Long-term prognosis after a first myocardial infarction: eight years follow up of the case-control study PAROKRANK.

Objective. To explore long-term cardiovascular outcomes and mortality in patients after a first myocardial infarction (MI) compared with matched controls in a contemporary setting. Methods. During 2010-2014 the Swedish study PAROKRANK recruited 805 patients <75 years with a first MI and 805 age-, gender-, and area-matched controls. All study participants were followed until 31 December 2018, through linkage with the National Patient Registry and the Cause of Death Registry. The primary endpoint was the first of a composite of all-cause death, non-fatal MI, non-fatal stroke, and heart failure hospitalization. Event rates in cases and controls were calculated using a Cox regression model, subsequently adjusted for baseline smoking, education level, and marital status. Kaplan-Meier curves were computed and compared by log-rank test. Results. A total of 804 patients and 800 controls (mean age 62 years; women 19%) were followed for a mean of 6.2 (0.2-8.5) years. The total number of primary events was 211. Patients had a higher event rate than controls (log-rank test p < .0001). Adjusted hazard ratio (HR) for the primary outcome was 2.04 (95% CI 1.52-2.73). Mortality did not differ between patients (n = 38; 4.7%) and controls (n = 35; 4.4%). A total of 82.5% patients and 91.3% controls were event-free during the follow up. Conclusions. In this long-term follow up of a contemporary, case-control study, the risk for cardiovascular events was higher in patients with a previous first MI compared with their matched controls, while mortality did not differ. The access to high quality of care and cardiac rehabilitation might partly explain the low rates of adverse outcomes.

[Residential multimodal job focused rehabilitation for teachers increases return to work]. / Internatbehandling hjälper lärare med utmattningssyndrom tillbaka i arbete - En kontrollerad studie av rehabilitering i internatform.

Stress induced exhaustion disorder is the disease that caused most sickleavedays in Sweden during the last 10 years. Teachers have the highest percentage of sick leave, and is the group where the number on sick leave increases most. No previous studies have achieved a statistically significant increased return to work after any specific treatment for exhaustion disorder. The current  multimodal occupational specific treatment for exhaustion disorder among teachers showed statistically significant return to work at follow-up 1-1.5 years after treatment. The treatment focus was reflective peer support group sessions which ended with a recommended an individualised course of action to deal with job stressors for each participant. The treatment model works well for teachers. Continued research is needed to test other occupational groups.

Undetected Dysglycemia Is an Important Risk Factor for Two Common Diseases, Myocardial Infarction and Periodontitis: A Report From the PAROKRANK Study.

OBJECTIVE: Information on the relationship among dysglycemia (prediabetes or diabetes), myocardial infarction (MI), and periodontitis (PD) is limited. This study tests the hypothesis that undetected dysglycemia is associated with both conditions. RESEARCH DESIGN AND METHODS: The PAROKRANK (Periodontitis and Its Relation to Coronary Artery Disease) study included 805 patients with a first MI and 805 matched control subjects. All participants without diabetes (91%) were examined with an oral glucose tolerance test. Abnormal glucose tolerance (AGT) (impaired glucose tolerance or diabetes) was categorized according to the World Health Organization. Periodontal status was categorized from dental X-rays as healthy (≥80% remaining alveolar bone height), moderate (79-66%), or severe (<66%) PD. Odds ratios (ORs) and 95% CIs were calculated by logistic regression and were adjusted for age, sex, smoking, education, marital status, and explored associated risks of dysglycemia to PD and MI, respectively. RESULTS: AGT was more common in patients than in control subjects (32% vs. 19%; P < 0.001) and was associated with MI (OR 2.03; 95% CI 1.58-2.60). Undetected diabetes was associated with severe PD (2.50; 1.36-4.63) and more strongly in patients (2.35; 1.15-4.80) than in control subjects (1.80; 0.48-6.78), but not when categorized as AGT (total cohort: 1.07; 0.67-1.72). Severe PD was most frequent in subjects with undetected diabetes, and reversely undetected diabetes was most frequent in patients with severe PD. CONCLUSIONS: In this large case-control study previously undetected dysglycemia was independently associated to both MI and severe PD. In principal, it doubled the risk of a first MI and of severe PD. This supports the hypothesis that dysglycemia drives two common diseases, MI and PD.

Symptoms of depression and their relation to myocardial infarction and periodontitis.

