Depression and cardiac surgery

Cardiovascular disease and depression are likely to be two of the three leading causes of global burden of disease. Depression is common in patients with coronary artery disease and is independently associated with increased cardiovascular morbidity and mortality. The incidence of major depressive disorder is two to three times higher in patients with cardiovascular disease than in the general population. In patients with coronary artery disease, clinically significant depression is prevalent in 31% to 45% of patients. Moderate to severe depression before coronary artery bypass grafting (CABG) is an indicator of worse long-term survival. The overall aim of this thesis was to study the association between depression and cardiovascular morbidity and mortality in patients undergoing cardiac surgery by epidemiological methods and cross-linking of national Swedish registers. Study I investigated the association between preoperative antidepressant use and long- term survival following primary isolated CABG. Of 10884 patients 11% were using antidepressants before surgery. After multivariable adjustment, antidepressant use was associated with increased mortality hazard ratio (HR) 1.45; 95% confidence interval (CI) 1.18–1.77, compared with non-use of antidepressants. Antidepressant use was also associated with an increased risk of rehospitalization (HR1.40; 95% CI 1.19–1.65) and the composite endpoint rehospitalization or death (HR 1.44; 95% CI 1.26–1.65). Study II We hypothesized that depressed patients would have lower use of guideline- directed medical therapy for secondary prevention of cardiovascular events following CABG. We included all 10586 patients who underwent primary isolated CABG in Sweden between 2006 and 2008. During the first year after CABG, 93% of all patients had at least two dispensed prescriptions for an antiplatelet agent, 68% for an ACEI/ARB, 91% for a beta-blocker, and 92% for a statin. 57% had prescriptions for all four medication classes. After four years (n=4034), 44% had filled prescriptions for all four medication classes. Preoperative depression was not significantly associated with a lower use of all four medication classes. Study III investigated major depression in 56064 patients who underwent primary, isolated, non-emergent CABG. During a mean follow-up of 7.5 years, 114 patients (35%) with depression died, compared with 13767 patients (25%) in the control group. Depression was significantly associated with increased mortality and the combined end point of death or rehospitalization for MI, heart failure, or stroke (multivariable- adjusted HR 1.65 95% CI 1.37 to 1.99 and 1.61, 1.38 to 1.89, respectively). Study IV investigated if socioeconomic factors modified the association between preoperative depression and survival following CABG. Antidepressant use was a proxy for depression. During a mean follow-up of 4.1 years, 11% patients died in the antidepressant group and 9.7% patients died in the control group. The adjusted risk for death was higher in patients with preoperative antidepressant use (HR 1.27; 95% CI 1.13–1.43), and was practically unchanged after the addition of educational level, family disposable income, and civil status (HR 1.25; 95% CI 1.11–1.41). Study V was a systematic review and meta-analysis performed to provide a summary estimate of the association between preoperative depression and long-term survival after CABG. Seven studies were included with a combined study population of 89490 patients (4002 depressed/85488 non-depressed). All studies observed a positive association between preoperative depression and all-cause mortality, and in 4 studies the association was statistically significant. Patients with depression had a pooled HR of 1.46 (95% CI: 1.23-1.73, p<0.001) for all-cause mortality with moderate heterogeneity (I2 = 50.1% p=0.061). In conclusion depression is a significant, independent risk factor, in patients with cardiovascular disease and should be considered as important as other well-known risk factors like for example heart failure and chronic kidney disease in patients undergoing CABG

Guideline-directed medical therapy for secondary prevention after coronary artery bypass grafting in patients with depression

