Vocal Cord Dysfunction (VCD) is characterized by paradoxical vocal cord movement during inspiration or expiration, and generally affects adolescents and predominantly women. Previous studies have shown a large inconsistency concerning terminology, definitions, etiology, assessment, differential diagnosis, co-morbidity and treatment. The purpose of this study was to map knowledge on and management of VCD in Sweden. The study was conducted as a written survey addressed to speech-language pathologists and physicians, and attained an answer percentage of 79 percent. The results showed that several professions were involved in the management of these patients, but no clear pattern of referral could be observed. The majority of the respondents considered intense physical exertion and psychological stress as triggering factors for VCD. Despite this, referral to a psychologist or psychiatrist seldom occurred. Asthma was the most frequent diagnosis regarding co-morbidity, and also the most frequent misdiagnosis. Respiratory exercises, relaxation and information about the diagnosis generally form the basis of VCD treatment. Physicians rated their knowledge on VCD greater compared to the speech-language pathologists. Several of the respondents stated that an increase in knowledge and awareness among nursing staff had contributed to an increase of patients with suspected or confirmed VCD. This study showed that there was no consensus regarding assessment, co-morbidity, misdiagnosis and treatment of VCD among speech-language pathologists and physicians in Sweden. / Vocal Cord Dysfunction (VCD) karakteriseras av paradoxala stämbandsrörelser vid in- eller utandning och drabbar vanligtvis ungdomar och huvudsakligen kvinnor. I tidigare studier framkom ingen konsensus kring terminologi, definition, etiologi, utredning, differentialdiagnostik, komorbiditet eller behandling. Syftet med föreliggande studie var att kartlägga kännedom om och handhavande av VCD i Sverige. Studien genomfördes i form av en enkätundersökning bland logopeder och läkare och svarsfrekvensen var 79 %. Ur resultatet framkom att flera professioner hade träffat dessa patienter men ingen tydlig remitteringsgång observerades. Majoriteten av respondenterna ansåg att intensiv fysisk ansträngning och psykologisk stress var utlösande faktorer till VCD. Däremot förekom sällan remittering till psykolog eller psykiater. Astma var den mest frekventa diagnosen gällande komorbiditet och feldiagnostisering. Andningsövningar, avspänning/avslappning samt information kring diagnosen inkluderades i behandlingen i hög grad. Läkarna skattade sin kunskapsnivå om VCD högre än logopederna. Flera av respondenterna angav att ökad kunskap och medvetenhet bland vårdpersonal hade bidragit till en ökning av diagnostisering av patienter med misstänkt eller konstaterad VCD. Föreliggande studie visade att det inte fanns någon enighet gällande utredning, komorbiditet, feldiagnostisering och behandling av VCD bland logopeder och läkare i Sverige.

Uppsatsens övergripande syfte var att undersöka profiler av samsjuklighet mellan depressiva symtom och olika undergrupper av social ångest hos unga vuxna (20-24 år) samt dess samband med livstillfredsställelse och upplevd social funktionsnedsättning inom yrkesliv/studier respektive sociala aktiviteter. Data har inhämtats via självskattningsformulär. Resultaten analyserades genom en klusteranalys. Två profiler med samsjuklighet mellan undergrupper av social ångest och depressiva symtom framkom. Denna samsjuklighet verkar vara relaterad till både en lägre grad av upplevd livstillfredsställelse samt till funktionsnedsättning inom två domäner, yrkesliv/studier och sociala aktiviteter. / The main purpose of this thesis was to investigate profiles of comorbidity between depressive symptoms and different subgroups of social anxiety in young adults (20-24 years) and its relationship to life satisfaction and social dysfunction within the domains occupation/education and social activities. The data used was gathered through questionnaires. The results were analyzed with cluster analysis.  Two profiles with comorbidity between subgroups of social anxiety and depressive symptoms were found. This comorbidity seems to be related to a lower level of experienced life satisfaction and to dysfunction within two domains, occupation/education and social activities.

The overarching goal of this thesis has been to enhance Internet-delivered psychological treatments for depression and its comorbidity. To this end, three randomized controlled trials (Study II, III and IV) with a total of 313 participants were conducted. A prevalence study (Study I) was also conducted to provide an up-to-date estimate of the prevalence of depression, anxiety disorders, and their comorbidity in the Swedish general population. Study I showed that more than every sixth individual in Sweden suffers from symptoms of depression and/or anxiety. Comorbidity between depression and anxiety was substantial and associated with higher symptom burden and lower health-related quality of life. Study II showed that a tailored Internet-based CBT protocol (ICBT) was effective in reducing symptoms of depression when compared to a control group. Among individuals with more severe depression and comorbidities, the tailored ICBT treatment worked better than standardized ICBT. Study III showed that a psychodynamic Internet-based psychotherapy was highly effective in the treatment of depression, when compared to a group who received psychoeducation and online support. In Study IV, an Internet-delivered affect-focused psychodynamic psychotherapy proved to have a large effect on depression and a moderately large effect on anxiety disorders. In conclusion, this thesis shows that in the context of treating depression and its comorbidity, Internet-delivered psychological treatments can be potentially enhanced by psychodynamic psychotherapy and by individualization. / Det övergripande syftet med denna avhandling har varit att vidareutveckla internetbaserad psykologisk behandling för depression och dess komorbiditet. Tre randomiserade kontrollerade studier (Studie II, III och IV) med totalt 313 deltagare genomfördes i linje med detta syfte. En prevalensstudie (Studie I) genomfördes också för att tillhandahålla ett uppdaterat estimat av prevalensen av depression, ångest och deras komorbiditet i Sverige. Studie I visade att mer än var sjätte individ i Sverige lider av symptom på depression och/eller ångest. Det fanns påtaglig komorbiditet mellan depression och ångest, vilket var associerat med högre symptombörda och lägre livskvalitét. Studie II visade att en skräddarsydd internetbaserad KBT-behandling var effektiv för att reducera symptom på depression, i jämförelse med en kontrollgrupp. Bland individer med svårare depression och komorbiditet, fungerade den skräddarsydda interventionen bättre än en standardiserad. Studie III visade att psykodynamisk internetbehandling var effektiv vid behandling av depression, i jämförelse med en grupp som fick psykoedukation och stödsamtal online. I Studie IV visades att en affektfokuserad psykodynamisk internetbehandling hade stor effekt vad gällde att reducera symptom på depression, och medelstor effekt vad gällde att reducera symptom på ångest. Sammanfattningsvis visar denna avhandling att internetbaserad psykologisk behandling kan potentiellt vidareutvecklas av psykodynamisk psykoterapi och individanpassning, vid behandling av depression och dess komorbiditet.

