| 1. |
- Aléx, Jonas, 1975-
(author)
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Cold exposure and thermal comfort among patients in prehospital emergency care : innovation research in nursing
- 2015
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Doctoral thesis (other academic/artistic)abstract
- BackgroundPatients’ cold exposure is a neglected problem in prehospital emergency care. Cold stress increases pain and anxiety and contributes to fear and an overall sense of dissatisfaction. When left untreated, cold stress disturbs vital body functions until ultimately reaches hypothermia.AimThe overall aim was to investigate patients’ experiences of thermal comfort and reactions to cold exposure in prehospital emergency care and to evaluate the effects of an intervention using active warming from underneath.MethodStudy I:Persons (n=20) injured in a cold environment in the north of Sweden were interviewed. Active heat was given to 13 of them.Study II:In wintertime, 62 patients were observed during prehospital emergency care. The field study was based on observations, questions about thermal discomfort, vital signs, and temperature measurements.Study III:Healthy young persons (n=23) participated in two trials each. Data were collected inside and outside a cold chamber. In one trial, the participants were lying on a regular ambulance stretcher and in a second trial on a stretcher supplied with a heated mattress. Outcomes were the Cold Discomfort Scale (CDS), back, finger, and core body temperature, four statements from the State-TraitAnxiety-Inventory (STAI), vital signs, and short notes about their experiences of the two stretchers.Study IV:A quantitative intervention study was conducted in prehospital emergency care in the north of Sweden. The patients (n=30) in the intervention group were transported in an ambulance supplemented with a heated mattress on the stretcher, whereas only a regular stretcher was used in the ambulance for the patients (n=30) in the control group. Outcomes were the CDS, finger, core body, and air temperature, and questions about cold experiences.ResultsStudy I:Patients suffered more because of the cold than from the pain of their injuries. The patients were in a desperate need of heat.Study II:Patients are exposed to cold stress due to cold environments. There was a significant decrease from the first measurement in finger temperature of patients who were indoors when the ambulance arrived, compared to the measurement taken in the ambulance. In the patient compartment of the ambulance, 85% of the patients had a finger temperature below the comfort zone and almost half of them experienced the patient compartment in the ambulance to be cold. The regular mattress surface temperature at the ambulance ranged from -22.3 to 8.4 ºC.Study III:A statistical increase of the participants’ back temperature was found between those lying on the heated mattress compared to those lying on the regular mattress. The heated mattress was experienced as warm, comfortable, providing security, and easy to relax on.Study IV:Thermal comfort increased for the patients in the intervention group and decreased in the control group. A significant higher proportion of the participants rated the stretcher as cold to lie on in the control group compared to the intervention group.ConclusionThe ambulance milieu is too cold to provide thermal comfort. Heat supply from underneath increased comfort and might prevent cold stress and hypothermia
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| 2. |
- Karlsson, Martin, 1982-
(author)
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Covering distance : essays on representation and political communication
- 2013
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Doctoral thesis (other academic/artistic)abstract
- Political representatives’ democratic legitimacy rests on their ability to cover the distance between themselves and citizens. Representatives must avoid being perceived as distant and aloof from the needs and wishes of those they represent. The aim of this thesis is to increase the understanding of how new forms of communication with citizens, through participatory initiatives as well as political blogging, are used by politicians in their roles as representatives. Underlying this aim is the question of whether new forms of communication can contribute to reducing the distance between representatives and citizens. The central argument of this thesis is that such types of communication aid representative democracy only to the extent that they offer representatives efficient channels for performing functions related to political representation.This study presents a theoretical framework that identifies potential functions of communication between representatives and citizens for political representation. Its empirical analyses, presented in five articles, find that representatives widely communicate with citizens through participatory initiatives and political blogging to aid their roles as political representatives. Furthermore, results show that representatives’ communication is significantly determined by strategic, practical, and normative factors. The representatives are found to act strategically as communication practices are adapted to accommodate their particular situations, needs and normative orientations. Keywords:
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| 4. |
- Gustafsson, Maria, 1971-
(author)
