Browsing Doctoral Theses /HS by Title

Child injuries at home – Prevention, Precautions and Intervention wit...
Carlsson, Anna : Malmö University Health and Society Faculty of Health and Society Doctoral Dissertation;2010:1 (2010)	DOCTORAL THESIS

Communication in Palliative Home Care, Grief and Bereavement - A moth...
Holmberg, Lena : Malmö University, Faculty of Health and Society Malmö University Health and Society Doctoral Dissertation;2007:1 (2007)	DOCTORAL THESIS

English abstract:

In this study a mother’s experiences of communication between her adult son dying in leiomyosarcoma and herself (the author), between his family and a palliative home care team and communication in the support of the mother in her parental grief and bereavement are described and analyzed. The mother’s experiences are captured in personal accounts, writings, during the year of her son’s illness with cancer and his palliative home care and during three years of grief and bereavement after her loss. The data analysis is carried out in four steps by the mother as a researcher: 1) Identification of events of experiences of communication and significant concepts in the writings 2) Construction of four narratives, illustrating the concepts and including excerpts from the writings 3) Interpretation, contextualization and validation of the narratives 4) Contextualization in broader contexts. The son’s hope and disavowal and the mother’s fear and despair emerged as important concepts in understanding the communication between them during his palliative home care. Recognition, acknowledgment and respect from the palliative home care team supported the mother. A network of supportive arrangements was made available to the son and his family. The team recognized the son’s and the family members’ emotional needs as well as the family members’ needs to do anything they could for their husband, father, brother and son. Trust was a key concept in the communication between the son and his family on one hand and the palliative home care team on the other. Trust seems to be a base for the empowerment of the family members. Main factors besides the team’s medical professionalism influencing trust were flexibility, accessibility and continuity. Information, control, friendship and shared experiences were important factors in supporting the mother in her first year of bereavement. The findings point to the necessity of customizing bereavement support, specifically for high risk mourners. In the short term perspective the mother found support in her pre school aged granddaughter, who had lost her father. These contacts provided breaks in the grief, actualized positive memories, established and sustained rituals. In the long term perspective confirmed family bonds helped the mother in her reconciliation process. Empathy, based on the welfare system, providing flexible structures in which the mother was recognized and acknowledged, felt trust, was looked upon as an individual, was empowered and finally was reached by support after her loss, was of substantial importance to her. Empathy based on compassion, shared experiences, shared loss and strengthened family bonds supported her. Empathy to self allowed her to make use of the support she received and was part of her reconciliation process.

Lena Holmberg MUEP.pdf (1.417Mb)

Designing online support for families living with depression
Stjernswärd, Sigrid : Malmö University, Faculty of Health and Society Malmö University Health and Society Doctoral Dissertation;6 (2009)	DOCTORAL THESIS

English abstract:

Families living with mental illness experience an added burden and may experience such psychological distress that they require therapeutic intervention. The Internet is used as a daily tool by a growing share of the population worldwide, including for health related matters. Its potential as a health care tool, including advantages and drawbacks, should be explored. The overall aim of the present thesis was to explore the relatives’ experiences of living close to a person with depression and the Internet’s potential to address their needs. Explorative qualitative research has been used to map the e-health field in relation to depression, to explore what the Internet offers the families living with depression, as well as the relatives’ experiences of living with a person with depression. An iterative design process was used in the development of a digitally based tool aimed at supporting the relatives in their daily life with depression. Users’ experiences of the tool were explored using qualitative explorative research. A vast array of different organizations and initiatives are represented within the e-health field. However, initiatives that are targeted and tailor-made for families living with depression are scarce. Research in the e-health field with focus on depression illuminates health seekers’ and online community users’ profiles, effects of online cognitive behavioral therapy (CBT), and a number of strengths (i.e. accessibility) and weaknesses (i.e. reliability) related to the Internet as a health care tool. Living close to a person with depression can strongly affect the private, social and professional areas of the relatives’ daily life. A growing feeling of not living one’s own life may arise, due to the difficulties of balancing relationships, a process of adaptation and re-evaluation of life circumstances, and a struggle to act as advocate and voice for the person with depression within the health care system and society. Relatives often come in contact with health professionals on 12 behalf of their ill kin and need information and support; needs that are rarely addressed by the health care system. A digitally based tool aimed at supporting the relatives in their daily life with depression was developed using an iterative design process. The tool’s development was carried out in close cooperation with users with the help of focus groups and prototypes. Motivations and obstacles to using online self-help tools were illuminated. Privacy stood out as an important factor when developing online tools. The study resulted in a website, www.sommarregn.se, entailing an online diary (private and encrypted), including scales, and a forum (members only access), including an e-mail function. Users’ experiences of the website over a 10 weeks test period were illuminated. The diary and forum appeared to fill a number of valuable functions, although a further development of the tool may enhance its usability, which was good. The tool promoted communication with the self and others. The Internet as a technology offered a number of advantages, such as convenience of use and perceived anonymity, and disadvantages, such as qualitative issues. The relatives’ needs ought to be addressed in order to support them in a daily life with depression. Empowered relatives are in a better position to help their ill kin and support may prevent ill health in the relatives themselves, and subsequently additional costs to society. Health care professionals meet patients that are also online health seekers. Professionals must be aware of the advantages and drawbacks of e-health when meeting patients. In an economically pressured society, alternative support options have to be explored in order to address the needs of target groups at risk.

