New onset postoperative atrial fibrillation and early anticoagulation after cardiac surgery.

OBJECTIVES: New onset postoperative atrial fibrillation (POAF) after cardiac surgery is associated with increased risk for thromboembolic complications. Compliance with anticoagulation treatment is prerequisite for successful outcome after POAF. We hypothesized that a disciplined anticoagulation protocol initiated instantly after POAF secures a long-term outcome. DESIGN: A total of 519 consecutive patients undergoing cardiac surgery were retrospectively analyzed. Patients received anticoagulation using warfarin whenever POAF lasted longer than five min. Postoperative outcome including mortality, myocardial infarction and stroke were compared with patients on sinus rhythm (non-POAF). RESULTS: Mean age of the study cohort was 64.3 ± 9.0 years and median follow-up time was 76 months. There were 177 (34%) POAF and 342 (66%) non-POAF patients. At discharge, 144 (81%) POAF patients complied with warfarin, while 82 (24%) non-POAF patients received warfarin for non-rhythm causes (p < .001). Mortality was higher in POAF as compared with non-POAF patients (p = .03). After adjustment for comorbidities, major adverse clinical events (MACE)- including a combination of late cardiovascular mortality, myocardial infarction, stroke and late atrial fibrillation- was independently associated with POAF (OR 2.73, 95%CI 1.69-4.45, p < .0001). CONCLUSIONS: POAF after cardiac surgery was associated with high risk of MACE. Early anticoagulation may be justified in POAF patients to secure a long-term outcome after cardiac surgery.

[Thoracic lavage and open cardiac massage as treatment of hypothermic cardiac arrest--case report]. / Avoin sydänhieronta ja rintaontelon huuhtelu hypotermisen sydänpysähdyksen hoitona.

Cardiopulmonary bypass is the treatment of choice for a severely hypothermic patient with cardiac arrest. However, the treatment is not always available. We describe a successful three-and-a-half hour resuscitation of a hypothermic cardiac arrest patient with manual chest compressions followed by open cardiac massage and rewarming with thoracic lavage.

[Emergency craniotomies at the North Karelia Central Hospital in 2006 to 2014]. / Hätäkraniotomiat Pohjois-Karjalan keskussairaalassa vuosina 2006-2014.

Traditionally, acute evacuations of traumatic intracranial hematomas are performed by neurosurgeons in university hospitals. However, most patients with traumatic brain injury are initially transported to regional hospitals that lack neurosurgical expertise. Thus, a trauma surgeon in a regional hospital may encounter a patient with an expanding hematoma that must be operated without delays. During 2006 to 2014, 14 craniotomies were performed at the North Karelia Central Hospital. Twelve patients were operated for acute traumatic subdural hematoma (ASDH): three patients made good recovery, two were left with severe disability, and seven died. Two patients operated with acute epidural hematoma (EDH) recovered well.

Randomized Multicenter Trial Comparing Glue Fixation, Self-gripping Mesh, and Suture Fixation of Mesh in Lichtenstein Hernia Repair (FinnMesh Study).

OBJECTIVE: Three different mesh fixation techniques were compared to find out how to perform a safe and cost-effective open inguinal hernioplasty in day-case setting with the best outcomes with regard to chronic pain. SUMMARY BACKGROUND DATA: Mesh fixation method may influence on the incidence of chronic pain after Lichtenstein hernioplasty. METHODS: Lichtenstein hernioplasty was performed under local anesthesia in 625 patients as day-case surgery in 8 Finnish hospitals. The patients were randomized to receive either a cyanoacrylate glue (Histoacryl, n = 216), self-gripping mesh (Parietex ProGrip, n = 202), or conventional nonabsorbable sutures (Prolene 2-0, n = 207) for mesh fixation. The incidence of wound complications, pain, recurrences, and patients discomfort was recorded on days 1, 7, 30, and 1 year after surgery. The primary endpoint was the sensation of pain measured by pain scores and the need of analgesics after 1 year of surgery. RESULTS: The type and size of inguinal hernias were similar in the 3 study groups. The duration of operation was 34 ±â€Š13, 32 ±â€Š9, and 38 ±â€Š9 minutes in the glue, self-gripping, and suture groups, respectively (P < 0.001). There were no significant differences postoperatively in pain response or need for analgesics between the study groups. Two superficial infections (0.3%), 31 wound seromas (5.0%), and 4 recurrent hernias (0.6%) were recorded during a 1-year follow-up. Some 25 patients (4.2%) needed occasionally analgesics for chronic groin pain. A feeling of a foreign object and quality of life were similar in all study groups. CONCLUSIONS: This randomized trial failed to prove that mesh fixation without sutures causes less inguinodynia than suture fixation in Lichtenstein hernioplasty. Mesh fixation without sutures is feasible without compromising postoperative outcome.

