Background: From October 2010 through February 2016, Arizona conducted surveillance for severe acute respiratory infections (SARI) among adults hospitalized in the Arizona-Mexico border region. There are few accurate mortality estimates in SARI patients, particularly in adults >= 65 years old. The purpose of this study was to generate mortality estimates among SARI patients that include deaths occurring shortly after hospital discharge and identify risk factors for mortality. Methods: Patients admitted to two sentinel hospitals between 2010 and 2014 who met the SARI case definition were enrolled. Demographic data were used to link SARI patients to Arizona death certificates. Mortality within 30 days after the date of admission was calculated and risk factors were identified using logistic regression models. Results: Among 258 SARI patients, 47% were females, 51% were white, non-Hispanic and 39% were Hispanic. The median age was 63 years (range, 19 to 97 years) and 80% had one or more pre-existing health condition; 9% died in hospital. Mortality increased to 12% (30/258, 30% increase) when electronic vital records and a 30-day post-hospitalization time frame were used. Being age >= 65 years (OR = 4.0; 95% CI: 1.6-9.9) and having an intensive care unit admission (OR = 7.4; 95% CI: 3.0-17.9) were independently associated with mortality. Conclusion: The use of electronic vital records increased SARI-associated mortality estimates by 30%. These findings may help guide prevention and treatment measures, particularly in high-risk persons in this highly fluid border population.

Atualmente, há uma escassez de estudos que avaliem desfechos positivos. A relação existente entre a autopercepção positiva de saúde bucal e processos de enfrentamento relacionados com a resiliência, por exemplo, parece ainda não ter sido investigada. O objetivo deste trabalho foi avaliar a autopercepção positiva de saúde bucal e sua associação com um conjunto de variáveis, entre elas a resiliência, através de um modelo teórico conceitual, em idosos vivendo na comunidade, na região Sul do Brasil. Foram avaliados 498 indivíduos, através de um estudo transversal aninhado em um estudo de coorte. Os participantes responderam a um questionário sócio-demográfico, a Escala de Resiliência e passaram por um breve exame aonde os pesquisadores realizaram a contagem do número de dentes. Baseado em uma análise hierárquica realizada através de regressão de Poisson com variância robusta, as razões de prevalência estimadas das variáveis que ficaram significativamente associadas com o desfecho em estudo, após a análise totalmente ajustada, foram: 1) alto potencial de resiliência: RP= 0,83, 95% IC (0,75-0,93), 2) localização geográfica do domicílio na área rural: RP= 1,18, 95% IC (1,06-1,32), 3) renda: RP= 1,18, 95% IC (1,07-1,3) e 4) não necessidade de mudanças de dieta: RP= 1,34, 95% IC (1,13-1,6). Portanto, os resultados confirmam a hipótese de associação entre elevado potencial de resiliência e autopercepção positiva de saúde bucal. / Currently, there are a few studies that assess positive outcomes. The importance of coping strategies, lead by resilience, on positive perception of oral health has drawn little attention from oral health researchers. The objective of this study was to evaluate positive self-perceived oral health and its association with a set of variables, including resilience, using a theoretical framework, among independent-living older persons in Southern Brazil. We studied 498 persons in a cross-sectional study nested in a cohort study. The participants were evaluated using a structured questionnaire to assess socio-demographic data and resilience potential (Resilience Scale). Furthermore, a brief oral examination assessing the number of teeth was performed. A hierarchical analysis was carried out using Poisson regression with robust variance. A final, fully adjusted regression model showed that the following variables were associated with positive self-perceived oral health 1) elevated resilience potential: PR=0,83, 95% IC (0,75-0,93), 2) living in the rural area: PR=1,18, 95% IC (1,06-1,32), 3) income: PR=1,18, 95% IC (1,07-1,3), and 4) unchanged diet due to oral problems: RP= 1,34, 95% IC (1,13-1,6). Therefore, the results confirm the hypothesis of an association between elevated resilience potential and positive self-perceived oral health.

