This thesis aims to highlight the relevance of patients engaging with their patient narratives as a tool in recovery from illness and in regaining their sense of agency. / This thesis aims to rename the term ‘illness narrative’ to a more disclosive writing called the ‘patient narrative’ as a means to focus on the patient as a person who experiences illness, instead of the illness label. Exploring patient narratives, such as Susannah Cahalan’s Brain on Fire: My Month of Madness, as a form of disclosive writing will highlight the need for this tool to act as a more personal and effective communication between patients, healthcare professionals, and caregivers. The thesis is presented in two parts: a critical essay and my patient narrative. Part One is a critical essay that explores how engaging with patient narratives contributes to the patient reclaiming their agency and sense of identity. In three subsections, the essay highlights the difficulties patients go through with illnesses or rare medical events, as well as the emotional and physical impacts that they experience, going beyond medical symptoms. The essay focuses on three points separated into three sections. The sections are: Recognizing Pathologies and Injuries, Communication and Language in the Patient Experience, and Reclaiming Agency. Part Two is my autopathography centring on the complications encountered while seeking a common surgery. After general anaesthesia, I develop Postoperative Cognitive Changes of unknown aetiology. This greatly complicates the situation when surgery is needed, and the ensuing cognitive impairments have lasting impacts on me academically, personally, emotionally, and socially. While both parts are distinct, together they mirror how patient narratives have the iv potential to bridge the communication gap between medicine and humanities. As such, patient narratives can communicate connections between patients, medical communities, and a broader audience which acts to underscore the need of a deeper awareness for the importance of compassion and empathy for those experiencing any form of health challenge. / Thesis / Master of Arts (MA) / Patient narratives are a form of expressive writing that enables the patient to regain their sense of identity and agency following a health illness. When a person first becomes a patient, they leave their known world of familiarity and comfort and enter into a new one on their health journey. Their language and ways of communicating are required to adapt to the world of medicine. The patient loses their sense of identity and agency as a result of their illness. This thesis is presented in two parts, a critical essay and my brief patient memoir, and will explore how the patient, when engaging with patient narratives such as Susannah Cahalan’s Brain on Fire: My Month of Madness, can reclaim their agency and sense of identity. The first part is an essay exploring the contributions of patient narratives. The second part is my memoir, exemplifying a patient narrative.

Bakgrund: Hälso- och sjukvården är en högriskverksamhet. Varje år drabbas ett stort antal patienter världen över av vårdskador, som kunde ha undvikits, och som i vissa fall leder till att patienter avlider. Vetenskaplig forskning tyder på att den vanligaste orsaken till tillbud och negativa händelser i vården är att kommunikationen brustit mellan vårdpersonal. Faktorer som kan ligga till grund för avvikelser vid överrapportering kan vara hög arbetsbelastning och stressiga arbetsförhållanden. Syfte: Litteraturstudiens syfte var att undersöka effekter av SBAR som kommunikationsmodell för överrapportering inom hälso- och sjukvården med avseende på SBAR-modellens inverkan på vårdpersonalens kommunikation och patientsäkerhet. SBAR är en strukturerad kommunikationsmodell som står för (Situation, Bakgrund, Aktuellt tillstånd ochRekommendation). Metod: Ett systematiskt tillvägagångssätt enligt Goodmans sju steg användes vid genomförandet och sammanställningen av studien. Data-bassökningen utfördes främst i PubMed och CINAHL. Resultat: Resultatet baserades på åtta vetenskapliga artiklar som visade att SBAR-modellen förbättrar kommunikationen, överapporteringskommunikation, teamwork och det kommunikativa självförtroendet hos vårdpersonal och studenter. Vårdpersonalens förbättrade kommunikation resulterade också i en ökad patienttillfredställelse.Slutsats: Studiernas resultat talar för användning av SBAR som strukturerad kommunikationsmodell vid överrapportering inom vården. Eftersom SBAR-modellen är en relativt ny metod för rapportering finns det ett behov av ökad kunskap och utbildning för att integrera denna metod i omvårdnadsarbetet.Vidare rekommenderas att kommunikation enligt SBAR bör inkluderas isjuksköterskeutbildningen. Vidare forskning behövs kring SBAR-modellens funktion och effekt inom hälso- och sjukvården i syfte att öka evidensen för SBAR-modellens effekt på vårdpersonalens kommunikation och patientsäkerhet. / Background: Healthcare is a high risk activity. Each year a large number of patients worldwide suffer from preventable harm that could have been avoided and in some cases leading to patients death. Scientific research suggests that the most common cause of incidents and adverse events in health care is the communication failure between healthcare professionals´. Factors that can influence the basis of differences in handover could be heavy