författare)
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Infective Endocarditis : aspects of pathophysiology, epidemiology, management and prognosis
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Infective endocarditis (IE) is a rare but complex disease that is fatal if untreated. With a modern combination of antimicrobial therapy and heart valve surgery, mortality is still 10-20 %. The structure of the endocarditis vegetation impedes the penetration of phagocytic cells such as monocytes and granulocytes. This leads to high bacterial counts inside the vegetation and the need for long treatment courses with a combination of intravenously administered bactericidal antibiotics.The aim of this thesis was to study the changes in epidemiology, management, and mortality at our hospital between 1980 and 2001, and to identify prognostic factors associated with mortality. To assess the issue of referral bias, differences between referred episodes and episodes from our local community were studied. Additional aims were to study the occurrence of the pro-chemotactic cytokines IL-8 and TNF-α in heart valves and vegetations during the active phase of IE, and to study the effect of the glycopeptide antibiotic vancomycin in dense staphylococcal cultures in vitro. As it is a rare and complex disease, management of IE is usually complicated for non-specialists. For this reason a computerised decision support system for IE was developed and evaluated.Between 1980 and 2001, the occurrence of Staphylococcus aureus IE and the use of early heart valve surgery increased significantly, regardless of whether the episodes were referred or of local origin. Glycopeptide antibiotics, mainly vancomycin, were used more frequently, especially among referred patients. Referred patients were younger, predominantly male, had more complications, and received surgical treatment more often than patients from our local community. The reason for the lower frequency of female patients in the referral cohort cannot be explained by more comorbidity or fewer complications. The differences between referred and local episodes seen in our study highlight the need for assessment and adjustment for referral bias in IE studies (Paper I).In six patients who needed early heart valve surgery, the largest numbers of IL-8-containing cells, and the greatest amount of inflammation, were seen in patients with short preoperative antimicrobial treatment courses. No such relationships were seen with respect to TNF-α-containing cells. The IL-8-containing cells and the inflammatory cells were predominantly scattered in the heart valve stroma or in the margin of the vegetation (Paper II). The primary effect of IL-8 is to stimulate chemotaxis of polymorphonuclear neutrophil granulocytes. This indicates that there is no deficiency of IL-8 in the area close to the vegetation as a cause of the localised agranulocytosis often present inside the vegetation.Our study revealed a need for computerised decision support systems (DSSs) in the field of IE, but to be used in clinical practice these DSSs need be part of knowledge bases covering larger domains (Paper IV). Some of our initial ideas described in Paper III, especially the use of Internet technology and the combination of rule-based advice and explanatory hypertext, will probably be included in these knowledge bases.In vitro, there is a rapid reduction of free vancomycin in broth containing dense staphylococcal cultures. Consequently, there is a simultaneous increase in broth MICs, particularly in high inocula, which is not caused by a development of resistance (Paper V). These findings need further evaluation in vivo, but indicate that the dosing regimen of vancomycin is of particular importance in staphylococcal infections with dense inocula, e.g. infective endocarditis.Diabetes mellitus and moderate to severe heart failure were independent risk factors for 6-month mortality in left-sided, Duke definite IE episodes, regardless of referral or local origin of the episodes. Early heart valve surgery had a positive impact on the 6-month mortality in the referral cohort of episodes, which may be due to referral bias (Paper VI).
