Publications by authors named "Irina Rinta-Kiikka"

41 Publications

Prospective comparison of F-PSMA-1007 PET/CT, whole-body MRI and CT in primary nodal staging of unfavourable intermediate- and high-risk prostate cancer.

Eur J Nucl Med Mol Imaging 2021 Mar 13. Epub 2021 Mar 13.

Department of Urology, University of Turku and Turku University Hospital, Turku, Finland.

Purpose: To prospectively compare F-prostate-specific membrane antigen (PSMA)-1007 positron emission tomography (PET)/CT, whole-body magnetic resonance imaging (WBMRI) including diffusion-weighted imaging (DWI) and standard computed tomography (CT), in primary nodal staging of prostate cancer (PCa).

Methods: Men with newly diagnosed unfavourable intermediate- or high-risk PCa prospectively underwent F-PSMA-1007 PET/CT, WBMRI with DWI and contrast-enhanced CT within a median of 8 days. Six readers (two for each modality) independently reported pelvic lymph nodes as malignant, equivocal or benign while blinded to the other imaging modalities. Sensitivity, specificity and accuracy were reported according to optimistic (equivocal lesions interpreted as benign) and pessimistic (equivocal lesions interpreted as malignant) analyses. The reference standard diagnosis was based on multidisciplinary consensus meetings where available histopathology, clinical and follow-up data were used.

Results: Seventy-nine patients completed all the imaging modalities, except for one case of interrupted WBMRI. Thirty-one (39%) patients had pelvic lymph node metastases, which were detected in 27/31 (87%), 14/31 (45%) and 8/31 (26%) patients by F-PSMA-1007 PET/CT, WBMRI with DWI and CT, respectively (optimistic analysis). In 8/31 (26%) patients, only F-PSMA-1007 PET/CT detected malignant lymph nodes, while the other two imaging modalities were reported as negative. At the patient level, sensitivity and specificity values for F-PSMA-1007 PET/CT, WBMRI with DWI and CT in optimistic analysis were 0.87 (95%CI 0.71-0.95) and 0.98 (95%CI 0.89-1.00), 0.37 (95%CI 0.22-0.55) and 0.98 (95%CI 0.89-1.00) and 0.26 (95%CI 0.14-0.43) and 1.00 (95%CI 0.93-1.00), respectively.

Conclusion: F-PSMA-1007 PET/CT showed significantly greater sensitivity in nodal staging of primary PCa than did WBMRI with DWI or CT, while maintaining high specificity.

Clinical Trial Registration: Clinicaltrials.gov ID: NCT03537391.
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http://dx.doi.org/10.1007/s00259-021-05296-1DOI Listing
March 2021

Perioperative acinar cell count method works well in the prediction of postoperative pancreatic fistula and other postoperative complications after pancreaticoduodenectomy.

Pancreatology 2021 Mar 27;21(2):487-493. Epub 2021 Jan 27.

Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. Electronic address:

Background: Earlier we have shown that high frequency of acinar cells in the pancreatic transsection line predicts postoperative pancreatic fistula after pancreaticoduodenectomy (PD). Acinar cell count method (ACM) is fast to perform during operation. In this study our aim was to validate the accuracy of ACM to compare it with other published risk prediction methods.

Methods: 87 patients who underwent PD without any trial including perioperative medications were collected from a single hospital. Data on demographics, surgical details, postoperative complications clinically relevant pancreatic fistulae (CR-POPF) and clinically relevant Clavien-Dindo complications (CR-CDC) were registered. Thirteen previously published risk prediction methods were included in the comparison, such as pancreatic duct diameter, palpable texture of pancreas, Braga score (BC), Fistula Risk Score, Modified Fistula Risk Score, Alternative Fistula Risk Score and multiple radiological parameters. ROC-curves were calculated to compare sensitivity and specificity for identifying high risk patients for CR-POPF and CR-CDC.

Results: The three most accurate risk prediction methods for CR-POPF were ACM (sensitivity 88.9%, specificity 52.6%; p = 0.043), BC (87.5%, 56.6%; p = 0.039) and visceral fat area to subcutaneous fat area ratio (75.5%, 80.0%; p = 0.032). In predicting CR-CDC the three most accurate methods were ACM (73.9%, 56.2%; p = 0.033), BC (68.4%, 59.5%; p = 0.036) and TPAI (78.3%, 41.7%; p = 0.012).

Conclusion: ACM was shown to be as good as the more complicated risk scoring methods in the prediction of CR-POPF. It was good also in predicting all clinically relevant complications. ACM is easy to use during operation and can be recommended as a routine risk prediction method.
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http://dx.doi.org/10.1016/j.pan.2021.01.005DOI Listing
March 2021

Diagnostic efficiency of whole-body F-FDG PET/MRI, MRI alone, and SUV and ADC values in staging of primary uterine cervical cancer.

Cancer Imaging 2021 Jan 22;21(1):16. Epub 2021 Jan 22.

Department of Radiology, Turku University Hospital and University of Turku, PO Box 52, 20521, Turku, Finland.

Background: The use of PET/MRI for gynecological cancers is emerging. The purpose of this study was to assess the additional diagnostic value of PET over MRI alone in local and whole-body staging of cervical cancer, and to evaluate the benefit of standardized uptake value (SUV) and apparent diffusion coefficient (ADC) in staging.

Methods: Patients with histopathologically-proven cervical cancer and whole-body F-FDG PET/MRI obtained before definitive treatment were retrospectively registered. Local tumor spread, nodal involvement, and distant metastases were evaluated using PET/MRI or MRI dataset alone. Histopathology or clinical consensus with follow-up imaging were used as reference standard. Tumor SUVmax and ADC were measured and SUVmax/ADC ratio calculated. Area under the curve (AUC) was determined to predict diagnostic performance and Mann-Whitney U test was applied for group comparisons.

Results: In total, 33 patients who underwent surgery (n = 23) or first-line chemoradiation (n = 10) were included. PET/MRI resulted in higher AUC compared with MRI alone in detecting parametrial (0.89 versus 0.73), vaginal (0.85 versus 0.74), and deep cervical stromal invasion (0.96 versus 0.74), respectively. PET/MRI had higher diagnostic confidence than MRI in identifying patients with radical cone biopsy and no residual at hysterectomy (sensitivity 89% versus 44%). PET/MRI and MRI showed equal AUC for pelvic nodal staging (both 0.73), whereas AUC for distant metastases was higher using PET/MRI (0.80 versus 0.67). Tumor SUVmax/ADC ratio, but not SUVmax or ADC alone, was significantly higher in the presence of metastatic pelvic lymph nodes (P < 0.05).