Abstract The aim of this study was to explore the prognosis and predictors of outcomes in DSM-III-R schizophrenic psychoses within the Northern Finland 1966 Birth Cohort (NFBC 1966, N = 12 017). Firstly, clinical and social outcomes were explored by using different definitions of good and poor outcomes, and early developmental, socio-demographic, illness-related and school-related predictors of outcome in schizophrenia (N = 59) were studied. Secondly, associations between early motor development and the course of illness in schizophrenia (N = 109) were explored. Thirdly, patterns of psychiatric hospitalisations in schizophrenic psychoses (N = 115) were studied. Fourthly, recovery in schizophrenia (N = 59) and other schizophrenia spectrum psychoses (N = 12) was assessed. As a result, good clinical outcome varied from 10% to 59%, and good social outcome 15–46%, depending on definition. Poor clinical outcome varied 41–77% and poor social outcome 37–54%. Lack of friends in childhood, father's high social class, lower school performance and earlier age of illness onset predicted poor outcomes. There were some associations between development and learning of basic skills at about age 1 and subsequent illness course. Those who learnt later (within normal limits) had mostly better outcomes, compared to early learners. A total of 81% of patients with schizophrenic psychoses were re-hospitalised during the follow-up and short first hospitalisation and family history of psychosis were linked to increased risk of re-hospitalisations. One (1.7%) schizophrenia subject and three (25%) subjects with other schizophrenia spectrum disorder recovered fully; one (1.7%) schizophrenia subject and two (16.7%) spectrum subjects experienced partial recovery after several years of follow-up. In this dissertation study outcomes and some predictors were analysed in a population-based sample of individuals with relatively young age and short duration of illness. In general, both clinical and social outcomes were heterogeneous and relatively poor, and the results were influenced by the definitions of outcomes. Persons having a sub-optimal developmental trajectory with family history of psychosis, poor social contacts, poor school performance, and early age of illness onset and those with short first hospitalisation seem to have the worst outcome. In addition, the neuromotor development of these individuals is complex and late development does not associate clearly with poor outcome of illness. The results of this study indicate that the outcome of schizophrenic psychoses is not good enough and that more effective treatments and rehabilitation for schizophrenia patients are needed. Also, there is a need for structured criteria for good and poor outcome and recovery in schizophrenia. / Tiivistelmä Tämän tutkimuksen tavoitteena oli tutkia DSM-III-R skitsofrenian ja muiden skitsofrenian kaltaisten psykoosien taudinkulkua ja ennustetta sekä niihin liittyviä tekijöitä Pohjois-Suomen vuoden 1966 syntymäkohortissa. Ensimmäiseksi tutkimuksessa selvitettiin skitsofrenian (N = 59) taudinkulkua ja sitä ennustavia sosio-demografisia ja kehitykseen, sairauteen ja koulumenestykseen liittyviä tekijöitä. Toiseksi, tutkittiin varhaislapsuuden kehityksen ja skitsofreenisten psykoosien (N = 109) taudinkulun välistä yhteyttä. Kolmanneksi, skitsofreenista psykoosia sairastavien henkilöiden (N = 115) psykiatrisia sairaalahoitoja ja niihin liittyviä tekijöitä tutkittiin. Neljänneksi tutkimuksessa selvitettiin skitsofreniasta (N = 59) ja muista skitsofreniaspektrin psykooseista (N = 12) toipumista. Tässä tutkimuksessa 10–59 % potilaista voi kliinisesti hyvin ja 15–46 % sosiaalisesti hyvin kun taas 41–77 % voi kliinisesti ja 37–54 % sosiaalisesti huonosti. Tulokset riippuivat paljolti siitä, mitä hyvän ja huonon taudinkulun kriteereitä käytettiin. Lapsuudessa ystävien puute, isän korkea sosiaaliluokka, huono koulumenestys ja taudin varhainen alkamisikä liittyivät huonoon taudinkulkuun. Aineistosta löydettiin yhteys (normaalirajoissa olevan) myöhäisemmän kehityksen ja hyvän taudinkulun välillä. Seurannassa 81 % potilaista joutui ensimmäisen sairaalahoidon jälkeen uudelleen sairaalaan. Lyhyt ensimmäinen sairaalahoito ja suvussa esiintyvä psykoosi liittyivät kohonneeseen riskiin joutua uudelleen sairaalaan. Skitsofreniapotilaista yksi (1.7 %) oli täysin ja yksi (1.7 %) osittain toipunut. Muista skitsofreniaspektrin potilaista kolme (25 %) oli täysin ja kaksi (16.7 %) osittain toipuneita usean vuoden seurannan jälkeen. Tässä tutkimuksessa selvitettiin skitsofrenian taudinkulkua ja analysoitiin taudinkulkuun vaikuttavia tekijöitä yleisväestöön pohjautuvassa aineistossa. Tulosten