Acute myocardial infarction : early diagnosis and the prognostic value of ECG and echocardiography

Introduction Acute myocardial infarction (AMI) is a main cause of death. Despite vast improvements in management and treatment strategies over the past decades, morbidity and mortality after an AMI remains high. For patients with AMI and ST-segment elevations (STEMI), urgent management has been shown to be associated with reductions in both morbidity and mortality. Various pre-hospital management strategies have been implemented, during which STEMI patients can be referred directly to the catheterization laboratory instead of first being assessed in the emergency department. Valuable minutes can thus be saved. However, it is important that the diagnosis is correct which can be more challenging in a setting where the referring cardiologist is not at the same location as the patient and the clinical setting therefore needs to be reported by the paramedic staff. Studies on the accuracy of pre-hospital STEMI diagnoses are limited. In order to expedite management for STEMI patients, international guidelines have included benchmark time targets. Little is known regarding gender differences in the achievement of these time targets, and the feasibility of obtaining a pre-hospital ECG within ten minutes of ambulance arrival has been questioned. For patients who survive an AMI, there is a risk of transient or permanent damage to the left ventricle. Such damage can be quantified by echocardiography. It is shown that patients with a reduced left ventricular ejection fraction (LVEF) have a higher risk of sudden cardiac death than patients with normal LVEF. For patients with reduced LVEF despite optimal medical treatment, an implantable cardioverter defibrillator (ICD) can reduce mortality. This benefit is not seen until after several months have passed since the AMI. This is further complicated by the fact that the risk of death is highest in the early days, weeks and months after an AMI. Therefore, finding predictors in the early phase after an AMI, preferably while the patient is still admitted to the ward, would likely be beneficial in the selection of patients for ICD treatment. Aims The overall aim of this thesis was to find easily obtainable measurements by ECG and echocardiography that could improve the prognosis for patients with acute myocardial infarction. More specifically, the aim was to study the rate of false-positive STEMI diagnoses based on pre-hospital ECGs (study I), study gender differences in time intervals and adherence to guideline set time targets (study II), study the predictive value of low-dose dobutamine stress echocardiography on the improvement of LVEF (study III) and investigate the use of discharge ECG in the early prediction of ICD candidates (study IV). Methods In study I all patients for whom a pre-hospital ECG had been transmitted to the investigating hospital during 2013 were included. In study II, patients with a STEMI diagnosis and a prehospital ECG between December 2010 and July 2015 were included. Information on whether a pre-hospital STEMI diagnosis had been set or not was collected from medical charts and the final diagnosis of STEMI was found in the national quality registry SWEDEHEART. For both study I and study II, information on time intervals were collected from ambulance charts, medical charts, a database collecting information on pre-hospital ECGs, and SWEDEHEART. In studies III and IV, adult patients with an at least moderately reduced left ventricular function (defined as LVEF ≤ 40%) with a life expectancy of more than one year and who were admitted for AMI were invited and followed by clinical visits and echocardiographic examinations. In study III, a low-dose dobutamine stress echocardiogram was performed within one week of the AMI and in study IV, the discharge ECG was reviewed. Results In study I, 16% (95% CI 10 – 23) out of 115 patients with a suspected STEMI based on prehospital ECGs were discharged with alternative diagnoses. Measured as the time from ambulance arrival at the patient’s location, the time target of reperfusion therapy within 90 minutes was achieved for almost all patients (98%), but the achievement of a pre-hospital ECG within ten minutes was only met for 16% of the cohort. The delay time to pre-hospital ECG was significantly longer for women than for men, 20 vs. 13 minutes (p < 0.001). In study II, 539 patients with STEMI and a pre-hospital ECG were included. A pre-hospital ECG was obtained within ten minutes for 22% of the cohort, and the target was more likely to be achieved for men than for women (29% vs. 14%, p = 0.001). Among all patients, 88% reached the target of reperfusion therapy within 90 minutes and there was no difference between men and women. Women had a significantly longer delay time between symptom onset and emergency call than men (median 61 vs. 45 minutes, p = 0.031). In study III, among 96 patients with an at least moderately reduced LVEF after an AMI, 60% had an LVEF ≥ 35% after three months. Patients with an LVEF ≤ 35% after three months had a significantly lower left ventricular function at both resting and stress echocardiography, measured as LVEF, mitral annular plane systolic excursion (MAPSE) and peak systolic velocity (PSV). Baseline LVEF was a good predictor of recovery with a C-statistic of 85% (95% CI 74 – 94). None of the other variables, including the stress echocardiography variables, were better discriminators. In study IV, 87 patients with LVEF ≤ 40% after an AMI were included. Patients who had a pathologic R-wave progression on the discharge ECG were four times more likely to receive an ICD than those with normal R-wave progression (HR 4.0, 95% CI 1.1-14.3, p = 0.033). None of the patients without a pathologic R-wave progression, pathologic Q-waves, or intraventricular conduction abnormalities, received an ICD or suffered from malignant arrhythmias during the follow-up period. Conclusions The rate of false-positive catheterization laboratory activations based on pre-hospital STEMI diagnoses is well in comparison to rates reported based on in-hospital triage. Still, there are gender differences favoring men in regards of delay time from symptom onset to emergency call and ambulance arrival to pre-hospital ECG. The target of obtaining a pre-hospital ECG within ten minutes is met for only around one fifth of the patients, and improvements regarding this are warranted. For patients with heart failure after an AMI, baseline LVEF is a strong predictor of improved recovery while simple measurements of LVEF, MAPSE and PSV during low-dose dobutamine stress echocardiography did not add prognostic information. Patients with a pathologic R-wave progression have a significantly higher risk of receiving an ICD, and patients without pathologic R-wave progression, or Q-waves, or intraventricular conduction abnormalities are unlikely to receive an ICD and could be seen as a low-risk population

