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  • 201.
    Gunnarsson, Ulf
    et al.
    Department of Surgery, Mora Hospital, S- 792 85 Mora, Sweden.
    Heuman, R
    Department of Surgery, Mora Hospital, S- 792 85 Mora, Sweden.
    Wendel-Hansen, V
    Department of Surgery, Mora Hospital, S- 792 85 Mora, Sweden.
    Patient evaluation of routines in ambulatory hernia surgery1996In: Ambulatory Surgery, ISSN 0966-6532, E-ISSN 1873-2097, Vol. 4, no 1, p. 11-13Article in journal (Refereed)
  • 202.
    Gunnarsson, Ulf
    et al.
    Kirurgiska kliniken, Mora lasarett.
    Heuman, Rolf
    Wendel-Hansen, Vidar
    Ljumskbråckskirurgi i öppen vård. Positiv patientupplevelse med förenklade rutiner.1997In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 94, no 14, p. 1292-1296Article in journal (Other academic)
  • 203.
    Gunnarsson, Ulf
    et al.
    Department of Surgery, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Gastrocentrum K53, 141 86, Huddinge, Stockholm, Sweden .
    Johansson, M
    Department of Physiotherapy, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden .
    Strigård, Karin
    Department of Surgery, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Assessment of abdominal muscle function using the Biodex System-4. Validity and reliability in healthy volunteers and patients with giant ventral hernia2011In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 15, no 4, p. 417-421Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The decrease in recurrence rates in ventral hernia surgery have led to a redirection of focus towards other important patient-related endpoints. One such endpoint is abdominal wall function. The aim of the present study was to evaluate the reliability and external validity of abdominal wall strength measurement using the Biodex System-4 with a back abdomen unit.

    MATERIAL AND METHOD: Ten healthy volunteers and ten patients with ventral hernias exceeding 10 cm were recruited. Test-retest reliability, both with and without girdle, was evaluated by comparison of measurements at two test occasions 1 week apart. Reliability was calculated by the interclass correlation coefficients (ICC) method. Validity was evaluated by correlation with the well-established International Physical Activity Questionnaire (IPAQ) and a self-assessment of abdominal wall strength.

    RESULTS: One person in the healthy group was excluded after the first test due to neck problems following minor trauma. The reliability was excellent (>0.75), with ICC values between 0.92 and 0.97 for the different modalities tested. No differences were seen between testing with and without a girdle. Validity was also excellent both when calculated as correlation to self-assessment of abdominal wall strength, and to IPAQ, giving Kendall tau values of 0.51 and 0.47, respectively, and corresponding P values of 0.002 and 0.004.

    CONCLUSION: Measurement of abdominal muscle function using the Biodex System-4 is a reliable and valid method to assess this important patient-related endpoint. Further investigations will be made to explore the potential of this technique in the evaluation of the results of ventral hernia surgery, and to compare muscle function after different abdominal wall reconstruction techniques.

  • 204.
    Gunnarsson, Ulf
    et al.
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Karlbom, U
    Docker, M
    Raab, Y
    Påhlman, L
    Proctocolectomy and pelvic pouch--is a diverting stoma dangerous for the patient?2004In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 6, no 1, p. 23-7Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: A diverting loop ileostomy was previously considered mandatory for minimizing the effects of septic complications in pelvic pouch surgery. During the past decade there has been a trend towards omission of the loop ileostomy without obvious signs of increased numbers of pouch complications or impaired long-term function. The aim of the present study was to evaluate the risk of complications associated with the construction and closure of the loop ileostomy itself.

    PATIENTS AND METHODS: Complications following diverting loop ileostomies in 143 patients subjected to restorative pelvic pouch surgery during the period 1983-97 were studied retrospectively by evaluation of case records.

    RESULTS: In the period between discharge after pelvic pouch surgery and closure of the loop ileostomy, 20 (14%) patients were hospitalized because of excessive stoma flow and 19 (13%) patients were treated for other surgical complications, of whom 10 (7%) required surgical intervention. In the early postoperative period (within 30 days) after closure of the loop ileostomy, 18 (13%) patients suffered complications necessitating surgery. Another 12 (8%) patients were hospitalized because of intestinal obstruction that could be treated conservatively.

    CONCLUSION: The proportion of complications associated with diverting loop ileostomies in pelvic pouch surgery was considerable. A randomised controlled multicentre study is ethically defensible and is recommended.

  • 205.
    Gunnarsson, Ulf
    et al.
    Department of Surgery, Uppsala Academic Hospital, Uppsala, Sweden.
    Lewenhaupt, Arvid
    Heuman, Rolf
    Ureteral wound caused by blunt abdominal trauma.2003In: Scandinavian Journal of Urology and Nephrology, ISSN 0036-5599, E-ISSN 1651-2065, Vol. 37, no 1, p. 88-89Article in journal (Refereed)
    Abstract [en]

    A man fell on icy ground whilst walking to an outdoor toilet. An initial CT scan with intravenous contrast medium was negative. As the man experienced increasing pain a plain abdominal radiograph was performed 2 h later and revealed extravasation of contrast medium emanating from a ureteral injury. This case underlines the possibility that important injuries may not be visible on the initial CT scan that is often used in trauma diagnostics.

  • 206.
    Gunnarsson, Ulf
    et al.
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Seligsohn, E
    Jestin, P
    Påhlman, L
    Registration and validity of surgical complications in colorectal cancer surgery.2003In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 90, no 4, p. 454-9Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Population-based quality registers have become an important tool in quality assessment during the past decade. For registers to be reliable, however, data must be checked carefully for validity.

    METHODS: The present study describes the validity of surgical complications registered in a national register run by the National Board of Health and Welfare (NBH), a register run by Regional Oncological Centres (ROC) and, for comparison, a local quality assurance system at Uppsala University Hospital (UUH). A specialized, independent surgeon checked 10 per cent of patient records against datasheets from the registers.

    RESULTS: The local quality assurance system at UUH showed the best validity for surgical complications. Data for complications of colonic cancer surgery were more valid than those for rectal cancer surgery. Registration of serious complications was more valid than that of wound infections. The calculated proportion of missed surgical complications was 0.69, 0.64, 0.40, 0.22 and 0.07 for rectal and colonic cancer in the NBH register, rectal and colonic cancer in the ROC register, and the UUH register respectively. Corresponding figures for reoperation were 0.45, 0.48, 0.04, 0.09 and 0.21.

    CONCLUSION: Local interest and routine use of data for quality assurance are crucial factors for valid registers. Careful monitoring of validity is necessary for use of registry data in structured systems for improvement of surgical results.

  • 207.
    Gunnarsson, Ulf
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stark, Birgit
    Stockholm, Sweden.
    Dahlstrand, Ursula
    Stockholm, Sweden.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Correlation between Abdominal Rectus Diastasis Width and Abdominal Muscle Strength2015In: Digestive Surgery, ISSN 0253-4886, E-ISSN 1421-9883, Vol. 32, no 2, p. 112-116Article in journal (Refereed)
    Abstract [en]

    Background: Surgery for Abdominal Rectus Diastasis (ARD) is a controversial topic and some argue that it is solely an aesthetic problem. Many symptoms in these patients are indefinite, and no objective criteria have been established, indicating which patients are likely to benefit from surgery. This study investigated the correlation between preoperative assessment and intraoperative measurement of ARD width, and objective measurements of muscle strength. Methods: 57 patients undergoing surgery for ARD underwent preoperative assessment of ARD width by clinical measurement and CT scan, and thereafter intraoperative measurement. Abdominal muscle strength was investigated using the Biodex System 4 including flexion, extension and isometric measurements. Correlations were calculated by the Spearman test. Results: Intraoperative ARD width between the umbilicus and the symphysis correlated strongly with Biodex measurements during flexion (p = 0.007, R = -0.35) and isometric work load (p = 0.01, R = -0.34). The following measurements showed no correlation: between muscle strength and BMI; muscle strength and waistline; or between muscle strength and ARD width above the umbilicus, assessed preoperatively at the outpatient clinic, by CT scan, or measured intraoperatively. Conclusion: There is a strong correlation between intraoperatively measured ARD width below the umbilicus and flexion and isometric abdominal muscle strength measured with the Biodex System 4.

  • 208.
    Gunnarsson, Ulf
    et al.
    Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet at the Karolinska University Hospital/Huddinge, 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 at the Karolinska University Hospital/Huddinge, Stockholm, Sweden.
    3D intrastomal ultrasonography, an instrument for detecting stoma-related fistula2012In: Techniques in Coloproctology, ISSN 1123-6337, E-ISSN 1128-045X, Vol. 16, no 3, p. 233-236Article in journal (Refereed)
    Abstract [en]

    The aim of the present study was to evaluate the recently developed 3D intrastomal ultrasonography in diagnosing stoma-associated complaints and suspected complications after parastomal hernia repair such as peristomal fistula and abscesses. 3D intrastomal ultrasonography was used to image peristomal tissue in two patients with complaints after parastomal hernia repair performed with IPOM (intraperitoneal onlay mesh). One patient had ulcerative colitis and one Crohn's disease. Both patients were investigated because of pain and in one case also signs of a subcutaneous abscess. Intrastomal ultrasonography revealed fistulas connected to the intestinal segment leading to the stoma in both cases. Both cases also showed signs of a fistula descending to the abdominal cavity. In one case, a subcutaneous abscess was identified and in the other a small abscess adjacent to the fistula and the edge of the fascia. Stoma complaints after surgery for parastomal hernia with implantation of IPOM mesh can be diagnosed using 3D intrastomal ultrasonography. This new 3D technique for imaging intrastomal hernia can be used to complement traditional methods in the detection of stoma-associated abscesses and fistulas with or without foreign material such as mesh.

