Ten-year experience with transcatheter and surgical aortic valve replacement in Finland

Aim: We investigated the outcomes of transcatheter (TAVR) and surgical aortic valve replacement (SAVR) in Finland during the last decade.

Methods: The nationwide FinnValve registry included data from 6463 patients who underwent TAVR or SAVR with a bioprosthesis for aortic stenosis from 2008 to 2017.

Results: The annual number of treated patients increased three-fold during the study period. Thirty-day mortality declined from 4.8% to 1.2% for TAVR (p?=?.011) and from 4.1% to 1.8% for SAVR (p?=?.048). Two-year survival improved from 71.4% to 83.9% for TAVR (p?<?.001) and from 87.2% to 91.6% for SAVR (p?=?.006). During the study period, a significant reduction in moderate-to-severe paravalvular regurgitation was observed among TAVR patients and a reduction of the rate of acute kidney injury was observed among both SAVR and TAVR patients. Similarly, the rate of red blood cell transfusion and severe bleeding decreased significantly among SAVR and TAVR patients. Hospital stay declined from 10.4?±?8.4 to 3.7?±?3.4 days after TAVR (p?<?.001) and from 9.0?±?5.9 to 7.8?±?5.1 days after SAVR (p?<?.001).

Conclusions: In Finland, the introduction of TAVR has led to an increase in the invasive treatment of severe aortic stenosis, which was accompanied by improved early outcomes after both SAVR and TAVR.

Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03385915

• Key Messages

• This study demonstrated that the introduction of transcatheter aortic valve replacement has led to its widespread use as an invasive treatment for severe aortic stenosis.

• Early and 2-year survival after transcatheter and surgical aortic valve replacement has improved during past decade.

• Transcatheter aortic valve replacement has fulfilled its previously unmet clinical needs and has surpassed surgical aortic valve replacement as the most common invasive treatment for aortic stenosis.

     

Diagnosis and management of tubal pregnancy: effect on fertility outcome

We analysed 188 ectopic pregnancies seen during a 2-year period. They represented 2.2% of the live births that occurred during the same time interval. Overall, 53% of the tubal pregnancies had ruptured at the time of examination. Location was ampullary in 51% of the cases, isthmic in 28%, and 10% had aborted. Sixty-nine (38%) patients had an IUD. Diagnostic sensitivity was 58%-93% for pregnancy tests, 79% for culdocentesis, 41% for ultrasound examination, 43% for dilatation and curettage, and 100% for laparoscopy. Salpingectomy was performed in 47% of the cases, salpingotomy in 27%, and tubal resection in 19%. During a follow-up of 116 women (mean 1.5 years, range 0.5-3 years) 49% delivered, 10% had repeat ectopic pregnancy, 10% had abortion, 17% were infertile and 15% practised birth control. Among those who delivered no difference was found between those who underwent salpingectomy and those who underwent conservative surgery.     

Ketoacidosis at the diagnosis of type 1 (insulin dependent) diabetes mellitus is related to poor residual beta cell function. Childhood Diabetes in Finland Study Group

The determinants of the degree of metabolic decompensation at the diagnosis of type 1 (insulin dependent) diabetes mellitus (IDDM) and the possible role of diabetic ketoacidosis in the preservation and recovery of residual beta cell function were examined in 745 Finnish children and adolescents. Children younger than 2 years or older than 10 years of age were found to be more susceptible to diabetic ketoacidosis than children between 2 and 10 years of age (< 2 years: 53.3%; 2-10 years: 16.9%; > 10 years: 33.3%). Children from families with poor parental educational level had ketoacidosis more often than those from families with high parental educational level (24.4% v 16.9%). A serum C peptide concentration of 0.10 nmol/l or more was associated with a favourable metabolic situation. Low serum C peptide concentrations, high requirement of exogenous insulin, low prevalence of remission, and high glycated haemoglobin concentrations were observed during the follow up in the group of probands having diabetic ketoacidosis at the diagnosis of IDDM. Thus diabetic ketoacidosis at diagnosis is related to a decreased capacity for beta cell recovery after the clinical manifestation of IDDM in children.     

