New-onset atrial fibrillation in critically ill adult patients-an SSAI clinical practice guideline

BACKGROUND

Acute or new-onset atrial fibrillation (NOAF) is the most common cardiac arrhythmia in critically ill adult patients, and observational data suggests that NOAF is associated to adverse outcomes.

METHODS

We prepared this guideline according to the Grading of Recommendations Assessment, Development and Evaluation methodology. We posed the following clinical questions: (1) what is the better first-line pharmacological agent for the treatment of NOAF in critically ill adult patients?, (2) should we use direct current (DC) cardioversion in critically ill adult patients with NOAF and hemodynamic instability caused by atrial fibrillation?, (3) should we use anticoagulant therapy in critically ill adult patients with NOAF?, and (4) should critically ill adult patients with NOAF receive follow-up after discharge from hospital? We assessed patient-important outcomes, including mortality, thromboembolic events, and adverse events. Patients and relatives were part of the guideline panel.

RESULTS

The quantity and quality of evidence on the management of NOAF in critically ill adults was very limited, and we did not identify any relevant direct or indirect evidence from randomized clinical trials for the prespecified PICO questions. We were able to propose one weak recommendation against routine use of therapeutic dose anticoagulant therapy, and one best practice statement for routine follow-up by a cardiologist after hospital discharge. We were not able to propose any recommendations on the better first-line pharmacological agent or whether to use DC cardioversion in critically ill patients with hemodynamic instability induced by NOAF. An electronic version of this guideline in layered and interactive format is available in MAGIC: https://app.magicapp.org/#/guideline/7197.

CONCLUSIONS

The body of evidence on the management of NOAF in critically ill adults is very limited and not informed by direct evidence from randomized clinical trials. Practice variation appears considerable.

The epidemiology of new persistent hypnotic/sedative use after surgical procedures: a retrospective cohort study

The use of hypnotic and sedative medication for sleep improvement is common and long-term use has been associated with an increased risk of adverse events and mortality. A proportion of patients might develop long-term use after initiating new persistent use following surgery. This retrospective cohort study aimed to determine the incidence of new persistent hypnotic/sedative use after surgical procedures and associated patient and procedural factors. Data on prescriptions for hypnotic and sedative medications used for sleep improvement were retrieved from the National Prescription Medicine Registry. Medication naivety was defined as not filling a prescription for hypnotics/sedatives from 365 days through 31 days preceding surgery, new use was defined as medication naivety followed by filling a prescription for hypnotic/sedative medication from 30 days before surgery through 14 days after surgery. New persistent hypnotic/sedative use was defined as new use followed by filling another hypnotic/sedative prescription from 15 days through 365 days after surgery. Of 55,414 patients included in the study, 43,297 were naive to hypnotic/sedative medications. Of those naive patients, 4.6% met the criteria for new peri-operative use, of whom 51.6% developed new persistent hypnotic/sedative use. Patient and procedural factors associated with increased risk of new persistent use were older age; female sex; the presence of malignant neoplasm; ischaemic heart disease; and having undergone either cardiac or thoracic surgery. The hazard of long-term mortality was higher for patients with new persistent use (1.39, 95%CI 1.22-1.59) compared with patients who remained naive. While a small ratio of surgical patients initiates the use of hypnotics/sedatives in the peri-operative period, a substantial proportion of these develop persistent use, which is associated with adverse outcomes. Over time, the proportion of patients using hypnotics/sedatives has declined, but the risk of persistent use within this group has remained stable.

[The incidence of postoperative and persistent usage of proton pump inhibitors following surgery]

INTRODUCTION

The use of proton pump inhibitors (PPI) has increased over the past decades. Some patients use the medication without an indication. It is possible that new use will start following surgery. The study aimed to examine the incidence of postoperative use of PPI following surgeries and the ratio of new persistent users over three months postoperatively as well as patient- and procedural variables associated with new use and new persistent use.

METHODS

Data of surgeries among adults that had undergone surgeries at the National University Hospital of Iceland from 2006 to 2018. The data were from the Icelandic perioperative database, containing information regarding medication usage preceding and following surgeries. The ratio of those who started using PPI within three months of surgery was assessed, and the ratio of persistent users.