The prevalence of abdominal aortic aneurysm is consistently high among patients with coronary artery disease.

OBJECTIVE: Emerging evidence suggests high prevalence of abdominal aortic aneurysm (AAA) among patients with coronary disease. Accurate characterization of the association between coronary disease and AAA and of the actual prevalence of AAA among patients with angiography-verified coronary artery disease (CAD) is needed to evaluate the possible benefits of systematic screening for AAA. METHODS: We searched for studies that reported the association between AAA and CAD or coronary heart disease (CHD; wider phenotype definition) in the general population (randomized controlled trials, prospective population cohorts) and those that reported the prevalence of AAA among patients with angiography-verified CAD through PubMed, Embase, and reference lists for the period between 1980 and 2014. Random-effects models were applied because of the high heterogeneity between included studies. RESULTS: Among the general population, 23 studies reported the association between CHD and the occurrence of subclinical AAA (positive ultrasound screening; meta-analyzed odds ratio of 2.38 with 95% confidence interval [CI] of 1.78-3.19; P = 4.1 × 10(-9)). According to four prospective studies, CHD is a strong predictor of future AAA events (fatal and nonfatal; meta-analyzed hazard ratio of 3.49 with 95% CI of 2.56-4.76; P = 2.4 × 10(-15)). Altogether, 10 studies reported the prevalence of AAA among patients with angiography-verified CAD or undergoing coronary artery bypass grafting. Among men, meta-analyzed prevalence was 9.5% (95% CI, 7.6%-11.7%). Among men undergoing coronary artery bypass grafting or with three-vessel disease, the prevalence was 11.4% (95% CI, 9.1%-13.9%). Among women, the prevalence was low (0.35%). CONCLUSIONS: The risk of subclinical AAA and future AAA events is high among patients with coronary disease. Screening for AAA among CAD patients by cardiologists would be easy and inexpensive, with possible benefits to survival and risk evaluation.

Screening Men with Coronary Heart Disease for Abdominal Aortic Aneurysm: A Prospective Cohort Study.

BACKGROUND: The prevalence of abdominal aortic aneurysms (AAA) is higher among patients with coronary heart disease (CHD) compared with control population. OBJECTIVE: To assess and determine the prevalence of non-diagnosed AAA in men with CHD. MATERIALS AND METHODS: A total of 438 active male out-patients with CHD were screened for AAA by abdominal ultrasound (US) examination. The largest infrarenal aortic dimension was registered. The patient was regarded to have AAA when the aortic diameter was greater than 30 mm. RESULTS: We found altogether 25 AAAs. The incidence of AAA was 5.7%. One AAA patient was operated on, and the other AAA patients are under surveillance. Independent predictors for AAA among CHD patients were increased age, family history of AAA, and current or previous smoking. The screening process took on average 5 min per patient, and the cost of screening was 15 ($18.50) per patient or 257 ($325) per found AAA. CONCLUSIONS: The prevalence of previously undiagnosed AAAs among patients with CHD is considerable. Screening of AAA should be considered among active patients with CHD. The most feasible and simplest option would be to perform the screening during any routine or elective cardiac US by a cardiologist, and we recommend to adopt it as a standard practice.

