| 1. |
- Gjessing, Kristian, 1967-
(författare)
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Impact of medical and non-medical Factors on Quality and Costs in Primary Care : A Conscious Look at Subconcious Processes
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background / IntroductionPhysicians and patients may be influenced by more than just the medical facts of the situation at hand. The physician is a part of the sociocultural environment and is under influence of this. The physician could be afraid of making mistakes and thus choose the safest option. In addition, economic considerations may apply. The perceived continuity or quality of the communication may also influence medical decision-making. Patients may not think about what allergens they are exposed to. Differences in socioeconomy or perceived morbidity may influence the patient's or their family’s desire to see the doctor or to use medications like antibiotics.Material and MethodsIn Paper 1, referrals from two Primary Healthcare centers in Norway were compared to each other and to the other referrals that were received by the local hospital. In Paper 2, Influenza-Like Illness (ILI) for children 2-12 years old was monitored for 7 years, and costs of treatment and parental absence due to ill children were calculated using real numbers. In Paper 3, the number of antibiotic prescriptions was compared to the patient’s socioeconomic background, to investigate possible inequalities. Paper 4 compares asthma and atopy incidence to the number of antibiotic prescriptions, to investigate if asthma patients are more often treated with antibiotics than nonasthma patients are. The analyses are based on regional healthcare data and the prospective ABIS study.ResultsPaper 1 showed that locum doctors and regular General Practitioners had the same referral rates, but the locum doctors had a distribution of diagnoses that differed significantly from the regular GPs and from the other referrals.Paper 2 showed that parental absence due to children with ILI follows the seasonal influenza pattern closely. The main burden of consultations and costs is carried by Primary Care.Paper 3 showed that parent-reported infectious morbidity at age 5, is associated with a higher number of antibiotic prescriptions in later childhood (5-14 years). Family income is a factor, where children from Q1 (wealthiest) receive significantly fewer antibiotics than children from Q3-Q5.Paper 4 found that asthma/ fur allergy at age 5 was associated with more antibiotic prescriptions in later childhood, but that wide-spectrum antibiotics are rarely used. Doctors seem to adhere to national and regional guidelines.ConclusionsPrimary care physicians seem to be affected by their grade of continuity and length of employment in their referral diagnosis distribution. Influenza-like illness in children carries a substantial cost in terms of loss of production, healthcare encounters, and personal suffering for vulnerable individuals. Parents’ perceptions of morbidity seem to influence antibiotic demand in children, along with socioeconomic factors. Children with asthma or airway allergies seem to receive more antibiotic prescriptions, possibly due to increased infectious vulnerability or to allergic exposure unknown to the doctor.
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| 2. |
- Cros, Olivier, 1975-
(författare)
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Image Analysis and Visualization of the Human Mastoid Air Cell System
- 2015
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- From an engineering background, it is often believed that the human anatomy has already been fully described. Radiology has greatly contributed to understand the inside of the human body without surgical intervention. Despite great advances in clinical CT scanning, image quality is still related to a limited amount X-ray exposure for the patient safety. This limitation prevents fine anatomical structures to be visible and, more importantly, to be detected. Where such modality is of great advantage for screening patients, extracting parameters like surface area and volume implies the bone structure to be large enough in relation to the scan resolution.The mastoid, located in the temporal bone, houses an air cell system whose cells have a variation in size that can go far below current conventional clinical CT scanner resolution. Therefore, the mastoid air cell system is only partially represented on a CT scan. Any statistical analysis will be biased towards air cells of smaller size. To allow a complete representation of the mastoid air cell system, a micro-CT scanner is more adequate. Micro-CT scanning uses approximately the same amount of X-rays but for a much longer exposure time compared to what is normally allowed for patients. Human temporal bone specimens are therefore necessary when using such scanning method. Where the conventional clinical CT scanner lacks level of minutes details, micro-CT scanning provides an overwhelming amount of fine details.Prior to any image analysis of medical data, visualization of the data is often needed to learn how to extract the structures of interest for further processing. Visualization of micro-CT scans is of no exception. Due to the high resolution nature of the data, visualization of such data not only requires modern and powerful computers, but also necessitates a