University Hospital Stockholm Research Articles

Cardiovascular and Lung Involvement in Patients with Autoimmune Pancreatitis

Introduction: Immunoglobulin G4-related disease (IgG4-RD) is a systemic immune-mediated disease characterised pathologically by the infiltration of IgG4-bearing plasma cells into the involved organs. Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis with a heavy lymphocytic infiltration and two distinct histopathological subtypes, namely: lymphoplasmacytic sclerosing pancreatitis (AIP type 1) and idiopathic duct-centric pancreatitis (AIP type 2). Lung involvement and aortic involvement have been reported in 12% and 9% of patients with systemic IgG4-RD, respectively. In series including patients with AIP, both lung and aortic involvement were described in 2% of the patients. Most of the epidemiological data come from Japan, and there is a lack of information from Europe, especially the Scandinavian countries. Patients and methods: We performed a single-centre retrospective study on a prospectively collected cohort of patients diagnosed with AIP at the Department for Digestive Diseases at Karolinska University Hospital in Stockholm, Sweden, from 2004 to 2019. Demographic and clinical data were collected from the medical charts. Results: One hundred and thirty-three patients with AIP were analysed. Six patients were excluded because they lacked some of the clinical data relevant to the study. Demographic and clinical features of 127 patients were presented. There were 98 patients with AIP type 1-35 (35.7%) female and 63 (64.3%) male, with a mean age of 55.4 ± 18.2. Among them, 15 (15.3%) patients had lung and/or cardiovascular involvement-11 (11.2%) patients had lung involvement, 10 (10.2%) patients had cardiovascular involvement (six patients had both). Most of them (67.0%) had never smoked. The mean follow-up time of the patients with AIP type 1 was 49 months. Conclusions: Lung and/or cardiovascular involvement were diagnosed in 15 (15.3%) patients in our historical cohort of patients with AIP type 1. Most of the lung involvement was presented in the form of nodular lesions in the lungs, non-specific infiltrates, “ground-glass” appearance with pleura thickening, and effusion. Aortic involvement was a major form of vascular involvement in patients with AIP, as in previous published studies on patients with IgG4-RD.

Pancreatic exocrine insufficiency and Crohn's disease.

According to the European evidence-based consensus, published by European Crohn's and Colitis Organization (ECCO), diseases of the pancreas are included as extra-intestinal manifestations in IBD in the forms of acute pancreatitis (AP), chronic pancreatitis (CP), autoimmune pancreatitis (AIP), pancreatic duct abnormalities and pancreatic exocrine insufficiency (PEI). Presence of pancreatic autoantibodies directed against the exocrine of the pancreas has been reported in about one-third of CD. However, association between CD and PEI is not fully elucidated. Patients with a diagnosis of CD were recruited at the Department for Digestive Diseases at Karolinska University Hospital in Stockholm, Sweden. Demographic, clinical and laboratory data were analyzed. Fecal elastase-1 (FE-1) measurements were performed using the enzyme-linked immunosorbent assay (ELISA) method. There were 20 patients included in the study, 13 (65%) males and 7 (35%) females, mean age 48.3±1.4 years (range 29-67 years). Mean duration of CD was 15.7±2.1 years (range 1-40 years). There were 11 (55%) patients without history of bowel surgery and 9 (45%) patients after ileocecal resection. FE-1 test was normal in all patients, among them 15 (75%) patients with the values of FE-1>500. Fecal elastase-1 level was normal in all patients with CD strongly indicated absence of PEI in this group of patients.

Post-stroke epilepsy in an ischemic stroke cohort-Incidence and diagnosis.

Stroke is a common cause of adult-onset epilepsy (post-stroke epilepsy, PSE). Despite an increasing awareness, there is a concern for underdiagnosis of the condition. We aimed to study the adherence to the latest updated epilepsy definition, as well as the incidence and diagnosis of PSE in an ischemic stroke cohort admitted to a tertiary University Hospital. We retrospectively investigated the occurrence and diagnosis of unprovoked seizures and PSE in all ischemic stroke patients admitted to Karolinska University Hospital in Stockholm during 2015 and registered in the Swedish Stroke Register. Patient records were scrutinized for the presence of post-stroke seizures/epilepsy. A total of 240 patients fulfilling the inclusion criteria were surveyed. Median follow-up time was 1062days (IQR 589-1195days). Thirteen patients were diagnosed with PSE according to the study criteria, the incidence of PSE 23/1000 person-years (95% CI 13-38/1000 person-years). Median time to PSE from stroke-onset was 237days (IQR 33-688). Eleven of 13 PSE patients received an epilepsy diagnosis, eight patients after one unprovoked seizure, and three patients after two. The majority of PSE patients were given a correct epilepsy diagnosis and treated with antiepileptic drugs. However, this study suggests that there still is potential for improvement in the adherence to the latest updated epilepsy definition. The incidence of PSE in a Swedish ischemic stroke cohort using updated epilepsy definitions is similar to previous studies. Larger studies are needed to confirm our findings on the incidence of PSE.

