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Dotevall H, Tuomi L, Lindell E, Finizia C. Long-term effects on swallowing and laryngeal function after treatment for severe COVID-19 disease in intensive care. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08648-3. [PMID: 38642087 DOI: 10.1007/s00405-024-08648-3] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/28/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE This study aimed to assess swallowing and laryngeal function at long-term follow-up in patients treated for severe COVID-19 in the ICU. METHODS Thirty-six patients with severe COVID-19 were prospectively examined with fiberendoscopic evaluation of swallowing (FEES) about 6 and 12 months after ICU discharge. Comparison with initial FEES examinations during the time in hospital was performed in 17 patients. Analysis of swallowing function and laryngeal features was performed from video recordings. Twenty-five participants responded to Eating Assessment Tool, Voice Handicap Index, and the Hospital Anxiety and Depression Scale at follow-up. RESULTS Penetration to the laryngeal vestibule (PAS ≥ 3) was seen in 22% and silent aspiration (PAS = 8) in 11% of patients on at least one swallow at follow-up. Fourteen percent had obvious residue in the vallecula and/or pyriform sinuses after swallowing thick liquid or biscuits. Self-reported eating and swallowing difficulties were found in 40% of patients. Abnormal findings in the larynx were present in 53% at follow-up. Thirty-three percent had reduced or impaired vocal fold movement, of whom 22% had bilateral impaired abduction of the vocal folds. Possible anxiety and depression were found in 36% and 24% of responders, respectively. CONCLUSION Although a majority of patients appear to regain normal swallowing function by 1 year after treatment for severe COVID-19, our results indicate that dysphagia, abnormal laryngeal function, and anxiety/depression may remain in a substantial proportion of patients. This suggests that swallowing and laryngeal function, and emotional symptoms, should be followed up systematically over time in this patient group.
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Affiliation(s)
- Hans Dotevall
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Lisa Tuomi
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden.
- Institute of Neuroscience and Physiology, Speech and Language Pathology Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Ellen Lindell
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Research, Education and Innovation, Södra Älvsborgs Hospital, Region Västra Götaland, Borås, Sweden
| | - Caterina Finizia
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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Aghajanzadeh S, Karlsson T, Tuomi L, Engström M, Finizia C. Postradiation trismus in head and neck cancer survivors: a qualitative study of effects on life, rehabilitation, used coping strategies and support from the healthcare system. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08609-w. [PMID: 38587650 DOI: 10.1007/s00405-024-08609-w] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/11/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE This study aimed to explore the experiences of head and neck cancer (HNC) survivors with postradiation trismus, specifically how oncological treatment affected their lives, rehabilitation, use of coping strategies, and healthcare experiences. METHODS A qualitative descriptive approach was used and semi-structured interviews of 10 HNC survivors with postradiation trismus were conducted 6-30 months after completing oncological treatment. The interviews were transcribed verbatim and analyzed by qualitative content analysis. RESULTS The analysis of interviews yielded four main categories: Bodily symptoms, Effects on life, Support from the healthcare system, and Strategies to handle life and symptoms. Participants reported ongoing problems with xerostomia, dysgeusia, eating, and limited physical fitness. Pain related to trismus was not a major issue in this cohort. Participants expressed limitations in their social lives due to their eating difficulties, yet a sense of thankfulness for life and overall satisfaction with the healthcare they received. Psychological and practical coping strategies developed by the participants were also revealed. CONCLUSION The results highlight areas of unmet need among HNC survivors that healthcare providers can target by establishing multi-professional teams dedicated to individualizing post-cancer rehabilitation care.
