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  • 1. Alinasab, Babak
    et al.
    Borstedt, Karl-Johan
    Rudström, Rebecka
    Ryott, Michael
    Sophiahemmet Högskola.
    Qureshi, Abdul Rashid
    Beckman, Mats O
    Stjärne, Pär
    New Algorithm for the Management of Orbital Blowout Fracture Based on Prospective Study2018Inngår i: Craniomaxillofacial Trauma & Reconstruction, ISSN 1943-3875, E-ISSN 1943-3883, Vol. 11, nr 4, s. 285-295Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Despite extensive debate and publications in the management of blowout fracture (BOF), there are still considerable differences in the surgeons' management of BOF due to a lack of reliable evidence-based studies. This article aimed to evaluate which BOF patients require surgical treatment due to functional and/or cosmetic deformities; evaluate which computed tomography (CT) scan findings predict these problems; and provide an algorithm in the management of BOF. Seventy-nine patients with BOF were treated conservatively and followed up prospectively regarding functional and cosmetic deformities for at least 1 year. The patients' CT scans were analyzed and several measurements were performed. Patients' symptoms and the clinical findings were correlated to the CT scan measurements. We found visible deformity in 37% of the patients, but only 10% chose to proceed to surgery due to cosmetic deformities. In patients with inferior BOF and a herniation < 1.0 mL, a visible deformity was found when the ratio between fracture and the fractured orbital wall areas was ≥42%, or the total area of the fracture was ≥ 2.3 cm 2 . In patients with inferior BOF and a herniation ≥ 1.0 mL, a visible deformity was found when the distance from the inferior orbital rim to the posterior edge of the fracture was ≥ 3.0 cm. In patients with inferomedial fracture, a visible deformity was found when the herniation was ≥ 0.9 mL. Diplopia improved significantly and remained in only 3% of the patients in nonoperated group. Hypoesthesia of the infraorbital nerve improved significantly, but 23% of the nonoperated and 50% of the operated patients still experienced loss of sensation at final control. In this prospective study, we found that not only herniated orbital volume but also other CT scan findings in BOF were crucial to predict late visible deformities. Based on these findings, we propose an algorithm for the prediction of late visible deformity with 83% accuracy. There are indications that diplopia without ocular motility disorder is due to edema and we recommend observation as long as the diplopia improves gradually.

  • 2. Alinasab, Babak
    et al.
    Borstedt, Karl-Johan
    Rudström, Rebecka
    Ryott, Michael
    Sophiahemmet Högskola.
    Qureshi, Abdul Rashid
    Stjärne, Pär
    Prospective Randomized Controlled Pilot Study on Orbital Blowout Fracture2018Inngår i: Craniomaxillofacial Trauma & Reconstruction, ISSN 1943-3875, E-ISSN 1943-3883, Vol. 11, nr 3, s. 165-171Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    To clarify the conflicting recommendations for care of blowout fracture (BOF), a prospective randomized study is required. Here, we present a prospective randomized pilot study on BOF. This article aimed to evaluate which computed tomography (CT) findings predict late functional and/or cosmetic symptoms in BOF patients with ≥ 1.0 mL herniation of orbital content into maxillary and/or ethmoidal sinuses. It also aimed to evaluate which patients with BOF would benefit from surgical treatment or observational follow-up. Twenty-six patients with BOF ≥ 1.0 mL herniation were randomized to observational ( n  = 10) or surgical treatments ( n  = 16) and were followed up for functional and cosmetic symptoms for at least 1 year. The results from CT scan measurements were correlated to the patients' symptoms and clinical findings which we report in this pilot study. Of the 10 patients randomized to observation, five had an inferomedial BOF with a herniation of ≥ 1.3 mL and all patients developed cosmetic deformities and required surgery. The remaining five patients in the observational group had inferior BOF and one of them had a distance of 3.3 cm from the inferior orbital rim to the posterior edge of the fracture and developed a cosmetic deformity but was unwilling to proceed to surgical treatment, and four patients had a median distance of 2.9 cm from the inferior orbital rim to the posterior edge of the fracture and did not develop cosmetic deformities. The median time from injury to surgery was 13 (3-17) days for the surgical group and 37 (17-170) days for the patients who underwent surgery in the observational group. The surgical results were similar for all the operated patients at the final control. Diplopia decreased and remained partly in one patient in the surgical group and in two patients in the observational group. Hypoesthesia of the infraorbital nerve decreased in nonsurgically treated patients, but surgery seemed to induce hypoesthesia. In this prospective randomized controlled pilot study on BOF, all patients in the observational group with inferomedial fractures developed visible deformity. Diplopia in BOF, without ocular motility limitation, is believed to be due to edema. Diplopia is not an indication for surgery as long as it reduces over time.

