Introduction: Dopamine agonists (DA) constitute primary treatment for prolactinomas.Recent international guidelines on prolactinoma management recommend use of cabergolineover other DAs and suggest attempting withdrawal after two years given certain criteria. Thelocal data on adherence to guidelines are scarce. Aim: This study aimed to compare local clinical practice to regional and internationalguidelines for prolactinomas and investigate management and outcome of patients with thisdiagnosis in a clinical setting in Örebro county. Methods: Medical records of patients with prolactinoma visiting the unit of endocrinology atÖrebro University Hospital between 2015-2019 were reviewed. Data on initial investigations,monitoring, treatment, and outcome were collected. Results: 91 patients with a median follow-up time of 69 months, were included. All patientshad initial investigations according to regional guidelines. 98.9% were ever treated with DA,and overall use of bromocriptine was higher than that of cabergoline. DA-withdrawal wasattempted in 40% of patients after a median treatment time of 6 years and was often successful.9.9% of patients had pituitary surgery. At last follow-up 37.4% of the patients were cured while20.9% had hypopituitarism. Treatment outcome differed significantly with adenoma size;microadenomas dominated among patients cured and macroadenomas among patients withremaining hypopituitarism (p<0.001). Conclusions:Local diagnostic prolactinoma care is in line with regional guidelines and patients are monitoredregularly. However, it is feasible that local practice concerning the choice of dopamine agonistand routines for its withdrawal could be revised and adjusted to international guidelines.

Introduction: An osteoporotic fracture affects every other woman and every fourth man in Sweden. To meet the needs, Örebro County implemented in 2007 a fracture liaison service(FLS) to identify, investigate and treat these patients. Aim: To evaluate the efficacy of the FLS in Örebro County by reporting the prevalence ofbone mineral density testing and anti-osteoporotic treatment initiation following a low traumafracture. Secondary aim was to evaluate adherence to treatment after 12 months. Methods: 1269 medical records were retrospectively examined for all patients, 50-85 yearsold, with a fractured wrist, upper arm, hip, pelvis or vertebra in Örebro County in 2016.Patient characteristics and continuation through the FLS was studied. Primary objectives wereall descriptive, but various subgroups were compared using chi-square and independent ttests.Limit of significance at p<0.05. Results: 738 patients were eligible for inclusion (mean age 71.00 (±9.16) years, 76.6%women). 391 (53.0%) were referred for investigation, of which 348 (89.0%) attended. 253(72.7%) of the measured patients had indication for treatment, later prescribed to 76.7% ofthese, mainly once weekly oral bisphosphonates (64.4%). Adherence after 12 months wasavailable for 176 patients, of which 119 (67.6%) were still persistent. Conclusion: The FLS in Örebro County seems to be in line with national and internationalcounterparts. Still, there is room for improvement. The major gap appears to be identificationand referral for investigation of patients at risk of osteoporosis. Once passed the identificationstep, the losses through the program are in much smaller proportions.

In the present study, an anger management treatment program was compared to a pseudo-social skills training program (self-help group) and waiting list control group to determine its effectiveness in reducing irritable/angry behavior in head injured subjects. Subjects consisted of 28 adults with previous head injury trauma who had difficulty with excessive irritability and anger. Subjects averaged 35.4 years of age and had an average of 8.9 years post head injury. Treatment consisted of 10 group sessions over a five week period. Anger management training was designed to teach subjects self management skills aimed at reducing the frequency of angry acting out behavior. Training methods included role playing, relaxation training, assertiveness training and cognitive restructuring. The pseudo-social skills training group was a self-help group designed to encourage discussion of irritability problems without teaching specific coping techniques. To assure some degree of homogeneity in cognitive abilities among subjects, minimum eligibility scores were required on five subtests of the Wechsler Adult Intelligence Scale - Revised and the Peabody Picture Vocabulary Test. Dependent measures were pre and posttreatment scores obtained from five categories of the Katz Adjustment Scale - Relative form: belligerence, negativity, general psychopathology, social obstreperousness, and social role functioning. In addition, pre and posttreatment recordings of observed angry/irritable behavior in the subjects were obtained from a significant other. Results failed to reveal statistically significant differences on the dependent measures between the three study groups. In addition, analysis failed to reveal any significant variables that predicted outcome. It is evident that much more organized research is needed to further investigate the possibilities of treatment for various problems encountered by those with head injuries.

