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Background: Stress-induced exhaustion disorder (SED) is the most common reason for long-term sick leave in Sweden and the recovery process may be long and troublesome. This study explores the symptoms of burnout, depression and anxiety among patients with SED 10 years after termination of a multimodal rehabilitation program. Another aim of the study was to investigate work situation, work functioning, and any remaining exhaustion and sleeping disorders among those who were gainfully employed at the 10-year follow-up. Methods: This longitudinal study included 107 patients (91 women and 16 men), who had been diagnosed with SED 10 years prior to the study. After establishing the diagnosis they all underwent and completed an multimodal rehabilitation program. Data on symptoms of burnout, anxiety and depression were collected before and after the multimodal rehabilitation program, and at follow-ups after additional 1 year and an additional 10 years. At the 10-year follow-up, work situation, work functioning, and symptoms of exhaustion and sleep disorders were assessed in those who were gainfully employed (89 patients). Results: Symptoms of burnout, anxiety, and depression remained stable from the 1- to the 10-year follow-up after completed rehabilitation. Among participants who were gainfully employed, 73% had changed workplaces, and 31.5% had reduced their working hours. Common reasons for these changes were lack of energy or because they had chosen to prioritise their lives differently. Work functioning was rated as moderate, one third self-reported SED to some extent, and one fifth reported moderate-to-severe insomnia. Conclusion: A relatively large proportion of former patients with SED have residual health problems 10 years after rehabilitation and some have not been able to return to full-time work. Preventive and early rehabilitative interventions with adjustments and measures at the organisational level are probably needed to achieve a more sustainable working li

An accurate rating of hand activity and force is essential in risk assessment and for the effective prevention of work-related musculoskeletal disorders. However, it is unclear whether the subjective ratings of workers and observers correlate to corresponding objective technical measures of exposure. Fifty-nine workers were video recorded while performing a hand-intensive work task at their workplace. Self-ratings of hand activity level (HAL) and force (Borg CR10) using the Hand Activity Threshold Limit Value® were assessed. Four ergonomist observers, in two pairs, also rated the hand activity and force level for each worker from video recordings. Wrist angular velocity was measured using inertial movement units. Muscle activity in the forearm muscles flexor carpi radialis (FCR) and extensor carpi radialis (ECR) was measured with electromyography root mean square values (RMS) and normalized to maximal voluntary electrical activation (MVE). Kendall’s tau-b correlations were statistically significant between self-rated hand activity and wrist angular velocity at the 10th, 50th, and 90th percentiles (0.26, 0.31, and 0.23) and for the ratings of observers (0.32, 0.41, and 0.34). Significant correlations for force measures were found only for observer-ratings in five of eight measures (FCR 50th percentile 0.29, time > 10%MVE 0.43, time > 30%MVE 0.44, time < 5% −0.47) and ECR (time > 30%MVE 0.26). The higher magnitude of correlation for observer-ratings suggests that they may be preferred to the self-ratings of workers. When possible, objective technical measures of wrist angular velocity and muscle activity should be preferred to subjective ratings when assessing risks of work-related musculoskeletal disorders.

Stress-related exhaustion is associated with cognitive deficits, measured subjectively using questionnaires targeting everyday slips and failures or more objectively as performance on cognitive tests. Yet, only weak associations between subjective and objective cognitive measures in this group has been presented, theorized to reflect recruitment of compensational resources during cognitive testing. This explorative study investigated how subjectively reported symptoms of cognitive functioning and burnout levels relate to performance as well as neural activation during a response inhibition task. To this end, 56 patients diagnosed with stress-related exhaustion disorder (ED; ICD-10 code F43.8A) completed functional magnetic resonance imaging (fMRI) using a Flanker paradigm. In order to investigate associations between neural activity and subjective cognitive complaints (SCCs) and burnout, respectively, scores on the Prospective and Retrospective Memory Questionnaire (PRMQ) and the Shirom-Melamed Burnout Questionnaire (SMBQ) were added as covariates of interest to a general linear model at the whole-brain level. In agreement with previous research, the results showed that SCCs and burnout levels were largely unrelated to task performance. Moreover, we did not see any correlations between these self-report measures and altered neural activity in frontal brain regions. Instead, we observed an association between the PRMQ and increased neural activity in an occipitally situated cluster. We propose that this finding may reflect compensational processes at the level of basic visual attention which could go unnoticed in cognitive testing but still be reflected in the experience of deficits in everyday cognitive functioning.

