Purpose: The aim of this thesis is to study the European (ESTRO/EAU/EORTC) and American (ABS) guidelines how to report the permanent seed implant and the most significant dosimetric parameters. It will also report on the permanent seed implant at Södersjukhuset, Karolinska University Hospital according to the guidelines. A large number of studies on pre- and post-implant dosimetry on permanent seed implants have recently been published but none is considered a standard. This makes it difficult, if not impossible, to compare data from different centres. The differences in reporting will also be discussed in this thesis. Another part of the study is to investigate how the morbidity correlates with the dose. The results in this report will give an overview of the experience at Södersjukhuset. Matherials and Methods: This study includes 198 patients who received implants between 2004-2007 with I-125 seeds under transperineal ultrasound at Södersjukhuset (to a prescribed dose of 145 Gy). The dose-planning system VariSeed 7.1 was used with an online connection to the ultrasound system with real-time verification. Dose constraints for the planning system are V(100)>99%, V(150)>60%, V(200)>25%, UrD(10)<130% and UrD(30)<125%. Outer and inner wall of rectum was outlined for 55 patients as recommended by ESTRO/EAU/EORTC and doses to rectum were also computed. Results: The median value for dosimetric parameters at Södersjukhuset, Karolinska University Hospital are for the prostate; D(90)=174Gy (153-194Gy), V(100)= 99% (93-100%), V(150)= 57% (40-74%), for the urethra; UrD(30) = 130% (112-147%), UrD(10) = 124% (107-142%) and for the rectum; RD2cc= 98Gy (73-128Gy), RD0.1cc=164Gy (119-240Gy), RV(100)=0.3cc (0.0-1.3cc), RV(150)=0.0cc (0.0-0.2cc). These values correspond to recommended data, except for the V(150) value. Regarding the clinically observed results, 3 patients had a relapse in their cancer, 2 patients had mild proctitis and 15 patients had urinary problems. Discussion and Conclusions: The significant dosimetric parameters for reporting according to ESTRO/EAU/EORTC and ABS for prostate are D90[Gy], V(100)[%] and V(150)[%], for urethra are D(30) and D(10), and for rectum RD2cc and RD0.1cc. These parameters consider as a minimum to use and they further recommend secondary parameters to report. Other authors have also recommended to report RV(100) and RV(150) for rectum. This study did not show any relationship between UrD(10), UrD(30) and urinary morbidity. According to the recommendations every patient should undergo a CT-based evaluation. Further investigations are needed on whether a post-implant CT-study is necessary for real-time implantation, as there is not enough published data on this aspect.

