| 1. |
- Munch, Marie W., et al.
(författare)
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Effect of 12 mg vs 6 mg of Dexamethasone on the Number of Days Alive Without Life Support in Adults With COVID-19 and Severe Hypoxemia The COVID STEROID 2 Randomized Trial
- 2021
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Ingår i: Journal of the American Medical Association (JAMA). - : AMER MEDICAL ASSOC. - 0098-7484 .- 1538-3598. ; 326:18, s. 1807-1817
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Tidskriftsartikel (refereegranskat)abstract
- Question What is the effect of 12 mg vs 6 mg of dexamethasone on the number of days alive without life support at 28 days in patients with COVID-19 and severe hypoxemia? Findings In this randomized trial that included 1000 patients with COVID-19 and severe hypoxemia, treatment with 12 mg/d of dexamethasone resulted in 22.0 days alive without life support at 28 days compared with 20.5 days in those receiving 6 mg/d of dexamethasone. This difference was not statistically significant. Meaning Compared with 6 mg of dexamethasone, 12 mg of dexamethasone did not statistically significantly reduce the number of days alive without life support at 28 days. This multicenter randomized clinical trial compares the effects of 12 mg/d vs 6 mg/d of dexamethasone in patients with COVID-19 and severe hypoxemia. IMPORTANCE A daily dose with 6 mg of dexamethasone is recommended for up to 10 days in patients with severe and critical COVID-19, but a higher dose may benefit those with more severe disease. OBJECTIVE To assess the effects of 12 mg/d vs 6 mg/d of dexamethasone in patients with COVID-19 and severe hypoxemia. DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial was conducted between August 2020 and May 2021 at 26 hospitals in Europe and India and included 1000 adults with confirmed COVID-19 requiring at least 10 L/min of oxygen or mechanical ventilation. End of 90-day follow-up was on August 19, 2021. INTERVENTIONS Patients were randomized 1:1 to 12 mg/d of intravenous dexamethasone (n = 503) or 6 mg/d of intravenous dexamethasone (n = 497) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was the number of days alive without life support (invasive mechanical ventilation, circulatory support, or kidney replacement therapy) at 28 days and was adjusted for stratification variables. Of the 8 prespecified secondary outcomes, 5 are included in this analysis (the number of days alive without life support at 90 days, the number of days alive out of the hospital at 90 days, mortality at 28 days and at 90 days, and >= 1 serious adverse reactions at 28 days). RESULTS Of the 1000 randomized patients, 982 were included (median age, 65 [IQR, 55-73] years; 305 [31%] women) and primary outcome data were available for 971 (491 in the 12 mg of dexamethasone group and 480 in the 6 mg of dexamethasone group). The median number of days alive without life support was 22.0 days (IQR, 6.0-28.0 days) in the 12 mg of dexamethasone group and 20.5 days (IQR, 4.0-28.0 days) in the 6 mg of dexamethasone group (adjusted mean difference, 1.3 days [95% CI, 0-2.6 days]; P = .07). Mortality at 28 days was 27.1% in the 12 mg of dexamethasone group vs 32.3% in the 6 mg of dexamethasone group (adjusted relative risk, 0.86 [99% CI, 0.68-1.08]). Mortality at 90 days was 32.0% in the 12 mg of dexamethasone group vs 37.7% in the 6 mg of dexamethasone group (adjusted relative risk, 0.87 [99% CI, 0.70-1.07]). Serious adverse reactions, including septic shock and invasive fungal infections, occurred in 11.3% in the 12 mg of dexamethasone group vs 13.4% in the 6 mg of dexamethasone group (adjusted relative risk, 0.83 [99% CI, 0.54-1.29]). CONCLUSIONS AND RELEVANCE Among patients with COVID-19 and severe hypoxemia, 12 mg/d of dexamethasone compared with 6 mg/d of dexamethasone did not result in statistically significantly more days alive without life support at 28 days. However, the trial may have been underpowered to identify a significant difference.
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| 2. |
- Akerstrom, Finn, et al.
