<p>Surgical treatment of hip fractures is frequently associated with secondary fracture displacement, in part due to weak osteoporotic bone. So far, improvements have focused on new metal implants although an alternative could be to augment the bone that surrounds the implant. </p><p>The aim of this thesis was to evaluate the use of calcium phosphate cement (Norian SRS) for augmentation of internally fixed hip fractures. Norian SRS is an injectable, biocompatible cement that hardens in situ without exothermic reaction. Over time it is remodeled and replaced by host bone. </p><p>In a biomechanical study the holding characteristics for different implants was measured when inserted with or without augmentation. The study showed that conventional bone cement (PMMA) improved maximum torque and pull-out for almost all modalities while Norian SRS increased the holding power mainly in low-density bone. </p><p>In a prospective and randomized study, patients with displaced femoral neck fractures were operated with internal fixation using screws alone or combined with Norian SRS for augmentation. The result showed improved stability when measured with radiostereometry (RSA) for the augmented fractures during the early rehabilitation period. The clinical evaluation of 118 patients included pain, walking aid, activities of daily living (ADLs), abductor muscle strength, mobility and range of motion. During the early course the augmented patients did better in some variables although over the total two-year study period there was no major difference between groups. Scintigraphic evaluation indicated that augmentation might compromise the circulation to the femoral head.</p><p>The final part included unstable trochanteric fractures fixed with a sliding screw device alone or the same device combined with Norian SRS for augmentation. Using RSA it was shown that augmentation significantly improved the fracture stability until healing. In a randomized multicenter study including 112 patients, augmentation with Norian SRS reduced pain during early rehabilitation and improved quality of life until healing. </p><p>In conclusion, augmentation with Norian SRS improved the early fracture stability in displaced femoral neck fractures while there was no major difference in clinical outcome. In unstable trochanteric fractures augmentation provided improved fracture stability and improved clinical course until healing. </p>

Surgical treatment of hip fractures is frequently associated with secondary fracture displacement, in part due to weak osteoporotic bone. So far, improvements have focused on new metal implants although an alternative could be to augment the bone that surrounds the implant. The aim of this thesis was to evaluate the use of calcium phosphate cement (Norian SRS) for augmentation of internally fixed hip fractures. Norian SRS is an injectable, biocompatible cement that hardens in situ without exothermic reaction. Over time it is remodeled and replaced by host bone. In a biomechanical study the holding characteristics for different implants was measured when inserted with or without augmentation. The study showed that conventional bone cement (PMMA) improved maximum torque and pull-out for almost all modalities while Norian SRS increased the holding power mainly in low-density bone. In a prospective and randomized study, patients with displaced femoral neck fractures were operated with internal fixation using screws alone or combined with Norian SRS for augmentation. The result showed improved stability when measured with radiostereometry (RSA) for the augmented fractures during the early rehabilitation period. The clinical evaluation of 118 patients included pain, walking aid, activities of daily living (ADLs), abductor muscle strength, mobility and range of motion. During the early course the augmented patients did better in some variables although over the total two-year study period there was no major difference between groups. Scintigraphic evaluation indicated that augmentation might compromise the circulation to the femoral head. The final part included unstable trochanteric fractures fixed with a sliding screw device alone or the same device combined with Norian SRS for augmentation. Using RSA it was shown that augmentation significantly improved the fracture stability until healing. In a randomized multicenter study including 112 patients, augmentation with Norian SRS reduced pain during early rehabilitation and improved quality of life until healing. In conclusion, augmentation with Norian SRS improved the early fracture stability in displaced femoral neck fractures while there was no major difference in clinical outcome. In unstable trochanteric fractures augmentation provided improved fracture stability and improved clinical course until healing.

