Landspítali University Hospital Research Archive
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The challenges of primary biliary cholangitis: What is new and what needs to be done.
No full textTo access publisher's full text version of this article click on the hyperlink belowPrimary Biliary Cholangitis (PBC) is an uncommon, chronic, cholangiopathy of autoimmune origin and unknown etiology characterized by positive anti-mitochondrial autoantibodies (AMA), female preponderance and progression to cirrhosis if left untreated. The diagnosis is based on AMA- or PBC-specific anti-nuclear antibody (ANA)-positivity in the presence of a cholestatic biochemical profile, histologic confirmation being mandatory only in seronegative cases. First-line treatment is ursodeoxycholic acid (UDCA), which is effective in preventing disease progression in about two thirds of the patients. The only approved second-line treatment is obeticholic acid. This article summarizes the most relevant conclusions of a meeting held in Lugano, Switzerland, from September 23rd-25th 2018, gathering basic and clinical scientists with various background from around the world to discuss the latest advances in PBC research. The meeting was dedicated to Ian Mackay, pioneer in the field of autoimmune liver diseases. The role of liver histology needs to be reconsidered: liver pathology consistent with PBC in AMA-positive individuals without biochemical cholestasis is increasingly reported, raising the question as to whether biochemical cholestasis is a reliable disease marker for both clinical practice and trials. The urgent need for new biomarkers, including more accurate markers of cholestasis, was also widely discussed during the meeting. Moreover, new insights in interactions of bile acids with biliary epithelia in PBC provide solid evidence of a role for impaired epithelial protection against potentially toxic hydrophobic bile acids, raising the fundamental question as to whether this bile acid-induced epithelial damage is the cause or the consequence of the autoimmune attack to the biliary epithelium. Strategies are needed to identify difficult-to-treat patients at an early disease stage, when new therapeutic approaches targeting immunologic pathways, in addition to bile acid-based therapies, may be effective. In conclusion, using interdisciplinary approaches, groundbreaking advances can be expected before long in respect to our understanding of the etiopathogenesis of PBC, with the ultimate aim of improving its treatment
Identifying out-of-hospital cardiac arrest patients with no chance of survival: An independent validation of prediction rules.
No full textTo access publisher's full text version of this article click on the hyperlink belowBackground: The Basic life support (BLS) and Advanced life support (ALS) are known prediction rules for termination of resuscitation (TOR) in out-of-hospital cardiac arrest (OHCA). Recently, a new rule was developed by Jabre et al. We aimed to independently validate and compare the predictive accuracy of these rules.
Methods: OHCA cases in Iceland from 2008 to 2017 from a population-based, prospectively registered database. Primary outcome was survival to discharge among patients that met all conditions of abovementioned rules: BLS (not witnessed by EMS personnel, no defibrillation nor ROSC before transport), ALS (BLS criteria plus not witnessed nor CPR by bystander) and Jabre (not witnessed by EMS personnel, initial rhythm non-shockable, no sustainable ROSC before third dose of adrenaline).
Results: Overall, 568 OHCA patients were included in validation of TOR rules. Mean age 67, males 74%, witnessed by EMS 11%, by bystander 66% that attempted CPR in 50%, transported to hospital 60%, overall survival 20%. All rules had high specificity for mortality, 99.6-100% (95%CI 95-100). The Jabre and BLS rules had similar sensitivity 47% (43-52) vs. 44% (40-49), respectively, the sensitivity of ALS was lower, 8% (5-11). Combined use of positive BLS and Jabre rules performed the best, identifying 88/226 (39%) of futile cases transported to hospital, specificity 100% (97-100) and sensitivity 59% (55-64).
Conclusions: The accuracy of the BLS and Jabre TOR rules to predict mortality after OHCA is very good and their combined use may be superior to the use of either one
Rhesus D alloimmunization in pregnancy from 1996 to 2015 in Iceland: a nation-wide population study prior to routine antenatal anti-D prophylaxis.
