Dissertations / Theses on the topic 'Patient's classification systems'

Der Einsatz elektronischer Dateneingabeinstrumente im medizinischen Bereich verbessert die Kollaboration zwischen Patienten, Arzt und Fachpersonal durch adaptive Inhalte, Plausibilitätsprüfung und vereinfachte Eingabemethoden. In einem interdisziplinären Gemeinschaftsprojekt des Lehrstuhls für Multimediatechnik der TU Dresden und des Multiple Sklerose Zentrum Dresdens wurde ein Touchscreen-basiertes System für die Selbstbefragung von Multiple Sklerose Patienten entwickelt, evaluiert und in das etablierte neurologische Dokumentationssystem MSDS eingebunden. Im vorliegenden Beitrag wird der Einfluss von Fragebögen bei Patientenkonsultationen beschrieben, die Evaluation Touchscreen-basierter Eingabemethoden und entwickelter Gestaltungskonzepte für elektronische Selbstbefragungen dargestellt sowie der Einsatz der entwickelten Benutzerschnittstelle für Multiple Sklerose Patienten mit dem MSDS aufgezeigt.

Rehabilitation outcomes are an important measurement of trauma system effectiveness. However, currently there is no clinically applicable trauma rehabilitation score or framework available to evaluate health and rehabilitation needs after trauma. The World report on Disability (2011) recommended the application of the World Health Organisation International Classification of Function, Disability and Health (ICF) as a framework for all aspects of rehabilitation. A standardised language, based on coded categories would aid in international efforts to evaluate health and disability globally. The ICF framework has not been applied in trauma rehabilitation or trauma systems to date. The objectives were to investigate rehabilitation needs of trauma patients and evaluate to what extent the ICF can be used as a framework to capture and assess health and rehabilitation outcome of patients following traumatic injuries. Two cohort studies with 103 and 308 patients respectively demonstrated the utility of the Rehabilitation Complexity Scale (RCS) in an acute trauma setting. The RCS outperformed other acute measures and rehabilitation complexity correlated with length of stay and discharge destination. A systematic review of 34 articles confirmed that outcome measures frequently used in trauma outcome studies represent only six percent of health concepts contained in the ICF. A quantitative international on-line questionnaire with expert clinicians working in trauma (n=217), identified 121 ICF categories pertinent to rehabilitation and health outcome of trauma patients. Qualitative patient interviews (n=32) identified nearly double the amount of ICF categories (n=234) compared to clinicians. Combined analysis of qualitative and quantitative data presents 109 ICF categories important for rehabilitation and health outcome assessment of trauma patients, using the ICF as a framework. This thesis describes the need for improved outcome evaluation of trauma patients. It demonstrates the acceptability of the ICF language and framework amongst clinicians and suggests the application of the ICF as a framework for trauma service delivery and outcome assessment.

Objective: The European League Against Rheumatism and the American College of Rheumatology jointly embarked on a new classification criteria for systemic lupus erythematosus (SLE) project. Its first phase involved generation of a broad set of items potentially useful for classification of SLE. This study was undertaken to add the patient perspective to an expert Delphi approach and an early patient cohort study. Methods: A national cross-sectional study was conducted. A self-report questionnaire was published in the ‘‘Schmetterling’’ (Butterfly), the quarterly journal of the German SLE patient association. Individuals with SLE were asked to anonymously complete the questionnaire, which asked for demographic details, organ manifestations, autoantibodies and symptoms. Results: A total of 339 completed questionnaires out of 2498 were returned, a response rate of 13.6%; 83.2% reported they were ANA positive and 81.7% reported joint, 66.1% skin and 33.0% renal involvement. For the time before and in the first year after their SLE diagnosis, the majority reported fatigue (89.4%), joint pain (86.7%), photosensitivity (79.4%) and myalgia (76.1%). Of interest, more than half of the patients reported fever as an early symptom (53.7%). Conclusion: For a Caucasian European SLE patient population, the overall characteristics suggest meaningful representation. While many symptoms were reported as expected, the high percentage of patients reporting fever and the significant number of patients with unexpected gastrointestinal complaints are of particular interest. These data add to the information on early SLE symptoms informing the development process of new SLE classification criteria.

Background and Purpose: In 2007, the WHO classification of brain tumors was extended by three new entities of glioneuronal tumors: papillary glioneuronal tumor (PGNT), rosette-forming glioneuronal tumor of the fourth ventricle (RGNT) and glioneuronal tumor with neuropil-like islands (GNTNI). Focusing on clinical characteristics and outcome, the authors performed a comprehensive individual patient data (IPD) meta-analysis of the cases reported in literature until December 2012. Methods: PubMed, Embase and Web of Science were searched for peer-reviewed articles reporting on PGNT, RGNT, and GNTNI using predefined keywords. Results: 95 publications reported on 182 patients (PGNT, 71; GNTNI, 26; RGNT, 85). Median age at diagnosis was 23 years (range 4–75) for PGNT, 27 years (range 6–79) for RGNT, and 40 years (range 2–65) for GNTNI. Ninety-seven percent of PGNT and 69% of GNTNI were located in the supratentorial region, 23% of GNTNI were in the spinal cord, and 80% of RGNT were localized in the posterior fossa. Complete resection was reported in 52 PGNT (73%), 36 RGNT (42%), and 7 GNTNI (27%) patients. Eight PGNT, 3 RGNT, and 12 GNTNI patients were treated with chemo- and/or radiotherapy as the primary postoperative treatment. Follow-up data were available for 132 cases. After a median follow-up time of 1.5 years (range 0.2–25) across all patients, 1.5-year progression-free survival rates were 52±12% for GNTNI, 86±5% for PGNT, and 100% for RGNT. The 1.5-year overall-survival were 95±5%, 98±2%, and 100%, respectively. Conclusions: The clinical understanding of the three new entities of glioneuronal tumors, PGNT, RGNT and GNTNI, is currently emerging. The present meta-analysis will hopefully contribute to a delineation of their diagnostic, therapeutic, and prognostic profiles. However, the available data do not provide a solid basis to define the optimum treatment approach. Hence, a central register should be established.

Effective prevention, or treatment, of invasive fungal infection in the neutropenic patient has hitherto been unsatisfactory because of either an inadequate anti-fungal spectrum of the agent or important toxicity. Itraconazole is effective against a broad spectrum of the opportunistic pathogens seen in Europe and North America. Prior problems with absorption, e.g. in the marrow transplant recipient, have been overcome with the introduction of an oral solution and an i.v. preparation. The deliberations of an expert meeting held in June, 1998 include recommendations on which patient requires one of these new preparations based on clinical trials, the dose and route. Important drug interactions are also detailed.<br>Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Frameless neuronavigational systems are a recent novelty for a precise approach to intracerebral tumours in open surgery. In this study 66 patients with a variety of intracranial tumours in various locations underwent surgical resection with neuronavigational guidance. Two different neuronavigational systems – the arm- and pointer-based ISG viewing wand and the miroscope-based MKM system – were compared for four different indications. Neuronavigation was used (a) in multiple tumours, e. g. brain metastases, (b) in solitary cortical or subcortical tumours located in eloquent brain areas, e. g. motor cortex or speech region, (c) in deep-situated brain tumours, including brain stem neoplasms, and (d) in infiltratively growing tumours to define the borders of the lesion. Using taped skin markers (MKM system) and a surface-fit algorithm (viewing wand) for registration, an accuracy of 1 to 2 mm deviation was achieved, which was sufficient for removal of all of the intracranial neoplasms investigated. Both systems proved to be safe and useful surgical tools regardless of the patient`s age, positioning of the patient during surgery or the location of the lesion. When these two systems were compared, the viewing wand was found to be preferable for resection of multiple brain tumours located in distant operative sides and solitary tumours in eloquent brain areas; this was because of the wide range of movement of the pointing device and the possibility of 3D reconstruction of the brain surface. As the MKM system provided the option of stereotactical guidance during the operative procedure, it was found to be superior in approaching small and deep-situated lesions. In certain cases brain shifting due to early drainage of the CSF led to minor underestimation of the real depth. For the precise definement of tumour borders of intraparenchymal neoplasms both system were equally suitable. However, intrusion of brain parenchyma into the resection cavity led to minor overestimation of the real tumour size in certain large intraparenchymal tumours.<br>Rahmenfreie Neuronavigationssysteme stellen eine Neuerung in der offenen operativen Behandlung intrazerebraler Tumoren dar. In dieser Studie wurden 66 Patienten mit verschiedenen intrakraniellen Tumoren in unterschiedlichen Lokalisationen mit Hilfe der Neuronavigation operiert. Hierbei wurden zwei verschiedene Navigationssysteme – ein Arm- und Pointer-basierendes System (ISG Viewing Wand) und ein Mikroskop-basierendes System (MKM) – für vier verschiedene Indikationen miteinander verglichen. Die Neuronavigation wurde verwendet (a) bei multiplen Tumoren, wie z.B. Hirnmetastasen, (b) bei solitären kortikalen oder subkortikalen Prozessen in eloquenten Hirnarealen, wie z.B. Motorkortex oder Sprachregion, (c) bei tiefgelegenen Hirntumoren einschließlich Hirnstammtumoren und (d) bei infiltrativ wachsenden Tumoren zur Bestimmung der Tumorgrenzen. Die Verwendung von Hautklebemarkern (MKM-System) und eines Oberflächen-Anpassungsalgorithmus (Viewing Wand) zur Registrierung war mit einer Genauigkeit von 1 bis 2 mm Abweichung für die operative Entfernung aller intrakraniellen Tumoren ausreichend. Beide Systeme bestätigten sich als sichere und geeignete chirurgische Hilfsmittel unabhängig vom Alter der Patienten, der Lagerung des Patienten unter dem chirurgischen Eingriff und der Lokalisation der Raumforderung. Im Systemvergleich zeigte die Viewing Wand durch einen weiten Bewegungsraum des Pointers und der Möglichkeit einer dreidimensionalen Rekonstruktion der Hirnoberfläche Vorteile in der Entfernung von multiplen, in entfernten Hirnregionen gelegenen Tumoren sowie von solitären Prozessen in eloquenter Lokalisation. Das MKM-System war durch die Bereitstellung einer stereotaktischen Führung während des operativen Eingriffes in der Ansteuerung kleiner tiefgelegener Prozesse zu bevorzugen. Eine frühzeitige Liquordrainage führte zu einem brain shifting mit einer diskreten Unterschätzung der wirklichen Tiefe. Für eine genaue Festlegung der Tumorgrenzen von intraparenchymalen Tumoren waren beide Systeme vergleichbar geeignet. Das Relabieren von Hirngewebe in die Resektionshöhle führte jedoch in einigen Fällen von großen intraparenchymalen Tumoren bei beiden Systemen zu einer geringen Überschätzung der wirklichen Tumorgrenzen.<br>Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Introduction: There has been a continuous development of new technologies in healthcare that are derived from national quality registries. However, this innovation needs to be translated into the workflow of healthcare delivery, to enable children with long-term conditions to get the best support possible to manage their health during everyday life. Since children living with long-term conditions experience different interference levels in their lives, healthcare professionals need to assess the impact of care on children’s day-to-day lives, as a complement to biomedical assessments. Aim: The overall aim of this thesis was to explore and describe the use of instruments about health-related quality of life (HRQOL) in outpatient care for children with long-term conditions on the basis of a national quality registry system. Methods: The research was conducted by using comparative, cross-sectional and explorative designs and data collection was performed by using different methods. The questionnaire DISABKIDS Chronic Generic Measure -37 was used as well as semi-structured interviews and video-recordings from consultations. Altogether, 156 children (8–18 years) and nine healthcare professionals participated in the studies. Children with Type 1 Diabetes (T1D) (n 131) answered the questionnaire DISABKIDS and children with rheumatic diseases, kidney diseases and T1D (n 25) were interviewed after their consultation at the outpatient clinic after the web-DISABKIDS had been used. In total, nine healthcare professionals used the HRQOL instrument as an assessment tool during the encounters which was video-recorded (n 21). Quantitative deductive content analysis was used to describe content in different HRQOL instruments. Statistical inference was used to analyse results from DISABKIDS and qualitative content analysis was used to analyse the interviews and video-recordings. Results: The findings showed that based on a biopsychosocial perspective, both generic and disease-specific instruments should be used to gain a comprehensive evaluation of the child’s HRQOL. The DISABKIDS instrument is applicable when describing different aspects of health concerning children with T1D. When DISABKIDS was used in the encounters, children expressed positive experiences about sharing their results with the healthcare professional. It was discovered that different approaches led to different outcomes for the child when the healthcare professionals were using DISABKIDS during the encounter. When an instructing approach is used, the child’s ability to learn more about their health and how to improve their health is limited. When an inviting or engaging approach is used by the professional, the child may become more involved during the conversations. Conclusions: It could be argued that instruments of HRQOL could be used as a complement to biomedical variables, to promote a biopsychosocial perspective on the child’s health. According to the children in this thesis, feedback on their results after answering to web-DISABKIDS is important, which implies that healthcare professionals need to prioritize time for discussions about results from HRQOL instruments in the encounters. If healthcare professionals involve the child in the discussion of the results of the HRQOL, misinterpreted answers could be corrected during the conversation. Concurrently, this claims that healthcare professionals invite and engage the child.