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Affiliation(s)
- Susan Aghajanzadeh
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology- Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Therese Karlsson
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology- Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lisa Tuomi
- Department of Otorhinolaryngology- Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Speech and Language Pathology Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - My Engström
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Surgery Gothenburg, Region Västra Götaland, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
| | - Caterina Finizia
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology- Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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de Bejczy A, Lidö H, Söderpalm B. A randomized, double-blind, placebo-controlled, multicentre trial on the efficacy of varenicline and bupropion in combination and alone for treatment of alcohol use disorder: Protocol for the COMB study. PLoS One 2024; 19:e0296118. [PMID: 38206930 PMCID: PMC10783749 DOI: 10.1371/journal.pone.0296118] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 12/04/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Alcohol Use Disorder (AUD) is a major cause of premature death, disability and suffering. Available treatments are of modest efficacy and under-prescribed so there is a pressing need for a well-tolerated and effective treatment option for AUD. Dopamine is hypothesized to be involved in the development of alcohol dependence. To challenge the low-dopamine hypothesis of addiction, this randomized, double-blind, placebo-controlled, 13-week, multicentre clinical trial with four parallel arms is designed to evaluate the efficacy of two substances raising dopamine levels, varenicline and bupropion, alone and in combination vs. placebo on alcohol consumption in AUD. Varenicline, a partial agonist at brain nicotinic acetylcholine receptors increases dopamine release, whereas bupropion is a centrally-acting, norepinephrine-dopamine reuptake inhibitor. Varenicline is previously shown to reduce alcohol intake in individuals with AUD. We hypothesize that the effect size of a combination of two drugs affecting dopamine levels in the brain will exceed that of approved AUD therapies. METHODS Consenting individuals with AUD will be recruited via media advertisements. Those fulfilling the eligibility criteria (N = 380) will be randomized to one of four interventions (n = 95 per arm). Treatment will comprise one week of titration (varenicline 0.5‒2 mg; bupropion SR 150‒300 mg) plus 12 weeks at steady state. Efficacy will be evaluated using two primary endpoints of alcohol consumption: Heavy Drinking Days and blood levels of phosphatidylethanol. Secondary objectives, exploratory and subgroup analyses will be also performed. The modified Intention-to-Treat and Per Protocol datasets will be evaluated using Analysis of Covariance. Last patient out is estimated to occur in December, 2022. DISCUSSION The COMB Study aims to evaluate the efficacy of the combination of varenicline and bupropion, two drugs affecting dopamine, on alcohol consumption, and to challenge the low-dopamine hypothesis of addiction. Study Code COMB-BO8, EudraCT 2018-000048-24, Version 3.2, Lidö & deBejczy, 2020-06-16; https://clinicaltrials.gov identifier NCT04167306.
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Affiliation(s)
- Andrea de Bejczy
- Addiction Biology Unit, Psychiatry and Neurochemistry Section, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Addiction and Dependency, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Helga Lidö
- Addiction Biology Unit, Psychiatry and Neurochemistry Section, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Addiction and Dependency, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bo Söderpalm
- Addiction Biology Unit, Psychiatry and Neurochemistry Section, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Addiction and Dependency, Sahlgrenska University Hospital, Gothenburg, Sweden
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Çevik-Aras H, Musa S, Olofsson R, Almståhl A, Almhöjd U. Patients with oral lichen planus display lower levels of salivary acidic glycoproteins than individuals without oral mucosal disease. Clin Oral Investig 2023; 28:2. [PMID: 38114810 PMCID: PMC10730629 DOI: 10.1007/s00784-023-05411-6] [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: 09/12/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVES Salivary proteins, acidic glycoproteins, and free calcium might take part in oral mucosal defence against inflammation in oral lichen planus (OLP). The study aimed to investigate whether the levels of sulfated and sialylated glycoproteins, total protein, and free calcium in saliva from patients with OLP differ from those of individuals without oral mucosal diseases. MATERIAL AND METHODS Patients diagnosed with OLP (n = 25) and two control groups without any oral mucosal disease; age- and gender-matched controls (n = 25, 65.6 ± 2.9 years), and younger controls (n = 25, 41.8 ± 2.5 years) were included. Subjective dry mouth (xerostomia) was assessed by asking a single-item question. Chew-stimulated whole saliva was collected to measure sulfated and sialylated glycoproteins by the Alcian Blue method. The total protein was determined spectrophotometrically, and the free calcium measured using an electrode. RESULTS The output of salivary sulfated and sialylated glycoproteins in the OLP group (21.8 ± 2.4 µg/min) was lower than in the age- and gender-matched controls (43.0 ± 2.9 µg/min, p = 0.0002), whereas the total protein and calcium output did not differ between the three groups (p > 0.05). The prevalence of xerostomia was significantly higher in the OLP group compared to both control groups (p = 0.038). CONCLUSIONS Patients with OLP showed a high prevalence of xerostomia and lower levels of salivary acidic type glycoproteins compared to the individuals without oral mucosa disease. CLINICAL RELEVANCE It is relevant to investigate the role of acidic glycoproteins in the pathogenesis of OLP.
