Appendectomy during pregnancy: rates, safety, and outcomes over a five-year period. A hospital-based follow-up study.

INTRODUCTION: Appendicitis is the most common acute abdominal complication during pregnancy. If appendix perforation occurs there is an increasing risk of preterm delivery and other pregnancy complications. OBJECTIVE: To assess the outcome of pregnancy after appendectomy, the mode of surgery used, appendectomy rates, and complications. METHODS: A prospective cohort study of pregnant women with, or without, appendectomy at South Stockholm General Hospital, December 2015 to February 2021 in a setting where pregnant women are prioritized for surgery and laparoscopic surgery was standard of care in first half of pregnancy. Data on preoperative imaging, surgical method, intraoperative findings, microscopic findings, hospital stay, pregnancy, and 30-day complications were prospectively recorded in a local appendectomy register. A non-pregnant control group was gathered comprising women of fertile age in the same study interval. RESULTS: During the study period 50 pregnant women, of whom 44 gave birth, underwent appendectomy of 38 199 women giving birth. There were no differences between women with or without appendectomy in proportion of preterm delivery (4.5% vs. 5.6%), small-for-gestational age (2.3% vs. 6.2%), or Cesarean delivery (18.2% vs. 20.4%). The rate of appendix perforation was 19% in non-pregnant control group compared to 12% among pregnancy. There was no case of perforated appendix in the second half of pregnancy. However, women with gestational age > 20 weeks more frequently had an unaffected appendix compared to those operated ≤ 20 gestational weeks (4/11 vs. 2/39, p = .005). Laparoscopic surgery was used in 97% of non-pregnant control group, 92% of appendectomies ≤ 20 weeks gestation, and in 27% >20 weeks. As compared to first half, the appendectomy rate was three times lower during the second half of pregnancy. Pregnant women had priority for surgery < 6 h compared to < 24 h among non-pregnant women, this resulted in a shorter time-to-surgery among pregnant women (p < .001). CONCLUSION: Routine laparoscopic surgery and time priority for pregnant surgery is associated with a low risk of perforation, preterm birth and other complications. However, a low threshold for surgery may increase the risk of a negative exploration.

High prevalence of an active human cytomegalovirus infection in patients with colonic diverticulitis.

BACKGROUND: Diverticulitis affects 10% of the western population and is characterized by microscopic inflammation of the colon. Increasing evidence suggests that human cytomegalovirus (HCMV) is an important pathogen in various inflammatory diseases. We hypothesized that HCMV contributes to the progression of diverticulitis, especially in immunocompromised patients in whom HCMV is a significant pathogen. OBJECTIVES: To determine if HCMV is associated with diverticulitis and with an increased frequency of diverticulitis complications. STUDY DESIGN: We examined the prevalence of an active HCMV infection in 23 patients with diverticulitis. Serum samples were analyzed for the presence of HCMV-IgG and HCMV-IgM antibodies in 11 of these patients. Immunohistochemistry was used for detection of HCMV early antigens in intestinal paraffin tissue sections obtained from the diverticulitis patients. RESULTS: HCMV-early proteins could be detected in intestinal cells in 16/23 (69.6%) patients with diverticulitis. All of the 11 patients with serum samples were HCMV-IgG positive and 2 of these were also HCMV-IgM positive. CONCLUSION: Active HCMV infection is frequently associated with diverticulitis and could contribute to the inflammatory process characteristic of diverticulitis.

Pancreatic carcinoma incidence and survival in Sweden in 1980-2000: a population-based study of 16,758 hospitalized patients with special reference to different therapies.

