INTRODUÇÃO: A asma grave acomete menos de 10% dos asmáticos, mas tem um impacto desproporcional sobre a utilização de recursos de saúde, contribuindo para, pelo menos, metade dos custos diretos e indiretos da doença. A proporção de indivíduos obesos ou com sobrepeso é elevada em pacientes com asma grave. Na verdade, a obesidade é um fator de risco para a asma, está associada com a gravidade da doença, com pior resposta a corticosteroides e pior controle clínico. Estudos sobre os efeitos da perda de peso em pacientes com asma ainda são escassos. OBJETIVOS: Avaliar o impacto da perda de peso com medidas clínicas em pacientes com asma grave e obesidade. MÉTODOS: Este é um estudo prospectivo randomizado aberto com dois grupos paralelos. Os participantes eram obesos e com asma grave e que, depois de um período de run-in de três meses, não estavam controlados de acordo com critérios da GINA. Os pacientes elegíveis foram randomizados em uma proporção de 2:1 (perda de peso: controle). Todos os participantes passaram por consultas bimensais no ambulatório de asma e foram acompanhados por seis meses. O desfecho primário foi o nível de controle da asma seis meses após o início do programa de redução de peso medido pelo Questionário de Controle da Asma (ACQ). Os desfechos secundários incluíram o Teste de Controle da Asma (ACT), resultados de função pulmonar, o Questionário Respiratório de St. George (SGRQ), a mudança na reatividade brônquica à metacolina, o uso diário de medicação de alívio para asma, percentagem de dias livres de sintomas, número de visitas ao pronto-socorro e exacerbações, marcadores de inflamação das vias aéreas medidos pelo escarro induzido e pelo óxido nítrico exalado (FeNO). IgE, proteína C reactiva, eotaxina, leptina e Transforming Growth Factor beta 1 (TGF 1) também foram medidos. RESULTADOS: Trinta e três foram randomizados. O grupo era composto predominantemente de mulheres com obstrução moderada, aprisionamento de ar, aumento da resistência das vias aéreas e marcada eosinofilia no escarro. O aumento dos níveis séricos de IgE foram consistentes com uma predominância de asma atópica. Dos 22 pacientes randomizados para submeterem-se a tratamento para a obesidade, 12 atingiram a meta de perda de peso de, pelo menos, 10% do peso corporal. A redução de peso no grupo de tratamento foi associada com melhor controle da asma medido pelo ACQ, ACT e SGRQ. Houve aumento de dias sem sintomas, menor uso de medicação de resgate e menos visitas ao serviço de emergência durante o período de estudo. Não houve diferença no número de exacerbações. A capacidade vital forçada (CVF) aumentou significativamente no grupo de tratamento e permaneceu inalterada no grupo de controle. As outras medidas da função pulmonar não mostraram diferenças entre os grupos. A hiperreatividade das vias aéreas, níveis de óxido nítrico exalado e celularidade do escarro induzido não se alterou ao longo do estudo. Os níveis de leptina diminuíram em ambos os grupos. Os níveis séricos de IgE, proteína C-reactiva, eotaxina, e TGF-1 não se alteraram. CONCLUSÃO: Nosso estudo adiciona informações à controvérsia sobre o impacto da obesidade e seu tratamento no controle da asma. Nossos resultados sugerem que a redução de peso em pacientes obesos com asma grave melhore os resultados de asma por mecanismos não relacionados com a inflamação das vias aéreas e que o controle da asma pobre em pessoas obesas é, pelo menos em parte, o resultado de fatores relacionados com a obesidade. A abordagem terapêutica para pacientes obesos com dificuldade de tratar a asma deve ser destinada à redução de peso, bem como à intensificação do tratamento anti-inflamatório / INTRODUTION: Severe asthma affects less than 10% of asthmatics, but has a disproportionate impact on the use of health resources, contributing to at least half of the direct and indirect costs of the disease. The proportion of obese or overweight individuals is elevated in patients with severe asthma. In fact, obesity is a risk factor for asthma, is associated with the severity of the disease, a poor response to corticosteroids and worse clinical control. Studies on the effects of weight loss in patients with asthma are still scarce. OBJECTIVES: Assess the impact of weight loss with a medical weight loss program in patients with severe asthma associated with obesity. METHODS: This is a prospective open study with two randomized parallel groups. The participants were obese and with severe asthma and, after a three month run-in period, were not controlled according to GINA criteria. Eligible patients were randomized in a 2:1 ratio (weight loss:control). All participants attended bimonthly consultations in the asthma clinic and were followed for six months. The primary outcome measure was the level of asthma control 6 months after initiation of the weight reduction program quantified by using