Akuutti ruoansulatuskanavan alaosan verenvuoto

English summaryPeer reviewe

Transcatheter Arterial Embolization in Lower Gastrointestinal Bleeding : Ischemia Remains a Concern Even with a Superselective Approach

Purpose To evaluate the safety. efficacy, and feasibility of transcatheter arterial embolization (TAE) in the treatment of lower gastrointestinal bleeding (LGIB). Methods Study group comprised all patients receiving angiography for LGIB in the Helsinki University Hospital during the period of 2004-2016. Hospital medical records provided the study data. Rebleeding, complication, and mortality rates 30 days) were the primary outcomes. Secondary outcomes included need for blood transfusions, durations of intensive care unit and hospital admissions, incidence of delayed rebleeding, and long-term complications, as well as overall survival. Results During the study period, angiography for LGIB was necessary on 123 patients. Out of 123, 55 (45%) underwent embolization attempts. TAE was technically successful in 53 (96%). Rebleeding occurred in 14 (26%). The complication rate was 36%, minor complications occurring in 10 (19%) and major in nine (17%). Major complications resulted in bowel resection in seven (13%). Post embolization ischemia was the most common single complication seen in nine (17%). The mortality rate was 6%. Survival estimates of 1 and 5 years were 79 and 49%. Discussion LGIB is a severe physiological insult occurring in patients who are often elderly and moribund. Although major post embolization complications occur, transcatheter arterial embolization should be the first-line approach over surgery in profuse LGIB in patients with hemodynamic instability, when colonoscopy fails or is unavailable, or when computerized tomography angiography detects small intestinal bleeding.Peer reviewe

Bleeding pancreatic pseudoaneurysms : management by angioembolization combined with therapeutic endoscopy

Bleeding pancreatic pseudocysts (PPCs) are a rare but lethal complication of pancreatitis. Transcatheter arterial embolization (TAE) is the first-line treatment of acute hemorrhage, but consensus on the definitive management of bleeding PPCs is lacking. The aim of this study was to evaluate the safety and efficacy of the combination of TAE and therapeutic endoscopy in the treatment of bleeding PPCs. Patients with acute or chronic pancreatitis treated for bleeding PPCs in Helsinki University Hospital during 2004-2014 comprised the study group. Inpatients with acute necrotizing pancreatitis were excluded. Patients underwent TAE as the primary treatment to control the bleeding. Therapeutic endoscopy performed on an outpatient visit after TAE allowed the definitive treatment of PPCs. A total of 58 patients underwent TAE. Re-bleeding rate (<30 days) was 15.5 %, necessitating re-embolization on seven and surgical intervention on two patients. Overall, TAE success rate was 96.6 %. Mortality rate (<30 days) was 3.4 %. Of the 58, 47 patients were followed up for their PPCs in our unit. PPCs resolved spontaneously in 13 (27.1 %). The remaining 34 had an endoscopic treatment attempt with endoscopic draining performed on 32 and unsuccessful cannulation on two (5.9 %). Of the 32 patients with initially successful endoscopy, 7 (21.9 %) needed an additional drainage procedure (six non-surgical and one surgical). Overall success rate of non-surgical management was 91.5 %. Post-endoscopy mortality rate (<30 days) was 2.9 %. Our follow-up continued for 15 (1-75) months. By the time of data retrieval, 35 of 58 patients had died with alcohol liver disease being the most common cause of death. Five-year survival estimate was 63 %. Bleeding pancreatic pseudoaneurysms require non-surgical management. We need more data on the optimal timing of therapeutic endoscopy and on the role of empirical embolizations.Peer reviewe

INtravenous Contrast computed tomography versus native computed tomography in patients with acute Abdomen and impaired Renal functiOn (INCARO) : a multicentre, open-label, randomised controlled trial - study protocol

