General thoracic surgery in Finland, a perspective from the Helsinki University Hospital

The field of thoracic surgery is a rapidly developing field due to exciting developments in technology and oncologic treatments as well as continuous innovation in surgical technique. Although the population of Finland is relatively small, general thoracic surgery is represented at a high level in five centralized university centers, Helsinki University Hospital, Tampere University Hospital, Turku University Hospital, Kuopio University Hospital and Oulu University Hospital. Thus, high case volume and good results are achieved in these centers. Here, we describe a short history, current state and future prospects of the field of cardiothoracic surgery in Finland, with a focus on general thoracic surgery and the perspective of Helsinki University Hospital. From the field's birth in Finland, marked by the first lobectomy, in the late 1930's, it has grown and adapted more and more modern techniques such as totally minimally invasive esophagectomy and robotic lung cancer surgery. Nowadays, most of general thoracic surgery in Helsinki University Hospital is either minimally invasive or robotic and open surgery is the exception to the norm. Helsinki University Hospital has a strong presence in the European general thoracic surgery community and aims to do so in the future by investing on training & education, research and surgical innovation.Peer reviewe

Barrettin ruokatorvi ja siihen liittyvä rauhassyöpä : tutkimuksia syntymekanismista, klinisestä levinneisyysluokituksesta ja syöpähoidon kustannusvaikuttavuudesta

