Periprosthetic hip infections in a Swedish regional hospital between 2012 and 2018: is there a relationship between Cutibacterium acnes infections and uncemented prostheses?

The purpose of this study was to evaluate patients requiring in-patient care due to a periprosthetic joint infection (PJI), with respect to bacterial agents, surgical treatment, antibiotics, and outcome. We retrospectively identified all infected total hip arthroplasties (THAs) in a Swedish regional hospital during a 7-year period (2012-2018) and reviewed medical records and microbiological data. A total of 89 infected THAs in 87 patients were identified. Standardized treatment with debridement with retention of the implant and antibiotics (DAIR) was initially performed in 53 cases (60 %), one or two stage revisions in 33 cases (37 %), and an immediate Girdlestone in 3 cases (3 %). Infection eradication was seen in 77 PJIs (87 %) in addition to six patients (7 %) ending up with a permanent but uninfected Girdlestone. All six patients with manifest failures were infected with Staphylococcus aureus, two of which were also polymicrobial. Cutibacterium acnes was found in 18 of 89 patients (16 %) distributed in 15 uncemented implants but only in 3 hybrids and cemented arthroplasties, while remaining pathogens were equally distributed in uncemented THAs ( n = 31 ) and THAs with at least one cemented component ( n = 40 ; p = 0.003 ). Eradication was achieved in all 18 patients when Cutibacterium acnes was the only culture ( n = 14 ) or clearly dominant among positive cultures ( n = 4 ). DAIR was successful in selected postoperative infections up to 6 months after hip replacement. Cutibacterium acnes infections in hip arthroplasty may be underdiagnosed. Cemented components in THAs seem to protect from colonization with Cutibacterium acnes.

Surgery in Iceland.

Icelandic surgeons provide a wide range of modern surgical services with excellent results. How can a nation of fewer than 300,000 persons accomplish this? The main reasons are a thriving economy, a high standard of living and education, and the training of surgeons. All Icelandic surgeons receive their training overseas, many at university hospitals in the other Nordic countries, particularly Sweden. Others receive training in the United States and Great Britain. Almost 50% of the general and orthopedic surgeons hold PhD degrees from major universities in the Nordic countries. In some other surgical subspecialties, an even greater number possess a PhD degree. This diverse background of training creates a stimulating and international outlook among the surgeons. All types of surgery are performed in Iceland, with the exception of surgery for complicated congenital heart disease and transplantation. Recently a living related renal transplant program was started with promising results.

Genetic epidemiologic aspects of gastric cancer in Iceland.

BACKGROUND: Association between gastric cancer and environmental factors (diet and infections) has been established, and genetic changes are well described in adenocarcinomas of the stomach. Less is known about clinical features of hereditary gastric cancer and whether the disease is associated with family clustering. STUDY DESIGN: Family trees of patients diagnosed with gastric cancer in Iceland between 1955 and 1999 were identified in the Genealogical Database of the University of Iceland. All probands with age of onset younger than 60 years were used in the study. Families of all probands (n = 455 men and 161 women) were traced to third degree. Through linkage of the genealogic data obtained by the Icelandic Cancer Registry (between 1955 and 1999), all reported cancers were identified in those families. The expected number of cases was calculated using age-specific population rates in Iceland. RESULTS: A relative risk (RR) of 2.2 (95% confidence interval [CI] = 1.6-3.0) and 1.3 (95% CI = 1.0-1.7) for the gastric cancer risk was observed among 2,846 first- and 8,658 second-degree relatives of male probands. For female probands the corresponding relative risks were 1.6 (95% CI = 1.1-2.6, n = 7,396) and 1.4 (95% CI = 0.9-2.0, n = 2,764). The increased risk was more pronounced for relatives of men and women diagnosed with gastric cancer before the age of 50 years. A minor difference in relative risk was found between relatives of probands who were diagnosed with intestinal type or diffuse type gastric cancer. Fifty-eight families with two or more relatives with cancer were identified. In 32 families 2 relatives with gastric cancer were identified and in 26 families 3 or more relatives had gastric cancer. CONCLUSIONS: Relatives of gastric cancer patients have two- to three-fold increased risk of developing gastric cancer. The risk is elevated for both genders.