Introduction CT is the primary imaging option for acute abdominal pain in adults. Intravenous (IV) contrast media use improves CT quality but may cause post-contrast acute kidney injury (PC-AKI). Retrospective studies show no association between reduced baseline renal function and IV contrast CT, but, to our knowledge, no data from randomised controlled trials exist. Methods and analysis The INCARO (INtravenous Contrast computed tomography versus native computed tomography in patients with acute Abdomen and impaired Renal functiOn) trial is a multicentre, open-label, parallel group, superiority, individually randomised controlled trial comparing IV contrast-enhanced CT to native CT in patients requiring emergency abdominal or body CT with impaired renal function defined as an estimated glomerular filtration rate (eGFR) of 15 to 45 mL/min/1.73 m(2). The primary outcome is a composite of all-cause mortality or renal replacement therapy (RRT) within 90 days from CT. Secondary outcomes are AKI measured by KDIGO (The Kidney Disease: Improving Global Outcomes) criteria within 72 hours from CT, organ dysfunction defined by mSOFA (modified Sequential Organ Failure Assessment) criteria after 48 hours from CT, alive and hospital-free days within 90 days after CT, and time from imaging to definitive treatment. All-cause mortality, need for RRT and renal transplant in long-term follow-up are also measured. The calculated sample size is 994 patients. Patient recruitment is estimated to take 3 years. Ethics and dissemination The Ethics Committee of Helsinki University Hospital approved the study. The findings will be disseminated in peer-reviewed academic journals.Peer reviewe

Learning Life – Mysteeri 24/7 : Virtuaalinen pakopeli nuorten ammatilliseen kuntoutukseen ja ohjaukseen

Mysteeri 24/7 -hankkeessa luotiin ammatillisen kuntouksen ja ohjauksen tueksi virtuaalinen (VR) pakopeli nuorille ja nuorille aikuisille. Peli on virtuaalilaseilla pelattava hyötypeli, jossa nuori voi aktiivisesti pakopelin ja virtuaalimaailman tunnelatausta ja koukuttavuutta hyödyntäen edistää arjen hallintaansa sekä opiskelu- tai työelämävalmiuksiaan erilaisia tehtäviä selvittäen. Pelistä on tehty myös tietokoneella pelattava versio ja pelin soveltamisen tueksi tuotettiin tekninen ohje sekä ammattilaisten käsikirja. Kohderyhmänä Mysteeri 24/7 -hankkeessa olivat 16–29-vuotiaat nuoret ja nuoret aikuiset sekä heidän kanssaan työskentelevät ammattilaiset. Yhteiskunnallisista panostuksista ja kehittämistyöstä huolimatta Suomessa on edelleen paljon nuoria ilman opiskelu- tai työpaikkaa. Lisäksi koronapandemia on lisännyt haasteita nuorten elämään. Nuoret voivat tarvita tukea arjen hyvinvointiin ja -hallintaan sekä opiskeluvalmiuksiinsa ja Kelan järjestämä ammatillinen kuntoutus on yksi keino tukea heitä. Mysteeri 24/7 -hanke toteutettiin Kajaanin ammattikorkeakoulun (KAMK), Laurea-ammattikorkeakoulun (Laurea) ja Hämeen ammattikorkeakoulun (HAMK) yhteistyönä. Hankkeessa tehtiin lisäksi iteratiivisissa sykleissä monitoimijaista yhteistyötä nuorten ja heidän kanssaan työskentelevien ammattilaisten, opettajien, opiskelijoiden, pelialan ammattilaisten ja tutkijoiden kesken. Kehitysprosessin tuloksena syntyi Learning Life – Mysteeri 24/7 -peli, jota pelataan Oculus Quest 2 -virtuaalilaseilla. Pelin tavoitteena on nuoren työ- tai opiskeluvalmiuksien sekä arjen hallinnan parantuminen. Pelissä nuori on aktiivinen toimija, hän ratkaisee tehtäviä ja tekee arjen valintoja. Peli on toiminnallinen ja vuorovaikutteinen työväline asiakastyön tueksi ja pelaamisen jälkeen ammattilainen käy nuoren kanssa ohjauskeskustelun, jossa voi hyödyntää ammattilaisen käsikirjaa. Ohjauskeskustelussa voidaan keskustella pelikokemuksesta ja liittää pelissä tehtyjä asioita nuoren omaan elämäntilanteeseen. Kohderyhmään kuuluvilla nuorilla ja heidän kanssaan työskentelevillä ammattilaisilla oli merkittävä rooli siinä, että pelistä ja ammattilaisen käsikirjasta saatiin heille soveltuva menetelmä nuoren ohjaukseen. Pilotointien yhteydessä tutkittiin nuorten ja ammattilaisten kokemuksia ja tutkimustulokset osoittavat pelin olevan tervetullut väline nuoren ohjaustyöhön. Lisäksi Learning Life – Mysteeri 24/7 -peliä voivat hyödyntää myös alan opiskelijat ja opettajat. Hankkeen kehitysprosessista ja tutkimuksen tuloksista on raportoitu erillisissä julkaisuissa.nonPeerReviewedVertaisarvioimato

