Thesis (M. Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.

Das Metabolische Syndrom stellt eine Kombination verschiedener metabolischer Anomalien in einem Individuum dar. Starkes Übergewicht gilt als maßgebende Größe in der Genese des Syndroms, welches mit einem enormen Risiko für kardiovaskuläre Erkrankungen einhergeht. Um die stark steigende Prävalenz des Metabolischen Syndroms einzudämmen, sind dringend Konzepte für die Behandlung, vor allem jedoch für die Prävention von Übergewicht erforderlich. Einen wichtigen Beitrag leisten diesbezüglich Ballaststoffe in der Ernährung. Sie tragen auf unterschiedlichen Wegen zur Gewichtskontrolle bei und beeinflussen zudem verschiedene mit dem Metabolischen Syndrom assoziierte Blutparameter. Ebenso werden protektive Effekte von Polyphenolen, welche zur Gruppe der sekundären Pflanzenstoffe zählen, beschrieben. Diese wirken u. a. auf den Glukose- sowie den Insulinhaushalt und greifen darüber hinaus in die Regulation der Fettverbrennung sowie des Energieverbrauches ein. Die Kombination beider Substanzgruppen verspricht bedeutendes gesundheitsförderndes Potential; dieses wurde gegenwärtig jedoch kaum untersucht. Carobballaststoff ist ein polyphenolreicher und vorwiegend unlöslicher Extrakt der Frucht des Johannisbrotbaumes (Ceratonia siliqua L). Bislang publizierte Studien zur physiologischen Wirksamkeit dieses Ballaststoffpräparates weisen sowohl beim Tier als auch beim Menschen bemerkenswerte hypocholesterinämische Eigenschaften nach. Inwiefern sich der Verzehr des Carobballaststoffes ebenso auf die Entwicklung von Übergewicht sowie anderen Messgrößen des Metabolischen Syndroms auswirkt, ist allerdings nicht bekannt. Die Zielstellung der Promotionsarbeit bestand darin, die postprandialen Wirkungen des Carobballaststoffverzehrs mit Hilfe einer Humanstudie aufzuzeigen. In die randomisierten, einfach verblindeten Untersuchungen im cross-over-Design wurden 20 gesunde Erwachsene im Alter zwischen 22 und 62 Jahren eingeschlossen. Unter Verwendung variierender Begleitmahlzeiten wurden die postprandialen Effekte verschiedener Mengen des Carobballaststoffes untersucht. Hierbei standen die Veränderungen der Plasmakonzentrationen von Glukose, Triglyceriden (TG), totalem und acyliertem Ghrelin sowie der Serumkonzentrationen von Insulin und nicht-veresterten Fettsäuren (NEFA) im Mittelpunkt der Betrachtungen. Der Verzehr des Carobballaststoffes in Kombination mit 200 ml Wasser und 50 g Glukose erhöhte die postprandialen Glukose- und Insulinkonzentrationen gegenüber der Glukoselösung ohne Ballaststoffzusatz. In Kombination mit 400 ml einer Flüssigmahlzeit verzehrt, senkte Carobballaststoff die postprandialen TG-, NEFA- und Ghrelin- (acyliert) Antworten. Die Untersuchung des respiratorischen Quotienten nach Zusatz von Carobballaststoff zur Flüssigmahlzeit mittels indirekter Respirationskalorimetrie bekräftigte die bereits bekannten Effekte auf den Lipidmetabolismus und wies zudem eine Steigerung der Fettverwertung unter Verminderung der Glukoseoxidation nach. Wurde Carobballaststoff schließlich in Lebensmittel eingebracht, sanken nach dem Verzehr dieser Lebensmittel erneut die postprandialen Konzentrationen an TG und NEFA. Gleichzeitig erhöhten sich die Glukose-, Insulin- sowie Ghrelin- (acyliert) Antworten. Carobballaststoff löst in Abhängigkeit von der jeweils verzehrten Begleitmatrix unterschiedliche Effekte aus. Das Präparat weist beachtliche Wirkungen auf die Blutlipide sowie den Energieverbrauch auf, hat indes ungünstige Wirkungen auf die Blutglukose, sofern er in Kombination mit einer veränderten Nährstoffmatrix aufgenommen wird. Carobballaststoff besitzt starkes gesundheitsförderndes Potential; jedoch sind weitere Studien notwendig, um seine Wirkungen sowie deren Voraussetzungen besser zu verstehen. Ferner sollten Untersuchungen über einen längeren Zeitraum vorgenommen werden, um die langfristige Relevanz der gewonnenen Ergebnisse darzulegen. Danach stellt die Anreicherung spezieller Lebensmittel mit Carobballaststoff einen geeigneten Weg dar, um von den viel versprechenden protektiven Wirkungen des Präparates zu profitieren. / The metabolic syndrome is a clustering of metabolic abnormalities and cardiovascular risk factors that occur in one individual. Since many individuals suffering of the metabolic syndrome are overweight, dietary treatment should primarily focus on weight reduction and control to handle and, much more importantly, to prevent the genesis of the syndrome. Dietary fiber could play a role in the management of the metabolic syndrome through its ability to control body weight as well as several parameters associated to the syndrome. Beside this, dietary polyphenols have been shown to influence glucose and insulin metabolism. Furthermore, studies in mice and men showed that polyphenols might increase fat oxidation and energy expenditure. The combination of both, dietary fiber and polyphenols, may exert beneficial health effects, which are not known up to now. A polyphenol-rich insoluble dietary fiber preparation from carob pulp (Ceratonia siliqua L; carob fiber) showed significant hypocholesterolemic activity in different animal trails and two human studies indicating that carob fiber may have potent health effects. However, short term effects on parameters associated with the control of the metabolic syndrome are not known. Therefore, a study was conducted to investigate the postprandial effects of carob fiber in healthy humans using different background food matrices. The study was designed as a randomized single-blind cross-over study in 20 subjects, aged 22 to 62 years. During several examinations plasma glucose, triglycerides (TG), total and acylated ghrelin, cholecystokinin (CCK) and peptide YY (PYY) as well as serum insulin and non-esterified fatty acids (NEFA) were repeatedly assessed before and after ingestion of carob fiber in combination with different test meals. The study results showed that carob fiber, consumed within a glucose load, increased plasma glucose and serum insulin compared to control. Plasma PYY increased after consumption of carob-enriched glucose solution. In a second part of the study, postprandial changes were assessed before and after ingestion of an isocaloric standardized liquid meal with or without carob fiber. Carob fiber intake lowered acylated ghrelin, triglycerides, and NEFA compared to control meal. Postprandial energy expenditure was increased and RQ was reduced after liquid meal with carob fiber compared to control meal. Finally, effects of the consumption of carob fiber-enriched foods were investigated at the subsequent day. Enrichment of foods increased plasma glucose and acylated ghrelin responses. Plasma triglycerides and serum NEFA responses were lower after bread ingestion compared to control. These results indicate that the effects of polyphenol-rich carob fiber on different blood parameters depend on the meal composition. Carob fiber showed beneficial effects on blood lipids as well as energy homeostasis, but also a deteriorated glycemic control when administered within a different food matrix. Further studies are needed to clarify observed effects and the mechanisms behind. Additionally, present study shows only short-term effects of carob fiber consumption, which might be less pronounced after long-term consumption due to adaptation mechanisms. Thus, future studies should elucidate the relevance of observed effects in long-term.