mukaan skitsofreniaa sairastavien henkilöiden sosiaalinen ja kliininen taudinkulku oli vaihteleva ja enimmäkseen suhteellisen huono. Tulokset riippuivat paljon siitä, millaisia hyvän ja huonon taudinkulun kriteereitä käytettiin. Henkilöillä, joilla on suvussa psykooseja, varhainen sairastumisikä, joilla on ollut huono koulumenestys ja vähäisiä sosiaalisia kontakteja lapsuudessa, ja joilla on ollut lyhyt ensimmäinen sairaalahoito, sairauden kulku on usein huono. Skitsofreniaa sairastavien henkilöiden viivästynyt varhainen motorinen kehitys ei ole yksiselitteisesti yhteydessä huonoon taudinkulkuun. Tämän tutkimuksen tulosten perusteella skitsofrenian ennuste ei ole yleensä hyvä. Yhteiskunnan tulisi entistä enemmän panostaa skitsofreniapotilaiden kokonaisvaltaiseen hoitoon ja kuntouttamiseen. Aiemman kirjallisuuden ja tämän tutkimuksen tulosten perusteella on myös selkeä tarve yhdenmukaisille ja strukturoiduille hyvän ja huonon ennusteen ja toipumisen kriteereille skitsofreniassa.

The increasing use of the Internet over recent years has forced governments and individuals to utilise Information & Communication Technology (ICT) in the form of electronic government (e-government), more specifically Public Sector Online Services (PSOS) as a subset of egovernment. However, the success of PSOS delivery is dependent on usage and on the growing concerns about the perceived information and service quality of PSOS and their influence on self-efficacy, satisfaction and personal outcome expectation towards ‘continuance intention’ to use the PSOS systems. Retaining current PSOS users is crucial to ensure better utilisation of ICT investments through a regulated process that considers citizens’ personal factors while using PSOS. If the level of PSOS quality is low, citizens are likely to revert to using traditional systems, leaving the new ICT systems underutilised. Few studies have investigated the influences of information and service quality on personal factors, such as self-efficacy, personal outcome expectation and satisfaction, towards intention to continuing to use PSOS. To fill this gap, the present study develops a PSOS quality model by associating it with citizens’ self-efficacy, satisfaction, personal outcome expectation, social influence, prior experience, and continuance intention. Therefore, the purpose of this study is to investigate the salient factors influencing citizens’ intention in the context of PSOS use. A research model of eight constructs is developed by integrating Social Cognitive Theory (SCT), Expectation Confirmation Theory (ECT), the DeLone and McLean IS success model, and E-S-QUAL. To validate the model, a quantitative-positivist approach methodology is used as the research paradigm; it employs a cross-sectional survey design as well as componentbased structural equation modelling (SEM) by using Analysis of Moment Structures (AMOS) as the data analysis technique. In total, 471 self-administrated questionnaires were found usable for data analysis and 17 hypotheses were formulated and tested. Overall, the modelling demonstrates a good fit with the observed data. The findings show that prior experience, social influence, information quality and services quality are significant predictors of citizens’ intention to use PSOS if these latent constructs are regulated through selfefficacy. The results exhibit positive relationships with the other constructs in the model except social influence and information quality towards personal outcome expectation and satisfaction. Further, the results show that service quality is the most influential variable in the present model. This highlights the vital role of service quality while delivering PSOS. Theoretically, the present study extends the roles of pre-adoption and post-adoption by offering a self-regulating process through self-efficacy as a physical ability. Further, the study reveals the importance of personal outcome expectation (internal stimuli) as well as satisfaction (external stimuli) as cognitive factors that represent personal goal assessments. Practically, the current study offers managers a mechanism in how to deal with end-users on a continuance basis while delivering online service through short- and long-term strategies. In summary, the present study marks a significant contribution in better understanding the utilisation of egovernment systems and can serve to better self-regulate outcomes for both citizens and government. Keywords: electronic service, e-service, electronic government, eGovernment, e-government, service quality, information quality, social influence, self-efficacy, personal outcome expectation, satisfaction, continuance intention.

