| 1. |
- Sjögren, Harmeet, 1954-
(författare)
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Injuries among the elderly : study of fatal and non-fatal injury events
- 1994
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In view of the expected increase in the proportion of elderly in the population in most western countries, we studied injuries among the elderly (>60 years) by investigating hospital-treated injuries in inpatients and outpatients, and fatal injuries.One-year Hospital Injury Data - Even though the elderly made up only 15% of the injured in one year, they accounted for 42% of the total cost of trauma medical care, showing that injuries among the elderly place a disproportional burden on the health care system. The mean medical care cost increased significantly from the age of 60 years. Serious injuries (MAIS>3) in the elderly cost almost 2.5 times more than those in the younger group (<60 years).Study of 1,313 injury events in 1,268 elderly showed annual injury, fracture, and mortality rates per 1,000 elderly population of 57, 31, and 0.6, respectively. Almost half were injured in the home environment, and 23% in the traffic environment. Most of the severe and critical injuries (MAIS>4) occurred in the traffic environment. Injury rate, severity of injuries, fractures, and the duration of hospitalization increased with age. Almost half of the injuries were fractures; most common were wrist and hip fractures. Women had a higher injury rate, more severe injuries, and longer duration in hospitalization than men had.Study of 621 injury events in 600 elderly injured in the home environment, showed annual injury and fracture rates of 30 and 15 per 1,000 elderly home population, respectively. Injuries were grouped into fall injuries (76%) and non-fall injuries (24%). The fall injury incidence was higher in women than in men. Most falls occurred indoors. Environmental factors played a role in half of the fall injuries, and intrinsic factors in at least one fifth. Intrinsic factors in falls became increasingly important with advancing age. Non-fall injuries were mostly sustained in woodworking. Fall injuries were of a greater severity and accounted for 80% of the cost of medical care of elderly in the home environment.Study of 298 injury events in 297 elderly injured in the traffic environment, showed that pedestrian falls accounted for 52% of the injuries, and vehicle-related events for 44%. The main groups in the vehicle-related injury category were bicyclists (48%), car occupants (34%), and pedestrians (4%). Two thirds of the pedestrian falls involved slipping on ice/snow. Ice/snow-related injuries (all categories) accounted for 37% of the total cost of all injuries in the elderly in the traffic environment. Vehicle-related crashes resulted in the most severe and critical injuries and the most fatalities, and cost (total and mean) more than pedestrian falls.Fatal Injury Data from Northern Sweden - Study of 379 elderly injured in the traffic environment in a ten-year period, showed that the car occupants (43%) made up the largest category followed by pedestrians (28%), bicyclists (15%), and two-wheel-motor-vehicle riders (8%), but the risk of fatal injury per unit distance travelled was highest for pedestrians and bicyclists. Males had double the death rate as females. Most car occupants were killed in multivehicle crashes, mostly in the daylight, and at intersections. Ice/snow was the major (31%) precrash factor. One quarter of pedestrians were injured at pedestrian crossings, and half of them during darkness. One in six pedestrians was under the influence of alcohol. All pedestrians and bicyclists were injured in collisions with motor vehicles and most were injured at intersections. Pedestrians and bicyclists had more serious head injuries than chest injuries.Study of 514 car drivers (>18 years) injured in a 13-year-period, showed that fatalities per unit distance, and per licensed driver were highest for the >70-year-old and 18-19-year-old drivers. Elderly (>60 year old) and <25 year old drivers had similar fatality frequencies. The older drivers (>60 years) initiated the crash more often than younger (<60 years) ones. Fatal head injuries decreased whilst chest injuries increased with age. The older drivers were more likely to die from post-trauma complications than younger ones.In a study of role of disease in 480 fatally injured drivers (>18 years) who died within three days of the crash, a grading system was developed to assess the probability of contribution of medical intrinsic factors (MIF) to the crash. Almost one quarter of the drivers were found to have MIF. Drivers with MIF were more often at fault than those without. Medical intrinsic factors were probably an underlying cause in 1 of 17 fatal crashes in all ages, and 1 of 5 fatal crashes in the elderly; in 4% of the elderly the probability was strong.A "passive automatic" approach which does not require any action on the part of the elderly, is to be recommended when improving safety in the home and in the traffic environments. The elderly drivers can be regarded as the "miner's canary" to indicate which passive safety improvements are needed in the traffic environment. In view of the expected population trends, it is important that authorities and public health workers accept the challenge to continue and intensify the injury preventive work for the elderly.
