Changes to ISO 14001: Effects on companies

ISO 14001:2004 is the most commonly used standard for third-party certification of Environmental Management Systems (EMS) in the world. It is currently undergoing an upgrading process, which will affect all the companies certified to ISO 14001. A first draft has been produced, the Committee Draft 1 (CD1). The thesis has two research questions: What are the most likely changes in the new version of ISO 1400 standard compared with the current version (ISO 14001:2004)? How will these likely changes affect the EMS of companies that are already using ISO 14001? From the CD1, seven major categories of changes were identified: strategy, leadership, environmental aspects and the value chain, environmental performance indicators, evaluation, communication and environmental design. The first two groups bring substantial change in the nature of ISO 14001, demanding that companies address their EMS on a strategic level as well as previously on an operational level. This will mean a considerable change on the EMS of most companies. The CD1 also places greater demands on the top management, with the need to understand the organisation and its context, and to take the environmental performance into the general strategic planning of the company. The other five groups can be seen as more of an extension of the former requirements of the ISO 14001 standard. Some of them will still however bring substantial change for companies, such as the need to add the value chain in the evaluation of environmental aspects. These seven groups formed a framework, which was used for gap analysis of the EMS of two Swedish companies, Nolato Gota and Haldex Landskrona. The two companies researched here are in the forefront of the corporate sustainability field. The resulting gap between the EMS of the companies and the CD1, identified in the gap analysis, revealed that the companies need to make a number of changes and updates in their ISO 14001 to meet the new demands as proposed in the CD1. Other companies than Nolato and Haldex, that are less mature in the implementation of ISO standards and other voluntary sustainability guidelines and initiatives, will most likely need to change their EMS more fundamentally

Aspects of Abnormal Glucose Regulation in Various Manifestations of Coronary Artery Disease

Background Diabetes is common among patients with coronary artery disease (CAD) and is associated with an approximate doubling of the mortality risk in this patient population. Prediabetes, an intermediate glycometabolic state between normal and diabetic glucose homeostasis, is also prevalent in patients with CAD but its prognostic impact has not been studied in detail. The optimal glucose-lowering treatment in CAD patients has been the subject of debate. Aims 1. To evaluate the association between admission glycaemia and future disturbance in glucose regulation, and mortality in patients with acute coronary syndrome (ACS). 2. To describe the association between diabetes and outcome after in-hospital cardiac arrest. 3. To evaluate the prevalence and the prognostic impact of abnormal glucose regulation after coronary artery bypass grafting (CABG). 4. To investigate whether increased mortality rates in insulin treated patients with type 2 diabetes and CAD can be explained by comorbidities. Study population This thesis is based on observational studies of four different study populations. To evaluate the association between admission glycaemia and future disturbance in glucose regulation (Study I) and mortality (Study II) we used data from the PRACSIS study comprising patients with ACS admitted to the coronary care unit at Sahlgrenska University Hospital, Gothenburg, between 1995 and 2001. Data on 1,810 patients, treated for in-hospital cardiac arrest between 1994 and 2006 at Sahlgrenska University Hospital and nine other hospitals in Sweden were used to analyse the association between diabetes and outcome (Study III). The prevalence and impact of abnormal glucose regulation were assessed in 276 patients undergoing CABG at Sahlgrenska University Hospital between 2003 and 2006 (Study IV). Data on 12,515 patients with type 2 diabetes undergoing coronary angiography between 2001 and 2009 were obtained from the NDR and the SCAAR registries and the association between glucose-lowering treatment and long-term mortality was analysed (Study V). Admission hyperglycaemia in patients with ACS In 762 ACS patients without known diabetes, the prevalence of diabetes at the 2.5 year follow-up increased with rising admission glucose, from 5% in those with plasma glucose of <6.1 mmol/l to 24% in those with plasma glucose of ≥7.0 mmol/l. Among 1,957 patients with ACS, admission hyperglycaemia defined as plasma glucose >9.4 mmol/l, was found to be an independent predictor of both 30-day mortality (HR 4.13, 95% CI: 2.54-6.70, p<0.0001) and late mortality (HR 1.57, 95% CI: 1.02-2.41, p=0.04) in patients without known diabetes. In patients with diabetes admission hyperglycaemia was an independent predictor of late mortality (HR 2.14, 95% CI: 1.21 to 3.78, p=0.009). Diabetes and survival after in-hospital cardiac arrest The in-hospital mortality rate was higher among patients with diabetes than among those without (70.7% vs 62.4%, p=0.001). The adjusted odds ratio of being discharged alive for patients with diabetes was 0.57 (95% CI: 0.40-0.79). Abnormal glucose regulation and prognosis after CABG Two-thirds (65%) of the patients undergoing CABG had either prediabetes or diabetes. During a mean follow-up period of 5.3 years there was a successive increase in the primary endpoint rate (a composite of all-cause mortality and hospitalisation for a cardiovascular event) from normoglycaemia through prediabetes to diabetes (adjusted HR 1.40; 95% CI, 1.01 to 1.96; p=0.045). Glucose-lowering treatment and prognosis Compared with diet treatment alone, insulin in combination with oral glucose-lowering treatment (adjusted HR 1.22; CI 1.06 to 1.40; p<0.005) and treatment with insulin alone (adjusted HR 1.17; CI 1.02 to 1.35; p<0.01) were independent predictors of long-term mortality in patients with type 2 diabetes undergoing coronary angiography. Conclusions These observational studies show that abnormal glucose regulation is prevalent and predicts a poor prognosis in patients with various manifestations of coronary artery disease. Not only patients with diabetes but also patients with acute phase hyperglycaemia and hyperglycaemia in the non-diabetic range appear to run an increased risk of unfavourable outcome. Treatment with insulin in type 2 diabetic patients undergoing coronary angiography predicts long-term mortality risk even after adjustment for comorbidities. Whether or not this association is causal remains to be clarified

