882 research outputs found

    The Inflammatory Prequel of Pediatric Appendicitis

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    AbstractBackground: Appendicitis is the most common disease requiring acute abdominal surgery in children, yet the pathogenesis of appendicitis is not fully understood. It can be challenging to diagnose appendicitis clinically, especially in young children, leading to high rates of initial misdiagnosis. It is not clear why some children are affected by a complicated disease course while others recover spontaneously. It has been proposed that different immune responses in different individuals propel the inflammation towards an uncomplicated or a complicated disease course. To date, there is no reliable measure to distinguish between patients with uncomplicated appendicitis and those with complicated appendicitis.Aims: To increase the knowledge of how the inflammatory processes anteceding pediatric appendicitis can be categorized, modulated, and detected.Methods: Papers I, IV and V were prospective clinical institution-based studies. Paper II was a retrospective institutionbased cohort study and Paper III a nationwide cohort study. In Paper I the diagnostic performances of four different clinical prediction scores for pediatric appendicitis were evaluated. In Papers II and III the associations of immunoglobulin E (IgE)-mediated allergy and complicated appendicitis in children were evaluated. In Paper IV we assessed the associations of biological stress, measured as hair cortisol concentrations (HCC) and pediatric appendicitis. In Paper V the associations of serum concentrations of IgE and T helper cell 2 (Th2)-associated cytokines with complicated appendicitis were evaluated.Results: The clinical prediction scores appendicitis inflammatory response (AIR) score and pediatric appendicitis risk calculator (pARC) displayed significantly higher specificity and positive predictive value and lower rates of negative appendectomies compared to the pediatric appendicitis score (PAS) and Alvarado score (I). Children with IgE-mediated allergy had a significantly reduced odds of complicated appendicitis (aOR 0.33 [95% CI 0.18-0.59], p<0.001 (II), and aOR 0.80 [95% CI 0.67-0.96], p=0.021 (III)). The risk of complicated appendicitis among allergic children was reduced by one-third compared to that in non-allergic children (IR 0.13 vs 0.20 per 1000 person-years, HR 0.68 [95% CI 0.58-0.81], p<0.001), while the risk of uncomplicated appendicitis did not vary with allergy status (IR 0.91 vs 0.91, HR 1.00 [95% CI 0.94-1.07], p=0.932). Seasonal antigen exposure was a protective factor for complicated appendicitis (aOR 0.82 [95% CI 0.71-0.94], p=0.004), and ongoing antihistamine medication was a risk factor (aOR 2.28 [95% CI 1.21-4.28], p=0.012) (III). An increase in HCC was associated with an increased risk of appendicitis (aOR 10.76 [95% CI 2.50-46.28], p=0.001) and complicated appendicitis (aOR 7.86 [95% CI 1.20-51.63], p=0.03) (IV). High concentrations of IL-13 were associated with an increased risk of complicated appendicitis (aOR 1.02 [95% CI 1.01-1.04], p=0.011). Serum concentrations of IgE, IL-4, and IL-9 were not significantly associated with the risk of complicated appendicitis (V).Conclusions: AIR score and pARC are superior to the PAS and Alvarado score for diagnosing appendicitis in children. Children with allergy have a lower risk of complicated appendicitis, but the same risk of uncomplicated appendicitis, compared to non-allergic children. Increased stress, measured as an increase in HCC, is associated with an increased risk of appendicitis and complicated appendicitis in children. High levels of IL-13 seem to be associated with an increased risk of complicated appendicitis in children

    Clinical Scoring Systems in the Management of Suspected Appendicitis in Children

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    New concepts in ulcerative colitis:A thin line between medicine and surgery

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    Although the vermiform appendix was generally regarded to be an evolutionary remnant, a substantial body of evidence has accumulated supporting its role in the development and course of UC. This thesis aims to investigate what the role of the appendix is in IBD, evaluate the natural history of UC, and demonstrate risk factors for postoperative complications after pouch surgery. Clinical studies were systematically reviewed and meta-analysed. The majority of the studies showed a significant inverse association between an appendectomy and the development of UC. Some studies found that previous appendectomy patients had a lower relapse rate, less steroid use and a decreased risk of colectomy. Furthermore, evidence elaborated in this thesis support the idea that a defective function and interaction with gut flora in the appendix play an essential role in the aetiology and probably also in the onset of UC. One third of UC patients with left-sided disease extended proximally during 10 years of follow up. The cumulative colectomy rate did not decrease over time. Anastomotic leakage represents a major early complication after IPAA surgery, which can lead to pouch dysfunction or pouch failure. Long-term disease course and the concurrent combination of steroid and anti-TNF treatment before IPAA surgery were independent risk factors for anastomotic leakage in IBD patients that underwent a proctocolectomy. Being overweight and high ASA score were independent risk factors in patients that underwent a completion proctectomy and IPAA at a later stage. These risk factors enable a tailored approach in patients undergoing IPAA surgery

