The ACUFLASH study. Acupuncture treatment for postmenopausal hot flashes : can traditional Chinese acupuncture in addition to self-care reduce hot flash frequency and intensity, compared with self-care alone?

Papers 1, 2 and 3 of the thesis are not available in Munin due to publishers' restrictions: 1. Borud EK, Alraek T, White A, Fonnebo V, Eggen AE, Hammar M, Astrand LL, Theodorsson E, Grimsgaard S: «The Acupuncture on Hot Flushes Among Menopausal Women (ACUFLASH) study, a randomized controlled trial», Menopause 2009, 16(3):484-493 (Lippincott). Available at http://dx.doi.org/10.1097/gme.0b013e31818c02ad 2. Borud EK, Alraek T, White A, Grimsgaard S: «The acupuncture treatment for postmenopausal hot flushes (Acuflash) study: traditional Chinese medicine diagnoses and acupuncture points used, and their relation to the treatment response», Acupuncture in Medicine 2009, 27;101-108 (British Medical Acupuncture Society). Available at http://dx.doi.org/10.1136/aim.2009.000612 3. Borud EK, Martinussen M, Eggen AE, Grimsgaard S: «The Women's Health Questionnaire (WHQ): a psychometric evaluation of the 36-item Norwegian version», Scandinavian journal of psychology 2009, 50: 183-189 (Wiley-Blackwell). Available at http://dx.doi.org/10.1111/j.1467-9450.2008.00701.xIntroduction. Hot flashes and night sweats are the most prevalent symptoms in menopause. Hormone therapy with oestrogen is considered the most effective treatment. However, recent research show that long term use of oestrogen increases the risk of serious adverse effects, and women and their health care providers are looking for alternatives. Acupuncture is one of the most frequently used complementary therapies in Norway, and is considered safe in the hands of competent practitioners. Previous data on acupuncture treatment for hot flashes were insufficient to draw any conclusions on the effect, but sufficient to justify further research. Acupuncture affects beta-endorphin activity in the central nervous system, and may thus also affect the calcitonin gene-related peptide (CGRP) excretion. CGRP is a potent vasodilator and stimulator of cholinergic sweat glands, and has been suggested as a mediator of hot flashes and sweating in postmenopausal women. The Women‟s Health Questionnaire (WHQ) is a health-related quality of life questionnaire, designed specifically to study possible changes that occur during menopause. Aims. We wanted to estimate the effectiveness of acupuncture in practice. Thus, our objective was to assess the effectiveness of a policy of use of traditional Chinese medicine (TCM) acupuncture plus self-care on hot flash frequency in postmenopausal women, compared with a policy of use of self-care alone. The effects on hot flash intensity (0-10 scale) and sleep and on health-related quality of life as measured by the Women‟s Health Questionnaire (WHQ) were also assessed, as were the changes in urine excretion of CGRP. Secondary research questions were: “do TCM diagnoses predict the overall treatment response”, and “are patients with different TCM diagnoses likely to experience a differential response in their symptoms”? The Norwegian version of the WHQ had not been validated, and the participants in the Acuflash study reported more vasomotor symptoms than participants in prior studies of the WHQ. Therefore, it was necessary to evaluate the psychometric properties of the instrument. Materials and methods. The study was a multicenter, pragmatic, randomized, controlled trial with two parallel arms. Participants were postmenopausal women experiencing on average seven or more hot flashes per 24 hours during seven consecutive days. The acupuncture group received ten individualized TCM acupuncture treatment sessions after initial TCM diagnosis, the control group received advice on self-care only. Frequency and severity (0-10 scale) of hot flashes and hours of sleep per night were registered in a diary. Urine excretion of calcitonin gene-related peptide (CGRP) was assessed at baseline and after 12 weeks. Primary endpoint was change in mean hot flash frequency from baseline to 12 weeks. Secondary endpoint was change in health related quality of life measured by the Women‟s Health Questionnaire (WHQ). Primary and secondary endpoints were also assessed at six and 12 months after study start. The acupuncturists recorded TCM diagnoses and acupuncture points for each treatment session. Treatment reactions and adverse events were also recorded. The evaluation of the WHQ was performed by examining the factor structure of the Norwegian version, assessing the internal consistency reliability and floor- and ceiling