| 1. |
- Liffner, Susanne, 1974-
(författare)
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Infertility in Men in Relation to Their Birth Characteristics
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: About 10-15 % of couples worldwide suffer from infertility, the inability to achieve a pregnancy after more than 12 months of unprotected intercourse. Causes can be related to female factors, male factors, or both. In about 20 % of the couples, the cause remains unexplained. Male factor infertility is based on semen sample evaluation and is defined as poor semen quantity or quality, preferably in two or more samples. When assisted reproductive technology (ART) is considered for a couple with male factor infertility, intra-cytoplasmic sperm injection (ICSI) where the sperm is injected into the oocyte, is often needed to achieve embryo development.Men born small for gestational age (SGA), with low birth weight (LBW, £2,5000g) and/or prematurely (before the 37th gestational week) do not become fathers as often as men born with appropriate size for gestational age (AGA) at term. The aims of the present thesis were to investigate if this lower likelihood to become a father for men born SGA, preterm, or with low birth weight could be related to an increased risk of male factor infertility, if ICSI and sperm donation more often were needed and if the chance of conceiving by ART was lower than in men born AGA. An additional aim was to investigate if sperm DNA damage was more common in men born SGA compared with men born with normal size for gestational age.Material and Methods: Paper I and II were based on retrospective case control studies on men becoming fathers by ART in study I, and infertile men, patients at the Centre of Reproductive Medicine, University Hospital, Linköping, Sweden (RMC), in study II. Paper III was based on a cohort study on all men born in Sweden between 1973 and 1993. All three studies used data from national registers held by the National Board of Health and Welfare and Statistics Sweden. Study III also used information from the Swedish National Quality Register of Assisted Reproduction.Paper IV was based on a case series study of sperm DNA fragmentation in infertile patients and sperm donors at RMC, where two different methods of measuring sperm DNA fragmentation were compared, Halosperm® (easier to perform) and Sperm Chromatin Structure Assay (reference method). Paper V was based on a cohort study of men undergoing ART at RMC. The proportion of sperm with DNA fragmentation was compared between men born SGA and men born AGA.Results and conclusions: Men becoming fathers after ART were more often born with low birth weight than men conceiving naturally. Men becoming fathers after ICSI, presuming a poor semen sample, were more often born SGA than men conceiving by conventional IVF, or conceiving without treatment. ICSI had to be performed in 63% of men born SGA but only in 45% of men born AGA. Men with male factor infertility were more often born SGA or with LBW than men with female factor infertility, or when the infertility was unexplained. The results after ART were not affected by birth weight or size at birth.The likelihood of becoming a father was lower for men born SGA or with LBW compared with men born with normal birth weight. These men were also more often single (never married or with a registered partner) and had a higher risk of being born with undescended testicles, which increases the risk of infertility. Men born SGA more often needed ICSI or sperm donation.The two different methods to analyse sperm DNA fragmentation had high correlation and agreement, and Halosperm® could be considered a reliable and more easily handled method in the clinical setting. The median proportion of sperm with DNA fragmentation were higher for men born SGA (16.6%) compared with men born AGA (6.4%). The result was not statistically significant as the absolute number of men born SGA was much smaller than expected in this sample of 550 men. Larger studies are needed to confirm the hypothesis that DNA fragmentation contributes to a lower likelihood to become a father in men born SGA.
