Päivystävän lääkärin kaikukuvausohjatut toimenpiteet : Askitesdreneeraus, pleurapunktio ja suprapuubisen katetrin asentaminen

Teema : päivystäjän kaikukuvaus. English summaryPeer reviewe

Screen-detected breast cancer and prognosis

The incidence of breast cancer has increased world-wide over recent decades. The survival rate of breast cancer patients has improved mainly due to innovative therapies and mammography screening programs. Despite improvements in survival, breast cancer is still the leading cause of cancer death among women. Breast cancers detected at screening mammography are, in general, smaller at the time of the diagnosis and less aggressive than cancers found by other methods, and are reported to be associated with generally favorable survival. It is, however, unclear whether this survival advantage can be explained by early detection and favorable tumor biology only, or whether other unknown factors might account for the survival advantage. The purpose of this study was to study the long-term prognosis and biological profiles of screen-detected breast cancers as compared to non-screen-detected cancers (FinProg database www.finprog.org). The generalizability and geographic transportability of breast cancer survival estimates were investigated by comparing the current study series, the FinProg database, with a large dataset from the United States, the SEER. Despite differences in demographic variables, use of adjuvant therapies and screening mammography between series, the prognostic factors produced close to overlapping survival curves. When commonly used prognostic factors, such as tumor size, nodal status and histological grade are evaluated, survival estimates were similar in these large unselected cohorts of breast cancer patients. The molecular subtypes associated with favorable survival rates were more frequent in screen-detected breast cancers than in non-screen-detected cancers. The differences in molecular subtypes between mammography screen-detected cancers and cancers found otherwise could not, however, explain all of the survival advantage associated with breast cancer detection at screening. Breast cancers detected by the mammography screening program had a significantly lower 10-year risk for distant recurrence than cancers of similar size diagnosed by other methods. Patients with screen-detected breast cancer had also significantly better breast cancer-specific survival compared with patients with non-screen-detected cancer. This advantage persisted over a 15-year follow-up period. There was no significant difference in the risk for contralateral breast cancer between these two groups. The biological factors investigated in the current study could not explain entirely the survival advantage associated with cancer detection at mammography screening, suggesting that there are other biological factors that may also explain the difference, which is in line with some previous studies. The risk for recurrence may be overestimated for women diagnosed by mammography screening unless the method of detection is taken into account in risk estimations, which may lead to overtreatment of patients with screen-detected breast cancer.Rintasyövän vuosittainen ilmaantuvuus on viimeisimpien vuosikymmenten aikana kasvanut maailmanlaajuisesti. Seulontamammografiaohjelma ja uudet hoitomuodot ovat parantaneet rintasyöpäpotilaan ennustetta. Kasvaimen biologisiin tekijöihin perustuvasta yksilöllisesti suunnitelluista hoidoista huolimatta yleisin naisten kuolemaan johtava syöpä on juuri rintasyöpä. Seulonnassa löydettyjen rintasyöpien epäillään ja on havaittukin - olevan muita hyväennusteisempiä ja vähemmän aggressiivisia. On epäselvää selittyykö tämä etu pelkästään kasvaimien biologisilla eroavaisuuksilla ja varhaisemmalla diagnosoimisella vai vaikuttaako diagnosointitapa vielä meille tuntemattomien tekijöiden välityksellä ennusteeseen. Toistaiseksi diagnosointitapa ei ole vakiinnuttanut paikkaansa yleisesti käytettynä ennustetekijänä. Tässä FinProg-tutkimuksen (www.finprog.org) osana tehdyssä seulonnan merkitystä itsenäisenä ennustetekijänä analysoivassa tutkimuksessa pyrittiin saamaan lisää tietoa seulonnassa löydettyjen rintasyöpien molekyylibiologiasta ja pitkäaikaisennusteesta verrattuna muulla tavoin todettuihin rintasyöpiin. Analysoimme lisäksi eloonjäämisennusteiden kansainvälistä yleistettävyyttä vertaamalla suomalaista aineistoa (FinProg) sitä vastaavaan amerikkalaiseen aineistoon (SEER). Aineistot todettiin eloonjäämiskäyrien suhteen yhteneviksi ja tämän perusteella yleisten ennustetekijöiden pohjalta tehdyt eloonjäämisarviot ovat yleistettävissä ja siirrettävissä laajoihin potilasmateriaaleihin maantieteellisesti riippumattomasti. Seulonnassa löydetyissä rintasyövissä esiintyi enemmän hyväennusteisempia molekulaarisia alatyyppejä kuin ei-seulonnassa löydetyissä. Kymmenen vuoden seurannassa seulonnassa löydetyt syövät olivat lähettäneet etäpesäkkeitä merkittävästi vähemmän kuin samankokoiset, muulla tavoin diagnosoidut rintasyövät. Seulonnan ennusteellinen hyöty säilyi myös pidemmällä, yli 15 vuoden, seuranta-ajalla eivätkä kasvaimien tunnetut biologiset eroavaisuudet selittäneet kokonaan seulonnan ennusteellista hyötyä. Rintasyövän sairastamisen jälkeinen toisen rinnan syövän riski ei eronnut näiden kahden diagnostisen ryhmän välillä. Diagnosointitavan huomiotta jättäminen ennustetekijänä uusiutumisriskin arvioinnissa ja hoitopäätösten teossa saattaa johtaa uusiutumisriskin yliarvioimiseen ja mahdollisesti jopa ylihoitamiseen niiden potilaiden osalta, joiden rintasyöpä on havaittu seulonnassa. Tietoa toteamistavasta (seulonta vs. ei-seulonta) voidaan käyttää ennusteellisena tekijänä yksilöllisten hoitopäätöksien tukena. Tämän tutkimuksen tuloksia voidaan soveltaa rintasyöpäpotilaisiin paitsi Suomessa myös kansainvälisesti

