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  • 251.
    Backman, Christian
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Johansson, Ulf
    University Health Care Research Center, Örebro University Hospital, Örebro, Sweden.
    Hellgren, Mikko
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. University Health Care Research Center.
    Knowledge in and support for standardised cancer care pathways among general practitioners and other physicians in Sweden2021Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 39, nr 1, s. 17-22Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To investigate the expertise in and support of the implemented new method of cancer patient pathways (CPPs) among general practitioners (GPs) and other working physicians in Sweden.

    DESIGN: A survey in the form of 10 knowledge-based multiple-choice questions (MCQs) and two general questions about CPPs.

    SETTING: Physicians from two different regions in Sweden answered the survey between December 2018 and January 2019.

    SUBJECTS: GPs in primary care compared to other physicians. 155 participants completed the survey and the response rate was 65%.

    MAIN OUTCOME MEASURES: Physicians' self-estimated knowledge of CPPs in general and opinion of CPPs effect on mortality and morbidity. Their scores on 10 different MCQs. Scores were analysed in subgroups related to the physicians medical specialty and experience.

    RESULTS: A majority of all physicians (63%) felt that they had insufficient knowledge regarding the procedure of CPPs, and the average score from the MCQs was 3.8 out of 10 correct answers. The results showed that GPs performed significantly better than specialists from other disciplines.

    CONCLUSIONS: The low percentage of correctly answered MCQs shows that the information about the entry part of CPPs needs to be improved. The study demonstrates a support for the system with CPPs because the physicians believed in its' positive effects on morbidity and mortality, however, it also reveals a lack of self-estimated knowledge about the system with CPPs.

    Key points

    Cancer patient pathways (CPPs) is a newly implemented method in Sweden that aims to equalize cancer care and reduce the time to diagnosis and treatment.

    • The proficiency of when to initiate an investigation according to a specific CPP seems low. General practitioners (GPs) performed significantly better on knowledge-based questions than other specialists did.
    • Physicians rated their knowledge as insufficient regarding the procedure of CPPs.
    • A clear majority of physicians believed that CPPs promotes a lower mortality and morbidity in cancer.
  • 252.
    Backman, Helena E.
    et al.
    Örebro universitet, Institutionen för hälsovetenskaper. Department of Obstetrics and Gynaecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Karefylakis, Christos
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Internal Medicine.
    Schwarcz, Erik
    Department of Internal Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Magnuson, Anders
    Department of Statistics, Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Branzell, Ida
    Division of Laboratory Medicine, Department of Clinical Chemistry, Örebro University Hospital, Örebro, Sweden.
    Nolan, Christopher J.
    School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Australian Capital Territory, Australia.
    Simmons, David
    Örebro universitet, Institutionen för medicinska vetenskaper. Macarthur Clinical School, Western Sydney University, Campbelltown, New South Wales, Australia.
    Diagnosis of Gestational Diabetes Mellitus: How Should We Measure Glucose?2024Ingår i: Diabetes Care, ISSN 0149-5992, E-ISSN 1935-5548, artikel-id dc231557Artikel i tidskrift (Refereegranskat)
  • 253.
    Backman, Olof
    et al.
    Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Science (Hand and Plastic Surgery), Umeå University, Umeå, Sweden.
    Bruze, Gustaf
    Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.
    Näslund, Ingmar
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Ottosson, Johan
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery.
    Marsk, Richard
    Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Neovius, Martin
    Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.
    Näslund, Erik
    Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Gastric Bypass Surgery Reduces De Novo Cases of Type 2 Diabetes to Population Levels: A Nationwide Cohort Study From Sweden2019Ingår i: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 269, nr 5, s. 895-902Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: The aim of this study was to determine long-term changes in pharmacological treatment of type 2 diabetes after primary Roux-en-Y gastric bypass (RYGB) surgery, in patients with and without pharmacological treatment of diabetes preoperatively.

    SUMMARY OF BACKGROUND DATA: Several studies have shown that gastric bypass has good effect on diabetes, at least in the short-term. This study is a nationwide cohort study using Swedish registers, with basically no patients lost to follow-up during up to 7 years after surgery.

    METHODS: The effect of RYGB on type 2 diabetes drug treatment was evaluated in this nationwide matched cohort study. Participants were 22,047 adults with BMI ≥30 identified in the nationwide Scandinavian Surgical Obesity Registry, who underwent primary RYGB between 2007 and 2012. For each individual, up to 10 general population comparators were matched on birth year, sex, and place of residence. Prescription data were retrieved from the nationwide Swedish Prescribed Drug Register through September 2015. Incident use of pharmacological treatment was analyzed using Cox regression.

    RESULTS: Sixty-seven percent of patients with pharmacological treatment of type 2 diabetes before surgery were not using diabetes drugs 2 years after surgery and 61% of patients were not pharmacologically treated up to 7 years after surgery. In patients not using diabetes drugs at baseline, there were 189 new cases of pharmacological treatment of type 2 diabetes in the surgery group and 2319 in the matched general population comparators during a median follow-up of 4.6 years (incidence: 21.4 vs 27.9 per 10,000 person-years; adjusted hazard ratio 0.77, 95% confidence interval 0.67-0.89; P < 0.001).

    CONCLUSIONS: Gastric bypass surgery not only induces remission of pharmacological treatment of type 2 diabetes but also protects from new onset of pharmacological diabetes treatment. The effect seems to persist in most, but not all, patients over 7 years of follow-up.

  • 254.
    Bader, Sam Er.
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery.
    Sönnerqvist, Caroline
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Paediatrics.
    Melander, Nils
    Örebro universitet, Institutionen för medicinska vetenskaper. Deptartment of Neurology.
    Olivecrona, Magnus
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Neurosurgery .
    A Validation Study of Kwon's Prognostic Scoring System for Chronic Subdural Haematoma2022Ingår i: World Neurosurgery, ISSN 1878-8750, E-ISSN 1878-8769, Vol. 165, s. e365-e372Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: Surgery for chronic subdural haematoma (CSDH) is one of the most frequent operations in neurosurgical practice. CSDH afflicts the elderly population most. In 2018, Kwon and co-workers published the Kwon Scoring System (KSS), whereby six clinical and radiological factors are used to facilitate, and promote quality in, surgical decision-making and counselling of relatives. The aim of this study is to validate the KSS.

    METHOD: Patients operated on for unilateral CSDH at Orebro University Hospital, Sweden, between 2013 and 2019 constituted the study population. General data and the six outcome predictors according to the KSS were extracted from the electronic patient records. The pre-operative mRS score and the post-operative six-month mRS score were assessed.

    RESULTS: We identified 133 patients (69.2% male) with a median age of 80.2 years (IQR 72.6-85.9). The median GCS at admission was 15; 57.1% had motor deficits and 36.81% were disoriented. For 39.1% of the patients, the prognosis was a favourable outcome (mRS 0-1) at six months. The median KSS score was 9; 63.9% of the patients scored ≥ 9, and 36 (42.4%) of these patients actually achieved a favourable outcome. This corresponds to a prediction model sensitivity of 0.667 and specificity of 0.424. A ROC curve analysis of the model yielded an AUC of 0.62441.

    CONCLUSION: In our material, the KSS did not predict outcome precisely enough to base treatment decisions or counselling of relatives on the scores obtained.

  • 255.
    Bakoyan, Zaki
    et al.
    School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden.
    Hansson, Stefan R.
    Department of Obstetrics and Gynecology, Institute of Clinical Science Lund, Lund University, Lund, Sweden.
    Karlsson, Johanna Patriksson
    University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Lodefalk, Maria
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. University Health Care Research Center.
    Childhood atopic disorders in relation to placental changes: A systematic review and meta-analysis2024Ingår i: Pediatric Allergy and Immunology, ISSN 0905-6157, E-ISSN 1399-3038, Vol. 35, nr 5, artikel-id e14141Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Fetal programming may arise from prenatal exposure and increase the risk of diseases later in life, potentially mediated by the placenta. The objective of this systematic review was to summarize and critically evaluate publications describing associations between human placental changes and risk of atopic disorders during childhood. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The inclusion criteria were original research articles or case reports written in English describing a human placental change in relation to disease occurring in offspring during childhood. The MEDLINE and EMBASE databases were searched for eligible studies. Risk of bias (RoB) was assessed using the ROBINS-I tool. The results were pooled both in a narrative way and by a meta-analysis. Nineteen studies were included (n = 12,997 participants). All studies had an overall serious RoB, and publication bias could not be completely ruled out. However, five studies showed that histological chorioamnionitis in preterm-born children was associated with asthma-related problems (pooled odds ratio = 3.25 (95% confidence interval = 2.22-4.75)). In term-born children, a large placenta (≥750 g) increased the risk of being prescribed anti-asthma medications during the first year of life. Placental histone acetylation, DNA methylation, and gene expression differences were found to be associated with different atopic disorders in term-born children. There is some evidence supporting the idea that the placenta can mediate an increased risk of atopic disorders in children. However, further studies are needed to validate the findings, properly control for confounders, and examine potential mechanisms.

  • 256.
    Balla, Hajnal Zsuzsanna
    et al.
    Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Ström, Jakob O.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
    Effect of Beta-Blockers on Stroke Outcome: A Meta-Analysis2021Ingår i: Clinical Epidemiology, ISSN 1179-1349, E-ISSN 1179-1349, Vol. 13, s. 225-236Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Introduction: Cardiovascular events and infections are common in the acute phase after stroke. It has been suggested that these complications may be associated with excessive sympathetic activation due to the stroke, and that beta-adrenergic antagonists (beta-blockers) therefore may be beneficial.

    Aim: The aim of the current meta-analysis was to investigate the association between beta-blocker treatment in acute stroke and the three outcomes: mortality, functional outcome and post-stroke infections.

    Methods: statistics. Random effect model was used when heterogeneity presented among studies; otherwise, a fixed-effect model was used. Publication bias was assessed using Egger's test and by visually inspecting funnel plots.

    Results: A total of 20 studies were eligible for at least one of the three outcomes. Two of the included studies were randomized controlled trials and 18 were observational studies. Quality assessments indicated that the risk of bias was moderate. The meta-analysis found no significant association between treatment with beta-blockers and any of the three outcomes. The studies analyzed for the outcomes mortality and infection were heterogeneous, while studies analyzed for functional outcome were homogeneous. The articles analyzed for mortality showed signs of publication bias.

    Conclusion: The lack of significant effects in the current meta-analysis, comprising more than 100,000 patients, does not support the proposed beneficial effects of beta-blockers in the acute phase of stroke.

  • 257.
    Balthazar, Jacqueline T.
    et al.
    Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia, USA.
    Golparian, Daniel
    Örebro universitet, Institutionen för medicinska vetenskaper. WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Unemo, Magnus
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Institute for Global Health, University College London, London, United Kingdom.
    Read, Timothy D.
    Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA; Emory Antibiotic Resistance Center, Emory University School of Medicine, Atlanta, Georgia, USA.
    Grosse, Miriam
    Department of Microbial Drugs, Helmholtz Centre for Infection Research, Braunschweig, Germany; German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany.
    Stadler, Marc
    Department of Microbial Drugs, Helmholtz Centre for Infection Research, Braunschweig, Germany; German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany.
    Pfarr, Kenneth
    Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany; German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany.
    Schiefer, Andrea
    Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany; German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany.
    Hoerauf, Achim
    Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany; German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany.
    Edwards, Jennifer L.
    The Center for Microbial Pathogenesis, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA.
    Vassylyev, Dmitry G.
    Department of Biochemistry and Molecular Genetics, Heersink School of Medicine, University of Alabama-Birmingham, Birmingham, Alabama, USA.
    Shafer, William M.
    Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Georgia, USA; Emory Antibiotic Resistance Center, Emory University School of Medicine, Atlanta, Georgia, USA; Laboratories of Bacterial Pathogenesis, Veterans Affairs Medical Center (Atlanta), Decatur, Georgia, USA.
    A laboratory-based predictive pathway for the development of Neisseria gonorrhoeae high-level resistance to corallopyronin A, an inhibitor of bacterial RNA polymerase2024Ingår i: Microbiology Spectrum, E-ISSN 2165-0497, Vol. 12, nr 6, artikel-id e0056024Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The continued emergence of Neisseria gonorrhoeae strains that express resistance to multiple antibiotics, including the last drug for empiric monotherapy (ceftriaxone), necessitates the development of new treatment options to cure gonorrheal infections. Toward this goal, we recently reported that corallopyronin A (CorA), which targets the switch region of the β' subunit (RpoC) of bacterial DNA-dependent RNA polymerase (RNAP), has potent anti-gonococcal activity against a panel of multidrug-resistant clinical strains. Moreover, in that study, CorA could eliminate gonococcal infection of primary human epithelial cells and gonococci in a biofilm state. To determine if N. gonorrhoeae could develop high-level resistance to CorA in a single step, we sought to isolate spontaneous mutants expressing any CorA resistance phenotypes. However, no single-step mutants with high-level CorA resistance were isolated. High-level CorA resistance could only be achieved in this study through a multi-step pathway involving over-expression of the MtrCDE drug efflux pump and single amino acid changes in the β and β' subunits (RpoB and RpoC, respectively) of RNAP. Molecular modeling of RpoB and RpoC interacting with CorA was used to deduce how the amino acid changes in RpoB and RpoC could influence gonococcal resistance to CorA. Bioinformatic analyses of whole genome sequences of clinical gonococcal isolates indicated that the CorA resistance determining mutations in RpoB/C, identified herein, are very rare (≤ 0.0029%), suggesting that the proposed pathway for resistance is predictive of how this phenotype could potentially evolve if CorA is used therapeutically to treat gonorrhea in the future. IMPORTANCE: The continued emergence of multi-antibiotic-resistant strains of Neisseria gonorrhoeae necessitates the development of new antibiotics that are effective against this human pathogen. We previously described that the RNA polymerase-targeting antibiotic corallopyronin A (CorA) has potent activity against a large collection of clinical strains that express different antibiotic resistance phenotypes including when such gonococci are in a biofilm state. Herein, we tested whether a CorA-sensitive gonococcal strain could develop spontaneous resistance. Our finding that CorA resistance could only be achieved by a multi-step process involving over-expression of the MtrCDE efflux pump and single amino acid changes in RpoB and RpoC suggests that such resistance may be difficult for gonococci to evolve if this antibiotic is used in the future to treat gonorrheal infections that are refractory to cure by other antibiotics.

