published_or_final_version / Mental Health / Master / Master of Social Sciences

Depression is a substantial psychopathology encountered in the dialysis population yet its association with potentially modifiable psychological antecedents are not well known. Of these potential antecedents, individual’s perception of their condition are likely to play an important role in how they adjust to their illness (Leventhal, Brissette, & Leventhal, 2003). The Common Sense Model suggests that illness representations guide the self-regulation of illness (Leventhal, Meyer, & Nerenz, 1980; Leventhal, Nerenz, & Steele, 1984). The model posits that the interpretation of illness (illness perceptions) influence the response and procedures adopted in order to regulate the illness threat. The overarching aim of the work here is to examine whether illness perceptions predict depression and its trajectory in End-Stage Renal Disease (ESRD) patients, and to establish if depression and illness perceptions are associated with adverse clinical outcomes in these patients. In order to achieve these aims it was first important to establish how best to assess depression and illness representations in the context of ESRD. A pilot study investigated whether the Beck Depression Inventory (BDI) and the Revised Illness Perception Questionnaire (IPQ-R) could be administered to haemodialysis patients (HD) while actively on dialysis. Patients completed the BDI and IPQ-R while on-dialysis and again at a time when off-dialysis (n=40). Level of agreement revealed no discernable difference between BDI and IPQ-R scores across the two conditions, although there was a slight bias with regards to scoring on somatic items of the BDI while on-dialysis. Given these data, on-dialysis assessments were employed in the studies reported. Furthermore the BDI was compared against a diagnostic standard for Major Depressive Disorder (MDD) in order to define an adjusted BDI cut-off score that would indicate potential depressive cases. The data revealed that a BDI≥16 had optimal sensitivity and specificity for MDD. This cut-off score was employed to define patients with “probable” depression. The factor structure of the BDI was the focus in the following chapter. BDI data from two larger studies (reported later in the thesis) were pooled in order to conduct confirmatory factor analysis, testing several proposed structures of the BDI. The analysis revealed that two and three factor solutions had relatively poor fit to the data. A relatively novel bi-factor model proposed by Ward (2006) had the best fit. In this model there is a general depression factor that loaded onto all of the 21 BDI items, and two smaller orthogonal cognitive and somatic factors. These factors collectively explained 91% of the total variance in BDI-II total scores, suggesting that the BDI provides a good overall measure of global depressive symptoms. The first study to examine the association between illness representations and depression was a cross-sectional study of established HD patients (n=215). Nearly 30% of the sample were depressed (BDI≥16), highlighting the extent of depressive symptoms in this patient group. Significant differences between depressed and non-depressed patients with regards to illness perceptions were evident. In logistic regression illness coherence, perceived consequences and treatment control perceptions predicted depression. Interestingly clinical variables including co-morbidity were unrelated to depression. This suggests that it is not disease severity or extra-renal co-morbidity per se that are vulnerabilities for depression, rather it is the interpretation of the disease that appears to be important. The proceeding chapter extended this cross-sectional investigation by examining the trajectory of depression (i.e. change in depression) over the first year of dialysis therapy in relation to illness representations. An incident cohort of dialysis patients (n=160) were seen at a point soon after dialysis initiation and followed up 6 and 12 months thereafter. In particular, differences between patients who start dialysis via planned route (i.e. those with progressive renal failure who had been “worked-up” to dialysis) vs. those who started dialysis suddenly (unplanned starters) were sought. Unplanned starters were more depressed than the planned patients and held different illness perceptions. Structural equation modelling of the baseline data revealed that illness perceptions predicted depression, and that path to dialysis had an indirect effect on depression as mediated through illness perceptions. Over time, depression and illness perceptions appeared to remain relatively stable although there was some evidence of a non-linear decline in depression scores over the follow-up period. In addition, illness identity decreased over time, while illness coherence (understanding) increased. Clinical and demographic factors were not associated with the trajectory of depression as assessed using Latent Growth Models. However several illness perceptions were associated with a change in depression over time, suggesting that patient’s illness representations assist in the regulation (or under-regulation) of mood. The first of two clinical oriented chapters examined the utility of illness representations in explaining fluid non-adherent behaviour. HD patients were categorised as either fluid adherent or non-adherent based upon Inter-dialytic Weight Gain (IDWG). Patients in the upper quartile of percent weight gain were defined as non-adherent (IDWG≥3.21% dry weight). The data revealed that non-adherent patients had lower timeline perceptions as compared to adherent patients. Logistic regression models were evaluated in order to identify predictors of fluid non-adherence. After several demographic and clinical variables had been controlled, lower consequence perceptions predicted non-adherence. This data points to the utility of understanding dialysis patient’s personal illness representations in relation to maladaptive health care behaviour. Finally, the potential association between depression, illness representations and short term survival in incident dialysis patients was evaluated. Patients were followed up for a mean of 545 (±271) days in which there were 27 deaths (16.9%). Patients were censored if they were lost to follow-up, transplanted or recovered renal function. In Cox survival models after controlling for several co-variates including co-morbidity, depression significantly predicted mortality. Furthermore, survival models including illness perceptions revealed that treatment control perceptions were also predictive of mortality. These results suggest that depression and beliefs surrounding treatment control contribute to the survival of dialysis patients. Possible explanations regarding these associations are presented. In conclusion the empirical investigations offered here support the thesis that illness perceptions predict depression in dialysis patients. Moreover there is evidence that illness representations are associated with maladaptive health behaviour (non-adherence) in dialysis patients. Depression and illness representations also predict short-term survival in incident patients after adjusting for important co-variates. Recent studies have shown that altering maladaptive illness perceptions via psychological intervention can have a positive influence upon outcomes (Petrie, Cameron, Ellis, Buick, & Weinman, 2002). Given the evidence presented in this thesis, testing interventions that target maladaptive illness representations in order to improve clinical and psychological outcomes seem highly relevant in this setting.

