Jyväskylä, Finland
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PubMed | University of Turku, University of Oulu, Central Hospital, Keski Suomi Central Hospital and Kuopio University Hospital
Type: | Journal: International journal of cardiology | Year: 2016

Recent studies have reported that patients with paroxysmal atrial fibrillation (AF) have lower risk of thromboembolism and better prognosis than patients with chronic AF. We sought to address the differences in ischaemic events in patients with paroxysmal AF and chronic AF.The FibStroke study is a cross-sectional observational multicenter registry that included AF patients with an ischaemic stroke, TIA (transient ischaemic attack) or intracranial bleed during 2003-2012 identified from discharge registries of four Finnish hospitals. Altogether 1448 patients with paroxysmal and 1808 patients with chronic atrial fibrillation suffered a total of 707 TIA-episodes and 2549 ischaemic strokes.Mortality within 30days after the index event was significantly lower in patients with paroxysmal AF than with chronic AF (7.6% vs 16.9%, p<0.01). At the onset of event, 62.8% of the patients with paroxysmal AF were in sinus rhythm, and these patients had better prognosis after the event compared to patients with other rhythm than sinus rhythm (mortality 5.2% vs 15.7%, p<0.01). In the propensity score matched analysis mortality after stroke was significantly lower in patients with paroxysmal AF than in patients with chronic AF (11.6% vs 17.8%, p<0.01), while mortality after TIA was also lower, but did not reach statistical significance (0.4% vs 1.7%, p=0.31).A significant proportion of strokes in AF patients occur in patients with paroxysmal AF, but they have better prognosis than patients with chronic AF. The prognosis is also significantly better in patients who are in sinus rhythm at the onset of event.


Palomaki A.,University of Turku | Mustonen P.,Keski Suomi Central Hospital | Hartikainen J.E.K.,Kuopio University Hospital | Nuotio I.,University of Turku | And 4 more authors.
European Journal of Neurology | Year: 2016

Background and purpose: Current guidelines recommend oral anticoagulation (OAC) for patients with atrial fibrillation (AF) and increased risk of thromboembolic events. The reasons for not using OAC in AF patients suffering stroke or transient ischaemic attack (TIA) were assessed. Methods: This retrospective registry included 3404 patients with previously diagnosed AF who suffered a total of 2955 ischaemic strokes and 895 TIAs during 2003-2012. Results: A CHA2DS2-VASc score ≥2 and a CHADS2 score ≥2 was observed in 3590 (93.2%) and in 2784 (72.3%) of the events, respectively. Of the high-risk patients (CHADS2 ≥2) only 55.1% were on OAC before the onset of stroke or TIA. The most frequently documented reasons for withholding OAC were infrequent paroxysms of AF (14%), previous bleeding episodes (13%) and the patient's decline/independent discontinuation of treatment (9%). Moreover, patients with paroxysmal AF (40% using OAC), previous bleeding (26% using OAC) and alcohol abuse (30% using OAC) were using OAC significantly less often than patients without these characteristics. A significant increase in the proportion of high-risk patients using OAC from 49% in 2003 to 65% in 2012 was seen. Conclusions: Underuse of anticoagulation is a common contributor to ischaemic strokes and TIA episodes in patients with AF. Infrequent AF episodes, previous bleeds, patient preference and alcohol abuse were the most common reasons for not using OAC. © 2016 European Academy of Neurology.


PubMed | University of Turku, University of Oulu and Keski Suomi Central Hospital
Type: Journal Article | Journal: Annals of medicine | Year: 2016

Postpericardiotomy syndrome (PPS) is a common complication after cardiac surgery. Previous epidemiological descriptions of the syndrome, however, are scarce.This retrospective analysis included all patients hospital admission due to PPS in patients aged 20-79 years. Data were collected from the Finnish national registry that included data on all cardiovascular hospital admissions (n=517669) during 9.5 years in 29 Finnish hospitals nationwide.There were 760 hospital admissions due to PPS during the study period. The patients were more likely male than female (67.8% versus 32.2%) with an age-adjusted RR of 2.37 (95% CI 1.85-3.02) for men (p<0.0001). When evaluating the rate of PPS in relation to cardiac surgeries, female gender was associated with a higher incidence of PPS (RR 1.78; 95% CI 1.45-2.19; p<0.001). The rate of PPS in relation to the number of cardiac surgery was highest in youngest patients followed by a gradual decrease (RR 0.59; 95% CI 0.55-0.65; p<0.0001 per 10-year increment in age) with aging.Hospital admission due to PPS was most common in men in their sixties. When stratified by the total number of performed cardiac operations the incidence of PPS was higher among women and younger patients.


