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  • 101. Dahlstrand, Ursula
    et al.
    Sandblom, Gabriel
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Wollert, Staffan
    Gunnarsson, Ulf
    CLINTEC, Karolinska Institute, Stockholm, Sweden and Gastro Center Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Chronic pain after femoral hernia repair: a cross-sectional study2011In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 254, no 6, p. 1017-1021Article in journal (Refereed)
    Abstract [en]

    Objective: To explore the prevalence of and to identify possible risk factors for chronic pain after surgery for femoral hernia.

    Background: Chronic pain has become a very important outcome in quality assessment of inguinal hernia surgery. There are no studies on the risk for chronic pain after femoral hernia surgery. Methods: The Inguinal Pain Questionnaire was sent to 1967 patients who had had a repair for primary unilateral femoral hernia between January 1, 1997 and December 31, 2006. A follow-up period of at least 18 months was chosen. Answers from 1461 patients were matched with data recorded in the Swedish Hernia Register and analyzed.

    Results: Some degree of pain during the previous week was reported by 24.2% (354) of patients. Pain interfered with daily activities in 5.5% (81) of patients. Emergency surgery (OR = 0.54; 95% CI = 0.40-0.74) and longer time since surgery (OR = 0.93; 95% CI = 0.89-0.98 for each year added) were associated with lower risk for chronic postoperative pain, whereas a high level of preoperative pain was associated with a higher risk for chronic pain (OR = 1.17; 95% CI = 1.10-1.25). Surgical technique was not found to influence the risk for chronic pain in multivariate logistic regression analysis.

    Conclusions: Chronic postoperative pain is as important a complication after femoral hernia surgery as it is after inguinal hernia surgery. In contrast to inguinal hernia surgery, no risk factor related to surgical technique was found. Further investigations into the role of preoperative pain are necessary.

  • 102.
    Dahlstrand, Ursula
    et al.
    Department of Surgical Science, Uppsala University, Uppsala, Sweden ; CLINTEC, Karolinska Institutet, Stockholm, Sweden ; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Sandblom, Gabriel
    CLINTEC, Karolinska Institutet, Stockholm, Sweden ; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Wollert, Staffan
    Department of Surgical Science, Uppsala University, Uppsala, Sweden.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. CLINTEC, Karolinska Institutet, Stockholm, Sweden ; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Limited potential for prevention of emergency surgery for femoral hernia2014In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 38, no 8, p. 1931-1936Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Femoral hernias are frequently operated on as an emergency. Emergency procedures for femoral hernia are associated with an almost tenfold increase in postoperative mortality, while no increase is seen for elective procedures, compared with a background population.

    OBJECTIVE: The aim of this study was to compare whether symptoms from femoral hernias and healthcare contacts prior to surgery differ between patients who have elective and patients who have emergency surgery.

    METHODS: A total of 1,967 individuals operated on for a femoral hernia over 1997-2006 were sent a questionnaire on symptoms experienced and contact with the healthcare system prior to surgery for their hernia. Answers were matched with data from the Swedish Hernia Register.

    RESULTS: A total of 1,441 (73.3%) patients responded. Awareness of their hernia prior to surgery was denied by 53.3% (231/433) of those who underwent an emergency procedure. Of the emergency operated patients, 31.3% (135/432) negated symptoms in the affected groin prior to surgery and 22.2% (96/432) had neither groin nor other symptoms. Elective patients had a considerably higher contact frequency with their general practitioner, as well as the surgical outpatient department, prior to surgery compared with patients undergoing emergency surgery (p < 0.001).

    CONCLUSIONS: Patients who have elective and patients who have emergency femoral hernia surgery differ in previous symptoms and healthcare contacts. Patients who need emergency surgery are often unaware of their hernia and frequently completely asymptomatic prior to incarceration. Early diagnosis and expedient surgery is warranted, but the lack of symptoms hinders earlier detection and intervention in most cases.

  • 103.
    Dahlstrand, Ursula
    et al.
    Department of Surgery, Uppsala University, Uppsala University Hospital, 75185 Uppsala, Sweden.
    Wollert, Staffan
    Department of Surgery, Uppsala University, Uppsala, Sweden.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandblom, Gabriel
    Division of Surgery, CLINTEC, Karolinska University Hospital Huddinge and Karolinska Institute, Stockholm, Sweden.
    Gunnarsson, Ulf
    Division of Surgery, CLINTEC, Karolinska University Hospital Huddinge and Karolinska Institute, Stockholm, Sweden.
    Emergency femoral hernia repair: a study based on a national register.2009In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 249, no 4, p. 672-676Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the characteristics of femoral hernias and outcome of femoral repairs, with special emphasis on emergency operations. BACKGROUND: Femoral hernias account for 2% to 4% of all groin hernias. However, the lack of large-scale studies has made it impossible to draw conclusions regarding the best management of these hernias. METHODS: The study is based on patients 15 years or older who underwent groin hernia repair 1992 to 2006 at units participating in the Swedish Hernia Register. RESULTS: Three thousand nine hundred eighty femoral hernia repairs were registered, 1490 on men and 2490 on women: 1430 (35.9%) patients underwent emergency surgery compared with 4.9% of the 138,309 patients with inguinal hernias. Bowel resection was performed in 22.7% (325) of emergent femoral repairs and 5.4% (363) of emergent inguinal repairs. Women had a substantial over risk for undergoing emergency femoral surgery compared with men (40.6% vs. 28.1%). An emergency femoral hernia operation was associated with a 10-fold increased mortality risk, whereas the risk for an elective repair did not exceed that of the general population. In elective femoral hernias, laparoscopic (hazard ratio, 0.31; 95% confidence interval, 0.15-0.67) and open preperitoneal mesh (hazard ratio, 0.28; confidence interval, 0.12-0.65) techniques resulted in fewer re-operations than suture repairs. CONCLUSIONS: Femoral hernias are more common in women and lead to a substantial over risk for an emergency operation, and consequently, a higher rate of bowel resection and mortality. Femoral hernias should be operated with high priority to avoid incarceration and be repaired with a mesh.

  • 104. Demirtas, Nihat
    et al.
    Barut, Oya
    Umeå University, Faculty of Medicine, Department of Odontology.
    Ozcan, Ilknur
    Bayer, Suzan
    Kazancioglu, Hakki Oguz
    Recurrent cherubism in an adult patient2015In: The Journal of craniofacial surgery (Print), ISSN 1049-2275, E-ISSN 1536-3732, Vol. 26, no 3, p. E225-E227Article in journal (Refereed)
    Abstract [en]

    Cherubism is an uncommon, nonneoplastic, fibro-osseous disorder of the jaws in childhood and adolescence. It affects the jaw bones by deforming the cortical shell. Clinical features include progressive painless and mostly bilateral expansion of the mandible and/or maxilla. Because fibrous connective tissue replaces osseous tissue, radiographic features generally include expansile osteolytic lesions and a ground-glass appearance. Several treatment protocols for cherubism have been recommended in the literature; however, despite surgical curettage treatment, recurrences may occur. Our aim was to emphasize the high recurrence rate of cherubic lesions. In this article, we present cherubism in a young girl that relapsed after 5 surgical operations before her appearance to our clinic.

  • 105.
    di Summa, Pietro G
    et al.
    Chirurgie Plastique et Reconstructive CHUV, Université de Lausanne, Rue de Bugnon 46, 1005 Lausanne, CH, Switzerland.
    Kingham, Paul J
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Raffoul, W
    Chirurgie Plastique et Reconstructive CHUV, Université de Lausanne, Rue de Bugnon 46, 1005 Lausanne, CH, Switzerland.
    Wiberg, Mikael
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Terenghi, Giorgio
    Blond McIndoe Research Laboratories. The University of Manchester, Manchester, UK.
    Kalbermatten, Daniel F
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Adipose-derived stem cells enhance peripheral nerve regeneration2010In: Journal of plastic, reconstructive and aesthetic surgery, ISSN 1878-0539, Vol. 63, no 9, p. 1544-1552Article in journal (Refereed)
    Abstract [en]

    Traumatic injuries resulting in peripheral nerve lesions often require a graft to bridge the gap. Although autologous nerve auto-graft is still the first-choice strategy in reconstructions, it has the severe disadvantage of the sacrifice of a functional nerve. Cell transplantation in a bioartificial conduit is an alternative strategy to create a favourable environment for nerve regeneration. We decided to test new fibrin nerve conduits seeded with various cell types (primary Schwann cells and adult stem cells differentiated to a Schwann cell-like phenotype) for repair of sciatic nerve injury. Two weeks after implantation, the conduits were removed and examined by immunohistochemistry for axonal regeneration (evaluated by PGP 9.5 expression) and Schwann cell presence (detected by S100 expression). The results show a significant increase in axonal regeneration in the group of fibrin seeded with Schwann cells compared with the empty fibrin conduit. Differentiated adipose-derived stem cells also enhanced regeneration distance in a similar manner to differentiated bone marrow mesenchymal stem cells. These observations suggest that adipose-derived stem cells may provide an effective cell population, without the limitations of the donor-site morbidity associated with isolation of Schwann cells, and could be a clinically translatable route towards new methods to enhance peripheral nerve repair.

  • 106. di Summa, Pietro G
    et al.
    Raffoul, Wassim
    Kalbermatten, Daniel F
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Plastic Surgery, CHUV, University of Lausanne, Lausanne, Switzerland.
    Paper clip microretractor2009In: Journal of reconstructive microsurgery, ISSN 0743-684X, E-ISSN 1098-8947, Vol. 25, no 4, p. 273-273Article in journal (Other academic)
  • 107.
    Dominguez, Cecilia A
    et al.
    Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Kalliomäki, Maija
    Department of Surgical Sciences, Anaesthesiology/Pain research, Uppsala University, Uppsala, Sweden; Department of Anaesthesiology, University of Tammerfors, Tampere, Finland.
    Gunnarsson, Ulf
    Department of Clinical Science, Intervention and Technology (Surgery), Karolinska Institutet, Huddinge, Sweden.
    Moen, Aurora
    National Institute of Occupational Health, Oslo, Norway; Department of Molecular Biosciences, University of Oslo, Norway.
    Sandblom, Gabriel
    Department of Clinical Science, Intervention and Technology (Surgery), Karolinska Institutet, Huddinge, Sweden.
    Kockum, Ingrid
    Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Lavant, Ewa
    Department of Biomedical Laboratory Science, Faculty of Health and Society, Malmö University/Labmedicine Skåne, Clinical Chemistry, Malmö, Sweden.
    Olsson, Tomas
    Nyberg, Fred
    Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.
    Rygh, Lars Jørgen
    Department of Anesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway.
    Røe, Cecilie
    Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Ullevaal, Norway.
    Gjerstad, Johannes
    National Institute of Occupational Health, Oslo, Norway; Department of Molecular Biosciences, University of Oslo, Norway.
    Gordh, Torsten
    Department of Surgical Sciences, Anaesthesiology/Pain research, Uppsala University, Uppsala, Sweden.
    Piehl, Fredrik
    Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    The DQB1*03:02 HLA haplotype is associated with increased risk of chronic pain after inguinal hernia surgery and lumbar disc herniation2013In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 154, no 3, p. 427-433Article in journal (Refereed)
    Abstract [en]

    Neuropathic pain conditions are common after nerve injuries and are suggested to be regulated in part by genetic factors. We have previously demonstrated a strong genetic influence of the rat major histocompatibility complex on development of neuropathic pain behavior after peripheral nerve injury. In order to study if the corresponding human leukocyte antigen complex (HLA) also influences susceptibility to pain, we performed an association study in patients that had undergone surgery for inguinal hernia (n=189). One group had developed a chronic pain state following the surgical procedure, while the control group had undergone the same type of operation, without any persistent pain. HLA DRB1genotyping revealed a significantly increased proportion of patients in the pain group carrying DRB1*04 compared to patients in the pain-free group. Additional typing of the DQB1 gene further strengthened the association; carriers of the DQB1*03:02 allele together with DRB1*04 displayed an increased risk of postsurgery pain with an odds risk of 3.16 (1.61-6.22) compared to noncarriers. This finding was subsequently replicated in the clinical material of patients with lumbar disc herniation (n=258), where carriers of the DQB1*03:02 allele displayed a slower recovery and increased pain. In conclusion, we here for the first time demonstrate that there is an HLA-dependent risk of developing pain after surgery or lumbar disc herniation; mediated by the DRB1*04 - DQB1*03:02 haplotype. Further experimental and clinical studies are needed to fine-map the HLA effect and to address underlying mechanisms.

