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- Holmer, Hampus
(author)
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Measuring global surgery, obstetrics and anaesthesia from health systems to patients
- 2019
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Doctoral thesis (other academic/artistic)abstract
- BackgroundWorldwide, an estimated 5 billion people lack access to safe, affordable surgical care when needed. This leads to millions of avertable deaths and unnecessary morbidity each year. To change this situation, urgent action is needed at many levels, but indicators and data have been lacking to guide improvement.AimsThe aim of this thesis was to describe and evaluate measurement of surgical public health. Organised according to the Lancet Commission on Global Surgery indicator framework, the thesis specifically aimed to: I. quantify global access to emergency obstetric care; II. describe the global distribution of specialist surgeons, anaesthesiologists and obstetricians; III. measure the rate and mortality of Caesarean sections in Sierra Leone, the country with the world’s highest maternal mortality; IV. to propose a new study design for collecting data on surgical outcomes; V. calculate the cost-effectiveness of surgical care, as exemplified by Ponseti club foot repair, and; VI. critically review the global data collection efforts of the six Lancet global surgery indicators.MethodsTo address these aims, a range of methodologies were employed: I. Available reports of national and sub-national data on the met need for emergency obstetric care were collected, reviewed and analysed; II. National data on the number and distribution of the specialist surgical workforce were collected; III. The rate and outcomes of Caesarean sections in Sierra Leone were analysed based on data from facilities and from the national Maternal Death Surveillance and Response system; IV. A protocol for collecting data on perioperative mortality of emergency abdominal surgery was developed; V. Cost effectiveness analysis was carried out for club foot repair; VI. Data on the six indicators proposed by the Lancet Commission on Global Surgery in 2015 were collected, and indicators analysed and critically reviewed.ResultsThe global met need for emergency obstetric care was 45% [interquartile range 28–57%], and the met need was significantly correlated with the proportion of births attended by skilled birth attendants. There were an estimated two million specialist surgeons, obstetricians and anaesthesiologists, of which only 20% serve the poorest half of the world. In 2016, the Sierra Leonean Caesarean section rate was 2.9% of all deliveries, with a perioperative mortality rate of 1.5%. A multicentre, international, prospective cohort study protocol for the measurement of perioperative mortality of emergency abdominal surgery was published. Clubfoot repair by the Ponseti method was highly cost-effective at 22 USD per averted Disability Adjusted Life Year. The six indicators proposed by The Lancet Commission on Global Surgery have been implemented to varying degrees, with definitional challenges as well as lack of commitment and structures for data collection.SignificanceMeasuring global surgery, obstetrics and anaesthesia – from health systems to patients explores methods of measuring surgical care in the context of a growing recognition of the need to increase access to safe, affordable surgical care around the globe. This research has provided baseline data on several indicators, some of which have been adopted by the WHO and the World Bank. Furthermore, it has critically reviewed the six indicators proposed for global implementation, and made suggestions for further improvement. Good quality indicators are paramount for guiding further efforts in global surgery, obstetrics and anaesthesia, with potential impact for surgical patients, families and societies today and in the future.
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| 2. |
- Tseli, Elena, et al.
