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  • 251. 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, 5- p.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.

  • 252.
    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, 439-442 p.Article 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.

  • 253.
    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, 689-695 p.Article 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.

  • 254.
    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, 2579-2583 p.Article 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.

  • 255.
    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.

  • 256.
    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, 1637-1640 p.Article 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.

  • 257.
    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, 1356-1358 p.Article 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.

  • 258.
    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, 118-121 p.Article 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.

  • 259. 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, 1541-1541 p.Article in journal (Refereed)
  • 260.
    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, 189-192 p.Article 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.

  • 261.
    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.

  • 262. 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, 373-381 p.Article 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.

  • 263. 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, 731-740 p.Article 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.

  • 264. 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, 977-986 p.Article 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.

  • 265. 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, 2683-2690 p.Article 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.

  • 266.
    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, 1623-1629 p.Article 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.

  • 267.
    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, 363-368 p.Article 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.

  • 268. 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, 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.

  • 269.
    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.

  • 270.
    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, 587-594 p.Article 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.

  • 271.
    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, 669-675 p.Article 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.

  • 272.
    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, 27-33 p.Article 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.

  • 273.
    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.

  • 274.
    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, 45-50 p.Article 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.

  • 275.
    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, 214-225 p.Article 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.

  • 276.
    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, 236-46 p.Article 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.

  • 277.
    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, 1-6 p.Article 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.

  • 278.
    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, 4601-4606 p.Article 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.

  • 279.
    Karalija, Amar
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Andersson, Magnus N
    The surgical treatment of familial cylindromatosis through subgaleal scalp excision.2015In: Case reports in plastic surgery & hand surgery, Vol. 2, no 3-4, 57-9 p.Article in journal (Refereed)
    Abstract [en]

    We treated a 65-year-old woman with familial cylindromatosis, with cylindromas covering the entire scalp. Subgaleal tumor excision and split skin grafting was performed. The graft take was deemed to be excellent, with almost 100% coverage 2.5 weeks after operation, no complications and a satisfying esthetic result.

  • 280.
    Kastensson, Ida
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Superficial perfusion ratio after sphincter injury (SPRASI)2017Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 281.
    Kersten, Christian
    et al.
    Southern Hospital Trust, Kristiansand, Norway.
    Louhimo, Johanna
    University of Helsinki, Finland.
    Ålgars, Annika
    Turku University Hospital, Turku, Finland.
    Lahdesmaki, Aleksi
    Pkorvoo Hospital, Porvoo, Finland.
    Cvancerova, Milada
    University of Agder, Kristiansand, Norway.
    Stenstedt, Kristina
    Karolinska University Hospital, Stockholm, Sweden.
    Haglund, Caj
    University of Helsinki, Helsinki, Finland.
    Gunnarsson, Ulf
    Department for Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden .
    Increased C-reactive protein implies a poorer stage-specific prognosis in colon cancer2013In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 52, no 8, 1691-1698 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: To characterize the stage-specific prognostic relevance of preoperative systemic inflammatory response, defined by C-reactive protein (CRP), in colon cancer (CC) patients.

    MATERIAL AND METHODS: Data from CC patients operated on from 1998 to 2007 at three hospitals from three different Nordic countries were collected retrospectively from national registries, local databases and/or patient records. Patients with emergency surgery, infection or auto-immune disease were excluded. Associations between clinical or histopathological variables and CRP were assessed. Patients were followed from the date of surgery to death or end of follow-up. Disease-specific survival (DSS) was the main endpoint.

    RESULTS: In total, 525 patients with age and stage distributions which were representative for CC patients were included. None of the patients was lost to follow-up. Age, TNM Stage, WHO differentiation grade and right-sided tumor location significantly associated with elevated CRP values, in contrast to postoperative morbidity, which did not. CRP levels were found to be a strong prognostic factor for DSS in CC. The risk of death due to CC was augmented with increasing levels of CRP in every stage of operated CC. Both short- and long-term DSS were impaired. The sub-hazard ratios for CRP-levels above 60 mg/L were 7.37 (CI 2.65-20.5) for stage I+ II, compared to 3.29 (CI 1.30-8.29) for stage III and 2.24 (CI 1.16-4.35) for stage IV.

    CONCLUSION: Increase of CRP concentrations correlate with clinically relevant poorer disease-specific survival in each stage of CC.

