Objective. Coronary heart disease has been on the rise in poorer countries and decreasing in developed countries over the last twenty years. However, the cardiac-related health-related quality of life (HRQOL) in poorer countries has not been studied. This study aimed to compare HRQOL following heart attack in a developing country in the East with that of a developed country in the West. Using the self-regulation of health and illness behaviour, the relationships between illness beliefs, coping cognitions and HRQOL are studied. Design. This study was a cross-sectional correlational survey and data were collected shortly before myocardial infarction patients were discharged from hospital. Methods. A sample of 243 individuals from the UK and Indonesia were recruited. Illness beliefs were assessed with the B-IPQ, along with coping cognitions (Brief-COPE) and health-related quality of life (MacNew questionnaire). Results. Illness beliefs and coping cognitions predicted HRQOL in the combined sample. Some aspects of socio-demographic and clinical variables were concurrently associated with HRQOL. Conclusion. The results demonstrate that people in the East have low illness beliefs and these are associated with worse HRQOL compared with those in the West. The findings suggest that there is an urgent need for smoking cessation campaigns in the East, while the West could benefit more from tailored-cardiac rehabilitation programme.

Older adults have an increased risk for illness and disease, factors that can lead to functional impairment and intensify the need for reliance on supportive services. Planning for long-term care needs is a vital component of healthy aging and continued autonomy. Yet, many older adults fail to make plans in advance, perhaps due to differences in personal characteristics. The moderating effects of trait hope on the relationship between health-related quality of life (HRQoL) and preparation for future care needs (PFCN) was studied in a sample of 65 older adult primary care patients (<65 years) in western New York. Participants completed a questionnaire on 5 dimensions of PFCN (awareness of risk, information gathering, decisions about care preferences, concrete planning, and active avoidance). In addition, data were collected on five HRQoL domains (physical function, physical role function, emotional role function, social function, and bodily pain) and trait hope. Moderated multiple regression was used to test the moderator hypothesis controlling for personal characteristics. Post-hoc probing was used to further examine significant interactions. At the bivariate level, social functioning, physical functioning, and emotion-based role were inversely related to PFCN and positively related to hope. Multivariate moderation models covarying age, sex, race, education, illness burden, and functional impairment indicated that hopefulness, particularly agentic thinking or goal identification, moderated the relationship between those three HRQoL dimensions and PFCN behaviors. Among those with greater role limitations, lower hope was associated with more awareness of risk and information gathering and less concrete decision making, whereas among individuals with fewer role limitations and better social and physical functioning, higher levels of hopefulness were associated with increased decision making. These results highlight the need for health professionals to gain a better understanding of their patients'intrapersonal characteristics when discussing issues related to future care planning.

Objectives: The primary objective was to assess the impact of two denture fabrication techniques, conventional and CAD/CAM, on oral health-related quality of life (OHRQoL) and patient satisfaction in complete denture wearers. The secondary objective was to compare the level of microorganisms present on complete dentures from the two fabrication techniques. Methods: Twenty-eight completely edentulous subjects (16 men and 21 women, age range from 49 to 87 years old.), who had been edentulous for at least 6 months, were wearing ill-fitting complete dentures, or unsatisfied with their existing complete dentures were recruited. Subjects were randomized to conventional and computer-aided design/ computer-aided manufacturing (CAD/CAM) treatment groups. Subjects in both groups were given the OHIP-EDENT (Oral Health Impact Profile for Edentulous Patients) and patient satisfaction questionnaires to record the data at baseline and at 1 month post-delivery of the new prostheses. Plaque samples were collected from intaglio surfaces of maxillary complete dentures at 1 month post-delivery to culture for any colonization of bacteria and/or yeasts. Results: There was a significant reduction in OHIP-EDENT scores within both treatment groups at the 1 month follow-up (p < 0.05). There was also a significant reduction in almost all OHIP-EDENT domains scores at 1 month. Gender was significantly associated with OHIP-EDENT score at baseline (p = 0.0419) and at 1 month (p = 0.0152). Female subjects tend to have higher OHIP-EDENT scores than male subjects. There was no significant difference in patient satisfaction between treatment groups both at baseline and at the 1 month visit for almost all aspects of satisfaction (p> 0.05). Appearance of maxillary denture was the only significant difference in patient satisfaction across treatment groups (p = 0.0213). The comparisons of microbial counts showed no significant difference between treatment groups. Conclusions: There were no significant difference on oral health-related quality of life (OHRQoL) and patient satisfaction between two treatment groups at baseline and 1 month. There was no significant difference in microbial counts between two treatment groups.

