New technologies for the further advancement of ERCP

Background: The capabilities of conventional endoscopic retrograde cholangiopancreatography (ERCP) are hampered by several limitations. Newly developed adjunct technologies such as single operator peroral cholangiopancreatoscopy (SOPCP) and new imaging techniques could overcome some of these limitations, but their role in common clinical practice have not yet been established. Aims: To assess the diagnostic and therapeutic yield of SOPCP in the diagnosis and treatment of biliopancreatic disease. To investigate patient-related risk factors for post procedural pancreatitis (PPP) following single-operator peroral pancreatoscopy. To determine the feasibility and potential clinical yield of bimodal ERCP. To assess radiation dose in cone beam ERCP. Methods: In paper I, All SOPCP procedures performed at Karolinska University Hospital between March 2007 and December 2014 were included in this study and each procedure’s diagnostic yield and therapeutic value was evaluated using a predefined 4 grade assessment scale. In paper II, all consecutive patients that underwent single operator pancreatoscopy (SOPP) at Karolinska University Hospital between April 2015 and Nov 2020 were included. The Swedish Registry for Gallstone Surgery and ERCP (GallRiks) was used to retrieve patient data and preprocedural imaging was reviewed in consensus by two senior radiologists. Pancreatic gland morphology and main pancreatic duct (MPD) diameter were evaluated as risk factors for PPP using uni- and multivariate logistic regression. In paper III, patients undergoing conventional ERCP had a previous T2-weighted magnetic resonance cholangiopancreatography (MRCP) sequence aligned and fused with the two-dimensional image generated from the fluoroscopy c-arm unit in real time and data regarding feasibility and clinical yield was retrieved. In paper IV, radiation exposure data from conventional ERCP procedures and cone beam ERCP (CB-ERCP) procedures performed between February 2016 and June 2017 at a tertiary high volume endoscopy unit was analyzed. CBERCP cases used either the standard exposure protocol ‘DR’ or the modified low dose exposure protocol‘DR Care’. Results: During the study period in paper I, 365 SOPCP procedures were performed. SOPCP was found to be of pivotal importance (grade 4) in 19% of cases, and of great clinical significance (grade 3) in 44% of cases. SOPCP did not affect clinical decision-making or alter clinical course (grade 1 and 2) in 37% of cases. In paper II, Postprocedural pancreatitis occurred in 15 (23%) of patients during the 30-day follow up. Univariate analysis of risk factors for PPP showed a significant association with chronic pancreatitis (OR 0.28 95% CI 0.08-0.92), insertion of a pancreatic stent (OR 0.28; 95% CI 0.08-0.95) and the ratio between MPD and pancreatic gland thickness in the body of pancreas (OR 1.14; 95% CI 1.03-1.28). In a multivariate regression model, the association between an increased body MPD/gland ratio in pancreatic body and PPP remained significant (OR 1.26; 95% CI 1.06-1.57) after adjustments for confounders including chronic pancreatitis. In paper III, 13 patients underwent bimodal ERCP for bile duct stricture, complex cholelithiasis or ductal leakage. Bimodal ERCP was feasible in all 13 cases, and image quality was assessed as “good” in 11 patients (85%). Bimodal ERCP aided in visualizing the lesion of interest (77 %), assisted in understanding the 3D anatomy of the biliopancreatic ductal system (62 %), and aided in finding a favorable position for the c-arm (38%) for subsequent therapeutic intervention. In paper IV, 728 conventional ERCP procedures were performed and 42 cases utilized CBERCP. The median total dose area product (DAP) was 48.9 Gycm2 for CB-ERCP procedures using the DR exposure protocol and 19.7 Gycm2 for CB-ERCP procedures using the DR care exposure protocol. The median total DAP was 6.5 Gycm2 when conventional ERCP was used. Conventional ERCP generated a significantly reduced total DAP compared to both CBERCP using the ‘DR’ exposure protocol (U=908, p < 0.001) and CB-ERCP using the ‘DR care’exposure protocol (U=3823, p < 0.001). Conclusions: SOPCP has a high impact on management of patients with complex cholelithiasis, indeterminate biliary strictures and pancreatic cystic lesions in a tertiary care setting, but the procedure contributes to a considerable risk of adverse events. There is an association between the pancreatic gland thickness and MPD diameter in the pancreatic body with the risk of developing PPP after SOPP. Bimodal ERCP is feasible and can aid in understanding biliary anatomy and visualizing the lesion of interest. Its future area of use may lie in the assessment and treatment of complex intrahepatic biliary disease. Cone beam asssisted ERCP procedures are associated with higher total radiation doses than conventional ERCP procedures, but it is possible to decrease radiation doses to acceptable levels with adjustments of exposure protocols. These adjustments do not compromise the capabilities of cone beam ERCP to provide enhanced intraprocedural guidance