AIMS: The purpose of this study was to analyze the incidence and survival of pancreatic carcinoma in Sweden during 1980-2000. METHODS: In this population-based study the patients were identified in the Swedish Hospital Discharge Register and Cancer Register. Data were matched with those in the Register of Causes of Death in Sweden, and 16,758 patients were identified. RESULTS: During the studied period, 1819 patients underwent pancreatic resection, 7457 were treated with palliative procedures and, in 7482, no intervention was carried out. The incidence of pancreatic carcinoma in Sweden for men dropped from 16 per 100,000 at the beginning of the period to 8 per 100,000 in the year 2000. Corresponding figures for women were 12 and 7, respectively. Patients who underwent pancreatic resection had significantly longer survival compared to the palliative procedure or no-intervention groups (p<0.001). After 12 months 49.7% of the resected patients were alive while the corresponding survival in the palliative procedure and no-intervention groups were 13.6% and 11.9%, respectively. The five-year survival rate after resection was 10.8%. In the resection group survival improved over time (p<0.001) and women survived longer than men (p<0.01), which was not the case in the palliative procedure or no-intervention groups. CONCLUSIONS: During the study period, the incidence of pancreatic carcinoma in Sweden decreased markedly. The resection rate increased and only in this group of patients an improved survival was noted over time. The survival was the same for patients who underwent palliative interventions as for those who only received supportive care.

Detection of cytotoxic CD13-specific autoantibodies in sera from patients with ulcerative colitis and Crohn's disease.

Recent evidence suggests an association between inflammatory bowel disease (IBD) and human cytomegalovirus (HCMV) infection, but the exact pathogenic role of HCMV in this disease remains unclear. HCMV infection has for a long time been known to be associated with various autoimmune manifestations and the formation of autoantibodies. Previous studies from our group have shown that HCMV is associated with a human protein, CD13 (aminopeptidase N) and that autoantibodies against this protein are frequently found in HCMV infected bone marrow transplant patients with chronic graft versus host disease. We have recently observed that 90% of IBD patients have an active HCMV infection. In this study, we examined the presence and cytotoxicity of CD13-specific autoantibodies in sera obtained from 28 patients with ulcerative colitis and 26 patients with Crohn's disease, and in sera obtained from healthy blood donors by using flow cytometric assays against mouse cells transfected with human CD13 or a microcytotoxicity assay against different CD13 positive human cells. Cytotoxic CD13-specific autoantibodies were identified in 66% of the sera obtained from HCMV-IgG positive patients with ulcerative colitis and in 58% of the sera obtained from HCMV-IgG positive patients with Crohn's disease, but not in control individuals. These cytotoxic autoantibodies may interfere with biological cell functions and could thereby contribute to the chronic inflammation in patients with IBD.

Tobacco smoking and periodontal hemorrhagic responsiveness.

OBJECTIVE: The influence of smoking on the periodontal hemorrhagic responsiveness was investigated in 2 different populations, one exclusively consisting of patients with established periodontal disease, the other of dental hospital admissions in general. MATERIAL AND METHODS: The hemorrhagic responsiveness of the patient was clinically found from "bleeding on gentle probing" expressed as the relative frequency of bleeding sites (%). In the periodontal patient population, gingival bleeding was assessed by 1 examiner with known probing force, whereas in the dental hospital admissions population assessments were done by a great number of non-calibrated examiners with unknown probing force. RESULTS: Smokers exhibited a significantly lower hemorrhagic responsiveness than non-smokers. This held principally true for both populations but the effect was much more clearly detectable in periodontal patients than in dental hospital patients in general. A dose-response effect was typically evident in the periodontal patient population. Accounting for the periodontal disease severity, however, the effect of smoking became clearly detectable also in the general patient population. CONCLUSION: Tobacco smoking is associated with a clinically suppressed hemorrhagic responsiveness of the periodontium.

A review of serious injuries and deaths from bicycle accidents in Sweden from 1987 to 1994.

BACKGROUND: Injured cyclists are often seen in emergency departments. The aims of this study were to determine the long-term incidence of injuries, age and gender distributions, mortality rates, and geographic differences among all patients admitted to hospitals because of bicycle accidents in Sweden. METHODS: Between 1987 and 1994, 34,606 persons (39,183 admissions) were injured in bicycle accidents in Sweden (19,978 men and 14,628 women). RESULTS: The annual frequency of hospital admissions ranged from 4,585 to 5,212. Fifty-seven patients were admitted with bicycle-related injuries per 100,000 population each year. Children between 5 and 14 years of age, especially boys, and men older than 70 were more commonly involved. Injuries to the head and brain were very frequent (46%). The survival rate was poorest in persons of older age, male gender, and cyclists involved in collisions with motor vehicles. CONCLUSION: About 4,900 cyclists have been hospitalized each year after bicycle accidents in Sweden. Young children were affected very often, with injuries of the brain and various types of fractures of the extremities being common. Significant factors for a poor survival outcome included old age, male gender, and collisions with motor vehicles.

