Negative associations between maternal prenatal hair cortisol and child socioemotional problems

Maternal prenatal distress can participate in the programming of offspring development, in which exposure to altered maternal long-term cortisol levels as measured by hair cortisol concentrations (HCC) may contribute. Yet, studies investigating whether and how maternal prenatal HCC associates with problems in child socioemotional development are scarce. Furthermore, questions remain regarding the timing and potential sex-specificity of fetal exposure to altered cortisol levels and whether there are interactions with maternal prenatal distress, such as depressive symptoms. The subjects were drawn from those FinnBrain Birth Cohort families that had maternal reports of child socioemotional problems (the Brief Infant-Toddler Social and Emotional Assessment [BITSEA] at 2 years and/or the Strengths and Difficulties Questionnaire [SDQ] at 5 years) as follows: HCC1 population: maternal mid-pregnancy HCC measured at gestational week 24 with 5 cm segments to depict cortisol levels from the previous five months (n = 321); and HCC2 population: end-of-pregnancy HCC measured 1-3 days after childbirth (5 cm segment; n = 121). Stepwise regression models were utilized in the main analyses and a sensitivity analysis was performed to detect potential biases. Negative associations were observed between maternal HCC2 and child BITSEA Total Problems at 2 years but not with SDQ Total difficulties at 5 years, and neither problem score was associated with HCC1. In descriptive analyses, HCC2 was negatively associated with Internalizing problems at 2 years and SDQ Emotional problems at 5 years. A negative association was observed among 5-year-old girls between maternal HCC1 and SDQ Total Difficulties and the subscales of Conduct and Hyperactivity/inattentive problems. When interactions were also considered, inverse associations between HCC2 and BITSEA Internalizing and Dysregulation Problems were observed in subjects with elevated prenatal depressive symptoms. It was somewhat surprising that only negative associations were observed between maternal HCC and child socioemotional problems. However, there are previous observations of elevated end-of-pregnancy cortisol levels associating with better developmental outcomes. The magnitudes of the observed associations were, as expected, mainly modest. Future studies with a focus on the individual changes of maternal cortisol levels throughout pregnancy as well as studies assessing both maternal and child HPA axis functioning together with child socioemotional development are indicated.

Hair cortisol, cortisone and DHEA concentrations and the composition of microbiota in toddlers

Animal research suggests that the gut microbiota and the HPA axis communicate in a bidirectional manner. However, human data, especially on early childhood, remain limited. In this exploratory design, we investigated the connections between long-term HPA axis functioning, measured as cortisol, cortisone or dehydroepiandrosterone concentrations and their ratios from hair segments of three centimeters, and gut microbiota profiles, (measured as diversity and bacterial composition by 16 S rRNA sequencing) in healthy 2.5-year-old toddlers (n = 135) recruited from the FinnBrain Birth Cohort Study. The alpha diversity of the microbiota was studied by linear regression. Beta diversity analyses with weighted UniFrac or Bray-Curtis distances were performed using PERMANOVA. The bacterial core genus level analyses were conducted using DESeq2 and ALDEx2. These analyses suggested that hair sample concentrations of separate hormones, cortisol/cortisone and cortisol/dehydroepiandrosterone ratios were associated with various gut bacterial genera such as the Veillonella, the [Ruminococcus] torques group and [Eubacterium] hallii group, although multiple testing correction attenuated the p-values. Alpha or beta diversity was not linked with either steroid concentrations or ratios. These findings in toddlers suggest that long-term HPA axis activity may be related to genera abundancies but not to ecosystem-level measures in gut microbiota. The influence of these observed interrelations on later child health and development warrants further research.

Prevalence of atrial fibrillation – a comprehensive nationwide analysis in Finland

Introduction

Prevalence of atrial fibrillation (AF) is strongly associated with age, and with longer life-time expectancy number of AF patients is worldwide strongly increasing. However, nationwide prevalence of AF is not known when primary care data as well is accessible.

Purpose

The FinACAF-study is a nationwide registry study including of all AF patients searched from all available national health care registers. To our knowledge, this is the first nationwide AF study including both primary, secondary, and tertiary health care register data. The aim of this study was to assess the prevalence of AF in unselected nationwide population in Finland.

Methods

In the FinACAF study we gathered data of all AF patients (hospitalizations and outpatient specialist visits and primary health care, and National Reimbursement Register) from all national health care registers from 01st January 2004 to 31st December 2018. The annual prevalence on December 31st of each year 2007–2018 was calculated as the cumulative number of patients alive with AF divided by the number of Finnish population on the last day of that year. The prevalence is presented for population ≥20 years, and with the entire population as the background population, as well as for populations ≥65 years, and ≥75 years.

Results

In total, 411,387 patients with the diagnosis of AF were documented during 2004–2018 in Finland. The number of adult patients with AF at the end of the study period in 2018 was 226,847, corresponding to an AF prevalence of 5.2% in the age group ≥20 years. The prevalence in the total Finnish population was 4.1%. The prevalence rates increased remarkably with increasing age and were higher in men compared to women (5.9% vs. 4.6%, p<0.001) in all age groups (Figure 1). The prevalence of AF in the adult population increased remarkably from 2.5% in 2007 to 5.2% in 2018 (p<0.001) (Figure 2). Among the population ≥65 years the prevalence in 2018 was 15.3%, and in the elderly, ≥75 years the prevalence of AF was 23.4%.

Conclusions

Based on comprehensive, nationwide data – also including the primary care – we observed extremely increasing prevalence of AF in the older population, as well as remarkably increasing prevalence of AF over time.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District

Characteristics of incident atrial fibrillation patients – a nationwide register-based study with information from primary-, secondary- and tertiary care

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a current prevalence of 4.1% in Finland. Many of the comorbidities associated with AF are known risk factors for the arrhythmia and vice versa, as well as contributors to the risk of stroke and other AF related adverse events. A generally used evaluation method for the risk of stroke is the clinical risk factor -based CHA2DS2-VASc score, but other thromboembolic risk factors also exist.

Purpose

To better understand current AF population, this study describes characteristics, comorbidities, medication, and laboratory values of Finnish AF patients at the time of first AF diagnosis.

Methods

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide register-based cohort study in which AF patient data has been linked from several Finnish health care- and national registers, with information from primary-, secondary-, and tertiary care. This substudy consists of patients over 20 years old with available laboratory data and an incident AF diagnosis (ICD-10 I48) between 1/1/2010–31/12/2018 in any of the used registers.

Results

Within the study period 143,455 patients with a new AF were registered. The mean age at time of diagnosis was 69.1 years for men and 76.3 years for women. The mean CHA2DS2-VASc score when entering the cohort was 3.48 (SD 1.88), and 84.9% of the cohort had at least one of the comorbidities included in the CHA2DS2-VASc score. The most prevalent comorbidities and medications of the cohort are shown in the figure, and a more comprehensive look is presented in the table. The medications listed have been in use during the year before cohort entry.

