| 1. |
- Hendrikx, Tijn, 1975-
(författare)
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Catch Atrial Fibrillation, Prevent Stroke : Detection of atrial fibrillation and other arrhythmias with short intermittent ECG
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Atrial fibrillation (AF) is the most common arrhythmia in the adult population, affecting about 5% of the population over 65 years. Occurrence of AF is an independent risk factor for stroke, and together with other cardiovascular risk factors (CHADS2/CHA2DS2- VASc), the stroke risk increases. Since AF is often paroxysmal and asymptomatic (silent) it may remain undiagnosed for a long time and many AF patients are not discovered before suffering a stroke.Aims: To estimate the prevalence of previously undiagnosed AF in an out-of-hospital population with CHADS2 ≥1, in patients with an enlarged left atrium (LA) and of total AF prevalence in sleep apnea (SA) patients, conditions that have been associated with AF. To compare the efficacy of short intermittent ECG with continuous 24h Holter ECG in detecting arrhythmias.Methods: Patients without known AF recorded 10−30 second handheld ECG (Zenicor-EKG®) registrations during 14−28 days at home, both regular, asymptomatic registrations twice daily and when having cardiac symptoms. Recordings were transmitted through the in-built SIM card to an internet-based database. Patients with palpitations or dizziness/presyncope referred for 24h Holter ECG were asked to additionally record 30-second handheld ECG registrations during 28 days at home.Results: In the out-of-hospital population with increased stroke risk, previously unknown AF was diagnosed in 3.8% of 928 patients. Comparing AF detection in patients with an enlarged LA versus normal LA showed that eleven of 299 patients had AF. Five of these had an enlarged LA (volume/BSA). No statistical difference in AF prevalence was found between patients with enlarged and normal LA, 3.3% and 3.2% respectively, (p = 0.974). AF occurred in 7.6% of 170 patients with sleep apnea, in 15% of patients with sleep apnea ≥60 years, and in 35% of patients with central sleep apnea. AF prevalence was also associated with severity of sleep apnea, male gender and diabetes. Comparing the efficacy of arrhythmia detection in 95 patients with palpitations or dizziness/presyncope with continuous 24h Holter and short intermittent ECG, 24h Holter found AF in two and AV-block II in one patient, resulting in 3.2% relevant arrhythmias detected. Short intermittent ECG diagnosed nine patients with AF, three with PSVT and one with AV-block II, in total 13.7% relevant arrhythmias. (p = 0.0094).Conclusions: Screening in the out-of-hospital patient population (mean age 69.8 years) yielded almost 4% AF, making it seem worthwhile to screen older patients with increased stroke risk for AF with this method. Screening patients with LA enlargement (mean age 73.1 years) did not result in higher detection rates compared with the general out-of-hospital population. AF occurred in 7.6% of patients with sleep apnea, (mean age 57.6 years) and was associated with severity of sleep apnea, presence of central sleep apnea, male gender, age ≥60 years, and diabetes. Short intermittent ECG is more effective in detecting relevant arrhythmias than 24h Holter ECG in patients with palpitations or dizziness/presyncope.
