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  • 51. E., Hedberg-Borenstein
    et al.
    Peter, Borenstein
    Göteborgs universitet.
    A., Lundgren
    I., Vidal
    The importance of disconnection and diaschisis in aphasia - A case study1992In: Scandinavian Journal of Rehabilitation Medicine, Supplement, ISSN 0346-8720, no 26, p. 81-82Article in journal (Refereed)
  • 52.
    Efraimsson, Eva
    University of Borås, School of Health Science.
    Vårdplaneringsmötet som institutionellt samtal2007Conference paper (Other academic)
  • 53. Efraimsson, Eva
    Äldreomsorgens grindvakter2007Conference paper (Other academic)
  • 54.
    Elfwén, Ludvig
    et al.
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute.
    Lagedal, Rickard
    Department of Surgical Sciences/Anesthesiology and Intensive Care Medicine, Uppsala University.
    James, Stefan
    Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology.
    Jonsson, Martin
    Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna.
    Jensen, Ulf
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute.
    Ringh, Mattias
    Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna.
    Claesson, Andreas
    Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna.
    Oldgren, Jonas
    Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Rubertsson, Sten
    Department of Surgical Sciences/Anesthesiology and Intensive Care Medicine, Uppsala University.
    Nordberg, Per
    Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna.
    Coronary angiography in out-of-hospital cardiac arrest without ST elevation on ECG-Short- and long-term survival.2018In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 200, p. 90-95, article id S0002-8703(18)30081-4Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The potential benefit of early coronary angiography in out-of-hospital cardiac arrest (OHCA) patients without ST elevation on ECG is unclear. The aim of this study was to evaluate the association between early coronary angiography and survival in these patients.

    METHODS: Nationwide observational study between 2008 and 2013. Included were patients admitted to hospital after witnessed OHCA, with shockable rhythm, age 18 to 80 years and unconscious. Patients with ST-elevation on ECG were excluded. Patients that underwent early CAG (within 24 hours) were compared with no early CAG (later during the hospital stay or not at all). Outcomes were survival at 30 days, 1 year, and 3 years. Multivariate analysis included pre-hospital factors, comorbidity and ECG-findings.

    RESULTS: In total, 799 OHCA patients fulfilled the inclusion criteria, of which 275 (34%) received early CAG versus 524 (66%) with no early CAG. In the early CAG group, the proportion of patients with an occluded coronary artery was 27% and 70% had at least one significant coronary stenosis (defined as narrowing of coronary lumen diameter of ≥50%). The 30-day survival rate was 65% in early CAG group versus 52% with no early CAG (P < .001). The adjusted OR was 1.42 (95% CI 1.00-2.02). The one-year survival rate was 62% in the early CAG group versus 48% in the no early CAG group with the adjusted hazard ratio of 1.35 (95% CI 1.04-1.77).

    CONCLUSION: In this population of bystander-witnessed cases of out-of-hospital cardiac arrest with shockable rhythm and ECG without ST elevation, early coronary angiography may be associated with improved short and long term survival.

  • 55. Engdahl, J
    et al.
    Abrahamsson, P
    Bång, A
    [external].
    Lindqvist, J
    Karlsson, T
    Herlitz, Johan
    [external].
    Is hospital care of major importance for outcome after out-of-hospital cardiac arrest? Experience acquired from patients with out-of-hospital cardiac arrest resuscitated by the same Emergency Medical Service and admitted to one of two hospitals over a 16-year period in the municipality of Göteborg2000In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 43, no 3, p. 201-211Article in journal (Refereed)
    Abstract [en]

    AIM: To describe patient characteristics, hospital investigations and interventions and early mortality among patients being hospitalized after out-of-hospital cardiac arrest in two hospitals. SETTING: Municipality of Göteborg, Sweden. PATIENTS: All patients suffering an out-of-hospital cardiac arrest who were successfully resuscitated and admitted to hospital between 1 October 1980 and 31 December 1996. All patients were resuscitated by the same Emergency Medical Service and admitted alive to one of the two city hospitals in Göteborg. RESULTS: Of 579 patients admitted to Sahlgrenska Hospital, 253 (44%) were discharged alive and of 459 patients admitted to Ostra Hospital, 152 (33%) were discharged alive (P < 0.001). More patients in Sahlgrenska Hospital were still receiving cardiopulmonary resuscitation (CPR) treatment (P = 0.03), but patients in Ostra had a lower systolic blood pressure and higher heart rate on admission. A larger percentage of patients admitted to Sahlgrenska Hospital underwent coronary angiography (P < 0.001), electrophysiological testing (P < 0.001), Holter recording (P < 0.001), echocardiography (P = 0.004), percutaneous transluminal coronary angioplasty (PTCA, P = 0.009), implantation of automatic implantable cardioverter defibrillator (AICD, P = 0.03) and exercise stress tests (P = 0.003). Inhabitants in the catchment area of Ostra Hospital had a less favourable socio-economic profile. CONCLUSION: Survival after out-of-hospital cardiac arrest may be affected by the course of hospital management. Other variables that might influence survival are socio-economic factors and cardiorespiratory status on admission to hospital. Further investigation is called for as more patients are being hospitalised alive after out-of-hospital cardiac arrest.

  • 56. Erhardt, L
    et al.
    Herlitz, Johan
    [external].
    Näslund, U
    Persson, S
    Allt mer komplicerad kombinationsterapi för att angripa ischemisk hjärtsjukdom1989In: Drugs, ISSN 0012-6667, E-ISSN 1179-1950, Vol. 86, no 52, p. 495-497Article in journal (Refereed)
  • 57. Everts, B
    et al.
    Karlson, BW
    Währborg, P
    Abdon, N-J
    Herlitz, Johan
    [external].
    Hedner, T
    Pain recollection after chest pain of cardiac origin1999In: Cardiology, ISSN 0008-6312, E-ISSN 1421-9751, Vol. 92, no 2, p. 115-120Article in journal (Refereed)
    Abstract [en]

    Memory for pain is an important research and clinical issue since patients ability to accurately recall pain plays a prominent role in medical practice. The purpose of this prospective study was to find out if patients, with an episode of chest pain due to suspected acute myocardial infarction could accurately retrieve the pain initially experienced at home and during the first day of hospitalization after 6 months. A total of 177 patients were included in this analysis. The patients rated their experience of pain on a numerical rating scale. The maximal pain at home was retrospectively assessed, thereafter pain assessments were made at several points of time after admission. After 6 months they were asked to recall the intensity of pain and once again rate it on the numerical rating scale. The results from the initial and 6-month registrations were compared. In general, patients rated their maximal intensity of chest pain as being higher at the 6-month recollection as compared with the assessments made during the initial hospitalization. In particular, in patients with a high level of emotional distress, there was a systematic overestimation of the pain intensity at recall.

  • 58. Fredriksson, M
    et al.
    Aune, S
    Bång, A
    University of Borås, School of Health Science.
    Thorén, A-B
    Lindqvist, J
    Karlsson, T
    Herlitz, Johan
    University of Borås, School of Health Science.
    Cardiac arrest outside and inside hospital in a community: mechanisms behind the differences in outcome and outcome in relation to time of arrest.2010In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 159, no 5, p. 749-756Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim was to compare characteristics and outcome after cardiac arrest where cardiopulmonary resuscitation was attempted outside and inside hospital over 12 years. METHODS: All out-of-hospital cardiac arrests (OHCAs) in Göteborg between 1994 and 2006 and all in-hospital cardiac arrests (IHCAs) in 1 of the city's 2 hospitals for whom the rescue team was called between 1994 and 2006 were included in the survey. RESULTS: The study included 2,984 cases of OHCA and 1,478 cases of IHCA. Patients with OHCA differed from those with an IHCA; they were younger, included fewer women, were less frequently found in ventricular fibrillation, and were treated later. If patients were found in a shockable rhythm, survival to 1 month/discharge was 18% after OHCA and 61% after IHCA (P < .0001). Corresponding values for a nonshockable rhythm were 3% and 21% (P < .0001). Survival was higher on daytime and weekdays as compared with nighttime and weekends after IHCA but not after OHCA. Among patients found in a shockable rhythm, a multivariate analysis considering age, gender, witnessed status, delay to defibrillation, time of day, day of week, and location showed that IHCA was associated with increased survival compared with OHCA (adjusted odds ratio 3.18, 95% CI 2.07-4.88). CONCLUSION: Compared with OHCA, the survival of patients with IHCA increased 3-fold for shockable rhythm and 7-fold for nonshockable rhythm in our practice setting. If patients were found in a shockable rhythm, the higher survival after IHCA was only partly explained by a shorter treatment delay. The time and day of CA were associated with survival in IHCA but not OHCA.