  • 108. D'souza, Melroy A.
    et al.
    Isaksson, Bengt
    Löhr, Matthias
    Enochsson, Lars
    Department of Clinical Science, Intervention, and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Swahn, Fredrik
    Lundell, Lars
    Arnelo, Urban
    The clinicopathological spectrum and management of intraductal papillary mucinous neoplasm of the bile duct (IPMN-B)2013In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 48, no 4, p. 473-479Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Intraductal papillary mucinous neoplasm of the bile duct (IPMN-B) is a rare but increasingly diagnosed clinical entity. Typical cholangioscopic findings usually include intraductal protruding papillary tumors that secrete mucus.

    METHODS: Clinical, radiological and histopathological data of seven consecutive patients who were found to have IPMN-B were analyzed.

    RESULTS: Six of the seven patients presented with obstructive jaundice/cholangitis as the presenting complaint. ERCP and other imaging were equivocal in five of these patients and peroral cholangioscopy (POCS, single-operator cholangioscopy system) was performed. This revealed mucin-producing intraductal tumors with numerous frond-like papillary projections; a macroscopic appearance consistent with IPMN-B. Preoperative biopsy revealed adenoma, with low-grade dysplasia in two patients and high-grade dysplasia in three. Three patients underwent Whipple resection; one underwent total pancreatectomy with left hepatectomy, one patient a pancreas preserving duodenectomy with common bile duct reimplantation and one patient an extended right hepatectomy. These patients were found to have IPMN-B with adenomatous changes with varying grades of dysplasia and even cholangiocarcinoma on final histopathology. One patient first underwent endoscopic papillectomy and on follow-up was found to have cholangiocarcinoma with metastases to the liver.

    CONCLUSION: POCS can be a key diagnostic investigation in the evaluation of patients with papillary tumors of the bile duct. IPMN-B has a heterogenous pathology and varying grades of dysplasia and even carcinoma may exist in the same patient. Surgical management should be radical and based on tumor extent.

  • 109. Duarte-Salles, Talita
    et al.
    Misra, Sandeep
    Stepien, Magdalena
    Plymoth, Amelie
    Muller, David
    Overvad, Kim
    Olsen, Anja
    Tjonneland, Anne
    Baglietto, Laura
    Severi, Gianluca
    Boutron-Ruault, Marie-Christine
    Turzanski-Fortner, Renee
    Kaaks, Rudolf
    Boeing, Heiner
    Aleksandrova, Krasimira
    Trichopoulou, Antonia
    Lagiou, Pagona
    Bamia, Christina
    Pala, Valeria
    Palli, Domenico
    Mattiello, Amalia
    Tumino, Rosario
    Naccarati, Alessio
    Bueno-de-Mesquita, H. B(as).
    Peeters, Petra H.
    Weiderpass, Elisabete
    Quiros, J. Ramon
    Agudo, Antonio
    Sanchez-Cantalejo, Emilio
    Ardanaz, Eva
    Gavrila, Diana
    Dorronsoro, Miren
    Werner, Mårten
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hemmingsson, Oskar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Ohlsson, Bodil
    Sjoberg, Klas
    Wareham, Nicholas J.
    Khaw, Kay-Tee
    Bradbury, Kathryn E.
    Gunter, Marc J.
    Cross, Amanda J.
    Riboli, Elio
    Jenab, Mazda
    Hainaut, Pierre
    Beretta, Laura
    Circulating Osteopontin and Prediction of Hepatocellular Carcinoma Development in a Large European Population2016In: Cancer Prevention Research, ISSN 1940-6207, E-ISSN 1940-6215, Vol. 9, no 9, p. 758-765Article in journal (Refereed)
    Abstract [en]

    We previously identified osteopontin (OPN) as a promising marker for the early detection of hepatocellular carcinoma (HCC). In this study, we investigated the association between prediagnostic circulating OPN levels and HCC incidence in a large population-based cohort. A nested case-control study was conducted within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. During a mean follow-up of 4.8 years, 100 HCC cases were identified. Each case was matched to two controls and OPN levels were measured in baseline plasma samples. Viral hepatitis, liver function, and a-fetoprotein (AFP) tests were also conducted. Conditional logistic regression models were used to calculate multivariable odds ratio (OR) and 95% confidence intervals (95% CI) for OPN levels in relation to HCC. Receiver operating characteristics curves were constructed to determine the discriminatory accuracy of OPN alone or in combination with other liver biomarkers in the prediction of HCC. OPN levels were positively associated with HCC risk (per 10% increment, ORmultivariable = 1.30; 95% CI, 1.14-1.48). The association was stronger among cases diagnosed within 2 years of follow-up. Adding liver function tests to OPN improved the discriminatory performance for subjects who developed HCC (AUC = 0.86). For cases diagnosed within 2 years, the combination of OPN and AFP was best able to predict HCC risk (AUC = 0.88). The best predictive model for HCC in this low-risk population is OPN in combination with liver function tests. Within 2 years of diagnosis, the combination of OPN and AFP best predicted HCC development, suggesting that measuring OPN and AFP could identify high-risk groups independently of a liver disease diagnosis.

  • 110. Duell, Eric J.
    et al.
    Travier, Noemie
    Lujan-Barroso, Leila
    Dossus, Laure
    Boutron-Ruault, Marie-Christine
    Clavel-Chapelon, Francoise
    Tumino, Rosario
    Masala, Giovanna
    Krogh, Vittorio
    Panico, Salvatore
    Ricceri, Fulvio
    Luisa Redondo, Maria
    Dorronsoro, Miren
    Molina-Montes, Esther
    Huerta, Jose M.
    Barricarte, Aurelio
    Khaw, Kay-Tee
    Wareham, Nick J.
    Allen, Naomi E.
    Travis, Ruth
    Siersema, Peter D.
    Peeters, Petra H. M.
    Trichopoulou, Antonia
    Fragogeorgi, Eirini
    Oikonomou, Eleni
    Boeing, Heiner
    Schuetze, Madlen
    Canzian, Federico
    Lukanova, Annekatrin
    Tjonneland, Anne
    Roswall, Nina
    Overvad, Kim
    Weiderpass, Elisabete
    Gram, Inger Torhild
    Lund, Eiliv
    Lindkvist, Bjorn
    Johansen, Dorthe
    Ye, Weimin
    Umeå University, Faculty of Medicine, Department of Biobank Research.
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Fedirko, Veronika
    Jenab, Mazda
    Michaud, Dominique S.
    Riboli, Elio
    Bueno-de-Mesquita, H. Bas
    Menstrual and reproductive factors in women, genetic variation in CYP17A1, and pancreatic cancer risk in the European prospective investigation into cancer and nutrition (EPIC) cohort2013In: International Journal of Cancer, ISSN 0020-7136, E-ISSN 1097-0215, Vol. 132, no 9, p. 2164-2175Article in journal (Refereed)
    Abstract [en]

    Menstrual and reproductive factors and exogenous hormone use have been investigated as pancreatic cancer risk factors in case-control and cohort studies, but results have been inconsistent. We conducted a prospective examination of menstrual and reproductive factors, exogenous hormone use and pancreatic cancer risk (based on 304 cases) in 328,610 women from the EPIC cohort. Then, in a case-control study nested within the EPIC cohort, we examined 12 single nucleotide polymorphisms (SNPs) in CYP17A1 (an essential gene in sex steroid metabolism) for association with pancreatic cancer in women and men (324 cases and 353 controls). Of all factors analyzed, only younger age at menarche (<12 vs. 13 years) was moderately associated with an increased risk of pancreatic cancer in the full cohort; however, this result was marginally significant (HR = 1.44; 95% CI = 0.992.10). CYP17A1 rs619824 was associated with HRT use (p value = 0.037) in control women; however, none of the SNPs alone, in combination, or as haplotypes were associated with pancreatic cancer risk. In conclusion, with the possible exception of an early age of menarche, none of the menstrual and reproductive factors, and none of the 12 common genetic variants we evaluated at the CYP17A1 locus makes a substantial contribution to pancreatic cancer susceptibility in the EPIC cohort.

  • 111. Edfeldt, Lennart
    et al.
    Stromback, Karin
    Grendin, Joakim
    Umeå University, Faculty of Medicine. ENT Clinic.
    Bunne, Marie
    Harder, Henrik
    Peebo, Markus
    Eeg-Olofsson, Mans
    Petersson, Carl-Magnus
    Konradsson, Konrad
    Evaluation of cost-utility in middle ear implantation in the 'Nordic School': a multicenter study in Sweden and Norway2014In: Acta Oto-Laryngologica, ISSN 0001-6489, E-ISSN 1651-2251, Vol. 134, no 1, p. 19-25Article in journal (Refereed)
    Abstract [en]

    Conclusion: Hearing restoration using an active middle ear implant (AMEI) is a highly cost-effective treatment for a selected group of patients with no other possibilities for auditory rehabilitation. Objectives: To evaluate the cost-utility of using an AMEI for hearing rehabilitation. Methods: This was a prospective, multicenter, single-subject repeated study in six tertiary referral centers. Twenty-four patients with sensorineural (SNHL), conductive (CHL), and mixed hearing loss (MHL) were implanted with the AMEI Vibrant Soundbridge (R) (VSB) for medical reasons. All patients were previously rehabilitated with conventional hearing aids. Multiple validated quality of life patient questionnaires, Health Utilities Index (HUI 2 and 3), and Glasgow Hearing Aid Benefit Profile (GHABP) were used to determine the utility gain and quality adjusted life years (QALY). Directly related treatment costs for the implantation were calculated and related to utility gain and QALY. Results: The cost/QALY for patients with SNHL was estimated at (sic)7260/QALY, and for patients with C/MHL at (sic)12 503/QALY.

  • 112.
    Edmundsson, David
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Chronic compartment syndrome also affects nonathletic subjects: a prospective study of 63 cases with exercise-induced lower leg pain2007In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 78, no 1, p. 136-142Article in journal (Refereed)
    Abstract [en]

    Background Chronic exertional compartment syndrome is most often reported in young and physically active people.

    Patients and methods We studied 73 consecutive patients (mean age 39 (16–77) years, 45 women) with a history of exercise-induced pain and suspicion of chronic exertional compartment syndrome (CECS) of the lower leg—clinically, radiographically and with intramuscular pressure measurements.

    Results Intramuscular pressure increased with reproduction of symptoms and fulfilled the criteria for diagnosis of CECS in 36 patients (mean age 36 (16–65) years, 22 women), with engagement of 66 anterior, 2 lateral and 7 posterior muscle compartments in 72 legs. The patients with CECS of the lower leg were divided into 4 etiological groups: 18 with overuse, 10 with earlier trauma, 4 insulin-treated diabetics, and 4 others. Two-thirds of the patients had pain during walking. The outcome after fasciotomy was excellent or good in 41/57 of the legs.

    Interpretation CECS of the lower leg probably has a multifactorial etiology and is more common in sedentary individuals than has been recognized previously. Fasciotomy appears to be beneficial in these cases also.

  • 113.
    Edmundsson, David
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Chronic exertional compartment syndrome of the lower leg: a novel diagnosis in diabetes mellitus: a clinical and morphological study of diabetic and non-diabetic patients2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Chronic exertional compartment syndrome (CECS) of the lower leg, defined as a condition with exercise-induced pain due to increased intramuscular pressure (IMP), has previously mainly been described in running athletes, and etiologic factors are poorly described. CECS has not been reported to occur together with other diseases and information about consequences on muscles morphology after treatment with fasciotomy is largely unknown. We investigated etiologic and pathophysiologic aspects to CECS in a consecutive series of 63 patients with exercise-related leg pain and in 17 diabetic patients with symptoms of intermittent claudication but no circulatory insufficiency. Clinical examination, radiography, scintigraphy and IMP measurements at rest and after reproduction of symptoms were done. Patients with CECS were recommended treatment with fasciotomy. Biopsies were taken from the tibialis anterior muscle at time of fasciotomy and at follow-up 1 year later. For comparison muscle samples were taken from normal controls. Enzyme- and immunohistochemical and morphometric methods were used for analysis of muscle fiber morphology/pathology, fiber phenotype composition, mitochondrial oxidative capacity and capillary supply.