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| 2. |
- Hörnsten, Åsa, 1963-
(författare)
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Experiences of diabetes care - patients' and nurses' perspectives
- 2004
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: In order to provide good diabetes care it is important for the health care professionals to share patients’ personal understanding of living with diabetes, which differs from a professional understanding of the illness. Patients’ beliefs about health, illness, control and cure are predictive of the outcome of lifestyle changes and pharmacological treatment. Narratives about illness could be used to elucidate what people believe to be central to their experience of an illness and its management. The overall aim of this thesis was to investigate experiences of diabetes and diabetes care among people with type 2 diabetes and district nurses responsible for diabetes care within primary health care. Methods: Forty-four patients diagnosed with diabetes during the previous 2 years were interviewed about their personal understanding of illness and experiences of care. They also participated in an intervention study consisting of group sessions during 9 months. The intervention focused on the patients’ understanding of living with diabetes and was directed at the patients and their nurses (n = 5). The outcome variables haemoglobin A1c (HbA1c), lipids, blood pressure (BP) and body mass index (BMI) as well as well-being, treatment satisfaction and diabetes symptoms of the intervention group were compared with those in a control group (n = 60). Another ten patients were interviewed about their views of their lives. Seventeen nurses in diabetes care were interviewed about their views of their work with patients. The narrative, thematic interviews and focus group interviews were analysed using qualitative content analysis. Findings: Patients’ personal understanding of illness included the categories “image of the disease”; “meaning of the diagnosis”; “integration of the illness”; “space for the illness”; “responsibility for care”; and “future prospects”. Patients’ narratives about their lives included views of knowledge, and capacity, motivation and courage, aspects important for effective self-management. Patients’ views on clinical encounters in diabetes care, interpreted as satisfying or not, included the themes “being in agreement v. in disagreement about the goals”; “being autonomous and equal v. being forced into adaptation and submission”; “feeling worthy as a person v. feeling worthless”; “being attended to and feeling welcome v. being ignored”; and “feeling safe and confident v. feeling unsafe and lacking confidence”. The results of the intervention study with group sessions showed improvements in metabolic balance and treatment satisfaction in the intervention group. At the 1-year follow-up the mean difference between groups in HbA1c was 0.94% (95% confidence interval (CI) 0.58–1.29). Nurses’ views of their work included the themes “Perspectives on illness and caring are not easily integrated into views of disease and its treatment”; “Nurses view their knowledge as more important than the patients’ knowledge”; Nurses’ conscience is challenged by some of their nursing decisions”; “The individuality of each patient is undermined when patients are regarded as a collective group”; and “Nurses are confirmed in their role of nurses by patients who assume a traditional patient role”. Conclusion: These results demonstrate that the understanding of illness and care differs between patients and nurses working in diabetes care; furthermore, that an intervention involving patients and their nurses based on patients’ personal understanding of illness is effective with regard to metabolic control and treatment satisfaction. The cost of the intervention is moderate. Also, we believe that it is possible to clinically implement this intervention within the existing resources for primary health care.
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| 3. |
- Jutterström, Lena, 1965-
(författare)
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Illness integration, self-management and patient-centred support in type 2 diabetes
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Type 2 diabetes is a serious disease that is increasing globally. The focus of diabetes care has been to prevent diabetes related complications and thereby reduce mortality. An older population, the disease progression and decreased ability to perform self-management activities increases the risk for complications. Group education and patient-centred care are recommended to improve self-management through increased patient empowerment. Despite these recommendations, professionals have been reluctant to adopt these methods referring to lack of knowledge, time and tools to deliver patient-centred care in diabetes. Focusing on the patient’s illness integration process has in the literature been suggested to improve self-management and metabolic balance.Aim: The overall aim of the thesis was to describe the experiences of illness integration, self-management and support in type 2 diabetes and to evaluate the metabolic effects of a nurse-led patient-centred model for self-management support.Methods: The study setting was primary health care in Västerbotten County, Sweden. In total, 21 diabetes nurses (Study I) and 257 patients (Studies II-IV) participated in the four studies (Study II, n=44; Study III, n= 18; Study IV, n= 195). Data consisted of focus group interviews (Study I), individual semi-structured interviews (Studies II-III) and laboratory measurements (Study IV). Methods for analyses were qualitative content analysis (Studies I-III) and statistics (Study IV).Results: Study I revealed that diabetes nurses found the ideal diabetes care complex to achieve. Conflicting paradigms, power relations and departmentalisation of work were described. Study II describes a process whereby illness integration and self-management in type 2 diabetes develop simultaneously. When a turning-point occurs, people view self-management as both necessary and feasible. In study III, turning points in self-management are illuminated. Turning-point transitions include existential and emotional aspects that increase inner motivation and power for lifestyle change. Study IV evaluates the effects of a nurse-led intervention in which haemoglobin A1c (HbA1c) was significantly decreased at 12 months’ follow-up. Group intervention and individual intervention were both effective compared to traditional diabetes care.Conclusions: There is a potential for improvement of type 2 diabetes care. Increased patient-centredness is important to support patients towards illness integration and self-management. Focusing on the patients’ illness experiences, including the existential and emotional aspects of having and managing type 2 diabetes, in counselling can lead to improved self-management and glycaemic control. Patients’ experiences of illness are central to their inner motives for change, and patient-centred self-management support and patient education preferably emanate from this perspective.