tremendous amount of time to adjust the hiding of irrelevant structures, to find the correct orientation, while emphasising the structure of interest. Once the quality of the data has been assessed, and a strategy for the image processing has been decided, the image processing can start, to in turn extract metrics such as the surface area or volume and draw statistics from it. The temporal bone being one of the most complex in the human body, visualization of micro-CT scanning of this bone awakens the curiosity of the experimenter, especially with the correct visualization settings.This thesis first presents a statistical analysis determining the surface area to volume ratio of the mastoid air cell system of human temporal bone, from micro-CT scanning using methods previously applied for conventional clinical CT scannings. The study compared current resul s with previous studies, with successive downsampling the data down to a resolution found in conventional clinical CT scanning. The results from the statistical analysis showed that all the small mastoid air cells, that cannot be detected in conventional clinical CT scans, do heavily contribute to the estimation of the surface area, and in consequence to the estimation of the surface area to volume ratio by a factor of about 2.6. Such a result further strengthens the idea of the mastoid to play an active role in pressure regulation and gas exchange.Discovery of micro-channels through specific use of a non-traditional transfer function was then reported, where a qualitative and a quantitative preanalysis was performed are described. To gain more knowledge about these micro-channels, a local structure tensor analysis was applied where structures are described in terms of planar, tubular, or isotropic structures. The results from this structural tensor analysis, also reported in this thesis, suggest these micro-channels to potentially be part of a more complex framework, which hypothetically would provide a separate blood supply for the mucosa lining the mastoid air cell system.
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| 3. |
- Dahlman, Joakim, 1974-
(författare)
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Psychophysiological and Performance Aspects on Motion Sickness
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Motion sickness is not an illness, but rather a natural autonomic response to an unfamiliar or specific stimulus. The bodily responses to motion sickness are highly individual and contextually dependent, making them difficult to predict. The initial autonomic responses are similar to the ones demonstrated when under stress. When under the influence of motion sickness, motivation and ability to perform tasks or duties are limited. However, little is known about how specific cognitive functions are affected. Furthermore, standard mitigation strategies involve medications that induce fatigue or strategies that require cognitive capabilities. Both of them may result in reduced capability to perform assigned tasks or duties. Hence, there is a need for alternative mitigation strategies.The aim of the thesis was to study psychophysiological and performance aspects on motion sickness. The long-term goal is to provide strategies for mitigation and prevention of motion sickness by identifying psychophysiological responses as predictors for both wellbeing and performance. This thesis comprises four studies, in which 91 participants were exposed to two different motion sickness stimuli, either an optokinetic drum or a motion platform. Before the tests, a method for extracting fixations from eye-tracking data was developed as a prerequisite for studying fixations as a possible mitigation strategy for reducing motion sickness. During exposure to stimuli that triggers motion sickness, performance was studied by testing short-term memory and encoding and retrieval. In the final study, the effects of an artificial sound horizon were studied with respect to its potential to subconsciously function as a mitigating source.The results of the measurements of the psychophysiological responses were in accordance with previous research, confirming the ambiguity and high individuality of the responses as well as their contextual dependencies. To study fixations, a centroid mode algorithm proved to be the best way to generate fixations from eye-movement data. In the final study, the effects of the sound horizon were compared to the effects of a non-positioned sound. In the latter condition, both fixation time and the number of fixations increased over time, whereas none of them showed a significant time effect in the sound horizon condition. The fixation time slope was significantly larger in the non-positioned sound condition compared to the sound horizon condition. Number of fixations, heart rate, and skin conductance correlated positively with subjective statements that referred to motion sickness. Among participants that were susceptible to motion sickness symptoms, short-term memory performance was negatively affected. However, no effects of motion sickness on encoding and retrieval were found, regardless of susceptibility.Future studies should continue focusing on autonomic responses and psychological issues of motion sickness. Factors such as motivation, expectancies, and previous experiences play a major and yet relatively unknown role within the motion sickness phenomena.
