| 1. |
- Karlsson, Philip A., et al.
(författare)
-
Antibiotic use during coronavirus disease 2019 intensive care unit shape multidrug resistance bacteriuria : A Swedish longitudinal prospective study
- 2023
-
Ingår i: Frontiers in Medicine. - : Frontiers Media S.A.. - 2296-858X. ; 10
-
Tidskriftsartikel (refereegranskat)abstract
- Objectives: High frequency of antimicrobial prescription and the nature of prolonged illness in COVID-19 increases risk for complicated bacteriuria and antibiotic resistance. We investigated risk factors for bacteriuria in the ICU and the correlation between antibiotic treatment and persistent bacteria.Methods: We conducted a prospective longitudinal study with urine from indwelling catheters of 101 ICU patients from Uppsala University Hospital, Sweden. Samples were screened and isolates confirmed with MALDI-TOF and whole genome sequencing. Isolates were analyzed for AMR using broth microdilution. Clinical data were assessed for correlation with bacteriuria.Results: Length of stay linearly correlated with bacteriuria (R2 = 0.99, p ≤ 0.0001). 90% of patients received antibiotics, primarily the beta-lactams (76%) cefotaxime, piperacillin-tazobactam, and meropenem. We found high prevalence of Enterococcus (42%) being associated with increased cefotaxime prescription. Antibiotic-susceptible E. coli were found to cause bacteriuria despite concurrent antibiotic treatment when found in co-culture with Enterococcus.Conclusion: Longer stays in ICUs increase the risk for bacteriuria in a predictable manner. Likely, high use of cefotaxime drives Enterococcus prevalence, which in turn permit co-colonizing Gram-negative bacteria. Our results suggest biofilms in urinary catheters as a reservoir of pathogenic bacteria with the potential to develop and disseminate AMR.
|
|
| 2. |
- Brodin, Daniel, et al.
(författare)
-
Inhaled ciclesonide in adults hospitalised with COVID-19 : a randomised controlled open-label trial (HALT COVID-19)
- 2023
-
Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 13:2
-
Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To assess the efficacy of inhaled ciclesonide in reducing the duration of oxygen therapy (an indicator of time to clinical improvement) among adults hospitalised with COVID-19.DESIGN: Multicentre, randomised, controlled, open-label trial.SETTING: 9 hospitals (3 academic hospitals and 6 non-academic hospitals) in Sweden between 1 June 2020 and 17 May 2021.PARTICIPANTS: Adults hospitalised with COVID-19 and receiving oxygen therapy.INTERVENTION: Inhaled ciclesonide 320 µg two times a day for 14 days versus standard care.MAIN OUTCOME MEASURES: Primary outcome was duration of oxygen therapy, an indicator of time to clinical improvement. Key secondary outcome was a composite of invasive mechanical ventilation/death.RESULTS: Data from 98 participants were analysed (48 receiving ciclesonide and 50 receiving standard care; median (IQR) age, 59.5 (49-67) years; 67 (68%) men). Median (IQR) duration of oxygen therapy was 5.5 (3-9) days in the ciclesonide group and 4 (2-7) days in the standard care group (HR for termination of oxygen therapy 0.73 (95% CI 0.47 to 1.11), with the upper 95% CI being compatible with a 10% relative reduction in oxygen therapy duration, corresponding to a <1 day absolute reduction in a post-hoc calculation). Three participants in each group died/received invasive mechanical ventilation (HR 0.90 (95% CI 0.15 to 5.32)). The trial was discontinued early due to slow enrolment.CONCLUSIONS: In patients hospitalised with COVID-19 receiving oxygen therapy, this trial ruled out, with 0.95 confidence, a treatment effect of ciclesonide corresponding to more than a 1 day reduction in duration of oxygen therapy. Ciclesonide is unlikely to improve this outcome meaningfully.TRIAL REGISTRATION NUMBER: NCT04381364.
