Medical decision-making capacity among geriatric patients with and without dementia : communication-based approaches for assessment and facilitation

Introduction: Medical decision-making capacity concerns a patient’s cognitive abilities to make autonomous decisions regarding own person in medical contexts such as to choose treatment or accept/decline participation in research projects. Cognitive communicative functions are needed in order to process information, reach a decision and articulate it. Communication within medical decision-making processes requires receptive, cognitive communicative and expressive language skills. The overall aim of the thesis is to investigate medical decision-making capacity using communication based approaches to facilitation and assessment in geriatric patients with and without dementia. Methods: Study I investigated whether participants at discharge planning meetings perceived better communication function in geriatric patients with cognitive impairment who had been prepared using the Talking mats method. Study II examined if medical decisionmaking capacity improved among patients with Alzheimer’s disease if written participant information were presented as linguistically adapted, more readable vignettes. The medical decision-making capacity was measured by Swedish linguistic instrument for medical decision-making. Study III developed a new test to assess medical decision-making capacity: Clinical instrument of medical decision-making capacity. The test was validated by comparing results between three groups: patients with Alzheimer’s disease, patients with Mild cognitive impairment and healthy controls. Test scores were compared to test results on designated linguistic and cognitive tests. Study IV used Clinical instrument of medical decision-making capacity to investigate the prevalence of impaired medical decision-making among geriatric in-patients without known cognitive impairment. Results: Neither Talking mats nor Adapted vignettes was found to improve geriatric patients’ ability to participate in the specified medical decision-making processes. Clinical instrument of medical decision-making capacity showed good test properties. Positive correlations were found between preserved medical decision-making capacity and longer formal education, well-functioning overall cognition, high premorbid cognitive function, and scores on specific tests assessing e. g. comprehension and vocabulary. An unexpected finding was that the prevalence of impaired medical decision-making capacity was as high among in-patients with somatic conditions as among out-patients in early stage of Alzheimer’s disease. Conclusions: Medical decision-making processes are difficult to participate in not only for patients with dementia but also for in-patients, regardless of whether a neurodegenerative process is present or not. A flow-chart was constructed from a cognitive communicative perspective. The purpose was to suggest a standardized way to promote the best possible participation and obtain the most accurate perception of the patient’s wishes when asking geriatric patients for informed consent

Promocijas darbs

Elektroniskā versija nesatur pielikumusPromocijas darbā pētītas epideiktiskās rētorikas likumsakarības un izpausmes Menandra „Rētorikā” – sengrieķu valodā sarakstītā teorētisku tekstu kopumā, kas pievēršas epideiktiskās rētorikas apcerējumam antīkās pasaules vēlīnajā laikposmā (3. gs.). Ņemot par pamatu Menandra „Rētoriku”, pētījumā apzināta un atklāta epideiktisko tekstu klasifikācija, attiecīgās klasifikācijas motivācija, kā arī aplūkoti vispārīgi epideiktisko tekstu izveides principi antīkajā pasaulē. Līdzās Menandra „Rētorikai” kritiski izvērtēti arī citi grieķu un romiešu teorētiskie darbi, kuros tiek vēstīts par epideiktisko rētoriku un tās vietu vārda mākslas teorētiskajā skatījumā, tādējādi apzinot arī epideiktiskās rētorikas tradīciju antīkajā pasaulē.The consistent patterns and manifestations of epideictic rhetoric in “Rhetoric” by Menander – a collection of theoretical texts written in Ancient Greek that describes the epideictic rhetoric in Late Antiquity (the 3rd century) – are researched in the PhD thesis. Taking “Rhetoric” by Menander as the basis, the classification of epideictic texts, motivation for particular classification, as well as the general principles of creation of epideictic texts in the Ancient World are examined and presented in the research. Besides Menander’s “Rhetoric”, other Greek and Roman theoretical works that are devoted to epideictic rhetoric and its place in the theoretic evaluation of the art of discourse are critically analyzed. As a result, the tradition of the epideictic rhetoric in the Ancient World is considered in the PhD thesis