Les antagonistes du récepteur N-méthyl-D-aspartate (NMDA) comme la kétamine, le dextrométhorphane et la mémantine sont utilisés pour la prise en charge de la douleur neuropathique. La kétamine est très efficace contre les douleurs neuropathiques réfractaires aux traitements conventionnels. Cependant, son utilisation est limitée du fait de nombreux effets indésirables. Un relais antalgique est alors proposé. Ce travail de thèse s’insère dans un programme de recherche dédié aux antagonistes du récepteur NMDA dans la prise en charge de la douleur neuropathique. Le premier objectif était d’évaluer dans une étude clinique randomisée, en simple insu, en groupes parallèles, contrôlée versus placebo, les effets antalgiques du dextrométhorphane et de la mémantine, administrés en relais de la kétamine chez 60 patients souffrant de douleurs neuropathiques d’origine périphérique. L’impact de ces traitements sur le statut cognitivo-émotionnel des patients et leur qualité de vie a également été examiné, ainsi que la modulation des effets de ces médicaments par le polymorphisme génétique impliqué dans le métabolisme (CYP2D6, CYP3A4,5), la biodisponibilité et l’élimination (NR1I2) de ces deux molécules. En parallèle une étude mécanistique centrée sur le dextrométhorphane a été réalisée chez vingt volontaires sains (étude randomisée, en double aveugle, en groupes croisés). L’objectif était d’étudier dans un modèle d’hyperalgie induite par le froid « Freeze injury » les caractéristiques pharmacologiques et mécanistiques déterminant les effets anti-nociceptifs, centraux et cognitifs du dextrométhorphane ainsi que le polymorphisme génétique impliqué dans leur modulation. Chez les patients, les effets antalgiques immédiats de la kétamine ont été confirmés et s’accompagnaient de l’amélioration des scores d’anxiété et de dépression, des aspects cognitifs et affectifs et du sommeil. Toutefois, par rapport au placebo, la mémantine et le dextrométhorphane n’ont pas permis de renforcer significativement l’antalgie induite par la kétamine. Chez les volontaires sains, le dextrométhorphane a révélé des effets anti-hyperalgiques suite à une sensibilisation périphérique et centrale. Cependant, aucun effet analgésique sur la douleur thermique aiguë n’a été observé. Ces deux approches clinique et mécanistique concernant l’effet curatif des antagonistes du récepteur NMDA ont permis d’une part de montrer : 1 - chez le patient, l’effet curatif prolongé de la kétamine et l’intérêt du dextrométhorphane et de la mémantine dans la prise en charge du retentissement négatif de la douleur neuropathique sur le statut cognitivo-émotionnel et la qualité de vie des patients; 2 - chez le volontaire sain, l’efficacité anti-hyperalgique du dextrométhorphane sur les phénomènes de sensibilisation périphérique et centrale ainsi que ses répercussions sédatives et cognitives. En complément de ces deux études et dans le but de confirmer en clinique les effets curatifs du dextrométhorphane sur le triptyque douleur-cognition-émotion, une étude clinique randomisée, en double aveugle, en groupes parallèles, contrôlée versus placebo est en cours de réalisation chez 40 patientes souffrant de douleur neuropathique chimio-induite subséquente au traitement du cancer du sein. En conclusion de ce travail de thèse, l’étude des effets du dextrométhorphane dans deux populations différentes souligne l’intérêt de la recherche translationnelle. Chez le sujet volontaire sain, le dextrométhorphane exerce un effet anti-hyperalgique marqué et provoque des effets centraux délétères. Chez le patient présentant une douleur neuropathique d’origine périphérique et étant répondeur à la kétamine, seule une tendance est observée en faveur de l’effet anti-nociceptif du dextrométhorphane donné en relais de la kétamine. En revanche l’administration de dextrométhorphane s’accompagne d’un certain bénéfice au niveau cognitif et sur la qualité de vie des patients. / N-methyl-D-aspartate (NMDA) receptor antagonists such as ketamine, dextromethorphan and memantine have gained an increasing interest in the management of neuropathic pain. In Pain Clinics, ketamine is widely used in the relief of neuropathic pain. However, its use in clinical practice is limited due to its numerous side effects. It is therefore necessary to propose to patients a drug relay with other NMDA receptor antagonists. This work is part of an academic program research dedicated to NMDA receptor antagonists in the management of neuropathic pain. Its first objective was to evaluate the antalgic effects of dextromethorphan and memantine. This randomized, single-blind, parallel-group, placebo-controlled study in 60 ketamine responder patients aimed also to assess the cognitive-emotional status of patients and their quality life. In parallel, a mechanistic study focusing on dextromethorphan was performed in 20 healthy volunteers in a randomized, double-blind, cross-over, placebo-controlled study. The objective was to investigate in a freeze-injury model the pharmacokinetic and mechanistic characteristics of the anti-nociceptive, central and cognitive effects of dextromethorphan as well as the genetic polymorphism involved in its response variability.In patients, the immediate analgesic effects of ketamine were confirmed with improved anxiety and depression scores, cognitive and affective aspects of pain, and different sleep parameters. However, memantine and dextromethorphan, compared to placebo, did not significantly increase the ketamine-induced analgesia. The analysis of the genetic polymorphism did not reveal any variability in the analgesic efficacy of these treatments. In healthy volunteers, dextromethorphan revealed anti-hyperalgesic effects following peripheral and central sensitization but no analgesic effect on acute heat pain. Moreover, the variability of the anti-nociceptive activity of dextromethorphan described in the literature seems to be more related to the genetic polymorphism of the CYP2D6 gene than to that of the CYP3A4,5 and ABCB1 genes. Finally, dextrorphan, the main active metabolite of dextromethorphan, appears to be responsible for the deleterious sedative and cognitive effects of the drug. These two clinical and mechanistic approaches concerning the curative effect of the NMDA receptor antagonists showed : 1 - in patients, the prolonged curative effect of ketamine and the interest of dextromethorphan and memantine in the management of the neuropathic pain-related cognitive-emotional and quality of life impairment; 2 - in healthy volunteers, the anti-hyperalgesic efficacy of dextromethorphan on peripheral and central sensitization and its sedative and cognitive side effects. In addition to these two studies, a randomized, double-blind, parallel-group, placebo-controlled clinical study is ongoing in 40 patients with chemotherapy-induced peripheral neuropathic pain subsequently to the treatment of breast cancer. In conclusion the assessment of the effects of dextromethorphan in two different populations led to discordant results. In the healthy volunteer, dextromethorphan exerts a marked anti-hyperalgesic effect and causes deleterious central effects. In the patient with peripheral neuropathic pain, only a trend is observed in favor of the anti-nociceptive effect of dextromethorphan given in ketamine responder patients. More studies with larger population are needed to determine the importance of the CYP2D6, CYP3A4,5 and ABCB1 genetic polymorphisms on the anti-nociceptive activity of dextromethorphan. The translational approach of this thesis does not allow a firm conclusion on the clinical use of dextromethorphan in the curative treatment of chronic peripheral neuropathic pain. The use of dextromethorphan as a preventive agent via other administration routes (i.e. local) or in combination with other drugs, all require further exploration in order to improve the benefit/risk ratio of this molecule.

