The two otolith organs (the saccule and utricle) are positioned perpendicular to each other and sense linear acceleration, head tilt, and gravity, with the primary role of providing input to the vestibulospinal reflex for postural stability. The vestibulospinal reflex serves to modulate posture via two descending pathways that aid in tonic contractions of the antigravity muscles in the arms and legs (lateral vestibulospinal tract) and activate neck motoneurons for the coordination of neck and eye movements (medial vestibulospinal tract). The lateral vestibulospinal tract receives the majority of its input from the otoliths and the cerebellum, whereas the medial vestibulospinal tract receives the majority of its input from the semicircular canals.

Background Although abdominal aortic aneurysm (AAA) growth is non-linear, serial measurements of aneurysm diameter are the mainstay of aneurysm surveillance and contribute to decisions on timing of intervention. Aneurysm biology plays a key part in disease evolution but is not currently routinely assessed in clinical practice. Magnetic Resonance Imaging (MRI) and Positron Emission Tomography-Computed Tomography (PET-CT) provide insight into disease processes on a cellular or molecular level, and represent exciting new imaging biomarkers of disease activity. Macrophage-mediated inflammation may be assessed using ultrasmall superparamagnetic particles of iron oxide (USPIO) MRI and the PET radiotracer 18FSodium Fluoride (18F-NaF) identifies microcalcification which is a response to underlying necrotic inflammation. The central aim of this thesis was to investigate these imaging modalities in patients with AAA. Methods and Results USPIO MRI: MULTI-CENTRE STUDY In a prospective multi-centre observational cohort study, 342 patients (85.4% male, mean age 73.1±7.2 years, mean AAA diameter 49.6±7.7mm) with asymptomatic AAA ≥4 cm anteroposterior diameter underwent MRI before and 24-36 hours after intravenous administration of USPIO. Colour maps (depicting the change in T2* caused by USPIO) were used to classify aneurysms on the basis of the presence of USPIO uptake in the aneurysm wall, representing mural inflammation. Intra- and inter-observer agreement were found to be very good, with proportional agreement of 0.91 (kappa 0.82) and 0.83 (kappa 0.66), respectively. At 1 year, there was 29.3% discordant classification of aneurysms on repeated USPIO MRI and at 2 years, discordance was 65%, suggesting that inflammation evolves over time. In the observational study, after a mean of 1005±280 days of follow up, there were 126 (36.8%) aneurysm repairs and 17 (5.0%) ruptures. Participants with USPIO enhancement (42.7%) had increased aneurysm expansion rates (3·1±2·5 versus 2·5±2·4 mm/year; difference 0·6 [95% confidence intervals (CI), 0·02 to 1·2] mm/year, p=0·0424) and had higher rates of aneurysm rupture or repair (69/146=47·3% versus 68/191=35·6%; difference 11·7%, 95% CI 1·1 to 22·2%, p=0·0308). USPIO MRI was therefore shown to predict AAA expansion and the composite of rupture or repair, however this was not independent of aneurysm diameter (c-statistic, 0·7924 to 0·7926; unconditional net reclassification -13·5%, 95% confidence intervals -36·4% to 9·3%). 18F-NaF PET-CT: SINGLE-CENTRE STUDY A sub-group of 76 patients also underwent 18F-NaF PET-CT, which was evaluated using the maximum tissue-to-background ratio (TBRmax) in the most diseased segment (MDS), a technique that showed very good intra- (ICC 0.70-0.89) and inter-observer (ICC 0.637-0.856) agreement. Aneurysm tracer uptake was compared firstly in a case-control study, with 20 patients matched to 20 control patients for age, sex and smoking status. 18F-NaF uptake was higher in aneurysm when compared to control aorta (log2TBRmax 1.712±0.560 vs. 1.314±0.489; difference 0.398 (95% CI 0.057, 0.739), p=0.023), or to non-aneurysmal aorta in patients with AAA (log2TBRmax 1.647±0.537 vs. 1.332±0.497; difference 0.314 (95% CI 0.0685, 0.560), p=0.004). An ex vivo study was performed on aneurysm and control tissue, which demonstrated that 18F-NaF uptake on microPET-CT was higher in the aneurysm hotspots and higher in aneurysm tissue compared to control tissue. Histological analysis suggested that 18F-NaF was highest in areas of focal calcification and necrosis. In an observational cohort study, aneurysms were stratified by tertiles of TBRmax in the MDS and followed up for 510±196 days, with 6 monthly serial ultrasound measurements of diameter. Those in the highest tertile of tracer uptake expanded more than 2.5 times more rapidly than those in the lowest tertile (3.10 [3.58] mm/year vs. 1.24 [2.41] mm/year, p=0.008) and were also more likely to experience repair or rupture (15.3% vs. 5.6%, log-rank p=0.043). In multivariable analyses, 18F-NaF uptake on PET-CT emerged as an independent predictor of AAA expansion (p=0.042) and rupture or repair (HR 2.49, 95% CI1.07, 5.78; p=0.034), even when adjusted for age, sex, body mass index, systolic blood pressure, current smoking and, crucially, aneurysm diameter. Conclusion These are the largest USPIO MRI and PET-CT studies in AAA disease to date and the first to investigate 18F-NaF. Both USPIO MRI and 18F-NaF PET-CT are able to predict AAA expansion and the composite of rupture and repair, with 18F-NaF PETCT emerging as the first imaging biomarker that independently predicts expansion and AAA events, even after adjustment for aneurysm diameter. This represents an exciting new predictor of disease progression that adds incremental value to standard clinical assessments. Feasibility and randomised clinical trials are now required to assess the potential of this technique to change the management and outcome of patients with AAA.