  • 3. Alinasab, Babak
    et al.
    Qureshi, Abdul Rashid
    Sophiahemmet Högskola.
    Stjärne, Pär
    Prospective study on ocular motility limitation due to orbital muscle entrapment or impingement associated with orbital wall fracture2017Inngår i: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 48, nr 7, s. 1408-1416, artikkel-id S0020-1383(17)30268-1Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    INTRODUCTION: The recommended urgent surgical management of ocular motility restriction due to orbital muscle entrapment or impingement associated with orbital wall fracture needs to be elucidated.

    AIM: To evaluate the importance of the time from injury to surgery for the outcome in ocular motility and diplopia, the time lapse of ocular motility, diplopia and hypesthesia recovery.

    MATERIAL AND METHODS: Patients with entrapment or impingement of orbital contents due to orbital wall fracture were followed up prospectively over 1year regarding ocular motility, diplopia, hypesthesia and cosmetic deformity.

    RESULTS: 21 patients (10 entrapments and 11 impingements) were included and treated surgically. The median time from injury to surgery was 36 (8-413)h for the entrapment group and 168 (48-326)h for the impingement group. The median time from study inclusion to surgery was 0 (0-1) days for the entrapment group and 1.0 (0.2-4.8) days for the impingement group. All the patients had ocular motility limitation and diplopia at the inclusion. Ocular motility improved gradually and was normal at final visit. Diplopia resolved gradually in all patients except in two with non-disturbing diplopia, at the final visit. Forced duction test was positive in 90% of the patients in the entrapment group and 70% in impingement group. At final visit, hypesthesia was found in none of the patients in the entrapment group but in 4 patients in the impingement group.

    CONCLUSIONS: In this, the first prospective long term follow up of orbital wall fractures with ocular motility restriction, we did not find any significant correlation between the time from injury to surgery and the outcomes in ocular motility and diplopia. An entrapment requires surgery as soon as possible; however, the surgical reduction is at least as important as surgical timing. Surgery should be delayed until it can be performed by an experienced surgeon. Ocular motility restriction causing diplopia due to impingement is not an ophthalmologic emergency and surgery is recommended if the diplopia and ocular motility has not improved over time. Clinical examination of ocular motility and not CT scan findings is crucial to determine whether a limitation of ocular motility exists or not.

  • 4. Bai, Lucy
    et al.
    Arver, Brita
    Johansson, Hemming
    Sandelin, Kerstin
    Wickman, Marie
    Sophiahemmet Högskola.
    Brandberg, Yvonne
    Body image problems in women with and without breast cancer 6-20 years after bilateral risk-reducing surgery: A prospective follow-up study2019Inngår i: Breast, ISSN 0960-9776, E-ISSN 1532-3080, Vol. 44, s. 120-127, artikkel-id S0960-9776(19)30019-0Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    PURPOSE: To prospectively follow-up and investigate women's perceptions of the cosmetic outcome of their implant-based breast reconstruction, body image, sexuality, anxiety/depressive symptoms, and health-related quality of life (HRQoL) 6-20 years after bilateral risk-reducing mastectomy (RRM), or complementary RRM after breast cancer diagnosis, due to increased risk of hereditary breast cancer.

    PATIENTS AND METHODS: Women with and without previous breast cancer diagnosis that underwent RRM between March 1997 and September 2010 were invited (n = 200). We compared 146 (73%) sets of long-term questionnaire responses (e.g., EORTC QLQ-BRR26, Body Image Scale, Sexuality Activity Questionnaire, Hospital Anxiety and Depression Scale, and SF-36) with responses one year after surgery. Women with and without previous breast cancer were compared at the long-term assessment point.

    RESULTS: The HRQoL and anxiety/depressive symptoms remained unchanged compared with one year after surgery, and there were no between-group differences. The negative impact on body image persisted in both groups for most of the items. 'Sexual discomfort' increased significantly for women with previous breast cancer (p = 0.016). Women with previous breast cancer also reported more problems with 'Disease treatment/surgery related symptoms' (p = 0.006) and 'Sexuality' (p = 0.031) in the EORTC QLQ-BRR26 questionnaire.

