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- Bromfalk, Åsa, 1967-
(author)
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Intervention for prevention : easing children’s preoperative anxiety
- 2024
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Doctoral thesis (other academic/artistic)abstract
- Background: Preoperative anxiety in children is associated with several adverse outcomes and consequences that can have a negative impact on the perioperative outcome and delay recovery. Anxiety can cause stress-induced cardiorespiratory instability, increased postoperative pain, nausea, emergence delirium, and long-term behavior changes. The ideal premedication for children is still debated. Only a few studies have examined the use of premedication in relation to total intravenous anesthesia (TIVA), and there is also a lack of studies exploring staff’s experiences of premedication. The aim of this thesis was to compare midazolam (a benzodiazepine), clonidine, and dexmedetomidine (a2-agonists) given as premedication to preschool children, regarding anxiety, cardiorespiratory response to sedation, time to postoperative recovery, posthospital negative behavior changes (NBCs), and staff’s experiences of the interventions.Methods: In a randomized clinical trial, 90 children aged 2–6 years, scheduled for TIVA and ear, nose, and throat surgery, were randomized to one of three groups, receiving midazolam 0.5 mg/kg, clonidine 4 mg/kg, or dexmedetomidine 2 mg/kg. The children were included at a 200-bed county hospital in northern Sweden and observed with validated tools from the day of surgery until two weeks postoperatively (Studies I–IV). To explore the clinical aspects, we conducted focus group interviews to elicit perioperative staff’s experiences of the studied interventions and analyzed the data with qualitative content analysis (Study V). Results: Midazolam reduced preoperative anxiety and provided perioperative cardiorespiratory stability. Clonidine and dexmedetomidine provided deeper sedation along with a minor decrease in heart rate. Some children, mainly from the clonidine group, awoke during the preoperative preparation, triggering anxiety, while the midazolam group remained conscious, calm, and cooperative. Postoperatively, the midazolam group emerged earlier from anesthesia compared to the two a2-agonist groups. However, the midazolam group had more episodes of postoperative anxiety, delirium, and pain compared to both groups receiving a2-agonists, and the overall recovery and discharge time from the post-anesthesia care unit was thus the same for all groups. The posthospital study showed at least one NBC in half of the children during the first two weeks after surgery. The staff’s experiences of premedication could be summarized in three themes: a matter of time, covering the efforts of building trust along with timing the administration and onset; don’t wake the sleeping bear, covering the challenge of maintaining sleep in the sleeping child in order to avoid a backlash if woken; and on responsive tiptoes, covering safety precautions and ethical perspectives on the interventions.Conclusion: The different premedications varied in their ability to reduce anxiety and to induce sleep, and this manifested itself throughout the perioperative process. Short-acting midazolam reduced preoperative anxiety but did not provide adequate sleep, and early postoperative emergence occasionally caused a rise in adverse symptom intensification. The long-lasting and sleep-inducing a2-agonists showed an unsatisfactory anxiolytic effect in comparison to midazolam. The sleep was superficial, and an awakening risked triggering anxiety. The staff strove to keep the sedated child asleep, and the recovery time was better and more peaceful when the children slept for a long time postoperatively. However, despite a calm perioperative process, one in two children presented with posthospital NBC. At the doses used in this study, all these premedications seem to be safe in cardiorespiratory terms, and the decision of which one to use should be tailored by individual and time.
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| 4. |
- Bromfalk, Åsa, 1967-, et al.
(author)
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Postoperative recovery in preschool‐aged children: A secondary analysis of a randomized controlled trial comparing premedication with midazolam, clonidine, and dexmedetomidine
- 2023
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In: Pediatric Anaesthesia. - : John Wiley & Sons. - 1155-5645 .- 1460-9592. ; 33:11, s. 962-972
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Journal article (peer-reviewed)abstract
- BackgroundPreoperative anxiety in pediatric patients can worsen postoperative outcomes and delay discharge. Drugs aimed at reducing preoperative anxiety and facilitating postoperative recovery are available; however, their effects on postoperative recovery from propofol-remifentanil anesthesia have not been studied in preschool-aged children. Thus, we aimed to investigate the effects of three sedative premedications on postoperative recovery from total intravenous anesthesia in children aged 2–6 years.MethodsIn this prespecified secondary analysis of a double-blinded randomized trial, 90 children scheduled for ear, nose, and throat surgery were randomized (1:1:1) to receive sedative premedication: oral midazolam 0.5 mg/kg, oral clonidine 4 μg/kg, or intranasal dexmedetomidine 2 μg/kg. Using validated instruments, outcome measures including time for readiness to discharge from the postoperative care unit, postoperative sedation, emergence delirium, anxiety, pain, and nausea/vomiting were measured.ResultsAfter excluding eight children due to drug refusal or deviation from the protocol, 82 children were included in this study. No differences were found between the groups in terms of median time [interquartile range] to readiness for discharge (midazolam, 90 min [48]; clonidine, 80 min [46]; dexmedetomidine 100.5 min [42]). Compared to the midazolam group, logistic regression with a mixed model and repeated measures approach found no differences in sedation, less emergence delirium, and less pain in the dexmedetomidine group, and less anxiety in both clonidine and dexmedetomidine groups.ConclusionsNo statistical difference was observed in the postoperative recovery times between the premedication regimens. Compared with midazolam, dexmedetomidine was favorable in reducing both emergence delirium and pain in the postoperative care unit, and both clonidine and dexmedetomidine reduced anxiety in the postoperative care unit. Our results indicated that premedication with α2-agonists had a better recovery profile than short-acting benzodiazepines; although the overall recovery time in the postoperative care unit was not affected.
