To Örebro University

INTRODUCTION: Same-day discharge after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) is increasing, but the optimal anaesthetic technique for outpatient pathways remains uncertain. Neuraxial anaesthesia is widely recommended based on observational evidence, whereas fast-track programmes using short-acting total intravenous anaesthesia may facilitate early mobilisation and discharge. No randomised controlled trial has compared general anaesthesia (GA) with spinal anaesthesia (SA) specifically in outpatient primary THA/TKA using a same-day discharge target.

METHODS AND ANALYSIS: GASPS is a pragmatic, multicentre, parallel-group superiority randomised controlled trial. Adults scheduled for outpatient primary THA or TKA will be randomised 1:1 to GA or SA, with stratification by site and procedure (THA/TKA). The primary outcome is successful same-day discharge (discharge on the day of surgery) without readmission within 48 h after discharge. The five key secondary outcomes are time to fulfilment of hospital discharge indicators, quality-of-recovery (QoR-15) trajectories over postoperative Days 1-35, patients' qualitative experiences of anaesthesia and recovery, cost per quality-adjusted life-year and safety (adverse events); all remaining outcomes-including pain, postoperative nausea and vomiting, opioid consumption, mobilisation and patient-reported outcomes (EQ-5D-5L and HOOS/KOOS)-are exploratory. An embedded qualitative study will explore patient experiences using semi-structured interviews, and an economic evaluation will compare costs and outcomes from healthcare and societal perspectives. Analyses will follow the intention-to-treat principle; a group sequential design with O'Brien-Fleming boundaries is planned for an interim analysis. Approval has been obtained from the Swedish Medical Products Agency. Written informed consent will be obtained from all participants. Results will be disseminated through peer-reviewed publications, conference presentations and reporting in the EU Clinical Trials Information System (CTIS).

CONCLUSION: This study is designed to determine the most effective anaesthetic method for same-day discharge after primary TKA and THA. With increasing outpatient surgeries, this study will be helpful for optimisation of outpatient processes.

TRIAL REGISTRATION: EU CT/CTIS: 2024-520127-89-00. CLINICALTRIALS: gov: NCT07334132.

INTRODUCTION: Emergency department visits are common following bariatric surgery and may be partially preventable. Health literacy and general self-efficacy are factors that may influence health-seeking behaviors in these patients. This study aimed to assess whether health literacy and general self-efficacy are associated with an increased frequency of emergency department visits after bariatric surgery.

METHODS: Patients who underwent bariatric surgery at a single hospital from 2018 to 2020 were evaluated for their health literacy and general self-efficacy levels before surgery. Data on emergency department visits within the patient's residential region were evaluated over a three-year period, with repeated emergency department visits for abdominal pain as the primary outcome.

RESULTS: During the follow-up period, 69 of 231 patients (29.9%) had at least one emergency department visit for abdominal pain, and 20 patients (8.7%) had three or more visits. Inadequate functional health literacy (OR 5.56, 95% CI 1.80-17.19, p = 0.003) and inadequate communicative and critical health literacy (OR 10.48, 95% CI 3.13-35.08, p < 0.001) were both significantly associated with an increased risk of repeated emergency department visits over the three-year period. No significant association was found between low general self-efficacy and the frequency of emergency department visits.

CONCLUSIONS: Inadequate health literacy is associated with an increased risk of repeated emergency department visits for abdominal pain following bariatric surgery.

Background: Antineutrophil cytoplasmic antibody associated vasculitis (AAV), which includes Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA), and Eosinophilic Granulomatosis with Polyangiitis (EGPA) are diseases which can cause patients to experience impaired Health-Related Quality of Life (HRQoL), higher levels of anxiety, depression, and fatigue throughout life. The aim of this study was to explore patient reported HRQoL, anxiety, depression, and fatigue among persons with AAV from different perspectives; Compare levels of HRQoL, anxiety, depression, fatigue and disease characteristics; Describe associations between disease characteristics and HRQoL, anxiety, depression and fatigue; Explore clusters of HRQoL, anxiety and depression.

Methods: This cross-sectional cohort study included adults with new and established diagnosis of AAV. Anxiety and depression were assessed with Hospital Anxiety and Depression Score, e.g., HADS anxiety (HADS-A), and HADS-depression (HADS-D). HRQoL was assessed with EQ-5D-3L (EQ-5D-index), EQ-Visual analogue scale (EQ-VAS), fatigue by Multidimensional assessment of Fatigue (MAF). Disease activity was measured by Birmingham Vasculitis Activity Score (BVAS), and scores ≥ 1 was defined as active disease. Disease duration ≤ 2 years was considered short disease duration. Mann-Whitney U-test and Kruskal Wallis H-test was used where appropriate to compare distributions between groups of patients. Bivariate correlations were analysed with Spearman’s rank-order correlation. A hierarchical cluster analysis was performed, based on EQ-5D-index, EQ-VAS, HADS-A and HADS-D.

