Permanent stoma rates after anterior resection for rectal cancer: risk prediction scoring using preoperative variables.

BACKGROUND: A permanent stoma after anterior resection for rectal cancer is common. Preoperative counselling could be improved by providing individualized accurate prediction modelling. METHODS: Patients who underwent anterior resection between 2007 and 2015 were identified from the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine presence of a stoma 2 years after surgery. A training set based on the years 2007-2013 was employed in an ensemble of prediction models. Judged by the area under the receiving operating characteristic curve (AUROC), data from the years 2014-2015 were used to evaluate the predictive ability of all models. The best performing model was subsequently implemented in typical clinical scenarios and in an online calculator to predict the permanent stoma risk. RESULTS: Patients in the training set (n = 3512) and the test set (n = 1136) had similar permanent stoma rates (13.6 and 15.2 per cent). The logistic regression model with a forward/backward procedure was the most parsimonious among several similarly performing models (AUROC 0.67, 95 per cent c.i. 0.63 to 0.72). Key predictors included co-morbidity, local tumour category, presence of metastasis, neoadjuvant therapy, defunctioning stoma use, tumour height, and hospital volume; the interaction between age and metastasis was also predictive. CONCLUSION: Using routinely available preoperative data, the stoma outcome at 2 years after anterior resection for rectal cancer can be predicted fairly accurately.

Usually, the goal of rectal cancer surgery is to remove the tumour and construct a bowel join. Sometimes, it is necessary to construct a stoma, which may become permanent. Swedish registry data were used to develop and test a statistical model to forecast the risk of a stoma 2 years after surgery. In addition, an online calculator was developed. The model performed reasonably well, and can be used to inform the patient and surgeon before surgery of the risk of a permanent stoma.

Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal pain (PREVSAM): a randomised controlled trial protocol.

BACKGROUND: Musculoskeletal pain is globally a leading cause of physical disability. Many musculoskeletal-related pain conditions, such as low back pain, often resolve spontaneously. In some individuals, pain may recur or persist, leading to ong-term physical disability, reduced work capacity, and sickness absence. Early identification of individuals in which this may occur, is essential for preventing or reducing the risk of developing persistent musculoskeletal pain and long-term sickness absence. The aim of the trial described in this protocol is to evaluate effects of an early intervention, the PREVSAM model, on the prevention of sickness absence and development of persistent pain in at-risk patients with musculoskeletal pain. METHODS: Eligible participants are adults who seek health care for musculoskeletal pain and who are at risk of developing persistent pain, physical disability, and sickness absence. Participants may be recruited from primary care rehabilitation centres or primary care healthcare centres in Region Västra Götaland. Participants will be randomised to treatment according to the PREVSAM model (intervention group) or treatment as usual (control group). The PREVSAM model comprises an interdisciplinary, person-centred rehabilitation programme, including coordinated measures within primary health care, and may include collaboration with participants' employers. The primary outcome sickness absence is operationalised as the number and proportion of individuals who remain in full- or part-time work, the number of gross and net days of sickness absence during the intervention and follow-up period, and time to first sickness absence spell. Secondary outcomes are patient-reported short-term sickness absence, work ability, pain, self-efficacy, health-related quality of life, risk for sickness absence, anxiety and depression symptoms and physical disability at 1 and 3 months after inclusion (short-term follow-up), and at 6 and 12 months (long-term follow-up). A cost-effectiveness analysis is planned and drug consumption will be investigated. DISCUSSION: The study is expected to provide new knowledge on the effectiveness of a comprehensive rehabilitation model that incorporates early identification of patients with musculoskeletal pain at risk for development of sickness absence and persistent pain. The study findings may contribute to more effective rehabilitation processes of this large patient population, and potentially reduce sickness absence and costs. TRIAL REGISTRATION: ClinicalTrials.gov Protocol ID: NCT03913325 , Registered April 12, 2019. Version 2, 10 July 2020. Version 2 changes: Clarifications regarding trial aim and inclusion process.

Fermentation of Cauliflower and White Beans with Lactobacillus plantarum - Impact on Levels of Riboflavin, Folate, Vitamin B12, and Amino Acid Composition.

