In order to obtain a closer look into the psychosocial impact of chronic conditions, symptom severity, loss of resources, and demoralization were investigated through a mediation analysis. The function and implication of social support was also explored within the circumstances of chronic conditions. Lastly, symptom chronicity was probed as an influential element in the understanding of the consequences of being chronically ill. Participants were 200 men and women, with a mean age of 46 years, and the dataset came from the VOICE (Verification of Illness and Coping Experience) survey. The concepts of Conservation of Resources (COR) theory and Demoralization Syndrome were utilized to portray the underlying processes experienced by individuals with chronic condition. Analyses between symptom severity and demoralization via loss of resources as the mediator were statistically significant. Symptom chronicity did not interact with symptom severity on predicting loss of resources, but analyses showed that individuals with less symptom chronicity reported both larger loss of resources and demoralization. Social support was confirmed as a moderator, buffering the effects of symptom severity on loss of resources. Exploratory analyses with the inclusion of both symptom severity and chronicity as the predictor variable and the use of age as a moderating factor at the prediction of loss of resources was statistically significant, showing that when symptoms were more severe and chronic, younger participants experienced more losses than older participants. Additionally, when age was included as a moderator of the effect of symptom chronicity and severity on the prediction of social support, it was indicated that when symptoms were less chronic and severe, the average perception of social support was higher among younger participants, but, on the other hand, when symptoms were more chronic and severe, younger participants suffered an abysmal drop in their social support perception. In light of the aforementioned results, risk, protective, and developmental aspects are discussed, along with implications for health care providers.

Introdução. Embora existam diferentes estratégias para a prestação de cuidados paliativos ao paciente com câncer, pouco se conhece sobre a efetividade desses modelos. Objetivos. Comparar os efeitos da equipe de cuidado paliativo integrada ao cuidado tradicional com o cuidado tradicional sozinho no controle de sintomas em paciente com câncer avançado hospitalizado. Método. Estudo longitudinal composto por dois grupos não randomizados. 73 pacientes foram admitidos para a equipe de cuidado paliativo integrada ao cuidado tradicional (Grupo ECP) e comparados a 75 atendidos no modelo de cuidado tradicional (Grupo CT). Os sintomas foram avaliados pela Escala de Avaliação de Sintomas de Edmonton (ESAS), a satisfação por escala numérica verbal (0-10), a funcionalidade pela Escala de Desempenho Funcional Físico Karnofsky (KPS) e a adequação analgésica pelo Índice de Manejo da Dor (IMD). Os pacientes foram avaliados na admissão, após 24 e 48 horas. O desfecho primário foi a melhora clinica significativa de 2 pontos na intensidade da dor e da náusea em 48 horas, comparados com a admissão. Os dados demográficos, os sintomas e sua redução foram comparados entre os Grupos pelo Teste Exato de Fisher ou Mann Whitney. O Teste de Wilcoxon analisou alterações dos sintomas intragrupos. A regressão múltipla de Poisson controlou fatores de confusão para a melhora do sintoma. O nível de significância adotado foi de 5%. Resultados. A prevalência de sintomas foi alta em ambos os grupos: no Grupo ECP a variação foi de 43.8% (depressão) a 87.7% (sensação de bem estar), e no Grupo CT, de 24% (dispneia) a 85.5% (dor). A magnitude dos sintomas, pelo escore da mediana, foi importante em ambos os Grupos: na admissão, no Grupo ECP, variou entre 5.5 (sensação de bem estar) a 8.0 (ansiedade, apetite, constipação e tristeza), e no Grupo CT, variou de 6.0 (sensação de bem estar e dispneia) a 9.0 (perda do apetite). A mediana de sobrecarga de sintomas, avaliada pelo ESAS, foi de 50.0 em ambos os grupos. Na análise de 24 horas (intragrupo), no Grupo ECP cinco sintomas (dor, náusea, perda do apetite, dispneia, prejuízo do sono) e sobrecarga de sintomas foram reduzidos (p<0.05), enquanto no Grupo