  • 282. Kjellin, A.
    et al.
    Hedman, Leif
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Escher, C.
    Fellander-Tsai, L.
    Hybrid simulation: bringing motivation to the art of teamwork training in the operating room2014In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 103, no 4, 232-236 p.Article in journal (Refereed)
    Abstract [en]

    Background and Aims: Crew resource management-based operating room team training will be an evident part of future surgical training. Hybrid simulation in the operating room enables the opportunity for trainees to perform higher fidelity training of technical and non-technical skills in a realistic context. We focus on situational motivation and self-efficacy, two important factors for optimal learning in light of a prototype course for teams of residents in surgery and anesthesiology and nurses. Material and Methods: Authentic operating room teams consisting of residents in anesthesia (n = 2), anesthesia nurses (n = 3), residents in surgery (n = 2), and scrub nurses (n = 6) were, during a one-day course, exposed to four different scenarios. Their situational motivation was self-assessed (ranging from 1 = does not correspond at all to 7 = corresponds exactly) immediately after training, and their self-efficacy (graded from 1 to 7) before and after training. Training was performed in a mock-up operating theater equipped with a hybrid patient simulator (SimMan 3G; Laerdal) and a laparoscopic simulator (Lap Mentor Express; Simbionix). The functionality of the systematic hybrid procedure simulation scenario was evaluated by an exit questionnaire (graded from 1 = disagree entirely to 5 = agree completely). Results and Conclusions: The trainees were mostly intrinsically motivated, engaged for their own sake, and had a rather great degree of self-determination toward the training situation. Self-efficacy among the team members improved significantly from 4 to 6 (median). Overall evaluation showed very good result with a median grading of 5. We conclude that hybrid simulation is feasible and has the possibility to train an authentic operating team in order to improve individual motivation and confidence.

  • 283. Klevebro, F.
    et al.
    Johnsen, G.
    Johnson, E.
    Viste, A.
    Myrnäs, T.
    Szabo, E.
    Jacobsen, A. -B.
    Friesland, S.
    Tsai, J. A.
    Persson, S.
    Lindblad, M.
    Lundell, L.
    Nilsson, M.
    Morbidity and mortality after surgery for cancer of the oesophagus and astro-oesophageal junction: a randomized clinical trial of neoadjuvant hemotherapy vs. neoadjuvant chemoradiation2015In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 41, no 7, 920-926 p.Article in journal (Refereed)
    Abstract [en]

    Objective: To compare the incidence and severity of postoperative omplications after oesophagectomy for carcinoma of the oesophagus and astro-oesophageal junction (GOJ) after randomized accrual to eoadjuvant chemotherapy (nCT) or neoadjuvant chemoradiotherapy (nCRT). ackground: Neoadjuvant therapy improves long-term survival after esophagectomy. To date, evidence is insufficient to determine whether ombined nCT, or nCRT alone, is the most beneficial. ethods: Patients with carcinoma of the oesophagus or GOJ, resectable ith a curative intention, were enrolled in this multicenter trial onducted at seven centres in Sweden and Norway. Study participants re andomized to nCT or nCRT followed by surgery with two-field ymphadenectomy. Three cycles of cisplatin/5-fluorouracil was dministered in all patients, while 40 Gy of concomitant radiotherapy as administered in the nCRT group. esults: Of the randomized 181 patients, 91 were assigned to nCT and 90 o nCRT. One-hundred-and-fifty-five patients, 78 nCT and 77 nCRT, nderwent resection. There was no statistically significant difference etween the groups in the incidence of surgical or nonsurgical omplications (P-value = 0.69 and 0.13, respectively). There was no 0-day mortality, while the 90-day mortality was 3% (2/78) in the nCT roup and 6% (5/77) in the nCRT group (P = 0.24). The median lavien-Dindo complication severity grade was significantly higher in he nCRT. group (P = 0.001). onclusion: There was no significant difference in the incidence of omplications between patients randomized to nCT and nCRT. However, omplications were significantly more severe after nCRT. Registration rial database: The trial was registered in the Clinical Trials tabase registration number NCT01362127). 

  • 284.
    Kolar, Mallappa K
    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.
    The use of adipose derived stem cells in spinal cord and peripheral nerve repair2014Licentiate thesis, comprehensive summary (Other academic)
    Abstract [en]

    Clinically, injuries affecting the spinal cord or peripheral nerves can leave those affected with severe disability and, at present, there are limited options for treatment. Peripheral nerve injury with a significant gap between the proximal and distal stumps is currently treated with autologous nerve grafting but this is limited by availability of donor nerve and has associated morbidities. In contrast, injuries to the spinal cord lead to an inhibitory environment caused by the glial cells and thereby, limit potential axonal regeneration. This thesis investigates the effects of human adipose derived stem cells (ASC) on regeneration after peripheral nerve and spinal cord injury in adult rats.

    Human ASC expressed various neurotrophic molecules and growth factor stimulation of the cells in vitro resulted in increased secretion of BDNF, GDNF, VEGF-A and angiopoietin-1 proteins. Stimulated ASC also showed an enhanced ability to induce capillary-like tube formation in an in vitro angiogenesis assay. In contrast to Schwann cells, ASC did not induce activation of astrocytes and supported neurite outgrowth from the adult rat sensory DRG neurons in culture.