As diets change in response to ethical, environmental, and health concerns surrounding meat consumption, fermentation has potential to improve the taste and nutritional qualities of plant-based foods. In this study, cauliflower, white beans, and a 50:50 cauliflower-white bean mixture were fermented using different strains of Lactobacillus plantarum. In all treatments containing cauliflower, the pH was reduced to <4 after 18 h, while treatments containing only white beans had an average pH of 4.8 after 18 h. Following fermentation, the riboflavin, folate, and vitamin B12 content of the cauliflower-white bean mixture was measured, and compared against that of an unfermented control. The riboflavin and folate content of the mixture increased significantly after fermentation. Relative to control samples, riboflavin increased by 76-113%, to 91.6 ± 0.6 µg/100 g fresh weight, and folate increased by 32-60%, to 58.8 ± 2.0 µg/100 g fresh weight. For one bacterial strain, L. plantarum 299, a significant 66% increase in vitamin B12 was observed, although the final amount (0.048 ± 0.013 µg/100 g fresh weight) was only a small fraction of recommended daily intake. Measurements of amino acid composition in the mixture revealed small increases in alanine, glycine, histidine, isoleucine, leucine, and valine in the fermented sample compared to the unfermented control.

Does early identification of work-related stress, combined with feedback at GP-consultation, prevent sick leave in the following 12 months? a randomized controlled trial in primary health care.

BACKGROUND: Experiencing work-related stress constitutes an obvious risk for becoming sick-listed. In primary health care, no established method to early identify, advise and treat people with work-related stress exists. The aim was to evaluate if the use of the Work Stress Questionnaire (WSQ) brief intervention, including feedback from the general practitioner (GP), had an impact on the level of sickness absence. METHOD/DESIGN: In total 271 (intervention group, n = 132, control group, n = 139) non-sick-listed employed women and men, aged 18 to 64 years, who had mental and physical health complaints and sought care at primary health care centers participated in this two-armed randomized controlled trial. The main outcomes were the number of registered sick leave days and episodes, and time to first sick leave during the 12-months follow-up. The intervention included early identification of work-related stress by the WSQ, GP awareness supported by a brief training session, patients' self-reflection by WSQ completion, GP feedback at consultation, and initiation of preventive measures. RESULTS: The mean days registered for the WSQ intervention group and the control group were 39 and 45 gross days respectively, and 31 and 39 net days respectively (ns). No statistical significant difference for the number of sick leave episodes or time to first day of sick leave episode were found between the groups. CONCLUSIONS: The WSQ brief intervention combined with feedback and suggestions of measures at patient-GP-consultation was not proven effective in preventing sick leave in the following 12 months compared to treatment as usual. More research is needed on methods to early identify, advise and treat people with work-related stress in primary health care, and on how and when GPs and other professionals in primary health care can be trained to understand this risk of sick leave due to work-related stress, on how to prevent it, and on how to advise and treat employees at risk. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT02480855 . Registered 20 May 2015.

High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study.

AIM: Fashioning a defunctioning stoma is common when performing an anterior resection for rectal cancer in order to avoid and mitigate the consequences of an anastomotic leakage. We investigated the permanent stoma prevalence, factors influencing stoma outcome and complication rates following stoma reversal surgery. METHOD: Patients who had undergone an anterior resection for rectal cancer between 2007 and 2013 in the northern healthcare region were identified using the Swedish Colorectal Cancer Registry and were followed until the end of 2014 regarding stoma outcome. Data were retrieved by a review of medical records. Multiple logistic regression was used to evaluate predefined risk factors for stoma permanence. Risk factors for non-reversal of a defunctioning stoma were also analysed, using Cox proportional-hazards regression. RESULTS: A total of 316 patients who underwent anterior resection were included, of whom 274 (87%) were defunctioned primarily. At the end of the follow-up period 24% had a permanent stoma, and 9% of patients who underwent reversal of a stoma experienced major complications requiring a return to theatre, need for intensive care or mortality. Anastomotic leakage and tumour Stage IV were significant risk factors for stoma permanence. In this series, partial mesorectal excision correlated with a stoma-free outcome. Non-reversal was considerably more prevalent among patients with leakage and Stage IV; Stage III patients at first had a decreased reversal rate, which increased after the initial year of surgery. CONCLUSION: Stoma permanence is common after anterior resection, while anastomotic leakage and advanced tumour stage decrease the chances of a stoma-free outcome. Stoma reversal surgery entails a significant risk of major complications.

Harmful alcohol habits were no more common in a sample of newly sick-listed Swedish women and men compared with a random population sample.