    Thirty-six of the 63 patients fulfilled the criteria for diagnosis of CECS in the anterior tibial compartment. The CECS patients could be divided into different etiologic groups: 18 healthy, 10 with history of trauma against the lower leg, 4 diabetic patients and 4 others. Only 5 of 36 CECS patients were athletes. The results after fasciotomy were good or excellent in 41 of 57 treated legs.  Sixteen of the 17 diabetic patients were diagnosed with CECS, 11 with diabetes type 1 and 5 with type 2. The diabetic patients differed from the other groups with longer symptom-duration, shorter pain-free walking distance, firm and tender lower leg muscles and higher IMP. The postoperative outcome was good or excellent in 15 of 18 treated legs. The muscle biopsies taken at fasciotomy showed frequent histopathological changes including small and large sized fibers, fiber atrophy, internal myonuclei, split fibers, fibrosis, disorganization of mitochondria in contrast to healthy CECS subjects having low muscle capillarization as the main finding. Muscular abnormalities were generally more complex, severe and widespread in diabetic patients. After 1 year, the majority of CECS patients could return to unrestricted physical activity and the histopathological muscle changes were clearly reduced. The muscle fiber size was larger and the muscles contained signs of regeneration and repair. Remaining muscle abnormalities were present mainly in diabetic patients.

    CECS is a new differential-diagnosis in diabetic patients with symptoms of claudication without signs of vascular disease. A low ability for physical activity, reflected by the signs of both myopathy and neuropathy, indicates that high IMP and circulatory impairment has deleterious effects for the involved muscles. Increased physical activity and normalization of muscle morphology 1 year after treatment shows the benefit of fasciotomy. The more severe clinical and morphological findings in diabetic compared to healthy subjects with CECS indicate differences in the pathogenesis. The unrestricted physical ability after treatment is very important for diabetic patients, since physical activity is an essential part of the therapy of the disease.

  • 114. Edmundsson, David S.
    et al.
    Toolanen, Goran L.
    Stål, Per S.
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB).
    Muscle changes in patients with diabetes and chronic exertional compartment syndrome before and after treatment with fasciotomy2018In: Muscle and Nerve, ISSN 0148-639X, E-ISSN 1097-4598, Vol. 57, no 2, p. 229-239Article in journal (Refereed)
    Abstract [en]

    Introduction: Muscle changes in patients with diabetes and lower leg pain due to chronic exertional compartment syndrome (CECS) were investigated before and after fasciotomy. Methods: The tibialis anterior muscle was analyzed with histochemical and morphological techniques in 7 patients with diabetes and CECS before fasciotomy and in 5 of them 1 year after fasciotomy. Nondiabetic patients with CECS and healthy participants served as references. Results: Before treatment, walking distance until occurrence of pain was limited (<0.2 km). Intramuscular pressure was significantly higher than in reference participants. Muscle analysis showed changes pathognomonic for neuropathy and myopathy and a restricted capillary network, with significantly more severe changes in the muscles of patients with diabetes than in the muscles of nondiabetic patients. Treatment with fasciotomy improved clinical signs, increased walking ability, and reduced muscle abnormalities, but muscle capillarization remained low. Discussion: Patients with diabetes and CECS have distinct pathological changes in affected muscles. Pressure-relieving fasciotomy triggers a regenerative response in the muscle tissue but not in the capillary bed.

  • 115.
    Edmundsson, David
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Svensson, Olle
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Toolanen, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Intermittent claudication in diabetes mellitus due to chronic exertinal compartment syndrome of the leg: an observation study of 17 patients2008In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 79, no 4, p. 534-539Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Intermittent claudication in diabetes mellitus is commonly associated with arterial disease but may occur without obvious signs of peripheral circulatory impairment. We investigated whether this could be due to chronic exertional compartment syndrome (CECS).

    Patients and methods: We report on 17 patients (3 men), mean age 39 (18–72) years, with diabetes mellitus—12 of which were type 1—and leg pain during walking (which was relieved at rest), without clinical signs of peripheral arterial disease. The duration of diabetes was 22 (1–41) years and 12 patients had peripheral neuropathy, retinopathy, or nephropathy. The leg muscles were tender and firm on palpation. Radiography, scintigraphy, and intramuscular pressure measurements were done during exercises to reproduce their symptoms.

    Results: 16 of the 17 patients were diagnosed as having CECS. The intramuscular pressures in leg compartments were statistically significantly higher in diabetics than in physically active non‐diabetics with CECS (p < 0.05). 15 of the 16 diabetics with CECS were treated with fasciotomy. At surgery, the fascia was whitish, thickened, and had a rubber‐like consistency. After 1 year, 9 patients rated themselves as excellent or good in 15 of the 18 treated compartments. The walking time until stop due to leg pain increased after surgery from less than 10 min to unlimited time in 8 of 9 patients who were followed up.

    Interpretation: Intermittent claudication in diabetics may be caused by CECS of the leg. The intramuscular pressures were considerably elevated in diabetics. One pathomechanism may be fascial thickening. The results after fasciotomy are good, and the increased pain‐free walking time is especially beneficial for diabetics.

  • 116.
    Edmundsson, David
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Toolanen, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Thornell, Lars-Eric
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Stål, Per
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Evidence for low muscle capillary supply as a pathogenic factor in chronic compartment syndrome2010In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 20, no 6, p. 805-813Article in journal (Refereed)
    Abstract [en]

    There is a paucity of data regarding the pathogenesis of chronic exertional compartment syndrome (CECS), its consequences for the muscles and the effects of treatment with fasciotomy. We analyzed biopsies from the tibialis anterior muscle, from nine patients, obtained during a decompressing fasciotomy and during follow-up 1 year later. Control biopsies were obtained from nine normal subjects. Muscle capillarity, fiber-type composition and fiber area were analyzed with enzyme- and immunohistochemistry and morphometry. At baseline, CECS patients had lower capillary density (273 vs 378 capillaries/mm(2), P=0.008), lower number of capillaries around muscle fibers (4.5 vs 5.7, P=0.004) and lower number of capillaries in relation to the muscle fiber area (1.1 vs 1.5, P=0.01) compared with normal controls. The fiber-type composition and fiber area did not differ, but focal signs of neuromuscular damage were observed in the CECS samples. At 1-year follow-up after fasciotomy, the fiber area and the number of fibers containing developmental myosin heavy chains were increased, but no enhancement of the capillary network was detected. Thus, morphologically, patients with CECS seemed to have reduced microcirculation capacity. Fasciotomy appeared to trigger a regenerative response in the muscle, however, without any increase in the capillary bed.

  • 117. Egenvall, Monika
    et al.
    Mörner, Malin
    Martling, Anna
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Prediction of outcome after curative surgery for colorectal cancer: preoperative haemoglobin, C-reactive protein and albumin2018In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 20, no 1, p. 26-34Article in journal (Refereed)
    Abstract [en]

    AIM: The aim was to evaluate a scoring system using the values of preoperative haemoglobin, C-reactive protein (CRP) and serum albumin to predict colorectal cancer recurrence and survival.

    METHOD: Data on all curative resections for Stages I-III colorectal cancer performed at a tertiary referral hospital 2007-2010 have been recorded ion the Swedish Colorectal Cancer Registry and were matched to the local databases for laboratory results and blood transfusion. Patients who died within 30 days or during primary hospital admission were excluded. Preoperative haemoglobin, CRP and albumin levels were recorded for 417 patients. A score (0-3) was derived on presence of anaemia (Hb <120 g/l for women and <130 g/l for men), raised CRP (>10 mg/ml) and low albumin (<35g/dl). The risks for recurrence and impaired overall survival were assessed using Cox regression analyses.

    RESULTS: Impaired overall survival was found when one, two or three of the criteria, anaemia, elevated CRP and low albumin, were present prior to surgery (HR 3.61, 1.66-7.85; HR 3.91, 1.75-8.74; HR 4.85, 2.15-10.93, respectively). The risk for recurrence, however, was not related to the presence of these criteria.

    CONCLUSION: Overall survival after curative surgery for Stages I-III colorectal cancer is impaired when anaemia, elevated CRP or low albumin exist prior to surgery. This article is protected by copyright. All rights reserved.

  • 118. Egenvall, Monika
    et al.
    Mörner, Malin
    Påhlman, Lars
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Karolinska Univ Hosp, Dept Surg Gastroenterol, K53,Huddinge 141, S-14186 Stockholm, Sweden.
    Degree of blood loss during surgery for rectal cancer: a population-based epidemiologic study of surgical complications and survival2014In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 16, no 9, p. 696-702Article in journal (Refereed)
    Abstract [en]

    AIM: the hypothesis tested in this study was that major blood loss during surgery for rectal cancer increases the risk for surgical complications and for small bowel obstruction (SBO) due to adhesions or tumour recurrence and reduces overall survival.

    METHOD: data were retrieved from the Uppsala/Örebro Regional Rectal Cancer Registry for all patients undergoing radical resection for rectal cancer 1997-2003 (n=1,843) and matched against the Swedish National Patient Registry regarding surgery and admission for SBO. These patient records were scrutinized to determine the etiology of surgery for SBO. The registry was scrutinized for blood loss and other surgical complications associated with surgery. Uni- and multivariate Cox analysis and logistic regression were used.

    RESULTS: 94 (5.1%) patients underwent surgery for SBO >30 days after the index operation. Of these 82 were caused by adhesions and 12 by tumour recurrence. The volume of blood lost did not influence the risk of surgery for SBO due to adhesions, but blood loss above the median (>800 ml) increased the risk for surgery for SBO caused by tumour recurrence (HR 10.52; 95% CI 1.36-81.51). Increased blood loss increased the risk of surgical complications (OR 2,09; 95% CI 1.60-2.75 with blood loss of 450 ml or more) but did not reduce overall survival. Irradiation before surgery increased blood loss, complications and admission for SBO.

    CONCLUSION: major blood loss during surgery for rectal cancer increases the risk of later surgery for SBO caused by tumour recurrence and surgical complications, but overall survival is not affected. This article is protected by copyright. All rights reserved.

  • 119.
    Ekdahl, Tove
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Löfgren, Jenny
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Wladis, Andreas
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Myggnät vid ljumskbråckskirurgi ett alternativ i låginkomstländer: interimsanalys av kontrollerad randomiserad studie visar goda resultat2014In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 111, no 34-35, p. 1358-1361Article in journal (Refereed)
    Abstract [sv]

    Behovet av förbättrade kirurgiska insatser i låginkomstländer är stort. 

    Ljumskbråck är en vanlig kirurgisk åkomma och opereras i höginkomstländer nästan uteslutande med nätteknik. I låginkomstmiljöer är kommersiella nät för dyra. 

    En randomiserad studie i Uganda undersöker om myggnät med liknande material som de kommersiella näten är jämförbara med kommersiella nät vid ljumskbråckskirurgi. 

    En interimsstudie har utförts för att tidigt påvisa om det föreligger allvarliga komplikationer i någon av behandlingsarmarna. Patienterna följdes upp 14 dagar och 1 år postoperativt.

    Interimsanalysen påvisade inga skillnader mellan behandlingsarmarna eller allvarliga komplikationer som skulle föranleda avbrott av studien.