Pancreatic islet beta cell failure causes type 2 diabetes in humans. To identify transcriptomic changes in type 2 diabetic islets, the Innovative Medicines Initiative for Diabetes: Improving beta-cell function and identification of diagnostic biomarkers for treatment monitoring in Diabetes (IMIDIA) consortium (www.imidia.org) established a comprehensive, unique multicentre biobank of human islets and pancreas tissues from organ donors and metabolically phenotyped pancreatectomised patients (PPP).

RESUMO - Caracterização do problema: A inadequação e ineficácia do sistema de financiamento ―por diária‖ dos cuidados de reabilitação resultaram na necessidade de criação de sistemas de classificação de doentes de reabilitação em regime de internamento, em muitos países. Também em Portugal é necessário implementar um sistema de financiamento, baseado num sistema de classificação de doentes, ajustado pela complexidade e necessidade de cuidados destes doentes. Objectivos: Caracterização dos cuidados de reabilitação em Portugal, e do actual sistema de financiamento destes doentes; realização de uma revisão de literatura dos sistemas de classificação de doentes de reabilitação já existentes, de modo a compreender quais as variáveis de agrupamento utilizadas e qual a capacidade de previsão dos custos destes mesmos sistemas; perceber a importância da implementação de um dos sistemas de classificação em Portugal, e quais as suas vantagens. Metodologia: Da revisão de literatura efectuada, foram encontrados quatro sistemas de classificação de doentes implementados e/ou em vias de serem implementados como base para um sistema de financiamento, nos EUA, Austrália e Canadá. Foi efectuada uma extensa caracterização e análise crítica dos mesmos. Conclusões: Podemos concluir, que dos poucos sistemas de classificação de doentes de reabilitação existentes, optou-se pelo estudo de uma possível adopção do sistema norte-americano para a realidade portuguesa, por ser o único sistema de classificação já utilizado para fins de financiamento para todos os doentes de reabilitação desde 2002, o que inclui mais variáveis de decisão na classificação dos doentes, e o que permite a maior previsão dos custos dos doentes em termos percentuais.<br>ABSTRACT - Background: The inadequacy and inefficiency of the “per diem” funding system of rehabilitation care resulted in the need to create classification systems for inpatient rehabilitation, in many countries. Also in Portugal it´s necessary to implement a funding system based on a patient classification system, adjusted by complexity and need for care of these patients. Aims: Characterization of rehabilitation care in Portugal, and the current funding system of these patients; conducting a literature review of patient classification systems for rehabilitation, in order to understand which are the grouping variables used and what is the ability of costs prediction in each of the systems; understand the importance of implementing a classification system in Portugal, and its advantages. Methods: A literature search was performed, and four patient classification systems were found in the U.S., Australia and Canada. Some are already implemented, and others are about to be implemented as the basis for a new funding system. An extensive description and critical analysis of these systems was performed. Conclusions: After the analysis of the existing patient classification systems for rehabilitation, we chose to study a possible adoption of the American system for the Portuguese reality, because it´s the only classification system already used for funding purposes for all rehabilitation patients since 2002, it includes more decision variables for the classification of patients, and which allows the highest cost estimate.

Background: Subtle and inconsistent differences in hypothalamic-pituitary-adrenal (HPA) axis activity have been reported for patients with panic disorder. While these patients show little or no alterations in basal ACTH and cortisol levels, it has been hypothesized that HPA hyperresponsivity was a trait in panic patients when exposed to novel and uncontrollable stimulation. Methods: Thirty-four patients (23 females, mean age 35 yrs) diagnosed with panic disorder were compared to 34 healthy controls matched for age, gender, smoking status, and use of oral contraceptives. Both groups were exposed twice to a potent laboratory stress protocol, the Trier Social Stress Test (TSST) on consecutive days. Free salivary cortisol levels and heart rate responses were repeatedly measured before and following the TSST. In addition, the cortisol awakening response (CAR) was assessed to further investigate HPA reactivity in PD patients. Results: While the TSST induced similar heart rate stress responses in both groups, cortisol responses were clearly absent in the panic patients with normal responses in the controls (F(1.96, 66) = 20.16; p < 0.001). No differences in basal cortisol levels were observed in the extended baseline period. The same cortisol stress non-response patterns were observed when patients with/without comorbid depression, or with/without psychotropic medication were compared. In contrast to their non-response to the psychosocial stressor, panic patients showed a significant CAR. Conclusion: These findings provide strong evidence to suggest that PD patients present with a striking lack of cortisol responsivity to acute uncontrollable psychosocial stress under laboratory conditions. This unresponsiveness of the HPA axis appears to be rather specific, since a normal CAR in the morning could be documented in these patients. Thus, the present results do not support the hypothesis that PD patients show a trait HPA hyperresponsiveness to novel and uncontrollable stimulation. In contrast, the data provide support for a hyporesponsive HPA axis under emotional stress in PD patients.

In den letzten Jahren wurde die Sentinel Node Biopsie in Studien zur Diagnostik und Behandlung des N0-Halses als Stagingverfahren untersucht. Ziel der vorliegenden Studie war der Vergleich der postoperativen Lebensqualität und des funktionellen Status bei Patienten mit oralen und oropharyngealen Karzinomen, die sich einer Sentinelbiopsie, bzw. einer selektiven Neck Dissection bei N0-Hals unterzogen haben. 57 Patienten mit primär operativ behandeltem Karzinom wurden im Rahmen der Studie untersucht, 29 nach Sentinel Node Biopsie und 28 nach selektiver Neck Dissection. Es wurde die postoperative gesundheitsbezogene (EORTC QLQ-C30) und krankheitsspezifische Lebensqualität (EORTC QLQ-H&N35) erfasst. Patientenbezogene psychosoziale Variablen wurden anhand der „Hospital Anxiety and Depression Scale“ (HADS) und der Kurzform des „Progredienzangst-Fragebogens“ (PA-F-KF) ermittelt. Die Erhebung des klinischen Gesundheitszustandes erfolgte unter besonderer Berücksichtigung des funktionellen Status nach zervikaler Lymphknotendissektion. Bezüglich der gesundheitsbezogenen Lebensqualität sowie der Angst und Depression existierten keine signifikanten Unterschiede. Hinsichtlich der krankheitsspezifischen Lebensqualität zeigte sich, dass die Patienten nach Sentinel Node Biopsie weniger Schluckbeschwerden angaben (p=0,037). Ebenso zeigte sich bei der klinischen Untersuchung eine geringere Beeinträchtigung durch die zervikalen Narben. Die Sentinel Node Biopsie bietet, neben dem geringeren operativen Aufwand, der schnelleren Rekonvaleszenz und der geringeren funktionellen Minderung der Patienten, eine tendenzielle Verbesserung der krankheitsspezifischen Lebensqualität. Als Grund für die subjektiv weniger beeinträchtigte Schluckfunktion kann die fehlende Präparation der suprahyoidalen Muskulatur und der entsprechend innervierenden Nerven in Erwägung gezogen werden.

