Abstract Introduction This study aimed to determine preoperative risk factors for nonsatisfaction 1 year after hysterectomy for benign indication and to analyze whether multiple co‐occurring preoperative risk factors increase the rate of nonsatisfaction. Material and Methods A historical register study was conducted using data from the Swedish National Register for Gynecological Surgery of women aged 18–56 years, who underwent hysterectomy for benign conditions between 2004 and 2023. Satisfaction 1 year postoperatively was dichotomized into satisfaction or nonsatisfaction. Multiple logistic regression was used to evaluate preoperative risk factors, with results presented as adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Nagelkerke's coefficient of determination (R2) assessed the explanatory power of the models. Results Among the 38 044 participating women, 3335 (8.8%) were not satisfied after 1 year. Preoperative risk factors for nonsatisfaction were smoking (aOR 1.34, 95% CI: 1.18–1.53), not being gainfully employed (aOR 1.60, 95% CI: 1.40–1.82), and the main symptoms leading to hysterectomy (pain (aOR 1.91, 95% CI: 1.70–2.15), pressure/heaviness (aOR 1.90, 95% CI: 1.53–2.21), other symptoms (aOR 2.24, 95% CI: 1.95–2.59), or several main symptoms (aOR 1.92, 95% CI: 1.53–2.41)). Protective factors for nonsatisfaction were age 46–50 years (aOR 0.87, 95% CI: 0.76–1.00) and minimally invasive hysterectomy (vaginal [aOR 0.69, 95% CI: 0.59–0.81], laparoscopic [aOR 0.79, 95% CI: 0.68–0.91], and robot‐assisted laparoscopic [aOR 0.82, 95% CI: 0.71–0.95]). The likelihood of being nonsatisfied rose with the accumulation of preoperative risk factors, as reflected by the full model's explanatory power (R2 = 0.141). Among individual predictors, the main symptom leading to hysterectomy contributed most to the explained variance (R2 = 0.029), followed by employment status (R2 = 0.009), while other factors, such as surgical route, age, and smoking only marginally contributed to the variance. Conclusions Nearly, 9% of the women were nonsatisfied with the outcome of the hysterectomy after 1 year. Lack of satisfaction appeared predictable from preoperative factors, notably smoking, not being gainfully employed, and nonbleeding symptoms leading to hysterectomy. These findings emphasize the need for individualized counseling before surgery. Given that most preoperative risk factors are resistant to immediate modification, more research is needed to develop targeted interventions that can reduce nonsatisfaction and enhance patient outcomes.

Introduction Robot-assisted laparoscopic surgical procedures are commonly perceived to result in fast recovery; however, the postoperative course can be challenging for many patients. We have previously found severe pain and a significant decrease in the patient-reported outcome measure Quality-of-Recovery 15 (QoR-15) in a cohort of patients undergoing robot-assisted upper urinary tract surgery. In similar settings, intrathecal analgesia is sometimes used to improve recovery; however, its benefits have not been established. Therefore, this study aims to examine the effects of intrathecal analgesia in this setting compared with an active comparator intravenous lidocaine.Methods and analysis In this randomised, assessor-blinded multicentre trial, 220 patients scheduled for robot-assisted upper urinary tract surgery under general anaesthesia are recruited after obtaining informed consent. They are randomised to receive either intrathecal analgesia or an intraoperative infusion with lidocaine. The primary study outcome is the decrease in QoR-15 from baseline to postoperative day 1. Other outcomes of interest include postoperative pain, length of stay and postoperative complications. Differences in intraoperative haemodynamics and postoperative inflammatory parameters will also be analysed.Ethics and dissemination This study has been approved by the Swedish Medical Products Agency (5.1.1-2023-69740 and 5.1.2-2025-030145). The results of this study will be presented at national and international meetings and submitted for publication in peer-reviewed international medical journals.Trial registration number NCT06349668.