workload and stressful working conditions. The aim: The aim of this literature review was to explore the effects of the SBAR-communication model for handover in healthcare with regard to the SBAR model’s impact on the nursing staff communication and patient safety. SBAR is a structured communication model that stands for (Situation, Background, Assessment and Recommendation). Method: A systematic approach of Goodman's seven steps wear used in the preparation and implementation of the study. The database search was performed primarily in PubMed and CINAHL. Results: The results were based on eight scientific studies that show that the SBAR-model improves communication, the handover-communication, teamwork and communicative self-confidence of healthcare professionals and students. The healthcare professionals´ improved communication also resulted in increased patient satisfaction. Conclusion: The studies findings supports the use of a structured communication model for handover in healthcare. Because the SBAR-model is a relatively new method of reporting, there is a need for increased knowledge and training to integrate this method in nursing. Furthermore it is recommended that SBAR-communication should be included in nursing education. Further research is required regarding the SBAR-model´s function and effect in healthcare in order to increase the evidence for the SBAR-model´s effect on nursing staff communication and patient safety.

Background: There are treatments available to manage overweight and obesity (O&O). Intragastric balloons (IGB) are one option; they fill the stomach, increasing the sensation of satiety, limiting the amount of food to be ingested, and thus leading to weight loss. However, data suggest that patients regain weight long-term after an IGB treatment. As IGB is a relatively recent procedure for O&O, there is limited information about patient care practices alongside treatment, and whether could explain success or failure to maintain weight loss long-term.  Objective: The aim of the study was to explore clinical dietitians’ perspectives on patient care practices alongside IGB procedures. Method: Six semi-structured qualitative interviews were recorded, transcribed, and explored using qualitative content analysis method, which resulted in three categories. Results: The results showed that the clinical dietitians had many practices in place to condition patients before treatment. Screening the patient, balloon role information, and setting realistic expectations were considered essential practices. The involvement of a multi-disciplinary team was viewed as a critical factor to ensure engagement and follow-up with patients. The findings showed a high level of variability of frequency and contact during treatment and after balloon removal. Developing patients’ self-efficacy through practices like motivational coaching, dietary education, and behavioural therapy were also common practices.  Conclusion: Although similar practice patterns were identified, the findings highlighted a high level of variability in practices between respondents’ workplaces. This study was a first attempt to explore dietitians’ perceptions on patient care practices in relation to IGB-treatments, and it is too early to determine whether differences in practices have any impact on long-term weight loss maintenance. These could be the focus of new studies. / Bakgrund: Olika behandlingar är tillgängliga för att hantera övervikt och fetma. Intragastriska ballonger (IGB) är ett alternativ; de fyller magen, ökar mättnadskänslan, begränsar mängden av mat som kan intas och leder därmed till viktminskning. Data tyder dock på att patienter långsiktigt går upp i vikt långsiktigt efter IGB-behandling. Eftersom IGB behandlingar är en relativt ny procedur för övervikt och fetma, finns det bara begränsad information om patientvårdsprocesser som används i samband med behandlingen, och om skillnader i dessa skulle kunna förklara framgång eller misslyckande med att upprätthålla viktminskning långsiktigt. Syfte: Syftet med studien var att utforska dietisters perspektiv på patientvårdsprocesser och stödmetoder i samband med IGB-behandlingar. Metod: Sex semi-strukturerade kvalitativa intervjuer spelades in, transkriberades och analyserades enligt kvalitativ innehållsanalysmetoden, vilket resulterade i tre kategorier. Resultat: Resultaten visade att dietister använde många processer/metoder för att förbereda patienten innan behandling. Patientundersökning, ballongsinformation och att sätta realistiska förväntningar ansågs vara väsentliga metoder. Engagemang av ett multidisciplinärt team sågs som en kritisk faktor för att säkerställa engagemang och uppföljning med patienten. Resultaten visade en stor variation av frekvens och kontakt från vårdpersonalen under och efter IGB-behandling. Att utveckla patientens förmåga att ta eget ansvar med metoder som motiverande samtal, kostundervisning och beteendeterapi var också vanliga. Slutsats: Även om liknande processer/metoder identifierades, resultaten visade en stor variation i praktiken mellan respondenternas arbetsplatser. Studien var ett första försök att undersöka dietisters uppfattningar om patientvårdsprocesser i samband med IGB-behandling, och det är för tidigt att avgöra om skillnader i metoderna har någon inverkan på patienternas viktminskning underhåll långsiktigt. Dessa kan vara i fokus för nya studier.

