Dissertations / Theses on the topic 'Medical / Internal Medicine'

Introduction: Stroke is the leading cause of death and disability amongst South Africans older than 60 years. The majority of stroke patients in South Africa are managed in general medical wards where little is known about the quality and cost of care. The aim of this study was to determine the cost of stroke care and to identify factors associated with increased expense , as well as to evaluate the quality of stroke care in general medical wards in order to identify areas where quality of care could be improved. Methods: We conducted a retrospective folder review of all acute stroke admissions to the general medical wards at Groote Schuur Hospital from 1 January to 31 December 2012. Patients younger than 45 years and those that received thrombolysis were excluded. The hospital's finance department provided the bed costs, as well as expenditure on consumables, pharmacy, laboratory and radiology for each subject. The quality of care was measured according to the South African Stroke Guidelines. Results: The inpatient care of 261 patients was evaluated. Although neuroradiology was performed on 95% of patients, carotid duplex Doppler ultrasonography and echocardiography were not often done. Although all patients with ischaemic stroke received inpatient antiplatelet or anti - coagulation therapy, not all risk factors were adequately addressed on discharge. The median cost of a stroke admission was R19,072.07 (IQR R10,899.85 to R27,789.43 ). The strongest correlation with cost 12 was with length of stay (LOS), r = 0.9977. The median LOS was 6 days (IQR 3 to 9 days). Using non -¬‐ parametric univariable analysis, clinical factors prolonging LOS were previous stroke ( P = 0.0 2 8) and inpatient complications: fever ( P < 0.0 0 1), urinary tract infections ( P < 0.0 0 1) and acute kidney injury ( P < 0.0 0 1) . The LOS increased as the number of inpatient complications increased (P = 0.059). Mortality was 20% and 68% of patients experienced at least one medical complication during admission. Fever and pneumonia were predict ors of death. Pneumonia was less prevalent amongst patients who were mobilised early (P = 0.002). Early nutritional support was beneficial in reducing the incidence of acute kidney injury (P < 0.001). The median LOS was significantly prolonged by delaying speech therapy (P < 0.001), nutritional support (P < 0.01), physiotherapy (P < 0.01) and occupational therapy (P < 0.001). Discharge to inpatient rehabilitation centres significantly prolonged LOS as compared with patients discharged home (P < 0.001). Conclusions: This is the first study evaluating the cost of acute stroke care in South Africa. Length of stay was the greatest determinant of cost. Improving the quality of care to reduce the number of complications, early referral to allied health professionals and effective discharge planning would result in shorter length of hospital stay and therefore cost saving. There is a need for increased access to stroke unit beds, albeit dedicated stroke beds in the general medical wards, to ensure specialised nursing care and early inpatient rehabilitation to reduce the number of inpatient complications, as well as implementation of protocols to allow for better adherence to national guidelines.

The purpose of the present study was to assess: a) perceived stress, burnout, depression, and empathy at three time points in internal medicine residents, b) the role of gender and trait mindfulness in stress response during residency and c) to evaluate the impact these variables have on performance evaluations. Additionally, specific tasks of the residency that may contribute to the experience of stress and burnout were evaluated to test a model of job strain. Stress predicted subsequent burnout and depression. Burnout predicted subsequent depression, and stress mediated this relationship. Women reported higher mean levels of empathy and burnout than men. The exploratory measure of job strain was not significantly related to stress outcomes. The acting with awareness facet of mindfulness was negatively related to burnout and depression. Performance was both negatively and positively related to stress outcomes. The results are discussed within the context of the current literature.

Background: Patients can struggle to comprehend and recall medical information, hindering their ability to participate in their own care. Research suggests that images may aid comprehension of medical information. Available for use in clinical practice, 3D medical images are relatively easy to interpret and could benefit lay people. However, little is known about patients’ experience of viewing them. Aim: The aim was to understand the role of a patient’s own 3D image in a clinical consultation. Four objectives were explored, to: (i) understand the impact for patients viewing their 3D image; (ii) understand how 3D images are incorporated into consultations; (iii) compare the experience of viewing 3D images, 2D images and no image alongside a diagnosis and (iv) understand whether informing participants of the occurrence of errors within image interpretation affects their trust in a diagnosis. Methods: A multi-method approach was adopted. Fourteen patients and four clinicians from a tertiary care orthopaedic outpatient clinic participated in semi-structured interviews and 10 clinical consultations were video-recorded. Additionally, 31 volunteers participated in focus groups and 252 volunteers participated in psychology laboratory experiments. Results: Patients considered their 3D images to be evidence, describing them to be truthful and authoritative. 3D images were used to explain diagnoses and treatments to patients during consultations. Participants showed better recall of the diagnosis when it was accompanied by 3D and 2D images compared to no image. Additionally, participants reported greater understanding and trust when the diagnosis was accompanied by 3D images compared to 2D images or no image. There was no significant difference in trust between participants who were informed of the potential for error within image interpretation and those who were not. Conclusion: Patients trust 3D images, perceiving them to provide authoritative knowledge. They may be a powerful resource for patients, increasing patient understanding, trust, and recall.

In England, medical, nursing and other healthcare professions are required by their codes of professional ethics to have a working knowledge of moral principles and to be able to apply them in practice. Little, if anything, is said explicitly by these professions about the virtues. However, much is said about the character of the doctor or the nurse, and their supposed ability to recognise moral issues in their professional work and make morally good decisions. Edmund Pellegrino has questioned the appropriateness of applying moral principles to medical practice in contemporary times without a firm foundation. He attempts to restore the moral foundation of the profession of medicine, by restricting an account of the good to the profession which he claims, unlike ethics in general, there can be agreement on norms. From this position, moral principles in medical ethics can be justified, agreed upon, and provide firm action guidance in practice, as well as provide an independent ground for medical virtues. I will claim that Pellegrino's concern about disagreement and a loss of norms in ethics in general is not resolved in the restricted field of professional medical ethics and that his understanding of principles and the link with virtue is confused. Then, using virtue terms Pellegrino himself thinks necessary for making good decisions in practice, I will show how a certain account of the virtues can provide a plausible account of how we can become good healthcare workers and so support Pellegrino's goal; though it will not support his confidence in supplying both clear, moral, and normative constraints in a code of professional medical ethics and firm decision-making in practice.

Proton Transfer Reaction Mass Spectrometry (PTR-MS) was applied to determine which volatile organic compounds in breath are associated with cirrhosis and hence diagnostically useful. A two-stage biomarker procedure was used. In the first-stage, alveolar breath samples of 31 cirrhotic patients and 30 controls were analysed and compared. In the second-stage, 12 of the patients had their breath analysed after liver transplant. The first-stage study showed that seven volatiles were elevated in patients’ breath compared to controls. Of these, limonene, methanol, 2-pentanone showed a statistically significant decrease post-transplant and hence can unequivocally be used as biomarkers for chronic liver disease. Limonene which is not produced in the body showed washout characteristics and the best diagnostic capability. These findings suggest that limonene, methanol and 2-pentanone are potential biomarkers for early-stage liver disease. Limonene was detected in higher levels in patients with symptoms of hepatic encephalopathy (HE) in comparison to those with no symptoms. Limonene discriminates patients suffering from HE, but not methanol or 2-pentanone. The elimination characteristics of post-operative isoflurane levels in breath of 5 patients were investigated. High concentrations of isoflurane remained in their breath for several weeks. This study raises the question about the effect of isoflurane in the neurocognitive function of patients after major surgery.

Traditional methods of measuring oxygen saturation, e.g. pulse oximetry, depend on an adequate peripheral circulation and have a 20–30 second lag time before readings are obtained. This was a series of evaluations of novel optical probes, designed to measure oxygen saturation using fibreoptic technology directly from internal organs including the brain, oesophagus and organs with splanchnic circulations. A series of pilot studies were proposed and research ethics approval obtained to carry out studies in humans, under general anaesthesia, using these probes. Innovative reflectance probes were designed specifically for each of the four applications, so as to obtain potentially useful signals needed for signal processing, analysis and evaluation. Signals were successfully obtained from the brain, oesophagus and splanchnic region in almost all of the patients recruited. Good quality photoplethysmograph signals were recorded and these were translated into clinically meaningful values of oxygen saturation comparable to traditional methods of pulse oximetry. Overall, the signals were prone to movement artefacts as well as occasional interference from surgical diathermy and other sources. Nonetheless, the probes could prove to be a useful alternative to conventional external transmittance pulse oximetry methods as well as providing useful information regarding regional perfusion and oxygenation. The success of these pilot studies will form the basis of more research in the area and further development of such probes on the medical engineering front.

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Aphasia is a disorder that affects the language in its receptive and expressive, syntactic, semantic and morphologic aspects. The most common cause is the cerebrovascular accident (CVA). The authors of studies about the clinical-topographical correlations of the aphasias have been presenting variable results regarding the cerebral location of the language. The objective of this study was to establish the clinicaltopographical correlations of the fluent and non-fluent aphasias, observing the contributions of Spect scanning to map the affectec areas in the aphasias. A total of 29 patients with aphasia due to first episode of CVA comprised the study. They were submitted to language evaluation by means of selected proofs of the Boston Diagnosis Aphasias Examination (BDAE). Spect scanning was used to evaluate perfusion alterations in the whole encephalon , and it was analyzed by a nuclear doctor and a radiologist, in order to supply fidelity to the location data. After clinical evaluation, it was observed that 62% of the patients presented non-fluent aphasia and 38% fluent aphasia. It was not possible to classify 17% of the sample according to the classic types of aphasia. The analysis of the main components based on covariances allowed to relate the non-fluent aphasias mainly to the left and right frontal regions , left temporal region, presence of contralateral cerebelar diasquise to the left, subcortical regions , among others. The fluent aphasias are related to the inferior and superior left parietal regions . These data have corroborated for the concept of neural net in which several cortical , subcortical and cerebelar regions are involved to perform a linguistic task. In this way, this study showed that other cerebral regions participate in the language process as a neural circuit. Cerebral Spect provided different xi contributions from other image methods, adding important information on the participation of subcortical and cerebelar areas in the language process.
A afasia é uma desordem que afeta a linguagem nos seus aspectos receptivo e expressivo, sintático, semântico e morfológico. Sua causa mais comum é o acidente vascular cerebral (AVC). Os autores de estudos sobre as correlações clínico-topográficas das afasias apresentam resultados variáveis quanto à localização cerebral da linguagem. O objetivo desse trabalho foi estabelecer as correlações clínico-topográficas das afasias fluentes e não fluentes, verificando as contribuições do Spect cerebral para mapear as áreas comprometidas nas afasias. Foram sujeitos desse estudo 29 pacientes com afasia decorrente de primeiro episódio de AVC, os quais foram submetidos à avaliação de linguagem por meio de provas selecionadas do Teste de Boston para o diagnóstico das afasias (BDAE). O Spect cerebral foi utilizado para avaliar alterações perfusionais em todo o encéfalo e foi analisado por médico nuclear e radiologista, a fim de fornecer fidelidade aos dados de localização. Após avaliação clínica, observou-se que 62% dos pacientes apresentaram afasia não fluente e 38% afasia fluente. Não foi possível classificar 17% da amostra dentro dos tipos clássicos de afasia. A análise dos componentes principais com base em covariâncias permitiu relacionar as afasias não fluentes principalmente às regiões frontal esquerda e direita, temporal esquerda, presença de diásquise cerebelar contralateral à esquerda, regiões subcorticais, entre outras. As afasias fluentes estão relacionadas às regiões parietal inferior e superior esquerda. Esses dados corroboram para o conceito de rede neural nas quais estão envolvidas várias regiões corticais, subcorticais e cerebelares para a execução de uma tarefa lingüística. Dessa forma, este estudo mostrou que outras regiões cerebrais participam do processamento da linguagem como um circuito neural. O Spect cerebral ofereceu contribuições diferentes das obtidas por outros métodos de imagem ix e acrescentou informações importantes sobre a participação de regiões subcorticais e cerebelares no processamento da linguagem.