    CONCLUSION: Problems with body image appeared to persist long time post-RRM. No differences in HRQoL were found at the long-term follow-up between women with and without previous breast cancer. The results of this investigation might be of use in improving future counselling before risk-reducing surgery for women in the decision-making process.

  • 5. Hellström, Per M
    et al.
    Samuelsson, Bodil
    Sophiahemmet Högskola.
    Al-Ani, Amer N
    Hedström, Margareta
    Normal gastric emptying time of a carbohydrate-rich drink in elderly patients with acute hip fracture: a pilot study2017Inngår i: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 17, nr 1, s. 23-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Guidelines for fasting in elderly patients with acute hip fracture are the same as for other trauma patients, and longer than for elective patients. The reason is assumed stress-induced delayed gastric emptying with possible risk of pulmonary aspiration. Prolonged fasting in elderly patients may have serious negative metabolic consequences. The aim of our study was to investigate whether the preoperative gastric emptying was delayed in elderly women scheduled for surgery due to acute hip fracture.

    METHODS: In a prospective study gastric emptying of 400 ml 12.6% carbohydrate rich drink was investigated in nine elderly women, age 77-97, with acute hip fracture. The emptying time was assessed by the paracetamol absorption technique, and lag phase and gastric half-emptying time was compared with two gender-matched reference groups: ten elective hip replacement patients, age 45-71 and ten healthy volunteers, age 28-55.

    RESULTS: The mean gastric half-emptying time in the elderly study group was 53 ± 5 (39-82) minutes with an expected gastric emptying profile. The reference groups had a mean half-emptying time of 58 ± 4 (41-106) and 59 ± 5 (33-72) minutes, indicating normal gastric emptying time in elderly with hip fracture.

    CONCLUSION: This pilot study in women with an acute hip fracture shows no evidence of delayed gastric emptying after an orally taken carbohydrate-rich beverage during the pre-operative fasting period. This implies no increased risk of pulmonary aspiration in these patients. Therefore, we advocate oral pre-operative management with carbohydrate-rich beverage in order to mitigate fasting-induced additive stress in the elderly with hip fracture.

    TRIAL REGISTRATION: ClinicalTrials.gov NCT02753010 . Registered 17 April 2016, retrospectively.

  • 6. Isaksson, Karin
    et al.
    Arver, Brita
    Bottai, Matteo
    Pettersson, Andreas
    Wickman, Marie
    Sophiahemmet Högskola.
    Sandelin, Kerstin
    Bilateral Risk-Reducing Mastectomies with Implant-Based Reconstructions Followed Long Term: A Consecutive Series of 185 Patients2019Inngår i: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 43, nr 9, s. 2262-2270Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Bilateral risk-reducing mastectomy (BRRM) is the most effective method to prevent breast cancer in genetically predisposed women and is often performed concomitantly with breast reconstruction. The reconstruction time varies and corrective surgeries are common.

    METHODS: This study evaluated 185 consecutive cases of BRRM and immediate breast reconstruction with implants with regard to surgical outcome and resource consumption. With an 18-year observation period, it was possible to compare permanent expander implants (PEIs) with permanent fixed volume implants (PIs).

    RESULTS: A minimum follow-up of 2 years for all participants but one was achieved. Seventy-five percent (n = 138) of the women received PEI and 25% (n = 47) PI. In a multivariate analysis including age, BMI (<25, ≥25), smoking (yes, no), implant type (PEI, PI), incision technique, operation time and specimen weight <350 g, ≥350 g), only BMI ≥25 was associated with an increased risk of an early complication (OR 7.1, 95% CI 2.44-20.4). As expected, there was a significant difference in median reconstruction time between PEI and PI (12.4 vs. 1.0 months, p < 0.001). The cumulative reoperation-free 2-year survival was significantly higher in the PI than in the PEI group (81% vs. 26%, p < 0.001).

    CONCLUSION: Implant-based reconstruction remains a valid option after BRRM in high-risk women. Whenever possible (low BMI and small breast volume without severe ptosis), permanent fixed volume implants can be safely recommended and are resource saving in comparison with permanent expander implants.