BACKGROUND: Psychosocial stress and depression are established risk factors for cardiovascular disease and a relationship to periodontitis has been suggested. We studied symptoms of depression and their relation to myocardial infarction and periodontitis. METHODS: In a Swedish case-control study, 805 patients, <75 years with a first myocardial infarction and 805 controls without myocardial infarction were matched for age, gender and geographic area. Mean age was 62±8 years and 81% were male. Standardised physical examination and dental panoramic X-ray for grading of periodontal status was performed. Medical history including risk factors related to cardiovascular disease and periodontitis was collected as was detailed information on perceived stress at home and work, and symptoms of depression (Montgomery Åsberg Depression Scale). A Montgomery Åsberg Depression Scale score ⩾13 was considered clinically relevant. RESULTS: A family history of cardiovascular disease, smoking and divorce was more frequent among patients than controls. Patients had more symptoms of depression than controls (14 vs 7%; p<0.001) but received less anti-depressive treatment (16 vs 42%; p<0.001). Symptoms of depression doubled the risk for myocardial infarction (Montgomery Åsberg Depression Scale: odds ratio 2.17 (95% confidence interval 1.41-3.34)). There was no difference in symptoms of depression between study participants with and without periodontitis. CONCLUSION: Patients with a first myocardial infarction were more frequently depressed than matched controls without myocardial infarction, but received less anti-depressive treatment. A relationship between depression and periodontitis could not be confirmed.

Possible Biomarkers of Chronic Stress Induced Exhaustion - A Longitudinal Study.

BACKGROUND: Vascular endothelial growth factor (VEGF), epidermal growth factor (EGF) and monocyte chemotactic protein-1 (MCP-1) have previously been suggested to be potential biomarkers for chronic stress induced exhaustion. The knowledge about VEGF has increased during the last decades and supports the contention that VEGF plays an important role in stress and depression. There is scarce knowledge on the possible relationship of EGF and MCP-1 in chronic stress and depression. This study further examines the role of VEGF, EGF and MCP-1 in women with chronic stress induced exhaustion and healthy women during a follow-up period of two years. METHODS AND FINDINGS: Blood samples were collected from 105 women with chronic stress induced exhaustion on at least 50% sick leave for at least three months, at inclusion (T0), after 12 months (T12) and after 24 months (T24). Blood samples were collected at inclusion (T0) in 116 physically and psychiatrically healthy women. The plasma levels of VEGF, EGF and MCP-1 were analyzed using Biochip Array Technology. Women with chronic stress induced exhaustion had significantly higher plasma levels of VEGF and EGF compared to healthy women at baseline, T12 and at T24. There was no significant difference in plasma levels of MCP-1. Plasma levels of VEGF and EGF decreased significantly in women with chronic stress induced exhaustion during the two years follow-up. CONCLUSIONS: The replicated findings of elevated levels of VEGF and EGF in women with chronic stress induced exhaustion and decreasing plasma levels of VEGF and EGF during the two years follow-up add important knowledge to the pathophysiology of chronic stress induced exhaustion.

Periodontitis Increases the Risk of a First Myocardial Infarction: A Report From the PAROKRANK Study.

BACKGROUND: The relationship between periodontitis (PD) and cardiovascular disease is debated. PD is common in patients with cardiovascular disease. It has been postulated that PD could be causally related to the risk for cardiovascular disease, a hypothesis tested in the Periodontitis and Its Relation to Coronary Artery Disease (PAROKRANK) study. METHODS AND RESULTS: Eight hundred five patients (<75 years of age) with a first myocardial infarction (MI) and 805 age- (mean 62±8), sex- (male 81%), and area-matched controls without MI underwent standardized dental examination including panoramic x-ray. The periodontal status was defined as healthy (≥80% remaining bone) or as mild-moderate (from 79% to 66%) or severe PD (<66%). Great efforts were made to collect information on possibly related confounders (≈100 variables). Statistical comparisons included the Student pairwise t test and the McNemar test in 2×2 contingency tables. Contingency tables exceeding 2×2 with ranked alternatives were tested by Wilcoxon signed rank test. Odds ratios (95% confidence intervals) were calculated by conditional logistic regression. PD was more common (43%) in patients than in controls (33%; P<0.001). There was an increased risk for MI among those with PD (odds ratio, 1.49; 95% confidence interval, 1.21-1.83), which remained significant (odds ratio, 1.28; 95% confidence interval, 1.03-1.60) after adjusting for variables that differed between patients and controls (smoking habits, diabetes mellitus, years of education, and marital status). CONCLUSIONS: In this large case-control study of PD, verified by radiographic bone loss and with a careful consideration of potential confounders, the risk of a first MI was significantly increased in patients with PD even after adjustment for confounding factors. These findings strengthen the possibility of an independent relationship between PD and MI.

Construction and evaluation of a self rating scale for stress-induced exhaustion disorder, the Karolinska Exhaustion Disorder Scale.