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Affiliation(s)
- H Çevik-Aras
- Department of Oral Medicine and Pathology, Institute of Odontology, University of Gothenburg, Gothenburg, Sweden.
- Specialist Clinic for Orofacial Medicine, Northern Älvsborg County Hospital, Public Dental Service, Trollhättan, Region Västra Götaland, Sweden.
| | - Shehed Musa
- Public Dental Service, Gothenburg, Region Västra Götaland, Sweden
| | - Richard Olofsson
- Specialist Clinic for Orofacial Medicine, Public Dental Service, Uddevalla-Trollhättan, Region Västra Götaland, Sweden
| | - Annica Almståhl
- Section 4, -Oral Health, Faculty of Odontology, Malmö University, Malmö, Sweden
- Department of Oral Microbiology and Immunology, Institute of Odontology, University of Gothenburg, Gothenburg, Sweden
| | - Ulrica Almhöjd
- Department of Cariology, Institute of Odontology, University of Gothenburg, Gothenburg, Sweden
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Arvidsson J, Eriksson S, Johansson E, Lagerstrand K. Arterial occlusion duration affects the cuff-induced hyperemic response in skeletal muscle BOLD perfusion imaging as shown in young healthy subjects. MAGMA 2023; 36:897-910. [PMID: 37330431 PMCID: PMC10667151 DOI: 10.1007/s10334-023-01105-y] [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] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Dynamic BOLD MRI with cuff compression, inducing ischemia and post-occlusive hyperemia in skeletal muscle, has been pointed out as a potential diagnostic tool to assess peripheral limb perfusion. The objective was to explore the robustness of this technique and its sensitivity to the occlusion duration. MATERIALS AND METHODS BOLD images were acquired at 3 T in 14 healthy volunteers. [Formula: see text]-imaging with 5- and 1.5-min occlusions were acquired and several semi-quantitative BOLD parameters were derived from ROI-based [Formula: see text]-time curves. Differences in parameters from the two different occlusion durations were evaluated in the gastrocnemius and soleus muscles using non-parametrical tests. Intra- and inter-scan repeatability were evaluated with coefficient of variation. RESULTS Longer occlusion duration resulted in an increased hyperemic signal effect yielding significantly different values (p < 0.05) in gastrocnemius for all parameters describing the hyperemic response, and in soleus for two of these parameters. Specifically, 5-min occlusion yielded steeper hyperemic upslope in gastrocnemius (41.0%; p < 0.05) and soleus (59.7%; p = 0.03), shorter time to half peak in gastrocnemius (46.9%; p = 0.00008) and soleus (33.5%; p = 0.0003), and shorter time to peak in gastrocnemius (13.5%; p = 0.02). Coefficients of variation were lower than percentage differences that were found significant. DISCUSSION Findings show that the occlusion duration indeed influences the hyperemic response and thus should play a part in future methodological developments.