PubMed | University of Turku, Keski Suomi Central Hospital, Satakunta Central Hospital and Kuopio University Hospital
Type: Journal Article | Journal: PloS one | Year: 2016

Atrial fibrillation may remain undiagnosed until an ischemic stroke occurs. In this retrospective cohort study we assessed the prevalence of ischemic stroke or transient ischemic attack as the first manifestation of atrial fibrillation in 3,623 patients treated for their first ever stroke or transient ischemic attack during 2003-2012. Two groups were formed: patients with a history of atrial fibrillation and patients with new atrial fibrillation diagnosed during hospitalization for stroke or transient ischemic attack. A control group of 781 patients with intracranial hemorrhage was compiled similarly to explore causality between new atrial fibrillation and stroke. The median age of the patients was 78.3 [13.0] years and 2,009 (55.5%) were women. New atrial fibrillation was diagnosed in 753 (20.8%) patients with stroke or transient ischemic attack, compared to 15 (1.9%) with intracranial hemorrhage. Younger age and no history of coronary artery disease or other vascular diseases, heart failure, or hypertension were the independent predictors of new atrial fibrillation detected concomitantly with an ischemic event. Thus, ischemic stroke was the first clinical manifestation of atrial fibrillation in 37% of younger (<75 years) patients with no history of cardiovascular diseases. In conclusion, atrial fibrillation is too often diagnosed only after an ischemic stroke has occurred, especially in middle-aged healthy individuals. New atrial fibrillation seems to be predominantly the cause of the ischemic stroke and not triggered by the acute cerebrovascular event.


PubMed | University of Turku, Kuopio University Hospital, Satakunta Central Hospital and Keski Suomi Central Hospital
Type: Journal Article | Journal: Clinical cardiology | Year: 2016

Patients with atrial fibrillation (AF) frequently undergo invasive procedures. Optimal perioperative use of oral anticoagulation (OAC) and heparin bridging is not well defined.Discontinuation of OAC for minor procedures/operations places AF patients at risk for thromboembolism.In this study, we assessed perioperative antithrombotic treatment in patients with AF who suffered a postoperative stroke or intracranial bleeding. The FibStroke Study includes AF patients with an ischemic stroke or intracranial bleed identified from the discharge registries of 4 Finnish hospitals. In total, 3632 consecutive patients developed 3252 ischemic strokes and 794 intracranial bleeds. All invasive procedures during the 30 days preceding the stroke or intracranial bleed were identified.A total of 194/3252 (6.0%) ischemic strokes and 23/794 (2.9%) intracranial bleeds were preceded by a procedure. Altogether, 69% of the patients were on OAC prior to index procedure, OAC was interrupted in 81.2% of the procedures preceding a stroke, and heparin bridging was used in 27.8% of interruptions. Of the procedures leading to stroke, 42.3% were low-bleeding-risk procedures, and OAC was interrupted in 84.7% of these procedures. The median time from procedure to stroke was 4 days. Heparin bridging was used in 54.5% of OAC interruptions preceding intracranial bleeding and combination of anticoagulation with antiplatelet therapy by 43.5% of patients with postoperative intracranial bleeding.Perioperative interruption of OAC is common in patients who suffer a postoperative stroke, even in patients with low-bleeding-risk procedures. Postoperative intracranial bleeding is frequently preceded by perioperative heparin bridging.


Mustonen P.,Keski Suomi Central Hospital | Lehtonen K.V.,Red Cross | Lehtonen K.V.,University of Helsinki | Javela K.,Red Cross | Puurunen M.,Red Cross
Lupus | Year: 2014

