Joel Starkopf

• MD, PhD
• Professor (Full) at University of Tartu

Computed tomography (CT) is widely used in diagnosing acute mesenteric ischemia (AMI), but robust identification of distinctive subtypes and stages of progression is lacking. Systematic literature search in PubMed, Cochrane Library, Web of Science and Scopus was conducted in May 2024. Studies including at least 10 adult patients and reporting radio...

Purpose: Gastrointestinal (GI) dysfunction is common in critically ill patients and associated with poor outcomes. There is a lack of standardised methods for daily monitoring of GI function. COSMOGI aimed to develop a Core Outcome Set (COS) for daily monitoring of GI function to improve consistency and comparability in future studies in criticall...

Background: There are no clinical or laboratory markers that can diagnose acute mesenteric ischemia (AMI) accurately. This study aimed to find differences in clinical and laboratory markers between arterial occlusive AMI and other acute abdominal diseases where AMI was initially suspected. Methods: This was a post hoc study of an international pros...

Background Acute mesenteric venous thrombosis (MVT) is rarely suspected as primary diagnosis in emergency departments and still carries an in-hospital mortality rate of above 20%. Objectives The aim of this study was to find differences in clinical and laboratory markers between patients with acute MVT and a control group of suspected but confirme...

Background Acute mesenteric ischaemia (AMI) is a life-threatening disease where early diagnosis is critical to avoid morbidity and mortality from extensive irreversible bowel necrosis. Appropriate prediction of presence of bowel necrosis is currently not available but would help to choose the optimal method of treatment. The study aims to identify...

Background The optimal amount and timing of protein intake in critically ill patients are unknown. REPLENISH (Replacing Protein via Enteral Nutrition in a Stepwise Approach in Critically Ill Patients) trial evaluates whether supplemental enteral protein added to standard enteral nutrition to achieve a high amount of enteral protein given from ICU d...

Background The aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI). Methods All adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023...

Background Patient safety (PS) is a serious global public health problem affecting all countries. Estimates show that around 10 percent of the patients are harmed during hospital care, resulting in 23 million disability-adjusted life years lost per year. Experts emphasize research advancements as a key precondition for safer care. Aim The Patient S...

Background Acute mesenteric ischaemia (AMI) is a disease with different pathophysiological mechanisms, leading to a life-threatening condition that is difficult to diagnose based solely on clinical signs. Despite widely acknowledged need for biomarkers in diagnosis of AMI, a broad systematic review on all studied biomarkers in different types of AM...

Background: Protein intake is recommended in critically ill patients to mitigate the negative effects of critical illness-induced catabolism and muscle wasting. However, the optimal dose of enteral protein remains unknown. We hypothesize that supplemental enteral protein (1.2 g/kg/day) added to standard enteral nutrition formula to achieve high am...

Background: Acute mesenteric ischaemia (AMI) is a disease with different pathophysiological mechanisms, leading to a life-threatening condition that is difficult to diagnose based solely on clinical signs. Despite widely acknowledged need for biomarkers in diagnosis of AMI, a broad systematic review on all studied biomarkers in different types of A...

Background The correlation between the standardized resource use ratio (SRUR) and standardized hospital mortality ratio (SMR) for neurosurgical emergencies is not known. We studied SRUR and SMR and the factors affecting these in patients with traumatic brain injury (TBI), nontraumatic intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH...

Background Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs. Objectives The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia i...

Background The optimal amount and timing of protein intake in critically ill patients are unknown. REPLENISH (Replacing Protein via Enteral Nutrition in a Stepwise Approach in Critically Ill Patients) trial evaluates whether supplemental enteral protein added to standard enteral nutrition to achieve a high amount of enteral protein given from ICU d...

Background: Protein intake is recommended in critically ill patients to mitigate the negative effects of critical illness-induced catabolism and muscle wasting. However, the optimal dose of enteral protein remains unknown. We hypothesize that supplemental enteral protein (1.2 g/kg/day) added to standard enteral nutrition formula to achieve high amo...

