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Holmström, Gerd
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Publications (10 of 61) Show all publications
Klevebro, S., Hammar, U., Holmström, G., Bottai, M., Hellstrom, A. & Hallberg, B. (2019). Adherence to oxygen saturation targets increased in preterm infants when a higher target range and tighter alarm limits were introduced. Acta Paediatrica, 108(9), 1584-1589
Open this publication in new window or tab >>Adherence to oxygen saturation targets increased in preterm infants when a higher target range and tighter alarm limits were introduced
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2019 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 108, no 9, p. 1584-1589Article in journal (Refereed) Published
Abstract [en]

Aim

European consensus guidelines published in May 2013 recommended a target peripheral capillary oxygen saturation (SpO2) range of 90–95% for preterm infants. These were incorporated into guidelines at the Karolinska University Hospital, Sweden, in November 2013. This study compared clinical practice before and after those local guidelines.

Methods

We included infants who were born between 23 + 0 and 30 + 6 weeks from January 1, 2013 to December, 31 2015 and received intensive care in two Karolinska units. The lower saturation target of 88–92% and alarm limits of 85–95% used before November 2013 were compared to the new higher saturation target of 90–95% and alarm limits of 89–96%.

Results

Data from 399 infants were analysed. The mean SpO2 was 92.4% with the higher target (n = 301) and 91.1% with the lower target (n = 98). Using the higher instead of lower target meant that the SpO2 was within the prescribed target range more frequently (51% versus 30%) and the proportion of time with SpO2 >95% was increased by 9% (95% confidence interval 7–11%, p < 0.001).

Conclusion

The higher saturation target and tighter alarm limits led to higher mean oxygen saturation, increased adherence to the target and increased time with hyperoxaemia.

Keywords
Oxygenation, Preterm infants, Pulse oximetry, Retinopathy of prematurity, Saturation target
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-393865 (URN)10.1111/apa.14808 (DOI)000479320100007 ()30951230 (PubMedID)
Available from: 2019-09-30 Created: 2019-09-30 Last updated: 2019-09-30Bibliographically approved
Norman, M., Hellstrom, A., Hallberg, B., Wallin, A., Gustafson, P., Tornqvist, K., . . . Holmström, G. (2019). Prevalence of Severe Visual Disability Among Preterm Children With Retinopathy of Prematurity and Association With Adherence to Best Practice Guidelines. JAMA NETWORK OPEN, 2(1), Article ID e186801.
Open this publication in new window or tab >>Prevalence of Severe Visual Disability Among Preterm Children With Retinopathy of Prematurity and Association With Adherence to Best Practice Guidelines
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2019 (English)In: JAMA NETWORK OPEN, ISSN 2574-3805, Vol. 2, no 1, article id e186801Article in journal (Refereed) Published
Abstract [en]

IMPORTANCE Retinopathy of prematurity (ROP) can cause severe visual disability even in high-resource settings. A better understanding of the prevalence and processes leading to ROP-induced severe visual impairment may help health care professionals design preventive measures. OBJECTIVES To determine the prevalence of severe visual disability among children born preterm in Sweden, evaluate adherence to best practice, and determine the health system's structural capacity. DESIGN, SETTING, AND PARTICIPANTS Population-based, nationwide cohort study of 1 310 227 children born between January 1, 2004, and December 31, 2015, in Sweden, of whom 17 588 (1.3%) were born very preterm (<32 weeks of gestation). Children born preterm with a verified diagnosis of severe visual disability had their medical records reviewed for evaluation of ROP screening, diagnosis, and treatment. In addition, a questionnaire on structural capacity was sent to all ophthalmology departments. EXPOSURES Stages 4 and 5 ROP. MAIN OUTCOMES AND MEASURES The primary outcome was prevalence of severe visual disability (visual acuity similar to 20/200 for both eyes) associated with ROP stages 4 and 5. Secondary outcomes included adherence to national ROP guidelines using a predefined protocol with 15 key performance indicators for screening, diagnosis, and treatment; assessment of whether visual disability was deemed avoidable; and examination of structural capacity, including information on equipment and facilities, staffing, and patients. RESULTS Seventeen children (10 boys; mean [range] birth weight, 756 [454-1900] g; mean [range] gestational age, 25 [22-33] weeks) became severely visually disabled because of ROP, corresponding to a prevalence of 1 in 1000 very preterm infants (< 32 weeks of gestational age) and 1 in 77 000 for all live births. Severe visual impairment was considered potentially avoidable in 11 of 17 affected children (65%) owing to untimely or no screening, missed diagnosis, or untimely and suboptimal treatment. Large variations in infrastructure (facilities, guidelines, staffing, and annual patient numbers) were also identified as potential contributors to these findings. CONCLUSIONS AND RELEVANCE Retinopathy of prematurity still causes severe visual disability in Sweden, resulting in 1 affected infant per 1000 very preterm births. In most of these infants, noncompliance with best practice was identified, indicating that a significant proportion could have been avoided.

