Akademiska Sjukhuset

Background Non-technical skills are the essential cognitive, social, and personal resources contributing to safe and efficient task performance. An assessment tool can facilitate the development and teaching of non-technical skills. The nurse anesthetist non-technical skills tool includes four categories and fifteen elements and is an adaptation of the existing tools for physician anesthetists and Danish nurse anesthetists. The ratings are on a five-step scale, with an option to select “Not Relevant”. Since there doesn’t exist an assessment tool for Swedish nurse anesthetists’ non-technical skills, the aim of the study was to translate and adapt the assessment tool for nurse anesthetists’ non-technical skills to a Swedish context and test its psychometric qualities among nurse anesthetists with experience in teaching nurse anesthetist students and junior nurse anesthetists in clinical settings. Methods In this prospective psychometric evaluation study, sixteen nurse anesthetists were recruited. They rated 12 video clips of simulated anesthesia scenarios after participating in a three-hour calibration workshop. Four weeks later, a test–retest was conducted, which included five video clips. Internal consistency, Interrater reliability, and test–retest reliability were examined. Results Internal consistency showed acceptable results on the element level and Interrater reliability indicated good results. Retest reliability showed poor to moderate reliability. The use of “Not Relevant” varied significantly depending on the length of the video clip and the provider being rated. The raters considered the assessment tool suitable but initially challenging to use for rating non-technical skills among nurse anesthetists and articulate non-technical skills in anesthesia nursing. Conclusions This initial testing of the Swedish nurse anesthetists’ non-technical skills tool shows acceptable psychometric qualities and gives a foundation for future research. However, the rating “Not Relevant” poses challenges that need to be addressed. Nevertheless, the participants consider the assessment of non-technical skills in Swedish nurse anesthetists to be appropriate.

Background: Research results are often not communicated to study participants or others with relevant lived experience. Effective communication of research results would help study participants understand their contribution to research and could improve trust in research and likelihood of research participation. Few randomized controlled trials (RCTs), however, have compared the effectiveness of research communication tools, and it is not known which tools work best for different people. We will conduct the Scleroderma Patient-centered Intervention Network-Communicating Latest Evidence and Results (SPIN-CLEAR) trial series via the multi-national SPIN Cohort to compare tool effectiveness. Primary objectives of each RCT will be to compare tools based on (1) information completeness, (2) understandability, and (3) ease of use. We will additionally evaluate comprehension of key aspects of disseminated research; likelihood that participants would enroll in a similar future study; and, for all primary and secondary outcomes, outcomes by participant characteristics (gender, age, race or ethnicity, country, language, education level, health literacy). Methods: An advisory team of people with systemic sclerosis (SSc, also known as scleroderma) participated in developing research questions, selecting outcomes, and designing the series of parallel-arm RCTs that will each compare two or more tools or tool variations to a plain-language summary comparator; the common comparator will facilitate across-trial comparisons. In each RCT, people with SSc and researchers will select a recent SSc research study to disseminate. Tools will be developed by experienced tool developers and people with SSc. SPIN Cohort participants (current N eligible = 1522 from 50 SPIN sites in Australia, Canada, France, UK, USA) and additional participants recruited via social media and patient organization partners who consent to participate will be randomized to a dissemination tool or plain-language summary comparator and complete outcomes. Analyses will be intent-to-treat and use linear regression models. Discussion: Each trial in the planned series of trials will build upon knowledge from previous trials. Results will contribute to the evidence base on how to best disseminate results to study participants and others with relevant lived experience. Trial registration: ClinicalTrials.gov NCT06373263. Registered on April 17, 2024 (first trial in series).

