Lymph node transfer in the treatment of postmastectomy lymphedema

Background: Lymphedema is a debilitating disorder with few treatment options. Clinical studies have shown that microvascular lymph node transfer may improve the lymphatic function of the affected limb. This study provides information about the clinical efficacy and safety of this procedure. Further, the biological background of this technique is clarified with an analysis of postoperative production of lymphatic growth factors and cytokines related to lymphangiogenesis. Patients and Methods: The effect of lymph node transfer to recipient and donor sites was analyzed with lymphoscintigraphy, limb circumference measurements, and appearance of clinical symptoms. Axillary seroma samples were analyzed from four patient groups: Axillary lymph node removal (ALND), Microvascular breast reconstruction (BR), lymph node transfer (LN) and combined lymph node transfer and breast reconstruction (LN-BR). Results: The postoperative lymphatic transport index was improved in 7/19 patients. Ten patients were able to reduce or discontinue compression therapy 6 - 24 months postoperatively. The donor lower limb lymphatic flow was slightly impaired (Ti >10) in 2 patients. No donor site lymphedema symptoms appeared during the 8 – 56-month follow-up. A high concentration of the VEGF-C protein was detected in the seroma fluid of all flap transfer groups. The concentration of the anti-inflammatory and anti-fibrotic cytokine IL-10 was increased in the LN-BR group samples when compared to the ALND or BR group. Conclusions: According to this preliminary study, the lymph node transfer seems to be beneficial for the lymphedema patients. However, a randomized study comparing the effect of BR and LN-BR is needed to evaluate the clinical efficacy of lymph node transfer. In addition, the effect of this surgery on the donor site needs to be studied further. The clinical effects of the lymph node transfer might be partly mediated by increased production of the lymphangiogenic growth factor (VEGF-C) as well as the anti-fibrotic cytokine (IL-10).Imusolmukesiirto rintasyöpähoitojen jälkeisen lymfedeeman hoidossa Tausta ja tavoitteet: Lymfedeema eli imunesteturvotus on etenevä imunestekierron sairaus, johon ei tunneta parantavaa hoitoa. Uusimpien tutkimusten mukaan mikrovaskulaarisella imusolmukesiirrolla voidaan parantaa lymfedeemaraajan imunestekiertoa. Tämän tutkimuksen tarkoituksena oli selvittää imusolmukesiirron tehoa ja turvallisuutta. Myös imusolmukesiirron biologista taustaa tutkittiin analysoimalla leikkauksen jälkeistä imutiekasvutekijä- ja sytokiinituotantoa. Potilaat ja menetelmät: Imusolmukesiirron vaikutusta sekä lymfedeemaraajaan että kielekkeen ottokohtaan analysoitiin lymfoskintigrafian, raajan ympärysmittausten ja kliinisten oireiden avulla. Kasvutekijä- ja sytokiinimääritykset tehtiin leikkausalueen seroomanäytteistä neljällä eri potilasryhmällä, joille tehtiin joko kainaloevakuaatio, mikrovaskulaarinen rintarekonstruktio, imusolmukesiirto tai yhdistetty rintarekonstruktio ja imusolmukesiirto. Tulokset: Imunestekierron nopeutuminen imusolmukesiirron jälkeen todettiin 7:llä potilaalla 19:stä. Kymmenen potilasta pystyi vähentämään tai lopettamaan yläraajan kompressiohoidon 6-24 kuukautta leikkauksen jälkeen. Alaraajassa, jolta puolelta kieleke otettiin, todettiin lievästi hidastunut imunestekierto 2:lla potilaalla. Yhdellekään potilaalle ei kuitenkaan seuranta-ajassa ole kehittynyt alaraajan turvotusoireita. Kaikkien kielekesiirtoryhmien seroomanäytteissä todettiin korkea imutiekasvutekijä (VEGF-C) -pitoisuus. Anti-inflammatorisen ja anti-fibroottisen sytokiinin IL-10:n pitoisuus yhdistetyssä rintarekonstruktio- ja imusolmukesiirtoryhmässä oli korkeampi kuin kainaloevakuaatio- tai pelkässä rintarekonstruktioryhmässä. Päätelmät: Osa lymfedeemapotilaista näyttäisi hyötyvän imusolmukesiirrosta. Jatkossa leikkauksen tehoa tulisi selvittää satunnaistetulla tutkimuksella, jossa verrataan pelkän rintarekonstruktion ja imusolmukesiirron vaikutusta imunestekiertoon. Myös leikkauksen vaikutusta kielekkeen ottoalueeseen on tutkittava lisää. Imutiekasvutekijä VEGFC: n sekä antifibroottisen sytokiinin IL-10:n lisääntynyt eritys selittävät osittain imusolmukesiirron hyödyllisiä vaikutuksia.Siirretty Doriast