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| 4. |
- Lundberg, Thorbjörn, 1965-
(författare)
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Assessment of tympanic membrane : a study of children with otitis media in general practice
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Acute otitis media (AOM) is a common disease in children and is causing great discomfort and disability worldwide but many areas are underserved regarding skilled professional. Tele-otology offers a promising technique to provide ear health globally. Diagnostic accuracy of AOM has regardless of method been found to be low. Grading the severity of AOM my offer a guide in decision on antibiotic treatment, however grading systems need improvement.Aim To describe and evaluate imaging of the tympanic membrane (TM), develop an image based grading scale for AOM and to study the characteristics and the course of acute otitis media (AOM) episodes in children with the use of telemedicine techniques.Method This thesis is based on two study populations, 63 children attending with othalgia at four primary health care centers in rural Sweden (papers I, II, IV) and 140 children attending a health clinic from a township in Johannesburg, South Africa, (paper III).Paper I: Image quality of endoscopic imaging of TM´s, from the Swedish study was assessed by an otologist and two general practitioners together with an evaluation of important characteristics of assessing TM appearance.Paper II: In development and validation of an image-based grading scale of AOM two expert panels of otologist’s evaluated the proposed grading scale stepwise and in a test and retest validation process.Paper III: A test of the scale in a clinical situation was set up, an otologist oto-microscopically examined children and used the grading scale, and his diagnoses were set as gold standard. A specially trained ear and hearing facilitator then recorded videos of the TM using video-otoscopy. Videos were remotely assessed by the same otologist and by a general practitioner twice; 4 and 8 weeks after the otologist’s on-site grading.Paper IV: Children with othalgia were followed with assessments of their symptoms and signs over a period of 3 months. An assessment group of two general practitioners and one otologist evaluated TM images, tympanograms and recorded symptoms and make a diagnose.Results The results from paper I show that image quality was good and the position and transparency of the TM was found to be the most important characteristics when assessing TM. In paper II the new grading scale (OMGRADE) was developed and validated. The image-based scale focuses on the position and transparency of the TM. The results from paper III showed that the OMGRADE scale could discriminate the normal ear as well as ears with otitis media with effusion (OME) in an unselected pediatric population. Paper IV showed that the bilateral AOM had more severe symptoms. The children with chagrinated TM’s took the longest time to resolve regarding TM appearance and tympanograms. Furthermore, symptoms resolved quicker than TM changes and tympanograms during the first week.Conclusions TM images or video recordings taken by a trained nurse or facilitator are sufficient for remote evaluation. The new grading scale of TM appearance is valid and reliable and may function as a diagnostic guide together with evaluation of middle ear effusion. TM appearance may be of importance in grading the severity of an AOM episode.