  • 258.
    Ban, L.
    et al.
    Division of Epidemiology and Public Health, School of Medicine, Nottingham City Hospital, University of Nottingham, Nottingham, United Kingdom.
    West, J.
    Division of Epidemiology and Public Health, School of Medicine, Nottingham City Hospital, University of Nottingham, Nottingham, United Kingdom.
    Sultan, A. Abdul
    Division of Epidemiology and Public Health, School of Medicine, Nottingham City Hospital, University of Nottingham, Nottingham, United Kingdom.
    Dhalwani, N. N.
    Division of Epidemiology and Public Health, School of Medicine, Nottingham City Hospital, University of Nottingham, Nottingham, United Kingdom.
    Ludvigsson, Jonas F.
    Region Örebro län.
    Tata, L. J.
    Division of Epidemiology and Public Health, School of Medicine, Nottingham City Hospital, University of Nottingham, Nottingham, United Kingdom.
    Limited risks of major congenital anomalies in children of mothers with coeliac disease: a population-based cohort study2015Ingår i: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 122, nr 13, s. 1833-1841Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To examine major congenital anomaly (CA) risks in children of mothers with coeliac disease (CD) compared with mothers without CD.

    Design: Population-based cohort study.

    Setting: Linked maternal-child medical records from a large primary care database from the UK.

    Population: A total of 562332 live singletons of mothers with and without CD in 1990-2013.

    Methods: We calculated the absolute major CA risks in children whose mothers had CD, and whether this was diagnosed or undiagnosed before childbirth. Logistic regression with a generalised estimating equation was used to estimate adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) for CAs associated with CD.

    Main outcome measures: Fourteen system-specific major CA groups classified according to the European Surveillance of Congenital Anomalies and neural tube defects (NTDs).

    Results: Major CA risk in 1880 children of mothers with CD was 293 per 10000 liveborn singletons, similar to the risk in those without CD (282; aOR 0.98, 95% CI 0.74-1.30). The risk was slightly higher in 971 children, whose mothers were undiagnosed (350; aOR 1.14, 95% CI 0.79-1.64), than in 909 children whose mothers were diagnosed (231; aOR 0.80, 95% CI 0.52-1.24). There was a three-fold increase in nervous system anomalies in the children of mothers with undiagnosed CD (aOR 2.98, 95%CI 1.06-8.33, based on five exposed cases and one had an NTD), and these women were all diagnosed with CD at least 4years after their children were born.

    Conclusions: There was no statistically significant increase in risk of major CAs in children of mothers with coeliac disease overall, compared with the general population.

  • 259.
    Ban, Lu
    et al.
    Division of Epidemiology & Public Health, University of Nottingham, Nottingham, United Kingdom; Division of Rheumatology, Orthopaedics and Dermatology, Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom.
    Sprigg, Nikola
    Stroke, Division of Neuroscience, University of Nottingham, Nottingham, United Kingdom.
    Abdul Sultan, Alyshah
    Division of Epidemiology & Public Health, University of Nottingham, Nottingham, United Kingdom; Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom.
    Nelson-Piercy, Catherine
    Women's Health Academic Centre, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
    Bath, Philip M
    Women's Health Academic Centre, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
    Ludvigsson, Jonas F.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Paediatrics, Örebro University Hospital, Örebro, Sweden.
    Stephansson, Olof
    Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
    Tata, Laila J
    Division of Epidemiology & Public Health, University of Nottingham, Nottingham, United Kingdom.
    Incidence of First Stroke in Pregnant and Nonpregnant Women of Childbearing Age: A Population-Based Cohort Study From England2017Ingår i: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, ISSN 2047-9980, E-ISSN 2047-9980, Vol. 6, nr 4, artikel-id e004601Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Pregnant women may have an increased risk of stroke compared with nonpregnant women of similar age, but the magnitude and the timing of such risk are unclear. We examined the risk of a first stroke event in women of childbearing age and compared the risk during pregnancy and in the early postpartum period with the background risk outside these periods.

    METHODS AND RESULTS: We conducted an open cohort study of 2 046 048 women aged 15 to 49 years between April 1, 1997, and March 31, 2014, using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care records in England. Risk of first stroke was assessed by calculating the incidence rate of stroke in antepartum, peripartum (2 days before until 1 day after delivery), and early (first 6 weeks) and late (second 6 weeks) postpartum periods compared with nonpregnant time using a Poisson regression model with adjustment for maternal age, socioeconomic group, and calendar time. A total of 2511 women had a first stroke. The incidence rate of stroke was 25.0 per 100 000 person-years (95% CI 24.0-26.0) in nonpregnant time. The rate was lower antepartum (10.7 per 100 000 person-years, 95% CI 7.6-15.1) but 9-fold higher peripartum (161.1 per 100 000 person-years, 95% CI 80.6-322.1) and 3-fold higher early postpartum (47.1 per 100 000 person-years, 95% CI 31.3-70.9). Rates of ischemic and hemorrhagic stroke both increased peripartum and early postpartum.

    CONCLUSIONS: Although the absolute risk of first stroke is low in women of childbearing age, healthcare professionals should be aware of a considerable increase in relative risk during the peripartum and early postpartum periods.

  • 260.
    Bang, Charlotte Sahlberg
    et al.
    Örebro universitet, Institutionen för hälsovetenskap och medicin.
    Kinnunen, Annica
    IRiSC, Fac Med & Hlth, Univ Örebro, Örebro, Sweden.
    Karlsson, Marie
    IRiSC, Fac Med & Hlth, Univ Örebro, Örebro, Sweden.
    Önnberg, Anna
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Dept Lab Med, Örebro Univ Hosp, Örebro, Sweden.
    Söderquist, Bo
    Örebro universitet, Institutionen för läkarutbildning. Region Örebro län. Dept Lab Med, Örebro University Hospital, Örebro, Sweden.
    Persson, Katarina
    Örebro universitet, Institutionen för läkarutbildning.
    The antibacterial effect of nitric oxide against ESBL-producing uropathogenic E-coli is improved by combination with miconazole and polymyxin B nonapeptide2014Ingår i: BMC Microbiology, E-ISSN 1471-2180, Vol. 14, artikel-id 65Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Nitric oxide (NO) is produced as part of the host immune response to bacterial infections, including urinary tract infections. The enzyme flavohemoglobin, coded by the hmp gene, is involved in protecting bacterial cells from the toxic effects of NO and represents a potentially interesting target for development of novel treatment concepts against resistant uropathogenic bacteria. The aim of the present study was to investigate if the in vitro antibacterial effects of NO can be enhanced by pharmacological modulation of the enzyme flavohemoglobin.

    Results: Four clinical isolates of multidrug-resistant extended-spectrum beta-lactamase (ESBL)-producing uropathogenic E. coli were included in the study. It was shown that the NO-donor substance DETA/NO, but not inactivated DETA/NO, caused an initial growth inhibition with regrowth noted after 8 h of exposure. An hmp-deficient strain showed a prolonged growth inhibition in response to DETA/NO compared to the wild type. The imidazole antibiotic miconazole, that has been shown to inhibit bacterial flavohemoglobin activity, prolonged the DETA/NO-evoked growth inhibition. When miconazole was combined with polymyxin B nonapeptide (PMBN), in order to increase the bacterial wall permeability, DETA/NO caused a prolonged bacteriostatic response that lasted for up to 24 h.

    Conclusion: An NO-donor in combination with miconazole and PMBN showed enhanced antimicrobial effects and proved effective against multidrug-resistant ESBL-producing uropathogenic E. coli.

  • 261.
    Bang, Charlotte Sahlberg
    et al.
    Örebro universitet, Institutionen för hälsovetenskap och medicin.
    Kruse, Robert
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Region Örebro län.
    Demirel, Isak
    Örebro universitet, Institutionen för hälsovetenskap och medicin.
    Önnberg, Anna
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Dept Lab Med, Örebro University Hospital, Örebro, Sweden.
    Söderquist, Bo
    Örebro universitet, Institutionen för läkarutbildning. Region Örebro län. Dept Lab Med, Örebro University Hospital, Örebro, Sweden.
    Persson, Katarina
    Örebro universitet, Institutionen för läkarutbildning.
    Multiresistant uropathogenic extended-spectrum β-lactamase (ESBL)-producing Escherichia coli are susceptible to the carbon monoxide releasing molecule-2 (CORM-2).2014Ingår i: Microbial Pathogenesis, ISSN 0882-4010, E-ISSN 1096-1208, Vol. 66, s. 29-35Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Carbon monoxide (CO) releasing molecules (CO-RMs) have been shown to inhibit growth of commensal Escherichia coli (E. coli). In the present study we examined the effect of CORM-2 on uropathogenic E. coli (UPEC) that produces extended-spectrum β-lactamase (ESBL). Viability experiments showed that CORM-2 inhibited the growth of several different ESBL-producing UPEC isolates and that 500 μM CORM-2 had a bactericidal effect within 4 h. The bactericidal effect of CORM-2 was significantly more pronounced than the effect of the antibiotic nitrofurantoin. CORM-2 demonstrated a low level of cytotoxicity in eukaryotic cells (human bladder epithelial cell line 5637) at the concentrations and time-points where the antibacterial effect was obtained. Real-time RT-PCR studies of different virulence genes showed that the expression of capsule group II kpsMT II and serum resistance traT was reduced and that some genes encoding iron acquisition systems were altered by CORM-2. Our results demonstrate that CORM-2 has a fast bactericidal effect against multiresistant ESBL-producing UPEC isolates, and also identify some putative UPEC virulence factors as targets for CORM-2. CO-RMs may be candidate drugs for further studies in the field of finding new therapeutic approaches for treatment of uropathogenic ESBLproducing E. coli.

  • 262.
    Bang, Peter
    et al.
    Fac Hlth Sci, Div Pediat, Dept Clin & Expt Med, Linköping Univ, Linköping, Sweden.
    Thorell, Anders
    Dept Clin Sci, Danderyds Hosp, Karolinska Inst, Stockholm, Sweden; Dept Surg, Ersta Hosp, Stockholm, Sweden.
    Carlsson-Skwirut, Christine
    Dept Woman & Child Hlth, Pediat Endocrinol Unit, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
    Ljungqvist, Olle
    Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Brismar, Kerstin
    Dept Mol Endocrinol, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
    Nygren, Jonas
    Dept Clin Sci, Danderyds Hosp, Karolinska Institute, Stockholm, Sweden; Dept Surg, Ersta Hosp, Stockholm, Sweden.
    Free dissociable IGF-I: Association with changes in IGFBP-3 proteolysis and insulin sensitivity after surgery2016Ingår i: Clinical Nutrition, ISSN 0261-5614, E-ISSN 1532-1983, Vol. 35, nr 2, s. 408-413Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Patients receiving a carbohydrate drink (CHO) before major abdominal surgery display improved insulin sensitivity postoperatively and increased proteolysis of IGFBP-3 (IGFBP-3-PA) compared to patients undergoing similar surgery after overnight fasting. Aims: We hypothesized that serum IGFBP-3-PA increases bioavailability of circulating IGF-I and preserves insulin sensitivity in patients given CHO. Design: Matched control study. Methods: At Karolinska University Hospital, patients given CHO before major elective abdominal surgery (CHO,n = 8) were compared to patients undergoing similar surgical procedures after overnight fasting (FAST,n = 10). Results from two different techniques for determination of free-dissociable IGF-I (fdIGF-I) were compared with changes in IGFBP-3-PA and insulin sensitivity. Results: Postoperatively, CHO displayed 18% improvement in insulin sensitivity (hyperinsulinemic clamp) and increased IGFBP-3-PA vs. FAST. As determined by IRMA, fdIGF-I increased by 48 +/- 25% in CHO while fdIGF-I decreased by 13 +/- 18% in FAST (p < 0.01 vs. CHO, when corrected for duration of surgery). However, fdIGF-I determined by ultra-filtration decreased similarly in both groups (-22 +/- 8% vs. -25 +/- 8%, p = 0.8) and IGFBP-1 increased similarly in both groups. Patients with less insulin resistance after surgery demonstrated larger increases in fdIGF-I by IRMA (r = 0.58, p < 0.05). Fifty-three % of the variability of the changes in fdIGF-I by IRMA could be explained by changes in IGFBP-3-PA and total IGF-I levels (p < 0.05), while IGFBP-1 did not contribute significantly. Conclusion: During conditions when serum IGF-I bioavailability is regulated by IGFBP-3 proteolysis, measurements of fdIGF-I by IRMA is of physiological relevance as it correlates with the associated changes in insulin sensitivity.

  • 263.
    Banhart, S.
    et al.
    Fachgebiet‚ Sexuell übertragbare bakterielle Krankheitserreger‘, Abteilung für Infektionskrankheiten, Robert Koch-Institut, Berlin, Deutschland.
    Jansen, K.
    Fachgebiet‚ HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen‘, Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland.
    Buder, S.
    Konsiliarlabor für Gonokokken, Vivantes Klinikum Neukölln, Berlin, Deutschland.
    Tamminga, T.
    Robert Koch Inst, Abt Infekt Krankheiten, Fachgebiet HIV AIDS & Andere Sexuell Oder Durch B, Berlin, Germany..
    Calvignac-Spencer, S.
    Projektgruppe‚ Epidemiologie hochpathogener Erreger‘, Robert Koch-Institut, Berlin, Deutschland.
    Pilz, T.
    Fachgebiet‚ Sexuell übertragbare bakterielle Krankheitserreger‘, Abteilung für Infektionskrankheiten, Robert Koch-Institut, Berlin, Deutschland.
    Martini, A.
    Fachgebiet‚ Sexuell übertragbare bakterielle Krankheitserreger‘, Abteilung für Infektionskrankheiten, Robert Koch-Institut, Berlin, Deutschland.
    Dudareva, S.
    Fachgebiet‚ HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen‘, Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland; WHO Collaborating Centre for Gonorrhoea and Other STIs, Faculty of Medicine and Health, Örebro University, Örebro, Schweden.
    Nikisins, S.
    Fachgebiet‚ HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen‘, Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland.
    Dehmel, K.
    Fachgebiet‚ HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen‘, Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland.
    Zuelsdorf, G.
    Fachgebiet‚ HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen‘, Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland.
    Guhl, E.
    Graeber, I
    Konsiliarlabor für Gonokokken, Vivantes Klinikum Neukölln, Berlin, Deutschland.
    Koh, P. K.
    Vivantes Klinikum Neukolln, Konsiliarlabor Gonokokken, Berlin, Germany..
    Unemo, Magnus
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. WHO Collaborating Centre for Gonorrhoea and Other STIs.
    Bremer, V
    Fachgebiet‚ HIV/AIDS und andere sexuell oder durch Blut übertragbare Infektionen‘, Abteilung für Infektionsepidemiologie, Robert Koch-Institut, Berlin, Deutschland.
    Heuer, D.
    Fachgebiet‚ Sexuell übertragbare bakterielle Krankheitserreger‘, Abteilung für Infektionskrankheiten, Robert Koch-Institut, Berlin, Deutschland.
    Identification of a new Association between Genogroup G10557 (G7072) and Cefixime Resistance by means of molecular Typing of Neisseria gonorrhoeae Isolates in Germany (2014-2017)2021Ingår i: Der Hautarzt, ISSN 0017-8470, E-ISSN 1432-1173, Vol. 72, nr Suppl. 1, s. S8-S9Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [de]

    Hintergrund/Fragestellung: Die Behandlung von Neisseria gonorrhoeae-Infektionen ist aufgrund sich neu entwickelnder Antibiotikaresistenzen gefährdet. Folglich sind Surveillance-Programme zur Beschreibung der antimikrobiellen Resistenz (AMR) und molekularen Epidemiologie bei Gonokokken auf nationaler und internationaler Ebene dringend erfor-derlich. In Deutschland wurde hierfür im Jahr 2013 das Gonokokken-Resistenznetzwerk (GORENET) etabliert. Unser Ziel war es, die geneti-sche Diversität von N. gonorrhoeae-Isolaten in Deutschland von 2014 bis 2017 mittels NG-MAST (N. gonorrhoeae multi-antigen sequence typing) zu beschreiben.