Place, publisher, year, edition, pages
AMER MEDICAL ASSOC, 2019
National Category
Ophthalmology
Identifiers
urn:nbn:se:uu:diva-383210 (URN)10.1001/jamanetworkopen.2018.6801 (DOI)000465422700045 ()30646195 (PubMedID)
Available from: 2019-05-23 Created: 2019-05-23 Last updated: 2019-05-23Bibliographically approved
Söderström, F., Normann, E., Holmström, G., Larsson, E., Ahlsson, F., Sindelar, R. & Ågren, J. (2019). Reduced rate of retinopathy of prematurity after implementing lower oxygen saturation targets.. Journal of Perinatology, 39, 409-414
Open this publication in new window or tab >>Reduced rate of retinopathy of prematurity after implementing lower oxygen saturation targets.
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2019 (English)In: Journal of Perinatology, ISSN 0743-8346, E-ISSN 1476-5543, Vol. 39, p. 409-414Article in journal (Refereed) Published
Abstract [en]

Objective: To evaluate an implementation of lower oxygen saturation targets with retinopathy of prematurity (ROP) as primary outcome, in infants at the lowest extreme of prematurity.

Study design: Retrospective cohort including infants born at 22-25 weeks of gestation in 2005-2015 (n = 325), comparing high (87-93%) and low (85-90%) targets; infants transferred early were excluded from the main analysis to avoid bias.

Results: Overall survival was 76% in high saturation era, and 69% in low saturation era (p = .17). Treatment-requiring ROP was less common in low saturation group (14% vs 28%, p < .05) with the most prominent difference in the most immature infants. Including deceased infants in the analysis, necrotizing enterocolitis was more frequent in low saturation era (21% vs 10%, p < .05).

Conclusions: Implementing lower saturation targets resulted in a halved incidence of treatment-requiring ROP; the most immature infants seem to benefit the most. An association between lower oxygenation and necrotizing enterocolitis cannot be excluded.

National Category
Pediatrics
Research subject
Pediatrics
Identifiers
urn:nbn:se:uu:diva-368851 (URN)10.1038/s41372-018-0300-y (DOI)000459549600010 ()30617284 (PubMedID)
Available from: 2018-12-08 Created: 2018-12-08 Last updated: 2019-03-26Bibliographically approved
Norman, M., Källén, K., Wahlström, E., Håkansson, S., Skiöld, B., Navér, L., . . . Wallin-Gyökeres, A. (2019). The Swedish Neonatal Quality Register - contents, completeness and validity. Acta Paediatrica, 108(8), 1411-1418
Open this publication in new window or tab >>The Swedish Neonatal Quality Register - contents, completeness and validity
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2019 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 108, no 8, p. 1411-1418Article in journal (Refereed) Published
Abstract [en]

Aim: To describe the Swedish Neonatal Quality Register (SNQ) and to determine its completeness and agreement with other registers.

