The Tilburg double blind randomised controlled trial comparing inguinal hernia repair according to Lichtenstein and the transinguinal preperitoneal technique

<p>Abstract</p> <p>Background</p> <p>Anterior open treatment of the inguinal hernia with a tension free mesh has reduced the incidence of recurrence and direct postoperative pain. The Lichtenstein procedure rules nowadays as reference technique for hernia treatment. Not recurrences but chronic pain is the main postoperative complication in inguinal hernia repair after Lichtenstein's technique. Preliminary experiences with a soft mesh placed in the preperitoneal space showed good results and less chronic pain.</p> <p>Methods</p> <p>The TULIP is a double-blind randomised controlled trial in which 300 patients will be randomly allocated to anterior inguinal hernia repair according to Lichtenstein or the transinguinal preperitoneal technique with soft mesh. All unilateral primary inguinal hernia patients eligible for operation who meet inclusion criteria will be invited to participate in this trial. The primary endpoint will be direct postoperative- and chronic pain. Secondary endpoints are operation time, postoperative complications, hospital stay, costs, return to daily activities (e.g. work) and recurrence. Both groups will be evaluated.</p> <p>Success rate of hernia repair and complications will be measured as safeguard for quality.</p> <p>To demonstrate that inguinal hernia repair according to the transinguinal preperitoneal (TIPP) technique reduces postoperative pain to <10%, with α = 0,05 and power 80%, a total sample size of 300 patients was calculated.</p> <p>Discussion</p> <p>The TULIP trial is aimed to show a reduction in postoperative chronic pain after anterior hernia repair according to the transinguinal preperitoneal (TIPP) technique, compared to Lichtenstein.</p> <p>In our hypothesis the TIPP technique reduces chronic pain compared to Lichtenstein.</p> <p>Trial registration</p> <p>ISRCTN 93798494</p

A theory-based educational intervention targeting nurses' attitudes and knowledge concerning cancer-related pain management: A study protocol of a quasi-experimental design

<p>Abstract</p> <p>Background</p> <p>Pain is one of the most frequent problems among patients diagnosed with cancer. Despite the availability of effective pharmacological treatments, this group of patients often receives less than optimal treatment. Research into nurses' pain management highlights certain factors, such as lack of knowledge and attitudes and inadequate procedures for systematic pain assessment, as common barriers to effective pain management. However, educational interventions targeting nurses' pain management have shown promise. As cancer-related pain is also known to have a negative effect on vital aspects of the patient's life, as well as being commonly associated with problems such as sleep, fatigue, depression and anxiety, further development of knowledge within this area is warranted.</p> <p>Methods/design</p> <p>A quasi-experimental study design will be used to investigate whether the implementation of guidelines for systematic daily pain assessments following a theory-based educational intervention will result in an improvement in knowledge and attitude among nurses. A further aim is to investigate whether the intervention that targets nurses' behaviour will improve hospital patients' perception of pain. Data regarding nurses' knowledge and attitudes to pain (primary outcome), patient perception regarding pain (secondary outcome), together with socio-demographic variables, will be collected at baseline and at four weeks and 12 weeks following the intervention.</p> <p>Discussion</p> <p>Nursing care is nowadays acknowledged as an increasingly complicated activity and "nursing complexity is such that it can be seen as the quintessential complex intervention." To be able to change and improve clinical practice thus requires multiple points of attack appropriate to meet complex challenges. Consequently, we expect the theory-based intervention used in our quasi-experimental study to improve care as well as quality of life for this group of patients and we also envisage that evidence-based guidelines targeting this patient group's pain will be implemented more widely.</p> <p>Trial Registration Number</p> <p>ClinicalTrials.gov <a href="http://www.clinicaltrials.gov/ct2/show/NCT01313234">NCT01313234</a></p