    Methoden: N. gonorrhoeae-Isolate aus den Jahren 2014–2017 (n=1220; 106 aus 2014, 122 aus 2015, 511 aus 2016 und 481 aus 2017) wurden deutschlandweit eingesandt und mittels AMR-Testung und NG-MAST charakterisiert.

    Ergebnisse: 88,4% aller Isolate stammten von Männern, 11,2% von Frauen. Das mediane Alter lag bei 32 Jahren (Interquartalsabstand; IQA: 25–44 Jahre). Insgesamt wurden 432 verschiedene NG-MAST-Sequenztypen (STs) einschließlich 146 neuer STs detektiert. Daraus resultieren 17 verschiedene Genogruppen, welche 59,2% aller Isolate beinhalten. Genogruppen G1407 und G10557 (G7072) waren signifikant mit Cefixim-Resistenz assoziiert. Dabei sank der Anteil dieser Genogruppen von 2014–2017 von 14,2 auf 6,2% (G1407) bzw. von 6,6 auf 3,1% (G10557 (G7072)),wohingegen der Anteil mehrerer Cefixim-empfindlicher Genogruppen (G11461, von 0,0 auf 5,6%; G17420, von 0,0 auf 5,0%; und G5441, von 0,9 und 4,8%) im gleichen Zeitraum anstieg.

    Schlussfolgerungen: In dieser Arbeit beschreiben wir Neisseria gonorrhoeae in Deutschland als eine genetisch diverse und variable Population und identifizieren eine neue Assoziation zwischen Genogruppe G10557 (G7072) und Cefixim-Resistenz. Diese Ergebnisse unterstreichen die Bedeutung der AMR-Überwachung auf der detaillierten Ebene molekularer Typisierung. Darüber hinaus deuten unsere Daten darauf hin, dass es mit Einführung einer dualen Therapie aus Ceftriaxon und Azithromycin und dem konsekutiv verminderten Einsatz von Cefixim zu einem Rückgang von Cefixim-resistenten Stämmen gekommen ist.

  • 264.
    Banhart, Sebastian
    et al.
    Unit 'Sexually Transmitted Bacterial Infections', Department for Infectious Diseases, Robert Koch Institute, Berlin, Germany.
    Jansen, Klaus
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Buder, Susanne
    German Reference Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
    Tamminga, Thalea
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Calvignac-Spencer, Sébastien
    Project Group 'Epidemiology of Highly Pathogenic Microorganisms', Robert Koch Institute, Berlin, Germany.
    Pilz, Tanja
    Unit 'Sexually Transmitted Bacterial Infections', Department for Infectious Diseases, Robert Koch Institute, Berlin, Germany.
    Martini, Andrea
    Unit 'Sexually Transmitted Bacterial Infections', Department for Infectious Diseases, Robert Koch Institute, Berlin, Germany.
    Dudareva, Sandra
    Charité Universitätsmedizin Berlin, Berlin, Germany; Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Nikisins, Sergejs
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Dehmel, Kerstin
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Zuelsdorf, Gabriele
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Guhl, Eva
    German Reference Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
    Graeber, Ingeborg
    German Reference Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
    Kohl, Peter K.
    German Reference Laboratory for Gonococci, Department of Dermatology and Venerology, Vivantes Hospital Berlin, Berlin, Germany.
    Unemo, Magnus
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. WHO Collaborating Centre for Gonorrhoea and Other STIs.
    Bremer, Viviane
    Unit 'HIV/AIDS, STI and Blood-borne Infections', Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
    Heuer, Dagmar
    Unit 'Sexually Transmitted Bacterial Infections', Department for Infectious Diseases, Robert Koch Institute, Berlin, Germany.
    GORENET, Study Group
    Molecular epidemiological typing of Neisseria gonorrhoeae isolates identifies a novel association between genogroup G10557 (G7072) and decreased susceptibility to cefixime, Germany, 2014 to 20172020Ingår i: Eurosurveillance, ISSN 1025-496X, E-ISSN 1560-7917, Vol. 25, nr 41, artikel-id 1900648Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Emerging antimicrobial resistance (AMR) challenges gonorrhoea treatment and requires surveillance.AimThis observational study describes the genetic diversity of Neisseria gonorrhoeae isolates in Germany from 2014 to 2017 and identifies N. gonorrhoeae multi-antigen sequence typing (NG-MAST) genogroups associated with AMR or some patient demographics.

    Methods: 1,220 gonococcal isolates underwent AMR testing and NG-MAST. Associations between genogroups and AMR or sex/age of patients were statistically assessed.

    Results: Patients' median age was 32 years (interquartile range: 25-44); 1,078 isolates (88.4%) originated from men. In total, 432 NG-MAST sequence types including 156 novel ones were identified, resulting in 17 major genogroups covering 59.1% (721/1,220) of all isolates. Genogroups G1407 and G10557 (G7072) were significantly associated with decreased susceptibility to cefixime (Kruskal-Wallis chi-squared: 549.3442, df: 16, p < 0.001). Their prevalences appeared to decline during the study period from 14.2% (15/106) to 6.2% (30/481) and from 6.6% (7/106) to 3.1% (15/481) respectively. Meanwhile, several cefixime susceptible genogroups' prevalence seemed to increase. Proportions of isolates from men differed among genogroups (Fisher's exact test, p < 0.001), being e.g. lower for G25 (G51) and G387, and higher for G5441 and G2992. Some genogroups differed relative to each other in affected patients' median age (Kruskal-Wallis chi-squared: 47.5358, df: 16, p < 0.001), with e.g. G25 (G51) and G387 more frequent among ≤ 30 year olds and G359 and G17420 among ≥ 40 year olds.

    Conclusion: AMR monitoring with molecular typing is important. Dual therapy (ceftriaxone plus azithromycin) recommended in 2014 in Germany, or only the ceftriaxone dose of this therapy, might have contributed to cefixime-resistant genogroups decreasing.

  • 265.
    Barazzoni, R.
    et al.
    Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
    Deutz, N. E. P.
    Center for Translational Research in Aging & Longevity, Department of Health and Kinesiology, Texas A & M University, College Station TX, USA.
    Biolo, G.
    Department of Medical, Surgical and Health Sciences, Internal Medicine, University of Trieste, Trieste, Italy.
    Bischoff, S.
    Department of Nutritional Medicine/Prevention, University of Hohenheim, Stuttgart, Germany.
    Boirie, Y.
    Department of Clinical Nutrition, CHU de Clermont-Ferrand, CRNH, Université d'Auvergne, Clermont-Ferrand, France.
    Cederholm, T.
    Clinical Nutrition and Metabolism, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; Department of Geriatric Medicine, Uppsala University Hospital, Uppsala, Sweden.
    Cuerda, C.
    Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
    Delzenne, N.
    Department, Université Catholique de Louvain, Brussels, Belgium.
    Leon Sanz, M.
    Department of Medicine, Complutense University, Madrid, Spain.
    Ljungqvist, Olle
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery.
    Muscaritoli, M.
    Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy.
    Pichard, C.
    Nutrition Unit, Geneva University Hospital, Geneva, Switzerland.
    Preiser, J. C.
    Department of Intensive Care, Erasme University Hospital, Brussels, Belgium.
    Sbraccia, R.
    Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
    Singer, P.
    Department of Intensive Care, Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Israel.
    Tappy, L.
    Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
    Thorens, B.
    Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland.
    Van Gossum, A.
    Gastroenterology Service, Hospital Erasme, Brussels, Belgium.
    Vettor, R.
    Internal Medicine Unit and Center for the Study and Integrated Treatment of Obesity, Department of Medicine, Padua University, Padua, Italy.
    Calder, P. C.
    Faculty of Medicine, University of Southampton, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; University of Southampton, Southampton, United Kingdom.
    Carbohydrates and insulin resistance in clinical nutrition: Recommendations from the ESPEN expert group2017Ingår i: Clinical Nutrition, ISSN 0261-5614, E-ISSN 1532-1983, Vol. 36, nr 2, s. 355-363Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Growing evidence underscores the important role of glycemic control in health and recovery from illness. Carbohydrate ingestion in the diet or administration in nutritional support is mandatory, but carbohydrate intake can adversely affect major body organs and tissues if resulting plasma glucose becomes too high, too low, or highly variable. Plasma glucose control is especially important for patients with conditions such as diabetes or metabolic stress resulting from critical illness or surgery. These patients are particularly in need of glycemic management to help lessen glycemic variability and its negative health consequences when nutritional support is administered. Here we report on recent findings and emerging trends in the field based on an ESPEN workshop held in Venice, Italy, 8-9 November 2015. Evidence was discussed on pathophysiology, clinical impact, and nutritional recommendations for carbohydrate utilization and management in nutritional support. The main conclusions were: a) excess glucose and fructose availability may exacerbate metabolic complications in skeletal muscle, adipose tissue, and liver and can result in negative clinical impact; b) low-glycemic index and high-fiber diets, including specialty products for nutritional support, may provide metabolic and clinical benefits in individuals with obesity, insulin resistance, and diabetes; c) in acute conditions such as surgery and critical illness, insulin resistance and elevated circulating glucose levels have a negative impact on patient outcomes and should be prevented through nutritional and/or pharmacological intervention. In such acute settings, efforts should be implemented towards defining optimal plasma glucose targets, avoiding excessive plasma glucose variability, and optimizing glucose control relative to nutritional support. (C) 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.

  • 266.
    Barmparas, Galinos
    et al.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Harada, Megan Y.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Ko, Ara
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Dhillon, Navpreet K.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Smith, Eric J. T.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Li, Tong
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Division of Trauma and Emergency Surgery.
    Ley, Eric J.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    The Effect of Early Positive Cultures on Mortality in Ventilated Trauma Patients2018Ingår i: Surgical Infections, ISSN 1096-2964, E-ISSN 1557-8674, Vol. 19, nr 4, s. 410-416Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The purpose was to examine the incidence of positive cultures in a highly susceptible subset of trauma patients admitted to the surgical intensive care unit (SICU) for mechanical ventilation and to examine the impact of their timing on outcomes.

    Patients and Methods: A retrospective review was conducted of blunt trauma patients admitted to the SICU for mechanical ventilation at a level I trauma center over a five-year period. All urine, blood, and sputum cultures were abstracted. Patients with at least one positive culture were compared with those with negative or no cultures. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to calculate the adjusted hazard ratio (AHR).

    Results: The median age of 635 patients meeting inclusion criteria was 46 and 74.2% were male. A total of 298 patients (46.9%) had at least one positive culture, with 28.9% occurring within two days of admission. Patients with positive cultures were more likely to be severely injured with an injury severity score (ISS) 16 (68.5% vs. 45.1%, p<0.001). Overall mortality was 22%. Patients who had their first positive culture within two and three days from admission had a significantly higher AHR for mortality (AHR: 14.46, p<0.001 and AHR: 10.59, p=0.028, respectively) compared to patients with a positive culture at day six or later.

    Conclusions: Early positive cultures are common among trauma patients requiring mechanical ventilation and are associated with higher mortality. Early identification with damage control cultures obtained on admission to aid with early targeted treatment might be justified.

  • 267.
    Barth, Henrik
    et al.
    Dept Ophthalmol, Lund Univ, Lund, Sweden.
    Crafoord, Sven W.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Dept Ophthalmology, Örebro University Hospital, Örebro, Sweden.
    Arner, Karin
    Dept Ophthalmol, Lund Univ, Lund, Sweden.
    Ghosh, Fredrik K.
    Dept Ophthalmol, Lund Univ, Lund, Sweden.
    Cellular CD68 and CD45r0 positive inflammatory responses of vitrectomy with vitreous substitutes2016Ingår i: Investigative Ophthalmology and Visual Science, ISSN 0146-0404, E-ISSN 1552-5783, Vol. 57, nr 12Artikel i tidskrift (Refereegranskat)
  • 268.
    Bartha, Erzsebet
    et al.
    Karolinska University Hospital, Huddinge, Sweden.
    Helleberg, Johan
    Karolinska University Hospital, Huddinge, Sweden.
    Ahlstrand, Rebecca
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Bell, Max
    Karolinska University Hospital, Solna, Sweden.
    Björne, Hakan
    Karolinska University Hospital, Solna, Sweden.
    Brattström, Olof
    Karolinska University Hospital, Solna, Sweden.
    Nilsson, Lena
    University Hospital Linköping, Linköping, Sweden.
    Semenas, Egidijus
    Uppsala University Hospital, Uppsala, Sweden.
    Wiklund, Andreas
    Karolinska University Hospital, Solna, Sweden.
    Kalman, Sigridur
    Karolinska University Hospital, Huddinge, Sweden.
    Performance of prediction models of postoperative mortality in high-risk surgical patients in swedish university hospitals: Predictors, Risk factors and Outcome Following major Surgery study (PROFS study NCT02626546)2017Ingår i: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, nr 8, s. 1056-1057Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    Background: There are several progn ostic prediction models that estimate the probability of postoperative mortality. The role of these models is to support clinical decisions. Before implementation of a prediction model in routine care, it is necessary to analyze its performance in the target population. Our aim was to analyze the performance of four different prediction models of postoperative mortality in a high-risk surgical population.

    Methods: Data collected from 2015-11-01 until 2016-02-15 in a prospective consecutive observational study (PROFS study) in four university hospitals was used. The inclusion criteria were adult, ASA classification ≥3, and major/complex upper or lower gastrointestinal, urogenital or orthoped ic surgery (UK surgical severity codingA XA PPP). Four prediction models were evaluated: Surgical Outcome Risk Tool (SORT), Surgical APGAR, P-POSSUM and Surgical Risk Scale (SRS). The outcome measure was 90-day mortality. We evaluated the discrimination of the models by area under receiver operator characteristic curve (AUC ROC) before and after recalibration.

    Results: In total, 1 089 patients were included. Thirteen patients were excluded due to erroneous inclusion, and another three were lost to follow-up, so data from 1 073 was used in this analysis. The mean age was 73 years, the presence of malignancy was 41%, and 90-day mortality was 13% (n = 140). The SORT model had the best discrimination both before and after recalibration. The P-POSSUM model improved after recalibration. The SRS model overestimated, whereas the APGAR model underestimated, the risk of mortality.

    Conclusions: The original SORT model is promising and could be incorporated as decision support for high-risk surgical patients.

