Background: An Implantable Cardioverter Defibrillator (ICD) is a technical device used in the treatment of ventricular arrhythmias. After the implantation of an ICD the entire life situation can be affected with psychological and social consequences for the patient and his/her next of kin. The healthcare professionals play a vital role in providing educational information, support, and technical follow-up of the device. During recent years more and more hospitals have introduced a more team based organisation where the physicians collaborate with specialised ICD nurses. Aim: The overall aim of the thesis was to explore how patients with an ICD experienced their life situation and howhealthcare professionals described their experiences of delivering care to ICD patients. Methods: The design was descriptive, combining both quantitative and qualitative approaches, and the data was collected from Sweden and the USA. The Uncertainty of Illness Scale (MUIS-C) and Quality of life Index (QLI) instruments were used to determine the level of uncertainty and satisfaction with life (I), in-depth interviews with a phenomenographic approach was used to describe how Swedish and US patients living with an ICD conceived their life situation (II, III) and how healthcare professionals’ experienced delivering care to patients with an ICD, (IV). Finally, to explore clinical aspects of ICD care in Sweden, the Delivery of ICD Questionnaire (DOIQ) was used to describe the healthcare professionals’ experiences and a content analysis was used to describe the written educational information material provided to patients (V). Results: There were no differences in uncertainty between pre and post ICD implantation either in Swedish or the US patients. Satisfaction with life was significantly higher among US patients compared to Swedish patients both before and after ICD implantation within the health-functioning, socio-economic and psychological-spiritual domains. The Swedish ICD patients experienced a significantly higher satisfaction with life within the socioeconomic domain after 3 months. (I). The patients felt safe in having an ICD implanted, but the conceptions varied from seeing the device as a life saver to being worried about what could happen. Gratitude at having an ICD varied from happiness at being alive to something that was alien and disturbed the patient. Being more or less dependent included how patient experienced feelings from well-being to grief. Having a network varied from having sufficient support to loneliness. Having a belief in the future ranged from having confidence to look forward to resignation. Gaining awareness described patients’ adaptation to living with an ICD and limitations due to the ICD (II). The patients also underwent a transition from becoming aware of the restriction in the life situation through a process of adaption and having trust in the ICD. This phase was followed by a reorientation phase where they adapted to their life situation and the patient and his/her family regained of their lives (III). The healthcare professionals strove to provide competent and individualised care and infuse confirmation to the patients in form of information, education and support. They gave the patients tools to handle their life situation, through existential support and mediating security (IV). Half of the hospitals had nurse-based clinic and others planned to introduce them. Three hospitals performed follow-up in the form of remote home monitoring. The nurse had specific ICD education from ICD companies and/or various university courses. In the educational information material the biophysical dimensions dominated while the emotional dimension was scarcely described, and the spiritual-existential was not referred to at all (V). Conclusions: This thesis offers a further contribution to the scholarly discussion about the relationship between technology and human existence and how to cope with this transition. Our studies revealed that the embodiment of the ICD reflects a merger of experiences about its presence and potential from both patients’ and healthcare professionals’ perspective. This research hopefully encourages healthcare professionals to carefully reflect on what it is like to live with an ICD and to consider practice improvement for the patients’ and the next of kin.

