Thesis (Ph.D.)--Karolinska institutet, 2006. / Härtill 4 uppsatser Diss. (sammanfattning) Stockholm : Karol. inst., 2006 Available in PDF format via the World Wide Web.

<p>Den här uppsatsen har syftat till att redogöra vilka teorier som presenteras i studielitteraturen för direkt ledarskap i Försvarsmakten och U.S. Army. Uppsatsen har vidare syftat till att redogöra för skillnader och likheter i hur dessa teorier presenteras. Slutligen har syftet varit att visa hur detta påverkar ledare och soldater i praktiken.</p><p>För att genomföra arbetet har litteraturstudier med kvalitativ metod använts. För att visa på ovan nämnda likheter och skillnader har komparation använts.</p><p>Först har fem mätpunkter ställts upp och redogjorts för. Därefter har dessa jämförts och ett resultat har påvisats.</p><p>Resultatet som påvisats är att den jämförda litteraturen har samma ambition med vilken ledarstil som förespråkas samt hur denna beskrivs. Emellertid skiljer sig böckerna åt på ett flertal punkter såsom språkbruk, pedagogisk utformning, vetenskaplighet och användarvänlighet.</p><p>Vidare har konstaterats att ovanstående skillnader troligen påverkar hur ledaren tänker och agerar kring sitt ledarskap vilket förmodligen också påverkar underställda. </p> / <p>The purpose of this study is firstly, to describe the differences and similarities between theories presented in literature on leadership used by the Swedish Armed Forces and the U.S. Army. Secondly, to describe differences and similarities regarding how those theories have been presented in the literature. The final purpose is to find out how this can affect leaders and soldiers in real life.</p><p>To achieve the purposes described above, both a Swedish and an American book have been studied and then compared.</p><p>The comparison is based on five criteria which have been described and then compared and then conclusions have been drawn.</p><p>The result of this study shows that both the Swedish and the American literature focus on Transformational Leadership Style. This style is described in the same way in both books. However differences have been found between the books, which are the use of language, a pedagogical design, a scientific starting point and a user friendliness.</p><p>Finally, the result of the study indicates that the differences mentioned above affect the way a leader acts and looks upon his/her leadership (style) which in its turn influences the relationship between a leader and his/her subordinates.</p>

Den regionala utvecklingspolitikens karaktär har under de senaste decennierna skiftat dramatiskt. Utvecklingen har gått från centralstyrning till allt större regionalt självbestämmande. Från en inriktning på stödinsatser och regional utjämning till en starkare betoning av tillväxt i landets samtliga delar. Begreppet tillväxt har vunnit mark och man talar allt oftare om en regional tillväxtpolitik.  Samtidigt som man i stor utsträckning betonar den ekonomiska tillväxten finns också en ambition att bredda begreppet med en ekologisk och social dimension. Tilltron till att man genom statliga interventioner kan styra samhällsutvecklingen i Sverige har länge varit stark och stora resurser har avsatts för satsningar inte minst inom området för regionalpolitik. Själva logiken bakom interventionerna har dock sällan klarlagts.  I avhandlingen görs det utifrån en specifik regionalpolitisk insats, nämligen resurscentra för kvinnor. Det blir då tydligt hur regionalpolitiken, i form av policyn bakom interventionen, vilar på motsägelsefulla underliggande logiker vilka praktiken sedan i sin tur måste balansera. Något som i flera fall ger upphov till organisatoriska problem i verksamheten. Resurscentra för kvinnor utgör en regionalpolitisk satsning som funnits sedan mitten av 1990-talet och vars tillkomst och utformning delvis kan förstås mot bakgrund av den utveckling av regionalpolitiken som beskrivits ovan. Inrättandet skedde utifrån att man konstaterat att kvinnor varit missgynnade inom regionalpolitiken. Ett genusperspektiv där man i högre utsträckning tog hänsyn till kvinnors lokala och regionala villkor och förutsättningar efterfrågades därför. Som konsekvens av detta inrättades regionala resurscentra för kvinnor i samtliga län, många lokala resurscentra bildades också. Antalet har varierat över tid men det har i Sverige rört sig om ett hundratal regionala och lokala resurscentra. I avhandlingen står särskilt två län i fokus; Södermanland och Västmanland med två regionala och sjutton lokala resurscentra. Avhandlingen som bygger på en studie