Conclusion

Atrial fibrillation does not come alone. Almost all patients diagnosed with AF have previous comorbidities and medications. Future analysis will provide information on how these evolve after AF diagnosis and elucidate their association with different endpoints.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District

Risk of stroke and transient ischemic attack after elective cardioversion of atrial fibrillation: a nationwide study in Finland

Background

Cardioversion is routinely used to restore sinus rhythm in patients with atrial fibrillation (AF). Elective cardioversion (ECV) is associated with an increased risk of thromboembolic complications even during adequate oral anticoagulation (OAC).

Purpose

The aim was to analyze the incidence of ischemic stroke and transient ischemic attack (TIA) after first-ever ECV of AF in patients using guideline-recommended OAC.

Methods

This nationwide register-based study includes all (N=9625) AF patients undergoing their first-ever ECV between 2012 and 2018 in Finland. Data was obtained from the Finnish health care registers, including both primary and special health care. The risk of stroke and TIA within 30 days after ECV were estimated in patients using OAC.

Results

The mean age of patients was 68 (±9.9) years, 61.2% were men, and the mean CHA2DS2-VASc score was 2.6 (±1.6, range 0–9). Warfarin was used in 6245 (64.9%) and non-vitamin K oral anticoagulants in 3380 (35.1%) cardioversions, of which 1453 (15.1%) was rivaroxaban, 1246 (12.9%) apixaban, 635 (6.6%) dabigatran, and 46 (0.5%) edoxaban. Twenty-nine (0.3%; 95% confidence interval [CI] 0.2–0.4%) ischemic strokes or TIAs occurred within 30 days after ECV (median 3 days, interquartile range 2.0–8.5) (Figure 1 and Table 1). In warfarin-treated patients experiencing stroke or TIA, the mean INR value before ECV and at the time of stroke or TIA were 2.5 (±0.5) and 2.5 (±0.5), respectively. One of the patients had INR-value <2.0 before ECV and at the time of stroke and one patient had INR value <2.0 before ECV.

Conclusion

In our nationwide study, the rate of stroke and TIA after first-ever ECV was low (0.3%) in all OAC groups.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District

Gastrointestinal bleeding preceding new-onset atrial fibrillation - results from the nationwide FinACAF study

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District Funding The Finnish Foundation of Cardiovascular Research

Introduction

Initiation of oral anticoagulation (OAC) in case of a new-onset atrial fibrillation (AF) requires assessment of bleeding history. Gastrointestinal (GI) bleedings are among the most common bleeding events.

Purpose

We aimed to assess clinical characteristics and initiation of OAC in patients with new-onset AF and a history of previous GI bleeding.

Methods

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide study among AF patients conducted as a retrospective register-based linkage study combining data from several Finnish health care registers. The study population consists of all patients diagnosed with AF between the years 2010-2018 and with laboratory data available. Patients were identified from nationwide primary care and reimbursement registries and hospitalization records. OAC purchases at 90 days from cohort entry were obtained from the National Prescription Register upheld by the Social Insurance Institution of Finland.

Results

134 242 patients from the initial FinACAF cohort were included in this substudy. Of these, 6543 (4.9%) patients had a history of GI bleeding. Those with GI bleeding were more often male (52.6%), older (mean age 76.6 ± 11.4 vs 72.4 ± 13.1 years), and had more comorbidities. They also had lower blood hemoglobin (mean 124.9 ± 21.3 vs 135.8 ± 18.4 g/l) and higher serum creatinine (mean 99.7 ± 75.8 vs 87.5 ± 52.7 µmol/l) levels than patiens without preceding GI bleeding. Furthermore, initiation of OAC medication was less frequent in the GI bleeding group (46.9% vs 58.6%).

Patient characteristics of the study population including age, sex, comorbidities, OAC medication and laboratory findings are shown in Figures 1 and 2.

Conclusions

Patients with AF and preceding GI bleeding are vulnerable to rebleeding events. This may affect decision-making of clinicians, leading to more infrequent initiation of OAC medications.

CHA2DS2-VASc score and the risk of death in atrial fibrillation

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Sigrid Juselius Foundation

Background

Atrial fibrillation (AF) is recognized as a major public health problem due to increased mortality, morbidity and risk of stroke. Advanced age and burden of other comorbidities are potential contributors to AF development and adverse outcomes. Clinical risk factor based CHA2DS2-VASc score is widely used to assess thromboembolic risk in AF, but mortality risk associated with different CHA2DS2-VASc scores is not established.

Purpose

Using data from a nationwide AF registry study including comorbidities and outcomes of unselected AF patients, we wanted to study whether CHA2DS2-VASc score could be useful in estimating prognosis in newly diagnosed AF patients.

Methods

New-onset AF patients in Finland 2007-2017 were identified from comprehensive national registries. Comorbidities were gathered from individualized registry data on drug reimbursements and from ICD-10 diagnoses during hospitalizations and outpatient visits in primary and specialist care. These were used to create CHA2DS2-VASc risk score for each AF patient at cohort entry, including data on heart failure, hypertension, age, diabetes, stroke, vascular disease and sex. Patients were followed until the end of 2018 from the causes of death registry, which records every death in the country. All-cause mortality in each CHA2DS2-VASc category per 1000 person-years was determined, and relative risk (RR) of death according to the CHA2DS2-VASc category was calculated.

Results

A total of 229 357 patients with new-onset AF (mean age 73.2 ± 13.2 years, 50.0% female) were identified. Distribution of CHA2DS2-VASc score among these individuals is shown in Table. Mortality increased significantly with rising CHA2DS2-VASc risk score points, as demonstrated in Table. Compared to CHA2DS2-VASc 0, those with 2 points had a RR 2.9 (95%CI 2.7-3.1), 3 points RR 5.0 (4.7-5.3), 4 points RR 8.0 (7.5-8.4), 5 points RR 11.0 (10.4-11.7) and >5 points RR 14.8 (14.0-15.7) for all-cause mortality.

Conclusions

In new-onset AF, mortality increased drastically with increasing age and comorbidities as depicted in the CHA2DS2-VASc score. Besides assessing thromboembolic risk, CHA2DS2-VASc score seems to be useful in estimating survival of AF patients.

Mortality and causes of death after new-onset atrial fibrillation: a nationwide study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Sigrid Juselius Foundation

Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, and its prevalence is increasing with aging population. AF is associated with increased cardiovascular morbidity and mortality, but the prognosis of newly detected AF in the general population is not well established.

Purpose

Using data from the large FinACAF-study, a comprehensive nationwide retrospective cohort study including all diagnosed Finnish AF patients, we studied one-year mortality after new-onset AF in the general population and determined the causes of death of deceased AF patients.

Methods

All patients with new-onset AF in Finland 2007-17 were identified from nationwide primary care and reimbursements registries and hospitalization records. Baseline characteristics of these patients were determined, and their survival was followed from registries for one year. Principal cause of death was determined from death certificate’s International Classification of Diseases (ICD-10) Codes.

