Cancer-related fatigue trajectories up to 5 years after curative treatment for oesophageal cancer.

BACKGROUND: Whether cancer-related fatigue develops differently after curative-intended oesophageal cancer treatment and the related modifiable factors are unclear. METHODS: This population-based and longitudinal cohort included 409 oesophageal cancer patients who underwent curative oesophagectomy in 2013-2020 in Sweden. The main outcome was cancer-related fatigue trajectories with measurements at 1, 1.5, 2, 2.5, 3, 4 and 5 years postoperatively by validated EORTC QLQ-FA12 questionnaire, and analysed using growth mixture models. Weighted logistic regressions provided odds ratios (OR) with 95% confidence intervals (95% CI) for underlying sociodemographic, clinical, and patient-reported outcome factors in relation to the identified trajectories. RESULTS: Two distinct overall cancer-related fatigue trajectories were identified: low level of persistent fatigue and high level of increasing fatigue, with 64% and 36% of patients, respectively. The odds of having high level of fatigue trajectory were increased by Charlson comorbidity index (≥ 2 versus 0: OR = 2.52, 95% CI 1.07-5.94), pathological tumour Stage (III-IV versus 0-I: OR = 2.52, 95% CI 1.33-4.77), anxiety (OR = 7.58, 95% CI 2.20-26.17), depression (OR = 15.90, 95% CI 4.44-56.93) and pain (continuous score: OR = 1.02, 95% CI 1.01-1.04). CONCLUSIONS: Long-term trajectories with high level of increasing cancer-related fatigue and the associated modifiable factors were identified after oesophageal cancer treatment. The results may facilitate early identification and targeted intervention for such high-risk patients.

The paradox of workplace violence in the intensive care unit: a focus group study.

BACKGROUND: Conflicts with patients and relatives occur frequently in intensive care units (ICUs), driven by factors that are intensified by critical illness and its treatments. A majority of ICU healthcare professionals have experienced verbal and/or physical violence. There is a need to understand how healthcare professionals in ICUs experience and manage this workplace violence. METHODS: A qualitative descriptive analysis of four hospitals in Sweden was conducted using semi-structured focus-group interviews with ICU healthcare professionals. RESULTS: A total of 34 participants (14 nurses, 6 physicians and 14 other staff) were interviewed across the four hospitals. The overarching theme: "The paradox of violence in healthcare" illustrated a normalisation of violence in ICU care and indicated a complex association between healthcare professionals regarding violence as an integral aspect of caregiving, while simultaneously identifying themselves as victims of this violence. The healthcare professionals described being poorly prepared and lacking appropriate tools to manage violent situations. The management of violence was therefore mostly based on self-taught skills. CONCLUSIONS: This study contributes to understanding the normalisation of violence in ICU care and gives a possible explanation for its origins. The paradox involves a multifaceted approach that acknowledges and confronts the structural and cultural dimensions of violence in healthcare. Such an approach will lay the foundations for a more sustainable healthcare system.

Family members' experiences of COVID-19 visiting restrictions in the intensive care unit-A qualitative study.

OBJECTIVE: To describe how family members of critically ill patients experienced the COVID-19 visiting restrictions in Sweden. BACKGROUND: In Sweden, the response to COVID-19 was less invasive than in many other countries. However, some visiting restrictions were introduced for intensive care units, with local variations. Although there is a growing body of literature regarding healthcare professionals' and family caregivers' perspectives on visiting restriction policies, there may be inter-country differences, which remain to be elucidated. DESIGN: This study has a qualitative descriptive design. Focus group interviews with 14 family members of patients treated for severe COVID-19 infection were conducted. The interviews took place via digital meetings during the months after the patients' hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting of the study followed the COREQ checklist. RESULTS: Two categories-dealing with uncertainty and being involved at a distance-described family members' experiences of coping with visiting restrictions during the COVID-19 pandemic. These restrictions were found to reduce family members' ability to cope with the situation. Communication via telephone or video calls to maintain contact was appreciated but could not replace the importance of personal contact. CONCLUSIONS: Family members perceived that the visiting restriction routines in place during the COVID-19 pandemic negatively influenced their ability to cope with the situation and to achieve realistic expectations of the patients' needs when they returned home. RELEVANCE TO CLINICAL PRACTICE: This study suggests that, during the COVID-19 pandemic, the visiting restrictions were experienced negatively by family members and specific family-centred care guidelines need to be developed for use during crises, including the possibility of regular family visits to the ICU. PATIENT AND PUBLIC CONTRIBUTION: None in the conceptualisation or design of the study.

