京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22042号 / 医博第4527号 / 新制||医||1039(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 佐藤 俊哉, 教授 湊谷 謙司, 教授 稲垣 暢也 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

A definitive association between adverse childhood experiences (ACEs) and negative physical and mental health outcomes has been established. There is evidence that individuals in forensic psychiatric facilities are disproportionately exposed to ACEs, which may impact severity, prognosis, and age of onset of psychiatric symptoms, including behavioral concerns of institutional aggression, self-harm behaviors, and suicide attempts. Such psychiatric and behavioral concerns are often managed through multiple psychotropic prescriptions, leading to psychotropic polypharmacy. This study evaluated the relationship between ACEs, mental health and behavioral concerns, and psychotropic polypharmacy through analysis of archival data from a forensic inpatient psychiatric facility. A total of 182 patients met inclusion criteria. Through a comprehensive record review, ACE scores, mental health outcomes, behavioral concerns, and prescription practices were ascertained and subjected to a series of regression analyses. Results indicate that the current participants experience greater prevalence of ACEs and mental health outcomes, as well as higher rates of psychotropic polypharmacy. These relationships are mediated by history of self-harm behaviors. The higher polypharmacy rates yield greater negative side effects with the need to manage with additional medications. Taken as a whole, ACEs are a relevant consideration, as childhood adversity may lead to a lifetime of difficulty with managing emotional distress and symptoms of psychopathology. Pharmacological treatment may be necessary, particularly with those who experience more complex mental health outcomes. However, a primary focus on psychotropic intervention can result in high rates of medications and polypharmacy with significant side effects. Incorporation of non-pharmacological intervention should be a primary consideration with forensic inpatients to circumvent the potential for psychotropic polypharmacy and related negative consequences.

Bakgrund: Åtgärder för att förbättra sömn är en central del i sjuksköterskans omvårdnad då sömn utgör en grundläggande faktor i människans välbefinnande och även i återhämtning. Flertalet sjukdomar har inverkan på människans sömn. När kroppen inte får den sömn som krävs kan detta ge konsekvenser som kardiovaskulära sjukdomar, diabetes typ två, nedsatt beslutsfattningsförmåga, koncentrationsförmåga och det kan dessutom ge upphov till humörsvängningar. Syfte: Syftet var att belysa sjuksköterskans omvårdnad vid sömnproblematik hos vuxna patienter som vårdas på sjukhus. Metod: Allmän litteraturstudie med strukturerad sökmetod. Tio resultatartiklar valdes ut. Resultat: Analysen av resultatet genererade fyra kategorier: sjuksköterskans kunskap om patienters sömn; nattlig ljud- och ljusexponering som påverkar sömnen; ängslan, oro och smärta som påverkar sömnen samt organisatoriska faktorer som påverkar sömnen. Konklusion: Framförallt visade det sig att det krävs en omdirigering av vårdmiljön berörande ljudnivåer, ljusexponering samt störande omvårdnadsinsatser under nattetid. Vårdverksamheten behöver dessutom omstruktureras för att ge sjuksköterskan förutsättningar för att stödja patienters sömnhälsa. Sjuksköterskor upplever även att de ibland har otillräcklig kunskap för att vårda patienter med sömnproblem. / Backgroud: Sleep is an essential component of the nurse’s tending. It is also a fundamental factor in the human well-being and recovery. Numerous of diseases affect human sleep. When the body does not get the sleep that is required, it can result in consequenses such as menial ability to concentrate, impaired decision-making ability and it can also result in rised mood swings. In addition, it can contribute to cardiovascular disease and type two diabetes. Aim: The aim was to illustrate the nurse ́s nursing in the event of sleep problems in adult patients who are cared for in hospital. Method: General literature study with structured search method. Ten result articles were selected. Results: The result developed in four categories: the nurse’s knowledge about patients’ sleep; nightly sound and light exposure which affects the patient's sleep; anxiety, worry and pain which affects the patient's sleep and organizational factors which affects the patient's sleep. Conclusion: Above all, it turns out that a redirection of the care environment regarding noise levels, light exposure and disruptive nursing interventions at night is required. It also needs to be restructured within the business to give the nurse more suitable conditions and, in general, time to support patients’ sleep health. It was also stated that in some scenarios the nurse felt that some of the competence and knowledge for patients with sleep problems was lacking.