  • 269.
    Barzangi, Jir
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Specialist Dental Care, Västmanland County Council, Västerås, Sweden; Postgraduate Dental Education Center, Public Dental Health Service, Örebro, Sweden.
    Arnrup, Kristina
    University Health Care Research Center (UFC), Örebro, Sweden.
    Unell, Lennart
    School of Health Sciences, Örebro University, Örebro, Sweden; Postgraduate Dental Education Center, Public Dental Health Service, Örebro, Sweden.
    Skovdahl, Kirsti
    Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway.
    Experiences and perceptions of infant dental enucleation among Somali immigrants in Sweden: a phenomenographic study2019Ingår i: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 77, nr 8, s. 566-573Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: The aim of this study was to explore and describe ways of experiencing and perceiving the Eastern African practice of infant dental enucleation (IDE) among immigrants of Somali origin living in Sweden.

    Material and methods: Six informants, three men and three women aged 26-54 years, were recruited for semi-structured individual interviews. Phenomenographic analysis of the interview transcripts was performed.

    Findings: Informants described four ways of experiencing and perceiving IDE: as an effective, necessary treatment; as a disputed tradition; as an alternative to failure; and as a desperate measure. The experiences and perceptions were highly influenced by the contexts the informants had been in, namely, communities in which traditional treatments were used frequently, in which other people were influential over their daily lives, and in which negative experiences of formal health care were common, as well as other difficult circumstances beyond the informants' individual control.

    Conclusions: The findings contribute to deepened understanding of IDE and the importance of context to the practice of it. Further, the findings deepen understanding of the decision to have the practice performed on infants, which may help dental and health care personnel to adequately communicate with individuals of Somali origin about the harmfulness of IDE.

  • 270.
    Barzangi, Jir
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Dental Research Department, Public Dental Health Service.
    Unell, L.
    Dental Research Department, Public Dental Health Service, Örebro, Region Örebro County, Sweden; School of Health Sciences, Örebro University, Örebro, Sweden.
    Skovdahl, K.
    Faculty for Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway.
    Arnrup, Kristina
    Örebro universitet, Institutionen för hälsovetenskaper. Dental Research Department, Public Dental Health Service, Örebro, Region Örebro County, Sweden.
    Knowledge, experiences and attitudes of dental and health care personnel in Sweden towards infant dental enucleation2018Ingår i: European Archives of Paediatric Dentistry, ISSN 1818-6300, E-ISSN 1996-9805, Vol. 19, nr 4, s. 229-237Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    To examine self-rated knowledge of clinical experiences and attitudes towards the practice of infant dental enucleation among dental and health care personnel in Sweden.

    A questionnaire survey was performed among 776 licensed dental and health care personnel working in emergency departments, midwifery, child health centres, school health services and public dental health services in 10 Swedish cities. The response rate was 56.2% (n = 436).

    Fewer than a fifth of the respondents reported self-rated knowledge of the practice. Approximately 13% of personnel encountering children professionally believed they had seen subjected patients in their clinical practice. Personnel with self-rated knowledge and clinical experience worked mostly in dental care. Additionally, the personnel had diverging attitudes regarding agreement and disagreement concerning professional responsibility for patients subjected to or at risk of infant dental enucleation.

    The study indicated there is need for increased knowledge about the practice and for clarification of obligatory responsibilities among dental and health care personnel regarding management and prevention of cases of infant dental enucleation.

  • 271.
    Barzangi, Jir
    et al.
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Publ Dent Serv, Västmanland Cty Council, Västerås, Sweden.
    Unell, Lennart
    Region Örebro län. Sch Hlth & Med Sci, Univ Örebro, Örebro, Sweden.
    Söderfeldt, Björn
    Publ Dent Serv, Postgrad Dent Educ Ctr, Örebro Cty Council, Örebro, Sweden; Fac Odontol, Dept Oral Publ Hlth, Malmö Univ, Malmö, Sweden .
    Arnrup, Kristina
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Region Örebro län. Publ Dent Serv, Postgrad Dent Educ Ctr, Örebro Cty Council, Örebro, Sweden.
    Infant dental enucleation: A literature review on a traditional remedial practice in East Africa2014Ingår i: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 72, nr 3, s. 168-178Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Objective. To summarize and review the literature on infant dental enucleation, a traditional remedial procedure prevalent mainly in East Africa.

    Materials and methods. Literature searches were made electronically using general and specialized search engines. The main search was performed through a systematic strategy in PubMed, comprising tabulated keywords, search codes, and translated and transliterated terms. Criteria for the selection of studies were designed to provide a general understanding of the procedure. The findings were synthesized into two sections: a summary of the population prevalence studies, and a thematic literature review.

    Results. An overview of the known prevalence and clinical specifications was established. Insight was gained into the purpose of the procedure and the factors influencing its performance. Diverging suggestions were seen with regard to the rationale for use of infant dental enucleation between different populations. Moreover, reports of complications and consequences involving the general health and the dentoalveolar structures of patients were examined.

    Conclusions. Prevalence, clinical features and risks of infant dental enucleation point to a need for greater awareness of the procedure. Further, there is a need for specific guidelines regarding management of suspected cases within dental and healthcare communities.

  • 272.
    Barzangi, Jir
    et al.
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Publ Dent Serv, Västmanland Cty Council, Västerås, Sweden.
    Unell, Lennart
    Region Örebro län. Sch Hlth & Med Sci, Univ Örebro, Örebro, Sweden; Publ Dent Serv, Örebro Cty Council, Örebro, Sweden.
    Söderfeldt, Björn
    Publ Dent Serv, Örebro Cty Council, Örebro, Sweden; Fac Odontol, Dept Oral Publ Hlth, Malmö Univ, Malmö, Sweden .
    Bond, Jasmin
    Publ Dent Serv, Örebro Cty Council, Örebro, Sweden.
    Musse, Ifrah Ahmed
    Publ Dent Serv, Örebro Cty Council, Örebro, Sweden.
    Arnrup, Kristina
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Region Örebro län.
    Infant dental enucleation in an East African population in Sweden: a cross-sectional study on dental records2014Ingår i: International Journal of Paediatric Dentistry, ISSN 0960-7439, E-ISSN 1365-263X, Vol. 24, nr 3, s. 209-214Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aim: To examine the prevalence of infant dental enucleation (IDE) of primary canines, an East African traditional remedial procedure, in a multiethnic population of children in Sweden.

    Design: A cross-sectional study was conducted of dental records of 1133 patients (mean age 4.6years, SD +/- 1.4) attending one public dental service clinic in Sweden. The clinic was located in an area with a large multiethnic community. All were born within the years 2002-2006 and had received a check-up in one of the years 2007-2009. A registry was made of missing primary canines where no reason could be found. In documented cases, information about ethnic origin was extracted. Statistical grouping was made according to known East African ethnicities.

    Results: At least 36 ethnicities were recorded. Twenty-four (2.1%) patients were missing one or more canines according to the criteria for IDE. Significant difference was seen when comparison was made between patients of known East African ethnicities, of whom 20.8% (21/101) manifested findings consistent with the criteria, and the rest of the population (3/1032; P<0.001).

    Conclusions: Prevalence of cases suggestive of IDE among patients of East African origin points to a need for increased awareness within dental and healthcare communities.

  • 273.
    Bass, G. A.
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Gillis, A. E.
    Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    European Society for Trauma and Emergency Surgery (ESTES), Cohort Studies Group
    Self-reported and actual adherence to the Tokyo guidelines in the European snapshot audit of complicated calculous biliary disease2020Ingår i: BJS Open, E-ISSN 2474-9842, Vol. 4, nr 4, s. 622-629Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Complicated acute biliary calculous disease poses clinical challenges. The European Society of Trauma and Emergency Surgery (ESTES) snapshot audit of complicated biliary calculous disease aims to make novel comparisons between self-reported institutional adherence to the Tokyo guidelines (TG18) and 'real-world' contemporary practice across Europe.

    METHODS: A preplanned analysis of a prospective observational multicentre audit that captured patients undergoing emergency admission for complicated biliary calculous disease (complicated cholecystitis, biliary pancreatitis, or choledocholithiasis with or without cholangitis) between 1 and 31 October 2018 was performed. An anonymized survey was administered to participating sites.

    RESULTS: Following an open call for participation, 25 centres from nine countries enrolled 338 patients. All centres completed the anonymized survey. Fifteen centres (60 per cent) self-reported that a minority of patients were treated surgically on index admission, favouring interval cholecystectomy. This was replicated in the snapshot audit, in which 152 of 338 patients (45·0 per cent) underwent index admission cholecystectomy, 17 (5·0 per cent) had interval cholecystectomy, and the remaining 169 (50·0 per cent) had not undergone surgery by the end of the 60-day follow-up. Centres that employed a dedicated acute care surgery model of care were more likely to perform index admission cholecystectomy compared with a traditional general surgery 'on call' service (57 versus 38 per cent respectively; odds ratio 2·14 (95 per cent c.i. 1·37 to 3·35), P < 0·001). Six centres (24 per cent) self-reported routinely performing blood cultures in acute cholecystitis; patient-level audit data revealed that blood cultures were done in 47 of 154 patients (30·5 per cent). No centre self-reported omitting antibiotics in the management of acute cholecystitis, and 144 of 154 (93·5 per cent) of patients in the snapshot audit received antibiotics during their index admission.

    CONCLUSION: Awareness of TG18 recommendations was high, but self-reported adherence and objective snapshot audit data showed low compliance with TG18 in patients with complicated acute biliary calculous disease.

  • 274.
    Bass, G. A.
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Emergency Surgery & Surgical Critical Care, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA, USA; Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Gillis, Amy E.
    Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Patients over 65 years with Acute Complicated Calculous Biliary Disease are Treated Differently: Results and Insights from the ESTES Snapshot Audit2021Ingår i: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 45, nr 7, s. 2046-2055Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Accrued comorbidities are perceived to increase operative risk. Surgeons may offer operative treatments less often to their older patients with acute complicated calculous biliary disease (ACCBD). We set out to capture ACCBD incidence in older patients across Europe and the currently used treatment algorithms.

    METHODS: The European Society of Trauma and Emergency Surgery (ESTES) undertook a snapshot audit of patients undergoing emergency hospital admission for ACCBD between October 1 and 31 2018, comparing patients under and ≥ 65 years. Mortality, postoperative complications, time to operative intervention, post-acute disposition, and length of hospital stay (LOS) were compared between groups. Within the ≥ 65 cohort, comorbidity burden, mortality, LOS, and disposition outcomes were further compared between patients undergoing operative and non-operative management.

    RESULTS: The median age of the 338 admitted patients was 67 years; 185 patients (54.7%) of these were the age of 65 or over. Significantly fewer patients ≥ 65 underwent surgical treatment (37.8% vs. 64.7%, p < 0.001). Surgical complications were more frequent in the ≥ 65 cohort than younger patients, and the mean postoperative LOS was significantly longer. Postoperative mortality was seen in 2.2% of patients ≥ 65 (vs. 0.7%, p = 0.253). However, operated elderly patients did not differ from non-operated in terms of comorbidity burden, mortality, LOS, or post-discharge rehabilitation need.

    CONCLUSIONS: Few elderly patients receive surgical treatment for ACCBD. Expectedly, postoperative morbidity, LOS, and the requirement for post-discharge rehabilitation are higher in the elderly than younger patients but do not differ from elderly patients managed non-operatively. With multidisciplinary perioperative optimization, elderly patients may be safely offered optimal treatment.

    TRIAL REGISTRATION: ClinicalTrials.gov (Trial # NCT03610308).

  • 275.
    Bass, G. A.
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Departments of Surgery, Tallaght University Hospital, Dublin, Ireland; Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Pourlotfi, Arvid
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Donnelly, Mark
    Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    McIntyre, Caroline
    Departments of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma ande Emergency Surgery, department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden .
    Flod, Sara
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    McNamara, Deirdre
    Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland.
    Sarani, Babak
    Department of Surgery, George Washington University, Washington DC, USA.
    Gillis, Amy E.
    Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bile Duct Clearance and Cholecystectomy for Choledocholithiasis: Definitive Single-Stage Laparoscopic Cholecystectomy with Intra-Operative Endoscopic Retrograde Cholangiopancreatography (ERCP) versus Staged Procedures2021Ingår i: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763, Vol. 90, nr 2, s. 240-248Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner.

    METHODS: Records were reviewed for all patients admitted between January 2015-December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intra-operative rendezvous ERCP at index admission (one-stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two-stage) at the Irish hospital. Clinical characteristics, post-procedural complications, and inpatient duration were compared between cohorts.

    RESULTS: Three hundred and fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222(62.2%) underwent a one-stage procedure in Sweden, while 135(37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and pre-operative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein = 136±137 vs. 95±102mg/L,p=0.024), had higher incidence of co-morbidities (age-adjusted Charlson Comorbidity Index ≥3:37.8% vs 20.0%,p=0.003), and overall were less fit for surgery (ASA ≥3: 11.7% vs. 3.7%,p < 0.001). Despite this, a significantly-shorter mean time to definitive treatment, i.e., cholecystectomy (3.1±2.5 vs. 40.3±127 days,p=0.017), without excess morbidity, was seen in the one-stage compared to the two-stage cohort. Patients in the one-stage cohort experienced shorter mean post-procedure length of stay(3.0±4.7 vs 5.0±4.6 days,p < 0.001) and total length of hospital stay(6.5±4.6 vs 9.0±7.3 days,p=0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p=0.004).

    CONCLUSION: Where appropriate expertise and logistics exist within developing models of Acute Care Surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest this strategy significantly shortens the time to definitive treatment, decreases total hospital stay without any excess in adverse outcomes.

  • 276.
    Bass, Gary A
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA, USA; Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Örebro University, Örebro, Sweden; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA.
    Kaplan, Lewis J.
    Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia PA, USA.
    Ryan, Éanna J.
    Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Örebro University, Örebro, Sweden; Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Clinical Epidemiology and Biostatistics.
    Lane-Fall, Meghan
    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA; Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
    Duffy, Caoimhe C.
    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA; Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
    Vail, Emily A.
    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA; Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery.
    The snapshot audit methodology: design, implementation and analysis of prospective observational cohort studies in surgery2023Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, nr 1, s. 5-15Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Purpose: For some surgical conditionns and scientific questions, the "real world" effectiveness of surgical patient care may be better explored using a multi-institutional time-bound observational cohort assessment approach (termed a "snapshot audit") than by retrospective review of administrative datasets or by prospective randomized control trials. We discuss when this might be the case, and present the key features of developing, deploying, and assessing snapshot audit outcomes data.

    Methods: A narrative review of snapshot audit methodology was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Manuscripts were selected from domains including: audit design and deployment, statistical analysis, surgical therapy and technique, surgical outcomes, diagnostic testing, critical care management, concomitant non-surgical disease, implementation science, and guideline compliance.

