<p>The endothelium plays an important part in blood flow regulation by producing the vasodilatory substance nitric oxide (NO). Various studies have shown that commonly accepted risk factors for coronary heart disease, such as hypertension, diabetes, hypercholesterolemia, smoking and mental stress impair endothelium-derived vasodilation by the NO-pathway. This thesis focuses on the effects of mental stress on the endothelium. Furthermore, the effects of epinephrine (E) and norepinephrine (NE) and blockades of adrenergic receptors were studied in the forearm in young healthy subjects.</p><p>Different blockades were given locally in the forearm, not affecting general hemodynamics. β-adrenoceptor blockade impaired endothelium-dependent vasodilation (EDV), while α-adrenoceptor blockade and neurogenic blockade caused a general vasodilation which was not endothelium dependent. Neuropeptide Y did not seem to influence blood flow in the resting forearm.</p><p>A short period of mental stress induced by an arithmetic task, impaired EDV in the forearm. This negative effect could be blocked by β-adrenergic, but not α-adrenergic receptor blockade.</p><p>Local infusions of E and NE in the human forearm induced vasodilation and vasoconstriction, respectively. As both EDV and endothelium-independent vasodilation were affected by both E and NE, the two catecholamines did not seem to affect vascular tone by an endothelium-specific mechanism.</p><p>Both cold pressure stress and mental stress induced impairments in flow-mediated vasodilation (FMD) when normalised for the degree of hyperemic blood flow.</p><p>These findings give us new insights in how mental stress and sympathetic activation affects the endothelium and how the negative effects can be prevented.</p>

<p>In this thesis, different aspects of the insulin resistance syndrome in relation to plasminogen activator inhibitor-1 (PAI-1) activity are investigated in a longitudinal population-based study. Participants were men investigated at ages 50 and 70 with follow-up data on mortality.</p><p>High PAI-1 activity was associated with low insulin sensitivity, high concentrations of serum triglycerides, high body mass index and high waist/hip ratio, independently of each other and of potential confounders. Low birth weight predicted high blood pressure, insulin resistance, truncal obesity and high PAI-1 activity but not the abdominal obesity or dyslipidaemia present in the insulin resistance syndrome. Increased physical activity level between 50 and 70 years of age, in the absence of active intervention, was associated with improved glucose, insulin, proinsulin and lipoprotein metabolism. Insulin and proinsulin seemed to be important factors that mediate much of the association between a sedentary lifestyle and increased risk of cardiovascular disease. The reported dietary intake of both mono- and polyunsaturated fatty acids was positively associated with PAI-1 activity, whereas saturated fatty acid intake displayed no association. The associations present between PAI-1 activity and the fatty acid proportions in serum cholesterol esters were partly influenced by factors related with the insulin resistance syndrome.</p><p>This thesis provides further knowledge to the epidemiological view of the interrelations of the insulin resistance syndrome, PAI-1, birth weight, and lifestyle factors as physical activity and dietary habits. PAI-1 is a part of the insulin resistance syndrome and is associated both with modifiable and non-modifiable factors related with this syndrome.</p>

<p>Vitamin A and metabolites (retinoids) are crucial for normal epidermal maturation. Physiological effects are mediated by retinoic acid (RA) that activates nuclear retinoic acid receptors (RARs) in complexes with retinoid X receptors (RXRs), resulting in altered gene transcription.</p><p>Psoriasis is a common disease with unknown etiology. Lesions display inflammation, hyperproliferation, and disturbed epidermal maturation. Treatments include topical or oral synthetic retinoids that allegedly bind to and activate the RARs.</p><p>The mRNA expression of retinoid receptors RARα/γ and RXRα was studied in normal and psoriatic skin samples. RARα and RXRα were significantly reduced in psoriatic plaques as compared to non-lesional and normal skin. <i>In situ</i> immunofluorescence detection revealed altered distribution patterns of the receptor proteins in lesional skin. All three receptor proteins were more intensely detected in the lower half of the epidermis but were significantly reduced in the superficial epidermis compared to both normal and non-lesional skin. </p><p>In order to evaluate the retinoid signaling system in psoriatic lesions, we compared the effect of topical RA on the expression of the cellular RA-binding protein II (CRABPII) in psoriatic and normal skin. CRABPII was induced by RA on mRNA and protein level in non-lesional and normal skin but not in lesional skin, where the basal expression of CRABPII was already up-regulated.</p><p>Changes in retinoid signaling during keratinocyte differentiation <i>in vitro </i>were studied by measuring retinoid receptor and RAR-ligand levels<i>.</i> Exposure to differentiation-inducing levels of calcium, phorbol myristate acetate (PMA) or interferon-γ (IFNγ) led to increased RAR-ligand levels but PMA and IFNγ caused receptor protein loss due to increased proteasomal degradation. Since an increased IFNγ level is a hallmark of psoriatic inflammation, this might be a cause of altered retinoid signaling in lesional epidermis.</p><p><i>Conclusion:</i> Keratinocyte differentiation is accompanied by alterations in the retinoid signaling system. In psoriatic lesions, this system appears to be dysfunctioning due to reduced retinoid receptor levels, which might be an important event in the pathogenesis of the disease.</p>