Background: Stress is a commonly perceived cause of cancer, but the evidence to date is limited and inconclusive. We examined work-related stress in relation to cancer incidence in a population-based cohort, with outcome data from Swedish national registries. Methods: The study population included 113,057 participants in the Västerbotten Intervention Programme. HRs were estimated using Cox proportional hazards regression, for cancer overall and for types with ≥500 cases, and adjusting for several potential confounders. The primary exposure was prediagnostic work-related stress, using the well established Karasek job demand/control model. Demand and control variables were dichotomized at the median, and participants were classified according to combinations of these categories. We also considered social network and aspects of quality of life. Results: "High-strain" work (high demand/low control) was not associated with cancer risk compared with "low-strain" work (low demand/high control): multivariable HR 1.01 [95% confidence interval (CI), 0.94-1.08] for men and 0.99 (95% CI, 0.92-1.07) for women. Results were also null for most cancer types assessed: prostate, breast, colorectal, lung, and gastrointestinal (GI). The risk of GI cancer was lower for "passive" (low demand/low control) versus "low-strain" work, particularly for colorectal cancer in women: multivariable HR 0.71 (95% CI, 0.55-0.91), but statistical significance was lost after adjustment for multiple testing. Conclusions: The findings of this population-based, cohort study do not support a role for work-related stress in determining cancer risk. Impact: This study helps fill an important knowledge gap given the common concern about stress as a risk factor for cancer.

We compared hand activity and force ratings in women and men doing identical hand-intensive work tasks. Musculoskeletal disorders are more common in women and hand-intensive work leads to an increased risk of these disorders. Knowledge of the gender influence in the rating of work exposure is lacking. The aim of this study was to investigate whether women and men performing identical hand-intensive work tasks were equally rated using hand activity and normalized peak force levels with the Hand Activity Threshold Limit Value®. Fifty-six workers participated, comprising 28 women-men pairs. Four observers-two woman-man pairs-were also involved. Self-ratings and observers' ratings of hand activity and force level were collected. The results of these ratings showed no significant gender differences in self-rated hand activity and force, as well as observer-rated hand activity. However, there was a significant gender difference in the observer-rated force, where the women were rated higher (mean (SD): women 3.9 (2.7), men 3.1 (1.8) (p = 0.01)). This difference remained significant in the adjusted model (p = 0.04) with grip strength and forearm-finger anthropometrics. The results provide new insights that observers' estimates of force can be higher in women compared with men in the same work tasks. Force should be further investigated and preferably compared to objective measurements.

Background: Stress is a commonly perceived cause of cancer, but the evidence to date is limited and inconclusive. We examined work-related stress in relation to cancer incidence in a population-based cohort, with outcome data from Swedish national registries. Methods: The study population included 113,057 participants in the Västerbotten Intervention Programme. HRs were estimated using Cox proportional hazards regression, for cancer overall and for types with ≥500 cases, and adjusting for several potential confounders. The primary exposure was prediagnostic work-related stress, using the well established Karasek job demand/control model. Demand and control variables were dichotomized at the median, and participants were classified according to combinations of these categories. We also considered social network and aspects of quality of life. Results: "High-strain" work (high demand/low control) was not associated with cancer risk compared with "low-strain" work (low demand/high control): multivariable HR 1.01 [95% confidence interval (CI), 0.94-1.08] for men and 0.99 (95% CI, 0.92-1.07) for women. Results were also null for most cancer types assessed: prostate, breast, colorectal, lung, and gastrointestinal (GI). The risk of GI cancer was lower for "passive" (low demand/low control) versus "low-strain" work, particularly for colorectal cancer in women: multivariable HR 0.71 (95% CI, 0.55-0.91), but statistical significance was lost after adjustment for multiple testing. Conclusions: The findings of this population-based, cohort study do not support a role for work-related stress in determining cancer risk. Impact: This study helps fill an important knowledge gap given the common concern about stress as a risk factor for cancer.