Conclusions: PET/MRI shows higher accuracy than MRI alone for determining local tumor spread and distant metastasis emphasizing the added value of PET over MRI alone in staging of cervical cancer. Tumor SUVmax/ADC ratio may predict pelvic nodal involvement.
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http://dx.doi.org/10.1186/s40644-020-00372-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7821517PMC
January 2021

Inspiratory training and immediate lung recovery after resective pulmonary surgery: a randomized clinical trial.

J Thorac Dis 2020 Nov;12(11):6701-6711

Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.

Background: Prompt and uneventful recovery after resective pulmonary surgery benefits patients by decreasing length and total costs of hospital stay. Postoperative physiotherapy has been shown to be advantageous for patient recovery in several studies and lately inspiratory muscle training (IMT) physiotherapy has been used also in thoracic patients. This randomized controlled trial intended to evaluate whether IMT is an efficient and feasible method of physiotherapy compared to water bottle positive expiratory physiotherapy (PEP) immediately after lung resections.

Methods: Forty-two patients were randomly allocated into two intervention groups: water bottle PEP (n=20) and IMT group (n=22). Patients were given physiotherapeutic guidance once a day and patients were also instructed to do independent exercises. Measurements of pulmonary function were compared between the treatment groups according to intention to treat by using two-way repeated measures analysis of variances at three time points (preoperative, first postoperative day, and second postoperative day). Walking distance was measured at first and second postoperative day and similarly, evaluation of postoperative air leak during exercises was performed. Physiotherapy was modified or temporarily interrupted, if necessary, because of the air leak.

Results: Postoperative pulmonary function tests were equal between the intervention groups. Air leak was relatively common after lung resections: 31% of all patients had mild or moderate/severe air leak at first postoperative day and 14% of all patients had mild to severe air leak at second postoperative day respectively. There were no statistically significant differences in occurrence of air leak between intervention groups, but water resistance had to be reduced or physiotherapy discontinued significantly more often among the water bottle PEP group patients (P=0.01). Walking distance improved slightly faster in the IMT group between the first and the second postoperative day when compared to the water bottle PEP group, but the difference between the groups was not statistically significant.

Conclusions: IMT physiotherapy is equally effective to water bottle PEP training in postoperative physiotherapy after lung resection surgery evaluated with pulmonary function tests and walking distance. In addition, IMT physiotherapy is safe and more feasible form of physiotherapy during postoperative air leak compared to water bottle PEP.
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http://dx.doi.org/10.21037/jtd-20-1668DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7711407PMC
November 2020

Plasma suPAR may help to distinguish between chronic pancreatitis and pancreatic cancer.

Scand J Gastroenterol 2021 Jan 27;56(1):81-85. Epub 2020 Nov 27.

Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.

Objectives: SuPAR (soluble urokinase-type plasminogen activator receptor) is a biomarker reflecting the inflammatory state of the human body. Earlier studies suggest that urinary suPAR/creatinine ratio levels are elevated in chronic pancreatitis (CP), and that plasma suPAR (P-suPAR) level is elevated in pancreatic cancer (PC). Our aim was to study the levels of P-suPAR in CP in a long-term prospective follow-up setting to explore the possibility of distinguishing between PC and CP.

Materials And Methods: Two patient groups were compared. The first group included 83 patients who were prospectively followed up after their first acute alcohol-induced pancreatitis (AAP) for median 7.0 (range 0.3-9.8) years. Twelve patients in this group developed CP during follow-up, and two patients were further excluded from the CP cohort. The second group consisted of 25 patients operated on for suspicion of pancreatic malignancy and final pathological diagnosis of PC. P-suPAR levels were measured and compared within and between these groups.

Results: P-suPAR levels remained low during follow-up despite the development of CP. P-suPAR was significantly higher in PC patients [median 3.7 (IQR 3.1-4.4) ng/mL] than in CP patients [2.6 (1.8-3.6) ng/mL];  = .014. A cutoff value of 2.8 ng/mL resulted from a ROC curve with area under curve (AUC) of 0.79 (95% CI 0.61-0.97),  = .009 in differentiation between PC and CP with a sensitivity and a specificity of 88% and 70% respectively.

Conclusion: P-suPAR is higher in patients with PC than in patients with CP, and it could thus be used in differentiating between PC and CP.
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http://dx.doi.org/10.1080/00365521.2020.1849383DOI Listing
January 2021

A Comparison of Regions of Interest in Parenchymal Analysis for Breast Cancer Risk Assessment.

Annu Int Conf IEEE Eng Med Biol Soc 2020 07;2020:1136-1139

Computerized parenchymal analysis has shown potential to be utilized as an imaging biomarker to estimate the risk of breast cancer. Parenchymal analysis of digital mammograms is based on the extraction of computerized measures to build machine learning-based models for the prediction of breast cancer risk. However, the choice of the region of interest (ROI) for feature extraction within the breast remains an open problem. In this work we perform a comparison between five different methods suggested in the literature for automated ROI selection, including the whole breast (WB), the maximum squared (MS), the retro-areolar region (RA), the lattice-based (LB), and the polar-based (PB) selection methods. For the experiments, we built a retrospective dataset of 896 screening mammograms from 224 women (112 cases and 112 healthy controls). The performance of each ROI selection method was measured in terms of the area under the curve (AUC) values. The AUC values varied between 0.55 and 0.79 depending on the method and experimental settings. The best performance on an independent test set was achieved by the MS method (AUC of 0.59, 95% CI: 0.55-0.64). This method is fully-automated and does not require adjusting hyper-parameters. Based on our results, we prompt the use of the MS method for ROI selection in the computerized parenchymal analysis for breast cancer risk assessment.
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http://dx.doi.org/10.1109/EMBC44109.2020.9176200DOI Listing
July 2020

A New Benchmark and Method for the Evaluation of Chest Wall Detection in Digital Mammography

Annu Int Conf IEEE Eng Med Biol Soc 2020 07;2020:1132-1135

CAD systems have shown good potential for improving breast cancer diagnosis and anomaly detection in mammograms. A basic enabling step for the utilization of CAD systems in mammographic analysis is the correct identification of the breast region. Therefore, several methods to segment the pectoral muscle in the medio-lateral oblique (MLO) mammographic view have been proposed in the literature. However, currently it is difficult to perform and objective comparison between different chest wall (CW) detection methods since they are often evaluated with different evaluation procedures, datasets and the implementations of the methods are not publicly available. For this reason, we propose a methodology to evaluate and compare the performance of CW detection methods using a publicly available dataset (INbreast). We also propose a new intensity-based method for automatic CW detection. We then utilize the proposed evaluation methodology to compare the performance of our CW detection algorithm with a state-of-the-art CW detection method. The performance was measured in terms of the Dice's coefficient similarity, the area error and mean contour distance. The proposed method achieves yielded the best results in all the performance measures.
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http://dx.doi.org/10.1109/EMBC44109.2020.9175960DOI Listing
July 2020

The European evidence-based guidelines on pancreatic cystic neoplasms (PCN) in clinical practice: The development of relative and absolute indications for surgery during prospective IPMN surveillance.