Open Mesh Repair for Inguinal Hernia is Safer than Laparoscopic Repair or Open Non-mesh Repair: A Nationwide Registry Study of Complications.

BACKGROUND: Inguinal hernia repair is the most common elective procedure in general surgery. Therefore, the number of patients having complications related to inguinal hernia surgery is relatively large. The aim of this study was to compare complication profiles of inguinal open mesh (OM) hernioplasties with open non-mesh (OS) repairs and laparoscopic (LAP) repairs using retrospective nationwide registry data. METHODS: The database of the Finnish Patient Insurance Centre (FPIC) was searched for complications of inguinal and femoral hernia repairs during 2002-2010. Complications of OM repairs were compared to complications of OS repairs and LAP repairs. RESULTS: Over 75 % of all inguinal hernia procedures during the study period in Finland were OM hernioplasties. FPIC received 245 complication reports after OM repairs, 40 after OS repairs, and 50 after LAP repairs. Reported complications were significantly more severe after LAP and OS repairs than OM surgery (p<0.001). Visceral complications (p<0.001), deep infections (p<0.001), and deep hemorrhagic complications (p<0.001) were overrepresented in the LAP group. In the OS group, visceral complications (p<0.001), recurrences (p<0.001), and severe neuropathic pain (p<0.001) predominated. CONCLUSION: LAP and OS repairs of inguinal hernia were associated with more severe complications than open surgery with mesh in this study.

An autochthonous case of cystic echinococcosis in Finland, 2015.

We report a case of pulmonary cystic echinococcosis in a child from eastern Finland with no history of travelling abroad. The cyst was surgically removed and the organism molecularly identified as Echinococcus canadensis genotype G10. This parasite is maintained in eastern Finland in a sylvatic life cycle involving wolves and moose; in the present case, the infection was presumably transmitted by hunting dogs.

Fatal surgical or procedure-related complications: a Finnish registry-based study.

INTRODUCTION: In Finland, all healthcare personnel must be insured against causing patient injury. The Patient Insurance Centre (PIC) pays compensation in all cases of malpractice and in some cases of infection or other surgical complications. This study aimed to analyze all complaints relating to fatal surgical or other procedure-related errors in Finland during 2006-2010. MATERIALS AND METHODS: In total, 126 patients fulfilled the inclusion criteria. Details of patient care and decisions made by the PIC were reviewed, and the total national number of surgical procedures for the study period was obtained from the National Hospital Discharge Registry. RESULTS: Of the 94 patients who underwent surgery, most fatal surgical complications involved orthopedic or gastrointestinal surgery. Non-surgical procedures with fatal complications included deliveries (N = 10), upper gastrointestinal endoscopy or nasogastric tube insertion (N = 8), suprapubic catheter insertion (N = 4), lower intestinal endoscopy (N = 5), coronary angiogram (N = 1), pacemaker fitting (N = 1), percutaneous drainage of a hepatic abscess (N = 1), and chest tube insertion (N = 2). In 42 (33.3 %) cases, patient injury resulted from errors made during the procedure, including 24 technical errors and 15 errors of judgment. There were 19 (15.2 %) cases of inappropriate pre-operative assessment, 28 (22.4 %) errors made in postoperative follow-up, 23 (18.4 %) cases of fatal infection, and 11 (8.8 %) fatal complications not linked to treatment errors. CONCLUSION: Fatal surgical and procedure-related complications are rare in Finland. Complications are usually the result of errors of judgment, technical errors, and infections.

[Epiglottitis and necrotizing mediastinitis in a middle-aged man]. / Keski-ikäisen miehen epiglottiitti ja nekrotisoiva mediastiniitti.

Acute epiglottitis is nowadays a rare bacterial infection. Airway management and promptly started antimicrobial medication are essential in the treatment. Descending necrotizing mediastinitis is a life-threatening bacterial infection that typically spreads from an odontogenic, pharyngeal or neck infection. Despite the vagueness of symptoms, diagnosis must be made quickly. Owing to the high mortality rate, aggressive surgical treatment is indicated.