  • 120.
    Eklöf, Vincy
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Wikberg, Maria L.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Edin, Sofia
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Dahlin, A. M.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Jonsson, Björn-Anders
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Öberg, Å.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Palmqvist, Richard
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    The prognostic role of KRAS, BRAF, PIK3CA and PTEN in colorectal cancer2013In: British Journal of Cancer, ISSN 0007-0920, E-ISSN 1532-1827, Vol. 108, no 10, p. 2153-2163Article in journal (Refereed)
    Abstract [en]

    Background Mutations in KRAS, BRAF, PIK3CA and PTEN expression have been in focus to predict the effect of epidermal growth factor receptor-blocking therapy in colorectal cancer (CRC). Here, information on these four aberrations was collected and combined to a Quadruple index and used to evaluate the prognostic role of these factors in CRC. Patients We analysed the mutation status in KRAS, BRAF and PIK3CA and PTEN expression in two separate CRC cohorts, Northern Sweden Health Disease Study (NSHDS; n = 197) and Colorectal Cancer in Umea Study (CRUMS; n = 414). A Quadruple index was created, where Quadruple index positivity specifies cases with any aberration in KRAS, BRAF, PIK3CA or PTEN expression. Results Quadruple index positive tumours had a worse prognosis, significant in the NSHDS but not in the CRUMS cohort (NSHDS; P = 0.003 and CRUMS; P = 0.230) in univariate analyses but significance was lost in multivariate analyses. When analysing each gene separately, only BRAF was of prognostic significance in the NSHDS cohort (multivariate HR 2.00, 95% CI: 1.16-3.43) and KRAS was of prognostic significance in the CRUMS cohort (multivariate HR 1.48, 95% CI: 1.02-2.16). Aberrations in PIK3CA and PTEN did not add significant prognostic information. Conclusions Our results suggest that establishment of molecular subgroups based on KRAS and BRAF mutation status is important and should be considered in future prognostic studies in CRC.

  • 121.
    Elmqvist, Lars-Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
    Chronic anterior cruciate ligament tear: knee function and knee extensor muscle size, morphology and function before and after surgical reconstruction1988Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Knee function was evaluated by knee score, activity level, clinical findings and performance tests, muscle size by computerized tomography (CT), morphology by light (LM) and electron microscopy (EM), muscle function by electromyography (EMG) and isokinetic performance in 29 patients with chronic anterior cruciate ligament (ACL) tear. Preoperatively CT disclosed a significant mean atrophy of the quadriceps and nonsignificant changes of the other muscle areas of the injured leg. Morphology of m vastus lateralis of the injured leg was normal in more than half of the biopsies preoperatively, the rest showed signs of nonoptimal activation. Significant decreases in all isokinetic parameters were noticed together with significantly decreased EMG of the quadriceps muscle of the injured leg.

    Âfter surgical reconstruction the knees were immobilized in a cast for 6 weeks at either 30° or 70° of knee flexion. After cast removal CT showed significant decreases of all areas which also remained after training. The 30° group showed larger fibres (intracellular oedema) and more frequent morphological abnormalities than the 70° group. Fourteen weeks postoperatively the patients were allocated to either a combination of isometric and progressive resistance training or isokinetic training for 6 weeks. CT showed slightly larger areas at 20 weeks postoperatively than at 6 weeks. Morphological abnormalities were still prominent at 20 weeks postoperatively. Maximum isokinetic knee extensor mechanical output and endurance were markedly decreased at 14 weeks postoperatively but both improved progressively during the one year rehabilitation, mostly during the intensive 6 week training period but irrespective of training programme used. Fatiguability/endurance level improved over the preoperative level. Muscular work/integrated EMG was stable while EMG/t increased indicating neuromuscular relearning.

    The clinical result at 28 months foliowup was excellent or good in 93% of the patients and clinical stability improved in 66%. Independent upon primary knee immobilization angle or training programmes no differences could be demonstrated with respect to stability, range of motion, function or isokinetic mechanical output. Isokinetic performance was still significantly lower in the injured compared to the noninjured leg and not significantly different from the preoperative values. Morphology, only 6 cases, showed abnormalities similar to preoperative findings.

    In conclusion, the reason for the decreased maximum and total knee extensor performance in these patients with ACL tears is suggested to be nonoptimal activation of normal functioning muscle fibres depending on changes in knee joint receptor afferent inflow. No differences concerning the markedly improved postoperative clinical result could be seen between the different treatment modalities used. A nonoptimal muscular activation might explain the still decreased isokinetic performance present at followup.

  • 122.
    Emanuelsson, Peter
    et al.
    Department for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden and Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, 117 76, Stockholm, Sweden .
    Dahlstrand, Ursula
    Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Strömsten, U.
    Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden .
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden .
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm.
    Stark, Birgit
    Department for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden .
    Analysis of the abdominal musculo-aponeurotic anatomy in rectus diastasis: comparison of CT scanning and preoperative clinical assessment with direct measurement intraoperatively2014In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 18, no 4, p. 465-471Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To evaluate and compare the consistency of agreement of two methods for measuring abdominal rectus diastasis (ARD), preoperative computed tomography (CT) scanning and preoperative clinical assessment were compared with direct measurement intraoperatively.

    METHODS: Fifty-five consecutive patients were retrieved from an ongoing prospective randomised trial comparing two operative techniques for the repair of ARD. All patients underwent a preoperative clinical assessment and CT scan, and the results were compared with intraoperative measurement of the ARD width. Agreement between methods was described with Bland-Altman plots (BA plots) and calculated using Lin's Concordance Correlation Coefficient (CCC).

    RESULTS: The median width of the diastasis was 4.0 cm in the upper midline and 3.0 cm in the lower midline for the intraoperative measurement. BA plots showed that measurements on CT and intraoperatively are not in agreement in the lower midline, whereas the agreement was stronger between the clinical and the intraoperative method. The CCC was higher for clinical vs. intraoperative measurement (0.479) than for CT vs. intraoperative measurement (-0.002) in the lower midline, although the agreement was over all low. CT scanning underestimated the width of the ARD when compared to 87 % of preoperative clinical assessments, and 83 % of intraoperative measurements. Preoperative clinical assessment overestimated ARD in 35 % when compared with intraoperative measurements.

    CONCLUSION: Clinical assessment prior to surgery provides more accurate information than CT scanning in the assessment of ARD width. CT scanning underestimates ARD width when compared with intraoperative measurement.

  • 123. Emanuelsson, Peter
    et al.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Dahlstrand, Ursula
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stark, Birgit
    Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall muscle strength: a randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures2016In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 160, no 5, p. 1367-1375Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The primary aim of this prospective, randomized, clinical, 2-armed trial was to evaluate the risk for recurrence using 2 different operative techniques for repair of abdominal rectus diastasis. Secondary aims were comparison of pain, abdominal muscle strength, and quality of life and to compare those outcomes to a control group receiving physical training only.

    METHODS: Eighty-six patients were enrolled. Twenty-nine patients were allocated to retromuscular polypropylene mesh and 27 to double-row plication with Quill technology. Thirty-two patients participated in a 3-month training program. Diastasis was evaluated with computed tomography scan and clinically. Pain was assessed using the ventral hernia pain questionnaire, a quality-of-life survey, SF-36, and abdominal muscle strength using the Biodex System-4.

    RESULTS: One early recurrence occurred in the Quill group, 2 encapsulated seromas in the mesh group, and 3 in the suture group. Significant improvements in perceived pain, the ventral hernia pain questionnaire, and quality of life appeared at the 1-year follow-up with no difference between the 2 operative groups. Significant muscular improvement was obtained in all groups (Biodex System-4). Patient perceived gain in muscle strength assessed with a visual analog scale improved similarly in both operative groups. This improvement was significantly greater than that seen in the training group. Patients in the training group still experienced bodily pain at follow-up.

    CONCLUSION: There was no difference between the Quill technique and retromuscular mesh in the effect on abdominal wall stability, with a similar complication rate 1 year after operation. An operation improves functional ability and quality of life. Training strengthens the abdominal muscles, but patients still experience discomfort and pain.

  • 124.
    Emanuelsson, Peter
    et al.
    Department for Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stark, Birgit
    Department for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Early complications, pain, and quality of life after reconstructive surgery for abdominal rectus muscle diastasis: a 3-month follow-up2014In: Journal of Plastic, Reconstructive & Aesthetic Surgery, ISSN 1748-6815, E-ISSN 1532-1959, Vol. 67, no 8, p. 1082-1088Article in journal (Refereed)
    Abstract [en]

    AIM: The aim of this study was to evaluate early complications following retromuscular mesh repair with those after dual layer suture of the anterior rectus sheath in a randomised controlled clinical trial for abdominal rectus muscle diastasis (ARD).

    METHODS: Patients with an ARD wider than 3 cm and clinical symptoms related to the ARD were included in a prospective randomised study. They were assigned to either retromuscular inset of a lightweight polypropylene mesh or to dual closure of the anterior rectus fascia using Quill self-locking technology. All patients completed a validated questionnaire for pain assessment (Ventral Hernia Pain Questionnaire, VHPQ) and for quality of life (SF36) prior to and 3 months after surgery.

    RESULTS: The most frequently seen adverse event was minor wound infection. Of the patients, 14/57 had a superficial wound infection; five related to Quill and nine to mesh repair. No deep wound infections were reported. Patient rating for subjective muscular improvement postoperatively was better in the mesh technique group with a mean of 6.9 (range 0-10) compared to a mean of 4.8 (range 0-10) in the Quill group (p=0.01). The pre- and post-operative SF36 scores improved in both groups.

    CONCLUSIONS: There was no significant difference between the two surgical techniques in terms of early complications and perceived pain at the 3-month follow-up. Both techniques may be considered equally reliable for ARD repair in terms of adverse outcomes during the early postoperative phase, even though patients operated with a mesh experienced better improvement in muscular strength.

  • 125. Englund, Liselotte
    et al.
    Forsberg, Rebecca
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Saveman, Britt-Inger
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Survivors' experiences of media coverage after traumatic injury events2014In: International Emergency Nursing, ISSN 1755-599X, E-ISSN 1878-013X, Vol. 22, no 1, p. 25-30Article in journal (Refereed)
    Abstract [en]

    Survivors' experiences of media at traumatic events, is still a limited research area. The aim of this study is to explore survivors' experiences of interacting with journalists and media coverage, including their experiences of being portrayed in the media, following two Swedish train crashes. Qualitative interviews were conducted with passengers from two train crashes in Sweden. A qualitative content analysis generated meaning units, subcategories, and categories. Survivors experienced interacting with journalists mainly in three ways: harmful, inconsequential, and helpful. Media content and personal media exposure was experienced in a similar way: uncomfortable, insignificant, and useful. Journalists and media coverage have a large impact on survivors' experiences following a traumatic event. It is important that emergency responders, such as ambulance nurses, are aware of how victims are affected by journalists' presence and the media coverage that follows so that negative outcomes can be reduced and the positive can be enhanced. The present study also shows that media coverage in the long term can become important pieces of information for the victim in order to understand and process the traumatic event. (C) 2013 Elsevier Ltd. All rights reserved.

  • 126.
    Enochsson, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Sunderby Research Unit, Luleå.
    Blohm, My
    Sandblom, Gabriel
    Jonas, Eduard
    Hallerbäck, Bengt
    Lundell, Lars
    Österberg, Johanna
    Inversed relationship between completeness of follow-up and coverage of postoperative complications in gallstone surgery and ERCP: a potential source of bias in patient registers2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 1, article id e019551Article in journal (Refereed)
    Abstract [en]

    Objective: To analyse the completeness in GallRiks of the follow-up frequency in relation to the intraoperative and postoperative outcome.

    Design: Population-based register study.

    Setting: Data from the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP), GallRiks.

    Population: All cholecystectomies and ERCPs recorded in GallRiks between 1 January 2006 and 31 December 2014.

    Main outcome measures: Outcomes for intraprocedural as well as postprocedural adverse events between units with either a 30-day follow-up of AO% compared with those with a less frequent follow-up (<90%).

    Results: Between 2006 and 2014, 162 212 cholecystectomies and ERCP procedures were registered in GallRiks. After the exclusion of non-index procedures and those with incomplete data 152 827 procedures remained for final analyses. In patients having a cholecystectomy, there were no differences regarding the adverse event rates, irrespective of the follow-up frequency. However, in the more complicated endoscopic ERCP procedures, the postoperative adverse event rates were significantly higher in those with a more frequent and complete 30-day follow-up (OR 1.92; 95% Cl 1.76 to 2.11).

    Conclusions: Differences in the follow-up frequency in registries affect the reported outcomes as exemplified by the complicated endoscopic ERCP procedures. A high and complete follow-up rate shall serve as an additional quality indicator for surgical registries.

