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Bahlmann, H., Halldestam, I. & Nilsson, L. (2019). Goal-directed therapy during transthoracic oesophageal resection does not improve outcome: Randomised controlled trial. European Journal of Anaesthesiology, 36(2), 153-161
Open this publication in new window or tab >>Goal-directed therapy during transthoracic oesophageal resection does not improve outcome: Randomised controlled trial
2019 (English)In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 36, no 2, p. 153-161Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Goal-directed therapy (GDT) is expected to be of highest benefit in high-risk surgery. Therefore, GDT is recommended during oesophageal resection, which carries a high risk of postoperative complications.

OBJECTIVES: The aim of this study was to confirm the hypothesis that GDT during oesophageal resection improves outcome compared with standard care.

DESIGN: A randomised controlled study.

SETTING: Two Swedish university hospitals, between October 2011 and October 2015.

PATIENTS: Sixty-four patients scheduled for elective transthoracic oesophageal resection were randomised. Exclusion criteria included colonic interposition and significant aortic or mitral valve insufficiency.

INTERVENTION: A three-step GDT protocol included stroke volume optimisation using colloid boluses as assessed by pulse-contour analysis, dobutamine infusion if cardiac index was below 2.5 l min m and norepinephrine infusion if mean arterial blood pressure was below 65 mmHg.

MAIN OUTCOME MEASURE: The incidence of complications per patient at 5 and 30 days postoperatively as assessed using a predefined list.

RESULTS: Fifty-nine patients were available for analysis. Patients in the intervention group received more colloid fluid (2190 ± 875 vs. 1596 ± 759 ml, P < 0.01) and dobutamine more frequently (27/30 vs. 9/29, P < 0.01). The median [interquartile range, IQR] incidence of complications per patient 5 days after surgery was 2 [0 to 3] in the intervention group and 1 [0 to 2] in the control group (P = 0.10), and after 30 days 4 [2 to 6] in the intervention group and 2 [1 to 4] in the control group (P = 0.10).

CONCLUSION: Goal-directed therapy during oesophageal resection did not result in a reduction of the incidence of postoperative complications.

TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01416077.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2019
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:liu:diva-156264 (URN)10.1097/EJA.0000000000000908 (DOI)000462763800010 ()30431499 (PubMedID)2-s2.0-85059795456 (Scopus ID)
Note

Funding agencies: Linkoping Medical Society

Available from: 2019-04-10 Created: 2019-04-10 Last updated: 2019-04-18Bibliographically approved
Grossmann, B., Nilsson, A., Sjöberg, F. & Nilsson, L. (2019). Patient-controlled Sedation During Flexible Bronchoscopy: A Randomized Controlled Trial. Journal of Bronchology & Interventional Pulmonology
Open this publication in new window or tab >>Patient-controlled Sedation During Flexible Bronchoscopy: A Randomized Controlled Trial
2019 (English)In: Journal of Bronchology & Interventional Pulmonology, ISSN 1944-6586, E-ISSN 1948-8270Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background: Patient-controlled sedation (PCS) is a documented method for endoscopic procedures considered to facilitate early recovery. Limited data have been reported, however, on its use during flexible bronchoscopy (FB).

Materials and Methods: This study hypothesized that PCS with propofol during FB would facilitate early recovery, with similar bronchoscopist and patient satisfaction compared with nurse-controlled sedation (NCS) with midazolam. A total of 150 patients were randomized 1:1:1 into a control group (premedication with morphine-scopolamine and NCS with midazolam), PCS-MS group (premedication with morphine-scopolamine and PCS with propofol), and PCS-G group (premedication with glycopyrronium and PCS with propofol).

Results: The procedures included transbronchial biopsy, transbronchial needle aspiration, cryotherapy/biopsy, and/or multistation endobronchial ultrasound. FB duration values in median (range) were 40 (10 to 80), 39 (12 to 68), and 44 (10 to 82) minutes for the groups NCS, PCS-MS, and PCS-G, respectively. An overall 81% of the patients in the combined PCS groups were ready for discharge (modified Post Anaesthetic Discharge Scoring System, score 10) 2 hours after bronchoscopy compared with 40% in the control group (P<0.0001). Between PCS groups, 96% of the PCS-G group patients were ready for discharge compared with 65% in the PCS-MS group (P=0.0002) at 2 hours. Bronchoscopists’ and patients’ satisfaction scores were high in all groups. Postdischarge quality scores showed no differences among the groups.

