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  • 251.
    Israelsson, Leif A.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Surgery, Sundsvall Hospital.
    Millbourn, Daniel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Surgery, Sundsvall Hospital.
    Prevention of Incisional Hernias How to Close a Midline Incision2013In: Surgical Clinics of North America, ISSN 0039-6109, E-ISSN 1558-3171, Vol. 93, no 5, p. 1027-+Article in journal (Refereed)
    Abstract [en]

    The development of wound complications is closely related to the surgical technique at wound closure. The risk of the suture technique affecting the development of wound dehiscence and incisional hernia can be monitored through the suture length to wound length ratio. Mid line incisions should be closed in one layer by a continuous-suture technique using a monofilament suture material tied with self-locking knots. Excessive tension should not be placed on the suture. Closure must always be with a suture length to wound length ratio higher than 4.

  • 252.
    Israelsson, Leif A
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Smedberg, Sam
    Montgomery, Agneta
    Nordin, Pär
    Spangen, L
    Incisional hernia repair in Sweden 20022006In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 10, no 3, p. 258-261Article in journal (Refereed)
    Abstract [en]

    Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.

  • 253. Jaafar, Gona
    et al.
    Hammarqvist, Folke
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandblom, Gabriel
    Patient-Related Risk Factors for Postoperative Infection After Cholecystectomy2017In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 41, no 9, p. 2240-2244Article in journal (Refereed)
    Abstract [en]

    Background: The impact of patient-related risk factors on the incidence of postoperative infection after cholecystectomy is relatively unknown.

    Aim: The aim of this study was to explore potential patient-related risk factors for surgical site infection (SSI) and septicaemia following cholecystectomy.

    Materials and methods: All cholecystectomies registered in the Swedish national population-based register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2006–2014 were identified. The study cohort was cross-matched with the Swedish National Patient Register in order to obtain data on patient history and postoperative infections. Simple and multiple logistic regression analyses were performed in order to assess the impact of various comorbidities on the risk for SSI and septicaemia.

    Results: A total of 94,557 procedures were registered. A SSI was seen following 5300 procedures (5.6%), and septicaemia following 661 procedures (0.7%). There was a significantly increased risk for SSI in patients with connective tissue disease (odds ratio [OR] 1.404, 95% confidence interval [CI] 1.208–1.633), complicated diabetes (OR 1.435, CI 1.205–1.708), uncomplicated diabetes (OR 1.391, CI 1.264–1.530), chronic kidney disease (OR 1.788, CI 1.458–2.192), cirrhosis (OR 1.764, CI 1.268–2.454) and obesity (OR 1.630, CI 1.475–1.802). There was a significantly higher risk for septicaemia in patients with chronic kidney disease (OR 3.065, CI 2.120–4.430) or cirrhosis (OR 5.016, CI 3.019–8.336).

    Conclusion and discussion: Certain comorbidities have an impact on the risk for postoperative infection after cholecystectomy, especially SSI. This should be taken into account when planning the procedure and when deciding on prophylactic antibiotic treatment.

  • 254. Janson, A R
    et al.
    Jänes, Arthur
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Israelsson, Leif A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Laparoscopic stoma formation with a prophylactic prosthetic mesh.2010In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 14, no 5, p. 495-498Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: One year after stoma formation with an open technique, the rate of parastomal hernia is almost 50%. The herniation rate can be reduced to 10% with the use of a prophylactic mesh in a sublay position. For stomas formed with a laparoscopic technique, a surgical method with the use of prophylactic mesh should be sought. METHODS: Patients with a sigmoidostomy created with a laparoscopic technique were provided with a prophylactic large-pore, low-weight mesh in a sublay position. Follow-up examination was carried out after at least 12 months. RESULTS: Between March 2003 and May 2007, a sigmoidostomy was created in 25 patients. The patients' mean age was 65 years (range 31-89), the mean body mass index was 26 (range 21-32) and 15 were female. One stoma necrosis and two minor wound infections occurred. Parastomal hernia was present in 3 of 20 patients (15%) available for follow-up examination after 11-31 months (mean 19). No fistulas or strictures had developed. No mesh infection was noted and no mesh was removed. CONCLUSION: In laparoscopic stoma formation, a prophylactic large-pore, low-weight mesh in a sublay position is an easy and safe procedure associated with a low rate of parastomal hernia.

  • 255.
    Janunger, Karl-Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Benign and malignant gastric mucosal changes after partial gastrectomy1978Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The development of benign and malignant mucosal changes in the gastric remnant were studied early (1-3 years) postoperatively in 55 patients and late (10-24 years) postoperatively in 336 of 676 patients subjected to partial gastrectomy for ulcer disease.

    Chronic gastritis with atrophy, intestinal metaplasia and cystic dilatation of the gastric glands was found early postoperatively with the same prevalence in gastric and duodenal ulcer patients. Whereas the prevalence of atrophy, and of acute and chronic gastritis was the same both early and late postoperatively, the prevalence of intestinal metaplasia, cystic dilatation and lipid islands increased with time. The prevalence of inflammatory changes late postoperatively was not correlated to sex, age or type of anastomotic procedure.

    A significantly increased risk for stump carcinoma was found in male patients more than 12 years postoperatively. No difference correlated to type of ulcer disease or anastomotic procedure could be demonstrated. In duodenal ulcer patients the time interval between operation and diagnosis of carcinoma was independent of age at operation, while in gastric ulcer patients the interval was shorter with increasing age at operation.

    Gastric stump carcinomas were found in 12 of the 336 (3.6%) patients examined gastroscopically; four of these were early carcinomas. In four patients with stump carcinoma the correct diagnosis could not be established at the first examination.

    Gastric polyps and precancerous mucosal changes were the only macro- or microscopical findings in some cases with already existing non-visible carcinoma.

    The CEA immunohistochemical study of the gastric mucosa showed a positive reaction in 10 of 49 patients; 6 of the 10 had carcinoma, precancerous changes or adenomatous polyp. Three patients with diagnosed or later discovered carcinoma had CEA negative reactions. However, the results indicate that there is a correlation between demonstrated CEA content and increased risk for development of stump carcinoma. To evaluate whether this method can be used to identify patients at special risk for development of gastric carcinoma requires further study.

    Because of increased risk for stump carcinoma, gastric ulcer patients ought to be examined with gastroscopy from about 10 years after partial gastrectomy, and duodenal ulcer patients from about 15 years, irrespective of the type of anastomotic procedure. Re-examinations ought to be performed every two to four years. In patients with gastric polyps or precancerous mucosal changes re-examinations should be performed earlier, within 6-12 months.

  • 256.
    Jestin, Pia
    et al.
    Department of Surgical Sciences, University Hospital, Uppsala, SE 75185 Uppsala, .
    Heurgren, M
    Påhlman, L
    Glimelius, B
    Gunnarsson, Ulf
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Elective surgery for colorectal cancer in a defined Swedish population.2004In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 30, no 1, p. 26-33Article in journal (Refereed)
    Abstract [en]

    AIMS: The aim of this study was to describe variability in compliance to clinical guidelines in colorectal cancer surgery related to hospital structure.

    METHODS: All patients registered in the databases of the Regional Oncologic Centre, operated upon electively for colon cancer between the start of the register in 1997 until 2000 (n=1771) and for rectal cancer between the start of the register in 1995 until 2000 (n=1841) were selected for analysis.

    RESULTS: There was no difference in 5-year survival rate between colon and rectal cancer (mean follow-up 2.6 and 3.0 years, respectively; p=0.22). There was a significant difference in frequency of preoperative liver scan depending on hospital category with an increase in colon cancer from 39 to 46% (p=0.02) and in rectal cancer from 42 to 64% (p<0.001). For colon cancer there was no difference, according to hospital category, in quotient sigmoid and high anterior resection to left-sided resection. Furthermore, high anterior resection was more common at university and general district hospitals (8%) compared with district hospitals (4%) (p=0.01). Sphincter-saving surgery was more common at university hospitals and district general hospitals than at district hospitals (low anterior/abdomino-perineal resection quotients 2.3, 2.4 and 1.6, respectively; p<0.001).

    CONCLUSIONS: Population-based audit forms an appropriate and valuable basis for quality assurance projects. In addition to describing compliance to guidelines and pointing to process steps that can be improved, such investigations may also indicate changes due to scientific development. Linked to case-costing data, such results may form an important basis for decisions about modifications in health care.

  • 257.
    Jestin, Pia
    et al.
    Department of Surgical Sciences, Federation of County Councils, Stockholm.
    Nilsson, J
    Heurgren, M
    Påhlman, L
    Glimelius, B
    Gunnarsson, Ulf
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Emergency surgery for colonic cancer in a defined population.2005In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 92, no 1, p. 94-100Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to identify risk factors in emergency surgery for colonic cancer in a large population and to investigate the economic impact of such surgery.

    METHODS: Data from the colonic cancer registry (1997-2001) of the Uppsala/Orebro Regional Oncological Centre were analysed and classified by hospital category. Some 3259 patients were included; 806 had an emergency and 2453 an elective procedure. Data for calculating effects on health economy were derived from a national case-costing register.

    RESULTS: Patients who had emergency surgery had more advanced tumours and a lower survival rate than those who had an elective procedure (5-year survival rate 29.8 versus 52.4 per cent; P < 0.001). There was a stage-specific difference in survival, with poorer survival both for patients with stage I and II tumours and for those with stage III tumours after emergency compared with elective surgery (P < 0.001). Emergency surgery was associated with a longer hospital stay (mean 18.0 versus 10.0 days; P < 0.001) and higher costs (relative cost 1.5 (95 per cent confidence interval 1.4 to 1.6)) compared with elective surgery. The duration of hospital stay was the strongest determinant of cost (r(2) = 0.52, P < 0.001).

    CONCLUSION: Emergency surgery for colonic cancer is associated with a stage-specific increase in mortality rate.

  • 258.
    Jestin, Pia
    et al.
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Påhlman, Lars
    rtment of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Gunnarsson, Ulf
    rtment of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Risk factors for anastomotic leakage after rectal cancer surgery: a case-control study.2008In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 10, no 7, p. 715-21Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: With introduction of the total mesorectal excision technique and preoperative radiotherapy in rectal cancer surgery, the local recurrence rate has decreased and the overall survival has improved. One drawback, however, is the high anastomotic leakage rate of approximately 10-18%. Male gender and low anastomoses are known risk factors for such leakage. The aim of this study was to identify potentially modifiable risk factors.

    METHOD: In a case-control study, data from the Swedish Rectal Cancer Registry (1995-2000) were analysed. Cases were all patients with anastomotic leakage after an anterior resection (n = 134). Two controls were randomly selected for each case. The medical records (n = 402) were checked against a study protocol. Due to incorrect recording two cases and 28 controls were excluded from further analyses.

