This thesis investigates health trends among very old people and the allocation of public home-help services. A further aim is to examine methodological issues in mortality analysis. Three data sources are used: (1) The Tierp study of community-dwelling persons (n=421, ages 75+), (2) the SWEOLD nationally representative samples (n=537 in 1992 and n=561 in 2002, ages 77+), and 3) SNAC-K comprised of home-help recipients in a district of Stockholm (n=1108, ages 65+). Study I suggests that the length of the follow-up period may explain some of the differences found in predictor strength when comparing mortality studies. Predictors that can change rapidly (e.g., health) were found to be strongest for the short term, with a lower average mortality risk for longer follow-ups. Stable variables (e.g., gender) were less affected by length of follow-up. Studies II and III present a measure of complex health problems based on serious problems in at least two of three health domains. These were diseases/symptoms, mobility, and cognition/communication. Prevalence of complex health problems increased significantly between 1992 and 2002. Older age, female gender, and lower education increased the odds of having complex problems. Complex problems strongly predicted 4-year mortality. Controlled for age, gender, health, and education, mortality decreased by 20% between 1992 and 2002. Men with complex problems accounted for this decrease. Thus, in 2002 the gender difference in mortality risk was almost eliminated among the most vulnerable adults. Study IV revealed that physical and cognitive limitations, higher age, and living alone were significantly related to home-help allocation, with physical and cognitive limitations dominating. Psychiatric symptoms did not affect the assessment. The increased prevalence of complex health problems and increased survival among people with complex needs have important implications concerning the need for collaboration among service providers.

Vaginismus is a sexual pain disorder, where spasm of musculature of the outer third of the vagina interferes with intercourse. Vaginismus exists in two forms: total vaginismus, where intercourse is impossible, and the more seldom described partial vaginismus, in which intercourse is possible but painful. The aim of the thesis was to develop a useful definition of partial vaginismus for both clinical and scientific purposes; to describe the prevalence of partial vaginismus among women with superficial coital pain; to report on symptoms and clinical findings in women with partial vaginismus; and to present treatment results for women with vaginismus. In a clinical sample of 224 women with superficial coital pain, we found a great overlap of the clinical diagnoses of partial vaginismus (PaV) and vulvar vestibulitis (VVS) (nowadays called provoked vestibulodynia); 102 women had both PaV and VVS. All women with VVS had vaginismus. Partial vaginismus was more common in all our samples than total vaginismus. sEMG of pelvic floor muscles was found to be of no value in distinguishing women with partial vaginismus with or without vulvar vestibulitis (PaV+/-VVS) (n=47) from each other or from an asymptomatic group (n=27). Women with PaV+/-VVS (n=53) reported not only burning pain but also itch during a standardized penetration situation (sEMG of pelvic floor muscles), while asymptomatic women (n=27) did not. In most cases, the appearance of burning pain preceded the appearance of itch. In a retrospective interview study, 24 women with PaV+/-VVS reported pain after intercourse more often than pain during penetration at the onset of the problem. When the women ceased having intercourse, both symptoms were equally common. Intensity of pain during penetration increased dramatically from very low at onset of the problem to very high when the women ceased having intercourse, while intensity of pain after intercourse was already high at onset of the problem and increased to very high when the women ceased having intercourse. Pain after intercourse in women with PaV+/-VVS was described as burning and/or smarting and lasted in mean for two hours, while pain during penetration was described with words like sharp/incisive/bursting and lasted for one minute. At long-term follow-up (more than three years) of a group of women treated with cognitive behaviour therapy for vaginismus (n=59, response rate 44/59 on a questionnaire), a majority were able to have and enjoy intercourse. The proportion of women with positive treatment outcome was, however, associated to the definition of treatment outcome. An ability to have intercourse at end of therapy was maintained at follow-up. Every tenth women with vaginismus healed spontaneously after thorough assessment. Conclusion: Partial vaginismus was more common in our studies than total vaginismus, and all women with vulvar vestibulitis had partial vaginismus. Women with PaV+/-VVS reported not only burning pain during standardized penetration but also itch. When the problem started in women with PaV+/-VVS, pain after intercourse was more common than pain during penetration. Pain after intercourse was described as longlasting and burning and/or smarting, while pain during penetration was described as short and sharp/incisive/bursting. Long-term follow-up results of a series of women treated with CBT for vaginismus show good treatment outcome.

