New onset postoperative atrial fibrillation and early anticoagulation after cardiac surgery.

OBJECTIVES: New onset postoperative atrial fibrillation (POAF) after cardiac surgery is associated with increased risk for thromboembolic complications. Compliance with anticoagulation treatment is prerequisite for successful outcome after POAF. We hypothesized that a disciplined anticoagulation protocol initiated instantly after POAF secures a long-term outcome. DESIGN: A total of 519 consecutive patients undergoing cardiac surgery were retrospectively analyzed. Patients received anticoagulation using warfarin whenever POAF lasted longer than five min. Postoperative outcome including mortality, myocardial infarction and stroke were compared with patients on sinus rhythm (non-POAF). RESULTS: Mean age of the study cohort was 64.3 ± 9.0 years and median follow-up time was 76 months. There were 177 (34%) POAF and 342 (66%) non-POAF patients. At discharge, 144 (81%) POAF patients complied with warfarin, while 82 (24%) non-POAF patients received warfarin for non-rhythm causes (p < .001). Mortality was higher in POAF as compared with non-POAF patients (p = .03). After adjustment for comorbidities, major adverse clinical events (MACE)- including a combination of late cardiovascular mortality, myocardial infarction, stroke and late atrial fibrillation- was independently associated with POAF (OR 2.73, 95%CI 1.69-4.45, p < .0001). CONCLUSIONS: POAF after cardiac surgery was associated with high risk of MACE. Early anticoagulation may be justified in POAF patients to secure a long-term outcome after cardiac surgery.

Medication-induced acute esophageal necrosis: a case report.

BACKGROUND: Acute esophageal necrosis or Gurvits syndrome is a rare clinical condition characterized by necrotic esophageal mucosa with an abrupt end at the gastroesophageal junction. Its etiology is multifactorial, but mainly related to low-flow states. We describe a case in which a patient accidentally took the wrong medication, with clozapine and olanzapine most probably being the cause of his subsequent acute esophageal necrosis. This situation is, to the best of our knowledge, unprecedented in the medical literature. CASE PRESENTATION: A 65-year-old Finnish male patient with schizoaffective disorder accidentally took another patient's medication, including clozapine 300 mg, olanzapine 30 mg, teofyllamine 200 mg, warfarin 5 mg, and potassium chloride 1 g. He arrived at our hospital for a routine examination 6 h after the incident. At hospital he started to vomit brownish liquid and had tachycardia and fever. Gastroparesis was found. An endoscopy revealed necrotic esophageal mucosa that was typical for Gurvits syndrome. A computed tomography scan showed an edematous esophagus and raised suspicion of a proximal jejunal obstruction. A laparotomy was performed but only healthy paralytic bowel was found. Our patient healed uneventfully within a week. CONCLUSIONS: There are analogous case reports describing ischemic colitis associated with the use of clozapine and olanzapine, but none describing the same for the other medications our patient took. We believe that in this case clozapine and olanzapine caused acute esophageal necrosis and this possibility should be taken into account when treating patients with acute ischemic enteropathy.

[Emergency craniotomies at the North Karelia Central Hospital in 2006 to 2014]. / Hätäkraniotomiat Pohjois-Karjalan keskussairaalassa vuosina 2006-2014.

Traditionally, acute evacuations of traumatic intracranial hematomas are performed by neurosurgeons in university hospitals. However, most patients with traumatic brain injury are initially transported to regional hospitals that lack neurosurgical expertise. Thus, a trauma surgeon in a regional hospital may encounter a patient with an expanding hematoma that must be operated without delays. During 2006 to 2014, 14 craniotomies were performed at the North Karelia Central Hospital. Twelve patients were operated for acute traumatic subdural hematoma (ASDH): three patients made good recovery, two were left with severe disability, and seven died. Two patients operated with acute epidural hematoma (EDH) recovered well.

