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.

Cushing's syndrome due to an ACTH-producing neuroendocrine tumour in the nasal roof

A patient with ectopic adrenocorticotrophic hormone (ACTH) production from a neuroendocrine tumour of the nasal roof is presented. By indirect immunoperoxidase techniques the tumour cells were shown to be distinctly positive for ACTH and beta-endorphin but negative for other peptides derived from pro-opiomelanocortin. Neither corticotropin releasing hormone (CRF) found in some tumours associated with ectopic Cushing's syndrome, nor gastrin immunoreactivity, which coexists with ACTH in normal rat pituitary and in rat and human gastrointestinal cells, were demonstrable in the tumour. A review of other, previously recognized locations of CRF/ACTH producing tumours is given to increase the awareness of the ectopic Cushing's syndrome, which may lack the classical features and is characterized by fulminant clinical course, extreme fatigue, weakness, pale facial swelling, oedema and hypokalaemic alkalosis.

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.

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.

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.

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.

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.

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.

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]

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.

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.

Neutrophil response and microbiological findings around teeth and dental implants

The aim of this study was to compare the neutrophil response, measured as both functional and antigenic elastase, around teeth and titanium implants and to relate these findings to the microbiota. The 31 patients included in the study had been treated successfully for total or partial edentulism with titanium implants. Crevicular fluid and microbiological samples were taken from 3 sites: 1) crevices around teeth and 2) implants in 16 partially edentulous patients and 3) crevices around implants in 15 edentulous patients. All sites sampled showed similar degrees of inflammation assessed by gingival index and total protein concentration. The samples were analyzed for elastase activity and immunoreactive elastase. The elastase activity was significantly higher in crevices surrounding implants in partially edentulous patients compared with implants in edentulous patients. The antigenic elastase showed no difference among the 3 sites. Gram-positive cocci were the main bacterial species in all 3 groups. Edentulous patients tended to have lower frequency of black pigmenting anaerobes. No correlation of analyzed bacteria and elastase activity was found between the 3 sites. This study indicates that, despite a similar appearance of clinical parameters and absence of significant differences in the microbiota, the inflammation around implants in partially edentulous patients induces a stronger neutrophil response than does the inflammation around implants in edentulous patients.

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.

Infrequent detection of cytomegalovirus and Epstein-Barr virus DNA in synovial membrane of patients with rheumatoid arthritis

OBJECTIVE

To study the role of the cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus types 1 and 2 (HSV-1 and 2), varicella zoster virus (VZV), and human herpes virus 6 (HHV-6) in the etiology of rheumatoid arthritis (RA).

METHODS

Polymerase chain reaction (PCR) was used to detect DNA of the different herpes viruses in synovial membranes from 31 patients with chronic RA and 14 control patients. Specific antibodies were determined by indirect immunofluorescence and ELISA.

RESULTS

Out of 31 patients with RA, CMV DNA was detected in synovial membranes from 2 patients and EBV DNA was detected in synovial membranes from 2 other patients. All samples from the patients with RA were negative for DNA from HSV-1 and 2, VZV, and HHV-6. All samples from the 14 control patients were negative in all PCR assays. No statistically significant differences in IgG antibodies were found for CMV, HSV-1, VZV, and HHV-6 in patients with RA compared to controls. Higher titers of IgG antibodies against EBV viral capsid antigen were found in patients with RA, with a significance of p < 0.05.

CONCLUSION

Both CMV and EBV DNA were detected in synovial membranes from 6% of the patients with RA. We cannot exclude the possibility that these viruses were associated with disease development in a minority of patients with RA.

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.

Injury panorama and medical consequences for 1158 persons assaulted in the central part of Stockholm, Sweden

This retrospective study describes assaults, type of trauma, injury panorama, the abbreviated injury scale score and medical consequences for 1158 assaulted persons. All patients were examined by surgeons at the Emergency Department, Sabbatsberg's Hospital, Stockholm, Sweden, which is open around the clock. The police were not notified. The study group included all assaulted patients who attended and were examined at the Emergency Department from 1 April 1992 to 31 March 1993: 84% men and 16% women. Their median age was 25 years (range 13-86 years). Sixty-eight percent arrived at the Emergency Department between 11 p.m. and 4 a.m. In 44% the hospital staff registered in the case notes that the victims were drunk. Blunt trauma of low-energy type predominated, 44% were hit by fists and 30% by kicks. Penetrating trauma occurred in 10% of the assaults (knife 8%), and a combination of blunt and/or cutting trauma (bottle/ glass) in 10%. Eighty-two percent of the victims suffered an injury to the head, resulting in concussion in 116 cases, 4 skull fractures, 1 intracerebral contusion, 74 fractures of nose bones, 17 fractures of other face bones, and 6 mandible fractures. Two persons died because of knifestab wounds. Eighty-two percent of the victims had minor injuries, and 16% had moderate injuries according to the score on the Abbreviated Injury Scale (AIS). The present study shows that assault in the central part of Stockholm, Sweden, is mainly a problem involving young men, especially late in the evening, and that many of the victims are drunk. Injuries to the head due to low-energy trauma are the most common (hit by fists and kicks), but severe injuries seldom occur.