Depression och insomni är två vanliga former av psykisk ohälsa. I den här studien undersöktes om en bevisat effektiv behandling för insomni, (KBT-I), påverkade grad av depressiva symtom hos personer med konstaterade symtom på såväl depression som insomni. I studien kontrollerades för en minskning av nedstämdhet kunde tillskrivas en ökad fysisk aktivitetsnivå. En single case experimental design användes för ändamålet, med dagliga skattningar av sömn, nedstämdhet och fysisk aktivitetsnivå. Symtom på såväl insomi som nedstämdhet minskade signifikant hos tre av sex deltagare. Minskad nedstämdhet kunde inte förklaras av ökad fysisk aktivitetsnivå. Samvariation observerades mellan depression och insomni. Resultaten visar att insomni och depression kan påverkas av samma behandling, vilket antyder förekomst av gemensamma vidmakthållande mekanismer. / Insomnia and depression are two common mental health problems. This study investigated whether a proven effective treatment for insomnia CBT-I, would change the severity of depressive symptoms, for participants with comorbid insomnia and depression. It was controlled for, whether a reduction in depressive symptoms could be the result of increased physical activity. A single case experimental design, including daily measurements of sleep, depression and physical activity, was used as a means to answer the research questions. Symptoms of both depression and insomnia were significantly reduced for three out of six participants. Increased physical activity was not able to explain the decrease in depression scores. A correlation was observed, between depression and insomnia. The results shows that insomnia and depression can be affected by the same treatment, which implies existence of common perpetual mechanisms.

<p>Uvod - Etiologija sindroma gornjeg otvora grudnog ko&scaron;a (thoracic outlet syndrome- TOS) je udruženost vi&scaron;e faktora koji su posledica naru&scaron;avanja anatomsko-topografskih odnosa u nivou gornjeg otvora grudnog ko&scaron;a: kostoklavikularnog prostora, prednjeg skalenskog otvora, kao i same mehanike rebarnih zglobova i hrskavica, koji dovode do suženja prostora kroz koje prolaze neurovaskularne strukture, njihove kompresije, a samim tim i iritacije neurovaskularnih struktura. Sindrom gornjeg otvora grudnog ko&scaron;a je kompleks simptoma uzrokovanih kompresijom brahijalnog spleta, vene subklavije, arterije subklavije i simpatičkih vlakana, koji karakteri&scaron;u bol, parestezije, mi&scaron;ićna slabost i osećaj nelagodnosti u ruci/rukama koji se pojačava podizanjem ruke/ruku ili prekomernim pokretima glave i vrata, te dovode do smanjenja funkcionalne sposobnosti ruke/ruku i pote&scaron;koća u obavljanju svakodnevnih aktivnosti. Pored toga imaju često izraženu tahikardiju, osećaj stezanja u grudima, glavobolju, vrtoglavicu, zujanje u u&scaron;ima. Navedene tegobe su izraženije ponekad noću i dovode do poremećaja spavanja (problemi usnivanja, hrkanje, ka&scaron;ljanje, osećaj toplo/hladno, apnea, poremećaj dnevno/noćnog ritma- hronotipizacija, itd). Kao posledica lo&scaron;eg spavanja moguća je pojava depresivnih simptoma. U raspoloživoj literaturi, spavanje i kvalitet spavanja se uglavnom posmatraju kroz prizmu drugih bolesti i stanja. Materijal i metode - Istraživanjem je obuhvaćeno ukupno 181 (sto osam deset jedna) osoba. Od tog broja 53 mu&scaron;karca i 128 žena. Test grupu sačinjavalo je 82 ispitanika sa dijagnostikovanim TOS, a 99 zdravih osoba/osoba oba pola koji nemaju simptomatologiju TOS, je predstavljalo kontrolnu grupu. Grupe su bile ujednačene po polu i starosti (od 18 do 65). Tokom studije ispitanici su podvrgnuti kliničkom pregledu &ndash; fizikalnom i neurolo&scaron;kom pregledu. Pregled je podrazumevao pregled posture obolelog (posmatranje mi&scaron;ića regije vrata, ramena i ruku- trofika, tonus, konzistencija, mobilnost i kontraktilnost), posmatranje promena na koži (sa posebnim osvrtom na promene boje kože, trofičkih promena kože i noktiju i temperature kože ruku - &scaron;aka), testiranje refleksa, ispitivanje senzibiliteta u regijama inervacije odgovarajućih spinalnih korenova brahijalnog spleta. Takođe vr&scaron;ena je analiza stanja uhranjenosti (telesna visina, telesna masa, indeks telesne mase) i izvođenje provokativnih testova (Adson manevar, Rus test, Halsted test, Elvi test i Kostoklavikularni test). Kao deo ispitivanja obavljeno je i radiolo&scaron;ko snimanje vratne kičme kao i pregled oscilografom. Ispitanici su imali za zadatak da ispune sledeće upitnike: Upitnik o nesposobnosti ruke, ramena i &scaron;ake (DASH), Pitsbur&scaron;ki indeks kvaliteta spavanja (PSQI), Upitnik o hronotipizaciji (MEQ), Bekov upitnik o depresiji (BDI II). Na kraju ispitanici su davali odgovore na pitanja iz vodiča za istraživača sastavljenog sa ciljem evaluacije različitih aspekata spavanja. Rezultati - Rezultati su pokazali da su upotrebljene skale dale zadovoljavajuću pouzdanost. Pokazalo se da osobe sa dijagnozom TOS pored bogate simptomatologije imaju jo&scaron; i probleme sa spavanjem. Analizom rezultata do&scaron;lo se do zaključka da osobe sa dijagnozom TOS su starije, imaju vi&scaron;e problema sa spavanjem i veću nesposobnost ruke, ramena i &scaron;ake. Nije se pokazala razlika u hronotipizaciji kod osoba sa TOS u odnosu na kontrolnu grupu. Takođe može se zaključiti da osobe koje imaju izraženu nesposobnost ruku, ramena i &scaron;ake imaju značajno veću &scaron;ansu da imaju sindrom gornjeg otvora grudnog ko&scaron;a. Ove osobe pri tom imaju i veću &scaron;ansu da razviju depresiju i poremećaj spavanja, te se zaključuje da ova dva parametra svoj uticaj na TOS ostvaruju preko problema sa funkcionisanjem ruke, ramena i &scaron;ake. Dobar prediktor za postavljanje dijagnoze TOS može biti testiranje osoba DASH skalom. Zaključak - Rezultati studije mogu biti putokaz daljim istraživanjima, koja bi otvorila vrata formiranju protokola i opservaciji kvaliteta života osoba sa sindroma gornjeg otvora grudnog ko&scaron;a, sa posebnim osvrtom na poremećaje spavanja.