Bakgrund: I december 2019 upptäcktes ett nytt virus, SARS-CoV-2, som under 2020 gav upphov till en global pandemi. Pandemin resulterade i ett ökat vårdbehov världen över vilket gav upphov till nya utmaningar för hälso- och sjukvården. Sjukdomen resulterar i såväl fysiska som psykiska symtom och allvarlighetsgraden av dessa varierar mellan individer. Behandlingen riktas mot symtomen och kan kräva sjukhusvård. Sjuksköterskans kompetensområde är omvårdnad och skall utföra personcentrerad vård som innebär att förhålla sig till och vårda patienter som unika personer med individuella behov. Syfte: Att undersöka patienters upplevelser av vårdtiden med en Covid-19-infektion.  Metod: En litteraturöversikt baserad på 11 artiklar med kvalitativ ansats. Resultat: I resultatet framkom 5 teman: Rädslor och farhågor hos patienter, isolering och ensamhet, patienters behov av kommunikation och information, vårdpersonalens stödjande funktion samt nya insikter och tacksamhet. Konklusion: Patienters upplevelser av insjukna i Covid-19 är förenat med olika typer av lidande. Covid-19-diagnosen är förenat med känslor av rädsla och oro både inför patienters egna hälsa samt vänner och familj. Vikten av personcentrerad vård och att se situationer utifrån ett livsvärldsperspektiv gör att patienters behov bli tillfredsställda. Vårdpersonalen har stödjande funktion som är viktig för patienter som vårdas för Covid-19. / Background: In december 2019 a new virus was discovered, SARS-CoV-2, that during 2020 resulted in a global pandemic. The pandemic resulted in a bigger need for and led to new challenges faced by healthcare services worldwide. The illness leads to physical and mental symptoms and different types of severities. The treatment for Covid-19 is symptomatic and may require hospitalization. Nursing includes person centered-care which includes that the nurse acts and treats patients as unique people with individual needs. Aim: To examine patients' experiences during a hospitalization with a Covid-19 infection. Method: A literature review based on 11 articles with a qualitative approach. Findings: The results revealed 5 themes: Fears in patients, Experience of isolation and loneliness, patients' need for communication and information, the staff's supportive function and new insights and gratitude. Conclusion: The study shows that the patients experience during Covid-19-hospitalization includes different kinds of suffering. The illness is united with different kinds of fears and worries which includes the patients own health and the health of friends and family. Person centered-care is important and to see the patient from a lifeworld perspective can cater the patients needs.

Orientador: Marianne Ramos Feijó / Resumo: Existem poucos estudos sobre as dificuldades enfrentadas por mulheres com dependência de substâncias psicoativas (DSPA) e por familiares de mulheres em tratamento para DSPA. No presente trabalho, objetivou-se compreender dificuldades de apoio da família a mulheres com DSPA e a importância da relação de suporte durante o tratamento, segundo o olhar da mulher com DSPA e de familiares de mulheres com DSPA. Além dos dados bibliográficos sobre a participação da família no cuidado com pessoas com DSPA, foram feitas entrevistas semiestruturadas com 15 mulheres adultas, em tratamento para DSPA e com 16 familiares. Após análise de conteúdo dos dados coletados, foi proposta discussão embasada no levantamento bibliográfico atual, o que permitiu salientar a relevância da assunção de um novo olhar para essas pessoas, que possibilite a atenção integral e o cuidado, tanto para a mulher com DSPA, quanto para a sua família. Concluiu-se que compreensão, apoio, aproximação sem julgamento e facilitação do acesso aos direitos e aos recursos de saúde, podem inclusive contribuir para a redução de estigmas e de preconceitos relatados pelos participantes dos dois grupos entrevistados, mulheres e familiares. A pesquisa de mestrado resultou na produção de um artigo cientifico sobre o apoio familiar às mulheres com DSPA e na publicação de um capítulo sobre famílias em contexto de vulnerabilidade e dependência de substâncias. / Abstract: There are few studies on the difficulties faced by women with psychoactive substance dependence (PASD) and by family members of women undergoing treatment for PASD. In the present study, the objective was to understand difficulties in supporting women with PASD by the family and the importance of the support relationship during treatment, according to the perspective of the woman with PASD and the family members of women with PASD. In addition to the bibliographic data on family participation in caring for people with PASD, semi-structured interviews were conducted with 15 adult women, undergoing treatment for PASD and with 16 family members. After analyzing the content of the collected data, a discussion was proposed based on the current bibliographic survey, which allowed to highlight the relevance of taking a new look at these people, which enables comprehensive care and care, both for women with PASD, as well as for your family. It was concluded that understanding, support, approach without judgment and facilitating access to health rights and resources, can even contribute to the reduction of stigma and prejudice reported by the participants of the two groups interviewed, women and family members. The master's research resulted in the production of a scientific article on family support for women with PASD and the publication of a chapter on families in the context of vulnerability and substance dependence / Mestre