The aim of the study was to evaluate the health economics of nurse-led telephone follow-up contacts (TFUs) within six weeks after benign hysterectomy in a societal perspective, using a cost minimization analysis model. A randomized, single-blinded, controlled, Swedish multicenter study comprising 487 women undergoing benign hysterectomy. The women were allocated 1:1:1:1 to either Group A (no TFUs), Group B (one clinically structured TFU the day after discharge), Group C (as B, but with additional TFUs once weekly for six weeks, in total six TFUs), or Group D (as C, but by applying a coaching technique). Time consumption for planned TFUs, informal care, and the number of unplanned telephone contacts and visits were recorded. Costs were assessed using a cost-per-patient price list for Linköping University Hospital. The total cost per patient more than doubled in the groups with repeated TFUs (Groups C and D) compared with no TFUs (Group A). Group D demonstrated fewer unplanned telephone contacts and lower informal care costs. Group B, with only one TFU, exhibited the highest time consumption for TFU. The additional costs of six TFUs, with or without coaching, substantially increased the costs. The coaching TFU group (Group D) had the lowest cost for informal care. TFUs appeared to be costly and an inefficient way of using healthcare resources after benign hysterectomy. The coaching TFU seemed to reduce unplanned telephone contacts and lower informal care costs. Careful consideration of the costs and the impact on clinical outcomes is important before implementing TFU after surgery. This study is registered retrospectively in ClinicalTrial.gov: NCT01526668 on January 27, 2012. Date of enrollment of first patient: October 11; 2011.

Abstract Trauma teams handle severely injured patients under high temporal demands and need to coordinate and achieve collaborative decision-making and task execution through communication. Specific coordination and communication behaviours are taught in simulation training to enhance team performance. An examination of the role and nature of communication could increase the understanding of educational possibilities and assess the validity of in situ simulation on behalf of communication. Our study aim was to describe the relative use of communication within information and task management, the use of coordinating behaviours, and the use of talking to the room and closed-loop communication in in-real-life trauma assessment and in the simulated domain. We video-recorded all verbal communicative events in four real-world trauma teams and four teams during simulation training. The analysis showed that although the teamwork was task-oriented, information management dominated task management at 64% of all the utterances in-real-life and 68% during simulation. In-real-life, information management was dominated by the codes “request information” (24%) and “confirmation” (21%), whereas “task distribution” (43%) was most frequently used for task management. The only difference between domains was that “give information after request” represented a smaller proportion of the utterances in-real-life compared to simulation (p ≤ 0.001). Talking to the room was primarily used by the teams in both domains to provide information without request and to delegate tasks. Closed-loop communication was used at a low frequency, 3.6% in-real-life, but was significantly higher, 7.7%, in simulation training. We suspect that this outcome reflects the Hawthorne effect. In the simulations, greater information delivery was provided in response to questions, probably accounting for instructor information. Our results may be valuable for research on trauma team behaviour in a simulated environment to draw conclusions about similar activities in-real-life.

BACKGROUND:Postoperative mortality might be influenced by postoperative care, vigilance, and competence to rescue. This study aims to describe the course of events preceding death in a high-risk surgical cohort. METHODS:We analyzed hospital records of patients who died within 30 days after surgery in 4 high volume hospitals using (1) reflective narrative thematic approach to identify recurring themes reflecting issues with conduct of care and (2) Global Trigger Tool to describe incidence, timing, and types of adverse events (AEs) leading to harm. RESULTS:Preoperative predicted median risk of death in the studied group was 9%/13% according to SORT/P-POSSUM, respectively. Nine recurring themes were identified. Prominent themes were "consensus concerning aim and/or risk with planned surgery," "level of (intraoperative) competence and monitoring," and in the postoperative period "level of care and vigilance" on signs of deterioration. We found a total of 303 AEs, with only three patients (5%) having no adverse events. Most common severity category was "I," that is "contributed to patient's death" (n = 110, 36% of all AEs). Of these, 60% were classified as preventable or probably preventable. The peak incidence of AEs was seen on the day of index surgery. Most common types of AEs were "failure of vital functions" (n = 79, 26%), followed by infections (n = 45, 15%). CONCLUSIONS:A high predicted risk of death and a peak of adverse events on the day of index surgery were detected. Identified themes reflect lack of documented multi-professional consensus on how to handle prevalent perioperative risk, vigilance, and postoperative level of care.