Patient-orientated aspects of the postoperative course after hernia surgery

Operations for inguinal hernia are one of the most common surgical procedures performed. With the development of mesh techniques, recurrence rates have improved radically and patient-orientated endpoints have evolved as important outcome measures. In recent studies, 15-50% of patients may experience some form of pain years after repair. One reason for the diverging results is the lack of a uniform assessment of postoperative pain. Pain is not defined, nor is it measured in the same way in the different studies. Moreover, postoperative complications are infrequently recorded in everyday surgical practice and many hospitals lack a continuous structured follow-up, making reliable quality assurance assessments difficult. As quality assurance protocols are often retrospective studies rather than prospective, they will have to rely on questionnaires to be answered by the patient to get an estimate of postoperative pain and adverse events. In order to improve the performance in hernia surgery, the National Hernia Register (NHR) was started in Sweden in 1992 and today more than 90% of all inguinal and femoral hernia operations in patients 15 years and older are prospectively recorded. Information on age, gender, type of hernia as noted during the operation and type of repair as well as observed complications are recorded. Patients are entered in the register by their unique National Identification Number and can thus be traced in the register for subsequent operations regardless of the unit performing the operation as well as in other national registers. As of today more than 120 000 operations are gathered in the register. In the following papers, making the basis of this thesis, we have studied the following issues: Paper 1 is a study on the discordance between the patient's and the surgeon's perception of complications. Some 206 patients having surgery for inguinal hernia were invited to a follow-up 3-6 weeks after the operation. The patient was asked to fill in a questionnaire with 12 questions concerning postoperative complications prior to the visit. The examining surgeon who had not participated in the operation and was blinded to the patient's questionnaire filled in a similar protocol. The concordance between the surgeon and the patient in assessing complications was poor and reflects their different understanding of "adverse events", the surgeon assessing technical complications and the patient the symptoms. Paper 11 is based on a questionnaire study of postoperative adverse events submitted to 1643 patients recorded in the hernia register during 2 consecutive months in 2002. The response rate was 88% (1448 patients). The most common complications recorded were haematoma in 203 (14%) patients, severe pain in 168 (12%) patients, testicular pain in 120 (8%) patients and infection in 105 (7%) patients. The risk-factors for complications were age below the median of 59 years and laparoscopic repair. The National Hernia Register covered 25% of the complications recorded by the patients in the questionnaire, reflecting that a passive recording of complications, i.e. the clinic only record what comes to their knowledge, is less accurate than a structured follow-up. The study showed that a structured follow-up may improve quality control of surgery, since only a small number of the adverse events perceived by the patient come to the knowledge of the healthcare provider. Paper 111 introduces the novel Inguinal Pain Questionnaire (IPQ) which is the first assessment instrument specifically designed for evaluation of pain after hernia surgery. The questionnaire consists of 18 items and is divided in a pain intensity section using a 7-step behavioural rating scale and a section for interference with daily activities with a dichotomous scale. The aim of this study is to test its validity and reliability. The validity is tested in 100 patients filling in the IPQ and Brief Pain Inventory 1 and 4 weeks after the operation for a unilateral groin hernia. Reliability and internal consistency was tested in another 100 patients filling in the IPQ 3 years after the operation on 2 occasions one month apart. Non-surgery related pain was analysed in a cohort of 2853 patients derived from the NHR, and they were sent the IPQ by regular mail 2-3 years after the operation. Non-surgery related pain was assessed by comparing pain in the groin having surgery to the side that did not. In conclusion the validity, reliability and internal consistency were acceptable. The nonsurgery related pain did not exceed 5.5% for any item. Paper IV is a study on long-term pain after hernia surgery. From the NHR 2853 patients having surgery for a unilateral groin hernia were sent the IPQ 2-3 years after the operation by regular mail with 2456 patients (86%) responding. In response to the question "worst pain past week" 758 patients (31%) reported some pain and 144 patients (6%) reported pain that interfered with daily activities. Age below median, a high level of preoperative pain, techniques involving an anterior approach and the occurrence of any postoperative complication were found to predict long-term pain. In conclusion, quality assurance in groin hernia surgery can be facilitated by the use of local or national registers together with a structured follow-up in order to identify risk-factors and encourage a high standard of care

De traditionella flygbolagens överlevnad på den skandinaviska marknaden : en studie om SAS Sverige

