Comparison of Pain Management Strategies to Reduce Opioid Use Postoperatively in Free Flap Breast Reconstruction: Pain Catheter versus Nerve Block in Addition to Refinements in the Oral Pain Management Regime.

Background Perioperative management in autologous breast reconstruction has gained focus in recent years. This study compares two pain management protocols in patients undergoing abdominal-based free flap breast reconstruction: a past protocol (PP) and a current protocol (CP)-both intended to reduce opioid consumption postoperatively. The PP entails use of a pain catheter in the abdominal wound and the CP consists of an intraoperative nerve block in addition to refinements in the oral pain management. We hypothesize that the CP reduces opioid consumption compared to PP. Methods From December 2017 to January 2020, 102 patients underwent breast reconstruction with an abdominal-based free flap. Two postoperative pain management strategies were used during the period; from December 2017 to September 2018, the PP was used which entailed the use of a pain catheter with ropivacaine applied in the abdominal wound with continuous distribution postoperatively in addition to paracetamol orally and oxycodone orally pro re nata (PRN). From October 2018 to January 2020, the CP was used. This protocol included a combination of intraoperative subfascial nerve block and a postoperative oral pain management regime that consisted of paracetamol, celecoxib, and gabapentin as well as oxycodone PRN. Results The CP group ( n = 63) had lower opioid consumption compared to the PP group ( n = 39) when examining all aspects of opioid consumption, including daily opioid usage in morphine milligram equivalents and total opioid usage during the stay ( p < 0.001). The CP group had shorter length of hospital stay (LOS). Conclusion Introduction of the CP reduced opioid use and LOS was shorter.

[Incidence and outcomes of perioperative myocardial infarction associated with coronary artery bypass surgery].

INTRODUCTION: Perioperative myocardial infarction (PMI) after CABG can contribute to in-hospital morbidity and mortality, however, its clinical significance on long-term outcome, remains inadequately addressed. We studied both 30-day mortality and long-term effects of PMI in Icelandic CABG-patients. MATERIALS AND METHODS: A retrospective nationwide-study on 1446 consecutive CABG-patients operated at Landspitali in Iceland 2002-2018 without evidence of preoperative myocardial infarction. PMI was defined as a tenfold elevetion in serum-CK-MB associated with new ECG changes or diagnostic imaging consistent with ischemia. Patients with PMI were compared to a reference group with uni- and multivariate analyses. Long-term and MACCE-free survival were estimated with the Kaplan-Meier method and logistic regression used to determine factors associated with PMI. The mean follow-up time was 8.3 years. RESULTS: Out of 1446 patients 78 (5.4%) were diagnosed with PMI (range: 0-15.5%) with a significant annual decline in the incidence of PMI (12.7%, p<0.001). Over the same period preoperative aspirin use increased by 22.3% (p<0.018). PMI patients had a higher rate of short-term complications and a 11.5% 30-day mortality rate compared to 0.4% for non-PMI patients. PMI was found to be a predictor of 30-day mortality (OR 15.44, 95% CI: 6.89-34.67). PMI patients had worse 5-year MACCE-free survival (69.2% vs. 84.7, p=0,01), although overall survival was comparable between the groups. CONCLUSIONS: Although PMI after CABG is associated with significantly higher rates of short-term complications and 30-day mortality, long-term survival was similar to the reference group. Therefore, the mortality risk attributable to PMI appears to diminish after the immediate postoperative period.

Long-term outcome of surgical revascularization in patients with reduced left ventricular ejection fraction-a population-based cohort study.

OBJECTIVES: Surgical revascularization is an established indication for patients with advanced coronary artery disease and reduced left ventricular ejection fraction (LVEF). Long-term outcomes for these patients are not well-defined. We studied the long-term outcomes of patients with ischaemic cardiomyopathy who underwent surgical revascularization in a well-defined nationwide cohort. MATERIALS AND METHODS: A retrospective study on 2005 patients that underwent isolated coronary artery bypass grafting in Iceland between 2000 and 2016. Patients were categorized into two groups based on their preoperative LVEF; LVEF ≤35% (n = 146, median LVEF 30%) and LVEF >35% (n = 1859, median LVEF 60%). Demographics and major adverse cardiac and cerebrovascular events were compared between groups along with cardiac-specific and overall survival. The median follow-up was 7.6 years. RESULTS: Demographics were similar in both groups regarding age, gender and most cardiovascular risk factors. However, patients with LVEF ≤35% more often had diabetes, renal insufficiency, chronic obstructive pulmonary disease and a previous history of myocardial infarction. Thirty-day mortality was 4 times higher (8% vs 2%, P < 0.001) in the LVEF ≤35%-group compared to controls. Overall survival was significantly lower in the LVEF ≤35%-group compared to controls, at 1 year (87% vs. 98%, P < 0.001) and 5 years (69% vs. 91%, P < 0.001). In multivariable analysis LVEF ≤35% was linked to inferior survival with an adjusted hazard ratio of 2.0 (95%-CI 1.5 - 2.6, p<0.001). CONCLUSIONS: A good long-term outcome after coronary artery bypass grafting can be expected for patients with reduced LVEF, however, their survival is still significantly inferior to patients with normal ventricular function.