Sigrid Kappa final.pdf (325.2Kb)

Detection of Myocardial Ischemia using Real-Time Myocardial Contrast ...
Gudmundsson, Petri Malmö University Health and Society Dissertations;3 (2006)	DOCTORAL THESIS

English abstract:	Echocardiography is an ideal clinical method for obtaining information about morphology and function of the heart. Echocardiography is more accessible, mobile and inexpensive compared to other imaging techniques and has become the perhaps most used diagnostic method in cardiology during recent years. To assess myocardial ischemia, different types of stress echocardiography have been available, where mainly wall motion analysis at rest and stress has been used to evaluate the presence and extent of ischemia. During the last few years, second generation contrast agents have become clinically available. This has improved image quality in echocardiography, which, combined with new ultrasound technical developments, has made it possible to obtain echocardiographic images of myocardial perfusion. When this myocardial contrast echocardiography technique is carried out in real-time, as in the studies of this thesis, it is labelled real-time perfusion (RTP). RTP in combination of adenosine stress (RTP-ASE) has the potential to become a valuable clinical tool to evaluate myocardial ischemia. If proven as accurate as other clinically and scientifically accepted methods, such as 99mTc-sestamibi single-photon emission computed tomography (SPECT), RTP-ASE might become an alternative method. Compared to SPECT, it is more accessible, mobile, inexpensive, and without radiation, compared to dobutamine-atropine stress echocardiography (DSE) it is more tolerable and swifter, and it is more accurate than exercise ECG. In all studies of this thesis, we performed RTP-ASE in patients with known or suspected stable coronary artery disease (CAD), admitted to adenosine SPECT evaluation. Adenosine was infused to provoke relative regional hypo-perfusion in ischemic myocardial territories. Using a SONOS 5500 echocardiography machine, patients underwent RTP imaging during Sonovue infusion, before and throughout the adenosine stress, also used for SPECT. RTP images were stored for later, blinded, off-line analysis. In studies III and IV, the commercially available software Qontrast was used to generate parametric images of myocardial perfusion and quantitative values of perfusion replenishment from RTP-ASE image loops. Method of reference for the ischemia evaluation in the thesis was the presence or absence of reversible ischemia at SPECT. The left ventricular myocardium was divided into three territories corresponding to the distribution territories of the three main coronary arteries; left anterior descending (LAD), left circumflex (LCx) and right coronary artery (RCA). In studies I and II, we investigated the feasibility of RTP-ASE for the detection of ischemia using visual interpretation of RTP-ASE loops acquired at rest and stress. Study III was carried out to examine the value of quantitatively generated parametric perfusion images from RTP-ASE loops, in detecting myocardial ischemia. In study IV, the usefulness of quantitative detection of myocardial ischemia from RTP-ASE loops was assessed. Data comparing quantitative measurements of perfusion replenishment from RTP-ASE images at rest and stress were used as markers of ischemia. The results from the studies in this thesis suggest that visual evaluation of ischemia from RTP-ASE images, using angio-mode as well as high resolution grey scale mode, is accurate and feasible. It is therefore a clinically useful method in patients with known or suspected stable CAD. Quantification of ischemia or parametric imaging for ischemia evaluation using Qontrast, are not yet suitable for clinical use, as judged by the findings of this thesis. However, since further technical development can be expected, quantitative assessment of myocardial perfusion may well be a clinically useful method in the near future.
Swedish abstract:	Diagnostisering av syrebrist i hjärtmuskeln med hjälp av kontrastförstärkt ultraljudsundersökning av hjärtmuskelns genomblödning. Ultraljudsundersökning av hjärtat (ekokardiografi) används mycket inom hjärtsjukvården idag, oftast för att utreda hjärtats och hjärtklaffarnas anatomi och funktion. Ekokardiografi är en ofarlig och ganska enkel undersökning och apparaturen som används är förhållandevis billig och mobil om man jämför med andra bildgivande undersökningar av hjärtat, såsom röntgen, isotopundersökning eller magnetresonans tomografi. Syrebrist (ischemi) i hjärtmuskeln uppkommer genom att inte tillräckligt med syreförande blod når ett eller flera områden av hjärtmuskeln, vanligen pga. förträngningar i hjärtats kranskärl. Ischemi orsakar ofta, men inte alltid bröstsmärtor, vilket kallas "kärlkramp" i hjärtat. Utvärdering av ischemi i hjärtmuskeln rekommenderas för optimal behandling av patienter med misstänkt sjukdom i hjärtats kranskärl. Denna utvärdering kan göras med hjälp av olika typer av belastningstest. Metoder som finns att tillgå är arbets-EKG, isotopundersökning (99mTc-sestamibi single-photon emission computed tomography - SPECT) och stress-ekokardiografi. Liksom arbets-EKG utförs både SPECT och stress-ekokardiografi med olika typer av belastning. Belastning vid SPECT sker vanligen genom ergometercykling, men kan också utföras genom provokation med läkemedel (dobutamin, adenosin) som ger en belastning på hjärtmuskeln liknande den vid fysisk ansträngning. Vid stress-ekokardiografi görs belastningen vanligast med dobutamin (dobutamin-atropin stress-ekokardiografi - DSE) men kan också göras med ergometercykling eller adenosin. SPECT påvisar ischemi i hjärtmuskeln genom att jämföra genomblödningen (perfusionen) i hjärtmuskeln vid maximal belastning och vila. Minskad genomblödning under belastning är tecken på ischemi. Genomblödningen i hjärtmuskeln uppskattas vid SPECT genom att en radioaktiv isotop injiceras i patientens blod. Isotopen fördelas i hjärtmuskeln på samma sätt som blodet och strålarna från isotopen kan detekteras av en speciell detektor (gammakamera). Från områden utan eller med nedsatt genomblödning detekteras ingen eller nedsatt strålning och i dessa områden föreligger således ischemi. Vid DSE jämför man vanligen hjärtmuskelns förmåga att dra ihop sig (kontraktionsförmåga) i arbete och vila. Om kontraktionen minskar i någon del av hjärtmuskeln under belastning så talar det för ischemi i detta område. Både SPECT och DSE är väldokumenterade och bättre men dyrare än arbets-EKG. Att belasta hjärtat med dobutamin är ofta påtagligt obehagligt för patienten, medan belastning med adenosin ofta uppfattas som mindre obehaglig. Själva belastningen är dessutom oftast kortare än vid både ergometercykling och dobutamin-belastning. Till skillnad från sedvanlig stress-ekokardiografi räcker det dock inte att bedöma hjärtmuskelns kontraktion vid adenosin-belastning, utan det krävs även att genomblödningen bedöms. Genomblödningen i hjärtmuskeln har inte tidigare varit möjlig att värdera vid adenosin-stress-ekokardiografi (ASE). Det blev dock möjligt för några år sedan, då en typ av ny ultraljuds-kontrastmedel introducerades inom ekokardiografi. Kontrastmedlet för ultraljud som användes inom ramen för denna avhandling var Sonovue. En kombination av ny ultraljudsteknik (realtids perfusion - RTP) och kontrastmedel har gjort det möjligt att samtidigt bedöma genomblödningen i hjärtmuskeln och dess kontraktionsförmåga. Därigenom skulle RTP i kombination med ASE (RTP-ASE) kunna användas för att tillförlitligt detektera ischemi i hjärtmuskeln. Om RTP-ASE visar sig kunna detektera ischemi lika bra som en redan erkänd undersökning, exempelvis SPECT, kan RTP-ASE bli en bra alternativ undersökning. Jämfört med SPECT är RTP-ASE mer tillgänglig och utan radioaktiv strålning, jämfört med DSE är den snabbare och mindre obehaglig, och den är mera noggrann än arbets-EKG.