Results: 296 patients were included, equally distributed between women; 157 (53%) and men; 139 (57%), with a median age of 63 years (range: 18–90, IQR: 50–70). Two hundred and nine had GPA (70,6%), 75 had MPA (25,3%), and twelve had EGPA (4,1%). Their median BVAS score was 1 (range: 0–33, IQR: 0–12), and 46% had an inactive disease. Median disease duration was 2 years (range: 0–31, IQR: 0–6), and 55% had a disease duration of ≤ 2 years. The median current dose of prednisolone was 5 mg (range: 0–80, IQR: 0–12.5).

HRQoL, measured with EQ-VAS, was higher in patients < 65 years old, those with inactive disease, and those with long disease duration (≥3 years) (p = 0.005–0.017), while EQ-5D-3L only varied with disease activity (p = 0.014). Women, patients with active disease, and patients with shorter disease duration reported more anxiety (p = 0.001–0.03), and younger persons with active disease and short disease duration reported more fatigue (p = 0.002–0.03).

In the total group, disease activity and disease duration were both associated with HRQoL, anxiety, depression, and fatigue (rs -0.279 – 0.286). Among patients with EGPA, a moderate association (rs -0.736) between disease activity and EQ-5D-index, moderate association (rs 0.579) between disease duration and EQ-VAS, and a moderate association (rs -0.699) between disease duration and MAF was observed.

Four clusters based on EQ-5D index, EQ-VAS, and HADS were identified, containing patients with various levels of HRQoL and psychological distress across the disease course. The four clusters were denoted A-D. A: Low HRQoL, mild anxiety/depression, high disease activity and short disease duration. B: High HRQoL, no anxiety/depression, no disease activity and long disease duration. C: Moderate HRQoL, mild anxiety/depression, low disease activity and short disease duration. D: Moderate to high HRQoL, no anxiety/depression, no disease activity and longer disease duration. The four clusters had similar distributions between women, men, and age, and the three diagnoses were represented in each of the four clusters and were distinctive separated by EQ-VAS.

Conclusion: The impact of AAV on HRQoL, anxiety, depression, and fatigue, is persistent and varies depending on disease activity, disease duration, gender, and age. Associations between disease activity, disease duration and HRQOL, anxiety, depression, and fatigue were present in all diagnostic subgroups of AAV. Four clusters revealed the ongoing impact of AAV, emphasizing the continuous need for multiprofessional support during the disease course. In this study, EQ-VAS was better able to effectively distinguish levels of HRQoL than EQ-5D-index.

OBJECTIVES: To explore health-related quality of life (HRQoL), anxiety, depression and fatigue among persons with ANCA-associated vasculitis (AAV).

METHODS: In this cross-sectional study, patients were assessed with the EuroQoL five-dimension three-level questionnaire (EQ-5D-3L) and visual analogue scale (EQ-VAS), the Hospital Anxiety and Depression Score (HADS), and the Multidimensional Assessment of Fatigue questionnaire (MAF).

RESULTS: HRQoL measured with EQ-VAS was higher in younger patients, those with inactive disease (BVAS = 0), and those with long disease duration (≥3 years), while EQ-5D-3L only varied with disease activity. Women, patients with active disease, and patients with shorter disease duration reported more anxiety, and younger persons with active disease and short disease duration reported more fatigue. In the total group, disease activity and disease duration were both associated with HRQoL, anxiety, depression and fatigue. Four clusters based on EQ-5D, EQ-5D index, and HADS were identified, containing patients with various levels of HRQoL and psychological distress across the disease course.

CONCLUSION: In patients with AAV, HRQoL, anxiety, depression, and fatigue, is persistent but varies depending on disease activity, disease duration, gender, and age. Associations between disease activity and duration and HRQOL, anxiety, depression, and fatigue were present in all patients. Four clusters revealed the ongoing influence of AAV, emphasizing the continuous need for multiprofessional support during the disease course. In this study, EQ-VAS was better able than EQ-5D-index to effectively distinguish subgroups with different levels of HRQoL.