[Thoracic lavage and open cardiac massage as treatment of hypothermic cardiac arrest--case report]. / Avoin sydänhieronta ja rintaontelon huuhtelu hypotermisen sydänpysähdyksen hoitona.

Cardiopulmonary bypass is the treatment of choice for a severely hypothermic patient with cardiac arrest. However, the treatment is not always available. We describe a successful three-and-a-half hour resuscitation of a hypothermic cardiac arrest patient with manual chest compressions followed by open cardiac massage and rewarming with thoracic lavage.

Vascular comorbidities and demographics of patients with ruptured abdominal aortic aneurysms.

BACKGROUND: The results of previous studies reporting the epidemiology of ruptured abdominal aortic aneurysm (RAAA) are highly heterogeneous. Furthermore, although RAAA and the preceding abnormal dilation of the abdominal aorta (AAA) are associated with other cardiovascular comorbidities, the demographic profile of all patients with RAAA has not been thoroughly investigated. OBJECTIVE: To document accurately the epidemiology, survival, and demographic data (including vascular comorbidities and previous use of health care services) in RAAA-patients. MATERIAL AND METHODS: We conducted a comprehensive retrospective register study of all RAAA patients (operatively treated RAAA patients as well as in- and out-of-hospital nonsurvivors) in a well-defined geographic area during an 11-year period. RESULTS: We found 488 RAAA cases in a catchment area of 689,000. The annual incidence of RAAA was 6.5/100,000. Of these patients 43.2% were underwent surgery. Overall mortality was 79.5%, and 27.5% of the population died out-of-hospital. Age was the only independent risk factor affecting survival (P < .0001). The mean age at the time of RAAA was 73.6 years for men and 82.3 years for women. Off all unexpected RAAA patients, 40% had a previous history of cardiovascular disease (most often coronary artery disease: 32%), and 38% had visited a physician within the previous year. CONCLUSION: RAAA remains a highly lethal condition with age as the only significant risk factor for mortality. The proportion of women increases strongly with age. A large proportion of patients with unexpected RAAA have history of cardiovascular disease.

Randomized Multicenter Trial Comparing Glue Fixation, Self-gripping Mesh, and Suture Fixation of Mesh in Lichtenstein Hernia Repair (FinnMesh Study).

OBJECTIVE: Three different mesh fixation techniques were compared to find out how to perform a safe and cost-effective open inguinal hernioplasty in day-case setting with the best outcomes with regard to chronic pain. SUMMARY BACKGROUND DATA: Mesh fixation method may influence on the incidence of chronic pain after Lichtenstein hernioplasty. METHODS: Lichtenstein hernioplasty was performed under local anesthesia in 625 patients as day-case surgery in 8 Finnish hospitals. The patients were randomized to receive either a cyanoacrylate glue (Histoacryl, n = 216), self-gripping mesh (Parietex ProGrip, n = 202), or conventional nonabsorbable sutures (Prolene 2-0, n = 207) for mesh fixation. The incidence of wound complications, pain, recurrences, and patients discomfort was recorded on days 1, 7, 30, and 1 year after surgery. The primary endpoint was the sensation of pain measured by pain scores and the need of analgesics after 1 year of surgery. RESULTS: The type and size of inguinal hernias were similar in the 3 study groups. The duration of operation was 34 ±â€Š13, 32 ±â€Š9, and 38 ±â€Š9 minutes in the glue, self-gripping, and suture groups, respectively (P < 0.001). There were no significant differences postoperatively in pain response or need for analgesics between the study groups. Two superficial infections (0.3%), 31 wound seromas (5.0%), and 4 recurrent hernias (0.6%) were recorded during a 1-year follow-up. Some 25 patients (4.2%) needed occasionally analgesics for chronic groin pain. A feeling of a foreign object and quality of life were similar in all study groups. CONCLUSIONS: This randomized trial failed to prove that mesh fixation without sutures causes less inguinodynia than suture fixation in Lichtenstein hernioplasty. Mesh fixation without sutures is feasible without compromising postoperative outcome.