AIMS: To estimate harmful alcohol habits in a sample of incident sick-listed individuals compared with a random sample from the general population taking social background, health and work-related factors into account. METHODS: Data for this cross-sectional questionnaire study were collected in 2008 in the Västra Götaland region, Sweden. The study population (19-64 year olds) consisted of 2888 consecutive incident sick-leave sample (ISS) and 3567 individuals from a random population sample (RPS). The mailed questionnaire included Alcohol Use Disorder Identification Test and validated instruments on health and work-related factors. Socio-demographic data came from register data. Analyses were made with χ(2) tests and logistic regression analyses. RESULTS: No differences in prevalence of harmful alcohol habits were found between men in the ISS (22%) and the RPS (21%). Compared with women in the ISS, a higher proportion of women in the RPS were likely to report harmful alcohol habits [14 versus 9% (P < 0.001)]. This difference was confirmed in the logistic regression analyses where women in the RPS had higher odds of having harmful alcohol habits compared with women in the ISS [odds ratio (OR) = 1.54 (95% confidence interval (CI): 1.23-1.89)]. Even after controlling for significant confounders (age, low income, high self-reported health and high level of perceived symptoms), we found that the differences in harmful alcohol habits remained [OR = 1.44 (95% CI: 1.16-1.81)]. CONCLUSIONS: Harmful alcohol habits were no commoner in men and women who belonged to the sample of incident sick-leave cases. Future studies are needed to analyse the predictive value of harmful alcohol habits on sickness absence length and the time until return to work after sickness absence.

Identification and toxicological evaluation of cyclic sulfonium ion degradation products of sulphur mustard.

In the aftermath of WWII large amount seized German chemical munitions were dumped in the Baltic Sea by Allied forces. In this work, we have compared the chemical content of the solidified blocks of dumped WWII mustard gas collected from the Baltic Sea with solid precipitate from stored mustard gas, known as heel. We have identified the same cyclic sulfonium ions in both samples. In assessing the environmental and toxicological impact of dumped sulphur mustard munitions on the world's oceans the potential risk posed by cyclic sulphur mustard salts have so far not been incorporated. The toxicity of 1-(2-chloroethyl)-1,4-dithiane and its hydrolysis product 1-(2-hydroxyethyl)- 1,4-dithiane was evaluated using three different cell lines. Their effect on released pro-inflammatory cytokines was also measured. The toxicity tests showed low toxicity and low pro-inflammatory response and we therefore conclude that the environmental threat posed by these compounds is low.

Pelvicaliceal biomodeling as an aid to achieving optimal access in percutaneous nephrolithotripsy.

PURPOSE: To investigate prospectively the benefits of three-dimensional stereolithographic biomodeling produced from CT data as an aid to achieving optimal access for percutaneous nephrolithotripsy (PCNL). PATIENTS AND METHODS: Eight patients with complex urinary calculi were selected. Multislice CT scans of the kidney in native and excretory phases were acquired with the patient in the prone position to simulate the position during surgery. Contiguous reconstructed slices were produced from the data volume. The data of interest were processed to transform them into a format acceptable for production of a biomodel. Exact plastic replicas of the pelvicaliceal system and the calculi were created and used for morphologic assessment, preoperative planning, patient education, and surgical navigation. RESULTS: The survey results were based on subjective opinions rather than objective data. The biomodels enhanced the ability to visualize a patient's unique anatomy before surgery. This aided the planning and rehearsal of endourologic procedures. CONCLUSION: Although this study is only a preliminary investigation, we postulate that biomodeling has the advantage of allowing imaging data to be displayed in a physical form. In difficult cases, this technique may improve treatment, operative planning, and communication with colleagues and patients. The limitations of the technology include the manufacturing time and cost, but more accurate puncture-site selection may reduce costs by saving operating time.

Confidence in public institutions: A focus group study on views on the Swedish Social Insurance Agency.

BACKGROUND: From a public health perspective among the working population, it is very important that confidence in the welfare system is high, ensuring the citizens economic security and protecting them from economic stress when falling ill. OBJECTIVE: The aim of this study was to explore how people with experience of health insurance perceive their confidence in the Swedish Social Insurance Agency (SSIA). METHODS: Eight focus groups (n = 41) were conducted and each group met on one occasion. RESULTS: The participants described a systemic change in the work of the SSIA where the rule-of-law was disregarded, with arbitrary assessment, and no transparency. The reception by the SSIA shaped the image of the SSIA. The participants described vulnerability in relation to the SSIA. They felt mistrusted, which left a feeling of impotence that worsened their health. Experiencing vulnerability left a strong impression and affected the participants' confidence negatively. CONCLUSIONS: The following has to be acknowledged to prevent clients from experiencing impaired health, promote return-to-work possibilities, and to push public confidence in the institution in a more positive direction: Politicians and public administrators need to clarify the regulations. The decision-making process needs to be transparent and just. The entire procedure, including continuity as well as a personal, nice reception, has to be ensured.

