On the treatment of acute appendicitis in children

Acute appendicitis is a common condition in children and the treatment of this condition is both straightforward and complex at the same time. An appendectomy is the most common acute surgical intervention in children and the vast majority of children make a swift recovery without any complications. The surgical modality is however shifting from open to minimal access surgery and now further onto non-operative treatment. A well-performed clinical examination is still imperative but is currently aided by both evolving scoring systems and imaging. Imaging is developing from ultrasound via computed tomography-scanning to magnetic resonance imaging. The traditional belief that an inflamed appendix always progresses to gangrene and perforation does not hold its ground. Spontaneous resolution of acute appendicitis appears to be common. The aim of this thesis was to present modern benchmarks of different treatment modalities of acute appendicitis today, to present current evidence of non-operative treatment of acute appendicitis and to test if non-operative treatment of acute appendicitis in children is safe and feasible. All clinical studies have been based on children treated at the Astrid Lindgren Children´s Hospital, Stockholm, Sweden. In paper I we conducted a review of all children who underwent an appendectomy for acute appendicitis between 2006 and 2010. 1744 patients were operated, 1009 had a laparoscopic operation. We found no difference in the rate of complications between the two methods. We found that the operating time was longer for laparoscopic surgery and that the initial assumption that the postoperative length of stay in the laparoscopic group was shorter than in the open group was not due to the surgical modality but to a general trend over time. In paper II we studied recurrence of acute appendicitis in children after successful non-operative treatment of an imaging-confirmed appendiceal abscess. 89 patients were included in this study. Nine patients had an appendectomy during the 5.1 years of follow-up but only 2 had a recurrent acute appendicitis. Hence, the recurrence rate was 2.4% during 5.1 years of follow-up. This finding supports the strategy of not performing interval appendectomies on a routine basis. In paper III we performed a meta-analysis on randomised controlled trials on non-operative treatment of acute appendicitis in adults. We included 4 trials with a total of 896 patients. There were no difference in treatment failure but there were fewer complications in the non-operative treatment group. 73% of patients were found not to have had an appendectomy during 1 year of follow-up. We concluded that a randomised controlled trial in children was warranted. In paper IV we conducted a randomised controlled pilot trial of non-operative treatment versus surgery of acute appendicitis in children. We enrolled 50 patients in the trial, 26 were randomised to surgery. In the surgery group, all patients had a histologically confirmed acute appendicitis; none of these patients had any significant complications. Of the patients treated non-operatively with antibiotics, 92% had initial resolution of symptoms and only one patient (5%) had recurrence of acute appendicitis during the one-year follow-up period. Overall, 62% of patients have not had an appendectomy during the follow-up

Editorial : Current concepts and recent advances on pediatric appendicitis

Non peer reviewe

Odling av smultron

Odling av smultron är ett Partnerskapsprojekt som utförts under 2016 och 2017 på Solnäs Gård, Kiviks musteri, Bjärred. Två sorter, ’Rödluvan’ och ’Regina’ har odlats i torvsäckar vid två näringsnivåer, låg och hög. Tillväxt och utveckling, avkastning samt förekomst av skadegörare och sjukdomar har registrerats under båda växtsäsongerna. Resultaten visar att plantstorlek och avkastning år 1 inte påverkades av näringsnivån medan det däremot är stor skillnad på sorterna. ’Regina’ ger dubbelt så hög avkastning som ’Rödluvan’ under första odlingsåret. ’Rödluvan’ producerar mycket revor vilket knappt förekommer hos ’Regina’. Under andra odlingsåret är det stor skillnad på plantutvecklingen och plantor med hög näring är mer än dubbelt så stora som de med låg näring. Sorten ’Regina’ som fått den höga näringsnivån ger då den högsta avkastningen. För att vidareutveckla en konkurrenskraftig produktion av smultron bör försöksodling ske på enklare bord och i tunnlar för högre rationalitet och avkastning

Partial Biliary Diversion May Promote Long-Term Relief of Pruritus and Native Liver Survival in Children with Cholestatic Liver Diseases