Minimally invasive mitral valve surgery is associated with a low rate of complications.

Minimally invasive mitral valve surgery is generally performed through a right minithoracotomy, in contrast to the traditional full median sternotomy approach. Minimally invasive mitral valve surgery is performed with increasing frequency, and by reducing surgical trauma, several observational studies suggest potential benefits with decreased bleeding and postoperative pain, reduced incidence of sternal wound infections, reduced length of hospital stay and shortened recovery period after surgery. In this review, we present an overview of mitral valve surgery, summarize the available evidence regarding the minimally invasive approach and report our experiences from introducing a minimally invasive mitral valve surgery programme at the Karolinska University Hospital in Stockholm, Sweden.

Schools of Public Health Should be Accredited for, and Teach the Principles and Practice of Point-of-Care Testing.

Institutions offering public health education, especially those with epidemiology and preparedness concentrations, should be accredited for, and teach the principles and practice of point-of-care testing (POCT)3 (1–4) to enhance emergency preparedness, community resilience, and global response to disasters, complex crises, and outbreaks of highly infectious diseases. ### Rationale Enabling public health practitioners to use POCT will improve standards of crisis care and strengthen community resilience, especially in limited-resource settings (3). Public health services optimized geospatially can accelerate treatment, for example, by using POC cardiac troponin testing to rule in the diagnosis of acute myocardial infarction in rural settings, such as Thua Thien Hue Province in Central Vietnam (5). Early decision-making at points of need will help stop outbreaks of highly infectious diseases like Ebola virus disease (Ebola) (6–8), which recently crossed borders from the war-torn Democratic Republic of Congo. Critically ill patients must receive POCT support in isolation. Patients exposed in Africa and subsequently presenting suspicious for infection at the University of Nebraska in Omaha and Uppsala University Hospital in Stockholm in 2018–19 reaffirm that outbreaks must be stopped where they start. ### Education status A national survey published in Frontiers of Public Health showed that no schools or colleges of public health systematically teach POCT, nor are they encouraged to …

Complications and outcome of percutaneous endoscopic gastrostomy in a high-volume centre

Introduction: Percutaneous endoscopic gastrostomy (PEG) is the method of choice for long-term enteral feeding for patients with swallowing disorders and normal gut function. There is limited data regarding the demographics and clinical characteristics of patients from whom PEG was removed.Patients and methods: We performed a retrospective analysis of all consecutive adult patients who underwent first placement of PEG between 1 August 2013 and 31 December 2015 at Karolinska University Hospital in Stockholm, Sweden.Results: In total, 495 PEG were inserted in 495 patients during the study period, 56% male, mean age at insertion 67 years (range 19–95). Most patients belonged to the neurologic group (52%), followed by the oncologic (32%), another diagnosis (9%) and trauma (7%). Major complications occurred in 10 (2.0%) patients. There were no differences in the age or BMI of patients with either minor or major complications but both parameters were risk factors in terms of survival. PEG was removed from 165 (33.3%) patients, most of them from the oncology group, due to the improvement of general status of patients after specific oncologic treatment.Conclusion: Increased age and low BMI were identified as risk factors for mortality but did not correspond with the rate of complications. Antibiotic prophylaxis with sulfamethoxazole and trimethoprim provides good protection for patients with PEG.

Karolinska Institute and Karolinska University Hospital: Mark Nicholls speaks to key figures at the renowned Karolinska Institutet and Karolinska University Hospital in Stockholm, Sweden, that produce excellent research and deliver innovative clinical care. Part I of III, Introduction and Clinical Care.

Karolinska Institute and Karolinska University Hospital: Mark Nicholls speaks to key figures at the renowned Karolinska Institutet and Karolinska University Hospital in Stockholm, Sweden, that produce excellent research and deliver innovative clinical care. Part I of III, Introduction and Clinical Care.

Emotional reserve and prolonged post-concussive symptoms and disability: a Swedish prospective 1-year mild traumatic brain injury cohort study

ObjectiveProlonged post-concussive symptoms (PCS) affect a significant minority of patients withmild traumatic brain injury (mTBI). The aetiology is multifactorial depending on preinjury as well as peri-injury and postinjury factors. In...