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| 4. |
- Nosrati-Zarenoe, Ramesh
(författare)
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Idiopathic Sudden Sensorineural Hearing Loss : Corticosteroid Treatment, the Diagnostic Protocol and Outcome
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Idiopathic Sudden Sensorineural Hearing Loss (ISSNHL) is a rapid loss of hearing caused by damage to the cochlea or auditory nerve. Spontaneous recovery has been seen in 32%–81%. The incidence of the ISSNHL has been estimated to be between 5 and 20 per 100,000 per year. Different theories (vascular catastrophes, immunologic damage, infections or intracochlear membrane break) about the etiology have resulted in different treatment policies. The effect of therapy is difficult to evaluate for a single physician who sees just a few patients annually.The aim of the present thesis was: 1) to investigate the current management and treatment of ISSNHL patients in Sweden with regard to outcome, 2) to evaluate whether, in comparison to placebo, the most common drug given in the treatment of ISSNHL in any way influences the outcome, and 3) to analyze which variables such as background data, concomitant disease, audiogram shape and laboratory tests, best can predict the outcome of ISSNHL.A national database was developed with half of all ENT clinics in Sweden participating by submitting a questionnaire for each patient with SSNHL (I-II). The questionnaire covered the patient’s background, current disorder, past and family history of different diseases, examinations, and treatment. Audiograms at the onset of SSNHL and after three months were requested.A randomized placebo controlled multicenter trial (RCT) was performed (III) using a modified version of the questionnaire used in the national database. Prednisolone in high tapering dosage, or placebo was given with a total treatment period of eight days. If recovery was complete, treatment stopped, otherwise medication was continued at 10 mg daily to a total of 30 days from beginning. After an initial pure tone audiogram, new audiograms were taken at three follow-up visits: day eight of treatment, after one month, and after three months.Meta-analysis (IV) was used in order to strengthen the analysis from the RCT by increasing the material with corresponding data drawn from the Swedish national database for ISSNHL.Results from the national database showed that out of 400 patients included in the study with ISSNHL, almost 60% were medically treated, of which nearly 90% were given corticosteroids. Hearing improvement was not statistically associated with receipt of medication. 40% of all patients had an MRI or CT, where 3–4% had acoustic neuroma. 24% of the patients with ISSNHL who had hematological tests taken, had one or more pathological findings.In the RCT, 47 patients were randomized to Prednisolone and 46 to placebo. No significant difference of hearing recovery was observed between the Prednisolone group and placebo group at either first or final follow-up regarding the effect of treatment. Presence of vertigo had significant negative effect on hearing improvement in both groups. Inflammatory signs in laboratory work-up had a positive prognostic effect, irrespective of treatment.The meta-analysis showed no significant difference between the Prednisolone group and placebo/no treatment group (p>0.05). Vertigo at the onset of hearing loss and age had a negative prognostic value equally in all groups and signs of inflammation had a positive.Conclusion: Regardless of diagnostic protocol, treatment of ISSNHL in Sweden is mainly limited to corticosteroids (50%) or to no medical treatment. In a randomized placebo-controlled clinical trial no positive effect of Prednisolone on ISSNHL could be demonstrated. A Meta-analysis of patient data from the Swedish national database for SSNHL and the RCT for ISSNHL demonstrated no effect of Prednisolone on ISSNHL. Is it time to change the focus of research to find new ways to treat ISSNHL?