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| 2. |
- Vikström Eckevall, Josefin, 1984-
(författare)
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The influence of infertility and in vitro fertilization treatment on postpartum and long-term mental health in women
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: It is estimated that about 10-15% of couples suffer from infertility, i.e. the inability to achieve a clinical pregnancy after at least one year of regular, unprotected intercourse and that between 2-5% of births are a result of in vitro fertilization (IVF) treatment. Infertility and its treatment can have adverse effects on psychological well-being. While previous studies on postpartum depression (PPD) in IVF women suffer some methodological issues, there are no published studies on the risk of postpartum psychosis (PPP) after IVF pregnancies. Long-term, most women adjust well emotionally after IVF treatment but some, especially the childless, still suffer negative consequences. Meanwhile, few studies have extended beyond the first decade after treatment. Some studies have found that the childless elderly have social networks of less support potential but most show that psychological well-being is not affected by parental status. None of the studies have focused on the oldest old (≥85 years) and many have excluded those who live in institutional care, thus the frailest.Objective: The overall aim of this thesis was to study postpartum mental health in women who have undergone IVF treatment, using psychiatric diagnoses as outcomes, while controlling for major PPD and PPP risk factors as well as to determine the influences of childlessness, infertility and IVF treatment on long-term mental health in women. Materials and methods: Studies I-II are register-based, case control studies of 3532 (I) and 10,412 (II) primiparous women included in the Swedish IVF register. A control group of 8,553 (I) and 18,624 (II) primiparous women with spontaneous conceptions was selected from the Medical Birth Register. The main outcomes were PPD and PPP diagnoses the 1st year postpartum collected from the National Patient Register. Studies III-IV are cross-sectional. Study III included 470 women who had undergone IVF treatment 20-23 years previously. The Symptom Checklist-90 was used to investigate self-reported mental health. The results were compared with those from a population-based study and by parental status group. Study IV included 496 85-year olds. Psychological well-being, living situation, demographics and social network was investigated through a questionnaire and an interview.Results: Study I-II: There were no differences between the IVF and control group in the risk of receiving a PPD or PPP diagnosis. Having previously been diagnosed with any psychiatric, an affective or personality disorder increased the risk of PPD while any previous psychiatric, psychotic, bipolar, depressive, anxiety or personality disorder diagnosis increased the risk of PPP. None of the women had committed suicide. Study III: The IVF women reported symptoms of higher intensity and were at increased risk of symptoms of depression, obsessive-compulsion and somatisation compared with the reference group. Childless women, compared with parents, reported a higher level of mental health problems as well as symptoms of depression and phobic anxiety. Study IV: No differences in psychological wellbeing, living situation or having friends close by were found across parental status groups. The childless 85-year olds were less likely to have relatives close by and to receive help.Discussion: This thesis indicates that the risk of receiving a PPD or PPP diagnosis from in- or outpatient psychiatric care or of committing suicide during the first year postpartum is not increased in women who have undergone IVF treatment. Any negative effects of infertility and its treatment might have been mitigated by the “healthy patient effect”; those who choose to enter treatment are generally psychologically robust. A history of mental illness is a major risk factor for PPD and PPP. The risk of some adverse symptoms of mental illness might be increased in women who have undergone IVF treatment twenty years previously, especially in those who have remained childless. The childless elderly appear to have social networks of less support potential but are not more likely to live in institutional care and do not experience more adverse effects on psychological well-being than the elderly who are parents.
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| 3. |
- Crafoord, Kristina, 1950-
(författare)
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Genital prolapse surgery : A study of methods, clinical outcome and impact of pelvic floor muscle function
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objective: To evaluate whether a shift in the extent of genital prolapse surgery occurred between 1983 and 1993. If such a shift occurred, the need for subsequent prolapse surgery; the prevalence of symptoms of pelvic floor dysfunction (PFD) in women six years after vaginal prolapse surgery. And also to analyze predictive factors and the subjective and objective outcomes of prolapse surgery at long term follow up. To evaluate whether neurophysiologic findings of the pelvic floor muscles and anorectal manometry measurements respectively are associated with pre- and postoperative symptoms and the extent of prolapse.Methods/material: A retrospective study of 542 consecutive patients, operated on for genital prolapse, with primary surgery during 1983 and 1993 in three Swedish hospitals was conducted. Data were obtained from the patient records and were analyzed with emphasis on demographic, clinical and surgical data. A postal questionnaire with validated questions concerning symptoms of PFD was in 1999 sent to women operated in 1993 for primary POP and no subsequent POP surgery.A prospective study of 42 women with genital prolapse, stage 