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  • 1.
    Berkius, Johan
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet.
    Intensive care in chronic obstructive pulmonary disease: treatment with non-invasive ventilation and long-term outcome2013Doktoravhandling, med artikler (Annet vitenskapelig)
    Abstract [en]

    Background: Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality throughout the world. When we began this project our knowledge about the outcome of COPD patients admitted to the ICU in Sweden was scarce.

    Aims: To investigate the characteristics, survival and health-related quality of life (HRQL) of COPD patients admitted to Swedish ICUs. To investigate how ICU personnel decide whether to use invasive or non-invasive ventilatory treatment (NIV) of the newly admitted COPD patient in need of ventilatory support. To investigate outcome according to mode of ventilation.

    Material and methods: Detailed data, including HRQL during recovery, from COPD patients admitted to ICUs that participated in the Swedish intensive care registry were analysed. A questionnaire was distributed to personnel in 6 of the participating ICUs in order to define factors deemed important in making the choice between invasive and non-invasive ventilation immediately after admission. The answers were analysed.

    Results: The proportion of COPD patients admitted to Swedish ICUs in need of ventilatory support is 1.3-1.6 % of all admissions. The patients are around 70 years-old and are severely ill on admission, with high respiratory rates and most have life-threatening disturbances in their acid-base balance and blood gases. There are more women than men. The short- and long-term mortality is high despite intensive care treatment. The majority of patients are treated with NIV. The length of stay on the ICU is shorter when NIV is used. The choice between NIV and invasive ventilation in these patients may be irrational. It is guided by current guidelines, but other non-patient-related factors seem to influence this decision. NIV seems to be preferable to invasive ventilation at admission, not only according to short-term benefits but also to long-term survival. Failure of NIV followed by invasive ventilation does not have a poorer prognosis than directly employing invasive ventilation. The health-related quality of life of COPD patients after treatment on Swedish ICUs is lower than in the general population. However it does not decline between 6 and 24 months after ICU discharge. After 24 months the HRQL is quite similar to that of COPD patients not treated on the ICU.

    Conclusions: COPD patients in need of ventilatory support admitted to Swedish ICUs are severely ill on admission, and their short- and long-term mortality is high despite ICU care and ventilatory treatment. Non-invasive ventilation should be the first line treatment on admission. NIV has short- and long-term benefits compared to invasive ventilation, without increasing mortality risk in case of failure. After discharge from the ICU and recovery, the HRQL of COPD patients is lower than in the general population, but comparable to COPD patients not treated on the ICU.

    Delarbeid
    1. Characteristics and long-term outcome of acute exacerbations in chronic obstructive pulmonary disease: An analysis of cases in the Swedish Intensive Care Registry during 2002-2006
    Åpne denne publikasjonen i ny fane eller vindu >>Characteristics and long-term outcome of acute exacerbations in chronic obstructive pulmonary disease: An analysis of cases in the Swedish Intensive Care Registry during 2002-2006
    2008 (engelsk)Inngår i: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 52, nr 6, s. 759-765Artikkel i tidsskrift (Fagfellevurdert) Published
    Abstract [en]

    Background: Chronic obstructive pulmonary disease (COPD) represents a major and growing health problem. The purpose of this work was to examine characteristics, resource use and long-term survival in patients with an acute exacerbation of COPD that were admitted to Swedish intensive care units (ICU). Methods: Patient characteristics at admission, length of stay (LOS), resource use and outcome were collected for admissions due to COPD during 2002-2006 in the database of the Swedish Intensive Care Registry. Vital status was secured for 99.6% of the patients. Kaplan-Meier survival estimates were computed for index admissions only. Results: We identified 1009 patients with 1199 admissions due to COPD (1.3% of all intensive care admissions). The mean (SD) age was 70.2 (9.1) years and the proportion of women were 61.5%. Mean (SD) Acute Physiology and Chronic Health Evaluation II probability of hospital death was 0.31 (0.19). Median LOS was 28 (interquartile range 52) h. The number of readmissions was 190 during the 5-year study. Older patients had fewer readmissions (OR 0.96, 95% CI: 0.95-0.98/year increase in age). ICU mortality was 7.3% (87 of 1199 admissions) and 30-day mortality was 26.0% (262 of 1009 index admissions). Median survival was 14.5 months and 31% of patients survived 3 years after the index admission. Conclusions: Short (30 days) and long-term survival is poor in acute COPD. Readmissions are frequent reflecting the severity of this chronic illness. Patients are less likely to be readmitted with increasing age which may be due to withholding of further intensive care. © 2008 The Authors.