Darbo tikslas – įvertinti terapinio profilio slaugytojų darbo laiko sąnaudų ryšį su pacientų savarankiškumu. Uždaviniai: 1. Išanalizuoti terapinio profilio slaugytojų darbo laiko sąnaudas pagal priežiūros kategorijas ir slaugytojo veiklų grupes. 2. Nustatyti terapinio profilio pacientų savarankiškumo lygmenį. 3. Išanalizuoti terapinio profilio slaugytojų darbo laiko sąnaudas, atsižvelgiant į pacientų savarankiškumo lygmenį. Tyrimo metodika. Tyrimas atliktas VšĮ Vilkaviškio ligoninės trijuose terapinio profilio skyriuose (vidaus ligų, neurologijos, slaugos ir palaikomojo gydymo). Tyrimo trukmė - 3,5 mėn. Naudotas tiesioginis laiko ir slaugytojo veiksmų stebėjimo metodas (angl. time-and-motion studies). Iš viso atlikta 72 stebėjimai, kurie sudarė 777,2 val. slaugytojų darbo laiko sąnaudų. Pacientų savarankiškumas vertintas anketa. Rezultatai: Terapinio profilio slaugytojų didžiausios darbo laiko sąnaudos dienos (46,6 proc.) ir nakties (28,3 proc.) pamainoje skirtos tiesioginei pacientų priežiūrai. Mažiausia dalis slaugytojų darbo laiko praleista netiesioginei pacientų priežiūrai. Terapinio profilio skyriuose didžioji dalis pacientų (40,1 proc.) buvo savarankiški, 22,3 priklausomi ir 16 proc. - visiškai priklausomi. Slaugytojai per dvi darbo pamainas (dienos ir nakties), pusę savo darbo laiko skyrė visiškai priklausomiems pacientams slaugyti ir prižiūrėti, ketvirtadalį laiko - priklausomiems pacientams ir mažiausiai, t.y. 14 proc. - savarankiškiems pacientams. Išvados: 1... [toliau žr. visą tekstą]<br>Purpose – to evaluate the relationship between time spent caring a patient by nurses on a medical unit and the patients‘ levels of independence. Objectives: 1. Analyze time spent caring for a patient by nurses on a medical unit according to care categories and nurses activity groups. 2. Determine patients‘ independence levels on a medical unit. 3. Analyze time spent caring for patients according to independence levels by nurses on a medical unit. Methods. The study was completed at Vilkaviškis Hospital, in three medical units (internal medicine, neurology and nursing and hospice care) The length of the study was 3.5 months. Data was gathered through time and motion observation. Seventy-two observations yielded 777.2 hours of observed nursing time. Patient independence was evaluated using a questionnaire. Results: On medical units, the majority of nursing time during the day (46,6%) and night (28,3%) shifts is dedicated to direct patient care. The least amount of nursing time is spent in indirect patient care. On the medical units, a large number of patients (40,1%) were independent, 22,3% needed partial care and 16%. required total care. Nurses during two shifts (day and night) spent half their time providing total care to patients, a quarter of their time providing partial care and the least amount of time, i.e., 14%, providing care to independent patients. Conclusions: 1. Almost half of the nursing shift is spent in direct patient care; much time was spent administering... [to full text]

Background The detection of early warning signs is essential in the long-term treatment of bipolar disorders. However, in bipolar patients’ daily life and outpatient treatment the assessment of upcoming state changes faces several difficulties. In this trial, we examine the effectiveness of a smartphone based automated feedback about ambulatory assessed early warning signs in prolonging states of euthymia and therefore preventing hospitalization. This study aims to assess, whether patients experience longer episodes of euthymia, when their treating psychiatrists receive automated feedback about changes in communication and activity. With this additional information an intervention at an earlier stage in the development of mania or depression could be facilitated. We expect that the amount of time will be longer between affective episodes in the intervention group. Methods/design The current study is designed as a randomized, multi-center, observer-blind, active-control, parallel group trial within a nationwide research project on the topic of innovative methods for diagnostics, prevention and interventions of bipolar disorders. One hundred and twenty patients with bipolar disorder will be randomly assigned to (1) the experimental group with included automated feedback or (2) the control group without feedback. During the intervention phase, the psychopathologic state of all participants is assessed every four weeks over 18 months. Kaplan-Meier estimators will be used for estimating the survival functions, a Log-Rank test will be used to formally compare time to a new episode across treatment groups. An intention-to-treat analysis will include data from all randomized patients. Discussion This article describes the design of a clinical trial investigating the effectiveness of a smartphone-based feedback loop. This feedback loop is meant to elicit early interventions at the detection of warning signs for the prevention of affective episodes in bipolar patients. This approach will hopefully improve the chances of a timely intervention helping patients to keep a balanced mood for longer periods of time. In detail, if our hypothesis can be confirmed, clinical practice treating psychiatrists will be enabled to react quickly when changes are automatically detected. Therefore, outpatients would receive an even more individually tailored treatment concerning time and frequency of doctor’s appointments. Trial registration: ClinicalTrials.gov: NCT02782910: Title: “Smartphone-based Ambulatory Assessment of Early Warning Signs (BipoLife_A3)”. Registered May 25 2016. Protocol Amendment Number: 03. Issue Date: 26 March 2018. Author(s): ES.

En s'appuyant sur les résultats (prototypes textiles souples, capteurs et algorithmes) obtenus dans les projets scientifiques développés au sein de l’équipe de recherche (IOTFetMov (ANR), E-TexWeld (H2020)), cette thèse doctorale a pour objectif de développer un nouveau vêtement intelligent et connecté, afin de réaliser en temps-réel la détection et le suivi des symptômes du patient atteint de COVID-19 Long. De façon automatique, il s’agit de poser un pré-diagnostic basique à partir du traitement de signaux pertinents par des techniques intelligentes comme un outil d’aide à la décision à destination des équipes médicales. Ce vêtement intelligent, prenant la forme d’une ceinture instrumentée en contact étroit avec le corps du patient et sachant être portée sur la durée, intègre à la fois un ensemble de capteurs mesurant des signaux temporels physiologiques (température de la peau, électrocardiogramme) et embarque un système d'aide à la décision locale permettant à la fois d’estimer les paramètres physiologiques nécessaires à une détermination automatique de la sévérité de l’infection du patient connecté par apprentissage des signaux mesurés et de la connaissance experte médicale. Un diagnostic à distance pourra dès lors s'effectuer au travers d’échanges avec le médecin par le biais du vêtement intelligent et du smartphone utilisé comme une passerelle du patient connecté. De cette manière, toute aggravation rapide des symptômes sera précocement détectée et offrira aux médecins une réactivité plus rapide pour intervenir dans les meilleurs délais et protéger la santé des patients<br>Based on the results (prototypes, sensors, algorithms) obtained in our previous projects (IOTFetMov (ANR), TexWeld (H2020)), this PhD thesis aims at designing a new intelligent garment, in order to detect and monitor in real time, the symptoms of long COVID-19 patient. We establish a pre-diagnosis by processing relevant signals using intelligent techniques. This intelligent garment, a close-fitting belt, integrates both a set of sensors, measuring physiological indices (skin temperatures, electrocardiogram) and embed a local decision support system allowing to estimate relevant parameters used for an automatic estimation of the connected patient health status, by learning from the measured signals and from the medical expert knowledge. A remote diagnosis can be carried out through interactions with the doctor via the e-textile and the patient's smartphone. In this way, a rapid worsening of symptoms will be detected early, and doctors will be able to react more quickly to manage patients

Die demografische Entwicklung und die fachliche Spezialisierung medizinischer Organisationen führen zu immer komplexeren Behandlungswegen. Eine grundsätzliche Herausforderung komplexer Behandlungswege besteht darin, die Versorgungskontinuität zu wahren, obschon viele verschiedene Einrichtungen am Behandlungsweg agieren. Die Versorgungskontinuität hängt dabei maßgeblich von einer effektiven Kooperation und effizienten Kommunikation der beteiligten Akteure ab. Die folgende Arbeit ist der Frage gewidmet, welches Potenzial die elektronische Gesundheitskarte (eGK) in diesem transinstitutionellen Szenario für die Patienten birgt. Eine entscheidende Empfehlung im Rahmen des Requirements Engineering (RE) besteht darin, als Erstes die Anforderungen der Anwender zu analysieren und erst daran anschließend die Funktionalität des technischen Systems hinsichtlich der Anforderungskonformität zu evaluieren. Dieser Empfehlung folgend führte der Verfasser dieser Abhandlung dreizehn teilstrukturierte Interviews, fünf Projektsteuerungsmeetings und einen Workshop mit Patienten und medizinischen Experten durch, um fünf komplexe Behandlungswege aus der Perspektive der Patienten zu rekonstruieren. Die Auswertung, Strukturierung und Validierung der dem Behandlungskontext inhärenten Probleme mündeten in fünfundvierzig Einzelproblemen, die zu fünf finalen Patientenanforderungen verdichtet werden konnten. Im zweiten Schritt analysierte der Verfasser dieser Arbeit die Funktionalität der eGK hinsichtlich der Fähigkeit, diesen fünf Anforderungen gerecht zu werden. Die vorliegende Potenzialanalyse hebt sich von den bisherigen Forschungsarbeiten zur eGK insbesondere durch zwei Merkmale ab: Erstens erfolgt die Analyse konsequent aus der Perspektive der Patienten und zweitens sind dabei die organisatorischen Rahmenbedingungen intensiv berücksichtigt worden. In dieser Abhandlung werden die Behandlungswege von fünf Patienten fallstudienbasiert aus einer ganzheitlichen Perspektive beleuchtet. Es wird gezeigt, dass fünf grundsätzliche Patientenanforderungen zu erfüllen sind. Diese fünf Anforderungen basieren auf Problemen, die erstens mit einer effizienten Informationslogistik, zweitens mit dem Recht auf informationelle Selbstbestimmung, drittens mit der Versorgungskontinuität, viertens mit der Gesamtsteuerung der Behandlung und fünftens mit administrativen Aufgaben zusammenhängen. Auf dieser Basis konnten insgesamt zehn Fachanwendungen identifiziert und im Rahmen eines visionären Anwendungsfalles exemplarisch veranschaulicht werden, von denen angenommen wird, dass sie das Potenzial der geplanten Telematik-Infrastruktur (TI) hinsichtlich der Anforderungen der Patienten besonders gut ausschöpfen.