Purpose Rib fractures, common in blunt chest trauma, affect 10% of trauma patients and are linked to increased pulmonary morbidity and mortality. This study applies machine learning to identify predictors of complications in conservatively managed rib fracture patients. Methods Data from the 2013–2021 American College of Surgeons’ Trauma Quality Improvement Program included adults (≥ 18 years) with isolated thoracic injury from blunt trauma and conservatively managed rib fractures. Variables included demographics, comorbidities, injury severity, injury patterns, admission vitals, and complications. The permutation importance method identified top predictors of in-hospital complications. Results Of 321,355 rib fracture patients, 183,303 (57.0%) had isolated rib fractures. The five primary predictors of complications in all rib fracture patients were age, Glasgow Coma Scale (GCS) on admission, Revised Cardiac Risk Index (RCRI), chronic obstructive pulmonary disease (COPD), and alcohol use disorder. For isolated rib fracture patients, the same predictors applied but in the order: age, RCRI, GCS, COPD, and alcohol use disorder. A logistic regression model using these predictors showed acceptable discriminative capacity for complications in the full cohort [AUC (95% CI): 0.72 (0.71–0.72)] and isolated rib fracture patients [AUC (95% CI): 0.72 (0.71–0.73)]. Conclusion Cardiovascular risk, age, and level of consciousness on admission are key predictors of complications in conservatively managed rib fracture patients. Though complication rates remain low overall, elderly patients with multiple cardiovascular risk factors face a heightened risk of deterioration.

Introduction Non-operative management of early-stage rectal cancer is increasingly recognised as a subject of significant clinical and research interest. Contact X-ray brachytherapy (CXB) offers an alternative to surgery in appropriately selected cases. Current clinical evidence suggests the use of CXB in combination with chemoradiotherapy (CRT). Although proven effective, no randomised evidence exists for the combination of CXB and short-course radiotherapy (SCRT). In this Swedish national randomised phase II trial, we aim to compare the combination of CXB with either CRT or SCRT in patients with early-to-intermediate rectal cancer. Methods and analysis A total of 110 eligible, operable patients with early-to-intermediate rectal cancer (cT1–cT3ab), with tumours measuring <5 cm in largest diameter, involving <50% of the rectal circumference, N0–N1 (≤3 nodes <8 mm in diameter), located ≤10 cm from the anal verge and MX/M0, are randomised into two arms: standard arm (A) CXB with CRT and experimental arm (B) CXB with SCRT. The contact radiotherapy for rectal cancer (CORRECT) trial aims to evaluate whether the experimental treatment is non-inferior to standard treatment with respect to the primary endpoint 2-year organ preservation rate. On demonstrating non-inferiority in oncological outcomes compared with CXB+CRT, the combination of CXB+SCRT could pave the way for establishing a new standard of care for organ preservation in early-to-intermediate rectal cancer for patients who wish to avoid surgery. Ethics and dissemination CORRECT is conducted in accordance with research ethical approval (2024-02762-01) granted by the Swedish Research Ethics Committee on 4 June 2024. Informed consent will be obtained from all trial participants. The trial results will be published in international peer-reviewed journals. Trial registration number NCT06501053 .

We evaluated the association between cardiopulmonary bypass (CPB) time during surgery for acute type A aortic dissection (ATAAD) and mid-term survival. Data of 1122 patients who underwent surgery for ATAAD in eight Nordic centers from January 2005 to December 2014 were retrospectively analyzed. An adjusted logistic regression analysis was performed to investigate the association of incremental 30 min CPB time on 30-day mortality. In addition, the patients were divided into those that underwent surgery with >210 min (n = 369) or <210 min CPB time (n = 605) based on spline analysis and a receiver operating characteristic curve. The restricted mean survival time ratios adjusted for patient characteristics and surgical details between the groups were calculated for survival and aortic reoperation-free survival. The median follow-up time was 2.6 (inter-quartile range 0.9–4.9) years. Incremental CPB time was associated with higher 30-day mortality (OR 1.25 per 30 min, 95% CI 1.15–1.35, p < 0.001). Mid-term survival for all patients was inferior in the >210 min group as compared with the <210 min group (adjusted restricted mean survival time ratio 0.88, 95% confidence interval [CI] 0.81–0.96, p = 0.003). Reoperation-free survival was similar in patients with CPB time > 210 min as compared with <210 min. Prolonged CPB time is associated with higher 30-day mortality and inferior mid-term survival but not with inferior reoperation-free survival after surgical repair of ATAAD.