effects, and by exploring the construct validity of the instrument by comparing the WHQ to instruments measuring related constructs. Results. Hot flash frequency decreased by 5.8 per 24 hours in the acupuncture group (n = 134) and 3.7 per 24 hours in the control group (n=133), a difference of 2.1, p < 0.001. Hot flash intensity decreased by 3.2 units in the acupuncture group and 1.8 units in the control group, a difference of 1.4, p < 0.001. The acupuncture group experienced statistically significant improvements in the vasomotor, sleep and somatic symptoms dimensions of the Women‟s Health Questionnaire, compared with the control group. Urine CGRP excretion remained unchanged from baseline to week 12. We did not find statistically significant differences between the study groups regarding primary and secondary endpoint at six and 12 months after study start. Fifty percent of the participants in the acupuncture group were diagnosed with Kidney Yin Xu as their primary TCM syndrome diagnosis. No statistically significant differences were demonstrated between the syndrome groups regarding the distribution of responders and non-responders, nor regarding the changes in health-related quality of life scores. A core of common acupuncture points (SP6, HT6, KI7, KI6, CV4, LU7, LI4, and LR3) were used in all the syndromes and in addition multiple idiosyncratic points. Core point selection and frequency of use did not differ between responders and nonresponders. No serious adverse events were reported. Some deficiencies in the WHQ questionnaire were observed when applied to the present sample, including an unclear factor structure, low alpha values for some dimensions, and a strong floor effect in the vasomotor symptoms dimension. Conclusions. Use of TCM acupuncture in addition to self care can contribute to a quicker reduction of hot flash frequency and increase in health related quality of life among postmenopausal women, but probably has no long term effects. Other factors than the TCM syndrome diagnoses and the point selection may be of importance regarding the outcome of the treatment. When evaluating the psychometric properties of the WHQ, the total scale score appeared reliable. However, care should be taken when interpreting some of the subscales when the instrument is applied on women with a high frequency of hot flashes.Kan tradisjonell kinesisk akupunktur i tillegg til egenomsorg redusere frekvens og intensitet av hetetokter i overgangsalderen, sammenlignet med kun egenomsorg? Hetetokter og nattsvette er de vanligste symptomene forbundet med overgangsalderen hos kvinner, og mange er mye plaget. Hormonbehandling med østrogen er den mest effektive behandlingen for disse plagene, men nyere studier har vist at hormonterapi kan være forbundet med alvorlige bivirkninger. Mange kvinner og leger ser etter alternativer. Akupunktur er en av de mest brukte alternative behandlingsformene i Norge. Tidligere forskning på effekten av akupunktur på hetetokter i overgangsalderen var ikke tilstrekkelig til å dra noen konklusjoner, men interessant nok til å rettferdiggjøre videre forskning. Vi ønsket å evaluere effekten av akupunkturbehandling og egenomsorg, sammenliknet med kun egenomsorg, på frekvens og intensitet av hetetokter og på helserelatert livskvalitet hos kvinner i overgangsalderen. ACUFLASH - studien var en pragmatisk, multisenter, randomisert, kontrollert studie med to grupper deltakere. Deltakerne var kvinner i overgangsalderen med i gjennomsnitt minst syv hetetokter i døgnet over en periode på syv påfølgende dager. Kvinnene i akupunkturgruppa (n=134) fikk 10 akupunkturbehandlinger i løpet av 10 uker i tillegg til egenomsorg, og kvinnene i kontrollgruppa (n=133) fikk kun egenomsorg. Frekvensen og intensiteten (0-10 skala) av hetetokter ble registrert i en dagbok. Helserelatert livskvalitet ble målt med spørreskjemaet ”Spørreskjema om helse for kvinner” (Women’s Health Questionnaire – WHQ). Etter 12 uker var hetetoktfrekvensen redusert med 5,8 hetetokter pr. døgn i akupunkturgruppa og 3,7 hetetokter pr. døgn i kontrollgruppa, en statistisk signifikant forskjell på 2,1 hetetokter pr. døgn. Reduksjonen i intensitet og økningen i livskvalitet var også signifikant større i akupunkturgruppa etter 12 uker. Seks og 12 måneder etter studiestart var det ingen forskjell mellom gruppene vedrørende hetetokter eller livskvalitet. Vi konkluderte med at akupunkturbehandling i tillegg til egenbehandling kan bidra til en raskere reduksjon av hetetokter og bedring av helserelatert livskvalitet hos kvinner i overgangsalderen, men at behandlingen sannsynligvis ikke har noen langtidseffekt

