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Background Non-operative management of uncomplicated acute appendicitis is an option, but omission of antibiotics from the regimen has not been tested. Methods A double-blind, placebo-controlled, superiority RCT in adults with CT-confirmed uncomplicated acute appendicitis was designed to compare placebo with antibiotics (intravenous ertapenem followed by oral levofloxacin and metronidazole). The primary endpoint was treatment success (resolution resulting in discharge without appendicectomy within 10 days); secondary outcomes included pain scores, complications, hospital stay, and return to work. Results From May 2017 to September 2020, 72 patients with a mean(s.d.) age of 37.5 (11.1) years were recruited at five hospitals. Six were excluded after randomization (5 early consent withdrawals, 1 randomization protocol violation), 35 were assigned to receive antibiotics, and 31 to receive placebo. Enrolment challenges (including hospital pharmacy resources in an acute-care surgery setting) meant that only the lowest sample size of three predefined scenarios was achieved. The 10-day treatment success rate was 87 (95 per cent c.i. 75 to 99) per cent for placebo and 97 (92 to 100) per cent for antibiotics. This clinical difference of 10 (90 per cent c.i. −0.9 to 21) per cent was not statistically different for the primary outcome (1-sided P = 0.142), and secondary outcomes were similar. Conclusion The lack of antibiotic superiority statistically suggests that a non-inferiority trial against placebo is warranted in adults with CT-confirmed mild appendicitis. Registration number: EudraCT 2015-003634-26 (https://eudract.ema.europa.eu/eudract-web/index.faces), NCT03234296 (http://www.clinicaltrials.gov).

Background Contrast-enhanced CT is the reference standard used in diagnostic imaging for acute appendicitis in adults. The radiation dose has been of concern. This study aimed to assess whether a lower radiation dose would affect the diagnostic accuracy of CT. Methods This was a prospective single-centre cohort study of patients (aged over 16 years) with suspected appendicitis evaluated for enrolment in concurrent APPAC II–III trials. The diagnostic accuracy of contrast-enhanced low- and standard-dose CT was compared with study protocols guiding imaging based on BMI; this enabled direct CT imaging comparison only in patients with a BMI below 30 kg/m2. The on-call CT diagnosis was compared with the final clinical diagnosis. Results Among all 856 patients investigated, the accuracy of low-dose (454 patients) and standard-dose (402 patients) CT in identifying patients with and without appendicitis was 98·0 and 98·5 per cent respectively. In patients with a BMI under 30 kg/m2, respective values were 98·2 per cent (434 patients) and 98·6 per cent (210 patients) (P = 1·000). The corresponding accuracy for differentiating between uncomplicated and complicated acute appendicitis was 90·3 and 87·6 per cent in all patients, and 89·8 and 88·4 per cent respectively among those with a BMI below 30 kg/m2 (P = 0·663). The median radiation dose in the whole low- and standard-dose CT groups was 3 and 7 mSv respectively. In the group with BMI below 30 kg/m2, corresponding median doses were 3 and 5 mSv (P Conclusion Low- and standard-dose CT were accurate both in identifying appendicitis and in differentiating between uncomplicated and complicated acute appendicitis. Low-dose CT was associated with a significant radiation dose reduction, suggesting that it should be standard clinical practice at least in patients with a BMI below 30 kg/m2.

Background and objective: The prevalence of bacteremia in acute appendicitis is unknown. We aimed to assess prevalence and predictive factors of bacteremia in adult patients with appendicitis. Methods: In this prospective propensity score–matched cohort study, patients were recruited as part of one single-center prospective observational study assessing appendicitis microbiology in concurrence with two randomized controlled trials on non-operative treatment of uncomplicated acute appendicitis. All patients evaluated for enrollment in these three trials between April 2017 and December 2018 with both a confirmed diagnosis of appendicitis and available blood culture on admission were included in this study. Potential predictive factors of bacteremia (age, sex, body mass index (BMI), body temperature, C-reactive protein (CRP), leukocyte count, comorbidities, symptom duration, and appendicitis severity) were assessed. Prevalence of bacteremia was determined by all available blood cultures followed by propensity score matching using sex, age, BMI, CRP, leukocyte count, and body temperature of the patients without available blood culture. Results: Out of the 815 patients with appendicitis, 271 patients had available blood culture and the prevalence of bacteremia was 12% (n = 33). Based on propensity score estimation, the prevalence of bacteremia in the whole prospective appendicitis cohort was 11.1%. Bacteremia was significantly more frequent in complicated acute appendicitis (15%; 29/189) compared with uncomplicated acute appendicitis (5%; 4/82) (p = 0.015). Male sex (p = 0.024) and higher body temperature (p = 0.0044) were associated with bacteremia. Conclusions: Estimated prevalence of bacteremia in patients with acute appendicitis was 11.1%. Complicated appendicitis, male sex, and higher body temperature were associated with bacteremia in acute appendicitis.

Background Uncomplicated and complicated acute appendicitis seem to be two different forms of this common abdominal emergency. The contribution of appendiceal microbiota to appendicitis pathogenesis has been suggested, but differences between uncomplicated and complicated appendicitis are largely unknown. We compared the appendiceal microbiota in uncomplicated and complicated acute appendicitis. Methods This prospective single-center clinical cohort study was conducted as part of larger multicenter MAPPAC trial enrolling adult patients with computed tomography or clinically confirmed uncomplicated or complicated acute appendicitis. The microbial composition of the appendiceal lumen was determined using 16S rRNA gene amplicon sequencing. Results Between April 11, 2017, and March 29, 2019, 118 samples (41 uncomplicated and 77 complicated appendicitis) were available. After adjusting for age, sex, and BMI, alpha diversity in complicated appendicitis was higher (Shannon p = 0.011, Chao1 p = 0.006) compared to uncomplicated appendicitis. Microbial compositions were different between uncomplicated and complicated appendicitis (Bray-Curtis distance, P = 0.002). Species poor appendiceal microbiota composition with specific predominant bacteria was present in some patients regardless of appendicitis severity. Conclusion Uncomplicated and complicated acute appendicitis have different appendiceal microbiome profiles further supporting the disconnection between these two different forms of acute appendicitis. Study registration ClinicalTrials.gov NCT03257423.

Background and Aims: Low anterior resection syndrome is common after anterior resection for rectal cancer. Its severity can be tested with the low anterior resection syndrome score. We have translated the low anterior resection syndrome score to Finnish, and the aim of this study is to validate the translation. Materials and Methods: The translated Finnish low anterior resection syndrome score and European Organisation for Research and Treatment of Cancer quality-of-life questionnaire-C30 and QLQ-CR29 questionnaires were sent to 159 surviving patients operated with anterior resection for rectal adenocarcinoma between 2007 and 2014 in a tertiary referral center. Psychometric properties of the translation were evaluated in comparison to quality-of-life scales and in different risk factor groups. Results: In the study, 104 (65%) patients returned the questionnaires. Of these, 56 (54%) had major low anterior resection syndrome, 26 (25%) had minor low anterior resection syndrome, and 22 (21%) had no low anterior resection syndrome. Patients with major low anterior resection syndrome had a significantly lower quality of life and more defecatory symptoms as assessed with the European Organisation for Research and Treatment of Cancer questionnaires compared with those with no low anterior resection syndrome. Patients operated with total mesorectal excision had significantly higher low anterior resection syndrome scores compared with those operated with partial mesorectal excision (median/interquartile range 32/15 and 29/11, respectively, p = 0.037). The test–retest validity of the translation was good with an intraclass correlation coefficient of 0.77 (95% confidence interval 0.51–0.90). Conclusions: The Finnish low anterior resection syndrome score is a valid test in the assessment of postoperative bowel function and its impact on the quality of life. It can be implemented to use during regular follow-up visits of Finnish-speaking rectal cancer patients.