Contexte : En raison de la pandémie COVID-19, de nombreux programmes pédiatriques spécialisés en troubles des conduites alimentaires (TCA) ont fourni des soins à distance. L'état actuel de la pratique dans les programmes canadiens demeure toutefois inconnu. Ce mémoire vise donc à décrire les adaptations effectuées dans les programmes pédiatriques spécialisés en TCA au Canada et l'impact de ces adaptations sur l'expérience de prestation de soins. Méthodes : Une méthodologie mixte a été utilisée pour interroger des professionnels de la santé travaillant dans des programmes pédiatriques spécialisés en TCA au Canada à l'aide d'un questionnaire transversale et d'entretiens semi-structurés, entre octobre 2021 et mars 2022. Des statistiques descriptives et une analyse de contenu qualitative one été employés. Résultats : Dix-huit professionnels ont répondu au questionnaire. Six d'entre eux ont participé aux entretiens. La majorité des participants ont fourni des services multidisciplinaires à distance durant la pandémie par vidéoconférence (17/18) ou par téléphone (17/18). Souvent, ces services ont été combinés à des soins en personne. La plupart des participants (16/18) s'attendaient à ce que les soins virtuels soient utilisés dans le futur. L'analyse qualitative du contenu a permis de faire ressortir cinq thèmes décrivant l’expérience personnelle des professionnels de la santé qui fournissaient des soins durant la pandémie : (1) répondre à une demande accrue avec des ressources insuffisantes; (2) s'adapter aux changements dans la prestation des soins dus à la pandémie de COVID-19; (3) faire face à l'incertitude et à l'appréhension; (4) les soins virtuels en tant qu'outil clinique acceptable et utile; et (5) les conditions optimales et les attentes pour l'avenir. La plupart des participants aux entretiens avaient une vision globalement positive des soins virtuels. Conclusions : Tous les participants ont été en mesure de fournir des soins multidisciplinaires virtuels et les ont jugés acceptables en tant qu'outil supplémentaire au traitement standard. Ainsi, les soins hybrides, combinant le traitement en personne et virtuel, peuvent être bien adaptés au traitement des TCA chez les jeunes et contribuer à améliorer l’accès aux soins dans le futur. / Background: As a result of the COVID-19 pandemic, many specialized pediatric eating disorder (ED) programs adapted their services and provided care at a distance. The current state of practice in Canadian programs, however, remains unknown. Thus, this thesis aims to describe the adaptations made in specialized pediatric ED programs in Canada and the impact of these adaptations on health professionals’ experience of providing care. Methods: A mixed methods design was used to survey healthcare professionals working in specialized pediatric ED programs in Canada. Data were collected between October 2021 and March 2022 using a cross‐sectional questionnaire and via semi‐structured interviews. Quantitative data were summarized using descriptive statistics and qualitative data were interpreted using qualitative content analysis. Results: Eighteen healthcare professionals completed the questionnaire, of whom six participated in the semi‐structured interviews. The questionnaire showed that, unlike prior to the pandemic, the majority of participants provided multidisciplinary services at a distance, via videoconferencing (17/18) or telephone (17/18). In many cases, this was combined with in-person care. Most participants (16/18) expected that virtual care would continue to be used after the pandemic. Qualitative content analysis generated five themes describing the personal experiences of the health professionals who were providing care during the COVID-19 pandemic: (1) responding to increased demand with insufficient resources; (2) adapting to changes in care due to the COVID‐19 pandemic; (3) dealing with uncertainty and apprehension; (4) virtual care as an acceptable and useful clinical tool, and (5) optimal conditions and future expectations. Most interview participants had globally positive views of virtual care. Conclusions: All participants were able to provide multidisciplinary care virtually and found it to be acceptable as an additional tool to standard treatment. Thus, hybrid care, combining in-person and virtual treatment, may be well-suited to specialized pediatric ED treatment in Canada in the post-pandemic period. It may be a useful tool for increasing access to care in the future.