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Affiliation(s)
- Jonathan Arvidsson
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Stefanie Eriksson
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Kerstin Lagerstrand
- Department of Medical Radiation Sciences, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
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Petersson K, Finizia C, Pauli N, Dotevall H, Tuomi L. A randomized controlled study evaluating the head-lift exercise in head and neck cancer patients with radiation-induced dysphagia: effect on swallowing function and health-related quality of life over 12 months. Eur Arch Otorhinolaryngol 2023; 280:5445-5457. [PMID: 37584752 PMCID: PMC10620310 DOI: 10.1007/s00405-023-08183-7] [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: 04/19/2023] [Accepted: 08/07/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE Dysphagia is common after radiotherapy for head and neck cancer (HNC) and can affect health-related quality of life (HRQL). This randomized controlled trial aimed to evaluate the effect of the head-lift exercise (HLE) over 12 months in HNC patients with radiation-induced dysphagia. METHODS Sixty-one patients with dysphagia were randomized to intervention group (n = 30) and control group (n = 31) at 6-36 months after completion of radiotherapy for HNC. Dysphagia-specific HRQL was measured with the MD Anderson Dysphagia Inventory (MDADI); general and HNC-specific HRQL was measured with the European Organization for Research and Treatment of Cancer Quality of Life questionnaire Core 30 (EORTC QLQ-C30) and QLQ-H&N35. Measurements were made at baseline, and at 8 weeks and 12 months after start of intervention. RESULTS Adherence to the intervention was good throughout the year. When comparing change from baseline reports to each follow-up no statistically significant differences between the groups were found in any of the HRQL instruments. There were some statistically significant changes within groups compared to baseline. The intervention group improved self-rated swallowing function on the MDADI at 8 weeks (emotional domain, p = 0.03; functional domain, p = 0.007; total score, p = 0.01) and the control at twelve months (emotional domain, p = 0.03; functional domain, p = 0.02; physical domain, p = 0.004; total score, p = 0.002). CONCLUSION In this randomized control study, no effect was observed short term or at 12 months on HRQL after use of the HLE as rehabilitation for radiation-induced dysphagia.
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Affiliation(s)
- Kerstin Petersson
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, 41345, Gothenburg, Sweden.
| | - Caterina Finizia
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, 41345, Gothenburg, Sweden
| | - Nina Pauli
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, 41345, Gothenburg, Sweden
| | - Hans Dotevall
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, 41345, Gothenburg, Sweden
| | - Lisa Tuomi
- Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Region Västra Götaland, 41345, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Speech and Language Pathology Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Rosenqvist L, Hebelka H, Baranto A, Brisby H, Lagerstrand K. Detailed MRI evaluation of the spine: a 2-year follow-up study of young individuals reporting different training doses. Eur Spine J 2023; 32:4145-4152. [PMID: 37815636 DOI: 10.1007/s00586-023-07961-5] [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] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/21/2023] [Accepted: 09/16/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVE To characterize the discs and vertebrae in detail over time in a group of adolescent individuals with varying training doses using magnetic resonance imaging (MRI). METHOD Thirty-five students were recruited from regular high schools (n=13) as well as schools with athlete competitive skiing programmes (n = 22). The thoraco-lumbar spine of all individuals was examined at baseline and at 2-year follow-up using the same 1.5T scanner and imaging protocol. The individuals were grouped based on their reported training dose: low-to-normal training dose (≤5 h/week, n = 11, mean age 16.5 ± 0.5 years) and high training dose (>5 h/week, n = 24, mean age 17.2 ± 0.6 years.) RESULTS: At baseline, the signal intensity in the discs and vertebrae were significantly lower in individuals reporting high compared to low-to-normal training dose. The vertebral signal changed significantly over the 2-year period in both groups. However, only individuals reporting low-to-normal training dose displayed an overall disc signal change. Interestingly, the regional analysis displayed at baseline high annular signals in the more training-active individuals followed by a reduction over the two-year period. CONCLUSION This study suggests that disc degeneration is manifested earlier in individuals reporting a higher training dose. Over a 2-year period, however, the degeneration process did not accelerate further. Also, a significant difference in the vertebral signal, at baseline and follow-up as well as over time, could be seen between groups of individuals reporting high versus low-to-normal training dose.