RESULTS

Altogether, 2886 out of 42.530 patients filled PPI prescription within three months after their first surgery. Annual incidence was 67 per 1.000 surgeries, and the ratio of persistent users was 54%, although both the varied between years. The use was more common among women, highest in age group 56-65 years old, patients with polypharmacy (5-9 medicines) and who underwent abdominal surgeries.

CONCLUSIONS

New postoperative PPI use is common following surgery and half of the patients with new use develop new persistent use. The usage increased similar to the increased number of prescriptions and sales of PPI in other patient groups during the period. The results indicate the need for further monitoring of patients with PPI prescriptions following surgeries in Iceland.

The Nordic perioperative and intensive care registries-Collaboration and research possibilities

BACKGROUND

The Nordic perioperative and intensive care registries have been built up during the last 25 years to improve quality in intensive and perioperative care. We aimed to describe the Nordic perioperative and intensive care registries and to highlight possibilities and challenges in future research collaboration between these registries.

MATERIAL AND METHOD

We present an overview of the following Nordic registries: Swedish Perioperative Registry (SPOR), the Danish Anesthesia Database (DAD), the Finnish Perioperative Database (FIN-AN), the Icelandic Anesthesia Database (IS-AN), the Danish Intensive Care Database (DID), the Swedish Intensive Care Registry (SIR), the Finnish Intensive Care Consortium, the Norwegian Intensive Care and Pandemic Registry (NIPaR), and the Icelandic Intensive Care Registry (IS-ICU).

RESULTS

Health care systems and patient populations are similar in the Nordic countries. Despite certain differences in data structure and clinical variables, the perioperative and intensive care registries have enough in common to enable research collaboration. In the future, even a common Nordic registry could be possible.

CONCLUSION

Collaboration between the Nordic perioperative and intensive care registries is both possible and likely to produce research of high quality. Research collaboration between registries may have several add-on effects and stimulate international standardization regarding definitions, scoring systems, and benchmarks, thereby improving overall quality of care.

Association between pre-operative prolonged corrected QT interval and all-cause mortality after non-cardiac surgery

BACKGROUND

Prolonged corrected QT interval (QTc) has been linked to risk of arrhythmias and mortality in the general population. Pre-operative electrocardiography is often obtained for patient-and procedural cardiovascular risk assessment. The aim of this study was to investigate the association of pre-operative QTc and all-cause mortality in a non-cardiac surgical cohort.

METHODS

A retrospective study of all patients over 18 years undergoing non-cardiac surgery at Landspitali-the National University Hospital in Iceland between 2 January 2005 to 31 December 2015, with follow-up through 20 May 2016. Patients were separated into five categories according to their pre-operative QTc interval ≤ 379, 380-439 (reference group), 440-479, 480-519 and ≥520 ms. Primary outcome was long-term mortality and secondary outcome was 30-day mortality.

RESULTS

A total of 10,209 surgeries for 10,209 individuals were included. The median follow-up for mortality was 2691 days (interquartile range [IQR] 1620-3705 days). Patients with longer QTc interval had a higher comorbidity burden, were more likely to undergo emergency surgery and were often prescribed cardiac medications. After adjustment for confounding variables, the hazard ratio (HR) for long-term mortality compared with reference (QTc 380-439 ms) was 0.85 [CI: 0.66-1.09] for QTc ≤379, 1.08 [CI: 0.99-1.17] for QTc 440-479 ms, 1.26 [CI: 1.10-1.43] for QTc between 480 and 519 ms and 0.97 [CI: 0.78-1.21] for QTc ≥520 ms. When compared with reference, only patients with QTc interval between 480 and 519 ms had higher odds ratio for 30-day mortality as odds ratio for other groups were following; 1.12 [CI: 0.18-3.8] for ≤379 ms, 1.03 [CI: 0.70-1.51] for QTc 440-479 ms, 1.64 [CI: 1.02-2.60] for QTc 480-519 ms and 0.98 [0.44-2.06] for QTc ≥520 ms.

CONCLUSION

Pre-operative QTc between 480 and 519 ms is associated with both higher long-term and 30-day mortality after non-cardiac surgery. The results suggest that this could reflect an underlying cardiovascular risk.

Circulating N-formylmethionine and metabolic shift in critical illness: a multicohort metabolomics study

BACKGROUND

Cell stress promotes degradation of mitochondria which release danger-associated molecular patterns that are catabolized to N-formylmethionine. We hypothesized that in critically ill adults, the response to N-formylmethionine is associated with increases in metabolomic shift-related metabolites and increases in 28-day mortality.

