Visby lasarett

The incidence of cutaneous squamous cell carcinoma is increasing rapidly, and 1.5-5% of cases develop metastatic disease, which is associated with a markedly worse prognosis. This study aimed to describe the characteristics of the primary tumour, the patients, and the metastases, as well as treatment and outcomes in patients with metastatic cutaneous squamous cell carcinoma. A total of 137 patients with a diagnosis of metastatic cutaneous squamous cell carcinoma within the Stockholm region during 2012-2020 were identified and included. Median age was 81; 79% were male; 70% had a WHO performance status of 0-1. 50% of the primary tumours were classified as high-risk tumours according to the Brigham and Women's Hospital system. The median time between diagnosis of the primary tumour and the diagnosis of regional metastases was 7 months and 90% of the metastases were diagnosed within 2 years. Most patients were treated with a combination of surgery and radiotherapy. Overall survival at 2 years was 56%. This study shows that metastatic cutaneous squamous cell carcinoma occurs in elderly but otherwise generally healthy patients, that primary tumours with a high risk of causing metastases seem hard to identify, and that metastases occur within 2 years after primary tumour diagnosis. The patient group overall has a high mortality rate, particularly among those who do not undergo surgery.

World Heritage cities face the complex challenges of balancing cultural heritage protection with the UN Sustainable Development Goals, particularly reducing greenhouse gas emissions and achieving energy sustainability. However, implementing these commitments at the local level often presents challenges. Using the walled city of Jaipur, a UNESCO World Heritage site in India, as a case study, this article examines the impacts, opportunities, and challenges in implementing and applying international and national obligations to preserve cultural heritage in light of obligations to reduce energy use and greenhouse gas emissions in historic urban areas. This article is based on legal research, as well as 9 semi-structured interviews, which include one group interview with three municipal representatives and individual interviews with one state representative, five heritage professionals and consultants, and two heritage property owners. The results show that World Heritage status has enhanced cultural heritage protection while allowing measures toward energy sustainability. Traditional architectural practices, such as the passive climate design of havelis, are already energy efficient, while interventions, such as the integration of solar panels and adaptive re-use of havelis, demonstrate compatibility between heritage conservation and sustainability goals. However, there continue to be challenges, including limited expertise, capacity, and financial resources, while governance inefficiencies, commercialization pressures, inadequate support for residents, and limited community engagement further hinder progress. The study recommends strengthening the governance framework and enforcement mechanisms, providing targeted financial and technological support, and fostering inclusive collaboration and education among these actors to align heritage conservation with energy sustainability at the local level.

Esophagectomy is associated with pulmonary complications. This study evaluated if thoracoscopic minimally invasive esophagectomy (MIE) mitigates these risks by comparing pulmonary findings on postoperative computed tomography (CT) between open esophagectomy and MIE. Postoperative (day 5) thoracic CT from 40 patients (20 open and 20 MIE) who had undergone esophagectomy with epidural analgesia and right-sided thoracic drainage were reviewed. On an axial view, the areas of atelectasis and pleural effusion were measured at 1 and 5 cm above the right diaphragmatic dome and at the level of the carina. In addition, the total distribution of atelectasis and pleural effusion was estimated on an ordinal scale (0-5), with ≥3 considered clinically important. The groups were well-matched in terms of age, sex, and smoking status. There were no differences in the areas of atelectasis or pleural effusion for open surgery compared with MIE. The groups did not differ in the proportion of patients with clinically important atelectasis (right: 30% vs. 25%, left: 65% vs. 65%) or pleural effusion (right: 15% vs. 15%, left: 65% vs. 45%). More pleural effusion and atelectasis at the 1-cm level was present on the left side at day 5 in both open and MIE patients. Despite major differences in surgical trauma and ventilation strategies between open and MIE, CT evaluation at day 5 was surprisingly similar. Less right-sided pleural effusion demonstrates the effect of surgical drains. We believe that the defined levels of measurement used in this study, performed at clear anatomical landmarks, can be of value in future studies.