After bariatric surgery, adherence to lifestyle recommendations is crucial. Health literacy and self-efficacy may impact recovery after surgery. In this multicentre study performed in three hospitals in Sweden, we evaluated any relation between preoperative health literacy and general self-efficacy on the one side and weight loss, health-related quality of life, length of stay, and complications up to 2 years after bariatric surgery on the other. Of 686 included patients, 56% (n = 382) had limited functional health literacy, 42% (n = 278) had limited communicative and critical health literacy, and 40% (n = 266) reported low general self-efficacy. Preoperative functional, communicative and critical health literacy, and general self-efficacy were not associated with the degree of weight loss at 1 or 2 years after surgery. However, limited health literacy and low general self-efficacy scores were associated with both reduced quality of life and obesity-related problems postoperatively. Further, a higher proportion of those with inadequate health literacy had a prolonged length of stay. Although patients with limited health literacy and self-efficacy may experience similar maximum weight loss after bariatric surgery as other patients, they still might have reduced health-related quality of life in terms of obesity-related problems. Increased awareness of this association as well as patient-centered support before and after bariatric surgery may be of benefit.

AIM: To identify key aspects of recovery-oriented practice in caring for people with mental ill-health in general emergency departments.

DESIGN: A modified Delphi study with three rounds.

METHODS: A 24-member expert panel was recruited consisting of people with lived experience of mental ill-health, registered nurses working in emergency care, registered nurses specialised in psychiatric and mental health nursing and mental health recovery researchers. In the initial round, important aspects of recovery-oriented practice were identified through focus group interviews. Thematic analysis generated statements that were then reformulated as a questionnaire for subsequent rounds. The experts rated each statement's perceived importance on a 5-point Likert scale. The consensus level was set at ≥ 80%. Descriptive statistics were used to analyse the data.

RESULTS: Consensus was reached on the importance of 39 of 73 statements, with ≥ 80% deemed 'very important' in recovery-oriented practice in general emergency departments.

CONCLUSION: The study emphasises the delicate balance between the essential elements of recovery-oriented practice, their practical feasibility and the predominant biomedical perspective in general emergency department care. It proposes strategies to empower nursing staff and managers to adopt recovery-oriented practices that enhance the quality of care for people with mental ill-health. Enabling staff by providing the necessary prerequisites and a care environment that supports reflective practices is crucial. The responsibility for facilitating these changes needs to be a shared commitment between nursing staff and managers.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The identified issues can serve as a framework for interventions, education and training to support the integration of recovery-oriented practice in general emergency care. They can also be used to develop tools for evaluating emergency care environments and promoting alignment with recovery-oriented principles.

IMPACT: Problem addressed: People with mental ill-health are at risk of being neglected, judged and dismissed in general emergency department care, creating obstacles to their mental health recovery.

MAIN RESULTS: The Delphi study identified 39 key aspects of recovery-oriented practice in general emergency departments, emphasising person-centred, strength-based, collaborative and reflective care.

IMPACT: The research seeks to establish a foundation for developing training programmes, education and interventions and for the integration of recovery-oriented practices in general emergency care. It thus has the potential to enhance the quality and equality of care for patients with mental ill-health in emergency care. The impact extends to nursing staff and managers as it seeks to empower them to systematically reflect on and reevaluate established emergency department practices to ensure that every person, irrespective of their health condition, is treated with dignity and respect in emergency department settings.

REPORTING METHOD: The CREDES guidance on conducting and reporting Delphi studies.

PATIENT OR PUBLIC CONTRIBUTION: The authors have nothing to report.

Background: Antineutrophil cytoplasmic antibody associated vasculitis (AAV), which includes Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA), and Eosinophilic Granulomatosis with Polyangiitis (EGPA) are diseases which can cause patients to experience impaired Health-Related Quality of Life (HRQoL), higher levels of anxiety, depression, and fatigue throughout life.

Objectives: The aim of this study is to explore patient reported HRQoL, anxiety, depression and fatigue among persons with AAV from different perspectives: Compare levels of HRQoL, anxiety, depression, fatigue and disease characteristics; Describe associations between disease characteristics and HRQoL, anxiety, depression and fatigue; Explore clusters of HRQoL, anxiety and depression.

