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Coming dissertations at MedFak

  • The value of social investments : A health economic approach to evaluating parenting interventions Author: Camilla Nystrand Link: Publication date: 2020-12-21 12:14

    Child mental health problems are current welfare challenges and may be costly to the individual, the family and society at large. The problems may persist and result in adverse outcomes later in life, which also carries a large financial burden. Parenting interventions are effective strategies to prevent or reduce mental health problems in children and are potentially cost-effective and even cost-saving. This thesis sets out to fill the knowledge gaps regarding the social investment case for parenting interventions in Sweden. Study I evaluated five indicated parenting interventions compared to a waitlist control. Long-term projections of health-related quality-of-life and cost-offsets related to the reduction of externalising behaviour problems in children were made using an economic decision simulation model. Study II assessed the financial impact of the five parenting interventions, considering the child´s lifetime earnings. Study III assessed whether it was worth the extra spending to provide cognitive behavioural therapy for children, in addition to a parenting program, for the treatment of oppositional defiant disorder in children. A net benefit regression framework was employed to assess the willingness-to-pay needed for the intervention to become cost-effective. Study IV was a trial-based evaluation of a selective intervention delivered to Somali-born parents, valuing the health and economic impact on parents and children simultaneously, compared to a waitlist control. The evaluation merged impacts on parents and children to describe potential scenarios for cost-effectiveness. To provide an overview of the current evidence, Study V systematically reviewed the literature on the cost-effectiveness of parenting interventions, focusing on child outcomes. Results showed that the five indicated parenting interventions were highly cost-effective, and may yield substantial economic returns. Delivery of a parenting intervention in addition to an intervention for children yielded clinically relevant improvements but came at a cost exceeding estimates for the societal cost of children with oppositional defiant disorder. The delivery of a selective intervention generated significantly improved health outcomes, but cost-effectiveness depended on the willingness-to-pay, especially considering multiple effects concurrently. The systematic literature review suggested that parenting interventions were likely to be a cost-effective use of resources, particularly for the prevention of externalising and internalising problems. The findings suggest that parenting interventions may be a cost-effective approach for the prevention and treatment of child mental health problems, especially for externalising problems.

  • Aetiologies and Epidemiology of Subdural Haematoma in Infancy Author: Jacob Andersson Link: Publication date: 2020-12-18 13:22

    According to scientific studies, subdural haematoma (SDH) in combination with retinal haemorrhage and encephalopathy (usually denoted as the triad) during infancy is highly specific for abusive head trauma/shaken baby syndrome, if a fall from over one meter, a traffic accident and certain medical conditions have been excluded. Other studies have challenged this notion since there are witnessed falls from less than one meter which has caused acute SDH, birth-related SDH which have been confirmed to develop into chronic SDH, and external hydrocephalus that can be complicated by a spontaneous SDH or an SDH from minor trauma.

    These aetiologies have not been taken into consideration in prior studies on abusive head trauma. 

    An independent review on infant abusive shaking from the Swedish Agency for Health Technology Assessment concluded that there was insufficient evidence for determining the specificity of the triad for isolated shaking. 

    The aim of this thesis was to increase the understanding of the aetiologies and the epidemiology of infant SDH. This was accomplished by studying registry data (Paper I and II), descriptive reviews of infants with SDH (paper I, III and IV) and infants subjected to witnessed or spontaneously admitted shaking (paper V).

    The maximum incidence of fatal AHT in Sweden, 0.6/100 000, was at least 10 times lower than in other Western countries and the risk of unreported fatal AHT was low (Paper I). A majority of the deceased infants had neonatal conditions, several were twins and/or preterm, one had a cerebral vascular condition, and one signs of metabolic disorder (Paper I). Approximately 12 infants every year are diagnosed with SDH beyond the first week of life and the case-fatality rate for all SDH diagnosis categories is 6.2% (Paper II). Males, preterm born and twins have a higher risk to develop SDH in general, and those having an abuse diagnosis had increased odds of being born preterm and small-for-gestational age (Paper II). Chronic SDH has a higher freqency of male and premature infants and a lower mortality rate than acute SDH (Paper III). Infants with chronic CSDH, but not with acute SDH, tend to have findings on neuroimaging and a head circumference that are suggestive of external hydrocephalus complicated by spontaneous SDH or SDH from minor trauma (Paper IV). Intracranial and ocular findings in infants subjected to abusive shaking were rare, seen in 2 out of 36 infants, both with pre-existing intracranial pathology, and of non-specific character (Paper V).

    In conclusion this thesis provides evidence that non-abusive aetiologies for SDH in infancy may have been overlooked in previous research.   

  • Development of allergic and respiratory symptoms in adolescence and early adulthood : Risk factors and gender differences Author: Pia Kalm-Stephens Link: Publication date: 2020-11-26 09:45

    Background: Asthma and allergic diseases have increased in prevalence for several decades and affect a substantial number of individuals in everyday life, as well as their families and public healthcare resources. Subjects with asthma report impaired self-rated health. Fractional exhaled nitric oxide (FeNO) is a marker of type 2 inflammation in the airways and higher levels may precede the development of allergic and respiratory disease.

    Aims: To investigate the development of allergic and respiratory symptoms in adolescence and early adulthood, and related baseline risk factors. Further, to study self-rated health in young adults with reported asthma.

    Methods: A total of 959 schoolchildren completed a standardized respiratory questionnaire and underwent lung function and FeNO measurements at baseline (12–15 years; early adolescence). Four (late adolescence) and sixteen (early adulthood) years later, 921 (96%) and 502 (52%) of these individuals completed a similar questionnaire. A total of 491 subjects participated in all three examinations. Nineteen clinically assessed non-asthmatic subjects with elevated FeNO and 28 control subjects with low FeNO and without symptoms of asthma or allergy in early adolescence were identified. Their FeNO, IgE sensitization, airway responsiveness, and inflammatory markers in blood and sputum were measured.

    Results: The main finding was that higher FeNO in early adolescence was associated with an increased risk of developing allergic symptoms to cat and dog, but not pollen allergens, during adolescence. Gender-stratified data showed that obesity at baseline in girls and an atopic constitution in boys were associated with increased risk of developing wheeze during adolescence. The prevalence of asthma and wheeze had increased in early adulthood, but the increase was significant only in females. Reduced lung function at baseline in females and higher FeNO in males were associated with an increased risk of incident asthma sixteen years later. The increase in allergic symptoms during this period was significant but without sex differences. Asthmatic females rated their health worse than non-asthmatic females, a difference not observed in males. Non-asthmatic adolescents with higher FeNO at baseline were to a higher extent sensitized, had more reactive airways, higher blood eosinophil counts, and lower systemic activation of neutrophils, compared with controls.

    Conclusions: It is important to detect risk factors for the development of allergic and respiratory diseases at an early stage to optimize health and wellbeing. Gender differences in respiratory development, associated risk factors, and treatment of respiratory symptoms must be taken into account.