| 1. |
- Baker, Tim, et al.
(författare)
-
Single Deranged Physiologic Parameters Are Associated With Mortality in a Low-Income Country
- 2015
-
Ingår i: Critical Care Medicine. - 0090-3493 .- 1530-0293. ; 43:10, s. 2171-2179
-
Tidskriftsartikel (refereegranskat)abstract
- Objective: To investigate whether deranged physiologic parameters at admission to an ICU in Tanzania are associated with in-hospital mortality and compare single deranged physiologic parameters to a more complex scoring system. Design: Prospective, observational cohort study of patient notes and admission records. Data were collected on vital signs at admission to the ICU, patient characteristics, and outcomes. Cutoffs for deranged physiologic parameters were defined a priori and their association with in-hospital mortality was analyzed using multivariable logistic regression. Setting: ICU at Muhimbili National Hospital, Dar es Salaam, Tanzania. Patients: All adults admitted to the ICU in a 15-month period. Measurements and Main Results: Two hundred sixty-nine patients were included: 54% female, median age 35 years. In-hospital mortality was 50%. At admission, 69% of patients had one or more deranged physiologic parameter. Sixty-four percent of the patients with a deranged physiologic parameter died in hospital compared with 18% without (p < 0.001). The presence of a deranged physiologic parameter was associated with mortality (adjusted odds ratio, 4.64; 95% CI, 1.95-11.09). Mortality increased with increasing number of deranged physiologic parameters (odds ratio per deranged physiologic parameter, 2.24 [1.53-3.26]). Every individual deranged physiologic parameter was associated with mortality with unadjusted odds ratios between 1.92 and 16.16. A National Early Warning Score of greater than or equal to 7 had an association with mortality (odds ratio, 2.51 [1.23-5.14]). Conclusion: Single deranged physiologic parameters at admission are associated with mortality in a critically ill population in a low-income country. As a measure of illness severity, single deranged physiologic parameters are as useful as a compound scoring system in this setting and could be termed danger signs. Danger signs may be suitable for the basis of routines to identify and treat critically ill patients.
|
|
| 2. |
- Baker, Tim, et al.
(författare)
-
Vital Signs Directed Therapy : Improving Care in an Intensive Care Unit in a Low-Income Country
- 2015
-
Ingår i: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 10:12
-
Tidskriftsartikel (refereegranskat)abstract
- Background Global Critical Care is attracting increasing attention. At several million deaths per year, the worldwide burden of critical illness is greater than generally appreciated. Low income countries (LICs) have a disproportionally greater share of critical illness, and yet critical care facilities are scarce in such settings. Routines utilizing abnormal vital signs to identify critical illness and trigger medical interventions have become common in high-income countries but have not been investigated in LICs. The aim of the study was to assess whether the introduction of a vital signs directed therapy protocol improved acute care and reduced mortality in an Intensive Care Unit (ICU) in Tanzania. Methods and Findings Prospective, before-and-after interventional study in the ICU of a university hospital in Tanzania. A context-appropriate protocol that defined danger levels of severely abnormal vital signs and stipulated acute treatment responses was implemented in a four week period using sensitisation, training, job aids, supervision and feedback. Acute treatment of danger signs at admission and during care in the ICU and in-hospital mortality were compared pre and post-implementation using regression models. Danger signs from 447 patients were included: 269 pre-implementation and 178 post-implementation. Acute treatment of danger signs was higher post-implementation (at admission: 72.9% vs 23.1%, p<0.001; in ICU: 16.6% vs 2.9%, p<0.001). A danger sign was five times more likely to be treated post-implementation (Prevalence Ratio (PR) 4.9 (2.9-8.3)). Intravenous fluids were given in response to 35.0% of hypotensive episodes post-implementation, as compared to 4.1% pre-implementation (PR 6.4 (2.5-16.2)). In patients admitted with hypotension, mortality was lower post-implementation (69.2% vs 92.3% p = 0.02) giving a numbers-needed-to-treat of 4.3. Overall in-hospital mortality rates were unchanged (49.4% vs 49.8%, p = 0.94). Conclusion The introduction of a vital signs directed therapy protocol improved the acute treatment of abnormal vital signs in an ICU in a low-income country. Mortality rates were reduced for patients with hypotension at admission but not for all patients.
|
|
| 3. |
- Björkman, Ingeborg, et al.