Reduction in Restraints Following a Functional Analysis of Severe Problem Behavior and Communication Training

We combined a functional analysis of precursors and problem behavior with subsequent communication training to reduce time spent in restraint. The patient was a man in his thirties with autism and life-long severe problem behaviors resulting in restraint. The highest frequencies of both problem behavior and precursors were observed in the demand conditions of the functional analysis. However, the precursors were observed across all conditions. Based on these findings we introduced functional communication training to establish an alternative functional response. He was taught to ask for a break when demands where presented, first in an analog setting and later in natural settings throughout his daily life. This resulted in a significant reduction in problem behavior and what followed was a significant reduction in the time spent in restraints. The much-reduced level of restraint was maintained in the patient’s natural environment at a 12-month follow-up assessment. Our findings suggest that a functional analysis and functional communication training may be an approach to consider when the ultimate goal is to reduce the time spent in restraint. These findings need to be replicated with a better experimental design

Trening av Verbale Operanter og Differensiell Forsterkning Fører til Økning i Passende Vokalisering og Reduksjon i Upassende Vokalisering: Et Kasus Studie Basert på en Funksjonell Analyse.

Hyppig upassende vokalisering kan medføre stigmatisering og en rekke uheldige begrensninger i dagliglivet. Vi har undersøkt om upassende vokalisering kan reduseres ved først å identifisere denne atferdens funksjon og så etablere passende vokale operanter med samme funksjon. Studiens deltaker var en mann i 30 årene med diagnosen autisme, moderat utviklingshemning og bipolar lidelse. Den upassende vokaliseringens funksjon ble identifisert gjennom en interview-informed synthesized contingency analysis (IISCA). Dette innebærer en indirekte og deskriptiv funksjonell kartlegging og en påfølgende skreddsydd funksjonell analyse. Denne analysen tilsa at den upassende vokaliseringen var under kontroll av oppmerksomhet. Det ble derfor utarbeidet et tiltak som besto av trening av verbale operanter med samme funksjon og differensiell forsterkning av passende vokalisering. Gjennom en tiltaksanalyse arrangert i en multiple probe design ble effektene av tiltakene evaluert. Tiltakene førte til en reduksjon i upassende vokalisering, og en økning i passende vokalisering over to ulike settinger. Studien ble gjennomført i en kommunal bolig og kan være et eksempel på et pragmatisk og sosialt valid atferdsanalytisk tiltak