|
|
| 3. |
- Hambraeus, Johan, 1959-
(författare)
-
Interventional pain management focused on zygapophysial joint pain : a health-economic evaluation
- 2023
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The pain-system is a central mechanism in our life. Chronic pain is one of the major causes of impaired health-related quality of life according to the World Health Organization’s “Global Burden of Disease”-studies. Zygapophysial joint pain has been shown to account for the pain in 30% - 50% of patients with chronic pain. There are several well-established, evidence-based methods to treat zygapophysial joint pain in the cervical and lumbar regions.This thesis originates from this and starts by exploring whether the treatment of zygapophysial joint pain can improve health-related quality of life. This thesis describes methods for the diagnosis and treatment of zygapophysial joint pain in the thoracic region that can be applied to the treatment of all pain-foci localized to the zygapophysial joints. I show that the health-related quality of life was significantly improved after treatment, and that the clinical methods used for treating thoracic pain were similar to the methods that have been established previously for cervical and lumbar pain.In order to better understand the patients’ experiences we performed qualitative interviews with patients who underwent diagnostic tests and treatments. The overall theme revealed by these interviews was that of empowerment, in which the patients were empowered by the process of diagnostic tests and treatments.The next question was whether the method was cost-effective or not. In the first cost-effectiveness analysis, the patients served as their own controls and we evaluated the results against the limits set by the Swedish national board of health and welfare. The results showed that it was cost-effective in the moderate to low range.Finally, we compared the treatment to the “gold standard” for pain management in Sweden; i.e.pain rehabilitation. We mimicked a randomized controlled trial by using propensity score weighting to compare 254 patients agains 15,357 patients registered in the Swedish National Register of Pain Rehabilitation. The results showed that interventional pain management was cost-effective in the moderate (12 months after treatment) to low (≥24 months after) range whereas pain rehabilitation was in the very high range (after 12 months) and became cost-effective in the high range after 24 months of treatment. Currently, interventional pain management accounts for just 2% of all specialized pain management procedures in Sweden. If this could be increased to 25%, it may be possible to save 106 million SEK annually, while simultaneously gain 14 quality adjusted life years of health. If an interventional pain assessment is performed early in the process, treatable patients could be directed toward interventional treatment and away from interdisciplinary pain management programs, with the potential for further reductions in costs.
|
|
| 4. |
- Enlund, Mats, et al.
(författare)
-
Impact of general anaesthesia on breast cancer survival: a 5-year follow up of a pragmatic, randomised, controlled trial, the CAN-study, comparing propofol and sevoflurane
- 2023
-
Ingår i: EClinicalMedicine. - : Elsevier. - 2589-5370. ; 60
-
Tidskriftsartikel (refereegranskat)abstract
- Background Anaesthesia may impact long-term cancer survival. In the Cancer and Anaesthesia study, we hypothesised that the hypnotic drug propofol will have an advantage of at least five percentage points in five-year survival over the inhalational anaesthetic sevoflurane for breast cancer surgery. Methods From 2118 eligible breast cancer patients scheduled for primary curable, invasive breast cancer surgery, 1764 were recruited after ethical approval and individual informed consent to this open label, single-blind, randomised trial at four county- and three university hospitals in Sweden and one Chinese university hospital. Of surveyed patients, 354 were excluded, mainly due to refusal to participate. Patients were randomised by computer at the monitoring organisation to general anaesthesia maintenance with either intravenous propofol or inhaled sevoflurane in a 1:1 ratio in permuted blocks. Data related to anaesthesia, surgery, oncology, and demographics were registered. The primary endpoint was five-year overall survival. Data are presented as Kaplan-Meier survival curves and Hazard Ratios based on Cox univariable regression analyses by both intention-to-treat and perprotocol. EudraCT, 2013-002380-25 and ClinicalTrials.gov, NCT01975064. Findings Of 1764 patients, included from December 3, 2013, to September 29, 2017, 1670 remained for analysis. The numbers who survived at least five years were 773/841 (91.9% (95% CI 90.1-93.8)) in the propofol group and 764/829 (92.2% (90.3-94.0)) in the sevoflurane group, (HR 1.03 (0.73-1.44); P = 0.875); the corresponding results in the per-protocol-analysis were: 733/798 (91.9% (90.0-93.8)) and 653/710 (92.0% (90.0-94.0)) (HR = 1.01 (0.71-1.44); P = 0.955). Survival after a median follow-up of 76.7 months did not indicate any difference between the groups (HR 0.97, 0.72-1.29; P = 0.829, log rank test). Interpretation No difference in overall survival was found between general anaesthesia with propofol or sevoflurane for breast cancer surgery. Copyright (c) 2023 The Author(s). Published by Elsevier Ltd.
|
|
| 5. |
- Phattharapornjaroen, Phatthranit, et al.