2-3, scheduled for vaginal prolapse surgery was carried out. Preoperatively the women were examined with anorectal manometry, pudendal nerve neurography and concentric needle electromyography of the pubococcygeus muscles and the external anal sphincter muscle. Posterior colporrhaphy was part of the prolapse surgery in all women. Anatomical and subjective outcomes were evaluated six years postoperatively.Results: A shift from complete to selective repairs was seen between the two time periods, and posterior repair was often omitted in the latter period. The prevalence of subsequent prolapse surgery increased in the 1990s and the increase was more common in women with a selective repair than in those with complete repair. At long term, PFD-symptoms commonly occurred and were found to be associated with the extent of the prolapse surgery. Symptoms of prolapse and bowel emptying improved significantly after POP surgery in the prospective study. The cure rates of rectocele and apical descent were high, but low concerning cystocele. The results of the neurophysiologic investigations and anal sphincter pressures showed associations with the symptoms and the extent of the prolapse; the individual characteristics showed no discriminatory values.Conclusion: The extent of the surgical prolapse procedures changed between the two study periods and the extent of subsequent surgery also was greater in the second period. Symptoms of PFD and recurrence of prolapse, especially of the anterior compartment, were frequently seen. Prolapse and bowel symptoms were associated with the function of pelvic floor muscles but neither the results of the neurophysiologic nor the anorectal manometry measurements of the pelvic floor muscles were found to predict anatomical or subjective outcomes of POP surgery. More knowledge is needed of the pathophysiology of PFD in order to develop better means of prevention and to optimize treatment of POP. Development of new methods for identifying all defects of the pelvic floor and surgical techniques for restitution is also warranted for improving outcome of surgical treatment of genital prolapse.
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| 4. |
- Kempe, Per
(författare)
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Multiple Sclerosis in relation to sex steroid exposure
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Multiple sclerosis (MS) is a potentially severe chronic inflammatory disease of the central nervous system (CNS) and is usually diagnosed between 20 and 40 years of age. The incidence of MS is two to three times higher among women and the type and course of the disease often differ between the sexes. Sex steroids, especially estrogens, have been shown to influence the immunopathology involved in MS and the mouse model experimental allergic encephalomyelitis (EAE), as well as radiological and clinical signs of the disease. The ovarian cycle and hormonal contraception result in fluctuations in sex steroid concentrations that could possibly affect MS. The incidence of MS in women is highest at an age when a reliable contraceptive method is an important matter but the effects of estrogen-containing combined hormonal contraceptives (CHC) on MS have not been thoroughly studied. The general aim of the research for this thesis was to investigate how fluctuations in sex steroid exposure during the menstrual cycle and use of CHC affect MS in a clinical context.Paper I is based on female MS patients with or without hormonal contraception. Symptoms were reported prospectively in an MS-symptom diary. In contrast with results from previous retrospective studies, 16 women without hormonal contraception reported fewer complaints regarding one out of 13 symptoms during the low estrogen/progesterone phase of the menstrual cycle. Seven women who used CHC experienced three of the symptoms significantly more strongly during the low estrogen/progestogen, pill-free period. In paper II 22 women with MS who used CHC reported higher scores for four out of 10 symptoms during the “pill-free” week, i.e. during the low-estrogen/progestogen phase using a modified symptom diary. Women with MS who did not use hormonal contraception reported no differences in symptom scores between high and low estrogen/progesterone phases. Paper III included 770 women who answered a questionnaire that was designed to investigate whether longer periods of high estrogen concentration such as CHC-use and pregnancies delay the onset of MS. The mean age at MS onset was significantly higher among women who had been using COC before their first MS symptom (26 vs 19 years, p<0.001) and the longer the women had been using COC the higher the mean age at MS onset. The number of children born before the first symptom of MS was positively correlated with age at MS onset (r=0.6; p<0.001). Paper IV aimed to investigate if peripheral blood levels of cytokines, chemokines, and transcription factors for different T helper (Th) cell subsets change in relation to high and low estrogen/progestogen states in women with MS and healthy controls with and without CHC using multiplex bead technology and qPCR. Expression of the B cell-associated chemokine CXCL13 was generally higher in high the estrogen/progestogen phase than in the low estrogen/progestogen phase and the expression of the transcription factors showed a general activation of peripheral blood T cells during high estrogen and progestogen phases in women with MS as well as in healthy women.The clinical implication of these and other studies is that there is probably no reason for avoiding CHC as a contraceptive method in women with MS. It is also probably beneficial for women with MS to use CHC regimens with longer estrogen periods and fewer pill-free intervals. Future studies should investigate the outcomes of such regimens on relapse rate, MRI lesions, disease activity related cytokines and chemokines in CSF and peripheral blood and the women’s experiences of their symptoms.