An autochthonous case of cystic echinococcosis in Finland, 2015.

We report a case of pulmonary cystic echinococcosis in a child from eastern Finland with no history of travelling abroad. The cyst was surgically removed and the organism molecularly identified as Echinococcus canadensis genotype G10. This parasite is maintained in eastern Finland in a sylvatic life cycle involving wolves and moose; in the present case, the infection was presumably transmitted by hunting dogs.

The prevalence of abdominal aortic aneurysm is consistently high among patients with coronary artery disease.

OBJECTIVE: Emerging evidence suggests high prevalence of abdominal aortic aneurysm (AAA) among patients with coronary disease. Accurate characterization of the association between coronary disease and AAA and of the actual prevalence of AAA among patients with angiography-verified coronary artery disease (CAD) is needed to evaluate the possible benefits of systematic screening for AAA. METHODS: We searched for studies that reported the association between AAA and CAD or coronary heart disease (CHD; wider phenotype definition) in the general population (randomized controlled trials, prospective population cohorts) and those that reported the prevalence of AAA among patients with angiography-verified CAD through PubMed, Embase, and reference lists for the period between 1980 and 2014. Random-effects models were applied because of the high heterogeneity between included studies. RESULTS: Among the general population, 23 studies reported the association between CHD and the occurrence of subclinical AAA (positive ultrasound screening; meta-analyzed odds ratio of 2.38 with 95% confidence interval [CI] of 1.78-3.19; P = 4.1 × 10(-9)). According to four prospective studies, CHD is a strong predictor of future AAA events (fatal and nonfatal; meta-analyzed hazard ratio of 3.49 with 95% CI of 2.56-4.76; P = 2.4 × 10(-15)). Altogether, 10 studies reported the prevalence of AAA among patients with angiography-verified CAD or undergoing coronary artery bypass grafting. Among men, meta-analyzed prevalence was 9.5% (95% CI, 7.6%-11.7%). Among men undergoing coronary artery bypass grafting or with three-vessel disease, the prevalence was 11.4% (95% CI, 9.1%-13.9%). Among women, the prevalence was low (0.35%). CONCLUSIONS: The risk of subclinical AAA and future AAA events is high among patients with coronary disease. Screening for AAA among CAD patients by cardiologists would be easy and inexpensive, with possible benefits to survival and risk evaluation.

Screening Men with Coronary Heart Disease for Abdominal Aortic Aneurysm: A Prospective Cohort Study.

BACKGROUND: The prevalence of abdominal aortic aneurysms (AAA) is higher among patients with coronary heart disease (CHD) compared with control population. OBJECTIVE: To assess and determine the prevalence of non-diagnosed AAA in men with CHD. MATERIALS AND METHODS: A total of 438 active male out-patients with CHD were screened for AAA by abdominal ultrasound (US) examination. The largest infrarenal aortic dimension was registered. The patient was regarded to have AAA when the aortic diameter was greater than 30 mm. RESULTS: We found altogether 25 AAAs. The incidence of AAA was 5.7%. One AAA patient was operated on, and the other AAA patients are under surveillance. Independent predictors for AAA among CHD patients were increased age, family history of AAA, and current or previous smoking. The screening process took on average 5 min per patient, and the cost of screening was 15 ($18.50) per patient or 257 ($325) per found AAA. CONCLUSIONS: The prevalence of previously undiagnosed AAAs among patients with CHD is considerable. Screening of AAA should be considered among active patients with CHD. The most feasible and simplest option would be to perform the screening during any routine or elective cardiac US by a cardiologist, and we recommend to adopt it as a standard practice.

Open Mesh Repair for Inguinal Hernia is Safer than Laparoscopic Repair or Open Non-mesh Repair: A Nationwide Registry Study of Complications.