The aims of this DNP project were to evaluate the use of skin cancer preventive behaviors among Hispanic adults within a rural Southwestern Arizona community and to identify the role of self-efficacy expectations and outcome expectations associated with use of skin cancer preventive behaviors within this population. A 42-question survey addressing demographics, skin cancer risk factors, use of skin cancer preventative behaviors, self-efficacy and outcome expectations was developed. The survey was distributed in two primary care clinics in San Luis, Arizona. This survey study included a sample size of 153 Hispanic adults over the age of 18 years old. Findings of this study suggest moderate use of UVR protective behaviors, and minimal use of both CSE and SSE. Use of UVR protective behaviors were associated with skin examination self-efficacy and UVR protection self-efficacy. Results from this project can be used as preliminary data for a prospective intervention study to improve and maintain skin cancer preventive behaviors in Hispanics living in the Southwestern Arizona border area as well as along the entire U.S. –Mexico border. Abbreviations: Advanced Practice Nurse (APN), American Cancer Society (ACS), Clinical Skin Examination (CSE), Doctor of Nursing Practice (DNP), Institutional Board Review (IRB), Nonmelanoma Skin Cancer (NMSC), Primary Investigator (PI), Self-skin examination (SSE), Statistical Package for the Social Science (SPSS), Ultraviolet Radiation (UVR)

Abstract Hip fracture is a trauma with serious consequences, especially in the elderly. Etiological factors should be known better than nowadays to recognize the individuals at high risk. Also, the treatment of displaced femoral neck fractures has been controversial, and the factors leading to a functional outcome are not known well. The true impact of deep infection on the outcome after hip fracture surgery has also been insufficiently examined. The thesis is based on two etiological studies. In the first study, the geometrical parameters of the upper femur and pelvis in postmenopausal women with hip fracture were (n=70) compared to age-adjusted controls (n=40). Measurements were made from position-standardized and calibrated pelvic plain x-rays. The differences between the two different types of hip fracture, femoral neck fractures (n=46) and trochanteric fractures (n=24) were also defined. High femoral neck/shaft angle (NSA), thin femoral cortices, low femoral shaft diameter (FSD) and trochanter width and the pelvic dimensions associate strongly with the hip fracture risk in postmenopausal women. Greater NSA, smallest outer pelvic diameter and acetabular width, narrower FSD and smaller femoral neck/shaft cortex ratio were associated with femoral neck fracture rather than trochanteric fracture in postmenopausal women. In the second study, lifetime factors, some bone metabolism markers and bone mineral density were analyzed from postmenopausal women (n=74; 49 with femoral neck fracture, 25 with trochanteric fracture) and age-adjusted controls (n=40). Impaired functional ability, use of loop diuretics, antidiabetic, antidepressant and neuroleptic drugs, some concurrent diseases, such as stroke, diabetes, malignancy, cardiovascular diseases, low bone mineral density of the upper femur, low serum calcium, low serum 25-hydroxyvitamin D and high serum calcitonin, seem to be related to the risk of hip fracture, while low bone mineral density and low serum calcitonin are related to the trochanteric type of fracture in postmenopausal women. The treatment of displaced femoral fractures included two prospective case-control studies, and the first of these involved a comparison (357 matched pairs) of patients with osteosynthesis (OS) with two pins in Lund and patients with uncemented hemiarthroplasty (HA) in Oulu. The patients treated with OS had 4 months after fracture better ambulatory capacity, used walking aids less often and had less pain than the patients treated with HA. The other comparison (84 matched pairs) was made between OS with three screws and uncemented HA, and it revealed no significant differences between HA and OS in the short-term functional outcome. Both studies revealed a higher re-operation rate in OS patients than uncemented HA patients. The case-control study with 29 matched pairs showed that deep infection after a hip fracture operation impairs the short-term functional outcome and slightly increases mortality, with an attributable mortality rate of 10 %. In conclusion, this thesis suggests that the geometry of the upper femur and pelvis, the aforesaid lifetime factors, the aforesaid metabolism markers and bone mineral density are associated with the etiopathology and type of hip fracture in postmenopausal women. The short-term functional outcome was better in OS patients treated with two pins compared to uncemented HA, but the higher re-operation rate should be considered among the OS patients. Deep infection is a serious complication of hip fracture surgery, which impairs function and increases mortality.

