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Dialogue Therapy and Standard Psychiatric Treatment in Psychosis Psychological Aspects, Treatment and Outcome
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Patient participation, family involvement, and compassionate care in palliative cancer care: Health personnel and family caregiver`s experiences
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Hensikta med denne avhandlinga var å utvikle kunnskap om pasientmedverknad, familieinvolvering og “compassionate care” i dei ulike fasane av det palliative forløpet sett frå perspektiva til pårørande og helsepersonell. Verdens Helseorganisasjon anslår at omlag 40 millionar menneske har behov for palliativ behandling kvart år. Dette talet på pasientar som har behov for palliativ behandling vil auke, og der er politiske føringar for meir heimetid og for død i heimen. Det vil føre til at pårørande kan får ekstra stor omsorgsbyrde. Pasientmedverknad, familieinvolvering og «compassionate care» er viktig i det palliative forløpet.
Ulike teoretiske perspektiv vart valt i studiane: pasientmedverknad/-involvering, «compassionate care» og dei fire prinsippa for biomedisinsk etikk. Etymologisk har dei ulike begrepa ulike røter, men også fellestrekk. Forskningsspørsmåla og dei teoretiske perspektiva vart tilpassa de ulike gruppene som er studerte. Den første studien såg på pårørande si erfaring med informasjon og involvering. Den andre studien såg på sjukepleiarar si erfaring med «compassionate care» for pasientar og pårørande. Den tredje studien undersøkte legars perspektiv på pasientmedverknad og pårørandeinnvolvering.
I dette forskingsprosjektet har vi brukt ulike kvalitative tilnærmingar som vi såg som relevante utifrå forskingsspørsmåla og hensikta med studiane. I studie I hadde vi ei narrativ tilnærming, og i studie II og III ei hermeneutisk tilnærming. Deltakarane var frå både urbane og rurale strok i Norge, og hadde erfaring i frå dei ulike fasane av det palliative forløpet. Det vart gjennomført 11 individuelle intervju med dei pårørande, 13 intervju med legar og fire fokusgrupper med sjukepleiarar. Funna frå dei tre primærstudiane vart syntetisert til tre nye temaa i avhandlinga.
Tidleg involvering og profesjonelle beslutningar. Sjukepleiarane framheva betydinga av tidleg dialog mellom pasientar, pårørande og helsepersonell og meinte at tidleg involvering auka vilkåra for å kunne yte omsorgsfull behandling seinare i forløpet. Tverrfagleg samarbeid mellom spesialisthelsetenesta og primærhelsetenesta vart sett på som viktig for å betre omsorga. Pårørande gav uttrykk for at sjølv om dei var godt informert om pasienten si diagnose, opplevde dei lite involvering i prosessen med å definere problema og utfordringar knytt til behandlinga av pasienten. Dei ønska meir informasjon om korleis sjukdommen kunne utvikle seg, og kva dei kunne forvente ville oppstå i dei ulike fasane av forløpet. Legane beskreiv den tidlege fasa som krevjande for pasientar og pårørande. Dei gav uttrykk for at behandlingsval i denne fasa ofte vart gjort av legane fordi pasienten og pårørande var i en sårbar situasjon. Legane var opptekne av å gjere det dei trudde ville være til det beste for pasienten og pårørande.
Pasientsentrert omsorg og manglande anerkjenning av pårørande. Midtfasa var prega av pasientsentrert omsorg og samval. Helsepersonell ønskte å vere i forkant av utfordringar som kunne kome og gi pasientar og pårørande tryggleik og avklaringar. Det vart sett på som viktig å være merksam på pasientane og pårørande sine psykiske og fysiske behov. Å skape eit rom for å døy vart også framheva. Pårørande opplevde denne fasa som pasientsentrert, men dei opplevde samtidig at denne fasa kunne vere svært stressande der dei tok på seg ei omsorgsrolle som gjorde det vanskeleg å ivareta rolla som pårørande. Dei ga uttrykk for at deira eigne behov som pårørande ofte vart neglisjert. Sjukepleiarane og legane fortalte at å balansere mellom konfliktar hos pasientar og pårørande kunne vere ei utfordring i denne fasa.