</p> / <p>Etiology of thoracic outlet syndrome (TOS) is an association of several factors which are the result of disruption in the anatomical-topographical relations, in the level of superior thoracic aperture: costoclavicular space, anterior scalene aperture, as well as the mechanics of rib joints and cartilage, causing narrowing of space through which the neurovascular structures pass, their compression, and thus the irritation of neurovascular structures. Thoracic outlet syndrome is a complex of symptoms caused by the compression of the brachial plexus, subclavian vein, subclavian artery and sympathetic fibres, which is characterized by pain, parasthesias, muscle weakness and a feeling of discomfort in the arm / arms, which increases with raising the arm/arms or by excessive head and neck movements leading to a reduction of functional capabilities of the hands / arms and difficulties in everyday activities. In addition, patients often have expressed tachycardia, feeling of tightness in the chest, headache, dizziness, tinnitus. These problems are more pronounced at night and sometimes lead to sleep disorders (difficulty in falling asleep, snoring, coughing, feeling hot/cold, apnea, day/night rhythm disorder - Morningness/Eveningness disorder, etc.). As a result of poor sleeping depressive symptoms may occur. In the available bibliography, sleep and quality of sleep are mainly viewed through other diseases and conditions. The study included a total number of 181 (one hundred eighty one) people. Out of that 53 men and 128 women. The test group consisted of 82 patients diagnosed with TOS, and 99 healthy persons of both genders who had no symptoms of TOS, and constitute the control group. Groups were equalled by gender and age (18 to 65). Throughout the study subjects underwent clinical examination - both physical and neurological. This included an assessment of posture of the patient (observation of muscles in region of the neck, shoulders and arms - trophic, muscle tone, consistency, mobility and contractility), observation of changes on the skin (with a special emphasis on skin colour changes, trophic changes of the skin, nails and skin temperature of arms - hands), reflex testing, sensitivity testing in regions of innervations which correspond to spinal roots of the brachial plexus. Moreover, an analysis was conducted on the body composition analysis (body height, body weight, body mass index) as well as provocative tests (Adson manoeuvre, the Roos test, Halstead test, Elvy test and Costoclavicular test). Radiology scan of the cervical spine as well as oscillograph testing was conducted as a part of the test. The subjects were asked to fulfil the following questionnaires: Questionnaire on Disabilities of the Arm, Shoulder and Hand (DASH), Pittsburgh Sleep Quality Index (PSQI), The Morningness / Eveningness Questionnaire (MEQ), Beck Questionnaire on Depression (BDI II). Finally the subjects answered questions that researcher had drawn up in order to evaluate different aspects of sleep. The results showed that the scales used were reliable. It proved that persons diagnosed with TOS in addition to numerous symptoms also had problems with sleep. By analyzing the results it was concluded that people diagnosed with TOS are older, have more problems with sleep and greater disability of arms, shoulders and hands. There was no difference in Morningness/Eveningness type in patients with TOS in comparison to the control group. It can also be concluded that people who have pronounced disability of arms, shoulders and hands have a significantly greater chance of having thoracic outlet syndrome. These persons are more likely to develop depression and sleep disorders therefore those two entities impact TOS through the problems with the functioning of the arms, shoulders and hands. A good predictor in diagnosis of TOS may be testing people with DASH scale. The study findings can serve as a guideline for further research, opening the door into forming protocols and observation of the quality of life of people with the thoracic outlet syndrome, with special emphasis on sleep disorders.</p>

<p>Hronična opstruktivna bolest pluća (HOBP) jedna je od vodećih uzroka morbiditeta i mortaliteta &scaron;irom sveta. Uprkos stalnom napretku u medicini, uvođenju novih prognostičkih biomarkera, otkrivanju novih bronhodilatatornih, antiniflamatornih i antiinfektivnih lekova, ova bolest i danas beleži stalan porast broja obolelih i umrlih. Prema savremenom tumačenju HOBP je heterogena bolest koja je udružena sa brojnim komorbiditetima i sistemskim manifestacijama. Zajednički faktori rizika su osnova za javljanje udruženih hroničnih bolesti. Komorbiditeti i akutne egzacerbacije doprinose ukupnoj težini bolesti. S obzirom da se HOBP manifestuje i izvan pluća kod svakog pacijenta je neophodno proceniti postojanje sistemskih manifestacija i tragati za komorbiditetima. U reviziji &bdquo;Globalne strategije za dijagnozu, lečenje i prevenciju hronične opstruktivne bolesti pluća GOLD‖ iz 2011. godine navedene sledeće pridružene bolesti za kojima je potrebno aktivno tragati: kardiovaskularne bolesti, disfunkcija skeletnih mi&scaron;ića, metabolički sindrom, osteoporoza, depresija i karcinom pluća, bronhiektazije. Lečenje HOBP delimo u dve velike grupe: farmakolo&scaron;ko i nefarmakolo&scaron;ko. Farmakolo&scaron;ko lečenje prema GOLD-u, danas se zasniva na stepenastom pristupu. Treba ga sprovodi kod svakog pacijenta sa simptomima. Poslednjih godina na značaju veoma dobija nefarmakolo&scaron;ko lečenje pacijenata sa HOBP, zbog sve vi&scaron;e dokaza o pozitivnom efektu na smanjenje simptoma bolesti, popravljanja tolerancije na napor, smanjenje egzacerbacija. U nefarmakolo&scaron;ko lečenje ubrajamo: aktivno izbegavanje faktora rizika, prestanak pu&scaron;enja, oksigenoterapiju, vakcinaciju protiv gripa, psihosocijalnu podr&scaron;ku, respiratornu rehabilitaciju (RR) i hirur&scaron;ko lečenje. Danas se zna da RR ostvaruje brojne benefite kod pacijenata sa HOBP, kao i da je većina tih benefita zasnovana na dokazima (GOLD 2013): pobolj&scaron;ava kapacitet za vežbanje, smanjene osećaja nedostatka vazduha, pobolj&scaron;ava kvalitet života, smanjuje broj hospitalizacija i dužinu hospitalizacije, smanjuje anksioznost i depresiju povezane sa HOBP, efekti traju i nakon zavr&scaron;enog