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  • 301.
    Hirbayashi, Hidehiro
    et al.
    Nara Medical University, Kashihara , Japan.
    Hariz, Marwan
    Umeå University.
    Wårdell, Karin
    Linköping University, Department of Biomedical Engineering, Biomedical Instrumentation. Linköping University, The Institute of Technology.
    Blomstedt, Patric
    Umeå University.
    Impact of Parameters of Radiofrequency Coagulation on Volume of Stereotactic Lesion inPallidotomy and Thalamotomy2012In: Stereotactic and Functional Neurosurgery, ISSN 1011-6125, E-ISSN 1423-0372, Vol. 90, no 5, p. 307-315Article in journal (Refereed)
    Abstract [en]

    Background: One of the many reasons why lesional surgery for movement disorders has been more or less abandoned may have been the difficulty in predicting the shape and size of the stereotactic radiofrequency (RF) lesion. Objectives: To analyse the contribution of various RF coagulation parameters towards the volume of pallidotomies and thalamotomies. Methods: The relationship between temperature of coagulation, length of coagulated area and duration of coagulation on the one hand, and lesion volume on the other was retrospectively evaluated. Lesion diameters were measured on stereotactic thin-slice CT and MRI scans, and volumes of lesions were calculated concerning 36 pallidotomies and 14 thalamotomies in 46 patients who were operated using the same RF generator and same RF electrode. Results: The coagulation temperature, length of coagulated area and duration of coagulation were all correlated to the lesion volume. However, for a given length of coagulated area, the lesion´s size was most strongly influenced by the temperature. Despite this clear correlation, and the relatively homogenous coagulation parameters, the lesions’ volumes were markedly scattered. Conclusions: The volume of the stereotactic RF lesions could be correlated with the coagulation parameters, especially the temperature, at a group level, but could not be predicted in individual patients based solely on the RF coagulation parameters.

  • 302.
    Hollertz, Petter
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping. Vastervik Hosp, Sweden.
    Lindblad, M.
    Karolinska Univ Hosp, Sweden; Karolinska Inst, Sweden.
    Sandström, Per
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Halldestam, Ingvar
    Linköping University, Department of Biomedical and Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Neurosurgery.
    Edholm, David
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Outcome of microscopically non-radical oesophagectomy for oesophageal and oesophagogastric junctional cancer: nationwide cohort study2021In: BJS Open, E-ISSN 2474-9842, Vol. 5, no 3, article id zrab038Article in journal (Refereed)
    Abstract [en]

    Background: Microscopically non-radical (R1) oesophageal cancer resection has been associated with worse survival. The aim of this study was to identify risk factors for R1 resection and to investigate how this affects long-term survival. Methods: The Swedish National Register for Oesophageal and Gastric Cancer was used to identify all patients who underwent oesophageal cancer resection with curative intent between 2006 and 2017. Risk factors for R1 resection were assessed by multivariable logistic regression analysis, and factors predicting 5-year survival identified by multivariable Cox regression. Results: The study included 1460 patients. Surgical margins were involved microscopically in 142 patients (9.7 per cent). The circumferential resection margin was involved in 114 (7.8 per cent), the proximal margin in 53 (3.6 per cent), and the distal margin in 29 (2.0 per cent). In 30 specimens (2.1 per cent), two or all three margins were involved. Independent risk factors for R1 resection were male sex, low BMI, absence of neoadjuvant treatments, and clinical T4 disease. The 5-year survival rate for the entire cohort was 42.2 per cent, but only 18.0 per cent for those who had an R1 resection. Independent risk factors for death within 5 years of resection were male sex, age above 60 years, normal BMI, ASA fitness grade III, intermediate-level education, R1 resection (hazard ratio 1.80, 95 per cent c.i. 1.40 to 2.32), clinical T3 disease, and clinical lymph node metastasis. Conclusion: R1 resection is common and predicts poor 5-year survival. Absence of neoadjuvant treatment is a risk factor for R1 resection.

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  • 303.
    Holm, Anna
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Acute coronary syndrome: bleeding, platelets and gender2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    BACKGROUND

    Bleeding complications increase mortality in patients with acute coronary syndrome (ACS). Potential gender difference in bleeding regarding prevalence, location, severity and prognostic impact is still controversial and not well investigated. In regard to this aspect the relevance of triple antithrombotic therapy (TAT) is questioned. There is an ongoing debate on the clinical implications of TAT and furthermore assumed that bleeding complications, except impact on outcome, also are associated with great influence on health economy.

    The main focus of this thesis was to further investigate the incidence and impact of bleeding complications in patients treated for ACS, with special reference to gender disparities, TAT and health economics. The thesis will highlight the importance of improved bleeding prevention strategies for both men and women.

    METHOD

    Paper I, II and III

    Observational studies from the SWEDEHEART register.

    In paper I we investigated patients hospitalised with myocardial infarction (MI) during 2006–2008. Outcomes were in-hospital bleedings, in-hospital mortality and one-year mortality in hospital survivors.

    In paper II, all patients with MI, in the County of Östergötland, Sweden during 2010 were included and followed for one year. The patients' medical records were evaluated, in relation to short and long-term bleeding complications, bleeding location, withdrawal of platelet inhibiting drugs and nonfatal MI and death.

    Paper III included all patients discharged with (TAT) in the County of Östergötland 2009-2015. Information about bleeds and ischemic complications during one-year follow-up were retrieved from the medical records. Estimation of the health care costs associated with bleeding episodes were added to the evaluation.

    Paper IV

    Patients with MI, scheduled for coronary angiography were recruited. All patients received clopidogrel and aspirin. A subgroup of patients received GP IIb/IIIa-inhibitor. Outcomes were platelet aggregation assessed at several time points, using a Multiplate impedance aggregometer, measurement of P-selectin in plasma, evaluation of high residual platelet reactivity (HRPR) and low residual platelet reactivity (LRPR) respectively and incidence of bleeding complications. A comparison between women and men was performed.

    RESULTS

    Paper I

    A total number of 50.399 patients were included, 36.6% women. In-hospital bleedings were more common in women (1.9% vs. 3.1%, p<0.001) even after multivariable adjustment (OR 1.17, 95%, CI 1.01–1.37). The increased risk for women was found in STEMI (OR 1.46, 95% CI 1.10–1.94) and in those who underwent PCI (OR 1.80, 95% CI 1.45–2.24).

    In contrast the risk was lower in medically treated women (OR 0.79, 95% CI 0.62–1.00). After adjustment, in-hospital bleeding was associated with higher risk of oneyear mortality in men (OR 1.35, 95% CI 1.04–1.74), whereas this was not the case in women (OR 0.97, 95% CI 0.72–1.31).

    Paper II

    In total 850 consecutive patients were included. The total incidence of bleeding events was 24.4% (81 women and 126 men, p=ns). The incidence of all in hospital bleeding events was 13.2%, with no gender difference. Women had significantly more minor nonsurgery related bleeding events than men (5% vs 2.2%, p=0.02). During follow-up, 13.5% had a bleeding, with more non-surgery related bleeding events among women, 14.7% vs 9.7% (p=0.03). The most common bleeding localisation was the gastrointestinal tract, more in women than men (12.1% vs 7.6%, p=0.03). Women also had more access site bleeding complications (4% vs 1.7%, p=0.04), while men had more surgery related bleeding complications (6.4% vs 0.9%, p≤0.001). Increased mortality was found only in men with non-surgery related bleeding events (p=0.008).

    Paper III

    Among 272 identified patients, 156 bleeds occurred post-discharge, of which 28.8% were of gastrointestinal origin. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post-discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p=0.01) and bled more (48.6 vs. 37.1%, p=0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively.

    Paper IV

    We recruited 125 patients (37 women and 88 men). We observed significantly more inhospital bleeding events in women as compared to men (18.9% vs 6.8%, p=0.04). There were no differences in platelet aggregation using three different agonists, reflecting treatment of GPIIb/IIIa inhibitors, clopidogrel and aspirin, at four different time-points nor were there any differences in p-selectin in plasma 3 days after admission.

    CONCLUSION

    There is a remarkably high bleeding incidence among patients treated with DAPT and even more so if treated with TAT. Female gender is an independent risk factor of inhospital bleeding after myocardial infarction, this higher bleeding risk in women appears to be restricted to invasively treated patients and STEMI patients. Even if women had higher short- and long-term mortality, there was no difference between the genders among those who bled. After multivariable adjustment the prognostic impact of bleeding complications was higher in men

    Women seem to experience more minor/minimal bleeding complications than men, predominantly GI bleeding events and access site bleeding events, with no apparent impact on outcome.

    In contrast men with non-surgery related bleeding complications had higher mortality. There is a lack of differences between the genders concerning platelet aggregation. Our results do not support gender disparities in platelet reactivity and excess dosing as a major explanation for increased bleeding risk in women. Improved bleeding prevention strategies are warranted for both men and women.

    List of papers
    1. Gender difference in prognostic impact of in-hospital bleeding after myocardial infarction - data from the SWEDEHEART registry.
    Open this publication in new window or tab >>Gender difference in prognostic impact of in-hospital bleeding after myocardial infarction - data from the SWEDEHEART registry.
    2016 (English)In: European Heart Journal: Acute Cardiovascular Care, ISSN 2048-8726, E-ISSN 2048-8734, Vol. 6, p. 463-472Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: Bleeding complications increase mortality in myocardial infarction patients. Potential gender difference in bleeding regarding prevalence and prognostic impact is still controversial.

    OBJECTIVES: Gender comparison regarding incidence and prognostic impact of bleeding in patients hospitalised with myocardial infarction during 2006-2008.

    METHODS: Observational study from the SWEDEHEART register. Outcomes were in-hospital bleedings, in-hospital mortality and one-year mortality in hospital survivors.

    RESULTS: A total number of 50,399 myocardial infarction patients were included, 36.6% women. In-hospital bleedings were more common in women (1.9% vs. 3.1%, p<0.001) even after multivariable adjustment (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.01-1.37). The increased risk for women was found in ST-elevation myocardial infarction (OR 1.46, 95% CI 1.10-1.94) and in those who underwent percutaneous coronary intervention (OR 1.80, 95% CI 1.45-2.24). In contrast the risk was lower in medically treated women (OR 0.79, 95% CI 0.62-1.00). After adjustment, in-hospital bleeding was associated with higher risk of one-year mortality in men (OR 1.35, 95% CI 1.04-1.74), whereas this was not the case in women (OR 0.97, 95% CI 0.72-1.31).

    CONCLUSIONS: Female gender is an independent risk factor of in-hospital bleeding after myocardial infarction. A higher bleeding risk in women appeared to be restricted to invasively treated patients and ST-elevation myocardial infarction patients. Even though women have higher short- and long-term mortality, there was no difference between the genders among bleeders. After multivariable adjustment the prognostic impact of bleeding complications was higher in men.

    Place, publisher, year, edition, pages
    Sage Publications, 2016
    Keywords
    Myocardial infarction; bleeding; gender; prognosis
    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-124287 (URN)10.1177/2048872615610884 (DOI)000385817800008 ()26450782 (PubMedID)
    Available from: 2016-01-25 Created: 2016-01-25 Last updated: 2023-08-28
    2. Bleeding complications after myocardial infarction in a real world population - An observational retrospective study with a sex perspective
    Open this publication in new window or tab >>Bleeding complications after myocardial infarction in a real world population - An observational retrospective study with a sex perspective
    Show others...
    2018 (English)In: Thrombosis Research, ISSN 0049-3848, E-ISSN 1879-2472, Vol. 167, p. 156-163Article in journal (Refereed) Published
    Abstract [en]

    Introduction: The aim of the current study was to assess bleeding events, including severity, localisation and prognostic impact, in a real world population of men and women with myocardial infarction (MI). Methods and results: In total 850 consecutive patients were included during 2010 and followed for one year. Bleeding complications were identified by searching of each patients medical records and characterised according to the TIMI criteria. For this analysis, only the first event was calculated. The total incidence of bleeding events was 24.4% (81 women and 126 men, p=ns). The incidence of all inhospital bleeding events was 13.2%, with no sex difference. Women had significantly more minor non-surgery related bleeding events than men (5% vs 2.2%, p=0.02). During follow-up, 13.5% had a bleeding, with more non-surgery related bleeding events among women, 14.7% vs 9.7% (p=0.03). The most common bleeding localisation was the gastrointestinal tract, more in women than men (12.1% vs 7.6%, p=0.03). Women had also more access site bleeding complications (4% vs 1.7%, p=0.04), while men had more surgery related bleeding complications (6.4% vs 0.9%, p=0.001). Increased mortality was found only in men with non-surgery related bleeding events (p=0.008). Conclusions: Almost one in four patients experienced a bleeding complication through 12 months follow-up after a myocardial infarction. Women experienced more non-surgery related minor/minimal bleeding complications than men, predominantly GI bleeding events and access site bleeding events, with no apparent impact on outcome. In contrast men with non-surgery related bleeding complications had higher mortality. Improved bleeding prevention strategies are warranted for both men and women.

    Place, publisher, year, edition, pages
    PERGAMON-ELSEVIER SCIENCE LTD, 2018
    Keywords
    Myocardial infarction; Bleeding; Sex; Mortality
    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-149865 (URN)10.1016/j.thromres.2018.05.023 (DOI)000437845800027 ()29857272 (PubMedID)
    Note

    Funding Agencies|Ostergotland County Council [LIO610841]

    Available from: 2018-08-02 Created: 2018-08-02 Last updated: 2020-08-14
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    Acute coronary syndrome: bleeding, platelets and gender
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  • 304.
    Holm, Jonas
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart Center, Department of Thoracic and Vascular Surgery.
    Ferrari, Gabriele
    Orebro Univ, Sweden.
    Holmgren, Anders
    Umea Univ, Sweden; Umea Univ, Sweden.
    Vanky, Farkas
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart Center, Department of Thoracic and Vascular Surgery.
    Friberg, Örjan
    Orebro Univ, Sweden.
    Vidlund, Mårten
    Orebro Univ, Sweden; Sahlgrens Univ Hosp, Sweden.
    Svedjeholm, Rolf
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart Center, Department of Thoracic and Vascular Surgery.
    Effect of glutamate infusion on NT-proBNP after coronary artery bypass grafting in high-risk patients (GLUTAMICS II): A randomized controlled trial2022In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 19, no 5, article id e1003997Article in journal (Refereed)
    Abstract [en]

    Background Animal and human data suggest that glutamate can enhance recovery of myocardial metabolism and function after ischemia. N-terminal pro-brain natriuretic peptide (NT-proBNP) reflects myocardial dysfunction after coronary artery bypass surgery (CABG). We investigated whether glutamate infusion can reduce rises of NT-proBNP in moderate- to high-risk patients after CABG. Methods and findings A prospective, randomized, double-blind study enrolled patients from November 15, 2015 to September 30, 2020, with a 30-day follow-up at 4 academic cardiac surgery centers in Sweden. Patients underwent CABG +/- valve procedure and had left ventricular ejection fraction &lt; 0.30 or EuroSCORE II &lt; 3.0. Intravenous infusion of 0.125 M L-glutamic acid or saline at 1.65 mL/kg/h started 10 to 20 minutes before releasing the aortic cross-clamp, then continued for another 150 minutes. Patients, staff, and investigators were blinded to the treatment. The primary endpoint was the difference between preoperative and day-3 postoperative NT-proBNP levels. Analysis was intention to treat. We studied 303 patients (age 74 & PLUSMN; 7 years; females 26%, diabetes 47%), 148 receiving glutamate group and 155 controls. There was no significant difference in the primary endpoint associated with glutamate administration (5,390 & PLUSMN; 5,396 ng/L versus 6,452 & PLUSMN; 5,215 ng/L; p = 0.086). One patient died & LE;30 days in the glutamate group compared to 6 controls (0.7% versus 3.9%; p = 0.12). No adverse events linked to glutamate were observed. A significant interaction between glutamate and diabetes was found (p = 0.03). Among patients without diabetes the primary endpoint (mean 4,503 +/- 4,846 ng/L versus 6,824 & PLUSMN; 5,671 ng/L; p = 0.007), and the incidence of acute kidney injury (11% versus 29%; p = 0.005) was reduced in the glutamate group. These associations remained significant after adjusting for differences in baseline data. The main limitations of the study are: (i) it relies on a surrogate marker for heart failure; and (ii) the proportion of patients with diabetes had almost doubled compared to the cohort used for the sample size estimation. Conclusions Infusion of glutamate did not significantly reduce postoperative rises of NT-proBNP. Diverging results in patients with and without diabetes agree with previous observations and suggest that the concept of enhancing postischemic myocardial recovery with glutamate merits further evaluation.

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  • 305.
    Holm, Jonas
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart Center, Department of Thoracic and Vascular Surgery.
    Vanky, Farkas
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart Center, Department of Thoracic and Vascular Surgery.
    Svedjeholm, Rolf
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart Center, Department of Thoracic and Vascular Surgery.
    Glutamate Infusion Reduces Myocardial Dysfunction after Coronary Artery Bypass Grafting According to NT-proBNP: Summary of 2 Randomized Controlled Trials (GLUTAmate for Metabolic Intervention in Coronary Surgery [GLUTAMICS I-II])2023In: American Journal of Clinical Nutrition, ISSN 0002-9165, E-ISSN 1938-3207, Vol. 118, no 5, p. 930-937Article in journal (Refereed)
    Abstract [en]

    Background: Glutamate is reported to enhance the recovery of oxidative metabolism and contractile function of the heart after ischemia. The effect appears to be blunted in diabetic hearts. Elevated plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) reflects myocardial dysfunction. In the GLUTAmate for Metabolic Intervention in Coronary Surgery (GLUTAMICS) II trial, the proportion of patients with diabetes had nearly doubled to 47% compared with the cohort used for sample size estimation, and a significant effect on the postoperative rise in NT-proBNP was only observed in patients without diabetes. Objective: We aimed to summarize the pooled NT-proBNP results from both GLUTAMICS trials and address the impact of diabetes. Methods: Data from 2 prospective, randomized, double-blind multicenter trials with similar inclusion criteria and endpoints were pooled. Patients underwent a coronary artery bypass grafting (CABG) +/- valve procedure and had a left-ventricular ejection fraction of &lt;= 0.30 or a European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) of &gt;= 3.0 with at least 1 cardiac risk factor. Intravenous infusion of 0.125 M L-glutamic acid or saline at 1.65 mL/kg/h was started 10-20 min before reperfusion and continued for 150 min. The primary endpoint was the difference between pre-operative and day 3 postoperative NT-proBNP levels. Results: A total of 451 patients, 224 receiving glutamate and 227 controls, fulfilled the inclusion criteria. Glutamate was associated with a reduced primary endpoint (5344 +/- 5104 ng/L and 6662 +/- 5606 ng/L in glutamate and control groups, respectively; P = 0.01). Postoperative mortality at &lt;= 30 d was 0.9% and 3.5% (P = 0.11), whereas stroke at &lt;= 24 h was 0.4% and 2.6% in glutamate and control groups, respectively (P = 0.12). No adverse events related to glutamate were observed. A significant interaction regarding the primary endpoint was only detected between glutamate and insulin -treated diabetes groups (P = 0.04). Among patients without insulin-treated diabetes, the primary endpoint was 5047 +/- 4705 ng/L and 7001 +/- 5830 ng/L in the glutamate and control groups, respectively (P = 0.001). Conclusions: Infusion of glutamate reduced the postoperative rise in NT-proBNP after CABG in medium-to high-risk patients. A significantly blunted effect was observed only in insulin-treated patients with diabetes. Clinical trial details: This trial was registered at www.clinicaltrials.gov as NCT02592824.

  • 306.
    Holm, Sebastian
    et al.
    Uppsala Univ Hosp, Sweden.
    Tell, Katinka
    Uppsala Univ Hosp, Sweden.
    Karlsson, Matilda
    Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology.
    Huss, Fredrik
    Uppsala Univ Hosp, Sweden; Uppsala Univ, Sweden.
    Pompermaier, Laura
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Elmasry, Moustafa
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Löfgren, Jenny
    Karolinska Inst, Sweden; Karolinska Univ Hosp, Sweden.
    Sociodemographic Patterns of Pediatric Patients in Specialized Burn Care in Sweden2022In: Plastic and Reconstructive Surgery - Global Open, E-ISSN 2169-7574, Vol. 10, no 4, article id e4246Article in journal (Refereed)
    Abstract [en]

    Background: Trauma is a leading cause of mortality in children. Burns affect children disproportionally. Although burn incidence and mortality are decreasing, differences in the risk depend on socioeconomic status. The present study aimed to investigate the sociodemographic patterns of pediatric patients (0-17 years) managed at the two burn centers in Sweden. Uppsala, and Linkoping, between 2010 and 2020. Method: This retrospective register-based study used hospital records from the two burn centers combined with information front Statistics Sweden plus data regarding number of asylum seekers from the Swedish Migrations Agency. Choropleth maps representing the patients geographical distribution were created. Information about income levels per geographic area was added. A Wilcoxon signed-rank test was performed to investigate differences in median income levels between the areas where the patients lived, related to Swedens median income. Results: The study included 2455 patients. Most of the children aged below 5 years (76%) and were boys (60%). The mean percentage of total skin area was 4.2%. There was no significant increment or decrease in the incidence of pediatric burns during the study. Most patients with recorded zip codes lived in areas with an income level below the national median (n = 1974, 83%). Children with asylum status were over-represented compared with residents and/or Swedish citizens. Conclusions: In Sweden, most pediatric burns occur in families that live in areas with low-income levels. Pediatric burns affect children with asylum status disproportionally compared with those who are residents in and/or citizens of Sweden. Prevention strategies should be designed and implemented to alleviate this health inequity.