(författare)
-
Animal Production With Restrictive Use of Antibiotics to Contain Antimicrobial Resistance in Sweden : A Qualitative Study
- 2021
-
Ingår i: Frontiers in Veterinary Science. - : Frontiers Media S.A.. - 2297-1769. ; 7
-
Tidskriftsartikel (refereegranskat)abstract
- Antibacterial resistance (ABR), is a growing global threat to human and animal health. Efforts to contain ABR are urgently needed. This qualitative interview study explored perceptions of work to contain ABR among stakeholders in food animal production in Sweden, with focus on broiler production. Semi-structured interviews were carried out with a strategic sample of 13 stakeholders in different parts of production, from professionals at policy level, veterinary authorities, to poultry farmers and poultry veterinarians. Conventional inductive content analysis was used for data analysis. A latent theme, "Working in unison," emerged, based on the consistency expressed by the informants when they discussed ABR, use of antibiotics, and animal health management. This theme was built on four domains representing the content of the interviews: Knowledge and engagement; Cooperation; Animal health concept; and Development in balance with economic prerequisites. According to the informants, ABR has not been an isolated issue in Sweden but has been included in a tradition of animal health and welfare, and actions have been driven by the industry or by government regulations. Veterinarians described how they worked closely with farmers. Farmers felt involved in the development of animal health management methods. The One Health concept was well-known among stakeholders at national level but not at farm level. Close cooperation between stakeholders seems to facilitate development of animal production with low use of antibiotics.
|
|
| 4. |
- Björkman, Ingeborg, et al.
(författare)
-
Swedish Efforts to Contain Antibiotic Resistance in the Environment—A Qualitative Study among Selected Stakeholders
- 2022
-
Ingår i: Antibiotics. - : MDPI AG. - 2079-6382. ; 11:5, s. 646-646
-
Tidskriftsartikel (refereegranskat)abstract
- Antibiotic resistance is a serious global threat to human and animal health. In this study, we explored perceptions of work to contain antibiotic resistance with a focus on the environment. Nine stakeholders from six different areas were interviewed in 2018. A short information update was given by informants from four of the areas in 2021. Interview transcripts were analyzed by conventional content analysis. The stakeholders’ perceptions were concluded in three categories: “examples of actions taken to combat antibiotic resistance”, “factors influencing work”, and “factors hindering work”. All informants reported having a role to play. Some of them were very engaged in this issue, whereas among others, antibiotics and resistance were just one part of a general engagement. To be able to act, the policymaker stakeholders asked for more knowledge about antibiotics in the environment and possible actions to take. Actions from the government were requested by several informants. Coordination of the work to combat antibiotic resistance in the environment was not recognized and the One Health approach was known at policy level but not among practitioners. Still, actions seemed to be coordinated, but this was, according to the stakeholders, based on findings from research in their area rather than on strategies developed by national authorities
|
|
| 5. |
- Dalmar, Abdirisak Ahmed, et al.
(författare)
-
Rebuilding research capacity in fragile states : the case of a Somali-Swedish global health initiative
- 2017
-
Ingår i: Global Health Action. - Abingdon : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 10:1
-
Tidskriftsartikel (refereegranskat)abstract
- This paper presents an initiative to revive the previous Somali-Swedish Research Cooperation, which started in 1981 and was cut short by the civil war in Somalia. A programme focusing on research capacity building in the health sector is currently underway through the work of an alliance of three partner groups: six new Somali universities, five Swedish universities, and Somali diaspora professionals. Somali ownership is key to the sustainability of the programme, as is close collaboration with Somali health ministries. The programme aims to develop a model for working collaboratively across regions and cultural barriers within fragile states, with the goal of creating hope and energy. It is based on the conviction that health research has a key role in rebuilding national health services and trusted institutions.
|
|
| 6. |
- de Bruijn, Winnie, et al.