Essential thrombocythemia (ET) and polycythemia vera (PV) are rare in adolescent and young adult (AYA). These conditions, similar to those in older patients, are linked with thrombotic complications and the potential progression to secondary myelofibrosis (sMF). This retrospective study of ET and PV patients diagnosed before age 25 evaluated complication rates and impact of cytoreductive drugs on outcomes. Among 348 patients (278 ET, 70 PV) with a median age of 20 years, the of thrombotic events was 1.9 per 100 patient-years. Risk factors for thrombosis included elevated white blood cell count (>11 × 10⁹/L) (HR: 2.7, p = 0.012) and absence of splenomegaly at diagnosis (HR: 5.7, p = 0.026), while cytoreductive drugs did not reduce this risk. The incidence of sMF was 0.7 per 100 patient-years. CALR mutation (HR: 6.0, p < 0.001) and a history of thrombosis (HR: 3.8, p = 0.015) were associated with sMF risk. Interferon as a first-line treatment significantly improved myelofibrosis-free survival compared to other treatments or the absence of cytoreduction (p = 0.046). Although cytoreduction did not affect thrombotic event, early interferon use reduced sMF risk. These findings support interferon use to mitigate sMF risk in AYA ET and PV patients.

Purpose Frailty has gained recognition as a crucial determinant of patient outcomes following traumatic spinal injury (TSI), particularly due to its increasing incidence in elderly populations. The aim of the current investigation was therefore to compare the ability of several frailty scores to predict adverse outcomes in surgically managed isolated TSI patients without spinal cord injury. Methods All adult patients (18 years or older) who suffered an isolated TSI due to blunt trauma, and required surgical management, were extracted from the 2013–2021 Trauma Quality Improvement Program database. The ability of the Orthopedic Frailty Score (OFS), the Hospital Frailty Risk Score (HFRS), the 11-factor (11-mFI) and 5-factor (5-mFI) modified frailty index, as well as the Johns Hopkins Frailty Indicator to predict adverse outcomes was compared based on the area under the receiver-operating characteristic curve (AUC). Subgroup analyses were also performed on patients who were ≥ 65 years old and those who were injured due to a ground-level fall (GLF). Results A total of 39,449 patients were selected from the TQIP database. The 5-mFI and 11-mFI outperformed all other frailty scores when predicting in-hospital mortality (5-mFI AUC: 0.73) (11-mFI AUC: 0.73), any complication (5-mFI AUC: 0.65) (11-mFI AUC: 0.65), and FTR (5-mFI AUC: 0.75) (11-mFI AUC: 0.75). Among the 14,257 geriatric patients, however, the OFS demonstrated the highest predictive ability for in-hospital mortality (AUC: 0.65). The OFS (AUC: 0.64) also performed on the same level as both the 5-mFI (AUC: 0.63) and the 11-mFI (AUC: 0.63) when predicting FTR in this population. Among the 9616 patients who were injured due to a GLF, the OFS performed on par with the 5-mFI and 11-mFI when predicting in-hospital mortality and FTR. Conclusion Simpler scores like the 5-factor modified Frailty Index and Orthopedic Frailty Score outperform or perform on par with more complicated frailty scores when predicting mortality, complications, and failure-to-rescue in surgically managed isolated traumatic spinal injury patients without spinal cord injury, particularly among geriatric patients and those injured in a GLF.

