Anxiety and depression are common in children and adolescents, and involve individual suffering, risk of future psychiatric problems, and high costs to society. However, only a limited number of children experiencing debilitating anxiety and depression are identified and receive professional help. One approach that could possibly reduce the prevalence of these conditions is universal school-based prevention aimed at reducing the impact of risk factors and strengthening protective factors involved in the development of anxiety and depression. The current thesis aimed to contribute to the literature on universal prevention of anxiety and depression in children. Study I involved a meta-analysis of earlier randomized, and cluster-randomized trials of universal prevention of anxiety and depression. Overall, the meta-analysis showed small but significant effects of universal preventive interventions, meaning that lower levels of anxiety and depression were evident after intervention completion and partially evident at follow-up assessments. No variables were found to significantly enhance the effects, however, there was a tendency for larger effects to be associated with mental health professionals delivering the interventions. In Study II, a widely adopted prevention program called Friends for Life was evaluated in a large school-based cluster-randomized effectiveness trial. The results showed no evidence of an intervention effect for the whole sample. However, children with elevated depressive symptoms at baseline and children with teachers who highly participated in supervision, seemed to benefit from the intervention in the short term. Study III involved a 3-year follow-up of Study II and an examination of the effects of sample attrition. The results showed no long-term effects for the whole sample and no maintenance of the short-term subgroup effects observed in Study II. Finally, to increase our understanding of the development of anxiety in children and to assist future improvements of universal prevention, Study IV evaluated different trajectories of overall anxiety together with related patterns of disorder-specific symptoms in a school-based sample over 39 months. Evidence favored a model of three different developmental trajectories across age. One trajectory was characterized by increasing levels of overall anxiety, but fluctuating disorder-specific symptoms arguably related to the normal challenges of children’s developmental level, which warrants an increased focus on age-relevant challenges in universal prevention. The four studies provide further understanding of the overall effectiveness of universal prevention of anxiety and depression in children, the short- and long-term effects of universal prevention in a Swedish context, and ideas for further development of preventive interventions.

<p><strong>BACKGROUND: </strong></p> <p>Emergency Department (ED) visit rates for patients with symptomatic, recent onset atrial fibrillation or atrial flutter (RAFF) are on the rise, which in turn has resulted in high hospital admission rates (38-45%). Optimal management strategies need to be developed for reducing hospital admission rates.</p> <p><strong>STUDY QUESTION:</strong></p> <p>The primary objective of this study is to evaluate the effectiveness of a clinical pathway for the management of low-risk RAFF patients in the ED. The hypothesis is that an evidence-based clinical pathway will help ED physicians better manage AF patients and reduce hospital admissions.</p> <p><strong>STUDY DESIGN:</strong></p> <p>A prospective, blinded, stratified, two-arm cluster-randomized trial will be conducted. The intervention is a clinical pathway for the management of RAFF.</p> <p><strong>PRIMARY AND SECONDARY OUTCOMES:</strong></p> <p>The primary outcome of this trial will be the proportion of low-risk, RAAF patients admitted to the hospital from the ED. Secondary outcomes will include a range of safety outcomes.</p> <p><strong>STATISTICAL CONSIDERATIONS:</strong></p> <p>An intention-to-treat analysis will be conducted at the individual level using proportions and means according to the variable in question with an alpha level of 0.05 and power of 0.80 for the primary outcome. The cRCT (assuming a 30% RRR) will be conducted over a two year time period. A total of 13 clusters and 3500 ED visits will be recruited to each intervention arm.</p> <p><strong>SUMMARY:</strong></p> <p>This thesis explores the methodological issues relevant to the design of a cRCT evaluating a clinical pathway in the management of acute onset, low risk AF patients presenting to the ED.</p> / Master of Science (MSc)

<p>Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is the most preventable cause of death in hospitalized patients. Due to its high mortality, morbidity, and cost, health care providers are obligated to not only effectively diagnose and treat VTE, but also to prevent it if possible. This has been reinforced by a number of national and international quality initiatives to prevent hospital-acquired VTE. Despite the existence of well-accepted clinical practice guidelines on VTE prophylaxis, 1 in 3 hospitalized medical patients receives an inappropriate VTE prophylaxis strategy. Both underuse of prophylaxis in patients with VTE risk, and overuse of prophylaxis in patients without VTE risk are problems. The use of inappropriate VTE prophylaxis strategies is likely due to the complexity and heterogeneity of hospitalized medical patients, and the difficulty of applying “one size fits all” practice guidelines to this group. Institution-wide knowledge translation strategies are required to close the gap between evidence and practice, and promote evidence-based VTE prophylaxis strategies in hospitalized medical patients. The objective of this thesis is to design a cluster randomized controlled trial to determine if a standardized electronic order set, with an embedded computerized decision support system and audit and feedback component, affects the use of appropriate VTE prophylaxis in hospitalized medical patients. The unit of randomization in this study is the hospital, which serves as the cluster. The unit of observation in this study is the individual patient. The primary outcome of this study is the proportion of in-hospital days during which appropriate VTE prophylaxis is administered, in intervention versus control hospitals. Secondary outcomes are the rates of hospital-acquired VTE, major bleeding and mortality, in intervention versus control hospitals. Design, analytic and ethical challenges unique to cluster randomized trials will also be discussed. Strategies to overcome them in this trial will be presented.</p> / Master of Science (MSc)