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| 5. |
- Lindh Falk, Annika, 1967-
(författare)
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Interprofessional Collaboration in Health Care : Education and Practice
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Interprofessional collaboration is of global interest for addressing to the complex health care needs and improving patient safety in health care. Professionals have to develop collaborative skills and the ability to share knowledge. Interprofessional education describes learning activities where students learn with, from and about each other to improve collaboration. The dimension of interprofessional collaboration is complex and includes different collaborative competencies to bring about the best for the patients. To become a professional, often understood as someone exerting expertise within a specific field of practice, involves a learning process that challenges the boundaries of the professions. Boundaries are not only barriers, but also places that increase learning. There is a complexity to studying the phenomenon of interprofessional collaboration and learning regarding how it occurs in education and health care practice. By using a sociomaterial perspective on practice, it is possible to more robustly explore the collaborative context.Aim: The overarching aim of the thesis has been to explore interprofessional collaboration and learning in health care education and in interprofessional health care practice. More specifically, the research questions in the thesis were answered in two studies regarding how professional knowledge is developed and shared in interprofessional undergraduate health care education and in interprofessional health care practice.Methods: A questionnaire was distributed to students from a medicine, nursing, physiotherapy and occupational therapy programme who participated in a two-week period of practice at an Interprofessional Training Ward in Linköping. The data was analysed quantitatively to explore how female and male students experienced their professional identity formation. The open-ended responses were analysed using a sociomaterial perspective on practice.An ethnographic study was conducted in a hospital setting during a period of one year, during which two interprofessional teams were observed. A theory-driven analysis was made using a sociomaterial perspective on practice, and this provided a lens through which the nature of interprofessional collaboration and knowledge sharing could be observed.Findings: The main findings from the questionnaire showed that the practice architectures of the Interprofessional Training Ward, prefigured practices where different professional responsibilities were enacted in ways that were reproducing expected and unexpected roles in a traditional health care practice. That disrupted the students´ practical and general understandings of professional responsibilities and the nature of professional work including their professional identity formation.The findings from the ethnographic study showed different patterns of how knowledge was shared among professionals in their daily work practice as it unfolded, like chains of actions. The patterns arose through activities where collaboration between professionals was planned beforehand, and at other times it arose in more spontaneous or responsive ways. Due to the way the activities were arranged, the nursing assistants were totally or partially excluded from the collaborative practices.Conclusions: The way that educational and health care practices were arranged had an influence on the patterns of interactions between the students as well as the professionals. The arrangement at the Interprofessional Training Ward enabled and constrained the possibilities for students to learn professional and interprofessional competencies. Professional practices in health care hung together through chains of actions that influenced interprofessional collaboration and learning. The relations between human actors, material objects and artifacts are of importance for understanding interprofessional practices.