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| 5. |
- Lundqvist, Anette, 1963-
(författare)
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Nutritional aspects of behaviour and biology during pregnancy and postpartum
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundA well-balanced nutritious diet is important for the pregnant woman and the growing fetus, as well as for their future health. Poor nutrition results from both over-consumption of energy-rich foods which can lead to a higher weight gain than is healthy and under-nutrition of essential nutrients. Food intake is regulated in complex biological systems by many factors, where steroid hormone is one factor involved.The overall aim of this thesis is to describe dietary intake, vitamin D levels, dietary information and dietary changes, and to study the relation between allopregnanolone and weight gain during pregnancy and postpartum.Methods Study I was a qualitative study with focus group interviews with 23 pregnant women. The text was analysed with content analysis. Study II was a quantitative cross-sectional study conducted in early pregnancy (n=209) with a reference group (n=206). Self-reported dietary data from a questionnaire was analysed using descriptive comparative statistics and a cluster analysis model (Partial Least Squares modelling). Study III had a quantitative longitudinal design. Vitamin D concentrations were analysed in 184 women, collected on five occasions during pregnancy and postpartum. Descriptive comparative statistics and a linear mixed model were used. Study IV was a quantitative longitudinal study with 60 women. Concentrations of allopregnanolone were analysed in gestational week 12 and 35. Descriptive and comparative statistics as well as Spearman’s correlation (rho) were used to describe the relationship between weight gain and allopregnanolone concentrations. Results The focus group interviews showed that women wanted to know more about different foods to reduce any risk for their child but the information about foods was partly up to themselves to find out. They expressedfeelingsof insecurityand guiltif they accidentallyate something“forbidden”. The recommendationswere followedas best as possiblealong withcommon sense todeal with dietchanges. The main themes were “Finding out by oneself”, “Getting professional advice when health problems occur”, “Being uncertain” and “Being responsible with a pinch of salt”. Some differences in the dietary patterns were found among the pregnant women compared to references, with less, vegetables (47 g/day), potatoes/rice/pasta (31 g/day), meat/fish (24 g/day) and intake of alcohol and tobacco/snuff but a higher intake of supplements. Bothpregnant women and referenceshad intakes offolatethrough diet45% (pregnant) and 22% (references) lower than current recommendations(500vs400g/day). Vitamin Dintake was34% lower than the recommendationsof 10mg/day. At least a third of the participants had insufficient plasma levels below 50 nmol/L of vitamin D. Season was a strong factor influencing the longitudinal pattern. Gestational week, season, total energy intake, dietary intake of vitamin D, and multivitamin supplementation over the previous 14 days were factors related to vitamin D levels. A correlation betweenallopregnanoloneconcentrations ingestationalweek 35and weight gainin weeks12–35was seen (p = 0.016). Therewas alsoa correlation betweenthe increase inallopregnanolone(weeks12–35) andweight gain(see above) (p = 0.028). ConclusionsDietary recommendations were described as contradictory and confusing and the dietary advice felt inadequate. The women faced their diet changes and sought information on their own but would have wished for more extensive advice from the midwife. The intake of vitamins essential for pregnancy was lower than recommended, which is also confirmed by low plasma levels of vitamin D in at least one third of the pregnant women. Vitamin D levels peaked in late pregnancy. Aside from gestational week and season which were related to plasma levels, intake from foods and supplements also affected the levels. Reasons for weight gain are complex and depend on many factors. Allopregnanolone is a factor that was seen to relate to the weight gain of the studied pregnant women.
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| 6. |
- Made, Curt, 1941-
(författare)
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Alpine ski sport injuries in Swedish Lapland
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Downhill skiing is associated with recreation, youth, speed, aerials and crowded courses which carry increased risk of injuries. The aim of this study was to evaluate downhill sport injuries in a Swedish ski resort. Material and methodsIn a case-control study ongoing 1989/90–2006/07, 3,696 injured skiers were registered. After informed consent the injured were assessed by a physician and asked to answer a questionnaire concerning skier, skiing and injury. ResultsAfter three years 481 injured skiers (41% females, mean age 23) were assessed. The injury rate was 1.13/1,000 skier days. Knee injury was most common (28%), followed by head/neck (13%) and lower leg (11%). Fractures were less common (23%) than sprains (44%). Among skiers below the age of 20, fractures outnumbered sprains. Helmet usage was high among children (<10 years; 83%), but very rare in adults. The injured skiers rarely tested positive for alcohol (1.1%, uninjured 5.0%) and no effect on skiing or injury rates were registered.A one-year follow-up about the ski injury outcome shows that the mean sick leave was 40 