Under år 2011 levde ca 5800 personer i Sverige med diagnosen hiv (humant immunbristvirus) och 18 nya fall upptäcktes via MHV:s screening av gravida kvinnor. Risken att ett barn smittas under graviditet och förlossning är 15-25 % om kvinnan inte behandlas med antiretrovirala läkemedel. Riskerna ökar med ytterligare 10-15 % om kvinnan sedan väljer att amma sitt barn. Barn till kvinnor som behandlas med antiretrovirala läkemedel och har icke mätbara virusnivåer i blodet löper en risk på 0,4-1 % att smittas. RAV (referensgruppen för antivirala medel) uppdaterade 2010 sina behandlingsrekommendationer för hiv-1 positiva kvinnor under graviditet och förlossning. Detta till följd av att WHO ändrade sina riktlinjer samma år. En stor skillnad i rekommendationerna är att kvinnan får möjlighet till en vaginal förlossning om virusmängden och den obstetriska anamnesen tillåter. Syftet med studien var att granska PM för handhavandet av den hiv-1 positiva kvinnan och hennes barn under förlossning och puerperium på förlossningskliniker i Sverige. En kartläggningsstudie valdes med beskrivande och jämförande design. Metoden var att samla in samtliga förlossningsklinikers PM och/eller strategi för omhändertagande av patientgruppen. De insamlade PM:en granskades enligt RAV:s behandlingsrekommendationer och enligt AGREE som är ett validitetssäkrat instrument för granskning av kliniska riktlinjer. Resultatet visar på stor variation i både uppbyggnad av PM och följsamhet till behandlingsrekommendationer. Förlossningsklinikernas behandlingsstrategier skiljer sig också åt beroende på antal förlossningar/år och huruvida de tog emot eller skickade vidare patientgruppen. Vissa förlossningskliniker saknade helt PM och några av dessa tog ändå emot patientgruppen. Generellt sett var PM:ens utformning undermålig gällande uppbyggnad och uppdatering, samt att flera förlossningskliniker ej hade anammat de nya behandlingsrekommendationerna från RAV. / In 2011, approximately 5800 people in Sweden were living with an hiv (human immunodeficiency virus) diagnosis and 18 new cases were detected during antenatal screenings of pregnant women. The risk of a child being infected during pregnancy and delivery is 15-25 % if the woman hasn’t been treated with antiretroviral drugs. The risk will increase a further 10-15 % if the woman choses to breastfeed the child. The children of women that are treated with antiretroviral drugs and has non-measureable levels of virus in the blood runs a risk of 0.4-1 % of being infected. In consequence of WHO changing their guidelines in 2010, RAV (a reference group for antiviral treatment) updated their treatment recommendations for hiv-1 positive women during pregnancy and delivery. A major difference in the recommendation is that the woman is given an option of vaginal delivery, if allowed by the viral levels and obstetrical history.The purpose of this study was to review PM for the handling of the hiv-1 positive woman and her child during delivery and puerperium on maternity clinics in Sweden. A survey study was chosen with descriptive and comparative design. The method was to gather PM and/or strategy for care of the patient group from all clinics. The gathered PMs were reviewed according to RAV’s treatment recommendations and according to AGREE, an instrument for examination of clinical guidelines. The result displayed a great variation in both PM structure and adherence to the treatment recommendations. The care strategy of a maternity clinic was dependent of deliveries per year and also whether the patient group was admitted or referred. Some maternity clinics lacked PMs entirely and some of these would nevertheless admit the patient group. In general, the form of the PMs were substandard regarding structure and maintenance and several of the maternity clinics had not embraced the new treatment recommendations from RAV.

Bakgrund: Hypertoni är en av de vanligaste orsakerna till att besöka primärvården och en av de viktigaste modifierbara riskfaktorerna för hjärt- och kärlsjukdom. Livsstilsbehandling är grunden i all behandling av hypertoni. En stor andel av hypertonipatienter är obehandlade eller når ej behandlingsmål. Ett vårdprogram har därför tagits fram för att förbättra omhändertagandet av hypertonipatienter i primärvården. Syfte: Syftet är att undersöka personalens upplevelser och erfarenheter från implementeringen av vårdprogrammet för hypertoni på en vårdcentral. Metod: Studien är en explorativ intervjustudie. Datainsamlingsmetoden var enskilda semistrukturerade intervjuer. Urvalet bestod av nio personer som arbetade på Tierps vårdcentral. Materialet analyserades enligt kvalitativ innehållsanalys. Resultat: Informanterna var positiva till implementeringen av vårdprogrammet. De upplevde att implementeringen av vårdprogrammet för hypertoni skapade struktur och ökade kvaliteten på vårdcentralen. Vårdprogrammet förkortades och anpassades efter lokala förutsättningarna. Rutinerna dokumenterades i ett kvalitetsdokument. Samtliga yrkesgrupper som berördes av förändringarna fanns representerade i den arbetsgrupp som tog fram de lokala rutinerna, inklusive verksamhetschefen själv. En blodtrycksmottagning öppnades där en specialutbildad sjuksköterska arbetar. På så vis kunde utredning och uppföljning av hypertonipatienterna säkerställas, vilket förmodligen gynnar resurssvaga grupper. Implementeringen ledde till ett mer likriktat arbetssätt över hela verksamheten och medförde att livsstilsarbetet kunde utföras mer strukturerat. Utmaningar med att få patienterna till hälsosamtal kvarstår. Uppföljning planeras till hösten 2013. Slutsats: Informanternas upplevelse var att vårdprogrammet för hypertoni skapade struktur och ökade kvaliteten på vårdcentralen. Framgångsfaktorer var bl.a. att ha alla yrkesgrupper representerade arbetsgruppen, inklusive verksamhetschefen själv. Ett hinder för att implementera vårdprogram var att verksamheten är väldigt stor vilket försvårar att kommunicera ut tydlig information till alla enheter. Tidsbristen ses som ett hinder för att kunna följa upp implementeringsarbetet. / Background: Hypertension is one of the most common reasons for visiting primary care and one of the most important modifiable risk factors for cardiovascular disease. Lifestyle change is the foundation of all treatment of hypertension. Many hypertensive patients are untreated or unsuccessful in reaching treatment goals. Regional guidelines have therefore been developed to improve the care of hypertensive patients in primary care. Purpose: The aim is to study the staff’s experiences of an implementation of regional guidelines for hypertension at a medical centre. Method: The study is an exploratory interview study. Method for data collection was individual semi-structured interviews. The study selection consisted of nine employees at a medical center. The material was analyzed according to qualitative content analysis. Results: The participants were positive to the implementation of the regional guidelines. They experienced that the guidelines created structure and improved the quality at the medical centre. The guidelines were shorted and adjusted to the local settings.  They were documented in a quality document. All involved occupational groups were represented in the workgroup the developed the local routines, including the manager of the medical centre. A nurse reception opened especially for blood pressure patients, led by a specially trained nurse.   Success factors were to have all the professions represented in the work group, including the manager. Guidelines were shortened and localized with the best of the patient in favor. A nurse led practice was created to ensure that the guidelines are followed. The work resulted in a more consistent way of work and a more standardized way to work with life style. Challenges in making patients come to lifestyle counseling persist. An evaluation of the implementation is planned to take place autumn 2013.  Conclusion: They experienced that the guidelines created structure and improved the quality at the medical centre. A success factor was to have all occupational groups represented in the work group, including the manager. An obstacle was that the medical centre is very big which obstruct clear communication.  Lack of time was an obstacle for ensuring evaluation.

