The aim of this thesis was to study maternal and infant effects of delayed cord clamping (≥180 seconds, DCC) compared to early (≤10 seconds, ECC) in a randomised controlled trial. Practice and guidelines regarding when to clamp the cord vary globally, and different meta-analyses have shown contradictory conclusions on benefits and disadvantages of DCC and ECC. The study population consisted of 382 term infants born after normal pregnancies and randomised to DCC or ECC after birth. The primary objective was iron stores and iron deficiency at 4 months of age, but the thesis was designed to investigate a wide range of suggested effects associated with cord clamping. Paper I showed that DCC was associated with improved iron stores at 4 months (45% higher ferritin) and that the incidence of iron deficiency was reduced from 5.7% to 0.6%. Neonatal anaemia at 2-3 days was less frequent in the DCC group, 1.2% vs. 6.3%. There were no differences between the groups in respiratory symptoms, polycythaemia, or hyperbilirubinaemia. In paper II we demonstrated that DCC versus ECC was not associated with higher risk for maternal post partum haemorrhage and rendered a comparable ratio of valid umbilical artery blood gas samples. In paper III, the Ages and Stages Questionnaire was used to assess neurodevelopment at 4 months. The total scores did not differ, but the DCC group had a higher score in the problem-solving domain and a lower score in the personal-social domain. Immunoglobulin G level was 0.7 g/L higher in the DCC group at 2–3 days, but did not differ at 4 months. Symptoms of infection up to 4 months were comparable between groups. Finally, in paper IV, iron stores and neurodevelopment were similar between groups at 12 months. Gender specific outcome on neurodevelopment at 12 months was discovered, implying positive effects from DCC on boys and negative on girls. We conclude that delaying umbilical cord clamping for 180 seconds is safe and associated with a significantly reduced risk for iron deficiency at 4 months, which may have neurodevelopmental effects at a later age.

The overall aim of this thesis was to examine beliefs about human papillomavirus (HPV) prevention, especially vaccination, among parents, immigrant women, adolescents and school nurses, and to promote primary prevention among adolescents. The methods used in the thesis were focus group interviews, individual interviews, a web-based questionnaire, and finally, a randomised controlled intervention study. The immigrant women were largely in favour of HPV prevention, although barriers, such as logistic difficulties, and cultural or gender norms were found. Parents’ decision concerning vaccination of their daughters depended on several factors. Regardless of their final choice, they made the decision they believed was in the best interest of their daughter. The benefits outweighed the risks for parents choosing to vaccinate while parents declining made the opposite judgement. The majority of the school nurses reported that the governmental financial support given because of the vaccination programme had not been used for the intended purpose. Three out of four nurses had been contacted by parents who raised questions regarding the vaccine; most were related to side effects. The educational intervention had favourable effects on the adolescents’ beliefs regarding HPV prevention, especially among those with an immigrant background. Furthermore, the intention to use condom as well as actual vaccination rates among girls was slightly increased by the intervention. Trust in the governmental recommendations and the amounts of information given are important factors in the complex decision about HPV vaccination. Attention given to specific needs and cultural norms, as well as the possibility to discuss HPV vaccination with the school nurse and provision of extra vaccination opportunities at a later time are all strategies that might facilitate participation in the school-based HPV vaccination programme. School nurses need sufficient resources, knowledge and time to meet parents’ questions and concerns. The vaccinations are time-consuming and the governmental financial support needs to be used as intended, for managing the vaccination programme. A school-based intervention can have favourable effects on the beliefs and actual actions of young people and may possibly thus, in the long term, decrease the risk for HPV-related cancer.