    Raske trauma epidemioloogia Eestis

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    Väitekirja elektrooniline versioon ei sisalda publikatsiooneVigastussurmade tõttu kaotatud eluaastate hulk on suurem kui kasvajate ja südamehaiguste tõttu kaotatud eluaastate hulk kokku (Trunkey 1983). WHO andmetel hukkub trauma tõttu maailmas keegi iga kuue sekundi järel (WHO 2015). Vigastussurmade osakaal Eestis on üks Euroopa Liidu kõrgemaid (Eurosafe 2013, 2014, 2016). Käesoleva doktoritöö eesmärgiks oli uurida raskelt vigastatud patsientide demograafilisi andmeid ja tulemeid Eestis. Raske vigastus on defineeritud maailmas laialdaselt kasutatud Injury Severity Score’ (vigastuse raskuse skoor) alusel. Raskelt vigastatud haiged suunatakse spetsialiseerunud traumakeskustesse, mida Eestis esindavad Põhja-Eesti Regionaalhaigla ja Tartu Ülikooli Kliinikum. Haigete elulemus oli Eesti traumakeskuste vahel sarnane. Eesti traumasüsteem on ajas oluliselt arenenud, mida peegeldab oluliselt parem elulemus viimastel aastatel võrreldes varasema perioodiga taasiseseisvumise järgselt. Kõige enam vigastussurmasid toimus sündmuskohal, mis näitab ennetuse olulisust. Sagedasim surmapõhjus oli ajuvigastus, millele järgnes veritsussurm. Autoõnnetus oli peamine traumamehhanism vigastussurma korral. Traumade korral esines väga suurel hulgal (51%) patsientidel alkoholijoove, mis näitab vajadust pidevaks riiklikuks alkoholipoliitikaks.Traumatic deaths contribute to more years of life lost globally compared to cancer and cardiac related deaths combined (Trunkey 1983). It is estimated, that after every six seconds someone deceases secondary to an injury accounting for more than five million trauma related deaths every year (WHO 2015). Injury-related deaths in Estonia are among highest in the European Union (Eurosafe 2013, 2014, 2016). The current thesis investigated severely injured patients in Estonia with severe injury defined per worldwide utilized anatomical score Injury Severity Score. Severely injured patients are admitted to the North Estonia Medical Centre or Tartu University Hospital representing Level I trauma centers in Estonia. Outcomes in the management of severely injured patients were similar between Estonian trauma centers. Estonian trauma system has developed significantly in time comparing nineties and recent years. Highest proportion of severely injured patients died on scene showing the importance of prevention. Most frequent cause of death was head injuries followed by bleeding related deaths. Motor-vehicle accidents were the leading mechanism of injury after traumatic deaths. A very high proportion of patients (51%) had a positive blood alcohol level in the moment of death warranting continuous national preventive measures.https://www.ester.ee/record=b535928

    Optimized classification predictions with a new index combining machine learning algorithms

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    Voting is a commonly used ensemble method aiming to optimize classification predictions by combining results from individual base classifiers. However, the selection of appropriate classifiers to participate in voting algorithm is currently an open issue. In this study we developed a novel Dissimilarity-Performance (DP) index which incorporates two important criteria for the selection of base classifiers to participate in voting: their differential response in classification (dissimilarity) when combined in triads and their individual performance. To develop this empirical index we firstly used a range of different datasets to evaluate the relationship between voting results and measures of dissimilarity among classifiers of different types (rules, trees, lazy classifiers, functions and Bayes). Secondly, we computed the combined effect on voting performance of classifiers with different individual performance and/or diverse results in the voting performance. Our DP index was able to rank the classifier combinations according to their voting performance and thus to suggest the optimal combination. The proposed index is recommended for individual machine learning users as a preliminary tool to identify which classifiers to combine in order to achieve more accurate classification predictions avoiding computer intensive and time-consuming search

    Wses Jerusalem Guidelines For Diagnosis And Treatment Of Acute Appendicitis

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    Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.1

    Wses Jerusalem Guidelines For Diagnosis And Treatment Of Acute Appendicitis

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    Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.1

    Uncomplicated acute appendicitis – towards optimization of diagnostics, antibiotic management, and treatment costs

