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Al-Saadi J, Waldén M, Sandell M, Sohlmér J, Grankvist R, Friberger I, Andersson A, Carlsten M, Chien K, Lundberg J, Witman N, Holmin S. Endovascular transplantation of mRNA-enhanced mesenchymal stromal cells results in superior therapeutic protein expression in swine heart. Mol Ther Methods Clin Dev 2024; 32:101225. [PMID: 38516693 PMCID: PMC10950887 DOI: 10.1016/j.omtm.2024.101225] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 02/23/2024] [Indexed: 03/23/2024]
Abstract
Heart failure has a poor prognosis and no curative treatment exists. Clinical trials are investigating gene- and cell-based therapies to improve cardiac function. The safe and efficient delivery of these therapies to solid organs is challenging. Herein, we demonstrate the feasibility of using an endovascular intramyocardial delivery approach to safely administer mRNA drug products and perform cell transplantation procedures in swine. Using a trans-vessel wall (TW) device, we delivered chemically modified mRNAs (modRNA) and mRNA-enhanced mesenchymal stromal cells expressing vascular endothelial growth factor A (VEGF-A) directly to the heart. We monitored and mapped the cellular distribution, protein expression, and safety tolerability of such an approach. The delivery of modRNA-enhanced cells via the TW device with different flow rates and cell concentrations marginally affect cell viability and protein expression in situ. Implanted cells were found within the myocardium for at least 3 days following administration, without the use of immunomodulation and minimal impact on tissue integrity. Finally, we could increase the protein expression of VEGF-A over 500-fold in the heart using a cell-mediated modRNA delivery system compared with modRNA delivered in saline solution. Ultimately, this method paves the way for future research to pioneer new treatments for cardiac disease.
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Affiliation(s)
- Jonathan Al-Saadi
- Department of Clinical Neuroscience, Karolinska Institute, Tomtebodavägen 18A, 171 65 Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, 171 64 Stockholm, Sweden
- MedTechLabs, Stockholm, Sweden
| | - Mathias Waldén
- Department of Clinical Neuroscience, Karolinska Institute, Tomtebodavägen 18A, 171 65 Stockholm, Sweden
| | - Mikael Sandell
- Department of Clinical Neuroscience, Karolinska Institute, Tomtebodavägen 18A, 171 65 Stockholm, Sweden
- MedTechLabs, Stockholm, Sweden
- Division of Micro and Nanosystems, KTH Royal Institute of Technology, Malvinas väg 10, 114 28 Stockholm, Sweden
| | - Jesper Sohlmér
- Department of Cell and Molecular Biology, Karolinska Institute, Solnavägen 9, 171 65 Stockholm, Sweden
| | - Rikard Grankvist
- Department of Clinical Neuroscience, Karolinska Institute, Tomtebodavägen 18A, 171 65 Stockholm, Sweden
| | - Ida Friberger
- Department of Clinical Neuroscience, Karolinska Institute, Tomtebodavägen 18A, 171 65 Stockholm, Sweden
| | - Agneta Andersson
- Department of Medicine, Huddinge, Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Carlsten
- Department of Medicine, Huddinge, Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
- Center for Cell Therapy and Allogeneic Stem Cell Transplantation, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Kenneth Chien
- Department of Cell and Molecular Biology, Karolinska Institute, Solnavägen 9, 171 65 Stockholm, Sweden
| | - Johan Lundberg
- Department of Clinical Neuroscience, Karolinska Institute, Tomtebodavägen 18A, 171 65 Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, 171 64 Stockholm, Sweden
- MedTechLabs, Stockholm, Sweden
| | - Nevin Witman
- Department of Clinical Neuroscience, Karolinska Institute, Tomtebodavägen 18A, 171 65 Stockholm, Sweden
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institute, Tomtebodavägen 18A, 171 65 Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, 171 64 Stockholm, Sweden
- MedTechLabs, Stockholm, Sweden
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Daryapeyma A, Pettersson J, Blohmé L, Franzen Röhl E, Bartholdson E, Waldén M, Hultgren R. The Role of Antigranulocyte Scintigraphy in Diagnosis of Aortic Graft Infection and Evaluation of Treatment Outcome. Ann Vasc Surg 2024; 98:325-333. [PMID: 37536433 DOI: 10.1016/j.avsg.2023.06.032] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND The aim of this study was to assess the eventual added benefit of antigranulocyte monoclonal antibodies scintigraphy for the diagnostic imaging of aortic graft infection (AGI) and its role in evaluation of treatment outcome. METHODS A population-based, retrospective, register-based analysis was carried out of all patients with infected aortic grafts after treatment for aneurysmal or aortoiliac occlusive disease at Karolinska University Hospital, covering the greater Stockholm area during November 2012-December 2020. Cases were based on the definitions in the 2016 Management of Aortic Graft Infection Collaborations consensus. Using the in-hospital electronic patient registry (Take Care®) and the Swedish National Registry for Vascular Surgery (Swedvasc), 835 patients who had been treated for aortic aneurysms or aortoiliac occlusive