the Asthma Control Questionnaire (ACQ). Secondary clinical outcomes included the Asthma Control Test (ACT), lung function results, score on the St. Georges Respiratory Questionnaire (SGRQ), change in metacholine reactivity, daily use of asthma reliever medication, percentage of asthma symptom free days, number of visits to emergency room and exacerbations, markers of airway cellular inflammation measured in induced sputum and with exhaled nitric oxide (FeNO). IgE, C reactive protein, leptin, eotaxin and Transforming Growth Factor beta 1 (TGF1) levels in serum were also measured. RESULTS: Thirty-three patients were randomized. The group consisted predominantly of women with moderate airflow obstruction, air trapping, increased airway resistance and marked eosinophilia in the sputum. The increased serum levels of IgE were consistent with a predominance of atopic asthma. Of the 22 patients randomized to undergo treatment for obesity, 12 achieved the weight loss goal of at least 10% of body weight. The reduction in weight in the treatment group was associated with improvement in the control as measured by ACQ, ACT and SGRQ. There was increase of symptom-free days, less use of rescue medication and fewer visits to the emergency room during the study period. There were no differences in the number of exacerbations. The forced vital capacity (FVC) increased significantly in the treatment group and remained unchanged in the control group. The other measures of the pulmonary function showed no differences between groups. The airway hyperresponsiveness, exhaled nitric oxide levels and induced sputum cellularity did not change throughout the study. Leptin levels decreased in both groups. Serum levels of IgE, C-reactive protein, eotaxin, and TGF-1 did not change. CONCLUSION: Our study adds information to the controversy about the impact of obesity and its treatment on asthma control. Our results suggest that weight reduction in obese patients with severe asthma improves asthma outcomes by mechanisms not related to airway inflammation and that poor asthma control in people who are obese is at least in part the result of obesity-related factors. The therapeutic approach for obese patients with difficult-to-treat asthma should therefore be aimed at weight reduction as well as on intensifying antiinflammatory treatment

Bakgrund: En stor del av distriktssköterskors arbete inom primärvården består av telefonrådgivning. Det krävs stor kunskap inom omvårdnad, kommunikation, medicin och teknik för att kunna göra en korrekt bedömning av patientens hälsotillstånd. Inom telefonrådgivning finns det flertalet faktorer som försvårar bedömningen. Syfte: Syftet med denna studie var att beskriva distriktssköterskors upplevelser av svåra samtal vid telefonrådgivning inom primärvården. Metod: I studien användes en kvalitativ innehållsanalys med induktiv ansats. Intervjuer genomfördes med åtta distriktssköterskor. Resultat: I resultatet framkom fyra kategorier vilka var: Svårt att bedöma via telefonen, Svårt att inte kunna tillgodose allas önskemål, Organisationsrelaterade problem samt Stöd i bedömningen med tillhörande nio underkategorier. Distriktssköterskorna upplever att svåra samtal kan uppstå i många olika situationer samt att dessa påverkar distriktssköterskorna känslomässigt och deras arbete inom telefonrådgivning. Konklusion: Denna studie tydliggör vad distriktssköterskor upplever som svåra samtal och att dessa påverkar dem känslomässigt. Resultatet kan bidra till att öka medvetenheten av vad distriktssköterskor upplever sig behöva för att lättare kunna hantera svåra samtal. / Background: A large part of the district nurses’ work in primary health care consists of telephone counseling. This requires extensive knowledge of nursing, communications, medicine and technology to be able to make an accurate assessment of the patient's health. In the telephone counseling there are several factors that complicate the assessment. Aim: The purpose of this study was to describe district nurses’ experiences of difficult conversations in telephone counseling in primary health care. Method: The study used a qualitative content analysis with inductive approach. Interviews were conducted with eight district nurses. Results: The result shows four categories: Difficult to assess through the telephone, Difficult to not be able to accommodate everyone, Organizational problems and Support in the assessment. District nurses feel that difficult conversations can occur in many different situations and that they affect the district nurses emotionally and their work with telephone counseling. Conclusion: This study clarifies what the district nurses’ experience as difficult conversations and that they affect them emotionally. The results can help to raise awareness of what the district nurses feel they need to manage difficult conversations easier.