Risk factors for acute graft-versus-host disease in 291 consecutive HLA-identical bone marrow transplant recipients

We analysed 35 risk factors for acute GVHD in 291 consecutive recipients of HLA-identical sibling marrow transplants from 1975 to 1993. Of these, 16% developed moderate-to-severe acute GVHD following transplantation. In multivariate analysis, GVHD prophylaxis with monotherapy (MTX or CsA) (P = 0.015) seropositivity for several herpes viruses in the donor (P = 0.015) and seropositivity for CMV in the recipient (P = 0.037) before the transplants as well as early engraftment (P = 0.016), were the principal risk factors for GVHD. A high serum TNF-alpha level during conditioning therapy was also a significant risk factor in 75 recipients (P = 0.005). The risk of grades II-IV acute GVHD increased with the number of risk factors. Thus the cumulative incidence of acute GVHD was 1%, if no risk factor was present, 4% with one, 9% with two, 21% with three and 44% in patients with four risk factors. Factors reported to correlate with acute GVHD, such as age, diagnosis, female donor to male recipient, relative response and donor-responding capacity in MLC, MNS blood group antigen, splenectomy and bone marrow cell dose were not associated with acute GVHD in this study. Five-year survival was 24% in patients with grades II-IV GVHD vs 62% in patients with grades 0-I GVHD (P = 0.0001).

Cytomegalovirus DNA in peripheral blood leukocytes and plasma from bone marrow transplant recipients

Granulocytes, monocytes, and T- and B-lymphocytes were separated from 28 blood samples collected from 5 bone marrow transplant (BMT) recipients. About 40% of granulocyte, monocyte, and B-lymphocyte samples were CMV DNA-positive by polymerase chain reaction in recipients with cytomegalovirus (CMV) infection. CMV DNA was rarely detected in separated T-lymphocytes. Within each of the simultaneously separated paired samples, there were several with single positive cell subtypes. Monocytes, granulocytes, and B-lymphocytes were the single positive samples in some instances. Thus, it is important to have all of the different cell subtypes present in samples for detection of CMV DNA in peripheral blood. We also studied the appearance of CMV DNA in plasma and peripheral blood leukocytes (PBLs) from 351 blood samples collected from 30 BMT recipients during a follow-up period of at least 3 months after BMT. All cell subtypes were represented in the PBL samples. In the 13 recipients who developed symptoms possibly associated with CMV infection or CMV disease, a correlation with the detection of CMV DNA in < or = 2 x 10(5) PBLs was found. In PBLs from 11 of the 13 BMT recipients, CMV DNA was detected before the onset of symptoms. CMV DNA was not detected in < or = 2 x 10(5) PBLs from recipients without CMV infection. The virus load in PBLs decreased during ganciclovir treatment. Nine of the 13 recipients displayed PCR-positive plasma samples, and CMV DNA was detected frequently after the onset of symptoms.

[Increased number of knife assaults inspite of the legislation. Record of injuries among 399 patients]

From January 1985 to September 1993, 399 patients (368 men and 31 women), median age 28 years (mean 31.1, range 16-71 years), were admitted with stab wounds due to assault. The number of stab wounds per patient was one (N = 268 patients), two (N = 63), three (N = 31), four (N = 15), five (N = 7), or more than five (N = 15). The series as whole (N = 399) accounted for 543 sites of injury. Upper extremity wounds were the most frequent (35 per cent); of 188 arm injuries, 60 per cent were in the left arm. The next most frequent site was the head and neck region (N = 105; 12 per cent), followed by the chest (N = 75; 14 per cent), abdomen (N = 66;12 per cent), lower extremities (N = 59;11 per cent), back (N = 48;9 per cent), and the male genitalia (N = 2;0.4 per cent). Ninety-five major operations were performed in 74 patients. Seven patients died, and 40 had somatic or cosmetic life-time sequelae.