disease were identified. The diagnostic arsenal of laboratory tests, computed tomography (CT), and clinical signs has been supplemented by antigranulocyte monoclonal antibodies (anti-G mAb) scintigraphy. Data were analyzed using SPSS Statistics. RESULTS Eighteen cases of AGI out of 835 operations incorporating aortic grafts during the period were identified. Fourteen patients (78%) were categorized as diagnosed AGI (AGI-D), and the remaining 4 (22%) were classified as suspected AGI (AGI-S). In the AGI-D group (n = 14), 10 patients (71%) had positive CTs and 4 (29%) had low-probability CTs. In the group of 10 positive CTs, 9 patients also had positive scintigraphy scans with only one negative scintigraphy scan. There were no negative scintigraphy scans without ongoing antibiotic treatment at the time of investigation. In 15 of 18 cases, a culprit agent was identified, either preoperatively or perioperatively. Thirteen of the 18 patients were treated solely by antibiotics, whereas 5 underwent surgical treatment in addition to antibiotic treatment. The outcome has been divided into 3 groups: infection-free (n = 6; 33%), lifelong antibiotic treatment (n = 7; 39%), and deceased (n = 5; 28%). CONCLUSIONS The imaging modalities in AGI diagnostics are a cornerstone of the investigative work-up, complemented by clinical signs and laboratory methods. The main advantage conveyed by anti-G mAb scintigraphy is in postoperative imaging and its ability to differentiate between infection and general postoperative changes in the areas of concern. We have identified 6 patients in our cohort in whom antibiotic therapy was discontinued after a negative anti-G mAb scintigraphy scan. Anti-G mAb scintigraphy may fulfill a unique need for diagnosis in suspected cases, evaluation of therapeutic efficacy in patients requiring long-term antibiotic treatment, and aiding in the decision to discontinue antibiotic therapy.
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Affiliation(s)
- Alireza Daryapeyma
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Jennifer Pettersson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Linus Blohmé
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabeth Franzen Röhl
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Erika Bartholdson
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Mathias Waldén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Radiology, Peripheral Angio and Interventional Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Åkerlund I, Hägglund M, Lindblom H, Panagodage Perera N, Sonesson S, Waldén M. Prevalence, seasonal variation and nature of illness in youth floorball players: a prospective cohort study. J Sci Med Sport 2021. [DOI: 10.1016/j.jsams.2021.09.053] [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: 11/25/2022]
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von Below C, Daouacher G, Wassberg C, Grzegorek R, Gestblom C, Sörensen J, Ahlström H, Waldén M. Validation of 3 T MRI including diffusion-weighted imaging for nodal staging of newly diagnosed intermediate- and high-risk prostate cancer. Clin Radiol 2016; 71:328-34. [PMID: 26774372 DOI: 10.1016/j.crad.2015.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 06/25/2015] [Revised: 11/13/2015] [Accepted: 12/02/2015] [Indexed: 12/14/2022]
Abstract
AIM To prospectively validate 3 T magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI) for preoperative lymph node (LN) staging in a clinical setting, in intermediate- and high-risk prostate cancer (PCa) patients using laparoscopic extended LN dissection (ePLND) as the reference standard. MATERIALS AND METHODS Between August 2011 and May 2013, 40 newly diagnosed intermediate and high-risk PCa patients underwent preoperative LN staging with 3 T MRI DWI using histopathology of ePLND as the reference standard. The sensitivity, specificity, and accuracy of MRI DWI were calculated. A subgroup analysis of proven LN-positive patients was made to investigate differences in PSA, Gleason score, number, and size of LN metastases, estimated risk of LN involvement, and if curative treatment was indicated, between the true-positive and the false-negative groups. RESULTS A total of 728 LN were harvested from six anatomical regions per patient (external, obturator, internal) with a mean number of 18 LNs per patient (range 11-40). Twenty patients had histologically proven LN-positive disease. MRI DWI was true positive in 11 patients, false negative in nine patients, false positive in two patients, and true negative in 18 patients, resulting in 90% specificity, 55% sensitivity, and 72.5% accuracy. The true-positive patients had significantly more involved LNs (mean 6.9 versus 2.7, p=0.017), with larger diameter (mean 12.3 versus 5.2 mm, p=0.048) and fewer were treated with curative intent (six versus nine, p=0.03), compared with the false-negative group. CONCLUSION MRI DWI LN staging has a low sensitivity but high specificity. The true-positive patients have a considerably higher burden of LN metastases compared to false-negative patients.
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Affiliation(s)
- C von Below
- Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden.