Objectives Carbapenemase-producing Enterobacterales (CPE) have spread widely into health care facilities (HCF) but clusters caused by carbapenemase-producing (CP) Citrobacter freundii have been uncommon until recent years. Here we describe CP C. freundii clusters detected in Finland during 2016–20. Methods As a part of the national CPE surveillance, clinical microbiology laboratories send potential CP C. freundii isolates to the reference laboratory for confirmation and further characterization. Whole genome sequencing (WGS) with Illumina MiSeq sequencer was used to detect clusters. Resistance genes and STs were analysed using SRST2 and typing with core genome (cg) MLST. A case was defined as a patient with a CP C. freundii isolate belonging to one of the detected clusters. Results We detected three CP C. freundii clusters: cluster 1 included 16 cases in five HCFs during 2016–20, cluster 2 had two cases in two HCFs during 2018–19 and cluster 3 had two cases in one HCF in 2020. The isolates (11 clinical and 5 screening) in cluster 1 had KPC-2 carbapenemase and were sequence type (ST)18. Cluster 2 (2 clinical isolates) had OXA-181/GES-5 carbapenemases and were ST604 and cluster 3 (two screening isolates) had KPC-3 carbapenemase and were ST116. None of the cases had a history of recent travel abroad. Conclusions CP C. freundii also causes outbreaks and can be a reservoir of carbapenemase genes. The long intervals between successive cases, mostly found in clinical specimens in two clusters, suggest that besides unknown carriers, environmental contamination may play a role in transmission.

Importance Antibiotics are an effective and safe alternative to appendectomy for managing uncomplicated acute appendicitis, but the optimal antibiotic regimen is not known. Objective To compare oral antibiotics with combined intravenous followed by oral antibiotics in the management of computed tomography–confirmed uncomplicated acute appendicitis. Design, Setting, and Participants The Appendicitis Acuta (APPAC) II multicenter, open-label, noninferiority randomized clinical trial was conducted from April 2017 until November 2018 in 9 Finnish hospitals. A total of 599 patients aged 18 to 60 years with computed tomography–confirmed uncomplicated acute appendicitis were enrolled in the trial. The last date of follow-up was November 29, 2019. Interventions Patients randomized to receive oral monotherapy (n = 295) received oral moxifloxacin (400 mg/d) for 7 days. Patients randomized to receive intravenous antibiotics followed by oral antibiotics (n = 288) received intravenous ertapenem (1 g/d) for 2 days followed by oral levofloxacin (500 mg/d) and metronidazole (500 mg 3 times/d) for 5 days. Main Outcomes and Measures The primary end point was treatment success (≥65%) for both groups, defined as discharge from hospital without surgery and no recurrent appendicitis during 1-year follow-up, and to determine whether oral antibiotics alone were noninferior to intravenous and oral antibiotics, with a margin of 6% for difference. Results Among 599 patients who were randomized (mean [SD] age, 36 [12] years; 263 [44%] women), 581 (99.7%) were available for the 1-year follow-up. The treatment success rate at 1 year was 70.2% (1-sided 95% CI, 65.8% to ∞) for patients treated with oral antibiotics and 73.8% (1-sided 95% CI, 69.5% to ∞) for patients treated with intravenous followed by oral antibiotics. The difference was −3.6% ([1-sided 95% CI, −9.7% to ∞];P = .26 for noninferiority), with the confidence limit exceeding the noninferiority margin. Conclusion and Relevance Among adults with uncomplicated acute appendicitis, treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics. Trial Registration ClinicalTrials.gov Identifier:NCT03236961; EudraCT Identifier:2015-003633-10

Long-term results support antibiotics for uncomplicated acute appendicitis as an alternative to appendectomy. To our knowledge, treatment-related long-term patient satisfaction and quality of life (QOL) are not known.To determine patient satisfaction and QOL after antibiotic therapy and appendectomy for treating uncomplicated acute appendicitis.Open appendectomy vs antibiotics with intravenous ertapenem, 1 g once daily, for 3 days followed by 7 days of oral levofloxacin, 500 mg once daily, and metronidazole, 500 mg 3 times per day.This observational follow-up of the Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotics included 530 patients age 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis who were randomized to undergo appendectomy (273 [52%]) or receive antibiotics (257 [49%]). The trial was conducted from November 2009 to June 2012; the last follow-up was May 9, 2018. The data were analyzed in February 2019.In this analysis, post hoc secondary end points of postintervention QOL (EQ-5D-5L) and patient satisfaction and treatment preference were evaluated.Of the 530 patients enrolled in the trial (appendectomy group: 273 [174 men (64%)] with a median age of 35 years; (antibiotic group: 257 [155 men (60%)] with a median age of 33 years), 423 patients (80%) were available for phone interview at a median follow-up of 7 years; 206 patients (80%) took antibiotics and 217 (79%) underwent appendectomy. Of the 206 patients taking antibiotics, 81 (39%) had undergone appendectomy. The QOL between appendectomy and antibiotic group patients was similar (median health index value, 1.0 in both groups; 95% CI, 0.86-1.0; P = .96). Patients who underwent appendectomy were more satisfied in the treatment than patients taking antibiotics (68% very satisfied, 21% satisfied, 6% indifferent, 4% unsatisfied, and 1% very unsatisfied in the appendectomy group and 53% very satisfied, 21% satisfied, 13% indifferent, 7% unsatisfied, and 6% very unsatisfied in the antibiotic group; P .001) and in a subgroup analysis this difference was based on the antibiotic group patients undergoing appendectomy. There was no difference in patient satisfaction after successful antibiotic treatment compared with appendectomy (cumulative odds ratio [COR], 7.8; 95% CI, 0.5-1.3; P .36). Patients with appendectomy or with successful antibiotic therapy were more satisfied than antibiotic group patients who later underwent appendectomy (COR, 7.7; 95% CI, 4.6-12.9; P .001; COR, 9.7; 95% CI, 5.4-15.3; P .001, respectively). Of the 81 patients taking antibiotics who underwent appendectomy, 27 (33%) would again choose antibiotics as their primary treatment.In this analysis, long-term QOL was similar after appendectomy and antibiotic therapy for the treatment of uncomplicated acute appendicitis. Patients taking antibiotics who later underwent appendectomy were less satisfied than patients with successful antibiotics or appendectomy.Clinicaltrials.gov Identifier: NCT01022567.

We report an outbreak of invasive pneumococcal disease and pneumococcal pneumonia among shipyard workers, in Turku, Southwest Finland. In total, 31 confirmed and six probable cases were identified between 3 May and 28 November 2019. Streptococcus pneumoniae serotypes 12F, 4 and 8 were isolated from blood cultures of 25 cases. Occupational hygiene measures and vaccination of ca 4,000 workers are underway to control the outbreak at the shipyard.

Objectives: Recently, both the number and the complexity with associated increased technical difficulty of therapeutic ERCP procedures have significantly increased resulting in longer procedural and fluoroscopy times. During ERCP, the patient is exposed to ionizing radiation and the consequent radiation dose depends on multiple factors. The aim of this study was to identify factors affecting fluoroscopy time and radiation dose in patients undergoing ERCP. Materials and methods: Data related to patient demographics, procedural characteristics and radiation exposure in ERCP procedures (n = 638) performed between August 2013 and August 2015 was retrospectively reviewed and analyzed. Statistically significant factors identified by univariate analyses were included in multivariate analysis with fluoroscopy time (FT) and dose area product (DAP) as dependent variables. Effective dose (ED) was estimated from DAP measurements using conversion coefficient. Results: The factors independently associated with increased DAP during ERCP were age, gender, radiographer, complexity level of ERCP, cannulation difficulty grade, bile duct injury and biliary stent placement. In multivariate analysis the endoscopist, the complexity level of ERCP, cannulation difficulty grade, pancreatic duct leakage, bile duct dilatation and brushing were identified as predictors for a longer FT. The mean DAP, FT, number of acquired images and ED for all ERCP procedures were 2.33 Gy·cm², 1.84 min, 3 and 0.61 mSv, respectively. Conclusions: Multiple factors had an effect on DAP and FT in ERCP. The awareness of these factors may help to predict possible prolonged procedures causing a higher radiation dose to the patient and thus facilitate the use of appropriate precautions.