Unique characteristics of cluster randomized trials (CRTs) complicate the interpretation of standard research ethics guidelines. Variable interpretation by research ethics committees may further complicate review and conduct. An international web-based survey was administered to corresponding authors of 300 randomly sampled CRT publications. We investigated ethics review and consent practices, investigator experiences with ethics review, and the perceived need for CRT-specific ethics guidelines. The response rate was 64%. Ethics review and consent were under-reported in publications. Ethics approval was obtained in 91%, and consent from individual and cluster level participants in 79% and 82% of trials. Consent varied by level of experimental intervention, data collection, and cluster size. Respondents cited variability among ethics committees (46%), and negative impacts of ethics review on their studies (38%). The majority perceived a need for ethics guidelines (73%), and guidance for ethics committees (70%). CRT-specific ethics guidelines are required to ensure practices meet ethical standards.

The objective of the thesis was to evaluate the quality of diabetes care in the Canadian Forces by determining the extent to which physicians adhere to recommendations outlined in the 2008 Canadian Diabetes Association (CDA) clinical practice guidelines. In addition, the effect of patient age, sex, rank and size of base on quality of care was assessed and the accuracy of a diagnosis of diabetes in an extract of the electronic medical record (EMR) was evaluated. Fourteen bases within the Canadian Forces were selected for investigation, representing roughly half of the Canadian Forces population. Cases of diabetes were ascertained based on laboratory criteria following a chart review. Twenty-one CDA guideline recommendations were considered. The Canadian Forces demonstrated greater than 75% adherence with each of 9 recommendations, 50-75% adherence with each of 7 recommendations and less than 50% adherence with each of 5 recommendations. The overall adherence with all applicable recommendations per patient was 60.3% (SE 0.66). Age, sex, rank and size of base were not important factors influencing guideline adherence. The sensitivity of a diabetes diagnosis in an extract of the EMR was 84.5%, the specificity was 99.8%, the positive predictive value was 85.1% and the negative predictive value was 99.8%. This is similar to the performance of provincial and national diabetes registries. The quality of diabetes care in the Canadian Forces compared favourably with that of the civilian population within Canada and internationally. The creation of a diabetes registry is expected to lead to further improvements in diabetes care.