Among elderly people, falls lead to a considerable amount of immobility, morbidity, and mortality. The purpose of this study was to develop and evaluate methods for predicting falls, and to evaluate a fall prevention program among elderly people living in residential care facilities. A fall was defined as any event in which the resident unintentionally came to rest on the floor or the ground regardless of whether or not an injury was sustained. In developing the prediction methods, it was hypothesised that older persons showing difficulties in performing a familiar second task while walking were more likely to fall within six months. For residents who stopped walking when talking, the relative risk of falling was 3.5 (95% CL2.0-6.2) compared to those who continued walking. For residents with a time difference (diffTUG) of at least 4.5 seconds between two performances of the Timed Up&amp;Go test, with and without carrying a glass, the hazard ratio for falls was 4.7 (95% Cl: 1.5-14.2) compared to those with a shorter diffTUG. A screening tool, the Mobility Interaction Fall (MIF) chart, was developed and evaluated, then validated in a new sample. This tool included a mobility rating, ‘Stops walking when talking’, ‘diffTUG’, a test of vision, and a concentration rating. In the first sample, the hazard ratio was 12.1 (95% 0:4.6-31.8) for residents classified as ‘high-risk’ compared to ‘low-risk’. The positive predictive value was 78%, and the negative predictive value, the sensitivity, and the specificity were above 80% for falling in six months. In the second sample the prediction accuracy of the MIF chart was lower (hazard ratio 1.7, 95% Cl: 1.1-2.5) and a 6-month fall history or a global rating of fall risk by staff were at least equally valuable. A combination of any two of the methods - the MIF chart, staff judgement, fall history - was more accurate at identifying high risk residents than any method alone. Half of the residents classified by two methods as ‘high risk’ sustained a fall within 6 months. In a randomised study a prevention program directed to residents, staff, and environment resulted in a significant reduction in the number of residents falling (44% vs. 56%; odds ratio 0.62, 95% CF0.41-0.92), the incidence of falls (incidence rate ratio IRR 0.80, 95% CF0.69-0.94) and of femoral fractures (IRR 0.25, 95% 0:0.08-0.82) in the intervention compared to the control group. In conclusion, a combination of any two of the staff judgement, fall history or MIF chart has the potential to identify a large proportion of residents at particular high fall risk. A multidisciplinary and multifactorial fall prevention program directed to residents, staff, and the environment can reduce the numbnumber of residents falling, of falls and of femoral fractures. / <p>Diss. (sammanfattning) Umeå : Umeå universitet, 2000,, härtill 5 uppsatser</p> / digitalisering@umu

Background Stress urinary incontinence (SUI) is the leakage of urine when coughing, sneezing, or on exertion. It affects 10-35% of women, and can impair quality of life (QOL). First-line treatment is pelvic floor muscle training (PFMT). However, access barriers and embarrassment may prevent women from seeking care. There is a need for new, easily accessible ways to provide treatment. Aim To evaluate the treatment outcome, patient satisfaction, and cost-effectiveness of an Internet- based treatment programme for SUI. Methods We recruited 250 community-dwelling women aged 18-70 years, with SUI ≥1/week via our website. Participants were randomised to 3 months of PFMT with either an Internet-based programme (n=124), or a programme sent by post (n=126). We had no-face-to face contact with the participants, but the Internet group received individually tailored e-mail support from an urotherapist. Treatment outcome was evaluated after 4 months with intention-to-treat analysis. After treatment, we telephoned a strategic selection of participants (Internet n=13, postal n=8) to interview them about their experiences, and analysed the results according to grounded theory principles. We also performed a cost-utility analysis with a 1-year societal perspective, comparing the treatment programmes with each other and with a no-treatment alternative. To scrutinize our measure of QOL, we performed a reliability study of the ICIQ-LUTSqol questionnaire. Results Participants in both intervention groups achieved highly significant improvements (p&lt;0.001) with large effect sizes (&gt;0.8) in the primary outcomes symptom score (ICIQ-UI SF: mean change Internet 3.4 [SD 3.4], postal 2.9 [3.1]), and condition-specific QOL (ICIQ-LUTSqol: mean change Internet 4.8 [SD 6.1], postal 4.6 [SD 6.7]); however, the differences between the groups were not significant. Compared with the postal group, more participants in the Internet group perceived they were much or very much improved after treatment (40.9%, vs. 26.5%, p=0.01), reduced their use of incontinence aids (59.5% vs. 41.4%, p=0.02), and indicated satisfaction with the treatment programme (84.8% vs. 62.9%, p&lt;0.001). Results from the interviews fell into three categories: about life with SUI and barriers to seeking care; about the treatments and the patient-provider relationship; about the sense of empowerment many women experienced. A core category emerged: “Acknowledged but not exposed.” The extra cost per quality-adjusted life year (QALY) gained through use of the Internet-based programme compared with the postal programme was €200. The extra cost per QALY for the Internet-based programme compared with no treatment was €30,935. The condition-specific questionnaire ICIQ-LUTSqol is reliable in women with SUI, with high degrees of agreement between overall scores (Intraclass correlation coefficient 0.95, p&lt;0.001). Conclusion Internet-based treatment for SUI is a new, effective, and patient-appreciated treatment alternative, which can increase access to care in a sustainable way.

