Coming theses from other universities
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Från maktlöshet till empowerment : upplevelser av att vara närstående till en person med borderlinepersonlighetssyndrom/ emotionell instabilt personlighetssyndrom, bemötandet från hälso- och sjukvården, deras behov av stöd och känsla av empowerment
Link: http://urn.kb.se/resolve?urn=urn:nbn:se:mau:diva-70893
Being a significant other to a person with borderline personality disorder affects life in several ways. Stress, depression, anxiety and a heavy family burden arecommon, as well as feelings of shame and guilt, depowerment and stigmatisation. Support from health care in Sweden is available, albeit to a limited extent. One explanation is that in order to be offered support from health care, in most cases, persons with borderline personality disorder are assumed to be under treatment. This issue, in combination with limited resources, excludes a large group of significant others. Previous research has emphasized the need for development of further support for this group. Support should include knowledge regarding the diagnose, how to decrease family burden and stigmatisation, and focus on increasing empowerment.The overall aim of this thesis was to describe experiences of being a significant other to a person with borderline personality disorder, their needs and experiencesof support, and their sense of empowerment. The thesis consisted of four studies. Studies I, III and IV had a qualitative design, and study II had a descriptive mixed method design. All four studies were analyzed with qualitative content analyses. In the second study descriptive inferential statistics were used for the quantitative section. The first study aimed to explore significant others’ experiences of living close to someone with borderline personality disorder and their encounters with health care. A semistructured questionnaire was used followed by group interviews. The next study aimed to describe significant others’ experiences of a healthcare-providedsupport known as family skills training, their life situation before and after support, and measuring their levels of anxiety and depression symptoms beforeand after completed group participation. A semi-structured questionnaire was used and followed up by group interviews in the qualitative section. In the quantitative section the hospital anxiety and depression scale were used. The third study aimed to focus on experiences and need of support from the perspective ofsignificant others themselves and of health care professionals. Two focus group interviews were carried out in each group. The fourth study aimed to illustrate significant others’ sense of being empowered after participation in an empowerment-based support group with the help of individual interviews.The results from all four studies described how significant others’ both physicaland mental wellbeing were adversely affected due to their role. A poor encounterfrom health care professionals created feelings of hopelessness andstigmatisation, and the need for support was crucial. The poor encounter seemedto be associated with a lack of knowledge However, the support described instudies II and IV showed promising results. The time spent in the support groupsseemed to strengthen the significant others in a positive way, and their feelingsof empowerment increased. Studies I and III highlighted peer support organisedas an association specially for significant others as an important support effort. Instudy III one concrete example of support was spoken of in terms of aprofessional coordinator, with special knowledge regarding the significantothers’ situation and needs.Two findings emerged from the overall results. Firstly, it appears to be importantto offer correct support, at the right level and at the right time. Secondly,acceptance may play an important role when it comes to increased empowerment.These findings indicate the importance of various types of support efforts wheresignificant others can choose support efforts based on their specific needs. The conclusion of this thesis emphasises two areas that would benefit by further development. The first area includes development of increased knowledge for health care professionals where two measures are suggested: 1) development of a knowledge support regarding borderline personality disorder and its effects onsignificant others, 2) updating the Swedish clinical guidelines regarding the careof persons with borderline personality disorder from the perspective of significantothers. The second area includes the need of extended support for significant others. Three measures are suggested for development: 1) empowerment-basedpeer support groups, 2) a professional coordinator and 3) a digital platform with the possibility to choose support efforts based on the significant others specificneeds at the time. With support from the results of this thesis it is recommended that the measures regarding both areas are to be furthered examined.
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Associations between patient characteristics and outcomes in psoriatic disease : evidence from Swedish real-world data
Link: http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-229076
Background
Psoriatic disease, encompassing skin psoriasis and psoriatic arthritis, is a common condition affecting 2-3% of the Western population associated with reduced quality of life and increased healthcare costs. To improve patients’ lives and the stewardship of societal resources, a nuanced understanding of the associations between patient characteristics and health outcomes are needed for optimal clinical and societal decision making. While randomised clinical trials play a central role in evidence-based medicine, they have limitations relating to patient selection, follow-up duration, and idealised clinical conditions. In recent years, the role of real-world evidence in health research has grown, including in dermatology, due in part to its ability to describe and compare patients in routine clinical care. This thesis contains four analyses using Swedish real-world data describing associations between patient characteristics and outcomes in psoriatic disease.
Methods
Data from several administrative population registers in Sweden and the clinical registry PsoReg were collected for those with psoriatic disease in routine clinical care and linked at the patient level. The data include diagnoses, pharmacy dispensed medications, mortality, socioeconomic information, quality of life, and clinical severity. A matched non-psoriatic control group was also extracted.
The first analysis assessed the association between disease severity (measured by the Psoriasis Area and Severity Index [PASI]) and health-related quality of life (measured the EuroQol 5-dimension instrument [EQ-5D]) in 2,674 patients with longitudinal follow-up in PsoReg, a fixed effects regression model was deployed adjusting for confounding factors including certain types of unobserved confounding.