    Emneord
    chronic obstructive pulmonary disease; critical care; survival analysis
    HSV kategori
    Identifikatorer
    urn:nbn:se:liu:diva-44985 (URN)10.1111/j.1399-6576.2008.01632.x (DOI)78991 (Lokal ID)78991 (Arkivnummer)78991 (OAI)
    Tilgjengelig fra: 2009-10-10 Laget: 2009-10-10 Sist oppdatert: 2017-12-13bibliografisk kontrollert
    2. Long-term survival according to ventilation mode in acute respiratory failure secondary to chronic obstructive pulmonary disease: A multicenter, inception cohort study
    Åpne denne publikasjonen i ny fane eller vindu >>Long-term survival according to ventilation mode in acute respiratory failure secondary to chronic obstructive pulmonary disease: A multicenter, inception cohort study
    Vise andre…
    2010 (engelsk)Inngår i: JOURNAL OF CRITICAL CARE, ISSN 0883-9441, Vol. 25, nr 3Artikkel i tidsskrift (Fagfellevurdert) Published
    Abstract [en]

    Purpose: The aim of the study was to investigate 5-year survival stratified by mechanical ventilation modality in chronic obstructive pulmonary disease (COPD) patients treated in the ICU. Materials and Methods: Prospective, observational study of COPD patients with acute respiratory failure admitted to 9 multidisciplinary ICUs in Sweden. Characteristics on admission, including illness severity scores and the first blood gas, and survival were analyzed stratified by ventilation modality (noninvasive [NIV] vs invasive mechanical ventilation). Results: Ninety-three patients, mean age of 70.6 (SD, 9.6) years, were included. Sixteen patients were intubated immediately, whereas 77 were started on NIV. Patients who were started on NIV had a lower median body mass index (BMI) (21.9 vs 27.0; P andlt; .01) and were younger compared to those who were intubated immediately (median age, 70 vs 74.5 years; P andlt; .05). There were no differences in the initial blood gas results between the groups. Long-term survival was greater in patients with NIV (P andlt; .05, log rank). The effect of NIV on survival remained after including age, Acute Physiology and Chronic Health Evaluation II score, and BMI in a multivariate Cox regression model (NIV hazard ratio, 0.44; 95% confidence interval, 0.21-0.92). Fifteen patients with failed NIV were intubated and mechanically ventilated. Long-term survival in patients with failed NIV was not significantly different from patients who were intubated immediately. Conclusion: The short-term survival benefit of NIV previously found in randomized controlled trials still applies after 5 years of observation.

    sted, utgiver, år, opplag, sider
    Elsevier Science B. V., Amsterdam, 2010
    Emneord
    Intensive care, Mechanical ventilation, Noninvasive ventilation, Endotracheal intubation, Long-term outcome
    HSV kategori
    Identifikatorer
    urn:nbn:se:liu:diva-62148 (URN)10.1016/j.jcrc.2010.02.006 (DOI)000283719800028 ()
    Tilgjengelig fra: 2010-11-19 Laget: 2010-11-19 Sist oppdatert: 2013-11-11
    3. What determines immediate use of invasive ventilation in patients with COPD?
    Åpne denne publikasjonen i ny fane eller vindu >>What determines immediate use of invasive ventilation in patients with COPD?
    Vise andre…
    2013 (engelsk)Inngår i: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 57, nr 3, s. 312-319Artikkel i tidsskrift (Fagfellevurdert) Published
    Abstract [en]

    Background The choice between non-invasive ventilation (NIV) and invasive ventilation in patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may be irrational. The aim of this study was to examine those patient characteristics, and circumstances deemed important in the choice made between NIV and invasive ventilation in the intensive care unit (ICU). Methods We first examined 95 admissions of AECOPD patients on nine ICUs and identified variables associated with invasive ventilation. Thereafter, a questionnaire was sent to ICU personnel to study the relative importance of different factors with a possible influence on the decision to use invasive ventilation at once. Results Univariable analysis showed that increasing age [odds ratio (OR) 1.06 per year] and increasing body mass index (BMI) (OR 1.11 per kg/m2) were associated with immediate invasive ventilation, while there was no such association with arterial blood gases or breath rate. BMI was the only factor that remained associated with immediate invasive ventilation in the multivariable analysis [OR 1.12 (95% confidence interval 1.031.23) kg/m2]. Ranking of responses to the questionnaire showed that consciousness, respiratory symptoms and blood gases were powerful factors determining invasive ventilation, whereas high BMI and age were ranked low. Non-patient-related factors were also deemed important (physician in charge, presence of guidelines, ICU workload). Conclusion Factors other than those deemed most important in guidelines appear to have an inappropriate influence on the choice between NIV and immediate intubation in AECOPD in the ICU. These factors must be identified to further increase the appropriate use of NIV.