Surgical treatment of carpal tunnel syndrome in patients exposed to vibration from handheld tools

During 1985 at Sabbatsberg Hospital in Stockholm, carpal tunnel decompression was done for 50 men (58 hands) with carpal tunnel syndrome (CTS). In 1988 2.5 to 3 years after the operations, a questionnaire about their present health was answered by 43 men (50 hands). In 10/17 (59%) hands exposed to vibrations and 26/33 (79%) not exposed, carpal tunnel decompression had resulted in no recurrence of neurological symptoms at follow up. Preoperative signs of neurophysiological dysfunction of the ulnar nerve, which might indicate a more widespread neuropathy, did not correlate with poor postoperative function of the median nerve. We recommend that patients with carpal tunnel syndrome should be operated on, whether or not they have been exposed to vibration.

Acute carpal tunnel syndrome caused by peritendinitis calcarea. Case report

Two women presented with similar symptoms of acute pain in the hand that was diagnosed as acute carpal tunnel syndrome caused by peritendinitis calcarea. Radiological examinations in both cases showed calcifications in the carpal tunnel. Both patients were operated on immediately and the median nerve was decompressed. Both were completely relieved of pain after operation and hand function returned to normal.

Strong donor mononuclear cell reactivity for herpes simplex virus (HSV) antigen in HSV immune donors combined with recipient seropositivity for HSV is associated with acute graft-versus-host disease

Prior to bone marrow transplantation (BMT) titres of IgG antibodies for cytomegalovirus (CMV), herpes simplex virus (HSV) and varicella zoster virus (VZV) were analysed in 51 donors and recipients of allogeneic bone marrow. Donor mononuclear cells from peripheral blood and bone marrow cells were stimulated with antigen prepared from CMV, HSV and VZV. High IgG titres for HSV in the recipient were associated with grade II-III acute graft-versus-host disease (GVHD) (P = 0.05). Furthermore, the combination of positive IgG titre for HSV antibodies in the recipient, and strong donor blood mononuclear cell reactivity to HSV antigen in HSV immune donors, significantly increased the incidence of grade II-III acute GVHD (P = 0.04). The data suggest that HSV immune donor mononuclear cells may initiate a GVH reaction.

[Surgery cures numbness of the hand. Long-term follow-up of carpal tunnel decompression]

One hundred and ninety-one hands with suspected carpal tunnel syndrome (CTS) were treated with surgical decompression of the median nerve. In a retrospective analysis 2.5-3 years later, an inquiry was carried out by questionnaire and the patients' records were examined to evaluate the final outcome. The questionnaire was answered by all 158 still living patients (ie, 175 hands), of whom 91 per cent reported numbness in the hand to have been completely relieved after surgery, while 23 per cent had had a recurrence of numbness, or other hand problems not clearly related to CTS, though just under half of this 23 per cent reported their symptoms to be milder than prior to operation. Thus, 2.5-3 years after surgical intervention, 85 per cent of the patients had recovered completely or improved; and 96 per cent were satisfied with the outcome. To conclude, surgical treatment of CTS is a technically simple operation with good final results.

Markedly increased serum erythropoietin levels following conditioning for allogeneic bone marrow transplantation

Serum erythropoietin (EPO) levels were measured by radioimmunoassay in 36 patients undergoing allogeneic bone marrow transplantation (BMT). Serum EPO levels before conditioning treatment for BMT were generally higher than the levels obtained from healthy controls (49 +/- 17 (SEM) and 17 +/- 0.6, respectively). One day prior to BMT, after conditioning by chemotherapy with or without total body irradiation, the mean EPO level was markedly elevated (218 +/- 23 U/l, p less than 0.001) and reached to its highest level at 1 week post-BMT (269 +/- 40 U/l). Although, the EPO levels were significantly lower at 1 month (98 +/- 24 U/l, p less than 0.001), they were still elevated up to 3 months post-BMT, after which they gradually normalized. Patients given methotrexate and cyclosporine for prophylaxis against graft-versus-host disease (GVHD) had significantly lower EPO levels during the first 3 months post-BMT than patients transplanted with T cell-depleted marrow (p less than 0.05). Patients with post-transplant nephrotoxicity had lower, though not statistically significant, EPO levels than patients with normal renal function (p = 0.07). Acute GVHD and number of blood transfusions had no influence on serum EPO levels after BMT.

A European multicenter study of chronic graft-versus-host disease. The role of cytomegalovirus serology in recipients and donors--acute graft-versus-host disease, and splenectomy

A group of 466 leukemic bone marrow transplanted patients were reported from 17 European bone marrow transplantation teams. Of these, 285 survived more than 3 months and could be evaluated for chronic GVHD. The cumulative incidence of chronic GVHD was 32% two years after BMT. The following factors were statistically significantly associated with chronic GVHD in bivariate analysis: high donor and recipient age, splenecacute GVHD, pretransplant seropositivity to CMV among the recipients and the donors, and donor seropositivity to 3 or 4 different herpesviruses, compared with 0-2, prior to BMT. In multivariate analysis pretransplant recipient CMV seropositivity in combination with donor CMV seropositivity prior to BMT (P = 0.0006), a previous grade II-IV acute GVHD (P = 0.001), and splenectomy (P = 0.01) were significantly associated with chronic GVHD. Thus, in addition to acute GVHD, CMV immune donor cells may be triggered by latent CMV in the recipient, which may play a role in the triggering of chronic GVHD. The possible role of splenectomy in GVHD is also discussed.