  • 209.
    Gurmu, A
    et al.
    Department of Surgery, CLINTEC, Karolinska Institute at the Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Gunnarsson, Ulf
    Department of Surgery, CLINTEC, Karolinska Institute at the Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Strigård, Karin
    Department of Surgery, CLINTEC, Karolinska Institute at the Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Imaging of parastomal hernia using three-dimensional intrastomal ultrasonography2011In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 98, no 7, p. 1026-9Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Parastomal hernia is common in patients with a permanent stoma. At present there is no standard method for imaging a parastomal hernia. The aim of this study was to investigate the value of three-dimensional intrastomal ultrasonography in differentiating between a parastomal hernia and a bulge.

    METHODS: Twenty patients were divided into four groups according to ultrasonography setting and probe cover. All patients were tested using three different ultrasound probe frequencies (9, 13 and 16 MHz). The intrastomal examination was performed during provocation in both the supine and upright positions, with a protector or water-containing balloon surrounding the probe.

    RESULTS: The sharpest images were obtained using the rectal setting with a water-containing balloon surrounding the probe at 9 MHz in supine and erect positions, for evaluation of both fascia and muscle; in some instances even implanted mesh was detectable. When switched to render mode, the pictures improved in sharpness and it was easier to identify anatomical landmarks.

    CONCLUSION: Intrastomal ultrasonography using the rectal setting and a frequency of 9 MHz is a feasible method for imaging a parastomal hernia and differentiating it from an abdominal bulge. The image quality improves when render mode is used.

  • 210.
    Gurmu, Ambatchew
    et al.
    Department of Surgical Gastroenterology, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Nyköping Hospital, Nyköping, Sweden and Department of Surgical Gastroenterology, K53, Karolinska University Hospital, Huddinge, 141 86, Stockholm, Sweden .
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Sven
    Department of Radiology, Akademiska University Hospital, Uppsala, Sweden.
    Påhlman, Lars
    Department of Surgery, Akademiska University Hospital, Uppsala, Sweden.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gunnarsson, Ulf
    Department of Surgical Gastroenterology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    The inter-observer reliability is very low at clinical examination of parastomal hernia2011In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 26, no 1, p. 89-95Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Parastomal hernia in patients with a permanent colostomy is common. The aim of this study was to evaluate the reliability of the diagnosis based on clinical examination and to compare this examination with the result of a specially designed questionnaire and computerised tomography (CT) scan.

    METHODS: Forty-one patients operated upon with an abdominoperineal resection due to rectal cancer at three hospitals between 1996 and 2002 were included. At minimum of 4 years after the operation, they underwent clinical examination by two or three independent surgeons, answered a colostomy questionnaire and were offered a CT scan of the abdominal wall.

    RESULT: At Hospital I, 17 patients were examined by three surgeons, with inter-observer kappa values between 0.35 and 0.64. At Hospital II, 13 patients were examined by three surgeons, the kappa values ranged between 0.29 and 0.43. At Hospital III, 11 patients were examined by two surgeons, with kappa value of 0.73. The kappa value between CT scan and the colostomy questionnaire was 0.45.

    CONCLUSION: The inter-observer reliability was low, indicating that parastomal hernia is difficult to diagnose by patient history and clinical examination. Some herniae may not be detected by CT scan, and the correlation to patient-reported complaints is low. A more sensitive radiological method to detect parastomal hernia is needed.

  • 211.
    Gustafsson, Carl Pontus
    et al.
    Department of Surgery, Visby Hospital, Gotland, Sweden..
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Dahlstrand, Ursula
    Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden..
    Lindforss, Ulrik
    Department of Molecular Medicine and Surgery, Karolinska Institutet, and Centre for Digestive Diseases, Karolinska University Hospital, Solna, Sweden..
    Loop-ileostomy reversal: patient-related characteristics influencing time to closure2018In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 33, no 5, p. 593-600Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To identify factors associated with timing of stoma reversal after rectal cancer surgery in a large Swedish register-based cohort.

    METHODS: Three thousand five hundred sixty-four patients with rectal cancer who received a protective stoma during surgery in 2007-2013 were identified in the Swedish colorectal cancer register. Time to stoma reversal was evaluated over a follow-up period of one and a half years. Factors associated with timing of stoma reversal were analysed using Cox regression analysis. Reversal within 9 months (12 months if adjuvant chemotherapy) was considered latest expected time to closure.

    RESULTS: Stoma reversal was performed in 2954 (82.9%) patients during follow-up. Patients with post-secondary education had an increased chance for early stoma reversal (HR 1.13; 95% CI 1.02-1.25). Postoperative complications (0.67; 0.62-0.73), adjuvant chemotherapy (0.63; 0.57-0.69), more advanced cancer stage (stage III 0.74; 0.66-0.83 and stage IV 0.38; 0.32-0.46) and higher ASA score (0.80; 0.71-0.90 for ASA 3-4) were associated with longer time to reversal. Two thousand four hundred thirty-seven (68.4%) patients had stoma reversal within latest expected time to closure. Factors associated to decreased chance of timely reversal were more advanced cancer stage (stage III 0.64; 0.50-0.81 and stage IV 0.19; 0.13-0.27), postoperative complications (0.50; 0.42-0.59) and higher ASA score (0.77; 0.61-0.96 for ASA 3-4).

    CONCLUSIONS: Patients with a high level of education had a higher chance of timely reversal but medical factors had a stronger association to time to reversal. Patients with advanced rectal cancer are at high risk for non-reversal and should be considered for permanent stoma.

  • 212.
    Gustafsson, Moa
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Tumour stroma; markers for invasiveness and metastatic potential A pilot study of small differentiated papillary thyroid carcinomas2017Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 213.
    Gustafsson, Patrik
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Crenshaw, Albert G.
    Edmundsson, David
    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.
    Crnalic, Sead
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Muscle oxygenation in Type 1 diabetic and non-diabetic patients with and without chronic compartment syndrome2017In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 12, no 10, article id e0186790Article in journal (Refereed)
    Abstract [en]

    Background: Type 1 diabetic patients and non-diabetic patients were referred for evaluation for chronic exertional compartment syndrome (CECS) based on clinical examination and complaints of activity-related leg pain in the region of the tibialis anterior muscle. Previous studies using near-infrared spectroscopy (NIRS) showed greater deoxygenation during exercise for CECS patients versus healthy controls; however, this comparison has not been done for diabetic CECS patients. Methods: We used NIRS to test for differences in oxygenation kinetics for Type 1 diabetic patients diagnosed with (CECS-diabetics, n = 9) versus diabetic patients without (CON-diabetics, n = 10) leg anterior chronic exertional compartment syndrome. Comparisons were also made between non-diabetic CECS patients (n = 11) and healthy controls (CON, n = 10). The experimental protocol consisted of thigh arterial cuff occlusion (AO, 1-minute duration), and treadmill running to reproduce symptoms. NIRS variables generated were resting StO(2)%, and oxygen recovery following AO. Also, during and following treadmill running the magnitude of deoxygenation and oxygen recovery, respectively, were determined. Results: There was no difference in resting StO2% between CECS-diabetics (78.2 +/- 12.6%) vs. CON-diabetics (69.1 +/- 20.8%), or between CECS (69.3 +/- 16.2) vs. CON (75.9 +/- 11.2%). However, oxygen recovery following AO was significantly slower for CECS (1.8 +/- 0.8%/sec) vs. CON (3.8 +/- 1.7%/sec) (P = 0.002); these data were not different between the diabetic groups. StO2% during exercise was lower (greater deoxygenation) for CECS-diabetics (6.3 +/- 8.6%) vs. CON-diabetics (40.4 +/- 22.0%), and for CECS (11.3 +/- 16.8%) vs. CON (34.1 +/- 21.2%) (P<0.05 for both). The rate of oxygen recovery post exercise was faster for CECS-diabetics (3.5 +/- 2.6%/sec) vs. CON-diabetics (1.4 +/- 0.8%/sec) (P = 0.04), and there was a tendency of difference for CECS (3.1 +/- 1.4%/sec) vs. CON (1.9 +/- 1.3%/sec) (P = 0.05). Conclusion: The greater deoxygenation during treadmill running for the CECS-diabetics group (vs. CON-diabetics) is in line with previous studies (and with the present study) that compared non-diabetic CECS patients with healthy controls. Our findings could suggest that NIRS may be useful as a diagnostic tool for assessing Type 1 diabetic patients suspected of CECS.