A severe burn is a trauma fraught with stress and pain and may change the entire course of life. This thesis focuses on care utilisation, care experiences and patient satisfaction after a severe burn. The patients studied were treated at the Burn Unit at Uppsala University Hospital between 1980 and 2006. Burn-related health was examined using the Burn Specific Health Scale-Brief (BSHS-B), personality traits with the Swedish universities Scales of Personality (SSP), psychological symptoms using the Hospital Anxiety and Depression scale (HADS), symptoms of posttraumatic stress with the Impact of Event Scale-Revised (IES-R) and satisfaction with care using the Patient Satisfaction-Results and Quality (PS-RESKVA) questionnaire. Those utilising care years after injury reported poorer functioning on three of the BSHS-B subscales. Personality traits had a greater impact on care utilisation than injury severity. Social desirability was lower among care utilisers and was associated with burn-related health aspects. The participants reported a low level of negative care experiences, the most common of which was Powerlessness. Most patients were satisfied with care, more with quality of contact with the nursing staff, and less with treatment information. Multiple regressions showed that the BSHS-B Interpersonal relationships subscale was an independent variable related to all measured aspects of patient satisfaction. The highest adjusted R2 was 0.25. In a prospective assessment with multiple regression analyses, Age and Education, the personality traits of Stress susceptibility, Trait irritability, Detachment and Social desirability, in addition to the post-traumatic stress symptoms Intrusion and Hyperarousal, were predictors of satisfaction with care. The highest adjusted R2 was 0.19. The thesis has pointed out that interpersonal factors are related to care utilisation as well as satisfaction with care. However, satisfaction with care was only moderately associated with health and individual characteristics, which may imply that the care itself is of major importance.