Roux-en-Y gastric bypass (RYGBP) achieves superior short- and long-term weight loss compared to other weight loss modalities. Different operative techniques have been developed to technically facilitate the surgical procedure, with consequences in the form of an array of postoperative complications and gastrointestinal symptoms. Furthermore, as our follow-up on operated patients extends beyond the first postoperative years, it becomes apparent that a significant number of patients experience unsatisfactory weight result. Current research is just starting to chart factors associated with postoperative long-term weight regain with the ultimate goal of preventing it. In Paper I it is found that the linear stapled technique for the gastrojejunostomy in laparoscopic RYGBP is associated with shorter operative time, in-hospital stay and a lower incidence of surgical site infections and anastomotic strictures compared to the circular stapled technique. Paper II demonstrates that, despite no differences in weight result, the 21-mm circular stapled technique for the gastrojejunostomy is associated with a higher incidence of vomiting and endoscopic anastomotic dilatations compared to the 25-mm circular stapled technique and the linear stapled technique in the long-term after RYGBP. Paper III shows that despite differences in body composition, long-term weight responders and non-responders after RYGBP did not differ in resting, glucose-induced or activity-related energy expenditure. Lastly Paper IV shows long-term weight result is associated with fasting levels of leptin and ghrelin, and that the response of these hormones to a glucose load might contribute to perpetuate obesity.

Complications after surgical repair of intrasynovial flexor tendon injuries in the hand occur despite advanced suture techniques and structured postoperative rehabilitation regimens. Early controlled tendon mobilization prevents adhesion formations and improves tendon healing as well as digit range of motion. To allow early postoperative rehabilitation, the strength of the repair must withstand forces created during the rehabilitation maneuvers. Improvements in suture biomechanics have increased repair strength, but up to 18 percent of repaired tendons still rupture. The overarching aim of this thesis was to investigate how to best treat intrasynovial flexor tendon injuries with limited risk of repair rupture, decreased adhesion formations, and to estimate the effect of individual patient and injury characteristics on functional outcome. In two observational studies, we identified risk factors for rupture of repaired intrasynovial flexor digitorum profundus (FDP) tendons, and studied effects of these risk factors on the long-term outcome. Age was associated with increased risk of repair rupture and impaired digital mobility the first year after surgical repair. Concomitant flexor digitorum superficialis (FDS) transection was associated with increased risk of repair rupture without affecting digital mobility. Concomitant nerve transection lowered the rupture risk without affecting digital mobility. To better understand forces generated in the flexor tendons during rehabilitation maneuvers, we measured in vivo forces in the index finger FDP and FDS tendons during rehabilitation exercises. Highest forces were measured during isolated FDP and FDS flexion for the FDP and FDS respectively. For the FDS tendon, higher forces were observed with the wrist at 30° flexion compared to neutral position, and for the FDP tendon, forces were higher during active finger flexion compared to place and hold. PXL01 is a lactoferrin peptide with anti-adhesive effects previously demonstrated in animal studies and a clinical trial to improve digital mobility when administrated around repaired tendons. We studied the mechanism of action of its corresponding rabbit peptide, rabPXL01 in sodium hyaluronate (HA) in a rabbit model of flexor tendon transection and repair and used RT-qPCR to assess mRNA levels for different genes. Increased levels of PRG4 (encoding lubricin) were observed in rabPXL01 in HA treated tendons. The expression of Interleukin 1β, 6, and 8 was repressed in tendon sheaths. RabPXL01 in HA might stimulate the release of lubricin and diminish inflammation, which correspondingly reduces tendon-gliding resistance and adhesion formations during postoperative rehabilitation exercises. The results of this thesis suggest individually adapted treatment plans, depending on repair strength, patient and injury characteristics, as a possible way to improve outcome after flexor tendon repair.

During the surgical preparation of bone, prior to insertion of an implant, bone will be traumatized which leads to local resorption. Consequently, early implant fixation might be reduced. Impaired early fixation, as evidenced by radiostereometry, has been associated with increased risk of late loosening. Bisphosphonates are known to inhibit bone resorption by osteoclasts and have shown to increase implant fixation when administered systemically or locally directly at the bone prior to implant insertion. A method to bind bisphosphonates directly to the implant was developed. Stainless steel screws were coated with crosslinked fibrinogen, serving as an anchor for bisphosphonate attachment. The screws were inserted in the tibial metaphysis in rats and implant fixation was analyzed with pullout measurements. Bisphosphonate coated screws turned out to have 28 % higher pullout force at 2 weeks compared to control screws with the fibrinogen coating only. The next experiment was designed to measure at what stage in the healing process the strongest bisphosphonate effect was gained. Bisphosphonate coated screws were expected to reduce the resorption of the traumatized bone. However, no decreased fixation was found in the control group. Instead, the fixation increased with time, and so did the effect of the bisphosphonates. At 8 weeks, the pullout force was twice as high for screws with bisphosphonate compared to control screws. By histology at 8 weeks, a bone envelope was found around bisphosphonate coated screws but absent around control screws. Thus, the anti catabolic action of the bisphosphonate resulted in an increased amount of bone surrounding the bisphosphonate screws. Titanium is generally considered to be better fixated in bone compared to stainless steel. The coating technique was found to be applicable on titanium as well, again with improved fixation. A majority of fractures occur in osteoporotic bone. Despite the relatively low amount of bisphosphonates at the screws, the bisphosphonate coating improved implant fixation at 2 weeks also in rats made osteoporotic by ovariectomy. In conclusion, bisphosphonates bound to titanium or stainless steel screws coated with fibrinogen increased fixation in bone, in rats. These results suggest that the bisphosphonate and fibrinogen coating might improve the fixation of screw shaped implants and possibly also arthroplasties, in humans.