Contexte : La pandémie de COVID-19 a créé un besoin urgent d’agir pour réduire la propagation du virus et pour diminuer la congestion des services de santé, pour protéger les soignants et les aider à maintenir une qualité et une sécurité des soins satisfaisantes. Les plateformes de télésoins et de télésurveillance sont rapidement apparues comme des solutions potentielles. C’est ainsi qu’au Centre hospitalier de l’Université de Montréal, trois plateformes ont été mises en place : 1) une téléassistance (Telecare-Covid) apportée par des infirmiers et des médecins par des appels téléphoniques ; 2) une application de télésurveillance (CareSimple-Covid) qui permet un suivi à distance du patient à domicile, et; 3) une plateforme de téléconsultation (React- Teleconsultation) pour réaliser des consultations visuelles entre professionnels et patients. Objectif : Le but de cette étude est d’évaluer du point de vue des patients et des professionnels de santé utilisateurs des trois plateformes de télésanté mises en place pour les soins et le suivi à distance des patients atteints par la COVID-19, les dimensions suivantes : (1) la satisfaction sur la qualité et la sécurité des soins prodigués par les plateformes technologiques; (2) l’engagement des patients et le partenariat dans les soins lors de l’utilisation des plateformes technologiques; et (3) le rôle et la pertinence des plateformes technologiques en matière d’utilité, d’avantages et de limites. Méthode : Deux études transversales ont été réalisées entre juillet et septembre 2020. La première a été réalisée auprès de patients ayant utilisé une des deux plateformes Telecare-Covid et CareSimple-Covid. Des questionnaires ont été soumis par téléphone aux patients. Les données collectées ont été analysées à l’aide de statistiques descriptives et d’une analyse de test t. La deuxième s’intéresse à l’utilisation par les professionnels de Telecare-Covid et React- Téléconsultation. Les données ont été recueillies par courrier électronique auprès des professionnels de santé. Nous avons mené une analyse de statistique descriptive grâce au logiciel SPSSã et STATAã. Ainsi, certains tests spécifiques ont été appliqués tels que le t-test et celui de Fisher pour comparer les différentes perceptions des utilisateurs sur certaines dimensions étudiées. Résultats : Parmi les 85 patients qui ont utilisé les deux plateformes, 51 (60 %) ont participé à la première l’étude. Pour la deuxième étude, 1 545 professionnels de la santé ont été invités à participer et 491 (31,8 %) ont répondu au sondage. De manière générale, les résultats des deux études ont montré que les perceptions des utilisateurs quant à la qualité et la sécurité des soins offerts sur les plateformes de télésurveillance étaient positives pour l’ensemble des plateformes technologiques étudiées. Les principales caractéristiques très appréciées par la plupart des utilisateurs, que ce soit chez les patients ou chez les professionnels de santé, sont : (1) la facilité d’accès aux services et la proximité des membres de l’équipe de soins; (2) la convivialité des plateformes; (3) la continuité des soins prodigués et; (4) une gamme diversifiée de services offerts. Patients comme professionnels de santé utilisateurs de ces plateformes dans les deux études ont cependant identifié certaines limites techniques et ont soulevé certains problèmes, tels que l’importance de maintenir le contact humain malgré la distance, la sécurité et la confidentialité des données et la formation. Conclusion : Cette étude suggère que les plateformes de télésanté et de télésurveillance ont été bien accueillies par les patients et les professionnels de santé et les dimensions étudiées ont été globalement perçues positivement par l’ensemble des utilisateurs, même si certaines limites existent dont il faut tenir compte. Ainsi, pour contenir les limites et enjeux identifiés et pour améliorer ces trois plateformes et maximiser leur utilisation, un processus de développement collaboratif incluant patients, professionnels de santé, décideurs et fournisseurs/concepteurs de plateformes numériques est recommandé. / Background: The COVID-19 pandemic has created an urgent need for action to reduce the spread of the virus and reduce congestion in health services, protect caregivers and help them maintain satisfactory quality and safety of care. Telecare and telemonitoring platforms quickly emerged as potential solutions. Thus, at the University of Montreal Hospital Center, three platforms have been set up: 1) remote assistance (Telecare-Covid) provided by nurses and doctors by telephone calls, and 2) remote monitoring (CareSimple-Covid) which allows remote monitoring of the patient at home, and 3) a teleconsultation platform (React-Teleconsultation) to carry out visual consultations between professionals and patients. Objective: The aim of this study is to evaluate, from the point of view of patients and healthcare professionals who used three telehealth platforms for the care and remote monitoring of patients with COVID-19, the following dimensions: (1) satisfaction with the quality and safety of care provided by technological platforms; (2) patient engagement and partnership in care when using technology platforms; and (3) the role and relevance of technology platforms in terms of usefulness, benefits and problems, and limitations. Method: Two cross-sectional studies were carried out between July and September 2020. The first was carried out with patients who had used one of the two, Telecare-Covid and