Made available in DSpace on 2016-01-26T12:51:42Z (GMT). No. of bitstreams: 1 rosanagobibruetto_dissert.pdf: 1002931 bytes, checksum: 2f0ecd040d0c3d725a801b5ea3e328e6 (MD5) Previous issue date: 2012-01-23 / The estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m2 at admission is associated with increased risk of death after acute myocardial infarction (AMI). However, the role of admission eGFR on the incidence and mortality of acute kidney injury (AKI) after AMI has been poorly studied. The aim of this study is to investigate if impaired admission eGFR influences the incidence and mortality of AKI after AMI. A total of 1.012 consecutive AMI patients from a prospective database were analyzed and 828 subjects were included. The diagnostic criteria for AKI was a percent increase in serum creatinine (SCr) &#8805; 50 % from baseline (RIFLE criteria) in the first seven days of hospitalization. Patients were divided into four subgroups: admission eGFR &#8805; 60 mL/min/1.73m2 and no AKI (reference), admission eGFR < 60 mL/min/1.73m2 and no AKI, admission eGFR &#8805; 60 mL/min/1.73m2 and AKI, admission eGFR < 60 mL/min/1.73m2 and AKI. Impaired eGFR had no impact in the incidence of AKI. On the other hand, impaired admission eGFR had a striking influence on the mortality of AMI associated with AKI. In Cox multivariate analysis, 30 days mortality was significantly higher for eGFR < 60 mL/min/1.73m2 and no AKI (adjusted hazard ratio [AHR] 2.00, p=0.020), for eGFR &#8805; 60 mL/min/1.73m2 and AKI (AHR 4.76, p < 0.001) and for eGFR < 60 mL/min/1.73m2 and AKI (AHR 6.27, p < 0.001) compared to patients with eGFR &#8805; 60 mL/min/1.73m2 who did not develop AKI. One year mortality was significantly higher only for eGFR < 60 mL/min/1.73m2 and who developed AKI (AHR 3.05; p=0.002) compared with patients with eGFR &#8805; 60 mL/min/1.73m2 without AKI. In conclusion, overlap of low admission eGFR and AKI development was associated with the worst early prognosis after AMI. Remarkably, the long term mortality rate in patients who developed AKI, was only increased in the group with an impaired admission eGFR. / A Taxa de filtração glomerular estimada (TFGe) < 60 mL/min/1,73m2 na admissão hospitalar está associada a risco aumentado de morte em pacientes vítimas de infarto agudo do miocárdio (IAM). No entanto, a possível influência da TFGe à admissão hospitalar na incidência e na mortalidade da lesão renal aguda (LRA) associada a IAM é pouco conhecida. O objetivo deste estudo é investigar se a presença da TFGe diminuída à admissão hospitalar influencia a incidência e a mortalidade associada a LRA após IAM. Foram avaliados 1.012 pacientes consecutivos de um banco de dados prospectivo e 828 pacientes preencheram os critérios de inclusão. O critério diagnóstico de LRA foi o aumento de creatinina sérica (CrS) &#8805; 50% do valor basal (critério RIFLE), durante os primeiros sete dias de internação. Os pacientes foram divididos em quatro grupos após estimar a TFG na admissão: TFGe &#8805; 60 mL/min/1,73m2 e sem LRA (referência); TFGe < 60 mL/min/1,73m2 e sem LRA; TFGe &#8805; 60 mL/min/1,73m2 e que desenvolveram LRA; TFGe < 60 mL/min/1,73m2 e que desenvolveram LRA. A TFGe diminuída na admissão não teve impacto na incidência da LRA. Por outro lado, a TFGe diminuída na admissão foi associada às taxas de mortalidade mais elevadas em pacientes que desenvolveram LRA após IAM. Na análise múltipla de Cox, os grupos que apresentaram associação independente com mortalidade em 30 dias foram: TFGe < 60 mL/min/1,73m2 e sem LRA (hazard ratio ajustada [HRA] 2,00; p=0,020), TFGe &#8805; 60 mL/min/1,73m2 e que desenvolveram LRA (HRA 4,76; p < 0,001) e TFGe < 60 mL/min/1,73m2 com desenvolvimento de LRA (HRA 6,27; p< 0,001) em comparação com pacientes com TFGe &#8805; 60 mL/min/1,73m2 que não desenvolveram LRA. Em um ano, apenas o grupo com TFGe < 60 mL/min/1,73m2 e que desenvolveu LRA apresentou maior mortalidade (HRA 3,05; p=0,002) em comparação aos pacientes com TFGe &#8805; 60 mL/min/1,73m2 e que não desenvolveram LRA. Concluímos que a associação entre TFGe diminuída na admissão e o desenvolvimento de LRA foram associados a um pior prognóstico a curto prazo após o IAM. Entre os pacientes que desenvolveram LRA foi observado aumento na mortalidade a longo prazo somente no grupo com TFGe diminuída na admissão.