Smoking and subgingival microflora in periodontal disease.

AIM: The present investigation was undertaken to analyze the influence of smoking on the periodontal disease associated subgingival microflora. The population included 33 smokers and 31 non-smokers in the age range 36-86 years. METHODS: Microbial samples were obtained from 4 sites per patient. The checker-board DNA-DNA hybridization technology was used for detection of the bacterial species P. gingivalis, P. intermedia, P. nigrescens, B. forsythus, A. actinomycetemcomitans, F. nucleatum, T. denticola, P. micros, C. rectus, E. corrodens, S. noxia and S. intermedius. RESULTS: Using score 1 as cutoff, contrasting colonized versus non-colonized patients, 8 out of 12 species were detected in > or = 90% of both smokers and non-smokers. Using score 4 as cutoff, contrasting heavily colonized patients versus non-colonized and less heavily colonized patients, the detection rates decreased in both smokers and non-smokers. No significant differences in detection rates were observed between smokers and non-smokers. Logistic regression analysis indicated that neither smoking, probing depth nor gingival bleeding influenced the occurrence of the species analyzed. The lack of a smoking exposure dose-response further supported the indication of a limited influence of smoking. CONCLUSION: Smoking exerts little, if any, influence on the subgingival occurrence of several of the bacteria most commonly associated with periodontal disease.

Synthesis and SAR of benzamidine factor Xa inhibitors containing a vicinally-substituted heterocyclic core.

The selective inhibition of coagulation factor Xa has emerged as an attractive strategy for the discovery of novel antithrombotic agents. Here we describe highly potent benzamidine factor Xa inhibitors based on a vicinally-substituted heterocyclic core.

A review of serious injuries and deaths among car occupants after motor vehicle crashes in Sweden from 1987 to 1994.

Car occupants injured in motor vehicle crashes (MVC) are a common problem in emergency departments. The aims of this study were to determine the incidence over time, according to the type of injury, age and sex distribution, mortality rate and geographical differences among all patients admitted to Swedish hospitals because of MVC injuries. Between 1987 and 1994, Swedish hospitals admitted 37,871 persons (51,348 admissions) who had been involved in MVC as drivers or passengers. There were 23,369 men and 14,502 women. The annual frequency of hospital admissions ranged from 5,943 to 7,175. There were 74.8 injured persons admitted per 100,000 of the population each year. Males between 16 and 24 years of age were more commonly involved. Injuries to the head and neck were particularly frequent (39%). Older persons, males, and passengers had a poor survival outcome. The incidence of injured car occupants was significantly higher in sparsly populated areas of Sweden.

Pedestrians who required admission to hospital after collisions with motor vehicles in Sweden from 1987 to 1994.

OBJECTIVES: To report the incidence, range of injury, medical consequences, and mortality of pedestrians in collisions with motor vehicles in Sweden. DESIGN: Retrospective case study. SETTING: The Swedish Hospital Discharge Register (SHDR). SUBJECTS: 8684 pedestrians in collisions with motor vehicles had a total of 12,036 episodes treated in Swedish hospitals from 1987-1994. INTERVENTIONS: Statistical analysis of the Register. MAIN OUTCOME MEASURES: Incidence of pedestrians in collisions with motor vehicles in Sweden, mortality, range of injuries, and medical consequences. RESULTS: From 1987 to the end of 1994, a total of 8684 pedestrians were admitted to Swedish hospitals after collisions with motor vehicles. A mean of 17.6 persons were admitted/100,000 population/year. In all there were 12,036 admissions of injured pedestrians. There were 4593 men (53%) and 4091 women (47%), with a median age of 47 (range 1-100) years. The annual incidence of injured pedestrians (both men and women) decreased significantly during this period. Injuries to the extremities were commonest (39% fractures), followed by injuries to the head and neck (34%). The total number of deaths in our series of patients was 444 (5%). Of these, more than half had head injuries, 22% had fractures, and 5% abdominal or thoracic injuries. CONCLUSION: The number of pedestrians in collisions with motor vehicles is low in Sweden. Injuries to the extremities were commonest, followed by injuries to the head and neck. Old people were most likely to be injured and 5% of the patients treated in hospital died.