Pancreatology 2020 Oct 6;20(7):1393-1398. Epub 2020 Sep 6.

Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. Electronic address:

Introduction: The European evidence-based guidelines on PCN recommend surveillance for IPMN patients who are fit for surgery but who have no indication for immediate surgery. Our aim was to demonstrate the feasibility of the new guidelines in clinical practice.

Methods: This is a prospective cohort study of patients included in the IPMN register in Tampere University Hospital, Finland. IPMN was diagnosed from January 1, 2013 to December 31, 2018. Patients were analyzed for surveillance and indications for surgery according to the European guidelines on PCN.

Results: Out of 128 patients in register 23 was decided to operate upfront and 105 patients were included in the surveillance programme. Invasive carcinoma was found in 4/23 of operated patients. Median follow-up time was 26 months (6-69). Median size of the cyst at the beginning and end of the surveillance was 16 mm (4-58 mm). During surveillance 0/105 (0.0%) patients had or developed an absolute indication for surgery. Relative indication for surgery was present in 8/105 (7.6%) patients in the beginning surveillance and 9/105 (8.6%) patients developed at least one relative indication for surgery during surveillance. From the surveillance cohort 2/105 patients were operated. Surveillance was abandoned in 15/105 (14.1%) patients all due to poor general condition or other medical conditions.

Conclusions: In clinical practice, surveillance of IPMN according to the European guidelines on PCN is feasible. Among our patients 16% were detected to have relative indications for surgery during the median 26 (range 3-135) months of surveillance. Nearly 15% became surgically unfit during surveillance period.
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http://dx.doi.org/10.1016/j.pan.2020.09.003DOI Listing
October 2020

A Prospective Comparison of F-prostate-specific Membrane Antigen-1007 Positron Emission Tomography Computed Tomography, Whole-body 1.5 T Magnetic Resonance Imaging with Diffusion-weighted Imaging, and Single-photon Emission Computed Tomography/Computed Tomography with Traditional Imaging in Primary Distant Metastasis Staging of Prostate Cancer (PROSTAGE).

Eur Urol Oncol 2020 Jul 13. Epub 2020 Jul 13.

Department of Urology, University of Turku and Turku University Hospital, Turku, Finland.

Background: Computed tomography (CT) and bone scintigraphy (BS) are the imaging modalities currently used for distant metastasis staging of prostate cancer (PCa).

Objective: To compare standard staging modalities with newer and potentially more accurate imaging modalities.

Design, Setting, And Participants: This prospective, single-centre trial (NCT03537391) enrolled 80 patients with newly diagnosed high-risk PCa (International Society of Urological Pathology grade group ≥3 and/or prostate-specific antigen [PSA] ≥20 and/or cT ≥ T3; March 2018-June 2019) to undergo primary metastasis staging with two standard and three advanced imaging modalities.

Outcome Measurements And Statistical Analysis: The participants underwent the following five imaging examinations within 2 wk of enrolment and without a prespecified sequence: BS, CT, Tc-hydroxymethylene diphosphonate (Tc-HMDP) single-photon emission computed tomography (SPECT)-CT, 1.5 T whole-body magnetic resonance imaging (WBMRI) using diffusion-weighted imaging, and F-prostate-specific membrane antigen-1007 (F-PSMA-1007) positron emission tomography(PET)-CT. Each modality was reviewed by two independent experts blinded to the results of the prior studies, who classified lesions as benign, equivocal, or malignant. Pessimistic and optimistic analyses were performed to resolve each equivocal diagnosis. The reference standard diagnosis was defined using all available information accrued during at least 12 mo of clinical follow-up. Patients with equivocal reference standard diagnoses underwent MRI and/or CT to search for the development of anatomical correspondence. PSMA PET-avid lesions without histopathological verification were rated to be malignant only if there was a corresponding anatomical finding suspicious for malignancy at the primary or follow-up imaging.

Results And Limitations: Seventy-nine men underwent all imaging modalities except for one case of interrupted MRI. The median interval per patient between the first and the last imaging study was 8 d (interquartile range [IQR]: 6-9). The mean age was 70 yr (standard deviation: 7) and median PSA 12 ng/mL (IQR:7-23). The median follow-up was 435 d (IQR: 378-557). Metastatic disease was detected in 20 (25%) patients. The imaging modality F-PSMA-1007 PET-CT had superior sensitivity and highest inter-reader agreement. The area under the receiver-operating characteristic curve (AUC) values for bone metastasis detection with PSMA PET-CT were 0.90 (95% confidence interval [CI]: 0.85-0.95) and 0.91 (95% CI: 0.87-0.96) for readers 1 and 2, respectively, while the AUC values for BS, CT, SPECT-CT, and WBMRI were 0.71 (95% CI: 0.58-0.84) and 0.8 (95% CI: 0.67-0.92), 0.53 (95% CI: 0.39-0.67) and 0.66 (95% CI: 0.54-0.77), 0.77 (95% CI: 0.65-0.89) and 0.75 (95% CI: 0.62-0.88), and 0.85 (95% CI: 0.74-0.96) and 0.67 (95% CI: 0.54-0.80), respectively, for the other four pairs of readers. The imaging method F-PSMA-1007 PET-CT detected metastatic disease in 11/20 patients in whom standard imaging was negative and influenced clinical decision making in 14/79 (18%) patients. In 12/79 cases, false positive bone disease was reported only by PSMA PET-CT. Limitations included a nonrandomised study setting and few histopathologically validated suspicious lesions.

Conclusions: Despite the risk of false positive bone lesions, F-PSMA-1007 PET-CT outperformed all other imaging methods studied for the detection of primary distant metastasis in high-risk PCa.

Patient Summary: In this report, we compared the diagnostic performance of conventional and advanced imaging. It was found that F-prostate-specific membrane antigen-1007 positron emission tomography/computed tomography (F-PSMA-1007 PET-CT) was superior to the other imaging modalities studied for the detection of distant metastasis at the time of initial diagnosis of high-risk prostate cancer. PSMA PET-CT also appears to detect some nonmetastatic bone lesions.
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http://dx.doi.org/10.1016/j.euo.2020.06.012DOI Listing
July 2020

Do Mammographic Systems Affect the Performance of Computerized Parenchymal Analysis?

