This thesis is about cultural aspects of advanced medical technology for treating end-stage heart failure. New medical technologies like mechanical help-hearts save lives, but they also bring new uncertainties, risks, and challenges. Based on nine months of ethnographic field work in a Swedish academic hospital, this study examines the ways of managing uncertainties of end-stage heart failure and of high-tech treatment, and also how these practices tie into the shared understandings of life-threatening chronic illness, the body, and medical technology’s role.

This study draws on anthropological discussions of healing rituals as an analytical tool to make sense of social and cultural dimensions of mechanical help-heart implantation treatment. Viewed as a ritual, this treatment creates and maintains hope as a virtue through which possibilities of new medical technology are justified as culturally approved ways of handling the uncertainties of severe heart failure and mechanical help-heart treatment. Ultimately, even when treatment is regarded as successful, the patients may be saved but are never really ‘cured’ and remain, thus, permanently tied to the world of medicine. This new mode of existence is characterized by paradoxical permanent transit between uncertainty and hope.

This paper aims to describe the dynamics of objective health and welfare in five populations, from the year 2000 to 2009, qua a methodological study. It proposes a three step approach to ensure the validity criteria in the conducted research process:

1. firstly, to identify the relevant variables as predictors of the two phenomena, empiric studies and sociological theories by Esping-Andersen (1999) Nussbaum (1999, 2000, 2011), were consulted. This (with the data availability) frames the study to include five related categories of objective health and welfare indicators, including (1) demographic (e. g. life expectancy (LE), total fertility rate (TFR)), (2) child-welfare (i. e. under-five mortality rate (U5MR), (3) welfare services (immunization coverage and prevalence of tuberculosis (TB)), (4) education, and (5) indicators on health expenditure (HE). The applied theoretical frame–in a combination with the four posed research questions–indicates a need of an overall methodological approach that is primary quantitative. The data analysis follows an observational epidemiological type that is descriptive study, to analyse the indicators in five populations and two control groups.
2. The study obtains descriptive data from three data bases, which are selected upon a qualitative analysis, to account for their validity and reliability.
3. Further data analysis is strengthened qua the inclusion of the two control groups of populations, when appropriate. Since it wasn’t possible to compare data on populations across time, due to different data production methodologies.

Main findings indicate that HE, immunization, TFR, male and female LE, U5MR and school enrolment, tend to diverge between and within the five populations, expressed in absolute and relative terms. The comparison of the estimated data for the five populations with the two control groups of populations, shows that most objective health and welfare indicators tend to converge, (within categories 1, 2 and 3, except TFR) when expressed in absolute and relative terms. When estimated data is analysed in the light of two sociological theories, it is evident that the existing gap between male and female LE, U5MR, and HE indicators can improve further.

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Objectives: A multimarker strategy for the handling of patients with heart failure has been suggested in the literature. Therefore, the potential prognostic relevance of combined copeptin, high-sensitivity troponin T (HS-TnT), and N-terminal proBNP (NT-proBNP) measurement in plasma from elderly patients with symptoms of heart failure was evaluated

Methods: This study included 470 elderly patients (mean age 73 years) from a rural municipality with symptoms of heart failure. Clinical examination, echocardiography, and biomarker measurements were performed. All patients were followed for 13 years and all mortality was registered. Cardiovascular mortality was evaluated using Kaplan-Meier plots and multivariate Cox proportional hazard regression analyses.

Results: Copeptin, HS-TnT, and NT-proBNP measurements provided independent prognostic information in a multivariate setting over 5 years (hazard ratio, HR: 3.66; 95% confidence interval, CI 1.27-10.53, HR: 2.52; 95% CI 1.20-5.28, HR: 2.73; 95% CI 1.19-6.26, respectively). Also, the group with all three biomarkers below cut-off values had a low risk for cardiovascular death (1.8% of the patients in this group died in the 5-year follow-up period). In the 13-year follow-up, combined copeptin and HS-TnT measurement did not provide independent prognostic information.

Conclusion: Combined copeptin, HS-TnT, and NT-proBNP plasma measurements provide prognostic information on cardiovascular mortality that is superior to single biomarker use.

Objectives: Several studies have sought to analyze the cost-effectiveness of advanced home care andhome rehabilitation. However, the costs of informal care are rarely included in economic appraisals ofhome care. This study estimates the cost of informal care for patients treated in advanced home careand analyses some patient characteristics that influence informal care costs.Methods: During one week in October 1995, data were collected on all 451 patients in advanced homecare in the Swedish county of O¨ stergo¨ tland. Costs were calculated by using two models: one includingleisure time, and one excluding leisure time. Multiple regression analysis was used to analyze factorsassociated with costs of informal care.Results: Seventy percent of the patients in the study had informal care around the clock during theweek investigated. The patients had, on average, five formal care visits per week, each of which lastedfor almost half an hour. Thus, the cost of informal care constituted a considerable part of the costof advanced home care. When the cost of leisure time was included, the cost of informal care wasestimated at SEK 5,880 per week per patient, or twice as high as total formal caregiver costs. Whenleisure time was excluded, the cost of informal care was estimated at SEK 3,410 per week per patient,which is still 1.2 times higher than formal caregiver costs (estimated at SEK 2,810 per week per patient).Informal care costs were higher among patients who were men, who were younger, who had their ownhousing, and who were diagnosed with cancer.Conclusions: Studies of advanced home care that exclude the cost of informal care substantiallyunderestimate the costs to society, regardless of whether or not the leisure time of the caregiver isincluded in the calculations.

Background: Electronic-based alcohol screening and brief interventions for university students with problem drinking behaviours forms an important means by which to identify risky drinkers. Methods: In this study an e-SBI project was implemented to assess drinking patterns, and to provide personalised feedback about alcohol consumption and related health problems, to students in a Swedish university. In this study, third semester university students (n = 2858) from all faculties (colleges) at the University were invited to participate in e-SBI screenings. This study employed a randomised controlled trial, with respondents having a equal chance of being assigned to a limited, or full-feedback response. Results: The study shows that high risk drinkers tend to underestimate their own consumption compared to others, and that these high risk drinkers experience more negative consequences after alcohol intake, than other respondents. There was a strong belief, for both high-and low-risk drinkers, that alcohol helped celebrations be more festive. This study also confirms findings from other study locations that while males drank more than females in our study population; females reached the same peak alcohol blood concentrations as males. Conclusion: Obtaining clear and current information on drinking patterns demonstrated by university students can help public health officials, university administration, and local health care providers develop appropriate prevention and treatment strategies.

Background

Depressive disorders have been associated with a number of co-morbidities, and we   hypothesized that patients with a depression diagnosis would be heavy users of health   care services, not only when first evaluated for depression, but also for preceding   years. The aim of this study was to investigate whether increased health care utilisation   and co-morbidity could be seen during five years prior to an initial diagnosis of   depression.

Methods

We used a longitudinal register-based study design. The setting comprised the general   population in the county of Östergötland, south-east Sweden. All 2470 patients who   were 20 years or older in 2006 and who received a new diagnosis of depression (F32   according to ICD-10) in 2006, were selected and followed back to the year 2001, five   years before their depression diagnosis. A control group was randomly selected among   those who were aged 20 years or over in 2006 and who had received no depression diagnosis   during the period 2001-2006.

Results

Predictors of a depression diagnosis were a high number of physician visits, female   gender, age below 60, age above 80 and a low socioeconomic status.

Patients who received a diagnosis of depression used twice the amount of health care   (e.g. physician visits and hospital days) during the five year period prior to diagnosis   compared to the control group. A particularly strong increase in health care utilisation   was seen the last year before diagnosis. These findings were supported with a high   level of co-morbidity as for example musculoskeletal disorders during the whole five-year   period for patients with a depression diagnosis.

Conclusions

Predictors of a depression diagnosis were a high number of physician visits, female   gender, age below 60, age above 80 and a low socioeconomic status. To find early signs   of depression in the clinical setting and to use a preventive strategy to handle these   patients is important.