Objective: To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality. Design: Systematic review and meta-analysis. Data sources: MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022. Eligibility criteria: Studies reporting d...

Background: Patient safety (PS) is a serious global public health problem affecting all countries. Estimates show that around 10 percent of the patients are harmed during hospital care, resulting in 23 million disability-adjusted life years lost per year. Experts emphasize research advancements as a key precondition for safer care. Aim: The Patient...

Purpose The purpose of this study was to determine outcomes in patients presenting to emergency department (ED) with acute abdominal pain and suspected occult myocardial injury [OMI (high-sensitive cardiac troponin T, hs-cTnT level > 14 ng/L)] without clinical signs of myocardial ischaemia. We hypothesized that OMI is a common entity associated wit...

Gastrointestinal (GI) dysfunction is thought to be a motor of multiple organ dysfunction syndrome (MODS), but not included in scoring systems commonly used for MODS. One of the reasons for this contradiction is the fact that GI (dys)function in critically ill patients is most difficult to evaluate. Acute gastrointestinal injury (AGI) is a term sugg...

Background and aims Plasma citrulline and intestinal fatty acid binding protein (I-FABP) are biomarkers reflecting enterocyte function and intestinal mucosal injury. The aim was to describe daily dynamics of citrulline and I-FABP concentrations in association with enteral nutrition (EN) in adult ICU patients. We hypothesized that success or failure...

Background and aims To develop a five grade score (0-4 points) for the assessment of gastrointestinal (GI) dysfunction in adult critically ill patients. Methods This prospective multicenter observational study enrolled consecutive adult patients admitted to 11 intensive care units in nine countries. At all sites, daily clinical data with emphasis...

Background Liver cirrhosis and ascites are risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); however, data is scarce. We aimed to determine the prevalence of IAH/ACS in a population of critically ill cirrhotic patients with acute medical illness in intensive care and to assess for risk factors and clinica...

Purpose To evaluate the effect of deepening of sedation on intra-abdominal pressure (IAP). Methods 37 adult mechanically ventilated ICU patients with intra-abdominal hypertension received a bolus dose and subsequent infusion of propofol (bolus: 1 mg/kg, infusion: 3 mg/kg/h). IAP, mean arterial pressure (MAP), abdominal perfusion pressure (APP), de...

Background & aims Hypophosphatemia (HypoP) is associated with organ dysfunction and mortality. Despite its potential severe consequences, HypoP remains poorly characterized in terms of real prevalence and timing of onset. The primary objective was to determine the prevalence of HypoP defined as blood phosphate <0.8 and < 0.65 mmol/l on one particu...

Purpose To assess whether the combination of intra-abdominal hypertension (IAH, intra-abdominal pressure ≥ 12 mmHg) and hypoxic respiratory failure (HRF, PaO2/FiO2 ratio < 300 mmHg) in patients receiving invasive ventilation is an independent risk factor for 90- and 28-day mortality as well as ICU- and ventilation-free days. Methods Mechanically v...

Background: Gastrointestinal (GI) dysfunction is frequent in the critically ill but can be overlooked as a result of the lack of standardization of the diagnostic and therapeutic approaches. We aimed to develop a research agenda for GI dysfunction for future research. We systematically reviewed the current knowledge on a broad range of subtopics f...

Background and aims Hypophosphatemia (HypoP) is associated with organ dysfunction and mortality. Despite its potential severe consequences, HypoP remains poorly characterized in terms of real prevalence and timing of onset. The primary objective was to determine the prevalence of HypoP defined as blood phosphate <0.8 and <0.65 mmol/l on one particu...

Background & aims Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphatemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphatemia, associated morbidity and treatments. Methods A systematic review was c...

Abstract Background Vascular surgery patients have reduced tissues` blood supply, which may lead to mitochondrial dysfunction and accumulation of acylcarnitines (ACs). It has been suggested that remote ischaemic preconditioning (RIPC) has its organ protective effect via promoting mitochondrial function. The aim of this study was to evaluate the eff...