Background Close, continuous and efficient collaboration between different professions and sectors of care is necessary to provide patient-centered care for individuals with mental disorders. The lack of structured collaboration between in- and outpatient care constitutes a limitation of the German health care system. Since 2012, a new law in Germany (§64b Social code book (SGB) V) has enabled the establishment of cross-sectoral and patient-centered treatment models in psychiatry. Such model projects follow a capitation budget, i.e. a total per patient budget of inpatient and outpatient care in psychiatric clinics. Providers are able to choose the treatment form and adapt the treatment to the needs of the patients. The present study (EVA64) will investigate the effectiveness, costs and efficiency of almost all model projects established in Germany between 2013 and 2016. Methods/design A health insurance data-based controlled cohort study is used. Data from up to 89 statutory health insurance (SHI) funds, i.e. 79% of all SHI funds in Germany (May 2017), on inpatient and outpatient care, pharmaceutical and non-pharmaceutical treatments and sick leave for a period of 7 years will be analyzed. All patients insured by any of the participating SHI funds and treated in one of the model hospitals for any of 16 pre-defined mental disorders will be compared with patients in routine care. Sick leave (primary outcome), utilization of inpatient care (primary outcome), utilization of outpatient care, continuity of contacts in (psychiatric) care, physician and hospital hopping, re-admission rate, comorbidity, mortality, disease progression, and guideline adherence will be analyzed. Cost and effectivity of model and routine care will be estimated using cost-effectiveness analyses. Up to 10 control hospitals for each of the 18 model hospitals will be selected according to a pre-defined algorithm. Discussion The evaluation of complex interventions is an important main task of health services research and constitutes the basis of evidence-guided advancement in health care. The study will yield important new evidence to guide the future provision of routine care for mentally ill patients in Germany and possibly beyond. Trial registration This study was registered in the database “Health Services Research Germany” (trial number: VVfD_EVA64_15_003713).

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Ciências Farmacêuticas<br>O Lupus Eritematoso Sistémico (LES) é uma doença crónica inflamatória de etiologia desconhecida que pode afetar múltiplos órgãos. A doença caracteriza-se por períodos de exacerbação e de remissão e atinge particularmente as mulheres. A produção de autoanticorpos anti-nucleares tem um papel determinante no curso da doença, sendo responsável pelas principais manifestações clínicas que podem envolver o sistema nervoso central, pele, músculos, articulações e rins. As terapêuticas atuais do LES passam pelo uso de corticosteróides sistémicos que suprimem a ativação do sistema imunitário, pelo uso de agentes citotóxicos como a ciclosporina e a azatriopina (AZA), e pela imunoterapia com anticorpos. A terapêutica no LES deve ser individualizada e irá depender do grau de comprometimento do órgão ou sistema, sendo adaptada consoante o paciente responde ou não ao tratamento convencional. Neste ultimo caso de pacientes, sem dúvida, a imunoterapia assume-se como a ultima linha de tratamento. As complicações inerentes à própria doença e aos tratamentos usados tornam a pesquisa por novas terapêuticas, decisivas, de maneira a aumentar a qualidade de vida dos doentes.<br>Systemic Lupus Erythematosus (SLE) is an unknown infflammatory chronicle disease. This disease is characterized bu aggravation and relaxing and affects mainly the woman. The production of anti-nuclear antibodies as an important role on the disease course, being responsible for several clinical manifestations which may involve the central nervous system, skin, muscles, articulations and kidneys. The current therapies of SLE are mainly the application of systemic corticosteroids which supress the activation of the immune system, the use of cytotoxic agents like cyclosporine and azathioprine (AZA) and immune therapy with antibodies. SLE therapy must be individualized and will depende of the severity of the lesions in the organs and systems, and will be adapted if the patient doesn`t respond to conventional treatments. In this last case, without a doubt, immunotherapy assumes itself has the last line of treatment. The inherent complications to the particular disease and of the treatments used make the search of new therapies decisive in order to increase the quality of life of these patients.

The use of autonomous robots in our society is increasing every day and a robot is no longer seen as a tool but as a team member. The robots are now working side by side with us and provide assistance during dangerous operations where humans otherwise are at risk. This development has in turn increased the need of robots with more human-awareness. Therefore, this master thesis aims at contributing to the enhancement of human-aware robotics. Specifically, we are investigating the possibilities of equipping autonomous robots with the capability of assessing and detecting activities in human teams. This capability could, for instance, be used in the robot's reasoning and planning components to create better plans that ultimately would result in improved human-robot teamwork performance. we propose to improve existing teamwork activity recognizers by adding intangible features, such as stress, motivation and focus, originating from human behavior models. Hidden markov models have earlier been proven very efficient for activity recognition and have therefore been utilized in this work as a method for classification of behaviors. In order for a robot to provide effective assistance to a human team it must not only consider spatio-temporal parameters for team members but also the psychological.To assess psychological parameters this master thesis suggests to use the body signals of team members. Body signals such as heart rate and skin conductance. Combined with the body signals we investigate the possibility of using System Dynamics models to interpret the current psychological states of the human team members, thus enhancing the human-awareness of a robot.<br>Användningen av autonoma robotar i vårt samhälle ökar varje dag och en robot ses inte längre som ett verktyg utan som en gruppmedlem. Robotarna arbetar nu sida vid sida med oss och ger oss stöd under farliga arbeten där människor annars är utsatta för risker. Denna utveckling har i sin tur ökat behovet av robotar med mer människo-medvetenhet. Därför är målet med detta examensarbete att bidra till en stärkt människo-medvetenhet hos robotar. Specifikt undersöker vi möjligheterna att utrusta autonoma robotar med förmågan att bedöma och upptäcka olika beteenden hos mänskliga lag. Denna förmåga skulle till exempel kunna användas i robotens resonemang och planering för att ta beslut och i sin tur förbättra samarbetet mellan människa och robot. Vi föreslår att förbättra befintliga aktivitetsidentifierare genom att tillföra förmågan att tolka immateriella beteenden hos människan, såsom stress, motivation och fokus. Att kunna urskilja lagaktiviteter inom ett mänskligt lag är grundläggande för en robot som ska vara till stöd för laget. Dolda markovmodeller har tidigare visat sig vara mycket effektiva för just aktivitetsidentifiering och har därför använts i detta arbete. För att en robot ska kunna ha möjlighet att ge ett effektivt stöd till ett mänskligtlag måste den inte bara ta hänsyn till rumsliga parametrar hos lagmedlemmarna utan även de psykologiska. För att tyda psykologiska parametrar hos människor förespråkar denna masteravhandling utnyttjandet av mänskliga kroppssignaler. Signaler så som hjärtfrekvens och hudkonduktans. Kombinerat med kroppenssignalerar påvisar vi möjligheten att använda systemdynamiksmodeller för att tolka immateriella beteenden, vilket i sin tur kan stärka människo-medvetenheten hos en robot.<br><p>The thesis work was conducted in Stockholm, Kista at the department of Informatics and Aero System at Swedish Defence Research Agency.</p>

M.Cur.<br>The nursing service manager is accountable for the managerial outputs of the nursing service, being quality nursing care, cost effectiveness and quality nursing staff management. These managerial responsibilities will influence the overall management efficiency of the health delivery system. There is a need for a more scientific basis of staffing in South African critical care units. Various methods are used to determine staffing needs, but the most accurate and acceptable method being used is the patient classification system. The success of a critical care patient classification system is based upon the accurate determination of the ideal nurse-patient ratio. Ideal nursepatient ratio depends on matching the competency of the critical care nurse to the severity of the critical care patient's illness. Internationally and nationally very few guidelines describe the competency requirements that the critical care nurse should have to function effectively in the critical care unit. To maintain a high standard of quality nursing care, the critical care nurse should be assigned to a critical care patient according to her competency level. The aim of this study was to describe a scientific patient classification system for critical care patients according to which workload and nursing requirements can be ascertained. Secondly, to describe guidelines for the competency requirements of a registered critical care nurse assigned to nurse the different categories of critical care patients categorised by the patient classification system as prescribed. The aim of the study is justified by means of an exploratory, descriptive, contextual research design. A critical care patient classification system has been developed and validated by a group of critical care nursing experts using a structured two phase research method. The statistical validity of each item of the critical care patient classification system was determined by means of a content validity index. All the items of the critical care patient classification system were rated as valid and therefore the critical care patient classification system as a whole has been accepted as valid. The reliability of the critical care patient classification system was tested by means of a pilot study in two selected research units. It was determined that the inter-rater reliability was within the 95 per cent confidence interval, that the system could discriminate between different critical care patients and nurse-patient ratios were effectively determined by the system. Critical care nurse competency requirements were identified by critical care nursing experts by means of a focus group interview. The results obtained from the focus group interview were verified by a literature control and peer group review. Guidelines for the competency requirements of the critical care nurse were compiled. The critical care patient classification system developed will equip the critical care manager with a scientific instrument to assign personnel to critical care units. The critical care patient classification system will furthermore assist the critical care unit manager in the daily utilisation of valuable human resources, in that critical care nurses with the appropriate level of expertise can be assigned to each patient, thus facilitating quality critical care nursing.

碩士<br>國立陽明大學<br>衛生資訊與決策研究所<br>94<br>Background：In Taiwan ,the Department of Health built the first national patient safety reporting system in 2004. For saving the time and human resources to re-classify the reporting events. The aim of this study will find out an automatic classification system for patient safety reports. Material and Method：The training set include 1265 reports from September to December in 2005.The experts in charge this system to classify reports and to sift keywords out from ten kinds of report types. The testing set include 575 reports from February to March in 2006.Using information retrieval method called “space vector model” to classify the testing report events, the experts reviewer classify the same set been the “Golden Standard”. We calculate Kappa, Recall and Precision between system and experts to measure the performance of this system. Result：This program finds out 182 keywords in 10 types event. The Kappa value of the medicine was 0.82、the fall was 0.82、and the tube was 0.86,the performance were almost prefect. The whole Recall value was 0.56, in which the medicine was 0.90,the fall was 0.89 and the surgery was 0.82.The whole Precision value was 0.55, in which the medicine was 0.80、the fall was 0.86、the blood transfusion was 1、the security was 0.88 and the harm was 0.88. The performances of the other events were not ideal. Conclusion：Using information retrieval technology will classify the patient safety reports automatically. We will search and collect more keywords in all type events to improvement the performance of the system.