  • 59. Frisk, Matilda
    et al.
    Börjesson, Mats
    Herlitz, Johan
    Strömsöe, Anneli
    Outcome of exercise related Out of Hospital Cardiac Arrest in correlation with localisation: Sports Arena vs Outside Arena2018Conference paper (Refereed)
  • 60.
    Frisk Torell, Matilda
    et al.
    Institution of Neuroscience and physiology, Gothenburg University.
    Strömsöe, Anneli
    County Council of Dalarna, Dalarna University.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Claesson, Andreas
    Center of Resuscitation and Science, Karolinska Institute.
    Svensson, Leif
    Center of Resuscitation and Science, Karolinska Institute.
    Börjesson, Mats
    Institution of Neuroscience and physiology, Institution of Nutrition and Sport Science, University of Gothenburg, Sahlgrenska University Hospital/Östra.
    Outcome of exercise-related out-of-hospital cardiac arrest is dependent on location: Sports arenas vs outside of arenas.2019In: PLoS ONE, E-ISSN 1932-6203, Vol. 14, no 2, article id e0211723Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The chance of surviving an out-of-hospital cardiac arrest (OHCA) seems to be increased if the cardiac arrests occurs in relation to exercise. Hypothetically, an exercise-related OHCA at a sports arena would have an even better prognosis, because of an increased likelihood of bystander cardiopulmonary resuscitation (CPR) and higher availability of automated external defibrillators (AEDs). The purpose of the study was to compare survival rates between exercise-related OHCA at sports arenas versus outside of sports arenas.

    METHODS: Data from all treated exercise-related OHCA outside home reported to the Swedish Register of Cardiopulmonary Resuscitation (SRCR) from 2011 to 2014 in 10 counties of Sweden was analyzed (population 6 million). The registry has in those counties a coverage of almost 100% of all OHCAs.

    RESULTS: 3714 cases of OHCA outside of home were found. Amongst them, 268(7%) were exercise-related and 164 (61.2%) of those occurred at sports arenas. The 30-day survival rate was higher for exercise-related OHCA at sports arenas compared to outside (55.7% vs 30.0%, p<0.0001). OHCA-victims at sports arenas were younger (mean age±SD 57.6±16.3 years compared to 60.9±17.0 years, p = 0.05), less likely female (4.3% vs 12.2%, p = 0.02) and had a higher frequency of shockable rhythm (73.0% vs 54.3%, p = 0.004). OHCAs at arenas were more often witnessed (83.9% vs 68.9%, p = 0.007), received bystander CPR to a higher extent (90.0% vs 56.8%, p<0.0001) and the AED-use before EMS-arrival was also higher in this group (29.8% vs 11.1%, p = 0.009).

    CONCLUSION: The prognosis is markedly better for exercise-related OHCA occurring at sports arenas compared to outside. Victims of exercise-related OHCA at sports arenas are more likely to receive bystander CPR and to be connected to a public AED. These findings support an increased use of public AEDs and implementation of Medical Action Plans (MAP), to possibly increase survival of exercise-related OHCA even further.

  • 61. Gellerstedt, Martin
    et al.
    Rawshani, Nina
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Bång, Angela
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Gelang, Carita
    Andersson, Jan-Otto
    Larsson, Anna
    Rawshani, Araz
    Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain.2016In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 220, p. 734-738Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.

    METHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.

    RESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.

    CONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.

  • 62. Glantz, H
    et al.
    Thunström, E
    Herlitz, J
    University of Borås, School of Health Science.
    Cederin, B
    Nasic, S
    Ejdebäck, J
    Peker, Y
    Occurrence and predictors of obstructive sleep apnea in a revascularized coronary artery disease cohort2013In: Annals of the American Thoracic Society, ISSN 2329-6933, E-ISSN 2325-6621, Vol. 10, no 4, p. 350-356Article in journal (Refereed)
    Abstract [en]

    Background: Knowledge about the prevalence of obstructive sleep apnea (OSA) in coronary artery disease (CAD) is insufficient. The aim of the current report was to evaluate the occurrence and predictors of OSA among revascularized patients with CAD within the framework of a randomized controlled trial (Randomized Intervention with CPAP in Coronary Artery Disease and Sleep Apnea [RICCADSA]), evaluating the impact of continuous positive airway pressure on cardiovascular outcomes in CAD patients with OSA. Material and Methods: All patients undergoing percutaneous coronary intervention or coronary artery bypass grafting between September 2005 and November 2010 (n = 1,291) were invited to participate. Anthropometrics and medical history were obtained, ambulatory sleep recording was performed, and all subjects completed the Epworth Sleepiness Scale (ESS) questionnaire. Results: In total, 662 patients participated in the sleep study. OSA, defined as an apnea–hypopnea index equal to or greater than 15/hour, was found among 422 (63.7%). The prevalence of hypertension was 55.9%; obesity (body mass index ≥ 30 kg/m2), 25.2%; diabetes mellitus, 22.1%; and current smoking, 18.9%. The patients with CAD who did not participate in the study demonstrated an almost similar anthropometric and clinical profile compared with the studied group. The majority (61.8%) of the patients with OSA were nonsleepy (ESS score < 10). Patients with OSA had a higher prevalence of obesity, hypertension, diabetes mellitus, and history of atrial fibrillation, whereas current smoking was more common in the non-OSA group. Age, male sex, body mass index, and ESS score, but not comorbidities, were independent predictors of OSA. Conclusions: The occurrence of unrecognized OSA in this revascularized CAD cohort was higher than previously reported. We suggest that OSA should be considered in the secondary prevention protocols in CAD. Read More: http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201211-106OC?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed&

  • 63.
    Glantz, Helena
    et al.
    Skaraborg Hospital, Lidköping.
    Johansson, Magnus C
    Sahlgrenska Academy, University of Gothenburg.
    Thunström, Erik
    Sahlgrenska Academy, University of Gothenburg.
    Guron, Cecilia Wallentin
    Sahlgrenska Academy, University of Gothenburg.
    Uzel, Harun
    Sahlgrenska University Hospital.
    Saygin, Mustafa
    Süleyman Demirel University, Isparta, Turkey.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Peker, Yüksel
    Sahlgrenska Academy, University of Gothenburg.
    Effect of CPAP on diastolic function in coronary artery disease patients with nonsleepy obstructive sleep apnea: A randomized controlled trial.2017In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 241, p. 12-18, article id S0167-5273(16)34469-2Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Obstructive sleep apnea (OSA) has been associated with worse diastolic function in patients with coronary artery disease (CAD). This analysis determined whether continuous positive airway pressure (CPAP) treatment would improve diastolic function in CAD patients with nonsleepy OSA.

    METHODS: Between December 2005 and November 2010, 244 revascularized CAD patients with nonsleepy OSA (apnea-hypopnea index (AHI) ≥15/h, Epworth Sleepiness Scale [ESS] score<10) were randomly assigned to CPAP or no-CPAP. Echocardiographic measurements were obtained at baseline, and after 3 and 12months.

    RESULTS: A total of 171 patients with preserved left ventricular ejection fraction (≥50%), no atrial fibrillation or severe valve abnormalities, and technically adequate echocardiograms at baseline and follow-up visits were included (CPAP, n=87; no-CPAP, n=84). In the intention-to-treat analysis, CPAP had no significant effect on echocardiographic parameters of mild (enlarged left atrium or decreased diastolic relaxation velocity) or worse (increased E/é filling index [presumed elevated left ventricular filling pressure]) diastolic function. Post-hoc analysis revealed a significant association between CPAP usage for ≥4h/night and an increase in diastolic relaxation velocity at 12months' follow-up (odds ratio 2.3, 95% confidence interval 1.0-4.9; p=0.039) after adjustment for age, sex, body mass index, and left atrium diameter at baseline.

    CONCLUSIONS: CPAP did not improve diastolic dysfunction in CAD patients with nonsleepy OSA. However, good CPAP adherence was significantly associated with an increase in diastolic relaxation velocity after one year.