Conclusion: PCS with propofol during FB is feasible, as it shortened recovery time without compromising procedure conditions for bronchoscopists or patients. A rapid postsedation stabilization of vital signs facilitates surveillance before the patient leaves the hospital.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2019
Keywords
analgesia, patient-controlled, conscious sedation, anesthesia, intravenous, bronchoscopy, propofol
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-161081 (URN)10.1097/LBR.0000000000000610 (DOI)31478938 (PubMedID)2-s2.0-85072015123 (Scopus ID)
Available from: 2019-10-21 Created: 2019-10-21 Last updated: 2019-10-28Bibliographically approved
Grossmann, B., Nilsson, A., Sjöberg, F., Bernfort, L. & Nilsson, L. (2019). Patient-controlled sedation with propofol for endoscopic procedures: A cost analysis. Acta Anaesthesiologica Scandinavica
Open this publication in new window or tab >>Patient-controlled sedation with propofol for endoscopic procedures: A cost analysis
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2019 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background

Patient‐controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation.

Methods

Based on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine‐scopolamine or glycopyrronium.

Results

Propofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine‐scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups.

Conclusion

Propofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-161080 (URN)10.1111/aas.13463 (DOI)31436310 (PubMedID)
Available from: 2019-10-21 Created: 2019-10-21 Last updated: 2019-10-28Bibliographically approved
Grossmann, B., Nilsson, A., Sjöberg, F. & Nilsson, L. (2019). Rectal ketamine during paediatric burn wound dressing procedures: a randomised dose-finding study. Burns, 45(5), 1081-1088
Open this publication in new window or tab >>Rectal ketamine during paediatric burn wound dressing procedures: a randomised dose-finding study
2019 (English)In: Burns, ISSN 0305-4179, E-ISSN 1879-1409, Vol. 45, no 5, p. 1081-1088Article in journal (Refereed) Published
Abstract [en]

Background

Worldwide, ketamine is used during paediatric procedures, but no recommendations are available regarding a suitable dose for rectal administration during procedures involving high levels of pain and/or anxiety such as burn wound dressing change.

Methods

We evaluated three different single doses of rectally administered racemic ketamine mixed with a fixed dose of 0.5 mg/kg of midazolam. In total, 90 children – aged 6 months to 4 years – were randomised 1:1:1 to receive 4 mg/kg (K-4 group), 6 mg/kg (K-6 group) or 8 mg/kg (K-8 group) of racemic ketamine for a maximum of three consecutive procedures. Primary outcome measure was procedural pain evaluated by Face, Legs, Activity, Cry, Consolability (FLACC) behavioural scale. Secondary outcome included feasibility and recovery time. Patient safety was evaluated using surrogate outcomes.

Results

In total, 201 procedures in 90 children aged 19 ± 8 months were completed. The median maximum pain was FLACC 0 in all groups (p = 0.141). The feasibility was better for groups K-6 (p = 0.049) and K-8 (p = 0.027) compared with K-4, and the mean recovery time was the longest for group K-8 (36 ± 22 min) compared with groups K-4 (25 ± 15 min; p = 0.003) and K-6 (27 ± 20 min; p = 0.025). Median maximum sedation measured by the University of Michigan Sedation Scale (UMSS) was higher in group K-8 compared with group K-4 (p < 0.0001) and K-6 (p = 0.023). One child in group K-8 had a study drug-related serious adverse event — laryngospasm/airway obstruction. No rescue analgosedative medication was administered for group K-6.

Conclusions

A rectally administered mixture of racemic ketamine (6 mg/kg) and midazolam (0.5 mg/kg) during paediatric burn dressing procedures with a duration of approximately 30 min provides optimal conditions regarding pain relief, feasibility, recovery time and patient safety, with no need for rescue analgosedative medication.