Made available in DSpace on 2016-01-26T12:51:45Z (GMT). No. of bitstreams: 1 fernandobruettorodrigues_tese.pdf: 4591975 bytes, checksum: b79f74b1b34f2f124a27ea0da5458969 (MD5) Previous issue date: 2012-03-08 / Acute kidney injury (AKI) increases the risk of death after acute myocardial infarction (AMI). Recently, two new AKI definitions were proposed: Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) and Acute Kidney Injury Network (AKIN). There are no data comparing AMI-related AKIs diagnosed by both criteria. The purpose of this study is to compare the incidence and mortality of AKI diagnosed by RIFLE and AKIN in the AMI acute phase. In total, 1050 consecutive AMI patients were studied. AKI defined by RIFLE and AKIN occurred in 14.8% and 42.7% of patients, respectively, in the first 7 days of hospitalization. This difference resulted from the larger number of patients in AKIN stage 1 (36.2%) compared with the number in RIFLE stage Risk (9.6%, p < 0.001). Both AKI criteria were associated with an increased Adjusted Hazard Ratio (AHR) for 30-day and 1-year mortality. The subgroup of patients classified as non-AKI by RIFLE but as AKI by AKIN criteria showed an increased AHR for death (2.49; 95% confidence interval [CI] 1.37 4.51, p=0.003) at 30 days and at 1 year (1.99; 95% CI 1.20 3.31, p=0.008) compared with patients without AKI. In conclusion, AKIN has detected more AKI than RIFLE in the acute phase of AMI. Both definitions were associated with increased early and late mortality. Patients diagnosed with AKI by AKIN but not by RIFLE showed an increased AHR for early and late mortality. / A lesão Renal Aguda (LRA) aumenta o risco de morte, após o Infarto Agudo do Miocárdio (IAM). Recentemente, duas novas definições para LRA foram propostas: RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) e AKIN (Acute Kidney Injury Network). Ainda não existem estudos comparando o diagnóstico de LRA por ambos critérios, após IAM. O objetivo deste estudo é comparar os critérios AKIN e RIFLE quanto à incidência de LRA e mortalidade na fase aguda do IAM. Um total de 1.050 pacientes consecutivos com IAM foi estudado. A LRA definida por RIFLE ocorreu em 14,8% e por AKIN em 42,7% dos pacientes nos primeiros sete dias de internação. A diferença ocorreu devido a um grande número de pacientes no estágio um de AKIN (36,2%) em comparação com a categoria Risk do RIFLE (9,6%; p < 0,001). Ambos os critérios para LRA foram associados com aumento da Hazard Ratio Ajustada (HRA) para mortalidade em 30 dias e um ano. O sub-grupo de pacientes classificado com não LRA por RIFLE, mas como LRA por AKIN apresentou uma HRA para morte (2,49; intervalo de confiança [IC] 95% 1,37-4,51; p = 0,003) em 30 dias e em 1 ano (1,99; IC 95% 1,20-3,31; p = 0,008) em comparação a pacientes sem LRA. Concluímos que o critério AKIN detectou mais LRA que o RIFLE na fase aguda do IAM. Ambos os critérios foram associados com aumento da mortalidade precoce e tardia. Pacientes diagnosticados como LRA por AKIN, mas não por RIFLE também apresentaram um aumento da HRA para mortalidade precoce e tardia.