  • 127. Enochsson, Lars
    et al.
    Sandblom, Gabriel
    Österberg, Johanna
    Thulin, Anders
    Hallerbäck, Bengt
    Persson, Gunnar
    Kvalitetsregister för gallstenskirurgi har förbättrat vården2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, article id DCE6Article in journal (Refereed)
    Abstract [sv]

    The Swedish Registry for cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) (GallRiks) is a validated register with high coverage. The registry started on May 1, 2005 and serves as a base for audit on gallstone disease treatment and also provides a database for clinical research. The aim of this study is to present an overview of the clinical consequences and implementations in patient care that GallRiks research may have contributed to during a 10-year period. Results from studies on GallRiks data have reduced the use of antibiotic and thromboembolic prophylaxis as well as showed the importance of intraoperative cholangiography. Furthermore, the studies on GallRiks data have most probably changed the treatment strategies in ERCP. Studies on GallRiks data have changed and improved the management of patients in Sweden who undergo gallstone surgery or ERCP.

  • 128. Enochsson, Lars
    et al.
    Thulin, Anders
    Osterberg, Johanna
    Sandblom, Gabriel
    Persson, Gunnar
    The Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks): A nationwide registry for quality assurance of gallstone surgery.2013In: JAMA Surgery, ISSN 2168-6254, E-ISSN 2168-6262, Vol. 148, no 5, p. 471-8Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To describe the process of initiating and organizing a nationwide validated web-based quality registry of gallstone surgery and endoscopic retrograde cholangiopancreatography (ERCP) and to present some clinical data and the impact the registry has had on the clinical treatment of gallstones.

    DESIGN: Observational, population-based registry study.

    SETTING: Data from the nationwide Swedish Registry of Gallstone Surgery and ERCP (GallRiks).

    PATIENTS: From May 1, 2005, to December 31, 2011, 63 685 cholecystectomies (laparoscopic and open) and 37 860 ERCPs have been prospectively registered in GallRiks.

    INTERVENTIONS: Cholecystectomies, laparoscopic or conventional, as well as ERCP in a population-based setting.

    MAIN OUTCOME MEASURES: Registrations of all cholecystectomies and ERCPs are performed online by the surgeon or endoscopist. Thirty-day follow-up of both gallstone surgery and ERCP is mandatory, as is an additional 6-month follow-up of the cholecystectomies. Scores on the 36-Item Short Form Health Survey are registered preoperatively and 6 months postoperatively in elective cholecystectomies at selected units.

    RESULTS: The 30-day overall complication rate is 6.1% in elective cholecystectomy, 11.2% in urgent cholecystectomy, and 12.0% following ERCP. The use of antibiotic and thromboembolic prophylaxis in elective laparoscopic cholecystectomy in Sweden has decreased by 8.7% and 17.8% (2006-2011), respectively, mainly owing to presentation of GallRiks data both at meetings and published in peer-reviewed publications. The large database has also enabled several research projects, including one demonstrating that the intention to perform intraoperative cholangiography reduced the risk of death after cholecystectomy. The database has reached greater than 90% national coverage and is continuously validated.

    CONCLUSIONS: GallRiks is a validated national quality registry for gallstone surgery and ERCP, serving as a base for audit of gallstone disease treatment. It also provides a database for clinical research.

  • 129. Erba, P
    et al.
    Wettstein, R
    Tolnay, M
    Rieger, UM
    Pierer, G
    Kalbermatten, Daniel F
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital of Basel, CH-4031 Basel, Switzerland.
    Neurocutaneous sural flap in paraplegic patients2009In: Journal of Plastic, Reconstructive & Aesthetic Surgery, ISSN 1748-6815, E-ISSN 1532-1959, Vol. 62, no 8, p. 1094-1098Article in journal (Refereed)
    Abstract [en]

    Neurocutaneous flaps have been demonstrated to be a reliable option in different groups of patients but it remains unclear if distally-based sural flaps can be safety used in paraplegic patients because they suffer from significant nervous system alterations. The aim of this proof-of-concept study is to demonstrate that these flaps are reliable in paraplegic patients. We prospectively analysed a group (n = 6) of paraplegic patients who underwent reversed sural flap surgery for ulcers on the lateral malleolus. Measurement of area and photographic documentation techniques have been employed to quantify the defect area. Sural nerve biopsies have been analysed histologically with several different staining techniques to assess the neurovascular network and the myelinisation of the nerve. The patients showed uneventful wound heating, except one case that suffered a partial flap necrosis that heated by secondary intention. Histologic analysis revealed an intact neurovascular network and myelinated nerve fibres. In this small series of paraplegic patients that underwent a distally-based sural flap, the complication rate was low, with only one case of superficial partial necrosis demonstrating the reliability and safety of the flap in this subset of patients. Histologic evaluation of sural. nerve biopsies revealed an almost normal morphology. A possible explanation of this phenomenon is that the dorsal root ganglia remain intact in paraplegic patients and can preserve neural characteristics in the peripheral sensory nerve system.

  • 130. Eriksson, Lisbeth
    et al.
    Lindström, Britta
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Ekenberg, Lilly
    Patients' experiences of telerehabilitation at home after shoulder joint replacement2011In: Journal of Telemedicine and Telecare, ISSN 1357-633X, E-ISSN 1758-1109, Vol. 17, p. 25-30Article in journal (Refereed)
    Abstract [en]

    We investigated the experience of ten patients who received video-based physiotherapy at home for two months after a shoulder joint replacement. Videoconferencing took place via the patient's home broadband connection at a bandwidth of 256-768 kbit/s. Qualitative interviews were carried out, transcribed and analysed. Through qualitative content analysis six categories were identified: (1) a different reinforced communication; (2) pain-free exercising as an effective routine; (3) from a dependent patient to a strengthened person at home; (4) closeness at a distance; (5) facilitated daily living; and (6) continuous physiotherapy chain. The access to bodily knowledge, continuity, collaboration and being at home were all aspects that contributed to the patients' recovery. The patients described experiences of safety, and strengthening during their daily exercise routine at home. The frequent interplay with the patient during telerehabilitation made it possible for the physiotherapist to make an individual judgement about each patient; this could be one reason for the positive findings. Home video-based physiotherapy may be useful in other kinds of physiotherapy.

  • 131. Falk, Peter
    et al.
    Ruiz-Jasbon, Fernando
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Ivarsson, Marie-Lois
    An ex vivo model using human peritoneum to explore mesh-tissue integration2017In: Biology open, ISSN 2046-6390, Vol. 6, no 9, p. 1391-1395Article in journal (Refereed)
    Abstract [en]

    Biological compatibility, in terms of implantation of foreign mesh material in hernia surgery, still needs experimental investigation. Present study develops an experimental model using human peritoneum to study the integration between tissue and different mesh material. The ex vivo model using peritoneal tissue was studied with different mesh material, and integration was monitored over time using microscopy.It could be demonstrated that the peritoneal model may be kept viable in culture for several weeks. Cell migration was seen after 7-10 days in culture and could be further monitored over several weeks. The use of a human artificial model environment enabling the investigation of tissue/mesh integration has, to our knowledge, not been described previously.This proof-of-concept model was developed, for the investigation of peritoneal biology and the integration between tissue and different mesh material. It has the potential to be useful in studies on other important biological mechanisms involving the peritoneum.

  • 132.
    Farahmand, Dan
    et al.
    Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Qvarlander, Sara
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Malm, Jan
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Wikkelsö, Carsten
    Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Eklund, Anders
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Tisell, Magnus
    Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Intracranial pressure in hydrocephalus: impact of shunt adjustments and body positions2015In: Journal of Neurology, Neurosurgery and Psychiatry, ISSN 0022-3050, E-ISSN 1468-330X, Vol. 86, no 2, p. 222-228Article in journal (Refereed)
    Abstract [en]

    Background The association between intracranial pressure (ICP) and different shunt valve opening pressures in relation to body positions is fundamental for understanding the physiological function of the shunt.

    Objective To analyse the ICP and ICP wave amplitude (AMP) at different shunt settings and body positions in patients with hydrocephalus.

    Methods In this prospective study 15 patients with communicating hydrocephalus were implanted with a ligated adjustable ventriculoperitoneal shunt. They also received a portable intraparenchymatous ICP-monitoring device. Postoperative ICP and AMP were recorded with the patients in three different body positions (supine, sitting and walking) and with the shunt ligated and open at high, medium and low valve settings. In each patient 12 10 min segments were coded, blinded and analysed for mean ICP and mean AMP using an automated computer algorithm.

    Results Mean ICP and mean AMP were lower at all three valve settings compared with the ligated shunt state (p<0.001). Overall, when compared with the supine position, mean ICP was 11.5 +/- 1.1 (mean +/- SD) mm Hg lower when sitting and 10.5 +/- 1.1 mm Hg lower when walking (p<0.001). Mean ICP was overall 1.1 mm Hg higher (p=0.042) when walking compared with sitting. The maximal adjustability difference (highest vs lowest valve setting) was 4.4 mm Hg.

    Conclusions Changing from a supine to an upright position reduced ICP while AMP only increased at trend level. Lowering of the shunt valve opening pressure decreased ICP and AMP but the difference in mean ICP in vivo between the highest and lowest opening pressures was less than half that previously observed in vitro.

  • 133. Fedirko, V.
    et al.
    Lukanova, A.
    Bamia, C.
    Trichopolou, A.
    Trepo, E.
    Noethlings, U.
    Schlesinger, S.
    Aleksandrova, K.
    Boffetta, P.
    Tjonneland, A.
    Johnsen, N. F.
    Overvad, K.
    Fagherazzi, G.
    Racine, A.
    Boutron-Ruault, M. C.
    Grote, V.
    Kaaks, R.
    Boeing, H.
    Naska, A.
    Adarakis, G.
    Valanou, E.
    Palli, D.
    Sieri, S.
    Tumino, R.
    Vineis, P.
    Panico, S.
    Bueno-de-Mesquita, H. B(as).
    Siersema, P. D.
    Peeters, P. H.
    Weiderpass, E.
    Skeie, G.
    Engeset, D.
    Quiros, J. R.
    Zamora-Ros, R.
    Sanchez, M. J.
    Amiano, P.
    Huerta, J. M.
    Barricarte, A.
    Johansen, D.
    Lindkvist, B.
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Werner, Mårten
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Crowe, F.
    Khaw, K. T.
    Ferrari, P.
    Romieu, I.
    Chuang, S. C.
    Riboli, E.
    Jenab, M.
    Glycemic index, glycemic load, dietary carbohydrate, and dietary fiber intake and risk of liver and biliary tract cancers in Western Europeans2013In: Annals of Oncology, ISSN 0923-7534, E-ISSN 1569-8041, Vol. 24, no 2, p. 543-553Article in journal (Refereed)
    Abstract [en]

    The type and quantity of dietary carbohydrate as quantified by glycemic index (GI) and glycemic load (GL), and dietary fiber may influence the risk of liver and biliary tract cancers, but convincing evidence is lacking. The association between dietary GI/GL and carbohydrate intake with hepatocellular carcinoma (HCC; N = 191), intrahepatic bile duct (IBD; N = 66), and biliary tract (N = 236) cancer risk was investigated in 477 206 participants of the European Prospective Investigation into Cancer and Nutrition cohort. Dietary intake was assessed by country-specific, validated dietary questionnaires. Hazard ratios and 95% confidence intervals were estimated from proportional hazard models. HBV/HCV status was measured in a nested case-control subset. Higher dietary GI, GL, or increased intake of total carbohydrate was not associated with liver or biliary tract cancer risk. For HCC, divergent risk estimates were observed for total sugar = 1.43 (1.17-1.74) per 50 g/day, total starch = 0.70 (0.55-0.90) per 50 g/day, and total dietary fiber = 0.70 (0.52-0.93) per 10 g/day. The findings for dietary fiber were confirmed among HBV/HCV-free participants [0.48 (0.23-1.01)]. Similar associations were observed for IBD [dietary fiber = 0.59 (0.37-0.99) per 10 g/day], but not biliary tract cancer. Findings suggest that higher consumption of dietary fiber and lower consumption of total sugars are associated with lower HCC risk. In addition, high dietary fiber intake could be associated with lower IBD cancer risk.