Purpose: The purpose of this Qualitative Descriptive study was to describe the experience of hospitalized adults during the pandemic who did not have COVID-19. Specific Aims: The specific aims of the study were to: Describe the hospital experience, including but not limited to, interactions with hospital staff, visitation, isolation, physical and emotional stressors, and the environment. Identify perceived comfort needs during hospitalization and perceptions of the nurse’s role in providing comforting interventions. Examine the ability to achieve physical, psychospiritual, sociocultural, and environmental comfort during hospitalization despite the required infection control measures. Framework: This study was guided by Kolcaba’s Theory of Comfort (1994). Design: This was a qualitative descriptive study. Semi-structured interviews were conducted. Interview questions focused on the overall hospital experience, the nurse’s role in their experience, comfort needs, and the experience of having comfort needs met during the hospitalization. Results: Twenty participants took part in this study. Conventional content analysis revealed five main themes. The themes are: I don’t expect the hospital to be comfortable, I was always tense, Wanting human connection, Communication is important, and Nurses are busy. Conclusion: The findings identified a need for targeting education, research, and policy development to improve patient comfort (physical, psycho-spiritual, sociocultural, and environmental). This is important as we look toward improving the overall patient experience during hospitalization.

Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

Background: Home health is the fastest-growing healthcare setting in the country. Through Home Health Value-Based Purchasing (HHVBP), the Center for Medicare and Medicaid Services (CMS) provides incentives or penalties to HHAs based on outcomes. Hospitalization and emergency department use are weighted heaviest as poor outcomes. HHVBP requires HHAs to report on whether they are engaging in advance care planning (ACP) conversations. For this study, ACP was defined as a conversation held in advance of a medical crisis with a loved one and/or a health care provider about goals; values; preferences for future medical treatments; and choice of a surrogate decision-maker. Purpose: to determine whether the proportion of Black patients was correlated with robustness of HHAs’ ACP protocols and levels of acute care services use. Methods: A cross-sectional, quasi-interventional design was used. The sample size was n = 89. Electronic surveys about ACP protocols were distributed to HHAs. Existing data about demographics and acute care services use were accessed via CMS websites. Spearman’s correlation coefficient was used. Results: No relationship was found between robustness of ACP protocols and the proportion of Black population per agency. No relationship was found between overall acute care services use rates proportion of Black patients. However, a trend was found: The greater proportion of Black patients, the greater the tendency for an agency to have a higher hospitalization rate. Discussion: Results are compared to current literature and to a CMS-commissioned study’s discussion about the potential for value-based purchasing programs to exacerbate health disparities in vulnerable populations.