Spinal hyperbaric ropivacaine-fentanyl for day-surgery

BACKGROUND: Adequate intraoperative analgesia combined with faster mobilization might be achieved by replacing hyperbaric ropivacaine partly with fentanyl. METHODS: Sixty spinal anesthesia patients were randomized into 2 groups of either fentanyl 20 microg mixed with hyperbaric ropivacaine 10 mg (group FR10) or hyperbaric ropivacaine 15 mg (group R15). Forty-five patients underwent inguinal hernia repair and 15 patients had lower extremity surgery. Sensory block was tested by pinprick, and motor block was tested by use of a modified Bromage scale at 5-minute intervals for 30 minutes, 15-minute intervals for 60 minutes, and at 30-minute intervals until full recovery. RESULTS: The groups did not differ significantly regarding success (27 of 30 [group FR10] and 29 of 30 [group R15]), median onset time (10 [5 to 25] v 10 [5 to 20] minutes) or median duration of T10 sensory block (55 [20 to 115] v 80 [5 to 170] minutes), respectively. Recovery from spinal block was significantly quicker in group FR10 than in group R15, recorded in ability to walk (2.5 hours v 3 hours [P=.017]), full motor recovery (1 hour v 1.5 hour [ P <.001]), and sensory recovery to S1 (2.5 hours v 3.3 hours [ P=.026]). Pruritus occurred in 18 (60%) of group FR10 v 0 of group R15 patients ( P <.001). This symptom was mild in all except 1 patient, who received ondansetron 8 mg IV. In the OR, the groups did not differ hemodynamically: 9 (30%) of the group FR10 and 10 (33%) of the group R15 patients, respectively, required medication for hypotension and/or bradycardia. Full motor block (Bromage 3) developed less frequently (P <.001) in group FR10 patients than in group R15 patients (1 [3%] v 14 [47%]), and the group FR10 patients recovered faster in a median time of 60 v 90 minutes (P <.001). In both groups, sensory and motor blocks were more extensive on the operative side compared with the nonoperative side ( P <.001). CONCLUSION: Faster mobilization but equal onset and duration of analgesia were achieved with intrathecal hyperbaric ropivacaine 10 mg plus fentanyl 20 microg as compared with hyperbaric ropivacaine 15 mg.     

Urine, hair, and nails as indicators for ingestion of uranium in drinking water

The concentration of uranium in urine, hair, and nails due to continuous exposure through ingestion of drinking water was studied. The study population consisted of 205 individuals living in 134 different households in southern Finland where drinking water is supplied from private drilled wells. The population was selected to include a broad range of uranium daily intake from drinking water (0.03-2,775 microg d). The uranium content in drinking water, urine (overnight collection), hair and nails was determined by ICPMS. Uranium in urine was corrected for the matrix effects by use of thallium as an internal standard and adjusted by creatinine normalization. Hair and toenail samples were rinsed to remove external contamination prior to acid digestion and analysis. The uranium content in all excretion pathways was correlated with the uranium intake, particularly at elevated levels (> or =10 microg d) where drinking water was the major source of exposure to uranium. The median of the individual uranium absorption factors for urine, hair, and toenails were fu=0.003, fh=0.003, and fn=4 x 10, respectively. The association between the different bioassays was examined. The absorption factor, f1, was calculated for the population with an intake above 10 microg d and was below 0.01 for 72% of the study persons (range 0.0002 to 0.070). No statistically significant difference in f1 values was found between women and men. However, the absorption factor was higher among younger (< 60 y) than older (> or =60 y) subjects and among people with a lower exposure (below 100 microg d) than among those that ingest over 100 microg d.     

Induction of oxidative stress in murine cell lines by 3-chloro-4-(dichloromethyl)-5-hydroxy-2(5H)-furanone (MX)

3-Chloro-4-(dichloromethyl)-5-hydroxy-2(5H)-furanone (MX), the potent bacterial mutagen produced during chlorination of drinking water, was tested for the induction of oxidative stress in two murine cell lines: NIH 3T3 (fibroblasts) and L929 (fibrosarcoma cells). Following 1 h MX treatment at concentrations between 100 and 1000 microM, cellular stress conditions were monitored by measuring reactive oxygen species formation (ROS) and reduced glutathione levels (GSH). The kinetics of ROS formation and GSH depletion was investigated from 10 min to 1 h. MX caused detachment of cells at 1000 microM in L929 cells and at 300 microM in NIH 3T3 cells but the viability of the cells, measured by the trypan blue assay, decreased only by 20 and 7%, respectively, in 1h. MX increased ROS production in L929 cells in a dose-dependent manner, by 120% at 500 microM of MX in 1 h. The maximum ROS production was attained already in 10min. In NIH 3T3 cells, the ROS production was slightly, but not statistically significantly stimulated at 200 microM between 20 and 60 min. Concomitantly, MX decreased the intracellular content of GSH dose-dependently in both cell lines, by 48% in L929 cells at 500 microM of MX and 32% in NIH 3T3 cells at 200 microM of MX in one hour. The majority of this GSH depletion had occurred in 10 min. These findings indicate that MX induces oxidative stress in mammalian cells in vitro though the sensitivity of cells may differ for this effect.