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de Jong CMM, van den Hout WB, van Dijk CE, Heim N, van Dam LF, Dronkers CEA, Gautam G, Ghanima W, Gleditsch J, von Heijne A, Hofstee HMA, Hovens MMC, Huisman MV, Kolman S, Mairuhu ATA, van Mens TE, Nijkeuter M, van de Ree MA, van Rooden CJ, Westerbeek RE, Westerink J, Westerlund E, Kroft LJM, Klok FA. Cost-Effectiveness of Performing Reference Ultrasonography in Patients with Deep Vein Thrombosis. Thromb Haemost 2023. [PMID: 37984402 DOI: 10.1055/a-2213-9230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
BACKGROUND The diagnosis of recurrent ipsilateral deep vein thrombosis (DVT) with compression ultrasonography (CUS) may be hindered by residual intravascular obstruction after previous DVT. A reference CUS, an additional ultrasound performed at anticoagulant discontinuation, may improve the diagnostic work-up of suspected recurrent ipsilateral DVT by providing baseline images for future comparison. OBJECTIVES To evaluate the cost-effectiveness of routinely performing reference CUS in DVT patients. METHODS Patient-level data (n = 96) from a prospective management study (Theia study; NCT02262052) and claims data were used in a decision analytic model to compare 12 scenarios for diagnostic management of suspected recurrent ipsilateral DVT. Estimated health care costs and mortality due to misdiagnosis, recurrent venous thromboembolism, and bleeding during the first year of follow-up after presentation with suspected recurrence were compared. RESULTS All six scenarios including reference CUS had higher estimated 1-year costs (€1,763-€1,913) than the six without reference CUS (€1,192-€1,474). Costs were higher because reference CUS results often remained unused, as 20% of patients (according to claims data) would return with suspected recurrent DVT. Estimated mortality was comparable in scenarios with (14.8-17.9 per 10,000 patients) and without reference CUS (14.0-18.5 per 10,000). None of the four potentially most desirable scenarios included reference CUS. CONCLUSION One-year health care costs of diagnostic strategies for suspected recurrent ipsilateral DVT including reference CUS are higher compared to strategies without reference CUS, without mortality benefit. These results can inform policy-makers regarding use of health care resources during follow-up after DVT. From a cost-effectiveness perspective, the findings do not support the routine application of reference CUS.
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Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Sciences - Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Noor Heim
- National Health Care Institute, The Netherlands
| | - Lisette F van Dam
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Charlotte E A Dronkers
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Gargi Gautam
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Waleed Ghanima
- Department of Internal Medicine, Østfold Hospital Trust, Gralum, Norway
- Department of Haematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Anders von Heijne
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | - Marcel M C Hovens
- Department of Vascular Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stan Kolman
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcel A van de Ree
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | | | | | - Jan Westerink
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Lindqvist PG, Westerlund E, Hellgren M. Swedish obstetric thromboprophylaxis guideline: background and update. J OBSTET GYNAECOL 2023; 43:2241527. [PMID: 37551130 DOI: 10.1080/01443615.2023.2241527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/23/2023] [Indexed: 08/09/2023]
Abstract
Risk estimation concerning venous thromboembolism (VTE) and thromboprophylaxis for those at risk is routine in pregnancy. For 20 years, Swedish obstetricians have followed a weighted-risk algorithm guideline for risk estimation, based on which patient selection, timing, duration and dosage of thromboprophylaxis are determined. This article presents the latest update, the basis for the algorithm and its application for assessing moderate- to high obstetric VTE risk, defined as equal or greater absolute risk per time unit than the antepartum risk of women with one prior VTE. The risk score is based on risk factors conferring approximately fivefold increased risk of VTE or a multiple thereof. This article also presents algorithm efficacy data and describes lifestyle advice provided to patients. In our experience, the Swedish guideline for obstetric VTE risk estimation is easy to follow. It helps identify women at high risk. The risk of under- or overtreatment is thus minimised.
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Affiliation(s)
- Pelle G Lindqvist
- Department of Clinical Sciences and Education, Karolinska Institutet, Södersjukhuset, Sweden
- Department of Obstetrics and Gynaecology, Södersjukhuset, Stockholm, Sweden
| | - Eli Westerlund
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Margareta Hellgren
- Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Rosell A, Gautam G, Wannberg F, Ng H, Gry H, Vingbäck E, Lundström S, Mackman N, Wallén H, Westerlund E, Thålin C. Neutrophil extracellular trap formation is an independent risk factor for occult cancer in patients presenting with venous thromboembolism. J Thromb Haemost 2023; 21:3166-3174. [PMID: 37479035 DOI: 10.1016/j.jtha.2023.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/14/2023] [Accepted: 07/07/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE), particularly unprovoked VTE, is associated with occult cancer. The optimal screening regimen remains controversial. Neutrophil extracellular traps (NETs) are implicated in cancer-associated thrombosis, and elevated biomarkers of NET formation are associated with poor prognosis. OBJECTIVES To investigate the association between NET formation and occult cancer in patients with VTE. METHODS Blood biomarkers associated with NETs and neutrophil activation (nucleosomal citrullinated histone H3 [H3Cit-DNA], cell-free DNA, and neutrophil elastase) were quantified in patients with VTE. The primary outcome was cancer diagnosed during a one-year follow-up. RESULTS This study included 460 patients with VTE, of which 221 (48%) had isolated deep vein thrombosis. Forty-three patients had active cancer at inclusion and were excluded from the primary analysis Cancer during follow-up was diagnosed in 29 of 417 (7.0%) patients. After adjustment for age and unprovoked VTE, the hazard ratio of cancer during follow-up per 500 ng/mL increase of H3Cit-DNA was 1.79 (95% CI, 1.03-3.10). Furthermore, patients with cancer-associated VTE (known active cancer or cancer diagnosed during follow-up) had higher levels of H3Cit-DNA than cancer-free patients with VTE after adjustment for age, hemoglobin, gender, chronic obstructive pulmonary disease, previous cancer, and start of anticoagulant treatment (odds ratio 2.06 per 500 ng/mL increase of H3Cit-DNA [95% CI, 1.35-3.13]). CONCLUSIONS H3Cit-DNA is an independent predictor for occult cancer in patients with VTE and elevated in cancer-associated VTE, suggesting that H3Cit-DNA is potentially a useful diagnostic marker for cancer in patients with VTE and that elevated NET formation is a hallmark of cancer-associated VTE.
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Affiliation(s)
- Axel Rosell
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gargi Gautam
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Fredrika Wannberg
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Henry Ng
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Medical Cell Biology, SciLifeLab, Uppsala University, Uppsala Sweden
| | - Hanna Gry
- Division of Radiology, Danderyd Hospital, Danderyd, Sweden
| | - Emma Vingbäck
- Division of Internal Medicine and Infectious diseases, Danderyd Hospital, Danderyd, Sweden
| | - Staffan Lundström
- Palliative Care Services and R&D-unit, Stockholms Sjukhem Foundation, Stockholm, Sweden; Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Håkan Wallén
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Eli Westerlund
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Charlotte Thålin
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden.
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Malmer G, Åhlberg R, Svensson P, Af Ugglas B, Westerlund E. Age in addition to RETTS triage priority substantially improves 3-day mortality prediction in emergency department patients: a multi-center cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:55. [PMID: 37853463 PMCID: PMC10585720 DOI: 10.1186/s13049-023-01123-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 09/25/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Previous studies have shown varying results on the validity of the rapid emergency triage and treatment system (RETTS), but have concluded that patient age is not adequately considered as a risk factor for short term mortality. Little is known about the RETTS system's performance between different chief complaints and on short term mortality. We therefore aimed to evaluate how well a model including both RETTS triage priority and patient age (TP and age model) predicts 3-day mortality compared to a univariate RETTS triage priority model (TP model). Secondarily, we aimed to evaluate the TP model compared to a univariate age model (age model) and whether these three models' predictive performance regarding 3-day mortality varies between patients with different chief complaints in an unsorted emergency department patient population. METHODS This study was a prospective historic observational cohort study, using logistic regression on a cohort of patients seeking emergency department care in Stockholm during 2012-2016. Patient visits were stratified into the 10 chief complaint categories (CCC) with the highest number of deceased patients within 3 days of arrival, and to "other chief complaints". Patients with priority 1 were excluded. RESULTS The studied cohort contained 1,690,981 visits by 788,046 different individuals. The TP and age model predicted 3-day mortality significantly and substantially better than both univariate models in the total population and in each studied CCC. The age model predicted 3-day mortality significantly and substantially better than the TP model in the total population and for all but three CCCs and was not inferior in any CCC. There were substantial differences between the studied CCCs in the predictive ability of each of the three models. CONCLUSIONS Adding patient age to the RETTS triage priority system significantly and substantially improves 3-day mortality prediction compared to RETTS priority alone. Age alone is a non-inferior predictor of 3-day mortality compared to RETTS priority. The impact on 3-day mortality prediction of adding patient age to RETTS priority varies between CCCs but is substantial for all CCCs and for the total population. Including age as a variable in future revisions of RETTS could substantially improve patient safety.
