A growing body of research is examining effective treatment(s) for individuals with comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD). However, treatments for this comorbid population have been inadequately studied in the longer term. This study represents a long-term follow-up assessment of a randomized controlled trial that compared combined therapy (prolonged exposure + naltrexone) with monotherapies (prolonged exposure or naltrexone) for patients with PTSD and AD (see Foa, Yusko, McLean et al., 2013). Attempts were made to contact 120 participants 5-10 years after the original trial to assess the maintenance of treatment gains. Nineteen individuals were located and agreed to participate. A series of mixed ANCOVAs were conducted with PTSD symptom severity and percentage of days drinking and heavy drinking as the dependent variables. Findings revealed that reductions in PTSD symptoms and drinking behaviors generally were maintained 5-10 years after treatment. There was some relapse in heavy drinking days, and combination treatment was most effective for long-term PTSD outcomes. Challenges of conducting follow-up research with this population, implications and limitations of the present findings, and directions for future research are discussed.

There has recently been an intense debate about the increased rate of bipolar disorders (BPD) in children and adolescents observed in clinical settings. Thus, there is great interest in child and adolescent symptoms of hypomania and whether these symptoms subsequently will develop into BPD. More knowledge about early signs could give insight into the development of the disorder. There are also concerns that hypomanic symptoms in adolescence indicate excess risk of other health conditions. It has been reported that patients with mood disorders have a high consumption of prescription drugs in different ATC classes. The primary objective of this thesis was to better understand the mental health outcome of adolescents with hypomania spectrum symptoms and to identify early risk factors for adult bipolar disorder among adolescents with mood disorders. In order to widen the scope and investigate health outcome of mood disorder in general psychopharmacological outcomes were included. A community sample of adolescents (N=2 300) in the town of Uppsala, Sweden, was screened for depressive symptoms. Both participants with positive screening and matched controls (in total 631) were diagnostically interviewed. Ninety participants reported hypomania spectrum episodes, while another 197 fulfilled the criteria for major depressive disorder (MDD) without a history of a hypomania spectrum episode. A follow-up after 15 years included a blinded diagnostic interview, a self-assessment of personality disorders, and national register data on prescription drugs and health services use. Adolescent mood symptoms, non-mood disorders, and family characteristics were assessed. Univariate and multivariate analyses were used. The results indicate that the phenomenology of the hypomania spectrum episodes during childhood and adolescence per se does not predict adult bipolar disorder. However, having both affective symptoms during adolescence and a family history of bipolar disorder increases the risk of developing bipolar disorders in adulthood. Disruptive disorder in childhood or adolescence as well as family histories of BPD emerged as significant risk factors that differentiated between the future development of BPD and MDD. Adolescents with hypomania spectrum episodes and adolescents with MDD do not differ substantially in health outcomes in adulthood. Both groups are at increased risk for subsequent mental health problems, high consumption of prescription drugs, and high health care use, compared with the control group. The high rates of prescription drugs in many ATC classes found among the former depressed females seem to indicate a series of co-morbid somatic illnesses. Thus, it is important to identify and treat children and adolescents with mood disorders, and carefully follow the continuing course. Characteristics such as disruptive disorders and family history warrant particular attention.

Rehabilitation of edentulous patients with Implant-supported Complete Fixed Dental Prosthesis (ICFDP) is a well-documented treatment option. This dissertation assessed the relation between the rate of biological/mechanical complications and the type of metal framework alloy, length of cantilever extension. The results showed that long-term clinical outcomes of ICFDP were favorable. While 30% of patients experienced biological complications, 66.6% of the prostheses needed to be repaired during follow-up period. The risk of prosthesis failure and mechanical complications was significantly higher in silver-palladium frameworks as compared with palladium-silver or type IV gold alloys. The length of cantilever was not correlated with the amount of marginal bone loss. The rate of marginal bone loss around anterior implants was higher than that of posterior implants associated with cantilever segments. The treatment improved the patients’ quality of life and 96% of patients would undergo the same treatment again if required.

Rehabilitation of edentulous patients with Implant-supported Complete Fixed Dental Prosthesis (ICFDP) is a well-documented treatment option. This dissertation assessed the relation between the rate of biological/mechanical complications and the type of metal framework alloy, length of cantilever extension. The results showed that long-term clinical outcomes of ICFDP were favorable. While 30% of patients experienced biological complications, 66.6% of the prostheses needed to be repaired during follow-up period. The risk of prosthesis failure and mechanical complications was significantly higher in silver-palladium frameworks as compared with palladium-silver or type IV gold alloys. The length of cantilever was not correlated with the amount of marginal bone loss. The rate of marginal bone loss around anterior implants was higher than that of posterior implants associated with cantilever segments. The treatment improved the patients’ quality of life and 96% of patients would undergo the same treatment again if required.