Methods: SNQ collects data for infants admitted to neonatal units during the first four postnatal weeks. Completeness and registers' agreement were determined cross-linking SNQ data with Swedish population registers (the Inpatient, Medical Birth and Cause of Death Registers) for a study period of five years.

Results: In total, 84 712 infants were hospitalised. A total of 52 806 infants occurred in both SNQ and the population registers; 28 692 were only found in the population registers, and 3214 infants were only found in SNQ. Between gestational weeks 24-34, completeness of SNQ was 98-99%. Below and above these gestational ages, completeness was lower. Infants missing in SNQ were term or near-term in 99% of the cases, and their diagnoses indicated conditions managed in maternity units, or re-admissions for acute infections, managed in paediatric units. For most diagnoses, the agreement between SNQ and population registers was high, but some (bronchopulmonary dysplasia and grade of hypoxic-ischaemic encephalopathy) were often missing in the population registers.

Conclusion: SNQ completeness and agreement against other registers, especially for preterm infants, is excellent. SNQ is a valid tool for benchmarking, quality improvement and research.

Place, publisher, year, edition, pages
WILEY, 2019
Keywords
Completeness, Newborn infant, Quality of neonatal care, Register, Validation
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-390497 (URN)10.1111/apa.14823 (DOI)000474935600009 ()31006126 (PubMedID)
Funder
Stockholm County Council
Available from: 2019-08-14 Created: 2019-08-14 Last updated: 2019-08-14Bibliographically approved
Hellström, A., Källen, K., Carlsson, B., Holmström, G., Jakobsson, P., Lundgren, P., . . . Hellgren, K. (2018). Extreme prematurity, treated retinopathy, bronchopulmonary dysplasia and cerebral palsy are significant risk factors for ophthalmological abnormalities at 6.5 years of age. Acta Paediatrica, 107(5), 811-821
Open this publication in new window or tab >>Extreme prematurity, treated retinopathy, bronchopulmonary dysplasia and cerebral palsy are significant risk factors for ophthalmological abnormalities at 6.5 years of age
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2018 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 107, no 5, p. 811-821Article in journal (Refereed) Published
Abstract [en]

Aim: This study evaluated the contributions of various prenatal and postnatal predictive factors to a documented high prevalence of ophthalmological abnormalities in children aged 6.5 years who were born extremely preterm.

Methods: We carried out a prospective population‐based study of all children born in Sweden at a gestational age of 22 + 0 to 26 + 6 weeks based on the Extremely Preterm Infants in Sweden Study. The main outcome measures were a combined score of visual impairment, refractive errors and strabismus at 6.5 years of age. Models of univariate and multivariable regression were used to analyse potential prenatal and postnatal predictive factors at different clinically relevant time‐points from one minute after birth to 30 months.

Results: We focused on 399 known extremely preterm survivors and compared them to 300 full‐term controls. Significant antecedents for ophthalmological abnormalities included prematurity per se, retinopathy of prematurity that required treatment, severe bronchopulmonary dysplasia and cerebral palsy. Severe intraventricular haemorrhage was no longer a significant risk factor when we adjusted it for the 30‐month cognitive and neuromotor development outcomes.

Conclusion: This time‐course risk analysis model showed a changing panorama of significant risk factors for ophthalmological abnormalities in children aged 6.5 years who were born extremely preterm.

