Introduction: Hysterectomy is the most common major gynecological operation in the Western World and approximately 5000 benign hysterectomies are performed in Sweden every year. Consequently it is a surgical procedure that affects many women. The procedure comprises challenges concerning perioperative health care, perceived postoperative symptoms, quality of life aspects and health economics. The concept of fast track is a multimodal strategy to reduce hormonal surgical stress response and achieve an enhanced postoperative recovery and is today considered to be evidence based in relation to colorectal surgery. Spinal anesthesia, as an important part of fast track, provides benefits of extended effect on analgesia and reduced postoperative morbidity. It is reasonable to believe that employing the strategies of fast track including spinal anesthesia could also provide substantial benefits for women requiring surgical removal of the uterus. Aims: To determine whether duration of hospital stay, presence and intensity of postoperative symptoms, duration of sick leave and cost-effectiveness differ between women undergoing benign fast track abdominal hysterectomy in spinal anesthesia with intrathecal morphine (SA) and in standard general anesthesia (GA). Material & Methods: 180 women participated in this open randomized multicenter study with five participating hospitals in the southeast region of Sweden. One hundred and sixty two completed the study; 82 women were randomized to SA and 80 to GA. A fast track model comprising premedication without sedatives, intravenous fluid regulation, analgesics based on non-opioids, pre-emptive antiemetic therapy, early enteral nutrition and mobilization and standard criteria for discharge were used. End points were duration of hospital stay, use of analgesics, perceived postoperative symptoms, occurrence of postoperative complications, duration of sick leave and health economic evaluations. Results: Duration of hospital stay did not differ between the two modes of anesthesia. Vomiting and pruritus occurred significantly more often after SA. Complication rates did not differ between groups. Women with SA experienced less overall discomfort and had a reduced need for opioids postoperatively. Abdominal pain, drowsiness and fatigue occurred less often and with lower intensity among the women in the SA group. Health related quality of life improved faster and the duration of sick leave was shorter in women after SA. Total costs (hospital costs plus costs for productivity loss) were lower for the SA group. Within the first 29 days after hysterectomy the women in the SA group gained more QALYs than women in the GA group. Conclusions: The duration of hospitalisation after fast track abdominal hysterectomy was less than 50 hours and mode of anesthesia did not influence this. SA displayed considerable advantages regarding postoperative symptoms and recovery. SA was considered cost-effective in comparison with GA due to lower total costs and more QALYs gained. Our study indicates that SA should be recommended as the first choice of anesthesia in benign abdominal hysterectomy.

Diss. (sammanfattning) Stockholm : Karol. inst., 2006. / Härtill 6 uppsatser.

Objetivo: O presente estudo avaliou o efeito dos cuidados de fisioterapia respiratória, no período pós-operatório, na incidência de complicações pulmonares em pacientes submetidos à esofagectomia. Métodos: Este estudo retrospectivo avaliou 70 pacientes consecutivos (nenhuma exclusão) divididos em 2 grupos: controle (GC; N=30) e fisioterapia respiratória (GFR; N=40). As informações referentes aos períodos pré, peri e pós-operatório foram obtidas através do prontuário médico dos pacientes. Resultados: Os pacientes dos GC e GFR apresentaram média de idade (53,57 ± 12,51 vs 56,55 ± 14,23 anos) e de índice de massa corpórea (22,38 ± 3,41 vs 22,68 ± 3,91 kg/m2) semelhantes, assim como o percentual de diagnóstico de neoplasia que foi de 80% em ambos os grupos. As durações da cirurgia e da anestesia também foram similares entre GC e GFR, respectivamente (370 vs 390 min e 483,83 ± 98,45 vs 496,88 ± 125,77 min). Os pacientes submetidos à esofagectomia que receberam cuidados de fisioterapia respiratória (GFR) apresentaram uma redução nas complicações pulmonares quando comparado com o grupo controle (15,0% vs 36,3%; p<0,05). Esta foi conseqüente à redução na incidência de derrame pleural (10% vs 23%), atelectasia (2,5% vs 3,3%) e broncopneumonia (2,5% vs 10%). Foi também verificado que os pacientes do GFR fizeram menor uso de antibióticos (cefalosporina de 3ª geração), com finalidade terapêutica (p<0,05) e permaneceram menos tempo com o dreno no hemitórax direito (p<0,05). Conclusão: Nossos resultados sugerem que os cuidados de fisioterapia respiratória no período pós-operatório reduzem a incidência de complicações respiratórias, beneficiando os pacientes submetidos à esofagectomia. / The main goal of the present study was to evaluate the effect of late postoperative chest physiotherapy on pulmonary complications in patients submitted to oesophagectomy. This retrospective study involved a sample of 70 consecutive oesophagectomy patients (none excluded) who were divided into two groups as follows: control group (no physiotherapy) and chest physiotherapy group. Patients receiving chest physiotherapy were not submitted to positive airway pressure ventilation. Our results show that patients in the control group were similar to those in the chest physiotherapy group in terms of age and body mass index (53.5 ± 12.5 years vs. 56.5 ± 14.2 years; 22.3 ± 3.4 kg/m2 vs. 22.6 ± 3.9 kg/m2). Patients in the control group and chest physiotherapy group, respectively, also presented the same rate of surgery for malignant disease (80% vs. 80%), surgical time (370 vs. 390 min) and anaesthesia duration (483.8 ± 98.4 min vs. 496.8 ± 125.7 min). Patients in the chest physiotherapy group less frequently presented pulmonary complications (15% vs. 36.3%; p < 0.05), pleural effusion (10% vs. 23%), atelectasis (2.5% vs. 3.3%), and bronchopneumonia (2.5% vs. 10%). Among chest physiotherapy group patients, antibiotic (thirdgeneration cephalosporins) treatment regimens were of shorter duration (p < 0.05). In addition, right hemithorax drainage was less prolonged among the chest physiotherapy group patients (p < 0.05). Our results suggest that chest physiotherapy reduces pulmonary complications in patients undergoing oesophagectomy.