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| 5. |
- Zarenoe, Reza, 1969-
(författare)
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Tinnitus in Patients with Sensorineural Hearing Loss : Management, Quality of Life and Treatment Strategies
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Approximately 15% of Swedish people experience tinnitus, but only 2.4% experience severe problems. Treatment modalities for tinnitus vary, but the most common treatment is counseling. The majority of patients with tinnitus report some degree of hearing loss, and hearing aids have been used for many years in patients who suffer from both tinnitus and hearing impairment. The aim of the present thesis was to investigate disease management, determine quality of life and identify treatment strategies for patients with tinnitus and sensorineural hearing loss.The first two studies described here are retrospective, descriptive studies of patients who sought care for tinnitus and hearing loss at two Ear-Nose-Throat (ENT) clinics in Östergötland County, Sweden, during the years 2004 - 2007. Study I showed that 70% of the cohort had tinnitus; however, many did not initially receive a diagnosis of tinnitus. Information about vertigo, heredity for hearing loss and tinnitus, diabetes history, cardiovascular disease history and other factors related to health was often missing from the patients’ medical records. The results could show that the overall scores using the Tinnitus Handicap Inventory (THI) were higher in female patients than in male patients. Although it is likely that hearing aids would be beneficial for the majority of these patients, 314 (44%) of the 714 total patients had hearing aids. Furthermore, the outcomes from study II demonstrated that a majority of the patients (61%) who were dissatisfied with the care they had obtained had no hearing aids. This finding may indicate that the fitting of hearing aids is an important treatment for patients with both tinnitus and hearing loss.Studies III and IV were prospective studies. Data collection was based on patients who sought care for tinnitus and/or hearing loss at the ENT clinic in Linköping during 2012-2013. In study III, 92 patients were divided into two groups: one group contained individuals with both tinnitus and hearing loss, and the other group contained patients with only hearing loss. The patients were assessed using the Reading Span test, the Hearing in Noise Test (HINT) and three questionnaires (the THI, the Hearing Handicap Inventory for Elderly and the Pittsburg Sleep Quality Index) at baseline and follow-up. The results from the age-matched subgroups (n=30+30) generated from the full clinical groups (46+46) showed significantly improved Reading Span test performance and sleep quality in patients with both tinnitus and hearing loss. Similar results were observed in our full clinical population (n=46+46). However, the interpretation of this finding is difficult due to age differences between the groups. In conclusion, hearing aid fitting had a significantly positive impact on working memory capacity and sleep quality in patients with both tinnitus and hearing loss compared with patients with only hearing loss.In study IV, a brief Motivational Interviewing (MI) guide was integrated into the hearing rehabilitation process for 23 patients with both tinnitus and hearing loss, and they were compared against a control group (n=23) of patients with both tinnitus and hearing loss who underwent traditional hearing rehabilitation. The results showed that the patients who received the brief MI guide required fewer visits to complete their hearing rehabilitation compared with the patients in the control group. In addition, there was a significant difference in THI scores between the groups, which indicated that the intervention reduced tinnitus annoyance more in the MI group. Furthermore, both groups showed higher scores at follow-up compared with baseline on the International Outcome Inventory for Hearing Aids (IOI-HA) scale, which indicated that both approaches showed a positive effect on hearing aid satisfaction.Study V was a retrospective, descriptive study that focused on a part of a Stepped Care model and included patients who participated in half-day tinnitus information meetings from 2004 to 2011 in the audiology clinic at Linköping University Hospital. A total of 426 tinnitus patients with complete questionnaires (the THI and the Hospital Anxiety and Depression Scale, HADS) were included in the study. The results showed significant decreases in scores on the THI and the anxiety module of the HADS before and after the information session. However, there were no statistically significant changes in the depression module of the HADS.In conclusion, this thesis underscores the importance of hearing impairment, cognitive variables and motivational procedures in the management of tinnitus. Multidisciplinary group information needs to be further validated.