The submitted diploma thesis shows overview of the problem using upper extremity orthoses for adult with spasticity after the stroke. The aim of the thesis is to explore possibilities of using orthoses at different stages of the spasticity development. The theoretical part includes main information about the important point from central motoneuron disorder, it means spasticity. There is information about materials, production, availability and usability in various types of orthoses. Main part of the theoretical section shows research studies and available literature, which interprets using kinds of orthoses in various time when the spasticity was developed. The theoretical part follows the practical part. In the practical part are demonstrated available possibilities of using orthoses for interference spasticity in the upper extremity. For the practical part were chosen three groups of patients and each group of patients represents one case study. In the thesis are represented patients in acute, subacute and chronic stadium after the stroke. In each stadium were used different kind of orthoses: neoprene brace for acute, static-progressive for subacute and static thermoplastic for the chronic stadium. The measurement neuromuscular parameters were conducted according to Five steps clinical...

<p dir="ltr">Cystic fibrosis is a genetic disease that affects over 162,428 people worldwide. Currently, assessing cystic fibrosis from medical images requires a trained expert to manually annotate regions in the patient's lungs to determine the stage and severity of the disease. This process takes a substantial amount of time and effort to achieve an accurate assessment. </p><p dir="ltr">Recent advancements in machine learning and deep learning have been effective in solving classification, decision-making, identification, and segmentation problems in various disciplines. In medical research, these techniques have been used to perform image analyses that aid in organ identification, tissue classification, and lesion segmentation, which reduces the time required for physicians to analyze medical images. However, these techniques have yet to be widely applied in the assessment of cystic fibrosis. </p><p dir="ltr">This thesis describes an automated framework employed to assess the severity and extent of cystic fibrosis. The framework comprises three analysis stages: airways analysis, texture analysis, and lung lesions detection, that are utilized to extract cystic fibrosis features from CT scans, and which are used to assess the severity and extent of cystic fibrosis. The framework achieved an accuracy of 86.96\% in the staging process. The main contribution of this work is the development of a data-driven methodology used to design a quantitative cystic fibrosis staging and grading model.</p>

Thesis (MCur (Nursing Science))--University of Stellenbosch, 2008. / ENGLISH ABSTRACT: Clinical teaching and training is undertaken to correlate theory and practice (Mellish et al., 1998:211). Clinical teaching is the means by which student nurses learn to apply the theory of nursing in a clinical situation so that an integration of theoretical knowledge and practical skills in the clinical situation becomes the art and science of nursing. (Mellish et al., 1998:207). The role of the lecturer/facilitator is to bridge the theory-practice gap between nursing education and practice. Since the merger of the nursing colleges in the Eastern Cape Province (South Africa) and the abolishment of the clinical department in the hospital it became essential to evaluate the clinical facilitation needs of students and tutors. For the purpose of this study the researcher evaluated the clinical facilitation, with the focus area being on the clinical needs and problems of nursing tutors and nursing students at a nursing college in the Eastern Cape Province. The objectives of this study were to determine the following: the clinical facilitation needs of student nurses of the Nursing College, clinical facilitation needs of tutors of the Nursing College, clinical facilitation related problems facing student nurses and tutors in the Nursing College and associations between the clinical facilitation of the campuses of the Nursing College. The following research question was evaluated: What are the needs and problems of nursing students and tutors in clinical facilitation at the Lilitha Nursing College? The research methodology was a descriptive exploratory design with a quantitative approach. The population for this study was the fourth-year nursing students, and all tutors of the nursing college. A convenient sample was drawn. All students available at the time of data collection were included in the study. A structured questionnaire was used to collect the data. The final sample of students was N =100 (45%) of a total population of 222 students. The final sample of tutors was N=35 (36%) of a population of 97. Reliability and validity were assured by means of a pilot study and the use of experts in nursing education, research methodology and statistics. Data were collected personally by the researcher. Ethical approval was obtained from Stellenbosch University, Department of Health ECP, and Head of the Nursing College and Principals of the campuses. Informed written consent was obtained from the participants. Statistical associations with reference to clinical facilitation between the various campuses of the nursing college were determined using the Chi-square tests. The results of this study are presented in percentages, tables and histograms. On completion of the study the following recommendations were made: standardization of policies and procedures; preplanning and publishing of clinical placement dates; manuals, rules, student needs and outcomes be available before clinical placement; improvement of communication between clinical staff, facilitators and students; improvement of infrastructure, equipment and materials.