Bakgrund. En stor och viktig del av den palliativa vården är kommunikation med patienter och dess närstående. Sjuksköterskan finns närvarande runt patienten och dennes familj genom alla vårdinstanser och kan få frågor av olika karaktär i alla möjliga situationer. Svåra samtal kan exempelvis vara existentiella eller prognosrelaterade samt handla om döden. Vård i livets slut sker i varierande utsträckning inom de flesta vårdinstanser. Samtal om och kring döden kan vara känsligt för samtliga deltagare då det berör vår existens på djupet. Syftet med studien var att belysa sjuksköterskors upplevelser av svåra samtal med patienter och närstående inom palliativ vård. Litteraturöversikt var den metod som ansågs bäst svara på syftet genom att undersöka kunskapsläget inom området. Då studien undersöker upplevelser valdes endast kvalitativa artiklar till översikten. Innehållsanalys av resultaten användes för att undersöka likheter och skillnader mellan artiklarna med syftet att belysa sjuksköterskornas upplevelser. En förförståelse kring erfarenhetens påverkan fanns med genom hela studiens gång. Patricia Benners teori Från Novis till Expert ansågs därför lämplig som den teoretiska referensramen. Materialet analyserades även förutsättningslöst för att inte värdefullt material skulle missas. Resultaten visade att sjuksköterskornas förhållningssätt påverkade i hög grad den relation som skapas till patient och närstående och som följaktligen har stor påverkan på upplevelsen av samtalen. Sjuksköterskornas förhållningssätt inom palliativ vård passade väl in på teorin kring personcentrerad vård. Hur sjuksköterskorna berördes av samtalen påverkades i hög grad av tidigare erfarenhet, vilket var den viktigaste faktorn för att sjuksköterskorna skulle uppleva trygghet med att hålla svåra samtal. Osäkerhet lyftes som det största hindret för att en vårdrelation och således svåra men meningsfulla samtal skulle kunna uppstå. Slutsatsen av studien är att ett personcentrerad förhållningssätt behövs för att skapa en vårdande relation mellan sjuksköterska och patient. Äkta närvaro upplevdes viktigare än att ha alla svar. Erfarenhet var det som gav sjuksköterskorna störst trygghet i de svåra situationerna. Med tanke på hur viktigt samtalen är för att bland annat lindra existentiellt lidande är det av största vikt för utbildning och arbetsgivare att förbereda sjuksköterskestudenter respektive nyanställda för att minska osäkerheten i möjligaste mån. Stöd och utbildning för alla som möter patienter med svår sjukdom både inom specialiserad och allmän palliativ vård är av vikt. / Abstract. An important part of palliative care is communication with patients and their families. The nurse is close to the patient and their family wherever healthcare is provided and can receive different types of questions in any situation. Difficult conversations maycontainspiritual distress or concerns related to prognosis and death. End of life care is conducted in varyingextentwithin most places where care is provided. Discussions about death and dying can affect all members participating in the conversation on a deeper level. The aim of the study was to illustrate nurses experiences of difficult conversations with patients and their families in palliative care. The chosen method for the study was a literature review, as it was considered the best way to examine the current knowledge within the area. Since the focus of the study was on experiences, onlyarticles based on a qualitative approachwere included in the review. Content analysis of the results wasused to discover similarities and differences betweenthe articlesto highlight nursesexperiences. The authors had a preunderstanding that work experience would influence the nurses’ experiences and perceptions of difficult conversations. Patricia Benner's theory, From Novice to Expert, was therefore seen as an appropriate theoretical framework for the study. The material was also analyzedwith an open mind with the aim of minimizing the risk of leaving out othervaluable information. The results revealedthat the nurses approach highly affectedthe relationship with the patients and their families and further affected the experience of difficult conversations. The approach used by the nurses in palliative care correspondswell with the theory of person-centered care. How the nurses were affected by the conversations, was highly influenced by previous experience. Previous experience was the main factor enabling the nurses in feeling secure and comfortable enough to take part in difficult conversations. Insecurity was the most common barrier against creating caring