Η μελέτη εξετάζει την μετάδοση της βρουκέλλωσης από την πάσχουσα μητέρα στο έμβρυο, αναλύει τα κλινικά και εργαστηριακά ευρήματα στην παιδική βρουκέλλωση και τα επιδημιολογικά δεδομένα της νόσου στον Ν. Αχαΐας στην διάρκεια 15 ετών από το 1986 μέχρι το 2000. Η εργασία μας δείχνει ότι η νόσος μπορεί να μεταδοθεί διαπλακουντιακά από την πάσχουσα μητέρα στο έμβρυο. Έγινε αναδρομική ανάλυση κλινικών και εργαστηριακών ευρημάτων 52 παιδιών, που νοσηλεύθηκαν στην Παιδιατρική Κλινική του Πανεπιστημίου Πατρών για βρουκέλλωση. Στο 50% των καλλιεργειών αίματος απομονώθηκε B. abortus. Ο πυρετός, η αρθρίτιδα και η αρθραλγία ήταν τα πιο συχνά συμπτώματα. Τα μικρότερα σε ηλικία παιδιά είχαν πιο συχνά θετικές καλλιέργειες αίματος από τα μεγαλύτερα. Η μέση διάρκεια θεραπείας στα παιδιά ήταν 28 ημέρες και περιλάμβανε συνδυασμό φαρμάκων. Δεν υπήρχαν επιπλοκές, ενώ υποτροπή εμφάνισε μόνο ένα παιδί. Από τα 52 παιδιά επανεξετάσθηκαν 47, τουλάχιστον 6 μήνες μετά το πέρας της θεραπείας και ήσαν όλα υγιή. Η επίπτωση της βρουκέλλωσης στο Νομό Αχαΐας για την χρονική περίοδο 1986 έως 2000 ήταν συνολικά 7,3, στις αστικές περιοχές 3,1, στις ημιαστικές 68,0 και στις αγροτικές 9,9/100.000 κατοίκους. Η νόσος αποτελεί μείζον πρόβλημα υγείας σε συγκεκριμένες αγροτικές περιοχές (περιοχή Χαλανδρίτσας και Τριταίας, επίπτωση 28,9). Από τους 352 ασθενείς με βρουκέλλωση 96 ήταν παιδιά ηλικίας μικρότερης των 14 ετών. Η επίπτωση στα παιδιά υπολογίζεται σε 12,4 και είναι μεγαλύτερη από αυτή των ενηλίκων, που ήταν 6,3 (p< 0,001). Τα αγόρια προσβάλλονται πιο συχνά από τα κορίτσια, η διαφορά όμως δεν είναι στατιστικά σημαντική (επίπτωση 13,9 έναντι 10,9 p>0,1). Στους άνδρες η επίπτωση είναι στατιστικά σημαντικά μεγαλύτερη από τις γυναίκες (8,3 έναντι 4,3, p<0,001). Εξάρσεις της νόσου εμφανίζονται κατά την διάρκεια της άνοιξης. Δεν παρατηρήθηκε σημαντική μείωση της νόσου κατά την διάρκεια της μελέτης. Συμπερασματικά, η νόσος μπορεί να μεταδοθεί και διαπλακουντιακά από την μητέρα στο έμβρυο. Η βρουκέλλωση ήταν ήπια στα παιδιά, πιθανώς επειδή συχνά οφειλόταν σε B. abortus. Στο Νομό μας η νόσος προσβάλλει πιο συχνά παιδιά από ότι ενήλικες και αποτελεί μείζον πρόβλημα υγείας σε ορισμένες αγροτικές περιοχές και στις ημιαστικές περιοχές. / The purpose of this study was to examine the transplacentally transmission of brucellosis from the affected mother to the neonate, to evaluate the clinical and laboratory findings, the treatment modalities and the final outcomes in childhood brucellosis and to analyze the epidemiological data of the disease in Achaia for the years 1986 to 2000. Our findings demonstrate that brucellosis due to B. abortus can be also transplacentally transmitted from the affected mother to the neonate. Signs, symptoms, laboratory findings, treatment modalities and final outcomes were retrospectively analyzed in 52 children with brucellosis treated in the Department of Pediatrics. B. abortus was the main pathogen isolated in 50% of positive cultures. Fever and arthritis or arthralgia, were the main symptoms. Young children had statistically significantly more often positive blood cultures than older children. Treatment with a combination of antibiotics lasted for 28 days on average. There were no complications and relapses except one among the 52 children. Out of the 52 children 47 were reexamined for brucellosis at least 6 months after the end of treatment, and all of them were healthy. The incidence of brucellosis in the Prefecture of Achaia during the period 1986 to 2000 was in total 7.3, in urban regions 3.1, in suburban 68.0 and in rural 9.9/100.000 inhabitants. Brucellosis is an important problem in concrete rural regions of the Prefecture (Chalandritsa and Tritaia, incidence 28.9). Out of the 352 patients with brucellosis 96 (27.3%) were children. The incidence of brucellosis was statistically significantly higher in children than in adults (12.4 vs 6.3, p< 0.001) and in males than in females (8.3 vs 4.3, p< 0.001). Boys are also more often affected than girls, but the difference is not statistically significant (p>0.1). Exacerbations occurred during spring. The incidence of the disease did not change during the fifteen year-period. In conclusion, brucellosis can be also transmitted transplacentally from affected mother to neonate. The disease was mild among children probably because it was mainly due to B. abortus. In the Prefecture of Achaia brucellosis affect more often children than adults and is an important problem in the suburban regions as well as in some rural-areas.