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| 6. |
- Malmborg, Agota, 1979-
(författare)
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Happy with the method? : Sexual function changes in young women using contraception
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Sexuality and contraception are closely linked topics. In theory, hormonal contraception use might affect female sexual function in both positive and negative directions. Some women experience and report adverse sexual function changes while they use hormonal contraception while others report no or positive changes. Questions of causality, the potential mechanisms of action, and how to counsel women reporting adverse changes have been a matter of debate but scientific consensus is lacking on the answers.Material and Methods: The first study was a cross-sectional study with 1851 women, aged 22, 25 and 28 years, who answered a questionnaire regarding contraception use, positive and negative side effects, contraceptive counselling, and aspects of sexual function. The second study was a randomised double-blind placebo-controlled multicentre clinical trial. In this study we compared 102 women who used a combined oral contraceptive with 100 women who took placebo, regarding sexual function scores evaluated with the Mc Coy Female Sexuality Questionnaire. We measured testosterone level changes in serum and hair as a secondary outcome. The third study was a qualitative study in which we explored women’s experiences of the negative effects of hormonal contraceptive use on sexual function. We interviewed 24 selected women who had reported previous experiences of adverse sexual function changes while using a hormonal contraceptive method.Results and Conclusions: Young Swedish women who used hormonal contraception, reported a negative change in sexual desire more than twice as often as women who used hormone-free contraceptive methods. A similar difference was seen between users of the levonorgestrel-intrauterine system compared with users of the copper-intrauterine device.The experience of an adverse sexual desire effect, which the women thought was due to contraceptive use, was a strong predictive factor for reconsideration of the contraceptive method.We found no change in the total score of sexual function during the use of a combined oral contraceptive compared with placebo. Sexual interest and lubrication which were two aspects of the total sexual function, were found to be negatively associated with the use of the tested combined oral contraceptive. Changes were small however, and the clinical relevance of these findings is therefore unclear. Furthermore, lubrication change did not persist following adjustment for change in self-rated depression scores.The biologically active fraction of testosterone embedded in hair did not decrease during combined oral contraceptive treatment and no reliable associations were found between the induced serum testosterone level decrease and sexual desire changes. Women reporting negative sexual function effects while using hormonal contraception, described lubrication difficulties and decreased sexual desire associated with both contraceptive use and parts of the menstrual cycle. Associations became obvious with time and experience and consequently contraceptive choice became easier with age, experience, and better understanding, all of which we concluded could be facilitated by a responsive contraceptive counsellor.Our findings indicate the need for further evaluation of sexual function changes in the selected group of women who seem to be susceptible to the use of hormonal contraceptives.
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| 7. |
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| 8. |
- Ström, Jakob
(författare)
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The dose-dependent effects of estrogens on ischemic stroke
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Estrogens are a group of female sex hormones that in addition to central roles in reproductive functions also have profound impact on for example brain development, blood vessels, bone tissue, metabolism and the immune system. The dominant endogenous production sites for estrogens in females are the ovaries and adipose tissue, while exogenous sources include combined contraceptive hormone treatments and menopausal hormone therapy. A few decades ago, the observation that females in comparison to men seemed to be protected against cerebral ischemia, and that this benefit was partially lost during menopause, sparked the hypothesis that estrogens protect against stroke. This was later confirmed by epidemiological studies and a large number of experimental animal studies, which motivated extensive clinical trials in which estrogens and/or progestagens were administered with the intent to prevent degenerative conditions rather than to ameliorate menopausal symptoms. However, the results were generally disappointing. The largest study, the Women’s Health Initiative (WHI), was discontinued due to the observation of an increased risk of breast cancer, cardiovascular disease and stroke. In parallel, a small number of animal studies in which estrogens were shown to increase damage from cerebral ischemia were published, one of these originating from our laboratory. This was, despite the WHI outcome, a surprising result, since the vast majority of previous animal studies had demonstrated protective effects.Therefore, in an attempt to explain the discordant results, Paper 1, and later Paper 4, of the current thesis were planned, in which four 17β-estradiol administration methods were tested. Substantial differences in serum hormone concentrations resulted from the different methods. Most importantly, the commercially available slow-release pellets used in our earlier experiments resulted in extremely high serum concentrations of 17β-estradiol. In Paper 2, 66 published studies that had investigated the effects of estrogens on stroke were meta-analyzed to pin-point the methodological reasons for the result dichotomy. Strikingly, in all six studies in which estrogens had produced damaging effects, the same type of slow-release pellets had been used, although these were used in a minority of the total number of studies. Paper 3 substantially strengthened the hypothesis that administration methods were crucial by showing that repeating the earlier experiment from our laboratory in which pellets had been used, but using a low-dose regimen instead, switched the estrogen effects from neurodamaging to neuroprotective. In Paper 5, an effort was made to challenge the assumption that the dose, and not the administration method per se, was the key factor, however this failed due to large intra-group infarct size variability.The current thesis adds evidence to the notion that differences in administration methods and their resulting serum concentrations of 17β-estradiol constitute a major factor responsible for the dichotomous results in studies investigating estrogens’ effects on cerebral ischemia. Even though results from animal studies are difficult to extrapolate to humans, this has a bearing on the menopausal hormone therapy debate, indicating that the risk of stroke could be reduced if serum concentrations of estrogens are minimized.