| | - G Daouacher
- Department of Urology, Central Hospital of Karlstad, Karlstad, Sweden
| | - C Wassberg
- Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden
| | - R Grzegorek
- Department of Urology, Central Hospital of Karlstad, Karlstad, Sweden
| | - C Gestblom
- Department of Pathology, Central Hospital of Karlstad, Karlstad, Sweden
| | - J Sörensen
- Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden
| | - H Ahlström
- Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden
| | - M Waldén
- Department of Urology, Central Hospital of Karlstad, Karlstad, Sweden
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Kristenson K, Bjørneboe J, Waldén M, Andersen TE, Ekstrand J, Hägglund M. Injuries in male professional football: A prospective comparison between individual and team-based exposure registration. Scand J Med Sci Sports 2015; 26:1225-32. [DOI: 10.1111/sms.12551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2015] [Indexed: 11/29/2022]
Affiliation(s)
- K. Kristenson
- Division of Community Medicine; Department of Medical and Health Sciences; Linköping University; Linköping Sweden
- Football Research Group; Linköping Sweden
| | - J. Bjørneboe
- Department of Sports Medicine; Oslo Sports Trauma Research Center; Norwegian School of Sport Sciences; Oslo Norway
| | - M. Waldén
- Division of Community Medicine; Department of Medical and Health Sciences; Linköping University; Linköping Sweden
- Football Research Group; Linköping Sweden
| | - T. E. Andersen
- Department of Sports Medicine; Oslo Sports Trauma Research Center; Norwegian School of Sport Sciences; Oslo Norway
| | - J. Ekstrand
- Division of Community Medicine; Department of Medical and Health Sciences; Linköping University; Linköping Sweden
- Football Research Group; Linköping Sweden
| | - M. Hägglund
- Football Research Group; Linköping Sweden
- Division of Physiotherapy; Department of Medical and Health Sciences; Linköping University; Linköping Sweden
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Thomeé R, Waldén M, Hägglund M. Return to sports after anterior cruciate ligament injury: neither surgery nor rehabilitation alone guarantees success--it is much more complicated. Br J Sports Med 2015; 49:1422. [PMID: 26048896 DOI: 10.1136/bjsports-2015-094793] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2015] [Indexed: 11/04/2022]
Affiliation(s)
- R Thomeé
- Department of Health and Rehabilitation, Unit of Physiotherapy, Gothenburg University, Institute of Neuroscience and Physiology, Göteborg, Sweden
| | - M Waldén
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, Linköping, Sweden
| | - M Hägglund
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
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Hägglund M, Waldén M, Thomeé R. Should patients reach certain knee function benchmarks before anterior cruciate ligament reconstruction? Does intense 'prehabilitation' before anterior cruciate ligament reconstruction influence outcome and return to sports? Br J Sports Med 2015; 49:1423-4. [PMID: 26048899 DOI: 10.1136/bjsports-2015-094791] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2015] [Indexed: 11/03/2022]
Affiliation(s)
- M Hägglund
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - M Waldén
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, Linköping, Sweden
| | - R Thomeé
- Department of Health and Rehabilitation, Unit of Physiotherapy, Gothenburg University, Institute of Neuroscience and Physiology, Göteborg, Sweden
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Lindblom H, Waldén M, Carlfjord S, Hägglund M. IMPLEMENTATION OF A NEUROMUSCULAR TRAINING PROGRAMME IN FEMALE ADOLESCENT FOOTBALL: 3-YEAR FOLLOW-UP STUDY AFTER AN RCT. Br J Sports Med 2014. [DOI: 10.1136/bjsports-2014-093494.183] [Citation(s) in RCA: 2] [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: 11/04/2022]
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Kristenson K, Bjørneboe J, Waldén M, Andersen TE, Ekstrand J, Hägglund M. THE NORDIC FOOTBALL INJURY AUDIT: HIGHER INJURY RATES FOR PROFESSIONAL FOOTBALL CLUBS WITH THIRD-GENERATION ARTIFICIAL TURF AT THEIR HOME VENUE. Br J Sports Med 2014. [DOI: 10.1136/bjsports-2014-093494.166] [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: 11/03/2022]
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Bengtsson H, Ekstrand J, Waldén M, Hägglund M. MUSCLE INJURY RATES IN PROFESSIONAL FOOTBALL INCREASE WITH FIXTURE CONGESTION: AN 11-YEAR FOLLOW-UP OF THE UEFA CHAMPIONS LEAGUE INJURY STUDY. Br J Sports Med 2014. [DOI: 10.1136/bjsports-2014-093494.19] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Waldén M, Hägglund M, Orchard J, Kristenson K, Ekstrand J. Regional differences in injury incidence in European professional football. Scand J Med Sci Sports 2011; 23:424-30. [PMID: 22092416 DOI: 10.1111/j.1600-0838.2011.01409.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2011] [Indexed: 01/15/2023]
Abstract
The objective of this study was to investigate regional differences in injury incidence in men's professional football in Europe. A nine-season prospective cohort study was carried out between 2001-2002 and 2009-2010 involving 1357 players in 25 teams from nine countries. Teams were categorized into different regions according to the Köppen-Geiger climate classification system. Teams from the northern parts of Europe (n = 20) had higher incidences of injury overall [rate ratio 1.12, 95% confidence interval (CI) 1.06 to 1.20], training injury (rate ratio 1.16, 95% CI 1.05 to 1.27), and severe injury (rate ratio 1.29, 95% CI 1.10 to 1.52), all statistically significant, compared to teams from more southern parts (n = 5). In contrast, the anterior cruciate ligament injury incidence was lower in the northern European teams with a statistically significant difference (rate ratio 0.43, 95% CI 0.25 to 0.77), especially for noncontact anterior cruciate ligament injury (rate ratio 0.19, 95% CI 0.09 to 0.39). In conclusion, this study suggests that there are regional differences in injury incidence of European professional football. However, further studies are needed to identify the underlying causes.