Introduction: Hormone therapy (HT) has been considered as a safe treatment for menopausal symptoms. Use of HT increased dramatically in the 1980s and 1990s. Results from large randomized clinical trials (RCT) could, around the turn of the century, however not find evidence for long-term benefits with HT. These results attracted great attention from media and the scientific community leading to changed treatment guidelines and decreased use of HT. Aim: The overall aim of this thesis was to explore Swedish women’s conceptions, knowledge, management, and attitudes regarding the menopausal transition and HT. Material and methods: To explore and describe women’s conceptions of the menopausal transition women seeking medical advice due to climacteric symptoms were interviewed (n=20) and their statements were analyzed with a qualitative method (paper I). In 1999 (n=1760) and 2003 (n=1733) attitudes to (paper II) and knowledge of (paper III) the menopausal transition and HT among 53- and 54 year old women were investigated with a cross-sectional design using postal questionnaires. We also analyzed if attitudes differed before and after new scientific findings were published on risks and benefits of HT and if knowledge differed between educational levels. Since many women try to abandon use of HT a RCT was performed to study the effect of two different methods to discontinue HT, on recurrence of hot flushes, resumption of HT and on health related quality of life (HRQoL). Women (n=87) with vasomotor symptoms before initiating HT participated. Results: We found that the majority of the middle aged women in our study viewed the menopausal transition as a natural process the nature of which is affected by both hormonal changes and by ageing. Each woman seems to experience a set of psychological and physical symptoms that are in some sense unique to her experience. Women’s answers to the questions about HT demonstrate that attitudes towards HT held by women going through menopause have changed rather dramatically between 1999 and 2003. These changes probably reflect the influence on the women of media reports based on research that identified risks associated with HT that had not been identified before 1998. Women’s knowledge of the effects of HT seems to be unsatisfactory from a clinical perspective. No differences in hot flush frequency and resumption of HT were found between the women randomized to two different modes of discontinuation of HT. Almost 50 % of the women restarted HT within one year after discontinuation. Deteriorated wellbeing and severity of hot flushes were important predicting factors for resumption of HT. Conclusion: It is important to be aware of the individual woman’s conceptions and attitudes about and knowledge of the menopausal transition and HT to be able to individualize the counselling situation. Women who initiate HT due to hot flushes may experience recurrence of vasomotor symptoms and deteriorated HRQoL after discontinuation. A great proportion of them may resume HT. At present knowledge of possible advantages for the taper-down method when discontinuing HT is still lacking.