  • 214. Gustafsson, Pontus
    et al.
    Jestin, Pia
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lindforss, Ulrik
    Higher Frequency of Anastomotic Leakage with Stapled Compared to Hand-Sewn Ileocolic Anastomosis in a Large Population-Based Study2015In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 39, no 7, p. 1834-1839Article in journal (Refereed)
    Abstract [en]

    The stapling technique was recommended in a recent Cochrane analysis based on relatively small randomized trials between 1970 and 2009. Data from a large Swedish population-based quality register were analyzed in order to compare the leakage frequency between stapled and hand-sewn ileocolic anastomoses in colon cancer surgery. Three-thousand four-hundred and twenty-eight patients with an ileocolic anastomosis were entered in a Swedish regional quality register for colon cancer, including the type of anastomosis used. The patients were analyzed by logistic regression regarding risk for leakage, and Cox proportional hazard regression for survival associated with the technique used for anastomosis. Analyses were made for gender, age, elective or emergency surgery, duration of surgery, bleeding, cancer stage, and local radicality. Most anastomoses were hand sewn (1,908 of 3,428, 55.7 %, p < 0.001), whereas stapling was more common among emergency cases (342 of 618, 55.3 %, p < 0.001). Clinically relevant leakage appeared in 58 patients (1.7 %), of whom 51 (87.9 %) were re-operated. Leakage was found to be more frequent after stapled anastomosis (2.4 vs. 1.2 %, p = 0.006), and in multivariate analysis, stapled anastomosis was the only risk factor (OR = 2.04 95 % CI 1.19-3.50). There was no difference in overall survival related to the technique. Hand-sewn anastomosis is not associated with a higher leakage rate when comparing to a stapling procedure and is recommended for routine and emergency right-sided colon cancer surgery. This recommendation is based on what appears to be a lower leakage rate, similar survival and lower material cost.

  • 215. Gustavsson, Kajsa
    et al.
    Gunnarsson, Ulf
    Department of Surgical Gastroenterology, Karolinska University Hospital, Huddinge, Karolinska Institutet, 141 85, Stockholm, Sweden .
    Jestin, Pia
    Postoperative complications after closure of a diverting ileostoma-differences according to closure technique2012In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 27, no 1, p. 55-58Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The aim of this study was to compare three methods for closure of a diverting ileostoma according to development of postoperative small-bowel obstruction (SBO) and anastomotic leakage (AL).

    METHODS: Complications arising within 30 days after closure of a defunctioning loop ileostomy in 351 patients during the period 1999-2006 were studied retrospectively by evaluation of case records. The techniques employed were: hand-sewn anastomosis without bowel resection, hand-sewn anastomosis with bowel resection and stapled anastomosis.

    RESULTS: Of the 351 patients, 149 had a hand-sewn anastomosis without bowel resection (HS), 70 had a hand-sewn anastomosis with bowel resection (HSR) and 132 patients had a stapled anastomosis (S). The total number of SBOs was 44 patients (12.5%). In the two hand-sewn groups, 15.5% (34 patients) suffered postoperative SBO compared to 7.6% (10 patients) in the stapled group (p = 0.029). No difference in AL could be found between the groups, where the overall frequency was 2.8% (10 patients). Median hospital stay was 6 days in the HS group, 5 days in the HSR group and 4 days in the S group (p = 0.001).

    CONCLUSION: In the present study, stapled anastomosis was associated with a lower frequency of postoperative SBO and a shorter hospital stay compared to sutured anastomosis (either with or without a short small-bowel resection) after closure of a diverting ileostoma.

  • 216. Gutlic, Nihad
    et al.
    Rogmark, Peder
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Petersson, Ulf
    Montgomery, Agneta
    Impact of mesh fixation on chronic pain in total extraperitoneal inguinal hernia repair (TEP): a nationwide register-based study2016In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 263, no 6, p. 1199-1206Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Mesh fixation is used to prevent recurrence at the potential risk for chronic pain in TEP. The aim was to compare the impact of permanent fixation (PF) with no fixation (NF)/nonpermanent fixation (NPF) of mesh on chronic pain after TEP repair for primary inguinal hernia.

    METHODS: Men, 30 to 75 years old, consecutively registered in the Swedish Hernia Register for a TEP primary repair in 2005 to 2009, were included in a mail survey using SF-36 and the Inguinal Pain Questionnaire (IPQ). Primary endpoint was IPQ question "Did you have pain during past week that could not be ignored." Risk factors for chronic pain and recurrent operations were analyzed.

    RESULTS: A total of 1110 patients were included (325 PF, 785 NF/NPF) with 7.7% reporting pain at median 33 months follow-up. No difference regarding primary endpoint pain (P < 0.462), IPQ and SF-36 subscales were seen. Recurrent operation was carried out in 1.4% during 7.5 years follow-up with no difference between PF- and NF-groups including subgroups of medial hernias. All SF-36 subscale-scores were equal to or better than the Swedish norm. A postoperative complication was a risk factor for chronic pain (OR 2.44, 95% CI 1.23-5.25, P < 0.023).

    CONCLUSIONS: The TEP procedure for primary inguinal hernia repair in men is associated with a low frequency of chronic pain and recurrent operations, with no difference between permanent fixation and no/nonpermanent fixation of mesh in a nationwide population-based study. TEP without fixation reduces costs and is safe for all patients.

  • 217.
    Haapamäki, Markku M
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lindström, Monica
    Sandzén, Birger
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Low-volume bowel preparation is inferior to standard 4 l polyethylene glycol2010In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 3, p. 897-901Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Four liters or more of orally taken polyethylene glycol solution (PEG) has proved to be an effective large-bowel cleansing method prior to colonoscopy. The problem has been the large volume of fluid and its taste, which is unacceptable to some examinees. We aimed to investigate the effectiveness of 2 l PEG combined with senna compared with 4 l PEG for bowel preparation.

    METHODS: The design was a single-center, prospective, randomized, investigator-blinded study with parallel assignment, in the setting of the Endoscopy Unit of Umeå University Hospital. Outpatients (n = 490) scheduled for colonoscopy were enrolled. The standard-volume arm received 4 l PEG, and the low-volume arm received 36 mg senna glycosides in tablets and 2 l PEG. The cleansing result (primary endpoint) was assessed by the endoscopist using the Ottawa score. The patients rated the subjective grade of ease of taking the bowel preparation. Analysis was on an intention-to-treat basis.

    RESULTS: There were significantly more cases with poor or inadequate bowel cleansing after the low-volume alternative with senna and 2 l PEG (22/203) compared with after 4 l PEG (8/196, p = 0.027). The low-volume alternative was better tolerated by the examinees: 119/231 rated the treatment as easy to take compared with 88/238 in the 4 l PEG arm (p = 0.001).

    CONCLUSIONS: 4 l PEG treatment is better than 36 mg senna and 2 l PEG as routine colonic cleansing before colonoscopy because of fewer failures.

  • 218.
    Haapamäki, Markku M
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Pihlgren, Victoria
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lundberg, Owe
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandzén, Birger
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Physical performance and quality of life after extended abdominoperineal excision of rectum and reconstruction of the pelvic floor with gluteus maximus flap2011In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 54, no 1, p. 101-106Article in journal (Refereed)
    Abstract [en]

    The oncological outcome of the operation was acceptable, but functional drawbacks must be considered preoperatively in counseling the patient. More research is needed to find ways to preserve better function and well-being.

  • 219.
    Haapamäki, Markku
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandzén, Birger
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Öman, Mikael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Open cholecystectomy in the laparoscopic era:  Comment on (Br J Surg 2007; 94(11): 1382-1385)2008In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 4, p. 531-Article in journal (Refereed)
  • 220.
    Haapaniemi, S
    et al.
    Department of Surgery, Vrinnevi Hospital, Norrkoping, Sweden.
    Gunnarsson, Ulf
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Nordin, P
    Nilsson, E
    Reoperation after recurrent groin hernia repair.2001In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 234, no 1, p. 122-6Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To analyze reoperation rates for recurrent and primary groin hernia repair documented in the Swedish Hernia Register from 1996 to 1998, and to study variables associated with increased or decreased relative risks for reoperation after recurrent hernia.

    METHODS: Data were retrieved for all groin hernia repairs prospectively recorded in the Swedish Hernia register from 1996 to 1998. Actuarial analysis adjusted for patients' death was used for calculating the cumulative incidence of reoperation. Relative risk for reoperation was estimated using the Cox proportional hazards model.

    RESULTS: From 1996 to 1998, 17,985 groin hernia operations were recorded in the Swedish Hernia Register, 15% for recurrent hernia and 85% for primary hernia. At 24 months the risk for having had a reoperation was 4.6% after recurrent hernia repair and 1.7% after primary hernia repair. The relative risk for reoperation was significantly lower for laparoscopic methods and for anterior tension-free repair than for other techniques. Postoperative complications and direct hernia were associated with an increased relative risk for reoperation. Day-case surgery and local infiltration anesthesia were used less frequently for recurrent hernia than for primary hernia.

    CONCLUSIONS: Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community. This study supports the use of mesh by laparoscopy or anterior tension-free repair for recurrent hernia operations.

  • 221.
    Hallman, Mats
    et al.
    Umeå University, Faculty of Medicine, Department of Odontology, Oral and Maxillofacial Surgery. Department of Oral and Maxillofacial Surgery, Public Health Service, Gävle, Sweden; Center for Research and Development, Uppsala University/Gävleborg County Council, Gävleborg, Sweden.
    Mordenfeld, Arne
    Strandkvist, Tomas
    Bone replacement following dental trauma prior to implant surgery: present status2009In: Dental Traumatology, ISSN 1600-4469, E-ISSN 1600-9657, Vol. 25, no 1, p. 2-11Article, review/survey (Refereed)
    Abstract [en]

    Dento-alveolar trauma often leads to a need for reconstruction of the alveolar crest before an implant can be placed. Although autogenous bone grafts is considered the 'gold standard', this may be associated with patient morbidity and graft resorption. Consequently, the use of bone substitutes has increased. Today, a substantial number of biomaterials are available on the market, but only a few are well documented. The user should be aware that these biomaterials have different properties: resorbable or non-resorbable, time of resorption and resorption mechanism. The purpose of this review is to describe the function of various bone substitutes and indications for their use in reconstructive implant surgery and to give an overview of the current situation.