No full textTo access publisher's full text version of this article click on the hyperlink belowBackground: Rhesus D (RhD) incompatibility is still the most important cause of hemolytic disease of the fetus and newborn (HDFN) worldwide. The aim of this study was to investigate the incidence, causes, and consequences of anti-D alloimmunizations in pregnancy in Iceland, prior to implementation of targeted routine antenatal anti-D prophylaxis (RAADP) in 2018.
Study design and methods: This was a nation-wide cohort study of 130 pregnancies affected by RhD alloimmunization in Iceland in the period from 1996 through 2015. Data were collected from transfusion medicine databases, medical records, and the Icelandic Medical Birth Register.
Results: Of 130 RhD alloimmunizations, 80 cases (61.5%) represented new RhD immunization in the current pregnancy. Sensitization was discovered in the third trimester in 41 (51.3%) and occurred in the first pregnancy in 14 cases (17.5%). The most likely causative immunization event was the index pregnancy for 45 (56.25%), a previous pregnancy/birth for 26 (32.5%), abortion for 3 (3.75%), and unknown for 6 women (7.5%). Higher anti-D titers were associated with shorter gestational length, cesarean sections, positive direct antiglobulin test (DAT), and severe HDFN. Intrauterine transfusion (IUT) was performed in five pregnancies (3.8%), and 35 of 132 (26.5%) live-born neonates received treatment for HDFN; 32 received phototherapy (24.2%), 13 exchange transfusion (9.8%), and seven simple blood transfusion (5.3%).
Conclusion: In about half of cases, RhD alloimmunization was caused by the index pregnancy and discovered in the third trimester. Thus, the newly implemented RAADP protocol should be effective in reducing the incidence of RhD immunization in Iceland in the future
Uptake and effectiveness of two-drug compared with three-drug antiretroviral regimens among HIV-positive individuals in Europe.
No full textTo access publisher's full text version of this article click on the hyperlink belowObjective: To assess the use of two-drug antiretroviral regimens (2DR) and virologic and immunologic outcomes compared with three-drug regimens (3DR) in the EuroSIDA cohort.
Design: Multicentre, prospective cohort study.
Methods: Logistic regression was used to analyse the uptake and outcomes among HIV-positive individuals who started or switched to a 2DR compared with those on a 3DR. Virologic outcomes were assessed on-treatment as the proportion of individuals with controlled viral load (<400 copies/ml), or with a composite modified FDA snapshot endpoint (mFDA), with mFDA success defined as controlled viral load at 6 months or 12 months for individuals with a known viral load, no regimen changes, AIDS or death. Immunologic response was defined as a 100 cells/μl or a 25% increase in CD4 cell counts from baseline.
Results: Between 1 July 2010 and 31 December 2016, 423 individuals started or switched to a 2DR (eight antiretroviral-naive) and 4347 started a 3DR (566 naive). Individuals on 2DR tended to have suppressed viral load, higher CD4 cell counts and more comorbidities at baseline compared with those on 3DR. There were no differences in the proportions of individuals who obtained on-treatment or mFDA success, and no significant differences in the adjusted odds ratios for mFDA success or immunologic responses between the 2DR and 3DR groups at 6 months or 12 months.
Conclusion: In routine clinical practice, 2DR were largely used for virologically suppressed individuals with higher cumulative exposure to antiretrovirals and comorbidities. Virologic and immunologic outcomes were similar among those on 2DR or 3DR, although confounding by indication cannot be fully excluded due to the observational nature of the study
Hafa verkir eftir fæðingu áhrif á tengslamyndun móður og barns?
Get PDFTo access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadFlestir upplifa verki. Þeir geta verið þreytandi og truflandi. En
hvað gerir þetta móður með nýfætt barn? Hvernig gengur henni
að tengjast þessari nýju manneskju þegar henni sjálfri líður illa?
