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| 2. |
- Björklund, Erik, et al.
(författare)
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Comparison of Midterm Outcomes Associated With Aspirin and Ticagrelor vs Aspirin Monotherapy After Coronary Artery Bypass Grafting for Acute Coronary Syndrome.
- 2021
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Ingår i: JAMA network open. - : American Medical Association (AMA). - 2574-3805. ; 4:8
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Tidskriftsartikel (refereegranskat)abstract
- Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak.To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy.This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020.Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only.Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up.A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P=.34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P=.29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P=.011). Sensitivity analyses confirmed the results.In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.
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| 3. |
- Björklund, Erik, et al.
(författare)
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Postdischarge major bleeding, myocardial infarction, and mortality risk after coronary artery bypass grafting
- 2023
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Ingår i: HEART. - 1355-6037 .- 1468-201X.
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Tidskriftsartikel (refereegranskat)abstract
- Objective To investigate the incidence and mortality risk associated with postdischarge major bleeding after coronary artery bypass grafting (CABG), and relate this to the incidence of, and mortality risk from, postdischarge myocardial infarction.Methods All patients undergoing first-time isolated CABG in Sweden in 2006-2017 and surviving 14 days after hospital discharge were included in a cohort study. Individual patient data from the SWEDEHEART Registry and five other mandatory nationwide registries were merged. Piecewise Cox proportional hazards models were used to investigate associations between major bleeding, defined as hospitalisation for bleeding, with subsequent mortality risk. Similar Cox proportional hazards models were used to investigate the association between postdischarge myocardial infarction and mortality risk.Results Among 36 633 patients, 2429 (6.6%) had a major bleeding event and 2231 (6.1%) had a myocardial infarction. Median follow-up was 6.0 (range 0-11) years. Major bleeding was associated with higher mortality risk <30 days (adjusted HR (aHR)=20.2 (95% CI 17.3 to 23.5)), 30-365 days (aHR=3.8 (95% CI 3.4 to 4.3)) and >365 days (aHR=1.8 (95% CI 1.7 to 2.0)) after the event. Myocardial infarction was associated with higher mortality risk <30 days (aHR=20.0 (95% CI 16.7 to 23.8)), 30-365 days (aHR=4.1 (95% CI 3.6 to 4.8)) and >365 days (aHR=1.8 (95% CI 1.7 to 2.0)) after the event.Conclusions The increase in mortality risk associated with a postdischarge major bleeding after CABG is substantial and is similar to the mortality risk associated with a postdischarge myocardial infarction.
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| 6. |
- Enzell, Jonas, et al.
(författare)
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Modellförsök stärker betongdammars säkerhet
- 2023
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Ingår i: Bygg och Teknik. - 0281-658X .- 2002-8350. ; 115:6
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Tidskriftsartikel (populärvet., debatt m.m.)abstract
- Dammhaverier är mycket ovanliga och därför är kunskapen om brottförloppet vid ett potentiellt dammbrott begränsad. Uppstår brottet utan förvarning, eller finns tidiga tecken på allvarliga problem? Hur utvecklas brottsbräschen under brottförloppet? Detta är frågor som blivit än mer aktuella efter tre internationella dammhaverier under 2023. För att söka svar har en serie skalmodellförsök utförts där haverier av betongdammar simuleras. En viktig parameter vid säkerhetsbedömningen av en betongdamm består i att utvärdera dess stabilitet. Förenklat görs dettag enom att jämföra om dammkroppens vikt är tillräcklig för att stå emot lasten från vattnets tryck. Traditionellt beaktas enbart en mindre del av en betongdamm när dess stabilitet utvärderas men de nya försöken indikerar att det vore eftersträvansvärt att undersöka hela dammen samtidigt eftersom lasten fördelas mellan konstruktionsdelarna. Många betongdammars tillstånd övervakas idag genom automatiska mätningarav till exempel vattenstånd, förskjutningar och grundvattentryck. Dock finns det ingen standardiserad metod för att definiera larmgränser,vilket detta projekt syftar till att utveckla i framtiden.
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| 7. |
- Enzell, Jonas, et al.
(författare)
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Physical Model Tests of Concrete Buttress Dams with Failure Imposed by Hydrostatic Water Pressure
- 2023
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Ingår i: Water. - : MDPI. - 2073-4441. ; 15:20
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Tidskriftsartikel (refereegranskat)abstract
- Although the failure of a concrete dam is a complex and highly dynamic process, the current safety assessments of concrete gravity and buttress dams rely on a simplified 2D stability analysis, which neglects the load redistribution due to 3D monolith interactions and the valley shape. In addition, the estimation of breach parameters in concrete dams is based on assumptions rather than analyses, and better prediction methods are needed. Model tests have been conducted to increase the understanding of the failure behavior of concrete dams. A scale model buttress dam, with a scale of 1:15, consisting of 5 monoliths that were 1.2 m in height and 4 m in width, was constructed and loaded to failure using water pressure. The model dam had detachable abutment supports and shear keys to permit variations in the 3D behavior. The results showed that the shear transfer was large between the monoliths and that the failure of a single dam monolith is unlikely. A greater lateral restraint gives not only a higher failure load but also a better indication of impending failure. These findings suggest that the entire dam, including its boundary conditions, should be considered during a stability assessment. The results also suggest that the common assumption in dam safety codes that a single monolith fails during flooding analysis is not conservative. The dataset obtained provides a foundation for the future development of dam-monitoring alarm limits and for predictive models of dam-breaching processes.