  • 222. Hallén, M
    et al.
    Sevonius, D
    Westerdahl, J
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandblom, G
    Risk factors for reoperation due to chronic groin postherniorrhaphy pain2015In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 19, no 6, p. 863-869Article in journal (Refereed)
    Abstract [en]

    Chronic groin postherniorrhaphy pain (CGPP) is common and sometimes so severe that surgical treatment is necessary. The aim of this study was to identify risk factors for being reoperated due to CGPP. All 195,707 repairs registered in the Swedish Hernia Register between 1999 and 2011 were included in the study. Out of these, 28,947 repairs were excluded since they were registered as procedures on the same patient after a previous repair. Age, gender, hernia anatomy (indirect reference), method of repair (anterior sutured repair reference) and postoperative complications were included in a multivariate Cox analysis with reoperation due to CGPP as endpoint. Of the patients included in the study cohort, 218 (0.13 %) later underwent reoperation due to CGPP, including 31 (14 %) women. Median age at the primary repair was 61.5 years. Risk factors for being reoperated were age < median [hazard ratio (HR) 3.03, 95 % confidence interval (CI) 2.22-4.12], female gender (HR 2.13, CI 1.41-3.21), direct hernia (HR 1.35, CI 1.003-1.81), other hernia (HR 6.03, CI 3.08-11.79), Lichtenstein repair (HR 2.22, CI 1.16-4.25), plug repair (HR 3.93, CI 1.96-7.89), other repair (HR 2.58, CI 1.08-6.19), bilateral repair (HR 2.58, CI 1.43-4.66) and postoperative complication (HR 4.40, CI 3.25-5.96). Risk factors for being reoperated due to CGPP in this cohort included low age, female gender, a direct hernia, a previous Lichtenstein or plug repair, bilateral repair and postoperative complications. Further research on how to avoid CGPP and explore the effectiveness of surgery for CGPP is necessary.

  • 223.
    Hallén, Magnus
    et al.
    Department of Surgery, Clinical Sciences, Lund University and Lund University Hospital, Lund, Sweden.
    Sandblom, Gabriel
    CLINTEC, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Nordin, Pär
    Department of Surgery, Östersund Hospital.
    Gunnarsson, Ulf
    CLINTEC, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Kvist, Ulrik
    Center for Andrology and Sexual Medicine, Department of Medicine, Karolinska Institute, Stockholm, Sweden.
    Westerdahl, Johan
    Department of Surgery, Clinical Sciences, Lund University and Lund University Hospital, Lund, Sweden.
    Male infertility after mesh hernia repair: a prospective study2011In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 149, no 2, p. 179-184Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Several animal studies have raised concern about the risk for obstructive azoospermia owing to vasal fibrosis caused by the use of alloplastic mesh prosthesis in inguinal hernia repair. The aim of this study was to determine the prevalence of male infertility after bilateral mesh repair.

    METHODS: In a prospective study, a questionnaire inquiring about involuntary childlessness, investigation for infertility and number of children was sent by mail to a group of 376 men aged 18-55 years, who had undergone bilateral mesh repair, identified in the Swedish Hernia Register (SHR). Questionnaires were also sent to 2 control groups, 1 consisting of 186 men from the SHR who had undergone bilateral repair without mesh, and 1 consisting of 383 men identified in the general population. The control group from the SHR was matched 2:1 for age and years elapsed since operation. The control group from the general population was matched 1:1 for age and marital status.

    RESULTS: The overall response rate was 525 of 945 (56%). Method of approach (anterior or posterior), type of mesh, and testicular status at the time of the repair had no significant impact on the answers to the questions. Nor did subgroup analysis of the men </=40 years old reveal any significant differences.

    CONCLUSION: The results of this prospective study in men do not support the hypothesis that bilateral inguinal hernia repair with alloplastic mesh prosthesis causes male infertility at a significantly greater rate than those operated without mesh.

  • 224. Hallén, Magnus
    et al.
    Sevonius, Dan
    Holmberg, Henrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Sandblom, Gabriel
    Low complication rate and an increasing incidence of surgical repair of primary indirect sliding inguinal hernia2016In: Langenbeck's archives of surgery (Print), ISSN 1435-2443, E-ISSN 1435-2451, Vol. 401, no 2, p. 215-222Article in journal (Refereed)
    Abstract [en]

    Purpose The purpose of the present study was to explore the risk for complications and reoperations following open repairs for sliding groin hernias.

    Method All primary indirect inguinal hernia repairs registered in the Swedish Hernia Register 1998–2011 were identified. Repeated and bilateral procedures were excluded. The epidemiology, the incidence of per- and postoperative complications, and the reoperation rate due to recurrences were analyzed.

    Results 100 240 non-repeated unilateral repairs were registered with sliding hernias in 13 132 (13.1 %) (male 14 %, female 5 %) procedures. The methods of repair for sliding and non-sliding hernias were Lichtenstein and other open anterior mesh repairs (N = 10865, 82.7 % and N = 60790, 69.8 %), endoscopic techniques (N = 136, 1.0 % and N= 4352, 5.0 %), and other techniques (N= 2131, 16.2 % and N= 21966, 25.2 %). In multivariate analyses with adjustment for gender, acute/planned surgery, reducibility, method of repair and age, sliding hernias were associated with a low but slightly increased risk for perioperative complications (hazard ratio 1.30, 95 % confidence interval 1.04–1.62, p = 0.023) and postoperative hematoma (hazard ratio 1.13, confidence interval 1.02–1.26, p =0.019). There was no increased risk of reoperation due to recurrences.

    Conclusion Compared to older reports, the incidence of repairs due to primary indirect sliding inguinal hernias has increased over time and it is not just a male disease. The overall results are good with low and comparable complication rates, and no increased risk of reoperations due to recurrences.

  • 225.
    Hallén, Magnus
    et al.
    Department of Surgery, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.
    Westerdahl, Johan
    Nordin, Pär
    Department of Surgery, Östersund Hospital.
    Gunnarsson, Ulf
    CLINTEC, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Sandblom, Gabriel
    CLINTEC, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Mesh hernia repair and male infertility: a retrospective register study2012In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 151, no 1, p. 94-98Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Previous studies have suggested that the use of mesh in groin hernia repair may be associated with an increased risk for male infertility as a result of inflammatory obliteration of structures in the spermatic cord. In a recent study, we could not find an increased incidence of involuntary childlessness. The aim of this study was to evaluate this issue further.

    METHODS: Men born between 1950 and 1989, with a hernia repair registered in the Swedish Hernia Register between 1992 and 2007 were cross-linked with all men in the same age group with the diagnosis of male infertility according to the Swedish National Patient Register. The cumulative and expected incidences of infertility were analyzed. Separate multivariate logistic analyses, adjusted for age and years elapsed since the first repair, were performed for men with unilateral and bilateral repair, respectively.

    RESULTS: Overall, 34,267 men were identified with a history of at least 1 inguinal hernia repair. A total of 233 (0.7%) of these had been given the diagnosis of male infertility after their first operation. We did not find any differences between expected and observed cumulative incidences of infertility in men operated with hernia repair. Men with bilateral hernia repair had a slightly increased risk for infertility when mesh was used on either side. However, the cumulative incidence was less than 1%.

    CONCLUSION: Inguinal hernia repair with mesh is not associated with an increased incidence of, or clinically important risk for, male infertility.

  • 226.
    Hamberg, Katarina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Naredi, Peter
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Genusperspektiv i kirurgi2010In: Kirurgi / [ed] Bengt Jeppsson, Peter Naredi, Jörgen Nordenström, Bo Risberg, Studentlitteratur , 2010, p. 195-210Chapter in book (Other academic)
  • 227.
    Hansson, L-E
    et al.
    Department of Surgery at Sahlgrenska University Hospital, Gothenburg, Sweden.
    Laurell, H
    Department of Surgery, Mora Hospital, Mora.
    Gunnarsson, Ulf
    Department of Surgery, Uppsala University Hospital, Uppsala, Sweden .
    Impact of time in the development of acute appendicitis.2008In: Digestive Surgery, ISSN 0253-4886, E-ISSN 1421-9883, Vol. 25, no 5, p. 394-9Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to elucidate the natural history of appendicitis.

    METHODS: Data was collected prospectively from consecutive patients admitted to hospital for acute abdominal pain. The degree of appendiceal inflammation in relation to preoperative duration of pain was analysed.

    RESULTS: The study comprised 253 patients operated on for acute appendicitis that could recall the onset of abdominal pain. There was a longer duration of pre-hospital pain in patients, irrespective of age, with perforated appendicitis compared to patients with phlegmonous or gangrenous appendicitis (p < 0.001). In the multivariate analysis, patient age and preoperative duration of pain were independent risk factors for perforation.

    CONCLUSION: Patient delay in presentation is the predominant factor determining the incidence of complicated appendicitis, and this delay is not influenced by age or gender.

  • 228. Haraldsson, E
    et al.
    Lundell, L
    Swahn, F
    Enochsson, Lars
    Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
    Löhr, J M
    Arnelo, U
    Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study.2017In: United European Gastroenterology journal, ISSN 2050-6406, E-ISSN 2050-6414, Vol. 5, no 4, p. 504-510Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Many endoscopists acknowledge that the appearance of the papilla of Vater seems to affect biliary cannulation. To assess the association between the macroscopic appearance of the papilla and biliary cannulation and other related clinical issues, a system is needed to define the appearance of the papilla.

    OBJECTIVE: The purpose of this study was to validate an endoscopic classification of the papilla of Vater by assessing the interobserver and intraobserver agreements among endoscopist with varying experience.