Strong support for relocation to other work tasks: A cross-sectional study of attitudes to sickness insurance regulations in Sweden.

BACKGROUND: Profound changes are taking place in the Swedish welfare state. The general population's attitudes are important insofar changes will be perceived as fair and effective to become implemented. OBJECTIVE: The aim was to study attitudes to the strictness of the sick-leave rules, relocation to other work tasks after 3 months of sick leave and applications for new jobs after 6 months of sick leave. METHODS: Eligible for this questionnaire study were 1,140 individuals aged 19 to 64 years. Their attitudes were analyzed in relation to age, gender, political ideology and health status. Health status was measured as sick-leave experiences, self-reported health and level of symptoms. RESULTS: Showed that 42% considered the sick-leave rules to be too strict, 60% found relocation to other work tasks to be good while 35% found that applications for new work were good. In logistic regression analyses, high sick-leave experience was associated with increased odds of finding the sick-leave rules too strict and disagreement with relocation to other work tasks or application for new jobs. CONCLUSIONS: In conclusion, strong support was found for relocation to other work tasks with the present employer. Earlier research on returning to work has found workplace interventions to be efficient. From a policy perspective it seems relevant to promote such interventions given the strong public opinion in their favor.

Subcutaneous administration of heparin. A randomised comparison with intravenous administration of heparin to patients with deep-vein thrombosis.

One-hundred and forty-one patients with clinical signs of acute deep venous thrombosis (DVT) in the legs were randomly allocated to receive heparin either as two daily subcutaneous injections (s.c.) or as continuous intravenous infusion (i.v.). The thrombi extended into the popliteal or femoral veins in 83% of the patients. Verification of diagnosis and evaluation of therapy was performed by phlebography, plethysmography and thermography. The results showed that heparin administered s.c. twice daily was as efficient as continuous i.v. infusion in preventing extension of the thrombus. In two patients the s.c. administration was stopped due to local haematomas at the injection sites. Retroperitoneal or intramuscular bleedings occurred in four patients, two in each group. Two major, non-fatal pulmonary emboli occurred, one in each group.

Antithrombin III in patients with acute deep vein thrombosis during heparin treatment (subcutaneous and intravenous) and during and after treatment with oral coumarins.

The antithrombin III (AT-III) concentration was studied in 98 patients with symptomatic acute deep-vein thrombosis. All patients were initially treated with heparin randomly by subcutaneous injections or by continuous infusions. Then the patients were treated with coumarins during one or six months. The AT-III concentration was estimated daily during heparin treatment and repeatedly during the first year. The mean AT-III concentration decreased progressively 25% during 5 days of heparin treatment regardless of whether heparin was given intravenously or subcutaneously. The mean AT-III concentration during coumarin treatment was higher than after coumarin treatment. Eleven patients developed recurrent thromboembolic episodes during the follow-up period. The mean AT-III concentration in these patients was not lower than in the patients without recurrences.

Non-specific steroidal esterase activity and distribution in human and other mammalian tissues.

An NADPH dependent arylamine carcinogen and fatty acid steroid ester metabolizing esterase activity belonging to the B- or carboxylesterase class of non-specific esterase (EC 3.1.1.1) was measured by two different methods: (i) a spectrophotometric assay using alpha naphthyl acetate (ANA) as substrate and (ii) a radiometric method using the conversion of beclomethasone-17,21-dipropionate to beclomethasone-17-monopropionate as the endpoint. The two methods were strongly correlated when assayed in human mononuclear leukocytes (r = 0.89, P < 0.0001) and human mammary tissue (r = 0.91, P < 0.0001). Hence it was concluded that the two substrates are metabolized at least in part by the same enzyme. This esterase activity was abundant in human monocytes, present in T-lymphocytes and equally divided between CD4 and CD8 T-lymphocyte subsets. The same activity was expressed in human liver, colon, stomach, breast and brain tissues. The distribution of this esterase in human tissues showed high activity in liver, intermediate activity in colon, stomach and breast and low activity in brain tissue. The interorgan distribution observed in human tissues was closely mimicked when the esterase activity was assessed in liver, colon and brain tissues from three mouse strains and three rat strains. The non-specific steroidal esterase activity determined by ANA metabolism in human mammary tissue was shown to be reproducible when assayed as triplicate samples from each of 16 different women (intraclass correlation coefficient 67.3%, P < 0.03). The interindividual variation in mammary tissue was high (18.4-fold) and there was a positive correlation between the esterase activity and age (r = 0.58, P < 0.01), as well as a tendency toward bimodal distribution. To our knowledge, these data represent the first systematic study of interorgan and interspecies comparisons of a non-specific steroidal esterase activity.

