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Keratoconus generally manifests in adolescents, and can progress leading to severely impaired vision. The risk of progression is inversely correlated to age; thus younger patients are at higher risk than older ones. Progressive keratoconus can be halted by corneal crosslinking (CXL). The general indication for CXL is progressive keratoconus, although children are commonly treated with CXL upon diagnosis. Tomography is used to assess progression, and the most commonly used system is the Pentacam HR. Measurements made on different visits are compared to determine whether the patient’s keratoconus has progressed, and they should be referred for CXL. However, there is no consensus on which parameters should be used, or the change in magnitude of these parameters that indicates progression. An increase in the curvature power of the steepest point on the anterior surface, Kmax, of 1.0 dioptres is commonly used for all patients. However, there is little evidence that this is appropriate. Furthermore, inconsistent results have been presented regarding the magnitude at which progression can be detected. Such studies are often based on determinations of the repeatability of measurements made on one occasion. However, the progression of keratoconus is evaluated from measurements made on different occasions, and it is reasonable to assume that measurements obtained on different days will be subject to greater variation due to the biomechanical instability of corneae affected by keratoconus. Also, it has been suggested in studies that the repeatability of measurements in subjects with more severe keratoconus have poorer repeatability. Another important aspect of keratoconus is that it is a thinning disorder. A minimum corneal thickness of 400 µm has been suggested for the safe performance of CXL. Thus, a significant proportion of keratoconus patients will be excluded from the standard CXL treatment protocol.Thus, in the first study we elucidated the association between measurement error and disease severity. In the second investigation we investigated the inter-day repeatability and in the third investigation we investigated the Belin ABCD Progression Display. In the fourth study we investigate a protocol in which sterile water was added during the crosslinking procedure to increase the corneal thickness. The results demonstrated that the measurement error is associated to the disease severity and that limits at which progression is defined should be defined by inter-day measurements. The results also suggest that the diagnosis of progressive keratoconus by the Belin ABCD Progression Display will lead to overdiagnosis of progression. Further, the results suggest that the addition of sterile water is effective in increasing the corneal thickness above the suggested safety limits. These results have important clinical implications. The results demonstrate that limits at which progression is defined should be stratified according to the severity of the disease. Patients with less advanced keratoconus will be underdiagnosed as progressive if commonly used parameters are not stratified according to disease severity. This could lead to delayed referral for CXL, resulting in an avoidable risk of deterioration in vision. Patients with more advanced keratoconus, on the other hand, would be overdiagnosed as progressive, which could lead to unnecessary CXL, thus subjecting the patient to discomfort and possible treatment-associated complications. This risk of overdiagnosis of progression is also relevant when using the Belin ABCD Progression Display. Further, The data suggest that such a simple measure as adding sterile water during corneal crosslinking could enhance the corneal thickness above safety limits.

BACKGROUND: Progressive keratoconus can lead to severely impaired vision, but there is currently no consensus on the definition of progressive disease. Errors in the measurement of the parameters commonly used to establish progressive disease were evaluated in an attempt to determine the limits at which a true change in the values can be detected. The possible association between measurement error and disease severity was also investigated to evaluate the need for limits based on disease severity.METHODS: Sixty-one eyes were studied in 61 patients with keratoconus. Four replicate measurements were made in each patient using a Scheimpflug-based tomographic system (denoted the PC) and an auto-keratometer (denoted the AK). The repeatability coefficient, i.e., the level below which differences between two measurements are found in 95% of paired observations, was calculated. Patients were further divided into three groups based on disease severity (parameter magnitude).RESULTS: Increasing magnitude of all the keratometric parameters investigated was significantly associated with increasing measurement errors, and thus worse repeatability. The maximum keratometry value (Kmax) was the least repeatable parameter (1.23 D, 95% CI 1.11-1.35 D) and showed the strongest association between parameter magnitude and measurement error. The repeatability coefficient ranged between 0.32 and 1.62 D, depending on disease severity. The most repeatable parameter was the flattest central keratometry value (K1), measured with the PC (0.51 D, 95% CI 0.46-0.56 D) and the AK (0.54 D, 95% CI 0.48-0.59 D). K1 showed the weakest association between parameter magnitude and measurement error. The repeatability coefficient for K1 ranged between 0.40 and 0.54 D when using the PC, and between 0.34 and 0.70 D when using the AK in the three groups.CONCLUSIONS: The association between the magnitude of the keratometric parameters and their measurement errors suggests that limits should be based on disease severity to ensure reliable detection of progressive keratoconus. Further studies are, however, required.

Bakgrund Mäns våld mot kvinnor är ett globalt hälsoproblem, som spänner över såväl religiösa, geografiska som socioekonomiska gränser. En metod för att hitta dessa kvinnor är att administrera ett så kallat screeningverktyg eller frågeformulär. De tillgängliga verktygen är många och inget anses än vara vedertaget inom svensk hälso- och sjukvård. Syfte Att sammanställa en översikt av olika screeningverktyg som kan hjälpa sjuksköterskan att upptäcka mäns våld mot kvinnor. Metod Litteraturöversikt i form av en beskrivande sammanställning, baserad på tolv vetenskapliga artiklar av kvalitativ ansats. Resultat En sammanställning av sex screeninginstrument (ASI, HITS, PVS, STaT, WAST och WEB) presenteras. Frågeformulärens sensitivitet och specificitet redovisas, exempel på frågor samt styrkor och svagheter i formuläret beskrivs. Slutsats De sex beskrivna screeninginstrumenten har ett gemensamt syfte, att upptäcka våld. De skiljer sig åt i psykometriska egenskaper och är svåra att jämföra med varandra. En beskrivande översikt har utformats där läsaren själv kan bilda sig en uppfattning. Klinisk betydelse Översikten i denna uppsats skulle kunna hjälpa verksamheter i vården att lättare välja ut ett frågeformulär för våldsscreening som passar för just den verksamheten. Background Intimate partner violence is a global health issue concerning women, spanning across religious, geographic and socioeconomic boundaries. One way of finding these women is by administrating a screening tool, or questionnaire. There are many tools available but none of them are established in the Swedish healthcare system. Aim To compile an overview of different screening tools that can help the nurse to detect intimate partner violence. Method A literature overview in form of a descriptive compilation, based on twelve scientific articles of quantitative research. Result A presentation of six screening tools (ASI, HITS, PVS, STaT, WAST and WEB). The sensitivity, specificity and pros and cons of each questionnaire are described. Conclusion The six described screening instruments were all made to detect violence. They differ in psychometric properties and are difficult to compare. A descriptive overview has been designed where the reader himself can make an opinion. Clinical significance Intimate partner violence is a big health issue and it is of the out most concern that it is made public and that the women affected gets help. The screening tools presented may be the first step towards that.