METHODS

We performed metabolomics analyses on plasma from the 428-subject Correction of Vitamin D Deficiency in Critically Ill Patients trial (VITdAL-ICU) cohort and the 90-subject Brigham and Women's Hospital Registry of Critical Illness (RoCI) cohort. In the VITdAL-ICU cohort, we analyzed 983 metabolites at Intensive Care Unit (ICU) admission, day 3, and 7. In the RoCI cohort, we analyzed 411 metabolites at ICU admission. The association between N-formylmethionine and mortality was determined by adjusted logistic regression. The relationship between individual metabolites and N-formylmethionine abundance was assessed with false discovery rate correction via linear regression, linear mixed-effects, and Gaussian graphical models.

RESULTS

Patients with the top quartile of N-formylmethionine abundance at ICU admission had a significantly higher adjusted odds of 28-day mortality in the VITdAL-ICU (OR, 2.4; 95%CI 1.5-4.0; P = 0.001) and RoCI cohorts (OR, 5.1; 95%CI 1.4-18.7; P = 0.015). Adjusted linear regression shows that with increases in N-formylmethionine abundance at ICU admission, 55 metabolites have significant differences common to both the VITdAL-ICU and RoCI cohorts. With increased N-formylmethionine abundance, both cohorts had elevations in individual short-chain acylcarnitine, branched chain amino acid, kynurenine pathway, and pentose phosphate pathway metabolites.

CONCLUSIONS

The results indicate that circulating N-formylmethionine promotes a metabolic shift with heightened mortality that involves incomplete mitochondrial fatty acid oxidation, increased branched chain amino acid metabolism, and activation of the pentose phosphate pathway.

Management of patients with left main stem stenosis in Iceland 2010–2020: PCI or CABG?

Introduction

Coronary artery bypass surgery (CABG) has been standard treatment for patients with left main coronary artery disease (LMCAD) but percutaneous coronary intervention (PCI) is a good alternative in selected patients.

Our purpose was to evaluate the prevalence of LMCAD in Iceland, the impact of background factors on treatment choices, and treatment changes in recent years with respect to current guidelines.

Methods

This retrospective, population-based study analyzed data from the SCAAR-SWEDEHEART database. Patients with significant LMCAD on coronary angiography in Iceland 2010–2020, without previous history of CABG or contraindication for surgery were enrolled. Survival analysis was estimated with Kaplan-Meier and COX regression analysis for investigating the association between survival time and predictor variables.

Findings

Of 702 patients with LMCAD, 195 were treated with PCI, 460 with CABG and 47 with medical treatment only. The widest age range was in the PCI group and the mean age was highest in the medical therapy only group (p<0.001). Patients with LMCAD and either three vessel disease or heart valve disease were most often treated with CABG (76.1% and 84.4%, p<0.001).The majority of patients with LMCAD only were treated with PCI, as were patients with STEMI or cardiogenic shock (67.1% and 70.0%, p<0.001). The proportion of patients treated with PCI increased from 19.8% in 2010–2015 to 42.7% in 2016–2020. There was no significant difference in survival between PCI and CABG (p=0.41).

Conclusions

In patients with LMCAD the main factors that affect treatment choice are age, anatomical complexity and acuteness. Treatment choice appears to be in keeping with current guidelines. There is no significant difference in long term survival between PCI and CABG groups but the groups are different. There has been a significant increase in patients treated with PCI in recent years.

Funding Acknowledgement

Type of funding sources: None.

A nationwide study on characteristics and outcome of cancer patients with sepsis requiring intensive care

BACKGROUND

Sepsis is the leading cause of admission to the intensive care unit (ICU) for cancer patients and survival rates have historically been low. The aims of this nationwide cohort study were to describe the characteristics and outcomes of cancer patients admitted to the ICU with sepsis compared with other sepsis patients requiring ICU admission.

MATERIAL AND METHODS

This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014 and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria. Clinical characteristics and outcomes of sepsis patients with cancer were compared to those without cancer.