Background: To investigate if symptoms of depression, anxiety, and stress-coping capacity have an impact on the effect of telephone follow-up (TFU) on trajectories of six recovery measures after hysterectomy and influence the occurrence of unplanned telephone contacts (uTCs) and unplanned visits (uVs) to health care providers. Material and Methods: A post hoc nonrandomized analysis of participants enrolled in a randomized, four-armed, single-blinded, controlled multicenter intervention study comprising 487 women where the women were allocated 1:1:1:1 to one of four TFU models. The Swedish Postoperative Symptom Questionnaire (SPSQ) and two health-related quality of life questionnaires, the EuroQoL-5 dimension with three levels (EQ-5 D-3?L) and the Short-Form-Health Survey (SF-36) assessed the recovery measures. The six recovery measures consisted of the EQ-5D-3L health index, the SF-36 physical component summary (PCS) and mental component summary (MCS), and the maximum and average pain intensity, and symptom sum score obtained from the SPSQ. Psychological distress was evaluated by the psychometric forms, the Hospital Anxiety and Depression Scale and the Stress Coping Inventory. The occurrence of uTC and uV within the 6 weeks of follow-up was registered. Results: Preoperative anxiety, depression, and stress-coping capacity did not modify the effects of the TFU models on the trajectories of the recovery measures, although anxiety and depression were strongly associated with all six recovery measures. uTCs, but not uVs occurred more often in the women with anxiety. Conclusions: Preoperative anxiety, depression, and stress-coping capacity did not appear to influence the effects of TFU contacts on the recovery measures after hysterectomy. Preoperative anxiety seemed to increase the occurrence of uTC. Clinical Trials Registration: ClinicalTrials.gov (NCT01526668).

BackgroundThe objectives were to determine the prevalence of de novo and persistent pelvic pain after benign hysterectomy and to assess risk factors.MethodsA Swedish prospective multicenter study of 440 women undergoing benign hysterectomy was conducted between October 2011 and March 2017. Measures of pain, the spatial extent of bodily pain, and pain sensitivity were assessed using a self-reporting questionnaire, Margolis's patient pain drawing, and quantitative sensory testing of pain thresholds for pressure, heat, and cold, respectively. Quality of life was evaluated by EQ-5D-3L and SF-36. Psychological distress was assessed by the Hospital Anxiety and Depression Scaleand the Stress-Coping Inventory. Logistic regression models were used to assess risk factors, and the outcome was presented as an adjusted odds ratio (aOR) and 95% confidence interval (CI).ResultsPreoperatively, 18.0% of the women reported no bodily pain, 41.5% had pelvic pain, either as the only location (7.0%) or along with pain in other locations (34.5%), and 40.5% had non-pelvic pain only. Postoperatively, 6.2% developed de novo pelvic pain and 16.4% had persistent pelvic pain. De novo pelvic pain developed exclusively in women who preoperatively had non-pelvic pain only. Risk factors for de novo pelvic pain were a long hospital stay (aOR 1.50 (95%CI) 1.02-2.21)), high preoperative pain intensity (aOR 1.25 (95%CI 1.01-1.62)) and a high number of pain areas (aOR 1.15 (95%CI 1.05-1.27)), along with anxiety (aOR 10.61 (95%CI 1.84-61.03)) and low EQ-5D-3L health index (aOR 0.02 (95%CI 0.00-0.31)). Risk factors for persistent pelvic pain were lower age (aOR 0.89 (95%CI 0.81-0.97)), higher number of pain areas (aOR 1.08 (95%CI 1.02-1.14)), and a higher frequency of preoperative pain (aOR 12.75 (95%CI 2.24-72.66)).ConclusionAlthough hysterectomy appeared to be reasonably effective in curing pelvic pain, a non-negligible proportion of women developed de novo pelvic pain or had persistent pelvic pain. De novo pelvic pain seemed to affect only those who preoperatively had widespread bodily pain. Women at risk for de novo and persistent pelvic pain after hysterectomy could be identified preoperatively.Trial registrationsThe study was retrospectively registered in ClinicalTrial.gov (NCT01526668) on 01/27//2012.