av resurscentraverksamheten i Södermanland och Västmanland 2004-2006 visar hur flera av de organisatoriska problem verksamheten i praktiken brottas med kan förstås i relation till en motsägelsefull regionalpolitik. Vid en närmare studie av policyn bakom resurscentra kan den förstås som vilandes på tre olika och delvis självmotsägande underliggande logiker. Logiker som verksamheten i praktiken måste hantera och som många gånger ger upphov till motstridiga krav. / The characteristics of regional development policy during the past decades have altered dramatically. The trend has changed from central control to an increasingly larger regional independence; from a focus on support and regional equalization to a stronger emphasis on growth in all parts of the country. The general emphasis has been on economic growth, but there is also an ambition to widen the concept with an ecological and social dimension. The credence of controlling the development of society by means of interventions by the state has for a long time been strong and great resources have been reserved for interventions, not least in the area of regional development. However, the logic behind these interventions has seldom been investigated. This is done in the thesis in which the logic behind the specific regional policy intervention Resource centers for women is derived. From this perspective it becomes apparent how the regional policy, in the shape of the policy behind the intervention, is based on contradicting logics which the resource centers have to balance. This proves to be an unfeasible balance act where the intrinsic inconsistencies cause organizational problems.   Resource centers for women is a regional policy intervention that has been present since the mid 1990s and its establishment and formation can be understood by the background described above. The reason for its founding was that observations had been made that women were disfavored in regional policy. As a result of this, a request was raised of a gender perspective, where women’s local and regional terms were given larger attention. This led to the establishment of Resource centers for women in all Swedish counties; many local resource centers were also founded. The actual number of centers in Sweden has varied over time but there have been around 100 regional and local resource centers. In the thesis, two regions have the center of attention; Södermanland and Västmanland with two regional and 17 local resource centers. The thesis, which is based on a case study of the Resource centers in Södermanland and Västmanland 2004-2006, shows how several of the organizational problems can be understood in relation to a contradicting regional policy. A policy based on three separate and partly contradicting logics that have to be handled in practice by the organization and often is the cause of contradicting requirements.

Bakgrund: I Sverige är bröstcancer den vanligaste formen av kvinnlig cancer och utgör nära en tredjedel av kvinnlig cancer. I behandlingen av bröstcancer har kirurgi en betydande roll. Nära hälften av kvinnorna genomgår mastektomi, men det finns en stor variation inom landet. Att förlora ett bröst efter mastektomi har såväl en kroppslig som psykologisk innebörd. Avhandlingen omfattar fyra delstudier som beskriver detta på olika sätt. Syfte: Det övergripande syftet med avhandlingen är att studera betydelsen av att förlora ett bröst på grund av cancersjukdom samt motiv och beslutsprocess i ställningstagande till att leva med eller utan ett rekonstruerat bröst. Metod: Avhandlingen baseras på två populationer av kvinnor boende i norra Sverige som genomgått mastektomi på grund av bröstcancer: de kvinnor som genomgått mastektomi under 2003 (delstudie I–III) samt de kvinnor som genomgått mastektomi mellan oktober 2006 och september 2007 (delstudie IV). Dessa kvinnor identifierades via det regionala cancerregistret, onkologiskt centrum, Norrlands universitetssjukhus. Statistiska analyser genomfördes i delstudie I och IV och tematisk narrativ analys har tillämpats i delstudie II och III. Resultat: Delstudie I: År 2007 skickades ett nykonstruerat självskattningsformulär ”Life After Mastectomy” (LAM) ut till 149 kvinnor varav 85% (n=126) besvarades. Av dessa kvinnor hade 25% genomgått bröstrekonstruktion. Resultaten av en multipel regressionsanalys visade att bröstrekonstruktion var signifikant relaterat till lägre ålder, känsla av att vara attraktiv och sexuellt intresse. För att få en djupare och mer nyanserad förståelse kring innebörder av att förlora ett