Grupo CT três sintomas (dor, náusea e prejuízo do sono) foram reduzidos (p<0.05). Na análise de 48 horas (intragrupo), dez sintomas e sobrecarga de sintomas no Grupo ECP foram reduzidos (p<0.05), enquanto quatro sintomas melhoraram no Grupo CT (p<0.05). A regressão múltipla mostrou que a dor (RR= 2.2 [IC95%1.27-3.81]) e bem estar (RR=4.6 [IC95% 1.34-15.88]) reduziram 2 pontos e foi favorável somente no Grupo ECP. Verificou-se melhor adequação da analgesia no Grupo ECP comparado ao CT (p<0.05). A satisfação do doente foi elevada e similar em ambos os grupos. Conclusão. Os doentes de ambos os grupos mostraram grande sobrecarga de sintomas e somente o sintoma dor foi adequadamente controlado pelo Grupo ECP. Os resultados encontrados demandam análise de fatores da estratégia de tratamento que possam melhorar a efetividade das ações, como avaliação sistematizada dos sintomas em curtos períodos e estratégias que permitam ajuste rápido da terapêutica quando necessário. / Introduction. Although there are many different strategies for provision of palliative care to patients with cancer, little is known about the effectiveness of these modalities. Objective.To compare the effects of a palliative care team integrated with traditional care to traditional care alone on symptom control in inpatients with advanced cancer. Method. Longitudinal study composed of two non-randomized groups. Seventy-three patients were admitted to the palliative care team integrated to traditional care (PCT Group) and compared to 75 patients treated in the traditional care model (TC Group). Symptoms were assessed by the Edmonton Symptom Assessment Scale (ESAS), satisfaction with treatment by the verbal numeric scale (0-10), performance status by the Karnofsky Performance Status Scale (KPS) and analgesic adequacy by the Pain Management Index (PMI). Patients were assessed upon admission, and after 24 and 48 hours. The primary outcomes were significant clinical improvements of 2 points in pain intensity and nausea in 48 hours, compared to admission. The demographic data, symptoms, and reduction in symptoms were compared between the groups by using Fisher\'s or Mann Whitneys Exact Tests. The Wilcoxon test examined the intragroup alteration of symptoms. The Poisson multiple regression controlled for confounding factors of improvement in symptoms. A p-value of 0.05 indicated statistical significance for all analyses. Results. The prevalence of symptoms at admission was high in both groups. In the PCT Group, it ranged from 43.8% (depression) to 87.7% (loss of well-being) and, in the TC Group, it ranged from 24% (dyspnoea) to 85.5% (pain). The magnitude of median score of symptoms was substantial in both groups: at admission for the PCT group, it ranged from 5.5 (sense of well-being) to 8.0 (anxiety, appetite, constipation, sadness), while for the TC Group, it ranged from 6.0 (sense of well-being and dyspnoea) to 9.0 (loss of appetite). The median score of the symptom burden assessed by ESAS was 50.0 in both groups. In 24 hours (intragroup), the PCT Group had significant reductions in intensity of five symptoms (pain, nausea, loss of appetite, dyspnoea, and sleep disturbance) and symptom burden, while the TC Group had significant reductions in intensity of three symptoms (pain, nausea, and sleep disturbance). In 48 hours (intragroup), the PCT Group had significant reductions in intensity of ten symptoms and symptom burden and while the TC Group had significant improve in intensity of four symptoms. Multiple regression analysis showed that pain (RR = 2.2 [95% CI 1.27-3.81]) and loss of well-being (RR = 4.6 [95% CI 1.34-15.88]) were reduced by two points and it was significantly more favourable only in the PCT Group. The PMI revealed better adequacy of analgesia in the PCT Group. Satisfaction was high and similar in both groups. Conclusion. Patients with advanced cancer in both groups showed a pronounced burden of symptoms and only pain was properly controlled in the PCT Group. The results indicate that factors that can improve treatment strategy should be implemented to improve the effectiveness of clinical assistance. Examples of factors that can improve treatment are frequent and systematic assessment of symptoms in short periods, and strategies that allow for timely adjustment of therapy when necessary.