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| 5. |
- Bromfalk, Åsa, 1967-, et al.
(author)
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Preoperative anxiety in preschool children : A randomized clinical trial comparing midazolam, clonidine, and dexmedetomidine
- 2021
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In: Pediatric Anaesthesia. - : John Wiley & Sons. - 1155-5645 .- 1460-9592. ; 31:11, s. 1225-1233
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Journal article (peer-reviewed)abstract
- Introduction: Anxiety in pediatric patients may challenge perioperative anesthesiology management and worsen postoperative outcomes. Sedative drugs aimed to reducing anxiety are available with different pharmacologic profiles, and there is no consensus on their effect or the best option for preschool children. In this study, we aimed to compare the effect of three different premedications on anxiety before anesthesia induction in preschool children aged 2-6 years scheduled for elective surgery. The secondary outcomes comprised distress during peripheral catheter (PVC) insertion, compliance at anesthesia induction, and level of sedation.Patients and methods: In this double-blinded randomized clinical trial, we enrolled 90 participants aged 2-6 years, who were scheduled for elective ear-, nose-and-throat surgery. The participants were randomly assigned to three groups: those who were administered 0.5 mg/kg oral midazolam, 4 µg/kg oral clonidine, or 2 µg/kg intranasal dexmedetomidine. Anxiety, distress during PVC insertion, compliance with mask during preoxygenation, and sedation were measured using the modified Yale Preoperative Anxiety Scale, Behavioral Distress Scale, Induction Compliance Checklist, and Ramsay Sedation Scale, respectively.Results: Six children who refused premedication were excluded, leaving 84 enrolled patients. At baseline, all groups had similar levels of preoperative anxiety and distress. During anesthesia preparation, anxiety was increased in the children who received clonidine and dexmedetomidine; however, it remained unaltered in the midazolam group. There were no differences in distress during PVC insertion or compliance at induction between the groups. The children in the clonidine and dexmedetomidine groups developed higher levels of sedation than those in the midazolam group.Conclusions: In preschool children, midazolam resulted in a more effective anxiolysis and less sedation compared to clonidine and dexmedetomidine.
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- Engström, Birgitta, et al.
(author)
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Relatives' involvement in nursing care : a qualitative study describing critical care nurses' experiences
- 2011
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In: Intensive & Critical Care Nursing. - : Elsevier BV. - 0964-3397 .- 1532-4036. ; 27:1, s. 1-9
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Journal article (peer-reviewed)abstract
- ObjectivesWhen patients become critically ill it also affects their relatives. The aim of this study was to describe critical care nurses’ experience of relatives’ involvement in the nursing care of patients in an intensive care unitMethodSemi-structured personal interviews with eight critical care nurses in an intensive care unit in the northern part of Sweden were conducted during 2010. The interview texts were subjected to qualitative content analysis which resulted in the formulation of two main categories and five sub-categories.FindingsThe findings showed that relatives’ involvement was appreciated and seen as great resource for both patients and critical care nurses. Protecting the integrity of patients was one reason for limiting their involvement. The environment and lack of time were experienced as other obstacles to the involvement of relatives.ConclusionAligning the needs of the relatives to be involved in the care with the needs of the patient and the work situation of the nurses requires open communication between all three parties.
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- Folkersen, Lasse, et al.
(author)
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Genomic and drug target evaluation of 90 cardiovascular proteins in 30,931 individuals.
- 2020
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In: Nature metabolism. - : Springer Science and Business Media LLC. - 2522-5812. ; 2:10, s. 1135-1148
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Journal article (peer-reviewed)abstract
- Circulating proteins are vital in human health and disease and are frequently used as biomarkers for clinical decision-making or as targets for pharmacological intervention. Here, we map and replicate protein quantitative trait loci (pQTL) for 90 cardiovascular proteins in over 30,000 individuals, resulting in 451 pQTLs for 85 proteins. For each protein, we further perform pathway mapping to obtain trans-pQTL gene and regulatory designations. We substantiate these regulatory findings with orthogonal evidence for trans-pQTLs using mouse knockdown experiments (ABCA1 and TRIB1) and clinical trial results (chemokine receptors CCR2 and CCR5), with consistent regulation. Finally, we evaluate known drug targets, and suggest new target candidates or repositioning opportunities using Mendelian randomization. This identifies 11 proteins with causal evidence of involvement in human disease that have not previously been targeted, including EGF, IL-16, PAPPA, SPON1, F3, ADM, CASP-8, CHI3L1, CXCL16, GDF15 and MMP-12. Taken together, these findings demonstrate the utility of large-scale mapping of the genetics of the proteome and provide a resource for future precision studies of circulating proteins in human health.