<p>The generation of large volumes of solid and liquid wastes in urban and periurban areas of Ghana is a big problem for the people and government of Ghana. It contributes to the outbreak of many diseases in the country such as malaria, diarrhoea and typhoid fever. In managing the situation, a new concept called ecological sanitation (ecosan), which focuses on reuse of waste, has been introduced in the country. The objectives of the thesis were to criticise the environmental sanitation policy&nbsp / by analysing its content in relation to policy implementation arrangements, to discuss programmes and projects identified under the policy, to critically examine the implementation of an ecosan project as a way of achieving the goal and objectives by outlining its implementation processes, prospects and challenges, and to make appropriate recommendations. The analysis and discussion of the thesis were based on both primary and secondary data. The primary data, on one hand, were collected on the prospects and challenges that exist in the implementation of ecosan projects from Kumasi metropolis. The secondary data, on the other hand, were from&nbsp / books, journals and websites. From the research analysis, it emerged that the policy allows the implementation of many sanitation projects including ecosan. Secondly, stakeholders see ecosanto be a good approach to reduce waste generation in the country. However, the main challenges that exist in promoting the concept are inadequate financial support, unavailability of implementation guidelines and lack of knowledge about concept details. It is therefore argued that financial support, implementation guidelines and awareness-creation activities should be available in the implementation of ecosan in the metropolis. Government, private organisations, companies and individuals should each contribute their quota in the support and processes.</p>

Cervix cancer affects women of all ages and causes significant morbidity and mortality. Locally advanced disease is curable with radiotherapy (RT) in about 50% of patients, although often at the expense of serious side effects. In order to improve the therapeutic ratio of tumour control versus normal tissue toxicity, conformal intensity-modulated radiotherapy (IMRT) is being investigated. However, inter- and intra-fractional motion of cervix cancer can contribute to both geographical miss of the target and overdosing of surrounding normal tissues, particularly in the setting of conformal IMRT with steep dose gradients. Defining the target volume accurately and understanding the dose consequence of these complex intra-pelvic organ dynamics during external beam radiotherapy forms the essential foundations for future treatment optimization and adaptation. This in turn will lead to improvements in tumour control and disease-free survival while minimising treatment toxicity.

Den här rapporten undersöker vilken uppfattning och kunskap lärarna i förskolan har om naturvetenskap och hur den införlivas i praktiken enligt förskolans läroplan och lokala styrdokument. Syftet med den här undersökningen är att ta reda på: (i) Vad är naturvetenskap för lärarna i förskolan? (ii) Vilka mekanismer styr lärarnas planering och realisering av naturvetenskapen i det pedagogiska vardagsarbetet? Material och data till undersökningen har samlats ihop genom kvalitativa intervjuer med sju lärare i förskolan. Rapporten visar att övervägande delen av lärarna i förskolan ser naturvetenskapen som att vistas i skog och mark. Vad det gäller faktorer som påverkar planering och realisering av naturvetenskapen framkom det genom intervjumaterialet att det är: (i) Kompetens, (ii) förståelse av naturvetenskapen och dess innehåll och (iii) insikten av de styrdokument som förskolan lyder under. Utifrån gällanden styrdokument i förskolan är naturvetenskapen ett kunskapsområde som bör lyftas och synliggöras i den pedagogiska vardagen. För att uppfylla dessa krav bör lärarna i förskolan öka sin kunskap inom denna vetenskapsgren. / This report investigates the perception and knowledge of natural science amongst pre-school teachers and how natural science is currently incorporated into the pre-school curriculum. The aims of these investigations are in particular to: (i) Establish what natural science means (and implicates) to pre-school teachers. (ii) Identify factors that influence planning and implementation of natural science in the pre-school curriculum. Material and data for the abovementioned investigations have been gathered through qualitative interviews with seven active pre-school teachers. The report finds that a majority of the interviewees only have a very basic understanding of natural science and therefore often fail to adequately incorporate natural science in the daily pre-school curriculum. The report furthermore finds that amongst the interviewees the factors that influence planning and implementation of natural science in the pre-school curriculum are: (i) competence, (ii) perception and knowledge of natural science and (iii) interpretation of the pre-school curriculum guidelines. Current pre-school curriculum guidelines stresses the importance of natural science and encourages pre-school teachers to increase the awareness of natural science by incorporating it in the daily curriculum. This report argues that in order to increase the awareness of natural science the knowledge and perception of natural science amongst pre-school teachers must first be improved.