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Affiliation(s)
- G Malmer
- Karolinska Institutet Department of Clinical Sciences, Danderyd Hospital Division of Medicine, Stockholm, Sweden.
| | - R Åhlberg
- Department of Emergency Medicine, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - P Svensson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - B Af Ugglas
- Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
| | - E Westerlund
- Karolinska Institutet Department of Clinical Sciences, Danderyd Hospital Division of Medicine, Stockholm, Sweden
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5
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Medson K, Westerlund E, Paris RV, Fyrdahl A, Vidovic N, Nyren S, Lindholm P. Feasibility of monitoring the resolution of acute pulmonary embolism with non-contrast-enhanced magnetic resonance imaging at one day, one week, one, three, and six months. Acta Radiol 2023; 64:1371-1380. [PMID: 36461762 PMCID: PMC10084520 DOI: 10.1177/02841851221122449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/22/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a common cause of death with an incidence of approximately 1-2 cases per 1000 inhabitants in Europe and the United States. Treatment for PE is the administration of anticoagulants for at least three months. PURPOSE To assess the feasibility of following the resolution rate of PE over time using repeated imaging with a non-contrast-enhanced magnetic resonance imaging (MRI) protocol. MATERIAL AND METHODS Patients (n = 18) diagnosed with acute PE via computed tomography pulmonary angiography (CTPA) underwent non-contrast-enhanced MRI at two tertiary hospitals. The first MRI was performed within 36 h of CTPA, with follow-up at one week, one, three, and six months. The MRI sequence used was a non-contrast-enhanced standard two-dimensional steady-state free precession under free-breathing and without respiratory or cardiac gating. All MRI scans were then compared to the initial CTPA. The emboli were assessed visually for location and size, and clot burden was calculated using the Qanadli score. RESULTS MRI revealed complete resolution in seven cases at one week, in five cases at one month, and in three cases at three months. The most significant resolution of emboli occurred within the first few weeks, with only 10% of the diagnosed emboli persisting at the one-month examination. CONCLUSION The use of MRI imparts the ability to visualize PE without radiation and thus allows multiple examinations to be made, for example in studies investigating the resolution of PE or the evaluation of drug effect in clinical trials.
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Affiliation(s)
- Koshiar Medson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Internal medicine, Danderyd Hospital, Stockholm, Sweden
| | - Roberto Vargas Paris
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Alexander Fyrdahl
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Nina Vidovic
- Department of Radiology, Mälarsjukhuset, Eskilstuna, Sweden
| | - Sven Nyren
- Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA
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Brodin D, Tornhammar P, Ueda P, Krifors A, Westerlund E, Athlin S, Wojt S, Elvstam O, Neumann A, Elshani A, Giesecke J, Edvardsson-Källkvist J, Bunpuckdee S, Unge C, Larsson M, Johansson B, Ljungberg J, Lindell J, Hansson J, Blennow O, Andersson DP. Inhaled ciclesonide in adults hospitalised with COVID-19: a randomised controlled open-label trial (HALT COVID-19). BMJ Open 2023; 13:e064374. [PMID: 36813503 PMCID: PMC9950582 DOI: 10.1136/bmjopen-2022-064374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE To assess the efficacy of inhaled ciclesonide in reducing the duration of oxygen therapy (an indicator of time to clinical improvement) among adults hospitalised with COVID-19. DESIGN Multicentre, randomised, controlled, open-label trial. SETTING 9 hospitals (3 academic hospitals and 6 non-academic hospitals) in Sweden between 1 June 2020 and 17 May 2021. PARTICIPANTS Adults hospitalised with COVID-19 and receiving oxygen therapy. INTERVENTION Inhaled ciclesonide 320 µg two times a day for 14 days versus standard care. MAIN OUTCOME MEASURES Primary outcome was duration of oxygen therapy, an indicator of time to clinical improvement. Key secondary outcome was a composite of invasive mechanical ventilation/death. RESULTS Data from 98 participants were analysed (48 receiving ciclesonide and 50 receiving standard care; median (IQR) age, 59.5 (49-67) years; 67 (68%) men). Median (IQR) duration of oxygen therapy was 5.5 (3-9) days in the ciclesonide group and 4 (2-7) days in the standard care group (HR for termination of oxygen therapy 0.73 (95% CI 0.47 to 1.11), with the upper 95% CI being compatible with a 10% relative reduction in oxygen therapy duration, corresponding to a <1 day absolute reduction in a post-hoc calculation). Three participants in each group died/received invasive mechanical ventilation (HR 0.90 (95% CI 0.15 to 5.32)). The trial was discontinued early due to slow enrolment. CONCLUSIONS In patients hospitalised with COVID-19 receiving oxygen therapy, this trial ruled out, with 0.95 confidence, a treatment effect of ciclesonide corresponding to more than a 1 day reduction in duration of oxygen therapy. Ciclesonide is unlikely to improve this outcome meaningfully. TRIAL REGISTRATION NUMBER NCT04381364.
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Affiliation(s)
- Daniel Brodin
- Department of Medicine, Capio S:t Göran's Hospital, Stockholm, Sweden
| | - Per Tornhammar
- Functional Area of Emergency Medicine, Karolinska Institute, Stockholm, Sweden
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anders Krifors
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Västmanland, Uppsala University, Uppsala, Sweden
| | - Eli Westerlund
- Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - Simon Athlin
- School of Medical Science, Örebro University, Örebro, Sweden
| | - Sandra Wojt
- Department of Internal Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Olof Elvstam
- Department of Infectious Diseases, Central Hospital Växjö, Vaxjo, Sweden
| | - Anca Neumann
- Department of Medicine, Capio S:t Göran's Hospital, Stockholm, Sweden
| | - Arsim Elshani
- Department of Medicine and Geriatrics, Karlskoga Hospital, Karlskoga, Sweden
| | - Julia Giesecke
- Functional Area of Emergency Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Sayam Bunpuckdee
- Functional Area of Emergency Medicine, Karolinska Institute, Stockholm, Sweden
| | - Christian Unge
- Department of Internal Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Martin Larsson
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Björn Johansson
- Department of Infectious Diseases, Halland's Hospital Halmstad, Halmstad, Sweden
| | - Johan Ljungberg
- Department of Infectious Diseases, Halland's Hospital Halmstad, Halmstad, Sweden
| | - Jonas Lindell
- Department of Infectious Diseases, Visby Hospital, Visby, Sweden
| | - Johan Hansson
- Department of Infectious Diseases, Östersund Hospital, Ostersund, Sweden
| | - Ola Blennow
- Department of Medicine, Capio S:t Göran's Hospital, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Daniel Peter Andersson
- Department of Medicine Huddinge H7, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Westerlund E, Fili A, Svennberg E. Prolonged electrocardiography registration does not lead to increased diagnosis of atrial fibrillation in pulmonary embolism patients, but sex affects generic health-related quality of life: Findings from a randomized clinical trial. Medicine (Baltimore) 2022; 101:e32197. [PMID: 36482616 PMCID: PMC9726328 DOI: 10.1097/md.0000000000032197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Atrial fibrillation (AF) is the most common arrhythmia and is commonly detected in patients after embolic stroke. In this study, we set out to study if undiagnosed AF could be detected in patients with PE. In survivors of PE, persisting symptoms and exercise limitations are common. The disease burden of PE on quality of life (QoL) has received scarce attention. The primary aim was to study the prevalence of AF in patients with newly diagnosed PE. The secondary aim was to study QoL in PE patients. METHODS Patients with newly diagnosed acute PE were randomized 1:1 to long-term electrocardiogram (ECG) screening for AF (handheld ECG or ECG patch) or standard-of-care. The study participants were asked to complete RAND-36 questionnaires upon inclusion. RESULTS In total 89 PE patients (mean age 74.6 years) were included, and 40 out of these patients were randomized to AF screening. The study was terminated early due to futility when analysis 1 year after inclusion did not find any patients with newly detected AF.RAND-36 showed that QoL was affected in PE patients. Interestingly, sex differences were found; women had a significantly lower QoL in the dimensions of vitality (P = .006), general health (P = .039), and mental health (P = .041). CONCLUSION Screening for AF in PE patients did not yield a significant proportion of new cases. QoL is more affected in female patients with PE, and increased awareness of this is suggested.