Introduction Rare cholestatic liver diseases may cause debilitating pruritus in children. Partial biliary diversion (PBD) may relieve pruritus and postpone liver transplantation which is the only other alternative when conservative treatment fails. The aim was to report long-term outcome after PBD in a population of 26 million people during a 25-year period. Materials and Methods This is an international, multicenter retrospective study reviewing medical journals. Complications were graded according to the Clavien-Dindo classification system. Results Thirty-three patients, 14 males, underwent PBD at a median of 1.5 (0.3-13) years at four Nordic pediatric surgical centers. Progressive familial intrahepatic cholestasis was the most common underlying condition. Initially, all patients got external diversion, either cholecystojejunostomy (25 patients) or button placed in the gallbladder or a jejunal conduit. Early complications occurred in 14 (42%) patients, of which 3 were Clavien-Dindo grade 3. Long-term stoma-related complications were common (55%). Twenty secondary surgeries were performed due to stoma problems such as prolapse, stricture, and bleeding, or conversion to another form of PBD. Thirteen children have undergone liver transplantation, and two are listed for transplantation due to inefficient effect of PBD on pruritus. Serum levels of bile acids in the first week after PBD construction were significantly lower in patients with good relief of pruritus than in those with poor effect (13 [2-192] vs. 148 [5-383] mu mol/L; p =0.02). Conclusion PBD may ensure long-term satisfactory effect on intolerable pruritus and native liver survival in children with cholestatic liver disease. However, stoma-related problems and reoperations are common.Peer reviewe

Surgical Treatment and Major Complications within the First Year of Life in Newborns with Long-Gap Esophageal Atresia Gross Type a and B – a Systematic Review

Background The surgical repair of long-gap esophageal atresia (LGEA) is still a challenge and there is no consensus on the preferred method of reconstruction. We performed a systematic review of the surgical treatment of LGEA Gross type A and B with the primary aim to compare the postoperative complications related to the different methods within the first postoperative year. Methods Systematic literature review on the surgical repair of LGEA Gross type A and B within the first year of life published from January 01, 1996 to November 01, 2016. Results We included 57 articles involving a total of 326 patients of whom 289 had a Gross type A LGEA. Delayed primary anastomosis (DPA) was the most applied surgical method (68.4%) in both types, followed by gastric pull-up (GPU) (8.3%). Anastomotic stricture (53.7%), gastro-esophageal reflux (GER) (32.2%) and anastomotic leakage (22.7%) were the most common postoperative complications, with stricture and GER occurring more often after DPA (61.9% and 40.8% respectively) compared to other methods (pPeer reviewe

Evaluation of multi-level social learning for sustainable landscapes: perspective of a development initiative in Bergslagen, Sweden

To implement policies about sustainable landscapesand rural development necessitates social learningabout states and trends of sustainability indicators, normsthat define sustainability, and adaptive multi-level governance.We evaluate the extent to which social learning atmultiple governance levels for sustainable landscapesoccur in 18 local development initiatives in the network ofSustainable Bergslagen in Sweden. We mapped activitiesover time, and interviewed key actors in the network aboutsocial learning. While activities resulted in exchange ofexperiences and some local solutions, a major challengewas to secure systematic social learning and make newknowledge explicit at multiple levels. None of the developmentinitiatives used a systematic approach to securesocial learning, and sustainability assessments were notmade systematically. We discuss how social learning canbe improved, and how a learning network of developmentinitiatives could be realized

Typing Late Prehistoric Cows and Bulls—Osteology and Genetics of Cattle at the Eketorp Ringfort on the Öland Island in Sweden

Human management of livestock and the presence of different breeds have been discussed in archaeozoology and animal breeding. Traditionally osteometrics has been the main tool in addressing these questions. We combine osteometrics with molecular sex identifications of 104 of 340 morphometrically analysed bones in order to investigate the use of cattle at the Eketorp ringfort on the Öland island in Sweden. The fort is dated to 300–1220/50 A.D., revealing three different building phases. In order to investigate specific patterns and shifts through time in the use of cattle the genetic data is evaluated in relation to osteometric patterns and occurrence of pathologies on cattle metapodia. Males were genotyped for a Y-chromosomal SNP in UTY19 that separates the two major haplogroups, Y1 and Y2, in taurine cattle. A subset of the samples were also genotyped for one SNP involved in coat coloration (MC1R), one SNP putatively involved in resistance to cattle plague (TLR4), and one SNP in intron 5 of the IGF-1 gene that has been associated to size and reproduction