CareSimple- Covid platforms. Questionnaires were given to the patients by telephone. The data collected was analyzed using descriptive statistics and t-test analysis. The second focuses on the use by professionals of Telecare-Covid and React-Téléconsultation. The data was collected by email from healthcare professionals. The data were analyzed using SPSS software. Fisher analyzes were performed to compare perceptions of performance, safety and quality, issues and perceived problems among healthcare professionals. Results: Of the 85 patients who used both platforms, 51 (60%) participated in the first study. For the second study, 1545 healthcare professionals were invited to participate and 491 (31.8%) responded to the survey. In general, the results of the two studies showed that users' perceptions of the quality and safety of care offered on telemonitoring platforms were positive for all of the technological platforms studied. The main features highly valued by most users, whether for patients or healthcare professionals, are (1) ease of access to services and proximity to members of the care team; (2) platform usability; (3) continuity of care provided and (4) a diversified range of services offered. Both patients and healthcare professionals using these platforms in both studies have however identified certain technical limitations and raised certain issues, such as the importance of maintaining human contact despite the distance, security and confidentiality of data and training. Conclusion: This study suggests that the telehealth and telemonitoring platforms were well received by patients and health professionals and the dimensions studied were generally perceived positively by all users even if some limits exist and whose it is important to consider. Thus, to contain the identified limits and issues and improve these three platforms and maximize their use, a collaborative development process including patients, healthcare professionals, decision-makers and suppliers/designers of digital platforms is recommended.

No description available.

Bakgrund: Typ 2 diabetes är en folksjukdom som ökar både globalt och i Sverige. Bidragande faktorer för att utveckla sjukdomen är bland annat ohälsosamma kostvanor och stillasittande livsstil. Vid noggrann egenvårdsbehandling kring framför allt kost och motion kan blodsockernivåerna hållas jämna, vilket minskar risken för diabeteskomplikationer. Genom utbildning, stöd och motivation av vårdpersonal kan personer med typ 2 diabetes få hjälp att förändra ohälsosamma levnadsvanor. Syfte: Beskriva vårdpersonals upplevelser av att arbeta med förändring av levnadsvanor hos personer med typ 2 diabetes. Metod: Examensarbetet genomfördes som en litteraturstudie baserad på artiklar med kvalitativ ansats. Genom databaserna Cinahl och PubMed utvanns 10 artiklar vilka kvalitetsgranskades enligt SBU:s Granskningsmall för kvalitativ forskning och analyserades utifrån Fribergs analysmetod. Resultat: Efter analys av samtliga artiklar identifierades tre huvudkategorier; organisationens betydelse, kompetens hos vårdpersonalen och utmaningar i patientmötet där resultatet presenteras i 8 underkategorier. Slutsats: Vårdpersonalen upplevde flera faktorer, både positiva och negativa som påverkade arbete med livsstilsförändring hos personer med typ 2 diabetes. Samverkan i multiprofessionellt team, god relation till patienter och patienters stöd av närstående upplevdes främja följsamhet hos patienter. Negativa faktorer som kan ses som hinder vid förändring av levnadsvanor var tidsbrist i arbetet, otillräckliga organisatoriska verktyg i form av vårdprogram och riktlinjer samt kunskapsluckor hos såväl vårdpersonal som hos patienter. / Background: Type 2 diabetes is a public health disease that increases both globally and in Sweden. Contributing factors to the development of the disease include unhealthy eating habits and sedentary lifestyle. With accurate self-care, especially regarding diet and exercise, blood sugar levels can be kept even, which reduces the risk of diabetic complications. Through education, support and motivation from health care professionals people with type 2 diabetes can get help to change unhealthy lifestyle habits. Purpose: Describe healthcare professionals’ experiences of working with lifestyle change in people withtype 2 diabetes. Method: This degree project was conducted as a literature review based on articles with a qualitative approach. The literature study was based on ten scientific articles found in the databases Cinahl and PubMed. Quality review of the articles according to SBU’s Review template for qualitative research and data analysis based on Friberg’s analysis method was conducted. Findings: After analysis of all articles, three main categories were identified; the importance of the organization, competence of the healthcare professionals and challenges in the patient meeting. The results were categorized into a total of 8 subcategories. Conclusion: The healthcare professionals experienced several factors, both positive and negative that influenced the work with lifestyle changes in people with type 2 diabetes. Collaboration in a multi-professional team, good relationship with the patients and patient support from relatives were experienced to promote patient compliance. Negative factors that can be seen as obstacles to lifestyle change were lack of time, insufficient organizational tools such as health care programs and guidelines and knowledge gaps in both health care staff and patients.