Sjukvårdsfunktionen i Försvarsmakten är viktig när skador uppkommer. Försvarsmaktens förmåga eller oförmåga att erbjuda soldater kvalificerad sjukvård är avgörande för soldaternas förtroende till den egna förmågan. De svenska sjukvårdarna förväntas att oavsett terräng och hot kunna ta hand om en patient i nöd, de är därför utrustade med vapen för att kunna skydda sig själva och sin patient. I Försvarsmakten betyder det att sjukvårdaren bär en automatkarbin 5. Den här uppsatsen kommer att undersöka hur tre olika vapensystem passar in i rollen som huvudbeväpning på en sjukvårdsgrupp. Undersökningen visar att en PDW (Personal Defence Weapon) skulle vara ett bra alternativ till befintlig beväpning. / The ability to provide a good medical treatment to injured service personnel in the Swedish Armed Forces is important, but the Armed Forces' ability or inability to provide soldiers qualified care is also vital for the members of the armed forces confidence for their own ability. Swedish medics are expected to take care of a patient, whatever the terrain and threat may be. Swedish medics aren’t considered to be combatants in war or conflict but the law gives them the right to defend themselves and their patients. They are currently equipped with the Ak 5 to protect themselves and their patients, a weapon that is used by all service personel In the Swedish Armed Forces, this means that the medics carry a full length rifle. This report will examine the weapon best suited for a medical team to carry out its duties while also providing a level of personal protection should the need arise.

Sedan kalla kriget har inte bara omvärlden och föreställningen av motståndaren förändrats utan även reglementenas utformning. I dagsläget används på kompaninivå ett reglemente för alla manöverkompanier, tidigare har det i försvarsmakten funnits reglementen för specifika typer av kompanier. Denna uppsats behandlar vilken påverkan detta har på tydligheten i reglementena.Arbetet syftar till att undersöka tydlighet i föreställningar om infanteriförbandens taktik på kompaninivå idag jämfört med under mitten av kalla kriget i två vägledande instruktioner. Detta för att diskutera artikulering av taktik och dess implikationer på officersutbildning inom försvarsmakten. Den metod som används är kvalitativ textanalys med en komparativ design. Som analysverktyg har de grundläggande förmågorna använts och empirin utgörs av två reglementen, Infanterireglemente skyttekompani 1975 och markstridsreglemente 5 kompani.Undersökningen resulterar i att författaren upptäcker en tydlig skillnad i hur framför allt verkan och skydd artikuleras i de olika reglementena. I diskussionen visar det sig att detta kan bero på ett antal faktorer. Även utformningen av reglementet diskuteras och resultatet blir då, att för att finna vägledning i markstridsreglemente 5 kompani krävs tidigare erfarenhet av förbandstypen. Denna erfarenhet kan också påverka tolkningen av instruktionen. / Since the Cold War has not only the outside world and the perception of the opponent changed but also regulations design. In the current situation there is a Company level regulation for all fighting companies, when it previously was regulations for each of the specific types of companies. This paper discusses the impact that has on the clarity of the regulations.The work aims to investigate the transparency of notions of infantry formation tactics at company level today than during the middle of the Cold War in two guiding instructions. This is to discuss the articulation of tactics and its implications on the officer training in the armed forces. The method used is qualitative text analysis with a comparative design. To make the analysis the fundamental capabilities are used and empirical data consists of two regulations, Infanterireglemente skyttekompani 1975 and markstridsreglemente 5 kompani.The survey results in the author discovering a clear difference in how the capabilities effect and protection are articulated in the various the regulations. In the discussion, it appears that this may be due to a number of factors. The design of the regulations is also discussed and the result is that in order to find guidance in markstridsreglemente 5 kompani the reader needs previous experience of the specific company type. This experience can also affect the interpretation of the instruction.