Results

A total of 229 321 patients with first-diagnosed AF were identified (50.0% female). Mean age of men and women with new-onset AF was 69.4 ± 13.4 and 77.1 ± 11.8 years, respectively (p<0.001 for difference). In men and women, hypertension had been diagnosed in 68.0% vs 80.4% (p<0.001), congestive heart failure in 15.4% vs 19.3% (p<0.001), diabetes in 22.5% vs 20.7% (p<0.001) and vascular disease in 27.2% vs 24.8% (p<0.001), respectively. Prior stroke or transient ischemic attack had occurred in 14.0% of men and 16.8% of women (p<0.001).

During the one-year follow-up, 11.6% of men and 13.7% of women died (Figure). Most common cause of death in these patients was ischaemic heart disease (26.2% of all deaths), followed by malignancies (17.4%) and dementia (12.4%). Cerebrovascular diseases were responsible for 10.8% of mortality.

Conclusion

In this population-based nationwide study, we demonstrated that one-eight of patients with new AF died within one year of the diagnosis. Ischaemic heart disease was most frequent cause of death.

Use of antihypertensive medication before diagnosis of atrial fibrillation in Finland – results from the nationwide FinACAF -study

Background and aims

Long-standing arterial hypertension increases the risk of cardiovascular morbidity including atrial fibrillation (AF), coronary heart disease and renal failure. Arterial hypertension is the most common aetiologic factor associated with the development of AF and is also the most prevalent co-morbid cardiovascular disease in patients with AF. Coexisting arterial hypertension together with AF increases further the risk of stroke, heart failure and overall mortality.

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) -study is a nationwide retrospective register-based AF study that combines data from several Finnish health care registers. In this sub-study, we characterized the use of antihypertensive medications in patients with new-onset AF.

Methods

This sub-study included all adult new-onset AF patients of the FinACAF study from January 2007 to December 2018. Patients were excluded if they were under 18 years of age, had any oral anticoagulant purchase in the year prior to AF diagnosis, or had diagnosis of AF or warfarin purchases between the years 2004–2006.

Appropriate data such as anonymized study ID's, ICD-10 diagnoses, and drug purchases (dates, ATC-codes, amounts) were obtained from the National Prescription Register as well as the Finnish Hospital and Primary care registers. The antihypertensive medication purchases from the year preceding the AF diagnosis were analysed and identified by appropriate ATC-codes. Purchases one-month prior to the new-onset AF diagnosis were excluded from in order to avoid confounding by any medication changes due to AF diagnosis.

Results

Of 229,282 patients with new-onset AF 164,527 (71.8%) had purchased antihypertensive medication during the year prior to the AF diagnosis. The most common antihypertensive drugs used were beta blockers (n=108,510; 47.3%), ACE-inhibitors or angiotensin receptor blockers (n=104,840; 45.7%), diuretics (n=79,270; 34.6%) and selective calcium channel blockers (n=61,610; 26.9%). Diltiazem was purchased by 2,001 patients (0.9%) and verapamil by 1,508 patients (0.7%). At the beginning of the study period, beta-blockers were the most widely used antihypertensive agents, but between 2007 and 2018, RAAS-inhibitors (ACE inhibitors and ARB blockers) became the most widely used group of antihypertensive drugs (Figure 1).

Conclusion

Most Finnish new-onset AF patients had at least one pre-existing antihypertensive medication in use before the diagnosis of AF. Beta blockers were the most common antihypertensives until the latest years when RAAS-inhibitors became the most prescribed antihypertensive agents, whereas the use of diltiazem and verapamil was marginal in the treatment of hypertension before the AF diagnosis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Helsinki and Uusimaa Hospital District research fundThe Finnish Foundation for Cardiovascular Research Figure 1. Annual use of antihypertensive medication among Finnish new-onset AF patients prior to diagnosis. Annual number of new-onset AF patients plotted for reference.

Incidence of atrial fibrillation. A comprehensive nationwide analysis in Finland

Introduction

Atrial fibrillation (AF) is a chronic condition, and once diagnosed, most of the patients need life-long treatment for AF; rate and rhythm control for symptom relief and oral anticoagulation to mitigate the associated risk of stroke. Incidence of AF is strongly associated with age, and with longer life-expectancy the number of AF patients is worldwide rapidly increasing.

Purpose

The FinACAF study is a nationwide registry study including all AF patients searched from comprehensive national health care registers. To our knowledge, FinACAF is the first nationwide study including both primary, secondary, and tertiary health care register data. The aim of this study was to assess the incidence of new-onset AF in unselected nationwide population in Finland.

Methods

In the FinACAF study we gathered data (hospitalizations, outpatient specialist and primary health care visits, and drug reimbursement) from all national health care registers to identify new-onset AF patients from 01st January 2004 to 31st December 2018.

To minimize the risk of misclassification, we considered a patient to have incident AF only if the new-onset AF diagnosis emerged after 1st January 2007 allowing at least three years of registration in Finnish health care registers without diagnosis of AF. Furthermore, patients with warfarin prescriptions during 2004–2006 were excluded. Raw incidence rates (1/100 000) were calculated using the total number of incident AF cases during a given year as numerator, and the total number of Finnish population free of AF on the last day of that year as denominator. The age-standardized incidence rates (1/100 000) were calculated using the total number of new-onset AF cases per year compared to the Nordic population free of AF age distribution.

Results

In total, 411 080 patients with the diagnosis of AF were documented during 2004–2018 in Finland, and the number of new-onset AF patients during 2007–2018 was 256 323. The incidence of AF in relation to age is shown in the Figure 1, and the increasing incidence with advancing age is outstandingly seen. Incidence of AF was more than 2000/100 000 in the population 80 years or older. The incidence of new-onset AF in the whole Finnish population increased during the study period from 330/100 000 and peaked to 456/100 000 in 2018. However, after adjustment for age, the age-adjusted AF incidence remained unchanged during 2007–2018 (Figure 2), but an obvious leap in the incidence emerged during 2011–2013 when the national primary care register was established.

Conclusions

In 2018 the incidence of AF per the whole population was 456/100 000. Based on very novel data and including all the known, diagnosed AF patients in Finland, this is the highest reported incidence rate of AF. Incidence of AF is strongly age-dependent, but the age-standardized incidence was not significantly changed from 2007 to 2018.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District research fundThe Finnish Foundation for Cardiovascular Research The incidence of AF in relation to ageAge-adjusted annual incidence of AF

Renal function and use of medication preceding new-onset atrial fibrillation – results from the nationwide FinACAF study

Background and aims

Chronic kidney disease (CKD) is a global public health problem with an increasing number of patients due to obesity, hypertension, diabetes, and aging. CKD is an independent risk factor for atrial fibrillation (AF) and the incidence of AF in patients with CKD is two- to threefold higher compared to the general population. The relationship between CKD and AF is bidirectional, and the incidence of renal insufficiency is higher in patients with AF. Both AF and CKD are associated with increased risk of stroke and systemic thromboembolism, as well as an increased bleeding risk. The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide study among AF patients conducted as a retrospective register-based linkage study combining data from several Finnish health care registers. We aimed to characterize demographics and medications of patients with new-onset AF included FinACAF according to stages of renal function.