Risker och fördelar för juverhälsan vid kombinerad digivning och mjölkning

Intresset för en mer naturlig djurhållning ökar både hos konsumenter och mjölkbönder i Sverige och Europa. För att öka djurens möjlighet till ett mer naturligt liv kan man låta kalven gå med mamman under hela eller delar av mjölkutfodringstiden. Digivning har positiva effekter för både kalv och ko, men leder även till utmaningar som minskad mängd säljbar mjölk och risker för problem med juverhälsa. Målet med den här uppsatsen har varit att sammanställa vetenskapliga studier som omfattat effekt på mjölkkors juverhälsa av digivning i kombination med maskinmjölkning. Mjölkprover visar både lägre och högre celltal hos digivande kor, jämfört med icke digivande kor. Ett flertal studier har även utförts på tropiska raser i länder utanför EU, där man har andra regler för hygien, hållning och antibiotikaanvändning. Dessa variationer kan göra det svårt att överföra resultaten på våra svenska kor. Eftersom digivningen kan kontrolleras eller tillåtas i olika grad, vilket är en faktor som skiljer sig mellan studierna, gör även det att resultaten blir svåra att jämföra. En förebyggande faktor skulle kunna vara bättre tömning av juvret när kalven får dia efter mjölkning. Även kalvens saliv och mekaniska rengöring av spenarna skulle kunna vara till fördel för kon. Samtidigt finns det en risk att smitta överförs från kalvens mun till spenen in genom spenkanalen när kalven diar. Smittskydd är en viktig aspekt då djuren får mer kontakt och överföring av patogener kan ske via mjölk och avföring på spenarna. Det finns dock inte tillräckligt stora studier där man jämfört sjukdomsprevalens mellan besättningar där enda skillnaden är digivning. Man har däremot sett skillnader i beteende mellan kalvar som får och kalvar som inte får dia, både på kort och lång sikt. Studier på diande kalvar visar på en minskning av sugandet på andra kalvars kroppsdelar (cross-sucking) och slickande på omgivningen vilka är risker för både skador och smittoöverföring. Diande kalvar blir även bättre föräldradjur och lägger ner mer tid på att ta hand om sin avkomma. Granskningen av olika studier av hur digivning påverkar juverhälsan gav varierande resultat och generellt är de studier som gjorts inom området ofta utförda i små populationer och raserna varierar vilket gör det svårt att dra generella slutsatser.Awareness of animal welfare is strong among both consumers and farmers in Europe. One way to increase the possibility for animals in dairy production to perform natural behaviors is to let the calf suckle the mother for a part of or the entire milk feeding time, instead of artificial rearing. Better emptying of the udder when the calf is allowed to suckle after milking could prevent disease and calf saliva and mechanical cleaning of the teats may also have positive effects. On the other hand, there is a risk that pathogens are transferred from the mouth of the calf to the teat and even through the teat canal when the calf suckles. The aim of this review was to compile studies in the effect of suckling regarding udder health, primarily studies that included data on somatic cell count in milk. Studies show both an increase and decrease in SCC in suckled cows. Some of the studies have been made in tropical breeds in countries outside of the EU, with other rules and laws of hygiene, animal keeping and use of antibiotics which makes it difficult to transfer results to the Swedish cow population. Because nursing and suckling can be controlled to a varying extent, a factor that also differs between studies, it makes it even more difficult to compare data and draw conclusions. Disease control is one important aspect because of the close contact between animals in systems that include suckling. Pathogens can spread thru milk and feces on the surface of the teats. Unfortunately, there are no significant studies that include prevalence of disease between livestock where the only difference is nursing or not nursing. Some behavioral differences can be seen both short and long term. A decrease in calves sucking on the body parts of other calves (cross-sucking) as well as licking on the environment has been found, risks for both injuries and transfer of disease. Nursed calves also show greater mothering skills and spend more time taking care of their offspring. Studies on udder health in suckled cows have varying results, and most of the studies in the area are done with small group sizes and the cow breeds vary which makes it difficult to draw general conclusions

