Coming theses from other universities
-
Adolescent Idiopathic Scoliosis : Postural Stability, Prognostic factors and Impact of Conservative Treatments on Radiologic, Clinical and Self-Reported Outcomes
Link: http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-203011
Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional distortion of spinal curvature of unknown cause that develops during puberty. If the frontal plane curvature exceeds a Cobb angle of 24°, full-time bracing is recommended to prevent curve progression, negative health consequences or need for surgery. However, many patients decline full-time bracing, and limited evidence exists regarding alternative conservative treatments. Increasing knowledge of risk factors enables better identification of high-risk patients, thereby reducing the risk of over- or undertreatment.
The overall aim of this thesis was to evaluate evidence of association between scoliosis and postural stability to inform a potential treatment target, to investigate the effectiveness of three alternative conservative treatments for patients who declined full-time bracing, and to develop a prognostic model for future risk of increased curvature in AIS.
Methods: Data collection is based on one systematic literature review and meta-analysis, and one randomised controlled trial (RCT) for patients with AIS. In Paper I, literature was reviewed, and utilized posturography data to assess static postural stability to identify potential differences between patients with AIS and the control group (CON). In Papers II and III, patients were randomly assigned to either physical activity combined with hypercorrective Boston scoliosis night brace (NB), scoliosis-specific exercises (SSE), or a control group with physical activity alone (PA). Effects on trunk rotation, Cobb angle, self-reported physical activity, spinal appearance, and health-related quality of life were evaluated. Likewise, adherence, capability, and motivation in performing self-managed treatment were assessed. Follow-up was conducted at 6 months intervals until endpoint. The endpoint was defined as non-progression if the curvature increased by 6° or less at skeletal maturity, i.e., less than 1cm of growth over 6 months, or progression if the curvature increased by more than 6° before skeletal maturity. In Paper IV, data from the RCT were used for a longitudinal cohort analysis, developing and validating a prognostic model using Cox Proportional Hazards survival analysis.
Results: Paper I found reduced postural stability in AIS patients compared to CON with increased sway area, mediolateral and anteroposterior range, and a posterior shift in the sagittal plane. The RCT included 135 individuals, mean age of 12.7 years (SD1.4) and Cobb angle of 31° (SD5.3). At 6 months, patients reported high adherence (72-95%) and motivation (65-92%) to the treatment, particularly in the NB group. Both the SSE and PA groups increased physical activity levels compared to the NB group. At endpoint, adherence remained adequate, but better in the NB and PA groups compared with the SSE group (50-89%). Adherence increased with higher capability and motivation, which explained 53% of the variance in adherence at endpoint. The SSE group had higher proportion of moderate problems in mobility and usual activities than the NB and PA groups, with no other clinically relevant between-group differences. The prognostic model (n=127) for curve progression showed acceptable discriminative ability (0.791), with risk factors including skeletal immaturity, larger major curve, and worsening spinal appearance. The model was adjusted for treatment exposure, as NB reduced the risk of curve progression.
Conclusions: Patients with AIS have decreased postural stability with a posterior positional shift. Treatment evaluation at endpoint showed few between-group differences. However, the SSE group had higher proportion of moderate problems in mobility and usual activities compared to the other groups. Treatment adherence was adequate, but better in the NB and PA groups. Higher capability and motivation increased long-term adherence to the treatment. The treatment alternatives could be considered as the first option following a clinical decision on treatment. Including self-reported spinal appearance as a risk factor in the prognostic model may be clinically important for predicting which patients are at risk of curve progression.
-
Estrogen and its receptors in adipose tissue from women and men : Associations with age, adiposity and type 2 diabetes
Link: http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-524955
Obesity and its complications, such as insulin resistance and type 2 diabetes (T2D), are leading causes of morbidity and mortality globally. Adipose tissue is important for whole-body homeostasis, functioning as an energy storage reservoir and an endocrine organ. Estrogens mediate their effects through estrogen receptor alpha (ESR1) and beta (ESR2) and contribute to sex and menopause-related differences in body fat distribution. Moreover, estrogens can be produced from androgens in the adipose tissue by the enzyme aromatase. The overall aim of this thesis was to investigate the role of estrogen and estrogen signalling in human adipose tissue and their association with age, adiposity, and insulin resistance.