We propose several methods to address the tasks of appearance representation, variation modelling, landmark detection, pathology classification and evidence pinpointing in medical image analysis. Object class representation is one of the key steps in various medical image understanding techniques. We propose a part-based parametric appearance model built on Gaussian pyramids we refer to as a Deformable Appearance Model (DAP). A DAP models the variability within a population with local translations of multiscale parts and linear appearance variations of the assembly of the parts. The fitting process uses a two-step iterative strategy: local landmark searching followed by shape regularisation. We present a simultaneous local feature searching and appearance fitting algorithm based on the weighted Lucas-Kanade (LK) method. A shape regulariser is derived to calculate the maximum likelihood shape with respect to the prior and multiple landmark candidates from multi-scale parts, with a compact closed-form solution. We apply the DAP for the tasks of variation modelling and landmark detection. To reduce the redundancy in the representation, we further propose to replace the Gaussian pyramids with wavelet pyramids in the DAPs. The new appearance model is referred to as a Wavelet Appearance Pyramid (WAP). Logarithmic wavelets are adopted to decompose the images into pyramidal complementary channels, each of which represents the image with simple textures at a given scale. The complementary property of the wavelets allows the reconstruction of the object appearance from the image channels. The Supervised Descent Method (SDM) is adopted to model implicitly the prior knowledge and fit the model to new instances. We apply the WAPs for the tasks of landmark detection and pathology classification. To learn on large scale datasets annotated with only class labels and no landmarks, we propose a weakly-supervised method utilising the theories of sparse learning and stochastic optimisation. We pay attention to identifying which specific regions and features of images contribute to a certain classification. In the medical imaging scenario, these can be the evidence regions where abnormalities are most likely to appear, and the discriminative features of these regions supporting the pathology classification. The learning is weakly-supervised requiring only the pathological labelling of the data by clinicians and no other prior knowledge. It can also be applied to learn the salient description of an anatomy discriminative from background, in order to localise the anatomy before a classification step. We formulate evidence pinpointing as a sparse descriptor learning problem. Because of the large computational complexity, the objective function is composed in a stochastic way and is optimised by the Regularised Dual Averaging (RDA) algorithm. We apply the evidence pinpointing method for the tasks of anatomy localisation and pathology classification. We test our object representation and evidence pinpointing methods on the problem of Lumbar Spinal Stenosis (LSS). We validate the performance of DAPs and WAPs on around 200 studies consisting of routine axial and sagittal MRI scans. Intervertebral sagittal and parasagittal cross-sections are typically inspected for the diagnosis of LSS, we therefore build the appearance models on L3/4, L4/5 and L5/S1 axial cross-sections and parasagittal slices. For the task of landmark detection, experiments validate the performance of the DAPs as promising in terms of convergence range, robustness to local minima and segmentation precision compared with conventional shape and appearance models. A further improvement using WAPs is observed in landmark detection and pathology classification. We validate the evidence pinpointing method on three weakly annotated datasets on 600 axial images. Experiments show that compared with supervised methods trained with labels and landmarks, our method gives favourable results trained on larger scale data with only class labels, which demonstrates the learning ability of our method under weak-supervision.

The work in this thesis involves the development of a protected transesterification route for the production of novel cyanoacrylate monomers. As well as the modification of iodinated contrast agents to increase their solubility in cyanoacrylate, to enable monitoring of the adhesive within the body for possible use in the treatment of brain aneurysms. Chapter 1 provides an introduction to biological adhesives, in particular alky 2-cyanoacrylates and how they degrade to release formaldehyde. Details into iodinated X-ray contrast agents, their structure, uses and synthesis, as well as the current treatments for brain aneurysms. Chapter 2 focuses on the modification of several iodinated contrast agents in order to increase solubility in ethyl cyanoacrylate. Three existing contrast agents were protected using a variety of different protecting groups and tested for solubility in ethyl cyanoacrylate. Partition coefficients were calculated for the successfully modified compounds. Chapter 3 outlines the development of the anthracene protected route for the synthesis of cyanoacrylate monomers, utilising the Diels- Alder and retro-Diels-Alder reactions of anthracene. This route was subsequently used to synthesis a range of cyanoacrylate monomers. Polymerisation of these monomers gave a range of polymers which were tested to determine their rate of degradation through formaldehyde detection. Chapter 4 further details the first and final step of the anthracene protected route developed in chapter 3. It involved 1H NMR experiments to determine how substitution at the 9 and 10 position of anthracene affects the rate of reaction of the forward and retro-Diels-Alder reaction.

Within this short essay, we provide an overview of the development of “big data” and its possible influence on medical practice. In particular, we explore the underlying technology and demonstrate with practical examples how big data will sooner or later lead to the dissolution of economic consulting and treatment monopoly of classical medicine.

This thesis explores doctors’ and medical students’ attitudes toward older patients in UK hospital settings. There have been regular and strong assertions in the grey literature and the news media that negative attitudes toward older patients may contribute to the inequality of healthcare service provision and treatment for older patients, compared to younger patients (those aged under 65 years), in UK hospital settings. However, much of the evidence does not investigate or explore these attitudes using a theoretical framework of attitudes outlined in the scientific research literature. This thesis comprises three studies. Firstly, a systematic search and review (Study 1) was undertaken in order to determine how attitudes toward older patients had been explored to date in the English-language, scientific research literature. Results demonstrated that previous studies had focused on attitude measurement rather than exploring the content of attitudes toward older patients. In fact, there was little evidence that previous research had ever explored these attitudes, despite the number of studies attempting to measure them. Furthermore, the review indicated the lack of research emanating from UK settings. In Study 2, attitudes toward older patients and their care were explored in twenty-five in-depth interviews with medical students and doctors in a UK NHS Hospital trust. Data were thematically analysed and findings indicated that attitudes toward older patients and their care could be conceptualised as: (1) attitudes toward older patients and their healthcare needs, and (2) attitudes toward providing care for older patients (e.g. the social and organisational barriers and facilitators). Within these two domains, the themes, subthemes and nodes, which represent attitude content with increasing levels of specificity, are presented. The findings from Study 2 mark one of the first attempts in this research area to explore and describe the content of attitudes in line with a theoretical framework of attitudes. The final study, Study 3, explored the devaluation and unpopularity of the specialty of geriatric medicine as a future career choice in a sample of junior doctors. Having identified, in Study 2, that geriatric medicine was not highly regarded in a range of doctors and medical students, Study 3 aimed to ascertain whether this was due to the organisational and working environment or due to older patient-related factors in a recently-qualified sample of doctors. The findings indicated that organisational and work-related factors serve to discourage junior doctors from pursuing geriatric medicine, rather than factors related to the older patients treated on geriatric wards. This thesis contributes to the research literature in two main ways. Firstly, this thesis outlines the research gaps in the worldwide English-language scientific research. Secondly, this thesis presents a conceptualisation of doctors’ and medical students’ attitudes toward older patients in a UK hospital setting. Importantly, this conceptualisation provides research that is relevant to UK settings and is in line with a theoretical framework of attitudes that has been identified from the scientific research literature. The strengths and limitations of this work are discussed.

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No presente trabalho foi realizada uma reflexão sobre a condução do ensino médico no Brasil. Afirma-se que os catedráticos de Clínica Médica da Faculdade de Medicina do Rio de Janeiro, e em especial o Professor Clementino Fraga Filho, tiveram papel de liderança neste processo. A tese pretendeu mostrar que, acima de quaisquer modelos apontados pela bibliografia especializada franceses, germânicos ou norte-americanos - o grupo de catedráticos clínicos que chamamos de geração dos anos 1950 acreditou que a Clínica Médica seria a base do ensino de medicina. Apresenta-se, aqui, então, a 1ª Cátedra de Clínica Médica, do Professor Clementino Fraga Filho, como um arquétipo de excelência de ensino. Além de terem buscado estimular a homogeneização dos currículos das diversas faculdades de medicina do país, estes professores propuseram a criação de departamentos, em oposição à instituição tradicional cátedra, que, por ser conduzida por um único indivíduo, seu proprietário , constituía-se um entrave para a qualidade do ensino da medicina. Os catedráticos clínicos elaboraram propostas de uma reforma para o ensino médico e para o ensino superior, em geral, que culminaria, em muitos pontos, num evento distinto de suas perspectivas iniciais, a Reforma Universitária de 1968. Suas aspirações curriculares e estruturais para o ensino médico foram frustradas, pois, longe de resultar em maior diálogo entre as diversas disciplinas, a Reforma terminaria em sua fragmentação.

The book distills the available information on osteoporosis into an easily comprehensible format that serves as a practical guide for busy clinicians. Contents:Definition & epidemiology -- Basic bone pathophysiology -- Bone densitometry -- Diagnosis -- Identifying patients at risk of fractures -- Non-pharmacologic management of osteopenia and osteoporosis -- Pharmacologic management of osteoporosis, part 1 -- Pharmacologic management of osteoporosis, part 2 -- Monitoring patients on treatment -- Vertebral augmentation procedures -- Corticosteroid-induced bone loss -- Primary hyperparathyroidism -- Premenopausal women -- Men -- Atypical femoral shaft fractures -- Osteonecrosis of the jaw -- Osteoporosis in children and adolescents.
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Thesis (DMed)--Stellenbosch University, 2008.
The comparative study presented in this dissertation specifically aimed to assess fracture risk in black (Xhosa) and white South African women by evaluating known determinants of bone strength as well as the propensity to falls. We thus compared the prevalence of clinical (historic) risk factors for osteoporosis, measured and compared vertebral and femoral bone mineral density (BMD) employing dual energy X-ray absorptiometry (DEXA), ultrasound variables using the Sahara sonometer, serum parathyroid hormone (PTH) and 25-OH Vitamin D, mineral homeostasis and modern biochemical markers of bone turnover, bone geometry and the propensity to falls. Finally, we determined the prevalence of vertebral fractures in these black and white South African females. 1. Significant ethnic differences were noted in the presence and frequency of historical clinical and lifestyle risk factors for osteoporosis. Blacks were heavier and shorter, they consumed less calcium, were more inactive, preferred depot-medroxyprogesterone acetate as contraceptive agent and were of higher parity. Whites smoked more, preferred oral oestrogen containing contraceptive tablets and were more likely to have a positive family history of osteoporosis. Hormone therapy was used almost exclusively by postmenopausal whites. Inter-ethnic differences in weight, physical activity and high parity was most marked in the older subjects. 2. We found that peak spinal BMD was lower, but peak femoral BMD similar or higher (depending on the specific proximal femoral site measured) in black South-African females compared with whites. The lower peak spinal BMD was mainly attributed to lower BMD’s in the subgroup of black females with normal to low body weight, indicating that obesity either protected black females against a low spinal BMD or enhanced optimal attainment of bone mineral. An apparent slower rate of decline in both spinal- and femoral BMD with ageing was noted in the black females compared with whites in this cross-sectional study – an observation which will require confirmation in longitudinal, follow-up studies. This resulted in similar spinal BMD values in postmenopausal blacks and whites, but significantly higher femoral BMD measurements in blacks. The volumetric calculation of bone mineral apparent density (BMAD) at the lumbar spine and femoral neck yielded similar results to that of BMD. Spinal BMAD was similar in blacks and whites and femoral neck BMAD was consistently higher in all the menopausal subgroups studied. Weight significantly correlated with peak- and postmenopausal BMD at all sites in the black and white female cohorts. Greater and better maintained body weight may be partially responsible for slower rates of bone loss observed in black postmenopausal females. Most of the observed ethnic difference in BMD was, in fact, explained by differences in body weight between the two cohorts and not by ethnicity per se. 3. A low body weight and advanced age was identified as by far the most informative individual clinical risk factors for osteopenia in our black and white females, whereas physical inactivity was also identified as an important individual risk factor in blacks only. Risk assessment tools, developed and validated in Asian and European populations, demonstrated poor sensitivity for identification of South African women at increased risk of osteopenia. The osteoporosis risk assessment instrument (ORAI) showed the best results, with sensitivities to identify osteopenic whites at most skeletal sites approaching 80% (78% - 81%). The risk assessment tool scores appear to be inappropriate for our larger sized study cohort, especially our black subjects, thus resulting in incorrect risk stratification and poor test sensitivity. General discriminant analysis identified certain risk factor subsets for combined prediction of osteopenia in blacks and whites. These risk factor subsets were more sensitive to identify osteopenia in blacks at all skeletal sites, compared with the risk assessment tools described in the literature. 4. Higher ultrasonographically measured broadband ultrasound attenuation (BUA) and speed of sound (SOS) values were documented in our elderly blacks compared with whites, even after correction for differences in DEXA determined BMD at the spine and proximal femoral sites. BUA and SOS showed no decline with ageing in blacks, in contrast to an apparent significant deterioration in both parameters in ageing whites. If these quantitative ultrasound (QUS) parameters do measure qualitative properties of bone in our black population, independent of BMD as has been suggested in previous work in Caucasian populations, the higher values documented in elderly blacks imply better preservation of bone quality in ageing blacks compared with whites. The correlation between QUS calcaneal BMD and DEXA measured BMD at the hip and spine was modest at best. QUS calcaneal BMD was therefore unable to predict DEXA measured BMD at clinically important fracture sites in our study population. 5. Bone turnover, as assessed biochemically, was similar in the total pre- and postmenopausal black and white cohorts, but bone turnover rates appeared to differ with ageing between the two racial groups. A lower bone turnover rate was noted in blacks at the time of the menopausal transition and is consistent with the finding of a lower percentage bone loss at femoral sites at this time in blacks compared with whites. Bone turnover only increased in ageing postmenopausal blacks, and this could be ascribed, at least in part, to the observed negative calcium balance and the more pronounced secondary hyperparathyroidism noted in blacks. Deleterious effects of secondary hyperparathyroidism on bone mineral density at the proximal femoral sites were demonstrated in our postmenopausal blacks and contest the idea of an absolute skeletal resistance to the action of PTH in blacks. The increase in bone turnover and the presence of secondary hyperparathyroidism due to a negative calcium balance may thus potentially aggravate bone loss in ageing blacks, especially at proximal femoral sites. 6. Shorter, adult black women have a significantly shorter hip axis length (HAL) than whites. This geometric feature has been documented to protect against hip fracture. The approximately one standard deviation (SD) difference in HAL between our blacks and whites may therefore significantly contribute to the lower hip fracture rate previously reported in South African black females compared with whites. Average vertebral size was, however, smaller in black females and fail to explain the apparent lower vertebral fracture risk previously reported in this population. Racial differences in vertebral dimensions (height, width) and/or other qualitative bone properties as suggested by our QUS data may, however, account for different vertebral fracture rates in white and black women – that is, if such a difference in fact exists. 7. The number of women with a history of falls was similar in our black and white cohorts, and in both ethnic groups the risk of falling increased with age. There is a suggestion that the nature of falls in our black and white postmenopausal females may differ, but this will have to be confirmed in a larger study. Fallers in our postmenopausal study population were more likely to have osteoporosis than non-fallers. Postmenopausal blacks in our study demonstrated poorer outcomes regarding neuromuscular function, Vitamin D status and visual contrast testing and were shown to be more inactive with ageing compared with whites. An increased fall tendency amongst the black females could not however be documented in this small study. Quadriceps weakness and slower reaction time indicated an increased fall risk amongst whites, but were unable to distinguish black female fallers from non-fallers. 8. Vertebral fractures occurred in a similar percentage of postmenopausal blacks (11.5%) and whites (8.1%) in our study. Proximal femoral BMD best identified black and white vertebral fracture cases in this study. Quite a number of other risk factors i.e. physical inactivity, alcohol-intake, poorer physical performance test results and a longer HAL were more frequent in the white fracture cases and could therefore serve as markers of increased fracture risk, although not necessarily implicated in the pathophysiology of OP or falls. However, in blacks, only femoral BMD served as risk factor. Similar risk factors for blacks and whites cannot therefore be assumed and is deserving of further study. White fracture cases did not fall more despite lower 25-OH-Vitamin D, poorer physical performance and lower activity levels than non-fracture cases. Calcaneal ultrasonography and biochemical parameters of bone turnover were similar in fracture and non-fracture cases in both ethnic groups. Our study data on vertebral fractures in this cohort of urbanized blacks thus cautions against the belief that blacks are not at risk of sustaining vertebral compression fractures and emphasize the need for further studies to better define fracture prevalence in the different ethnic populations of South Africa. 9. In our study, hormone therapy in postmenopausal white women improved bone strength parameters and reduced fall risk. In hormone treated whites compared with non-hormone users, a higher BMD at the spine and proximal femur as determined by DEXA were documented and all QUS measurements were also significantly higher. The biochemically determined bone turnover rate, as reflected by serum osteocalcin levels, was lower in hormone users. Fall frequency was lower in the older hormone treated women (≥ 60yrs) and greater quadriceps strength and reduced lateral sway was noted. Only one patient amongst the hormone users (2%) had radiological evidence of vertebral fractures compared with four patients (6%) amongst the never-users. As hormone therapy was used almost exclusively by whites in this study population, the impact of hormone therapy on postmenopausal black study subjects could not be assessed.