Background Stuttering development in preschool children might be influenced by parents' concern, awareness and knowledge. Indirect treatment may therefore be appropriate. Intervention in a group format has been shown to be positive for stuttering and an online procedure increases the accessibility of the intervention. Aims The aim of this study was to investigate whether an online indirect group treatment for children who stutter could increase parents’ knowledge and confidence in managing the stuttering, reduce the impact of stuttering on the child and parents as well as reduce stuttering severity. Methods and Procedures All children having an ongoing contact with a speech‐language pathologist at the included clinics and meeting the inclusion criteria were invited to participate in the study. The participants were five families with children, aged 3:7–4:5, who had been stuttering for at least 12 months. Treatment consisted of six weekly online group sessions for parents, followed by 15 weeks of home consolidation. A single‐subject research design replicated across participants was used to investigate changes over baseline, treatment and consolidation phase. The outcome measures were Palin Parent Rating Scales and severity ratings of stuttering reported by parents. Mean values of each week's daily parent ratings of stuttering were used and converted to defined scale steps. Changes in all variables were visually analysed for each participant. Scale steps representing the mean values from baseline measurements were compared with those from the consolidation phase to analyse changes in scale steps (clinical relevance). Outcome and Results The findings indicate increased parents’ knowledge about stuttering and confidence in how to support their child, as well as a positive trend in the impact of stuttering on child and parents, and stuttering severity, during the intervention. The size of the changes in the included outcome measures (e.g., from low to high or very high) varied between participants. The changes were clinically relevant in one to three, out of four, outcome measures for each child, also for those at risk of persistent stuttering. Conclusions and Implications The online group format can be an effective way to increase parents’ ability to handle the child's stuttering at an early stage. Further studies are needed to ensure what treatment effects can be expected, following this indirect online format. WHAT THIS PAPER ADDS What is already known on the subject Indirect therapy involving parents has been shown to benefit preschool children who stutter. These therapies typically include providing information about stuttering, teaching strategies for managing stuttering and improving overall communication skills. What this paper adds to existing knowledge This study evaluates a novel form of online group therapy (involving five families) which has not been previously studied. The results demonstrate that most of the parents gain knowledge and confidence in managing their child's speech disorder. Additionally, some parents report a reduced negative impact of stuttering on both the child and the family after the treatment. What are the potential or actual clinical implications of this work? This approach can be a valuable tool for speech and language therapists working with preschool children who stutter. The online format offers a practical option for families who face challenges attending in‐person sessions, while also providing opportunities to connect with other parents in similar situations.

Aims The aim of this study was to perform an external validation of an automatic machine learning algorithm for heart rhythm diagnostics using smartphone photoplethysmography (PPG) recorded by patients with atrial fibrillation (AF) and atrial flutter (AFL) pericardioversion in an unsupervised ambulatory setting. Methods and results Patients undergoing cardioversion for AF or AFL performed 1-min heart rhythm recordings peri-cardioversion at least twice daily for 4–6 weeks, using an iPhone 7 smartphone running a PPG application (CORAI Heart Monitor) simultaneously with a single-lead ECG recording (KardiaMobile). The algorithm uses support vector machines (SVM) to classify heart rhythm from smartphone-PPG. The algorithm was trained on PPG recordings made by patients in a separate cardioversion cohort. Photoplethysmography recordings in the external validation cohort were analysed by the algorithm. Diagnostic performance was calculated by comparing the heart rhythm classification output to the diagnosis from the simultaneous ECG recordings (gold standard). In total 460 patients performed 34 097 simultaneous PPG and ECG recordings, divided into 180 patients with 16 092 recordings in the training cohort and 280 patients with 18 005 recordings in the external validation cohort. Algorithm classification of the PPG recordings in the external validation cohort diagnosed AF with sensitivity, specificity and accuracy of 99.7/99.7/99.7%, and AF/AFL with sensitivity, specificity and accuracy of 99.3/99.1/99.2%. Conclusion A machine learning based algorithm demonstrated excellent performance in diagnosing atrial fibrillation and atrial flutter from smartphone-PPG recordings in an unsupervised ambulatory setting, minimizing the need for manual review and ECG verification, in elderly cardioversion populations.