Effect of triclosan-coated sutures on the incidence of surgical wound infection after lower limb revascularization surgery: a randomized controlled trial.

BACKGROUND: Surgical wound infection (SWI) is a common complication after peripheral vascular surgery. In a prospective study, triclosan-coated sutures were reported to decrease the incidence of surgical site infection after various surgical procedures. The aim of our study was to test the hypothesis that use of triclosan-coated sutures decreases the incidence of SWI after lower limb vascular surgery. METHODS: This prospective, randomized, multicenter, double-blinded trial was conducted between July 2010 and January 2011 in five hospitals in Finland. We randomly allocated 276 patients undergoing lower limb revascularization surgery to a study (n = 139) or a control (n = 137) group. Surgical wounds in the study group were closed with triclosan-coated suture material, and wounds in the control group were closed with noncoated sutures. The main outcome measure was SWI. A surgical wound complication was considered to be an infection if there were bacteria isolated from the wound or if there were areas of localized redness, heat, swelling, and pain around the wound appearing within 30 days after the operative procedure. Logistic regression analysis was used to assess the independent effect of triclosan-coated sutures on the incidence of SWI. RESULTS: Altogether, 61 (22.1 %) patients developed SWI. SWI occurred in 31 (22.3 %) patients in the study group and in 30 (21.9 %) patients in the control group (odds ratio 1.10, 95% confidence interval 0.61-2.01, p = 0.75.) CONCLUSIONS: The use of triclosan-coated sutures does not reduce the incidence of SWI after lower limb vascular surgery.

Supplemental postoperative oxygen in the prevention of surgical wound infection after lower limb vascular surgery: a randomized controlled trial.

BACKGROUND: Surgical wound infection (SWI) is a common complication after peripheral vascular surgery. Infections increase morbidity and costs of treatment. The aim of the present study was to test the hypothesis that supplemental postoperative oxygen decreases the incidence of SWI after lower limb revascularization. METHODS: This prospective, randomized, multicenter, single-blinded trial was conducted between May 2009 and February 2010 in six secondary referral hospitals in Finland. We randomly allocated 274 patients undergoing surgery for lower limb revascularization to the study group (n=137) or a control group (n=137). The study group received supplemental inspired oxygen for the first 2 days after surgery. The main outcome was SWI. Patients were followed up for 30 days or until the SWI was healed. Logistic regression analysis was used to assess the independent effect of supplemental oxygen on the incidence of SWI. RESULTS: Altogether 63 (23%) patients developed SWI; 47 (75%) of the infections were superficial. There were two vascular graft infections. SWI occurred in 25 patients (18.2%) in the study group and in 38 patients (27.7%) in the control group [odds ratio (OR) 0.56, 95% confidence interval (CI) 0.30-1.04; P=0.07]. In isolated groin incisions, 3 patients of 52 (5.8%) in the study group and 12 patients of 51 (23.5%) in the control group developed SWI; OR=0.20, 95% CI 0.04-0.95; P=0.04. CONCLUSIONS: There was an indication that supplemental inspired oxygen tended to decrease the incidence of SWI after lower limb vascular surgery. In isolated groin incisions, the decrease of SWI incidence in the supplemental oxygen group was significant.

Metoprolol versus amiodarone in the prevention of atrial fibrillation after cardiac surgery: a randomized trial.