In recent years, we have witnessed a rise in antifungal resistance, notably due to the emergence of Trichophyton indotineae, which is highly resistant to terbinafine. In Denmark, Trichophyton rubrum remains the most frequent causative agent. Antifungal susceptibility testing when resistance is suspected is critical for guiding treatment decisions. To prevent recalcitrant dermatophytosis from becoming endemic, it is essential to implement surveillance programs, screen close contacts, and restrict the use of topical antifungal agents.

This study explores co-generation as a key strategy for the advancement and consequent uptake of hydro-climate servicesfor decision-making within the drinking water supply sector, focusing on the SMHI Aqua service as a case study for Sweden. The co-generation process investigated here is based on a four-pillar structure (co-design, co-development, co-delivery and co-evaluation), and it involves engagement and collaborative efforts among three main actors: service purveyors, data providers and users. The case studies were carried out in different regions of Sweden, with mainparticipation from Region Gotland and three other Swedish water-related users (Nodra, Karlskrona Municipality and Metsä Board). SMHI Aqua hydro-climate service is the result of this collective undertaking and it integrates data assimilation, forecast production and a web-based decision support system.Addressing primarily the needs of drinking water producers and providers, freshwater availability was identified as the most descriptive indicator for supporting decisions for water management and drinking water supply. Two hydrological models were customized for the local conditions to simulate hydrological dynamics in surface and groundwater reservoirs. These models produce short- (up 10 days ahead) and long-range (up to 6 months ahead) forecasts which are updatedtwice a day, incorporating real-time hydro-meteorological measurements to update and initialize the model. Additionally, the service simulates various future freshwater availability scenarios by implementing different yearly water extraction strategies provided by the users. A user-friendly web-based platform displays the real-time (measured and modelled) and the future (forecasted) hydro-meteorological situation in the area of interest.Outcomes of this study highlight the significance of knowledge co-evolution in facilitating the successful uptake of hydro-climate services. Effective communication of hydro-meteorological information, including its propagated uncertainty, proves to be crucial for water managers to takeinformed decisions. Beyond benefiting water-related users, co-generated hydro-climate services contribute to broader impacts reaching policy makers and the wider public by ensuring freshwater access, and improving awareness and preparedness for extreme conditions. User feedback emphasizes the substantial improvement in operational routines for drinking water management consequent to the implementation of SMHI Aqua. The active engagement and close collaboration of stakeholders throughout co-generation has a pivotal role leading to the successful uptake of the service when taking short- and long-term decisions. Overall, the co-generated SMHI Aqua hydro-climate service stands as a proof to the efficacy of co-generation in achieving informed decision-making, sustainable water resource utilization, and improved resilience especially under extreme conditions.

IntroductionIn recent decades, centralization of health care has resulted in a number of obstetric unit closures. While studies support better infant outcomes in larger facilities, few have investigated maternal outcomes. We investigated obstetric unit closures over time and whether obstetric volume is associated with onset of labor, postpartum hemorrhage (PPH) and obstetric anal sphincter injury (OASIS).Material and MethodsAll births registered in Sweden between 1992 and 2019 (Medical Birth Register, N = 2 931 140), linked with data on sociodemographic characteristics and maternal/infant diagnoses, were used to describe obstetric unit closures. After excluding congenital malformations, obstetric volume was categorized (low: 0–1999, medium: 2000–3999, high: ≥4000 births per year). Restricting to 2004 onwards (after most closures), the association between volume and onset of labor (spontaneous as reference) was estimated. Restricting to spontaneous, full‐term (≥37 weeks gestation) cephalic births, we then investigated the association between volume and PPH and, after excluding planned cesarean sections, OASIS. Odds ratios from multilevel (logistic) models clustered by hospital were estimated.ResultsThe 20 dissolved obstetric units (1992–2019) had relatively stable volume until their closure. Compared to the average, women birthing in the highest volume hospitals were older (31.3 years vs. 30.4) and a higher proportion had >12 years of education (57 vs. 51%). Compared to high‐volume hospitals, there was no significant difference in labor starting by elective cesarean section or induction, rather than spontaneously, among low (OR 0.88, 95% CI: 0.73–1.06) and medium (OR 0.84, 95% CI 0.71–1.01) volume hospitals. There were lower odds of PPH among low (OR 0.72, 95% CI 0.63–0.85) and medium (OR 0.83, 95% CI 0.72–0.97) volume hospitals. No significant association was found between obstetric volume and OASIS (low: OR 0.98, 95% CI 0.82–1.18; medium: OR 0.90, 95% CI 0.77–1.05).ConclusionsThere was not a strong relationship between obstetric volume and maternal outcomes. Reduced odds of PPH for women birthing in smaller units may be due to triaging high‐risk pregnancies to larger hospitals. While there was no significant association between obstetric volume and onset of labor or OASIS, other important factors related to closures, such as workload and overcrowding, should be investigated.

