Short- and long-term mortality and causes of death after reconstruction of cancers of the head and neck with free flaps.

The use of free flaps to reconstruct cancers of the head and neck is accompanied by appreciable postoperative morbidity and high long-term mortality, but the causes of death and the impact of postoperative complications on survival have not been well studied. We have therefore analysed retrospectively the causes of death and survival of 146 such patients operated on between 2008 and 2016 of whom a total of 62 (43%) had died by the end of 2016. The cause of death was the primary disease in 45 of the 62. The median survival of those who died with the primary cancer as the cause of death did not differ from that of those who died of other causes. In a multivariate Cox model indicators of five-year mortality were male sex, low body mass index (BMI), American Society of Anesthesiologists (ASA) grade more than II, and late medical complications. Neither the size of the tumour nor any operative factors were independent risks for five-year mortality. Ten patients died within six months of operation, all of whom had higher postoperative C-reactive protein concentrations than those who survived for more than six months. The cause of death of most patients who died after free flap operations for head and neck cancer was the primary diagnosis. According to these results, patient-related factors (male sex, ASA grade more than II, low BMI, and low albumin concentration) have an important role in long-term survival, which highlights the importance of careful selection of patients for operative treatment.

Complications and outcome after free flap surgery for cancer of the head and neck.

We retrospectively studied 136 patients who had free flap reconstruction for cancer of the head and neck at a single centre (2008-2015) to evaluate complications, assess factors associated with them, and analyse their impact on outcome. Preoperative and perioperative data, and surgical and medical complications were recorded, and the impact of the complications on duration of hospital stay and survival were assessed. A total of 86 (63%) patients had complications. Compared with those who did not, they had a higher rate of alcohol abuse (21/86, compared with 5/50, p=0.039), longer operations (median (IQR) 565 (458-653 compared with 479 (418-556) minutes, p<0.001), and greater intraoperative loss of blood (725 (400-1150) compared with 525 (300-800) ml, p=0.042). Complications were more common in patients who had fibular flaps and T4 disease (22/86 compared with 4/50, p=0.010; 47/80 compared with 16/47, p=0.015, respectively). Those who had complications also stayed in hospital longer (median (IQR) 9 (7-12) compared with 15 (10-21) days, p<0.001). Cumulative mortality was higher in patients with late complications (those that occurred after the fourth postoperative day) (61% compared with 36%, p=0.004). In conclusion, complications in more than half the patients were related to alcohol abuse, a more complicated intraoperative course, and fibular flaps. Complications were associated with a longer hospital stay, and survival was higher in those who did not have late complications than in those who did.

Spinal or general anaesthesia for lower-limb amputation in peripheral artery disease - a retrospective cohort study.

BACKGROUND: The present study aimed to determine which method of anaesthesia (spinal anaesthesia or general anaesthesia) is better in reducing post-operative analgesic requirements in patients undergoing major limb amputation for lower-limb ischaemia. Another aim was to find out if anaesthesiologists use neuraxial anaesthesia in high-risk patients despite abnormal coagulation profile or use of anticoagulation. METHODS: The study was a retrospective cohort study. All patients undergone above-the-knee amputation or below-the-knee amputation due to peripheral artery disease between 1996 and 2010 were reviewed to evaluate post-operative opioid consumption and complications. RESULTS: A total of 434 amputations in 323 patients were included in the study. The number of surgical complications, the need for surgical revision and the number of intensive care unit admissions were significantly higher in the general anaesthesia group. The need for post-operative opioid medication was significantly lower in patients with above-the-knee amputation and spinal anaesthesia. The use of post-operative epidural analgesia did not reduce analgesic requirements. In the present study, there were patients who received neuraxial anaesthesia despite abnormal coagulation profile or uninterrupted warfarin or clopidogrel. There were no reported cases of spinal or epidural haematoma. CONCLUSION: Patients with spinal anaesthesia had a lower rate of surgical complications, re-operations and intensive care unit admissions. Patients with above-the-knee amputation and spinal anaesthesia had a lesser need for opioid medication in the post-operative period than patients with general anaesthesia. Anaesthesiologists performed neuraxial anaesthesia and/or analgesia in high-risk patients despite abnormal coagulation profile or ongoing anticoagulation, but no adverse outcomes were reported.

Has the income of the residential area impact on the use of intensive care?