PETRI+Kappa+till+MUEP.pdf (3.630Mb)

Interactions of Biopolymers and Metalcomplexes at Biological Interfaces
Hamit Eminovski, Jildiz : Malmö University Doctoral Dissertation;2011:3 (2011)	DOCTORAL THESIS

English abstract:

The present work concerns interaction between biopolymers at interfaces. Examples from real systems such as saliva and bacterial surfaces as well as model systems have been studied. Using atomic force microscopy (AFM), normal forces between the surface of the filamentous bacterium Microthrix parvicella and AFM-tips have been studied, before and after treatment with specific polyaluminium compounds used at wastewater treatment plants to control the growth of the bacterium. Measurements were performed using hydrophobized and hydrophilic tips in order to explore the interactive spectrum of the bacterium and also the changes of which, if any, on treatment with polyaluminium chloride. No preferential interaction was found to any of the tips. However, the studies revealed that long-range steric repulsion dominates the interaction on approach. It was also found that the steric repulsion is reduced by addition of polyaluminium compounds, indicating a compaction of the polymer layer on the surface of the bacterium. A mucin model system, i.e. Bovine Submaxillary Mucin (BSM), adsorbed at solid surfaces has been studied using ellipsometry and quartz crystal microbalance with dissipation (QCM-D). Using the optical method ellipsometry, time resolved data on the adsorbed amount per unit area and the average layer thickness of adsorbed BSM films were determined. From QCM-D measurements the Voigt mass per unit area and viscoelastic properties of an adsorbed BSM film (including coupled water) were determined. Combining these two methods the water content of BSM adsorbed at gold, hydrophobized, and hydrophilic silica surfaces was estimated. From the results structures for BSM adsorbed on gold, hydrophobized, and hydrophilic silica were proposed. Furthermore, effects by the addition of polyaluminium chloride of different hydrolysis ratio were investigated and compared to those of AlCl3 and a ferric chloride formulation. Hence, compaction of the BSM film was initiated at concentrations as low as 0.001 mM AlCl3. At higher concentrations, related to those used at wastewater treatment plants, addition of polyaluminium chloride formulations and AlCl3 induced an initial rapid decrease in thickness followed by an increase. An increasing adsorbed mass was also observed. Combining ellipsometry and QCM-D data it was determined that aluminium species precipitate in or on top of the pre-adsorbed BSM film and the ensemble swells over time. By rinsing the precipitate layer was removed, but with some fraction remaining associated to the film. The rate of removal was slow and proceeded over a period of tens of hours. Combining the data, the swelling of the precipitate was monitored and the water content calculated. It was obvious that the increase on adsorption and decrease on depletion is mainly related to swelling. The impact of surface characteristics was also investigated and surface charge influences in terms of electrostatic interactions between the surface and the cationic aluminium compound were inferred. Friction forces between hydroxyapatite surfaces coated with human whole salivary (HWS) films were measured and the friction coefficient of the salivary films was determined. Measurements were performed using AFM-colloidal probe using two hydroxyapatite spheres. The salivary film was found to show high compressibility and mechanical resistance. Treatment with an anionic surfactant, sodium dodecyl sulphate, however induced desorption and an irreversible structural change of the film.