A violência contra a criança constitui-se como um problema de saúde pública ao implicar simultaneamente fatores individuais, familiares e sociais. Estudos enfatizam prejuízos cognitivos na população de crianças vítimas de abuso sexual, principalmente quanto aos aspectos atencionais, memória e funções executivas. Esta pesquisa teve por objetivo estudar os fatores clínicos e de risco associados ao desempenho cognitivo de crianças vítimas de abuso sexual. A amostra do estudo foi composta por 50 crianças com idade entre sete e 12 anos, distribuídas em dois grupos, o de pesquisa (n = 25), crianças com histórico de abuso sexual (atendidas no Programa de Psiquiatria Forense e Psicologia Jurídica (NUFOR) do Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e o de controle (n = 25) composto por crianças, sem histórico de violência sexual, oriundas de Escolas Públicas de ensino infantil e fundamental da Rede Estadual de São Paulo. O método do trabalho foi composto por: questionário de avaliação do abuso sexual, com o objetivo de verificar os dados sociodemográficos, consequências clínicas relacionadas com sintomatologia do Transtorno de estresse pós-traumático e indicadores de risco. Para avaliação das funções cognitivas foram utilizados os seguintes instrumentos: Vocabulário, Dígitos, Cubos, Semelhanças [subtestes da Escala Wechsler de Inteligência para Crianças (WISC-III)], Teste Wisconsin de Classificação de Cartas (WCST), Selective Reminding Test (SRT), Trail Making, Teste de Fluência Verbal - Semântica (FAS) e Figura Complexa de Rey. Da avaliação do abuso sexual, identificamos a prevalência do abuso intrafamiliar, e a criança ainda ter um contato com o abusador, e por isso, destacamos a necessidade de melhora na eficácia de medidas de proteção dessas vítimas. Encontramos os seguintes aspectos clínicos: dificuldade para dormir, dificuldade de concentração, alterações comportamentais raiva/irritabilidade e alteração emocional medo. E constatamos uma influência clínica, a alteração emocional medo, que quando presente, o tempo de execução da prova Trail Making, principalmente na parte que avaliou a atenção alterada visual, aumentou de modo significativo, demonstrando a associação entre os aspectos clínicos e desempenho cognitivo, mais especificamente na esfera atencional. Destacamos, ainda, resultados significativamente inferiores do grupo de pesquisa, nas provas Trail Making, no aspecto perdas de set (flutuação atencional) no teste Wisconsin. Assim, os achados sugerem a possibilidade de um déficit atencional primário na referente população, que influencia no desempenho das demais funções cognitivas. Concluímos que o estudo contribuiu para a possibilidade do estabelecimento de um protocolo de avaliação de crianças vítimas de abuso sexual / Violence against children is constituted as a public health problem while simultaneously involve individual, family and social factors. Studies emphasize cognitive impairments in the population of children victims of sexual abuse, especially regarding the attention aspects, memory and executive functions. This research aimed to study the clinical and risk factors associated with cognitive performance of children victims of sexual abuse. The study sample consisted of 50 children aged between seven and 12 years, divided into two groups, the research (n = 25), children with a history of sexual abuse (seen at the Forensic Psychiatry Program and Legal Psychology (NUFOR) Institute of Psychiatry, Hospital Clinical, Faculty of Medicine, University of São Paulo and the control (n = 25) consisted of children with no history of sexual violence, coming from Public Schools kindergarten and elementary of the State of São Paulo. The method consisted of: assessment questionnaire of sexual abuse, in order to verify the sociodemographic, clinical consequences related to symptoms of posttraumatic stress disorder and risk indicators for assessing cognitive function were used the following instruments: Vocabulary, Digit, cubes, Similarities [subtests of the Wechsler Intelligence Scale for Children (WISC-III)], Test Wisconsin Card Sorting (WCST), Selective Reminding Test (SRT), Trail Making, Fluency Test Verbal Semantic (FAS) and the Rey Complex Figure. The evaluation of sexual abuse, identified the prevalence of intra-family abuse, and the child still have contact with the abuser, and therefore highlight the need for improvement in the effectiveness of protective measures these victims. We found the following clinical features: difficulty sleeping, difficulty concentrating, behavioral changes anger / irritability and emotional fear change. And we find a clinic influence, changing emotional fear, that when present, the execution time of the Trail Making test, mostly in evaluating the visual amended attention, increased significantly, demonstrating the association between clinical and cognitive performance, more specifically in attentional ball. We point, also, significantly lower results of the research group, the Trail Making tests in respect of losses set (attentional fluctuations) in the Wisconsin test. Thus, the findings suggest the possibility of a primary deficit in attentional regarding population, which influences the performance of the other cognitive functions. We conclude that the study contributed to the possibility of establishing an evaluation protocol of child victims of sexual abuse