A personal health record (PHR) allows a patient to exert control over his/her healthcare by enhancing communication with healthcare providers. According to research, patients find value in having access to information contained in their medical records. Often a glossary is required to aid in interpreting the information and understanding the content. However, giving patients the ability to speak with providers about their medical conditions empowers them to participate as informed healthcare consumers. The majority of patients (75%) at Medical Specialists expressed their intention to adopt the PHR if it is made available to them. Although the perceived usefulness of a PHR was a significant determining factor, comfort level with technology, health literacy, and socioeconomic status were indirectly related to intention to adopt as well. Perceived health status was not found to be a significant factor in this population for determining intention to adopt a PHR. The majority of patients in each category of gender, age, marital status, and race/ethnicity (except American Indian/Alaska Native) expressed interest in adopting a PHR, with most categories being above 70%. Findings indicate a broad acceptance of this new technology by the patients of Medical Specialists. Improvement of adoption and use rates may depend on availability of office staff for hands-on training as well as assistance with interpretation of medical information. Hopefully, over time technology barriers will disappear, and usefulness of the information will promote increased demand.
ID: 028916585; System requirements: World Wide Web browser and PDF reader.; Mode of access: World Wide Web.; Thesis (Ph.D.)--University of Central Florida, 2010.; Includes bibliographical references (p. 160-172).
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Health and Public Affairs
Public Affairs

La Corea di Huntington (MH) e' una malattia neurodegenerativa tra le piu' diffuse e studiate all'interno del gruppo di patologie causate da espansione poliglutaminica. La prevalenza e' di 3-10 soggetti affetti per 100000 individui nei paesi dell'ovest (Rawlins 2010; Spinney 2010). La malattia e' stata descritta la prima volta nel 19th secolo da George Huntington, che identifica sia le sue caratteristiche cliniche che la sua natura ereditaria. La MH e' una patologia genetica neurodegenerativa con eredita' autosomico dominante causata da una espansione instabile di triplette CAG nel gene HTT (Huntington's Disease Collaborative Research Group 1993; Kremer et al. 1994) che codifica per una proteina chiamata huntingtina (htt). La lunghezza della mutazione influenza l'eta' di insorgenza e la progressione, mentre la espansione omozigote induce una neuropatologia e un decorso piu' severo (Squitieri et al., 2003). Sebbene l' eta' di insorgenza dei sintomi piu' comune e' intorno ai 40 anni, la malattia puo' iniziare molto presto o molto tardi a seconda della penetranza della mutazione (Rubinsztein et al., 1996). Questo fa si' che negli individui a rischio, che si sottopongono ad un test presintomatico e scoprono di avere la malattia, non sia possibile predire l'eta' di insorgenza dei sintomi solo in base al numero di ripetizioni CAG che influisce sulla variazione dell'eta' di insorgenza solo per il 60-70%. Altri fattori biologici e ambientali, incluso i geni modificatori possano svolgere una grande influenza sull'inizio e lo sviluppo dei sintomi (Squitieri et al. 2000a; Wexler et al. 2004). Solo quando la mutazione e' particolarmente espansa e tossica, la malattia ha inizio in eta' infantile con effetti devastanti (Quarrel et al. 2009). Quindi l'impossibilita' di predire l'eta' di insorgenza e la progressione di malattia fra i diversi soggetti, rende la ricerca sui marcatori necessaria per monitorare lo sviluppo dei sintomi nei portatori a rischio e l'andamento patologico nei pazienti. Infatti, marcatori che traccino la progressione di malattia, in individui sintomatici, risultano ugualmente necessari per il monitoraggio di terapie sperimentali. Un buon biomarcatore dovrebbe essere facilmente rilevabile and ottenibile in maniera non-invasiva e soprattutto riflettere un meccanismo patogenetico della malattia. Attualmente non esistono marcatori con queste caratteristiche nella pratica clinica della MH.
Huntington disease (HD) is the most common and well-studied polyglutamine neurodegenerative disorder. It has a prevalence of 3- 10 affected subjects per 100000 individuals in Western Countries (Rawlins 2010; Spinney 2010). The disorder was first clinically described as a familial neuropsychiatric disease in the 19th century by George Huntington, but the responsible gene and its mutation were identified in 1993 (Huntington's Disease Collaborative Research Group 1993). Since then, the knowledge on clinical and molecular aspects of the disease has been increasing exponentially. HD is an autosomal dominant neurodegenerative disorder caused by the expansion of an unstable CAG triplet repeat beyond 36 in the HTT gene (Kremer et al. 1994), which codes for a large and ubiquitously expressed protein named huntingtin (htt). The mutation length influences the age at onset and the disease progression, the expansion homozygosity causing a particularly more severe disease course and neuropathology (Squitieri et al., 2003). Although, most of cases show an age at onset around 40s, the disease may start early in the life or very late in the elderly according to the penetrance of the mutation (Rubinsztein et al., 1996). This leaves the pathology unpredictable in at risk individuals who undergo a predictive genetic test and discovery to be mutation carriers, the number of CAG repeats accounting for only 60-70% of the age at onset variation. Other factors of biological and/or environmental origin including gene modifiers contribute therefore to the beginning and development of the disease (Squitieri et al., 2000a; Wexler et al., 2004). Only when the mutation is particularly expanded and toxic, the disease starts in children even very early in life with a devastating course (Quarrel et al. 2009). Therefore the age at onset unpredictability of most HD cases and the progression variability among patients strongly advises to search for markers sensitive enough to monitor the devolopmet of the pathological process in absence of symptoms in unaffected at risk subjects. Similarly, markers to test the progression of the disease other than the symptom changes would be crucial for monitoring the efficacy of further, yet unavailable, therapies, in symptomatic patients. Good biomarkers should be easy to get from mutation carrier subjects and must reflect a pathogenic mechanism of the disease. So far, no validate markers have been described and introduced into the clinical practice.

Chlamydia is the most reported sexually transmitted infection in the US and is caused by the obligate intracellular bacterium Chlamydia trachomatis. Typically, this presents as a lower genital tract infection (cervicitis or urethritis), but can ascend to the upper genital tract, causing pelvic inflammatory disease, tubal infertility, epididymitis, or ectopic pregnancy. While chlamydia infections can be cured with a single-dose oral antibiotic, repeat infections are common and having multiple chlamydial infections increases a woman’s risk of developing serious chronic conditions. Previous research has shown that estrogen has a positive effect on C. trachomatis infections—an important finding, connecting fluctuating estrogen levels in females to variance in pathogenesis.The mechanism behind this hormonal influence remains unknown; however, previous work in our laboratory indicates that estrogen-stimulated stromal cell effectors play a role in enhancing C. trachomatis infections in a polarized endometrial epithelial Ishikawa (IK)/stromal (SHT-290) cell co-culture model. Specifically, our data indicate that estrogen exposure stimulates osteopontin and vimentin release from stromal cells in co-culture with endometrial epithelial cells. Furthermore, we noted that Chlamydia-infected, polarized Ishikawa cells exposed to a combination of recombinant osteopontin and estrogen released significantly more infectious chlamydia than cultures exposed to estrogen alone. Most tissue culture models being used today employee non-polarized cells. Given the fact that epithelial cell polarization is known to impact C. trachomatis serovar E development, in the current study we sought to determine if the estrogen-induced stromal cell effectors, osteopontin and vimentin, affect C. trachomatis viability and infectivity in non-polarized Ishikawa cells. Non-polarized Ishikawa cells were exposed to osteopontin or vimentin in the presence or absence of estrogen, infected with C. trachomatis serovar E, and collected for examination of chlamydial infectivity and progeny production. Our initial data show that osteopontin and vimentin impact chlamydial progeny production in a concentration dependent fashion, with higher concentrations of recombinant effectors +/- estrogen significantly decreasing progeny production. These data suggest that polarization of host cells influences the way hormone-stimulated effectors interact with the cell to impact on chlamydial infection. Future research goals are to explore other stromal effectors such as fibronectin with estrogen and to study the cell signaling mechanism osteopontin and vimentin use to affect chlamydial infections in polarized epithelial cell cultures.