Second, the independent associations of skin psoriasis and somatic comorbidity with incident psychiatric illness were described across 93,239 psoriasis patients and 1.4 million controls. Their individual contributions and synergistic interaction were assessed using a time-to-event model. Diagnosis codes were used to construct the composite psychiatric illness outcome consisting of depression, anxiety, and suicidality. Diagnosis codes were also used to create the Elixhauser and Charlson comorbidity indexes to measure somatic comorbidity.
The third analysis assessed age-related inequities in biologic prescriptions in 1,465 patients enrolled in PsoReg using a time-to-event analysis controlling for decision-making variables including disease severity. The analysis also described the non-parametric relationship between age and incident biologic prescriptions using a kernel regression.
Finally, the fourth analysis describes rates of non-persistence in individuals with psoriatic arthritis treated with adalimumab, ustekinumab, and secukinumab using a time-to-event model. A total of 4,649 drug exposure period across 3,918 patients were assessed. Non-persistence was defined as a treatment switch or discontinuation, the latter defined as a failure to refill an existing prescription within two times the days of drug supplied.
Results
The analysis found a statistically significant, negative association between PASI and the EQ-5D ( =-0.0186, 95% confidence interval [CI]: -0.0360, -0.0201) which was non-linear ( =0.0003, 95% confidence interval [CI]: 0.0001, 0.0004). Incremental PASI improvements for those with less skin involvement were associated with larger increases in quality of life than in those with more skin involvement.
Skin psoriasis was found to be independently associated with the onset of psychiatric illness (hazard ratio [HR]=1.32, 95% CI: 1.27-1.36) as was somatic comorbidity (HR=2.09, 95%CI: 2.06-2.13). However, the results were compatible with a lack of synergistic effect between skin psoriasis and somatic comorbidity on psychiatric illness (HR=0.93; 95% CI: 0.81-1.04).
Older psoriasis patients appeared less likely to initiate biologic therapies than their younger counterparts after controlling for disease severity and comorbidity (HR=0.97, 95% CI: 0.95-0.99).
Individuals with psoriatic arthritis treated with ustekinumab were found to have lower rates of non-persistence compared to adalimumab (HR=0.56, 95% CI: 0.49-0.64). Secukinumab and adalimumab appeared to have similar rates of non-persistence (HR=1.01, 95% CI: 0.88-1.15), although the results differed in biologic-naïve and biologic-experienced subgroups. The definition of discontinuation was sensitive and had material effects on the results.
Conclusions
Patient characteristics appear to play an important role in a variety of health outcomes in psoriatic disease, demonstrated across four real-world settings. The utilisation of data from routine clinical care enabled the investigation of research questions that are not suitable for clinical trial contexts, providing relevance for patients in everyday clinical practice. The study designs and methodologies applied in this thesis are associated with a variety of strengths and limitations, many of which are closely linked to the observational nature of the data, which have material importance for the interpretation of the results and implications for healthcare and policy. Understanding the associations between patient characteristics and subsequent outcomes is an important element in the delivery of holistic, personalised healthcare.
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Adverse effects during treatment in adolescents with crowded and displaced teeth : clinical and methodological studies on external root resorption and pain associated with fixed appliances
Link: http://urn.kb.se/resolve?urn=urn:nbn:se:mau:diva-70805
Malocclusion is a common condition in children and adolescents with a worldwide prevalence of 56%. It is estimated that approximately 30% of Swedish children and adolescents undergo orthodontic treatment at specialist clinics under Sweden’s free comprehensive dental care for children and young patients, with crowded and displaced teeth being one of the main reasons. One of the treatments used to align teeth is placing fixed appliances with brackets on the teeth. The beneficial effects of the treatment include well-aligned teeth and healthy, stable occlusion. However, every orthodontic treatment entails a risk of adverse effects such as external root resorption and pain. In recent decades, a technique that uses passive self-ligating brackets has gained in popularity. This technique is said to generate less frictional resistance, more physiological tissue response and reduced adverse effects compared to conventional techniques. According to a Cochrane report from 2021, the current evidence is sparse regarding fixed appliance treatment in general, and specifically for the treatment effect of passive self-ligating brackets compared to conventional bracket systems in the treatment of crowded teeth in children.
Radiographic examinations before, during and after the treatment are recommended to monitor the risk of severe external root resorption. The recommendations given in textbooks and scientific articles are contradictive as different check-up intervals and radiographic modalities are recommended. Moreover, the grounds for the recommendations are weak, and due to radiation doses and the ALADA (“as low as diagnostically acceptable”) principle, it may not be justifiable for all patients.
The CROWDIT (Crowded Displaced Teeth) project was started to decrease knowledge gaps concerning fixed appliance treatment of adolescents with crowded and displaced teeth, from the perspective of patients, clinicians and society. The overall aim of this thesis was to present a systematic, comprehensive evaluation of external apical root resorption and pain levels across various treatment phases during the orthodontic treatment of adolescents with crowded and displaced teeth. These evaluations were based on an RCT (Randomized Clinical Trial) consisting of treatments performed without extractions using either passive self-ligating or conventional bracket systems.