Implementation of activity-based flex offices (AFOs) are becoming increasingly common. The aim of this study was to evaluate the effects of an AFO on perceived productivity, satisfaction, work environment and health. Questionnaire data from the longitudinal, quasi-experimental Active Office Design Study was used. The study evaluates a public organization relocating staff to either an AFO or to cell offices. Measures from baseline, 6 and 18 months after relocation, were analyzed. Employees in the AFO experienced a decreased productivity and satisfaction with the office design. Lack of privacy as well as increased noise disturbance, less satisfaction with sit comfort and work posture were reported. Employees in the AFO with work tasks requiring a high degree of concentration experienced lower productivity while those with a high proportion of teamwork rated productivity to be continually high. No significant group differences were found between the two office types in general health, cognitive stress, salutogenic health indicators or pain in the neck, shoulder or back. The study highlights the importance of taking work characteristics into account in the planning and implementation process of an AFO. Flexible and interactive tasks seem more appropriate in an AFO, whereas individual tasks demanding concentration seem less fit.

Background: Stress-related exhaustion is associated with cognitive impairment as measured by both subjective cognitive complaints (SCCs) and objective cognitive test performance. This study aimed to examine how patients diagnosed with exhaustion disorder differ from healthy control participants in regard to levels and type of SCCs, and if SCCs are associated with cognitive test performance and psychological distress. Methods: We compared a group of patients with stress-related exhaustion disorder (n = 103, female = 88) with matched healthy controls (n = 58, female = 47) cross-sectionally, concerning the type and magnitude of self-reported SCCs. We furthermore explored the association between SCCs and cognitive test performance as well as with self-reported depression, anxiety and burnout levels, in the patient and the control group, respectively. Results: Patients reported considerably more cognitive failures and were more likely than controls to express memory failures in situations providing few external cues and reminders in the environment. In both groups, SCCs were associated with demographic and psychological factors, and not with cognitive test performance. Conclusion: Our findings underline the high burden of cognitive problems experienced by patients with exhaustion disorder, particularly in executively demanding tasks without external cognitive support. From a clinical perspective, SCCs and objective cognitive test performance may measure different aspects of cognitive functioning, and external cognitive aids could be of value in stress rehabilitation. Trial registration: Participants were recruited as part of the Rehabilitation for Improved Cognition (RECO) study (ClinicalTrials.gov: NCT03073772). Date of registration: 8 March 2017

Studies using technical measurements of physical behavior show wide interindividual variations. This study aimed to explore underlying factors related to sitting, standing and walking among office workers. Cross-sectional data for background characteristics, work-related variables, and device-based measures for sitting, standing and walking were collected among office workers in either a cell office or a flex office with activity-based work. Data were analyzed by Factor Analysis of Mixed Data (FAMD) and multiple robust linear regression. The FAMD resulted in the combination of underlying factors describing six character types. The (1) harmonic and healthy, (2) disabled with poor health, (3) manager that spend a lot of time in meetings and has very high workload, (4) engaged with high workload, (5) employee with creative and computer intense work, with high workload and, (6) employee with high BMI with creative and collaborative work. Regression analysis showed that the character type that was "engaged with high workload" sat more and stood less, while the character type with "high BMI and with creative and collaborative work" sat less. The results suggest that physical behavior among office workers is influenced by a complex combination of factors, which should be taken into account in the evaluation of future studies of larger cohorts.

Emerging evidence suggests that mental fatigue is a central component of the cognitive and clinical characteristics of stress-related exhaustion disorder (ED). Yet, the underlying mechanisms of mental fatigue in this patient group are poorly understood. The aim of this study was to investigate cortical and subcortical structural neural correlates of mental fatigue in patients with ED, and to explore the association between mental fatigue and cognitive functioning. Fifty-five patients with clinical ED diagnosis underwent magnetic resonance imaging. Mental fatigue was assessed using the Concentration subscale from the Checklist Individual Strength. Patients with high levels of mental fatigue (n = 30) had smaller caudate and putamen volumes compared to patients with low-moderate levels of mental fatigue (n = 25). No statistically significant differences in cortical thickness were observed between the groups. Mediation analysis showed that mental fatigue mediated the relationship between caudate volume and working memory; specifically, smaller caudate volume was associated with higher level of mental fatigue and mental fatigue was positively associated with working memory performance. Our findings demonstrate that the structural integrity of the striatum is of relevance for the subjective perception of mental fatigue in ED, while also highlighting the complex relationship between mental fatigue, cognitive performance and its neural underpinnings.