RESULTS

In the study period, 235 of 971 (24%) patients admitted to Icelandic ICUs because of sepsis had cancer, most often a solid tumour (100), followed by metastatic tumours (69) and haematological malignancies (66). Infections were more often hospital-acquired in cancer patients (52%) than other sepsis patients (18%, p < 0.001) and sites of infections differed, with abdominal infections being most common in patients with solid and metastatic tumours but lungs and bloodstream infections in haematological malignancies. The length of stay in the ICU was shorter for sepsis patients with metastatic disease than other sepsis patients (2 vs. 4 days, p < 0.001) and they were more likely to have treatment limitations (52 vs. 19%, p < 0.05). Median survival of patients with metastatic disease was 19 days from ICU admission. The 28-day mortality (25%) of solid tumour patients was comparable to that of sepsis patients without cancer (20%, p < 0.001).

CONCLUSIONS

Cancer is a common comorbidity in patients admitted to the ICU with sepsis. The clinical presentation and outcome differs between cancer types. Individuals with metastatic cancer were unlikely to receive prolonged invasive ICU care treatment. Comparable short-term outcome was found for patients with solid tumours and no cancer.

Temporal trends in the epidemiology, management, and outcome of sepsis-A nationwide observational study

BACKGROUND

Registry-based studies have shown increasing incidence of sepsis and declining mortality rates in recent years, but are inherently at risk of bias. The objectives of this study were to describe 11-year trends in the incidence, treatment and outcome of sepsis using clinical criteria with chart review.

METHODS

This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014, and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria (sepsis-2). Incidence, patient characteristics, treatment and outcome were compared across the study years.

RESULTS

During the six study years, 9166 patients were admitted to Icelandic ICUs, 971 (10.6%) because of severe sepsis or septic shock. The crude incidence of sepsis requiring admission to ICU remained stable between 0.55 and 0.75 per 1000 inhabitants. No statistically significant trends were observed over time in median patient age (67 years), APACHE II score (21), SOFA score (8) or Charlson Comorbidity Index (4). The time to antibiotic administration (median 1.8 h) in the emergency departments was stable over the study period but the time to lactate measurements decreased from 4.1 h in 2006 to 1.2 h in 2016, p < .001. The 28-day mortality was 25% and 1-year mortality 41%, both with no observed change with time.

CONCLUSIONS

In a nationwide cohort, diagnosed with clinical criteria, the incidence of sepsis requiring intensive care did not change over an 11-year period. Mortality remained stable and only minimal changes were observed in initial resuscitation in the emergency departments.

Short- and long-term mortality after deep sternal wound infection following cardiac surgery: experiences from SWEDEHEART

OBJECTIVES

Deep sternal wound infection (DSWI) is a serious complication after open-heart surgery. We investigated the association between DSWI and short- and long-term all-cause mortality in a large well-defined nationwide population.

METHODS

A retrospective, nationwide cohort study, which included 114676 consecutive patients who underwent coronary artery bypass grafting (CABG) and/or valve surgery from 1997 to 2015 in Sweden. Short- and long-term mortality was compared between DSWI patients and non-DSWI patients using propensity score inverse probability weighting adjustment based on patient characteristics and comorbidities. Median follow-up was 8.0 years (range 0-18.9).

RESULTS

Altogether, 1516 patients (1.3%) developed DSWI, most commonly in patients undergoing combined CABG and valve surgery (2.1%). DSWI patients were older and had more disease burden than non-DSWI patients. The unadjusted cumulative mortality was higher in the DSWI group compared with the non-DSWI group at 90 days (7.9% vs 3.0%, P < 0.001) and at 1 year (12.8% vs 4.5%, P < 0.001). The adjusted absolute difference in risk of death was 2.3% [95% confidence interval (CI): 0.8-3.9] at 90 days and 4.7% (95% CI: 2.6-6.7) at 1 year. DSWI was independently associated with 90-day [adjusted relative risk (aRR) 1.89 (95% CI: 1.38-2.59)], 1-year [aRR 2.13 (95% CI: 1.68-2.71)] and long-term all-cause mortality [adjusted hazard ratio 1.56 (95% CI: 1.30-1.88)].

CONCLUSIONS

Both short- and long-term mortality risks are higher in DSWI patients compared to non-DSWI patients. These results stress the importance of preventing these infections and careful postoperative monitoring of DSWI patients.

Mild Stage 1 post-operative acute kidney injury: association with chronic kidney disease and long-term survival

Background

Mild cases of acute kidney injury (AKI) are identified by a small rise in serum creatinine (SCr) according to the KDIGO AKI definition. The aim of this study was to examine the long-term outcomes of individuals with mild AKI.