Thesis (MPhil)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: Removable Prosthetic Dentistry (PRO400) is a fourth year module of the undergraduate dentistry programme which consists of a large clinical component. After reviewing relevant literature and conducting module evaluations, clinical tests were introduced and implemented in 2008 as an additional clinical assessment method. The intention of introducing the clinical tests was an attempt to ensure that students were assessed fairly, that their theoretical knowledge and the ability to apply it clinically were properly assessed, and to provide feedback on their clinical performance. The purpose of this concurrent mixed methods study was to compare the relationship between the students‟ performance in the clinical tests and daily clinical grades with their theoretical performance in the PRO400 module. The second part of the study explored the academic staff s‟ perceptions of the clinical test as clinical assessment tool in the PRO400 module. The case study design enabled the researcher to explore the question at hand in considerable depth. The mixed methods approach was useful to capture the best of both the qualitative and quantitative approaches. For the quantitative data-collection, record reviews of the results of fourth-year dental students‟ who completed the PRO400 module at the end of 2007 were used, and included 110 students. For the qualitative component three full-time lecturers within the Prosthetic department were interviewed. The clinical test marks and clinical session marks of all the students (n=109) in PRO400 were compared to their theory mark of that year. The tests marks were entered into a spreadsheet in Microsoft Excel and the data analysis was done with the assistance of a statistician. The analytical abstraction method was used to assist with the qualitative data analysis; first the basic level of analysis was done in the narrative form, followed by second higher level of data analysis. The basic and higher levels of analysis were discussed under the following themes: clinical tests, student performances, alignment of theory and clinical assessment and personal influence on supervisors‟ assessment practices and attitude. Role-taking and the supervisors‟ perceptions and concerns regarding the students were explored as emergent themes. The quantitative findings were displayed using tables and graphs. Forty five students. clinical marks were 10% higher than their theory mark, while only 8 students. theory marks were 10% higher than their clinical test mark. There appeared to be hardly any relationship between the students. clinical daily grade assessment marks and their theory marks. The average theory mark was 47%, the average clinical test marks were 55% and the average daily clinical grade was 63%. Integration of the data obtained from the different data collection methods was done at the level of data interpretation. The clinical test as an assessment tool is well accepted by the supervisors and they agreed that it is more reliable and accurate than the clinical daily grade assessment method. The quantitative findings relate well to other reported studies that concluded that the daily grade was poorly correlated with the competency exams (a similar phenomenon in the clinical test of the PRO400 module). From the findings of this study it appeared that there is a better correlation of the clinical test mark and the theory mark, than clinical daily mark and the theory mark. This finding related well with the lecturers. views that the clinical tests were more reliable as a clinical assessment tool than the daily