Type 2 diabetes is a global health problem. Evidence indicates that type 2 diabetes can lead to serious complications, such as a cardiac event, which usually require critical nursing care. Patients with type 2 diabetes and with a history of cardiac disease are at greater risk of a further cardiac event requiring readmission to hospital. Evidence indicates that improved diabetes management assists patients with type 2 diabetes to manage their condition efficiently, reduces risks of a further cardiac event, and therefore reduces hospitalisations. However, there is limited information found regarding a diabetes management program specifically for patients who have already had cardiac complications. Difficulties in developing patients' skills in managing and modifying their daily lives also present a challenge to coronary care staff. Therefore, there is a real need to develop a special diabetes management program for patients with diabetes who have experienced a critical cardiac event, which will be commenced in the Coronary Care Unit (CCU). The aim of this research is to gain a greater understanding of the characteristics, secondly to obtain in-depth understanding of needs and experiences of patients with type 2 diabetes hospitalised for a critical cardiac event. A further aim is to develop and pilot test a diabetes management program, specific to the patients with diabetes in the context of the CCU. The design of this research employed three studies: Study I was an exploratory study, which obtained patients' demographic and disease characteristics from the hospital records of all patients with diabetes admitted to the CCU of one public hospital between 1 January 2000 to 31 December 2003. Study II used a qualitative interpretative approach and aimed to gain an in-depth understanding of the perspectives of patients with type 2 diabetes who have experienced a critical cardiac event in managing their everyday lives with both diabetes and cardiac conditions. Study III included two parts. The first utilised the information from the first two studies and the literature (self-efficacy theory) to develop a diabetes self-management program specifically for patients with diabetes who have had a critical cardiac event. The second part pilot tested the newly-developed diabetes self-management program for patients with diabetes admitted to CCU following a critical cardiac event. The pilot study used a randomised controlled trial research design to evaluate the efficacy of the program. Study I collected data from one hospital's records retrospectively from 2000 to 2003. The results of Study I showed there were 233 (14.7%) patients admitted to CCU that had diabetes out of the total 1589 CCU admissions during the study period. More than 22% of CCU patients with diabetes were readmitted to hospital within 28 days, compared to 6% of CCU patients without diabetes. Patients with diabetes who had a longer CCU stay were more likely to be readmitted. These results indicate that a significant proportion of a CCU population had type 2 diabetes and is more likely to be readmitted to hospital. Study II used an interpretive approach comprising open-ended interviews to collect data from patients with type 2 diabetes experiencing a cardiac event who had a CCU admission in 2000-2003. The findings revealed that patients with diabetes who had a critical cardiac event experienced considerable feelings of hopelessness and fatigue. Patients also had concerns in the areas of self-confidence and confidence in health professionals. Patients indicated that greater self-confidence and confidence in health professionals would help their ability to manage their daily lives. Therefore, it is very important that intervention programs for these at-risk patients need to improve patients' confidence levels, and reduce their feelings of hopelessness and fatigue. The information gathered from Study I and Study II provided important insight into the development of an effective diabetes self-management specifically designed for patients with type 2 diabetes following a critical cardiac event, which is presented in Study III in this thesis. Study III also provided a preliminary evaluation of the newly developed program. The evaluation used a randomised controlled trial research design for the new program and the current educational program provided in the CCU. The results of the program indicate the feasibility of commencing the new diabetes self-management program in the CCU, and to be continued in wards or at home. The results also showed significant improvements in patients' knowledge in the experimental group, but not in other outcome variables (self-efficacy, vitality and mental health levels). However, as a small sample size was used in this pilot study, a larger study is needed to ensure adequate testing of the intervention. Future research is also recommended to incorporate the new diabetes self-management program into the current cardiac education program. Staff's further professional development in providing such a program also needs to be examined. Improvements in quality of care, and patients' quality of life are expected in the future.