Självskattningsformulär utgör ett viktigt kliniskt redskap för både utredning och intervention av röstproblem men i nuläget är tillgången till olika formulär i Sverige begränsad då antalet validerade svenska översättningar är få. Syfte med studien var att översätta och preliminärt validera The Voice Symptom Scale (VoiSS) som består av 30 frågor tilldelade komponenterna Nedsättning, Emotionellt och Fysiskt. Den svenska versionen av VoiSS framtogs genom ”Forward-backward Translation” med en efterföljande pilotstudie. Sammanlagt deltog 203 vuxna individer som rekryterades via webb- och pappersenkät. Av dessa uppgav 86 deltagare att de upplevde röstbesvär. Resultaten visade på tydliga gruppskillnader där gruppen Med upplevda röstproblem genererade högre genomsnittliga svarspoäng än gruppen Utan upplevda röstproblem. Inga överlappningar kunde konstateras. En principalkomponentanalys (PCA) var i stort sett förenlig med en trekomponentstruktur som tillsammans med gruppseparationen visade på hög konstruktvaliditet. Vidare noterades samstämmighet mellan den svenska versionen och VoiSS-originalet. Sensitivitets- och specificitetsvärden bekräftade en hög diagnostisk validitet. Slutsatsen drogs att formuläret med god validitet förmår att diagnosticera upplevelse av röstproblem. Den preliminära valideringen visade således att den svenska versionen av VoiSS kan användas som ett instrument vid utredning av röstproblem men att ytterligare forskning behövs för att säkerställa formulärets användbarhet i klinisk verksamhet. / Self-assessment questionnaires are important clinical instruments for both investigation and intervention of voice problems but at date access to various questionnaires in Sweden is limited due to few validated translations. The objective of this study was to translate and preliminary validate the Voice Symptom Scale (VoiSS) consisting of 30 questions assigned Impairment, Emotional and Physical. The Swedish version of VoiSS was developed through ”Forward-backward Translation” followed by a pilot study. The questionnaire was completed by a total of 203 adults who were recruited by web and paper survey. Out of these, 86 participants experienced voice problems. Obvious group differences were observed in that the group With experienced voice problems generated higher mean scores than the group Without experienced voice problems. No overlaps were observed. A principal component analysis (PCA) was largely consistent with a three component structure that, combined with the group separation, affirmed high construct validity. Moreover, concurrence between the Swedish version and the VoiSS-original was found. Calculated values of sensitivity and specificity confirmed a high diagnostic validity. The conclusion was made that the self-assessment questionnaire with good validity was able to diagnose experience of voice problems. In conclusion, preliminary validation showed that the Swedish version of VoiSS can be used as a diagnostic tool in assessing voice problems. However, more research needs to be done to ensure the questionnaires adaptation to clinical context.

People's inability to cope with the demands of modern life, has led to a significant increase in the incidence of anxiety being experienced by people from all walks of life. People are suffering from anxiety without knowing the root cause of it and it was found from the anxiety cases studied that its origin can in many cases be traced to the birth experience where specific negative suggestions were imprinted on the subconscious. In this study the influence of the birth experience as the underlying cause of anxiety and the effect of it on the formation of the self-concept and self-actualisation have been explored. The research shows that a subconscious origin exists in the development of anxiety. In the research for this study, Medical Hypnoanalysis, which is based on a process of diagnosis and therapy, was used as therapeutic method with several clients suffering from anxiety symptoms. In this research the perceptions formed in the subconscious during the birth experience were examined and related to the anxiety experienced during childhood and later life. The case studies, their diagnoses and the follow-up therapeutic sessions relating to the birth experience were investigated and discussed. Educational Psychologists show a specific interest in and a tendency to get involved with, or implement Medical Hypnoanalysis in therapy. It became obvious from this study that Medical Hypnoanalysis supplements the needs of the Educational Psychologist as a tool in therapy. In this study guide lines have been presented to the Educational Psychologist for the treatment of anxiety originating from the birth trauma by regressing the client back to this traumatic experience. Suggestions on how to conduct the birth regression sessions have also been presented and clarified. Through the case studies the identification and removal of the highly charged emotional and negative beliefs that were responsible for the anxiety symptom have been demonstrated. The case studies have furthermore demonstrated the successful utilisation of positive and healing suggestions to achieve the therapeutic goals. The results of this study show that Medical Hypnoanalysis can be used effectively in the treatment of the root causes of anxiety. / Psychology of Education / D. Ed. (Psychology of Education)