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  • 307.
    Holmberg, Lars
    et al.
    Uppsala Univ, Sweden; Kings Coll London, England.
    Skogmar, Sten
    Lund Univ, Sweden.
    Garmo, Hans
    Uppsala Univ, Sweden; Kings Coll London, England.
    Hagberg, Oskar
    Lund Univ, Sweden.
    Haggstrom, Christel
    Uppsala Univ, Sweden; Umea Univ, Sweden.
    Gardmark, Truls
    Danderyd Hosp, Sweden.
    Strock, Viveka
    Sahlgrens Univ Hosp, Sweden; Univ Gothenburg, Sweden.
    Aljabery, Firas
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Jahnson, Staffan
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Hosseini, Abolfazl
    Karolinska Inst, Sweden; Danderyd Hosp, Sweden.
    Jerlstrom, Tomas
    Orebro Univ, Sweden.
    Sherif, Amir
    Umea Univ, Sweden.
    Soderkvist, Karin
    Umea Univ, Sweden.
    Ullen, Anders
    Karolinska Inst, Sweden.
    Malmstrom, Per-Uno
    Uppsala Univ, Sweden.
    Liedberg, Fredrik
    Lund Univ, Sweden; Skane Univ Hosp, Sweden; Lund Univ, Sweden; Lund Univ, Sweden.
    Cumulative incidence of and risk factors for BCG infection after adjuvant BCG instillations2024In: BJU International, ISSN 1464-4096, E-ISSN 1464-410XArticle in journal (Refereed)
    Abstract [en]

    ObjectivesTo investigate the cumulative incidence proportion of disseminated or local Bacillus Calmette-Guerin (BCG) infections after adjuvant BCG instillations in patients with non-muscle-invasive bladder cancer (NMIBC).Patients and MethodsWe analysed the timing and occurrence of BCG infections and absolute and relative risk in relation to patient characteristics available in the Swedish nationwide database 'BladderBaSe 2.0'. The cumulative incidence proportion of a BCG infection was indicated by a reported diagnosis of tuberculosis (TB) in the patient registry or filing a prescription for tuberculostatic drugs.ResultsThe cumulative incidence proportion was 1.1% at the 5-year follow-up in 5033 patients exposed to adjuvant BCG instillations. The incidence rate was highest during the first 2 years after start of BCG instillations. Women had a lower risk than men (hazard ratio 0.23, 95% confidence interval 0.07-0.74). Age and calendar time at diagnosis, comorbidity, tumour risk group, previous medication with corticosteroids, immunosuppressive drugs, or time between transurethral resection of the bladder tumour and commencing the adjuvant BCG instillation were not associated with risk.ConclusionsThese data further supports that the overall risk of a BCG infection after BCG-instillation treatment for NMIBC is low. The great majority of infections occur in the first 2 years, calling for an awareness of the diverse symptoms of BCG infection during this period. We provide evidence for male sex as a risk factor; however, the statistical precision is low and with a risk of selection bias, making it difficult to rule out the other suggested risk factors without further studies with different approaches.

  • 308.
    Holmbom, Martin
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Andersson, Maria
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Medicine Center, Department of Infectious Diseases.
    Grabe, Magnus
    Lund Univ, Sweden.
    Peeker, Ralph
    Univ Gothenburg, Sweden.
    Saudi, Aus
    Linköping University, Department of Biomedical and Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Styrke, Johan
    Umea Univ, Sweden.
    Aljabery, Firas
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Community-onset urosepsis: incidence and risk factors for 30-day mortality - a retrospective cohort study2022In: Scandinavian journal of urology, ISSN 2168-1805, E-ISSN 2168-1813, Vol. 56, no 5-6, p. 414-420Article in journal (Refereed)
    Abstract [en]

    Background Urosepsis is a life-threatening condition that needs to be addressed without delay. Two critical issues in its management are: (1) Appropriate empirical antibiotic therapy, considering the patients general condition, comorbidity, and the pathogen expected; and (2) Timing of imaging to identify obstruction requiring decompression. Objectives To identify risk factors associated with 30-day mortality in patients with urosepsis. Methods From a cohort of 1,605 community-onset bloodstream infections (CO-BSI), 282 patients with urosepsis were identified in a Swedish county 2019-2020. Risk factors for mortality with crude and adjusted odds ratios were analysed using logistic regression. Results Urosepsis was found in 18% (n = 282) of all CO-BSIs. The 30-day all-cause mortality was 14% (n = 38). After multivariable analysis, radiologically detected urinary tract disorder was the predominant risk factor for mortality (OR = 4.63, 95% CI = 1.47-14.56), followed by microbiologically inappropriate empirical antibiotic therapy (OR = 4.19, 95% CI = 1.41-12.48). Time to radiological diagnosis and decompression of obstruction for source control were also important prognostic factors for survival. Interestingly, 15% of blood cultures showed gram-positive species associated with a high 30-day mortality rate of 33%. Conclusion The 30-day all-cause mortality from urosepsis was 14%. The two main risk factors for mortality were hydronephrosis caused by obstructive stone in the ureter and inappropriate empirical antibiotic therapy. Therefore, early detection of any urinary tract disorder by imaging followed by source control as required, and antibiotic coverage of both gram-negative pathogens and gram-positive species such as E. faecalis to optimise management, is likely to improve survival in patients with urosepsis.

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  • 309.
    Holmgren, Rafael
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Neurobiology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Neurosurgery.
    Abu Hamdeh, Sami
    Akademiska sjukhuset, Uppsala, Sverige.
    Nilsson, Daniel
    Sahlgrenska universitetssjukhuset, Göteborg, Sverige.
    Sandvik, Ulrika
    Karolins-ka universitetssjukhuset Solna, Sverige.
    Handläggning av de tre vanligaste barnneurokirurgiska tillstånden2023In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 120Article, review/survey (Refereed)
    Abstract [sv]

    Barnneurokirurgi är en subspecialitet inom neurokir­urgin. Barnens neurokirurgiska sjukdomar skiljer sig från de vuxnas med andra diagnoser, patofysiologiska mekanismer, tumörtyper och inte minst annan prognos.

    I denna artikel belyser vi de tre vanligaste barnneurokirurgiska tillstånden: hjärntumörer, hydrocefalus samt neuralrörsdefekter inklusive ryggmärgsbråck.

    Vi sammanfattar bakgrund, symtombild och initial handläggning samt ger en översikt av neurokirurgisk behandling av sjukdomarna. 

    Prognosen är oftast god, men samtliga tillstånd är allvarliga och både sjukdom och behandling riskerar att ge livslånga konsekvenser för individen och dess anhöriga.

  • 310.
    Holmqvist, Annica
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Oncology.
    Lindahl, Gabriel
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Oncology. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology.
    Mikivier, Rasmus
    Linköping University, Department of Health, Medicine and Caring Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Regionledningskontoret, Regional Cancer Center.
    Uppugunduri, Srinivas
    Linköping University, Department of Health, Medicine and Caring Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Regionledningskontoret, Regional Cancer Center.
    Age as a potential predictor of acute side effects during chemoradiotherapy in primary cervical cancer patients2022In: BMC Cancer, ISSN 1471-2407, E-ISSN 1471-2407, Vol. 22, no 1, article id 371Article in journal (Refereed)
    Abstract [en]

    Background

    Toxicity during chemoradiotherapy (CRT) in cervical cancer patients might limit the chances of receiving an optimal treatment and to be cured. Few studies have shown relationships between acute side effects and patients age. Here, the association between age and acute side effects such as nausea/vomiting, diarrhea and weight loss during CRT was analysed in cervical cancer patients.

    Methods

    This study included 93 patients with primary cervical cancer stage IBI to IVA who received CRT from 2013 to 2019. The frequency of symptoms/toxicity grade was analysed by using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0.

    Results

    Patients ≥ 52 years had a significantly higher frequency of nausea/vomiting and increased grade  ≥ 3 toxicity during CRT compared to younger patients (p<0.001, p = 0.001). Toxicity grade ≥ 3 of nausea/vomiting was associated with increased frequency of weight loss (p = 0.001), reduced ADL (p = 0.001) and dose modifications of both radiotherapy (RT) (p = 0.020) and chemotherapy (CT) (p = 0.030) compared to toxicity grade 2. The frequency of diarrhea (p = 0.015) and weight loss (p = 0.020) was higher in older patients compared to younger.

    Conclusions

    Older patients have an increased risk of acute side effects as nausea/vomiting, diarrhea and weight loss. Age could be useful in predicting acute side effects in primary cervical cancer patients with CRT.

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  • 311.
    Hooke, Alexander
    et al.
    Biomechanics Core Mayo Clinic, Rochester, MN, USA.
    Hallbeck, Susan M.
    Mayo Clinic, Robert D. and Patricia E. Kerns Center for the Science of Health Care Delivery, Rochester, MN, USA.
    Prytz, Erik
    Linköping University, Department of Computer and Information Science, Human-Centered systems. Linköping University, Faculty of Arts and Sciences.
    Jonson, Carl-Oscar
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Disaster Medicine and Traumatology.
    Tissue Properties during Tourniquet Application: Mechanical Assessment Informing Design of Trainers2019Conference paper (Other academic)
  • 312.
    Hruskova, Zdenka
    et al.
    Charles Univ Prague, Czech Republic; Gen Univ Hosp, Czech Republic.
    Pippias, Maria
    Univ Amsterdam, Netherlands.
    Stel, Vianda S.
    Univ Amsterdam, Netherlands.
    Abad-Diez, Jose M.
    Aragon Hlth Serv, Spain.
    Sanchez, Manuel Benitez
    Hosp Juan Ramon Jimenez, Spain.
    Caskey, Fergus J.
    Southmead Hosp, England; Univ Bristol, England.
    Collart, Frederic
    French Belgian ESRD Registry, Belgium.
    De Meester, Johan
    Dutch Speaking Belgian Renal Registry NBVN, Belgium.
    Finne, Patrik
    Univ Helsinki, Finland; Helsinki Univ Hosp, Finland; Finnish Registry Kidney Dis, Finland.
    Heaf, James G.
    Zealand Univ Hosp, Denmark.
    Magaz, Angela
    Unidad Informac Pacientes Renales Comunidad Auton, Spain.
    Palsson, Runolfur
    Landspitali Natl Univ Hosp Iceland, Iceland; Univ Iceland, Iceland.
    Varberg Reisaeter, Anna
    Oslo Univ Hosp, Norway.
    Salama, Alan D.
    UCL, England.
    Segelmark, Mårten
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Nephrology.
    Traynor, Jamie P.
    ISD Scotland, Scotland.
    Massy, Ziad A.
    Ambroise Pare Univ Hosp, France; INSERM, France; Univ Paris Saclay, France.
    Jager, Kitty J.
    Univ Amsterdam, Netherlands.
    Tesar, Vladimir
    Charles Univ Prague, Czech Republic; Gen Univ Hosp, Czech Republic.
    Characteristics and Outcomes of Patients With Systemic Sclerosis (Scleroderma) Requiring Renal Replacement Therapy in Europe: Results From the ERA-EDTA Registry2019In: American Journal of Kidney Diseases, ISSN 0272-6386, E-ISSN 1523-6838, Vol. 73, no 2, p. 184-193Article in journal (Refereed)
    Abstract [en]

    Rationale amp; Objective: Data for outcomes of patients with end-stage renal disease (ESRD) secondary to systemic sclerosis (scleroderma) requiring renal replacement therapy (RRT) are limited. We examined the incidence and prevalence of ESRD due to scleroderma in Europe and the outcomes among these patients following initiation of RRT. Study Design: Registry study of incidence and prevalence and a matched cohort study of clinical outcomes. Setting amp; Participants: Patients represented in any of 19 renal registries that provided data to the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry between 2002 and 2013. Predictor: Scleroderma as the identified cause of ESRD. Outcomes: Incidence and prevalence of ESRD from scleroderma. Recovery from RRT dependence, patient survival after ESRD, and graft survival after kidney transplantation. Analytical Approach: Incidence and prevalence were calculated using population data from the European Union and standardized to population characteristics in 2005. Patient and graft survival were compared with 2 age- and sex-matched control groups without scleroderma: (1) diabetes mellitus as the cause of ESRD and (2) conditions other than diabetes mellitus as the cause of ESRD. Survival analyses were performed using Kaplan-Meier analysis and Cox regression. Results: 342 patients with scleroderma (0.14% of all incident RRT patients) were included. Between 2002 and 2013, the range of adjusted annual incidence and prevalence rates of RRT for ESRD due to scleroderma were 0.11 to 0.26 and 0.73 to 0.95 per million population, respectively. Recovery of independent kidney function was greatest in the scleroderma group (7.6% vs 0.7% in diabetes mellitus and 2.0% in other primary kidney diseases control group patients, both Pamp;lt;0.001), though time required to achieve recovery was longer. The 5-year survival probability from day 91 of RRT among patients with scleroderma was 38.9% (95% CI, 32.0%-45.8%), whereas 5-year posttransplantation patient survival and 5-year allograft survival were 88.2% (95% CI, 75.3%-94.6%) and 72.4% (95% CI, 55.0%-84.0%), respectively. Adjusted mortality from day 91 on RRT was higher among patients with scleroderma than observed in both control groups (HRs of 1.25 [95% CI, 1.05-1.48] and 2.00 [95% CI, 1.69-2.39]). In contrast, patient and graft survival after kidney transplantation did not differ between patients with scleroderma and control groups. Limitations: No data for extrarenal manifestations, treatment, or recurrence. Conclusions: Survival of patients with scleroderma who receive dialysis for more than 90 days was worse than for those with other causes of ESRD. Patient survival after transplantation was similar to that observed among patients with ESRD due to other conditions. Patients with scleroderma had a higher rate of recovery from RRT dependence than controls.

  • 313.
    Hult, Mari
    et al.
    Karolinska Inst, Sweden; Karolinska Univ Hosp, Sweden.
    Bonn, Stephanie E.
    Karolinska Inst, Sweden.
    Brandt, Lena
    Karolinska Inst, Sweden.
    Wirén, Mikael
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Norrköping.
    Lagerros, Ylva Trolle
    Karolinska Inst, Sweden; Stockholm Hlth Serv, Sweden.
    Womens Satisfaction with and Reasons to Seek Bariatric Surgerya Prospective Study in Sweden with 1-Year Follow-up2019In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 29, no 7, p. 2059-2070Article in journal (Refereed)
    Abstract [en]

    Background/Objectives Despite profound weight loss after bariatric surgery, some patients are dissatisfied with the results. Pre-surgery expectations, as well as post-surgery items of satisfaction, need to be clarified. The main objective in this study was to investigate the primary reasons to seek bariatric surgery and assess items of satisfaction 1-year post-surgery. Subjects/Methods This is a prospective cohort study of women (n = 50) undergoing bariatric surgery in Stockholm, Sweden. Presurgery assessment included reasons to seek surgery, expected weight loss, co-morbidities, and quality of life. Post-surgery assessment included items of satisfaction, weight loss, co-morbidities, and quality of life. In total, two women did not undergo surgery, and 40 women had complete data from all pre- and post-surgery assessments. Results Mean change in body mass index (BMI) pre- and post-surgery was -12.9 (3.7) kg/m(2). At 1-year post-surgery, the mean percent of excess weight loss (% EWL) was 86.9 (26.3). Pre-surgery, the most reported reason to seek surgery was "weight loss" (47.9%), while the most reported item of satisfaction post-surgery was "improved self-esteem" (55.6%). Satisfaction with the result 1-year post-surgery was associated with the extent of % EWL. Satisfied patients (n = 32) had a mean % EWL of 94.6 (22.9), while those not satisfied (n = 8) had a mean % EWL of 59.9 (17.6). Conclusions The primary reason to seek bariatric surgery was weight loss. However, despite profound weight loss, improved self-esteem was the item of most satisfaction post-surgery. Our findings may be useful in the clinical setting when informing patients pre- surgery about what to expect as well as when meeting a patient post-surgery to discuss results.

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  • 314. Order onlineBuy this publication >>
    Hultkvist, Henrik
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Implications of myocardial dysfunction before and after aortic valve intervention2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    BACKGROUND

    Postoperative heart failure in the setting of aortic valve surgery results in poor long-term survival. We hypothesized that there could be a myocardial factor that is not addressed by risk scores currently available. We speculated that this myocardial factor could be diastolic dysfunction. By evaluating postoperative heart failure, the EuroSCORE, the NT-proBNP level, and diastolic function, we might achieve a deeper understanding of the outcome for individuals with postoperative heart failure.

    METHODS

    This research project was built upon four cohort studies. The first two studies (I and II) were retrospective in nature, and studies III and IV were prospective, observational, and longitudinal. All work was based on data from clinical and national databases. In Study I, we compared the outcome of patients with or without postoperative heart failure, evaluated according to the preoperative risk score. In Study II, we explored the effect of underlying heart disease on the preoperative level of NT-proBNP and the relationships between NT-proBNP and severe postoperative heart failure and short-term mortality. In Study III, we described the dynamics

    of NT-proBNP, from a preoperative evaluation to a six-month follow-up, in patients that underwent one of two different procedures: a surgical aortic valve replacement and a transcatheter implantation. We related both pre- and postprocedural NT-proBNP levels to one-year mortality. In Study IV, we evaluated diastolic function in patients that underwent surgical aortic valve replacement and its influence on outcome. We also evaluated NT-proBNP levels and postoperative heart failure as predictors of long-term mortality.

    RESULTS

    Study I

    This study included 397 patients that underwent isolated surgical aortic valve replacements. Of these, 45 patients (11%) were treated for postoperative heart failure. With an average follow-up of 8.1 years (range 5.2-11.2), among patients at low risk (EuroSCORE≤7), the crude five-year survival rates were 58% in patients with postoperative heart failure and 89% in those without postoperative heart failure (p<0.001). Among patients with postoperative heart failure, those classified as low risk had the same poor long-term prognosis as those classified as high risk (EuroSCORE>7). In the high risk group, survival rates were similar between patients with or without postoperative heart failure (57% vs. 64%; p=0.60).

    Study II

    This study included a cohort of 2978 patients with coronary artery disease, aortic stenosis, and mitral regurgitation. Preoperative NTproBNP levels were found to be 1.7-fold higher in patients with aortic stenosis than in patients with coronary artery disease and 1.4-fold higher in patients with mitral regurgitation than in patients with coronary disease. The power of preoperative NT-proBNP for predicting severe postoperative heart conditions was good among patients with coronary heart disease and patients with mitral regurgitation, but not as good among patients with aortic stenosis. NT-proBNP also showed good discriminating power for short-term mortality among patients with coronary artery disease. Moreover, NT-proBNP was found to be an independent predictor for both severe postoperative heart failure and short-term mortality in patients with coronary artery disease.

    Study III

    This study included 462 patients that underwent preoperative evaluations for aortic valve disease. Aortic valve interventions elicited a rise in NT-proBNP that was more pronounced in patients undergoing surgical aortic valve replacement compared to patients undergoing transcatheter valve implantation. No deterioration in NT-proBNP was observed during the waiting time before the intervention, despite a median duration of four months. At six months after the intervention, NT-proBNP levels had decreased to or below the preoperative levels in all groups. Among patients that received surgical aortic valve replacements, pre-and early postoperative NT-proBNP levels showed good discriminatory power for oneyear mortality. This discriminatory power was not observed among patients that had undergone a transcatheter procedure; those patients had higher levels of both pre- and postoperative NT-proBNP compared to patients that had undergone surgery.

    Study IV

    We evaluated 273 patients that underwent aortic valve surgery. High left ventricular filling pressure was present in 22% (n=54) of patients at the time of surgery. At six months after surgery, diastolic function deteriorated in 24/193 (12%) patients and improved in 27/54 (50%) patients. Diastolic dysfunction was not found to be associated with long-term mortality. However, both postoperative heart failure and preoperative NTproBNP levels were associated with increases in long-term mortality. In a multivariable Cox analysis, NT-proBNP remained predictive of long-term mortality.

