Östersunds Hospital

BackgroundGrowing evidence supports long-acting injectable (LAI) buprenorphine in opioid use disorder treatment. Implementation is limited due to concerns about costs as well as potential reduction of support, which could increase strain on health care services. This real-life study follows clinical patients one year prospectively and one year retrospectively from switching from daily sublingual or peroral opioid agonist treatment (OAT) to LAI buprenorphine exploring how this impacts days of inpatient care and emergency room (ER) visits.MethodsFrom electronic medical records, from four Swedish OAT clinics, we identified all patients (n=128) who had switched from sublingual or peroral OAT, to LAI buprenorphine during the first two years of implementation (2019-2021 in three clinics, 2021–2023 in the fourth). In this within-subject mirror study, patients served as their own controls. The number of days of inpatient care and ER visits were extracted from the electronic medical records using a standard operating procedure. Quasi-Poisson models were used to compare health care utilization before and after starting LAI buprenorphine.ResultsAmong the 128 patients, 28 (22%) were female and mean age was 37.8 (SD 9.0) years. Days of inpatient care were reduced by half, dropping from an average of 9.0 to 4.5 days (incidence rate ratio [IRR]: 0.5, 95% CI 0.41–0.61, p<.001), with a health care cost reduction of SEK 45,081 (~USD 4,090) per patient. The decline in days of inpatient care was even steeper among the 85 patients who remained on LAI buprenorphine treatment at 12 months (IRR 0.26, 95% CI 0.20–0.34, p<.001), with a decrease in health care costs of SEK 73,210 (~USD 6,642) per patient. ER visits showed no significant change (IRR: 0.93, 95%CI 0.79 - 1.09). One-year treatment retention to LAI buprenorphine was high (67%). Most patients who discontinued LAI buprenorphine transitioned to other sublingual/peroral forms of OAT, resulting in an overall OAT continuation rate of 89%.ConclusionsImplementation of LAI buprenorphine in OAT clinical settings was associated with a significant reduction in inpatient care and substantially reduced health care costs. These results challenge common economic hesitations and support wider integration of LAI options in opioid use disorder treatment.Clinical trial numberNot applicable.

A case of massive overdose of sustained release bupropion tablets is described. The patient presented with GCS 3, tachycardic and in vasoplegic shock. ECHO and EKG were initially normal. The hemodynamic situation was stabilised with vasopressors, but 18 h after presentation the patient deteriorated with wide complex arrhythmias rapidly progressing to cardiac arrest. The patient was put on VA-ECMO after 35 minutes of CPR. Circulation could be stabilized and ECMO was discontinued after 36 h. The patient was extubated on day 6 and made a complete recovery on discharge two weeks after presentation. At 34h, with ongoing ECMO, 236 tablets (with visible print identifying them as bupropion) were evacuated from the patient's stomach by gastroscopy. The tablets were analysed by NMR (nuclear magnetic resonance) but no longer contained any active substance. Blood levels of bupropion and hydroxybupropion at 36h were 790 and 1300 µg/l. The case illustrates a worrying surge in serious bupropion poisonings as noted by the Swedish Poisons Information Centre during the last 5 years.

ABSTRACT To improve the wagon brake performance and to investigate the wheel skidding on the rail during braking, the comprehensive rail freight wagon models with consideration of braking are generated by using the Gensys software package, which includes the masses of a wagon carbody, two bolsters, four sideframes, eight axle boxes and eight wheelsets. The nonlinear characteristics of secondary and the primary suspensions are considered among the mass connections. The tangential wheel-rail contact creepages and creep forces are calculated by a modified FASIM method with consideration of decreasing changes after saturation points. The brake type of air-pressed friction shoe on wheel tread surface is taken into account and the reference brake force profiles are considered with the characteristics of increasing friction coefficient with wagon speed decreasing. The wagon rolling resistance is also considered by using the equations used in Australian rail industries. The wagon braking stopping distance at an operation speed and the wheel slipping and skidding during braking situations can be simulated, and the effect of wheel-rail surface conditions (dry, wet, low coefficient friction (LCF) modifier and grease), wagon loading distribution, etc., to the braking performance can be examined, and the discussions on the wagon braking operation are given.