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The assessment of learning in medical schools has been a constant concern of institutions, students, academic and professional communities. Many schools are introducing new teaching and learning methodologies to be adapted to the reality of contemporary medical education and population needs. In our course of Medicine in Faculty of Medical and Health Sciences of PUCSP, a new curriculum, based on active learning methodologies, was implemented in 2006. In this new curriculum, formative and self-assessment, allowing reflection and improvement of pedagogical approaches are considered essential. This study had the initial purpose of introducing practical self-assessment of learning for students of the internship during the phase of transition to the new curriculum. These students were still attending a traditional curriculum, where the formative assessment was not very considered. From this idea, we created for these students, who were in the fifth and sixth years of the course at the time, activities that allow self-assessment of learning, mediated by software tools, the first of them created by ourselves and subsequently using the Moodle platform. Sixth year s Student activities were offered exclusively online at the beginning of the project and sequentially on mixed activities based on anatomo clinical sessions that were evaluated online. The students' participation in these activities in b-learning was voluntary and not obtained the expected adherence. When we posteriorly introduced these activities to students of the fifth grade, we observed good compliance only for mandatory tasks, but still with high resistance to the use of the Moodle platform. Sequentially, because of the low adherence of these students, we introduced b-learning activities also to the residents of the residency program in internal medicine. This population was composed by medical graduates in institutions with different curricula, and some based on active learning methodologies. In this group of residents we observed more adherence and interesting results. These doctors showed great interest in search of information, preparation of cases for the classroom discussion and in preparation to complement the theoretical discussion and also in answer the self-assessment of learning, introduced in Moodle. Our study was complemented with the introduction of formative assessment to the students of 2nd and 4th grades of the new curriculum in elective curricular activities. As expected, we observed a greater commitment of these students and positive results in the self-assessment of learning. We noted, throughout this process of introducing online activities of formative assessment that the proposal, even with adequate feedback, alone or in sequential classroom activities, not motivated students used to traditional curriculum, teacher-centered. Moreover, commitment of students in residency programs and graduate students accustomed to active methods, was high. Thus, we believe that actions with the use of digital media, which can cause the interaction of teaching and learning can be effective tools to encourage formative assessments
A avaliação do aprendizado nas escolas médicas tem sido uma preocupação constante das instituições, formandos, comunidades acadêmicas e profissionais. Muitas escolas vêm introduzindo novas metodologias de ensino e aprendizagem para adequação do ensino médico à realidade contemporânea e às necessidades da população. Em nosso curso de Medicina da Faculdade de Ciências Médicas e da Saúde da PUCSP, foi implantado um novo currículo, baseado em metodologias ativas de aprendizagem, em 2006. Neste novo currículo, a avaliação formativa e a autoavaliação, que permitem reflexões e aperfeiçoamento das abordagens pedagógicas são pontos de destaque. Este nosso estudo teve o propósito inicial de introduzir práticas de autoavaliação da aprendizagem aos estudantes do internato da fase de transição curricular, que estavam ainda cursando um currículo tradicional, que pouco valorizava a avaliação formativa. A partir desta ideia, criamos para estes estudantes, que cursavam o quinto e sexto ano na ocasião, atividades que permitiam a autoavaliação do aprendizado, mediadas por ferramentas disponibilizadas por softwares, inicialmente de construção própria e, posteriormente, por ferramentas próprias da plataforma Moodle. Aos estudantes da sexta série as atividades foram ofertadas exclusivamente on-line ao início do projeto e sequencialmente como atividades mistas, sendo as atividades presenciais baseadas no estudo de casos clínicos reais em sessões anátomo clínicas e avaliação on-line. A participação dos estudantes nestas atividades em b-learning era voluntária e não obtivemos a adesão esperada. Quando introduzimos as atividades aos estudantes da quinta série, em um segundo momento, houve boa adesão somente quando se tornaram obrigatórias, mesmo assim com refratariedade ao uso da plataforma Moodle, que, por outro lado, era muito bem aceita pelos alunos do novo currículo. Sequencialmente, introduzimos atividades em b-learning aos médicos residentes do programa de residência em clínica médica, recém-formados em instituições com currículos diversos e alguns, baseados em metodologias ativas de aprendizagem. No grupo de médicos residentes observamos maior adesão e resultados mais interessantes. Estes médicos se destacaram na busca de informações, preparação dos casos reais para a discussão presencial, na preparação da fundamentação teórica para complementar a discussão e na autoavaliação do aprendizado, introduzida no Moodle. Nosso estudo foi complementado com a introdução de uma avaliação formativa on-line aos estudantes das 2ª e 4ª séries do novo currículo em atividades curriculares eletivas. Como esperado, houve um maior comprometimento destes alunos e resultados positivos na autoavaliação do aprendizado. Observamos, ao longo de todo este processo de introdução de atividades on-line de avaliação formativa que a proposta, mesmo com feedbacks adequados, isoladamente ou sequenciais a atividades presenciais, não motivaram os estudantes formados no currículo tradicional, centrado no docente. Por outro lado, a adesão dos estudantes em programa de residência médica e dos estudantes de graduação habituados a metodologias ativas, foi elevada. Assim, consideramos que ações com a utilização das mídias digitais, capazes de provocar a interação do ensino e aprendizagem podem ser eficientes ferramentas para incentivar as avaliações formativas

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To evaluate the effects on the placenta of the administration to rats during embryogenesis, of sodium cyclamate or aspartame. Method: Administration of respectively, 14 mg/kg of aspartame via an orogastric sound to a group of rats during their tenth to fourteenth day of pregnancy, of 60 mg/Kg of sodium cyclamate intraperitonially to another group, and of equivalent volumes of saline by the same routes to controls. On the twentieth day of pregnancy five foetuses of each group were aleatorily selected for study. Karyometry was used to evaluate nuclear parameters of the decidua, spongy layers and chorionic villi of the placenta. Results: Weights of foetuses and placentas, as well as lengths of umbilical cords were lower in treated rats, compared to control. While no changes were observed in the decidual layer of the cyclamate-treated group, this layer was altered by aspartame treatment. Nuclear parameters in the spongy layer and chorionic villi were altered in both, cyclamate and aspartame-treated groups. Conclusions: The study numerically demonstrated placenta intoxication by sodium cyclamate or aspartame, and consequent repercussion on foetuses of the use of these substances during pregnancy.
Avaliar os efeitos do ciclamato de sódio na placenta de ratas com sua administração no período da embriogênese. Método: Foi administrado por sonda orogástrica nas ratas de um grupo tratado a dose de 14 mg/Kg de aspartame, e nas ratas do outro grupo tratado a dose de 60 mg/Kg de ciclamato de sódio por via intraperitoneal, do décimo ao décimo quarto dia de gestação, e volume equivalente de solução salina no grupo controle, pela mesma via. No vigésimo dia de prenhez, 5 fetos de cada grupo foram escolhidos ao acaso para estudo. A técnica de cariometria foi utilizada para avaliação dos parâmetros nucleares das células das camadas decídua, esponjosas e das vilosidades coriônicas da placenta. Resultados: O peso dos fetos tratados e de suas placentas, e o comprimento do cordão umbilical, foram menores do que o grupo controle. Não ouveram alterações na camada decídua do grupo tratado com ciclamato de sódio, enquanto tal camada mostru-se alterada no tratamento com aspartame. Foram alterados parâmetros nucleares nas camadas esponjosas e vilosidades coriônicas do grupo tratado com ciclamato de sódio, e do grupo tratado com aspartame. Conclusão: Este estudo demonstrou numéricamente a intoxicação placentária com o ciclamato de sódio e com aspartame, e a conseqüente repercussão fetal com o uso destas substâncias durante a gravidez.

Myeloid-derived suppressor cells (MDSCs) numbers increase significantly in sepsis and are associated with high mortality rates. These myeloid cell precursors promote immunosuppression, especially in the late (post sepsis) stage. However, the mechanisms that underlie MDSC expansion and programming are not completely understood. To investigate these mechanisms, we used a cecal-ligation and puncture (CLP) mouse model of polymicrobial sepsis that progresses from an early/acute proinflammatory phase to a late/chronic immunosuppressive phase. Previous studies in our laboratory showed that microRNA (miR)-21 and miR-181b elevate levels of the transcription factor nuclear factor 1 (NFI-A) that promotes MDSC expansion. We report here that miR-21 and miR-181b regulate NFI-A expression via a post-transcriptional regulatory mechanism by recruiting RNA-binding proteins HuR and Ago1 to stabilize NFI-A mRNA, thus increasing its protein levels. Studies in our laboratory also showed that inflammatory mediator S100A9 accumulates in the nucleus in Gr1+CD11b+ myeloid precursors in the later phases of sepsis and is necessary for their expansion and programming into immunosuppressive MDSCs. We demonstrate here that nuclear S100A9 associates with specific transcription factors that activate miR-21 and miR-181b expressions. In our final manuscript, we uncover another layer of the mechanisms of MDSC expansion and programming. We found that long non-coding RNA (lncRNA) Hotairm1 binds to and recruits S100A9 to the nucleus to program Gr1+CD11b+ myeloid precursors into MDSCs in the later phases of sepsis. Together, our results reveal three regulatory layers involving NFI-A, S100A9 and Hotairm1 in the pathway leading to MDSCs development in sepsis and suggest that therapeutically targeting these molecular switches might improve sepsis survival.

In Part I, the most useful methods for the estimation of the time of death are reviewed, with special emphasis being placed on the post-mortem rate of cooling because this method is commonly used for estimating the interval after death. Theories and models of the post-mortem loss of heat from the human body are summarised and discussed. The Microwave Thermography System, a new device which is applied to this field for the first time, is described and its mode of operation is discussed. Using this device, it is possible to measure temperatures of internal organs of the body by placing the sensory elements on the skin. The reliability of the system and factors affecting the accuracy of temperature measurements made with the device are assessed and discussed. Results of a study of the cooling rate of 117 fatalities are given. All cases were studied under controlled conditions and two groups were collected in which the bodies were monitored either naked or covered with blankets. In each case, the environmental temperature as well as the temperatures at three body sites were continuously monitored over a period beginning shortly after death and ending up to 60 hours post-mortem or more. Rectal and environmental temperatures were measured with thermocouples while the temperature of the brain and liver were measured using microwave probes, therefore by non-invasive and ethically acceptable methods. The data were recorded on tape following Analogue to Digital (AD) conversion using a BBC Microcomputer. These data were processed and temperatures at the moment of death for the three body sites were estimated by extrapolation backwards. Processed data were transferred to a mainframe computer where sophisticated curve-fitting procedures were performed. These indicated that the cooling curves were adequately represented by three-term exponential equations containing six empirically derived parameters. Statistical analysis of the parameters yielded average formulae and the use of these formulae to improve the ease and accuracy of the estimation of the time of death is discussed. Lastly, suggestions for future work are given. In Part II, biochemical methods of estimating the time of death are reviewed and limitations of their use are duscussed. Steroids were selected as potential indicators of the post-morem interval by virtue of their metabolism and degradation after death. Aspects of steroid biochemistry are summarised. Various methods of steroid analysis were assessed using radioassays and thin layer chromatography. Three reversed phase chromatography systems were evaluated for separation and recovery of steroids extracted from blood, tissues and faeces. The use of different numbers of Sep-Pak C18 cartridges for the purification of steroid extracts was examined and steroid recoveries were measured and compared. The results indicated that recoveries were best when 4-6 cartridges were used. Rapid and slow procedures of enzymatic hydrolysis and acidic solvolysis of steroid conjugates were compared. A new and relatively rapid method for analysis of steroid profiles in biological samples was developed. Assessment of this method showed that steroid recoveries were improved compared to existing methods. A pilot study of the post-mortem changes in the steroid profiles of blood, tissues and faeces was carried out using the rat as a suitable and convenient animal model. Liver and adrenal tissues, faeces and blood samples collected from 30 rats either at the moment of death or 24 hours after death were analysed and their steroids were studied qualitatively and quantitatively using selctive ion monitoring GC-MS techniques. Thus chromatographic peaks were identified by comparison of their retention times and mass spectrometric characteristics with those of standards and quantitative analysis was performed. The occurrence of significant steroid changes was difficult to ascertain but some changes in the steroid profiles of the biological samples were shown to have occurred. Lastly, the practicability of this method for the estimation of time of death is discussed.

Thesis (Ph.D.)--George Mason University, 2008.
Vita: p. 210. Thesis director: David M. Hart. Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Public Policy. Title from PDF t.p. (viewed Jan. 11, 2009). Includes bibliographical references (p. 196-209). Also issued in print.

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This essay is a historical-review study aiming to revise some reports based on reflexions of authors of the health field in relation to Evidence-Based-Medicine since its beginning until the current tendencies. Despite the great technological and scientific advances nowadays, we have been wondering about if there is some space for medical practice as art connected with science. The research was outlined based in some events and figures from the history of medicine, mainly the ones concerned to Gerolamo Fracastoro,s seminaria prima , Louis Pasteur, s néants and Ignácio Philipe Semmelweis, s dirty hands . Through these, we were able to understand a direction to the scientific knowledge by means of these author,s privileged intuition and others to the highest point; that his, the so-called Evidence-Based-Medicine. Through history, we have been certified that our ancestor from the medical field had coped with precarious science, however using much work and art to fulfil such failure. This should guide to return of an intuitive creativity parallel to the current knowledge available nowadays, therefore, the Evidence-Based-Medicine can be the great further advances for clinical activities
Este ensaio de natureza histórica, teve como objetivo a revisão de trabalhos e reflexões de vários autores da área de saúde, desde a Renascença até a data atual, visando os primórdios e a compreensão crítica da atual tendência denominada Medicina Baseada em Evidências. Procuramos compreender se, malgrado os grandes avanços científicos e tecnológicos de nossa era, ainda restaria espaço para o exercício da medicina como arte aliada à ciência. Tomando como fio condutor da pesquisa, alguns fatos e personagens da história da medicina, principalmente os que se referem à concepção da seminária prima de Gerolamo Fracastoro, aos nadas de Louis Pasteur e às "mãos sujas" denunciadas por Ignácio Philipe Semmelweis, pudemos vislumbrar o caminho aberto para o conhecimento científico, tantas vezes pela intuição privilegiada destes e de outros autores, para a culminância da chamada Medicina Baseada em Evidências. Compreendemos que a história de nossos antepassados da área médica, de ciência precária, mas muito engenho e arte para suprir tal deficiência, deveria nortear-nos ainda, não para um retomo ao obscurantismo científico, mas a uma retomada da criatividade intuitiva que, aliada ao conhecimento atualmente disponível, poderá fazer da Medicina Baseada em Evidências, um verdadeiro salto para o futuro das atividades clínicas.