This secondary analysis of a randomized clinical trial assesses potential preintervention findings associated with primary nonresponsiveness to antibiotics in adults with uncomplicates acute appendicitis.

Objective: Endoscopic stents are used to relieve obstructive jaundice. The purpose of this prospective randomized study was to compare the patency of antireflux and conventional plastic biliary stent in relieving distal malignant biliary obstruction. Materials and Methods: All jaundiced patients admitted to hospital with suspected unresectable malignant distal biliary stricture between October 2009 and September 2010 were evaluated for the study. Eligible patients were randomized either to antireflux or conventional plastic stent arms. The primary endpoint was stent patency and the follow-up was continued either until the stent was occluded or until 6 months after the stent placement. Results: At an interim analysis, antireflux stents (ARSs; n = 6) had a significantly shorter median patency of 34 (8–49) days compared with the conventional stent (n = 7) patency of 167 (38–214) days (P = .0003). Based on these results, the study was terminated due to ethical concerns. Conclusion: According to these...

IntroductionBased on the epidemiological and clinical data, acute appendicitis can present either as uncomplicated or complicated. The aetiology of these different appendicitis forms remains unknown. Antibiotic therapy has been shown to be safe, efficient and cost-effective for CT-confirmed uncomplicated acute appendicitis. Despite appendicitis being one of the most common surgical emergencies, there are very few reports on appendicitis aetiology and pathophysiology focusing on the differences between uncomplicated and complicated appendicitis. Microbiology APPendicitis ACuta (MAPPAC) trial aims to evaluate these microbiological and immunological aspects including immune response in the aetiology of these different forms also assessing both antibiotics non-responders and appendicitis recurrence. In addition, MAPPAC aims to determine antibiotic and placebo effects on gut microbiota composition and antimicrobial resistance.Methods and analysisMAPPAC is a prospective clinical trial with both single-centre and multicentre arm conducted in close synergy with concurrent trials APPendicitis ACuta II (APPAC II) (per oral (p.o.) vs intravenous+p.o. antibiotics,NCT03236961) and APPAC III (double-blind trial placebo vs antibiotics,NCT03234296) randomised clinical trials. Based on the enrolment for these trials, patients with CT-confirmed uncomplicated acute appendicitis are recruited also to the MAPPAC study. In addition to these conservatively treated randomised patients with uncomplicated acute appendicitis, MAPPAC will recruit patients with uncomplicated and complicated appendicitis undergoing appendectomy. Rectal and appendiceal swabs, appendicolith, faecal and serum samples, appendiceal biopsies and clinical data are collected during the hospital stay for microbiological and immunological analyses in both study arms with the longitudinal study arm collecting faecal samples also during follow-up up to 12 months after appendicitis treatment.Ethics and disseminationThis study has been approved by the Ethics Committee of the Hospital District of Southwest Finland (Turku University Hospital, approval number ATMK:142/1800/2016) and the Finnish Medicines Agency. Results of the trial will be published in peer-reviewed journals.Trial registration numberNCT03257423

Acute appendicitis may present as uncomplicated and complicated and these disease forms differ both epidemiologically and clinically. Complicated acute appendicitis has traditionally been defined as an appendicitis complicated by perforation or a periappendicular abscess, and an appendicolith represents a predisposing factor of complicated disease. There are histopathological differences between uncomplicated acute appendicitis and the previously established traditional forms of complicated acute appendicitis, but to our knowledge, the histopathological differences between uncomplicated acute appendicitis and complicated acute appendicitis presenting with an appendicolith have not yet been reported. The study purpose was to assess these differences with two prospective patient cohorts: (1) computed tomography (CT) confirmed uncomplicated acute appendicitis patients enrolled in the surgical treatment arm of the randomized APPAC trial comparing appendectomy with antibiotics for the treatment of uncomplicated acute appendicitis and (2) patients with CT-verified acute appendicitis presenting with an appendicolith excluded from the APPAC trial.The following histopathological parameters were assessed: appendiceal diameter, depth of inflammation, micro-abscesses, density of eosinophils, and neutrophils in appendiceal wall and surface epithelium degeneration.Using multivariable logistic regression models adjusted for age, gender, and symptom duration, statistically significant differences were detected in the depth of inflammation ≤ 2.8 mm (adjusted OR 2.18 (95%CI: 1.29-3.71, p = 0.004), micro-abscesses (adjusted OR 2.16 (95%CI: 1.22-3.83, p = 0.008), the number of eosinophils and neutrophils ≥ 150/mmThese results corroborate the known clinical association of an appendicolith to complicated acute appendicitis.

This review gathers information about the current legal requirements related to the emission of ammonia and greenhouse gases from animal housing in 21 out of the 28 EU countries and in 5 non-EU countries. Overall the review shows that most of the included countries have established substantial procedures to limit ammonia emission and practically no procedures to limit greenhouse gas emission. The review can also be seen as an introduction to the substantial initiatives and decisions taken by the EU in relation to ammonia emission from animal housing, and as a notification on the absence of corresponding initiatives and decisions in relation to greenhouse gases. An EU directive on industrial emissions from 2010 and an implementation decision from 2017 are the main general instruments to reduce ammonia emission from animal housing in the EU. These treaties put limits to ammonia emissions from installations with more than 2000 places for fattening pigs, with more than 750 places for sows and with more than 40,000 places for poultry. As an example, the upper general limit for fattening pigs is 2.6 kg ammonia per animal place per year. This review indicates that the important animal producing countries in the EU have implemented the EU requirements, and, that only a few countries with a large pig population, in relation to their geographical size, have implemented requirements that are stricter than what is required by the EU.

Kansallisen ilmasto- ja energiastrategian mukaisesti Suomi tulee lisäämään maatalouspohjaisen biomassan energiakäyttöä hyödyntäen erityisesti muita kuin ruuaksi käytettäviä kasveja ja kasvinosia, sekä elintarviketuotannon sivujakeita ja jätteitä (ml. lanta). Yksi hyödyntämiskeino on biokaasuteknologia, jossa yhdistyvät uusiutuvan energian tuotannon ohella ravinteiden kierrätys, biojätteiden käsittely, jätehuolto sekä päästöjen hallinta. Vaikka biomassan hyödyntäminen energiakäyttöön tuottaakin mahdollisia päästövähennyksiä, on haitallisten ilmastovaikutusten minimoimiseksi kuitenkin tärkeää huomioida koko käsittelyketju raaka-aineiden hankinnasta lopputuotteiden käyttöön. Tämän tutkimuksen tavoitteena oli tarkastella pääasiassa lantaa käsittelevien biokaasulaitoksien energia- ja ravinnetaseita sekä löytää ilmastonmuutoksen hillinnän näkökulmasta parhaat toimintatavat. Biokaasuketjut pyrittiin määrittelemään nykykäytäntöjä vastaaviksi perustuen aiempiin tutkimuksiin, kirjallisuustietoon sekä asiantuntija-arvioihin. Tarkasteltavaksi kokoluokaksi valittiin kapasiteetiltaan 19 500 tonnia vuodessa käsittelevä laitos mikä vastaa Suomen mittakaavassa usean kotieläintilan lantoja käsittelevää biokaasulaitosta, jonka syötemateriaali koostui sian lietelannasta (16 000 tonnia/vuosi) ja lisäsyötteestä (3 500 tonnia/vuosi). Lisäsyöte oli joko sian lietelannasta erotettua kuivajaetta, HVP-nurmea (hoidettu viljelemätön pelto) tai elintarviketeollisuuden sivutuotetta. Tarkastellut biokaasuketjut sisälsivät myös syötemateriaalien hankinnan ja lopputuotteiden, kuten sähkön ja lämmön, käytön sekä lannoitteena käytettävän käsittelyjäännöksen sellaisenaan tai separoituna neste- ja kuivajakeeksi. Tarkastelussa verrattiin kolmea eri syöteseosta käyttävää biokaasuketjua referenssitilanteeseen, jossa syötemateriaalit eivät päädy biokaasuprosessiin. Tarkastelussa havaittiin, että lisäsyötteen vaikutus käsittelyjäännöksen ominaisuuksiin oli vähäinen, koska lietelannan osuus oli syötteessä huomattavan suuri. Käsittelyjäännöksen separoinnissa typpi ja kalium päätyivät pääosin nestejakeeseen ja jopa 70 % fosforista puolestaan kiintoaineeseen. Kaikki kolme biokaasuketjua tuottivat energiaa yli oman tarpeen, senkin jälkeen, kun huomioitiin laitoksen oma kulutus sekä materiaalien kuljetus ja peltolevitys. Ilmastovaikutukset kaikissa tarkastelluissa biokaasuketjuissa olivat pienemmät verrattuna referenssitilanteeseen, sillä tuotetulla biokaasulla korvattiin fossiilisia polttoaineita ja saatiin siten päästöhyvityksiä. Jonkin verran hyvityksiä saatiin myös mineraalilannoitteiden korvaamisesta kierrätysravinteilla, mutta tämä ei ollut kovin suuri ja hyvitys koski myös referenssiketjuja. Suurimmat ilmastohyödyt saatiin biokaasuketjusta, jonka raaka-aineena käytettiin sian lietelantaa ja HVP-nurmea, sillä se tuotti eniten energiaa jolloin korvaushyöty vältetystä fossiilisesta energiasta (kivihiili) oli suurin. Korvattavan energiamuodon valinnalla onkin suuri merkitys ilmastovaikutustulokseen. Referenssitilanteessa suurin osa kasvihuonekaasupäästöistä aiheutui lannan varastoinnista ja peltokäytöstä kun taas biokaasuketjujen suurin päästölähde oli käsittelyjäännöksen peltokäyttö, sillä oletuksena oli, että lanta kuljetetaan tuoreeltaan biokaasulaitokselle suljettuihin säiliöihin, jolloin vältetään lannan varastoinnista aiheutuvat päästöt. Lannan ohella myös käsittelyjäännöksen varastoinnin päästöt minimoitiin varastoimalla jäännös suljetuissa säiliöissä.