  • 64. Graves, JR
    et al.
    Herlitz, Johan
    [external].
    Bång, A
    [external].
    Axelsson, Å
    Ekström, L
    Holmberg, M
    Holmberg, S
    Lindqvist, J
    Sunnerhagen, K
    Survivors of out-of-hospital cardiac arrest. Their prognosis, longevity, and functional status1997In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 35, no 2, p. 117-121Article in journal (Refereed)
    Abstract [en]

    This paper reports, consistent with Utstein Style definitions, 13 years experience observing out-of-hospital cardiac arrest survivors' prognosis, longevity and functional status. We report for all patients, available outcome information for out-of-hospital cardiac arrest survivors in Göteborg Sweden between 1980 and 1993. Patients were followed for at least 1 year and some for over 14 years. From 1980 to 1993 Göteborg EMS treated 3754 out-of-hospital cardiac arrests. 9% (n = 324) were discharged from the hospital alive. Survivors' median age was 67 and 21% (n = 67) were women. Mortality rate was: 21% (n = 61) at 1 year; 56% (n = 78) by 5 years; and 82% (n = 32) by 10 years following the arrest. During the first 3 years, 16% (n = 46) experienced another cardiac arrest, 19% (n = 53) had an acute myocardial infraction and a total of 81% (n = 232) were rehospitalized for various conditions. 14% (n = 40) returned to previous employment, and 74% (n = 229) had retired before their arrest occurred. Cerebral performance categories (CPC) scores were: At hospital discharge N = 324; Data available for 320-1 = 53% (n = 171), 2 = 21% (n = 66), 3 = 24% (n = 77), 4 = 2% (n = 6). One year post arrest N = 263; Data available for 212-1 = 73% (n = 156), 2 = 9% (n = 18), 3 = 17% (n = 36), 4 = 1% (n = 2). Overall, 21% (n = 61) of cardiac arrest survivors died during the first year, and an additional 16% (n = 46) experienced another arrest. 73% of those patients who were still alive after 1 year returned to pre-arrest function.

  • 65. Gräsner, Jan-Thorsten
    et al.
    Lefering, Rolf
    Koster, Rudolph W
    Masterson, Siobhán
    Böttiger, Bernd W
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Wnent, Jan
    Tjelmeland, Ingvild B M
    Ortiz, Fernando Rosell
    Maurer, Holger
    Baubin, Michael
    Mols, Pierre
    Hadžibegović, Irzal
    Ioannides, Marios
    Škulec, Roman
    Wissenberg, Mads
    Salo, Ari
    Hubert, Hervé
    Nikolaou, Nikolaos I
    Lóczi, Gerda
    Svavarsdóttir, Hildigunnur
    Semeraro, Federico
    Wright, Peter J
    Clarens, Carlo
    Pijls, Ruud
    Cebula, Grzegorz
    Correia, Vitor Gouveia
    Cimpoesu, Diana
    Raffay, Violetta
    Trenkler, Stefan
    Markota, Andrej
    Strömsöe, Anneli
    Burkart, Roman
    Perkins, Gavin D
    Bossaert, Leo L
    EuReCa ONE-27 Nations, ONE Europe, ONE Registry: A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe.2016In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 105, p. 188-195Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: The aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe.

    METHODS: This was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries.

    RESULTS: Data on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge.

    CONCLUSION: The results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe. EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events.

  • 66. Gustafsson, I
    et al.
    Malmberg, K
    Rydén, L
    Wedel, H
    Birkeland, K
    Bootsma, M
    Dickstein, K
    Efendic, S
    Fisher, M
    Hamsten, A
    Herlitz, Johan
    [external].
    Hildebrandt, PR
    MacLeod, K
    Laakso, M
    Torp-Pedersen, CT
    Waldentrom, A
    Metabolic control by means of insulin in patients with type 2 diabetes and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity--secondary publication2006In: Ugeskrift for læger, ISSN 0041-5782, E-ISSN 1603-6824, Vol. 168, no 6, p. 581-584Article in journal (Refereed)
    Abstract [en]

    Patients with diabetes have an unfavourable prognosis after an acute myocardial infarction. The DIGAMI 2 study investigated the effect of various metabolic treatment strategies in type 2 diabetic patients with acute myocardial infarction: acutely introduced, long-term insulin treatment did not improve survival when compared with conventional management at similar levels of glucose control. However, good glucose control seems important since the glucose level was found to be a strong predictor of long-term mortality in this patient category.

  • 67.
    Hagiwara Andersson, Magnus
    et al.
    University of Borås, School of Health Science.
    Lundberg, Lars
    University of Borås, School of Health Science.
    Suserud, Björn-Ove
    University of Borås, School of Health Science.
    Henricson, Maria
    Sjökvist, Bengt-Arne
    Jonsson, Anders
    University of Borås, School of Health Science.
    Decision support system in prehospital care: a randomized controlled simulation study2013In: American Journal of Emergency Medicine, ISSN 0735-6757, E-ISSN 1532-8171, Vol. 31, no 1, p. 143-153Article in journal (Refereed)
    Abstract [en]

    Introduction Prehospital emergency medicine is a challenging discipline characterized by a high level of acuity, a lack of clinical information and a wide range of clinical conditions. These factors contribute to the fact that prehospital emergency medicine is a high-risk discipline in terms of medical errors. Prehospital use of Computerized Decision Support System (CDSS) may be a way to increase patient safety but very few studies evaluate the effect in prehospital care. The aim of the present study is to evaluate a CDSS. Methods In this non-blind block randomized, controlled trial, 60 ambulance nurses participated, randomized into 2 groups. To compensate for an expected learning effect the groups was further divided in two groups, one started with case A and the other group started with case B. The intervention group had access to and treated the two simulated patient cases with the aid of a CDSS. The control group treated the same cases with the aid of a regional guideline in paper format. The performance that was measured was compliance with regional prehospital guidelines and On Scene Time (OST). Results There was no significant difference in the two group's characteristics. The intervention group had a higher compliance in the both cases, 80% vs. 60% (p < 0.001) but the control group was complete the cases in the half of the time compare to the intervention group (p < 0.001). Conclusion The results indicate that this CDSS increases the ambulance nurses' compliance with regional prehospital guidelines but at the expense of an increase in OST.

  • 68.
    Hagiwara, M
    et al.
    University of Borås, School of Health Science.
    Bremer, A
    University of Borås, School of Health Science.
    Claesson, A
    University of Borås, School of Health Science.
    Axelsson, C
    University of Borås, School of Health Science.
    Norberg, Gabriella
    University of Borås, School of Health Science.
    Herlitz, J
    University of Borås, School of Health Science.
    The impact of direct admission to a catheterisation lab/CCU in patients with ST-elevation myocardial infarction on the delay to reperfusion and early risk of death: results of a systematic review including meta-analysis2014In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 22, no 67Article in journal (Refereed)
    Abstract [en]

    Background For each hour of delay from fist medical contact until reperfusion in ST-elevation myocardial infarction (STEMI) there is a 10% increase in risk of death and heart failure. The aim of this review is to describe the impact of the direct admission of patients with STEMI to a Catheterisation laboratory (cath lab) as compared with transport to the emergency department (ED) with regard to delays and outcome. Methods Databases were searched for from April-June 2012 and updated January 2014: 1) Pubmed; 2) Embase; 3) Cochrane Library; 4) ProQuest Nursing and 5) Allied Health Sources. The search was restricted to studies in English, Swedish, Danish and Norwegian languages. The intervention was a protocol-based clinical pre-hospital pathway and main outcome measurements were the delay to balloon inflation and hospital mortality. Results Median delay from door to balloon was significantly shorter in the intervention group in all 5 studies reported. Difference in median delay varied between 16 minutes and 47 minutes. In all 7 included studies the time from symptom onset or first medical contact to balloon time was significantly shorter in the intervention group. The difference in median delay varied between 15 minutes and 1 hour and 35 minutes. Only two studies described hospital mortality. When combined the risk of death was reduced by 37%. Conclusion An overview of available studies of the impact of a protocol-based pre-hospital clinical pathway with direct admission to a cath lab as compared with the standard transport to the ED in ST-elevation AMI suggests the following. The delay to the start of revascularisation will be reduced. The clinical benefit is not clearly evidence based. However, the documented association between system delay and outcome defends the use of the pathway.