Place, publisher, year, edition, pages
Pergamon Press, 2019
National Category
Anesthesiology and Intensive Care Public Health, Global Health, Social Medicine and Epidemiology Surgery
Identifiers
urn:nbn:se:liu:diva-156837 (URN)10.1016/j.burns.2018.12.012 (DOI)000470856100010 ()31060760 (PubMedID)2-s2.0-85065014700 (Scopus ID)
Note

Funding agencies: County Council of Ostergotland, Sweden

Available from: 2019-05-14 Created: 2019-05-14 Last updated: 2019-07-15Bibliographically approved
Hahn, R. G., Bahlmann, H. & Nilsson, L. (2017). Preoperative fluid retention increases blood loss during major open abdominal surgery. Perioperative Medicine, 6, Article ID 12.
Open this publication in new window or tab >>Preoperative fluid retention increases blood loss during major open abdominal surgery
2017 (English)In: Perioperative Medicine, ISSN 0908-6919, E-ISSN 2047-0525, Vol. 6, article id 12Article in journal (Refereed) Published
Abstract [en]

Background

Quantification of renal fluid conservation is possible by urine analysis, and the results can indicate dehydration. The present report sought to determine whether this fluid retention correlates with fluid requirements during major abdominal surgeries that have estimated operating times ≥ 2 h.

Methods

Urine colour, specific weight, osmolality and creatinine concentration were used to calculate a composite “fluid retention index” (FRI) in 97 patients prior to major abdominal surgery. Goal-directed fluid volume optimization, with hydroxyethyl starch supplemented with a background administration of crystalloid fluid, was used.

Results

The median preoperative FRI was 3.0. Fluid retention, considered as present when FRI ≥ 3.5, was found in 37% of the patients. Fluid retention was followed by a significantly larger blood loss (+ 125%; 450 vs. 200 ml), higher haemorrhage rate (+ 41%; 123 vs. 87 ml/h) and greater need for both colloid (+ 43%; 1.43 vs. 1.00 l) and crystalloid (+ 18%; 1.28 vs. 1.08 l) fluids. Despite the larger blood loss, the total fluid balance was more positive after surgery in the dehydrated patients (+ 26%; 1.91 vs. 1.51 l; P < 0.02).

Conclusions

Preoperative fluid retention, as detected in a urine sample, was associated with a greater blood loss and a more positive fluid balance during major abdominal surgery.

Place, publisher, year, edition, pages
BioMed Central, 2017
Keywords
Abdominal; Blood loss; Dehydration; Surgery; Urine specimen collection
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:liu:diva-145041 (URN)10.1186/s13741-017-0068-1 (DOI)000409221000001 ()28878889 (PubMedID)
Available from: 2018-02-08 Created: 2018-02-08 Last updated: 2020-01-20Bibliographically approved
Bahlmann, H., Hahn, R. G. & Nilsson, L. (2016). Agreement between Pleth Variability Index and oesophageal Doppler to predict fluid responsiveness. Acta Anaesthesiologica Scandinavica, 60(2), 183-192
Open this publication in new window or tab >>Agreement between Pleth Variability Index and oesophageal Doppler to predict fluid responsiveness
2016 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 60, no 2, p. 183-192Article in journal (Refereed) Published
Abstract [en]

Background: Optimisation of stroke volume using oesophageal Doppler is an established technique to guide intraoperative fluid therapy. The method has practical limitations and therefore alternative indices of fluid responsiveness, such as ventilator-induced variation in the pulse oximetric signal (Pleth Variability Index (PVI)) could be considered. We hypothesised that both methods predict fluid responsiveness in a similar way. Methods: Seventy-five patients scheduled for open major abdominal surgery were randomised to fluid optimisation using fluid bolus algorithms based on either PVI (n = 35) or Doppler (n = 39). All patients were monitored with both methods; the non-guiding method was blind. Primary endpoint was the concordance between the methods to predict fluid responsiveness. We also analysed the ability of each method to predict a stroke volume increase &gt;= 10% after a fluid bolus, as well as the accumulated intraoperative bolus fluid volume. Results: PVI indicated a need for fluid in one-third of the situations when Doppler did so, Cohens kappa = 0.03. A fluid bolus indicated by the PVI algorithm increased stroke volume by &gt;= 10% in half the situations. The same was found for the Doppler algorithm. The mean total bolus volume given was 878 ml when the fluid management was governed by PVI compared to 826 ml with Doppler (P = 0.71). Conclusion: PVI-and Doppler-based stroke volume optimisations agreed poorly, which did not affect the amount of fluid administered. None of the algorithms showed a good ability to predict fluid responsiveness. Our results do not support the fluid responsiveness concept.