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| 2. |
- Blind, Per Jonas, 1947-
(författare)
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Carboxylic ester hydrolase in acute pancreatitis : a clinical and experimental study
- 1994
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Diagnosis of acute pancreatitis (AP) is erroneous in up to one third of patients when based on clinical criteria and elevated serum amylase values. Furthermore, according to autopsy reports fatal pancreatitis remains clinically undiagnosed in 22 to 86 % of hospitalised patients. Consequently, search for better methods for the diagnosis of AP seems not only justified but urgent. The pancreas secretes an nonspecific lipase, the carboxylic ester hydrolase (CEH) with molecular properties different from other pancreatic secretory enzymes. These differences may imply that sites and rates of clearances from blood of pancreatic enzymes differ. Except for the pancreas this enzyme is secreted from the lactating mammary gland with milk.A sensitive and reproducible sandwich-ELISA for quantitative determination of CEH was developed. When establishing referent values it was noted that in individuals aged 20 to 65 years serum concentrations of CEH did not depend on age, gender, the time of the day or duration from food intake to blood sampling, or use of nicotine. The mammary gland did not contribute significantly to basal serum levels of CEH; enzyme levels in lactating women or women with mammary tumours were identical to those of the reference population.Seventy percent of patients with the diagnosis AP, based on elevated serum amylase levels and abdominal pain, had elevated CEH values. Among the patients with elevated amylase alone a probable cause of pancreatitis was lacking in the majority of patients. Contrastingly, a likely cause of AP could be identified in all patients presenting with abdominal pain and elevated CEH levels alone. These findings suggested that an elevated CEH level indicated AP more reliably than an elevated amylase level.In patients with AP diagnosed by contrast enhanced computed tomography (CECT) alone, or combined with histopathological diagnosis, serum CEH levels were elevated on admission in all but one patient, and in all within the next 24 h. Furthermore, in patients with severe pancreatitis CEH levels remained at a raised level from the second to at least the 10:th day following admission, whereas a significant decrease was noted in patients with mild pancreatitis. In contrast, serum amylase values were higher in patients with mild pancreatitis during the observation period than in those with severe pancreatitis. CEH levels were higher in patients with three or more Ranson signs than in those with less than three signs from the first day after admission. CEH levels were within referent range in 164 patients without known pancreatic disease admitted due to abdominal emergency conditions, or due to planned surgery for chronic extrapancreatic gastrointestinal diseases, and 16 patients having CECT without pathological findings in the pancreas. This suggests that AP can be excluded with very high degree of probability in presence of non-elevated CEH levels.A sandwich ELISA for determination of Guinea pig CEH and a model for graded pancreatitis in the same species were developed. CEH levels showed proportional to severity of inflammation, thus confirming previous clinical observations. CEH levels in bile were proportional to inflammation, while it was absent in urine. Amylase levels in urine were identical regardless of severity of inflammation, but low in bile. These results suggested differences in sites and rates of clearance between the two enzymes.Seemingly elevated CEH levels allowed identification of clinically significant pancreatitis following ERCP, which amylase levels did not.The presented studies have shown that quantitative determination in serum of CEH by the described method is a more reliable test for the diagnosis of AP than determination of amylase activity. The differences between CEH and amylase are, at least partly, due to differences in molecular properties determining rates and routes of clearances of the two enzymes from serum.