Introdução. Embora existam diferentes estratégias para a prestação de cuidados paliativos ao paciente com câncer, pouco se conhece sobre a efetividade desses modelos. Objetivos. Comparar os efeitos da equipe de cuidado paliativo integrada ao cuidado tradicional com o cuidado tradicional sozinho no controle de sintomas em paciente com câncer avançado hospitalizado. Método. Estudo longitudinal composto por dois grupos não randomizados. 73 pacientes foram admitidos para a equipe de cuidado paliativo integrada ao cuidado tradicional (Grupo ECP) e comparados a 75 atendidos no modelo de cuidado tradicional (Grupo CT). Os sintomas foram avaliados pela Escala de Avaliação de Sintomas de Edmonton (ESAS), a satisfação por escala numérica verbal (0-10), a funcionalidade pela Escala de Desempenho Funcional Físico Karnofsky (KPS) e a adequação analgésica pelo Índice de Manejo da Dor (IMD). Os pacientes foram avaliados na admissão, após 24 e 48 horas. O desfecho primário foi a melhora clinica significativa de 2 pontos na intensidade da dor e da náusea em 48 horas, comparados com a admissão. Os dados demográficos, os sintomas e sua redução foram comparados entre os Grupos pelo Teste Exato de Fisher ou Mann Whitney. O Teste de Wilcoxon analisou alterações dos sintomas intragrupos. A regressão múltipla de Poisson controlou fatores de confusão para a melhora do sintoma. O nível de significância adotado foi de 5%. Resultados. A prevalência de sintomas foi alta em ambos os grupos: no Grupo ECP a variação foi de 43.8% (depressão) a 87.7% (sensação de bem estar), e no Grupo CT, de 24% (dispneia) a 85.5% (dor). A magnitude dos sintomas, pelo escore da mediana, foi importante em ambos os Grupos: na admissão, no Grupo ECP, variou entre 5.5 (sensação de bem estar) a 8.0 (ansiedade, apetite, constipação e tristeza), e no Grupo CT, variou de 6.0 (sensação de bem estar e dispneia) a 9.0 (perda do apetite). A mediana de sobrecarga de sintomas, avaliada pelo ESAS, foi de 50.0 em ambos os grupos. Na análise de 24 horas (intragrupo), no Grupo ECP cinco sintomas (dor, náusea, perda do apetite, dispneia, prejuízo do sono) e sobrecarga de sintomas foram reduzidos (p<0.05), enquanto no Grupo Grupo CT três sintomas (dor, náusea e prejuízo do sono) foram reduzidos (p<0.05). Na análise de 48 horas (intragrupo), dez sintomas e sobrecarga de sintomas no Grupo ECP foram reduzidos (p<0.05), enquanto quatro sintomas melhoraram no Grupo CT (p<0.05). A regressão múltipla mostrou que a dor (RR= 2.2 [IC95%1.27-3.81]) e bem estar (RR=4.6 [IC95% 1.34-15.88]) reduziram 2 pontos e foi favorável somente no Grupo ECP. Verificou-se melhor adequação da analgesia no Grupo ECP comparado ao CT (p<0.05). A satisfação do doente foi elevada e similar em ambos os grupos. Conclusão. Os doentes de ambos os grupos mostraram grande sobrecarga de sintomas e somente o sintoma dor foi adequadamente controlado pelo Grupo ECP. Os resultados encontrados demandam análise de fatores da estratégia de tratamento que possam melhorar a efetividade das ações, como avaliação sistematizada dos sintomas em curtos períodos e estratégias que permitam ajuste rápido da terapêutica quando necessário. / Introduction. Although there are many different strategies for provision of palliative care to patients with cancer, little is known about the effectiveness of these modalities. Objective.To compare the effects of a palliative care team integrated with traditional care to traditional care alone on symptom control in inpatients with advanced cancer. Method. Longitudinal study composed of two non-randomized groups. Seventy-three patients were admitted to the palliative care team integrated to traditional care (PCT Group) and compared to 75 patients treated in the traditional care model (TC Group). Symptoms were assessed by the Edmonton Symptom Assessment Scale (ESAS), satisfaction with treatment by the verbal numeric scale (0-10), performance status by the Karnofsky Performance Status Scale (KPS) and analgesic adequacy by the Pain Management Index (PMI). Patients were assessed upon admission, and after 24 and 48 hours. The primary outcomes were significant clinical improvements of 2 points in pain intensity and nausea in 48 hours, compared to admission. The demographic data, symptoms, and reduction in symptoms were compared between the groups by using Fisher\'s or Mann Whitneys Exact Tests. The Wilcoxon test examined the intragroup alteration of symptoms. The Poisson multiple regression controlled for confounding factors of improvement in symptoms. A p-value of 0.05 indicated statistical significance for all analyses. Results. The prevalence of symptoms at admission was high in both groups. In the PCT Group, it ranged from 43.8% (depression) to 87.7% (loss of well-being) and, in the TC Group, it ranged from 24% (dyspnoea) to 85.5% (pain). The magnitude of median score of symptoms was substantial in both groups: at admission for the PCT group, it ranged from 5.5 (sense of well-being) to 8.0 (anxiety, appetite, constipation, sadness), while for the TC Group, it ranged from 6.0 (sense of well-being and dyspnoea) to 9.0 (loss of appetite). The median score of the symptom burden assessed by ESAS was 50.0 in both groups. In 24 hours (intragroup), the PCT Group had significant reductions in intensity of five symptoms (pain, nausea, loss of appetite, dyspnoea, and sleep disturbance) and symptom burden, while the TC Group had significant reductions in intensity of three symptoms (pain, nausea, and sleep disturbance). In 48 hours (intragroup), the PCT Group had significant reductions in intensity of ten symptoms and symptom burden and while the TC Group had significant improve in intensity of four symptoms. Multiple regression analysis showed that pain (RR = 2.2 [95% CI 1.27-3.81]) and loss of well-being (RR = 4.6 [95% CI 1.34-15.88]) were reduced by two points and it was significantly more favourable only in the PCT Group. The PMI revealed better adequacy of analgesia in the PCT Group. Satisfaction was high and similar in both groups. Conclusion. Patients with advanced cancer in both groups showed a pronounced burden of symptoms and only pain was properly controlled in the PCT Group. The results indicate that factors that can improve treatment strategy should be implemented to improve the effectiveness of clinical assistance. Examples of factors that can improve treatment are frequent and systematic assessment of symptoms in short periods, and strategies that allow for timely adjustment of therapy when necessary.