IntroductionPrimary care placement for nursing and medical students is vital for developing the competence to accommodate the increasing number of patients with multimorbid and complex conditions. Prior studies have suggested that interaction quality in primary care placement empowers learning. However, research mapping interaction quality in primary care placements in municipal emergency care units is lacking. This study aimed to systematically map interaction quality for nursing and medical students in primary care placement in two municipal emergency care units.Materials and methodsThis study adopted a systematic descriptive observational design. Systematic observations (n = 201 cycles) of eight nursing students (n = 103 cycles) and six medical students (n = 98 cycles) were used to map interaction quality across six learning situations between March and May 2019. Observations were coded using the Classroom Assessment Scoring System-Secondary (CLASS-S). Data were analyzed using descriptive statistics and Spearman correlations.ResultsInteraction quality is described in three domains: (I) emotional support, (II) framework for learning, and (III) instructional support, and the overall measure, student engagement. The results indicated middle-quality interactions in the emotional and instructional support domains and high quality in the framework for learning domain and student engagement. Correlations exhibited similar patterns and ranged from non-significant to strong correlations.ConclusionThe interaction qualities indicated a generally positive and supportive learning environment contributing to nursing and medical students’ learning and active participation in work tasks related to their professional roles. Thus, this new form for primary care placement for nursing and medical students in the municipal emergency care units was found to be a positive learning arena. These results may enhance nursing and medical education programs in countries with similar health services and education. Health education, supervisors, peers, and others contributing to students’ learning should recognize which interaction qualities may affect learning and how to improve quality, thus affecting supervisors’ approach to training students. While the CLASS-S showed potential for mapping interaction qualities for nursing and medical students in primary care placement in municipal emergency care units, further studies are needed to validate the CLASS-S for use in clinical placement settings.

BackgroundExercise-induced laryngeal obstruction (EILO) is diagnosed by the continuous laryngoscopy during exercise (CLE) test. Whether or how much CLE test scores vary over time is unknown. This study aimed to compare CLE test scores in athletes over time, irrespective of respiratory symptoms and grade of laryngeal obstruction.MethodsNinety-eight athletes previously screened for EILO were invited for a follow-up CLE test irrespective of CLE scores and respiratory symptoms. Twenty-nine athletes aged 16–27 did a follow-up CLE test 3–23 months after the baseline test. Laryngeal obstruction at the glottic and supraglottic levels was graded by the observer during exercise, at baseline and follow-up, using a visual grade score (0–3 points).ResultsAt baseline, 11 (38%) of the 29 athletes had moderate laryngeal obstruction and received advice on breathing technique; among them, 8 (73%) reported exercise-induced dyspnea during the last 12 months. At follow-up, 8 (73%) of the athletes receiving advice on breathing technique had an unchanged supraglottic score. Three (17%) of the 18 athletes with no or mild laryngeal obstruction at baseline had moderate supraglottic obstruction at follow-up, and none of the 3 reported exercise-induced dyspnea.ConclusionsIn athletes with repeated testing, CLE scores remain mostly stable over 3–24 months even with advice on breathing technique to those with EILO. However, there is some intraindividual variability in CLE scores over time.Trial registrationISRCTN, ISRCTN60543467, 2020/08/23, retrospectively registered, ISRCTN – ISRCTN60543467: Investigating conditions causing breathlessness in athletes.

