The Anderson and Aday access framework (1974) is utilized to investigate the association of individual and community level, predisposing, socio-demographic, and enabling factors, on potential and realized access to coronary heart disease (CHD) preventive care. The cross-sectional study is based on a sample of adults age 18-85 from the Medical Expenditure Panel Survey (MEPS) who were identified with CHD risk or who had a CHD diagnosis.Variables from the MEPS and the Area Resource File (ARF) are used to test logistic regression models for dependent variables measuring primary and secondary CHD preventive care services. The primary preventive care measures include blood cholesterol testing, blood pressure checks, and, diet, exercise and smoking cessation counseling. The secondary preventive measures include beta-blocker reciept after myocardial infarction (MI) and statin drug use for the treatment of high blood cholesterol.Being uninsured is associated with a reduced likelihood of receiving primary CHD preventive care. Overall study results indicated gender and race are more consistent predictors of the receipt of CHD preventive care services than individual enabling or community characteristics. Women had a greater likelihood of receiving primaryCHD preventive care services than men. Hispanics are less likely than Caucasians to receive primary CHD preventive care services, except for blood cholesterol testing for which they are more likely to receive. Blacks are more likely than Caucasians to have blood cholesterol testing, but are no less likely to receive the other primary CHD preventive care measures. Blacks demonstrate a lower likelihood of receiving secondary CHD preventive care than Caucasians, specifically beta-blocker post myocardial infarction indicating that disparities in secondary CHD preventive care persist for segments of the study population. Persons over 75 years of age are less likely to receive primary CHD preventive care services as well as the secondary preventive measure ofstatin use for high blood cholesterol.Community level factors did not improve the logistic regression model for the receipt of CHD preventive care, yet, when predicting potential access for preventive services, persons from a higher percent Hispanic or black community were less likely to have a usual source of care.

Les cellules souches embryonnaires (cellules ES) ont la capacité unique de se diviser indéfiniment et de pouvoir se différencier en de multiples types cellulaires. Elles apparaissent donc très prometteuses comme agents thérapeutiques dans les traitements médicaux du futur. Un enjeu majeur de la recherche actuelle consiste à comprendre la contribution des protéines régulatrices de la chromatine à la plasticité et au contrôle de l'expression du génome des cellules. La famille des remodeleurs Chd, qui fait partie de la super famille SNF2, comprend neuf membres, soit le tiers des remodeleurs exprimés dans les cellules ES murines. L'objectif principal de ce projet de thèse a consisté à identifier de manière exhaustive les gènes cibles de chaque facteur pour comprendre comment ils participent à la régulation du génome et se partagent le remodelage de la chromatine. Nous avons entrepris un projet à grande échelle dans lequel chaque gène codant chaque Chd a été fusionné, à son extrémité carboxy-terminale, à une séquence codant une étiquette, par recombinaison homologue en cellules ES. Les cellules ES étiquetées ont ensuite été utilisées pour des expériences d'immunoprécipitation de chromatine (ChIP-seq). La présence de l'étiquette a permis de standardiser et d'optimiser les méthodes d'immunoprécipitation des protéines. Les fragments d'ADN isolés ont ensuite été séquencés dans le laboratoire d'Ivo Gut (CEA/CNG -Evry- et CNAG -Barcelone-). Nous avons également analysé les transcriptomes des cellules ES où la déplétion de chaque protéine Chd a été réalisée, par hybridation sur puce et RNA-seq. Ces données ont permis de montrer le rôle de NuRD (Chd4, Hdac2) au sein des réseaux de la régulation transcriptionnelle des ES. Les données obtenues pour les facteurs Chd1, Chd8 et Chd4 montrent des rôles différents mais interconnectés pour chaque protéine. Enfin, ces données nous ont permis de proposer des hypothèses pour expliquer comment ces protéines contribuent à la régulation du génome.