(author)
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Prognostic Factors for Physical Functioning After Multidisciplinary Rehabilitation in Patients With Chronic Musculoskeletal Pain : A Systematic Review and Meta-Analysis
- 2019
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In: The Clinical Journal of Pain. - : Lippincott Williams & Wilkins. - 0749-8047 .- 1536-5409. ; 35:2, s. 148-173
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Research review (peer-reviewed)abstract
- OBJECTIVES: This systematic review aimed to identify and evaluate prognostic factors for long-term (≥6 mo) physical functioning in patients with chronic musculoskeletal pain following multidisciplinary rehabilitation (MDR).MATERIALS AND METHODS: Electronic searches conducted in MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science, and Cochrane CENTRAL revealed 25 original research reports, published 1983-2016, (n=9436). Potential prognostic factors relating to initial pain and physical and psychological functioning were synthesized qualitatively and quantitatively in random effects meta-analyses. The level of evidence (LoE) was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE).RESULTS: Pain-related factors (intensity and chronicity) were not associated with function/disability at long-term follow-up, odds ratio (OR)=0.84; 95% confidence interval (CI), 0.65-1.07 and OR=0.97; 95% CI, 0.93-1.00, respectively (moderate LoE). A better function at follow-up was predicted by Physical factors; higher levels of initial self-reported functioning, OR=1.07; 95% CI, 1.02-1.13 (low LoE), and Psychological factors; low initial levels of emotional distress, OR=0.77; 95% CI, 0.65-0.92, low levels of cognitive and behavioral risk factors, OR=0.85; 95% CI, 0.77-0.93 and high levels of protective cognitive and behavioral factors, OR=1.49; 95% CI, 1.17-1.90 (moderate LoE).DISCUSSION: While pain intensity and long-term chronicity did not predict physical functioning in chronic pain patients after MDR, poor pretreatment physical and psychological functioning influenced the prognosis negatively. Thus, treatment should further target and optimize these modifiable factors and an increased focus on positive, psychological protective factors may perhaps provide an opening for yet untapped clinical gains.
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| 3. |
- Jonsson, M., et al.
(author)
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Survival after out-of-hospital cardiac arrest is associated with area-level socioeconomic status
- 2019
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In: Heart. - : BMJ. - 1355-6037 .- 1468-201X. ; 105:8, s. 632-638
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Journal article (peer-reviewed)abstract
- Objective Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the Western world. In this study we aimed to investigate the relationship between area-level socioeconomic status (SES) and 30-day survival after OHCA. We hypothesised that high SES at an area level is associated with an improved chance of 30-day survival. Methods Patients with OHCA in Stockholm County between 1 January 2006 and 31 December 2015 were analysed retrospectively. To quantify area-level SES, we linked the patient's home address to 250 x 250/1000 x 1000 meter grids with aggregated information about income and education. We constructed multivariable logistic regression models in which area-level SES measures were adjusted for age, sex, emergency medical services response time, witnessed status, initial rhythm, aetiology, location and year of cardiac arrest. Results We included 7431 OHCAs. There was significantly greater 30-day survival (p=0.003) in areas with a high proportion of university-educated people. No statistically significant association was seen between median disposable income and 30-day survival. The adjusted OR for 30-day survival among patients in the highest educational quintile was 1.70 (95% CI 1.15 to 2.51) compared with patients in the lowest educational quintile. We found no significant interaction for sex. Positive trend with increasing area-level education was seen in both men and women but the trend was only statistically significant among men (p=0.012) Conclusions Survival to 30 days after OHCA is positively associated with the average educational level of the residential area. Area-level income does not independently predict 30-day survival after OHCA.
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| 4. |
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| 5. |
- Singh, Sukhi, 1990, et al.
(author)
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Adrenaline Improves Platelet Reactivity in Ticagrelor-Treated Healthy Volunteers
- 2019
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In: Thrombosis and Haemostasis. - : Georg Thieme Verlag KG. - 0340-6245 .- 2567-689X. ; 119:5, s. 735-743
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Journal article (peer-reviewed)abstract
- BACKGROUND: Administration of agents that enhance platelet reactivity may reduce the perioperative bleeding risk in patients treated with the adenosine diphosphate (ADP)-receptor antagonist ticagrelor. Adrenaline potentiates ADP-induced aggregation and activation in blood samples from ticagrelor-treated patients, but it has not previously been evaluated in vivo.METHODS: Ten healthy male subjects were included in an interventional study. A loading dose of ticagrelor (180 mg) was administered, followed 2 hours later by a gradually increased intravenous adrenaline infusion (0.01, 0.05, 0.10 and 0.15 µg/kg/min; 15 minutes at each step). Blood pressure, heart rate, platelet aggregation (impedance aggregometry), platelet activation (flow cytometry), clot formation (rotational thromboelastometry) and adrenaline plasma concentration were determined before and after ticagrelor administration and at the end of each adrenaline step.RESULTS: = 0.007).CONCLUSION: Infusion of adrenaline at clinically relevant doses improves in vivo platelet reactivity and clot formation in ticagrelor-treated subjects. Adrenaline could thus potentially be used to prevent perioperative bleeding complications in ticagrelor-treated patients. Studies in patients are necessary to determine the clinical importance of our observations.TRIAL REGISTRY NUMBER: ClinicalTrials.gov NCT03441412.