relationships and dealing with difficult conversations. The conclusion of this study is that a person-centered care approach is needed to create a caring relationship between nurse and patient. A genuine presence was seen as more important than having all the answers. Previous experience gave most confidence in difficult situations. Considering how important conversations can be to alleviate spiritual distress as well asother difficult issues, it is of great importance for nursing education and employers to be aware of situations affecting nurses. Better preparationby educationand workplaceintroduction is vital forreducing uncertainty. Support and an education for all personnel working with patients in any form of palliative care is of importance.

Svåra samtal förekommer på samtliga arbetsplatser, dock resulterar de oftast i misslyckanden (Bradley & Campbell, 2016). Därför krävs det av ledare att anamma vissa strategier för att nå ett tillfredsställande resultat. Studiens fokus är att från ett ledarskapsperspektiv öka förståelsen om hur mellanchefer hanterar svåra samtal på sina arbetsplatser och hur de hanterar möjliga risker av svåra samtal både för sig själva och organisationen. Således utgår studien från tre frågeställningar där den första berör mellanchefernas användning av empati för svåra samtal och den andra om vilka strategier mellancheferna använder för svåra samtal. Vidare handlar den tredje frågeställningen om att undersöka vilka risker mellancheferna upplever kan uppkomma av svåra samtal både för sig själva och organisationen. Studiensempiri har samlats in genom semistrukturerade intervjuer samt att den bygger på en hermeneutisk forskningsansats. Empirin har vidare analyserats med hjälp av SCARFmodellen som handlar om den neurologiska påverkan hos anställda baserat på vilka strategierledare använder sig av under svåra samtal. Resultatet visar att mellanchefernas upplevelse av svåra samtal är både positivt och negativt, för både dem och för organisationen. Exempelvis upplever mellancheferna en känsla av obehag inför svåra samtal men att det i efterhand ofta resulterar i en förbättring, både på ett personligt och organisatoriskt plan. Resultatet visar även de strategier mellancheferna tenderar att använda sig av under svåra samtal samt hur de använder sig av empati för att öka sin kommunikationsförmåga under svåra samtal. Till exempel visar studien att mellancheferna använder den empatiska kompetensen för att bättre förstå sina medarbetares situation. Vidare använder mellancheferna sig av olika strategier, som exempelvis att visa att de förstår situationen genom att agera på det medarbetarna berättar. / Difficult conversations occur at all workplaces, although they tend to result in failure (Bradley & Campbell, 2016). Therefore it is required that leaders embrace certain strategies in order to reach a satisfying result. The aim of the study is to, through a leadership perspective, increase the understanding regarding how middle managers handle difficult conversations both for themselves as well as the organization. Thus, the study utilizes three questions whereas the first one refers to the middle managers adaptation of empathy during difficult conversations and the second refers to what strategies the middle managers adapt during difficult situations. Furthermore, the aim of the third question is to examine what risks middle managers believe can occur from difficult conversations both for themselves as well as the organization. The empiric was gathered through semi-structured interviews and is based on a hermeneutic research approach. The empiric has been further analyzed by dint of the SCARF model about how the employees neurologic influence is affected by the strategies used by the middle managers. The result shows that the experience of handling difficult conversations affects the middle managers both positively and negatively, for both themselves and the organization. For example, the middle managers experience a sense of discomfort before difficult conversations but in the end it results in improvement, both on a personal level and an organizational level. In addition, the result shows how those strategies the middle managers tend to adapt during difficult conversations as well as how they use empathy in order to increase their communication skills. For example, the study shows how the middle managers use their empathic competency as a way of increasing their understanding of the employees situation. Furthermore, the middle managers use different strategies, for example they show understanding of the employees situation by reacting to what they say.

