Causes and predictors of death among Finnish patients with systemic sclerosis

OBJECTIVE

The aim of this study was to assess causes and predictors of death among Finnish patients with systemic sclerosis (SSc).

METHOD

Medical records of patients registered with the ICD-10 code M34 from 1996 to 2018 in two university hospitals were reviewed retrospectively. Clinical data were collected until the end of 2020. Death certificates were obtained from Statistics Finland up to August 2021. Using death certificates and patient records, the cause of death for each patient was determined. The mean age at death, median time from SSc diagnosis, and factors predicting death were analysed.

RESULTS

Among 313 SSc patients, 91 deaths occurred between April 2000 and September 2020. Overall 5 and 10 year survival rates were 88.4% and 80.2%, respectively. SSc was the most common primary cause of death (n = 35) and interstitial lung disease (ILD) was the most common SSc-related cause of death (n = 13). Moreover, 52% of the patients with diffuse SSc and 33% of those with limited cutaneous SSc died as a result of SSc itself. Patients who died because of SSc were significantly younger [mean ± sd age 65.6 ± 12.7 years, 95% confidence interval (CI) 61.2-70.1] than those who died from other causes (74.2 ± 9.6 years, 95% CI 71.5-76.9) (p = 0.0006). ILD, pulmonary arterial hypertension, gastrointestinal involvement, male gender, and older age at disease onset predicted death.

CONCLUSION

The disease itself was the major cause of death among Finnish SSc patients, in both diffuse and limited forms of SSc.

Empowering Support for Family Members of Brain Injury Patients in the Acute Phase of Hospital Care: A Mixed-Methods Systematic Review

This review aimed to identify and synthesize empowering support for the family members of patients in the acute phase of traumatic brain injury hospital treatment. CINAHL, PubMed, Scopus, and Medic databases were searched from 2010 to 2021. Twenty studies met the inclusion criteria. Each article was critically appraised using the Joanna Briggs Institute Critical Appraisals Tools. Following a thematic analysis, four main themes were identified about the process of empowering traumatic brain injury patients' family members in the acute phases of hospital care: (a) needs-based informational, (b) participatory, (c) competent and interprofessional, and (d) community support. This review of findings may be utilized in future studies focusing on designing, implementing, and evaluating an empowerment support model for the traumatic brain injury patient's family members in the acute care hospitalization to strengthen the current knowledge and develop nursing practices.

Systemic sclerosis: changes in the incidence rates in the Finnish population during the years 1999-2018

OBJECTIVE

The aim of our study was to examine changes in the incidence of systemic sclerosis (SSc) in Finland using two different classification criteria.

METHOD

Medical records of patients who had been registered with ICD-10 code M34 from 1999 to 2018 in two university hospitals were reviewed retrospectively. This period was divided into 5 year periods: 1999-2003, 2004-2008, 2009-2013, and 2014-2018. Using American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 2013 criteria and clinical findings, we reclassified patients into four groups: diffuse SSc, limited SSc, sine SSc, or early SSc. In the same population, we also investigated whether the ACR 1980 criteria were fulfilled.

RESULTS

In 1999-2018, 246 new patients with SSc and 45 patients with early SSc were identified using ACR/EULAR 2013 criteria. Of these patients, 70 fulfilled the ACR 1980 criteria. Using ACR/EULAR 2013 criteria, the increase in new diagnoses was statistically significant when comparing the fourth period with the first period (p = 0.0012). The increase was due to a rise in limited SSc. Mean annual incidence rates in these groups were 0.9, 1.2, 1.9, and 2.8 per 100 000 inhabitants ≥ 16 years old. An increasing trend was also seen when using ACR 1980 criteria, but this was not statistically significant.

CONCLUSION

The incidence of SSc increased during the period between 1999-2003 and 2014-2018 using ACR/EULAR 2013, but not using ACR 1980 criteria. The increase was detected within a limited SSc subclass, owing to more sensitive classification criteria.

Three-Dimensional Exoscopic Versus Microscopic Resection of Vestibular Schwannomas: A Comparative Series

BACKGROUND

Microsurgical resection of vestibular schwannoma (VS) is highly challenging, especially because surgical treatment nowadays is mainly reserved for larger (Koos grade 3 and 4) tumors.

OBJECTIVE

To assess the performance of three-dimensional exoscope use in VS resection in comparison with the operative microscope.