L’organisation mondiale de la santé et la fédération dentaire internationale appellent depuis plusieurs décennies les gouvernements à fédérer les actions de prévention des pathologies buccodentaires et des maladies chroniques. L’élaboration des programmes de promotion de la santé doit s’appuyer sur l’identification préalable des besoins des populations. L’objectif de ce travail est de recueillir les éléments nécessaires à la mise en place d’un programme de promotion de la santé buccodentaire en Nouvelle-Calédonie. Dans un premier temps, l’état buccodentaire et les déterminants sociaux, environnementaux et comportementaux qui sont liés à la santé orale ont été évalués dans un échantillon représentatif des enfants de 6 ans, 9 ans et 12 ans scolarisés en Nouvelle-Calédonie. Dans un deuxième temps, les déterminants de santé communs pour les maladies buccodentaires et métaboliques ont été recherchés chez les pré-adolescents de 12 ans, afin de vérifier la pertinence d’une approche préventive ciblée par facteurs de risque commun. De plus, dans le cadre de cette enquête, l’évaluation de la qualité de vie en relation avec la santé orale était nécessaire. Pour cela, le questionnaire Child Oral Health Impact Profile (COHIP) a été validé dans une version française adaptée au contexte néo-calédonien dans le cadre de ce travail. Enfin, en tenant compte des résultats de ces évaluations et des recommandations en promotion de la santé, ce travail propose qu’un programme de promotion de la santé orale soit intégré en complément des programmes de santé déjà existants en Nouvelle-Calédonie. / The World Health Organization and the World Dental Federation are calling for decades governments to unite actions to prevent oral diseases and chronic diseases. Curriculum development of health promotion programs should be based on prior identification of needs. The objective of this work is to gather the information needed to set up a program to promote oral health in New Caledonia. Initially, dental status and the social, environmental and behavioral determinants that are related to oral health were assessed in a representative sample of children aged 6, 9 and 12 years schooled in New Caledonia. Secondly, common determinants for oral and metabolic diseases were investigated in pre-teens, to verify the relevance of targeted preventive approach by common risk factors. In addition, as part of this investigation, the assessment of oral health related quality of life was necessary. For this, the questionnaire Child Oral Health Impact Profile (COHIP) was validated in a suitable French version for New Caledonia as part of this work. Finally, taking into account the results of these evaluations and recommendations for health promotion, this work proposes an oral health promotion program to be integrated with existing programs in New Caledonia.

<p>Delirium is common among old patients admitted to hospital, but is often a neglected problem in patient care. The principal aim of this thesis was to evaluate aspects of delirium in relation to incidence, risk factors, behavioural changes, cognitive function and health-related quality of life (HRQOL). A further aim was to describe patients’ experiences of being delirious. The study was prospective, descriptive and comparative, with repeated measures (six-month follow up). The sample consisted of 225 consecutive patients, aged 65 years or older, who were to be operated on due to hip fracture or hip replacement. Exclusion criteria were serious cognitive disorder or delirium on admission. Data were collected via frequent daily observations, cognitive functioning tests (MMSE), HRQOL questionnaires (SF-36) and interviews. Delirium was assessed according to the DSM-IV criteria. A total of 45/225 became delirious, with an incidence of 24.3% among patients undergoing hip fracture surgery and 11.7% among those with hip replacement surgery. A predictive model for delirium included four factors: impaired hearing, passivity, low cognitive functioning, and waiting more than 18h for hip fracture surgery. Disorientation and urgent calls for attention were the most frequent behavioural changes in the prodromal phase prior to delirium. Delirium in connection with hip fracture revealed deteriorated HRQOL and cognitive functioning when measured at a six-month follow-up. The experience of being delirious was described by the patients as a sudden change of reality. Such an experience gave rise to strong emotional feelings, as did recovery from delirium. Nurses’ observations of behavioural changes in old patients with impaired cognitive function may be the first step in managing and reducing delirium. The predictive model of delirium ought to be tested further before use in clinical practice.</p>