Background: The survival rates for very low birthweight (VLBW; birthweight ≤1500 g) children are increasing, but they run a greater risk than controls of developing neurosensory disabilities and other functional problems during childhood. However, there is a great need for more knowledge regarding long-term outcome to adulthood in VLBW subjects. Aims: To evaluate long-term outcomes in a regional cohort of VLBW children born in 1987-88 regarding hospital readmissions, morbidity, neurological conditions, cognitive function, reading skills, school achievements, behaviour, growth, general health, and social functioning in relation to gender, neonatal risk factors, disability and Magnetic Resonance Imaging (MRI) findings. Study design: Prospective longitudinal case-controlled long-term regional follow-up. Material and Methods: A total of 86 (80.4%) children (47 boys out of 60 and 39 girls out of 47 live-borns) survived the neonatal period and were recruited to the follow-up study. A total of 86 term controls (45 boys and 41 girls) were included from the newborn period. Readmissions, hospital diagnoses, need of habilitation and child psychiatric care were checked in registers to 15 years of age. The VLBW children were enrolled in the follow-up study at 40 weeks gestational age and at 4, 9, and 15 years of age in assessing neurological conditions. At 15 years of age, the groups were assessed in cognition (WISC III), reading skills, school outcome, behaviour, vision and growth. Fifty-nine (69%) VLBW children were examined using cerebral MRI. Physical and mental health, weight and height, education, and socio-economic situation were assessed at 20 years of age in 77/85 VLBW and 69/84 control subjects by means of postal questionnaires. Results: VLBW boys had three times more readmissions compared with control boys (p=0.003). Gestational age below 30 weeks, birthweight less than 1000 g, and mechanical ventilation were neonatal risk factors for readmissions. Five (5.8%) children had moderate/severe cerebral palsy, 5 (5.8%) had attention deficit hyperactivity disorder, and 1 was blind due to retinopathy of prematurity. VLBW children were inferior in neurological function in comparison with controls at 40 weeks of gestational age and 4 and 15 years of age. Fourteen of 56 (25%) VLBW children without overt disability had abnormal MRI findings. Mechanical and/or intraventricular haemorrhages (IVH) were significantly related to less favourable neurological outcome. VLBW children performed significantly lower than their controls on a few reading variables and on WISC III. Half of them had IQ lower than 85. Ten VLBW children with IQ < 70 had not been clinically identified earlier and a majority of these children attended mainstream school. Small head circumference correlated with low IQ. Mechanical ventilation and IVH correlated with lower IQ and poorer reading skills. At 20 years of age, the VLBW subjects did not differ significantly from the controls in self-perceived health, education, occupation and way of living. Conclusions: Most VLBW subjects were without major health problems up to 20 years of age and had attended mainstream schools. The presence of IVH and mechanical ventilation during the neonatal period negatively influenced health outcomes. VLBW children without overt neurological disability performed somewhat less well in neurological examinations in comparison with controls. VLBW children achieved poorer results in cognitive tests, but reading skills made a catch-up to 15 years