Method

The FinACAF study includes data from 411000 patients covering all Finnish AF patients from 1 January 2004 to 31 December 2018. Using national unique personal identification numbers, individual patients' data from ten nationwide population registries and six regional laboratory databases were linked together. The inclusion criteria of this substudy were all patients 20 years or older with a new-onset AF diagnosis between January 2010 and December 2018 and a measured estimated glomerular filtration rate (eGFR) within the proximity of the AF diagnosis. Drug purchases (date, Anatomical Therapeutic Chemical (ATC) codes, and amount) were obtained from the National Prescription Register upheld by the Social Insurance Institution of Finland.

Results

147001 patients from the initial FinACAF cohort were included in this substudy. The mean age at the time of AF diagnosis was 73 years (range 20 to 107 years), 48.9% of the patients were female. The mean age of AF patients increased in various stages of glomerular filtration at the cohort entry during 2010–2018. Baseline medications are shown in Table. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) at the cohort entry decreased from 27.4% to 22.1% during 2010–2018 (p<0.001).

Conclusions

Medications were used increasingly with worsening renal function, except for NSAIDs.

NSAIDs use remained remarkably high in all stages of renal function, albeit much less with the lowest eGFRs. The number of patients with lipid-lowering medication was unexpectedly low considering the high cardiovascular risk in patients with impaired renal function.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This work was supported by Aarne Koskelo Foundation, Yrjö Jahnsson Foundation, The Finnish Foundation for Cardiovascular Research, and Helsinki and Uusimaa Hospital District research fund (TYH2019309).

All you want to know about the arrhythmia: A comprehensive, nationwide registry study of atrial fibrillation in Finland

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District Funding The Finnish Foundation for Cardiovascular Research

OnBehalf

FinACAF

Introduction

The number of atrial fibrillation (AF) patients is increasing, and thus, the socio-medico-economic impact of AF is exploding.  Up-to-date, multifaceted data about the characteristics of AF patients, their treatments, and outcomes are urgently needed.

Purpose

The aim of the Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is to evaluate the incidence and prevalence of AF, risk of stroke, thromboembolic complications, myocardial infarction, major bleeding events, and mortality in AF patients using comprehensive nationwide registries regulated by law. Assessment of the socio-medico-economic aspects of AF and the effect of socio-economic factors on the AF treatment play a central role in this study.

Methods

The FinACAF study collects data from 411 000 patients covering all Finnish AF patients from 1st January 2004 to 31st December 2018. Using national unique personal identification number, individual patient data from ten nationwide population registries and six regional laboratory databases (∼282000, 77 % of the patients) are linked together. All the register data were obtained during Q1-Q2/2020. The main results will be expected during Q1-2/2021.

Results

Since the introduction of the national primary care register in 2012, 9% of all AF patients were identified outside hospital care registers. The total number of AF patients on 31st December 2018 was 227 114, which translates to an AF prevalence of 4.1% in Finland (population of 5 517 900).

The Table represents the registries used in the FinACAF study.

Conclusions

The FinACAF study records all patient contacts with the health care institutions and organizations, as well as incomes and places of domicile. Thus, the database allows a unique possibility to investigate the epidemiology and socio-medico-economic impact of AF as well as the cost effectiveness of different AF management strategies in a completely unselected, nationwide population. This data will markedly help "leading with data" when the increasing number of AF patients are treated. The registries used in the FinACAF study Register Registry Information obtained Finnish Care Register for Health Care: Primary, Hospital and Social care registries National Institute for Health and Welfare Diagnosis (ICD-10), procedure codes and date; non-hospital institutionalizations National Prescription Register, National Reimbursement Register The Social Insurance Institution of Finland Drug purchases (date, ATC codes, amount), Reimbursement decisions for chronic diseases (date, ICD-10) National Causes of Death Register, The Register of Completed Education and Degrees Statistics Finland Deaths and causes of deaths (ICD-10), Education and socio-economic status National Cancer Registry (1st Jan 1950 to 31st Dec 2018) Finnish Cancer Registry National registry of all cancer cases (e.g. date, ICD-O-3, TNM) Population Register, Tax register Population Register Center, Tax Administration Places of domicile, Income and taxes Laboratory databases (1st Jan 2010 to 31st Dec 2018) Six largest regional laboratory databases INR and other relevant laboratory measurements

Scraping up CHA2DS2-VASc - defining components of the acronym in a nationwide registry study

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital district Finnish foundation for cardiovascular research

Introduction

Atrial fibrillation (AF) is a major cause of ischemic stroke. The risk of stroke is strongly associated with age, sex and comorbidities of the patients. Therefore, it is crucial that the comorbidities are consistently recorded in medical records as well as health care registries.

Purpose

This study aims to evaluate the prevalence of the comorbidities related to AF stroke risk in Finnish nationwide population registries, and assess how the use and combination of these registries affect the calculated CHA2DS2-VASc risk score. The comorbidities evaluated were Hypertension, Diabetes, Stroke or TIA, Heart Failure, and Vascular Disease.

Methods

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study collected data on all Finnish AF patients from 1st January 2004 to 31st December 2018. Due to the initiation of the national primary care register in 2012, this substudy uses the data of patients with a new AF diagnosis during 2012-2018 (n = 168 353). Using a unique personal identification code, individual patient data were linked from the Finnish national health care registries "AvoHILMO" (primary care) and "HILMO" (secondary and tertiary care), National Prescription Register (ATC codes of purchased medication) and the National Reimbursement Register for reimbursed medication upheld by the Social Insurance Institute (KELA).

Results

The average CHA2DS2-VASc risk score when entering the cohort, and including information from all registries, equaled 2.91 for men (mean age 70.0 years) and 4.42 for women (mean age 76.9 years). The highest prevalence of diabetes and hypertension were found based on the National Reimbursement Register (ATC codes). Stroke or TIA and heart failure were identified almost exclusively based on secondary and tertiary hospital records.

The table represents our results. 

Conclusion

Comprehensive registry analysis of AF patients requires the inclusion of both hospital and medication data. The role of primary care information was limited. Comorbidity and CHA2DS2-VASc weight Total Prevalence Primary care ICD-10 codes Primary care ICPC-2 codes Secondary and tertiary care ICD-10 codes ATCcodes Medication reimbursement codes Hypertension 1 82%137 317 28%47 337 13%21 427 39%66 252 77%130 400 7%10 957 Diabetes 1 24%41 017 13%22 666 13%22 547 14%23 793 21%35 942 12%20 295 Stroke or TIA 2 17%28 653 4%6 254 1%1 968 16%27 379 - - Heart Failure 1 18%29 827 5%7 630 1%1 398 16%26 366 - 1%1 908 Vascular Disease1 28%47 420 12%19 581 2%3 265 25%41 647 - 7%11 802 Average CHA2DS2-VASc contribution 1.86 0.65 0.31 1.26 0.99 0.26 The prevalence of the comorbidities and average CHA2DS2-VASc risk score contribution by registry and combined.