<p>The overall aims of the studies were to investigate the effects of different training modalities on exercise capacity and health-related quality of life (HRQoL) in patients with moderate or severe COPD and, further, to explore two of the physical tests used in pulmonary rehabilitation.</p><p>In <b>study I</b>, the 12-minute walking distance (12MWD) did not increase on retesting in patients with exercise-induced hypoxemia (EIH) whereas 12MWD increased significantly on retesting in the non-EIH patients. In <b>study II</b>, we found that the incremental shuttle walking test was as good a predictor of peak exercise capacity (W peak) as peak oxygen uptake (VO₂ peak) is. In <b>study III</b>, we investigated the effects of two different combination training programmes when training twice a week for eight weeks. One programme was mainly based on endurance training (group A) and the other on resistance training and callisthenics (group B). W peak and 12MWD increased in group A but not in group B. HRQoL, anxiety and depression were unchanged in both groups. Ratings of perceived exertion at rest were significantly lower in group A than in group B after training and during 12 months of follow-up. Twelve months post-training, 12MWD was back to baseline in group A, but significantly shorter than at baseline in group B. Thus, a short endurance training intervention delayed decline in 12MWD for at least one year. Patients with moderate and severe COPD responded to training in the same way. In <b>study IV</b>, both interval and continuous endurance training increased W peak, VO₂ peak, peak exhaled carbon dioxide (VCO₂ peak) and 12MWD. Likewise, HRQoL, dyspnoea during activities of daily life, anxiety and depression improved similarly in both groups. At a fixed, submaximal workload (isotime), the interval training reduced oxygen cost and ventilatory demand significantly more than the continuous training did.</p>

The overall aim of this thesis was to describe experiences of emergency treatment among people injured in traffic accidents, and to test and evaluate the effects of follow-up telephone calls from a nurse during the subsequent phase. The thesis is based on four sub-studies of motorists, bicyclists, and pedestrians who had fallen in traffic during the years 2002-2005. The participants were aged 18 to 70 years old and had minor (MAIS 1) or nonminor (MAIS 2+) injuries. Sub-study I was a qualitative study in which individual narrative interviews were conducted with nine persons who had sustained traffic injuries. The aim of this study was to describe the injured individuals’ experiences of pre-hospital and hospital care and subsequent rehabilitation. The interviews were analysed using content analysis, and the experiences of the interviewees were formulated into four themes: facing commotion, experiencing trust and security, lacking security and support, and struggling to return to everyday life. The results showed that a sensitive caregiver who provides comprehensible information facilitates both the emergency treatment and the subsequent period of care and rehabilitation. Sub-study II was a cross-sectional study in which the participants (n=565) estimated their perceptions of the quality of care in the accident and emergency department (A&amp;E) after an injury event. The Mini-KUPP (“Quality from the Patient’s Perspective”) questionnaire was used to estimate quality of care at the A&amp;E. The questionnaire was posted to the subjects’ home addresses three weeks after the visit to the A&amp;E. The results showed that the quality of care was scored on the top half of the scale by all three road user categories. In a multiple logistic regression analysis, significant connections emerged between good quality of care and a short waiting time, non-minor injuries (MAIS2+), higher age, and higher levels of education. The factor most closely associated with the perception of good quality of care was a short waiting time. Sub-study III was a stratified and randomised intervention study including 568 injured persons. In addition to modern trauma care, the intervention group received follow-up via telephone, three weeks after the injury, by a nurse who provided advice and support during the rehabilitation period. The control group received modern trauma care but no follow-up. Both groups estimated their health-related quality of life two weeks (baseline) and six months after the injury. After six months, estimates of health-related quality of life were generally higher in the intervention group than in the control group. A sub-group analysis found that the differences were most pronounced for the group who had received adequate advice in connection with the telephone follow-up. Of the three road user categories, the motorists gained the greatest benefit from the telephone intervention, with milder problems with regard to pains/difficulties and essential activities. Sub study IV was a health economic study. The calculations were built on the results from study III (n=568). A cost utility analysis was performed, including the costs for the intervention and the QALYs gained. The results showed that the telephone intervention was cost-effective. The total gain in the intervention group was 2.60 QALYs, while the car occupants gained 1.54 QALYs. The cost per QALY gained was 16 000 SEK overall and 8 500 SEK for car occupants. Conclusion: A sensitive caregiver who also provides good information can instil security and trust in the patient. For the purposes of generally improving the quality of care in an A&amp;E, the aim above all should be a short waiting time, but the treatment of minor injuries should also be improved. Access to a supportive nurse who is able to provide advice during the subsequent phase has the potential to improve health-related quality of life in a cost-effective way.