This article examines the creation of narratives between people with severe disabilities and the personnel working with them. It shows that although a co-created narrative of what it means to be severely disabled (the story of dependence) seems to prevail, another narrative (the story of autonomy) is also told, where the story of dependence is rejected by the person with disabilities. However, this story of autonomy only becomes clear if we recognize three central claims: (1) there is a connection between where the physical body of the person with disabilities is positioned in space and what he or she is allowed or able to be and do; (2) since the body is a communicative tool, the moving of the body could be interpreted as a narrative, told through the embodiment of space; and (3) the embodied story can challenge existing social structures. The article highlights the inherent struggle for power within narrations and how the creation of alternative narratives can contest existing social structures.

The main purpose of the dissertation is to understand meaning-making practices used by people suffering from acquired brain damage with severe physical and communicative disabilities, in order to create and sustain their identity and personhood in relation to other people. The study emanates from the idea that identity and personhood, also in relation to disability, are created/sustained in ongoing interaction between people in everyday situations, and that the ability to narrate is central to such a creation of identity. Therefore, it is of particular interest to try to understand what communicative and storytelling abilities/possibilities people with severe acquired brain damage have in presenting their identity.

The study is ethnographic and based upon a year-long field study of participant observations at a day centre for people with acquired brain damage. Gathered data consist of written field notes, informal interviews conducted with both participants and personnel and approximately 70 hours of video data.

The study shows how an identity as ‘severely disabled’ is created in the co-created storytelling between participants and personnel and that this identity seems to mean that one is dependent upon others to get along in everyday life at least if one listens only to spoken stories. Yet the study also shows that there exist different opinions about what this identity as ‘severely disabled’ could mean that there is a wish among the participants to be able to present a desirable identity as “normal”, and that such an identity comes to mean to be independent and self-determined. Normality, however, must be understood in relation to surrounding society (and the grand cultural narratives that surround us). Thus the study shows that normality in relation to severe disabilities is almost impossible to achieve because normality in relation to illness/disease/body contains the hope of a cure or an improvement. The participants in this study, however, have all been labelled as incurable – there is no hope of such a cure or improvement. That, on the other hand, does not mean that the participants do not try to tell such stories anyway in their quest to achieve this desirable identity. However, in order to hear this story we need to listen to stories that usually remain untold. A palpable hierarchy between different modes of language use was identified, where verbal/spoken language is supreme, resulting in the disabled participants not being perceived as competent interactors/communicators due to their difficulties in using verbal communication. Hence their ways of creating/telling stories, through embodiment and enactment, are not recognised as valid ways to create/tell stories; this is discussed in relation to both practical implications for health care settings as well as for further narrative research.

In this article, I consider narratives told within a clinical setting. I argue that personnel in a day center for people with acquired brain damage are constantly involved in narrating about the disabled participants. The negotiation of who the participant is, and foremost will be, is in constant negotiation in regard to issues of hope. I further argue that hope is a meaning-making process and, as such, it has been defined as crucially connected to time. Hope has been said to enable a connection between the present and the future, because action taken in the present could bring about (positive) change in the future. However, I show that hope, in relation to narratives told about people with severe disabilities that are considered "incurable," must be understood within a realm of narrative foreclosure. Time seems to have lost the openness of its horizon for these people, and a narrative that tells of immediacy rather than chronology is created, resulting in hope being established within the present.

This article examines the concepts of identity and personhood in relation to people with severe communicative disabilities. Data gathered at a Swedish day centre for people with acquired brain damage show that three main strategies in communication between able-speaking and impaired-speaking persons can be found; (1) perfunctory, (2) jigsaw puzzle, and (3) conjectural, all three strategies being based on the act of speaking. This article shows why it seems important to talk with one’s own physical voice instead of using augmentative and/or facilitated communication, even when one has a highly impaired speech pattern. I argue that an ideology of spoken language exists within western culture and that such an ideology has practical implications for the (re-)creation of meaning-making strategies in relation to people with severe communicative disorders. Implications for health-care personnel working with communicatively impaired people are also identified, as well as implications for researchers studying this field of interest.

The thesis investigates how the notion of ‘ontology’ has been used in the field of medical informatics and knowledge representation. Partly to investigate what an ‘ontology’ can be said to represent and what requirements we can have on a good ‘ontology’. The author studies the already existing medical terminologies and ‘ontologies’ to elucidate what theories they are based on. The terminological theories of Eugen Wüster and his legacy in medical informatics are studied. It is noted that terminological theories handling linguistic entities are not suited for describing and representing medical theories, since these are assumed to refer to the real world, which consists of more than linguistics entities.

In order to find a metaphysical theory in accordance with the world view that medical theories describe, the author turn to the critical realism of Karl Popper, Roy Bhaskar and Ilkka Niiniluoto. These theories, taken together with the metaphysical theories regarding universals of David M Armstrong and Ingvar Johansson, are used as a basis to find out what an ‘ontology’ can be said to represent, and what criteria and requirements we can have on a good ‘ontology’. Among the requirements presented in the thesis are stability, interoperability and the requirement that a good ‘ontology’ must be in accordance with our best available theories.

Finally, it is discussed how these requirements and criteria can come into conflict with one another, and how one should reason when handling these trade-offs. The author emphasises the importance of including the medical expertise in the process of creating ‘ontologies’, in order to produce as useful and relevant ‘ontologies’ as possible.

Patients often experience hard-to-treat neuropathic pain and other sensations after surgery; consequently, they could develop chronic pain conditions. The phantom limb phenomenon is a well-documented postoperative pain condition. However, phantom phenomena after mastectomies are less documented. The reviews report several views on the prevalence of breast phantoms and coexisting distress. Researchers observed that new methodological approaches might facilitate further research of these issues. This prospective, qualitative study used semistructured interviews to acquire knowledge of if and how phantom breast phenomena appear within the range of other postmastectomy symptoms and sensations. The study revealed that a phantom breast could be difficult to describe and position spatially. The phantom breast phenomenon varied from classic phantom extremity phenomenon and did not seem to cause much distress. However, it proved to be a phenomenon so unknown and different that there is urgent need for more knowledge. This study highlights the importance of further investigation regarding how information and communication related to a phantom breast might be developed.

Perspective: The phantom breast is only one piece of a complicated puzzle. Because it was relatively unknown for the women in the study, it is important that analyses of this phenomenon, as a part of a postmastectomy syndrome, be conducted in a dialogue with the patients, by scientifically using qualitative methods.

Background

Phantom phenomena – pain or other sensations appearing to come from amputated body parts – are frequent consequences of amputation and can cause considerable suffering. Also, stump pain, located in the residual limb, is in the literature often related to the phantom phenomena. The condition is not specific to amputated limbs and has, to a lesser extent, been reported to be present after radical surgery in other body parts such as breast, rectum and teeth.

Multi-causal theories are used when trying to understand these phenomena, which are recognized as the result of complex interaction among various parts of the central nervous system confirmed in studies using functional brain imaging techniques.

Functional brain imaging has yielded important results, but without certainty being related to phantom pain as a subjective clinical experience.

There is a wide range of treatment methods for the condition but no documented treatment of choice.

Aims

In this study a qualitative, explorative and prospective design was selected, in the aim to understand the patients’ personal experience of phantom phenomena.

The research questions focused at how patients affected by phantom pain and or phantom sensations describe, understand, and live with these phenomena in their daily life.

This study expanded ‘phantom phenomena’ to also encompass phantom breast phenomenon. Since the latter phenomenon is not as well investigated as the phantom limb, there is clinical concern that this is an underestimated problem for women who have had breasts removed.

Methods

The present study forms the first part of a larger, longitudinal study. Only results associated with data from the first interviews with patients, one month after an amputation, are presented here. At this occasion, 28 patients who had undergone limb amputation (20) or mastectomy (8) were interviewed. The focused, semi-structured interviews were recorded, transcribed, and then analyzed using discourse-narrative analysis.