A violência contra a criança constitui-se como um problema de saúde pública ao implicar simultaneamente fatores individuais, familiares e sociais. Estudos enfatizam prejuízos cognitivos na população de crianças vítimas de abuso sexual, principalmente quanto aos aspectos atencionais, memória e funções executivas. Esta pesquisa teve por objetivo estudar os fatores clínicos e de risco associados ao desempenho cognitivo de crianças vítimas de abuso sexual. A amostra do estudo foi composta por 50 crianças com idade entre sete e 12 anos, distribuídas em dois grupos, o de pesquisa (n = 25), crianças com histórico de abuso sexual (atendidas no Programa de Psiquiatria Forense e Psicologia Jurídica (NUFOR) do Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e o de controle (n = 25) composto por crianças, sem histórico de violência sexual, oriundas de Escolas Públicas de ensino infantil e fundamental da Rede Estadual de São Paulo. O método do trabalho foi composto por: questionário de avaliação do abuso sexual, com o objetivo de verificar os dados sociodemográficos, consequências clínicas relacionadas com sintomatologia do Transtorno de estresse pós-traumático e indicadores de risco. Para avaliação das funções cognitivas foram utilizados os seguintes instrumentos: Vocabulário, Dígitos, Cubos, Semelhanças [subtestes da Escala Wechsler de Inteligência para Crianças (WISC-III)], Teste Wisconsin de Classificação de Cartas (WCST), Selective Reminding Test (SRT), Trail Making, Teste de Fluência Verbal - Semântica (FAS) e Figura Complexa de Rey. Da avaliação do abuso sexual, identificamos a prevalência do abuso intrafamiliar, e a criança ainda ter um contato com o abusador, e por isso, destacamos a necessidade de melhora na eficácia de medidas de proteção dessas vítimas. Encontramos os seguintes aspectos clínicos: dificuldade para dormir, dificuldade de concentração, alterações comportamentais raiva/irritabilidade e alteração emocional medo. E constatamos uma influência clínica, a alteração emocional medo, que quando presente, o tempo de execução da prova Trail Making, principalmente na parte que avaliou a atenção alterada visual, aumentou de modo significativo, demonstrando a associação entre os aspectos clínicos e desempenho cognitivo, mais especificamente na esfera atencional. Destacamos, ainda, resultados significativamente inferiores do grupo de pesquisa, nas provas Trail Making, no aspecto perdas de set (flutuação atencional) no teste Wisconsin. Assim, os achados sugerem a possibilidade de um déficit atencional primário na referente população, que influencia no desempenho das demais funções cognitivas. Concluímos que o estudo contribuiu para a possibilidade do estabelecimento de um protocolo de avaliação de crianças vítimas de abuso sexual / Violence against children is constituted as a public health problem while simultaneously involve individual, family and social factors. Studies emphasize cognitive impairments in the population of children victims of sexual abuse, especially regarding the attention aspects, memory and executive functions. This research aimed to study the clinical and risk factors associated with cognitive performance of children victims of sexual abuse. The study sample consisted of 50 children aged between seven and 12 years, divided into two groups, the research (n = 25), children with a history of sexual abuse (seen at the Forensic Psychiatry Program and Legal Psychology (NUFOR) Institute of Psychiatry, Hospital Clinical, Faculty of Medicine, University of São Paulo and the control (n = 25) consisted of children with no history of sexual violence, coming from Public Schools kindergarten and elementary of the State of São Paulo. The method consisted of: assessment questionnaire of sexual abuse, in order to verify the sociodemographic, clinical consequences related to symptoms of posttraumatic stress disorder and risk indicators for assessing cognitive function were used the following instruments: Vocabulary, Digit, cubes, Similarities [subtests of the Wechsler Intelligence Scale for Children (WISC-III)], Test Wisconsin Card Sorting (WCST), Selective Reminding Test (SRT), Trail Making, Fluency Test Verbal Semantic (FAS) and the Rey Complex Figure. The evaluation of sexual abuse, identified the prevalence of intra-family abuse, and the child still have contact with the abuser, and therefore highlight the need for improvement in the effectiveness of protective measures these victims. We found the following clinical features: difficulty sleeping, difficulty concentrating, behavioral changes anger / irritability and emotional fear change. And we find a clinic influence, changing emotional fear, that when present, the execution time of the Trail Making test, mostly in evaluating the visual amended attention, increased significantly, demonstrating the association between clinical and cognitive performance, more specifically in attentional ball. We point, also, significantly lower results of the research group, the Trail Making tests in respect of losses set (attentional fluctuations) in the Wisconsin test. Thus, the findings suggest the possibility of a primary deficit in attentional regarding population, which influences the performance of the other cognitive functions. We conclude that the study contributed to the possibility of establishing an evaluation protocol of child victims of sexual abuse