Coronary Artery Bypass Grafting - Postoperative Employment and 20-year Mortality : Impact of Obesity, Metabolic Syndrome and Diabetes Mellitus

Tausta Sydän- ja verenkiertoelimistön sairauksilla on tärkeä merkitys ihmiskunnan tautikirjossa, koska ne ovat useimmissa maissa johtava kuolinsyy. Sepelvaltimoiden ohitusleikkaus, joka ensimmäisen kerran tehtiin 1960-luvulla, kehittyi Suomessakin vaikean sepelvaltimotaudin rutiininomaiseksi hoitotavaksi 1980-luvulla. Sekundaariprevention keskeinen merkitys sepelvaltimotaudin pitkäaikaishoidossa tuli ilmeiseksi 1980- ja 1990-luvuilla. Pääosa sepelvaltimoiden ohitusleikkauksen jälkeisistä pitkäaikaisennustetta selvittävistä tutkimuksista on ollut pisimmillään 5 – 10 vuoden kestoisia ja siten ne ovat tarjonneet rajallista tietoa hitaiden muutosten merkityksestä. Tavoitteet Tutkimuksen tavoitteena oli selvittää sepelvaltimoiden ohitusleikkauksen jälkeistä ennustetta 20 vuoden seurannassa leikkauksen jälkeen työssä olon, kokonaiskuolleisuuden ja sydänkuolleisuuden avulla. Tarkoituksena oli myös selvittää, miten pitkäaikaisennuste korreloi lihavuuteen, metaboliseen syndroomaan (MetS) ja diabetekseen (DM). Statiinilääkkeiden käyttöä selvitettiin osana ennustetta. Aineisto ja menetelmät Tutkimusprojekti käsitti kaksi eri aineistoa. Seurantatutkimukseen osallistui 922 sepelvaltimoiden ohitusleikkauspotilasta, jotka leikattiin 1.1.1993 – 30.6.1994 Tampereen yliopistollisessa sairaalassa. Vuosikohorttien tutkimukseen osallistui 946 Tampereen yliopistollisessa sairaalassa leikattua ja Kanta-Hämeen keskussairaalassa 1.1.1990 – 31.12.2009 jatkohoidettua sepelvaltimoiden ohitusleikkauspotilasta. Tutkimustiedot kerättiin sairauskertomuksista, potilaskyselyistä ja kansallisista arkistoista. Suhteellista ennustetta verrattiin vastaavaan taustaväestöön ja analysoitiin Life Table-menetelmällä. Lihavuuden, MetS:n ja DM:n itsenäistä merkitystä ennusteeseen selvitettiin Bayesin filosofiaan pohjautuvalla monimuuttuja-analyysillä. Tulokset Lähes 60 % leikkausta edeltäen eläköitymättömistä ohitusleikkauspotilaista palasi leikkauksen jälkeen työelämään. Ikä ja leikkausta edeltävän sairasloman tai määräaikaisen työkyvyttömyyseläkkeen kesto olivat tärkeimmät työkykyyn vaikuttavat tekijät. Leikkauksen jälkeen työhön palanneiden potilaiden työkyvyn säilyminen oli verrattavissa saman ikäiseen muuhun väestöön. Diabetes jo ensimmäisellä postoperatiivisella vuosikymmenellä ja lihavuus tai MetS toisella vuosikymmenellä huononsivat merkittävästi potilaiden ennustetta. Toisaalta potilaat, jotka eivät sairastaneet diabetesta tai MetS:a pärjäsivät yhtä hyvin kuin leikkausvuosi, ikä ja sukupuolivakioitu taustaväestö. Vähäinen statiinien käyttö liittyi huonoon ennusteeseen. Vuosikohorttien tutkimuksessa statiinien käyttö lisääntyi 20- kertaiseksi seuranta-aikana. Johtopäätökset Sepelvaltimoiden ohitusleikkauspotilaiden työkykyyn ja ennusteeseen vaikuttavat olennaisesti sepelvaltimotaudin ja sen riskitekijöiden tehokas ja viiveetön hoito. Lihavuus, metabolinen oireyhtymä ja erityisesti diabetes lisäävät kuolleisuutta. Niin ikään statiinien vähäinen käyttö assosioituu huonoon ennusteeseen. Tutkimustulokset kannustavat sepelvaltimotautipotilaiden metabolisten riskitekijöiden tehokkaaseen hoitoon.Background Cardiovascular disorders play a crucial role in the global burden of diseases, being in most countries the leading cause of death. Coronary artery bypass, introduced in the mid-1960s, became the standard treatment in severe coronary artery disease (CAD) in the 1980s also in Finland. The role of preventive measures in long-term survival of CAD became evident in the 1980s and 1990s. Most studies addressing long-term survival after coronary artery bypass grafting (CABG) have covered study periods ranging from five to ten years and thus their ability to find slow alterations has been limited. Aims The aim of this study was to evaluate the postoperative prognosis of CABG patients for up to 20 years. It was approached through postoperative employment together with total and cardiovascular mortality. The aim was also to examine how long-term survival was related to obesity, metabolic syndrome (MetS) and diabetes mellitus (DM). The effect of statin treatment upon survival was also studied. Subjects and methods Two different populations were included. The follow-up studies comprised 922 CABG patients operated on during the period 1 January 1993 – 30 June 1994 at Tampere University Hospital. The study population for the annual cohorts consisted of 946 CABG patients treated in Kanta-Häme Central Hospital during the time period 1 January 1990 – 31 December 2009. Study data was collected from patient records, questionnaires and national registries. The relative survival rates compared to matched background populations were analysed using the Life Table method. To study the independent significance of obesity, MetS and DM for clinical outcome, multivariate analysis based on the Bayesian approach was used. Results Almost 60 percent of patients, preoperatively not retired, remained employed after surgery. Age and length of preoperative sick leave or temporary retirement were the most important factors affecting postoperative employment. Having once returned to work, patients’ retention at work was comparable to that in the general population. Diabetes mellitus already during the first postoperative decade and obesity and MetS during the second postoperative decade were related to impaired survival. Patients without DM or MetS had an equally good prognosis as their operation year, age and gender matched background populations. Scant statin use was also related to poor survival. Statin use in the annual cohorts population increased up to 20-fold during the study period. Conclusions The retention of working capacity is high after CABG. Effective and prompt treatment of coronary heart disease and its risk factors significantly improves long-term prognosis and continuation in employment. Obesity, MetS and especially diabetes mellitus have deleterious impact on mortality rates. In addition, non-adherence to statin use is associated with increased mortality. The results encourage the effective treatment of metabolic risk factors among patients with coronary artery disease