Coronary heart disease (CHD) is the single largest cause of death in Australia. Lack of physical activity is a primary risk factor for CHD. The thesis aimed to quantify the efficacy of walking in reducing CHD risk. Meta-analyses were performed for the quantification with the application of random-effect meta-regression models. The thesis also aimed to quantify reductions in CHD-related direct healthcare costs, productivity loss and disease burden resulting from walking interventions in Australia, using the population attributable fraction model, the work and leisure models, and the consumer surplus model. Economic evaluations were also conducted to estimate CHD-related productivity loss using the human capital and the friction methods. The results indicated that 30 minutes of normal walking a day for 5-7 days a week compared to physical inactivity reduced CHD risk by 24%. There existed a dose-response relationship between walking and CHD risk reduction. An increment of approximately 30 minutes of normal walking a day for 5 days a week reduced CHD risk by 19%. The annual productivity loss resulting from CHD was estimated at AU$1.79 billion based on the human capital method and AU$25.05 million under the friction method. 30 minutes of normal walking a day for 5-7 days a week by the country???s ???sufficient??? walking population was shown to generate an estimated $126.73 million in net direct healthcare savings annually. The net economic savings could increase to AU$419.9 million if the whole inactive population engaged in ???sufficient??? walking. The study also found that 30 minutes of normal walking a day for 5-7 days a week reduced the burden of CHD by an estimated 25,065 DALYs and the productivity loss by AU$162.65 million annually under the leisure model. If the whole inactive population engaged in such walking, the total disease burden and productivity loss could be reduced by approximately one third. The findings present epidemiological and economic evidence in support of the national physical activity guidelines, which encourage the general public to engage in moderate physical activity including walking for a minimum of 30 minutes a day for 5-7 days a week.

Respiratory Syncytial Virus (RSV) infection is common among young children. Congenital Heart Disease (CHD) is a risk factor of severe illness and hospitalization. Palivizumab prophylaxis reduces the severity of RSV infection and reduces the risk of hospitalization for children at high risk of severe illness, such as children born premature or with CHD. The aim of this thesis was to evaluate compliance with national guidelines for prophylactic treatment and to study the Relative Risk (RR) of hospitalization due to RSV and unspecified Respiratory Tract Infection (RTI) for children with CHD. In a prospective study, questionnaires were sent to all paediatric cardiology centres in Sweden with questions about prophylactic treatment. Hospitalization rates were retrieved from the national inpatient registry. Heart defects were grouped according to type and the relative risk of hospitalization was calculated for each group and for summer and winter seasons. Half of the patients received prophylactic treatment later than recommended in the guidelines. The risk of hospitalization due to RSV infection was increased (RR=2.06 95% CI 1.6-2.6; p < 0.0001) for children with CHD compared to children without CHD. The RR of hospitalization was also increased for all CHD subgroups, and was further increased during summer for children with the more severe CHD. We conclude that guidelines for prophylactic treatment were not followed and that the risk of hospitalization due to RSV and unspecified RTI was increased for all subgroups of CHD. The risk was increased both during winter and summer and we therefore argue that information to health personnel and parents should include that the risk of severe RTI is present all year round for children with CHD. / Respiratoriskt syncytialvirus (RSV) är det vanligaste förkylningsviruset och de allra flesta barn drabbas före två års ålder. RSV kan leda till allvarlig luftvägsinfektion hos alla barn, men speciellt hos dem med medfött hjärtfel. Någon botande läkemedelsbehandling finns inte för RSV, utan de medicinska insatserna får inriktas mot att mildra sjukdomsförloppet och för svårt sjuka barn krävs sjukhusvård för att exempelvis erhålla syrgasbehandling. Det finns inget vaccin mot RSV, men barn som riskerar att bli svårt sjuka kan behandlas profylaktiskt med en monoklonal antikropp (Palivizumab) som ges som injektion en gång per månad under vintersäsong. Vissa barn med svårt hjärtfel får denna profylaktiska behandling enligt nationella riktlinjer. Vår första studie visade att ungefär hälften av barnen med medfött hjärtfel, aktuella för profylax mot RSV, fick behandlingen senare än vad de nationella riktlinjerna rekommenderade. Denna studie genomfördes via en enkät till alla landets barnkliniker under två vintersäsonger. Vi såg även att något fler barn än förväntat (4.6%) fick RSV-infektion trots profylaktisk behandling och för cirka en tredjedel av dessa barn fördröjdes tiden till hjärtoperation. Behovet av sjukhusvård kan användas som mått på hur svårt ett sjukdomsförlopp är, och baserat på Socialstyrelsens slutenvårdsregister studerade vi alla barn under två års ålder och fann att den relativa risken för sjukhusvård på grund av RSV var högre för barn med hjärtfel än för barn utan hjärtfel (RR=2.06 95% CI 1.6-2.6; p < 0.0001). I vår andra studie, baserad på slutenvårdsregistret, beräknade vi den relativa risken för sjukhusvård på grund av RSV, för barn med olika former av hjärtfel och uppdelat i sommar- och vintersäsong. Risken för sjukhusvård var ökad för alla barn oavsett typ av hjärtfel, och detta gällde såväl under vintern som under sommaren. Barn med de allvarligaste formerna av hjärtfel hade högre risk för sjukhusvård under sommaren jämfört med deras risk under vintern, medan barn med vad som anses vara lättare hjärtfel hade ökad risk för sjukhusvård under hela året, utan någon större skillnad i risk mellan vinter och sommar. Att barn med hjärtfel riskerar att bli svårt sjuka i RSV är väl känt, men våra resultat visar att denna risk även existerar under sommarhalvåret, då det inte är RSV-säsong och då profylax inte ges. Vi fann också att barn med vad som anses vara lättare hjärtfel löper lika stor risk att drabbas av svårare sjukdomsförlopp med sjukhusvård under vintern, som barn med svårare hjärtfel. Att denna information sprids till såväl sjukvårdspersonal som arbetar med denna patientgrupp som till föräldrar med hjärtsjuka barn är viktigt, för att belysa att även dessa barn behöver skyddas, och detta inte bara under vintern och RSV-säsongen.