Purpose: Postnatal depression has significant negative outcomes for both mother and baby. Cognitive-behavioural interventions have proven promising in its treatment, but there are a number of barriers, specific to the postnatal period, which lead to low take-up of treatment. Online interventions may circumvent some of these barriers. However, evidence of long-term follow-up is sparse, in spite of the importance of knowing how such treatments work over the longer-term. Methods: Long-term follow-up of postnatal women participating in a feasibility randomised controlled trial of NetmumsHWD, an online behavioural activation treatment with telephone support. Results: Retention rates of over 70 percent were obtained. There were small but non-significant effects of treatment on depressive symptomology and behavioural activation scores at 16 months post-randomisation. Baseline depression and behavioural activation scores predicted attrition prior to the implementation of outreach strategies for data collection; these systematic differences in attrition disappeared post-implementation. Measures of treatment adherence were not related to outcome. Conclusions: Collection of long-term follow-up data from postnatal women appears feasible. The findings demonstrate the importance of outreach in maximising retention, especially in relation to the generalizability of results. Future research should consider ways to assess treatment engagement and its relationship with outcome.

The primary aim was to compare the effectiveness of smoking cessation interventions of different intensities in a clinical dental and a telephone setting in Sweden. Methods: A total of 300 smokers were randomized to High or Low Intensity Treatment (HIT or LIT) at the Public Dental Service, County Council of Västmanland. Effectiveness (abstinence rate) was measured after 1yr (paper I) and 5-8yrs (paper III). A cost-effectiveness analysis was conducted, based on intervention costs, number of abstinent participants after 1yr, and a Markov modelling of future costs and health (in QALYs) consequences (paper II). In paper IV, 586 callers to the Swedish National Tobacco Quitline (SNTQ) were randomized to high-intensity proactive or low-intensity reactive service, and effectiveness was measured after 1 yr. Effectiveness measures were self-reported point prevalence, 6-month continuous abstinence, and sustained abstinence. Results: Absolute quit rates were 7% higher with HIT than with LIT on all measures and increased by 8% from 1yr to 5-8yrs. Point prevalence was 23% vs. 16% (p=.11) after 1yr and 31% vs. 24% (p=.16) after 5-8yrs. Six-month continuous abstinence was 18% vs. 9% (p =.02) after 1yr and 26% vs.19% (p=.18) after 5-8yrs. Sustained abstinence was 12% vs. 5% (p =.03) after 5-8yrs. Nicotine dependence was a strong predictor for abstinence at 1yr and achieved abstinence at 1yr was a strong predictor for abstinence at long-term follow-up. The cost-effectiveness analysis showed that both HIT and LIT were cost-effective, and LIT was even cost-saving compared with doing nothing. HIT was more costly and more effective than LIT, and the cost of each extra QALY gained by HIT was 100,000SEK, which is considered very cost-effective in Sweden. Proactice and reactive services were equally effective at the SNTQ. Point prevalence was 27% and 6-month continuous abstinence was 21% after 1yr. Being smoke-free at baseline was the strongest predictor for abstinence at 1yr. Conclusion: Support at high as well as low intensity in a clinical dental setting in Sweden and at the SNTQ was effective in achieving smoking cessation. Both high- and low-intensity interventions were very cost-effective in a clinical dental setting.

Survivors of childhood cancer are a relatively new phenomenon in the medical world. The introduction of treatment protocols in the 1970s started a trend in curing children of cancer that historically had been a death sentence. Under these treatment protocols children were given different treatment regimens based on past research that helped remove cancerous cells from their bodies, but were later found to be the cause of treatment related morbidities years into the future; for most survivors roughly ten to 20 years post treatment. These morbidities, commonly called late-effects, are the prime reason that survivors of childhood cancer need to participate in survivorship care. Survivors of childhood cancer are particularly vulnerable to late-effects because the majority of them receive their treatment at a time when their bodies are still growing and developing. Survivorship care services vary by site, but all maintain the common goals of providing long-term follow up for the survivor and education about the ways in which treatments may affect a survivors’ health as they age. Similar to many other facets of healthcare and medicine, there are many populations who do not participate in survivorship care. The purpose of this research is to identify possible barriers to care, assess the level of impact these barriers have upon the survivor’s potential for participation and provide suggestions as to how these barriers can be mitigated. Additionally, this research highlights areas that need further research and analysis.