(författare)
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Association between catheter ablation of atrial fibrillation and mortality or stroke
- 2024
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Ingår i: Heart. - : BMJ PUBLISHING GROUP. - 1355-6037 .- 1468-201X. ; 110, s. 163-169
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Tidskriftsartikel (refereegranskat)abstract
- Objective Catheter ablation of atrial fibrillation effectively reduces symptomatic burden. However, its long-term effect on mortality and stroke is unclear. We investigated if patients with atrial fibrillation who undergo catheter ablation have lower risk for all-cause mortality or stroke than patients who are managed medically. Methods We retrospectively included 5628 consecutive patients who underwent first-time catheter ablation for atrial fibrillation between 2008 and 2018 at three major Swedish electrophysiology units. Control individuals with an atrial fibrillation diagnosis but without previous stroke were selected from the Swedish National Patient Register, resulting in a control group of 48 676 patients. Propensity score matching was performed to produce two cohorts of equal size (n=3955) with similar baseline characteristics. The primary endpoint was a composite of all-cause mortality or stroke. Results Patients who underwent catheter ablation were healthier (mean CHA(2)DS(2)-VASc score 1.4 +/- 1.4 vs 1.6 +/- 1.5, p<0.001), had a higher median income (288 vs 212 1000 Swedish krona [KSEK]/year, p<0.001) and had more frequently received university education (45.1% vs 28.9%, p<0.001). Mean follow-up was 4.5 +/- 2.8 years. After propensity score matching, catheter ablation was associated with lower risk for the combined primary endpoint (HR 0.58, 95% CI 0.48 to 0.69). The result was mainly driven by a decrease in all-cause mortality (HR 0.51, 95% CI 0.41 to 0.63), with stroke reduction showing a trend in favour of catheter ablation (HR 0.75, 95% CI 0.53 to 1.07). Conclusions Catheter ablation of atrial fibrillation was associated with a reduction in the primary endpoint of all-cause mortality or stroke. This result was driven by a marked reduction in all-cause mortality.
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| 3. |
- Hansson, Emma C., 1985, et al.
(författare)
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Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel : a nationwide study
- 2016
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Ingår i: European Heart Journal. - : Oxford University Press (OUP). - 0195-668X .- 1522-9645. ; 37:2, s. 189-197
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Tidskriftsartikel (refereegranskat)abstract
- AIMS:Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients.METHODS AND RESULTS:All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012-13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued <24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72-120 or >120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53-1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72-120 vs. >120 h before surgery (OR 1.71 (95% CI 1.04-2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56-0.92), P = 0.012].CONCLUSION:The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued <24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel.
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| 4. |
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| 5. |
- Semb, Gunvor, et al.
(författare)
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A Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 1. Planning and management.
- 2017
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Ingår i: Journal of Plastic Surgery and Hand Surgery. - : Taylor & Francis. - 2000-656X .- 2000-6764. ; 51:1, s. 2-13
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND AND AIMS: Longstanding uncertainty surrounds the selection of surgical protocols for the closure of unilateral cleft lip and palate, and randomised trials have only rarely been performed. This paper is an introduction to three randomised trials of primary surgery for children born with complete unilateral cleft lip and palate (UCLP). It presents the protocol developed for the trials in CONSORT format, and describes the management structure that was developed to achieve the long-term engagement and commitment required to complete the project.METHOD: Ten established national or regional cleft centres participated. Lip and soft palate closure at 3-4 months, and hard palate closure at 12 months served as a common method in each trial. Trial 1 compared this with hard palate closure at 36 months. Trial 2 compared it with lip closure at 3-4 months and hard and soft palate closure at 12 months. Trial 3 compared it with lip and hard palate closure at 3-4 months and soft palate closure at 12 months. The primary outcomes were speech and dentofacial development, with a series of perioperative and longer-term secondary outcomes.RESULTS: Recruitment of 448 infants took place over a 9-year period, with 99.8% subsequent retention at 5 years.CONCLUSION: The series of reports that follow this introductory paper include comparisons at age 5 of surgical outcomes, speech outcomes, measures of dentofacial development and appearance, and parental satisfaction. The outcomes recorded and the numbers analysed for each outcome and time point are described in the series.TRIAL REGISTRATION: ISRCTN29932826.
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| 6. |
- Andersson, Emma, 1983-, et al.
(författare)
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Improved Railway Timetable Robustness for Reduced Traffic Delays – a MILP approach
- 2015
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Ingår i: 6th International Conference on Railway Operations Modelling and Analysis, Tokyo, Mars 23-26, 2015..
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Konferensbidrag (refereegranskat)abstract
- Maintaining high on-time performance and at the same time having high capacity utilization is a challenge for several railway traffic systems. The system becomes sensitive to disturbances and delays are easily propagating in the network. One way to handle this problem is to create more robust timetables; timetables that can absorb delays and prevent them from propagating. This paper presents an optimization approach to reduce the propagating of delays with a more efficient margin allocation in the timetable. A Mixed Integer Linear Programming (MILP) model is proposed in which the existing margin time is re-allocated to increase the robustness for an existing timetable. The model re-allocates both runtime margin time and headway margin time to increase the robustness at specific delay sensitive points in a timetable. We illustrate the model’s applicability for a real-world case where an initial, feasible timetable is modified to create new timetables with increased robustness. These new timetables are then evaluated and compared to the initial timetable. We evaluate how the MILP approach affects the initial timetable structure and its capability to handle disturbances by exposing the initial and the modified timetables to some minor initial disturbances of the range 1 up to 7 minutes. The results show that it is possible to reduce the delays by re-allocating margin time, for example, the total delay at end station decreases with 28 % in our real-world example.
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| 7. |
- Andersson, Emma, 1983-, et al.
