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Paajanen H.,Kuopio University Hospital | Paajanen H.,Central Hospital of Mikkeli | Kossi J.,Paijat Hame Central Hospital | Silvasti S.,North Karelia Central Hospital | And 2 more authors.
British Journal of Surgery | Year: 2011

Background: Chronic pain may be a long-term problem related to mesh fixation and operative trauma after Lichtenstein hernioplasty. The aim of this study was to compare the feasibility and safety of tissue cyanoacrylate glue versus absorbable sutures for mesh fixation in Lichtenstein hernioplasty. Methods: Lichtenstein hernioplasty was performed under local anaesthesia as a day-case operation in one of three hospitals. The patients were randomized to receive either absorbable polyglycolic acid 3/0 sutures (Dexon®; 151 hernias) or 1 ml butyl-2-cyanoacrylate tissue glue (Glubran®; 151 hernias) for fixation of lightweight mesh (Optilene®). Wound complications, pain, discomfort and recurrence were identified at 1 and 7 days, 1 month and 1 year after surgery. Results: A total of 302 patients were included in the study. The mean(s.d.) duration of operation was 34(12) min in the glue group and 36(13) min in the suture group (P = 0·113). The need for analgesics was similar during the first 24 h after surgery. Five wound infections (3·4 per cent) were detected in the glue group and two (1·4 per cent) in the suture group (P = 0·448). The recurrence rate at 1 year was 1·4 per cent in each group (P = 1·000). The rates of foreign body sensation, acute and chronic pain were similar in the two groups. Logistic regression analysis showed that the type of mesh fixation did not predict chronic pain 1 year after surgery. Conclusion: Mesh fixation without sutures in Lichtenstein hernioplasty was feasible without compromising postoperative outcome. Registration number: NCT00659542 (). © 2011 British Journal of Surgery Society Ltd. Published by John Wiley and Sons Ltd.


Vaahersalo J.,University of Helsinki | Bendel S.,Kuopio University Hospital | Reinikainen M.,North Karelia Central Hospital | Kurola J.,Kuopio University Hospital | And 5 more authors.
Critical Care Medicine | Year: 2014

OBJECTIVES: Optimal oxygen and carbon dioxide levels during postcardiac arrest care are currently undefined and observational studies have suggested harm from hyperoxia exposure. We aimed to assess whether mean and time-weighted oxygen and carbon dioxide levels during the first 24 hours of postcardiac arrest care correlate with 12-month neurologic outcome. DESIGN: Prospective observational cohort study. SETTING: Twenty-one ICUs in Finland. PATIENTS: Out-of-hospital cardiac arrest patients treated in ICUs in Finland between March 2010 and February 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Arterial blood PaO2 and PaCO2 during the first 24 hours from admission were divided into predefined categories from the lowest to the highest. Proportions of time spent in different categories and the mean PaO 2 and PaCO2 values during the first 24 hours were included in separate multivariable regression models along with resuscitation factors. The cerebral performance category at 12 months was used as primary endpoint. A total of 409 patients with arterial blood gases analyzed at least once and with a complete set of resuscitation data were included. The average amount of PaO2 and PaCO2 measurements was eight per patient. The mean 24 hours PaCO2 level was an independent predictor of good outcome (odds ratio, 1.054; 95% CI, 1.006-1.104; p = 0.027) but the mean PaO2 value was not (odds ratio, 1.006; 95% CI, 0.998-1.014; p = 0.149). With multivariate regression analysis, time spent in the PaCO 2 band higher than 45 mm Hg was associated with good outcome (odds ratio, 1.015; 95% CI, 1.002-1.029; p = 0.024, for each percentage point increase in time) but time spent in different oxygen categories were not. CONCLUSIONS: In this multicenter study, hypercapnia was associated with good 12-month outcome in patients resuscitated from out-of-hospital cardiac arrest. We were unable to verify any harm from hyperoxia exposure. Further trials should focus on whether moderate hypercapnia during postcardiac arrest care improves outcome. © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.


