Viral gastrointestinal infections in allogeneic hematopoietic stem cell transplant patients

Gastrointestinal symptoms, and elevated liver enzymes, are common after HSCT, often due to drug toxicity, graft-versus-host disease (GVHD) or infections. It is essential to distinguish between GVHD and infection, since both conditions may progress to lethal disease, but require opposite strategies for the immunosuppressive treatment. Several of the viral gastrointestinal infections are easily transmitted and can cause outbreaks in health care facilities. In this thesis I studied viral gastrointestinal infections in HSCT patients, with focus on human adenovirus (HAdV), norovirus and hepatitis E virus (HEV), addressing transmission within health care, clinical importance, risk factors for severe/prolonged disease and the importance of secretor-status. In paper I we analyzed an outbreak of HAdV at the Center for Allogeneic Hematopoietic Stem Cell transplantation (CAST), Karolinska University Hospital. We identified nine patients with HAdV A31. Hygiene measures were implemented, but the outbreak continued for a prolonged time. High strain on the staff during the early part of the outbreak, possible contamination of the facilities of the ward, and unidentified cases with sparse symptoms, may have contributed to the prolonged outbreak. The clinical consequences were significant, although no patient developed severe HAdV disease. Paper II was a retrospective study of the clinical importance, and risk factors for long-term symptoms, in 63 HSCT patients with norovirus infection. In paper III, we analyzed if secretor-status influenced the clinical course of norovirus infection in 89 HSCT patients with norovirus infection, of whom 63 also had been included in paper II. we found chronic symptoms of norovirus (>30 days) in 18/89 (20%) of the patients. Severe combined immunodeficiency (SCID) diagnosis was associated with chronic norovirus symptoms in both paper II and III, which may be due to the delayed immune reconstitution in many of these patients. The number of secretor-negative patients was low compared to the general population, indicating that secretor-negative genotype may protect against norovirus even when the patient is severely immunocompromised. Paper IV was a retrospective study of the frequency and clinical importance of HEV infection in a cohort of 236 HSCT recipients. HEV RNA was detected in 8/236 (3.4%) patients 6 months after HSCT. We found that elevated alanine aminotransferase (ALT) at six months after HSCT was associated with HEV infection. Spontaneous clearance was common, but one patient died of multiorgan failure where HEV infection may have contributed. In conclusion, we found that an outbreak of HAdV can be difficult to control and may have serious consequences. Norovirus causes chronic symptoms (> 30 days) in 20% of HSCT patients, and SCID as indication for HSCT is associated with a chronic course of norovirus infection. We found that problems discriminating symptoms of HAdV, or norovirus, from symptoms of gastrointestinal GVHD, are a significant clinical challenge. HEV infection is an infrequent, but potentially severe, differential diagnosis in patients with elevated ALT six months after HSCT

Constitutional Law—The Public Forum in Nontraditional Areas—Lehman v. City of Shaker Heights, 418 U.S. 298 (1974)

In 1970, Harry Lehman, a candidate for election to the Ohio state legislature, attempted to purchase advertising space on local buses belonging to the city of Shaker Heights\u27 rapid transit system. Although space was available, the advertising agent for the transit company rejected Lehman\u27s request because its contract with the city proscribed political advertising on buses. Lehman sought a declaratory judgment and an injunction, alleging violation of the first and fourteenth amendments. The trial court denied relief, and the state supreme court affirmed. In a 5-4 decision, the United States Supreme Court affirmed. In the plurality opinion, Justice Blackmun concluded that no first amendment public forum existed and that no equal protection violation had occurred. Concurring in the result, Justice Douglas argued that there was no constitutional right to spread a message before a captive audience on a public bus. Justice Brennan, speaking for the dissent, maintained that the city itself had created a public forum by accepting and displaying commercial advertising. Having opened such a forum, the city could not discriminate solely upon the subject matter of the message. To do so, he contended, violated both the first and fourteenth amendments

Isolated specialist or system integrated physician – different views on sickness certification among orthopaedic surgeons: an interview study