bröst efter mastektomi och motiv till att avstå från eller genomgå bröstrekonstruktion gjordes ett strategiskt urval av 15 kvinnor från delstudie I som deltog i en forskningsintervju(delstudie II). I den tematiska narrativa analysen identifierades tre typberättelser. I den första typberättelsen beskrevs mastektomin som ”no big deal” och att genomgå en bröstrekonstruktion var inte ens värt att överväga. I den andra typberättelsen beskrevs mastektomin som ”att förlora sig själv” och en bröstrekonstruktion beskrevs som ett sätt att återställa sig som person, kvinna och sexuell varelse. Den tredje typberättelsen intog en position mellan ”no big deal” och ”att förlora sig själv” och en bröstrekonstruktion beskrevs som ett välkommet erbjudande vilket gjorde det enklare att se och känna sig som kvinna. I delstudie III undersöktes sex kvinnors erfarenheter av att genomgå bröstrekonstruktion. Samtliga kvinnor var oförberedda på den krävande procedur som de genomgick. De beskrev processen som svår och smärtsam med upprepade operationer och en oväntat lång konvalescenstid. Även om kvinnorna var oförberedda på hur tufft det skulle komma att bli både fysiskt och emotionellt beskrevs bröstrekonstruktionen  som betydelsefull för dem. Delstudie IV: I denna uppföljningsstudie inkluderades kvinnorna 10 månader efter mastektomin då självskattningsformuläret LAM skickades ut. Datainsamlingen med samma formulär upprepades två år senare (tre år efter mastektomin). Kvinnornas (n=76) känsla av attraktivitet och kvinnlighet hade inte förändrats mellan de två mättillfällena, med undantag för vissa aspekter av sexualitet som hade försämrats. Vid uppföljningen hade 21% av kvinnorna genomgått bröstrekonstruktion och dessa kvinnor var yngre. I övrigt kundeinga signifikanta skillnader ses mellan de kvinnor som genomgått respektiveej genomgått bröstrekonstruktion. Slutsats: Denna avhandling ger en inblick i betydelsen av att förlora ett bröst efter mastektomi. Att förlora ett bröst efter mastektomi kan vara av mindre eller större betydelse. För de kvinnor som upplevde bröstförlusten som en förlust av sig själva, kom en bröstrekonstruktion att betraktas som en livsnödvändighet (delstudie II). De flesta av kvinnorna 75% i delstudie I och 79% i delstudie IV genomgick inte någon bröstrekonstruktion. De kvinnor som genomgick rekonstruktiv kirurgi beskrev proceduren som svår fysiskt och emotionellt, men trots detta sågs den som viktig för dem (delstudie III). Vid uppföljningen i delstudie IV, var kvinnornas upplevelse av attraktivitet och kvinnlighet oförändrade, men upplevelsen av att känna sig bekväm vid sexuell intimitet utvecklades negativt. Detta var oberoende av om kvinnan genomgått bröstrekonstruktion eller inte, vilket kan ses som överraskande. Det är viktigt att som sjukvårdpersonal uppmärksamma hur den enskilda kvinnan själv upplever betydelsen av att ha förlorat ett bröst för att inte låta sig styras av vaga schabloner kring relationen bröst–sexualitet–kvinnlighet. / Background: Breast cancer is the most common cancer in women, representing nearly one-third of all cancer cases among women in Sweden. The mainstay in breast cancer treatment is surgery and nearly half of the women undergo a mastectomy but there is considerable variation between different counties. Understanding the impact of losing a breast and what motivates women to decide for or against breast reconstructive surgery after mastectomy is necessary in caring for women affected by breast cancer. This PhD thesis comprises four studies that examine this topic in different ways. Aim: The overall aim of the thesis is to explore meanings of losing a breast after mastectomy and what motivates women to opt for reconstruction or no reconstruction of the lost breast. Methods: The thesis is based on two populations, all women who underwent mastectomy in 2003 (Studies I–III) and all women living in northern Sweden who underwent mastectomy during November 2006 to October 2007 (Study IV). The women were identified by the Oncological Centre, at Umeå University Hospital, Umeå, Sweden. In Studies I and IV statistical analyses were performed while in Studies II and III thematic narrative analyses were applied. Results: Study I: in 2007 149 women received a newly developed selfreported questionnaire titled ‘Life After Mastectomy (LAM)’. In total 85% (n=126) of the women completed and returned the questionnaire, 25% of whom had undergone breast reconstruction. Multiple regression analysis showed that these women were younger and scored lower on feelings of attractiveness and