Background and purpose: The COVID-19 pandemic impacted substantially on cancer healthcare, including the temporary suspension of screening activities. We compared cancer incidence rates and stage during 2020–2021 to pre-pandemic rates in the Nordic countries. Material and methods: Using data from the national cancer registries in Denmark, Finland, Iceland, Norway, and Sweden, we estimated age-, sex-, and period-adjusted incidence rate ratios, expressed as relative percentage change (%) with 95% confidence intervals (CIs), comparing rates in 2020–2021 to those in 2017–2019 (pre-pandemic). Results: In 2020–2021, 340,675 cancer cases were diagnosed. The incidence rates declined during the first pandemic wave (Q2 2020), ranging from –21.7% [95% CI: –23.3%; –20.2%] (Sweden) to –7.9% [–17.7%; 3.0%] (Iceland). Incidence rates also declined in the second pandemic wave (Q1 2021), ranging from –8.6% [–10.2%; –6.9%] (Sweden) to –2.3% [–4.6%; 0.1%] (Norway), and in Sweden also by –3.1% [–4.8%; –1.3%] in the third pandemic wave (Q4 2021). Stage I breast cancer incidence declined during 2020 in Denmark/Norway/Sweden, with some catch-up in stage II incidence in 2021. Prostate cancer rates declined in Denmark/Finland/Norway/Sweden during 2020–2021, while melanoma rates declined in Finland in 2020. During 2020, colon cancer rates declined in Denmark and Iceland, while rectal cancer rates declined in Denmark, and lung and kidney cancer rates declined in Norway. Interpretation: During 2020–2021, cancer incidence rates declined across the Nordic countries with the largest declines in Sweden. During the third pandemic wave, the incidence rates were mostly similar to pre-pandemic rates. Changes in cancer stage may reflect reduced screening activities.

Chronic thromboembolic pulmonary hypertension (CTEPH) can develop subsequent to acute pulmonary embolism, with exertional dyspnea being the predominant symptom. Initial evaluation of CTEPH patients should prioritize surgical intervention via pulmonary thromboendarterectomy (PEA). For cases where surgical intervention is not feasible, balloon pulmonary angioplasty (BPA) emerges as a potential treatment. Post-treatment, patients are expected to demonstrate both subjective and objective amelioration. The technique often requires multiple sessions. The safety profile of BPA is comparable to that of open surgical PEA. Further research is imperative to comprehensively evaluate the long-term efficacy and safety of this therapeutic modality.

Background and hypothesis Finerenone, a selective nonsteroidal MRA, and SGLT2is both reduce CKD progression and improve kidney/CV outcomes. The CONFIDENCE study (NCT05254002; EudraCT 2021-003037-11) hypothesis is that early combination of finerenone and empagliflozin, a SGLT2i, is superior to either drug alone in reducing UACR over 6 months. Methods CONFIDENCE is an ongoing, fully enrolled, randomized, controlled, double-blind, multicentre phase 2 clinical trial in adults (≥18 years of age) with CKD and T2D, eGFR of 30 to 90 ml/min/1.73 m2, and UACR of ≥100 to <5000 mg/g. Participants taking the clinically maximum tolerated dose of a renin–angiotensin system inhibitor for >1 month at screening were eligible. Participants were randomized 1:1:1 to once daily finerenone plus empagliflozin, finerenone plus placebo, or empagliflozin plus placebo; doses were 10 mg once daily for empagliflozin and 10 or 20 mg once daily for finerenone, depending on eGFR at baseline. Randomization was stratified by eGFR (< or ≥60 ml/min/1.73 m2) and UACR (≤ or >850 mg/g). The primary efficacy outcome is the relative change in UACR from baseline at Day 180. Results There were 818 participants randomized across 143 sites from 14 countries between July 2022 and August 2024. Mean eGFR (ml/min/1.73 m2 [SD]) was 54.2 (17.1). Median UACR (mg/g [IQR]) was 583 (292, 1140). Mean HbA1c (% [SD]) was 7.3 (1.2). Mean systolic/diastolic BP (mmHg) was 135.2/77.3. GLP-1 RAs and insulin were used by 182 (23%) and 313 (39%) participants, respectively. Atherosclerotic CV disease, diabetic retinopathy, and a history of heart failure were present in 223 (28%), 126 (16%), and 30 (4%) participants, respectively. Conclusions The CONFIDENCE trial enrolled a diverse population with CKD and T2D and will determine the impact of simultaneous initiation of combination finerenone and a SGLT2i versus individual therapy on potentially mitigating the progression of CKD in people with T2D. Trial registration number: Clinicaltrials.gov NCT05254002; EudraCT 2021-003037-11.