  • 134. Fedirko, V
    et al.
    Trichopolou, A
    Bamia, C
    Duarte-Salles, T
    Trepo, E
    Aleksandrova, K
    Nöthlings, U
    Lukanova, A
    Lagiou, P
    Boffetta, P
    Trichopoulos, D
    Katzke, VA
    Overvad, K
    Tjønneland, A
    Hansen, L
    Boutron-Ruault, MC
    Fagherazzi, G
    Bastide, N
    Panico, S
    Grioni, S
    Vineis, P
    Palli, D
    Tumino, R
    Bueno-de-Mesquita, HB
    Peeters, PH
    Skeie, G
    Engeset, D
    Parr, CL
    Jakszyn, P
    Sánchez, MJ
    Barricarte, A
    Amiano, P
    Chirlaque, M
    Quirós, JR
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Werner, Mårten
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Sonestedt, E
    Ericson, U
    Key, TJ
    Khaw, KT
    Ferrari, P
    Romieu, I
    Riboli, E
    Jenab, M
    Consumption of fish and meats and risk of hepatocellular carcinoma: the European Prospective Investigation into Cancer and Nutrition (EPIC)2013In: Annals of Oncology, ISSN 0923-7534, E-ISSN 1569-8041, Vol. 24, no 8, p. 2166-2173Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: While higher intake of fish and lower consumption of red/processed meats have been suggested to play a protective role in the etiology of several cancers, prospective evidence for hepatocellular carcinoma (HCC) is limited, particularly in Western European populations.

    METHODS: The associations of fish and meats with HCC risk were analyzed in the EPIC cohort. Between 1992 and 2010, 191 incident HCC were identified among 477 206 participants. Baseline diet was assessed using validated dietary questionnaires. A single 24-h diet recall from a cohort subsample was used for calibration. Multivariable proportional hazard regression was utilized to estimate hazard ratios (HR) and 95% confidence intervals (CI). In a nested case-control subset (HCC = 122), HBV/HCV status and liver function biomarkers were measured.

    RESULTS: HCC risk was inversely associated with intake of total fish (per 20 g/day increase, HR = 0.83, 95% CI 0.74-0.95 and HR = 0.80, 95% CI 0.69-0.97 before and after calibration, respectively). This inverse association was also suggested after adjusting for HBV/HCV status and liver function score (per 20-g/day increase, RR = 0.86, 95% CI 0.66-1.11 and RR = 0.74, 95% CI 0.50-1.09, respectively) in a nested case-control subset. Intakes of total meats or subgroups of red/processed meats, and poultry were not associated with HCC risk.

    CONCLUSIONS: In this large European cohort, total fish intake is associated with lower HCC risk.

  • 135. Fedirko, Veronika
    et al.
    Duarte-Salles, Talita
    Bamia, Christina
    Trichopoulou, Antonia
    Aleksandrova, Krasimira
    Trichopoulos, Dimitrios
    Trepo, Elisabeth
    Tjønneland, Anne
    Olsen, Anja
    Overvad, Kim
    Boutron-Ruault, Marie-Christine
    Clavel-Chapelon, Françoise
    Kvaskoff, Marina
    Kühn, Tilman
    Lukanova, Annie
    Boeing, Heiner
    Buijsse, Brian
    Klinaki, Eleni
    Tsimakidi, Chrysanthi
    Naccarati, Alessio
    Tagliabue, Giovanna
    Panico, Salvatore
    Tumino, Rosario
    Palli, Domenico
    Bueno-de-Mesquita, H Bas
    Siersema, Peter D
    Peters, Petra H
    Lund, Eiliv
    Brustad, Magritt
    Standahl Olsen, Karina
    Weiderpass Vainio, Elisabete
    Zamora, Raul
    Sánchez, María-José
    Ardanaz, Eva
    Amiano, Pilar
    Navarro, Carmen
    Quirós, J Ramón
    Werner, Mårten
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lindkvist, Björn
    Malm, Johan
    Travis, Ruth C
    Khaw, Kay-Tee
    Stepien, Magdalena
    Scalbert, Augustin
    Romieu, Isabelle
    Lagiou, Pagona
    Riboli, Elio
    Jenab, Mazda
    Pre-diagnostic circulating vitamin D levels and risk of hepatocellular carcinoma in European populations: a nested case-control study2014In: Hepatology, ISSN 0270-9139, E-ISSN 1527-3350, Vol. 60, no 4, p. 1222-1230Article in journal (Refereed)
    Abstract [en]

    The association between vitamin D status and hepatocellular carcinoma has not been well investigated, despite experimental evidence supporting an important role of vitamin D in liver pathophysiology. Our objective was to investigate the association between pre-diagnostic circulating 25-hydroxyvitamin D [25(OH)D] serum levels and risk of hepatocellular carcinoma in a prospective, nested case-control study among 520,000 participants in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. Each case (n = 138) diagnosed between 1992 and 2010 was matched to one control by age, sex, study center, date and time of blood collection, and fasting status. Serum baseline levels of 25(OH)D were measured by liquid chromatography/tandem mass spectrometry. Multivariable incident rate ratios (IRR) of hepatocellular carcinoma associated with continuous (per 10 nmol/L) or categorical levels (tertiles or a priori-defined categories) of pre-diagnostic 25(OH)D. Higher 25(OH)D levels were associated with a 49% reduction in the risk of hepatocellular carcinoma (highest vs. lowest tertile: multivariable IRR = 0.51, 95% confidence interval, 0.26 to 0.99; Ptrend = 0.04; per 10 nmol/L increase: IRR = 0.80, 95% confidence interval, 0.68-0.94). The finding did not vary substantially by time from enrolment to diagnosis, and did not change after adjustment for biomarkers of pre-existing liver damage, nor chronic infection with hepatitis B or C viruses. The findings were not modified by body size or smoking status. Conclusion: In this prospective study on Western European populations, serum levels of 25(OH)D were inversely associated with risk of hepatocellular carcinoma. Given the rising incidence of this cancer in low-risk developed countries and the strong public health interest surrounding the potentially cancer-protective roles of vitamin D, additional studies in different populations are required. (Hepatology 2014;).

  • 136. Ferrari, Pietro
    et al.
    Rinaldi, Sabina
    Jenab, Mazda
    Lukanova, Annekatrin
    Olsen, Anja
    Tjonneland, Anne
    Overvad, Kim
    Clavel-Chapelon, Francoise
    Fagherazzi, Guy
    Touillaud, Marina
    Kaaks, Rudolf
    von Ruesten, Anne
    Boeing, Heiner
    Trichopoulou, Antonia
    Lagiou, Pagona
    Benetou, Vassiliki
    Grioni, Sara
    Panico, Salvatore
    Masala, Giovanna
    Tumino, Rosario
    Polidoro, Silvia
    Bakker, Marije F.
    van Gils, Carla H.
    Ros, Martine M.
    Bueno-de-Mesquita, H. Bas
    Krum-Hansen, Sanda
    Engeset, Dagrun
    Skeie, Guri
    Pilar, Amiano
    Sanchez, Maria-Jose
    Buckland, Genevieve
    Ardanaz, Eva
    Chirlaque, Dolores
    Rodriguez, Laudina
    Travis, Ruth
    Key, Tim
    Khaw, Kay-Tee
    Wareham, Nicholas J.
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Slimani, Nadia
    Norat, Teresa
    Aune, Dagfinn
    Riboli, Elio
    Romieu, Isabelle
    Dietary fiber intake and risk of hormonal receptor-defined breast cancer in the European Prospective Investigation into Cancer and Nutrition study2013In: American Journal of Clinical Nutrition, ISSN 0002-9165, E-ISSN 1938-3207, Vol. 97, no 2, p. 344-353Article in journal (Refereed)
    Abstract [en]

    Background: Limited scientific evidence has characterized the association between dietary fiber intake and risk of breast cancer (BC) by menopausal status and hormone receptor expression in tumors. ' Objective: We investigated the relation between total dietary fiber and its main food sources (vegetables, fruit, cereals, and legumes) and BC risk by using data from the European Prospective Investigation into Cancer and Nutrition (EPIC). Design: A total of 11,576 invasive BC cases in 334,849 EPIC women mostly aged 35-70 y at baseline were identified over a median follow-up of 11.5 y. Dietary fiber was estimated from country-specific dietary questionnaires. Multivariable Cox proportional hazards regression models were used to quantify the association between dietary variables and BC risk with energy adjustment by using the residual method. Subgroup analyses were performed by menopausal status and estrogen receptor (ER) and progesterone receptor (PR) expression in tumors. Results: BC risk was inversely associated with intakes of total dietary fiber [hazard ratio comparing fifth quintile to first quintile (HRQ5-Q1): 0.95; 95% CI: 0.89, 1.01; P-trend = 0.03] and fiber from vegetables (0.90; 0.84, 0.96; P-trend < 0.01) but not with fiber from fruit, cereals, or legumes. Overall, associations were homogeneous by menopausal status and ER and PR expression in tumors. For vegetable fiber, stronger associations were observed for estrogen receptor-negative and progesterone receptor-negative (HRQ5-Q1: 0.74; 95% CI: 0.59, 0.93; P-trend = 0.01) than for estrogen receptor-positive and progesterone receptor-positive tumors (0.92: 0.81, 1.03; P-trend = 0.05), with P-heterogeneity = 0.09. Conclusion: Diets rich in dietary fiber and, particularly, fiber from vegetables may be associated with a small reduction in risk of BC, independently of menopausal status. 

  • 137.
    Ferry, Tomas
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Bergström, Ulrica
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Hedström, Erik M
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Lorentzon, Ronny
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine.
    Zeisig, Eva
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Epidemiology of acute knee injuries seen at the Emergency Department at Umeå University Hospital, Sweden, during 15 years2014In: Knee Surgery, Sports Traumatology, Arthroscopy, ISSN 0942-2056, E-ISSN 1433-7347, Vol. 22, no 5, p. 1149-1155Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To describe the incidence and injury distribution of knee injuries in the general population of a European setting. METHODS: Retrospective study of all knee injuries registered at the Emergency Department at Umeå University Hospital, Sweden, during 1995-2009 in relation to age, sex, diagnosis, location and activity at the time of injury, mechanism of injury, and treatment and/or follow-up plan. RESULTS: During 1995-2009, 12,663 knee injuries were registered, 8 % of all injuries. The incidence of knee injuries resulting in a visit to the Emergency Department was six cases per 1,000 person years. One-third of all injuries occurred during sports. And 30 % were 15-24 years. More men than women were injured during sporting activities and women were mostly injured during transportation. CONCLUSION: Knee injuries in a general population are common and the injury distribution varies with age and sex. Sports activities and young age were prominent features of the injured population. LEVEL OF EVIDENCE: IV.

  • 138. Fisher, James L.
    et al.
    Pettersson, David
    Palmisano, Sadie
    Schwartzbaum, Judith A.
    Edwards, Colin G.
    Mathiesen, Tiit
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurosurgery.
    Prochazka, Michaela
    Bergenheim, Tommy
    Florentzson, Rut
    Harder, Henrik
    Nyberg, Gunnar
    Siesjo, Peter
    Feychting, Maria
    Loud Noise Exposure and Acoustic Neuroma2014In: American Journal of Epidemiology, ISSN 0002-9262, E-ISSN 1476-6256, Vol. 180, no 1, p. 58-67Article in journal (Refereed)
    Abstract [en]

    The results from studies of loud noise exposure and acoustic neuroma are conflicting. A population-based case-control study of 451 acoustic neuroma patients and 710 age-, sex-, and region-matched controls was conducted in Sweden between 2002 and 2007. Occupational exposure was based on historical measurements of occupational noise (321 job titles summarized by a job exposure matrix) and compared with self-reported occupational noise exposure. We also evaluated self-reported noise exposure during leisure activity. Conditional logistic regression was used to estimate odds ratios. There was no statistically significant association between acoustic neuroma and persistent occupational noise exposure, either with or without hearing protection. Exposure to loud noise from leisure activity without hearing protection was more common among acoustic neuroma cases (odds ratio = 1.47, 95% confidence interval: 1.06, 2.03). Statistically significant odds ratios were found for specific leisure activities including attending concerts/clubs/sporting events (odds ratio = 1.82, 95% confidence interval: 1.09, 3.04) and participating in workouts accompanied by loud music (odds ratio = 2.84, 95% confidence interval: 1.37, 5.89). Our findings do not support an association between occupational exposure to loud noise and acoustic neuroma. Although we report statistically significant associations between leisure-time exposures to loud noise without hearing protection and acoustic neuroma, especially among women, we cannot rule out recall bias as an alternative explanation.