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| 5. |
- Engström, Johanna, 1981-
(författare)
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Ice, wood and rocks : regulating elements in riverine ecosystems
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Riparian ecosystems are of great importance in the landscape, connecting landscape elements longitudinally and laterally and often encompassing sharp environmental gradients in ecological processes and communities. They are influenced by fluvial disturbances such as flooding, erosion and sediment deposition, which create dynamic and spatially heterogeneous habitats that support a high diversity of species. Riverine ecosystems belong among the world’s most threatened systems. In rivers throughout the world, human alterations to fluvial disturbance regimes have resulted in degraded ecosystems and species loss. For example, in Sweden, watercourses of all sizes have been channelized to facilitate timber floating, but in the last 10–20 years the impacts in some of the affected rivers have been reduced by restoration actions. The objectives of this thesis are to evaluate how riverine ecosystems in general, with specific focus on riparian communities, are affected by (1) restoration of channelized reaches by boulder replacement, (2) ice formation, and (3) restoration of in-stream wood abundance in the stream channel. Objective (1) was assessed by quantifying the retention of plant propagules in channelized and restored stream reaches and by evaluating effects on riparian plant and bryophyte communities in disconnected and re-opened side channels. Retention of plant propagule mimics was highest at low flows and in sites where boulders and large wood had been replaced into the channel. Propagules are however unlikely to establish unless they can be further dispersed during subsequent spring high flows to higher riparian elevations suitable for establishment. Thus, immigration to new suitable sites may occur stepwise. Our study demonstrates that restoration of channel complexity through replacement of boulders and wood can enhance retention of plant propagules, but also highlights the importance of understanding how restoration effects vary with flow. We detected no differences in riparian diversity between re-opened and disconnected side channels, but we did observe significant differences in species composition of both vascular plant and bryophyte communities. Disconnected sites had more floodplain species, whereas restored sites had more species characteristic of upland forest. This suggests that the reopening of side channels resulted in increased water levels, resulting in new riparian zones developing in former upland areas, but that the characteristic floodplain communities have not had time to develop in response to the restored fluvial regime. Objective (2) was approached by evaluating the effect of both natural anchor ice formation and experimentally created ice in the riparian zone. Riparian plant species richness and evenness proved to be higher in plots affected by anchor ice. Plants with their over-wintering organs above the ice sheet suffered from the treatment but the overall species richness increased in ice-treated plots. Objective (3) was evaluated by studying wood recruitment and movement, channel hydraulics, propagule retention and fish abundance in streams restored with large wood. Only one stream experienced reduced velocities after large wood addition. The large size and reduced velocity were probably also the reasons why this stream proved to be the best one in trapping natural, drifting wood. Increased retention and decreased mechanical fragmentation in large wood sites will lead to decreased loss of detritus from the site and therefore higher availability of coarse particulate organic matter which can result in more species rich shredder communities. Our study did not show that the occurrence of large wood had an important role in controlling density or biomass of brown trout.
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| 6. |
- Erlandsson, Anna, 1973-
(författare)
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Neural Stem Cell Differentiation and Migration
- 2003
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Neural stem cells are the precursors of neurons, astrocytes and oligodendrocytes. During neural development, the division of stem cells takes place close to the lumen of the neural tube, after which they migrate to their final positions within the central nervous system (CNS). Soluble factors, including growth factors, regulate neural stem cell proliferation, survival, migration and differentiation towards specific cell lineages.This thesis describes the function of platelet-derived growth factor (PDGF) and stem cell factor (SCF) in neural stem cell regulation. PDGF was previously suggested to stimulate neuronal differentiation, but the mechanisms were not defined. This study shows that PDGF is a mitogen and a survival factor that expands a pool of immature cells from neural stem cells. The PDGF-treated cells can be stained by neuronal markers, but need further stimuli to continue their maturation. They can become either neurons or glia depending on the secondary instructive cues. Moreover, neural stem cells produce PDGF. Inhibition of this endogenous PDGF negatively affects the cell number in stem cell cultures. We find that SCF stimulates migration and supports the survival of neural stem cells, but that it has no effect on their proliferation or differentiation into neurons and glia. Intracellular signaling downstream from the receptors for PDGF and SCF includes activation of extracellular signal-regulated kinase (ERK). This investigation shows that active ERK is not needed for the differentiation of stem cells into neurons, at least not during early stages.Neural stem cells have a future potential in the treatment of CNS disorders. To be able to use neural stem cells clinically we need to understand how their proliferation, differentiation, survival and migration are controlled. The results presented in this thesis increase our knowledge of how neural stem cells are regulated by growth factors.