    METHODS: An endoscopic classification, based on pictures captured from 140 different papillae, containing four types of papillae was proposed. The four types are (a) Type 1: regular papilla, no distinctive features, 'classic appearance'; (b) Type 2: small papilla, often flat, with a diameter ≤ 3 mm (approximately 9 Fr); (c) Type 3: protruding or pendulous papilla, a papilla that is standing out, protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous with the orifice oriented caudally; and (d) Type 4: creased or ridged papilla, where the ductal mucosa seems to extend distally, rather out of the papillary orifice, either on a ridge or in a crease. To assess the level of interobserver agreement, a web-based survey was sent out to 18 endoscopists, containing 50 sets of still images of the papilla, distributed between the four different types. Three months later a follow-up survey, with images from the first survey was sent to the same endoscopists.

    RESULTS: Interobserver agreement was substantial (κ = 0.62, 95% confidence interval (CI) 0.58-0.65) and were similar for both experts and non-experts. The intraobserver agreement assessed with the second survey was also substantial (κ = 0.66, 95% CI 0.59-0.72).

    CONCLUSION: The proposed endoscopic classification of the papilla of Vater seems to be easy to use, irrespective of the level of experience of the endoscopist. It carries a substantial inter- and intraobserver agreement and now the clinical relevance of the four different papilla types awaits to be determined.

  • 229. Haraldsson, Erik
    et al.
    Swahn, Fredrik
    Verbeke, Caroline
    Mattsson, Johanna S M
    Enochsson, Lars
    Ung, Kjell-Arne
    Lundell, Lars
    Heuchel, Rainer
    Löhr, J-Matthias
    Arnelo, Urban
    Endoscopic papillectomy and KRAS expression in the treatment of adenoma in the major duodenal papilla.2015In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 50, no 11, p. 1419-1427Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The use of endoscopic papillectomy for resecting adenomas in the major duodenal papilla is increasing. This study focuses on the following three issues: Can endoscopic papillectomy be performed as a safe diagnostic and/or therapeutic procedure in biopsy-verified or suspected ampullary adenoma? Does expression of mutated KRAS in resected adenomatous tissue predict long-term outcome? What other factors may affect long-term outcome and should, therefore, be considered in decision making prior to endoscopic papillectomy?

    MATERIAL AND METHODS: Thirty-six prospectively collected patients who underwent endoscopic papillectomy at Karolinska University Hospital between 2005 and 2014 were analyzed.

    RESULTS: The rate of exact agreement between the histomorphological grading of the endoscopic biopsies and the papillectomy specimens was low (48%). Obstructive jaundice at presentation increased the risk of undetected adenocarcinoma (RR = 3.98; 95% CI = 1.46-10.85, p = 0.007). Lesions with malignancies were significantly larger (mean 30.6 mm) than those where only adenomas were found (mean 14.4 mm, p = 0.001). Mutated KRAS was detected in 9 of the 36 post-papillectomy specimens, including 4 of the 5 cases of ampullary adenocarcinoma. Eighteen cases were endoscopically cured after a mean follow-up period of 47 months (range 16-92 months).

    CONCLUSIONS: Endoscopic papillectomy is a valuable staging tool because of the limitations of endoscopic biopsy. Endoscopic papillectomy concomitantly offers a curative treatment for most patients with adenoma in the major duodenal papilla. Jaundice at presentation and large adenomas may indicate the presence of more advanced disease. Determination of mutated KRAS seems to be of limited value in predicting long-term outcome.

  • 230.
    Hariz, Marwan I
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurosurgery.
    Krack, P
    Alesch, F
    Augustinsson, L-E
    Bosch, A
    Ekberg, R
    Johansson, F
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurology.
    Johnels, B
    Meyerson, B A
    N'Guyen, J-P
    Pinter, M
    Pollak, P
    von Raison, F
    Rehncrona, S
    Speelman, J D
    Sydow, O
    Benabid, A-L
    Multicentre European study of thalamic stimulation for parkinsonian tremor: a 6 year follow-up2008In: Journal of neurology, neurosurgery and psychiatry, ISSN 1468-330X, Vol. 79, no 6, p. 694-699Article in journal (Refereed)
    Abstract [en]

    AIM: To evaluate the results of ventral intermediate (Vim) thalamic deep brain stimulation (DBS) in patients with tremor predominant Parkinson's disease (PD) at 6 years post surgery.

    METHODS: This was a prolonged follow-up study of 38 patients from eight centres who participated in a multicentre study, the 1 year results of which have been published previously. Total scores as well as scores for individual items of the motor part and the disability part of the Unified Parkinson's Disease Rating Scale were used for evaluation.

    RESULTS: Tremor was still effectively controlled by DBS and appendicular rigidity and akinesia remained stable compared with baseline. Axial scores (speech, gait and postural instability), however, worsened, and in parallel the initial improvement in activities of daily living scores at the 1 year follow-up had disappeared at 6 years, despite sustained improvement of tremor. Remarkably, neither daily doses of dopaminergic medication nor fluctuations and dyskinesias had changed at 6 years compared with baseline in this particular patient group.

    CONCLUSION: This study confirms that patients with tremor dominant PD who do not present with fluctuations and dyskinesias may have a relatively benign progression of the disease. Vim DBS, although having no effect on akinesia and rigidity, is a relatively lenient surgical procedure and may still have a place for long term symptomatic control of PD tremor in selected patients.

  • 231.
    Hart, Andrew McKay
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    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 Centre, Royal Free and University College Medical School, London, UK.
    Exogenous leukaemia inhibitory factor enhances nerve regeneration after late secondary repair using a bioartificial nerve conduit2003In: British Journal of Plastic Surgery, ISSN 0007-1226, E-ISSN 1465-3087, Vol. 56, no 5, p. 444-450Article in journal (Refereed)
    Abstract [en]

    The clinical outcome of peripheral nerve injuries remains disappointing, even in the ideal situation of a primary repair performed with optimal microsurgical techniques. Primary repair is appropriate for only about 85% of injuries, and outcome is worse following secondarynerverepair, partly owing to the reduced regenerative potential of chronically axotomised neurons. Leukaemiainhibitoryfactor (LIF) is a gp-130 neurocytokine that is thought to act as an ‘injury factor’, triggering the early-injury phenotype within neurons and potentially boosting their regenerative potential aftersecondarynerverepair. At 2–4 months after sciatic nerve axotomy in the rat, 1 cm gaps were repaired using either nerve isografts or poly-3-hydroxybutyrate conduits containing a calcium alginate and fibronectin hydrogel.

    Regeneration was determined by quantitative immunohistochemistry 6 weeks afterrepair, and the effect of incorporating recombinant LIF (100 ng/ml) into the conduits was assessed. LIF increased the regeneration distance in repairs performed after both 2 months (69%, P=0.019) and 4 months (123%, P=0.021), and was statistically comparable to nerve graft. The total area of axonal immunostaining increased by 21% (P>0.05) and 63% (P>0.05), respectively. Percentage immunostaining area was not increased in the 2 months group, but increased by 93% in the repairs performed 4 months after axotomy. Exogenous LIF, therefore, has a potential role in promoting peripheral nerveregenerationaftersecondaryrepair, and can be effectively delivered within poly-3-hydroxybutyrate bioartificialconduits used for nerverepair.

  • 232.
    Hedberg, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stroke during cardiac surgery: risk factors, mechanisms and survival effects2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Introduction: Neurological complications and stroke in association with cardiac surgery is a serious problem. The stroke event can occur during surgery (early stroke) or in the postoperative period with a symptom free interval (delayed stroke). Particle embolization due to aortic manipulation during surgery has been suspected as a mechanism for early stroke. The present thesis address mechanisms and survival effects of stroke both clinically (I-III) and experimentally (IV-V).

    Methods: Study I) Within a cohort of 2641 consecutive cases, a group of cardiac surgery patients with stroke and evaluated by computed tomography (CT) were studied (n=77). CT-findings were analyzed in relation to stroke symptoms. Study II) Data from 9122 patients undergoing coronary surgery were analyzed. Records of patients with any signs of neurological complications were reviewed to extract 149 subjects with stroke at extubation (early, 1.6%) versus 99 patients having a free interval (delayed, 1.1%). Early and delayed stroke were evaluated separately. Independent risk factors for stroke were analyzed by logistic regression and survival by Cox regression (9.3 years median follow-up). Study III) Patients with early (n=223) and delayed stroke (n=116) were identified among 10809 patients undergoing cardiac and aortic surgery, both groups exposed to cardiopulmonary bypass. Stroke patients were subdivided by the hemispheric location of lesions. Subgroups were compared and their associated pre- and peroperative variables and survival were analyzed. Study IV) Aortic cross-clamp manipulation was studied in a human cadaveric perfusion model. The pressurized aorta was repeatedly cross-clamped and washout samples were collected before and after clamp maneuvers. Particles in the washout samples were evaluated by microscopy and by digital image analysis. Study V) Pig aortas were pressurized and cannulated. Washout samples were collected before and after cannulation (n = 40). Particles were deposited onto a 10-μm filter to be evaluated by microscopy and digital image analysis.