Preoperative dexamethasone reduces postoperative pain, nausea and vomiting following mastectomy for breast cancer

<p>Abstract</p> <p>Background</p> <p>Dexamethasone has been reported to reduce postoperative symptoms after different surgical procedures. We evaluated the efficacy of preoperative dexamethasone in ameliorating postoperative nausea and vomiting (PONV), and pain after mastectomy.</p> <p>Methods</p> <p>In this prospective, double-blind, placebo-controlled study, 70 patients scheduled for mastectomy with axillary lymph node dissection were analyzed after randomization to treatment with 8 mg intravenous dexamethasone (<it>n </it>= 35) or placebo (<it>n </it>= 35). All patients underwent standardized procedures for general anesthesia and surgery. Episodes of PONV and pain score were recorded on a visual analogue scale. Analgesic and antiemetic requirements were also recorded.</p> <p>Results</p> <p>Demographic and medical variables were similar between groups. The incidence of PONV was lower in the dexamethasone group at the early postoperative evaluation (28.6% <it>vs</it>. 60%; <it>p </it>= 0.02) and at 6 h (17.2% <it>vs</it>. 45.8%; <it>p </it>= 0.03). More patients in the placebo group required additional antiemetic medication (21 <it>vs</it>. 8; <it>p </it>= 0.01). Dexamethasone treatment significantly reduced postoperative pain just after surgery (VAS score, 4.54 ± 1.55 <it>vs</it>. 5.83 ± 2.00; <it>p </it>= 0.004), at 6 h (3.03 ± 1.20 <it>vs</it>. 4.17 ± 1.24; <it>p </it>< 0.0005) and at 12 h (2.09 ± 0.85 <it>vs</it>. 2.54 ± 0.98; <it>p </it>= 0.04). Analgesics were required in more patients of the control group (21 <it>vs</it>. 10; <it>p </it>= 0.008). There were no adverse events, morbidity or mortality.</p> <p>Conclusions</p> <p>Preoperative intravenous dexamethasone (8 mg) can significantly reduce the incidence of PONV and pain in patients undergoing mastectomy with axillary dissection for breast cancer.</p> <p>Trial registration number</p> <p>NCT01116713</p