Pårørande si involvering i omsorg og aksept av døden. Pårørande omtala denne fasa som utfordrande då dei fleste av dei ikkje hadde opplevd død tidlegare, og dei kjende seg usikre på kva som ville skje. Dei fekk lite informasjon om dødsprosessen, og nokre pårørande
kjende seg åleine med ansvaret og byrda. Sjukepleiarane og legane framheva betydinga av å gi informasjon både til pasientar og pårørande. Pårørande erfarte at dei var sterkt involverte i denne fasa, og dei var ofte slitne; det å få informasjon om behandling var avgjerande for å kunne forstå og meistre situasjonen. Legane erfarte at pårørande som kjende seg involvert i det palliative forløpet, kjende seg tryggare og kunne få ein mildare sorgprosess. Pårørande, sjukepleiarar og legar beskreiv etterlattesamtale som viktige, spesielt i tilfelle med krevjande dødsprosessar.
Denne avhandlinga gir ny kunnskap om pasientmedverknad, familieinvolvering og «compassionate care» for pasientar og pårørande i dei ulike fasane av det palliative forløpet. Et viktig funn er at pårørande opplever manglande involvering gjennom heile forløpet. Dei opplever å ikkje verte sett på som en del av det palliative behandlingsteamet. Avhandlinga reiser også nye spørsmål: Korleis påverkar fokuset på pasientsentrert omsorg pårørande? Å overføre ansvar i palliasjon til pårørande krev forsking som belyser pårørande sin situasjon.Summary
The overall aim of this thesis was to obtain knowledge about patient participation, family involvement, and compassionate care as experienced by family caregivers and health personnel in the different phases of the palliative cancer care pathway. According to the World Health Organization it is estimated that approximately 40 million people need palliative care each year. The number of patients needing palliative care will increase, and the political documents call for more patients to remain at home and die at home. More time at home and home death will mean family caregivers will experience additional burdens linked to caring for patients. Patient participation, family involvement, and Compassionate care is crucial in the palliative pathway.
Various theoretical frameworks were chosen in the studies: patient participation/ involvement, compassionate care, and the four principles of biomedical ethics. Etymologically the various concepts have different roots, but they still have common features. The research questions and theories were adapted to the different groups of participants under study. The first study explored how family caregivers experience information and involvement. The second study explored nurses’ experiences of compassionate care for patients and family caregivers. The third study explored physicians’ perspectives of patients’ participation and family caregivers’ involvement.
In this research project, we have used different qualitative approaches appropriate for the research questions and aims of the studies. In Study I, we adopted a narrative approach, and in Studies II and III a hermeneutic approach. We employed purposive sampling, and participants with experience from various phases of the palliative pathway were chosen. Eleven family caregivers and thirty-four health personnel from rural and urban areas in Norway participated. Individual interviews with family caregivers and physicians, and four focus groups with nurses were conducted. The findings from the three primary studies were synthesised into three new themes in the thesis.
Early involvement and professional decisions. The nurses highlighted the importance of early dialogue between patients, family caregivers, and healthcare personnel, and felt that early involvement increased their ability to provide compassionate care. Interdisciplinary collaboration between specialist healthcare services and primary healthcare was considered important to improve compassionate care. Family caregivers expressed that although they were well informed about the patient’s diagnosis, they experienced low involvement in defining problems and challenges regarding the care of the patient. They wanted more information about how the disease would develop and what to expect in the different phases of the pathway. The physicians described the early phase as demanding for patients and family caregivers. They expressed that treatment choices in this phase were often made by the physicians because the patient and family caregivers were in a vulnerable situation. The physicians were concerned with doing what they thought would benefit the patient and family caregivers.
Patient-centred care and lack of acknowledgement of family caregivers. The middle phase was characterised by patient-centred care and shared decision-making, and patients and family caregivers were provided with security, predictability, and clarification. It was seen as important to be aware of patients’ and family caregivers’ mental and physical needs. Creating a space for dying was also highlighted. Family caregivers experienced this phase as patientcentred, but they also found it to be a very stressful phase in which they took on a caregiving role rather than a role as a family member. They expressed that their own needs as family caregivers were often neglected. Nurses and physicians sometimes described balancing conflicts among patients and family caregivers as challenging in this phase.
Family caregivers' involvement in care and acceptance of death. Family caregivers described this phase as challenging as most of them had not experienced death before, and they felt insecure about what would happen. They received little information about the death process, and some family caregivers felt alone with the responsibility and burden. Nurses and physicians highlighted the importance of providing information both to patients and family caregivers. Family caregivers were strongly involved in this phase, and they were often tired; receiving information about treatment was essential for them in coping and understanding what had been decided. The physicians expected that family caregivers who were involved in the palliative process would endure a softer grieving process and feel more secure. The family caregivers, nurses, and physicians all described bereavement conversations as important, especially in cases with demanding death processes.