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| 6. |
- Magnusson, Anders, 1957-
(författare)
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Evaluation of surgically assisted rapid maxillary expansion and orthodontic treatment : Effects on dental, skeletal and nasal structures and rhinological findings
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Surgically Assisted Rapid Maxillary Expansion (SARME) is frequently used to treat skeletal maxillary transverse deficiency (MTD) in skeletally mature and non-growing individuals. Despite previous research in the field, questions remain with respect to the long-term stability of SARME and its effects on hard and soft tissue.The overall aim of the present doctoral work was to achieve a greater understanding of SARME, using modern image technology and a multidisciplinary approach, with special reference to effects on the hard and soft tissues and respiration. A more specific aim was to evaluate the long-term stability in a retrospective sample of patients treated with SARME and orthodontic treatment and to compare the results with a matched, untreated control group. The studies in this doctoral project are thus based on two different samples and study designs.The first sample, Study I (Paper I), is a retrospective, consecutive, long-term follow-up material of study models from 31 patients (17 males and 14 females) treated with SARME and orthodontic treatment between 1991 and 2000. The mean pre-treatment age was 25.9 years (SD 9.6) with a mean follow-up time of 6.4 years (SD 3.3). Direct measurements on study models were made with a digital sliding caliper at reference points on molars and canines. To evaluate treatment outcome and long-term stability, the results were compared with study models from an untreated control group, matched for age, gender and follow-up time.The second sample, Study II (Papers II-IV), is a prospective consecutive, longitudinal material of 40 patients scheduled to undergo SARME and orthodontic treatment between 2006 and 2009.In Paper II, one patient was excluded because of a planned adenoidectomy. The final sample comprised 39 patients (16 males and 23 females). The mean age at treatment start was 19.9 years (range 15.9 – 43.9). Acoustic rhinometry, rhinomanometry and a questionnaire were used to assess the degree of nasal obstruction at three time-points; pre-treatment, three months after expansion and after completed treatment (mean 18 months).In Papers III–IV, three patients declined to participate and two had to be excluded because their CT-records were incomplete. The final sample comprised 35 patients (14 males and 21 females). The mean age at treatment start was 19.7 years (range 16.1 – 43.9). Helical CT-images were taken pre-treatment and eighteen months’ post-expansion. 3D models were registered and superimposed at the anterior cranial base. The automated voxel-based image registration method allows precise, accurate measurements in all areas of the maxilla. In Papers II–IV, the treatment groups constituted their own control groups.The main findings in the retrospective, long-term follow-up study were that SARME and orthodontic treatment normalized the transverse discrepancy and was stable for a mean of 6 years post-treatment. Pterygoid detachment did not entirely eliminate the side effect of buccal tipping of the posterior molars. Relapse is time-related and is most pronounced during the first 3 years after treatment. Thus the retention period should be extended and should be considered for this period. The main rhinological findings in the prospective longitudinal study were that SARME had a shortterm, favourable effect on nasal respiration, but the effect did not persist in the long-term. However, subjects with pre-treatment nasal obstruction reported a lasting sensation of improved nasal function.SARME and orthodontic treatment had a significant but non-uniform skeletal treatment effect, with significantly greater expansion posteriorly than anteriorly. The expansion was parallel anteriorly but not posteriorly. The lateral tipping of the posterior segment was significant, despite careful surgical separation. No correlation was found between tipping and the patient's age. Furthermore, SARME and orthodontic treatment significantly affected all dimensions of the external features of the nose. The most obvious changes were at the most lateral alar-bases. The difference in lateral displacement profoundly influenced the perception of a more rounded nose. There were no predictive correlations between the changes. Patients with narrow and constrained nostrils can benefit from these changes with respect to the subjective experience of nasal obstruction. It is questionable whether an alar-cinch suture will prevent widening at the alar-base.The 3D superimposition applied in Study II is a reliable method, circumventing projection and measurement errors. In conclusion, SARME and orthodontic treatment normalize the transverse deficiency, with long-term stability. SARME has a favourable effect on the subjective perception of nasal respiration. SARME significantly affects dental, skeletal and nasal structures.