The long-term experience of being a family caregiver of patients surgically treated for oesophageal cancer.

AIM: This qualitative study aimed to explore the experience of being family caregivers of patients treated for oesophageal cancer 2 years after treatment. To better understand the family caregiver's situation, a conceptual model was used in the analysis. The results of the study can guide future interventions to support family caregivers of patients treated for oesophageal cancer. DESIGN: A qualitative descriptive study using semi-structured telephone interviews. An abductive approach was used in the analysis to reach deeper knowledge about the family caregivers' experiences and to better understand deeper patterns. METHODS: A qualitative study was conducted and included 13 family caregivers of patients surgically treated for oesophageal cancer in Sweden in 2018 who participated in a population-based nationwide cohort study. Individual telephone interviews were held in 2020, 2 years after the patients' surgery. The analysis of the interviews started with an inductive approach using thematic analysis. Thereafter, a deductive approach was used to interpret the findings in relation to the conceptual model, The Cancer Family Caregiving Experience. RESULTS: The most essential/evident stress factors for the family caregivers were distress regarding the patients' nutrition, fear of tumour recurrence and worry about the future. In addition, a transition was experienced, going from a family member to a caregiver, and the many psychosocial aspects of this transition were highlighted during the disease trajectory. CONCLUSION: Despite, the long-term survival of the patient, family caregivers were still struggling with psychosocial consequences because of the patient's cancer diagnosis and treatment. Furthermore, there is a need to improve supportive interventions for family caregivers during the whole disease trajectory. IMPACT: The current study includes comprehensive information about the family caregivers' experiences when caring for a patient treated for oesophageal cancer. Family caregivers struggle with the psychosocial consequences of the patient's cancer and worry about tumour recurrence even 2 years after surgery. These findings can be useful in the development of supportive interventions, which may facilitate life for family caregivers. PATIENT OR PUBLIC CONTRIBUTION: The study was discussed and planned together with our research partnership group including patients and family caregivers. In addition, the manuscript was reviewed by some of the members to cross-check the results and discussed them to avoid misinterpretation.

Intensive care nurses' lived experience of altruism and sacrifices during the Covid-19 pandemic: A phenomenological study.

AIM: The aim of this study was to understand the lived experience of altruism and sacrifices among Swedish nurses working in intensive care units (ICU) during the COVID-19 pandemic. DESIGN: This was a descriptive phenomenological study. METHODS: The study was conducted between June 2020 and March 2021 and included 20 nurses who were directly involved in the ICU care of COVID-19 patients in Sweden during the pandemic. The text transcripts were analysed using Malterud's Systematic Text Condensation. FINDINGS: The analysis revealed four themes. The work situation changed from 1 day to another-the nurses were brutally confronted with a new and highly demanding situation. Adapting to the chaotic situation-despite fear, anguish and exhaustion, the nurses adapted to the new premises. They shouldered the moral responsibility and responded to the needs of the patients and the health care system since they had the competence. Being confronted with ethical and moral challenges-the nurses were overwhelmed by feelings of helplessness and inadequacy because despite how hard they worked, they were still unable to provide care with dignity and of acceptable quality. The importance of supporting each other-collegiality was fundamental to the nurses' ability to cope with the situation. CONCLUSIONS: Taken together, being exposed to a constantly changing situation, facing the anguish and misery of patients, families, and colleagues, and being confronted with a conflict between the moral obligation to provide care of high quality and the possibility to fulfil this commitment resulted in suffering among the nurses. Collegial back-up and a supportive culture within the caring team were important for the nurses' endurance. IMPACT: The study contributes an understanding of nurses' lived experience of working during the COVID-19 pandemic and highlights the importance of protecting and preparing nurses and nursing organisation for potential future crises.