Anatomical pancreatic variants in intraductal papillary mucinous neoplasm patients : a cross-sectional study

Background No previous studies have examined the possible relationship between intraductal papillary mucinous neoplasm (IPMN) and the developmental ductal variations of the pancreas, such as an ansa pancreatica and a meandering main pancreatic duct (MMPD). Methods This retrospective cross-sectional study enrolled 214 patients, 108 with IPMN disease and 106 subjects from a community at the tertiary care unit. The main pancreatic duct (MPD) was evaluated in the head of the pancreas by its course, which were non-MMPD: descending, vertical, and sigmoid, or MMPD including loop types, reverse-Z subtypes, and an N-shape, which was identified for the first time in this study. IPMN patients were also evaluated for worrisome features (WF) or high-risk stigmata (HRS), and the extent of IPMN cysts. Results Among IPMN patients, 18.4% had MMPD, which we observed in only 3.0% of the control group (P < 0.001). Patients with MMPD were more likely to belong to the IPMN group compared with non-MMPD patients [odds ratio (OR) 6.4, 95% confidence interval (CI) 2.2-24.9]. Compared with a descending shape MPD, IPMN patients with an N-shaped MPD were more likely to have a cystic mural nodule (OR 5.9, 95% CI 1.02-36.0). The presence of ansa pancreatica associated with more extent IPMN disease (OR 12.8, 95% CI 2.6-127.7). Conclusions IPMN patients exhibited an MMPD more often than control patients. Ansa pancreatica associated with multiple cysts. Furthermore, an N-shape in IPMN patients associated with cystic mural nodules, suggesting that this shape serves as a risk factor for more severe IPMN.Peer reviewe

MRI follow-up for pancreatic intraductal papillary mucinous neoplasm : an ultrashort versus long protocol

Purpose To evaluate whether an ultrashort-protocol (USP) MRI including only T2-weighted HASTE axial and 3D MRCP SPACE sequences adequately measures the largest diameter of the largest cyst and the main pancreatic duct (MPD) and identifies worrisome features (WF) and high-risk stigmata (HRS) when compared to longer protocols (LP, long protocol; SP, short protocol; S-LP, short or long protocol). We also calculated reductions in costs associated with USP. Methods This retrospective study included 183 IPMN patients. Two radiologists compared two imaging sets (USP versus S-LP) per patient, comparing the mean values of the largest cyst and MPD and agreement regarding the presence or absence of cystic or MPD mural nodules and solid pancreatic tumors. The interobserver agreement for cystic mural nodules and WF/HRS was evaluated, using the Bland-Altman plot and Cohen's Kappa. Results A total of 112 IPMN patients were evaluated. For detecting cysts or MPD nodules, WF/HRS, and solid pancreatic tumors, USP and S-LP coincided in 94.9%, 99.1%, 92.4%, and 99.1% of cases, respectively. Both USP and S-LP identified all true cystic mural nodules. The mean size of the largest cyst and MPD was 19.48/19.67 mm and 3.24/3.33 mm using USP versus S-LP, while the mean differences for USP versus S-LP were 0.19 mm and 0.08 mm. The USP cost was 39% of LP cost and 77% of SP. Interobserver agreement was moderate to strong. Conclusions For IPMN surveillance, an ultrashort-protocol MRI provides nearly identical information to the more expensive longer protocols.Peer reviewe

A retrospective study of intraductal papillary neoplasia of the pancreas (IPMN) under surveillance

Background and objective: The growing number of identified intraductal papillary mucinous neoplasm (IPMN) patients places greater pressure on healthcare systems. Only a minority of patients have IPMN-related symptoms. Thus, more precise surveillance is required. Methods: In this retrospective single-center cross-sectional study, patients with an active diagnosis of branch duct IPMN (BD-IPMN) and >6 months of surveillance were classified as follows: presence/absence of worrisome features (WF) or high-risk stigmata (HRS), newly developed WF/HRS, under/over 15 mm cyst, growing/not growingPeer reviewe

Fadolmidine – Favourable adverse effects profile for spinal analgesia suggested by in vitro and in vivo models