Results

The interviewees had no conceptual problems in talking about the phenomena or distinguishing between various types of discomfort and discomfort episodes. Their experience originated from a vivid, functioning body that had lost one of its parts. Further, the interviewees reported the importance of rehabilitation and advances in prosthetic technology. Loss of mobility struck older amputees as loss of social functioning, which distressed them more than it did younger amputees. Phantom sensations, kinetic and kinesthetic perceptions, constituted a greater problem than phantom pain experienced from the amputated body parts. The descriptions by patients who had had mastectomies differed from those by patients who had lost limbs in that the phantom breast could be difficult to describe and position spatially.

The clinical implication of this study is that when phantom phenomena are described as everyday experience, they become a psychosocial reality that supplements the definition of phantom phenomena in scientific literature and clinical documentation.

Conclusions

There is a need for clinical dialogues with patients, which besides, providing necessary information about the phenomena to the patients creates possibilities for health professionals to carefully listen to the patients’ own descriptions of which functional losses or life changes patients fear the most. There is a need for more qualitative studies in order to capture the extreme complexity of the pain–control system will be highlighted.

Background and aim: The curious phenomenon phantom limbs early became the object of research, and its underlying mechanisms have been discussed over the years. The complex nature of phantom phenom- ena makes interpretation of the results ambiguous, regarding both prevalence and the accompanying suffering. There is a lack of knowledge about how amputees experience the meaning and consequences of phantom phenomena. The present aim, therefore, was to investigate how individuals, in an interview situation, described the qualities of possible perceived phantom phenomena, and how their experience affected their lives one month after the amputation/mastectomy.

Methods: Twenty-eight women and men who had undergone a limb amputation or mastectomy were interviewed. The focused, narrative-oriented interviews were transcribed verbatim and the scripts were analysed with content analysis.Results: One month after the amputation the informants described and related their phantom pain and phantom sensations in sensory-discriminative, motivational-affective and cognitive-evaluative dimen- sions. The phantom sensations were experienced mainly as more agonizing than the phantom pain.

Despite both the high intensity of and the high annoyance at the phantom pain and phantom sensations, a majority felt that the phantom phenomena were not a hindrance in their attempts to recapture ordinary life. But when the hindrance was evaluated as high, the annoyance was evaluated as the highest possible for both phenomena or for the phantom sensations alone, never for phantom pain alone. The interviewees’ reported attitudes of hindrance were also described and estimated in the light of their sociocultural circumstances. Thus, other preceding and/or co-existent pain conditions as well as factors such as pre- operative information, the respondents’ views on pain treatment, and their knowledge and understanding of phantom phenomena were mentioned and related to the pain-producing situation.

Two-thirds of the interviewees had received post-surgical information and for some, the phenomena were well-known from earlier experience. A majority applied some version of the medical explanation model, irrespective of age or level of education. However neither information nor medical explanation, or both, sufficed for them to understand their own phantom phenomena. Thus, differences between the concepts explanation and understanding seemed significant for the annoyance related to the phantom phenomena.

Regarding background data: (i) the majority of the interviewees had had pre-amputation pain prob- lems; (ii) the breast-cancer phantoms differed in several ways; (iii) there were some age and gender differences in the descriptions of hindrance.Conclusions and implications: These findings highlight the importance of observing the individual approach to the phenomena as a process of evaluation and selection. In addition, experience and under- standing of the phantoms also have sociocultural aspects. There follows the need for individualized communication and information from the clinician, and for incorporating a socioscientific and meaning- centred approach in future studies. The present insights could also be of value in other iatrogenic pain conditions. 

Children born with non-optimal birth characteristics — that is, are small for gestational age and/or preterm — have an increased risk for several long-term effects such as neurological sequelae and chronic disease. The purpose of this study was to examine whether twins exhibited a different outcome, compared with singletons, in terms of hospitalization during adolescence and early adulthood, and to what extent differences remain when considering the divergence in birth characteristics between singletons and twins. Persons born between 1973 and 1983 in Sweden and surviving until age 13 were included and followed until the end of 2006. Data on birth characteristics, parental socio-demographic factors, and hospitalizations were collected from national registers. Adjusting for parental socio-demographic factors, twins had a higher risk of being hospitalized than singletons (odds ratio, OR = 1.17, 95% confidence interval, CI = 1.10–1.25) and more often due to ‘Congenital anomalies’ (OR = 1.18, 95% CI = 1.06–1.28), ‘Infections’ (OR = 1.14; 95% CI = 1.08–1.20), ‘External causes of illness’ (OR = 1.10, 95% CI = 1.06–1.15), and ‘Diseases of the nervous system’ (OR = 1.18, 95% CI = 1.10–1.26). Stratifying for birth characteristics, this difference diminishes, and for some diagnoses non-optimal twins seem to do slightly better than non-optimal singletons. Thus, twins with non-optimal birth characteristics had a lower risk of hospitalization than non-optimal singletons on, for example, ‘Congenital anomalies’ and ‘Diseases of the nervous system’ (OR = 0.86, 95% CI = 0.77–0.96; OR = 0.88, 95% CI = 0.81–0.97, respectively) and Total (any) hospitalization (OR = 0.87, 95% CI = 0.83–0.92). Among those with optimal birth characteristics, twins had an increased hospitalization due to ‘External causes of illness’ (OR = 1.07, 95% CI = 1.02–1.13) compared with optimal singletons. Twins have higher hospitalization rates than singletons. In stratifying for birth characteristics, this difference diminishes, and for some diagnoses, non-optimal twins seem to do less poorly than non-optimal singletons.

Background

During the last decades there has been a steady increase of twin births. A combination of improved medical treatment of preterm and small-for-gestational age children has contributed to a higher number of surviving twins. Prematurity is known to affect reproduction in a negative way. Few studies have focused on the potential effect twinning may have on future reproduction. Thus, the aim of this study was to investigate the effect of being born a twin compared to being born a singleton have on future reproduction.

Methods

In a national population-based register study, all individuals born between 1973–1983 who were alive and living in Sweden at 13 years of age (n = 1 016 908) constituted the sample. Data on each study subject’s own birth as well as the birth of their first offspring, and parental socio-demographic factors were collected from Swedish population based registers. Hazard ratios and corresponding 95% CI was calculated using Cox proportional hazards model.

Results

Twins, both men and women, had a reduced likelihood of reproducing compared to singletons (women: HR = 0.89, 95% CI = 0.86-0.93; men: HR = 0.92, 95% CI = 0.87-0.97). This difference in birth rates can only partly be explained by diverging birth characteristics. Amongst men and women born very preterm, twins had an increased likelihood of reproducing compared to singletons (women: HR = 1.25, 95% CI = 1.02-1.62; men: HR = 1.34, 95% CI = 1.01-1.78).

Conclusions

Twins have lower reproduction rates compared to singletons, which only to a certain degree can be explained by diverging birth characteristics.

Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnoea syndrome (OSAS), but side-effects are common. No validated self-rating scale measuring side-effects to CPAP treatment exists today. The aim was to develop the side-effects to CPAP treatment inventory (SECI), and investigate the validity and reliability of the instrument among patients with OSAS. SECI was developed on the basis of: (1) in-depth interviews with 23 patients; (2) examination of the scientific literature and (3) consensus agreement of a multi-professional expert panel. This yielded 15 different types of side-effects related to CPAP treatment. Each side-effect has three sub-questions (scales): perceived frequency (a) and magnitude (b) of the side-effect, as well as its perceived impact on CPAP use (c). A cross-sectional descriptive design was used. A total of 329 patients with OSAS with an average use of CPAP treatment for 39 months (2 weeks to 182 months) were recruited. Data were collected with SECI, and obtained from medical records (clinical variables and data related to CPAP treatment). Construct validity was confirmed with factor analysis (principal component analysis with orthogonal rotation). A logical two-factor solution, the device subscale and symptom subscale, emerged across all three scales. The symptom subscale describing physical and psychological side-effects and the device subscale described mask and device-related side-effects. Internal consistency reliability of the three scales was good (Cronbach’s α = 0.74–0.86) and acceptable for the subscales (Cronbach’s α = 0.62–0.86). The satisfactory measurement properties of this new instrument are promising and indicate that SECI can be used to measure side-effects to CPAP treatment.