Annu Int Conf IEEE Eng Med Biol Soc 2019 Jul;2019:4863-4866

Early identification of women at high risk of developing breast cancer is fundamental for timely diagnosis and treatment. Recently, researchers have demonstrated that the computerized analysis of parenchymal (breast tissue) patterns in mammograms can be utilized to assess the risk level of patients. However, parenchymal analysis being an image-based biomarker, its performance may be affected by the acquisition parameters of the mammogram. Unfortunately, research on the effect of the mammographic system on the performance of parenchymal analysis is very scarce. In this paper, we implement a parenchymal analysis algorithm and study the effect of different mammographic systems on its performance. We show in a setting of 286 women that the use of different mammographic systems can yield differences of up to 24% in the area under the ROC curve. Results suggest the the construction of models for risk assessment based on parenchymal analysis should incorporate the imaging technologies into the analysis.
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http://dx.doi.org/10.1109/EMBC.2019.8856948DOI Listing
July 2019

Morphological Area Gradient: System-independent Dense Tissue Segmentation in Mammography Images.

Annu Int Conf IEEE Eng Med Biol Soc 2019 Jul;2019:4855-4858

Breast density has been identified as one of the strongest risk factors for breast cancer. However, the development of reliable and reproducible methods for the automatic dense tissue segmentation has been an important challenge. Due to the complexity of the acquisition process of mammography images, current approaches need to be calibrated for specific mammographic systems or require access to raw mammograms. In this work, we introduce the Morphological Area Gradient (MAG) as a generic measure for mammography images. MAG is generic in the sense that it does not need calibration or access to raw mammograms. At the core of MAG is the derivative of the area of segmented tissue with respect to the pixel intensity. We have found that the high-density regions can be automatically segmented by minimizing the MAG of a mammogram. To verify the performance of MAG, we collected 566 full-field digital mammograms using two different medical devices and a human expert manually annotated the high-density regions in each image. The proposed MAG method yields a median absolute error of 7.6% and a Dices similarity coefficient of 0.83, which are superior to other clinically validated state-of-the-art algorithms.
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http://dx.doi.org/10.1109/EMBC.2019.8857320DOI Listing
July 2019

Clinical evaluation of a fully-automated parenchymal analysis software for breast cancer risk assessment: A pilot study in a Finnish sample.

Eur J Radiol 2019 Dec 17;121:108710. Epub 2019 Oct 17.

Department of Oncology, Tampere University Hospital, 33521 Tampere, Finland.

Purpose: To assess the association between breast cancer risk and mammographic parenchymal measures obtained using a fully-automated, publicly available software, OpenBreast.

Methods: This retrospective case-control study involved screening mammograms of asymptomatic women diagnosed with breast cancer between 2016 and 2017. The 114 cases were matched with corresponding healthy controls by birth and screening years and the mammographic system used. Parenchymal analysis was performed using OpenBreast, a software implementing a computerized parenchymal analysis algorithm. Breast percent density was measured with an interactive thresholding method. The parenchymal measures were Box-Cox transformed and adjusted for age and percent density. Changes in the odds ratio per standard deviation (OPERA) with 95% confidence intervals (CIs) and the area under the ROC curve (AUC) for parenchymal measures and percent densities were used to evaluate the discrimination between cases and controls. Differences in AUCs were assessed using DeLong's test.

Results: The adjusted OPERA value of parenchymal measures was 2.49 (95% CI: 1.79-3.47). Parenchymal measures using OpenBreast were more accurate (AUC = 0.779) than percent density (AUC = 0.609) in discriminating between cases and controls (p < 0.001).

Conclusions: Parenchymal measures obtained with the evaluated software were positively associated with breast cancer risk and were more accurate than percent density in the prediction of risk.
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http://dx.doi.org/10.1016/j.ejrad.2019.108710DOI Listing
December 2019

Biodegradable biliary stents preferable to plastic stent therapy in post-cholecystectomy bile leak and avoid second endoscopy.

Scand J Gastroenterol 2018 Oct - Nov;53(10-11):1376-1380. Epub 2018 Nov 5.

a Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland.

Background: The treatment of post-cholecystectomy bile leak is endoscopic retrograde cholangiography (ERC) with plastic stent (PS) insertion combined with external drainage. Self-expanding biodegradable biliary stents (BDBS) have only recently become available.

Aim: The aim was to compare success rate, adverse events and costs of BDBS with PS in the treatment of post-cholecystectomy cystic duct leak Materials and methods: Patients recruited prospectively for treatment with BDBS during the period 2014-2017 were compared to a control group treated with PS in a non-randomized setting.

Results: Altogether 32 patients (median age 68, range 33-88, 59% male) were treated for Strasberg A bile leak over a period of 3.5 years, accounting for 1.8% of all ERCs. Eight patients were treated with BDBS and 24 with PS. Treatment with BDBS was safe; rate of readmissions and 30-day adverse events were 13% in both groups. There was no statistical difference in the clinical success rate. All cases with laparoscopic lavation or re-ERC with stent exchange occurred in the PS group. Total drain output was lower in BDBS patients (330ml vs 83ml, p=.002). All PS patients required another endoscopy for stent removal, whereas all BDBS patients were spared repeated endoscopy.

Conclusion: Treatment of cystic duct leak with BDBS is highly successful and as safe as traditional treatment with PS. The most obvious benefit of BDBS is that it avoids stent removal. The lower drain output after ERC with a trend for fewer unplanned interventions may indicate more efficient leak resolution with the large bore BDBS.
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http://dx.doi.org/10.1080/00365521.2018.1518480DOI Listing
April 2019

Traumatic cervical spinal cord injury: recovery of penetration/aspiration and functional feeding outcome.

Spinal Cord 2018 Oct 12;56(10):1000-1007. Epub 2018 Mar 12.

Faculty of Social Sciences, University of Tampere, Tampere, Finland.

Study Design: Prospective cohort study.

Objectives: This prospective cohort study aims to evaluate the recovery of penetration/aspiration and functional feeding outcome in patients with acute TCSCI.

Setting: Tampere University Hospital, Tampere, Finland METHODS: Forty-six patients with TCSCI were enrolled. All the patients received speech therapeutic interventions based on their clinical needs and were examined with a videofluoroscopic swallowing study (VFSS) at enrollment. The incidence of VFSS-verified laryngeal penetration/aspiration according to Rosenbek's Penetration-Aspiration Scale (PAS) served as the primary outcome. The secondary outcome was the level of functional oral intake (as per the Functional Oral Intake Scale; FOIS). Based on the PAS results, the patients were divided into two groups: (i) penetrator/aspirators (PAS score ≥3) and (ii) non-penetrator/aspirators (PAS score ≤2). Follow-up VFS studies were primarily conducted on the patients with penetration/aspiration in prior VFS studies. The follow-up VFS studies were scheduled on the basis of clinical demand.