While previous studies successfully identified the core neural substrates of the animal subtype of specific phobia, only few and inconsistent research is available for dental phobia. These findings might partly relate to the fact that, typically, visual stimuli were employed. The current study aimed to investigate the influence of stimulus modality on neural fear processing in dental phobia. Thirteen dental phobics (DP) and thirteen healthy controls (HC) attended a block-design functional magnetic resonance imaging (fMRI) symptom provocation paradigm encompassing both visual and auditory stimuli. Drill sounds and matched neutral sinus tones served as auditory stimuli and dentist scenes and matched neutral videos as visual stimuli. Group comparisons showed increased activation in the insula, anterior cingulate cortex, orbitofrontal cortex, and thalamus in DP compared to HC during auditory but not visual stimulation. On the contrary, no differential autonomic reactions were observed in DP. Present results are largely comparable to brain areas identified in animal phobia, but also point towards a potential downregulation of autonomic outflow by neural fear circuits in this disorder. Findings enlarge our knowledge about neural correlates of dental phobia and may help to understand the neural underpinnings of the clinical and physiological characteristics of the disorder.

The aim of this thesis is to improve the reliability and quality of new requested functionality, and existing modules, at Fortum HR System Solutions. This was conducted through an evaluation of the test processes by implementing principles of Software Testing and Test Management. For the study to successfully improve the testing performed at HR System Solutions, existing test processes were analyzed. The analysis was conducted by evaluating the current test processes using theoretical test evaluation styles called maturity models. The methodology of choice was the Testing Maturity Model (TMM), which was adapted to the nature of HR System Solutions requirements, experience and needs. The evaluation used qualitative methods together with pedagogical principles to conduct interviews and workshops to consolidate the theoretical evaluation. Interviews and workshops were conducted within the team of HR System Solutions, where all members of them team contributed to the thesis at some point. An external interview also took place for comparative study. Results of the evaluation, interviews and workshop were compiled and analyzed accordingly. With the analyzed results in place, flaws in the testing processes were apparent. A generalization of the flaws led to the conclusion in the form of a suggestion. The conclusive suggestion was for Fortum HR System Solutions to establish a test committee/group role within the team. Considering the current economical and organizational situation this job role would be a divided job role appointed to current members of the HR System Solutions team. The research creates a walkthrough on a potential method on understanding inefficiencies within testing processes of a company and providing a cause-based solution. / Undersökningen är inriktad på att förbättra tillförlitligheten och kvalitén på ny begärd funktionalitet, och befintliga moduler, på Fortum HR System Solutions. Detta genomfördes genom en utvärdering av testprocesser genom implementation av principer inom Software Testing samt Test Management. För att förbättra testningen som utförs på HR System Solutions var det nödvändigt att analysera de befintliga testprocesserna. Analysen genomfördes genom att utvärdera de nuvarande testprocesserna med hjälp av teoretiska utvärderingsmetoder som kallas Maturity Models. Den valda metoden var Testing Maturity Model (TMM) som tillämpades med avseende på HR System Solutions förutsättningar, erfarenheter och behov. Utvärderingen använder sig av kvalitativa metoder samt pedagogiska principer för att genomföra intervjuer och workshops stärka den teoretiska utvärderingen från TMM. Intervjuer och workshops genomfördes inom HR System Solutions arbetslag, där alla medlemmar bidrog till examensarbetet. Även en extern intervju gjordes i jämförande syfte. Resultatet av utvärderingen sammanställdes och analyserades i enlighet med de förnämnda teoretiska ramvärken. Med hjälp av analyserna visade sig bristerna hos HR System Solutions testprocesser. En generalisering av bristerna gjordes, vilket ledde till slutsatsen i form av ett förslag. Det slutliga förslaget innebar att Fortum HR System Solutions behöver upprätta en testkommitté/grupp inom arbetslaget. Undersökningen visar en potentiell metod för att förstå ineffektiviteten inom testprocesser i ett företag, och tillhandahålla en orsaks-baserad lösning.

