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| 2. |
- Wallin, Jeanette, et al.
(författare)
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Discrepancy in responses to the surprise question between hemodialysis nurses and physicians, with focus on patient clinical characteristics : A comparative study
- 2023
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Ingår i: Hemodialysis International. - : John Wiley & Sons. - 1492-7535 .- 1542-4758. ; 27:4, s. 454-464
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: The surprise question (SQ) "Would I be surprised if this patient died within the next xx months" can be used by different professions to foresee the need of serious illness conversations in patients approaching end of life. However, little is known about the different perspectives of nurses and physicians in responses to the SQ and factors influencing their appraisals. The aim was to explore nurses' and physicians' responses to the SQ regarding patients on hemodialysis, and to investigate how these answers were associated with patient clinical characteristics. Methods: This comparative cross-sectional study included 361 patients for whom 112 nurses and 15 physicians responded to the SQ regarding 6 and 12 months. Patient characteristics, performance status, and comorbidities were obtained. Cohen's kappa was used to analyze the interrater agreement between nurses and physicians in their responses to the SQ and multivariable logistic regression was applied to reveal the independent association to patient clinical characteristics. Findings: Proportions of nurses and physicians responding to the SQ with "no, not surprised" was similar regarding 6 and 12 months. However, there was a substantial difference concerning which specific patient the nurses and physicians responded "no, not surprised", within 6 (kappa = 0.366, p < 0.001, 95% CI = 0.288-0.474) and 12 months (kappa = 0.379, p < 0.001, 95% CI = 0.281-0.477). There were also differences in the patient clinical characteristics associated with nurses' and physicians' responses to the SQ. Discussion: Nurses and physicians have different perspectives in their appraisal when responding to the SQ for patients on hemodialysis. This may reinforce the need for communication and discussion between nurses and physicians to identify the need of serious illness conversations in patients approaching the end of life, in order to adapt hemodialysis care to patient preferences and needs.
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| 3. |
- Melin, Jan, et al.
(författare)
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Bedside BNP as a marker of overhydration in hemodialysis patients
- 2017
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Ingår i: Journal of the American Society of Nephrology. - 1046-6673 .- 1533-3450. ; 28:Suppl., s. 878-878
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundManagement of hydration status in dialysis patients is a great challenge to nephrologists, and new tools to understand the hydration status (HS) are needed. The aim of this study was to investigate the usefulness of brain natriuretic peptide (BNP), analyzed bedside, as a marker of overhydration (OH) in hemodialysis (HD) patients.MethodsWe investigated the distribution of BNP, measured by Alere Triage® BNP Test, and analyzed the correlation between BNP and HS, defined by bioimpedance spectroscopy (BIS) in 64 HD patients. We assumed there would be a difference in HS between patients with high levels of BNP (h-BNP) and low levels of BNP (l-BNP) and choose an arbitrary cut off of 500 ng/ml, and then differences between the groups were tested for significance. HS, blood pressure (BP) and heart rate was measured, and BNP analyzed, before one mid-week dialysis session. Blood samples were also drawn for analysis of NT-proBNP and inflammatory markers. Demographic data, comorbidities, lab values and nutritional status were collected from medical records.ResultsA positive correlation was found between BNP and OH (r = 0.4), although many severely overhydrated patients had normal or just slightly elevated BNP. BNP levels were above 500 in 38 % (n=24) of the participants. The level of OH before dialysis was higher in the h-BNP group than in the l-BNP group. There was no difference in BP before or after dialysis, but patients in the h-BNP group were older, had lower muscle strength and lower Hemoglobin and Albumin levels compared to the l-BNP group.ConclusionA normal BNP does not rule out OH as defined by BIS in HD patients, on the other hand euvolemia was rare in patients with elevated BNP. This suggests that BNP might serve as a marker of OH in a subgroup of old and frail patients. In a further study we aim to investigate if the relationship between BNP, when elevated, and OH is reproducible at an individual level.
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| 4. |
- Stenberg, Jenny, 1976-, et al.