Glioblastoma multiforme (GMB) is an extremely aggressive and invasive brain cancer with a median survival of less than one year. In addition, due to its anaplastic nature the histological classification of this cancer is not simple. These characteristics make this disease an interesting and important target for new methodologies of analysis and classification. In recent years, molecular information has been used to segregate and analyze GBM patients, but generally this methodology utilizes single-`omic' data to perform the classification or multi-’omic’ data in a sequential manner. In this project, a novel approach for the classification and analysis of patients with GBM is presented. The main objective of this work is to find clusters of patients with distinctive profiles using multi-’omic’ data with a real integrative methodology. During the last years, the TCGA consortium has made publicly available thousands of multi-’omic’ samples for multiple cancer types. Thanks to this, it was possible to obtain numerous GBM samples (> 300) with data for gene and microRNA expression, CpG sites methylation and copy-number variation (CNV). To achieve our objective, a mixture of linear models were built for each gene using its expression as output and a mixture of multi-`omic' data as covariates. Each model was coupled with a lasso penalization scheme, and thanks to the mixture nature of the model, it was possible to fit multiple submodels to discover different linear relationships in the same model. This complex but interpretable method was used to train over \numprint{10000} models. For \texttildelow \numprint{2400} cases, two or more submodels were obtained. Using the models and their submodels, 6 different clusters of patients were discovered. The clusters were profiled based on clinical information and gene mutations. Through this analysis, a clear separation between the younger patients and with higher survival rate (Clusters 1, 2 and 3) and those from older patients and lower survival rate (Clusters 4, 5 and 6) was found. Mutations in the gene IDH1 were found almost exclusively in Cluster 2, additionally, Cluster 5 presented a hypermutated profile. Finally, several genes not previously related to GBM showed a significant presence in the clusters, such as C15orf2 and CHEK2. The most significant models for each clusters were studied, with a special focus on their covariants. It was discovered that the number of shared significant models were very small and that the well known GBM related genes appeared as significant covariates for plenty of models, such as EGFR1 and TP53. Along with them, ubiquitin-related genes (UBC and UBD) and NRF1, which have not been linked to GBM previously, had a very significant role. This work showed the potential of using a mixture of linear models to integrate multi-’omic’ data and to group patients in order to profile them and find novel markers. The resulting clusters showed unique profiles and their significant models and covariates were comprised by well known GBM related genes and novel markers, which present the possibility for new approaches to study and attack this disease. The next step of the project is to improve several elements of the methodology to achieve a more detail analysis of the models and covariates, in particular taking into account the regression coefficients of the submodels.

Aged people who live independently require continuous monitoring of their health and activities of daily living in order to be supported by different health services and maintain their health status. This need can be addressed in the home setting, by providing a “health smart home” living environment for them. Using a health smart home approach has many advantages, such as, reducing the cost of health services by minimizing visits to hospitals, improving the quality of life for aged people recovering from illness at home instead of hospital, providing a secure and safe place for aged people who live independently, and routinely monitoring health status and daily activities to assist in improving health life of aged people. To provide such solution, it is required to classify the activities of daily living by using an activity recognition system. The development of sensing technologies that are cheap in price and provide an appropriate level of accuracy has opened the door for a wide range of research in the field of human activity recognition, including health applications. Different types of sensing technologies, modelling approaches and computational methods have been proposed for use in activity recognition systems, some of which are very complex. However, no one system solution has been widely accepted as optimal, providing scope for more investigations and improvements in this very rapidly growing area. The aim of this thesis is to develop a rule-based system to classify the activities of daily living in different hierarchical levels by using a cheap and sufficiently accurate ultrasonic location system (Hexamite19). Moreover, using a simple classification method based on initial application of activity distinguishing rules and then improving these results using finite state machine methods that can provide a high level of accuracy similar or better to previous research. In addition, a comparison of the system performance with existing classification methods is desirable, and in this case a decision-tree method (implemented in Sipina software) was used. To achieve the aims of the thesis, a systematic approach was followed, that included defining the research questions, setting up the experimental facility, selecting wearable sensor technology, collection of data on typical daily activities, development of methods for pre-processing of data followed by windowing, feature extracting, classification and finally the analysis of the rule-based system performance and accuracy. The rule-based system deployed three classification methods (range-based method, backward range-based method and symmetric range-based method). Range-based method deploys only rules, where backward range-based method and symmetric range-based method deploy rules and finite state machine extensions. The difference between backward range-based method and symmetric range-based method is the improvement of classification for undefined activity. System testing accuracy was used to assess the accuracy values of the different hierarchical levels. The rule-based system performance and accuracy was improved by using the finite state machine and the best method was symmetric range-based method for all hierarchical levels, except for the second hierarchical level where the accuracy of the three classification methods was equal. Moreover, it was found that the accuracy range of rule-based system was 83.4%-100%. By comparing the accuracy range of rule-based system with previous research and decision-tree method of Sipina software, it was found that the performance and accuracy of rule-based system were comparable with previous research and better in some cases. By using the decision-tree method of Sipina software, the accuracy range was 74.4%-99.3%. By comparing the accuracy range of rule-based system and decision-tree method of Sipina software, it is obvious that the rule-based system performance and accuracy was better, except for the activities sleep, walk straight and walk curvy. In conclusion, based on the analysis it was found that the rule-based system succeeded in classifying the activities of daily living into hierarchical levels; the finite state machine improved the accuracy of the rule-based system and the rule-based system accuracy was comparable with previous research and better than the decision-tree method of Sipina software (for all activities except for sleep, walk straight and walk curvy). It is therefore claimed that the deployed rule-based system has fulfilled the objectives of providing a robust and computationally inexpensive solution for common home-based activity recognition.

Die Hyperaktivität der HHN-Achse ist bei der Multiplen Sklerose umfassend untersucht und mehrfach bestätigt; der genaue Pathomechanismus bleibt jedoch ungeklärt. Das serotonerge System ist eng mit der HHN-Achse verbunden und besitzt die Eigenschaft, die HHN-Achse herabzuregulieren. Daraus ergab sich im Umkehrschluss, dass die HHN-Achsen-Hyperaktivierung bei Patienten mit Multipler Sklerose im Zusammenhang mit einer reduzierten serotonergen Verfügbarkeit stehen könnte. Um die HHN-Achse und das serotonerge System zu untersuchen, schlossen wir 17 Patienten mit Multipler Sklerose und 13 gesunde Kontrollpersonen ein. Die HHN-Achse wurde mittels des Dex-CRH-Tests untersucht und die zentrale Verfügbarkeit des präsynaptischen Serotonintransporters mittels einer [11C]DASB-PET in 31 Hirnregionen gemessen. Die Patientengruppe hatte insgesamt höhere Kortisolwerte, dementsprechend erniedrigt war die ACTH-Kortisol-Ratio, so dass wir das Vorliegen einer HHN-Achsen-Hyperaktivität bestätigen konnten. Am ausgeprägtesten waren die Unterschiede in der Gruppe der primär chronisch progredienten MS. Eine signifikant reduzierte Verfügbarkeit des Serotonintransporters fand sich im Hypothalamus, den Raphe-Kernen, limbischen Strukturen, dem linken Temporallappen und Thalamus, auch hier war die Gruppe der PPMS am stärksten betroffen. Zusätzlich erhobene Fragebögen hinsichtlich Depression, Fatigue und Lebensqualität (BDI, WEIMuS, WEIMuS 1, WEIMuS 2, EuroQol, EuroQolScale und VAS) zeigten durchgängig signifikant unterschiedliche Ergebnisse bei den Patienten im Vergleich zur Kontrollgruppe. Zusammenfassend, konnten wir darstellen, dass die HHN-Achsen-Aktivierung bei der Multiplen Sklerose in enger Verbindung mit der serotonergen Aktivität steht, eine direkte Korrelation fand sich jedoch nicht. Dennoch kann davon ausgegangen werden, dass die serotonergen Neurone durch ihre enge anatomische Verbindung zu einer negativen Modulation der HHN-Achse beitragen. Der Einsatz von SSRI könnte therapeutisches Potential bieten, indem die herabregulierte serotonerge Aktivität sowie HHN-Achse wieder normalisiert werden könnten.:Inhaltsverzeichnis I Abkürzungsverzeichnis III 1. Einleitung 1 1.1 Einführung in die Fragestellung 1 1.2 Multiple Sklerose 1 1.2.1 Definition, Epidemiologie, Ätiologie und Pathogenese 1 1.2.2 Diagnosekriterien, Verlaufsformen, Klinik und Therapie 6 1.2.3 Fatigue und Multiple Sklerose 9 1.3 Die Hypothalamus-Hypophysen-Nebennierenrinden-Achse 10 1.4 Das serotonerge System und die Hypothalamus-Hypophysen-Nebennierenrinden-Achse 13 1.5 Aufgabenstellung 16 2. Materialien und Methoden 17 2.1 Durchführung 17 2.2 Einschlusskriterien 17 2.3 Ausschlusskriterien 18 2.4 Allgemeiner Ablauf 19 2.5 Dexamethason-CRH-Test 19 2.6 Positronen-Emissions-Tomographie 20 2.7 Magnetresonanztomographie 22 2.8 Genotypisierung 22 2.9 Fragebögen zu Depression, Fatigue und Lebensqualität 22 2.9.1 Beck-Depressions-Inventar 22 2.9.2 Würzburger Erschöpfungsinventar bei Multipler Sklerose 23 2.9.3 Europäischer Lebensqualitäts-Fragebogen 23 2.10 Statistische Datenanalyse 24 I 3. Ergebnisse 25 3.1 Klinische und demographische Daten 25 3.2 Dexamethason-CRH-Test 27 3.3 Verfügbarkeit des Serotonintransporters 29 (mittlere Distribution Volume Ratios) 3.4 Lateralität des Serotonintransporters 32 3.5 Beziehung der neuroendokrinen Funktion zur Serotonintransporter-Verfügbarkeit 33 3.6 Fatigue und Depression 34 4. Diskussion 35 4.1 Dexamethason-CRH-Test und Hypothalamus-Hypophysen-Nebennierenrinden-Achse 35 4.2 Das serotonerge System 37 4.3 Fatigue 41 4.4 Lateralität 42 4.5 Methodenkritik 44 4.6 Therapeutischer Ausblick 45 5. Zusammenfassung der Arbeit 48 6. Literaturverzeichnis 50 7. Thematisch assoziierte Publikation als Zweitautorin 69 8. Anlagen 79 8.1 Fragebögen 79 8.2 Selbständigkeitserklärung 87 8.3 Lebenslauf 88 8.4 Danksagung 90 II 3. Ergebnisse 25 3.1 Klinische und demographische Daten 25 3.2 Dexamethason-CRH-Test 27 3.3 Verfügbarkeit des Serotonintransporters 29 (mittlere Distribution Volume Ratios) 3.4 Lateralität des Serotonintransporters 32 3.5 Beziehung der neuroendokrinen Funktion zur Serotonintransporter-Verfügbarkeit 33 3.6 Fatigue und Depression 34 4. Diskussion 35 4.1 Dexamethason-CRH-Test und Hypothalamus-Hypophysen-Nebennierenrinden-Achse 35 4.2 Das serotonerge System 37 4.3 Fatigue 41 4.4 Lateralität 42 4.5 Methodenkritik 44 4.6 Therapeutischer Ausblick 45 5. Zusammenfassung der Arbeit 48 6. Literaturverzeichnis 50 7. Thematisch assoziierte Publikation als Zweitautorin 69 8. Anlagen 79 8.1 Fragebögen 79 8.2 Selbständigkeitserklärung 87 8.3 Lebenslauf 88 8.4 Danksagung

