京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第21031号 / 社医博第85号 / 新制||社医||10(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 小池 薫, 教授 今中 雄一, 教授 湊谷 謙司 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

In Botswana, nurses play a major role in the provision of healthcare. Most of the time it is the professional nurses who frequently discover patients with cardiac arrests and it is necessary for them to be trained to perform CPR as efficiently as possible. The aim of this study is to describe and explore the perceptions, barriers and needs as experienced by nurses in Botswana during the provision of CPR. For this study, the researcher utilised both quantitative and qualitative research designs in four phases. Phase one assessed and audited the existing available facilities in the provision of CPR. Phase two investigated the existing knowledge and skills of registered nurses in the performance of CPR. Focus groups discussions and semi-structured interviews were held during phase three to identify the perceived barriers, needs in the performance of CPR. In phase four, the researcher made recommendation to improve the provision of CPR in relation to system, nurse and patient. Convenience sampling and purposive sampling were used in this study respectively. The auditing of the equipment in the two referral hospitals showed that the availability of equipment was below 50%. The CPR knowledge and skills demonstrated by the nurses in the pre-test were inadequate. Following CPR training with the help of a manikin, the knowledge and skills among registered nurses improved substantially. The focus group discussions and semi-structured interviews among registered nurses and senior nurse mangers revealed that there was a lack of organisational support and resources, lack of knowledge and skills among registered nurses, inadequate policies and protocols are the major contributory factors affecting the registered nurses performance in the provision of CPR. In order to enhance the performance of the registered nurses while providing CPR, the researcher recommends the two referral hospitals to • have adequate provision of equipment • introduce regular BLS training program for registered nurses • have clearly defined policies regarding the nurses’ role on end-of-life care / Health Studies

In Botswana, nurses play a major role in the provision of healthcare. Most of the time it is the professional nurses who frequently discover patients with cardiac arrests and it is necessary for them to be trained to perform CPR as efficiently as possible. The aim of this study is to describe and explore the perceptions, barriers and needs as experienced by nurses in Botswana during the provision of CPR. For this study, the researcher utilised both quantitative and qualitative research designs in four phases. Phase one assessed and audited the existing available facilities in the provision of CPR. Phase two investigated the existing knowledge and skills of registered nurses in the performance of CPR. Focus groups discussions and semi-structured interviews were held during phase three to identify the perceived barriers, needs in the performance of CPR. In phase four, the researcher made recommendation to improve the provision of CPR in relation to system, nurse and patient. Convenience sampling and purposive sampling were used in this study respectively. The auditing of the equipment in the two referral hospitals showed that the availability of equipment was below 50%. The CPR knowledge and skills demonstrated by the nurses in the pre-test were inadequate. Following CPR training with the help of a manikin, the knowledge and skills among registered nurses improved substantially. The focus group discussions and semi-structured interviews among registered nurses and senior nurse mangers revealed that there was a lack of organisational support and resources, lack of knowledge and skills among registered nurses, inadequate policies and protocols are the major contributory factors affecting the registered nurses performance in the provision of CPR. In order to enhance the performance of the registered nurses while providing CPR, the researcher recommends the two referral hospitals to • have adequate provision of equipment • introduce regular BLS training program for registered nurses • have clearly defined policies regarding the nurses’ role on end-of-life care / Health Studies

Bakgrund: Plötsligt hjärtstopp är en av de vanligaste orsakerna till för tidig död i vårt samhälle och den största dödsorsaken runt om i världen. Syfte: Syftet med studien var att studera vilken kunskap, utbildning och beredskap i hjärt-lungräddning (HLR), som medarbetarna i primärvården anser sig ha och om det fanns skillnader i detta mellan yrkesprofessioner och mellan vårdcentraler i stad respektive landsort. Metod: Designen är en deskriptiv och jämförande tvärsnittsstudie. En enkät användes för att få med så många respondenter som möjligt. Resultat: Resultatet baseras på svar från 144 respondenter. Av samtliga medarbetare hade 87 ­% gen­omgått en HLR utbildning det senaste året. Detta till trots ansåg sig endast 66 % ha tillräckliga kunskaper i HLR. Någon signifikant skillnad mellan yrkesprofessioner gällande kunskap i HLR gick inte att signifikant säkerställa (p = 