BACKGROUND: Inguinal hernia repair is the most common elective procedure in general surgery. Therefore, the number of patients having complications related to inguinal hernia surgery is relatively large. The aim of this study was to compare complication profiles of inguinal open mesh (OM) hernioplasties with open non-mesh (OS) repairs and laparoscopic (LAP) repairs using retrospective nationwide registry data. METHODS: The database of the Finnish Patient Insurance Centre (FPIC) was searched for complications of inguinal and femoral hernia repairs during 2002-2010. Complications of OM repairs were compared to complications of OS repairs and LAP repairs. RESULTS: Over 75 % of all inguinal hernia procedures during the study period in Finland were OM hernioplasties. FPIC received 245 complication reports after OM repairs, 40 after OS repairs, and 50 after LAP repairs. Reported complications were significantly more severe after LAP and OS repairs than OM surgery (p<0.001). Visceral complications (p<0.001), deep infections (p<0.001), and deep hemorrhagic complications (p<0.001) were overrepresented in the LAP group. In the OS group, visceral complications (p<0.001), recurrences (p<0.001), and severe neuropathic pain (p<0.001) predominated. CONCLUSION: LAP and OS repairs of inguinal hernia were associated with more severe complications than open surgery with mesh in this study.

Rewarming a patient with accidental hypothermia and cardiac arrest using thoracic lavage.

The optimal treatment for severe accidental hypothermia is cardiopulmonary bypass because this offers the most rapid rate of rewarming. However, cardiopulmonary bypass therapy is not available in every hospital. In these circumstances, rewarming has to be achieved with other methods. We present a patient who was successfully rewarmed with thoracic lavage after he had been found with a core temperature of 21°C and asystole.

[Epiglottitis and necrotizing mediastinitis in a middle-aged man]. / Keski-ikäisen miehen epiglottiitti ja nekrotisoiva mediastiniitti.

Acute epiglottitis is nowadays a rare bacterial infection. Airway management and promptly started antimicrobial medication are essential in the treatment. Descending necrotizing mediastinitis is a life-threatening bacterial infection that typically spreads from an odontogenic, pharyngeal or neck infection. Despite the vagueness of symptoms, diagnosis must be made quickly. Owing to the high mortality rate, aggressive surgical treatment is indicated.

Fatal surgical or procedure-related complications: a Finnish registry-based study.

INTRODUCTION: In Finland, all healthcare personnel must be insured against causing patient injury. The Patient Insurance Centre (PIC) pays compensation in all cases of malpractice and in some cases of infection or other surgical complications. This study aimed to analyze all complaints relating to fatal surgical or other procedure-related errors in Finland during 2006-2010. MATERIALS AND METHODS: In total, 126 patients fulfilled the inclusion criteria. Details of patient care and decisions made by the PIC were reviewed, and the total national number of surgical procedures for the study period was obtained from the National Hospital Discharge Registry. RESULTS: Of the 94 patients who underwent surgery, most fatal surgical complications involved orthopedic or gastrointestinal surgery. Non-surgical procedures with fatal complications included deliveries (N = 10), upper gastrointestinal endoscopy or nasogastric tube insertion (N = 8), suprapubic catheter insertion (N = 4), lower intestinal endoscopy (N = 5), coronary angiogram (N = 1), pacemaker fitting (N = 1), percutaneous drainage of a hepatic abscess (N = 1), and chest tube insertion (N = 2). In 42 (33.3 %) cases, patient injury resulted from errors made during the procedure, including 24 technical errors and 15 errors of judgment. There were 19 (15.2 %) cases of inappropriate pre-operative assessment, 28 (22.4 %) errors made in postoperative follow-up, 23 (18.4 %) cases of fatal infection, and 11 (8.8 %) fatal complications not linked to treatment errors. CONCLUSION: Fatal surgical and procedure-related complications are rare in Finland. Complications are usually the result of errors of judgment, technical errors, and infections.

Traumatic intercostal arterial bleeding controlled with a novel surgical technique: a case report.