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Affiliation(s)
- Eli Westerlund
- Karolinska Institutet, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
- * Correspondence: Eli Westerlund, Karolinska Institutet, Department of Clinical Sciences, Danderyd University Hospital, Stockholm 182 88, Sweden (e-mail: )
| | - Awat Fili
- Karolinska Institutet, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Emma Svennberg
- Karolinska Institutet, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
- Karolinska Institutet, Department of Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
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8
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Medson K, Yu J, Liwenborg L, Lindholm P, Westerlund E. Comparing ‘clinical hunch’ against clinical decision support systems (PERC rule, wells score, revised Geneva score and YEARS criteria) in the diagnosis of acute pulmonary embolism. BMC Pulm Med 2022; 22:432. [DOI: 10.1186/s12890-022-02242-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022] Open
Abstract
Abstract
Background
Pulmonary embolism (PE) is a common and potentially life-threatening condition. Since it is considered a ‘do not miss’ diagnosis, PE tends to be over-investigated beyond the evidence-based clinical decision support systems (CDSS), which in turn subjects patients to unnecessary radiation and contrast agent exposure with no apparent benefits in terms of outcome.
The purpose of this study was to evaluate the yield of ‘clinical hunch’ (gestalt) and four CDSS: the PERC Rule, Wells score, revised Geneva score, and Years criteria.
Methods
A review was conducted on the Electronic Medical Records (EMR) of 1566 patients from the Emergency Department at a tertiary teaching hospital who underwent CTPA from the 1st of January 2018 to the 31st of December 2019. The scores for the four CDSS were calculated retrospectively from the EMR data. We considered that a CTPA had been ordered on a clinical hunch when there was no mention of CDSS in the EMR, and no D-dimer test. A bypass of CDSS was confirmed when any step of the diagnostic algorithms was not followed.
Results
Of the total 1566 patients who underwent CTPA, 265 (17%) were positive for PE. The diagnosis yield from the five decision groups (clinical hunch and four CDSS) was as follows—clinical hunch, 15%; PERC rule, 18% (6% when bypassed); Wells score, 19% (11% when bypassed); revised Geneva score, 26% (13% when bypassed); and YEARS criteria, 18% (6% when bypassed).
Conclusion
Clinicians should trust the evidence-based clinical decision support systems in line with the international guidelines to diagnose PE.
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Gwozdz AM, de Jong CMM, Fialho LS, Likitabhorn T, Sossi F, Jaber PB, Højen AA, Arcelus JI, Auger WR, Ay C, Barco S, Gazzana MB, Bayley J, Bertoletti L, Cate-Hoek AT, Cohen AT, Connors JM, Galanaud JP, Labropoulos N, Langlois N, Meissner MH, Noble S, Nossent EJ, de León Lovatón PP, Robert-Ebadi H, Rosovsky RP, Smolenaars N, Toshner M, Tromeur C, Wang KL, Westerlund E, de Wit K, Black SA, Klok FA. Development of an international standard set of outcome measures for patients with venous thromboembolism: an International Consortium for Health Outcomes Measurement consensus recommendation. Lancet Haematol 2022; 9:e698-e706. [PMID: 36055334 DOI: 10.1016/s2352-3026(22)00215-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
The International Consortium for Health Outcomes Measurement assembled an international working group of venous thromboembolism experts and patient representatives to develop a standardised minimum set of outcomes and outcome measurements for integration into clinical practice and potentially research to support clinical decision making and benchmarking of quality of care. 15 core outcomes important to patients and health-care professionals were selected and categorised into four domains: patient-reported outcomes, long term consequences of the disease, disease-specific complications, and treatment-related complications. The outcomes and outcome measures were designed to apply to all patients with venous thromboembolism aged 16 years or older. A measurement tool package was selected for inclusion in the core standard set, with a minimum number of items to be measured at predefined timepoints, which capture all core outcomes. Additional measures can be introduced to the user by a cascade opt-in system that allows for further assessment if required. This set of outcomes and measurement tools will facilitate the implementation of the use of patient-centred outcomes in daily practice.
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Affiliation(s)
- Adam M Gwozdz
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Science, Guy's and Saint Thomas' Hospital, King's College London, London, UK; Academic Section of Vascular Surgery, Department of Surgery and Cancer and Department of Vascular Surgery, Imperial College Healthcare NHS Trust, Imperial College London, London, UK
| | - Cindy M M de Jong
- Department of Medicine: Thrombosis and Haemostasis, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Luz Sousa Fialho
- International Consortium for Health Outcomes Measurement, London, UK
| | | | - Frieda Sossi
- International Consortium for Health Outcomes Measurement, London, UK
| | | | - Anette Arbjerg Højen
- Aalborg Thrombosis Research Unit, Department of Cardiology, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Juan I Arcelus
- Department of Surgery, University of Granada Medical School, University of Granada, Granada, Spain
| | - William R Auger
- Department of Pulmonary Medicine, University of California, San Diego, CA, USA
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Centre for Thrombosis and Haemostasis, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marcelo B Gazzana
- Department of Pulmonology and Thoracic Surgery, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil; National Association of Private Hospitals, Porto Alegre, Rio Grande do Sul, Brazil
| | - Julie Bayley
- Lincoln Impact Literacy Institute, University of Lincoln, Lincoln, UK
| | - Laurent Bertoletti
- Department of Vascular and Therapeutic Medicine, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; CIC-1408, INSERM, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; French Clinical Research Infrastructure Network [F-CRIN] INNOvenous thromboembolism, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; UMR1059, INSERM, Université Jean-Monnet, Saint-Étienne, France
| | - Arina Ten Cate-Hoek
- Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht University, Maastricht, Netherlands
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and Saint Thomas' Hospital, King's College London, London, UK
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Stony Brook Hospital, Stony Brook, NY, USA
| | - Nicole Langlois
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mark H Meissner
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Esther J Nossent
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Helia Robert-Ebadi
- Division of Angiology and Haemostasis, Geneva University Hospitals, University of Geneva, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Rachel P Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Noa Smolenaars
- Department of Industrial Design, University of Technology Eindhoven, Eindhoven, Netherlands
| | - Mark Toshner
- Heart Lung Research Institute, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Cécile Tromeur
- French Clinical Research Infrastructure Network [F-CRIN] INNOvenous thromboembolism, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; Department of Internal Medicine and Pneumology, University Hospital of Brest, Brest, France; Group d'etude de la thrombose de Bretagne Occidentale, Université de Bretagne Occidentale, Brest, France
| | - Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet; Danderyd Hospital, Danderyd, Sweden
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada; Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Stephen A Black
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Science, Guy's and Saint Thomas' Hospital, King's College London, London, UK
| | - Frederikus A Klok
- Department of Medicine: Thrombosis and Haemostasis, Leiden University Medical Center, Leiden University, Leiden, Netherlands.
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10
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van Dam LF, Dronkers CEA, Gautam G, Eckerbom Å, Ghanima W, Gleditsch J, van Haren GR, von Heijne A, Huisman MV, Stöger JL, Westerlund E, Kroft LJM, Klok FA. Detection of upper extremity deep vein thrombosis by magnetic resonance non-contrast thrombus imaging. J Thromb Haemost 2021; 19:1973-1980. [PMID: 34018662 PMCID: PMC8361740 DOI: 10.1111/jth.15394] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Compression ultrasonography (CUS) is the first-line imaging test for diagnosing upper extremity deep vein thrombosis (UEDVT), but often yields inconclusive test results. Contrast venography is still considered the diagnostic standard but is an invasive technique. OBJECTIVES We aimed to determine the diagnostic accuracy of magnetic resonance noncontrast thrombus imaging (MR-NCTI) for the diagnosis of UEDVT. METHODS In this international multicenter diagnostic study, we prospectively included patients with clinically suspected UEDVT who were managed according to a diagnostic algorithm that included a clinical decision rule (CDR), D-dimer test, and diagnostic imaging. UEDVT was confirmed by CUS or (computed tomography [CT]) venography. UEDVT was excluded by (1) an unlikely CDR and normal D-dimer, (2) a normal serial CUS or (3) a normal (CT) venography. Within 48 h after the final diagnosis was established, patients underwent MR-NCTI. MR-NCTI images were assessed post hoc by two independent radiologists unaware of the presence or absence of UEDVT. The sensitivity, specificity, and interobserver agreement of MR-NCTI for UEDVT were determined. RESULTS Magnetic resonance noncontrast thrombus imaging demonstrated UEDVT in 28 of 30 patients with UEDVT and was normal in all 30 patients where UEDVT was ruled out, yielding a sensitivity of 93% (95% CI 78-99) and specificity of 100% (95% CI 88-100). The interobserver agreement of MR-NCTI had a kappa value of 0.83 (95% CI 0.69-0.97). CONCLUSIONS Magnetic resonance noncontrast thrombus imaging is an accurate and reproducible method for diagnosing UEDVT. Clinical outcome studies should determine whether MR-NCTI can replace venography as the second-line imaging test in case of inconclusive CUS.