days and that 29% still had symptoms.94 injured telemark skiers were assessed over 11 years (females 36%, mean age 28). The ankle was the most common injury location (28%), followed by knee injury (19%) and injuries of head/neck (17%). Beginners suffered most ankle injuries (37%). The use of high-shafted boots increased (24% to 67%), while injuries to the ankle/foot diminished from 35% to 22%.568 snowboard injured were studied over 10 years (females 34%, mean age 19). Snowboard riding increased strongly during the period (<5% to 26%). The injury rate was 3/1,000 skier days. Injuries were mostly located in the upper extremities (54%). Head/neck accounted for 17%. Wrist fracture was the most common diagnosis (20%). Beginners had a higher incidence of lower arm/wrist injuries while advanced riders had more head/neck injuries.1,833 injured alpine skiers were evaluated over 16 years (females 45%, mean age 24). The injury rate was the lowest of all downhill ski sports (1.1/1,000 skier days). The lower extremity was the most common injury location (51%), the knee being the most commonly injured body part. Knee injuries affected females (39%) more often than males (23%). Head/neck injury came second (12%). Lower leg injury was most frequent in children (<10 y; 32%). Sprains were more common (43%) than fractures (22%). Beginners took fewer risks, had more falls and were injured relatively often. Helmet usage increased (25% to 58%). Helmet users reduced their risk of head injury. The severity of injury (AIS 3–6) decreased (3,4% to 1,6%).The over all results (18 years) showed similar injury incidences to the separate studies but a few specific diagnoses, e.g. knee injuries showed variations. ConclusionThe injury rate was highest in snowboarding and lowest in alpine skiing. Knee injury, especially in females, was the most common injury, the upper extremity in snowboarding and the lower extremity in telemark skiing. Helmet usage increased rapidly. Helmets have a protective effect. Ski safety work should focus on risk groups. Lift owners need to take the responsibility for ski safety work.
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| 7. |
- Wennberg, Anna Lena, 1952-
(författare)
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Pregnant women and midwives are not in tune with each other about dietary counseling : studies in Swedish antenatal care
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background During pregnancy, a healthy diet is beneficial for the expecting mother and her fetus. Midwives in antenatal care have an ideal position for promoting a healthy diet and thereby help women to not only lower the risks of pregnancy complications and adverse birth outcomes, but improve maternal health. The overall aim of this thesis was to describe diet and dietary changes during pregnancy from the women’s and the midwives’ perspectives with a focus on dietary counseling. The thesis comprises four studies. The specific aims in the respective studies were to: I) Describe pregnant women’s attitudes to and experiences of dietary information and advice, as well as dietary management during pregnancy. II) Explore midwives’ strategies in challenging dietary counseling situations. III) Describe how midwives’ perceive their role and their significance in dietary counseling of pregnant women. IV) Describe women’s food habits during pregnancy and up to six months postpartum.Methods Studies I-III were qualitative. Study I included focus group interviews with 23 pregnant women. Study II included telephone interviews with 17 experienced midwives working in Swedish antenatal health care. Study III included the same 17 interviews from study II and supplemented them with four face-to-face-interviews. Qualitative content analysis was performed in all three studies. Study IV was a longitudinal study including a quantitative analysis of a questionnaire, which was given to women at five occasions during and after pregnancy. It concerned their food habits and it was answered by 163 women. The quantitative data was analyzed using comparative and descriptive statistics.Results The overall findings of the thesis were summarized as the main theme “Pregnant women and midwives are not in tune with each other about dietary counseling”. The main theme included the two themes ‘Pregnant women are concerned about risks for their child but fail to change to healthier dietary habits over time’, and ‘Midwives view themselves as authorities, though questioned ones’. In subthemes it was highlighted that pregnant women are well informed and interested in risk reduction for their child’s best and that they try to do their best to improve their diet during pregnancy. However, their diet did not reach levels of healthy eating recommendations and became even unhealthier after pregnancy. It was also highlighted that midwives experienced insufficient knowledge in dietary issues and related risks and that they had difficulties to give dietary support to pregnant women. Midwives were found to mainly focus on giving information and they lacked sufficient competence for challenging counseling.Conclusion Pregnant women, on the one hand, experience a lack of support from the midwives when dealing with dietary changes. The midwives, on the other hand, feel exposed and express a need for both further education in dietary issues and training in counseling. Women’s food habits during, but in particular after pregnancy need improvement, and dietary counseling could be more focused on healthy eating in a long-term perspective.
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