Background. Heart failure (HF) which is a chronic, disabling disorder is mainly found in older people and is one of the leading causes of hospitalisation and readmission around the world. Unfortunately, the mortality and morbidity rates for HF remain high. HF is a complex combination of symptoms which are related to an inadequate perfusion of the body tissues caused by fluid and sodium retention. Hence, enhancing HF patients’ self-efficacy to change their behaviours to perform fluid & sodium control is one of the most important issues for the management of HF. A self-management program has the potential to raise self-efficacy and self-care which is a method to improve health for those with chronic illness and to decrease patients’ health service utilisation and also to enhance these patients’ health status. Aim. The study aims to examine the effectiveness of a self-management program, based on self-efficacy theory, in older people with heart failure in Taiwan. Methods. An experimental design was used to examine the effectiveness of a self-management program on diet and fluid control among HF patients. A total of 93 subjects from two medical centres in Taiwan were randomly assigned to the intervention and control groups. In order to examine the effectiveness of self-management, data were collected at baseline, week 4, and week 12 using the following instruments: self-efficacy for salt and fluid control, HF self-management behaviour, HF related symptoms, and body weight. Moreover, health service utilisation and patient’s evaluation of care received were collected on all patients for the 12 weeks prior to commencing the study and for the 12 week study period. Demographic and disease information was also collected including age, gender, marital state, education, and New York Heart Association (NYHA) functional classification. A structured, individualized self-management training program created by the investigator was implemented for the intervention group through home visits and telephone follow-ups. This program emphasized self-monitoring of diet control and body weight for the self-management of heart failure. The purpose was to improve patients’ self-efficacy in their diet control behaviour. The “diet control” in this study focussed on sodium and fluid restriction. Outcome measures were analysed using the Statistical Package for the Social Sciences (SPSS) 15.0 version, and the level of significance (á) was set at 0.05 for statistical analysis. Results. There were differences for older Taiwanese HF patients’ self-efficacy for salt and fluid control, self-management behaviour, and HF related symptoms for participants who received a self-management intervention compared to those who did not. However, there were no significant differences between the two groups in weight and health serves utilization (p>.001). Conclusion. The self-management program had a positive impact on the improvement of self-efficacy for salt and fluid control, HF related self-management behaviours and symptoms in older Taiwanese with HF. This program may bridge the gap between theory and practice. Health care providers need to provide older people in Taiwan with HF the appropriate skills for self-managing their condition and thereby promoting their health status. These patients with HF and their caregivers have to receive individualized education that emphasizes self-efficacy in the self-management of their disease, thus improving their quality of life.