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Affiliation(s)
- Lisette F. van Dam
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Charlotte E. A. Dronkers
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal MedicineHaaglanden Medical CenterThe HagueThe Netherlands
| | - Gargi Gautam
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Åsa Eckerbom
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Waleed Ghanima
- Internal Medicine ClinicØstfold Hospital TrustØstfoldNorway
- Department of HaematologyOslo University Hospital and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | | | - Guido R. van Haren
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Anders von Heijne
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - J. Lauran Stöger
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Eli Westerlund
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Lucia J. M. Kroft
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
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11
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van Dam LF, Gautam G, Dronkers CEA, Ghanima W, Gleditsch J, von Heijne A, Hofstee HMA, Hovens MMC, Huisman MV, Kolman S, Mairuhu ATA, Nijkeuter M, van de Ree MA, van Rooden CJ, Westerbeek RE, Westerink J, Westerlund E, Kroft LJM, Klok FA. Safety of using the combination of the Wells rule and D-dimer test for excluding acute recurrent ipsilateral deep vein thrombosis. J Thromb Haemost 2020; 18:2341-2348. [PMID: 32613731 PMCID: PMC7497055 DOI: 10.1111/jth.14986] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/20/2020] [Accepted: 06/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The diagnostic accuracy of clinical probability assessment and D-dimer testing for clinically suspected recurrent deep vein thrombosis (DVT) is largely unknown. AIM To evaluate the safety of ruling out acute recurrent DVT based on an unlikely Wells score for DVT and a normal D-dimer test. METHODS This was a predefined endpoint of the Theia study in which the diagnostic accuracy of magnetic resonance direct thrombus imaging in acute recurrent ipsilateral DVT was validated. The Wells rule and D-dimer test, performed as part of the study protocol, were not used for management decisions. The primary outcome of this analysis was the incidence of recurrent DVT at baseline or during 3-month follow-up for patients with an unlikely Wells score and a normal D-dimer test. RESULTS Results of both Wells score and D-dimer tests were available in 231 patients without anticoagulant treatment. The recurrent DVT prevalence was 45% (103/231). Forty-nine patients had an unlikely Wells score and normal D-dimer test, of whom 3 (6.1%, 95% confidence interval [CI] 1.3%-18%) had recurrent DVT at baseline/follow-up, yielding a sensitivity of 97% (95% CI 92%-99%) and specificity of 36% (95% CI 28%-45%). Thus, if clinical probability scoring and D-dimer testing would have been applied, radiological imaging could have been omitted in 21% of patients with a diagnostic failure rate of 6.1%. CONCLUSION By applying clinical probability scoring and D-dimer testing, radiological imaging could be spared in one fifth of patients with suspected recurrent ipsilateral DVT. However, the high failure rate does not support implementation of this strategy in daily practice.
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Affiliation(s)
- Lisette F. van Dam
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Gargi Gautam
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Charlotte E. A. Dronkers
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal MedicineHaaglanden Medical CenterThe Haguethe Netherlands
| | - Waleed Ghanima
- Department of Internal MedicineØstfold Hospital TrustØstfoldNorway
- Department of HaematologyInstitute of Clinical MedicineUniversity of OsloOsloNorway
| | | | - Anders von Heijne
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Herman M. A. Hofstee
- Department of Internal MedicineHaaglanden Medical CenterThe Haguethe Netherlands
| | | | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Stan Kolman
- Department of Vascular MedicineDiakonessenhuisUtrechtthe Netherlands
| | | | - Mathilde Nijkeuter
- Department of Vascular MedicineUniversity Medical Center UtrechtUtrechtthe Netherlands
| | | | | | | | - Jan Westerink
- Department of Vascular MedicineUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Eli Westerlund
- Department of Clinical SciencesKarolinska InstituteDanderyd HospitalStockholmSweden
| | - Lucia J. M. Kroft
- Department of RadiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
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12
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Olausson N, Mobarrez F, Zubarev R, Chernobrovkin A, Rutishauser D, Bremme K, Westerlund E, Hovatta O, Wallén H, Henriksson P. Changes in the plasma microvesicle proteome during the ovarian hyperstimulation phase of assisted reproductive technology. Sci Rep 2020; 10:13645. [PMID: 32788624 PMCID: PMC7423945 DOI: 10.1038/s41598-020-70541-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 07/22/2020] [Indexed: 11/26/2022] Open
Abstract
The incidence of pulmonary and venous thromboembolism is increased during the first trimester of pregnancies after assisted reproductive technology (ART) compared to spontaneous conception. We previously found that haemostatic plasma variables changed but within normal limits during controlled ovarian hyperstimulation (COH) concomitant with a major increase in plasma microvesicles (MVs) and markers indicating cell activation. We now explored the proteome of these MVs. Thirty-one women undergoing ART were blood sampled at down-regulation (DR) of oestrogen and at high level stimulation (HLS) with its 10–100-fold increased oestrogen level. Samples were analysed by liquid chromatography and tandem mass spectrometry to identify and quantify the proteome. We identified 306 proteins in the MVs and 72 had changed significantly at HLS compared to DR and more than 20% of them were associated with haemostasis. Thus, proteins related to both haemostasis and complement activation altered in plasma MVs in parallel with MV activation during COH. This needs to be further explored in the clinical context.
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Affiliation(s)
- Nina Olausson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 18288, Stockholm, Sweden.
| | - Fariborz Mobarrez
- Department of Medical Sciences, Uppsala University, 75185, Uppsala, Sweden
| | - Roman Zubarev
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Alexey Chernobrovkin
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Dorothea Rutishauser
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Katarina Bremme
- Department of Women's and Children's Health, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Eli Westerlund
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 18288, Stockholm, Sweden
| | - Outi Hovatta
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 18288, Stockholm, Sweden
| | - Peter Henriksson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 18288, Stockholm, Sweden
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13
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Olausson N, Discacciati A, Nyman AI, Lundberg F, Hovatta O, Westerlund E, Wallén HN, Mobarrez F, Bottai M, Ekbom A, Henriksson P. Incidence of pulmonary and venous thromboembolism in pregnancies after in vitro fertilization with fresh respectively frozen-thawed embryo transfer: Nationwide cohort study. J Thromb Haemost 2020; 18:1965-1973. [PMID: 32289205 DOI: 10.1111/jth.14840] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/19/2020] [Accepted: 04/08/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The assisted reproductive technique in vitro fertilization (IVF) is associated with an increased risk of venous thromboembolism (VTE) and pulmonary embolism (PE) during the first trimester. OBJECTIVES To compare the incidence of VTE and PE during the first trimester of IVF pregnancies using fresh or frozen-thawed embryo transfer to that during natural pregnancies. PATIENT/METHODS Nationwide Swedish registry-based cohort study of women who gave birth (n = 902 891) at the age of 15-50 years to their first child from the 1st of January 1992 until the 31st of December 2012. Exposure groups were IVF with fresh respectively frozen-thawed embryo transfer. Incidences of VTE and PE were calculated, and time-varying hazard ratios estimated for all trimesters after fresh respectively frozen-thawed embryo transfer IVF and compared to natural conception. RESULTS AND CONCLUSION Women giving birth after fresh embryo transfer IVF had a more than eightfold increased incidence of venous thromboembolism (hazard ratio [HR] 8.96, 95% CI 6.33 to 12.67) and pulmonary embolism during the first trimester, (HR 8.69, 95% CI 3.83 to 19.71) compared to women giving birth after natural conception. The incidence of VTE in women giving birth after frozen-thawed embryo transfer was not increased during the first trimester. To conclude, fresh embryo transfer IVF was associated with a significantly increased incidence of VTE and PE during the first trimester. These results suggest that frozen-thawed embryo transfer could be a preferred method of IVF with a minimised maternal risk.