    CONCLUSION

    Postoperative heart failure contributed to long-term mortality, even in patients considered to be at low risk preoperatively. Our results suggested that pressure overload, followed by a volume overload led to a NTproBNP response that was more pronounced than the ischemia response. Elevated levels of NT-proBNP were associated with both short- and long-term mortality. In these studies, we could not corroborate the notion that high left ventricular filling pressure was associated with long-term mortality.

    List of papers
    1. The combined impact of postoperative heart failure and euroScore on long-term outcome after surgery for aortic stenosis
    Open this publication in new window or tab >>The combined impact of postoperative heart failure and euroScore on long-term outcome after surgery for aortic stenosis
    2011 (English)In: Journal of Heart Valve Disease, ISSN 0966-8519, E-ISSN 2053-2644, Vol. 20, no 6, p. 633-638Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND AND AIM OF THE STUDY:

    Although the EuroSCORE was developed for predicting operative mortality after cardiac surgery, it has also been shown to predict long-term mortality. It has been reported that postoperative heart failure (PHF) in association with surgery, albeit comparatively benign in the short term, has a profound impact on five-year survival after surgery for aortic stenosis (AS). The study aim was to determine the combined impact of EuroSCORE and PHF on long-term survival after isolated aortic valve replacement (AVR) for AS.

    METHODS:

    A total of 397 patients (48% females; average age 70 +/- 10 years) who underwent AVR for AS at the authors' institution between 1995 and 2000 was studied. The cohort was subdivided according to the additive EuroSCORE into a high-risk group (EuroSCORE >7) and a low-risk group (EuroSCORE < or = 7), and further analyzed in relation to PHF.

    RESULTS:

    The average follow up was 8.1 years (range: 5.2-11.2 years). Forty-five patients (11%) were treated for procedure-associated PHF. Patients with or without PHF and a high-risk EuroSCORE had crude five-year survivals of 57% and 64%, respectively (p = 0.6), whereas those with or without PHF but with a low-risk EuroSCORE had crude five-year survivals of 58% and 89%, respectively (p = 0.0003).

    CONCLUSION:

    Both PHF and a high EuroSCORE were associated with poor long-term survival. The role of PHF per se for the long-term prognosis was illustrated by the fact that the negative impact on long-term survival was almost as profound in patients of the low-risk group as of the high-risk group.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-73431 (URN)000306675200005 ()22655493 (PubMedID)
    Available from: 2012-01-03 Created: 2012-01-03 Last updated: 2021-03-14Bibliographically approved
    2. Impact of underlying heart disease per se on the utility of preoperative NT-proBNP in adult cardiac surgery
    Open this publication in new window or tab >>Impact of underlying heart disease per se on the utility of preoperative NT-proBNP in adult cardiac surgery
    Show others...
    2018 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 13, no 2, article id e0192503Article in journal (Refereed) Published
    Abstract [en]

    Objective The primary aim was to investigate the role of underlying heart disease on preoperative NT-proBNP levels in patients admitted for adult cardiac surgery, after adjusting for the known confounders age, gender, obesity and renal function. The second aim was to investigate the predictive value of preoperative NT-proBNP with regard to severe postoperative heart failure (SPHF) and postoperative mortality. Methods A retrospective cohort study based on preoperative NT-proBNP measurements in an unselected cohort including all patients undergoing first time surgery for coronary artery disease (CAD; n = 2226), aortic stenosis (AS; n = 406) or mitral regurgitation (MR; n = 346) from April 2010 to August 2016 in the southeast region of Sweden (n = 2978). Concomitant procedures were not included, with the exception of Maze or tricuspid valve procedures. Results Preoperative NT-proBNP was 1.67 times (pamp;lt;0.0001) and 1.41 times (pamp;lt;0.0001) higher in patients with AS or MR respectively, than in patients with CAD after adjusting for confounders. NT-proBNP demonstrated significant discrimination with regard to SPHF in CAD (AUC = 0.79, 95% CI 0.73 +/- 0.85, pamp;lt;0.0001), MR (AUC = 0.80, 95% CI 0.72 +/- 0.87, pamp;lt;0.0001) and AS (AUC = 0.66, 95% CI 0.51 +/- 0.81, p = 0.047). In CAD patients NT-proBNP demonstrated significant discrimination with regard to postoperative 30-day or in-hospital mortality (AUC = 0.78; 95% CI 0.71 +/- 0.85, pamp;lt;0.0001). The number of deaths was too few in the AS and MR group to permit analysis. Elevated NT-proBNP emerged as an independent risk factor for SPHF, and postoperative mortality in CAD. Conclusions Patients with AS or MR have higher preoperative NT-proBNP than CAD patients even after adjusting for confounders. The predictive value of NT-proBNP with regard to SPHF was confirmed in CAD and MR patients but was less convincing in AS patients.

    Place, publisher, year, edition, pages
    PUBLIC LIBRARY SCIENCE, 2018
    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-145771 (URN)10.1371/journal.pone.0192503 (DOI)000424517900085 ()29420603 (PubMedID)
    Note

    Funding Agencies|Region Ostergotland [LIO-443891]

    Available from: 2018-03-22 Created: 2018-03-22 Last updated: 2024-01-10
    3. Rise and fall of NT-proBNP in aortic valve intervention.
    Open this publication in new window or tab >>Rise and fall of NT-proBNP in aortic valve intervention.
    2018 (English)In: Open heart, E-ISSN 2053-3624, Vol. 5, no 1, article id e000739Article in journal (Refereed) Published
    Abstract [en]

    Objectives: To describe the dynamics of N-terminal pro-B-type natriuretic peptide (NT-proBNP) from preoperative evaluation to 6-month follow-up in patients undergoing aortic valve intervention, and to evaluate NT-proBNP with regard to 1-year mortality.

    Methods: At preoperative evaluation, we prospectively included 462 patients accepted for aortic valve intervention. The median time to surgical aortic valve replacement (SAVR; n=336) or transcatheter aortic valve implantation (TAVI; n=126) was 4 months. NT-proBNP was measured at enrolment for preoperative evaluation, on the day of surgery, postoperatively on day 1, day 3 and at the 6-month follow-up. Subgroups of patients undergoing SAVR with aortic regurgitation and aortic stenosis with and without coronary artery bypass were also analysed.

    Results: NT-proBNP remained stable in all subgroups during the preoperative waiting period, but displayed a substantial transient early postoperative increase with a peak on day 3 except in the TAVI group, which peaked on day 1. At the 6-month follow-up, NT-proBNP had decreased to or below the preoperative level in all groups. In the SAVR group, NT-proBNP preoperatively and on postoperative days 1 and 3 revealed significant discriminatory power with regard to 1-year mortality (area under the curve (AUC)=0.79, P=0.0001; AUC=0.71, P=0.03; and AUC=0.79, P=0.002, respectively). This was not found in the TAVI group, which had higher levels of NT-proBNP both preoperatively and at the 6-month follow-up compared with the SAVR group.

    Conclusions: The dynamic profile of NT-proBNP differed between patients undergoing TAVI and SAVR. NT-proBNP in the perioperative course was associated with increased risk of 1-year mortality in SAVR but not in TAVI.

    Keywords
    aortic valve disease, heart failure, surgery-valve
    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-149013 (URN)10.1136/openhrt-2017-000739 (DOI)29632678 (PubMedID)
    Available from: 2018-06-25 Created: 2018-06-25 Last updated: 2024-01-10
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  • 315.
    Humble, Caroline A. S.
    et al.
    Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping (ANOPIVA). Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Huang, Stephen
    Univ Sydney, Australia.
    Jammer, Ib
    Univ Bergen, Norway; Haukeland Hosp, Norway.
    Bjork, Jonas
    Lund Univ, Sweden; Skane Univ Hosp, Sweden.
    Chew, Michelle
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping (ANOPIVA).
    Prognostic performance of preoperative cardiac troponin and perioperative changes in cardiac troponin for the prediction of major adverse cardiac events and mortality in noncardiac surgery: A systematic review and meta-analysis2019In: PLOS ONE, E-ISSN 1932-6203, Vol. 14, no 4, article id e0215094Article, review/survey (Refereed)
    Abstract [en]

    Background Increased postoperative cardiac troponin (cTn) independently predicts short-term mortality. Previous studies suggest that preoperative cTn also predicts major adverse cardiovascular events (MACE) and mortality after noncardiac surgery. The value of preoperative and perioperative changes in cTn as a prognostic tool for adverse outcomes has been sparsely investigated. Methods and findings A systematic review and meta-analysis of the prognostic value of cTns for adverse outcome was conducted. Adverse outcome was defined as short-term (in-hospital or amp;lt; 30 days) and long-term (amp;gt; 30 days) MACE and/or all-cause mortality, in adult patients undergoing noncardiac surgery. The study protocol (CRD42018094773) was registered with an international prospective register of systematic reviews (PROSPERO). Preoperative cTn was a predictor of short-(OR 4.3, 95% CI 2.9-6.5, pamp;lt;0.001, adjusted OR 5.87, 95% CI 3.24-10.65, pamp;lt;0.001) and long-term adverse outcome (OR 4.2, 95% CI 1.0-17.3, p=0.05, adjusted HR 2.0, 95% CI 1.4-3.0, pamp;lt;0.001). Perioperative change in cTn was a predictor of short-term adverse outcome (OR 10.1, 95% CI 3.2-32.3, pamp;lt;0.001). It was not possible to conduct pooled analyses for adjusted estimates of perioperative change in cTn as predictor of short (a single study identified) and long-term (no studies identified) adverse outcome. Further, it was not possible to conduct pooled analyses for unadjusted estimates of perioperative change in cTn as predictor of long-term adverse outcome, since only one study was identified. Bivariate analysis of sensitivities and specificities were performed, and overall prognostic performance was summarized using summary receiver operating characteristic (SROC) curves. The pooled sensitivity and specificity for preoperative cTn and short-term adverse outcome was 0.43 and 0.86 respectively (area under the SROC curve of 0.68). There were insufficient studies to construct SROCs for perioperative changes in cTn and for long-term adverse outcome. Conclusion Our study indicates that although preoperative cTn and perioperative change in cTn might be valuable predictors of MACE and/or all-cause mortality in adult noncardiac surgical patients, its overall prognostic performance remains uncertain. Future large, representative, high-quality studies are needed to establish the potential role of cTns in perioperative cardiac risk stratification.

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  • 316.
    Huss, Fredrik R.M.
    Linköping University, Department of Clinical and Experimental Medicine, Burn Center. Linköping University, Faculty of Health Sciences.
    In vitro and in vivo studies of tissue engineering in reconstructive plastic surgery2005Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    To correct, improve, and maintain tissues, and their functions, are common denominators in tissue engineering and reconstructive plastic surgery. This can be achieved by using autolo-gous tissues as in flaps or transplants. However, often autologous tissue is not useable. This is one of the reasons for the increasing interest among plastic surgeons for tissue engineering, and it has led to fruitful cross-fertilizations between the fields. Tissue engineering is defined as an interdisciplinary field that applies the principles of engineering and life sciences for development of biologic substitutes designed to maintain, restore, or improve tissue functions. These methods have already dramatically improved the possibilities to treat a number of medical conditions, and can arbitrarily be divided into two main principles:

    > Methods where autologous cells are cultured in vitro and transplanted by means of a cell suspension, a graft, or in a 3-D biodegradable matrix as carrier.

    > Methods where the tissue of interest is stimulated and given the right prerequisites to regenerate the tissue in vivo/situ with the assistance of implantation of specially designed materials, or application of substances that regulate cell functions - guided tissue regeneration.

    We have shown that human mammary epithelial cells and adipocytes could be isolated from tissue biopsies and that the cells kept their proliferative ability. When co-cultured in a 3-D matrix, patterns of ductal structures of epithelial cells embedded in clusters of adipocytes, mimicking the in vivo architecture of human breast tissue, were seen. This indicated that human autologous breast tissue can be regenerated in vitro.

    The adipose tissue is also generally used to correct soft tissue defects e.g. by autologous fat transplantation. Alas 30-70% of the transplanted fat is commonly resorbed. Preadipocytes are believed to be hardier and also able to replicate, and hence, are probably more useful for fat transplantation. We showed that by using cell culture techniques, significantly more pre-adipocytes could survive and proliferate in vitro compared to two clinically used techniques of fat graft handling. Theoretically, a biopsy of fat could generate enough preadipocytes to seed a biodegradable matrix that is implanted to correct a defect. The cells in the matrix will replicate at a rate that parallels the vascular development, the matrix subsequently degrades and the cell-matrix complex is replaced by regenerated, vascularized adipose tissue.

    We further evaluated different biodegradable scaffolds usable for tissue engineering of soft tissues. A macroporous gelatin sphere showed several appealing characteristics. A number of primary human ecto- and mesodermal cells were proven to thrive on the gelatin spheres when cultured in spinner flasks. As the spheres are biodegradable, it follows that the cells can be cultured and expanded on the same substrate that functions as a transplantation vehicle and scaffold for tissue engineering of soft tissues.

    To evaluate the in vivo behavior of cells and gelatin spheres, an animal study was performed where human fibroblasts and preadipocytes were cultured on the spheres and injected intra-dermally. Cell-seeded spheres were compared with injections of empty spheres and cell suspensions. The pre-seeded spheres showed a near complete regeneration of the soft tissues with neoangiogenesis. Some tissue regeneration was seen also in the ‘naked’ spheres but no effect was shown by cell injections.

    In a human pilot-study, intradermally injected spheres were compared with hyaluronan. Volume-stability was inferior to hyaluronan but a near complete regeneration of the dermis was proven, indicating that the volume-effect is permanent in contrast to hyaluronan which eventually will be resorbed. Further studies are needed to fully evaluate the effect of the macroporous gelatin spheres, with or without cellular pre-seeding, as a matrix for guided tissue regeneration. However, we believe that the prospect to use these spheres as an injectable, 3D, biodegradable matrix will greatly enhance our possibilities to regenerate tissues through guided tissue regeneration.

    List of papers
    1. Mammary epithelial cell and adipocyte co-culture in a 3-D matrix: The first step towards tissue-engineered human breast tissue
    Open this publication in new window or tab >>Mammary epithelial cell and adipocyte co-culture in a 3-D matrix: The first step towards tissue-engineered human breast tissue
    2001 (English)In: Cells Tissues Organs, ISSN 1422-6405, Vol. 169, no 4, p. 361-367Article in journal (Refereed) Published
    Abstract [en]

    Reconstruction of the female breast after cancer surgery is a demanding task where the methods used today suffer from several disadvantages. In the present study we have investigated the possibility to use tissue engineering methods to regenerate human autologous breast tissue. Human mammary epithelial cells and preadipocytes were derived from breast tissue biopsies from healthy women undergoing reduction mammoplasty, and the two celltypes were co-cultured with conventional cell culture methods as well as in 3-D matrices. The study shows that it is possible to harvest both human mammary epithelial cells and preadipocytes in a single session, propagate several subcultures, and that the cells maintain a normal intercellular distribution and growth-pattern when co-cultured in a 3-D collagen gel. We propose that growth and formation of a tissue closely resembling normal human breast tissue be readily obtained in the described in vitro cell culture set-up using basic tissue engineering principles. This concept may be of great importance in the development of new methods for reconstruction of the human breast.

    Keywords
    Tissue engineering, Adipocyte, Mammary epithelial cell, Breast tissue
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-14344 (URN)10.1159/000047903 (DOI)
    Available from: 2007-03-16 Created: 2007-03-16 Last updated: 2021-12-29
    2. Adipose tissue processed for lipoinjection shows increased cellular survival in vitro when tissue engineering principles are applied: Culture techniques and survival of fat
    Open this publication in new window or tab >>Adipose tissue processed for lipoinjection shows increased cellular survival in vitro when tissue engineering principles are applied: Culture techniques and survival of fat
    2002 (English)In: Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, ISSN 0284-4311, Vol. 36, no 3, p. 166-171Article in journal (Refereed) Published
    Abstract [en]

    Correcting soft tissue defects by autologous fat grafting is a routine procedure in plastic surgery. Its efficacy and safety has been discussed extensively and several techniques of lipoinjection have been developed. However, one is bound to overcorrect by 30%-70% or need to repeat the procedure because of resorption of the transplant. The reasons are that many of the transplanted cells are already differentiated, and also that there is no nutritional support to the inner cell layers when they are transplanted as fragments. By culturing autologous adipocytes one can ensure that only non-differentiated, but committed, preadipocytes are transplanted and the procedure can be done in a way that ensures optimal nutritional support for the cells. In the present study we have compared our cell culture technique with two common clinical ways of processing liposuction material and found that (pre)adipocytes survive and proliferate significantly better in cell culture.

    Keywords
    words, cell culture, fat grafting, tissue engineering
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-14345 (URN)
    Available from: 2007-03-16 Created: 2007-03-16 Last updated: 2021-12-29
    3. New degradable polymer scaffold for regeneration of the dermis In vitro and in vivo studies
    Open this publication in new window or tab >>New degradable polymer scaffold for regeneration of the dermis In vitro and in vivo studies
    Show others...
    Manuscript (Other academic)
    Identifiers
    urn:nbn:se:liu:diva-14346 (URN)
    Available from: 2007-03-16 Created: 2007-03-16 Last updated: 2010-01-13
    4. Growth of cultured human ecto- and mesodermal cells on macroporous biodegradable gelatin spheres
    Open this publication in new window or tab >>Growth of cultured human ecto- and mesodermal cells on macroporous biodegradable gelatin spheres
    Show others...
    Manuscript (Other academic)
    Identifiers
    urn:nbn:se:liu:diva-14347 (URN)
    Available from: 2007-03-16 Created: 2007-03-16 Last updated: 2010-01-13
    5. Macroporous gelatine spheres as culture substrate, transplantation vehicle, and biodegradable scaffold for guided regeneration of soft tissues.: In vivo study in nude mice
    Open this publication in new window or tab >>Macroporous gelatine spheres as culture substrate, transplantation vehicle, and biodegradable scaffold for guided regeneration of soft tissues.: In vivo study in nude mice
    2007 (English)In: Journal of Plastic, Reconstructive, and Aesthetic Surgery, ISSN 1748-6815, Vol. 60, no 5, p. 543-555Article in journal (Refereed) Published
    Abstract [en]

    In the course of development of a new type of filler for the correction of small defects in soft tissues we studied macroporous gelatine spheres as culture substrate, transplantation vehicle, and biodegradable scaffold for guided regeneration of soft tissues in vivo. We injected intradermally in nude mice gelatine spheres that had either been preseeded with human fibroblasts or preadipocytes, or left unseeded. We compared the extent of regenerated tissue with that found after injections of saline or single-cell suspensions of human fibroblasts or preadipocytes. Routine histological examinations and immunohistochemical staining for von Willebrand factor (indicating neoangiogenesis) were made after 7, 21, and 56 days. Injected saline or single-cell suspensions had no effect. However, a quick and thorough tissue regeneration with developing neoangiogenesis was elicited by the gelatine spheres and the effect of spheres preseeded with preadipocytes surpassed the effect of spheres preseeded with fibroblasts, which in turn surpassed the effect of unseeded gelatine spheres. We suggest that minor soft tissue defects such as wrinkles or creases can be corrected by injection of naked macroporous gelatine spheres, whereas larger defects are best corrected by injection of macroporous gelatine spheres preseeded with fibroblasts, or preadipocytes, or both.

    Keywords
    Filler, Soft tissue defect, Guided tissue regeneration, Tissue engineering, Animal, In vivo
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-14348 (URN)10.1016/j.bjps.2005.10.031 (DOI)
    Available from: 2007-03-16 Created: 2007-03-16 Last updated: 2021-12-29
    6. Use of macroporous gelatine spheres as a biodegradable scaffold for guided tissue regeneration in humans: An in vivo study
    Open this publication in new window or tab >>Use of macroporous gelatine spheres as a biodegradable scaffold for guided tissue regeneration in humans: An in vivo study
    2005 (English)In: Journal of Plastic, Reconstructive, and Aesthetic Surgery, ISSN 1748-6815Article in journal (Refereed) Submitted
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-14349 (URN)
    Available from: 2007-03-16 Created: 2007-03-16 Last updated: 2021-12-29
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  • 317.
    Hägg, Mary
    et al.
    Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Otorhinolaryngology in Linköping. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Hudiksvall, Uppsala University/County Council of Gävleborg, Gävle, Uppsala, Sweden.
    Tibbling, Lita
    Hudiksvall, Uppsala University/County Council of Gävleborg, Gävle, Uppsala, Sweden.
    Effect of oral IQoro(R) and palatal plate training in post-stroke, four-quadrant facial dysfunction and dysphagia: A comparison study2015In: Acta Oto-Laryngologica, ISSN 0001-6489, E-ISSN 1651-2251, Vol. 135, no 9, p. 962-968Article in journal (Refereed)
    Abstract [en]

    Conclusion: Training with either a palatal plate (PP) or an oral IQoro(R) screen (IQS) in patients with longstanding facial dysfunction and dysphagia after stroke can significantly improve facial activity (FA) in all four facial quadrants as well as swallowing capacity (SC). Improvements remained at late follow-up. The training modalities did not significantly differ in ameliorating facial dysfunction and dysphagia in these patients. However, IQS training has practical and economic advantages over PP training. Objectives: This study compared PP and oral IQS training in terms of (i) effect on four-quadrant facial dysfunction and dysphagia after a first-ever stroke, and (ii) whether the training effect persisted at late follow-up. Methods: Patients were included during two periods; 13 patients in 2005-2008 trained with a PP, while 18 patients in 2009-2012 trained with an IQS. Four-quadrant facial dysfunction was assessed with an FA test and swallowing dysfunction with a SC test: before and after a 3-month training period and at late follow-up. FA and SC significantly improved (p less than 0.001) in both groups. FA test scores after training and at late follow-up did not differ significantly between the groups, irrespective of whether the interval between stroke incidence and the start of training was long or short.