higher on sexual activity compared with the women who had opted not to have breast reconstruction. In Study II, to gain a more nuanced understanding of the women’s lived experiences of losing a breast and what had motivated them to opt for or against breast reconstruction, a strategic sample of 15 women from Study I were selected to participate in a research interview. Using thematic narrative analysis of the interviews we identified three types of storylines. In the first storyline the mastectomy was described as ‘no big deal’ and breast reconstruction was not even worth considering. In the second storyline the mastectomy was described as a ‘loss of self’ and the breast reconstruction was perceived as a means to be restored as a person, a woman and a sexual being. The third storyline fell in between ‘no big deal’ and ‘loss of self’, with breast reconstruction described as a welcome offer that made it easier to look and feel like a woman. In Study III, a pilot study, we explored six women’s experiences of undergoing breast reconstructive surgery. All women had not been prepared for the strenuous experience: the process was described as difficult and painful, consisting of several operations and an unexpectedly long recovery period. Although the women were ill prepared for how arduous it would be, both physically and emotionally, having a breast reconstruction had been important to all of them. Study IV: in this follow-up study, women completed the self-reported LAM questionnaire 10 months after mastectomy and again 2 years later, i.e. about 3 years after mastectomy. It appeared that their feelings of attractiveness and femininity had not changed during the follow-up time, except for some aspects of sexuality which had been negatively affected. At follow-up, 21% of the women had undergone breast reconstruction. When comparing these women with those who had not undergone reconstructive surgery, we found no significant differences apart from their younger age. Conclusion: This thesis provides insight into the meanings of losing a breast due to mastectomy. Loss of a breast can be of minor or major importance. For those women who experienced the loss of a breast as a loss of the self, breast reconstruction became a necessity for restoring personhood (Study II). However, most women studied, 75% in study I and 79% in study IV, chose not to undergo breast reconstruction. Those who did, described it as a very tough procedure, both physically and emotionally. Having a breast reconstruction had been important for them (Study III). After a 2-year follow-up of the women (Study IV), their feelings of attractiveness and femininity were unchanged, but not their experiences of sexual intimacy and comfort, which had decreased regardless of whether they had undergone breast reconstruction or not. This finding was unexpected. It is important for health care professionals to be attentive to how women themselves experience the personal meaning of losing a breast. Care professionals should guard against popular preconceptions of the female breast and how it is associated with sexuality and womanliness, and hence of the patient’s needs.

In the European Union political visions of a ‘Social Europe’ are being fuelled by the creation of common EU employment and social policy. The aim of the study is to investigate the workings and dynamics of policy-making in the area of employment, as an integral part of the fashioning of the European Union. Policies are channels for the cultural flows of ideas and notions and are in this way a part of forming ‘society’. The study is an ethnography of the work of bureaucrats in the European Union institutions and the member state governments, in particular in the European Commission and the Swedish government. In this bureaucratic culture of policy-making the Eurocrats move between different EU meetings to negotiate, discuss and decide on common ‘EU’ positions, in this way creating a postnational EU. At the core of the study is the tracing of the policy process of framing the vision of ‘Social Europe’ by the notion of ‘quality in work’. Particular focus is placed on turning this idea into ‘quality in work’ indicators. More specifically, the study explores the processes of making policy decisions quantifiable and transparent, and the assumptions underlying these processes. The development of indicators may be seen as part of a general global trend responding to demands for accountability, transparency and control over policy processes, a trend labelled audit society or audit cultures.