Changes in muscle compartment pressure after cardiopulmonary bypass.

PURPOSE: Hemodilution and inflammation lead to edema and increased muscle compartment pressure after cardiac surgery. The aim of this study was to find whether muscle compartment pressure was affected by the addition of albumin and mannitol to the pump prime, heparin coating or leukocyte depletion. Additionally, we studied the relationship between intraocular pressure and lower leg muscle compartment pressure. Edema during and following cardiac surgery is due to hemodynamic, osmotic and inflammatory changes, according to Starling's Law. We attempted to influence the osmotic balance and reduce the inflammatory response in order to reduce the edema. METHODS: Thirty-six patients who underwent cardiac surgery were randomly allocated into four groups. Group A received albumin and mannitol into the pump prime. Group B had an, heparin-coated perfusion system, Group C had a leukocyte-depletion arterial line filter and Group D was the control group, where intraocular pressure was also measured. RESULTS: Lower leg muscle compartment pressure increased significantly during and after cardiac surgery in all groups, but this increase was significantly less in Group A than in the control group 24 h after surgery. No correlation was found between muscular compartment pressure and intraocular pressure. The intraocular pressure profile is different from the muscular compartment pressure and recovers much faster. CONCLUSION: Lower leg muscle compartment pressure and intraocular pressure behave differently during and after cardiac surgery. Albumin and mannitol added to the pump prime decreases muscle compartment pressure after cardiac surgery.

Effect of incidental detection for survival of patients with renal cell carcinoma: results of population-based study of 701 patients.

OBJECTIVES: To conduct a population-based study to evaluate the effect of incidental detection of renal cell carcinoma (RCC) on survival. Incidental detection of RCC has increased significantly in recent years because of widespread use of abdominal imaging. The patients with incidentally diagnosed RCC have better survival; however, because of possible "lead time" bias and stage migration, the real implications of incidental detection on survival have been a matter of debate. METHODS: All living patients diagnosed with RCC in Iceland between 1971 and 2000 were included (n = 701). The histologic findings were verified, the stage (extent) of the disease was determined, and the incidence, mortality, and survival were evaluated. RESULTS: The strongest predictors of mortality were stage and nuclear grade. After correcting for these factors in the multivariate analysis, incidental diagnosis, histologic subtype, and gender lost their significance as independent prognostic factors of death. However, the incidentally diagnosed tumors were 2.3 cm smaller on average and at a lower stage and grade than symptomatic tumors, with significantly better patient survival than those with symptomatic tumors on univariate analysis (76% versus 44% 5-year disease-specific survival). An increased incidence of RCC was only seen in men, but incidental detection increased threefold during the study period in both sexes, with significant improvement in survival for the whole group as a result. CONCLUSIONS: The increased frequency of incidental detection has improved the survival of patients with RCC in Iceland. Incidental detection was not an independent prognostic factor of death, indicating that these tumors are of a similar biologic nature as symptomatic RCCs, only diagnosed earlier.

Renal oncocytoma: a clinicopathological analysis of 45 consecutive cases.

OBJECTIVE: To evaluate the clinical behaviour and pathology of renal oncocytoma in a well-defined population over a 30-year period. PATIENTS AND METHODS: In a retrospective population-based study we assessed relevant clinical and pathological factors in 45 patients (31 men and 14 women) diagnosed with renal oncocytoma in Iceland between 1971 and 2000. Clinical presentation, pathology, survival and causes of death were evaluated. RESULTS: The age-standardized incidence was 0.3 per 100,000 per year for both men and women, the incidence of oncocytomas being 5.5% of renal cell carcinomas (RCCs) diagnosed during the same period in Iceland. Fourteen patients were diagnosed at autopsy for an unrelated disease. Of 31 living patients (mean age 70.5 years), seven were diagnosed incidentally (23%), and the others had presented with haematuria (32%), abdominal pain (29%), and weight loss (10%). All the patients had a radical nephrectomy, except for one with bilateral oncocytoma who had a partial nephrectomy. The mean (range) tumour size was 5.7 (0.9-12) cm. Eighteen patients (58%) were diagnosed at Tumour-Node-Metastasis stage I, 10 at stage II (32%) and three at stage III (10%), all of those at stage III having renal capsular penetration or tumour invasion into perirenal fat tissue (T3aN0M0). No patients were diagnosed with lymph node or distant metastasis. Two cases of coexisting RCC were detected. After a median follow-up of 8.3 years there were no recurrences or deaths from oncocytoma (100% disease-specific survival). The overall 5-year survival was 63%, with most patients dying from cardiovascular diseases or nonrenal cancers. CONCLUSIONS: In most cases renal oncocytoma behaves like a benign tumour; the long-term prognosis is excellent. Thus, in the present patients, radical nephrectomy could be regarded as an over-treatment and nephron-sparing surgery as more appropriate, especially in patients with small tumours. However, both coexisting RCC and perirenal fat invasion, a hallmark of malignant behaviour, might indicate that more radical surgery is warranted in some of these patients.