  • 318.
    Hägglund, Martin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Waldén, Markus
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Ekstrand, Jan
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Injury recurrence is lower at the highest professional football level than at national and amateur levels: does sports medicine and sports physiotherapy deliver?2016In: British Journal of Sports Medicine, ISSN 0306-3674, E-ISSN 1473-0480, Vol. 50, no 12, p. 751-758Article in journal (Refereed)
    Abstract [en]

    Background Previous injury is a well-documented risk factor for football injury. The time trends and patterns of recurrent injuries at different playing levels are not clear. Aim To compare recurrent injury proportions, incidences and patterns between different football playing levels, and to study time trends in recurrent injury incidence. Methods Time-loss injuries were collected from injury surveillance of 43 top-level European professional teams (240 team-seasons), 19 Swedish premier division teams (82 team-seasons) and 10 Swedish amateur teams (10 team-seasons). Recurrent injury was defined as an injury of the same type and at the same site as an index injury within the preceding year, with injury amp;lt;2 months defined as an early recurrence, and amp;gt;2 months as a delayed recurrence. Seasonal trend for recurrent injury incidence, expressed as the average annual percentage of change, was analysed using linear regression. Results 13 050 injuries were included, 2449 (18.8%) being recurrent injuries, with 1944 early (14.9%) and 505 delayed recurrences (3.9%). Recurrence proportions were highest in the second half of the competitive season for all cohorts. Recurrence proportions differed between playing levels, with 35.1% in the amateur cohort, 25.0% in the Swedish elite cohort and 16.6% in the European cohort (chi(2) overall effect, pamp;lt;0.001). A decreasing trend was observed in recurrent injury incidence in the European cohort, a -2.9% average annual change over the 14-year study period (95% CI -5.4% to -0.4%, p=0.026). Similarly, a decreasing tendency was also seen in the Swedish premier division. Conclusions Recurrence proportions showed an inverse relationship with playing level, and recurrent injury incidence has decreased over the past decade.

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  • 319.
    Högstedt, Alexandra
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Farnebo, Simon
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Tesselaar, Erik
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Medical radiation physics. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine.
    Ghafouri, Bijar
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Investigation of proteins important for microcirculation using in vivo microdialysis after glucose provocation: a proteomic study2021In: Scientific Reports, E-ISSN 2045-2322, Vol. 11, no 1, article id 19093Article in journal (Refereed)
    Abstract [en]

    Insulin has metabolic and vascular effects in the human body. What mechanisms that orchestrate the effects in the microcirculation, and how the responds differ in different tissues, is however not fully understood. It is therefore of interest to search for markers in microdialysate that may be related to the microcirculation. This study aims to identify proteins related to microvascular changes in different tissue compartments after glucose provocation using in vivo microdialysis. Microdialysis was conducted in three different tissue compartments (intracutaneous, subcutaneous and intravenous) from healthy subjects. Microdialysate was collected during three time periods; recovery after catheter insertion, baseline and glucose provocation, and analyzed using proteomics. Altogether, 126 proteins were detected. Multivariate data analysis showed that the differences in protein expression levels during the three time periods, including comparison before and after glucose provocation, were most pronounced in the intracutaneous and subcutaneous compartments. Four proteins with vascular effects were identified (angiotensinogen, kininogen-1, alpha-2-HS-glycoprotein and hemoglobin subunit beta), all upregulated after glucose provocation compared to baseline in all three compartments. Glucose provocation is known to cause insulin-induced vasodilation through the nitric oxide pathway, and this study indicates that this is facilitated through the interactions of the RAS (angiotensinogen) and kallikrein-kinin (kininogen-1) systems.

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  • 320.
    Illini, Oliver
    et al.
    Karl Landsteiner Inst Lung Res & Pulm Oncol, Austria.
    Fabikan, Hannah
    Karl Landsteiner Inst Lung Res & Pulm Oncol, Austria.
    Swalduz, Aurelie
    Claude Bernard Lyon 1 Univ, France; Univ Lyon, France; Univ Lyon, France.
    Vikström, Anders
    Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Respiratory Medicine.
    Krenbek, Dagmar
    Klin Floridsdorf, Austria.
    Schumacher, Michael
    OKL Elisabethinen Linz, Austria.
    Dudnik, Elizabeth
    Assuta Med Ctr, Israel.
    Studnicka, Michael
    Paracelsus Med Univ, Austria.
    Ohman, Ronny
    Univ Hosp Skane Lund, Sweden.
    Wurm, Robert
    Med Univ Graz, Austria.
    Wannesson, Luciano
    Ist Oncol Svizzera Italian, Switzerland.
    Peled, Nir
    Shaare Zedek Med Ctr, Israel.
    Kian, Waleed
    Shaare Zedek Med Ctr, Israel.
    Bar, Jair
    Chaim Sheba Med Ctr, Israel; Tel Aviv Univ, Israel.
    Daher, Sameh
    Canc Ctr Haim Sheba MC Tel, Israel.
    Addeo, Alfredo
    Univ Hosp Geneva, Switzerland.
    Rotem, Ofer
    Beilinson Med Ctr, Israel.
    Pall, Georg
    Univ Hosp Innsbruck, Austria.
    Zer, Alona
    Rambam Hlth Campus, Israel.
    Saad, Akram
    Sheba Med Ctr, Israel; Tel Aviv Univ, Israel.
    Cufer, Tanja
    Univ Clin Golnik, Slovenia; Univ Ljubljana, Slovenia.
    Sorotsky, Hadas Gantz
    Canc Ctr Haim Sheba MC Tel, Israel.
    Hashemi, Sayed M. S.
    Vrije Univ Amsterdam Med Ctr, Netherlands.
    Mohorcic, Katja
    Univ Clin Golnik, Slovenia.
    Stoff, Ronen
    Sheba Med Ctr, Israel.
    Rovitsky, Yulia
    Carmel Hosp, Israel.
    Keren-Rosenberg, Shoshana
    Carmel Hosp, Israel.
    Winder, Thomas
    Acad Teaching Hosp Feldkirch, Austria; Univ Zurich, Switzerland.
    Weinlinger, Christoph
    Karl Landsteiner Inst Lung Res & Pulm Oncol, Austria.
    Valipour, Arschang
    Klin Floridsdorf, Austria; Karl Landsteiner Inst Lung Res & Pulm Oncol, Austria.
    Hochmair, Maximilian J.
    Klin Floridsdorf, Austria; Karl Landsteiner Inst Lung Res & Pulm Oncol, Austria.
    Real-world experience with capmatinib in MET exon 14-mutated non-small cell lung cancer (RECAP): a retrospective analysis from an early access program2022In: Therapeutic Advances in Medical Oncology, ISSN 1758-8340, Vol. 14, article id 17588359221103206Article in journal (Refereed)
    Abstract [en]

    Background: Patients with non-small cell lung cancer (NSCLC) presenting with mesenchymal-epithelial transition (MET) exon 14 skipping mutation have an unfavorable prognosis with standard treatments. Capmatinib is a selective MET inhibitor, which showed promising efficacy in this patient population in early trials. Methods: We performed a retrospective, international, multicenter efficacy and safety analysis in patients with NSCLC treated with capmatinib in an early access program between March 2019 and December 2021. Results: Data from 81 patients with advanced MET exon 14 mutated NSCLC treated with capmatinib in first- or later-line therapy were analyzed. Median age was 77 years (range, 48-91), 56% were women, 86% had stage IV disease, and 27% had brain metastases. For all patients, the objective response rate (ORR) to capmatinib was 58% (95% CI, 47-69), whereas it was 68% (95% CI, 50-82) in treatment-naive and 50% (95% CI, 35-65) in pretreated patients. The median progression-free survival was 9.5 months (95% CI, 4.7-14.3), whereas it was 10.6 months (95% CI, 5.5-15.7) in first-line and 9.1 months (95% CI, 3.1-15.1) in pretreated patients. After a median follow-up of 11.0 months, the median overall survival was 18.2 months (95% CI, 13.2-23.1). In patients with measurable brain metastases (n = 11), the intracranial ORR was 46% (95% CI, 17-77). Capmatinib showed a manageable safety profile. Grade &gt; 3 treatment-related adverse events included peripheral edema (13%), elevated creatinine (4%), and elevated liver enzymes (3%). Conclusion: In patients with MET exon 14 skipping mutation, capmatinib showed durable systemic and intracranial efficacy and a manageable safety profile. This analysis confirms previously reported phase II data in a real-world setting.

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  • 321.
    Isaksson, Karolin
    et al.
    Lund Univ, Sweden.
    Katsarelias, Dimitrios
    Univ Gothenburg, Sweden.
    Mikiver, Rasmus
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Business support and Development, Regional Cancer Center.
    Carneiro, Ana
    Lund Univ, Sweden.
    Ny, Lars
    Univ Gothenburg, Sweden.
    Olofsson Bagge, Roger
    Univ Gothenburg, Sweden.
    A Population-Based Comparison of the AJCC 7th and AJCC 8th Editions for Patients Diagnosed with Stage III Cutaneous Malignant Melanoma in Sweden2019In: Annals of Surgical Oncology, ISSN 1068-9265, E-ISSN 1534-4681, Vol. 26, no 9, p. 2839-2845Article in journal (Refereed)
    Abstract [en]

    Background

    Cutaneous melanoma is steadily increasing worldwide. The new AJCC 8th edition was recently launched and introduced several changes in melanoma staging, particularly for stage III. We conducted a population-based registry study with the purpose to evaluate the impact and prognostic accuracy of the new classification in Sweden.

    Methods

    Consecutive patients diagnosed with stage III melanoma between January 2005 and September 2017 were identified by the Swedish Melanoma Registry (SMR) and included for analyses. Patients with multiple primary melanomas were excluded. Patients were classified according to the AJCC 7th as well as the 8th edition. Melanoma-specific survival (MSS) was retrieved from the Swedish Cause of Death Registry.

    Results

    A total of 2067 eligible patients were identified from the SMR; 1150 patients (57%) changed stage III subgroup when reclassified according to the AJCC 8th edition. The median 5- and 10-year MSS for the whole cohort of stage III melanoma patients was 59% and 51% respectively. The MSS for substage IIIA, B, and C were all improved when patients were reclassified by using to the AJCC 8th edition. The newly defined substage IIID had the worst prognosis with a 10-year MSS of 16%.

    Conclusions

    A high proportion of patients diagnosed with stage III melanoma in Sweden between 2005 and 2017 was restaged to another subgroup, when they were reclassified according to the AJCC 8th of staging manual. We established an improved MSS for all substages compared with the former AJCC 7th edition. This may have implications on decisions about adjuvant treatment.

  • 322.
    Islam, Mohammad Mirazul
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Cell Biology. Linköping University, Faculty of Medicine and Health Sciences. Harvard Medical School, Boston, MA USA.
    Buznyk, Oleksiy
    Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences. Filatov Institute of Eye Diseases and Tissue Therapy of the NAMS of Ukraine, Odessa, Ukraine.
    Reddy, Jagadesh C
    Tej Kohli Cornea Institute, LV Prasad Eye Institute, Hyderabad, India.
    Pasyechnikova, Nataliya
    Filatov Institute of Eye Diseases and Tissue Therapy of the NAMS of Ukraine, Odessa, Ukraine.
    Alarcon, Emilio I
    Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON Canada.
    Hayes, Sally
    School of Optometry and Vision Sciences College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK; 7Cardiff Institute for Tissue Engineering and Repair (CITER), Cardiff University, Cardiff, UK.
    Lewis, Philip
    School of Optometry and Vision Sciences College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK; 7Cardiff Institute for Tissue Engineering and Repair (CITER), Cardiff University, Cardiff, UK.
    Fagerholm, Per
    Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Ophthalmology in Linköping.
    He, Chaoliang
    Key Laboratory of Polymer Eco-materials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, China.
    Iakymenko, Stanislav
    Filatov Institute of Eye Diseases and Tissue Therapy of the NAMS of Ukraine, Odessa, Ukraine.
    Liu, Wenguang
    School of Materials Science and Engineering, Tianjin University, Tianjin, China.
    Meek, Keith M
    School of Optometry and Vision Sciences College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK; 7Cardiff Institute for Tissue Engineering and Repair (CITER), Cardiff University, Cardiff, UK.
    Sangwan, Virender S
    Tej Kohli Cornea Institute, LV Prasad Eye Institute, Hyderabad, India.
    Griffith, May
    Linköping University, Department of Clinical and Experimental Medicine, Division of Cell Biology. Linköping University, Faculty of Medicine and Health Sciences. University of Montreal, Montreal, Canada.
    Biomaterials-enabled cornea regeneration in patients at high risk for rejection of donor tissue transplantation2018In: NPJ Regenerative medicine, ISSN 2057-3995, Vol. 3, article id 2Article in journal (Refereed)
    Abstract [en]

    The severe worldwide shortage of donor organs, and severe pathologies placing patients at high risk for rejecting conventional cornea transplantation, have left many corneal blind patients untreated. Following successful pre-clinical evaluation in mini-pigs, we tested a biomaterials-enabled pro-regeneration strategy to restore corneal integrity in an open-label observational study of six patients. Cell-free corneal implants comprising recombinant human collagen and phosphorylcholine were grafted by anterior lamellar keratoplasty into corneas of unilaterally blind patients diagnosed at high-risk for rejecting donor allografts. They were followed-up for a mean of 24 months. Patients with acute disease (ulceration) were relieved of pain and discomfort within 1-2 weeks post-operation. Patients with scarred or ulcerated corneas from severe infection showed better vision improvement, followed by corneas with burns. Corneas with immune or degenerative conditions transplanted for symptom relief only showed no vision improvement overall. However, grafting promoted nerve regeneration as observed by improved touch sensitivity to near normal levels in all patients tested, even for those with little/no sensitivity before treatment. Overall, three out of six patients showed significant vision improvement. Others were sufficiently stabilized to allow follow-on surgery to restore vision. Grafting outcomes in mini-pig corneas were superior to those in human subjects, emphasizing that animal models are only predictive for patients with non-severely pathological corneas; however, for establishing parameters such as stable corneal tissue and nerve regeneration, our pig model is satisfactory. While further testing is merited, we have nevertheless shown that cell-free implants are potentially safe, efficacious options for treating high-risk patients.

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  • 323.
    Istefan, Emanuel
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences.
    Zimmerman, Malin
    Helsingborg Hosp, Sweden; Lund Univ, Sweden.
    Dahlin, Lars
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Lund Univ, Sweden; Skane Univ Hosp, Sweden.
    Nyman, Erika
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Benign nerve tumours in the upper limb: a registry-based study of symptoms and surgical outcome2023In: Scientific Reports, E-ISSN 2045-2322, Vol. 13, no 1Article in journal (Refereed)
    Abstract [en]

    Surgery for benign nerve tumours is performed for pathoanatomical diagnosis and symptomatic relief, but might cause residual problems. We aimed to assess patient-reported symptoms and disability before and after surgery at a national level. In total, 206 cases surgically treated for a benign peripheral nerve tumour 2010-2019 registered in the Swedish Quality Registry for Hand Surgery (HAKIR; response rates 22-34%) were analysed. Surgery reduced overall disability in the affected limb (QuickDASH 18/100 [IQR 5-36] preoperatively and 5/100 [IQR 0-22] 12 months postoperatively), improved ability to perform daily activities (HQ-8; 11/100 [IQR 0-50] preoperatively and 0/100 [IQR 0-20] 12 months postoperatively) and decreased three evaluated pain modalities: pain at rest (HQ-8; 20/100 [IQR 0-40] preoperatively and 0/100 [IQR 0-10] 12 months postoperatively), pain on motion without load (HQ-8; 20/100 [IQR 0-40] preoperatively and 0/100 [IQR 0-10] 12 months postoperatively), and pain on load (HQ-8; 24/100 [IQR 1-69] preoperatively and 1/100 [IQR 0-30] 12 months postoperatively). Cold sensitivity was a minor problem both before and after surgery (HQ-8; 0/100 [IQR 0-30] preoperatively and 1/100 [IQR 0-40] 12 months postoperatively). We conclude that surgery for benign peripheral nerve tumours provides good symptomatic relief with low risk for residual problems.

  • 324.
    Jahnson, Staffan
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Rosell, Johan
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Business support and Development, Regional Cancer Center.
    Abdul-Sattar Aljabery, Firas
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Modulation of the inflammatory response after sclerotherapy for hydrocoele/spermatocoele2019In: BJU International, ISSN 1464-4096, E-ISSN 1464-410X, Vol. 123, no 5A, p. E63-E68Article in journal (Refereed)
    Abstract [en]

    Objective

    To investigate the modulation of the inflammatory response after sclerotherapy for hydrocoele/spermatocoele.

    Patients and Methods

    All patients with hydrocoele or spermatocoele presenting at the Department of Urology, University Hospital, Linköping, Sweden, from 2006 to 2012, were included in this prospective observational study of sclerotherapy for hydrocoele/spermatocoele using polidocanol as a sclerosing agent and adjuvant antibiotic and anti‐inflammatory medication (AAAM) for modulation of the inflammatory response. Patients were clinically evaluated within 24–48 h after a complication or adverse event possibly related to sclerotherapy. Evaluation of cure was scheduled after 3 months and re‐treatment, if necessary was carried out in the same manner as the first treatment. Groups of patients were compared using the chi‐squared test and logistic regression analysis.

    Results

    From a total of 191 patients, AAAM was given to 126, of whom 5% had subclinical epididymitis/swelling (SES) compared to 26% of the patients without AAAM (P < 0.001). No other complication was observed. The rate of cure for the whole group of patients was 93% after one or two treatments and significantly higher in the group with AAAM than in the group without AAAM (96% vs 88%, P = 0.03).

    Conclusions

    Modulation of the inflammatory response after sclerotherapy resulted in a lower incidence of SES and an increased cure rate.

  • 325.
    Jancke, Georg
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Rosell, Johan
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Health and Developmental Care, Regional Cancer Center South East Sweden.
    Jahnson, Staffan
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Urology in Östergötland.
    Impact of surgical experience on recurrence and progression after transurethral resection of bladder tumour in non-muscle-invasive bladder cancer2014In: SCANDINAVIAN JOURNAL OF UROLOGY, ISSN 2168-1805, Vol. 48, no 3, p. 276-283Article in journal (Refereed)
    Abstract [en]

    Introduction: To evaluate the impact of experience in transurethral resection of bladder tumor (TUR-BT) on recurrence and progression in primary Ta/T1 urinary bladder cancer.

    Methods: Clinical and pathological characteristics of patients with primary Ta/T1 urinary bladder cancer were recorded prospectively from 1992 to 2007 inclusive. Data on surgeons’ experience were categorized as follows: (a) experience by training status (residents or specialists); (b) number of TUR-BTs performed by each surgeon during the registration period, with cut-off levels at > 100, > 150, > 200, > median, and > third quartile of surgical volume; (c) lifetime high-volume surgeons (> 100 TUR-BTs). Hazard ratios (HRs) were estimated using Cox regression with 95% confidence intervals (CIs) in both univariate and multivariate analysis.

    Results: The analysis included 768 evaluable patients with a median follow-up of 60 months. Recurrence was observed in 478 patients (62%) and progression in 71 (9%). Surgery was performed by residents in 100 cases and specialists in 668, with recurrence in 75 (75%) and 403 (60%) patients, and progression in 9 (9%) and 62 (9%), respectively. Surgery performed by residents was statistically associated with recurrence (HR = 0.69, 95% CI = 0.54-0.89) but not progression (HR = 0.72, 95% CI = 0.35-1.48). Surgical volume (b and c) was not found to have a significant impact on recurrence or progression in any of the analyses at the chosen cut-offs.

