The overall aim of the thesis was to study post-resuscitation care of cardiac arrest (CA) patients with a focus on therapeutic hypothermia treatment, outcomes up to six months post-CA and relatives’ experiences during the hospital stay. In Paper I, the aim was to asses effectiveness of hypothermia treatment with cold, 4°C, intravenous crystalloid infusion combined with ice packs. In conclusion, the described cooling method was found to be useful for inducing and maintaining hypothermia, allowed good temperature control during rewarming and to be feasible in clinical practice. The aim in Paper II was to investigate biomarkers and the association of serum glial fibrillary acidic protein (GFAP) levels with outcome, and to compare GFAP with neuron-specific enolas (NSE) and S100B. The result showed increased GFAP levels in the poor outcome group, but did not show sufficient sensitivity to predict neurological outcome. Both NSE and S100B were shown to be better predictors. A combination of the investigated biomarkers did not increase the ability to predict neurological outcome. In Paper III, the aim was to investigate whether there were any changes in and correlations between anxiety, depression and health-related quality of life (HRQoL) over time, between hospital discharge and one and six months post-CA. There was improvement over time in HRQoL, but changes over time in anxiety and depression were not found. Physical problems seemed to affect HRQoL more than psychological problems. The results also indicate that the less anxiety and depression patients perceive, the better their HRQoL. In the fourth paper, the aim was to describe relatives’ experiences during the next of kin’s hospital stay after surviving a CA. The analysis resulted in three themes: The first period of chaos, Feeling secure in a difficult situation, and Living in a changed existence. In conclusion, the results of the thesis have helped to improve knowledge within the areas studied and reveal aspects that should be taken into account in the overall treatment of this group of patients. The thesis have also shown the importance of developing an overall view and establishing a chain of care from an individual’s CA until follow-up for both the patient and his/her relatives.

Dyadic data analysis methods are underutilized in child and youth care, where much of the practice relies on relationships with individuals and groups. In this exploratory study, a dyadic data analysis approach was used to study the interdependence amongst client-counsellor dyads in a voluntary counselling setting. Ten counsellors and thirty-six clients from a Canadian voluntary counselling agency participated in this study. Counselling sessions ranged from two to 20 sessions. Clients completed a session rating scale, a measure of the therapeutic alliance. In addition, clients and counsellors completed an outcome rating scale and personal change questions. A one-with-many design was used to explore the similarity between client-counsellor dyads, the degree of consensus, assimilation, and uniqueness as well as the level of reciprocity for perceived client well-being. Multi-level modeling was used to partition the variance on the outcome rating scale to account for sources of non-independence in client-counsellor dyads, and the indirect relationships between multiple clients working with the same counsellor. Implications of the study and recommendations for future research are discussed. / Graduate

Faecal incontinence (FI) is defined as the inability to control bowel movements. The causes of FI are many and diverse. One of the more uncommon reasons for FI is Anorectal Malformations (ARMs). An ARM is a congenital anomaly that affects somewhere between 1/2500 and 1/5000 live born babies. Many ARM patients have persistent FI. Several different procedures have been utilised to address this issue. This thesis aims to evaluate (1) the long-term outcome in adulthood of ARMs in relation to the modern Krickenbeck classification, and (2) scope for treating FI with transanal injection with dextranomer in non-animal stabilised hyaluronic acid (NASHA/Dx), in patients both with and without ARMs. All patients treated for ARMs in Uppsala up to 1993 were invited to participate in a questionnaire study of quality of life and function. The study included 136 patients and compared them with 136 age- and sex-matched controls. The Krickenbeck classification was found to predict functional outcome, and ARM patients had more problems with incontinence and obstipation, as well as inferior Quality of Life (QoL), compared with controls.  Thirty-six patients with FI, owing to causes other than ARMs, were treated with transanal submucous injection of NASHA/Dx. The patients were monitored for two years after treatment. Significant reductions in both their incontinence score and the number of their incontinence episodes were achieved.  A significant improvement in QoL was observed in patients who had at least a 75% reduction in incontinence episodes. No serious complications occurred. A prospective study of transanal injection of NASHA/Dx was conducted on seven patients with persistent FI after ARMs. After six months a significant reduction in the number of incontinence episodes was obtained. A significant improvement in QoL was also found. No serious complications occurred. In conclusion, adult patients with ARMs have inferior outcome of anorectal function and QoL compared with controls. NASHA/Dx is effective and appears to be safe in treating FI in general. This effect seems to be the same in selected patients with persistent FI after ARMs.