Trends in the incidence and severity of stab wounds in Sweden 1987-1994.

OBJECTIVE: To evaluate the incidence, types of injury, medical consequences, and mortality of patients with stab wounds in Sweden. DESIGN: Retrospective case study. SETTING: The Swedish National Hospital Discharge Register (SNHDR) and the Register of Causes of Death, Statistics Sweden (RCDSS) SUBJECTS: 1315 patients with stab wounds. All 1507 episodes were treated in Swedish hospitals from 1987-1994. MAIN OUTCOME MEASURES: Incidence of stab wounds in Sweden, mortality, types of injuries and medical consequences. RESULTS: From 1987 to 1994, 1315 people were admitted to Swedish hospitals with stab wounds, which corresponds to 2.1 injuries/100,000 population/year. In all, 1507 episodes were treated in hospital. There were 1121 men (85%) and 194 women (15%), with a median age of 32 years (range 1-88). The annual incidence was relatively constant during this period. The total number of deaths was 45/1315 (3.4%). Among these, 13 (29%) had thoracic, 9 (21%) abdominal, 7 (16%) head/neck and 7 (15%) extremity injuries. Twenty percent of those admitted to hospital had to spend more than one week there. CONCLUSIONS: The incidence of stab wounds was low and the annual incidence stable. Young men in urban areas were the commonest victims. Injuries of the trunk were commonest, followed by injuries to the head and neck and limbs, 80% of the patients were discharged from hospital within a week, and 3% of those treated in hospital for stab wounds died.

Smoking and GCF levels of IL-1beta and IL-1ra in periodontal disease.

AIMS: GCF levels of the cytokine IL-1beta and its receptor antagonist IL-1ra were analyzed with respect to smoking in patients with moderate to severe periodontal disease. The study population included 22 smokers and 18 non-smokers in the age range 32-86 years. Concomitantly, the GCF levels of IgA, IgG, albumin and total protein were analyzed. METHOD: Samples of GCF were obtained from 2 diseased sites in each patient by means of an aspiration method. IL-1beta, IL-1ra, IgA and IgG were determined with immunoelectrophoresis. Total protein was determined by the BCA method. RESULTS: The clinical characteristics in terms of probing depth and frequency of diseased sites and supragingival plaque did not differ between smokers and non-smokers. Gingival bleeding, however, was significantly depressed in smokers. IL-1beta was detected in GCF of 95% of both smokers and non-smokers and IL-1ra in all patients. The GCF level of IL-1ra was approximately 1,000-fold that of IL-1beta. The GCF levels of IL-1beta and IL-1ra were high in comparison with those of TNF-alpha and IL-6 determined by the same method in our earlier studies. CONCLUSION: Our observations did not reveal any influence of smoking on the levels of IL-1beta and IL-1ra in GCF.

Isoxazolines and isoxazoles as factor Xa inhibitors.

3,4,5-Trisubstituted isoxazolines (2) and isoxazoles (3) were prepared and evaluated for their in vitro and in vivo antithrombotic efficacy. They were compared to 3,5,5-trisubstituted isoxazolines (1) for Factor Xa selectivity and potency. They were also compared in an arterio-venous (A-V) shunt model of thrombosis.

A review of serious injury and death from gunshot wounds in Sweden: 1987 to 1994.