programa rehabilitacije, pobolj&scaron;ava preživljavanje ovih pacijenata. Primarni ciljevi na&scaron;eg istraţivanja bili su da se utvrdi procenat ispitanika kod kojih je ostvaren pozitivan ishod respiratorne rehabilitacije, da se odredi povezanost sledećih faktora sa ishodom respiratorne rehabilitacije: pol, godine života, &bdquo;pack/years―, dužina trajanja bolesti, broj egzacerbacija u prethodnoj godini, pridružena oboljenja: ishemijska bolest srca, srčana insuficijencija, hipertenzija, osteoporoza, depresija, dijabetes, bronhiektazije, karcinom pluća, tuberkuloza pluća. Takođe smo želeli da utvrdimo i uticaj sledećih parametara na ishod rr:FEV1, BMI, satO2, 6-minutni test hoda, &bdquo;CAT― upitnik, &bdquo;mMRC― upitnik, BODE indeks. Urađena je retrospektivno-prospektivna studija, koja je uključila 500 pacijenata sa HOBP, svih stadijuma I-IV , u stabilnoj fazi bolesti, koji su u toku dvogodi&scaron;njeg perioda odradili kompletan program ambulantne respiratorne rehabilitacije. Program je sprovođen u Poliklinici za plućne bolesti, Instituta za plućne bolesti Vojvodine. Dobijeni rezultati pokazali su da je 452 pacijenta (90,4%) ostvarilo pozitivan ishod RR: najvi&scaron;e ispitanika 142 (28,4%) bilo je u kategoriji vrlo dobar, potom slede kategorije dobar sa 129 ispitanika (25,8%), zadovoljavajući sa 102 ispitanika (20,4%), i na kraju kategorija odličan sa ukupno 79 (15,8%) ispitanika. Nakon programa RR do&scaron;lo je do statistički značajnih pobolj&scaron;anja u vrednostima FEV1, 6MTH, satO2, CAT, mMRC, BODE indeksa. Pol, starost, pu&scaron;ački status, dužina trajanja bolesti i &ge;2 egzacerbacije u prethodnoj godini nemaju uticaja na uspe&scaron;an ishod RR. Utvrđeno je postojanje statistički značajne negativne korelacije između srčane slabosti i pozitivnog ishoda respiratorne rehabilitacije, dok nije nađena statistički značajna povezanost ostalih ispitivanih komorbiditeta sa pozitivnim ishodom respiratorne rehabilitacije. Kao statistički značajni univarijantni prediktori pozitivnog ishoda respiratorne rehabilitacije jesu: manji broj pridruženih bolesti, odsustvo srčane slabosti, niža saturacija hemoglobin kiseonikom, veći BMI, mMRC &ge; 2, CAT &ge; 10, B i D stadijumi bolesti, dok je multivarijantnom logističkom regresionom analizom pokazano da su nezavisni prediktori pozitivnog ishoda respiratorne rehabilitacije: manji broj pridruženih bolesti, odsustvo srčane slabosti, veći BMI, CAT &ge; 10.</p> / <p>Chronic obstructive pulmonary disease (COPD) is one of the leading morbidity and mortality causes all over the world. Despite the steady advance in scientific research, introduction of novel prognostic biomarkers, new and potent bronchodilation, anti-inflammatory and anti-infectious drugs, a constant increase in the number of the affected and deceased from chronic obstructive pulmonary diseas has still been permanently evidenced in the 21st century. In a modern concept, the chronic obstructive pulmonary disease (COPD) is understood as a heterogenous disorder associated with numerous comorbidities and systemic manifestations. Common risk factors represent the basis for concomitant chronic diseases to develop. Comorbidities and acute exacerbations contribute to the overall disease severity. As a COPD may develop extrapulmonary manifestations as well, each patient should be evaluated for systemic manifestations and comorbidities. The 2011 update of the &bdquo;Global Strategy for Chronic Obstructive Lung Disease Diagnosis, Management, and Prevention &ndash;GOLD‖ lists the following comorbidities to be actively searched for: cardiovascular diseases, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, lung cancer and bronchiectases. The treatment of COPD can be devided in two groups: pharmacological and non-pharmacological. Pharmacological treatment is today, according to GOLD, based on incremental approach. It should be carry out in every patient with simptoms. In last few years, non-pharmacological treatment of COPD is very popular, due to the evidence of positive effects on decreasing the simptoms, increasing the tolerance to exertion and decreasing the exacerbations. Non-pharmacological treatment consider: active avoiding the risk factors, smoking cessation, oxigenotherapy, vaccination against the flu, psicho-social support, respiratory rehabilitation and surgery. It is well known today that respiratory rehabilitation achieve numerous benefits in COPD patients and most of that benefits are evidence based (GOLD 2013): increasing the exercise capacity, decreasing the shortness of breath, increasing the quality of life, reduces the number and length of hospital stay, decreasing the anxiety and depression conected to COPD, the effects lasts and after the rehabilitation program, improves the survival of this patients. The primary goals of this investigation were to establish the percentage of patients with positive outcome after the respiratory rehabilitation, to determine the conection of the following factors with the outcome of respiratory rehabilitation: gender, age, &bdquo;pack/years―, duration of the disease, the number of exacerbations in previous year, comorbidities: ischemic heart disease, heart failure, arterial hypertension, osteoporosis, depression, diabetes mellitus, bronchiectasis, lung cancer, tuberculosis. The other goals were to establish the influence of some parametars on the outcome of respiratory rehabilitation: FEV1, BMI, SaO2 ,6 minute walk test, &bdquo;CAT― questionnaire, &bdquo;mMRC― questionnaire, BODE index. This was retrospective-prospective study the included 500 patients with COPD, from I to IV stadium, in stable disease, who have done the two years complete program of ambulatory respiratory rehabilitation. The program have been done in polyclinic for respiratory diseases, Institute for pulmonary disesases of Vojvodina, Sremska Kamenica. The results showed that 452 patients (90,4%) achieved positive outcome of respiratory rehabilitation. The majority of patients 142 (28,4%) were in ―very good‖ caterogy, the 129 patients (25,8%) in category ―good‖, ―satisfied‖ 102 patients (20,4%) and ―excellent‖ 79 patients (15.8%). After completion of the respiratory