A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / As research into the treatment of cancers improves patient’s chances for survival, the number of cancer survivors continues to increase. These patients are often treated with chemotherapy and radiation regimens that can increase their risk for cancers and other complications such as heart disease later on. Patients with Hodgkin’s lymphoma tend to be younger than patients with other cancers. Current treatment regimens lead to cures in many Hodgkin’s lymphoma patients with many long term survivors. However, these treatments place survivors at risk for numerous complications, most importantly other cancers and heart disease. Organizations such as the American Cancer Society recommend regular screening and surveillance by a patient’s doctor to detect these potential complications. To assess the factors that affect a patient’s follow‐up care we sent a survey to 365 Hodgkin’s Lymphoma survivors in Arizona and asked them about their specific follow‐up care. The survivors were identified using the Arizona Cancer registry, and 49 (13.4%) responded to our survey. However, of the 365 letter invitations that were sent out, 118 were returned undeliverable leading to a corrected response rate of 19.8%. Of the respondents 93% reported they were getting follow up care. We also looked at patient satisfaction with their care as a second outcome, 34 (72.3%) of the patients stated that they were strongly satisfied with their follow‐ up care. In order to assess physician‐patient communication, we asked patients if they had received a written follow‐up care plan. Of the respondents to this question, 14 (29.7%) noted that they had received a written follow up care plan. These two outcomes were stratified to various demographic factors (age, gender, education status, etc.) to determine if any of these caused a statistically significant difference in a patient’s satisfaction or whether or not they had received a written follow‐up plan. Due to the low number of responders, no statistically significant difference was found. Future studies are needed to further determine whether or not these sorts of demographic factors play a significant role but we believe studies like this are important as cancer survivorship continues to increase.

Patients who are unable to comply with their health care regimen are almost 3 times more likely to have an adverse health outcome and are more likely to suffer irreversible progression of a chronic disease process. Increasing patient return clinic visits is essential, not only to curtail rapidly rising costs of health care but also to improve patient outcomes. This project focused on an uninsured patient population of a clinic in a rural community in the southeastern United States. The purpose of the project was to conduct a systematic review of the literature and identify the barriers and motivating factors for chronic care return primary care visits among uninsured patients. The theoretical models supporting the project were the health belief model and the chronic care model. A search of scholarly databases resulted in 366 articles meeting the inclusion criteria of peer-reviewed English-language literature published since 2014 that focused on outpatient care among uninsured populations. All identified articles were reviewed, and several interventions emerged as options to increase patient return rates: care transition and coordination services, patient education, patient follow up, pharmacy assistance programs, food assistance programs, and integration of computer-based literacy interventions. The clinic administrators determined that the best option for the site would be implementation of an on-site food program. The findings of this project have potential to create social change in clinics for uninsured in the community by addressing food insecurity and providing patients an incentive to return for care every 6 months.