  • 7. Lindegren, A
    et al.
    Schultz, I
    Sinha, I
    Cheung, L
    Khan, A A
    Tekle, M
    Wickman, Marie
    Sophiahemmet Högskola.
    Halle, M
    Autologous fat transplantation alters gene expression patterns related to inflammation and hypoxia in the irradiated human breast2019Inngår i: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 106, nr 5, s. 563-573Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Radiation-induced fibrosis, an adverse effect of breast cancer treatment, is associated with functional and cosmetic impairment as well as surgical complications. Clinical reports suggest improvement following autologous fat transplantation, but the mechanisms underlying this effect are unknown. A global gene expression analysis was undertaken to identify genetic pathways dysregulated by radiation and evaluate the impact of autologous fat transplantation on gene expression.

    METHODS: Adipose tissue biopsies were taken synchronously from irradiated and contralateral non-irradiated breasts, before and 1 year after autologous fat transplantation. Whole-genome gene expression analyses were performed, and Hallmark gene set analysis used to explore the effect of radiotherapy and autologous fat transplantation on gene expression.

    RESULTS: Forty microarrays were analysed, using bilateral biopsies taken from ten patients before and after autologous fat transplantation. Forty-five pathways were identified among the 3000 most dysregulated transcripts after radiotherapy in irradiated compared with non-irradiated breast (P ≤ 0·023; false discovery rate (FDR) no higher than 0·026). After autologous fat transplantation, 575 of the 3000 genes were again altered. Thirteen pathways (P ≤ 0·013; FDR 0·050 or less) were identified; the top two canonical pathways were interferon-γ response and hypoxia. Correlative immunohistochemistry showed increased macrophage recruitment in irradiated tissues.

    CONCLUSION: The present findings contribute to understanding of how autologous fat transplantation can ameliorate radiation-induced fibrosis. This further supports the use of autologous fat transplantation in the treatment of radiation-induced fibrosis. Surgical relevance Clinical studies have indicated that autologous fat transplantation (AFT) stimulates regression of chronic inflammation and fibrosis caused by radiotherapy in skin and subcutaneous fat. However, there is a paucity of biological evidence and the underlying processes are poorly understood. Human data are scarce, whereas experimental studies have focused mainly either on the effect of irradiation or AFT alone. The present results indicate that radiotherapy causes dysregulated gene expression in fibrosis-related pathways in adipose tissues in humans. They also show that AFT can cause a reversal of this, with several dysregulated genes returning to nearly normal expression levels. The study provides biological evidence for the impact of AFT on radiation-induced dysregulated gene expression in humans. It supports the use of AFT in the treatment of radiation-induced fibrosis, associated with severe morbidity and surgical challenges.

  • 8. Lindegren, Anna
    et al.
    Schultz, Inkeri
    Wickman, Marie
    Sophiahemmet Högskola.
    Improved patient-reported outcomes after autologous fat transplantation and corrective surgery after breast surgery2019Inngår i: Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, ISSN 2000-656X, E-ISSN 2000-6764, Vol. 53, nr 2, s. 111-118Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Autologous fat transplantation (AFT) is being increasingly used to improve the results after breast-conserving surgery and breast reconstruction. However, studies on patient-reported outcomes (PROs) and health-related quality of life (HRQoL) after AFT are scarce. The aim of this prospective longitudinal case-series study was to assess PRO in women who had undergone AFT after surgery for breast cancer or risk-reducing mastectomy.

    METHODS: Fifty women, who had undergone breast-conserving surgery or breast reconstruction, needing corrective surgery, were consecutively included between 2008 and 2013. A 20-item study-specific questionnaire (SSQ) and the Short Form Health Survey (SF-36) were used pre-operatively and 6 months, 1 year and 2 years post-operatively, to evaluate PRO and HRQoL.

    RESULTS: The patients underwent three (1-4) AFT procedures, with the injection of 164 ml (median) (range 40-516) fat. Thirty-eight and 34 patients completed the study-specific questionnaire and the SF-36, respectively, both pre-operatively and after 2 years. Sixteen of the 20 items in the SSQ were improved after 2 years, including breast size (p < 0.0001), shape (p < 0.0001), appearance (p < 0.0001), softness of the breast (p = 0.001), pain in the region (p = 0.005), scarring from previous breast surgery (p < 0.001) and willingness to participate in public physical activities (p < 0.001). HRQoL did not largely differ before and after AFT, or between the study group and a reference population.