Prolonged stress (≥ six months) may cause a condition which has been named exhaustion disorder (ED) with ICD-10 code F43.8. ED is characterised by exhaustion, cognitive problems, poor sleep and reduced tolerance to further stress. ED can cause long term disability and depressive symptoms may develop. The aim was to construct and evaluate a self-rating scale, the Karolinska Exhaustion Disorder Scale (KEDS), for the assessment of ED symptoms. A second aim was to examine the relationship between self-rated symptoms of ED, depression, and anxiety using KEDS and the Hospital Anxiety and Depression Scale (HAD). Items were selected based on their correspondence to criteria for ED as formulated by the Swedish National Board of Health and Welfare (NBHW), with seven response alternatives in a Likert-format. Self-ratings performed by 317 clinically assessed participants were used to analyse the scale's psychometric properties. KEDS consists of nine items with a scale range of 0-54. Receiver operating characteristics analysis demonstrated that a cut-off score of 19 was accompanied by high sensitivity and specificity (each above 95%) in the discrimination between healthy subjects and patients with ED. Reliability was satisfactory and confirmatory factor analysis revealed that ED, depression and anxiety are best regarded as different phenomena. KEDS may be a useful tool in the assessment of symptoms of Exhaustion Disorder in clinical as well as research settings. There is evidence that the symptom clusters of ED, anxiety and depression, respectively, reflect three different underlying dimensions.

All-Cause and Cause-Specific Mortality after Long-Term Sickness Absence for Psychiatric Disorders: A Prospective Cohort Study.

OBJECTIVE: The aim was to examine if long-term psychiatric sickness absence was associated with all-cause and diagnosis-specific (cardiovascular disease (CVD), cancer and suicide) mortality for the period 1990-2007. An additional aim was to examine these associations for psychiatric sickness absence in 1990 and 2000, with follow-up on mortality during 1991-1997 and 2001-2007, separately. METHODS: Employees within municipalities and county councils, 244,990 individuals in 1990 and 764,137 individuals in 2000, were followed up to 2007 through register linkages. Analyses were conducted with flexible parametric survival models comparing sickness absentees due to psychiatric diagnoses (>90 days) with those not receiving sick leave benefit. RESULTS: Long-term sickness absence for psychiatric disorders was associated with an increased risk of mortality due to all causes; CVD; cancer (smoking and non-smoking related); and suicide during the period 1990-2007. After full adjustment for socio-demographic covariates and previous inpatient care due to somatic and psychiatric diagnoses, these associations remained significant for all-cause mortality (Hazard ratios (HR) and 95% confidence interval (CI)): HR 1.56, 95% CI 1.3-1.8; CVD: HR 1.35, 95% CI 1.0-1.9, and suicide: HR 3.84, 95% CI 2.4-6.1. For both cohorts 1990 and 2000 estimates point in the same direction. For the time-period 2000-2007, we found increased risks of mortality in the fully adjusted model due to all causes: HR 1.47, 95% CI 1.2-1.7; CVD: HR 1.83, 95% CI 1.2-2.7; overall cancer: HR 1.33, 95% CI 1.0-1.7; and suicide: HR 2.15, 95% CI 1.3-3.7. CONCLUSION: Long-term sickness absence for psychiatric disorders predicted premature mortality from all-causes, cardiovascular disease, cancer, and suicide.

Self-reported treatment, workplace-oriented rehabilitation, change of occupation and subsequent sickness absence and disability pension among employees long-term sick-listed for psychiatric disorders: a prospective cohort study.

AIM: To examine whether self-reported treatments, workplace-oriented rehabilitation and change of occupation were associated with subsequent sickness absence and disability pension among long-term sick-listed for psychiatric disorders. DESIGN: A prospective cohort study. SETTING AND PARTICIPANTS: 5200 employees (80% from the Swedish municipalities and county councils and 20% manual workers from the Swedish industry) were randomly selected who in 1999 in the register of AFA Insurance had a new spell of long-term sickness absence due to a psychiatric disorder. Of these, 99 were excluded (duplicates and deaths, persons living abroad, with protected personal information), and 5101 received a questionnaire in 2001. 3053 individuals responded (60%). After the exclusion of employees with no sick leave in 1999 according to the Swedish social insurance agency, aged 62 years and older, with disability pension 1999-2001, no self-reported treatment, and with missing information on the covariates, our final study group was 2324 individuals. Logistic regression analyses were performed. OUTCOME MEASURES: Sickness absence (>90 days) and disability pension (>0 day). RESULTS: 45% had sickness absence and 18% a new disability pension in 2002. Drug treatment and physiotherapy, respectively, were associated with increased odds of sickness absence (OR 1.56, 95% CI 1.28 to 1.90; OR 1.43, 95% CI 1.21 to 1.69), and disability pension (OR 1.79, 95% CI 1.34 to 2.41; OR 1.75, 95% CI 1.40 to 2.18). Workplace-oriented rehabilitation and change of occupation, respectively, reduced the odds of sickness absence (OR 0.70, 95% CI 0.59 to 0.83; OR 0.35, 95% CI 0.27 to 0.45). CONCLUSIONS: We found a pattern of poorer outcome of drug treatment and physiotherapy compared with other treatments (psychotherapy, workplace-oriented rehabilitation and complementary or alternative medicine) in terms of increased odds of sickness absence and disability pension. Workplace-oriented rehabilitation and/or change of occupation were associated with reduced odds of sick leave. Studies with a randomised controlled trial design are needed to examine the effect on sick leave of a workplace-oriented intervention.