Place, publisher, year, edition, pages
WILEY-BLACKWELL, 2016
National Category
Health Sciences
Identifiers
urn:nbn:se:liu:diva-124622 (URN)10.1111/aas.12632 (DOI)000368139700006 ()26373826 (PubMedID)
Note

Funding Agencies|Department of Anaesthesiology and Intensive Care, Linkoping University Hospital; County Council of Ostergotland

Available from: 2016-02-09 Created: 2016-02-08 Last updated: 2019-04-10
Andersson Hagiwara, M., Nilsson, L., Stromsoe, A., Axelsson, C., Kangstrom, A. & Herlitz, J. (2016). Patient safety and patient assessment in pre-hospital care: a study protocol. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 24(14)
Open this publication in new window or tab >>Patient safety and patient assessment in pre-hospital care: a study protocol
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2016 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 24, no 14Article in journal (Refereed) Published
Abstract [en]

Background: Patient safety issues in pre-hospital care are poorly investigated. The aim of the planned study is to survey patient safety problems in pre-hospital care in Sweden. Methods/Design: The study is a retro-perspective structured medical record review based on the use of 11 screening criteria. Two instruments for structured medical record review are used: a trigger tool instrument designed for pre-hospital care and a newly development instrument designed to compare the pre-hospital assessment with the final hospital assessment. Three different ambulance organisations are participating in the study. Every month, one rater in each organisation randomly collects 30 medical records for review. With guidance from the review instrument, he/she independently reviews the record. Every month, the review team meet for a discussion of problematic reviews. The results will be analysed with descriptive statistics and logistic regression. Discussion: The findings will make an important contribution to knowledge about patient safety issues in prehospital care.

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2016
Keywords
Adverse events; Patient assessment; Pre-hospital care; Patient safety
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-126134 (URN)10.1186/s13049-016-0206-7 (DOI)000370594000001 ()26868416 (PubMedID)
Available from: 2016-03-15 Created: 2016-03-15 Last updated: 2017-11-30
Nilsson, A., Grossmann, B., Kullman, E., Uustal, E., Sjöberg, F. & Nilsson, L. (2015). Sedation during endoscopic retrograde cholangiopancreatography: A randomised controlled study of patient-controlled propofol sedation and that given by a nurse anaesthetist. Scandinavian Journal of Gastroenterology, 50(10), 1285-1292
Open this publication in new window or tab >>Sedation during endoscopic retrograde cholangiopancreatography: A randomised controlled study of patient-controlled propofol sedation and that given by a nurse anaesthetist
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2015 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 50, no 10, p. 1285-1292Article in journal (Refereed) Published
Abstract [en]

Objective: Different regimens are used for sedation during ERCP (endoscopic retrograde cholangiopancreatography). Our objectives were to compare safety, ease of treatment, time to recovery and patients’ experiences using PCS (patient-controlled sedation) with propofol as well as sedation given by a nurse anaesthetist (ACS) with propofol or midazolam during ERCP.

Material and methods: The study included 281 adults in 301 procedures. The PCS group (n=101) delivered bolus doses of 5 mg of propofol according to their need for sedation. The ACS group (n=100) had 2-8 mg/kg/hour of propofol infused, with the target for sedation being Level 3 of the Observer’s Assessment of Alertness/Sedation scale (OAA/S). The control group was given 2-3 mg of midazolam for induction and additional 1 mg if required.

Results: PCS and ACS increased the ease of the procedure and reduced the numbers of sedation failures compared to midazolam sedation (ACS n=0; PCS n=4; midazolam n=20). The ACS group had more deeply sedated patients (OAA/S Level 2), desaturations and obstructed airways than the PCS and midazolam groups. Over 90% of all patients had recovered (Aldrete score≥9) by the time they returned to the ward. PCS resulted in the least fatigue and pain after the procedure. Patients’ preference for PCS and ACS were the same.

Conclusion: PCS with propofol is superior to midazolam and comparable to ACS. PCS resulted in a rapid recovery, tended to be the safest and was almost as effective as ACS in ensuring a successful examination.