of age. A majority of VLBW subjects managed transition to adulthood similar to that of controls. / Bakgrund: Överlevnaden för nyfödda barn med mycket låg födelsevikt (1500 g eller lägre; VLBW) har ökat avsevärt under de senaste årtionden och man finner nu att ca 90 % av barnen skrivs ut från neonatalavdelningar. Risken för cerebral pares (CP) har visat sig vara ökad jämfört med barn födda i fullgången tid. Studier visade att VLBW-barn som kommit upp i skolåldern hade högre frekvens av läs- och skrivsvårigheter, oftare behövde specialundervisning, samt hade högre grad av beteendeproblem jämfört med klasskamrater. Uppföljningsstudier var tidigare mestadels gjorda på populationer från större sjukhus, kontrollgrupp saknades eller inlemmades efter flera år, uppföljningstiden var kort och flera viktiga områden av barnets utveckling var ofullständigt undersökta. I Sverige saknades en studie med långtidsuppföljning av VLBW-barn födda under en tidsperiod då alltfler barn hade börjat erhålla andningshjälp med respirator. Socioekonomiska förhållanden i Sverige kan inte heller helt och hållet jämföras med flertalet andra länder. Syfte: Den här avhandlingens syfte var att studera hur det går för VLBW-barn upp till 15 års ålder avseende sjuklighet, motoriska funktioner, kognitiva funktioner, skolprestationer och beteende, samt vid 20 års ålder avseende hälsotillstånd, sysselsättning och boende. Undersökningsresultaten relaterades till nyföddhetsfaktorer och fynd vid magnet resonans-undersökning (MRI) av hjärnan vid 15 års ålder. Material och metoder: 86 överlevande VLBW-barn samt 86 barn födda i fullgången tid från 1/2 1987 till 30/4 1988 i sydöstra sjukvårdsregionen (Jönköpings, Kalmar och Östergötlands län) har ingått i studien. Uppgift om antalet sjukhusinläggningar och huvuddiagnos inhämtades från Slutenvårdsregistret, Epidemiologiskt centrum, Socialstyrelsen. Uppgifter om antalet barn med CP, ADHD, mental retardation och barnpsykiatriskt vårdbehov inhämtades från habiliteringscentraler och barnpsykiatriska kliniker i regionen. Information om skolbetyg från 9:e årskursen och skolgång inhämtades från kommunerna. Neurologiska och motoriska undersökningar utfördes på barn utan synligt handikapp enligt särskilda protokoll såväl neonatalt som vid 4, 9 och 15 års ålder. Vikt och längd, kognitiv test (WISC III), lästester och MRI undersökning (enbart VLBW-barn) gjordes vid 15 års ålder. Barn och föräldrar fick fylla i formulär om beteende. Vid 20 års ålder (december 2007) fick deltagarna tre frågeformulär: ett studiespecifikt med frågor om hälsa, vikt och längd, användning av tobak och alkohol, gymnasiestudier, nuvarande sysselsättning och boende; SF-36, som belyser fysisk kapacitet, allmän hälsa, vitalitet och psykiskt välbefinnande; samt KASAM (känsla av sammanhang), som belyser hur man upplever sitt eget sätt att fungera, uppdelat i begriplighet, hanterbarhet och meningsfullhet. Resultat: VLBW-barn (mest pojkar) vårdades oftare på sjukhus under första levnadsåren jämfört med kontroller. Infektioner och neurologiska sjukdomar dominerade för både VLBW-pojkar och -flickor. Fem (5.8 %) VLBW-barn hade måttlig/svår CP och fem hade ADHD. Hjärnblödning eller respiratorbehandling under nyföddhetsperioden var de faktorer som oftast var relaterade till sämre hälsotillstånd. Det var ingen skillnad i antal barn med behov av barnpsykiatrisk vård mellan grupperna. Det var ingen skillnad i summering av 9 slutbetyg mellan grupperna, men VLBW-pojkar hade lägre betyg i matematik och teknologi jämfört med