Treatment of Ewing Sarcoma, Paediatric Bone Sarcomas and Severe Paediatric Spinal Deformities in Finland

Background: Ewing sarcomas are rare highly malignant tumours. There are not many population-based studies including both bone and soft tissue tumours. Previous reports have suggested that the incidence of Ewing sarcoma in the paediatric population may be lower in Northern Europe compared to other parts of Europe. Ewing sarcomas frequently arise in the pelvis and other axial sites and rarely in the spine. Surgical techniques of vertebral column resection to treat spinal tumours or severe spinal deformities have evolved with techniques using only a posterior approach. Aims: Our aim was to find out how the treatment of Ewing sarcoma is carried out in Finland and what are the five-year survival rates and to reveal the surgical treatment and its complications. We also aimed at establishing the incidence rates of bone sarcomas in the paediatric and adolescent population in Finland and to establish the ten-year survival rates. Additionally, we aimed to report the results of a population-based material on paediatric vertebral column resection. Material and methods: We identified all Finnish patients with Ewing sarcoma diagnosed during 1990-2009, all paediatric bone sarcoma patients diagnosed during 1991-2005 and all paediatric patients who underwent vertebral column resection during 2005-2009. The medical records were reviewed for detailed information and these data were analysed. The study is retrospective, nationwide and population-based. Results: Seventy-six Ewing sarcoma patients were included in the final analyses. The five-year sarcoma-specific survival rates were 70% for those with localized and 33% for those with metastatic disease (p=0.001). Fifty-seven patients underwent surgical treatment of the primary tumour. The annual incidence rates of osteosarcoma, Ewing sarcoma and chondrosarcoma per million 0-18-year-old people in Finland during 1991-2005 were 3.6, 1.2 and 0.3, respectively. The ten-year overall survival was 74% for osteosarcoma, 76% for Ewing sarcoma and 80% for chondrosarcoma. Fourteen paediatric patients underwent vertebral column resection during 2005-2009. There were no differences between those operated via posterior-only approach (n=7) compared to those operated via antero-posterior approach (n=7) in the mean final radiological corrections or the quality-of-life results. Conclusions: We conclude that the outcomes of treatment of Ewing sarcoma and paediatric bone sarcomas in Finland are comparable to previously reported outcomes. The incidence of Ewing sarcoma in Finland seems to be a bit lower than reported elsewhere in Europe. Posterior-only approach in paediatric vertebral column resections carry comparable results to anteroposterior approach.Tausta: Ewingin sarkooma on harvinainen pahanlaatuinen kasvain. Sekä luun että pehmytkudoksen kasvaimia käsitteleviä, väestöön pohjautuvia tutkimuksia on julkaistu vain vähän. Aiemmat tutkimukset ovat viitanneet siihen, että Ewingin sarkooma olisi Pohjois-Euroopassa harvinaisempi kuin muissa osissa Eurooppaa. Ewingin sarkooma voi harvoin sijaita myös selkärangassa. Kirurgiset tekniikat rangan kasvainten ja vaikeiden epämuodostumien hoidossa ovat kehittyneet ja nykyisin leikkauksia voidaan tehdä yhtä selän puoleista avausta käyttäen. Tavoitteet: Tavoitteemme oli selvittää miten Ewingin sarkooman hoito, erityisesti kirurginen hoito, on Suomessa on toteutunut ja mitkä ovat potilaiden viiden vuoden elossaololuvut. Halusimme myös selvittää lasten ja nuorten luusarkoomien ilmaantuvuusluvut ja 10 vuoden elossaololuvut. Lisäksi tavoitteenamme selvittää lasten nikamanpoistojen tulokset Suomessa. Aineisto ja menetelmät: Tunnistimme kaikki potilaat, joilla oli diagnosoitu Suomessa vuosina Ewingin sarkooma 1990-2009 ja kaikki alle 18-vuotiaat, joilla oli diagnosoitu luusarkooma vuosina 1991-2005 ja kaikki alle 18-vuotiaat, joille oli 2005-2009 tehty nikamanpoistoleikkaus. Sairaskertomukset käytiin läpi yksityiskohtaisten tietojen saamiseksi ja kerätyt aineistot analysoitiin. Tutkimus on malliltaan takautuva, valtakunnallinen ja väestöön pohjautuva. Tulokset: Lopullisiin analyyseihin otettiin mukaan 76 Ewingin sarkooma sairastanutta potilasta. Viiden vuoden elossaololuvut olivat 70% paikallista tautia sairastaneilla ja 33% levinnyttä tautia sairastaneilla (p=0.001). Potilaista 57:llä primaarikasvain hoidettiin kirurgisesti. Osteosarkooman, Ewingin sarkooman ja kondrosarkooman vuosittaiset ilmaantuvuusluvut miljoonaa alle 18-vuotiasta kohden olivat 3.6, 1.2 ja 0.3. 10 vuoden elossaololuvut olivat vastaavasti 74%, 76% ja 80%. Suomessa tehtiin 2005-2009 nikamanpoistoleikkaus 14:lle alle 18-vuotiaalle potilaalle. Verrattaessa sekä selän- että etupuolelta suoritettuja toimenpiteitä (n=7) niihin, jotka suoritettiin pelkästä selän puoleisesta viillosta (n=7), eroja ei ollut radiologisen virheasennon korjautumisen tai elämänlaatua mittaavien kyselytulosten suhteen. Yhteenveto: Tutkimuksen perusteella voidaan todeta, että Ewingin sarkooman ja lasten luusarkoomien hoito Suomessa on tuloksiltaan hyvää kansainvälistä tasoa. Ewingin sarkooman ilmaantuvuus Suomessa alle 18-vuotiailla näyttäisi hieman pienemmältä kuin mitä muualla Euroopassa on raportoitu. Pelkästä selän puoleisesta viillosta suoritettujen nikamanpoistojen tulokset ovat hyvät, eivätkä eroa sekä selän- että etupuolelta tehtyjen toimenpiteiden tuloksista