Bakgrund: Fler kvinnor överlever sin bröstcancer tack vare tidig upptäckt och behandling av tumörer. Den primära behandlingen för bröstcancer är omfattande med operation, cellgifter samt strålning som ger biverkningar. Den ökade överlevnaden ställer krav på uppföljningsvården, där uppgiften är att följa upp förändringar i hälsan efter avslutad primär behandling. Syfte: Syftet var att belysa kvinnors upplevelser av vården efter primär behandling för bröstcancer. Metod: En litteraturöversikt genomfördes enligt Fribergs metod. Databassökningen av resultatartiklar gjordes med sökord relaterade till “bröstcancer”, “uppföljningsvård” samt “upplevelser” eller “erfarenheter” i MEDLINE with Full Text samt Cinahl Complete. Sökningarna gjordes med begräsningen att artiklarna skulle ha publicerats mellan åren 2008 och 2018. Nio kvalitativa studier samt en med mixad metod analyserades avseende likheter/skillnader och tematiserades. Resultat: Analysen resulterade i tre teman. Kvinnornas informationsbehov som har två underteman: Informationsbrist angående uppföljningsvården som handlar om informationsbrist från specialistvården vid utskrivning av primär behandling som påverkade kvinnorna i tiden efter och informationsbrist i uppföljningsvården som handlar om informationsbrist under uppföljningar. Det andra huvudtemat är: Hur kvinnorna föredrogs att följas upp och kontinuitet. Det tredje huvudtemat är: Stressade besök och att inte bli bemött utifrån sina behov. Diskussion: I metoddiskussionen diskuteras litteraturöversiktens styrkor samt svagheter. I resultatdiskussionen diskuteras resultatet utifrån bakgrunden, annan forskning samt Antonovskys teori om känsla av sammanhang. Resultatet visar att kvinnor efter avslutad primär behandling upplever att det finns informationsbrister. Författarna diskuterar sjuksköterskans roll i uppföljningsvården av bröstcancerpatienter. / Background: More women survive their breast cancer due to early detection and treatment of the tumour. The primary treatment for breast cancer is extensive with surgery, chemotherapy, radiation and side effects. The increased survival poses higher demands for the follow-up care, where the task is to monitor changes in health after completion of primary treatment. Aim: The aim was to explore women's’ experience of care following end of primary treatment for breast cancer. Method: A literature review was performed according to Friberg's method. The following electronic databases were searched: Cinahl Complete and Medline with Full Text. Terms related to “breast cancer”, “follow upp care” samt “experience” eller “perceptions” were used in all searches. One mixed method and nine qualitative articles, published between 2008 and 2018, were included in the review. Results were thematized based on similarities and differences. Results: The analysis resulted in three themes. Women's information needs that have two sub-themes: Lack of information regarding follow-up care, which is about the lack of information from the specialist care which affected women posttreatment and The lack of information in the follow-up care which is about information shortages during follow-ups. The second main theme is: Womens preference about follow-up care and continuity. The third main theme is: Stressful visits and not being met from their needs. Discussion: In the method discussion the literature review strength and weaknesses are discussed. In the result discussion, the results are discussed based on the background, new research, and Antonovsky's theory of sense of coherence. The result shows that there are information shortages. The authors discuss the role of the nurse in the after care for breast cancer patients.

Background: Cancer is a collective name for many different diseases and occurs when the balance in a cell is disturbed and transforms into a tumor cell. Cancer is one of the leading causes of death worldwide. Suffering from cancer affects a person physically and psychologically, and surviving cancer can be just as wearing.  Aim: The purpose of the study was to describe people's experiences of surviving a cancer disease. Method: A literature study was used as a method. 12 articles were selected for the result. The articles were found in the databases Cinahl and PsycInfo. Results: The result gave rise to three main themes: "Loss of trust in healthcare", "Living with consequences" and "Feelings about the future". With seven associated subthemes: "Not getting information", "Feeling forgotten", “Lack of identity”, “Strategies for change”, “Having someone to talk to”, "Not feeling safe'' and “Daring to dream”. The results show how complicated the aftercare of cancer can be, both for healthcare professionals but not least for cancer survivors. Experiences of having survived cancer differed depending on the support network around. Conclusion: The results of the study showed that the healthcare system is lacking in several aspects when it comes to aftercare for cancer survivors. Where the healthcare system failed, there were family, friends and people with similar experiences as support. Fear of relapse, fear of dying and anxiety were leading emotions in the study's results.

[pt] No percurso desta tese buscamos analisar a prática do acompanhamento terapêutico, visando investigar as especificidades que compõem este dispositivo clínico. Para tanto, nos empenhamos em refletir acerca da relação estabelecida entre acompanhante e sujeito acompanhado, tendo-se a cidade como cenário. O AT desponta como estratégia de intervenção eminentemente clínico-política, a qual reúne, em uma mesma abordagem, questões relacionadas tanto aos processos de subjetivação, quanto ao domínio mais amplo da cultura. A sua potência interventiva reside em compor novas modalidades relacionais pautadas por uma política da amizade, a partir das possibilidades abertas pelos espaços públicos. / [en] In the course of this thesis, we seek to analyze the practice of therapeutic follow-up care, aiming to investigate the specificities that compose this clinical device. For this purpose, we aspire to reflect on the relationship established between the carer and the person being cared, having the city as a scenario. The therapeutic follow-up care emerges as a highly clinical-political strategy of intervention, which gathers, in a single approach, questions related to subjectification processes and to a wider cultural domain. Its interventional potency lies in composing new relationship modalities guided by a friendship policy, originated by the possibilities opened by the public spaces.