IntroductionTriple-negative breast cancer (TNBC) has limited treatment options, as chemotherapy is the only systemic therapy. This poses a challenge in the elderly population due to the limited research done, but also the increased risk for adverse events. Aim To describe the treatment pattern, identify the risk of hospitalization and potential risk factors for hospitalization within 1 year from diagnosis, and investigate the causes of death in elderly with TNBC and possible predictors for mortality. Methods We performed a registry-based cohort study using the BCBaSe database which links cases of breast cancer from 3 Swedish healthcare regions with socioeconomic factors, hospitalizations and causes of death. Women ≥ 70 years old with non-metastatic TNBC, between 1/1 2007 and 31/12 2012 were chosen (n = 413). Logistic regression and Cox proportional hazards regression analyses were used. Results Age, stage and comorbidities influenced administration of chemotherapy. The risk of hospitalization overall was increased in the group receiving chemotherapy (OR 2.35, 95% CI 1.30 – 4.26) mainly due to toxicities. Chemotherapy use was not associated with either breast cancer-specific (HR 0.95, 95% CI 0.51 – 1.79) or overall survival (HR 0.72, 95% CI 0.44 – 1.18). Stage at diagnosis and comorbidities were associated with both breast cancer-specific mortality and overall mortality, whereas age was only associated with overall mortality. ConclusionsIn elderly TNBC patients, chemotherapy use was associated with increased risk for hospitalization within 1 year from diagnosis without improving breast cancer-specific or overall survival. No benefit regarding mortality was seen in those who were administered chemotherapy.

Background: The aging population has become ha global phenomenon. The care for elderly people are therefore facing huge obstacles when it comes to meeting the aging population’s future needs. For various reasons many older people are seeking help and have to spend time in hospitals and when they return to their home environment they often have to rely on different health and care efforts. Aim: Describe older people’s experiences of their life situation and the different care interventions after hospitalization. Method: This study has a descriptive design with a qualitative approach and a total of nine individual semi-structured interviews were conducted. The collected material was analyzed using qualitative content analysis. Main result: An underlying theme appeard: The value of being independent, both past, present and future and were the overall result. After hospitalization the informants experienced numerous limitations that impaired their autonomy. The restrictions made them dependent on family members and effeorts from home care services to cope with the new situation. The informants were both adapted to and accepted the new situation and different values according to the new life situation could be discerned. The values could be various achievements, being outdoors or social interactions. Conclusion: To arrive home from the hospital with other conditions than prior hospital stay, is a transition that older people often have to go through. The older person needs help in this transition, both from the surroundings and the specialist nurse in the care of the elderly, as well as general nurses and assistant nurses have a significant role in how the new life situation is experienced. / Bakgrund: Den åldrande befolkningen har blivit ett globalt fenomen och det kommer att ställas krav på såväl sjukvård som vård- och omsorg av äldre personer för att kunna möta den åldrande befolkningens framtida behov. Många äldre personer vårdas av olika anledningar inom den slutna hälso- och sjukvården och när de återkommer till hemmet är de ofta i fortsatt beroende av olika vård- och omsorgsinsatser. Syfte: Beskriva äldre personers upplevelse av sin livssituation och av olika vård- och omsorgsinsatser efter sjukhusvistelse. Metod: Studien har en beskrivande design med en kvalitativ ansats och totalt har nio individuella semistrukturerade intervjuer genomförts. Det insamlade materialet har analyserats med kvalitativ innehållsanalys. Huvudresultat: Ett underliggande tema framträdde: Värdet av att vara självständig, i dåtid, nutid och framtid och var det övergripande resultatet. Informanterna upplevde efter sjukhusvistelsen olika begränsningar som försämrade deras självständighet. Begränsningarna gjorde dem beroende av närstående och insatser från hemtjänsten för att klara av den nya livssituationen. Informanterna anpassade sig till och accepterade den nya livssituationen och olika värden av betydelse för den nutida livssituationen kunde urskiljas. Dessa värden kunde vara olika framsteg, utomhusvistelse eller social samvaro. Slutsats: Att komma hem från sjukhuset med andra förutsättningar än innan sjukhusvistelsen är en transition som äldre personer ofta måste gå igenom. Genom transitionen behöver den äldre personen stöd och hjälp från omgivningen och specialistsjuksköterskan inom vård av äldre, liksom allmänsjuksköterskor, undersköterskor och vårdbiträden har en betydande roll för hur den nya livssituationen upplevs.