Appendiceal tumors are rare, but high neoplasm rates have been reported at interval appendectomy after periappendicular abscess. Non-operative management of uncomplicated acute appendicitis has shown promising results. The data on appendiceal tumor incidence and presentation among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. Objective was to assess appendiceal tumor incidence and tumor association to appendicitis in patients with uncomplicated and complicated acute appendicitis. This nationwide population-based registry study was conducted from 2007 to 2013. The Finnish Cancer Registry and the National Institute for Health Registry were used to combine data on all appendiceal tumors and acute appendicitis diagnosis with medical reports evaluated at eight study hospitals. Altogether, 840 appendiceal tumors were identified, and out of these, 504 patient reports were reviewed, including 472 patients in this study. Tumor was diagnosed at appendectomy for suspected acute appendicitis in 276 patients (58%). In the whole study, histologically acute appendicitis and tumor were both present in 53% (n = 250), and out of these, 41% (n = 102) were complicated and 59% (n = 148) uncomplicated acute appendicitis. The associated tumor risk was significantly higher in complicated acute appendicitis compared with uncomplicated cases (3.24% vs. 0.87%, p

OBJECTIVE To compare diagnostic accuracy of contrast enhanced low-dose computed tomography (CT) accomplished in the OPTICAP trial phantom phase to standard CT in patients with suspected acute appendicitis. BACKGROUND Increasing use of CT as the gold standard in diagnosing acute appendicitis has raised concerns regarding radiation exposure. Unenhanced low-dose CT protocols have shown similar diagnostic accuracy with standard CT for diagnosing appendicitis. To our knowledge, there are no other trials in which the same patient with suspected acute appendicitis underwent both standard and low-dose CT allowing interpatient comparison. METHODS OPTICAP is an interpatient protocol sequence randomized noninferiority single-center trial performed at Turku University Hospital between November, 2015 and August, 2016. Sixty patients with suspected acute appendicitis and body mass index

To analyze the results of abdominoperineal excisions (APE) for locally advanced rectal cancer at our institution before and after the adoption of extralevator abdominoperineal excision (ELAPE) with a special reference to long-term survival. A retrospective cohort study conducted in a tertiary referral center. All consecutive patients operated for locally advanced (TNM classification T3–4) rectal cancer with APE in 2004–2009 were compared to patients with similar tumors operated with ELAPE in 2009–2016. Forty-two ELAPE and 27 APE patients were included. Circumferential resection margin (CRM) was less than 1 mm (R1-resection) in 10 (24%) of ELAPE patients and 11 (41%) of APE patients (p = 0.1358). Intraoperative perforation (IOP) occurred in 4 (10%) patients and 6 (22%) patients in ELAPE and APE groups, respectively (p = 0.1336). There were 3 (7%) local recurrences (LRs) in ELAPE group and 5 (19%) in APE (p = 0.2473). There were no statistical differences in adverse events, overall survival, or disease-free survival between ELAPE and APE groups. We found a non-significant tendency to lower rates of IOP and positive CRM as well as lower rate of LR in the ELAPE group. Long-term survival and adverse events did not differ between the groups. ELAPE is beneficial for the surgeon in offering better vicinity to the perineal area and better work ergonomics. These technical aspects and the clinically very important tendency to lower rate of LR support the use of ELAPE technique in spite of the lack of survival benefit.

Context We studied the influence of human activities and climate change on water quantity and quality. Human activities included methods of agricultural policy, i.e. land use and management practices.

Background and Aims: To assess the accuracy of computed tomography in diagnosing acute appendicitis with a special reference to radiologist experience. Material and Methods: Data were collected prospectively in our randomized controlled trial comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (APPAC trial, NCT01022567). We evaluated 1065 patients who underwent computed tomography for suspected appendicitis. The on-call radiologist preoperatively analyzed these computed tomography images. In this study, the radiologists were divided into experienced (consultants) and inexperienced (residents) ones, and the comparison of interpretations was made between these two radiologist groups. Results: Out of the 1065 patients, 714 had acute appendicitis and 351 had other or no diagnosis on computed tomography. There were 700 true-positive, 327 true-negative, 14 false-positive, and 24 false-negative cases. The sensitivity and the specificity of computed tomography were 96.7% (95% confidence interval, 95.1–97.8) and 95.9% (95% confidence interval, 93.2–97.5), respectively. The rate of false computed tomography diagnosis was 4.2% for experienced consultant radiologists and 2.2% for inexperienced resident radiologists (p = 0.071). Thus, the experience of the radiologist had no effect on the accuracy of computed tomography diagnosis. Conclusion: The accuracy of computed tomography in diagnosing acute appendicitis was high. The experience of the radiologist did not improve the diagnostic accuracy. The results emphasize the role of computed tomography as an accurate modality in daily routine diagnostics for acute appendicitis in all clinical emergency settings.

The aim was to evaluate effects of voltage, noise input (NI) and iterative reconstruction (IR) on radiation dose and image quality in order to establish a contrast enhanced low-dose protocol for assessment of acute appendicitis. An anthropomorphic abdominal phantom mimicking contrast enhanced abdomen was scanned with 80, 100 and 120 kV, standard and strong IR and 11 NIs (66 protocols). A total of 14 test tubes of increasing iodine dilutions and one tube with an appendicolith were evaluated within the phantom. The dose, HUs, noise, contrast-to-noise ratio (CNR) and figure of merit (FOM) were determined. Visual quality scores were assessed by two readers. A clinically used voltage-IR combination (120 kV, standard IR) was used as a reference. Overall, 100 kV with standard IR (p = 0.002) and 80 kV with both IRs (p < 0.001) showed higher CNR than the reference, but noise was most pronounced at 80 kV (p < 0.001). The highest FOM was found in the 100 kV protocols (p < 0.001). The reference and 100 kV with standard IR had highest image quality scores, where the 100 kV protocol enabled a distinct dose reduction. Lowering the voltage seems to be a more favorable tool than IR changes in optimizing the dose in contrast enhanced abdominal CT. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01022567.