This thesis provides new knowledge of patient participation, family involvement, and compassionate care for patients and family caregivers in various phases of the palliative pathway. An important finding is that family caregivers experience a lack of involvement throughout the process. They do not experience to be seen as part of the palliative care around the patient. The thesis also raises new questions: How does the focus on patientcentred care affect family caregivers? Transferring responsibility in palliative care to family caregivers requires research that sheds better light on family caregivers' situation.Digital fulltext is not availabl
Perceptions of patient participation in the myocardial infarction pathway among patients and healthcare professionals
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Bakgrunn
Akutt hjerteinfarkt er en av de vanligste og alvorligste sykdommene globalt. Sykdommen har ofte en akutt debut, men er forårsaket av kronisk underliggende aterosklerose som medfører forkalkninger og innsnevringer i hjertets kransårer. Behandlingen består derfor av både akutt livreddende behandling, etterfulgt av langsiktig behandling av den underliggende årsaken for å hindre videreutvikling av aterosklerose og tilbakefall. Hjerteinfarkt er en skremmende og livstruende situasjon for pasientene som rammes og deres pårørende. Pasientmedvirkning er utfordrende i akuttsituasjoner, likevel trenger pasienten tydelig informasjon om sykdommen og behandlingsforløpet.
Tidligere forskning har vist at pasienter og helsepersonell kan ha ulike oppfatninger av helsetjenestene og pasientmedvirkning. Derfor er det viktig å studere helsetjenestene fra ulike perspektiv for å kunne møte pasientenes behov for medvirkning i ulike faser av pasientforløpet. Forskning har funnet at pasientmedvirkning fører til bedre pasienttilfredshet, økt samarbeid med helsepersonell og bedre mestring av sykdom. Hensikten med denne avhandlingen er å studere pasientmedvirkning i ulike faser av hjerteinfarktforløpet fra et pasient-, sykepleie- og legeperspektivet. Avhandlingen er en syntese av tre vitenskapelige artikler.
Metode
Avhandlingen har et kvalitativt design. En kvalitativ tilnærming er verdifull når en ønsker å få en helhetlig forståelse av fenomenet en studerer. Artikkel I omhandler hvordan pasienter erfarte å medvirke i pasientforløpet ved hjerteinfarkt. En narrativ tilnærming ble valgt. Individuelle intervju ble gjennomført med ti pasienter to til fem måneder etter sykehusinnleggelsen. Datainnsamling ble foretatt på to sykehus uten koronar angiografi i januar og februar 2016. Artikkel II og III belyser sykepleiere og leger sine oppfatninger av pasientmedvirkning i hjerteinfarktforløpet. I artikkel II ble det gjennomført 5 fokusgrupper med 22 sykepleiere som arbeidet i ulike faser av hjerteinfarktforløpet. I artikkel III ble ni erfarne leger individuelt intervjuet. Datainnsamling til artikkel II og III ble gjennomført fra februar til november i 2018 på to sykehus, ett med koronar angiografi og ett uten. En hermeneutisk tilnærming ble valgt.
Funn
Pasientene, sykepleierne og legene erfarte at graden av pasientmedvirkning varierte i pasientforløpet og at de ulike fasene gav ulike behov og muligheter for pasientmedvirkning.
I akuttfasen vurderte sykepleierne og legene at pasientmedvirkning var vanskelig å oppnå, og de prioriterte å diagnostisere og initiere riktig behandlingen innenfor behandlingstidsfristene. Pasientenes fortellinger løftet frem betydningen av tydelig informasjon i akuttfasen.
Under behandlingen med perkutan koronar intervensjon fikk pasienten individuelt tilpasset informasjon. Ved slutten av behandlingen fikk de oppsummerende informasjon om diagnose og hvilken behandling de hadde fått.
Pasienter, sykepleiere og leger erfarte at mangel på kontinuitet og koordinering hindret pasientmedvirkning under sykehusoppholdet og frem til utskrivelse. Legene og sykepleierne etterlyste sjekklister for pasientinformasjon. Pasientene erfarte mangel på informasjon om livsstilsendringer, medisiner og rehabilitering. Sykepleierne og legene erfarte at systemet begrenset mulighetene deres for å tilrettelegge for pasientmedvirkning. Måten arbeidet deres var organisert på, gav begrensede muligheter for kontinuitet i behandling og pleie. I tillegg manglet sykehusene rom hvor private samtaler mellom pasient og helsepersonell kunne foregå.