rehabilitation program, statistically significant improvements of the following parameters have been achieved: FEV1, 6MTH, SaO2, mMRC, BODE index. Gender, age, smoking, duration of the disease and &ge;2 exacerbations in previous year did not have influence on the successful respiratory rehabilitation outcome. The statistically significant negative correlation between the heart failure and positive respiratory rehabilitation outcome has been achieved, while there were no statistically significant correlations among other comorbidities and the successful respiratory rehabilitation outcome. The statistically significant univariant predictors of positive outcome of respiratory rehabilitation are: less comorbidities, absence of heart failure, lower oxygen saturation, higher BMI, , mMRC &ge; 2, CAT &ge; 10, B i D stadium of disease, while multivariant logistic regression analysis showed that the independent predictors of positive outcome of respiratory rehabilitation are: less comorbidities, absence of heart failure, higher BMI, CAT &ge; 10.</p>

Insomni och depression är psykiatriska åkommor som idag drabbar många människor. Forskning har visat att det råder en stor samsjuklighet mellan diagnoserna där många drabbade lider av samtidig insomni och depression vilket utgör en stor belastning för den enskilde individen. Patienter rapporterar ofta en negativ påverkan på kognitiva funktioner, bland annat minnessvårigheter och problem med koncentration och uppmärksamhet. Inom forskningen råder det i dagsläget en osäkerhet kring vilka kognitiva nedsättningar som karakteriserar personer med dessa diagnoser och på vilka sätt de skiljer sig åt. Det finns också ett behov av att undersöka vilken roll kognitiv förmåga spelar för människors möjlighet att tillgodogöra sig psykologisk behandling. I föreliggande studie var syftet att undersöka dessa båda områden. Resultaten visade inte på några signifikanta skillnader mellan personer med insomni, personer med depression och personer med det komorbida tillståndet avseende kognitiva funktioner, när det mättes genom test av uppmärksamhet, arbetsminne och exekutiva funktioner. Däremot framkom vissa samband mellan arbetsminne och förbättring av upplevda sömnbesvär, liksom mellan förmåga till bibehållen uppmärksamhet och förbättring av depressionssymtom. Vidare forskning med större och jämnare urvalsgrupper behövs för att undersöka stabiliteten i dessa fynd.

Fear is an innate emotion and an adaptive response to provide protection from potential harm. When fear is excessive and out of proportion in relation to the confronted situation, it can lead to the development of an anxiety disorder. Many individuals feel anxious at some point, but not all experience clinical anxiety or meet the diagnostic criteria of an anxiety disorder. Still, anxiety disorders are the most prevalent form of psychiatric disorder in the general population. More often than not people suffering from one anxiety disorder also present other psychiatric conditions. As of today, cognitive and behavioural treatments have been tested and found to positively affect anxiety disorders, making them the treatment of choice. Nevertheless, many patients do not seek or receive adequate treatment. One common critique of the research trials from which the recommendations for treatments stem is the use of a single protocol targeting only one diagnosis. This is because many people suffer from comorbidities. Another problem connected to the recommendation that cognitive behavioural therapy (CBT) should be the treatment of choice for anxiety disorders is the lack of therapists with adequate training. One possible way of dealing both with the shortcoming of therapists and making CBT more accessible is the use of the Internet. Internet-based CBT (ICBT) has been tested in numerous trials during the last 15 years, showing positive outcomes for a large variety of disorders. Many ICBT trials also make use of a single protocol. Another way of dealing with comorbidities might be to tailor the treatment to let characteristics and preferences of the patient guide the design of the protocol. Little is known about possible effects of tailoring the ICBT, the effects of therapeutic relationships in ICBT, and the effectiveness and cost-effectiveness of these treatments. This thesis is based on three studies on two separate randomized controlled trials (RCTs) using the same set of modules accessible for the tailored protocol. Study I was an RCT investigating treatment effects up to two-year after completion, showing favourable outcomes of the treatment in a self-recruited sample at all measure points. Study II was a secondary analysis exploring possible relations between working alliance and treatment outcome for participants in the treatment group recruited for Study I indicating that working alliance predict outcome in this tailored treatment. The second RCT was an effectiveness trial (Study III) analysing treatment effects and cost-effectiveness of the treatment up to one year post treatment in a primary-care population. This study showed positive treatment effects both regarding symptom reduction and cost-effectiveness, and that effects were sustained at one year post treatment. Conclusions drawn from these studies are that individually tailored ICBT seems to be a feasible approach for patients with anxiety disorders regardless of comorbidities, and a responsible choice in terms of societal costs. / Rädsla är en medfödd känsla och en adaptiv respons för att skydda organismen från potentiell skada. När rädslan blir överdriven och oproportionerlig i relation till den konfronterade situationen, kan det leda till utvecklandet av ångestsyndrom. Många personer upplever någon gång ångest, men inte alla upplever klinisk ångest eller uppfyller de diagnostiska kriterierna för något ångestsyndrom. Trots detta är ångest det vanligaste psykiatriska tillståndet i befolkningen i stort och oftast uppfyller personer som lider av ett ångestsyndrom även andra  psykiatriska tillstånd. Till dags dato har både kognitiva och beteendeinriktade behandlingar testats och visat sig verksamma vid ångestproblem, vilket gjort dem till de behandlingar som