    In a peripheral nerve injury model, ASC were seeded into a fibrin conduit, which was used to bridge a 10 mm rat sciatic nerve gap. After 2 weeks, ASC enhanced GAP-43 and ATF-3 expression in the spinal cord, reduced c-jun expression in the DRG and increased the vascularity of the fibrin nerve conduits. The animals treated with stimulated ASC showed an enhanced axon regeneration and reduced caspase-3 expression in the DRG.

    After transplantation into the injured C3-C4 cervical spinal cord. ASC continued to express neurotrophic factors and laminin and stimulated extensive ingrowths of 5HT-positive raphaespinal axons into the trauma zone. In addition, ASC induced sprouting of raphaespinal terminals in C2 contralateral ventral horn and C6 ventral horn on both sides. Transplanted cells also changed the structure and the density of the astroglial scar. Although the transplanted cells had no effect on the density of capillaries around the lesion site, the reactivity of OX42-positive microglial cells was markedly reduced.

  • 285.
    Koskinen, Lars-Owe D.
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Grayson, David
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Olivecrona, Magnus
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    The complications and the position of the Codman MicroSensor (TM) ICP device: an analysis of 549 patients and 650 Sensors2013In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 155, no 11, 2141-2148 p.Article in journal (Refereed)
    Abstract [en]

    Complications of and insertion depth of the Codman MicroSensor ICP monitoring device (CMS) is not well studied. To study complications and the insertion depth of the CMS in a clinical setting. We identified all patients who had their intracranial pressure (ICP) monitored using a CMS device between 2002 and 2010. The medical records and post implantation computed tomography (CT) scans were analyzed for occurrence of infection, hemorrhage and insertion depth. In all, 549 patients were monitored using 650 CMS. Mean monitoring time was 7.0 +/- 4.9 days. The mean implantation depth was 21.3 +/- 11.1 mm (0-88 mm). In 27 of the patients, a haematoma was identified; 26 of these were less than 1 ml, and one was 8 ml. No clinically significant bleeding was found. There was no statistically significant increase in the number of hemorrhages in presumed coagulopathic patients. The infection rate was 0.6 % and the calculated infection rate per 1,000 catheter days was 0.8. The risk for hemorrhagic and infectious complications when using the CMS for ICP monitoring is low. The depth of insertion varies considerably and should be taken into account if patients are treated with head elevation, since the pressure is measured at the tip of the sensor. To meet the need for ICP monitoring, an intraparenchymal ICP monitoring device should be preferred to the use of an external ventricular drainage (EVD).

  • 286.
    Kverneng Hultberg, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Angenete, E.
    Lydrup, M. -L
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Matthiessen, P.
    Rutegård, Martin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nonsteroidal anti-inflammatory drugs and the risk of anastomotic leakage after anterior resection for rectal cancer2017In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 43, no 10, 1908-1914 p.Article in journal (Refereed)
    Abstract [en]

    Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely used in colorectal surgery due to their opioid-sparing effect. However, several studies have indicated an increased risk of anastomotic leakage following NSAID treatment, although conflicting results exist. The primary goal of this study was to further examine whether postoperative NSAIDs are independently associated with anastomotic leakage after anterior resection for rectal cancer. Methods: Patients who underwent anterior resection for rectal cancer during 2007-2013 in 15 different hospitals in three healthcare regions in Sweden were included in the study. Registry data and information from patient records were retrieved. The association between NSAID treatment (for at least two days in the first postoperative week) and symptomatic anastomotic leakage (within 90 days) was evaluated with multiple logistic regression, with adjustment for pertinent confounding factors. Results: Some 1495 patients were included in the study. Of these, 27% received postoperative NSAIDs for at least two days in the first postoperative week. Symptomatic anastomotic leakage occurred in 11% and 14% in the NSAID and non-NSAID group, respectively. With adjustment for confounders, the odds ratio for leakage among patients who received NSAIDs compared with those who did not was 0.88 (95% CI 0.65-1.20). No differences were seen between non-selective and COX-2-selective NSAIDs. Conclusion: Postoperative NSAID treatment does not seem to increase the risk of symptomatic anastomotic leakage after anterior resection for rectal cancer. NSAID use appears to be safe, but a well-powered randomized clinical trial is warranted.