(författare)
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Brain natriuretic peptide reflects individual variation in hydration status in hemodialysis patients
- 2019
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Ingår i: Hemodialysis International. - : Wiley. - 1492-7535 .- 1542-4758. ; 23:3, s. 402-413
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Fluid management in hemodialysis patients is a controversial topic. Brain natriuretic peptide (BNP) is secreted from the heart in response to volume overload, and may be a marker of overhydration in hemodialysis patients. Our aim was to investigate the correlation between BNP and overhydration in a cohort of hemodialysis patients, and to find out whether BNP and overhydration correlate in repeated measurements within individuals with elevated BNP.METHODS: The study was prospective, observational, and had a cross-sectional part and a longitudinal follow-up. The distribution of BNP was investigated in a cohort of 64 hemodialysis patients. Blood samples and bioimpedance spectroscopy measurements were performed before midweek dialysis. Subsequently, 11 study participants with elevated BNP concentrations (>500 pg/mL) were assessed in another nine dialysis sessions each. These individuals also had their cardiac function and heart rate variability (HRV) examined.FINDINGS: BNP was above 500 pg/mL in 38% of the participants, and correlated positively with overhydration (rs = 0.381), inflammation and malnutrition, but not with systolic blood pressure. In comparison to participants with BNP below 500 pg/mL, participants with elevated BNP were older, had lower muscle strength, lower bodyweight and lower levels of hemoglobin and albumin. Echocardiography revealed cardiac anomalies in all 11 participants in the longitudinal follow-up, and HRV, as measured by SDNN, was pathologically low. In repeated measurements, the between-individuals variation of BNP in relation to overhydration was greater (SD = 0.581) than the within-person variation (SD = 0.285).DISCUSSION: BNP correlates positively to overhydration, malnutrition, and inflammation. In a subgroup of patients with elevated BNP, who are mainly elderly and frail, BNP reflects individual variation in hydration status, and hence seems to be a modifiable marker of overhydration. These data suggest that BNP is best applied for measuring changes in hydration status within an individual over time.
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| 5. |
- Stenberg, Jenny, 1976-, et al.
(författare)
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Clinical praxis for assessment of dry weight in Sweden and Denmark : A mixed-methods study
- 2016
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Ingår i: Hemodialysis International. - : Wiley. - 1492-7535 .- 1542-4758. ; 20:1, s. 111-119
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Tidskriftsartikel (refereegranskat)abstract
- Overhydration is an independent predictor of mortality in hemodialysis (HD) patients. More than 30% of HD patients are overhydrated, motivating the development of new methods for assessing hydration status. This study surveyed clinical praxis and local guidelines for dry weight (DW) assessment in Swedish and Danish HD units, and examined if differences in routines and utilization of bioimpedance spectroscopy (BIS) and other assistive technology affected frequency of DW adjustments and blood pressure (BP) levels. Cross-sectional information on praxis, guidelines and routines, plus treatment-related data from 99 stratified patients were collected. Qualitative data were analyzed with content analysis and interpreted in convergence with statistical analysis of quantitative data in a mixed-methods design. Local guidelines concerning DW existed in 54% of the units. A BIS device was present in 52%, but only half of those units used it regularly, and no correlations to frequency of DW adjustments or BP were found. HD nurses were authorized to adjust DW in 60% of the units; in these units, the frequency of DW adjustments was 1.6 times higher and systolic BP pre-HD 8 mmHg lower. There is a wide variation in routines for DW determination, and there are indications that authorization of HD nurses to adjust DW may improve DW assessment. BIS is sparsely used; its implementation may have been delayed by uncertainty over how to manage the device and interpret measurements. Hence, better methods and guidelines for assessing DW and using BIS need to be developed.
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| 6. |
- Stenberg, Jenny, 1976-, et al.
(författare)
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Clinical praxis for assessment of dry weight in Sweden and Denmark: : a mixed-methods study
- 2015
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Konferensbidrag (refereegranskat)abstract
- BackgroundOverhydration is an independent predictor of mortality in hemodialysis (HD) patients, and more than 30% of all HD patients may be overhydrated. Insufficient volume control has actuated development of objective tools, e.g. bioimpedance spectroscopy (BIS), for assessment of hydration status.ObjectivesThe aim was to investigate clinical praxis, local guidelines and routines for assessment of dry weight (DW) in Swedish and Danish HD units, and to compare differences in routines with levels of blood pressure (BP).MethodsIn this cross-sectional study a questionnaire was used to collect information about clinical praxis, routines and guidelines; qualitative and quantitative data were analyzed convergent with statistical analysis of retrospective treatment related data of 99 stratified patients, in a mixed methods design.ResultsWritten local guidelines concerning DW existed in 54% of the units, and 52% had a BIS-device, but few used it on regular basis. HD nurses (HDN) were prime initiators of utilization of BIS. The frequency of DW adjustment was 1.6 times higher and systolic BP preHD 8 mmHg lower if HDN were authorized to adjust DW.Conclusion/Application to practiceThere is wide variation in routines for DW assessment in Swedish and Danish HD units, and implementation of BIS may have been delayed by uncertainty of how to manage the device and interpret measurements. There may be a correlation between morefrequent DW adjustments, authorization of HDN to adjust DW and lower BP. Adequate hydration status is fundamental in HD, thus better methods and guidelines for assessment of DW and utilization of BIS need to be developed.