    sted, utgiver, år, opplag, sider
    Wiley-Blackwell, 2013
    HSV kategori
    Identifikatorer
    urn:nbn:se:liu:diva-89802 (URN)10.1111/aas.12049 (DOI)000314652400007 ()
    Merknad

    Funding Agencies|Health Research Council in the southeast of Sweden (FORSS)||

    Tilgjengelig fra: 2013-03-07 Laget: 2013-03-07 Sist oppdatert: 2017-12-06
    4. A prospective longitudinal multicentre study of health related quality of life in ICU survivors with COPD
    Åpne denne publikasjonen i ny fane eller vindu >>A prospective longitudinal multicentre study of health related quality of life in ICU survivors with COPD
    Vise andre…
    2013 (engelsk)Inngår i: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 17, nr 5, s. R211-Artikkel i tidsskrift (Fagfellevurdert) Published
    Abstract [en]

    INTRODUCTION: Mortality amongst COPD patients treated on the ICU is high. Health-related quality of life (HRQL) after intensive care is a relevant concern for COPD patients, their families and providers of health care. Still, there are few HRQL studies after intensive care of this patient group. Our hypothesis was that HRQL of COPD patients treated on the ICU declines rapidly with time.

    METHODS: Fifty-one COPD patients (COPD-ICU group) with an ICU stay longer than 24 hours received a questionnaire at 6, 12 and 24 months after discharge from ICU. HRQL was measured using two generic instruments: the EuroQoL instrument (EQ-5D and EQ-VAS) and the Short Form 36 Health Survey (SF-36). The results were compared to HRQL of two reference groups from the general population; an age- and sex-adjusted reference population (Non-COPD reference) and a reference group with COPD (COPD reference).

    RESULTS: HRQL of the COPD-ICU group at 6 months after discharge from ICU was lower compared to the COPD reference group: Median EQ-5D was 0.66 vs. 0.73, P=0.08 and median EQ-VAS was 50 vs.55, P<0.05. There were no significant differences in the SF-36 dimensions between the COPD-ICU and COPD-reference groups, although the difference in physical functioning (PF) approached statistical significance (P=0.059). Patients in the COPD-ICU group who were lost to follow-up after 6 months had low HRQL scores at 6 months. Scores for patients who died were generally lower compared to patients who failed to respond to the questionnaire. The PF and social functioning (SF) scores in those who died were significantly lower compared to patients with a complete follow up. HRQL of patients in the COPD-ICU group that survived a complete 24 months follow up was low but stable with no statistically significant decline from 6 to 24 months after ICU discharge. Their HRQL at 24 months was not significantly different from HRQL in the COPD reference group.

    CONCLUSIONS: HRQL in COPD survivors after intensive care was low but did not decline from 6 to 24 months after discharge from ICU. Furthermore, HRQL at 24 months was similar to patients with COPD who had not received ICU treatment.

    sted, utgiver, år, opplag, sider
    BioMed Central, 2013
    HSV kategori
    Identifikatorer
    urn:nbn:se:liu:diva-100737 (URN)10.1186/cc13019 (DOI)000331540900132 ()24063309 (PubMedID)
    Tilgjengelig fra: 2013-11-11 Laget: 2013-11-11 Sist oppdatert: 2017-12-06bibliografisk kontrollert
  • 2.
    Berkius, Johan
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Department of Anaesthesia and Intensive Care, Västervik County Hospital, Västervik, Sweden.
    Engerström, Lars
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Sinnescentrum, Anestesi- och intensivvårdskliniken VIN.
    Orwelius, Lotti
    Östergötlands Läns Landsting, Sinnescentrum, Anestesi- och intensivvårdskliniken US. Linköpings universitet, Institutionen för klinisk och experimentell medicin. Linköpings universitet, Hälsouniversitetet.
    Nordlund, Peter
    Department of Anaesthesia and Intensive Care, Ryhov Hospital, Jönköping,.
    Sjöberg, Folke
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Sinnescentrum, Hand- och plastikkirurgiska kliniken US. Östergötlands Läns Landsting, Sinnescentrum, Anestesi- och intensivvårdskliniken US.
    Fredrikson, Mats
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för inflammationsmedicin. Linköpings universitet, Hälsouniversitetet.
    Walther, Sten M
    Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland. Linköpings universitet, Institutionen för medicin och hälsa, Fysiologi. Linköpings universitet, Hälsouniversitetet.
    A prospective longitudinal multicentre study of health related quality of life in ICU survivors with COPD2013Inngår i: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 17, nr 5, s. R211-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    INTRODUCTION: Mortality amongst COPD patients treated on the ICU is high. Health-related quality of life (HRQL) after intensive care is a relevant concern for COPD patients, their families and providers of health care. Still, there are few HRQL studies after intensive care of this patient group. Our hypothesis was that HRQL of COPD patients treated on the ICU declines rapidly with time.