Tissue MicroArray analyses of pancreatic duodenal homeobox-1 in human cancers.

In previous studies, we demonstrated that rat insulin promoter (RIP)-driven gene therapy successfully targeted human pancreatic tumor PANC-1 cells and mouse insulinoma NIT-1 cells, which are both pancreatic duodenal homeobox-1 (PDX-1)-positive. The purpose of this study was to perform a human tissue array analysis to determine potential targets for RIP-driven gene therapy. A custom-designed tissue MicroArray analysis of various human cancer specimens was performed using a PDX-1 polyclonal antibody generated in our laboratory. The custom-designed Tissue MicroArray of human tumor specimens consists of human cancer specimens from different origins, such as the pancreas, breast, colon, prostate, kidney, liver, lung, and ovary. A panel of normal human specimens from 20 organs or tissues was used as a control. All tissues were fixed in formalin and embedded in paraffin. The immunohistochemistry studies of the cytoplasm and the nuclear expression levels were compared using the Loda method and blind reviews. Data are presented as the mean +/- SEM (p < 0.05 was considered significant by the unpaired student t-test). PDX-1 expression intensity was elevated in both benign and malignant tissues from the same patient with pancreas, breast, colon, prostate, and kidney cancers, whereas normal human tissues from control subjects without cancer did not express PDX-1. These results suggest that PDX-1 is an early marker for these cancers and could be potentially used as a diagnostic parameter and perhaps could be targeted by PDX-1-activated gene therapies, such as RIP-TK.

Histological subtyping and nuclear grading of renal cell carcinoma and their implications for survival: a retrospective nation-wide study of 629 patients.

OBJECTS: The aim of this study was to evaluate the prognostic significance of the current WHO histological subtyping and Fuhrman nuclear grading on the survival of patients with renal cell carcinoma (RCC). MATERIALS AND METHODS: A retrospective population-based study was carried out on all patients with a histopathologically confirmed diagnosis of RCC in Iceland between 1971 and 2000. Fuhrman grade, TNM stage, and survival were evaluated and multivariate analysis applied in order to determine prognostic factors. RESULTS: Out of 629 patients (387 males, 242 females, mean age 64 years), 558 (88.7%) had clear cell, 53 (8.4%) papillary, and 13 (2.1%) chromophobe RCC. Patient demographics were comparable for the two major subtypes, but chromophobe RCCs were larger in size and were diagnosed at a younger age. Clear cell RCCs were more often of higher grades (G3+G4, 48.4%) and at advanced TNM stages (III+IV, 59.3%) than papillary RCCs (22.6% and 34% respectively, p<0.001). Linear regression analysis showed a strong correlation between grade, tumor size, and stage (p<0.001). Chromophobe RCCs had a better survival in univariate analysis than both papillary and clear cell RCCs (84.6% vs. 66.5% and 54.9% 5-year disease specific survival, p<0.001). However, in the multivariate analysis, only the patient's age, calendar year of diagnosis, TNM stage, and nuclear grade were independent prognostic factors of survival. CONCLUSION: In this complete nation-wide series nuclear grading is important in predicting survival of patients with RCC. It is strongly related to both tumor size and stage, with stage being by far the strongest prognostic factor. Different histological subtypes confer different survival. However, in spite of the distinctive cytogenetic and molecular characteristics of the subtypes, the survival difference is to a large extent due to differences in grade and particularly stage.