INTRODUÇÃO: A simpatectomia é o tratamento de escolha para hiperidrose localizada primária. A evolução da técnica visa à melhora dos resultados operatórios e à minimização dos efeitos colaterais, sendo o principal deles o suor reflexo. Esse suor reflexo pode afetar a satisfação em longo prazo, e pode variar conforme as estações do ano, juntamente com a satisfação dos pacientes com os resultados da operação. No entanto, não há dados objetivos quanto ao efeito da sazonalidade sobre os resultados operatórios e sobre os fatores relacionados à satisfação. Os objetivos do presente estudo são: avaliação da variabilidade sazonal sobre o grau das resoluções da sudorese palmar e plantar, bem como a incidência e a intensidade do suor reflexo e análise da influência desses fatores sobre a satisfação; avaliação da dor como fator relacionado à satisfação imediata; avaliação da segurança dos métodos de expansão pulmonar pós-operatória com e sem drenagem pleural e relação dos mesmos à dor. MÉTODOS: Estudo clínico, prospectivo, em duas fases. A primeira, para avaliação de fatores imediatos relacionados à satisfação (fatores antropométricos, dor, presença e intensidade do suor reflexo, grau de resolução da sudorese palma r e plantar, época do ano em que a simpatectomia foi realizada) e segurança dos métodos de expansão pulmonar, cujo desenho é prospectivo, aleatorizado e cego. A segunda, para as avaliações tardias e sazonais dos fatores relacionados à satisfação (fatores antropométricos, presença e intensidade do suor reflexo, grau de resolução da sudorese palmar e plantar), possui desenho prospectivo de coorte. Foram eleitos para o estudo pacientes com hiperidrose palmo-plantar primária submetidos à simpatectomia torácica videoassistida; o período de inclusão foi de 16 meses e o seguimento médio final de 623,63 ± 15,13 dias. Foram então avaliados no período de hospitalização (avaliação da dor, método de expansão pulmonar e do pneumotórax residual) e no sétimo dia de pós-operatório (dor, resultados operatórios e satisfação). Então, tardiamente, na primavera, no verão e no outono/inverno (resultados operatórios e satisfação). Foram considerados resultados operatórios os graus de resolução palmar e plantar e a presença e a intensidade do suor reflexo. Foram estudadas como variáveis independentes relacionadas à satisfação a época do ano onde a simpatectomia foi feita, a dor, os graus de resolução palmar e plantar, presença e intensidade do suor reflexo e fatores antropométricos, a saber, idade, gênero, etnia, índice de massa corporal. RESULTADOS: Foram incluídos 82 pacientes consecutivos, sendo que 80 completaram o seguimento imediato e 75 completaram todo o seguimento. Os resultados operatórios (resolução palmar e plantar, presença e intensidade do suor compensatório) tiveram variação entre todas as estações do ano. A satisfação teve igual variação sazonal e os fatores que estiveram relacionados à queda da satisfação foram distintos, conforme a estação do ano. A drenagem pleural tubular fechada e a expansão com Valsalva foram igualmente eficientes quanto à presença de pneumotórax residual, porém a drenagem pleural em selo d\'água aumentou o tempo cirúrgico e a dor pós-operatória nas primeiras 12 horas; o pneumotórax residual não aumentou a dor. CONCLUSÕES: OS melhores resultados operatórios foram obtidos imediatamente e na primavera, os piores no verão e em nível intermediário no outono/inverno. Na primavera, o único parâmetro relacionado à queda na satisfação foi a não resolução plantar; já no verão e no outono/inverno, foi a presença do suor reflexo, indepedente da sua intensidade. A drenagem pleural tubular fechada teve desempenho inferior à expansão pulmonar sob visão direta com manobra de Valsalva. O pneumotórax residual não influenciou a intensidade dor pós-operatória. / INTRODUCTION: Sympathectomy is the treatment of choice for primary and localized hyperhidrosis. Efforts in evolution of this technique have the aim to improve the surgical results and minimizing the collateral effects, witch told to be the sudomotor reflex. This sudomotor reflex could influence the long term satisfaction; it also could change between the seasons of the year, as well as the satisfaction could change in this matter. However, there is no objective data regarding the influence of the seasonality over the surgical results and satisfaction. The objectives of this study is to assess the seasonal variability of palmar and plantar resolution, as well as the incidence of sudomotor reflex and its intensity; to correlate this factors with satisfaction. To evaluate the pain as a factor related to immediate satisfaction; to assess the safety of lung expansion