Aim: To study patient-related functional outcome measures, implant survival and radiographic loosening after total wrist arthroplasty (TWA) using four different implants. To evaluate a new TWA design biomechanically and clinically. Methods: The studies included two cohort studies with prospectively collected data (n=206 and n=219), an anatomic and kinematic analysis in a cadaveric model and a pilot study (n=20). Results: The Maestro TWA had a significantly greater improvement of radial/ulnar deviation than the Biax and Remotion TWAs. Summarized patientrelated functional outcome was significantly better for the Maestro than for the Remotion TWA. Cumulative implant survival after 8 years was 94% for Remotion, and 95% for Maestro implants. Radiographic loosening five years postoperatively was present in 26% of the Biax wrists, 18% of those with Remotion, and 2% of those with Maestro. Following TWA with the new implant design in a cadaveric model, there were no statistically significant changes compared to a native wrist regarding flexion, extension, radial deviation, the extension/radial deviation component of the dart-thrower’s motion, or the circumduction range of motion. Clinically, there was significant improvement of COPM, PRWE and VAS pain scores. Wrist extension and ulnar deviation improved, while grip strength remained largely unchanged. Conclusions: TWA is a surgical procedure which may offer a high level of patient satisfaction. Implant design may affect patient-related functional outcome after TWA. Implant survival as well as the frequency of radiographic loosening differed considerably between the four types of implants and might be a result of different implant design. Kinematic analysis of the new TWA design suggests that a stable and functional wrist is achievable with this design. Surgical placement of the new total wrist implant was reproducible and the implant yielded good patient-related outcome measures in the short term. Since TWA is an evolving procedure, further studies are warranted in order to refine indications and the place for TWA in modern hand surgery.

Abstract Primary intracerebral hemorrhage (ICH) comprises 10–15% of all strokes. Arterial hypertension and warfarin use are well documented risk factors for ICH, but aspirin use also seems to predispose to ICH. The annual incidence of primary ICH in western populations is 12–31 / 100,000. Mortality is high: 14–52% during the first month and 14–80% during the first year after ICH. The size and location of the hemorrhage, a midline shift in head computed tomography, intraventricular spread of the hemorrhage, level of consciousness on admission, and high blood glucose independently predict mortality. For a risk factor study, 98 consecutive patients admitted into the Department of Neurology, Oulu University Hospital, because of ICH between January 1993 and September 1995 were compared with 206 control subjects drawn from a population register. Thromboxane and prostacyclin biosynthesis were measured from serial urine samples of 43 patients. For outcome studies, all subjects (n = 208) with incident ICH during the study period in the population of Northern Ostrobothnia, Finland, were identified. Untreated hypertension was the main modifiable risk factor for ICH. Use of aspirin appeared to be a significant risk factor for ICH in the subjects with a history of epistaxis. Enhanced thromboxane and prostacyclin biosynthesis were observed in the acute phase and 3 months after ICH. Regular use of aspirin preceding ICH doubled the 3-month mortality rate compared with nonusers of aspirin/warfarin. Aspirin use also associated with early hematoma growth. Patients with ICH showed increased long-term mortality up to 7 years after ICH compared to controls. No excess mortality was observed among those with good recovery at 3 months, but those who were severely disabled at 3 months after ICH showed marked excess mortality.