Objectives: Depression is often unrecognised or sub-optimally treated in primary care. This has led to research exploring the barriers and enablers to effective recognition but little is known about health care professionals’ (HCPs) beliefs or personal illness models about depression in patients with long term conditions (LTCs), the presence of which may affect recognition and management. Using Leventhal’s Common Sense or Self-regulatory Model this thesis aimed to: explore HCPs’ illness representations and management in people with LTCs and depression; to understand the role of personal models and perceived barriers to depression recognition and management; and to address them in a theory-based online training intervention. Methods: This thesis was undertaken in three stages; a scoping review with narrative synthesis was conducted to explore the role of HCPs’ personal illness models of depression, a qualitative study using semi-structured interviews with 16 HCPs to investigate their illness beliefs about depression in patients with LTCs and finally, the development and feasibility assessment of a theory-based online training intervention to target HCPs’ attitudes, beliefs and self-efficacy. During this stage a new measure of HCPs’ beliefs and attitudes towards depression in patients with LTCs was developed as no appropriate measures were currently available to capture HCPs’ personal illness models of depression as a comorbid condition. Results: Twenty-seven papers were included in a mixed method scoping review. The review concluded that HCPs mainly normalised depression but lacked a complete conceptualisation of depression in primary care. HCPs reported time constraints and lack of skills as important barriers to recognising of depression in primary care. Negative attitudes towards depression and lack of confidence to recognise and manage depression were also commonly reported. In the qualitative study, the main themes were; 1) Recognition of depression in people with LTCs is complex (unclear illness identity) 2) Attitudes towards recognition and management of depression in people with LTCs act as either barriers and enablers to depression management 3) The necessary level of condition-related knowledge and understanding of depression in the context of a LTC 4) Controllability of depression in people with LTCs. The findings suggested that HCPs’ illness beliefs about depression in people with LTC varied in crucial ways with some participants prioritising the management of the LTC or expecting patients with diabetes or CHD to diagnose depression themselves due to time constraints. Some HCPs also reported simplistic views of causation which appeared to impact on their decisions whether or not to detect depression in people with LTCs. The findings of the qualitative study were used to inform the content of a novel online training intervention using illustrations to facilitate engagement. Thirty one HCPs were recruited and 15 completed the evaluation. The results of the feasibility study suggested that the method, context and mode of intervention was feasible but the lack of validated measures and the small sample size hinder conclusions about changes in participants’ illness beliefs, intentions, self-efficacy and perceived barriers towards depression. Comments: The scoping review study provided new insights into why HCPs may not engage with detection of depression but only a limited amount of research has explored HCPs’ beliefs about depression in patients with LTCs. The qualitative study addressed this and contributes new knowledge about the way HCPs conceptualise depression in patients with LTC and was used to design an online intervention to improve the management and recognition of depression in these patients. Further research to develop this intervention and evaluate it on a larger scale is needed.