METHODS

Duration of surgery and clinical and radiological results were collected for 13 consecutive exoscopic schwannoma surgeries. Results were compared with 26 preceding microsurgical resections after acknowledging similar surgical complexity between groups by assessment of tumor size (maximum diameter and Koos grade), the presence of meatal extension or cystic components, and preoperative hearing and facial nerve function.

RESULTS

Total duration of surgery was comparable between microscopically and exoscopically operated patients (264 minutes ± 92 vs 231 minutes ± 84, respectively; P = .276). However, operative time gradually decreased in consecutive exoscopic cases and in a multiple regression model predicting duration of surgery, and exoscope use was associated with a reduction of 58.5 minutes (95% CI -106.3 to -10.6; P = .018). Tumor size was identified as the main determinant of duration of surgery (regression coefficient = 5.50, 95% CI 3.20-7.80) along meatal extension and the presence of cystic components. No differences in postoperative hearing preservation and facial nerve function were noted between the exoscope and the microscope.

CONCLUSION

Resection of VS using a foot switch-operated three-dimensional exoscope is safe and leads to comparable clinical and radiological results as resection with the operative microscope.

The feasibility of existing JADAS10 cut-off values in clinical practice: a study of data from The Finnish Rheumatology Quality Register

BACKGROUND

The ten-joint juvenile arthritis disease activity score (JADAS10) is designed to measure the level of disease activity in non-systemic juvenile idiopathic arthritis by providing a single numeric score. The clinical JADAS10 (cJADAS10) is a modification of the JADAS10 that excludes erythrocyte sedimentation rate (ESR). Three different sets of JADAS10/cJADAS10 cut-offs for disease activity states have been published, i.e., the Backström, Consolaro, and Trincianti cut-offs. The objective of this study was to investigate the performance of existing JADAS10 cut-offs in real-life settings using patient data from The Finnish Rheumatology Quality Register (FinRheuma).

METHODS

Data were collected from the FinRheuma register. The proportion of patients with an active joint count (AJC) above zero when classified as being in clinically inactive disease (CID) or low disease activity (LDA) groups according to existing JADAS10/cJADAS10 cut-off levels were analyzed.

RESULTS

A significantly larger proportion of the patients classified as being in CID had an AJC > 0 when using the JADAS10/cJADAS10 cut-offs by Trincianti et al. compared to those for the other cut-offs. In the LDA group, a significantly larger proportion of the polyarticular patients (35%/29%) had an AJC of two when Trincianti JADAS10/cJADAS10 cut-offs were used compared with when Backström (11%/10%) and Consolaro (7%/3%) JADAS10/cJADAS10 cut-offs were used.

CONCLUSIONS

We found the cut-offs proposed by Consolaro et al. to be the most feasible, since these cut-off levels for CID do not result in the misclassification of active disease as remission, and the proportion of patients with AJC > 1 in the LDA group is lowest using these cut-offs.

3D Exoscopes in Experimental Microanastomosis: A Comparison of Different Systems

Background: In recent years, three-dimensional exoscopes have been increasingly applied in neurosurgery. Multiple exoscopic systems are available, all offering specific features. In this study, we assessed practical and visualization performance of four different exoscopic systems in a highly challenging microsurgical procedure, and evaluated whether these affected the quality of work. Methods: We included four different exoscopes: Olympus ORBEYE, Zeiss KINEVO, Storz VITOM, and Aesculap AEOS. With each exoscope, ten experimental bypass procedures were carried out on chicken wing vessels at a depth of 3 cm. We evaluated the quality of the anastomoses, the practical considerations for the setup of the exoscopic systems, and the visualization quality by tracking the number of unnecessary movements. Results: All included exoscopes enabled us to perform the bypass procedures with mostly adequate or excellent results. Surgically, the most pronounced difference between the exoscopes was the duration of the procedure, which was mainly due to the number of unnecessary movements. Practically, the exoscopes differ highly which is important when considering which exoscope to apply. Conclusions: This is the first study comparing different exoscope systems while performing the same challenging microsurgical procedure. We found major practical differences between the exoscopes that determine the suitability of an exoscope based on the demands and conditions of the surgical procedure. Therefore, preprocedural practical training with the exoscope is required.