Self-reported skills and self-confidence in point-of-care ultrasound : a cross-sectional nationwide survey amongst Finnish emergency physicians

Background: The use of point-of-care ultrasound (POCUS) is increasing. Numerous investigators have evaluated the learning curves in POCUS, but there are no published studies on how emergency physicians perceive their own competence level with this skill. Methods: A nationwide survey amongst Finnish emergency physicians was conducted. The respondents reported their use of POCUS and how it has affected their clinical decision-making. The number of POCUS examinations performed was compared to the self-assessed skill level with different applications. Cut-off values were determined for the number of examinations required to acquire a good self-assessed skill level in each POCUS application. The correlation between self-confidence and the self-estimated skill level was analyzed. Several different statistical methods were used, such as Student’s t-test, Pearson’s correlation test, Loess method and ROC curve analysis. Results: A total of 134 out of 253 Finnish emergency medicine specialists and residents (52%) responded to the survey. The most commonly used POCUS applications were POCUS-assisted procedures, pleural effusion and pneumothorax, inferior vena cava and lower extremity deep venous thrombosis. The initial rate of perceived skill acquisition was very steep with the curve flattening with greater skill and more experience. The number of examinations performed to reach a self-assessed good competence varied from seven to 75 with different applications. The lowest cut-off point for self-assessed good competence was obtained for rapid ultrasound for the shock and hypotension-protocol and the highest for focused cardiac examinations. There was an excellent correlation between self-confidence and the self-assessed skill level. Conclusions: The Finnish emergency practitioners’ self-assessed development of POCUS skills parallels the previously published learning curves of POCUS. The correlation of self-confidence and the self-assessed skill level was found to be excellent. These findings add information on the development of perceived POCUS skills amongst emergency physicians and could complement a formal performance assessment.publishedVersionPeer reviewe