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Affiliation(s)
- M Waldén
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
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Werner J, Hägglund M, Waldén M, Ekstrand J. UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. Br J Sports Med 2011; 43:1036-40. [PMID: 19945984 DOI: 10.1136/bjsm.2009.066944] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Groin injury is a common injury in football and a complicated area when it comes to diagnosis and therapy. There is a lack of comprehensive epidemiological data on groin injuries in professional football. OBJECTIVE To investigate the incidence, pattern and severity of hip and groin injuries in professional footballers over seven consecutive seasons. STUDY DESIGN Prospective cohort study. SETTING European professional football. METHODS During the 2001/2 to 2007/8 seasons, between nine and 17 clubs per season (23 clubs in total) were investigated, accounting for 88 club seasons in total. Time loss injuries and individual exposure during club and national team training sessions and matches were recorded. MAIN OUTCOME MEASURE Injury incidence. RESULTS A total of 628 hip/groin injuries were recorded, accounting for 12-16% of all injuries per season. The total injury incidence was 1.1/1000 h (3.5/1000 match hours vs 0.6/1000 training hours, p<0.001) and was consistent over the seasons studied. Eighteen different diagnostic entities were registered, adductor (n = 399) and iliopsoas (n = 52) related injuries being the most common. More than half of the injuries (53%) were classified as moderate or severe (absence of more than a week), the mean absence per injury being 15 days. Reinjuries accounted for 15% of all registered injuries. In the 2005/6 to 2007/8 seasons, 41% of all diagnoses relied solely on clinical examination. CONCLUSIONS Hip/groin injuries are common in professional football, and the incidence over consecutive seasons is consistent. Hip/groin injuries are associated with long absences. Many hip/groin diagnoses are based only on clinical examination.
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Affiliation(s)
- J Werner
- Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden.
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Abstract
All 12 female football clubs (228 players) and 11 of 14 male clubs (239 players) in the Swedish premier league were followed prospectively during the 2005 season. Individual exposure (playing time), injuries (time loss), and injury severity (days lost due to injury) were recorded by the team medical staffs. Injury incidence was higher for male players during both training (4.7 vs 3.8 injuries/1000 h, P=0.018) and match play (28.1 vs 16.1, P<0.001). However, no difference was found in the incidence of severe injury (absence >4 weeks) (0.7/1000 h in both groups). The thigh, especially the hamstrings, was the overall most commonly injured region in both sexes, while the hip/groin was more commonly injured in male players and the knee in female players. Knee ligament injuries accounted for 31% and 37% of the total time lost from football for male and female players, respectively. In conclusion, male elite players had a higher injury incidence than their female counterparts although no difference was observed in the incidence of moderate to severe injury. We recommend that preventive measures should be focused on hamstring and knee ligament injury in order to reduce the overall injury burden.
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Affiliation(s)
- M Hägglund
- Department of Medical and Health Sciences, Linköping University, Sweden.
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Abstract
OBJECTIVE To study the injury characteristics in professional football and to follow the variation of injury incidence during a match, during a season and over consecutive seasons. DESIGN Prospective cohort study where teams were followed for seven consecutive seasons. Team medical staff recorded individual player exposure and time-loss injuries from 2001 to 2008. SETTING European professional men's football. PARTICIPANTS The first team squads of 23 teams selected by the Union of European Football Associations as belonging to the 50 best European teams. MAIN OUTCOME MEASUREMENT Injury incidence. RESULTS 4483 injuries occurred during 566 000 h of exposure, giving an injury incidence of 8.0 injuries/1000 h. The injury incidence during matches was higher than in training (27.5 vs 4.1, p<0.0001). A player sustained on average 2.0 injuries per season, and a team with typically 25 players can thus expect about 50 injuries each season. The single most common injury subtype was thigh strain, representing 17% of all injuries. Re-injuries constituted 12% of all injuries, and they caused longer absences than non re-injuries (24 vs 18 days, p<0.0001). The incidence of match injuries showed an increasing injury tendency over time in both the first and second halves (p<0.0001). Traumatic injuries and hamstring strains were more frequent during the competitive season, while overuse injuries were common during the preseason. Training and match injury incidences were stable over the period with no significant differences between seasons. CONCLUSIONS The training and match injury incidences were stable over seven seasons. The risk of injury increased with time in each half of matches.
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Affiliation(s)
- J Ekstrand
- Department of Medical and Health Sciences, Linköping University, Solstigen 3, S-589 43 Linköping, Sweden.
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Abstract
OBJECTIVE To study the incidence and nature of injuries at European Championships, to compare training and match injury characteristics and to study differences in injury incidence between tournaments. DESIGN Team physicians prospectively recorded individual player exposure and time loss injuries during 12 European Championships (men's EURO n = 1, men's Under-21 n = 2, men's Under-19 n = 3, men's Under-17 n = 3, women's Under-19 n = 3) from 2006 to 2008. SETTING International football tournaments. PARTICIPANTS 1594 men and 433 women. MAIN OUTCOME MEASUREMENT Injury incidence. RESULTS 224 injuries (45 training, 179 match play) were registered among 208 (10%) players. No differences in training injury incidence were seen between tournaments (range 1.3-3.9 injuries/1000 hours). The men's EURO had the highest match injury incidence (41.6 injuries/1000 hours) followed by the men's Under-21 tournaments (33.9). The lowest match injury incidence was seen in the women's Under-19 tournaments (20.5). Training injuries constituted 20% of all injuries and caused 26% of all match unavailability. A greater proportion of match injuries were due to trauma (83 vs 47%, p<0.001) and occurred from player contact (75 vs 48%, p = 0.018) compared to training injuries. A higher frequency of re-injury was found among training injuries than match injuries (20 vs 6%, p = 0.009). CONCLUSIONS Match injury incidence increased with age, indicating greater risk with higher intensity of play. Training injury incidence was relatively low, but training injuries were responsible for a quarter of all match unavailability and may thus have a profound impact on team performance and should be the object of preventive measures.