Maternal prenatal psychological distress and hair cortisol levels associate with infant fecal microbiota composition at 2.5 months of age

BACKGROUND

Maternal prenatal stress associates with infant developmental outcomes, but the mechanisms underlying this association are not fully understood. Alterations in the composition and function of infant intestinal microbiota may mediate some of the observed health effects, a viewpoint that is supported by animal studies along with a small human study showing that exposure to prenatal stress modifies the offspring's intestinal microbiota. In the current study, we aim to investigate the associations between maternal prenatal psychological distress (PPD) and hair cortisol concentration (HCC) with infant fecal microbiota composition in a large prospective human cohort.

METHODS

The study population was drawn from FinnBrain Birth Cohort Study. Maternal PPD was measured with standardized questionnaires (EPDS, SCL, PRAQ-R2, Daily Hassles) three times during pregnancy (n = 398). A measure addressing the chronicity of PPD was composed separately for each questionnaire. HCC was measured from a five cm segment at gestational week 24 (n = 115), thus covering the early and mid-pregnancy. Infant fecal samples were collected at the age of 2.5 months and analyzed with 16S rRNA amplicon sequencing.

RESULTS

Maternal chronic PPD (all symptom measures) showed positive associations (FDR < 0.01) with bacterial genera from phylum Proteobacteria, with potential pathogens, in infants. Further, chronic PPD (SCL, PRAQ-R2, and Daily Hassles negative scale) associated negatively with Akkermansia. HCC associated negatively with Lactobacillus. Neither maternal chronic PPD nor HCC associated with infant fecal microbiota diversity.

CONCLUSION

Chronic maternal PPD symptoms and elevated HCC associate with alterations in infant intestinal microbiota composition. In keeping with the earlier literature, maternal PPD symptoms were associated with increases in genera fromProteobacteria phylum. Further research is needed to understand how these microbiota changes are linked with later child health outcomes.

Alexithymic Traits and Hair Cortisol Concentrations in Pregnant Women

INTRODUCTION

Alexithymia, a personality construct characterized by difficulties in identifying and expressing emotions, and an externally oriented thinking style, has been associated with a number of stress-related disorders, and physiological markers of stress. We examined the relationships of alexithymia and hair cortisol concentrations (HCC), a measure of long-term cortisol levels, in pregnant women.

METHODS

Participants were 130 women from the FinnBrain Birth Cohort study. Alexithymia was measured with the Toronto Alexithymia Scale (TAS-20). Analysis of covariance and regression analyses were used to assess the associations between alexithymia and HCC. Educational level, current depressive symptoms, and body mass index (BMI) were applied as covariates.

RESULTS

In the adjusted analyses, individuals with moderate to high alexithymic traits had significantly higher HCC (F = 5.11, partial η² = 0.040 , p = 0.026) compared to non-alexithymics. Regression analyses in the whole sample revealed that, of the individual dimensions of alexithymia, Difficulty Identifying Feelings (DIF) was associated with HCC (β = 0.187, t = 2.064, p = 0.041).

CONCLUSIONS

Alexithymia, and especially its dimension DIF, were associated with higher HCC and, therefore, may be linked to increased chronic physiological stress. Implications for pregnancy outcomes and infant development are discussed.

Maternal prenatal hair cortisol is associated with prenatal depressive symptom trajectories

Maternal prenatal cortisol levels have been inconsistently associated with self-reports of prenatal psychological distress (PD). Previous research has linked hair cortisol concentration (HCC) evaluating cumulatively the previous months with cross-sectional PD measures that usually cover the past week(s), which may lead to misleading conclusions on their relations. We aimed to investigate how maternal HCC relates to cumulative PD measures across pregnancy.

METHODS

Subjects (N = 595) were drawn from the FinnBrain Birth Cohort Study. Maternal HCC was measured from hair samples collected at gestational week (gwk) 24 (HCC1, n = 467) and at delivery (HCC2, n = 222). As HCC1 and HCC2 comprised mostly of different subjects, they were considered as independent populations. Maternal PD assessments at gwks 14, 24, and 34 were the Edinburgh Postnatal Depression Scale (EPDS), the anxiety subscale of the Symptom Checklist (SCL-90), the Pregnancy-Related Anxiety Questionnaire -Revised2 (PRAQ-R2), and a daily hassles scale. Cumulative PD comprised of the mean scores of two consecutive assessments (mean1 = gwks 14 and 24; mean2 = gwks 24 and 34). In addition, EPDS and SCL scores were modelled by using growth mixture modelling to identify symptom trajectory categories. Regression models were adjusted for age, body mass index, education and use of selective serotonin/serotonin-norepinephrine reuptake inhibitor medication.

RESULTS

In the adjusted regression model, higher HCC2 was related to the "consistently elevated" prenatal depressive symptoms trajectory in comparison to "consistently low" (β =.71, p =.021) and "low and increasing" (β =.82, p = .011) symptom trajectories. Additionally, the cumulative mean (mean 1) of daily hassles in relationships was associated with HCC1 (β = 0.25, p = .004). General or pregnancy-related anxiety symptoms were unrelated to HCC after adjustment for the covariates.

CONCLUSIONS

The assessment of cumulative or trajectory measures of PD can reveal important associations with maternal prenatal HCC, even though the associations are generally weak. Of the different dimensions of PD, prenatal trajectories of depressive symptoms were most consistently linked with end-pregnancy HCC levels.

Left atrial appendage morphology and relative contrast agent concentration in patients undergoing coronary artery CTA

AIM

To evaluate whether certain morphological features of the left atrial appendage (LAA) would influence the LAA/ascending aorta (AA) radiodensity ratio, as a reflection of the blood flow conditions in the LAA.

MATERIALS AND METHODS

Eight-hundred and eight consecutive patients undergoing computed tomography angiography (CCTA) were evaluated. Of these, 749 had no history of atrial fibrillation and none had suffered acute stroke. The LAA/AA radiodensity ratio, and the length, lobe number, and morphological classification of LAAs were assessed.

RESULTS

The distribution of morphological classes for LAAs were: windsock 62.3%, cactus 18.6%, chicken wing 10.0%, and cauliflower 9.2%. The mean LAA/AA radiodensity ratio was 0.87±0.14 (range 0.22-1.44). Female gender (p=0.001), elevated body mass index (BMI; r=-0.129; p=0.003), and diabetes (p=0.03) were associated with lower LAA/AA radiodensity ratios, while heart failure (p=0.017), significant coronary artery stenosis (p=0.010), and LAAs with multiple lobes (p=0.018), exhibited higher LAA/AA radiodensity ratios. Multiple regression analysis revealed that a short one-lobed cauliflower morphology was an independent predictor (p=0.007) of a decreased LAA/AA radiodensity ratio.