Background. The definition of a "difficult" cannulation varies considerably in reports of endoscopic retrograde cholangiopancreatography (ERCP). Aims. To define a difficult cannulation, which translates into higher risk of post-ERCP pancreatitis. Patients and methods. Prospective consecutive recording of 907 cannulations in Scandinavian centers done by experienced endoscopists. Inclusion: indication for biliary access in patients with intact papilla. Exclusion: acute non-biliary and chronic pancreatitis at time of procedure. Results. The primary cannulation succeeded in 74.9%, with median values for time 0.88 min (53 s), with two attempts and with zero pancreatic passages or injections. The overall cannulation success was 97.4% and post-ERCP pancreatitis (PEP) rate was 5.3%. The median time for all successful cannulations was 1.55 min (range 0.02-94.2). If the primary cannulation succeeded, the pancreatitis rate was 2.8%; after secondary methods, it rose to 11.5%. Procedures lasting less than 5 min had a PEP rate of 2.6% versus 11.8% in those lasting longer. With one attempt, the PEP rate was 0.6%, with two 3.1%, with three to four 6.1%, and with five and more 11.9%. With one accidental pancreatic guide-wire passage, the risk of the PEP was 3.7%, and with two passages, it was 13.1%. Conclusions. If the increasing rate of PEP is taken as defining factor, the wire-guided cannulation of a native papilla can be considered difficult after 5 min, five attempts, and two pancreatic guide-wire passages when any of those limits is exceeded.

Importance The step after conservative treatment of periappendicular abscess arouses controversy, ranging from recommendations to abandon interval appendectomy based on low recurrence rates of the precipitating diagnosis to performing routine interval appendectomy owing to novel findings of increased neoplasm risk at interval appendectomy. To our knowledge, there are no randomized clinical trials with sufficient patient numbers comparing these treatments. Objective To compare interval appendectomy and follow-up with magnetic resonance imaging after initial successful nonoperative treatment of periappendicular abscess. Design, Setting, and Participants The Peri–Appendicitis Acuta randomized clinical trial was a multicenter, noninferiority trial conducted in 5 hospitals in Finland. All patients between age 18 and 60 years with periappendicular abscess diagnosed by computed tomography and successful initial nonoperative treatment from January 2013 to April 2016 were included. Data analysis occurred from April 2016 to September 2017. Interventions Patients were randomized either to interval appendectomy or follow-up with magnetic resonance imaging; all patients underwent colonoscopy. Main Outcomes and Measures The primary end point was treatment success, defined as an absence of postoperative morbidity in the appendectomy group and appendicitis recurrence in the follow-up group. Secondary predefined end points included neoplasm incidence, inflammatory bowel disease, length of hospital stay, and days of sick leave. Results A total of 60 patients were included (36 men [60%]; median [interquartile range] age: interval appendectomy group, 49 [18-60] years; follow-up group, 47 [22-61] years). An interim analysis in April 2016 showed a high rate of neoplasm (10 of 60 [17%]), with all neoplasms in patients older than 40 years. The trial was prematurely terminated owing to ethical concerns. Two more neoplasms were diagnosed after study termination, resulting in an overall neoplasm incidence of 20% (12 of 60). On study termination, the overall morbidity rate of interval appendectomy was 10% (3 of 30), and 10 of the patients in the follow-up group (33%) had undergone appendectomy. Conclusions and Relevance The neoplasm rate after periappendicular abscess in this small study population was high, especially in patients older than 40 years. If this considerable rate of neoplasms after periappendicular abscess is validated by future studies, it would argue for routine interval appendectomy in this setting. Trial Registration ClinicalTrials.gov identifier:NCT03013686

This study reports a previously healthy, immunocompetent adult male in whom human herpesvirus 7 (HHV-7) DNA was detected continuously from the cerebrospinal fluid (CSF). This patient developed definite sarcoidosis with primary symptomatic manifestations in the central nervous system (CNS). The initial presentation was with loss of visual acuity and papilledema. Brain MR imaging at presentation confirmed papilledema, but otherwise there were no focal abnormalities or signs of hydrocephalus. CSF investigation revealed pleocytosis and elevated protein levels. HHV-7 DNA was detected repeatedly from CSF but not from blood over 1 year follow-up. High resolution computed tomography of lungs was normal. Positron emission tomography showed several metabolically active lymph nodes in the mediastinum, and the histopathological investigation revealed granulomatous inflammation consistent with sarcoidosis. The finding of HHV-7 DNA in the CSF in the context of neurosarcoidosis has not been reported previously. The detection of HHV-7 DNA may result from the selective activation of CD4+ T-lymphocytes in the CSF caused by neurosarcoidosis. Further studies are needed to establish whether the detection of HHV-7 DNA in the CSF in association with neurosarcoidosis represents a clinically significant HHV-7 CNS infection.

Self-expanding metal stents (SEMSs) are increasingly used for the palliative treatment of incurable obstructing colorectal cancer. The aim of the current study was to evaluate clinical outcome, including technical and clinical success of stenting, and to identify factors associated with late complications of SEMS in palliation of incurable obstructing colorectal cancer.Between 2003 and 2010 details of 56 patients who underwent an attempt of SEMS insertion for obstructive incurable colorectal cancer at Turku University Hospital were recorded to our database prospectively and analyzed retrospectively.Technical success was achieved in 42 patients (75%) and clinical success in 39 patients (70%). Late complications related to SEMS occurred in 13 patients (31%). Ten patients (24%) needed re-intervention because of a complication: Eight ostomies, one Hartmann´s procedure due to late perforation and one re-stenting because of stent migration. Three patients with stent-related complications were treated conservatively. Chemotherapy and prolonged survival were risk factors for SEMS-related late complications and re-intervention.SEMS insertion is a feasible procedure for the palliative treatment of obstructing colorectal cancer in patients with severe comorbidities and short life expectancy. However, for patients who are candidates for chemotherapy and have a longer life expectancy, other treatment options such as palliative tumor resection should also be considered.

Objective Gastrointestinal fistulae are a heterogenous entity originating from various etiologies. When occurring, these fistulae are associated with considerable morbidity and even mortality. One third of the fistulae heal spontaneously and the rest have traditionally required major revisional surgery at a later stage. Even after surgery, the healing rate remains at a level of 75% to 90%. During the last years, gastrointestinal fistulae have been successfully treated endoscopically with fibrin glue. Methods All (n = 8) consecutive patients with diagnosed internal upper or lower gastrointestinal fistula treated endoscopically with fibrin glue. Results During the minimum follow-up of 11 months, 7 of 8 patients (87.5%) were successfully treated endoscopically, and in only 1 case (12.5%) with a major diagnostic delay, a reoperation was required. Conclusions Our results support the view that endoscopic treatment with fibrin glue may be considered as a first-line therapy to treat small caliber gastrointestinal fistulas.

Deep biliary cannulation is the key for successful endoscopic retrograde cholangiopancreatography (ERCP) procedures. Guidewire-assisted cannulation is associated both with a higher success rate and a reduced risk of post-ERCP pancreatitis compared with standard catheter cannulation. However, to our knowledge there are no prospective, randomized studies comparing the use of different guidewires in biliary cannulation. The goal of this study was to compare the performance of an angled-tipped guidewire (AGW) with a straight-tipped guidewire (SGW) in achieving successful deep biliary cannulation. Patients with intended biliary cannulation of an intact papilla were prospectively randomized to angled- or straight-tipped hydrophilic guidewire arms in a tertiary, referral, university hospital setting. Randomized cannulation method was applied either until successful cannulation of the bile duct or until 2 min had passed. Crossover was not included in the study protocol. The main outcome measurements were the cannulation success rate and duration of cannulation. Of the 239 consecutive patients, 155 patients were randomized: in the final analysis 70 patients were included in the AGW arm and 83 patients in the SGW arm. Cannulation time [median; seconds (s)] was shorter with the AGW compared with the SGW (20 vs. 63 s, p = 0.01). There was no difference in the cannulation success rate or the complication rate between the two study groups. AGW may facilitate biliary cannulation in ERCP.