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Affiliation(s)
- M Hägglund
- Department of Medical and Health Sciences, Linköping University, SE-581 83 Linköping, Sweden.
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16
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Abstract
BACKGROUND Previous injury is often proposed to be a risk factor for football injury, but most studies rely on players reporting their own medical history and are thus potentially subject to recall bias. Little is known about the natural variation in injury pattern between seasons. OBJECTIVES To study whether prospectively recorded injuries during one season are associated with injuries sustained during the following season, and to compare injury risk and injury pattern between consecutive seasons. METHODS The medical staffs of 12 elite Swedish male football teams prospectively recorded individual exposure and time loss injuries over two full consecutive seasons (2001 and 2002). A multivariate model was used to determine the relation between previous injury, anthropometric data, and the risk of injury. RESULTS The training and match injury incidences were similar between seasons (5.1 v 5.3 injuries/1000 training hours and 25.9 v 22.7/1000 match hours), but analysis of injury severity and injury patterns showed variations between seasons. Players who were injured in the 2001 season were at greater risk of any injury in the following season compared with non-injured players (hazard ratio 2.7; 95% confidence interval 1.7 to 4.3, p<0.0001). Players with a previous hamstring injury, groin injury, and knee joint trauma were two to three times more likely to suffer an identical injury in the following season, whereas no such relation was found for ankle sprain. Age was not associated with an increased injury risk. CONCLUSIONS This study confirmed previous results showing that previous injury is an important risk factor for football injury. Overall injury incidences were similar between consecutive seasons, indicating that an injury surveillance study covering one full season can provide a reasonable overview of the injury problem among elite football players in a specific environment. However, a prolonged study period is recommended for analyses of specific injury patterns.
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Affiliation(s)
- M Hägglund
- Department of Health and Society, Linköping University, S-58183 Linköping, Sweden.
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Waldén M, Hägglund M, Ekstrand J. High risk of new knee injury in elite footballers with previous anterior cruciate ligament injury. Br J Sports Med 2006; 40:158-62; discussion 158-62. [PMID: 16432004 PMCID: PMC2492018 DOI: 10.1136/bjsm.2005.021055] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [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] [Accepted: 07/26/2005] [Indexed: 01/15/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) injury is a severe event for a footballer, but it is unclear if the knee injury rate is higher on returning to football after ACL injury. OBJECTIVE To study the risk of knee injury in elite footballers with a history of ACL injury compared with those without. METHOD The Swedish male professional league (310 players) was studied during 2001. Players with a history of ACL injury at the study start were identified. Exposure to football and all time loss injuries during the season were recorded prospectively. RESULTS Twenty four players (8%) had a history of 28 ACL injuries in 27 knees (one rerupture). These players had a higher incidence of new knee injury of any type than the players without ACL injury (mean (SD) 4.2 (3.7) v 1.0 (0.7) injuries per 1000 hours, p = 0.02). The risk of suffering a knee overuse injury was significantly higher regardless of whether the player (relative risk 4.8, 95% confidence interval 2.0 to 11.2) or the knee (relative risk 7.9, 95% confidence interval 3.4 to 18.5) was used as the unit of analysis. No interactive effects of age or any other anthropometric data were seen. CONCLUSION The risk of new knee injury, especially overuse injury, was significantly increased on return to elite football after ACL injury regardless of whether the player or the knee was used as the unit of analysis.
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Affiliation(s)
- M Waldén
- Department of Health and Society, Linköping University, S-581 83 Linköping, Sweden.
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Wang Y, Waldén M. Laparoscopic radical prostatectomy: our experience of 180 operations. Urology 2005. [DOI: 10.1016/j.urology.2005.06.031] [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: 10/25/2022]
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19
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Abstract
BACKGROUND No previous study on adult football involving several different countries has investigated the incidence and pattern of injuries at the highest club competitive level. OBJECTIVE To investigate the risk exposure, risk of injury, and injury pattern of footballers involved in UEFA Champions League and international matches during a full football season. METHOD Eleven top clubs (266 players) in five European countries were followed prospectively throughout the season of 2001-2002. Time-lost injuries and individual exposure times were recorded during all club and national team training sessions and matches. RESULTS A total of 658 injuries were recorded. The mean (SD) injury incidence was 9.4 (3.2) injuries per 1000 hours (30.5 (11.0) injuries per 1000 match hours and 5.8 (2.1) injuries per 1000 training hours). The risk of match injury was significantly higher in the English and Dutch teams than in the teams from France, Italy, and Spain (41.8 (3.3) v 24.0 (7.9) injuries per 1000 hours; p = 0.008). Major injuries (absence > 4 weeks) constituted 15% of all injuries, and the risk of major injury was also significantly higher among the English and Dutch teams (p = 0.04). National team players had a higher match exposure, with a tendency towards a lower training injury incidence than the rest of the players (p = 0.051). Thigh strain was the most common injury (16%), with posterior strains being significantly more common than anterior ones (67 v 36; p < 0.0001). CONCLUSIONS The risk of injury in European professional football is high. The most common injury is the thigh strain typically involving the hamstrings. The results suggest that regional differences may influence injury epidemiology and traumatology, but the factors involved are unclear. National team players have a higher match exposure, but no higher risk of injury than other top level players.