It is important to understand how people with exhaustion disorder (ED) perceive interventions aiming to facilitate cognitive functioning. Therefore, the overall aim of this study was to explore experiences from persons with ED after participating in a 12-week intervention of either computerized cognitive training or aerobic training. Both interventions were performed in addition to a multimodal rehabilitation programme. Thirteen participants, 11 women and 2 men, were interviewed about pros and cons with participating in the training. The interviews were analysed with Qualitative Content Analysis. The analyses resulted in the theme hopeful struggling for health and the categories support, motivation and sensations. It was hard work recovering from ED. Support from others who are in the same situation, family members, and technology and routines for the training were strongly emphasized as beneficial for recovery. Timing, i.e., matching activities to the rehabilitation programme, getting feedback and perceiving joy in the training were important for motivation. Participants in both interventions experienced positive sensations with improved memory performance, everyday life functioning and increased faith in the prospect of recovery. However, it is important to consider various aspects of support and motivation in both computerized cognitive training and aerobic training to enable participants to pursue their participation.

The aim of this study was to investigate facilitating and hindering factors when implementing a physical activity (PA)-promoting program among office workers moving to a flex office, by conducting a process evaluation. Additionally, we evaluated self-reported and perceived PA behaviors. With a mixed methods design, analyses were based upon data from interviews with 70 employees and repeated questionnaires from 152 employees. The PA-promoting program was fully implemented and supported by management. There was a strong health promoting culture, encouraging PA in the organization already at the start of the study. The lecture and the office design were rated as the most motivating program components. The use of stairs, breaks during meetings and social acceptance for standing and walking at work increased. Employees described a strive for variation, and how managers, the office environment, productivity and ergonomic aspects influenced sedentary behavior (SB) and PA. The need for the PA-promoting program was questioned, and the timing of the program was debated. To conclude, a strong organizational health culture combined with a facilitating physical environment can create sustainable positive PA behaviors in office settings. A thorough understanding of organizational needs and a participatory process are needed to tailor organizational interventions to decrease SB., Originally included in thesis in manuscript form.

It is important to understand how people with exhaustion disorder (ED) perceive interventions aiming to facilitate cognitive functioning. Therefore, the overall aim of this study was to explore experiences from persons with ED after participating in a 12-week intervention of either computerized cognitive training or aerobic training. Both interventions were performed in addition to a multimodal rehabilitation programme. Thirteen participants, 11 women and 2 men, were interviewed about pros and cons with participating in the training. The interviews were analysed with Qualitative Content Analysis. The analyses resulted in the theme hopeful struggling for health and the categories support, motivation and sensations. It was hard work recovering from ED. Support from others who are in the same situation, family members, and technology and routines for the training were strongly emphasized as beneficial for recovery. Timing, i.e., matching activities to the rehabilitation programme, getting feedback and perceiving joy in the training were important for motivation. Participants in both interventions experienced positive sensations with improved memory performance, everyday life functioning and increased faith in the prospect of recovery. However, it is important to consider various aspects of support and motivation in both computerized cognitive training and aerobic training to enable participants to pursue their participation.

Activity-based Flexible Offices (A-FOs) are implemented with varying degree of success. Employees relocate from cell or open-plan offices, from different organizational backgrounds, varying design and implementation processes, and have different types of work tasks. This study aims at investigating whether preference for the A-FO correlate with these preconditions. The results from Chi-square tests and Spearman's non-parametric correlation of post-relocation questionnaires distributed to 11 A-FO sites, showed that a high preference for the A-FO correlated strongest with an A-FO preference prior to relocation, being a former open-plan office occupier and with frequent performance of innovation. Low preference for the A-FO correlated with frequent performance of concentration demanding tasks. Working with tasks with high confidentiality did not predict the preference ratings.

Objectives: The aim of this study was to investigate effects of a multicomponent program promoting physical activity on sedentary behavior, physical activity, and body measures, when relocating from cell offices to either a flex or cell office. Methods: The Active Office Design (AOD) study is a longitudinal non-randomized controlled study performed in a municipality in northern Sweden. A subsample of 86 participants were randomly recruited from the AOD study to objectively measure sedentary behavior and physical activity, using ActivPAL and ActiGraph, before and after relocation to the two different office types. The multicomponent program promoting physical activity was performed in both offices. Data were analyzed using linear mixed models. Results: Eighteen months after relocation, the total number of steps per work day increased by 21% in the flex office and 3% in the cell office group, compared to baseline. Moderate and vigorous physical activity (MVPA) during work hours increased by 42% in the flex office group and 19% in the cell office group. No changes were seen regarding sitting time at work. Small additive effects for walking and MVPA were seen for both groups during non-work time. Weight increased in the flex office group. Conclusions: This long-term study shows that a multicomponent workplace intervention can lead to increased walking time, steps, and MVPA in a flex compared to a cell office. Small additive increases of physical activity were seen during non-work time in both groups. More long-term controlled studies are needed to confirm these results.