rekommenderas för dessa tillstånd. Trots god effekt av behandling söker många patienter ändå inte hjälp, alternativt erhåller inte adekvat behandling. En vanlig kritik mot den forskning från vilka behandlingsrekommendationerna för ångestsyndrom stammar är att många använt en manual eller ett protokoll som riktar sig mot bara en diagnos. Detta på grund av den stora komorbiditeten. Ett annat problem kopplat till rekommendationerna att kognitiv beteendeterapi (KBT) ska vara förstahandsval vid behandling av ångest är bristen på behandlare med adekvat utbildning. Ett möjligt sätt att göra KBT mer tillgängligt är att använda Internet. Internet- förmedlad KBT (IKBT) har prövats i ett stort antal studier de senaste 15 åren dessa har visat positiva resultat vid ett stort antal psykiatriska tillstånd. Flertalet av dessa studier har dock använt ett enda behandlingsprotokoll. En annan möjlighet att hantera komorbiditet kan vara att skräddarsy behandlingen för att låta patientens egenskaper och preferenser vara med och styra utformningen av behandlingsprotokollet. Möjliga effekter av att skräddarsy IKBT är relativt lite undersökt, likaså effekterna av terapeutiska relationer i IKBT samt klinisk effektivitet och kostnadseffektiviteten för dessa behandlingar. Denna avhandling bygger på tre studier från två randomiserade kontrollerade studier med samma uppsättning av moduler tillgängliga för att skräddarsy behandlingsprotokollen. I Studie I undersöktes behandlingseffekter upp till två år efter avslutad behandling i en självrekryterad grupp patienter. Studie II var en sekundäranalys av behandlingsgruppen från Studie I där eventuella samband mellan arbetsallians och behandlingsresultat undersöktes. Den andra randomiserade kontrollerade studien var en prövning av huruvida denna behandling var effektiv för en klinisk population (Studie III) rekryterad via primärvården. Förutom behandlingseffekter undersöktes även kostnadseffektiviteten upp till ett år efter behandlingsavslut. De slutsatser som dras utifrån dessa studier är att skräddarsydd IKBT verkar vara en framkomlig väg för patienter med ångest oavsett komorbiditet, att arbetsalliansen kan vara en faktor som påverkar utfallet, samt att det är ett ansvarsfullt val vad gäller samhälleliga kostnader.

<p>Hronična bolest bubrega (HBB) je zdravstveni problem koji se javlja &scaron;irom sveta i povezana je sa visokim kardiovaskularnim komorbiditetom i smrtno&scaron;ću. Veliki porast broja bolesnika koji imaju terminalnu bubrežnu slabo&scaron;ću (TBS) nastaje kao posledica eksponencijalnog porasta broja bolesnika čija je slabost bubrega posledica hipertenzije i dijabetesa, kao i porasta broja starih sa TBS. Zbog toga vi&scaron;e od 50% bolesnika sa HBB umire zbog kardiovaskularnih bolesti i pre započinjanja lečenja metodama za zamenu funkcije bubrega. Utvrditi kliničke karakteristike bolesnika sa i bez kontrastom indukovane nefropatije (pre svega varijable bubrežne funkcije definasane pomoću AKIN i RIFLE kriterijuma) podvrgnutih kardiohirur&scaron;kim operacijama, potom utvrditi postojanje razlike u mortalitetu i postoperativnom morbiditetu između bolesnika sa i bez kontrastom indukovane nefropatije, a koji se podvrgavaju kardiohirur&scaron;koj operaciji i takođe utvrditi prediktore mortaliteta i morbiditeta kod bolesnika sa prethodnom kontrastom indukovanom nefropatijom koji se podvrgavaju kardiohirur&scaron;koj operaciji. Studija je koncipirana kao retroprospektivna opservaciona studija u ukupnom trajanju od pet godina retrospektivnog perioda i pola godine prospektivnog perioda kojim su obuhvaćene dve grupe bolesnika: I grupa - pacijenti sa kontrastom indukovanom nefropatijom (CIN) i II grupa - pacijenti bez CIN; koji su podvrgnuti kardiohirur&scaron;kim operacijama (koronarna, valvularna, kombinovana hirurgija i ostale) na Institutu za kardiovaskularne bolesti Vojvodine u Sremskoj Kamenici. Od ukupnog broja operisanih pacijenata u ovom perioda (oko 5000 bolesnika) u ovu studiju je uključeno 1269 bolesnika. U na&scaron;oj studiji ukupno je analizirano 1269 bolesnika koji su svrstani u dve grupe. Prvu grupu je činilo 59 (4,6%) pacijenata koji su koronarografisani (dijagnostička, terapijska) i razvili CIN te su upućeni u istoj hospitalizaciji po indikaciji konzilijuma na koronarnu, valvularnu i kombinovanu hirurgiju. Drugu grupu je činilo 1210 (95,4%) bolesnika kod kojih nakon koronarografije nije razvijena kontrastom indukovana nefropatija, a takođe su tokom iste hospitalizacije operisani. Kriterijumi za uključivanje pacijenata u studiju su svi punoletni bolesnici koji su upućeni na kardiohirur&scaron;ke operacije (koronarna, valvularna, kombinovana i ostale). CIN je definisan kao porast vrednosti kreatinina unutar pet dana nakon koronarografije za 25% u odnosu na vrednost kreatina pre koronarografije. Praćene su preoperativne, operativne i postoperativne karakteristike bolesnika sa CIN i bolesnika bez CIN. U disertaciji su kori&scaron;ćene mere deskriptivne statistike: aritmetička sredina, standardna devijacija, medijana, kvartili, frekvence i procenti. Za poređenje srednjih vrednosti varijabli dve populacije primenjen je test za nezavisne uzorke i Man-Vitnijev test. Povezanost kategorijskih varijabli ispitana je pomoću Hi-kvadrat testa za tabele kontigencije ili pomoću Fi&scaron;erovog testa. Određivanje uticaja promenljivih na ishod lečenja izvr&scaron;en je primenom univarijantne i multivarijantne binarne logističke regresije, koja je poslužila i za pravljenje nove varijable (modela) za procenu ishoda lečenja. Prediktivni kvalitet varijabli na ishod ocenjen je pomoću ROC krivih. Za određivanje dužine preživljavanja primenjena je Kaplan-Meier analiza preživljavanja. Uticaj varijabli na preživljavanje izvr&scaron;en je na osnovu Coxove regresione analize. Za statistički značajnu testa uzeta je vrednost p&lt;0,05. Statistička obrada podataka izvedena je primenom statističkog paketa SPSS 17. Dokazana je statistička značajnost u ispitivanim grupama u pogledu akutizacije bubrežne insuficijencije (p=0,007). Broj bolesnika sa akutizacijom bubrežne insuficijencije u grupi CIN je bio 3 (5,1%), a u grupi bez CIN je 6 (0,5%). Dokazana je statistička značajnost u