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. 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. 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.

The aims of this thesis are threefold: (1) To investigate cancer patients’ satisfaction with and utilisation of an Individual Psychological Support (IPS) intervention. (2) To evaluate the effects of Individual Support (IS), comprising IPS combined with Intensified Primary Health Care and Nutritional Support, on psychological distress and quality of life during the first year after diagnosis. (3) To explore to what extent aspects of quality of life and emotional functioning one year after diagnosis can be predicted by medical, psychological and socio-demographic factors at diagnosis. The analyses are based on data from the Support-Care-Rehabilitation project, using a prospective randomised design to compare four conditions: (1) Individual Support (IS) starting at diagnosis, (2) Group Rehabilitation (GR) starting three months later, (3) a combination of IS and GR, and (4) Standard Care (SC). The study sample consisted of patients newly diagnosed with breast cancer, colorectal cancer, gastric cancer or prostate cancer. A total of 481 patients were randomised and followed for 24 months. The IPS was an individually tailored, problem-focused intervention based on psychosocial oncology and cognitive behaviour therapy. Half of the patients receiving IPS had more than 2 sessions. Patients reporting that they had problems to address received more IPS sessions and reported more benefits of the intervention. Receiving an extensive medical treatment, young age, and not having someone besides the family to rely on in times of difficulties increased the odds of receiving tree or more sessions of IPS. The IS had limited impact on psychological distress and quality of life in intention-to-treat analyses. Additional analyses with stratification for baseline anxiety and/or depression levels suggested that for IS patients with higher levels of anxiety and/or depression, these problems continued to diminish below those of Control patients during the first year after diagnosis. Linear regression models were used to explore, one year after diagnosis, quality of life aspects indicative of rehabilitation needs. High levels of baseline anxiety and / or depressive symptoms were associated with lower levels of Emotional Functioning, and high self-rated well-being was associated with higher levels of Emotional Functioning. Extensive medical treatment and presence of comorbid conditions during the year before diagnosis predicted a low Global Quality of Life, whereas self-rated wellbeing predicted a high Global Quality of Life. Advanced disease, one or more comorbid conditions and high age were found to be associated with lower levels of Physical Functioning. A high level of activities outside the home during the year before diagnosis and high self-rated wellbeing were predictive of a better Physical Functioning. In conclusion, a large proportion of cancer patients offered IPS in conjunction with diagnosis and primary treatments seized this opportunity to discuss their situation, and perceived the experience as beneficial. Thus, offering newly diagnosed cancer patients these psychosocial support services may facilitate their situation.