Background PUFAs, especially from vegetable fat sources, have been suggested to contribute to weight regulation and be protective to cardiometabolic health. However, a few longitudinal studies on childhood exposure are available, with short follow-up time and conflicting results. Objectives To study the relationship between plasma proportions of PUFA in childhood and adolescence and cardiometabolic risk factors in young adulthood, such as obesity, body composition, blood pressure (BP), and blood lipids in a prospective cohort study. Methods We included n = 688 participants of the BAMSE (Barn, Allergi, Miljö, Stockholm, Epidemiologi) cohort in Stockholm, Sweden, with data on plasma phospholipid proportions of n-3 and n-6 fatty acids [α-linolenic acid (ALA), EPA, docosapentaenoic acid, DHA, linoleic acid (LA), and arachidonic acid (AA)] at 8 and 16 y and body mass index (BMI), waist circumference, fat mass %, BP, and blood lipids at 24 y. Associations between PUFAs and cardiometabolic health outcomes were assessed with sex-stratified multivariable-adjusted linear and logistic regression models. Results In females, LA and ALA at 16 y were inversely associated with BMI [B: −0.35 (−0.54, −0.17) and B: −6.1 (−11, −1.5), respectively], and similarly with waist circumference and fat mass at 24 y. Also in females, LA was inversely associated with BP, triglycerides, LDL-cholesterol), and total cholesterol (e.g., B −0.044 [−0.079, −0.0099] for LA at 16 y and LDL-cholesterol), whereas ALA was only inversely associated with LDL-cholesterol. No associations were found between long chain n-3 fatty acids or AA and any of the studied outcomes. Conclusions Plasma phospholipid proportions of LA and ALA, biomarkers of vegetable oil intake, during childhood and adolescence were inversely associated with measures of obesity and cardiometabolic health in young adulthood, with a potential sex difference. These findings accord with short-term feeding trials suggesting a possible preventive role of LA on body fat accumulation.

Background Creatinine-based estimated glomerular filtration rate (eGFR) equations are widely used in clinical practice but exhibit inherent limitations. On the other side, measuring GFR is time consuming and not available in routine clinical practice. We developed and validated machine learning models to assess the trustworthiness (i.e. the ability of equations to estimate measured GFR (mGFR) within 10%, 20% or 30%) of the European Kidney Function Consortium (EKFC) equation at the individual level. Methods This observational study used data from European and US cohorts, comprising 22,343 participants of all ages with available mGFR results. Four machine learning and two traditional logistic regression models were trained on a cohort of 9,202 participants to predict the likelihood of the EKFC creatinine-derived eGFR falling within 30% (p30), 20% (p20) or 10% (p10) of the mGFR value. The algorithms were internally and then externally validated on cohorts of respectively 3,034 and 10,107 participants. The predictors included in the models were creatinine, age, sex, height, weight, and EKFC. Results The random forest model was the most robust model. In the external validation cohort, the model achieved an area under the curve of 0.675 (95%CI 0.660;0.690) and an accuracy of 0.716 (95%CI 0.707;0.725) for the P30 criterion. Sensitivity was 0.756 (95%CI 0.747;0.765) and specificity was 0.485 (95%CI 0.460; 0.511) at the 80% probability level that EKFC falls within 30% of mGFR. At the population level, the PPV of this machine learning model was 89.5%, higher than the EKFC P30 of 85.2%. A free web-application was developed to allow the physician to assess the trustworthiness of EKFC at the individual level. Conclusions A strategy using machine learning model marginally improves the trustworthiness of GFR estimation at the population level. An additional value of this approach lies in its ability to provide assessments at the individual level.