Methods. This was a retrospective cohort study of all adult patients who underwent abdominal, cardiothoracic, vascular or orthopaedic surgery at Landspitali–The National University Hospital of Iceland in 1998–2015. Incident chronic kidney disease (CKD), progression of pre-existing CKD and long-term survival were compared between patients with mild Stage 1 AKI (defined as a rise in SCr of ≥26.5 μmol/L within 48 h post-operatively without reaching 1.5× baseline SCr within 7 days), and a propensity score-matched control group without AKI stratified by the presence of CKD.

Results

Pre- and post-operative SCr values were available for 47 333 (42%) surgeries. Of those, 1161 (2.4%) had mild Stage 1 AKI and 2355 (5%) more severe forms of AKI. Mild Stage 1 AKI was associated with both incident CKD and progression of pre-existing CKD (P < 0.001). After exclusion of post-operative deaths within 30 days, mild Stage 1 AKI was not associated with worse 1-year survival in patients with preserved kidney function (94% versus 94%, P = 0.660), and same was true for patients with pre-operative CKD (83% versus 82%, P = 0.870) compared with their matched individuals.

Conclusions. Mild Stage 1 AKI is associated with development and progression of CKD, but not with inferior 1-year survival. These findings support the inclusion of a small absolute increase in SCr in the definition of AKI.

New-onset postoperative atrial fibrillation after heart surgery

BACKGROUND

New-onset postoperative atrial fibrillation (poAF) complicates approximately 20-60% of all cardiac surgical procedures and is associated with an increased periprocedural mortality and morbitity, prolonged hospital stay, increased costs, and worse long-term survival. Unfortunately multiple advances in surgery and perioperative care over the last two decades have not led to a reduction in the incidence of poAF or associated complications in the daily clinical practice.

METHODS

A narrative review of the available literature was performed.

RESULTS

An extensive review of the pathophysiology of poAF following cardiac surgery, clinical, and procedural risk-factors is provided, as well as prophylactic measures and treatment.

CONCLUSION

Multiple strategies to prevent and manage poAF following heart surgery already exist. Our hope is that this review will facilitate more rigorous testing of prevention strategies, implementation of prophylaxis regimens as well as optimal treatment of this common and serious complication.

Improved long-term outcome of surgical AVR for AS: Results from a population-based cohort

BACKGROUND

The aim of this retrospective study was to determine changes in outcomes after surgical aortic valve replacement (SAVR) for aortic stenosis (AS) in Iceland over a 15-year period.

METHODS

We included 587 patients who underwent SAVR for AS in Iceland during the period 2002-2016, with a total follow-up of 3245 patient-years. Short-term and long-term outcomes, 30-day mortality, and long-term survival (Kaplan-Meier) were analyzed. Univariate linear regression and univariate and multinomial logistic regression analyses were performed on preoperative and perioperative variables. Poisson regression analysis was used to evaluate changes in rates of short-term outcomes.

RESULTS

Mean age was 71 years, 65.1% were males, and mean EuroSCORE II was 3.9. Mean preoperative aortic valve area increased significantly (0.013 cm² /year; P < .001) and mean aortic cross-clamp time declined (108 minutes, 2.8 min/year; P < .001). The rate of complications decreased, including new-onset atrial fibrillation (60.9% overall, decreased by 3.1%/year, P = .02), acute kidney injury (17.1%, 7.6%/year, P < .001), and reoperation for bleeding (12.5%, 6.3%/year, P = .02). Operative mortality did not change (5.4%); nor did 1- and 5-year overall survival (92.5% and 81.6%, respectively). Notable long-term events were chronic heart failure (27.7 admissions/100 patient-years), embolic event (15.9/100 patient-years), and bleeding (13.0/100 patient-years).

CONCLUSIONS

Results of SAVR in this well-defined nationwide cohort of patients in Iceland have improved. This may be related to the patients having less severe AS at the time of operation and shorter operating times, as reflected by lower rates of short-term complications. However, the rate of long-term complications did not change significantly, with prosthetic valve-specific events being rare.

Resection rate and operability of elderly patients with non-small cell lung cancer: Nationwide study from 1991 to 2014

OBJECTIVES

An increasing number of elderly patients are diagnosed with non-small cell lung cancer (NSCLC). We compared the surgical resection rate, operability and survival in this age group (≥75 years) to younger patients using centralized databases in Iceland.