The purification and biochemical characterization of the substance P (SP) hydrolyzing enzyme, substance P endopeptidase (SPE), have been carried out; with subsequent orientation in neurobiological fundamental processes involved in opioid dependence, withdrawal, and heat-stress. SPE was purified from rat spinal cord, human spinal cord and cerebrospinal fluid (CSF), rat ventral tegemental area (VTA), and rat hippocampus. The enzyme activity was found to release the biologically active fragments SP(1-7) and SP(1-8) as major products. The purified enzymes were characterized with regard to their biochemical and kinetic properties. The typical SPE is neither inhibited by phosphoramidon nor captopril nor phenylmethanesulfonylflourid (PMSF). In comparison to other known proteases SPE differed in characteristics regarding substrate specificity, inhibition-profile, cleavage pattern, and other kinetic parameters. The technically very delicate approach of micro purification of SPE from the rat ventral tegemental area (VTA) (this is a very small tissue), turned out to be possible with the ÄKTA™-purifier system. Studies revealed a crucial role of SPE in a series of clinically important neuropathological conditions, such as opioid tolerance, and withdrawal (SPE, increased); and heat-stress (SPE, increased). These findings emerged from assessment of enzyme activity in hypothalamus, nucleus accumbens (NAc) periaqueductal gray (PAG), pituitary, striatum, substantia nigra (SN), VTA, spinal cord. Viewing the role of SPE in morphine tolerance, it was possible to note regional differences with a decrease in PAG, and striatum, whereas an increase was seen in SN, and VTA. After heat-stress treatment, SPE was raised in several regions (cerebral cortex, hippocampus, diencephalon, cerebellum, spinal cord), and the most precise observation of this was located to the hippocampus structure.

The melanocortin (MC) receptors are G-protein coupled receptors thatparticipate in several important physiological functions such as the regulation of the energy balance. This thesis focuses on the evolutionary aspect of the MC receptors and their pharmacology. One MC4 receptor and two MC5 receptor subtypes were found in a teleost fish, zebrafish. This indicates that the MC receptor subtypes arose very early in vertebrate evolution. Important pharmacological and functional properties, as well as gene structure and syntenic relationships have been highly conserved over a period of more than 400 million years implying that these receptors participate in vital physiological functions. Moreover, we found a MC4 receptor from a shark, spiny dogfish that represents the most distant MC receptor gene cloned to date. We also characterized the pharmacology of a MC4 receptor in goldfish. The conserved central expression pattern and physiological role in regulation of food intake of the MC4 receptor suggests that neuronal pathways of the melanocortin system may be important for regulation of energy homeostasis in most vertebrates. We determined the chromosomal position of the chicken MC receptors genes and found conserved synteny of the MC2, MC5, and MC4 receptor genes. These results suggest that there exist a clustering of these genes that is ancient. Analysis of conserved synteny with mammalian genomes and paralogon segments prompted us to predict an ancestral gene organization that may explain how this family has been formed through both local duplication and tetraploidization processes. There are several common point mutations in the human MC1 receptor that are over represented in North European red-heads, and in individuals with pale skin. We pharmacologically characterised four naturally occurring human MC1 receptor variants providing molecular explanation to the respective phenotype. The MC receptor subtypes have highly diverse physiological functions despite having relative high similarities in their primary structure. Our studies on the structural and functional properties of the MC receptor subtypes have provided insight into the molecular mechanism of how the specification of these receptors may have occurred.

