BackgroundReal-world data on hospitalised SARS-CoV-2-positive patients are important for post-pandemic preventive measures.ObjectivesThis study aims to explore 60-day mortality of immunocompromised patients hospitalised in later Omicron period, accounting for the relevance of COVID-19 for hospital care.MethodsA retrospective population-based cohort study in & Ouml;sterg & ouml;tland County, Sweden, included all adult patients with a positive SARS-CoV-2 PCR test within 3 weeks of hospital admission. Clinical data including functional level (combined assessment of frailty and performance status), and COVID-19's impact on hospital care were collected from medical records. An adjusted binary logistic regression model was applied for the main outcome of 60-day COVID-19-related mortality, with immunosuppression as the main exposure.Results1128 hospitalised SARS-CoV-2-positive patients were included in the analysis whereof 12.9% were immunocompromised. Hospital admission due to COVID-19 was significantly more common among immunocompromised than non-immunocompromised (71.9% vs 49.5%), and 60-day COVID-19 mortality was 10.5% and 8.0% (p = 0.41), respectively. The median age of patients hospitalised due to COVID-19 was 78 years, with most having low/very low functional levels and >= 3 comorbidities. Adjusted for possible confounders, immunosuppression showed a significantly increased risk of 60-day COVID-19-related mortality (OR 2.41, 95% CI 1.06-5.47, p = 0.04).ConclusionA majority of COVID-19-related hospitalisations during later Omicron period in a high immunity population, involved people over 70 years with low/very low functional levels and multiple comorbidities. Immunocompromised patients had a 2.5 times higher risk of 60-day COVID-19-related mortality. These findings underscore the need for targeted preventive measures in vulnerable elderly and immunocompromised populations to mitigate COVID-19-related hospitalisations and deaths.

ObjectiveTo investigate the experiences of healthcare staff in nursing homes during the COVID-19 pandemic.DesignIndividual interviews. Latent qualitative content analysis.SettingTen nursing homes in Sweden.SubjectsPhysicians, nurses and nurse assistants working in Swedish nursing homes.Main outcome measuresParticipants' experiences of working in nursing homes during the COVID-19 pandemic.ResultsFour manifest categories were found, namely: Balancing restrictions and allocation of scarce resources with care needs; Prioritizing and acting against moral values in advance care planning; Distrust in cooperation and Leadership and staff turnover - a factor for moral distress. The latent theme Experiences of handling ethical challenges caused by the COVID-19 pandemic gave a deeper meaning to the categories.ConclusionDuring the pandemic, nursing home staff encountered ethical challenges that caused moral distress. Moral distress stemmed from not being given adequate conditions to perform their work properly, and thus not being able to give the residents adequate care. Another aspect of moral distress originated from feeling forced to act against their moral values when a course of action was considered to cause discomfort or harm to a resident. Alerting employers and policymakers to the harm and inequality experienced by staff and the difficulty in delivering appropriate care is essential. Making proposals for improvements and developing guidelines together with staff to recognize their role and to develop better guidance for good care is vital in order to support and sustain the nursing home workforce. The COVID-19 pandemic has affected both patients and staff in nursing homes, in Sweden and worldwide.Our study highlights that during the COVID-19 pandemic, nursing home staff encountered several ethical challenges which caused moral distress.Moral distress stemmed from not being given adequate conditions to perform their work, thus not giving the residents appropriate care.Moral distress could also originate from nursing home staff's feeling of being forced to act against their moral values.

Background and aim: The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations. Methods: A narrative review was carried out. Results: When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs. Conclusions: Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.

Current studies indicate that robotic-assisted surgery is not inferior to laparoscopic or open surgery regarding oncologic or functional outcomes. An exception may be uterine cervix cancer, where the survival after minimal invasive surgery might not be as good as after open surgery. There is less bleeding and need for blood transfusion after robotic-assisted surgery, and postoperative complications are similar to open or laparoscopic surgery. Robotic-assisted surgery offers ergonomic advantages compared to laparoscopic surgery. The effect of the surgical learning curve is not sufficiently studied. Presently robotic-assisted surgery is not cost-effective due to high costs of investments. The operation is more time consuming than laparoscopic or open surgery with risks of delaying and cancellation of other operations.

Onkologiskt och funktionellt resultat vid robotassisterad kirurgi skiljer sig inte från laparoskopisk eller öppen kirurgi. Ett undantag kan vara sämre överlevnad vid cervixcancer.

Robotassisterad kirurgi är inte kostnadseffektiv i dagsläget på grund av investeringskostnaderna.

Robotassisterad kirurgi erbjuder ergonomiska fördelar och ger ingen ökning av postoperativa komplikationer. Operationstiderna är längre, men möjligen är blödning och transfusionsbehov mindre och vårdtiden kortare.

Inlärningseffekterna är ofullständigt undersökta.

Det finns etiska skäl att vara observant på undanträngningseffekter till följd av ökad användning av robotkirurgi.

Objectives Incident reporting (IR) systems have the potential to improve patient safety if they enable learningfrom the reported risks and incidents. The aim of this study was to investigate incidents registered in an IR system in a Swedish county council.

Methods The study was conducted in the County Council of Östergötland, Sweden. Data were retrieved from the IR system, which included 4755 incidents occurring in somatic care that resulted in patient injuries from 2004 to 2012. One hundred correctly classified patient injuries were randomly sampled from 3 injury severity levels: injuries leading to deaths, permanent harm, and temporary harm. Three aspects were analyzed: handling of the incident, causes of the incident, and actions taken to prevent its recurrence.