  • 287.
    Kärrholm, Johan
    et al.
    Sahlgrenska University Hospital.
    Nivbrant, Bo
    University of Western Australia.
    Thanner, Jonas
    Sahlgrenska University Hospital.
    Anderberg, Christian
    Sahlgrenska University Hospital.
    Börlin, Niclas
    Umeå University, Faculty of Science and Technology, Department of Computing Science.
    Herberts, Peter
    Sahlgrenska University Hospital.
    Malchau, Henrik
    Massachusetts General Hospital, Boston, MA.
    Radiostereometric evaluation of hip implant design and surface finish: Micromotion of cemented femoral stems2000Other (Other academic)
  • 288. Køstner, Anne Helene
    et al.
    Kersten, Christian
    Löwenmark, Thyra
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Ydsten, Karin A
    Peltonen, Reetta
    Isoniemi, Helena
    Haglund, Caj
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Isaksson, Bengt
    The prognostic role of systemic inflammation in patients undergoing resection of colorectal liver metastases: C-reactive protein (CRP) is a strong negative prognostic biomarker2016In: Journal of Surgical Oncology, ISSN 0022-4790, E-ISSN 1096-9098, Vol. 114, no 7, 895-899 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND OBJECTIVES: Systemic inflammation has been associated with poor survival in several tumor types, but has been less extensively studied in resectable metastatic disease. The aim of the present study was to evaluate the prognostic role of CRP in colorectal cancer patients with liver metastases (CRLM) compared to conventional tumor- and patient-related clinicopathological features as well as other indicators of the systemic inflammatory response (SIR).

    METHODS: A multinational retrospective study of 492 CRLM patients undergoing potentially curative resection of liver metastases between 1999 and 2009. Clinicopathological findings and the SIR markers CRP, hypoalbuminemia, and their combined Glasgow Prognostic Score (GPS) were analyzed.

    RESULTS: Multivariate analysis showed that preoperative CRP >10 mg/L was a strong predictor of compromised survival (HR = 1.72, 95%CI 1.84-2.50, P < 0.01). Patients with CRP ≤10 mg/L had a median survival of 4.27 years compared to only 47 days in patients with CRP ≥30 mg/L (P < 0.01). Similarly, increased GPS was independently predictive of poor survival (HR 1.67, 95%CI 1.22-2.27, P < 0.01), but hypoalbuminemia alone did not have significant prognostic value.

    CONCLUSIONS: CRP alone is a strong prognostic factor, following curative resection of colorectal liver metastases and should be taken into consideration when selecting treatment strategies in CRLM patients. 

  • 289. Kühn, Tilman
    et al.
    Kaaks, Rudolf
    Becker, Susen
    Eomois, Piia-Piret
    Clavel-Chapelon, Françoise
    Kvaskoff, Marina
    Dossus, Laure
    Tjønneland, Anne
    Olsen, Anja
    Overvad, Kim
    Chang-Claude, Jenny
    Lukanova, Annekatrin
    Buijsse, Brian
    Boeing, Heiner
    Trichopoulou, Antonia
    Lagiou, Pagona
    Bamia, Christina
    Masala, Giovanna
    Krogh, Vittorio
    Sacerdote, Carlotta
    Tumino, Rosario
    Mattiello, Amalia
    Buckland, Genevieve
    Sánchez, María-José
    Menéndez, Virginia
    Chirlaque, María-Dolores
    Barricarte, Aurelio
    Bueno-de-Mesquita, H Bas
    van Duijnhoven, Fränzel J B
    van Gils, Carla H
    Bakker, Marije F
    Weiderpass, Elisabete
    Skeie, Guri
    Brustad, Magritt
    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.
    Wareham, Nick
    Khaw, Kay Tee
    Travis, Ruth C
    Schmidt, Julie A
    Rinaldi, Sabina
    Romieu, Isabelle
    Gallo, Valentina
    Murphy, Neil
    Riboli, Elio
    Linseisen, Jakob
    Plasma 25-hydroxyvitamin D and the risk of breast cancer in the European prospective investigation into cancer and nutrition: A nested case-control study2013In: International Journal of Cancer, ISSN 0020-7136, E-ISSN 1097-0215, Vol. 133, no 7, 1689-1700 p.Article in journal (Refereed)
    Abstract [en]

    Experimental evidence suggests that vitamin D might play a role in the development of breast cancer. Although the results of case-control studies indicate that circulating 25-hydroxyvitamin D [25(OH)D] is inversely associated with the risk of breast cancer, the results of prospective studies are inconsistent. A case-control study embedded in the European Prospective Investigation into Cancer and Nutrition (EPIC) was carried out comprising 1,391 incident breast cancer cases and 1,391 controls. Multivariable conditional logistic regression models did not reveal a significant overall association between season-standardized 25(OH)D levels and the risk of breast cancer (ORQ4-Q1 [95% CI]: 1.07 [0.85-1.36], ptrend = 0.67). Moreover, 25(OH)D levels were not related to the risks of estrogen receptor positive tumors (ORQ4-Q1 [95% CI]: 0.97 [0.67-1.38], ptrend = 0.90) and estrogen receptor negative tumors (ORQ4-Q1 [95% CI]: 0.97 [0.66-1.42], ptrend = 0.98). In hormone replacement therapy (HRT) users, 25(OH)D was significantly inversely associated with incident breast cancer (ORlog2 [95% CI]: 0.62 [0.42-0.90], p = 0.01), whereas no significant association was found in HRT nonusers (ORlog2 [95% CI]: 1.14 [0.80-1.62], p = 0.48). Further, a nonsignificant inverse association was found in women with body mass indices (BMI) < 25 kg/m(2) (ORlog2 [95% CI]: 0.83 [0.67-1.03], p = 0.09), as opposed to a borderline significant positive association in women with BMI ≥ 25 kg/m(2) (ORlog2 [95% CI]: 1.30 [1.0-1.69], p = 0.05). Overall, prediagnostic levels of circulating 25(OH)D were not related to the risk of breast cancer in the EPIC study. This result is in line with findings in the majority of prospective studies and does not support a role of vitamin D in the development of breast cancer.