3D Exoscopes are Noninferior to Operating Microscopes in Aneurysm Surgery: Comparative Single-Surgeon Series of 52 Consecutive Cases

OBJECTIVE

The literature on exoscope use in cerebrovascular neurosurgery is scarce, mainly comprising small case series and focused on visualization quality and ergonomics. As these devices become widely used, direct comparison to the operating microscope regarding efficacy and patient safety is necessary.

METHODS

Fifty-two consecutive clipping procedures, performed by 1 senior vascular neurosurgeon, were analyzed. Either an operating microscope with a mouth switch (25 cases with 27 aneurysms; 13 ruptured) or a three-dimensional exoscope with a foot switch (27 cases with 34 aneurysms; 6 ruptured) were used. Durations of major surgical stages, number of device adjustments, numbers of clip repositionings and clips implanted were extracted from surgical videos. Demographic data, imaging characteristics, clinical course and outcomes were extracted from digital patient records.

RESULTS

Duration of surgery and different stages did not differ between devices, except for final site inspection. The number of device adjustments was higher with the exoscope. With progressive experience in exoscope use, the number of device adjustments increased significantly, whereas surgery duration remained unchanged. Favorable outcome (modified Rankin Scale score 0-2) was observed in 80% and 88% of patients in the microscope and exoscope groups, respectively. Ischemic events were found in 2 patients in each group; no other complications occurred.

CONCLUSIONS

In aneurysm clipping, three-dimensional exoscopes are noninferior to operating microscopes in terms of surgery duration, safety, and outcomes, based on our limited series. Progressive experience enables the surgeon to perform significantly more device adjustments within the same amount of surgical time.

The validity of rheumatoid arthritis diagnoses in Finnish biobanks

OBJECTIVE

The aim of this study was to determine the validity of rheumatoid arthritis (RA) diagnoses in patients participating in Finnish biobanks.

METHOD

We reviewed the electronic medical records of 500 Finnish biobank participants: 125 patients with at least one visit with a diagnosis of seropositive RA, 125 patients with at least one visit with a diagnosis of seronegative RA, and 250 age- and gender-matched controls. The patients were chosen from five different biobank hospitals in Finland. A rheumatologist reviewed the medical records to assess whether each patients' diagnosis was correct. The diagnosis was compared with the diagnostic codes in the Finnish Care Register for Health Care (CRHC) and special reimbursement data of the Social Insurance Institution of Finland.

RESULTS

The positive predictive value (PPV) of CRHC diagnosis of RA (for seropositive and seronegative RA combined) was 0.82. For patients with a special reimbursement for anti-rheumatic medications for RA, the PPV was 0.89. The PPV was higher in patients with more than one visit. For one, two, five, and 10 visits, the PPV was 0.82, 0.85, 0.89, and 0.90, respectively, and for patients who also had the special reimbursement, the PPV was 0.89, 0.91, 0.93, and 0.94 for one, two, five, and 10 visits, respectively. In patients positive for anti-citrullinated protein antibodies, the PPV was 0.98.

CONCLUSION

These results demonstrate that the validity of RA diagnoses in Finnish biobanks was good and can be further improved by including data on special reimbursement for medication, number of visits, and serological data.

The validity of systemic sclerosis diagnoses in two university hospitals in Finland

OBJECTIVE

This study aimed to determine the validity of systemic sclerosis (SSc) diagnoses in Finnish university hospitals.

METHOD

Electronic medical records for 385 patients with a registered diagnosis of SSc (ICD-10 code M34) in two Finnish university hospitals from 2008 to 2018 were reviewed to assess whether each patient's diagnosis was correct.

RESULTS

The positive predictive value (PPV) of a diagnosis of SSc was 0.66 when fulfilment of the 2013 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for SSc was required; the PPV was 0.75 if patients meeting the 2001 LeRoy and Medsger classification criteria for early SSc were also included. When a diagnosis of SSc was made in a department of rheumatology, the PPV was 0.78, and 0.90 when including patients with early SSc. For the more specific diagnosis of limited cutaneous SSc (lcSSc), the PPV was 0.80, and 0.95 when including early SSc. For an lcSSc diagnosis made in rheumatology, the PPV was 0.81, and 0.97 with early SSc included.