    RESULTS: In the multivariate analysis significant risk factors were American Society of Anesthesiologists score > 2 [OR = 1.40 (95% CI 1.05-1.83)], preoperative radiotherapy [OR = 1.34 (95% CI 1.06-1.69)], intraoperative adverse events [OR = 1.85 (95% CI 1.32-2.58)], level of anastomosis <or= 6 cm [OR = 1.39 (95% CI 1.01-1.90)] and severe bleeding [OR = 1.45 (95% CI 1.14-1.84)]. Diverting stoma protected from leakage [OR = 0.68 (95% CI 0.52-0.88)]. Male gender was a risk factor in the univariate but not in the multivariate analysis [OR = 1.30 (95% CI 1.04-1.63) and OR = 1.26 (95% CI 1.00-1.58), respectively]. Except for a protective stoma, none of the variables considered as possible targets for improvement, such as postoperative epidural anaesthesia, observation at intensive care unit for more than 24 h, and intraabdominal drainage, proved to be protective factors either in the univariate or in the multivariate analyses.

    CONCLUSION: The most important risk factors for leakage were adverse intraoperative events, low anastomoses and preoperative radiotherapy. A diverting stoma is protective and can reduce the consequences when leakage occurs. Further analyses with focus on the surgical technique and individual surgeon may be valuable in identifying targets for improvement.

  • 259.
    Jiang, G X
    et al.
    Division of Neurology, Department of Clinical Neuroscience and Family Medicine, Huddinge University Hospital, Huddinge, Sweden.
    de Pedro-Cuesta, J
    Division of Neurology, Department of Clinical Neuroscience and Family Medicine, Huddinge University Hospital, Huddinge, Sweden. Department of Applied Epidemiology, National Centre for Epidemiology, Carlos III Institute of Health, Madrid, Spain.
    Strigård, Karin
    Department of Surgery, Huddinge University Hospital, Karolinska Institutet, Stockholm, Sweden.
    Olsson, T
    Division of Neurology, Department of Clinical Neuroscience and Family Medicine, Huddinge University Hospital, Huddinge, Sweden.
    Link, H
    Division of Neurology, Department of Clinical Neuroscience and Family Medicine, Huddinge University Hospital, Huddinge, Sweden.
    Pregnancy and Guillain-Barré syndrome: a nationwide register cohort study.1996In: Neuroepidemiology, ISSN 0251-5350, E-ISSN 1423-0208, Vol. 15, no 4, p. 192-200Article in journal (Refereed)
    Abstract [en]

    In this study, we determined the relationship between Guillain-Barré syndrome (GBS) and pregnancy. By taking advantage of several nationwide registers and the availability of personal identification numbers, we calculated person-years for Swedish females aged 15-49 years in the following categories: (1) neither pregnant nor postpartum; (2) pregnant; (3) in the first month postpartum, or (4) in the first 3 months postpartum during 1973-1983. For these women, we determined the corresponding exposure status of hospital-registered GBS cases. Medical records were examined for GBS cases hospitalized during the 2-week period postpartum and 1-month period after the last menstruation. Poisson regression analysis yielded age-adjusted relative risks (RRs) of 0.86 (95% CI 0.40-1.84) for pregnant women, and 1.47 (0.54-3.99) and 2.21 (0.55-8.94) for females during the 3-month and the 30-day period after delivery. The risk for GBS seems to be lower during pregnancy and increases after delivery.

  • 260.
    Johagen, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    The scientific evidence of arterial line filtration in cardiopulmonary bypass2016In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111X, Vol. 31, no 6, p. 446-457Article in journal (Refereed)
    Abstract [en]

    Background: The indication for arterial line filtration (ALF) is to inhibit embolisation during cardiopulmonary bypass. Filtration methods have developed from depth filters to screen filters and from a stand-alone component to an integral part of the oxygenator. For many years, ALF has been a standard adopted by a majority of cardiac centres worldwide. The following review aims to summarize the available evidence in support for ALF and report on its current practice in Europe. Method: The principles and application of ALF in Europe was investigated using a survey conducted in 2014. The scientific evidence for ALF was examined by performing a systematic literature search in six different databases, using the following search terms: Cardiopulmonary bypass AND filters AND arterial. The primary endpoint was protection against cerebral injury verified by the degree of cerebral embolisation or cognitive tests. The secondary endpoint was improvement of the clinical outcome verified elsewise. Only randomised clinical trials were considered. Results: The response rate was 31% (n=112). The great majority (88.5%) of respondents were using ALF, following more than 10 years of experience. Integrated arterial filtration was used by 55%. Of respondents not using ALF, fifty-four percent considered starting using integrated arterial filtration. The systematic literature database search returned 180 unique publications where 82 were specifically addressing ALF in cardiopulmonary bypass. Only four out of the 82 identified publications fulfilled our inclusion criteria. Of these, three were more than 20 years old and based on the use of bubble oxygenation. Conclusion: ALF is a standard implemented in a majority of cardiopulmonary bypass procedures in Europe. The level of scientific evidence available in support of current arterial line filtration methods in cardiopulmonary bypass is, however, poor. Large, well-designed, randomised trials are warranted.

  • 261.
    Johannesson, Gauti
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Ophthalmology.
    Hallberg, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Eklund, Anders
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Koskela, Timo
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Ophthalmology.
    Linden, Christina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Ophthalmology.
    Change in intraocular pressure measurement 2 years after myopic laser-assisted subepithelial keratectomy2012In: Journal of cataract and refractive surgery, ISSN 0886-3350, E-ISSN 1873-4502, Vol. 38, no 9, p. 1637-1642Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To evaluate intraocular pressure (IOP) measurements 24 months after laser-assisted subepithelial keratectomy (LASEK) with 3 tonometry methods-Goldmann applanation tonometry (DCT), Pascal dynamic contour tonometry (DCT), and applanation resonance tonometry (ART)-and to compare them with measurements taken preoperatively and 3 and 6 months postoperatively. SETTING: Department of Ophthalmology, Umea University, lima Sweden. DESIGN: Prospective randomized single-center. METHODS: One randomized eye per person from myopic healthy individuals who had LASEK was included. Visual acuity, central corneal thickness (CCT), corneal curvature, and IOP were measured at all time points. Six IOP measurements were performed per method, with a 5-minute lapse between methods. RESULTS: The study evaluated 38 eyes. Two years after LASEK, dynamic ART was the only method that did not measure significantly lower IOP than before LASEK (mean -0.2 mm Hg +/- 1.6 [SD]). The greatest difference was with GAT (mean -1.9 +/- 1.7 mm Hg) followed by static ART (mean -1.2 +/- 1.6 mm Hg) and then DCT (mean -0.9 +/- 1.3 mm Hg). All methods measured significantly lower IOP at 3 months and 6 months. CONCLUSIONS: Dynamic ART, which analyses IOP measurement during indentation, showed no significant difference in measured IOP after 24 months. The convex tip of the ART device and the continuous sampling of data during corneal indentation seem to be factors in why dynamic ART was less affected by corneal properties and therefore more suitable for IOP measurement in LASEK-treated eyes, although this must be confirmed in larger trials.

  • 262.
    Johansson, Bengt
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Holmgren, Anders
    Hedström, Magnus
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Engström-Laurent, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Evaluation of hyaluronan and calcifications in stenotic and regurgitant aortic valves.2011In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 39, no 1, p. 27-32Article in journal (Refereed)
    Abstract [en]

    Objective: Hyaluronan (HA) is a major component of the interstitium and has been observed in normal heart valves. The function of HA in heart valves is unknown but contribution to biomechanical function has been proposed. The purpose of this investigation was to study the distribution of HA in relation to calcifications in diseased human aortic valves. Methods: Human aortic valves were collected at aortic valve replacement, of whom nine patients had regurgitation and 13 stenotic disease. The valves were decalcified and stained for the visualisation of HA. The specimens were macroscopically evaluated for magnitude of calcification using image analysis. The microscopic amount and distribution of HA and calcifications were semiquantitatively evaluated using histochemistry. Results: The overall HA staining showed an inverse relationship against the magnitude of observed valve calcifications (p<0.001) and type of disease (p=0.014). Multiple-group comparison revealed regionally reduced HA staining in diffuse and heavy calcified regions inside the valve (both p<0.001) compared with normal-structured parts of the valve. HA was concentrated on the ventricular side of the valve (p=0.002). Conclusions: The content of HA was reduced in calcified aortic valves and had a heterogeneous distribution, potentially contributing to poor valve function. HA may also be involved in the pathophysiological process in degenerative aortic stenosis.

  • 263.
    Johansson, Christer
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Elite sprinters, ice hockey players, orienteers and marathon runners: isokinetic leg muscle performance in relation to muscle structure and training1987Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    In male athletes from different sports, isokinetic knee extensor, and in orienteers also plantar flexor peak torque (PT), contractional work (CW) and integrated surface electromyograms (iEMG) were analysed.

    Single contraction PT, CW and iEMG in sprinters and marathon runners were signi­ficantly correlated to the cross-sectional area (CSA) of m. quadriceps, and to the Type II fibre area of m. vastus lateralis. When correcting PT, CW and iEMG for CSA of m. quadriceps, such correlations were found only for Type IIA fibre area at 180° s~1. Elec- tromyographically, m. vastus lateralis (biopsied muscle) was representative for m. quadriceps. Calculated optimal mean power (CW s~1) and electrical efficacy (CW/iEMG) approximated for sprinters 450° s-1 and for marathon runners 270° s~1, i.e. velocities at or above the upper limit of the dynamometers. In orienteers, plantar flexor PT increased during winter training, but decreased during competitive season. Knee extensor PT increased over the whole year. At 30 and 60° s~1 only knee extensor PT was negatively associated with the running velocity at onset of blood lactate accu­mulation (VOBLA)- Changes in VOBLA during winter period were negatively associated with changes in knee extensor PT at 180° s~1. During competitive season, changes in Vobla were negatively associated with the ratio quality : quantity running. In ice hockey players PT varied non-systematically with training and games.

    The biopsy specimens of marathon runners showed irregular fibre shapes, an in­creased amount of connective tissue and central fibre nuclei, indicating an early strain disease or functional adaptation to extreme demands.

    During repetitive contractions in sprinters and marathon runners, fatigue, i.e. slope of decline in CW, was significantly associated with the Type II fibre area of m. vastus lateralis. For knee extensors of sprinters, ice hockey players and orienteers, a steep de­crease in CW/iEMG was observed. In contrast, knee extensors of marathon runners and plantar flexors of orienteers showed an almost unaltered CW/iEMG throughout the test. The knee extensor endurance level (CW/iEMG) was significantly correlated to the maximal oxygen uptake. In orienteers, an increase in endurance level of both tested muscle groups during winter training parallelled an increase in VOBLA and V02obla- In hockey players, fatigue and endurance pattern (CW and CW/iEMG) changed non-systematically with training and games.