Background

Obstructive sleep apnoea (OSA) has been linked to hypertension in sleep clinic populations, but little is known about the symptom profile of undiagnosed OSA in hypertensive outpatients in primary care.

Aim

To explore characteristics associated with undiagnosed OSA in hypertensive primary care patients.

Methods

Cross-sectional design, including 411 consecutive patients (52% women), mean age 57.9 years (standard deviation [SD] 5.9 years), with diagnosed hypertension (blood pressure >140/90 mmHg) fromfour primary care centres. All subjects underwent a full-night, home-based, respiratory recording to establish the presence and severity of OSA. Clinical variables, medication and comorbidities, as well as data from self-rating scales regarding symptoms/characteristics, insomnia, excessive daytime sleepiness, depressive symptoms and health were collected during a clinical examination. Factor analyses and structural equation modelling (SEM) were used to explore the relationships between selfrated symptoms, clinical characteristics and objectively verified diagnosis of OSA.

Main outcome

Measures symptom profile of undiagnosed OSA (as measured by the Apnoea/ Hypopnoea Index [AHI]) in hypertensive outpatients in primary care.

Results

Fifty-nine percent of the patients had an AHI _ 5/hour indicating OSA. An exploratory factor analysis based on 19 variables yielded a six-factor model (anthropometrics, blood pressure, OSA-related symptoms, comorbidity, health complaints and physical activity) explaining 58% of the variance. SEM analyses showed strong significant associations between anthropometrics (body mass index, neck circumference, waist circumference) (0.45), OSA-related symptoms (snoring, witnessed apnoeas, dry mouth) (0.47) and AHI. No direct effects of OSA on comorbidities, blood pressure, dyssomnia or self-rated health were observed.

Conclusion

OSA was highly prevalent and was directly associated with anthropometrics and OSArelated symptoms (snoring, witnessed apnoeas and dry mouth in the morning). When meeting patients with hypertension, these characteristics could be used by general practitioners to identify patients who are in need of referral to a sleep clinic for OSA evaluation. 

BACKGROUND: Bridging the knowledge-to-practice gap in health care is an important issue that has gained interest in recent years. Implementing new methods, guidelines or tools into routine care, however, is a slow and unpredictable process, and the factors that play a role in the change process are not yet fully understood. There is a number of theories concerned with factors predicting successful implementation in various settings, however, this issue is insufficiently studied in primary health care (PHC). The objective of this article was to apply implementation theory to identify key factors influencing the adoption of an innovation being introduced in PHC in Sweden.

METHODS: A qualitative study was carried out with staff at six PHC units in Sweden where a computer-based test for lifestyle intervention had been implemented. Two different implementation strategies, implicit or explicit, were used. Sixteen focus group interviews and two individual interviews were performed. In the analysis a theoretical framework based on studies of implementation in health service organizations, was applied to identify key factors influencing adoption.

RESULTS: The theoretical framework proved to be relevant for studies in PHC. Adoption was positively influenced by positive expectations at the unit, perceptions of the innovation being compatible with existing routines and perceived advantages. An explicit implementation strategy and positive opinions on change and innovation were also associated with adoption. Organizational changes and staff shortages coinciding with implementation seemed to be obstacles for the adoption process.

CONCLUSION: When implementation theory obtained from studies in other areas was applied in PHC it proved to be relevant for this particular setting. Based on our results, factors to be taken into account in the planning of the implementation of a new tool in PHC should include assessment of staff expectations, assessment of the perceived need for the innovation to be implemented, and of its potential compatibility with existing routines. Regarding context, we suggest that implementation concurrent with other major organizational changes should be avoided. The choice of implementation strategy should be given thorough consideration.

Diabet. Med. 29, 10551059 (2012) Aim To examine the availability of insulin pump therapy in patients with Type 1 diabetes. Methods Patients using insulin pumps among a cohort of 7224 patients with Type 1 diabetes were studied. Results In logistic regression, used to evaluate variables not changing over time among the total cohort, use of insulin pumps varied by outpatient clinic (P andlt; 0.001) and sex (P andlt; 0.001). Cox regression analysis in 5854 patients with detailed patient data prior to use of an insulin pump showed higher HbA1c (P andlt; 0.0001), lower creatinine (P = 0.002), high and low insulin doses (P andlt; 0.0001), younger age (P andlt; 0.0001) and female sex (P andlt; 0.0001) to be associated with use of an insulin pump. Women were 1.5-fold more likely to start using an insulin pump (hazard ratio 1.52, 95% confidence interval 1.291.79) and patients in the 20- to 30-years age range were more than twice as likely to begin use of an insulin pump than patients aged 4050 years (hazard ratio 8.63, 95% confidence interval 5.9112.59 and hazard ratio 3.98, 95% confidence interval 2.805.64, respectively). A 10-mu mol/l higher level of creatinine was associated with a hazard ratio of 0.56 (95% confidence interval 0.390.81) of starting use of an insulin pump. Conclusions At 10 hospital outpatient clinics in Sweden, use of insulin pumps therapy varied by clinic. A higher proportion of women began using insulin pumps. Younger patients and patients with fewer complications were also more likely to start using an insulin pump. Further research is needed to confirm these findings in other geographical regions and to understand whether the availability of insulin pumps today is optimized.

Objectives To analyse how comorbidity among patients with back pain, depression and osteoarthritis influences healthcare costs per patient. A special focus was made on the distribution of costs for primary healthcare compared with specialist care, hospital care and drugs.

Design Population-based cross-sectional study.

Setting The County of Östergötland, Sweden.

Patients Data on diagnoses and healthcare costs for all 266 354 individuals between 20 and 75 years of age, who were residents of the County of Östergötland, Sweden, in the year 2006, were extracted from the local healthcare register and the national register of drug prescriptions.

Main outcome measures The effects of comorbidity on healthcare costs were estimated as interactions in regression models that also included age, sex, number of other health conditions and education.

Results The largest diagnosed group was back pain (11 178 patients) followed by depression (7412 patients) and osteoarthritis (5174 patients). The largest comorbidity subgroup was the combination of back pain and depression (772 patients), followed by the combination of back pain and osteoarthritis (527 patients) and the combination of depression and osteoarthritis (206 patients). For patients having both a depression diagnosis and a back pain diagnosis, there was a significant negative interaction effect on total healthcare costs. The average healthcare costs among patients with depression and back pain was SEK 11 806 lower for a patient with both diagnoses. In this comorbidity group, there were tendencies of a positive interaction for general practitioner visits and negative interactions for all other visits and hospital days. Small or no interactions at all were seen between depression diagnoses and osteoarthritis diagnoses.

Conclusions A small increase in primary healthcare visits in comorbid back pain and depression patients was accompanied with a substantial reduction in total healthcare costs and in hospital costs. Our results can be of value in analysing the cost effects of comorbidity and how the coordination of primary and secondary care may have an impact on healthcare costs.

The aim of this study was to investigate if individuals born with sub-optimal birth characteristics have reduced probability of reproducing in adulthood. less thanbrgreater than less thanbrgreater thanUsing population-based registries, the authors included 522 216 males and 494 692 females born between 1973 and 1983 and examined their reproductive status as of 2006. Outcome measure was the hazard ratio (HR) of reproducing. Adjustments were made for socio-economic factors. less thanbrgreater than less thanbrgreater thanMales and females born very premature displayed a reduced probability of reproducing [HR 0.78, 95 confidence interval (CI): 0.700.86 for males; HR 0.81, CI: 0.750.88 for females]. Likewise for very low birthweight (HR 0.83, CI: 0.710.95 for males; HR 0.80, 95 CI: 0.720.89 for females). Individuals born large for gestational age (LGA) displayed no significant changes. Males born small for gestational age (SGA) had a 9 lower reproductive rate (CI: 0.890.94) and that reduction increased as the individuals aged. Women born SGA tended to start reproducing at an earlier age. less thanbrgreater than less thanbrgreater thanThe results suggest that being born with low birthweight, premature or SGA (for males) is associated with a reduced probability of reproducing as an adult. LGA shows no statistically significant relationship with future reproduction.