  • 69.
    Hagiwara, Magnus
    University of Borås, School of Health Science.
    Development and evaluation of a computerised decision support system for use in pre-hospital care2014Doctoral thesis, monograph (Other academic)
    Abstract [en]

    The aim of the thesis was to develop and evaluate a Computerised Decision Support System (CDSS) for use in pre-hospital care. The thesis was guided by a theoretical framework for developing and evaluating a complex intervention. The four studies used different designs and methods. The first study was a systematic review of randomised controlled trials. The second and the last studies had experimental and quasi-experimental designs, where the CDSS was evaluated in a simulation setting and in a clinical setting. The third study included in the thesis had a qualitative case study design. The main findings from the studies in the thesis were that there is a weak evidence base for the use of CDSS in pre-hospital care. No studies have previously evaluated the effect of CDSS in pre-hospital care. Due to the context, pre-hospital care is dependent on protocol-based care to be able to deliver safe, high-quality care. The physical format of the current paper based guidelines and protocols are the main obstacle to their use. There is a request for guidelines and protocols in an electronic format among both clinicians and leaders of the ambulance organisations. The use of CDSS in the pre-hospital setting has a positive effect on compliance with pre-hospital guidelines. The largest effect is in the primary survey and in the anamnesis of the patient. The CDSS also increases the amount of information collected in the basic pre-hospital assessment process. The evaluated CDSS had a limited effect on on-the-scene time. The developed and evaluated CDSS has the ability to increase pre-hospital patient safety by reducing the risks of cognitive bias. Standardising the assessment process, enabling explicit decision support in the form of checklists, assessment rules, differential diagnosis lists and rule out worst-case scenario strategies, reduces the risk of premature closure in the assessment of the pre-hospital patient.

  • 70.
    Hansson, Per-Olof
    et al.
    Sahlgrenska Academy, University of Gothenburg.
    Andersson Hagiwara, Magnus
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Brink, Peter
    University West.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Wireklint Sundström, Birgitta
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Prehospital identification of factors associated with death during one-year follow-up after acute stroke.2018In: Brain and Behavior, ISSN 2162-3279, E-ISSN 2162-3279, article id e00987Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: In acute stroke, the risk of death and neurological sequelae are obvious threats. The aim of the study was to evaluate the association between various clinical factors identified by the emergency medical service (EMS) system before arriving at hospital and the risk of death during the subsequent year among patients with a confirmed stroke.

    MATERIAL AND METHODS: All patients with a diagnosis of stroke as the primary diagnosis admitted to a hospital in western Sweden (1.6 million inhabitants) during a four-month period were included. There were no exclusion criteria.

    RESULTS: In all, 1,028 patients with a confirmed diagnosis of stroke who used the EMS were included in the analyses. Among these patients, 360 (35%) died during the following year. Factors that were independently associated with an increased risk of death were as follows: (1) high age, per year OR 1.07; 95% CI 1.05-1.09; (2) a history of heart failure, OR 2.08; 95% CI 1.26-3.42; (3) an oxygen saturation of <90%, OR 8.05; 95% CI 3.33-22.64; and (4) a decreased level of consciousness, OR 2.19; 95% CI 1.61-3.03.

    CONCLUSIONS: Among patients with a stroke, four factors identified before arrival at hospital were associated with a risk of death during the following year. They were reflected in the patients' age, previous clinical history, respiratory function, and the function of the central nervous system.

  • 71.
    Hardig, Bjarne Madsen
    et al.
    Physio-Control, Lund.
    Lindgren, Erik
    Uppsala University.
    Östlund, Ollie
    Uppsala University.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Karlsten, Rolf
    Uppsala University.
    Rubertsson, Sten
    Uppsala University.
    Outcome among VF/VT patients in the LINC (LUCAS IN cardiac arrest) trial-A randomised, controlled trial.2017In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 115, p. 155-162, article id S0300-9572(17)30156-9Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: The LINC trial evaluated two ALS-CPR algorithms for OHCA patients, consisting of 3min' mechanical chest compression (LUCAS) cycles with defibrillation attempt through compressions vs. 2min' manual compressions with compression pause for defibrillation. The PARAMEDIC trial, using 2min' algorithm found worse outcome for patients with initial VF/VT in the LUCAS group and they received more adrenalin compared to the manual group. We wanted to evaluate if these algorithms had any outcome effect for patients still in VF/VT after the initial defibrillation and how adrenalin timing impacted it.

    METHOD: Both groups received manual chest compressions first. Based on non-electronic CPR process documentation, outcome, neurologic status and its relation to CPR duration prior to the first detected return of spontaneous circulation (ROSC), time to defibrillation and adrenalin given were analysed in the subgroup of VF/VT patients.

    RESULTS: Seven hundred and fifty-seven patients had still VF/VT after initial chest compressions combined with a defibrillation attempt (374 received mechanical CPR) or not (383 received manual CPR). No differences were found for ROSC (mechanical CPR 58.3% vs. manual CPR 58.6%, p=0.94), or 6-month survival with good neurologic outcome (mechanical CPR 25.1% vs. manual CPR 23.0%, p=0.50). A significant difference was found regarding the time from start of manual chest compression to the first defibrillation (mechanical CPR: 4 (2-5) min vs manual CPR 3 (2-4) min, P<0.001). The time from the start of manual chest compressions to ROSC was longer in the mechanical CPR group.

    CONCLUSIONS: No difference in short- or long-term outcomes was found between the 2 algorithms for patients still in VF/VT after the initial defibrillation. The time to the 1st defibrillation and the interval between defibrillations were longer in the mechanical CPR group without impacting the overall outcome. The number of defibrillations required to achieve ROSC or adrenalin doses did not differ between the groups.

  • 72. Hasselqvist, Ingela
    et al.
    Herlitz, Johan
    University of Borås, School of Health Science.
    Svensson, Leif
    Impact of bystander CPR on survival after out of hospital cardiac arrest2012Conference paper (Refereed)
  • 73. Hasselqvist-Ax, I
    et al.
    Herlitz, J
    University of Borås, School of Health Science.
    Rosenqvist, M
    Hollenberg, J
    Nordberg, P
    Ringh, M
    Jonsson, M
    Axelsson, C
    Lindqvist, J
    Svensson, L
    The Assessment aand Value of Bystander Cardiopulmonary Resuscitation2013Conference paper (Refereed)
  • 74.
    Hasselqvist-Ax, Ingela
    et al.
    Karolinska Institutet.
    Nordberg, Per
    Karolinska Institutet.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Svensson, Leif
    Karolinska Institutet.
    Jonsson, Martin
    Karolinska Institutet.
    Lindqvist, Jonny
    Sahlgrenska University Hospital.
    Ringh, Mattias
    Karolinska Institutet.
    Claesson, Andreas
    Karolinska Institutet.
    Björklund, Johan
    Fire and Rescue Service Dala Middle, Falun.
    Andersson, Jan-Otto
    Emergency Medical Services, Skövde Emergency Department, Skövde.
    Ericson, Caroline
    Sahlgrenska University Hospital.
    Lindblad, Pär
    Värnamo County Hospital, Jönköping County.
    Engerström, Lars
    SOS Alarm Centers, Stockholm.
    Rosenqvist, Mårten
    Karolinska Institutet.
    Hollenberg, Jacob
    Karolinska Institutet.
    Dispatch of Firefighters and Police Officers in Out-of-Hospital Cardiac Arrest: A Nationwide Prospective Cohort Trial Using Propensity Score Analysis.2017In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, ISSN 2047-9980, E-ISSN 2047-9980, Vol. 6, no 10, article id e005873Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Dispatch of basic life support-trained first responders equipped with automated external defibrillators in addition to advanced life support-trained emergency medical services personnel in out-of-hospital cardiac arrest (OHCA) has, in some minor cohort studies, been associated with improved survival. The aim of this study was to evaluate the association between basic life support plus advanced life support response and survival in OHCA at a national level.

    METHODS AND RESULTS: This prospective cohort study was conducted from January 1, 2012, to December 31, 2014. People who experienced OHCA in 9 Swedish counties covered by basic life support plus advanced life support response were compared with a propensity-matched contemporary control group of people who experienced OHCA in 12 counties where only emergency medical services was dispatched, providing advanced life support. Primary outcome was survival to 30 days. The analytic sample consisted of 2786 pairs (n=5572) derived from the total cohort of 7308 complete cases. The median time from emergency call to arrival of emergency medical services or first responder was 9 minutes in the intervention group versus 10 minutes in the controls (P<0.001). The proportion of patients admitted alive to the hospital after resuscitation was 31.4% (875/2786) in the intervention group versus 24.9% (694/2786) in the controls (conditional odds ratio, 1.40; 95% confidence interval, 1.24-1.57). Thirty-day survival was 9.5% (266/2786) in the intervention group versus 7.7% (214/2786) in the controls (conditional odds ratio, 1.27; 95% confidence interval, 1.05-1.54).