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| 9. |
- Berin, Emilia, 1992-
(författare)
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Resistance Training and Physical Activity in Postmenopausal Women : Effects on Vasomotor Symptoms, Quality of Life and Microcirculation
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Menopause is a physiological event, but is associated with bothersome symptoms as well as physical changes that affect women’s health. About 75 % of women experience vasomotor symptoms (hot flushes and night sweats) related to menopause that often reduce quality of life. The vasomotor symptoms may be attributed to dysfunctional temperature regulation centrally in the hypothalamus and peripherally in the skin’s circulation. The most effective treatment for vasomotor symptoms is menopausal hormone therapy, but not all women are able to, or want to, use it. In addition to the impact on quality of life, studies have associated vasomotor symptoms and menopause with macrovascular endothelial dysfunction. Previous studies on the association of these factors with the skin’s microcirculatory function are small and few. Observational studies have associated physical activity and exercise with less vasomotor symptoms, but the evidence from intervention trials is of low quality and the results are ambiguous. Physical activity has established general health effects, and could potentially decrease vasomotor symptoms by effects on endogenous opioids centrally, and by more efficient thermoregulation peripherally. The aim of this thesis was to investigate the effect of resistance training on vasomotor symptoms and health-related quality of life in postmenopausal women, and to explore the women’s experiences of the training to find barriers and facilitators. We also aimed to investigate whether the skin’s microcirculatory function differed between women regarding menopausal status, vasomotor symptoms, menopausal hormone therapy, and physical activity. Material and methods The first study was an open randomized controlled trial including 65 postmenopausal women with moderate to severe vasomotor symptoms and low physical activity levels. We randomized the women to 15 weeks of resistance training (intervention) or unchanged physical activity (control). The participants registered vasomotor symptoms daily in a diary, and answered health-related quality of life questionnaires at baseline and at 15 weeks. The first 15 women to finish the intervention were recruited to a qualitative study. The women’s experiences of the resistance training intervention were explored in individual interviews after the intervention period, and all were followed-up with telephone interviews after one year. The third study was cross-sectional, including 1148 women from Linköping, 50-64 years old, who participated in the Swedish CArdioPulmonary bioImage Study (SCAPIS). These women answered a questionnaire about menopausal status, vasomotor symptoms and menopausal hormone therapy use, and wore accelerometers for seven days to assess physical activity. The skin’s microcirculation was assessed at rest and during post-occlusive reactive hyperemia. Results Moderate to severe vasomotor symptoms per 24 hours decreased significantly more in the group of women randomized to resistance training compared with the control group (mean difference -2.7, 95% CI -4.2 to -1.3). The resistance training group improved in domains of menopause-specific health-related quality of life compared with the control group but there was little impact on generic health-related quality of life. In the qualitative study we found that the vasomotor symptoms acted as a “trigger” for the women to become motivated to exercise. Their motivation then evolved from being driven by hopes of symptom relief into being driven by a wish for general well-being, which was still a driving force after one year. Microvascular function did not differ between postmenopausal and premenopausal women, or between women with or without vasomotor symptoms or menopausal hormone therapy. Women with higher levels of objectively measured and self-reported physical activity had a better reactivity of the skin’s microcirculation. The differences remained significant after adjusting for BMI, smoking, hypertension, diabetes, and education. Conclusions Resistance training could be effective for decreasing vasomotor symptoms and improving some aspects of health-related quality of life in motivated postmenopausal women. The vasomotor symptoms themselves spurred motivation to exercise, indicating they present an opportunity to increase physical activity. When a woman seeks medical advice for vasomotor symptoms, this could be a chance for health care professionals to help her initiate or increase exercise. Women who performed more physical activity and exercise had better skin microvascular function, but no association with VMS was found. Future studies are needed to investigate what type and dose of exercise is the most effective to reduce vasomotor symptoms and whether there is a way to predict for whom exercise will or will not be an effective intervention.