Syfte: Syftet var att utvärdera effekten av sjuksköterskans föreslagna omvårdnadsåtgärder på cytostatikarelaterade biverkningar hos cancerpatienter som genomgår cytostatikabehandling. Metod: Examensarbetet utfördes som en litteraturöversikt. Resultatet grundar sig på 13 stycken kvantitativa artiklar. För datainsamlingen användes databaserna PubMed och Cinahl. Resultat: Resultatet visade att sjuksköterskan kan utföra omvårdnadsåtgärder som minskar patienters upplevelse av cytostatikarelaterade biverkningar. Effekterna som framkom av sjuksköterskans omvårdnadsåtgärder presenteras under rubrikerna; oral kryoterapi vid oral mukosit, personcentrerad patientutbildning med underrubriken utbildning utifrån ett teoretiskt perspektiv, automatiserad och sjuksköterske- assisterad symtombehandling samt musikterapi, bildspråk och avslappning. Slutsats: Sjuksköterskan kan genom olika omvårdnadsåtgärder hjälpa patienter att lindra symtom från cytostatikarelaterade biverkningar. / Aim: To evaluate the impact of the nurse's suggested nursing interventions on chemotherapy-related side effects in cancer patients undergoing chemotherapy treatment. Method: The work was conducted as a literature review. The results are based on 13 quantitative articles. For data collection the databases PubMed and Cinahl was used. Results: The results showed that nurses can perform nursing interventions that reduce patients' experience of chemotherapy-related side effects. The effects that emerged from the nursing interventions are presented under the headings; oral cryotherapy for oral mucositis, person-centered patient education with the subtitle education from a theoretical perspective, self-care, automated and nurses assisted symptom management, music therapy, imagery and relaxation. Conclusion: Nurses can through various nursing interventions help patients to relieve symptoms from chemotherapy-related side effects.

Background: In Myocardial infarction (MI) it is well established that timely diagnosis and treatment may reduce mortality and improve the prognosis. Therefore it is important that patients with MI seek medical care as soon as possible. Patients with diabetes have a higher risk for MI and worse prognosis compared to patients without diabetes. Previous research is inconclusive regarding symptoms and pre-hospital delay times in MI among patients with diabetes and there is lack of research in how patients with diabetes perceive, interpret and respond to MI symptoms.  Aim: The overall aim of this thesis was to explore symptoms and care seeking behaviour during MI in patients with diabetes.  Methods: This thesis comprises four studies. Studies I and II were based on data from the Northern Sweden MONICA myocardial infarction registry to describe symptoms in 4028 patients (I) and pre-hospital delay and factors associated with pre-hospital delay of ≥ 2 h in 4266 patients (II). Study III included 694 patients, at five hospitals in Sweden. The patients answered a questionnaire about symptoms, response to symptoms and delay times in MI. In study IV data were collected through interviews about experiences of getting MI and the decision to seek medical care.  Results: Study I showed that typical MI symptoms according to MONICA criteria were common in both men and women, both with and without diabetes, and no differences between the groups were found. Study II showed that more patients with diabetes had pre-hospital delay times of ≥ 2 h compared to patients without diabetes. In Study III, chest pain was the most common self-reported MI symptom in patients with and without diabetes and there were no differences between the groups. Shoulder pain/discomfort, shortness of breath and tiredness were more common in patients with diabetes whereas cold sweat was less common compared to patients without diabetes. Less than 40 % of patients with diabetes called the emergency medical services (EMS) as their first medical contact (FMC) and about 60 % initially contacted a spouse after symptom onset. Patients with diabetes reported longer patient delay than patients without diabetes, but after age and gender adjustments the results were not significant. Pain, pressure or discomfort in the stomach, anxiety, symptoms that come and go and thoughts that the symptoms would disappear were associated with longer patient delay in patients with diabetes. In study IV, the analysis revealed the core category “Becoming ready to act” and the categories perceiving symptoms, becoming aware of illness, feeling endangered, and acting on illness experience. Patients with diabetes described a variety of different MI symptoms, the onsets of MI varied and it was sometimes difficult to interpret symptoms as related to MI. The decision to seek medical care for MI was complex with several barriers for timely care seeking.  