Kohti voimaannuttavaa painonhallintaa

Tämä opinnäytetyö toteutettiin Laurea-ammattikorkeakoulu Lohjan yksikössä, yhteistyökumppanina oli Perusturvakuntayhtymä Karviainen. Tässä opinnäytetyössä tarkoituksena oli kartoittaa Perusturvakuntayhtymä Karviaisen ja osaksi Laurean sairaanhoitajaopiskelijoiden toteuttamaan painohallintaryhmään osallistuvien kokemuksia motivoitumisesta, sitoutumisesta, voimaantumisesta ja ryhmässä olemisen vaikutuksista painonhallintaan. Opinnäytetyön tavoitteena oli painonhallintaryhmäläisten kokemusten kautta mahdollisten kehityskohteiden löytäminen. Opinnäytetyö kuului osaksi Pumppu-hanketta, joka päättyi keväällä 2014. Tämän opinnäytetyön kohderyhmänä oli painonhallintaryhmä, jossa oli alun perin kaksitoista jäsentä. Painonhallintaryhmä kokoontui keväästä 2013 kevääseen 2014. Teoreettinen viitekehys muodostui ylipainon, painonhallinnan, voimaantumisen ja ryhmäohjauksen käsitteiden määrittelystä. Opinnäytetyö toteutettiin laadullista tutkimusmenetelmää käyttäen. Aineis-tonkeruumenetelminä käytettiin sekä puolistrukturoitua kyselylomaketta että focus group -haastattelua. Aineisto analysoitiin deduktiivisen sisällönanalyysin avulla. Opinnäytetyössä etsittiin painonhallintaan sitouttavia, motivoivia ja voimaantumista edistäviä tekijöitä sekä mahdollisia kehityskohteita. Tuloksista kävi ilmi, että teoriatieto, läheisiltä saatu tuki, vertaistuki, oma tahto ja mahdollisuudet vaikuttaa painonhallintaryhmän tapaamisten sisältöön edesauttoivat painonhallintaa. Painonhallintaryhmän kehittämiskohteiksi ryhmäläiset ehdottivat yksilöllisesti laadittuja ohjeita ruokavalioon ja liikuntaan. Tärkeimmiksi kehittämiskohteiksi nousivat esille psykologisen avun ja stressinhallintaohjelman liittäminen osaksi painonhallintaryhmiä. Useimmiten painonhallintaryhmissä painotetaan ravitsemuksen ja liikunnan merkitystä, yksilöllisten ja psykologisten tekijöiden jäädessä taka-alalle. Säännölliset terveystarkastukset ja yksilöllisemmin räätälöidyt ohjelmat voisivat parantaa painonhallintaryhmien tuloksellisuutta. Tulevaisuuden tutkimuskohteena voisi olla painonhallintaryhmien ohjaajien näkemysten kartoittaminen. Tällöin voitaisiin yhdistää molempien sekä ohjaajien että painonhallintaryhmäläisten näkemyksiä toimivampien painonhallintaryhmien luomiseen tulevaisuudessa. Asiasanat:ylipaino, painonhallinta, ryhmäohjaus, voimaantuminen, motivaatio, sitoutuminen.This thesis has been carried out in Laurea University of Applied Sciences Lohja in co-operation with Karviainen Joint Municipal Authority for Health Care and Social Services’ (hence, JMA Karviainen). The objective of this thesis is to chart the experiences of the participants of a body weight management group concerning motivation, commitment, empowering and the impact of being in a body weight management group. The body weight management group was carried out by JMA Karviainen with nursing students of Laurea Lohja. The aim of this thesis was to find possible targets of development through the experiences of the participants of the body weight management group. This thesis was part of Pumppu project which ended in spring 2014. The target group of this thesis was a body weight management group which originally had twelve participants. The body weight management group met from spring 2013 till spring 2014. The theoretical framework consisted of the definition of overweight, body weight control, empowerment and group counselling. The study was carried out using qualitative research method. The survey was carried out in a form of a half structured questionnaire and focus group interview. The empirical data was analysed by using a deductive content analysis. The thesis sought factors affecting commitment, motivation and empowering in body weight control and possible targets of development. The results of the study indicated that theoreti-cal knowledge, support of the people close to you, peer support, one`s own will to lose weight and possibilities to influence the content of the group meetings enhanced body weight management. To improve body weight management groups in the future, group members suggested individually tailored programmes for diet and exercise. Inclusion of psychological support and stress management programme as part of the weight management groups came up as the most important targets of development. Usually in weight management groups the significance of diet and exercise are emphasized causing individual and psychological factors being left behind. Regular health checks and more individually tailored programmes could improve the results of the body weight management groups. In the future a research subject could be surveying the views of the weight management group instructors. Then it would be possible to combine views from the instructors and the weight management group members to create better functioning weight management groups in the future. Keywords: overweight, weight control, group counselling, empowerment, motivation, commitment