It has been suggested that persons with intellectual disabilities (ID) manifest the full range of mental health problems. The main purpose of this thesis is to adapt and evaluate two clinical assessment instruments and to investigate the occurrence of mental health problems as well as psychiatric care utilisation in persons with ID. The psychometric properties of a Swedish version of the two instruments [Reiss Screen for Maladaptive Behaviour (RSMB) and the Psychopathology Inventory for Mentally Retarded Adults (PIMRA)] were investigated in a random, institutional and clinical sample of administratively defined (ADDEF) adults with ID (n = 199). The analyses suggest that the RSMB could be used as intended by staff as a primary screening device for the identification of mental health problems in persons with ID, and that the PIMRA had a potential to identify individuals with a specific mental disorder. The psychometric evaluation reveals that the Swedish versions of the RSMB and PIMRA measure a construct related to the diagnostic categories in the DSM-III-R and DSM-IV. This construct could be conceptualised as mental health problems. The RSMB and PIMRA results show that the overall occurrence of mental health problems in ADDEF samples of persons with ID (175 men and 148 women) ranged from 34 to 64%. The preliminary level of ID was mild (23%), moderate (39%) and severe (38%). The most common mental health problems were aggressive and self-injurious behaviours, depression, anxiety and adjustment disorders. In registered patients receiving out- or in-patient psychiatric care the occurrence of adults with an ICD-10 diagnosis of ID was approximately 1% (70 to 90% had a mild level of ID). In contrast to the high frequency of mental health problems reported, psychiatric care was used infrequently. This tendency is particularly evident in persons with moderate and severe ID.

This thesis deals with some challenges related to the mitigation of climate change and the overall aim is to present and assess different possibilities for the mitigation of climate change by: • Suggesting some measures with a potential to abate net greenhouse gas (GHG) emissions, • Discussing ideas for how decision-makers could tackle some of the encountered obstacles linked to these measures, and • Pointing at some problems with the current Kyoto framework and suggesting modifications of it. The quantification of the net CO2 effect from a specific project, frequently referred to as emissions accounting, is an important tool to evaluate projects and strategies for mitigating climate change. This thesis discusses different emissions accounting methods. It is concluded that no single method ought to be used for generalisation purposes, as many factors may affect the real outcome for different projects. The estimated outcome is extremely dependent on the method chosen and, thus, the suggested approach is to apply a broader perspective than the use of a particular method for strategic decisions. The risk of losing the integrity of the Kyoto Protocol when over-simplified emissions accounting methods are applied for the quantification of emission credits that can be obtained by a country with binding emissions targets for projects executed in a country without binding emission targets is also discussed. Driving forces and obstacles with regard to energy-related co-operations between industries and district heating companies have been studied since they may potentially reduce net GHG emissions. The main conclusion is that favourable techno-economic circumstances are not sufficient for the implementation of a co-operation; other factors like people with the true ambition to co-operate are also necessary. How oxy-fuel combustion for CO2 capture and storage (CCS) purposes may be much more efficiently utilised together with some industrial processes than with power production processes is also discussed. As cost efficiency is relevant for the Kyoto framework, this thesis suggests that CCS performed on CO2 from biomass should be allowed to play on a level playing field with CCS from fossil sources, as the outcome for the atmosphere is independent of the origin of the CO2. / QC 20101015