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| 4. |
- Andræ, Margareta, 1943-
(författare)
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Facing death : physicians' difficulties and coping strategies in cancer care
- 1994
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Even if the treatment of cancer has developed over the last decades 50% of the patients still die of their cancer. The doctor's way of dealing with his and his patient's anxiety must surely be of significance for the treatment the patient receives.In the first part of the thesis earlier studies of physicians' stress and ways of coping are reported. There is a lack of systematic studies which show how doctors working with cancer patients adjust to this work. The aim of this investigation is to study cancer doctors' difficulties and coping strategies. The theoretical frame of the study embraces parts of psychoanalytical theory and coping models, emphasizing that both unconscious and conscious psychological processes play their part in the coping process.The second, empirical part of the study includes 23 physicians strategically selected out of a population of physicians who work with institutional care and who have daily contact with adult cancer patients. The main method of data collection has been a series of recorded interviews. The focus of the interview was the physician's perception of how he reacts, thinks, talks and acts in different phases of the cancer disease. To illustrate the defence strategies of the interviewers, the projective percept-genetic test, the "Defence Mechanism Test" (DMT) is used. The "Structural Analysis of Social Behaviour" (SASB) has been used to study the doctors' self image.The results indicate that the stated difficulties deeply affect the doctor as a human being. The statements reflect conflicting feelings and wishes in relation to authority, conflicting feelings and wishes in relation to frightening and injuring, conflicting feelings and wishes in relation to intimacy/distance. Thirty themes of coping strategies frequently recur and they have been grouped into seven categories. Most of the doctors "seek knowledge" and support from scientific literature. The majority of them state that attempting to "solve a problem" is their main strategy. Most of the doctors "seek support " as a part of their coping strategy. An interesting observation is that the doctors to a higher extent "seek a relation" to their patients rather than to their colleagues. Almost one third use "denial of the severity of a situation" as their main strategy. All the doctors consciously or unconsciously use "diverting strategies", i.e. undertake tasks which are devoid of contact with patients, such as research and administration or other activities which allow them to avoid the patient. One third use "projective manoeuvres" but this is never a main strategy.In the third part of the study the credibility of the results and their pedagogical and practical implications are discussed.
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| 5. |
- Wikman, Marianne, 1941-
(författare)
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To desire and to choose : aspects of women's and men's urge to have children
- 1994
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this study was to increase available knowledge about women's and men’s desire for pregnancy and for a child/children to serve as a basis for further studies of problems and inconsistencies in the reproductive sphere. The motivation to become a parent was hypothesized as being not only of an existential, social, interpersonal and intrapsychic character but also a biologically anchored personality trait.The first part of the study deals with the development of a method for collecting valid information concerning this intimate and personal sphere of life and to categorize this information into measurable dimensions. A questionnaire was constructed and factor analysis was used as a statistical tool. There are two versions of the final instrument, one for women and one for men. Interviews were used as a means of testing the validity of the instrument. Experiences from the methodological development process revealed that it was meaningful to deal with the issue though suitable wording was not easily found.In the main part of the study, two large populations, one reference group of 416 women and 329 men of fertile ages and one group of expecting parents, 369 women and 345 men, were investigated by means of the questionnaire. Attitudes were dominated by two opposing views of children: 'Children mean existential satisfaction' and 'Children mean restriction of freedom'. This confirmed the findings of earlier studies and clinical experience that ambivalence is a natural phenomenon, that may be associated with feelings of guilt. The view of one's own parents as models in parenthood was a third important dimension. The view of the child's sex was a fourth important and complex dimension.The similarities between women and men were striking. There were only subtle differences between reference women and pregnant women. Reference men and child-expecting men had different response patterns, child-expecting men emphasizing more the advantages of having children.In the last part of the study 48 women were followed during pregnancy and after childbirth using the questionnaire and determination of levels of the intestinal peptide gastrin. Gastrin may be a marker of energy-storing characteristics, thus influencing reproductive capacity. There were some attitudinal differences between 0-parous women and parous women, the latter agreeing less with the view of 'children as restriction of freedom'. The view of 'children as existential satisfaction' was agreed with more after childbirth than during pregnancy. The view of one’s own parents as models in parenthood correlated with the levels of gastrin during this period.