BACKGROUND: Current guidelines recommend ß-blockers as the first-line preventive treatment of atrial fibrillation (AF) after cardiac surgery. Despite this, 19% of physicians report using amiodarone as first-line prophylaxis of postoperative AF. Data directly comparing the efficacy of these agents in preventing postoperative AF are lacking. OBJECTIVE: To determine whether intravenous metoprolol and amiodarone are equally effective in preventing postoperative AF after cardiac surgery. DESIGN: Randomized, prospective, equivalence, open-label, multicenter study. (ClinicalTrials.gov registration number: NCT00784316) SETTING: 3 cardiac care referral centers in Finland. PATIENTS: 316 consecutive patients who were hemodynamically stable and free of mechanical ventilation and AF within 24 hours after cardiac surgery. INTERVENTION: Patients were randomly assigned to receive 48-hour infusion of metoprolol, 1 to 3 mg/h, according to heart rate, or amiodarone, 15 mg/kg of body weight daily, with a maximum daily dose of 1000 mg, starting 15 to 21 hours after cardiac surgery. MEASUREMENTS: The primary end point was the occurrence of the first AF episode or completion of the 48-hour infusion. RESULTS: Atrial fibrillation occurred in 38 of 159 (23.9%) patients in the metoprolol group and 39 of 157 (24.8%) patients in the amiodarone group (P = 0.85). However, the difference (-0.9 percentage point [90% CI, -8.9 to 7.0 percentage points]) does not meet the prespecified equivalence margin of 5 percentage points. The adjusted hazard ratio of the metoprolol group compared with the amiodarone group was 1.09 (95% CI, 0.67 to 1.76). LIMITATIONS: Caregivers were not blinded to treatment allocation, and the trial evaluated only stable patients who were not at particularly elevated risk for AF. The withdrawal of preoperative ß-blocker therapy may have increased the risk for AF in the amiodarone group. CONCLUSION: The occurrence of AF was similar in the metoprolol and amiodarone groups. However, because of the wide range of the CIs, the authors cannot conclude that the 2 treatments were equally effective. PRIMARY FUNDING SOURCE: The Finnish Foundation for Cardiovascular Research and the Kuopio University EVO Foundation.

[Gas in the abdominal cavity--due to cholecystitis caused by gas-producing bacteria]. / Kaasua vapaassa vatsaontelossa--syynä kaasua tuottavien bakteerien aiheuttama sappirakkotulehdus.

In most cases, gas in the abdominal cavity indicates perforation of the gastrointestinal wall. We describe a patient, in whom the cause of abdominal gas detected in computed tomography turned out to be emphysematous cholecystitis caused by gas-producing bacteria. It is a rare disease characterized by accumulation of gas into the gall bladder or its wall. The gas can be easily observed in computed tomography. The disease easily becomes complicated and is associated with high mortality. Prompt cholecystectomy and antibiotic therapy are the cornerstones of the treatment.

Lichtenstein hernioplasty versus totally extraperitoneal laparoscopic hernioplasty in treatment of recurrent inguinal hernia--a prospective randomized trial.

OBJECTIVE: To compare the Lichtenstein hernioplasty with a totally extraperitoneal preperitoneal laparoscopic technique (TEP) in treatment of recurrent inguinal hernias. SUMMARY BACKGROUND DATA: Only a few studies thus far have compared an open and laparoscopic approach with the treatment of recurrent inguinal hernia in a prospective randomized study setting. METHODS: Ninety-nine patients undergoing surgery for recurrent inguinal hernia were prospectively randomized into having either open or laparoscopic mesh repair. Pre, peri- and postoperative factors were recorded in addition to 3-year follow-up data at the outpatient clinic. At 5-10 years, the patients were interviewed via telephone for recurrent symptoms. The primary end-points chosen were hernia recurrence and chronic pain. RESULTS: Preoperative factors did not differ between the 2 groups. Rerecurrence rates were 3 in the Lichtenstein group and none in the TEP group (6.4% versus 0.0%, respectively), but this difference was statistically not significant. Chronic pain was more prevalent in the Lichtenstein group compared with the TEP group (13 [27.7%] versus 4 [8.2%] patients, respectively, P = 0.02). Postoperatively, the Lichtenstein group needed more pain medication than the TEP group (4.4 versus 3.0 doses, respectively, P = 0.02) and returned to work later (17.9 versus 14.8 days, respectively, P = 0.05). CONCLUSIONS: The laparoscopic technique with mesh in the treatment of recurrent inguinal hernia was proven superior to the open mesh repair in several important clinical aspects, with concomitant improvement in patient satisfaction.

Preoperative alterations in correlation properties and complexity of R-R interval dynamics predict the risk of atrial fibrillation after coronary artery bypass grafting in patients with preserved left ventricular function.