    Results: Snapshot audits all conform to a similar structure: being time-bound, non-interventional, and multi-institutional. A successful diverse steering committee will leverage expertise that includes clinical care and data science, coupled with librarian services. Pre-published protocols (with specified aims and analyses) greatly helps site recruitment. Mentored trainee involvement at collaborating sites should be encouraged through manuscript contributorship. Current funding principally flows from medical professional organizations.

    Conclusion: The snapshot audit approach to assessing current care provides insights into care delivery, outcomes, and guideline compliance while generating testable hypotheses.

  • 277.
    Bass, Gary Alan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA; Center for Peri-Operative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA.
    Duffy, Caoimhe C.
    Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA; Center for Peri-Operative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA.
    Kaplan, Lewis J.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, USA; Corporal Michael Cresenscz Veterans Affairs Medical Center (CMCVAMC), Philadelphia, USA.
    Sarani, Babak
    Center for Trauma and Critical Care, George Washington University School of Medicine & Health Sciences, Washington D.C., USA.
    Martin, Niels D.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
    Mohammad Ismail, Ahmad
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Clinical Epidemiology and Biostatistics.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma & Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures2023Ingår i: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 54, nr 1, s. 56-62Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture.

    METHODS: All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders.

    RESULTS: 96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome.

    CONCLUSIONS: Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.

  • 278.
    Bass, Gary Alan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourlotfi, Arvid
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; 5 Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Matthiessen, Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cardiac risk stratification in emergency resection for colonic tumours2021Ingår i: BJS Open, E-ISSN 2474-9842, Vol. 5, nr 4, artikel-id zrab057Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Despite advances in perioperative care, the postoperative mortality rate after emergency oncological colonic resection remains high. Risk stratification may allow targeted perioperative optimization and cardiac risk stratification. This study aimed to test the hypothesis that the Revised Cardiac Risk Index (RCRI), a user-friendly tool, could identify patients who would benefit most from perioperative cardiac risk mitigation.

    METHODS: Patients who underwent emergency resection for colonic cancer from 2007 to 2017 and registered in the Swedish Colorectal Cancer Registry (SCRCR) were analysed retrospectively. These patients were cross-referenced by social security number to the Swedish National Board of Health and Welfare data set, a government registry of mortality, and co-morbidity data. RCRI scores were calculated for each patient and correlated with 90-day postoperative mortality risk, using Poisson regression with robust error of variance.

    RESULTS: Some 5703 patients met the study inclusion criteria. A linear increase in crude 90-day postoperative mortality was detected with increasing RCRI score (37.3 versus 11.3 per cent for RCRI 4 or more versus RCRI 1; P < 0.001). The adjusted 90-day all-cause mortality risk was also significantly increased (RCRI 4 or more versus RCRI 1: adjusted incidence rate ratio 2.07, 95 per cent c.i. 1.49 to 2.89; P < 0.001).

    CONCLUSION: This study documented an association between increasing cardiac risk and 90-day postoperative mortality. Those undergoing emergency colorectal surgery for cancer with a raised RCRI score should be considered high-risk patients who would most likely benefit from enhanced postoperative monitoring and critical care expertise.

    Ladda ner fulltext (pdf)
    Cardiac risk stratification in emergency resection for colonic tumours
  • 279.
    Bass, Gary Alan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Ryan, Eanna
    Biloslavo, Alan
    General Surgery Department, Cattinara University Hospital, Trieste, Italy.
    Tolonen, Matti
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Kurihara, Hayato
    Pourlotfi, Arvid
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Kaplan, Lewis J.
    Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia PA, USA.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Techniques for Mesoappendix Transection and Appendix Resection When Performing Acute Appendectomy: Insights from the SnapAppy Group Audit2022Ingår i: Journal of the American College of Surgeons, ISSN 1072-7515, E-ISSN 1879-1190, Vol. 235, nr 5 Suppl. 2, s. S24-S24Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    Introduction: Surgically managed appendicitis exhibits great heterogeneity regarding mesoappendix transection, and appendix amputation from its base. It is unclear whether a particular surgical technique provides an outcome benefit or reduces complication.

    Methods: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during the SnapAppy time-bound prospective multi-institutional non-randomized observational cohort study between November 1st 2020 - August 31st 2021 at 71 centers in 14 countries. Poisson regression models were employed for investigating the association between different surgical techniques for mesoappendix as well as stump management and postoperative complication while adjusting for potential confounding.

    Results: A total of 2,252 patients were included in the analyses of the technique used for dividing the mesoappendix, 69% by electrocautery and 31% by energy device. 3,729 patients were included for analyses of the management of the stump. The appendix was amputated using looped ligatures in 37%, staples in 38%, and clips in 25% of cases. After adjusting for confounders, the risk of postoperative complication was reduced by 42% when an energy device was used for handling the mesoappendix [adjusted incidence rate ratio (95% CI): 0.58 (0.41-0.82), p = 0.002]; however, no difference was detected between the techniques used for dividing the appendix at its base.

    Conclusion: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Energy devices are associated with a lower rate of overall complication while no differences were observed when comparing the techniques used for dividing the appendix base.

  • 280.
    Bass, Gary Alan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Emergency Surgery Committee, European Society for Trauma and Emergency Surgery (ESTES), Pölten, Austria; Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland; Department of Surgery, Örebro University School of Medical Sciences, Örebro, Sweden; Department of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Gillis, Amy
    Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Clinical Epidemiology and Biostatistics.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Emergency Surgery Committee, European Society for Trauma and Emergency Surgery (ESTES), Pölten, Austria; Department of Surgery, Örebro University School of Medical Sciences, Örebro, Sweden.
    Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES 'snapshot audit' of practice2022Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, s. 23-25Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Acute complications of biliary calculi are common, morbid, and complex to manage. Variability exists in the techniques utilized to treat these conditions at an individual surgeon and unit level.

    Aim: To identify, through an international prospective nonrandomized cohort study, the epidemiology and areas of practice variability in management of acute complicated calculous biliary disease (ACCBD) and to correlate them against reported outcomes.

    Methods: A preplanned analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Complicated Biliary Calculous Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. All eligible patients with acute complicated biliary calculous disease were recorded contemporaneously using a standardized predetermined protocol and a secure online database and followed-up through to 60 days from their admission.

    Endpoints: A two-stage data collection strategy collecting patient demographics, details of operative, endoscopic and radiologic intervention, and outcome metrics. Outcome measures included mortality, surgical morbidity, ICU stay, timing of operative intervention, and length of hospital stay.

    Results: Three hundred thirty-eight patients were included, with a mean age of 65 years and 54% were female. Diagnosis at admission were: cholecystitis (45.6%), biliary pancreatitis (21%), choledocholithiasis with and without cholangitis (13.9% and 18%). Index admission cholecystectomy was performed in just 50% of cases, and 28% had an ERCP performed. Morbidity and mortality were low.

    Conclusion: This first ESTES snapshot audit, a purely descriptive collaborative study, gives rich 'real world' insights into local variability in surgical practice as compared to international guidelines, and how this may impact upon outcomes. These granular data will serve to improve overall patient care as well as being hypothesis generating and inform areas needing future prospective study.

  • 281.
    Bass, Gary Alan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA.
    Kaplan, Lewis J.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, USA.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Walsh, Thomas N.
    Royal College of Surgeons in Ireland Medical University, Busaiteen, Bahrain.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Clinical Epidemiology and Biostatistics.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery.
    Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study2023Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, nr 1, s. 17-32Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications.

    MATERIAL AND METHODS: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs).

    RESULTS: Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices.

    CONCLUSIONS: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.

  • 282.
    Bass, Gary Alan
    et al.
    Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA, USA.
    Kaplan, Lewis Jay
    Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA; Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA.
    Gaarder, Christine
    Department of Traumatology at Oslo University Hospital Ullevål (OUH U), Olso, Norway.
    Coimbra, Raul
    Riverside University Health System Medical Center, Moreno Valley, CA, USA; Loma Linda University School of Medicine, Loma Linda, CA, USA; Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA.
    Klingensmith, Nathan John
    Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA.
    Kurihara, Hayato
    State University of Milan, Milan, Italy; Emergency Surgery Unit, Ospedale Policlinico di Milano, Milan, Italy.
    Zago, Mauro
    General & Emergency Surgery Division, A. Manzoni Hospital, ASST, Lecco, Lombardy, Italy.
    Cioffi, Stefano Piero Bernardo
    Sapienza University, Rome, Italy.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, United Arab Emirates; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sugrue, Michael
    Letterkenny Hospital and Galway University, Letterkenny, Ireland.
    Tolonen, Matti
    Emergency Surgery, Meilahti Tower Hospital, HUS Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029, Helsinki, HUS, Finland.
    Valcarcel, Cristina Rey
    Hospital General Universitario Gregorio Marañón, Madrid (HGGM), Madrid, Spain.
    Tilsed, Jonathan
    Hull Royal Infirmary, Anlaby Road, Hu3 2Jz, Hull, England, UK.
    Hildebrand, Frank
    Department of Orthopaedics Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany.
    Marzi, Ingo
    Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany.
    European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities2024Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 50, nr 2, s. 367-382Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    BACKGROUND: European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature.

    METHODS: Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society.

    RESULTS: Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training.

    CONCLUSIONS: This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

  • 283.
    Bass, Gary Alan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Division of Trauma & Emergency Surgery, Örebro University Hospital, Örebro, Sweden; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma & Emergency Surgery.
    Ryan, Éanna J.
    Tallaght University Hospital, Dublin, Ireland.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma & Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Tolonen, Matti
    Helsinki University Hospital HUS Meilahden Tornisairaala, Helsinki, Finland.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Clinical Epidemiology and Biostatistics.
    Kaplan, Lewis J.
    Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, USA.
    Clinical practice selectively follows acute appendicitis guidelines2023Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, nr 1, s. 45-56Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Acute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to these guidelines provides insight into independent surgical practice patterns and institutional resource constraints as impediments to best practice. We explored data from the recent ESTES SnapAppy observational cohort study to determine guideline compliance in contemporary practice to identify opportunities to close evidence-to-practice gaps.

    METHODS: We undertook a preplanned analysis of the ESTES SnapAppy observational cohort study, identifying, at a patient level, congruence with, or deviation from WSES Jerusalem guidelines for the diagnosis and management of acute appendicitis and the Surviving Sepsis Campaign in our cohort. Compliance was then correlated with the incidence of postoperative complications.

    RESULTS: Four thousand six hundred and thirteen (4613) consecutive adult and adolescent patients with acute appendicitis were followed from date of admission (November 1, 2020, and May 28, 2021) for 90 days. Patient-level compliance with guideline elements allowed patients to be grouped into those with full compliance (all 5 elements: 13%), partial compliance (1-4 elements: 87%) or noncompliance (0 elements: 0.2%). We identified an excess postoperative complication rate in patients who received noncompliant and partially compliant care, compared with those who received fully guideline-compliant care (36% and 16%, versus 7.3%, p < 0.001).

    CONCLUSIONS: The observed diagnostic and treatment practices of the participating institutions displayed variability in compliance with key recommendations from existing guidelines. In general, practice was congruent with recommendations for preoperative antibiotic surgical site infection prophylaxis administration, time to surgery, and operative approach. However, there remains opportunities for improvement in the choice of diagnostic imaging modality, postoperative antibiotic stewardship to timely discontinue prophylactic antibiotics, and the implementation of ambulatory treatment pathways for uncomplicated appendicitis in the healthy young adult.

  • 284.
    Bass, Gary Alan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Stephen, Christopher
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Bailey, Joanelle A.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Mohseni, Shahin
    Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Chreiman, Kristen
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Duffy, Caoimhe
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Seamon, Mark J.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Cannon, Jeremy W.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Martin, Niels Douglas
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury2022Ingår i: Journal of Surgical Research, ISSN 0022-4804, E-ISSN 1095-8673, Vol. 277, s. 310-318Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Damage to the thoracic cage is common in the injured patient, both when the injuries are confined to this single cavity and as part of the overall injury burden of a polytraumatized patient. In a subset of these patients, the severity of injury to the intrathoracic viscera is either underappreciated at admission or blossom over the following 48-72 h. The ability to promptly identify these patients and abrogate complications therefore requires triage of such at-risk patients to close monitoring in a critical care environment. At our institution, this triage hinges on the Pain, Inspiratory effort, Cough (PIC) score, which generates a composite unitless score from a nomogram which aggregates several variables-patient-reported Pain visual analog scale, Incentive spirometry effort, and the perceived adequacy of Cough. We thus sought to audit PIC's discriminant power in predicting intensive care unit (ICU) need.

    METHODS: This retrospective cohort study was performed at an urban, academic, level 1 trauma center. All isolated chest wall injuries (excluded any Abbreviated Injury Score >2 in head or abdomen) from January 2020 to June 2021 were identified in the local trauma registry. The electronic medical record was queried for standard demographics, admission PIC score, postadmission destination, ICU and hospital length of stay (LOS), and any unplanned admissions to the ICU. Chi-squared tests were used to determine differences between PIC score outcomes and the recursive partitioning method correlated admission PIC score to ICU LOS.

    RESULTS: Two hundred and thirty six isolated chest wall injury patients were identified, of whom 194 were included in the final analysis. The median age was 60 (interquartile range [IQR] 50-74) years, 63.1% were male, and the median (IQR) number of rib fractures was 3.0 (2.0-5.0). A cutoff PIC score of 7 or lower was associated with ICU admission (odds ratio [OR] 95% CI: 8.19 [3.39-22.55], P < 0.001 with a PPV = 41.4%, NPV = 91%), and with ICU admission for greater than 48 h [OR (95% CI): 26.86 (5.5-43.96), P < 0.001, with a PPV = 25.9%, NPV = 98.7%] but not anatomic injury severity score, hospital LOS or ICU, or the requirement for mechanical ventilation. The association between PIC score 7 or below and the presence of bilateral fractures, flail chest, or sternal fracture did not meet statistical significance. The accurate cut point of the PIC score to predict ICU admission over 48 h in our retrospective cohort was calculated as PIC ≤ 7 for P = 0.013 and PIC ≤ 6 for P = 0.001.

    CONCLUSIONS: Patients with isolated chest wall injuries require effective reproducible triage for ICU-level care. The PIC score appears to be a moderate discriminator of critical care need, per se, as judged by our recorded complication rate requiring critical care intervention. This vigilance may pay dividends in early detection and abrogation of respiratory failure emergencies. Furthermore, PIC score delineation for ICU need appears to be appropriate at 7 or less; this threshold can be used during admission triage to guide care.