A role of herpes virus serology for the development of acute graft-versus-host disease. Leukaemia Working Party of the European Group for Bone Marrow Transplantation

Pretransplant herpes virus serology and acute graft-versus-host disease (GVHD) were studied in 379 leukaemic bone marrow transplant (BMT) recipients and their HLA-identical sibling donors. In logistic multivariate regression analysis pretransplant seropositivity to three or more different herpes viruses among the recipients was the only significant factor associated with grade II-IV acute GVHD (p = 0.03). If this factor was excluded, older donor age (p less than 0.001), absence of T cell depletion (p less than 0.001), pharmacological immunosuppression by monotherapy of methotrexate or cyclosporin versus a combination therapy of both (p = 0.002), and seropositivity to three or more herpes viruses among the donors (p = 0.03) prior to BMT, were also significantly associated with acute GVHD. The data indicate that latent herpes viruses in the host may act as minor histocompatibility antigens or by other means to trigger acute GVHD.

Variables predicting deep fungal infections in bone marrow transplant recipients

Deep fungal infections (FI) were diagnosed in 27 out of 209 consecutive bone marrow transplantation (BMT) recipients. Autopsy verified that the incidence of deep FI was 10% and the overall incidence was 13%. Using bivariate logistic regression analysis at the time of BMT, high recipient age (p = 0.003), low bone marrow cell dose (p = 0.007), recipient cytomegalovirus (CMV) seropositivity (p = 0.009) and splenectomy (p = 0.03) were significant risk factors for deep FI. In multivariate analysis, splenectomy (p = 0.008), recipient CMV seropositivity (p = 0.01) and low bone marrow cell dose (p = 0.01) held as significant. At 30 days post-BMT anti-thymocyte globulin treatment (p = 0.0006) and graft-versus-host disease grade II-IV (p = 0.005) were significant risk variables in bivariate logistic regression analysis and Fisher's exact probability test. Patients with these risk factors are candidates for treatment with antifungal drugs when they suffer from leukopenia and unclear fever.

Pretransplant herpes virus serology and chronic graft-versus-host disease

The influence of pretransplant herpes virus antibodies in patients and donors in the subsequent development of chronic graft-versus-host disease (GVHD) was analysed in 150 consecutive HLA identical bone marrow recipients. The Cox regression bivariate analysis showed that (i) pretransplant seropositivity for cytomegalovirus (CMV) in the patients and the donors, (ii) donor seropositivity for herpes simplex virus and Epstein-Barr virus, (iii) high donor and patient age, (iv) a previous grade II-IV acute GVHD, (v) patients receiving unirradiated donor buffy coat cells post-transplant, (vi) overall CMV infection, (vii) high donor herpes virus load (positive serology for 3-4 herpes viruses versus 0-2), and (viii) high recipient herpes virus load prior to BMT were all associated with a high incidence of chronic GVHD. In Cox regression multivariate analysis, high pretransplant donor herpes virus load (p less than 0.001) and a previous grade II-IV acute GVHD (p = 0.02) were the strongest predictors of chronic GVHD. Thus, herpes virus immune cells in the donated marrow may play a role in the pathophysiology of chronic GVHD.

Pretransplant herpesvirus serology and acute graft-versus-host disease

Logistic regression was used to analyze the influence of pretransplant herpesvirus antibodies, in both patients and donors, on the development of acute graft-versus-host disease in 111 consecutive HLA-identical bone marrow recipients. In bivariate analysis, recipient seropositivity for cytomegalovirus (P = 0.01), donor seropositivity for herpes simplex virus (P = 0.02), and low bone marrow cell dosage (P less than 0.05) were associated with a high incidence of grade II-IV acute GVHD. In multivariate analysis the P values were P less than 0.05 for a positive recipient CMV serology and P = 0.07 for a positive donor HSV serology. Positive serology for 1-2 herpes-viruses among recipients or donors both resulted in a 12% incidence of grade II-IV acute GVHD. Positive serology for 3-4 herpesviruses among patients or donors resulted in an incidence of 32% and 38% of acute GVHD, respectively (P less than 0.05). It is concluded that recipient and donor pretransplant herpesvirus immunity can be used to calculate the risk of moderate-to-severe acute GVHD.