Aims and objectives.  To explore nursing home staff members’ experiences of what dignity in end of life care means to older people and to themselves.

Background.  Dignity is a concept often used in end-of-life care, but its meaning is rarely clarified.

Design.  Qualitative descriptive study.

Methods.  Content analysis. This study is based on interviews with 21 staff members in four different nursing homes in Sweden.

Findings.  The results show that staff members balanced between providing for the older person’s physical needs while wishing to be able to deliver a ‘deeper’ level of care. The older people’s dignity is presented in the main theme: Feeling trust – Showing respect. The staff members’ dignity is presented in the main theme: Maintaining self-respect – Being shown respect. Threats to dignity are presented in the main theme: conflicts between the ideal and the reality.

Conclusions.  The results reveal that nursing home staff members deal with a moral conflict between what they are able to deliver and what they would like to provide in the care of older people.

Relevance to clinical practice.  To promote older people’s dignity, there is a need to take account of staff members’ work situation. Supervision and continuous education could be one way of achieving this.

This article provides a deeper understanding of how meaning can be created in everyday life at a nursing home. It is based on a primary study concerning dignity involving 12 older people living in two nursing homes in Sweden. A secondary analysis was carried out on data obtained from three of the primary participants interviewed over a period of time (18-24 months), with a total of 12 interviews carried out using an inductive hermeneutic approach. The study reveals that sources of meaning were created by having a sense of: physical capability, cognitive capability, being needed, and belonging. Meaning was created through inner dialogue, communication and relationships with others. A second finding is that the experience of meaning can sometimes be hard to realize. © 2008 SAGE Publications.

Aims. This paper reports a study describing how patients, relatives and healthcare professionals dealt with the variety of problems and responsibilities that occur in discharge planning conferences and especially how they managed to do this given the institutional frame that surrounded the meeting. Background. In Sweden, the aim of a discharge planning conference is to co-ordinate social and healthcare resources as patients are discharged from hospitals. Patients, relatives and hospital staff, along with healthcare professionals responsible for outpatient care, assemble to achieve an individual care plan. One of the explicit principles informing the discharge planning conference is to increase patients' influence on decision-making. However, research points at shortcomings in this respect. Method. A discourse analysis was conducted using transcriptions of eight video-recorded discharge planning conferences. The selected patients were eight older women expected to be discharged from hospital. Other participants were staff nurses, social workers and occasionally relatives, an occupational therapist, district nurse or home care aide. Findings. Participants adopted different roles as persons/patients, relative/next of kin and healthcare professionals/institutional representatives during the discharge planning conference, which they simultaneously struggled to act upon. The findings are presented under the categories 'ss14Clashing roles and perspectives' and 'ss18Facing the institutional frame'. Conclusions. The performance of the discharge planning conference in its present form interferes with a caring perspective that protects patients' integrity and gives prominence to their life worlds. Moreover, it does not satisfy patients' and relatives' right to expect proceedings that enhance their possibility to express their personal wishes in a dignified manner. © 2006 Blackwell Publishing Ltd.

Background. The aim of discharge planning conferences (DPCs) is to co-ordinate resources and to enhance patient involvement in care in connection with relocation from hospital. DPCs can be characterized as institutional conversations, and are often executed as standard procedures, but the scientific basis for the activity is weak. Aims and objectives. The aim of this study was to illuminate and describe the communication at DPCs. Design. A purposeful and consecutive sample of eight DPCs was collected in which the future care of eight women, aged 70 years or more, was discussed. Methods. Transcribed video recordings were analysed in two steps. 'The initial analysis' aimed at describing the structure and content of the communication. This description constituted the basis for an interpretation, leading to 'the focused analysis' aiming at finding evidence for the assumptions made in the interpretation. Results. The result revealed that the participation of patients was very less the DPCs. The decisions had often already been made, and the women were expected to be pleased with the decision, institutional representatives (IRs) frequently justified their actions by referring to bureaucratic praxis. Conclusions. The women were both encouraged and excluded from participation by the IRs. This dichotomy occurred because the IRs, as professionals, struggled to simultaneously realize their caring mission and their obligation to enforce the values and rules of the institution, i.e. efficiency and rationality. Thus, IRs and patients were equally imprisoned within the institutional system. Relevance to clinical research. This result illustrates how conflicting paradigms are imbedded and reproduced by healthcare professionals in their communicative praxis. Awareness of this is a prerequisite for improvements in working procedures congruent with a caring paradigm that support patient participation.

Aim: To examine the effect of hospitalization during adolescence on the likelihood of giving birth.

Methods: 142 998 women born in 1973-75 were followed with the help of the Swedish Medical Birth Register (MBR) and the Swedish Total Population Register (TPR) up until the end of 2000 with respect to their likelihood of giving birth. All analyses were adjusted for parental socio-economic characteristics and factors related to the studied women's own birth.

Results: The likelihood of giving birth between 20 and 27 years of age was positively affected by hospitalization at least once during adolescence according to the Swedish Hospital Discharge Register (HDR); adjusted hazard ratio (HR) = 1.32, 95% confidence interval: 1.29-1.35. Women hospitalized due to genitourinary diseases, respiratory diseases, abdominal problems and abuse of alcohol and drugs were more likely to have given birth during the study period, while hospitalizations according to cerebral palsy and congenital malformations tended to decrease childbearing. Women hospitalized due to psychiatric diseases had an increase likelihood of given birth at 20-24 years but a reduced thereafter.

Conclusion: A majority of the causes of hospitalization during adolescence increased the likelihood of giving birth between ages 20 to 27.

Background: Preterm birth and reduced intrauterine growth appear to be related to morbidity in childhood and later adulthood. We studied whether the risk of all-cause hospitalization in adolescence and early adulthood differed between individuals who were born preterm or small for gestational age (SGA) compared with those bom at term and appropriate for gestational age.

Methods: Using Swedish registries, we followed 304,275 men and women born in 1973-1975 for any hospitalizations occurring in 1987-1996. Preterm birth was defined as <37 weeks of gestation and SGA as babies smaller than 2 standard deviations below the mean weight for gestational length, according to Swedish standards. We created 3 mutually exclusive categories: "preterm" (<37 weeks and not SGA), "SGA" (SGA and not preterm), and "both preterm and SGA." The comparison group was all term births not SGA. Childhood socioeconomic characteristics were accounted for in the analyses.

Results: The overall risk of hospitalization was higher for men and women bom SGA (adjusted odds ratio = 1.16; 95% confidence interval = 1.12-1.21), for those born preterm (1.06; 1.02-1.10), and for those born both preterm and SGA (1.42; 1.26-1.59). In addition to higher risks for previously reported adverse health outcomes, such as neurodevelopment sequelae and congenital anomalies, men and women born SGA or preterm were more likely to be hospitalized due to unspecified symptoms. SGA also appeared to be associated with genitourinary diseases and drug use.

Conclusions: Men and women born SGA or preterm were at higher risk for hospitalization during adolescence and early adulthood, with men and women born SGA more at risk than those bom preterm.

Objective To estimate the intergenerational effects of preterm birth and reduced intrauterine growth.

Design Population-based cohort study.

Settings Mother–first-born offspring pairs recorded in the Swedish Medical Birth Registry.

Population Children born before 2001 to 38 720 women born in 1973–75.

Methods The relationships between the mother's and the child's birth characteristics were estimated using logistic regression analysis. Adjustments were made for smoking habits, body mass index (BMI), and current and childhood socio-economic conditions. Analyses were performed on all mother–offspring pairs and on the pairs for which information on neither of the included background variables was missing (n= 24 520).

Main outcome measures Preterm birth (<37 weeks of gestation) and small for gestational age (SGA) (<−2 SD of the Swedish standard).