Fadolmidine is an α2-adrenoceptor full agonist developed for spinal analgesia with a local mode of action. The purpose of this study was to demonstrate the safety of fadolmidine on known α2-adrenoceptor-related effects: kidney function, urodynamics and cardiovascular variables. Furthermore, the binding affinity of fadolmidine for the 5-HT3 receptor prompted functional studies on 5-HT3. According to the binding affinity data, fadolmidine demonstrated partial agonism on the 5-HT3 receptor in transfected cells and in guinea pig ileum preparation. However, intravenous (IV) fadolmidine did not produce any 5-HT3-related hemodynamic effects in anaesthetised rats. In urodynamic studies, intrathecal (IT) fadolmidine interrupted volume-evoked voiding cycles and induced overflow incontinence at high concentrations in anaesthetised rats; however, at the analgesic dose range, the effects were mild. The effects of fadolmidine on kidney function were studied in conscious rats after IV and IT dosing. While IT fadolmidine increased dose-dependent urine output, sodium ion concentration, IV doses increased only sodium ion concentration The effects of IT fadolmidine on heart rate (HR), mean arterial pressure (MAP) and sedation were evaluated in the home cage and in the open field using a telemetry system. In resting conditions, fadolmidine decreased HR dose-dependently and increased initial MAP, whereas in actively moving rats, there were no effects at analgesic doses. The results suggest that at anticipated analgesic clinical doses, IT fadolmidine provides analgesia without significant adverse effects on sedation, MAP or HR and with only modest effects on kidney function and urodynamics.</p

Lipoprotein docosapentaenoic acid is associated with serum matrix metalloproteinase-9 concentration

BACKGROUND: Polyunsaturated fatty acids (PUFA) are thought to play important roles in inflammation. The n-3 series is considered as anti-inflammatory, and some studies have reported increased plasma n-3 polyunsaturated fatty acid pattern in chronic inflammatory conditions. In this study we sought to clarify relationships of the levels of arachidonic acid and the polyunsaturated n-3 fatty acid compositions of isolated LDL, HDL(2 )and HDL(3 )particles with matrix metalloproteinase-9 (MMP-9), a marker of inflammation. RESULTS: The subjects were divided into two groups: those with lower and those with higher than the median serum MMP-9 concentration. In all lipoprotein fractions, the mean percentage of docosapentaenoic acid (C22:5n-3) was higher in the group of subjects with higher MMP-9 level than in those with lower serum MMP-9 concentration (P < 0.01 for all). Likewise, the ratio of docosapentaenoic acid to arachidonic acid (C20:4n-6) was higher in the subjects with higher MMP-9 compared with the lower MMP-9 group (P < 0.001 for all). CONCLUSION: So far, the evidence for an anti-inflammatory role of the n-3 PUFA has come from dietary interventions. Our results were obtained from a free-living population and indicate that there is a positive correlation between n-3 docosapentaenoic acid and MMP-9. What had triggered the rise in MMP-9 is not known, since serum level of MMP-9 is raised in many inflammatory conditions. These findings may indicate an increased biosynthesis of n-3 polyunsaturated fatty acids in subclinical inflammation

Delta-6-desaturase gene polymorphism is associated with lipoprotein oxidation in vitro

Background Oxidative modification of low-density lipoprotein (LDL) is a key event in the oxidation hypothesis of atherogenesis. We have previously shown that HDL does not protect LDL from oxidation in vitro, but is in fact oxidized fastest of all lipoproteins due to its rich polyunsaturated fatty acid (PUFA) composition, which is oxidation promoting. Evidence has accumulated to show that in addition to diet, common polymorphisms in the fatty acid desaturase (FADS) gene cluster have very marked effects on human PUFA status. There is a deletion [T/-] in the promoter region of the Δ6 –desaturase gene (FADS2, rs 3834458), which has a direct inhibitory influence on production of PUFA from linoleic and alpha-linolenic acid. To investigate the possible role of rs 3834458 in lipoprotein modification, oxidation of LDL with HDL2 or HDL3 were analyzed from plasma of 58 free-living individuals. Results Total eicosapentaenoic acid and arachidonic acid were significantly decreased in plasma from the 10 subjects homozygous for the deletion in FADS2 rs 3834458. When the isolated LDL and HDL2 were subjected to Cu2+-induced oxidation, these subjects showed decreased rate of appearance (p = 0.027) and the final concentration of conjugated dienes (p = 0.033) compared to the other genotypes. For oxidation of LDL with HDL3, the final concentration of conjugated dienes was also significantly decreased in subjects with [−/−] compared with [T/T] and [T/-] (p = 0.034). Conclusion We conclude that FADS2 genotype may play a role in peroxidation susceptibility of lipoproteins.BioMed Central open acces

Aortan dissekoituma - päivystyksen musta joutsen

Vertaisarvioitu. English abstract.Aortan dissekoituminen on henkeä uhkaava tilanne, jossa aortan seinämäkerrokset irtoavat toisistaan sisäkalvossa tapahtuneen repeämän vuoksi. Klassinen oire on äkillisesti alkava ja dissekoituman edetessä paikkaa vaihtava rintakipu. Tämän oireen puuttuessa diagnoosiin pääsy voi olla haasteellista, sillä oireet tulevat useista eri elinjärjestelmistä dissekoituman sijainnin ja etenemisen mukaisesti. Kuvaamme kaksi potilastapausta, joissa molemmissa klassinen oirekuva puuttui