"Where There Are Stars, There Is Also Darkness": Young Icelandic Men's Experience of Prescription Drug Misuse.

Misuse of prescription drugs is a public health problem in many places around the world, including Iceland. It is considered most common among 18- to 25-year-olds, various risk factors and motives explain this trend. The purpose of this study was to examine young Icelandic men's experience of prescription drug misuse. Participants in this study were seven Icelandic males, 18-26 years old, mean age was 20.9. Data were collected through 14 interviews and then processed using a qualitative methodological approach based on Vancouver's school of phenomenology. The overriding theme of the study "Where there are stars, there is also darkness" refers to the common thread in participants' experiences of misuse of prescription drugs that were initially positive but quickly turned negative. Four main themes were identified: influence factors, reasons, onset, and continued drug misuse. The influencing factors were social influence, social group, lack of knowledge, and curiosity. The main reasons for the drug misuse were to suppress distress, improve capacity and efficiency, or have fun and avoid boredom. The onset of prescription drug misuse was characterized by quick fixes, misuse of one's own medication or medication from a friend/family member. Continued misuse was characterized by a vicious circle, black market, medical visits on false pretenses, and symptoms of dependence and addiction. It is necessary to highlight this public health problem that prescription drug misuse among young Icelandic males appear to be and it needs to be considered as a multifarious problem as the results indicate that its nature is truly complex.

Transition from open to robotically assisted approach on radical prostatectomies in Iceland. A nationwide, population-based study.

OBJECTIVES: In January 2015, radical prostatectomies (RPs) in Iceland changed almost entirely from being performed as open (ORP) to robotically assisted (RARP). This study assesses early surgical and short-term oncological outcome after ORP and RARP and evaluates the safety of transition between the two surgical techniques. METHODS: The study population involved 160/163 (98%) of all radical prostatectomies performed in Iceland between January 2013 and April 2016. Data on patients was collected retrospectively from medical records. Early surgical and short-term oncological outcomes were compared between the two surgical techniques. RESULTS: The ORP and RARP cohorts were comparable with respect to all clinical and pathological variables, except for median prostate volume, which was 45 mL in the ORP cohort and 37 mL in the RARP cohort (p = 0.03). Intraoperative blood loss was higher, hospital stay longer, catheterization time longer, and risk of complications within 30 days of surgery higher after ORP than RARP (p < 0.01). The operative time, positive surgical margin rate and recurrence free survival, within two years, was comparable between the two surgical techniques. CONCLUSIONS: The transition from ORP to RARP in Iceland was safe and resulted in improved early surgical outcome. However, no conclusion can be drawn from this study regarding oncological outcome, due to short follow up and a small sample size.

[Long term outcome of valve repair for degenerative mitral valve disease in Iceland].

OBJECTIVES: Degenerative mitral valve disease is the most common indication for mitral valve repair in the Western world. The aim of this study was to study the long term outcome of mitral valve repair for degenerative mitral valve regurgitation in Iceland. MATERIAL AND METHODS: A retrospective study of 101 consecutive mitral valve repair patients (average age 57.7 years, 80.2% male) operated in Iceland 2004-2018 for degenerative mitral valve regurgitation. Long term survival and MACCE (major adverse cardiac and cerebrovascular event) free survival was estimated using the Kaplan-Meier method and compared to age and gender matched reference population. Median follow-up time was 83 months. RESULTS: On average there were 6,7 (range 1-14) mitral valve repairs performed annually with 99% of the patients receiving ring annuloplasty. A total of 82 (82,2%) underwent resection of the posterior leaflet and 64.4% recieved Gore-Tex®-chordae. Major early complications occured in 28.7% of cases, most commonly perioperative myocardial infarction (11.9%) and reoperation for bleeding (8.9%). Mortality within 30 days was 2%, the median duration of intensive care unit stay was one day and the median hospital length of stay was 8 days. One patient needed reoperation later for recurrent mitral regurgitation. Five and ten year MACCE-free survival was 91.1% (95%-CI: 85.3-97.2) and 81.0 (95%-CI: 71.6-91.6), respectively. Five year survival was 93.5% (95-CI: 88.6-98.7) and 10 year survival 85.3% (95%-CI: 76.6-94.9), which was not different from an age and gender matched reference population (p=0.135, log-rank test). CONCLUSION: Outcomes of mitral valve repair due to degenerative mitral regurgitation is good in Iceland and results are comparable to larger institutions overseas. Long term prognosis is generally good although early postoperative complications often occur.