  • 290.
    Laestadius, Vidar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Surgical treatment for pilonidal sinus; a study comparing Karydakis flap, Bascom’s technique and healing by secondary intention2015Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 291. Larcher, Martin
    et al.
    Forsberg, Rebecca
    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.
    Holgersson, Annelie
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Solomos, George
    Effectiveness of finite-element modelling of damage and injuries for explosions inside trains2016In: Journal of Transportation Safety and Security, ISSN 1943-9962, Vol. 8, 83-100 p.Article in journal (Refereed)
    Abstract [en]

    The rail-bound sector has become a preferred target of terrorist attacks because of its vulnerability, and the most frequent way to carry out these attacks has been the use of explosive devices.The aim of this study is to investigate the effectiveness of modelling detonation effects inside train carriages using explicit finite element techniques. The numerical simulations consider fluid-structure interaction phenomena and several parametric studies are conducted. Carriage damage and injuries to the passengers are examined. Displacements in the model of the carriage structure do not vary greatly for small changes of the charge size, its location, or by open doors. Changing charge size, the location of the detonation, and door setting however had significant impact on the risk of eardrum rupture and fatality. Comparison of the simulation and real life data demonstrate a good agreement between the real and calculated displacements of the carriage, whereas the risk of death and eardrum rupture is slightly higher in the calculations. The model presented can reproduce a reliable actual situation if more parameters that influence injuries of blast waves were considered.

  • 292.
    Larsson, Hans-Olov
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics. Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Quantitative morphological studies of the parathyroid gland1983Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    This work is based upon a series of quantitative morphological studies of the parathyroid glands of Mongolian gerbils and rats. Standard stereological methods were used on light and electron microscopical levels.

    Subclassification of the chief cells based on the staining affinity and electron density of the cytoplasm was not correlated with contents (volume and surface densities) of organelles.

    Compared to fixation by immersion, fixation by perfusion caused a remarkable reduction in the number of light chief cells and atrophic cells, indicating that the occurrence of those kind of cells is dependent on factors of artifactual nature.

    The early response of the parathyroid gland to altered concentrations of extracellular calcium was studied in vitro. At six hours of "incubation, enlargement of the Golgi zone (Golgi complex and presecretory granules), but unaltered endoplasmic reticulum, was seen in glands incubated in low (0,5 mM) compared to those incubated in high (3,0 mM) calcium concentrations.

    Prolonged hypocalcemia induced in vivo by intraperitoneal injections of ethylenediaminetetraacetate and calcium deficient diet for eight days, did not give rise to any major quantitative morphological changes in the individual parathyroid cell, and furthermore, the quantitative morphology of the parathyroid cell was unchanged in experimentally induced hyperparathyroidism (calcium deficient diet for 16 weeks).

    The morphological data do not support the opinion of a functional cycle in the parathyroid chief cell, but suggest that the early response of this cell to altered extracellular calcium may be funtional activities associated with the Golgi zone.

  • 293.
    Larsson, Niklas
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Claesson Lingehall, Helena
    Umeå University, Faculty of Medicine, Department of Nursing.
    Al Zaidi, Nefar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Claesson, Jonas
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Jensen-Waern, Marianne
    Lehtipalo, Stefan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Percutaneously inserted long-term central venous catheters in pigs of different sizes2015In: Laboratory Animals. Journal of the Laboratory Animal Science Association, ISSN 0023-6772, E-ISSN 1758-1117, Vol. 49, no 3, 215-219 p.Article in journal (Refereed)
    Abstract [en]

    Pigs are used for long-term biomedical experiments requiring repeated injections, infusions and collections of blood samples. Thus, it is necessary for vascular catheters to be indwelling to avoid undue stress to the animals and the use of restraints. We propose a refined model of percutaneous insertion of long-term central venous catheters to minimize the surgical trauma and postoperative complications associated with catheter insertion. Different sizes of needles (18 Ga versus 21 Ga) for initial puncture of the veins were compared. In conventional pigs weighing less than 30 kg, catheter insertion may be facilitated by using a microintroducer set with a 21 Ga needle. In pigs weighing 50 kg, a standard 18 Ga needle may be preferable.