Background: Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphataemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphataemia, associated morbidity and treatments. Methods: A systematic review was condu...

Background and Aims Despite the presumed importance of preventing and treating micronutrient and mineral deficiencies, it is still not clear how to optimize measurement and administration in critically ill patients. In order to design future comparative trials aimed at optimizing micronutrient and mineral management, an important first step is to g...

Background Vascular surgery affects tissues` blood supply and microcirculation and might lead to mitochondrial dysfunction, which may result in the accumulation of acylcarnitines (ACs). It has been suggested that remote ischaemic preconditioning (RIPC) has its organ protective effect via promoting mitochondrial function. The aim of this study was t...

Background Vascular surgery affects tissues` blood supply and microcirculation and might lead to mitochondrial dysfunction, which may result in the accumulation of acylcarnitines (ACs). It has been suggested that remote ischaemic preconditioning (RIPC) has its organ protective effect via promoting mitochondrial function. The aim of this study was t...

Background Vascular surgery patients have reduced tissues` blood supply , which may lead to mitochondrial dysfunction and accumulation of acylcarnitines (ACs). It has been suggested that remote ischaemic preconditioning (RIPC) has its organ protective effect via promoting mitochondrial function. The aim of this study was to evaluate the effect of R...

Objectives: The primary aim of this study was to evaluate the effects of remote ischaemic preconditioning (RIPC) on preventing the leakage of cardiac damage biomarkers in patients undergoing vascular surgery. Methods: Randomised, sham-controlled, double-blinded, single-centre study has been carried out. In recruitment patients undergoing open abdom...

Background and aims: Perioperative kidney injury affects 12.7% of patients undergoing lower limb revascularisation surgery. Remote ischaemic preconditioning (RIPC) is a potentially protective procedure against organ damage and consists of short nonlethal episodes of ischaemia. The main objective of this substudy was to evaluate the effect of RIPC...

Aims To describe the pharmacokinetics (PK) and concentration‐related effects of dobutamine in critically ill neonates in the first days of life, using nonlinear mixed effects modelling. Methods Dosing, plasma concentration and haemodynamic monitoring data from a dose‐escalation study were analysed with a simultaneous population PK and pharmacodyna...

Abdominal compartment syndrome (ACS) refers to a severe increase in intra-abdominal pressure associated with single or multiorgan failure. ACS with specific pathophysiological processes and detrimental outcomes may occur in a variety of clinical conditions. Patients with ACS are predominantly managed in critical care settings, however, a wide range...

Objective: Coronary artery disease contributes to noncommunicable disease deaths worldwide. In order to make preventive methods more accurate, we need to know more about the development and progress of this pathology, including the genetic aspects. Humanin is a small peptide known for its cytoprotective and anti-apoptotic properties. Our study loo...

Objective: The main aim of this study was to evaluate the effect of remote ischaemic preconditioning (RIPC) on preventing the leakage of cardiac damage biomarkers in patients undergoing vascular surgery. Methods: This is a randomised, sham-controlled, double-blinded, single-centre study. Patients undergoing open abdominal aortic aneurysm repair,...

Background: Blunt cardiac injuries (BCI) result in poor outcomes following chest trauma. Admission ECG and troponin levels are frequently obtained in patients with suspected BCI, nevertheless, the prognostic value of cardiac troponins remains controversial. The purpose of the current study was to review the prognostic value of elevated high-sensit...

Background Coronary artery disease contributes to noncommunicable disease deaths worldwide. In order to make preventive methods more accurate, we need to know more about the development and progress of this pathology, including the genetic aspects. Humanin is a small peptide known for its cytoprotective and anti-apoptotic properties. Our study look...

Purpose of review: To present a pragmatic approach to facilitate clinician's implementing the recent European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on clinical nutrition in the intensive care unit. Recent findings: The ESPEN guidelines include 54 recommendations with a rationale for each recommendation. All data publis...