METHODS

The study population comprised all patients diagnosed with NSCLC in Iceland from 1991 to 2014. A total of 140 elderly patients (≥75 years) with NSCLC underwent pulmonary resection and were compared with 550 surgically resected patients less than 75 years, with respect to resection rate, short and long-term survival and complications of surgery. Reasons for exclusion from surgery were registered for elderly surgical candidates (stages IA-IIB).

RESULTS

Surgical resection rate in the elderly group was 18% compared to 32% in the younger age group ( P <  0.001). The most frequent reasons for not operating on elderly patients in stages IA-IIB were poor pulmonary function (58%), heart disease (17%) or multiple comorbidities (17%). The rate of major complications following surgery was comparable in the elderly versus the younger age group, 13 vs 11%, respectively ( P =  0.578). The same was true for 30 day mortality (2 vs 1%, P =  0.397). Five-year overall survival was 40% vs 44% ( P =  0.019) and cancer-specific survival 51% vs 50% ( P =  0.802).

CONCLUSIONS

Elderly patients with resectable NSCLC according to stage are frequently excluded from surgery due to comorbid conditions. Although the operated patients may represent a selected group, their favourable 30-day and long-term survival indicate that more elderly patients with NSCLC could be operated on.

Patient-reported Outcomes and Clinical Response in Patients with Moderate-to-severe Plaque Psoriasis Treated with Tonsillectomy: A Randomized Controlled Trial

Psoriasis is a chronic inflammatory skin disease with profound effects on patients' health-related quality of life (HRQoL). Twenty-nine patients with plaque psoriasis and a history of streptococcal-associated psoriasis exacerbations were randomly assigned to tonsillectomy (n = 15) or control (n = 14) groups and followed for 24 months. Patients were evaluated with the Psoriasis Disability Index, Psoriasis Life Stress Inventory and Psoriasis Area and Severity Index. HRQoL and psoriasis-related stress improved significantly in the tonsillectomy group compared with the control group (p = 0.037 and p = 0.002, respectively), with a mean 50% improvement in HRQoL and a mean 59% improvement in psoriasis-induced stress. Clinical improvement correlated significantly with improved HRQoL (r = 0.297, p = 0.008) and psoriasis-related stress (r = 0.310, p = 0.005). Of the tonsillectomized patients, 87% concluded that the procedure was worthwhile. Tonsillectomy may improve quality of life for selected patients with plaque psoriasis.

Airflow obstruction, atherosclerosis and cardiovascular risk factors in the AGES Reykjavik study

BACKGROUND AND AIMS

Airflow limitation, i.e. reduced forced expiratory volume in 1-s (FEV1), is associated with increased prevalence of atherosclerosis, however, causal mechanisms remain elusive. The objective of the study was to determine if the association between airflow obstruction and markers of atherosclerosis is mediated by systemic inflammation.

METHODS

1154 subjects from the longitudinal AGES Reykjavik study were included. Population characteristics, systemic inflammation markers from blood (white blood cell counts (WBC) and level of C-reactive protein (CRP)) were compared between patients with and without airflow limitation defined by reduced FEV1 on spirometry. Atherosclerosis burden was quantified by measurements of coronary artery calcium, aortic arch and distal aortic calcification in addition to carotid intimal media thickness (CIMT).

RESULTS

Subjects were split into four groups according to smoking status and whether airflow limitation was present. There was a higher overall burden of atherosclerosis in ever-smokers compared to never-smokers, and in individuals with airflow obstruction compared to individuals without airflow obstruction. After adjusting for population characteristics, Framingham cardiovascular risk factors and markers of systemic inflammation (WBC and CRP), there was a significantly increased aortic arch and distal aorta calcification and higher CIMT measurement in individuals with airflow obstruction compared to individuals without airflow obstruction. After adjusting for population characteristics, Framingham cardiovascular risk factors and markers of systemic inflammation (WBC and CRP), there was a significantly increased aortic arch and distal aorta calcification and higher CIMT measurement in individuals with airflow obstruction compared to individuals without airflow obstruction.

CONCLUSIONS

Systemic inflammation (WBC and CRP) does not appear to mediate the association between airflow limitation and atherosclerosis. Only airflow limitation and not systemic inflammation (WBC and CRP) appears to be an independent predictor of atherosclerosis.