(författare)
-
Assessing Thai Hospitals’ Evacuation Preparedness Using the Flexible Surge Capacity Concept and Its Collaborative Tool
- 2023
-
Ingår i: International Journal of Disaster Risk Science. - : Springer Science and Business Media LLC. - 2095-0055 .- 2192-6395. ; 14:1, s. 52-63
-
Tidskriftsartikel (refereegranskat)abstract
- According to the concept of “flexible surge capacity,” hospitals may need to be evacuated on two occasions: (1) when they are exposed to danger, such as in war; and (2) when they are contaminated, such as during the Covid-19 pandemic. In the former, the entire hospital must be evacuated, while in the latter, the hospital becomes a pandemic center necessitating the transfer of its non-contaminated staff, patients, and routine activities to other facilities. Such occasions involve several degrees of evacuation—partial or total—yet all require deliberate surge planning and collaboration with diverse authorities. This study aimed to investigate the extent of hospital evacuation preparedness in Thailand, using the main elements of the flexible surge capacity concept. A mixed method cross-sectional study was conducted using a hospital evacuation questionnaire from a previously published multinational hospital evacuation study. The tool contained questions regarding evacuation preparedness encompassing surge capacity and collaborative elements and an open-ended inquiry to grasp potential perspectives. All 143 secondary care, tertiary care, and university hospitals received the questionnaire; 43 hospitals provided responses. The findings indicate glitches in evacuation protocols, particularly triage systems, the inadequacies of surge planning and multiagency collaboration, and knowledge limitations in community capabilities. In conclusion, the applications of the essential components of flexible surge capacity allow the assessment of hospital preparedness and facilitate the evaluation of guidelines and instructions through scenario-based training exercises.
|
|
| 6. |
- Forsgärde, Elin-Sofie, et al.
(författare)
-
Physicians’ experiences and actions in making complex level-of-care decisions during acute situations within older patients’ homes : a critical incident study
- 2023
-
Ingår i: BMC Geriatrics. - : BioMed Central (BMC). - 1471-2318. ; 23:1
-
Tidskriftsartikel (refereegranskat)abstract
- Background: Complex level-of-care decisions involve uncertainty in which decisions are beneficial for older patients. Knowledge of physicians’ decision-making during acute situations in older patients’ homes is limited. Therefore, this study aimed to describe physicians’ experiences and actions in making complex level-of-care decisions during the assessment of older patients in acute situations within their own homes. Methods: Individual interviews and analyses were performed according to the critical incident technique (CIT). In total, 14 physicians from Sweden were included. Results: In making complex level-of-care decisions, physicians experienced collaborating with and including older patients, significant others and health care professionals to be essential for making individualized decisions regarding the patients’ and their significant others’ needs. During decision-making, physicians experienced difficulties when doubt or collaborative obstructions occurred. Physicians’ actions involved searching for an understanding of older patients’ and their significant others’ wishes and needs, considering their unique conditions, guiding them, and adjusting care according to their wishes. Actions further involved promoting collaboration and reaching a consensus with all persons involved. Conclusion: Physicians strive to individualize complex level-of-care decisions based on older patients’ and their significant others’ wishes and needs. Furthermore, individualized decisions depend on successful collaboration and consensus among older patients, their significant others and other health care professionals. Therefore, to facilitate individualized level-of-care decisions, the health care organizations need to support physicians when they are making individualized decisions, provide sufficient resources and promote 24 − 7 collaboration between organizations and health care professionals.
|
|
| 7. |
- Dranichnikov, Paul, MD, PhD Candidate, 1980-, et al.
(författare)
-
The Impact on Postoperative Outcomes of Intraoperative Fluid Management Strategies During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy
- 2023
-
Ingår i: European Journal of Surgical Oncology. - : Elsevier. - 0748-7983 .- 1532-2157. ; 49:8, s. 1474-1480
-
Tidskriftsartikel (refereegranskat)abstract
- Background The impact of intraoperative fluid management during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) on postoperative outcomes has been poorly investigated. This study aimed to investigate the impact of intraoperative fluid management strategy on postoperative outcomes and survival focusing on postoperative hemorrhage. Methods 509 patients undergoing CRS and HIPEC at Uppsala University Hospital/Sweden 2004-2017 were categorized into two groups according to the intraoperative fluid management strategy: pre-goal directed therapy (pre-GDT) and goal directed therapy (GDT), where a hemodynamic monitor (CardioQ or FloTrac/Vigileo) was used to optimize fluids management. Impact on morbidity, postoperative hemorrhage, length-of-stay and survival was analyzed. ResultsThe pre-GDT group received higher intraoperative fluid volume compared to the GDT group (mean 19.9 vs. 16.2 ml/kg/h, p<0.001). Overall postoperative morbidity Grade III-V was higher in the GDT group (30% vs. 22%, p=0.03). Multivariable adjusted odds ratio (OR) for Grade III-V morbidity was 1.80 (95%CI 1.10-3.10, p=0.02) in the GDT group. Numerically, more cases of postoperative hemorrhage were found in the GDT group (9% vs. 5%, p=0.09), but no correlation was observed in the multivariable analysis 1.37 (95%CI 0.64-2.95, p=0.40). An oxaliplatin regimen was a significant risk factor for postoperative hemorrhage (p=0.03). Mean length of stay was shorter in the GDT group (17 vs. 26 days, p<0.0001). Survival did not differ between the groups.ConclusionWhile GDT management increased the risk for postoperative morbidity, it was associated with shortened hospital stay. Intraoperative fluid management during CRS and HIPEC did not affect the postoperative risk for hemorrhage, while the use of an oxaliplatin regimen did.
|
|
| 8. |
- Kielt, Matthew, et al.