Gallstone disease in a Swedish population : an epidemiological investigation

The main objective of the present thesis was to study the prevalence of gallstone disease in a community survey in Danderyd. Symptoms and risk factors for gallstone disease and the changing incidence of cholecystectomy in Stockholm County was also studied. In a further study plasma levels oflathosterol and 7-a-hydroxy-4-cholestene-3-one was also investigated ascirculating markers for the biosynthesis of cholesterol and bile acids. Incidence of cholecystectomy per 100 000 inhabitants 1932-1957 showed an increase from less than 100 to 315 and from 1958-1990 a decrease to 67. After the introduction of the laparoscopic technique an increase was again noted to a present incidence of 110. Changing indications are believed to be thecause. Acute cholecystectomy had an increasing part of all cholecystectomies and in relation to elective operations increased from 0.15 to 0.40. The prevalence of gallstone disease in 556 randomly selected men and women aged 40 and 60 years was in men 4% and 15%. In women the prevalence was 11% and 25%, in overall 15%. Fifty per cent of subjects withgallstone disease were cholecystectomised. Several symptoms were investigated but there was no single symptom that could predict gallstones in men or women. Subjects already cholecystectomised and patients waiting for elective cholecystectomy had significantly more symptoms than subjects with incidental gallstones. Common risk factors for gallstone disease were investigated. Heredity was asignificant risk factor as relatives to subjects with gallstone disease had known gallstones in 39% compared with 18% in relatives to gallstone free subjects. Obesity was a risk factor for gallstone formation in women but not men. Weight increase since age 20 was a significant risk factor in women but not in men. Parity was a risk factor in women with five or more children (RR 4.05). Duration of fertility period or breast feeding was not a risk factor although increased age of menopause was correlated positively to gallstones. Plasma levels of 7-a-hydroxy-4-cholestene-3-one were not depressed in gallstone subjects but 40% higher. There was no difference in the plasma levels of lathosterol. Hypersecretion of cholesterol in gallstone subjects isnot due to a single metabolic defect but rather of multifactorial aetiology

Frodi - Discover coding : Hur kan man introducera programmering för barn i åldrarna 6-8 år?

This report is about coding and programming for children in the Swedish primary school. Even though we live in an increasingly digitalized world, programming is not available as a subject in the Swedish school. Sweden has relatively good access to computers and the Internet, yet we are already lag behind in terms of knowledge when it comes to programming. My thesis is a proposal on how to introduce computational thinking and programming for children in primary schools in a simple, analogous manner, without the need for PCs or tablets. To best be able to answer the question: How can you introduce computational thinking for children between 6 and 8 years old, I have conducted interviews with children, teachers and programmers. The project has been carried out in Umeå during ten weeks. Observations and interviews were conducted in Stockholm, at Mälarhöjden’s school and in Malmö at FooCafé. The workshop I held with teachers revealed that the availability of computers and tablets in primary school is not very good, something that complicated the teaching of programming. Another important factor that emerged is that teachers today have no proven methods nor materials to teach programming, all responsibility for teaching programming is solely on the teachers and their dedication to the subject. Teachers would like to see a material that is ready to use, the situation now creates reluctance from teachers, which means that other organizations step in and take over the school’s role. The problem with that is that these organizations do not manage to meet the demand, waiting lists for CoderDojo or Barnhack (Nonprofit organizations) is over one year. The basis for this work was that the product was not allowed to require that there is a computer or internet access available in the children’s homes. During the process I also took the decision that the product should not require a computer or tablet at all because the teachers expressed a great desire for a material that did not need to be used with a computer to function, but basically is plug and play

Frodi - Discover coding : Hur kan man introducera programmering för barn i åldrarna 6-8 år?

This report is about coding and programming for children in the Swedish primary school. Even though we live in an increasingly digitalized world, programming is not available as a subject in the Swedish school. Sweden has relatively good access to computers and the Internet, yet we are already lag behind in terms of knowledge when it comes to programming. My thesis is a proposal on how to introduce computational thinking and programming for children in primary schools in a simple, analogous manner, without the need for PCs or tablets. To best be able to answer the question: How can you introduce computational thinking for children between 6 and 8 years old, I have conducted interviews with children, teachers and programmers. The project has been carried out in Umeå during ten weeks. Observations and interviews were conducted in Stockholm, at Mälarhöjden’s school and in Malmö at FooCafé. The workshop I held with teachers revealed that the availability of computers and tablets in primary school is not very good, something that complicated the teaching of programming. Another important factor that emerged is that teachers today have no proven methods nor materials to teach programming, all responsibility for teaching programming is solely on the teachers and their dedication to the subject. Teachers would like to see a material that is ready to use, the situation now creates reluctance from teachers, which means that other organizations step in and take over the school’s role. The problem with that is that these organizations do not manage to meet the demand, waiting lists for CoderDojo or Barnhack (Nonprofit organizations) is over one year. The basis for this work was that the product was not allowed to require that there is a computer or internet access available in the children’s homes. During the process I also took the decision that the product should not require a computer or tablet at all because the teachers expressed a great desire for a material that did not need to be used with a computer to function, but basically is plug and play