Results Of the 300 injuries, 79% were handled in the departments where they occurred. The department head decided what actions should be taken to prevent recurrence in response to 95% of the injuries. A total of 448 causes were identified for the injuries; problems associated with procedures, routines, and guidelines were most common. Decisions taken for 80% of the injuries could be classified using the IR system documentation and root cause analysis. The most commonly pursued type of action was change of work routine or guideline.

Conclusions The handling, causes, and actions taken to prevent recurrence were similar for injuries of different severity levels. Various forms of feedback (information, education, and dialogue) were an integral aspect of the IR system. However, this feedback was primarily intradepartmental and did not yield much organizational learning.

Granulocyte transfusions have been administered to patients with life-threatening infections for more than five decades. However, to what extent this should be the case is far from established. On the one hand, the clinical effects of these transfusions are difficult to prove in clinical studies, and the donors of granulocytes may be exposed to certain risks. On the other hand, clinical experience seems to support the idea that granulocyte transfusions do play an important role for severely ill patients, and the donors are primarily motivated by altruistic reasons. In this paper, we first discuss the ethical issues that arise from the fact that there is a conflict between clinical experience and the results from the attempts to perform randomized control trials, and second, the risk/benefit assessment that has to be made between two different parties, namely the recipient and the donor of granulocyte transfusions.

A retrospective review of medical records (2017-2018) at Linköping University Hospital compared hospital mortality for the 2-month period of summer vacations (group A) with two months of regular activity (group B). The mortality was 163 patients in group A and 216 in group B. Emergency admittance dominated (95%) in both groups. Comorbidity was found in 81%, and at admittance the risk for death during the hospital stay was estimated to more than 50% in three out of four patients. There was no difference between the groups regarding demography, hospital stay, or diagnosis. Due to a 30% reduction of hospital beds during the summer some patients were relocated to other specialties. No relocated patient died in group A but six in group B. Eight deaths were judged as probably preventable, but none definitely preventable. The similarity between the groups regarding mortality does not allow estimations of differences in adverse events in general. Low mortality among relocated patients is probably due to identification of high-risk patients not suitable for relocation.

Mortaliteten på Universitetssjukhuset i Linköping ökade inte under sommaren (1,5 procent) jämfört med under våren (1,6 procent).

Mer än 9 av 10 patienter lades in oplanerat. 

De flesta (75–77 procent) hade dåligt allmäntillstånd vid ankomsten.

Patienternas samsjuklighet var hög (81 procent) under såväl sommar som vår.

Ingen utlokaliserad patient avled under sommaren, däremot avled 6 patienter under våren.

Ingen av patienterna hade en uppenbart undvikbar dödsorsak. Däremot var dödsorsaken sannolikt undvikbar hos 8 patienter under både våren och sommaren.

The Swedish fast-track diagnostic pathway was applied during 2017 for 146 patients with serious non-specific symptoms including weight loss, fatigue and anemia. Within five days all patients had a physical examination and a decision was made of radiologic investigations. The waiting time was short for e.g. CT-scan of the abdomen and thorax. A diagnosis of a malignant condition was made in 38 patients (26%) with a median age of 75 (48-91) years. There were 24 men and 14 women. Most common diagnoses were lung cancer and colorectal cancer. Hematologic malignancy was diagnosed in 8 patients. Stage IV disease occurred in 17 of the patients with carcinoma (57%). About 60 benign main diagnoses were made in 108 patients without malignant disease. Two of them have developed cancer during 2018 (breast cancer, pancreatic cancer).

Av 146 patienter med allvarliga ospecifika symtom som kunde vara associerade med cancer diagnostiserades 38 (26 procent) med malign sjukdom.

Gruppen med diagnostiserad malignitet bestod av 24 män och 14 kvinnor. Medianåldern var 75 år (48–91 år).

Generaliserad tumörsjukdom förekom hos mer än hälften av cancerpatienterna.

Gruppen där malign sjukdom avskrevs bestod av 61 män och 47 kvinnor. Medianåldern var 70 år (23–93 år).

Där cancermisstanken kunde avskrivas förekom ett 60-tal diagnoser. De tre vanligaste diagnosgrupperna var gastrointestinal sjukdom, psykoneurotisk sjukdom och lungsjukdom.

En cancerutredning bör göras med utgångspunkt från patientens samtliga behov.

The TARGIT-A (TARGeted Intraoperative radioTherapy) multicentre study of early breast cancer compared intraoperative radiotherapy with external radiotherapy. While the intraoperative radiotherapy was standardised, the external postoperative comparison treatment followed established routines in the participating treatment centres resulting in substantial variations in dosages and treatment durations. The uncertainties in the interpretation of the study results created by the design of the TARGIT-A study constitute substantial obstacles to the possible introduction of intraoperative radiotherapy for early breast cancer.

Risk of optic nerve injury after prolonged Trendelenburgs position Postoperative loss of vision due to acute ischaemic optic nerve injury is a rare complication following pelvic surgery. A steep Trendelenburgs position of the patient, high intraabdominal pressure and a long operative time in Trendelenburgs position are recognised risk factors associated with robot-assisted pelvic surgery. This manuscript presents the underlying pathophysiologic mechanism. Practical tips and tricks for prevention are discussed.