Bakgrund: När njurfunktionen blir försämrad bör dialysbehandling påbörjas. I Sverige får ungefär 2700 patienter hemodialysbehandling och 800 patienter behandlas med peritonealdialys. Vid dialysbehandling uppstår svårigheter som kan påverka patientens liv på flera olika sätt. För att patienten ska kunna hantera den svåra tiden med dialysbehandling kan copingstrategier användas. Det har visat sig att sjuksköterskan spelar en viktig roll för att stödja och uppmuntra patienter under den svåra tiden med dialysbehandling. Syfte: Att beskriva patienters upplevelser av dialysbehandling samt att granska valda artiklars datainsamlingsmetod. Metod: En beskrivande design och 13 vetenskapliga artiklar med kvalitativ ansats har använts i denna litteraturstudie. Databaserna CINAHL, Medline via PubMed och PsycINFO användes vid sökning av artiklar. Huvudresultat: Att vara beroende av långvarig dialysbehandling gjorde att patienterna var tvungna att spendera mycket tid på sjukhuset. Detta begränsade deras frihet att utföra dagliga aktiviteter, resa eller arbeta. Patienternas självbild påverkades negativt på grund av kroppsliga förändringar relaterade till sjukdomen och behandlingen. Känslomässiga reaktioner såsom rädsla, depression och oro inför framtiden var de vanligaste förekommande upplevelserna hos patienterna. För att övervinna dessa svåra situationer använde patienterna sig av copingstrategier. De inkluderade 13 artiklarna i denna litteraturstudie hade en kvalitativ ansats och intervjuer användes som datainsamlingsmetod. Slutsatser: Den svåra tiden med dialysbehandling påverkade patienterna fysiskt, psykiskt och socialt. För att klara av negativa och krävande omständigheter som sjukdomen och behandlingen medförde behövde patienterna olika strategier. Det krävdes även att sjuksköterskor gav stöd och information som kunde underlätta för patienter att hantera situationer som kunde uppstå relaterat till dialysbehandlingen / Background: When renal function is impaired should dialysis treatment start. In Sweden, there are about 2700 people have hemodialysis treatment and 800 individuals on peritoneal dialysis. On dialysis treatment, there are many difficulties that affect the patient's life in several ways. To handle the tough times with the dialysis treatment can patient use coping strategies. In addition it has been shown that the nurse plays an important role in supporting and encouraging patients during the difficult period of dialysis treatment. Aim: To describe patients' experiences of dialysis treatment and to review data collection method of the included articles. Method: A descriptive design and 13 scientific articles with qualitative approach were used in this study. The databases CINAHL, MEDLINE though PubMed and PsycINFO were used for searching articles. Results: To be depended on the long-term dialysis treatment made the patients had to spend a lot of time in the hospital. This limited the patient's freedom to perform daily activities, to travel or to work. There was a negative impact on patients' self-image because of bodily changes related to the disease and treatment. Emotional reactions such as fear, depression and anxiety about the future were the common experiences of the patients. One way to overcome these difficult situations, patients used coping strategies. The included 13 articles in this study had a qualitative approach and interviews were used as data collection method. Conclusion: During the difficult period of dialysis treatment, the patient was affected physically, psychologically and socially. To cope with the adverse and demanding circumstances that the disease and treatment caused, patients needed different strategies. It also requires that nurses provide support and information that can help patients to handle these situations.