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| 7. |
- Stenberg, Jenny, 1976-
(författare)
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Fluid Management in Haemodialysis : Studies on current practices and new methods
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Chronic fluid overload has been identified as an independent predictor of mortality in haemodialysis patients, and 30% remain fluid overloaded at dry weight. The use of bioimpedance spectroscopy (BIS) in fluid management may improve blood pressure control and cardiovascular status. However, the importance of regular and careful clinical assessment of fluid balance is repeatedly emphasised.This thesis is based on five papers and the overall aim was to investigate current practices and new methods for fluid management in haemodialysis, and to develop a management tool for dry weight determination, based on multiple complementary methods. The purpose was to contribute to reduced prevalence of fluid overload and intradialytic symptoms in haemodialysis patients, by providing the healthcare team and the patient with a tool, that facilitates communication and enables informed decision-making in dry weight determination.In the initial, cross-sectional study, clinical praxis for dry weight assessment in Sweden and Denmark was investigated. A wide variation in routines was found. Despite high access, BIS was sparsely used. Instead, nurses’ authorisation to adjust haemodialysis patients’ dry weight was associated with improved fluid status. The second study had a qualitative approach. Focus group interviews, with healthcare professionals, were carried out to achieve a deeper understanding of the factors preventing or facilitating the use of BIS. In the third study, the usefulness of a biomarker, brain natriuretic peptide (BNP), for assessing fluid status in haemodialysis patients, was investigated. An association between BNP and fluid overload was established. The between-individual variation in BNP levels was greater than the within-individual variation over time. Therefore, if BNP is to be used as a marker for fluid overload, repeated measurements are required. In the fourth study, we developed and validated a multifactorial decision aid, Recova®, that incorporates BIS in dry weight determination. Recova® is based on physiological parameters routinely measured in haemodialysis and provides guidance on when and how to respond to recognised fluid alterations. In the fifth study, the decision aid’s effect on volume status was tested in a cohort of haemodialysis patients. Implementation of Recova® had effect on fluid status symptoms, BIS-measured hydration status and NT-proBNP levels.
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| 8. |
- Stenberg, Jenny, 1976-, et al.
(författare)
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Implementation of a decision aid for recognition and correction of volume alterations (Recova®) in haemodialysis patients
- 2020
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Ingår i: Upsala Journal of Medical Sciences. - : Taylor & Francis Group. - 0300-9734 .- 2000-1967. ; 125:4, s. 281-292
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Fluid overload is associated with mortality in haemodialysis patients, and 30% of patients remain fluid-overloaded after dialysis. The aim of this study was to evaluate if implementation of Recova®, a decision aid combining clinical assessment with bioimpedance spectroscopy, facilitates individualization of target weight determination and thereby contributes to improved fluid status in maintenance haemodialysis patients.METHODS: The impact of the implementation was measured as the proportion of participants at an adequate target weight at the end of the study, assessed as change in symptoms, hydration status, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Nurses were instructed to use Recova every 2 weeks, and the process of the intervention was measured as frequencies of fluid status assessments, bioimpedance measurements, and target weight adjustments.RESULTS: Forty-nine patients at two haemodialysis units were enrolled. In participants with fluid overload (n = 10), both overhydration and fluid overload symptom score decreased. In fluid-depleted participants (n = 20), target weight adjustment frequency and the estimated target weight increased. The post-dialytic negative overhydration was reduced, but NT-proBNP increased.CONCLUSIONS: Implementation of Recova in haemodialysis care increased the monthly frequencies of bioimpedance measurements and target weight adjustments, and it contributed to symptom reduction.TRIAL REGISTRATION: The Uppsala County Council Registry of Clinical Trials: FoU 2019-0001-15.
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| 9. |
- Stenberg, Jenny, 1976-, et al.