<p><strong>ABSTRACT</strong><strong></strong></p> <p><strong>Background</strong>: Healthcare-associated infections (HAIs) and HAI disease outbreaks present challenges for healthcare facilities. In 2008, a <em>Clostridium difficile</em> outbreak in Ontario resulted in the deaths of 91 patients and raised awareness of HAIs. Over the last 5 years, the outbreak rate has risen dramatically. Traditionally, HAI research has focused on epidemiology, healthcare systems, and the economic burden. Little is known about the impact HAI disease outbreaks have on the work of healthcare professionals.</p> <p><strong>Purpose</strong>: The purpose of this study was to examine the effects of HAI outbreaks on healthcare professionals in a large acute care hospital in Ontario.</p> <p><strong>Methods</strong>:<strong> </strong>A retrospective exploratory case study approach was used, including individual interviews, document analysis, and incidence analysis of HAIs hospital data. The sample was frontline nurses, clinical managers, infection control professionals, and environmental service staff. Document analysis included hospital policies and protocols related to infectious diseases and HAI disease outbreaks.</p> <p><strong>Findings</strong>: The incidence rates of Methicillin-resistant s<em>taphylococcus aureus</em>, <em>Clostridium difficile</em>, and Vancomycin-resistant<em> </em>enterococci<em> </em>have decreased but remained above the provincial benchmarks. The daily work of healthcare professionals was impacted by HAI outbreaks. Nurses experienced workload challenges, time pressures, and increased documentation. Infection control professionals' responsibilities have expanded. The environmental services staffs' cleaning processes have become more intensive. In response, several unique innovations were developed by hospital staff.</p> <p><strong>Conclusion</strong>: The daily work of healthcare professionals at the study site has been affected by HAI outbreaks. Implications for future research include the need to review healthcare professionals’ workloads and evaluate contributing factors to HAI outbreaks.</p> / Master of Science in Nursing (MSN)

Aim The purpose of this study is to map the use and attitude towards prescription of physical activity among healthcare professionals in Sweden.    Design The study took a quantitative approach, using a questionnaire survey. The collected data was analyzed using a descriptive and inferential analysis.   Results  The results showed a high usage of towards prescription of physical activity in the 217 respondents (77%), those with knowledge of the method had a positive approach to prescription of physical activity, but that there is a lack of resources to implement it effectively.    Conclusion  Regional differences in knowledge and positive attitudes towards prescription of physical activity were noted, but barriers such as lack of knowledge and resources were identified. In conclusion, there is a positive attitude towards prescription of physical activity among primary care professionals in Sweden, but further support is needed for better implementation.

Yes / Clinical guidelines are an integral part of healthcare. Whilst much progress has been made in ensuring that guidelines are well developed and disseminated, the gap between routine clinical practice and current guidelines often remains wide. A key reason for this gap is that implementation of guidelines typically requires a change in the behaviour of healthcare professionals – but the behaviour change component is often overlooked. We adopted the Theoretical Domains Framework Implementation (TDFI) approach for supporting behaviour change required for the uptake of a national patient safety guideline to reduce the risk of feeding through misplaced nasogastric tubes.