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Affiliation(s)
- Louise Rosenqvist
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Hanna Hebelka
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Adad Baranto
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Helena Brisby
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kerstin Lagerstrand
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
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Schubert-Hjalmarsson E, Fasth A, Ickmans K, Mårdbrink EL, Söderpalm AC, Lundberg M. Central sensitization in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome-a feasibility study. Pilot Feasibility Stud 2023; 9:97. [PMID: 37316864 DOI: 10.1186/s40814-023-01320-3] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/16/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Pain is a major symptom in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome. Although the underlying mechanism causing generalized pain in children with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome is unclear, central sensitization has been suggested as a possible explanation. The aim of this study was to explore the feasibility of a study protocol for a future case-control study, investigating features of central sensitization in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome. METHODS Central sensitization features were measured in ten patients and nine healthy controls aged 13-17 years via experimental pain measurement quantifying primary and secondary hyperalgesia, endogenous pain modulation, and exercise-induced hyperalgesia. Descriptive statistics were used. Frequency, median, and range values were calculated. RESULTS Eleven out of 57 patients chose to participate. No control could be recruited through public schools. Therefore, a convenience sampling strategy was used for the recruitment of the control group. The process of assessing primary and secondary hyperalgesia, endogenous pain modulation, and exercise-induced hyperalgesia was well tolerated by all participants (patients and controls). When assessing endogenous pain modulation via conditioned pain modulation, two participants in the patient group and three in the control group did not achieve a pain experience ≥ 3 on the numerical rating scale when immersing their hands in cold water. CONCLUSION This study investigated the feasibility, safety, and toleration of experimental pain measurements in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome. Although the test protocol proved to be sufficiently feasible for use with the participant group, it will need to be adapted in the main study in order to obtain more reliable data. Recruitment, especially of participants for the control group, can be a major obstacle for future studies and requires careful planning. TRIAL REGISTRATION Researchweb.org, 270,501. Registered on 9 May 2019.
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Affiliation(s)
- Elke Schubert-Hjalmarsson
- Division of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Physiotherapy, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden.
| | - Anders Fasth
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Rheumatology and Immunology, Silvia Children's Hospital, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Queen, Sweden
| | - Kelly Ickmans
- Pain in Motion (PAIN) Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium
- Movement & Nutrition for Health & Performance Research Group, Department of Movement & Sport Sciences, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eva-Lott Mårdbrink
- Department of Physiotherapy, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Ann-Charlott Söderpalm
- Department of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mari Lundberg
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
- University of Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Basic C, Hansson PO, Sandström TZ, Johansson B, Fu M, Mandalenakis Z. Heart failure outcomes in low-risk patients with atrial fibrillation: a case-control study of 680 523 Swedish individuals. ESC Heart Fail 2023. [PMID: 37139589 PMCID: PMC10375091 DOI: 10.1002/ehf2.14375] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/13/2023] [Accepted: 03/08/2023] [Indexed: 05/05/2023] Open
Abstract
AIMS Knowledge of long-term outcomes in patients with atrial fibrillation (AF) remains limited. We sought to evaluate the risk of new-onset heart failure (HF) in patients with AF and a low cardiovascular risk profile. METHODS AND RESULTS Data from the Swedish National Patient Register were used to identify all patients with a first-time diagnosis of AF without underlying cardiovascular disease at baseline between 1987 and 2018. Each patient was compared with two controls without AF from the National Total Population Register. In total, 227 811 patients and 452 712 controls were included. During a mean follow-up of 9.1 (standard deviation 7.0) years, the hazard ratio (HR) for new-onset HF was 3.55 [95% confidence interval (CI) 3.51-3.60] in patients compared with controls. Women with AF (18-34 years) had HR for HF onset 24.6 (95% CI 7.59-80.0) and men HR 9.86 (95% CI 6.81-14.27). The highest risk was within 1 year in patients 18-34 years, HR 103.9 (95% CI 46.3-233.1). The incidence rate within 1 year increased from 6.2 (95% CI 4.5-8.6) per 1000 person-years in young patients (18-34 years) to 142.8 (95% CI 139.4-146.3) per 1000 person-years among older patients (>80 years). CONCLUSIONS Patients studied had a three-fold higher risk of developing HF compared with controls. Young patients, particularly women, carry up to 100-fold increased risk to develop HF within 1 year after AF. Further studies in patients with AF and low cardiovascular risk profile are needed to prevent serious complications such as HF.