Vaara S.T.,University of Helsinki | Reinikainen M.,North Karelia Central Hospital | Wald R.,St Michaels Hospital | Bagshaw S.M.,University of Alberta | Pettila V.,University of Helsinki
Clinical Journal of the American Society of Nephrology | Year: 2014

Background and objectives: No data on the development of conventional indications for RRT (refractory acidosis, hyperkalemia, uremia, oliguria/anuria, and volume overload) related to timing of RRT exist. The prevalence of conventional indications among critically ill patients on RRT for AKI was evaluated, and patients manifesting indications versus patients without indications were compared in terms of crude and adjusted 90-day mortality. Design, setting, participants, & measurements: In this substudy of the Finnish Acute Kidney Injury study conducted in 2011 and 2012 in 17 intensive care units with 2901 patients, patients were classified as pre-emptive (no conventional indications) and classic (one ormore indications) RRT recipients. Patientswith classic RRTwere divided into classic-urg nt (RRT initiated#12 hours frommanifesting indications) and classic-delayed (RRT>12 hours fromfirst indication). Additionally, 2450 patients treated without RRT were matched to patients with preemptive RRT. Results: Of 239 patients treated with RRT, 134 (56.1%; 95%confidence interval [95%CI], 49.8% to 62.4%) fulfilled at least one conventional indication before commencing RRT. Crude 90-day mortality of 134 patients with classic RRTwas 48.5%(95%CI, 40.0%to 57.0%), and itwas 29.5%(95%CI, 20.8%to 38.2%) for the 105 patients with preemptive RRT. Classic RRT was associated with a higher risk formortality (adjusted odds ratio, 2.05; 95% CI, 1.03 to 4.09). Forty-four patients with classic–delayed RRT showed higher crude mortality (68.2%; 95% CI, 54.4% to 82.0%) compared with patients with classic–urgent RRT, and this association persisted after adjustment for known confounders (odds ratio, 3.85; 95% CI, 1.48 to 10.22). Crude 90-day mortality of 67 1:1 matched patients with pre-emptive RRT was 26.9% (95% CI, 6.3% to 37.5%), and it was 49.3% (95% CI, 37.3% to 61.2%; P=0.01) for their non-RRT matches. Conclusions: Patients on RRT after one or more conventional indications had both higher crude and adjusted 90-day mortality compared with patients without conventional indications. These findings require confirmation in an adequately powered, multicenter, randomized controlled trial. © 2014 by the American Society of Nephrology.


Vaara S.T.,University of Helsinki | Pettila V.,University of Helsinki | Reinikainen M.,North Karelia Central Hospital | Kaukonen K.-M.,University of Helsinki
Critical Care | Year: 2012

Introduction: Acute kidney injury (AKI) increases mortality and morbidity of critically ill patients. Mortality of patients treated with renal replacement therapy (RRT) is high. We aimed to evaluate the nationwide incidence of RRT-treated AKI in Finland, hospital and six-month mortality, and health-related quality of life (HRQoL) of these patients.Methods: We performed a retrospective cohort study including all general intensive care unit (ICU) admissions in Finland in 2007 through 2008. We identified patients who had received RRT due to AKI (RRT patients) and compared these patients to ICU patients who were not treated with RRT (non-RRT patients). The HRQoL was assessed by the EQ-5D index and visual analogue scale (VAS).Results: We analysed the final cohort of 24,904 patients, of whom 1,686 received RRT due to AKI. The incidence of RRT-treated AKI was 6.8% (95% confidence interval (CI) 6.5 to 7.1%) among ≥ 15-year-old general ICU patients, which corresponds to a yearly population-based incidence of 19.2 per 100,000 (95% CI 17.9 to 20.5/100,000). According to RIFLE (Risk, Injury, Failure) classification 26.6% (95% CI 26.0 to 27.2%) of patients had AKI (RIFLE R-F). Hospital and six-month mortality of RRT patients were 35.0% and 49.4%. At six-months, RRT patients perceived their health as good as non-RRT patients by VAS.Conclusions: The population-based incidence of AKI treated with RRT was 19.2 per 100,000 in Finland and 6.8% of all general ICU patients. The hospital and six-month mortality rates were lower than previously reported for ICU-treated RRT patients. © 2012 Vaara et al.; licensee BioMed Central Ltd.