BackgroundEarly and late readmissions after Transcatheter Aortic Valve Replacement (TAVR) are common and associated with worse outcome. A risk prediction model (TAVR-30) was recently developed using readily available clinical variables to identify patients at risk for hospital readmission within 30 days after TAVR. We performed an independent external validation of the TAVR-30 model. MethodsThe Swedish TAVR-registry, linked together with other mandatory national registries was used to identify all TAVR procedures, variables from the original model, hospitalizations and deaths between the years 2008 to 2021. ResultsA total of 8459 patients underwent TAVR, 7693 patients had complete data and were included in the analysis. Out of these, 928 patients experienced a readmission within 30 days. Using the estimates from the original model, a concordance (c)-index of 0.51, a calibration slope of 0.07 and intercept of −0.62 were obtained respectively, overall implying poor model performance. ConclusionsThis independent external validation indicates poor performance of the TAVR-30 model in a Swedish setting. Further research is needed to develop more reliable tools for predicting the risk of early hospital readmission after TAVR, as well as, for providing a deeper understanding of how to develop risk models that performs well in patients with multiple underlying comorbidities.

BackgroundBalanced transfusions, including platelets, are critical for bleeding patients to maintain hemostasis. Many rural hospitals have no or limited platelet inventory, with several hours of transport time from larger hospitals. This study aimed to evaluate the feasibility of using cryopreserved platelets that can be stored for years, in remote hospitals with no or limited platelet inventory.Material and methodsThree remote hospitals participated in a prospective study including adult bleeding patients where platelet transfusions were indicated. Cryopreserved platelets were prepared in a university hospital, concentrated in 10 ml, transported on dry ice, and stored at −80°C at the receiving hospital. At request, the concentrated platelet units were thawed and diluted in fresh frozen plasma. The indications, blood transfusion needs, and laboratory parameters pre- and post-transfusion, as well as logistics, such as time from request to transfusion and work efforts in preparing cryopreserved platelets, were evaluated.ResultsTwenty-three bleeding patients were included. Nine patients (39%) were treated for gastrointestinal bleeding, five (22%) for perioperative bleeding, and four (17%) for trauma bleeding. The transfusion needs were 4.9 ± 3.3 red blood cell units, 3.2 ± 2.3 plasma units, and 1.9 ± 2.2 platelet units, whereof cryopreserved were 1.5 ± 1.1 (mean ± SD). One patient had a mild allergic reaction. We could not show the difference in laboratory results between pre- and post-transfusion of the cryopreserved units in the bleeding patients. The mean time from the order of cryopreserved platelets to transfusion was 64 min, with a range from 25 to 180 min.ConclusionCryopreserved platelets in remote hospitals are logistically feasible in the treatment of bleeding. The ability to have platelets in stock reduces the time to platelet transfusion in bleeding patients where the alternative often is many hours delay. Clinical effectiveness and safety previously shown in other studies are supported in this small feasibility study.