OBJECTIVE: To evaluate the incidence, range and causes of injury, medical consequences, and mortality of patients with gunshot wounds (GSW) in Sweden. DESIGN: Retrospective case study. SETTING: The Swedish Hospital National Discharge Register (SNHDR). SUBJECTS: 1559 patients with gunshot wounds, in all 2394 episodes treated in Swedish hospitals from 1987-1994. INTERVENTIONS: Statistical analysis of the Register. MAIN OUTCOME MEASURES: Incidence of GSW in Sweden, mortality, range of injuries and medical consequences. RESULTS: From 1987 to 1994 a total of 1559 people were admitted to Swedish hospitals with GSW, which corresponds to 2.3 injuries/100000 population/year. In all, 2394 episodes were treated in hospitals. There were 1373 men (88%) and 186 women (12%), with a median age of 29 years (range 1-92). Of these, 990 were recorded as accidents (63%), 257 as suicides (16%), 174 as attempted murder (11%), and 138 as of "unknown cause" (9%). The annual incidence of GSW in Sweden was relatively constant during this period. The total number of deaths in our series of patients was 111 (7%), including 74 suicides, 16 accidents, 14 homicides, and 7 of "unknown cause". Among these, 53% had a head injury, 11% thoracic, and 8% abdominal injuries. Compared with other countries in the world, the incidence of GSW in Sweden is comparable with New Zealand and Finland, but lower than in the USA. Injuries to extremities were most common, followed by injuries to the head and neck. Thirty percent of all those admitted to hospital required more than one week in hospital. CONCLUSIONS: The incidence of GSW is low in Sweden, and they are mainly caused by accidents or attempted suicide. Injuries to the extremities were most common, followed by injuries to the head and neck. Two thirds of the patients left hospital within a week. Seven percent of patients treated for GSW in hospital died.

Unarmed violence-related injuries requiring hospitalization in Sweden from 1987 to 1994.

BACKGROUND: Physical abuse and assault are common problems in the Western hemisphere. The aims of this study were to investigate the injury incidence, distribution of injuries, the age and sex distribution, and the geographical differences in all patients admitted to Swedish hospitals between 1987 and 1994 because of injuries related to unarmed assault. METHODS: Patients admitted to hospitals in Sweden between 1987 and 1994 after physical abuse were included in the Swedish Hospital Discharge Register. A description of the types of injuries, surgical procedures, and lengths of hospital stay are presented. The change in the incidence of hospital admissions for unarmed violence-related injuries was evaluated. Linear regression analysis was used to correlate population density with incidence of hospital admission and to evaluate the change in age-standardized incidence of hospital admissions over time. RESULTS: Information was available on 17,453 persons, of whom 79% were males. The mean age was 30 years. Craniocerebral injury was the most common (72%) followed by injuries to the extremities (10%), thorax (5%), and abdomen (3%). The mean in-hospital stay was 3 days. Thirty-eight people (0.2%) died of their injuries. The age-standardized incidence of hospital admissions increased significantly over the years in males, but not in females. No correlation was detected between population density and incidence of injury. CONCLUSION: Young males are at the greatest risk of incurring physical injuries from assaults that warrant hospital admission, and the incidence in this group has increased significantly. Injuries to the head are the most common. Fatal injuries are rare. The in-hospital stay is usually brief. The frequencies of assaults are similar in urban and rural areas.

[More precise indications for fluid therapy during transportation to hospital are required]. / Tydliga indikationer krävs för att ge vätska under transport till sjukhus.

Although early intravenous fluid therapy for haemorrhage and shock is usually given before arrival at the hospital, its value is unclear and more precise indications are needed. The indications will take into account such factors as transport time, volume and type of bleeding, and the presence or absence of concomitant head injury. Fluid resuscitation can be omitted if transport time is less than 30 min, but may be beneficial if it is more than 30 min. Choice of infusion rate should be guided by the estimated risk of re-bleeding when haemorrhage is uncontrolled, and by cerebral perfusion where severe head injury is present.

Design and synthesis of isoxazoline derivatives as factor Xa inhibitors. 1.

Thrombosis is a major cause of mortality in the industrialized world. Therefore, the prevention of blood coagulation has become a major target for new therapeutic agents. One attractive approach is the inhibition of factor Xa (FXa), the enzyme directly responsible for prothrombin activation. We report a series of novel biaryl-substituted isoxazoline derivatives in which the biaryl moiety was designed to interact with the S(4) aryl-binding domain of the FXa active site. Several of the compounds herein have low nanomolar affinity for FXa, have good in vitro selectivity for FXa, and show potent antithrombotic efficacy in vivo. The three most potent compounds (33, 35, and 37) have inhibition constants for human FXa of 3.9, 2.3, and 0.83 nM, respectively, and ID(50)'s ranging from 0.15 to 0.26 micromol/kg/h in the rabbit arterio-venous thrombosis model.