Activity-based Flexible Offices (A-FOs) are implemented with vary- ing degree of success. Employees relocate from cell or open-plan offices, from different organizational backgrounds, varying design and implementation pro- cesses, and have different types of work tasks. This study aims at investigating whether preference for the A-FO correlate with these preconditions. The results from Chi-square tests and Spearman’s non-parametric correlation of post- relocation questionnaires distributed to 11 A-FO sites, showed that a high pref- erence for the A-FO correlated strongest with an A-FO preference prior to relo- cation, being a former open-plan office occupier and with frequent performance of innovation. Low preference for the A-FO correlated with frequent perfor- mance of concentration demanding tasks. Working with tasks with high confi- dentiality did not predict the preference ratings., QC 20181122QC 20210104

Stress-related exhaustion has been associated with selective and enduring cognitive impairments. However, little is known about how to address cognitive deficits in stress rehabilitation and how this influences stress recovery over time. The aim of this open-label, parallel randomized controlled trial (ClinicalTrials.gov: NCT03073772) was to investigate the long-term effects of 12 weeks cognitive or aerobic training on cognitive function, psychological health and work ability for patients diagnosed with exhaustion disorder (ED). One-hundred-and-thirty-two patients (111 women) participating in multimodal stress rehabilitation were randomized to receive additional cognitive training (n = 44), additional aerobic training (n = 47) or no additional training (n = 41). Treatment effects were assessed before, immediately after and one-year post intervention. The primary outcome was global cognitive function. Secondary outcomes included domain-specific cognition, self-reported burnout, depression, anxiety, fatigue and work ability, aerobic capacity and sick-leave levels. Intention-to-treat analysis revealed a small but lasting improvement in global cognitive functioning for the cognitive training group, paralleled by a large improvement on a trained updating task. The aerobic training group showed improvements in aerobic capacity and episodic memory immediately after training, but no long-term benefits. General improvements in psychological health and work ability were observed, with no difference between interventional groups. Our findings suggest that cognitive training may be a viable method to address cognitive impairments for patients with ED, whereas the effects of aerobic exercise on cognition may be more limited when performed during a restricted time period. The implications for clinical practice in supporting patients with ED to adhere to treatment are discussed.

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Stress-related exhaustion has been associated with selective and enduring cognitive impairments. However, little is known about how to address cognitive deficits in stress rehabilitation and how this influences stress recovery over time. The aim of this open-label, parallel randomized controlled trial (ClinicalTrials.gov: NCT03073772) was to investigate the long-term effects of 12 weeks cognitive or aerobic training on cognitive function, psychological health, and work ability for patients diagnosed with exhaustion disorder (ED). One-hundred-and-thirty-two patients (111 women) participating in multimodal stress rehabilitation were randomized to receive additional cognitive training (n = 44), additional aerobic training (n = 47), or no additional training (n = 41). Treatment effects were assessed before, immediately after and one-year post intervention. The primary outcome was global cognitive function. Secondary outcomes included domain-specific cognition, self-reported burnout, depression, anxiety, fatigue and work ability, aerobic capacity, and sick-leave levels. Intention-to-treat analysis revealed a small but lasting improvement in global cognitive functioning for the cognitive training group, paralleled by a large improvement on a trained updating task. The aerobic training group showed improvements in aerobic capacity and episodic memory immediately after training, but no long-term benefits. General improvements in psychological health and work ability were observed, with no difference between interventional groups. Our findings suggest that cognitive training may be a viable method to address cognitive impairments for patients with ED, whereas the effects of aerobic exercise on cognition may be more limited when performed during a restricted time period. The implications for clinical practice in supporting patients with ED to adhere to treatment are discussed.