    In conclusion, isokinetic measurements and iEMG reflect the structural properties of the knee extensor muscles in sprinters and marathon runners. The demonstrated characteristics and changes in leg muscle function in different groups of athletes apparently reflect varying demands from different sports activities.

  • 264. Johansson, M
    et al.
    Gunnarsson, Ulf
    Department of Surgery, CLINTEC, Karolinska Institute, Karolinska University Hospital, Gastrocentrum K53, 141 86, Huddinge, Stockholm, Sweden .
    Strigård, Karin
    Department of Surgery, CLINTEC, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
    Different techniques for mesh application give the same abdominal muscle strength2011In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 15, no 1, p. 65-68Article in journal (Refereed)
    Abstract [en]

    PURPOSE: This study investigates abdominal muscle strength after surgery for giant hernia with the onlay, sublay or intraperitoneal (IPOM) method. Theoretically, placement of the mesh may result in different possibilities regarding function and postoperative physical activity related to abdominal muscle function.

    METHOD: Twenty-four patients operated for large ventral hernias using the onlay, sublay or IPOM technique were evaluated 1 year following surgery for abdominal wall strength using Biodex system 4.

    RESULTS: Despite the different surgical techniques used, no differences were observed in abdominal wall strength between the groups.

    CONCLUSION: The postoperative strength of abdominal wall muscles is independent of the method used for reconstruction of large abdominal wall hernia, and the choice of surgical technique should be directed by anatomical circumstances.

  • 265. Jones, Rebecca M.
    et al.
    Hart, Andrew M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Surgical treatment of a Morel-Lavallee lesion of the distal thigh with the use of lymphatic mapping and fibrin sealant2012In: Journal of Plastic, Reconstructive & Aesthetic Surgery, ISSN 1748-6815, E-ISSN 1532-1959, Vol. 65, no 11, p. 1589-1591Article in journal (Refereed)
    Abstract [en]

    Introduction: A Morel-Lavallee lesion can occur after a closed degloving injury. It is a persistent seroma that may be resistant to conservative methods of treatment such as percutaneous drainage and compression therapy. We present a novel, successful method of surgical treatment. Case report: A 70 year-old lady developed a 30 x 15 cm rapidly enlarging right medial thigh/knee swelling after being hit by a car. Conservative treatments failed, sarcoma was excluded, and the diagnosis confirmed, by MR imaging and cytology prior to referral. The lesion was excised, and blue dye lymphatic mapping used to identify and ligate feeding lymphatic vessels. The cavity was then closed using fibrin sealant spray and resorbable quilting sutures. A pressure garment was fitted. Result: The wound healed without complication, with no recurrence at six months. The patient returned to normal activities without pressure garments. Conclusion: This method provides a novel, successful approach to the surgical treatment of a chronic Morel-Lavallee lesion. (c) 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

  • 266.
    Jonsson, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Tingvall, Claes
    Krafft, Maria
    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.
    The risk of whiplash-induced medical impairment in rear-end impacts for males and females in driver seat compared to front passenger seat2013In: IATSS Research, ISSN 0386-1112, Vol. 37, no 1, p. 8-11Article in journal (Refereed)
    Abstract [en]

    The objective of this study was to study whiplash injury outcome in front-seat occupants in rear-end impacts using double paired comparison technique. The combination of gender, seated position, and outcome was analyzed. Folksam, a Swedish insurance company, has a database of whiplash injuries. A questionnaire was used to collect study data. The response rate was 81%. The inclusion criteria included medical impairment one year after the impact, as judged by medical specialists. The study included rear-end impacts between 1990 and 1999 that resulted in at least one permanent neck injury impairment; in total, 430 impacts with 860 occupants and 444 impairments. Of those suffering impairment, 302 were female and 142 male; 235 were seated in the driver's seat and 209 in the front passenger seat. Relative risk estimates for impairing whiplash injury, by gender and seated position:

    1.Driver male (DM)/passenger female (PF) relative risk = 0.5 n = 218

    2.Driver male (DM)/passenger male (PM) relative risk = 1.4 n = 57

    3.Driver female (DF)/passenger female (PF) relative risk = 2.5 n = 102

    4.Driver female (DF)/passenger male (PM) relative risk = 4.6 n = 67.

    Females had a relative risk of medical impairment of 3.1 compared to men after adjustment for the average increased risk in the driver position. The driver position had a doubled relative risk compared to the front passenger position. As a conclusion it may be of value to take risk differences between male and female occupants and between driver and front passenger positions into account in future automotive car and seat construction.

  • 267.
    Jonsson, Josefin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Surgical treatment of colorectal liver metastases - Radiofrequency ablation does not provide long-term survival compared to liver resection2017Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 268. Jorkjend, Lars
    et al.
    Johansson, Anders
    Johansson, Ann-Katrin
    Bergenholtz, Axel
    Umeå University, Faculty of Medicine, Department of Odontology.
    Resting and stimulated whole salivary flow rates in Sjogren's syndromepatients over time: a diagnostic aid for subsidized dental care?2004In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 62, no 5, p. 264-268Article in journal (Refereed)
    Abstract [en]

    The aim of the present study was to evaluate Swedish and Norwegian criteria currently applied in the assessment of eligibility for subsidized dental care of Sjogren's syndrome (SS) patients. These criteria are partly based on a single salivary test showing a resting whole salivary secretion rate of less than or equal to0.1 mL/min. Thirty secondary Sjogren (SSS) patients (29 F and 1 M) participated for the duration of the study, in which resting (RWS) and stimulated (SWS) whole salivary flow rates were collected in the morning and afternoon, over 3 consecutive weeks, once per week, as well as at different times over a 5-year period. Twenty patients presented levels of RWS flow rates of less than or equal to 0.1 mL/min on one or more occasions over a 3-week period, while 8 of these also exceeded, on one or more occasions, the cut-off level of 0.1 mL/min, indicating that salivary flow rates varied over time. Six patients showed consistently low secretion rates of RWS as well as of SWS, estimated as less than or equal to0.1 mL/min and less than or equal to0.7 mL/min, respectively. Based on the results, salivary tests that are to be used as a diagnostic aid for SS diagnosis, and thus as a basis for inclusion within the subsidy net for dental care, must be taken on several occasions in order to more accurately give information about salivary gland function. In line with this, current regulations governing the eligibility of SS patients within subsidized dental care programs should be reviewed.

  • 269.
    Jung, Bärbel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Authors' reply: Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection (Br J Surg 2007; 94: 689–695)2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 10, p. 1306-1306Article in journal (Other (popular science, discussion, etc.))
  • 270.
    Jung, Bärbel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    On effectiveness in colorectal surgery: mechanical bowel preparation or not in elective colonic surgery and treatment options for elderly patients with rectal cancer2008Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The management of patients undergoing colorectal surgery has changed in recent decades. Efforts have been made to show that perioperative physiological stress to the patient can be minimised with standardised care programmes and thus improve short term outcome after colorectal surgery. Mechanical bowel preparation (MBP), for instance, has been questioned as part of standard management. There are studies highlighting the effect of cancer treatment and its side effects in the elderly, showing that geriatric patients benefit from oncological therapy in much the same way as younger patients. The impact of this information on surgical and oncological practice in Sweden today is not known. To assess the effectiveness of colorectal surgery we need both randomised controlled trials and population-based cohort studies. We have performed a trial on colonic surgery with and without preoperative mechanical bowel preparation, as well as a nation-wide register study comparing treatment and outcome of rectal cancer in two age groups. In a randomised controlled trial 1505 patients from 21 hospitals were randomised to MBP or no-MBP prior to open elective colonic resection. There were no differences in overall complication rates between the groups: cardiovascular 5.1% with MBP vs. 4.6% without MBP; general infection 7.9% vs. 6.8%; and surgical site complications 15.1% vs. 16.1%. The proportion of patients reaching at least one primary endpoint was 24.5% vs. 23.7% respectively. The patients experience of and postoperative recovery after MBP or no-MBP was evaluated in 105 of the patients in the bowel preparation trial at three of the participating hospitals. Sixty-five patients received MBP and 40 patients did not. In the MBP group 52% needed assistance with bowel preparation. Day 4 postoperatively patients in the no-MBP group perceived more discomfort than patients in the MBP group, p<0.05. Bowel emptying occurred significantly earlier in the no-MBP group than in the MBP group, p<0.05.

    In an experimental study the effect of MBP on intramucosal bacterial count was evaluated. Macroscopically normal colon mucosa was collected from 37 patients (20 MBP and 17 No-MBP) undergoing elective colorectal surgery at three hospitals. MBP did not influence the median colony count of E. coli, Bacteroides, or total median colony count, information that was previously unknown. These three studies imply that MBP can be omitted before elective colonic resection. In a population-based register study, treatment for rectal cancer in patients ≥ 75 years and those < 75 years was evaluated using data from the Swedish Rectal Cancer Register 1995-2004 (N=15104). This study revealed that preoperative radiotherapy was used less in patients > 75 years. There was also a higher threshold for surgery in this group, and they more often received a permanent stoma compared to younger patients. Outcome in terms of 5-year local recurrence rate and 5-year cancer-specific survival differed very little between the older and younger patient groups who underwent abdominal tumour resection with curative intent. We suggest future studies focusing on ways of reducing surgical and perioperative stress and on quality of life when assessing suitable treatment modalities for rectal cancer.

  • 271. Jung, Bärbel
    et al.
    Lannerstad, Olof
    Påhlman, Lars
    Arodell, Malin
    Unosson, Mitra
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Kirurgi.
    Preoperative mechanical preparation of the colon: the patient's experience2007In: BMC Surgery, ISSN 1471-2482, E-ISSN 1471-2482, Vol. 7, p. 5-Article in journal (Refereed)
    Abstract [en]

    Background Preoperative mechanical bowel preparation can be questioned as standard procedure in colon surgery, based on the result from several randomised trials.

    Methods As part of a large multicenter trial, 105 patients planned for elective colon surgery for cancer, adenoma, or diverticulitis in three hospitals were asked to complete a questionnaire regarding perceived health including experience with bowel preparation. There were 39 questions, each having 3 – 10 answer alternatives, dealing with food intake, pain, discomfort, nausea/vomiting, gas distension, anxiety, tiredness, need of assistance with bowel preparation, and willingness to undergo the procedure again if necessary.