Höfundur hefur sjálfur sinnt sængurkonu með það mikla verki
að ekkert annað komst að. Þegar verkjastillingu var loksins náð
var þessi kona uppgefin og steinsofnaði. Samskiptin við barnið
voru því lítil og í þau fáu skipti sem konan var verkjalaus og
vakandi, þá gat hún ekki einu sinni litið í áttina að barninu. Hún
firrtist við að hafa það í herberginu eða að heyra í því. Það kom á
daginn að hún tengdi barnið við verkina.
Á endanum löguðust verkir sængurkonunnar og hún varð
orkumeiri. Með mikilli hvatningu og stuðningi fjölskyldu,
vina og starfsfólks samþykkti hún að reyna að hafa barnið hjá
sér og fljótlega fór henni að líða vel með barnið hjá sér. Góð
tengslamyndun hófst á endanum en sérstakt eftirlit var sett upp
hjá ljósmóður út af því hve illa þetta byrjaði.
Í þessari grein sem byggir á fræðilegri ritgerð úr námskeiðinu
Inngangur að ljósmóðurfræði verður athugað hvort tengsl séu
milli verkja móður og tengslamyndunar hennar við barnið sitt
Postoperative infection after surgery for colorectal cancer
No full textTo access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadTilgangur: krabbamein í ristli og endaþarmi er þriðja algengasta
krabbameinið á Íslandi hjá báðum kynjum. Skurðaðgerð er ein mikilvægasta meðferðin til lækningar á sjúkdómnum. algengi sýkinga
eftir aðgerð er hægt að nota sem mælikvarða á árangur hjúkrunar. Í
þessari rannsókn var kannað hve tíðar sýkingar voru eftir skurðaðgerðir á krabbameini í ristli og endaþarmi á Landspítala en það
var ekki þekkt. jafnframt var kannað hve alvarlegar slíkar sýkingar
voru.
Aðferð: gerð var framsýn, lýsandi rannsókn. kannað var hvort sjúklingar sem fóru í skurðaðgerð vegna krabbameins á ristli eða endaþarmi á skurðdeild Landspítala frá 15. mars 2015 til 15. september
2015 fengu sýkingar innan 30 daga í kjölfar aðgerðarinnar. Þátttakendur í rannsókninni voru 70 sjúklingar. upplýsingum var safnað
með viðtölum við þátttakendur og úr sjúkraskrám. Öll einkenni sýkinga sem þörfnuðust meðferðar voru metin sem fylgikvillar. Þær
sýkingar sem upp komu voru flokkaðar samkvæmt flokkun ClavienDindo þar sem veitt meðferð við sýkingunum ræður flokkuninni.
Niðurstöður: Sýkingu fengu 44,3% sjúklinga (31/70). Þvagfærasýking
var algengust (24,5%), kviðarholssýking varð hjá 18,6% og sárasýking
hjá 14,3%. Sýkingu í blóð fengu 8,6%. aðrar sýkingar sem upp komu
voru: Munnsýkingar, lungnabólga, sýking í stóma og sýking af
vankómýcín-ónæmum enterókokkum (VÓE). Dánartíðni vegna
sýkinga var 1,4% (n=1).
Ályktanir: Sýkingar eftir aðgerð vegna krabbameins í ristli eða endaþarmi eru tíðar miðað við sambærilegar aðgerðir í nágrannalöndum. Sérstök nauðsyn er á að yfirfara verklag við notkun og meðhöndlun þvagleggja. Þessi niðurstaða undirstrikar einnig nauðsyn
þess að hafa framsýna skráningu á sýkingum eftir skurðaðgerðir svo
hægt sé að meta gæði og árangur hjúkrunarAim: Colorectal cancer is the third most common cancer in iceland for both men and women. Surgery is the main treatment for
colorectal cancer with the aim to cure. infection rate can be used
to evaluate the quality of perioperative nursing care. The aim of
this study was to explore the rate of postoperative infections after
surgery for colorectal cancerin the Landspitali national university
hospital in iceland which was unknown.