<p>Urinary incontinence is a prevalent condition; nevertheless few women seek professional help. One aim of this study was to investigate all women aged 18-70 years in a Swedish community regarding (a) the prevalence rate and risk factors of urine leakage and (b) the quality of life for women with and without urine leakage, for women with stress incontinence versus urge incontinence, and for women with urine leakage who had or had not sought help. A second aim was to study all women aged 18-46 years from the same population four years later regarding (a) the quality of life and natural history of urine leakage, (b) why some women with persistent urine leakage seek help and others do not, and (c) how they deal with their urine leakage.</p><p>Every fourth woman aged 18-70 years was found to have urine leakage. The number of women with urine leakage increased with increasing age, the number of deliveries, the presence of urinary tract infection, and the use of oestrogen substitutions. Women with urine leakage had a lower quality of life in all eight dimensions of the SF-36 as compared with women without urine leakage. Furthermore, in women with urge incontinence the quality of life was lower compared with women with stress incontinence in all dimensions of the SF-36. Women with urine leakage who had sought help had lower quality of life in seven of eight SF-36 dimensions as compared with women with urine leakage who had not sought help.</p><p>At the four-year follow-up the quality of life had deteriorated in five of eight SF-36 dimensions in women aged 18-46 years with persistent urine leakage as compared with women with persistent continence. The mean annual incidence and remission rates of urine leakage were on the same low level (4%). Most women with slight or moderate long-term urine leakage had not sought professional help, largely because they considered their leakage a minor problem. Pelvic floor exercises was the most commonly used management method for all participants.</p>

<p>The overall aim of the present thesis was three-fold. The overall aim of the present thesis was three-fold. The first was to study occupational performance in individuals with severe mental disorders and their experiences of occupational therapy, the second to study experienced burden of family caregivers and the third to test the validity and the homogeneity of assessment tools in this area. The samples consisted of individuals with severe mental disorders participating in organised occupations (n= 112), occupational therapy records (n=64), occupational therapists working in mental health care (n=7) and family caregivers of individuals with severe mental disorders (n=256). Data were collected by questionnaires, structured and narrative interviews, observations and occupational therapy records. Individuals with severe mental disorders reported problems related to leisure and work activities and the occupational therapists recorded problems concerning how to organise and structure occupational performance. Individuals functioning on a high cognitive level experienced problems related to work and productive activities. Participation in occupational therapy strengthened their confidence in their own ability. The "Experience of Occupational Performance Questionnaire" (EOPQ) was developed from data on the experiences of women participating in occupational therapy. A principal component analysis gave seven factors with acceptable homogeneity. There is a need for assessment tools to evaluate occupational therapy. The EOPQ represents an attempt to fulfil this need. Family caregivers experienced limitations of daily activities as a burden. The ability to perform daily activities was studied from three perspectives, the individuals’, the occupational therapists’, and the experienced burden of the family caregivers. These perspectives are complementary and thus necessary for planning and implementation of individually adapted occupational therapy as well as for the evaluation of outcomes.</p>

