Bakgrund: Fetma har blivit en folksjukdom med dramatisk ökning och omkring en halv miljon svenskar har idag fetma (BMI>30). I takt med att fetman ökar sker även en ökning av överviktskirurgi där gastric bypass står för 95 % av operationerna. Det har tidigare genomförts studier med fokus på medicinska och fysiologiska effekter efter en gastric bypassoperation. Dessa studier har påvisat framförallt de positiva fysiologiska och medicinska effekterna efter en sådan operation. Däremot har personers upplevelser av en eventuell psykisk ohälsa efter en gastric bypassoperation inte studerats i samma omfattning. Syfte: Belysa hur personer som genomgått en gastric bypassoperation beskriver sin upplevda psykiska ohälsa efter operationen Metod: Litteraturöversikt baserad på tio vetenskapliga artiklar med kvalitativ ansats. Resultat: I studien framkom fyra huvudkategorier som svarade till syftet: ”Upplevelse av tomhet – en saknad av mat”, ”Upplevelse av misslyckande”, ”En negativ självbild och ett ifrågasättande av den nya kroppen” samt ”Upplevelse av smärta och sårbarhet inför omgivningens reaktioner”. Slutsats: Studiens resultat visade på att upplevelser av psykisk ohälsa förekom efter gastric bypassoperation. Studien belyser ett tidigare ganska outforskat område och bidrar med ökad kunskap och förståelse för målgruppen. Resultatet är av vikt för omvårdnadssituationer och för att öka kompetensen hos omvårdnadspersonal kring psykisk ohälsa efter en gastric bypassoperation.

Nociceptin/OrphaninFQ, N/OFQ, and its receptor NOP represent a non-opioid branch of the opioid family. There is growing interest in the involvement of this system during inflammation and sepsis as it is present in immune cells and modifies immunocyte function. Systemic N/OFQ increased mortality in an animal model of sepsis and there is limited evidence for increased plasma N/OFQ in patients with sepsis who died compared to those who survived. This thesis explores changes in the expression of NOP and ppN/OFQ-mRNA by polymorphs (PMN) and of N/OFQ peptide in plasma during inflammation and sepsis. A further aim was to investigate the relationship between the N/OFQ system with physiological and biochemical indicators of severity of disease. Forty patients undergoing cardiopulmonary bypass (CPB) and 49-patients with sepsis in the Intensive Care Unit (ICU) were recruited into 2-studies. In the CPB study we observed a 57% reduction of NOP-mRNA and a 95% reduction of ppN/OFQ-mRNA expression in PMN. Plasma N/OFQ concentrations increased by over 30%. Higher plasma N/OFQ was associated with lower NOP-mRNA. These changes were related to prolonged aortic cross clamp time. In patients with sepsis there was an 85% reduction of ppN/OFQ-mRNA expression compared to a sample taken after recovery from sepsis. Lower expression of ppN/OFQ-mRNA was associated with increased inotropic support and lactate concentrations on the first day of sepsis. Our data did not show any differences amongst survivors and non-survivors. During inflammation(CPB) and sepsis there was reduced expression of NOP and ppN/OFQ-mRNA with an inverse relationship between plasma N/OFQ(CPB study) and NOP-mRNA expression, suggestive of a possible feedback mechanism. Based on the current evidence (this thesis and literature) we suggest that N/OFQ could contribute to the complex pathophysiological process occurring during inflammation and sepsis and warrant further study.