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| 7. |
- Mjönes, Anna-Britta, 1947-
(författare)
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Svalgproblem och hiatushernia : reflektioner över symptom och fynd
- 2009
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Denna licentiatavhandling består av tre delarbeten. Dessa tre arbeten handlar omsymtom som inte alltid kommer i fråga när det gäller gastroesofageal reflux.I det första arbetet var syftet att undersöka huruvida patienter medmagmunsbråck (hiatushernia) blev förbättrade med avseende på symtom somfelsväljning till larynx (MSL) och till näsan (MSN), samt heshet (H), som ettresultat av hiatusherniaoperation. Nittio patienter, som undersöktes före ochefter hiatusherniaoperation, fyllde i frågeformulär om H, MSL och MSN. Hos30% av patienterna förekom MSL och lika många hade MSN. Heshet fanns hos25% av patienterna före operation. Dessa symtom hade ett signifikant inbördessamband (p<0.008). Alla symtom minskade efter antirefluxkirurgi (p<0.001).Förbättringen var oberoende av patienternas vikt.I det andra arbetet studerades huruvida felsväljning var en extralaryngeal orsaktill heshet och om det var någon skillnad i prevalensen för felsväljning ochheshet mellan patienter med hiatushernia med gastroesofageal refluxsjukdom(GERD) och patienter med hiatushernia utan patologisk gastroesofageal reflux(GER). Patientmaterialet bestod av 198 patienter, som befunnits ha hiatusherniavid undersökning med esofagusmanometri och pH-refluxtest och somkontrollgrupp 262 personer ur normalbefolkningen, vilka inte visade sig hahiatushernia vid endoskopi. Dessa grupper svarade på ett frågeformulärangående symtom på heshet, felsväljning och halsbränna. Jämförelsen mellanpatientgrupp och kontrollgrupp visade H hos 35% respektive 13%, MSL hos35% respektive 5%, MSN hos 22% respektive 1% och halsbränna hos 85%respektive 6% (p<0.001). Båda symtomen MSL och MSN var vanliga(p<0.0001). H och MSL hade inget inbördes förhållande. H och MSL var likavanligt i gruppen med GERD som i gruppen med GER. Slutsatsen blev att detfinns en predisponering för H och MSL hos patienter med hiatushernia, menorsakssambandet är oklart. Heshet verkar inte vara orsakat av GERD.
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| 8. |
- Zarenoe, Reza
(författare)
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Tinnitus in Patients with Sensorineural Hearing Loss : Management and Quality of Life
- 2012
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Approximately 15 % of Swedish people experience tinnitus, but only 2.4 % of them experience severe problems. Treatment modalities for tinnitus are varied, but the most common treatment model is counselling. The majority of patients with tinnitus report some degree of hearing loss, and in addition, hearing aids have been used for many years in patients who suffer from both tinnitus and hearing impairment.The aim of the present thesis was to investigate the disease management and identify the quality of life in patients with tinnitus and sensorineural hearing loss.Both studies described here are retrospective, descriptive studies of patients who sought care for tinnitus and hearing loss at the two ENT clinics in Östergötland County, Sweden, during 2004 - 2007 and who also received a diagnosis code. A medical record review of all patients (study I contained 1672 subjects) revealed that 714 patients were diagnosed with both tinnitus and SNHL between 2004 and 2007 and could be included in study II.The results showed that 70% of our cohort had tinnitus, but many of the patients initially did not receive a diagnosis for their tinnitus. Information about the patients’ vertigo, heredity for hearing loss and tinnitus, diabetes history, cardiovascular disease history and other factors related to their health was often missing from the medical records. Our findings showed that the Stepped Care Model, which however was only used in a minority of the cases, could be effective in patients with tinnitus and could provide a better care process for these patients. Of the cohort, 56% of the patients received a diagnosis of bilateral hearing loss. The pure tone average (PTA) of the left ear was significantly higher than that of the right ear. There were 314 patients (44%) who had hearing aids out of the total of 714, even though it is likely that hearing aids could be beneficial for these patients. We found that the overall scores for the Tinnitus Handicap Inventory (THI) were higher in female patients than male patients. All patients who participated in study II estimated their life quality and general health at a good level. This could be due to the fact that they were investigated 4.5 years after they first reported their tinnitus and that tinnitus annoyance decrease over time. Further, the outcomes of study II demonstrated that the majority of patients, who were dissatisfied with the care they obtained, had no hearing aids. This could indicate a support the use of hearing aids fitting as main treatment model in patients with both tinnitus and hearing loss.Future research is needed to investigate how hearing aid professionals could motivate patients who suffer from both tinnitus and hearing loss to use hearing aids.
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