methods and relate this with postoperative pain. METHODS: A two stage prospective clinical assay. The first stage consists of assessment of the immediate factors related to satisfaction (anthropometrics factors, pain, presence and intensity of the sudomotor reflex, palmar and plantar resolutions, season of the year in witch the operation was performed) and the safety of lung expansion methods; it is a prospective, randomized and blinded study. The second stage is a cohort study, assessing the late factors related to satisfaction (anthropometrics factors, presence and intensity of the sudomotor reflex and palmar and plantar resolutions), under distinct climatic situations. There were included patients with typical palmar and plantar primary hyperhidrosis treated by thoracic video-assisted sympathectomy; the inclusion period was 16 months and the final follow-up time was 623 ± 15,13 days in average. They were assessed in hospital stay (pain, lung expansion technique and residual pneumothorax) and at seventh postoperative day (pain, surgical results and satisfaction). Thereafter they were assessed in spring, summer and autumn/winter (surgical results and satisfaction). The surgical results were palmar and plantar resolutions and presence and intensity of the sudomotor reflex. The independent variables related to satisfaction were season of the year in that the sympathectomy was performed, pain, palmar and plantar resolutions, sudomotor reflex (presence and intensity) and anthropometric parameters (age, gender, ethnics, body mass index). RE8UL T8: 82 consecutives patients were included; thereafter, 80 completed the immediate assess and 75 completed the long term follow-up. The surgical results (palmar and plantar resolutions, presence and intensity of the sudomotor reflex) had significant variation throughout the seasons of the year. Equally, the satisfaction had significant variation, as well as the factor related to dissatisfaction, throughout the seasons of the year. The underwater pleural drainage and the lung expansion with Valsalva maneuver were equally efficient in matter of residual pneumothorax; however the underwater pleural drainage was more painful and more operating time consuming; the residual pneumothorax do not increased the postoperative pain. CONCLUSIONS: The best results are obtained in immediate postoperative period and in spring; the worst results are seen in spring; the intermediate results are obtained in autumn/winter. In the spring, the unique factor related to dissatisfaction was the non resolution of plantar hyperhidrotic symptoms; in the summer and in the autumn/winter the presence of the sudomotor reflex, independently of its intensity, was related to dissatisfaction. The underwater pleural drainage should not be indicating after thoracic video-assisted sympathectomy for lung expansion. The residual pneumothorax does not influence the postoperative pain.

Intravenös anestesi med Propofol eller inhalationsanestesi med gasen Sevofluran är de två vanligaste anestesiformerna i Sverige. Syftet med studien vara att undersöka om patienters postoperativa återhämtning skiljer sig åt beroende på om de sövts med Propofol eller Sevofluran. Datainsamlingen till studien genomfördes med systematisk litteraturöversikt baserad på integrativ metod. Både kvalitativa och kvantitativa studier samlades in, men enbart kvantitativa artiklar inkluderades. Resultatet visade att det under den postoperativa återhämtningen var vanligt förekommande med två postoperativa komplikationer, smärta samt illamående och kräkningar. Resultatet visar inga statistiskt signifikanta skillnader när det gällde dessa beroende på val av anestesimedel. Men vidare studier behövs inom ämnet, framför allt om kön eller ålder kan vara ytterligare påverkande faktorer. / Intravenous anesthesia with Propofol or inhalation anesthesia with the gas Sevoflurane are the two most common forms of anesthesia in Sweden. The purpose of the study was to investigate whether patient's postoperative recovery differs depending on whether they have been anesthetized with Propofol or Sevoflurane. The data collection for the study was carried out with a systematic literature review based on integrative research Both qualitative and quantitative studies were collected, but only quantitative articles were included. The results showed that during postoperative recovery it was common with two postoperative complications, pain, nausea, and vomiting. The results show no statistically significant differences in these depending on the choice of anesthetic agents. However, further studies are needed in the subject, especially if gender or age can be additional influencers.