CONCLUSION

A decline in the LAA/AA radiodensity ratio may reflect decreased blood flow in the LAA, paralleling spontaneous echo contrast in transoesophageal echocardiography. Thus, CCTA might be of value in recognising LAA structures that predispose to decreased blood flow.

Hair cortisol concentration (HCC) as a measure for prenatal psychological distress - A systematic review

Prenatal environment reportedly affects the programming of developmental trajectories in offspring and the modification of risks for later morbidity. Among the increasingly studied prenatal exposures are maternal psychological distress (PD) and altered maternal hypothalamus-pituitary-adrenal (HPA) axis functioning. Both prenatal PD and maternal short-term cortisol concentrations as markers for HPA axis activity have been linked to adverse child outcomes and it has been assumed that maternal PD affects the offspring partially via altered cortisol secretion patterns. Yet, the existing literature on the interrelations between these two measures is conflicting. The assessment of cortisol levels by using hair cortisol concentration (HCC) has gained interest, as it offers a way to assess long-term cortisol levels with a single non-invasive sampling. According to our review, 6 studies assessing the associations between maternal HCC during pregnancy and various types of maternal PD have been published so far. Measures of prenatal PD range from maternal symptoms of depression or anxiety to stress related to person's life situation or pregnancy. The aim of this systematic review is to critically evaluate the potential of HCC as a biomarker for maternal PD during pregnancy. We conclude that HCC appears to be inconsistently associated with self-reported symptoms of prenatal PD, especially in the range of mild to moderate symptom levels. Self-reports on PD usually cover short time periods and they seem to depict partly different phenomena than HCC. Thus, methodological aspects are in a key role in future studies evaluating the interconnections across different types of prenatal PD and maternal HPA axis functioning. Further, studies including repetitive measurements of both HCC and PD during the prenatal period are needed, as timing of the assessments is one important source of variation among current studies. The significance of prenatal HCC in the context of offspring outcomes needs to be further investigated.

Plasma levels of haemostatic factors in patients with pulmonary embolism on admission and seven months later

INTRODUCTION

With the exception of D-dimer, not much is known about the plasma levels of haemostatic factors during acute venous thromboembolism (VTE) compared to their basic levels in a stable phase. The goal of this study was to examine how plasma levels of factor V, VIII, XIIIa, von Willebrand factor antigen (vWF:Ag), fibrinogen, thrombomodulin evolve from the point of diagnosis of acute VTE to the end of standard treatment period.

METHODS

Sixty-three consecutive patients (mean 57, range 18-86 years, 33 females) with acute pulmonary embolism (PE) were included. Laboratory samples were collected upon arrival (acute phase) and seven months later (stable phase). Fifteen similar aged individuals served as controls.

RESULTS

Plasma levels of factor XIIIa (87.5% vs 117.7%, P < .001) and soluble thrombomodulin (36.6 vs 47.5 ng/L, P < .001) were lower, whereas plasma levels of vWF:Ag (2.66 vs 2.01 IU/mL, P < .001) and fibrinogen (4.3 vs 3.9 g/L, P < .05) were higher on admission compared to the stable phase. In the stable phase, vWF:Ag (2.01 vs 1.43 IU/mL, P < .01) and soluble thrombomodulin (47.5 vs 38.0 ng/mL, P < .05), but not FXIIIa levels, were higher in PE patients compared to healthy controls.

CONCLUSION

This study confirms the concept of FXIIIa consumption during acute phase of VTE by showing its intraindividual normalization during the follow-up. vWF:Ag, known to be associated with the risk of VTE, was constantly elevated in the majority of the patients. Soluble thrombomodulin levels were lower in acute phase compared to stable phase, a finding which significance needs to be evaluated in the future.

Underuse of anticoagulation in stroke patients with atrial fibrillation--the FibStroke Study

BACKGROUND AND PURPOSE

Current guidelines recommend oral anticoagulation (OAC) for patients with atrial fibrillation (AF) and increased risk of thromboembolic events. The reasons for not using OAC in AF patients suffering stroke or transient ischaemic attack (TIA) were assessed.

METHODS

This retrospective registry included 3404 patients with previously diagnosed AF who suffered a total of 2955 ischaemic strokes and 895 TIAs during 2003-2012.

RESULTS

A CHA2DS2-VASc score ≥2 and a CHADS2 score ≥2 was observed in 3590 (93.2%) and in 2784 (72.3%) of the events, respectively. Of the high-risk patients (CHADS2 ≥2) only 55.1% were on OAC before the onset of stroke or TIA. The most frequently documented reasons for withholding OAC were infrequent paroxysms of AF (14%), previous bleeding episodes (13%) and the patient's decline/independent discontinuation of treatment (9%). Moreover, patients with paroxysmal AF (40% using OAC), previous bleeding (26% using OAC) and alcohol abuse (30% using OAC) were using OAC significantly less often than patients without these characteristics. A significant increase in the proportion of high-risk patients using OAC from 49% in 2003 to 65% in 2012 was seen.

CONCLUSIONS

Underuse of anticoagulation is a common contributor to ischaemic strokes and TIA episodes in patients with AF. Infrequent AF episodes, previous bleeds, patient preference and alcohol abuse were the most common reasons for not using OAC.

Persistent antiphospholipid antibody (aPL) in asymptomatic carriers as a risk factor for future thrombotic events: a nationwide prospective study

Objectives

The long-term prognosis of individuals fulfilling the laboratory criteria, but not clinical criteria, of antiphospholipid syndrome (APS) has not been widely investigated. The primary aim of this study was to evaluate the incidence of first thrombotic event (deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), stroke or transient ischaemic attack (TIA) in a nationwide antiphospholipid antibody (aPL) carrier cohort.

Design

We conducted a prospective nationwide cohort study.

Setting

The aPL profile of participants was recorded from the laboratory database. Information was collected about thrombotic and pregnancy complications, subsequent medical history, other risk factors for thrombosis, use of prophylactic antithrombotic medication and general health.

Participants

Participants included adult asymptomatic aPL carriers recognized in Finland during 1971–2009.

Main outcome measure

The main outcome measure was incidence of first thrombotic event.

Results

A total of 119 (89% female) aPL carriers were followed for mean (SD) of 9.1 (7.5) years (range 3–41 years). Sixty-one per cent of the study participants had autoimmune disease, most often systemic lupus erythematosus (SLE). Thirty-six of 119 (30%) were either double or triple positive, 56% single lupus anticoagulant (LA) positive, and 8% and 5% single anticardiolipin antibodies (aCL) and anti-β2glycoprotein I antibodies (aβ2GPI) positive, respectively. Nine (7.6%) study patients experienced a first thrombotic event (five DVT, one PE, two MI, one TIA) mean (SD) 7.2 (8.3) years (range 1–26 years) after aPL detection (annual incidence rate 0.8%). All individuals who developed thrombotic complications had autoimmune disease. Annual rate of first thrombotic event in carriers of single positivity (0.65%) was equal to the known risk of thrombosis in the healthy Caucasian population, whereas the rate was two times higher in carriers of double or triple positivity (1.27%). Sixteen of 79 (20%) women experienced pregnancy complications.