Påverkan av e-handelns framtida utveckling på pappersförpackningsbranschen

Syftet med denna studie har varit att analysera förpackningsbehoven hos olika e-handelsföretag som säljer varor till konsumenter. En ökning av den direkta distributionen av varor till konsumenter är av allmänt intresse på grund av dess inverkan på distributionskedjorna. Eftersom varor kommer att levereras som styckegods direkt till slukund istället för i stora volymer till en grossist kommer förpackningarna att behöva utvecklas. För det första kommer distributionen av varor via e-handeln att öka behovet av förpackningsmaterial eftersom varje enskild produkt behöver förpackas vid transport till slutkund. För det andra kommer nya typer av högkvalitativa förpackningar, som är skräddarsydda för att passa enskilda produkter, att behövas. Följaktligen, belyser denna studie förpackningsbehovet hos olika e-handelsföretag som säljer varor direkt till svenska konsumenter. Sverige har en av de högsta siffrorna för internethandel i Europa, 74% av vuxna i åldrarna 16-74 hade någon gång under år 2012 handlat produkter online. Den totala omsättningen för den svenska e-handel uppgick år 2012 till 31,6 miljarder kronor, vilket går att jämföra med 17,7 miljarder kronor år 2007. Studien har genomförts med hjälp av kvalitativa intervjuer med tio e-handelsföretag som distribuerar hemelektronik, kläder och skor direkt till slutkonsumenter. Resultaten presenteras med avseende på viktiga förpacknings- och leverantörsegenskaper. De förpackningsegenskaper som enligt studien värdesätts mest är hållbarhet, prisvärdhet, funktionalitet, flexibilitet och produktanpassning. Dessa egenskaper är viktiga eftersom företagen distribuerar många olika typer av varor samtidigt som förpackningarna många gånger påverkar konsumenternas helhetsintryck av köpet samt kan fungera som en kanal för marknadsföring. E-handelsföretagen anser att attraktiva egenskaper hos en förpackningsleverantör kännetecknas av att de är innovativa, goda samarbetspartners, har viljan att utvecklas tillsammans med sina kunder och är serviceinriktade. Utifrån studiens resultat går det att konstatera att e-handelns kraftiga tillväxt, visar att karakteriseringen av förpackningar som en mogen bransch inte är särskilt användbar. Studien är genomförd i samarbete med DS Smith Packaging, en ledande leverantör av förpackningar. Studien har utifrån resultatet givit förslag på hur DS Smith Packaging kan möta sina kunders framtida förpackningsbehov. DS Smith Packaging ska försöka bygga ett förtroende till sina kunder genom att erbjuda innovativa förpacknings- och servicerbjudanden. Förutom säljare som är bra på att skapa långvariga relationer, är det viktigt att involvera sina ingenjörer och designers i kundrelationerna. Detta för att försöka utveckla en utökad förståelse för varje enskild kunds specifika behov och distributionsprocesser. Genom en sådan process kan lämpliga affärer och erbjudanden utvecklas som är av ömsesidig affärsnytta för både e-handelskunderna och DS Smith Packaging som förpackningsleverantör.This research concerns the packaging needs of e-commerce firms who sell goods to consumers. An increase in the direct distribution of goods to consumers is of general interest because of its impact on distribution supply chains. The change from transporting large batches of products to retails to transporting small parcles to consumers implies several developments. Firstly, e-commerce distribution will be large users of packaging material because every single product must be packed for redistribution to consumers. Secondly, new types of high-quality packaging, which are tailored to suit the transportation of individual products, are likely to be needed. Accordingly, this study assessed the packaging needs of e-commerce firms that sell goods directly to Swedish consumers. Sweden has one of the highest internet trading figures in Europe, with 74% of adults in the ages 16-74 having purchased products online. E-commerce to the consumer segment has increased in Sweden to 31.6 billion SEK in 2012 from 17.7 billion SEK in 2007. Qualitative interviews were conducted with ten e-commerce firms that distribute electronics, clothing and shoes directly to consumers. Findings are grouped into packaging attributes and packaging supplier characteristics. The required attributes of the packaging are sustainable, affordable, functional, flexible and tailored for individual products. These attributes are important because firms distribute many different types of goods and distribution packaging can influence consumer perceptions of both the branding of the consumer goods as well as the retailers brands. E-commerce firms consider that the characteristics of attractive business suppliers of packaging materials are that the supplier is innovative, has good cooperation skills, has the desire to grow business together with its customers and is service oriented. These findings, together with growth of e-commerce, illustrates that the characterization of packaging as a mature industry may not be particularly useful. The study was conducted in collaboration with DS Smith Packaging, a leading supplier of packaging. This study has several implications for DS Smith Packaging. DS Smith ought to increasingly inspire the confidence of e-commers customers by innovating their service based offerings. In addition to sales personnel that take a long term business perspective, it is important to involve engineers and packaging designers directly into customer relationships. The reason for involving engineers and designers is to develop a specific understanding for each customer firms’ particular e-commerce packaging and distribution processes. Through such process understanding, appropriate business offerings can be developed that are of mutual business benefit to the e-commerce customer and DS Smith Packaging