INTRODUCTION: A blunt thoracic trauma may cause arterial bleeding requiring operative treatment or endovascular embolization or endovascular aortic stenting. A novel damage control technique to stop such bleeding is presented. CASE PRESENTATION: We present the case of an 82-year-old Caucasian man who experienced rib fractures I-VII on the left side and bleeding from damaged intercostal arteries after a blunt thoracic trauma. Emergency thoracotomy was performed. CONCLUSIONS: Effective hemostasis was achieved by using a rolled surgical swab and inserting it against the chest wall next to the aorta with sutures pulled through the intercostal muscles and then sutured to the back side of the patient. The patient died four days after the surgery due to a head injury sustained in the car crash.

Effect of triclosan-coated sutures on the incidence of surgical wound infection after lower limb revascularization surgery: a randomized controlled trial.

BACKGROUND: Surgical wound infection (SWI) is a common complication after peripheral vascular surgery. In a prospective study, triclosan-coated sutures were reported to decrease the incidence of surgical site infection after various surgical procedures. The aim of our study was to test the hypothesis that use of triclosan-coated sutures decreases the incidence of SWI after lower limb vascular surgery. METHODS: This prospective, randomized, multicenter, double-blinded trial was conducted between July 2010 and January 2011 in five hospitals in Finland. We randomly allocated 276 patients undergoing lower limb revascularization surgery to a study (n = 139) or a control (n = 137) group. Surgical wounds in the study group were closed with triclosan-coated suture material, and wounds in the control group were closed with noncoated sutures. The main outcome measure was SWI. A surgical wound complication was considered to be an infection if there were bacteria isolated from the wound or if there were areas of localized redness, heat, swelling, and pain around the wound appearing within 30 days after the operative procedure. Logistic regression analysis was used to assess the independent effect of triclosan-coated sutures on the incidence of SWI. RESULTS: Altogether, 61 (22.1 %) patients developed SWI. SWI occurred in 31 (22.3 %) patients in the study group and in 30 (21.9 %) patients in the control group (odds ratio 1.10, 95% confidence interval 0.61-2.01, p = 0.75.) CONCLUSIONS: The use of triclosan-coated sutures does not reduce the incidence of SWI after lower limb vascular surgery.

Supplemental postoperative oxygen in the prevention of surgical wound infection after lower limb vascular surgery: a randomized controlled trial.

BACKGROUND: Surgical wound infection (SWI) is a common complication after peripheral vascular surgery. Infections increase morbidity and costs of treatment. The aim of the present study was to test the hypothesis that supplemental postoperative oxygen decreases the incidence of SWI after lower limb revascularization. METHODS: This prospective, randomized, multicenter, single-blinded trial was conducted between May 2009 and February 2010 in six secondary referral hospitals in Finland. We randomly allocated 274 patients undergoing surgery for lower limb revascularization to the study group (n=137) or a control group (n=137). The study group received supplemental inspired oxygen for the first 2 days after surgery. The main outcome was SWI. Patients were followed up for 30 days or until the SWI was healed. Logistic regression analysis was used to assess the independent effect of supplemental oxygen on the incidence of SWI. RESULTS: Altogether 63 (23%) patients developed SWI; 47 (75%) of the infections were superficial. There were two vascular graft infections. SWI occurred in 25 patients (18.2%) in the study group and in 38 patients (27.7%) in the control group [odds ratio (OR) 0.56, 95% confidence interval (CI) 0.30-1.04; P=0.07]. In isolated groin incisions, 3 patients of 52 (5.8%) in the study group and 12 patients of 51 (23.5%) in the control group developed SWI; OR=0.20, 95% CI 0.04-0.95; P=0.04. CONCLUSIONS: There was an indication that supplemental inspired oxygen tended to decrease the incidence of SWI after lower limb vascular surgery. In isolated groin incisions, the decrease of SWI incidence in the supplemental oxygen group was significant.