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| 7. |
- Näsman, Birgitta, 1937-
(författare)
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The limbic-hypothalamic-pituitary-adrenal axis in Alzheimer's disease
- 1994
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Dysfunction of the limbic-hypothalamic-pituitary-adrenal (LHPA) axis is a common finding in advanced dementia. In this study, the function of the LHPA axis at different levels was investigated in patients with dementia and in healthy elderly.A subtle disturbance in the feedback regulation of the LHPA axis was found in patients with early (i.e., mild to moderate) Alzheimer’s disease (AD). After 0.5 mg dexamethasone, serum cortisol levels were less suppressed in AD patients and plasma adrenocorticotropin (ACTH) levels were lower as compared with healthy elderly. After stimulation with human corticotropin-releasing hormone a blunted ACTH response was found in AD patients while relative serum cortisol, dehydroepiandrosterone, and androstenedione responses were increased. Significant correlations were found between low plasma ACTH levels and temporal lobe atrophy and between low peak plasma ACTH levels and hippocampal atrophy measured with computer tomography. Patients with advanced AD and multi-infarct dementia had lower basal levels of dehydroepiandrosterone sulphate in combination with no difference in cortisol levels, resulting in a high cortisol/DHAS ratio. The difference persisted after adjustments for age and sex in a multivariate analysis. In patients with early AD, basal serum levels of dehydroepiandrosterone and androstenedione were increased, and this increase was accentuated after stimulation with ACTH. Peripheral glucocorticoid sensitivity was examined by skin vasoconstrictor blanching tests. Patients with AD and patients treated with glucocorticoids showed skin blanching at higher clobetasol concentrations than healthy elderly.These findings justify further investigations on the role of LHPA axis dysfunction in Alzheimer’s disease and its possible importance for the pathophysiology of the disease.
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| 8. |
- Söderberg, Stefan, et al.
(författare)
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Prevalence of HIV-1 infection in rural, semi-urban and urban villages in southwest Tanzania : estimates from a blood-donor study.
- 1994
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Ingår i: AIDS. - 0269-9370 .- 1473-5571. ; 8:7, s. 971-976
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: To measure the prevalence of HIV-1 infection in different subgroups of blood donors and to identify groups at high risk of acquiring HIV-1.METHODS: Between March 1988 and April 1991 all blood donors at Ilembula Lutheran Hospital, Tanzania were asked about their age, marital status, home village and occupation, and tested for the presence of HIV antibodies using a first generation, whole virus lysate enzyme-linked immunosorbent assay (ELISA). Some negative (n = 265) and nearly all positive samples (439 out of 485) were subjected to confirmatory testing including recombinant and peptide-based ELISA and Western blot assays.RESULTS: A total of 3474 male and 1287 female blood donors were studied. The overall HIV-1 prevalences for men and women were 6.6 and 7.0%, respectively, with a higher prevalence in urban villages (13.6 and 15.0%, respectively), an intermediate prevalence in semi-urban villages (7.2 and 7.9%, respectively), and a lower prevalence in rural villages (3.7 and 3.0%, respectively). HIV-1 infection occurred mostly in men aged 20-44 and women aged 15-34 years. Urban donors, but not semi-urban and rural donors from the highlands, had a higher HIV-1 prevalence (21.4%) than the corresponding group from the lowlands (10.2%). Apart from area of residence, HIV-1 infection was found to be associated with occupation and marital status. There was an increase in HIV-1 prevalence, although not statistically significant, during the period studied. None of the blood donors were positive for HIV-2.CONCLUSIONS: Male and female donors from urban and semi-urban villages, non-farmers from urban villages, and unmarried donors were identified as high-risk groups, which is consistent with more extensive risk behaviour in urban communities. In addition to using an HIV test with high sensitivity, the importance of pre-donation selection of blood donors is stressed.
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| 9. |
- Bodlund, Owe, et al.