[Frequency of serious complications following laparoscopic cholecystectomy.].

UNLABELLED: In the the last decade laparoscopic cholecystectomy has emerged as the prefered method in the treatment of gallbladder stones. It has proved to be safe and has a relatively low rate of complications. However, major bile duct injuries occur more frequently during laparoscopic cholecystectomy when compared to the open procedure. The aim of this study was to examine the types and frequency of complications occurring during the initial period of laparoscopic cholecystectomy (1991-1998) at Landspitali University Hospital with a special emphasis on major bile duct injuries. MATERIALS AND METHODS: A retrospective analysis was performed on patients charts and operative notes of those who underwent laparoscopic cholecystectomy during the years 1991-1998. RESULTS: 1008 consecutive patients were included in the study of which 727 (72%) were females. Bile leak from the cystic duct or the gallbladder bed was the most common complication and occurred in 23 patients (2.3%). Twenty patients (2%) had an intra-abdominal bleeding postoperatively. Seventeen (1.5%) of the patients had retained stones. Four patients (0.4%) developed a haematoma in the gallbladder bed. Two patients (0.2%) had a lesion of a bile duct and three patients (3%) died in the postperative phase. One hundred and six (10.5%) laparoscopic cholecystectomies were converted to an open procedure with the number of conversions highest in the second year (23%) of the procedure but thereafter the conversion rate was between 5 and 10%. Of the operations which required conversion from a laparoscopic procedure to an open one 74 (70%) were operations done urgently or as an emergency. CONCLUSION: Laparoscopic cholecystectomy at Landspitali University Hospital is a safe procedure with a low incidence of complications including major biliary injury. These findings are in accordance with results from other similar studies.

[Primary pancreatic lymphoma causing obstructive jaundice in a 71 year old man. A case report and review of the literature.].

Primary lymphoma of the pancreas is a very rare disease. They are difficult to diagnose and have good prognosis, due to their sensitivity to chemotherapy and radiation. As compared to the more common pancreatic adenocarcinomas which usually have bad prognosis. Histological diagnosis relies on good biopsy. We report a case of primary pancreatic non-Hodgkin s lymphoma diagnosed in a 71 year old icteric man. Chemotherapy and radiation therapy was started after relieving the jaundice with a PTC-introduced stent through the pancreatic part of the choledochus. This is the first reported case of pancreatic lymphoma in Iceland.

[Rectal cancer at Landspítalinn 1980-1995.].

OBJECTIVE: Surgery for rectal cancer is difficult and complications following surgery frequent. In the longer perspective a local recurrence is a serious problem. With better operative strategy and local radiation preoperatively a considerable progress has been made in treatment of this disease in large cancer centers. The aim of this study was to investigate symptoms, diagnostic delay, treatment, complications and survival of patients with rectal cancer treated at our institution. MATERIAL AND METHODS: A retrospective study of 43 consecutive patients (22 males, 21 females, mean age 73 years) diagnosed with rectal adenocarcinoma at Landspítalinn between 1980 and 1995 was performed. RESULTS: The most common symptoms were rectal bleeding (77%), change of bowel habits (63%) and abdominal pain (37%). More than 80% of the patients had a delay of more than one month before diagnosis and 53% of the tumors were located in the lower third of the rectum. One third of the patients were diagnosed with disease outside the rectum (Duke's-stage C and "D") and 54% were Duke's stage B. Of 43 patients 41 were operated, 30 (73%) with curative surgery. Low anterior resection of rectum was the most commonly performed procedure (n=17) with two cases of anastomostic leakage. Eleven patients underwent abdominoperineal resection and four patients were operated on because of metastasis with colostomy only. Surgical mortality was 0%. Five-year survival was 30% for the whole group and 52% for patients in stage B. CONCLUSION: There was no operative mortality in this series. Long-term survival for patients in comparable stages is inferior to recently published studies from larger and more specialized centers. The different results obtained could be explained by standardized surgical procedures and routine preoperative radiotherapy. Similar emphasis will be adopted to standardize rectal cancer surgery.