Healthcare workers' experiences of patient safety in the intensive care unit during the COVID-19 pandemic: A multicentre qualitative study.

AIM: To describe healthcare workers' experiences of preconditions and patient safety risks in intensive care units during the COVID-19 pandemic. BACKGROUND: Healthcare workers' ability to adapt to changing conditions is crucial to promote patient safety. During the COVID-19 pandemic, healthcare workers' capacity to maintain safe care was challenged and a more in-depth understanding on frontline experiences of patient safety is needed. DESIGN: A qualitative descriptive design. METHODS: Individual interviews were conducted with 29 healthcare workers (nurses, physicians, nurse assistants and physiotherapists) from three Swedish hospitals directly involved in intensive care of COVID-19 patients. Data were analysed with inductive content analysis. Reporting followed the COREQ checklist. RESULTS: Three categories were identified. Hazardous changes in working conditions describes patient safety challenges associated with the extreme workload with high stress level. Imperative adaptations induced by changed preconditions for patient safety which include descriptions of safety risks following adaptations related to temporary intensive care facilities, handling shortage of medical equipment and deviations from routines. Safety risks triggered by reorganisation of care describe how the diluted skill-mix and team disruptions exposed patients to safety risks, and that safety performance mostly relied on individual healthcare worker's responsibility. CONCLUSIONS: The study suggests that healthcare workers experienced an increase in patient safety risks during the COVID-19 pandemic mainly because the extremely high workload, imperative adaptations, and reorganisation of care regarding skill-mix and teamwork. Patient safety performance relied on the individuals' adaptability and responsibility rather than on system-based safety. RELEVANCE TO CLINICAL PRACTICE: This study provides insights on how healthcare workers' experiences can be used as a source of information for recognition of patient safety risks. To improve detection of safety risks during future crises, guidelines on how to approach safety from a system perspective must include healthcare workers' perceptions on safety risks. PATIENT AND PUBLIC CONTRIBUTION: None in the conceptualisation or design of the study.

Patients' experiences of preparing for transfer from the intensive care unit to a hospital ward: A multicentre qualitative study.

BACKGROUND: The transfer from an intensive care unit (ICU) to a regular ward often causes confusion and stress for patients and family members. However, little is known about the patients' perspective on preparing for the transfer. AIM: The purpose of the study was to describe patients' experiences of preparing for transfer from an ICU to a ward. STUDY DESIGN: Individual interviews with 14 former ICU patients from three urban hospitals in Stockholm, Sweden were conducted 3 months after hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting followed the consolidated criteria for reporting qualitative research checklist. RESULTS: The results showed that the three categories, the discharge decision, patient involvement, and practical preparations were central to the patients' experiences of preparing for the transition from the intensive care unit to the ward. The discharge decision was associated with a sense of relief, but also worry about what would happen on the ward. The patients felt that they were not involved in the decision about the discharge or the planning of their health care. To handle the situation, patients needed information about planned care and treatment. However, the information was often sparse, delivered from a clinician's perspective, and therefore not much help in preparing for transfer. CONCLUSIONS: ICU patients experienced that they were neither involved in the process of forthcoming care nor adequately prepared for the transfer to the ward. Relevant and comprehensible information and sufficient time to prepare were needed to reduce stress and promote efficient recovery. RELEVANCE TO CLINICAL PRACTICE: The study suggests that current transfer strategies are not optimal, and a more person-centred discharge procedure would be beneficial to support patients and family members in the transition from the ICU to the ward.

Caregiver burden and health-related quality of life among family caregivers of oesophageal cancer patients: a prospective nationwide cohort study.