The rapid evolution and popularity of the Internet technologies, and the World Wide Web, have resulted in unrestricted worldwide access to medical and health information. This has provided the medical profession with the ability to access up to date research more immediately than by traditional means, and has created the potential for advanced information collation. Also the availability of medical literature, previously difficult to obtain for the general public, is having an effect that is both a benefit and a burden to the medical profession. Whilst benefits exist in the use of the Internet in General Practice for clinical support, communication and education, there are also barriers to its inclusion in daily clinical practice. These include the issues of security, access availability, quality, time, research experience and Internet navigation familiarity. Questions remain as to whether or not the Internet can be used in General Practice efficiently, in order to provide a significant advantage over traditional information dissemination methods. This issue is also relevant for other primary health care providers such as pharmacists. In Australia, there has been a relatively slow adoption of both the technology and the use of the Internet for acquiring clinical and medical information. This thesis investigates the current issues surrounding the use of the Internet in general practice and pharmacy in Western Australia. The underlying assumption that the Internet is a useful tool for such information retrieval is examined in terms of useability and usefulness in clinical practice. Further the attitudes to the use of the Internet technology as an effective medium of information delivery were sought.

A forma de tratar os pacientes pode ser ensinada não somente pela teoria e prática formais, mas principalmente pelas atitudes do mestre e pela relação médico paciente que ele estabelece. O principal objetivo deste trabalho é avaliar os efeitos positivos ou deletérios da visita médica em grupo ao leito dos pacientes da Enfermaria da Clínica Médica Geral pois ela pode melhorar ou piorar a ansiedade e a depressão já contidas e instaladas no paciente e testar um modelo de visita médica hospitalar que priorize o paciente enquanto sujeito. Estudaram-se 95 pacientes com idades entre 16 e 65 anos, divididos em três grupos: um com 36 pacientes chamado G0 que passa visita na enfermaria mas não discute à beira do leito; outro com 34 pacientes chamado G1 que passa visita na enfermaria e discute à beira do leito e um novo, experimental, com 25 pacientes chamado G2, com visita na enfermaria e nova forma de discutir ao leito, com participação ativa do paciente em seu processo de recuperação . O Método utilizado foi: todos os pacientes, na véspera da visita, foram submetidos à escala HAD para medir ansiedade e depressão e à parte pré-visita do Questionário de Avaliação da Internação do Paciente da Clínica Médica Geral (QAIPCMG). No dia da visita, após a mesma, reaplicou-se aos três grupos a escala HAD, a parte pós-visita do QAIPCMG , a qual contém um quadro de Sentimentos e Sensações a serem escolhidos como tendo sido sentidos pelos pacientes durante a visita médica, o Teste de Apercepção Temática - TAT, pranchas 1 e 15 e o Questionário Desiderativo. Os critérios de inclusão foram: pacientes com doenças crônicas menores e agudas maiores internados há mais de uma semana e não mais do que duas. Para a análise estatística utilizaram-se os testes: Qui quadrado e Kruskal Wallis. As medidas de ansiedade e depressão da escala HAD pré e pós visita não apresentaram diferenças estatisticamente significantes. O grupo experimental G2, que se apresentou, propôs ao paciente que se sentasse, não usou termos técnicos para discutir o caso, explicou quais eram as medidas propostas para continuar o tratamento, pediu sua autorização para realizar novos exames e procedimentos, olhou e ouviu suas colocações, obteve referências de alegria (p= 0,0009) e tranqüilidade (p= 0,0058) por parte dos pacientes, estatisticamente significantes quando comparados às respostas dos outros dois grupos. O grupo G2 referiu um número maior de aspectos positivos observados na visita médica, (p = 0,0186) se comparados aos grupos G0 e G1. Os testes psicológicos projetivos possibilitaram medir e analisar as capacidades de abstração e elaboração mental de 52% da amostra, apontando que, nos 3 grupos 37,68% dos pacientes, mostrou boa capacidade para elaborar o impacto da internação e da doença, porém 40% apresentou pouca capacidade para conter aspectos negativos de suas personalidades. Conclui-se que, se não se cuidar do que e como se fala, não olhando e ouvindo o paciente, considerando-o como sujeito, a visita médica pode ser iatrogênica.
How to treat patients is something that can be taught not merely by theory and formal practices, but mainly through the teacher’s attitudes and how the physician-patient relationship is established. The main goal of this paper is to assess positive or deleterious effects of a group medical visit to patients’ bedsides at Internal Medicine Infirmary, as visits can improve or worsen anxiety and depression already existing in patients and test a model for hospital medical visits which allocates priority to patients as subjects. 95 patients with ages between 16 and 65 were studied, divided into three groups: one with 36 patients called G0, visiting patients with no discussion at the bedside; another with 34 patients called G1, visited in the infirmary with discussions, and a new, experimental group with 25 patients called G2, with infirmary visits and a new mode of discussion by the bedside, with the patient’s active participation in the recovery process. The method used was: the day before the visit, all patients underwent the HAD scale to measure anxiety and depression and the pre-visit part of the Questionnaire to Assess Hospitalization. On the day of the visit, after the call, the HAD scale was once again applied to the three groups, and the after visit part of the Questionnaire, using the chart on Feelings and Sensations that are selected to reflect patients feelings during the visit, the Theme Apperception Test - TAT, diagrams 1 and 15 and the Desiderative Questionnaire. Inclusion criteria included: patients with minor or greater chronic diseases extending for more than a week, not exceeding two weeks. The following tests were used for statistical analysis: chi square and Kruskal Wallis. The HAD scale measurements of anxiety and depression before and after the visits did not present significant statistical differences. The G2 experimental group introduced itself and proposed to the patient that he/she sit, avoided using technical terms to discuss the case, explained the measures being set forth to continue treatment and requested authorization to carry out new tests and procedures, heard the patient’s comments, obtained references on happiness (p= 0,0009) and calmness (p= 0,0058) expressed by patients that were statistically significant when compared to the responses of the other two groups. Group G2 referred to a greater number of positive aspects observed in the medical visits, (p = 0,0186) when compared to groups G0 and G1. The projective psychological enabled the measurement and analysis of the capacity for abstraction and mental elaboration of 52% of the sample, demonstrating that in the 3 groups, 37,68% of the patients had a good ability to elaborate on the impact of hospitalization and the disease, whilst 40% had little capacity when it came to containing or controlling negative aspects in their personalities. The conclusion therefore is that if no caution is taken on how to speak to patients, if physicians do not look at and listen to patients, considering them as subjects, medical visits may be iatrogenic.

The purpose of the study was to:

• Study the effect of vascular gas bubbles on the brain and lung

• Study changes in the endothelial function caused by gas bubbles

• Study the preventive effects of monoclonal anti-C5a antibody on functional changes caused by gas bubbles

It is important to reveal any changes in the function of the endothelium caused by gas bubbles, as the endothelium probably plays an important role in the development of decompression sickness (DCS). Furthermore, we followed up previous studies using monoclonal anti-C5a antibody trying to prevent damages caused by gas bubbles. In order to prevent damages causes by gas bubbles and maybe prevent DCS, the mechanisms behind have to be revealed. This thesis is part of an ongoing project that for several years has tried to bring to light the “secrets” of DCS.

Pressemelding:

Behandling av type 2 diabetes har trolig best effekt i en tidlig fase av sykdommen. Dette skriver assistentlege Elisabeth Qvigstad (36) fra Grimstad i doktoravhandlingen sin ved Norges teknisk-naturvitenskapelige universitet NTNU. Arbeidet kan bidra til at det utvikles nye medisiner mot diabetes.

Avhandlingen tar utgangspunkt i type 2 diabetes, som rammer 105-120 000 nordmenn. Tidligere forskning i form av celle- og dyreforsøk har vist at vedvarende høye nivåer av fettsyrer i blodet og langvarig stimulering av insulinfrigjøring kan svekke funksjonen til de insulinproduserende beta-cellene i bukspyttkjertelen. Avhandlingen ville teste om lignende forhold er til stede hos mennesker og om korrigerende tiltak ville bedre insulinfrigjøringen ved type 2 diabetes.

Nivået av frie fettsyrer hos personer med type 2 diabetes er oftest forhøyet. Langvarig faste hos friske gir også forhøyet fettsyrenivå og kan ses på som en modellsituasjon for type 2 diabetes. Qvigstad fant redusert insulinfrigjøring hos friske forsøkspersoner etter 58 timer faste.

Fettsyrenivået i blod under testing ble senket ved hjelp av et nikotinsyrederivat hos friske personer og personer med type 2 diabetes. Hos friske påvirket ikke medikamentet insulinfrigjøring eller -følsomhet. Imidlertid virket behandlingen positivt på insulinfrigjøring hos de diabetikerne som hadde best blodsukker-kontroll. Derimot, når type 2 diabetikere reduserte fett i kosten, ga dette ingen utslag på insulinfrigjøringen, men noe nedsatt insulinfølsomhet. Nivået av fettvevshormoner (leptin, adiponectin) ble redusert. Den egne insulinfrigjøringen ble hemmet med medikamentet diazoxid, og insulininjeksjoner ble brukt som erstatning. Insulinfrigjøringen økte uten å endre insulinbehov eller blodsukkerkontroll sammenliknet med placebo. Disse resultatene tyder på at "betacelle-hvile" er gunstig ved type-2 diabetes.

Qvigstads doktorgradsarbeid bidrar til økt forståelse av betydningen av fettsyrer for insulinfrigjøring og insulinfølsomhet hos friske og ved type 2 diabetes. I tillegg støtter funnene betydningen av "betacelle-hvile», som kan bidra til utvikling av nye medisiner mot diabetes.

http://www.ntnu.no/doktorgrader/dr.med/02.03/qvigstad.htm

The main purpose of the present work was to evaluate the efforts taken by the Norwegian surgical community in order to promote and enhance the standards of rectal cancer treatment on a national level, in particular:

- to examine the outcome of rectal cancer surgery following implementation of total mesorectal excision as the standard rectal resection technique

- to explore the prognostic impact of the circumferential resection margin on local recurrence, distant metastases and overall survival following mesorectal excision

- to evaluate the oncological outcomes following mesorectal excision of cancer of the lower rectum, particularly the rates of local recurrence and overall survival for patients with tumours in this areas

- to illustrate the influence of a rectal cancer registry as a quality control instrument on outcome of rectal treatment, and furthermore, to investigate the rates of postoperative mortality, anastomic leakage, local recurrence (LR) and overall survival related to hospital caseload among Norwegian hospitals during implementation of mesorectal excision.

The aim of this thesis is to explore why parents bring their children to homeopaths and to investigate the effect of homeopathic treatment for prevention of upper respiratory tract infections (URTI) in children. The reason for doing studies on this is that there has been a nearly threefold increase in the proportion of children among patients visiting Norwegian homeopaths. This raised the question of why it is so. Furthermore, recurrent respiratory complaints are a main reason why child patients consult homeopaths. This raised the question of the effect of homeopathic treatment in this patient group, because there is very little research on this. The thesis builds on four different studies conducted between August 2002 and June 2004.

Parents of nine children that recently had been to a homeopath for the first time were interviewed to explore why parents take their children to homeopaths. All parents had been to a medical doctor before consulting the homeopath. It was the experiences with conventional medical treatment that led the parents to look for alternatives. The reasons were that 1) the parents did not want to give the medication prescribed by the doctor, 2) they wanted treatment while waiting for a problem to be assessed, 3) they did not want to continue to use the prescribed medication, 4) they stopped taking conventional medication due to side effects or 5) they were not offered any treatment by the medical doctor. The parents would consult a medical doctor if they felt insecure about the health conditions of the child and would visit a homeopath when they felt that the situation was clarified. There are parents who take their child to homeopaths despite not understanding or having belief in whether ultramolecular homeopathic medicines can have effects.

One hundred and sixty-one children who had been diagnosed with an URTI by a medical doctor were recruited to participate in a trial on the effect of treatment by homeopaths for prevention of URTI in children. The children were randomly allocated to two groups. One group received an appointment immediately with one of five homeopaths who treated the patients as they do in their everyday practice. The other group (control) got such treatment after three months. The occurrence of URTI judged by the parents were significantly lower among those treated immediately by homeopaths (median 8 days in three months) compared to the control group who used self-selected conventional health care (median 13 days) (p=0.006).