[Indications and outcomes of TAVI (transcatheter aortic valve implantation) in Iceland].

INTRODUCTION: Surgical aortic valve replacement (SAVR) has been the standard of treatment for aortic stenosis but transcatheter aortic valve implantation (TAVI) is increasingly used as treatment in Iceland and elsewhere. Our objective was to assess the outcome of TAVI in Iceland, focusing on indications, complications and survival. MATERIAL AND METHODS: This retrospective study included all TAVI-procedures performed in Iceland between January 2012 and June 2020. Patient characteristics, outcome and complications were registered, and overall estimated survival compared to an age and sex matched Icelandic reference-population. The mean follow-up was 2.4 years. RESULTS: Altogether 189 TAVI procedures (mean age 83±6 years, 41.8% females), were performed, all with a self-expanding biological valve. Most patients (81.5%) had symptoms of severe heart failure (NYHA-class III-IV) and median EuroSCORE-II was 4.9 (range: 0.9-32). Echocardiography pre-TAVI showed a mean aortic-valve area of 0.67 cm2 and a max aortic-valve gradient of 78 mmHg. One out of four patients (26.5%) needed permanent pacemaker implantation following TAVI. Other complications were mostly vascular-related (13.8%) but cardiac cardiac temponade and stroke occurred in 3.2 and 2.6% of cases, respectively and severe paravalvular aortic valve regurgitation in 0.5% cases. Thirty-day mortality was 1.6% (n=3) with one-year survival of 93.5% (95% CI: 89.8-97.3). Finally long-term survival survival of TAVI-patients was similar to the matched reference population (p=0.23). CONCLUSIONS: The outcome of TAVI-procedures in Iceland is good, especially regarding 30-day mortality and long-term survival that was comparable to a reference population. Incidence of major complications was also low.

Reoperation for bleeding following coronary artery bypass surgery with special focus on long-term outcomes.

Objectives: We studied the incidence and risk factors of reoperation for bleeding following CABG in a nationwide cohort with focus on long-term complications and survival. Design: A retrospective study on 2060 consecutive, isolated CABG patients operated 2001-2016. Outcome of reoperated patients (n = 130) were compared to non-reoperated ones (n = 1930), including major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Risk factors for reoperation were determined using multivariate logistic regression and a Cox proportional hazards model to assess prognostic factors of long-term survival. Median follow-up was 7.6 years. Results: One hundred thirty patients (6.3%) were reoperated with an annual decrease of 4.1% per year over the study period (p=.04). Major complications (18.5 vs. 9.6%) and 30-day mortality (8.5 vs. 1.9%,) were higher in the reoperation group (p<.001). The use of clopidogrel preoperatively (OR 3.62, 95% CI: 1.90-6.57) and reduced left ventricular ejection fraction (OR 2.23, 95% CI: 1.25-3.77) were the strongest predictors of reoperation, whereas off-pump surgery was associated with a lower reoperation risk (OR 0.44, 95% CI: 0.22-0.85). After exluding patients that died within 30 days postoperatively, no difference in long-term survival or freedom from MACCE was found between groups, and reoperation was not an independent risk factor for long-term mortality in multivariate analysis. Conclusions: The reoperation rate in this study was relatively high but decreased significantly over time. Reoperation was associated with twofold increased risk for major complications and fourfold 30-day mortality, but comparable long-term MACCE and survival rates. This implies that if patients survive the first 30 days following reoperation, their long-term outcome is comparable to non-reoperated patients.

[Effectiveness of medical treatment in the adult ADHD unit of Landspitali 2015-2017].