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Affiliation(s)
- Nina Olausson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Andrea Discacciati
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anastasia I Nyman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Frida Lundberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Outi Hovatta
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Eli Westerlund
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Håkan N Wallén
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Fariborz Mobarrez
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Matteo Bottai
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ekbom
- Department of Medicine Solna, Karolinska Institutet, Karolinska Institutet, Stockholm, Sweden
| | - Peter Henriksson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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14
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Varo P, Laine R, Koivistoinen P, Asp NG, Menger A, Reimann S, Robertson JB, Schweizer TF, Selvendran RR, Siljestrom M, Southgate DAT, Theander O, Soest PJV, Westerlund E. Effect of Heat Treatment on Dietary Fiber: Interlaboratory Study. J AOAC Int 2020. [DOI: 10.1093/jaoac/66.4.933] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
The effects of thermal treatments on the dietary fiber composition of cereal and potato samples were studied at 8 laboratories using different analytical methods. Thermal treatments included extrusion cooking for cereals, and boiling and frying for potatoes. No changes in the amounts of dietary fiber or starch were observed in the extruded samples. Heat-treated potato samples contained significantly more water-insoluble dietary fiber (cellulose) and less starch than did raw potato. However, this may be due, at least in part, to the sample preparation procedure rather than the heat treatment alone. The study indicates that gravimetric and sequential hydrolysis methods give similar results, but the variation in most cases is still wide. Further standardization of methods is evidently needed, especially if legislative measures for setting limits on the fiber content of foods are to be introduced. Standardization of starch analysis should also be of primary importance in future work on carbohydrate methodology. This can be concluded from the variation in results concerning this extremely important food constituent. It should be noted that the sample matrix in the present study was simpler than that of complex meals or diets.
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Affiliation(s)
- Perth Varo
- University of Helsinki, Department of Food Chemistry and Technology, SF-00710 Helsinki, Mand
| | - Raili Laine
- University of Helsinki, Department of Food Chemistry and Technology, SF-00710 Helsinki, Mand
| | - Pekka Koivistoinen
- University of Helsinki, Department of Food Chemistry and Technology, SF-00710 Helsinki, Mand
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15
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Affiliation(s)
- Anna Nordgren Rogberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Thoracic radiology, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Deepa Gopalan
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Imperial College NHS Trust, Hammersmith Hospital, London, Britain
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyds Hospital, Stockholm, Sweden
- Division of Medicine, Danderyds Hospital, Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Thoracic radiology, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
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16
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Ruge T, Malmer G, Wachtler C, Ekelund U, Westerlund E, Svensson P, Carlsson AC. Age is associated with increased mortality in the RETTS-A triage scale. BMC Geriatr 2019; 19:139. [PMID: 31122186 PMCID: PMC6533755 DOI: 10.1186/s12877-019-1157-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 05/13/2019] [Indexed: 11/26/2022] Open
Abstract
Background Triage is widely used in the emergency department (ED) in order to identify the patient’s level of urgency and often based on the patient’s chief complaint and vital signs. Age has been shown to be independently associated with short term mortality following an ED visit. However, the most commonly used ED triage tools do not include age as an independent core variable. The aim of this study was to investigate the relationship between age and 7- and 30-day mortality across the triage priority level groups according to Rapid Emergency Triage and Treatment System – Adult (RETTS-A), the most widely used triage tool in Sweden. Methods In this cohort, we included all adult patients visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015, n = 639,387. All patients were triaged according to the RETTS-A and subsequently separated into three age strata: 18–59, 60–79 and ≥ 80 years. Descriptive analyses and logistic regression was used. The primary outcome measures were 7- and 30-day mortality. Results We observed that age was associated with both 7 and 30-day mortality in each triage priority level group. Mortality was higher in older patients across all triage priority levels but the association with age was stronger in the lowest triage group (p-value for interaction = < 0.001). Comparing patients ≥80 years with patients 18–59 years, older patients had a 16 and 7 fold higher risk for 7 day mortality in the lowest and highest triage priority groups, respectively. The corresponding numbers for 30-d mortality were a 21- and 8-foldincreased risk, respectively. Conclusion Compared to younger patients, patients above 60 years have an increased short term mortality across the RETTS-A triage priority level groups and this was most pronounced in the lowest triage level. The reason for our findings are unclear and data suggest a validation of RETTS-A in aged patients.
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Affiliation(s)
- T Ruge
- Department of Emergency Medicine, Huddinge, Karolinska University Hospital, Stockholm, Sweden. .,Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
| | - G Malmer
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - C Wachtler
- Division for Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - U Ekelund
- Faculty of Medicine, Department of Clinical Sciences Lund, Emergency Medicine, Lund University, Lund, Sweden
| | - E Westerlund
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - P Svensson
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - A C Carlsson
- Division for Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
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17
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Vargas Paris R, Skorpil M, Westerlund E, Lindholm P, Nyrén S. Diffusion-weighted imaging in acute pulmonary embolism: a feasibility study. Acta Radiol Open 2018; 7:2058460118783013. [PMID: 30013795 PMCID: PMC6039903 DOI: 10.1177/2058460118783013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/19/2018] [Indexed: 11/21/2022] Open
Abstract
Background Magnetic resonance imaging (MRI) can be an alternative method to computed tomography angiography (CTA) for pulmonary embolism. Purpose To evaluate the feasibility of diffusion-weighted imaging (DWI) detecting acute pulmonary embolism (PE) in free-breathing humans. Material and Methods Twenty patients with PE verified by CTA and 20 controls were investigated with MRI (1.5 Aera, Siemens Healthcare). All sequences were performed in the transversal plane using free-breathing without gating. The protocol consisted of a two-dimensional steady-state free precession (SSFP) and a single-shot DWI echo-planar imaging sequence with a voxel resolution of 2 × 2 × 5 mm. Three b values were used: 50, 400, and 800 s/mm2. Images were analyzed in two orders: an open source analysis (OSA); and a blinded only DWI analysis (BDA) simulating clinical work. Results OSA of corresponding images showed 370 findings on CTA (i.e. one elongated emboli could be represented in multiple images). SSFP identified 237 of those (64%). DWI with b values of 50, 400, and 800 identified 327 (88%), 245 (66%), and 138 (37%), respectively. In BDA we found 160 true emboli (according to CTA) on b50, 78 on b400, and 54 on b800. Fifty-two of these findings at the subsegmental level could be correlated to PE on CTA but were not visible on SSFP. Conclusions DWI has a high sensitivity for detecting PE but suffers from poor specificity. It could potentially be used as an eye catcher, i.e. where to look for PE in other MRI sequences.
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Affiliation(s)
- Roberto Vargas Paris
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Abdominal Radiology, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Skorpil
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Division of Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Thoracic Radiology, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sven Nyrén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Thoracic Radiology, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
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Dronkers CEA, Klok FA, van Haren GR, Gleditsch J, Westerlund E, Huisman MV, Kroft LJM. Diagnosing upper extremity deep vein thrombosis with non-contrast-enhanced Magnetic Resonance Direct Thrombus Imaging: A pilot study. Thromb Res 2018; 163:47-50. [PMID: 29353683 DOI: 10.1016/j.thromres.2018.01.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/07/2018] [Accepted: 01/08/2018] [Indexed: 11/18/2022]
Abstract
Diagnosing upper extremity deep vein thrombosis (UEDVT) can be challenging. Compression ultrasonography is often inconclusive because of overlying anatomic structures that hamper compressing veins. Contrast venography is invasive and has a risk of contrast allergy. Magnetic Resonance Direct Thrombus Imaging (MRDTI) and Three Dimensional Turbo Spin-echo Spectral Attenuated Inversion Recovery (3D TSE-SPAIR) are both non-contrast-enhanced Magnetic Resonance Imaging (MRI) sequences that can visualize a thrombus directly by the visualization of methemoglobin, which is formed in a fresh blood clot. MRDTI has been proven to be accurate in diagnosing deep venous thrombosis (DVT) of the leg. The primary aim of this pilot study was to test the feasibility of diagnosing UEDVT with these MRI techniques. MRDTI and 3D TSE-SPAIR were performed in 3 pilot patients who were already diagnosed with UEDVT by ultrasonography or contrast venography. In all patients, UEDVT diagnosis could be confirmed by MRDTI and 3D TSE-SPAIR in all vein segments. In conclusion, this study showed that non-contrast MRDTI and 3D TSE-SPAIR sequences may be feasible tests to diagnose UEDVT. However diagnostic accuracy and management studies have to be performed before these techniques can be routinely used in clinical practice.