Raj R.,University of Helsinki | Skrifvars M.B.,University of Helsinki | Bendel S.,Kuopio University Hospital | Selander T.,Kuopio University Hospital | And 3 more authors.
Critical Care | Year: 2014

Introduction: The aim of this study was to evaluate the usefulness of the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score II) and SOFA (Sequential Organ Failure Assessment) scores compared to simpler models based on age and Glasgow Coma Scale (GCS) in predicting long-term outcome of patients with moderate-to-severe traumatic brain injury (TBI) treated in the intensive care unit (ICU).Methods: A national ICU database was screened for eligible TBI patients (age over 15 years, GCS 3-13) admitted in 2003-2012. Logistic regression was used for customization of APACHE II, SAPS II and SOFA score-based models for six-month mortality prediction. These models were compared to an adjusted SOFA-based model (including age) and a reference model (age and GCS). Internal validation was performed by a randomized split-sample technique. Prognostic performance was determined by assessing discrimination, calibration and precision.Results: In total, 1,625 patients were included. The overall six-month mortality was 33%. The APACHE II and SAPS II-based models showed good discrimination (area under the curve (AUC) 0.79, 95% confidence interval (CI) 0.75 to 0.82; and 0.80, 95% CI 0.77 to 0.83, respectively), calibration (P > 0.05) and precision (Brier score 0.166 to 0.167). The SOFA-based model showed poor discrimination (AUC 0.68, 95% CI 0.64 to 0.72) and precision (Brier score 0.201) but good calibration (P > 0.05). The AUC of the SOFA-based model was significantly improved after the insertion of age and GCS ({increment}AUC +0.11, P < 0.001). The performance of the reference model was comparable to the APACHE II and SAPS II in terms of discrimination (AUC 0.77; compared to APACHE II, ΔAUC -0.02, P = 0.425; compared to SAPS II, ΔAUC -0.03, P = 0.218), calibration (P > 0.05) and precision (Brier score 0.181).Conclusions: A simple prognostic model, based only on age and GCS, displayed a fairly good prognostic performance in predicting six-month mortality of ICU-treated patients with TBI. The use of the more complex scoring systems APACHE II, SAPS II and SOFA added little to the prognostic performance. © 2014 Raj et al.; licensee BioMed Central Ltd.


Strandberg T.E.,University of Helsinki | Strandberg T.E.,University of Oulu | Kolehmainen L.,North Karelia Central Hospital | Vuorio A.,Mehilainen Airport Health Center | Vuorio A.,Finnish Institute of Occupational Health
JAMA - Journal of the American Medical Association | Year: 2014

IMPORTANCE: Hypercholesterolemia is common among people older than 80 years. Substantial functional heterogeneity exists among older patients, and decision making for statin use differs in older patients relative to younger ones. OBJECTIVE: To discuss the presentation, modifying factors, and treatment of hypercholesterolemia (usually with statins) among persons older than 80 years. EVIDENCE REVIEW MEDLINE: and other sources were searched from January 1990 to June 2014. Personal libraries and a hand search of reference lists from guidelines and reviews from January 2000 to June 2014 were also used. FINDINGS: Norandomized clinical trials (RCTs) of statin or any other hypocholesterolemic medication included persons older than80years at baseline. Findings from 75- to 80-year-old patients enrolled in RCTs and information from observational studies support statin treatment for secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and probably in patients with diabetes without ASCVD. Harms from statin drugs are not increased in older patients, so the use of these agents for primary prevention is possible. Because people older than80years are biologically heterogeneous with varying life expectancy,may have frailty or comorbid conditions, andmay take multiple medications, the decision to treat with statins must be individualized. CONCLUSIONS AND RELEVANCE: Ideally, treatment of hypercholesterolemia for patients at risk of ASCVD should start before they turn 80 years old. No RCT evidence exists to guide statin initiation after age 80 years. Decisions to use statins in older individuals are made individually and are not supported by high-quality evidence. Copyright 2014 American Medical Association. All rights reserved.