OBJECTIVES:To determine whether intrathecal morphine (ITM) analgesia in abdominal surgery for presumed gynecological malignancy was associated with better self-reported sleep quality postoperatively compared with epidural analgesia (EDA), and to evaluate risk factors for bad sleep quality.METHODS:A secondary analysis of a randomized open controlled trial, comparing ITM and EDA as postoperative analgesia in 80 women undergoing laparotomy under general anaesthesia in an enhanced recovery after surgery framework. A total of 38 women allocated to ITM and 39 to EDA completed the study. The Swedish Postoperative Symptoms Questionnaire assessed symptoms and sleep quality during the first postoperative week. Multiple logistic regression models evaluated risk factors. The results are presented as adjusted odds ratios with 95% CIs.RESULTS:The sleep quality night-by-night did not differ significantly between the women who had ITM or EDA. Risk factors for bad sleep quality for night 1 were age (0.91; 0.84-0.99), operation time (1.02; 1.00-1.03), and opioid consumption (0.96; 0.91-0.99). For night 2, regular use of hypnotics preoperatively (15.81; 1.52-164.27) and opioid consumption (1.07; 1.00-1.14) were independent risk factors for bad sleep. After the second night, no risk factors were disclosed.CONCLUSIONS:ITM and EDA did not appear to affect the sleep quality postoperatively differently in women undergoing laparotomy for presumed gynecological malignancy. Risk factors for self-reported bad sleep quality varied during the first 3 days after surgery. Younger age, longer operation time, and preoperative use of hypnotics were associated with bad sleep quality, whereas the effect of opioid consumption on sleep quality varied depending on the time since surgery. These findings merit further studies.

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

In trauma teams, coordination can be established through a centralised leader. The team can also use a decentralised strategy. In this descriptive study of video-recorded trauma resuscitations, using quantification of qualitative data, Social Network analysis of all real-time communications of eight in-real-life (IRL) and simulated trauma teams explained team social structure. The communication network structures in the simulated scenarios were more centralised using individually directed speech and had a high proportion of communication to update all team members. Such a structure might be the result of work performed in a complexity-stripped simulation environment where simplified task-executions required less interactions, or from work revolving around a deteriorating patient, imposing high demands on rapid decision-making and taskwork. Communication IRL was mostly decentralised, with more variability between cases, possibly due to unpredictability of the IRL case. The flexibility to act in a decentralised manner potentiates adaptability and seems beneficial in rapidly changing situations.Practitioner summary: Efficient collaboration in trauma teams is essential. Communication in in-real-life and simulated trauma teams was analysed using social network analysis. The simulation teams were overall more centralised compared to the IRL teams. The flexibility to act decentralised seems beneficial for emergency teams as it enables adaptability in unpredictable situations.

Purpose The study aimed to determine if planned telephone follow-up, especially when adding structured, oriented coaching, reduces the intensity of postoperative symptoms and decreases analgesics consumption after benign hysterectomy. Methods A randomized, single-blinded, four-armed, controlled multicenter trial of 525 women scheduled for hysterectomy was conducted in 5 hospitals in the southeast health region of Sweden. The women were allocated 1:1:1:1 into four follow-up models: (A) no telephone follow-up (control group); (B) one planned, structured, telephone follow-up the day after discharge; (C) as B but with additional telephone follow-up once weekly for 6 weeks; and (D) as C but with oriented coaching telephone follow-up on all occasions. Postoperative symptoms were assessed using the Swedish Postoperative Symptoms Questionnaire. Analgesic consumption was registered. Unplanned telephone contacts and visits were registered during the 6 weeks of follow-up. Results In total, 487 women completed the study. Neither pain intensity, nor symptom sum score or analgesic consumption differed between the intervention groups. Altogether, 224 (46.0%) women had unplanned telephone contacts and 203 (41.7%) had unplanned visits. Independent of intervention, the women with unplanned telephone contacts had higher pain intensity and symptom sum scores, particularly if an unplanned telephone contact was followed by a visit, or an unplanned visit was preceded by an unplanned telephone contact. Conclusion Telephone follow-up did not seem to affect recovery regarding symptoms or analgesic consumption after benign hysterectomy in an enhanced recovery after surgery (ERAS) setting. Unplanned telephone contacts and visits were associated with more postoperative symptoms, especially pain. Trial registration The study is registered in ClinicalTrial.gov: NCT01526668 retrospectively from January 27; 2012. Date of enrolment of first patient: October 11; 2011.