    Conclusions: Surgical experience (specialist/resident) was a predictive factor for recurrence after TUR-BT for Ta/T1 bladder cancer. However, surgeon volume was not associated with recurrence at the chosen cut-off levels. Training programs, checklist

  • 326.
    Janson, Annika
    et al.
    Karolinska Univ Hosp, Sweden; Karolinska Inst, Sweden.
    Jarvholm, Kajsa
    Skane Univ Hosp, Sweden; Sahlgrens Univ Hosp, Sweden.
    Gronowitz, Eva
    Sahlgrens Univ Hosp, Sweden.
    Sjogren, Lovisa
    Sahlgrens Univ Hosp, Sweden.
    Klaesson, Sven
    Sodertalje Hosp, Sweden; Karolinska Inst, Sweden.
    Engstrom, My
    Univ Gothenburg, Sweden; Sahlgrens Univ Hosp, Sweden.
    Peltonen, Markku
    Natl Inst Hlth & Welf, Finland.
    Ekbom, Kerstin
    Karolinska Inst, Sweden.
    Dahlgren, Jovanna
    Sahlgrens Univ Hosp, Sweden.
    Olbers, Torsten
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Norrköping. Sahlgrens Univ Hosp, Sweden.
    A randomized controlled trial comparing intensive non-surgical treatment with bariatric surgery in adolescents aged 13-16 years (AMOS2): Rationale, study design, and patient recruitment2020In: Contemporary Clinical Trials Communications, E-ISSN 2451-8654, Vol. 19, article id 100592Article in journal (Refereed)
    Abstract [en]

    Background: Previous non-randomized studies show similar outcomes in adolescents and adults after bariatric surgery. We describe the study protocol, recruitment, and selected baseline data of patients in a randomized multi-center study, the Adoles cent Morbid Obesity Surgery 2 (AMOS2). Methods: Three clinics in Sweden collaborated in designing the study and recruitment of patients from August 1, 2014 to June 30, 2017. Patients were selected among adolescents 13-16 years of age attending third-level obesity care for at least one year. Patients were randomized 1:1 to bariatric surgery (predominantly Roux-en-Y gastric bypass) or intensive non-surgical treatment starting with an eight-week low-calorie-diet. Results: Fifty adolescents (37 girls) were randomized, 25 (19 girls) to bariatric surgery. Mean age was 15.7 years (range 13.3-16.9), weight 122.6 kg (range 95-183.3), Body Mass Index (BMI) 42.6 kg/m(2) (range 35.7-54.9) and BMI-SDS 3.45 (range 2.9-4.1). One patient had type 2 diabetes mellitus, and 12/45 (27%) had elevated liver enzymes. There were no significant differences between the groups. For the 39 eligible patients who were offered but declined inclusion, BMI was not different from included patients. However, patients who declined were younger, 15.2 years (p = 0.021). A sex difference was also noted with more of eligible girls, 37/53 (69.8%), than boys, 13/36 (36.1%), wanting to participate in the study (p = 0.002). Conclusions: This clinical trial, randomizing adolescents with severe obesity to bariatric surgery or intensive non-surgical treatment, aims at informing about whether it is beneficial to undergo bariatric surgery in early adolescence. It will also enlighten the outcome of comprehensive non-surgical treatment.

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  • 327.
    Janson, Annika
    et al.
    Karolinska universitetssjukhuset, Sweden.
    Järvholm, Kajsa
    Skånes universitetssjukvård, Sweden.
    Gronowitz, Eva
    Drottning Silvias barn- och ungdomssjukhus, Sweden.
    Önnerfält, Jenny
    Skånes universitetssjukvård, Sweden.
    Ekbom, Kerstin
    Karolinska universitetssjukhuset, Sweden.
    Engström, My
    Sahlgrenska universitetssjukhuset, Sweden.
    Elimam, Amira
    Karolinska universitetssjukhuset, Sweden.
    Thorell, Anders
    Karolinska institutet, Sweden.
    Sjögren, Lovisa
    Drottning Silvias barn- och ungdomssjukhus, Sweden.
    Dahlgren, Jovanna
    Drottning Silvias barn- och ungdomssjukhus, Sweden.
    Olbers, Torsten
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Norrköping.
    Fetmakirurgi bör kunna erbjudas före 18 vid allvarlig fetma2019In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 116Article in journal (Other academic)
  • 328.
    Janzon, Magnus
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Henriksson, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Center for Medical Image Science and Visualization (CMIV).
    Hasvold, Pål
    AstraZeneca Nordic-Baltic, Södertälje, Sweden.
    Hjelm, Hans
    Nyköping Hospital, Nyköping, Sweden.
    Thuresson, Marcus
    Statisticon AB, Uppsala, Sweden.
    Jernberg, Tomas
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm, Sweden.
    Long-term resource use patterns and healthcare costs after myocardial infarction in a clinical practice setting - results from a contemporary nationwide registry study2016In: European Heart Journal - Quality of Care and Clinical Outcomes, ISSN 2058-5225, Vol. 2, p. 291-298Article in journal (Refereed)
    Abstract [en]

    Aims Long-term contemporary nationwide data on resource use and healthcare costs after myocardial infarction (MI) in a clinical practice setting are not widely studied, and the aim of this study was to investigate resource use patterns and healthcare costs in patients with MI in a nationwide clinical practice setting.

    Methods and results This retrospective cohort study included all patients identified in the compulsory Swedish nationwide patient register with a diagnosis of MI between 1 July 2006 and 30 June 2011. Cardiovascular hospitalization and outpatient visits data from the patient register were combined with data from the cause of death register and the drug utilization register. For a subset of patients, data were also available from a primary care register. Healthcare resource use patterns and annual costs [reported in 2014 euros (€) converted from Swedish kronor (SEK) using the exchange rate €1 = SEK 9.33)] were estimated for the year prior to the occurrence of MI as well as for a maximum follow-up period of 6 years post-MI. The study included 97 252 patients with a diagnosis of MI with a total number of 285 351 observation years. The majority of healthcare consumption occurred within the first year of MI where patients were on average hospitalized 1.55 times, made 1.08 outpatient care visits, and 3.80 primary care visits. In the long term, for the majority of resource use categories, average consumption was higher in the years after MI compared with the year prior to MI. Healthcare costs at 6 years of follow-up were approximately €20 000 of which €12 460 occurred in the first year, and the major part was attributed to hospitalizations.

    Conclusion For patients with 6 years of follow-up after MI, healthcare costs were approximately €20 000. The major part of costs occurred in the first year after MI and was driven by hospitalizations

  • 329.
    Jarefors, Erik
    et al.
    Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Hansson, Thomas
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
    Functional outcome in 17 patients whose mandibles were reconstructed with free fibular flaps2017In: Journal of Plastic Surgery and Hand Surgery, ISSN 2000-656X, E-ISSN 2000-6764, Vol. 51, no 3, p. 178-181Article in journal (Refereed)
    Abstract [en]

    Objective: The vascularised free fibular flap is considered to be a reliable choice for reconstruction of oromandibular defects, especially after resection of malignant tumours in the area. This study evaluates the functional outcome of this method.

    Method: From January 2001 - May 2014, 37 patients were treated at the University Hospital of Linköping using the free fibular flap. The authors present the results from 17. This study reviewed their records and used the University of Washington Quality-of-Life questionnaire (UW-QoL), the Head and Neck Performance Status Scale (PSS), and interviews to assess their outcome.

    Results and conclusions: Functional evaluation showed a significant decrease in chewing (16 out of 17 patients), appearance (n = 10), salivation (n = 6), sensitivity in the mouth and skin (n = 16), occlusive problems in the mouth (n = 13), and range of mouth opening (n = 12). The remaining domains showed acceptable results, although most of them probably could not compare with the preoperative function. Out of 17 patients, six had to adjust their eating in public significantly, three thought their activity to be considerably restricted and two their recreation to be notably diminished. Common postoperative complications were infections or fistula in the mandible (n = 6), partial or complete rejection of the cutaneous flap (n = 4), and rupture of some of the sutures (n = 3). Nine patients required at least one more operation to repair defects, and six required a new soft tissue flap.

  • 330.
    Jarvholm, Kajsa
    et al.
    Univ Gothenburg, Sweden; Lund Univ, Sweden.
    Olbers, Torsten
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Norrköping.
    Engstrom, My
    Univ Gothenburg, Sweden; Sahlgrens Univ Hosp, Sweden.
    Patients views of long-term results of bariatric surgery for super-obesity: sustained effects, but continuing struggles2021In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 17, no 6, p. 1152-1164Article in journal (Refereed)
    Abstract [en]

    Background: Bariatric surgery is a standard treatment for severe obesity, but little is known about patients perceptions about the long-term impact of such surgery. Objective: The aim of this study was to explore patients experiences of living with a bariatric procedure for more than a decade. Setting: University hospital. Methods: At the 10-year follow-up after undergoing Roux-en-Y gastric bypass (RYGB) or bilio-pancreatic diversion with duodenal switch (BPD/DS), 18 consecutive patients from a previous randomized controlled trial were assessed with a semi-structured interview. Data were analyzed using thematic analysis. Results: When asked to reflect broadly on their experiences of living with bariatric surgery for over a decade, the participants rarely mentioned procedure-specific issues and complications. Instead, their accounts revealed 2 broad themes: sustained effects after surgery, incorporating subthemes of better health, brighter futures, and better eating and weight regulation, and continuing struggles, including difficulties with physical activity, finding support, helping their children with overweight, and self-criticism. Many positive changes were sustained, but continuing personal struggles were similar to those presurgery. Conclusions: Participants expressed overall satisfaction with their bariatric surgery and related outcomes. Most participants acknowledged a continued effect on their appetite, which could be important information for patients who worry about a diminished effect after the first year postsurgery. Participants were prone to self-blame when things did not turn out the way they wanted. Therefore, healthcare providers must build a trustful relationship with their patients, so they will not hesitate to return when they face problems such as weight gain. (C) 2021 American Society for Bariatric Surgery. Published by Elsevier Inc.

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  • 331.
    Jensen, Elisabeth Kjaer
    et al.
    Rigshosp, Denmark.
    Bäckryd, Emmanuel
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Hilden, Jorgen
    Univ Copenhagen, Denmark.
    Werner, Mads U.
    Copenhagen Univ Hosp, Denmark.
    Trajectories in severe persistent pain after groin hernia repair: a retrospective analysis2021In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 21, no 1, p. 70-80Article in journal (Refereed)
    Abstract [en]

    Objectives: Severe persistent post-surgical pain (PPSP) remains a significant healthcare problem. In the third most common surgical procedure in the U.K., groin hernia repair, including 85,000 surgeries, estimated 1,500-3,000 patients will annually develop severe PPSP. While the trajectory of PPSP is generally considered a continuation of the acute post-surgery pain, recent data suggest the condition may develop with a delayed onset. This study evaluated pain-trajectories in a consecutive cohort referred from groin hernia repair-surgeons to a tertiary PPSP-center. Potential explanatory variables based on individual psychometric, sensory, and surgical profiles were analyzed. Methods: Patients completed graphs on pain trajectories and questionnaires on neuropathic pain, pain-related functional assessments, and psychometrics. Surgical records and quantitative sensory testing profiles were obtained. Pain trajectories were normalized, and pre- and post-surgical segments were analyzed by a normalized area-under-the-curve (AUC) technique. Principal component analysis (PCA) was applied to the explanatory variables. Significant PCA-components were further examined using multiple logistic regression models. Results: In 95 patients, the AUC identified groups of post-surgical pain trajectories (p&lt;0.0001): group I (n=48), acute high-intensity pain progressing to PPSP; group II (n=28), delayed onset of PPSP; group III (n=7), repeat-surgery gradually inducing PPSP. Data from groups IV (n=3) and V (n=9) were not included in the statistical analysis due to small sample size and data heterogeneity, respectively. The PCA/logistic analyses indicated that neuropathic pain scores, composite pain scores, and pain-related functional assessments were explanatory variables for groups I and II. Conclusions: Pain trajectories in PPSP after groin hernia repair are heterogeneous but can be classified into meaningful groups. Examination of pain trajectories, mirroring the transition from acute to severe persistent post-surgical pain, has the potential of uncovering clinically relevant pathophysiological mechanisms.

  • 332. Order onlineBuy this publication >>
    Jiang, Huiqi
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    NT-proBNP as a marker of postoperative heart failure in adult cardiac surgery2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Postoperative heart failure (PHF) remains the major cause of mortality after cardiac surgery. Unfortunately, generally accepted diagnostic criteria for PHF are lacking. This may explain why the evidence for the efficacy and safety of current treatment of PHF with inotropes is insufficient. In cardiology practice N-terminal pro-B-type natriuretic peptide (NT-proBNP) is an established biomarker for heart failure. However, the association between NT-proBNP and PHF after cardiac surgery needs further clarification. Glutamate is a key intermediate in myocardial metabolism, which may improve myocardial tolerance to ischemia and facilitate post-ischemic recovery. Glutamate was associated with a reduced risk of developing severe PHF in high-risk patients undergoing coronary artery bypass surgery (CABG). The aim of this thesis was to study the role of NT-proBNP for prediction and assessment of PHF in cardiac surgery (Paper I-III) and the impact of intravenous glutamate infusion on postoperative NTproBNP after CABG (Paper IV).

    Paper I: We retrospectively studied the role of underlying heart disease for preoperative NT-proBNP in patients admitted for first time CABG (n=2226), aortic valve surgery (AVR) for aortic stenosis (AS) (n=406) and mitral valve surgery for mitral valve regurgitation (MR) (n=346) by adjusting for non-cardiac confounders (age, gender, obesity and renal function). The level of NT-proBNP in AS or MR was 1.67 (p<0.0001) and 1.41 times (p<0.0001) higher respectively than in coronary artery disease (CAD) after adjusting for confounders. Preoperative NT-proBNP was predictive of severe PHF in CAD and MR patients but less so in AS patients. Preoperative NT-proBNP emerged as an independent risk factor for severe PHF and postoperative mortality in CAD patients.

    Paper II-III: We prospectively studied the association between postoperative NT-proBNP and PHF in two cohorts, patients undergoing AVR for AS (n=203) and patients undergoing isolated CABG for acute coronary syndrome (ACS) from the GLUTAMICS-trial (n=382). NT-proBNP was measured preoperatively, on the first (POD1) and third postoperative morning (POD3). An end-points committee blinded to NT-proBNP used prespecified criteria to diagnose PHF and its severity. After AVR for AS only NT-proBNP level on POD1 provided good discrimination of PHF. PHF with NT-proBNP POD1 ≥ 5290 ng•L-1 emerged as an independent risk factor for long-term mortality (Paper II). After isolated CABG for ACS both absolute postoperative levels on POD1 and POD3 and postoperative increases of NT-proBNP were associated with PHF and the levels reflected the severity of PHF (Paper III).

    Paper IV: We prospectively studied the impact of intravenous glutamate infusion on postoperative NT-proBNP in a randomized double-blind study on patients undergoing CABG for ACS from the GLUTAMICS-trial (n=399). Patients were randomly allocated to intravenous infusion of L-glutamate (n=200) or saline (n=199). No effect of glutamate on postoperative NT-proBNP levels was detected in the whole cohort. According to post-hoc analysis glutamate was associated with less increase of NT-proBNP from preoperative level to POD3 and significantly lower absolute levels on POD3 among high risk patients with EuroSCORE II ≥4.15 (upper quartile).

    Conclusion: Patients with AS or MR have higher preoperative NT-proBNP than CAD patients after adjusting for confounders. The predictive value of NT-proBNP with regard to severe PHF and postoperative mortality was confirmed in CAD patients. Postoperative NTproBNP may prove a useful tool for assessment of PHF after AVR for AS and isolated CABG. NT-proBNP POD1 identifies patients with PHF at risk of a poor long-term survival after AVR for AS. Intravenous infusion of glutamate may prevent or mitigate PHF in highrisk patients undergoing CABG but these results need to be confirmed.

    List of papers
    1. Impact of underlying heart disease per se on the utility of preoperative NT-proBNP in adult cardiac surgery
    Open this publication in new window or tab >>Impact of underlying heart disease per se on the utility of preoperative NT-proBNP in adult cardiac surgery
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    2018 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 13, no 2, article id e0192503Article in journal (Refereed) Published
    Abstract [en]

    Objective The primary aim was to investigate the role of underlying heart disease on preoperative NT-proBNP levels in patients admitted for adult cardiac surgery, after adjusting for the known confounders age, gender, obesity and renal function. The second aim was to investigate the predictive value of preoperative NT-proBNP with regard to severe postoperative heart failure (SPHF) and postoperative mortality. Methods A retrospective cohort study based on preoperative NT-proBNP measurements in an unselected cohort including all patients undergoing first time surgery for coronary artery disease (CAD; n = 2226), aortic stenosis (AS; n = 406) or mitral regurgitation (MR; n = 346) from April 2010 to August 2016 in the southeast region of Sweden (n = 2978). Concomitant procedures were not included, with the exception of Maze or tricuspid valve procedures. Results Preoperative NT-proBNP was 1.67 times (pamp;lt;0.0001) and 1.41 times (pamp;lt;0.0001) higher in patients with AS or MR respectively, than in patients with CAD after adjusting for confounders. NT-proBNP demonstrated significant discrimination with regard to SPHF in CAD (AUC = 0.79, 95% CI 0.73 +/- 0.85, pamp;lt;0.0001), MR (AUC = 0.80, 95% CI 0.72 +/- 0.87, pamp;lt;0.0001) and AS (AUC = 0.66, 95% CI 0.51 +/- 0.81, p = 0.047). In CAD patients NT-proBNP demonstrated significant discrimination with regard to postoperative 30-day or in-hospital mortality (AUC = 0.78; 95% CI 0.71 +/- 0.85, pamp;lt;0.0001). The number of deaths was too few in the AS and MR group to permit analysis. Elevated NT-proBNP emerged as an independent risk factor for SPHF, and postoperative mortality in CAD. Conclusions Patients with AS or MR have higher preoperative NT-proBNP than CAD patients even after adjusting for confounders. The predictive value of NT-proBNP with regard to SPHF was confirmed in CAD and MR patients but was less convincing in AS patients.

    Place, publisher, year, edition, pages
    PUBLIC LIBRARY SCIENCE, 2018
    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-145771 (URN)10.1371/journal.pone.0192503 (DOI)000424517900085 ()29420603 (PubMedID)
    Note

    Funding Agencies|Region Ostergotland [LIO-443891]

    Available from: 2018-03-22 Created: 2018-03-22 Last updated: 2024-01-10
    2. NT-proBNP and postoperative heart failure in surgery for aortic stenosis
    Open this publication in new window or tab >>NT-proBNP and postoperative heart failure in surgery for aortic stenosis
    Show others...
    2019 (English)In: Open heart, E-ISSN 2053-3624, Vol. 6, no 1, article id UNSP e001063Article in journal (Refereed) Published
    Abstract [en]

    Objective Postoperative heart failure (PHF) after aortic valve replacement (AVR) for aortic stenosis (AS) may initially appear mild and transient but has serious long-term consequences. Methods to assess PHF are not well documented. We studied the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) and PHF after AVR for AS.

    Methods This is a prospective, observational, longitudinal study of 203 patients undergoing elective first-time AVR for AS. Plasma NT-proBNP was assessed at preoperative evaluation, the day before surgery, and the first (POD1) and third postoperative morning. A clinical endpoints committee, blinded to NT-proBNP results, used prespecified haemodynamic criteria to diagnose PHF. The mean follow-up was 8.6±1.1 years.

    Results No patient with PHF (n=18) died within 30 days after surgery, but PHF was associated with poor long-term survival (HR 3.01, 95% CI 1.45 to 6.21, p=0.003). NT-proBNP was significantly higher in patients with PHF only on POD1 (6415 (3145–11 220) vs 2445 (1540–3855) ng/L, p<0.0001). NT-proBNP POD1 provided good discrimination of PHF (area under the curve=0.82, 95% CI 0.72 to 0.91, p<0.0001; best cut-off 5290 ng/L: sensitivity 63%, specificity 85%). NT-proBNP POD1 ≥5290 ng/L identified which patients with PHF carried a risk of poor long-term survival, and PHF with NT-proBNP POD1 ≥ 5290 ng/L emerged as a risk factor for long-term mortality in the multivariable Cox regression (HR 6.20, 95% CI 2.72 to 14.1, p<0.0001).

    Conclusions The serious long-term consequences associated with PHF after AVR for AS were confirmed. NT-proBNP level on POD1 aids in the assessment of PHF and identifies patients at particular risk of poor long-term survival.

    Place, publisher, year, edition, pages
    BMJ Publishing Group Ltd, 2019
    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-159019 (URN)10.1136/openhrt-2019-001063 (DOI)000471922200086 ()31218010 (PubMedID)2-s2.0-85066069325 (Scopus ID)
    Note

    Funding Agencies|Medical Research Council of Southeast Sweden FORSS [12657, 23891, 159851, 311341]; County Council of Ostergotland, Sweden [LIO-610951, LIO 693091, LIO-796412]

    Available from: 2019-07-19 Created: 2019-07-19 Last updated: 2024-01-10Bibliographically approved
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    NT-proBNP as a marker of postoperative heart failure in adult cardiac surgery
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  • 333.
    Johan, Scheer
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences.
    Lars, Adolfsson
    Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
    Patterns of triangular fibrocartilage complex (TFCC) injury associated with severely dorsally displaced extra-articular distal radius fractures2012In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 43, no 6, p. 926-932Article in journal (Refereed)
    Abstract [en]

    Purpose: The aim of the study was to examine triangular fibrocartilage (TFCC) injury patterns associated with unstable, extra-articular dorsally displaced distal radius fractures.