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- Pavedahl, Veronica, 1980-
(author)
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Person-centered fundamental care in the emergency room : Patient and registered nurse perspectives
- 2023
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Doctoral thesis (other academic/artistic)abstract
- Patients who suffer from life-threatening illness or injury – experiencing conditions such as cardiac arrest, breathing problems, or trauma – are cared for at designated emergency rooms within the emergency department. In the emergency room, the registered nurse is responsible for those who are exposed and vulnerable and have complex needs. In these rooms, the biomedical focus may reinforce a culture that values the medical-technical aspects of nursing. Meeting patients’ fundamental care needs, such as respect, information, and toileting, in a person-centered way seems challenging in emergency rooms. When care is not provided correctly, the consequences for the patient’s health can be serious, for instance resulting in physical complications in the form of pressure injuries from breathing masks and spine boards or psychological complications such as worry, anxiety, or post-traumatic stress syndrome. Little is known about how person-centered fundamental care is made visible and valued both for and by patients in emergency rooms. In this thesis the understanding of fundamental care is guided by the Fundamentals of Care framework, in order to maintain an optimal person-centered care that considers the patient’s fundamental care needs with a holistic view of the patient. The overall aim of this thesis is to explore how person-centered fundamental care needs are met for life-threateningly ill patients in emergency rooms, from both patient and registered nurse perspectives.Study I explored how fundamental care needs of life-threateningly ill or injured patients were met by observing the daily activities of registered nurses in the emergency room, through 108 observations. The results showed that registered nurses were initially engaged and active in meeting patients’ needs, but that this decreased over the duration of the care. Registered nurses met the patients’ physical needs to a greater extent than their psychosocial and relational ones. The environment affected the registered nurses’ ability to meet the patients’ fundamental care needs.To describe fundamental care needs in the emergency room, based on life-threateningly ill patients’ experiences, an interview study (Study II) was conducted with 15 persons who had been cared for in an emergency room. The interviews were analyzed using deductive content analysis based on the Fundamentals of Care framework. The results showed that relationship, timely and personalized information, and existential needs were identified as essential fundamental care needs, which were not (or only partly) met. The physical environment limited patients in having their fundamental care needs met, and they adopted a “patient role” to avoid adding to healthcare professionals’ stress.Study III described registered nurses’ work approach and prerequisites for meeting life-threateningly ill patients’ care needs from the perspective of a person-centered fundamental care framework, through 14 interviews. The results revealed that registered nurses structure their work approach in meeting patients’ fundamental care needs based on prevailing organizational and personal prerequisites.In Study IV the content of guidelines governing the registered nurses’ work in the emergency room was investigated. The results revealed that the registered nurses’ work in Swedish emergency rooms was guided by an instrumental and task-oriented approach to care. The guidelines lacked guidance in providing for patients’ fundamental care needs, and did not support the registered nurses in conducting holistic, comprehensive patient assessments and interventions.The organizational prerequisites contribute to a task-oriented and instrumental way of working, and patients are not having their fundamental care needs fully met. Fundamental care is not being promoted or prioritized, as the organization and responsibilities for providing person-centered fundamental care are unclear, unspecified, and lacking in direction for how it is to be performed – neither the organization nor the culture supports the registered nurses’ work and profession.
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| 10. |
- Abdellah, Tebani, et al.
(author)
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Annotation of pituitary neuroendocrine tumors with genome-wide expression analysis
- 2021
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In: Acta neuropathologica communications. - : BioMed Central (BMC). - 2051-5960. ; 9:1
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Journal article (peer-reviewed)abstract
- Pituitary neuroendocrine tumors (PitNETs) are common, generally benign tumors with complex clinical characteristics related to hormone hypersecretion and/or growing sellar tumor mass. PitNETs can be classified based on the expression pattern of anterior pituitary hormones and three main transcriptions factors (TF), SF1, PIT1 and TPIT that regulate differentiation of adenohypophysial cells. Here, we have extended this classification based on the global transcriptomics landscape using tumor tissue from a well-defined cohort comprising 51 PitNETs of different clinical and histological types. The molecular profiles were compared with current classification schemes based on immunohistochemistry. Our results identified three main clusters of PitNETs that were aligned with the main pituitary TFs expression patterns. Our analyses enabled further identification of specific genes and expression patterns, including both known and unknown genes, that could distinguish the three different classes of PitNETs. We conclude that the current classification of PitNETs based on the expression of SF1, PIT1 and TPIT reflects three distinct subtypes of PitNETs with different underlying biology and partly independent from the expression of corresponding hormones. The transcriptomic analysis reveals several potentially targetable tumor-driving genes with previously unknown role in pituitary tumorigenesis.
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