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Optimizing drug therapy among people with dementia : the role of clinical pharmacists
- 2016
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Doctoral thesis (other academic/artistic)abstract
- Background: Drugs are one of the cornerstones in the management of many diseases. In general, drugs are used for diagnosis, prevention, mitigation of symptoms, and, sometimes, to cure disease. However, drug treatment in elderly people, especially those with dementia and cognitive impairments, may involve significant risk of adverse drug events. The aim of this thesis was to identify the extent of potentially inappropriate drug treatment among people with dementia and cognitive impairment and to assess the occurrence and character of drug-related problems that lead to acute hospital admissions. Another aim was to assess the potential impact of a comprehensive medication review conducted by clinical pharmacists as part of a health care team on quality of patients’ drug therapy and drug-related hospital readmission rates.Method: Long-term use of antipsychotic/psychotropic drugs and associated factors were investigated among 344 and 278 people respectively with dementia living in specialized care units. Trends in the prescribing of potentially inappropriate drugs between 2007 and 2013, comprising 2772 and 1902 people, living in nursing homes in the county of Västerbotten, were assessed using six national quality indicators. Data on drug use, function in the activities of daily living, cognitive function and behavioral and psychological symptoms were collected using the Multi-Dimensional Dementia Assessment Scale. Further, an investigation of a separate corresponding population from 2012 was done, where potentially inappropriate drug use was measured before and after a total of 895 medication reviews. Finally, a randomized, controlled trial was carried out among people 65 years or older with dementia or cognitive impairment in internal medicine and orthopedic wards at two hospitals in northern Sweden. The proportion of hospital admissions that were drug-related were estimated, and also whether comprehensive medication reviews conducted by clinical pharmacists as part of a health care team could affect the risk of drug-related hospital readmissions.Results: Antipsychotic and other psychotropic drugs were frequently prescribed to people with dementia living in specialized care units for prolonged periods. Associations were found between behavioral and psychological symptoms and different psychotropic drugs. The extent of potentially inappropriate drug use declined between 2007 and 2013. In the separate corresponding population from 2012, the frequency of potentially inappropriate drug use was significantly reduced among people who underwent medication reviews. Hospitalizations due to drug-related problems among old people with dementia or cognitive impairment were prevalent. We found that inclusion of a clinical pharmacist in the health care team significantly reduced the risk of drug-related 30-day and 180-day readmissions. However, in a subset of patients with concomitant heart failure no effect was seen.Conclusion: Among patients with dementia or cognitive impairment long-term treatment with antipsychotic and other psychotropic drugs is common. The results indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals, despite limited evidence of their efficacy and the high risk of adverse effects. Drug-related problems, such as adverse drug reactions, constituted a major cause of hospital admissions. By reducing potentially inappropriate drug use and optimizing overall drug therapy, inclusion of clinical pharmacists in a health care team might improve the quality of patient care and reduce the risk of hospital readmissions among people with dementia.
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| 5. |
- Karlsson, Jessica, 1987-
(author)
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Endocannabinoid metabolism : the impact of inflammatory factors and pharmacological inhibitors
- 2018
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Doctoral thesis (other academic/artistic)abstract
- The endocannabinoid (eCB) system is an endogenous signaling system consisting of ligands (referred to as endocannabinoids, eCBs), receptors and metabolic enzymes. The eCB system is involved in homeostatic control of a variety of biological functions such as neuronal signaling, mood, appetite and pathological conditions such as pain, inflammation and tumour progression. The main eCBs N- arachidonoylethanolamine (AEA, anandamide) and 2-arachidonoylglycerol (2-AG) are synthesised upon stimuli when and where their action is demanded. The signaling is brief and the eCBs are quickly degraded. The enzyme primarily responsible for eCB degradation is fatty acid amide hydrolase (FAAH) for AEA and monoacylglycerol lipase (MAGL) for 2-AG. In addition, both substances are substrates for cyclooxygenase-2 (COX-2). COX-2 is upregulated in inflammation, pain and in several tumours including prostate cancers, but it is not known whether COX-2 contribute significantly to eCB metabolism under these conditions.Increasing endogenous levels of eCBs by inhibiting their degradation is exploited as a future therapy for pain conditions. One suggested therapeutic strategy is dual inhibition of enzymes FAAH and COX-2 to raise AEA levels. Paper I and II of this thesis investigates FAAH and COX inhibitory effects of: the major metabolites and