Depression is common in haemodialysis (HD) patients and is often unrecognised and undertreated, though associated with excess morbidity and mortality. Diagnosis is challenging due to symptom overlap with kidney failure, with fatigue being the most common overlapping symptom. Research on the effectiveness of antidepressant medication in this setting is sparse. A recent systematic review advocated well-designed Randomised Controlled Trials (RCTs) in this setting. The studies reported in this thesis had a number of aims. The main aim was to undertake a multicentre feasibility randomised, double blind, placebo-controlled trial of sertraline in patients on HD with Major Depressive Disorder (MDD). To identify suitable patients for this, a screening phase was required, which also allowed determination of the prevalence of depression in this setting and of the relative effectiveness of screening tools Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-9 (PHQ-9), and Beck Depression Inventory-II (BDI-II). It also allowed examination of the relationships of fatigue in this setting (assessed mainly by the Multidimensional Fatigue Inventory (MFI), including those with a diagnosis, and management of depression. The finding, during screening, that a large proportion of the HD cohort was already on antidepressant treatment, presented the opportunity to study 'real-life' practice patterns in the management of antidepressant treatment in this setting. Recruitment into the RCT was difficult. 1,355 patients in five HD centres were considered for screening, but 243 of these were excluded, mainly because of their inability to read and understand English. Of the remaining 1,110 patients, 709 consented to screening. 231 of these screened positive for high depression symptoms but 130 were not considered for the trial phase, mainly because of concurrent treatment for depression (68 patients), and other contraindicated conditions and medication. In addition, 38 patients declined to take part in the psychiatric interview necessary for diagnosis of MDD. Of the 63 who underwent the diagnostic interview, 37 (58.7%) were diagnosed with MDD and 30 consented to enter the RCT and were randomised into sertraline or placebo groups. This was half of the anticipated recruitment into the RCT. Twenty-one patients (70%) completed the six-month study, eight of 15 in the sertraline group and 13 of 15 in the placebo group (p < 0.05). Drop out was mainly due to adverse or serious adverse events. Depression scores (BDI-II and Montgomery-Åsberg Depression Rating Scale (MADRS)) improved significantly in both the sertraline and placebo groups over six months but there were no significant differences between the treatment groups. There was a slight suggestion of more rapid improvement over the first two months on sertraline, but this was not significant. Fatigue scores were high in all sub-domains - with only a weak relationship with age and comorbidity. Mental fatigue was the strongest independent predictor of high depressive symptoms (BDI-II ≥16, PHQ-9 ≥8), while physical fatigue had the strongest relationship with dialysis recovery time, and survival. Distinguishing between these components of fatigue may have a role in refining the diagnosis and management of MDD. Forty-one of the 76 patients on antidepressant medication at screening were followed up for a mean of 14±5 months. Ten different antidepressant agents were being taken - the most common being Citalopram (39%). Most had been prescribed by GPs. Two-thirds of patients either deteriorated or failed to improve in terms of BDI-II scores during follow-up, many of whom had had no adjustment of medication during this time. Diagnostic evaluation at follow-up showed 37% to be suffering from current or recurrent major depressive episodes (MDE), 48% to have evidence of past MDE, and 15% to have no evidence of ever having been depressed. These empirical studies confirm that depression is very common in HD patients. Its diagnosis is complicated due to symptom overlap with the uraemic syndrome. Fatigue seems to be a key area of overlap with symptoms of depression with a complex relationship. There was no obvious benefit from antidepressants in this feasibility RCT and there was a high drop-out rate due to adverse events, particularly in the sertraline group. These findings raise concerns about the benefits and risks of antidepressants in patients on HD. Current practice patterns may be subjecting patients to substantial risk for little or no benefit. Identifying whether antidepressant medication is effective in this context is a major clinical need, hence the requirement for a definitive study. There is no doubt that to undertake a definitive study would pose considerable recruitment challenges. The findings presented here emphasise the importance of finding ways to overcome these challenges that might include efforts to incorporate patients already taking antidepressants.