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    Acute appendicitis is the most common reason for acute abdominal pain, currently known to present in two different forms: uncomplicated and complicated acute appendicitis. This difference in appendicitis severity between these two forms can be quite accurately differentiated prior to treatment assessment using computed tomography (CT) imaging. Complicated acute appendicitis most often requires emergency appendectomy. However, recent accumulating evidence has shown antibiotic treatment to be a safe and feasible treatment alternative for uncomplicated acute appendicitis. Furthermore, in uncomplicated acute appendicitis, the overall treatment costs of antibiotics at short-term follow-up are lower compared to surgery. The main aim of this thesis was to evaluate oral (p.o.) antibiotic monotherapy as a first-line treatment for CT-confirmed uncomplicated acute appendicitis by comparing p.o. antibiotic monotherapy to a combination of intravenous (i.v.) followed by p.o. antibiotics in a randomized multicenter non-inferiority clinical trial (APPAC II). The second aim of this study evaluated the overall costs of surgical and antibiotic treatment for uncomplicated acute appendicitis at long-term follow-up of the APPAC randomized controlled trial (RCT) comparing antibiotics with appendectomy. The third aim of this study was to determine whether the radiation dose of the diagnostic CT imaging could be significantly lowered without compromising diagnostic accuracy by using low-dose CT imaging. In the treatment of CT-confirmed uncomplicated acute appendicitis, p.o. antibiotic monotherapy had similar clinical treatment efficacy as a combination of i.v. and p.o. antibiotics with 1-year success rates of 70.2% and 73.8%, respectively. At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. The accuracy of low-dose CT and standard CT was comparable in diagnosing acute appendicitis as well as in differentiating uncomplicated and complicated acute appendicitis. The low-dose CT was associated with a significant radiation dose reduction compared to standard-dose CT.Komplisoitumaton akuutti umpilisäketulehdus – Kohti diagnostiikan, antibioottihoidon ja kustannusten optimointia Akuutti umpilisäketulehdus eli appendisiitti on yleisin akuutin vatsakivun syy. Akuuttia appendisiittia on kahta eri muotoa: lievempi komplisoitumaton ja vaikeampi komplisoitunut akuutti appendisiitti. Nykyään nämä kaksi eri muotoa voidaan erottaa toisistaan tarkasti jo ennen hoidon määrittämistä tietokonetomografiakuvauksen (TT) avulla. Komplisoitunut akuutti appendisiitti vaatii tavanomaisesti välitöntä leikkaushoitoa. Viimeaikaisten tutkimustulosten mukaan antibioottihoito on osoitettu turvalliseksi ja käyttökelpoiseksi hoitovaihtoehdoksi komplisoitumattomassa appendisiitissa. Käytettävissä olevien lyhyen seurantavälin tutkimustulosten mukaan komplisoitumattoman appendisiitin hoidosta antibiootilla aiheutuu vähemmän kustannuksia verrattuna leikkaushoitoon. Tämän väitöskirjatyön tarkoituksena oli tutkia suun kautta otettavaa antibioottihoitoa ensilinjan hoitona komplisoitumattomassa akuutissa appendisiitissa vertaamalla tablettimuotoisen antibioottihoidon tehoa suonensisäisen ja suun kautta otettavan antibioottihoidon yhdistelmään satunnaistetussa non-inferioriteetti-monikeskustutkimuksessa (APPAC II). Lisäksi tutkimme antibioottihoidon ja leikkaushoidon kokonaiskustannuksia pitkän aikavälin seurannassa. Arvioimme myös, voiko appendisiittin diagnostiikassa käytetyn TT-kuvauksen potilaalle aiheuttamaa säderasitusta pienentää heikentämättä kuvauksen diagnostista tarkkuutta. Komplisoitumattoman akuutin appendisiitin hoidossa tablettimuotoinen antibioottihoito oli kliinisesti yhtä tehokas kuin yhdistelmäantibioottihoito, hoidon onnistuessa vuoden seurantajakson aikana 70.2 %:lla tablettimuotoista ja 73.8 %:lla yhdistelmäantibioottihoitoa saaneilla. Viiden vuoden seurannassa antibioottihoidosta aiheutui tilastollisesti merkitsevästi vähemmän kustannuksia verrattuna leikkaushoitoon. Matala-annoksisen ja standardiannos-TT-kuvantamisen tarkkuus oli toisiaan vastaava sekä akuutin appendisiitin diagnosoinnissa että komplisoitumattoman ja komplisoituneen akuutin appendisiitin erottamisessa. Matala-annoskuvantamisesta aiheutui tilastollisesti merkitsevä sädeannoksen pieneneminen verrattuna standardiannoksiseen TT-kuvantamiseen

    Psychological aspects of recurrent abdominal pain of childhood

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