Sykepleierne og legene anbefalte pasientene å delta i hjerterehabiliteringsprogram etter utskrivelse. De fortalte at pasientmedvirkning var en viktig forutsetning for å oppnå livsstilsendringer og medikamentell etterlevelse. Pasientenes fortellinger understøttet betydningen av pasientmedvirkning og samvalg i hjerterehabiliteringsprogrammene.
Konklusjon
Denne avhandlingen har gitt innsikt i pasientmedvirkning i ulike faser i pasientforløpet ved hjerteinfarkt fra et pasient- og helsepersonellperspektiv. Pasientmedvirkning er kontekstuelt, og de ulike fasene i pasientforløpet gav ulike muligheter og utfordringer for pasientmedvirkning.
Pasientene og helsepersonellet synes å ha en felles forståelse av at pasientmedvirkning er vanskelig å oppnå i akuttfasen av et hjerteinfarkt. Helsepersonell må være spesielt oppmerksomme på pasientenes behov for tydelig informasjon i denne fasen.
Pasienter, sykepleiere og leger opplevde at mangel på kontinuitet og koordinering hindret pasientmedvirkning under sykehusoppholdet. Funnene i denne avhandlingen viser at det er nødvendig med en omstrukturering av hjerteinfarktforløpet. Standardiserte sjekklister for pasientinformasjon kan sikre at alle pasienter får en viss mengde med informasjon om sykdommen, behandlingen og sekundær forebygging som kan øke pasientens helsekompetanse. Det er behov for å styrke samarbeidet mellom helsepersonell og mellom sykehusene i pasientforløpet for å øke kontinuiteten og bedre koordinering av pasientforløpet.
Denne avhandlingen fremhever den viktige rollen til hjerterehabiliteringsprogrammene i hjerteinfarktforløpet. Pasientene, sykepleierne og legene understreket at pasientmedvirkning og samvalg var et sentralt fokus i hjerterehabiliteringsprogrammene for å øke pasientens muligheter til å oppnå sekundærprofylaktiske behandlingsmål.SUMMARY
Background
Acute myocardial infarction is one of the most common serious illnesses; its acute onset is caused by an underlying cardiovascular disease. Life-saving treatment is implemented in the acute phase, followed by long-term treatment to prevent its recurrence. Myocardial infarction is a frightening and life-threatening condition for affected patients and their relatives. Patient participation is challenging in acute situations; however, patients need clear information about the disease and the clinical pathway.
Previous research has shown that patients and healthcare professionals have different perceptions of healthcare services and patient participation. Therefore, it is important to examine healthcare services from different perspectives to meet the patients’ demands for participation in the different phases of the pathway. Studies have found that patient participation leads to improved patient satisfaction, co-operation with healthcare professionals, and enhanced management of the disease. Thus, this thesis aims to explore patient participation in the different phases of the myocardial infarction pathway from the perspectives of patients, nurses, and physicians. It is a synthesis of three scientific papers.
Methods
This thesis has a qualitative design that is valuable for gaining a complex and detailed understanding of the phenomenon under investigation. Paper I explored how patients experienced their participation in the myocardial infarction pathway. A narrative approach was applied. Individual interviews were conducted with ten patients two to five months after their hospital admission. The data were collected from two hospitals without percutaneous coronary intervention facilities in January and February 2016.
Papers II and III explored nurses’ and physicians’ perceptions of patient participation in the myocardial infarction pathway. In the former, 5 focus groups were conducted with 22 nurses working in different phases of the myocardial infarction pathway. In Paper III, nine experienced physicians were interviewed individually. The data collection for Papers II and III was carried out from February to November 2018 at two hospitals, one with percutaneous coronary intervention facilities and one without them. A hermeneutic approach was used in these studies.
Findings
The patients, nurses, and physicians experienced that the level of patient participation varied during the pathway and that the different phases led to diverse needs and opportunities for patient participation.
In the acute phase, the nurses and physicians did not consider patient participation as achievable, as they prioritised diagnosing correctly and initiating treatment within the time limits. The patients’ narratives highlighted the importance of clear information in this phase.
Patient involvement during treatment was achieved through individualised patient information throughout the percutaneous coronary intervention. A summary of the diagnosis and treatment was provided at the end of the intervention.
