Bakgrund: Ett hjärtstopp är ett ytterst allvarligt tillstånd som påverkar inte bara patienten själv utan hela familjen, speciellt en nära anhörig. Patienten svävar mellan liv och död, och om patienten överlever är det ofta med mer eller mindre bestående men. Vid patientens sida finns de anhöriga som vill vara nära, hjälpa och stöda sin närstående samtidigt som det också kan vara en mycket svår situation för dem. Syfte: Syftet med den här kvalitativa litteraturstudien var att belysa anhörigas upplevelser av en närståendes hjärtstopp, för att i framtiden bättre kunna tillmötesgå dem inom vården. Metod: En kvalitativ sammanfattande litteraturstudie baserad på åtta vetenskapliga artiklar som hade studerat anhörigas upplevelser under själva hjärtstoppet, på intensiv-vårdsavdelningen eller efter hemkomst. Resultat: Hjärtstoppet var en kaotisk och traumatisk upplevelse för den anhöriga. Patienten var viktigast, all fokus var på patienten men det lämnade ofta den anhöriga ensam med den oro och rädsla situationen framkallat. Tillgång till kontinuerlig information och professionellt bemötande var ytterst viktigt för den anhöriga. Möjligheten att få vara nära närstående dygnet runt ingav säkerhet och trygghet. Brist på information och uppföljning efter utskrivning och en känsla av att vara ensam med allt ansvar var återkommande teman. Slutsats: Att som anhörig vara nära vid ett hjärtstopp var en stark existentiell upplevelse där alla aspekter av delaktighet fanns beskrivna; att veta, att göra och att vara. För bästa resultat, ett delaktigt vårdande i ljuset, krävs en samverkan mellan den vårdande personalen, patient och anhörig. Mer stöd och uppmärksamhet bör i framtiden riktas även mot den anhöriga. / Background: Sudden cardiac arrest is a life threatening condition, not only affecting the patient but the whole family. The patient’s life is on hold and if the patient survives, this is often with more or less physical and psychological complications. Close to the patient a family member or relative, tries to support and help the patient while at the same time the situation may be extremely stressful for the relative. Aim: The aim of this qualitative literature review was to get a better understanding of family members lived experiences during a loved one’s sudden cardiac arrest, in order to better also support the relatives in healthcare. Method: A summary of the literature based on eight qualitative studies on the perceptions of family members experiences of a sudden cardiac arrest by a loved one; during the cardiac arrest, at the intensive care unit and after discharge from hospital. Results: The cardiac arrest was experienced as a chaotic and traumatic event by the relative. The patient was the most important person at the moment but at the same time it left the relative alone with her feelings of anxiety and fear that the situation induced. Receiving information continuously about their next of kin’s condition as well as a considerate and professional encounter with the intensive care unit staff was important for the relative. The possibility to stay with the patient at the intensive care unit felt comforting, reassuring and safe. Lack of information and follow up, as well as a feeling of being alone with the responsibility, was a common theme after discharge from the hospital. Conclusion: To be present during the next of kin’s cardiac arrest was a strong existential experience where all aspects of involvement and participation were described; to know, to do and to be. For best results, an involving care in the light, collaboration between the professional care, the patient and the family member is needed. More support and attention should be given to family members in the future.