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Affiliation(s)
- C E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - G R van Haren
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - J Gleditsch
- Department of Radiology, Ostfold Hospital Trust, Ostfold, Norway
| | - E Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Mobarrez F, Wallen H, Westerlund E, Hovatta O, Henriksson P, Olausson N. Microparticles reveal cell activation during IVF – a possible early marker of a prothrombotic state during the first trimester. Thromb Haemost 2017; 116:517-23. [DOI: 10.1160/th15-12-0970] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/10/2016] [Indexed: 01/07/2023]
Abstract
SummaryCell-derived microparticles (MPs) are known to be elevated in a number of diseases related to arterial and venous thromboembolism (VTE), such as acute myocardial infarction, VTE (deep-vein thrombosis and pulmonary embolism) and peripheral arterial disease. IVF-associated pregnancies have previously been shown to be associated with an increased incidence of VTE, mechanisms behind being unknown and sparsely studied. Our objective was to assess cell activation during IVF through analysis of MP levels and phenotype following ovarian stimulation. Thirty-one women undergoing IVF were included and blood samples were collected at down regulation of oestrogen and at high level stimulation with 10- to 100-fold increased endogenous oestrogen levels. MPs were analysed by flow cytometry and phenotyped according to size and protein expression. We found that overall phosphatidylserine positive platelet-, endothelial- and monocyte-derived MPs significantly increased following ovarian stimulation with increased levels of platelet activation markers CD40 ligand and P-selectin. Furthermore, there was an increase in endothelial-derived MPs exposing activation marker E-selectin and monocyte-derived MPs, while neutrophil-derived MPs decreased slightly. In conclusion we found a major increase in MPs and markers indicating cell activation in parallel with the profound oestrogen boost during IVF. To assess whether these changes in MPs are associated with thromboembolic events requires extended longitudinal studies.
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Nordgren Rogberg A, Nyrén S, Westerlund E, Lindholm P. How to train radiology residents to diagnose pulmonary embolism using a dedicated MRI protocol. Acta Radiol Open 2017; 6:2058460117734244. [PMID: 28989798 PMCID: PMC5624355 DOI: 10.1177/2058460117734244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/30/2017] [Indexed: 11/26/2022] Open
Abstract
Background In recent years, magnetic resonance imaging (MRI) has been suggested as an alternative to computed tomography angiography (CTA) to diagnose pulmonary embolism (PE). In previous studies, only senior radiologists have been evaluated as reviewers. Purpose To investigate if radiology residents can be trained to review MRI regarding PE and to determine the learning curve effects. Material and Methods Four residents independently went through a training program consisting of 70 participants that had undergone steady-state free precession MRI. The individuals were randomized into ten training sessions. For each exam, the review time and presence or absence of embolus was recorded. After completing each session, the residents received feedback on diagnostic accuracy compared to a consensus reading by two specialists. The residents were also presented with the corresponding CTA. Results The review time was nearly halved (P = 0.0002) during the training program. Comparing the first three sessions with the last three sessions for all residents, the review time decreased from 5:22 min to 2:51 min. The inter-reader agreement improved for all residents during the training program reaching a clinically acceptable level after seven sessions. Conclusion Our study suggests that radiology residents can be trained to independently review MRI investigations regarding PE within a short training program. Similar training programs could be more extensively used as effective teaching method for residents.
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Affiliation(s)
- Anna Nordgren Rogberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Thoracic Radiology, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sven Nyrén
- Thoracic Radiology, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Stockholm, Sweden.,Division of Medicine, Danderyds Hospital, Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Thoracic Radiology, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
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Olausson N, Discacciati A, Nyman A, Hovatta O, Westerlund E, Wallen H, Bottai M, Ekbom A, Henriksson P. P1610Ovarian stimulation explains the increased incidence of pulmonary embolism and venous thromboembolism in IVF. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.p1610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nyrén S, Nordgren Rogberg A, Vargas Paris R, Bengtsson B, Westerlund E, Lindholm P. Detection of pulmonary embolism using repeated MRI acquisitions without respiratory gating: a preliminary study. Acta Radiol 2017; 58:272-278. [PMID: 27273375 DOI: 10.1177/0284185116651003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background Pulmonary embolism (PE) is a severe medical condition with non-specific clinical findings. Computed tomography angiography (CTA) using iodinated contrast agents is the golden standard for diagnosis, but many patients have contraindications for CTA. Purpose To investigate the diagnostic accuracy of repeated acquisitions of magnetic resonance imaging (MRI), without respiratory gating or breath holding, in diagnosing PE using CTA as the reference standard. Material and Methods Thirty-three patients with clinically suspected PE underwent MRI within 48 h after diagnostic CTA. A control group of 37 healthy participants underwent MRI and was matched with an equal number of negative CTA exams. The MRI protocol was based on free-breathing steady-state free precession producing 4.5 mm slices in axial, sagittal, and coronal planes. Instead of respiratory or cardiac gating five repetitive slices were obtained in each anatomical position to compensate for movement and artifacts. Clinical assessment including d-dimer and Well's score was performed prior to imaging. One radiologist reviewed the CTA exams and two radiologists reviewed the MRI scans. Results All 70 MRI exams were of diagnostic quality and the total acquisition time for each MRI scan was 9 min 34 s. On CTA, 29 patients were diagnosed with PE and the MRI readers detected 26 and 27 of those, respectively. Specificity was 100% for both readers. Sensitivity was 90% and 93%, respectively. Inter-reader agreement using Cohen's kappa was 0.97. Conclusion Our unenhanced MRI protocol shows a high sensitivity and specificity for PE, but further studies are required before considering it as a safe diagnostic test.
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Affiliation(s)
- Sven Nyrén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordgren Rogberg
- Department of Radiology Solna, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Roberto Vargas Paris
- Department of Radiology Solna, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Bonnie Bengtsson
- Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Eli Westerlund
- Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Lindholm
- Department of Radiology Solna, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Olausson N, Henriksson P, Zubarev R, Hovatta O, Westerlund E, Wallen H, Mobarrez F. P-070: The microparticle proteome in IVF – changes during the oestrogen surge of controlled ovarian hyperstimulation. Thromb Res 2017. [DOI: 10.1016/s0049-3848(17)30168-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Westerlund E, Woodhams BJ, Eintrei J, Söderblom L, Antovic JP. The evaluation of two automated soluble fibrin assays for use in the routine hospital laboratory. Int J Lab Hematol 2013; 35:666-71. [PMID: 23790234 DOI: 10.1111/ijlh.12117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 05/27/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The soluble fibrin monomer (sFM) assay, like the D-dimer (DDi) assay, has the potential to be used both as an aid in the diagnosis of disseminated intravascular coagulation (DIC) and as a thrombotic marker. It differs from DDi in that it is a much earlier produced fragment produced only by thrombin action on fibrinogen, whereas DDi is a much later produced fragment formed by plasmin cleavage of cross-linked fibrin. METHODS In our study, we compared two commercially available automated sFM assays in the routine hospital setting using samples obtained from the general hospital ward and the emergency room. The results obtained with the two automated assays (Stago LIA sFM assays and the LPIA-Iatro SF assay) were compared with each other and with the results obtained using the routine semiquantitative hemagglutination assay. RESULTS The study showed that both automated assays were comparable with each other. No patient sample previously classified as positive would be missed, but with the higher sensitivity in the automated tests, more samples are positive. CONCLUSION In conclusion, we suggest that both automated tests are suitable for routine laboratory use. Both assays had the advantage over the hemagglutination assay in that previously frozen samples could be used, and the assays are easier and quicker to perform. The LIA sFM Stago has slightly better sensitivity but has a tendency to lower specificity than the Iatro SF test.