enantiomers of derivatives (flu-AM1 and ibu-AM5) of the current clinically used NSAIDs ibuprofen and flurbiprofen. The metabolites 3 ́hydroxyibuprofen and 4 ́hydroxyflurbiprofen retained the FAAH and COX- inhibitory effects seen by the parent compounds although at lower potencies. Both enantiomers of flu-AM1 were equally potent as FAAH inhibitors and displayed a useful substrate selective COX-2 inhibition profile, favoring eCBs as substrates rather than arachidonic acid.Paper III explores the impact of COX-2 and the effect of (R)-flu-AM1 upon AEA levels and degradation in mouse leukemic macrophage RAW264.7 cells. Despite the high inhibitory potency in enzyme assays, neither (R)-flu-AM1 nor the combination of a FAAH inhibitor with flurbiprofen increased AEA levels in the intact cells to any great extent. This suggests that the eCB turnover in these cells is rather slow. Further, in paper IV, induction of COX-2 did not unmask an ability of this enzyme to “gate” the uptake of AEA analogous to that seen with FAAH.Paper IV and V focus upon the role of the eCB system in prostate cancer. The eCB system is altered in cancer and is linked to the progression and prognosis of prostate cancer. How and whereby this change occurs is unknown. This thesis explores the impact of the inflammatory factors TNFα, IL-6 and lactic acid induced low pH upon the mRNA levels of eCB related enzymes and the functional impact upon AEA degradation in human DU145 and rat AT-1 prostate cancer cells. TNFα treatment of DU145 and IL-6 and lactic acid induced low pH exposure of AT-1 changed the mRNA levels of 2-AG related enzymes leaving AEA rather unaffected other than for a substantial induction of COX-2 mRNA in DU145 cells. Thus, AEA homeostasis was not shifted in prostate cancer cell lines exposed to inflammatory factors. The results suggest that COX-2 does not gate the uptake of AEA and is a minor contributor to AEA degradation in intact cells.
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| 6. |
- Lövheim, Hugo, 1981-
(author)
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Psychotropic and analgesic drug use among old people : with special focus on people living in institutional geriatric care
- 2008
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Doctoral thesis (other academic/artistic)abstract
- Old people in general, and those affected by dementia disorders in particular, are more sensitive to drug side effects than younger people. Despite this, the use of nervous system drugs and analgesics among old people is common, and has increased in recent years.Institutional geriatric care accommodates people who need round-the-clock supervision and care, due to somatic, psychiatric, cognitive or behavioral symptomatology. A majority of those living in institutional geriatric care suffers from dementia disorders.This thesis is based on three different data collections. Two large cross-sectional studies, the AC1982 and AC2000 data collections, including all those living in institutional geriatric care in the county of Västerbotten in May 1982 and 2000 respectively (n=3195 and n=3669) and one study, the GERDA/Umeå 85+ data collection, including a sample of very old people, living at home and in institutions (n=546), in the municipalities of Umeå, Sweden and Vaasa and Mustasaari, Finland, in 2005-2006.The use of psychotropic drugs and analgesics was common among old people living in geriatric care and among very old people in general. A higher proportion of people with dementia received certain nervous system drugs, such as antipsychotic drugs. The use of antipsychotic drugs among people with cognitive impairment living in geriatric care was found to be correlated to several behaviors and symptoms that are not proper indications for antipsychotic drug use, and also factors related more to the staff and the caring situation.Over the course of eighteen years, from 1982 to 2000, there has been a manifold increase in the use of antidepressants, anxiolytics and hypnotics in geriatric care, but the use of antipsychotics had decreased slightly. During the same time, the prevalence of several depressive symptoms decreased significantly, correcting for demographical changes. One analysis of calculated numbers needed to treat, however, indicated poor remission rates, suggesting that even better results might be achievable. The prevalence of depressive symptoms among people with moderate cognitive impairment remained unchanged between 1982 and 2000, despite the fact that about 50% were receiving treatment with antidepressants in 2000. One possible explanation might be that depressive symptoms have different etiologies in different stages of a dementia disorder.Approximately a quarter of the people experiencing pain in geriatric care were not receiving any regular analgesic treatment. One possible reason might be misconceptions among the caring staff regarding whether or not the residents were receiving analgesic treatment. Such misconceptions were found to be common.In conclusion, psychotropic and analgesic drug use among old people in geriatric care, and very old people in general, was found to be common and in many cases possibly inappropriate. The use of antipsychotics among people with dementia deserves particular concern, because of the high risk of severe adverse events and the limited evidence for positive effects. The use of antidepressants, on the other hand, might have contributed to a lower prevalence of depressive symptoms among old people.