Chaque année, environ 40000 patients subissent un arrêt cardiaque extra-hospitalier en France. Malgré l’amélioration de la prise en charge initiale, ces patients développent fréquemment une dysfonction neurologique, cardiaque et multi-viscérale, à l’origine d’une survie extrêmement faible. L’une des stratégies susceptible d’améliorer la survie chez les patients est l’induction d’une hypothermie thérapeutique modérée à 32-34°C. Cela présente néanmoins un bénéfice très limité chez l’Homme par rapport à celui décrit dans les études expérimentales. L’une des explications pourrait être la vitesse d’induction de l’hypothermie chez l’Homme par rapport à celle réalisée chez l’animal de laboratoire. Dans ce contexte, le laboratoire d’accueil étudie une approche capable de maximiser la vitesse de refroidissement par ventilation liquide totale (VLT). Cette stratégie consiste à ventiler les poumons avec des perfluorocarbones liquides et à utiliser cet organe comme bio-échangeur thermique, tout en assurant des échanges gazeux normaux.L’objectif de mon travail a été de d’étudier expérimentalement les conséquences de l’induction d’une hypothermie ultra-rapide dans différentes situation d’arrêt cardiaque chez le lapin. Cela permettrait à terme de déterminer la situation la plus pertinente pour le transfert clinique de la VLT.Nous avons tout d’abord étudié l’effet d’une hypothermie induite par de grande quantités de fluides froids pendant la réanimation cardio-pulmonaire après un arrêt cardiaque choquable. Cela n’a pas permis d’induire de bénéfice sur les chances de réanimation en l’absence d’administration d’adrénaline. Dans un second temps, nous avons démontré que la VLT était associée à une puissante neuroprotection et cardioprotection à la fois après un arrêt cardiaque choquable avec infarctus du myocarde sous-jacent, ou après un d’arrêt cardiaque non choquable d’origine respiratoire. Ce bénéfice s’exerçait très précocement au décours de l’arrêt cardiaque, par une inhibition de la perméabilité de la barrière hémato-encéphalique, de la production d’espèces réactives de l’oxygène, de l’hyperhémie cérébrale et de la réponse inflammatoire.Ces résultats démontrent l’existence d’une fenêtre thérapeutique très précoce, au cours de laquelle la VLT hypothermisante peut procurer une puissante protection neurologique et cardiaque à la suite d’un arrêt cardiaque. Dans la perspective d’un transfert clinique de la VLT, la situation de l’arrêt cardiaque non choquable serait particulièrement pertinente, en raison du pronostic très sombre qui lui est associé. / Cardiac arrest is a major public health issue, concerning 40000 patients every year in France. Among the successfully resuscitated patients, most of them develop severe neurological, cardiac and multivisceral dysfunctions, leading to an aggravation of the prognosis. One of the strategies that could improve this prognosis is mild therapeutic hypothermia at 32-34 degres°C during 24 hours. However, recent clinical studies demonstrated limited benefits in patients, as compared to experimental studies. One of the explanations could be the relatively prolonged delay for hypothermia achievement in humans as compared to laboratory animals. In order to induce similar cooling rate in humans than animals, the laboratory is investigating a strategy for ultra-fast cooling through total liquid ventilation (TLV). This strategy consists in lungs ventilation with cold perfluorocarbons, which could use the lungs as a heat-exchanger while maintaining normal gas exchanges.The general goal of the present study was to experimentally investigate the consequences of ultra-fast cooling in different situations of cardiac arrest in rabbits. This could lead to determine the most relevant clinical setting for a further clinical translation of TLV in patients.Accordingly, we initially studied the effect of conventional hypothermia through fluid administration during cardiac massage in a rabbit model of shockable cardiac arrest. Such conventional hypothermia did not provide any benefit. Then, we investigated the effect of cooling induced by TLV in rabbits submitted to cardiac arrest from different causes. After ischemic cardiac arrest from shockable rhythm, TLV was associated with potent neuro- and cardioprotective effects, along with strong survival improvement and multivisceral dysfunction limitations. After cardiac arrest from respiratory and non-shockable cause, TLV provided potent neurological benefit. This was exerted very early after resuscitation through the reduction of the blood-brain barrier permeability, reactive oxygen species production, acute cerebral hyperhaemia or inflammatory response.In conclusion, TLV-induced cooling provides potent neurological and systemic benefits after experimental cardiac arrest from different causes in rabbits. These works describe the existence of a therapeutic window for hypothermia, very early after cardiac arrest. This strengthens the relevance of TLV for cooling induction. For a further clinical translation, non-shockable cardiac arrest could be a relevant clinical situation, considering the very poor prognosis.