Self reported skin morbidity and ethnicity: a population-based study in a Western community

<p>Abstract</p> <p>Background</p> <p>Recent studies have shown ethnic differences concerning cardio-vascular disease, diabetes and mental health. Little is known about ethnic differences in skin morbidity. The purpose of this study was to describe possible ethnic differences in self-reported skin morbidity in a Western urban community.</p> <p>Methods</p> <p>The design was cross sectional. 40 888 adults in Oslo, Norway, received a postal questionnaire providing information on socio-demographic factors and self-reported health, including items on skin complaints.</p> <p>Results</p> <p>18770 individuals answered the questionnaire. In the sample 84% were from Norway. The largest immigrant group was from Western countries (5%) and the Indian Subcontinent (3%). Itch was the most prevalent reported skin symptom (7%), and was significantly more reported by men from East Asia (18%) and Middle East/North Africa (13%). The same observations were seen for reported dry and sore skin. Hair loss was a dominating complaint for men from the Indian Subcontinent and the Middle East/North Africa (23% and 25%) and for women from the same ethnic groups. Women from Sub-Saharan Africa reported significantly more pimples than in the other groups (17%).</p> <p>Conclusion</p> <p>The study showed that there were significant differences in self-reported skin complaints among ethnic groups. Issues concerning the cultural value of some skin symptoms should be examined further.</p

Cerebrospinal fluid HIV-1 RNA, intrathecal immunoactivation, and drug concentrations after treatment with a combination of saquinavir, nelfinavir, and two nucleoside analogues: the M61022 study

BACKGROUND: The way various antiretroviral drugs and drug combinations affect HIV-1 infection in the central nervous system is still largely unknown. The aim of this study was to determine the cerebrospinal fluid (CSF) steady-state concentrations of saquinavir and nelfinavir in relation to plasma concentrations, and to study their effect in combination with two nucleoside reverse transcriptase inhibitors (NRTIs) on CSF viral loads, intrathecal immunoactivation, and blood-brain barrier integrity. METHODS: Paired CSF and plasma samples from 8 antiretroviral-naïve HIV-1 infected patients starting combination therapy with saquinavir, nelfinavir, and two nucleoside analogues were collected prior to treatment, and again after approximately 12 and 48 weeks of antiretroviral therapy. Additional plasma samples were taken at weeks 2, 4, 8, 24, and 36. The concentrations of protease inhibitors were analysed, as were levels of HIV-1 RNA, CD4+ T-cell count, β2-microglobulin, neopterin, albumin ratio, IgG index, and monocytic cell count. RESULTS: None of the patients in the study presented with HIV-1 RNA < 50 copies/mL in CSF or plasma prior to treatment, compared to 5/7 at the end of the study. Signs of cell-mediated intrathecal immunoactivation, measured by neopterin and β2-microglobulin, decreased significantly in both CSF and serum, although only 1/7 reached normal CSF neopterin levels after 48 weeks of treatment. There was no significant reduction of albumin ratio, IgG index or CSF monocytic cell count. Saquinavir median (range) concentrations were < 2.5 (< 2.5–96.0) nM unbound in plasma, and < 2.5 (< 2.5–9.0) nM total in CSF. Nelfinavir median (range) concentrations were 10.0 (< 2.0–31.0) nM unbound in plasma, and < 2.0 (< 2.0–23.0) nM total in CSF. Saquinavir and nelfinavir were detectable in 7/15 and 9/15 CSF samples, respectively. CONCLUSION: Saquinavir and nelfinavir, in combination with two NRTIs, decrease the CSF viral load and, to a lesser extent, intrathecal immunoactivation. We found reasonably high CSF concentrations of nelfinavir, but suboptimal concentrations of saquinavir