Diss. (sammanfattning) Linköping : Univ., 2003. / Härtill 4 uppsatser.

<p>Tuberkulos (tbc) är en luftburen droppsmitta orsakad av mykobakterium tuberkulosis. Tbc är den sjukdom som efter AIDS orsakar flest dödsfall, trots att botande behandling finns. Behandlingen är krävande för den tbc-smittade att genomgå och bygger på en kombination av en rad antibiotika som måste intas under minst sex månader. Ett avvikande i behandlingen kan resultera i att mykobakterium tuberkulosis blir resistent mot de ordinerade antibiotika. Följsamhet av långtidsbehandlingar som tbc-behandling graderas till 50 %. Syftet med litteraturstudien var att ur ett globalt perspektiv beskriva hur sjuksköterskan kan påverka följsamhet vid tbc-behandling i syfte att minska resistensutvecklingen av mykobakterium tuberkulosis. Studien genomfördes som en litteraturstudie där 12 vetenskapliga artiklar granskades och analyserades. Resultatet visar tydligt att specifika faktorer påverkar följsamhet och därigenom resistensutvecklingen. Faktorerna innefattar patientundervisning, behandlingsstrategier, omgivningens påverkan och stöd.  Undervisningen resulterar i att patienten får ökad förståelse för behandlingen. För att minska stigmatiseringen och det lidande den innebär för den tbc-smittade är även omgivningen i behov av ökad kunskap och information om tbc. Ett flertal studier visar att DOTS-strategin är betydelsefull för ökad följsamhet vid antituberkulos behandling. Litteraturstudien medför ett förslag om att sjuksköterskeprogrammet ska öka fokuseringen på följsamhet vid läkemedelsanvändning. Sjuksköterskan är i behov av att redan under grundutbildningen få kunskap om ansvarsfull antibiotikahantering som leder till en följsamhetsomtanke.</p> / <p>Tuberculosis (TB) is an airborne droplet infection caused by mycobacterium tuberculosis. TB is the disease after AIDS that is most deadly, even though curative treatment exists. The treatment is demanding for the TB-infected to undergo and consists of a combination of a number of antibiotics that must be administered for at least six months. A dissenting in anti-tuberculosis treatment might result in mycobacterium tuberculosis strains that are resistant to antibiotics. As adherence to long-term treatment is graded at a low percentage (50 %) the aim of the literature study was from a global perspective to develop a working-strategy for nurses that promote compliance in TB-treatment in order to reduce resistance development of mycobacterium tuberculosis. The study was conducted as a literature study where 12 research articles were reviewed and analyzed. The results describe specific factors that are essential to compliance. These factors comprise patient education, treatment strategies, social influences and support. As knowledge gives the patient a better understanding for the treatment it provokes compliance. The social environment of the TB-infected patient demands increased knowledge in order to reduce stigma. Several studies show that the DOTS strategy is important for increasing compliance in anti-tuberculosis treatment. The literature study results in a proposal for the nursing program to focus more on compliance in taking medication. The nursing program’s attendants need to gain knowledge about prudent antibiotic treatment that leads to a compliance concern.</p>