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Affiliation(s)
- Carmen Basic
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Diagnosvägen 11, 41650, Gothenburg, Sweden
- Region Västra Götaland, Department of Medicine Geriatric and Emergency Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Per-Olof Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Diagnosvägen 11, 41650, Gothenburg, Sweden
- Region Västra Götaland, Department of Medicine Geriatric and Emergency Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Tatiana Zverkova Sandström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Diagnosvägen 11, 41650, Gothenburg, Sweden
| | - Birgitta Johansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Diagnosvägen 11, 41650, Gothenburg, Sweden
- Region Västra Götaland, Department of Medicine Geriatric and Emergency Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Diagnosvägen 11, 41650, Gothenburg, Sweden
- Region Västra Götaland, Department of Medicine Geriatric and Emergency Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Zacharias Mandalenakis
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Diagnosvägen 11, 41650, Gothenburg, Sweden
- Region Västra Götaland, Department of Medicine Geriatric and Emergency Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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10
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Chen J, Wang J, Wu X, Simon N, Svensson CI, Yuan J, Hart DA, Ahmed AS, Ackermann PW. eEF2 improves dense connective tissue repair and healing outcome by regulating cellular death, autophagy, apoptosis, proliferation and migration. Cell Mol Life Sci 2023; 80:128. [PMID: 37084140 PMCID: PMC10121543 DOI: 10.1007/s00018-023-04776-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/23/2023] [Accepted: 04/09/2023] [Indexed: 04/22/2023]
Abstract
Outcomes following human dense connective tissue (DCT) repair are often variable and suboptimal, resulting in compromised function and development of chronic painful degenerative diseases. Moreover, biomarkers and mechanisms that guide good clinical outcomes after DCT injuries are mostly unknown. Here, we characterize the proteomic landscape of DCT repair following human Achilles tendon rupture and its association with long-term patient-reported outcomes. Moreover, the potential regulatory mechanisms of relevant biomarkers were assessed partly by gene silencing experiments. A mass-spectrometry based proteomic approach quantified a large number (769) of proteins, including 51 differentially expressed proteins among 20 good versus 20 poor outcome patients. A novel biomarker, elongation factor-2 (eEF2) was identified as being strongly prognostic of the 1-year clinical outcome. Further bioinformatic and experimental investigation revealed that eEF2 positively regulated autophagy, cell proliferation and migration, as well as reduced cell death and apoptosis, leading to improved DCT repair and outcomes. Findings of eEF2 as novel prognostic biomarker could pave the way for new targeted treatments to improve healing outcomes after DCT injuries.Trial registration: NCT02318472 registered 17 December 2014 and NCT01317160 registered 17 March 2011, with URL http://clinicaltrials.gov/ct2/show/NCT02318472 and http://clinicaltrials.gov/ct2/show/study/NCT01317160 .
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Affiliation(s)
- Junyu Chen
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, 171 76, Stockholm, Sweden.
| | - Jin Wang
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, People's Republic of China
- The Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310014, China
| | - Xinjie Wu
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, 171 76, Stockholm, Sweden
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, 100029, China
| | - Nils Simon
- Department of Physiology and Pharmacology, Center for Molecular Medicine, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Camilla I Svensson
- Department of Physiology and Pharmacology, Center for Molecular Medicine, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Juan Yuan
- Department of Cell and Molecular Biology, Karolinska Institutet, 17176, Stockholm, Sweden
| | - David A Hart
- Department of Surgery, Faculty of Kinesiology, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Aisha S Ahmed
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, 171 76, Stockholm, Sweden.