    Results: Study I) In the group of patients exposed to routine cardiac surgery (i.e., clamping and cannulation) and with early stroke, right-hemispheric lesions were more frequent than of the contra-lateral side (P=0.005). Patients with aortic dissections had a strong dominance of bilateral findings, which was different from the unilateral pattern in the routine-surgery group (P<0.001). Study II) Early and delayed stroke did not share any risk factors. Both early and delayed stroke explained mortality in the early postoperative period (P<0.001, P<0.001 respectively) but also at long term follow-up (P=0.008, P<0.001 respectively). For patients surviving their first postoperative year, delayed but not early stroke influenced long-term mortality (P=0.001 and P=0.695, respectively). Study III) Stroke lesions in association to cardiac surgery were near exclusively ischemic. Early stroke had a preponderance for right-hemispheric lesions (P=0.009). In contrast, patients with early stroke that had undergone surgery of the aorta with circulatory arrest showed a pattern with more bilateral lesions compared to ‘cardiac-type’ operations (P<0.001). Patients with bilateral lesions had a dramatically impaired survival compared to those with unilateral lesions (P<0.001). Study IV) In the cadaveric perfusion model, cross-clamping produced a significant output of particles, which was seen for size intervals of 1 mm and smaller (P=0.002 to P=0.022). In all size intervals the particle output correlated with the degree of overall aortic calcification (P =0.002 to P=0.025). Study V) At cannulation of the pig aorta, more particles were noted after cannulation compared to before the maneuver (P<0.001). This increase included small (<0.1 mm, P<0.001) and intermediate-size particles (0.1-0.5 mm, P< 0.001). Particles above 0.5 mm were few and were not associated with cannulation.

    Conclusions: The influence of stroke on mortality was devastating, for both early and delayed stroke. These two stroke groups had obvious differences in both their risk factors and their hemispheric distribution. It is here emphasized that early and delayed stroke should be considered as two separate entities with suggested mechanistic differences. Ischemic lesions accounted for near all stroke events seen in association to cardiac surgery. For early stroke, these were mostly located within the right hemisphere. Results from the experimental studies underscore microembolic risks associated with aortic manipulation.

  • 233.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Boivie, Patrik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Early and delayed stroke after coronary surgery: an analysis of risk factors and the impact on short- and long-term survival2011In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 40, no 2, p. 379-387Article in journal (Refereed)
    Abstract [en]

    Objective: Stroke is a serious complication to cardiac surgery, and is generally considered as a uniform disease regardless of its temporal relationship to surgery. Our hypothesis suggests that stroke, in association with surgery, reflects other characteristics than stroke occurring with a free interval. This issue was here explored for risk factors and survival effects.

    Methods: Data were collected from 7839 procedures of isolated coronary artery bypass grafting (CABG), 297 off-pump CABG, and 986 combined CABG and valve procedures. Records of patients with any signs of neurological complications were reviewed to extract 149 subjects with stroke at extubation (early, 1.6%) versus 99 patients having a free interval (delayed, 1.1%). Survival data were complete, with a median follow-up time of 9.3 years (maximum 16.3 years). Independent risk factors were analyzed by logistic regression and survival by Cox regression.

    Results: Risk factors for early stroke were advanced age, high preoperative creatinine level, extent of aortic atherosclerosis, and long cardiopulmonary bypass time (all P<0.001). Factors associated with delayed stroke were female gender (P<0.001), unstable angina (P=0.003), previous cerebrovascular disease (P=0.009), inotropic support requirement (P<0.001), and postoperative atrial fibrillation (P<0.001). Stroke explained mortality not only in the early postoperative period (P<0.001), but also at long-term follow-up (P<0.001). Early and delayed stroke were associated with mortality hazard ratios (HRs) of 1.44 and 1.85 (P=0.008, P<0.001), respectively. However, for patients surviving their first postoperative year, early stroke did not influence long-term mortality (HR 1.07, P=0.695). This was in contrast to delayed stroke (HR 1.71, P=0.001).

    Conclusions: Early and delayed stroke differed in their related risk factors. The influence of stroke on short-term mortality was obvious and devastating. Mortality in association with early stroke mainly presented itself in the acute period, whereas for delayed stroke survival continued to be impaired also in the long-term perspective. Our report emphasizes that early and delayed stroke should be considered as two separate entities.

  • 234.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Boivie, Patrik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Early and delayed stroke after coronary surgery: an analysis of risk factors and the impact on short and long-term survivalManuscript (preprint) (Other academic)
  • 235.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Hemispheric distribution of stroke after cardiac surgery: patient characteristics and survival impactManuscript (preprint) (Other academic)
  • 236.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Funck, Bertil
    Swedish National Food Administration, Food Control Department, Meat Inspection Division, Luleå, Sweden.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cannulation of the noncalcified aorta generates particles of microembolic nature: an experimental study using pig aorta2008In: Journal of cardiac surgery, ISSN 0886-0440, E-ISSN 1540-8191, Vol. 23, no 1, p. 39-43Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND AIM OF THE STUDY: Aortic cannulation during cardiac surgery is a potential etiological factor for perioperative stroke. Cannulae may dislodge aortic-wall calcifications. In addition, the sharp edge of the cannula-tip may shear off vessel-wall tissue, which can be expelled into the lumen. This hypothesis concerning source of emboli was tested in a noncalcified aortic perfusion model.

    METHODS: Pig aortas were pressurized and cannulated. Washout samples were collected before and after cannulation (n = 40). Particles were deposited onto a 10-microm filter and evaluated by microscopy and digital image analysis.

    RESULTS: A higher incidence of particles generated by cannulation was noted as compared to before the maneuver (p < 0.001). This increase included small (<0.1 mm, p < 0.001) and intermediate-size particles (0.1-0.5 mm, p < 0.001). Particles above 0.5 mm were few and were not associated with cannulation.

    CONCLUSIONS: Cannulation was a source of embolic material in the noncalcified aortic model. However, these particles were less than 0.5 mm in diameter and may contribute to neurocognitive decline after cardiac surgery.

  • 237.
    Hedström, Erik M
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Svensson, Olle
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Bergström, Ulrica
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Michno, Piotr
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Epidemiology of fractures in children and adolescents: Increased incidence over the past decade: a population-based study from northrn Sweden2010In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 81, no 1, p. 148-153Article in journal (Refereed)
    Abstract [en]

    Background and purpose Fractures are most common in youth and in the elderly, with differences in incidence over time and between regions. We present the fracture pattern in a population of youths <= 19 years of age, who were seen at Umeå University Hospital, Sweden. Material and methods All injuries seen at the hospital have been recorded in a database since 1993. The data include variables such as age, sex, date, type of injury, mechanism of injury, and treatment. For the period 1993-2007, there were 10,203 injury events that had resulted in at least 1 fracture. Results The incidence for the whole period was 201/10<sup>4</sup> person years. The incidence increased by 13% during the period 1998-2007, when we were able to control for registration errors. The most common fracture site was the distal forearm. The most common type of injury mechanism was falling. The peak incidence occurred at 11-12 years in girls and at 13-14 years in boys, with a male-to-female incidence ratio of 1.5. We found variations in mechanisms and activities at injury with age, and over time. Interpretation Fractures are caused by a combination of intrinsic and extrinsic factors that vary with age. We believe the increase in incidence is partly explained by changes in children's activity patterns over time. Further research may help to identify preventive measures to reduce the number of fractures, in particular those involving hospital care, surgical treatment, and-most importantly-long-term impairment.

  • 238. Hellspong, Gustaf
    et al.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Dahlstrand, Ursula
    Sandblom, Gabriel
    Diabetes as a risk factor in patients undergoing groin hernia surgery2017In: Langenbeck's archives of surgery (Print), ISSN 1435-2443, E-ISSN 1435-2451, Vol. 402, no 2, p. 219-225Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Diabetes is a known risk factor for early postoperative complications. Even so, the incidence of acute postoperative complications following routine hernia surgery is seldom described, and the risk for reoperation for recurrence has hardly been studied. Our aim was to explore if diabetes is a significant risk factor for complications after inguinal hernia surgery.

    METHODS: All inguinal hernia repairs registered in the Swedish Hernia Register between 2002 and 2011 were identified. Information on comorbidity and postoperative complications was obtained through cross-referencing with the National Patient Register at the National Board of Health and Welfare. Complicated diabetes was defined as diabetes with secondary manifestations (corresponding to aDCSI >0). The hazards for postoperative complications and reoperation for recurrence after the index hernia operation were calculated.

    RESULTS: Altogether 162,713 inguinal hernia repairs on 143,041 patients were registered. Of these, the number of patients with diabetes was 4816 (3.4 %), including 1123 (0.8 %) patients with complicated diabetes (aDCSI > 0). A significantly increased risk for postoperative complications was observed up to 30 days after hernia surgery when adjusted for gender, age, BMI, history of liver disease, kidney disease or HIV/AIDS, type of hernia and surgical method (odds ratio 1.35, 95 % confidence interval 1.14-1.60). No significantly increased risk for reoperation up until December 31, 2011, was observed in either patient group.

    CONCLUSION: Diabetes seems to increase the risk for postoperative complications within 30 days of inguinal hernia surgery, especially for complicated diabetes. Diabetes does not seem to increase the long-term risk for reoperation for recurrence.