<p>Abstract</p> <p>Background</p> <p>Sickness certification is a frequent and sometimes problematic task for orthopaedic surgeons.</p> <p>Our aim was to explore how orthopaedic surgeons view their sick-listing commission and sick-listing practice.</p> <p>Methods</p> <p>Semi-structured interviews with seventeen orthopaedic surgeons from five orthopaedic clinics in four Swedish counties. The focus was on the experiences of these physicians in relation to handling of sickness certification. Phenomenographic analysis was performed to reveal differences in existing views.</p> <p>Results</p> <p>The orthopaedic surgeons' views on sick-listing seemed mainly to be a consequence of how they perceived their role in the healthcare system. Three categories were found: The "<it>isolated specialists"</it>, whose work and responsibilities were confined to the orthopaedic clinic, and did not really include sickness certification; the "<it>orthopaedic advisers"</it>, who saw themselves mainly as advice-givers in the general health care system and perceived sickness certification as part of their job; the "<it>system-integrated physicians"</it>, who perceived the orthopaedic clinic as one part of the healthcare system and whose ultimate goal was to get the patient well functioning in her life again with regained work ability, seeing sick-listing as one of the instruments to achieve this. Some informants described difficulties in handling conflicting opinions with patients in relation to the need for sick-leave.</p> <p>Conclusion</p> <p>Orthopaedic surgeons certify a large proportion of total sickness benefits. Some orthopaedic surgeons may certify sickness benefits sub-optimally for patients and society due to a narrow view of their role in the health care system or due to poor skills in handling discordant opinions with the patient. This problem can be addressed at the level of the individual physician and at the system level.</p

Views on sick-listing practice among Swedish General Practitioners – a phenomenographic study

<p>Abstract</p> <p>Background</p> <p>The number of people on sick-leave started to increase in Sweden and several other European countries towards the end of the 20^thcentury. Physicians play an important role in the sickness insurance system by acting as gate-keepers. Our aim was to explore how General Practitioners (GPs) view their sick-listing commission and sick-listing practice.</p> <p>Methods</p> <p>Semi-structured interviews with 19 GPs in 17 Primary Health Care settings in four mid-Sweden counties. Interview transcripts were analysed with phenomenographic approach aiming to uncover the variation in existing views regarding the respondents' sick-listing commission and practice.</p> <p>Results</p> <p>We found large qualitative differences in the GPs' views on sick-listing. The sick-listing commission was experienced to come either from society or from patients, with no responsibility for societal interests, or as an integration of these two views. All the GPs were aware of a possible conflict between the interests of society and patients. While some expressed feelings of strong conflict, others seemed to have solved the conflict, at least partly, between these two loyalties.</p> <p>Some GPs experienced carrying the full responsibility to decide whether a patient would get monetary sick-leave benefits or not and they were not comfortable with this situation. Views on the physician's and the patient's responsibility in sick-listing and rehabilitation varied from a passive to an empowering role of the physician.</p> <p>GPs expressing a combination of less inclusive views of the different aspects of sick-listing experienced strong conflict and appeared to feel distressed in their sick-listing role. Some GPs described how they had changed from less to more inclusive views.</p> <p>Conclusion</p> <p>The clearer understanding of the different views on sick-listing generated in this study can be used in educational efforts to improve physicians' sick-listing practices, benefiting GPs' work situation as well as their patients' well-being. The GP's role as a gatekeeper in the social security system needs further exploration. Our findings could be used to develop a questionnaire to measure the distribution of different views in a wider population of GPs.</p

In vivo photosensitizer tomography inside the human prostate

Interstitial photodynamic therapy (IPDT) provides a promising means to treat large cancerous tumors and solid organs inside the human body. The treatment outcome is dependent on the distributions of light, photosensitizer, and tissue oxygenation. We present a scheme for reconstructing the spatial distribution of a fluorescent photosensitizer. The reconstruction is based on measurements performed in the human prostate, acquired during an ongoing IPDT clinical trial, as well as in optical phantoms. We show that in an experimental setup we can quantitatively reconstruct a fluorescent inclusion in a fluorescent background. We also show reconstructions from a patient showing a heterogeneous distribution of the photosensitizer mTHPC in the human prostate. (C) 2009 Optical Society of Americ