Coronary Artery Bypass Grafting - Postoperative Employment and 20-year Mortality : Impact of Obesity, Metabolic Syndrome and Diabetes Mellitus

Tausta Sydän- ja verenkiertoelimistön sairauksilla on tärkeä merkitys ihmiskunnan tautikirjossa, koska ne ovat useimmissa maissa johtava kuolinsyy. Sepelvaltimoiden ohitusleikkaus, joka ensimmäisen kerran tehtiin 1960-luvulla, kehittyi Suomessakin vaikean sepelvaltimotaudin rutiininomaiseksi hoitotavaksi 1980-luvulla. Sekundaariprevention keskeinen merkitys sepelvaltimotaudin pitkäaikaishoidossa tuli ilmeiseksi 1980- ja 1990-luvuilla. Pääosa sepelvaltimoiden ohitusleikkauksen jälkeisistä pitkäaikaisennustetta selvittävistä tutkimuksista on ollut pisimmillään 5 – 10 vuoden kestoisia ja siten ne ovat tarjonneet rajallista tietoa hitaiden muutosten merkityksestä. Tavoitteet Tutkimuksen tavoitteena oli selvittää sepelvaltimoiden ohitusleikkauksen jälkeistä ennustetta 20 vuoden seurannassa leikkauksen jälkeen työssä olon, kokonaiskuolleisuuden ja sydänkuolleisuuden avulla. Tarkoituksena oli myös selvittää, miten pitkäaikaisennuste korreloi lihavuuteen, metaboliseen syndroomaan (MetS) ja diabetekseen (DM). Statiinilääkkeiden käyttöä selvitettiin osana ennustetta. Aineisto ja menetelmät Tutkimusprojekti käsitti kaksi eri aineistoa. Seurantatutkimukseen osallistui 922 sepelvaltimoiden ohitusleikkauspotilasta, jotka leikattiin 1.1.1993 – 30.6.1994 Tampereen yliopistollisessa sairaalassa. Vuosikohorttien tutkimukseen osallistui 946 Tampereen yliopistollisessa sairaalassa leikattua ja Kanta-Hämeen keskussairaalassa 1.1.1990 – 31.12.2009 jatkohoidettua sepelvaltimoiden ohitusleikkauspotilasta. Tutkimustiedot kerättiin sairauskertomuksista, potilaskyselyistä ja kansallisista arkistoista. Suhteellista ennustetta verrattiin vastaavaan taustaväestöön ja analysoitiin Life Table-menetelmällä. Lihavuuden, MetS:n ja DM:n itsenäistä merkitystä ennusteeseen selvitettiin Bayesin filosofiaan pohjautuvalla monimuuttuja-analyysillä. Tulokset Lähes 60 % leikkausta edeltäen eläköitymättömistä ohitusleikkauspotilaista palasi leikkauksen jälkeen työelämään. Ikä ja leikkausta edeltävän sairasloman tai määräaikaisen työkyvyttömyyseläkkeen kesto olivat tärkeimmät työkykyyn vaikuttavat tekijät. Leikkauksen jälkeen työhön palanneiden potilaiden työkyvyn säilyminen oli verrattavissa saman ikäiseen muuhun väestöön. Diabetes jo ensimmäisellä postoperatiivisella vuosikymmenellä ja lihavuus tai MetS toisella vuosikymmenellä huononsivat merkittävästi potilaiden ennustetta. Toisaalta potilaat, jotka eivät sairastaneet diabetesta tai MetS:a pärjäsivät yhtä hyvin kuin leikkausvuosi, ikä ja sukupuolivakioitu taustaväestö. Vähäinen statiinien käyttö liittyi huonoon ennusteeseen. Vuosikohorttien tutkimuksessa statiinien käyttö lisääntyi 20- kertaiseksi seuranta-aikana. Johtopäätökset Sepelvaltimoiden ohitusleikkauspotilaiden työkykyyn ja ennusteeseen vaikuttavat olennaisesti sepelvaltimotaudin ja sen riskitekijöiden tehokas ja viiveetön hoito. Lihavuus, metabolinen oireyhtymä ja erityisesti diabetes lisäävät kuolleisuutta. Niin ikään statiinien vähäinen käyttö assosioituu huonoon ennusteeseen. Tutkimustulokset kannustavat sepelvaltimotautipotilaiden metabolisten riskitekijöiden tehokkaaseen hoitoon.Background Cardiovascular disorders play a crucial role in the global burden of diseases, being in most countries the leading cause of death. Coronary artery bypass, introduced in the mid-1960s, became the standard treatment in severe coronary artery disease (CAD) in the 1980s also in Finland. The role of preventive measures in long-term survival of CAD became evident in the 1980s and 1990s. Most studies addressing long-term survival after coronary artery bypass grafting (CABG) have covered study periods ranging from five to ten years and thus their ability to find slow alterations has been limited. Aims The aim of this study was to evaluate the postoperative prognosis of CABG patients for up to 20 years. It was approached through postoperative employment together with total and cardiovascular mortality. The aim was also to examine how long-term survival was related to obesity, metabolic syndrome (MetS) and diabetes mellitus (DM). The effect of statin treatment upon survival was also studied. Subjects and methods Two different populations were included. The follow-up studies comprised 922 CABG patients operated on during the period 1 January 1993 – 30 June 1994 at Tampere University Hospital. The study population for the annual cohorts consisted of 946 CABG patients treated in Kanta-Häme Central Hospital during the time period 1 January 1990 – 31 December 2009. Study data was collected from patient records, questionnaires and national registries. The relative survival rates compared to matched background populations were analysed using the Life Table method. To study the independent significance of obesity, MetS and DM for clinical outcome, multivariate analysis based on the Bayesian approach was used. Results Almost 60 percent of patients, preoperatively not retired, remained employed after surgery. Age and length of preoperative sick leave or temporary retirement were the most important factors affecting postoperative employment. Having once returned to work, patients’ retention at work was comparable to that in the general population. Diabetes mellitus already during the first postoperative decade and obesity and MetS during the second postoperative decade were related to impaired survival. Patients without DM or MetS had an equally good prognosis as their operation year, age and gender matched background populations. Scant statin use was also related to poor survival. Statin use in the annual cohorts population increased up to 20-fold during the study period. Conclusions The retention of working capacity is high after CABG. Effective and prompt treatment of coronary heart disease and its risk factors significantly improves long-term prognosis and continuation in employment. Obesity, MetS and especially diabetes mellitus have deleterious impact on mortality rates. In addition, non-adherence to statin use is associated with increased mortality. The results encourage the effective treatment of metabolic risk factors among patients with coronary artery disease