    Methods: Twenty adult patients with an Arbeitsgemeinschaft für Osteosynthesefragen (AO), type A2 or A3, distal radius fracture with an initial dorsal angulation greater than 20° were included. Nine had a tip fracture (distal to the base) of the ulnar styloid and 11 had no such fracture. They were all openly explored from an ulnopalmar approach and TFCC injuries were documented. Eleven patients also underwent arthroscopy and intra-articular pathology was recorded.

    Results: All patients had TFCC lesions of varying severity, having an extensor carpi ulnaris subsheath avulsion in common. Eighteen out of 20 also displayed deep foveal radioulnar ligament lesions, with decreasingly dorsal fibres remaining. The extent of this foveal injury could not be appreciated by radiocarpal arthroscopy.

    Conclusions: Severe displacement of an extra-articular radius fracture suggests an ulnar-sided ligament injury to the TFCC. The observed lesions concur with findings in a previous cadaver study. The lesions follow a distinct pattern affecting both radioulnar as well as ulnocarpal stabilisers.

  • 334.
    Johan, Scheer
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences.
    Lars, Adolfsson
    Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
    Radioulnar laxity and clinical outcome after a distal radius fracture do not correlate after a distal radius fracture2011In: Journal of Hand Surgery - British and European Volume, ISSN 0266-7681, E-ISSN 1532-2211, Vol. 36, no 6, p. 503-508Article in journal (Refereed)
    Abstract [en]

    Injury to the triangular fibrocartilage complex associated with distal radius fracture may cause symptoms of ulnar instability. Assessed by a radioulnar stress test, increased laxity of the distal radio-ulnar joint has in two previous studies been depicted to be associated with poorer outcome. This prospective study of 40 adults investigates the correlation of this test with functional outcome as measured by DASH. No clinically significant difference was found in relation to this test at two and five years after injury. Therefore using this test alone to decide whether or not to perform an acute repair of the TFCC cannot be recommended.

  • 335. Order onlineBuy this publication >>
    Johansen, Karin
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Effects of Pancreatic Surgery: Quality of Life, Cost-effectiveness and Postoperative Results2023Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    BACKGROUND  

    Pancreatic operations are large procedures with high rates of complications and other potentially impactful consequences such as diabetes and pancreatic exocrine insufficiency. Due to this, and due to the fact that the operations are often occasioned by periampullary tumours with a poor prognosis, it is important to evaluate how the operations affect patients in terms of postoperative results and quality of life. In the constantly developing field of pancreatic surgery, it is also important to evaluate the cost-effectiveness of new methods.  

    METHODS  

    The first study was a register study including all patients in the Swedish National Pancreatic and Periampullary Cancer Registry with a diagnosis from 2010-2018 who underwent pancreaticoduodenectomy (PD). Patients were divided into age groups of <70, 70-79 and ≥80 years old and were compared regarding preoperative, perioperative and postoperative data as well as survival.  

    The second and third studies were based on the randomized controlled trial LAPOP performed in Linköping from 2015-2019 where 60 patients were randomized 1:1 to open or laparoscopic distal pancreatectomy and followed for two years with repeated quality of life questionnaires. For the second study, the EORTC QLQ-C30 and PAN26 questionnaires were collected and compared between groups. For the third study, the EQ-5D questionnaire was used in a cost-effectiveness analysis together with costs collected from patients’ medical records, including all health care-related costs up to 2 years postoperatively. Nonparametric bootstrapping with 10 000 samples was performed to compare quality-adjusted life years  (QALYs) and costs between groups.  

    The fourth study was a qualitative interview study in which 20 patients undergoing total pancreatectomy (TP) from 2020-2021 in Linköping or Karolinska University Hospitals were interviewed 6-9 months postoperatively about symptoms and life changes after the operation.  

    RESULTS  

    In the first study, 2793 patients underwent PD in the study period, of which 1137 patients were 70-79 years of age, and 148 patients were ≥80 years of age. There were no significant differences between groups regarding short-term mortality or the rate of severe complications according to the Clavien-Dindo classification of complications. Patients in the two older groups had a worse preoperative condition and a higher rate of medical and some surgical complications postoperatively.   

    In the LAPOP trial, 54 patients were included in the quality of life analysis. There was a significant difference in six of the quality of life-domains measured with QLQ-C30 and PAN26 with better results in the laparoscopic group. When comparing values at the two-year measurement, 3 domains had a significant difference and 16 domains a clinically relevant difference of 10 or more, all with better results in the laparoscopic group. In the cost-effectiveness analysis, 56 patients were included in the analysis. Mean health care costs were €3 863 lower in the laparoscopic group (95% CI: -€8 020 to €385), and the QALYs were 0.08 higher (95% CI: -0.09 to 0.25). In the bootstrap analysis, 79% of samples had higher QALYs and lower costs for the laparoscopic group, and 95% were in favour of laparoscopic resection with a cost-per-QALY threshold of €50 000.  

    Patients undergoing total pancreatectomy voiced symptoms and life changes that revolved around the two main themes: ‘changes in everyday life’ and ‘psychological journey’. In the former, patients described the impact of diabetes, food intake, diarrhoea and the process of recovery, where diabetes in particular appeared to be challenging for some. In the second theme, patients outlined the diagnosis processing, the importance of support from family, friends and the health care system, and a need for more thorough information.   

    CONCLUSIONS  

    Despite a worse preoperative condition, elderly patients undergoing PD did not have an increase in short-term mortality or serious complications. With continued careful preoperative examination, in particular regarding cardiovascular comorbidity, octogenarians can likely safely continue to be offered to undergo PD.   

    After distal pancreatectomy, there was a considerable difference between groups regarding postoperative quality of life in favour of the laparoscopic method, which seemed to remain as long as 2 years postoperatively. The laparoscopic method was also favoured in the cost-effectiveness analysis where it was associated with lower costs and higher QALYs. These results support the ongoing transition from open to minimally invasive distal pancreatectomies.   

    After TP, patients struggle with a lack of support and education, particularly regarding their diabetes treatment. Efforts should be undertaken to improve and standardize the diabetes care for this group.    

    List of papers
    1. There Is No Increase in Perioperative Mortality After Pancreaticoduodenectomy in Octogenarians: Results From the Swedish National Registry for Tumors in the Pancreatic and Periampullary Region
    Open this publication in new window or tab >>There Is No Increase in Perioperative Mortality After Pancreaticoduodenectomy in Octogenarians: Results From the Swedish National Registry for Tumors in the Pancreatic and Periampullary Region
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    2020 (English)In: Annals of Surgery Open, ISSN 2691-3593, Vol. 1, no 2Article in journal (Refereed) Published
    Abstract [en]

    Objective: The aim of this observational study was to compare postoperative mortality and complications between octogenarians and younger patients following pancreaticoduodenectomy (PD).

    Summary Background Data: With the growing elderly population and improved operative and postoperative results, PD is performed more frequently in octogenarians. Despite recent studies, it is uncertain whether elderly patients experience worse postoperative outcomes than younger patients.

    Methods: All patients registered in the Swedish National Registry for tumors in the pancreatic and periampullary region from 2010 to 2018 who underwent PD were included in the analysis.

    Results: Out of 13,936 patients included in the registry, 2793 patients underwent PD and were divided into the following age groups: <70 (n = 1508), 70–79 (n = 1137), and ≥80 (n = 148) years old. There was no significant difference in in-hospital, 30- or 90-day mortality among groups. The 2 older groups had a higher rate of medical and some surgical complications but not a significantly higher rate of complications ≥IIIa according to the Clavien-Dindo classification system. The 2 older groups had lower body mass index, higher American Society of Anesthesiologists and Eastern Cooperative Oncology Group scores, lower smoking rates, and a higher rate of preoperative biliary drainage than the <70-year-old group (all P < 0.001). The operation time was shorter in the oldest group.

    Conclusions: Despite the worse preoperative condition of octogenarians than younger patients, short-term mortality and serious complications were not increased. The shorter operation time, however, may indicate that patients in the oldest group were more strictly selected. With careful preoperative consideration, especially regarding cardiovascular morbidity, more octogenarians can potentially be safely offered PD.

    Place, publisher, year, edition, pages
    Wolters Kluwer, 2020
    Keywords
    pancreaticoduodenectomy, pancreatic surgery, octogenarians, surgical outcome
    National Category
    Surgery
    Identifiers
    urn:nbn:se:liu:diva-193059 (URN)10.1097/AS9.0000000000000015 (DOI)
    Available from: 2023-04-12 Created: 2023-04-12 Last updated: 2023-04-19Bibliographically approved
    2. Quality of life after open versus laparoscopic distal pancreatectomy: long-term results from a randomized clinical trial
    Open this publication in new window or tab >>Quality of life after open versus laparoscopic distal pancreatectomy: long-term results from a randomized clinical trial
    Show others...
    2023 (English)In: BJS Open, E-ISSN 2474-9842, Vol. 7, no 2, article id zrad002Article in journal (Refereed) Published
    Abstract [en]

    Background Pancreatic surgery is rapidly transitioning towards minimally invasive methods. Positive results have been published regarding the safety and efficacy of laparoscopic distal pancreatectomy, but postoperative quality of life after operation remains relatively unexplored. The aim of this study was to assess the long-term quality of life after open versus laparoscopic distal pancreatectomy.Methods A long-term analysis of quality-of-life data after laparoscopic and open distal pancreatectomy based on the LAPOP trial (a single-centre, superiority, parallel, open-label, RCT in which patients undergoing distal pancreatectomy were randomized 1 : 1 to either the open or laparoscopic approach). Patients received the quality-of-life questionnaires QLQ-C30 and PAN26 before surgery and at 5-6 weeks, 6 months, 12 months, and 24 months after surgery.Results Between September 2015 and February 2019, a total of 60 patients were randomized, and 54 patients (26 in the open group and 28 in the laparoscopic group) were included in the quality-of-life analysis. A significant difference was observed in six domains in the mixed model analysis, with better results among patients who underwent laparoscopic surgery. At the 2-year measurement, a statistically significant difference between groups was seen in three domains, and a clinically relevant difference of 10 or more was seen in 16 domains, with better results among the patients who underwent laparoscopic resection.Conclusion Considerable differences were shown in postoperative quality of life after laparoscopic compared with open distal pancreatectomy, with better results among the patients who had undergone laparoscopic resection. Of note, some of these differences persisted up to 2 years after surgery. These results strengthen the ongoing transition from open to minimally invasive pancreatic surgery for distal pancreatectomy. Registration number: ISRCTN26912858 (http://www.controlled-trials.com).

    Place, publisher, year, edition, pages
    OXFORD UNIV PRESS, 2023
    National Category
    Surgery
    Identifiers
    urn:nbn:se:liu:diva-192929 (URN)10.1093/bjsopen/zrad002 (DOI)000946741700002 ()36893287 (PubMedID)
    Note

    Funding Agencies|Medical Research Council of Southeast Sweden (Forskningsradet i Sydostra Sverige) [567361]

    Available from: 2023-04-06 Created: 2023-04-06 Last updated: 2024-05-02
    3. Laparoscopic distal pancreatectomy is more cost-effective than open resection: results from a Swedish randomized controlled trial
    Open this publication in new window or tab >>Laparoscopic distal pancreatectomy is more cost-effective than open resection: results from a Swedish randomized controlled trial
    Show others...
    2023 (English)In: HPB, ISSN 1365-182X, E-ISSN 1477-2574, Vol. 25, no 8, p. 972-979Article in journal (Refereed) Published
    Abstract [en]

    Background

    Laparoscopic distal pancreatectomy is being implemented worldwide. The aim of this study was to perform a cost-effectiveness analysis from a health care perspective.

    Methods

    This cost-effectiveness analysis was based on the randomized controlled trial LAPOP, where 60 patients were randomized to open or laparoscopic distal pancreatectomy. For the follow-up of two years, resource use from a health care perspective was recorded, and health-related quality of life was assessed using the EQ-5D-5L. The per-patient mean cost and quality-adjusted life years (QALYs) were compared using nonparametric bootstrapping.

    Results

    Fifty-six patients were included in the analysis. The mean health care costs were lower, €3863 (95% CI: -€8020 to €385), for the laparoscopic group. Postoperative quality of life improved with laparoscopic resection and resulted in a gain in QALYs of 0.08 (95% CI: −0.09 to 0.25). The laparoscopic group had lower costs and improved QALYs in 79% of bootstrap samples. With a cost-per-QALY threshold of €50 000, 95.4% of the bootstrap samples were in favour of laparoscopic resection.

    Conclusion

    Laparoscopic distal pancreatectomy is associated with numerically lower health care costs and improvements in QALYs compared with the open approach. The results support the ongoing transition from open to laparoscopic distal pancreatectomies.

    Place, publisher, year, edition, pages
    ELSEVIER SCI LTD, 2023
    National Category
    Surgery
    Identifiers
    urn:nbn:se:liu:diva-196431 (URN)10.1016/j.hpb.2023.04.021 (DOI)001055518900001 ()37198071 (PubMedID)
    Funder
    Medical Research Council of Southeast Sweden (FORSS), 567361
    Note

    Funding: Medical Research Council of Southeast Sweden (FORSS) [660741, 757551];  [567361]

    Available from: 2023-08-03 Created: 2023-08-03 Last updated: 2024-05-03
    4. Symptoms and life changes after total pancreatectomy: a qualitative study
    Open this publication in new window or tab >>Symptoms and life changes after total pancreatectomy: a qualitative study
    Show others...
    2023 (English)In: HPB, ISSN 1365-182X, E-ISSN 1477-2574, Vol. 25, no 2, p. 269-277Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: Total pancreatectomy (TP) is a major surgical procedure that involves lifelong exocrine and endocrine pancreatic insufficiency. Qualitative evidence is sparse regarding patients' experiences after the operation. The aim of this study was to explore patients' experiences of symptoms that occur after TP and how these symptoms affect their health and life situations.

    METHODS: A qualitative design with prospective consecutive sampling and an inductive thematic analysis was used. Semistructured interviews were postoperatively performed at 6-9 months with 20 patients undergoing TP in two university hospitals in Sweden.

    RESULTS: Two main themes emerged from the analysis: "Changes in everyday life" and "Psychological journey". Patients experienced symptoms related to diabetes as the major life change after the operation, and they were also limited by symptoms of exocrine insufficiency, difficulties with food intake and physical weakness. In the psychological journey that patients underwent, the support received from family, friends and the health care system was important. Moreover, patients experienced a general need for more extensive information, especially regarding diabetes.

    CONCLUSION: Patients experience a lack of sufficient support and education after TP, particularly concerning their diabetes. Further efforts should be undertaken to improve information and the organization of diabetes care for this patient group.

    Place, publisher, year, edition, pages
    ELSEVIER SCI LTD, 2023
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-192258 (URN)10.1016/j.hpb.2022.11.010 (DOI)000948415400001 ()36526539 (PubMedID)
    Available from: 2023-03-09 Created: 2023-03-09 Last updated: 2023-04-12Bibliographically approved
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  • 336.
    Johansen, Karin
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Khodakaram, Kaveh
    Sahlgrens Univ Hosp, Sweden.
    Lundgren, Linda
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Hasselgren, Kristina
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Gasslander, Thomas
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Sandström, Per
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Bratlie, Svein Olav
    Sahlgrens Univ Hosp, Sweden.
    Björnsson, Bergthor
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Preoperative Biliary Drainage Does Not Independently Reduce Survival After Pancreaticoduodenectomy Among Patients With Pancreatic Ductal Adenocarcinoma: A National Registry Study2021In: Annals of Surgery Open: perspectives of surgical history, education, and clinical approaches, ISSN 2691-3593, Vol. 2, no 3, article id e090Article in journal (Refereed)
    Abstract [en]

    Objective: This study aimed to explore a possible relationship between preoperative biliary drainage (PBD) and overall survival in a national cohort of Swedish patients who underwent pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). Background: PBD has been shown to increase postoperative complications after PD, but its use is steadily increasing. There are a few small studies that have indicated that PBD might in itself negatively affect overall survival after PD. Methods: Patients from the Swedish National Registry for tumors in the pancreatic and periampullary region diagnosed from 2010 to 2019 who underwent PD for PDAC were included. Kaplan-Meier curves, log-rank tests and Cox proportional hazards analyses were performed to investigate survival. Results: Out of 15,818 patients in the registry, 3113 had undergone PD, of whom 1471 had a histopathological diagnosis of PDAC. Patients who had undergone PBD had significantly worse survival, but the effect of PBD disappeared in the multivariable analysis when elevated bilirubin at any time was included. Conclusions: PBD does not independently influence survival after PD for PDAC, but this study implies that even a nominally increased preoperative bilirubin level might impair long-term survival.

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    fulltext
  • 337.
    Johansen, Karin
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Lindhoff Larsson, Anna
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Gasslander, Thomas
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Lundgren, Linda
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Hasselgren, Kristina
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Sandström, Per
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Borch, Kurt
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Björnsson, Bergthor
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Complications and chemotherapy have little impact on postoperative quality of life after pancreaticoduodenectomy - a cohort study2022In: HPB, ISSN 1365-182X, E-ISSN 1477-2574, Vol. 24, no 9, p. 1464-1473Article in journal (Refereed)
    Abstract [en]

    Background: With the poor prognosis of pancreatic cancer and the high rate of postoperative complications after pancreaticoduodenectomy, it is important to evaluate how the operation affects patients quality of life. Methods: This single-centre study included all patients undergoing pancreaticoduodenectomy from 2006 to 2016. Quality of life was measured with two questionnaires preoperatively, and at 6 and 12 months postoperatively. Comparisons between groups were made using a linear mixed models analysis. Results: Of 279 patients planned for pancreaticoduodenectomy, 245 underwent the operation. The postoperative response rates were all 80% or more. Differences were found in one domain between the early and late time periods and three domains between patients receiving and not receiving adjuvant chemotherapy. No significant differences were found between patients with and without severe postoperative complications. However, the demographic variables of age group, sex, preoperative diabetes and smoking all exerted a significant impact on postoperative quality of life. Conclusion: While little or no impact was shown for the factors of postoperative complications, time period and adjuvant chemotherapy, demographic data, such as age, sex, preoperative diabetes and smoking, had considerable impacts on postoperative quality of life after pancreaticoduodenectomy.

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  • 338.
    Johansen, Karin
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Lindhoff Larsson, Anna
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Lundgren, Linda
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Gasslander, Thomas
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Hjalmarsson, Claes
    Hosp Halland, Sweden.
    Sandström, Per
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Björnsson, Bergthor
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Quality of life after open versus laparoscopic distal pancreatectomy: long-term results from a randomized clinical trial2023In: BJS Open, E-ISSN 2474-9842, Vol. 7, no 2, article id zrad002Article in journal (Refereed)
    Abstract [en]

    Background Pancreatic surgery is rapidly transitioning towards minimally invasive methods. Positive results have been published regarding the safety and efficacy of laparoscopic distal pancreatectomy, but postoperative quality of life after operation remains relatively unexplored. The aim of this study was to assess the long-term quality of life after open versus laparoscopic distal pancreatectomy.Methods A long-term analysis of quality-of-life data after laparoscopic and open distal pancreatectomy based on the LAPOP trial (a single-centre, superiority, parallel, open-label, RCT in which patients undergoing distal pancreatectomy were randomized 1 : 1 to either the open or laparoscopic approach). Patients received the quality-of-life questionnaires QLQ-C30 and PAN26 before surgery and at 5-6 weeks, 6 months, 12 months, and 24 months after surgery.Results Between September 2015 and February 2019, a total of 60 patients were randomized, and 54 patients (26 in the open group and 28 in the laparoscopic group) were included in the quality-of-life analysis. A significant difference was observed in six domains in the mixed model analysis, with better results among patients who underwent laparoscopic surgery. At the 2-year measurement, a statistically significant difference between groups was seen in three domains, and a clinically relevant difference of 10 or more was seen in 16 domains, with better results among the patients who underwent laparoscopic resection.Conclusion Considerable differences were shown in postoperative quality of life after laparoscopic compared with open distal pancreatectomy, with better results among the patients who had undergone laparoscopic resection. Of note, some of these differences persisted up to 2 years after surgery. These results strengthen the ongoing transition from open to minimally invasive pancreatic surgery for distal pancreatectomy. Registration number: ISRCTN26912858 (http://www.controlled-trials.com).