Homeopathic medicines are frequently used for self-treatment (over the counter-OTC). It is not known if the choice of the patient is the same, as a homeopath would have prescribed. A study was therefore conducted to explore if there can be developed indications for homeopathic medicines that facilitate that parents can chose the same medicine as a homeopath would prescribe for children with URTI. Firstly, data from a survey was used to find three medicines Calcarea carb, Pulsatilla and Sulphur that accounted for 60% of all prescription made by Norwegian homeopaths for children with URTI. Simplified constitutional indications for these medicines were developed and tested by comparing the choices of 70 parents with the prescription of eleven homeopaths. The parents were able to choose the same homeopathic medicine as homeopaths prescribed for 55% of the children.

Two hundred and fifty-nine children who had been diagnosed with an URTI by a medical doctor were recruited to participate in a trial on the effect of one of three self-selected ultramolecular homeopathic medicines for prevention of URTI in children. The indications developed were used. The children was randomly allocated to receive either ultramolecular homeopathic medicine (C-30) or placebo. There was no difference in the occurrence of URTI judged by the parents among getting ultramolecular homeopathic medicine compared to those getting placebo (median 9 days in three months for both groups) (p=0.531).

Hensikten med denne avhandlingen er å undersøke hvorfor foreldre tar sine barn med til homøopat og å undersøke effekten av homøopatisk behandling i forebygging av øvre luftveisinfeksjoner (ØLI) hos barn. Bakgrunnen for de undersøkelsene som er gjort, er at det nesten er en tredobling i andelen barn blant pasienter hos homøopat. Dette utløste spørsmål om hvorfor det er slik. Videre er gjentatte luftveisplager en hovedårsak til at barn oppsøker homøopat. Fordi det er lite forskning på dette temaet ble spørsmålet om effekten av homøopatisk behandling i denne pasientgruppen også utløst. Avhandlingen bygger på fire ulike undersøkelser som er gjennomført mellom august 2002 og juni 2004.

Foreldre til ni barn som nylig hadde vært hos homøopat for første gang ble intervjuet for å undersøke hvorfor foreldre tar sine barn med til homøopat. Alle foreldrene hadde vært hos lege før de kontaktet homøopaten, og det var erfaringer med legebehandlingen som fikk foreldrene til å søke alternativer. Årsakene var at foreldrene 1) ikke ønsket å gi den behandlingen lege foreskrev til barnet, 2) ønsket behandling mens barnet ventet på å bli ferdig utredet, 3) ønsket å avslutte bruken av de medisinene legen hadde foreskrevet for barnet, 4) opplevde at barnet fikk bivirkninger av behandlingen legen hadde gitt og 5) ikke ble tilbudt noen behandling hos legen. Foreldre oppsøker først lege når de er usikre eller bekymret for barnets helsetilstand. De oppsøker homøopat for behandling når dette er avklart. Det er foreldre som oppsøker homøopat med sine barn selv om de ikke forstår eller tror på effekten av homøopatiske medisiner (som kan være svært fortynnet).

Ett hundre og sekstini barn som hadde vært til lege på grunn av en øvre luftveisinfeksjon ble rekruttert til å være med på en undersøkelse av effekten av behandling hos homøopat i forebyggingen av ØLI hos barn. Barna ble tilfeldig fordelt i to grupper. Barna i den ene gruppen fikk time med en gang hos en av fem homøopater som foreskrev homøopatisk behandling på vanlig måte. Den andre gruppen fikk slik behandling etter 3 måneder. Forekomsten av ØLI Hensikten med denne avhandlingen er å undersøke hvorfor foreldre tar sine barn med til homøopat og å undersøke effekten av homøopatisk behandling i forebygging av øvre luftveisinfeksjoner (ØLI) hos barn. Bakgrunnen for de undersøkelsene som er gjort, er at det nesten er en tredobling i andelen barn blant pasienter hos homøopat. Dette utløste spørsmål om hvorfor det er slik. Videre er gjentatte luftveisplager en hovedårsak til at barn oppsøker homøopat. Fordi det er lite forskning på dette temaet ble spørsmålet om effekten av homøopatisk behandling i denne pasientgruppen også utløst. Avhandlingen bygger på fire ulike undersøkelser som er gjennomført mellom august 2002 og juni 2004. Foreldre til ni barn som nylig hadde vært hos homøopat for første gang ble intervjuet for å undersøke hvorfor foreldre tar sine barn med til homøopat. Alle foreldrene hadde vært hos lege før de kontaktet homøopaten, og det var erfaringer med legebehandlingen som fikk foreldrene til å søke alternativer. Årsakene var at foreldrene 1) ikke ønsket å gi den behandlingen lege foreskrev til barnet, 2) ønsket behandling mens barnet ventet på å bli ferdig utredet, 3) ønsket å avslutte bruken av de medisinene legen hadde foreskrevet for barnet, 4) opplevde at barnet fikk bivirkninger av behandlingen legen hadde gitt og 5) ikke ble tilbudt noen behandling hos legen. Foreldre oppsøker først lege når de er usikre eller bekymret for barnets helsetilstand. De oppsøker homøopat for behandling når dette er avklart. Det er foreldre som oppsøker homøopat med sine barn selv om de ikke forstår eller tror på effekten av homøopatiske medisiner (som kan være svært fortynnet).

Ett hundre og sekstini barn som hadde vært til lege på grunn av en øvre luftveisinfeksjon ble rekruttert til å være med på en undersøkelse av effekten av behandling hos homøopat i forebyggingen av ØLI hos barn. Barna ble tilfeldig fordelt i to grupper. Barna i den ene gruppen fikk time med en gang hos en av fem homøopater som foreskrev homøopatisk behandling på vanlig måte. Den andre gruppen fikk slik behandling etter 3 måneder. Forekomsten av ØLI var signifikant lavere hos de som fikk behandling hos homøopat med én gang (median 8 dager på tre måneder) sammenlignet med den andre gruppen som brukte standard behandling ved behov mens de ventet (median 13 dager) (p=0,006).

Homøopatisk medisin brukes internasjonalt i stor grad til selvbehandling. Man vet ikke om pasientens eget valg av homøopatisk

medisin er lik det en homøopat ville foreskrevet. Det ble derfor gjennomført en undersøkelse av om det kan utvikles beskrivelser for indikasjoner for homøopatiske medisiner som gjør at foreldre kan velge samme medisin som en homøopat foreskriver for barn med ØLI. Først ble det funnet fram til tre medisiner, Calcarea carb, Pulsatilla og Sulphur som homøopater i Norge foreskriver til 60% av barn med ØLI. Så ble det utviklet indikasjoner for disse tre medisinene som ble testet ut ved at valgene til 70 foreldre ble sammenlignet med foreskrivingen til 11 homøopater. Foreldrene valgte samme medisin som homøopaten for 55% av barna.

To hundre og femtien barn som hadde vært til lege på grunn av en øvre luftveisinfeksjon ble rekruttert til å være med på en undersøkelse av effekten av en av tre selvvalgte homøopatiske medisiner i forebyggingen av ØLI hos barn. Indikasjonene som ble utviklet ble brukt. Barna ble tilfeldig fordelt til enten å få homøopatisk medisin eller placebo. Det var ingen signifikant forskjell i forekomsten av ØLI mellom de som fikk homøopatisk medisin sammenlignet med de som fikk placebo (median 9 dager på tre måneder i begge grupper) (p=0,531).

The aims of this dissertation were to investigate alcohol-related seizures in clinical neurological practice. We wanted to assess the extent of this problem, to classify the seizures, and to investigate methods to improve the clinical diagnosis of such seizures. We propose an arbitrary but simple and reproducible way of diagnosing alcohol-related seizures and alcohol withdrawal seizures. Papers I and II relate to seizure classification and the extent of the problem in relation to the level and weekly pattern of alcohol use. Paper III investigates the performance of various biological markers as aids in the diagnosis of alcohol-related seizures. Paper IV explores pitfalls in the result interpretation for two methods for detection of CDT in patients with neurological disorders. Paper V investigates the utility of standard EEG for the identification of alcohol-related seizures.

Even though the general alcohol consumption in our region is low, every third patient with an epileptic seizure leading to hospitalisation had hazardous alcohol consumption.

Evidence of focal lesions or focal seizure start was found in a high proportion of alcohol-related seizures. All such seizures were secondarily generalized and thus, we challenge the establishment impression that the vast majority of alcohol-related seizures are primarily generalized. Binge drinking (more than six drinks for men or four drinks for women, in a single drinking occasion) was common, but had little influence on seizure susceptibility or timing of seizures. In contrast to prior knowledge, we found that in some patients there was no time lag from cessation of drinking to the occurrence of a seizure, but falling intake levels prior to withdrawal seizures were demonstrated. This indicates that a state of relative withdrawal while still drinking may be sufficient to induce a seizure. Carbohydrate-deficient transferring (CDT) is the most accurate biomarker for alcohol use and good adjunct to the diagnosis of alcohol-related seizures, but its accuracy does not compete with a good clinical investigation. Generally poor accuracy should be expected for fertile women. Women on enzyme-inducing antiepileptic drugs who drink no or little alcohol seem to be at risk of having false positive CDT. Other variables associated with increased CDT were low body mass index, or having total transferring levels outside normal range. A definitely abnormal EEG suggests epilepsy or symptomatic seizures unrelated to alcohol use. The predictive value of a normal EEG is limited, but the typical post-ictal finding in alcohol-related seizures is nevertheless a normal low-amplitude EEG record.

The best method for identification of alcohol-related seizures is a clinical work-up based on a thorough medical history. The Alcohol Use Disorders Identification Test (AUDIT) provides a reliable measure of drinking habits. CDT is a good supplement to the clinical diagnosis when there is doubt, if factors associated with false-positive values are appreciated. The diagnostic value of EEG is limited.

The main purpose of the theses is to explore the significance of anxiety and depression in patterns of pain, fatigue, quality of life. Lifestyle, functional disability, co-morbidity and gender among individuals given the diagnosis of fibromyalgia by their doctor.

Diabetic nephropathy (DN) is associated with morbidity and mortality due to cardiovascular disease and renal failure. This study focused on the impact of glycemic control on the development of DN and the metabolic consequences of DN. The euglycemic hyperinsulinemic clamp technique was used to assess insulin sensitivity and insulin clearance. Two different registries, the Diabetes Incidence Study in Sweden (DISS) and the Swedish Childhood Diabetes Registry, as well as questionnaires and data from medical records were used to study diabetic complications in population-based cohorts.

Microalbuminuria is an early marker of DN and may also be associated with impaired insulin sensitiv-ity in diabetic and non-diabetic subjects. We studied the relationship between insulin sensitivity and the degree of albuminuria in patients with type 1 diabetes and micro- or macroalbuminuria but normal glomerular filtration rate (GFR). We did not find a direct quantitative association between the degree of albuminuria and insulin resistance, arguing against a cause-effect relationship.

With progression of DN, a decline in GFR is seen. Patients with severe renal failure have both im-paired insulin sensitivity and insulin clearance. We studied insulin sensitivity and insulin clearance in type 1 diabetes patients with three different degrees of renal involvement (none, only albuminuria, and slightly reduced GFR, ~40-70 ml/min/1.73 m2, respectively). A clear reduction in insulin sensitivity in vivo, but not in insulin clearance, was seen in the group with reduced GFR, and concomitant changes in the levels of PTH, IGF-1, IL-6 and TNF-α were found. In parallel, cellular insulin sensitivity and insulin degradation were examined in vitro, in subcutaneous fat cells but no differences were found between the three groups of patients.

To study the occurrence of renal involvement in patients with modern diabetes treatment we moni-tored a cohort of young adults from the DISS-registry with onset of diabetes in 1987-88 at age 15-34 years. We found that ~7% of the patients had signs of renal involvement, i.e. incipient nephropathy (5%) and overt nephropathy (2%), after a median follow-up of ~9 years and the strongest risk markers were poor glycemic control (HbA1c) and high blood pressure. Patients with type 2 diabetes were most prone to have renal involvement in this age group.

Retrospectively, we studied 94 patients diagnosed with type 1 diabetes in 1981-1992 at age 0-14 years at the Umeå University Hospital. Incipient nephropathy and background retinopathy occurred in 18 and 45%, respectively, of the patients, during ~12 years of follow-up. Glycemic control, also during the first five years of diabetes, was a strong risk marker. Young age at onset of diabetes prolonged the time to development of microvascular complications.

Conclusion: Despite modern diabetes treatment some patients with diabetes develop renal involvement within the first ten years. Inadequate glycemic control, also early in the disease, is a risk marker as well as type 2 diabetes and high blood pressure. In patients with type 1 diabetes and diabetic neph-ropathy a slightly reduced GFR, but not albuminuria, is associated with insulin resistance. Concomi-tant changes in insulin-antagonistic hormones and cytokines may be involved.