NYU-EDA in modelling the effect of COVID-19 on patient volumes in a Finnish emergency department

Background: Emergency departments (EDs) worldwide have been in the epicentre of the novel coronavirus disease (COVID-19). However, the impact of the pandemic and national emergency measures on the number of non-COVID-19 presentations and the assessed acuity of those presentations remain uncertain. Methods: We acquired a retrospective cohort containing all ED visits in a Finnish secondary care hospital during years 2018, 2019 and 2020. We compared the number of presentations in 2020 during the national state of emergency, i.e. from March 16 to June 11, with numbers from 2018 and 2019. Presentations were stratified using localized New York University Emergency Department Algorithm (NYU-EDA) to evaluate changes in presentations with different acuity levels. Results: A total of 27,526 presentations were observed. Compared to previous two years, total daily presentations were reduced by 23% (from 113 to 87, p <.001). In NYU-EDA classes, Non-Emergent visits were reduced the most by 42% (from 18 to 10, p <.001). Emergent presentations were reduced by 19 to 28% depending on the subgroup (p <.001). Number of injuries were reduced by 25% (from 27 to 20, p <.001). The NYU-EDA distribution changed statistically significantly with 4% point reduction in Non-Emergent visits (from 16 to 12%, p <.001) and 0.9% point increase in Alcohol-related visits (from 1.6 to 2.5%, p <.001). Conclusions: We observed a significant reduction in total ED visits in the course of national state of emergency. Presentations were reduced in most of the NYU-EDA groups irrespective of the assessed acuity. A compensatory increase in presentations was not observed in the course of the 3 month lockdown. This implies either reduction in overall morbidity caused by decreased societal activity or widespread unwillingness to seek required medical advice.publishedVersionPeer reviewe