Results: Of the 46 patients, 48% had penetration/aspiration in the first VFSS. The second VFSS was conducted on 20 patients, of whom 6 patients (30%) had penetration/aspiration. The third VFSS was conducted on 9 patients. Of these, only two (22%) patients were still penetrator/aspirators. The majority (n = 37, 88%) of the patients presented a total oral intake without restrictions at the time of the final follow-up. Only one patient (2%) was still tube-dependent with consistent oral intake.

Conclusion: Swallowing physiology in patients with TCSCI improved during the first months after injury, and the number of penetrator/aspirators decreased progressively.
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http://dx.doi.org/10.1038/s41393-018-0091-1DOI Listing
October 2018

MRI texture analysis in differentiating luminal A and luminal B breast cancer molecular subtypes - a feasibility study.

BMC Med Imaging 2017 12 29;17(1):69. Epub 2017 Dec 29.

Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland.

Background: The aim of this study was to use texture analysis (TA) of breast magnetic resonance (MR) images to assist in differentiating estrogen receptor (ER) positive breast cancer molecular subtypes.

Methods: Twenty-seven patients with histopathologically proven invasive ductal breast cancer were selected in preliminary study. Tumors were classified into molecular subtypes: luminal A (ER-positive and/or progesterone receptor (PR)-positive, human epidermal growth factor receptor type 2 (HER2) -negative, proliferation marker Ki-67 < 20 and low grade (I)) and luminal B (ER-positive and/or PR-positive, HER2-positive or HER2-negative with high Ki-67 ≥ 20 and higher grade (II or III)). Co-occurrence matrix -based texture features were extracted from each tumor on T1-weighted non fat saturated pre- and postcontrast MR images using TA software MaZda. Texture parameters and tumour volumes were correlated with tumour prognostic factors.

Results: Textural differences were observed mainly in precontrast images. The two most discriminative texture parameters to differentiate luminal A and luminal B subtypes were sum entropy and sum variance (p = 0.003). The AUCs were 0.828 for sum entropy (p = 0.004), and 0.833 for sum variance (p = 0.003), and 0.878 for the model combining texture features sum entropy, sum variance (p = 0.001). In the LOOCV, the AUC for model combining features sum entropy and sum variance was 0.876. Sum entropy and sum variance showed positive correlation with higher Ki-67 index. Luminal B types were larger in volume and moderate correlation between larger tumour volume and higher Ki-67 index was also observed (r = 0.499, p = 0.008).

Conclusions: Texture features which measure randomness, heterogeneity or smoothness and homogeneity may either directly or indirectly reflect underlying growth patterns of breast tumours. TA and volumetric analysis may provide a way to evaluate the biologic aggressiveness of breast tumours and provide aid in decisions regarding therapeutic efficacy.
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http://dx.doi.org/10.1186/s12880-017-0239-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747252PMC
December 2017

A pilot study of endoscopically inserted biodegradable biliary stents in the treatment of benign biliary strictures and cystic duct leaks.

Gastrointest Endosc 2018 Apr 8;87(4):1132-1137. Epub 2017 Nov 8.

Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; Medical School, University of Tampere, Tampere, Finland.

Background And Aims: Self-expanding biodegradable biliary stents (BDBSs) have recently become available for use in endoscopic retrograde cholangiography (ERC). The aim was to evaluate the effectiveness and safety of novel BDBSs in iatrogenic cystic duct leaks and benign biliary strictures (BBSs).

Methods: Patients providing informed consent were recruited for the prospective study. Braided self-expanding poly-dioxanone BDBSs were inserted using ERC during from 2014 to 2016. Repeated liver function tests and magnetic resonance imaging were performed during follow-up. The main outcomes were treatment success and adverse events.

Results: Thirteen patients, 5 women, median age 67 years (range, 43-79) underwent BDBS insertion for iatrogenic cystic duct leak (n = 7) or BBS (n = 6). Stent insertion using ERC was successful in all cases. All bile leaks were treated uneventfully with BDBSs. In BBSs, the clinical success rate of BDBS therapy was 83% in a median of 21 months of follow-up (range, 14-25). Early ERC-related adverse events included 1 cholangitis (8%) and 1 pancreatitis (8%), both in the stricture group. During the first 90 days, 23% of patients were readmitted for mild cholangitis.

Conclusions: The short- and long-term safety of endoscopically inserted poly-dioxanone BDBSs was satisfactory. The management of cystic duct leaks and benign distal common bile duct strictures was highly successful. Episodes of mild cholangitis during stent indwelling seemed to be typical of BDBSs. The advantage of BDBSs is the avoidance of repeated endoscopy for stent removal. (Clinical trial registration number: NCT02353286.).
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http://dx.doi.org/10.1016/j.gie.2017.10.042DOI Listing
April 2018

A randomized trial of early detection of clinically significant prostate cancer (ProScreen): study design and rationale.

Eur J Epidemiol 2017 06 31;32(6):521-527. Epub 2017 Jul 31.

Department of Urology, Faculty of Medicine and Life Sciences, Tampere University Hospital, University of Tampere, Tampere, Finland.

The current evidence of PSA-based prostate cancer screening shows a reduction in cause-specific mortality, but with substantial overdiagnosis. Recently, new developments in detection of clinically relevant prostate cancer include multiple kallikreins as biomarkers besides PSA, and multiparametric magnetic resonance imaging (mpMRI) for biopsy decision. They offer opportunities for improving the outcomes in screening, particularly reduction in overdiagnosis and higher specificity for potentially lethal cancer. A population-based randomized screening trial will be started, with 67,000 men aged 55-67 years at entry. A quarter of the men will be allocated to the intervention arm, and invited to screening. The control arm will receive no intervention. All men in the screening arm will be offered a serum PSA determination. Those with PSA of 3 ng/ml or higher will have an additional multi-kallikrein panel and those with indications of increased risk of clinically relevant prostate cancer will undergo mpMRI. Men with a malignancy-suspect finding in MRI are referred to targeted biopsies. Screening interval is 6 years for men with baseline PSA < 1.5 ng/ml, 4 years with PSA 1.5-3.0 and 2 years if initial PSA > 3. The main outcome of the trial is prostate cancer mortality, with analysis at 10 and 15 years. The statistical power is sufficient for detecting a 28% reduction at 10 years and 22% at 15 years. The proposed study has the potential to provide the evidence to justify screening as a public health policy if mortality benefit can be sustained with substantially reduced overdiagnosis.
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http://dx.doi.org/10.1007/s10654-017-0292-5DOI Listing
June 2017

Risk factors for laryngeal penetration-aspiration in patients with acute traumatic cervical spinal cord injury.