The traditional airlines exist on a market that is distinguished by an increasing competition. They are often partly or completely owned by the government and are characterized by slow decision making. Because of their existing structure and old business culture the traditional airlines find it hard to use price as a means of competition. Consequently the traditional airlines need to create loyalty amongst their customers. The purpose of this essay was to analyze and evaluate SAS long-term marketing strategies through a comparative study of the companies’ management, employees and customers. To shed light on the problem a gap analysis has been performed on SAS Swedens management, emloyees and customers. The theoretical part of the study takes into account customer value, organization and loyalty. The result shows that the gap between SAS management and customers was relatively small due to the management’s knowledge and insight in respect to customer expectations. On the other hand the gap between SAS management and employees was much larger. The internal communication within SAS is today insufficient which can lead to major problems. To create customer loyalty SAS has to concentrate on their internal problems and focus on their employees. In this way the employees will mediate customers expectations so that SAS profile and image will correspond with customers expectations. SAS needs to have a strong business concept and a vision that all employees should try to achieve, which they do not have today. The conclusion is that SAS will find it hard to survive on a long term basis with the conditions and structure they have today. Suggestions for additional research would be to study other effects made by the incorporation of SAS as well as to study factors that are important for creating good internal communication within the SAS group.De traditionella flygbolagen verkar på en marknad som kännetecknas av en ökad konkurrens. De är ofta delvis eller helt statligt ägda och präglas av tröga beslutsprocesser. På grund av sin befintliga struktur och gamla affärskultur har de svårt att konkurrera med priset som konkurrensmedel och måste därför fokusera på att skapa kundlojalitet. Uppsatsens syfte var att analysera och utvärdera SAS långsiktiga marknadsföringsstrategier genom en jämförande studie av företagets ledning, anställda samt kunder. För att belysa problemet har en gapanalys genomförts på SAS Sveriges ledning, anställda och kunder. Studiens teoridel är baserad på teorier om mervärdeskapande, organisation och lojalitet. Resultatet visar att gapet mellan SAS ledning och kunder var relativt litet då ledningen har kunskap och insikt om kundernas förväntningar på SAS tjänster. Gapet mellan SAS ledning och de anställda var däremot mycket större. Den interna kommunikationen inom SAS är idag bristande vilket är ett stort problem. För att SAS skall ha en möjlighet att skapa kundlojalitet måste de börja internt och fokusera på de anställda, så att de levererar vad kunderna förväntar sig. Detta i sin tur bidrar till att SAS profil och image överensstämmer. SAS måste ha en stark affärsidé och vision som alla anställda strävar efter, vilket de inte har idag. Studiens slutsats är att SAS har svårt att långsiktigt överleva med de förutsättningar och den struktur de har idag. Som förslag på vidare forsknings gavs att studera ytterligare effekter av SAS bolagisering, samt att studera faktorer som är viktiga för att skapa en bra intern kommunikation inom hela SAS koncernen

SERVQUAL : ett lämpligt mätinstrument av upplevd tjänstekvalitet inom reseindustrin?

The travel agencies exist on a market that is distinguished by increasing competition. A majority of the travel agencies offer different services that all satisfie the same customer need. However, one major difference in the market aspect is the service quality, this making it an important mean of competition. There are several acknowledged methods of measurement when it comes to service quality and it is important to use an instrument that takes into consideration the fact that charter tours is a complex merger of several services. The purpose of this essay is to establish if the SERVQUAL method is a suitable instrument for measuring service quality in the travel industry. This study is a thorough analysis and evaluation of what Apollo’s customers think about the service quality of Apollo as well as how they perceive that Apollo fulfils their travelling expectations. Moreover, the essay will examine which factors affect travellers’ experiences of the service quality on charter tours. The study has an objective outlook and the authors have applied a deductive approach. The authors have performed a quantitative study on 70 of Apollo’s customers. The aforementioned study was carried out using a questionnaire that was based on the SERVQUAL method and the theories that were used in the theoretical part of that study. The result show that the SERVQUAL method only considered the aspects that involve the travel agency and did not consider the other aspects that affect the traveller’s overall experience of the service quality. In conclusion this study determines that the SERVQUAL method is not a suitable instrument for measuring service quality on charter tours in the travel industry.Researrangörer verkar på en marknad som kännetecknas av en ökad konkurrens, där ett flertal researrangörer erbjuder olika tjänster som tillfredställer samma behov. Något som särskiljer researrangörerna åt är kvaliteten, vilket medför att den blir ett viktigt konkurrensmedel. Då det finns flera erkända metoder för att mäta upplevd tjänstekvalitet är det viktigt att använda ett mätinstrument som tar hänsyn till att charterresor är en komplex uppsättning av deltjänster. Syftet med denna uppsats är att klargöra om SERVQUAL metoden är ett lämpligt mätinstrument inom reseindustrin genom att analysera och utvärdera vad kunderna anser om Apollos tjänstekvalitet samt om Apollo uppfyller kundernas förväntningar. Detta med hjälp av att undersöka vilka faktorer som påverkar resenärers upplevda tjänstekvalitet på charterresor. Uppsatsen utgår från ett objektivistiskt synsätt där författarna har tillämpat en deduktiv ansats. En kvantitativ enkätundersökning har utförts på 70 stycken av Apollos kunder där enkätundersökningen är baserad på SERVQUAL samt de teorier som behandlas i studiens teorikapitel. Resultatet visar att SERVQUAL metoden endast tar upp de aspekter som rör researrangören, och inte alla de aspekter som påverkar kundernas upplevda tjänstekvalitet. Med detta som utgångspunkt anser författarna att SERVQUAL metoden är bristande som mätinstrument när det gäller att mäta resenärers uppfattning av tjänstekvalitet på charterresor

VÅLDSPREVENTIVT ARBETE I SKOLAN: SPRÅKETS IMPLIKATIONER I PRAKTIKEN : En kvalitativ studie av skolkuratorers och lärares sätt att prata om våldsprevention