One of the major constraints limiting the efficiency of sheep production is the control of gastrointestinal nematode parasites. Parasite control by strategic use of anthelmintics is threatened by the emergence of nematode populations that are resistant to the drugs available. It is therefore increasingly apparent that steps toward maintaining sustainable productivity in the growing face of anthelmintic resistance (AR) is required by farmers. To facilitate the uptake of sustainable approaches to parasite management, a comprehensive understanding of the various factors that may influence farmers’ decision-making processes is required. In order to establish which factors are influential, and determine their impact on farmers’ roundworm control behaviours, both qualitative and quantitative research methods were used including focus groups as well as attitudinal and behavioural questionnaires. A retrospective analysis was initially conducted of historical surveys designed to identify farm specific characteristics and parasite management practices including anthelmintic usage. The objectives of the analysis were to identify factors associated with uptake of best practice advice including farm characteristics and information sourcing. In addition, the implementation of sustainable roundworm control practices was investigated using two surveys conducted in 2000 and 2010. Logistic regression models were applied for univariable and multivariable analysis of dependent and independent variables. The next step was to conduct a series of focus groups in different geographic regions of Scotland. The main purposes were to explore sheep farmers’ attitudes towards different aspects of roundworm management, as well as to identify potential motivators and barriers to uptake of sustainable parasite control practices. The findings aided in the development of an attitudinal questionnaire used to canvass opinions representative on a national level. The concluding study involved a telephone survey of 400 Scottish sheep farmers, designed to elicit attitudes regarding roundworm control, AR and sustainable roundworm control practices. A quantitative statistical analysis technique (Structural Equation Modelling) was then used to test the relationships between socio-psychological factors and the uptake of sustainable roundworm control practices. The analysis of historical questionnaire data demonstrated evidence of a shift towards the use of practices to reduce the rate of AR development, most notably a decline in the practice of ‘dose and move’ as well as an overall reduction in treatment frequency. Statistical analysis identified significant associations between farm characteristics and specific treatment strategies. For example, larger farms were more likely to adopt a set treatment regimen (P=0.036), compared with smaller farms, which were more likely to treat based on clinical signs of infection (P=0.021). Sourcing of roundworm control information primarily from veterinarians was most associated with treatment timings with no parallels between time points. From the qualitative focus group studies conducted we identified four overarching themes impacting on sheep producers’ attitudes to roundworm control and best practice advice. These themes comprised: a lack of perceived need to change, the complexity of advice, the ease of implementation of recommended practices and the effectiveness of extension approaches. Additionally, the most important and implementable guidelines identified by sheep farmers were: ‘working out a roundworm control strategy with an advisor’ and ‘administering anthelmintics effectively’ with regard to correct drenching practice i.e. appropriate dosing, administration and drug storage procedures. These findings exhibited similarities with veterinarians’ rankings with also, ‘testing for AR’, ‘preserving susceptible parasites’ and ‘reducing dependence on anthelmintics’ receiving the lowest rankings for importance and implementability. The quantitative analysis from the attitudinal/behavioural questionnaire identified eleven factors with significant influences on the adoption of sustainable roundworm control practices. The key influences on overall adoption were farmers’ baseline understanding about roundworm control and self-reported confirmation of anthelmintic resistance in their flock. Additional positive influences included, positive attitudes to veterinary services, enterprise type and perceived risk of AR. Factors that were shown to have the greatest relative effects on individual parasite control practices included; the perceived resource requirements for implementing a quarantine strategy, farmers’ AR suspicions for instigating AR testing and the confirmation of AR for adopting faecal egg count monitoring. The findings have highlighted several factors which can influence sheep farmers’ decisions to reject or adopt recommended roundworm control practices. It is evident that the perceived complexity, lack of need and practicality of the current recommendations necessitates changes to how extension is designed and disseminated to farmers. The findings also suggest that improving farmers’ acceptance and uptake of diagnostic testing and improving underlying knowledge and awareness about nematode control is a significant target to influencing adoption of best practice behaviours. The importance of veterinarians as highly-trusted information resources validates the need for further engagement with veterinarians concerning sustainable parasite control approaches, to facilitate collaboration with farmers. The need for interaction between farmers and their advisors is key to resolving the issues raised to enable the necessary explanation, justification and execution of recommended practices to suit farmers’ needs and farming conditions.

This diploma thesis deals with the role of exusers (former habit-forming substances abusers) in the treatment of addicted clients and in the management processes utilised within the communities of the Betel organisation. Extensive attention is paid to the description of the methods of work in the Betel organisation, which uses in the majority, the self- help therapeutic potential of the exusers in its long-term residential programme. Throughout this thesis, the alternative approach in treatment used in Betel is compared to the more frequently used concept of professionally managed therapeutic communities. The theoretical part of this thesis is divided into five main chapters. The first chapter deals with the description of the workings of professionally managed therapeutic communities, their place in the system of help to the addicted in the Czech Republic, and their effectiveness in the treatment. The second chapter describes in detail the methods and specifics of the help that is used in Betel and especially points out the role of exusers in this concept. The third chapter focuses on the history of community lifestyle with an emphasis on the self-help therapeutic impact. In the forth chapter there is a description of the specifics of the management processes utilised in both the therapeutic and...