To Örebro University

BACKGROUND: Intensive care unit (ICU) admissions among older patients are increasing, posing significant challenges to already strained healthcare systems. Decision-making around ICU admission in times of limited resources may provide important knowledge about difficult prioritisations, particularly for older patients. Thus, the aim was to investigate ICU-admission decisions for older patients with COVID-19.

METHODS: A mixed-methods approach. We audio-recorded ten COVID Rounds and nine Moral Case Deliberations for 34 patients across three Swedish hospitals during the pandemic, and collected data from medical records of 329 patients aged ≥ 65 diagnosed with COVID-19. Data were analysed using qualitative content analysis and multiple regression.

RESULTS: Among 239 patients with documented decisions in medical records, 56% included explicit justifications. The justifications included considerations of medical benefit (not-too- ill/too-ill), general condition (good/frail), age (not-too-old/high age), professional duty (benefit of the doubt/do no harm) and "worth giving it a go" (grit and will to live/lack of will and coping). A minority (31%) of decisions favoured ICU admission. Justifications supporting admission were predominantly drawn from discussions in COVID Rounds and MCDs, where patient grit was a recurring argument. In regression analyses, age ≥ 80 years was the only factor significantly associated with not being admitted to ICU and having a documented justification. Few decisions explicitly referred to COVID-19-specific factors.

CONCLUSION: Our findings reflect patterns similar to pre-pandemic ICU decision-making, suggesting continuity in clinical reasoning. However, the limited documentation of justifications-especially in favour of admission-warrants attention, emphasising the need for clearer reasoning in medical records. Our findings identify chronological age as a key triage factor, normatively supported by the ethical principles of non-maleficence, justice, and Sweden's legal priority-setting principle of Needs and Solidarity-which emphasises care only when benefit is likely. We therefore advocate for national (and potentially international) guidance on triage systems that support a palliative approach for very old patients. While grit may be relevant to ICU admission due to its link to potential benefit, its use raises ethical concerns, particularly in relation to Needs and Solidarity and Human Dignity. We recommend its cautious application pending further research.

BACKGROUND: Coping with disabilities after stroke in midlife can be challenging, with potential gender differences that may have implications for quality of life (QoL) and support. This study aimed to explore QoL and resilience among midlife stroke survivors from a gender perspective.

METHODS: Quantitative questionnaire data related to demographics, function, service, resilience and QoL were gathered from a stroke register including 51 individuals (of whom 29 were men) aged 40-64 years. Results of gender were compared using two-sided t-tests and chi-square tests. Additionally, eight semi-structured telephone interviews were conducted, with equal representation of men and women. Qualitative content analysis was used to explore deeper and capture nuanced insights.

RESULTS: The quantitative analysis revealed no statistically significant gender differences. However, the qualitative data revealed three central themes: (1) "A Forced Lifestyle Change," (2) "Lack of Understanding and Support," and (3) "Importance of Independence and Coping Strategies." Men talked about feelings of being restricted in their post-stroke lives and expressed a greater need for support from healthcare providers, family, and friends. In contrast, women described having more well-developed coping strategies and reported a higher perceived QoL.

CONCLUSION: Qualitative findings suggest men may face greater challenges in adapting to post stroke life. The result suggests that men struggle with accepting limitations that prevent them from participating in social contexts and require more support from healthcare services. These difficulties, potentially due to less effective coping mechanisms, may result in a lower QoL. Gender-sensitive interventions addressing these needs could improve QoL and adaptation.

BACKGROUND: Post-stroke fatigue (PSF) is a common complication following stroke that affects approximately 50% of stroke survivors.

PURPOSE: The purpose of this study was to investigate the role of comorbidities in PSF and the impact of PSF on Quality of Life (QoL). To achieve this, residual stroke symptoms have also been considered.

METHODS: The participants were stroke survivors living in a Swedish municipality. Self-reported data were collected via the Fatigue Assessment Scale (FAS), the Riksstroke questionnaire, and the Short Form Health Survey 36 (SF-36). Linear multiple regression and Spearman's correlation coefficient were used to analyze the data.

RESULTS: A total of 142 participants (83 men) with a mean age of 74.8 (SD 9.7) years were included in the study. Fatigue levels were classified as normal (FAS 10-21) for 70 (49.3%) individuals, mild-to-moderate (FAS 22-34) for 56 (39.4%) individuals, and severe (FAS 35-50) for 16 (11.3%) individuals. The mean FAS score was 23.3 (SD 8.2). Multiple regression analysis indicated that the presence of vertigo (β = 0.24, p = 0.004), chronic pulmonary disorders (β = 0.29, p = 0.003), and hemiparesis (β = 0.18, p = 0.05) were associated with more severe PSF. The model explained 19.2% of the variance in PSF. A higher level of PSF was associated with worse QoL in all eight SF-36 domains (r = -0.38 to -0.67).

CONCLUSIONS: Vertigo, chronic pulmonary disorders, and hemiparesis were significantly associated with more severe PSF. Additionally, higher levels of fatigue were associated with a worse QoL. These findings confirm that PSF is a multifaceted phenomenon, underscoring the importance of addressing PSF in rehabilitation to improve outcomes for stroke survivors.

INTRODUCTION: Adherence to wearing prescribed footwear is paramount in reducing the risk of developing diabetes-related foot ulcers, but adherence is often lower than optimal. This study aimed to investigate predictors of footwear adherence and variations in adherence and activity in people at risk of diabetes-related foot ulceration.

METHODS: Sixty people at high foot ulcer risk were included. We measured the proportion of weight-bearing acitivity time the prescribed footwear was worn for seven days. Multiple linear regression and analysis of variance were used.