(författare)
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Increasing robustness at single-track lines using the indicator robustness in passing pointss
- 2023
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Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
- When several trains are planned to use the same infrastructure resource, there is always a risk for spreading of delays, which can be hard to recover from. It is a challenge for the Infrastructure Manager to make timetables that accommodate as much traffic as possible, without causing bad on-time performance. Timetable planners are in need of quantitative indicators to assess timetable robustness and accurate methods for how to make the timetable more robust.In this paper we assess the robustness for single-track lines with non-periodic timetables. At single-track lines, trains use the line for running in both directions and the trains can only pass or overtake each other at passing loops. This makes the system more sensitive for delays. In this paper we present a robustness indicator which captures the dependencies between trains at a single-track line. The indicator can be used to illustrate weaknesses in a timetable and also to indicate where and how to insert more robustness. In a simulation study, we show that it is possible to improve the performance by making small timetable adjustments according the indicator, without increasing runtimes or capacity utilization.
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| 8. |
- Andersson, Emma, 1983-, et al.
(författare)
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Introducing a New Quantitative Measure of Railway Timetable Robustness Based on Critical Points
- 2013
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Ingår i: 5th International Seminar on Railway Operations Modelling and Analysis - RailCopenhagen 2013. - 9788773272466
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Konferensbidrag (refereegranskat)abstract
- The growing demand for railway capacity has led to high capacity consumption at times and a delay-sensitive network with insufficient robustness. The fundamental challenge is therefore to decide how to increase the robustness. To do so there is a need for accurate measures that return whether the timetable is robust or not and indicate where improvements should be made. Previously presented measures are useful when comparing different timetable candidates with respect to robustness, but less useful to decide where and how robustness should be inserted. In this paper, we focus on points where trains enter a line, or where trains are being overtaken, since we have observed that these points are critical for the robustness. The concept of critical points can be used in the practical timetabling process to identify weaknesses in a timetable and to provide suggestions for improvements. In order to quantitatively assess how crucial a critical point may be, we have defined the measure RCP (Robustness in Critical Points). A high RCP value is preferred, and it reflects a situation at which train dispatchers will have higher prospects of handling a conflict effectively. The number of critical points, the location pattern and the RCP values constitute an absolute value for the robustness of a certain train slot, as well as of a complete timetable. The concept of critical points and RCP can be seen as a contribution to the already defined robustness measures which combined can be used as guidelines for timetable constructors.
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| 9. |
- Andersson, Emma, et al.
(författare)
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Robustness in Swedish Railway Traffic Timetables
- 2011
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Ingår i: Railrome 2011.
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Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
- A tendency seen for quite some time in the Swedish railway network is a growing demand for capacity which no longer can be accommodated. This causes congestion and delays, and the relationships between the trains and how they affect eachother are significantly harder to overview and analyse. Railway traffic timetables normally contain margins to make them robust, and enable trains to recover from certain delays. How effective these margins are, depends on their size and location as well as the frequency and magnitude of the disturbances that occur. Hence, it is important to include marigns so, that they can be used operationally to recover from a variety of disturbances and not restricted to a specific part of the line and/or the timetable. In a case study we compare the performance of a selection of passenger train services to the different prerequisites given by the timetable (e.g. available margins and their location, critical train dependencies). The study focuses on the Swedish Southern mainline between Stockholm and Malmö on which a wide variety of train services operate, e.g. freight trains, local and regional commuter train services as well as long-distance trains with different speed profiles. The analysis shows a clear mismatch between where margins are placed and where delays occur. We also believe that the most widely used performance measure, which is related to the delay when arriving at the final destination, might give rise to an unnecessarily high delay rate at intermediate stations.
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| 10. |
- Andersson, Emma V.
(författare)
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Assessment of Robustness in Railway Traffic Timetables
- 2014
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A tendency seen for the last decades in many European railway networks is a growing demand for capacity. An increased number of operating trains has led to a delay sensitive system where it is hard to recover from delays, where even relatively small delays are easily propagating to other traffic.The overall aim of this thesis is to analyse the robustness of railway traffic timetables; why delays are propagating in the network and how the timetable design and dispatching strategies influence the delays. In this context we want to establish quantitative measures of timetable robustness. There is a need for measures that can be used by the timetable constructors. Measures that identify where and how to improve the robustness and thereby indicating how and where margin time should be inserted. It is also important that the measures can capture interdependencies between different trains.In this thesis we introduce the concept of critical points, which is a practical approach to identify robustness weaknesses in a timetable. In contrast to other measures, critical points can be used to identify specific locations in both time and space. The corresponding measure, Robustness in Critical Points (RCP) provides the timetable constructors with concrete suggestions for which trains that should be given more runtime or headway margin. The measure also identifies where the margin time should be allocated to achieve a higher robustness.In a case study we show that the delay propagation is highly related to the operational train dispatching. This study shows that the current prioritisation rule used in Sweden results in an economic inefficiency and therefore should be revised. This statement is further supported by RCP and the importance of giving the train dispatchers more flexibility to efficiently solve conflict situations.
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