Le pronostic des victimes d’arrêts cardiaques traumatiques (ACT) est considéré comme très péjoratif et la « futilité » d’une réanimation est souvent évoquée chez ces patients. Les recommandations internationales concernant leur prise en charge font l’objet d’un réel débat. L’objectif de cette thèse est de fournir des données épidémiologiques à grande échelle de ces patients, de leur prise en charge et de leur survie afin d’orienter les recommandations.Matériel et Méthode : Etude nationale multicentrique basée sur les données du Registre national français des arrêts cardiaques (RéAC). Tous les ACT survenus entre le 01/07/2011 et le 01/01/2016 dont les données étaient disponibles dans la base RéAC étaient inclus. La première étape consistait en la description de la population. La seconde partie consistait en la comparaison de la population d’ACT à une population d’AC médicaux (ACM) avant et après appariement sur score de propension.Résultats : Sur la période choisie, 3303 patients ont été inclus. Trois quarts des victimes d’ACT étaient des hommes et l’âge médian était de 45 ans. L’ACT survenait hors domicile dans 75,9% des cas. Un témoin était présent lors de l’AC dans 54,3% des cas mais ils n’initiaient une réanimation cardiopulmonaire (RCP) que chez 31,8% des victimes. A l’arrivée du SMUR, 86,9% des patients étaient en asystolie, 5,9% présentaient un rythme sans pouls, 1,4% un rythme choquable et 5,8% une activité efficace. Une RCP spécialisée avait été initiée chez 71,3% des patients, au décours ou à l’issue de laquelle 16,5% avaient eu une reprise d’activité cardiaque spontanée. A l’admission, 14,5% étaient en vie. A J+30, 1,5% (n=51) avaient survécu dont 67,4% avec un bon pronostic neurologique. Parallèlement, 48 patients (1,4%) avaient fait l’objet d’un prélèvement d’organes: à cœur arrêté (n=8) ou sur patient en état de mort encéphalique (n=40).Sur la même période, 42628 ACM ont été inclus. Cette population était statistiquement plus âgée, plus féminine et l’ACM survenait davantage à domicile. Les patients étaient plus pris en charge par les témoins, les pompiers et le SMUR. A l’admission comme à J+30, les victimes d’ACM survivaient plus (OR des ACT respectivement 0,629[0,570;0,695]; p<10-3 et 0,253[0,191;0,335]; p<10-3). Après appariement, 2449 paires ont été obtenues. Ainsi, sur populations appariées, les victimes d’ACT survivaient statistiquement moins que les victimes d’ACM. Leurs chances de survie étaient 2,4 fois moindres à l’admission (OR : 0,416[0,359;0,482]; p<10-3) et 6 fois moindres à J+30 (OR : 0,168[0,117;0,241]; p<10-3).Discussion : Les caractéristiques des victimes d’ACT incluses sont comparables à une partie du corpus bibliographique, notamment européen. On constate des faiblesses dans la chaîne de survie qui ont été évoquées par ailleurs. Les taux de survie sont faibles, parfois même en comparaison de la littérature. Cependant, on retrouve des survivants, quels que soient le rythme et les caractéristiques lésionnelles, fait contestant, en particulier, la bibliographie américaine ainsi que les recommandations en découlant. Toutefois, dans un contexte quasi-expérimental, les chances de survie des ACT étaient significativement inférieures aux ACM, contredisant certaines des rares études antérieures. Ainsi, les recommandations européennes qui soulevaient ces lacunes peuvent bénéficier de ce nouvel apport. Les ACT ont des taux de survie significativement inférieurs aux ACM toutes choses égales par ailleurs. Néanmoins, ils suggèrent qu'il n'est pas « futile » de proposer une RCP préhospitalière pour ces patients. Les résultats nous permettent de nous positionner davantage dans le sens proposé par les recommandations européennes qu’en celui proposé par les Etats-Unis. Toutefois, ces nouvelles données pourraient permettre de les affiner. Enfin, Il est important de garder à l’esprit que le don d’organe n’est pas anecdotique dans cette jeune population. / Traumatic cardiac arrests (TCA) prognosis is known to be dismal and resuscitation attempts “futility” is often discussed. Hence, resuscitation international guidelines regarding their care are frequently debated. This PhD work objective is to provide large scale epidemiological data on these patients, on their care and survival in order to bring matter for orientating the forthcoming guidelines.Material and Methods: National multicentre study based on the French national cardiac arrest registry (RéAC) data. All TCA which occurred between the 01/07/2011 and 01/01/2016 for which RéAC data were available were included. The first step consisted in a description of the TCA population. The second one consisted in a comparison of TCA to medical CA (MCA) before and