The thesis deals with the application of NIC, NOC classifications in patients with stoma. Every nurse uses a classification system of health care which describes activities or interventions done by nurses as a part of planning phase of nursing process in connection with creation of nursing care plan. These classifications also focus on developement of nursing care objectives and evaluating of the effect of nursing care results. Due to these classifications, the nursing care results are mesurable. In the theoretical part of the thesis, we focus on classification systems of nursing care, then on GIT diseases which lead to insertion of stoma, its care, care of patients with stoma and last but not least, on nursing documentation. Several objectives were set to meet the main target of the thesis. Firstly, to map nurses' opinion on nursing classifications; secondly, to find out which NOC indicators are usually judged by nurses in the care of patients with stoma; thirdly, to find out which activities are usually used by nurses in the care of patients with stoma; fourthly, to check up on application of NIC, NOC classification in the care of patients with stoma. The qualitative reserch was hold in two phases. In the first phase of the qualitative research, a nursing documentation was created on the basis of NIC and NOC classification related to care of the patients with stoma. In the second phase of the qualitative research, we interviewed ten nurses who had worked with the particular nursing documentation.

Eine Dysregulation neuro-immunologischer Interaktionen und eine veränderte Stressantwort werden als Teil der Pathogenese der Rheumatoiden Arthrtitis (RA) diskutiert. Dabei könnte eine autonome Dysfunktion eine wichtige Rolle spielen. Um dem nachzugehen, wurde an Patienten mit unterschiedlicher Krankheitsaktivität die Aktivität des autonomen Nervensystems in Ruhe und in Reaktion auf minor Stress sowie erstmals deren Assoziation zu Gen-Polymorphismen β2- adrenerger Rezeptoren (β2ARs), welche sich u.a. auf Immunzellen befinden, untersucht. Zur Bestimmung autonomer Aktivität wurde an 112 RA- und 48 Osteoarthrose-Patienten die sympathische Hautantwort (SSR) sowie die Herzratenvariabilität (HRV) getestet. Standardisierte Stresstests kamen zur Anwendung. Eine Allel-spezifische Polymerase-Ketten-Reaktion diente zur Ermittlung der Varianten des β2ARs an Aminosäureposition 16, 27 und 164. Es konnte gezeigt werden, dass die autonome Aktivität bei RA in Ruhe durch eine signifikant erhöhte Herzfrequenz, ein Überwiegen des Sympathikus im Verhältnis zum Parasympathikus sowie eine signifikant erniedrigte Parasympathikusaktivität gekennzeichnet ist. Die Stressantwort bei RA war signifikant häufiger pathologisch als bei der Kontrollgruppe und durch signifikante Hypoaktivität und Hyporeaktivität des Parasympathikus sowie eine signifikant erniedrigte HRV charakterisiert. Das Zusammenspiel beider Schenkel des ANS erschien gestört. Die SSR-Werte befanden sich im Normbereich. Schlechtere Werte waren jedoch signifikant mit hohem CRP assoziiert. Desweiteren war Heterozygotie an allen Gen-Positionen der β2ARs signifikant mit RA assoziiert. Gln27Gln (signifikant häufiger für Gesunde) ging mit signifikant niedrigerer Krankheitsaktivität einher. Starkes Überwiegen des SNS in Ruhe sowie niedrige parasympathische Aktivität (HRV-Daten) waren signifikant mit hoher Krankheitsaktivität assoziiert. Zusammenfassend weist die vorliegende Arbeit auf eine autonome Dysregulation bei Patienten mit RA hin, was mit klinischen Parametern der RA assoziiert war. Weiterhin unterstreicht die Studie die Assoziation von β2AR Polymorphismen mit einer RA und liefert einen weiteren Beitrag zum Verständnis der Pathogenese dieser Erkrankung.

This article describes the knowledge-based system THEMPO (Therapy Management in Pediatric Oncology), which supports protocol-directed therapy planning and configuration in pediatric oncology. THEMPO provides a semantic network controlled by graph grammars to cover the different types of knowledge relevant in the domain, and offers a suite of acquisition tools for knowledge base authoring. Medical problem solvers, operating on the oncological network, reason about adequate therapeutic and diagnostic timetables for a patient. Furthermore, a corresponding patient record, also based on semantic networks and graph grammars, has been implemented to represent the course of therapy of an oncological patient.

The thesis is focused on the up-to-date issues of application of NIC and NOC to nursing care at standard wards. Implementation of unified nursing language is a great challenge for Czech nursing. Application of unified professional terminology and standardized electronic data improves effectiveness of cooperation between health care staff from different facilities and develops nursing statistic registers, which are useful for development of research in nursing care and substantially improve the quality of nursing care in heath care facilities. This thesis is a part of research grant project implemented by the Department of Nursing of the Faculty of Health Care and Social Studies of the University of South Bohemia in České Budějovice, GAJU JU 079/2010/S, called Application of conceptual model and classification systems to nursing documentation. In the theoretical part we map the basic theses, principles and novelties of development, classification systems, particularly from foreign literature. We set four basic goals before the research, focused on application of classification systems to standard departments, on the aspects affecting introduction of classification systems to standard departments, elaboration of proposals and solution of application of classification systems and verification of application of classification systems to standard departments. The research was implemented in cooperation with the following South Bohemian workplaces: České Budějovice Hospital, Český Krumlov Hospital, Jindřichův Hradec Hospital, Prachatice Hospital, Strakonice Hospital, Tábor Hospital, and Písek Hospital. The empiric part was based on qualitative-quantitative method. We chose the techniques of document content analysis and semi structured interview. The quantitative research was based on questionnaire research. We examined the diagnostic-nursing management from selected documents from the involved hospitals by means of content analysis. We conducted interviews with head nurses and we particularly focused on the spheres of nursing documentation topics and diagnostic classification systems. Three research questions were linked to the interviews. The interviews were interpreted in the form of thought maps. The questionnaire research was designed for general nurses from standard surgical and internal wards. Four hypotheses were related to the questionnaire research. The quantitative data were processed in statistic form; we used frequency tables and also worked with the chi-square test of compliance. A basic nursing diagnostic module according to NANDA-I, NIC and NOC, which has been presented to nurses ? professionals from practice ? for testing is the output of the thesis. Nursing specialists were informed on the content analysis results at the 3rd South Bohemian Conference of non doctoral health care workers in České Budějovice.