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| 7. |
- Gustavsson, Christer, 1968-
(författare)
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Added value from biomass by broader utilization of fuels and CHP plants
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The present work, where additional value-creating processes in existing combined heat and power (CHP) structures have been examined, is motivated by a political- and consumer-driven strive towards a bioeconomy and a stagnation for the existing business models in large parts of the CHP sector.The research is based on cases where the integration of flash pyrolysis for co-production of bio-oil, co-gasification for production of fuel gas and synthetic biofuels as well as leaching of extractable fuel components in existing CHP plants have been simulated. In particular, this work has focused on the CHP plants that utilize boilers of fluidized bed (FB) type, where the concept of coupling a separate FB reactor to the FB of the boiler forms an important basis for the analyses. In such dual fluidized bed (DFB) technology, heat is transferred from the boiler to the new reactor that is operating with other fluidization media than air, thereby enabling other thermochemical processes than combustion to take place. The result of this work shows that broader operations at existing CHP plants have the potential to enable production of significant volumes of chemicals and/or fuels with high efficiency, while maintaining heat supply to external customers.Based on the insight that the technical preconditions for a broader operation are favourable, the motivation and ability among the incumbents in the Swedish CHP sector to participate in a transition of their operation towards a biorefinery was examined. The result of this assessment showed that the incumbents believe that a broader operation can create significant values for their own operations, the society and the environment, but that they lack both a strong motivation as well as important abilities to move into the new technological fields.If the concepts of broader production are widely implemented in the Swedish FB based CHP sector, this can substantially contribute in the transition towards a bioeconomy.
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| 8. |
- Hall, Bo G, 1938-
(författare)
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Perspektiv på Patron : Bruksägaren och statsministern Christian Lundeberg (1842–1911)
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The dissertation is a biography of the industrialist and statesman Christian Lundeberg, a leading and stongly pronounced conservative actor in Swedish political life during the decades around1900, but nowadays almost forgotten. The purpose is to identify the main forces – convictions as well as external factors – behind his actions. He was very influential within a range of important sectors, i.a. compulsory national service, repeated interventions to keep the iron ore of Norrland under Swedish ownership, establishment of a regular conservative party and the decision on the vote to right (for men) in 1907. His most well-known action was as Swedish Prime Minister and head architect behind the peaceful dissolution in 1905 of the union with Norway.However for a long time biographies have not been regarded as ”real” scientific work within the concerned academic Swedish circles. For this reason the introductory chapter analyses these discussions and concludes that time now is ready for the genre to come in from the cold , enumerating six criteria regarded to be of paramount importance. These are being observed in the consecutive parts of the study.The following chapter studies the concept of paternalism as defined within Swedish professional circles, forming a background to the remaining parts of the dissertation. In their turn these present thorough reviews both of Lundeberg’s activities as a paternalistic foundry proprietor in the local family owned community of Forsbacka and of his contributions on the central political level.The final chapter summarizes the driving forces behind Lundeberg’s activities in stating that he was not an ultraconservative person, a priori opposing all progress. Instead as the years passed he developed a clear readiness for compromise solutions. Three key concepts are said to be central to the understanding of his person: “Fatherland”, ”Responsibility” and “Duty”. Throughout all his life he adhered to many of the paternalistic principles and values he learnt at an early age in Forsbacka. His present anonymity is explained by the fact that he in a retrospective very often is considered as being defeated in a number of political convictions now regarded as important.