sina kontroller. VLBW-barnen var lättare och kortare, men skillnaderna var störst mellan VLBW-flickor och deras kontroller. VLBW-barnen (fr.a. pojkarna) presterade lägre i neurologiska undersökningar, samt i kognitiva test. Tio av tolv av barnen som hade IQ under 70 var tidigare inte kända. Det fanns skillnader mellan grupperna i lästester, men signifikant enbart i ett test. Jämfört med lästester vid 9 års ålder hade VLBW-barnen gjort en upphämtning. Det framkom inga skillnader i beteende mellan grupperna, men VLBW-flickor uppgav färre beteendeproblem än sina kontroller. Vid 20 års ålder framkom inga skillnader i självuppskattad hälsa eller behov av vårdkontakter och läkemedel mellan grupperna. Tobaksanvändning var lika i grupperna, men fler i VLBW-gruppen var icke-användare av alkohol. Det var ingen signifikant skillnad i andel som gått ut gymnasiet, nuvarande sysselsättning eller boendeform mellan grupperna. Det var inga signifikanta skillnader i resultat på SF-36 och KASAM mellan grupperna. Konklusion: Hjärnblödning och respiratoranvändning under nyföddhetsperioden var de faktorer som hade störst inverkan på VLBW-barnens hälsotillstånd upp till 20 års ålder. CP och ADHD förekom hos relativt få, men lågt IQ var vanligt. VLBW-pojkar hade större sjukvårdsbehov, presterade lägre i neurologiska test och hade lägre skolbetyg än sina kontroller. VLBW-gruppen skilde sig inte från kontroll-gruppen avseende beteendeproblem. Självuppskattad hälsa vid 20 år skilde sig inte mellan grupperna. Särskilda uppföljningsprogram för VLBW-barn är nödvändigt där kognitiva tester ingår vilka bör utföras före skolstart.

This investigation was undertaken to examine effects of motor skill intervention in children with motor difficulties consistent with developmental co-ordination disorder (DCD) diagnosed in child health care before school entrance, to analyse the parents' descriptions of their children, and to follow up the children's motor status in a short-term perspective. Thirteen studies on the effects of motor skill intervention were submitted to a meta-analysis (Study I). Thirty-seven children who at age 5 to 6 years were diagnosed as having motor difficulties consistent with DCD were enrolled in an experimental investigation of effects of group motor skill intervention on motor skills (Study II) and on self-perceived competence (Study III). The parents' descriptions of their children were obtained at an interview (Study IV). The children's motor status was re-examined when they were 7 to 8 years old (Study V). Motor skill intervention, using the Specific Skills approach, in a group setting or in a home programme, 3 to 5 times per week, was found beneficial for children with DCD who were older than 5 years of age. The non-specific group motor skill intervention influenced the number of children with borderline motor difficulties who changed to having no motor difficulties, and seemed to enhance awareness of motor competence. Parents whose children had definite motor difficulties were more inclined to support their children in physical activity, and reported worry and uncertainty. The children had not changed their motor status at the age of 7 to 8 years. The children with definite motor difficulties, in particular, continued to have these difficulties. Children who when 5 to 6 years old have motor difficulties and who score at the 5th percentile or below at the Movement ABC motor test, seem to need active support in joyful motor learning situations to reduce unwillingness and displeasure.