Smoking and crevicular fluid levels of IL-6 and TNF-alpha in periodontal disease.

Smoking is a well-documented risk factor for periodontal disease, although the mechanisms of its negative influence are not well understood. In the present study, the influence of smoking on the gingival crevicular fluid (GCF) content of the pro-inflammatory cytokines IL-6 and TNF-alpha was investigated in patients with moderate to severe forms of the disease. The study base consisted of 108 patients including 45 current smokers, 28 former smokers and 35 non-smokers. The median GCF sample levels of IL-6 and TNF-alpha were 5.0 pg/ml and 61.0 pg/ml, respectively, for current smokers, 13.0 pg/ml and 51.0 pg/ml, respectively, for former smokers, and 10.0 pg/ml and 12.0 pg/ml, respectively, for non-smokers. The differences between smoking groups with regard to IL-6 were not significant suggesting that the IL-6 content was not influenced by smoking. In contrast, the TNF-alpha content was significantly increased in current smokers as compared to non-smokers confirming our previous observations. The present results in patients with moderate to severe periodontal disease may indicate different mediator functions of IL-6 and TNF-alpha in response to smoking.

Clinical expression of TNF-alpha in smoking-associated periodontal disease.

The level of TNF-alpha in gingival crevicular fluid (GCF) was analyzed with respect to smoking in patients with untreated moderate to severe periodontal disease including 30 current smokers, 19 former smokers and 29 non-smokers, in the age range 31-79 years. Concomitantly the occurrence of the periopathogens Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg) and Prevotella intermedia (Pi) and the GCF levels of albumin, IgA and IgG were analyzed. With regard to clinical characteristics, there were no statistically significant differences between smoking groups. The occurrence of patients positive for the periopathogens Aa, Pg and Pi was 28.2%, 41.0% and 91.0%, respectively. There were no statistically significant differences between smoking groups with regard to occurrence or relative frequency of these periopathogens. An exception was a significantly lower occurrence of Aa in former smokers as compared to non-smokers. The chief novelty of the study was the observation of a clearly increased level of TNF-alpha in GCF associated with smoking. Both current and former smokers exhibited significantly higher levels of TNF-alpha in comparison to non-smokers, whereas the levels of albumin, IgA and IgG were the same irrespective of smoking. In conclusion, the present observations in patients with moderate to severe periodontal disease suggest that smoking is associated with elevated GCF levels of the cytokine TNF-alpha.

Influence of smoking on the outcome of periodontal surgery. A 5-year follow-up.

The 5-year outcome following periodontal surgery was evaluated in 57 patients that had received regular maintenance care throughout the follow-up period. The study population included 20 smokers, 20 former smokers and 17 non-smokers in the age range 37-77 years. The clinical characteristics evaluated were supragingival plaque, gingival bleeding and pocket probing depth. The region assigned for surgery was, in addition, radiographically evaluated in terms of periodontal bone height. Furthermore, the occurrence of the periopathogens Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg) and Prevotella intermedia (Pi) and the gingival crevicular fluid (GCF) levels of tumor necrosis factor alpha (TNF-alpha) were assessed at follow-up. Plaque index was 28.5% at baseline and 32.9% at follow-up, indicating a good standard of oral hygiene, and gingival bleeding 31.7% and 24.9%, respectively, suggesting a low to moderate level of gingival inflammation. In regions assigned for surgery, pocket probing depth decreased significantly from on average 5.6 mm to 4.3 mm (p<0.0001) and periodontal bone height increased significantly from on average 62.5% to 67.5% (p<0.0001). In terms of bone height, the outcome was less favorable among smokers compared with non-smokers. There was a predominance of smokers among patients exhibiting loss of bone height after the 5 years of maintenance. No significant associations were found between the therapeutical outcome and supragingival plaque or subgingival occurrence of periopathogens. The associations between GCF levels of TNF-alpha and probing depth and bone height were unclear, whereas the level of TNF-alpha was significantly elevated in smokers.