No obesity paradox in out-of-hospital cardiac arrest: Data from the Swedish registry of cardiopulmonary resuscitation

Background: Although an “obesity paradox”, which states an increased chance of survival for patients with obesity after myocardial infarction has been proposed, it is less clear whether this phenomenon even exists in patients suffering out-of-hospital cardiac arrest (OHCA) and if diabetes, which is often associated with obesity, implies an additional risk. Objective: To investigate if and how obesity, with or without diabetes, affects the survival of patients with OHCA. Methods: This study included 55,483 patients with OHCA reported to the Swedish Registry of Cardiopulmonary Resuscitation between 2010 and 2020. Patients were classified in five groups: obesity only (Ob), type 1 diabetes only (T1D), type 2 diabetes only (T2D), obesity and any diabetes (ObD), or belonging to the group other (OTH). Patient characteristics and outcomes were studied using descriptive statistics, logistic, and Cox proportional regression. Results: Obesity only was found in 2.7% of the study cohort, while 3.2% had obesity and any type of diabetes. Ob patients were significantly younger than all other patients (p ≤ 0.001); the 30 day-survival was 9.6% in Ob, and 10.6%, 7.3%, 6.9%, and 12.7% in T1D, T2D, ObD, and OTH, respectively, with OR (95% CI) of 0.69 (0.57–0.82), 0.78 (0.56–1.05), 0.65 (0.59–0.71), and 0.55 (0.45–0.66) for Ob, T1D, T2D, and ObD, respectively (reference group OTH). No time-related trends in 30-days survival were found. Conclusion: Obesity was present in 6% of the population and was associated with younger age and a 30% reduction in survival; a combination of obesity and diabetes further reduced the survival rate

Change in mitral regurgitation severity impacts survival after transcatheter aortic valve replacement

Background: The impact of a change in mitral regurgitation (MR) following TAVR is unknown. We studied the impact of baseline MR and early post-procedural change in MR on survival following TAVR. Methods: The SWEDEHEART registry included all TAVRs performed in Sweden. Patients were dichotomized into no/mild and moderate/severe MR groups. Vital status, echocardiographic data at baseline and within 7 days after TAVR were analyzed. Results: 1712 patients were included. 1404 (82%) had no/mild MR and 308 (18%) had moderate/severe MR. Baseline moderate/severe MR conferred a higher mortality rate at 5-year follow-up (adjusted HR 1.29, CI 1.01–1.65, p = 0.04). Using persistent ≤mild MR as the reference, when moderate/severe MR persisted or if MR worsened from ≤mild at baseline to moderate/severe after TAVR, higher 5-year mortality rates were seen (adjusted HR 1.66, CI 1.17–2.34, p = 0.04; adjusted HR 1.97, CI 1.29–3.00, p = 0.002, respectively). If baseline moderate/severe MR improved to ≤mild after TAVR no excess mortality was seen (HR 1.09, CI 0.75–1.58, p = 0.67). Paravalvular aortic regurgitation (PVL) was inversely associated with MR improvement after TAVR (OR 0.4, 95%: CI 0.17–0.94; p = 0.034). Atrial fibrillation (OR 2.1, 95% CI: 1.27–3.39, p = 0.004), self-expanding valve (OR 3.8, 95% CI: 2.08–7.14, p < 0.0001), and PVL (4.3, 95% CI 2.32–7.78. p < 0.0001) were associated with MR worsening. Conclusions: Moderate/severe baseline MR in patients undergoing TAVR is associated with a mortality increase during 5 years of follow-up. This risk is offset if MR improves to ≤mild, whereas worsening of MR after TAVR is associated with a 2-fold mortality increase