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Coming dissertations at MedFak

  • Endoscopic retrograde cholangiopancreatography : Perforation and long-term outcomes after endoscopic sphincterotomy Author: Ann Langerth Link: Publication date: 2020-05-08 13:42

    Endoscopic retrograde cholangio pancreatography (ERCP) is a commonly used procedure in various disorders of the pancreatobiliary tract. When extracting common bile duct stones (CBDS), the major duodenal papilla is divided using a papillotome to perform an endoscopic sphincterotomy (ES). Adverse events occurring shortly after ES are well-known and include perforation which, however, is difficult to investigate due to its low frequency. ES is often used in elderly and/or infirm patients with gallstone pancreatitis and cholangitis, to prevent relapse in biliary events linked to CBDS. Subsequent cholecystectomy in these patients remains controversial. What happens in the long term after ES is still partially unknown.

    In Paper I, we found an increased risk for both cholangitis and pancreatitis after ES for CBDS, without synchronic relapse of CBDS and when compared with the general population was found. In Paper II, we retained the ES group, but replaced the control group with controls with a history of gallstone disease. The increased risk for both cholangitis and pancreatitis without relapse of CBDS still remains but, no higher risk for malignancy in the pancreatobiliary tract was noted.

    We conducted study III, a prospective follow-up after ES, to evaluate to what extent ES prevents relapse into biliary events after cholangitis and pancreatitis caused by bile duct stones. We included 100 patients who did not have earlier gallbladder surgery and who were treated for pancreatitis and/or cholangitis. The patients then underwent ES but not cholecystectomy and were followed for a mean of 42 months. None of the patients had recurrent pancreatitis and one had cholangitis. This indicates that ES alone is an alternative to cholecystectomy in the prevention of further attacks of acute pancreatitis and cholangitis.

    Paper IV consists of 52,140 ERCPs that were registered with GallRiks, a Swedish population based register. A total of 376 cases were registered as perforations and 75 patients had a fatal outcome. These data showed that sphincterotomy in the pancreatic duct increased the risk of death from perforation but the risk of death was reduced when ERCP was performed at a Q4 centre.

  • Self-efficacy in breastfeeding mothers of term and preterm born infants Author: Emma Gerhardsson Link: Publication date: 2020-05-06 11:13

    Breast milk is beneficial for all infants, but especially for infants born preterm and optimizing breastfeeding can enhance health outcomes. Despite this, breastfeeding duration has declined in more than twenty years in Sweden and even more among preterm infants. Mothers’ self-efficacy is a modifiable factor that can affect breastfeeding duration and Breastfeeding Self-efficacy Scale-Short Form (BSES-SF) has been tested in several countries in order to identify mothers with low self-efficacy in breastfeeding, however, the scale has not been validated for a Swedish sample. Moreover, there is a need for evidence-based breastfeeding support programs adapted for the healthcare professionals (HCPs) working with mothers of preterm infants.

    A first aim of the present thesis was to psychometrically test the BSES-SF among mothers to both term- and preterm infants and to examine whether self-efficacy predicts breastfeeding duration. A secondary aim was to evaluate a breastfeeding support program based on Baby-Friendly Hospital Initiative for Neonatal Intensive Care (Neo-BFHI) and to describe HCPs’ experiences of the program.

    Papers I and II show potential for BSES-SF to be used in research with the aim to identify mother’s self-efficacy in breastfeeding. In Paper III findings reveal that self-efficacy predicts the mother’s adaptation to the infant. This is an important finding as the mother's adaptation to the infant is closely related to the theories of bonding and attachment. Paper IV describes and evaluates a training program for neonatal intensive HCPs based on Neo-BFHI’s ten steps to successful breastfeeding, with main results indicating that the training program was appreciated by the HCPs. In Paper V, we constructed and evaluated an instrument that measures the attitudes to breastfeeding and skin-to-skin contact among neonatal intensive care units’ HCPs. Findings suggest that the instrument could be used to evaluate future Neo-BFHI interventions to improve breastfeeding duration as well as HCPs’ support and skills.

    The main conclusion of this thesis is that mothers’ low self-efficacy in the early phase can be an important predictor for shorter breastfeeding duration. The breastfeeding training program was regarded as relevant and useful according to different HCPs categories and was shown to increase the HCPs’ interest in breastfeeding and provide them with tools for improved breastfeeding support. The program is designed in a way that makes it easy to copy and spread to other neonatal intensive care units in Sweden and it can also be used for newly employed HCPs.

  • Fluid Management in Haemodialysis : Studies on current practices and new methods Author: Jenny Stenberg Link: Publication date: 2020-05-06 10:20

    Chronic fluid overload has been identified as an independent predictor of mortality in haemodialysis patients, and 30% remain fluid overloaded at dry weight. The use of bioimpedance spectroscopy (BIS) in fluid management may improve blood pressure control and cardiovascular status. However, the importance of regular and careful clinical assessment of fluid balance is repeatedly emphasised.

    This thesis is based on five papers and the overall aim was to investigate current practices and new methods for fluid management in haemodialysis, and to develop a management tool for dry weight determination, based on multiple complementary methods. The purpose was to contribute to reduced prevalence of fluid overload and intradialytic symptoms in haemodialysis patients, by providing the healthcare team and the patient with a tool, that facilitates communication and enables informed decision-making in dry weight determination.

    In the initial, cross-sectional study, clinical praxis for dry weight assessment in Sweden and Denmark was investigated. A wide variation in routines was found. Despite high access, BIS was sparsely used. Instead, nurses’ authorisation to adjust haemodialysis patients’ dry weight was associated with improved fluid status. The second study had a qualitative approach. Focus group interviews, with healthcare professionals, were carried out to achieve a deeper understanding of the factors preventing or facilitating the use of BIS. In the third study, the usefulness of a biomarker, brain natriuretic peptide (BNP), for assessing fluid status in haemodialysis patients, was investigated. An association between BNP and fluid overload was established. The between-individual variation in BNP levels was greater than the within-individual variation over time. Therefore, if BNP is to be used as a marker for fluid overload, repeated measurements are required. In the fourth study, we developed and validated a multifactorial decision aid, Recova®, that incorporates BIS in dry weight determination. Recova® is based on physiological parameters routinely measured in haemodialysis and provides guidance on when and how to respond to recognised fluid alterations. In the fifth study, the decision aid’s effect on volume status was tested in a cohort of haemodialysis patients. Implementation of Recova® had effect on fluid status symptoms, BIS-measured hydration status and NT-proBNP levels.