<p>This study examined relationships between 24-hour ambulatory BP and components of the insulin resistance syndrome, and investigated the prognostic significance of 24-hour BP for cardiovascular morbidity in a longitudinal population-based study of 70-year-old men. The findings indicated, that a reduced nocturnal BP fall, nondipping, was a marker of increased risk primarily in subjects with diabetes. A low body mass index and a more favourable serum fatty acid composition at age 50 predicted the development of white-coat as opposed to sustained hypertension over 20 years. Furthermore, cross-sectionally determined hypertensive organ damage at age 70 was detected in sustained hypertensive but not in white-coat hypertensive subjects. In a prospective analysis, 24-hour ambulatory pulse pressure and systolic BP variability at age 70 were strong predictors of subsequent cardiovascular morbidity, independently of office BP and other established risk factors. Isolated ambulatory hypertension, defined as having a normal office BP but increased daytime ambulatory BP, was associated with a significantly increased incidence of cardiovascular events during follow-up. </p><p>Hypertension constitutes part of the insulin resistance syndrome, and is a common and powerful risk factor for cardiovascular disease in elderly. Blood pressure (BP) measured with 24-hour ambulatory monitoring gives however more detailed information and may be a better estimate of the true BP than conventional office BP. </p><p>In summary, these data provide further knowledge of 24-hour ambulatory BP and associated metabolic risk profile, and suggest that the prognostic value of 24-hour ambulatory BP is superior to conventional BP in an elderly population.</p>

<p>The purpose of this thesis was to study different aspects of nursing content in patient records with special reference to nursing home care. The thesis focused on the content, comprehensiveness, accuracy and auditing of records, as well as the practice and perceptions of nurses in relation to recording. A national sample of nurses was asked to complete a questionnaire. The effects on recording and nurses' practice and perceptions in nursing homes following educational intervention were studied. Accuracy was examined through record reviews and interviews with nurses and patients. A literature review of record auditing methods was performed and findings from this search were applied in the assessment of a set of records.</p><p> The results indicate that the VIPS model, as a structure for nursing recording, is widespread and shows validity across various areas in Swedish health care. After the educational intervention program, documentation in nursing home care improved significantly in the study group concerning notes on nursing history, nursing status, nursing diagnoses, interventions and discharge notes. Systematic and comprehensive assessment grounded in research-based criteria were not used in the records. Accuracy varied considerably and was significantly better for some areas in the study group. After intervention, the nurses in the study group indicated that they recorded assessments of patients with greater frequency, showed greater satisfaction with their documentation and spent less time on oral reports. Procedures in auditing patient records were found to encompass four approaches: formal structure, process comprehensiveness, knowledge based and accuracy. </p><p> In conclusion, the evidence suggests that there are serious flaws in the nursing content of nursing home records though improvements can be achieved through educational means. Presently, there are serious limitations in using the patient record as the sole source of data for care delivery, quality assessment and evaluation of care.</p>

<p>The overall aim was to study self-care, foot problems and self-perceived health in 150 consecutively invited Tanzanian diabetic patients and to compare them with gender- and age-matched Swedish diabetic patients (n=150) from a middle Sweden area. The main study was cross-sectional and took place at a diabetes clinic in Dar es Salaam. All patients answered questions about their self-care satisfaction, diabetes knowledge and skills, and educational needs. Foot examination also included questions about foot-care and perceived foot problems. The patients' health was assessed using the SF-36 general health questionnaire. The Swahili version of SF-36 was pre-tested in 518 Tanzanian diabetic patients showing an acceptable validity and reliability. Glycaemic control was measured by HbA1c. The results indicated that 45% of Tanzanians and 43% of the Swedes reported satisfaction with their self-care. The Tanzanian patients reported that following doctor's advice was the most important factor necessary for feeling well, whereas the Swedish patients emphasised diet and exercise. Lack of drugs and education were reasons of dissatisfaction in the Tanzanian group, whilst the Swedes were dissatisfied with their own behaviour. None of the Tanzanians monitored their blood glucose themselves, whilst 50% of the Swedes did it on a daily or weekly basis. Significantly more Swedes than Tanzanians knew the interaction between insulin, food and exercises, and how to manage hyperglycaemia and hypoglycemia. The Tanzanians wanted more education about diabetes, treatment and injection technique, whereas the Swedes wanted education about psychological aspects of diabetes, foot-care and oral anti-diabetic treatment. Foot problems reported in the Tanzanian group were pain, numbness and pricking sensations, whereas the Swedes reported ingrown toenails, pain and fissures. Seven Tanzanians and one Swede had foot ulcers. Twenty Tanzanians and 103 Swedes reported to inspect their own feet. The Tanzanians had significantly poorer self-perceived health and glycaemic control than the Swedish patients. A follow-up study was performed with the Tanzanian group of patients after two years. Many patients did not return for the second investigation and 70 patients were re-assessed. They showed an improved self-perceived health and a significant decrease in HbA1c-value. In conclusion the results indicated that Tanzanian patients needed better access to a continuous and regular supply of diabetes drugs. Furthermore the Tanzanians' burden of diabetes influenced their possibilities to work, whilst Swedish patients were hindered in social activities. In both countries the importance of regular foot inspections of the patients' feet should be emphasised. Glycaemic control and self-perceived health seemed to be poorly related and for that reason diabetes nurse specialists need to use both measures in order to guide the patients towards the goals experiencing a good health despite having diabetes.</p>