Background: Renal cell carcinoma (RCC) is most lethal of the urological cancers, with more than 40% dying of the disease. About 30% of the patients have metastases at initial diagnosis and up to 40% undergoing nephrectomy for localized RCC develop metastasis. A follow-up protocol based on accurate prognostic variables allows identification of low and high risk patients and selection of those most likely to benefit from adjuvant therapy. I have studied a number of prognostic patient-related factors, including tumour stage and grade, angiogenetic factors and tumour markers, in order to improve follow-up guideline as well as to try to predict prognosis and clinical outcome for individual patients. Material and Methods: The studies are based on patients treated for RCC between 1982 and 2002. All patients eligible for surgery with or without metastasis were treated with nephrectomy and were followed according to a scheduled follow-up programme. Serum samples were collected after obtained informed consent. Multiple clinicopathological, laboratory variables and preoperative radiological examinations were analyzed. Results: Study I- After nephrectomy in 187 patients with non-metastatic RCC, 30% developed metastases during the follow-up. The risk for metastases was greater for more advanced stage and was adjusted by size and DNA ploidy. The median time to the diagnosis of metastases was 14.5 months. Metastases occurred in 43% of the patients within one year, within 2 years in 70% and 80% in 3 years. Patients with tumours less than 5 cm and diploid pT1>5cm and pT2 tumours survived longer than those with larger and aneuploid tumours. The 5-years survival rate for pT1, pT2, pT3 tumours were 95%, 87%, and 37% respectively. In pT3 tumours DNA ploidy had no relation to survival time. Study II and IV- The median survival time for patients with metastatic RCC was 7 months. Cytoreductive nephrectomy was associated with longer survival time. Factors including performance status (PS), number of metastatic sites, erythrocyte sedimentation rate (ESR), calcium in serum, vein invasion, capsule invasion had independent prognostic value with Cox multivariate analysis. Study III- The incidence of adrenal tumour involvement was 5.3 %, unaffected of RCC type, tumour location or side. Gender (male) and locally advanced tumours (pT3 > 5cm) were factors predicting adrenal involvement. The presence of adrenal involvement was a significant adverse prognostic variable, indicating a significantly shorter survival in patients both with and without distant metastases. Conclusion: Optimal follow-up guidelines are important from both medical and economic perspectives. The risk for progression depends mainly on stage, which in combination with other prognostic factors may allow more individualized and cost effective follow-up, in some cases by avoiding unnecessary examinations in a third of the patients. Cytoreductive nephrectomy in patients with good PS, metastases limited to one organ, low ESR, normal calcium and no vein invasion were factors associated to long survival time. Soluble angiogenic factors in serum gave no prognostic information. Ipsilateral adrenalectomy in conjunction with radical nephrectomy should be performed if an adrenal lesion cannot be cleared of suspicion during preoperative work up. Ipsilateral adrenal involvement is a highly adverse prognostic factor and should be staged as M1a in the TNM staging system.

Monitoring is an important tool for gaining insight into an organisation’s environmental performance and for learning about the environmental condition and the effectiveness of environmental management measures. Development of environmental monitoring has generally relied on research aiming at improving monitoring methodology, technique or practice within a particular management tool. Little empirical research has taken into account the organisation’s reality where several management tools are used in parallel. This thesis analyses the practice of environmental monitoring in public authorities with the aim of identifying barriers and possibilities for environmental monitoring as an instrument for improving environmental performance, using the Swedish Rail Administration as a case organisation. The study identified two different types of environmental monitoring: environmental performance measurement (EPM) and activity monitoring, both important for achieving environmental improvements. EPM involves gathering and evaluating data to determine whether the organisation is meeting the criteria for environmental performance set by the management of the organisation. EPM can further be used for judging the success and failure of environmental objectives and strategies. Activity monitoring provides each project of the organisation with information to minimise the negative effects on the natural environment or human health and to ensure that the organisation’s operations conform with regulations. Problems encountered comprised a variety of little co-ordinated monitoring activities, poor utilization of the monitoring results as well as limited internal feedback on monitoring results. Some of the problems identified seem to be an effect of the management transition from a traditional ‘command and control’ system to a self-administered organisation managed by economic incentives and voluntary management systems. This thesis suggests several improvements to make monitoring more efficient. Primarily, the monitoring systems must have a clear structure and be adapted to its specific function. The EPE system would benefit from being integrated with the organisation’s central performance measurement, presenting progress towards organisational strategic objectives as well as operational objectives. The system for activity monitoring must not only focus on inputs and outputs to the system but must also include the environmental condition of the system. In order to improve communication and learning, monitoring data within both EPE and activity monitoring must be better transmitted and utilised within the structure of the permanent organisation. Experience from all monitoring activities that now is scattered and inaccessible to the individuals of the organisation could beneficially be stored within a well-structured organisational ‘memory‘. Such a system would facilitate an iterative management process where the monitoring results and the knowledge gained are used for making future plans and projects more adaptive, thereby improving the environmental performance of the organisation. / QC 20100729

No description available.