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder among children but symptoms may persist into adulthood. At Landspitali - the National University Hospital an interdisciplinary unit is responsible for ADHD-diagnosis and for commencing treatment of adult ADHD. The aim of this study is to evaluate the effectiveness of pharmaceu-tical treatment provided by the unit and the effects of psychiatric comorbidities. METHODS: The study is retrospective and includes all individuals ≥18 years of age who received pharmaceutical treatment in the adult ADHD unit at Landspitali 2015-2017. Individuals who had previously received treatment by the unit or were already on medication for ADHD were excluded. Information on symptoms and wellbeing before and after treatment were obtained from three questionnaires, an ADHD rating scale, DASS and QOLS. RESULTS: Of 211 patients who met inclusion criteria 144 (68%) completed the treatment provided by the unit on average 143 days. Impulsivity/hyperactivity predicted treatment failure with OR=0.96 (p=0.015). There was a statistically significant difference in all key response variables before and after pharmaceutical treatment (p<0.001). The Cohen's d effect size for ADHD variables were 3.18 for attention-deficit and 1.40 for impulsivity/hyperactivity. The effect size for quality of life was 1.00 and among the DASS subscales the maximum effect size was 1.43 for stress. Increased quality of life correlated with decreased symptoms as rated by DASS and the ADHD rating scale. Treatment success rates were significantly -higher for DASS but not for attention-deficit, impulsivity/hyperactivity and quality of life among individuals with psychiatric comorbidities alongside ADHD. Gender did not affect treatment effectiveness. CONCLUSIONS: Those who complete treatment within the ADHD unit achieve good results with decreased psychiatric symptoms and improved quality of life. Treatment discontinuation is a challenge.

The prognostic effect of known and newly detected type 2 diabetes in patients with acute coronary syndrome.

BACKGROUND: Dysglycemia is a well-established risk factor of coronary artery disease. Less is known of the prognostic effect of dysglycemia in acute coronary syndromes (ACSs). The aim of this study was to evaluate the long-term outcome of patients with ACSs according to glucometabolic categories. METHODS: Patients with ACSs were consecutively included in the study. Among those with no previous history of type 2 diabetes (T2DM) glucose metabolism was evaluated with fasting glucose in plasma, glycated hemoglobin and a standard 2-h oral glucose tolerance test. Patients were classified having normal glucose metabolism, prediabetes, newly detected T2DM (nT2DM) and previously known T2DM (kT2DM). The clinical outcome parameters were death or myocardial infarction and other major adverse cardiac events (MACEs). RESULTS: A total of 372 ACS patients (male 75.8%, 65.1 years (SD: 11.8)) constituted the study population. The proportion diagnosed with normal glucose metabolism, prediabetes, nT2DM and kT2DM was 20.7%, 46.5%, 6.2% and 26.6%, respectively. The mean follow-up period was 2.9 years. Patients with prediabetes, nT2DM and kT2DM had a hazard ratio of 5.8 (95% confidence interval (CI) 0.8-44.6), 10.9 (95% CI 1.2-98.3) and 14.9 (95% CI 2.0-113.7), respectively, for death/myocardial infarction and 1.4 (95% CI 0.6-3.1), 2.9 (95% CI 1.1-8.0) and 3.3 (95% CI 1.5-7.6), respectively, for a composite of MACEs. CONCLUSION: Patients with ACS and nT2DM or kT2DM were at increased risk of death/myocardial infarction and MACE compared with patients with normal glucose metabolism after approximately three years of follow-up.

Immediate and long-term need for permanent cardiac pacing following aortic valve replacement.

Introduction: Atrioventricular (AV) node conduction disturbances are common following surgical aortic valve replacement (SAVR), and in some cases the patient needs a permanent pacemaker (PPM) implantation before discharge from hospital. Little is known about the long-term need for PPM and the PPM dependency of these individuals. We determined the incidence of PPM implantation before and after discharge in SAVR patients. Methods: We studied 557 consecutive patients who underwent SAVR for aortic stenosis in Iceland between 2002 and 2016. Timing and indication for PPM were registered, with a new concept, ventricular pacing proportion (VPP), defined as ventricular pacing ≥90% of the time, being used to approximate pacemaker dependency. The median follow-up time was 73 months. We plotted the cumulative incidence of pacemaker implantation, treating death as a competing risk. Results: Of the 557 patients, 22 (3.9%) received PPM in the first 30 days after surgery, most commonly for complete AV block (n = 14) or symptomatic bradycardia (n = 8); Thirty-eight other patients (6.8%) had a PPM implanted >30 days postoperatively, at a median of 43 months after surgery (range 0‒181), most often for AV block (n = 13) or sick-sinus syndrome (n = 10). The cumulative incidence of PPM implantation at 1, 5, and 10 years postoperatively was 5.0%, 9.2%, and 12.3%, respectively. During follow-up, 45.0% of the 60 patients had VPP ≥90%. Conclusion: The cumulative incidence of permanent pacemaker implantation following SAVR was about 12% at 10 years, with every other patient having VPP ≥90% during follow-up. This suggests that AV node conduction disturbances extend significantly beyond the perioperative period.