This thesis aims to highlight the relevance of patients engaging with their patient narratives as a tool in recovery from illness and in regaining their sense of agency. / This thesis aims to rename the term ‘illness narrative’ to a more disclosive writing called the ‘patient narrative’ as a means to focus on the patient as a person who experiences illness, instead of the illness label. Exploring patient narratives, such as Susannah Cahalan’s Brain on Fire: My Month of Madness, as a form of disclosive writing will highlight the need for this tool to act as a more personal and effective communication between patients, healthcare professionals, and caregivers. The thesis is presented in two parts: a critical essay and my patient narrative. Part One is a critical essay that explores how engaging with patient narratives contributes to the patient reclaiming their agency and sense of identity. In three subsections, the essay highlights the difficulties patients go through with illnesses or rare medical events, as well as the emotional and physical impacts that they experience, going beyond medical symptoms. The essay focuses on three points separated into three sections. The sections are: Recognizing Pathologies and Injuries, Communication and Language in the Patient Experience, and Reclaiming Agency. Part Two is my autopathography centring on the complications encountered while seeking a common surgery. After general anaesthesia, I develop Postoperative Cognitive Changes of unknown aetiology. This greatly complicates the situation when surgery is needed, and the ensuing cognitive impairments have lasting impacts on me academically, personally, emotionally, and socially. While both parts are distinct, together they mirror how patient narratives have the iv potential to bridge the communication gap between medicine and humanities. As such, patient narratives can communicate connections between patients, medical communities, and a broader audience which acts to underscore the need of a deeper awareness for the importance of compassion and empathy for those experiencing any form of health challenge. / Thesis / Master of Arts (MA) / Patient narratives are a form of expressive writing that enables the patient to regain their sense of identity and agency following a health illness. When a person first becomes a patient, they leave their known world of familiarity and comfort and enter into a new one on their health journey. Their language and ways of communicating are required to adapt to the world of medicine. The patient loses their sense of identity and agency as a result of their illness. This thesis is presented in two parts, a critical essay and my brief patient memoir, and will explore how the patient, when engaging with patient narratives such as Susannah Cahalan’s Brain on Fire: My Month of Madness, can reclaim their agency and sense of identity. The first part is an essay exploring the contributions of patient narratives. The second part is my memoir, exemplifying a patient narrative.

Postoperative Komplikationen nach Eingriffen an Pankreas, Kolon und Rektum können nach bis zu jeder zweiten Operation auftreten und lebensbedrohlich verlaufen. Ihr potenzielles Risiko, ihr Schweregrad und ihre Auswirkungen können jedoch durch frühzeitige Einleitung angemessener Diagnostik und Therapie erheblich reduziert werden. Serious Gaming ist eine innovative Lehrmethode, die Spiel mit Wissenserwerb, erhöhter Konzentration und schneller Entscheidungsfindung kombiniert und einen Mehrwert für die klinisch orientierte medizinische Ausbildung bringen könnte. Ziel dieses Promotionsprojektes ist es, eine fallbasierte Serious Gaming-Plattform für das Komplikationsmanagement in der Pankreas- und Kolorektalchirurgie zu entwickeln, die Anwendung durch den Vergleich der Spielverläufe verschiedener Berufsgruppen im Gesundheitswesen zu validieren und die Akzeptanz im Rahmen der klinischen Ausbildung zu testen. Es wurden sechs fiktive, realitätsnahe Patientenfälle konzipiert und zur Bearbeitung zur Verfügung gestellt. Nach einer kurzen Fallpräsentation sollte der virtuelle Patient triagiert, eine erste Verdachtsdiagnose gestellt und im Verlauf ein dreistufiger Behandlungsplan entworfen werden. Eine Präsentation der Ergebnisse der von dem Teilnehmenden ausgewählten diagnostischen und therapeutischen Maßnahmen erfolgte zwischen den Managementstufen. Im Zuge der Auswertung wurde das durchgeführte