after propensity score matching.Results: On the selected time span, 3303 TCA victims were included. Three quarter of them were males and the median age was 45. TCA occurred out of home in 75,9% cases. Bystander(s)’ presence was recorded in 54,3% cases. Yet, only 31,8% provided a basic life support. At mobile medical teams’ arrival, 86,9% of patients were in asystole, 5,9% had a pulseless electrical activity, 1,4% had a shockable rhythm and 5,8% had an effective activity. An advanced life support was attempted in 71,3% of patients and 15,6% sustained a return of spontaneous activity. At hospital admission, 14,5% were alive. At Day 30, 1,5% (n=51) survived among which 67,4% had a good neurological outcome. Besides, 48 patients (1,4%) gave their organs, in non-beating heart framework (n=8) or in encephalic death organ retrieval framework (n=40).On the same period, 42628 MCA were included. This population was significantly older, more feminine and most of them occurred at home. Patients were more often cared by bystanders, firemen and medical teams. At hospital admission and at 30 days, their survival chances were higher than in TCA population (TCA OR respectively 0,629[0,570;0,695]; p<10-3 and 0,253[0,191;0,335]; p<10-3). After adjustment, TCA survival odds were even lower than in MCA: 2,4 times lower at admission (OR: 0,416[0,359;0,482]; p<10-3) and 6 times lower at day 30 (OR: 0,168[0,117;0,241]; p<10-3). Included TCA characteristics are coherent with a part of the bibliographical corpus, mostly European. We observe weaknesses in the TCA chain of survival which were also described elsewhere. Survival rate are indeed low, sometimes even regarding some other studies. However, we record survivors regardless of initial recorded rhythm of lesional characteristics. This fact particularly questions American literature and guidelines. However, in a quasi-experimental context, TCA odds of survival were significantly lower than MCA, contradicting the scarce literature dealing with this issue. Therefore, European guidelines that raised these shortcomings can henceforth benefit from this new contributionConclusion: TCA have significantly lower survival rates than MCA all things being equal. Still, prehospital life support initiation does not seem futile in these patients. These results enable us to position ourselves more in favour of European guidelines than in American ones. Yet, this new information could help to refine them. Finally, we can also keep in mind that organ donation is not anecdotical in this young population.

Bakgrund: Att drabbas av hjärtstopp kan upplevas som en dramatisk händelse som påverkar både hälsan och livsvärlden. Alla patienter innehar ett existentiellt sammanhang som påverkar hälsan, livet och patienten själv. Sjuksköterskan behöver kunna se till patientens livsvärld och förstå hur olika sammanhang påverkar patientens upplevelse av sin hälsa. Syfte: Syftet var att beskriva patientens upplevelse av att överleva ett hjärtstopp. Metod: Den valda metoden var en litteraturbaserad studie med kvalitativ ansats som inkluderade 11 artiklar som analyserats med en metod beskriven av Friberg. Resultat: Ur analysen av datamaterialet framträdde tre huvudteman: en ny vardag, ett förändrat liv och livsavgörande begränsning med inopererad defibrillator med tio underteman. Konklusion: Majoriteten av patienterna upplevde oro, rädsla och ångest i sin vardag. De behövde utveckla nya strategier för att kunna hantera sitt nya liv i form av rutiner och planering för att minska stress i vardagen. / Background: To suffer from cardiac arrest can be experienced as a dramatic event that affects both the health and life world. All of the patients have an existential coherency that affects the health, life and the patient itself. As a nurse you will be able to see the patient's life world and understand how different contexts affects the patient's experienced health. Purpose: The purpose was to describe the patient’s experience of surviving cardiac arrest. Method: The chosen method was a literature based study with a qualitative approach that included 11 articles that was analyzed using a method described by Friberg. Results: Through analysis of the data material three main themes was generated with associated sub themes. From the analysis of the data emerged three main themes a new every day life, a changed life and a life changing limitation with an inoperable defibrillator with ten undertheme. Conclusion: The majority of the patients experienced worry, fear and anxiety in their everyday life. They needed to develop new strategies to cope with their new life with the help of routines and planning to decrease stress in their everyday life.