  • 239.
    Hellström, Martin
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Hellström, Sten
    Department of Audiology and Neurotology, Karolinska University Hospital, Stockholm, Sweden.
    Engström-Laurent, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Bertheim, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    The structure of the basement membrane zone differs between keloids, hypertrophic scars and normal skin: A possible background to an impaired function2014In: Journal of Plastic, Reconstructive & Aesthetic Surgery, ISSN 1748-6815, E-ISSN 1532-1959, Vol. 67, no 11, p. 1564-1572Article in journal (Refereed)
    Abstract [en]

    Scar tissues were collected from patients with keloids, hypertrophic scars and mature scars. Normal skin was obtained from healthy individuals. Clinical attributes were used to select which tissue to obtain but the distribution of the specific hyaluronan (HA) staining was then used for the definite classification of the various scar types. Light microscopic and ultrastructural analyses were performed with an HA-binding probe, antibodies for collagen I and III and staining for mast cells. Ultrastructural studies of keloids revealed an altered collagen structure in the dermal layers, with an abundance of collagen fibres of similar diameter in both the reticular dermis (RD) and the papillary dermis (PD) compared to normal skin. Furthermore, the keloids displayed epidermal changes, which involved the basement membrane (BM), with fewer hemidesmosomes and an altered shape of desmosomes in the entire enlarged spinous layer. The frequency of mast cells found in keloids was lower than in other scar tissues and normal skin. These alterations in epidermis could influence the hydrodynamic and cell regulatory properties of the wounded skin with impaired function and insufficient regulative capacity to hinder the ever-growing collagen tissue that is characteristic for keloids. (C) 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

  • 240. Hemberg, A
    et al.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Holmberg, H
    Tobacco use as a risk factor for groin hernia repair2015In: lSI World Conference on Abdominal Wall Hernia Surgery, april 25, 2015., 2015, Vol. 19, p. S278-S278Conference paper (Refereed)
    Abstract [en]

    The pathogenesis and etiology of groin hernias are not fully understood. Some risk factors are unknown and some are debated. Tobacco has been speculated as a possible risk factor for groin hernias. Some studies have not showed any connection, whereas other has showed that smokers have primary hernias at a younger age and that recurrences of hernias are more common among smokers. There have also been several studies showing a connection between smoking and changes in collagen metabolism. Present study evaluates the connection between groin hernia repair and tobacco use.

  • 241.
    Hemmingsson, Oskar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    ASNA1 and cisplatin resistance: studies in C. elegans and in human tumor cells2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Platinum based chemotherapy is widely used to treat cancer. Cisplatin (diamminedichloroplatinum) combination treatments provide cure for metastatic testicular cancer and prolong survival for patients suffering from ovarian, head and neck, bladder and non small cell lung cancer. Tumors that initially respond to treatment may eventually acquire resistance, resulting in treatment failure. Cisplatin resistant cells are crossresistant to arsenite and antimonite and these metalloids are exported from bacteria by the ars-operon.

    In this thesis, we describe the human ArsA homolog, ASNA1, as a protein involved in a novel resistance mechanism to cisplatin, arsenite and antimonite. ASNA1 was downregulated by antisense and siRNA techniques in human melanoma and ovarian carcinoma cell lines. These cells displayed increased sensitivity to arsenite and the platinum based drugs cisplatin, carboplatin and oxaliplatin. In both melanoma and ovarian carcinoma, cisplatin resistant cells overexpressed ASNA1.

    Blockage of ASNA1 resulted in increased apoptosis and retarded growth, complicating further characterization of ASNA1 in human cell lines. ASNA1 also promotes insulin signaling and mediates membrane insertion of tail-anchored proteins. To explore different aspects of ASNA1 function with respect to cisplatin resistance, we used the model organism C. elegans.

    In the nematode C. elegans, asna-1 (rnai) treated larvae were hypersensitive to cisplatin, arsenite and antimonite. Adult asna-1 mutant worms were cisplatin sensitive and this hypersensitivity was seen even when apoptosis was blocked. Expression of human ASNA1 rescued the cisplatin hypersensitivity in asna-1 mutants, showing conservation of function. Transgene expression of mutated forms of asna-1 separated the cisplatin hypersensitivity phenotype from the insulin signaling phenotype of asna-1 mutants. Three ASNA-1 residues, His164, Cys285 and Cys288 were identified as essential for ASNA-1 promoted cisplatin resistance but not for insulin signaling. Finally, studies of the C. elegans germline revealed increased numbers of apoptotic cells in asna-1 mutants.

    In conclusion, C. elegans is a suitable model organism to identify and characterize cisplatin response mechanisms. A targeted therapy against ASNA1 could sensitize cisplatin resistant cells and improve outcome for cancer patients.

  • 242.
    Hemmingsson, Oskar
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Zhang, Youyi
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Still, Maria
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Naredi, Peter
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    ASNA1, an ATPase targeting tail-anchored proteins, regulates melanoma cell growth and sensitivity to cisplatin and arsenite2009In: Cancer Chemotherapy and Pharmacology, ISSN 0344-5704, E-ISSN 1432-0843, Vol. 63, no 3, p. 491-499Article in journal (Refereed)
    Abstract [en]

    Purpose ASNA1 is homologous to E. coli ArsA, a well characterized ATPase involved in efflux of arsenite and antimonite. Cells resistant to arsenite and antimonite are cross-resistant to the chemotherapeutic drug cisplatin. ASNA1 is also an essential ATPase for the insertion of tail-anchored proteins into ER membranes and a novel regulator of insulin secretion. The aim of this study was to determine if altered ASNA1 levels influenced growth and sensitivity to arsenite and cisplatin in human melanoma cells.

    Methods Cultured melanoma T289 cells were transfected with plasmids containing sense or antisense ASNA1. Cells were exposed to cisplatin, arsenite and zinc. Cell growth and chemosensitivity were evaluated by the MTT assay and apoptosis by a TUNEL assay.

    Results ASNA1 expression was necessary for growth. T289 clones with decreased ASNA1 expression exhibited 51 ± 5% longer doubling times than wildtype T289 (P = 0.0091). After exposure to cisplatin, ASNA1 downregulated cells displayed a significant increase in apoptosis. The cisplatin IC50 in ASNA1 underexpressing cells was 41.7 ± 1.8% compared to wildtype (P = 0.00097) and the arsenite IC50 was 59.9 ± 3.2% of wildtype IC50 (P = 0.0067).

    Conclusions Reduced ASNA1 expression is associated with significant inhibition of cell growth, increased apoptosis and increased sensitivity to cisplatin and arsenite.

  • 243.
    Henje, Catharina
    et al.
    Umeå universitet.
    Stenberg, Gunilla
    Umeå universitet.
    Carlsson, Anna
    Chalmers Tekniska Högskola.
    Lundälv, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Upplevda risker och problem i trafikmiljön för användare av elrullstol2019In: Sammanställning av referat från Transportforum 2019 / [ed] Camilla Ekström, Fredrik Hellman, Mattias Haraldsson, VTI (Statens väg- och transportforskningsinstitut) , 2019Conference paper (Other academic)
  • 244.
    Henriksson, Otto
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Protection against cold in prehospital trauma care2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Protection against cold is vitally important in prehospital trauma care to reduce heat loss and prevent body core cooling.

    Objectives: Evaluate the effect on cold stress and thermoregulation in volunteer subjects byutilising additional insulation on a spineboard (I). Determine thermal insulation properties of blankets and rescue bags in different wind conditions (II). Establish the utility of wet clothing removal or the addition of a vapour barrier by determining the effect on heat loss within different levels of insulation in cold and warm ambient temperatures (III) and evaluating the effect on cold stress and thermoregulation in volunteer subjects (IV).

    Methods: Aural canal temperature, sensation of shivering and cold discomfort was evaluated in volunteer subjects, immobilised on non-insulated (n=10) or insulated (n=9) spineboards in cold outdoor conditions (I). A thermal manikin was setup inside a climatic chamber and total resultant thermal insulation for the selected ensembles was determined in low, moderate and high wind conditions (II). Dry and wet heat loss and the effect of wet clothing removal or the addition of a vapour barrier was determined with the thermal manikin dressed in either dry, wet or no clothing; with or without a vapour barrier; and with three different levels of insulation in warm and cold ambient conditions (III). The effect on metabolic rate, oesophageal temperature, skin temperature, body heat storage, heart rate, and cold discomfort by wet clothing removal or the addition of a vapour barrier was evaluated in volunteer subjects (n=8), wearing wet clothing in a cold climatic chamber during four different insulation protocols in a cross-over design (IV).

    Results: Additional insulation on a spine board rendered a significant reduction of estimated shivering but there was no significant difference in aural canal temperature or cold discomfort (I). In low wind conditions, thermal insulation correlated to thickness of the insulation ensemble. In greater air velocities, thermal insulation was better preserved for ensembles that were windproof and resistant to the compressive effect of the wind (II). Wet clothing removal or the use of a vapour barrier reduced total heat loss by about one fourth in the cold environment and about one third in the warm environment (III). In cold stressed wet subjects, with limited insulation applied, wet clothing removal or the addition of a vapour barrier significantly reduced metabolic rate, increased skin rewarming rate, and improved total body heat storage but there was no significant difference in heart rate or oesophageal temperature cooling rate (IV). Similar effects on heat loss and cold stress was also achieved by increasing the insulation. Cold discomfort was significantly reduced with the addition of a vapour barrier and with an increased insulation but not with wet clothing removal.

    Conclusions: Additional insulation on a spine board might aid in reducing cold stress inprolonged transportations in a cold environment. In extended on scene durations, the use of a windproof and compression resistant outer cover is crucial to maintain adequate thermal insulation. In a sustained cold environment in which sufficient insulation is not available, wet clothing removal or the use of a vapour barrier might be considerably important reducing heat loss and relieving cold stress.