La Société Européenne de Cardiologie recommande pour les patients insuffisants cardiaques, en plus de la prise en charge médicamenteuse et interventionnelle, une prise en charge de type « éducation du patient » pour améliorer leur qualité de vie. En France, des programmes multidisciplinaires d’éducation du patient en hôpital ont mesuré leurs effets sur les ré-hospitalisations, la mortalité et le taux de participation des patients aux programmes. Certaines études internationales ont mesuré l’effet de programmes éducatifs délivrés par des équipes hospitalières multidisciplinaires, d’autres ont recruté des patients en soins primaires, mais les programmes étaient conduits par des infirmières ou des assistants des médecins généralistes. Ce type de programme ne reflète pas la situation actuelle en France où la plupart des patients sont suivis en ambulatoires par leurs médecins généralistes. Il semblait nécessaire de connaître plus précisément l'effet de programmes d'éducation du patient délivrés par les médecins généralistes auprès de leurs propres patients. L’objectif principal de l’étude ETIC (Education thérapeutique des patients insuffisants cardiaques) était d’évaluer si un programme d’éducation des patients insuffisants cardiaques délivré par leurs médecins traitants et suivis en médecine générale, améliorait leur qualité de vie. Cette étude interventionnelle, contrôlée, randomisée en grappes, a inclus 241 patients insuffisants cardiaques chroniques suivis par 54 médecins généralistes pendant 19 mois. Les médecins généralistes du groupe intervention ont été sensibilisés pendant 2 jours au programme d’éducation du patient et entrainés à adapter leurs propres objectifs d'éducation aux attentes du patient. Plusieurs séances d'éducation ont été simulées au cours de la formation des médecins. La 1re séance comportait un bilan éducatif explorant le mode de vie et les habitudes alimentaires, l'activité physique, les activités de loisirs, les projets et les ressources des patients. Les patients bénéficiaient de 4 séances d’éducation tous les 3 mois pendant 12 mois puis d’une séance d’éducation de synthèse au 19e mois de suivi. Le critère d’évaluation principal était la qualité de vie mesurée par une échelle de qualité de vie générique, la MOS 36-Item Short Form Health Survey (SF-36), et par une échelle de qualité de vie spécifique de l’insuffisance cardiaque, le Minnesota Living with Heart Failure Questionnaire (MLHFQ). La moyenne d’âge des patients était 74 ans (± 10.5), 62% était des hommes, et leur fraction d’éjection ventriculaire gauche moyenne était de 49.3% ± 14.3%. A la fin du suivi, le score MLHFQ moyen dans les groupes intervention et témoin étaient respectivement 33.4 ± 22.1 versus 27.2 ± 23.3; p = 0.74, intra-cluster coefficient [ICC] = 0.11. A la fin du suivi, la moyenne des scores SF-36 mental et physique dans les groupes intervention et témoin étaient respectivement 58 ± 22.1 versus 58.7 ± 23.9 (p = 0.58, ICC = 0.01) et 52.8 ± 23.8 versus 51.6 ± 25.5 (p = 0.57, ICC = 0.01). Le nombre de patients insuffisants cardiaques à fraction d’éjection conservée (ICFEp) était de 93 (80.9%) dans le groupe intervention et de 94 (74.6%) dans le groupe témoin (p = 0.24). Une étude exploratoire a été réalisée pour décrire les traitements prescrits dans la population de cette étude : évaluation de l’adhésion des médecins généralistes aux recommandations pour les patients à fraction d’éjection réduite (ICFEr) et description des traitements prescrits aux patients ICFEp. Le programme d’éducation du patient délivré dans le cadre de l’étude ETIC, n’a pas fait la preuve d’une amélioration de la qualité de vie des patients. D’autres recherches sont nécessaires pour améliorer la qualité de vie de ces patients. Les stratégies et les méthodes d’éducation restent un champ de recherche à développer. / The European Society of Cardiology guidelines recommend non-pharmacological management to improve patients’ quality of life. In France, patient education programs delivered by hospital multidisciplinary teams in outpatient clinics have been assessed for their impact in patients with heart failure (HF). Some international studies assessed patient education interventions for heart failure patients recruited in the hospital. These programs were delivered by hospital multidisciplinary teams. Others have recruited patients with heart failure in primary care but the patient education programs were delivered by nurses or general practitioner assistants. This does not reflect the situation of the majority of patients in France, most of whom are ambulatory