Postoperative nausea and vomiting in women : An unglamorous aspect of anaesthesia

Postoperative nausea and vomiting (PONY) still remains a common and undesirable side effect of anaesthesia. Women are afflicted by PONY two to three times more often than men and a substantial number of patients consider PONV to be the worst part of the entire surgical procedure. Despite recent advances within the practice of anaesthesia little has been done to improve our understanding of the fundamental mechanisms of PONV. The aims of this dissertation were to identify the incidence of PONV after the various surgical procedures performed in women, and to investigate whether alternate anaesthetic regimens or prophylactic pharmacological or non-pharmacological interventions could influence the incidence of PONY Various blood- borne factors that may be of importance for the development of PONV in women undergoing breast cancer surgery were also studied. Methods: In total 546 women were included in six different studies. Women undergoing termination of pregnancy and breast cancer surgery under different anaesthetic regimens were studied with respect to the incidence of PONV and to identify potentially favourable anaesthetic combinations with regards to PONY The antiemetic effects of the 5-HT3 receptor antagonist tropisetron, intra-operative positive suggestion or coinduction with the alpha2 adrenoceptor agonist clonidine were studied in women undergoing laparascopic gynaecological surgery and breast cancer surgery under general anaesthesia. To study further the basic mechanisms responsible for PONV, various blood-borne factors (serotonin, epinephrine, norepinephrine, dopamine, vasopressin, CCK, gastrin, blood glucose and platelet count) that may be of importance for the development of PONV in women undergoing breast cancer surgery were analysed. Results: The incidences of PONV after termination of pregnancy, breast cancer surgery and laparoscopic gynaecological surgery were 7.5%, 57% and 47%, respectively. No clinically important differences with regard to the incidence of PONY were found between the anaesthetic regimens studied. Prophylactic treatment with tropisetron or intra-operative positive suggestion did not reduce the incidence of PONV, but recall of nausea and vomiting 24 hrs postoperatively was reduced in patients exposed to intra-operative positive suggestion (p < 0.05). Co-induction with clonidine reduced the dose of propofol (p < 0.04), sevoflurane (p < 0.03) and early need for ketobemidone (p < 0.04) and most importantly increased the number of PONV freepatients compared to placebo (66% vs. 36%; p < 0.04). Women with PONV after breast cancer surgery under general anaesthesia had a larger dispersion of platelet counts (p = 0.001), a reduced platelet count on the first postoperative day (p = 0.02) and a less pronounced relationship between platelet count and whole blood serotonin (p = 0.002) compared to PONV-free subjects. No reduction in epinephrine levels in response to the induction of anaesthesia (p 0.03) as well as increased levels of vasopressin (p = 0.00004), epinephrine (p = 0.005) and blood glucose (p 0.004) were also observed during the early postoperative period in patients with PONV. Conclusion: Approximately 50 % of women experience PONV after breast cancer surgery and laparoscopic gynaecological surgery. Various combinations of anaesthetic drugs did not have any major impact on the incidence of PONY but co-induction with clonidine was found to increase the number of PONV-free patients. Three different platelet-related factors and an altered epinephrine pattern were found in women suffering from PONV after breast cancer surgery, a finding that may suggest a genetic link to PONV

Surgery in Armed Conflicts : Predicting surgical treatment needs and improving resource use in resource-constrained settings