Method: This was a descriptive, prospective study. The occurrence
of infections in all patients who underwent surgery for colorectal
cancer from March 15 to September 15 2015 within 30 days postoperatively were explored. Participants were 70 patients. information was obtained by interviews with the subjects and from patient
records. all symptoms of infection that required treatment during
the 30 day postoperative period were defined as complications.
The Clavien-Dindo system, which classifies complications according to the treatment needed, was used.
Results: Postoperative infection occured in 44.3% (31/70). urinary
tract infections were most frequent (24.5%), followed by intraabdominal infections (18.6%), surgical site infections (14.3%) and
sepsis (8.6%). Other infections that occurred where oral infection,
pneumonia, stomatitis and vancomycin-resistant enterococci
(VrE) infection. Mortality caused by infection was 1,4%.
Conclusion: Postoperative infection rate after surgery for colorectal cancer was high compared to other countries. use of procedures related to urinary catheters deserves special attention. The
study results indicate the importance of having prospective registry for infections to evaluate quality of surgery and nursing car
Six commonly used empirical body surface area formulas disagreed in young children undergoing corrective heart surgery.
Get PDFTo access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadAim: Formulas for empirical body surface area (BSA), which is used to estimate body size and standardise physiological parameters, may disagree in children. We compared six commonly used BSA formulas-Du Bois, Boyd, Costeff, Haycock, Meban and Mosteller-in a surgical cohort.
Methods: This retrospective single-centre cohort study comprised 68 children who had corrective heart surgery at Skåne University Children's Hospital, Lund, Sweden, from February 2010 to March 2017.
Results: The children (51% female) underwent surgery at a mean weight of 7.0 kilograms (range 2.7-14.1 kg) and a mean age 11 months (range 0-43 months). All the BSA formulas showed good correlation with mean BSA, but there were considerable variations between them. Mosteller's formula was exactly the same as the mean BSA (bias 0.000). The Du Bois and Boyd formulas had the largest mean BSA deviations (bias -0.012 and 0.015). Costeff's formula showed good agreement with mean BSA, Haycock's formula showed minimal overestimation and Meban's formula demonstrated a systemic error in older children.
Conclusion: Commonly used BSA formulas did not agree in young children undergoing heart surgery, but they were all close to the overall mean of the six formulas, with the Mosteller formula producing the same value
Awareness of polycystic ovary syndrome among obstetrician-gynecologists and endocrinologists in Northern Europe.
Get PDFTo access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadObjective: To date, little is known about differences in the knowledge, diagnosis making and treatment strategies of health care providers regarding polycystic ovary syndrome (PCOS) across different disciplines in countries with similar health care systems. To inform guideline translation, we aimed to study physician reported awareness, diagnosis and management of PCOS and to explore differences between medical disciplines in the Nordic countries and Estonia.
Methods: This cross-sectional survey was conducted among 382 endocrinologists and obstetrician-gynaecologists in the Nordic countries and Estonia in 2015-2016. Of the participating physicians, 43% resided in Finland, 18% in Denmark, 16% in Norway, 13% in Estonia, and 10% in Sweden or Iceland, and 75% were obstetrician-gynaecologists. Multivariable logistic regression models were run to identify health care provider characteristics for awareness, diagnosis and treatment of PCOS.
Results: Clinical features, lifestyle management and comorbidity were commonly recognized in women with PCOS, while impairment in psychosocial wellbeing was not well acknowledged. Over two-thirds of the physicians used the Rotterdam diagnostic criteria for PCOS. Medical endocrinologists more often recommended lifestyle management (OR = 3.6, CI 1.6-8.1) or metformin (OR = 5.0, CI 2.5-10.2), but less frequently OCP (OR = 0.5, CI 0.2-0.9) for non-fertility concerns than general obstetrician-gynaecologists. The physicians aged 56 (adjusted odds ratio (OR) = 0.4, 95% CI 0.2-0.8).