BACKGROUND: Oesophageal cancer surgery is extensive with high risk of long-term health-related quality of life (HRQL) reductions. After hospital discharge, the family members often carry great responsibility for the rehabilitation of the patient, which may negatively influence their wellbeing. The purpose was to clarify whether a higher caregiver burden was associated with psychological problems and reduced HRQL for family caregivers of oesophageal cancer survivors. MATERIAL AND METHODS: This was a nationwide prospective cohort study enrolling family members of all patients who underwent surgical resection for oesophageal cancer in Sweden between 2013 and 2020. The family caregivers reported caregiver burden, symptoms of anxiety, depression, post-traumatic stress, and HRQL 1 year after the patient's surgery. Associations were analysed with multivariable logistic regression and presented as odds ratios (OR) with 95% confidence intervals (CI). Differences between groups were presented as mean score differences (MSD). RESULTS: Among 319 family caregivers, 101 (32%) reported a high to moderate caregiver burden. Younger family caregivers were more likely to experience a higher caregiver burden. High-moderate caregiver burden was associated with an increased risk of symptoms of anxiety (OR 5.53, 95%CI: 3.18-9.62), depression (OR 8.56, 95%CI: 3.80-19.29), and/or posttraumatic stress (OR 5.39, 95%CI: 3.17-9.17). A high-moderate caregiver burden was also associated with reduced HRQL, especially for social function (MSD 23.0, 95% CI: 18.5 to 27.6) and role emotional (MSD 27.8, 95%CI: 19.9 to 35.7). CONCLUSIONS: The study indicates that a high caregiver burden is associated with worse health effects for the family caregiver of oesophageal cancer survivors.

Patient and public involvement in oesophageal cancer survivorship research.

BACKGROUND: Good clinical research is often conducted in close collaboration between patients, the public, and researchers. Few studies have reported the development of patient and public involvement (PPI) in research outside the United States and the United Kingdom, and for patients with more aggressive cancers. The study aimed to describe and evaluate the development of PPI in oesophageal cancer survivorship research in Sweden by the use of a framework to support the process. METHODS: Oesophageal cancer survivors were recruited to a PPI research collaboration at Karolinska Institutet, Sweden. The development process was supported by the use of a framework for PPI, 'Patient and service user engagement in research'. Insights, benefits, and challenges of the process were described and discussed among the collaborators. RESULTS: The collaboration resulted in joint publications with a more patient- and family-focussed perspective. It also contributed to the development of information folders about survivorship after oesophageal cancer surgery and national conference arrangements for patients, their families, healthcare workers, and researchers. Since the PPI contributors were represented in patient organisations and care programmes, the dissemination of research results increased. Their contributions were highly valued by the researchers, but also revealed some challenges. The use of a structured framework contributed to support and facilitated the process of establishing PPI in research collaboration. CONCLUSIONS: A genuine interest in establishing PPI in research and an understanding and respect for the patients' expertise in providing a unique inside perspective was imperative for a successful collaboration. Research focus should not only be on mortality and reductions in daily life, but also on positive outcomes. Using a framework supports development and avoids pitfalls of PPI collaboration. PATIENT AND PUBLIC CONTRIBUTION: Patient partners were equal collaborators in all aspects of the study.

Psychological distress after esophageal cancer surgery and the predictive effect of dispositional optimism: a nationwide population-based longitudinal study.

PURPOSE: To examine the trajectory of psychological distress from 1 to 2 years after esophageal cancer surgery, and whether dispositional optimism could predict the risk of postoperative psychological distress. METHODS: This Swedish nationwide longitudinal study included 192 patients who had survived for 1 year after esophageal cancer surgery. We measured dispositional optimism with the Life Orientation Test-Revised (LOT-R) 1 year post-surgery and psychological distress with the Hospital Anxiety and Depression Scale 1, 1.5, and 2 years post-surgery. Latent growth curve models were used to assess the trajectory of postoperative psychological distress and to examine the predictive validity of dispositional optimism. RESULTS: One year after surgery, 11.5% (22 of 192) patients reported clinically significant psychological distress, and the proportion increased to 18.8% at 1.5 years and to 25.0% at 2 years post-surgery. Higher dispositional optimism predicted a lower probability of self-reported psychological distress at 1, 1.5, and 2 years after esophageal cancer surgery. For each point increase in the LOT-R sum score, the odds of psychological distress decreased by 44% (OR, 0.56; 95% CI, 0.40 to 0.79). CONCLUSION: The high prevalence and longitudinal increase of self-reported psychological distress after esophageal cancer surgery indicate the unmet demands for timely psychological screening and interventions. Measuring dispositional optimism may help identify patients at higher risk of developing psychological distress, thereby contributing to the prevention of postoperative psychological distress.