Submitted by Rosangela Silva (rosangela.silva3@unioeste.br) on 2018-05-24T17:46:38Z No. of bitstreams: 2 Isabel Cristina Moresco.pdf: 778049 bytes, checksum: 0c5c3dc6a4ac6f42d2f9a40313cd38c6 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2018-05-24T17:46:39Z (GMT). No. of bitstreams: 2 Isabel Cristina Moresco.pdf: 778049 bytes, checksum: 0c5c3dc6a4ac6f42d2f9a40313cd38c6 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2018-03-08 / In the last 20 years, with the emergence of multiresistant gram-negative bacteria, polymyxins, which had fallen into disuse due to their high toxicity, were once again used as an alternative for the treatment of these infections. This antibiotic group is active against most enterobacteria and non-fermenting gram-negative bacteria, ocular, urinary tract, meninges, and bloodstream infections. The recommended dose of polymyxin B (PMB) in patients with normal renal function is 1.5 to 2.5 mg.kg-1.day-1 and the dose can be divided twice. For patients with impaired renal function, it is recommended to adjust the dose according to creatinine clearance. Because nephrotoxicity is the major limiting factor in the use of this class of antibiotics, a retrospective observational study was conducted to identify possible risk factors for the development of acute renal injury (ARF) in patients using the antibiotic PMB. The necessary information was collected to perform the study in medical records, medical prescriptions and results of laboratory tests from the patients who used PMB in a period of 5 years in a Brazilian hospital. Inclusion criteria for the study were: patients over 18 years of age who used intravenous PMB for more than 72 hours. To classify ARI levels, baseline creatinine was calculated by the average of the last five serum creatinine tests before the first dose of the antibiotic. This calculated value and the highest level of serum creatinine during treatment were used to identify and classify renal damage according to the criteria of the RIFLE (Risk, Injury and Failure and Loss and End-stage renal disease) filtration rate. The study included 120 patients, most of them male (89; 74.2%) with an average age of 50 years. The most frequent pre-existing comorbidities were systemic hypertension (50; 41.7%), diabetes mellitus (21; 17.5%), nephropathies (14; 11.7%) and obesity (13; 10.8%). The main infection was pneumonia (35.8%) and the most frequently identified infectious agent was Acinetobacter baumannii (67.9%). PMB treatments were performed for 13 days and the average daily dose was 191.5 mg. The high incidence of mortality in the studied population (46.7%) may be related to the critical clinical status of the patients, because at some point of hospitalization, 111 patients (92.5%) needed intensive care. In the population studied to evaluate risk factors, 12 patients (13.5%) presented risk, 22 (25.0%) injury, 30 (34.1%) renal failure, according to RIFLE criteria. In addition, in the group that patients developed ARF, 51.9% died, whereas in the group that did not present, only 12.5% died. There was a statistically significant difference between the groups that developed or not ARF, for the following variables: treatment time greater than 10 days, accumulated PMB dose, hypoalbuminemia and concomitant use of furosemide. However, the variables that remained in the final multivariate logistic regression model were treatment time greater than 10 days and hypoalbuminemia. Several factors inherent to the patient and the drug are related to ARF and strategies should be created in order to minimize these effects. The monitoring of renal function in all patients, especially those at risk, and the follow-up of the infection to reduce the time of treatment are highlighted. / Nos últimos 20 anos, com o surgimento de bactérias gram-negativas multirresistentes, as polimixinas, que tinham caído em desuso pela elevada toxicidade, voltaram a ser utilizadas como uma alternativa para tratamento dessas infecções. Esse grupo de antibiótico é ativo contra a maioria das enterobactérias e das bactérias gram-negativas não fermentadoras, em infecções oculares, do trato urinário, das meninges e da corrente sanguínea. A dose recomendada de polimixina B (PMB), em pacientes com função renal normal, é de 1,5 a 2,5 mg Kg-1 dia-1 e a dose pode ser dividida em duas vezes. Para os pacientes com alteração da função renal, recomenda-se ajustar a dose de acordo com a depuração de creatinina. Como a nefrotoxicidade é o maior limitante do uso dessa classe de antibióticos, um estudo observacional retrospectivo foi realizado com o objetivo de identificar os possíveis fatores de risco para o desenvolvimento de injúria renal aguda (IRA) em pacientes que utilizaram o antibiótico PMB. Foram coletadas as informações necessárias para realizar o estudo em prontuários, prescrições médicas e resultados de exames laboratoriais dos pacientes que utilizaram