clinical mark. / AFRIKAANSE OPSOMMING: "Removable Prosthetic Dentistry (PRO400)" is 'n vierdejaar-module in die voorgraadse tandheelkundeprogram wat 'n groot kliniese komponent bevat. Na 'n oorsig gedoen is van die relevante literatuur, en nadat die module-evaluering afgehandel is, is kliniese toetse in 2008 ingevoer en geimplementeer as 'n bykomende metode van kliniese assessering. Die kliniese toetse is ingestel in 'n poging om te verseker dat studente se teoretiese kennis en hul vermoe om dit klinies toe te pas op . regverdige wyse geassesseer word en om terugvoer te kan gee oor die studente se kliniese prestasie. Die doel van hierdie studie, waarin gelyktydige gemengde metodes gebruik is, was om die verband tussen die studente se prestasie in die kliniese toetse, asook hul daaglikse kliniese punte en hul teoretiese prestasie in die PRO400-module vas te stel. Die tweede deel van die studie het ondersoek ingestel na die akademiese personeel se persepsies van die kliniese toets as 'n instrument vir kliniese assessering in die PRO400-module. 'n Dwarssnit-gevallestudie-ontwerp is gebruik en 'n gemengdemetode-benadering was nuttig om sowel kwalitatiewe as kwantitatiewe data in te samel. Vir die kwantitatiewe data-insamelingverslae is die uitslae van 109 vierdejaar-tandeheelkundestudente in die PRO400-module aan die einde van 2007 gebruik. Vir die kwalitatiewe data-insameling is onderhoude gevoer met drie voltydse dosente in die Prostetiese Tandheelkunde-departement. Die kliniese toetspunte en die kliniese sessiepunte van al die studente (n=109) in die PRO400-module is met hul teoriepunte van daardie jaar vergelyk. Die toetspunte is op 'n sigblad in Microsoft Excel ingevoer en die data-analise is met die hulp van 'n statistikus gedoen. Die analitiese abstraksiemetode is vir die analise van die kwalitatiewe data gebruik. Die basiese vlak van data-analise in die narratiewe vorm is eerste gedoen. Dit is gevolg deur 'n tweede, hoervlak-data-analise. Die basiese en hoer vlakke van analise is onder die volgende temas bespreek: kliniese toetse, studenteprestasie, ooreenstemming van teorie en kliniese assessering, en persoonlike invloed op studieleiers se assesseringspraktyke en houding. Rol-aanneming en die studieleiers se persepsies, asook kwessies rakende die studente is as ontluikende temas ondersoek. Die resultate van hierdie studie het aangetoon dat die kliniese punte van 45 studente 10% hoër was as hul teoriepunte, en dat slegs agt studente se teoriepunte 10% hoër as hul kliniese toetspunte was. Dit het geblyk dat daar feitlik geen verband was tussen die studente se kliniese daaglikse assesseringspunte en hul teoriepunte nie. Die gemiddelde teoriepunt was 47%, die gemiddelde kliniese toetspunt was 55% en die gemiddelde daaglikse kliniese punt was 63%. Al die studieleiers het die kliniese toets as assesseringsinstrument goed aanvaar en hulle het saamgestem dat dit meer betroubaar en akkuraat is as die daaglikse kliniese assesseringsmetode. Die kwantitatiewe bevindings hou goed verband met dié van soortgelyke studies waarin daar bevind is dat die daaglikse prestasie swak gekorreleer het met die bevoegdheidseksamen (ʼn soortgelyke beginsel as die kliniese toets van die Pro400). Dit het ook uit die bevindings van hierdie navorsing geblyk dat daar ʼn beter korrelasie is tussen die kliniese toetspunt en die teoriepunt as tussen die daaglikse kliniese punt en die teoriepunt. Hierdie bevinding het ʼn duidelike verband getoon met die dosente se siening dat die kliniese toetse as ʼn kliniese assesseringsinstrument meer betroubaar is as die daaglikse kliniese punt in die PRO400-module in die Tandheelkunde-program.