Clinical practice selectively follows acute appendicitis guidelines

Peer reviewe

Systematic reviews of observational studies of Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS) : introduction and methodology

Funding Information: The Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS) project was conducted by the Clinical Urology and Epidemiology (CLUE) Working Group and supported by the Academy of Finland (309387, 340957), Sigrid Jusélius Foundation and Competitive Research Funding of the Helsinki University Hospital (TYH2019321; TYH2020248). The sponsors had no role in the analysis and interpretation of the data or the manuscript preparation, review, or approval. Funding Information: KMA received a research grant from Astra Zeneca, and is consultant for Gedeon Richter, and received reimbursement for attending a scientific meeting from GSK (Tesaro Bio). RMT received reimbursement for attending a scientific meeting from Olympus. LIL, GHG, YL, RC, ALL, VJS, IEJK, PJK, RJC, RLA, KA, KMA, IB-L, MHB, JLC, SC, PJG, HAG-P, FZG, HAG, LH, MLI-K, KMJ, PKK, NK, TPK, AJK, TK, HL, AKM, BTN, TPN, CN, SMO, SP, NP, CBBR, ARR, TS, RMT, RWMV, YW, YX, LY, JH, and KAOT have no financial conflicts of interest. GHG and RC were panel members of the European Association of Urology (EAU) ad hoc Guideline on Thromboprophylaxis in Urological Surgery. KAOT was chair of the European Association of Urology (EAU) ad hoc Guideline on Thromboprophylaxis in Urological Surgery and panel member of the American Society of Hematology (ASH) Guideline Panel on Prevention of Venous Thromboembolism (VTE) in Surgical Hospitalized Patients. Publisher Copyright: © 2021, The Author(s).Background Venous thromboembolism (VTE) and bleeding are serious and potentially fatal complications of surgical procedures. Pharmacological thromboprophylaxis decreases the risk of VTE but increases the risk of major post-operative bleeding. The decision to use pharmacologic prophylaxis therefore represents a trade-off that critically depends on the incidence of VTE and bleeding in the absence of prophylaxis. These baseline risks vary widely between procedures, but their magnitude is uncertain. Systematic reviews addressing baseline risks are scarce, needed, and require innovations in methodology. Indeed, systematic summaries of these baseline risk estimates exist neither in general nor gynecologic surgery. We will fill this knowledge gap by performing a series of systematic reviews and meta-analyses of the procedure-specific and patient risk factor stratified risk estimates in general and gynecologic surgeries. Methods We will perform comprehensive literature searches for observational studies in general and gynecologic surgery reporting symptomatic VTE or bleeding estimates. Pairs of methodologically trained reviewers will independently assess the studies for eligibility, evaluate the risk of bias by using an instrument developed for this review, and extract data. We will perform meta-analyses and modeling studies to adjust the reported risk estimates for the use of thromboprophylaxis and length of follow up. We will derive the estimates of risk from the median estimates of studies rated at the lowest risk of bias. The primary outcomes are the risk estimates of symptomatic VTE and major bleeding at 4 weeks post-operatively for each procedure stratified by patient risk factors. We will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate evidence certainty. Discussion This series of systematic reviews, modeling studies, and meta-analyses will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding in general and gynecologic surgeries. Our work advances the standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at the best estimates of risk (including modeling of the timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the GRADE approach. Systematic review registration PROSPERO CRD42021234119Peer reviewe

Remdesiviiri sairaalahoitoisessa COVID-19-taudissa : pragmaattinen, adaptiivinen, satunnaistettu Solidarity Finland -monikeskustutkimus