Biochar has been presented as a key technology for avoiding dangerous climate change. Pyrolysis converts part of the biomass feedstock into a gaseous fraction, which can be used for energy production. The remaining fraction is char, which is highly stable and resistant to biodegradation. When char is added to soil it increases carbon storage, reduces emissions and improves soil quality. Agricultural residues such as straw, stover and hulls are seen as the most accessible raw material. These residues could also be used as insulation in passive energy housing. Straw bale construction is a relatively simple technology, which has been applied for decades. It can store the carbon of the straw material into walls structures and in the process provides energy efficient housing. The climate benefits from improved energy efficiency depend on local conditions and energy production forms. In this study life cycle assessment was used to compare the climate impacts of biochar production and straw bale construction. On a life cycle perspective, straw bale construction results in higher net carbon storage than biochar production (3.3 t CO 2 eq vs. 0.9 t CO 2 eq/t of straw). However the result was found to be highly dependent on the assumptions on the overall energy efficiency of the replaced building stock.

Soil test P (STP) concentration indicates whether annual P applications can be expected to give yield increases and can also indicate an elevated risk of P mobilization and potential for P transfer to surface waters and groundwater from a particular field. Changes in STP with time thus project agronomic benefits and environmental risks of different P use strategies. To predict STP changes with time, we constructed a simple dynamic model for which the input variables are P balance and initial STP. The model parameters (soil type-specific constants) were fitted using data originating from 44 P fertilizer experiments with different P rates. Model performance was evaluated using independent data sets that either had reasonably accurate input values ( = 103) or were obtained from farmers through interviews ( = 638). The simulations were in agreement with measured STP changes for both evaluation data sets when fittings were performed separately for four main soil types (clays, silts, coarse mineral soils, and organic soils). Statistical analysis confirmed that the model captured the trends in STP (NHOAc test) with acceptable accuracy and precision, with of 0.83 and 0.66 for the data with more accurate input and for farmer interview data, respectively; the corresponding model efficiency statistics were 0.88 and 0.66. The model is not restricted to use with one soil test, as fittings for several different types of soil tests can be generated. In this study, we fitted the model for Olsen P data retrieved from the literature. Agronomic use of the model includes evaluation of P use strategies, e.g., when a certain STP level is targeted or when long-term economy of P use is calculated. In an environmental context, the model can be used to predict STP changes with time under variable P balance regimes, which is essential for realistic assessment of changes in the potential for dissolved P losses.

There has been lively debate, especially in Finland and Sweden, on the climate impacts of peat fuel. Previous studies of peat fuel's life-cycle climate impacts were controversial in their interpretation. The aim of this paper is conclusive examination of the issues of LCA methodology, derived from critical review of previous studies and recalculation based on the latest knowledge of greenhouse gas balances related to peat fuel’s utilisation and the radiative forcing impacts of greenhouse gases. The most recent findings on emissions and the gas fluxes between soil, vegetation and atmosphere were used in calculation of the life-cycle climate impacts of the various peat fuel utilisation chains by means of LCA methodology. In the main, the calculation methods and rules were the same as in the previous studies, with the aim being to distinguish the impact of peat fuel’s utilisation from that of the natural or semi-natural situation. A dynamic method was employed for assessing changes in radiative forcing. The results of alternative peat fuel utilisation chains were compared to the corresponding result for coal. There are many steps in peat fuel LCA, where different assumptions lead to different outcomes. Determining the functional unit, reference situations and system boundaries, as well as the emission calculation methods, is important from this point of view. Determination of the initial reference situation emerged as one of the critical points in the calculations. Time scale can strongly affect the final outcomes in a study where effects of long-term land-use change are considered. Each peatland area is unique. The higher the greenhouse gas emissions in the initial reference situation, the greater is the climate impact of the area and the more suitable the area is for peat extraction. The study showed that more greenhouse gas flux measurements are needed, for better assessment of the climate impacts of different potential peat extraction sites. Climate change mitigation requires quick actions, and uncertainties related to emissions are higher for longer time spans. Therefore, it can be concluded that a perspective spanning more than 100 years is inappropriate in peat fuel's life-cycle climate impact assessments.

Traditionally, a 2-step protocol has been used for deep biliary cannulation. The purpose of the present prospective study was to find out the feasibility and safety of the novel sequential 3-step protocol (traditional cannula with guidewire, double-guidewire, and needle-knife techniques) for deep biliary cannulation. All consecutive patients admitted for endoscopic retrograde cholangiopancreatography (ERCP) to a single, very experienced ERCP endoscopist during the year 2009 with intended biliary cannulation and with unhindered access to a native papilla (n=105) were included in the present study. The overall success rate for deep biliary cannulation was 99% (104/105). Cannulation with cannula and guidewire was attempted in all patients and proved successful in 80% (84/105) of the attempts, the double-guidewire technique was applied in 19% (20/105) and was successful in 65% (13/20) of the cases, and the needle-knife technique was applied in 7% (7/105) with success in all cases. The median cannulation time was 1 minute (range, 0 to 27 min). The rate of post-ERCP pancreatitis was 3% (3/105) and post-ERCP cholangitis 2% (2/105). We conclude that in experienced hands, the novel sequential 3-step protocol for biliary cannulation tested herein proved to be an effective cannulation protocol with the overall success rate of 99%. The complication rate of these ERCP procedures (5%) was within acceptable limits.

Suomessa kasvatetun kirjolohen pääasialliset ympäristövaikutukset tutkittiin Maa- ja elintarviketalouden tutkimuskeskuksen, Riista- ja kalatalouden tutkimuslaitoksen ja Suomen ympäristökeskuksen tekemässä yhteistyöhankkeessa 2009-2012. Tutkimus suoritettiin elinkaariarviointimenetelmällä ja tutkitut kvantitatiivisesti lasketut ympäristövaikutusluokat olivat rehevöityminen, ilmastonmuutos ja happamoituminen. Tutkimuksen pääasiallinen tavoite oli päivittää kymmenen vuoden takaiset tutkimustulokset (Seppälä ym. 2001). Tutkimustarve tiedostettiin, koska ennakolta tiedettiin kalankasvatuksen rehevöittävän kuormitusten pienentyneen johtuen rehun käyttömäärien pienentymisestä suhteessa kasvatettuun kalamäärään sekä rehujen kehityksestä. Saaristomeren ja Ahvenanmeren kalankasvatus poistettiin Suomen ympäristöministeriön vaatimuksesta Itämeren pahimpien ympäristökuormittajien niin kutsutulta hotspot-listalta Itämeren suojelukomission Helcomin 18.-19.11.2002 Tukholmassa pidetyssä kokouksessa. Tutkimuksen tavoitteena oli myös osoittaa kirjolohen kasvatuksen kehittämismahdollisuudet, vertaamalla erilaisten tuotantomenetelmien ympäristövaikutuksia. Kirjolohen kasvatuksen elinkaarisia ympäristövaikutuksia verrattiin myös ravitsemuksen kannalta muiden vaihtoehtoisten tuotteiden ympäristövaikutuksiin. Tässä vertailussa erityistä huomiota kiinnitettiin tuotteiden erilaiseen ravintosisältöön, nimenomaan kirjolohen sisältämiin arvokkaisiin omega3-rasvahappoihin. Elinkaariarvioinnissa huomioitiin kasvatetun kirjolohen tuotejärjestelmän toiminnot sisältäen rehun tuotantoketjuun kuuluvien alkutuotannon panostuotannon, raaka-aineiden viljely- sekä kalastusprosessin, rehun valmistusprosessin, poikaslaitoksen toiminnot, kasvatustoiminnat, erilaisten raaka-aineiden sekä rehun kuljetukset, pakkausten valmistuksen sekä kalan fileoinnin. Vertailtavien lihatuotteiden rajaukset tehtiin yhteneväisiksi ja siten vertailukelpoisiksi kirjolohen kanssa. Tärkein havainto oli se, että rehevöittävät päästöt olivat suhteessa tuotettuun kalamäärään vähentyneet vuosina 2002-2009 26 % johtuen sekä rehujen että ruokintatekniikan kehittymisestä. Elinkeinon absoluuttiset päästöt olivat pienentyneet noin 10 %. Muiden muutosten arviointi on vielä kesken, mutta rehun kulutusmäärä suhteessa kasvatettuun kalamäärään (rehukerroin) oli pienentynyt noin 10 %, mikä vaikuttaa hiilijalanjälkeen, happamoitumiseen ja primaarienergian kulutukseen. Hiilijalanjäljeksi saatiin fileetonnia kohti 4060 kg CO2-ekv/t ja rehevöittäviksi päästöiksi 38,6 kg PO4-ekv/t. Huomattava mahdollisuus vähentää kirjolohen kasvatuksen rehevöittäviin päästöihin havaitiin olevan tutkimustulosten mukaan Itämeren kalan käyttäminen kirjolohen ravintona. Tällöin ravinteita poistuisi Itämerestä kalastuksen mukana enemmän kuin mitä kirjolohen kasvatuksessa päätyy vesistöön.