Resumo: A doença arterial coronariana (DAC) é uma das principais causas de óbito e de perda de qualidade de vida ao longo do tempo. Seu tratamento pode ser clínico ou por meio de técnicas como a angioplastia percutânea ou a revascularização cirúrgica do miocárdio. Multidimensional, a DAC exerce fortes impactos físicos, emocionais e sociais. Por isso, além das avaliações clínicas, são indispensáveis as informações sobre a qualidade de vida e funcionalidade dos pacientes para uma análise mais precisa de suas condições após o tratamento. O objetivo deste estudo foi avaliar a percepção da qualidade de vida e a funcionalidade em pacientes com DAC nos momentos antes da revascularização cirúrgica ou da angioplastia, na alta hospitalar e 60 dias após a intervenção. Foram avaliados 90 pacientes divididos em grupos por procedimento. Utilizou-se uma ficha com perfil demográfico, questionário genérico de avaliação da qualidade de vida "The Medical Study 36-item Short-Form Health Survey" (SF-36) e escala de "Medida de Independência Funcional" (MIF). Observou-se, no perfil demográfico, a predominância do gênero masculino (58,9%), escolaridade com o ensino fundamental incompleto (64,4%) e índice de massa corporal (IMC) acima do ideal (37,8% sobrepeso e 25,6% obesidade). O grupo de angioplastia apresentou os melhores escores de qualidade de vida antes do procedimento nos domínios "aspectos físicos", "dor", "vitalidade", "aspectos sociais" e na questão de avaliação da saúde anterior. Na alta isso se manteve com o acréscimo do domínio "capacidade funcional". No momento 60 dias após o procedimento, a angioplastia obteve melhores escores em "aspectos físicos" e "aspectos sociais". Na comparação entre os momentos, os domínios "capacidade funcional" e "dor" pioraram na alta para o grupo cirurgia, e melhoraram após 60 dias... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Coronary artery disease (CAD) is a leading cause of death and loss of quality of life over time. The treatment is clinical in early stages of disease or the technique is percutaneous angioplasty or coronary artery bypass grafting. The DAC is a multidimensional disease, which has strong physical, emotional and social impacts. Besides to clinical assessments, information about the quality of life and functionality of patients are essential for a more precise analysis of their condition after treatment. The aim of this study was to evaluate the perceived quality of life and functionality in patients with CAD in the moments before surgical revascularization or angioplasty, at discharge and 60 days after the intervention. We evaluated 90 patients divided into groups by procedure. We used a form with demographic profile, generic questionnaire for assessing quality of life "The Medical Study 36-item Short-Form Health Survey (SF-36) and scale of" Functional Independence Measure (FIM). It was observed in the demographic, the predominance of males (58.9%), schooling and incomplete primary education (64.4%) and body mass index (BMI) above the ideal (37.8% overweight and 25.6% obese). The angioplasty group had the best scores of quality of life before the procedure in the domains "physical aspects", "pain," "vitality" and "social aspects" and the issue of evaluation of previous health. These results remained at hospital discharge with the addition of domain "functional capacity". At present 60 days after the procedure, angioplasty had higher scores in "physical aspects" and "social aspects". Comparing the times, the domains "physical functioning" and "pain" got worse at the group of discharge for surgery and improved after 60 days for both groups. In the domains "general health" and "vitality", both groups improved in the third stage of evaluation. Angioplasty only group showed improvement... (Complete abstract click electronic access below) / Orientador: Marcos Augusto de Moraes Silva / Coorientador: Juliana Bassalobre Carvalho Borges / Banca: Antonio Sérgio Martins / Banca: Reinaldo Ayer de Oliveira / Mestre