Tidal currents and rivers are promising sources of renewable energy given that suitable turbines for kinetic energy conversion are developed. To be economically and technically feasible, a velocity distribution that can give a high degree of utilization (or capacity factor), while the ratio of maximum to rated velocity is low would be preferable. The rated velocity is defined as the velocity at which rated power is achieved. Despite many attempts to estimate the resource, however, reports on the possible degree of utilisation from tidal currents and rivers are scarce. In this paper the velocity distribution from a number of regulated rivers, unregulated rivers and tidal currents have been analysed regarding the degree of utilisation, the fraction of converted energy and the ratio of maximum to rated velocity. Two methods have been used for choosing the rated velocity; one aiming at a high fraction of converted energy and one aiming at a high degree of utilisation. Using the first method, with a rated velocity close to the maximum velocity, it is unlikely that the turbine will reach the cut-out velocity. This results in, on average, a degree of utilisation of 23% for regulated rivers, 19% for unregulated rivers and 17% for tidal currents while converting roughly 30-40% of the kinetic energy. Choosing a rated velocity closer to the mean velocity resulted in, on average, a degree of utilisation of 57% for regulated rivers, 52% for unregulated rivers and 45% for tidal currents. The ratio of maximum to rated velocity would still be no higher than 2.0 for regulated rivers, 1.2 for unregulated rivers and 1.6 for tidal currents. This implies that the velocity distribution of both rivers and tidal currents is promising for kinetic energy conversion. These results, however, do not include weather related effects or extreme velocities such as the 50-year velocity. A velocity factor is introduced to describe what degree of utilisation can be expected at a site. The velocity factor is defined as the ratio U-max/U-rate at the desired degree of utilisation, and serves as an early indicator of the suitability of a site.

Le système canadien de soins de santé coûte cher et il a besoin d’être amélioré afin de devenir plus performant. Cette amélioration du système de soins de santé passe par une recherche innovatrice, c’est-à-dire une recherche basée sur la collaboration entre les producteurs et les utilisateurs de cette recherche. Cette collaboration favorise l’utilisation de la recherche. De nombreuses études ont démontré qu'un facteur déterminant favorise l'utilisation de la recherche: les bonnes relations interpersonnelles entre chercheurs et utilisateurs à toutes les étapes de la recherche, partant de l’identification des priorités de recherche et de l'élaboration des questions de recherche, jusqu'à la mise en œuvre des résultats. Cette thèse offre des pistes pour comprendre les attitudes et les comportements qui favorisent les bonnes relations interpersonnelles entre chercheurs et utilisateurs, ce qui servira à mettre en place des processus de transfert de connaissances efficaces qui mèneront à l'utilisation de la recherche.

L'émergence des systèmes pair-à-pair et la possibilité de réaliser des calculs et d'échanger des données par des services web conduit à des systèmes d'intégration de données à large échelle où l'évaluation de requêtes et d'autres traitements complexes sont réalisés par composition de services. Un problème important dans ce type de systèmes est l'absence de connaissances globales. Il est difficile par exemple de choisir le meilleur pair pour le routage des requêtes, le meilleur service lors de la composition de services ou de décider parmi les données locales à un pair celles à rafraîchir, à mettre en cache, etc. La notion de choix implique celle de classement. Bien qu'il soit possible de comparer et classer des entités d'après leur contenu ou d'autres métadonnées associées, ces techniques sont généralement basées sur des descriptions homogènes et sémantiquement riches. Une alternative intéressante dans le contexte d'un système à large échelle est le classement basé sur les liens qui exploite les relations entre les différentes entités et permet de faire des choix fondés sur des informations globales. Cette thèse présente un nouveau modèle générique de classement de services fondé sur leurs liens de collaboration. Nous définissons une importance globale de service en exploitant des connaissances spécifiques sur sa contribution aux autres services à travers les appels reçus et les données échangées. L'importance peut être calculée efficacement par un algorithme asynchrone sans génération de messages supplémentaires. La notion de contribution est abstraite et nous avons étudié son instanciation dans le cadre de trois applications: (i) le classement de services basé sur les appels où la contribution reflète la sémantique des services ainsi que leur utilisation avec le temps; (ii) le classement de services par l'utilisation des données où la contribution des services est fondée sur l'utilisation de leurs données pendant l'évaluation des requêtes dans un entrepôt distribué; (iii) la définition des stratégies de cache distribuées qui sont basées sur la contribution d'une mise en cache des données à réduire la charge du système.