INTRODUCTION: We evaluated whether there are constant preoperative alterations in nonlinear R-R interval dynamics that associate with the risk of postoperative atrial fibrillation in patients with preserved left ventricular function. METHODS: We analyzed mean normal-to-normal R-R intervals, short-term scaling exponent of detrended fluctuation analysis (DFA alpha(1)), approximate entropy and entropy of symbolic dynamics (SymDyn En) from 10-minute ECG recordings during rest, paced breathing, and passive tilt performed 1 day before surgery in 67 elective coronary artery bypass grafting patients. RESULTS: Nineteen patients developed postoperative atrial fibrillation. The preoperative DFA alpha(1) was constantly lower in patients developing postoperative atrial fibrillation than in patients remaining in sinus rhythm (P = 0.016); during spontaneous breathing, the DFA alpha(1) was 0.93 +/- 0.33 in patients with atrial fibrillation and 1.13 +/- 0.24 in patients with sinus rhythm. The entropy of symbolic dynamics was higher during the spontaneous breathing in patients with atrial fibrillation than in patients with sinus rhythm (4.72 +/- 0.51 vs 4.36 +/- 0.51, P = 0.012). Higher short-term scaling exponent of detrended fluctuation analysis during the spontaneous breathing period reduced the risk of postoperative atrial fibrillation (OR 0.31 for an interquartile increase in DFA alpha(1), 95% CI 0.13-0.78), while higher entropy of symbolic dynamics increased it (OR 3.16 for an interquartile increase in SymDyn En, 95% CI 1.23-8.10), independently of age and clinical risk factors. CONCLUSION: The preoperatively altered nonlinear R-R interval dynamics were independent predictors of postoperative atrial fibrillation and might become a useful tool for the risk assessment of atrial fibrillation.

Intravenous administration of metoprolol is more effective than oral administration in the prevention of atrial fibrillation after cardiac surgery.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia to occur after cardiac surgery, with an incidence of 20% to 40%. AF is associated with postoperative complications, including increased risk of stroke and need of additional treatment, as well as prolonged hospital stay and increased costs. It has been shown that prophylactic oral administration of beta-blocker therapy reduces the incidence of postoperative AF after cardiac surgery. However, it is possible that absorption of drugs is impaired after cardiopulmonary perfusion associated with cardiac surgery. The purpose of this prospective, controlled, randomized trial was to study compare intravenous and per oral metoprolol administration in the prevention of AF after cardiac surgery. METHODS AND RESULTS: 240 consecutive patients who were scheduled to undergo their first on-pump coronary artery bypass graft (CABG), aortic valve replacement, or combined aortic valve replacement and CABG were randomized to receive 48-hour infusion of metoprolol or oral metoprolol starting on the first postoperative morning. Patients were excluded if they had contraindications for beta-blocker or had to stay >1 day in the intensive care unit. Dosage of metoprolol was adjusted according to heart rate. The dosage was 1 to 3 mg/h in the intravenous group and from 25 mg twice per day to 50 mg 3 times per day in the oral group. The incidence of postoperative AF was significantly lower in the intravenous group than in the oral group (16.8% versus 28.1%, P=0.036). No serious adverse effects were associated with intravenous metoprolol therapy. CONCLUSIONS: Our study suggests that intravenous metoprolol is well-tolerated and more effective than oral metoprolol in the prevention of AF after cardiac surgery.

Tumour suppressor protein (p53), apoptosis inhibiting protein (Bcl-2) and proliferating cell nuclear antigen (PCNA) expressions in a rat pancreatic tumour model.