Esophageal and gastroesophageal junction (GEJ) adenocarcinoma is rapidly increasing disease with a pathophysiology connected to oxidative stress. Exact pre-treatment clinical staging is essential for optimal care of this lethal malignancy. The cost-effectiviness of treatment is increasingly important. We measured oxidative metabolism in the distal and proximal esophagus by myeloperoxidase activity (MPA), glutathione content (GSH), and superoxide dismutase (SOD) in 20 patients operated on with Nissen fundoplication and 9 controls during a 4-year follow-up. Further, we assessed the oxidative damage of DNA by 8-hydroxydeoxyguanosine (8-OHdG) in esophageal samples of subjects (13 Barrett s metaplasia, 6 Barrett s esophagus with high-grade dysplasia, 18 adenocarcinoma of the distal esophagus/GEJ, and 14 normal controls). We estimated the accuracy (42 patients) and preoperative prognostic value (55 patients) of PET compared with computed tomography (CT) and endoscopic ultrasound (EUS) in patients with adenocarcinoma of the esophagus/GEJ. Finally, we clarified the specialty-related costs and the utility of either radical (30 patients) or palliative (23 patients) treatment of esophageal/GEJ carcinoma by the 15 D health-related quality-of-life (HRQoL) questionnaire and the survival rate. The cost-utility of radical treatment of esophageal/GEJ carcinoma was investigated using a decision tree analysis model comparing radical, palliative, and hypothetical new treatment. We found elevated oxidative stress ( measured by MPA) and decreased antioxidant defense (measured by GSH) after antireflux surgery. This indicates that antireflux surgery is not a perfect solution for oxidative stress of the esophageal mucosa. Elevated oxidative stress in turn may partly explain why adenocarcinoma of the distal esophagus is found even after successful fundoplication. In GERD patients, proximal esophageal mucosal anti-oxidative defense seems to be defective before and even years after successful antireflux surgery. In addition, antireflux surgery apparently does not change the level of oxidative stress in the proximal esophagus, suggesting that defective mucosal anti-oxidative capacity plays a role in development of oxidative damage to the esophageal mucosa in GERD. In the malignant transformation of Barrett s esophagus an important component appears to be oxidative stress. DNA damage may be mediated by 8-OHdG, which we found to be increased in Barrett s epithelium and in high-grade dysplasia as well as in adenocarcinoma of the esophagus/GEJ compared with controls. The entire esophagus of Barrett s patients suffers from increased oxidative stress ( measured by 8-OhdG). PET is a useful tool in the staging and prognostication of adenocarcinoma of the esophagus/GEJ detecting organ metastases better than CT, although its accuracy in staging of paratumoral and distant lymph nodes is limited. Radical surgery for esophageal/GEJ carcinoma provides the greatest benefit in terms of survival, and its cost-utility appears to be the best of currently available treatments.Ruokatorven ja mahansuun rauhassyöpä on nopeasti lisääntyvä huonoennusteinen sairaus, jonka syntymekanismi on liitetty oksidatiiviseen stressiin. Taudin tarkka kliininen levinneisyysluokitus on tärkeää hoidon onnistumiseksi. Hoidon paras mahdollinen kustannustehokkuus on entistä tärkeämpää. Ensimmäisessä ja toisessa osatyössä määritimme ruokatorven oksidatiivista metaboliaa ruokatorven ylä- ja alapäästä otetuista näytteistä. Oksidativiivisen metabolian merkkiaineina toimivat kudoksen myeloperoksidaasi-entsyymin ja superoksidi-entsyymin aktiivisuus sekä glutathioni-pitoisuus. Ensimmäiset näytteet otettiin ennen fundoplikaatioleikkausta ja potilaita seurattiin aina 4 vuoteen asti. Kolmannessa osatyössä analysoimme 51 potilaan ruokatorven kudosnäytteistä oksidatiivisen stressin aiheuttamaa DNA muutosta, 8-hydroksideoksiguanosiinia (8-OHdG). Neljännessä ja viidennessä osatyössä tarkastelimme ensin 42 potilaan ennen leikkaushoitoa tehtyä kliinistä levinneisyysluokitusta verrattuna leikkauksen jälkeen tiedossa olevaan patologiseen luokitukseen. Jatkoimme edelleen potilaskeräystä aina 55 potilaaseen saakka ja tälle joukolle teimme analyysin positroniemissiotomografian hyödyllisyydestä ennusteen laatimiseen. Kuudennessa osatyössä selvitimme ruokatorven syövän kustannuksia ja sen hoitoon liittyvää elämänlaatua hoidon eri vaiheissa 53:lla potilaalla. Laadimme kustannustehokkuusanalyysin näistä tiedoista. Tutkimuksemme löydökset ja johtopäätökset olivat seuraavat: 1) refluksinesto kirurgia ei pysty normalisoimaan oksidatiivisen stressin vaurioittamaa limakalvoa ja näin ollen syövän kehittyminen on edelleen mahdollista vialliselle limakalvolle huolimatta toimivasta fundoplikaatiosta 2) koko ruokatorven limakalvon antioksidatiivinen puolustusmekanismi vaikuttaa olevan puutteellinen, näinollen uusia tutkimuksia tarvitaan - voisiko ruokatorven antioksidatiivista puolustusta auttaa refluksitaudista kärsivillä esim. uusilla lääkeaineilla? 3) oksidatiiviseen stressiin liittyvä DNA muutos (8-OHdG) näyttää olevan mukana ruokatorven rauhassyövän kehittymisessä, siten todetut oksidatiiviset DNA muutokset ruokatorven rauhaskarsinooman synnyssä kannustavat jatkamaan uusissa tutkimuksissa syövän syntymekanismin selvittämistä tältä suunnalta 4) PET parantaa muihin elimiin levinneen ruokatorven rauhassyövän toteamista ja näin ollen helpottaa huonon ennusteen potilaiden tunnistamista. Täten PET puoltaa paikkaansa ruokatorven rauhassyövän kliinisessä luokittelussa ja ennusteen tunnistamisessa erityisesti huonon ennusteen potilailla. Tämä auttaa resurssien järkevässä suuntaamisessa. 5) kirurginen, parantamiseen tähtäävä hoito on kustannustehokkain vaihtoehto oikein valituille ruokatorven rauhassyöpäpotilaille. Näin ollen ruokatorven rauhasyövän parantamiseen tähtäävä kirurginen hoito on kannattavaa sekä elämänlaatua parantavana että myös kustannustehokkaana hoitomuotona oikein valituille potilaille