The patients, nurses, and physicians perceived that lack of continuity and coordination challenged patient participation during hospitalisation and at the point of discharge. The nurses and physicians called for checklists of patient information. The patients experienced lack of information about lifestyle changes, medications, and rehabilitation.
The nurses and physicians expressed that the system limited their opportunities to facilitate patient participation. The way their work was organised provided scarce opportunities for continuity in treatment and care. In addition, the hospitals lacked facilities where private conversations between patients and healthcare professionals could occur.
The nurses and physicians recommended that the patients attend cardiac rehabilitation programmes after discharge. They considered patient participation as an important precondition to achieve adherence to lifestyle changes and medications. The patients’ narratives acknowledged the importance of patient participation and shared decisionmaking in cardiac rehabilitation programmes.
Conclusion
This thesis provides new insights into patient participation in the different phases of the myocardial infarction pathway from the perspectives of patients and healthcare professionals. Patient participation is contextual, and the various phases of the pathway provide different opportunities for it.
Patients and healthcare professionals seemed to have a shared understanding that patient participation was difficult to achieve in the acute phase of myocardial infarction. The healthcare professionals must be aware of the former’s need for clear information.
Patients, nurses, and physicians perceived that a lack of continuity and coordination challenged patient participation during hospitalisation. The findings of this thesis show the need for a restructuring of the myocardial infarction pathway. Standardised checklists for patient information might provide basic knowledge about the disease, acute treatment, and secondary prevention that might increase patients’ health literacy.
It is necessary to strengthen the collaboration between healthcare professionals and between transferring hospitals to reinforce continuity, which might lead to better coordination of the pathway.
This thesis highlighted the important role of cardiac rehabilitation programmes in the myocardial infarction pathway. The patients, nurses, and physicians emphasised that these programmes focused on patient participation and shared decision-making to increase the possibility of patients achieving secondary prevention treatment goals
Enhancing Palliative Care in Primary Healthcare for Patients with Cancer: Integrating Advance Care Planning to Support Home-Based Care at the End-of-Life
Get PDFAccording to the World Health Organization (WHO), cancer is a significant global health issue and one of the leading causes of death worldwide. An increasing number of cancer patients, live longer with modern oncology treatment, supported by palliative care (PC) to improve the quality of life (QoL) of patients and their families. Advance care planning (ACP) involves planning for future healthcare and communicating the person’s preferences. Robust evidence supports the benefits of ACP within person-centred end of life (EoL) care but it is still under-utilised in clinical practice. Responsibility for the ACP process should be shared between primary and specialist healthcare. To decide when, where, and how to initiate the ACP process at individual patient level and how to conduct it, is challenging. The impact on favoured outcomes that are in line with patients preferences is dependent on both, implementation on system level and execution at individual patient level. Enhancing our understanding of patients’ preferences and their experiences with ACP, coupled with insights into the impact of ACP, can cultivate greater empathy for individuals nearing EoL. Additionally, this knowledge can empower policy makers to more effectively allocate healthcare resources to meet the PC needs of patients, family caregivers, and healthcare providers.
In this thesis, comprising three papers (I-III), a comprehensive investigation of advanced cancer patients was conducted using both qualitative and quantitative research methods. The research explored the home as the place of care before death and the place of death itself. Specifically, it delved into the experiences of patients at home and evaluated the effects of implementing and conducting ACP conversations and documenting conclusions within patients’ PC plans. Paper I retrospectively investigated the impact of ACP conversations in primary healthcare on both the number of days spent at home at EoL and the frequency of home deaths for 250 palliative cancer patients who died in the Romsdal region between September 2018 and August 2020. Cancer patients who had undergone an ACP conversation in primary healthcare (n=125) were likely to spend around 10 more days at home (DAH) during the last 90 days of life and they had a four times greater probability of dying at home; while 50% of patients with advanced cancer had ACP conversations in primary healthcare, 66% of these had the ACP conversation together with their general practitioner (GP).
Paper II analysed prospectively the home as the place of care before death and the location of death for 128 advanced cancer patients, based on whether they had ACP conversations with a summarising PC plan in a primary healthcare setting (n=67). Additionally, the study assessed the preferred and actual place of death. In contrast to the results in Paper I, patients who had ACP conversations and a PC plan in primary healthcare did not spend more time at home at EoL. The number of home deaths was similar in the ACP and control groups. However, the overall number of home deaths was high (30%) for both groups, contrasting with the national average among cancer patients in Norway, which was around 16% in 2021. Patients with ACP conversations and PC plans less often died in hospital. Among patients stating a preferred place of death (PPOD) during the last statement in the observation period, 62% expressed a desire to die at home. Overall, 33% of the patients died at their preferred place, 40% in the ACP group vs. 27% in the control group.