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Affiliation(s)
- M Waldén
- Department of Health and Society, Linköping University, S-581 83 Linköping, Sweden.
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20
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Abstract
A problem with epidemiological studies of football injuries is the inconsistent manner in which injury is defined and data are collected. Projects have been initiated to study the incidence and causes of injury in football, but there is no uniformly accepted reporting system. In this report, some common pitfalls encountered in the recording of injury are addressed, and practical guidelines for epidemiological studies are provided. An injury reporting system developed for the UEFA Football Safety Project for studies on professional footballers is used as a starting point for a general discussion on injury registration and compared with other existing reporting systems. The recording definition of injury may vary between studies depending on its purpose. A time loss injury definition is practical for all playing levels, and, as a minimum, results on time loss injuries should therefore always be reported separately to allow direct comparisons between studies. There is a need to agree on a uniform sports injury classification system with corresponding diagnostic criteria, as well as standardised return to play criteria after injury.
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Affiliation(s)
- M Hägglund
- Department of Social Medicine and Public Health Science, Linköping University, Linköping, Sweden
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21
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Ekstrand J, Waldén M, Hägglund M. A congested football calendar and the wellbeing of players: correlation between match exposure of European footballers before the World Cup 2002 and their injuries and performances during that World Cup. Br J Sports Med 2005; 38:493-7. [PMID: 15273193 PMCID: PMC1724854 DOI: 10.1136/bjsm.2003.009134] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.9] [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: 11/03/2022]
Abstract
OBJECTIVES To investigate the correlation between exposure of footballers in European clubs to match play in the months before the World Cup 2002 and their injuries and performances during that World Cup. METHODS The team doctors at 11 of the best football clubs in Europe prospectively recorded players' exposure and injuries during the 2001-2002 season (July 2001-May 2002). Sixty five players participated in the World Cup in Korea/Japan (June 2002). During the World Cup, the clubs reported injuries sustained by these players, and their performance was evaluated by three international experts. RESULTS The number of team matches during the season varied between 40 and 76 for the different countries involved. The individual player had a mean of 36 matches during the season. Top players played more matches, especially during the final period of the season. Players who participated in the World Cup played more matches during the season than those who did not (46 v 33 matches). World Cup players did not show any increased risk of injury during the season. About 29% incurred injuries during the World Cup, and 32% performed below their normal standard. The players who underperformed had played more matches during the 10 weeks before the World Cup than those who performed better than expected (12.5 v 9, p<0.05). Twenty three (60%) of the 38 players who had played more than one match a week before the World Cup incurred injuries or underperformed during the World Cup. CONCLUSIONS There is considerable variation in the number of matches played per season in European professional football leagues. Top level players are obliged to play many matches especially during the final period of the season.
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Affiliation(s)
- J Ekstrand
- Department of Social Medicine and Public Health Science, Linköping University, Linköping, Sweden.
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22
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Fridén T, Roberts D, Ageberg E, Waldén M, Zätterström R. Review of knee proprioception and the relation to extremity function after an anterior cruciate ligament rupture. J Orthop Sports Phys Ther 2001; 31:567-76. [PMID: 11665744 DOI: 10.2519/jospt.2001.31.10.567] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Several tests of human conscious knee proprioception have been described, but there is no consensus or reference standard established. Difficulties remain in the separation of information originating from muscles, tendons, and joints, and the tests cannot discriminate between loss of afferent signals or altered activity in the remaining receptors. There is convincing evidence from several descriptive studies that the afferent information is altered after a knee ligament injury and severely disturbed in some patients with anterior cruciate ligament (ACL) injuries. However, an inherent inferior proprioceptive ability may also exist in some individuals, which makes them vulnerable to injuries. The deficits in proprioception have mostly been studied and related to the consciously registered sense, whereas the extent of possible disturbances of the unconscious or reflectory mechanisms is largely unknown. The latter may, at least from a theoretical point of view, be predominantly contributing to the overall afferent regulation, and a possibility for major defects thus exists, since there is no knowledge of the quantified relation between the conscious and unconscious part. The clinical importance of the altered afferent information has not been evaluated properly, and the role of proprioception that contributes to function has yet to be investigated. A higher physiological sensitivity to detecting a passive joint motion closer to full extension has been found both experimentally and clinically, which may protect the joint due to the close proximity to the limit of joint motion. Proprioception has been found to have a relation to subjective knee function, and patients with symptomatic ACL deficiency seem to have larger deficits than asymptomatic individuals. Little is known about whether training can restore defects in sensory information or by which mechanisms possible compensatory pathways are established. In rehabilitation, each patient must, however, create muscle strength, alertness, and stiffness in harmony with the disturbed mechanics of the knee, which are present both after nonoperative treatment of the ACL and after a reconstruction of the ACL.