The primary purpose of this study was to investigate the association between burnout and neural activation during working memory processing in patients with stress-related exhaustion. Additionally, we investigated the neural effects of cognitive training as part of stress rehabilitation. Fifty-five patients with clinical diagnosis of exhaustion disorder were administered the n-back task during fMRI scanning at baseline. Ten patients completed a 12-week cognitive training intervention, as an addition to stress rehabilitation. Eleven patients served as a treatment-as-usual control group. At baseline, burnout level was positively associated with neural activation in the rostral prefrontal cortex, the posterior parietal cortex and the striatum, primarily in the 2-back condition. Following stress rehabilitation, the striatal activity decreased as a function of improved levels of burnout. No significant association between burnout level and working memory performance was found, however, our findings indicate that frontostriatal neural responses related to working memory were modulated by burnout severity. We suggest that patients with high levels of burnout need to recruit additional cognitive resources to uphold task performance. Following cognitive training, increased neural activation was observed during 3-back in working memory-related regions, including the striatum, however, low sample size limits any firm conclusions.

BACKGROUND: Patients with stress-related exhaustion suffer from cognitive impairments, which often remain after psychological treatment or work place interventions. It is important to find effective treatments that can address this problem. Therefore, the aim of this study was to investigate the effects on cognitive performance and psychological variables of a 12-week aerobic training program performed at a moderate-vigorous intensity for patients with exhaustion disorder who participated in a multimodal rehabilitation program. METHODS: In this open-label, parallel, randomized and controlled trial, 88 patients diagnosed with exhaustion disorder participated in a 24-week multimodal rehabilitation program. After 12 weeks in the program the patients were randomized to either a 12-week aerobic training intervention or to a control group with no additional training. Primary outcome measure was cognitive function, and secondary outcome measures were psychological health variables and aerobic capacity. RESULTS: In total, 51% patients in the aerobic training group and 78% patients in the control group completed the intervention period. The aerobic training group significantly improved in maximal oxygen uptake and episodic memory performance. No additional improvement in burnout, depression or anxiety was observed in the aerobic group compared with controls. CONCLUSION: Aerobic training at a moderate-vigorous intensity within a multimodal rehabilitation program for patients with exhaustion disorder facilitated episodic memory. A future challenge would be the clinical implementation of aerobic training and methods to increase feasibility in this patient group. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03073772 . Retrospectively registered 21 February 2017.

Background: Patients with stress-related exhaustion suffer from cognitive impairments, which often remain after psychological treatment or work place interventions. It is important to find effective treatments that can address this problem. Therefore, the aim of this study was to investigate the effects on cognitive performance and psychological variables of a 12-week aerobic training program performed at a moderate-vigorous intensity for patients with exhaustion disorder who participated in a multimodal rehabilitation program. Methods: In this open-label, parallel, randomized and controlled trial, 88 patients diagnosed with exhaustion disorder participated in a 24-week multimodal rehabilitation program. After 12 weeks in the program the patients were randomized to either a 12-week aerobic training intervention or to a control group with no additional training. Primary outcome measure was cognitive function, and secondary outcome measures were psychological health variables and aerobic capacity. Results: In total, 51% patients in the aerobic training group and 78% patients in the control group completed the intervention period. The aerobic training group significantly improved in maximal oxygen uptake and episodic memory performance. No additional improvement in burnout, depression or anxiety was observed in the aerobic group compared with controls. Conclusion: Aerobic training at a moderate-vigorous intensity within a multimodal rehabilitation program for patients with exhaustion disorder facilitated episodic memory. A future challenge would be the clinical implementation of aerobic training and methods to increase feasibility in this patient group. Trial registration: ClinicalTrials.gov: NCT03073772. Retrospectively registered 21 February 2017.