(författare)
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Implementation of a Decision Aid for Recognition and Correction ofVolume Alterations (Recova®) in Hemodialysis
- 2020
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Konferensbidrag (refereegranskat)abstract
- Background: Chronic fluid overload is an independent predictor of mortality inhemodialysis. Clinical assessment of fluid status is subjective and unprecise, and 30% of the patients remain fluid overloaded at dry weight. This study evaluates the effects of implementing a recently developed decision aid, Recova®, which combines a systematized fluid status procedure with bioimpedance spectroscopy, for individualized dry weight determination in hemodialysis.Methods: The study was a prospective implementation intervention carried out at two hemodialysis units. The impact of the intervention was measured as the proportion of participants at an adequate dry weight at the end of the study, assessed as change in symptoms, hydration status, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Hemodialysis nurses were instructed to use Recova® every two weeks, assessing the study participants’ fluid status and adjusting their dry weights as appropriate. The process of the intervention was measured as frequencies of fluid status assessments, bioimpedance measurements, and dry weight adjustments.Results: Forty-nine patients were enrolled. In participants with fluid overload (n = 10), both bioimpedance-measured overhydration and fluid overload symptom score decreased. In fluid-depleted participants (n = 20), dry weight adjustment frequency and dry weight increased. The post-dialytic negative overhydration was reduced, but NTproBNP increased. In the remaining 19 participants, with low volume status scores, no significant changes were observed.Conclusions: Recova® defines how and when dry weight should be evaluated in hemodialysis patients. Its purpose is to provide the multidisciplinary team with a common language, and thereby facilitate early recognition and appropriate response to fluid alterations. Implementation of Recova® in hemodialysis care increased the monthly frequencies of bioimpedance measurements and dry weight adjustments, and contributedto symptom reduction.
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| 10. |
- Stenberg, Jenny, 1976-, et al.
(författare)
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Migrant informal caregiver perceptions and experiences of caring for a family member with dementia : A systematic review and thematic synthesis
- 2023
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Ingår i: Journal of Clinical Nursing. - : John Wiley & Sons. - 0962-1067 .- 1365-2702. ; 32:9-10, s. 2178-2192
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Tidskriftsartikel (refereegranskat)abstract
- Aims and Objectives: To describe migrant family caregivers' experiences and perceptions of caring for a family member with dementia.Background: There are demographic trends of aging populations and increased migration between countries. Age-associated diseases, such as dementia, are expected to increase, with migrants being at significantly increased risk. Knowledge of how dementia care is provided within migrant families is scarce.Design: Systematic review and thematic synthesis of qualitative research were performed to inform the development of interventions that can acknowledge and respond to the needs, concerns and preferences of migrant family caregivers.Methods: Searches were performed in PubMed, PsycINFO and CINAHL and reference lists in published articles were reviewed for the period 2000-October 2020. The CASP checklist for qualitative research was used to assess evidence quality, and the ENTREQ framework was used as a guide for study reporting.Results: Twenty-six articles from 10 Western countries, including 360 informal migrant caregivers from more than 30 countries of origin, were eligible. Within four areas of construct-perceptions of dementia and initial help-seeking; barriers to accessing and using formal dementia care; caregiver burden and coping and resilience-12 descriptive themes were identified. Several concepts cut across the themes, such as language difficulties; the role of the family in relation to care and support; cultural perceptions of dementia and care; stigma, pride and shame; the importance of religion and the importance of trust.Conclusions: The review revealed commonalities among migrant family caregivers that resulted in reduced understanding of dementia and the importance of diagnosis and treatment.Relevance to Clinical Practice: To prevent a negative trajectory in caregiving, with perceived demands causing high levels of stress and strain, several barriers to migrants accessing and using formal care need to be assessed and addressed.
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| 11. |
- Stenberg, Jenny, 1976-, et al.
(författare)
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Perspectives on clinical use of bioimpedance in hemodialysis : focus group interviews with renal care professionals.
- 2018
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Ingår i: BMC Nephrology. - : Springer Science and Business Media LLC. - 1471-2369. ; 19:1
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Inadequate volume control may be a main contributor to poor survival and high mortality in hemodialysis patients. Bioimpedance measurement has the potential to improve fluid management, but several dialysis centers lack an agreed fluid management policy, and the method has not yet been implemented. Our aim was to identify renal care professionals' perceived barriers and facilitators for use of bioimpedance in clinical practice.METHODS: Qualitative data were collected through four focus group interviews with 24 renal care professionals: dieticians, nephrologists and nurses, recruited voluntarily from a nation-wide selection of hemodialysis centers, having access to a bioimpedance-device. The participants were connected to each other and a moderator via equipment for telemedicine and the sessions were recorded. The interviews were semi-structured, focusing on the participants' perceptions of use of bioimpedance in clinical practice. Thematic content analysis was performed in consecutive steps, and data were extracted by employing an inductive, interactive, comparative process.RESULTS: Several barriers and facilitators to the use of bioimpedance in clinical practice were identified, and a multilevel approach to examining barriers and incentives for change was found to be applicable to the ideas and categories that arose from the data. The determinants were categorized on five levels, and the different themes of the levels illustrated with quotations from the focus groups participants.CONCLUSIONS: Determinants for use of bioimpedance were identified on five levels: 1) the innovation itself, 2) the individual professional, 3) the patient, 4) the social context and 5) the organizational context. Barriers were identified in the areas of credibility, awareness, knowledge, self-efficacy, care processes, organizational structures and regulations. Facilitators were identified in the areas of the innovation's attractiveness, advantages in practice, and collaboration. Motivation, team processes and organizational capacities appeared as both barriers and facilitators.