  • 285.
    Bassford, Chris
    et al.
    Warwick Medical School, University of Warwick, Coventry, UK; Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
    Griffiths, Frances
    Warwick Medical School, University of Warwick, Coventry, UK.
    Svantesson, Mia
    Örebro universitet, Institutionen för hälsovetenskaper. Region Örebro län. University Health Care Research Center.
    Ryan, Mandy
    Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
    Krucien, Nicolas
    Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
    Dale, Jeremy
    Warwick Medical School, University of Warwick, Coventry, UK.
    Rees, Sophie
    Warwick Medical School, University of Warwick, Coventry, UK.
    Rees, Karen
    Warwick Medical School, University of Warwick, Coventry, UK.
    Ignatowicz, Agnieszka
    Warwick Medical School, University of Warwick, Coventry, UK; Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
    Parsons, Helen
    Warwick Medical School, University of Warwick, Coventry, UK.
    Flowers, Nadine
    Warwick Medical School, University of Warwick, Coventry, UK.
    Fritz, Joe
    Warwick Medical School, University of Warwick, Coventry, UK; Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK; The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK.
    Perkins, Gavin
    Warwick Medical School, University of Warwick, Coventry, UK; Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK.
    Quinton, Sarah
    Warwick Medical School, University of Warwick, Coventry, UK; ealth Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
    Symons, Sarah
    White, Catherine
    Huang, Huayi
    Warwick Medical School, University of Warwick, Coventry, UK.
    Turner, Jake
    Warwick Medical School, University of Warwick, Coventry, UK.
    Brooke, Mike
    Warwick Medical School, University of Warwick, Coventry, UK.
    McCreedy, Aimee
    Warwick Medical School, University of Warwick, Coventry, UK.
    Blake, Caroline
    Warwick Medical School, University of Warwick, Coventry, UK.
    Slowhter, Anne
    Warwick Medical School, University of Warwick, Coventry, UK.
    Developing an intervention around referral and admissions to intensive care: a mixed-methods study2019Rapport (Övrigt vetenskapligt)
    Abstract [en]

    Background: Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.

    Objectives: To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.

    Methods: A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UKintensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records The tool was tested for inter-rater and intersite reliability in 120 patient records.

    Results: Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importanceof interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.

    Limitations: Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approachthat mitigated the potential limitations of the component studies. Conclusions: Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve thedecision-making for and, ultimately, the care of critically ill patients.

    Future work: Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of trainingfor clinicians involved in these decisions should be a priority for future work.

  • 286.
    Bassford, Christopher R.
    et al.
    Warwick Medical School, University of Warwick, Coventry, United Kingdom; University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.
    Krucien, Nicolas
    Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
    Ryan, Mandy
    Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
    Griffiths, Frances E.
    Warwick Medical School, University of Warwick, Coventry, United Kingdom.
    Svantesson, Mia
    Örebro universitet, Institutionen för hälsovetenskaper. Region Örebro län. University Health Care Research Center.
    Fritz, Zoe
    Warwick Medical School, University of Warwick, Coventry, United Kingdom; The Healthcare Improvement Studies (THIS) Institute, Cambridge University, Cambridge, United Kingdom.
    Perkins, Gavin D.
    Warwick Medical School, University of Warwick, Coventry, United Kingdom; University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital, Birmingham, United Kingdom.
    Quinton, Sarah
    University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital, Birmingham, United Kingdom.
    Slowther, Anne-Marie
    Warwick Medical School, University of Warwick, Coventry, United Kingdom.
    U.K. Intensivists' Preferences for Patient Admission to ICU: Evidence From a Choice Experiment2019Ingår i: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 47, nr 11, s. 1522-1530Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: Deciding whether to admit a patient to the ICU requires considering several clinical and nonclinical factors. Studies have investigated factors associated with the decision but have not explored the relative importance of different factors, nor the interaction between factors on decision-making. We examined how ICU consultants prioritize specific factors when deciding whether to admit a patient to ICU.

    DESIGN: Informed by a literature review and data from observation and interviews with ICU clinicians, we designed a choice experiment. Senior intensive care doctors (consultants) were presented with pairs of patient profiles and asked to prioritize one of the patients in each task for admission to ICU. A multinomial logit and a latent class logit model was used for the data analyses.

    SETTING: Online survey across U.K. intensive care.

    SUBJECTS: Intensive care consultants working in NHS hospitals.

    MEASUREMENTS AND MAIN RESULTS: Of the factors investigated, patient's age had the largest impact at admission followed by the views of their family, and severity of their main comorbidity. Physiologic measures indicating severity of illness had less impact than the gestalt assessment by the ICU registrar. We identified four distinct decision-making patterns, defined by the relative importance given to different factors.

    CONCLUSIONS: ICU consultants vary in the importance they give to different factors in deciding who to prioritize for ICU admission. Transparency regarding which factors have been considered in the decision-making process could reduce variability and potential inequity for patients.

  • 287.
    Baumbach, L.
    et al.
    Res. Unit for Musculoskeletal Function and Physiotherapy, Dept. of Sports Sci. and Clinical Biomechanics, Univ. of Southern Denmark, Odense, Denmark.
    Ankerst, D.
    Dept. of Mathematics and Sch.of Life Sci. Technical Univ. of Munich, Munich, Germany.
    Nyberg, Lillemor A.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Cottrell, E.
    Primary Care Ctr. Versus Arthritis, Keele Univ., Keele, United Kingdom.
    Roos, E. M.
    Res. Unit for Musculoskeletal Function and Physiotherapy, Dept. of Sports Sci. and Clinical Biomechanics, Univ. of Southern Denmark, Odense, Denmark.
    Lykkegaard, J.
    Dept. of Publ. Hlth., Res. Unit for Gen. Practice, Univ. of Southern Denmark, Odense, Denmark.
    ASSOCIATION BETWEEN RECEIVING DIFFERENT ELEMENTS OF CARE AND SATISFACTION WITH CARE IN PATIENTS WITH KNEE OSTEOARTHRITIS TREATED BY THEIR GENERAL PRACTITIONER2020Ingår i: Osteoarthritis and Cartilage, ISSN 1063-4584, E-ISSN 1522-9653, Vol. 28, s. S450-S450, artikel-id 670Artikel i tidskrift (Refereegranskat)
  • 288.
    Baumbach, Linda
    et al.
    Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
    Ankerst, Donna
    Department of Mathematics and School of Life Sciences, Technical University of Munich, Munich, Germany.
    Roos, Ewa M.
    Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
    Nyberg, Lillemor A.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Cottrell, Elizabeth
    Primary Care Centre Versus Arthritis, Keele University, Keele, UK.
    Lykkegaard, Jesper
    Department of Public Health, Research Unit for General Practice, University of Southern Denmark, Odense, Denmark.
    Association between received treatment elements and satisfaction with care for patients with knee osteoarthritis seen in general practice in Denmark2021Ingår i: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 39, nr 2, s. 257-264Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: While education, exercise, and weight reduction when indicated, are recommended first-line treatments for knee osteoarthritis patients, they remain poorly implemented in favour of pain killer treatment, imaging and referral to surgery. A reason could be that patients are more satisfied with receiving these adjunctive treatment elements. This study aimed to investigate the associations between the received elements of care and the patient's satisfaction with the care for knee osteoarthritis in general practice.

    Design: Cross-sectional study.

    Setting: A Danish general practice.

    Subjects: All consecutive patients >= 30 years of age who consulted the general practitioner (GP) with chronic knee complaints during 18 months and who replied to a mailed questionnaire (n = 136).

    Main outcome measures: The questionnaire addressed patient's knee-related quality of life, and overall satisfaction with care, as well as reception of seven types of information, which are known quality indicators. Information on reception of adjunctive treatment elements was obtained from electronic medical records.

    Results: Patient satisfaction (versus neutrality/dissatisfaction) was positively associated with reception of information on: physical activity and exercise (relative risks [RR] 1.38, 95% bootstrap percentile interval [BPI] 1.02-4.33), and the relationship between weight and osteoarthritis (1.38, 1.01-4.41). No significant associations were found for the five remaining types of information and all the adjunctive treatment elements.

    Conclusion: Providing information as education to patients with knee osteoarthritis as part of the treatment is positively associated with satisfaction with care.

  • 289.
    Baumbach, Linda
    et al.
    Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Department of Health Economics and Health, Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
    Roos, Ewa M.
    Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
    Ankerst, Donna
    Department of Mathematics and Life Science Systems, Technical University of Munich, Munich, Germany.
    Nyberg, Lillemor A.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Cottrell, Elizabeth
    Primary Care Centre Versus Arthritis, Keele University, Keele, UK.
    Lykkegaard, Jesper
    Research Unit for General Practice Institute of Public Health, University of Southern Denmark, Odense, Denmark.
    Changes in received quality of care for knee osteoarthritis after a multicomponent intervention in a general practice in Denmark2021Ingår i: Health Science Reports, E-ISSN 2398-8835, Vol. 4, nr 4, artikel-id e402Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: First-line treatment for patients with knee osteoarthritis should ideally prescribe patient education, exercise, and if needed, weight loss. In practice, however, adjunctive treatments, including painkillers and referrals to specialists, are typically introduced before these measures. This study evaluated interventions to sustainably improve general practitioner delivered care for patients with knee osteoarthritis.

    Design: Comparison of impacts of knee osteoarthritis care during four half-year periods: before, 6, 12, and 18 months after primary intervention based on electronic medical records (EMR) and patient questionnaires.

    Setting: Danish general practitioners (GPs) treating 6240 patients.

    Participants: Four GPs, two GP trainees, and six staff members.

    Interventions: Six pre-planned primary interventions: patient leaflet, GP and staff educational session, knee osteoarthritis consultation, two functional tests monitoring patient function, EMR phrase aiding consultation, and waiting room advertisement and three supportive follow-up interventions.

    Main outcome measures: Usage of first-line and adjunctive treatment elements, the functional tests, and the EMR phrase.

    Results: Approximately 50 knee osteoarthritis cases participated in each of the four half-year periods. Primary interventions had only transient effects lasting <12 months on the knee osteoarthritis care. Functional tests and EMR phrases were used predominantly during the first 6 months, where a transient drop in the referral rate to orthopedics was observed. Use of educational elements was moderate and without significant change during follow-up.

    Conclusion: More routine use of the primary or inclusion of novel increased-adherence interventions is needed to sustainably improve care for knee osteoarthritis patients in Danish general practice.

  • 290.
    Baumgart, Juliane
    et al.
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Region Örebro län. Department of Obstetrics and Gynecology.
    Nilsson, Kerstin
    Örebro universitet, Institutionen för läkarutbildning. Region Örebro län. Department of Obstetrics and Gynecology, Örebro University Hospital, Örebro, Sweden.
    Evers, A. Stavreus
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden .
    Kallak, T. Kunovac
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Kushnir, M. M.
    ARUP Institute for Clinical and Experimental Pathology, Salt Lake City UT, USA; Department of Pathology, University of Utah School of Medicine, Salt Lake City, USA; Analytical Chemistry/Department of Chemistry, Biomedical Center and SciLife Laboratory, Uppsala University, Uppsala, Sweden.
    Bergquist, J.
    Department of Pathology, University of Utah School of Medicine, Salt Lake City UT, USA; Analytical Chemistry/Department of Chemistry, Biomedical Center and SciLife Laboratory, Uppsala University, Uppsala, Sweden.
    Poromaa, I. Sundström
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden .
    Androgen levels during adjuvant endocrine therapy in postmenopausal breast cancer patients2014Ingår i: Climacteric, ISSN 1369-7137, E-ISSN 1473-0804, Vol. 17, nr 1, s. 48-54Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To investigate plasma steroid hormone levels in postmenopausal breast cancer patients with and without adjuvant endocrine therapy and in healthy postmenopausal women.

    Methods: Steroid hormone levels in postmenopausal breast cancer patients treated with aromatase inhibitors (n = 32) were compared with breast cancer patients treated with tamoxifen (n = 34), breast cancer patients without adjuvant endocrine therapy (n = 15), and healthy postmenopausal women (n = 56). Pregnenolone, 17-hydroxypregnenolone, 17-hydroxyprogesterone, 11-deoxycortisol, cortisol, cortisone, dehydroepiandrosterone (DHEA), androstenedione, total testosterone, dihydrotestosterone, estrone and estradiol were measured using liquid chromatography-tandem mass spectrometry. Sex hormone binding globulin was measured by solid-phase chemiluminescent immunometric assays, and the free androgen index was calculated.

    Results: Aromatase inhibitor users did not differ in dihydrotestosterone, total testosterone, androstenedione, DHEA, or free androgen index levels from healthy controls or untreated breast cancer patients. The highest total testosterone levels were found in tamoxifen-treated women, who had significantly higher plasma concentrations than both women treated with aromatase inhibitors and breast cancer patients without adjuvant treatment. Concentrations of cortisol and cortisone were significantly greater in aromatase inhibitor users as well as tamoxifen users, in comparison with healthy controls and untreated breast cancer patients. Aromatase inhibitor users had lower estrone and estradiol plasma concentrations than all other groups.

    Conclusion: Adjuvant treatment with aromatase inhibitors or tamoxifen was associated with increased cortisol and cortisone plasma concentrations as well as decreased estradiol concentrations. Androgen levels were elevated in tamoxifen-treated women but not in aromatase inhibitor users.

  • 291.
    Baumgart, Juliane
    et al.
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Region Örebro län. Department of Obstetrics and Gynecology.
    Nilsson, Kerstin
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Region Örebro län. Department of Obstetrics and Gynecology.
    Evers, Anneli Stavreus
    Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
    Kallak, Theodora Kunovac
    Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
    Poromaa, Inger Sundström
    Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
    Sexual dysfunction in women on adjuvant endocrine therapy after breast cancer2013Ingår i: Menopause: The Journal of the North American Menopause, ISSN 1072-3714, E-ISSN 1530-0374, Vol. 20, nr 2, s. 162-168Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: The goal of this study was to investigate sexual function in postmenopausal breast cancer patients treated with aromatase inhibitors.

    Methods: A population-based, cross-sectional study was conducted among postmenopausal breast cancer patients on adjuvant endocrine treatment and age-matched controls with and without estrogen treatment. Sexual function was assessed with a standardized questionnaire.

    Results: In all, 42.4% of aromatase inhibitor-treated breast cancer patients were dissatisfied with their sex life in general, and 50.0% reported low sexual interest; this was significantly more common than in tamoxifen-treated patients and controls (P < 0.05). Aromatase inhibitorYtreated patients reported insufficient lubrication in 73.9% and dyspareunia in 56.5% of cases, which were significantly more common than in controls, irrespective of hormonal use (P < 0.05). Tamoxifen-treated patients reported significantly more dyspareunia (31.3%; P < 0.05) but resembled controls in all other concerns.

    Conclusions: Our findings suggest that sexual dysfunction in aromatase inhibitorYtreated women is a greatly underestimated problem.

  • 292.
    Baylis, Rebecca
    et al.
    Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
    Ewald, Uwe
    Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
    Gradin, Maria
    Region Örebro län.
    Nyqvist, Kerstin Hedberg
    Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
    Rubertsson, Christine
    Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
    Blomqvist, Ylva Thernstrom
    Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
    First-time events between parents and preterm infants are affected by the designs and routines of neonatal intensive care units2014Ingår i: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 103, nr 10, s. 1045-1052Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aim: Early parental bonding with preterm babies is particularly important, and the aim of our study was to explore when parents experienced what they regarded as important events for the first time while their infant was in the neonatal intensive care unit (NICU).