RESULTS: Mean overall adherence was 63%. Adherence was lower at home than away from home (59% vs. 74%), while activity was higher at home (2.2 vs. 1.2 h/day). Adherence was similar across activities (61%-63%). No variable predicted the overall adherence. Higher Hba1c predicted lower adherence at home (β = -0.34, p = 0.045, R2 = 11.6%). More daily steps predicted lower adherence away from home (β = -0.30, p = 0.033, R2 = 9.3%). Adherence and activity were highest in mornings (71%, 1.1 h) and afternoons (71%, 1.5 h), and lower in evenings (40%, 0.8 h) and at nights (9%, 0.1 h). Adherence was similar on weekdays and weekend days (63% vs. 60%), but activity was higher on weekdays (3.4 vs. 3.0 h).

CONCLUSION: Adherence levels and predictors thereof differed between adherence at home and away from home, so we suggest to treat them as different concepts. Due to the low explained variance, future studies should focus on other predictors such as psychological variables.

BACKGROUND: Despite the presence of both national and regional clinical practical guidelines (CPGs) in Sweden, no previous studies have investigated the quality of CPGs or the level of agreement between national and regional CPGs.

OBJECTIVES: This study aimed to assess the quality of national CPGs recommending prosthetics and orthotics (P&O) and quantify the agreement between national and regional CPGs in Sweden.

STUDY DESIGN: Literature Review.

METHODS: National and regional CPGs were identified in public databases and by surveyed local nurse practitioners. Quality of the national guidelines was assessed by using AGREE II. Agreement between recommendations in the national and regional CPGs was quantified on a 4-grade rating scale ("similar," "partially similar," "not similar/not present," and "different").

RESULTS: Of 18 national CPGs, 3 CPGs (CPGs of Diabetes, Musculoskeletal disorders, and Stroke) had 9 recommendations related to P&O. The Musculoskeletal disorders and Stroke CPGs had quality scores .60% in all domains, and the Diabetes CPG had scores .60% in 5 of 6 domains according to AGREE II. Seven regional CPGs for P&O treatment were identified. Three national recommendations (in Diabetes CPGs) showed "similar" content for all regions, and 2 national recommendations (in Diabetes CPGs) showed "not similar" content for all regions. The remaining recommendations (Diabetes, Musculoskeletal disorders, and Stroke CPGs) had varying agreement with regional CPGs.

CONCLUSIONS: There is a limited number of national recommendations for treatment within P&O. There was variation in the agreement of P&O-related recommendations in national and regional CPGs, which might lead to unequal care throughout the national healthcare system.

AIMS: Risk factors for lower limb amputation (LLA) in individuals with diabetes have been under-studied. We examined how 1/demographic and socioeconomic, 2/medical, and 3/lifestyle risk factors may be associated with LLA in people with newly diagnosed diabetes.

METHODS: Using the Swedish national diabetes register from 2007 to 2016, we identified all individuals ≥18 years with an incident diabetes diagnosis and no previous amputation. These individuals were followed from the date of diabetes diagnosis to amputation, emigration, death, or the end of the study in 2017 using data from the In-Patient Register and the Total Population Register. The cohort consisted of 66,569 individuals. Information about demographic, socioeconomic, medical, and lifestyle risk factors was ascertained around the time of the first recorded diabetes diagnosis, derived from the above-mentioned registers. Cox proportional hazard models were used to obtain hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS: During the median follow-up time of 4 years, there were 133 individuals with LLA. The model adjusting for all variables showed a higher risk for LLA with higher age, HR 1.08 (95% CI 1.05-1.10), male sex, HR 1.57 (1.06-2.34), being divorced, HR 1.67 (1.07-2.60), smokers HR 1.99 (1.28-3.09), insulin treated persons HR 2.03 (1.10-3.74), people with low physical activity (PA) HR 2.05 (1.10-3.74), and people with an increased foot risk at baseline HR > 4.12. People with obesity had lower risk, HR 0.46 (0.29-0.75).

CONCLUSIONS: This study found a higher risk for LLA among people with higher age, male sex, who were divorced, had a higher foot risk group, were on insulin treatment, had lower PA levels, and were smokers. No significant association was found between risk for LLA and education level, country of origin, type of diabetes, blood glucose level, hypertension, hyperlipidemia, creatinine level, or glomerular filtration rate. Obesity was associated with lower risk for LLA. Identified variables may have important roles in LLA risk among people with diabetes.

AIMS: Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.

MATERIALS AND METHODS: We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability.

RESULTS: For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice.

CONCLUSION: These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

Purpose: The aim was to investigate the associations between cognitive impairment and biopsychosocial factors among older stroke survivors and predictors of poststroke return to daily life.

Materials and methods: This cross-sectional study involved 117 stroke survivors (61% men) with an average age of 77 years (range 65-91). The participants completed two questionnaires (Riksstroke and Short Form 36 questionnaires). The Montreal Cognitive Assessment (MoCA) was used to assess cognitive abilities. The International Classification of Functioning, Disability, and Health (ICF) framework guided the selection of biopsychosocial variables. We used Spearman's correlation coefficient and multiple logistic regression in the analyses.

Results: The average MoCA score was 21.7 points (range: 4-30, SD 5.6). The need for assistance from relatives and professionals, need for help with dressing and household chores, reliance on others for mobility, and reading and balance problems were correlated with more severe cognitive impairment (r = 0.20-0.33). Cognitive impairment, fatigue, and balance issues predicted an unfavorable return to daily life (odds ratio: 6.2-6.8).

Conclusion: The study indicated that cognitive impairment is associated with difficulties in all ICF domains. Cognitive impairment, fatigue, and balance issues are associated with an unsuccessful return to daily life. Prioritizing these factors and screening for cognitive impairment with objective assessment tools may improve rehabilitation outcomes and enhance overall quality of life poststroke.