Hormonaalisesti aktiivisen lisämunuaiskasvaimen diagnostiikka ja perioperatiivinen hoito

Lisämunuaiskasvaimen poistoa harkitaan, jos se erittää hormoneja tai sen hyvänlaatuista luonnetta ei pystytä kuvantamalla varmistamaan. Yleensä leikataan myös yli 4 cm:n kokoiset kasvaimet. Hormonaalisesti aktiiviset lisämunuaiskasvaimet voivat erittää adrenaliinia, noradrenaliinia, kortisolia tai aldosteronia. Primaarinen lisämunuaisen kuorikerroksen adrenokortikaalinen karsinooma voi erittää kortisolia tai aldosteronia sekä harvinaisissa tapauksissa myös androgeeneja ja estrogeeneja. Hormonaalisesti aktiivisten lisämunuaiskasvainten leikkaushoitoon liittyy lisääntynyt kirurgisten komplikaatioiden vaara hormonierityksen aiheuttamien hemodynaamisten muutosten ja liitännäissairauksien vuoksi. Lisämunuaiskasvainten huolellinen leikkausta edeltävä selvittely, hormonierityksen vaikutusten hallinta, anestesian aikainen seuranta ja hoito sekä siirtyminen laparo- tai retroperitoneoskooppisiin leikkausmenetelmiin vähentää perioperatiivisia komplikaatioita. Hormonaalisesti aktiivisten lisämunuaiskasvainten leikkaamisesta päätetään moniammatillisessa kokouksessa, ja leikkaukset tekee perioperatiiviseen hoitoon perehtynyt tiimi. Hoidon laatua tulee seurata ja raportoida.publishedVersionPeer reviewe

Genetic testing for familial hypercholesterolemia in a Finnish cohort of patients with premature coronary artery disease and elevated LDL-C levels

BackgroundBased on Finnish LDLR-founder variations, the prevalence of familial hypercholesterolemia (FH) in Finland is estimated to be at least 1:600. Patients with FH have increased risk of premature coronary artery disease (CAD) and thus the prevalence of FH is expected to be higher in this subgroup.ObjectiveTo assess the prevalence of monogenic FH in a Finnish cohort of patients with premature CAD and elevated low-density lipoprotein cholesterol (LDL-C) levels.MethodsAmong 28,295 patients undergoing angiography at Heart Hospital at Tampere University Hospital between 2007 and 2017, we identified 162 patients diagnosed with premature CAD (men aged <55 years and women aged <60 years) and history of high LDL-C (≥5 mmol/L) levels without secondary causes of hypercholesterolemia. Clinical probability of FH was estimated, and genetic testing of FH was carried out in 80 patients with informed consent.ResultsOf the 80 patients with premature CAD and history of high LDL-C levels, 70% were men; the age at diagnosis of CAD for male and female patients was 48 and 53 years, respectively. In total, 58 (73%) patients had probable (n = 54) or definite (n = 4) FH based on Dutch Lipid Clinic Network criteria. A pathogenic variant of FH was found in five (6%) patients. Prevalence of the genetically verified FH was 1:16. The FH variant was found in 75% of patients with definite FH.ConclusionsThe prevalence of genetically verified FH was 1:16 among patients with premature CAD and elevated LDL-C level, which is 38 times higher than the estimated prevalence of 1:600 in the general Finnish population

Clinical characteristics and outcomes of patients operated for primary hyperparathyroidism at Tampere University Hospital in 2017–2018

Background and objective: Studies on the outcomes of parathyroid surgery are scarce. The aim was to report the outcomes and to study the association between pre- and peri-operative information with the outcomes of patients operated for primary hyperparathyroidism. Methods: This was a retrospective, descriptive study with unselected patients treated surgically for primary hyperparathyroidism from a catchment population of 704,500 in Finland. Data were acquired from the electronic hospital registers based on parathyroid surgery procedure codes between 1 January 2017 and 31 December 2018. Preoperative data, surgical data, preoperative and postoperative laboratory values, histopathological findings, and postoperative clinical data were recorded. Results: During the 2-year study period, 149 patients with primary hyperparathyroidism were treated surgically with a 97% remission rate. Surgical complications included postoperative bleeding in two patients (1%) and vocal cord paralysis in one patient (0.6%). No postoperative infections were reported. Three patients (2%) developed postoperative hypoparathyroidism necessitating the use of alfacalcidol more than 1 month after surgery. Ionized calcium measured 0–1 days after surgery was not statistically significantly associated with remission or postoperative hypoparathyroidism. Serum parathyroid hormone (PTH) assessed 0–1 days postoperatively was associated with persistent disease, but not with postoperative hypoparathyroidism. The histopathological diagnosis was adenoma or hyperplasia in 112 patients (75%), atypical adenoma in 28 patients (19%), and carcinoma in five patients (3%). Patients with parathyroid carcinoma had higher preoperative ionized calcium and PTH values than those with adenoma or hyperplasia. Conclusions: Most patients who were operated due to primary hyperparathyroidism achieved normocalcemia after surgery, and the frequency of complications was low. Ionized calcium taken 0–1 days after surgery was not associated with remission of hyperparathyroidism or postoperative hypoparathyroidism. High postoperative serum PTH predicted persistent disease.Peer reviewe

Glycaemic control in insulin deficient patients using different insulin delivery and glucose sensoring devices : Cross-sectional real-life study