Työkyky kuntoon -hankkeen kuntoutustoiminnan vaikutusten arviointi

Etelä-Karjalan alueella vuosina 2007 - 2009 toteutetussa Työkyky kuntoon-hankkeessa pitkäaikaistyöttömien työkykyyn pyrittiin vaikuttamaan erilaisten kuntoutustoimien avulla. Hanke oli suunnattu 1970-luvulla syntyneille pitkäai-kaistyöttömille. Tämä opinnäytetyö sisältää Työkyky kuntoon -hankkeen kuntoutustoiminnan vaikutusten arviointitutkimuksen. Arviointitutkimus on toteutettu kyselytutkimuksena, jossa asiakkaat täyttivät alku- ja loppukyselyn. Tutkimuksessa käytettiin kyselylomaketta pitkäaikaistyöttömien työkyvyn seurantaan. Kyselylomake oli käytössä ensimmäistä kertaa pitkäaikaistyöttömien tutkimisessa. Opinnäytetyön teoriaosiossa perehdytään arviointitutkimuksessa käytettyihin käsitteisiin. Opinnäytetyön toinen osio on arviointitutkimuksen vaikutusten arviointiraportti, joka on toimitettu vaikutusten arviointiraportin tilaajalle eli Etelä-Karjalan työvoiman palvelukeskukselle. Opinnäytetyön loppuosassa on koko opinnäytetyötä koskevaa pohdintaa. Työkyky kuntoon -hankeen käynnistysvaiheessa kohderyhmään kuului 250 asiakasta. Tavoitteena oli saada hankkeeseen osallistujia noin 75. Arviointitut-kimukseen saatiin 19 hankkeeseen osallistujaa, jotka vastasivat sekä alku- että loppukyselyyn. Arviointitutkimuksen perusteella tämän hankkeen kuntoutustoiminnan vaikutukset eivät olleet tilastollisesti merkitseviä. Tutkimuksen mukaan 68% osallistuneista arveli olevansa työkykyisiä kahden vuoden kuluttua. Hankkeen tulosten yleistettävyys ei tässä tutkimuksessa ole korkea, koska kyselyyn vastaamis- ja osallistumisaktiivisuus oli vähäistä. Suurimpana ongelmana vaikutusten arviointitutkimuksessa oli se, että hankkeeseen osallistujat eivät osallistuneet heille suunniteltuihin toimintoihin. Tutkimuksen kohderyhmä on hankalasti aktivoitavissa, ja jos aktiivisuustaso ei ole korkea, ei voida olettaa saavutettavan positiivisia tuloksia. Tulevaisuudessa pitkäaikaistyöttömille suunnattujen hankkeiden haasteena on saada aktivoitua osallistujat heille suunniteltuihin ohjelmiin. Se kuinka tämä jatkossa toteutetaan ihmisiä kunnioittaen ja taloudellisesti kannattavasti, on hankkeita suunnittelevien otettava huomioon.During the years from 2007-2009 in South Karelia a project was conducted for unemployed people born in the 1970`s. The project concentrated in rehabilita-tion for work. This thesis was done to evaluate the rehabilitation process of the project partic-ipants. The participants responded to a questionnaire at the beginning and at the end of the project. The questionnaire used had been designed for unem-ployed people and was now used for the very first time. The first part of the thesis, the theory, describes the essential concepts of eval-uation. The second part includes an evaluation of the rehabilitation process, and third part includes conclusion of the thesis. There were 250 unemployed persons in South Karelia born in the 1970`s. The project aimed to get 75 participants. However, only 19 participants responded to both questionnaires. Therefore this thesis could not draw any statistical conclusions. Thirteen out of 19 the participants thought they would be able to work after two years. The biggest problem concerning this evaluation was that participants did not take part in the programme as expected. Some unemployed persons might be short of social ability to participate in group work. The project included many groups including a physical exercise group and Nordic walking group. It is clear, that without exercise there will be no positive results. In the future it would be challenging to find such groups that would better motivate people to prticipate

CISE as a Tool for Sharing Sensitive Cyber Information in Maritime Domain

The ECHO project aims at organizing and coordinating an approach to strengthen proactive cyber security in the European Union through effective and efficient multi-sector collaboration. One important tool for this aim is the ECHO Early Warning System (E-EWS). The development of the E-EWS will be rooted in a comprehensive review of information sharing and trust models from within the cyber domain, as well as models from other domains. In 2009, the Commission adopted a Communication Towards the integration of maritime surveillance in the EU: “A common information sharing environment for the EU maritime domain (CISE),” setting out guiding principles towards its establishment. The aim of the COM(2010)584 final was to generate a situational awareness of activities at sea and impact overall maritime safety and security. As a outcome of COM(2010)584 final, the EUCISE2020 project has developed a test-bed for maritime information sharing. This case study analyses information sharing models in the maritime domain, the EUCISE2020 test bed and the CISE itself as an alternative for cyber information sharing system. The maritime sector represents a suitable research case because it is already digitized in many aspects