The current study examined the mediating role of possible food preferences on the temperamentweight relationship among 18-month-old toddlers. Parents of 37 typically developing toddlers completed the Early Childhood Behavior Questionnaire (ECBQ). During a lab visit toddlers’ weight and recumbent length were measured and recorded. Toddlers also completed a sequential touching task to examine their ability to categorize a healthy group of foods and an unhealthy group of foods. The only temperament measure found to associate with both child weight status and food categorization was inhibitory control. Toddlers’ food categorization was not found to mediate the relationship between inhibitory control and their weight status. The results of this study suggest that there is a continued need for a nonparent report measure of food preferences.

No description available.

Bakgrund: Det ställs höga krav på anestesisjuksköterskor i samband med extubation, de ska klara av att ge en säker vård, kommunicera med sitt team samt bedöma patientens alla mätvärden och riskfaktorer. Att extubera innebär alltid en risk och kan leda till komplikationer för patienten.  Syfte: Syftet med studien var att beskriva anestesisjuksköterskans erfarenheter vid svårigheter av extubation.  Metod: En kvalitativ metod användes och tolv semistrukturerade intervjuer utfördes. Det insamlade datamaterialet analyserades med kvalitativ innehållsanalys baserat på Graneheim och Lundman.  Resultat: I analysen framkom sex subkategorier som resulterade i tre kategorier. Dessa var praktisk och mental handlingsberedskap som innefattade hur anestesisjuksköterskan förberedde sig inför extubationsmomentet. Andra kategorin upplevelse av svår extubation beskriver hur anestesisjuksköterskan kände trygghet i erfarna kollegor samt hur de med tiden utvecklade ett professionellt lugn. Sista kategorin teamarbete belyste att rak och tydlig kommunikation främjade ett bra samarbete. Som övergripande tema framträdde att vara beredd på det oväntade, plötsligt händer det. Slutsats: Svårigheter med extubation är relativt ovanligt, därför behövs tydligare riktlinjer som anestesisjuksköterskan kan vända sig till vid extubationssvårigheter. Simuleringsövningar kan vara ett hjälpmedel för att tryggare kunna hantera komplexa extubationer. För att upprätthålla patientsäkerheten samt få hjälp vid kritiska moment beskrevs att en rak och tydlig kommunikation behövdes på sal vilket även främjade ett gott samarbete. / Background: High demands are placed on the nurse anesthetists during extubation, they must be able to provide safe care, communicate with the team and assess all the patient's measurement, readings and risk factors. Extubation always involves a risk and can lead to complications for the patient.  Purpose: The purpose of the study was to describe the nurse anesthetists experiences with difficulties of extubation.  Method: A qualitative method was used and twelve semi-structured interviews were conducted. The collected data material were analyzed with qualitative content analysis based on Graneheim and Lundman.  Results: In the analysis, eight subcategories emerged which resulted in three categories. These were ability to take action practically and mentally which included how the nurse anesthetist prepared for the extubation moment. The second category, experience of difficult extubation, describes how the nurse anesthetist felt safe in the company of experienced colleagues and how they developed a professional calm over time. The last category teamwork highlighted that straight and clear communication promoted good cooperation. As a theme to be prepared for the unexpected, suddenly it happens emerged.  Conclusion: Difficulties with extubation are relatively uncommon, therefore clearer guidelines are needed to which the nurse anesthetists can turn to in the event of extubation difficulties. Simulation exercises can prepare the nurse in being able to handle complex extubations more safely. In order to maintain patient safety and get help at critical moments, it was described that straight and clear communication was needed in the room, which also promoted good cooperation.