Keywords
Bronchopulmonary dysplasia, Intraventricular haemorrhage, Ophthalmological outcome, Perinatal risk factors, Retinopathy of prematurity
National Category
Pediatrics Ophthalmology
Identifiers
urn:nbn:se:uu:diva-353365 (URN)10.1111/apa.14206 (DOI)000430115100015 ()29281748 (PubMedID)
Funder
Swedish Research Council, 2006-3858]Swedish Research Council, 2009-4250]Swedish Society of Medicine
Available from: 2018-06-19 Created: 2018-06-19 Last updated: 2018-06-19Bibliographically approved
Hreinsdottir, J., Kaul, Y. F., Hellström-Westas, L., Rosander, K., von Hofsten, C. & Holmström, G. (2018). Impaired cognitive ability at 2.5 years predicts later visual and ophthalmological problems in children born very preterm. Acta Paediatrica, 107(5), 822-830
Open this publication in new window or tab >>Impaired cognitive ability at 2.5 years predicts later visual and ophthalmological problems in children born very preterm
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2018 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 107, no 5, p. 822-830Article in journal (Refereed) Published
Abstract [en]

Aim: To identify possible predictive factors for visual problems at 6.5 years in children born very preterm.

Methods: During 2004–2007, all very preterm infants (gestational age [GA] <32 weeks) in Uppsala County, Sweden were screened for retinopathy of prematurity (ROP) neonatally; at four months, visual tracking was tested; at 2.5 years, visuospatial and cognitive tests were carried out. At 6.5 years, 84 preterm children and a reference group of 64 full‐term children underwent ophthalmological testing.

Results: Mean visual acuity (VA) did not differ between the groups, but subnormal VA (≤0.8) was more common in the preterm group (31% vs 14%; p < 0.05). More often than full‐term children, preterm children had impaired contrast sensitivity (<0.5) (36% vs 19%; p < 0.05) and strabismus (8% vs 0%; p < 0.05). Low GA, ROP, intraventricular haemorrhage 3‐4/periventricular leukomalacia and cognitive disability at 2.5 years predicted ophthalmological and visual problems at 6.5 years. Visual tracking ability at four months was not predictive of ophthalmological outcome.

Conclusion: Children born preterm had more ophthalmological problems at 6.5 years of age, including subtle dysfunctions. ROP, early brain injury and impaired cognitive function around 2.5 years predicted later ophthalmological dysfunctions.

Keywords
Cognition, Long term, Risk factor, Very preterm, Visual outcome
National Category
Ophthalmology Pediatrics
Identifiers
urn:nbn:se:uu:diva-348648 (URN)10.1111/apa.14209 (DOI)000430115100016 ()29288532 (PubMedID)
Available from: 2018-04-16 Created: 2018-04-16 Last updated: 2018-06-19Bibliographically approved
Holmström, G., Tornqvist, K., Al-Hawasi, A., Nilsson, Å., Wallin, A. & Hellström, A. (2018). Increased frequency of retinopathy of prematurity over the last decade and significant regional differences. Acta Ophthalmologica, 96(2), 142-148
Open this publication in new window or tab >>Increased frequency of retinopathy of prematurity over the last decade and significant regional differences
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2018 (English)In: Acta Ophthalmologica, ISSN 1755-375X, E-ISSN 1755-3768, Vol. 96, no 2, p. 142-148Article in journal (Refereed) Published
Abstract [en]

Purpose: Retinopathy of prematurity (ROP) causes childhood blindness globally in prematurely born infants. Although increased levels of oxygen supply lead to increased survival and reduced frequency of cerebral palsy, increased incidence of ROP is reported.

Methods: With the help of a Swedish register for ROP, SWEDROP, national and regional incidences of ROP and frequencies of treatment were evaluated from 2008 to 2015 (n=5734), as well as before and after targets of provided oxygen changed from 85-89% to 91-95% in 2014.

Results: Retinopathy of prematurity (ROP) was found in 31.9% (1829/5734) of all infants with a gestational age (GA) of <31weeks at birth and 5.7% of the infants (329/5734) had been treated for ROP. Analyses of the national data revealed an increased incidence of ROP during the 8-year study period (p=0.003), but there was no significant increase in the frequency of treatment. There were significant differences between the seven health regions of Sweden, regarding both incidence of ROP and frequency of treatment (p<0.001). Comparison of regional data before and after the new oxygen targets revealed a significant increase in treated ROP in one region [OR: 2.24 (CI: 1.11-4.49), p=0.024] and a borderline increase in one other [OR: 3.08 (CI: 0.99-9.60), p=0.052].