Adrenal tumours, discovered en passant in patients undergoing radiological examinations for non-adrenal disease, so-called adrenal incidentalomas, have increased dramatically in the recent era of more sophisticated diagnostic modalities such as high resolution multidetector computed tomography (CT) and magnetic resonance imaging (MRI). Furthermore, primary aldosteronism (PA) has been documented in several screening studies as being far more common than previously believed among hypertensive patients. In this thesis, a long-term follow-up cohort of patients who had undergone surgery for PA revealed that there was an excellent effect on blood-pressure, reduction of anti-hypertensive medication and hypokalaemia after surgery, even though the majority of these patients still required some anti-hypertensive medication. This was also true, in the higher than expected number of dominant nodular hyperplasia (nIHA) found in the study, but was slightly less pronounced than in aldosterone producing adenomas (APA).  Surgery was thus effective in lateralized PA. Metomidate positron emission tomography (MTO-PET) was explored in relation to histopathology in post-operative patients and found to be highly specific and sensitive in categorizing adrenocortical disease. Also, a higher standardized uptake value (SUV) ratio between tumours and normal adrenal cortex was found in hormonally hypersecreting adenomas as well as in adrenocortical cancer (ACC). The resolution limited the diagnosis of small tumours (&lt;1-1.5 cm). MTO-PET was compared to standard radiological modalities (CT and MRI) in the diagnostic work-up of adrenal incidentalomas. All three modalities categorized and characterized the lesions well, with MTO-PET showing the highest sensitivity and specificity.  However this method is currently recommended to be used as complementary to the others in unclear cases, due to high costs and less availability. The resolution of MTO-PET was improved with respect to less noise and better delineation of small tumours when applying masked volume-wise principal component analysis (MVW-PCA), which will possibly enable future detection of small tumours in PA patients. Dexamethasone suppression treatment prior to MTO-PET examinations in PA patients decreased SUV in normal adrenal cortex but could not be shown to increase the SUV ratio between adenoma and normal cortex enabling better detection of small tumours, even though all the tumours were readily categorized in the study. Heterogenic SUV reactions to dexamethasone treatment indicate a need for further studies and refinement of the suppression method. In conclusion, long-term results of surgery for lateralized PA are good. MTO-PET is a highly sensitive and specific method for categorizing adrenocortical disease. Modulation of the method, e.g. by using MVW-PCA and refined dexamethasone suppression treatment, may improve the resolution of the method in delineating small tumours in PA, thus making MTO-PET a non-invasive and non-operator dependent future alternative to the currently recommended adrenal venous sampling (AVS) for lateralization diagnosis prior to surgery for PA.

Licentiatavhandling Ronneby : Blekinge tekniska högskola, 2007.