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Affiliation(s)
- E Westerlund
- Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
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Henriksson P, Westerlund E, Wallén H, Brandt L, Hovatta O, Ekbom A. Incidence of pulmonary and venous thromboembolism in pregnancies after in vitro fertilisation: cross sectional study. BMJ 2013; 346:e8632. [PMID: 23321489 PMCID: PMC3546085 DOI: 10.1136/bmj.e8632] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2012] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To estimate the risk of pulmonary embolism and venous thromboembolism in pregnant women after in vitro fertilisation. DESIGN Cross sectional study. SETTING Sweden. PARTICIPANTS 23,498 women who had given birth after in vitro fertilisation between 1990 and 2008 and 116,960 individually matched women with natural pregnancies. MAIN OUTCOME MEASURES Risk of pulmonary embolism and venous thromboembolism (identified by linkage to the Swedish national patient register) during the whole pregnancy and by trimester. RESULTS Venous thromboembolism occurred in 4.2/1000 women (n=99) after in vitro fertilisation compared with 2.5/1000 (n=291) in women with natural pregnancies (hazard ratio 1.77, 95% confidence interval 1.41 to 2.23). The risk of venous thromboembolism was increased during the whole pregnancy (P<0.001) and differed between the trimesters (P=0.002). The risk was particularly increased during the first trimester, at 1.5/1000 after in vitro fertilisation versus 0.3/1000 (hazard ratio 4.22, 2.46 to 7.26). The proportion of women experiencing pulmonary embolism during the first trimester was 3.0/10,000 after in vitro fertilisation versus 0.4/10,000 (hazard ratio 6.97, 2.21 to 21.96). CONCLUSIONS In vitro fertilisation is associated with an increased risk of pulmonary embolism and venous thromboembolism during the first trimester. The risk of pulmonary embolism is low in absolute terms but because the condition is a leading cause of maternal mortality and clinical suspicion is critical for diagnosis, an awareness of this risk is important. TRIAL REGISTRATION ClinicalTrials.gov NCT01524393.
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Affiliation(s)
- Peter Henriksson
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, SE 182 88 Stockholm, Sweden.
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Westerlund E, Eintrei J, Söderblom L, Antovic JP. C0127 Evaluation of new automatized soluble fibrin/fibrin monomer method. Thromb Res 2012. [DOI: 10.1016/j.thromres.2012.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Persson L, Henriksson P, Westerlund E, Hovatta O, Angelin B, Rudling M. Endogenous estrogens lower plasma PCSK9 and LDL cholesterol but not Lp(a) or bile acid synthesis in women. Arterioscler Thromb Vasc Biol 2011; 32:810-4. [PMID: 22207727 DOI: 10.1161/atvbaha.111.242461] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Cholesterol and lipoprotein metabolism display pronounced gender differences. Premenopausal women have lower LDL and higher HDL cholesterol, whereas men display higher synthetic rates of bile acids and cholesterol. The effects of the administration of exogenous hormones to humans and animals indicate that these gender differences can often be explained by estrogens. We evaluated how increased levels of endogenous estrogens modulate cholesterol and lipoprotein metabolism in women. METHODS AND RESULTS We studied healthy women during initiation of in vitro fertilization using blood samples obtained when endogenous estrogens were low and high. Cholesterol in VLDL and LDL, but not in HDL, was reduced 20% when estrogens were high. Apolipoprotein B levels decreased 13%. Apolipoprotein A-I and triglyceride levels increased 8% and 37%, respectively, whereas lipoprotein(a) levels were unchanged. Circulating PCSK9, a suppressor of LDL receptors, was reduced 14% when estrogens were high. Serum markers of bile acid and cholesterol synthesis were unaltered. Growth hormone levels increased 3-fold when estrogens were high, whereas insulin-like growth factor-1 and fibroblast growth factor-21 concentrations were unaltered. CONCLUSION In women, Apolipoprotein B-containing particles and circulating PCSK9 are reduced when endogenous estrogens are high, indicating that endogenous estrogens induce hepatic LDL receptors partly through a posttranscriptional mechanism. However, estrogens do not stimulate bile acid or cholesterol synthesis.
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Affiliation(s)
- Lena Persson
- Metabolism Unit, Department of Endocrinology, Metabolism and Diabetes, Karolinska Institute at Karolinska University Hospital Huddinge S-141 86 Stockholm, Sweden
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Persson L, Henriksson P, Westerlund E, Hovatta O, Angelin B, Rudling M. 97 ACUTE STIMULATION OF ENDOGENOUS ESTROGEN IN WOMEN ALTERS CHOLESTEROL METABOLISM AND REDUCES PCSK9 AND LDL CHOLESTEROL LEVELS. ATHEROSCLEROSIS SUPP 2011. [DOI: 10.1016/s1567-5688(11)70098-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Westerlund E, Henriksson P, Wallen N, Hovatta O, Blombäck M, Antovic A. P.3 ETP – a sensitive marker of haemostasis in women undergoing in vitro fertilization. Thromb Res 2011. [DOI: 10.1016/s0049-3848(11)70058-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
In 115 consecutive cataract extractions with implantation of artificial lens a clinical evaluation of absorbable sutures--polyglactin (910) (Vicryl 7-0) and polyglycolic acid (Dexon 8-0)--in corneolimbal incision has been performed. The corneolimbal wounds were closed by continuous suture technique with one double loop knot at the 12 o'clock and 5-6 loops on each side of the 12 o'clock knot. The suture had disappeared after 8 weeks in 95% of the eyes. Two months after operation the visual acuity, the power of corneal astigmatism and astigmatic orientation remained unchanged in both the Vicryl and the Dexon sutured group. This provided effectuation of early full prescription of glasses. Most complications in this material were suture independent and appeared during the early postoperative period. In only one eye inadequate wound closure was noticed. Shallow anterior chamber and hypotonia of short duration occurred in 5 eyes. Four of these patients developed corneal dystrophy. In the Vicryl sutured group suture reactions took place in 87% of the eyes. With dexon suture no such reaction appeared. The use of absorbable sutures in corneolimbal incision technique implies several surgical advantages and is seemingly safe.
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Eriksson I, Andersson R, Westerlund E, Andersson R, Aman P. Structural features of an arabinan fragment isolated from the water-soluble fraction of dehulled rapeseed. Carbohydr Res 1996; 281:161-72. [PMID: 8839183 DOI: 10.1016/0008-6215(95)00337-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A water-soluble polysaccharide fraction was prepared from dehulled rapeseed meal (winter rapeseed variety Casino). Further purification yielded two major fractions having a high content of arabinose and galactose residues, with Ara/Gal ratios of 5.4 (G1) and 1.8 (G2). The Ara/Gal ratio of the high molecular weight fraction G1 was stable over the whole gel filtration peak, indicating that the arabinose and galactose residues are part of the same polysaccharide. The high molecular weight fraction G1 was studied further by methylation analysis and several NMR techniques. Structural studies showed G1 to consist mainly of arabian fragments, which have terminal alpha-L-arabinofuranosyl groups with anomeric carbons bound (1-->5) (A) or (1-->2) (B), and 2,5-substituted arabinosyl residues with anomeric carbons bound (1-->5) (D) or (1-->2) (C) to adjacent arabinosyl residues. The A:B:C:D ratios were 2:1:1:1 according to results from NMR and methylation analysis.
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Affiliation(s)
- I Eriksson
- Department of Food Science, Swedish University of Agricultural Sciences, Uppsala
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Theander O, Aman P, Westerlund E, Andersson R, Pettersson D. Total dietary fiber determined as neutral sugar residues, uronic acid residues, and Klason lignin (the Uppsala method): collaborative study. J AOAC Int 1995; 78:1030-44. [PMID: 7580315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A joint AOAC/American Association of Cereal Chemists (AACC) collaborative study was conducted to determine by the Uppsala method the dietary fiber content and its composition in various foods. The method includes preparation of a residue by treatment with thermostable alpha-amylase and amyloglucosidase and then ethanol precipitation of solubilized dietary fiber components while leaving low-molecular weight carbohydrates in solution. After acid hydrolysis of residue, neutral polysaccharide residues are determined as alditol acetates by gas-liquid chromatography, uronic acid residues are determined by colorimetry, and ash-free acid-insoluble residue (Klason lignin) is determined gravimetrically. Total dietary fiber, including enzyme-resistant starch, is calculated as the sum of nonstarch polysaccharide residues and Klason lignin. Nine laboratories completed the study, analyzing in duplicate 8 unknown dried products that included 4 cereal products, green peas, potato fiber, carrots, and apples. Total dietary fiber contents of products tested ranged from 4.6 to 84.3%, with an average RSDR value of 8.4% (range, 4.8-11.1%). Total neutral polysaccharide residues ranged from 3.8 to 64.1%, with an average RSDR value of 7.5% (range, 5.4-10.5%). Individual neutral sugars (rhamnose, arabinose, xylose, mannose, galactose, and glucose) and uronic acid residues present at more than 1% generally had good RSDR values (3.3-22.8%), whereas, as expected for Klason lignin, only the wheat bran sample with a high content (16%) had an excellent RSDR value (5.0%). The gas chromatographic-colorimetric-gravimetric method (Uppsala method) for determination of total dietary fiber (as neutral sugar residues, uronic acid residues, and Klason lignin) has been adopted first action by AOAC INTERNATIONAL.