Individuell refleksjon som verktøy for lederutvikling: Operasjonalisering av Konsept for leder- og ledelsesutvikling i Hæren

Denne oppgaven handler om lederutvikling i Hæren. Flere studier de senere år viser at lederutvikling ved avdeling i Hæren har forbedringspotensiale. Dette til tross for at sjef Hæren i 2018 gav ut et eget konsept med hensikt å sette lederutvikling på dagsorden. Studien har til hensikt å utforske hvorvidt det lar seg gjennomføre å utvikle et lederutviklingstiltak på bakgrunn av de retningslinjer som konseptet trekker opp, og de rammebetingelser som eksisterer i avdeling. Problemstillingen lyder: Hvordan kan Konsept for leder- og ledelsesutvikling i Hæren operasjonaliseres på kompaninivå? Dette er en erfaringsbasert masteroppgave gjennomført som aksjonsforskning med et kvalitativt design. Aksjonsforskningen har til hensikt å utvikle kunnskap av betydning for egen profesjon, gjennom å forske i, og forbedre egen praksis. Dette er gjennomført ved å kartlegge grunnlaget fra Forsvarets normative dokumenter for ledelse og forskningslitteratur på feltet, samt rammebetingelsene i et manøverkompani i Hæren. På bakgrunn av dette er det utviklet et lederutviklingstiltak hvor lederne i kompaniet daglig gjennomfører 10-15 minutter skriftlig individuell refleksjon over sin egen praksis. Dette utføres over en periode på 8 uker. Datainnsamlingen baseres på dokumentundersøkelser og fokusgruppeintervju av lederne som gjennomfører tiltaket. Studien viser at Konsept for leder- og ledelsesutvikling i Hæren kan operasjonaliseres ved bruk av individuell refleksiv praksis. Den daglige refleksjonen har ført til at lederne er mer bevisst seg selv og andre, samtidig har det ført til utvikling innenfor kompetanseområdene i Kompetansemodellen for lederutvikling. Særlig innenfor selv- og sosial kompetanse. Lederutvikling trenger ikke være avansert for å skape effekt. Selv små tiltak kan produsere økt bevissthet og utvikling, og refleksiv praksis kan være én måte å oppnå dette på. Det er en forutsetning at tiltaket utvikles for å passe avdelingen og individene som deltar, samt at det forankres og integreres på en god måte med allerede eksisterende aktivitet og arenaer for lederutvikling. Samtidig peker studien i samme retning som tidligere forskning når det kommer til behovet for en mer helhetlig tilnærming til lederutvikling i avdeling gjennom samordning mellom Hæren, Hærens Våpenskole og Forsvarets Høgskole

What are the channel preferences of different experiential types of customers?