Delirium is common among old patients admitted to hospital, but is often a neglected problem in patient care. The principal aim of this thesis was to evaluate aspects of delirium in relation to incidence, risk factors, behavioural changes, cognitive function and health-related quality of life (HRQOL). A further aim was to describe patients’ experiences of being delirious. The study was prospective, descriptive and comparative, with repeated measures (six-month follow up). The sample consisted of 225 consecutive patients, aged 65 years or older, who were to be operated on due to hip fracture or hip replacement. Exclusion criteria were serious cognitive disorder or delirium on admission. Data were collected via frequent daily observations, cognitive functioning tests (MMSE), HRQOL questionnaires (SF-36) and interviews. Delirium was assessed according to the DSM-IV criteria. A total of 45/225 became delirious, with an incidence of 24.3% among patients undergoing hip fracture surgery and 11.7% among those with hip replacement surgery. A predictive model for delirium included four factors: impaired hearing, passivity, low cognitive functioning, and waiting more than 18h for hip fracture surgery. Disorientation and urgent calls for attention were the most frequent behavioural changes in the prodromal phase prior to delirium. Delirium in connection with hip fracture revealed deteriorated HRQOL and cognitive functioning when measured at a six-month follow-up. The experience of being delirious was described by the patients as a sudden change of reality. Such an experience gave rise to strong emotional feelings, as did recovery from delirium. Nurses’ observations of behavioural changes in old patients with impaired cognitive function may be the first step in managing and reducing delirium. The predictive model of delirium ought to be tested further before use in clinical practice.

Chronic obstructive pulmonary disease, COPD, places a substantial burden of disability on the growing number of patients and causes large costs for the society. Tobacco smoke is the most important risk factor. Progressive exertional dyspnea is the major symptom which leads to diminished physical and social activities, reduced physical capacity and decreased health related quality of life, HRQoL. The aim of this thesis was to evaluate different physical training modalities in patients with COPD with regard to physical capacity and HRQoL. Patients with moderate to severe COPD were included in the studies. In the first intervention, 20 patients trained on a treadmill with or without supplemental oxygen, three times per week, during eight weeks. In the second intervention, 30 patients were randomised to high-intensity group training either in water or on land, and 13 patients were included in a control group. The patients in the water and land groups trained three times per week during three months and once a week during the following six months. Oxygen supplementation during physical training did not enlarge the positive effects of the same training with air in patients with exercise-induced hypoxaemia. Both groups improved the distance walked after training. High-intensity group training in water and on land was found to be effective with regard to walking distance and HRQoL compared to the control group. Training in water seemed to be of greater benefit compared to training on land concerning walking distance and experienced physical health when the training was accomplished three times per week. The thigh muscle strength increased after training in both the water and the land group. The muscle endurance in knee extension was low in the majority of the patients and was not improved after the training intervention. An evaluation of the long-term effects of physical group training and the effects of decreased training frequency showed that training with low frequency (once a week) during six months did not seem to be sufficient to maintain the level achieved after a three months period of higher frequency training (three times per week). However, the two periods combined seemed to prevent decline in physical capacity and HRQoL compared to baseline. The conclusion is that physical training is of benefit for patients with COPD with regard to physical capacity and HRQoL. Training can be performed individually or in groups, with high intensity, in water and on land. It is also concluded that the training can, under controlled conditions, be performed without supplemental oxygen even in patients with exercise-induced hypoxaemia.