Erikoistumiskoulutuksella asiantuntijaksi

Ammattikorkeakoulujen erikoistumiskoulutuksen tavoitteena on opiskelijan asiantuntijuuden kehittyminen siten, että hän kykenee toimimaan vaativissa asiantuntijatehtävissä määritellyllä työelämän osa-alueella. Asiantuntijuus sisältää erityisosaamista tai monialaisen kokonaisuuden hallintaa. Lisäksi erikoistumiskoulutuksen tavoitteena on, että opiskelija arvioi ja kehittää erityisalansa ammatillisia käytäntöjä ja toimii yhteisöissä ja -verkostoissa oman erityisalansa asiantuntijana. Asiantuntijuus on kontekstisidonnaista ja asiantuntijuusosaaminen teoreettis-käsitteellisestä, käytännöllis-kokemuksellisesta ja itsesäätelyä sekä toiminnan säätelyä koskevasta osaamisesta, jotka yhdistyvät keskenään

Efficacy of the implementation of the National Emergency X-Radiography Utilization Study II decision rule to clinical practice for paediatric head injury patients

Aim To investigate the usefulness of the National Emergency X-Radiography Utilization Study (NEXUS) II head trauma decision rule in clinical practice for paediatric patients in a tertiary university hospital serving as the only paediatric hospital in the area. Methods We compared how doctors evaluated and examined patients with head injury during two time periods, before and after the introduction of NEXUS II decision rule. Multiple implementation strategies were used as follows: education, tutoring and written instructions for the use of NEXUS II. Results Two hundred and forty-four head injury patients visited the hospital before and 385 after the introduction of the NEXUS II decision rule. The number of hospital admissions (56%) and the mean duration of hospitalisation (2.5 days) remained the same during the two periods. In the NEXUS II evaluated group, there was a decrease of 40% in the number of hospital admissions. NEXUS II was applied in only 62 (16%) cases. The number of head imaging procedures remained the same. No patients with a clinically significant head injury were missed with the NEXUS II evaluation. Conclusion NEXUS II was ineffective as our implementation failed. When used, NEXUS II reduced expenses in our study population by decreasing the number of hospital admissions.Peer reviewe

Main Clinical Use of Additive Manufacturing (Three-Dimensional Printing) in Finland Restricted to the Head and Neck Area in 2016-2017

Background and Aims: Additive manufacturing or three-dimensional printing is a novel production methodology for producing patient-specific models, medical aids, tools, and implants. However, the clinical impact of this technology is unknown. In this study, we sought to characterize the clinical adoption of medical additive manufacturing in Finland in 2016-2017. We focused on non-dental usage at university hospitals. Materials and Methods: A questionnaire containing five questions was sent by email to all operative, radiologic, and oncologic departments of all university hospitals in Finland. Respondents who reported extensive use of medical additive manufacturing were contacted with additional, personalized questions. Results: Of the 115 questionnaires sent, 58 received answers. Of the responders, 41% identified as non-users, including all general/gastrointestinal (GI) and vascular surgeons, urologists, and gynecologists; 23% identified as experimenters or previous users; and 36% identified as heavy users. Usage was concentrated around the head area by various specialties (neurosurgical, craniomaxillofacial, ear, nose and throat diseases (ENT), plastic surgery). Applications included repair of cranial vault defects and malformations, surgical oncology, trauma, and cleft palate reconstruction. Some routine usage was also reported in orthopedics. In addition to these patient-specific uses, we identified several off-the-shelf medical components that were produced by additive manufacturing, while some important patient-specific components were produced by traditional methodologies such as milling. Conclusion: During 2016-2017, medical additive manufacturing in Finland was routinely used at university hospitals for several applications in the head area. Outside of this area, usage was much less common. Future research should include all patient-specific products created by a computer-aided design/manufacture workflow from imaging data, instead of concentrating on the production methodology.Peer reviewe