Dispositional optimism and all-cause mortality after esophageal cancer surgery: a nationwide population-based cohort study.

PURPOSE: To examine the association between dispositional optimism and all-cause mortality after esophageal cancer surgery and whether pathological tumor stage and the COVID-19 pandemic modified this association. METHODS: This nationwide, population-based prospective cohort study included 335 patients undergoing esophageal cancer surgery in Sweden between January 1, 2013, and December 31, 2019. Dispositional optimism was measured 1 year post-surgery using Life Orientation Test-Revised (LOT-R). A higher LOT-R sum score represents higher dispositional optimism. Mortality information was obtained from the Swedish Register of the Total Population. All patients were followed up until death or until December 31, 2020, whichever occurred first. Cox regression with adjustments for confounders was used. RESULTS: The median follow-up was 20.8 months, during which 125 (37.3%) patients died. Among the included 335 patients, 219 (65.4%) patients had tumor pathologically staged Tis-II, and 300 (89.6%) patients entered the cohort before the COVID-19 pandemic. Both tumor stage and the COVID-19 pandemic were effect modifiers. For each unit increase in LOT-R sum score, the risk of all-cause mortality decreased by 11% (HR 0.89, 95% CI 0.81 to 0.98) among patients with tumor staged Tis-II before the COVID-19 pandemic. This association was non-significant in patients with tumor staged III-IV (HR 0.99, 95% CI 0.92 to 1.07) and during the COVID-19 pandemic (HR 1.08, 95% CI 0.94 to 1.25). CONCLUSION: Assessing dispositional optimism may help predict postoperative survival, especially for patients with early and intermediate esophageal cancer. Increasing dispositional optimism might be a potential intervention target to improve survival after esophageal cancer surgery.

Experiences of being a family caregiver to a patient treated for oesophageal cancer-1 year after surgery.

PURPOSE: There is a need to put family caregivers on the cancer survivorship research agenda. Therefore, the aim of this is study is to explore the experiences of being a family caregiver to a patient treated for oesophageal cancer. METHOD: This qualitative study was based on the ongoing nationwide and prospective Oesophageal Surgery on Cancer patients - Adaptation and Recovery study (OSCAR) including patients surgically treated for oesophageal cancer in Sweden and their closest family caregiver. One year after the patient's surgery, each family caregiver received a self-report questionnaire kit to fill in. For the purpose of this study, the responses to the open-ended question "Is there anything else you would like to share?" were used and analysed by conducting thematic analysis. RESULTS: In total, 112 responses to the open-ended question were transcribed and analysed. The text rendered three themes: Discontinued support from healthcare-mostly a positive experience before surgery and in the acute survivorship phase. However, after discharge from the hospital, the family caregiver felt as though they were left alone, fully responsible for the patient's care. A changed life-unprepared for life-changing situation after the patient received the cancer diagnosis. A feeling that nothing will ever be the same and like your sense of self is lost. Psychological distress-was described as a feeling of being alone. Family caregivers felt invisible and no longer important to family and friends. The patient was the one that mattered. CONCLUSION: This study indicates that patients and family caregivers would benefit from a more family-centred healthcare, where the patients' as well as the caregivers' perspectives would be acknowledged.

Caregiver burden and emotional wellbeing in informal caregivers to ICU survivors-A prospective cohort study.

BACKGROUND: Informal caregivers to intensive care unit (ICU) survivors may develop post-intensive care syndrome family (PICS-F), including depression, anxiety and post-traumatic stress (PTS). Our primary aim was to investigate associations between caregiver burden in informal caregivers cohabiting with ICU survivors and patients' physical and psychological outcomes. METHODS: A prospective, multicentre cohort study in four ICUs in Sweden. Adults cohabiting with ICU patients included in a previous study were eligible for inclusion. Three months post-ICU, informal caregivers received questionnaires assessing caregiver burden, health-related quality of life (HRQL) and symptoms of depression, anxiety and PTS. In parallel, patients reported their three-month physical and psychological status via validated questionnaires. The primary outcome of this study was to compare caregiver burden in informal caregivers to patients with and without adverse physical and psychological outcomes 3 months post-ICU. Secondary outcomes were correlations between caregiver burden and informal caregivers' mental HRQL. RESULTS: Among 62 included informal caregivers, 55 (89%) responded to the follow-up questionnaires. Caregiver burden was higher among informal caregivers to patients with an adverse outcome, compared to informal caregivers to patients without an adverse outcome, caregiver burden scale score mean (±standard deviation) 52 (11) and 41 (13) respectively (p = 0.003). There was strong negative correlation between caregiver burden and informal caregivers' mental HRQL (rs -0.74, p < 0.001). CONCLUSION: Informal caregivers to ICU survivors with adverse physical or psychological outcome experience a higher caregiver burden. A higher caregiver burden correlates with worse caregiver mental HRQL. ICU follow-up programs should consider screening and follow-up of informal caregivers for mental health problems.