anunger, Karl-Gunnar. Benign and malignant gastric mucosal changes after partial gastrectomy. The development of benign and malignant mucosal changes in the gastric remnant were studied early (1-3 years) postoperatively in 55 patients and late (10-24 years) postoperatively in 336 of 676 patients subjected to partial gastrectomy for ulcer disease. Chronic gastritis with atrophy, intestinal metaplasia and cystic dilatation of the gastric glands was found early postoperatively with the same prevalence in gastric and duodenal ulcer patients. Wiereas the prevalence of atrophy, and of acute and chronic gastritis was the same both early and late postoperatively, the prevalence of intestinal metaplasia, cystic dilatation and lipid islands increased with time. The prevalence of inflammatory changes late postoperatively was not correlated to sex, age or type of anastomotic procedure. A significantly increased risk for stump carcinoma was found in male patients more than 12 years postoperatively. No difference correlated to type of ulcer disease or anastomotic procedure could be demonstrated. In duodenal ulcer patients the time interval between operation and diagnosis of carcinoma was independent of age at operation, while in gastric ulcer patients the interval was shorter with increasing age at operation. Gastric stump carcinomas were found in 12 of the 336 (3.6%) patients examined gastroscopically; four of these were early carcinomas. In four patients with stump carcinoma the correct diagnosis could not be established at the first examination. Gastric polyps and precancerous mucosal changes were the only macro- or microscopical findings in some cases with already existing non-visible carcinoma. The CEA immunohistochemical study of the gastric mucosa showed a positive reaction in 10 of 49 patients; 6 of the 10 had carcinoma, precancerous changes or adenomatous polyp. Three patients with diagnosed or later discovered carcinoma had CEA negative reactions. However, the results indicate that there is a correlation between demonstrated CEA content and increased risk for development of stump carcinoma. To evaluate whether this method can be used to identify patients at special risk for development of gastric carcinoma requires further study. Because of increased risk for stump carcinoma, gastric ulcer patients ought to be examined with gastroscopy from about 10 years after partial gastrectomy, and duodenal ulcer patients from about 15 years, irrespective of the type of anastomotic procedure. Re-examinations ought to be performed every two to four years. In patients with gastric polyps or precancerous mucosal changes re-examinations should be performed earlier, within 6-12 months. / digitalisering@umu.se

Background: Despite the improvements in burn care during the last decades, burns remain catastrophic for the patients and a challenge for the care-givers.  The early outcome of burn care is to assess its quality and to improve it, but the crucial outcome is mortality, which is the main focus of this thesis. In particular, I address questions about mortality that have arisen from working with burned patients and that can have clinical consequences: the impact of pre- existing medical conditions; long-term survival; the causes of unexpected deaths; and the possible differences between sexes in the provision of resources. Patients with burns share the fact that the time of their injury is known, its severity can be quantified from the size of the burn, and the care is relatively standardised. The analysis of outcome among burned patients treated at a single burn centre may therefore be of general value to others who treat burns. Methods: We retrospectively analysed data that had been collected prospectively (the burn    unit database) from patients with burns admitted consecutively to a national burn centre in Sweden during the last 25 years. Results: Age and percentage of total body surface area burned (TBSA %) affected the in- hospital mortality, whereas pre-existing medical conditions did not influence the prediction of outcome (Paper I). After discharge, both age and the presence of full thickness burns reduced the long-term survival, whereas the extent of the burn (TBSA %) did not (Paper II). Most patients with moderate burns who die in hospital despite a good prognosis, die for reasons   other than the burn (Paper III). Previously, it has been shown that sex is not an independent factor for mortality during burn care; in this thesis we show that the sex of the patients did not affect the number of medical interventions given either (Paper IV). Conclusion: The addition of “coexisting condition” to a mortality model based on age and   size of burn does not improve its predictive value; rather, the factor “age” is sufficient to adjust for comorbidity in the assessment of a burn and its outcome (Paper I). If patients with burns survive, the long-term prognosis is good. The effect