Background: Patients with sleep apnea have frequent apneas and hypopneas during sleep. Apneas can be either central or obstructive. The apnea-hypopnea index (AHI) is the mean number of apneas and hypopneas per hour of sleep. Aims: 1) To evaluate the effect of a mandibular advancement device on obstructive apneas and sleep; 2) to evaluate the influence of body position on central apnea frequency; 3) to investigate whether obstructive or central apnea is related to mortality in patients with stroke; and 4) to investigate sleep and sleeping positions in women. Methods: Subjects were investigated during whole-night sleep respiratory recordings, either polysomnography including continuous recordings of EEG, EOG, EMG, airflow, respiratory effort, ECG, pulse oximetry and body position, or simplified sleep apnea recordings without EEG, EOG and EMG. Results: The frequency of obstructive apneas, hypopneas and arousals decreased and rapid eye movement (REM) sleep increased in patients with mild, moderate and severe sleep apnea during treatment with a mandibular advancement device. Central apneas were more prevalent in the supine position compared with the non-supine position in patients with Cheyne-Stokes respiration. The mean ± SD central AHI was 41 ± 13 in the supine position and 26 ± 12 in the non-supine position, p&lt;0.001. Stroke patients with obstructive sleep apnea ran an increased risk of death during 10 ± 0.6 years of follow-up with an adjusted hazard ratio of 1.76 (95% CI 1.05-2.95) compared with controls, independent of hypertension, age, body mass index, gender, smoking, diabetes mellitus, atrial fibrillation, Mini-Mental State Examination and Barthel-ADL. Central apnea was not related to early death. Total sleep time, sleep efficiency, rapid eye movement sleep, slow wave and time in the supine position decreased with age in women. Sleep quality in women was reduced with age, body mass index, obstructive sleep apnea, smoking, alcohol and hypertension. Conclusions: Obstructive sleep apneas and arousals are reduced and REM sleep is increased using a mandibular advancement device in patients with mild, moderate and severe sleep apnea. The frequency of central apneas and hypopneas is increased in the supine position in patients with Cheyne-Stokes respiration. Stroke patients with obstructive sleep apnea run an increased risk of early death. Central sleep apnea was not related to early death among the present patients. Normal values for sleep stages and sleeping positions are presented in a population-based sample of women. Age, body mass index, obstructive sleep apnea, smoking, alcohol and hypertension reduce sleep quality in women.

Background: Tobacco smoking is the main cause of chronic obstructive pulmonary disease, COPD, but the mechanisms by which cigarette smoke induces COPD are still elusive. T lymphocytes have been implicated in the pathogenesis of the disease, but their role in the airway inflammation in COPD is not fully understood. The aim of this thesis was therefore to address T lymphocyte subsets and their activation in the airways of subjects with COPD, in comparison to smokers with normal lung function (S) and never smokers (NS). Methods: Subjects with moderate to severe COPD were recruited along with controls. They were all non-atopic and clinically stable, without any exacerbation during at least three months prior to inclusion. Only medication with short-acting β2-agonists and/or anti-cholinergic drugs was permitted. All subjects underwent bronchoscopy with endobronchial mucosal biopsy sampling as well as bronchial wash, BW, and bronchoalveolar lavage, BAL, collection. Biopsies were immunohistochemically stained for inflammatory cells and markers. BW and BAL fluids were prepared for differential cell counts. Soluble markers were measured in BW and lymphocyte subsets were determined in BAL using flow cytometry. Results: In biopsies, an increase in epithelial CD3+ and CD8+ cells was found in COPD, compared to NS. In BAL fluid, CD8+ cells were enhanced, whereas CD4+ cells were reduced in subjects with COPD and S, compared to NS. Furthermore, CD4+ and CD8+ cells were more activated both in COPD and S, in terms of increased expression of CD25, CD69 and HLA-DR. NKG2D-expressing CD8+ T cells in BAL fluid were enhanced in both COPD and S. CD4+CD25bright cells were upregulated in COPD and S, suggesting the presence of regulatory T cells. Further analyses of T cell subsets with the more specific markers for regulatory T cells, FoxP3 and CD127, indicated a smoking-induced expansion of non-regulatory T cells, which tended to normalize after smoking cessation in COPD. Currently smoking subjects with COPD still expressed high proportions of activated non-regulatory CD4+ T cells. The data on FoxP3 expression further indicated that the increase in CD25 expression in COPD and S was not only associated with the expansion of regulatory T cells. As CD127 expression is reported to be inversely associated with FoxP3, the data indicate the expansion of a non-regulatory CD25+ population in smokers and patients with stable COPD. The immunohistochemical staining for the NKG2D ligands MICA and MICB on epithelial cells was unchanged. Conclusion: The results of this thesis suggest a role for CD4+ and CD8+ T-cells in clinically stable COPD, indicating that T-cells are of importance in the long-term inflammatory response in COPD. Regardless of current smoking habits, activated CD8+ T lymphocytes were found to be increased in BAL fluid from subjects with COPD, suggesting that changes in CD8+ T cells are associated with a persistent immune response and, thus, of importance in COPD pathogenesis. In contrast, the expansion of non-regulatory CD25+CD4+ cells in BAL fluid seemed to be preferentially smoke-related. In summary, the data indicate that, among airway T cells, changes in CD8+ cells seem to be highly associated with COPD pathogenesis, whereas changes in CD4+ cells appear to be related to cigarette smoke-induced responses. Further, a non regulatory population of helper T cells was identified in BAL fluid of COPD patients, which may contribute to the persistent cytotoxic T cell responses.