PMB em um período de 5 anos em um hospital brasileiro. Os critérios de inclusão para o estudo foram: pacientes maiores de 18 anos que utilizaram PMB por via endovenosa por mais de 72 horas. Para classificar os níveis de IRA, a creatinina basal foi calculada pela média entre os cinco últimos exames de creatinina sérica antes da primeira dose do antibiótico. Esse valor calculado e o maior nível de creatinina sérica durante o tratamento foram usados para identificar e classificar o dano renal segundo os critérios da taxa de filtração glomerular de RIFLE (Risk, Injury and Failure and Loss, and End-stage renal disease). Foram inclusos no estudo 120 pacientes, a maioria do sexo masculino (89; 74,2%) com média de idade de 50 anos. As comorbidades pré-existentes presentes com maior frequência foram hipertensão arterial sistêmica (50; 41,7%), diabetes mellitus (21; 17,5%) nefropatias (14; 11,7%) e obesidade (13; 10,8%). A principal infecção tratada foi pneumonia (35,8%) e o agente infeccioso mais identificado foi o Acinetobacter baumannii (67,9%). Os tratamentos com a PMB foram realizados durante 13 dias e a dose média diária de 191,5 mg. A alta incidência de mortalidade da população estudada (46,7%) pode estar relacionada ao estado clínico crítico dos pacientes, pois, em algum momento do internamento, 111 pacientes (92,5%) precisaram de cuidados intensivos. Na população estudada para avaliar os fatores de risco, 12 pacientes (13,5%) apresentam risco, 22 (25,0%) injúria, 30 (34,1%) falência renal, segundo os critérios de RIFLE. Além disso, no grupo que os pacientes desenvolveram IRA, 51,9% foram a óbito, enquanto que no grupo que não apresentou foram apenas 12,5%. Houve diferença estatisticamente significativa entre os grupos que desenvolveram, ou não, IRA, para as seguintes variáveis: tempo de tratamento superior a 10 dias, dose acumulada de PMB, hipoalbuminemia e uso concomitante de furosemida. Porém, as variáveis que permaneceram no modelo final de regressão logística multivariável foram o tempo de tratamento superior a 10 dias e a hipoalbuminemia. Vários fatores inerentes ao paciente e à droga estão relacionados à IRA e estratégias devem ser criadas com o intuito de minimizar esses efeitos. Destacam-se a monitorização da função renal em todos os pacientes, principalmente os de risco, e o acompanhamento da infecção para diminuir o tempo de tratamento.

The discussion regarding the second amendment and gun control in the United States has been a controversial and highly debated topic for many years. However, with the several school shootings taking place, the discussion about gun controls has been taken to a new level. The purpose of this essay is to give an overview of the debate and answer to the main question ”how is the relationship between freedom and rights expressed in the debate about strengthened gun control, in relation to positive and negative liberty, and over time?  In order to achieve the purpose, three different kinds of analyzes have been made. First, two pro-contra analyzes were made on two different occasions. Next, the arguments found was examined through two concepts of liberty: positive and negative liberty. Lastly, a comparison was made between the arguments from the two different occasions. The results show that there are three different core issues in the debate, and that positive liberty is dominating the pro-gun control side, while negative liberty and individual rights are dominating the contra-gun control side. The debate has not been going through a radical change. However, some arguments have grown stronger over the years.

The main purpose was describe the issue of shooting success rate at high altitude (1 500 - 3 000m a. s. l.). Shooting success rate of elite racers was evaluated using analysation of results from individual races at high altitude in the period 1990/1991 - 2013/2014. High altitude had no statistical effect (p<0,05) on shooting success rate of women and men biathletes in the comparision with lowland but it had more negative effect to women shooting success rate than men shooting success rate. Ten national level biathletes were tested in three tests in lowland, four tests at high altitude and five tests in lowland after the return from high altitude. The test included rest shooting in the prone and standing positions and load shooting in both positions which took part of three kilometers running. Twelve days training camp at high altitude did not improve shooting success rate, shooting velocity and running time in the determinated heart rate. Rest shooting and shooting in the prone position did not change statistically during the whole testing period. At high altitude critical days were registered in load shooting in standing position (6th day, p<0,05) and average running time (9th day, p<0,05). Rifle manipulation and shooting are automate motions which are not influenced by high altitude. Most...