of age is the one that governs survival, whereas the effect of the extent of the burn ends when the patient is discharged (Paper II). The in-hospital mortality during burn care is low, but some patients die for reasons other than the actual burn (Paper III). In a centre where the mortality is independent of the sex of the patient, the provision of medical interventions is also equal between men and women (Paper IV). / Questa tesi tratta del rischio di morte in seguito ad ustioni ed affronta, con approccio scientifico, alcune domande sollevate frequentemente da pazienti e da addetti ai lavori. In particolare: <ol type="I">a presenza di altre malattie a prescindere dall´ustione (diabete, nefropatie, alcolismo, etc.) peggiora la prognosi del paziente? L´essere sopravvissuto ad un´ustione riduce l´aspettativa di vita dopo la dimissione dall´ospedale? Qual è la causa di morte in quei (rari) pazienti che muoiono con ustioni di modesta entità? Il sesso del paziente influenza le cure prestate durante il ricovero ed, in tal caso, qual è l´effetto sulla prognosi? Spesso avevamo risposto a questi interrogativi di interesse clinico basandoci sull´esperienza o su luoghi comuni accettati acriticamente. Con questa tesi abbiamo cercato con metodo scientifico delle risposte di valore generale, analizzando i dati raccolti durante l´ultimo ventennio sui pazienti ricoverati a causa di traumi termici al Centro Nazionale Grandi Ustioni dell´Università di Linköping. In Svezia, come negli altri paesi a reddito medio-alto, il tasso di mortalità in seguito ad ustioni è diminuito notevolmente negli ultimi anni, tuttavia l´obbiettivo principale tra gli addetti ai lavori rimane quello di diminuire ulteriormente la mortalità. L´identificazione precoce di pazienti ad alto rischio di morte fornisce un mezzo utile per migliorarne la prognosi. A tale proposito sono stati sviluppati numerosi modelli matematici in grado di calcolare la probabilità di morte in seguito ad ustioni, basati principalmente sull`età del paziente e sull´ estensione dell´ustione. Infatti, è intuitivamente comprensibile che il rischio di morire aumenti con l´età del paziente e la gravità dell´ustione. Nel nostro primo studio abbiamo aggiunto ad un modello prognostico basato su età e superficie corporea ustionata informazioni sulle malattie già presenti nel paziente prima dell`ustione. Contrariamente a quanto ipotizzato, la presenza di altre malattie negli ustionati non ne aumenta la probabilità di morte.  Nel nostro secondo studio abbiamo seguito i pazienti sopravvissuti all´ustione dopo la dimissione dal nostro Centro ed abbiano dimostrato che l´ustione in se´ non ne accorcia la vita ne´a breve termine (nei 30 giorni seguenti la dimissione), ne´a lungo termine. È piuttosto inusuale che pazienti con ustioni di modesta gravitá muioiano durante il ricovero ospedaliero. Nel nostro terzo studio abbiamo dimostrato che la principale cause di morte tra questi pazienti non è correlata all´ustione in se´, ma ad altre patologie indipendenti dal trauma termico, quali l´ictus o l´infarto miocardico. A livello internazionale è stato ampiamente documentato un impari impiego delle cure mediche tra i sessi, a discapito delle donne. Questa disparità riguarda principalmente la diversa allocazione delle risorse terapeutiche, ma ha conseguenze negative sul´esito finale della cura. Studi provenienti da diversi centri per la terapia delle grandi ustioni (USA, Australia, India) hanno dimostrato che il rischio di morte in ospedale è maggiore per le pazienti femmine. In contrasto con questo, una precedente ricerca svolta presso il nostro centro non ha mostrato alcuna differenza nella sopravvivenza tra uomini e donne. Anche tra i pazienti della terapia intensiva generale svedese la mortalità è simile per entrambi i sessi, nonostante gli uomini ricevano più trattamenti rispetto alle donne. Questa osservazione apre le porte ad un´ovvia domanda, e cioè: se le donne ricevessero le stesse attenzioni degli uomini morirebbero esse su scala minore? In linea con i risultati riguardanti la mortalità precedentemente pubblicati dal nostro centro, col nostro quarto studio abbiamo dimostrato che non esiste alcuna disparità tra i sessi nella distribuzione delle risorse. In sintesi, con questa tesi abbiamo dimostrato che: <ol type="i">i fattori che maggiormente influenzano la prognosi in caso di ustione sono l'età del paziente e l´area corporea ustionata; la presenza di altre patologie non aumenta significativamente il rischio di morte. L´essere sopravvissutto ad un´ustione non riduce l´aspettativa di vita dopo la dimissione dall´ospedale. Una percentuale non indifferente delle morti che si verificano durante il periodo di cura per ustioni di modesta gravità è causata da fattori indipendenti dall´ustione stessa. Uomini e donne nel nostro centro ricevono equo trattamento. La prognosi per donne e uomini ricoverati nel nostro centro è la stessa. Riteniamo che i risultati