Associations of metabolic syndrome and diabetes mellitus with 16-year survival after CABG

The associations of metabolic syndrome (MetS) or diabetes mellitus (DM) on long-term survival after coronary artery bypass grafting (CABG) have not been extensively evaluated. The aim of the present study was to assess the impact of MetS and DM on the 16-year survival after CABG. Methods Diabetic and metabolic status together with relevant cardiovascular data was established in 910 CABG patients operated in 1993-94. They were divided in three groups as follows: neither DM nor MetS (375 patients), MetS alone (279 patients) and DM with or without MetS (256 patients). The 16-year follow-up of patient survival was carried out using national health databases. The relative survival rates were analyzed using the Life Table method comparing the observed survival rates of three patient groups to the rates based on age-, sex- and time-specific life tables for the whole population in Finland. To study the independent significance of MetS and DM for clinical outcome, multivariate analysis was made using an optimizing stepwise procedure based on the Bayesian approach. Results Bayesian multivariate analysis revealed together six variables to predict clinical outcome (2 months to 16 years) in relation to the national background population, i.e. age, diabetes, left ventricular ejection fraction, BMI, perfusion time during the CABG and peripheral arterial disease. Our principal finding was that after postoperative period the 16-year prognosis of patients with neither DM nor MetS was better than that of the age-, sex-and time-matched background population (relative survival against background population 1.037, p < 0.0001). The overall survival of MetS patients resembled that of the matched background population (relative survival 0.998, NS). DM was associated with significantly increased mortality (relative survival 0.86, p < 0.0001). Additionally, mortality was even higher in patients receiving insulin treatment than in those without. Excess death rate of DM patients was predominantly caused by cardiovascular causes. Conclusion In this long-term follow-up study patient groups without diabetes had at least equal 16 years’ survival after CABG than their matched background populations. Survival of DM patients started to deteriorate already few years after the operation.BioMed Central open acces

Self-reported skills and self-confidence in point-of-care ultrasound : a cross-sectional nationwide survey amongst Finnish emergency physicians

Background: The use of point-of-care ultrasound (POCUS) is increasing. Numerous investigators have evaluated the learning curves in POCUS, but there are no published studies on how emergency physicians perceive their own competence level with this skill. Methods: A nationwide survey amongst Finnish emergency physicians was conducted. The respondents reported their use of POCUS and how it has affected their clinical decision-making. The number of POCUS examinations performed was compared to the self-assessed skill level with different applications. Cut-off values were determined for the number of examinations required to acquire a good self-assessed skill level in each POCUS application. The correlation between self-confidence and the self-estimated skill level was analyzed. Several different statistical methods were used, such as Student’s t-test, Pearson’s correlation test, Loess method and ROC curve analysis. Results: A total of 134 out of 253 Finnish emergency medicine specialists and residents (52%) responded to the survey. The most commonly used POCUS applications were POCUS-assisted procedures, pleural effusion and pneumothorax, inferior vena cava and lower extremity deep venous thrombosis. The initial rate of perceived skill acquisition was very steep with the curve flattening with greater skill and more experience. The number of examinations performed to reach a self-assessed good competence varied from seven to 75 with different applications. The lowest cut-off point for self-assessed good competence was obtained for rapid ultrasound for the shock and hypotension-protocol and the highest for focused cardiac examinations. There was an excellent correlation between self-confidence and the self-assessed skill level. Conclusions: The Finnish emergency practitioners’ self-assessed development of POCUS skills parallels the previously published learning curves of POCUS. The correlation of self-confidence and the self-assessed skill level was found to be excellent. These findings add information on the development of perceived POCUS skills amongst emergency physicians and could complement a formal performance assessment.Peer reviewe