Depression und die koronare Herzkrankheit zeigen hohe Komorbiditäten. Dabei ist das Vorliegen einer Depression nicht nur für die Lebensqualität der Patienten, sondern auch für die Prognose der koronaren Herzkrankheit bezüglich Morbidität und Mortalität relevant. Als pathophysiologische Ursache des Zusammenhangs spielen Folgen der depressiven Symptome auf der Verhaltensebene eine wichtige Rolle, die zu einem schlechteren Gesundheitsverhalten und einer geringeren Modifikation von Risikofaktoren als bei Patienten ohne depressive Symptome führen. Daneben werden aber auch gemeinsame pathophysiologische Prozesse für beide Krankheitsentitäten diskutiert, dazu gehören Veränderungen in der HPA-Achse, dem Immunsystem und einer Aktivierung des sympathischen Nervensystems, die sowohl bei der koronaren Herzkrankheit als auch bei der Depression nachgewiesen wurden. In der vorliegenden Untersuchung wurden depressive Symptome anhand der Hospital Anxiety and Depression Scale und des Patient Health Questionnaire-2 systematisch in Form einer prospektiven Beobachtungsstudie an 288 herzchirurgischen Patienten erfasst, bevor sich diese einer ACB-Operation unterzogen. Der Zusammenhang von depressiven Symptomen und präoperativem HbA1c- beziehungsweise präoperativem CRP-Wert sowie peri- und postoperative Komplikationen während des operationsbezogenen Krankenhausaufenthaltes wurde untersucht. Zwischen Patienten mit depressiven und solchen ohne depressive Symptome ließen sich keine Unterschiede bezüglich der präoperativen HbA1c-Werte im Gesamtkollektiv feststellen. Höhere HbA1c-Werte fanden sich bei depressiven Patienten nach Ausschluss der Patienten mit notfallmäßiger Koronarrevaskularisation. Präoperative CRP-Werte unterschieden sich bei Patienten mit und ohne depressive Symptome nicht. Bezüglich peri- und postoperativer Komplikationen waren auffällige Ergebnisse in der HADS-D nicht mit einem erhöhten Komplikationsrisiko während des operationsbezogenen Krankenhausaufenthaltes assoziiert. Auffällige Punktwerte im PHQ-2 waren signifikant mit verlängerter Beatmungszeit und postoperativer Revision assoziiert, für Minor Complications gesamt, therapiebedürftige Wundheilungsstörung und postoperative Mortalität zeigte sich ein Trend zu einem höheren Risiko bei Vorliegen einer Depression. Unterschiede ließen sich aber auch bereits für einzelne Items des PHQ-2 darstellen. Anhedonie war signifikant mit einem erhöhten Risiko für postoperative Mortalität, Major Complications und Revision assoziiert. Depressive Symptome stellen mit mittlerer Effektstärke einen wichtigen Risikofaktor für postoperative Komplikationen noch während des operationsbezogenen Krankenhausaufenthaltes, insbesondere bezüglich der frühen Mortalität, dar. Die systematische Erfassung depressiver Symptome sollte daher Eingang in die präoperative Vorbereitung von Patienten vor operativer Koronarrevaskularisation finden. Inwieweit sich durch spezifische Interventionen präoperativ oder in der präoperativen Vorbereitung das Depressions-assoziierte perioperative Risiko beeinflussen lässt, sollte Gegenstand zukünftiger Untersuchungen sein. / Depression and coronary artery disease show high comorbidities. The presence of depression is not only of substantial relevance for the patients’ quality of life but also for the prognosis of the coronary artery disease in terms of morbidity and mortality. On the pathophysiological side depressive symptomatology accounts for behavioral consequences, which plays a crucial role in health orientated behavior and modification of risk factors for coronary artery disease between patients with and without depressive symptoms. Moreover, common pathophysiological pathways involving both disease entities are currently under discussion, among them alterations in the hypothalamus-pituitary axis, the immune system and an activation of the sympathetic nervous system; all of them have been shown to play a role in coronary artery disease and in depression. The present study is a prospective observational study on 288 patients undergoing cardiac surgery. We systematically evaluated depressive symptoms prior to coronary artery bypass grafting (CABG) surgery with two psychometric scales: Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire-2 (PHQ-2). We examined the relationship between depressive symptoms and preoperative glycated hemoglobin (hemoglobin A1c, HbA1c), depressive symptoms and preoperative C-reactive protein as well as depressive symptoms and perioperative and postoperative complications during inpatient treatment associated with CABG surgery. Overall, there were no differences in preoperative glycated hemoglobin between patients with and without depressive symptoms. After exclusion of emergency CABG procedures depressed patients showed higher preoperative glycated hemoglobin. Preoperative C-reactive protein did not differ in patients with and without depressive symptoms. Relevant depressive symptoms measured with the depression scale of the HADS were not associated with an increased risk for perioperative or postoperative complications during inpatient treatment associated with CABG surgery. Relevant depressive symptoms measured with the PHQ-2 were significantly associated with prolonged ventilation and postoperative re-exploration; depressive symptoms evaluated with the PHQ-2 were also associated with an increased risk for minor complications overall, poor wound healing or wound infection with a need for therapeutic intervention and postoperative mortality. Differences in perioperative and postoperative complications were even detectable for single items of the PHQ-2: anhedonia was independently associated with an increased risk for postoperative mortality, major complications overall and postoperative re-exploration. Depressive symptoms are an important risk factor of medium effect size for perioperative and postoperative complications even during inpatient treatment associated with CABG surgery, especially with regard to early mortality. A systematic evaluation of depressive symptoms should therefore be incorporated in preoperative assessment of patients before CABG surgery. Further research is needed to evaluate if specific interventions applied preoperatively or in the preoperative assessment are able to alter the perioperative and postoperative risk associated with depressive symptoms and depression.