Humor är livets ångestventil - En studie om humors betydelse för familjeterapeuter

The aim of the study is to highlight the use of humour by psychotherapists in family therapy. We used semistructured interviews and processed the interviews based on a phenomenological approach and using an inductive thematic analysis. The analysis resulted in three main themes; alliance and psychotherapeutic techniques and personality. All the psychotherapists interviewed in the study described that humour is an integral part of their approach to therapy and that humour is used primarily in creating a good alliance with clients. Humour is a necessity in achieving success in the therapeutic process and is present throughout the treatment. Humour is also used to create balance in the room, lighten the mood and find new and shared descriptions of the problem. The psychotherapists describe that humour is a part of their personality and therefore cannot be avoided in their contact with the clients. They point out that humour cannot be seen as a specific technique which can be learned, but that humour can be strengthened and developed as a part of psychotherapy training. The focus should be then to highlight both its positive and negative effects, and how, when and for what purposes humour can be used.Studiens syfte är att belysa psykoterapeuters användande av humor i familjeterapi. Vi använde oss av semistrukturerade intervjuer och bearbetade intervjumaterialet med utgångspunkt från fenomenologisk metod och med hjälp av en induktiv tematisk analys. Analysarbetet utmynnade i två huvudsakliga teman, Allians och Psykoterapeutisk teknik och personlighet. Samtliga psykoterapeuter beskrev att humor är en självklar del av deras förhållningssätt i terapin och att humor framförallt används för att skapa en god allians med klienterna. Humor är en nödvändighet för att nå framgång i den terapeutiska processen och finns med under hela behandlingen. Humor används även för att skapa balans i rummet, lätta upp stämningen och hitta nya och gemensamma beskrivningar av problemet. Psykoterapeuterna beskriver att humor är en del av deras personlighet och därför inte går att välja bort i mötet med klienterna. De framhåller att humor inte kan ses som en specifik teknik som går att lära ut, men att humor kan stärkas och utvecklas genom att bli en del av de psykoterapeutiska utbildningarna. Fokus bör då vara att lyfta fram dess positiva och negativa effekter och hur, när och i vilket syfte humor kan användas

A cross-sectional and semantic investigation of self-rated health in the northern Sweden MONICA-study