    Results 60 patients received mechanical bowel preparation (MBP) and 45 patients did not (No-MBP). In the MBP group 52% needed assistance with bowel preparation and 30% would consider undergoing the same preoperative procedure again. In the No-MBP group 65 % of the patients were positive to no bowel preparation. There was no significant difference between the two groups with respect to postoperative pain and nausea. On Day 4 (but not on Days 1 and 7 postoperatively) patients in the No-MBP group perceived more discomfort than patients in the MBP group, p = 0.02. Time to intake of fluid and solid food did not differ between the two groups. Bowel emptying occurred significantly earlier in the No-MBP group than in the MBP group, p = 0.03.

    Conclusion Mechanical bowel preparation is distressing for the patient and associated with a prolonged time to first bowel emptying.

  • 272.
    Jung, Bärbel
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Matthiessen, Peter
    Smedh, Kenneth
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Ransjö, Ulrika
    Påhlman, Lars
    Mechanical bowel preparation does not affect the intramucosal bacterial colony count2010In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 25, no 4, p. 439-442Article in journal (Refereed)
    Abstract [en]

    Purpose The aim of this study was to determine if mechanical bowel preparation (MBP) influences the intramucosal bacterial colony count in the colon.

    Materials and methods Macroscopically normal colon mucosa was collected from 37 patients (20 with and 17 without MBP) who were undergoing elective colorectal surgery at three hospitals. The biopsies were processed and cultured in the same laboratory. Colony counts of the common pathogens Escherichia coli and Bacteroides as well as of total bacteria were conducted. The study groups were comparable with regard to age, gender, antibiotics use, diagnosis and type of resection.

    Results MBP did not influence the median colony count of E. coli, Bacteroides or total bacteria in our study.

    Conclusions MBP did not affect the intramucosal bacterial count in this study. Further studies are suggested to confirm these findings.

  • 273.
    Jung, Bärbel
    et al.
    Kirurgi.
    Påhlman, Lars
    Nyström, P-O
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Kirurgi.
    Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 6, p. 689-695Article in journal (Refereed)
    Abstract [en]

    Background: Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery. This randomized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery.

    Methods: A total of 1505 patients, aged 18-85 years with American Society of Anesthesiologists grades I-III, were randomized to MBP or no MBP before open elective surgery for cancer, adenoma or diverticular disease of the colon. Primary endpoints were cardiovascular, general infectious and surgical-site complications within 30 days, and secondary endpoints were death and reoperations within 30 days.

    Results: A total of 1343 patients were evaluated, 686 randomized to MBP and 657 to no MBP. There were no significant differences in overall complications between the two groups: cardiovascular complications occurred in 5.1 and 4.6 per cent respectively, general infectious complications in 7.9 and 6.8 per cent, and surgical-site complications in 15.1 and 16.1 per cent. At least one complication was recorded in 24.5 per cent of patients who had MBP and 23.7 per cent who did not.

    Conclusion: MBP does not lower the complication rate and can be omitted before elective colonic resection.

  • 274.
    Juto, Hans
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Möller, Michael
    Wennergren, David
    Edin, Klas
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Apelqvist, Ida
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Morberg, Per
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Substantial accuracy of fracture classification in the Swedish Fracture Register: evaluation of AO/OTA-classification in 152 ankle fractures2016In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 47, no 11, p. 2579-2583Article in journal (Refereed)
    Abstract [en]

    Introduction: Since 2011 the Swedish Fracture Register (SFR) has collected information on fracture epidemiology, treatment and outcome. More than 112 000 fractures, including 11 600 ankle fractures, have been registered so far. The accuracy of the classification is crucial when using the register in future research and quality improvement of care. In this study we examine the degree of accuracy of the AO/ OTA-classification in which ankle fractures are recorded in the SFR.

    Methods: 152 randomly selected ankle fractures registered in the SFR were classified independently by a reference group of three orthopedic surgeons on two occasions. The agreed AO/OTA-classification of the reference group was regarded as the gold standard classification for each case. The originally recorded classification in the SFR was subsequently compared with the classification of the reference group and accuracy calculated.

    Results: The agreement between the classification in the SFR and of the reference group was 74%, corresponding to kappa 0.67, 95% CI (0.58-0.76) for AO/OTA group level. An agreement of 88% equivalent to kappa 0.77, 95% CI (0.67-0.87) was noted for AO/OTA type level. The agreement corresponds to substantial according to Landis and Koch. The kappa value of inter-and intraobserver agreement ranged from 0.67 to 0.93.

    Conclusions: The study results show substantial agreement between classifications made in the SFR and gold standard classification. The finding is equivalent to or higher than in previous studies. Consequently, we conclude that classifications of ankle fractures in the SFR are accurate and valid.

  • 275.
    Jänes, Arthur
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Parastomal hernia: clinical studies on definitions and prevention2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The aims of the studies was to evaluate the short and long term effects on the development of parastomal hernia and stoma complications of a prophylactic prosthetic mesh placed in a sublay position at the index operation.  Also the purpose was to validate a definition of parastomal hernia at clinical examination and a method and a definition of parastomal hernia at CT-scan.

    In the first two studies 27 patients were randomized to a conventional stoma or to a stoma with the addition of a partly absorbable low weight large pore mesh in sublay position. Patients were examined after one and five years.  After five years the rate of parastomal hernia was 80% with a conventional stoma and 14% with the addition of a mesh.  A prophylactic mesh did not increase the rate of complications. In the third study a prophylactic mesh was intended at stoma formation in 93 consecutive patients in routine surgery. In 75 patients provided with a mesh the rate of parastomal hernia after one year was 13%. Complication rates were not increased in 19 severely contaminated wounds. In the fourth study 27 patients with ostomies were examined by tree surgeons and parastomal hernia was defined as any protrusion in the vicinity of the stoma. CT-scans with patients examined in the supine and prone positions were assessed by three radiologists. Herniation was then defined as any intra abdominal content protruding beyond peritoneum or the presence of a hernia sac. Kappa was 0.85 for surgeons and 0.85 for radiologists with CT-scan in the prone position. Kappa was 0.80 for surgeons and radiologists collectively, with CT-scan in the prone position. Four parastomal hernias detected at CT-scan in the prone position could not be detected in the supine position. A parastomal hernia diagnosed at clinical examination was always detected at CT-scan in the prone position.

    Conclusions: A prophylactic mesh placed in a sublay position at the index operation reduces the rate of parastomal hernia without increasing the rate of complications. Parastomal hernia should at clinical examination be defined as any protrusion in the vicinity of the stoma with the patient straining in the supine and erect positions.  At CT-scan, with the patient examined in the prone position, herniation should be defined as any intra abdominal content protruding beyond peritoneum or the presence of a hernia sac.

  • 276.
    Jänes, Arthur
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cengiz, Yucel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Israelsson, Leif A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Experiences with a prophylactic mesh in 93 consecutive ostomies2010In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 34, no 7, p. 1637-1640Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Parastomal hernia may be present in half of patients after one year. A prophylactic low-weight prosthetic mesh in a sublay position at the index operation reduces the risk of parastomal hernia, without increasing the rate of complications. MATERIAL: Between April 2003 and November 2006 all patients with an ostomy created at an open laparotomy were followed for at least one year. RESULTS: A prophylactic mesh was used in 75 of 93 patients. In 9 a prophylactic mesh could not be placed due to scarring after previous surgery. In 9 a mesh was omitted after surgeon's decision. In 19 patients a mesh was used in severely contaminated wounds. With a mesh 6 of 73 (8%) patients developed a surgical site infection and without a mesh 4 of 15 (27%). With a mesh parastomal hernia was present in 8 of 61 (13%) patients and without a mesh in 8 of 12 (67%). CONCLUSIONS: Creating a stoma in routine open surgery a prophylactic mesh can be placed in most patients. A mesh does not increase the rate of complications and can be used in severely contaminated wounds.

  • 277.
    Jänes, Arthur
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cengiz, Yucel
    Department of Surgery, Sundsvalls sjukhus, Sundsvall.
    Israelsson, Leif A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Preventing parastomal hernia with a prosthetic mesh2004In: Archives of surgery (Chicago. 1960), ISSN 0004-0010, E-ISSN 1538-3644, Vol. 139, no 12, p. 1356-1358Article in journal (Refereed)
    Abstract [en]

    HYPOTHESIS: Parastomal hernia is a common complication following colostomy. The lowest recurrence rate has been produced when repair is with a prosthetic mesh. This study evaluated the effect on stoma complications of using a mesh during the primary operation. DESIGN: Randomized clinical study. METHODS: Patients undergoing permanent colostomy were randomized to have either a conventional stoma or the addition of a mesh placed in a sublay position. The mesh used was a large-pore lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material. RESULTS: Twenty-seven patients had a conventional stoma, and in 27 patients the mesh was used. No infection, fistula formation, or pain occurred (observation time, 12-38 months). At the 12-month follow-up, parastomal hernia was present in 13 of 26 patients without a mesh and in 1 of 21 patients in whom the mesh was used. CONCLUSIONS: A lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material placed in a sublay position at the stoma site is not associated with complications and significantly reduces the rate of parastomal hernia.

  • 278.
    Jänes, Arthur
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cengiz, Yucel
    Kirurgkliniken, Sundsvalls sjukhus, Department of Surgery, Sundsvall, Sweden.
    Israelsson, Leif A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Preventing parastomal hernia with a prosthetic mesh: a 5-year follow-up of a randomized study2009In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 33, no 1, p. 118-121Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Parastomal hernia is a major clinical problem. In a randomized, clinical trial, a prosthetic mesh in a sublay position at the index operation reduced the rate of parastomal hernia at 12-month follow-up, without any increase in the rate of complications. This study was designed to evaluate the rate of complications after 5 years.

    METHODS: Between January 2001 and April 2003, 54 patients who had a permanent ostomy were randomized to a conventional stoma or to a stoma with the addition of a mesh in a sublay position. A large-pore, lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material was used.

    RESULTS: After 5 years, 21 patients with a conventional stoma were alive and parastomal herniation was recorded in 17 patients, of whom repair had been demanded in 5. In 15 patients operated on with the addition of a mesh herniation, that did not require repair, was present in 2 (P<0.001). No fistulas or strictures developed. No mesh infection was noted and no mesh was removed during the study period.

    CONCLUSIONS: At stoma formation, a prophylactic low-weight mesh in a sublay position is a safe procedure that reduces the rate of parastomal hernia.