Conclusion: The Swedish national ROP register revealed an increased incidence of ROP during an 8-year period and significant regional differences regarding the incidence of ROP and frequency of treatment.

Place, publisher, year, edition, pages
WILEY, 2018
Keywords
incidence, oxygen, retinopathy of prematurity, treatment
National Category
Ophthalmology
Identifiers
urn:nbn:se:uu:diva-347537 (URN)10.1111/aos.13549 (DOI)000425369200039 ()29068172 (PubMedID)
Available from: 2018-04-04 Created: 2018-04-04 Last updated: 2018-04-04Bibliographically approved
Larsson, E., Molnar, A. & Holmström, G. (2018). Repeatability, reproducibility and interocular difference in the assessments of optic nerve OCT in children– a Swedish population-based study. BMC Ophthalmology, 18(270), Article ID 30348126.
Open this publication in new window or tab >>Repeatability, reproducibility and interocular difference in the assessments of optic nerve OCT in children– a Swedish population-based study
2018 (English)In: BMC Ophthalmology, ISSN 1471-2415, E-ISSN 1471-2415, Vol. 18, no 270, article id 30348126Article in journal (Refereed) Published
Abstract [en]

Background: The aim was, first, to collect normative data of the optic nerve head and the peripapillary retinal nerve fibre layer (RNFL) thickness assessed with Cirrus SD-OCT, in healthy children in a population-based study; second, using these data, to examine repeatability, reproducibility and the interocular difference.

Methods: One-hundred and ten eyes from 57 children aged 6–15 born at term, were examined. Best-corrected visual acuity and refraction were assessed. Both eyes were examined and the interocular difference was calculated. Repeatability was calculated by one examiner performing three assessments. Thereafter, a second examiner repeated the assessments to calculate reproducibility.

Results: Mean RNFL thickness was 99.2 (SD 8.8) μm, mean disc area 1.89 (SD 0.37) mm2 and mean rim area 1.52 (SD 0.26) mm2. No significant correlations with age, gender or refraction were found. Repeatability and reproducibility were good overall. There was interocular symmetry between the eyes.

Conclusions: Normal values for optic nerve head and RNFL thickness assessed with Cirrus SD-OCT were gathered to obtain a normal material in children. High repeatability and reproducibility indicated reliability of assessments performed by different examiners on different occasions. Overall, good correlation between right and left eyes was found.

Place, publisher, year, edition, pages
London: Springer, 2018
Keywords
Optical coherence tomography (OCT), Children, Normal values, Repeatability, Reproducibility, Interocular difference
National Category
Ophthalmology
Research subject
Ophtalmology
Identifiers
urn:nbn:se:uu:diva-365158 (URN)10.1186/s12886-018-0940-x (DOI)000448013500001 ()30348126 (PubMedID)
Funder
Swedish Society of Medicine
Available from: 2018-11-09 Created: 2018-11-09 Last updated: 2019-01-14Bibliographically approved
Åkerblom, H., Holmström, G. & Larsson, E. (2018). The rim area of the optic nerve head, assessed with Heidelberg retina tomography, is smaller in prematurely born children than in children born at term. Acta Ophthalmologica, 96(7), 699-704
Open this publication in new window or tab >>The rim area of the optic nerve head, assessed with Heidelberg retina tomography, is smaller in prematurely born children than in children born at term
2018 (English)In: Acta Ophthalmologica, ISSN 1755-375X, E-ISSN 1755-3768, Vol. 96, no 7, p. 699-704Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To examine the optic nerve head with Heidelberg tomography (HRT) in prematurely born school-age children and compare them to children born at term.

METHODS: Sixty-three 5-16-year-old children born with a gestational age (GA) of ≤32 weeks were included in the study and compared to 54 children of the same age, born at term. In the preterm group, 29 children had had retinopathy of prematurity (ROP) and nine children had neurological complications. The optic nerve head was assessed with HRT. Three measurements were performed, and the different topographic parameters were noted.