    Download full text (pdf)
    fulltext
  • 339.
    Johansen, Karin
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Lindhoff Larsson, Anna
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology.
    Lundgren, Linda
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology.
    Gasslander, Thomas
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Hjalmarsson, Claes
    Department of Surgery, Hospital of Halland, Halland, Sweden.
    Sandström, Per
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology.
    Lyth, Johan
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henriksson, Martin
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Björnsson, Bergthor
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology.
    Laparoscopic distal pancreatectomy is more cost-effective than open resection: results from a Swedish randomized controlled trial2023In: HPB, ISSN 1365-182X, E-ISSN 1477-2574, Vol. 25, no 8, p. 972-979Article in journal (Refereed)
    Abstract [en]

    Background

    Laparoscopic distal pancreatectomy is being implemented worldwide. The aim of this study was to perform a cost-effectiveness analysis from a health care perspective.

    Methods

    This cost-effectiveness analysis was based on the randomized controlled trial LAPOP, where 60 patients were randomized to open or laparoscopic distal pancreatectomy. For the follow-up of two years, resource use from a health care perspective was recorded, and health-related quality of life was assessed using the EQ-5D-5L. The per-patient mean cost and quality-adjusted life years (QALYs) were compared using nonparametric bootstrapping.

    Results

    Fifty-six patients were included in the analysis. The mean health care costs were lower, €3863 (95% CI: -€8020 to €385), for the laparoscopic group. Postoperative quality of life improved with laparoscopic resection and resulted in a gain in QALYs of 0.08 (95% CI: −0.09 to 0.25). The laparoscopic group had lower costs and improved QALYs in 79% of bootstrap samples. With a cost-per-QALY threshold of €50 000, 95.4% of the bootstrap samples were in favour of laparoscopic resection.

    Conclusion

    Laparoscopic distal pancreatectomy is associated with numerically lower health care costs and improvements in QALYs compared with the open approach. The results support the ongoing transition from open to laparoscopic distal pancreatectomies.

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  • 340.
    Johansen, Karin
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Lundgren, Linda
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Gasslander, Thomas
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Hasselgren, Kristina
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology.
    Sandström, Per A
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology.
    Björnsson, Bergthor
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping. Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology.
    High resection rate improves overall survival in elderly patients with pancreatic head cancer - A cohort study2021In: International Journal of Surgery Open, E-ISSN 2405-8572, Vol. 34, article id 100362Article in journal (Refereed)
    Abstract [en]

    Background: There is evidence that a high hospital volume of pancreaticoduodenectomy improves short-and long-term outcomes, but there are few population-based studies on the effect of a high resection rate in the population. The aim of this national, observational study was primarily to investigate differences in overall survival among elderly patients with cancer in the pancreatic head between high and low resection rate groups and secondarily to determine if counties with high resection rates of pancreaticoduodenectomy had more severe complications after surgery. Materials and methods: All patients in the Swedish National Registry for tumours in the pancreatic and periampullary region diagnosed between 2010 and 2018 with pancreatic head cancer were included in this retrospective cohort study. Patients were divided into low and high resection rate groups according to the yearly resection rates in the respective counties. For operative outcomes, all patients who had undergone pancreaticoduodenectomy were included regardless of diagnosis. The primary outcome of the study was overall survival among patients aged &gt;= 70 years with pancreatic head cancer. Results: Among 13 933 patients in the registry, 7661 were 70 years or older, of whom 3006 had pancreatic head cancer. Overall survival was longer in high resection rate groups for patients aged &gt;= 70 years, as for the age subgroups 70-79 years and &gt;= 80 years (all p &lt; 0.001). Among patients who had undergone pancreaticoduodenectomy aged &gt;= 80 years the high resection rate counties showed an increased rate of severe complications, but no increase in 90-day mortality. Conclusion: High resection rate groups show a significantly longer overall survival among elderly patients with pancreatic head cancer in Sweden. This implies that there could be a survival benefit from increasing resections in low resection rate groups. (C) 2021 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

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  • 341.
    Johansen, Karin
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Lundgren, Linda
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Gasslander, Thomas
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Sandström, Per A
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    Björnsson, Bergthor
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
    There Is No Increase in Perioperative Mortality After Pancreaticoduodenectomy in Octogenarians: Results From the Swedish National Registry for Tumors in the Pancreatic and Periampullary Region2020In: Annals of Surgery Open, ISSN 2691-3593, Vol. 1, no 2Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this observational study was to compare postoperative mortality and complications between octogenarians and younger patients following pancreaticoduodenectomy (PD).

    Summary Background Data: With the growing elderly population and improved operative and postoperative results, PD is performed more frequently in octogenarians. Despite recent studies, it is uncertain whether elderly patients experience worse postoperative outcomes than younger patients.

    Methods: All patients registered in the Swedish National Registry for tumors in the pancreatic and periampullary region from 2010 to 2018 who underwent PD were included in the analysis.

    Results: Out of 13,936 patients included in the registry, 2793 patients underwent PD and were divided into the following age groups: <70 (n = 1508), 70–79 (n = 1137), and ≥80 (n = 148) years old. There was no significant difference in in-hospital, 30- or 90-day mortality among groups. The 2 older groups had a higher rate of medical and some surgical complications but not a significantly higher rate of complications ≥IIIa according to the Clavien-Dindo classification system. The 2 older groups had lower body mass index, higher American Society of Anesthesiologists and Eastern Cooperative Oncology Group scores, lower smoking rates, and a higher rate of preoperative biliary drainage than the <70-year-old group (all P < 0.001). The operation time was shorter in the oldest group.

    Conclusions: Despite the worse preoperative condition of octogenarians than younger patients, short-term mortality and serious complications were not increased. The shorter operation time, however, may indicate that patients in the oldest group were more strictly selected. With careful preoperative consideration, especially regarding cardiovascular morbidity, more octogenarians can potentially be safely offered PD.

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  • 342.
    Johansson, Emma K.
    et al.
    Karolinska Inst, Sweden; Karolinska Univ Hosp, Sweden.
    Brenneche, Andreas
    LEO Pharma AB, Sweden.
    Trangbaek, Dennis
    LEO Pharma AB, Sweden.
    Stelmaszuk, M. Natalia
    Parexel Int Ltd, Sweden.
    Freilich, Jonatan
    Parexel Int Ltd, Sweden; Umea Univ, Sweden.
    Anderson, Chris
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Cell Biology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Medicine Center, Department of Dermatology and Venerology.
    Treatment Patterns among Patients with Atopic Dermatitis in Secondary Care: A National, Observational, Non-interventional, Retrospective Study in Sweden2022In: Acta Dermato-Venereologica, ISSN 0001-5555, E-ISSN 1651-2057, Vol. 102, article id adv00774Article in journal (Refereed)
    Abstract [en]

    This non-interventional, observational, longitudinal study describes treatment patterns of atopic dermatitis (AD) in Sweden. Data from 3 Swedish registries were merged, and included patients who received an AD diagnosis (during the period 1997 to 2019) and had AD treatment prescribed (during the period 2006 to 2020). Treatment persistence, treatment sequencing, time-to-event analysis, and 12-month prevalence were analysed. Overall, data for 99,885 patients with AD were included, of whom 4,086 (4.1%) received systemic treatments. Median persistence rates were 12.6 (95% CI 11.9, 13.4) months for methotrexate, 10.8 (9.1, 13.0) months for azathioprine, 5.6 (3.8, 6.2) months for mycophenolate, 5.1 (4.4, 5.7) months for alitretinoin and 3.4 (3.2, 3.7) months for cyclosporine. Median (Q1, Q3) time from first secondary care visit for AD to first systemic treatment was 5.8 (2.2, 11.0) years overall and 4.4 (1.3, 9.1) years in the Stockholm region. Methotrexate was a prominent first- and second-line treatment used during the period 2006 to 2020. Dupilumab was introduced during the study period and was increasingly used as first- or second-line therapy over time. The 12-month prevalence of AD generally remained steady, with a gradual increase observed over time for the overall population. A steep increase was observed in Stockholm from 2011. This study shows that a small proportion of patients with AD are offered systemic treatments in Sweden, with long periods in secondary care prior to systemic treatments and low persistence on systemic treatments. Regional differences highlight a need for national treatment guidelines.

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  • 343. Order onlineBuy this publication >>
    Johansson, Johannes
    Linköping University, Department of Biomedical Engineering, Biomedical Instrumentation. Linköping University, The Institute of Technology.
    Thermocoagulation in Deep Brain Structures: Modelling, simulation and experimental study of radio-frequency lesioning2006Licentiate thesis, comprehensive summary (Other academic)
    Abstract [en]

    Radio-frequency (RF) lesioning is a method utilising high frequency currents for thermal coagulation of pathological tissue or signal pathways. The current is delivered from an electrode with a temperature sensor, permitting control of the current at a desired target temperature. In the brain RF-lesioning can e.g. be used for severe chronic pain and movement disorders such as Parkinson’s disease. This thesis focuses on modelling and simulation with the aim of gaining better understanding and predictability of the lesioning process in deep brain structures. The finite element method (FEM) together with experimental comparisons was used to study the effects of electrode dimensions, electrode target temperature, electric and thermal conductivity of the brain tissue, blood perfusion and cerebrospinal fluid (CSF) filled cysts. Equations for steady current, thermal transport and incompressible flow were used together with statistical factorial design and regression analysis for this purpose.

    Increased target temperature, electrode tip length and electrode diameter increased the simulated lesion size, which is in accordance with experimental results. The influence of blood perfusion, modelled as an increase in thermal conductivity in non-coagulated tissue, gave smaller simulated lesions with increasing blood perfusion as heat was more efficiently conducted from the rim of the lesion. If no consideration was taken to the coagulation the lesion became larger with increased thermal conductivity instead, as the increase in conducted heat was compensated for through an increased power output in order to maintain the target temperature. Simulated lesions corresponded well to experimental in-vivo lesions.

    The electric conductivity in a homogeneous surrounding had little impact on lesion development. However this was not valid for a heterogeneous surrounding. CSF-filled cysts have a much higher electric conductivity than brain tissue focussing the current to them if the electrode tip is in contact with both. Heating of CSF can also cause considerable convective flow and as a result a very efficient heat transfer. This affected simulated as well as experimental lesion sizes and shapes resulting in both very large lesions if sufficient power compared to the cysts size was supplied and very small lesions if the power was low, mitigating the heat over a large volume.

    In conclusion especially blood perfusion and CSF can greatly affect the lesioning process and appear to be important to consider when planning surgical procedures. Hopefully this thesis will help improve knowledge about and predictability of clinical lesioning.

    List of papers
    1. Radio-frequency lesioning in brain tissue with coagulation-dependent thermal conductivity: modelling, simulation and analysis of parameter influence and interaction
    Open this publication in new window or tab >>Radio-frequency lesioning in brain tissue with coagulation-dependent thermal conductivity: modelling, simulation and analysis of parameter influence and interaction
    Show others...
    2006 (English)In: Medical and Biological Engineering and Computing, ISSN 0140-0118, E-ISSN 1741-0444, Vol. 44, no 9, p. 757-766Article in journal (Refereed) Published
    Abstract [en]

    Radio-frequency brain lesioning is a method for reducing e.g. symptoms of movement disorders. A small electrode is used to thermally coagulate malfunctioning tissue. Influence on lesion size from thermal and electric conductivity of the tissue, microvascular perfusion and preset electrode temperature was investigated using a finite-element model. Perfusion was modelled as an increased thermal conductivity in non-coagulated tissue. The parameters were analysed using a 24-factorial design (n = 16) and quadratic regression analysis (n = 47). Increased thermal conductivity of the tissue increased lesion volume, while increased perfusion decreased it since coagulation creates a thermally insulating layer due to the cessation of blood perfusion. These effects were strengthened with increased preset temperature. The electric conductivity had negligible effect. Simulations were found realistic compared to in vivo experimental lesions.

    Place, publisher, year, edition, pages
    Heidleberg: Springer, 2006
    Keywords
    Electrosurgery, RF ablation, Brain, Blood perfusion, Finite-element method
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-15926 (URN)10.1007/s11517-006-0098-1 (DOI)000240378700003 ()16941099 (PubMedID)2-s2.0-33748485613 (Scopus ID)
    Note

    The original publication is available at www.springerlink.com: Johannes D Johansson, Ola Eriksson, Joakim Wren, Dan Loyd and Karin Wårdell, Radio-frequency lesioning in brain tissue with coagulation-dependent thermal conductivity: modelling, simulation and analysis of parameter influence and interaction, 2006, Medical and Biological Engineering and Computing, (44), 9, 757-766. http://dx.doi.org/10.1007/s11517-006-0098-1 Copyright: Springer Science Business Media http://www.springerlink.com/

    Available from: 2008-12-16 Created: 2008-12-16 Last updated: 2020-12-09Bibliographically approved
    2. Comparison between a detailed and a simplified finite element model of radio-frequency lesioning in the brain
    Open this publication in new window or tab >>Comparison between a detailed and a simplified finite element model of radio-frequency lesioning in the brain
    Show others...
    2004 (English)In: 26th Annual International Conference of the IEEE Engineering in Medicine and Biology Society, San Fransisco, USA, 2004, Vol. 4, p. 2510-2513Conference paper, Published paper (Refereed)
    Abstract [en]

    A detailed and a simplified model of a lesioning electrode was made using the finite element method. 15 simulations of the lesioning procedure were performed for each model and the resulting lesion volumes were compared in order to investigate if the simplified model is adequate. The simplified model resulted in a very slight overestimation of the volume compared to the detailed model. It was thus concluded that the simplified model is adequate for simulations.

    National Category
    Engineering and Technology
    Identifiers
    urn:nbn:se:liu:diva-13995 (URN)10.1109/IEMBS.2004.1403723 (DOI)
    Available from: 2006-09-25 Created: 2006-09-25 Last updated: 2020-12-09Bibliographically approved
    3. Simulations of radio-frequency lesions with varying brain electrode dimensions
    Open this publication in new window or tab >>Simulations of radio-frequency lesions with varying brain electrode dimensions
    Show others...
    2005 (English)In: 13th Nordic Baltic conference biomedical engineering and medical physics, Umeå, Sweden, 2005, Vol. 9, p. 62-63Conference paper, Published paper (Refereed)
    Abstract [en]

    Radio-frequency (RF) lesioning in the

    brain was simulated using the finite element method

    (FEM). Heating for 60 s with temperature control in

    order to keep the tip at 80 °C was simulated. Length,

    L, (2 – 4 mm) and diameter, D, (0.5 – 2.5 mm) of the

    electrode tip were varied and the resulting lesion

    volumes were used to calculate a regression model:

    Lesion Volume = – 13.1D + 15.7LD + 13.1D2 mm3.

    The results can be useful for electrode design and

    prediction of lesion size.

    Keywords
    Radio-frequency surgery, Brain, Lesion size, Electrode dimensions, Finite Element Method (FEM)
    National Category
    Engineering and Technology
    Identifiers
    urn:nbn:se:liu:diva-13996 (URN)
    Available from: 2006-09-25 Created: 2006-09-25 Last updated: 2020-12-09Bibliographically approved
    4. Impact of cysts during radio frequency (RF) lesioning in deep brain structures: a simulation and in-vitro study
    Open this publication in new window or tab >>Impact of cysts during radio frequency (RF) lesioning in deep brain structures: a simulation and in-vitro study
    2007 (English)In: Journal of Neural Engineering, ISSN 1741-2560, E-ISSN 1741-2552, Vol. 4, no 2, p. 87-95Article in journal (Refereed) Published
    Abstract [en]

    Radiofrequency lesioning of nuclei in the thalamus or the basal ganglia can be used to reduce symptoms caused by e.g. movement disorders such as Parkinson's disease. Enlarged cavities containing cerebrospinal fluid (CSF) are commonly present in the basal ganglia and tend to increase in size and number with age. Since the cavities have different electrical and thermal properties compared with brain tissue, it is likely that they can affect the lesioning process and thereby the treatment outcome. Computer simulations using the finite element method and in vitro experiments have been used to investigate the impact of cysts on lesions' size and shape. Simulations of the electric current and temperature distributions as well as convective movements have been conducted for various sizes, shapes and locations of the cysts as well as different target temperatures. Circulation of the CSF caused by the heating was found to spread heat effectively and the higher electric conductivity of the CSF increased heating of the cyst. These two effects were together able to greatly alter the resulting lesion size and shape when the cyst was in contact with the electrode tip. Similar results were obtained for the experiments.

    Place, publisher, year, edition, pages
    Institute of Physics Publishing (IOPP), 2007
    Keywords
    Electrosurgery, RF ablation, Brain, Blood perfusion, Finite-element method
    National Category
    Other Medical Engineering
    Identifiers
    urn:nbn:se:liu:diva-13997 (URN)10.1088/1741-2560/4/2/009 (DOI)000247947300015 ()17409483 (PubMedID)2-s2.0-34247183212 (Scopus ID)
    Note

    Original Publication: Johannes D. Johansson, Dan Loyd, Karin Wårdell and Joakim Wren, Impact of cysts during radio frequency (RF) lesioning in deep brain structures: a simulation and in-vitro study, 2006, Journal of Neural Ingeneering, (4), 2, 87-95. http://dx.doi.org/10.1088/1741-2560/4/2/009 Copyright: Institute of Physics Publishing http://www.iop.org/

    Available from: 2008-12-16 Created: 2008-12-16 Last updated: 2020-12-09Bibliographically approved
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    FULLTEXT01
  • 344. Johansson, K E
    et al.
    Ask, Per
    Linköping University, Department of Biomedical Engineering, Physiological Measurements. Linköping University, The Institute of Technology.
    Boeryd, B
    Fransson, S G
    Tibbling, Lita
    Oesophagitis, signs of reflux, and gastric acid secretion in patients with symptoms of gastro-oesophageal reflux disease.1986In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 21, no 7, p. 837-847Article in journal (Refereed)
    Abstract [en]

    In a study comprising 100 patients referred to a surgical clinic with symptoms suggestive of gastro-oesophageal reflux disease the value of different diagnostic procedures was investigated. Positive acid perfusion and 24-h pH tests were the commonest findings. Forty-nine per cent showed a normal oesophageal mucosa or diffuse oesophagitis at endoscopy. The severity of heartburn and regurgitation did not differ between patients with normal oesophageal mucosa and oesophagitis of various severities. The severity of macroscopic oesophagitis was significantly correlated to the total reflux time, the presence of reflux or a hiatal hernia at radiology, an open cardia or reflux at endoscopy, pressure transmission or reflux and low lower oesophageal sphincter pressure at manometry. Gastric hypersecretion was found in 66% of the patients. Gastric acid secretion was not correlated to the severity of oesophagitis or to the findings at 24-h pH test. In patients with severe oesophagitis the sensitivity for radiologic, manometric, and endoscopic signs of incompetence of the gastro-oesophageal junction was 94%.

  • 345.
    Johansson, Mats
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Escobar Kvitting, John-Peder
    Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Flatebø, Torun
    Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
    Nicolaysen, Anne
    Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
    Nicolaysen, Gunnar
    Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
    Walther, Sten
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Inhibition of constitutive nitric oxide synthase does not influence ventilation: matching in normal prone adult sheep with mechanical ventilation2016In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 123, no 6, p. 1492-1499Article in journal (Refereed)
    Abstract [en]

    Background

    Local formation of nitric oxide (NO) in the lung in proportion to ventilation, leading to vasodilation, is a putative mechanism behind ventilation- perfusion matching. We examined the role of local constitutive NO formation on regional distributions of ventilation (V) and perfusion (Q) and ventilation-perfusion matching (V/Q) in mechanically ventilated adult sheep with normal gas exchange.

    Methods

    V and Q were analyzed in lung regions (≈1.5 cm3) before and after inhibition of constitutive nitric oxide synthase (cNOS) with Nω-nitro-L-arginine methyl ester (L-NAME) (25 mg/kg) in seven prone sheep ventilated with PEEP. V and Q were measured using aerosolized fluorescent and infused radiolabeled microspheres, respectively. The animals were exsanguinated while deeply anaesthetized; lungs were excised, dried at total lung capacity and divided into cube units. The spatial location for each cube was tracked and fluorescence and radioactivity per unit weight determined.

    Results

    Pulmonary artery pressure increased significantly after L-NAME (from mean 16.6 to 23.6 mmHg, P<0.01) while there were no significant changes in PaO2, PaCO2 or SD log(V/Q). Distribution of V was not influenced by L-NAME but a small redistribution of Q from ventral to dorsal lung regions resulting in less heterogeneity in Q along the gravitational axis was seen (p<0.01). Perfusion to regions with the highest ventilation (5th quintile of the V distribution) remained unchanged with L-NAME.

    Conclusions

    There was minimal or no influence of cNOS inhibition by L-NAME on the distributions of V and Q, and V/Q in prone anesthetized and ventilated adult sheep with normal gas exchange.