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Affiliation(s)
- T Fridén
- Department of Orthopedics, University Hospital, Lund, Sweden.
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23
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Abstract
To study home uroflowmetry and to compare this method to free or "traditional" uroflowmetry in the evaluation of the patient with symptomatic benign prostatic hyperplasia (BPH), and the relationship between the values of home uroflowmetry parameters and bladder outlet obstruction (BOO). Twenty-five patients (mean age, 67 years) with symptomatic BPH were examined with home uroflowmetry, free uroflowmetry, and pressure-flow measurement. The patients were assessed using the International Prostate Symptom score; digital rectal examination; routine blood chemistry, including serum prostate-specific antigen level; urinanalysis; transrectal ultrasonography; and post-void residual urine. The 24 hr were divided into "active time" (AT) and "sleep time" (ST). AT home uroflowmetry parameters were compared to ST ones. The home uroflowmetry parameters were compared to respective ones of the free uroflowmetry as well and those obtained by pressure-flow measurement. The patients were asked about their opinion of home uroflowmetry. Home uroflowmetry was found to be a simpler and more acceptable method than free uroflowmetry. The mean Qmax of AT was significantly greater than the mean Qmax of ST, but the mean voided volume and mean voiding time of ST were significantly larger than those of AT. There was a close relationship between the mean Qmax at home and the Qmax in hospital, but the voided volume and voiding time measured in hospital were significantly larger than those at home. Home uroflowmetry provided an estimation of BOO for 46% of the patients as low if the home mean Qmax was >14 ml/sec, and as high if the home mean Qmax was <10 ml/sec. Home uroflowmetry was well accepted by the patients and gave more information than free uroflowmetry. In 46% of the cases, an estimation of BOO was obtained with home uroflowmetry.
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Affiliation(s)
- R Boci
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
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24
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Waldén M, Dahlstrand C, Schäfer W, Pettersson S. How to select patients suitable for transurethral microwave thermotherapy: a systematic evaluation of potentially predictive variables. Br J Urol 1998; 81:817-22. [PMID: 9666763 DOI: 10.1046/j.1464-410x.1998.00656.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify clinical variables useful in predicting outcome after transurethral microwave thermotherapy (TUMT) of the prostate with Prostasoft v. 2.0. PATIENTS AND METHODS Thirty-eight men with symptomatic benign prostatic hyperplasia (BPH) were treated with TUMT using the Prostatron device with the low-energy (v. 2.0) software. Before and 6 months after treatment symptoms were evaluated using the Madsen-Iversen (M-I) symptom score, a clinical examination and suprapubic pressure-flow measurement, free urinary peak flow rate (Qmax) and determination of post-void residual urine volume (PVR). Bladder outlet obstruction was assessed from urodynamic pressure-flow studies using the classification of Abrams and Griffiths, the obstruction grading of Schäfer, and calculation of other published factors, e.g. the urethral resistance, an obstruction index and the detrusor adjusted mean passive urethral resistance factor (DAMPF). Categories of M-I score (total, irritative and obstructive), PVR and Qmax were investigated to determine whether any could predict the outcome after low-energy TUMT. The values after treatment and changes in Qmax, M-I score and PVR were used as efficacy variables. RESULTS Variables describing infravesical obstruction had predictive characteristics that may be useful in selecting patients for TUMT v. 2.0 and significantly better results were obtained in patients with a low to moderate obstruction as graded using the DAMPF classification of obstruction. The results also indicated that patients with a high irritative M-I score or a Qmax of 7-14 mL/s were those who fared best after TUMT. CONCLUSIONS Variables expressing the obstruction grade seem to be useful in predicting outcome after TUMT (v. 2.0). Patients with a high obstruction index are probably unsuitable for TUMT (v. 2.0).
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Affiliation(s)
- M Waldén
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
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Waldén M, Acosta S, Carlsson P, Pettersson S, Dahlstrand C. A cost-effectiveness analysis of transurethral resection of the prostate and transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia: two-year follow-up. Scand J Urol Nephrol 1998; 32:204-10. [PMID: 9689700 DOI: 10.1080/003655998750015584] [Citation(s) in RCA: 16] [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] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To compare costs of transurethral prostatic resection (TURP) and transurethral microwave thermotherapy (TUMT) for symptomatic benign prostatic hyperplasia (BPH) in a randomized, controlled trial. METHODS In 70 BPH patients all costs were calculated for management, including complications and repeat treatment, during TURP or TUMT and 24-month follow-up. Clinical outcome was judged from Madsen-Iversen symptom score, peak urinary flow and residual urine. The effect of changes in some critical variables was assessed by sensitivity analysis. A cost-effectiveness analysis was carried out to compare the two methods. RESULTS Symptom reduction after 2 years was 92% in the TURP group and 83% in the TUMT group. The total costs over 2 years were SEK 24,234 and 14,830 in the respective groups. Costs for retreatments were higher after TUMT, while complication costs were higher in the TURP group. TUMT costs depend on the investment for the equipment, including disposable probes, and the degree of its utilization. TUMT was more cost-effective than TURP in relieving BPH-related symptoms during the 2-year follow-up. CONCLUSIONS Primary treatment costs were lower for TUMT than for TURP. Complication costs were higher in the trial's TURP arm, while retreatment costs were greater in the TUMT arm. TUMT costs depend on investment in and utilization of the equipment and reuse of treatment probes. TUMT was more cost-effective than TURP in the 2-year study period.