Hamit Eminovski MUEP ny.pdf (861.3Kb)

Interactions of Mucins with Biopolymers and Drug Delivery Particles
Svensson, Olof : Malmö University (2008)	DOCTORAL THESIS

English abstract:

The main components in the mucous gels apart from water are mucins, which are proteins with high molecular weights and an abundance of negatively charged oligosaccharide side chains. The aim of the investigations was to characterize interactions between mucins and other proteins that are present in the mucous gel, and also between mucins and components used in pharmaceutical formulations. More specifically, the main objectives were (I) to investigate the possibility to assemble multilayer films with mucins and oppositely charged polymers or proteins on solid substrates; (II) to evaluate mucoadhesive proper-ties of drug delivery particles by examination of their interactions with mucins. The construction of multilayer films was performed on silica and hydrophobized silica surfaces by alternate adsorption, and the adsorbed amount and thickness of the films were measured in situ by time resolved ellipsometry. It was demonstrated that films could be assembled using mucins in combination with both chitosan and lactoperoxidase. The build-up was characterized by adsorption and redissolution processes, and the extent of redissolution could be explained by taking the charge densities and concentrations of the components into account. It was also demonstrated that the nature of the substrate can be crucial for the possibilities to assemble multilayer films, and from the results it may be concluded that a high amount of mucin in the first step is important for successful layer-by-layer assembly. Furthermore, it was demonstrated that lactoperoxidase is catalytically active when adsorbed to mucin layers, and it may thereby exert its antimicrobial action. The evaluation of mucoadhesive properties of drug delivery particles was performed with lipid nanoparticles stabilized by a poly(ethylene oxide) based polymer and with particles modified by chitosan. Both types of model particles (unmodified and chitosan modified) were investigated by measuring their adsorption to mucin-coated silica surfaces by ellipsometry. It was shown that the binding of unmodified particles to mucin-coated silica surfaces was weak and pH-dependent. Based on the pH and electrolyte dependence of the adsorption, it was proposed that the interaction is mediated by hydrogen bonding between protonated carboxyl groups in the mucin molecule and oxygen atoms in poly(ethylene oxide). Chitosan modified particles, on the other hand, showed a substantial and strong binding to mucin-coated surfaces, which can probably be attributed to interactions between amino groups in chitosan and negatively charged groups in the mucin layer. The findings from the present investigations are in agreement with previous reports on the interaction of mucins with poly(ethylene oxide) and chitosan. It can therefore be concluded that the methodology applied is useful for evaluating mucoadhesive properties of nanoparticles.

Olof Svensson Kappan.pdf (2.785Mb)

In search of evidence-based practices. Exploring factors influencing ...
Bahtsevani, Christel : Malmö University Malmö University, Faculty of Health and Society Doctoral Dissertation;4 (2008)	DOCTORAL THESIS

English abstract:

Within the evidence-based movement means are developed to support the practitioner in becoming a research consumer with knowledge and skills to create an evidence-based practice (EBP). But little is actually known about whether, and how, this evidence-based accumulation of knowledge is used by practitioners and in what way any actual use leads to improved outcomes. Clinical practice guidelines (CPGs) are described to provide means to keep up with scientific development and may serve as an interface between science and practice. Implementation of evidence and guidelines in daily care are very complex and knowledge about the best way to implement evidence to facilitate best practices is still limited. The overall aim of this thesis was to explore factors that influence an evidence-based clinical practice, and more specifically, to investigate outcomes of an evidence-based practice, the dissemination and awareness of evidence-based literature, and to describe factors of importance when implementing CPGs. A systematic review was conducted to identify outcomes, and different experimental designs have been used for the purpose of describing awareness and dissemination of evidence-based literature as well as experience of the implementation of CPGs. Furthermore, a test-retest was conducted to test the reliability of items constructed from factors drawn from The Promoting Action on Research Implementation in Health Services (PARIHS) framework. The findings of the systematic review showed that it is difficult to prove effects of an EBP and the studies that managed this had implemented evidence-based CPGs. Although improvements in outcomes were reported for patients, personnel and the organisation, the synthesis showed a weak scientific foundation for the overall result since the studies included were heterogeneous in their designs. In a questionnaire study, in the area of psychiatric nursing with a pre-post design in relation to published evidence-based nursing reports, some differences were detected over time. But still 39.5 % of the sample reported no access to evidence-based literature one year after the publication of the two evidence-based nursing reports, and few of the respondents who had access to evidence-based literature reported any use of it. In the test-retest items of factors such as clinical experience, patients experience, leadership, context, culture, evaluation and facilitation was included. The findings of the test-retest showed that the reliability varied from good to fair agreement regarding the Kappa values, with a predominance of moderate agreement. The interview study, with an interpretive qualitative design, revealed several factors that appeared to be of importance for the implementation CPGs. The factors seemed to form a base consisting of circumstances, conditions and requirements. These have a relation to components that constitute a process, thus illustrating that implementing CPGs are continuous processes of creating reliable and tenable routines which involve all staffs member and are expected to lead to better and safer care of patients and increase knowledge and confidence among the staff. In conclusion, it is complicated, but not impossible, to demonstrate the outcomes of an EBP. To implement evidence-based CPGs is one way to make an evidence-based care visible. But more research is needed to strengthen the scientific foundation and to establish whether the tendency towards improved outcomes reported can be further supported. To implement CPGs is described as processes of bringing about a certain level of best practice that benefits patients as well as the staff. There are several factors influencing the process in relation to both positive and negative aspects and depending on which aspects will rise in the foreground the processes are visible or concealed, move forward or stagnate, promote or impede a successful implementation.

MUEP Bathsevani.pdf (3.457Mb)

In vitro and in vivo studies of salivary films at solid/liquid interf...
Svendsen, Ida Malmö University health and society doctoral dissertations;2 (2009)	DOCTORAL THESIS

English abstract:

A conditioning film, the pellicle, of which many salivary proteins are important constituents, covers the surfaces present in the mouth. The pellicle forms in a selective adsorption process, and it has protective and lubricating functions as well as an influence on the adherence of oral microbes that ultimately leads to the development of dental plaque. Understanding the interactions responsible for the selective pellicle formation would make it possible to strive at creating a pellicle that serves its protective and lubricating functions and also promotes a healthy biofilm for the benefit of the individual. The aim of this research was to characterize the adsorption of salivary proteins to different types of substrates, to evaluate the influence of different protein-surface interactions on the adsorption process, and also to assess substrate dependent differences in film composition. Furthermore, as it is well known that complexes form between different salivary proteins and mucins (large glycoproteins) in bulk saliva, the aim was also to study interactions between mucins and other pellicle constituents at the solid/liquid interface. Additionally, the effects of a surfactant, sodium dodecyl sulphate (SDS), on the protein films were investigated, to evaluate the stability of the films and also the possibilities to completely remove the in vivo formed pellicle. The adsorption experiments were performed in vitro using null ellipsometry, by which parameters such as adsorbed amount per unit area and average layer thickness can be obtained. Hydrophilic and hydrophobized silica were used as model substrates. The adsorption behaviour of the cationic, antimicrobial proteins lactoferrin, lactoperoxidase, lysozyme, and histatin 5 indicated that the adsorption on hydrophilic substrates was mainly driven by electrostatics, while on hydrophobized substrates hydrophobic interactions also influenced the adsorption process. Furthermore, it was shown that 12 sequential alternating adsorption of the anionic salivary mucin MUC5B and lactoperoxidase resulted in the build-up of multilayered structures on the surface. The rate of build-up was influenced by the surface characteristics. Sequential adsorption studies showed that neither MUC5B nor human whole saliva (HWS) was able to exchange substantial amounts of the pre-adsorbed anionic pellicle proteins acidic proline-rich protein 1 (PRP-1) or statherin, respectively. The resistance of the adsorbed mixed protein films to SDS elution depended on surface properties as well as on the number of layers adsorbed and adsorbed components. Pre-adsorbed PRP-1 was to some extent protected from SDS elution by the sequential adsorption of MUC5B to the PRP-1 film. Pellicles formed on natural tooth enamel were collected in vivo and investigated using two-dimensional gel electrophoresis (2-DE). Mechanicallyassisted SDS elution was used to collect the in vivo formed pellicle. The effectiveness of the collection procedure was validated in vitro by means of mechanical removal in combination with HCl treatment. The results indicated that rubbing the tooth surfaces with fibre pellets soaked in 0.5 % (w/v) SDS was sufficient to completely remove the pellicle from human enamel. In addition, 2-DE analysis of pellicles formed in vitro on human enamel and the dental materials titanium and poly (methyl methacrylate) (PMMA) showed differences in composition when compared to each other, revealing that the pellicle is influenced by the substrate properties.