Objectives: The long-term prognosis of individuals fulfilling the laboratory criteria, but not clinical criteria, of antiphospholipid syndrome (APS) has not been widely investigated. The primary aim of this study was to evaluate the incidence of first thrombotic event (deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), stroke or transient ischaemic attack (TIA) in a nationwide antiphospholipid antibody (aPL) carrier cohort.Design: We conducted a prospective nationwide cohort study.Setting: The aPL profile of participants was recorded from the laboratory database. Information was collected about thrombotic and pregnancy complications, subsequent medical history, other risk factors for thrombosis, use of prophylactic antithrombotic medication and general health.Participants: Participants included adult asymptomatic aPL carriers recognized in Finland during 1971-2009.Main outcome measure: The main outcome measure was incidence of first thrombotic event.Results: A total of 119 (89% female) aPL carriers were followed for mean (SD) of 9.1 (7.5) years (range 3-41 years). Sixty-one per cent of the study participants had autoimmune disease, most often systemic lupus erythematosus (SLE). Thirty-six of 119 (30%) were either double or triple positive, 56% single lupus anticoagulant (LA) positive, and 8% and 5% single anticardiolipin antibodies (aCL) and anti-b2glycoprotein I antibodies (ab2GPI) positive, respectively. Nine (7.6%) study patients experienced a first thrombotic event (five DVT, one PE, two MI, one TIA) mean (SD) 7.2 (8.3) years (range 1-26 years) after aPL detection (annual incidence rate 0.8%). All individuals who developed thrombotic complications had autoimmune disease. Annual rate of first thrombotic event in carriers of single positivity (0.65%) was equal to the known risk of thrombosis in the healthy Caucasian population, whereas the rate was two times higher in carriers of double or triple positivity (1.27%). Sixteen of 79 (20%) women experienced pregnancy complications.Conclusions: Double or triple positivity for aPL is a risk factor for future thrombotic events, especially in individuals with an underlying autoimmune disease, whereas single positivity does not seem to carry an elevated risk of thrombosis. © The Author(s) 2014.


Salonen A.J.,Kuopio University Hospital | Taari K.,University of Helsinki | Ala-Opas M.,University of Helsinki | Viitanen J.,Pohjois Karjala Central Hospital | And 2 more authors.
Journal of Urology | Year: 2012

Purpose: We conducted a randomized trial to compare intermittent and continuous androgen deprivation in patients with advanced prostate cancer. We studied time to progression, overall and prostate cancer specific survival, and time to treatment failure. Materials and Methods: Between May 1997 and February 2003, 852 men with locally advanced or metastatic prostate cancer were enrolled to receive androgen deprivation therapy for 24 weeks. Patients in whom prostate specific antigen decreased to less than 10 ng/ml, or by 50% or more if less than 20 ng/ml at baseline, were randomized to intermittent or continuous androgen deprivation. In the intermittent therapy arm androgen deprivation therapy was withdrawn and resumed again for at least 24 weeks based mainly on prostate specific antigen decrease and increase. Results: There were 298 patients who did not meet the randomization criteria. The remaining 554 patients were randomized, with 274 (49.5%) to intermittent androgen deprivation and 280 (50.5%) to the continuous androgen deprivation arm. Median followup was 65.0 months. Of these patients 392 (71%) died, including 186 (68%) in the intermittent androgen deprivation arm and 206 (74%) in the continuous androgen deprivation arm (p = 0.12). There were 248 prostate cancer deaths, comprised of 117 (43%) in the intermittent androgen deprivation and 131 (47%) in the continuous androgen deprivation arm (p = 0.29). Median times from randomization to progression were 34.5 and 30.2 months in the intermittent androgen deprivation and continuous androgen deprivation arms, respectively. Median times to death (all cause) were 45.2 and 45.7 months, to prostate cancer death 45.2 and 44.3 months, and to treatment failure 29.9 and 30.5 months, respectively. Conclusions: Intermittent androgen deprivation is a feasible, efficient and safe method to treat advanced prostate cancer compared with continuous androgen deprivation. © 2012 American Urological Association Education and Research, Inc.


Salonen A.J.,Kuopio University Hospital | Taari K.,University of Helsinki | Ala-Opas M.,University of Helsinki | Viitanen J.,Pohjois Karjala Central Hospital | And 2 more authors.
European Urology | Year: 2013

Background: Intermittent dosing may reduce the adverse events (AEs) of androgen-deprivation therapy (ADT). Objective: To compare intermittent androgen deprivation (IAD) and continuous androgen deprivation (CAD) with regard to health-related quality of life (QoL). Design, setting, and participants: A total of 852 men with advanced prostate cancer (PCa) were enrolled to receive goserelin acetate 3.6 mg every 28 d for 24 wk. A total of 554 patients whose prostate-specific antigen (PSA) decreased to <10 ng/ml or by ≥50% (<20 ng/ml at baseline) were randomised to IAD or CAD. Intervention: In the IAD arm, ADT was resumed for at least 24 wk whenever PSA increased >20 ng/ml or above baseline. Outcome measurements and statistical analysis: QoL was monitored with a validated Cleary 30-item questionnaire and analysed by the Mann-Whitney U test, 0.5 standard deviation rule, and repeated measures analysis of variance. AEs and adverse drug reactions (ADRs) were analysed by the chi-square test. Results and limitations: Median follow-up was 65 mo. Significant differences in QoL emerged in activity limitation, physical capacity, and sexual functioning, favouring IAD. No significant differences emerged in the prevalence of AEs: 87 patients in the IAD arm (31.8%) and 95 in the CAD arm (33.9%) had cardiovascular (CV) AEs (p = 0.59), with 25 (9.1%) and 29 (10.4%) withdrawn (p = 0.62), and 21 (7.7%) and 24 (8.6%) dying because of a CV event (p = 0.70), respectively; bone fractures occurred in 19 (6.9%) and 15 (5.4%) patients (p = 0.44), respectively. Hot flushes or night sweats were the most common ADRs (47.1% vs 50.4%; p = 0.44). Erectile dysfunction (15.7% vs 7.9%; p = 0.042) and depressed mood (2.2 vs 0%; p = 0.032) were more common in the IAD arm. Conclusions: IAD showed benefits in the treatment of advanced PCa with respect to QoL. The prevalence of AEs was not significantly lower with IAD. Trial registration: ClinicalTrials.gov, NCT00293670. © 2012 European Association of Urology.