Background  In armed conflicts, civilian health care struggles to cope. Understanding the relationship between demographics, injury mechanism, and injury patterns to predict what surgical resources are needed is therefore vital. In the 1990s the International Committee of the Red Cross (ICRC) implemented the Red Cross Wound Score (RCWS) for the assessment of penetrating injuries. It is unknown to what extent RCWS can be used to predict surgical resource consumption and in-hospital mortality. A substantial portion of surgical resources in conflicts are used in the treatment of infected wounds, which entails antibiotics, debridements, and change of dressings. Many health care providers advocate for the use of honey as an adjunct due to its bactericidal and hyperosmotic properties. However, the scientific evidence to support this notion is insufficient. If efficacy for honey could be demonstrated, the need for repeated debridements and antibiotics could potentially be reduced, subsequently allowing for more efficient use of surgical resources.   Objectives  To increase knowledge regarding the relationship between demographics, injury mechanism, injury patterns, treatment received (Paper I), treatment trends (Paper II), and surgical resources consumption (Paper III). To identify predictive methods (Paper III) and practices (Paper IV) that can improve how surgical resources are used in resource-constrained conflict settings.   Materials and Methods  In Papers I – III routine clinical data from patients treated at three ICRC hospitals were used. The patients had weapon-related injuries from either the conflict around the Afghanistan – Pakistan border or the conflict in the Kivu region in the Democratic Republic of the Congo (DRC). In Paper I, the relationships between gender, injury mechanism, injury patterns, and treatment received were examined with univariate statistics. In Paper II, differences in treatment practices between 1992 – 1995 and 2009 – 2012 for extremity injuries were analysed with univariate statistics and logistic regression to adjust for differences in injury mechanism and severity. In Paper III, univariate statistics, logistic regression, receiver operating characteristics curves, and goodness of fit were used to determine the predictive ability of RCWS and commonly used trauma scores for surgical resource consumption. In Paper IV, 50 standardized wounds on two pigs were infected with S. aureus and separately treated with either topical honey or intramuscular gentamicin to determine if topical honey is non-inferior to systemic gentamicin treatment. Treatment efficacy was evaluated with quantitative cultures, wound area measurements, histological and immunohistochemical assays, as well as assessment of inflammatory response.   Main findings  In both conflicts, most of the patients were males in their mid-twenties with injuries to the extremities. Injuries from indiscriminate weapons (such as bombs, missiles, and explosives) were more predominant in the Afghanistan – Pakistan border conflict, and gunshot injuries were more frequent in the Kivu conflict. Soft tissue procedures were the most common type of surgery. Less than 20% of the patients were subjected to major surgery, and in-hospital mortality was under 5% (Papers I – III). Females were more frequently injured by indiscriminate weapons, had more severely affected vital parameters, received more blood transfusions, and were subjected to more extensive surgery than the males (Paper I). During the last decades, the risk for amputation remained unchanged, while the use of external fixation and split skin grafts decreased (Paper II). RCWS predicted high surgical resource consumption better than and in-hospital mortality at least equal to commonly used trauma scores (Paper III). Wound size was unchanged with topical honey and decreased with intramuscular gentamicin. However, there was no difference in bacterial count between honey and gentamicin at the end of treatment (Paper IV).  Conclusions  Females were more frequently injured by indiscriminate weapons, had more severe injuries, and had greater surgical treatment needs than the males (Paper I). Even though injuries to the extremities remain common in armed conflicts, the use of limb-preserving treatment techniques seems to have decreased during the last decades (Paper II). RCWS demonstrated a better predictive ability for surgical resource consumption compared to commonly used trauma scores (Paper III). Topical honey may be non-inferior to gentamicin in reducing S. aureus colonization on the wound’s surface, but not in reducing wound size (Paper IV).  