[The results of surgical treatment for cryptorchidism at Landspitalinn, 1970-1993.].

OBJECTIVE: Cryptorchidism is a common congenital genito-urological anomali in males with increased risk of infertility and testicular cancer. In this retrospective study the results of operations for undescended testis at Landspitalinn University Hospital were reviewed with special emphasis on patients diagnosed with testicular cancer later in life. MATERIAL AND METHODS: The study includes 593 males with undescended testis who were operated on between 1970 and 1993. Information was gathered from hospital records, including birth-weight, age at diagnosis and operation, localization of the testes and complications to surgery. Information on patients diagnosed with testicular cancer was aquired from the Icelandic Cancer Registry. RESULTS: The average birth-weight was 3461 g, including 58 boys (10%) with low birth-weight (

Spasmolytic polypeptide-expressing metaplasia (SPEM) associated with gastric cancer in Iceland.

Recent studies have described a spasmolytic polypeptide-expressing metaplastic cell lineage (SPEM) in the gastric fundic mucosa associated with both chronic H. pylori infection and gastric adenocarcinoma. We investigated the association of SPEM both with early gastric adenocarcinoma and in biopsies taken from patients prior to diagnosis of cancer. Two cohorts were examined. First, gastric resections from 29 patients with early gastric cancer were examined. Second, biopsies taken from 18 patients prior to the diagnosis of gastric cancer were compared with their respective resection specimens as well as with control biopsies from a cohort of 19 patients diagnosed with gastritis without subsequent development of cancer. The presence of SPEM and intestinal metaplasia (IM) adjacent to and distant from the cancer was compared and spasmolytic polypeptide (SP) immunostaining within dysplastic/cancerous cells was identified. SPEM was present adjacent to cancer in all early cancer cases where the tumor was located in the body or at the body/antrum junction, and was present in the body mucosa distant from the cancer in 76% of cases. Intestinal metaplasia was found adjacent to the tumor in 76% of cases and in body sections in 52% of resections. SP immunostaining was noted within cancer cells in 62% of tumors, and within dysplastic cells in 76% of resections where dysplasia was present. SPEM was present in 82% of the biopsies obtained prior to the diagnosis of cancer, compared with only 37% in the gastritis cohort. IM was present in only 57% of biopsies. In conclusion, SPEM is strongly associated with early gastric cancers and is observed in gastric biopsies prior to the development of cancer. In addition, early gastric cancers demonstrated a high incidence of SP expression. These results suggest that SPEM merits consideration as an important pre-neoplastic gastric lesion.

[Acute pancreatitis. Prospective study of incidence, aetiology, severity, and mortality in Iceland.].

OBJECTIVE: To evaluate the aetiology, severity and mortality of patients with acute pancreatitis at Landspítali - University Hospital (LSH) and to estimate the incidence in Iceland. MATERIAL AND METHODS: A prospective study of all patients diagnosed with acute pancreatitis LSH during the one-year period October 1998 - September 1999 inclusive. The main outcome measures were APACHE II, Ranson, and Imrie scores, and C-reactive protein (CRP) concentrations. The Balthazar - Ranson criteria were used for scoring of computed tomograms (CT). RESULTS: Twenty seven of the 50 patients were male. The median age of the whole series was 60 years (range 19-85). The estimated incidence was 32/100000 for the first attack of acute pancreatitis. The causes were; gallstones 42%, alcohol 32%, miscellaneous 24%, and idiopathic 2%. Thirty three percentage of the patients had APACHE II scores 9, 38% had Ranson scores of 3, 50% had Imrie scores of 3, and 34% had CRP concentrations >210 mg/L during the first 4 days or >120 mg/L during the first week. Seven patients had severe pancreatitis. Two patients in the whole group died, and both had clinically severe pancreatitis. CONCLUSIONS: Incidence and aetiology of acute pancreatitis in Iceland is in concordance to that described in other studies. Prospective assessment makes it possible to evaluate the aetiological factors more accurately. Measurement of the CRP concentration is an attractive and simple alternative to the severity scoring systems currently in use.