Diagnostic and evaluative methods used in voice care are mostly designedfor the speaking voice, and are not necessarily directly applicable to thesinging voice. This thesis investigated the possibilities of fine tuning, improvingand quantifying the voice status assessment of the singer, focusingespecially on the Western operatic female voice. In Paper I, possible singer-specific Voice Range Profile (VRP) characteristicsand tasks were explored and VRP data for 30 professional female Western opera singers was collected. Vocal productions were controlled for a physiological VRP (VRPphys) and for a stage performance context (VRPperf) and outcome differences were identified. Task design was critical for the(VRPphys) but had very little effect on the VRPperf. Significant voice category differences (between soprano,mezzo-soprano and contralto) were limited to frequencyrelated metrics. Two new VRP metrics, the area above 90 dB (Perc90dB) and the sound pressure level extent (SPLext), were found to be key metrics to the study of VRPs for singers. Paper II investigated, in conjunction with the VRP, whether the sound pressure level (SPL) or the skin acceleration level (SAL) was more correlated to the subglottal pressure (Ps). SAL was much less F0 dependent than SPL and facilitated the interpretation of VRP data. However, the correlation between SAL and Ps was found to be weaker than that between SPL and Ps. Papers III and IV explored the mapping of self-perceived impairmentrelated difficulties into the VRP. A modified phonetograph was tested first with a healthy singer population and then with a singer-patient group. Subjects used a button device to communicate their self-perceptions while singing, and were consistent in task replications as well as across different tasks. Healthy singers pressed mostly at the extreme limits of the VRP, where loss of vocal control could be expected and their presses were mostly concentrated on the periphery of the VRP area. Singer patient button- press patterns were distinct from patterns observed in healthy singers. Singer patients pressed mainly inside the VRP boundaries, in the higher range and at intermediate intensities. In Paper V, the Voice Handicap Index for singers was translated and adapted to Swedish (Röst Handikap Index för sångare or RHI-s). The questionnaire was found to be a reliable and a valid instrument. High correlations between general perceptual patient VAS ratings and the questionnaire scores underscored the instrument’s internal coherence. Overall, patient scores (including subscales) were significantly higher than healthy singer scores. The results showed implicitly the necessity and usefulness of adapting clinical procedures to specific patient populations.Together, the results of these five papers can ultimately be of value tovoice clinicians who are treating singers. The results obtained also contributeto the understanding of the singing voice and underline the importance ofproperly documenting the singing voice. / QC 20100726

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Les dérèglements émotionnels ont été largement avancés dans le développement et le maintien des conduites addictives. Ces perturbations des processus émotionnels sont associées à l’utilisation privilégiée de stratégies compensatoires mal adaptées qui vont à leur tour entériner les conduites addictives et entraver une consolidation de l’abstinence. Ce travail vise une meilleure compréhension des facteurs de vulnérabilité de la rechute à l’alcool par l’étude de l’évolution des compétences émotionnelles avec l’abstinence à travers trois volets expérimentaux. Pour cela, nous étudierons spécifiquement les mécanismes de régulation émotionnelle considérés comme centraux dans la problématique addictive. Nous utiliserons des outils particuliers pour étudier ces mécanismes que sont des indicateurs physiologiques du système nerveux autonome.Dans un premier volet, nous avons étudié les réponses du système sympathique par la mesure du diamètre pupillaire en réponse à la présentation d’images neutres etémotionnelles (positives et négatives). Nous avons démontré qu’en situation d’induction émotionnelle les patients abstinents à court terme présentent une activation plus forte du système d’alerte sympathique que les abstinents à long terme et les participants contrôles. Le niveau intermédiaire de la réponse pupillaire observé chez les abstinents à long terme suggère une amélioration partielle dans l’activation sympathique à la présentation d’une information émotionnelle (étude 1). La variabilité de la fréquence cardiaque (VFC) est un indicateur du système parasympathique, est reconnue comme marqueur de la régulation émotionnelle. L’étude de la VFC avant pendant et après une situation d’induction émotionnelle a montré une normalisation de la VFC en réponse aux stimuli émotionnels avec une abstinence à long terme. Cependant, les résultats pour les stimuli à valence négative ne sont pas différents entre les groupes abstinents à court et à long terme. Ce pattern de réponse appuie l’hypothèse d’un maintien de vulnérabilité aux émotions négatives en dépit d’une abstinence prolongée. De plus, une corrélation négative a été observée pour les deux groupes de patients entre les scores de craving et une augmentation de la VFC (étude 2). Enfin, dans un dernier volet expérimental, nous avons investigué les compétences et difficultés de régulation émotionnelle par des autoquestionnaires(CERQ et DERS) auprès de patients abstinents de quelques semaines à plusieurs années. Les résultats supportent l’hypothèse d’une limite de récupération capacités après deux ans d’abstinence (étude 3). L’étude de