Methods: This cross-sectional cohort study included adults with new and established diagnose of AAV. Anxiety and depression were assessed with Hospital Anxiety and Depression Score, e.g., HADS anxiety (HADS-A), and HADS-depression (HADS-D). HRQoL was assessed with EQ-5D-3L (EQ-5D-index), EQ-Visual analogue scale, (EQ-VAS), fatigue by Multidimensional assessment of Fatigue, (MAF). Disease activity was measured by Birmingham Vasculitis Activity Score (BVAS), scores ≥ 1 was defined as active disease. Disease duration ≤ 2 years was considered short disease duration. Mann-Whitney U-test and Kruskal Wallis H-test was used where appropriate to compare distributions between groups of patients. Bivariate correlations were analysed with Spearman's rank-order correlation. A hierarchical cluster analysis was performed, based on EQ-5D-index, EQ-VAS, HADS-A and HADS-D.

Results: 296 patients were included, equally distributed between women; 157 (53%) and men; 139 (57%), with a mean age of 59 years (SD 15.6, range 18-90). Two hundred and nine had GPA (70,6%), 75 had MPA (25,3%), and twelve had EGPA (4,1%). Mean disease duration was 4.2 years (SD 5.5, range 0-31). 55% of patients had a disease duration of ≤ 2 years, and 45% ≥ 3 years, and mean BVAS score was 6.3 (SD 8.68, range 0-33). Distributions of EQ-5D-index, EQ-VAS, HADS-A, HADS-D and MAF were similar for all three AAV diagnosis (p=0.35 - 0.69). HADS-A was higher in females, patients with active disease, and patients with short disease duration (p=0.001 - 0.013). EQ-5D-index was higher in patients with inactive disease (p=0.014). EQ-VAS was higher in patients with inactive disease, long disease duration and age > 65 years (p=0.005 - 0.017). MAF was higher in patients with active disease, short disease duration and < 65 years old (p=0.03 - 0.05). Weak associations were found among all patients between disease activity respective disease duration and EQ-VAS, MAF, HADS-A and HADS-D (rs -0.279 - 0.286). Among patients with EGPA, a moderate negative association (rs -0.736) between disease activity and EQ-5D-index, moderate positive (rs 0.579) association between disease duration and EQ-VAS, and a moderate negative association between disease duration and MAF (rs -0.699) was observed. Four clusters were identified based on EQ-5D-index, EQ-VAS, HADS-A and HADS-D. A: Low HRQoL, mild anxiety/depression, high disease activity and short disease duration. B: High HRQoL, no anxiety/depression, no disease activity and long disease duration. C: Moderate HRQoL, mild anxiety/depression low disease activity and short disease duration. D: Moderate to high HRQoL, no anxiety/depression, no disease activity and longer disease duration. All four clusters had similar distributions between women, men, and age, and the three diagnoses were represented in each of the four clusters (Table 1).

Conclusion: In this study we evaluated the impact of AAV on patients HRQoL, psychological well-being and fatigue. Disease activity, disease duration, gender and age affected HRQoL, anxiety, depression, and fatigue. In the small group of EGPA strong associations were found between HRQoL measured with EQ-index, and BVAS, as well as between HRQoL measured with EQ-VAS, fatigue and disease duration. The cluster analysis describes the impact of AAV on a person's life in different stages of the disease, which highlights the continuous need for multi professional care during the disease course. Interestingly, in this study it appears that EQ-VAS better distinguish levels of HRQoL, than EQ-5D-index, which should be further investigated.

Health literacy (HL) is a critical determinant of health, as it affects health behavior and outcomes, in addition to equity in health. This study aimed to translate, culturally adapt, and validate the Swedish version of HLS19-Q12 (HLS19-Q12-SE). The HLS19-Q12 is a widely used instrument that consists of 12-items and is often used to assess HL in Europe. A convergent mixed-methods design was applied, including cognitive interviews (n = 8) and psychometric testing with a survey sample (n = 374) and test-retest group (n = 28). The instrument was forward and backwards translated and culturally adapted. Data was analyzed using confirmatory and exploratory factor analysis, correlation testing, and reliability assessments. Cognitive interviews explored the clarity, interpretation, and contextual relevance of the items. Participants found the HLS19-Q12-SE clear and easy to understand, though some reported difficulties with unfamiliar health situations and uncertainty of the term "health information." Based on the interviews, the examples for one of the items were culturally adapted. Psychometric testing showed good feasibility, no floor or ceiling effects on scale level, and moderate positive correlations with other HL instruments, supporting internal and external validity. Structural validity was confirmed, and internal consistency and test-retest reliability were satisfactory. However, ceiling effects were observed at the dichotomous item level, and correlations with self-rated health and social status were low. The HLS19-Q12-SE is a reliable and valid instrument for assessing general HL in Sweden. While psychometric properties were strong overall, future research should address ceiling effects on item level and explore the instrument's performance in more diverse populations.