A cross-sectional and semantic investigation of self-rated health in the northern Sweden MONICA-study. Methodology, 12: 154 http://dx.doi. org/10.1186/1471-2288-12-154 Access to the published version may require subscription. N.B. When citing this work, cite the original published paper. BMC Medical Research Permanent link to this version: http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-64328 R E S E A R C H A R T I C L E Open Access A cross-sectional and semantic investigation of self-rated health in the northern Sweden MONICA-study The aim of this paper is to examine the meaning of two questions on self-rated health, the statistical distribution of the answers, and whether the context of the question in a questionnaire affects the answers. Methods: Statistical and semantic methodologies were used to analyse the answers of two different SRH questions in a cross-sectional survey, the MONICA-project of northern Sweden. Results: The answers from 3504 persons were analysed. The statistical distributions of answers differed. The most common answer to the General SRH was "good", while the most common answer to the Comparative SRH was "similar". The semantic analysis showed that what is assessed in SRH is not health in a medical and lexical sense but fields of association connected to health, for example health behaviour, functional ability, youth, looks, way of life. The meaning and function of the two questions differ -mainly due to the comparing reference in Comparative SRH. The context in the questionnaire may have affected the statistics. Conclusions: Health is primarily assessed in terms of its sense-relations (associations) and Comparative SRH and General SRH contain different information on SRH. Comparative SRH is semantically more distinct. The context of the questions in a questionnaire may affect the way self-rated health questions are answered. Comparative SRH should not be eliminated from use in questionnaires. Its usefulness in clinical encounters should be investigated

Cellular demands of secreted protein products – systems and synthetic biology improve quality and titer

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The kinetics and mechanism of the organo-iridium catalysed racemisation of amines

The dimeric iodo-iridium complex [IrCp*I2 ]2 (Cp*=pentamethylcyclopentadiene) is an efficient catalyst for the racemisation of secondary and tertiary amines at ambient and higher temperatures with a low catalyst loading. The racemisation occurs with pseudo-first-order kinetics and the orresponding four rate constants were obtained by monitoring the time dependence of the concentrations of the (R) and (S) enantiomers starting with either pure (R) or (S) and show a first-order dependence on catalyst concentration. Low temperature 1H NMR data is consistent with the formation of a 1:1 complex with the amine coordinated to the iridium and with both iodide anions still bound to the metal-ion, but at the higher temperatures used for kinetic studies binding is weak and so no saturation zero-order kinetics are observed. A cross-over experiment with isotopically labelled amines demonstrates the intermediate formation of an imine which can dissociate from the iridium complex. Replacing the iodides in the catalyst by other ligands or having an amide substituent in Cp* results in a much less effective catalysts for the racemisation of amines. The rate constants for a deuterated amine yield a significant primary kinetic isotope effect kH/kD = 3.24 ndicating that hydride transfer is involved in the rate-limiting step

Predictor variables and screening protocol for depressive and anxiety disorders in cancer outpatients

Background Cancer patients are at increased risk of persistent depressive and anxiety symptoms and disorders compared to the general population. However, these issues are not always identified, which may worsen the prognosis and increase morbidity and mortality. Therefore, the objectives of this study are to identify predictor variables (demographic and clinical) for the development of mood and anxiety disorders in cancer outpatients and to propose a probabilistic screening protocol considering these variables and certain standardized screening instruments. Methods A total of 1,385 adults, of both genders, receiving outpatient cancer care were evaluated using a questionnaire and screening instruments. Thereafter, 400 of these subjects responded to the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID-IV) by telephone to confirm or rule out the presence of a Current Major Depressive Episode (CMDE) or Anxiety Disorder (AD). Results Of the patients surveyed, 64% met the criteria for CMDE and 41% for AD. Female gender was found to be a risk factor for both disorders, and the presence of previous psychiatric history and marital status (divorced and widowed) were risk factors for anxiety disorders. When scoring above the recommended cutoff score, the screening instruments also indicated a risk of the studied disorders. Based on these findings, a screening protocol and nomograms were created for the quantification, combination and probabilistic estimate of risk, with accuracy indicators >0.68. Conclusion The prevalence rates for the disorders under study are extremely high in cancer patients. The use of the proposed protocol and nomogram can facilitate rapid and wide screening, thus refining triage and supporting the establishment of criteria for referral to mental health professionals, so that patients can be properly diagnosed and treated.info:eu-repo/semantics/publishedVersio