The iPSC perspective on schizophrenia

Over a decade of schizophrenia research using human induced pluripotent stem cell (iPSC)-derived neural models has provided substantial data describing neurobiological characteristics of the disorder in vitro. Simultaneously, translation of the results into general mechanistic concepts underlying schizophrenia pathophysiology has been trailing behind. Given that modeling brain function using cell cultures is challenging, the gap between the in vitro models and schizophrenia as a clinical disorder has remained wide. In this review, we highlight reproducible findings and emerging trends in recent schizophrenia-related iPSC studies. We illuminate the relevance of the results in the context of human brain development, with a focus on processes coinciding with critical developmental periods for schizophrenia.Peer reviewe

Tracheal and laryngotracheal resections and reconstructions-a single-centre experience

Background: Surgical resection has proven to be the most effective long-term treatment in managing airway stenoses and has shown to decrease the risk of tumor recurrence and mortality in patients with tumor infiltration to the airways. However, there are only a few Nordic reports on the results of a tracheal resection (TR) and cricotracheal resection (CTR). This study aimed to evaluate the volume and short-term outcome of TR and CTR at our institution. Methods: Retrospective review of patients who underwent TR or CTR between 2004 and 2019 at the Results: Forty-four patients were included, of which 21 (47.7%) underwent surgery for a tumor, whereas 23 (52.3%) were operated for a benign stenosis. The most common tumor type was thyroid carcinoma with tracheal invasion (15.9%). The distance between the upper margin of the stenosis or tumor infiltration and the vocal cords was in median 3 [interquartile range (IQR), 2???5] cm and the median length of resection 2.5 (IQR, 2???3.5) cm. Overall success rate was 75% (no need for reoperation or postoperative intervention). Complications occurred in 20 (45.5%) patients, of which 10 patients were operated for a tumor, and 10 for a benign stenosis. Conclusions: Tracheal and CTRs were effective in treating tracheal and subglottic stenoses with variable etiology. However, complications were common especially following cricotracheal tumor resections. These procedures show a clear need for further centralization due to their complex nature and should therefore be performed primarily at institutes with highly experienced multi-professional teams.Peer reviewe

Cognitive–Linguistic and Constructivist Mnemonic Triggers in Teaching Based on Jerome Bruner’s Thinking

Effective teachers use mnemonic tools or mnemonic triggers to improve the students’ retention of the study material. This article discusses mnemonic triggers from a theoretical viewpoint based on Jerome S. Bruner’s writings. Fifty small linguistic–cognitive, constructive-, rhetorical-, and phonological–mnemonic triggers are detected. These triggers may become supporting elements for our memory system when we are “constructing the realities” in a Brunerian sense when we are ordering, differentiating, comparing, and handling information, stories and experiences in our mind. Many of these are small, hidden linguistic elements in speech. This article discusses their usage in the educational talk and textbooks

Loss of skeletal muscle mass during neoadjuvant treatments correlates with worse prognosis in esophageal cancer : a retrospective cohort study

Background: Nutritional deficits, cachexia, and sarcopenia are extremely common in esophageal cancer. The aim of this article was to assess the effect of loss of skeletal muscle mass during neoadjuvant treatment on the prognosis of esophageal cancer patients. Methods: Esophageal cancer patients (N = 115) undergoing neoadjuvant therapy and surgery between 2010 and 2014 were identified from our surgery database and retrospectively analyzed. Computed tomography imaging of the total cross-sectional muscle tissue measured at the third lumbar level defined the skeletal muscle index, which defined sarcopenia (SMI <52.4 cm2/m2 for men and <38.5 cm2/m2 for women). Images were collected before and after neoadjuvant treatments. Results: Sarcopenia in preoperative imaging was prevalent in 92 patients (80%). Median overall survival was 900 days (interquartile range 334-1447) with no difference between sarcopenic (median = 900) and non-sarcopenic (median = 914) groups (p = 0.872). Complication rates did not differ (26.1% vs 32.6%, p = 0.725). A 2.98% decrease in skeletal muscle index during neoadjuvant treatment correlated with poor 2-year survival (log-rank p = 0.04). Conclusion: Loss of skeletal muscle tissue during neoadjuvant treatment correlates with worse overall survival.Peer reviewe

Research letter : Oncological treatment reported by the Finnish Cancer Registry compared to given neoadjuvant treatment in patients undergoing esophagectomy for cancer-A nationwide study

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