Objective The aim of the present trial was to ascertain whether laparoscopic cholecystectomy (LCC) can prevent recurrent attacks of idiopathic acute pancreatitis (IAP). Summary Up to 50% to 75% of IAP may be due to microlithiasis, which is undetectable by conventional imaging methods. Methods This randomized, prospective trial included 85 patients (39 in the LCC and 46 in the control group) in 8 hospitals in Finland. We included adult patients (over 18 years) with their first attack of IAP. The diagnosis of IAP was based on the exclusion of common etiological reasons for acute pancreatitis (AP), whereafter the patients were randomized into conservative watchful waiting (controls) or LCC group. The primary end point was the number of patients with recurrent AP during the follow-up. All recurrent attacks of AP after an initial IAP episode were registered. Results During a median follow-up of 36 (5-58) months, the recurrence of IAP was significantly higher in the control group than in LCC group (14/46 vs. 4/39, P = 0.016), as was also the number of recurrences (23/46 vs. 8/39, P = 0.003). In the subgroup of patients with at least 24 months' follow-up, the recurrence was still higher among controls (14/37 vs. 4/35, P = 0.008). In patients with normal liver function, recurrence was also significantly higher in the control than in the LCC group (13/46 vs. 4/39, P = 0.026). During surgery, 23/39 (59%) of the gallbladders were found to contain biliary stones or sludge. Conclusions LCC can effectively prevent the recurrence of IAP when all other possible etiologies of pancreatitis are carefully excluded. A total of 5 patients needed to be treated (NNT-value) to prevent 1 IAP.

The aim of the study, on which this paper is based, was to provide guidance to consumers to make environmentally responsible choices in their food consumption, to assist food supply chain stakeholders to identify the key areas for environmental improvements, and to provide policy makers with a tool for monitoring the potential impacts on climate change resulting from developments within the food sector. At the macro level, the EIO-LCA model was developed specifically for the Finnish food chain; at the micro level, LCAs were performed on 30 lunch portions. The contribution of the Finnish food chain to climate change was 14%, which comprised 40% CO 2 emissions, 25% CH 4 emissions, and 34% N 2 O emissions. The share of impacts from domestic agricultural processes was the highest, at 69%. The impact of a single lunch portion ranged between 0.65 and 3.80 kg of equivalent CO 2 . According to the EIO-LCA model, the average impact was 7.7 kg CO 2 eq/person daily. The consumer phase accounted for between 8 and 47% of the climate change impacts for homemade portions. In ready-to-eat portions industry and retail phases were emphasized, representing 25–38% of climate change impacts. We present an approach to steer the Finnish food sector onto an environmentally sustainable path; practical tools for consumers and farmers will especially need to be developed further.

Background and Aims: Laparoscopic cholecystectomy (LC) via three or four ports has been the standard operation for gallstone disease. Recently, the development of multichannel port devices has allowed LCs to be performed through a single fascial incision in the umbilicus. Here, we report our experiences of the adoption of the single incision laparoscopic cholecystectomy (SILC) in two small-volume community hospitals. Material and Methods: From January until July 2010, 51 consecutive patients (41 females and 10 males, the mean age 44 (21–75) years, BMI 26 (18–35)) underwent elective SILC for symptomatic gallstone disease in Salo (n = 29) and Loimaa (n = 22) hospitals. Results: Of the 51 operations, 42 (82%) were accomplished without additional troacars. Seven (14%) procedures were converted to multiple-port technique and two (4%) to open cholecystectomy. In 25 (49%) operations, transabdominal retraction sutures through the gallbladder were used to maintain a good view of the triangle of Calot. The mean operative time was 74 (31–155) min. No major intraoperative complications occurred. The mean hospital stay was 0.6 (0–3) days. During a mean follow up of 4 (1–7) months, five (10%) patients had wound infection, and one (2%) had hematoma and prolonged pain in the insertion site of the retraction suture. One (2%) patient was reoperated for continuous pain in umbilical wound without findings at operation but with good results. One (2%) patient had subphrenic abscess seven months postoperatively. Conclusions: Our initial experiences indicate that SILC can be adopted without major complications in small-volume hospitals but the rate of wound infections seems to increase with the introduction of SILC.

After the introduction of laparoscopic cholecystectomy (LC), scientific discussion and concern about iatrogenic bile duct injuries (BDIs) have been limited mostly to BDIs sustained in LC, while BDIs sustained in open cholecystectomy (OC) and in all cholecystectomies have not been the center of attention. This study included all patients who sustained BDI in OC or LC in southwest Finland between 1997 and 2007. All data were collected retrospectively in June 2009. Altogether 75 BDIs were encountered in a total of 8349 cholecystectomies, for an overall incidence of 0.90%. Twenty BDIs (15 Amsterdam type A and 5 type B, C, or D) occurred in the 1616 OCs (incidence rate = 1.24%), and 55 (26 type A and 29 type B, C, or D) in the 6733 LCs (incidence rate = 0.82%). All the BDIs in the OCs were missed while 11/29 of the major BDIs in the LCs were detected at the time of surgery. Fifty-four of 59 type A, B, and C BDIs could be treated endoscopically. In the laparoscopic era, OC is associated with a high number of BDIs, if minor BDIs are included. Excluding some major LC BDIs, BDIs are, as a rule, missed at the time of surgery. More than 90% of Amsterdam types A, B, and C BDIs can be treated endoscopically, whereas type D BDI remains an absolute indication for surgery.