BACKGROUND: Previous studies have shown that, cultured rat pancreatic carcinoma cells, derived from azaserine-induced acinar tumours, yield tumours with a ductal phenotype. MATERIALS AND METHODS: In order to find out the molecular characteristics of this tumour model, tumour suppressor protein (p53), apoptosis inhibiting protein (Bcl-2) and proliferating cell nuclear antigen (PCNA) expressions were analysed in rat pancreatic and subcutaneous tumours, as well as in normal rat pancreas. RESULTS: Immunoreactivity for p53 protein was found in 86% of intrapancreatic tumours and in 100% of subcutaneous tumours. The average fraction of positive carcinoma cells was over 50%. Normal rat pancreas showed only slight positive or negative staining for p53. Bcl-2 did not show positive immunoreactivity in rat tumour samples. For PCNA all tumour samples showed positive staining. Also normal pancreas of 6-week-old animals were clearly positive, whereas the samples of the older animals were only slightly positive. CONCLUSION: Possible mutations in the p53 tumour suppressor gene and a strong expression of PCNA were shown in carcinoma cell line-induced rat pancreatic tumours. These features of the rat pancreatic tumour model resemble human pancreatic carcinoma and may favour the use of this model in pancreatic cancer studies.

Corticosteroids for the prevention of atrial fibrillation after cardiac surgery: a randomized controlled trial.

CONTEXT: Atrial fibrillation (AF) is the most common arrhythmia to occur after cardiac surgery. An exaggerated inflammatory response has been proposed to be one etiological factor. OBJECTIVE: To test whether intravenous corticosteroid administration after cardiac surgery prevents AF after cardiac surgery. DESIGN, SETTING, AND PATIENTS: A double-blind, randomized multicenter trial (study enrollment August 2005-June 2006) in 3 university hospitals in Finland of 241 consecutive patients without prior AF or flutter and scheduled to undergo first on-pump coronary artery bypass graft (CABG) surgery, aortic valve replacement, or combined CABG surgery and aortic valve replacement. INTERVENTION: Patients were randomized to receive either 100-mg hydrocortisone or matching placebo as follows: the first dose in the evening of the operative day, then 1 dose every 8 hours during the next 3 days. In addition, all patients received oral metoprolol (50-150 mg/d) titrated to heart rate. MAIN OUTCOME MEASURE: Occurrence of AF during the first 84 hours after cardiac surgery. RESULTS: The incidence of postoperative AF was significantly lower in the hydrocortisone group (36/120 [30%]) than in the placebo group (58/121 [48%]; adjusted hazard ratio, 0.54; 95% confidence interval, 0.35-0.83; P = .004; number needed to treat, 5.6). Compared with placebo, patients receiving hydrocortisone did not have higher rates of superficial or deep wound infections, or other major complications. CONCLUSION: Intravenous hydrocortisone reduced the incidence of AF after cardiac surgery. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00442494.

Medication-induced acute esophageal necrosis: a case report.

BACKGROUND: Acute esophageal necrosis or Gurvits syndrome is a rare clinical condition characterized by necrotic esophageal mucosa with an abrupt end at the gastroesophageal junction. Its etiology is multifactorial, but mainly related to low-flow states. We describe a case in which a patient accidentally took the wrong medication, with clozapine and olanzapine most probably being the cause of his subsequent acute esophageal necrosis. This situation is, to the best of our knowledge, unprecedented in the medical literature. CASE PRESENTATION: A 65-year-old Finnish male patient with schizoaffective disorder accidentally took another patient's medication, including clozapine 300 mg, olanzapine 30 mg, teofyllamine 200 mg, warfarin 5 mg, and potassium chloride 1 g. He arrived at our hospital for a routine examination 6 h after the incident. At hospital he started to vomit brownish liquid and had tachycardia and fever. Gastroparesis was found. An endoscopy revealed necrotic esophageal mucosa that was typical for Gurvits syndrome. A computed tomography scan showed an edematous esophagus and raised suspicion of a proximal jejunal obstruction. A laparotomy was performed but only healthy paralytic bowel was found. Our patient healed uneventfully within a week. CONCLUSIONS: There are analogous case reports describing ischemic colitis associated with the use of clozapine and olanzapine, but none describing the same for the other medications our patient took. We believe that in this case clozapine and olanzapine caused acute esophageal necrosis and this possibility should be taken into account when treating patients with acute ischemic enteropathy.