0,107). Endast 80 % av medarbetarna visste hur ambulans larmas. I en jämförelse mellan stad och landsort fanns dock ingen signifikant skillnad i den kunskapen (p = 0,12). Slutsats: Det är viktigt att skapa förutsättningar för fortlöpande utbildningar till medarbetarna för att öka kunskap, utbildning och beredskap i HLR, vilket även kan ses som ett kvalitetssäkringsarbete i vården. / Background: Sudden cardiac arrest is one of the most common causes of premature death in our society and the largest cause of death worldwide. Purpose: The purpose of this study was to investigate primary health care employee’s knowledge, training and preparedness they consider themselves to have in cardiopulmonary resuscitation (CPR) and to study whether there are differences between professional roles as well as differences in urban and rural health centers. Method: The design of this study is a descriptive and comparative cross-sectional study.  To capture as many respondents as possible a questionnaire was used. Result: The result in this study is based on responses from 144 respondents. Eighty-seven percent of employees have been training CPR the last year. Despite that only 66 % felt they have sufficient know­­ledge. There was no significant differences indicated in knowledge in CPR between professions roles (p = 0,107). Only 80 % knew how to alert the ambulance. In a comparison between urban and rural no significant difference in knowledge can be seen (p = 0, 12). Conclusion: The conclusion of the study is that it´s important to create competence for the employees, education for members of the CPR in order to improve the skills which can also be seen as a quality work in health care centers.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第21296号 / 医博第4385号 / 新制||医||1030(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 小池 薫, 教授 福原 俊一, 教授 木村 剛 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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<p>Research using mice and rats has gained interest because they are robust test beds for clinical drug development and are used to elucidate disease etiologies. Blood vessel visualization and blood flow measurements are important anatomic and physiologic indicators to drug/disease stimuli or genetic modification. Cardio-pulmonary blood flow is an important indicator of heart and lung performance. Small animal functional imaging provides a way to measure physiologic changes minimally-invasively while the animal is alive, thereby allowing for multiple measurements in the same animal with little physiologic perturbation. Current methods of measuring cardio-pulmonary blood flow suffer from some or all of these limitations-they produce relative measurements, are limited to global or whole animal or organ regions, do not provide vasculature visualization, limited to a few or singular samples per animal, are not able to measure acute changes, or are very invasive or requires animal sacrifice. The focus of this work was the development of a small animal x-ray imaging system capable of minimally invasive real-time, high resolution vascular visualization, and cardio-pulmonary blood flow measurements in the live animal. The x-ray technique used was digital subtraction angiography (DSA). This technique is a particularly appealing approach because it is easy to use, can capture rapid physiological changes on a heart beat-to-beat basis, and provides anatomical and functional vasculature information. This DSA system is special because it was designed and implemented from the ground up to be optimized for small animal imaging and functional measurements. This system can perform: 1) minimally invasive in vivo blood flow measurements, 2) multiple measurements in the same animal in a rapid succession (every 30 seconds-a substantial improvement over singular measurements that require minutes to acquire by the Fick method), 3) very high resolution (up to 46 micron) vascular visualization, 4) quantitative blood flow measurements in absolute metrics (mL/min instead of arbitrary units or velocity) and relative blood volume dynamics from discrete ROIs, and 5) relative mean transit time dynamics on a pixel-by-pixel basis (100 µm x 100 µm). The end results are 1) anatomical vessel time course images showing the contrast agent flowing through the vasculature, 2) blood flow information of the live rat cardio-pulmonary system in absolute units and relative blood volume information at discrete ROIs of enhanced blood vessels, and 3) colormaps of relative transit time dynamics. This small animal optimized imaging system can be a useful tool in future studies to measure drug or disease modulated blood flow dynamics in the small animal.</p> / Dissertation

