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- Darehed, David, 1986-, et al.
(författare)
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In-hospital delays in stroke thrombolysis : every minute counts
- 2020
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Ingår i: Stroke. - : American Heart Association. - 0039-2499 .- 1524-4628. ; 51:8, s. 2536-2539
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Tidskriftsartikel (refereegranskat)abstract
- Background and Purpose: Intravenous thrombolysis is a well-established treatment for acute ischemic stroke. Our aim was to quantify the effect of each minute delay in door-to-needle time (DNT) on 90-day survival, intracerebral hemorrhagic complication <36 hours, and functional outcomes at 3 months, in routine clinical practice.Methods: Our nationwide registry-based study included 14 132 adult patient admissions with ischemic stroke receiving intravenous thrombolysis from 2010 to 2017. Outcomes were analyzed using multivariable logistic regression, adjusting for potential confounders.Results: Median DNT was 47 minutes, with an improvement from 65 to 38 minutes during the study. Median age was 74 years, and median National Institutes of Health Stroke Scale 8 points. We found a significant impact of each minute delay in DNT with reduced odds of survival by 0.6%, increased odds of intracerebral hemorrhagic and worse activities of daily living by 0.3%, and worse living conditions and mobility by 0.4%.Conclusions: Improving DNT is a key factor in achieving good outcomes after stroke. We estimate that in Sweden alone in 2017, compared with 2010, the shorter DNT achieved have saved 38 lives, avoided 8 intracerebral hemorrhagic transformations, and spared, respectively, 36, 51, and 52 patients from a worsening in activities of daily living, living conditions, and mobility. DNT is sensitive for interventions and should be targeted in quality improvement efforts.
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| 2. |
- Darehed, David, 1986-
(författare)
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The impact of organizational and temporal factors on acute stroke care in Sweden
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Acute stroke carries a high risk of morbidity and death, but early treatment can improve outcomes. Intravenous stroke thrombolysis (IVT) is one such treatment, it is however time-sensitive and show better outcomes the sooner it is given. Most studies on time to IVT so far have looked at fixed time-intervals, and studies of short delays in clinical practice are relatively scarce. Another well-established treatment is managing acute stroke patients in stroke units (SU). Admission rates to a SU as first destination of hospital care have improved over time in Sweden. In the past decade however, the rates have leveled out at around 75-80% without further improvement. A hypothesis is that in-hospital overcrowding contributes. Previous studies have shown that outcomes after stroke differ between hospital types, and also vary depending on time of admission, with higher mortality seen for off-hours, weekend and winter admissions. The reasons behind temporal variations are not fully understood, but it has been proposed that environmental, patient-related and organizational factors contribute. The overall aim of this thesis was to study the effect of organizational factors on quality of care and outcomes after stroke, primarily focusing on the role of in-hospital overcrowding, in-hospital time to IVT and time of admission, while also studying differences between hospitals.Methods: All papers in this thesis were based on data from the Swedish stroke register (Riksstroke), a national quality register that holds data on patient related factors, acute care and outcomes. Paper I included 13,955 patient admissions from 14 hospitals in Region Norrbotten and Region Skåne from 2011-2014, enriched with data on in-hospital bed occupancy. Papers II-IV included all 72 Swedish hospitals caring for patients with acute stroke. Paper II included data from 2011-2015 (N=113,862), paper III from 2011-2016 (N=132,744) and paper IV from 2010-2017 (N=14,132). Analyses included descriptive statistics, unadjusted analyses and multivariable adjusted analyses.Results: We found that each percent increase in in-hospital bed occupancy above 85% decreased admission rates to a SU as first destination of hospital care by 1.5% (odds ratio (OR) 0.985, 95% confidence interval (CI) 0.978-0.992), with significant differences between hospitals. Admission rates were also lower off-hours, compared to on-hours (OR 0.73, 95% CI 0.70-0.75). Over time, admission rates to a SU as first destination of hospital care decreased in university hospitals, while they increased in specialized non-university hospitals and community hospitals. Each minute delay in door-to-needle time (DNT) decreased the odds of 90-day survival by 0.6% (OR 0.994, 95% CI 0.992-0.996), increased the odds of ICH within 36 hours by 0.3% (OR 1.003, 95% CI 1.000-1.006), and led to significantly higher odds of a worsening in functional outcomes at 3 months by 0.3-0.4%. DNT within 30 minutes was most likely daytime, and varied between hospital types. 90-day survival was lowest for patients admitted in January (81.5%), and highest for those admitted in May (84.1%) (OR 1.28, 95% CI 1.17-1.40).Conclusion: We found that in-hospital overcrowding decrease admission rates to a SU as first destination of hospital care, and that even short delays in DNT decreases survival, increases ICH complications and leads to a worsening in functional outcomes in routine clinical practice. We also found that quality of care varied depending on time of admission and between hospitals, indicating unequal care. Organizational differences should be accessible through quality improvement efforts aiming to implement robust local guidelines for in-hospital stroke treatment.