<p><strong>Aim:</strong> The aim of this study was to describe the total energy expenditure (TEE) and physical activity levels (PAL) within a group of children with cystic fibrosis (CF) and to compare the results with a control group with healthy children. The aim also was to compare the rated activity levels between the groups as well comparing the difference between boys and girls within the groups. <strong>Method:</strong> The study included 30 participating children, divided into two groups with 15 participants in each group. One of the groups was a CF-group and the other a group of controls, matched for gender and age. Activity diaries were studied and data were presented decrepitly and analyzed with Wilcoxon rank sum test. <strong>Result:</strong> The result showed no difference between the groups while comparing TEE and PAL. Half of the participants in both groups (53,34 % and 46,67 %) reached a moderate or high physical activity level during the registration. No significance was proved between the groups as they rated their activity level, numbered 6-9, in their activity diaries. Neither could any differences be proved significant in rated activity between the boys and girls within the groups. <strong>Conclusion:</strong> The conclusion was that no significant differences appeared regarding TEE or PAL between the CF-group and the control group participating in this study. Neither were there any differences in activity level between boys and girls within the groups.</p> / <p><strong>Syfte:</strong> Syftet med studien var att beskriva energiomsättning och fysisk aktivitetsnivå hos en grupp barn med cystisk fibros (CF) och jämföra resultatet med friska barn i en kontrollgrupp. Syftet var också att jämföra skattade aktivitetsnivåer mellan grupperna samt mellan flickor och pojkar inom de båda grupperna. <strong>Metod:</strong> I studien deltog 30 barn, indelade i två grupper om 15 deltagare. Grupperna var en CF-grupp och en kontrollgrupp matchad efter kön och ålder. Aktivitetsdagböcker granskades och data sammanställdes och data presenterades deskriptivt och analyserades med Wilcoxsons rangsummetest. <strong>Resultat:</strong> Resultatet visade att det inte fanns skillnad mellan de båda grupperna vid jämförelse av TEE och PAL. Ungefär hälften av alla deltagare (53,34 % resp. 46,67 %) nådde moderat eller hög aktivitetsnivå under de registrerade dagarna. Det förekom ingen signifikant skillnad mellan grupperna med avseende antal skattade 6-9:or i aktivitetsdagboken. Inte heller någon skillnad mellan könen inom de båda grupperna kunde påvisas. <strong>Slutsats:</strong> Slutsatsen var att det inte fanns någon signifikant skillnad beträffande energiomsättning eller fysisk aktivitet mellan barn med CF och friska barn som deltog i denna studie. Inte heller kunde någon skillnad i aktivitetsnivå mellan könen inom grupperna påvisas.</p>

In chronic inflammatory diseases like asthma or rheumatoid arthritis, erroneous and exaggerated accumulation of leukocytes in a tissue inadvertently causes the body harm. Several efficient anti-inflammatory drugs exist, for example corticosteroids and cyclo-oxygenase inhibitors. However, these drugs have potent and diverse effects and often act by inhibiting events subsequent to initiation of the inflammatory response, leading to more or less severe side-effects, especially when used in high doses for long periods of time. For this reason, strategies aimed at early inhibition of recruitment and activation of leukocytes have been suggested as safer and more specific approaches to reduce inflammation. Leukocyte adhesion to activated endothelium is a prerequisite to the following activation and extravasation, and takes place in the initial phase of inflammation. By using a model that allows leukocytes to adhere to tumour necrosis factor (TNF)-activated endothelial cells, thus mimicking aspects of an inflammatory reaction, we found that uridine, 4-thiouridine and isomaltitol could all reduce adhesion. This suggested that they may have anti-inflammatory potential. We therefore tried the three substances in a Sephadex-induced lung inflammation model and found that uridine and 4-thiouridine have several anti-inflammatory effects, such as being able to reduce leukocyte accumulation, decrease TNF protein levels and partly inhibit the oedema induced by Sephadex. Isomaltitol turned out to have immunomodulating, rather than anti-inflammatory, effects, which could be of interest in diseases where inadequate inflammatory responses are a problem.