Experiences occur every time a customer interacts with a company, and can be either positive or negative. When positive, experiences can lead to an increase in customer satisfaction and loyalty. By decomposing the ambiguous term “experience” into manageable dimensions that are more tangible and easier to understand, companies could seek to take advantage of the fact that their customer base likely is diverse and made up by different people which have their own unique preferences in regards to what type of experiences they favor. Catering to different type of customers could for instance be done by examining if a company‟s service channels differ by appealing to different types of experiential groups of customers, with a special focus cost effective self-service technology channels. This thesis provides an overview on the existing literature the customer experience concept and follows it up by categorizing a selection of consumers of telecommunications services in Norway based on their experiential preferences and examines differences between the groups with regards to channel preference. I find that there are indeed differences between what type of experiences a consumer prefer and the type of channel that the same consumer prefers to use. Marketers could benefit by choosing to explore their customers‟ experiential profiles and achieve higher accuracy when designing appropriate channel mixes to suit their customer needs

Hva skal jeg si? Å møte ungdom som har selvskadet

Bakgrunn og hensikt: Forståelsen av hva som gjør at ungdom selvskader eller har selvmordstanker er varierende blant helsearbeidere, og det er en oppfatning blant kolleger om at det føles vanskelig og utfordrende å møte denne gruppen ungdom. Hensikten med studien er å se på ulike grunner til hvorfor ungdom velger å selvskade eller forsøker å ta sitt eget liv, og sette det inn i en større kontekst av hvordan barnesykepleieren oppfatter og møter denne typen ungdom og hvordan man kan gi best mulig sykepleie i disse møtene. Problemstilling: Hvordan kan vi som barnesykepleiere møte ungdom som har selvskadet, på en best mulig måte? Metode: Det er benyttet litteraturstudie som metode, og det er blitt gjort søk i tre databaser for innhenting av artikler. Artikler er lest og vurdert ved hjelp av vurderingsverktøy, med fokus på relevans og kvalitet. Både kvalitative og kvantitative artikler er inkludert. Alle artikler har blitt analysert og tematisert basert på funn. Funn og konklusjon: Det er mange utfordringer rundt det å forstå og snakke om selvskading. Mange ungdommer vil ikke vise sine vanskelige følelser utad, gjerne på grunn av skam, selvforakt, kulturell eller familiær oppfatning, og således heller vende dem innover og skade seg selv. Svært få ungdom dør i Norge som følge av selvmord, men konsekvensene av selvskading eller selvmordsforsøk i ungdomsalder kan manifestere seg i ung voksen alder, og føre til økning i sykemeldinger, arbeidsledighet, og nye forsøk på selvskading og selvmord. Mange helsearbeidere synes det er svært krevende å møte ungdommer som selvskader eller er suicidale, og beskriver stor forbedring i sitt arbeid etter gjennomføring av målrettet opplæring i å møte denne gruppen ungdom. Som Barnesykepleiere har vi en god forståelse av problemer ved ulike utviklingstrinn, og er vant til å jobbe tett med ungdom og pårørende. Å kunne jobbe instrumentelt, uten å gi selvskadende handlinger oppmerksomhet, men å likevel kunne møte ungdommen på samme plan er utfordrende men viktig. Nøkkelord: Selvskading, selvmordsforsøk, ungdom mellom 13 og 18 år, kommunikasjon, barnesykepleier

Social and life skills in adolescents who have self-harmed: analysis of survey responses from a national sample of adolescents in Norway

publishedVersio

Chinese medicine treatment for menopausal symptoms in the UK health service: Is a clinical trial warranted?

Objectives The aims of this pilot study were to evaluate treatment effects, ascertain safety and formulate best practice Chinese medicine protocols relevant for London women suffering from menopausal symptoms. Study design This clinical pilot study employed a case series design within a wider action-based research project. 117 perimenopausal women between 45 and 55 years of age recruited from the general population were treated for menopausal symptoms by six experienced practitioners of Chinese medicine at the Polyclinic of the University of Westminster. Practitioners were instructed to treat as near to their usual practice style as possible. This involved using Chinese herbal medicine and/or acupuncture along with dietary and lifestyle advice. A maximum of 12 treatments over 6 months was allowed per patient. Outcome measures The menopause specific quality of life questionnaire (MenQoL), the Greene climacteric scale, and flushing diaries were used to evaluate treatment outcomes. Liver and kidney function tests were carried out at intake and after 1, 6 and 12 treatments to evaluate the safety particularly in relation to the use of herbal medicines. Results Patients showed significant improvement across all domains measured by the MenQoL and Greene climacteric scales. Reduction on the MenQoL scale between first and last visit was from 4.31 to 3.27 (p < 0.001) and on the Green climacteric scale from 21.01 to 13.00 (p < 0.001). Study participants did not reliably complete their flushing diaries. No adverse events or abnormal liver or kidney function values were observed during the course of the study. Conclusions Further research that seeks to investigate the effects observed in more detail and to evaluate them against other forms of treatment and/or no-treatment controls is warranted. This could be achieved by way of a pragmatic randomized controlled trial that evaluated Chinese medicine against orthodox medical care