Gamma-radiation induced ADP-ribosyl transferase activity and mammalian longevity.

The levels of ADP-ribosyl transferase (ADPRT) activity following a standardized dose of 100 Gy gamma-radiation have been determined in leukocytes from 12 different mammalian species. Here, we report that the 100 Gy-induced levels of ADPRT correlated in a highly significant manner to the line spans of the mammals.

Urinary calculi and urinary tract infection. A clinical and microbiological study.

The problem of urinary calculi in association with urinary tract infection (UTI) was investigated. Fifty-two (7%) of 796 patients attending our outpatient stone clinic had UTI which was considered of pathogenic importance for their stone formation. Proteus was the most common microorganism. Metabolic disorders were found in one third and anatomical and functional abnormalities in two thirds of the patients. The infected patients had lower urinary calcium excretion and higher serum creatinine than idiopathic stone formers and had a higher frequency of stone operations. The prevalence of staghorn calculi as a cause of urimia was low (1.5% of 481 dialysis patients). Eight such patients were studied and six of them had metabolic and anatomical disorders. The time taken for the uremia to develop was 7.4 +/- 2.0 (SD) years. In 535 patients treated surgically for renal calculi, about one third had positive urine culture at the time of operation and E. coli was the most common bacterial strain (35%). Proteus was found in 28% and these patients had the highest frequency of UTI episodes, most of which occurred before hospitalization. Patients infected with E. coli had a higher frequency of phosphate-containing calculi than non-infected patients, in whom the highest frequency of calcium oxalate calculi was found. A new broad-spectrum cephalosporin, ceftazidime, was used as perioperative prophylaxis in 15 patients operated upon for renal calculi and UTI. Ten had bacterial growth in the renal pelvis and all strains were eradicated. Bacterial growth was found in two out of six cultured stones from patients with bacterial growth in the pelvis. The pharmacokinetics of the drug was studied and the decreases in the ceftazidime levels in serum and renal tissue seemed to be parallel. Bacterial binding of urinary isolates to hydroxyapatite (HAP) particles was studied. Two E. coli strains (A5089 and E7704) and one Proteus mirabilis strain (A5076), all obtained from stone patients, were compared with two E. coli strains (2683 and M7810) with well defined cell-surface properties. Hemagglutination tests were performed and the cell-surface hydrophobicity was determined by a salt-aggregating test. When the strains were cultured at 37 degrees C to promote fimbriae formation they hemagglutinated erythrocytes and displayed hydrophobic cell-surface properties, and showed higher capacity for binding to HAP than when cultured at 18 degrees C to suppress fimbriae formation, when they showed almost complete absence of hemagglutination and low cell-surface hydrophobicity. Bacterial cell-surface properties seem to influence the binding of uropathogens to HAP particles.

Repeat abortion and contraceptive use. Report from an Interview Study in Stockholm.

Semistructured interviews were made among a random sample of applicants for abortion in Stockholm, when legal abortion on demand had been available in Sweden for 10 years. One hundred and twenty women were interviewed, 75 of them having their first abortion and 45 having a repeat abortion. The use of contraceptives was similar among first-time aborters and repeat aborters, but 70% in both groups had temporarily been without contraceptives at the time of conception. The interviews show that the family circumstances were more difficult for the women who had already experienced an abortion than for those who had not. The study indicates that the male partner and family circumstances were important for the decision to abort. Thus, family planning programs should reach also men. The main way to prevent repeat abortions seen in this study is to prevent abortions in general, by making contraceptives accepted by and easily obtainable for all groups in society, thus diminishing those times when sexually active men and women temporarily do not use contraceptives.