Transcatheter Arterial Embolization (TAE) is a method in which a catheter is inserted into an artery under fluoroscopy guidance. By using material that creates a thrombus, inserted through the catheter, the artery can be occluded and the bleeding stopped. Endoscopy is the treatment of choice in upper gastrointestinal (GI) bleeding, but 10% to 30% of patients rebleed and needs other treatment options. Post Partum Hemorrhage (PPH) may evolve rapidly and can become life threatening. Obstetrical treatment will manage most cases, but in some cases emergency surgery is needed and in the worst case hysterectomy. The primary aim of this thesis was to evaluate the clinical usefulness, improve the TAE technique and compare the outcome of TAE with surgery used as “salvage therapy” in patients with upper GI bleeding. Evaluate TAE technique and the long-term effect on the menstrual cycle and fertility in severe PPH. To evaluate the clinical usefulness 13 patients were treated with TAE after endoscopic treatment failure and 5 were treated for recurrent hemorrhage after emergency surgery. The clinical outcome and mortality rate of 40 patients treated with TAE was compared with 51 patients treated with surgery of upper GI bleedings. In 13 patients the ulcer was marked with placement of a metallic clip at endoscopy to be able to locate the exact site of the bleeding ulcer during the TAE procedure. A retrospective study of 20 patients with severe PPH treated with bilateral TAE of the uterine artery was performed. TAE was found to be effective and an alternative to emergency surgery for control of massive upper GI bleeding. The 30-day mortality was lower in the TAE group (3%) compared to the surgical group (14%). By marking the bleeding ulcer at endoscopy using a metallic clip the site of bleeding could be identified on angiography without extravasation of contrast media. No major impact on fertility or menstruation cycle was found in patients treated with TAE in PPH. TAE in PPH is safe and have no major long-term side effect. By using TAE in PPH hysterectomy can be avoided.

Living kidney donation is a clinical situation with unique features in the sense that healthy individuals voluntarily expose themselves to certain risks and inconveniences. Therefore, eliminating as much of the associated discomfort as possible is crucial. The primary aim of this study was to evaluate whether it is possible to use the examination with computed tomography (CT), which is essential to the investigation, also for determining the ratio of the two kidneys’ function – the split renal function. If possible, an examination with gamma camera renography could be excluded from the work-up. To investigate this possibility, 27 subjects who had underwent CT and renography as part of kidney donor investigation were studied retrospectively. The quantity of contrast material in each kidney was considered proportional to that kidney’s function, and measurement was made in each of the two available contrast phases. The results were compared to the results from renography. A similar analysis was conducted in 38 patients investigated for suspected renal artery stenosis with CT and renography, including a study of an automatized method for the acquisition of data from CT. For further scrutiny, a respiratory triggered dynamic contrast-enhanced magnetic resonance imaging (MRI) examination was investigated in 26 individuals. Results of split renal function were compared with renography and with CT in a subgroup. To study the possibility of facilitating the data analysis with CT, a formula for approximation of the contrast attenuation was studied in 64 subjects. An analysis of the significance of choice of contrast phase was also conducted in 43 subjects. Unsatisfactory agreement with renography resulted from the CT analysis of previous donors, partly due to technical shortcomings. However, the technique was recognized to have a potential value. In the subsequent material, the settings were improved, with beneficial effects on the agreement. Respiratory-triggered MRI generated high quality examinations of renal uptake and excretion, with results harmonizing well with renography and CT. The approximation formula applied to CT resulted in higher accuracy for renal volume assessment than with the automatic method, and an acceptable agreement of the split renal function estimate. From the presented results, a revision of the current donor investigation protocol is suggested. CT gives sufficient information to exclude renography as a routine examination. In cases of uncertainty, renography is recommended for secondary evaluation.

Syftet med detta arbete är att försöka ta reda på vilka egenskaper som framtidens ledare kommer att behöva inom den kommunala sektorn, men också om det finns eventuella förutsättningar som måste förändras för framtidens ledare. Tio intervjuer genomfördes med personer på ledande positioner inom fyra kommuner i Mellansverige. Utifrån detta sammanställdes intervjumaterialet, och ur detta framkom tre övergripande huvudområden organisation, egenskaper och framtid som sen utmynnade i ett antal ledord. Mot dessa tolkades teorier i ett försök att koppla de till det framtida ledarskapet. Slutsatsen är att det inte finns bara en teori att förhålla sig till, utan det gäller att kunna hantera kontexten och förutsättningarna, och utifrån den kunna anpassa sig. Ett transformativt synsätt kring ledarskap kan vara ett sätt att lyckas i framtiden.