Sammanfattning

Syfte

Syftet med studien var att undersöka de kvinnliga internernas upplevda hälsa under anstaltsvistelsen. Frågeställningarna var följande:

• Vad uttrycker de intagna kvinnorna gällande sin upplevda fysiska och psykiska hälsa under anstaltsvistelsen?

• Vad upplever de intagna kvinnorna att anstalten gör för att förbättra deras hälsa?

Metod

Till grund för studien användes en kvalitativ metod. Intervjuer med semistrukturerade frågor genomfördes med fem intagna kvinnor. Urvalet skedde genom ett bekvämlighetsurval. Intervjuerna tolkades och analyserades sedan med utgångspunkt i det aktuella forskningsläget och den för studien teoretiska ansatsen.

Resultat

Samtliga kvinnor i studien beskrev sin upplevda hälsa som oförändrad eller bättre i jämförelse med innan de kom till anstalten. Kvinnorna som beskriver sig ha en bra upplevd hälsa är också de som verkar känna meningsfullhet under vistelsen på anstalt. De kvinnorna verkar även uppleva att de har ett mål att sträva mot, under och efter anstaltsvistelsen. Ett annat tydligt mönster som framkom var att de kvinnor som ville förändra sin situation och själva verkade redo att ta tag i den, upplevdes ha en bra hälsa. Det som internerna fann mest meningsfullt var programverksamheten och studierna. Majoriteten av de intervjuade kvinnorna ansåg inte att anstalten gör något för att de ska få en ökad hälsa under anstaltsvistelsen.

Slutsats

Slutsatsen av denna studie är att den upplevda hälsan hos de intagna kvinnorna var efter omständigheterna bra. Detta är ett motsatt resultat gentemot tidigare forskning. Det som framförallt var utmärkande för de kvinnor som upplevde sig ha en bra hälsa var att de kände en mening med anstaltsvistelsen, att de hade mål och en vilja att förändra sin situation. Att anstalten inte gör något för att främja de intagnas hälsa var kvinnorna överens om till en början. Men vid eftertanke ansåg de flesta att programverksamheten och studierna är något som anstalten gör.

Os problemas dermatológicos afetam aproximadamente um terço da população em algum momento da sua vida e, em aproximadamente 10 a 15% de todas as consultas médicas, a queixa principal deve-se a um problema dermatológico. A despeito desta importância, diversos estudos têm demonstrado deficiências no ensino de dermatologia nos cursos de graduação em medicina. Os sistemas de educação a distância baseados na internet representam uma das alternativas para corrigir esta deficiência e oferecer um maior contato do estudante de medicina com a especialidade. Considerando este cenário, o objetivo deste estudo foi desenvolver um programa de educação a distância em dermatologia para estudantes de graduação em medicina e avaliar o impacto deste mecanismo de ensino no aprendizado dos alunos. Foi realizado um estudo prospectivo incluindo estudantes do segundo ano da Faculdade de Medicina da Universidade de Tecnologia e Ciências de Salvador Bahia Brasil. Os 44 alunos selecionados foram divididos em dois grupos; o grupo que participou de atividades presenciais apenas e o grupo que participou das atividades presenciais associado ao curso de educação a distância (curso híbrido). Todos os alunos foram submetidos a uma avaliação pré e pós curso e o desempenho foi comparado entre os dois grupos. Os estudantes que participaram do curso híbrido apresentaram escores pós-teste superiores (8,9 ± 0,8) aos obtidos pelos alunos que participaram apenas das aulas presenciais (7,75 ± 0,98). Esta diferença foi estatisticamente significante (p <0,05). Os resultados indicaram que o desempenho dos alunos de graduação , do curso de educação a distância em dermatologia associado a atividades presenciais, foi superior ao curso presencial apenas
Dermatological disorders affects approximately one third of the general population. It is estimated that 10 to 15% of all office visits are for dermatologic complaints. Despite this fact, in medical school, the available time for teaching dermatology is usually very limited. The internet based distance education represents a viable alternative to provide greater contact with medical student with this specialty and meet the current deficiencies. Given this scenario, the objective of this study was to develop a program of internet based distance education in dermatology to undergraduate medical students and evaluate the impact of this tool on student learning. This prospective study included student form the second year of School of Medicine at the University of Technology and Science of Salvador Bahia Brazil. The 44 selected students were divided into two groups: the group that participated in classroom activities and the group that participated in classroom activities associated with distance education course (blended course). Tests were applied for all students before and after the course and both scores were evaluated. Students who participated of online discussions associated with face-to face activities had statistically higher post-test scores (8.9±0.8) than those who participated of the classroom activities alone (7.75±0.98). This difference was statistically significant (p <0.05). The results indicated superior performance of undergraduate students who participated in the course of distance education in dermatology associated with classroom activities (blended course) compared to classroom activities alone

The overall aim of this thesis was to characterize single-channel aEEG/EEG, recorded during the first postnatal days in preterm infants, in relation to brain function and two-year outcome. Study I investigated if aEEG/EEG was associated with neonatal brain injury, inflammation and outcome in 16 very preterm (VPT) infants. The interburst interval (IBI) was prolonged, and aEEG amplitudes were lower in infants with brain injury, and in infants developing handicap. Cord blood TNF-α correlated with IBI. Study II investigated inter-rater agreement of visual burst detection, as compared to automated burst detection based on a non-linear energy operator (NLEO) in an EEG data set from 12 extremely preterm (EPT) and 6 VPT infants. The sensitivity of the NLEO was 64 % and 69 % (EPT and VPT infants, respectively) and the specificity 96 % and 88 %. The algorithm was then modified to further improve the accuracy. Study III investigated if arterial carbon dioxide and plasma glucose is associated with EEG continuity. In 247 sets of samples (PaCO2, plasma glucose, IBI) from 32 EPT infants there was a positive association between PaCO2 and IBI; higher PaCO2 was associated with longer IBI. Corrected for carbon dioxide, plasma glucose had a U-shaped association with IBI in infants with good outcome. Study IV investigated the predictive value of aEEG/EEG in 41 EPT and 8 VPT infants. All VPT infants had good outcome. Predictors of outcome in EPT infants included presence or absence of burst-suppression, continuous activity and cyclicity, median IBI and interburst%. Seizures were associated with neonatal brain damage but not with outcome. Improved preterm brain monitoring may in the future be used for early identification of infants at high risk of brain damage and adverse outcome, which may have implications for direction of care and for early intervention.

The studies in the present thesis sought to define virus and host factors that can influence on the susceptibility to murine retrovirus infection. In addition, we wanted to study possible correlations between events of early infection and subsequent disease progression. For an extensive discussion of the major findings, the reader is referred to papers I-IV. The following section will give a general discussion concerning 1) some methodological aspects; 2) the course of FIS-2 infection; 3) determinants responsible for erythroleukaemia; 4) determinants responsible for immunosuppression; and, 5) does sex matter?

In questo volume di tesi viene analizzato il processo di creazione di una web-app in ambito medico. La tesi è divisa in 3 capitoli ognuno propedeutico per il successivo e necessari al fine di avere una completa visione del progetto. Si inizia descrivendo la storia del web e le sue tecnologie, poi si descrivono i suoi usi in campo medico, con una parentesi introduttiva anche nello specifico di dove viene usata l'applicazione. Si analizzano le tecnologie usate (linguaggi, framework, strumenti esterni), trattando sia della loro storia che delle loro specifiche. Infine si descrive lo sviluppo del progetto realizzato, vero fulcro della tesi. Si descrivono le richieste, l’analisi, la progettazione, le scelte adoperate, alcuni pezzi di codice e gli sviluppi futuri dell'applicazione.

Introduction. The challenge of Emergency Medicine is to guarantee optimal care in very complex and environmentally dependent situations. Within all acute events, cardiac arrest is the most dramatic event that could occur. Having tools for training, research and the validation of protocols and procedures is necessary. Simulation encompasses all of these aspects and could meet the challenge of increasingly good patient care. Aim. My main project was to develop new simulation modalities to improve training and research in cardiac arrest. Methods. 1) Holo-BLSD is an Augmented Reality self-instruction training system, in which a standard CPR manikin is “augmented” within an interactive virtual environment that reproduces realistic scenarios. During the experience, users were trained to use the device while being guided through an emergency simulation and, at the end, were asked to complete a survey to assess the usability of the Holo-BLSD. Subsequently we enrolled 58 volunteer first-year nursing students randomly split in two groups: 29 participants underwent a self- training with the Holo-BLSD tool, and 29 students (control group) were trained in a traditional instructor-led course. We analyzed the appropriateness of action learning. 2) This study is a multi-center randomized controlled three-arm trial based on simulation. The intervention arm tested the PediAppRREST app; the two control arms, instead, were allocated to the PALS pocket card and to no cognitive aid, respectively. All participants are residents in Pediatrics, Anesthesia and Intensive Care or Emergency Medicine. The primary outcome of the study is a score calculated according to the c-DEV15plus checklist, which represents the number of deviations from PALS guidelines performed by each team during the management of the simulated cardiac arrest scenario. Results. 1) Holo-BLSD was rated easy to use (mean 4.00, SD 0.94), and the trainees stated that most people would learn to use it very quickly (mean 4.00, SD 0.89). Voice (mean 4.48, SD 0.87), gaze (mean 4.12, SD 0.97), and gesture interaction (mean 3.84, SD 1.14) were judged positively, although some hand gesture recognition errors reduced the feeling of having the right level of control over the system (mean 3.40, SD 1.04). The average overall examiner scores of the two groups are rather close (39.48 for the traditional training group, 37.07 for the Augmented Reality training group, on a maximum score of 44) and their difference is not statistically significant. 2) This is an interim analysis of the trial, including a sample size equal to approximately 78% of the final sample; so far, 82 teams. The c-DEV15plus score, expressed as median (IQR), was 3.0 (2.0-4.0) in the intervention arm and 6.0 (4.0-7.0) and 6.0 (5.0-7.0) in the CtrlPALS+ and CtrlPALS- control arms, respectively (p<0.0001). The CPT score, a validated indicator of the resuscitation performance, showed an improvement trend in the intervention group, which is statistically significant (p=0.0059). The team leaders’ workload resulted similar in the three groups. With regards the time of the first compression and to first adrenaline administration, no statistically significant differences were shown between the study groups. RCP quality was suboptimal, with no significant statistical differences between the three groups. The usability of the app was good according to the System Usability Scale (median of 77.5). Conclusions. The different simulation modalities (AR and High fidelity) were used in both the training and research and showed good results
Introduction. The challenge of Emergency Medicine is to guarantee optimal care in very complex and environmentally dependent situations. Within all acute events, cardiac arrest is the most dramatic event that could occur. Having tools for training, research and the validation of protocols and procedures is necessary. Simulation encompasses all of these aspects and could meet the challenge of increasingly good patient care. Aim. My main project was to develop new simulation modalities to improve training and research in cardiac arrest. Methods. 1) Holo-BLSD is an Augmented Reality self-instruction training system, in which a standard CPR manikin is “augmented” within an interactive virtual environment that reproduces realistic scenarios. During the experience, users were trained to use the device while being guided through an emergency simulation and, at the end, were asked to complete a survey to assess the usability of the Holo-BLSD. Subsequently we enrolled 58 volunteer first-year nursing students randomly split in two groups: 29 participants underwent a self- training with the Holo-BLSD tool, and 29 students (control group) were trained in a traditional instructor-led course. We analyzed the appropriateness of action learning. 2) This study is a multi-center randomized controlled three-arm trial based on simulation. The intervention arm tested the PediAppRREST app; the two control arms, instead, were allocated to the PALS pocket card and to no cognitive aid, respectively. All participants are residents in Pediatrics, Anesthesia and Intensive Care or Emergency Medicine. The primary outcome of the study is a score calculated according to the c-DEV15plus checklist, which represents the number of deviations from PALS guidelines performed by each team during the management of the simulated cardiac arrest scenario. Results. 1) Holo-BLSD was rated easy to use (mean 4.00, SD 0.94), and the trainees stated that most people would learn to use it very quickly (mean 4.00, SD 0.89). Voice (mean 4.48, SD 0.87), gaze (mean 4.12, SD 0.97), and gesture interaction (mean 3.84, SD 1.14) were judged positively, although some hand gesture recognition errors reduced the feeling of having the right level of control over the system (mean 3.40, SD 1.04). The average overall examiner scores of the two groups are rather close (39.48 for the traditional training group, 37.07 for the Augmented Reality training group, on a maximum score of 44) and their difference is not statistically significant. 2) This is an interim analysis of the trial, including a sample size equal to approximately 78% of the final sample; so far, 82 teams. The c-DEV15plus score, expressed as median (IQR), was 3.0 (2.0-4.0) in the intervention arm and 6.0 (4.0-7.0) and 6.0 (5.0-7.0) in the CtrlPALS+ and CtrlPALS- control arms, respectively (p<0.0001). The CPT score, a validated indicator of the resuscitation performance, showed an improvement trend in the intervention group, which is statistically significant (p=0.0059). The team leaders’ workload resulted similar in the three groups. With regards the time of the first compression and to first adrenaline administration, no statistically significant differences were shown between the study groups. RCP quality was suboptimal, with no significant statistical differences between the three groups. The usability of the app was good according to the System Usability Scale (median of 77.5). Conclusions. The different simulation modalities (AR and High fidelity) were used in both the training and research and showed good results