Aims: To assess glycaemic control in ≥15-year-old patients with type 1 diabetes treated in Tampere University Hospital in a real-life cross-sectional registry study. Methods: Glycaemic control was assessed with HbA1c, time in range (TIR) and the incidence of acute complications. The effect of age, BMI, gender, duration of diabetes, daily insulin dose, and device group on the glycaemic control was studied. Results: The study included 1,132 patients. Eighty-four percent of the patients had TIR≤70%. Two percent of patients had an episode of diabetic ketoacidosis and 0,2% had severe hypoglycemia within the last 12 months. Intermittently scanned CGM (IsCGM) with MDI was used in 59%, continuous subcutaneous insulin infusion (CSII) with glucose sensor in 15%, and sensor-augmented/hybrid closed-loop pump (SAP/HCL) in 9% of the patients. In the logistic regression analysis, TIR≤70% was associated with young age group (OR 2.70; 95% CI 1.43–5.09) and daily insulin dose per weight (OR 6.66; 95% CI 3.53–12.57). CSII with glucose sensor and IsCGM with MDI were associated with poor glycaemic control compared to SAP/HCL. Conclusion: There is room for improvement in the glycaemic control in our area although serious acute complications are rare. Closed insulin pump system was more effective than open system.Peer reviewe

Thyroid function test variability and cardiovascular morbidity in hyperthyroidism

Objective: The variability of thyroid function tests (TFTs) during antithyroid drug (ATD) therapy and its association with adverse health outcomes have not been previously studied. The aim of this study was to evaluate the association of TFT variability and cardiovascular morbidity during ATD therapy. Design: Retrospective cohort study. Patients and Measurements: Hyperthyroid patients (n = 394) treated with ATD therapy at Tampere University Hospital between March 2016 and December 2018 were followed up for a median time of 1.5 years (interquartile range 0.8–2.0). The coefficients of variation (CVs) of the follow-up thyroid-stimulating hormone (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) measurements were determined. The associations of TFT variability and baseline clinical factors with cardiovascular disease (CVD) -associated hospital visits were assessed with logistic regression analyses. Results: In the multivariable analyses, age (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 1.03–1.09), male gender (OR: 2.33, 95% CI: 1.03–5.28) and fT4-CV (OR: 1.02, 95% CI: 1.01–1.04) were independent risk factors for cardiovascular morbidity, whereas baseline positive thyrotropin receptor antibodies (TRAbs) were associated with lower cardiovascular morbidity (OR: 0.29, 95% CI: 0.14–0.61). When the patients with baseline TRAb positivity were studied separately, fT4-CV was associated with cardiovascular morbidity (OR: 1.03, 95% CI: 1.00–1.05). Conclusions: During ATD therapy, fT4 variability is associated with an increased cardiovascular morbidity. Although positive TRAbs are associated with a lower cardiovascular morbidity compared with hyperthyroidism with negative autoantibodies, the variability of fT4 is associated with cardiovascular morbidity also in patients with positive TRAbs.Peer reviewe

Gorham–Stout disease with life-threatening pleural effusion treated with a pleuro-peritoneal shunt : a case report

Gorham–Stout disease (GSD) is a rare bone disease characterized by massive osteolysis and lymphatic proliferation. The origin of the condition is unknown, and no established treatment protocol exists. Massive pleural effusion is a frequent complication of GSD in the thoracic region. We present the case of a 23-year-old male with thoracic GSD, subsequent paraparesis, and life-threatening pleural effusion. The patient was managed by a multidisciplinary team with a good recovery. The pleural effusion was successfully treated with a pleuro-peritoneal shunt. This is the first report of the use of this mini-invasive technique in the management of pleural effusion related to GSD. Further, we present the potential role of interleukin-6 and bone resorption markers in the measurement of the disease activity.publishedVersionPeer reviewe

Insulinoomat Tampereen yliopistollisen sairaalan erityisvastuualueella 1980-2010

METHODS: Retrospective analysis of insulinomas diagnosed in Tampere University Hospital. RESULTS: We found 23 iNET cases corresponding to an incidence of 0.7/million/year. All had neuroglycopenic symptoms and 83% had autonomic ones. The median diagnostic delay (from first symptoms up to diagnosis) was 25 months. Preoperative imaging found the tumor in 87%. Twenty-one out of 22 patients who underwent surgery recovered completely. CONCLUSIONS: Despite improved imaging the diagnostic delay of iNETs remained unchanged. Hypoglycemia and insulinoma should be considered as a cause of unspecific, symptomatic attacks

Stress hormone response to instrumented elective lumbar spine fusion surgery

Purpose: To understand the systemic effect of major spine surgery, we investigated stress, anabolic and catabolic hormonal levels and their association with interleukin 6 (IL-6) in patients undergoing elective lumbar spine fusion surgery. Methods: Blood samples were collected preoperatively, and at 1, 3, 42, 90 days postoperatively (POD) from 49 patients who underwent elective lumbar spine fusion surgery. Results: Serum concentration of cortisol was below the preoperative value at POD 1 but did not differ from the baseline values thereafter. Adrenocorticotropic hormone (ACTH) decreased at PODs 1 and 3. Testosterone decreased at PODs 1 and 3 in men, and at POD 3 in women. Sex hormone-binding globulin decreased at PODs 1 and 3 in both genders. No changes were observed in free testosterone or growth hormone concentrations. Insulin-like growth factor 1 increased significantly above the preoperative level at PODs 42 and 90 in women, and at POD 42 in men. IL-6 was significantly elevated at PODs 1 and 3. Increases in IL-6 from the preoperative level to POD 1 correlated significantly with decreases of cortisol at POD 1 but not with ACTH. Conclusions: There were only short-term stress hormonal changes after elective lumbar spine fusion surgery. Cortisol changes after elective lumbar spine surgery are transient and might be partly cytokine induced and non-ACTH driven since there was association between cortisol and IL-6 but not with ACTH and IL-6.Peer reviewe