- Department of Physiology, University of Helsinki, Helsinki, Finland.
| | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, 171 76, Stockholm, Sweden
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11
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Bramsved R, Mårild S, Bygdell M, Kindblom JM, Lindh I. Impact of BMI and smoking in adolescence and at the start of pregnancy on birth weight. BMC Pregnancy Childbirth 2023; 23:206. [PMID: 36973709 PMCID: PMC10041706 DOI: 10.1186/s12884-023-05529-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/17/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Birth weight is an indicator of intra-uterine conditions but also a determinant for future health. The importance of preconception health for a healthy birth weight has been emphasized, but evidence is lacking on how modifiable factors in adolescence, such as body mass index (BMI) and smoking, affect future pregnancy outcome. We evaluated associations between BMI and smoking in adolescence and at the start of pregnancy and birth weight of the first-born child. METHODS This longitudinal study included 1256 mothers, born 1962-1992, and their first-born children, born between 1982-2016. Self-reported questionnaire information on weight, height and smoking at age 19 was cross-linked with national register data obtained at the start of pregnancy and with the birth weights of the children. Univariable and multivariable linear regressions were performed to determine the impact of maternal factors at 19 years of age and at the start of the pregnancy respectively, and the importance of BMI status at these points of time for the birth weight of the first child. RESULTS BMI and smoking at the start of the pregnancy displayed strong associations with birth weight in a multivariable analysis, BMI with a positive association of 14.9 g per BMI unit (95% CI 6.0; 23.8 p = 0.001) and smoking with a negative association of 180.5 g (95% CI -275.7; -85.4) p = 0.0002). Smoking and BMI at 19 years of age did not show this association. Maternal birth weight showed significant associations in models at both time-points. Becoming overweight between age 19 and the start of the pregnancy was associated with a significantly higher birth weight (144.6 (95% CI 70.7;218.5) p = 0.0002) compared to mothers with normal weight at both time points. CONCLUSIONS Our findings indicate that the time period between adolescence and first pregnancy could be a window of opportunity for targeted health promotion to prevent intergenerational transmission of obesity.
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Affiliation(s)
- Rebecka Bramsved
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
| | - Staffan Mårild
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Maria Bygdell
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Jenny M Kindblom
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Pediatric Clinical Research Center, Gothenburg, Sweden
| | - Ingela Lindh
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
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12
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Idahl A, Liv P, Darelius A, Collins E, Sundfeldt K, Pålsson M, Strandell A. HOPPSA update: changes in the study protocol of Hysterectomy and OPPortunistic SAlpingectomy, a registry-based randomized controlled trial. Trials 2023; 24:222. [PMID: 36959664 PMCID: PMC10037841 DOI: 10.1186/s13063-023-07244-w] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 03/13/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND The HOPPSA trial is a multi-center national registry-based randomized controlled trial to test the safety and effectiveness of performing opportunistic salpingectomy at hysterectomy to reduce the risk of epithelial ovarian cancer (EOC). The study protocol was first published in January 2019 and is available at https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3083-8 . Here, we report amendments made to the study protocol since commencement of the trial. CHANGES IN METHODS AND ANALYSIS The primary outcomes analyses have been changed. (1) Complications will be analyzed using binomial generalized estimating equation (GEE) with log link function, while the unadjusted analyses according to Miettinen and Nurminen will be performed as a sensitivity analysis. (2) Absolute change in Menopause Rating Scale (MRS) will primarily be analyzed using a mixed effects model, adjusted for baseline MRS and center as a random effect. (3) Time to EOC will be analyzed using the mixed effects Cox regression model with center as random effect, while the unadjusted log-rank test will be performed as a sensitivity analysis. The primary outcome Complications will be based solely on the specific assessment in the GynOp quality registry. The Clavien-Dindo classification will be evaluated as a secondary outcome. Furthermore, MRS is also measured three years postoperatively to better pinpoint the onset of menopausal symptoms. DISCUSSION The changes to the protocol mainly concern the analyses of data. No changes to recruitment, randomization, intervention, or follow-up of primary outcomes have been made. An interim analysis during 2021 concluded that the study should continue until the target sample size is reached. TRIAL REGISTRATION ClinicalTrials.gov, NCT03045965 . Registered 8 February 2017.