Syfte: Syftet med studien var att undersöka hur olika axiala tryck och skjuvkrafter påverkade marginal och intern passform i en sexledsbro i titan i överkäkens frontregion.Material och metod: En litteratursökning gjordes för att insamla bakgrundsmaterial. Stödtänderna 13 12 11 21 22 23 preparerades på en plastmodell för en sexledsbro och en anatomiskt utformad bro i titan framställdes med hjälp CAD/CAM. En mastermodell av stödtänderna tillverkades i epoxyresin. Genom att använda replikateknik utvärderades brons passform vid olika cementeringstryck; 20, 35, 50, 70 N och 50 N med skjuvkrafter. Varje replika snittades med hjälp av en ”jig” och cementspalten analyserades i ett mikroskop. All data granskades statistiskt.Resultat: Resultatet visade att ett tryck med 20 N generellt gav en ej acceptabel passform och ett tryck med 35 N hade en stor spridning. Vid tryck med 50 N kunde mindre cementspalter ses. De blev inte mindre vid test med 70 N. När skjuvkrafter adderades försämrades resultaten jämfört med försöken med 50 N och 70 N.Konklusion: Ett tryck vid cementering som överstiger 50 N förbättrar ej passformen markant. Närvaro av skjuvkrafter påverkar passformen negativt. Ett lägre tryck på 20 N ger dock en mindre fördelaktig passform jämfört med skjuvkrafter förutsatt att ett tillräckligt högt tryck används. Alla slutsatser var statistiskt signifikanta.
Purpose: The purpose of this study is to investigate how different axial seating loads and shear loads influences the marginal and internal fit of a titanium six unit FDP in the upper jaw frontal region.Materials and Methods: A literature search was made to acquire background material. Preparations of abutment teeth for a six unit FDP 13 12 11 21 22 23 were made on plastic teeth, and an anatomically designed titanium FDP was constructed using CAD/CAM. A master cast of the abutment teeth was fabricated in epoxy resin. Using the impression replica technique the fit of the FDP was evaluated by different seating loads during cementation; 20, 35, 50, 70 N and 50 N under the presence of shear loads. The replicas were sectioned using a jig and the cement gap was analysed using a microscope. All the data were statistically analysed.Results: The results showed that a seating load of 20 N generally gave an unacceptable fit and that the seating load of 35 N had great range. At seating loads of 50 N less cement gaps could be seen, i.e. more favourable fit. These results did not improve when testing with 70 N. With a presence of shear loads the results were poorer than when testing with 50 and 70 N.Conclusions: A seating load exceeding 50 N during cementation does not markedly give a more favourable fit. The presence of shear loads affects the fit negatively. A lower seating load of 20 N gives a less favourable fit compared to shear loads provided that a seating load high enough is used. All of these conclusions were statistically significant.

Myelomatose (benmargskreft) er en blodsyk dom som rammer ca 200 nordmenn årlig. Sykdommen kan ikke kureres og karakteriseres av symptomer som benmargssvikt og infeksjonstendenns, men kanskje først og fremst av sykelig nedbrytning av skjelettet. Pasientene rammes i høy utstrekning av benbrudd, hvirvelsammenfall og skjelettsmerter. Mekanismene for bennedbrytning og vekstkontroll står sentralt i avhandlingsarbeidet som består av fem artikler om cytokiners rolle i myelomatose. Cytokiner er signalsubstanser som benyttes i celle-celle-kommunikasjon. Det er sannsynligvis ubalanse av cytokiner som forårsaker den sykelige nedbrytningen av bensubstansen.

Det første delarbeidet omhandler funnet av hepatocyttvekstfaktor (HGF) som er uttrykt hos nesten alle pasienter med myelomatose Dette påvises med forskjellige teknikker og det benyttes bl a en separasjonsmetode for myelomceller basert på Ugelstadkuler som ble utviklet ved IKM i 1993. Videre påvises forhøyede nivåer av HGF i serum fra pasienter. Et interessant funn er at HGF reseptor også er uttrykt i pasientprøver, hvilket kan tale for at myelomceller kan ha en selvstimulerende (autokrin) funksjon.

I det andre delarbeidet vises en dyremodell for myelomatose i immundefekte mus. Et hovedpoeng er at det lar seg gjøre å få vekst av myelomceller i musebenmarg med påvisbare tegn til patologisk bennedbrytning på røntgen og ved histologisk undersøkelse. Musene har forhøyede nivåer av HGF i serum. Benlesjonene ble karakterisert ved hjelp av histomorfometri. Denne undersøkelse viste 99% reduksjon av de bendannende cellene (osteoblaster) og 33% reduksjon av bennedbrytende celler (osteklaster).

I tredje delarbeidet viser man at HGF induserer interleukin (IL)-11-produksjon i osteoblaster. IL-11 er en kjent påskynder av benresorpsjon og osteoklastaktivator. Et interessant fenomen er at HGF ser ut til å være bundet til heparansulfat på cellemembranen og at slikt membranbundet HGF virker bedre enn løselig HGF. Effekten av HGF potensieres av cytokinene TGF-beta og IL-1. En styrke ved arbeidet er at såvel ferskisolerte pasientceller som cellelinjer viser identiske mønstre. Arbeidet angir en mulig måte som HGF kan befremme bennedbrytning.

I fjerde delarbeid vises at cytokinet IL-15 forhindrer programmert celledød (apoptose) i myelomcellelinjen OH-2. Det var fra før kjent at myelomceller relativt hyppig lar seg stimulere av cytokinet IL-6, som fortsatt er den mest anerkjente myelomvekstfaktoren. IL-15 var tilnærmet like potent antiapoptotisk som IL-6, og befremmet også kortvarig proliferasjon. IL-15s effekt kunne potensieres av TNF-alfa

I femte delarbeid påvises at cytokinet benmorfogent protein (BMP)-4 hemmer vekst av myelomceller. BMP-4 befremmer bendannelse. Effekten av BMP-4 kom fram i IL-6-stimulerte cellelinjer og pasientprøver. Effekten skyldtes såvel induksjon av apoptose som stopp i cellesyklus G1-fase. Dette er et mulig viktig funn siden man kan tenke seg at pasienter med myelomatose kunne behandles med BMP-4 eller lignende substanser. På slik måte ville såvel skjelettnedbrytningen som myelomcellevekst kunne påvirkes gunstig.

Arbeidet bidrar til forståelse av molekylære mekanismer for bendestruksjon og myelomcellevekst og ble veiledet av profesor dr. med. Anders Waage. Henrik Hjorth-Hansen har vært stipendiat i Den norske kreftforening, og undersøkelsen ble dessuten støttet av Kreftfondet ved RiT og Blix’ legat.

Cognitive behaviour therapy (CBT) is an effective treatment for depression but access is limited. One way of increasing access is to offer CBT via the Internet. In Study I, guided Internet-based CBT was found to have a large effect on depressive symptoms compared to taking part in an online discussion group. Approximately two hours were spent on guiding each patient and the large effect found differs from previous studies that showed smaller effects, probably due to lack of guidance. The intervention had no effect on the participants’ quality of life but significantly decreased their level of anxiety. Internet-based versions of self-report measures can be more practical and efficient than paper versions. However, before implementation, evidence of psychometrical equivalence to the paper versions should be available. This was tested in Studies II and III for the Montgomery-Åsberg Depression Rating Scale – Self-rated (MADRS-S) and the Beck Depression Inventory – Second Edition (BDI-II). When the full scales were investigated, equivalent psychometric properties were found in the two versions of the MADRS-S and BDI-II. However, in the Internet-version of the BDI-II, a lower score was found for the question about suicidality and the difference was statistically significant. Although the difference was small, this indicates that suicidality might be underestimated when using the Internet-based BDI-II. As the long-term prognosis after treatment for depression is poor, in Study IV we investigated the possibility of delivering CBT-based relapse prevention via the Internet. The results revealed that fewer participants in the intervention group experienced a relapse compared to the control group and that the time spent on guiding each participant was approximately 2.5 hours. A trend towards a higher remission rate was found in the CBT group at the six-month follow-up and a reduction of depressive symptoms was associated with a lowered risk of relapse. CBT-based relapse prevention via the Internet can potentially be made available to large numbers of patients, thus improving their prognosis. The Internet increases the possibilities for health care providers in the management of depression.

Ultraljud av halsartärer är en duplexultraljud undersökning som har en förmåga attavbilda samt mäta flödeshastigheten i halskärlen. Med undersökningen kaneventuella förändringar i form av plack, stenoser samt ocklusioner utredas ihalsens artärer. Arteria carotis interna (ICA) anses vara ett väsentligt kärl belägenanatomiskt posteriort om halsen med huvuduppgift att försörja hjärnan med blod.Stenoser i ICA kan leda till ett flertal allvarliga symptom såsom transistoriskischemisk attack, övergående blindhet samt stroke. Den dominerande orsaken tilldessa allvarliga symptom samt förändringar i kärlen är arterioskleros. För korrektbehandling för den drabbade patienten betraktas bedömningen av stenosgradenvara väldigt viktigt. Syftet med denna studie är att undersöka sambandet mellanstenosgraden bedömd utifrån systolisk flödeshastighet i ICA och stenosgradberäknad med hastighetskvot mellan maximal systolisk flödeshastighet i ICA ochmaximal systolisk flödeshastighet i arteria carotis communis (CCA) samtslutdiastolisk flödeshastighet i ICA. Till studien inkluderades totalt 200 kärl(höger och vänster), av de användes 130 kärl. Parametrar som behövdes tillstudien var slutdiastoliska flödeshastighet i ICA samt maximal systoliskaflödeshastighet i ICA och CCA. Patienterna hade olika stenosgrader <40%->95%,i höger och vänster ICA. Hastighetskvoten ICA/CCA beräknades och användesför undersökning av sambandet med hjälp av statistiska analysmetoder. Resultatenav studien uppvisade att det föreligger ett signifikant samband mellanstenosgraden bedömd med maximal systolisk flödeshastighet i ICA ochstenosgraden bedömd med hastighetskvoten och slutdiastolisk flödeshastighet.Däremot så har hastighetskvoten ICA/CCA starkare överensstämmelse medstenosgraden bedömd med maximal systolisk flödeshastighet, jämfört med det förslutdiastolisk flödeshastighet. Slutsatsen är att hastighetskvoten kan användas fören säker bedömning av stenosgraden och bör med stor säkerhet återspeglastenosgraden i ICA.
Ultrasound of carotid arteries is a duplex ultrasonography that has the ability toimage as well as measure the flow rate in the vessels. With this analysis it ispossible to detect any changes in the shape of plaque, stenosis and occlusions incarotid arteries. Internal carotid artery (ICA) is considered to be an essentialvessel, supplies the anterior part of the brain with blood. Internal carotid stenosisleads to several severe symptoms such as transient ischemic attack, transientblindness and stroke. The main reason of these symptoms and changes in thevessels is atherosclerosis. Degree of stenosis is considered very important to givepatients the proper treatment. The aim of this study is to investigate therelationship between the degree of stenosis evaluated with maximum systolic flowrate in ICA and degree of stenosis evaluated with calculated flow rate ratio ICAand common carotid artery (CCA) and end diastolic flow rate in ICA. The studyincluded a total of 200 vessels (right and left), of which 130 vessels were used.Parameters needed for the study were vessels with stenosis degree of internalcarotid artery, end diastolic flow rate in ICA and maximum systolic flow rate inICA and CCA. The patients had different degrees of stenosis between <40% ->95% in the right and left ICA. The rate ratio ICA/CCA was calculated and used toinvestigate the relationship using statistical analysis methods. The results of thestudy showed that there is a strong and significant correlation between the degreeof stenosis assessed with maximum systolic flow rate in ICA and the degree ofstenosis assessed with the rate ratio and end diastolic flow rate. In contrast, therate ratio ICA/CCA has stronger compliance with the degree of stenosis assessedat maximum systolic flow rate, compared with that for end diastolic flow rate.This leads to the conclusion that the rate ratio can be used for a safe assessment ofthe degree of stenosis in ICA and should with great certainty reflect the degree ofstenosis in ICA.