This study investigated the relationships among attachment styles, affect regulation, and outcome in a clinical sample receiving treatment for depression. Sixty-six clients completed questionnaire measures of adult attachment, dysfunctional attitudes, interpersonal problems, self-esteem, and depression. Clients’ levels of affect regulation were assessed with an observer-rated measure of affect regulation. The study’s purpose was to extend previous research by examining the relationship between adult attachment and affect regulation within a clinical context. Results indicated significant and positive associations between clients’ attachment security and their levels of affect regulation at early and late stages of psychotherapy. Late modulation of expression and arousal were found to mediate the relationship between pre-treatment attachment insecurity and outcome. Pre-treatment attachment avoidance, characterized by high discomfort with closeness, had a direct relationship with depressive symptoms not mediated by the cognitive-affective processes of affect regulation. Implications of present findings for the treatment of depression are discussed.

Despite the evident advantages of assistive technologies, many are still abandoned within the first few months of use. The key to changing this may lie in the assessment process, which has been described as the most consequential phase in the provision of assistive technology [14]. The purpose of this research was to create a protocol for the assessment and delivery of individualized access technologies based on the concepts of response efficiency theory. The protocol was applied with three children, ages 12 to 14, who were seeking new access technologies. The results suggest that a protocol based on this theory will result in a technology that is appropriate to the user, and as a result will be less likely to be abandoned and will contribute to goal achievement and potentially improve participation.

Group psychotherapy is the most widely utilized treatment modality for convicted sex offenders, and the therapeutic alliance is considered a fundamental concept in virtually all applications of psychotherapy. However, empirical examination of how the therapeutic alliance impacts upon treatment effectiveness for sex offenders has been neglected. In a prospective design, a sample of 95 consecutive admissions to an inpatient treatment program for convicted adult male sex offenders was studied with regard to their experience of the therapeutic alliance with treatment staff, with their copatients, and with the overall treatment program. Patients of the Phoenix Program (Alberta Hospital Edmonton) rated their sense of alliance at monthly intervals. The therapists who worked with them (n = 21) also completed monthly evaluations of their own emotional responses toward these same patients. Pre- to post-treatment comparisons on personality tests, interpersonal distress, and interpersonal functioning showed a number of statistically significant changes consistent with treatment goals. Patients self-report over time in treatment showed a gradual, consistent increase of large effect size on all three alliance targets. Sex offenders in this sample were able to experience positive alliance with therapists and peers and the sense of alliance was shown to grow stronger over time. Staff ratings revealed that positive and negative affect increased as patients time in treatment increased. Significant associations between patient-rated alliance and outcome were found to be positive and in desired directions. The growth rate in alliance toward therapists was positively and significantly associated with the growth rate of conflict within oneself among female therapists. Male therapists also reported significant growth in conflict within oneself but this was independent of patient-rated alliance growth rates. Thus, female therapists experienced heightened affect in the face of greater patient alliance, while male therapists also experienced heightened affect but for reasons unrelated to patient alliance. There was virtually no reduction in negative affect toward patients despite moderate increases in positive affect toward patients. This study represents an important endorsement of a treatment model that seeks to improve general adjustment and ameliorate risk factors associated with recidivism, via positive changes in interpersonal relationships. / Psychiatry

This study examined the relationships between attachment style and the levels of self-criticism (comparative and introjective) and forms of dependency (neediness and connectedness) and the working alliance and outcome variables over the course of psychotherapy. Sixty-five adult clients receiving therapy at a mental health clinic completed questionnaires after the first, fifth, and second to last sessions. Strong positive correlations were found between neediness and insecure attachment and negative correlations between neediness and secure attachment. Similar, yet weaker relationships were found between connectedness and attachment. Comparative self-criticism was positively associated with preoccupied and fearful attachment and negatively associated with secure attachment. Similar, yet weaker relationships were found between introjective self-criticism and attachment. Connectedness was associated with a strong working alliance across therapy and comparative self-criticism with a poor working alliance at session five. Although neediness was associated with poor outcome, preoccupied attachment was the best predictor of poor therapeutic outcome. / Counselling Psychology