    CONCLUSIONS: In this nationwide interventional trial, using propensity score matching, dispatch of first responders in addition to emergency medical services in OHCA was associated with a moderate, but significant, increase in 30-day survival.

    CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02184468.

  • 75.
    Hedén, Lena E
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    von Essen, Louise
    Ljungman, Gustaf
    Effect of morphine in needle procedures in children with cancer.2011In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 15, no 10Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim was to investigate whether children experience less fear, distress, and/or pain when they receive oral morphine vs. placebo before a needle is inserted in a subcutaneously implanted intravenous port when combined with topical anesthesia.

    METHOD: Fifty children 1-18 years of age who were treated in a pediatric oncology and hematology setting were included consecutively when undergoing routine needle insertion into an intravenous port. All children were subjected to one needle insertion following topical anesthetic (EMLA) application in this randomized, triple-blind, placebo-controlled study comparing orally administered morphine (n=26) 0.25 mg/kg body weight with placebo (n=24). The patients' fear, distress, and pain were reported by parents, nurses and the children themselves (if ≥ 7 years of age) on 0-100 mm Visual Analogue Scales. In addition, observational methods were used to measure distress and procedure pain.

    RESULTS: No differences between the morphine and the placebo group were found with respect to age, weight, height, physical status, sex, weeks from diagnosis, or weeks from latest needle insertion. According to, parents, nurses, and children, oral morphine at a dose of 0.25 mg/kg body weight did not reduce fear, distress or pain compared with placebo.

    CONCLUSION: We could not reject the null hypothesis that there is no difference between the oral morphine and placebo groups assuming an effect size of 15 mm on VAS. Therefore it seems that oral morphine at 0.25 mg/kg does not give any additional reduction of fear, distress or pain compared with placebo when combined with topical anesthesia in pediatric patients undergoing subcutaneous port needle insertion, and would not be expected to be of any advantage for similar procedures such as venipuncture and venous cannulation when topical anesthesia is used.

  • 76.
    Hedén, Lena
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Pöder, Ulrika
    von Essen, Louise
    Ljungman, Gustaf
    Parents' perceptions of their child's symptom burden during and after cancer treatment.2013In: Journal of Pain and Symptom Management, ISSN 0885-3924, E-ISSN 1873-6513, Vol. 46, no 3Article in journal (Refereed)
    Abstract [en]

    CONTEXT: Previously reported studies of children with cancer mostly provide cross-sectional knowledge of the prevalence of symptoms but do not show when during the disease trajectory and after the end of successful treatment certain symptoms are most prevalent and/or distressing.

    OBJECTIVES: The aim was to describe parents' perceptions of their child's symptom burden longitudinally during and after cancer treatment and to investigate whether parents' perceptions vary with child characteristics and parent gender.

    METHODS: One hundred sixty parents (49% fathers) of 89 children answered a modified version of the Memorial Symptom Assessment Scale (MSAS) 10-18 at six different time points from one week after the child's diagnosis (T1) to 12-18 months after the end of successful treatment (T6).

    RESULTS: Feeling drowsy, pain, and lack of energy are initially the most prevalent symptoms. During treatment, the most prevalent symptom is less hair than usual. Pain, feeling sad, and nausea are initially the most distressing symptoms. Pain is both prevalent and distressing throughout the treatment. The child's symptom burden decreases over time. There is no difference regarding the reported symptom burden between the parents of a daughter or a son, or parents of a child older or younger than seven years of age. Mothers' and fathers' assessments of the symptom number, total MSAS and the subscales, are associated, but mothers' assessments are often higher than fathers' assessments.

    CONCLUSION: The prevalence and distress of symptoms and symptom burden decrease over time. However, even though the cancer is cured, feeling sad is reported as being prevalent and psychological distress is an issue. A dialogue between staff and the family about distressing symptoms and when they can be expected may increase acceptance and adaptation in children and parents during the disease trajectory.

  • 77.
    Hedén, Lena
    et al.
    University of Borås, School of Health Science. University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    von Essen, Louise
    Ljungman, Gustaf
    Effect of high-dose paracetamol on needle procedures in children with cancer: a RCT2014In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 103, no 3, p. 314-319Article in journal (Refereed)
    Abstract [en]

    AIM: The aim was to investigate whether children experience less pain, fear and/or distress when they receive high-dose paracetamol compared with placebo, using a needle insertion in a subcutaneously implanted intravenous port as a model. METHODS: Fifty-one children ranging from 1 to 18 years of age being treated in a paediatric oncology setting were included consecutively when undergoing routine needle insertion into a subcutaneously implanted intravenous port. All children were subjected to one needle insertion following topical anaesthetic (EMLA) application in this double-blind, placebo-controlled RCT, comparing orally administered paracetamol (n = 24) 40 mg/kg body weight (max 2000 mg) with placebo (n = 27). The patients' pain, fear and distress were reported by parents, nurses and children (≥7 years of age) using 0- to 100-mm visual analogue scales (VAS). In addition, pain observation, procedure time and cortisol reduction were assessed. RESULTS: No differences between the paracetamol and the placebo group were found with respect to demographic characteristics. According to VAS reports, paracetamol did not reduce pain, fear and distress compared with placebo. Pain observation, cortisol reduction and procedure time did not differ between the study groups. CONCLUSION: Paracetamol provides no additive effect in reducing pain, fear and distress when combined with topical anaesthesia in children undergoing port needle insertion.

  • 78.
    Henricson, Maria
    University of Borås, School of Health Science.
    Tactile touch in intensive care: Nurses’ preparation, patients’ experiences and the effect on stress parameters2008Doctoral thesis, monograph (Other academic)
    Abstract [en]

    Aim: The overall aim of this thesis was to acquire knowledge about whether tactile touch as a complementary method can (i) promote comfort and (ii) reduce stress reactions during care in an intensive care unit (ICU) Method: In Paper I, five nurses with a touch therapist training were interviewed about their experiences of preparation before giving tactile touch in an ICU. To analyse the meaning of preparation as a phenomenon, Giorgi’s descriptive phenomenological approach was used. In Paper II and III a randomised controlled trial was set up to investigate the effects of a five-day tactile touch intervention on patients’ oxytocin levels in arterial blood (II), on patients’ blood pressure, heart rate and blood glucose level, and on patients’ levels of anxiety, sedation and alertness (III). Forty-four patients were randomised to either an intervention group (n = 21) or a control group (n = 23). Data were analysed with non-parametric statistics. In Paper IV, six patients who had received the tactile touch intervention were interviewed to illuminate the experience of receiving tactile touch during intensive care. To gain a deeper understanding of the phenomenon and to illuminate the meaning, Ricoeur’s phenomenological hermeneutical method, developed by Lindseth and Norberg, was used. Findings: The nurses need four constituents (inner balance, unconditional respect for the patients’ integrity, a relationship with the patient characterized by reciprocal trust and a supportive environment) to be prepared and go through the transition from nurse to touch therapist (I). In the intervention study, no significant differences were shown for oxytocin levels between intervention and control group over time or within each day (II). There were significantly lower levels of anxiety for patients in the intervention group. There were no significant differences between the intervention and control groups for blood pressure, heart rate, the use of drugs, levels of sedation or blood glucose levels (III). The significance of receiving tactile touch during intensive care was described as the creation of an imagined room along with the touch therapist. In this imagined room, the patients enjoyed tactile touch and gained hope for the future (IV). Conclusion: Nurses needed internal and external balance to be prepared for providing tactile touch. Patients did not notice the surroundings as much as the nurses did. Patients enjoyed the tactile touch and experienced comfort. The impact on stress parameters were limited, except for levels of anxiety which declined significantly. The results gave some evidence for the benefit of tactile touch given to patients in intensive care.