AbstractBackgroundWe hypothesized that depressed patients would have lower use of guideline-directed medical therapy for secondary prevention of cardiovascular events following coronary artery bypass grafting (CABG).MethodsWe included all patients who underwent primary isolated CABG in Sweden between 2006 and 2008. We cross-linked individual level data from national Swedish registers. Preoperative depression was defined as at least one antidepressant prescription dispensed before surgery. We defined medication use as at least two dispensed prescriptions in each medication class (antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blocker (ARB), and statins) within a rolling 12 month period. We calculated adjusted risk ratios (RR) for the use of each medication class, and for all four classes, after one and four years, respectively.ResultsDuring the first year after CABG, 93% of all patients (n = 10,586) had at least two dispensed prescriptions for an antiplatelet agent, 68% for an ACEI/ARB, 91% for a beta-blocker, and 92% for a statin. 57% had prescriptions for all four medication classes. After four years (n = 4034), 44% had filled prescriptions for all four medication classes. Preoperative depression was not significantly associated with a lower use of all four medication classes after one year (RR 0.98, 95% confidence interval (CI) 0.93–1.03) or after four years (RR 0.97, 95% CI 0.86–1.09).ConclusionsPreoperative depression was not associated with lower use of guideline-directed medical therapy for secondary prevention after CABG. These findings suggest that the observed higher mortality following CABG among depressed patients is not explained by inadequate secondary prevention medication

Up-regulation of endothelin type B receptors in the human internal mammary artery in culture is dependent on protein kinase C and mitogen-activated kinase signaling pathways

<p>Abstract</p> <p>Background</p> <p>Up-regulation of vascular endothelin type B (ET_B) receptors is implicated in the pathogenesis of cardiovascular disease. Culture of intact arteries has been shown to induce similar receptor alterations and has therefore been suggested as a suitable method for, <it>ex vivo</it>, in detail delineation of the regulation of endothelin receptors. We hypothesize that mitogen-activated kinases (MAPK) and protein kinase C (PKC) are involved in the regulation of endothelin ET_Breceptors in human internal mammary arteries.</p> <p>Methods</p> <p>Human internal mammary arteries were obtained during coronary artery bypass graft surgery and were studied before and after 24 hours of organ culture, using <it>in vitro </it>pharmacology, real time PCR and Western blot techniques. Sarafotoxin 6c and endothelin-1 were used to examine the endothelin ET_Aand ET_Breceptor effects, respectively. The involvement of PKC and MAPK in the endothelin receptor regulation was examined by culture in the presence of antagonists.</p> <p>Results</p> <p>The endohtelin-1-induced contraction (after endothelin ET_Breceptor desensitization) and the endothelin ET_Areceptor mRNA expression levels were not altered by culture. The sarafotoxin 6c contraction, endothelin ET_Breceptor protein and mRNA expression levels were increased after organ culture. This increase was antagonized by; (1) PKC inhibitors (10 μM bisindolylmaleimide I and 10 μM Ro-32-0432), and (2) inhibitors of the p38, extracellular signal related kinases 1 and 2 (ERK1/2) and C-jun terminal kinase (JNK) MAPK pathways (10 μM SB203580, 10 μM PD98059 and 10 μM SP600125, respectively).</p> <p>Conclusion</p> <p>In conclusion, PKC and MAPK seem to be involved in the up-regulation of endothelin ET_Breceptor expression in human internal mammary arteries. Inhibiting these intracellular signal transduction pathways may provide a future therapeutic target for hindering the development of vascular endothelin ET_Breceptor changes in cardiovascular disease.</p