Objective: The aim of the study was to evaluate the clinical outcomes of oral implant treatment provided at the School of Dentistry, University of Otago from 1989 to 2005. Methods: Oral implant patients (n=320) with 586 implants were identified and invited to attend for a clinical examination. Implant demographics of all the patients were extracted from the files. Implant demographics of the examined and unexamined patients were compared to assess if the examined patients were representative of the total group. One hundred and three patients with 214 implants agreed to attend for an examination. In the clinical examination full mouth plaque scores, probing depths, bleeding on probing and suppuration were measured. In addition, around implants recession and width of keratinized gingiva were also recorded. For the radiographic examination, baseline radiographs and radiographs taken at the time of examination were digitized and compared to measure the amount of bone lost or gained around implants using NIH Image J software. Results: There were equal numbers of males and females with a mean age of 46.3 � 15 years at the time of implant placement. The smoking history at the time of examination was recorded, 56% of the patients were non-smokers, 37% former smokers, and 7% were current smokers. More than half of the implants (56%) were placed in the anterior region. Based on the type of implant system, 79% were Branemark implants, 10% Straumann, 6% Southern implants and 4% were unknown. Most of the patients (64%) had implant-supported crowns, 19% had fixed denture prostheses, and 17% had implant-supported overdentures. The overall implant survival rate was 97.7% with five implants lost (2.3%) and 8 implants treated for peri-implantitis (3.8%). The mean PD around implants was 2.3mm (SD 0.6mm), mean recession was 0.5mm (SD 0.8mm) and mean attachment level of 2.8mm (SD 0.9mm). Probing depths [greater than or equal to] 4mm with BOP were recorded around implants in 8.9% of patients. The mean full mouth plaque score was 30% while mean plaque score around implants was 15.9%. The average bone loss around implants was 0.3mm (SD 0.8). Maximum bone loss observed was 2.9 mm. Conclusion: The prevalence of peri-implant inflammation and implant survival rates in this group of patients appeared comparable to that reported in the literature. The prevalence of peri-implant lesions was low in the group of patients examined.