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An impedance bioanalyzer system comprising an in-vitro biotransducer, instrumentation and control software for the measurement of urea, potentially in blood dialysate, has been developed. The biotransducer comprises of a microlithographically fabricated interdigitated microsensor electrode (IME) onto which was cast a biorecognition layer conferred with the specificity of the enzyme urease. Urease hydrolysis of urea produces NH4+, HC03- and OH- ions that decrease the device's impedance. The temporal rate of change (kinetic) and the extent of change (equilibrium) of ion concentration were measured as the sensor's response. Five formats: [i) unPEGylated urease-containing poly(hydroxyethylmethacrylate) [p(HEMA)] hydrogel, ii) PEGylated urease-containing p(HEMA) hydrogel, iii) via glutaraldehyde crosslinking in the presence of albumin, iv) the direct covalent immobilization of urease to the IME, and v) solution borne urease]. Michaelis-Menten parameters KM, ZMAX and kcat revealed the following rank: PEGylated urease-Gel >> Free Urease > unPEGylated urease-Gel = BSA in Glutaraldehyde > covalently immobilized urease. The unPEGylated-urease sensor provided a higher enzyrne- substrate binding rate and catalysis rate than PEGylated and thus provided a faster impedimetric response to various molar concentrations of urea. Long-term stability (one month) of the PEGylated-urease hydrogel was favorable. A dedicated three-element array impedimetric instrument, the 3EIC BioAnalyzer was designed and produced. A pair of demodulating logarithmic amplifiers (AD8302) was used to calculate the change in phase and amplitude corresponding to the impedimetric response to a 4.0 kHz, 50 mVPP sine wave from a function generator (MAX038). A graphic user interface (GUI), programmed in LabVIEW 7.0 established instrument control, data acquisition via a USB-48A-30A16 μDAQ and graphical data presentation of temporal impedimetric responses.

Coagulation is a ubiquitous process in the treatment of raw surface water for eventual potable use. Despite its capabilities, the sheer scale of its use is manifested in the volumes of chemicals it demands and waste sludge it produces. Recovering and reusing the chemical activity of the coagulant sludge in water treatment is a logical solution but this practice has been restricted by the presence of contaminants within the sludge. This thesis has investigated methods that can separate the coagulant metals from these primarily natural organic contaminants, with an aim of producing a sufficiently pure coagulant for effective treatment performance when reused. A process of ultrafiltration of the impure regenerated coagulant followed by a powdered activated carbon polishing stage compared favourably to a number of other separation processes and was found to remove the most dissolved organic compounds. When the purified coagulant was used to treat raw water, it provided better turbidity removal than commercial coagulant and matched its removal of trihalomethane precursors, making the process suitable for consideration at full-scale. Analysis of the whole life cost suggested that such performance could be reproduced at full-scale within a 25 year payback period. The reuse of even purified recovered coagulants in drinking water treatment still carries risks which may deter its implementation. Therefore the efficacy of recovered coagulants in the role of phosphorus removal from wastewater was also investigated. This showed that both acidified and unacidified waterworks sludges, with sufficient contact time, could remove similar levels of phosphorus as fresh coagulants, at approximately half the whole life cost.