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| 6. |
- Peters, Lynn, et al.
(author)
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Multiple antibiotic resistance as a risk factor for mortality and prolonged hospital stay: A cohort study among neonatal intensive care patients with hospital-acquired infections caused by gram-negative bacteria in Vietnam
- 2019
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In: PLOS ONE. - : PUBLIC LIBRARY SCIENCE. - 1932-6203. ; 14:5
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Journal article (peer-reviewed)abstract
- Background Antibiotic resistance (ABR) is an increasing burden for global health. The prevalence of ABR in Southeast Asia is among the highest worldwide, especially in relation to hospital acquired infections (HAI) in intensive care units (ICU). However, little is known about morbidity and mortality attributable to ABR in neonates. Aim This study aimed to assess mortality and the length of hospitalization attributable to ABR in gram-negative bacteria (GNB) causing HAI in a Vietnamese neonatal ICU (NICU). Methods We conducted a prospective cohort study (n = 296) in a NICU in Hanoi, Vietnam, from March 2016 to October 2017. Patients isolated with HAI caused by GNB were included. The exposure was resistance to multiple antibiotic classes, the two outcomes were mortality and length of hospital stay (LOS). Data were analysed using two regression models, controlling for confounders and effect modifiers such as co-morbidities, time at risk, severity of illness, sex, age, and birthweight. Results The overall case fatality rate was 44.3% and the 30 days mortality rate after infection was 31.8%. For every additional resistance to an antibiotic class, the odds of a fatal outcome increased by 27% and LOS increased by 2.1 days. These results were statistically significant (p amp;lt; 0.05). Conclusion ABR was identified as a significant risk factor for adverse outcomes in neonates with HAI. These findings are generally in line with previous research in children and adults. However, heterogeneous study designs, the neglect of important confounders and varying definitions of ABR impair the validity, reliability, and comparability of results.
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| 7. |
- Hultkvist, Henrik, 1968-
(author)
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Implications of myocardial dysfunction before and after aortic valve intervention
- 2019
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Doctoral thesis (other academic/artistic)abstract
- BACKGROUNDPostoperative heart failure in the setting of aortic valve surgery results in poor long-term survival. We hypothesized that there could be a myocardial factor that is not addressed by risk scores currently available. We speculated that this myocardial factor could be diastolic dysfunction. By evaluating postoperative heart failure, the EuroSCORE, the NT-proBNP level, and diastolic function, we might achieve a deeper understanding of the outcome for individuals with postoperative heart failure.METHODSThis research project was built upon four cohort studies. The first two studies (I and II) were retrospective in nature, and studies III and IV were prospective, observational, and longitudinal. All work was based on data from clinical and national databases. In Study I, we compared the outcome of patients with or without postoperative heart failure, evaluated according to the preoperative risk score. In Study II, we explored the effect of underlying heart disease on the preoperative level of NT-proBNP and the relationships between NT-proBNP and severe postoperative heart failure and short-term mortality. In Study III, we described the dynamicsof NT-proBNP, from a preoperative evaluation to a six-month follow-up, in patients that underwent one of two different procedures: a surgical aortic valve replacement and a transcatheter implantation. We related both pre- and