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| 7. |
- Ringnér, Anders, 1975-
(author)
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Information till föräldrar som har barn med cancer
- 2013
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Doctoral thesis (other academic/artistic)abstract
- Bakgrund. Föräldrar till barn som har cancer upplever en livssituation som präglas av osäkerhet och oro och de ställs inför sociala och känslomässiga utmaningar. Jämfört med föräldrar till friska barn, upplever de också högre stress och drabbas i större utsträckning av posttraumatiska stressymptom. Trots att information om barnets sjukdom är ett centralt behov för föräldrarna, upplever de otillfredsställelse med den information som ges.Syfte. Syftet med denna avhandling var att inom barnonkologisk vård beskriva vårdares och föräldrars upplevelser av information, studera deras inbördes interaktion samt beskriva upplevelser och effekter av en intervention för personcentrerad information till föräldrar.Metod. I delstudie I–III användes fokusgruppintervjuer (I, II), individuella intervjuer (II, III) och deltagande observationer (III). Deltagarna bestod av 20 vårdare (I), 14 föräldrar till barn med cancer (II) respektive 25 vårdare och 25 föräldrar (III). Data analyserades med kvalitativ innehållsanalys (I, II) och diskurspsykologi (III). I delstudie IV testades en intervention för personcentrerad information på åtta föräldrar med hjälp av en experimentell single-case-design. Data samlades in med kvalitativa intervjuer och internetenkäter. Upplevd stress, kroppsliga symptom på stress, ångest, nedstämdhet och tillfredsställelse med information var utfallsmått.Resultat. I delstudie I bestod resultatet av två teman: anpassa mängden information till föräldrarnas behov, som handlade om skillnader i hur mycket information som gavs till föräldrarna utifrån vårdarnas bedömning av föräldrarnas behov, och navigera i en vag struktur, som handlade om brister i ansvar, miljö, tajming och språk när informationen lämnades.I delstudie II konstruerades två teman. Känna sig bekräftad som en viktig person handlade om att föräldrarna kände sig trygga, kunde hålla hoppet uppe och fick stöd från andra föräldrar. Temat var mer framträdande under behandlingens tidiga skeden. Det andra temat var känna sig som en objuden gäst vilket handlade om att kännas övergiven vid viktiga milstolpar, att tvingas tjata sig till information och att belastas av att själv behöva informera andra inom sjukvården.I delstudie III använde vårdarna tolkningsrepertoarer som var barn-, föräldra- eller familjeorienterade, vilket avspeglade deras primära fokus i interaktionen. Föräldrarna använde tolkningsrepertoarer som talesperson, observatör eller familjemedlem. Hur dessa kombinerades inbördes påverkade interaktionen.I delstudie IV erfor föräldrarna stor tillfredsställelse med den personcentrerade informationen och upplevde att de hade nytta av att på egen hand få diskutera barnets sjukdom och ställa frågor de annars inte skulle ställt. Interventionen visade ingen effekt på stress eller kroppsliga symptom på stress, ångest och nedstämdhet.Slutsatser. För att förbättra information till föräldrar som har barn med cancer är det en central uppgift att bedöma hur mycket och vilken information som ska ges vid varje tillfälle, att uppmärksamma att föräldrarna kan ha andra informationsbehov än barnet och att möten med föräldrarna ska ske i lugn och ro samt att organisera vården så att ansvaret är tydligt. I synnerhet bör det ske förbättringar kring det som föräldrarna upplever som viktiga milstolpar under barnets sjukdomstid. Interventionen för personcentrerad information uppskattades av föräldrar som har barn med cancer men effekten på föräldrarnas psykosociala välbefinnande behöver utforskas ytterligare.