Background: Patients with antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV), which includes Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA), and Eosinophilic Granulomatosis with Polyangiitis (EGPA), can experience a substantial disease burden with lower Health-Related Quality of Life (HRQoL), higher levels of anxiety, depression and fatigue [1]. Several earlier studies have investigated the extent of patient experiences among two or three patient groups, however, only a few has studied any differences in between the three different AAV patient groups.

Objectives: The aim of this study is to analyse HRQoL, fatigue, anxiety and depression in patients with AAV and to identify any differences between patients with GPA, MPA, and EGPA.

Methods: This is a cross sectional study, consecutively including both newly diagnosed and current adult patients with AAV. For this study, the EQ Visual analogue scale (EQ-VAS, scale 0-100), and the first question in MAF (scale 1-10), assessing degree of fatigue were included in the analysis, besides the two dimensions of HADS anxiety (HADS-A, scale 0-21), and HADS-depression (HADS-D, scale 0-21). Disease activity was measured by Birmingham Vasculitis Activity Score (BVAS). BVAS scores of zero was considered as inactive disease, whereas a BVAS scores ≥ 1 was defined as active disease.

Patient reported outcomes (PROM) were analysed by Kruskal Wallis H test for differences between the tree diagnosis, and Mann-Whitney U test for differences between two groups, e.g short versus long disease duration. Additional bivariate correlations between PROMS and disease durations for patient groups were analysed with Spearman’s rank-order correlation.

Results: Three hundred and fifty-nine patients were included in the analysis, GPA n=250 (70%), MPA n=95 (27%), and EGPA n=14 (4%). In all, the AAV patients were equally distributed between men; 172 (48%) and women; 187 (52%), with a mean age of 59 years (SD 16.3, range 18-90). Forty-two percent of patients had a BVAS of zero, and 58 % a BVAS of ≥ 1. Mean disease duration was 3.7 years (SD 5.3, range 0-31). Sixty percent of patients had a disease duration of ≤ 2 years, and 40% ≥ 3 years.

Distributions of HRQoL, fatigue, anxiety and depression scores were similar for all AAV groups. HRQoL, fatigue, anxiety and depression scores for groups GPA, EGPA, MPA were not statistically significantly different (Table 1).

Patients with disease duration < 2 years compared to disease duration ≥ 3 years reported lower HRQoL (median 60, IQR 47-75, vs median 70, IQR 50-80, p= 0.005), higher fatigue (median 7, IQR 5-8 vs median 7, IQR 4-8, p= 0.014) and depression (median 6, IQR 3-9 vs median 4, IQR 2-7, p= 0.004). No significant differences were found for anxiety (median 4, IQR 2-7, vs median 3, IQR 1-6, p= 0.080), between short and long disease duration.

Significant, however weak associations were found between disease duration and HRQoL, fatigue, anxiety and depression in all patients (rs <0.29) and the subgroups GPA (rs < 0.30) and MPA (rs <0.31). In the small group of EGPA, disease duration had stronger associations than GPA and MPA, for disease duration and all explored PROMs (rs < 0.61) (Table 2.).

Conclusion: No significant differences in HRQoL, fatigue, anxiety and depression median scores were found between the three patient groups GPA, MPA, and EGPA. In all patients, a weak correlation was found between disease duration and HRQoL, fatigue, anxiety and depression. However, the group with EGPA had a stronger association between disease duration and both HRQoL and fatigue, which indicates some differences between diagnoses, that should be further explored. Additionally, patients with disease duration < 2 years reported worse HRQoL, fatigue, and depression which indicate that patients with AAV need special attention during the first two years after diagnosis.

Objective: This review aims to describe interventions that promote health literacy in a surgical setting and identify knowledge gaps for future research.

Methods: A scoping review with a systematic search was performed in Medline, CINAHL, Scopus, and Web of Science between January 1, 2012, and January 23, 2024. All screening was conducted using the Covidence software. In total, the search yielded 6 281 articles.

Results: Eighteen articles were included in the results. Studies were heterogeneous regarding the type of health literacy measured, type of surgery, and type of intervention. Most interventions were educational to improve knowledge, decision making or health literacy through digital media, group sessions or consent forms. Most interventions had a positive impact on health literacy.

Conclusions: Patients with limited health literacy may benefit from a variety of interventions. However, research in this area is sparse. Further research is needed into interventions that may be beneficial for patients.

Practice implications: Measure, evaluate and implement health literacy-friendly options to ensure people can make safe and sound decisions for their care. Researchers need to consider the type of health literacy investigated and the type of instrument used in the research.