RESULTS: Rim area of the optic nerve was significantly smaller in prematurely born children than in children born at term. The mean difference was 0.146 mm2 (p = 0.02). No difference between the groups was found regarding disc area or cup area. In the preterm group, both disc and rim areas were reduced with increasing GA. No correlations with birthweight, ROP or neurological complications were found.

CONCLUSION: Reduced rim area of the optic nerve head was found in preterm children of school age. Previous ROP or neurological complication did not influence the result, suggesting the preterm birth per se was the reason for the reduction. Establishing whether this finding was caused by disturbed maturation of the optic nerve or by injury of the axons, or a combination of the two, will require further research.

Keywords
Heidelberg retina tomography, children, optic nerve head, prematurely born
National Category
Clinical Medicine
Research subject
Ophtalmology
Identifiers
urn:nbn:se:uu:diva-360768 (URN)10.1111/aos.13785 (DOI)000451035500005 ()30218494 (PubMedID)
Available from: 2018-09-18 Created: 2018-09-18 Last updated: 2019-01-18Bibliographically approved
Lundgren, P., Lundberg, L., Helgren, G., Holmström, G., Hard, A.-L., Smith, L. E., . . . Hellstrom, A. (2017). Aggressive Posterior Retinopathy of Prematurity Is Associated with Multiple Infectious Episodes and Thrombocytopenia. Neonatology, 111(1), 79-85
Open this publication in new window or tab >>Aggressive Posterior Retinopathy of Prematurity Is Associated with Multiple Infectious Episodes and Thrombocytopenia
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2017 (English)In: Neonatology, ISSN 1661-7800, E-ISSN 1661-7819, Vol. 111, no 1, p. 79-85Article in journal (Refereed) Published
Abstract [en]

Background: The most severe form of rapidly progressing retinopathy of prematurity (ROP) is termed aggressive posterior ROP (APROP). APROP frequently causes severe visual impairment in affected preterm infants despite timely and appropriate laser treatment. Objectives: We investigated the postnatal characteristics associated with APROP development in a national Swedish cohort. Methods: This retrospective, 1: 1 matched case-control study included all infants that developed APROP in zone 1 (n = 9) between 2008 and 2012. Control infants, matched for gestational age and birth weight, developed ROP no worse than stage 2 (n = 9). We retrieved data from medical records on infant birth characteristics, postnatal morbidities, and blood analyses from birth to the first ROP treatment. Infectious episodes included sepsis, C-reactive protein >= 10 mg/l, and other clinical signs of infection that required antibiotic treatment. A plate-let count < 100 x 10(9)/l was considered to be thrombocytopenia. Results: All APROP cases postnatally developed at least two infectious episodes, one in the first month and one around the time of ROP diagnosis. All APROP cases exhibited thrombocytopenia in the first month, and 6/9 exhibited thrombocytopenia around the time of ROP diagnosis. Compared to the controls, APROP cases more frequently developed necrotizing enterocolitis (8/9 vs. 1/9; p < 0.01) and sepsis (9/9 vs. 3/9; p < 0.01), and they had significantly lower median platelet counts (90 x 10 (9)/l, range 4-459, vs. 158 x 10(9)/l, range 20-500; p < 0.001). Conclusion: Multiple infectious episodes and thrombocytopenia, particularly around the time of ROP diagnosis, were associated with APROP development.

Keywords
Aggressive posterior retinopathy of prematurity, Preterm infant, Thrombocytopenia, Sepsis
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-359813 (URN)10.1159/000448161 (DOI)000390554700013 ()27631399 (PubMedID)
Funder
EU, FP7, Seventh Framework Programme, 305485
Available from: 2018-09-14 Created: 2018-09-14 Last updated: 2018-09-14Bibliographically approved
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