Randomized Controlled Trial of the Clinical Recovery and Biodegradation of Polylactide-co-glycolide Implants Used in the Intramedullary Nailing of Children's Forearm Shaft Fractures with at Least Four Years of Follow-Up

The preferred surgical fixation of forearm shaft fractures in children is Elastic Stable Intramedullary Nailing (ESIN). Due to known disadvantageous effects of metal implants, a new surgical method using biodegradable polylactide-co-glycolide (PLGA) intramedullary nails has been developed but its long-term outcomes are unclear. The aim of this study was to compare the long-term outcomes of Biodegradable Intramedullary Nailing (BIN) to ESIN and assess the biodegradation of the study implants via magnetic resonance imaging (MRI). The study population of the prospective, randomized trial consisted of paediatric patients whose forearm shaft fractures were treated with BIN (n = 19) or ESIN (n = 16). Forearm rotation at minimally four years' follow-up was the main outcome. There was no clinically significant difference in the recovery of the patients treated with the BIN as compared to those treated with the ESIN. More than half of the implants (57.7%, n = 15/26) were completely degraded, and the rest were degraded almost completely. The PLGA intramedullary nails used in the treatment of forearm shaft fractures in this study resulted in good function and anatomy. No unexpected disadvantages were found in the degradation of the implants. However, two implant failures had occurred in three months postoperatively.Peer reviewe

Randomized Controlled Trial of the Clinical Recovery and Biodegradation of Polylactide-co-glycolide Implants Used in the Intramedullary Nailing of Children's Forearm Shaft Fractures with at Least Four Years of Follow-Up

The preferred surgical fixation of forearm shaft fractures in children is Elastic Stable Intramedullary Nailing (ESIN). Due to known disadvantageous effects of metal implants, a new surgical method using biodegradable polylactide-co-glycolide (PLGA) intramedullary nails has been developed but its long-term outcomes are unclear. The aim of this study was to compare the long-term outcomes of Biodegradable Intramedullary Nailing (BIN) to ESIN and assess the biodegradation of the study implants via magnetic resonance imaging (MRI). The study population of the prospective, randomized trial consisted of paediatric patients whose forearm shaft fractures were treated with BIN (n = 19) or ESIN (n = 16). Forearm rotation at minimally four years' follow-up was the main outcome. There was no clinically significant difference in the recovery of the patients treated with the BIN as compared to those treated with the ESIN. More than half of the implants (57.7%, n = 15/26) were completely degraded, and the rest were degraded almost completely. The PLGA intramedullary nails used in the treatment of forearm shaft fractures in this study resulted in good function and anatomy. No unexpected disadvantages were found in the degradation of the implants. However, two implant failures had occurred in three months postoperatively.Peer reviewe

Non-interventional follow-up versus fluid bolus in RESPONSE to oliguria in hemodynamically stable critically ill patients : a randomized controlled pilot trial

Peer reviewe

Cranioplasty After Severe Traumatic Brain Injury: Effects of Trauma and Patient Recovery on Cranioplasty Outcome

Background: In patients with severe traumatic brain injury (sTBI) treated with decompressive craniectomy (DC), factors affecting the success of later cranioplasty are poorly known.Objective: We sought to investigate if injury- and treatment-related factors, and state of recovery could predict the risk of major complications in cranioplasty requiring implant removal, and how these complications affect the outcome.Methods: A retrospective cohort of 40 patients with DC following sTBI and subsequent cranioplasty was studied. Non-injury-related factors were compared with a reference population of 115 patients with DC due to other conditions.Results: Outcome assessed 1 day before cranioplasty did not predict major complications leading to implant removal. Successful cranioplasty was associated with better outcome, whereas a major complication attenuates patient recovery: in patients with favorable outcome assessed 1 year after cranioplasty, major complication rate was 7%, while in patients with unfavorable outcome the rate was 42% (p = 0.003). Of patients with traumatic subarachnoid hemorrhage (tSAH) on admission imaging 30% developed a major complication, while none of patients without tSAH had a major complication (p = 0.014). Other imaging findings, age, admission Glasgow Coma Scale, extracranial injuries, length of stay at intensive care unit, cranioplasty materials, and timing of cranioplasty were not associated with major complications.Conclusion: A successful cranioplasty after sTBI and DC predicts favorable outcome 1 year after cranioplasty, while stage of recovery before cranioplasty does not predict cranioplasty success or failure. tSAH on admission imaging is a major risk factor for a major complication leading to implant removal

Ewingin sarkooman diagnostiikka ja hoito

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