  • 294. Laurell, H
    et al.
    Hansson, L E
    Department of Surgery, Mora Hospital, Mora.
    Gunnarsson, Ulf
    The Department of Surgical Sciences, Akademiska sjukhuset, Colorectal Unit, Uppsala University, SE 751 85, Uppsala, Sweden.
    Why do surgeons miss malignancies in patients with acute abdominal pain?2006In: Anticancer Research, ISSN 0250-7005, E-ISSN 1791-7530, Vol. 26, no 5B, 3675-8 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to characterize patients seeking medical advice for acute abdominal pain who were later diagnosed with an intra-abdominal malignancy.

    PATIENTS AND METHODS: Patients with acute abdominal pain were registered between 1997 and 2000, employing a detailed schedule comprising 111 parameters. The diagnoses (n=2395 patients) were re-evaluated one year later.

    RESULTS: A total of 66 patients (2.8%) were found to have an intra-abdominal malignancy at follow-up, of whom 37 cases had been undetected at discharge. Malignancy of the liver, biliary tract and pancreas constituted 30% and colorectal cancer 32% of the tumours undetected at discharge. Constipation, intestinal obstruction and non-specific abdominal pain (NSAP) were the most common preliminary diagnoses in patients among whom abdominal malignancy was later detected.

    CONCLUSION: Except for age and pain duration, the history and clinical investigation provide few clues to suggest an abdominal malignancy in patients with acute abdominal pain. NSAP, of unknown or known etiology, including constipation, should be suspected as a possible sign of abdominal malignancy in all patients over 50 years of age.

  • 295.
    Laurell, H
    et al.
    Department of Surgery, Mora Hospital, Mora, Sweden.
    Hansson, L-E
    Gunnarsson, Ulf
    The Department of Surgical Sciences, Akademiska sjukhuset, Colorectal Unit, Uppsala University, SE 751 85, Uppsala, Sweden.
    Acute abdominal pain among elderly patients.2006In: Gerontology, ISSN 0304-324X, E-ISSN 1423-0003, Vol. 52, no 6, 339-44 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Diagnosis of acute abdominal pain in older persons is a challenge, with the age-related increase in concurrent diseases. In most western countries the number of elderly people is constantly rising, which means that an increasing proportion of patients admitted for abdominal pain at the emergency department are elderly.

    OBJECTIVE: To characterize differences in clinical presentation and diagnostic accuracy between younger and more elderly patients with acute abdominal pain.

    METHODS: Patients admitted to Mora Hospital with abdominal pain of up to seven days' duration were registered according to a detailed schedule. From 1st February 1997 to 1st June 2000, 557 patients aged 65-79 years and 274 patients aged > or = 80 years were registered. Patients aged 20-64 years (n = 1,458) served as a control group.

    RESULTS: A specific diagnosis, i.e. other than 'nonspecific abdominal pain', was established in 76 and 78% of the patients aged 65-79 and > or = 80 years respectively, and in 64% of those aged 20-64 (p < 0.001). Pain duration before admission increased with age (p < 0.003), as did frequency and duration of hospitalization (p < 0.0001). Hospital stay increased from 170 days per 100 emergency admissions in the control group to 320 and 458 days in the younger and older study groups, respectively. At the emergency department, older patients were more often misdiagnosed than control patients (52 vs. 45%; p = 0.002). At discharge the diagnosis was more accurate in the control group (86 vs. 77%; p < 0.0001). Hospital mortality was higher among older patients (23/831 vs. 2/1,458; p < 0.001). The admission-to-surgery interval was increased (1.8 vs. 0.9 days, p < 0.0001) in patients > or = 65 years. Rebound tenderness (p < 0.0001), local rigidity (p = 0.003) and rectal tenderness (p = 0.004) were less common in the older than in the control patients with peritonitis. In patients > or = 65 years, C-reactive protein did not differ between patients operated on and those not, contrary to the finding in patients < 65 years (p < 0.0001).

    CONCLUSION: Both the preliminary diagnosis at the emergency department and the discharge diagnosis were less reliable in elderly than in younger patients. Elderly patients more often had specific organic disease and arrived at the emergency department after a longer history of abdominal pain compared to younger patients.

  • 296.
    Laurell, H
    et al.
    Department of Surgery at Mora Hospital, Mora, Sweden and Department of Surgery at Uppsala University Hospital, Uppsala.
    Hansson, L-E
    Department of Surgery at Sahlgrenska University Hospital, Gothenburg, Sweden.
    Gunnarsson, Ulf
    Department of Surgery at Uppsala University Hospital, Uppsala.
    Acute diverticulitis--clinical presentation and differential diagnostics.2007In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 9, no 6, 496-501; discussion 501 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the clinical presentation of acute diverticulitis in an emergency department and to characterize the natural history of diverticulitis in the short perspective. Comparisons are made with an important differential diagnosis, nonspecific abdominal pain (NSAP).