  • 245.
    Henriksson, Otto
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lundgren, Peter
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Kuklane, Kalev
    Lunds universitet, Insitutionen för designvetenskaper.
    Holmér, Ingvar
    Lunds universitet, Insitutionen för designvetenskaper.
    Björnstig, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Protection against cold in prehospital care: thermal insulation properties of blankets and rescue bags in different wind conditions2009In: Prehospital and disaster medicine : the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation, ISSN 1049-023X, Vol. 24, no 5, p. 408-415Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: In a cold, wet, or windy environment, cold exposure can be considerable for an injured or ill person. The subsequent autonomous stress response initially will increase circulatory and respiratory demands, and as body core temperature declines, the patient's condition might deteriorate. Therefore, the application of adequate insulation to reduce cold exposure and prevent body core cooling is an important part of prehospital primary care, but recommendations for what should be used in the field mostly depend on tradition and experience, not on scientific evidence.

    OBJECTIVE: The objective of this study was to evaluate the thermal insulation properties in different wind conditions of 12 different blankets and rescue bags commonly used by prehospital rescue and ambulance services.

    METHODS: The thermal manikin and the selected insulation ensembles were setup inside a climatic chamber in accordance to the modified European Standard for assessing requirements of sleeping bags. Fans were adjusted to provide low (< 0.5 m/s), moderate (2-3 m/s) and high (8-9 m/s) wind conditions. During steady state thermal transfer, the total resultant insulation value, Itr (m2 C/Wclo; where C = degrees Celcius, and W = watts), was calculated from ambient air temperature (C), manikin surface temperature (C), and heat flux (W/m2).

    RESULTS: In the low wind condition, thermal insulation of the evaluated ensembles correlated to thickness of the ensembles, ranging from 2.0 to 6.0 clo (1 clo = 0.155 m2 C/W), except for the reflective metallic foil blankets that had higher values than expected. In moderate and high wind conditions, thermal insulation was best preserved for ensembles that were windproof and resistant to the compressive effect of the wind, with insulation reductions down to about 60-80% of the original insulation capacity, whereas wind permeable and/or lighter materials were reduced down to about 30-50% of original insulation capacity.

    CONCLUSIONS: The evaluated insulation ensembles might all be used for prehospital protection against cold, either as single blankets or in multiple layer combinations, depending on ambient temperatures. However, with extended outdoor, on-scene durations, such as during prolonged extrications or in multiple casualty situations, the results of this study emphasize the importance of using a windproof and compression resistant outer ensemble to maintain adequate insulation capacity.

  • 246.
    Henriksson, Otto
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lundgren, Peter
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Kuklane, Kalev
    Lunds universitet, Institutionen för designvetenskaper.
    Holmér, Ingvar
    Lunds universitet, Institutionen för designvetenskaper.
    Giesbrecht, Gordon
    University of Manitoba.
    Naredi, Peter
    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.
    Protection against cold - the effect on thermoregulation by wet clothing removal or addition of a vapour barrier in shivering subjectsManuscript (preprint) (Other academic)
  • 247.
    Henriksson, Otto
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lundgren, Peter
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Kuklane, Kalev
    Lunds universitet, Insitutionen för designvetenskaper.
    Holmér, Ingvar
    Lunds universitet, Insitutionen för designvetenskaper.
    Naredi, Peter
    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.
    Protection against cold in prehospital care: evaporative heat loss reduction by wet clothing removal or the addition of a vapour barrier - a thermal manikin study2012In: Prehospital and Disaster Medicine, ISSN 1049-023X, E-ISSN 1945-1938, Vol. 26, no 6, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Introduction: In the prehospital care of a cold and wet person, early application of adequate insulation is of utmost importance to reduce cold stress, limit body core cooling, and prevent deterioration of the patient’s condition. Most prehospital guidelines on protection against cold recommend the removal of wet clothing prior to insulation, and some also recommend the use of a waterproof vapor barrier to reduce evaporative heat loss. However, there is little scientific evidence of the effectiveness of these measures.

    Objective: Using a thermal manikin with wet clothing, this study was conducted to determine the effect of wet clothing removal or the addition of a vapor barrier on thermal insulation and evaporative heat loss using different amounts of insulation in both warm and cold ambient conditions.

    Methods: A thermal manikin dressed in wet clothing was set up in accordance with the European Standard for assessing requirements of sleeping bags, modified for wet heat loss determination, and the climatic chamber was set to -15 degrees Celsius (°C) for cold conditions and +10°C for warm conditions. Three different insulation ensembles, one, two or seven woollen blankets, were chosen to provide different levels of insulation. Five different test conditions were evaluated for all three levels of insulation ensembles: (1) dry underwear; (2) dry underwear with a vapor barrier; (3) wet underwear; (4) wet underwear with a vapor barrier; and (5) no underwear. Dry and wet heat loss and thermal resistance were determined from continuous monitoring of ambient air temperature, manikin surface temperature, heat flux and evaporative mass loss rate.

    Results: Independent of insulation thickness or ambient temperature, the removal of wet clothing or the addition of a vapor barrier resulted in a reduction in total heat loss of 19-42%. The absolute heat loss reduction was greater, however, and thus clinically more important in cold environments when little insulation is available. A similar reduction in total heat loss was also achieved by increasing the insulation from one to two blankets or from two to seven blankets.

    Conclusion: Wet clothing removal or the addition of a vapor barrier effectively reduced evaporative heat loss and might thus be of great importance in prehospital rescue scenarios in cold environments with limited insulation available, such as in mass-casualty situations or during protracted evacuations in harsh conditions.

  • 248.
    Hermansson, Cecilia
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Breast Cancer Liver Metastasis – Survival after Surgical Treatment2016Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 249. Hjortshoj, Cristel Sorensen
    et al.
    Jensen, Annette Schophuus
    Sorensen, Keld
    Nagy, Edit
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Kronvall, Thomas
    Dellborg, Mikael
    Estensen, Mette-Elise
    Holmstrom, Henrik
    Turanlahti, Maila
    Thilen, Ulf
    Sondergaard, Lars
    Epidemiological changes in Eisenmenger syndrome in the Nordic region in 1977-20122017In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 103, no 17, p. 1353-1358Article in journal (Refereed)
    Abstract [en]

    Objective: Improved diagnostic tools, timely closure of the shunt and a better understanding of the complexity of Eisenmenger syndrome (ES) have led to improved care and treatment in tertiary centres. These may have decreased the incidence of ES and improved survival of patients with ES, although evidence is still lacking. The aim of this study was to investigate temporal changes in incidence, prevalence and mortality in patients with ES for 35 years in the Nordic region.

    Methods: This was a retrospective population-based study including 714 patients with ES. Survival analysis was performed based on all-cause mortality and accounting for immortal time bias.

    Results: The incidence of ES decreased from 2.5/million inhabitants/year in 1977 to 0.2/million inhabitants/year in 2012. Correspondingly, prevalence decreased from 24.6 to 11.9/million inhabitants. The median survival was 38.4 years, with 20-year, 40-year and 60-year survival of 72.5%, 48.4%, and 21.3%, respectively. Complex lesions and Down syndrome were independently associated with worse survival (HR 2.2, p<0.001 and HR 1.8, p<0.001, respectively). Age at death increased from 27.7 years in the period from 1977 to 1992, to 46.3 years from July 2006 to 2012 (p<0.001).

    Conclusions: The incidence and prevalence of ES in the Nordic region have decreased markedly during the last decades. Furthermore, the median age at death increased throughout the study period, indicating prolonged life expectancy in the ES population. However, increasing age represents decreased incidence, rather than improved survival. Nonetheless, longevity with ES is still shorter than in the background population.

  • 250. Hodges, Gethin W.
    et al.
    Bang, Casper N.
    Eugen-Olsen, Jesper
    Olsen, Michael H.
    Boman, Kurt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Ray, Simon
    Kesäniemi, Antero Y.
    Jeppesen, Jørgen L.
    Wachtell, Kristian
    SuPAR predicts postoperative complications and mortality in patients with asymptomatic aortic stenosis2018In: Open heart, E-ISSN 2053-3624, Vol. 5, no 1, article id e000743Article in journal (Refereed)
    Abstract [en]

    Background We evaluated whether early measurement of soluble urokinase plasminogen activator receptor (suPAR) could predict future risk of postoperative complications in initially asymptomatic patients with mild-moderate aortic stenosis (AS) undergoing aortic valve replacement (AVR) surgery.

    Methods Baseline plasma suPAR levels were available in 411 patients who underwent AVR surgery during in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Cox analyses were used to evaluate suPAR in relation to all-cause mortality and the composite endpoint of postoperative complications (all-cause mortality, congestive heart failure, stroke and renal impairment) occurring in the 30-day postoperative period.

    Results Patients with initially higher levels of suPAR were at increased risk of postoperative mortality with a HR of 3.5 (95% CI 1.4 to 9.0, P=0.008) and postoperative complications with a HR of 2.7 (95% CI 1.5 to 5.1, P=0.002), per doubling in suPAR. After adjusting for the European System for Cardiac Operative Risk Evaluation or Society of Thoracic Surgeons risk score, suPAR remained associated with postoperative mortality with a HR 3.2 (95% CI 1.2 to 8.6, P=0.025) and 2.7 (95% CI 1.0 to 7.8, P=0.061); and postoperative complications with a HR of 2.5 (95% CI 1.3 to 5.0, P=0.007) and 2.4 (95% CI 1.2 to 4.8, P=0.011), respectively.

    Conclusion Higher baseline suPAR levels are associated with an increased risk for postoperative complications and mortality in patients with mild-moderate, asymptomatic AS undergoing later AVR surgery. Further validation in other subsets of AS individuals are warranted.

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