Hintergrund Die chronische myeloische Leukämie (CML) ist eine myeloproliferative Er- krankung, die aufgrund ihres Modellcharakters unter der Behandlung mit Tyrosin-Kinase- Inhibitoren (TKI) gut für eine Beschreibung mittels computerbasierter Modelle geeignet ist. Grundlage für die Entstehung einer CML ist die Bildung eines Philadelphia-Chromosoms durch eine Translokation der Chromosomen 9 und 22. Es resultiert das Onkogen BCR- ABL1, welches für eine konstitutiv aktive Tyrosinkinase codiert. Diese führt zu ungeregelter Proliferation der betroffen Zellen und zur Verdrängung der gesunden Blutbildung. Das überaktivierte Protein kann durch TKIs gezielt gehemmt werden. Damit ist es möglich, die Tumorlast erheblich zu senken und das Fortschreiten der Erkrankung aufzuhalten. Aktuell werden in der klinischen Anwendung außerhalb von Studien TKIs für die gesamte Lebensdauer der Patienten eingesetzt. Absetzstudien zeigten, dass circa 50% der Patienten nach einer über zwei Jahren nicht nachweisbaren BCR-ABL1-Last nach Behandlungsstopp kein erneutes Anwachsen der Tumorlast aufwiesen. Die Anwendung von computergestützten Modellsimulationen hilft, Zugriff auf die klinisch nur schwer zu messenden leukämischen Stammzellen zu bekommen und darüber Vorhersagen über den weiteren Therapieverlauf zu treffen. Aufgabenstellung Im Rahmen der vorliegenden Arbeit sollen Möglichkeiten der Übertragung von Patientendaten auf das etablierte Modell nach Roeder und Loeffler (2002) verbessert werden. Die vom Modell vorhergesagten Stammzellkinetiken sollen abschließend auf Praxistauglichkeit geprüft werden. Material und Methoden Aufgrund der Vergleichbarkeit zu früheren Untersuchungen erfolgte die Auswahl von 51 Patienten des deutsches Armes der IRIS-Studie. Deren Therapieverläufe wurden analysiert und können über eine biphasische exponentielle (biexponentielle) bzw. über eine stückweise lineare Funktion beschreiben werden. Als Erweiterung der Arbeiten von Horn et al. (2013) wurden alle Parameter der biexponentiellen Funktion in die Entwicklung neuer Methoden einbezogen. Zusätzlich wurde untersucht, ob die Einbeziehung von zensierten Messpunkte die Form der biexponentiellen Funktion verändert. Basierend auf den Therapiedaten der IRIS-Patienten erfolgte die Ermittlung eines Para meterraumes für Eingangsparameter der Modellsimulation (Modellparameter), welcher in 270.400 individuelle Paramterkombinationen unterteilt wurde. Es erfolgten anschließend die Simulation und Auswertung nach der biexponentiellen Beschreibung. Auf Basis dieser erheblich größeren Datengrundlage konnten zwei neue Verfahren der Modellparameteridentifikation für individuelle Patienten entwickelt werden. Einerseits wurde in Anlehnung an die Arbeit von Horn et al. (2013) ein Verfahren unter Nutzung der Regression vorgestellt. Andererseits konnte über den Vergleich der Abstände zwischen simulierten und realen Therapieverläufen eine Suche (lookup-table) etabliert werden. Die Berechnung des Abstandes zwischen Therapieverläufen ermöglicht gleichzeitig den Vergleich der verschiedenen Verfahren und damit eine Aussage über deren Anpassungsgüte. Zum Schluss wurde beispielhaft für einen Patienten das Verfahren der lookup-table angewendet und die resultierende Stammzellkinetik weiter analysiert. Ergebnisse Einführend erfolgte die Analyse der resultierenden biexponentiellen Funktion mit und ohne Einbeziehung von Messunsicherheiten. Es zeigte sich, dass der Verlauf dieser Funktion besonders in Bereichen, die von einbezogenen Messunsicherheiten betroffen sind, abweichend ist. Die Beschreibung des Langzeitverlaufs erfolgt jedoch annähernd gleich. Anschließend erfolgte die Validierung der Größe des vorsimulierten Datenpool anhand eines Vergleichs der statistischen Parameter von Patienten und Simulationen. Dieser zeigte sich dabei für die weiteren Untersuchungen geeignet. Die Nutzung der lookup-table zur Identifikation der am besten zu einem Patienten passenden Therapiesimulation ist überlegen sowohl gegenüber von der Horn et al. (2013) beschriebenen als auch in dieser Arbeit neu entwickelten Regressionsverfahren. Diese ergeben deutliche Abweichungen zwischen Patientendaten und Simulation. Eine Analyse des vorhergesagten Therapieverlaufes im Stammzellkompartiment ergibt jedoch, dass ähnliche Therapieverläufe im peripheren Blut durch stark unterschiedliche Stammzellkonfigurationen beschrieben werden können. Es resultiert eine starke Streuung der vorhergesagten Zeitpunkte eines möglichen Therapieendes. Schlussfolgerungen Die Nutzung der lookup-table zu Identifikation einer passenden Therapiesimulation ist hoch effektiv und anderen Verfahren, die auf Regression basieren, überlegen. Die etablierte Computersimulation nach Roeder und Loeffler (2002) bietet Zugriff auf die Therapie in der Ebene der Stammzellen. Die in weiteren Analysen gezeigten Streuungen der vorhergesagten Therapieverläufe im Stammzellkompartiment lassen den Schluss zu, dass Methoden zur Eingrenzung der Stammzellverläufe entwickelt werden müssen, um die Vorhersagen klinisch nutzbar zu machen. Weiterhin muss anhand von Messungen an Knochenmarkproben von realen Patienten geprüft werden, ob die von der Simulation postulierten Verläufe der Tumorlast im Stammzellkompartiment der realen Behandlung entsprechen. Ausblick Die in aktuellen Arbeiten beschriebene Rolle des Immunsystems im Therapieverlauf der CML (Saussele et al. 2016; Clapp et al. 2016) sollte in eine Verbesserung des Stammzellmodells nach Roeder und Loeffler (2002) einfließen. Weiterhin kann die Validierung der im Rahmen der Individualmedizin zu treffenden Absetzvorhersagen letztendlich nur über klinische Absetzuntersuchungen ermöglicht werden.<br>Background Chronic myeloic leukaemia (CML) is a myeloproliferative disease, which is well suited for modelling approaches. It is characterized by the oncogenic BCR-ABL1 fusion gene originating from an inverse translocation of the chromosomes 9 and 22 leading to the Philadelphia chromosome. The result is a constitutively activated tyrosine-kinase. This is followed by an extensive proliferation of leukaemic stem cells leading to a displacement of normal haematopoesis. The molecular specificity of CML forms the basis of a highly efficient, targeted therapy by tyrosine kinase inhibitors (TKIs). TKIs can decrease the tumour burden and slow down or eventually stop progressing of the disease. Currently, in clinical applications drugs are administered for the remaining life span. Interestingly, in recent treatment cessation trials patients were stopped after two years of non-detectable tumour burden and about 50% remained without relapse. The application of computer-based modelling helps to gain access to stem cell counts being difficult to measure clinically. This forms the basis for predictions of long-term therapy outcomes. Aim of this work This work aims on identifying a suitable algorithm to efficiently identify model simulations that optimally decribe individual patient kinetics. Furthermore, the clinical usability of the new methods was investigated. Material and methods The analysed group of patients was chosen out of the German cohort of the IRIS trial to ensure comparability to former investigations. It consists of 51 individuals. The course of leukaemic burden , i. e. leukaemic vs. non-leukaemic cells on a single patient level can be described as a biphasic exponential (bi-exponential) or a piecewise linear function. As an extension to former methods described by Horn et al. (2013) all parameters are included into further method development. Additionally, an investigation was conducted whether censored data points change the functional behaviour of a bi-exponential fit based on patients’ data. According to therapy data of all patients an input parameter space for the model simulation was delimited, such that all observed patient kinetics can be mimicked by the model. This parameter space was uniformly divided into 270.400 discrete parameter combinations. The therapy simulation of each combination was conducted and described by a bi-exponential function likewise to the patients’ fit. With the help of these huge variety of in silico therapies two new methods of model parameter identification for individual patients were developed. The first one is an advanced approach based on a regression model proposed by Horn et al. (2013). The second one by comparing distances between the patients’ and the models’ bi-exponential functions (lookup table). The comparison of the distances between different therapy courses (either simulated or patients’ data) was also used to compare the quality of different methods. As an example, for one patient the stem cell kinetics from the model were analysed in more detail and checked for robustness. Such a strategy, which might build the basis for clinical applications. Results A comparison between the different bi-exponential functions with and without censored data points revealed differences especially in the area in which censoring was performed. However, for the long-term tumour burden censored data had no influence. Secondly, an investigation was performed showing the sufficiency of the pre-simulated therapy courses for the new methods, i. e. lookup-table and regression models. The lookup- table turns out to be superior to identify a therapy simulation for a unique patient, since the complexity of linear regression models lead to increased deviations between patients’ therapy courses and the simulations. Unfortunately, distinct stem cell configurations lead to similar therapy descriptions in peripheral blood, assuming the correctness of the model. As a result, the prediction of a safe treatment cessation is often widely spread. Conclusions The new developed lookup-table to identify model simulations suitable for an individual patient is highly effective and superior to other methods using regression models. The simulation of the TKI treatment using the agent-based model of Roeder und Loeffler (2002) gives easy access to therapy courses on the level of leukaemic stem cells. Unfortunately, the finding of a well fitting simulation within the peripheral blood is not enough to provide a point of safe treatment cessation, since different stem cell configurations can lead to similar therapy courses. Additionally, it is necessary to check which of the assumed therapy courses on the stem cell level is appropriate. This could be done by gathering more information from bone-marrow punctures during the course of treatment. Outlook Investigations of new data showed the important role of the immune system in CML treatment (Saussele et al. 2016; Clapp et al. 2016). This should be taken into account by improving the model of Roeder und Loeffler (2002). Additionally, data from cessation trials can be used to validate the model assumptions.