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| 10. |
- Enblom, Anna, 1978-
(författare)
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Nausea and vomiting in patients receiving acupuncture, sham acupuncture or standard care during radiotherapy
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background and aim: Many patients with cancer experience emesis (nausea and vomiting) during radiotherapy. The overall aim of this thesis was to improve the situation for patients with risk for emesis during radiotherapy, by evaluating emesis in patients receiving verum (genuine) acupuncture, sham (simulated) acupuncture or standard care during radiotherapy.Methods: In study I, a cross-sectional sample (n=368) treated with radiotherapy over various fields answered a study-specific questionnaire. In study II, 80 healthy volunteers were randomized to receive needling with verum acupuncture or non-penetrating telescopic sham needles by one of four physiotherapists. In study III, 215 patients were randomly allocated to verum (n=109) or non-penetrating telescopic sham (n=106) acupuncture during their entire radiotherapy period over abdominal or pelvic fields. The same 215 patients were also included in study IV. They were compared to 62 patients irradiated over abdominal or pelvic fields, selected from study I.Results: In study I, the weekly prevalence of nausea was 39 % in all radiotherapy-treated patients and 63 % in abdominal or pelvic irradiated patients. Age younger than 40 years and previous experience of nausea in other situations were characteristics associated with an increased risk for nausea. Of the 145 nauseous patients, 34 % considered their antiemetic treatment as insufficient. Patients with nausea reported lower level of quality of life compared to patients free from nausea. In study II, most individuals needled with verum (68 %) or sham (68 %) acupuncture could not identify needling type, and that blinding result varied from 55 to 80 % between the four therapists. In study III, nausea was experienced by 70 % (mean number of days=10.1) and 25 % vomited during the radiotherapy period. In the sham group 62 % experienced nausea (mean number of days=8.7) and 28 % vomited. Ninety five percent in the verum and 96 % in the sham group believed that the treatment had been effective for nausea. In both groups, 67 % experienced other positive effects, on relaxation, mood, sleep or pain-reduction, and 89 % were interested in receiving the treatment again. In study IV, the weekly prevalence of nausea and vomiting was 38 and 8 % in the verum group, 37 and 7 % in the sham group and 63 and 15 % in the standard care group. The nausea difference between the acupuncture and the standard care cohort was statistically significant, also after overall adjustments for potential confounding factors. The nausea intensity in the acupuncture cohort was lower compared to the standard care cohort (p=0.002). Patients who expected nausea had increased risk for nausea compared to patients who expected low risk for nausea (Relative risk 1.6).Conclusions and implications: Nausea was common during abdominal or pelvic field irradiation in patients receiving standard care. Verum acupuncture did not reduce emesis compared to sham acupuncture, while reduced emesis was seen in both patients treated with verum or sham acupuncture. Health-care professionals may consider identifying and treating patients with increased risk for nausea in advance. The telescopic sham needle was credible. Researchers may thus use and standardize the sham procedure in acupuncture control groups. The choice of performing acupuncture during radiotherapy cannot be based on arguments that the specific characters of verum acupuncture have effects on nausea. It is important to further study what components in the acupuncture procedures that produce the dramatic positive but yet not fully understood antiemetic effect, making it possible to use those components to further increase quality of care during radiotherapy.
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