Conclusions

Double or triple positivity for aPL is a risk factor for future thrombotic events, especially in individuals with an underlying autoimmune disease, whereas single positivity does not seem to carry an elevated risk of thrombosis.

Comparison of the use of minimized cardiopulmonary bypass with conventional techniques on the incidence of retinal microemboli during aortic valve replacement surgery

OBJECTIVES

Minimized cardiopulmonary bypass (MCPB) circuits have been shown to reduce cerebral and retinal microembolisation during coronary artery bypass graft (CABG) surgery compared to conventional CPB (CCPB) circuits. Our aim was to evaluate whether the reduction of microembolisation is sustained in aortic valve surgery, as well as to evaluate the effects of MCPB on inflammatory, endothelial, and platelet activation markers.

MATERIAL AND METHODS

Patients were randomized to undergo aortic valve replacement (AVR), with or without CABG, with MPCB (n=20) or CCPB (n=20). After anaesthesia induction and termination of CPB, standardized digital retinal fluorescein angiography images were obtained on both eyes and analyzed in a blinded fashion. Blood samples were collected at eight time points until the third postoperative day.

RESULTS

Fewer patients in the MCPB group showed evidence of microembolic perfusion defects on postperfusion retinal fluorescein angiographs compared to the CCPB group (37% vs. 63%, absolute difference 26%, 95% CI -5% -51%, P = 0.194). Polymorphonuclear leukocyte (PMN) elastase and von Willebrand factor release were statistically significantly reduced in the MCPB group, but there were no significant differences in other markers of inflammation, coagulation or endothelial activation. A significantly higher three-fold increase in the amount of shed blood was collected to the cell saver with a higher rate of intraoperative platelet transfusion in the MCPB group compared to CCPB.

CONCLUSIONS

The use of MCPB was associated statistically insignificantly with less retinal microemboli compared to CCPB. MCPB was complicated by excess bleeding and need for transfusion. The feasibility of MCPB techniques in valve surgery requires further studies.

The BH3-mimetic ABT-737 induces mast cell apoptosis in vitro and in vivo: potential for therapeutics

Mast cells and their mediators are implicated in the pathogenesis of many different diseases. One possible therapeutic intervention in mast cell-associated diseases can be to reduce the number of tissue mast cells by inducing mast cell apoptosis. In this study, we demonstrate that mast cells exhibit a high sensitivity to ABT-737, a BH3-only mimetic molecule that induces apoptosis through high-affinity binding to the prosurvival proteins, Bcl-2, Bcl-XL, and Bcl-w. Primary mast cells as well as mast cell lines tested succumbed to apoptosis in response to the inhibitor at varying but seemingly low concentrations compared with other leukocytes investigated. I.p. injections of ABT-737 in mice resulted in a total abolishment of mast cells in the peritoneum. Confocal microscopy analysis of peritoneal cells revealed apoptotic bodies of mast cells being phagocytosed by macrophages. In addition, ex vivo treatment of human skin biopsies with ABT-737 demonstrated increased mast cell apoptosis. The data we present in this article show exceptional mast cell sensitivity to ABT-737, a selective inhibitor of antiapoptotic proteins, rendering a possible application for BH3-only mimetic compounds like ABT-737 in mast cell-associated diseases, such as mastocytosis, allergy, asthma, and other chronic inflammations.

Cost analysis of 109 microsurgical reconstructions and flap monitoring with microdialysis

Few studies have examined the cost-effectiveness of microsurgery, and little is known about the cost-effectiveness of flap monitoring. We studied the costs related to microsurgery during 2004 to 2006 in Kuopio University Hospital. A total of 99 patients were reconstructed with 109 flaps. Primary success was achieved in 64% of cases. Reoperation for anastomosis was conducted in 25% and for other surgical complications in 27%. The intended result was achieved in 94% of cases. The mean total cost of hospital care was 20,000 euro in head and neck cancer surgery, 15,500 euro in defects of the lower extremities, and 9200 euro in breast reconstruction. The costs were greatly influenced by surgical complications (i.e., if the primary reconstruction failed, then the secondary microvascular flap almost doubled the expense involved; mean expenses per case 27,900 euro). Microdialysis was used in flap monitoring with an additional cost of 535 euro per patient. We found that microdialysis provided an early diagnosis of perfusion failure and helped to save the flap. It was estimated that if one or two flaps per year are saved due to more effective monitoring, then the extra costs of using microdialysis are covered.

[Antithrombotic medication of cardiac patient in connection with surgery and minor operations]

A major proportion of cardiac patients use long-time antithromobitic medication. It is not uncommon that these patients require surgery and operations. Discontinuation of antithrombotic therapy may be used to decrease risk of hemorrhage, but on the other hand the medication break will make the patient susceptible to thrombotic and thromboembolic complications. The attending physician must decide which is safer: to break the medication or to continue it. Often the best choice is a compromise of the above, i.e. application of a somewhat reduced compensatory antithrombotic therapy.

Learning curve for add-on stereotactic core needle breast biopsy

PURPOSE

To evaluate the learning curve for an add-on 14 G stereotactic core needle biopsy (SCNB).

MATERIAL AND METHODS

A total of 231 non-palpable breast lesions that had undergone add-on SCNB were evaluated in this prospective study. Five radiologists performed their first three biopsies under supervision. Subsequent, independently performed, biopsies were also evaluated. The samples were collected in three different containers: the first sample in container A, the second and third samples in container B, and subsequent samples in container C (available for four radiologists from the first biopsy on). Technically successful biopsies and false-negative rate in three container combinations (A, A+B, A+B+C) were reported as a function of operator experience.

RESULTS

Technically unsuccessful biopsies occurred significantly more often in microcalcifications than in masses (14.9% versus 3.8%; P=0.04). For microcalcifications, the rate of successful biopsies was 75% (18/24) for the first 5 biopsies and 87.8% (79/90) for the subsequent biopsies (P=0.335); rates for the masses were 95.7% (22/23) and 96.3% (79/82) (P=1.0), respectively. A tendency was noted for the false-negative rate to be higher for the first five biopsies in three container combinations than in subsequent cases.

CONCLUSION

Our results support the existence of a learning curve, especially in the biopsy of microcalcifications. More than three mentor-guided biopsies are needed.