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Affiliation(s)
- M Waldén
- Department of Urology, Sahlgrenska Hospital, Gothenburg, Sweden
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26
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Waldén M, Dahlstrand C, Petersson S, Lindstedt G. Effect of transurethral microwave thermotherapy on serum concentrations of total and free prostate-specific antigen. Scand J Urol Nephrol 1997; 31:173-7. [PMID: 9165582 DOI: 10.3109/00365599709070325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study includes 15 men between 48 and 81 years of age with treatment-requiring symptomatic benign prostatic hyperplasia (BPH). No patient with a urinary infection or prostate cancer was included. The serum concentrations of prostate-specific antigen (PSA), total as well as "free", i.e. noncomplex bound, were repeatedly determined before and up to 3 months after transurethral microwave thermotherapy (TUMT) of the prostate. After TUMT we found significant rises of the ratios of the serum total PSA concentration/prostate volume (up to 55-fold, mean 13.1) and of the serum free PSA concentration/ prostate volume (up to 26-fold, mean 10.2). The highest values for the serum total PSA concentration/prostate volume ratio were found on the first day after TUMT. Maximal serum free PSA concentration/prostate volume ratio occurred 3-6 h after treatment. The serum concentration/prostate volume ratios for total and free PSA returned to normal within 3 months. The results indicate that PSA determinations might be used as effect indicators of TUMT.
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Affiliation(s)
- M Waldén
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
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27
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Waldén M, Geirsson G, Pettersson S, Schäfer W, Dahlstrand C. Does anamnestic symptom evaluation or clinical examination give enough information to evaluate the severity of obstruction in benign prostatic hyperplasia? Scand J Urol Nephrol 1995; 29:469-76. [PMID: 8719365 DOI: 10.3109/00365599509180029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In this study we have investigated 70 men fulfilling the usual criteria accepted for transurethral resection of the prostate (TURP). The anamnestic evaluation included the Madsen-Iversen symptom score and a quality of life questionnaire. The clinical examination included suprapubic pressure flow measurement, free urinary flow, the determination of residual urine and the ultrasound evaluation of the size of the prostate. The clinical data were correlated with the grade of obstruction according to Schäfer calculated from the pressure/flow studies. No correlation was found between the grade of obstruction and anamnestic symptom data, the size of the prostate or residual urine. A slight correlation was found between the Schäfer grade of obstruction and the flow curve pattern or peak flow.
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Affiliation(s)
- M Waldén
- Department of Urology, Sahlgrensku sjukhuset, Göteborg, Sweden
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28
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Dahlstrand C, Waldén M, Geirsson G, Pettersson S. Transurethral microwave thermotherapy versus transurethral resection for symptomatic benign prostatic obstruction: a prospective randomized study with a 2-year follow-up. Br J Urol 1995; 76:614-8. [PMID: 8535682 DOI: 10.1111/j.1464-410x.1995.tb07788.x] [Citation(s) in RCA: 101] [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] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To compare the outcome of transurethral resection of the prostate (TURP) and transurethral microwave thermotherapy (TUMT) on symptomatic benign prostatic hyperplasia (BPH). PATIENTS AND METHODS Patients with symptomatic BPH were treated by either TURP (32 patients; mean age 70 +/- 6 years) or TUMT (37 patients; mean age 67 +/- 9 years) and assessed using the Madsen-Iversen symptom score, measurements of urinary free flow rate and post-void residual urine volume, digital rectal examination, transrectal ultrasonography, cystometry and pressure-flow measurement, ultrasonography or intravenous pyelography (IVP) of the upper urinary tract, urine analysis and routine blood chemistry including serum prostate-specific antigen (PSA) level. Examinations were repeated at fixed intervals for up to 24 months after treatment. RESULTS After both TURP and TUMT there was an improvement in symptom score, residual urine volume, free flow rate and infravesical obstruction. The improvements of free flow rate and obstruction were more pronounced after TURP. Serious complications, such as bleeding requiring a re-operation, occurred only in patients who underwent TURP. CONCLUSION Satisfactory results were obtained after both treatments and the improvements with either treatment lasted for at least 24 months.
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Affiliation(s)
- C Dahlstrand
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
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Dahlstrand C, Waldén M, Geirsson G, Sommar S, Pettersson S. Transurethral microwave thermotherapy versus transurethral resection for BPH. Prog Clin Biol Res 1994; 386:455-461. [PMID: 7528415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- C Dahlstrand
- Department of Urology, Sahlgrenska Sjukhuset, University of Göteborg, Sweden
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30
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Abstract
Eighty-six patients with ureteral colic were included in a randomised, prospective, double-blind study of the analgesic efficacy and tolerance of ketoprofen versus diclofenac, both administered intramuscularly. There were no significant differences regarding pain-relief or side-effects.
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Affiliation(s)
- M Waldén
- Department of Urology, Central Hospital, Karlstad, Sweden
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Waldén M. [A frustrating case of Borrelia misdiagnosed as supratentorial pain]. Lakartidningen 1986; 83:3012. [PMID: 3773607] [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: 01/07/2023]
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