Two forms of group therapy and individual treatment of work-related depression: a one-year follow-up study.

Patients on long-term sick-leave (> 90 days) from white collar work, with a diagnosis of work-related depression, dysthymia, or maladaptive stress reaction were randomized either to cognitive group therapy (CGT), focused psychodynamic group therapy (FGT), or to a comparison group. All patients were interviewed and responded to self-report questionnaires before the start of treatment and at 6 and 12 months. At the 12-month follow-up, 70% of the patients met the criteria for reliable change of the target symptom (depression), and the sample as a whole improved significantly on all measures used. However, there were no differences in outcome between the three treatment groups.

Reduction in personnel and long-term sickness absence for psychiatric disorders among employees in Swedish county councils: an ecological population-based study.

OBJECTIVE: The aim was to examine whether staff downsizing was related to long-term psychiatric sickness absence. METHODS: We used aggregate data on sickness absence from AFA insurance, as well as information on staff numbers from the Swedish Association of Local Authorities and Regions. Bootstrap regression analyses were used to elucidate whether there was a relationship between reduction in personnel and changes in sickness rates. RESULTS: A staff reduction of 1% increased the sickness rate, on average, by 9%. The associations were similar in men and women as well as in different age groups, although statistical significance was only reached in the groups of women and middle-aged employees. CONCLUSIONS: Our findings suggest that downsizing may be related to subsequent increases in psychiatric sickness absence. The association appeared after a time-delay of several years.

Burnout levels and self-rated health prospectively predict future long-term sickness absence: a study among female health professionals.

OBJECTIVE: This study investigates the predictive validity of the Oldenburg Burnout Inventory (OLBI), and of three health indicators (depression, anxiety, and self-rated health), for long-term sickness absence (LTSA). METHODS: Questionnaires were sent to all employees in a Swedish County Council (N = 6118), and the overall response rate was 65% (N = 3976). As 82% were women, only women were included in the study. Certified LTSA data were collected. RESULTS: Logistic regression analyses showed that high scores on exhaustion, depression, and poor self-rated health increased the risk of future LTSA (≥90 days). Support for the proposed two-factorial structure of the OLBI was found, including the dimensions of exhaustion and disengagement from work. CONCLUSION: Using burnout measures might be useful to identify those at risk for LTSA, and to enable preventive solutions in organizations.

Can scales assessing psychological and social factors at work be used across different occupations?

AIM: To assess the psychometric properties of a comprehensive tool for assessing psychosocial work characteristics(the QPSNordic), focusing on measurement invariance (MI) across occupations. METHODS: QPSNordic consists of 26 scales covering task, individual, and organizational aspects of work. Multiple group confirmatory factor analyses were performed in order to elucidate MI across a variety of occupational groups. SUBJECTS: Private sector employees and health care workers from the public sector participated. Equal size (n = 500) groups from six different occupations were drawn and entered in multiple group confirmatory factor analyses for assessment of MI. RESULTS: Nine of the 24 analysed scales functioned well across all occupational groups and could thus be used for valid comparisons across professions. The majority of the remaining scales showed MI at least across some groups. CONCLUSION: With some exceptions, the QPSNordic has good psychometric properties. Scales measuring organizational aspects of work could also be used across professional groups, enabling valid comparisons between differing workplaces and occupations.

Novel biochemical markers of psychosocial stress in women.

BACKGROUND: Prolonged psychosocial stress is a condition assessed through self-reports. Here we aimed to identify biochemical markers for screening and early intervention in women. METHODS: Plasma concentrations of interleukin (IL) 1-alpha, IL1-beta, IL-2, IL-4, IL-6, IL-8, IL-10, interferon-gamma (INF-gamma), tumor necrosis factor-alpha (TNF-alpha), monocyte chemotactic protein-1 (MCP-1), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), thyroid stimulating hormone (TSH), total tri-iodothyronine (TT3), total thyroxine (TT4), prolactin, and testosterone were measured in: 195 women on long-term sick-leave for a stress-related affective disorder, 45 women at risk for professional burnout, and 84 healthy women. RESULTS: We found significantly increased levels of MCP-1, VEGF and EGF in women exposed to prolonged psychosocial stress. Statistical analysis indicates that they independently associate with a significant risk for being classified as ill. CONCLUSIONS: MCP-1, EGF, and VEGF are potential markers for screening and early intervention in women under prolonged psychosocial stress.