Bakgrunden beskriver hjärt-och lungräddning som en utmaning för ambulanssjuksköterskan.Utmaningen består i att göra det som upplevs vara rätt för patienten, anhöriga och vårdare.Trots begränsad tillgång på förhandsinformation och skiftande vårdmiljö, förväntasambulanssjuksköterskan ta snabba och livsavgörande beslut inom ett kort tidsfönster ochsamtidigt leda omvårdnadsarbetet för ambulansteamet och arbeta personcentrerat. Syftet var att beskriva etiska dilemman som uppstår hos ambulanspersonalen vid prehospitalahjärtstopp hos vuxna. Metoden var en litteraturstudie med systematisk ansats innehållande kvalitativa vetenskapligaartiklar från databaserna PubMed och Cinahl. Totalt har 15st vetenskapliga originalartiklarsom besvarade syftet inkluderats och efter kvalitetsgranskning gjordes en integrerad analys. Resultatet visar ett övergripande tema: Att göra det rätta. Temat delades in i trehuvudkategorier; Att bära ett stort ansvar i en allvarlig situation, När livet tar slut och Att orkaför allas skull. Etiska dilemman uttrycktes runt att göra rätt utifrån patienten perspektiv,reaktioner och interaktion med anhöriga, konflikter runt sina egna etiska värderingar ochrädslan för juridiska konsekvenser eller repressalier utifrån organisatoriska faktorer ochriktlinjer och då bli anklagad för att ha agerat fel vid hjärtstopp. Slutsatsen var att ambulanspersonal ibland upplever en svår etisk stress i situationer därförmågan att göra snabba och ofta livsavgörande beslut konkurrerar med denpersoncentrerade omvårdnaden och anhöriga i kris. Hantering av stressfyllda ochkänslomässiga situationer upplevdes som lättare i och med ökad erfarenhet och en stabilgrund bestående av personlig och professionell mognad och en bra relation med kollegor ocharbetsgivare. Vidare forskning på området skulle kunna förbättra personcentreradeomvårdnadsarbetet, förbättra arbetsmiljön och den psykiska hälsan hos ambulanspersonal. / Background describes cardio-pulmonary resuscitation as a major challenge to ambulance nurses. The challenge is to act upon the best interest for the patient, relatives and the caregiver. Despite limited initial information and great environmental diversities, the ambulance nurse is expected to make quick and life dependent decisions within a limited time frame and still lead the team through the intervention with a Patient-centered care focus. Aim was to describe ambulance personnel's experiences of ethical dilemmas in relation to out-of-hospital cardiac arrest in adults. Method used was a literature review with a systematic approach of 15 qualitative research articles from the databases PubMed and Cinahl. The articles were evaluated for quality and an integrated analysis was performed Results revealed an overall theme: To do the right thing. The theme consisted of three main categories; To have a great responsibility in a difficult situation, When life ends and To have the strength for everyone. Expressed ethical dilemmas concerned doing the right by the patient, reactions and interactions with relatives, conflicts between personal ethical values and the fear of legal consequences or being subject to reprisals and being accused for not adhering to organizational factors and policies in the event of a cardiac arrest. Conclusion made was that ambulance personnel are subject to severe ethical stress in situations where the ability to make quick and life dependent decisions compete with the patient centered care and relatives in crisis. Dealing with stressful and emotional situations became easier as experience was gained. Experience included a solid foundation of personal and professional maturity and a steady relationship with colleagues and employment organization. Further research is suggested to improve the person-centered care, improvement of working environment and psychological health for ambulance personnel.

In this work, new methods of feature extraction, feature selection, stochastic data characterization/modeling, variance reduction and measures for parametric discrimination are proposed. These methods have implications for data mining, machine learning, and information theory. A novel decision-support system is developed in order to guide intervention during cardiac arrest. The models are built upon knowledge extracted with signal-processing, non-linear dynamic and machine-learning methods. The proposed ECG characterization, combined with information extracted from PetCO2 signals, shows viability for decision-support in clinical settings. The approach, which focuses on integration of multiple features through machine learning techniques, suits well to inclusion of multiple physiologic signals. Ventricular Fibrillation (VF) is a common presenting dysrhythmia in the setting of cardiac arrest whose main treatment is defibrillation through direct current countershock to achieve return of spontaneous circulation. However, often defibrillation is unsuccessful and may even lead to the transition of VF to more nefarious rhythms such as asystole or pulseless electrical activity. Multiple methods have been proposed for predicting defibrillation success based on examination of the VF waveform. To date, however, no analytical technique has been widely accepted. For a given desired sensitivity, the proposed model provides a significantly higher accuracy and specificity as compared to the state-of-the-art. Notably, within the range of 80-90% of sensitivity, the method provides about 40% higher specificity. This means that when trained to have the same level of sensitivity, the model will yield far fewer false positives (unnecessary shocks). Also introduced is a new model that predicts recurrence of arrest after a successful countershock is delivered. To date, no other work has sought to build such a model. I validate the method by reporting multiple performance metrics calculated on (blind) test sets.