Ida_Svendsen_thesis.pdf (849.4Kb)

Lactobacillus reuteri in health and disease
Sinkiewicz, Gabriela Malmö University Health and Society Doctoral Dissertation;2010:3 (2010)	DOCTORAL THESIS

English abstract:

People have exploited fermentation by lactobacilli for centuries as a means of preparing and preserving foods. Several different bacterial species are today used as probiotic bacteria in different products both for human and animal applications. By definition probiotic bacteria are “live microorganisms which when administered in adequate amounts confer a health benefit on the host”. The most commonly used bacteria for the probiotic concept are found within the lactic acid bacteria (LAB) group. One of several genera included in the LAB group is Lactobacillus. One species of Lactobacillus, Lactobacillus reuteri has been studied extensively and certain strains have been shown to be probiotic i.e. health promoting with diverse beneficial effects, and thus it was interesting to further investigate the properties of these bacteria. To put this thesis work into context, the field of probiotic research is described and examples of proven probiotic effects are discussed. The overall aim was to investigate L. reuteri and its microbial action in the microbiota of humans and its relationship to health and disease. L. reuteri was shown to be a natural component of human milk. It was found in approximately one in seven nursing mothers living in geographically widely separated countries. Breast milk may be considered as a natural synbiotic and evidence from these results suggest that L. reuteri is one of the beneficial components in this regard. L. reuteri was also proven to be effective in reducing both gingivitis and dental plaque in patients with moderate to severe gingivitis, suggesting an improvement in periodontal health. Bacterial antagonism through the probiotic administration in the oral cavity might have contributed to the observed alleviation of symptoms and clinical manifestations of periodontal disease. It was shown that L. reuteri supplementation of pregnant mothers and their offspring during the first year of life resulted in detection of L. reuteri in breast milk and infant stool. Administration of L. reuteri resulted in the presence of L. reuteri in saliva, but no significant effect on supra- or subgingival microbiota was observed. The significant increase in plaque index in the control group with no significant change in the test group may however indicate a probiotic effect of L. reuteri in this study population of healthy individuals.

GS_dissertation.pdf (1.380Mb)

LIVING WITH CHILDHOOD DIABETES – Family experiences and Long-Term eff...
Wennick, Anne : Lund University, Faculty of Medicine Doctoral Dissertation Series (2007)	DOCTORAL THESIS

English abstract:

The overall aim of this thesis was to investigate families’ experiences when a child is diagnosed as having type 1 diabetes, and at one and three years after diagnosis. Since childhood health and the circumstances around it in the family have been shown to have a lasting impact on adult health and circumstances, an additional aim was to examine the long-term effect of childhood diabetes on education level attained and self-assessed health. The work described in this thesis was carried out using a combination of qualitative and quantitative methods. In study 1, a longitudinal qualitative study design was used with interviews for data collection, and in study 2 a cross-sectional quantitative study design was used with register data based on structured interviews for data collection. The sample of the first study (papers I–III) was made through a consecutive series of families with children diagnosed with type 1 diabetes in 2003, who were interviewed individually in 2003 (n=12), 2004 (n=11), and then again in 2006 (n=11). Data collected in 2003 and 2004 was analysed using a hermeneutic phenomenological approach, whereas data from 2006 was analysed using latent content analysis. The sample from the second study (paper IV) was made through a set of pooled cross-sectional population survey data, supplemented with register data. It comprised 106 individuals diagnosed with diabetes before age 19 and 20,564 individuals not diagnosed before age 19, aged 19–38, who were interviewed for the Swedish Biennial Survey of Living Conditions (Undersökningar om Levnadsförhållanden, ULF). The data were analysed using two multiple regressions: one for educational level attained and one for self-assessed health, using a human-capital model as a theoretical framework. Findings in study 1 demonstrate that after the affected child had been diagnosed with type 1 diabetes, the family entered an ongoing learning process where they learnt about the inevitable and the extent. The learning process was a recurrent phenomenon whenever the families were exposed to new situations and contexts. One year after diagnosis the family described that they were living an ordinary yet different life, and the family experienced acceptance, health, independence and confidence during periods of well-balanced blood glucose levels. The integration of the illness into the family’s everyday life was, however, obstructed during episodes of unbalanced blood glucose levels, which affected the whole family negatively. Three years after diagnosis all family members had acquired a sound basis for managing the diabetes regimen. They had learnt more about diabetes, which was a natural element of the families’ everyday life, although still affecting the family members differently in their daily life. Furthermore, in study 2, controlling for a set of independent variables, childhood diabetes was found to be associated with lower levels of attained education and self-assessed health in comparison with the general population. More educated individuals reported better health, though. Hence, further research is needed to decide which method of treatment is most beneficial for the individual family when a child is striken with type 1 diabetes. The importance of showing receptivity to each family member’s needs and experiences was further suggested when the families were interviewed three years after the diagnosis, as it revealed that the illness affected the daily life of family members to a different degree. It is also important early in life to strengthen the possibility of having and reaching an agreeable level of attained education for children diagnosed with diabetes, as this may lead to increased health for the child later in life.