l’étendue des récupérations des compétences émotionnelles est une piste majeure dans la consolidation de l’abstinence. Ces trois études confirment la récupération des compétences émotionnelles avec l’abstinence mais surtout la persistance d’une vulnérabilité dans les processus émotionnels. Le caractère partiel des récupérations de ces mécanismes suppose non seulement le maintien d’une vulnérabilité en dépit d’une abstinence prolongée et met également en évidence la nécessité d’un travail d’accompagnement dans la remédiation de ces compétences à long terme. Un ensemble de perspectives de recherches et d’applications cliniques s’ouvrent au regard de ces résultats, et seront ici discutées. / Emotional disorders are recognized as a major factor of development andcontinuity of addictive behavior. These perturbations of the emotional processes areassociated with the preference given to ill-suited compensatory strategies which will inturn perpetuate addictive behaviors and interfere with the consolidation of abstinence.This study aimed to give a better understanding of the vulnerability factors of alcoholrelapse by studying the evolution of emotional competence with abstinence over threeexperimental chapters. For this purpose, we looked more closely at the mechanisms ofemotional regulation, which are considered as crucial in the addiction problem. In orderto study these mechanisms we used specific tools like the physiological cues of theautonomic nervous system.In a first chapter, we studied sympathetic system response by measuringpupillary diameter after exposure to neutral and emotional pictures (positive andnegative). We showed that when exposed to emotional induction, short-term abstinentpatients showed a stronger activation of the sympathetic nervous system than long-termabstinent patients as well as the control group. The intermediary level of pupillaryresponse found among long-term abstinent patients suggests a partial improvement ofsympathetic activation when exposed to emotional information (study 1). Heart RateVariability (HRV) is an indicator of the parasympathetic system and is viewed as amarker of emotional regulation. The study of HRV before, during and after a situation ofemotional induction showed a normalization of HRV in response to emotional stimuliwith long-term abstinence. However, results for stimuli with negative valence are notdifferent between the long-term and short-term abstinence groups. This responsepattern supports the hypothesis that there is still a vulnerability to negative emotionsdespite the prolonged abstinence. Moreover, a negative correlation between cravingscores and increase of HRV has been observed for the two patient groups (study 2).Finally, in a last experimental chapter, emotional competence and emotional regulationdifficulties were assessed by presenting the Difficulties in Emotion Regulation Scale(DERS) and the Cognitive Emotion Regulation Questionnaire (CERQ) to few weeks tofew years abstinent patients. Results support the hypothesis of a recovery shift of twoyears of abstinence for these abilities (study 3).The study of the extent of the recoveries of emotional competence is a major leadfor the consolidation of abstinence. Those three studies confirm the retrieval ofemotional competence with abstinence but they particularly show the persistence of avulnerability in the emotional processes. The fact that there is a recovery shift for thosemechanisms not only involves the continuity of a vulnerability despite a prolongedabstinence, but also underlines the need of a work of support for the remediation ofemotional competence in the long term. These results can lead to several researchprospects and clinical applications that will be discussed here.

Bakgrund: Riksrevisionens statistik visar på en allt högre belastning på ambulanssjukvården i landet, detta har medfört att flera regioner infört rutiner för ambulanssjuksköterskan att bedöma det aktuella vårdbehovet hos patienterna för att hänvisa till rätt vårdnivå om det inte föreligger transportbehov med ambulans. Syfte: Syftet med studien var att undersöka ambulanssjuksköterskors upplevelser av att hänvisa patienter till annan vårdnivå när inget behov av ambulanstransport föreligger. Metod: Två kvalitativa fokusgruppsintervjuer genomfördes på två ambulansstationer inom Region Norrbotten. Ett ändamålsenligt urval användes för att rekrytera ambulanssjuksköterskor. Deltagarna var mellan 33 och 48 år och yrkeserfarenheten sträckte sig mellan 8 och 20 år. Data analyserades med en kvalitativ innehållsanalys. Resultat: Analysen resulterade i fyra huvudkategorier: Erfarenheter, magkänsla och bemötande gav förutsättningar för bedömning, Att välja vårdnivå var tidskrävande men värt arbetsinsatsen, Patienter som transporteras utan vårdbehov skapar frustration, En förändring kräver information, utbildning och stöd i beslut. Resultatet visade att ambulanssjuksköterskorna använde sig av intuition tillsammans med de befintliga rutinerna och kände sig då trygga med att bedöma och hänvisa patienterna till en annan vårdnivå. De saknade möjligheten till stöd av ambulansläkare för att underlätta vid bedömning och beslut. Ambulanssjuksköterskorna upplevde det som en begränsning att inte privata vårdgivare var anslutna till rutinen för att hänvisa patienter. Frustration uppstod när de var tvungna att transportera patienter utan vårdbehov.  Slutsats: För att kunna optimera akutsjukvårdens resurser så behöver rutiner ses över så att samtliga hälsocentraler i regionen ingår i “vårdstigen”. En ambulansläkare bör omgående rekryteras som ett stöd i ambulanssjuksköterskornas dagliga arbete och vid hänvisning av patienter till annan vårdnivå.