Background: Work-related stress (WRS) is associated with musculoskeletal pain (MSP), changes in the autonomic nervous system (ANS) and anxiety. Objective: To determine the feasibility of a follow-up study and treatment efficacy of the Reaset Approach on MSP, ANS and State-Trait anxiety. Methods: 15 subjects with WRS and MSP were assigned into 3 groups (Body, Head-Neck, Head-Neck-Body). Each group received a single 25 minute ‘Reaset Approach’ intervention. Heart rate variability (HRV), electro-dermal activity (EDA), State Trait Anxiety (STAI) and MSP were measured. Results: HRV parameters: SDNN increased in 13 of 15 subjects while SD1 and SD2 increased in 12 of 15 subjects. EDA reduced in 10 of 14 subjects. State Anxiety reduced in all subjects and Trait Anxiety reduced in 14 of 15 subjects. MSP reduced in all subjects after the intervention and were still lower three days afterwards. Conclusions: This pilot study determined that a follow-up study can ensue provided minor modifications are implemented and that the ‘Reaset Approach’ has an influence on the ANS, anxiety and MSP. Results do differ between groups. The intervention groups including the head and neck modalities demonstrated better results.:I. Abstract (En) III II. Abstract (De) IV III. Table of Contents V IV. Index of figures VIII V. Index of tables IX VI. Index of abbreviations X 1 Introduction 1 2 Background 2 2.1 Work-related musculoskeletal pain 2 2.2 Work-related stress 3 2.3 Osteopathy and the autonomic nervous system 3 2.4 Stress, pain and osteopathy 4 3 Questions 6 3.1 Feasibility 6 3.2 Treatment effect 6 4 Methods 7 4.1 Study design 7 4.2 Participants 8 4.2.1 Inclusion criteria 8 4.2.2 Exclusion criteria 8 4.2.3 Recruitment 8 4.2.4 Randomization 10 4.3 Parameters 11 4.3.1 Heart rate variability 11 4.3.2 Electro-dermal activity 11 4.3.3 State anxiety 11 4.3.4 Trait anxiety 12 4.3.5 Perceived pain 12 4.4 Measuring Instruments 13 4.4.1 Heart rate variability 13 4.4.2 Electro-dermal Activity 13 4.4.3 State-Trait Anxiety Inventory 13 4.4.4 Short-Form McGill Pain Questionnaire 13 4.5 Interventions 14 4.5.1 Intervention ‘B’: Body 14 4.5.2 Intervention ‘HN’: Head and Neck 16 4.5.3 Intervention ‘HNB’: Head, Neck and Body 16 4.6 Study flow 18 4.7 Statistics 20 5 Results 21 5.1 Autonomic nervous system: Heart rate variability 21 5.1.1 SDNN 22 5.1.2 SD1 25 5.1.3 SD2 28 5.2 Autonomic Nervous System: Electro-dermal activity 31 5.3 Anxiety 34 5.3.1 State anxiety 34 5.3.2 Trait anxiety 37 5.4 Musculoskeletal pain 39 5.4.1 Visual analogue scale 40 5.4.2 Total Short-Form McGill Pain Questionnaire 43 6 Discussion 46 6.1 Discussion of the method 46 6.2 Discussion of the results 50 6.2.1 Autonomic nervous system 50 6.2.1.1 Heart rate variability 50 6.2.1.2 Electro-dermal activity 51 6.2.2 Anxiety 51 6.2.2.1 State anxiety 51 6.2.2.2 Trait Anxiety 52 6.2.3 Musculoskeletal pain 52 6.3 Suggestions for future research 53 7 Conclusion 54 8 Literature 55 9 Addendum 63 9.1 Table: SF-MPQ with Sensory, Affective and Evaluative dimension 63 9.2 Patient Information Sheet 64 9.3 Structured telephone interview 70 9.4 Structured pre-treatment interview 72 9.5 SF-MPQ permission 73 9.6 SF-MPQ 74 9.7 STAI License 76 9.8 STAI forms Y-1 and Y-2 77<br>Hintergrund: Arbeitsbedingter Stress (ABS) ist verbunden mit muskelschmerzen, Veränderungen im autonomen Nervensystem (ANS) und Angst. Ziel: Machbarkeit einer Follow-up-Studie und Wirksamkeit der Behandlung des Reaset Ansatzes auf ANS, Muskelschmerzen und State und Trait- Angst bestimmen. Methoden: 15 Patienten mit ABS und Muskelschmerzen wurden in 3 Gruppen eingeteilt (Körper, Kopf-Hals, Kopf-Hals-Körper). Jede Gruppe erhielt eine einzige 25 Minuten dauernde 'Reaset Approach’-Behandlung. Herzfrequenzvariabilität (HRV), elektro-dermale Aktivität (EDA), State-Trait-Angstsinventar (STAI) und Muskelschmerzen (SF-MPQ) wurden gemessen. Ergebnisse: Die HRV-wert: SDNN ist bei 13 von 15 Probanden erhöht, während SD1 und SD2 bei 12 von 15 Probanden zugenommen hat. EDA war bei 10 von 14 Probanden reduziert. Die State-Angst hat bei allen Probanden und die Trait-Angst bei 14 der 15 Probanden abgenommen. Muskelschmerzen waren bei alle Probanden anschließend an und drei Tage nach der Intervention reduziert. Schlussfolgerung: Diese Pilotstudie hat gezeigt, dass eine Follow-up-Studie fortgesetzt werden kann, sofern kleinere Änderungen durchgeführt werden. Die 'Reaset Approach’ hat einen günstigen Einfluss auf die ANS, State-Trait-Angst und Muskelschmerzen. Ergebnisse zwischen den Gruppen sind unterschiedlich. Die Interventionsgruppen mit einschließlich der Kopf-Hals-Modalitäten zeigten bessere Ergebnisse..:I. Abstract (En) III II. Abstract (De) IV III. Table of Contents V IV. Index of figures VIII V. Index of tables IX VI. Index of abbreviations X 1 Introduction 1 2 Background 2 2.1 Work-related musculoskeletal pain 2 2.2 Work-related stress 3 2.3 Osteopathy and the autonomic nervous system 3 2.4 Stress, pain and osteopathy 4 3 Questions 6 3.1 Feasibility 6 3.2 Treatment effect 6 4 Methods 7 4.1 Study design 7 4.2 Participants 8 4.2.1 Inclusion criteria 8 4.2.2 Exclusion criteria 8 4.2.3 Recruitment 8 4.2.4 Randomization 10 4.3 Parameters 11 4.3.1 Heart rate variability 11 4.3.2 Electro-dermal activity 11 4.3.3 State anxiety 11 4.3.4 Trait anxiety 12 4.3.5 Perceived pain 12 4.4 Measuring Instruments 13 4.4.1 Heart rate variability 13 4.4.2 Electro-dermal Activity 13 4.4.3 State-Trait Anxiety Inventory 13 4.4.4 Short-Form McGill Pain Questionnaire 13 4.5 Interventions 14 4.5.1 Intervention ‘B’: Body 14 4.5.2 Intervention ‘HN’: Head and Neck 16 4.5.3 Intervention ‘HNB’: Head, Neck and Body 16 4.6 Study flow 18 4.7 Statistics 20 5 Results 21 5.1 Autonomic nervous system: Heart rate variability 21 5.1.1 SDNN 22 5.1.2 SD1 25 5.1.3 SD2 28 5.2 Autonomic Nervous System: Electro-dermal activity 31 5.3 Anxiety 34 5.3.1 State anxiety 34 5.3.2 Trait anxiety 37 5.4 Musculoskeletal pain 39 5.4.1 Visual analogue scale 40 5.4.2 Total Short-Form McGill Pain Questionnaire 43 6 Discussion 46 6.1 Discussion of the method 46 6.2 Discussion of the results 50 6.2.1 Autonomic nervous system 50 6.2.1.1 Heart rate variability 50 6.2.1.2 Electro-dermal activity 51 6.2.2 Anxiety 51 6.2.2.1 State anxiety 51 6.2.2.2 Trait Anxiety 52 6.2.3 Musculoskeletal pain 52 6.3 Suggestions for future research 53 7 Conclusion 54 8 Literature 55 9 Addendum 63 9.1 Table: SF-MPQ with Sensory, Affective and Evaluative dimension 63 9.2 Patient Information Sheet 64 9.3 Structured telephone interview 70 9.4 Structured pre-treatment interview 72 9.5 SF-MPQ permission 73 9.6 SF-MPQ 74 9.7 STAI License 76 9.8 STAI forms Y-1 and Y-2 77

Adverse birth outcomes can have an overwhelmingly negative impact on many aspects of society – the infant, mother and family are intimately affected, but there are also major consequences on the overall health system. For the purpose of this study, adverse birth outcomes were defined as: premature birth, low birth weight, congenital conditions, stillbirth and neonatal death. The few studies, based overseas, that have investigated the health system costs of women following adverse birth outcomes showed these costs were significant and needed to be addressed. To date, no such studies have been conducted with Australian data. This thesis contributes to this area by quantifying the difference in maternal health system costs of women who experienced adverse birth outcomes and those that did not, using Australian data. The cost differentials were assessed across both hospital and out-of-hospital systems. In addition, statistical and actuarial techniques were employed on a comprehensive dataset – with linkages between various administrative data and longitudinal data collected on a large, broadly representative, sample of women. The techniques adopted in this study enabled an in-depth analysis of the complexities in the area, in particular the associations between risk factors and their impact on health system costs. These results were used to develop cost-effective health policy recommendations. The results showed that the mean maternal health system cost differentials for adverse births were substantial at 23% and 27% for hospital and out-of-hospital costs, respectively. These amounts are broadly in line with the existing literature. The key cost risk factors were mode of delivery, use of In Vitro Fertilisation treatments, specialist and general practitioner use for perinatal services, private health insurance status, adverse births, area of residence, diabetes, smoking status and mental health factors. The findings of this project showed that there were a number of key areas where health resources may be directed and smoking and mental health policy were considered further. With regard to smoking, programs providing incentives for smokers to quit during pregnancy have been found to produce successful outcomes and recommended for further consideration. For mental health, numerous mental health initiatives were recommended as a priority for attention. These included a national universal mental health screening protocol for antenatal and postnatal periods in conjunction with improved screening methods and health services that focus on holistic, proactive early intervention so that mental health problems are detected and treated early. While these recommendations are likely to require increased funding in some areas, the results of this study suggest they are worth exploring further as investing in preventative strategies are likely to reduce costs in the future when these women experience major life events such as the birth of a baby. Not only are the initiatives likely to be cost-effective, but more importantly, they are likely to improve the health outcomes for those women who are most at risk of experiencing these adverse conditions.

The diploma thesis deals with problems of depression in older people. Mainly the work is focused on identifying and analyzing the role of nurses in screening for depression in older people in primary care, acute care, long-term care and home care. This thesis was focused on theoretical direction and was used the method of design and demonstration. In this thesis was set one main goals with five research questions. The main goal was to identify and analyze the role of nurses in screening for depression in the elderly. RQ 1: What is the role of the nurse in screening for depression in the elderly? RQ 2: What is the role of the nurse in the primary care in screening for depression in the elderly? RQ 3: What is the role of the nurse in screening for depression in hospitalized patients in acute care? RQ 4: What is the role of the nurse in screening for depression in seniors in long-term and home care? RQ 5: What rating scales and methods are used in screening for depression in the elderly? The thesis introduce the concept of depression. The following are specified the causes of and the important factors that affect depression in the elderly. It also deals the differences in the clinical symptomatology of depression in old age. It explains possibilities and various barriers in the diagnosis of depression. Another chapter introduces complete geriatric examination, diagnostic classification systems, possible screening methods and scales for detection of depression in the elderly population. It also deals methods of pharmacological and non-pharmacological treatment and its possible complications associated with older age. By reason of increased suicide rate caused by depressive disorder the issue of suicidal behavior in the elderly is introduced. The next chapter deals with the nursing process, which is used by nurses in practice. It consists of the evaluation of the patient's health condition, making nursing diagnosis, creating nursing plan and subsequent implementation and evaluation. The nursing process is also needy for providing quality care. The nursing process in the stage of nursing diagnosis, introduces possible nursing diagnosis for a patient suffering from depression, which are based on the latest classification. Finally is described the role of nurses in screening for depression in the elderly in different health facilities and their contribution to the timely evaluation of depression in the elderly. This chapter introduces the role of nurses, nursing screening and collaboration with a physician. The role of nurses in screening for depression in different medical facilities is based on the first phase of the nursing process of assessment. On the basis of objective and subjective information, the nurse will assess the overall health and mental condition of the patient. Primarily, it was investigated what is the role of the nurse in screening for depression. On the basis of content analysis and synthesis it was necessary to used and processed domestic and foreign literature. A number of relevant sources are the results of various studies and Meta-analyzes, mostly from abroad, but also from the Czech Republic. The thesis can serve as a basis for nurses. The result of this thesis is to create e-learning material available for students in the Faculty of Health and Social Sciences of South Bohemia in Ceske Budejovice in the tutorial called Moodle.