Results Mothers who themselves had been born preterm were not significantly more likely to deliver their own children preterm, compared with those who had been born at term (adjusted OR 1.24, 95% CI 0.95–1.62). Also, preterm birth in the mothers did not influence the occurrence of SGA in the children. However, the odds ratio for giving birth to SGA and preterm children, respectively, was higher among SGA mothers (OR 2.68, 95% CI 2.11–3.41 and OR 1.30, 95% CI 1.05–1.61). Mothers whose intrauterine growth was moderately reduced but who did not meet the criterion of being born SGA were also at higher risk of giving birth to both preterm and SGA children, respectively.

Conclusions The present study showed evidence of intergenerational effects of reduced intrauterine growth even when socio-economic factors as well as BMI and smoking were adjusted for. There was, however, no consistent intergenerational effect of preterm birth.

The primary aim of this study was to investigate whether women born prematurely or with impaired fetal growth have a reduced probability of giving birth. Using Swedish population-based registries, the authors identified 148,281 women born in 1973–1975 for follow-up until 2001. Of these women, 4.1% were born preterm and 0.32% very preterm, 0.29% were born with a very low birth weight, and 5.4% were small for gestational age. Outcome measures were the hazard ratios for giving birth during the study period. Adjustments were made for socioeconomic factors. Very-low-birth-weight women displayed a reduced probability of giving birth (hazard ratio = 0.74, 95% confidence interval: 0.60, 0.91), most apparent among women aged 25 or more years. There were also tendencies of reduced hazard ratios of giving birth among women born preterm or very preterm in this age interval. Women born small for gestational age (below –2 standard deviations) seemed to be more likely to have given birth (hazard ratio = 1.09, 95% confidence interval: 1.04, 1.14), but when a more extreme group of small-for-gestational-age women (below –3 standard deviations) was defined, the association was less evident (hazard ratio = 1.04, 95% confidence interval: 0.94, 1.16). The results suggest that very-low-birth-weight women and, possibly, women born preterm or very preterm have a reduced probability of giving birth, while the results regarding small for gestational age are less clear.

This article is an outline of a critically oriented and empirically grounded theory of the weight order, as a complement to theories of more widely recognized and studied ordering systems. We 1) expose the weight orders "absent presence" in humanistic and social science-oriented research treating overweight and fatness as a personal or social problem, 2) outline the contours and characteristics of this specific ordering system, and 3) suggest a set of sensitizing concepts for analysis of this ordering system. Two primary forms of activity, maintaining order and putting in order, are analysed. The first is making thin people into order and overweight people into disorder, and thus maintains order in the weight order. The other, putting in order, covers different activities supposed to make sure that people keep their bodies thin or try to become thin. These ordering activities meet resistance when overweight people stop dieting and/or define overweight as a personal choice and themselves as good enough, or even healthy and beautiful. We call these forms of resistance alternative weight-doings.

The purpose of this thesis is to develop a conceptual and theorizing understanding of circumstances and possibilities in fat people’s lives. Starting in interviews with fifteen fat Swedes, this research finally ended up as an articulation of processes and sub-processes within the weight order. The weight order is a system that orders all of us horizontally as underweight, normal weight or overweight. It also orders us vertically as super- or subordered depending on which weight category we belong to. This means that some are favoured while others are unfairly treated. The fact that fat people in Western cultures tend to be sub-ordered, oppressed and unfairly treated because of their body sizes and weights has already been shown in previous research, and this study does not treat that issue to any great extent. Instead it focuses on the ordering system that is evident in fat people’s statements and in previous research about fatness and overweight within the humanities and social sciences. By theorizing around weight order I wish to broaden the understanding of how subordination, oppression and unfair treatment of fat people are possible. The weight order is not a system for subordination of fat people. Those who dominate are also in some sense dominated. Subordination is rather an effect driven by the weight-ordered system.

The weight order is a more inclusive conception than has been presented in this study. The theoretical treaties examine four processes, sub-processes and elements within the weight order. These include weight-ordering conditions, weightification, subsuming weightdoing, and downplaying weightification. Weight-ordering conditions deal with cultural and social circumstances that make the weight order possible. These conditions are processes that no one can fully escape. In the other processes it is only fat people’s positions and roles within the weight order that is in focus. Weightification consists of the processes that make body weight important in people’s lives. In this work weightification highlights different forms that make fat people experience and understand their overweight as negatively important in their lives. Subsuming weight-doings deals with social and cultural means that are intended to make fat people thin (-er). These also tend to make the  body weight negative for fat people. The three first processes treat the first part of the aim, fat people’s conditions. The second part of the aim, possibilities, is dealt with in the fourth and last process, downplaying weightification. Downplaying weightification can simply be described as including the opposite forces to weightification, and deals with how fat people can make their overweight less important.

Objective: The nucleoporin Nup88 is overexpressed in a series of human malignancies, however, its clinicopathological significance has not been studied. Our aims were to analyze Nup88 expression in normal mucosa, primary tumors and metastases from colorectal cancer patients and further to identify relationships of Nup88 expression with clinicopathological and other factors.

Materials and Methods: Using immunohistochemistry, we investigated Nup88 expression in 198 primary colorectal tumors, 96 normal mucosa samples and 35 lymph node metastases.

Results: The results showed that the intensity of Nup88 expression increased from the normal mucosa to the primary tumors (p < 0.0001) and tended to increase from the primary tumors to the metastases (p = 0.15). Both primary tumors and metastases presented stronger expression in the invasive margin and vascular-invaded areas. Nup88 expression was positively related to distal tumor location (p = 0.01), infiltrative growth pattern (p = 0.04) and higher proliferative activity (p = 0.04) and reversely to the grade of differentiation (p = 0.02) and apoptosis (p = 0.049). Strong expression of Nup88 predicted a worse outcome in the patients with distal tumors during the follow-up period of up to 3 years (p = 0.02).

Conclusions: It seems that overexpression of Nup88 was involved in the tumorigenesis and aggressiveness of colorectal cancers, and Nup88 may be used as a prognostic factor in patients with distal tumors.

The problem of vesico-vagina fistula still remains a ravaging scourge in resource-poor countries of which Nigeria is visibly prominent. A majority of the cases are attributed to prolonged complicated labour due to inaccessibility of adequate and immediate obstetric health care. Complicated labour arises as a result of narrow pelvis bones of victims due to suffering from poor nutrition. While the above factors are noted as the direct cause to the prevalent of VVF, there are other socio-cultural conditions which predispose victims to this disease. Notable among them are the following: poverty; marital age; illiteracy; hazardous traditional practices, such as female circumcision. VVF victims often live an unworthy life. Many of them have been abandoned or divorced by their husbands and become ostracised by families and societies because of their repulsive smell and inability to engage in sexual activity and bear children. VVF victims suffer both physical and social consequences, many of them find it difficult to engage in any economic activity, surviving the hardship is very complicated and pathetic; some victims turn to street begging, while others survive through hawking of “bagged” water and selling firewood.

Most studies conducted on the problem of Vesico vaginal fistula are done from the medical perspectives, often neglecting the psycho-social consequences faced by the sufferers. This study, however, discusses the socio-cultural and the psychological consequences of the disease. Locally and internationally, attempts are being made to eradicate the problem of VVF, however, if the Nigerian government does not recognise the incidence of VVF as a major public health issue, it will continue to ravage lives of Nigerian women, hence increasing maternal mortality in the country. This study proffers recommendations to help eradicate or alleviate the problem in Nigeria.

Introduction

Akt is a signalling modulator for many cellular processes, including metabolism, cell proliferation, cell survival and cell growth. Three isoforms of Akt have been identified, but only a few studies have concerned the isoform-specific roles in the prognosis of breast cancer patients. The aim of this study was to investigate the prognostic value of v-akt murine thymoma viral oncogene homologue 1 (Akt1) and v-akt murine thymoma viral oncogene homologue 2 (Akt2) in oestrogen receptor positive (ER+) and oestrogen receptor negative (ER–) breast cancer with long-term follow-up.