Study of Plasma Protein Binding of Radiopharmaceuticals Summary The purpose of this work is the study of binding of substances (177 Lu-DOTA- [Lys3]bombesin, 177 Lu-NOTA-[Lys3]bombesin, 177 Lu-PCTA-[Lys3]bombesin, and 177 Lu- DOTA-MG47) to plasma proteins by equilibrum dialysis in 37řC, particularly using plasma samples of beef, rabbit, rat and human. Within this group, these substances were compared interspecifically. The substances 177 Lu-DOTA-[Lys3]bombesin, 177 Lu-NOTA-[Lys3]bombesin, 177 Lu- PCTA-[Lys3]bombesin, and 177 Lu-DOTA-MG47 are the newly developed receptor- specific radiolabeled peptides. For all the newly collected data, the interspecific comparison and subsequent statistical evaluation was performed. The indicated bombesin derivates were compared and statistically analyzed even between themselves. During the interspecies comparisons and the determination of the statistical significance of the data, there were found statistically significant and statistically highly significant differences between some of the examined samples. A highly significant difference was found during comparing with samples of 177 Lu-NOTA- [Lys3]bombesin and statistical evaluation, there was found a statistically highly significant difference. Despite the differences found, it is clear that the plasma binding concerning...

Title: Selected exercise trends and its effect on trunk stabilization function in dialysed patients - overview of the literature. Objective: Objective of this diploma thesis was to obtain and compare available studies dealing with exercise trends such as yoga, pilates, tai chi and balance training devices and to evaluate their effect on musculature which participates on trunk stabilization system of dialysed patients. Methods: This diploma thesis has descriptively-analytical character and is structured in a form of literary review. Results: Issue of dialysis in connection with trunk stabilization system has not been sufficiently explored yet in literary sources.In conclusion, there were no studies found dealing with effects of particular exercise trends on spine stabilization system of dialysed patients.In order to comprehend this issue an overview was written to define the effect of such trends on dialysed patients. Also, complications arising from renal failure and dialysis were mentioned such as hypertension, diabetes melitus and obesity.The effect of these trends on trunk stabilization system of healthy population as well as patients suffering from chronic back pain was described too. Conclusion: Some extent of coherence was found between strengthening musculature which plays an important role...

(v AJ) Introduction: The literature indicates that progressive aging of the population leads to increasing number of elderly patients with chronic kidney failure, initiating long-term dialysis treatment. ERA - EDTA (European Renal Association - European Dialysis and Transplant Association was issued in 2016 for treatment of elderly patients with advanced kidney disease. For easier orientation in the issue to withold or withdraw from dialysis therapy recommendations have been made in 2010 Renal Physicians Association (RPA). The issue of chronic kidney disease is also dealt with nurses organization The European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA). Aim: The aim of this research was to point out the reasons, for which patients with chronic kidney failure decide to withold or withdraw from dialysis therapy. Methodology: The thesis was performed through a qualitative research. Data were collected by individual guided interviews. The research sample included five participants. Four individuals decided to withold or withdraw from dialysis therapy and were further followed in the pre-dialysis nephrology outpatient clinic. One participant, who initially had started dialysis therapy acutely, later repeatedly stopped it and started it again with the...

Abstract This pilot study aimed to establish if an exercise programme utilizing the world’s first manual compression foot-pump, commonly known as “Venous Anti-Stasis Slippers”, could be used as an intervention to improve dialysis efficacy (Kt/V) and the quality of life (QOL) of patients with end stage renal disease (ESRD). The entire population of 34 self-care renal patients at the Flora Clinic renal unit were screened and 19 patients who met the inclusion criteria for the study were invited to participate in this 16 week pilot study. Baseline dialysis efficacy values were obtained from the analysis of routine blood tests and quality of life values were established with the use of the South African English version of the EQ-5D health questionnaire. This was followed by an eight week non-intervention period. Pre-intervention values were then established prior to the implementation of an eight week exercise programme using the manual compression foot pumps. A single group time series design was used and 12 of the initial 19 subjects completed the study by performing seated calf raising exercises, with manual compression foot pumps on their feet, for 20 minutes per hour during the first three hours of their routine dialysis sessions (2 - 3 times per week) over a period of eight weeks. Exercise diaries were kept to record exercise times, heart rates and exercise intensities. At the end of the eight week exercise programme, dialysis efficacy and quality of life values were re-measured. An intention to treat analysis of routine blood test results revealed statistically significant changes in dialysis efficacy (Kt/V) values between baseline (1.70 ± 0.48), pre-intervention (1.39 ± 0.43) and post intervention (1.50 ± 0.47) with a resultant 7.91% improvement in Kt/V values as a result of the exercise programme. There were however no statistically significant changes observed in overall quality of life (QOL) values, but noticeable improvements in self-care ability and a reduction in depression/anxiety scores were observed during this pilot study. The frequency of exercise per week had no significant effect on the changes in Kt/V.