Lähtökohdat : Remdesiviiriä tutkittiin Solidarity Finland -tutkimuksessa. Menetelmät : COVID-19-taudin takia sairaalahoitoon joutuneet potilaat satunnaistettiin saamaan standardihoitoa tai sen lisäksi remdesiviiriä. Solidarity-tutkimuksessa ja satunnaistettujen ­tutkimusten meta-analyysissä ensisijainen päätetapahtuma oli sairaalahoitoajan kuolleisuus. Tulokset : Rekrytoimme 208 potilasta yhdestätoista sairaalasta. Sairaalahoidon aikana ­remdesiviiriryhmässä (n = 114) kuoli 1 % ja standardihoitoryhmässä (n = 94) 4 %. Invasiiviseen hengityslaitehoitoon joutui 5 % molemmissa ryhmissä. Tehohoitoa sai 11 % remdesiviiri- ja 12 % standardihoitoryhmässä. Maksaentsyymit nousivat merkittävästi 5 %:lla remdesiviiri- ja 2 %:lla standardihoitoryhmässä. Meta-analyysin alaryhmäanalyysissä remdesiviiri vähensi kuoleman riskiä potilailla, jotka eivät sairaalahoidon alkaessa saaneet hengityslaitehoitoa (RR 0,85, 95 % LV 0,75­–0,96). Päätelmät : Suomessa on pandemian aikana mahdollista rekrytoida merkittävä määrä potilaita suuriin, satunnaistettuihin tutkimuksiin, joilla voidaan saada luotettavia tuloksia nopeasti. Remdesiviiristä voi olla apua sairaalahoitoisessa COVID-19-taudissa varhain aloitettuna.publishedVersionPeer reviewe

Effect of remdesivir post hospitalization for COVID-19 infection from the randomized SOLIDARITY Finland trial

We report the first long-term follow-up of a randomized trial (NCT04978259) addressing the effects of remdesivir on recovery (primary outcome) and other patient-important outcomes one year after hospitalization resulting from COVID-19. Of the 208 patients recruited from 11 Finnish hospitals, 198 survived, of whom 181 (92%) completed follow-up. At one year, self-reported recovery occurred in 85% in remdesivir and 86% in standard of care (SoC) (RR 0.94, 95% CI 0.47-1.90). We infer no convincing difference between remdesivir and SoC in quality of life or symptom outcomes (p > 0.05). Of the 21 potential long-COVID symptoms, patients reported moderate/major bother from fatigue (26%), joint pain (22%), and problems with memory (19%) and attention/concentration (18%). In conclusion, after a one-year follow-up of hospitalized patients, one in six reported they had not recovered well from COVID-19. Our results provide no convincing evidence of remdesivir benefit, but wide confidence intervals included possible benefit and harm.Peer reviewe

Systematic reviews of observational studies of Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS): introduction and methodology

Background: Venous thromboembolism (VTE) and bleeding are serious and potentially fatal complications of surgical procedures. Pharmacological thromboprophylaxis decreases the risk of VTE but increases the risk of major post-operative bleeding. The decision to use pharmacologic prophylaxis therefore represents a trade-off that critically depends on the incidence of VTE and bleeding in the absence of prophylaxis. These baseline risks vary widely between procedures, but their magnitude is uncertain. Systematic reviews addressing baseline risks are scarce, needed, and require innovations in methodology. Indeed, systematic summaries of these baseline risk estimates exist neither in general nor gynecologic surgery. We will fill this knowledge gap by performing a series of systematic reviews and meta-analyses of the procedure-specific and patient risk factor stratified risk estimates in general and gynecologic surgeries.Methods: We will perform comprehensive literature searches for observational studies in general and gynecologic surgery reporting symptomatic VTE or bleeding estimates. Pairs of methodologically trained reviewers will independently assess the studies for eligibility, evaluate the risk of bias by using an instrument developed for this review, and extract data. We will perform meta-analyses and modeling studies to adjust the reported risk estimates for the use of thromboprophylaxis and length of follow up. We will derive the estimates of risk from the median estimates of studies rated at the lowest risk of bias. The primary outcomes are the risk estimates of symptomatic VTE and major bleeding at 4 weeks post-operatively for each procedure stratified by patient risk factors. We will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate evidence certainty.Discussion: This series of systematic reviews, modeling studies, and meta-analyses will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding in general and gynecologic surgeries. Our work advances the standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at the best estimates of risk (including modeling of the timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the GRADE approach.Systematic review registration: PROSPERO CRD42021234119</p