    Methods: The study was part of a longitudinal project on Kangaroo Mother Care at two Swedish university hospitals. The parents of 81 infants completed questionnaires during their infants' hospital stay.

    Results: Most parents saw and touched their infants immediately after birth, but only a few could hold them skin to skin or swaddle them. Other important events identified by parents included the first time they performed care giving activities and did so independently, interaction and closeness with the infant, signs of the infant's recovery and integration into the family. The timing of the events depended on the physical design of the NICU, whether parents' could stay with their infant round-the-clock and when they were allowed to provide care under supervision and on their own.

    Conclusion: The design and routines of the NICU dictated when parents first interacted with their infants. Clinical guidelines that facilitate early contact with preterm babies can help parents to make the transition to their parental role.

  • 293.
    Bazargani, Farhan
    et al.
    Region Örebro län. Örebro universitet, Institutionen för hälsovetenskaper. Department of Orthodontics, Postgraduate Dental Education Center.
    Knode, Vanessa
    Private orthodontic office, Traben-Trarbach, Germany.
    Plaksin, Alexander
    Private orthodontic office, Moscow, Russia.
    Magnuson, Anders
    Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Ludwig, Björn
    Private orthodontic office, Traben-Trarbach, Germany; Department of Orthodontics, University of Saarland, Homburg/Saar, Germany.
    Three-dimensional comparison of tooth-borne and tooth-bone-borne RME appliances: a randomized controlled trial with 5-year follow-up2023Ingår i: European Journal of Orthodontics, ISSN 0141-5387, E-ISSN 1460-2210, Vol. 45, nr 6, s. 690-702Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To compare the long-term skeletal effects of tooth-borne (TB) and tooth-bone-borne (TBB) rapid maxillary expansion in growing children, using 3D imaging.

    Materials and methods: In total, 52 consecutive patients who met the eligibility criteria were recruited and allocated to either the TB group, mean age 9.3 years (SD 1.3), or the TBB group, mean age 9.5 years (SD 1.2). Cone-beam computed tomography records and plaster models were taken before (T-0), directly after (T-1), 1 year after (T-2), and 5 years after expansion (T-3).

    Randomization: Participants were randomly allocated in blocks of different sizes, using the concealed allocation principle in a 1:1 ratio. The randomization list was also stratified by sex to ensure homogeneity between groups.

    Blinding: Due to clinical limitations, only the outcome assessors were blinded to the groups to which the patients were allocated.

    Results: At T-1, the midpalatal suture at its anterior part showed a statistically significant difference between the groups with a mean of 0.6 mm (CI 0.2-1.1) more expansion in the TBB group (P < 0.01). This difference was also more evident in boys at T-1 with a mean of 0.8 mm (CI 0.2-1.4) (P < 0.01). These differences, however, blotted out at T-2 and T-3. The nasal width also showed similar differences between the groups, with a significantly larger expansion in the TBB group by a mean of 0.7 mm (CI 0.1-1.4) (P = 0.03). This group difference in favour of the TBB group was maintained at T-2 (1.6 mm) and T-3 (2.1 mm) (P < 0.01 T-2 and T-3, respectively).

    Conclusions: Skeletal expansion in the midpalatal suture was significantly higher in the TBB group; however, the magnitude of this expansion was around 0.6 mm more and may not be clinically significant. Skeletal expansion at the level of the nasal cavity was significantly higher in the TBB group. There were no differences between boys and girls with regard to skeletal expansion.

  • 294.
    Bazargani, Farhan
    et al.
    Region Örebro län. Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthodontics, Postgraduate Dental Education Center, Örebro, Sweden..
    Lund, Henrik
    Institute of Odontology, Sahlgrenska Academy, Department of Oral and Maxillofacial Radiology, University of Gothenburg, Göteborg, Sweden.
    Magnuson, Anders
    School of Medical Sciences, Örebro University, Sweden.
    Ludwig, Björn
    Private Orthodontic Office, Traben-Trarbach, Germany; Department of Orthodontics, University of Saarland, Homburg/Saar, Germany.
    Skeletal and dentoalveolar effects using tooth-borne and tooth-bone-borne RME appliances: a randomized controlled trial with 1-year follow-up2021Ingår i: European Journal of Orthodontics, ISSN 0141-5387, E-ISSN 1460-2210, Vol. 43, nr 3, s. 245-253Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: To evaluate and compare the skeletal and dentoalveolar effects of tooth-borne (TB) and tooth-bone-borne (TBB) rapid maxillary expansion (RME).

    MATERIALS AND METHODS: Fifty-two consecutive patients who met the eligibility criteria were recruited and allocated to either the TB group, mean age 9.3 years [standard deviation (SD) 1.3], or the TBB group, mean age 9.5 years (SD 1.2). Cone-beam computed tomography (CBCT) records and plaster models were taken before (T0), directly after (T1), and 1 year after expansion (T2). Dentoalveolar and skeletal measurements were made on the CBCT images. The dental expansion was also measured on the plaster models.

    RANDOMIZATION: Participants were randomly allocated in blocks of different sizes using the concealed allocation principle in a 1:1 ratio. The randomization list was also stratified by sex to ensure homogeneity between groups.

    BLINDING: Due to clinical limitations, only the outcomes assessors were blinded to the groups to which the patients were allocated.

    RESULTS: Skeletal expansion in the midpalatal suture and at the level of the nasal cavity was significantly higher in the TBB group. However, the magnitude of the expansion in the midpalatal suture was around 1 mm [95 per cent confidence interval (CI) 0.5-1.7, P = 0.001] more and perhaps not clinically significant. The magnitude of the expansion at the level of the nasal cavity was almost two times higher in the TBB group (95 per cent CI 0.7-2.6, P = 0.001). The dental expansion, alveolar bending, tipping of the molars, and stability 1 year post-expansion did not show any statistically significant differences between the groups. The actual direct cost of the treatment for the TBB group was approximately €300 higher than TB group.

    LIMITATIONS: Double blinding was not possible due to the clinical limitations.

    CONCLUSIONS: In young preadolescents with constricted maxilla and no signs of upper airway obstruction, it seems that conventional TB RME achieves the same clinical results with good stability 1 year post-expansion at lower cost.

    TRIAL REGISTRATION: The trial was not registered.

  • 295.
    Bazargani, Farhan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Orthodontics.
    Magnuson, Anders
    Örebro University Hospital, Örebro, Sweden.
    Ludwig, Björn
    Private Orthodontic Office, Traben-Trarbach, Germany; University of Saarland, Homburg, Germany.
    Effects on Nasal Airflow and Resistance Using Two Different RME Appliances: A Randomized Controlled Trial2018Ingår i: European Journal of Orthodontics, ISSN 0141-5387, E-ISSN 1460-2210, Vol. 40, nr 3, s. 281-284Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To evaluate and compare the effects of tooth-borne (TB) and tooth-bone-borne (TBB) rapid maxillary expansion (RME) on nasal airflow and resistance. Material and methods: Fifty-four consecutive patients who met the eligibility criteria were recruited from September 2010 to December 2015. Of these 54 subjects, 40 agreed to participate in the part of the study involving evaluation of nasal flow and resistance. The 40 subjects were allocated to either the TB group, mean age 9.7 years (SD 1.5), or the TBB group, mean age 10.2 years (SD 1.4). All subjects performed rhinomanometric registration at baseline (T-0), but only 30 attended the post-expansion registration (T-1), of whom 16 had been randomized to the TB group and 14 to the TBB group. The study outcomes, nasal airflow and nasal airway resistance, were evaluated with linear regression adjusted for baseline variable of the outcome to compare the study groups with complete cases strategy as well as after multiple imputation (MI). Randomization: Participants were randomly allocated in blocks of different sizes, using the concealed allocation principle in a 1:1 ratio. The randomization list was computer generated to ensure homogeneity between groups. Blinding: Blinding was done only for outcome assessor due to clinical limitations. The care providers at the ENT unit who conducted all the rhinomanometry examinations were blinded to which group the patients were allocated to. Results: Complete case analysis showed significantly higher post-expansion nasal airflow values for the TBB group compared with the TB group, mean difference 51.0 cm(3)/s (P = 0.018). The evaluation after MI showed a similar significant mean difference, 52.7 cm(3)/s (P = 0.020) in favour of the TBB group when taking into account the missing values from the T-1 examination. Even reduction in nasal airway resistance showed similar pattern in favour of the TBB group. Limitations: Our results represent the short-term effects. A longer follow-up period would have been preferable. Conclusions: The TBB RME induced significantly higher nasal airway flow and lower nasal resistance values than TB RME. It might be wiser to use TBB RME in cases with constricted maxilla and upper airway obstruction.

  • 296.
    Bazov, Igor
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Kruse, Robert
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Bergemalm, Daniel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Gastroenterology.
    Eriksson, Carl
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Gastroenterology.
    Hedin, C. R.
    Karolinska Institutet, Department of Medicine, Solna, Stockholm, Sweden; Karolinska University Hospital, Gastroenterology unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden.
    Carlson, M.
    Uppsala University, Department of Medical Sciences, Uppsala, Sweden.
    van Nieuwenhoven, Michiel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Gastroenterology.
    Keita, Å. V.
    Linköping University, Department of Biomedical and Clinical Sciences, Linköping, Sweden.
    Magnusson, M. K.
    University of Gothenburg, Sahlgrenska Academy, Department of Microbiology and Immunology, Institute of Biomedicine, Gothenburg, Sweden.
    Almer, S.
    Karolinska Institutet, Department of Medicine, Solna, Stockholm, Sweden; Karolinska university hospital, Gastroenterology unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden.
    Strid, H.
    Södra Älvsborgs Hospital, Department of Internal Medicine, Borås, Sweden.
    Mathisen, C. Bache-Wiig
    Oslo University Hospital, Department of Gastroenterology, Oslo, Norway; University of Oslo, Institute of Clinical Medicine, Oslo, Norway.
    Bengtsson, M. B.
    Vestfold Hospital Trust, Department of Gastroenterology, Tønsberg, Norway.
    Aabrekk, T. Bergene
    University of Oslo, Institute of Clinical Medicine, Oslo, Norway; Vestfold Hospital Trust, Department of Gastroenterology, Tønsberg, Norway.
    Medhus, A. W.
    Oslo University Hospital, Department of Gastroenterology, Oslo, Norway; University of Oslo, Institute of Clinical Medicine, Oslo, Norway.
    Detlie, T. E.
    Akershus University Hospital, Department of Gastroenterology, Lørenskog, Norway; University of Oslo, Insititute of Clinical Medicine, Oslo, Norway.
    Frigstad, S. O.
    Vestre Viken Hospital Trust- Bærum Hospital, Department of Internal Medicine, Bærum, Norway.
    Huppertz-Hauss, G.
    Telemark Hospital Trust, Skien, Department of Gastroenterology, Skien, Norway.
    Opheim, R.
    Oslo University Hospital, Department of Gastroenterology, Oslo, Norway; University of Oslo, Institute of Health and Society, Oslo, Norway.
    Ricanek, P.
    Akershus University Hospital, Department of Gastroenterology, Lørenskog, Norway; Lovisenberg Diaconal Hospital, Department of Gastroenterology, Oslo, Norway.
    Kristensen, V. A.
    Oslo University Hospital, Department of Gastroenterology, Oslo, Norway; Lovisenberg Diaconal Hospital, Unger-Vetlesen Institute, Oslo, Norway .
    Salihovic, Samira
    Örebro universitet, Institutionen för medicinska vetenskaper.
    D'Amato, M.
    Karolinska Institutet, Clinical Epidemiology Division, Department of Medicine Solna, Stockholm, Sweden; IKERBASQUE, Basque Foundation for Science, Bilbao, Gastrointestinal Genetics Lab, CIC bioGUNE - BRTA, Bilbao, Spain.
    Öhman, L.
    University of Gothenburg, Sahlgrenska Academy, Department of Microbiology and Immunology, Institute of Biomedicine, Gothenburg, Sweden.
    Söderholm, J. D.
    Linköping University, Department of Biomedical and Clinical Sciences, Linköping, Sweden.
    Lindqvist, C. M.
    Örebro University, School of Medical Sciences, Faculty of Medicine and Health, Örebro, Sweden.
    Repsilber, Dirk
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Høivik, M. L.
    Oslo University Hospital, Department of Gastroenterology, Oslo, Norway; University of Oslo, Institute of Clinical Medicine, Oslo, Norway.
    Halfvarson, Jonas
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Gastroenterology.
    A novel serum protein signature as biomarker for Inflammatory Bowel Disease: A diagnostic performance and prediction modelling study using data from two independent inception cohorts2023Ingår i: Journal of Crohn's & Colitis, ISSN 1873-9946, E-ISSN 1876-4479, Vol. 17, nr Suppl. 1, s. I314-I315, artikel-id P154Artikel i tidskrift (Övrigt vetenskapligt)
  • 297.
    Bazzo, M. L.
    et al.
    Molecular Biology, Microbiology and Serology Laboratory, Federal University of Santa Catarina, Florianópolis, Brazil.
    Golfetto, L.
    Molecular Biology, Microbiology and Serology Laboratory, Federal University of Santa Catarina, Florianópolis, Brazil.
    Gaspar, P. C.
    Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil.
    Pires, A. F.
    Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil; University of Brasilia Postgraduate Program in Collective Health, Brasilia, Brazil.
    Ramos, M. C.
    Brazilian STD Society, Porto Alegre, Brazil.
    Franchini, M.
    Laboratory Consultant, Brasília, Brazil.
    Ferreira, W. A.
    Alfredo da Mata Foundation, Manaus, Brazil.
    Unemo, Magnus
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden.
    Benzaken, A. S.
    Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil.
    First nationwide antimicrobial susceptibility surveillance for Neisseria gonorrhoeae in Brazil, 2015-162018Ingår i: Journal of Antimicrobial Chemotherapy, ISSN 0305-7453, E-ISSN 1460-2091, Vol. 73, nr 7, s. 1854-1861Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: Gonorrhoea and antimicrobial resistance (AMR) in Neisseria gonorrhoeae are major public health concerns globally. Enhanced AMR surveillance for gonococci is essential worldwide; however, recent quality-assured gonococcal AMR surveillance in Latin America, including Brazil, has been limited. Our aims were to (i) establish the first nationwide gonococcal AMR surveillance, quality assured according to WHO standards, in Brazil, and (ii) describe the antimicrobial susceptibility of clinical gonococcal isolates collected from 2015 to 2016 in all five main regions (seven sentinel sites) of Brazil.

    Methods: Gonococcal isolates from 550 men with urethral discharge were examined for susceptibility to ceftriaxone, cefixime, azithromycin, ciprofloxacin, benzylpenicillin and tetracycline using the agar dilution method, according to CLSI recommendations and quality assured according to WHO standards.