The overall aim of this thesis was to describe subjects with chronic obstructive pulmonary disease (COPD) from different perspectives. Focus was on patients at the time of diagnosis, impact of the disease in comparison to other chronic diseases, factors associated with good health and quality of life (QoL), and diagnostic spirometry in clinical practice. Methods: Qualitative method, grounded theory, was used to analyse patients´ perspectives at the time of diagnosis in a primary care setting (n=10). Public health surveys in the general population were used to compare chronic diseases (n=10,755) and analyse factors associated with health outcomes in COPD (n=1,475). Medical records and spirometry reports, from primary and secondary care, were analysed to assess diagnosis of COPD in clinical practice (n=533). Results: In clinical practice, 70% of patients at the time of diagnosis of COPD lacked spirometry results confirming the diagnosis. Factors related to consequences of smoking, shame and restrictions in physical activity (PA) in particular, were described by patients at the time of diagnosis of COPD. In general subjects with COPD (84%), rheumatoid arthritis (74%) and diabetes mellitus (72%) had an activity level considered too low to maintain good health. In COPD, the most important factor associated with good health and quality of life was a high level of PA. Odds ratios (OR (95%CI)) varied from 1.90 (1.47-2.44) to 7.57 (4.57-12.55) depending on the degree of PA, where subjects with the highest PA level had the best health and QoL. Conclusions: Subjects with COPD need to be diagnosed at an early stage, and health professionals should be aware that feelings of shame could delay patients from seeking care and thus obtaining a diagnosis. The use of spirometry and the diagnostic quality should be emphasised. In patients with COPD greater attention should be directed on increasing the physical activity level, as patients with a low level of physical activity display worse health and quality of life.

Bakgrunden till studien bygger på ett samarbete mellan sjukgymnastprogrammet på Mälardalens högskola och ett sjukhus i Sörmlands läns landsting. Syftet var att utvärdera om behandling bestående av fyra veckors KOL-skola haft effekt på patienternas hälsa, välbefinnande och fysiska kapacitet. KOL-skolan bestod utav fyra tillfällen under vilka olika vårdprofessioner gav patienterna information om bl.a. symptompåverkan, känslomässiga upplevelser och vikten av fysisk aktivitet. Det var tio patienter med kronisk obstruktiv lungsjukdom (KOL) i stadium två till fyra som deltog i interventionen. Utvärderingsinstrument som användes var The St George’s Respiratory Questionnaire och sex minuters gångtest. Resultaten visade att ingen signifikant skillnad i enkäten eller sex minuters gångtest förelåg efter intervention för gruppen. Tidigare forskning har visat att de psykosociala faktorerna har en stor inverkan på patienter med KOL och deras välbefinnande. Författarna anser därför att framtida forskning och verksamhetsutveckling bör utforma behandlingsstrategier för patienter med KOL utifrån den biopsykosociala modellen. / The background of this study is based on a cooperation between the physiotherapy program at Mälardalen University and a hospital in the county of Södermanland. The aim of the study was to evaluate whether a four week treatment of COPD-school have had an impact on patient health, well being and physical capacity. The COPD-school consisted of four occasions in which different health care professionals gave patients information on subjects including; symptom impact, emotional experiences and the importance of physical activity. There were ten patients with chronic obstructive pulmonary disease (COPD) in stage two to four who participated in the intervention. The instruments for evaluation that were used were The St. George's Respiratory Questionnaire and six minute walk test. The results showed no significant difference in the survey or six minute walk test for the group after the intervention. Previous research has shown that psychosocial factors have a profound effect on patients with COPD and their wellbeing. The authors therefore believe that future research should focus on designing treatment for patients with COPD based on the biopsychosocial model.