Spine J 2018 01 30;18(1):81-87. Epub 2017 Jun 30.

Department of Neurosurgery, Tampere University Hospital, PO Box 2000, Tampere FI-33521, Finland.

Background Context: Laryngeal penetration-aspiration, the entry of material into the airways, is considered the most severe subtype of dysphagia and is common among patients with acute cervical spinal cord injury (SCI).

Purpose: The aim of this study was to investigate risk factors for penetration-aspiration in patients with acute traumatic cervical spinal cord injury (TCSCI).

Study Design: This is a prospective cohort study.

Patient Sample: Thirty-seven patients with TCSCI were included in the study.

Outcome Measures: The highest Rosenbek penetration-aspiration scale (PAS; range 1-8) score of each patient was the primary outcome measure. The risk factors consisted of patient characteristics, demographics, and clinical signs observed during a clinical swallowing trial.

Materials And Methods: A clinical swallowing trial and videofluoroscopic swallowing study (VFSS) was performed on all patients within 28 days post injury. For group comparisons, the patients were divided into two groups: (1) penetrator-aspirators (PAS score ≥3) and (2) non-penetrator-aspirators (PAS score ≤2).

Results: Of the 37 patients, 83.8% were male. The mean age at the time of the injury was 61.2 years. Most patients had an incomplete TCSCI (78.4%) caused by a fall (75.7%). In the VFSS, 51.4% of the patients were penetrator-aspirators, and 71.4% had silent aspiration. The risk factors for predicting penetration-aspiration were (1) necessity of bronchoscopies, (2) lower level of anterior cervical operation, (3) coughing, throat clearing, choking related to swallowing, and (4) changes in voice quality related to swallowing. Binary logistic regression identified coughing, throat clearing, choking, and changes in voice quality related to swallowing as independent risk factors for penetration-aspiration.

Conclusions: The necessity of bronchoscopies, postinjury lower cervical spine anterior surgery, coughing, throat clearing, choking, and changes in voice quality related to swallowing was a markedrisk factor for aspiration and penetration following a cervical SCI. These factors and signs should be used to suspect injury-related pharyngeal dysfunction and to initiate preventive measures to avoid complications. The clinical swallowing evaluation is a relevant adjunct in the management of these patients and can improve the detection of penetration and aspiration.
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http://dx.doi.org/10.1016/j.spinee.2017.06.033DOI Listing
January 2018

Author's response: Endoscopic biodegradable biliary stents in the treatment of benign biliary strictures: First report of clinical use in patients.

Dig Endosc 2017 09 18;29(6):732. Epub 2017 Jul 18.

Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.

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http://dx.doi.org/10.1111/den.12911DOI Listing
September 2017

LOW-DOSE CT PROTOCOL OPTIMIZATION FOR THE ASSESSMENT OF ACUTE APPENDICITIS: THE OPTICAP PHANTOM STUDY.

Radiat Prot Dosimetry 2018 Jan;178(1):20-28

Department of Radiology, Medical Imaging Center of Southwest Finland, Turku University Hospital, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland.

The aim was to evaluate effects of voltage, noise input (NI) and iterative reconstruction (IR) on radiation dose and image quality in order to establish a contrast enhanced low-dose protocol for assessment of acute appendicitis. An anthropomorphic abdominal phantom mimicking contrast enhanced abdomen was scanned with 80, 100 and 120 kV, standard and strong IR and 11 NIs (66 protocols). A total of 14 test tubes of increasing iodine dilutions and one tube with an appendicolith were evaluated within the phantom. The dose, HUs, noise, contrast-to-noise ratio (CNR) and figure of merit (FOM) were determined. Visual quality scores were assessed by two readers. A clinically used voltage-IR combination (120 kV, standard IR) was used as a reference. Overall, 100 kV with standard IR (p = 0.002) and 80 kV with both IRs (p < 0.001) showed higher CNR than the reference, but noise was most pronounced at 80 kV (p < 0.001). The highest FOM was found in the 100 kV protocols (p < 0.001). The reference and 100 kV with standard IR had highest image quality scores, where the 100 kV protocol enabled a distinct dose reduction. Lowering the voltage seems to be a more favorable tool than IR changes in optimizing the dose in contrast enhanced abdominal CT.

Trial Registration: ClinicalTrials.gov number, NCT01022567.
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http://dx.doi.org/10.1093/rpd/ncx070DOI Listing
January 2018

Life-course risk factor levels and coronary artery calcification. The Cardiovascular Risk in Young Finns Study.

Int J Cardiol 2016 Dec 28;225:23-29. Epub 2016 Sep 28.

Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku and Turku University Hospital, Kiinamyllynkatu, 20520 Turku, Finland; Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7005, Australia.

Background: Risk factors measured in early life have been shown to predict coronary artery calcium (CAC) in adulthood. However, limited data exist on when risk factor profiles of those who develop CAC diverge from those who do not. We investigated the associations of coronary heart disease risk factor trajectories beginning in adolescence and CAC measured at middle-age.

Methods: CAC was measured among 589 participants aged 39-45years in whom cardiovascular risk factors (serum lipids, blood pressure, body mass index, physical activity, smoking habits, and fruit, vegetable, fish, and butter intake) had been collected in 1980, 1983, 1986, 2001, and 2007 as part of the Cardiovascular Risk in Young Finns Study.

Results: Mean levels of low-density lipoprotein cholesterol (LDL-C), total cholesterol, apolipoprotein B (Apo-B), and systolic blood pressure (SBP) levels across the 27-year period were significantly higher among those with CAC vs. those without. The difference between the groups was 0.25mmol/l (95% confidence interval, 95%CI, 0.079-0.41) for LDL-C, 0.26mmol/l (95%CI 0.080-0.44) for total cholesterol, 0.05mmol/l (95%CI 0.0085-0.091) for Apo-B and 1.92mmHg (95%CI 0.10-3.74) for SBP after adjustment for other risk factors. Those with CAC at age 39-45years had higher serum lipid levels already in adolescence or early adulthood compared with those without CAC, with these differences becoming more pronounced during the life-course.

Conclusions: Long-time risk factor exposure to higher LDL-C, total cholesterol and Apo-B levels already starting in adolescence and higher SBP levels in adulthood is associated with CAC at middle-age.
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http://dx.doi.org/10.1016/j.ijcard.2016.09.080DOI Listing
December 2016

Endoscopic biodegradable biliary stents in the treatment of benign biliary strictures: First report of clinical use in patients.