Hernesniemi J.A.,North Karelia Central Hospital | Vanni V.,North Karelia Central Hospital | Hakala T.,North Karelia Central Hospital
Journal of Vascular Surgery | Year: 2015

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. © 2015 Society for Vascular Surgery.


Turtiainen J.,North Karelia Central Hospital | Hakala T.,North Karelia Central Hospital | Hakkarainen T.,North Karelia Central Hospital | Karhukorpi J.,Eastern Finland Laboratory Center
European Journal of Vascular and Endovascular Surgery | Year: 2014

Objective: To study the relationship between surgical wound bacterial colonization and the development of surgical site infection (SSI) after lower limb vascular surgery. SSI is a major problem after lower limb vascular surgery. Most SSIs in vascular surgery are caused by Staphylococcal species that are part of normal skin flora. A prospective observational investigator blind study to examine quantitative and qualitative analysis of surgical wound bacterial colonization and the correlation with the development of SSI has been conducted. Methods: The study cohort comprised 94 consecutive patients with 100 surgical procedures. Swabs for microbiological analyses were taken from surgical wounds at four different time intervals: before surgery, just before the surgical area had been scrubbed, at the end of surgery, and on the first and second postoperative days. Postoperative complications were recorded. Results: Three hundred and eighty-seven skin bacterial samples from 100 surgical wounds were analyzed. The most common bacteria isolated were coagulase-negative staphylococci (80%), Corynebacterium species (25%), and Propionibacterium species (15%). In 13 (62%) cases, the same bacterial isolates were found in the perioperative study samples as in the infected wounds. The incidence of SSI was 21%. Multivariate analysis revealed that high bacterial load on the second postoperative day and diabetes independently increased the risk of SSI. Elective redo surgery was protective against the development of SSI. Conclusions: A high bacterial load in the postoperative surgical wound independently increases the risk of the development of SSI after lower limb vascular surgery. © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.


Reinikainen M.,North Karelia Central Hospital | Syvaoja S.,North Karelia Central Hospital | Hara K.,North Karelia Central Hospital
Acta Anaesthesiologica Scandinavica | Year: 2014

Background We evaluated the analgesic effect of ropivacaine infiltration into the surgical wound after caesarean section. Methods In a double-blind trial, 67 patients who were scheduled for caesarean section under spinal anaesthesia were randomly assigned to receive either 0.75% ropivacaine or placebo (NaCl 0.9%) through a multi-orifice catheter that was placed into the surgical wound, between the muscle fascia and the subcutaneous tissue. The study drug was administered as a bolus of 10 ml at the end of the operation, followed by an infusion at 2 ml/h for 48 h. All patients were also given paracetamol and ibuprofen. The primary outcome was the total amount of rescue oxycodone needed during the first 48 h post-operatively. Secondary outcomes included pain and patient satisfaction scores. Analyses were according to intention to treat. Results The mean (± standard deviation) amount of oxycodone administered during the first 48 h was 47.5 ± 20.9 mg in the ropivacaine group and 57.8 ± 29.4 mg in the placebo group (95% confidence interval for the difference between means, -22.8-2.2 mg; P = 0.10). There were no differences between the groups in pain scores or in patient satisfaction scores. Conclusion Continuous wound infiltration with ropivacaine did not decrease the need for opioids and had no impact on pain scores or patient satisfaction after caesarean section. © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.


Turtiainen J.,North Karelia Central Hospital | Hakala T.,North Karelia Central Hospital
Scandinavian Journal of Surgery | Year: 2014

Surgical wound infection is one of the most common complications after peripheral vascular surgery. It increases the affected patient’s risk for major amputation as well as mortality. Furthermore, surgical wound infection is an additional cost. Wound infections after vascular surgery are of multifactorial nature and generally result from the interplay of patient- and procedure-related factors. The use of systemic antibiotic prophylaxis may be the most important method in preventing surgical wound infections. In this review article, we report the current literature of surgical wound infections after peripheral vascular surgery. © 2014, Finnish Surgical Society. All rights reserved.

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