(författare)
-
Classifying multicenter approaches to invasive mechanical ventilation for infants with bronchopulmonary dysplasia using hierarchical clustering analysis
- 2023
-
Ingår i: Pediatric Pulmonology. - : John Wiley & Sons. - 8755-6863 .- 1099-0496. ; 58:8, s. 2323-2332
-
Tidskriftsartikel (refereegranskat)abstract
- IntroductionEvidence-based ventilation strategies for infants with severe bronchopulmonary dysplasia (BPD) remain unknown. Determining whether contemporary ventilation approaches cluster as specific BPD strategies may better characterize care and enhance the design of clinical trials. The objective of this study was to test the hypothesis that unsupervised, multifactorial clustering analysis of point prevalence ventilator setting data would classify a discrete number of physiology-based approaches to mechanical ventilation in a multicenter cohort of infants with severe BPD.MethodsWe performed a secondary analysis of a multicenter point prevalence study of infants with severe BPD treated with invasive mechanical ventilation. We clustered the cohort by mean airway pressure (MAP), positive end expiratory pressure (PEEP), set respiratory rate, and inspiratory time (Ti) using Ward's hierarchical clustering analysis (HCA).ResultsSeventy-eight patients with severe BPD were included from 14 centers. HCA classified three discrete clusters as determined by an agglomerative coefficient of 0.97. Cluster stability was relatively strong as determined by Jaccard coefficient means of 0.79, 0.85, and 0.77 for clusters 1, 2, and 3, respectively. The median PEEP, MAP, rate, Ti, and PIP differed significantly between clusters for each comparison by Kruskall–Wallis testing (p < 0.0001).ConclusionsIn this study, unsupervised clustering analysis of ventilator setting data identified three discrete approaches to mechanical ventilation in a multicenter cohort of infants with severe BPD. Prospective trials are needed to determine whether these approaches to mechanical ventilation are associated with specific severe BPD clinical phenotypes and differentially modify respiratory outcomes.
|
|
| 9. |
|
|
| 10. |
- Nordin, Anna, et al.
(författare)
-
Intensive Care Managers' Experiences of the COVID-19 Pandemic: A Dramatic Change of the Intensive Care Landscape
- 2023
-
Ingår i: Journal of Nursing Management. - : Wiley-Hindawi. - 0966-0429 .- 1365-2834.
-
Tidskriftsartikel (refereegranskat)abstract
- Aim. To describe intensive care managers' experiences of premises and resources of care in intensive care units during the COVID-19 pandemic.Background. Intensive care units (ICUs) were enormously pressured during the COVID-19 pandemic from many ill patients, requiring advanced care. Hospital and community volunteers increased staff strength. Obligatorily, recruitments were also conducted using transfer of staff from different hospital departments. However, there is little knowledge about intensive care managers' (ICMs) experiences of leadership during the COVID-19 pandemic.Methods. A qualitative descriptive study was conducted from March to April 2022. Semistructured interviews were held with 12 ICMs who were purposively sampled from the ICU in ten Swedish hospitals. Data were analysed using qualitative content analysis.Results. Two themes emerged: a dramatic change of the intensive care landscape and we could handle more than we thought, but at a steep price. Participants described that the ICUs had to perform extraordinary changes at a very fast pace, which initially created a sense of cohesion. Training and introduction to war-like conditions associated with uncertainty meant that ICMs had to support ICU staff in prioritising interventions. Participants described how ICUs stood strong against a pandemic, but stress, worries, and anxiety took a heavy toll on ICU staff and ICMs. The pandemic eroded the resilience in ICUs. Participants described a deterioration in health and said that sick leaves and resignations occurred.Conclusion. Our findings show ICMs' experiences as a field of tension between resources and demands, whereby the changes created a heavy burden that left intensive care weakened.Implications for Nursing Management. Findings emphasised the importance of creating working conditions using human resources and materials in order to rebuild resilience in intensive care with the ability to conduct safe patient care.
|
|