Fallmanagement mit dem idealen Fallmanagement nach klinischen Leitlinien verglichen. Benutzerfreundlichkeit, Anwendbarkeit, Validität und Akzeptanz der Anwendung wurden in einer anonymisierten, prospektiven, offenen Beobachtungsstudie im Anschluss an die Spielteilnahme bewertet. Insgesamt 131 Fälle wurden im Erhebungszeitraum vollständig bearbeitet. Ärzte wählten geeignetere therapeutische Maßnahmen aus als nicht-ärztliches Klinikpersonal. Design, Struktur, Relevanz, Aktualität und Interessenförderung wurden überwiegend positiv bewertet. Die Mehrheit der Teilnehmenden empfand die Anwendung im Hinblick auf die Steigerung der Problemlösungskompetenz (78%), Selbstreflexion (78%) sowie Anwendbarkeit (80%) als überlegen im Vergleich zu herkömmlichen Vortragsformaten (Fortbildungen, Vorlesungen, Seminare). Fallbasiertem Serious Gaming kann anhand der Ergebnisse ein pädagogisches Potenzial für das Komplikationsmanagement in der Chirurgie zugesprochen werden und könnte damit zu einer Verbesserung der postoperativen Patientenversorgung beitragen.:1 Einleitung 1.1 Derzeitige ärztliche Aus- und Fortbildung 1.1.1 Humanmedizinstudium 1.1.2 Facharztausbildung 1.1.3 Weiter- und Fortbildungen 1.2 Anforderungen an die medizinische Ausbildung 1.2.1 Anforderungen an das Humanmedizinstudium 1.2.2 Anforderungen an die Facharztausbildung 1.2.3 Anforderungen an die Fort- und Weiterbildung 1.3 Serious Gaming 1.3.1 Serious Gaming in der Medizin 1.3.2 Serious Gaming in der ärztlichen Ausbildung 1.4 Ziel der Studie 1.5 Postoperatives Komplikationsmanagement 1.6 Clavien-Dindo-Klassifikation 1.7 Komplikationen nach Pankreaseingriffen 1.7.1 Postoperative Pankreasfistel 1.7.2 Postpankreatektomie-Hämorrhagie 1.7.3 Biliodigestive Anastomoseninsuffizienz 1.7.4 Magenentleerungsstörung 1.8 Komplikationen nach kolorektalen Eingriffen 1.8.1 Anastomoseninsuffizienz 1.8.2 Postoperative Blutung 1.8.3 Postoperativer Ileus 1.9 Allgemeine postoperative Komplikationen 1.9.1 Schmerzexazerbation 1.9.2 Postoperative Thromboembolien und Hyperkoagulabilität 1.9.3 Infektionen 2 Material und Methoden 2.1 Pilottestung 2.1.1 Probandenkollektiv 2.1.2 Fallbeispiele 2.1.3 Spielablauf 2.1.4 Spielende 2.1.5 Validitäts- und Nützlichkeitsanalyse 2.2 Methoden der Datenauswertung 2.2.1 Der Idealweg 2.2.2 Statistische Auswertung 2.3 Studienendpunkte 3 Ergebnisse 3.1 Allgemeine Statistik 3.2 Inhaltliche Ergebnisdarstellung 3.2.1 Ergebnisdarstellung: Verdachtsdiagnose 3.2.2 Ergebnisdarstellung: Therapie-Eskalation nach Fall 3.2.3 Einordnung der Fallbearbeitungen in die Clavien Dindo Klassifikation 3.2.4 Weitere inhaltliche Ergebnisdarstellungen 3.3 Ergebnisse der Validitäts- und Nützlichkeitsanalyse 3.3.1 Nicht-vergleichende Analyse 3.3.2 Vergleichende Analyse 3.3.3 Analyse des Zusammenhangs zwischen der Spielbewertung und dem -Verlauf 3.3.4 Spielbewertung nach Berufsgruppe und Ausbildungsstufe 4 Diskussion 4.1 Potenzial fallbasierter Serious Games in der medizinischen Ausbildung 4.2 Serious Games als Abbild der medizinischen Wissenschaft 4.3 Nutzeranforderungen an Lehrmethoden 4.4 Generalisierbarkeit der Ergebnisse 4.5 Konzeptualisierungsschwierigkeiten 4.6 Lerntypen, Lernmethoden und Auswirkungen digitaler Methoden 4.7 Zukünftige Evaluation der Effektivität von Serious Gaming 5 Schlussfolgerung 6 Literaturverzeichnis Anhangsverzeichnis / The potential risk and subsequent impact of serious complications after pancreatic and colorectal surgery can be significantly reduced through early recognition, correct assessment, and timely initiation of appropriate therapy. Serious gaming is an innovative teaching method that combines play with knowledge acquisition, increased concentration, and quick decision-making, and could therefore be used for clinically-oriented education. This study aims to design a case-based serious gaming platform for complication management in pancreatic and colorectal surgery, to validate the application by comparing game courses of various professional groups in the health care sector, and to test the acceptance of the developed platform in the context of clinical education. Six realistic patient cases were implemented. Following a brief case presentation, participants were asked to triage the virtual patient, make an initial suspected diagnosis, and design a three-step management plan, throughout which the results of selected diagnostic and therapeutic actions were presented. Participants’ proposed case management was