  • 79. Henriksson, C
    et al.
    Larsson, M
    Herlitz, J
    University of Borås, School of Health Science.
    Karlsson, JE
    Wernroth, L
    Lindahl, B
    Influence of health related quality of life on time from symptom onset to hospital arrival and the risk of readmission in patients with myocardial infarction2014In: Open heart, E-ISSN 2053-3624, Vol. 1, no 1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite increased awareness of the importance of early treatment in acute myocardial infarction (AMI), the delay from symptom onset to hospital arrival is still too long and rehospitalisations are frequent. Little is known about how health-related quality of life (HRQL) affects delay time and the frequency of readmissions. METHOD: We used quality registers to investigate whether patients' HRQL has any impact on delay time with a new AMI, and on the rate of readmissions during the first year. Patients with AMI <75 years, with HRQL assessed with EQ-5D at 1-year follow-up, and who thereafter had a new AMI registered, were evaluated for the correlation between HRQL and delay time (n=454). The association between HRQL and readmissions was evaluated among those who had an additional AMI and a new 1-year follow-up registration (n=216). RESULTS: Patients who reported poor total health status (EQ-VAS ≤50), compared to those who reported EQ-VAS 81-100, had tripled risk to delay ≥2 h from symptom onset to hospital arrival (adjusted OR 3.01, 95% CI 1.43 to 6.34). Patients scoring EQ-VAS ≤50 had also a higher risk of readmissions in the univariate analysis (OR 3.08, 95% CI 1.71 to 5.53). However, the correlation did not remain significant after adjustment (OR 1.99, 95% CI 0.90 to 4.38). EQ-index was not independently associated with delay time or readmissions. CONCLUSIONS: Aspects of total health status post-AMI were independently associated with delay time to hospital arrival in case of a new AMI. However, the influence of total health status on the risk of readmissions was less clear.

  • 80.
    Herlitz, J
    University of Borås, School of Health Science.
    Rapport från det Svenska Hjärt-lungräddningsregistret2014Conference paper (Other academic)
  • 81.
    Herlitz, J
    University of Borås, School of Health Science.
    Svenska Hjärt-lungräddningsregistret. Årsrapport 20132013Report (Other academic)
  • 82.
    Herlitz, J
    University of Borås, School of Health Science.
    Årsrapport för det Svenska Hjärt-lungräddningsregistret 20142014Report (Other academic)
  • 83.
    Herlitz, Johan
    University of Borås, School of Health Science.
    Epidemiologi kring icke kardiella hjärtstopp2014Conference paper (Other academic)
  • 84.
    Herlitz, Johan
    University of Borås, School of Health Science.
    Kunskapen bakom kedjan som räddar liv2014Conference paper (Other academic)
  • 85.
    Herlitz, Johan
    et al.
    [external].
    Brandrup-Wognsen, G
    Haglid, M
    Karlson, BW
    Hartford, M
    Karlsson, T
    Predictors of death during 5 years after coronary artery bypass grafting1998In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 64, no 1, p. 15-23Article in journal (Refereed)
    Abstract [en]

    Aim: To describe predictors of death during five years of follow-up after coronary artery bypass grafting (CABG). Methods: All patients who underwent CABG during a period of three years in Western Sweden were included in the analysis and were prospectively followed for five years. Mortality was related to preoperative and peroperative factors as well as findings at physical examination and medication 4–7 days after the operation. Results: In all 2121 patients underwent CABG without simultaneous valve surgery during the study period. The overall five-year mortality was 14.6%. The following appeared as independent predictors of death during five years but >30 days after CABG: Current smoking (relative risk ratio 2.43 [95% Ci 1.64–3.61]) degree of impairment of left ventricular function (1.51 [1.23–1.86]), a history of congestive heart failure (1.91 [1.35–2.70]), age (1.04 [1.02–1.06]) arrhythmia 4–7 days after CABG (1.89 [1.26–2.83]), intermittent claudication (1.73 [1.19–2.52]), a history of diabetes (1.71 [1.16–2.51]), time in respirator (1.43 [1.13–1.81]), a history of cerebrovascular disease (1.72 [1.13–2.64]), treatment with digitalis at day 4–7 (1.48 [1.07–2.05]), enzyme release (1.49 [1.03–2.16]). Conclusion: Among patients who underwent CABG 11 independent predictors for mortality were found including smoking habits at CABG, history of cardiovascular diseases, left ventricular dysfunction, age, post operative complications and medication after CABG.

  • 86.
    Herlitz, Johan
    et al.
    [external].
    Bång, A
    Isaksson, L
    Karlsson, T
    Ambulance despatchers´ estimation of intensity of pain and presence of associated symptoms in relation to outcome among patients who call for an ambulance because of acute chest pain1995In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 16, no 12, p. 1789-1794Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A large number of patients who call for an ambulance because of acute chest pain have an acute ischaemic event, but some do not. AIM. To relate the ambulance despatcher's estimated severity of pain and presence of associated symptoms, in patients who call for an ambulance because of acute chest pain, to whether they develop acute myocardial infarction (AMI) and to the risk of early death. PATIENTS: All those with acute chest pain who contacted the despatch centre in Göteborg over a 2-month period. RESULTS: In all, 503 patients fulfilled the inclusion criteria. Patients judged as having severe chest pain (68%) developed AMI during the first 3 days in hospital on 26% of occasions as compared with 13% among patients judged as having only vague chest pain (P = 0.0004). The difference was less marked among the elderly and women. The presence of any of the following associated symptoms, dyspnoea, nausea, vertigo, cold sweat or syncope, tended to be associated with a higher infarction rate (24%) than if none of these symptoms was present (17%, P = 0.06). Mortality during the pre-hospital and the hospital phase was not associated with the estimated severity of pain or the presence of associated symptoms. CONCLUSIONS: The despatcher's estimation of the severity of pain and the presence of associated symptoms appears to be associated with the development of AMI but not with early mortality.

  • 87.
    Herlitz, Johan
    et al.
    [external].
    Dellborg, M
    Hartford, M
    Karlsson, T
    Risenfors, M
    Karlsson, BW
    Luepker, R
    Holmberg, S
    Swedberg, K
    Hjalmarson, Å
    Mortality and morbidity 1 year after early thrombolysis in suspected AMI: results from the TEAHAT Study1991In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 734, no suppl 1, p. 43-51Article in journal (Refereed)
    Abstract [en]

    We randomized 352 patients with suspected acute myocardial infarction (AMI) to treatment with rt-PA (n = 177) or placebo (n = 175). Patients were eligible if evaluated within 2 h and 45 min from onset of chest pain, and if aged less than 75 years. There were no ECG criteria for inclusion. A mobile coronary-care unit with a cardiologist present was used to initiate treatment at home in 29% of cases. During 1 year of follow-up the mortality in patients treated with rt-PA was 10.2%, as compared with 14.3% in patients the initial ECG, the mortality during the first year was 8% in the rt-PA group vs. 18% in the placebo group (P less than 0.05). Among patients without ST-elevation the mortality was 9% for the rt-PA group vs. 12% for the placebo group (NS). Requirement for rehospitalization, symptoms of angina pectoris and congestive heart failure, time of return to work and requirement for various medications did not differ significantly between the two groups, regardless of the initial ECG pattern.

  • 88.
    Herlitz, Johan
    et al.
    [external].
    Engdahl, J
    Svensson, L
    Young, M
    Ängquist, KA
    Holmberg, S
    Decrease in the occurrence of ventricular fibrillation as the initially observed arrhythmia after out-of-hospital cardiac arrest during 11 years in Sweden2004In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 60, no 3, p. 283-290Article in journal (Refereed)
    Abstract [en]

    Aim: To describe the change in the occurrence of ventricular fibrillation as initially observed arrhythmia among patients suffering from out-of-hospital cardiac arrest in Sweden. Patients: All patients included in the Swedish cardiac arrest registry between 1991 until 2001. The registry covers 85% of the population in Sweden. Methods: All patients with bystander witnessed out-of-hospital cardiac arrest included in the Swedish Cardiac Arrest Registry between 1991 and 2001 from the same ambulance organisation each year were included in the survey. Results: Over 11 years, among patients in Sweden with a bystander witnessed out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted (n = 9666), the occurrence of ventricular fibrillation as the initially obseved arrhythmia decreased from 45% in 1991 to 28% in 2001 (P < 0.0001) if the arrest occurred at home, and from 57% to 41% if the arrest occurred outside home (P < 0.0001). This was found despite the fact that the proportion who received bystander CPR increased from 29% in 1991 to 39% in 2001 if the arrest occurred at home (P < 0.0001) and from 54% to 60% if the arrest occurred outside home (NS). There was a significant increase in age among patients with out-of-hospital cardiac arrest at home, no change in the estimated interval between collapse and call but an increase in the interval between call and arrival of the ambulance among patients with out-of-hospital cardiac arrest outside home. Conclusion: During 11 years in Sweden, there was a marked decrease in the proportion of patients found in ventricular fibrillation among patients with a bystander witnessed cardiac arrest regardless whether the arrest occurred at home or outside home. A modest increase in age and interval between call for, and arrival of, the ambulance was associated with these findings.