Spontaneous ethics in nurses' willingness to work during a pandemic.

Background: In modern healthcare, the role of solidarity, altruism and the natural response to moral challenges in life-threatening situations is still rather unexplored. The COVID-19 pandemic provided an opportunity to obtain a deeper understanding of nurses' willingness to care for patients during crisis.Objective: To elucidate clinical expressions of ontological situational ethics through nurses' willingness to work during a pandemic.Research design, participants and context: A qualitative study with an interpretive design was applied. Twenty nurses who worked in intensive care unit at two Swedish hospitals during the first, second, and third waves of the COVID-19 pandemic were interviewed. The analysis was interpretative and applied a theoretical ethics perspective.Ethical considerations: The study was approved by the Swedish Ethical Review Authority and informed consent was obtained from all participants.Findings: From a philosophical perspective, the nurses expressed sovereign life expressions of mercy and compassion, which arose spontaneously in response to seeing vulnerable fellow humans. They referenced ''the nurse inside me'' and their choice of profession as motives to provide care. Ontological situational ethics in culture and norms were noted in the constructs of competence, responsibility, solidarity with colleagues and organization; and interest and learning were driving forces. Ethical demand was evident when nurses expressed ideas of meaningfulness in helping their fellow humans; but themes of ambiguity, exhaustion and unwillingness were also present.Conclusions: The nurses showed a high willingness to care for patients during a crisis. Responding to the ethical demand and to care for vulnerable human beings while risking their own health and lives could be interpreted as an inter-human vocation. These spontaneous altruistic actions saved the lives of many patients during the pandemic and need to be understood and supported.

Higher Dispositional Optimism Predicts Better Health-Related Quality of Life After Esophageal Cancer Surgery: A Nationwide Population-Based Longitudinal Study.

PURPOSE: To assess whether higher dispositional optimism could predict better health-related quality of life (HRQL) after esophageal cancer surgery. METHODS: This Swedish nationwide longitudinal study included 192 patients who underwent esophagectomy for cancer. The exposure was dispositional optimism measured by the Life Orientation Test-Revised (LOT-R) at 1 year post-surgery. Patients were categorized into four subgroups (very low, moderately low, moderately high, and very high dispositional optimism) based on the quartile of the LOT-R sum score. The outcome was HRQL assessed by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30) and Quality of Life Questionnaire-Esophago-Gastric module 25 (QLQ-OG25) at 1, 1.5, and 2 years post-surgery. Linear mixed-effects models, adjusted for potential confounders, were used to examine the mean score difference (MSD) with 95% confidence interval of HRQL among the four patient subgroups. RESULTS: Patients with very high dispositional optimism reported clinically relevantly better global quality of life, emotional function, and social function (MSD range 10-16) and less severe symptoms in pain, dyspnea, diarrhea, eating difficulty, anxiety, dry mouth, trouble with taste, worry about weight loss, and self-doubt about body image (MSD range - 9 to - 22) than patients with lower dispositional optimism. Patients with moderately high dispositional optimism reported clinically and statistically significantly better global quality of life (MSD 10) and less severe diarrhea (MSD - 9) than patients with lower dispositional optimism. Adjusted MSDs were constant over the three time points in all aspects except for eating difficulty. CONCLUSIONS: Measuring dispositional optimism could help identify patients at higher risk of poor HRQL recovery after esophageal cancer surgery.

Social distancing during the COVID-19 pandemic and health-related quality of life among esophageal cancer survivors.