Purpose:Quantitative sensory testing (QST) can be applied to quantify the sensitivity to different painful stimuli. This study aims to evaluate the association between preoperative pressure and thermal pain thresholds and trajectories of measurements of postoperative recovery (patient-reported daily maximum and average pain intensity, sum score of symptoms, and analgesic consumption) after benign hysterectomy. Patients and Methods:A prospective, longitudinal single-blinded, observational multicenter study was conducted in five hospitals in the southeast of Sweden between 2011 and 2017. A total of 406 women scheduled for abdominal or vaginal hysterectomy for benign conditions were enrolled in the study. QST measuring pressure (PPT), heat (HPT), and cold pain thresholds (CPT) were performed preoperatively. The cut-off levels for dichotomizing the pain thresholds (low/high) were set at the 25-percentile for PPT and HPT and the 75-percentile for CPT. The Swedish Postoperative Symptom Questionnaire was used to measure postoperative pain and other symptoms of discomfort (symptom sum score) on 13 occasions for six weeks postoperatively. Daily analgesic consumption of opioids and non-opioids was registered. Results:A CPT above the 75-percentile was associated with high postoperative maximum pain intensity (p = 0.04), high symptom sum score (p = 0.03) and greater consumption of non-opioids (p = 0.03). A HPT below the 25-percentile was only associated with greater consumption of non-opioids (p = 0.02). PPT was not associated with any of the outcome measures. Conclusion:CPT seemed to be predictive for postoperative pain and symptoms of discomfort after benign hysterectomy. Preoperative QST may be used to individualize the management of postoperative recovery for low pain threshold individuals.

The aim of this study was to explore interaction of interprofessional hospital trauma teams. A theory about how team cognition is developed through a dynamical process was established using grounded theory methodology. Video recordings of in-real-life resuscitations performed in the emergency ward of a Scandinavian mid-size urban hospital were collected and eligible for inclusion using theoretical sampling. By analyzing interactions during seven trauma resuscitations, the theory that trauma teams perform patient assessment and resuscitation by alternating between two process modes, the two main categories "team positioning" and "sensitivity to the patient," was generated. The core category "working with split vision" explicates how the teams interplay between the two modes to coordinate team focus with an emergent mental model of the specific situation. Split vision ensures that deeper aspects of the team, such as culture, knowledge, empathy, and patient needs are absorbed to continuously adapt team positioning and create precision in care for the specific patient.

Background: The provision of home healthcare is increasing in response to the growing aging population with the need for chronic disease management in their homes. Safety work differs from hospital care. The incidence of ad-verse events in home healthcare is sparsely studied but is estimated to occur in-one third of patients, and most are deemed preventable. Although nursing care is crucial for risk assessment and preventive work in the home environment, the role of registered nurses in the prevention of no-harm incidents and adverse events has not re-ceived sufficient scientific attention. Objectives: To explore nursing-sensitive events in patients receiving home healthcare. Design, setting and participants: A Swedish national multicenter study based on a structured record review of 600 randomly chosen healthcare records from 10 organizations in different regions of the country. Methods: Ten trained teams, each including physician(s) and registered nurses, undertook a review based on the Global Trigger Tool method. The review covered a maximum of 90 days from admission to home healthcare. First, each record was screened for the presence of 38 predefined triggers. In the second step, every potential event was assessed according to preventability, types of events, severity, time of occurrence, consequences of the event, and potential contributing causes. Results: In total, 699 events were identified in the study. Of these, 495 (74.0%) were classified as nursing-sensitive (227 no-harm incidents and 268 adverse events) and affected 267 (44.5%) patients, with a mean of 1.9 events per patient. The majority (n = 367, 73.1%) were considered preventable. The most prominent types of nursing -sensitive event were falls (n = 138, 27.9%), pressure ulcers (n = 62, 12.5%), healthcare-associated infections (n = 58, 11.7%) and medication management (n = 50, 10.1%). Concerning severity, 45.9% were classified as no-harm incidents and another 36.6% resulted in temporary harm that required extra healthcare resources: 226 hospital days, 66 physician visits in outpatient care, and 99 in home healthcare. All severity types occurred from day 1, except death, which included only one patient. The most frequent contributing factors were deficien-cies in nursing care, treatment & diagnosis, with the subgroups nursing care, observation, treatment & follow-up, followed by deficiencies in the organization. Conclusions: Nursing-sensitive events in home healthcare are common, often preventable, and occur from the start of the care period. This study contributes to increased knowledge of patient safety shortcomings and points to the important role that registered nurses play in patient safety work.(c) 2022 Elsevier Ltd. All rights reserved.