Aim: The aim of this study was to describe the total energy expenditure (TEE) and physical activity levels (PAL) within a group of children with cystic fibrosis (CF) and to compare the results with a control group with healthy children. The aim also was to compare the rated activity levels between the groups as well comparing the difference between boys and girls within the groups. Method: The study included 30 participating children, divided into two groups with 15 participants in each group. One of the groups was a CF-group and the other a group of controls, matched for gender and age. Activity diaries were studied and data were presented decrepitly and analyzed with Wilcoxon rank sum test. Result: The result showed no difference between the groups while comparing TEE and PAL. Half of the participants in both groups (53,34 % and 46,67 %) reached a moderate or high physical activity level during the registration. No significance was proved between the groups as they rated their activity level, numbered 6-9, in their activity diaries. Neither could any differences be proved significant in rated activity between the boys and girls within the groups. Conclusion: The conclusion was that no significant differences appeared regarding TEE or PAL between the CF-group and the control group participating in this study. Neither were there any differences in activity level between boys and girls within the groups. / Syfte: Syftet med studien var att beskriva energiomsättning och fysisk aktivitetsnivå hos en grupp barn med cystisk fibros (CF) och jämföra resultatet med friska barn i en kontrollgrupp. Syftet var också att jämföra skattade aktivitetsnivåer mellan grupperna samt mellan flickor och pojkar inom de båda grupperna. Metod: I studien deltog 30 barn, indelade i två grupper om 15 deltagare. Grupperna var en CF-grupp och en kontrollgrupp matchad efter kön och ålder. Aktivitetsdagböcker granskades och data sammanställdes och data presenterades deskriptivt och analyserades med Wilcoxsons rangsummetest. Resultat: Resultatet visade att det inte fanns skillnad mellan de båda grupperna vid jämförelse av TEE och PAL. Ungefär hälften av alla deltagare (53,34 % resp. 46,67 %) nådde moderat eller hög aktivitetsnivå under de registrerade dagarna. Det förekom ingen signifikant skillnad mellan grupperna med avseende antal skattade 6-9:or i aktivitetsdagboken. Inte heller någon skillnad mellan könen inom de båda grupperna kunde påvisas. Slutsats: Slutsatsen var att det inte fanns någon signifikant skillnad beträffande energiomsättning eller fysisk aktivitet mellan barn med CF och friska barn som deltog i denna studie. Inte heller kunde någon skillnad i aktivitetsnivå mellan könen inom grupperna påvisas.

This thesis investigates the possibilities of increasing efficacy and general improvement of unsupervised medical treatments by implementing electronics and embedded systems (so-called smart devices) to allow the physician to monitor or track the treatment and adherence of the patient to it. The diseases in focus are respiratory: asthma and Chronic Obstructive lung [Pulmonary] Disease (COPD). This thesis will furthermore attempt to show that shortcomings in the current treatment of these diseases incur significant human costs by loss of quality of life for the patients and causes (avoidable) costs to health-care systems and societies on a macro-economic scale, both direct and indirect. It will find that the technology to create a smart-inhaler exists, and while not a panacea, it can address many of the identified issues with the current mode of treatment.This thesis was written in partnership with SHL Medical AB, and the author wishes to extend specialthanks to Plamen Balkandjiev and Mattias Myrman for their help, support, and patience. / Detta examensarbete undersöker möjligheterna att öka effektiviteten samt allmänna förbättringar av oövervakad medicinsk behandling genom implementering av elektronik och inbyggda system (så kallade smarta-apparater) för att möjliggöra för läkare att övervaka eller följa behandlingen samt huruvida patienten fullföljer den eller ej. Sjukdomarna i fokus är astma och Kronisk Obstruktiv Lungsjukdom (KOL). Vidare kommer detta arbete försöka visa att tillkortakommanden i den befintliga behandlingen av sjukdomar inte bara medför signifikanta minskningar i livskvalitet för patienten utan även orsakar (icke oundvikliga) kostnader för sjukvårdssystem och samhällen på en makro-ekonomisk skala, indirekt såsom direkt. Den kommer även visa att tekniken som krävs för att skapa en smartinhalator existerar, och medans denna inte är en panacé kan den likväl åtgärda många av de identifierade problemen med den befintliga behandlingsmetoden.Detta exmanensarbete skrevs i samarbete med SHL Medical AB och dess författare önskar utsträckaett särskilt tack till Plamen Balkandjiev och Mattias Myrman för deras hjälp, stöd och tålamod.