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Affiliation(s)
- Annika Idahl
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
| | - Per Liv
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Anna Darelius
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Elin Collins
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Karin Sundfeldt
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mathias Pålsson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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13
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Choong OK, Jakobsson R, Bergdahl AG, Brunet S, Kärmander A, Waldenström J, Arvidsson Y, Altiparmak G, Nilsson JA, Karlsson J, Nyström K, Johansson ME. SARS-CoV-2 replicates and displays oncolytic properties in clear cell and papillary renal cell carcinoma. PLoS One 2023; 18:e0279578. [PMID: 36595529 PMCID: PMC9810192 DOI: 10.1371/journal.pone.0279578] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 12/09/2022] [Indexed: 01/04/2023] Open
Abstract
The SARS-CoV-2 virus is currently causing a global pandemic. Infection may result in a systemic disease called COVID-19, affecting primarily the respiratory tract. Often the gastrointestinal tract and kidneys also become involved. Angiotensin converting enzyme 2 (ACE2) serves as the receptor for SARS-CoV-2. The membrane proteins, Transmembrane serine protease 2 (TMPRSS2) and Neuropilin 1 (NRP1) are accessory proteins facilitating the virus entry. In this study we show that the human proximal kidney tubules, express these factors. We hypothesized that cancers derived from proximal tubules as clear cell (CCRCC) and papillary renal cell carcinoma (PRCC), retain the expression of the SARS-CoV-2 entry factors making these cancers susceptible to SARS-CoV-2 infection. We used bioinformatics, western blotting, and assessment of tissue micro arrays (TMA) including 263 cases of CCRCC, 139 cases of PRCC and 18 cases of chromophobe RCC to demonstrate that the majority of CCRCC and PRCC cases retained the RNA and protein expression of the entry factors for SARS-CoV-2. We furthermore show that SARS-CoV-2 virus propagated robustly in primary cultures of CCRCC and PRCC cells with a visible virus cytopathogenic effect correlating with viral RNA expression levels. We also noted that the delta-variant of SARS-CoV-2 causes cancer cells to form syncytia in-vitro. This phenomenon was also identified histologically in CCRCC tissue from a patient that had been hospitalized for COVID-19, twelve months prior to nephrectomy. Our data provide insights into SARS-CoV-2 infectivity in renal cell carcinoma and that the virus causes a distinct cytopathogenic effect.
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Affiliation(s)
- Oi Kuan Choong
- Department of Laboratory Medicine, Sahlgrenska Center for Cancer Research, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rasmus Jakobsson
- Department of Laboratory Medicine, Sahlgrenska Center for Cancer Research, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery and Urology, Skaraborg Hospital, Skövde, Sweden
| | - Anna Grenabo Bergdahl
- Department of Urology, Institute of Clinical Science, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sofia Brunet
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ambjörn Kärmander
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jesper Waldenström
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Yvonne Arvidsson
- Department of Laboratory Medicine, Sahlgrenska Center for Cancer Research, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gülay Altiparmak
- Department of Laboratory Medicine, Sahlgrenska Center for Cancer Research, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonas A. Nilsson
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska Center for Cancer Research, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia
| | - Joakim Karlsson
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska Center for Cancer Research, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia
| | - Kristina Nyström
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- * E-mail: (MEJ); (KN)
| | - Martin E. Johansson
- Department of Laboratory Medicine, Sahlgrenska Center for Cancer Research, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
- * E-mail: (MEJ); (KN)
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