Perinatal asphyxia is a significant contributor to neonatal brain injury. In the clinical environment there is variability in the severity of neural injury in neonates with similar clinical histories. Whilst the duration and intensity of hypoxia is well known to influence the severity of neurological outcome, the global physiological responses to hypoxia may also affect the subsequent variability in neurological outcome. The first step in this project was to identify which physiological response/s during a constant global hypoxic-ischemic insult influence the severity of neurological outcome in the newborn piglet and to assess the relative importance of these responses. Hypoxia/hypercapnia was induced in anaesthetized piglets by reducing the fraction of inspired oxygen to 0.1 (10%) and the ventilation rate from 30-10 breaths per minute for 45 minutes. Neurological outcome was determined by using functional markers including aEEG amplitude and cerebral impedance, and the structural marker microtubule associated protein-2 immunohistochemistry at 6 hours post hypoxia. The results from the initial study indicated that there was significant variability in neurological outcome following a constant hypoxia/hypercapnia insult. Serum cortisol concentrations were highly variable at the end of hypoxia (mean ± SD; 240.7 ± 90.9 nmol/L) and associated with cardiovascular function (time heart rate below baseline; r = 0.69) and neurological outcome (r = 0.70). Cardiovascular function (time heart rate was below baseline) and neurological outcome were strongly associated (r = 0.77). In this study we observed an oscillating pattern in cardiovascular function during hypoxia in some animals. In the regression analysis variability in cortisol concentrations and cardiovascular function explained 68% of the variability in the severity of neurological outcome. Additional physiological factors did not improve the strength of the association with neurological outcome. The variability in the physiological responses, particularly cardiovascular and endocrine responses to hypoxia may be more important determinants of neurological outcome then previously recognised. Results from the initial study opened up several questions about the relationship between cortisol and cardiovascular function during hypoxia and the relationship to the subsequent neurological outcome. Since variability in cortisol concentrations was associated with both cardiovascular function and neurological outcome the second step of this thesis was to investigate what factors contributed to the variability in serum cortisol concentrations during hypoxia. It is important to understand why some individuals produce more cortisol than others, and as a result are protected against brain injury. The aim was to determine if the variability in serum cortisol concentrations was the result of variability in ACTH concentrations during acute global hypoxia. The results from this study showed that early changes in serum cortisol concentration (15 minutes) were not correlated with ACTH (R2 = 0.26, P = 0.1), however, later changes (30 – 45 minutes) were (R2 0.45 - 0.68). This suggests that the primary factor controlling serum cortisol concentrations before hypoxia and during later hypoxia is ACTH concentrations. These data suggest that other factors may control cortisol secretion during early hypoxia; a key mechanism responsible for these changes may be the activity of the sympathetic nervous system and the maturity of the adrenal medullae. Since, higher cortisol concentrations were associated with better cardiovascular function and neurological outcome. As a result of this observation the aim of this study was to determine if cortisol concentrations during hypoxia are the causative factor responsible for improved cardiovascular function and better neurological outcome. The results from this study showed that manipulating serum cortisol concentrations into high (<500nmol/l) and low (>50nmol/l) levels during hypoxia did not affect cardiovascular function (P = 0.68) or neurological outcome (P = 46). Within each group (low, high and control hypoxia group) there was significant variability in cardiovascular function during hypoxia, which was associated with neurological outcome. (r = -0.63, p = 0.01). This study showed that serum cortisol concentrations during hypoxia are not the causative factor impacting on improved cardiovascular function and neurological outcome. It is possible that factors affecting both cardiovascular function and cortisol production such as activity of the sympathetic nervous system, may be a possible mechanism behind the variability in neurological outcome and cardiovascular function. Additionally, this study showed that cortisol concentrations at 3 hours post hypoxia were associated with neurological outcome (r = -0.67, p = 0.01). The animals with poorer outcome may also be those with greater multi-organ damage and thus reduced ability to clear cortisol from the systemic circulation. In light of this finding it may be interesting to assess cortisol concentration in the human neonate at 3 hours post hypoxia and determine the relationship to neurological outcome. In the final study of this thesis the function of the cardiovascular system during hypoxia was investigated in more detail because of its strong association with neurological outcome (results observed in Chapter 2 and 4. Few researchers have reported on oscillations in cardiovascular function, particularly type-3 waves, during hypoxia in the neonate. The aim of this study was to determine the characteristics and occurrence of type-3 waves in the neonatal piglet and their relationship to neurological outcome following acute global hypoxia. The result showed that the development of type-3 waves in cardiovascular function occurred in 56% of animals. An oscillating pattern was significantly associated with better neurological outcome (p = 0.01) and a lower duration of hypotension during hypoxia (p = 0.02), and occurred more frequently in females (p = 0.024). The development of type-3 waves during acute global hypoxia is a key mechanism in promoting natural tolerance; and may be the result of greater activity, maturity or sensitivity of the sympathetic nervous system in females compared to males. This may explain the improved neurological outcome following hypoxia in the female neonate seen in the clinical setting.