IntroductionThe study aimed to investigate in which way performance-based reimbursement (PBR) systems in Swedish healthcare services (1) subjectively impacted physicians’ work and patient care and (2) were associated with the occurrence of stress-induced exhaustion disorders among physicians.MethodThe study applied a mixed-method design. Data were collected from a representative sample of Swedish physicians. In the questionnaire, respondents were asked to answer an open-ended question regarding their reflections on PBR. The answers to the open-ended question were analysed using thematic analysis. Respondents were also asked to rate the impact of PBR on their work. The association between PBR and self-rated stress-induced exhaustion disease was analysed with logistic regressions. Stress-induced exhaustion disorder was measured using the Burnout Assessment Scale.ResultsThematic analysis resulted in four themes: (1) Money talks, (2) Patients are affected, (3) Medical morals are challenged, and (4) PBR increase the quantity of illegitimate tasks. Logistic regressions showed that physicians who experienced PBR had an impact on their work and had a two-fold higher risk of stress-induced exhaustion disorder.DiscussionOur findings suggest that current reimbursement systems in Sweden play an essential role in Swedish healthcare and negatively influence physicians’ work and health. Also, current PBR impact patients negatively. No previous study has explored the potentially harmful impact of PBR on how physicians perceive work, health and patient care. Results indicate that policymakers should be encouraged to deeply review PBR systems and focus on ways that they can limit the negative impact on physicians’ work and health while meeting future challenges.

BackgroundOur previous study showed that rheumatoid arthritis (RA) was associated with higher one-year mortality after first acute myocardial infarction (AMI). Studies have shown increased mortality already within 30 days after cardiovascular events (AMI or stroke) in RA patients compared to non-RA patients.ObjectivesWe aimed to study if antirheumatic medical treatment affected survival within 30 days after a first AMI in patients with RA versus non-RA patients.MethodsData for 198944 patients with a first AMI were drawn from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions for 2006-2017. We used the National Patient Register to identify RA patients with AMI. RA was defined as ≥2 visits to a Rheumatology or Internal Medicine department with a diagnosis of RA, 3725 patients were diagnosed. Antirheumatic medical treatment prescribed during six months prior to the first AMI in RA and non-RA patients was obtained from the National Prescribed Drug Register. The drugs and all their combinations were divided into five groups: Corticosteroids, NSAID (Non-steroidal anti-inflammatory drug), csDMARD (conventional syntethic Disease-modifying antirheumatic drug), anti-TNF (anti Tumor Necrosis Factor), bDMARD (biological Disease-modifying antirheumatic drug). Logistic regression analysis was used to identify variables associated with increased mortality within 30 days after first AMI in each treatment group.ResultsIncreased risk of death was found in the corticosteroid group in both non-RA and RA groups (OR 1.61 and 1.66). Treatment with csDMARD and anti-TNF in the RA group were associated with increased survival (OR 0.81 and 0.72), Table 1.ConclusionWe showed that patients treated with corticosteroids had an increased risk of death after first AMI. RA patients treated with csDMARD and anti-TNF had an increased survival which could imply that high inflammatory activity in RA patients may be part of the explanation of the increased mortality after first AMI.

Background Return-to-work (RTW) resources for persons with mental health disorders are limited and costs are typically shared by several stakeholders in society. Occupational therapists (OT) provide RTW interventions for this target group, however, increased knowledge of health, and employment effects, as well as costs are needed to better inform decision makers in their prioritisations. Aims/objectives To identify and summarise evidence of cost-effectiveness of RTW interventions for persons with mental health disorders which OTs provide. Materials and methods A systematic search was applied and resulted in 358 articles. After screening, nine articles met inclusion criteria and were reviewed. Quality assessment was conducted using the economic evaluation tool by Joanna Briggs Institute. Results Supported employment, Individual Placement and Support was cost-effective in several contexts while three studies showed larger effects and higher costs. An OT intervention added to treatment for major depression was indicated to be cost-beneficial and an advanced supported employment was cost-saving. The methodological quality varied considerably between studies. Conclusions and significance The results of the included studies are promising, however, to further strengthen the economic perspective in OT RTW interventions, the need for conducting more and methodologically robust economic evaluations is crucial in future studies.