Dig Endosc 2017 Jan 22;29(1):118-121. Epub 2016 Sep 22.

Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.

The first clinical experience of endoscopically inserted polydioxanone biodegradable biliary stents (BDBS) in the treatment of benign biliary strictures is reported. Two patients with a benign common bile duct stricture were endoscopically treated with 8-mm-bore BDBS during endoscopic retrograde cholangiography. Both BDBS insertions were technically successful and without adverse events. At 6 months, the stricture resolution was excellent and BDBS degradation was predicted in repeated magnetic resonance imaging. The first experience with endoscopic BDBS seems promising in the treatment of benign biliary strictures. During 6 months of follow up, BDBS seemed sufficient for remodeling and resolution of strictures. Further studies are needed to confirm the effectiveness of biodegradable biliary stents in endoscopic management of benign biliary strictures.
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http://dx.doi.org/10.1111/den.12709DOI Listing
January 2017

Pancreatic MRI for the surveillance of cystic neoplasms: comparison of a short with a comprehensive imaging protocol.

Eur Radiol 2017 Jan 31;27(1):41-50. Epub 2016 May 31.

Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Radiology, C1-46 Karolinska University Hospital, 14186, Stockholm, Sweden.

Objectives: The study aims were to evaluate: (1) whether a short-protocol (SP) MRI for the surveillance of pancreatic cystic neoplasms (PCN) provides equivalent clinical information as a comprehensive-protocol (CP), and (2) the cost reduction from substituting CP with SP for patient surveillance.

Methods: This retrospective study included 154 consecutive patients (median age: 66, 52 % men) with working-diagnosis of PCN and available contrast-enhanced MRI/MRCP. Three radiologists evaluated independently two imaging sets (SP/CP) per patient. The CP included: T2-weighted (HASTE/MRCP), DWI and T1-weighted (chemical-shift/pre-/post-contrast) images [acquisition time (AT) ≈ 35 min], whereas the SP included: T2-weighted HASTE and T1-weighted pre-contrast images (AT ≈ 8 min). Mean values of largest cyst/main pancreatic duct diameter (D/D) were compared. Agreement regarding presence/absence of cystic/MPD mural nodules (MN/MN), inter-observer agreement and cost differences between SP/CP were calculated.

Results: For D and D, mean values with SP/CP were 21.4/21.7 mm and 3.52/3.58 mm, while mean differences SP-CP were 0.3 mm (p = 0.02) and 0.06 mm (p = 0.12), respectively. For presence/absence of MN and MN, SP/CP coincided in 93 % and 98 % of cases, respectively. Inter-observer agreement was strong for SP/CP. SP-cost was 25 % of CP-cost.

Conclusions: For the surveillance of PCN, short-protocol MRI provides information equivalent to the more time-consuming and costly comprehensive-protocol.

Key Points: • Pancreatic cystic neoplasms (PCN) are increasingly diagnosed in the general population. • Multiple imaging controls are recommended for the surveillance of patients with PCN. • Short and comprehensive MRI-protocols are equivalent for decision-making in PCN under surveillance. • Evaluation of imaging risk factors in PCNs is comparable with both MRI-protocols. • Use of the short MRI-protocol may rationalise healthcare resources.
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http://dx.doi.org/10.1007/s00330-016-4377-4DOI Listing
January 2017

[FAST ultrasonography].

Duodecim 2016 ;132(8):791-5

FAST ultrasonography has established its status as part of the initial evaluation of a trauma patient. FAST allows for the rapid identification of the presence of free fluid (blood) in the pericardium or in the abdominal cavity. In practical work, examination of the pleurae is usually included in the approach and examination. In addition to free fluid, findings indicating pneumothorax can be searched from them.
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June 2016

Childhood Psychosocial Factors and Coronary Artery Calcification in Adulthood: The Cardiovascular Risk in Young Finns Study.

JAMA Pediatr 2016 05;170(5):466-72

The Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland21Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland.

Importance: There is increasing evidence supporting the importance of psychosocial factors in the pathophysiology of atherosclerotic disease. They have been shown to be associated with the population attributable risk for myocardial infarction.

Objective: To determine if a score of favorable childhood psychosocial factors would be associated with decreased coronary artery calcification in adulthood.

Design, Setting, And Participants: The analyses were performed in 2015 using data gathered in 1980 and 2008 within the longitudinal Cardiovascular Risk in Young Finns Study. The data source consisted of 311 individuals who had psychosocial factors measured at ages 12 years to 18 years and coronary artery calcification measured 28 years later in adulthood. The summary measure of psychosocial factors in childhood comprised measures of socioeconomic factors, emotional factors, parental health behaviors, stressful events, self-regulation of the child, and social adjustment of the child.

Main Outcomes And Measures: Coronary artery calcification at ages 40 years to 46 years.

Results: Of the 311 participants, 48.2% were men. Of the participants, 55 (17.7%) had some calcium observed in their coronary arteries. A 1-SD increase in a favorable summary score of childhood psychological factors was associated with an adulthood coronary artery calcification probability of 0.85 (95% CI, 0.76-0.95) (P = .006). This inverse relationship remained significant after adjustment for age, sex, and conventional childhood risk factors (0.85; 95% CI, 0.74-0.97; P = .02) or for age, sex, adulthood conventional cardiovascular risk factors, socioeconomic status, social support, and depressive symptoms (0.83; 95% CI, 0.71-0.97; P = .02).

Conclusions And Relevance: In this longitudinal study, we observed an independent association between childhood psychosocial well-being and reduced coronary artery calcification in adulthood. A positive childhood psychosocial environment may decrease cardiovascular risk in adulthood and may represent a potentially modifiable risk determinant.
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http://dx.doi.org/10.1001/jamapediatrics.2015.4121DOI Listing
May 2016

Tumor-like Chronic Pancreatitis Is Often Autoimmune Pancreatitis.

Anticancer Res 2015 Nov;35(11):6163-6

Department of Surgery, Helsinki University Hospital, Helsinki, Finland Research Programs Unit, Translational Cancer Biology, University of Helsinki, Helsinki, Finland.

Background: Distinguishing between pancreatic cancer and chronic pancreatitis (CP) is often difficult. Certain (5-6%) CP cases are autoimmune in nature, and these patients respond to corticosteroid treatment, making surgery avoidable. Our aim was to evaluate the incidence of autoimmune pancreatitis (AIP) among patients operated on for a pancreatic mass with a final histology of CP.