presentati in questa tesi dovrebbero essere tenuti in considerazione nella terapia dei pazienti ustionati: il trattamento attivo dovrebbe essere offerto a chiunque abbia una ragionevole possibilità di sopravvivenza, calcolata sulla base dell´età e della gravità dell´ustione. Una volta guariti da un´ustione l´aspettativa di vita è buona. Non va scordato che, tra i pazienti che muoiono in seguito ad un´ustione, le cause di morte potrebbero essere dovute a patologie di altra natura. Non si evidenziano differenze nelle mortalitá, lí dove venga offerto uguale trattamento a uomini e donne. / Dödligheten efter brännskador har minskat under de senaste årtiondena, likväl kvarstår målet att ytterligare minska risken att avlida. Syftet med denna avhandling var att studera prognosen efter brännskador, och i synnerhet att analysera dödligheten ur olika perspektiv. De modeller som brukar användas inom brännskadevård för att förutse dödlighet baseras framför allt på brännskadeyta och ålder. Det är emellertid oklart huruvida patientens samsjuklighet påverkar prognosen, och huruvida åldern kan ersätta uppgifter om samsjukligheten. I det första arbetet har detta undersökts genom analys av befintliga vårdregisterdata i Sverige. Att addera information om samsjukligheten till en modell baserat   på ålder och brännskadeyta gav inte säkrare förutsägelser. En återkommande fråga inom brännskadevården har varit huruvida patienter som överlever tiden på sjukhus har förkortad långsiktig överlevnad. I det andra arbetet har detta undersökts genom en uppföljning av samtliga patienter som behandlats vid det nationella brännskadecentrat i Linköping. Resultaten visar att skadans svårighetsgrad (brännskadeytan) inte påverkar hur länge patienterna lever efter utskrivning, medan effekten av ålder är avgörande för överlevnaden på lång sikt. Det är ovanligt att patienter som vårdas på sjukhus för brännskador avlider. En viktig observation som gjorts i detta sammanhang är att bland dem som dör under dessa omständigheter återfinns individer vars dödsorsak inte är relaterad till själva brännskadan. Detta gäller särskilt för dem som dör trots att skadeutbredningen är relativt sett liten. Fokus för det tredje arbetet var att undersöka vilka dödsorsaker som är relevanta för gruppen i fråga. Resultaten visar att en inte oväsentlig del av dödsfallen var orsakade av andra faktorer än de som är direkt kopplade till själva brännskadan, exempelvis hjärnblödning eller hjärtinfarkt. Det är väl dokumenterat att ojämlikhet mellan könen ofta föreligger vid medicinsk vård med en diskriminering för kvinnor både avseende resursallokering och utfall (dödlighet). Detta finns visat inom olika sektorer, till exempel finns det visat att mortalitetsutfallet är lika mellan män och kvinnor inom allmän svensk intensivvård men att män får fler behandlingsinsatser än kvinnor. Studier från olika brännskadecentra (USA, Australien, Indien) har visat att risken att avlida på sjukhus efter en brännskada är högre för kvinnliga patienter. I motsats till detta finns resultat från en studie vid Brännskadecentrum i Linköping där ingen skillnad i överlevnad kunde påvisas efter justering för skadans storlek och patienternas ålder. I det fjärde arbetet har resursfördelning undersökts ur ett könsperspektiv. Validerade metoder för att mäta vårdinterventioner har använts. I linje med tidigare resultat, med lika överlevnad mellan könen, visade även denna studie att ingen skillnad i resursfördelning mellan könen kunde påvisas. Sammanfattningsvis visar fynden i denna avhandling att risken av dö av brännskador ökar   med åldern och brännskadeytans storlek, och att addering av samsjuklighet inte ger säkrare förutsägelser därutöver. Vidare, att den långsiktiga prognosen är god för de brännskadepatienter som överlever vårdtiden på sjukhus. En inte oväsentlig del av dödsfallen som sker under vårdtiden är orsakade av andra faktorer än de som är direkt kopplade till själva brännskadan. Slutligen har vi visat att behandlingen av manliga och kvinnliga patienter vid ett nationellt brännskadecentrum är jämlik med avseende på resursfördelning och överlevnad. Slutsatserna som presenteras i denna avhandling bör beaktas vid behandling av brännskadepatienter: data stödjer således ytterligare att aktiv behandling bör erbjudas alla som har en rimlig chans att överleva beräknat utifrån de prediktioner som kan göras med de prediktionsmodeller som presenterats. Denna konklusion är mycket viktig sett ur ett behandlingsperspektiv för denna patientgrupp. Prognostiska modeller avseende mortalitetsprediktion optimeras om dödsfall med dödsorsaker som inte är relaterade till brännskadan tas bort vid analysen. Vid ett brännskadecentrum där könsjämlik behandling av brännskadepatienter tillämpas, påverkar patientens kön inte utfallet. Detta resultat är glädjande men samtidigt unikt, sett ur ett övergripande vårdperspektiv.

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