Une naissance prématurée vient interrompe le développement normal de plusieurs organes, notamment du cœur et des poumons, occasionnant des altérations structurelles et fonctionnelles des systèmes jusqu’à l’âge adulte. Bien que les bienfaits de la pratique d’activité physique (AP) sur la santé générale et la capacité d’exercice chez la population en santé et la population à risque sont bien connus. Toutefois, aucune étude n’a encore évalué si la population de jeunes adultes nés très prématurément pourrait également bénéficier de ces bienfaits. Le présent mémoire a donc pour objectif d’évaluer la faisabilité et d’estimer l’effet d’une intervention supervisée en exercice de 14 semaines sur la santé cardiorespiratoire et musculaire des jeunes adultes nés très prématurément comparativement à des jeunes adultes nés à terme (contrôles). Les données de cet essai clinique pilote non randomisé ont été recueillies avant, pendant et après l’exercice. La première étude a rapporté que l’intervention en exercice était sécuritaire, appréciée et bien respectée par les jeunes adultes nés très prématurément, mais que le recrutement était difficile, dû au haut niveau d’engagement nécessaire. Cette même étude a également révélé que l’intervention a permis aux jeunes adultes nés très prématurément d’augmenter leur niveau d’AP d’intensité moyenne à élevée. La seconde étude a pu estimer la réponse des femmes ayant complété un nombre suffisant de séances d’entrainement et a révélé qu’elles ont amélioré leur endurance musculaire (pompes et redressements assis) ainsi que leur capacité aérobie. Toutefois, suivant l’intervention, la force et la puissance de leurs membres inférieurs de même que leur ventilation minute durant l’effort sont demeurées moindres que celles des femmes nées à terme. L’intervention par l’exercice est donc faisable et sécuritaire pour des individus nés très prématurément et suggère l’amélioration de certains paramètres cardiorespiratoires et musculaires des femmes nées très prématurément. Ces résultats indiquent le potentiel de l’exercice comme intervention non pharmacologique pour contrer les dommages physiologiques causés par une naissance prématurée. / Premature birth interrupts the normal development of several organs, particularly the heart and lungs, causing structural and functional alterations of the systems in adulthood. Although the benefits of physical activity on general health and exercise capacity in healthy and at-risk populations are well known, no studies have yet evaluated whether the population of young adults born very preterm could also benefit from these effects. The objective of this master’s thesis is therefore to evaluate the feasibility and estimate the effect of a supervised 14-week exercise intervention on the cardiorespiratory and muscular health of young adults born very preterm compared to young adults born at term (controls). Data from this non- randomized pilot trial were collected before, during, and after the exercise intervention. The first study showed that the exercise intervention was safe, valuable, and appreciated by young adults born very preterm, but that recruitment in the program was difficult due to the high level of commitment. The same study also showed that young adults born very preterm increased their moderate-to-high intensity PA levels following the intervention. The second study estimated the response of women who completed a sufficient number of training sessions and revealed that women born very preterm improved their muscular endurance (push-ups and sit-ups) as well as their aerobic capacity. However, following the intervention, their lower limb strength and endurance as well as their minute ventilation during exercise remained lower than women born at term. Exercise intervention is therefore feasible and safe for individuals born very preterm and could lead to improvement of certain cardiorespiratory and muscular parameters in women born very preterm, demonstrating the potential of exercise as a non-pharmacological intervention to mitigates the effects of premature birth on health.