    CONCLUSIONS: AFT alone or in combination with other corrective surgical procedures, improved PRO after breast-conserving surgery and breast reconstruction in both irradiated and non-irradiated women.

  • 9. Marcano, Alejandro I
    et al.
    Nordenvall, Richard
    Karlsson, Pär
    Gerdin, Martin
    Adami, Johanna
    Sophiahemmet Högskola.
    Palme, Mårten
    Mattila, Ville M
    Bahmanyar, Shahram
    Felländer-Tsai, Li
    Income change after cruciate ligament injury: A population-based study2019Inngår i: Knee (Oxford), ISSN 0968-0160, E-ISSN 1873-5800, Vol. 26, nr 3, s. 603-611, artikkel-id S0968-0160(18)30722-1Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: To investigate the association between choice of treatment and patients' income after cruciate ligament (CL) injury and assess the effect of different covariates such as sex, age, comorbidities and type of work.

    METHODS: This entire-population cohort study in Sweden included working patients with a diagnosed CL injury between 2002 and 2005, identified in The National Swedish Patient Register (n = 13,662). The exposure was the treatment choice (operative or non-operative treatment). The main outcome measure was average yearly income five years after CL diagnosis, adjusted for the following covariates: sex, age, comorbidities, type of work, region, calendar year, education and income.

    RESULTS: Relative to non-operative treatment, operative treatment was associated with greater average yearly incomes (nine to 15%) after injury among patients between 20 and 50 years, patients with partial university education, patients living in large cities and patients with one comorbidity, despite no overall significant association in the national cohort. Delayed operative treatment (>1 year) had no significant association with income change, whereas early operative treatment (<1 year) was associated with higher average yearly incomes (11 to 16%) among females, patients between 20 and 50 years, patients living in large cities and patients with one comorbidity.

    CONCLUSIONS: In a broad sense, treatment choice was not associated with changes in income five years after CL injuries among patients in the workforce, however earlier operative treatment was associated with higher average incomes among patients with ages between 20 and 50, females, living in large cities, with one comorbidity and with a high level of education.

  • 10. Richter, Martinus
    et al.
    Agren, Per-Henrik
    Sophiahemmet Högskola.
    Besse, Jean-Luc
    Cöster, Maria
    Kofoed, Hakon
    Maffulli, Nicola
    Rosenbaum, Dieter
    Steultjens, Martijn
    Alvarez, Fernando
    Boszczyk, Andrzej
    Buedts, Kris
    Guelfi, Marco
    Liszka, Henryk
    Louwerens, Jan-Willem
    Repo, Jussi P
    Samaila, Elena
    Stephens, Michael
    Witteveen, Angelique G H
    EFAS Score - Multilingual development and validation of a patient-reported outcome measure (PROM) by the score committee of the European Foot and Ankle Society (EFAS)2018Inngår i: Foot and Ankle Surgery, ISSN 1268-7731, E-ISSN 1460-9584, Vol. 24, nr 3, s. 185-204, artikkel-id S1268-7731(18)30186-3Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: A scientifically sound validated foot and ankle specific score validated ab initio for different languages is missing. The aim of a project of the European Foot and Ankle Society (EFAS) was to develop, validate, and publish a new score(the EFAS-Score) for different European languages.

    METHODS: The EFAS Score was developed and validated in three stages: (1) item (question) identification, (2) item reduction and scale exploration, (3) confirmatory analyses and responsiveness. The following score specifications were chosen: scale/subscale (Likert 0-4), questionnaire based, outcome measure, patient related outcome measurement. For stage 3, data were collected pre-operatively and at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using analyses from classical test theory and item response theory.

    RESULTS: Stage 1 resulted in 31 general and 7 sports related questions. In stage 2, a 6-item general EFAS Score was constructed using English, German, French and Swedish language data. In stage 3, internal consistency of the scale was confirmed in seven languages: the original four languages, plus Dutch, Italian and Polish (Cronbach's Alpha >0.86 in all language versions). Responsiveness was good, with moderate to large effect sizes in all languages, and significant positive association between the EFAS Score and patient-reported improvement. No sound EFAS Sports Score could be constructed.

    CONCLUSIONS: The multi-language EFAS Score was successfully validated in the orthopaedic ankle and foot surgery patient population, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.

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