Background: There is need for an updated systematic review of associations between occupational exposures and ischaemic heart disease (IHD), using the GRADE system. Methods: Inclusion criteria: (i) publication in English in peer-reviewed journal between 1985 and 2014, (ii) quantified relationship between occupational exposure (psychosocial, organizational, physical and other ergonomic job factors) and IHD outcome, (iii) cohort studies with at least 1000 participants or comparable case-control studies with at least 50 + 50 participants, (iv) assessments of exposure and outcome at baseline as well as at follow-up and (v) gender and age analysis. Relevance and quality were assessed using predefined criteria. Level of evidence was then assessed using the GRADE system. Consistency of findings was examined for a number of confounders. Possible publication bias was discussed. Results: Ninety-six articles of high or medium high scientific quality were finally included. There was moderately strong evidence (grade 3 out of 4) for a relationship between job strain and small decision latitude on one hand and IHD incidence on the other hand. Limited evidence (grade 2) was found for iso-strain, pressing work, effort-reward imbalance, low support, lack of justice, lack of skill discretion, insecure employment, night work, long working week and noise in relation to IHD. No difference between men and women with regard to the effect of adverse job conditions on IHD incidence. Conclusions: There is scientific evidence that employees, both men and women, who report specific occupational exposures, such as low decision latitude, job strain or noise, have an increased incidence of IHD.

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Background: Sick leave rates due to mental and behavioural disorders have increased in Sweden during the last decades. The aim of this prospective study was to investigate changes in the level of burnout in a working subset of the general population and to identify how such changes relate to changes in work situation and self-perceived economic situation. Methods: A cohort of 1000 persons from a subset of the 2004 northern Sweden MONICA (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease) general population survey was followed over a five-year period (2004–2009). In total, 623 persons (323 women and 300 men) were included in the analysis. Burnout levels were measured at baseline and follow-up using the Shirom Melamed Burnout Questionnaire. Risk factors were assessed at both measuring points. Results: In the whole study cohort, a small (−0.15) but statistically significant reduction in burnout level was found. No differences in change of burnout were found between men and women. Constant strain at work, an increased risk of unemployment, and a perceived worsening of economic situation during the study time period were related to an increased burnout level. An accumulation of these risk factors was associated with increased burnout level. Conclusions: Risk factors in work situation and self-perceived economy are related to changes in burnout level, and special attention should be directed towards persons exposed to multiple risk factors.

Aim: The aim of this study was to investigate the personal experiences and perceived effects on mind from visits to forest environments in a subset of patients with severe exhaustion disorder (ED), who participated in a randomized controlled trial for evaluation of forest-based rehabilitation. Participants: A subsample of 19 patients with diagnosed ED, who completed the three-month forest-based rehabilitation programme in the ForRest project, was interviewed. Method: The forest-based rehabilitation consisted of repeated forest visits with the main objective of spending time in rest and solitude in a chosen forest setting. Semi-structured interviews were carried out and analysed using Grounded Theory. Result: A core category and five subcategories were set up to describe the patients' experiences and development during the forest-based rehabilitation. As patients mostly reported that they strove to achieve peace of mind during the forest visits, Striving for serenity was chosen to be the core category. At first the patients were frustrated when left alone with their own thoughts in an unfamiliar forest environment. They gradually became familiar with the forest environments and also found their favourite places where they experienced peace of mind. They were then able to rest and begin reflective thinking about their life situation, which led to ambitions to change it. The preferred forest environments were characterised by openness, light and a good view, and were felt to be undemanding, peaceful and stimulating. Conclusion: Visits to the forest provided favourite places for rest, were experienced as restorative, seemed to improved reflection and may have contributed to starting the coping process for these patients. However, forest visits, as the only treatment option, are not sufficient as rehabilitation from severe and long-term ED. We suggest that forest visits should be integrated with cognitive behavioural therapy to further improve the recovery and enhance co

Modern society is faced with increasing incidence of mental and behavioural disorders. The objective of this study was to evaluate whether visits to boreal forests can be utilised for rehabilitation from exhaustion disorder (ED). This randomised controlled trial comprised of a forest rehabilitation group (n = 35) and a waiting list group (control group) (n = 43) with subsequent cognitive behavioural rehabilitation (CBR) for all participants in both groups. The recovery from ED was compared between the forest rehabilitation and the control group at baseline, after the forest rehabilitation (3 months), and at the end of the CBR (1 year). Both groups had enhanced recovery from ED after the 3-month intervention period and at the end of the CBR (1 year), and there were no significant differences between the groups in terms of psychological health measures. Mental state, attention capacity and preferences for different forest environments were studied during the forest visits. Mental state was improved, but it showed some seasonal differences. A significant effect on attention capacity was found for single forest visits, but there was no effect found for the rehabilitation period as a whole. The most popular forest environments contained easily accessible, open and bright settings with visible water and/or shelter. Forest rehabilitation did not enhance the recovery from ED compared to the control group, but the participants’ well-being was improved after single forest visits.