ispitivanim grupama na osnovu perikardnog izliva (p=0,046). Statističku značajnost treba uslovno prihvatiti jer je broj bolesnika sa perikardnim izlivom u grupi sa CIN bio samo 1 (1,7%). Dokazana je statistička značajnost u ispitivanim grupama na osnovu mortaliteta (p&lt;0,0005). Broj umrlih u grupi pacijenata sa CIN je 8 (13,6%), a u grupi pacijenata bez CIN je 23 (1,9%). Dokazana je statistička značajnost u ispitivanim grupama na osnovu AKIN kriterijuma (p&lt;0,0005). Broj bolesnika bez AKIN kriterijuma u grupi sa CIN bio je 29 (49,2%), a u grupi pacijenata bez CIN je 1210 (100,0%). U Stadijumu 1 AKIN kriterijuma broj bolesnika u grupi sa CIN bio je 26 (44,1%), a u grupi bolesnika bez CIN je 0 (0,0%). U Stadijumu 2 AKIN kriterijuma broj bolesnika u grupi sa CIN bio je 1 (1,7%), a u grupi bolesnika bez CIN bio je 0 (0,0%). U Stadijumu 3 AKIN kriterijuma broj bolesnika u grupi sa CIN bio je 3 (5,1%), a u grupi bolesnika bez CIN bio je 0 (0,0%). Dokazana je statistička značajnost u ispitivanim grupama na osnovu RIFLE kriterijuma (p&lt;0,0005). Broj bolesnika bez RIFLE kriterijuma u grupi sa CIN bio je 0 (0,0%), a u grupi pacijenata bez CIN bio je 1169 (96,6%). U riziku (Risc) RIFLE kriterijuma broj bolesnika u grupi sa CIN bio je 51 (86,4%), a u grupi bolesnika bez CIN bio je 41 (3,4%). U o&scaron;tećenju (Injury) RIFLE kriterijuma broj bolesnika u grupi sa CIN bio je 5 (8,5%), a u grupi bolesnika bez CIN bio je 0 (0,0%). U stabost (Failure) RIFLE kriterijuma broj bolesnika u grupi sa CIN bio je 3 (5,1%), a u grupi bolesnika bez CIN bio je 0 (0,0%). Dokazana je statistička značajnost u ispitivanim grupama na osnovu broja komplikacija (p&lt;0,0005). Broj bolesnika bez komplijacija u grupi sa CIN bio je 39 (66,1%), a u grupi pacijenata bez CIN bio je 1027 (84,9%). Broj bolesnika sa 1 komplijacijom u grupi sa CIN bio je 12 (20,3%), a u grupi pacijenata bez CIN bio je 146 (12,1%). Broj bolesnika sa 2 komplijacije u grupi sa CIN bio je 6 (10,2%), a u grupi pacijenata bez CIN bio je 20 (1,7%). Broj bolesnika sa 3 komplijacije u grupi sa CIN bio je 1 (1,7%), a u grupi pacijenata bez CIN bio je 11 (0,9%). Broj bolesnika sa 4 komplijacije u grupi sa CIN bio je 1 (1,7%), a u grupi pacijenata bez kontrastom indukovane nefropatije bio je 6 (0,5%). Dokazana je statistička značajnost u ispitivanim grupama na osnovu MACE komplikacija (p&lt;0,0005). Broj bolesnika sa MACE komplikacijama u grupi sa CIN bio je 20 (33,9%), a u grupi pacijenata bez CIN bio je 183 (15,1%). Akutna bubrežna slabost je relativno česta komplikacija kardiohirur&scaron;kih operacija. Posebno su ugroženi bolesnici sa visokim preoperativnim rizikom, u na&scaron;oj studiji pacijenti sa prethodnim CIN-om, kod kojih je akutizacija bubrežne slabosti znatno učestalija. Kardiohirur&scaron;ki bolesnici kod kojih nastane akutna bubrežna slabost imaju, kao i u na&scaron;oj studiji, vi&scaron;e postoperativnih komplikacija, produžen boravak u jednici intenzivne nege, kao i rizik za nastanak hronične bubrežne bolesti.</p> / <p>Chronic kidney disease (CKD) is a healthcare problem that occurs worldwide and is associated with high cardiovascular comorbidity and mortality. A large increase in the number of patients with terminal renal failure (TRF) occurs as a result of an exponential increase in the number of patients whose renal failure is due to hypertension and diabetes, as well as an increase in the number of elderly with TRF. As a result, more than 50% of patients with CKD die from cardiovascular disease even before starting treatment with kidney replacement therapy. To determine the clinical characteristics of patients with and without contrast-induced nephropathy (CIN) (renal function parameters defined by AKIN and RIFLE criteria) undergoing cardiac surgery, to determine the difference in mortality and postoperative morbidity between patients with and without CIN who are submitted to cardiac surgery and also to determine predictors of mortality and morbidity in patients with CIN undergoing cardiac surgery. The study was conceived as a retroprospective observational study with a total duration of five years of retrospective period and half a year of prospective period which included two groups of patients: Group I - patients with contrast-induced nephropathy (CIN) and Group II - patients without CIN; who underwent cardiac surgery (coronary, valvular, combined surgery and other) at the Institute for Cardiovascular Diseases of Vojvodina in Sremska Kamenica. Out of the total number of operated patients in this period (about 5000 patients), 1269 patients were included in this study. In our study, a total of 1269 patients were analyzed, which were classified into two groups. The first group consisted of 59 (4.6%) patients who underwent coronary angiography (diagnostic, therapeutic) and developed CIN and were submitted to surgery in the same hospitalization as indicated by heart team. The second group consisted of 1210 (95.4%) patients who did not develop CIN after coronary angiography but were also operated on during the same hospitalization. Criteria for inclusion of patients in the study are: all adult patients who are referred for cardiac surgery (coronary, valvular, combined and other). CIN was defined as a at least 25% increase in creatinine value within five days after coronary angiography compared to creatine value before coronary angiography. Preoperative, operative and postoperative characteristics of patients with CIN and patients without CIN were analyzed. Statistical analyses included measures of descriptive statistics: arithmetic mean, standard deviation, median, quartiles, frequencies and percentages. To compare the mean values of the variables of the two populations, t-test for independent samples and the Mann-Whitney test were applied. The correlation of categorical variables was examined using the Chi-square test for contingency tables or using the Fisher test. The influence of variables on the treatment outcome was determined by applying univariate and multivariate binary logistic regression, which also served to create a new variable (model) for assessing the treatment outcome. The predictive quality of outcome variables was assessed