In Paper I, we assessed ESR1 and ESR2 gene expression in subcutaneous adipose tissue (SAT) from pre- and postmenopausal women, and investigated the effects of estradiol on adipocyte glucose uptake. We found that ESR2 gene expression was higher in postmenopausal women than premenopausal women. Moreover, in late, but not pre- or early postmenopausal women, estradiol incubation reduced basal and insulin-stimulated glucose uptake, which corresponded to an increase in ESR2 gene expression levels. The inhibiting effect of estradiol on adipocyte glucose uptake was prevented using an ESR2 antagonist.
Subsequently, in Paper II we assessed the role of ESR2 in SAT lipid and glucose metabolism and preadipocyte differentiation. ESR2 expression in SAT was inversely correlated with markers of central adiposity and positively correlated with markers of lipid accumulation. Moreover, ESR2 knockdown impaired subcutaneous preadipocyte differentiation and glucose utilization.
In Paper III, we focused on adipocyte lipolysis in women, which is regulated, in part, by catecholamines. OCT3, which mediates catecholamine transport into adipocytes, where they can be degraded, was increased in SAT with age, and higher in postmenopausal women than premenopausal women. Moreover, its expression was negatively associated with markers of insulin resistance and ex vivo lipolysis. Estradiol incubation of SAT downregulated OCT3 gene expression, which may explain lower OCT3 gene expression in premenopausal compared to postmenopausal women.
In Paper IV, we focused on the role of aromatase and estradiol in SAT from men. We found that aromatase expression was higher in SAT from men with obesity and T2D compared to subjects without obesity and T2D, respectively, and was positively associated with markers of central obesity and markers of insulin resistance. Contrastingly, ESR1 expression in SAT was lower in men with obesity and T2D compared to subjects without obesity and T2D, respectively, and negatively associated with markers of obesity and insulin resistance. ESR2 expression was higher in SAT from men with T2D compared to men without T2D. Estradiol reduced insulin-stimulated glucose uptake, however, neither testosterone, nor aromatase inhibition, altered adipocyte glucose uptake.
In this thesis, we found that estrogen has important metabolic effects in adipose tissue, including regulating lipid accumulation, glucose uptake capacity, and catecholamine transport. Overall, our findings suggest that estrogen and estrogen receptors may have an important role in age-, menopausal- and sex-dependent differences in body fat distribution, and may serve as potential targets for the prevention and treatment obesity and insulin resistance.
-
The effects and experiences of internet-delivered cognitive behavioural therapy : The perspectives of patients with non-cardiac chest pain and healthcare professionals in the emergency and cardiac care
Link: http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-202649
Background
Non-cardiac chest pain (NCCP) is a common issue, accounting for roughly half of all emergency department visits related to chest pain. Patients afflicted with NCCP often endure cardiac anxiety, misinterpreting the pain as heart-related and fearing it, despite the absence of any life-threatening cardiac issues. This anxiety often leads to the avoidance of physical activities, negatively impacting their quality of life. Cognitive behavioural therapy (CBT) has been shown to be effective in managing psychological distress such as anxiety and depression. CBT is a structured process that helps patients identify and restructure their negative thoughts, get a corrected and more realistic perception of their symptoms, and learn to manage their thoughts about chest pain. Despite its effectiveness, CBT is resource-intensive, and therefore internet-delivered cognitive behavioural therapy (iCBT) may be an alternative as it increases accessibility and is more cost-effective compared to traditional therapy methods. However, there is a lack of re-search on the effectiveness of this treatment approach for patients with NCCP and cardiac anxiety. Moreover, digital care technologies are still relatively unfamiliar in clinical practice, particularly in emergency departments, and the successful implementation of iCBT relies on healthcare professionals' acceptance and integration of digital care into clinical practice.
Aim
The overall aim of this dissertation was to evaluate the short- and long-term effects of a nurse-led iCBT program on psychological distress in patients with NCCP, and to explore their experiences participating in the iCBT program. In addition, the study aimed to describe healthcare professionals' perceptions of digital care in the emergency and cardiac care for patients with NCCP.