In Paper III, interviews with 12 advanced cancer patients gave insights from their experiences at home while receiving palliative treatment and engaging in ACP in primary healthcare settings. Participants emphasised the importance of (1) preserving normality at home which was influenced by (1a) the challenge of deterioration and the aspects of (1b) the value and burden of family caregivers. (2) Compassionate healthcare personnel made a difference by fostering a culture of understanding participants’ preferences and concerns. (3) Preparing for the future, was considered important, especially the EoL discussions initiated by healthcare personnel (HCP). Guidance from the ACP process provided participants with a sense of certainty and control.
The results of this dissertation indicate that cancer patients with ACP in primary healthcare more frequently died at home or in nursing homes. The results varied regarding the extent to which ACP was associated with time spent at home and home death, which can be explained by the differences in the patient samples and study designs between study I and study II. The success of ACP in primary healthcare largely depends on building strong relationships, especially between community cancer nurses and patients with advanced cancer. GPs play an important role in the ACP process. However, the ACP process and the formulation of a summarising PC plan are not always visible to patients. Discussing sensitive topics related to EoL preparation can be challenging for patients, family members and HCPs. Nevertheless, compassionate care and continuous communication emerge as crucial factors for both time at home and death at home. ACP conversations are associated with increased time spent at home and a greater likelihood of dying at home. A common PC plan for patients and HCPs might prevent hospital admissions in the EoL phase. A shared responsibility between primary and specialist healthcare may be a central component in planning and coordinating home-based palliative services
Ortostatisk hypotensjon 13 år etter gastric bypass operasjon for alvorlig fedme
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Ortostatiske symptomer er rapportert som bivirkning etter «metabolic bariatric surgery» (MBS). De fleste studier har tatt for seg ortostatisk intoleranse (OI) etter MBS innenfor en ramme på fem år etter operasjon. Det er gjennomført få studier som ser på ortostatisk hypotensjon (OH) etter MBS og som knytter OH opp mot helserelatert livskvalitet (HRQOL). Vi fant ingen studier som har sett på verken OH eller OI mer enn fem år etter operasjon.
Mål for studien
Målet med denne tverrsnittstudien har vært å undersøke forekomsten av OH 10-15 år etter MBS, vurdere sammenhengen mellom OH og demografiske, antropometriske og fysiologiske variabler, samt undersøke hvordan OH påvirker HRQOL.
Materiale og metode
Dette er en understudie av BAROBS-prosjektet. BAROBS-prosjektet undersøker langtidseffekter etter fedmekirurgi utført ved offentlige sykehus i Midt-Norge fra 2003 til 2015. BAROBS2 er en tverrsnittstudie hvor pasienter operert mellom 2010-2015 blir innkalt til kontroll av helsetilstand >10 år etter MBS. Datainnsamlingen startet våren 2023 og fortsetter ut 2025. Totalt 1 400 pasienter gjennomgikk MBS i Midt-Norge fra 2010 til 2015. 400 ble operert med VSG og 1 000 med RYGB. Av de 292 pasientene som møtte inklusjonskriteriene per 31.08.2024, ble tre ekskludert grunnet manglende blodtrykksmålinger for å stille diagnosen OH. For å vurdere MBS som direkte årsak til OH i vår pasientgruppe, valgte vi også å ekskludere pasienter med tilstander kjent for å gi økt risiko for utvikling av OH. Dette er tilstander som autonom neuropati, hjernestammeinfarkt og kardiale tilstander med redusert minuttvolum i hvile eller anstrengelse som klaffefeil/blodstrømsobstruksjon og vesentlig redusert pumpefunksjon. Etter nøye gjennomgang av medisinlister og journal fra utvalgte pasienter basert på nevnte kriterier utelukket vi ytterligere fire pasienter fra studien. Til slutt ble 285 pasienter inkludert i studien. Multiple og univariat logistisk og lineær regresjonsanalyse ble brukt for å undersøke sammenhengen mellom OH, ortostatiske blodtrykksendringer og utvalgte variabler.