<p>The aim of the present thesis is to evaluate the effects of an Intensified Primary Health Care (IPHC) intervention on GPs' and home care nurses' possibilities to monitor and support cancer patients, and on cancer patients utilisation of medical services. A further aim is to identify determinants of cancer patients' utilisation of such services. A total of 485 patients newly diagnosed with breast, colorectal, gastric or prostate cancer were randomised to the intervention or to a control group. The follow-up period was 24 months for all patients.</p><p>Patients randomised to the IPHC were referred to the home care nurse. The home care nurse and the GP received copies of the medical record each time the patient was discharged from hospital after a period of in-patient care, or had visited a specialist out-patient clinic. In addition to this, recurrent education and supervision in cancer care were arranged.</p><p>The IPHC resulted in a marked increase of home care nurse follow-up contacts. The majority of control patients (74%) reported no such contacts, while 89% of IPHC patients reported this. High age (=80 yr) was the strongest predictor within the IPHC group for reporting a continuing home care nurse contact. Furthermore, the IPHC increased GPs' knowledge about patients' disease and treatments, and appeared to facilitate their possibilities to support the patients. The IPHC reduced the utilisation of specialist care among elderly cancer patients. The number of days of hospitalisation for older patients (=70 yr) randomised to the IPHC were 393 less than for older control patients during the 3 first months after inclusion. Regression analyses defined diagnosis, extensive treatment, comorbidity, low functional status, pain and socio-economic factors as predictors of a high utilisation of medical services.</p>

<p>The aims of the present thesis were to study: 1. reported eating attitudes, dieting behavior and body image over a 1-year period among preadolescent girls (age 7-8); 2. differences in eating attitudes and coping between groups of teenage girls differing in dieting frequency, and to assess changes with increasing age (age 13-17); and 3. to what extent eating attitudes, self-esteem and coping predict disturbed eating attitudes. A final aim was to explore differences in the reported wish to be thinner, dieting, and eating attitudes between two age-matched cohorts of girls in 1995 and 1999 (7-15 years).</p><p>The project is designed as a longitudinal prospective study, spanning seven years. 1300 girls in the ages (1995) 7, 9, 11, 13 and 15 years have been assessed annually for three consecutive years (1995-1997) (Main Cohort). An additional group matched for age with the original group was recruited in 1999 (Societal Cohort). The results suggest that dieting and the wish to be thinner starts as early as at 7 years of age, and that repeated dieting attempts correlate with disturbed eating attitudes. A marked increase of the wish to be thinner was evident in the 10- to 14-year age range, and significant increases in dieting attempts occurred mainly between ages 9 and 13. There were no differences between 1995 (Main Cohort) and 1999 (Societal Cohort) (except among 7 and 11-year-olds) with regard to dieting, the wish to be thinner and disturbed eating attitudes. Eating patterns and attitudes were shown to be the strongest predictors of disturbed eating attitudes three years later. Assessment of dieting, the wish to be thinner and eating attitudes is suggested BS a component in school health care.</p>