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| 9. |
- Hasselquist, Eliza Maher, 1977-
(författare)
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Gradients of time and complexity : understanding how riparian and instream ecosystems recover after stream restoration
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Why evaluations of the ecological outcomes of stream and river restoration have largely reported inconclusive or negative results has been the subject of much debate over the last decade or more. Understanding the reasons behind the lack of positive results is important for bettering future restoration efforts and setting realistic expectations for restoration outcomes. This thesis explores possible explanations for why researchers have failed to find clear and predictable biotic responses to stream restoration: recovery time has been too short, that restoration of habitat complexity is not clearly linked to instream biodiversity, that one monitored organism group is not representative of the entire community, that restoration effort was not intense enough to restore the potential habitat complexity of a system, and that reach-scale restoration done in the presence of catchment-scale degradation obscures restoration results. The overarching goal of this thesis is to study the holistic effect of reach-scale restoration of historic reach-scale simplification, due to timber floating in northern Swedish streams, thus avoiding the added pressure of catchment-scale degradation typically found at most restoration sites (e.g., non-point-source pollution and impervious cover). Using this model system, I was able to show that it took 25 years for riparian plant species richness at restored sites to increase above that of channelized sites. Furthermore, it was clear that restoration of these streams caused a large and rapid change in N-processing in the riparian zone and this alteration persists for at least 25 years. Additionally, multiple metrics of geomorphic complexity were needed to explain some of the more subtle responses of organism groups. Macroinvertebrates, diatoms, and macrophytes did not respond concordantly and cannot serve as surrogates or indicators for each other. I found that older best practice methods of restoration rarely restored the large-scale features needed to bring the sites up to their potential complexity because these elements were destroyed or removed from the system. Advanced restoration techniques used in more recent restorations added big boulders and instream wood and increased complexity to a level that elicited a biological response. By combining surveys of multiple metrics of structure, diversity of multiple organism groups, and process in this thesis I was able to get a holistic view of the effects of restoration of streams after timber floating. We now know that it takes at least 25 years for riparian plants and N-cycling to recover, we understand that multiple metrics of geomorphic complexity should be measured to be able to explain biotic responses, and that restored complexity should better match the potential complexity of the site in order to elicit a biological response. Finally, we know that multiple organism groups need to be assessed when evaluating the response of biodiversity to restoration.
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| 10. |
- Holmberg, Benny, 1958-
(författare)
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Analysis of risk factors in patients with severe chronic kidney disease. The role of atorvastatin.
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background and aim: There had been no randomized end-point studies with statins for patients with severe renal failure. The purpose of this prospective, open, randomized, controlled study was to investigate whether atorvastatin (10 mg/day) would alter cardiovascular end-points and the overall mortality rate of patients with chronic kidney disease stage 4 or 5 (creatinine clearanceMaterial & Methods: This was an open, prospective, randomized study. A total of 143 patients were included: 73 were controls and 70 were prescribed 10 mg/day of atorvastatin. As efficacy variables, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglyceride levels were determined at the start of the study and at 1, 3, 6, 12, 18, 24, 30 and 36 months. The primary end-points were all cause of mortality, non-lethal acute myocardial infarction, and coronary artery intervention. Various risk factors were studied. In the 97 patients on haemodialysis inter dialysis weight gain (IDWG) was calculated as ultrafiltration in kg/body weight in kg given in percentage of the weight. The burden of IDWG was analyzed.Results: In the atorvastatin group, total cholesterol and low-density lipoprotein cholesterol were significantly reduced, the latter by 35% at 1 month and then sustained. Atorvastatin was withdrawn in 23% of patients due to unacceptable side effects, most frequent complaints being gastrointestinal discomfort and headache. Primary end-points occurred in 74% of the subjects. There was no difference in cardiovascular endpoint and survival between the control and atorvastatin groups. The 5-year end-point-free survival rate from study entry was 20%. There was no evidence of more benefit of atorvastatin for patients with diabetes mellitus and chronic kidney disease versus the other patients; instead plasma fibrinogen increased. The IDWG was significantly larger in patients who suffered from end-points due to cardiovascular reasons, cardiac reasons, congestive heart failure, aortic aneurysm, and intracerebral bleeding.Conclusion: These data showed that in contrast to other patient groups, patients with severe chronic kidney disease 4 and 5, including those with diabetes mellitus, seem to have no benefit from 10mg/day of atorvastatin. Instead we found a high IDWG to be an important risk factor that should be prevented. There was no evident connection between atorvastatin medication and IDWG.
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