Våld i olika former beskrivs av många vara ett omfattande och ihållande samhällsproblem, ett som skapar en uppsättning av negativa påföljder; psykiska, fysiska och ekonomiska. Hur våldet ska motarbetas blir därför på grund av dess komplexitet svårt att ge tydliga direktiv på. Olika vetenskapliga ställningstaganden kring vilka interventioner som är effektiva kan vara något motsägelsefulla för den som försöker sätta fingret på vad våldsförebyggande arbete inom skolan betyder. Denna studie syftar därför till att undersöka lärares och skolkuratorers sätt att prata om våldsprevention; vad det innebär och hur det ser ut för dem i deras vardag. Studien utfördes utifrån en kvalitativ metodansats där datan samlades in genom semistrukturerade intervjuer med lärare och kuratorer från skolor inom olika utbildningsnivåer. Resultatet analyserades genom en diskursanalys för att få fram essensen i deltagarnas svar, men även för att undersöka vilken betydelse dessa svar har i det praktiska våldspreventiva arbetet. Resultatet visar att en god elev-lärare relation, tillsammans med samverkan mellan skolkuratorer och lärare, kan vara viktiga aspekter i det våldspreventiva arbetet; liksom att undersöka konstruktionen av våld utifrån ett genusperspektiv.Violence in various forms is often described by many as a widespread and persistent social problem, one that creates a range of negative consequences; psychological, physical and economic. Because of its complexity, it is difficult to give clear directives on how to combat violence. Different scientific positions on which interventions are effective can be somewhat contradictory for those trying to pinpoint what violence prevention work in schools means. The purpose of this study is therefore to investigate teachers' and school counselors' way of talking about violence prevention, what it means and how it looks for them in their everyday lives. The study was carried out using a qualitative approach, where the data was collected through semi-structured interviews with teachers and counselors from schools at different education levels. The results were analyzed through a discourse analysis to bring out the essence of the participants' responses, but also to examine the significance of these responses in practical violence prevention. The results show that a good student-teacher relationship, along with collaboration between school counselors and teachers, can be important aspects in violence prevention; as well as examining the construction of violence from a gender perspective.

Institutional barriers : a study on corruption in India from Swedish companie´s perspectives

The globalization today has led to increased global competition. As companies seek out foreign markets in order to internationalize their operations, it is common that they encounter many cultural problems. Bribery and corruption is a common problem in international trade. Corruption is strongly linked to the national culture which means that corruption is accepted in differing degrees within different nations. This can be a problem when companies establish their operations in foreign markets. The purpose of this essay is to examine and analyze how companies act in a corrupt market without participating in corrupt activities. The authors have performed both a qualitative and a quantitative study. Seven companies have been interviewed and 23 companies participated in a questionnaire survey. All companies that participated in the study are Swedish companies that have established their operations in India. The questions that are used in the interviews as well as the questionnaire are based on theories and literature that were used in the theoretical part of the essay. The results show that the companies that participated in the study do not work entirely in accordance with the theory "strategies for coping with corruption". Swedish companies in India are mainly influenced by the administrative and little corruption in India. The majority of companies that participated in the study are acting in accordance with the rational choice theory. This is likely because the companies constantly work to maximize their profits, which leads to participation in some corrupt activities. Corruption may benefit the individual company while it may disfavour society as a whole.Den globalisering som präglar samhället idag har medfört att konkurrensen ökat globalt. Då företag söker sig till främmande marknader för att internationalisera sin verksamhet är det vanligt att det uppstår många kulturella problem. Ett vanligt problem inom internationella affärstransaktioner är mutor och korruption. Korruption är starkt kopplat till en nations kultur vilket gör att korruption accepteras olika på olika marknader. Därav kan det bli problem när företag etablerar sin verksamhet på främmande marknader.  Syftet med denna studie är att undersöka och analysera hur företag agerar på en korrupt marknad utan att själva delta i korrupt verksamhet.  Studien utgår ifrån både en kvalitativ och kvantitativ undersökningens metod. Sju intervjuer och en enkätundersökning med 23 svenska företag som är verksamma i Indien har genomförts. Frågorna som undersökningarna är baserade på utgår ifrån studiens teorier och litteratur.  Resultatet visar att företagen som deltog i studien inte arbetar helt i enlighet med teorin om strategier för hantering av korruption. Svenska företag i Indien påverkas främst av den administrativa och lilla korruptionen i Indien. En majoritet av företagen som deltog i studien agerar i enlighet med teorin rational choice då de strävar efter att hela tiden vinstmaximera, vilket innebär att de ibland deltar i korrupt verksamhet. Korruption kan gynna det enskilda företaget samtidigt som det kan missgynna samhället som helhet.