Conclusion: Chest pain was common in patients with diabetes and in contrast to our hypothesis chest pain was equally common in both patients with and without diabetes. There were more similarities than differences in MI symptoms between patients with and without diabetes. However, patients with diabetes were more likely to have pre-hospital delay for 2 hours or more compared to those without diabetes and there seems to be an underutilization of the use of emergency medical services as first medical contact. The process to seek care for MI was complex, initiated by perceiving symptoms, followed by illness awareness, feelings of being endangered and finally acting on the illness experience. / Bakgrund: Vid hjärtinfarkt är det sedan tidigare väl känt att snabb vård och behandling är viktigt för att förbättra prognosen. Det är därför av stor vikt att patienter med hjärtinfarkt söker vård så snart som möjligt efter att symtomen startat. Patienter med diabetes löper större risk att drabbas av hjärtinfarkt och prognosen efter en hjärtinfarkt är sämre än för patienter utan diabetes. Tidigare forskning har varit ofullständig när det gäller symtom och fördröjning att söka sjukvård vid hjärtinfarkt hos patienter med diabetes. Det saknas också forskning om hur patienter med diabetes uppfattar, tolkar och agerar vid symtom på hjärtinfarkt.  Syfte: Det övergripande syftet med föreliggande avhandling var att utforska symtom och hur man agerar vid hjärtinfarkt hos patienter med diabetes.  Metod: Avhandlingen består av fyra delstudier. Studie I och II baseras på data från norra Sveriges MONICA-hjärtinfarktregister för att beskriva symtom hos 4028 patienter samt pre-hospital fördröjning och faktorer som har samband med fördröjning hos 4266 patienter. Studie III inkluderade 694 patienter från 5 sjukhus i Sverige som alla besvarade en enkät om symtom, agerande och fördröjningstider vid hjärtinfarkt. I studie IV samlades data in via intervjuer som handlade om upplevelsen av att drabbas av hjärtinfarkt och beslutet att söka medicinsk vård.  Resultat: Studie I visade att typiska hjärtinfarktsymtom enligt MONICA kriterier var vanliga hos både män och kvinnor, med och utan diabetes och ingen skillnad mellan grupperna kunde påvisas. Studie II visade att en större andel av patienter med diabetes jämfört med patienter utan diabetes hade pre–hospital fördröjning ≥2 timmar. I studie III var bröstsmärta det vanligaste hjärtinfarktsymtomet hos patienter med diabetes och det var ingen skillnad jämfört med patienter utan diabetes. Smärta/obehag i skulderpartiet, andningsbesvär och trötthet var vanligare hos patienter med diabetes medan kallsvett var mindre vanligt i jämförelse med patienter utan diabetes. Mindre än 40 % av patienterna med diabetes kontaktade SOS alarm som första kontakt med sjukvården och ungefär 60 % kontaktade initialt en partner efter symtomdebut. Patienter med diabetes rapporterade längre fördröjningstider jämfört med patienter utan diabetes, men efter justeringar för ålder och kön var skillnaden inte signifikant. Smärta obehag eller tryck i magen, ångest, intermittenta symtom samt att man trodde att symtomen skulle gå över hade samband med längre patientfördröjning hos patienter med diabetes. I studie IV resulterade analysen i kärnkategorin ”Att bli redo att agera” och kategorierna att uppleva symtom, inse att man är sjuk, känna ett hot och agera utifrån upplevelsen. Patienter med diabetes beskrev en mängd olika hjärtinfarktssymtom, debuten av symtom varierade och det var ibland svårt att tolka symtomen som hjärtinfarkt. Beslutet att söka vård vid hjärtinfarkt var komplext och beslutet fördröjdes på grund av flera barriärer.  Slutsats: Sammanfattningsvis var bröstsmärta vid hjärtinfarkt vanligt och i motsats till vår hypotes lika vanligt hos patienter med som utan diabetes. Det fanns fler likheter än skillnader i hjärtinfarktsymtom mellan grupperna, Patienter med diabetes hade dock längre pre-hospital fördröjning jämfört med patienter utan diabetes. Trots betydelsen av snabb medicinsk vård vid hjärtinfarkt underutnyttjades SOS alarm som första medicinska kontakt. Processen att söka vård för hjärtinfarkt var komplex. Den började med upplevelsen av symtom, följt av insikten att man är sjuk, att man känner ett hot och slutligen agerar utifrån upplevelsen av sjukdom.