Iäkkään muistisairaan kohtaamisen menetelmät- kuvaileva kirjallisuuskatsaus

Tämän opinnäytettyön aiheena on iäkkään muistisairaan potilaan kohtaamisen mentelmät. Opinnäytettyön työelämäkummpani on Hugo & Maria Winbergin säätiö, tarkemmin heidän senioriasumisyksikkö, Tunaberg. Tutkimuksen tarkoitus on kuvailla iäkkään muistisairaan potilaan kohtaamisen menetelmiä. Tavoite on, että Tunabergin henkilökunta pystyy hyödyntämään opinnäytetyön avulla tuotettua tietoa ja kehittää osaamistaan niin että kohtaaminen, kommunikointi ja kanssakäyminen muistisairaan potilaan kanssa heidän yksikössään olisi molemmin puolin mahdollisimman sujuvaa ja helppoa. Opinnäytettyö toteutettiin kuvailevana kirjallisuuskatsauksena. Aineistoa kerättiin tutkimuskysymyksiin pohjautuvilla hakusanoilla enimmäkseen sähköisiä tietokantoja hyödyntäen mutta myös manuaalihakua ja kirjallisuutta käyttäen. Kerätty aineistoa analysoitiin ja luokiteltiin induktiivista sisällönanalyysia hyödyntämällä. Iäkkäitä muistisairaita on Suomessa paljon ja luvut vain kasvavat. Heille täytyy pystyä tarjoamaan hyvää, laadukasta ja turvallista hoitoa. Tähän tarvitaan tietynlaista osaamista ja mahdollisesti jatkokoulutusta. Tunabergin henkilökunta on tuonut tämän tarpeen esille ja siksi tämä opinnäytetyö on ajankohtainen ja tarpeellinen heille. Kyseinen tarve on varmasti myös ajankohtainen muissa yksiköissä missä kohdataan ja hoidetaan iäkkäitä muistisairaita. Tuloksien perusteella iäkkään muistisairaan kohtaaminen koostuu potilaan yksilöllisestä ja ammattitaitoisesta kohtaamisesta sekä hoitajan osaamisesta ja kokemuksesta hoitaa iäkästä muistisairasta ihmistä. Isossa roolissa tuli esiin kommunikaation merkitys ja siihen liittyvä koulutustarve hoitajilla. Tuttu ja turvallinen hoitoympäristö ja läheisten kanssa sujuva yhteistyö vaikuttaa muistisairaan kohtaamiseen

RELATIONEN ARBETE &amp; PRIVATLIV : Enhetschefers upplevelser och strategier i relation till sin hälsa

Syftet med denna studie var att ta reda på hur enhetschefer inom Umeå Kommun upplever relationen mellan arbete och privatliv i förhållande till sin upplevda hälsa. Nio semistrukturerade intervjuer genomfördes för att tolka, förstå och förmedla enhetschefernas upplevelser. Resultatet visade på något skilda upplevelser gällande relationen mellan arbete och privatliv och kopplingen till hälsa. Upplevelsen av att ha en bra balans mellan arbete och privatliv framkom men enhetscheferna upplevde också att arbetslivet i perioder tog allt för stor plats i privatlivet. Enhetscheferna upplevde vissa svårigheter med att släppa tankarna på arbete utanför arbetstid vilket i sin tur kunde leda till stress och sömnsvårigheter. Samtliga enhetschefer upplevde att privatlivet inte inverkade på arbetslivet i någon större utsträckning. Positiva faktorer som bidrog till att balansera arbete och privatliv var möjligheten till flexibel arbetstid och organisatoriskt stöd i form av exempelvis företagshälsovård. Planering och framförhållning, att lämna sin arbetstelefon och dator på kontoret samt att prioritera var strategier som framkom för att lättare hantera relationen mellan arbete och privatliv

Case Company X : A green company of today

The textile business is one of the oldest industries of our time, and it employs nearly 1.4 million workers within the European Union alone. It is not unusual that this is the foundation of a country’s industrialisation. Even though the industry brings many positive factors, there are also negative factors that will influence the industry’s growth in the future. One of the textile industry’s largest negative factor is the effect it has on the environment.The current recession that is effecting our society is spreading all over the world. It is for the future to decide what kind of fashion companies that will survive. According to analysts, it is the companies with a nisch that are mostly expected to survive, for example, Case Company X which is working with design, production and sales of ecological fashion clothes. It is therefore important and relevant for Case Company X to make not only short but also long-term strategies to keep up with the fashion industry’s competition and dynamic development.The purpose of this study is to identify the main target group for Case Company X and to present possible sales channels and strategies for the company.We have used the hermeneutical perspective since the different research areas can be seen as a whole. Our method of working has been abduction, since we have chosen to alternate between empirical data and theory. The study combines both qualitative and quantitative methods. The qualitative method has been used to make deeper research within Case Company X, and the quantitative method has been used in the work with the questionnaire to try and find the company’s main target group. According to which part of the study that has been researched, the choice of data has varied. To make the study more reliable, we have chosen to use both primary and secondary data.We have been able to identify the main target group and we have also been able to suggest suitable future sales channels and strategies for the company. The main target group for Case Company X are working women aged between 20-45, with a middle to high income, and who buy clothes on average once a month.Taken together, our results indicate that the following two factors are important in the choice of sales channels for Case Company X, (i) how the company and its brand can be introduced to the high street i.e. sold in shops like Mouche, NK Designers, NK Mode, Grace, Solo, and Venti Nove (ii), how the staff can effectively explain the positive effects of ecological clothes. We believe that Drömma, Åhléns, Hildur as well as Case Company X own website are retailers of interest.IIWe recommend that Case Company X should only work with one segment and try to satisfy one specific target group. Therefore, we suggest that Case Company X initially should establish itself as a nisch company on the Swedish market.Program: Textilekonomutbildninge