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| 3. |
- Pérez Caro, Lluís, 1985-, et al.
(författare)
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Prediction of shape distortions during forming and welding of a double-curved strip geometry in alloy 718
- 2020
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Ingår i: The International Journal of Advanced Manufacturing Technology. - : Springer. - 0268-3768 .- 1433-3015. ; 107:7-8, s. 2967-2981
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Tidskriftsartikel (refereegranskat)abstract
- The finite element method (FEM) has considerably contributed to the development of advanced manufacturing methods for metal structures. The prediction of the final shape of a component is of great interest to the manufacturing industry. The level of demand may increase due to multistage processes. Therefore, including all steps of the manufacturing chain in the simulations is a key to being successful. This has been done for a long time in the stamping industry, which involves sequences of forming, trimming, and springback. However, more complex manufacturing procedures that include assembling of formed parts with forgings and castings via welding have been modelled with simplifications, resulting in a reduced prediction accuracy. In the present study, a double-curved part manufactured from alloy 718 is formed at 20 °C and laser-welded using the bead-on-plate procedure. The coupling of different manufacturing analyses, including cold forming, trimming, result mapping, welding, cooling, and springback, is achieved using LS-DYNA. Additionally, the effect of adding a damage and failure model in the forming simulation is studied. The results of the forming analysis are used as inputs for the material model *MAT_CWM in the welding simulation. The anisotropic thermomechanical properties of alloy 718 are determined at temperatures up to 1000 °C. Encouraging agreement is found between the model predictions and the results of forming and welding tests. The findings underscore the importance of including the material history and accurate process conditions along the manufacturing chain to both the prediction accuracy of shape distortions, and to the potential of the industry.
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| 4. |
- Pérez Caro, Lluís, 1985-, et al.
(författare)
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Springback prediction and validation in hot forming of a double-curved component in alloy 718
- 2021
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Ingår i: International Journal of Material Forming. - : Springer-Verlag Italia s.r.l.. - 1960-6206 .- 1960-6214. ; 14:6, s. 1355-1373
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Tidskriftsartikel (refereegranskat)abstract
- The demands associated with the production of advanced parts made of nickel-base superalloys are continuously increasing to meet the requirements of current environmental laws. The use of lightweight components in load-carrying aero-engine structures has the potential to significantly reduce fuel consumption and greenhouse gas emissions. Furthermore, the competitiveness of the aero-engine industry can benefit from reduced production costs and shorter development times while minimizing costly try-outs and increasing the efficiency of engines. The manufacturing process of aero-engine parts in superalloys at temperatures close to 950 °C produces reduced stamping force, residual stresses, and springback compared to traditional forming procedures occurring at room temperature. In this work, a hot forming procedure of a double-curved component in alloy 718 is studied. The mechanical properties of the material are determined between 20 and 1000 °C. The presence and nature of serrations in the stress–strain curves are assessed. The novel version of the anisotropic Barlat Yld2000-2D material model, which allows the input of thermo-mechanical data, is used in LS-DYNA to model the behaviour of the material at high temperatures. The effect of considering the stress-relaxation data on the predicted shape distortions is evaluated. The results show the importance of considering the thermo-mechanical anisotropic properties and stress-relaxation behaviour of the material to predict the final geometry of the component with high accuracy. The implementation of advanced material models in the finite element (FE) analyses, along with precise process conditions, is vital to produce lightweight components in advanced materials of interest to the aerospace industry.
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| 5. |
- Wilhelmson, Katarina, 1958, et al.
(författare)
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Comprehensive Geriatric Assessment for Frail Older People in Swedish Acute Care Settings (CGA-Swed) : A Randomised Controlled Study
- 2020
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Ingår i: Geriatrics (Basel, Switzerland). - : MDPI AG. - 2308-3417 .- 0016-867X. ; 5:1
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Tidskriftsartikel (refereegranskat)abstract
- The aim of the study is to evaluate the effects of the Comprehensive Geriatric Assessment (CGA) for frail older people in Swedish acute hospital settings - the CGA-Swed study. In this study protocol, we present the study design, the intervention and the outcome measures as well as the baseline characteristics of the study participants. The study is a randomised controlled trial with an intervention group receiving the CGA and a control group receiving medical assessment without the CGA. Follow-ups were conducted after 1, 6 and 12 months, with dependence in activities of daily living (ADL) as the primary outcome measure. The study group consisted of frail older people (75 years and older) in need of acute medical hospital care. The study design, randomisation and process evaluation carried out were intended to ensure the quality of the study. Baseline data show that the randomisation was successful and that the sample included frail older people with high dependence in ADL and with a high comorbidity. The CGA contributed to early recognition of frail older people's needs and ensured a care plan and follow-up. This study is expected to show positive effects on frail older people's dependence in ADL, life satisfaction and satisfaction with health and social care.
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