compared to ideal case management according to clinical guidelines. Usability, applicability, validity, and acceptance of the application was assessed in an anonymized, prospective, open, observational study. A total of 131 cases were answered. Physicians selected more appropriate therapeutic measures than non-physicians. Design, structure, relevance, timeliness, and interest promotion were predominantly rated positively. Most participants perceived the application to be superior to conventional lecture-based formats (training courses, lectures, seminars) in terms of problem-solving skills (78%), self-reflection (78%), and usability and applicability (79%). Case-based serious gaming has educative potential for complication management in surgery and could thereby contribute to improvements in postoperative patient care.:1 Einleitung 1.1 Derzeitige ärztliche Aus- und Fortbildung 1.1.1 Humanmedizinstudium 1.1.2 Facharztausbildung 1.1.3 Weiter- und Fortbildungen 1.2 Anforderungen an die medizinische Ausbildung 1.2.1 Anforderungen an das Humanmedizinstudium 1.2.2 Anforderungen an die Facharztausbildung 1.2.3 Anforderungen an die Fort- und Weiterbildung 1.3 Serious Gaming 1.3.1 Serious Gaming in der Medizin 1.3.2 Serious Gaming in der ärztlichen Ausbildung 1.4 Ziel der Studie 1.5 Postoperatives Komplikationsmanagement 1.6 Clavien-Dindo-Klassifikation 1.7 Komplikationen nach Pankreaseingriffen 1.7.1 Postoperative Pankreasfistel 1.7.2 Postpankreatektomie-Hämorrhagie 1.7.3 Biliodigestive Anastomoseninsuffizienz 1.7.4 Magenentleerungsstörung 1.8 Komplikationen nach kolorektalen Eingriffen 1.8.1 Anastomoseninsuffizienz 1.8.2 Postoperative Blutung 1.8.3 Postoperativer Ileus 1.9 Allgemeine postoperative Komplikationen 1.9.1 Schmerzexazerbation 1.9.2 Postoperative Thromboembolien und Hyperkoagulabilität 1.9.3 Infektionen 2 Material und Methoden 2.1 Pilottestung 2.1.1 Probandenkollektiv 2.1.2 Fallbeispiele 2.1.3 Spielablauf 2.1.4 Spielende 2.1.5 Validitäts- und Nützlichkeitsanalyse 2.2 Methoden der Datenauswertung 2.2.1 Der Idealweg 2.2.2 Statistische Auswertung 2.3 Studienendpunkte 3 Ergebnisse 3.1 Allgemeine Statistik 3.2 Inhaltliche Ergebnisdarstellung 3.2.1 Ergebnisdarstellung: Verdachtsdiagnose 3.2.2 Ergebnisdarstellung: Therapie-Eskalation nach Fall 3.2.3 Einordnung der Fallbearbeitungen in die Clavien Dindo Klassifikation 3.2.4 Weitere inhaltliche Ergebnisdarstellungen 3.3 Ergebnisse der Validitäts- und Nützlichkeitsanalyse 3.3.1 Nicht-vergleichende Analyse 3.3.2 Vergleichende Analyse 3.3.3 Analyse des Zusammenhangs zwischen der Spielbewertung und dem -Verlauf 3.3.4 Spielbewertung nach Berufsgruppe und Ausbildungsstufe 4 Diskussion 4.1 Potenzial fallbasierter Serious Games in der medizinischen Ausbildung 4.2 Serious Games als Abbild der medizinischen Wissenschaft 4.3 Nutzeranforderungen an Lehrmethoden 4.4 Generalisierbarkeit der Ergebnisse 4.5 Konzeptualisierungsschwierigkeiten 4.6 Lerntypen, Lernmethoden und Auswirkungen digitaler Methoden 4.7 Zukünftige Evaluation der Effektivität von Serious Gaming 5 Schlussfolgerung 6 Literaturverzeichnis Anhangsverzeichnis

Postoperativt illamående och kräkning är fortfarande ett vanligt förekommande problem i samband med anestesi. Förutom obehaget med detta finns även medicinska risker som aspiration av maginnehåll eller sårruptur. PONV går att förebygga till viss del med hjälp av läkemedel, pre-operativ riskskattning samt genom anpassad anestesimetod. Genom att göra en riskskattning kan personal uppskatta vilka patienter som ligger i riskzonen för PONV och därigenom anpassa behandlingen. Syftet med denna studie var att undersöka hur riktlinjerna för att riskbedöma och förebygga PONV följs vid en dagkirurgisk avdelning. Studien genomfördes som en prospektiv observationsstudie med en kvantitativ ansats. Sammanlagt deltog 49 patienter i studien. De fick svara på om de kände av illamående och/eller kräkningar 2 samt 4 timmar postoperativt. Datan analyserades sedan i  Package for Social Science (SPSS). Resultatet visade att rutinen följdes i 63% av fallen och att förekomsten av PONV var på 16%. Slutsatser som kan dras ifrån detta är att rutinen för PONV följs i samma utsträckning som många andra rutiner inom hälso- och sjukvård och att förekomsten av PONV är som förväntat utifrån tidigare studier. Rutinen borde dock kunna följas i fler än 63% av fallen. Vidare forskning kring huruvida ökad följsamhet skulle kunna sänka förekomsten av PONV behövs.