Comparison of spatially and temporally resolved diffuse-reflectance measurement systems for determination of biomedical optical properties

Time-resolved and spatially resolved measurements of the diffuse reflectance from biological tissue are two well-established techniques for extracting the reduced scattering and absorption coefficients. We have performed a comparison study of the performance of a spatially resolved and a time-resolved instrument at wavelengths 660 and 785 nm and also of an integrating-sphere setup at 550-800 nm. The first system records the diffuse reflectance from a diode laser by means of a fiber bundle probe in contact with the sample. The time-resolved system utilizes picosecond laser pulses and a single-photon-counting detection scheme. We extracted the optical properties by calibration using known standards for the spatially resolved system, by fitting to the diffusion equation for the time-resolved system, and by using an inverse Monte Carlo model for the integrating sphere. The measurements were performed on a set of solid epoxy tissue phantoms. The results showed less than 10% difference in the evaluation of the reduced scattering coefficient among the systems for the phantoms in the range 9-20 cm(-1), and absolute differences of less than 0.05 cm(-1) for the absorption coefficient in the interval 0.05-0.30 cm(-1). (C) 2003 Optical Society of America

Light Scattering By Multiple Red Blood Cells

The interaction of light with multiple red blood cells was systematically investigated by the finite-different time-domain method. The simulations show that the lateral multiple scattering between red blood cells is very weak. The polarization is shown to have an almost insignificant influence on the distribution of the scattered light. The numerical results were compared with three approximate methods: the superposition approximation, the Rytov approximation and the discrete dipole approximation. The agreement was very good

Fluorescence spectra provide information on the depth of fluorescent lesions in tissue

The fluorescence spectrum measured from a fluorophore in tissue is affected by the absorption and scattering properties of the tissue, as well as by the measurement geometry. We analyze this effect with Monte Carlo simulations and by measurements on phantoms. The spectral changes can be used to estimate the depth of a fluorescent lesion embedded in the tissue by measurement of the fluorescence signal in different wavelength bands. By taking the ratio between the signals at two wavelengths, we show that it is possible to determine the depth of the lesion. Simulations were performed and validated by measurements on a phantom in the wavelength range 815-930 nm. The depth of a fluorescing layer could be determined with 0.6-mm accuracy down to at least a depth of 10 mm. Monte Carlo simulations were also performed for different tissue types of various composition. The results indicate that depth estimation of a lesion should be possible with 2-3-mm accuracy, with no assumptions made about the optical properties, for a wide range of tissues

Disgusting as it may be to us - en analys av identitetsskapande i Ugandas antigaydiskurs

Uganda antog i februari 2014 Anti-Homosexuality Act 2014 vilket fått stor uppmärksamhet internationellt. Argumenten för lagen har till stor del handlat om att homosexualitet är ett hot mot den ugandiska kulturen, och syftet med denna studie är att undersöka hur vi kan förstå vilken roll antigaydiskursen i Uganda spelar i formandet av en nationell identitet. Denna fråga besvaras med hjälp av diskursteoretisk analys vilken utgår från modellen problem – orsak – lösning genom vilket temana Homosexuella som ett hot, Homosexualitet och Väst samt Religion och normalitet urskiljs. Utifrån dessa teman konstrueras analogikedjor för att blottlägga de föreställningar som den ugandiska identiteten förknippas med. Analysen finner att homosexuella konstrueras som en separat grupp som inte är delaktig i det ugandiska samhället. Istället ses homosexuella som ett hot mot majoritetsbefolkningen med starka kopplingar till västerländsk kolonialism. Ugandierna konstrueras som beskyddare av de svaga, agerande i självförsvar när deras existens hotas