BACKGROUND:Fluid therapy during major surgery can be managed by providing repeated bolus infusions until stroke volume no longer increases by ≥ 10%. However, the final bolus in an optimization round increases stroke volume by < 10% and is not necessary. We studied how different cut-off values for the hemodynamic indications given by esophagus Doppler monitoring, as well as augmentation by pulse oximetry, are associated with a higher or smaller chance that stroke volume increases by ≥ 10% (fluid responsiveness) before fluid is infused. METHODS:An esophagus Doppler and a pulse oximeter that displayed the pleth variability index were used to monitor the effects of a bolus infusion in 108 patients undergoing goal-directed fluid therapy during major open abdominal surgery. RESULTS:The analyzed data set comprised 266 bolus infusions. The overall incidence of fluid responsiveness was 44%, but this varied greatly depending on pre-infusion hemodynamics. The likelihood of being fluid-responsive was 30%-38% in the presence of stroke volume > 80 mL, corrected flow time > 360 ms, or pleth variability index < 10%. The likelihood was 21% if stroke volume had decreased by <8% since the previous optimization, which decreased to 0% if combined with stroke volume > 100 mL. By contrast, the likelihood of fluid responsiveness increased to 50%-55% when stroke volume ≤ 50 mL, corrected flow time ≤ 360 ms, or pleth variability index ≥ 10. A decrease in stroke volume by > 8% since the previous optimization was followed by a 58% likelihood of fluid responsiveness that, in combination with any of the other hemodynamic variables, increased to 66%-76%. CONCLUSIONS:Single or combined hemodynamic variables provided by esophagus Doppler monitoring and pulse oximetry derived pleth variability index could help clinicians avoid unnecessary fluid bolus infusions.

Background:Older and frail individuals are at high risk of dying from COVID-19, and residents in nursing homes (NHs) are overrepresented in death rates. We explored four different periods during the COVID-19 pandemic to analyze the effects of improved preventive routines and vaccinations, respectively, on mortality in NHs. Methods:We undertook a population-based systematic retrospective chart review comprising 136 NH facilities in southeast Sweden. All residents, among these facilities, who died within 30 days after a laboratory-verified COVID-19 diagnosis during four separate 92-day periods representing early pandemic (second quarter 2020), middle of the pandemic (fourth quarter 2020), early post-vaccination phase (first quarter 2021), and the following post-vaccination phase (second quarter 2021). Mortality together with electronic chart data on demographic variables, comorbidity, frailty, and cause of death was collected. Results:The number of deaths during the four periods was 104, 120, 34 and 4, respectively, with a significant reduction in the two post-vaccination periods (P < 0.001). COVID-19 was assessed as the dominant cause of death in 20 (19%), 19 (16%), 4 (12%) and 1 (3%) residents in each period (P < 0.01). The respective median age in the four studied periods varied between 87and 89 years, and three or more diagnoses besides COVID-19 were present in 70-90% of the respective periods' study population. Considerable or severe frailty was found in all residents. Conclusions:Vaccination against COVID-19 seems associated with a reduced number of deaths in NHs. We could not demonstrate an effect on mortality merely from the protective routines that were undertaken.

Abstract Background. Fluid therapy during major surgery can be managed by providing repeated bolus infusions until stroke volume no longer increases by ≥ 10%. However, the final bolus, also called an optimisation round, is not necessary, as it results in fluid overload. We studied how different cut-off values for the haemodynamic indications given by oesophagus Doppler monitoring, possibly augmented by pulse oximetry, are associated with a higher or smaller chance that stroke volume increases by ≥ 10% (fluid responsiveness) before the fluid is infused. Methods. An oesophagus Doppler and a pulse oximeter that displayed the Pleth Variability Index were used to monitor the effects of a bolus infusion in 110 patients undergoing goal-directed fluid therapy during major open abdominal surgery. Results. The overall incidence of fluid responsiveness was 44%, but this varied greatly depending on pre-infusion haemodynamics. The likelihood of being fluid-responsive was 30–38% in the presence of stroke volume > 80 mL, flow-corrected time > 360 ms, or Pleth Variability Index < 10%. The likelihood was 21% if stroke volume had decreased by < 8% since the previous optimisation, which decreased to 0% if combined with stroke volume > 100 mL. By contrast, the likelihood of fluid responsiveness increased to 50–55% when stroke volume ≤ 50 mL, flow-corrected time ≤ 360 ms, or Pleth Variability Index ≥ 10. A > 8% decrease in stroke volume since the previous optimisation was followed by a 58% likelihood of fluid responsiveness that, in combination any of the other mentioned haemodynamic variables, increased to 66–76%. Conclusions. Single or combined haemodynamic variables provided by oesophagus Doppler monitoring and pulse oximetry could help clinicians avoid unnecessary fluid bolus infusions. Trial registration: Clinical Trials (NCT01458678) registered on October 25, 2011, before any patient recruitment was initiated.