using ROC curves. Kaplan-Meier survival analysis was used to determine survival length. The influence of variables on survival was performed based on Cox regression analysis. For a statistically significant test, the value of p &lt;0.05 was taken. Statistical data processing was performed using the statistical package SPSS 17. Statistical significance was observed in the examined groups regarding the acutization of renal failure (p = 0.007). The number of patients with acute renal failure in the CIN group was 3 (5.1%), and in the group without CIN it was 6 (0.5%). Statistical significance was observed between the examined groups based on pericardial effusion (p = 0.046). Statistical significance should be conditionally accepted because the number of patients with pericardial effusion in the group with CIN was only 1 (1.7%). Statistical significance was demonstrated in the examined groups based on mortality (p &lt;0.0005). The number of deaths in the group of patients with CIN was 8 (13.6%), and in the group of patients without CIN it was 23 (1.9%). Statistical significance was demonstrated in the examined groups based on the AKIN criteria (p &lt;0.0005). The number of patients without AKIN criteria in the group with CIN was 29 (49.2%), and in the group of patients without CIN it was 1210 (100.0%). In Stage 1 of the AKIN criterion, the number of patients in the group with CIN was 26 (44.1%), and in the group of patients without CIN it was 0 (0.0%). In Stage 2 of the AKIN criterion, the number of patients in the group with CIN was 1 (1.7%), and in the group of patients without CIN it was 0 (0.0%). In Stage 3 of the AKIN criterion, the number of patients in the group with CIN was 3 (5.1%), and in the group of patients without CIN it was 0 (0.0%). Statistical significance was demonstrated between the examined groups based on the RIFLE criteria (p &lt;0.0005). The number of patients without RIFLE criteria in the group with CIN was 0 (0.0%), and in the group of patients without CIN it was 1169 (96.6%). In the Risk of the RIFLE criterion, the number of patients in the group with CIN was 51 (86.4%), and in the group of patients without CIN it was 41 (3.4%). In the Injury of the RIFLE criterion, the number of patients in the group with CIN was 5 (8.5%), and in the group of patients without CIN it was 0 (0.0%). In the Failure of the RIFLE criterion, the number of patients in the group with CIN was 3 (5.1%), and in the group of patients without CIN it was 0 (0.0%). Statistical significance was demonstrated in the examined groups based on the number of complications (p &lt;0.0005). The number of patients without complications in the group with CIN was 39 (66.1%), and in the group of patients without CIN it was 1027 (84.9%). The number of patients with 1 complication in the group with CIN was 12 (20.3%), and in the group of patients without CIN it was 146 (12.1%). The number of patients with 2 complications in the group with CIN was 6 (10.2%), and in the group of patients without CIN it was 20 (1.7%). The number of patients with 3 complications in the group with CIN was 1 (1.7%), and in the group of patients without CIN it was 11 (0.9%). The number of patients with 4 complications in the group with CIN was 1 (1.7%), and in the group of patients without contrast-induced nephropathy it was 6 (0.5%). Statistical significance was demonstrated between the examined groups based on MACE complications (p &lt;0.0005). The number of patients with MACE complications in the group with CIN was 20 (33.9%), and in the group of patients without CIN it was 183 (15.1%). Acute renal failure is a relatively common complication of cardiac surgery. Vulnerable patients are particularly at risk, in our study patients with previous CIN, in whom the acutazation of renal failure is significantly more frequent. Cardiac surgery patients who develop acute renal failure have, as demonstrated in our study, more postoperative complications, prolonged stay in the intensive care unit, as well as the risk of developing chronic kidney disease.</p>

The objective of this study was to investigate the utilization of the diagnose-based Charlson Comorbidity Index (CCI) and the medication-based Rx-Risk Comorbidity Index on Swedish administrative data. Data was collected over a ten-year period from the National Patient Register and the National Prescribed Medication Register on 3609 respondents from the national public health survey 2018, aged 16-84 and registered in Stockholm County. The overall aim was to identify comorbid conditions in the study population; and to examine if the identified comorbidities differ between indices, based on subject characteristics such as age and gender. Moreover, the specific aim was to quantify correlation between the indices, as well as within indices over look-back periods of up to ten years. Among the study population, 13 % were identified with at least one comorbid condition through CCI, and 87 % had medications indicative of at least one condition covered by Rx-Risk. Both the original Charlson weights and updated weights by Quan were used to compute the comorbidity scores for CCI. Results showed that when CCI and Quan may have scored low, the Rx-Risk picked up more conditions. The Spearman rank correlation between CCI and Quan scores resulted in relatively high correlation with a coefficient of 0.82 (p-value &lt; 0.05) over look-back periods of 2, 5 and 10 years. Moreover, the correlation between CCI and Rx-Risk was fairly low over all look-back periods with a correlation coefficient of 0.34 (p-value &lt; 0.05) at most. The within-correlation showed that CCI identified much of the comorbidity between the one- and two-year look-back periods, whilst Rx-Risk identified much comorbidity within the one-year look-back period. The overall implications of the presented results are that a utilization of Charlson index and Rx-Risk is likely to capture comorbid conditions in different health care settings, and thus expected correlation is to be of modest level between the two indices. The research question of interest should therefore determine which index is favorable when assessment of comorbidity is desired.