Bakgrund: Ren intermittent katetrisering (RIK) är en åtgärd som utförs dagligen på ett flertal patienter inom sjukvården, där sjukvårdspersonal tränger innanför patientens integritetssfär. Patienter har olika personliga gränser för när den personliga integriteten hotas och deras upplevelse vid RIK postoperativt, är sparsamt belyst i tidigare forskning.  Syfte: Att beskriva patienters upplevelse av ren intermittent kateterisering postoperativt. Metod: Datainsamlingen genomfördes med semistrukturerade intervjuer där tretton patienter som kateteriserats postoperativt deltog. Data analyserades med kvalitativ innehållsanalys. Resultat: Resultatet visade att patienterna upplevde vårdpersonalen som kompetenta och de förlitade sig på att vårdpersonalen visste vad som var bäst för patienterna som också kände sig omhändertagna. Det upplevdes vara viktigt att bevara den personliga integriteten och de påtalade vikten av tillräckligt insynsskydd vid kateteriseringen vilket inte alltid varit tillfyllest. Patienterna uttryckte också rädsla dels för smärta i samband med kateteriseringen och dels för att de trodde att det var något fel eftersom de inte kunde urinera. Några beskrev det som en lättnad att få hjälp att tömma blåsan, medan andra kände sig utlämnade och upplevde det som att de inte hade något val. Majoriteten av patienterna hade inte fått/kom inte ihåg att de fått adekvat information om att kateterisering kunde komma att behövas postoperativt och de påtalade vikten av att detta gavs innan operationen. Slutsats: Vårdpersonalens bemötande av patienter som behöver genomgå RIK är av största vikt för patientens upplevelse av vårdsituationen. Vikten av att information ges, som är adekvat och lättförståelig, poängteras. Det är en fördel om patienten görs delaktig i sin vård och att hänsyn även tas till speciella önskemål, som t.ex. kön på den som utför kateteriseringen. / Background: Clean intermittent catheterization is an action that is performed daily on several patients in health care, where health care staff penetrates inside the patients privacy sphere. Patients’ have different personal limits when privacy is threatened and research with focus on the patients experience of clean intermittent catheterization postoperatively is limited. Aim: To describe patients’ experience of clean intermittent catheterization postoperatively. Method: Data collection was conducted by using semi-structured interviews with thirteen patients that had been catheterized postoperatively. Data were analysed using qualitative content analysis. Result: The result showed that patients’ experienced health care staff as competent and they relied on that the medical staff knew what was best for the patients who also felt cared for. It felt to be important to preserve privacy and they stressed the importance of sufficient transparency protection during catheterization which had not always been satisfactory. The patients’ expressed fear partly for pain associated with catheterization and partly because they thought there was something wrong since they were unable to urinate. Some described it as a relief to get help emptying the bladder, while others felt vulnerable and felt that they had no choice. The majority of patients’ had not got or could not remember if they had received adequate information that catheterization could be needed postoperatively and they emphasized importance of that this information was given before surgery. Conclusion: Health care staff treatment of patient’s requiring clean intermittent catheterisation is crucial for the patient's experience of the care situation. The importance that the information given is adequate and understandable was emphasized. It is an advantage if the patient is involved in care and that consideration to special requests, such as that the gender of the person performing catheterisation is considered.