Place, publisher, year, edition, pages
Taylor & Francis, 2015
Keywords
Conscious sedation, propofol, Cholangiopancreatography, Endoscopic Retrograde
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:liu:diva-112371 (URN)10.3109/00365521.2015.1038848 (DOI)000361324600013 ()
Available from: 2014-11-24 Created: 2014-11-24 Last updated: 2019-05-13Bibliographically approved
Nilsson, A., Nilsson, L., Schnider, T., Uustal, E. & Sjöberg, F. (2015). Should Propofol and Alfentanil Be Combined in Patient-Controlled Sedation? A Randomised Controlled Trial Using Pharmacokinetic Simulation. Open Journal of Anesthesiology, 5(6), 122-129
Open this publication in new window or tab >>Should Propofol and Alfentanil Be Combined in Patient-Controlled Sedation? A Randomised Controlled Trial Using Pharmacokinetic Simulation
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2015 (English)In: Open Journal of Anesthesiology, ISSN 2164-5558, Vol. 5, no 6, p. 122-129Article in journal (Refereed) Published
Abstract [en]

Background: Patient-controlled sedation (PCS) is increasingly used for moderate sedation. Detailed understanding is essential for maintaining safety and giving the most benefit. We wanted to explore the associations between patients’ characteristics, perioperative pain and anxiety, the procedure, and the calculated concentrations at the effect site (Ce) of propofol. We also wanted to analyse the pharmacokinetic profiles of propofol and alfentanil during PCS, and their association with respiratory complications.

Methods: 155 patients were double-blinded and randomised to have propofol or propofol and alfentanil for PCS during gynaecological surgery. Pharmacokinetic simulation of Ce and multiple regressions aided the search for correlations between explanatory variables and concentrations of drugs.

Results: In group propofol, treatment for incontinence, anterior repair, and the patient’s weight correlated the best (B-coef = 0.20, 0.20 and 0.01; r = 0.69; r² = 0.48). When alfentanil was added, alfentanil and the patient’s weight were associated with Ce of propofol (B-coef = -0.40 and 0.01; r = 0.70; r² = 0.43). Logistic regression indicated that age and Ce of drugs were related to ten cases of respiratory complications.

Conclusions: Patients’ weights and the type of surgery performed were associated with the Ce of propofol; this knowledge could be used for refinement of the doses given during PCS. Because the pharmacokinetic profiles of propofol and alfentanil are different, the alfentanil effect becomes predominant during the time course of sedation. In order to reduce the risk of early and late respiratory depression, alfentanil should not be added to propofol in the same syringe.

Place, publisher, year, edition, pages
Scientific Research Publishing, 2015
Keywords
Anaesthetics, Intravenous, Propofol, Analgesics, Opioids, Alfentanil, Sedation
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-126606 (URN)10.4236/ojanes.2015.56023 (DOI)
Note

At the time for thesis presentation publication was in status: Manuscript

Available from: 2016-03-31 Created: 2016-03-31 Last updated: 2016-12-16Bibliographically approved
Rutberg, H., Borgstedt Risberg, M., Sjödahl, R., Nordqvist, P., Valter, L. & Nilsson, L. (2014). Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method. BMJ Open, 4(5), 004879
Open this publication in new window or tab >>Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method
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2014 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 4, no 5, p. 004879-Article in journal (Refereed) Published
Abstract [en]

Objectives: To describe the level, preventability and categories of adverse events (AEs) identified by medical record review using the Global Trigger Tool (GTT). To estimate when the AE occurred in the course of the hospital stay and to compare voluntary AE reporting with medical record reviewing. Design: Two-stage retrospective record review. Setting: 650-bed university hospital. Participants: 20 randomly selected medical records were reviewed every month from 2009 to 2012. Primary and secondary outcome measures: AE/1000 patient-days. Proportion of AEs found by GTT found also in the voluntary reporting system. AE categorisation. Description of when during hospital stay AEs occur. Results: A total of 271 AEs were detected in the 960 medical records reviewed, corresponding to 33.2 AEs/1000 patient-days or 20.5% of the patients. Of the AEs, 6.3% were reported in the voluntary AE reporting system. Hospital-acquired infections were the most common AE category. The AEs occurred and were detected during the hospital stay in 65.5% of cases; the rest occurred or were detected within 30 days before or after the hospital stay. The AE usually occurred early during the hospital stay, and the hospital stay was 5 days longer on average for patients with an AE. Conclusions: Record reviewing identified AEs to a much larger extent than voluntary AE reporting. Healthcare organisations should consider using a portfolio of tools to gain a comprehensive picture of AEs. Substantial costs could be saved if AEs were prevented.

Place, publisher, year, edition, pages
BMJ Publishing Group: Open Access / BMJ Journals, 2014
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-108944 (URN)10.1136/bmjopen-2014-004879 (DOI)000336976900075 ()
Available from: 2014-07-15 Created: 2014-07-13 Last updated: 2017-12-05
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-7489-9077

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