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| 8. |
- Hedbrant, Johan, 1959-
(author)
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On the thermal inertia and time constant of single-family houses
- 2001
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Licentiate thesis (other academic/artistic)abstract
- Since the nineteen-seventies, electricity has become a common heating source in Swedish single-family houses. About one million smallhouses can use electricity for heating, about 600.000 have electricity as the only heating source.A liberalised European electricity market would most likely raise the Swedish electricity prices during daytime on weekdays and lower it at other times. In the long run, electrical heating of houses would be replaced by fuels, but in the shorter perspective, other strategies may be considered. This report evaluates the use of electricity for heating a dwelling, or part of it, at night when both the demand and the price are low. The stored heat is utilised in the daytime some hours later, when the electricity price is high.Essential for heat storage is the thermal time constant. The report gives a simple theoretical framework for the calculation of the time constant for a single-family house with furniture. Furthermore the “comfort” time constant, that is, the time for a house to cool down from a maximum to a minimum acceptable temperature, is derived. Two theoretical model houses are calculated, and the results are compared to data from empirical studies in three inhabited test houses.The results show that it was possible to store about 8 kWh/K in a house from the seventies and about 5 kWh/K in a house from the eighties. The time constants were 34 h and 53 h, respectively. During winter conditions with 0°C outdoor, the “comfort” time constants with maximum and minimum indoor temperatures of 23 and 20°C were 6 h and 10 h.The results indicate that the maximum load-shifting potential of an average single family house is about 1 kW during 16 daytime hours shifted into 2 kW during 8 night hours. Up-scaled to the one million Swedish single-family houses that can use electricity as a heating source, the maximum potential is 1000 MW daytime time-shifted into 2000 MW at night.
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| 9. |
- Pellfolk, Tony, 1976-
(author)
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Physical restraint use and falls in institutional care of old people : effects of a restraint minimization program
- 2010
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Doctoral thesis (other academic/artistic)abstract
- Physical restraint use and falls are common in institutional care of old people and various attempts have been made to reduce their occurrence. Falls and concomitant injuries are a major problem due to their negative effect on morbidity and mortality. Prevention of falls and injuries is the most common reason for physically restraining old people in institutional care. Its use has, however, been questioned both from an ethical perspective, since restraints can be perceived as coercive and also because of the lack of sound evidence of their effectiveness in preventing falls, as well as the adverse effects associated with their use. The main purposes of this thesis were to investigate differences in the us of physical restraints over time, to identifify risk factors for falls among people with dementia, to evaluate the effects of a restraint minimization program on staff knowledge, attitudes, and work environment and use of physical restraints and the quality of care. The present thesis is based on three main data collections, two census surveys conducted within institutional care for old people in the county of Västerbotten in 2000 (n=3,804) and 2007 (n=2,970) and one cluster-Randomized Controlled Trial (RCT) including 40 group dwellings for people suffering from dementia where the intervention consisted of staff education. The use of physical restraints increased slightly between 2000 and 2007 (16.2% to 18.4%, p=0.016). Analyses suggest that the increase might be independent of any change in resident characteristics. Restrained residents were also subjected to restraints for longer times in 2007. During a six-month follow-up 64/160 (40.0%) residents in group dwellings for those with dementia sustained at least one fall. Independent risk factors for falls were ‘requiring help with hygiene’, ‘displaying verbally disruptive/attention-seeking behavior’, ‘able to rise from a chair’, ‘walking with assistive devices’, and ‘participating in outdoor walks’, which explained 36.1% of the falls. The majority of the 191 falls were un-witnessed, 35% occurred during the night and anxiety and confusion were the most common symptoms preceding the falls. A six-month restraint minimization program showed a positive impact on staff knowledge, attitudes and work environment as well as on the use of physical restraints and subjectively estimated quality of care. Residents in the intervention group present throughout the entire study period had lower odds, relative to the residents in the control group of being physically restrained at follow-up (OR= 0.21, CI 95%=0.08-0.57) after controlling for potential confounders and the cluster effect. Adjusted analyses including all residents present at either baseline or follow-up also showed that the use of physical restraints was less in the intervention group relative to the control group at follow-up. There was no change in the occurrence of falls or use of psychoactive drugs. The intervention also reduced stress of conscience, job demands and strain in the staff, and improved their job control and the caring climate. Subgroup analysis indicated a greater effect in units where the use of physical restraints had been reduced or remained constant. In conclusion, physical restraint use and falls remains common in institutional care of old people. The practice of physical restraint seems to have changed. In the RCT it was found that it is possible to change restraint practice and also to improve staff work environment. Falls among residents with dementia require a certain mobility function and anxiety and confusion are common symptoms preceding falls.
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