Adolescents’ experiences of obesity surgery: a qualitative study

BackgroundThe positive effects of behavioural treatment and weight management in adolescents with severe obesity are modest. Obesity surgery can be an option for adolescents, but is not the first-hand choice of treatment. The knowledge about adolescents’ own experiences of having undergone surgery and their thoughts and feelings of the follow-up period are limited. ObjectivesTo describe adolescents’ decision to go through obesity surgery as teenager and their experiences of the follow-up period. SettingNational Childhood Obesity Centre at Karolinska University Hospital in Stockholm, Sweden. MethodsPhone interviews with 20 young adults that went through obesity surgery as teenagers. Interviews were analysed with qualitative systematic text condensation. Results“Lost in the healthcare system” and “A rough but well worth journey to a healthier life” were the categories that appeared in our analysis. The participant had a feeling of uncertainty about contacts with the healthcare system and the transition to primary care was confusing. Most of the participants were happy with the decision to go through obesity surgery as teenager, despite it had been a difficult time. ConclusionsOur results show implications for improving the clinical care of adolescents undergoing obesity surgery, which should be offered as a last choice. Information and individualized supports should be offered more often during first year postsurgery and should be given by a multidisciplinary team. This multifaceted population should be given priority for a successful transition.

Sports Physical Therapy Section Poster Presentations (Abstracts SPO1-SPO166).

These abstracts are presented here as prepared by the authors. The accuracy and content of each abstract remain the responsibility of the authors. In the identification number above each abstract, SPO designates a Sports Physical Therapy Section poster presentation. J Orthop Sports Phys Ther 2018;48(1):A203-A276. doi:10.2519/jospt.2018.48.1.A203.

Wait a minute? An observational cohort study comparing iron stores in healthy Swedish infants at 4 months of age after 10-, 60- and 180-second umbilical cord clamping

Background and objectiveUmbilical cord blood (UCB) is a valuable stem cell source used for transplantation. Immediate umbilical cord (UC) clamping is widely practised, but delayed UC clamping is increasingly advocated...

Hypo-Attenuated Leaflet Thickening and Reduced Leaflet Motion in Sutureless Bioprosthetic Aortic Valves.

BackgroundThe prevalence of hypo‐attenuated leaflet thickening (HALT) and reduced leaflet motion (RLM) is unknown in surgically implanted bioprostheses because systematic investigation of HALT and/or RLM is limited to a few catheter‐based valves. The aim of this study was to investigate the prevalence of HALT and RLM by cardiac computed tomography in patients who underwent surgical aortic valve replacement and received a Perceval sutureless aortic valve bioprosthesis.Methods and ResultsThis was a single‐center prospective observational study that included 47 patients (83.5% of the total number of implantations) who underwent surgical aortic valve replacement with implantation of the Perceval sutureless bioprosthesis (LivaNova PLC, London, UK) at Karolinska University Hospital in Stockholm, Sweden from 2012 to 2016 and were studied by cardiac computed tomography. Cardiac computed tomography was performed at a median of 491 days (range 36–1247 days) postoperatively. HALT was found in 18 (38%) patients and RLM in 13 (28%) patients. All patients with RLM had HALT. Among patients with HALT, 5 out of 18 patients (28%) were treated with anticoagulation (warfarin or any novel oral anticoagulant) at the time of cardiac computed tomography. Among patients with RLM, 3 out of 13 patients (23%) were treated with anticoagulation.Conclusions HALT and RLM were prevalent in the surgically implanted Perceval sutureless aortic valve bioprosthesis. Both HALT and RLM were found in patients with ongoing anticoagulation treatment. Whether these findings are associated with adverse events needs further study.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02671474.

High- but not low-grade histologic chorioamnionitis is associated with spontaneous preterm birth in a Swedish cohort

ABSTRACTObjective: To examine whether different grades of placenta inflammation are associated with risk for spontaneous preterm birth, taking into consideration maternal and delivery factors. Placentas from spontaneous preterm births were compared with a control group from full-term deliveries.Methods: Placentas from 98 full-term, 71 late preterm (gestational week 34–37), and 65 early preterm (gestational week 22–33) singleton deliveries were analysed from the Karolinska University Hospital in Stockholm. The placentas were examined for histologic chorioamnionitis (HCA) grade 1 (low) and 2 (high). Mother, child, and delivery parameters were collected from maternity centre and delivery forms.Results: There was a relatively low incidence of HCA in the preterm groups (26.7% and 38.5% in the late and early preterm groups, respectively). HCA 2 was most common in the early preterm group and HCA 1 was most common in the full-term group. The odds of early preterm birth was lower for placentas with HCA 1 compared to HCA 2 (OR = 0.17) and higher for placentas with HCA 2 compared to no HCA (OR = 2.17).Conclusions: Despite a relatively low incidence of HCA in the preterm groups, HCA 2 seems to be associated with early preterm birth whereas HCA 1 seems to be part of the full-term delivery.