Aim Conventional outcomes such as survival, tumour recurrence and complication rates after surgery for rectal cancer have been rigorously assessed, but the importance of maintaining quality of life (QOL) after surgery for rectal cancer has received less attention. The aim of the current study was to analyse QOL and the occurrence of pelvic dysfunction after the surgical treatment of rectal cancer. Method Between May 2005 and May 2008, 150 patients with rectal cancer underwent abdominoperineal resection (APR) or anterior resection (AR). Seventy-four answered two preoperative questionnaires. At a follow up of 1 year, 65 were alive without sign of recurrence and answered the same questionnaires: (a) validated RAND 36-item health survey QOL questionnaire; and (b) self-administered disease-related questionnaire with special reference to anorectal and urogenital function. Results The postoperative general QOL was similar after surgery, and mental functioning was better (P

Background: Laparoscopic cholecystectomy (LC) is today the operation of choice for symptomatic gallstone disease. Before the laparoscopic era intraoperative cholangiography (IOC) was generally considered as a fundamental step in cholecystectomy while nowadays the role of IOC is controversial: is there a need for IOC to specify anatomy of biliary tree in order to avoid bile duct injuries (BDI) and to detect possible common bile duct (CBD) stones or not? Patients and Methods: We studied retrospectively all the elective LCs done in Turku City Hospital for Surgery during the ten years (1992–2001). Cholecystectomy was performed to 1101 patients, 874 (79%) female and 227 (21%) male patients, mean age 53y (range 15–89). LC was possible in 1022 (93%) cases while 79 (7%) had to be converted to open procedure. The number and severity of bile duct injuries were recorded. The cases with endoscopic retrograde cholangiopancreatography (ERCP) and/or magnetic resonance cholangiopancreatography (MRCP) during the follow-up and the findings in ERCP and MRCP were recorded from patient records and radiological database. Results: IOC was performed in 32 operations (20 in LC and 12 after conversion) and CBD stones were found in seven patients. There were four primary BDIs: two CBD injuries and two minor bile leaks. During a mean follow-up of 72 months (range 36–144) ERCP was performed in 16 and MRCP in three patients. Three patients underwent both MRCP and ERCP. CBD stones were detected in ten patients and a postoperative late CBD stricture was found in one case. Conclusions: According to our data, both the incidence of BDIs (0.5%) and symptomatic postoperative CBD stones (0.9%) remain low without the routine use of IOC.

Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis, but long-term outcomes are not known.To determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis.Five-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotic therapy, in which 530 patients aged 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis were randomized to undergo an appendectomy (n = 273) or receive antibiotic therapy (n = 257). The initial trial was conducted from November 2009 to June 2012 in Finland; last follow-up was September 6, 2017. This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone.Open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole.In this analysis, prespecified secondary end points reported at 5-year follow-up included late (after 1 year) appendicitis recurrence after antibiotic treatment, complications, length of hospital stay, and sick leave.Of the 530 patients (201 women; 329 men) enrolled in the trial, 273 patients (median age, 35 years [IQR, 27-46]) were randomized to undergo appendectomy, and 257 (median age, 33 years, [IQR, 26-47]) were randomized to receive antibiotic therapy. In addition to 70 patients who initially received antibiotics but underwent appendectomy within the first year (27.3% [95% CI, 22.0%-33.2%]; 70/256), 30 additional antibiotic-treated patients (16.1% [95% CI, 11.2%-22.2%]; 30/186) underwent appendectomy between 1 and 5 years. The cumulative incidence of appendicitis recurrence was 34.0% (95% CI, 28.2%-40.1%; 87/256) at 2 years, 35.2% (95% CI, 29.3%-41.4%; 90/256) at 3 years, 37.1% (95% CI, 31.2%-43.3%; 95/256) at 4 years, and 39.1% (95% CI, 33.1%-45.3%; 100/256) at 5 years. Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis, 76 had uncomplicated appendicitis, 2 had complicated appendicitis, and 7 did not have appendicitis. At 5 years, the overall complication rate (surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms) was 24.4% (95% CI, 19.2%-30.3%) (n = 60/246) in the appendectomy group and 6.5% (95% CI, 3.8%-10.4%) (n = 16/246) in antibiotic group (P .001), which calculates to 17.9 percentage points (95% CI, 11.7-24.1) higher after surgery. There was no difference between groups for length of hospital stay, but there was a significant difference in sick leave (11 days more for the appendectomy group).Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis, the likelihood of late recurrence within 5 years was 39.1%. This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis.ClinicalTrials.gov Identifier: NCT01022567.

BACKGROUND Extrahepatic cholestasis is usually caused by either a bile duct stone or a stricture. In early phase in primary care, when novel imaging studies such as magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography (ERCP) are seldom available, the differential diagnosis between benign and malignant causes is clinically challenging. The aim of the present study was to analyze the value of the degree of common bile duct dilatation in differential diagnosis of extrahepatic cholestasis. METHODS In all, 212 consecutive patients in whom a bile duct stricture (n=103) or a stone (n=109) had been found in ERCP were included in the study population. The maximum diameter of the common bile duct was measured from ERCP images. Plasma bilirubin concentration was measured before ERCP. RESULTS The median (range) values for the common bile duct diameter for the patients with a stricture and those with a stone were 16 (5 to 33 mm) and 15 mm (6 to 29 mm), respectively (P=0.0038). In receiver operating characteristic analysis, the difference was barely significant when compared with random value (P=0.0399). Area under curve for bile duct diameter was 0.615. CONCLUSIONS In conclusion, the degree of bile duct dilatation does not aid in differential diagnosis between benign and malignant causes of extrahepatic cholestasis.

This article presents the development process of a consumer-oriented, illustrative benchmarking tool enabling consumers to use the results of environmental life cycle assessment (LCA) to make informed decisions. LCA provides a wealth of information on the environmental impacts of products, but its results are very difficult to present concisely and in a way that is understandable to non-experts. A participatory co-development process was thus deemed necessary to create an easy-to-use presentation format. A brochure presenting the benchmarking tool was developed in an iterative process involving consumer focus groups, stakeholder workshops, and questionnaire-based feedback. The co-development process proved its value: in addition to learning what works and what does not, detailed suggestions on improved wording and figures were obtained, as well as a wealth of ideas for future applications.

Patients with iatrogenic bile duct injury often require a variety of interventions that may range from endoscopic procedures to complex open surgery. Injuries involving both stricture and leakage, in particular, are a clinical challenge as early measures are mandatory because of leakage. However, early open surgery is often hazardous in these cases because of ongoing infection at the point of injury and around it caused by the leakage. Therefore, these patients should be treated endoscopically and percutaneously as long as possible, although iatrogenic, often narrow stricture hampers these efforts. In the present paper, the clinical value of a rendezvous technique is emphasized. This technique improves the success rate for endoscopic stenting in iatrogenic bile duct injuries. In the literature, there are no earlier reports on biliary rendezvous procedures in patients with bile duct injuries.

Iatrogenic bile duct injury carries high morbidity. After the introduction of laparoscopic cholecystectomy the incidence of these injuries has at least doubled, and even after the learning curve, the incidence has plateaued at the level of 0.5%.A total of 32 patients sustained biliary tract injuries of the 3736 laparoscopic cholecystectomies performed in and around Turku University Central Hospital between January 1995 and April 2002. The data concerning primary treatment and long-term results were collected and analyzed retrospectively.The overall incidence for bile duct injuries, including all the minor injuries (cystic duct leaks and bile duct strictures), was 0.86%; for major injuries alone the incidence was 0.38%. Nineteen percent of the injuries were detected intraoperatively. All the cystic duct leaks were treated endoscopically with a 90% success rate. Of the bile duct strictures 88% were treated successfully with endoscopic techniques. Ninety-three percent of the major injuries, including tangential lesions of common bile duct and total transections, were treated operatively. The operation of choice was either hepaticojejunostomy or cholangiojejunostomy in 69% of the cases; the rest were treated with simple suturing over a T-tube or an endoscopically placed stent. The long-term results, with a median follow-up period of 7.5 years, are good in 79% of the operated patients and in 84% of the whole study population. Mortality rate was 3% and acute or chronic cholangitis was seen in 13% of the patients during follow-up.Most of the minor bile duct injuries, including cystic duct leaks and bile duct strictures, are well treatable with endoscopic techniques, whereas most of the major injuries require operative treatment, which at optimal circumstances gives good results.

Life cycle assessment (LCA) has been recognized in the EU in the context of ‘Integrated Product Policy’ (IPP) as providing “the best framework for assessing the potential environmental impacts of products currently available.” A study to promote the use of LCA-based product information was designed, with the following objectives: (a) to develop different benchmarks to which the LCA results of various products can be compared, (b) to study how consumers understand the different benchmarks and what proposals for improvement they have, and (c) to propose a few presentation formats and benchmarks for presenting LCA-based information in communications to consumers. Here we present the final results, i.e., the suggested benchmarks and presentation formats, ‘eco-benchmark’. We also present some lessons derived from the feedback gained from consumers and other stakeholders, and point out future directions for improving the benchmarks and their utilization.