  • 279. Jänes, Arthur
    et al.
    Israelsson, Leif
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Cengiz, Yucel
    Department of General Surgery, Kirurgkliniken, Sundsvalls sjukhus, 851 86, Sundsvall, Sweden.
    Preventing parastomal hernia with a prosthetic mesh: a 5-year follow-up of a randomized study: reply to letter2009In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 33, no 7, p. 1541-1541Article in journal (Refereed)
  • 280.
    Jänes, Arthur
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Weisby, Lena
    Israelsson, Leif A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Parastomal hernia: clinical and radiological definitions2011In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 15, no 2, p. 189-192Article in journal (Other academic)
    Abstract [en]

    INTRODUCTION: Parastomal hernia is a frequent complication after stoma formation. No consistent definition of parastomal hernia has been used in previous studies using clinical examination or computed tomography (CT) scan. The correlation between herniation rates found with clinical examination and CT scan has been poor. A definition of parastomal hernia with clinical examination that correlates with findings from CT scan should be sought.

    METHODS: Parastomal hernia, was with surgeons' clinical examination, defined as any protrusion in the vicinity of the stoma with the patient straining in a supine and an erect position. A new CT scan method was developed with the patient examined in the prone position. Radiologists defined herniation as any intra-abdominal content protruding beyond the peritoneum or the presence of a hernia sac. The correlation between investigators and methods were estimated by calculating Fleiss' Kappa values.

    RESULTS: Twenty-seven patients were assessed by three surgeons and three radiologists. For the surgeons, the Kappa value was 0.85. For the radiologists, it was 0.85 with CT scan in the prone position and 0.82 in the supine position. For the surgeons and radiologists collectively, the Kappa value was 0.80 for CT scan in the prone position and 0.63 in the supine position.

    CONCLUSION: With the new CT scan method examining patients in the prone position, the clinical and radiological definitions were highly reproducible and correlated strongly between methods and raters. With the strong correlation between clinical and radiological assessments, clinical examination alone is sufficient as follow-up. Conventional CT scan with the patient supine is not a reliable tool for diagnosing parastomal hernia.

  • 281.
    Jönsson, Maria
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    The neuronal and non-neuronal substance P, VIP and cholinergic systems in the colon in ulcerative colitis2009Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Ulcerative colitis (UC) is a chronic relapsing inflammatory bowel disease. Neuropeptides, especially vasoactive intestinal peptide (VIP) and substance P (SP), have long been considered to play key roles in UC. Among other effects, these neuropeptides have trophic and growth-modulating as well as wound-healing effects. Furthermore, whilst VIP has anti-inflammatory properties, SP has pro-inflammatory effects. It is generally assumed that the main source of SP and VIP in the intestine is the tissue innervation. It is not known whether or not they are produced in the epithelial layer. The details concerning the expressions of their receptors in UC are also, to a great extent, unclear. Apart from the occurrence of peptidergic systems in the intestine, there are also neuronal as well as non-neuronal cholinergic systems. The pattern concerning the latter is unknown with respect to UC.

    The studies in this thesis aimed to investigate the expression of SP and VIP and their major receptors (NK-1R and VPAC1) in UC colon, compared to non-UC colon. The main emphasis was devoted to the epithelium. A second aim was to examine for levels of these neuropeptides in blood plasma in UC. Another aim was to examine for the non-neuronal cholinergic system in UC, thus, to investigate whether there is acetylcholine production outside nerves in the UC colon. Methods used in the thesis were immunohistochemistry, in situ hybridization, enzyme immunosorbent assay, and in vitro receptor autoradiography.

    For the first time, mRNA for VIP and SP has here been found in the colonic epithelium. That was especially noted in UC mucosa showing a rather normal morphology, and in non-UC mucosa. Marked derangement of the mucosa was found to lead to a distinct decrease in VIP binding, and also a decrease in the expression level of VIP receptor VPAC1 in the epithelium. In general, there was an upregulation of the SP receptor NK-1R in the epithelium when the mucosa was deranged. The plasma levels of SP and VIP were higher for UC patients compared to healthy controls. There were marked correlations between the levels of the peptides in plasma, their levels in the mucosa and the degree of mucosal derangement/inflammation. A pronounced nonneuronal cholinergic system was found in both UC and non-UC colon. Certain changes occurred in this system in response to inflammation/derangement in UC. The present study shows unexpectedly that expressions for VIP and SP are not only related to the nerve structures and the inflammatory cells. The downregulation of VPAC1 expression, and the tendencies of upregulation of NK-1R expression levels when there is marked tissue derangement, may be a drawback for the intestinal function. The study also shows that there is a marked release of neuropeptides to the bloodstream in parallel with a marked derangement of the mucosa in UC. The cholinergic effects in the UC colon appear not only to be associated with nerverelated effects, but also effects of acetylcholine produced in local non-neuronal cells. The thesis shows that local productions for not only acetylcholine, but also SP and VIP, occur to a larger extent than previously considered.

  • 282. Jörgren, F.
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Arnadottir, H.
    Lindmark, G.
    The importance of rectal washout for the oncological outcome after Hartmann's procedure for rectal cancer: analysis of population-based data from the Swedish Colorectal Cancer Registry2017In: Techniques in Coloproctology, ISSN 1123-6337, E-ISSN 1128-045X, Vol. 21, no 5, p. 373-381Article in journal (Refereed)
    Abstract [en]

    During rectal cancer surgery the bowel may contain viable, exfoliated cancer cells, a potential source for local recurrence (LR). The amount and viability of these cells can be reduced using intraoperative rectal washout, a procedure that reduces the LR risk after anterior resection. The aim of this study was to analyse the impact of washout on oncological outcome when performed in Hartmann's procedure (HP) for rectal cancer. A national cohort study on data for patients registered from 1995 to 2007 in the Swedish Colorectal Cancer Registry was carried out. The final analysis included patients belonging to TNM stages I-III who had undergone R0 HP with a registered 5-year follow-up. Multivariate analysis was performed. A total of 1188 patients were analysed (686 washout and 502 no washout). No differences were detected between the washout group and the no washout group concerning rates of LR [7% (49/686) vs. 10% (49/502); p = 0.13], distant metastasis (DM) [17% (119/686) vs. 18% (93/502); p = 0.65], and overall recurrence (OAR) [21% (145/686) vs. 24% (120/502); p = 0.29]. For both groups, the 5-year cancer-specific survival was below 50%. In multivariate analysis, washout neither decreased the risk of LR, DM, or OAR nor increased overall or the cancer-specific 5-year survival. The oncological outcome did not improve when washout was performed in HP for rectal cancer.

  • 283. Jörgren, Fredrik
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lindmark, Gudrun
    Oncological outcome after incidental perforation in radical rectal cancer surgery2010In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 25, no 6, p. 731-740Article in journal (Refereed)
    Abstract [en]

    Identification of risk factors of poor oncological outcome in rectal cancer surgery is of utmost importance. This study examines the impact of incidental perforation on the oncological outcome. Using the Swedish Rectal Cancer Registry, patients were selected who received major abdominal surgery for rectal cancer between 1995 and 1997 with registered incidental perforation. A control group was also selected for analysis of the oncological outcome after 5-year follow-up. Multivariate analysis was performed. Registry data were validated, and additional data were supplemented from medical records. After validation and exclusion of non-radically operated patients, 118 patients with incidental perforation and 155 controls in TNM stages I-III were included in the analysis. The rate of local recurrence (LR) [20% (23/118) vs. 8% (12/155) (p = 0.007)] was significantly higher among patients with perforation, whereas the rates of distant metastasis [27% (32/118) vs. 21% (33/155) (p = 0.33)] and overall recurrence (OAR) [35% (41/118) vs. 25% (38/155) (p = 0.087)] were not significantly different between the groups. Overall as well as cancer-specific 5-year survival rates were significantly reduced for the patients with perforation [44 vs. 64% (p = 0.002) and 66 vs. 80% (p = 0.026), respectively]. In the multivariate analysis, perforation was a significant risk factor of increased rates of LR and OAR as well as reduced 5-year overall and cancer-specific survival. Incidental perforation in rectal cancer surgery is an important risk factor of poor oncological outcome and should be considered in the discussion concerning postoperative adjuvant treatment as well as the follow-up regime.

  • 284. Jörgren, Fredrik
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lindmark, Gudrun
    Risk factors of rectal cancer local recurrence: population-based survey and validation of the Swedish rectal cancer registry2010In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 12, no 10, p. 977-986Article in journal (Refereed)
    Abstract [en]

    Aim: Despite advances in rectal cancer treatment, local recurrence (LR) remains a significant problem. To select high-risk patients for different treatment options aimed at reducing LR, it is essential to identify LR risk factors. Method: Local recurrence and survival rates of 4153 patients registered 1995-1997 in the Swedish Rectal Cancer Registry were analysed. LR risk factors were analysed by multivariate methods. For LR patients the registry was validated and additional data retrieved. Results: The 5-year overall and cancer-specific survival rates were 45% and 62% respectively. LR was registered in 326 (8%) patients. After R0-resections for tumours in TNM stages I-III, LR developed in 10% of tumours at 0-5 cm, 8% at 6-10 cm and 6% at 11-15 cm above the anal verge. Preoperative radiotherapy (RT) reduced the LR rate irrespective of height [0-5 cm: OR 0.50 (0.30-0.83), 6-10 cm: OR 0.42 (0.25-0.71), and 11-15 cm: OR 0.29 (0.13-0.64)]. Patients without preoperative RT had significantly higher LR risk after rectal perforation [OR 2.50 (1.48-4.24)], and almost significantly decreased LR risk when rectal washout was performed [OR 0.65 (0.43-1.00)]. Preoperative RT prolonged time to LR but did not significantly influence the survival among LR patients. LR was an isolated tumour manifestation in 103 (39%) patients with validated LR. Conclusion: Preoperative RT should be considered for rectal cancer also in the upper third of the rectum. Intraoperative perforation should be avoided, and rectal washout is indicated as valuable. Follow-up for the detection of isolated LR is important. Extended follow up should be considered for patients treated with RT.