An investigation into the prevalence of dog bites to primary school children in Trinidad

<p>Abstract</p> <p>Background</p> <p>To estimate the prevalence of dog bites to primary school children between the ages of 8–12 years using a semi-structured interview process. With the increase in the pet population and popularity of dangerous breeds of dog and a high stray dog population combined with a dearth of information on the risk of dog attacks to children in Trinidad, a semi-structured interview process was used to determine risk factors associated with dog attacks.</p> <p>Methods</p> <p>A questionnaire survey of 1109 primary school children between the ages of 8–12 years was conducted in Trinidad from November 2002 to September 2003. The survey was conducted to determine the risk factors such as age, gender, size of dog and relationship of dog and victim, in dog bite incidents. The chi-square statistic and odds ratios were used to estimate risk factors for a bite incident.</p> <p>Results</p> <p>Twenty-eight percent of children were bitten at least once by a dog. Gender (male) and owning a dog were statistically significant risk factors (p = 0.003 and 0.008 respectively, χ²<it>df</it>, 95% confidence). Most attacks occurred outside of the home (58.0%) followed by the victims' home (42.0%) and were by a dog known but not owned (54.6%) by the victim. Many victims (33.0%) were bitten without having any interaction with the dog and the majority (61.9%) of victims did not receive professional medical assistance. Overall, the lower leg or foot was most often injured (39.3%).</p> <p>Conclusion</p> <p>A public educational campaign is needed on responsible pet ownership. In addition, children must be taught effective ways of avoiding attacks or reducing injury in the event of a dog attack. The Dangerous dogs Act 2000 must be proclaimed in parliament by the Government of Trinidad and Tobago to exert more pressure on pet owners to safeguard the public from the menace of dog attacks.</p

The effect of TCM acupuncture on hot flushes among menopausal women (ACUFLASH) study: A study protocol of an ongoing multi-centre randomised controlled clinical trial

BACKGROUND: After menopause, 10–20% of all women have nearly intolerable hot flushes. Long term use of hormone replacement therapy involves a health risk, and many women seek alternative strategies to relieve climacteric complaints. Acupuncture is one of the most frequently used complementary therapies in Norway. We designed a study to evaluate whether Traditional Chinese Medicine acupuncture-care together with self-care is more effective than self-care alone to relieve climacteric complaints. METHODS/DESIGN: The study is a multi-centre pragmatic randomised controlled trial with two parallel arms. Participants are postmenopausal women who document ≥7 flushes/24 hours and who are not using hormone replacement therapy or other medication that may influence flushes. According to power calculations 200 women are needed to detect a 50% reduction in flushes, and altogether 286 women will be recruited to allow for a 30% dropout rate. The treatment group receives 10 sessions of Traditional Chinese Medicine acupuncture-care and self-care; the control group will engage in self-care only. A team of experienced Traditional Chinese Medicine acupuncturists give acupuncture treatments. DISCUSSION: The study tests acupuncture as a complete treatment package including the therapeutic relationship and expectation. The intervention period lasts for 12 weeks, with follow up at 6 and 12 months. Primary endpoint is change in daily hot flush frequency in the two groups from baseline to 12 weeks; secondary endpoint is health related quality of life, assessed by the Women's Health Questionnaire. We also collect data on Traditional Chinese Medicine diagnoses, and we examine treatment experiences using a qualitative approach. Finally we measure biological variables, to examine potential mechanisms for the effect of acupuncture. The study is funded by The Research Council of Norway