  • 89.
    Herlitz, Johan
    et al.
    [external].
    Haglid, M
    Wiklund, I
    Caidahl, K
    Karlson, BW
    Sjöland, H
    Karlsson, T
    Improvement in Quality of Life during 5 years after coronary artery bypass grafting1998In: Coronary Artery Disease, ISSN 0954-6928, E-ISSN 1473-5830, Vol. 9, no 8, p. 519-526Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the changes in various aspects of quality of life (QOL) from before coronary artery bypass grafting (CABG) to 5 years after the procedure. PATIENTS AND METHODS: Patients who underwent CABG in the western region of Sweden in 1988-1991 were approached with questionnaires evaluating their QOL prior to and 3 months and 1, 2, and 5 years after the operation. Three different instruments were used: the Nottingham Health Profile, the Psychological General Well-Being Index, and the Physical Activity Score. RESULTS: In all 2121 patients underwent CABG, of whom 310 died during 5 years of follow-up. With all three instruments QOL had improved 5 years after CABG compared with prior to the operation. However, all three instruments revealed a slight but significant deterioration in estimated QOL between 2 and 5 years after CABG. CONCLUSIONS: QOL 5 years after CABG is better than that prior to the operation, but between 2 and 5 years after the operation a slight deterioration in QOL is observed.

  • 90.
    Herlitz, Johan
    et al.
    [external].
    Hjalmarson, Å
    Slutredovisning av metoprololstudien från göteborg1984In: Hässle Information, ISSN 0346-9751, Vol. 7, p. 1-14Article in journal (Refereed)
  • 91.
    Herlitz, Johan
    et al.
    [external].
    Hjalmarson, Å
    Lomsky, M
    Wiklund, I
    The relationship between infarct size and morbidity and mortality during short-term and long-term follow-up after acute myocardial infarction1988In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 116, no 5, p. 1378-1382Article in journal (Refereed)
  • 92.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Bång, A
    [external].
    Lindqvist, J
    Characteristics and outcome for patients with acute chest pain in relation to whether or not they were transported by ambulance2000In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 7, no 3, p. 195-200Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to describe the characteristics and long-term outcome for patients suffering from acute chest pain in relation to whether or not they were transported to hospital by ambulance. All patients with acute chest pain who were admitted over a 21-month period to the emergency department at Sahlgrenska Hospital in Göteborg with symptoms of acute chest pain were included in the study. Consecutive patients were prospectively registered and followed with regard to mortality and morbidity over 5 years. In all, 4270 patients took part in the evaluation, of whom 1445 (34%) were transported by ambulance. Patients transported by ambulance were older (p < 0.0001) and had a higher prevalence of previous myocardial infarction, angina pectoris, hypertension, diabetes mellitus, and congestive heart failure (p < 0.0001 for all) than the others. They more frequently developed acute myocardial infarction (28% vs. 11%; p < 0.0001) and there was a final diagnosis of either confirmed or possible myocardial infarction/ischaemia in 69% compared with 38% for patients not transported by ambulance (p < 0.0001). The 5-year mortality among ambulance-transported patients was 41% vs. 16% among those who were not (p < 0.0001). When correcting for dissimilarities at baseline including final diagnosis the adjusted risk ratio for death among ambulance transported patients was 1.44 (95% confidence limit 1.26-1.65). However, we did not correct for severe non-cardiac diseases. It is concluded that among patients admitted to the emergency department with acute chest pain, those transported by ambulance had a much higher mortality during the subsequent 5 years than those who were not transported by ambulance. This was not entirely explained by observed differences at baseline. This information should be considered when ambulance organizations are being constructed.

  • 93.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Sjölin, M
    Lindqvist, J
    Ten year mortality for patients discharged after hospitalization for chest pain or other symptoms raising suspicion of acute myocardial infarction in relation to hospital discharge diagnosis2002In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 251, no 6, p. 526-253Article in journal (Refereed)
    Abstract [en]

    Keywords: mortality; myocardial infarction; myocardial ischaemia; prognosis Abstract. Herlitz J, Karlson BW, Sjölin M, Lindqvist J (Sahlgrenska University Hospital, Göteborg, Sweden). Ten-year mortality for patients discharged after hospitalization for chest pain or other symptoms raising suspicion of acute myocardial infarction in relation to hospital discharge diagnosis. J Intern Med 2002; 251: 526–532. Aim. To describe the 10-year prognosis for patients discharged after hospitalization for chest pain or other symptoms giving an initial suspicion of acute myocardial infarction (AMI) in relation to the final hospital diagnosis and furthermore to compare the outcome amongst these patients with the outcome amongst a sex-, age- and community-matched con- trol population. Methods. All patients who were hospitalized because of chest pain or other symptoms raising a suspicion of AMI and who were discharged alive from hospital. Patients were divided into three groups according to the final diagnosis: (1) confirmed or possible AMI, (2) confirmed or possible myocardial ischaemia and (3) other aetiology. Information on 10-year mortality was available in 3103 patients. A sex-, age- and community-matched control population (n=3221) was compared with the study population in terms of 10-year mortality. Time of the survey. 15 February 1986 to 9 November 1987. Setting. Sahlgrenska University Hospital. Results. Patients with confirmed or possible AMI (n=849) had a significantly higher mortality (59.4%) than patients with confirmed or possible myocardial ischaemia (n=1191) who had a mortality of 49.5% (P < 0.0001). The latter group had a higher mortality than patients with `other aetiology' (n=1063) of whom 40.6% died (P < 0.0001). When comparing the prognosis for patients with AMI and myocardial ischaemia, there was a significant interaction with sex, with a more marked difference in women than in men. Amongst all patients, the 10-year mortality was 49.1 vs. 37.3% in the control group (P < 0.0001). Conclusion. The very long term prognosis was strongly associated with diagnosis amongst patients hospitalized and discharged alive because of chest pain or other symptoms raising suspicion of AMI. The absolute mortality difference between patients who were discharged from hospital with confirmed diagnosis of AMI and those whose symptoms were considered to have other aetiology than AMI or ischaemia was nearly 20%. However, the absolute mortality difference between the patients included in the survey and a control population was only 12%.

  • 94.
    Herlitz, Johan
    et al.
    [external].
    Starke, M
    Hansson, E
    Ringvall, E
    Karlson, BW
    Waagstein, L
    Characteristics and outcome among women and men transported by ambulance due to symptoms arousing suspicion of acute coronary syndrome2002In: Medical Science Monitor, ISSN 1234-1010, E-ISSN 1643-3750, Vol. 8, no 4, p. 251-256Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The purpose of this study was to describe the characteristics and outcome in relation to sex in consecutive patients who were transported by an ambulance due to symptoms arousing suspicion of acute coronary syndrome. MATERIAL/METHODS: Our research involved all patients transported by ambulance over a 3-month period in the community of Göteborg due to such symptoms. The P-values were age adjusted. RESULTS: Of the 930 transported patients fulfilling the given criteria, 452 (49%) were of women. The women were older and had a lower incidence of previous acute myocardial infarction, angina pectoris, and current smoking. Women less frequently had a final diagnosis of acute coronary syndrome (22.3% vs 36.6%; p<0.0001) or acute myocardial infarction (10.1% vs 17.9%; p<0.0001). However, the mortality rate during one year was the same in women (17.2%) and men (18.7%). Women were less frequently clammy on admission to the ambulance (17% vs 30%; p<0.0001) and less frequently showed signs of myocardial ischemia in ECG upon admission to the emergency department (26% vs 38%; p<0.0001) compared to men. Among those patients with an acute coronary syndrome, women more frequently complained of dyspnea than men (27% vs 12%; p=0.018). CONCLUSIONS: Our study suggests that among ambulance transported patients with suspicion of acute coronary syndrome there are some differences between women and men in terms of their characteristics and underlying etiology, but not in terms of the risk of mortality.