Perinatal asphyxia is a significant contributor to neonatal brain injury. In the clinical environment there is variability in the severity of neural injury in neonates with similar clinical histories. Whilst the duration and intensity of hypoxia is well known to influence the severity of neurological outcome, the global physiological responses to hypoxia may also affect the subsequent variability in neurological outcome. The first step in this project was to identify which physiological response/s during a constant global hypoxic-ischemic insult influence the severity of neurological outcome in the newborn piglet and to assess the relative importance of these responses. Hypoxia/hypercapnia was induced in anaesthetized piglets by reducing the fraction of inspired oxygen to 0.1 (10%) and the ventilation rate from 30-10 breaths per minute for 45 minutes. Neurological outcome was determined by using functional markers including aEEG amplitude and cerebral impedance, and the structural marker microtubule associated protein-2 immunohistochemistry at 6 hours post hypoxia. The results from the initial study indicated that there was significant variability in neurological outcome following a constant hypoxia/hypercapnia insult. Serum cortisol concentrations were highly variable at the end of hypoxia (mean ± SD; 240.7 ± 90.9 nmol/L) and associated with cardiovascular function (time heart rate below baseline; r = 0.69) and neurological outcome (r = 0.70). Cardiovascular function (time heart rate was below baseline) and neurological outcome were strongly associated (r = 0.77). In this study we observed an oscillating pattern in cardiovascular function during hypoxia in some animals. In the regression analysis variability in cortisol concentrations and cardiovascular function explained 68% of the variability in the severity of neurological outcome. Additional physiological factors did not improve the strength of the association with neurological outcome. The variability in the physiological responses, particularly cardiovascular and endocrine responses to hypoxia may be more important determinants of neurological outcome then previously recognised. Results from the initial study opened up several questions about the relationship between cortisol and cardiovascular function during hypoxia and the relationship to the subsequent neurological outcome. Since variability in cortisol concentrations was associated with both cardiovascular function and neurological outcome the second step of this thesis was to investigate what factors contributed to the variability in serum cortisol concentrations during hypoxia. It is important to understand why some individuals produce more cortisol than others, and as a result are protected against brain injury. The aim was to determine if the variability in serum cortisol concentrations was the result of variability in ACTH concentrations during acute global hypoxia. The results from this study showed that early changes in serum cortisol concentration (15 minutes) were not correlated with ACTH (R2 = 0.26, P = 0.1), however, later changes (30 – 45 minutes) were (R2 0.45 - 0.68). This suggests that the primary factor controlling serum cortisol concentrations before hypoxia and during later hypoxia is ACTH concentrations. These data suggest that other factors may control cortisol secretion during early hypoxia; a key mechanism responsible for these changes may be the activity of the sympathetic nervous system and the maturity of the adrenal medullae. Since, higher cortisol concentrations were associated with better cardiovascular function and neurological outcome. As a result of this observation the aim of this study was to determine if cortisol concentrations during hypoxia are the causative factor responsible for improved cardiovascular function and better neurological outcome. The results from this study showed that manipulating serum cortisol concentrations into high (<500nmol/l) and low (>50nmol/l) levels during hypoxia did not affect cardiovascular function (P = 0.68) or neurological outcome (P = 46). Within each group (low, high and control hypoxia group) there was significant variability in cardiovascular function during hypoxia, which was associated with neurological outcome. (r = -0.63, p = 0.01). This study showed that serum cortisol concentrations during hypoxia are not the causative factor impacting on improved cardiovascular function and neurological outcome. It is possible that factors affecting both cardiovascular function and cortisol production such as activity of the sympathetic nervous system, may be a possible mechanism behind the variability in neurological outcome and cardiovascular function. Additionally, this study showed that cortisol concentrations at 3 hours post hypoxia were associated with neurological outcome (r = -0.67, p = 0.01). The animals with poorer outcome may also be those with greater multi-organ damage and thus reduced ability to clear cortisol from the systemic circulation. In light of this finding it may be interesting to assess cortisol concentration in the human neonate at 3 hours post hypoxia and determine the relationship to neurological outcome. In the final study of this thesis the function of the cardiovascular system during hypoxia was investigated in more detail because of its strong association with neurological outcome (results observed in Chapter 2 and 4. Few researchers have reported on oscillations in cardiovascular function, particularly type-3 waves, during hypoxia in the neonate. The aim of this study was to determine the characteristics and occurrence of type-3 waves in the neonatal piglet and their relationship to neurological outcome following acute global hypoxia. The result showed that the development of type-3 waves in cardiovascular function occurred in 56% of animals. An oscillating pattern was significantly associated with better neurological outcome (p = 0.01) and a lower duration of hypotension during hypoxia (p = 0.02), and occurred more frequently in females (p = 0.024). The development of type-3 waves during acute global hypoxia is a key mechanism in promoting natural tolerance; and may be the result of greater activity, maturity or sensitivity of the sympathetic nervous system in females compared to males. This may explain the improved neurological outcome following hypoxia in the female neonate seen in the clinical setting.