Conclusion: Despite well-organized healthcare, awareness, diagnosis and management of PCOS is suboptimal, especially in relation to psychosocial comorbidities, among physicians in the Nordic countries and Estonia. Physicians need more education on PCOS and evidence-based information on Rotterdam diagnostic criteria, psychosocial features and treatment of PCOS, with the recently published international PCOS guideline well needed and welcomed.Sigrid Juselius Foundation
Academy of Finland
Finnish Medical Associatio
Reoperation for bleeding following coronary artery bypass surgery with special focus on long-term outcomes.
No full textTo access publisher's full text version of this article click on the hyperlink belowObjectives: We studied the incidence and risk factors of reoperation for bleeding following CABG in a nationwide cohort with focus on long-term complications and survival. Design: A retrospective study on 2060 consecutive, isolated CABG patients operated 2001-2016. Outcome of reoperated patients (n = 130) were compared to non-reoperated ones (n = 1930), including major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Risk factors for reoperation were determined using multivariate logistic regression and a Cox proportional hazards model to assess prognostic factors of long-term survival. Median follow-up was 7.6 years. Results: One hundred thirty patients (6.3%) were reoperated with an annual decrease of 4.1% per year over the study period (p=.04). Major complications (18.5 vs. 9.6%) and 30-day mortality (8.5 vs. 1.9%,) were higher in the reoperation group (p<.001). The use of clopidogrel preoperatively (OR 3.62, 95% CI: 1.90-6.57) and reduced left ventricular ejection fraction (OR 2.23, 95% CI: 1.25-3.77) were the strongest predictors of reoperation, whereas off-pump surgery was associated with a lower reoperation risk (OR 0.44, 95% CI: 0.22-0.85). After exluding patients that died within 30 days postoperatively, no difference in long-term survival or freedom from MACCE was found between groups, and reoperation was not an independent risk factor for long-term mortality in multivariate analysis. Conclusions: The reoperation rate in this study was relatively high but decreased significantly over time. Reoperation was associated with twofold increased risk for major complications and fourfold 30-day mortality, but comparable long-term MACCE and survival rates. This implies that if patients survive the first 30 days following reoperation, their long-term outcome is comparable to non-reoperated patients
Feasibility and accuracy of a robotic guidance system for navigated spine surgery in a hybrid operating room: a cadaver study.
Get PDFTo access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadThe combination of navigation and robotics in spine surgery has the potential to accurately identify and maintain bone entry position and planned trajectory. The goal of this study was to examine the feasibility, accuracy and efficacy of a new robot-guided system for semi-automated, minimally invasive, pedicle screw placement. A custom robotic arm was integrated into a hybrid operating room (OR) equipped with an augmented reality surgical navigation system (ARSN). The robot was mounted on the OR-table and used to assist in placing Jamshidi needles in 113 pedicles in four cadavers. The ARSN system was used for planning screw paths and directing the robot. The robot arm autonomously aligned with the planned screw trajectory, and the surgeon inserted the Jamshidi needle into the pedicle. Accuracy measurements were performed on verification cone beam computed tomographies with the planned paths superimposed. To provide a clinical grading according to the Gertzbein scale, pedicle screw diameters were simulated on the placed Jamshidi needles. A technical accuracy at bone entry point of 0.48 ± 0.44 mm and 0.68 ± 0.58 mm was achieved in the axial and sagittal views, respectively. The corresponding angular errors were 0.94 ± 0.83° and 0.87 ± 0.82°. The accuracy was statistically superior (p < 0.001) to ARSN without robotic assistance. Simulated pedicle screw grading resulted in a clinical accuracy of 100%. This study demonstrates that the use of a semi-automated surgical robot for pedicle screw placement provides an accuracy well above what is clinically acceptable