Cardiopulmonary resuscitation (CPR) and defibrillation are the interventions performed by health care professionals in order to preserve the life of a patient suffering cardiac arrest. These tasks are important to the role of nurses because they are the most common first responders to in-hospital cardiac arrest scenarios. The early initiation of CPR and defibrillation is essential in increasing the likelihood of a patient surviving cardiac arrest. Despite possessing the knowledge, skills, training, and professional obligation to deploy CPR and defibrillation independently, nurses may hesitate to perform the appropriate actions in a timely manner. This topic has been studied previously; however, there have been no studies directly examining this issue in the Ontario context. This thesis explored the factors that influence the behaviour of nurses in the first responder role by employing a mixed-methods research design. The quantitative portion of the study consisted of a series of scales on an online survey that examined teamwork factors and nurses’ experience with CPR events. The qualitative part of the study consisted of open-ended questions on the survey as well as individual interviews with nurses to understand the barriers and enablers to the role of nurses in the enactment of basic life support (BLS). The qualitative data were analyzed with a modified grounded theory approach. The qualitative data analysis followed the guidelines developed by Charmaz (2006) and employed the conceptual framework on optimizing scopes of practice developed by the Canadian Academy of Health Sciences (2014) to extrapolate findings on the influence of nurses’ scope of practice on their behaviour. This study revealed a number of contextual factors in Ontario influencing nurses’ deployment of CPR and defibrillation including variations in hospital unit types, geography, workload, the availability and quality of technology, legislation and regulation, accountability, as well as economic constraints.

Rates of survival of victims of sudden cardiac arrest (SCA) using cardio pulmonary resuscitation (CPR) have shown little improvement over the past three decades. Since registered nurses (RNs) comprise the largest group of healthcare providers in U.S. hospitals, it is essential that they are competent in performing the four primary measures (compression, ventilation, medication administration, and defibrillation) of CPR in order to improve survival rates of SCA patients. The purpose of this experimental study was to test a color-coded SMOCK system on:1) time to implement emergency patient care measures 2) technical skills performance 3) number of medical errors, and 4) team performance during simulated CPR exercises. The study sample was 260 RNs (M 40 years, SD=11.6) with work experience as an RN (M 7.25 years, SD=9.42).Nurses were allocated to a control or intervention arm consisting of 20 groups of 5-8 RNs per arm for a total of 130 RNs in each arm. Nurses in each study arm were given clinical scenarios requiring emergency CPR. Nurses in the intervention group wore different color labeled aprons (smocks) indicating their role assignment (medications, ventilation, compression, defibrillation, etc) on the code team during CPR. Findings indicated that the intervention using color-labeled smocks for pre-assigned roles had a significant effect on the time nurses started compressions (t=3.03, p=0.005), ventilations (t=2.86, p=0.004) and defibrillations (t=2.00, p=.05) when compared to the controls using the standard of care. In performing technical skills, nurses in the intervention groups performed compressions and ventilations significantly better than those in the control groups. The control groups made significantly (t=-2.61, p=0.013) more total errors (7.55 SD 1.54) than the intervention group (5.60, SD 1.90). There were no significant differences in team performance measures between the groups. Study findings indicate use of colored labeled smocks during CPR emergencies resulted in: shorter times to start emergency CPR; reduced errors; more technical skills completed successfully; and no differences in team performance.

Introduktion: Hjärtstopp är ett livshotande tillstånd med hög dödlighet där hjärtats pumpförmåga har upphört att fungera. Under 2019 utfördes hjärt- och lungräddning (HLR) på 8404 personer till följd av ett hjärtstopp i Sverige. Patienterna som överlever hjärtstopp kan drabbas av komplikationer som kan påverka deras återhämtning och livskvalitet. Syfte: Att beskriva patienters upplevelser efter att ha överlevt ett hjärtstopp med utförd HLR. Metod: En litteraturstudie baserat på tio kvalitativa originalartiklar från databaserna APA PsycInfo och PubMed. Resultat: Fyra kategorier och tolv subkategorier identifierades. Mötet med vården beskriver upplevelser av bemötandet från vårdpersonal, patienternas informationsbehov och att utskrivningen från sjukhuset var en kritisk period. Påverkan efter hjärtstopp innefattar de fysiska och kognitiva besvär patienten upplever. Känslor efter hjärtstopp beskriver att patienterna upplevde oro och rädsla efter hjärtstoppet samt att synen på livet och döden förändrades. Vägen tillbaka innefattar hur patienten bearbetar händelsen och strävar efter en återgång till normalitet. Slutsats: Att överleva ett hjärtstopp är en livsomvälvande händelse som medför en ny syn på livet. Patienterna upplevde oro och rädsla inför risken för ännu ett hjärtstopp. Brist på information skapar osäkerhetskänslor hos patienterna som påverkar dem i sin vardag. Genom tillräcklig information kring händelsen och känslorna som uppstår kan sjuksköterskan minska patientens oro. Genom kunskap om förändrade familjerelationer kan sjuksköterskan bättre möta patienter och anhöriga och hjälpa dem med de nya rollerna de numera behöver inta. / Introduction: Cardiac arrest is a life-threatening condition with a high mortality where the heart’s ability to contract has ceased to function. In 2019 cardiopulmonary resuscitation (CPR) was performed on 8404 cardiac arrest patients in Sweden. Survivors face potential complications that can affect their recovery and quality of life. Aim: To describe the experiences after surviving a cardiac arrest with performed CPR.  