Patients And Methods: A total of 33 patients were operated on at the Tampere or Helsinki University Hospital for suspicion of cancer, but with final histopathological diagnosis of CP. The median age was 58 (31-81) years; 26 patients (79%) were male. There were 28 pancreaticoduodenectomes and five left pancreatic resections. Surgical specimens were re-evaluated by experienced pathologists, with representative samples chosen for immunohistochemistry Each sample was scored as positive or negative for immunoglobulin G4 (IgG4) independently by two pathologists. Honolulu consensus criteria served for AIP sub-typing.

Results: Out of the 33 specimens, 10 (30%) were positive for IgG4. Histopathological re-evaluation of these revealed all to be type 1 AIP.

Conclusion: The proportion of AIP, according to IgG4-positive immunohistochemistry and histological re-evaluation, was much higher than expected. This suggests that by focusing on diagnosis of AIP preoperatively, certain patients might be treated with corticosteroids and possibly avoid unnecessary surgery.
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November 2015

Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial.

JAMA 2015 Jun;313(23):2340-8

Division of Digestive Surgery and Urology, Departments of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland2Department of Surgery, Turku University, Turku, Finland.

Importance: An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis.

Objective: To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography (CT).

Design, Setting, And Participants: The Appendicitis Acuta (APPAC) multicenter, open-label, noninferiority randomized clinical trial was conducted from November 2009 until June 2012 in Finland. The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Patients were randomly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period.

Interventions: Patients randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy.

Main Outcomes And Measures: The primary end point for the surgical intervention was the successful completion of an appendectomy. The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period.

Results: There were 273 patients in the surgical group and 257 in the antibiotic group. Of 273 patients in the surgical group, all but 1 underwent successful appendectomy, resulting in a success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic group, 70 patients (27.3%; 95% CI, 22.0% to 33.2%) underwent appendectomy within 1 year of initial presentation for appendicitis. Of the 256 patients available for follow-up in the antibiotic group, 186 (72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0% (95% CI, -31.6% to ∞) (P = .89). Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery. Of the 70 patients randomized to antibiotic treatment who subsequently underwent appendectomy, 58 (82.9%; 95% CI, 72.0% to 90.8%) had uncomplicated appendicitis, 7 (10.0%; 95% CI, 4.1% to 19.5%) had complicated acute appendicitis, and 5 (7.1%; 95% CI, 2.4% to 15.9%) did not have appendicitis but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients randomized to antibiotic treatment.

Conclusions And Relevance: Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications.

Trial Registration: clinicaltrials.gov Identifier: NCT01022567.
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http://dx.doi.org/10.1001/jama.2015.6154DOI Listing
June 2015

Accuracy of 18F-FDG PET/CT, Multidetector CT, and MR Imaging in the Diagnosis of Pancreatic Cysts: A Prospective Single-Center Study.

J Nucl Med 2015 Aug 4;56(8):1163-8. Epub 2015 Jun 4.

Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.

Unlabelled: Accurate diagnosis of the nature of pancreatic cysts is challenging but more important than ever, in part because of the increasing number of incidental cystic findings in the pancreas. Preliminary data suggest that (18)F-FDG PET/CT may have a significant influence on clinical decision making, although its role is still evolving. Our aim was to prospectively compare the accuracy of combined (18)F-FDG PET and contrast-enhanced CT ((18)F-FDG PET/CT), multidetector CT (MDCT), and MR imaging in differentiating malignant from benign pancreatic cysts.

Methods: Thirty-one consecutive patients with pancreatic cysts were enrolled in the study. They underwent a protocol including (18)F-FDG PET/CT, MDCT, and MR imaging combined with MR cholangiopancreatography, all of which were evaluated in a masked manner. The findings were confirmed macroscopically at surgery or histopathologic analysis (n = 22) or at follow-up (n = 9).

Results: Of the 31 patients, 6 had malignant and 25 had benign lesions. The diagnostic accuracy was 94% for (18)F-FDG PET/CT, compared with 77% and 87% for MDCT (P < 0.05) and MR imaging, respectively. (18)F-FDG PET/CT had a negative predictive value of 100% and a positive predictive value of 75% for pancreatic cysts. The maximum standardized uptake value was significantly higher in malignant (7.4 ± 2.6) than in benign lesions (2.4 ± 0.8) (P < 0.05). When the maximum standardized uptake value was set at 3.6, the sensitivity and specificity were 100% and 88%, respectively. Furthermore, when compared with MDCT and MR imaging, respectively, (18)F-FDG PET/CT altered the clinical management of 5 and 3 patients, respectively.

Conclusion: (18)F-FDG PET/CT is an accurate imaging modality for differentiating between benign and malignant pancreatic cysts. We recommend the use of (18)F-FDG PET/CT in the evaluation of diagnostically challenging pancreatic cysts.
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http://dx.doi.org/10.2967/jnumed.114.148940DOI Listing
August 2015

Symptoms of Sternal Nonunion Late after Cardiac Surgery.

Thorac Cardiovasc Surg 2017 Jun 24;65(4):325-331. Epub 2015 Apr 24.

Department of Cardiothoracic Surgery, Heart Center Co., Tampere University Hospital, Tampere, Finland.

 A cohort of patients having symptoms of sternal nonunion late after sternotomy was studied to find out whether the complaints were related to true sternal nonunion or decreased bone density.  A survey was mailed to 2,053 cardiac surgical patients operated in our institution between July 2007 and June 2010. The patients were requested about symptoms referring to sternal instability. A group of symptomatic individuals as well as 1:1 age- and time-matched asymptomatic controls were examined with sternal palpation, ultrasound during standardized sternal pressure provocation, and computed tomography (CT).  The number of patients replied in the survey was 1,918 (93.4%); 2.3% (44 patients) reported sensation of movement or clicking in sternum during body movements and during coughing. Symptomatic patients living within 200 km to the hospital (21) and their asymptomatic controls (21) were selected for further clinical and imaging studies. Mean period between the initial operation and the examinations was 36 (22-56) months. Sternal palpation pain was significantly associated with reported symptoms suggestive of sternal nonunion (odds ratio [OR] 22.0; 95% confidence interval [CI] 2.5-195); however, none of the patients had clinically unstable sternum or nonunion in the sternal imaging. The symptoms of sternal instability were more frequent in patients whose bone mineralization rate (as measured with T-scores) was higher.  Symptoms suggestive of sternal nonunion were experienced by 2.3%. However, their symptoms did not correlate with CT scans or provocation ultrasound although palpation pain was evident. Thus the pain is derived from nonmechanical etiologies. Higher bone mineralization rate correlated with abnormal symptoms of sternal wound.
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http://dx.doi.org/10.1055/s-0035-1549360DOI Listing
June 2017