  • 139.
    Floodeen, Hannah
    et al.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Hallböök, Olof
    Department of Surgery, Linköping University Hospital, Linköping, Sweden.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sjödahl, Rune
    Department of Surgery, Linköping University Hospital, Linköping, Sweden.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Early and late symptomatic anastomotic leakage following low anterior resection of the rectum for cancer: are they different entities?2013In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 15, no 3, p. 334-340Article in journal (Refereed)
    Abstract [en]

    Aim The aim of the study was to compare patients with symptomatic anastomotic leakage following low anterior resection of the rectum (LAR) for cancer diagnosed during the initial hospital stay with those in whom leakage was diagnosed after hospital discharge. Method Forty-five patients undergoing LAR (n=234) entered into a randomized multicentre trial (NCT 00636948), who developed symptomatic anastomotic leakage, were identified. A comparison was made between patients diagnosed during the initial hospital stay on median postoperative day 8 (early leakage, EL; n=27) and patients diagnosed after hospital discharge at median postoperative day 22 (late leakage, LL; n=18). Patient characteristics, operative details, postoperative course and anatomical localization of the leakage were analysed. Results Leakage from the circular stapler line of an end-to-end anastomosis was more common in EL, while leakage from the stapler line of the efferent limb of the J-pouch or side-to-end anastomosis tended to be more frequent in LL (P=0.057). Intra-operative blood loss (P=0.006) and operation time (P=0.071) were increased in EL compared with LL. On postoperative day 5, EL performed worse than LL with regard to temperature (P=0.021), oral intake (P=0.006) and recovery of bowel activity (P=0.054). Anastomotic leakage was diagnosed most often by a rectal contrast study in EL and by CT scan in LL. The median initial hospital stay was 28days for EL and 10days for LL (P<0.001). Conclusion The present study has demonstrated that symptomatic anastomotic leakage can present before and after hospital discharge and raises the question of whether early and late leakage after LAR may be different entities.

  • 140.
    Folkesson, J
    et al.
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    Nilsson, J
    Påhlman, L
    Glimelius, B
    Gunnarsson, Ulf
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    The circular stapling device as a risk factor for anastomotic leakage.2004In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 6, no 4, p. 275-9Article in journal (Refereed)
    Abstract [en]

    AIM: To investigate the relation between the type of circular stapler and anastomotic leak in rectal cancer surgery.

    BACKGROUND: During the past decades results from rectal cancer surgery have improved considerably regarding risk of local recurrence and survival. Two main paradigm changes are considered to be the cause for this: the introduction of total mesorectal excision (TME) and the increasing use of radiotherapy. However, rectal cancer surgery is associated with an unacceptably high frequency of complications of which anastomotic leak is one of the most severe ones. The hypothesis was raised that the choice of stapler influenced the leakage rates.

    METHODS: A questionnaire was sent to all departments of surgery (n = 66) performing rectal cancer surgery in Sweden to determine the choice of circular stapler when performing anterior resection for rectal cancer. These data were linked to the Swedish Rectal Cancer Registry for the period 1995-99.

    RESULTS: A total of 3316 patients had an anterior resection. The choice of circular stapling device was determined in 70% of the cases. When stapler A was used, the leakage rate was 11% whereas it was 7% when stapler B was used (P = 0.0039). In the cases where it was impossible to determine which stapler had been used the leakage rate was 8%.

    CONCLUSION: Quality control is an important part of medicine and the present study suggests that it also must include surgical instruments. A prospective randomised study is needed to confirm the results.

  • 141.
    Folkesson, Joakim
    et al.
    Department of Surgical Sciences and Oncology, Radiology, and Clinical Immunology, Uppsala University Hospital, Uppsala, Sweden.
    Birgisson, Helgi
    Department of Surgical Sciences and Oncology, Radiology, and Clinical Immunology, Uppsala University Hospital, Uppsala, Sweden.
    Pahlman, Lars
    Department of Surgical Sciences and Oncology, Radiology, and Clinical Immunology, Uppsala University Hospital, Uppsala, Sweden.
    Cedermark, Bjorn
    Glimelius, Bengt
    Gunnarsson, Ulf
    Departments of Surgical Sciences and Oncology, Radiology, and Clinical Immunology, Uppsala University Hospital, Uppsala, Sweden.
    Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate2005In: Journal of Clinical Oncology, ISSN 0732-183X, E-ISSN 1527-7755, Vol. 23, no 24, p. 5644-5650Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To evaluate the long-term effects on survival and recurrence rates of preoperative radiotherapy in the treatment of curatively operated rectal cancer patients.

    PATIENTS AND METHODS: Of 1,168 randomly assigned patients in the Swedish Rectal Cancer Trial between 1987 and 1990, 908 had curative surgery; 454 of these patients had surgery alone, and 454 were administered preoperative radiotherapy (25 Gy in 5 days) followed by surgery within 1 week. Follow-up was performed by matching against three Swedish nationwide registries (the Swedish Cancer Register, the Hospital Discharge Register, and the Cause of Death Register).

    RESULTS: Median follow-up time was 13 years (range, 3 to 15 years). The overall survival rate in the irradiated group was 38% v 30% in the nonirradiated group (P = .008). The cancer-specific survival rate in the irradiated group was 72% v 62% in the nonirradiated group (P = .03), and the local recurrence rate was 9% v 26% (P < .001), respectively. The reduction of local recurrence rates was observed at all tumor heights, although it was not statistically significant for tumors greater than 10 cm from the anal verge.

    CONCLUSION: Preoperative radiotherapy with 25 Gy in 1 week before curative surgery for rectal cancer is beneficial for overall and cancer-specific survival and local recurrence rates after long-term follow-up.

  • 142.
    Folkesson, Joakim
    et al.
    Department of Surgery, Uppsala University Hospital, 751 85, Uppsala, Sweden .
    Brown, Steven S R
    Sheffield Teaching Hospitals, Sheffield, UK .
    Gunnarsson, Ulf
    Centre of Surgical Gastroenterology, Karolinska University Hospital, Huddinge and Karolinska Institute, Stockholm, Sweden.
    Påhlman, Lars
    Department of Surgery, Uppsala University Hospital, 751 85, Uppsala, Sweden .
    Randomised multicentre trial of circular stapling devices2012In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 27, no 2, p. 227-232Article in journal (Refereed)
    Abstract [en]

    PURPOSE: In a register study, the risk of anastomotic leakage correlated to the choice of circular stapling device with a 4% difference between the two brands used. Based on those data, a randomised multicentre study was started to explore the risk of an anastomotic leakage based upon the surgical device.

    METHODS: Patients above 18 years with a rectal cancer, able to give informed consent, and scheduled for an anterior resection were eligible for the study. Perioperative randomisation was to Ethicon™ PROXIMATE™ ILS™ or Autosuture™ Premium Plus CEEA™. Anastomotic leakage was defined as a clinically manifest leak.

    RESULTS: Five hundred twenty-nine patients were randomised (58% male). A leak occurred in 8.3%. The anastomoses created by PROXIMATE™ ILS™ leaked in 25/265 (9.4%) anastomoses, and the Premium Plus CEEA™ leaked in 19/260 (7.3%), p = .419.

    CONCLUSION: No difference in the leak rate could be revealed. Several centres replaced one of the staplers by a new product, and the study was ended before the stipulated number of patients was reached. In the future, surgical devices may have to prove superiority in randomised trials or be monitored in quality registers before they can be introduced into day to day surgical practice. The study was registered at ClinicalTrials.gov: NCT00399009.

  • 143.
    Folkesson, Joakim
    et al.
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Påhlman, Lars
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    Gunnarsson, Ulf
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    Population-based study of local surgery for rectal cancer2007In: The British journal of surgery, ISSN 1365-2168, Vol. 94, no 11, p. 1421-1426Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim was to determine long-term survival and recurrence rates after local excision of rectal cancer from a prospectively registered population-based database. METHODS: Swedish Rectal Cancer Registry data from 1995 to 2001, including 10 181 patients of whom 643 (6.3 per cent) had a local excision, were analysed. Complete 5-year follow-up data from 1995 to 1998 were available. Cumulative relative and cancer-specific survival rates, and rates of local recurrence and distant metastases, were calculated by actuarial methods. RESULTS: The 5-year cancer-specific survival rate for 256 patients with stage I disease who had local excision was 95.3 (95 per cent confidence interval 91.5 to 99.1) per cent. The 5-year local recurrence rate was 7.2 per cent. After adjustment for age, sex, tumour stage and preoperative radiotherapy, the relative risk of death from cancer was the same as that after major resection. CONCLUSION: Population-based results after local excision of rectal cancer are the same as those reported in controlled series for early-stage tumours after abdominal resection. A low relative survival and a high median age indicate the use of local excision in patients with a high level of co-morbidity. To achieve acceptable long-term results, optimal preoperative and postoperative staging is needed.

  • 144.
    Fong, Gloria
    et al.
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Backman, Ludvig
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Andersson, Gustav
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Scott, Alexander
    Vancouver Coastal Health and Research Institute.
    Danielson, Patrik
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Human tenocytes are stimulated to proliferate by acetylcholine through an EGFR signalling pathway2013In: Cell and Tissue Research, ISSN 0302-766X, E-ISSN 1432-0878, Vol. 351, no 3, p. 465-475Article in journal (Refereed)
    Abstract [en]

    Studies of human patellar and Achilles tendons have shown that primary tendon fibroblasts (tenocytes) not only have the capacity to produce acetylcholine (ACh) but also express muscarinic ACh receptors (mAChRs) through which ACh can exert its effects. In patients with tendinopathy (chronic tendon pain) with tendinosis, the tendon tissue is characterised by hypercellularity and angiogenesis, both of which might be influenced by ACh. In this study, we have tested the hypothesis that ACh increases the proliferation rate of tenocytes through mAChR stimulation and have examined whether this mechanism operates via the extracellular activation of the epidermal growth factor receptor (EGFR), as shown in other fibroblastic cells. By use of primary human tendon cell cultures, we identified cells expressing vimentin, tenomodulin and scleraxis and found that these cells also contained enzymes related to ACh synthesis and release (choline acetyltransferase and vesicular acetylcholine transporter). The cells furthermore expressed mAChRs of several subtypes. Exogenously administered ACh stimulated proliferation and increased the viability of tenocytes in vitro. When the cells were exposed to atropine (an mAChR antagonist) or the EGFR inhibitor AG1478, the proliferative effect of ACh decreased. Western blot revealed increased phosphorylation, after ACh stimulation, for both EGFR and the extracellular-signal-regulated kinases 1 and 2. Given that tenocytes have been shown to produce ACh and express mAChRs, this study provides evidence of a possible autocrine loop that might contribute to the hypercellularity seen in tendinosis tendon tissue.

  • 145.
    Forsberg, Rebecca
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Train crashes: consequences for passengers2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Globally, and in Sweden, passenger railway transport is steadily increasing. Sweden has been relatively free from severe train crashes in the last decades, but the railway infrastructure is alarmingly worn and overburdened, which may be one reason for an increasing number of reported mishaps. Worldwide, major train crashes/disasters are a frequent cause of mass casualty incidents. Several shortcomings, especially within the crash and post-crash phases cause severe consequences for the passengers.

    Aim: To investigate the consequences of train crashes on passengers, focusing on factors of importance in the crash and post-crash phases. The specific aims are: (I) to identify the historical development and magnitude of passenger train disasters globally on various continents and countries, (II, III) to identify injury panorama and injury objects in two train crashes, (IV) to explore survivor´s experiences from a train crash, and (V) to explore their experiences of journalists and media coverage.