and cared for by general practitioners (GPs). Therefore, more evidence is needed on the effect of patient education programs delivered by GPs. As GPs are the doctors closest to patients, we hypothesized that their patient education could improved the HF patients quality of life. The ETIC (Education thérapeutique des patients insuffisants cardiaques) trial aimed to determine whether a pragmatic education intervention in general practice could improve the quality of life of patients with chronic heart failure (CHF) compared with routine care. This cluster randomised controlled clinical trial included 241 patients with CHF attending 54 general practitioners (GPs) in France and involved 19 months of follow-up. The GPs in the intervention group were trained during an interactive 2-day workshop to provide a patient education program. Several patient education sessions were simulated during the 2-day workshop. Patients had a further four education sessions, at 4, 7, 10 and 13 months, followed by an overview session at 19 months. The primary outcome was patients’ quality of life, as measured by the MOS 36-Item Short Form Health Survey (SF-36), a generic instrument, and the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The mean age of the patients was 74 years (± 10.5), 62% were men and their mean left-ventricular ejection fraction was 49.3% (± 14.3). At the end of the follow-up period, the mean MLHFQ scores in the Intervention and Control Groups were 33.4 ± 22.1 versus 27.2 ± 23.3 (p = 0.74, intra-cluster coefficient [ICC] = 0.11). At the end of the follow-up period, SF-36 mental and physical scores in the Intervention and Control Groups were 58 ± 22.1 versus 58.7 ± 23.9 (p = 0.58, ICC = 0.01) and 52.8 ± 23.8 versus 51.6 ± 25.5 (p = 0.57, ICC = 0.01), respectively. Patients with heart failure with preserved ejection fraction (HFpEF) in the intervention group and in the control group were respectively: 93 (80.9%) and 94 (74.6%) (p = 0.24). A comprehensive data set of this trial was used to assess the prescription behaviour of GPs: GP’s guideline adherence for pharmacotherapy of heart failure with reduced ejection fraction (HFrEF) patients and to describe pharmacotherapy of HFpEF patients. Conclusions Patient education delivered by GPs to elderly patients with stable heart failure in the ETIC program did not demonstrate an improvement in their quality of life compared with routine care. Further research on improving the quality of life of elderly patients with CHF in primary care is needed. Patient education strategies and methods, as well as relevant tools and adapted criteria used to assess them, remain a field of research to develop. This area of investigation will be the following of this work.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2018. / Background: Chronic non-specific low back pain (CNSLBP) is a common ailment treated by chiropractors. Most chiropractors focus on the localised lumbar area of pain. Other chiropractors focus on restoring function to compensating articulations in the ‗full kinematic chain‘ by assessing and treating the lower extremity in conjunction to the low back. Patients with LBP often exhibit decreased hip-related ranges of motion that may result in future LBP, relapse and a prolonged recovery time. Studies investigating the effect of treating the kinematic chain in relation to LBP are limited and the literature, although widely taught and practiced, is largely anecdotal. Chiropractic manipulation has shown to be effective in the treatment of LBP and many lower extremity conditions. Objectives: This study set out to determine if a combination of low back and hip manipulation would result in a more beneficial outcome for the participant, suffering with CNSLBP, than low back manipulation alone in terms of objective and subjective outcomes. Method: The study was a randomised controlled clinical trial which, through purposive sampling, consisted of 50 participants with CNSLBP and hip joint dysfunction. The participants were randomly divided into two groups of 25 each [A and B]. Group A received low back manipulation alone and Group B received combined low back and hip manipulation. Subjective data was obtained through the Oswestry Low Back Pain Disability Index (ODI) and the Numerical Pain Rating Scale (NPRS). Objective data was obtained through the use of a Force Dial Algometer and an Inclinometer. Data collection occurred at the first, third and fifth consultations and was coded and analysed using IBM SPSS version 24.0. A p-value value of less than 0.05 was considered to be statistically