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| 12. |
- Stenberg, Jenny, 1976-, et al.
(författare)
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Social support as perceived, provided and needed by family-members of migrants with type 2 diabetes - a qualitative study
- 2024
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Ingår i: BMC Public Health. - : BioMed Central (BMC). - 1471-2458. ; 24:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: Social support provided by a family member has been found to have a buffering effect on distress and is associated with better diabetes self-care. This study explores the meaning of social support, as described by close family members of foreign-born people living with type 2 diabetes (PWDM) in Sweden. It also explores the support provided by family members, and the support they need to be able to support the PWDM.Methods: Qualitative explorative study, semi-structured interviews for data collection. Qualitative content analysis based on a theoretical framework on social support. Purposive sample of 13 family members, 18-52-years-old, born in countries in the Middle East, Africa, and Russia.Results: The meaning of support was described as social and emotional. Most participants described a stressful situation; feelings of sadness/worry about the risk of the PWDM developing complications added to a strained life situation from which one could not opt out. Frequent daily contacts in a family network were evident, particularly by children trained as healthcare professionals. Caring for a family member was considered a filial piety, but it was also a chance to reciprocate. The support provided was mainly informational (e.g., reminders about nutritional intake), but it was also instrumental/practical (administering medicines, helping with economy/logistics, planning/cooking meals, basic care) and emotional (sharing meals, thoughts, and activities). The support the family members needed was getting first-hand information by attending the physician visits, being able to book appointments themselves at suitable times, and preventing the withholding of important information about the PWDM. They also desired an open telephone-line, oral and written information, particularly on diet.Conclusions: To family-members, supporting the PWDM was normal and a filial piety. Support provided and needed was not only informational but also instrumental/practical and emotional. In diabetes care, addressing foreign-born individuals, diabetes education needs to be developed, also including family members. Informational material, particularly on diet, and improved access to healthcare and information about the healthcare system have the potential to increase family members' control over the situation and prevent a negative trajectory in caregiving with perceived demands causing high levels of stress.
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| 13. |
- Stenberg, Jenny, 1976-, et al.
(författare)
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Systematic fluid assessment in haemodialysis care: : Development and validation of adecision aid
- 2019
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Konferensbidrag (refereegranskat)abstract
- BackgroundOverhydration is a mortality risk factor in haemodialysis patients, and about a third of patients have poorly controlled fluid balance. Bioimpedance is a technique that can detect excess body water. However it is important to recognize that bioimpedance adds information to what is already a complex decision-making process, rather than providing a simple target applicable to all patients. Clinical guidelines incorporating the information from bioimpedance in determination of dry weight are lacking.ObjectivesTo develop and validate a decision aid, which standardizes the process of recording, scoring and responding to changes in routinely measured physiological parameters, and provides a basis for a unified and systematic approach to the assessment of volume status in haemodialysis care.MethodsWe are developing a scoring system, which we have named Subjective Volume Status Score (SVSS). Experts in theuse of bioimpedance have been included to address face-validity. In order to test the reliability of SVSS, nurses from a number of British and Swedish haemodialysis units will be recruited to use SVSS in individual assessments of four typical patient cases. Their assessments will be analyzed with inter-rater agreement analysis.ResultsSVSS consists of:A scoring system, built upon six physiological parameters, for detection and assessment of clinical symptoms of impaired hydration statusThresholds and triggers, a simple track-and-trigger system guiding the caregiver in deciding when and how to respondA decision aid, which helps to incorporate the information from bioimpedance when setting the dry weight, and aims to facilitate communication in the team, by providing a common language.Conclusion/Application to practiceOur guiding principle is that if SVSS is going to work in diverse haemodialysis care settings, then it must be simple to implement and must use physiological parameters that are already being routinely measured in the haemodialysis care.
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