    Methods: Study I is a register study based on 529 railway disasters worldwide, whereas studies II-V are case studies from the two latest severe train crashes in Sweden (Nosaby and Kimstad). These studies are based on 73 and 21 passengers respectively. Studies I-III is essentially quantitative where descriptive statistics (I, III), multivariate analysis (III), and content analysis (II, III) are used. Studies II and III are also supplemented by semi-structured interviews. Studies IV and V are qualitative and the interviews (n=14, n=30) have been analyzed with qualitative content analysis. Study IV is also supplemented with quantitative data.

    Results: The number of railway disasters, fatalities, and non-fatally injured passengers has increased throughout the last hundred years - particularly during the last four decades (1970–2009) when 88% of all disasters occurred (I). Passengers in the first overturned carriage suffered most severe and lethal injuries (III). Internal structures such as tables, chairs, internal walls, as well as luggage, other passengers (II, III), glass (II), and wood pellets (III) induced many of the injuries. Those who traveled facing forward with a table in front of them, in carriages that did not overturn, were more likely to sustain injuries to their abdomen/pelvis than those without a table (III). Passengers who traveled rear facing had higher rates of whiplash injuries. Surviving a train crash was experienced as "living in a mode of existential threat". The long term consequences however were diverse for different persons (IV). All experienced that they had cheated death, but some became "shackled by history", whereas others overcame the "haunting of unforgettable memories." The centrality of others and the importance of reconstructing the turn of events were important when "dealing with the unthinkable". The media coverage were experienced as positive in the recovery process and the journalists were also perceived as helpful (V). By some the journalist’s nevertheless were also perceived as harmful or negligible, and the subsequent media coverage as either uncomfortable or insignificant.

    Conclusion: Despite extensive crash avoidance systems severe railway crashes still occur. Improved interior safety, as has been implemented in the automobile and aviation industries, would have an important reduction in injuries and facilitate evacuation. Being surrounded by family, friends, fellow passengers and participating in crash investigations, and experiencing descriptive media coverage were some crucial factors when dealing with the traumatic event and should be promoted.

  • 146.
    Forsberg, Rebecca
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Holgersson, Annelie
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Bodén, Ida
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Björnstig, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    A study of a mass casualty train crash, focusing on the cause of injuries2014In: Journal of Transportation Safety & Security, ISSN 1943-9962, Vol. 6, no 2, p. 152-166Article in journal (Refereed)
    Abstract [en]

    This case study includes 73 fatally and nonfatally injured passengers from a level-crossing train crash in Nosaby, Sweden, in 2004. The aim was to identify the injury panorama and the injury objects and to determine the injury-inducing variables. Data were analyzed with descriptive statistics, quantitative content analysis, and multivariate data analysis. The first carriage overturned, and its occupants were the ones who suffered the most severe and lethal injuries. Injury type and injury location for these passengers also differed significantly from the passengers on the other two carriages. Tables significantly influenced injury type and injury location in all carriages, whereas the injured persons’ seating position had significant effect only in the second and third carriage. Those who had travelled facing forward with a table in front of them in Carriages 2 and 3 were more likely to have sustained injuries to their abdomen or pelvis. Other injury-inducing objects were seats, interior structures, wood pellets from the truck, and other passengers. Neck sprains were significantly more prevalent among those who had travelled facing backward. Improved train crashworthiness also needs to include interior safety, which would have a potential to reduce crash injuries.

  • 147.
    Forsberg, Rebecca
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Iglesias Vazquez, Jose Antonio
    A Case Study of the High-speed Train Crash Outside Santiago de Compostela, Galicia, Spain2016In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 31, no 2, p. 163-168Article in journal (Refereed)
    Abstract [en]

    Introduction: The worldwide use of rail transport has increased, and the train speeds are escalating. Concurrently, the number of train disasters has been amplified globally. Consequently, railway safety has become an important issue for the future. High-velocity crashes increase the risk for injuries and mortality; nevertheless, there are relatively few studies on high-speed train crashes and the influencing factors on travelers' injuries occurring in the crash phase. The aim of this study was to investigate the fatal and non-fatal injuries and the main interacting factors that contributed to the injury process in the crash phase of the 2013 high-velocity train crash that occurred at Angrois, outside Santiago de Compostela, Spain. Methods: Hospital records (n = 157) of all the injured who were admitted to the six hospitals in the region were reviewed and compiled by descriptive statistics. The instant fatalities (n = 63) were collected on site. Influencing crash factors were observed on the crash site, by carriage inspections, and by reviewing official reports concerning the approximated train speed. Results: The main interacting factors that contributed in the injury process in the crash phase were, among other things, the train speed, the design of the concrete structure of the curve, the robustness of the carriage exterior, and the interior environment of the carriages. Of the 222 people on board (218 passengers and four crew), 99% (n = 220) were fatally or non-fatally injured in the crash. Thirty-three percent (n = 72) suffered fatal injuries, of which 88% (n = 63) died at the crash site and 13% (n = 9) at the hospital. Twenty-one percent (n = 32) of those admitted to hospital suffered multi-trauma (ie, extensive, severe, and/or critical injuries). The head, face, and neck sustained 42% (n = 123) of the injuries followed by the trunk (chest, abdomen, and pelvis; n = 92; 32%). Fractures were the most frequent (n = 200; 69%) injury. Conclusion: A mass-casualty incident with an extensive amount of fatal, severe, and critical injuries is most probable with a high-velocity train; this presents prehospital challenges. This finding draws attention to the importance of more robust carriage exteriors and injury minimizing designs of both railway carriages and the surrounding environment to reduce injuries and fatalities in future high-speed crashes.

  • 148.
    Franklin, Karl A.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haglund, Bengt
    Axelsson, Susanna
    Holmlund, Thorbjörn
    Rehnqvist, Nina
    Rosen, Måns
    Frequency of serious complications after surgery for snoring and sleep apnea2011In: Acta Oto-Laryngologica, ISSN 0001-6489, E-ISSN 1651-2251, Vol. 131, no 3, p. 298-302Article in journal (Refereed)
    Abstract [en]

    Conclusion: No case of death related to surgery in the form of uvulopalatopharyngoplasty, uvulopalatoplasty or nasal surgery for snoring or sleep apnea has been recorded in Sweden among 4876 patients treated between 1997 and 2005. Severe complications of surgery in the peri-and postoperative period, especially in the form of bleedings and infections, were most common after uvulopalatopharyngoplasty, occurring in 3.7%. Objective: To investigate the frequency of serious complications, including death, of surgery for treatment of snoring and sleep apnea. Methods: All Swedish adults who were treated surgically because of snoring or sleep apnea from January 1997 to December 2005 were identified in the National Patient Register. Mortality and serious complications within 30 days from surgery were obtained from the National Cause of Death Register and the National Patient Register. Results: A total of 4876 patients were treated surgically. Uvulopalatopharyngoplasty was performed in 3572 patients, uvulopalatoplasty in 929 patients, and nasal surgery in 375 patients. None of the surgically treated patients died in the peri-and postoperative period. Severe complications, mainly bleedings and infections, were recorded in 37.1 per 1000 patients treated with uvulopalatopharyngoplasty, in 5.6 per 1000 patients after uvulopalatoplasty, and in 8.8 per 1000 patients after nasal surgery.

  • 149.
    Franklin, Karl A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Rehnqvist, Nina
    Freyschuss, Bo
    Axelsson, Susanna
    Obesity surgery in sleep apnea? The effect should be studied in RCTs.2008In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 105, no 37, p. 2499-2500Article in journal (Other (popular science, discussion, etc.))
  • 150.
    Franklin, Oskar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stromal components and micro-RNAs as biomarkers in pancreatic cancer2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background Pancreatic ductal adenocarcinoma (PDAC) patients have the poorest 5-year survival rates of all cancer forms. It is difficult to diagnose at early disease stages, tumour relapse after surgery is common, and current chemotherapies are ineffective. Carbohydrate antigen 19-9 (Ca 19-9), the only clinically implemented PDAC biomarker, is insufficient for diagnostic and screening purposes.

    PDAC tumours are characterised by a voluminous stroma that is rich in extracellular matrix (ECM) molecules such as collagens, hyaluronan (HA) and matricellular proteins. These stromal components have been suggested to promote PDAC cell migration, proliferation, evasion of apoptosis and chemotherapy resistance. Those events are mediated via interactions with adhesion receptors, such as integrins and CD44 receptors expressed on cancer cell surfaces.

    Micro-RNAs (miRNA) post-transcriptionally regulate gene expression in health and disease. At the time of PDAC diagnosis, miRNA levels are altered both in plasma and tumour tissue. Before PDAC diagnosis, tissue miRNA levels are altered in precursor lesions, raising the possibility that plasma miRNAs might aid in early detection.

    In this thesis, it is hypothesised that stromal components and miRNAs can serve as tissue or blood based biomarkers in PDAC. The aims are: (1) to characterise the expression of stromal components and their receptors in normal and cancerous tissue; (2) to find potential stroma-associated tissue and blood-based biomarkers for diagnosis and prognosis estimates; (3) to determine the cellular effects of type IV collagen (Col IV) in PDAC; (4) to determine if plasma miRNAs that are altered in manifest PDAC can be used to diagnose PDAC earlier.

    Methods The expression patterns of Col IV, Col IV-binding integrin subunits (α1, α2, β1), Endostatin, Osteopontin (OPN) and Tenascin C (TNC) were analysed in frozen PDAC and normal pancreatic tissue. A tissue microarray (TMA) was constructed using formalin-fixed, paraffin-embedded primary tumours and lymph node metastases. The TMA was used to study the expression levels and associations with survival of the standard CD44 receptor (CD44s), its variant isoform 6 (CD44v6), HA, OPN and Col IV. Circulating levels of HA, Col IV, Endostatin, OPN and TNC were measured in PDAC patients and healthy individuals, and compared with conventional tumour markers (Ca 19-9, CEA, Ca 125 and TPS). The functional roles of Col IV were studied in PDAC cell lines by: (1) growth on different matrices (2) blocking Col IV binding integrin subunits, (3) blocking the Col IV domains 7s, CB3 and NC1, and (4) by down regulation of PDAC cell synthesis of Col IV using siRNA transfection. Plasma miRNAs alterations were screened for in samples from patients with manifest disease, using real-time quantitative PCR (RT-qPCR). To find early miRNA alterations, levels of those miRNAs that were altered at diagnosis were measured in prediagnostic plasma samples.

    Results High tissue expression of both the standard CD44 receptor (CD44s) and its variant isoform CD44v6 as well as low expression of stromal OPN were associated with poor survival. In addition, high CD44s and low OPN predicted poor survival independent of established prognostic factors.

    Circulating Col IV, Endostatin, OPN, TNC and HA were increased in preoperative samples from PDAC patients. Preoperatively, higher levels of serum-HA and plasma-Endostatin were associated with shorter survival. Postoperatively, higher levels of Col IV, Endostatin and OPN were associated with shorter survival. On the contrary, only one of the conventional tumour markers was associated with survival (Ca 125).

    Col IV stimulated PDAC cell proliferation and migration and inhibited apoptosis in vitro, dependent on the collagenous domain (CB3) of Col IV and the Col IV binding integrin subunit β1. Reduced endogenous Col IV synthesis inhibited these effects, suggesting that PDAC cells synthesise Col IV to stimulate tumour-promoting events via a newly discovered autocrine loop.

    15 miRNAs were altered in early stage PDAC patients and the combination of these markers outperformed Ca 19-9 in discriminating patients from healthy individuals. However, none of the miRNAs were altered in prediagnostic samples, suggesting that plasma miRNA alterations appear late in the disease course.

    Conclusions Up regulated stromal components in PDAC tumours are detectable in blood samples and are potential diagnostic and prognostic biomarkers in PDAC. High circulating levels of Col IV, Endostatin, OPN and HA predict poor survival, as well as high expression of CD44s and CD44v6 and low expression of OPN in tumour tissue. PDAC cells synthesise Col IV, which forms BM-like structures close to cancer cells and promote tumour progression in vitro via an autocrine loop. Several plasma-miRNAs are altered in PDAC, but are not useful for early discovery. 

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