The main purpose was describe the issue of shooting success rate at high altitude (1 500 - 3 000m a. s. l.). Shooting success rate of elite racers was evaluated using analysation of results from individual races at high altitude in the period 1990/1991 - 2013/2014. High altitude had no statistical effect (p<0,05) on shooting success rate of women and men biathletes in the comparision with lowland but it had more negative effect to women shooting success rate than men shooting success rate. Ten national level biathletes were tested in three tests in lowland, four tests at high altitude and five tests in lowland after the return from high altitude. The test included rest shooting in the prone and standing positions and load shooting in both positions which took part of three kilometers running. Twelve days training camp at high altitude did not improve shooting success rate, shooting velocity and running time in the determinated heart rate. Rest shooting and shooting in the prone position did not change statistically during the whole testing period. At high altitude critical days were registered in load shooting in standing position (6th day, p<0,05) and average running time (9th day, p<0,05). Rifle manipulation and shooting are automate motions which are not influenced by high altitude. Most...

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Sweden’s Defence Forces are in the process of procuring a new personal firearm to replace the current Ak5 (a version of the FN FNC) which has been in service for almost 35 years. There are many opinions on this matter and a great deal of interest among the future users, ie the soldiers and officers.  Our study aims to develop a deeper understanding of the user expectations for this new weapon. We are using a qualitative, inductive method with semi-structured interviews and netnography.von Hippel’s lead user concept has been the main reference for the design of this thesis, which means that we have interviewed those users who are perceived to have more to gain from a product development than other users. A lead user is often knowledgeable in his or her topic, might be leading development within the topic and it is not unusual for the lead user to have a social standing permitting him or her to influence others regarding the topic. We have also used internet forums discussing firearms to broaden the study since we know that a lot of the current discussions are occurring online and we expect this trend to continue in the near future. On top of the characteristics users want in a new weapon, some other aspects have come to light during the course of our research, these are also discussed in the thesis. Why is there an unproportionate amount of time spent on discussing firearms? Is there a greater value to a personal firearm than just its function? What role should the user perspective play in the Swedish Armed Forces? What are the consequences of the users being dissatisfied with the product? What is the role of the assault rifle in the Swedish Defence Forces and what specific purpose is it meant to fill? Is it possible to fit all purposes with one single weapon, which has been the role of the Ak5 for long periods of time. How should the Swedish Defence Forces respond to the fact that heavy body armour is issued to Russian troops? The Swedish Armed Forces has made an attempt at involving the user perspective in the process but our study should be seen as an important complement to this effort. / Sverige är på väg att göra en anskaffning av ett nytt eldhandvapen för att ersätta Ak5 som snart har tjänstgjort 35 år i Försvarsmakten. Det finns många åsikter bland de framtida brukarna och intresset är stort. I vår studie försöker vi få en djupare förståelse för vilka förväntningar användarna, dvs. soldaterna och officerarna, har på det nya vapnet. Metoden vi har använt är en kvalitativ, induktiv metod med semistrukturerade intervjuer och netnografi. Vi har använt oss av von Hippels lead user concept (von Hippel, 2005) , vilket innebär att vi har intervjuat de användare som av olika skäl anses ha mer att ge i en produktutveckling jämfört med andra användare. Oftast är en lead user mycket väl insatt i sitt ämne, kan driva utveckling inom ämnet och har inte sällan en social ställning som gör att hen kan påverka andra brukares åsikt i ämnet. Vi har även breddat studien med analys av nätforum som diskuterar ämnet nästa eldhandvapen, då vi menar att mycket av diskussionen pågår just online och att även mycket av diskussionen i samband med och efter införandet kommer att ske i dessa forum. Förutom en bild av vilka egenskaper användarna vill ha i det nya vapnet, så har det under studien framkommit en del andra aspekter, vilka också diskuteras i uppsatsen.   Varför läggs oproportionerligt mycket tid på att diskutera just eldhandvapen? Är eldhandvapnets betydelse större än själva funktionen? Vilken roll bör brukarperspektivet ha i Försvarsmakten? Vilka är konsekvenserna om användarna är missnöjda med produkten? Vilken är automatkarbinens roll i Försvarsmakten, dvs vilken funktion skall den fylla? Går det att lösa alla våra behov med ett enhetsvapen, vilket Ak5 i perioder har varit.  Hur ska Försvarsmakten lösa problemet med att Ryssland utrustar sina soldater med tunga kroppsskydd?Försvarsmakten har gjort en ansats till att omhänderta brukarperspektivet men vi menar att vår studie är ett viktigt tillskott till detta.