Objectives The main aim of this study was to evaluate the effect of remote ischaemic preconditioning (RIPC) on arterial stiffness in patients undergoing vascular surgery. Methods This was a randomised, sham controlled, double blind, single centre study. Patients undergoing open abdominal aortic aneurysm repair, surgical lower limb revascularisatio...

Objectives To identify the prevalence, risk factors, and outcomes of intra-abdominal hypertension in a mixed multicenter ICU population. Design Prospective observational study. Setting Fifteen ICUs worldwide. Patients Consecutive adult ICU patients with a bladder catheter. Interventions None. Measurements and Main Results Four hundred ninety-o...

Purpose Goal of this study was to describe incidence and outcome of gastrointestinal failure (GIF) in ICU patients, evaluate its additive role to SOFA score in mortality prediction and describe GIF according to etiology. Materials and methods A retrospective study with prospective data collection was conducted in mixed adult ICU patients admitted...

The purpose of this work was to develop and validate an HPLC-MS/MS method suitable for quantifying two important cardiovascular drugs, milrinone and dobutamine, in neonatal and paediatric patients’ blood plasma samples. Sufficiently low LLOQ levels were required to obtain adequate pharmacokinetic data for the evaluation of optimal dosing. Since the...

Objectives: The postoperative course of patent ductus arteriosus ligation is often complicated by postligation cardiac syndrome, occurring in 10-45% of operated infants. Milrinone might prevent profound hemodynamic instability and improve the recovery of cardiac function in this setting. The present study aimed to describe the population pharmacok...

PurposeTrauma mechanisms and patterns of severe injuries during the Estonian independence have not been evaluated. The aim of the study was to compare the incidence and outcomes of severe injuries between time periods of early independence from the Soviet Union and the present time. Methods After the ethics review board approval, all adult trauma a...

PurposeTo provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. Methods We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed syst...

Limited available data for dosing in obesity of the medicines used in this case are discussed, with the emphasis on ertapenem. The case illustrates the difficulties in dosing medicines to morbidly overweight patients. The number of such patients is increasing but data on adequate doses of medicines are scarce. We demonstrate that ertapenem 1,5 g i....

AIM To determine the effects of implementing an enteral feeding protocol on the nutritional delivery and outcomes of intensive care patients. METHODS An uncontrolled, observational before-and-after study was performed in a tertiary mixed medical-surgical intensive care unit (ICU). In 2013, a nurse-driven enteral feeding protocol was developed and...

Poster

Serum troponin (Tn) measurement is widely used in emergency department for diagnosing and excluding acute coronary syndromes. There are Tn assays which are highly sensitive (hs-cTn) and capable of detecting minimal concentrations of Tn in blood serum. Higher sensitivity causes a dec rease in speci f icit y. It is not uncom mon to detect Tn values r...

Background: Milrinone has been suggested as a possible first-line therapy for preterm neonates to prevent postligation cardiac syndrome (PLCS) through decreasing systemic vascular resistance and increasing cardiac contractility. The optimal dosing regimen, however, is not known. Objective: To model the dosing of milrinone in preterm infants for...

Purpose of review: The current review summarizes different aspects of assessment of gastrointestinal function and provides a practical approach to management of adult patients with gastrointestinal dysfunction in the ICU. Recent findings: Different ways to define gastrointestinal failure have been used in the past. Recently, the term 'acute gast...

Background Glycaemia control (GC) remains an important therapeutic goal in critically ill patients. The enhanced Model Predictive Control (eMPC) algorithm, which models the behaviour of blood glucose (BG) and insulin sensitivity in individual ICU patients with variable blood samples, is an effective, clinically proven computer based protocol succes...

Troponiinide (Tn) määramine on erakorralise meditsiini osakonnas (EMO) laialdaselt kasutusel, seda ennekõike ägedate koronaarsündroomide (ÄKS) diagnoosimiseks ja välistamiseks. Nüüdseks on kasutusel testid, mis on tuntud kui kardiaalse troponiini (cTN) määramise kõrgtundlikud testid (ingl high-sensitive cardiac troponin, hs-cTn). Nende testidega on...