Purpose An age-cohort was studied with long-term follow-up. The population was born in 1915, living in the municipality of Skellefteå in 1981. The purpose was to investigate the prevalence and incidence of pseudoexfoliation (PEX), its influence on intraocular pressure (IOP) and development of open-angle glaucoma (OAG). Another purpose was to estimate the value of screening for glaucoma by comparing the screened group within the cohort with the remaining unscreened group. Methods In 1981, 339 (40%) of the 856 individuals in the cohort underwent an eye examination. This screened group was re-examined at seven-year intervals until 2002. At each visit the presence of PEX was registered, IOP was measured and the presence of glaucoma was assessed. After the 21-year follow-up period, glaucoma cases were also searched for in the medical records of the remaining unscreened individuals in the cohort. Proportions of glaucoma were compared between the two groups. Results The prevalence of PEX was 23% (95% confidence interval (CI): 20-26%) at the age of 66 and increased to 61% (CI: 50-71%) at the age of 87. The annual incidence of PEX was 1.8% (CI: 1.3-2.4%). The prevalence of OAG increased from 2.1% (CI: 0.8-4.3%) at the age of 66 years to 25 % (CI: 16-35%) at 87 years. The overall annual incidence of OAG was 0.9% (CI: 0.6-1.3%) and for OAG with PEX 2.1% (CI: 1.2-3.3%). PEX increased the risk of developing glaucoma at least four-fold. The incidence of diagnosed OAG in women was higher in the screened group than in the unscreened group (incidence rate ratio (IRR)=1.94, p=0.035). A corresponding difference could not be verified for men (p=0.58). The mean, agedependent, increase in IOP during the 21-year observation period was 0.05 mmHg/year. Conclusion The prevalence of PEX in this study population was the highest reported, and it increased with age. The presence of PEX increased the risk of developing OAG four times. In this study a higher proportion of OAG was revealed by screening among women but not among men. The age-related IOP increase was clinically insignificant.

Les progrès thérapeutiques réguliers ont transformé le pronostic des enfants atteints de leucémie aiguë, posant avec une grande acuité le problème des effets secondaires tardifs, de l'insertion sociale mais aussi de la qualité de vie des patients et de leur entourage, ainsi que des déterminants mis en jeu. L'ensemble des acteurs du système de soins ont la responsabilité de l'étude de ces effets secondaires tardifs et de leur prise en compte. En 2004, le projet LEA (Leucémie de l'Enfant et de l'Adolescent) a débuté avec pour objectif d'évaluer l'état de santé et la qualité de vie à moyen et long terme de patients traités pour une leucémie aiguë de l'enfance après 1980. La volonté était de mettre en oeuvre un système pouvant produire de la connaissance dans une démarche de recherche traditionnelle, mais aussi de s'inscrire rapidement dans une démarche pragmatique de production d'informations susceptibles de modifier les pratiques de prise en charge et de suivi. L'objectif général de ce travail cherche à démontrer l'utilité de dispositifs lourds comme la mise en oeuvre d'une cohorte, dans la double logique de fournir une information d'une part directement utile à la décision clinique, et d'autre part susceptible d'éclairer la décision publique. Les travaux scientifiques s'articulent autour de : 1. La visibilité de la cohorte LEA au regard des autres dispositifs existants au niveau international ; 2. Les conséquences à distance des traitements lourds reçus par les patients ; 3. La qualité de vie de l'entourage à distance de l'épisode aigu de la maladie ; 4. L'utilité d'un suivi systématisé dans la diminution des inégalités d'accès au système de santé entre les classes sociales. / Regular advances in cancer treatment have dramatically improved the prognosis of children with acute leukemia, raising with a great acuity the problem of the late physical side effects, social integration, quality of life of the patients and their family as well as identification of the determinants of these outcomes. It is the responsibility of all the care system actors to consider these objective and subjective late effects. The LEA project (Leucémie de l'Enfant et de l'Adolescent - childhood and adolescent leukemia) was initiated in 2004 with the aim of studying the long-term health status and quality of life of children treated for leukemia after January 1980. As soon as the project began, the aim was to implement a system that can produce knowledge in a traditional research approach, but also to rapidly become a pragmatic approach of producing information that could affect both care and monitoring practices. The general objective of this manuscript seeks to demonstrate the utility of heavy plan such as the implementation of a cohort, in the double approach of providing information on the one hand directly relevant to clinical decision, and on the other hand likely to enlighten public decision. The present scientific works are based on: 1. The visibility of LEA in relation to other cohorts of childhood cancer survivors existing internationally; 2. The long-term impact of the heavy modalities of treatment, as the hematopoietic stem cell transplantation or irradiation; 3. The quality of life of the family long after the completion of cancer therapy; 4. The usefulness of a systematic follow-up in reducing inequalities in access to health care among social classes.

52 7.2 Souhrn v anglickém jazyce Malignant melanoma is the most lethal skin cancer whose incidence has been worldwide increasing. The prognosis of the disease is dependent on many factors - the effected locality, age, form of the tumor and the growth stage at which it was surgically removed. There has been no reliable adjuvant treatment available so far; although cytokins have been recently administered to high-risk patients. The accent is therefore put mainly on the timely detection and the relevant extent of surgical intervention whose degree depends on the stage of the disease. The result of the above mentioned facts is the necessity of an early diagnosis of new cases and permanent follow-up of the patients in whom melanoma has been already confirmed. The patients in the follow-up care are regularly checked, for the rest of their lives, at by the so called melanoma commissions, usually at dermatological clinics. The permanent contact with fact of the possible presence of the disease (information about the diagnosis, repeated follow-ups, waiting for the results of the examination) is stressful for these patients, although they become, to a certain extent, gradually adapted to stress. A good adaptation is however dependent also on the extent of social support, depression, the severity of the disease and...