The first study of the thesis was a systematic review aimed at evaluating the scientific evidence and identifying knowledge gaps concerning external root resorption. During the preparatory work for the systematic review, no appropriate tool was found to assess the risk of bias in studies of adverse effects associated with orthodontic treatment. For this reason, a tool was designed to assess that risk of bias.
The tool and its application in a systematic review identified knowledge gaps and highlighted issues concerning the planning, conducting and reporting of studies. Based on this new knowledge, a methodological study was carried out of reliability and agreement in root length measurements, and two randomized controlled trials were conducted investigating external apical root resorption and pain.
We expect that the outcomes of this thesis and the further studies planned as part of the CROWDIT project will decrease the knowledge gaps and that the results will be integrated into the national guidelines for orthodontic treatment. We anticipate that the outcomes will thereby influence future oral healthcare so that the treatment of adolescents with crowded and displaced teeth using fixed appliances will be supported by scientific evidence.
This thesis was thus based on the following studies:
Paper I: Development of a tool for assessing the risk of bias was developed and applied in a systematic review to answer the following questions:
· What frequencies and severities of external root resorption have been reported?
· Is frequency and severity of external root resorption related to the patient’s age, sex, malocclusion or type of appliance?
Paper II: A methodological study that aimed to investigate:
· The inter-rater and intra-rater reliability and agreement for measurements of the root length of all teeth from incisors to molars using multiplanar reconstruction in CBCT examinations during different phases of orthodontic treatment in adolescents with fixed appliances.
Paper III: Originated from a multi-centre RCT that aimed to investigate:
· The frequency and severity of external apical root resorption identified through CBCT examinations obtained before treatment, after levelling of the teeth and insertion of the first 0.019 x 0.025 stainless steel archwire, and after treatment using either passive self-ligating or conventional fixed appliance systems. A further aim was to assess the results in relation to the most affected tooth groups, the time required for levelling, the duration of the 0.019 x 0.025 stainless steel archwire, total treatment time, differences in sex and initial irregularity of teeth.
· The relevance of intermediate radiography for the early detection of severe or extreme external apical root resorption.
Paper IV: Originated from a multi-centre RCT that aimed to investigate:
· Self-reported pain levels across various treatment phases for patients using passive self-ligating or conventional bracket systems.
· Pain levels in relation to sex, initial archwire dimension, intake of analgesics, degree of displacement of the anterior teeth and impact on everyday activities.
Key findings of Paper I:
· External root resorption of ≥ 2 mm varied across studies by between 10% and 29% for maxillary incisors.
· Data concerning external root resorption as related to patients’ age sex, malocclusion, and type of treatment was contradictory
· The quality of the evidence, evaluated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, was low due to study limitations, imprecision and inconsistency of study results.
Key findings of Paper II
· CBCT using MPR is a reproducible method for measuring root length during different phases of orthodontic treatment.
· Root shortening of ≤ 2 mm measured by CBCT using MPR, for clinical or research purposes, should be interpreted with caution as it may represent a measurement error.
Key findings of Paper III
· The mean external apical root resorption in mm for upper incisors was 0.20 in the passive self-ligating group and 0.51 in the conventional group, while the corresponding proportion of roots with clinically relevant EARR (≥ 2 mm) was 5.0% and 7.2% respectively.
· None of the variables treatment time, sex or initial irregularity of teeth could significantly predict the mean external apical root resorption of the upper incisors.
· It would appear that the relevance of intermediate radiographic examination is negligible for the early detection of severe external apical root resorption.
Key findings of Paper IV
· Pain levels of 9 to 10 on a 10-point scale were reported from 21.8% of patients in the passive self-ligating group and 30.3% in the conventional group on the most painful day (NS).
· Statistically significant, lower mean pain scores and a lower intake of analgesics were reported in the passive self-ligating group than in the conventional group on the first days after bonding in both arches.
· After the insertion of the full-size stainless steel archwire, 40% of patients reported taking analgesics.
· It was found that girls reported lower pain scores compared to boys.
Conclusions and clinical implications:There is a low quality of scientific evidence regarding external root resorption associated with orthodontic treatment with fixed appliances.
Measurement of root length in CBCT images ia a reproducible method for measuring root length but measured values below 2 mm should be interpreted with caution as they may contain measurement errors.
The frequency and severity of external apical root resorption was generally low and similar for patients treated with passive self-ligating and conventional bracket systems.
Intermediate radiography may be avoided in an adolescent population with crowded teeth treated without extraction, which aligns with the ALADA principle and underlines the importance of individual indications for radiographic examinations and the minimization of radiation doses.
Patients treated with passive self-ligating brackets report lower pain levels and intake of analgesics compared to those treated with conventional bracket systems after treatment initiation. In general girls reported lower pain scores compared to boys.
It is important to inform the patients and their parents before treatment that pain levels are generally substantially high after bonding as well as after insertion of a full-size stainless steel archwire.