  • 346.
    Johansson, Mats
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Flatebö, Torun
    Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
    Nicolaysen, Anne
    Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
    Nicolaysen, Gunnar
    Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
    Walther, Sten
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Minimal redistribution of regional ventilation-perfusion ratios by 10 and 20 cmH2O positive end-expiratory pressure in prone sheep2014Manuscript (preprint) (Other academic)
    Abstract [en]

    Background

    Positive end-expiratory pressure (PEEP) has posture dependent effects on the distributions of ventilation (V) and perfusion (Q). We examined if redistribution of regional ventilation-perfusion ratios (V/Q) by PEEP was identical in prone and supine.

    Methods

    Mechanically ventilated sheep (n=16) were studied in prone or supine with 0, 10 and 20 cmH2O PEEP. V and Q were measured with a fluorescent microsphere aerosol and an intravenous infusion of microspheres, respectively. The right lung was dried at total lung capacity and diced into approx. 1000 regions tracking the spatial location of each region.

    Results

    In prone V/Q was close to unity in all horizontal planes with 0 PEEP and remained so with 10 and 20 PEEP. In supine V/Q was imperfect in the most dependent planes with 0 and 10 PEEP. V/Q approached unity in these planes when 20 PEEP was applied, but V/Q in non-dependent planes increased. The slope of the linear relationship between vertical height and V/Q was not different from zero at any PEEP in prone, but was larger than zero with all PEEP levels in supine. Mean V/Q heterogeneity (SDlogV/Q) was lower in prone at all PEEP levels (0 PEEP: 0.22 vs. 0.37,  10 PEEP: 0.21 vs. and 0.32 and 20 PEEP: 0.19 vs. 0.39, P<0.01).

    Conclusions

    Redistribution of regional V/Q was minimal in prone with PEEP and remained close to ideal in all horizontal planes. The absence of high V/Q with PEEP in prone may be clinically important when recruitment fails in the supine posture.

  • 347.
    Johansson, Torsten
    Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Orthopaedic Centre, Department of Orthopaedics Linköping.
    Displaced Femoral Neck Fractures: A prospective randomized study of clinical outcome, nutrition and costs2002Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Displaced femoral neck fractures comprise more than a third of all hip fractures. There is controversy as to the optimal treatment. Despite attempts to improve the methods for internal fixation, complication rates have been almost unchanged: 20-40% non-union and late segmental collapse in another 10-20%. Internal fixation has been the preferred treatment in Scandinavia, whereas primary hemi- or total arthroplasty have been more prevalent in the rest of Europe and North America.

    In this study, patients 75 years or older, including those with mental impairment, were randomized to either internal fixation or cemented primary total hip arthroplasty (THA). A total of 146 hips in 143 patients were followed for two years. After one year 23% had died, and after two years 29%. Mortality was about the same in both groups. The accumulated mortality was pronounced among the mentally impaired patients.

    In the internal fixation group, 44% underwent further surgery. In the THA group, 18% dislocated. The dislocation rate was higher for the mentally impaired patients. The Harris hip scores were higher in the THA group, whereas pain was more common in the internal fixation group.

    The first 50 patients in each treatment group were studied concerning heterotopic ossification (HO), a well-known complication after THA. The incidence of HO in the THA group was similar to what is found after THA due to osteoarthritis. However, only 1/39 developed severe symptoms.

    A subgroup of 100 patients was included in a study concerning nutritional status and functional capacity using the Modified Norton scale, Katz index of ADL and a questionnaire measuring instrumental activities of daily living. The THA group fared better concerning weight change over time, locomotion and pain. The nutritional intervention did not show any measurable effects.

    All patients were followed until two years postoperatively and all fracturerelated hospital costs, including reoperations, were calculated. We found no difference in total costs between the treatment groups. Costs to the municipality were calculated comparing the baseline cost before surgery with the average cost per month during the first postoperative year. No difference was found between the treatment groups.

    On the basis of our results, we recommend arthroplasty for patients in this age group with normal mental function and high functional demands.

    List of papers
    1. Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures
    Open this publication in new window or tab >>Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures
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    2000 (English)In: Acta Orthopaedica Scandinavica, ISSN 0001-6470, Vol. 71, no 6, p. 597-602Article in journal (Refereed) Published
    Abstract [en]

    100 patients 75 years or older, with displaced femoral neck fractures, were randomly assigned to osteosynthesis with two parallel and percutaneously inserted screws (Olmed) or total hip arthroplasty (Lubinus IP). Mean age was 84 (75-101) years, 74% were women and 45% had mental dysfunction. General complications were commoner in the arthroplasty group but the mortality rates did not differ. In the osteosynthesis group, fracture complications were seen in 27/50 hips. In the arthroplasty group, dislocation was the main complication and occurred in 11/50 cases. At 3 months and after 1 year, the Harris Hip Scores were significantly better in the arthroplasty group. When mental dysfunction was present, the dislocation rate after arthroplasty was 32%, whereas the reoperation rate after osteosynthesis was 5%. The opposite pattern of complications was found in patients with normal mental function, 12% versus 60%. The 2-year mortality rate among those with mental dysfunction was 26/45, compared to 7/55 of those with normal function (p < 0.001). We conclude that total hip arthroplasty should be considered for a displaced femoral neck fracture in old patients with normal mental function and high functional demands.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-13728 (URN)
    Available from: 2002-05-12 Created: 2002-05-12 Last updated: 2009-08-19
    2. Heterotopic bone formation following internal fixation or arthroplasty for displaced femoral neck fractures: a prospective randomized study
    Open this publication in new window or tab >>Heterotopic bone formation following internal fixation or arthroplasty for displaced femoral neck fractures: a prospective randomized study
    2001 (English)In: International Orthopaedics, ISSN 0341-2695, Vol. 25, no 4, p. 223-225Article in journal (Refereed) Published
    Abstract [en]

    One hundred hips in 99 patients of 75 years or older, with a displaced femoral neck fracture, were studied for heterotopic ossification (HO). The patients were randomized to either internal fixation or total hip arthroplasty (THA). In the THA group HO was found in 32 of 45 hips compared with 1 of 39 in the internal fixation group (P<0.0012). The frequency of HO after THA corresponds well with findings in other studies on patients receiving THA for osteoarthrosis. In cervical fractures the surgical procedure of total hip replacement seems to be a prerequisite for HO, indicating that the procedure itself is more important than the patient's age and the diagnosis. Severe symptoms due to HO were found in only one patient. HO following THA for a femoral neck fracture is of little clinical importance and prophylaxis is unnecessary.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-13729 (URN)10.1007/s002640100263 (DOI)
    Available from: 2002-05-12 Created: 2002-05-12 Last updated: 2009-08-19
    3. Nutritional status and functional capacity after femoral neck fractures: a prospective randomized one-year follow-up study
    Open this publication in new window or tab >>Nutritional status and functional capacity after femoral neck fractures: a prospective randomized one-year follow-up study
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    2000 (English)In: Aging, ISSN 1945-4589, E-ISSN 1945-4589, Vol. 12, no 5, p. 366-374Article in journal (Refereed) Published
    Abstract [en]

    The primary aim of this study was to evaluate the effect of two different surgical methods on nutritional status and functional capacity during the first postoperative year in patients with displaced femoral neck fractures. A further aim was to evaluate the effect of nutritional support. One hundred patients were randomly assigned to treatment with either primary total hip arthroplasty (THA) or osteosynthesis. Half of the patients in each treatment group received protein- and energy-enriched food in the hospital in addition to individual nutritional advice in order to optimize their intake of protein- and energy-rich food. Nutritional state and functional capacity were examined at baseline, one and three months, and one year after the operation. Pain was examined at three months and one year. The effect of nutritional intervention was equal within both surgical groups. Logistic regression showed that the dependent variable "living at one year" was significantly associated with serum albumin levels at one month. Advanced age, mental impairment and deteriorated nutritional status were predominant in the non-survivors. Overall, the primary THA group performed better compared with the osteosynthesis group concerning weight change over time, locomotion and pain. This study also showed that primary THA could safely be performed in the elderly without an increased postoperative mortality rate.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-13730 (URN)11126523 (PubMedID)
    Available from: 2002-05-12 Created: 2002-05-12 Last updated: 2017-12-13Bibliographically approved
    4. The total costs of a displaced femoral neck fracture: comparison of internal fixation and total hip replacement. A randomised study of 146 hips
    Open this publication in new window or tab >>The total costs of a displaced femoral neck fracture: comparison of internal fixation and total hip replacement. A randomised study of 146 hips
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    2006 (English)In: International Orthopaedics, ISSN 0341-2695, Vol. 30, no 1, p. 1-6Article in journal (Refereed) Published
    Abstract [en]

    We randomised 143 patients –age 75 years or older–with displaced femoral neck fracture to either internal fixation or total hip replacement (THR) and compared the socio-economic consequences. In the internal fixation group, 34 of 78 hips underwent secondary surgery. In the THR group, 12 of 68 hips dislocated, the majority in mentally impaired patients. We calculated the total hospital costs for two years after operation. When secondary surgery was included, there was no difference in costs between the internal fixation and THR groups, or between the mentally impaired and lucid subgroups. The costs to the community were calculated comparing the baseline cost before surgery with the average cost per month during the first postoperative year. No difference was found between the treatment groups. The Harris hip scores were higher in the THR group, and pain was more common in the internal fixation group. In lucid patients, THR gives a better clinical result at the same cost.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-13731 (URN)10.1007/s00264-005-0037-z (DOI)
    Available from: 2002-05-12 Created: 2002-05-12
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  • 348.
    Jonsson, Eythor Ö
    et al.
    epartment of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
    Wänström, Johan
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
    Björnsson Hallgren, Hanna
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
    Adolfsson, Lars
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
    The Oxford Elbow Score demonstrated good measurement properties when used with a shortened 7-day recall period2023In: JSES international, ISSN 2666-6383, Vol. 7, no 3, p. 499-505Article in journal (Refereed)
    Abstract [en]

    The Oxford Elbow Score (OES) is a well-validated, elbow-specific, patient-reported outcome measure (PROM), originally assigned a 4-week recall period. For PROMs, short recall periods could have some advantages, such as optimizing validity by minimizing the negative effects of inaccurate recollection and temporal trends (increase or decrease) in symptoms over the course of the recall period. Temporal trends in elbow function can, for example, be expected to occur over 4 weeks in patients recovering from an injury or surgery. The purpose of this study was to evaluate the measurement properties of the OES using a shortened, 7-day, recall period (OES-7d).

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  • 349. Order onlineBuy this publication >>
    Jonsson, Åsa
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    How to create and analyze a Heart Failure Registry with emphasis on Anemia and Quality of Life2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background and aims

    Heart failure (HF) is a major cause of serious morbidity and death in the population and one of the leading medical causes of hospitalization among people older than 60 years. The aim of this thesis was to describe how to create and how to analyze a Heart Failure Registry with emphasis on Anemia and Quality of Life. (Paper I) We described the creation of the Swedish Heart Failure Registry (SwedeHF) as an instrument, which may help to optimize the handling of HF patients and show how the registry can be used to improve the management of patients with HF. (Paper II) In order to show how to analyze a HF registry we investigated the prevalence of anemia, its predictors, and its association with mortality and morbidity in a large cohort of unselected patients with HFrEF included in the SwedeHF, and to explore if there are subgroups of HF patients identifying high--‐risk patients in need of treatment. (Paper III) In order to show another way of analyzing a HF registry we assessed the prevalence of, associations with, and prognostic impact of anemia in patients with HFmrEF and HFpEF. (Paper IV) Finally we examined the usefulness of EQ--‐ 5D as a measure of patient--‐reported outcomes among HF patients using different analytical models and data from the SwedeHF, and comparing results about HRQoL for patients with HFpEF and HFrEF.

    Methods

    An observational study based on the SwedeHF database, consisting of about 70 variables, was undertaken to describe how a registry is created and can be used (Paper I). One comorbidity (anemia) was applied to different types of HF patients, HFrEF (EF <40%) (II) and HFmrEF (EF 40--‐49% ) or HFpEF (> 50%) (III) analyzing the data with different statistical methods. The usefulness of EQ--‐5D as measure of patient--‐ reported outcomes was studied and the results about HRQoL were compared for patients with HFpEF and HFrEF (IV).

    Results

    In the first paper (Paper I) we showed how to create a HF registry and presented some characteristics of the patients included, however not adjusted since this was not the purpose of the study. In the second paper (Paper II) we studied anemia in patients with HFrEF and found that the prevalence of anemia in HFrEF were 34 % and the most important independent predictors were higher age, male gender and renal dysfunction. One--‐year survival was 75 % with anemia vs. 81 % without (p<0,001). In the matched cohort after propensity score the hazard ratio associated with anemia was for all--‐cause death 1.34. Anemia was associated with greater risk with lower age, male gender, EF 30--‐39%, and NYHA--‐class I--‐II. In the third paper (Paper III) we studied anemia in other types of HF patients and found that the prevalence in the overall cohort in patients with EF > 40% was 42 %, in HFmrEF 38 % and in HFpEF (45%). Independent associations with anemia were HFpEF, male sex, higher age, worse New York Heart Association class and renal function, systolic blood pressure <100 mmHg, heart rate ≥70 bpm, diabetes, and absence of atrial fibrillation. One--‐year survival with vs. without anemia was 74% vs. 89% in HFmrEF and 71% vs. 84% in HFpEF (p<0.001 for all). Thus very similar results in paper II and III but in different types of HF patients. In the fourth paper (Paper IV) we studied the usefulness of EQ--‐5D in two groups of patients with HF (HFpEF and HFrEF)) and found that the mean EQ--‐5D index showed small reductions in both groups at follow--‐up. The patients in the HFpEF group reported worsening in all five dimensions, while those in the HFrEF group reported worsening in only three. The Paretian classification showed that 24% of the patients in the HFpEF group and 34% of those in the HFrEF group reported overall improvement while 43% and 39% reported overall worsening. Multiple logistic regressions showed that treatment in a cardiology clinic affected outcome in the HFrEF group but not in the HFpEF group (Paper IV).

    Conclusions

    The SwedeHF is a valuable tool for improving the management of patients with HF, since it enables participating centers to focus on their own potential for improving diagnoses and medical treatment, through the online reports (Paper I). Anemia is associated with higher age, male gender and renal dysfunction and increased risk of mortality and morbidity (II, III). The influence of anemia on mortality was significantly greater in younger patients in men and in those with more stable HF (Paper II, III). The usefulness of EQ--‐5D is dependent on the analytical method used. While the index showed minor differences between groups, analyses of specific dimensions showed different patterns of change in the two groups of patients (HFpEF and HFrEF). The Paretian classification identified subgroups that improved or worsened, and can therefore help to identify needs for improvement in health services (Paper IV).

    List of papers
    1. Heart failure registry: a valuable tool for improving the management of patients with heart failure
    Open this publication in new window or tab >>Heart failure registry: a valuable tool for improving the management of patients with heart failure
    2010 (English)In: European Journal of Heart Failure, ISSN 1388-9842, E-ISSN 1879-0844, Vol. 12, no 1, p. 25-31Article in journal (Refereed) Published
    Abstract [en]

    Guidelines on how to diagnose and treat patients with heart failure (HF) are published regularly. However, many patients do not fulfil the diagnostic criteria and are not treated with recommended drugs. The Swedish Heart Failure Registry (S-HFR) is an instrument which may help to optimize the handling of HF patients. The S-HFR is an Internet-based registry in which participating centres (units) can record details of their HF patients directly online and transfer data from standardized forms or from computerized patient documentation. Up to December 2007, 16 117 patients from 78 units had been included in the S-HFR. Of these, 10 229 patients had been followed for at least 1 year, and 2133 deaths were recorded. Online reports from the registry showed that electrocardiograms were available for 97% of the patients. Sinus rhythm was found in 51% of patients and atrial fibrillation in 38%. Echocardiography was performed in 83% of the patients. Overall, 77% of patients were treated with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers, 80% were on beta-blockers, 34% on aldosterone antagonists, and 83% on diuretics. The S-HFR is a valuable tool for improving the management of patients with HF, since it enables participating centres to focus on their own potential for improving diagnoses and medical treatment, through the online reports provided.

    Keywords
    Heart failure; Registry; Diagnostics; Medical treatment
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-52877 (URN)10.1093/eurjhf/hfp175 (DOI)
    Available from: 2010-01-13 Created: 2010-01-12 Last updated: 2017-12-12
    2. A comprehensive assessment of the association between anemia, clinical covariates and outcomes in a population-wide heart failure registry
    Open this publication in new window or tab >>A comprehensive assessment of the association between anemia, clinical covariates and outcomes in a population-wide heart failure registry
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    2016 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 211, p. 124-131Article in journal (Refereed) Published
    Abstract [en]

    Background: The aim was to investigate the prevalence of, predictors of, and association with mortality and morbidity of anemia in a large unselected cohort of patients with heart failure (HF) and reduced ejection fraction (HFrEF) and to explore if there were specific subgroups of high risk. Methods: In patients with HFrEF in the Swedish Heart Failure Registry, we assessed hemoglobin levels and associations between baseline characteristics and anemia with logistic regression. Using propensity scores for anemia, we assessed the association between anemia and outcomes with Cox regression, and performed interaction and sub-group analyses. Results: There were 24 511 patients with HFrEF (8303 with anemia). Most important independent predictors of anemia were higher age, male gender and renal dysfunction. One-year survival was 75% with anemia vs. 81% without (p &lt; 0.001). In the matched cohort after propensity score the hazard ratio associated with anemia was for all-cause death 1.34 (1.28-1.40; p &lt; 0.0001), CV mortality 1.28 (1.20-1.36; p &lt; 0.0001), and combined CV mortality or HF hospitalization 1.24 (1.18-1.30; p &lt; 0.0001). In interaction analyses, anemia was associated with greater risk with lower age, male gender, EF 30-39%, and NYHA-class I-II. Conclusion: In HFrEF, anemia is associated with higher age, male gender and renal dysfunction and increased risk of mortality and morbidity. The influence of anemia on mortality was significantly greater in younger patients, in men, and in those with more stable HF. The clinical implication of these findings might be in the future to perform targeted treatment studies. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

    Place, publisher, year, edition, pages
    ELSEVIER IRELAND LTD, 2016
    Keywords
    Heart failure; Reduced ejection fraction; Anemia; Outcomes; Observational study
    National Category
    Mathematics Clinical Medicine
    Identifiers
    urn:nbn:se:liu:diva-127741 (URN)10.1016/j.ijcard.2016.02.144 (DOI)000373918100029 ()26999301 (PubMedID)
    Note

    Funding Agencies|Swedish National Board of Health and Welfare; Swedish Association of Local Authorities and Regions; Swedish Society of Cardiology; Linkoping University; Swedish HF Registry foundation

    Available from: 2016-05-12 Created: 2016-05-12 Last updated: 2017-11-30
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    How to create and analyze a Heart Failure Registry with emphasis on Anemia and Quality of Life
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  • 350.
    Järhult, J
    et al.
    Department of Surgery, Ryhov County Hospital, SE-551 85, Jönköping, Sweden.
    Landerholm, K
    Department of Surgery, Ryhov County Hospital, SE-551 85, Jönköping, Sweden.
    Outcome of hypocalcaemia after thyroidectomy treated only in symptomatic patients2016In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 103, no 6, p. 676-683Article in journal (Refereed)
    Abstract [en]

    Background: Calcium supplementation has been proposed after bilateral thyroid surgery, either to all patients or to those with biochemical hypocalcaemia. It has also been suggested that supplementation aids parathyroid recovery and prevents permanent hypoparathyroidism. This single-centre study investigated the feasibility of a restrictive management of post-thyroidectomy hypocalcaemia.

    Methods: Serum calcium was checked before surgery, on postoperative day 1 (POD) 1, at a follow-up visit 6-8 weeks after surgery and after a minimum of 12 months in all patients. Regardless of serum calcium levels, patients with symptoms of hypocalcaemia were prescribed oral calcium supplementation (0·5-1·0 g twice daily) and asymptomatic patients were not. Asymptomatic patients were informed about hypocalcaemic symptoms and instructed to contact the surgical ward should symptoms appear.

    Results: Some 640 patients underwent bilateral thyroid surgery without previous or intentional simultaneous parathyroidectomy. A subnormal serum calcium level (below 2·15 mmol/l) was observed in 412 patients (64·4 per cent) on POD 1. By comparison, only 63 patients (9·8 per cent) experienced symptoms of hypocalcaemia in the postoperative period, all but one with a corresponding biochemical hypocalcaemia on POD 1. Calcium levels in all patients with asymptomatic postoperative hypocalcaemia recovered to normal without supplementation. Serum calcium was also normalized during follow-up in all symptomatic patients, except 22 (3·4 per cent) who became permanently hypoparathyroid. No patient without early hypocalcaemic symptoms developed permanent hypoparathyroidism.

    Conclusion: The proposed restrictive management of postoperative hypocalcaemia after bilateral thyroid surgery avoids unnecessary supplementation for most patients.

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