CONCLUSION

These results demonstrate that in these two Finnish university hospitals, the diagnostic validity of a diagnosis of SSc was good if it was diagnosed in the department of rheumatology. For a more specific diagnosis of lcSSc, the most prevalent form of SSc in Finland, the validity was good even when registered in any department.

AB0164 ARE PATIENTS WITH RA IN REMISSION IN FINLAND DURING THE COVID TIMES? RESULTS FROM THE FINNISH QUALITY REGISTER

Background

Worries have been expressed, concerning the care of chronic diseases during the Covid times (1).

Objectives

To study the current status of patients with RA in the Finnish quality register database.

Methods

Patients who receive care for RA were identified in the database. Clinical and demographic data from the last visits during 2020-21 were collected, including swollen (SJC46) and tender joint counts (TJC46), doctor assessment of disease activity (Dr global), laboratory tests for inflammatory and serology markers, patient reported outcomes (PROs), and DAS28. Regression models were applied to compare measures of clinical status between the health care regions, adjusted for gender, age, ACPA status, and disease duration.

Results

A total of 14163 patients (72% female, mean (SD) age 62 (14) years, median (IQR) disease duration 8.5 (2.6, 20) years, 84% ACPA positive) were identified. For the entire population, the median (IQR) SJC46 was 0 (0, 1), TJC46 0 (0, 2), ESR 8 (5, 18), CRP 3 (1, 6), and dr global 8 (0, 19). Among PROs, median (IQR) HAQ was 0.5 (0, 1), pain 26 (10, 51), fatigue 28 (8, 54) and patient global 29 (11, 51). Between health care regions, statistically significant differences were found for all variables due to a large sample size. The mean (SD) DAS28 was 2.3 (0.9) for the entire group and 69 % of all patients had DAS28<2.6. The median DAS28 ranged from 2 to 2.7 among health care regions (Figure 1) (p<0.001). Majority of patients were taking csDMARDs only.

Figure 1.

Rheumatoid arthritis in 2020-21: The median DAS28-values in 19 regions in Finland.

Conclusion

The quality register provides comprehensive real-world data on the current status of patients with RA. A majority of patients can be considered being in remission even during the Covid times.

References

[1]Glintborg et al. Rheumatology (Oxford) 2021 Oct 9;60(SI):SI3-SI12

Acknowledgements

I would like to thank The Finnish Society for Rheumatology and The Finnish Psoriasis Association for their grants.

Disclosure of Interests

None declared

AB0168 DISEASE BURDEN MEASURED BY PROs: DOES PSORIATIC ARTHRITIS (PsA) FEEL WORSE THAN RHEUMATOID ARTHRITIS (RA)? A CROSS-SECTIONAL STUDY

Background

Little comparative research has been done comparing disease burden between PsA and RA. Previous studies from Nordic countries and the US have shown small differences (0-10/100 VAS units) in patients with PsA vs. RA. The mean and median VAS levels for PsA and RA ranged between 30-40 for pain and 40-50 for fatigue and patient global health in cross-sectional settings (1, 2, 3).

Objectives

To study the current differences in PROs between PsA and RA in Finland.

Methods

3731 patients receiving care for PsA and 14163 for RA were identified in the national quality register for inflammatory arthritides in 2020-21. Patients were divided into groups by sex and age; <50 years, 50-60 years, 60-70 years and ≥70 years. The VAS values of pain, fatigue and patient global health at the most recent visit were compared in PsA vs. RA between the groups. Descriptive statistics and regression models were used for comparison.

Results

Patients with PsA vs RA were younger (mean (sd) age 54(14) vs 62(14)) and less often women (51% vs. 72%). Median (IQR) disease duration after the first symptoms was 8.6 (3.7, 17) years for PsA and 9.5 (3.3, 21) years for RA. The median (IQR) pain was 29 (10, 56) for all patients with PsA and 26 (10,51) for patients with RA. The corresponding values were: fatigue 28 (9, 60) in PsA vs 28 (8, 54) in RA, and patient global health 28 (10, 51) in PsA and 29 (11, 51) in RA.

Median pain was slightly higher in female PsA patients compared to RA patients in all age groups (29 and 18, 35 and 28, 32 and 27 and 48 and 38) (p<0.001). In males, higher levels of pain in PsA vs. RA were seen in age groups older than 50 years old. Figure 1 illustrates the mean (95% CI) pain for PsA and RA in the age and sex groups.