Present situation The theoretical part of the diploma thesis is divided into four separate chapters. The first chapter deals with cerebrovascular accident (CVA). Another chapter describes the consequences of illness in various areas of human life. The third chapter defines the concept of follow-up care and the fourth chapter deals with diagnosed obesity. Aims of the work and research questions The aim of the diploma thesis is to map out the influence of obesity on follow-up care of patients after cerebrovascular accident. Research questions: 1. How does obesity affect patient mobility after CVA? 2. How does obesity affect the hygienic care of patients after CVA? 3. How does obesity affect normal daily activities of CVA patients? 4. What is the impact of obesity on developing self-sufficiency in CVA patients? Quality research was done through semi-structured interviews with CVA patients who were hospitalized in the aftercare department. Other interviews were conducted with general nurses providing nursing care to CVA patients. Research group The research group consisted of 11 general nurses working at different follow-up care hospital stations, and 16 patients who were hospitalized at these departments after the CVA. Results By analyzing the information obtained, it has been determined that obesity affects the patients mobility especially after the cerebrovascular event. At the same time, it represents a physical and psychological burden for nursing staff, but also for patients. The problem has been the fact, that most patients do not perceive obesity as a condition affecting their whole life. Conclusion The diploma thesis has provided insight into the problematic of the influence of obesity on the follow-up care in patients after cerebrovascular accident. The findings should lead to a reflection on the issue of prevention of obesity in terms of both CVA risk and follow-up care, but also the need for educational activities.

The Effectiveness of Therpay for Drug Addicts and Their Integration within Society The purpose of my thesis "The Effectiveness of Therapy for Drug Addicts and Their Integration in Society" is to elucidate the lifestyles of addicts during different stages of therapy and to help people to understand the problems of drug addicts. The function of the brain can be altered by a number of psycho-active drugs that can influence a person's behavior, conscience, morals and mood. Drug addiction results in an uncontrollable urge to acquire drugs, regardless of the consequences. This behavior leads to a gradual exclusion of the drug addict from society. Re-integration into society must be the goal of treatment. The social exclusion of addicts seriously hampers their attemts to find employment. Many addicts started to use illicit drugs before the age of 18 years. Their education has not been completed and their bonds with their family members have been broken. Health problems caused by drugs, alcohol, a low quality nourishment, often untreated infections, poor hygiene, poor or absent living arrangements are factors that contribute to the exclusion of drug addicts from society. The abstinence from drugs, for longer than three months, creates a precondition for recovery and re-integration into society. However, in the absence of a postive change in attitude of the addict towards society and in the abscence of a social safety net, drug abstinence alone does not represent a reliably positive prognostic indicator. Complex social services that include protected housing, employment, job counselling, out-patient or in-patient psychotherapy, are necessary for successful treatment.

Bakgrund: Utvecklingen av intensivvården har under de senaste åren lett till att antalet personer som överlever intensivvården har ökat. Över hälften av alla överlevare drabbas av olika komplikationer i efterförloppet som kräver behandling och rehabilitering. Kunskapen om detta är av betydelse för sjuksköterskan för att förstå vikten av personcentrerad vård efter intensivvårdsbehandling. Syfte: Syftet med litteraturstudien var att sammanställa intensivvårdsbehandlade patienters upplevelser av efterförloppet. Metod: En kvalitativ litteraturstudie med induktivt förhållningssätt. Databaserna PubMed, Cinahl och SveMed+ användes för att ta fram material för studien. En kvalitetsgranskning av studierna utfördes med SBU:s granskningsmall för kvalitativa studier. Resultat: Resultatet redovisas utifrån sex kategorier: fysisk, psykisk och kognitiv påverkan, en lång återhämtningsprocess, behov av stöd från närstående, behov av omvårdnad, behov av hanteringsstrategier och förändringar av livet. Konklusion: Studiens resultat skildrar de intensivvårdsbehandlade patienternas olika upplevelser i efterförloppet. Patienterna upplevde att deras behov inte blev tillgodosedda samt att tillgången till och kvaliteten på den uppföljande vården var begränsad. De upplevde även en brist på information om vad tiden efter intensivvårdsbehandlingen skulle innebära. Den uppföljande vården har utvecklats under den senaste tiden, men behöver fortsatt utveckling för att kunna tillgodose behoven hos denna patientgrupp. / Background: The development of intensive care during the latest years have led to increasing numbers of ICU survivors. More than half of all survivors are affected by different complications after intensive care treatment that needs treatment and rehabilitation. This knowledge is of meaning for the nurse to understand the importance of person-centred care after intensive care treatment. Aim: The aim of the study was to compile patients’ experiences of recovery after intensive care treatment. Method: A literature review with a qualitative approach was used. Literature searches were performed in the databases PubMed, Cinahl and SveMed+. The quality of the selected studies was assessed using SBU’s review tamplet for qualitative studies. Results: The results are reported based on six categories: physical, mental, and cognitive impact, a long recovery-process, need for support from family and friends, need for care, need for coping strategies and changes in life. Conclusion: The results of the study describes the patients´ different experiences during the recovery from intensive care treatment. The patients experienced that their needs weren´t fullfilled and that the availability and quality of the follow-up care was limited. They also experienced that there was a lack of information about the recovery. The follow-up care has developed during the recent years, but it needs further development to be able to meet the needs of this group of patients.