postprocedural NT-proBNP levels to one-year mortality. In Study IV, we evaluated diastolic function in patients that underwent surgical aortic valve replacement and its influence on outcome. We also evaluated NT-proBNP levels and postoperative heart failure as predictors of long-term mortality.RESULTSStudy IThis study included 397 patients that underwent isolated surgical aortic valve replacements. Of these, 45 patients (11%) were treated for postoperative heart failure. With an average follow-up of 8.1 years (range 5.2-11.2), among patients at low risk (EuroSCORE≤7), the crude five-year survival rates were 58% in patients with postoperative heart failure and 89% in those without postoperative heart failure (p<0.001). Among patients with postoperative heart failure, those classified as low risk had the same poor long-term prognosis as those classified as high risk (EuroSCORE>7). In the high risk group, survival rates were similar between patients with or without postoperative heart failure (57% vs. 64%; p=0.60).Study IIThis study included a cohort of 2978 patients with coronary artery disease, aortic stenosis, and mitral regurgitation. Preoperative NTproBNP levels were found to be 1.7-fold higher in patients with aortic stenosis than in patients with coronary artery disease and 1.4-fold higher in patients with mitral regurgitation than in patients with coronary disease. The power of preoperative NT-proBNP for predicting severe postoperative heart conditions was good among patients with coronary heart disease and patients with mitral regurgitation, but not as good among patients with aortic stenosis. NT-proBNP also showed good discriminating power for short-term mortality among patients with coronary artery disease. Moreover, NT-proBNP was found to be an independent predictor for both severe postoperative heart failure and short-term mortality in patients with coronary artery disease.Study IIIThis study included 462 patients that underwent preoperative evaluations for aortic valve disease. Aortic valve interventions elicited a rise in NT-proBNP that was more pronounced in patients undergoing surgical aortic valve replacement compared to patients undergoing transcatheter valve implantation. No deterioration in NT-proBNP was observed during the waiting time before the intervention, despite a median duration of four months. At six months after the intervention, NT-proBNP levels had decreased to or below the preoperative levels in all groups. Among patients that received surgical aortic valve replacements, pre-and early postoperative NT-proBNP levels showed good discriminatory power for oneyear mortality. This discriminatory power was not observed among patients that had undergone a transcatheter procedure; those patients had higher levels of both pre- and postoperative NT-proBNP compared to patients that had undergone surgery.Study IVWe evaluated 273 patients that underwent aortic valve surgery. High left ventricular filling pressure was present in 22% (n=54) of patients at the time of surgery. At six months after surgery, diastolic function deteriorated in 24/193 (12%) patients and improved in 27/54 (50%) patients. Diastolic dysfunction was not found to be associated with long-term mortality. However, both postoperative heart failure and preoperative NTproBNP levels were associated with increases in long-term mortality. In a multivariable Cox analysis, NT-proBNP remained predictive of long-term mortality.CONCLUSIONPostoperative heart failure contributed to long-term mortality, even in patients considered to be at low risk preoperatively. Our results suggested that pressure overload, followed by a volume overload led to a NTproBNP response that was more pronounced than the ischemia response. Elevated levels of NT-proBNP were associated with both short- and long-term mortality. In these studies, we could not corroborate the notion that high left ventricular filling pressure was associated with long-term mortality.