relevant. Results: Intra-group testing showed that there was a significant difference over time, within both groups, with regards to internal rotation and external rotation of the hip, flexion of the lumbar spine, increased pain tolerance in Algometer tests, decreased NPRS values and decreased ODI scores. Within Group A, the mean scores for hip flexion reflected a more significant increase over time than those of Group B. Within Group B, the mean scores for left and right rotation of the lumbar spine reflected a more significant change over time than those of Group A. Inter-group testing showed no significantly differential treatment effect for any of the subjective and objective outcomes. This means that both treatments were equally effective and the hypothesis, that suggested that Group B would improve more than Group A, was incorrect. Conclusion: Both treatment groups improved subjectively and objectively with regards to CNSLBP. Inter-group testing showed that statistically, and for all outcome measurements, there were no significant differences between the two treatment group‘s results. This suggested that there was no additional benefit in combining hip joint manipulation with low back manipulation in the treatment of CNSLBP. / M

Objetivos: O objetivo do estudo foi avaliar se uma estratégia restritiva de transfusão de hemácias era superior a uma estratégia liberal na redução de mortalidade em 28 dias de pacientes oncológicos críticos com choque séptico. Desenho: unicêntrico, randomizado, duplo cego e controlado. Local: Unidade de Terapia Intensiva do Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo. Pacientes: Pacientes adultos com neoplasia admitidos na Unidade de Terapia Intensiva (UTI) nas primeiras 6 horas do diagnóstico de choque séptico. Intervenção: Os pacientes foram randomizados para uma estratégia liberal (transfusão de hemácias se hemoglobina < 9 g/dL) ou para uma estratégia restritiva (transfusão de hemácias se hemoglobina < 7 g/dL) durante a permanência na Unidade de Terapia Intensiva. Desfecho primário: Mortalidade por todas as causas após 28 dias. Resultados: O estudo foi realizado no período de junho de 2012 a maio de 2014. Foram randomizados 300 pacientes para as estratégias de transfusão liberal (n = 149) ou restritiva (n = 151). A mortalidade após 28 dias da randomização ocorreu em 67 pacientes do grupo liberal (45%) e em 84 pacientes do grupo restritivo (56%) (RR 1,53; intervalo de confiança 95%, 0,97-2,52, P=0,07). A mortalidade 90 dias após a randomização foi de 59% no grupo liberal e 70% no grupo restritivo (RR 1,63; intervalo de confiança 95%, 1,01-2,63; P=0,044). Os pacientes do grupo liberal receberam mais unidades de transfusão de hemácias quando comparados aos pacientes do grupo restritivo (1 [0-3] unidade vs 0 [0-2] unidade, P < 0,001). Conclusões: O estudo confirmou que uma estratégia restritiva de transfusão de hemácias quando comparada a uma estratégia liberal, não reduziu a mortalidade em 28 dias de pacientes oncológicos com choque séptico / Objective: To assess whether a restrictive strategy of red blood cell (RBC) transfusion reduces 28-day mortality when compared to a liberal strategy in cancer patients with septic shock. Design: Single center, randomized, double-blind controlled trial. Setting: Teaching hospital. Patients: Adult cancer patients with septic shock in the first 6 hours of Intensive Care Unit (ICU) admission. Interventions: Patients were randomized to a liberal (hemoglobin threshold < 9 g/dL) or to a restrictive strategy (hemoglobin threshold < 7 g/dL) of red blood cell transfusion during ICU stay. Measurements and Main Results: The primary outcome was 28-day all-cause mortality after randomization. Between June 2012 and May 2014, 300 patients were randomized to the liberal transfusion strategy (n=149) or to the restrictive transfusion strategy (n=151) strategy. At 28 days after randomization, mortality rate in the liberal group was 45% (67 patients) compared with 56% (84 patients) in the restrictive group (hazard ratio, 1.53; 95% confidence interval, 0.97 to 2.52; P=0.07). At 90 days after randomization, mortality rate in the liberal group was 59% compared with 70% in the restrictive group (hazard ratio, 1.63; 95% confidence interval, 1.01 to 2.63; P=0.044). Patients in the liberal group received more RBC units than patients in the restrictive group (1 [0-3] unit vs. 0 [0-2] unit, P < 0.001). Conclusions: A restrictive strategy of RBC transfusion did not decrease 28-day mortality rate of patients admitted to ICU due to septic shock when compared to a liberal strategy