Thesis objectives: The thesis deals with the comparison of wound healing management in acute and subsequent care. The theoretical part presents the knowledge of acute and chronic wounds, wound healing and their phases. Furthermore, the thesis deals with methods of wound treatment. The last chapter of the theoretical part deals with management and the role of a nurse in caring for a patient with a wound. In the empirical part, the first goal was to find out whether nurses from the Hradec Králové Region hospitals know the division and types of wounds. The second goal was to map out the possibilities for nurses to heal wounds. Another aim was to compare the differences between wound healing in acute and subsequent care. The fourth goal mapped the knowledge of nurses about wound healing materials. The following aim was to find out which materials for wound care are available at the hospital of the Hradec Králové Region. The sixth goal was to compare the economic and time-consuming wound healing at the acute and aftercare departments. The last goal of the thesis is to elaborate a seminar within the framework of lifelong education of general nurses on the topic of effective wound healing. Five hypotheses and two research questions were formulated to meet the goals of the thesis. Method for achieving the objectives: The set goals were achieved through quantitative questionnaire research and qualitative observation and interview research, which were chosen to complement the results. The sample included general nurses working in the internal department, the surgical department, the intensive care unit, the anesthesiology-resuscitation department and the aftercare departments in the hospitals of the Hradec Králové region. The total number of respondents was 120. Scientific benefits of the thesis: Overall research shows that nurses have sufficient knowledge of wounds and their treatment, but deficiencies in some areas are still evident. Furthermore, the research shows that nurses do not have enough therapeutic material to work on their workplaces. The interviewed group of general nurses said they think that modern dressing materials have a positive effect on wound healing. The results of the work can be used for practice, in hospital and other health care facilities to improve wound healing. The findings and conclusions: In the tracked file, we verified that the length of treatment of wounds on beds of acute and subsequent care differs (p = 0.002); the results show that the average time of wound dressing is prolonged in subsequent care. Conversely, the availability of dressing materials in the respective departments did not differ (p = 0.159). Furthermore, we found that the economic intensity of the after-care beds is lower, despite the fact that more wound dressings are done than in the acute care.

Hypertension (HTN) is the most common chronic disease among jail inmates. Many inmates treated for HTN while incarcerated in the Fairfax County Jail do not continue treatment when they return to their communities. Factors that contribute to discontinuing HTN management once the inmate returns to the community include homelessness, low income, and lack of access to care. The purpose of this quality improvement project was to educate inmates with HTN about community-based outreach services for HTN management and continuity of care while in the community. The outcome measured was the number of inmates who returned to jail reporting use of a community-based clinic for follow-up HTN care after their last release from jail. The project was conducted in 2 phases during a 6-month period. A pre-HTN survey questionnaire measuring HTN history and lifestyle was administered on initial incarceration. A post-HTN survey was completed when the inmates return to the jail during the 6-month period and measured adherence to post jail follow up HTN care. The findings of this quality improvement project indicate that both inmates who returned to jail in Phase 2 of the project followed up their HTN care in the community after release from jail. This project shows promise as a first step in the process of social change in planning discharge for inmates with HTN at the time of incarceration.