Methods
This dissertation comprises two quantitative and two qualitative studies. A randomised clinical trial (RCT) (studies I, II, and III) was conducted to evaluate cardiac anxiety, measured with the Cardiac Anxiety Questionnaire (CAQ); and secondary outcomes such as fear of body sensations, measured with The Body Sensations Questionnaire (BSQ); depressive symptoms, assessed with the Patient Health Questionnaire-9 (PHQ-9); health-related quality of life (HRQoL), measured using the EuroQol Visual Analog Scale (EQ-VAS); and chest pain frequency with a self-developed question. The RCT cohort consisted of 109 patients who had at least two healthcare consultations for NCCP in the past 6 months, experienced cardiac anxiety (CAQ score ≥24), and were randomised into a 5-week iCBT program (n=54) or psychoeducation (n=55). An intention-to-treat analysis was conducted, and linear mixed model analysis was used to assess between-group differences in primary and secondary outcomes. The iCBT program included psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments and feedback, while the control (psychoeducation) group received readable psychoeducation program aimed to increase knowledge about their mental health, symptoms, and the strategies that can be used to manage chest pain and improve their well-being. Study I was a short-term follow-up with a three-month duration. Study III was a longitudinal study with a 12-month follow-up. Additionally, factors impacting the treatment effect of iCBT on cardiac anxiety were also explored. Study II was a semi-structured qualitative study utilising an inductive approach with content analysis following Patton (2015). Face-to-face interviews were conducted with 16 participants from the iCBT group. Study IV was a qualitative descriptive study involving individual, digital/face-to-face semi-structured interviews with 17 licensed healthcare professionals (physicians and nurses) working in emergency care or cardiology. Data were analysed using inductive thematic analysis based on Braun and Clarke (2006).
Result
In Study I, no significant differences were found between the iCBT and control (psychoeducation) groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen’s d=0.31). A positive change score (≥11 points on the CAQ) was reported by 16 patients in the iCBT group (36%) compared to 13 patients (27%) in the control (psychoeducation) group, indicating a slightly greater improvement in cardiac anxiety in the iCBT group. However, the difference between the groups was non-significant (p=.213). Within-group analysis showed significant improvement in cardiac anxiety (p=.037) at the 3-month follow-up compared to the 5-week follow-up in the iCBT group, but not in the control (psychoeducation) group.
In Study III, there was no statistically significant interaction effect of time and group between the iCBT and control (psychoeducation) groups regarding cardiac anxiety over the 12-month follow-up. However, there was a statistically significant interaction effect of time and group (p=.009) regarding chest pain frequency for the iCBT group and a group effect on health-related quality of life (p=.03) for the iCBT group. Furthermore, the regression analysis showed that higher scores of "avoidance" on the CAQ at baseline were associated with improvement in cardiac anxiety at the 12-month follow-up in both groups.
In Study II, participants described their experiences, leading to three main categories: "driving factors for participation in the iCBT program", "the program as a catalyst" and "learning to live with chest pain." Participants described how pain impacted their lives, the struggle that led them to participate in the program, and how they found the program helpful, trustworthy, and viewed it as a tool for gaining the strength and skills they needed to live a normal life despite chest pain.
In Study IV, healthcare professionals described their perception of digital care, resulting in four themes: "new ground to walk on”, "a challenge for the current healthcare system", "digital care has its potential" and "prerequisites for use in clinical practice". These themes describe healthcare professionals' knowledge and experience with digital care, the challenges associated with implementing digital care in the current healthcare system, the opportunities it presents, and identify facilitators for the implementation of digital care in clinical practice.
Conclusions
In studies I and III, iCBT was not superior to psychoeducation in reducing cardiac anxiety in patients with NCCP. However, both iCBT and psychoeducation have demonstrated utility as interventions for reducing cardiac anxiety in these patients. Moreover, patients with an increased propensity to avoid activities or situations they believe may trigger cardiac -related symptoms, were found to have reduced cardiac anxiety. Patients generally perceived the iCBT program positively, viewing it as a tailored and effective tool for confronting fears and restoring normalcy in their lives.
Healthcare professionals express a mixture of caution and optimism towards digital care, emphasising the importance of clear leadership, education, technical competence, and positive attitudes to ensure successful implementation and maximise benefits for patients with NCCP.