  • 285. Kaaks, Rudolf
    et al.
    Johnson, Theron
    Tikk, Kaja
    Sookthai, Disorn
    Tjønneland, Anne
    Roswall, Nina
    Overvad, Kim
    Clavel-Chapelon, Françoise
    Boutron-Ruault, Marie-Christine
    Dossus, Laure
    Rinaldi, Sabina
    Romieu, Isabelle
    Boeing, Heiner
    Schütze, Madlen
    Trichopoulou, Antonia
    Lagiou, Pagona
    Trichopoulos, Dimitrios
    Palli, Domenico
    Grioni, Sara
    Tumino, Rosario
    Sacerdote, Carlotta
    Panico, Salvatore
    Buckland, Genevieve
    Argüelles, Marcial
    Sánchez, María-José
    Amiano, Pilar
    Chirlaque, Maria-Dolores
    Ardanaz, Eva
    Bueno-de-Mesquita, H Bas
    van Gils, Carla H
    Peeters, Petra H
    Andersson, Anne
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Weiderpass, Elisabete
    Gram, Inger Torhild
    Lund, Eiliv
    Khaw, Kay-Tee
    Wareham, Nick
    Key, Timothy J
    Travis, Ruth C
    Merritt, Melissa A
    Gunter, Marc J
    Riboli, Elio
    Lukanova, Annekatrin
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Insulin-like growth factor I and risk of breast cancer by age and hormone receptor status: A prospective study within the EPIC cohort2014In: International Journal of Cancer, ISSN 0020-7136, E-ISSN 1097-0215, Vol. 134, no 11, p. 2683-2690Article in journal (Refereed)
    Abstract [en]

    Experimental evidence shows cross-talk in mammary cells between estrogen, insulin-like growth factor I (IGF-I) and their respective receptors and possible synergistic effects of estrogen receptor (ER) activation and increased IGF-I signaling with regard to breast tumor development, and epidemiological evidence suggests that circulating IGF-I levels may be related more to the risk of ER-positive than ER-negative breast cancer. Using a case–control study nested within the prospective European EPIC cohort (938 breast cancer cases and 1,394 matched control subjects), we analyzed the relationships of prediagnostic serum IGF-I levels with the risk of estrogen and progesterone receptor-positive and -negative breast tumors. IGF-I levels were positively associated with the risk of ER+ breast tumors overall (pre- and postmenopausal women combined, odds ratio (OR)Q4-Q1 = 1.41 [95% confidence interval (CI) 1.01–1.98] for the highest vs. lowest quartile; OR = 1.17 [95% CI 1.04–1.33] per 1-standard deviation (SD) increase in IGF-I, ptrend = 0.01) and among women who were diagnosed with breast cancer at 50 years or older (ORQ3-Q1 = 1.38 [95% CI 1.01–1.89]; OR = 1.19 [95% CI 1.04–1.36] per 1-SD increase in IGF-I, ptrend = 0.01) but not with receptor-positive disease diagnosed at an earlier age. No statistically significant associations were observed for ER− breast tumors overall and by age at diagnosis. Tests for heterogeneity by receptor status of the tumor were not statistically significant, except for women diagnosed with breast cancer at 50 years or older (phet = 0.03 for ER+/PR+ vs. ER−/PR− disease). Our data add to a global body of evidence indicating that higher circulating IGF-I levels may increase risk specifically of receptor-positive, but not receptor-negative, breast cancer diagnosed at 50 years or older.

  • 286. Kadum, B.
    et al.
    Inngul, C.
    Ihrman, R.
    Sjödén, Göran O.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Sayed-Noor, Arkan S.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Higher preoperative sensitivity to pain and pain at rest are associated with worse functional outcome after stemless total shoulder arthroplasty: a prospective cohort study2018In: The Bone & Joint Journal, ISSN 2049-4394, E-ISSN 2049-4408, Vol. 100B, no 4, p. 480-484Article in journal (Refereed)
    Abstract [en]

    Aims: The aims of this study were to investigate any possible relationship between a preoperative sensitivity to pain and the degree of pain at rest and on exertion with postoperative function in patients who underwent stemless total shoulder arthroplasty (TSA). Patients and Methods: In this prospective study, we included 63 patients who underwent stemless TSA and were available for evaluation one year postoperatively. There were 31 women and 32 men; their mean age was 71 years (53 to 89). The pain threshold, which was measured using a Pain Matcher (PM) unit, the degree of pain (visual analogue scale at rest and on exertion, and function using the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), were recorded preoperatively, as well as three and 12 months postoperatively. Results: We found an inverse relationship between both the preoperative PM threshold and pain (VAS) at rest and the 12-month postoperative QuickDASH score (Pearson correlation coefficient (r) >= 0.4, p < 0.05). A linear regression analysis showed that the preoperative PM threshold on the affected side and preoperative pain (VAS) at rest were the only factors associated with the QuickDASH score at 12 months. Conclusion: These findings indicate the importance of central sensitization in the restoration of function after TSA. Further studies are required to investigate whether extra analgesia and rehabilitation could influence the outcome in at risk patients.

  • 287.
    Kadum, Bakir
    et al.
    Sundsvall Hosp, Dept Orthopaed, S-85186 Sundsvall, Sweden.
    Mafi, Nader
    Sundsvall Hosp, Dept Orthopaed, S-85186 Sundsvall, Sweden.
    Norberg, Sigge
    Sundsvall Hosp, Dept Orthopaed, S-85186 Sundsvall, Sweden.
    Sayed-Noor, Arkan S
    Sundsvall Hosp, Dept Orthopaed, S-85186 Sundsvall, Sweden.
    Results of the Total Evolutive Shoulder System (TESSA(A (R))): a single-centre study of 56 consecutive patients2011In: Archives of Orthopaedic and Trauma Surgery, ISSN 0936-8051, E-ISSN 1434-3916, Vol. 131, no 12, p. 1623-1629Article in journal (Refereed)
    Abstract [en]

    Shoulder arthroplasty surgery has undergone remarkable progress. New concepts like reverse and stemless shoulder prostheses have been widely used. The Total Evolutive Shoulder System (TESSA (R)) is a new innovative system that provides the surgeon with different prosthetic versions. The purpose of the present study was to evaluate our short-term results and complications of the TESS. 56 consecutive patients were operated with one of the two versions of TESS (anatomical or reverse) between October 2007 and December 2009. Preoperative and postoperative evaluation of the function and life quality was achieved by the Quick Disability of the Arm, Shoulder and Hand (DASH) index and EQ-5D self-report questionnaire, respectively. Radiographic follow-up by anteroposterior, axillary and lateral views was done. The anterosuperior approach was used in all cases. We compared the outcome in fracture patients with other categories. 49 patients were available for 9-24 months (mean 14) clinical and radiographic postoperative follow-up. The mean of quick DASH improved from 56 preoperatively to 34 postoperatively (p < 0.001) and EQ-5D from 0.36 preoperatively to 0.73 postoperatively (p < 0.001). The complications were few and we had no radiolucencies or scapular notching during the study period. Fracture patients did worse compared to other categories. TESS prosthesis showed promising short-term results with few complications. The reverse version could be implanted without stem if initial stability was adequate. Long-term follow-up is required to confirm the results of this innovative system in the long run.

  • 288.
    Kadum, Bakir
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Sayed-Noor, Arkan S.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Perisynakis, Nikolaos
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Baea, Saida
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Sjödén, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Radiologic assessment of glenohumeral relationship: reliability and reproducibility of lateral humeral offset2015In: Surgical and Radiologic Anatomy, ISSN 0930-1038, E-ISSN 1279-8517, Vol. 37, no 4, p. 363-368Article in journal (Refereed)
    Abstract [en]

    It has been shown that anatomical reconstruction is an important step in achieving good function after shoulder arthroplasty. It is essential to reconstruct the distance between the coracoid process and greater tubercle as this relates to the moment arm of the deltoid and rotator cuff muscles. This study evaluated the reliability of measurement of the lateral humeral offset (LHO) on plain radiographs and on computed tomography (CT). Four independent observers performed measurements of LHO on radiographs and CT from 26 patients awaiting shoulder reconstruction. The interobserver reliability and intraobserver reproducibility were assessed. Interobserver reliability and intraobserver reproducibility of LHO in axial CT scans were excellent. Plain radiography showed fair to excellent interobserver reliability and variable intraobserver reproducibility. CT is a reliable tool to measure LHO supporting its use in preoperative planning. When AP radiography is used for preoperative planning the examiner should be aware of its limitations and standardisation protocols should be considered.

  • 289. Kailembo, Alexander
    et al.
    Preet, Raman
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stewart Williams, Jennifer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 2.Research Centre for Generational Health and Ageing, Faculty of Health, University of Newcastle.
    Common risk factors and edentulism in adults, aged 50 years and over, in China, Ghana, India and South Africa: results from the WHO Study on global AGEing and adult health (SAGE)2016In: BMC Oral Health, ISSN 1472-6831, E-ISSN 1472-6831, Vol. 17, article id 29Article in journal (Refereed)
    Abstract [en]

    Background: Edentulism (loss of all teeth) is a final marker of disease burden for oral health common among older adults and poorer populations. Yet most evidence is from high-income countries. Oral health has many of the same social and behavioural risk factors as other non-communicable diseases (NCDs) which are increasing rapidly in low- and middle-income countries with ageing populations. The "common risk factor approach" (CRFA) for oral health addresses risk factors shared with NCDs within the broader social and economic environment. Methods: The aim is to improve understanding of edentulism prevalence, and association between common risk factors and edentulism in adults aged 50 years and above using nationally representative samples from China (N = 11,692), Ghana (N = 4093), India (N = 6409) and South Africa (N = 2985). The data source is the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 (2007-2010). Multivariable logistic regression describes association between edentulism and common risk factors reported in the literature. Results: Prevalence of edentulism: in China 8.9 %, Ghana 2.9 %, India 15.3 %, and South Africa 8.7 %. Multivariable analysis: in China, rural residents were more likely to be edentulous (OR 1.36; 95 % CI 1.09-1.69) but less likely to be edentulous in Ghana (OR 0.53; 95 % CI 0.31-0.91) and South Africa (OR 0.52; 95 % CI 0.30-0.90). Respondents with university education (OR 0.31; 95 % CI 0.18-0.53) and in the highest wealth quintile (OR 0.68; 95 % CI 0.52-0.90) in China were less likely to be edentulous. In South Africa respondents with secondary education were more likely to be edentulous (OR 2.82; 95 % CI 1.52-5.21) as were those in the highest wealth quintile (OR 2.78; 95 % CI 1.16-6.70). Edentulism was associated with former smokers in China (OR 1.57; 95 % CI 1.10-2.25) non-drinkers in India (OR 1.65; 95 % CI 1.11-2.46), angina in Ghana (OR 2.86; 95 % CI 1.19-6.84) and hypertension in South Africa (OR 2.75; 95 % CI 1.72-4.38). Edentulism was less likely in respondents with adequate nutrition in China (OR 0.68; 95 % CI 0.53-0.87). Adjusting for all other factors, compared with China, respondents in India were 50 % more likely to be edentulous. Conclusions: Strengthening the CRFA should include addressing common determinants of health to reduce health inequalities and improve both oral and overall health.

  • 290.
    Kalbermatten, Daniel
    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.
    Nerve gap repair by the use of artificial conduits and cultured cells2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Peripheral nerve injuries are often associated with loss of nerve tissue and require autologous nerve grafts to provide a physical substrate for axonal growth. This thesis investigates the use of fibrin as both a tubular conduit to guide nerve regeneration and also as a matrix material to suspend various regenerative cell types within/on poly-3-hydroxybutyrate (PHB) nerve conduits. Adipose derived stem cells (ASC) are found in abundant quantities. In this thesis the ability of rat ASC to differentiate into Schwann cells was determined and a preliminary study of the neurotrophic potential of human ASC was also investigated.