The purpose of this study was to determine how often smoking patients receive quit advice and if patient age, and number and type of clinical encounters are associated with odds of receipt. Behavioral Risk Factor Surveillance System (BRFSS) 2000 data were used to study 10,582 smokers (aged ³ 18) having ³ 1 of three types of clinical encounters in the past year: routine checkups, other physician encounters, or dental visits. Multivariate-adjusted odds ratios (ORs) for quit advice by patient age, encounter type, and number of doctor's visits were calculated. Almost 55% of patients were advised to quit smoking. There was a 4-23% chance of receiving quit advice at any given doctor's visit. Odds of receiving advice did not increase with increasing number of visits. With advancing age, men were more likely, women less likely, to receive quit advicebut only significantly for White men. Compared to those having dental visits, ORs for receiving quit advice for patients having checkups and other physician encounters were 3.35 (95% CI 2.ll, 5.31) and 3.03 (95%CI 1.32, 6.97) respectively. These cross-sectional data suggest that whereas a small majority of smoking patients are advised to quit at some clinical encounter, smoking patients are not advised to quit at the majority of encounters. Being young and male, or seeing dentists rather than doctors made patients less likely to receive quit adviceas did having lower education or BMI, no insurance or coverage other than military or private, not having asthma, or not having breast exams or follow-up Papanicolaou smears if female. Based on a previously-reported absolute quit difference of 1.9%, if smoking patients received quit advice just once at any of their encounters with physicians in a year, at least 800,000 more U.S. smokers would quit at an economic savings of $2.4 billion.

I varje projekt finns det brister i kommunikation som kan leda till att kostnad, tid och kvalitét påverkas. Varje projekt är en tillfällig organisation med olika företag och olika personer med varierande erfarenheter inom projektering. Detta medför att varje projekt är i sig unikt och hur alla ska kommunicera med varandra kan vara stora frågetecken under projekteringens förlopp. Denna rapport tittar närmare på vilka brister och svårigheter som kan uppkomma i projekteringskedet.

In Florida, the increased installation of non-traversable medians and directional median opening has produced an increased number of U-turns on multilane highways. Arguments have been advanced by some opponents of median modification projects that the increased numbers of U-turns may result in safety and operational problems on multilane highways. The primary objective of this study is to evaluate the operational effects of U-turn movement on multilane roadways. To achieve this research objective, extensive data were collected. Field measurements were conducted at 40 sites in the Tampa Bay area of Florida to collect traffic operations data. Besides, the crash histories of 179 selected roadway segments in central Florida were investigated. Statistical analysis was conducted based on the collected traffic operations data and crash data to quantitatively evaluate the operational performance of U-turn movement. Delay and travel time were compared for different driveway left- turn alternatives that are widely used in Florida and nationally. Crash rate models were developed to evaluate how the separation distance between a driveway exit and the downstream U-turn bay impacts the safety performance of vehicles making right-turns followed by U-turns (RTUT). With the crash data analysis results, the minimum separation distances under different roadway conditions were determined to facilitate driver use of RTUTs. The capacity of U-turn movement was analyzed under two different situations: (1) U-turns are provided at a signalized intersection; and (2) U-turns are provided at an unsignalized intersection. Adjustment factors were developed to quantify the impacts of the presence of U-turning vehicles on the capacity of a signalized intersection. The critical gaps and follow-up time for U-turn movement at unsignalized intersections were estimated. With the estimated critical gaps and follow-up time, the Harders model was used to determine the capacity of U-turn movem ent at an unsignalized intersection. This study also looks extensively at the minimum roadway width and median width required by vehicles to perform U-turn maneuvers on 4-lane divided roadways. It was found that a roadway width of 46 ft is generally sufficient for most types of design vehicles (except heavy vehicles) to perform a continuous U-turn maneuver without impedance.