Material and methods

The expression of Akt in tumour tissue was analysed with immunohistochemistry in a cohort of 272 postmenopausal patients with stage II breast cancer. The median follow-up time was 19 years. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using the Cox’s proportional hazards model.

Results

The risk of distant recurrence was reduced for patients with ER+ tumours expressing Akt2 compared to patients with no Akt2 expression (HR = 0.49, 95% CI 0.29–0.82, p = 0.007). When adjusting for important clinical tumour characteristics and treatment, Akt2 was still an independent prognostic factor (HR = 0.38, 95% CI 0.21–0.68, p = 0.001) and the association remained long-term. The prognostic value of Akt2 increased with higher oestrogen receptor levels from no effect among patients with ER– tumours to 68% risk reduction for the group with high ER-levels (P for trend = 0.042). Akt1 showed no significant prognostic information.

Conclusion

Our results indicate that Akt2 expression is associated with a lower distant recurrence rate for patients with ER+ tumours and that this association remains long-term. The prognostic value of Akt2 increases with higher oestrogen receptor expression, motivating further mechanistic studies on the role of Akt2 in ER+ breast cancer.

Pain research is still dominated by biomedical perspectives and the need to articulate pain in ways other than those offered by evidence based medical models is pressing. Examining closely subjective experiences of pain, this book explores the way in which pain is situated, communicated and formed in a larger cultural and social context.

Dimensions of Pain

explores the lived experience of pain, and questions of identity and pain, from a range of different disciplinary perspectives within the humanities and social sciences. Discussing the acuity and temporality of pain, its isolating impact, the embodied expression of pain, pain and sexuality, gender and ethnicity, it also includes a cluster of three chapters discusses the phenomenon and experience of labour pains.

This volume revitalizes the study of pain, offering productive ways of carefully thinking through its different aspects and exploring the positive and enriching side of world-forming pain as well as its limiting aspects. It will be of interest to academics and students interested in pain from a range of backgrounds, including philosophy, sociology, nursing, midwifery, medicine and gender studies.

Eros manifests itself in multiple ways: as tragic eros and philosophical eros, as love, sexuality, seduction, care, desire, and friendship. Eros both defines us as beings and dislocates our existence. It breaks down our certitudes about selfhood and otherness, familiarity and strangeness. This volume gathers together contributions toward a phenomenological understanding of eros. The first part examines eros in relation to ancient philosophy and religion, the second part examines eros in relation to modern phenomenology. The analyses presented show how the question of eros brings us to the core of philosophy. Questions of time, desire, embodiment, intersubjectivity, and perception are all implicated in the phenomenology of eros.

There is perhaps no experience that better brings to light to us the singularity and solitude of our lives than the experience of pain. Hannah Arendt, for instance, describes the experience of great bodily pain as being “the most private and least communicable of all,” isolating us from others who have no access to the privacy of our experience (1958: 50). When we are in overwhelming and allconsuming pain, we are urgently and immediately present to ourselves without words, images or metaphors to shield us or to connect us in recognizable ways to our surrounding world and to others. There are, as Virginia Woolf writes so fittingly, “no words for the shiver and the headache […] let a sufferer try to describe a pain in his head to a doctor and language at once runs dry” (2002: 7). Elaine Scarry goes further and famously argues that pain does not simply resist language but has the power of destroying language. The experience of acute pain, writes Scarry, transports us back to “a state anterior to language, to the sounds and cries a human being makes before language is learned” (1985: 4). One of the reasons for this resistance to language is that pain is not intentionally directed towards any object in the world and a body in pain is wholly selfreferential. Pain does not relate to anything external and transcendent to it and it is fundamentally not about anything except itself. Even though it is urgently and indubitably present as perhaps the most tangible of experiences, its lack of intentionality at the same time makes pain amorphous and elusive, constituting it as unsharable in essential ways. In the following I partly want to challenge the idea that pain is unsharable. Without denying the privacy of the experience of pain and its often devastating force of isolation, I want to draw attention also to the ways in which pain is sharable and binds us to one another. The sense of sharing I want to bring to light is not one starting out from individual entities such as human bodies but, rather, one that constitutes individual beings and the singularity of their experience. I take seriously the insight that the body in pain is wholly self-referential and turn to the notion of intercorporeality in order to bring out the relationality of embodiment and thereby provide a more comprehensive view of how to understand the self-referentiality of the body in pain. I suggest that the experience of pain brings to light the relationality of embodied subjectivity and the corporeal character of this relationality. It makes manifest embodiment as primarily intercorporeal and the force of isolation as destructively altering the intercorporeal attachments of our bodies, depriving them of the dynamic structure essential to their being and at the same time making these attachments urgently present precisely as damaged and absent.

Purpose. The aim of this study was to get a deeper understanding into how adults with cerebral palsy (CP) experience physiotherapy and physical activity in a perspective from childhood to adulthood; and how personal and environmental factors influence possibilities for physiotherapy and physical activity. Method. Data was collected through interviews with 22 community-living adults (35-68 years) with CP, from five counties in Sweden. The questions were open-ended and the interviews were taped and transcribed to written language. The material was analysed through qualitative content analysis, a classification process resulting in different themes. Results. The narratives from the 22 informants, based on experiences from childhood to adulthood, resulted in a description of prerequisites for carrying out physiotherapy and physical activity. Five different themes were identified: (i) Being enjoyable, (ii) Giving effects, (iii) Being comprehensible, (iv) Being integrated in daily life, and (v) Supportive healthcare with competent professionals. Conclusion. The information from the interviews elucidates the importance of a lifelong support from healthcare professionals. Physiotherapists with attentiveness to different life situations in combination with good understanding and knowledge in CP could facilitate continuous physical activity in people growing up and ageing with CP.

Background: Psychosocial strain has been demonstrated to be a risk factor for coronary artery disease (CAD) and also to be associated with a dysfunctional HPA-axis. Based on a proposal on cortisol resistance in maladaptive monocytes as a potential mechanism linking psychosocial strain with CAD, this study aimed at testing the association between levels of salivary cortisol and matrix metalloproteinase-9 (MMP-9) in a normal population.

Methods: 359 participants (50 % women) aged 45-69 were enrolled to this study, randomly drawn from a normal population in Sweden. Saliva samples were collected thrice per day (at awakening, 30 minutes after awakening, and just before going to bed) during three consecutive days. Cortisol levels at awakening and 30 minutes after awakening were used to estimate the diurnal peak. Cortisol was analyzed using a radioimmunoassay method. MMP-9 was measured in plasma using an ELISA-method.

Results: After adjustment for age and sex, significant trends regarding MMP-9 were found both for cortisol peak quintiles (beta +1.9 ng/mL per quintile, p=0.029) and cortisol evening values (beta +2.1 ng/ml per quintile, p=0.017). These findings were consistent in regressions either excluding participants with known diagnoses of myocardial infarction, angina pectoris, rheumatoid arthritis, diabetes, cancer with ongoing treatment, chronic obstructive lung disease, osteoporosis and hypothyroidism, or adjusting for these diseases, also after adjustment for cardiovascular risk factors.

Conclusions: The associations found between cortisol levels and MMP-9 in a normal population hint at a potential pathway linking prolonged psychosocial strain with cardiovascular events.

Objective: When cortisol measurements are to be studied in large populations, cost-effective analyses are needed. This study aimed at testing whether one pooled cortisol value over three consecutive days is as reliable as using the arithmetic mean of the samples from the same measure points.

Material and methods: Thirty participants aged between 45 and 69 collected saliva in salivettes immediately after awakening (t₁), 30 min after awakening (t₂) and in the evening (t₃) during 3 consecutive days. A fixed volume from each of the samples (t₁, t₂ and t₃) was pooled prior to laboratory analysis. Mean levels over 3 days for t₁, t₂ and t₃ were compared to corresponding levels of pooled vials. Cortisol levels were analysed using a radio immunoassay.