Banken blir inte bättre än rådgivaren du träffar : En jämförande fallstudie om hur belöningssystem motiverar personal som utför avancerade tjänster

To manage peoples’ behaviors in different directions has become increasingly important, especially in the business of services, where employees are the organization's greatest competitive advantage. This study is limited to the banking- and finance industry, which belongs to a category of advanced services. In this industry, where customer relationships are directly linked to the advisers, it is critical for organizations to motivate its staff to sustain and perform in the workplace. Reward systems have become one of the most frequently used instruments for an organization to motivate its staff. Earlier research claims that reward system motivates employees to perform profitable for banks, and it tends to describe reward systems as completely comparable. The purpose of this study is to explain how long-term and short-term reward system influences employees’ motivation within the category of advanced services. The study intends to examine both how reward system affects employees’ propensity to remain in the workplace, and how the different time perspectives of the reward system motivates employees to achieve corporate goals. In order to answer the research question of the study a qualitative study were used, where a comparison was made between the two chosen companies with different reward systems within the chosen industry. The empirical data was collected through interviews. The study presented that the reward system is not a motivating factor in any of the two companies. What rather motivated the employees were factors such as a good working environment, opportunities for progress, and other soft rewards. The result showed that it is important to the employees how they are perceived by their surroundings, which displaces the individual goals. The reward systems will thus be inadequate and needs to be reformed.Keywords: Financial control, reward system, motivation, advanced services, consulting, customer relationship.Validerat; 20150818 (global_studentproject_submitter

Banken blir inte bättre än rådgivaren du träffar : En jämförande fallstudie om hur belöningssystem motiverar personal som utför avancerade tjänster

To manage peoples’ behaviors in different directions has become increasingly important, especially in the business of services, where employees are the organization's greatest competitive advantage. This study is limited to the banking- and finance industry, which belongs to a category of advanced services. In this industry, where customer relationships are directly linked to the advisers, it is critical for organizations to motivate its staff to sustain and perform in the workplace. Reward systems have become one of the most frequently used instruments for an organization to motivate its staff. Earlier research claims that reward system motivates employees to perform profitable for banks, and it tends to describe reward systems as completely comparable. The purpose of this study is to explain how long-term and short-term reward system influences employees’ motivation within the category of advanced services. The study intends to examine both how reward system affects employees’ propensity to remain in the workplace, and how the different time perspectives of the reward system motivates employees to achieve corporate goals. In order to answer the research question of the study a qualitative study were used, where a comparison was made between the two chosen companies with different reward systems within the chosen industry. The empirical data was collected through interviews. The study presented that the reward system is not a motivating factor in any of the two companies. What rather motivated the employees were factors such as a good working environment, opportunities for progress, and other soft rewards. The result showed that it is important to the employees how they are perceived by their surroundings, which displaces the individual goals. The reward systems will thus be inadequate and needs to be reformed.Keywords: Financial control, reward system, motivation, advanced services, consulting, customer relationship.Validerat; 20150818 (global_studentproject_submitter

Arbetsgivares utrednings- och åtgärdsskyldighet : Vid trakasserier och sexuella trakasserier

Validerat; 20140220 (global_studentproject_submitter