Svåra samtal på arbetsplatsen handlar ofta om disciplinära och omvårdande samtal. Dessa hålls mellan chef och medarbetare men stöttas oftast av en HR-praktiker för att leda samtalet. HR-praktikens roll i samtalet kan handla om att strukturera samtalet, stötta chefen och hantera motreaktioner från den berörda medarbetaren. Denna studie syftar till att besvara hur HR-praktiker hanterar och utvecklar sin kompetens att hålla svåra samtal med särskilt fokus på disciplinära och omvårdande samtal på arbetsplatsen. För att undersöka studiens syfte och frågeställningar har en kvalitativ undersökning gjorts där sju personer inom HR-professionen intervjuats. Vidare har det empiriska materialet analyserats med utgångspunkt från studiens frågeställningar. Detta har gjorts i koppling till Argyris single och double loop- lärande (1991) samt Kolb (1984) och Mumfords (1995) teorier om erfarenhetsbaserat lärande. Resultatet visar att HR-praktiker upplever dessa samtal tuffa men att nivån kan öka utan vissa förutsättningar och samtalsverktyg samt att erfarenheten gör det lättare för samtalsledaren att genomföra dem. Det visar även hur hanteringen av det svåra samtalet kan sammankopplas med ett double loop-lärandet samt hur reflektioner från mindre lyckade samtal bidragit till det erfarenhetsbaserade lärandet. HR-praktikerna har därmed hittat olika verktyg för att lättare hantera de utmaningar som de ställs inför i det svåra samtalet. / Difficult conversations in the workplace are often about disciplinary or nurturing conversations. These are held between manager and employee but are usually supported by an HR practitioner to lead the conversation. The HR practitioner's role in the conversation may involve structuring the conversation, supporting the manager and handling backlash from the concerned employee. The conversations are often described as tough, but that experience makes it easier for the person leading the conversation to carry them out. This study aims to answer how HR practitioners manage and develop their skills to hold difficult conversations with a particular focus on disciplinary and nursing conversations in the workplace. In order to investigate the purpose and questions of the study, a qualitative survey was conducted in which seven people within the HR profession were interviewed. Furthermore, the empirical material has been analyzed based on the study's questions. This has been done in connection with Argyris' single and double loop learning (1991) and Kolb's (1984) and Mumford's (1995) theories of experience-based learning. The result shows that the experience and handling of the difficult conversation can be connected with a double loop learning and how reflections from less successful conversations contributed to the experience-based learning. The HR practitioners have thus found different tools to more easily handle the challenges they face in the difficult conversation.

No description available.

В выпускной квалификационной работе рассмотрено понятие семьи и основания, по которым семья может считаться как находящаяся в трудной жизненной ситуации, определены основные понятия и характеристики восстановительного подхода и обозначены нормативно-правовые основы его применения в социальных службах. Опыт применения и реализации медиативного (восстановительного) подхода в урегулировании семейных конфликтов в практической деятельности социальных служб был изучен на примере работы специалистов-медиаторов некоммерческой организации. В заключении сделан вывод о готовности специалистов к реализации медиативного подхода при работе с семейными конфликтами, а также о возможностях и ограничениях данного подхода. / The final qualifying work examines the concept of family and the grounds on which a family can be considered to be in a difficult life situation, defines the basic concepts and characteristics of the restorative approach and outlines the legal framework for its application in social services. The experience of applying and implementing the mediation (restorative) approach to resolving family conflicts in the practical activities of social services was studied using the example of the work of specialist mediators of a non-profit organization. In conclusion, a conclusion was drawn about the readiness of specialists to implement the mediation approach when working with family conflicts, as well as the possibilities and limitations of this approach.