Melvin Samsom: Rebuilding hospitals for patients

The visionary Karolinska chief executive, Melvin Samsom, is transforming patients’ experience by restructuring and rebuilding hospitals—despite staff resistance. Jacqui Wise interviews him Melvin Samsom arrived at the Karolinska University Hospital...

Review of the aetiology, diagnostics and outcomes of childhood encephalitis from 1970 to 2009.

Encephalitis is a rare, serious condition, and antiviral therapies, increased knowledge of inflammatory pathways and improved diagnostics have increased the therapeutic possibilities. We describe 40 years of childhood encephalitis in Sweden, covering the diagnostics, aetiology and outcomes. We reviewed the clinical data that were available for all children discharged from the Karolinska University Hospital in Stockholm following treatment for encephalitis from 1970 to 2009. The hospital treated all children in the region with the condition during the study period. There were 408 episodes of encephalitis from 1970 to 2009 and the incidence was similar over the whole period, ranging from 6.4 to 8.7 per 100 000 child years. Although mortality markedly decreased from 10% in the first decade to zero in the last decade, and aetiologies shifted, no clear long-term improvements in outcome were seen. The need for intensive care was unchanged (18-20%) for each of the study intervals, possibly indicating that the severity of cases remained unaltered. Understanding the pathophysiological mechanisms of encephalitis is vitally important for developing more efficient treatment regimens. As well as reporting the results of this 40-year study, this study considers possible explanations, addresses current therapeutic options and explores directions for central nervous system infection research.

Medical Abortion Provided by Nurse-Midwives or Physicians in a High Resource Setting: A Cost-Effectiveness Analysis.

ObjectiveThe objective of the present study is to calculate the cost-effectiveness of early medical abortion performed by nurse-midwifes in comparison to physicians in a high resource setting where ultrasound dating is part of the protocol. Non-physician health care professionals have previously been shown to provide medical abortion as effectively and safely as physicians, but the cost-effectiveness of such task shifting remains to be established.Study designA cost effectiveness analysis was conducted based on data from a previously published randomized-controlled equivalence study including 1180 healthy women randomized to the standard procedure, early medical abortion provided by physicians, or the intervention, provision by nurse-midwifes. A 1.6% risk difference for efficacy defined as complete abortion without surgical interventions in favor of midwife provision was established which means that for every 100 procedures, the intervention treatment resulted in 1.6 fewer incomplete abortions needing surgical intervention than the standard treatment. The average direct and indirect costs and the incremental cost-effectiveness ratio (ICER) were calculated. The study was conducted at a university hospital in Stockholm, Sweden.ResultsThe average direct costs per procedure were EUR 45 for the intervention compared to EUR 58.3 for the standard procedure. Both the cost and the efficacy of the intervention were superior to the standard treatment resulting in a negative ICER at EUR -831 based on direct costs and EUR -1769 considering total costs per surgical intervention avoided.ConclusionEarly medical abortion provided by nurse-midwives is more cost-effective than provision by physicians. This evidence provides clinicians and decision makers with an important tool that may influence policy and clinical practice and eventually increase numbers of abortion providers and reduce one barrier to women’s access to safe abortion.

Morbidité néonatale précoce après sortie de maternité : étude comparative entre deux maternités à Stockholm et Marseille

The consequences of early postpartum discharge (EPPD, within 2 days after birth) on newborn health remain debated. Early discharge has been associated with increased neonatal morbidity. However, neonatal re-hospitalization can be prevented by careful follow-up during the 1st week after birth. We compared the early neonatal hospitalization of term newborns over 2 years in two hospitals: Karolinska University Hospital in Stockholm (n=7300 births), which allowed early discharge from 6h after birth with specific neonatal follow-up, and Marseille University Hospital (AP-HM) (n=4385) where postpartum discharge was more conventional after 72 h. During the study period, the EPPD rate was 41% vs. 2% in Stockholm and Marseille, respectively (P<0.001). Hospital readmission was comparable (5.6‰ vs. 7‰, P=0.2). The leading cause associated with hospitalization was icterus in Stockholm (76% vs. 26%, P<0.001) and feeding difficulties in Marseille (17% vs. 48%, P<0.001). In conclusion, close neonatal follow-up during the 1st week of life associated with restricted maternal and neonatal eligibility criteria for EPPD are required to prevent early neonatal re-hospitalization.