(författare)
-
Introduction and Utilization of High Priced HCV Medicines across Europe : Implications for the Future
- 2016
-
Ingår i: Frontiers in Pharmacology. - : Frontiers Media SA. - 1663-9812. ; 7
-
Tidskriftsartikel (refereegranskat)abstract
- Background: Infection with the Hepatitis C Virus (HCV) is a widespread transmittable disease with a diagnosed prevalence of 2.0%. Fortunately, it is now curable in most patients. Sales of medicines to treat HCV infection grew 2.7% per year between 2004 and 2011, enhanced by the launch of the protease inhibitors (Hs) boceprevir (BCV) and telaprevir (TVR) in addition to ribavirin and pegylated interferon (pegIFN). Costs will continue to rise with new treatments including sofosbuvir, which now include interferon free regimens. Objective: Assess the uptake of BCV and TVR across Europe from a health authority perspective to offer future guidance on dealing with new high cost medicines. Methods: Cross-sectional descriptive study of medicines to treat HCV (pegIEN, ribavirin, BCV and TVR) among European countries from 2008 to 2013. Utilization measured in defined daily doses (DDDs)/1000 patients/quarter (DIOs) and expenditure in Euros/DDD. Health authority activities to influence treatments categorized using the 4E methodology (Education, Engineering, Economics and Enforcement). Results: Similar uptake of BCV and TVR among European countries and regions, ranging from 0.5 DIQ in Denmark, Netherlands and Slovenia to 1.5 DIQ in Tayside and Catalonia in 2013. However, different utilization of the new Pls vs. ribavirin indicates differences in dual vs. triple therapy, which is down to factors including physician preference and genotypes. Reimbursed prices for BCV and TVR were comparable across countries. Conclusion: There was reasonable consistency in the utilization of BCV and TVR among European countries in comparison with other high priced medicines. This may reflect the social demand to limit the transmission of HCV. However, the situation is changing with new curative medicines for HCV genotype 1 (GT1) with potentially an appreciable budget impact. These concerns have resulted in different prices across countries, with their impact on budgets and patient outcomes monitored in the future to provide additional guidance.
|
|
| 7. |
- Eriksen, Jaran, et al.
(författare)
-
Antiretroviral treatment for HIV infection: Swedish recommendations 2016.
- 2017
-
Ingår i: Infectious diseases (London, England). - : Informa UK Limited. - 2374-4243 .- 2374-4235. ; 49:1, s. 1-34
-
Tidskriftsartikel (refereegranskat)abstract
- The Swedish Medical Products Agency and the Swedish Reference Group for Antiviral Therapy (RAV) have jointly published recommendations for the treatment of HIV infection on seven previous occasions (2002, 2003, 2005, 2007, 2009, 2011 and 2014). In February 2016, an expert group under the guidance of RAV once more revised the guidelines. The most important updates in the present guidelines are as follows: Tenofovir alafenamide (TAF) has recently been registered. TAF has several advantages over tenofovir disoproxilfumarate (TDF) and is recommended instead of TDF in most cases. First-line treatment for previously untreated individuals includes dolutegravir, boosted darunavir or efavirenz with either abacavir/lamivudine or tenofovir (TDF/TAF)/emtricitabine. Pre-exposure prophylaxis (PrEP) is recommended for high-risk individuals. As in the case of the previous publication, recommendations are evidence-graded in accordance with the Oxford Centre for Evidence Based Medicine ( http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ ) ( Table 1 ). This document does not cover treatment of opportunistic infections and tumours. [Table: see text].
|
|
| 8. |
- Eriksen, Jaran, et al.
(författare)
-
Exploring the One Health Perspective in Sweden's Policies for Containing Antibiotic Resistance
- 2021
-
Ingår i: Antibiotics. - : MDPI. - 2079-6382. ; 10:5
-
Tidskriftsartikel (refereegranskat)abstract
- Antibiotic resistance is considered to be a major threat to global health. The main driver of antibiotic resistance is antibiotic use. Antibiotics are used in humans, animals, and food production and are released into the environment. Therefore, it is imperative to include all relevant sectors in the work to contain antibiotic resistance, i.e., a One Health approach. In this study, we aimed to describe and analyse Sweden's policies related to containing antibiotic resistance, from a One Health perspective. Twenty-three key policy documents related to containment of antibiotic resistance in Sweden were selected and analysed according to the policy triangle framework. Sweden started early to introduce policies for containing antibiotic resistance from an international perspective. Systematic measures against antibiotic resistance were implemented in the 1980s, strengthened by the creation of Strama in 1995. The policies involve agencies and organisations from human and veterinary medicine, the environment, and food production. All actors have clear responsibilities in the work to contain antibiotic resistance with a focus on international collaboration, research, and innovation. Sweden aims to be a model country in the work to contain antibiotic resistance and has a strategy for achieving this through international cooperation through various fora, such as the EU, the UN system, and OECD.
|
|
| 9. |
- Eriksen, Jaran, et al.