    METHOD: Patients admitted to our hospital with abdominal pain of up to 7 days' duration were registered prospectively using a detailed schedule for history, symptoms and signs, from 1 February 1997 to 1 June 2000. Of 3349 patients initially included, 3073 (92%) were eligible for follow up after 1-3 years.

    RESULTS: Acute diverticulitis was the final diagnosis in 145 patients and NSAP in 1142 patients. The incidence of hospitalized patients with diverticulitis was 47 per year and 100 000 population, with a mean hospital stay of 3.3 days. Patients with diverticulitis, more frequently than NSAP, had a longer history and laboratory signs of inflammatory activity. Isolated left abdominal tenderness was more common in diverticulitis, whereas isolated right abdominal tenderness was more common in NSAP. Duration of symptoms on arrival was independent of age and was not correlated to C-reactive protein, leucocytes or body temperature. Sensitivity of diverticulitis as primary diagnosis was 64% and specificity 97%. Corresponding figures for NSAP were 43% and 90% respectively. Age and gender did not influence diagnostic accuracy or risk of surgery.

    CONCLUSION: Diverticulitis differs significantly from NSAP in clinical presentation and laboratory parameters. Sensitivity of primary diagnosis for diverticulitis and NSAP was low.

  • 297.
    Laurell, H.
    et al.
    Department of Surgery, Mora Hospital, Mora, Sweden.
    Hansson, L.-E.
    Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Gunnarsson, Ulf
    Department of Surgery, Karolinska Institute, Stockholm, Sweden.
    Manifestations of acute appendicitis: a prospective study on acute abdominal pain.2013In: Digestive Surgery, ISSN 0253-4886, E-ISSN 1421-9883, Vol. 30, no 3, 198-206 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND/AIMS: The aim of this prospective study was to identify the clinical symptoms and signs most important for the prediction of appendicitis among patients with acute abdominal pain.

    METHODS: Clinical findings in 2,478 patients admitted to the emergency department of Mora Hospital from February 1997 to June 2000, with acute abdominal pain of up to 7 days' duration, were registered in a database. The medical records were reviewed after 1 year.

    RESULTS: A total of 432 patients were suspected of having appendicitis and in 221 this diagnosis was confirmed. Some 53 patients, with another preliminary diagnosis, were eventually found to suffer from appendicitis, making a total of 274 patients with appendicitis. Appendectomy was performed in 316 patients and was negative in 14%. Clinical diagnosis of appendicitis had a sensitivity of 0.81, a specificity of 0.90, a positive predictive value of 0.51, a positive likelihood ratio of 8.1, and a diagnostic accuracy of 0.89. The highest odds ratios were found for isolated tenderness in the right iliac fossa (3.29), rebound tenderness (3.00), right-sided rectal tenderness (2.53), migration of pain to the right iliac fossa (2.18), and local guarding (2.11).

    CONCLUSION: Clinical findings indicating localised inflammation in the right iliac fossa were reliable in predicting acute appendicitis. The patients' history of pain combined with a careful clinical examination still plays an important role in detecting appendicitis among patients with acute abdominal pain.

  • 298.
    Laurell, Helena
    et al.
    Department of Surgery at Mora Hospital, Mora, Sweden and Uppsala University Hospital, Uppsala, Sweden.
    Hansson, Lars-Erik
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Gunnarsson, Ulf
    Uppsala University Hospital, Uppsala, Sweden.
    Diagnostic pitfalls and accuracy of diagnosis in acute abdominal pain2006In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 41, no 10, 1126-1131 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To identify the differential diagnostic difficulties in acute abdominal pain at the emergency department and during hospitalization.

    MATERIAL AND METHODS: Patients with abdominal pain lasting for up to 7 days were registered during 1997-2000 and re-evaluated one year after discharge (n=2851).

    RESULTS: Diagnoses with low sensitivity at the emergency department but markedly increased sensitivity at discharge were non-specific abdominal pain with a sensitivity value at the emergency department of 0.43, appendicitis 0.80, gallstones 0.68, constipation 0.74 and peptic ulcer 0.26. Corresponding kappa-values were 0.48, 0.74, 0.84, 0.88 and 0.93, respectively. Malignancy, gynaecological complaints, dyspepsia, urinary tract infection and diverticulitis displayed fairly good concordance between the preliminary and discharge judgements, but the predictive diagnostic value was still low at discharge. Sensitivity values at discharge were 0.40, 0.75, 0.73, 0.77 and 0.83, respectively. Among 479 surgically treated patients, 104 initially received a diagnosis usually not requiring surgery and had a median delay until operation of 22 h (95% CI 30-50 h), compared with 8 h (12-18 h) for referrals.

    CONCLUSIONS: Non-specific abdominal pain is the main differential diagnostic problem in the emergency department also for diagnoses requiring surgery. Constipation is a diagnostic pitfall and when making this diagnosis a careful re-evaluation is necessary.