Median fatigue levels were quite similar between the groups. The median patient global health was higher in female PsA compared to RA patients in age groups <50 years and 50-60 years (20 vs. 29 and 30 vs 37) (p<0.001).

Figure 1.

Mean (95 % CI) pain in VAS-units for women and men by age groups in 2020-2021

Conclusion

Female patients with PsA report higher levels of pain in all age groups compared to patients with RA. The same was seen in men >50 years old. Concerning fatigue and patient global health, the differences between PsA and RA were smaller. Compared to earlier research in other countries, disease burden observed by PROs appears lower both in PsA and RA in Finland.

References

[1]Pilgaard T et al. Severity of fatigue in people with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis – Results of a cross-sectional study, PLoS One, 2019; 14(6): e0218831

[2]Egholm CL et al. Discordance of Global Assessments by Patient and Physician Is Higher in Female than in Male Patients Regardless of the Physician’s Sex: Data on Patients with Rheumatoid Arthritis, Axial Spondyloarthritis, and Psoriatic Arthritis from the DANBIO Registry, The Journal of rheumatology, 2015 Oct;42(10):1781-5.

[3]Mease PJ et al. Comparative Disease Burden in Patients with Rheumatoid Arthritis, Psoriatic Arthritis, or Axial Spondyloarthritis: Data from Two Corrona Registries, Rheumatology and therapy, 2019 Dec;6(4):529-542

Acknowledgements

I would like to thank The Finnish Society for Rheumatology and The Finnish Psoriasis Association for their grants.

Disclosure of Interests

None declared

Early vs. late enoxaparin for the prevention of venous thromboembolism in patients with ICH: A double blind placebo controlled multicenter study

BACKROUND

Venous thromboembolism (VTE) after primary intracerebral hemorrhage (ICH) worsens patient prognosis. Administering low-molecular weight heparins (LMWH) to prevent VTE early (24 h) may increase the risk of hematoma enlargement, whereas administering late (72 h) after onset may decrease its effect on VTE prevention. The authors investigated when it is safe and effective to start LMWH in ICH patients.

METHODS

In the setting of double blinded, placebo controlled randomization, patients >18 years of age with paretic lower extremity, and admitted to the emergency room within 12 h of the onset of ICH, were randomized into two groups. Patients in the enoxaparin group received 20 mg twice a day 24 h (early) after the onset of ICH and in the placebo group 72 h (late) after onset respectively. Both groups immediately received intermittent pneumatic compression stockings at the ER. Patients were prospectively and routinely screened for VTE and hemorrhagic complications 1 day after entering the study and again before discharge.

RESULTS

139 patients were included for randomization in this study. Only 3 patients developed VTE, 2 in the early enoxaparin group and one in the late enoxaparin group. No patients developed PE. Thromboembolic events (p = 0.901), risk of hematoma enlargement (p = 0.927) and overall outcome (P = 0.904) did not differ significantly between the groups.

CONCLUSION

Administering 40 mg/d LMWH for prevention of VTE to a spontaneous ICH patient is safe regardless of whether it is started 24 h (early) or 72 h (late) after the hemorrhage. Risk of hemorrhage enlargement is not associated with early LMWH treatment. Administering LMWH late did not increase VTEs.

AB1251 VALIDITY OF RHEUMATOID ARTHRITIS DIAGNOSES IN FINNISH BIOBANK PATIENTS

Background:

Finnish healthcare registers are used in medical research, but there is little data about the validity of these registers in rheumatology.

Objectives:

The aim of our study was to determine the validity of rheumatoid arthritis (RA) diagnoses in patients participating in the Finnish Biobanks.

Methods:

We reviewed the electronic patient charts of 125 patients with at least one visit with a diagnosis of seropositive RA, 125 patients with at least one visit with a diagnosis of seronegative RA and 250 age-and-sex matched controls. Patients were randomly selected from Finnish biobank participants. We evaluated whether the patients’ diagnosis of RA recorded in the hospital discharge registry at the participating hospital was correct according to chart review and expert opinion. In the control group it was investigated whether the diagnosis of RA was written in the patients’ chart, but the diagnosis code was not recorded.