    Results: The levels of resistance (intermediate susceptibility) to tetracycline, ciprofloxacin, benzylpenicillin and azithromycin were 61.6%(34.2%), 55.6%(0.5%), 37.1% (60.4%) and 6.9% (8.9%), respectively. All isolates were susceptible to ceftriaxone and cefixime using the US CLSI breakpoints. However, according to the European EUCAST cefixime breakpoints, 0.2% (n= 1) of isolates were cefixime resistant and 6.9% (n = 38) of isolates had a cefixime MIC bordering on resistance.

    Conclusions: This study describes the first national surveillance of gonococcal AMR in Brazil, which was quality assured according to WHO standards. The high resistance to ciprofloxacin (which promptly informed a revision of the Brazilian sexually transmitted infection treatment guideline), emerging resistance to azithromycin and decreasing susceptibility to extended-spectrum cephalosporins necessitate continuous surveillance of gonococcal AMR and ideally treatment failures, and increased awareness when prescribing treatment in Brazil.

  • 298.
    Beale, M.
    et al.
    Wellcome Sanger Institute, Cambridge, UK.
    Marks, M.
    London School of Hygiene and Tropical Medicine, London, UK.
    Cole, M.
    National Infection Service, Public Health England, London, UK.
    Lee, M.
    British Columbia Centre for Disease Control, Vancouver, Canada.
    Pitt, R.
    National Infection Service, Public Health England, London, UK.
    Ruis, C.
    University of Cambridge Department of Medicine, Cambridge, UK.
    Naidu, P.
    Alberta Precision Laboratories, Edmonton, Canada.
    Unemo, Magnus
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, National Reference Laboratory for STI.
    Krajden, M.
    British Columbia Centre for Disease Control, Vancouver, Canada.
    Lukehart, S.
    University of Washington, Seattle, USA.
    Morshed, M.
    British Columbia Centre for Disease Control, Vancouver, Canada.
    Fifer, H.
    National Infection Service, Public Health England, London, UK.
    Thomson, N.
    Wellcome Sanger Institute, Cambridge, UK; London School of Hygiene and Tropical Medicine, London, UK.
    CONTEMPORARY SYPHILIS IS CHARACTERISED BY RAPID GLOBAL SPREAD OF PANDEMIC TREPONEMA PALLIDUM LINEAGES2021Ingår i: Sexually Transmitted Infections, ISSN 1368-4973, E-ISSN 1472-3263, Vol. 97, nr Suppl. 1, s. A17-A17, artikel-id O01.8Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    Background: Syphilis is an important sexually transmitted infection caused by the bacterium Treponema pallidum subspecies pallidum. The last two decades have seen syphilis incidence rise in many high-income countries, yet the evolutionary and epidemiological relationships that underpin this are poorly understood, as is the global T. pallidum population structure.

    Methods: We assembled a geographically and temporally diverse collection of clinical and laboratory samples, performing direct sequencing on the majority, and combining these with 133 publicly available sequences to compile a dataset comprising 726 T. pallidum genomes. We analysed the resulting genomes using detailed phylogenetic analysis and clustering.

    Results: We show that syphilis globally can be described by only two deeply branching lineages, Nichols and SS14. We show that both of these lineages can be found circulatingcon currently in 12 of the 23 countries sampled. To provide further phylodynamic resolution we subdivided Treponema pallidum subspecies pallidum into 17 distinct sublineages. Importantly, like SS14, we provide evidence that two Nichols sublineages have expanded clonally across 9 countries contemporaneously with SS14. Moreover, pairwise genome analysis showed that recent isolates circulating in 14 different countries were genetically identical in their core genome to those from other countries, suggesting frequent exchange through international transmission pathways. This contrasts with the majority of samples collected prior to 1983, which are phylogenetically distinct from these more recently isolated sublineages. Bayesian temporal analysis provided evidence of a population bottleneck and decline occurring during the late 1990s, followed by a rapid population expansion a decade later. This was driven by the dominant T. pallidum sublineages circulating today, many of which are resistant to macrolides.

    Conclusion: Combined we show that the population of contemporary syphilis in high-income countries has undergone a recent and rapid global expansion. This dataset will provide a framework for future characterisation and epidemiological investigation of syphilis populations.

  • 299.
    Beale, Mathew A.
    et al.
    Parasites and Microbes Programme, Wellcome Sanger Institute, Hinxton, UK.
    Marks, Michael
    Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK.
    Cole, Michelle J.
    HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK.
    Lee, Min-Kuang
    British Columbia Centre for Disease Control, Public Health Laboratory, Vancouver, British Columbia, Canada.
    Pitt, Rachel
    HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK.
    Ruis, Christopher
    Molecular Immunity Unit, MRC-Laboratory of Molecular Biology, Department of Medicine, University of Cambridge, Cambridge, UK; Department of Veterinary Medicine, University of Cambridge, Cambridge, UK.
    Balla, Eszter
    Bacterial STIs Reference Laboratory, Department of Bacteriology, National Public Health Centre, Budapest, Hungary.
    Crucitti, Tania
    Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium.
    Ewens, Michael
    Brotherton Wing, Leeds General Infirmary, Leeds, UK.
    Fernández-Naval, Candela
    Microbiology Department, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.
    Grankvist, Anna
    National Reference Laboratory for STIs, Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Guiver, Malcolm
    Laboratory Network, Manchester, UK Health Security Agency, Manchester Royal Infirmary, Manchester, UK.
    Kenyon, Chris R.
    Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium.
    Khairullin, Rafil
    Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia.
    Kularatne, Ranmini
    Centre for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa.
    Arando, Maider
    STI Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Hospital Vall d'Hebron, Barcelona, Spain.
    Molini, Barbara J.
    Department of Medicine, University of Washington, Seattle, WA, USA.
    Obukhov, Andrey
    Tuvan Republican Skin and Venereal Diseases Dispensary, Ministry of Health of Tuva Republic, Kyzyl, Russia.
    Page, Emma E.
    Virology Department, Old Medical School, Leeds Teaching Hospitals Trust, Leeds, UK.
    Petrovay, Fruzsina
    Bacterial STIs Reference Laboratory, Department of Bacteriology, National Public Health Centre, Budapest, Hungary.
    Rietmeijer, Cornelis
    Colorado School of Public Health, University of Colorado, Denver, CO, USA.
    Rowley, Dominic
    Midlands Regional Hospital Portlaoise, Laois, Ireland.
    Shokoples, Sandy
    Alberta Precision Laboratories, Edmonton, Alberta, Canada.
    Smit, Erasmus
    Clinical Microbiology Department, Queen Elizabeth Hospital, Birmingham, UK; Institute of Environmental Science and Research, Wellington, New Zealand.
    Sweeney, Emma L.
    The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
    Taiaroa, George
    Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
    Vera, Jaime H.
    Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.
    Wennerås, Christine
    National Reference Laboratory for STIs, Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden.
    Whiley, David M.
    The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Pathology Queensland Central Laboratory, Brisbane, Queensland, Australia .
    Williamson, Deborah A.
    Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
    Hughes, Gwenda
    Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
    Naidu, Prenilla
    Alberta Precision Laboratories, Edmonton, Alberta, Canada; Department of Laboratory Medicine and Pathology, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada .
    Unemo, Magnus
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, National Reference Laboratory for STIs, Faculty of Medicine and Health.
    Krajden, Mel
    British Columbia Centre for Disease Control, Public Health Laboratory, Vancouver, British Columbia, Canada; Clinical Microbiology Department, Queen Elizabeth Hospital, Birmingham, UK.
    Lukehart, Sheila A.
    Departments of Medicine/Infectious Diseases and Global Health, University of Washington, Seattle, WA, USA.
    Morshed, Muhammad G.
    British Columbia Centre for Disease Control, Public Health Laboratory, Vancouver, British Columbia, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
    Fifer, Helen
    Blood Safety, Hepatitis, STI and HIV Division, UK Health Security Agency, London, UK.
    Thomson, Nicholas R.
    Parasites and Microbes Programme, Wellcome Sanger Institute, Hinxton; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
    Global phylogeny of Treponema pallidum lineages reveals recent expansion and spread of contemporary syphilis2021Ingår i: Nature Microbiology, E-ISSN 2058-5276, Vol. 6, nr 12, s. 1549-1560Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Syphilis, which is caused by the sexually transmitted bacterium Treponema pallidum subsp. pallidum, has an estimated 6.3 million cases worldwide per annum. In the past ten years, the incidence of syphilis has increased by more than 150% in some high-income countries, but the evolution and epidemiology of the epidemic are poorly understood. To characterize the global population structure of T. pallidum, we assembled a geographically and temporally diverse collection of 726 genomes from 626 clinical and 100 laboratory samples collected in 23 countries. We applied phylogenetic analyses and clustering, and found that the global syphilis population comprises just two deeply branching lineages, Nichols and SS14. Both lineages are currently circulating in 12 of the 23 countries sampled. We subdivided T. p. pallidum into 17 distinct sublineages to provide further phylodynamic resolution. Importantly, two Nichols sublineages have expanded clonally across 9 countries contemporaneously with SS14. Moreover, pairwise genome analyses revealed examples of isolates collected within the last 20 years from 14 different countries that had genetically identical core genomes, which might indicate frequent exchange through international transmission. It is striking that most samples collected before 1983 are phylogenetically distinct from more recently isolated sublineages. Using Bayesian temporal analysis, we detected a population bottleneck occurring during the late 1990s, followed by rapid population expansion in the 2000s that was driven by the dominant T. pallidum sublineages circulating today. This expansion may be linked to changing epidemiology, immune evasion or fitness under antimicrobial selection pressure, since many of the contemporary syphilis lineages we have characterized are resistant to macrolides.

  • 300.
    Beaudoin, Melissa
    et al.
    Research Center, Montreal Heart Institute, Montreal QC, Canada.
    Goyette, Philippe
    Research Center, Montreal Heart Institute, Montreal QC, Canada.
    Boucher, Gabrielle
    Research Center, Montreal Heart Institute, Montreal QC, Canada.
    Lo, Ken Sin
    Research Center, Montreal Heart Institute, Montreal QC, Canada.
    Rivas, Manuel A.
    Center for the Study of IBD (CSIBD) Genetics, The Broad Institute, Cambridge MA, United States.
    Stevens, Christine
    Center for the Study of IBD (CSIBD) Genetics, The Broad Institute, Cambridge MA, United States.
    Alikashani, Azadeh
    Research Center, Montreal Heart Institute, Montreal QC, Canada.
    Ladouceur, Martin
    Research Center, Montreal Heart Institute, Montreal QC, Canada.
    Ellinghaus, David
    Christian-Albrechts-University, Kiel, Germany.
    Törkvist, Leif
    Karolinska Institutet, Stockholm, Sweden.
    Goel, Gautam
    Harvard School of Medicine, Boston MA, USA.
    Lagace, Caroline
    Research Center, Montreal Heart Institute, Montreal QC, Canada.
    Annese, Vito
    Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy; Unit of Gastroenterology SOD2, Azienda Ospedaliero Universitaria (AOU) Careggi, Florence, Italy.
    Bitton, Alain
    McGill University Health Centre, Royal Victoria Hospital, Montreal QC, Canada.
    Begun, Jakob
    Harvard School of Medicine, Boston MA, USA.
    Brant, Steve R.
    Johns Hopkins University, Baltimore MD, USA.
    Bresso, Francesca
    Karolinska University Hospital, Solna, Sweden.
    Cho, Judy H.
    Yale University, New Haven CT, USA.
    Duerr, Richard H.
    Graduate School of Public Health, University of Pittsburgh, Pittsburgh PA, USA.
    Halfvarson, Jonas
    Örebro universitet, Institutionen för hälsovetenskap och medicin. Region Örebro län.
    McGovern, Dermot P. B.
    Cedars-Sinai Medical Center, Los Angeles CA, USA.
    Radford-Smith, Graham
    University of Queensland, Brisbane, Australia.
    Schreiber, Stefan
    Christian-Albrechts-University, Kiel, Germany.
    Schumm, Philip L.
    University of Chicago, Chicago ILL, USA.
    Sharma, Yashoda
    Yale University, New Haven CT, USA.
    Silverberg, Mark S.
    University of Toronto, Toronto ON, Canada.
    Weersma, Rinse K.
    University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
    D'Amato, Mauro
    Karolinska Institutet, Stockholm, Sweden.
    Vermeire, Severine
    University Hospital Gasthuisberg, Leuven, Belgium.
    Franke, Andre
    Christian-Albrechts-University, Kiel, Germany.
    Lettre, Guillaume
    Research Center, Montreal Heart Institute, Montreal QC, Canada; Universite de Montreal, Montreal QC, Canada .
    Xavier, Ramnik J.
    Harvard School of Medicine, Boston MA, USA; Broad Institute of MIT and Harvard University, Cambridge MA, USA .
    Daly, Mark J.
    Massachusetts General Hospital, Harvard Medical School, Boston MA, USA.
    Rioux, John D.
    Research Center, Montreal Heart Institute, Montreal QC, Canada; Universite de Montreal, Montreal QC, Canada.
    Deep Resequencing of GWAS Loci Identifies Rare Variants in CARD9, IL23R and RNF186 That Are Associated with Ulcerative Colitis2013Ingår i: PLOS Genetics, ISSN 1553-7390, E-ISSN 1553-7404, Vol. 9, nr 9, artikel-id e1003723Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Genome-wide association studies and follow-up meta-analyses in Crohn's disease (CD) and ulcerative colitis (UC) have recently identified 163 disease-associated loci that meet genome-wide significance for these two inflammatory bowel diseases (IBD). These discoveries have already had a tremendous impact on our understanding of the genetic architecture of these diseases and have directed functional studies that have revealed some of the biological functions that are important to IBD (e.g. autophagy). Nonetheless, these loci can only explain a small proportion of disease variance (similar to 14% in CD and 7.5% in UC), suggesting that not only are additional loci to be found but that the known loci may contain high effect rare risk variants that have gone undetected by GWAS. To test this, we have used a targeted sequencing approach in 200 UC cases and 150 healthy controls (HC), all of French Canadian descent, to study 55 genes in regions associated with UC. We performed follow-up genotyping of 42 rare non-synonymous variants in independent case-control cohorts (totaling 14,435 UC cases and 20,204 HC). Our results confirmed significant association to rare non-synonymous coding variants in both IL23R and CARD9, previously identified from sequencing of CD loci, as well as identified a novel association in RNF186. With the exception of CARD9 (OR = 0.39), the rare non-synonymous variants identified were of moderate effect (OR = 1.49 for RNF186 and OR = 0.79 for IL23R). RNF186 encodes a protein with a RING domain having predicted E3 ubiquitin-protein ligase activity and two transmembrane domains. Importantly, the disease-coding variant is located in the ubiquitin ligase domain. Finally, our results suggest that rare variants in genes identified by genome-wide association in UC are unlikely to contribute significantly to the overall variance for the disease. Rather, these are expected to help focus functional studies of the corresponding disease loci.

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