    METHODS: Fifty-one COPD patients (COPD-ICU group) with an ICU stay longer than 24 hours received a questionnaire at 6, 12 and 24 months after discharge from ICU. HRQL was measured using two generic instruments: the EuroQoL instrument (EQ-5D and EQ-VAS) and the Short Form 36 Health Survey (SF-36). The results were compared to HRQL of two reference groups from the general population; an age- and sex-adjusted reference population (Non-COPD reference) and a reference group with COPD (COPD reference).

    RESULTS: HRQL of the COPD-ICU group at 6 months after discharge from ICU was lower compared to the COPD reference group: Median EQ-5D was 0.66 vs. 0.73, P=0.08 and median EQ-VAS was 50 vs.55, P<0.05. There were no significant differences in the SF-36 dimensions between the COPD-ICU and COPD-reference groups, although the difference in physical functioning (PF) approached statistical significance (P=0.059). Patients in the COPD-ICU group who were lost to follow-up after 6 months had low HRQL scores at 6 months. Scores for patients who died were generally lower compared to patients who failed to respond to the questionnaire. The PF and social functioning (SF) scores in those who died were significantly lower compared to patients with a complete follow up. HRQL of patients in the COPD-ICU group that survived a complete 24 months follow up was low but stable with no statistically significant decline from 6 to 24 months after ICU discharge. Their HRQL at 24 months was not significantly different from HRQL in the COPD reference group.

    CONCLUSIONS: HRQL in COPD survivors after intensive care was low but did not decline from 6 to 24 months after discharge from ICU. Furthermore, HRQL at 24 months was similar to patients with COPD who had not received ICU treatment.

  • 3.
    Berkius, Johan
    et al.
    Västervik hospital.
    Mårdh, C
    Central Hospital, Kristianstad.
    Karlström, G
    Landstinget i Värmland.
    Walther, Sten
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och hälsa, Fysiologi. Östergötlands Läns Landsting, Hjärtcentrum, Thorax-kärlkliniken.
    Characteristics and long-term outcome of acute exacerbations in chronic obstructive pulmonary disease: An analysis of cases in the Swedish Intensive Care Registry during 2002-20062008Inngår i: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 52, nr 6, s. 759-765Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Chronic obstructive pulmonary disease (COPD) represents a major and growing health problem. The purpose of this work was to examine characteristics, resource use and long-term survival in patients with an acute exacerbation of COPD that were admitted to Swedish intensive care units (ICU). Methods: Patient characteristics at admission, length of stay (LOS), resource use and outcome were collected for admissions due to COPD during 2002-2006 in the database of the Swedish Intensive Care Registry. Vital status was secured for 99.6% of the patients. Kaplan-Meier survival estimates were computed for index admissions only. Results: We identified 1009 patients with 1199 admissions due to COPD (1.3% of all intensive care admissions). The mean (SD) age was 70.2 (9.1) years and the proportion of women were 61.5%. Mean (SD) Acute Physiology and Chronic Health Evaluation II probability of hospital death was 0.31 (0.19). Median LOS was 28 (interquartile range 52) h. The number of readmissions was 190 during the 5-year study. Older patients had fewer readmissions (OR 0.96, 95% CI: 0.95-0.98/year increase in age). ICU mortality was 7.3% (87 of 1199 admissions) and 30-day mortality was 26.0% (262 of 1009 index admissions). Median survival was 14.5 months and 31% of patients survived 3 years after the index admission. Conclusions: Short (30 days) and long-term survival is poor in acute COPD. Readmissions are frequent reflecting the severity of this chronic illness. Patients are less likely to be readmitted with increasing age which may be due to withholding of further intensive care. © 2008 The Authors.