The present study evaluated whether a computerized process-based cognitive training program improves cognitive function in patients with stress-related exhaustion (n=59). Results showed training effects that were generalizable beyond the specific training tasks, suggesting that cognitive training may be a viable part of the rehabilitation of stress-related exhaustion.

Objectives: Previous studies have shown that biomarkers in blood plasma can predict bleeding complications during anticoagulant treatment as well as thromboembolic events and may improve existing risk stratification schemes in patients on or considered for oral anticoagulant treatment. The aim of this study was to investigate if levels of D-dimer, tissue plasminogen activator (tPA) and its complex with plasminogen inhibitor type 1 (tPA/PAI-1 complex) can predict major bleedings, cardiovascular events and all-cause mortality in patients with warfarin treatment. Design and methods: In a longitudinal cohort study, 719 patients on oral anticoagulant treatment were followed for a total of 3001 treatment years. Major bleeding, stroke, arterial emboli, myocardial infarction and death were recorded and classified. Blood samples collected at baseline were analyzed for D-dimer, tPA, and tPA/PAI-1 complex. Results: In multivariate Cox regression analysis, high levels of D-dimer were associated with major bleeding (HR 1.27 per SD; 95% CI: 1.01-1.60), cardiovascular events (HR 1.23 per SD; 95% CI: 1.05-1.45) and all-cause mortality (HR 1.25 per SD; 95% CI: 1.06-1.47). Neither tPA nor the tPA/PAI-1 complex was associated with major bleeding, cardiovascular events or all-cause mortality. Conclusion: We conclude that high levels of D-dimer predict major bleeding, cardiovascular events and all-cause mortality during warfarin treatment. (C) 2014 The Canadian Society of Clinical Chemists.

This experimental study investigated differences in perceived restorativeness, mood, attention capacity and physiological reactions when visiting city and forest environments. Twenty female patients diagnosed with exhaustion disorder visited three different forest environments and one city environment in randomized order. They performed a standardized 90-min test procedure in each of these environments. Evaluation of the environments and psychological effects in mood were studied with self-administered questionnaires. Attention capacity was studied with Necker Cube Pattern Control task. Physiological responses were measured with regularly scheduled controls of heart rate and blood pressure, and a single test of heart rate recovery. Visits to the forest environments were perceived as significantly more restorative, enhancing mood and attention capacity compared to the city. This also applies to the results of heart rate and to some extent to the results of the diastolic blood pressure. The results from this experimental study support our hypothesis that short visits to forest environments enhance both psychological and physiological recovery and that visits to forest environments are likely to be beneficial when suffering from exhaustion disorder.

Aims. Oral anticoagulation (OAC), predominantly with warfarin, is an effective treatment to prevent thromboembolic events. Serious bleeding is a frequent and feared treatment complication. In this longitudinal cohort study of OAC-treated patients, we aimed to evaluate the relationship between von Willebrand factor (VWF) levels and risk of bleeding complications, cardiovascular mortality and all-cause mortality. Methods and results. A total of 719 patients receiving warfarin treatment were observed for a mean duration of 4.2 years. All bleeding complications causing hospitalization were registered and classified into clinically relevant bleeding (CRB) and major bleeding. Ischaemic stroke, peripheral arterial embolism, myocardial infarction, and death were also recorded. We identified 113 cases of CRB and 73 of major bleeding. In total, 161 deaths occurred during follow-up with cardiovascular disease identified as the cause of death in 110 patients. Patients in the highest tertile of VWF had a significantly increased risk of bleeding complications: hazard ratio (HR) 2.53 (95% CI 1.41-4.56) for major bleeding and HR 2.19 (95% CI 1.38-3.48) for CRB. VWF, expressed either in tertiles or as a continuous variable, showed a significant association with cardiovascular mortality (HR 1.68, 95% CI 1.40-2.01) and all-cause mortality (HR 1.77, 95% CI 1.52-2.05). In multivariate Cox regression analysis, the findings remained significant after adjusting for age, high-sensitivity C-reactive protein and creatinine. Conclusions. Patients with high levels of VWF had an increased risk of bleeding complications, cardiovascular mortality and all-cause mortality during OAC treatment. Our findings imply that the use of VWF as a risk marker for thromboembolic events is complicated by the association of VWF with bleeding complications.