    Rat sciatic nerve axotomy was performed proximally in the thigh to create a 10-mm gap between the nerve stumps and the gap was bridged using the various conduits.  At early time points the nerve grafts were harvested and investigated for axonal and Schwann cell markers.  After 16 weeks the regenerative response from sensory and motor neurons was also evaluated following retrograde labelling with Fast Blue fluorescent tracer. Stem cells were treated with a mixture of glial growth factors and after 2 weeks in vitro the expression of Schwann cell markers was analysed by immunocytochemistry and Western blotting.  ASC were cocultured with the NG108-15 neuronal cell line to determine their ability to promote neurite outgrowth.  Human ASC were isolated from the deep and superficial layers of abdominal fat tissue obtained during abdominoplasty procedures.  RT-PCR was used to investigate the expression of neurotrophic factors.

    Immunohistochemistry showed a superior nerve regeneration distance in the fibrin conduit compared with PHB. The fibrin conduit promoted regeneration of 60% of sensory neurones and 52% of motor neurones when compared with an autograft group at 16 weeks. The total number of myelinated axons in the distal nerve stump in the fibrin-conduit group reached 86% of the graft and the weight of gastrocnemius and soleus muscles recovered to 82% and 89% of the controls, respectively. In vitro studies showed that rat ASC could be differentiated to a Schwann cell phenotype. These treated cells enhanced both the number of NG108-15 cells expressing neurites and neurite length. In the same coculture model system, human superficial fat layer ASC induced significantly enhanced neurite outgrowth when compared with the deep layer fat cells. RT-PCR analysis showed ASC isolated from both layers expressed neurotrophic factors.

    These results indicate that a tubular fibrin conduit can be used to promote neuronal regeneration following peripheral nerve injury. There was also a beneficial effect of using a fibrin matrix to seed cells within/on PHB conduits which should ultimately lead to improved functional recovery following nerve injury.  There might also be an advantage to use a simple strip of PHB rather than a conventional tube-like structure implying that single fascicle nerve grafting could be advantageous for nerve repair.  The results of in vitro experiments indicate adipose tissue contains a pool of regenerative stem cells which can be differentiated to a Schwann cell phenotype and given that human ASC express a range of neurotrophic factors they are likely to be of clinical benefit for treatment of peripheral nerve injuries.

  • 291.
    Kalbermatten, Daniel F
    et al.
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Erba, P
    Mahay, Daljeet
    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.
    Pierer, Gerhard
    Terenghi, Giorgio
    Schwann cell strip for peripheral nerve repair2008In: Journal of Hand Surgery - British and European Volume, ISSN 0266-7681, E-ISSN 1532-2211, Vol. 33, no 5, p. 587-594Article in journal (Refereed)
    Abstract [en]

    Many strategies have been investigated to provide an ideal substitute to treat a nerve gap injury. Initially, silicone conduits were used and more recently conduits fabricated from natural materials such as poly-3-hydroxybutyrate (PHB) showed good results but still have their limitations. Surgically, a new concept optimising harvested autologous nerve graft has been introduced as the single fascicle method. It has been shown that a single fascicle repair of nerve grafting is successful. We investigated a new approach using a PHB strip seeded with Schwann cells to mimic a small nerve fascicle. Schwann cells were attached to the PHB strip using diluted fibrin glue and used to bridge a 10-mm sciatic nerve gap in rats. Comparison was made with a group using conventional PHB conduit tubes filled with Schwann cells and fibrin glue. After 2 weeks, the nerve samples were harvested and investigated for axonal and Schwann cell markers. PGP9.5 immunohistochemistry showed a superior nerve regeneration distance in the PHB strip group versus the PHB tube group (> 10 mm, crossed versus 3.17+/- 0.32 mm respectively, P<0.05) as well as superior Schwann cell intrusion (S100 staining) from proximal (> 10 mm, crossed versus 3.40+/- 0.36 mm, P<0.01) and distal (> 10 mm, crossed versus 2.91+/- 0.31 mm, P<0.001) ends. These findings suggest a significant advantage of a strip in rapidly connecting a nerve gap lesion and imply that single fascicle nerve grafting is advantageous for nerve repair in rats.

  • 292.
    Kalbermatten, Daniel F
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery. Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Kingham, Paul J
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Mahay, Daljeet
    Mantovani, Cristina
    Pettersson, Jonas
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery. Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Raffoul, W
    Balcin, H
    Pierer, G
    Terenghi, Giorgio
    Fibrin matrix for suspension of regenerative cells in an artificial nerve conduit2008In: Journal of plastic, reconstructive and aesthetic surgery, ISSN 1878-0539, Vol. 61, no 6, p. 669-675Article in journal (Refereed)
    Abstract [en]

    Peripheral nerve injury presents with specific problems of neuronal reconstructions, and from a clinical viewpoint a tissue engineering approach would facilitate the process of repair and regeneration. We have previously used artificial nerve conduits made from bioresorbable poly-3-hydroxybutyrate (PHB) in order to refine the ways in which peripheral nerves are repaired and reconnected to the target muscles and skin. The addition of Schwann cells (SC) or differentiated mesenchymal stem cells (dMSC) to the conduits enhances regeneration. In this study, we have used a matrix based on fibrin (Tisseel) to fill optimally the nerve-conduits with cells. In vitro analysis showed that both SC and MSC adhered significantly better to PHB in the presence of fibrin and cells continued to maintain their differentiated state. Cells were more optimally distributed throughout the conduit when seeded in fibrin than by delivery in growth medium alone. Transplantation of the nerve conduits in vivo showed that cells in combination with fibrin matrix significantly increased nerve regeneration distance (using PGP9.5 and S100 distal and proximal immunohistochemistry) when compared with empty PHB conduits. This study shows the beneficial combinatory effect of an optimised matrix, cells and conduit material as a step towards bridging nerve gaps which should ultimately lead to improved functional recovery following nerve injury.

  • 293.
    Kalbermatten, Daniel F
    et al.
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Pettersson, Jonas
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Kingham, Paul J
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Pierer, Gerhard
    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
    New fibrin conduit for peripheral nerve repair2009In: Journal of reconstructive microsurgery, ISSN 0743-684X, E-ISSN 1098-8947, Vol. 25, no 1, p. 27-33Article in journal (Refereed)
    Abstract [en]

    An ideal substitute to treat a nerve gap has not been found. Initially, silicone conduits were employed. Later, conduits were fabricated from collagen or polyesters carbonates. More recently, it has been shown that a bioresorbable material, poly-3-hydroxybutyrate (PHB), can enhance nerve repair. The present investigation shows the use of fibrin as a conduit to guide nerve regeneration and bridge nerve defects. In this study we prepared and investigated a novel nerve conduit made from fibrin glue. Using a rodent sciatic nerve injury model (10-mm gap), we compared the extent of nerve regeneration through the new fibrin conduits versus established PHB conduits. After 2 and 4 weeks, conduits containing proximal and distal stumps were harvested. We evaluated the initial axon and Schwann cell stimulation using immunohistochemistry. The conduits presented full tissue integration and were completely intact. Axons crossed the gap after 1 month. Immunohistochemistry using the axonal marker PGP 9.5 showed a superior nerve regeneration distance in the fibrin conduit compared with PHB (4.1 mm versus 1.9 mm). Schwann cell intrusion (S100 staining) was similarly enhanced in the fibrin conduits, both from the proximal (4.2 mm versus 2.1 mm) and distal ends (3.2 mm versus 1.7 mm). These findings suggest an advantage of the new fibrin conduit for the important initial phase of peripheral nerve regeneration. The use of fibrin glue as a conduit is a step toward a usable graft to bridge peripheral nerve lesions. This might be clinically interesting, given the widespread acceptance of fibrin glue among the surgical community.

  • 294.
    Kalbermatten, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    Schaakxs, Dominique
    Kingham, Paul
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy.
    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.
    Neurotrophic activity of human adipose stem cells isolated from deep and superficial layers of abdominal fatManuscript (preprint) (Other academic)
    Abstract [en]

    New approaches to the clinical treatment of traumatic nerve injuries may one day utilize stem cells to enhance nerve regeneration.  Adipose derived stem cells (ASC) are found in abundant quantities and can be harvested by minimally invasive procedures which should facilitate their use in such regenerative applications.  In this study, we have analyzed the properties of human ASC isolated from the deep and superficial layers of abdominal fat tissue obtained during abdominoplasty procedures.  Cells from the superficial layer proliferated significantly faster than those from the deep layer. Both in the deep and superficial layers, ASC expressed the pluripotent stem cell markers oct4 and nanog and also the stro-1 cell surface antigen.  Superficial layer ASC induced significantly enhanced neurite outgrowth from NG108-15 motor neuron like cells when compared with the deep layer cells.  However, RT-PCR analysis showed that ASC isolated from both layers expressed similar levels of the neurotrophic factors NGF, BDNF, GDNF and NT-3.  These results indicate that human ASC have promising potential for the treatment of traumatic nerve injuries and that superficial layer ASC might represent the more optimal cell type for such applications.

  • 295.
    Kald, A
    et al.
    Department of Surgery at the University of Linkoping, Sweden..
    Nilsson, E
    Anderberg, B
    Bragmark, M
    Engström, P
    Gunnarsson, Ulf
    Department of Surgery, Mora Hospital, S- 792 85 Mora, Sweden.
    Haapaniemi, S
    Lindhagen, J
    Nilsson, P
    Sandblom, G
    Stubberöd, A
    Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies.1998In: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 164, no 1, p. 45-50Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Analysis of reoperation and recurrence rates three years after repair of groin hernias.

    DESIGN: Prospective audit by questionnaire and selective follow-up.

    SETTING: Eight Swedish hospitals.

    SUBJECTS: All groin hernia operations done during 1992 on patients between the ages of 15 and 80 years.

    MAIN OUTCOME MEASURES: Postoperative complications, reoperation for recurrence, and recurrence.

    RESULTS: During 1992, 1565 hernia operations were done. The postoperative complication rate was 8% (125/1565). At 36 months postoperatively 108 recurrences had already been reoperated on, six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up. The interhospital variation in recurrence rate ranged from 3% to 20%. Postoperative complications, recurrent hernia, direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence.

    CONCLUSIONS: The recurrence rate exceeded the reoperation rate for recurrence by almost 40% which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia. An audit scheme, based on prospective recording, reoperation rate, and (periodic) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement.