(författare)
-
High adherence to the 'Wise List' treatment recommendations in Stockholm : a 15-year retrospective review of a multifaceted approach promoting rational use of medicines
- 2017
-
Ingår i: BMJ Open. - London, UK : BMJ Publishing Group Ltd. - 2044-6055. ; 7:4
-
Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: To present the 'Wise List' (a formulary of essential medicines for primary and specialised care in Stockholm Healthcare Region) and assess adherence to the recommendations over a 15-year period.DESIGN: Retrospective analysis of all prescription data in the Stockholm Healthcare Region between 2000 and 2015 in relation to the Wise List recommendations during the same time period.SETTING: All outpatient care in the Stockholm Healthcare Region.PARTICIPANTS: All prescribers in the Stockholm Healthcare Region.MAIN OUTCOME MEASURES: The number of core and complementary substances included in the Wise List, the adherence to recommendations by Anatomic Therapeutic Chemical (ATC) 1st level using defined daily doses (DDDs) adjusted to the DDD for 2015, adherence to recommendations over time measured by dispensed prescriptions yearly between 2002 and 2015.RESULTS: The number of recommended core substances was stable (175-212). Overall adherence to the recommendations for core medicines for all prescribers increased from 75% to 84% (2000 to 2015). The adherence to recommendations in primary care for core medicines increased from 80% to 90% (2005 to 2015) with decreasing range in practice variation (32% to 13%). Hospital prescriber adherence to core medicine recommendations was stable but increased for the combination core and complementary medicines from 77% to 88% (2007 to 2015). Adherence varied between the 4 therapeutic areas studied.CONCLUSIONS: High and increasing adherence to the Wise List recommendations was seen for all prescriber categories. The transparent process for developing recommendations involving respected experts and clinicians using strict criteria for handling potential conflicts of interests, feedback to prescribers, continuous medical education and financial incentives are possible contributing factors. High-quality evidence-based recommendations to prescribers, such as the Wise List, disseminated through a multifaceted approach, will become increasingly important and should be developed further to include recommendations and introduction protocols for new expensive medicines.
|
|
| 10. |
- Eriksen, Jaran
(författare)
-
Managing childhood malaria in rural Tanzania : focusing on drug use and resistance
- 2006
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Malaria is a leading cause of death in underfive children in Africa. Due to the spread of chloroquine (CQ) resistance, sub-Saharan African countries such as Tanzania have changed their malaria treatment policies. In 2001 Tanzania replaced CQ with sulfadoxine/pyrimethamine (SP) as first line malaria treatment. Resistance to SP is known to develop fast and little is known about how a new policy is adopted. Main aim: The aim was to explore the influence of the national malaria policy change on malaria case management of children under five and development of resistance to antimalarials in rural Tanzania. Methods: The thesis consists of five cross-sectional studies performed in three different rural districts of Tanzania. During data collection, the national malaria treatment policy was changed and our studies were patterned accordingly: two studies were conducted before (I & II) and three studies after (III, IV & V) the policy change. Four studies were conducted at health facility level (I, II, IV & V) and one was conducted in the community (III). Consultations of 652 and 117 underfives, attending all public primary health facilities in Kibaha district (I) and eight health facilities in Mkuranga district (IV), respectively, were observed and mothers/guardians were interviewed upon exit. Caretakers in 729 randomly selected households in Kibaha district were interviewed about knowledge of the new malaria treatment policy and FGDs were performed with caretakers and health professionals (III). In Kilosa district we assessed efficacy of SP and CQ before the policy change (II) and SP and Amodiaquine (AQ) after the policy change (V). In study II and V, 117 and 96 underfives with malaria, respectively, were treated with the mentioned drugs. Clinical status, parasite densities, blood drug levels, haemoglobin levels and parasite mutations were monitored for 28 days. In all studies (I-V), blood was sampled from children and analysed for antimalarial content. Results: Before the policy change , quality of care was poor in terms of history taking, physical examination and prescribing. Self-treatment was common as 98% of children had detectable CQ in blood prior to seeking formal health care (I). Clinical failure rates with CQ and SP were only 10% and 2%, respectively, despite high drug pressure in the community (II). Six months after the policy change, 51% of caretakers knew that SP was the new first line treatment. Interviewees reported seeking care at public health facilities instead of self-treatment and only 18% of children had measurable levels of SP in blood (III). Although quality of care was still poor and health workers scored 18% when performance was assessed by quality indicators, most febrile children (89%) received antimalarial treatment, in line with guideline recommendations (IV). SP resistance levels had not increased and drug pressure was lower than before the policy change (V). Discussion: Progression of resistance to SP was not seen despite its use as first line treatment for three years (II & V), probably caused by changed drug use and thereby decreased drug pressure (I-V). Although the thesis mainly consists of data from health facilities, the findings indicate that the Tanzanian policy diffused well to the studied community (III). Quality of diagnosis at health facilities was poor (I & IV). Future malaria treatment policies include challenges such as high drug costs and poor compliance. In this aspect, inhibited drug resistance and changed patterns of drug use is positive, but quality of care at health facilities needs to be improved.
|
|