Lukioiden ja ammatillisten oppilaitosten opiskeluterveydenhuollon terveystarkastuskäytännöt, työtavat ja -ympäristöt

OPTE-hank

Combining diagnostic memory clinic with rehabilitation follow-up after hip fracture

Purpose: Cognitive impairment and dementia are common in older hip fracture patients. We describe new diagnoses of cognitive disorders (NDCDs) and associated factors in a two-year post-hip fracture follow-up including the use of the diagnostic facilities of a memory clinic.Methods: Data were collected on admission and at outpatient assessment 4–6 months post-hip fracture. Diagnoses of cognitive disorders followed the evidence-based Finnish national care guideline including internationally accepted criteria. NDCDs up to 2 years post-hip fracture were extracted manually from the patient files. Logistic regression models were computed to examine the associations between the pre-fracture factors and the domains of the outpatient geriatric assessment and NDCDs.Results: Of the 1165 hip fracture patients aged ≥ 65 years, 831 had no previous diagnosis of cognitive disorder. Of these, NDCD was documented in 23.3%. Alzheimer’s disease (AD) with or without vascular cognitive impairment (VCI) was the most common diagnosis. Cognitive disorder was usually at a moderate stage. Age, higher ASA score and poor nutritional status on admission were associated with new cognitive disorders. At the outpatient follow-up, poorer activities of daily living and mobility disability were associated with NDCD. Patients with a NDCD were more likely to suffer greater mobility impairment, poorer nutritional status and to have more supported living arrangements at follow-up than in the pre-fracture situation.Conclusion: NDCDs are common after hip fracture and associated with impaired rehabilitation outcomes and poor nutritional status. A post-hip fracture assessment co-organized in the form of a memory clinic seems to be feasible to detect previously undiagnosed cognitive disorders. Earlier diagnosis of cognitive disorders is warranted.</p

Phase 1 Lymfactin (R) Study : Short-term Safety of Combined Adenoviral VEGF-C and Lymph Node Transfer Treatment for Upper Extremity Lymphedema

Objective: To study the safety and tolerability of Lymfactin (R) treatment combined with microvascular lymph node transfer surgery in patients with upper limb lymphedema. Background: Upper limb lymphedema is a common clinical challenge after breast cancer surgery and/or radiotherapy. Lymfactin (R) is an adenovirus type 5-based gene therapy involving expression of human vascular endothelial growth factor C (VEGF-C) in the damaged tissue. It aims to correct deficient lymphatic flow by promoting the growth and repair of lymphatic vessels. Methods: In Phase I, Lymfactin (R) was combined with microvascular lymph node transfer surgery to study the safety and tolerability of Lymfactin (R) and the biodistribution of the viral vector in patients with upper limb lymphedema. Results: Fifteen patients with breast cancer-associated secondary lymphedema of the upper arm were recruited between December 2016 and February 2018. Three patients received a lower dose (1 x 10(10)) and 12 a higher dose (1 x 10(11)) of viral particles, respectively. No dose-limiting toxicities were observed, and the study was completed with the pre-determined maximum dose. Commonly reported adverse events during the 12-month follow-up were common cold, fever, gastroenteritis, pain in the operation area, headache, muscle ache and elevated liver enzymes. Serious adverse events consisted of two erysipelas infections in the lymphedema arm (requiring hospitalization) and one hematoma of the flap donor site. Conclusions: After 12 months' follow-up, results indicate that Lymfactin (R) is well tolerated. The study continues with a 36-months efficacy and 5 years safety follow-up of the patients. The oncological safety aspects of Lymfactin (R) will require a longer follow-up period. (c) 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Pub-lished by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)Peer reviewe