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Affiliation(s)
- O Theander
- Swedish University of Agricultural Sciences, Department of Chemistry, Uppsala
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Zhang JX, Lundin E, Reuterving CO, Hallmans G, Stenling R, Westerlund E, Aman P. Effects of rye bran, oat bran and soya-bean fibre on bile composition, gallstone formation, gall-bladder morphology and serum cholesterol in Syrian golden hamsters (Mesocricetus auratus). Br J Nutr 1994; 71:861-70. [PMID: 8031735 DOI: 10.1079/bjn19940192] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The effects of rye bran, oat bran and soya-bean fibre on serum lipids, bile composition and gallstone formation were studied in male Syrian golden hamsters (Mesocricetus auratus). The control groups received fibre-free stone-provoking (O1 diet) or non-stone-provoking (O2 diet) diets. The serum cholesterol levels were lower for all groups fed on the diets supplemented with the dietary fibre sources compared with the control groups. The total content of bile acids in bile was higher in groups given rye-bran diets compared with the corresponding controls. The proportion of cholic acid was higher and that of chenodeoxycholic and lithocholic acid lower in the groups given rye-bran-, oat-bran- or soya-bean-fibre-supplemented diets, compared with the corresponding controls. The secondary:primary bile acid ratio was lower in the group given the rye-bran-supplemented O1 diet. The lithocholic:deoxycholic acid ratio was lower in the groups given rye-bran-, oat-bran- or soya-bean-fibre-supplemented diets than in the corresponding controls. A lower frequency of gallstones was observed only for the group receiving the rye-bran-supplemented O1 diet while the lithogenic index was lower in the groups given the rye-bran-supplemented O2 diet. A decreased epithelial volume density of the gall-bladder and an increased smooth muscular volume density were observed in animals given oat-bran- and rye-bran-supplemented O1 diets, whereas for the soya-bean-fibre-supplemented O1 diet, only the smooth muscular volume density was increased.
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Affiliation(s)
- J X Zhang
- Department of Pathology, University of Umeå, Sweden
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Theander O, Aman P, Westerlund E, Graham H. Enzymatic/chemical analysis of dietary fiber. J AOAC Int 1994; 77:703-9. [PMID: 7516754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The Uppsala methodology for rapid analysis and characterization of total dietary fiber, defined as the sum of dietary fiber polysaccharides (DFP) and Klason lignin, was studied. A sugar- and starch-free residue was prepared by treatment with a thermostable amylase and amyloglucosidase. Neutral DFP residues were quantified by gas chromatography as alditol acetates after acid hydrolysis of this residue, and the acid-insoluble fraction, Klason lignin, was determined gravimetrically. Uronic acid residues were quantified by decarboxylation of the original sample. The efficacy of the Uppsala methodology was tested with foods varying in fiber content and composition, including heat-treated samples. The present method allowed the analysis of up to 40 samples per week. It had good repeatability and coefficients of variation of 3-5% for the main fiber components. Fiber contents determined with the method were higher than those determined with a similar method that excludes Klason lignin and starch resistant to amylases but soluble in dimethyl sulfoxide and lower than those determined with an enzymatic/gravimetric method. Important aspects of fiber analysis, like enzyme purity and the recovery of soluble fiber on ethanol precipitation, also were investigated.
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Affiliation(s)
- O Theander
- Swedish University of Agricultural Sciences, Department of Chemistry, Uppsala
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Zhang JX, Hallmans G, Adlercreutz H, Aman P, Westerlund E, Lundin E, Stenling R. Effects of oat and rye fractions on biliary and faecal bile acid profiles in Syrian golden hamsters (Mesocricetus auratus). Br J Nutr 1993; 70:525-36. [PMID: 8260479 DOI: 10.1079/bjn19930146] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The effects of bran and starchy endosperm fractions of oat and rye on faecal weight and on biliary and faecal bile acids were studied in Syrian golden hamsters (Mesocricetus auratus). The animals fed on diets supplemented with steam-flaked oat bran, oat bran or rye bran had higher wet and dry weights of faeces compared with the animals fed on the fibre-free or low-fibre endosperm diets. A higher mean percentage of biliary cholic acid and a lower mean percentage of chenodeoxycholic and lithocholic (LCA) acids was observed in the bran-supplemented dietary groups. Animals fed on the bran-supplemented diets had increased daily faecal excretion of both total saponifiable and total free bile acids compared with the animals fed on fibre-free or endosperm-supplemented diets. The mean percentage of total saponifiable bile acids in the faeces was higher, and that of free bile acids lower in the animals fed on bran-supplemented diets. A significantly lower concentration of faecal free LCA was observed in the animals fed on the rye-bran diet. Both bran and endosperm diets reduced the faecal LCA:deoxycholic acid compared with the fibre-free diet, but the bran diets had a more pronounced effect than endosperm diets.
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Affiliation(s)
- J X Zhang
- Department of Pathology, University of Umeå, Sweden
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Zhang JX, Lundin E, Hallmans G, Bergman F, Westerlund E, Petterson P. Dietary effects of barley fibre, wheat bran and rye bran on bile composition and gallstone formation in hamsters. APMIS 1992; 100:553-7. [PMID: 1319177 DOI: 10.1111/j.1699-0463.1992.tb00910.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The effects of brewer's spent grain (BSG), wheat bran and rye bran on bile composition, gallstone formation and serum cholesterol were studied in Syrian golden hamsters. The frequency of gallstone formation in the animals fed diets supplemented with low (10%) and high (20%) concentrations of BSG or wheat bran was significantly lower than that of the animals fed a stone-provoking, fibre-free diet. The ratios of secondary to primary bile acids were lower in the animals fed the diets supplemented with a high dose of BSG, wheat bran and rye bran than in the controls. The ratio of LCA to DCA was reduced only in the animals fed the diet supplemented with rye bran as compared with controls. No significant changes in bile and serum cholesterol levels were observed in the experiment.
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Affiliation(s)
- J X Zhang
- Department of Pathology, University of Umeå, Sweden
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Westerlund E, Andersson R, Hämäläinen M, Åman P. Principal component analysis - an efficient tool for selection of wheat samples with wide variation in properties. J Cereal Sci 1991. [DOI: 10.1016/s0733-5210(09)80021-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Zhang JX, Bergman F, Hallmans G, Johansson G, Lundin E, Stenling R, Theander O, Westerlund E. The influence of barley fibre on bile composition, gallstone formation, serum cholesterol and intestinal morphology in hamsters. APMIS 1990; 98:568-74. [PMID: 2166543 DOI: 10.1111/j.1699-0463.1990.tb01072.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Frequency of gallstones, concentration of bile acids and cholesterol in bile, concentration of cholesterol in serum, and structure of the small intestinal mucosa were analyzed in male Syrian Golden hamsters fed a stone provoking fibre-free diet with or without supplementation of brewer's spent grain (BSG), a concentrated barley fibre source from the by-product of brewing. A significantly lower frequency of gallstones was found in the animals with 10% BSG dietary supplementation. Addition of 30% BSG after an initial 6-week period with a fibre-free, stone provoking diet seemed to dissolve previously formed gallstones. Total bile acid concentration was higher in bile from animals given a diet supplemented with 10% BSG. In addition, the cholesterol concentration in both serum and bile was lower in the 30% BSG supplemented group. Structurally, a 10% BSG supplementation decreased ileal epithelium height whereas a high supplementation (30%) of BSG induced a decrease in epithelial height both of jejunal and ileal mucosa. The results show that BSG has significant effects on the metabolism of bile acids and cholesterol as well as on the morphology of the small intestinal mucosa.
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Affiliation(s)
- J X Zhang
- Department of Pathology and Nutritional Research, University of Umeå, Sweden
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Affiliation(s)
- O Theander
- Department of Chemistry, Swedish University of Agricultural Sciences, Uppsala
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Siljeström M, Björck I, Westerlund E. Transglycosidation Reactions Following Heat Treatment of Starch – Effects on Enzymic Digestibility. STARCH-STARKE 1989. [DOI: 10.1002/star.19890410306] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Siljeström M, Westerlund E, Björck I, Holm J, Asp NG, Theander O. The effects of various thermal processes on dietary fibre and starch content of whole grain wheat and white flour. J Cereal Sci 1986. [DOI: 10.1016/s0733-5210(86)80035-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Westerlund E. [Internal television--an aid in dental practice]. Tandlakartidningen 1972; 64:298-9. [PMID: 4502846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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