Abstract Systematic analyses of infections in critical illness are sparse and mostly restricted to specific infection categories. Thus, a prospective study was carried out in a medical-surgical ICU during 14 months on patients whose ICU stay was longer than 48 h. The prospectively gathered data included detailed patient history, infection survey, severity of illness scores (APACHE II, SOFA), resource use, short-term and long-term outcome and quality of life following hospital discharge. Altogether 335 patients were included, of whom 251 (74.9%) had an infection on admission; 59.3% had a community-acquired infection (CAI) and 40.7% a hospital-acquired infection (HAI), while 84 (25.1%) did not have any infection (NI). APACHE II scores and ICU or hospital mortality rates did not differ between the groups. The median hospital stay was longer in the HAI than in the CAI or NI groups. Eighty (23.9%) of the 335 patients developed an ICU-acquired infection (48 per 1000 patient days): ventilator-associated pneumonia (VAP) in 33.8% of the cases, central catheter-related (CRI) or primary bloodstream infections in 6.3% and urinary tract infections in 1.3%, while the corresponding device-related incidences per 1000 days were 18.8, 2.2 and 0.5, respectively. ICU-acquired infection was an independent risk factor for hospital mortality. It doubled the risk for hospital mortality in patients with an infection on admission and caused a threefold the risk in patients without an infection on admission and an almost fourfold increase in the use of nursing resources. Of the 272 hospital survivors, 83 (30.5%) died after discharge during the median follow-up of 17 weeks. Infection status on admission or during the ICU stay did not affect long-term mortality. ICU-acquired infection did not have an impact on patients' quality of life. The current general level of health compared to the status before ICU admission did not differ between the groups, either. Only 36% of those employed resumed their previous jobs. Three-fourths of patients had an infection on admission, while nearly one fourth acquired an ICU infection. The high VAP rate suggests a need for re-evaluation of preventive measures, whereas the low CRI indicates more successful prevention. ICU-acquired infection was a significant risk factor for hospital mortality, but did not affect patients' long-term survival or quality of life.

Abstract The purpose of the study was to analyze the angiographic and clinical results of endovascularly treated intracranial aneurysms in Oulu University Hospital, Finland. The study population consisted of 416 consecutive patients (467 aneurysms, 332 ruptured), who were referred for endovascular treatment of intracranial aneurysm(s) between December 1993 and July 2004. Technical failures were analyzed for an assesment of technical feasibility. Angiographic results were assessed using modified Raymond Classification. Clinical results were analyzed from patient files using the Glasgow Outcome Scale (GOS). Patient, aneurysm, and procedure related variables were tested with an intention to find the predictors of the angiographic and clinical outcome. The clinical effects on presenting symptoms were analyzed for a subgroup of patients with a symptomatic unruptured aneurysm (n = 30). The mean results on technical feasibility, complications, and angiographic results were separately assessed for three time periods (1993–1997, 1998–2000 and 2001–2004) to demonstrate potential significant changes in outcome. Endovascular treatment of saccular aneurysms was technically feasible in 91.4% of the treatments. Initially, 25.7% of the aneurysms were completely occluded, 57.9% had a neck remnant, and 16.3% remained incompletely occluded. In follow-up, the rates for complete occlusions, neck remnants and incomplete occlusions were 37.6%, 49.7% and 12.7%, respectively. Small aneurysm size predicted complete aneurysm occlusion, while a wide aneurysm neck and location in the posterior circulation predicted incomplete occlusion. In follow-up (mean 38.2 months), 78.1% of the patients with a ruptured aneurysm and 92.3% of the patients with an unruptured aneurysm had resumed independent life (GOS 4-5). The predictors of good outcome were young age, good preprocedural clinical condition, small amount of blood in CT scan, and uncomplicated procedure. Ten of the treated aneurysms involved intracranial bleeding in follow-up, and the annual risk for bleeding after endovascular treatment was 0.95% among the patients with ruptured aneurysms and 0.33% among those with unruptured aneurysms. The risk of bleeding was associated with larger aneurysm size and lower occlusion grade. In the subgroup of symptomatic unruptured aneurysms, 53.4% of the patients showed either resolution or improvement of the symptoms after treatment. The rates of procedural complications, morbidity, and mortality were 16.5%, 6.7%, and 1.7%, respectively. The risk for procedural complications was higher when the balloon remodeling technique was used and lower in retreatments. Technical feasibility (85.6%, 90.6%, and 95.7%, respectively) and the percentage of complete occlusions (initially 16.5%, 23.0%, and 32.9%, respectively) were significantly improved by increased experience, while no statistical difference was detected in the total procedural complication rates (15.4%, 15.7%, and 18.3%, respectively) or the combined procedural morbidity and mortality rates (8.0%, 8.3%, and 9.1%, respectively). All six dissecting aneurysms treated with parent artery occlusion or the stent remodeling technique resulted in complete occlusions. The present results confirmed endovascular treatment of intracranial aneurysms as a feasible, safe, and effective method in preventing further bleeding of aneurysms. Increased experience in a single center improved the feasibility of the treatment as well as the angiographic results.