Results:

The positive predictive value (PPV) of a single hospital registry diagnosis of seropositive RA was 0.74 but rose to 0.98 in patients with a special reimbursement for seropositive RA and 0.98 in anti-citrullinated protein antibody positive patients. For seronegative RA, the PPV of a diagnosis was 0.72 and in patients with a special reimbursement for seronegative RA 0.89. The PPV was higher in patients with more than one visit with the diagnosis: 0.92 if the patients had at least 5 visits with seropositive RA and 0.88 with at least 5 visits with seronegative RA. Negative predictive value for RA diagnosis was 0.99.

Conclusion:

These results demonstrate that the validity of RA diagnoses in healthcare registers can be markedly improved with data about special reimbursement for medication, number of visits and serological data.

Disclosure of Interests:

Antti Palomäki Consultant of: Pfizer, Speakers bureau: Pfizer, Sanofi, MSD, Johanna Paltta Consultant of: Lilly, Abbvie, Laura Pirilä Consultant of: Novartis, MSD Finland, Roche, Bristol-Myers-Squibb, Pfizer, Sanofi, Abbvie, Oy Eli LIlly Finland Ab, UCB Pharma Oy Finland, Jansen-Cilag, Mylan, Sandoz, Boehringer-Ingelheim, Paid instructor for: Boehringer -Ingelheim, MSD Finland, Speakers bureau: Boehringer-Ingelheim, Pfizer Finland, Hanna-Kaisa Heikkilä: None declared, Pia Isomäki Consultant of: Abbvie, BMS, Eli Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, Johanna Huhtakangas Consultant of: Boehringer Ingelheim, Tuulikki Sokka-Isler: None declared, Oili Kaipiainen-Seppänen Speakers bureau: Boehringer Ingelheim, Kari Eklund Consultant of: Celgene, Lilly, Speakers bureau: Pfizer, Roche

The Identification of Factors That Influence the Quality of Bypass Anastomosis and an Evaluation of the Usefulness of an Experimental Practical Scale in This Regard

BACKGROUND

Several factors associated with interrupted and continuous suturing techniques affect the quality of bypass anastomosis. It is difficult to determine the impact of these factors during surgery. The primary objective of this study was to evaluate factors with the potential to influence the quality of bypass anastomosis using either interrupted or continuous suturing. A secondary objective was to evaluate the usefulness of a practical scale when comparing interrupted and continuous suturing techniques to improve bypass anastomosis.

METHODS

Interrupted (n = 100) and continuous (n = 100) suturing techniques were used in 200 end-to-side bypasses to a depth of 3 cm and were assessed by 5 neurosurgeons.

RESULTS

Vessel closing time (P < 0.001), stitch distribution (P < 0.001), intima-intima attachment (P < 0.001), and size of the orifice (P < 0.001) had a significant impact on the quality of the bypass regardless of the suturing technique used. The suturing technique used (interrupted or continuous) and positioning of the recipient vessel (vertical or horizontal) did not significantly influence the quality of anastomosis. Using multivariate analysis, the highest statistical significance with regard to bypass quality was attributed to the large size of the orifice and intimal attachment.

CONCLUSIONS

There were advantages and disadvantages to both suturing techniques. The scale was a practical way to measure and improve performance.

Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms: treatment and outcome of 620 consecutive patients

OBJECTIVE

Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome.

METHODS

In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death.

RESULTS

Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0-2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4-5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment-related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt.

CONCLUSIONS

Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment-related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.

The Identification of Factors That Influence the Quality of Bypass Anastomosis and an Evaluation of the Usefulness of an Experimental Practical Scale in This Regard

BACKGROUND

Several factors associated with interrupted and continuous suturing techniques affect the quality of bypass anastomosis. It is difficult to determine the impact of these factors during surgery. The primary objective of this study was to evaluate factors with the potential to influence the quality of bypass anastomosis using either interrupted or continuous suturing. A secondary objective was to evaluate the usefulness of a practical scale when comparing interrupted and continuous suturing techniques to improve bypass anastomosis.

METHODS

Interrupted (n = 100) and continuous (n = 100) suturing techniques were used in 200 end-to-side bypasses to a depth of 3 cm and were assessed by 5 neurosurgeons.