  • 4.
    Berkius, Johan
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Kardiologi. Linköpings universitet, Hälsouniversitetet.
    Sundh, J
    Örebro University Hospital, Sweden .
    Nilholm, L
    Örebro University Hospital, Sweden .
    Fredrikson, Mats
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Yrkes- och miljömedicin. Linköpings universitet, Hälsouniversitetet.
    Walther, Sten
    Linköpings universitet, Institutionen för medicin och hälsa, Fysiologi. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    What determines immediate use of invasive ventilation in patients with COPD?2013Inngår i: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 57, nr 3, s. 312-319Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background The choice between non-invasive ventilation (NIV) and invasive ventilation in patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may be irrational. The aim of this study was to examine those patient characteristics, and circumstances deemed important in the choice made between NIV and invasive ventilation in the intensive care unit (ICU). Methods We first examined 95 admissions of AECOPD patients on nine ICUs and identified variables associated with invasive ventilation. Thereafter, a questionnaire was sent to ICU personnel to study the relative importance of different factors with a possible influence on the decision to use invasive ventilation at once. Results Univariable analysis showed that increasing age [odds ratio (OR) 1.06 per year] and increasing body mass index (BMI) (OR 1.11 per kg/m2) were associated with immediate invasive ventilation, while there was no such association with arterial blood gases or breath rate. BMI was the only factor that remained associated with immediate invasive ventilation in the multivariable analysis [OR 1.12 (95% confidence interval 1.031.23) kg/m2]. Ranking of responses to the questionnaire showed that consciousness, respiratory symptoms and blood gases were powerful factors determining invasive ventilation, whereas high BMI and age were ranked low. Non-patient-related factors were also deemed important (physician in charge, presence of guidelines, ICU workload). Conclusion Factors other than those deemed most important in guidelines appear to have an inappropriate influence on the choice between NIV and immediate intubation in AECOPD in the ICU. These factors must be identified to further increase the appropriate use of NIV.

  • 5.
    Berkius, Johan
    et al.
    Linköpings universitet, Institutionen för medicin och hälsa, Kardiologi. Linköpings universitet, Hälsouniversitetet.
    Sundh, Josefin
    Orebro University Hospital.
    Nilholm, Lennart
    Orebro University Hospital.
    Fredrikson, Mats
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Yrkes- och miljömedicin. Linköpings universitet, Hälsouniversitetet.
    Walther, Sten
    Linköpings universitet, Institutionen för medicin och hälsa, Fysiologi. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärtcentrum, Thorax-kärlkliniken.
    Long-term survival according to ventilation mode in acute respiratory failure secondary to chronic obstructive pulmonary disease: A multicenter, inception cohort study2010Inngår i: JOURNAL OF CRITICAL CARE, ISSN 0883-9441, Vol. 25, nr 3Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Purpose: The aim of the study was to investigate 5-year survival stratified by mechanical ventilation modality in chronic obstructive pulmonary disease (COPD) patients treated in the ICU. Materials and Methods: Prospective, observational study of COPD patients with acute respiratory failure admitted to 9 multidisciplinary ICUs in Sweden. Characteristics on admission, including illness severity scores and the first blood gas, and survival were analyzed stratified by ventilation modality (noninvasive [NIV] vs invasive mechanical ventilation). Results: Ninety-three patients, mean age of 70.6 (SD, 9.6) years, were included. Sixteen patients were intubated immediately, whereas 77 were started on NIV. Patients who were started on NIV had a lower median body mass index (BMI) (21.9 vs 27.0; P andlt; .01) and were younger compared to those who were intubated immediately (median age, 70 vs 74.5 years; P andlt; .05). There were no differences in the initial blood gas results between the groups. Long-term survival was greater in patients with NIV (P andlt; .05, log rank). The effect of NIV on survival remained after including age, Acute Physiology and Chronic Health Evaluation II score, and BMI in a multivariate Cox regression model (NIV hazard ratio, 0.44; 95% confidence interval, 0.21-0.92). Fifteen patients with failed NIV were intubated and mechanically ventilated. Long-term survival in patients with failed NIV was not significantly different from patients who were intubated immediately. Conclusion: The short-term survival benefit of NIV previously found in randomized controlled trials still applies after 5 years of observation.

  • 6.
    von Walter, J
    et al.
    Nyköping Hospital, Sweden.
    Berkius, Johan
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Västervik Hospital, Sweden.
    Wickerts, CJ
    Danderyd Hospital and Karolinska Institutet, Stockholm.
    Walther, Sten
    Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.
    Immediate intubation vs. intubation delayed by a non-invasive ventilation trial in COPD patients with acute respiratory failure: a nationwide observational cohort study of long term survival2013Inngår i: Intensive Care Medicine, Supplement 2, Volume 39, 2013Konferansepaper (Fagfellevurdert)
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