Väpnade konflikter leder till kollaps av existerande hälso-och sjukvårdssystem, vilket snabbt begränsar eller omöjliggör kirurgisk vård för patienter med potentiellt livshotande skador. Dessutom är skador i väpnade konflikter ofta mer komplexa och resurskrävande än skador som förekommer i fredstid. För vårdgivare behövs därför kunskap om vad som påverkar det kirurgiska resursbehovet i konflikter, men även metoder för att kunna följa och förutsäga det samma. Internationella Rödakorskommittén (ICRC) har sedan 1990-talet använt ett system för sårklassificering (RCWS) för att hjälpa kirurger att bedöma och prioritera penetrerande sårskador. Det är okänt i vilken utsträckning RCWS eller andra klassificeringssystem som används i civil traumasjukvård kan användas för att förutsäga kirurgiskt resursbehov och dödlighet i resursknappa konfliktmiljöer. En betydande del av kirurgiska resurser i konflikter används för behandling av infekterade sår. Många vårdgivare förespråkar användande av honung som del i denna behandling. Detta på grund av honungs bakteriedödande och uttorkande egenskaper. Det saknas dock vetenskapligt stöd för denna uppfattning. Om honung kan påvisas vara effektivt som behandling för infekterade sår skulle behovet av antibiotika och upprepade kirurgiska behandlingar kunna minskas. Detta skulle möjliggöra mer effektivt användande av kirurgiska resurser. Denna avhandling syftar till att öka kunskapen kring hur kirurgiska resurser används i resursknappa konfliktmiljöer. Detta med målsättningen att identifiera metoder för att förutsäga och mäta det kirurgiska resursbehovet och göra användandet av det samma mera effektivt. I tre av de studier som ingår i avhandlingen har rutinmässigt insamlade journaluppgifter från patienter som behandlats vid tre ICRC sjukhus använts. Patienterna hade vapen-orsakade skador från konflikten vid gränsen mellan Afghanistan och Pakistan eller konflikten i Kivu-regionen i Demokratiska republiken Kongo (DRC). I den första studien undersöktes förhållandet mellan kön, skademekanism, uppkomna skador och erhållen kirurgisk behandling för patienter som behandlats vid ICRC sjukhuset i Peshawar, Pakistan. I den andra studien undersöktes hur behandlingen av vapen-orsakade extremitetsskador skilde sig mellan perioderna 1992 – 1995 och 2009 – 2012 vid ICRC sjukhus i Quetta och Peshawar, Pakistan. I den tredje studien prövades hur väl RCWS samt poängssystem som används i civil traumasjukvård kunde förutsäga det kirurgiska behandlingsbehovet hos patienter vid ICRC sjukhus i Peshawar, Pakistan, och Goma, DRC. I den sista studien jämfördes honung och antibiotika som behandling av infekterade sår i en försöksdjursmodell. De båda behandlingarna utvärderades och jämfördes genom bakterieodlingar, mätningar av såryta, histologiska och immunhistokemiska analyser samt inflammatoriskt svar. På de studerade ICRC sjukhusen var de flesta patienterna män i tjugoårsåldern med skador på armar eller ben. Skador från urskillningslösa vapen, som granater, missiler och bomber, var mer frekvent förekommande i gränskonflikten mellan Afghanistan och Pakistan, medan skottskador var vanligare i Kivu-konflikten. Behandling av mjukdelsskador var den vanligaste typen av kirurgi. Mindre än 20% av patienterna genomgick större operationer och dödligheten under sjukhusvistelsen var mindre än 5%. Kvinnor skadades i större omfattning av urskillningslösa vapen, hade allvarligare skador, fick oftare blodtransfusioner och behandlades med mera omfattande kirurgi än männen. Trots att skador på armar och ben är vanligt förekommande i väpnande konflikter så hade användandet av frakturstabiliserande åtgärder och hudtransplantationer minskat under de senaste årtiondena, medan risken för amputation var oförändrad. RCWS var bättre på att förutsäga kirurgisk resursförbrukning än de poängsystem som används i civil traumasjukvård. Slutligen visade den sista studien i avhandlingen att varken honung eller antibiotika minskar antalet bakterier i sår efter avslutad behandling. Däremot minskade sårens storlek med antibiotika, men var oförändrade med honung. Möjligen skulle därför honung kunna vara effektivt för att förhindra bakterieväxt på sårytan. Det finns därför anledning att undersöka om honung kan vara ett värdefullt tillägg till antibiotika och kirurgisk behandling. Detta skulle kunna förbättra användandet av de begränsade kirurgiska resurser som finns tillgängliga i väpnade konflikter.Funding agencies:• Elsa and Sigurd Golje Foundation• Linköping Society of Medicine• RALF and ALF grants, Region Östergötland• Kamprad Family Foundation</p