  • 95.
    Herlitz, Johan
    et al.
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Svensson, Leif
    Karolinska Institutet, Stockholm.
    Strömsöe, Annelie
    Högskolan, Dalarna.
    Flera faktorer påverkar prognosen: Vid hjärtstopp2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, no 2015-03-31Article in journal (Refereed)
  • 96.
    Herlitz, Johan
    et al.
    [external].
    Wiklund, I
    Caidahl, K
    Hartford, M
    Haglid, M
    Karlson, BW
    Sjöland, H
    Karlsson, T
    The feeling of loneliness prior to coronary artery bypass grafting might be a predictor of short and long term postoperative mortality1998In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 16, no 2, p. 120-125Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To evaluate the effect of different aspects of quality of life (QL) upon mortality during short-and long-term follow-up after coronary artery bypass grafting (CABG). DESIGN: Prospective evaluation. MATERIALS: Consecutive patients from western Sweden who during 3 years underwent CABG. METHODS: They answered a questionnaire at the time of coronary angiography prior to CABG. Quality of life was measured with questions from the Nottingham Health Profile (NHP) part I. RESULTS: In all, 1290 patients were included in the analyses. When accounting for various preoperative factors known to be independently associated with morality the NHP question "I feel lonely" was found to be associated with mortality, both at 30 days (RR 2.61; 95% CI 1.15-5.95; p = 0.02) and at 5 years (RR 1.78; 95% CI 1.17-2.71; p = 0.007) after the operation. Thirteen per cent reported they felt lonely. At 5 years was, in addition, the statement "I have difficulty climbing stairs" also independently associated with mortality (RR 1.50; 95% CI 1.02-2.22; p = 0.04). CONCLUSION: Among the 38 statements in NHP as a judgment of QL prior to CABG, one of them, "I feel lonely" was independently associated with survival both at 30 days and 5 years after CABG.

  • 97.
    Hirlekar, G
    et al.
    Sahlgrenska University Hospital.
    Karlsson, T
    Sahlgrenska University Hospital.
    Aune, S
    Sahlgrenska University Hospital.
    Ravn-Fischer, A
    Sahlgrenska University Hospital.
    Albertsson, P
    Sahlgrenska University Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Libungan, B
    Sahlgrenska University Hospital.
    Survival and neurological outcome in the elderly after in-hospital cardiac arrest.2017In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 118, p. 101-106, article id S0300-9572(17)30294-0Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There have been few studies of the outcome in elderly patients who have suffered in-hospital cardiac arrest (IHCA) and the association between cardiac arrest characteristics and survival.

    AIM: The aim of this large observational study was to investigate the survival and neurological outcome in the elderly after IHCA, and to identify which factors were associated with survival.

    METHODS: We investigated elderly IHCA patients (≥70years of age) who were registered in the Swedish Cardiopulmonary Resuscitation Registry 2007-2015. For descriptive purposes, the patients were grouped according to age (70-79, 80-89, and ≥90years). Predictors of 30-day survival were identified using multivariable analysis.

    RESULTS: Altogether, 11,396 patients were included in the study. Thirty-day survival was 28% for patients aged 70-79 years, 20% for patients aged 80-89 years, and 14% for patients aged ≥90years. Factors associated with higher survival were: patients with an initially shockable rhythm, IHCA at an ECG-monitored location, IHCA was witnessed, IHCA during daytime (8 a.m.-8 p.m.), and an etiology of arrhythmia. A lower survival was associated with a history of heart failure, respiratory insufficiency, renal dysfunction and with an etiology of acute pulmonary oedema. Patients over 90 years of age with VF/VT as initial rhythm had a 41% survival rate. We found a trend indicating a less aggressive care with increasing age during cardiac arrest (fewer intubations, and less use of adrenalin and anti-arrhythmic drugs) but there was no association between age and delay in starting cardiopulmonary resuscitation (CPR). In survivors, there was no significant association between age and a favourable neurological outcome (CPC score: 1-2) (92%, 93%, and 88% in the three age groups, respectively).

    CONCLUSIONS: Increasing age among the elderly is associated with a lower 30-day survival after IHCA. Less aggressive treatment and a worse risk profile might contribute to these findings. Relatively high survival rates among certain subgroups suggest that discussions about advanced directives should be individualized. Most survivors have good neurological outcome, even patients over 90 years of age.

  • 98.
    Hirlekar, Geir
    et al.
    Department of Cardiology, Sahlgrenska University Hospital.
    Jonsson, Martin
    Karolinska Institutet, Department of Medicine, Centre for Resuscitation Science.
    Karlsson, Thomas
    Health Metrics Unit, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg.
    Hollenberg, Jacob
    Karolinska Institutet, Department of Medicine, Centre for Resuscitation Science.
    Albertsson, Per
    Department of Cardiology, Sahlgrenska University Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Analysis of data for comorbidity and survival in out-of-hospital cardiac arrest.2018In: Data in Brief, E-ISSN 2352-3409, Vol. 21, p. 1541-1551Article in journal (Refereed)
    Abstract [en]

    The data presented in this article is supplementary to the research article titled "Comorbidity and survival in out-of-hospital cardiac arrest" (Hirlekar et al., 2018). The data contains information of how Charlson Comorbidity Index (CCI) is calculated and coded from ICD-10 codes. Multivariable logistic regression was used in the analysis of association between comorbidity and return of spontaneous circulation. We present baseline characteristics of patients found in VF/VT. All patients with non-missing data on all baseline variables are analyzed separately. We compare the baseline characteristics of patients with and without complete data set. Analysis of when comorbidity was identified in relation to outcome is also shown.

  • 99.
    Hirlekar, Geir
    et al.
    Department of Cardiology, Sahlgrenska University Hospital.
    Jonsson, Martin
    Karolinska Institutet, Department of Medicine, Centre for Resuscitation Science.
    Karlsson, Thomas
    Health Metrics Unit, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg.
    Hollenberg, Jacob
    Karolinska Institutet, Department of Medicine, Centre for Resuscitation Science.
    Albertsson, Per
    Department of Cardiology, Sahlgrenska University Hospital.
    Herlitz, Johan
    Comorbidity and survival in out-of-hospital cardiac arrest.2018In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 133, p. 118-123, article id S0300-9572(18)30988-2Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Patients suffering out-of-hospital cardiac arrest (OHCA) have a poor prognosis but survival among subgroups differs greatly. Previous studies have shown conflicting results on whether patient comorbidity affects outcome. The aim of this national study was to investigate the effect of comorbidity on outcome after OHCA in Sweden.

    METHODS: We included all patients with bystander-witnessed OHCA from 2011 to 2015 in the national Swedish Registry of Cardiopulmonary Resuscitation. In order to assess comorbidity, the database was merged with the comprehensive National Patient Registry, which includes all out-patient and in-patient care in Sweden. The Charlson comorbidity index (CCI) and the specific comorbidity conditions constituting the CCI was used to identify whether comorbidity was associated with outcome.

    RESULTS: A total of 12,012 patients were included in the study. Of these, 1598 patients survived to 30 days (13%). The most common comorbidities were a history of congestive heart failure (29%), myocardial infarction (24%), and diabetes without complications (23%). Renal disease (odds ratio [OR] 0.53; 95% CI 0.53‒0.72), diabetes with complications (OR 0.65; 95% CI 0.49‒0.84), diabetes without complications (OR 0.63; 95% CI 0.52‒0.75), congestive heart failure (OR 0.84; 95% CI 0.71‒0.99), and metastatic carcinoma (OR 0.61; 95% CI 0.40‒0.93) were significantly associated with a reduced chance of 30-day survival when adjusted for demographic characteristics and also resuscitation-associated factors such as shockable initial rhythm, bystander cardiopulmonary resuscitation (CPR), and place of arrest. With increasing comorbidity, the chance of 30-day survival decreased: adjusted OR was 0.82 (59% CI 0.68-0.99) for CCI 3-4, 0.62 (95% CI 0.47-0.83) for CCI 5-6, and 0.51 (95% CI 0.36-0.72) for CCI > 6, respectively, all in relation to those with CCI 0-2. Additionally, increasing morbidity was associated with reduced odds of return of spontaneous circulation (ROSC) and ROSC at hospital admission.

    CONCLUSION: This large national study showed that increasing comorbidity decreased the chance of survival to 30 days in OHCA. This association remained after covariate adjustment.

  • 100. Hoffman, R
    et al.
    James, SK
    Svensson, L
    Frick, Mats
    Lindahl, B
    Ekelund, U
    Omerovic, E
    Herlitz, J
    University of Borås, School of Health Science.
    Witt, N
    Determination of the role of Oxygen in Acute Myocardial Infarction(DETO2X-AMI trial)2013Conference paper (Refereed)
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