Cervix cancer affects women of all ages and causes significant morbidity and mortality. Locally advanced disease is curable with radiotherapy (RT) in about 50% of patients, although often at the expense of serious side effects. In order to improve the therapeutic ratio of tumour control versus normal tissue toxicity, conformal intensity-modulated radiotherapy (IMRT) is being investigated. However, inter- and intra-fractional motion of cervix cancer can contribute to both geographical miss of the target and overdosing of surrounding normal tissues, particularly in the setting of conformal IMRT with steep dose gradients. Defining the target volume accurately and understanding the dose consequence of these complex intra-pelvic organ dynamics during external beam radiotherapy forms the essential foundations for future treatment optimization and adaptation. This in turn will lead to improvements in tumour control and disease-free survival while minimising treatment toxicity.

The primary purpose of this study was to determine the effect of ingesting an 8% carbohydrate (CHO) beverage during a moderate intensity exercise trial on performance outcomes, fuel utilization and blood glucose levels of wheelchair athletes (spinal cord injury (SC I) or cerebral palsy (CP)). The secondary purpose was to analyze the dietary intake of the eight participants and to determine if they were meeting current sport nutrition guidelines for macronutrients and fluids recommended in the joint position statement developed by the American Dietetic Association (ADA), the American College of Sports Medicine (ACSM) and Dietitians of Canada (DC).<p> Under random, double blind conditions eight athletes (6 males, 2 females); mean age 36 ± 8.5 y with a SCI (n = 7) or CP (n = 1) completed two exercise trials on an adapted stationary hand cycle; each trial was 60 minutes in duration at 65 % VO2peak followed immediately by a 30-minute performance trial. During the first 60-minutes the participants were given four 200 ml dosages (15, 30, 45, 60-min) of an 8% CHO beverage or a taste-matched placebo beverage. Blood lactate and glucose levels were sampled during the 60-minute exercise trial (pre, 20, 40, 60-min) and immediately after the 30-minute performance trial (post, 2, 5, 10-min). Heart rate was monitored continuously during the exercise and performance trial. Expired gas samples were also taken for 5-min periods during the exercise trial and then continuously during the performance trial. These values were used to calculate respiratory exchange ratio (RER) and carbohydrate oxidation. Dietary intake was assessed with a three day food record.<p> No significant differences were apparent between beverage trials for total distance (km), average speed (kmhr-1) or maximum speed achieved (kmhr-1). Significant differences were evident for blood glucose values, RER and CHO oxidation between the two beverage trials (p< .05). At the end of the 30-minute performance trial blood glucose values were significantly higher in the CHO trial (4.8 ± 1.3 mmol.l-1 vs. 4.0 ± 0.5 mmol.l-1 for placebo trial; p< .05). The CHO beverage resulted in higher CHO oxidation during the last 5 minutes of the performance trial, 2.1 ± 1.0 gmin-1 vs. the placebo beverage 1.9 ± 1.0 gmin-1 (p< .05). The CHO beverage trial resulted in significantly higher RER values during the final 5 minutes of the exercise trial and during the final 10 minutes of the performance trial. At the 20-25 minute mark RER values were significantly higher with the CHO beverage trial (1.04 ± 0.10) vs. the placebo trial (1.01 ± 0.11) (p< .05). During the final 5 minutes of the performance trial RER values were also significantly higher with the CHO beverage trial (1.06 ± 0.11) vs. the placebo trial (1.01 ± 0.10) (p< .05). The results indicated the participants were not meeting the current dietary guidelines for able-bodied athletes and active adults. Only 25% of the participants met the daily caloric requirements for active adults. Carbohydrate recommendations of 6 to 10 gkg-1 body weightd -1 were not met by any of the wheelchair athletes Seven participants were within the acceptable macronutrient range (AMDR) for CHO. For protein intake, 63% of the participants were meeting the protein recommendations active adults and all of them were within the AMDR. Average caloric intake from fat exceeded current recommendations of 20 to 25%; two participants were above the AMDR. The results demonstrate that the 8% CHO beverage consumed during exercise resulted in higher CHO oxidation rates and elevated blood glucose values, but it did not result in a performance gain.