<p>Enligt WHO är övervikt en global epidemi. Gastric bypass-operationer för viktminskning blir vanligare. Syftet med studien var att undersöka psykologiska aspekter och konsekvenser av att genomgå en Gastric bypass-operation. Åtta intervjuer utfördes och analyserades med Grundad teori. Sex kategorier utformades: negativt bemötande/positivt bemötande, jag/andra, dumping som vän/dumping som fiende, att tillhöra massan/att stå ut från massan, eget ansvar/andras ansvar och bevarad självbild/förändrad självbild. Kärnkategorin kognitiv dissonans sågs genomgående i alla kategorier. Den kognitiva dissonansen reduceras genom att en eller båda kognitionerna ändras så att de bättre stämmer överens eller genom att överbryggande kognitioner läggs till. Studiens kärnkategori, kognitiv dissonans, leder till tanken att för att operationen skall vara framgångsrik långsiktigt bör den opererade: 1) se sig som ansvarig för viktnedgången, 2) se sig som en smal/normalviktig individ och 3) tro att den är värd framgång.</p>

<p> </p><p>The aim of the study was auditing medical records examine postoperative blood glucose levels after undergoing CABG surgery. Furthermore the aim was to determine if the ward staff abides the local guidelines frame of reference concerning each ward, regarding blood glucose measurements and blood glucose levels. The study included 70 patients undergoing CABG surgery at the cardiothoracic surgery, Uppsala University Hospital. The study was conducted by retrospective medical record auditing. Studied factors were postoperative blood glucose levels, number of registered blood glucose measurements, a current diagnosis of DM and preoperative HbA_1c. Mean level of blood glucose levels stayed continuously above the local guidelines frame of reference for both TIVA/TIMA and the care ward throughout the continuity of patient care. The number of registered blood glucose measurements per postoperative day at TIVA/TIMA where within the local guidelines. The result showed that the local guidelines frame of reference concerning the ward were not reached. A difference could be seen between patients with DM and patients without DM regarding the previously mentioned factors. Preoperative elevated levels of HbA_1c could have influenced the number of postoperative blood glucose measurements. Recommendations will therefore be too audit the current local guideline that concerns the treatment, therapy goals and the number of blood glucose measurements. Establishing criterions regarding termination of blood glucose measurements and the transfer day between TIVA/TIMA and the care ward are recommended.</p><p> </p>

<p>Roux-en-Y gastric bypass (RYGBP) sustains weight loss and ameliorates diseases common in the morbid obese (BMI>40 kg/m²), but leaves the stomach and duodenum inaccessible. Morbidly obese patients have increased operative risks and in other fields minimal surgery is known to facilitate the postoperative course.</p><p>The aim of this thesis was to evaluate hand-assisted laparoscopy in RYGBP and develop techniques to study the excluded stomach.</p><p>The hand-assisted technique was developed in 13 patients and subsequently compared to open surgery in a blinded, prospective, randomised trial of 50 patients.</p><p>Hand-assistance was feasible with a low need for conversions or re-operations. The duration of surgery was longer (150 versus 85 minutes) and postoperative results were similar to those in open surgery. Thus, the patients did not appear to derive benefits from hand-assisted laparoscopy. Interventional radiology accessed the excluded stomach and allowed endoscopy, barium studies and acid measurements. Chronic gastritis and low acid production were found. After RYGBP, 8 of 22 patients (36%) had duodenogastric bile reflux (DGBR), when studied by HIDA-scintigraphy. No DGBR was seen among controls. The gastric mucosa was evaluated by serology</p><p>(pepsinogen I (PGI), H. pylori and H,K-ATPase) in 64 patients before and 1-4 years after operation. RYGBP, in contrast to gastric restriction, had reduced PGI levels postoperatively. According to serology, the mucosa is atrophic or in a resting state.</p><p>This study focuses on safety in RYGBP. Hand-assisted laparoscopy was feasible, but not favourable compared to an optimised open procedure. The excluded stomach is no longer inaccessible and characterised by chronic gastritis, low acid production and frequent bile reflux.</p>