Background: Current palliative care recommendations stress the right to care according to palliative principles at the end of life for all people in need thereof, regardless of care place and including those who are old. The international literature indicates that residents in nursing homes often do not have access to palliative care competence. Accordingly, insufficient management and lack of communication about end-of-life issues have been reported. There is a scarcity of robust Swedish studies about the quality of care at the end of life in nursing homes. Aim: To explore the care being provided in the final week of life of older people in nursing homes. Method: The study used data from the Swedish Register of Palliative Care, of all registered individuals aged 60 and older, who died in nursing homes 2011 and 2012. Variables pertaining to monitoring and treatment of symptoms, end-of-life discussions, and circumstances around death, and individual characteristics of the deceased individuals, were explored with descriptive statistics. Results: The most common underlying causes of death were circulatory diseases (42.2%) and dementia (22.7%). The most prevalent symptom was pain (58.7%), followed by rattles (42.4%), anxiety (33.0%), confusion (21.8%), shortness of breath (14.0%) and nausea (11.1%). Pain was the symptom with the highest degree of total relief (46.3%), whereas shortness of breath and confusion were totally relieved in 6.1% and 4.3% of all individuals, respectively. The use of valid instruments for symptom assessments was reported for pain in 12.3% and 7.8% for other symptoms. The most prevalent individual prescriptions for injection PRN were for pain treatment (79.5%) and rattles (72.8%). End-of-life discussions were performed with 27.3% of all the deceased individuals, and with 53.9% of their relatives. Of all individuals, 82.1% had someone present at death, and 15.8% died alone. Of the all nursing home resident deaths recorded, 45.3% died in their preferred place. Conclusion: There were large variations in the degree of relief from the different symptoms in the final week of life. Pain was the most prevalent symptom, and was also the symptom with the highest proportion of total/partial relief. Other symptoms were less prevalent but also less well relieved. The results indicate a need for improvements in palliative care in nursing home settings, focusing management of distressing symptoms and end-of-life discussions. / Bakgrund: Målet om rätt till palliativ vård för alla som behöver, oavsett vårdplats och inkluderande äldre personer. Äldre individer har ofta multisjuklighet, inklusive kognitiv svikt som ställer särskilda krav på kompetens under livets sista tid. Internationella studier indikerar dock att personer som dör på vård- och omsorgsboenden ofta inte får tillgång till palliativ kompetens, med till exempel inadekvat symtomlindring och bristande kommunikation om döden. Robusta svenska studier om innehållet i vården i livets slutskede för personer på vård-och omsorgsboenden saknas. Syfte: Att beskriva vården under den sista levnadsveckan, för äldre personer på vård-och omsorgsboenden. Metod: Studien baserades på data från Svenska Palliativregistret av alla registrerade individer &gt; 60 år som avlidit inom vård- och omsorgsboenden 2011 och 2012. Variabler relaterade till symtom, symtomkontroll, brytpunktssamtal och omständigheter kring döden samt individuella karaktärsdata utforskades med deskriptiv statistik. Resultat: Vanligaste underliggande dödsorsak var cirkulatoriska sjukdomar (42.2%) och demenssjukdomar (22.7%). Mest förekommande symtomet var smärta (58.7%) följt av rosslighet (42.4%), ångest (33.0%), förvirring (21.8%), andfåddhet (14.0%) och illamående (11.1%). Symtomet som lindrades till största del var snärta som helt lindrades för (46.3%) medan andfåddhet och förvirring lindrades helt hos 6.1% respektive 4.3% av individerna. Validerat skattningsinstrument användes för smärta i 12.3% av fallen och i 7.8% för andra symtom. Vanligast förekommande individuella vid behovsordinationen för injektion var för behandling av smärta (79.5%) och mot rosslighet (72.8%).Brytpunktsamtal genomfördes med 27.3% av alla individer och med 53.9% av alla närstående. Önskad dödsplats uppfylldes hos 45.3% av individerna. Av alla individer hade 82.1% någon, i registret valbar, hos sig vid dödsögonblicket och i (15.8%) dog individen ensam. Slutsats: Det fanns stora variationer i graden av lindring för symtom under sista levnadsveckan. Smärta var vanligast förekommande och även det symtom som till högst grad lindrades helt eller delvis. Andra symtom förekom mer sällan men lindrades även till lägre grad. Resultaten indikerar ett behov av förbättring inom den palliativa vården inom vård- och äldreboenden, fokuserat mot hantering av besvärliga symtom samt brytpunktssamtal.