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| 8. |
- Enzell, Jonas, et al.
(författare)
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Realistic numerical simulations of concrete dam failures
- 2023
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Konferensbidrag (refereegranskat)abstract
- Dam failures may have catastrophic consequences, including the release of largeamounts of water, significant property damage, and loss of life. However, safety assessments ofconcrete gravity and buttress dams often rely on simplified methods that do not consider the interactionbetween monoliths, the shape of the foundation or the presence of stiff abutments. Numericalmodeling can be a valuable tool for analyzing the stability of these dams, but it can bedifficult to validate these models due to a lack of documented dam failures. This paper presentsthe results of a numerical study examining the ability of dynamic finite element analyses to simulatedam failures. The study used the results from a series of physical model tests as a case studyfor validation. It was found that the numerical model was able to accurately reproduce the failuremode and breach development observed in the physical model tests and capture the effect of theloading rate on the failure mode and time for the failure to develop. Simulations were also performedin prototype scale to verify that the model tests were representative of a real dam failure.Further research is needed to determine the reliability of the numerical models under differentloading conditions and in realistic geological settings. However, these findings suggest that numericalmodeling can be a valuable tool for analyzing the stability of concrete gravity and buttressdams and predicting the development of failures.
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| 9. |
- Enzell, Jonas
(författare)
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Toward Realistic Failure Evaluations for Concrete Buttress Dams
- 2023
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Concrete dams, complex structures supporting massive loads, have traditionally been assessed using simplified 2D analytical stability analyses based on the rigid body assumption. Previous studies have shown that 3D behavior, such as the interaction between the monoliths and the valley's geology, can greatly impact the load-bearing capacity of gravity dams but remains largely unexplored in buttress dams. Internal failure modes have also been shown to impact the load-bearing capacity and failure modes of concrete dams. The dam breach geometry and breach development time are important factors for flooding simulations used for emergency plans. There are no available methods for estimating the breach parameters for concrete dams. Instead, they are usually assumed based on simplified national recommendations, which introduces large uncertainties in the analysis. Thus, developing methods to estimate failure behavior in concrete gravity and buttress dams could significantly enhance flood simulation accuracy.This licentiate thesis aims to develop more realistic analysis methods for determining the load-bearing capacity and failure behavior of concrete buttress dams. To achieve this aim, studies using physical model tests were conducted to determine the 3D effects of the boundary conditions and the interaction between the monoliths and verify the results from finite element simulations. Numerical studies were performed to examine the failure behavior of concrete buttress dams and to determine suitable methods for such simulations. The results from the physical model tests suggest that 3D effects significantly impact the load-bearing capacity and the failure behavior of concrete buttress dams. Therefore, the entire dam should be considered in stability analyses rather than just single monoliths. The numerical studies showed that finite element models could successfully simulate dam failures, including the 3D behavior of concrete buttress dams and internal failure modes. However, there remain questions about the best methods for representing phenomena such as first-order roughness, valley shape, and fracture planes in these models.The model tests showed that while dam failures can occur abruptly with little to no initial signs of displacement, the presence of rough foundations, cohesion, and rock-strengthening measures in real-world dams suggests actual dam failures may not be as sudden. The results helped establish knowledge in the field to potentially create better alarm limits for automatic monitoring systems.
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| 10. |
- Gremyr, Andreas, et al.
(författare)
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How a Point-of-Care Dashboard Facilitates Co-production of Health Care and Health for and with Individuals with Psychotic Disorders : A Mixed-methods Case Study
- 2022
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Ingår i: BMC Health Services Research. - : BioMed Central (BMC). - 1472-6963. ; 22
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundIndividuals with psychotic disorders experience widespread treatment failures and risk early death. Sweden’s largest department specializing in psychotic disorders sought to improve patients’ health by developing a point-of-care dashboard to support joint planning and co-production of care. The dashboard was tested for 18 months and included more than 400 patients at two outpatient clinics.MethodsThis study evaluates the dashboard by addressing two questions:Can differences in health-related outcome measures be attributed to the use of the dashboard?How did the case managers experience the accessibility, use, and usefulness of the dashboard for co-producing care with individuals with psychotic disorders? This mixed-method case study used both Patient-Reported Outcome Measures (PROM) and data from a focus group interview with case managers. Data collection and analysis were framed by the Clinical Adoption Meta Model (CAMM) phases: i) accessibility, ii) system use, iii) behavior, and iv) clinical outcomes. The PROM used was the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0), which assesses functional impairment and disability. Patients at clinics using the dashboard were matched with patients at clinics not using the dashboard. PROM data were compared using non-parametric statistics due to skewness in distribution. The focus group included five case managers who had experience using the dashboard with patients.ResultsCompared to patients from clinics that did not use the dashboard, patients from clinics that did use the dashboard improved significantly overall (p = 0.045) and in the domain self-care (p = 0.041). Focus group participants reported that the dashboard supported data feedback-informed care and a proactive stance related to changes in patients’ health. The dashboard helped users identify critical changes and enabled joint planning and evaluation.ConclusionDashboard use was related to better patient health (WHODAS scores) when compared with matched patients from clinics that did not use the dashboard. In addition, case managers had a positive experience using the dashboard. Dashboard use might have lowered the risk for missing critical changes in patients’ health while increasing the ability to proactively address needs. Future studies should investigate how to enhance patient co-production through use of supportive technologies.
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