RESULTS

Vessel closing time (P < 0.001), stitch distribution (P < 0.001), intima-intima attachment (P < 0.001), and size of the orifice (P < 0.001) had a significant impact on the quality of the bypass regardless of the suturing technique used. The suturing technique used (interrupted or continuous) and positioning of the recipient vessel (vertical or horizontal) did not significantly influence the quality of anastomosis. Using multivariate analysis, the highest statistical significance with regard to bypass quality was attributed to the large size of the orifice and intimal attachment.

CONCLUSIONS

There were advantages and disadvantages to both suturing techniques. The scale was a practical way to measure and improve performance.

CTA analysis and assessment of morphological factors related to rupture in 413 posterior communicating artery aneurysms

Posterior communicating artery (PcomA) aneurysms are frequently encountered, but there are few publications on their morphology. A growing number of aneurysms are incidental findings, which makes evaluation of rupture risk important. Our goal was to identify morphological features and anatomical variants associated with PComA aneurysms and to assess parameters related to rupture. We studied CT angiographies of 391 consecutive patients treated between 2000 and 2014 at a single institution. We determined clinically important morphological parameters and performed univariate and multivariate analysis. There were a total of 413 PComA aneurysms: 258 (62%) were ruptured and 155 (38%) unruptured. Ruptured PComA aneurysms had the potential to cause severe bleeding with IVH and/or temporal ICH (n = 170, 66% of ruptured). The main types of PComA origin were classified as follows: (1) separate (32%), (2) side by side (21%) and (3) a joint neck with the aneurysm (6%). After the multivariate logistic regression, the morphological parameters related to PComA aneurysm rupture were an irregular aneurysm dome, neck diameter, and aspect ratio >1.5. The most marked morphological features of the PComA aneurysms were: saccular nature (99%), infero-posterior dome orientation (42%), infrequency of large or giant aneurysms (4%), narrow neck compared to the aneurysm size, PComA originating directly from the aneurysm neck or the dome (28%), and fetal or dominant PComA on the side of the aneurysm (35%). There were location-related parameters that were more strongly associated with PComA aneurysm rupture than aneurysm size: an irregular aneurysm dome, larger diameter of the aneurysm neck and aspect ratio >1.5.

Long-Term Excess Mortality After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose—

There is high case-fatality rate and loss of productive life-years related to aneurysmal subarachnoid hemorrhage (aSAH) but data on long-term survival of patients with aSAH are scarce. We aim to evaluate long-term excess mortality and related risk factors after an aSAH event.

Methods—

Survivors (n=3078) of aSAH who had survived for ≥1 year were reviewed for this retrospective follow-up study, which was conducted in the Department of Neurosurgery in Helsinki between 1980 and 2007. Follow-up started 1 year after the aSAH and continued until death or the end of 2012 (48 918 patient-years). Mortality and relative survival ratios were derived using a matched general population.

Results—

Survivors of aSAH after 20 years showed 17% excess mortality compared with the general population. Even young patients and patients with good recovery showed excess mortality. The highest excess mortality was among patients with multiple aneurysms, old age, poor preoperative clinical condition, conservative aneurysm treatment, and unfavorable clinical outcome at 1 year.

Conclusions—

Even after initially favorable recovery from an aSAH, survivors experience excess mortality in the long run in comparison to a matched general population. Cardiovascular disease at younger age and cerebrovascular events were overrepresented as causes of death, which indicates the importance of treatment of vascular risk factors. Young patients and patients with multiple aneurysms who are recovering from an aSAH should be followed-up and treated most actively.

Negative regulation of human parathyroid hormone gene promoter by vitamin D3 through nuclear factor Y

The negative regulation of the human parathyroid hormone (PTH) gene by biologically active vitamin D3 (1,25-dihydroxyvitamin D3; 1,25(OH)2D3) was studied in rat pituitary GH4C1 cells, which express factors needed for the negative regulation. We report here that NF-Y binds to sequences downstream of the site previously reported to bind the vitamin D receptor (VDR). Additional binding sites for NF-Y reside in the near vicinity and were shown to be important for full activity of the PTH gene promoter. VDR and NF-Y were shown to exhibit mutually exclusive binding to the VDRE region. According to our results, sequestration of binding partners for NF-Y by VDR also affects transcription through a NF-Y consensus binding element in GH4C1 but not in ROS17/2.8 cells. These results indicate that 1,25(OH)2D3 may affect transcription of the human PTH gene both by competitive binding of VDR and NF-Y, and by modulating transcriptional activity of NF-Y.