Pulmonary carcinoid tumours: incidence, histology, and surgical outcome. A population-based study.

BACKGROUND: Pulmonary carcinoids (PCs) represent only a minority of all primary pulmonary malignancies but they are the most common type of pulmonary malignancy diagnosed in children and adolescents. In this nationwide study, we analyzed data on all PC tumours in the Icelandic population over a 60-year period and concentrated especially on incidence and patient outcomes. METHODS: We studied all cases of PCs diagnosed in Iceland in the period 1955‒2015. Histological specimens were re-evaluated and the tumours were staged according to the TNM system (seventh edition). Survival was estimated using the Kaplan-Meier method, with a mean follow-up of 15.7 years. RESULTS: Altogether, 88 patients (median age 51.0 years, 65.9% women) were diagnosed with PCs in the study period. The incidence increased from 0.19/100,000/year in the first decade (1955‒1964) to 0.58/100,000/year in the last decade (2005‒2015), with a mean increase of 29.0% per decade of the study period (p < 0.001). The rise in incidental detection was, however, not significant. The median tumour diameter was 2.2 cm (range 0.4‒7.0) and typical histology was seen in 74 patients (84.1%). The other 14 patients (15.9%) had atypical histology. In all, 90.9% of the patients underwent pulmonary resection, 81.2% of them with lobectomy, with all of them surviving at least 30 days postoperatively. Most patients (n = 52, 62.7%) were stage IA at diagnosis, 15 (18.1%) were stage IB, nine (10.8%) were stage IIA, and three were stage IIIA (3.6%). Four patients (4.8%) had distant metastases (stage IV), two of whom had typical histology. Five-year survival was 89.8% for all patients: 93.2% for patients with typical histology and 70.7% for those with atypical histology. CONCLUSION: The incidence of PCs in Iceland has increased significantly over the last six decades, which cannot be explained by a rise in incidental detection at chest imaging. Most patients have localized disease and a favourable histology, where the long-term outcome is excellent.

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.

[Early outcome of surgical aortic valve replacement for aortic stenosis in Icelandic females].

INTRODUCTION: Aortic valve replacement (AVR) for aortic stenosis (AS) is the second most common open-heart procedure performed in Iceland. The aim of this study was to analyze the early outcome of AVR among females in Iceland. MATERIALS AND METHODS: This was a retrospective study including 428 patients who underwent surgical AVR due to AS in Iceland from 2002-2013. Information was gathered from medical records, including pre- and postoperative results of echocardiography and complications. Overall survival was estimated (Kaplan-Meier) and logistic regression used to identify predictors of operative mortality. The median follow-up time was 8.8 years (0-16.5 years). RESULTS: Of the 428 patients, 151 were female (35.3%), that were on average 2 years older than men (72.6 ± 9.4 vs. 70.4 ± 9.8 yrs., p=0.020). Preoperative symptoms were similar, but women had significantly higher EurosSCORE II than men (5.2 ± 8.8 vs. 3.2 ± 4.6, p=0.002). Maximal pressure-gradient across the aortic valve was higher for women (74.4 ± 29.3 mmHg vs. 68.0 ± 23.4 mmHg, p=0,013) but postoperative complications, operative mortality (8.6% vs. 4.0%, p=0.068) and 5-year survival (78.6% vs. 83.1%, p=0.245) were comparable for women and men. Logistic regression analysis showed that female gender was not an independent predictor of 30-day mortality (OR 1.54, 95% CI 0.63-3.77). CONCLUSIONS: Females constitute one third of patients that undergo AVR for AS in Iceland. At the time of surgery females are two years older than men and appear to have a more significant aortic stenosis at the time of surgery. However, complication rates, operative mortality and long-term survival were comparable for both genders.