Resultater
Tjue av 285 (7%) deltakerne hadde OH 13 år etter RYGB. Pasientene i studiegruppen (SG) hadde i snitt et høyere systolisk (SBP) og diastolisk blodtrykk (DBP) liggende sammenlignet med referansegruppen (RG) (p<0,001). SBP i SG var i snitt 151 (SD 20) mmHg og DBP var 86 (10) mmHg, sammenlignet med 127 (17) mmHg og 79 (8) mmHg i RG. Ved analyse av medikamentlisten fant vi at 3 (15%) i SG og 9 (3%) i RG brukte et diuretikapreparat (p=0,013). Multippel regresjonsanalyse viste at diuretikabruk gav 43% økt risiko for å utvikle OH. I tillegg viste analysen at selvrapportert svimmelhet når pasienten reiste seg og økende SBP liggende medførte høyere risiko for utvikling av OH. Økende BMI ved oppfølging gav en noe lavere risiko for utvikling av OH. OH hadde innvirkning på HRQOL i denne studien.
Konklusjon
Denne studien gir innblikk i langtidsforekomsten av OH 10-15 år postoperativt, noe som ikke har blitt beskrevet før. 7% av deltakerne hadde OH 13 år etter operasjon. Multippel regresjonsanalyse viste at bruk av diuretika gav 43% økt risiko for utvikling av OH, og var den viktigste prediktoren for utvikling av OH.Background
Orthostatic symptoms is a reported side effect after metabolic bariatric surgery (MBS). Few studies have researched orthostatic hypotension (OH) after MBS and related it to health-related quality of life (HRQOL). No studies have been performed on ortostatic intolerance (OI) or OH more than 5 years postoperatively.
Goal
This is a cross-sectional study to explore the incidence of OH 10-15 years after MBS. In addition, to assess the relation between OH and demographic, anthropometric and physiological variables and how OH affects HRQOL.
Material and method
This is a sub study of the BAROBS project. The BAROBS project research long term effects after bariatric surgery procedures in Central Norway from 2003 to 2015. BAROBS2 is a cross-sectional study where patients operated between 2010-2015 are called in to follow up >10 years postoperatively. Collection of data started in the spring of 2023 and will continue in 2025. One-thousand-four-hundred patients were undergoing bariatric surgery in Central Norway from 2010 to 2015. Four hundred was operated with ventricular sleeve gastrectomy (VSG) and 1000 with Roux-en-Y gastric bypass (RYGB). Two-hundred and ninety-two patients met the criteria for inclusion by 31.08.24 but was excluded due to lack of adequate measurement of blood pressure to diagnose OH. We excluded patients with known conditions which increase the risk of developing OH to assess MBS as a direct cause for OH. This is conditions such as autonomic neuropathy, infarction of the brainstem and cardiac conditions with reduced cardiac output in rest or exertion such as valve diseases, obstructed blood flow and reduced pump function. We went through medications and the journal of selected patients based on these criteria and excluded 4 more patients from the study. Two-hundred and eighty-five patients were included in the study. Multiple and univariate logistic and linear regression analysis was used to assess the correlation between OH and orthostatic blood pressure changes and chosen variables.
Results
Twenty of 285 (7%) participants had OH 13 years after RYGB. The patients in the study group (SG) had on average, higher prone systolic (SBP) and diastolic blood pressure (DBP) compared to the reference group (RG) (p<0,001). The average SBP in SG was 151 (SD 20) mmHg and the average DBP was 86 (10) mmHg compared to 127(17) mmHg and 79 (8) mmHg in RG. 3 (15%) in SG and 9 (3%) in RG used a diuretic (p=0,013). Multiple regression showed that use of diuretics gave a 43% increased risk of developing OH. In addition, did the analysis show that self-reported dizziness when the patient stood up and increasing prone SBP increased the risk of developing OH. Increased body mass index (BMI) at control was related to a smaller risk of developing OH. We could not show that OH had an impact on HRQOL.
Conclusion
This study provides insight into the long-term incidence of OH 10-15 years after MBS, which has not been studied before. 7% of the participants had OH 13 years after MBS. Multiple regression showed that the use of diuretics increased the risk of developing OH with 43%, and thus was the most important predictor of OH
Dialogue Therapy and Standard Psychiatric Treatment in Psychosis Psychological Aspects, Treatment and Outcome
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Appropriate Similarity Measures for Author Cocitation Analysis
Get PDFWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
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