PURPOSE: The purpose was to investigate whether social distancing during the COVID-19 pandemic reduced health-related quality of life (HRQL) in esophageal cancer patients and if so, to identify factors related to the HRQL changes. METHODS: A prospective Swedish nationwide study of patients who undergone surgery for esophageal cancer between 2013 and 2019. Telephone interviews were conducted 5 weeks and 13 weeks after the introduction of social distancing recommendations. The participants responded to a few scales and items from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. Regression models adjusted for potential confounders were used to examine mean score differences (MSD) with 95% confidence intervals (CI) between compliance with the recommendations and HRQL. RESULTS: In total, 134 individuals participated in the study. At 5 weeks, a reduction in role function was seen for individuals who fully (MSD -8, 95% CI: -16 to 0) and to a large extent (MSD -19, 95% CI: -26 to -12) complied with the recommendations. Less fatigue (MSD 9, 95% CI: 3-15) was also detected for this group. Being female, elderly, having comorbidities, living in a region with higher COVID-19 incidence, living in a villa, and being considered as an at-risk person were related to changes in role function. At 13 weeks, reductions in role function continued for those who fully complied with the recommendations (MSD -10, 95% CI: -19 to -1), but the risk variables were of less importance. Improvements in fatigue were no longer detected. Global quality of life, emotional function, or insomnia remained stable over time. CONCLUSIONS: This study indicates that individuals who undergone surgery for esophageal cancer and fully or to a large extent complied with the recommendations experienced reductions in role function, but not in global quality of life or emotional function, during the COVID-19 pandemic.

Long-term consequences in critically ill COVID-19 patients: A prospective cohort study.

BACKGROUND: COVID-19 can cause severe disease with need of treatment in the intensive care unit (ICU) for several weeks. Increased knowledge is needed about the long-term consequences. METHODS: This is a single-center prospective follow-up study of COVID-19 patients admitted to the ICU for respiratory organ support between March and July 2020. Patients with invasive ventilation were compared with those with high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) regarding functional outcome and health-related qualify of life. The mean follow-up time was 5 months after ICU discharge and included clinical history, three well-validated questionnaires about health-related quality of life and psychological health, pulmonary function test, 6-minute walk test (6MWT) and work ability. Data were analyzed with multivariable general linear and logistic regression models with 95% confidence intervals. RESULTS: Among 248 ICU patients, 200 patients survived. Of these, 113 patients came for follow-up. Seventy patients (62%) had received invasive ventilation. Most patients reported impaired health-related quality of life. Approximately one-third suffered from post-traumatic stress, anxiety and depression. Twenty-six percent had reduced total lung capacity, 34% had reduced 6MWT and 50% worked fulltime. The outcomes were similar regardless of ventilatory support, but invasive ventilation was associated with more bodily pain (MSD -19, 95% CI: -32 to -5) and <80% total lung capacity (OR 4.1, 95% CI: 1.3-16.5). CONCLUSION: Among survivors of COVID-19 who required respiratory organ support, outcomes 5 months after discharge from ICU were largely similar among those requiring invasive compared to non-invasive ventilation.

Patient-reported outcomes 1 year after oesophageal cancer surgery.

Purpose: To improve survivorship in patients who have undergone curatively intended treatment for oesophageal cancer, we aimed to identify key targets for future patient-reported outcomes research.Methods: This nationwide Swedish prospective cohort study enrolled patients between 2014 and 2019 who had undergone surgical resection for oesophageal cancer 1 year earlier. Eight well-validated patient-reported outcome measures, including health-related quality of life, psychological status and sleep, were presented as proportions and mean scores (MS) with 95% confidence intervals (CIs).Results: Among 281 participants, approximately half of the patients reported problems associated with food intake such as eating restrictions (49%) and food aversion (47%). Other common problems were sleep (51%), fatigue (41%) and anxiety (36%). Fewer patients suffered from financial difficulties (9%), trouble swallowing saliva (4%) and hair loss (7%). However, these problems were perceived as highly burdensome on an individual level.Conclusions: This nationwide, population-based study indicates that symptom burden is high in oesophageal cancer survivors 1 year after surgery. The most common problems are associated with food intake, sleep, fatigue and anxiety. However, less frequent symptoms were sometimes more debilitating for the individual patient.