Multiplex HLA-DR-DQ genotyping : for genetic epidemiology and clinica...
Lavant, Ewa : Malmö University. Faculty of Health and Society Doctoral Dissertation;2012:3 (2012)	DOCTORAL THESIS

English abstract:

The human leukocyte antigens (HLA) are highly polymorphic cell surface proteins encoded in the major histocompatibility complex (MHC) region on chromosome 6. The HLA system has been well known as transplantation antigens but the primary biological role of the HLA molecules is regulation of immune response by presenting peptide fragments to T-lymphocytes. As regulators of immune responses the HLA molecules are also of importance for susceptibility to several autoimmune and inflammatory diseases. Genotyping of these loci is therefore significant in research targeting the mechanisms of HLA associated diseases, in exploring new epidemiological associations between HLA and specific disease, and as a clinical tool for risk assessment for diseases with well defined associations. Although several commercial HLA genotyping methods are available, many require multiple steps, have low throughput and high cost. The aim of the work within this dissertation was to develop a robust, costeffective method for HLA-DRB1, -DQA1 and -DQB1 genotyping suitable for use in an epidemiological context and clinical investigation. The method was optimized with specific focus on risk alleles for type 1 diabetes mellitus and celiac disease, two autoimmune disorders with significant impact on public health. By combining PCR with sequence specific primers (PCR-SSP), product separation by capillary gel electrophoresis and fluorescence detection in the developed method, all three loci could be analyzed in a single step, resulting in low reagent cost and fast turnaround time. This in combination with the low total consumption of DNA template allows the method to be used in epidemiological studies. 10 A simplified version of the developed method is currently used for clinical risk assessment for celiac disease when histological and/or serologic results are ambiguous in investigated subjects or when a gluten-free diet has been initiated before diagnostic tests have been performed. The low cost of this newly developed method has enabled HLA typing as a tool in screening programs for high-risk groups, such as individuals with Down syndrome or type 1 diabetes, to preclude the risk for celiac disease and thus avoid periodic screening for auto-antibodies. This method is also used to analyze samples from children all over Sweden with newly diagnosed diabetes in the Better Diabetes Diagnosis project. The developed method was also used in two explorative association studies not related to type 1 diabetes or celiac disease. In one study the association between HLA-DRB1, -DQA1 and -DQB1 and acute myocardial infarction was investigated showing only weak associations. In the second study the HLA-DR-DQ haplotype effect on developing chronic pain after inguinal hernia surgery was explored demonstrating an HLA dependent risk of developing pain

Ewa Lavant HS muep.pdf (531.3Kb)

Oral health in an outpatient psychiatric population : oral status, li...
Persson, Karin : Faculty of Health and Society, Malmö University (2009)	DOCTORAL THESIS

English abstract:

Oral health has generally improved in Sweden over the past 30 years. Investigations of living conditions have indicated that people with chronic mental health problems requiring psychiatric services diverge from that pattern. Research into oral health-related quality of life in this group might enhance our knowledge of the relationship between oral health, health perceptions, life satisfaction, and oral status, and its impact on quality of life in people with mental health problems. It could contribute to the description and broaden the understanding of the concept quality of life. The overall aims of this thesis were to describe oral health and oral health-related quality of life in persons attending psychiatric outpatient services; and to investigate oral health in relation to its biological aspects and perceived quality of life, including self-related variables and social aspects. Additional aims were to describe how persons with severe mental illness perceive oral health problems and to analyze the support they receive in counteracting dry mouth. The population studied consisted of 113 persons attending outpatient psychiatric services who voluntarily underwent a visual oral examination and a structured interview monitoring different aspects of life. Ten persons took part in a longitudinal investigation of how people with severe mental illness perceive oral health problems and support by means of regular visits aimed to evaluate the increase of such support. The findings showed that people in the total cohort were missing an average of 2.4 teeth. Poor oral hygiene was found in 41% of the group and 44% had objective signs of dry mouth. Seventy percent were assessed to be in need of some kind of dental treatment: 50% were overdue for scaling and polishing, 13% required more extensive dental treatment, and in 7% the need was acute. Routine dental visits were not uncommon: 75% had visited the dentist during the last year. Use of psychopharmceuticals was prevalent: 65% reported taking two or more prescribed 10 drugs. The investigation improved the understanding of psychological aspects associated with oral health among those studied, and showed measurably lower scores on life satisfaction items than is found in the general population. Analyses of the relationships between perceived oral health-related quality of life and biological and psychological factors demonstrated a correlation with numbers of teeth, type of psychiatric diagnosis, and gender. In the study population, number of teeth, life satisfaction, perceived physical health, and gender were found important. In relation to the psychiatric diagnoses, number of teeth was a significant factor in participants diagnosed with mood disorders and within the schizophrenia spectra. In participants diagnosed with anxiety and other psychiatric diagnoses, life satisfaction and reliance on chance were significant. The perception of health explained the variance in males. To females, number of teeth, life satisfaction, dental fear, and reliance on chance were also significant factors. In the study describing experience of oral health and perceived support, the result was illustrated by five categories: feelings and experiences related to poor oral health, experiences of dental care, experience of self-care, strategies for handling poor oral health, and experience of support. Oral health was important to the informants’ ability to relate to their social environment. A compromised dental status caused feelings of shame and stigma. Dental care revealed positive as well as negative experiences associated with the provider’s ability to meet the informant’s special needs. Strategies for dealing with poor oral health were mostly circumventions and were at best given ad-hoc solutions. Receiving support in oral health matters from staff was almost perceived as offensive; oral care reminders were often disregarded in an apparent assertion of the autonomy of informants, even though such behaviour could have negative consequences for their health. In conclusion, the findings showed that dental status, expressed as numbers of missing teeth, was higher for those attending psychiatric outpatient services than in a general population. The need for prophylactic dental treatment was considerable, suggesting that oral health issues need to receive increased attention during the course of psychiatric care in order to treat the whole patient. Experiences of oral health-related quality of life are of importance to the total appreciation of quality of life in an individual. This study might also contribute to the understanding of health problems in an outpatient psychiatric population since the perception of oral health-related quality of life was found to be dependent on the particular psychiatric diagnosis and gender. Questions regarding oral health in people with severe mental illness need to receive increased interest from dental, psychiatric, and social services in order to encourage self-care and enhance the autonomy of individuals.