Bakgrund: Medfödd hjärtsjukdom (congenital heart disease, CHD) är ett samlingsnamn för flera olika sjukdomstillstånd som omfattar en medfödd dysfunktion av hjärtat. Årligen genomgår omkring 450 barn och ungdomar hjärtkirurgi i Sverige, vilket leder till att de flesta patienterna överlever sjukdomen. Studier har visat att hela familjen påverkas psykosocialt och detta kan i sin tur ha inflytande på föräldrarnas möjlighet att närvara och stötta barnet inför, under samt efter sjukhusvistelse och operation. Syfte: Att beskriva upplevelser hos föräldrar vars barn har en medfödd hjärtsjukdom och genomgått hjärtkirurgi. Metod: Litteraturstudie av 12 vetenskapliga artiklar som analyserades med kvalitativ innehållsanalys. Resultat: Analysen resulterade i fyra kategorier: Att växla från oro och rädsla till lättnad och glädje, Att ifrågasätta sin förmåga som förälder och vårdare, Att få andra prioriteringar, samt Att behöva och ta emot stöd. Slutsats: Trots att barnet är den som är patient behöver sjuksköterskan även se till föräldrarnas upplevelser och hälsa för att kunna främja barnets hälsa och välbefinnande, och därför ha ett familjecentrerat fokus och se familjen som en enhet för hälsa. Genom att tillgodose föräldrars behov av stöd och den information de behöver kring sjukdomen, operationen och eftervården, går det att ingjuta en trygghet hos föräldrarna som sedan kan speglas i barnet.

No description available.

No description available.

No description available.

Congenital Heart Disease (CHD) is one of the most common birth defects. It is the single most modifiable cause of infant mortality under one year of age. Therefore, the causes of CHD have been extensively researched in the past but the etiology remains largely unknown. Environmental risks, particularly maternal risk factors for congenital cardiac malformation have been evaluated in the original BWIS previously. However, in this research we examined one of the additional risk factors. We sought to determine whether maternal headache during six months prior to conception and throughout gestation until birth is a risk factor for CHD in the BWIS dataset. Among 3274 singleton cases and 3519 controls, a maternal report of headache was found to be associated with a nearly 20% increase in the risk of a congenital heart defect (OR= 1.2 p=0.001). Moreover, any medications use for headache 1-6 months prior to conception increased the risk of abnormal cardiac development by 1.3 fold (OR = 1.3, p=0.0004). Aspirin or aspirin containing analgesics were found to increase the risk for CHD at the defined risk period. According to subgroup analysis, aspirin or aspirin containing analgesics and acetaminophen or acetaminophen containing analgesics were found to be the risk factor for CTD i.e. Conotruncal defects. Furthermore, aspirin or aspirin containing analgesics increased the risk for PVSD i.e. Peri-membranous Ventricular Defect in offspring when the mother uses these drugs 1-6 months prior to conception. Additionally, the risk for CVD i.e. critical valve disease were found to be increased when women were exposed to aspirin or aspirin containing analgesics during third trimester after pregnancy. In conclusion, maternal headache increased the risk for CHD by 20% and the use of headache medications specifically pain relievers during 1-6 months prior to conception modulated type of defect was observed.