BACKGROUND: The socioeconomic factors have an impact on case mix and outcome in critical illness, but how these factors affect the use of intensive care is not studied. The aim of this study was to evaluate the incidence of intensive care unit (ICU) admissions in patients from residential areas with different annual incomes. METHODS: Single-center, retrospective study in Northern Finland. All the non-trauma-related emergency admissions from the hospital district area were included. The postal codes were used to categorize the residential areas according to each area's annual median income: the low-income area, €18,979 to €28,841 per year; the middle-income area, €28,879 to €33,856 per year; and the high-income area, €34,221 to €53,864 per year. RESULTS: A total of 735 non-trauma-related admissions were included. The unemployment or retirement, psychiatric comorbidities and chronic alcohol abuse were common in this population. The highest incidence, 5.5 (4.6-6.7)/1000/year, was in population aged more than 65 years living in high-income areas. In working-aged population, the incidence was lowest in high-income areas (1.5 (1.3-1.8/1000/year) compared to middle-income areas (2.2 (1.9-2.6)/1000/year, P = 0.001) and low-income areas (2.0 (1.7-2.4)/1000/, P = 0.009). Poisonings were more common in low-income areas. There were no differences in outcome. CONCLUSION: The incidence of ICU admission in working-aged population was 25% higher in those areas where the annual median income was below the median annual income of €38,775 per inhabitant per year in Finland.

Evaluating helicopter emergency medical missions: a reliability study of the HEMS benefit and NACA scores.

BACKGROUND: The benefits of the Helicopter Emergency Medical Service (HEMS) and dispatch accuracy are continuously debated, and a widely accepted score to measure the benefits of the mission is lacking. The HEMS Benefit Score (HBS) has been used in Finnish helicopter emergency medical services, but studies are lacking. The National Advisory Committee for Aeronautics (NACA) score is widely used to measure the severity of illness or injury in the pre-hospital setting, but it has many critics due to its subjectivity. We investigated the inter-rater and rater-against-reference reliability of these scores. METHODS: Twenty-five fictional HEMS missions were created by an expert panel. A total of 22 pre-hospital physicians were recruited to participate in the study from two different HEMS bases. The participants received written instructions on the use of the scores. Intraclass correlation coefficients (ICCs) and mean differences between rater-against-reference values were calculated. RESULTS: A total of 17 physicians participated in the study. The ICC was 0.70 (95% CI 0.57-0.83) for the HBS and 0.65 (95% CI 0.51-0.79) for the NACA score. Mean differences between references and raters were -0.09 (SD 0.72) for the HBS and 0.28 (SD 0.61) for the NACA score, indicating that raters scored some lower NACA values than reference values formed by an expert panel. CONCLUSION: The HBS and NACA score had substantial inter-rater reliability. In addition, the rater-against-reference values were acceptable, though large differences were observed between individual raters and references in some clinical cases.

Fatal injuries in rural and urban areas in northern Finland: a 5-year retrospective study.

BACKGROUND: Finland has the fourth highest injury mortality rate in the European Union. To better understand the causes of the high injury rate, and prevent these fatal injuries, studies are needed. Therefore, we set out to complete an analysis of the epidemiology of fatal trauma, and any contributory role for alcohol, long suspected to promote fatal injuries. As a study area, we chose the four northernmost counties of Finland; their mix of remote rural areas and urban centres allowed us to correlate mortality rates with 'rurality'. METHODS: The Causes of Death Register was consulted to identify deaths from external causes over a 5-year time period. Data were retrieved from death certificates, autopsy reports and medical records. The municipalities studied were classified as either rural or urban. RESULTS: Of 2915 deaths categorized as occurring from external causes during our study period, 1959 were eligible for inclusion in our study. The annual crude mortality rate was 54 per 100,000 inhabitants; this rate was higher in rural vs. urban municipalities (65 vs. 45 per 100,000 inhabitants/year). Additionally, a greater number of pre-hospital deaths from accidental high-energy trauma occurred in rural areas (78 vs. 69%). 42% of all pre-hospital deaths occurred under the influence of alcohol. CONCLUSION: The crude mortality rate for fatal injuries was high overall as compared to other studies, and elevated in rural areas, where pre-hospital deaths were more common. Almost half of pre-hospital deaths occurred under the influence of alcohol.

Acute poisoning in children under the age of six: a two-decade study of hospital admissions and trends.

AIM: To evaluate the incidence, clinical features and outcome of acute poisoning in children of less than 6 years of age in northern Finland. METHODS: Children hospitalized with acute poisoning at the Oulu University Hospital between 1991 and 2010 were retrospectively evaluated from hospital records. RESULTS: There were 334 hospital admissions due to acute poisoning during the study period, with an overall incidence rate of 5.2 per 10 000 per year, decreasing slightly from 6.7 in 1991-1995 to 4.5 in 2006-2010. Mean length of a hospital stay was 1.2 (SD ± 1.26) days. The most common substances ingested were terbutaline (12.3%), benzodiazepines (12.0%) and dishwasher powder (9.3%). Almost half of the patients were admitted to the paediatric intensive care unit, but most only required supportive care. Specific antidotes were administered in 16 cases. Three patients suffered from aspiration pneumonia as a result of ingesting poison, but no children died during the study. CONCLUSION: Poisoning is a fairly common cause of hospital admission in children under the age of six. In most cases, their clinical condition is good, and they can be discharged after a short surveillance period.