Dosing of thromboprophylaxis and mortality in critically ill COVID-19 patients.

BACKGROUND: A substantial proportion of critically ill COVID-19 patients develop thromboembolic complications, but it is unclear whether higher doses of thromboprophylaxis are associated with lower mortality rates. The purpose of the study was to evaluate the association between initial dosing strategy of thromboprophylaxis in critically ill COVID-19 patients and the risk of death, thromboembolism, and bleeding. METHOD: In this retrospective study, all critically ill COVID-19 patients admitted to two intensive care units in March and April 2020 were eligible. Patients were categorized into three groups according to initial daily dose of thromboprophylaxis: low (2500-4500 IU tinzaparin or 2500-5000 IU dalteparin), medium (> 4500 IU but < 175 IU/kilogram, kg, of body weight tinzaparin or > 5000 IU but < 200 IU/kg of body weight dalteparin), and high dose (≥ 175 IU/kg of body weight tinzaparin or ≥ 200 IU/kg of body weight dalteparin). Thromboprophylaxis dosage was based on local standardized recommendations, not on degree of critical illness or risk of thrombosis. Cox proportional hazards regression was used to estimate hazard ratios with corresponding 95% confidence intervals of death within 28 days from ICU admission. Multivariable models were adjusted for sex, age, body mass index, Simplified Acute Physiology Score III, invasive respiratory support, and initial dosing strategy of thromboprophylaxis. RESULTS: A total of 152 patients were included: 67 received low-, 48 medium-, and 37 high-dose thromboprophylaxis. Baseline characteristics did not differ between groups. For patients who received high-dose prophylaxis, mortality was lower (13.5%) compared to those who received medium dose (25.0%) or low dose (38.8%), p = 0.02. The hazard ratio of death was 0.33 (95% confidence intervals 0.13-0.87) among those who received high dose, and 0.88 (95% confidence intervals 0.43-1.83) among those who received medium dose, as compared to those who received low-dose thromboprophylaxis. There were fewer thromboembolic events in the high (2.7%) vs medium (18.8%) and low-dose thromboprophylaxis (17.9%) groups, p = 0.04. CONCLUSIONS: Among critically ill COVID-19 patients with respiratory failure, high-dose thromboprophylaxis was associated with a lower risk of death and a lower cumulative incidence of thromboembolic events compared with lower doses. TRIAL REGISTRATION: Clinicaltrials.gov NCT04412304 June 2, 2020, retrospectively registered.

ICU discharge screening for prediction of new-onset physical disability-A multinational cohort study.

BACKGROUND: Methods to identify patients at risk for incomplete physical recovery after intensive care unit (ICU) stay are lacking. Our aim was to develop a method for prediction of new-onset physical disability at ICU discharge. METHODS: Multinational prospective cohort study in 10 general ICUs in Sweden, Denmark, and the Netherlands. Adult patients with an ICU stay ≥12 hours were eligible for inclusion. Sixteen candidate predictors were analyzed with logistic regression for associations with the primary outcome; new-onset physical disability 3 months post-ICU, defined as a ≥10 score reduction in the Barthel Index (BI) compared to baseline. RESULTS: Of the 572 included patients, follow-up data are available on 78% of patients alive at follow-up. The incidence of new-onset physical disability was 19%. Univariable and multivariable modeling rendered one sole predictor for the outcome: physical status at ICU discharge, assessed with the five first items of the Chelsea critical care physical assessment tool (CPAx) (odds ratio 0.87, 95% confidence interval (CI) 0.81-0.93), a higher score indicating a lower risk, with an area under the receiver operating characteristics curve of 0.68 (95% CI 0.61-0.76). Negative predictive value for a low-risk group (CPAx score >18) was 0.88, and positive predictive value for a high-risk group (CPAx score ≤18) was 0.32. CONCLUSION: The ICU discharge assessment described in this study had a moderate AUC but may be useful to rule out patients unlikely to need physical interventions post-ICU. For high-risk patients, research to determine post-ICU risk factors for an incomplete rehabilitation is mandated.