  • 296.
    Kalliomäki, Maija-L
    et al.
    Institute of Surgical Sciences, Uppsala University, Sweden.
    Meyerson, Josefine
    Institute of Surgical Sciences, Uppsala University, Sweden.
    Gunnarsson, Ulf
    Institute of Surgical Sciences, Uppsala University, Sweden.
    Gordh, Torsten
    Institute of Surgical Sciences, Uppsala University, Sweden.
    Sandblom, Gabriel
    Institute of Surgical Sciences, Uppsala University, Sweden.
    Long-term pain after inguinal hernia repair in a population-based cohort: risk factors and interference with daily activities2008In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 12, no 2, p. 214-225Article in journal (Refereed)
    Abstract [en]

    In the Swedish Hernia Register 2834 inguinal hernia repairs in 2583 patients were registered in the county of Uppsala 1998-2004. In May 2005 the 2421 patients still alive were requested by mail to fill in a validated questionnaire concerning postherniorrhaphy pain. The final response rate became 72%. Altogether 519 patients (29%) stated that they had pain in the operated groin to some extent during past week. In 98 patients (6%) the pain interfered with daily activities. Factors associated with an increased risk of residual pain in a multivariate logistic regression analysis were age below median, operation for recurrence, open repair technique, history of preoperative pain, and less than three years from surgery. Factors not associated with occurrence of residual pain were gender, method of anaesthesia during surgery, hernia sac diameter, postoperative complications, hernia type, need for emergency operation, reducibility of the hernia sac and complete dissection of the hernia sac. Factors found to be associated with impairment of function due to pain in a multivariate logistic regression analysis were: age below median, female gender, medial hernia, open repair technique, postoperative complications, need for operation for recurrence, presence of preoperative pain and less than three years from surgery. The possibility of long-term pain as an outcome after hernia operations should be taken into consideration in the decision making prior to operation.

  • 297.
    Kalliomäki, Maija-Liisa.
    et al.
    Institute of Surgical Sciences, Uppsala University, Uppsala, Sweden and Department of Anaesthesiology, Tampere University Hospital, Tampere, Finland .
    Sandblom, Gabriel
    Department of Surgery, Uppsala University Hospital, Uppsala, Sweden and Department of Surgery, University Hospital of Lund, Lund, Sweden .
    Gunnarsson, Ulf
    Clintec, division of Surgery, Karolinska Institute, Stockholm, Sweden, .
    Gordh, T
    Institute of Surgical Sciences, Uppsala University, Uppsala, Sweden and Department of Anaesthesiology, Uppsala University Hospital, Uppsala, Sweden and Multidisciplinary Pain Centre, Uppsala University Hospital, Uppsala, Sweden and Uppsala Berzelii Centre, Uppsala, Sweden .
    Persistent pain after groin hernia surgery: a qualitative analysis of pain and its consequences for quality of life.2009In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 53, no 2, p. 236-46Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite a high prevalence of persistent groin pain after hernia repair, the specific nature of the pain and its clinical manifestation are poorly known. The aim of this study was to determine the type of post-herniorrhaphy pain and its influence on daily life.

    METHODS: In order to assess long-term pain qualitatively and to explore how it affects quality of life, 100 individuals with persisting pain, identified in a cohort study of patients operated for groin hernia, were neurologically examined, along with 100 pain-free controls matched for age, gender and type of operation. The patients were asked to answer the SF-36 questionnaire, the hospital anxiety and depression scale, the Swedish Scales of Personality (SSP) and a standardised questionnaire for assessing everyday life coping. The patients were approached approximately 4.9 years after surgery.

    RESULTS: Twenty-two patients from the pain group had become pain free by the time of examination, whereas 76 patients still had pain, of whom 47 (68%) suffered from neuropathic pain and 11 from nociceptive pain. The remaining patients suffered from mixed pain, neuropathic and nociceptive, or were found to have another reason for pain. All dimensions of SF-36 were poorer for the pain group than the control group.

    CONCLUSION: Persistent post-herniorrhaphy pain is mainly neuropathic and has a substantial impact on health-related quality of life.

  • 298.
    Kalliomäkia, Maija-Liisa
    et al.
    Uppsala University, Department for Surgical Sciences, Uppsala, Sweden. Department of Anaesthesia, Tampere University Hospital, Finland.
    Sandblom, Gabriel
    Karolinska Institutet, CLINTEC, Stockholm, Sweden.
    Mathias, Hallberg
    Department of Pharmaceutical Biosciences, Division of Biological Research on Drug Dependence, Uppsala University, Uppsala, Sweden.
    Grönbladh, Alfhild
    Department of Pharmaceutical Biosciences, Division of Biological Research on Drug Dependence, Uppsala University, Uppsala, Sweden.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gordh, Torsten
    Uppsala University, Department for Surgical Sciences, Uppsala, Sweden. Pain Centre, Uppsala University Hospital, Uppsala, Sweden.
    Ginya, Harumi
    Division of IVD System Development, Precision System Science Co., Ltd., Chiba, Japan.
    Nyberg, Fred
    Department of Pharmaceutical Biosciences, Division of Biological Research on Drug Dependence, Uppsala University, Uppsala, Sweden.
    Genetic susceptibility to postherniotomy pain: the influence of polymorphisms in the Mu opioid receptor, TNF-α, GRIK3, GCH1, BDNF and CACNA2D2 genes2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 12, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Background and aims: Despite improvements in surgical technique, 5%–8% of patients undergoing herniorrhaphy still suffer from clinically relevant persistent postherniotomy pain. This is a problem at both individual and society levels. The aim of this study was to determine whether or not a single nucleotide polymorphism in a specific gene contributes to the development of persistent pain after surgery.

    Methods: One hundred individuals with persistent postherniotomy pain, along with 100 without pain matched for age, gender and type of surgery were identified in a previous cohort study on patients operated for groin hernia. All patients underwent a thorough sensory examination and blood samples were collected. DNA was extracted and analysed for single nucleotide polymorphism in the Mu opioid receptor, TNF-α, GRIK3, GCH1, BDNF and CACNA2D2 genes.

    Results: Patients with neuropathic pain were found to have a homozygous single nucleotide polymorph in the TNF-α gene significantly more often than pain-free patients (P = 0.036, one-tailed test).

    Conclusions: SNP in the TNF-α gene has a significant impact on the risk for developing PPSP.

    Implications: The result suggests the involvement of genetic variance in the development of pain and this requires further investigation.

  • 299.
    Kamel, Ashraf F
    et al.
    Department of Pediatrics, Huddinge University Hospital, Huddinge, Sweden.
    Norgren, Svante
    Department of Pediatrics, Huddinge University Hospital, Huddinge, Sweden.
    Strigård, Karin
    Department of Surgery, Huddinge University Hospital, Huddinge, Sweden.
    Thörne, Anders
    Endocrine Research Unit, Huddinge University Hospital, Huddinge, Sweden.
    Fakhrai-Rad, Hossein
    Department of Molecular Medicine, Karolinska Hospital, Stockholm, Sweden.
    Galli, Joakim
    Department of Molecular Medicine, Karolinska Hospital, Stockholm, Sweden.
    Marcus, Claude
    Department of Pediatrics, Huddinge University Hospital, Huddinge, Sweden.
    Age-dependent regulation of lipogenesis in human and rat adipocytes.2004In: Journal of Clinical Endocrinology and Metabolism, ISSN 0021-972X, E-ISSN 1945-7197, Vol. 89, no 9, p. 4601-4606Article in journal (Refereed)
    Abstract [en]

    The regulation of adipocyte metabolism is of importance for adipose tissue growth and therefore also for the development of obesity. This study was designed to investigate the regulation of basal and insulin-induced lipogenesis, glucose transport, and glucose transporter protein expression in human and rat adipocytes from different age groups. The study included 21 infants, 21 children, nine adults, and 80 male weaned and 20 male adult Fischer rats. The lipogenesis experiments were performed under conditions at which glucose transport is rate limiting. Basal lipogenesis was approximately three times higher in infants and children than in adults, whereas insulin-induced lipogenesis was two times higher in infants than in children and adults. In rats, basal lipogenesis, insulin-induced lipogenesis, and insulin sensitivity were two times higher in weaned than in adult animals. Moreover, basal and insulin-induced glucose transport were two times higher in weaned than in adult rats. No differences were detected in GLUT1 or GLUT4 content between any of the age groups in human or in rat adipocytes. In conclusion, basal and insulin-stimulated lipogenesis are increased in adipocytes early in life. This may promote adipose tissue growth in early age. The data indicate that age-dependent variation in basal and insulin-stimulated lipogenesis is differently regulated.

  • 300. Karakatsanis, Andreas
    et al.
    Christiansen, Peer Michael
    Fischer, Lone
    Hedin, Christina
    Pistioli, Lida
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rasmussen, Nils Ryegaard
    Jørnsgård, Hjørdis
    Tegnelius, Daniel
    Eriksson, Staffan
    Daskalakis, Kosmas
    Wärnberg, Fredrik
    Markopoulos, Christos J.
    Bergkvist, Leif
    The Nordic SentiMag trial: a comparison of super paramagnetic iron oxide (SPIO) nanoparticles versus Tc(99) and patent blue in the detection of sentinel node (SN) in patients with breast cancer and a meta-analysis of earlier studies.2016In: Breast Cancer Research and Treatment, ISSN 0167-6806, E-ISSN 1573-7217, Vol. 157, no 2, p. 281-294Article in journal (Refereed)
    Abstract [en]

    The aim of the study is to compare the efficacy of SPIO as a tracer in sentinel node biopsy (SNB) in breast cancer with Tc and patent blue in a multicentre prospective study and perform a meta-analysis of all published studies. It also aims to follow skin discoloration after SPIO injection and describe when and how it resolves. Totally 206 patients with early breast cancer were recruited. Tc and patent blue were administered in standard fashion. Patients were injected with SPIO (Sienna+) preoperatively. SNB was performed and detection rates were recorded for both methods. Skin discoloration was followed and documented postoperatively. Data extraction and subsequent meta-analysis of all previous studies were also performed. SN detection rates were similar between standard technique succeeded and SPIO both per patient (97.1 vs. 97.6 %, p = 0.76) as well as per node (91.3 vs. 93.3 %, p = 0.34), something which was not affected by the presence of malignancy. Concordance rates were also consistently high (98.0 % per patient and 95.9 % per node). Discoloring was present in 35.5 % of patients postoperatively, almost exclusively in breast conservation. It fades slowly and is still detectable in 8.6 % of patients after 15 months. Meta-analysis depicted similar detection rates (p = 0.71) and concordance rates (p = 0.82) per patient. However, it seems that SPIO is characterized by higher nodal retrieval (p < 0.001). SPIO is an effective method for the detection of SN in patients with breast cancer. It is comparable to the standard technique and seems to simplify logistics. Potential skin discoloration is something of consideration in patients planned for breast conservation.

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