  • 299. LeBleu, Valerie
    et al.
    Sund, Malin
    Sugimoto, Hikaru
    Birrane, Gabriel
    Kanasaki, Keizo
    Finan, Elizabeth
    Miller, Caroline A
    Gattone, Vincent H
    McLaughlin, Heather
    Shield, Charles F
    Kalluri, Raghu
    Identification of the NC1 domain of α3 chain as critical for α3α4α5 type IV collagen network assembly2010In: Journal of Biological Chemistry, ISSN 0021-9258, E-ISSN 1083-351X, Vol. 285, no 53, 41874-41885 p.Article in journal (Refereed)
    Abstract [en]

    The network organization of type IV collagen consisting of α3, α4, and α5 chains in the glomerular basement membrane (GBM) is speculated to involve interactions of the triple helical and NC1 domain of individual α-chains, but in vivo evidence is lacking. To specifically address the contribution of the NC1 domain in the GBM collagen network organization, we generated a mouse with specific loss of α3NC1 domain while keeping the triple helical α3 chain intact by connecting it to the human α5NC1 domain. The absence of α3NC1 domain leads to the complete loss of the α4 chain. The α3 collagenous domain is incapable of incorporating the α5 chain, resulting in the impaired organization of the α3α4α5 chain-containing network. Although the α5 chain can assemble with the α1, α2, and α6 chains, such assembly is incapable of functionally replacing the α3α4α5 protomer. This novel approach to explore the assembly type IV collagen in vivo offers novel insights in the specific role of the NC1 domain in the assembly and function of GBM during health and disease.

  • 300. Leenders, Max
    et al.
    Chuang, Shu-Chun
    Dahm, Christina C
    Overvad, Kim
    Ueland, Per Magne
    Midttun, Oivind
    Vollset, Stein Emil
    Tjønneland, Anne
    Halkjaer, Jytte
    Jenab, Mazda
    Clavel-Chapelon, Françoise
    Boutron-Ruault, Marie-Christine
    Kaaks, Rudolf
    Canzian, Federico
    Boeing, Heiner
    Weikert, Cornelia
    Trichopoulou, Antonia
    Bamia, Christina
    Naska, Androniki
    Palli, Domenico
    Pala, Valeria
    Mattiello, Amalia
    Tumino, Rosario
    Sacerdote, Carlotta
    van Duijnhoven, Fränzel J B
    Peeters, Petra H M
    van Gils, Carla H
    Lund, Eiliv
    Rodriguez, Laudina
    Duell, Eric J
    Pérez, María-José Sánchez
    Molina-Montes, Esther
    Castaño, José María Huerta
    Barricarte, Aurelio
    Larrañaga, Nerea
    Johansen, Dorthe
    Lindkvist, Björn
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Ye, Weimin
    Khaw, Kay-Tee
    Wareham, Nicholas J
    Michaud, Dominique S
    Riboli, Elio
    Xun, Wei W
    Allen, Naomi E
    Crowe, Francesca L
    Bueno-de-Mesquita, H Bas
    Vineis, Paolo
    Plasma cotinine levels and pancreatic cancer in the EPIC cohort study.2012In: International Journal of Cancer, ISSN 0020-7136, E-ISSN 1097-0215, Vol. 131, no 4, 997-1002 p.Article in journal (Refereed)
    Abstract [en]

    Smoking is an established risk factor for pancreatic cancer, previously investigated by the means of questionnaires. Using cotinine as a biomarker for tobacco exposure allows more accurate quantitative analyses to be performed. This study on pancreatic cancer, nested within the European Prospective Investigation into Cancer and Nutrition (EPIC cohort), included 146 cases and 146 matched controls. Using liquid chromatography-mass spectrometry, plasma cotinine levels were analyzed on average 8.0 years before cancer onset (5-95% range: 2.8-12.0 years). The relation between plasma cotinine levels and pancreatic cancer was analyzed with conditional logistic regression for different levels of cotinine in a population of never and current smokers. This was also done for the self-reported number of smoked cigarettes per day at baseline. Every increase of 350 nmol/L of plasma cotinine was found to significantly elevate risk of pancreatic cancer [odds ratio (OR): 1.33, 95% confidence interval (CI): 1.11-1.60]. People with a cotinine level over 1187.8 nmol/L, a level comparable to smoking 17 cigarettes per day, have an elevated risk of pancreatic cancer, compared to people with cotinine levels below 55 nmol/L (OR: 3.66, 95% CI: 1.44-9.26). The results for self-reported smoking at baseline also show an increased risk of pancreatic cancer from cigarette smoking based on questionnaire information. People who smoke more than 30 cigarettes per day showed the highest risk compared to never smokers (OR: 4.15, 95% CI: 1.02-16.42). This study is the first to show that plasma cotinine levels are strongly related to pancreatic cancer.

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