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| 8. |
- Jiang, Huiqi, 1981-
(author)
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NT-proBNP as a marker of postoperative heart failure in adult cardiac surgery
- 2019
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Doctoral thesis (other academic/artistic)abstract
- Postoperative heart failure (PHF) remains the major cause of mortality after cardiac surgery. Unfortunately, generally accepted diagnostic criteria for PHF are lacking. This may explain why the evidence for the efficacy and safety of current treatment of PHF with inotropes is insufficient. In cardiology practice N-terminal pro-B-type natriuretic peptide (NT-proBNP) is an established biomarker for heart failure. However, the association between NT-proBNP and PHF after cardiac surgery needs further clarification. Glutamate is a key intermediate in myocardial metabolism, which may improve myocardial tolerance to ischemia and facilitate post-ischemic recovery. Glutamate was associated with a reduced risk of developing severe PHF in high-risk patients undergoing coronary artery bypass surgery (CABG). The aim of this thesis was to study the role of NT-proBNP for prediction and assessment of PHF in cardiac surgery (Paper I-III) and the impact of intravenous glutamate infusion on postoperative NTproBNP after CABG (Paper IV).Paper I: We retrospectively studied the role of underlying heart disease for preoperative NT-proBNP in patients admitted for first time CABG (n=2226), aortic valve surgery (AVR) for aortic stenosis (AS) (n=406) and mitral valve surgery for mitral valve regurgitation (MR) (n=346) by adjusting for non-cardiac confounders (age, gender, obesity and renal function). The level of NT-proBNP in AS or MR was 1.67 (p<0.0001) and 1.41 times (p<0.0001) higher respectively than in coronary artery disease (CAD) after adjusting for confounders. Preoperative NT-proBNP was predictive of severe PHF in CAD and MR patients but less so in AS patients. Preoperative NT-proBNP emerged as an independent risk factor for severe PHF and postoperative mortality in CAD patients.Paper II-III: We prospectively studied the association between postoperative NT-proBNP and PHF in two cohorts, patients undergoing AVR for AS (n=203) and patients undergoing isolated CABG for acute coronary syndrome (ACS) from the GLUTAMICS-trial (n=382). NT-proBNP was measured preoperatively, on the first (POD1) and third postoperative morning (POD3). An end-points committee blinded to NT-proBNP used prespecified criteria to diagnose PHF and its severity. After AVR for AS only NT-proBNP level on POD1 provided good discrimination of PHF. PHF with NT-proBNP POD1 ≥ 5290 ng•L-1 emerged as an independent risk factor for long-term mortality (Paper II). After isolated CABG for ACS both absolute postoperative levels on POD1 and POD3 and postoperative increases of NT-proBNP were associated with PHF and the levels reflected the severity of PHF (Paper III).Paper IV: We prospectively studied the impact of intravenous glutamate infusion on postoperative NT-proBNP in a randomized double-blind study on patients undergoing CABG for ACS from the GLUTAMICS-trial (n=399). Patients were randomly allocated to intravenous infusion of L-glutamate (n=200) or saline (n=199). No effect of glutamate on postoperative NT-proBNP levels was detected in the whole cohort. According to post-hoc analysis glutamate was associated with less increase of NT-proBNP from preoperative level to POD3 and significantly lower absolute levels on POD3 among high risk patients with EuroSCORE II ≥4.15 (upper quartile).Conclusion: Patients with AS or MR have higher preoperative NT-proBNP than CAD patients after adjusting for confounders. The predictive value of NT-proBNP with regard to severe PHF and postoperative mortality was confirmed in CAD patients. Postoperative NTproBNP may prove a useful tool for assessment of PHF after AVR for AS and isolated CABG. NT-proBNP POD1 identifies patients with PHF at risk of a poor long-term survival after AVR for AS. Intravenous infusion of glutamate may prevent or mitigate PHF in highrisk patients undergoing CABG but these results need to be confirmed.
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| 9. |
- Johansson, Anders, et al.