Microdialysis Detects Postoperative Perfusion Failure in Microvascular Flaps

In microvascular tissue transfers, it is essential postoperatively to follow-up on the perfusion of the transferred flap because of the risk of anastomotic failure. The diagnosis of pedicle obstruction is usually made by clinical observation, but some techniques have been reported as more reliable than clinical observation in detecting perfusion failure. The authors used microdialysis (MD), a method developed to assess in situ tissue metabolism, in the follow-up of 80 consecutive microvascular flaps from October, 2001 to October, 2003. Of the 78 flaps with postoperative data, 58 flaps were uneventful clinically and using MD, and served as the reference material for normal postoperative metabolism. Twenty flaps showed some abnormality in the clinical course or with MD. Of these, 13 flaps were reoperated for anastomosis thrombosis (9 arterial, 4 venous). All thromboses were clearly recognized by MD via a decrease in the glucose concentration in the tissue (< 2.7 mmol/l) and an increase in the lactate concentrations (> 5.7 mmol/l). In some cases, MD indicated a pathological trend in glucose and lactate concentrations hours before there were any clinical signs. A system of alarm levels was developed for the staff: when the limits were reached, a critical evaluation of the situation was undertaken, and the need for reoperation was considered. In the series, the salvage rate of all thrombosed flaps was 77 percent, with a final success rate in microvascular reconstruction of 95 percent. No flap was lost due to a delay in the diagnosis of secondary ischemia, if on-line MD monitoring was available. Microdialysis is a clinically feasible and sensitive monitoring method for all kinds of microvascular flaps, especially for those in which clinical observation is difficult or impossible. The performance of the analysis is easy and can be done by even less experienced nursing staff working in institutes with a low frequency of microsurgery.

Breast Lesions Causing Nipple Discharge: Preoperative Galactography-Aided Stereotactic Wire Localization

OBJECTIVE

Lesions that present with nipple discharge typically are not visible on mammography or sonography but can be detected on galactography. Therefore, the usual methods for preoperative localization (wire placement under sonography or stereotactic guidance) are not applicable. We report our preliminary experience of galactography-aided stereotactic wire (n = 8) or coil (n = 1) localization of small intraductal lesions.

CONCLUSION

Galactography-aided wire or coil localization is a practical localization method for intraductal lesions not detectable on mammography or sonography.

Recurrences after immediate reconstruction in breast cancer

AIM

To determine the incidence of and reasons for recurrences after immediate breast reconstruction in breast cancer patients.

MATERIAL AND METHODS

The data of 79 patients undergoing immediate breast reconstruction between 1998 and 2001 in Kuopio University Hospital were re-examined from both the local cancer register and the patient charts at the end of year 2003.

RESULTS

There were five local recurrences (6.3%), one regional recurrence (1.2%), and three cases (3.8%) presented bone and/or visceral metastases. All recurrences except one (primary tumor noninvasive) appeared within the first two years after primary therapy. Young age and increasing size of the tumour were risk factors for distant or logoregional metastases.

CONCLUSION

Immediate breast reconstruction is a safe procedure in breast cancer patients, but a multidisciplinary team is needed for careful patient selection.

The surgical and oncological safety of immediate breast reconstruction

AIM

The aim of our study was to (1) examine the incidence of surgical complications, (2) determine the incidence of loco-regional recurrences and (3) examine the safety of saving the nipple-areola-complex after immediate breast reconstructions in breast cancer.

METHODS

Sixty-six immediate breast reconstructions were performed. Wide local excision (WLE), skin sparing mastectomy and subcutaneous mastectomy (SCM) were performed to 12, 20 and 34 patients, respectively. In all patients with WLE the reconstruction was performed with the latissimus dorsi (LD) miniflap. In other patients reconstructions were done with a free TRAM-flap (n=26) LD-flap (n=27) or with a prosthesis only (n=1).

RESULTS

Major flap necrosis developed in four patients. Local recurrence rate was 8.3% in the group where nipple-areola-complex was removed and 7.1% in the group where nipple-areola-complex was saved. Metastases were found in 12.5 and 0%, respectively.

CONCLUSION

SCM compared to skin sparing mastectomy may lead to an enhanced risk of immediate surgical complications, but does not threat the oncological safety. Saving the nipple-areola-complex in immediate breast reconstructions is possible in early breast cancer, if the tumour is not in the central part of the breast.

Supplemental oxygen for prevention of nausea and vomiting after breast surgery

BACKGROUND

Administration of supplemental oxygen 80% has been shown to halve the incidence of postoperative nausea and vomiting (PONV). We tested the efficacy of supplemental oxygen 50% in decreasing the incidence of PONV after breast surgery.

METHODS

One hundred patients receiving standardized sevoflurane anaesthesia were randomly assigned to two groups: oxygen 30% administration (Group 30); and oxygen 50% administration (Group 50). Oxygen was administered during surgery and for 2 h from the end of surgery.

RESULTS

The incidence of PONV over 24 h after surgery showed no difference between the groups: 82% in Group 30 and 89% in Group 50. However, during the postoperative oxygen administration, eight patients vomited in Group 30, compared with none in Group 50 (P<0.05). After oxygen therapy ceased, there was no difference in the incidence of vomiting between the groups. Nausea and need for rescue antiemetics did not differ between the groups.

CONCLUSION

The incidence of vomiting decreased during the short postoperative administration of supplemental oxygen 50%. However, perioperative oxygen 50% administration did not prevent PONV over the 24-h follow-up period in patients undergoing breast surgery performed under general anaesthesia.

Viewpoints on oncoplastic surgery in invasive breast cancer

Breast conserving therapy is the best method to the breast cancer treatment when concerning the psychological sequelae to the patient. Cosmetic results after conservative surgery are not always acceptable: about 20% of patients need a revision operation and correcting the residual defect of the breast or asymmetry of the breasts afterwards. Oncoplastic surgery means that the methods familiar to plastic surgeon are used to increase the number of patients treated with conservative surgery without compromising the oncologic results. Even wider margins than in normal breast conservation can be gained, if local glandular flaps, musculocutaneous latissimus dorsi flaps or microvascular free TRAM flaps are used to immediately preserve the shape and symmetry of the breasts. With plastic surgery it is possible to reshape the breast, replace the nipple and gain breast symmetry. As we know every tenth woman will have a breast cancer during her lifetime, and 80% of breast cancer women will survive. It is important to operate breast cancer immediately to save costs and help a patient feel that her breasts are still a part of her own body.

Epinephrine--via activation of p38-MAPK--abolishes the effect of aspirin on platelet deposition to collagen

The mechanism by which epinephrine enhances experimental thrombosis in the presence of aspirin is poorly understood. In this study, we set to explore, in aspirinised platelet-rich plasma (PRP), the effect of epinephrine (100 nmol/l) on platelet deposition to immobilised collagen and the subsequent involvement of several intracellular pathways. Under these experimental conditions, which allow platelet aggregation on top of the collagen-adherent platelets, epinephrine increased platelet deposition by 55-86%. This enhancement could be specifically prohibited by the alpha(2A)-adrenoceptor antagonist, atipamezole, the p38 mitogen-activated protein kinase (p38MAPK) inhibitor SB203580, and the cytosolic phospholipase A(2) (cPLA(2)) inhibitor, mepacrine. The effect of epinephrine coincided with increased phosphorylation of p38MAPK and cPLA(2) and with arachidonic acid (AA) release from platelet membrane. We conclude that epinephrine enhanced platelet deposition on collagen in aspirinised PRP via a mechanism dependent on both free AA in platelet cytosol (released by cPLA(2)) and p38MAPK.