Burnout, working conditions and gender— results from the northern SwedenMONICAStudy,”BMCPublic Health,

Abstract Background: Sick-leave because of mental and behavioural disorders has increased considerably in Sweden since the late nineties, and especially in women. The aim of this study was to assess the level of burnout in the general working population in northern Sweden and analyse it&apos;s relation to working conditions and gender. Methods: In this cross-sectional study the survey from the MONICA-study (Monitoring of Trends and Determinants in Cardiovascular Disease) in northern Sweden 2004 was used. A burnout instrument, the Shirom Melamed Burnout Questionnaire (SMBQ), was incorporated in the original survey which was sent to a random sample of 2500 individuals with a response rate of 76%. After including only actively working people, aged 25-64 years, our study population consisted of 1000 participants (497 women and 503 men). ANOVA and multiple linear regression models were used. Results: The prevalence of a high level of burnout (SMBQ &gt;4.0) was 13%. Women had a higher level of burnout than men with the most pronounced difference in the age group 35-44 years. In both sexes the level of burnout decreased with age. Demand and control at work, and job insecurity were related to burnout. In women the level of education, socioeconomic position, work object, and working varying hours were of importance. Interaction effects were found between sex and work object, and sex and working hours. In a multiple regression analysis almost half of the gender difference could be explained by work related and life situational factors. Conclusions: Working life conditions contributed to the level of burnout in this actively working sample from the general population in northern Sweden. Especially in women, socioeconomic position was associated with burnout. The high level of burnout in women compared to men was partly explained by more unfavourable working conditions and life situational factors. Efforts to level out gender differences in burnout should probably focus on improving both working and socioeconomic conditions for women

The value of “diaphragmatic relaxing incision” for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial

BackgroundSurgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair.Patients and methodsAll individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II–IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh.ResultsThe primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation.Trial RegistrationClinicalTrials.gov, identification number NCT04179578

Chromosome 1p13 genetic variants antagonize the risk of myocardial infarction associated with high ApoB serum levels

PMCID: PMC3480949This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

The effect of leisure-time physical activity on the risk of acute myocardial infarction depending on Body Mass Index: a population-based case-control study

BACKGROUND: High body mass index (BMI) and lack of physical activity have been recognized as important risk factors for coronary heart disease. The aim of the present study was to evaluate whether leisure-time physical activity compensates for the increased risk of acute myocardial infarction associated with overweight and obesity. METHODS: Data from the SHEEP (Stockholm Heart Epidemiology Program) study were used. The SHEEP study is a large Swedish population-based case-control study, comprising 1204 male and 550 female cases, and 1538 male and 777 female controls, conducted in Stockholm County, Sweden, during the period 1992–1994. Odds ratios (OR), together with 95 % confidence intervals (95% CI), were calculated using unconditional logistic regression, as estimates of the relative risks. RESULTS: Regular leisure-time physical activity was associated with a decreased risk of myocardial infarction among lean, normal-weight and overweight subjects, but not among obese subjects. Obese (BMI ≥ 30) and physically active persons had an almost twofold risk of myocardial infarction, compared with normal-weight and sedentary persons (OR 1.85, 95% CI 1.07–3.18). The results were similar for men and women. CONCLUSION: While regular leisure-time physical activity seems to provide protection against myocardial infarction among lean, normal-weight and overweight subjects, this does not appear to be the case in obese subjects

Preoperative biliary drainage by plastic or self-expandable metal stents in patients with periampullary tumors: results of a randomized clinical study