(author)
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Technical feasibility and ambulance nurses’ view of a digital telemedicine system in pre-hospital stroke care – A pilot study
- 2019
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In: International Emergency Nursing. - : Elsevier BV. - 1755-599X. ; 44, s. 35-40
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Journal article (peer-reviewed)abstract
- Background: High-quality telemedicine in cases of suspected stroke has comparable precision with on-site medical examinations. A novel technical concept was developed in order to deliver a video/audio system to achieve more efficient patient assessment and diagnostic support. Aims and objectives: The aim of the present pilot-study was to evaluate in a clinical setting the quality of a linked image and sound transmission in the prehospital assessment of patients with suspected stroke. In addition, we wanted to elucidate how ambulance nurses experienced the use of this innovative technology. Design: The study used a quantitative method using questionnaires with fixed response options, combined with a qualitative approach to assess complementary statements of prehospital emergency care nurses (PEN)that had used the system. Methods: The study was conducted in one ambulance care office and one hospital in southern Sweden. Six PEN and one neurological specialist (Dr)expressed their perceptions based on 11 cases with suspected stroke. Responses were assessed in the dimensions of the technology (Dr – image quality/sound quality; Dr and PEN), safety, sense of increased control and uniform assessment. A questionnaire technique was used, complemented with a qualitative part of the content analysis (PEN views). Results: In the technology dimension, the Dr evaluated the image quality as Very good to Good (100%)while 75% of PEN answered that the digital stroke concept felt reliable to use and the digital stroke assessment is believed to increase uniform assessment. Asked if the present digital concept should be further developed and if further digital systems should be developed in general, the PEN were split in their responses (50 vs 50%), which could be related to a conception of unclear efficacy of the concept. Descriptions of the decisive comments emerged in three categories; Minor operating interference, Physician's competence crucial and Unclear efficacy. Conclusion: All respondents seem to have confidence in the assessed digital stroke concept. The image quality is perceived suitable in the assessment situation but the nurses expressed ambiguity about the efficiency of the entire concept. The ambulance nurses also highlighted the physician's skills and personality as important factors for further development of the concept.
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| 10. |
- Pellegrini, Mariangela
(author)
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Regional Lung Mechanics and Influence of an Active Diaphragm in Experimental Lung Injury
- 2019
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Doctoral thesis (other academic/artistic)abstract
- Despite being an essential life-support strategy in severe respiratory failure, mechanical ventilation can, if not optimally set and monitored, lead to injury of the lung parenchyma and diaphragm. These conditions are called ventilator-induced lung injury and ventilator-induced diaphragmatic dysfunction (VIDD), respectively. Although substantial progress has been made in the ventilator management of severely lung-injured patients, we are still far from a fully protective mechanical ventilation. In consideration of this gap of knowledge, this doctoral thesis aimed at investigating regional lung mechanics during both inspiration and expiration, in both controlled and assisted ventilation. Particular emphasis was placed on the expiratory phase, which is involved in expiratory flow limitation, airway closure and atelectasis formation, although commonly considered non-harmful.A novel methodological approach has been the fundamental basis for this research project. The combination of respiratory mechanics, diaphragmatic electromyographic activity and lung imaging enabled a breath-by-breath analysis at high temporal and spatial resolution.In Study I, the gravitational field affected the distribution of gas and transpulmonary pressures, as previously shown. This effect differed between healthy and injured lungs. Moreover, lung injury induced a heterogeneous distribution of gas within the lungs, as well as an increased gravitational gradient in transpulmonary pressure. Study I was mainly aimed at testing the new methodological approach centred on the investigation of regional lung mechanics.In Study II, the focus was on assisted ventilation and the phenomenon of gas redistribution within the lungs. Large pendelluft events had been demonstrated in disproportionate inspiratory efforts. In Study II, we showed that large pendelluft resulting from pathological respiratory drive could be attenuated by high positive end expiratory pressure (PEEP). Moreover, we showed that transient and widespread small gas redistribution events occur at all times during inspiration. Assisted ventilation and high PEEP reduced the size of gas redistribution as compared with controlled ventilation and low PEEP.In Study III, we demonstrated a diaphragmatic expiratory contraction in lungs prone to collapse, serving to brake the expiratory flow. It preserved end expiratory lung volume (EELV) and counteracted tidal atelectasis. However, the expiratory brake induced by diaphragmatic contraction is a known cause of VIDD.In Study IV, we tested the effects of external expiratory resistances (ExpR). We showed that, by applying ExpR, an expiratory brake was induced. The beneficial effects on EELV were retained, while the diaphragm could quickly relax during the expiration, thus reducing the risk of VIDD.
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