Poststroke Physical Activity Levels No Higher in Rehabilitation than in the Acute Hospital

Returning to physical activity is a common goal for stroke survivors undergoing rehabilitation, and higher levels of activity have been linked to better gait and greater independence in activities of daily living. Our aim was to determine if inpatient rehabilitation settings promoted higher levels of physical activity in stroke survivors than an acute stroke unit setting. Stroke survivors were recruited from the inpatient rehabilitation wards of 4 different hospitals in southern Sweden and from the acute stroke unit at Karolinska University Hospital in Stockholm. Participants were observed for 1 minute every 10 minutes from 8:00 a.m. to 5:00 p.m. At each observation, the person's highest level of physical activity, location, and other people present were recorded. We collected data from 190 stroke survivors (104 rehabilitation, 86 acute). Contrary to our hypothesis, there was no significant difference between the groups in the amount of time spent in moderate-to-high physical activity (rehabilitation median 24%, acute median 23%; adjusted P = .74). Compared to those in the acute setting, participants in the rehabilitation setting spent less time lying in bed, more time sitting supported out of bed, less time in their bedroom, and more time with a therapist (all adjusted P < .001). In the context of stroke, the inpatient rehabilitation environment does not appear to promote higher levels of physical activity than the acute hospital environment.

Referring physicians' experiences of outsourcing radiological examinations – A variety of views on the consequences

IntroductionThere are strengths, weaknesses, opportunities and challenges when outsourcing advanced radiological examinations such as magnetic resonance examinations from university hospitals to external private institutions. AimThe aim of this study was to explore the experiences of referring physicians when their referrals for radiological examinations are outsourced from a university hospital in Stockholm, Sweden. MethodThis qualitative study is a part of a larger study investigating the consequences of outsourcing referrals for radiological examinations from a university hospital to private external units. Ten referring physicians from orthopedic and oncology departments, representing clinics with large volumes of radiological referrals at a university hospital, were interviewed. ResultsThe results showed that the requirements for radiological services differ between these specialties. The overall opinion was that examinations performed by external radiology departments needed additional re-assessment work which causes higher costs for their clinics. This indicates that there is insufficient communication between referring physicians and the radiological department at the University Hospital. ConclusionsFor better planning of radiological services, radiology departments must consider the referring physicians' needs and develop suitable contract when organizing the practice of outsourcing. The management structure in radiology departments and communication between referring physicians and radiologists in the radiology departments should be studied further, to promote better understanding and improve the efficiency of the outsourcing process.

Quality control of CT systems by automated monitoring of key performance indicators: a two-year study.

The purpose of this study was to develop a method of performing routine periodical quality controls (QC) of CT systems by automatically analyzing key performance indicators (KPIs), obtainable from images of manufacturers' quality assurance (QA) phantoms. A KPI pertains to a measurable or determinable QC parameter that is influenced by other underlying fundamental QC parameters. The established KPIs are based on relationships between existing QC parameters used in the annual testing program of CT scanners at the Karolinska University Hospital in Stockholm, Sweden. The KPIs include positioning, image noise, uniformity, homogeneity, the CT number of water, and the CT number of air. An application (MonitorCT) was developed to automatically evaluate phantom images in terms of the established KPIs. The developed methodology has been used for two years in clinical routine, where CT technologists perform daily scans of the manufacturer's QA phantom and automatically send the images to MonitorCT for KPI evaluation. In the cases where results were out of tolerance, actions could be initiated in less than 10 min. 900 QC scans from two CT scanners have been collected and analyzed over the two‐year period that MonitorCT has been active. Two types of errors have been registered in this period: a ring artifact was discovered with the image noise test, and a calibration error was detected multiple times with the CT number test. In both cases, results were outside the tolerances defined for MonitorCT, as well as by the vendor. Automated monitoring of KPIs is a powerful tool that can be used to supplement established QC methodologies. Medical physicists and other professionals concerned with the performance of a CT system will, using such methods, have access to comprehensive data on the current and historical (trend) status of the system such that swift actions can be taken in order to ensure the quality of the CT examinations, patient safety, and minimal disruption of servicePACS numbers: 87.57.C‐, 87.57.N‐, 87.57.Q‐