Background and study aims Preoperative biliary drainage in patients with periampullary tumors and jaundice has been popularized to improve the quality of life and minimize the risks associated with subsequent radical surgery. The aim of this study was to investigate the possible superiority of self-expandable metal stents (SEMS) over plastic stents, by comparing the amount of bacteria in intraoperatively collected bile and using this variable as a proxy for the efficacy of the respective biliary drainage modalities. Patients and methods In this randomized clinical trial, 92 patients with obstructive jaundice were enrolled; 45 were allocated to the plastic stent group and 47 to the SEMS group. The primary outcome was the extent and magnitude of biliary bacterial growth at the time of surgical exploration. Secondary outcomes were: macroscopic grading of inflammation of the stented bile ducts, occurrence of adverse events after stenting, stent dysfunction, recognized surgical complexities, and incidence of postoperative complications. Results The patients were well matched regarding clinical and disease-specific characteristics. At surgery, there were no group differences in the bacterial amount and composition of the bile cultures or the perceived difficulty of surgical dissection. During the preoperative biliary drainage period, more instances of stent dysfunction requiring stent replacement were recorded in the plastic stent group (19 % vs. 0 %; P = 0.03). Postoperative complications in patients who underwent curative surgery were more common in patients with plastic stents (72 % vs. 52 %), among which clinically significant leakage from the pancreatic anastomoses seemed to predominate (12 % vs. 3.7 %); however, none of these differences in postoperative adverse events reached statistical significance. Conclusion This randomized clinical study was unable to demonstrate any superiority of SEMS in the efficacy of preoperative bile drainage, as assessed by the amount of bacteria in the intraoperatively collected bile. However, some data in favor of SEMS were observed among the clinical secondary outcomes variables (preoperative stent exchange rates) without increases in local inflammatory reactions

Usability and User Experience Evaluation of Nordnet : Focusing on novice users on the mobile application

This thesis evaluates the usability and user experience (UX) of the Nordnet mobile application, with a focus on the challenges or barriers faced by novice users. Nordnet is one of the leading digital platforms and banks for savings, investments, loans, and pensions, in the Nordic. As financial technologies continue to advance, good usability and user experience of mobile financial applications become important, especially for users with no or limited experience using financial applications such as Nordnet. Through a combination of usability testing with interviews and the use of the System Usability Scale (SUS), this study aims to uncover the primary barriers novice users encounter, and from those recommend design improvements to enhance the usability and overall user experience.The methodology used consists of a task-based evaluation with a total of five first-time users performing a predefined set of tasks to assess different usability aspects such as learnability, efficiency, cognitive load, and the overall user experience. The findings indicate significant challenges in navigation, feature discoverability, and complex interface, affecting the overall usability and user experience negatively. The overall usability rating calculated through the SUS questionnaire was rated as below average, with only one test participant rating it as above average. Despite these challenges, certain features were appreciated for their functionality and ease of use. Suggested improvements include simplifying the interface to reduce cognitive load and enhancing the clarity of icons with the help of text labels.This research contributes to the field by highlighting the critical areas where mobile financial applications such as Nordnet can improve to better serve its novice users

Usability and User Experience Evaluation of Nordnet : Focusing on novice users on the mobile application

This thesis evaluates the usability and user experience (UX) of the Nordnet mobile application, with a focus on the challenges or barriers faced by novice users. Nordnet is one of the leading digital platforms and banks for savings, investments, loans, and pensions, in the Nordic. As financial technologies continue to advance, good usability and user experience of mobile financial applications become important, especially for users with no or limited experience using financial applications such as Nordnet. Through a combination of usability testing with interviews and the use of the System Usability Scale (SUS), this study aims to uncover the primary barriers novice users encounter, and from those recommend design improvements to enhance the usability and overall user experience.The methodology used consists of a task-based evaluation with a total of five first-time users performing a predefined set of tasks to assess different usability aspects such as learnability, efficiency, cognitive load, and the overall user experience. The findings indicate significant challenges in navigation, feature discoverability, and complex interface, affecting the overall usability and user experience negatively. The overall usability rating calculated through the SUS questionnaire was rated as below average, with only one test participant rating it as above average. Despite these challenges, certain features were appreciated for their functionality and ease of use. Suggested improvements include simplifying the interface to reduce cognitive load and enhancing the clarity of icons with the help of text labels.This research contributes to the field by highlighting the critical areas where mobile financial applications such as Nordnet can improve to better serve its novice users

Zur Frage der Arterienelastizität: Einige Bemerkungen anläßlichThomas letzter Arbeit im Bande 236 dieses Archivs

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