Thesis (MScPhysio)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Aim: The aim of this study is to determine if the addition of a pre-extubation recruitment manoeuvre to standard care is safe and will improve lung compliance and subsequent PaO2/FiO2 (PF ratio) after extubation in postoperative coronary artery bypass graft surgery patients. Design: Prospective, triple blind, randomised, controlled trial. Method: This study was conducted in a private hospital in the Northern suburbs of Cape Town, South Africa. All patients admitted between 03/10/2010 and 22/11/2011, for uncomplicated elective coronary artery bypass graft (CABG) surgery were eligible for inclusion into the study. Patients were randomly allocated into either the intervention group or the control group. The intervention group received a gradual build-up lung recruitment manoeuvre (RM). The primary outcome was PaO2/FiO2 (PF ratio). The secondary outcomes were safety and static lung compliance. ICU length of stay (LOS) and hospital LOS were also recorded. The pre-RM hemodynamic stability of the patient was checked before the intervention and repeated at 5 minutes after the intervention by the nursing sister. Data to calculate static lung compliance was captured at the same time. Criteria for safety and discontinuation of the RM were monitored during the intervention by the principle investigator only. Results: Of the 69 patients eligible for the study 47 were randomly allocated into the intervention group (n=22) and control group (n=25) respectively. Groups were the same at baseline with regards to sex, pulmonary risk, sedation and surgical procedures. The RM could be completed in all patients. The prior defined criteria for discontinuation of the RM were not reached in any of the patients. No adverse effects were noted. The PaO2/FiO2 (PF ratio) decreased significantly in both groups from pre-surgery measurements compared to when measured before the RM (p<0.001). There was a tendency noted for the intervention group to return to pre-surgery measurements of PF ratio within 12 hours after extubation when compared to the control group. There was no significant difference between the groups from extubation to 24 hours (p = 0.6). The static compliance improved at 5 minutes following the RM (p<0.001) and remained improved until extubation (p<0.001) for the intervention group. No difference was noted in the static compliance of the control group over the same time period. The mean hospital length of stay for the intervention group was 8.61 (95% confidence interval 7.26 to 9.96 days) and 10.08 (95% confidence interval 8.52 – 11.63 days) for the control group. Conclusion: A gradual recruitment manoeuvre at 30cmH2O 30minutes before extubation significantly improved static lung compliance within 5 minutes with no adverse hemodynamic side effects. There was noted maintained improved PF ratio at extubation or immediately afterwards for the intervention group and no difference in the PF ratio between the intervention group and control group. / AFRIKAANSE OPSOMMING: Doel: Die doel van hierdie studie is om te bepaal of die toevoeging van ’n pre-ekstubasie herwinningstegniek tot standaard sorg veilig is, en of dit longvervormbaarheid en gevolglike PaO2/FiO2 (PF-verhouding) na ekstubasie in post-operatiewe kroonaaromleidingchirurgiepasiënte sal verbeter. Ontwerp: Prospektiewe, trippel-blinde, ewekansige, gekontroleerde proefneming. Metode: Hierdie studie is uitgevoer in ’n privaat hospitaal in die noordelike voorstede van Kaapstad, Suid-Afrika. Alle pasiënte wat tussen 03/10/2010 en 22/11/2011 gehospitaliseer is vir ongekompliseerde elektiewe kroonaaromleidingchirurgie, kon in aanmerking kom vir die studie. Pasiënte is op ewekansige wyse ingedeel in die intervensie- en kontrolegroepe. ’n Geleidelike-opbou-van-druk-longherwinningstegniek (HT) is op die intervensiegroep toegepas. Die primêre uitkoms was die PaO2 /FiO2 (PF-verhouding). Die sekondêre uitkoms was veiligheid en statiese longvervormbaarheid. ISE-verblyf en hospitaalverblyf is ook genoteer. Die navorsingsassistent het data van bestaande eenheiddokumentasie geneem. Die pre-HT-hemodinamiese stabiliteit van die pasiënte is gemonitor voor en weer 5 minute na die intervensie. Inligting om die statiese longvervormbaarheid te bereken is terselfdertyd genoteer. Kriteria vir veiligheid en vir die staking van die HT is gemonitor tydens uitvoering deur die primêre ondersoeker en die verpleegkundige. Resultate: Van die 69 pasiënte wat in aanmerking kon kom vir die studie is 47 op ewekansige wyse ingedeel in die intervensiegroep (n=22) en die kontrolegroep (n=25). Die groepe was dieselfde by die basislyn. Die herwinningstegniek kon volledig op alle pasiënte uitgevoer word. Die vooraf gedefinieerde kriteria vir staking van die HT is met geen pasiënte bereik nie. Geen nadelige uitwerking is genoteer nie. Die PaO2 /FiO2 (PF-verhouding) het beduidend verminder in beide groepe van pre-operatiewe metings in vergelyking met meting voor die HT (p<0.001). ‘n Neiging is genoteer dat die intervensiegroep binne 12 uur na ekstubasie tot pre-chirurgie PF-metings teruggekeer het. Daar was geen merkbare verskil tussen die groepe vanaf ekstubasie tot 24 uur (p=0.6) nie. Die statiese vervormbaarheid het verbeter teen 5 minute na HT (p<0.001) en het verbeter gebly tot ekstubasie (p<0.001) vir die intervensiegroep. Daar was geen verskil in die statiese vervormbaarheid van die kontrolegroep nie. Die gemiddelde hospitaalverblyf vir die intervensiegroep was 8.61 (95% betroubaarheidsinterval 7.26 tot 9.96 dae) en 10.08 (95% betroubaarheidsinterval 8.52 – 11.63 dae) vir die kontrolegroep. Gevolgtrekking: ’n Geleidelike herwinningstegniek teen 30cmH2O 30 minute voor ekstubasie het statiese longvervormbaarheid beduidend verbeter binne 5 minute, met geen nadelige hemodinamiese newe-effekte nie. Daar was geen verskil in die oksigenasie-indeks tussen die intervensie- en kontrolegroep na ekstubasie nie.