Favorable Survival after Aortic Valve Replacement Compared to the General Population

BACKGROUND

A comparison was made between the long-term survival of patients undergoing aortic valve replacement (AVR) for aortic stenosis and of the general Icelandic population, using centralized registries.

METHODS

A total of 366 AVR patients (231 males, 135 females; mean age 70.1 years) operated on for aortic stenosis in Iceland between 2002 and 2011 was included in the study. Concomitant coronary artery bypass grafting was performed in 54% of cases. Short-term complications and 30-day mortality were analyzed. The patients' overall survival was compared with the survival of Icelanders of the same age and gender. The median follow up was 4.7 years.

RESULTS

A bioprosthesis was used in 81% of the patients; the median prosthesis size was 25 mm. Atrial fibrillation (68%) and acute kidney injury (23%) were the most common complications, and the 30-day operative mortality was 6%. Overall survival at one year and five years was 92% and 82%, respectively. There was no difference in survival between the surgical cohorts and expected survival of Icelanders of the same age and gender (p = 0.08), except for the first 30 postoperative days.

CONCLUSIONS

Despite the significant rate of short-term complications, the long-term survival of patients undergoing AVR for aortic stenosis was good compared to the general population of the same age and gender. These results confirmed the value of AVR as an excellent treatment option for aortic stenosis, as it offers a normalization of the patients' life expectancy.

Improvement of psoriasis after tonsillectomy is associated with a decrease in the frequency of circulating T cells that recognize streptococcal determinants and homologous skin determinants

Exacerbation of chronic psoriasis can be associated with streptococcal throat infections, and T cells that respond to peptide sequences common to streptococcal M proteins and skin keratins have been detected in patients' blood. To our knowledge, we have conducted the first blinded, prospective study to assess the impact of tonsillectomy on psoriasis. Twenty-nine patients with chronic psoriasis and history of exacerbation after sore throat were randomly assigned to tonsillectomy (n = 15) or control (n = 14) groups and monitored for 2 y clinically and by enumeration of circulating skin homing T cells that respond to short homologous M protein or keratin peptides. Thirteen patients (86%) showed sustained improvement after tonsillectomy ranging from 30 to 90% reduction in disease severity. Furthermore, there was a close correlation between the degree of clinical improvement in individual patients and reduction in the frequency of peptide-reactive skin-homing T cells in their circulation. No corresponding clinical or immunologic changes were observed among the controls. These findings indicate that tonsillectomy may have a beneficial effect on chronic psoriasis because the palatine tonsils generate effector T cells that recognize keratin determinants in the skin.

[Aortic valve replacement for aortic stenosis in Iceland 2002-2006: Indications and short term complications]

OBJECTIVE

Information on surgical outcome of aortic valve replacement (AVR) has not been available in Iceland. We therefore studied the indications, short-term complications and operative mortality in Icelandic patients that underwent AVR with aortic stenosis.

MATERIAL AND METHODS

This was a retrospective study including all patients that underwent AVR for aortic stenosis at Landspitali between 2002 and 2006, a total of 156 patients (average age 71.7 years, 64.7% males). Short term complications and operative mortality (≤ 30 days) were registered and risk factors analysed with multivariate analysis.

RESULTS

The most common symptoms before AVR were dyspnea (86.9%) and angina pectoris (52.6%). Preop. max aortic valve pressure gradient was on average 74 mmHg, the left ventricular ejection fraction 57.2% and EuroSCORE (st) 6.9%. The average operating time was 282 min and concomitant CABG was performed in 55% of the patients and mitral valve surgery in nine. A bioprothesis was implanted in 127 of the patients (81.4%), of which 102 were stentless valves, and a mechanical valve in 29 (18.6%) cases. The mean prosthesis size was 25.6 mm (range 21-29). Atrial fibrillation (78.0%) and acute renal injury (36.0%) were the most common complications and 20 patients (13.0%) developed multiple-organ failure. Twenty-six patients (17.0%) needed reoperation due to bleeding. Median hospital stay was 13 days and operative mortality was 6.4%.

CONCLUSIONS

The rate of short term complications following AVR was relatively high, including reoperations for bleeding and atrial fibrillation. Operative mortality is twice that of CABG, which is in line with other studies.