Roux-en-Y gastric bypass (RYGBP) sustains weight loss and ameliorates diseases common in the morbid obese (BMI&gt;40 kg/m2), but leaves the stomach and duodenum inaccessible. Morbidly obese patients have increased operative risks and in other fields minimal surgery is known to facilitate the postoperative course. The aim of this thesis was to evaluate hand-assisted laparoscopy in RYGBP and develop techniques to study the excluded stomach. The hand-assisted technique was developed in 13 patients and subsequently compared to open surgery in a blinded, prospective, randomised trial of 50 patients. Hand-assistance was feasible with a low need for conversions or re-operations. The duration of surgery was longer (150 versus 85 minutes) and postoperative results were similar to those in open surgery. Thus, the patients did not appear to derive benefits from hand-assisted laparoscopy. Interventional radiology accessed the excluded stomach and allowed endoscopy, barium studies and acid measurements. Chronic gastritis and low acid production were found. After RYGBP, 8 of 22 patients (36%) had duodenogastric bile reflux (DGBR), when studied by HIDA-scintigraphy. No DGBR was seen among controls. The gastric mucosa was evaluated by serology (pepsinogen I (PGI), H. pylori and H,K-ATPase) in 64 patients before and 1-4 years after operation. RYGBP, in contrast to gastric restriction, had reduced PGI levels postoperatively. According to serology, the mucosa is atrophic or in a resting state. This study focuses on safety in RYGBP. Hand-assisted laparoscopy was feasible, but not favourable compared to an optimised open procedure. The excluded stomach is no longer inaccessible and characterised by chronic gastritis, low acid production and frequent bile reflux.

Enligt WHO är övervikt en global epidemi. Gastric bypass-operationer för viktminskning blir vanligare. Syftet med studien var att undersöka psykologiska aspekter och konsekvenser av att genomgå en Gastric bypass-operation. Åtta intervjuer utfördes och analyserades med Grundad teori. Sex kategorier utformades: negativt bemötande/positivt bemötande, jag/andra, dumping som vän/dumping som fiende, att tillhöra massan/att stå ut från massan, eget ansvar/andras ansvar och bevarad självbild/förändrad självbild. Kärnkategorin kognitiv dissonans sågs genomgående i alla kategorier. Den kognitiva dissonansen reduceras genom att en eller båda kognitionerna ändras så att de bättre stämmer överens eller genom att överbryggande kognitioner läggs till. Studiens kärnkategori, kognitiv dissonans, leder till tanken att för att operationen skall vara framgångsrik långsiktigt bör den opererade: 1) se sig som ansvarig för viktnedgången, 2) se sig som en smal/normalviktig individ och 3) tro att den är värd framgång.

The performance of low latency Network on Chip (NoC) architectures, which incorporate fast bypass paths to reduce communication latency, is limited by crosstalk induced skewing of signal transitions on link wires. As a result of crosstalk interactions between wires, signal transitions belonging to the same flit or bit vector arrive at the destination at different times and are likely to violate setup and hold time constraints for the design. This thesis proposes a two-step technique: TransSync- RecSync, to dynamically eliminate packet errors resulting from inter-bit-line transition skew. The proposed approach adds minimally to router complexity and involves no wire overhead. The actual throughput of NoC designs with asynchronous bypass designs is evaluated and the benefits of augmenting such schemes with the proposed design are studied. The TransSync, TransSync-2-lines and RecSync schemes described here are found to improve the average communication latency by 26%, 20% and 38% respectively in a 7X7 mesh NoC with asynchronous bypass channel. This work also evaluates the bit-error ratio (BER) performance of several existing crosstalk avoidance and error correcting schemes and compares them to that of the proposed schemes. Both TransSync and RecSync scheme are dynamic in nature and can be switched on and off on-the-fly. The proposed schemes can therefore be employed to impart unequal error protection (UEP) against intra-flit skewing on NoC links. In the UEP, a larger fraction of the energy budget is spent in providing protection to those parts of the data being transmitted on the link which have a higher priority, while expending smaller effort in protecting relatively less important parts of the data. This allows us to achieve the prescribed level of performance with lower levels of power. The benefits of the presented technique are illustrated using an H.264 video decoder system-on-chip (SoC) employing NoC architecture. We show that for Akyio test streams transmitted over 3mm long link wires, the power consumption can be reduced by as much as 20% at the cost of an acceptable degradation in average peak signal to noise ratio (PSNR) with UEP.