(författare)
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Axis V--Global Assessment of Functioning Scale. Evaluation of a self-report version
- 1994
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Ingår i: Acta Psychiatr Scand. - : Wiley. - 0001-690X .- 0001-690X .- 1600-0447. ; 90:5
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Tidskriftsartikel (refereegranskat)abstract
- The present study examines a self-report version of the Global Assessment of Functioning Scale according to Axis V (GAF self-report). The sample (n = 73) was a psychiatric outpatient population from a catchment area clinic. Patients with psychotic and organic mental disorders were not included. The diagnostic distribution on Axis I was similar to the findings from previous studies. Axis II disorders were identified among 47%, of whom a majority also had a concomitant Axis I disorder. The mean GAF expert score was 66.5 (range: 48-86). High complexity and severity of disorders and a high number of fulfilled Axis II criteria were significantly associated with low GAF scores. Independent expert ratings on GAF were correlated with the GAF self-report overall at r = 0.62, varying from 0.45 to 0.91 between different diagnostic groups. In general, the patients scored themselves lower (mean: -4.4 units) than expert ratings. Patients with depressive symptoms from an adjustment disorder or mood disorder were most prone to underestimation. Women also tended to score themselves lower than experts did. Conclusively, the GAF self-report turned out to be a valid and reliable unidimensional instrument measuring psychological, social and occupational functioning. The GAF is easy to handle, and with a self-report version as a complement, Axis V could be more frequently used in future clinical practice and research.
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| 10. |
- Bodlund, Owe, 1949-
(författare)
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Transsexualism and personality : methodological and clinical studies on gender identity disorders
- 1994
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Patients suffering from transsexualism (TS) who apply for sex reassignment surgery (SRS) go through a complex evaluation process before being accepted for treatment. In general, the results from SRS are satisfying. However, further knowledge is needed to clearly delineate transsexualism from other related gender identity disorders (GID) and to improve the selection of candidates for SRS. Personality has for a long time been considered as the key concept for that purpose but systematic studies using reliable instruments are lacking. The present study aims at improving the assessment procedure, validating the concept of transsexualism and studying the outcome of SRS and important prognostic factors.Two methodological studies deal with the development and validation of two self-report instruments based on DSM-III-R: SCID screen covering Axis II personality disorders/traits and Global Assessment of Functioning (GAF-scale, Axis V). SCID screen diagnoses of personality disorders (PD) were compared with diagnoses from independent structured interviews by means of the SCID-II. The overall kappa in identifying a PD was 0.78 varying from 0.34 to 0.81 for the specific PDs when cut-off was adjusted. When applied to a group of GID-patients SCID screen diagnoses agreed well with clinical diagnoses (kappa 0.77). Self-report of the GAF also proved to be a reliable (overall Pearson r=0.62) and useful method and the study lends further support to the validity of Axis V.In three papers a group of 19 transsexuals was studied by means of a) SCID screen to examine their personality in a dimensional and traditional categorical way, b) the GAF-scale to study psychosocial functioning, c) Structural Analysis of Social Behavior (SASB) to examine self-image and d) Defense Mechanism Test (DMT) to analyze psychological defense structures from a psychodynamic perspective. Patients with atypical gender identity disorders (GIDAANT) and patients with borderline personality disorders as well as healthy subjects were used as contrast groups. Among the transsexuals 10 out of 19 had an additional axis I disorder and 37% had at least one PD, predominantly within cluster B. When analyzed dimensionally according to SCID screen, frequent subthreshold personality pathology was found and biological women fulfilled more axis II criteria than men. TS had less axis I and II pathology compared with GIDAANT and psychiatric patients. According to SASB, TS had a positive self-image with both self-control and spontaneous self and predominating self-love. They appeared significantly more healthy on self-image measures than GIDAANT patients. The DMT revealed a different pattern; TS patients were more disturbed in several areas than patients with borderline personality disorder. TS showed no ”emotional investment” and poorer reality orientation in contrast to both healthy controls and the borderline group but shared a similar pregenital pathology with the borderline patients.Finally, five-year outcome was studied among the transsexuals from a multidimensional approach (e.g. work, interpersonal relations, partnership, subjective opinion) and related to index- measurements on DSM-III-R, SCID screen, GAF, SASB and DMT. Based on combined outcome variables, 68% of the subjects were judged to have improved and 16% had an unsatisfactory outcome. One single case regretted the sex change. SCID screen pathology and SASB disturbances emerged as significant predictors for negative outcome, as well as male biological sex and lack of partnership. It was concluded, that although outcome is in general very favorable, the instruments under investigation, in particular SCID screen and SASB, revealed valuable prognostic information and they are suggested to become part of the future routine assessment of candidates for SRS.
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