Recurrent bacterial pneumonia in Irish Wolfhounds: Clinical findings and etiological studies

Background: Increased incidence of bacterial pneumonia (BP) has been reported in Irish Wolfhounds (IWHs), and recurrence of BP is common. The etiology of recurrent pneumonia in IWHs is largely unknown. Objectives: To describe clinical findings in IWHs with recurrent BP and investigate possible etiologies. Animals: Eleven affected IWHs, 25 healthy IWHs, 28 healthy dogs of other Sighthound breeds, and 16 healthy dogs of other breeds. Methods: Prospective cross-sectional observational study. All affected IWHs underwent thorough clinical examinations including thoracic radiographs, thoracic computed tomography, electron microscopic evaluation of ciliary structure, and bronchoscopy and bronchoalveolar lavage fluid (BALF) cytology and culture. Serum and BALF immunoglobulin concentrations were measured using an ELISA method, and peripheral blood lymphocyte subpopulations were analyzed using flow cytometry. Esophageal function was assessed by fluoroscopy (n = 2). Results: Median age of onset was 5.0 years (range, 0.4-6.5 years), and when presented for study, dogs had experienced a median of 5 previous episodes of BP (range, 2-6). The following predisposing factors to BP were detected: focal bronchiectasis (10/11), unilateral (2/9) and bilateral (1/9) laryngeal paralysis, and esophageal hypomotility (2/2). Local or systemic immunoglobulin deficiencies or primary ciliary defects were not detected. Conclusions and Clinical Importance: Recurrent BP affects mostly middle-aged and older IWHs without any evident immune deficit or primary ciliary defects. Focal BE was a frequent finding in affected dogs and likely contributed to the development of recurrent respiratory infections. Laryngeal and esophageal dysfunction identified in a minority of dogs may contribute to recurrent BP.Peer reviewe

Ammattikorkeakoulujen opiskeluterveydenhuollon terveystarkastuskäytännöt, työtavat ja -ympäristöt

Opiskelijoiden terveysseurannan kehittäminen -hanke, OPTE-hank

Anti-inflammatory effects of flap and lymph node transfer

Background: Transfer of healthy tissue is commonly used in the treatment of complicated wounds and in reconstruction of tissue defects. Recently, microvascular lymph node transfer (LN) has been used to improve the lymphatic function in lymphedema patients. To elucidate the biological effects of flap transfer (with and without lymph nodes), we have studied the postoperative production of proinflammatory, anti-inflammatory, prolymphangiogenic and antilymphangiogenic cytokines, and growth factors (interleukin 1 alpha [IL-1 alpha], IL-1 beta, tumor necrosis factor alpha [TNF-alpha], IL-10, transforming growth factor beta 1 [TGF-beta 1], IL-4 and IL-13, and vascular endothelial growth factor C [VEGF-C] and VEGF-D) in postoperative wound exudate samples. Methods: Axillary wound exudate samples were analyzed from four patient groups: axillary lymph node dissection (ALND), microvascular breast reconstruction (BR), LN, and combined LN and BR (LN-BR). Results: The concentration of proinflammatory cytokines was low in all the flap transfer groups as opposed to the ALND group, which showed an extensive proinflammatory response. The level of anti-inflammatory and antifibrotic cytokine IL-10 was increased in the LN-BR group samples compared with the ALND and BR groups. In the LN and LN-BR groups, the cytokine profile showed an anti-inflammatory response. Conclusions: Transfer of healthy tissue hinders the proinflammatory response after surgery, which may explain the beneficial effects of flap transfer in various patient groups. In addition, flap transfer with lymph nodes seems to also promote an antifibrotic effect. The clinical effects of LN in lymphedema patients may be mediated by the increased production of prolymphangiogenic growth factor (VEGF-C) and antifibrotic cytokine (IL-10). (C) 2015 Elsevier Inc. All rights reserved.Peer reviewe