Results: All measures tested had high correlations between mean values and pooled samples, exemplified with diurnal deviation rdif t_2–t350.974 (CI 0.946;0.987), and awakening response r_dif t_2–t150.982 (CI 0.963;0.991). There were no statistical differences between the pooled values and the arithmetic means.

Conclusion: Pooling samples gave as reliable results as arithmetic means did. Pooling samples prior to laboratory analysis is a cost-effective method for measuring general diurnal cortisol variation in field research projects.

Background: Elevated levels of circulating matrix metalloproteinase-9 (MMP-9) have been demonstrated in patients with established coronary artery disease (CAD). The aim of this study was to analyse levels of MMP-9 in a population free from symptomatic CAD and investigate their associations with cardiovascular (CV) risk factors, including C-reactive protein (CRP).

Methods: A cross-sectional study was performed in a population based random sample aged 45–69 (n = 345, 50% women). MMP-9 levels were measured in EDTA-plasma using an ELISA-method. CV risk factors were measured using questionnaires and standard laboratory methods.

Results: Plasma MMP-9 was detectable in all participants, mean 38.9 ng/mL (SD 22.1 ng/mL). Among individuals without reported symptomatic CAD a positive association (p<0.001) was seen, for both men and women, of MMP-9 levels regarding total risk load of eight CV risk factors i.e. blood pressure, dyslipidemia, diabetes, obesity, smoking, alcohol intake, physical activity and fruit and vegetable intake. The association was significant also after adjustment for CRP, and was not driven by a single risk factor alone. In regression models adjusted for age, sex, smoking, alcohol intake and CRP, elevated MMP-9 levels were independently positively associated with systolic blood pressure (p = 0.037), smoking (p<0.001), alcohol intake (p = 0.003) and CRP (p<0.001). The correlation coefficient between MMP-9 and CRP was r = 0.24 (p<0.001).

Conclusions: In a population without reported symptomatic CAD, MMP-9 levels were associated with total CV risk load as well as with single risk factors. This was found also after adjustment for CRP

Objective: To test the association between psychosocial factors and circulating levels of matrix metalloproteinase-9 (MMP-9) in a normal population sample. Psychosocial factors have been associated with inflammatory markers and are of prognostic significance for coronary artery disease (CAD). The degrading enzyme MMP-9 is upregulated in inflammatory processes and hypothesized to play a role in the rupture of atherosclerotic plaques. Methods: A total of 402 participants (50% women), aged 45 to 69 years, were drawn randomly from a normal population. Psychosocial instruments covered depression (Center for Epidemiological Studies Depression Questionnaire, CES-D), vital exhaustion, hostile affect, cynicism, mastery, self-esteem, sense of coherence (SOC), emotional support, and social integration. Plasma MMP-9 was measured by an enzyme-linked immunosorbent assay method. Linear regression models were adjusted for age, sex, known CAD, rheumatoid arthritis, cancer, cardiovascular risk factors including C-reactive protein and ongoing medication. Results: After full adjustment, there were independent associations of elevated MMP-9 levels with CES-D (+2.9 ng/ml per SD, p=.02), hostile affect (+3.0 ng/ml per SD, p=.02), cynicism (+3.5 ng/ml per SD, p=.006), and SOC (-2.5 ng/ml per SD, p=.046). A principal component analysis extracted three components. The first was mainly extracted from CES-D, vital exhaustion, self-esteem, mastery, and SOC; the second was mainly extracted from hostile affect and cynicism. Both were independently associated with MMP-9 (p=.02, p=.04) when run in the same model. Conclusions: MMP-9 levels were associated with psychosocial factors in a middle-aged normal population sample, independently of traditional risk factors. The findings may constitute a possible link between psychosocial factors and cardiovascular risk.

Rationale, aims and objectives: The aim of this article is to argue for the necessity of emotional professional virtues in the understanding of good clinical practice. This understanding is required for a proper balance of capacities in medical education and further education of physicians. For this reason, an ideal physician, incarnating the required virtues, skills and knowledge, is compared with a non-emotional robot that is bound to moral rules. This fictive confrontation is meant to clarify why certain demands on the personality of the physician are justified, in addition to a rule- and principle-based moral orientation and biomedical knowledge and skills.

Methods: Philosophical analysis of thought experiments inspired by science fiction literature by Isaac Asimov.

Results: Though prima facie a rule-oriented robot seems more reliable and trustworthy, the complexity of clinical judgment is not met by an encompassing and never contradictory set of rules from which one could logically derive decisions. There are different ways in which the robot could still work, but at the cost of the predictability of its behaviour and its moral orientation. In comparison, a virtuous human doctor who is also bound to these rules, though less strictly, will more reliably keep to moral objectives, be understandable, be more flexible in case the rules come to their limits and will be more predictable in these critical situations. Apart from these advantages of the virtuous human doctor referring to his own person, the most problematic deficit of the robot is its lacking deeper understanding of the inner mental events of patients which makes good contact, good communication and good influence impossible.

Conclusion: Though an infallibly rule-oriented robot seems more reliable at first view, in situations that require complex decisions such as clinical practice, the agency of a moral human person is more trustworthy. Since this is a crucial precondition for good clinical practice, sufficient attention should be given to develop these virtues in addition to the usual attention on knowledge, skills and adherence to moral rules and principles.

This contribution analyzes four versions of the traditional analogy between a human being and a machine: medieval Christian ideas of creation, Descartes, La Mettrie, as well as mechanistic and deterministic ideas used in human genetics. The analysis takes into account the intended depth of the analogy (comparison, metaphor, model, theory, or ontology) as well as the varying concepts of a „machine”.

Rationale, aims and objectives The aim of this article is to argue for the necessity of emotional professional virtues in the understanding of good clinical practice. This understanding is required for a proper balance of capacities in medical education and further education of physicians. For this reason an ideal physician, incarnating the required virtues, skills and knowledge is compared with a non-emotional robot that is bound to moral rules. This fictive confrontation is meant to clarify why certain demands on the personality of the physician are justified, in addition to a rule-and principle-based moral orientation and biomedical knowledge and skills. less thanbrgreater than less thanbrgreater thanMethods Philosophical analysis of thought experiments inspired by science fiction literature by Isaac Asimov. less thanbrgreater than less thanbrgreater thanResults Although prima facie a rule-oriented robot seems more reliable and trustworthy, the complexity of clinical judgment is not met by an encompassing and never contradictory set of rules from which one could logically derive decisions. There are different ways how the robot could still work, but at the cost of the predictability of its behaviour and its moral orientation. In comparison, a virtuous human doctor who is also bound to these rules, although less strictly, will more reliably keep at moral objectives, be understandable, be more flexible in case the rules come to their limits, and will be more predictable in these critical situations. Apart from these advantages of the virtuous human doctor referring to her own person, the most problematic deficit of the robot is its lacking deeper understanding of the inner mental events of patients which makes good contact, good communication and good influence impossible. Conclusion Although an infallibly rule-oriented robot seems more reliable at first view, in situations that require complex decisions like clinical practice the agency of a moral human person is more trustworthy. Furthermore, the understanding of the patients emotions must remain insufficient for a non-emotional, non-human being. Because these are crucial preconditions for good clinical practice, enough attention should be given to develop these virtues and emotional skills, in addition to the usual attention on knowledge, technical skills and the obedience to moral rules and principles.

In professional medical ethics, the physician traditionally is obliged to fulfil specific duties as well as to embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired underlying attitude of physicians. In this article, one of them—empathy—is presented in an interpretation that is meant to depicture (together with the two additional concepts compassion and care) this attitude. Therefore empathy in the clinical context is defined as the adequate understanding of the inner processes of the patient concerning his health-related problems. Adequacy is scrutinized on behalf of the emotional and subjective involvement of he physician, and on the necessary dependence on medical—moral—goals. In the present interpretation, empathy alone is no guarantee of the right moral attitude, but a necessary instrumental skill in order to perceive and treat a patient as an individual person. The concepts of compassion and care that will be discussed in two forthcoming articles are necessary parts to describe the desired moral attitude of the physician more completely.