KP_kappa.pdf (1.272Mb)

Prevention of foot ulcers in patients with diabetes mellitus
Annersten Gershater, Magdalena (2011)	DOCTORAL THESIS

English abstract:

Amputation in patients with diabetes mellitus preceded by a foot ulcer is a serious complication. Patients with the highest risk of developing a foot ulcer are often found in home nursing settings. The overall aim was to focus on how registered nurses are working with prevention of foot ulcers in patients with diabetes mellitus in outpatient settings: - to identify factors related to short term outcome of foot ul-cers in patients treated in a multi-disciplinary system until healing was achieved. - to assess what was documented by registered nurses regarding diabetes care in a Swed-ish municipality’s home nursing service; to what extent nursing actions were planned for, performed and evaluated according to the goals of metabolic control, treatment and prevention of complications.- to explore registered nurses’ professional work with foot ulcer prevention in home nursing settings. - to explore whether participant driven group information has an impact on ulceration in a patient group with previ-ous diabetes foot ulcer. Study I used logistic regression analysis to identify factors related to outcome in a cohort of 2480 consecutive patients with diabetic foot ulcer at a multidisciplinary foot clinic. Results: Healed primarily: 65% (n=1617), 9% (n=250) after minor am-putation, 8% (n=193) after major amputation and 17% (n=420) died unhealed. Primary healing was related to co- morbidity, duration of diabetes, extent of periph-eral vascular disease and type of ulcer. In neuropathic ulcers, deep foot infection, site of ulcer and co-morbidity was related to amputation. In neuro-ischemic/ischemic ul-cers amputation was related to co morbidity, peripheral arterial disease and type of ulcer. Study II was a cross sectional assessment of all nursing records of patients with dia-betes (N=172) in a municipality’s home nursing setting and analyzed with manifest content analysis. Results: The overall standard of nursing records was insufficient. Evaluation of blood glucose was documented in 61% (n=105) of the records, weight was documented in 6% (n=10), blood pressure in 10% (n=17) and ongoing foot ul-cers were documented in 21% (n=36). Study III was a qualitative interview study of 15 registered nurses from four munici-palities, analyzed with manifest content analysis. Results: Registered nurses in home nursing settings worked mainly through health care assistants. The nurses used lead-ership and education as the main tools to enable the nursing process. They mainly relied on experience based competence. Study IV was a randomized controlled trial comparing participant driven education in group with standard information, in patients with diabetes and previous foot ul-cers. An interim analysis was made 6 months after intervention of 131 included pa-tients. Results: After 6 months follow up, 58% (n=57) of the 98 evaluated patients had not developed a new foot ulcer. There was no statistical difference between the two interventions. The most common reasons for ulceration were plantar stress ulcer and minor external trauma. Five patients had deceased and 10 had withdrawn con-sent to participate. Conclusion: Patients with diabetes and high risk of developing foot ulcer constitute a fragile group that needs special foot protective attention. This requires a well edu-cated staff in the home nursing organization. In the future patient education should target low risk patients.

MAG muep.pdf (1.433Mb)

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Daily activities among persons with developmental disabilities. Asses...
Dychawy-Rosner, Irena : Studentlitteratur (2003)	DOCTORAL THESIS

Rättssäkerhet och tvångsvård: en rättssociologisk studie
Staaf, Annika : Lund : Sociologiska institutionen, Univ. Lund studies in sociology of law;22 (2005)	DOCTORAL THESIS