PubMed | University of Oulu, University of Helsinki, Keski Suomi Central Hospital and Kanta Hame Central Hospital
Type: Journal Article | Journal: Techniques in coloproctology | Year: 2016

Laparoscopic ventral rectopexy has been used to treat male patients with external rectal prolapse, but evidence to support this approach is scarce. The aim of this study was to evaluate the results of this new abdominal rectopexy surgical technique in men.This was a retrospective multicenter study. Adult male patients who were operated on for external rectal prolapse using ventral rectopexy in five tertiary hospitals in Finland between 2006 and 2014 were included in the study. Patient demographics, detailed operative, postoperative and short-term follow-up data were collected from patient registers in participating hospitals. A questionnaire and informed consent form was sent to all patients. The questionnaire included scores for anal incontinence, obstructed defecation syndrome, urinary symptoms and sexual dysfunction. The main outcome measure was the incidence of recurrent rectal prolapse. Surgical morbidity, the need for surgical repair due to recurrent symptoms and functional outcomes were secondary outcome measures.A total of 52 adult male patients with symptoms caused by external rectal prolapse underwent ventral rectopexy. The questionnaire response rate was 64.4%. Baseline clinical characteristics and perioperative results were similar in the responder and non-responder groups. A total of 9 (17.3%) patients faced complications. There were two (3.8%) serious surgical complications during the 30-day period after surgery that necessitated reoperation. None of the complications were mesh related. Recurrence of the prolapse was noticed in nine patients (17%), and postoperative mucosal anal prolapse symptoms persisted in 11 patients (21%). As a result, the reoperation rate was high. Altogether, 17 patients (33%) underwent reoperation during the follow-up period due to postoperative complications or recurrent rectal or mucosal prolapse. According to the postoperative questionnaire data, patients under 40 had good functional results in terms of anal continence, defecation, urinary functions and sexual activity.Laparoscopic ventral rectopexy is a safe surgical procedure in male patients with external prolapse. However, a high overall reoperation rate was noticed due to recurrent rectal and residual mucosal prolapse. This suggests that the ventral rectopexy technique should be modified or combined with other abdominal or perineal methods when treating male rectal prolapse patients.


PubMed | Helsinki Malmi City Hospital, University of Helsinki, Kuopio University Hospital and Keski Suomi Central Hospital
Type: Journal Article | Journal: Heart, lung & circulation | Year: 2016

We investigated the ability of cardiac biomarkers and total pulmonary artery (PA) clot score to predict right ventricular dysfunction (RVD) on admission and at seven-month follow-up in subjects with acute pulmonary embolism (APE).Sixty-three normotensive patients with APE were divided into two groups: patients with (n= 32, age 5819 years) and without (n=31, age 5516 years) echocardiographic RVD. Transthoracic echocardiography (TTE), N-terminal pro-brain natriuretic peptide (NT-proBNP), and high-sensitivity troponin T (hsTnT) were assessed upon arrival and repeated at seven months. Total PA clot score was determined on admission.The age- and sex dependent NT-proBNP on admission, on day 5, and at seven months exhibited the best sensitivity (admission 94%, day 5 100%, seven months 100%) and negative predictive value (NPV) (89%, 100%, 100%) for detecting RVD. Six patients (10%) had persistent RVD at seven months. Total PA clot score showed only low to moderate sensitivity (77%) and PPV (7%) for detection of RVD at seven months.Normal age- and sex dependent NT-proBNP on admission or measured five days later seems to be useful in exclusion of RVD at follow up. Total PA clot score shows only to be of modest benefit for predicting persistent RVD.

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