Abstract OBJECTIVE: To assess the effect of body mass index on ICU outcome and on the development of ICU-acquired infection. DESIGN: A substudy of the Intensive Care Over Nations audit. SETTING: Seven hundred thirty ICUs in 84 countries. PATIENTS: All adult ICU patients admitted between May 8 and 18, 2012, except those admitted for less than 24 hou...

In experimental setting the concept of myocardial preconditioning by hyperoxia has been introduced and different intracellular protective mechanisms and their effects have been described. To study whether similar protective phenotype can be induced by hyperoxia also in humans, gene expression profile after hyperoxic exposure was analyzed. Adult pat...

The purpose of this study was to investigate epidemiology of severe injuries in Estonia while comparing outcomes at regional trauma facilities. After the ethics review board approval, all consecutive trauma admissions with Injury Severity Score (ISS) > 15 to North Estonia Medical Center/Tallinn Children's Hospital (NEMC + TCH) and Tartu University...

Background The purpose of the study was to evaluate the pharmacokinetics (PK) and pharmacodynamics (PD) of piperacillin and tazobactam during high-volume haemodiafiltration (HVHDF).MethodsA single dose of piperacillin/tazobactam (4/0.5 g) was administered as 30 minute infusion during HVHDF to 10 patients with acute kidney injury due to septic shock...

Abdominal problems, both as a primary reason for admission or developing as a part of multiple organ dysfunction syndrome during an ICU stay, are common in critically ill patients. The definitions, assessment, incidence and outcome of different abdominal signs, symptoms and syndromes are assessed in the current review. General abdominal signs and s...

Background: High volumes of haemofiltration are used in septic patients to control systemic inflammation and improve patient outcomes. We aimed to clarify if extended intermittent high volume online haemodiafiltration (HVHDF) influences patient haemodynamics and cytokines profile and/or has effect upon sublingual microcirculation in critically ill...

Although enteral nutrition (EN) in critically ill patients is increasingly common, enteral underfeeding remains problematic. In the present study, we aimed to identify the reasons for insufficient EN. In this single-centre, prospective, observational study in a general intensive care unit, the nurses documented cases experiencing enteral underfeedi...

Pharmacokinetics (PK) of doripenem was determined during high volume hemodiafiltration (HVHDF) in patients with septic shock. A single 500 mg dose of doripenem was administered as a 1 hour infusion during HVHDF to 9 patients. Arterial blood samples were collected before and at 30 or 60 min intervals over 8 h (12 samples) after study drug administra...

Kaugisheemiline eelkohastamine (KIE) on meetod, mida kasutatakse sihtelundi isheemia-reperfusioonikahjustuse vähendamiseks. Meetod põhineb lühiajaliste isheemia- ja reperfusiooniepisoodide tekitamises, enamasti jäsemetel. KIE kaitsvat mõju ja mehhanisme on uuritud nii loomadel kui ka inimestel. Saadud on paljulubavaid tulemusi eelkõige südame ja ne...

Background and objective: The incidence of postoperative complications and death is low in the general population, but a subgroup of high-risk patients can be identified amongst whom adverse postoperative outcomes occur more frequently. The present study was undertaken to describe the incidence of postoperative complications, length of stay, and mo...

Background & aims: While feeding intolerance (FI) is clinically important in the critically ill it is inconsistently defined. By evaluating definitions of FI based on relationships between symptoms and signs of gastrointestinal (GI) dysfunction and mortality the objective was to define FI using the definition that was most strongly associated with...

Gastrointestinal (GI) problems after surgery are common and are not limited to patients undergoing abdominal surgery. GI function is complicated to monitor and is not included in organ dysfunction scores widely used in the ICUs. In most cases, it recovers after surgery, if systemic and local inflammation and perfusion improve, gut oedema resolves,...