Method: A literature review based on ten qualitative original articles from the databases APA PsycInfo and PubMed. Result: Four categories and twelve subcategories were identified. The meeting with healthcare describes experiences of the treatment from healthcare workers, patients' need for information and that the discharge was a critical time. Effects after cardiac arrest includes patients’ experiences regarding physical and cognitive difficulties. Feelings after cardiac arrest describes that the patients experienced anxiety and fear after the cardiac arrest and a changed view on life and death. The way back includes the processing of the event and the strive for normality. Conclusion: Surviving a cardiac arrest is a life-changing event that entails a new view on life. The patients experienced anxiety and fear due to the risk of another cardiac arrest. Lack of information created feelings of uncertainty in the patients that affected them in their everyday life. Through sufficient information regarding the event and the emotions that follows the nurse can ease the patients concerns. Through knowledge about changed family relations the nurse can better aid patients and relatives in their new roles.

Thesis (MPH) -- University of Limpopo, 2007. / Aim of the study: To determine knowledge of CPR and heart attack or cardiac arrest signs and symptoms among university students. Study Design: A questionnaire based descriptive, cross – sectional study. Setting: University of Limpopo – Turfloop Campus in Limpopo Province of South Africa. Subjects: A total sample of 400 students participated in the study. The sample was selected randomly using simple random sampling techniques. Outcome measures: The faculty, age, gender and level of study were determined as well as the knowledge each student has on signs and symptoms of impending heart attack and CPR. Results: Of the 400 students only 26% (n=104) knew the signs and symptoms of an impending heart attack as well as out of hospital management of heart attack by performing CPR. There were differences between and within faculties, age groups, gender and level of study. Based on the Bonferroni test the student from faculty of Sciences, Health and Agriculture are more likely (p-value 0017) to know when to perform CPR compared to students from other faculties. Level of study is not associated (p-value 0128) with how much the students know about the timing and indications of CPR. Overall female students performed worse with 79% (n=123) responding incorrectly to the questions compared to 69% (n=169) males. Conclusion: Based on the results of this study it safely can be concluded that the students’ knowledge of signs and symptoms of an impending heart attack and CPR procedure is poor. It is therefore important for the university as a center of teaching and learning to consider including as part of university curriculum, basic life support v and first aid courses which include CPR. The inclusion of basic life support and first aid in university curriculum will prepare students to be able to effectively manage out of hospital heart attack and reduce mortality resulting from the latter. The findings of this study might to a certain extent be reflecting what the public’s knowledge on the subject is, hence the need for the policy makers to take serious note of the findings when public health promotion programmes are developed.

Sudden out-of-hospital cardiac arrest is the third leading cause of death in industrialized nations. Many of these lives could be saved if bystander cardiopulmonary resuscitation rates were better. "All citizens of the world can save a life-CHECK-CALL-COMPRESS." With these words, the International Liaison Committee on Resuscitation launched the 2019 global "World Restart a Heart" initiative to increase public awareness and improve the rates of bystander cardiopulmonary resuscitation and overall survival for millions of victims of cardiac arrest globally. All participating organizations were asked to train and to report the numbers of people trained and reached. Overall, social media impact and awareness reached up to 206 million people, and >5.4 million people were trained in cardiopulmonary resuscitation worldwide in 2019. Tool kits and information packs were circulated to 194 countries worldwide. Our simple and unified global message, "CHECK-CALL-COMPRESS," will save hundreds of thousands of lives worldwide and will further enable many policy makers around the world to take immediate and sustainable action in this most important healthcare issue and initiative. / Revisión por pares

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第22380号 / 社医博第102号 / 新制||社||医11(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 中山 健夫, 教授 小池 薫, 教授 今中 雄一 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM