1
|
Nikkonen S, Somaskandhan P, Korkalainen H, Kainulainen S, Terrill PI, Gretarsdottir H, Sigurdardottir S, Olafsdottir KA, Islind AS, Óskarsdóttir M, Arnardóttir ES, Leppänen T. Multicentre sleep-stage scoring agreement in the Sleep Revolution project. J Sleep Res 2024; 33:e13956. [PMID: 37309714 PMCID: PMC10909532 DOI: 10.1111/jsr.13956] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 06/14/2023]
Abstract
Determining sleep stages accurately is an important part of the diagnostic process for numerous sleep disorders. However, as the sleep stage scoring is done manually following visual scoring rules there can be considerable variation in the sleep staging between different scorers. Thus, this study aimed to comprehensively evaluate the inter-rater agreement in sleep staging. A total of 50 polysomnography recordings were manually scored by 10 independent scorers from seven different sleep centres. We used the 10 scorings to calculate a majority score by taking the sleep stage that was the most scored stage for each epoch. The overall agreement for sleep staging was κ = 0.71 and the mean agreement with the majority score was 0.86. The scorers were in perfect agreement in 48% of all scored epochs. The agreement was highest in rapid eye movement sleep (κ = 0.86) and lowest in N1 sleep (κ = 0.41). The agreement with the majority scoring varied between the scorers from 81% to 91%, with large variations between the scorers in sleep stage-specific agreements. Scorers from the same sleep centres had the highest pairwise agreements at κ = 0.79, κ = 0.85, and κ = 0.78, while the lowest pairwise agreement between the scorers was κ = 0.58. We also found a moderate negative correlation between sleep staging agreement and the apnea-hypopnea index, as well as the rate of sleep stage transitions. In conclusion, although the overall agreement was high, several areas of low agreement were also found, mainly between non-rapid eye movement stages.
Collapse
Affiliation(s)
- Sami Nikkonen
- Department of Technical PhysicsUniversity of Eastern FinlandKuopioFinland
- Diagnostic Imaging CenterKuopio University HospitalKuopioFinland
| | - Pranavan Somaskandhan
- School of Information Technology and Electrical EngineeringThe University of QueenslandBrisbaneQueenslandAustralia
| | - Henri Korkalainen
- Department of Technical PhysicsUniversity of Eastern FinlandKuopioFinland
- Diagnostic Imaging CenterKuopio University HospitalKuopioFinland
| | - Samu Kainulainen
- Department of Technical PhysicsUniversity of Eastern FinlandKuopioFinland
- Diagnostic Imaging CenterKuopio University HospitalKuopioFinland
| | - Philip I. Terrill
- School of Information Technology and Electrical EngineeringThe University of QueenslandBrisbaneQueenslandAustralia
| | - Heidur Gretarsdottir
- Reykjavik University Sleep Institute, School of TechnologyReykjavik UniversityReykjavikIceland
| | - Sigridur Sigurdardottir
- Reykjavik University Sleep Institute, School of TechnologyReykjavik UniversityReykjavikIceland
| | | | - Anna Sigridur Islind
- Reykjavik University Sleep Institute, School of TechnologyReykjavik UniversityReykjavikIceland
- Department of Computer ScienceReykjavík UniversityReykajvíkIceland
| | - María Óskarsdóttir
- Reykjavik University Sleep Institute, School of TechnologyReykjavik UniversityReykjavikIceland
- Department of Computer ScienceReykjavík UniversityReykajvíkIceland
| | - Erna Sif Arnardóttir
- Reykjavik University Sleep Institute, School of TechnologyReykjavik UniversityReykjavikIceland
| | - Timo Leppänen
- Department of Technical PhysicsUniversity of Eastern FinlandKuopioFinland
- Diagnostic Imaging CenterKuopio University HospitalKuopioFinland
- School of Information Technology and Electrical EngineeringThe University of QueenslandBrisbaneQueenslandAustralia
| |
Collapse
|
2
|
Kaulamo JT, Lätti AM, Koskela HO. Recurrent Cough in the Elderly: A Forgotten Entity. Lung 2023; 201:545-553. [PMID: 37964136 PMCID: PMC10673973 DOI: 10.1007/s00408-023-00654-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION Recurrent cough is little researched in adults. We investigated the prevalence, risk factors, and consequences of recurrent cough, and compared the results to those of isolated chronic cough. METHODS Cross-sectional email survey in an elderly community-based population. Recurrent cough was defined as ≥ 3 cough episodes within one year (each lasting ≥ 1 week) and no current chronic cough. Isolated chronic cough was defined as current cough lasting ≥ 8 weeks and no recurrent cough. RESULTS The prevalence of recurrent cough was 3.8% among all respondents (n = 5983). Recurrent cough was associated with asthma (aOR 3.32 (95% CI 2.13-5.18)), chronic rhinosinusitis (2.91 (1.89-4.46)), family history of chronic cough (2.59 (1.88-3.56)), analgesic intolerance (2.13 (1.27-3.57)), male gender (1.92 (1.39-2.66)), gastro-esophageal reflux disease (1.73 (1.21-2.47)), obstructive sleep apnoea (1.69 (1.23-2.32)), symptom sum (1.12 per symptom (1.03-1.22)), and younger age (0.96 per year (0.93-1.00)). Isolated chronic cough was associated with chronic rhinosinusitis (3.45 (2.39-4.97)), asthma (2.17 (1.38-3.41), gastro-esophageal reflux disease (1.80 (1.32-2.47)), family history of chronic cough (1.80 (1.35-2.41)), obstructive sleep apnoea (1.49 (1.12-2.00)), symptom sum (1.18 per symptom (1.10-1.27)), and body mass index (0.96 per unit (0.93-1.00)). Among subjects with recurrent and isolated chronic cough, the prevalence of depressive symptoms were 7.7% and 4.2%, p = 0.11, the Leicester Cough Questionnaire total scores 15.2 (14.6-15.8) and 16.3 (16.0-16.6), P = 0.001, and the mean number of yearly cough-related doctor`s visits 0.58 (0.45-0.71) and 0.36 (0.19-0.53), P = 0.007, respectively. CONCLUSION The risk factors and consequences of recurrent and isolated chronic cough were comparable. Recurrent cough seems beneficial to address in cough evaluation.
Collapse
Affiliation(s)
- Johanna Tuulikki Kaulamo
- School of Medicine, Institute of Clinical Sciences, Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland.
- Mehiläinen Terveyspalvelut Oy, Healthcare Services for Prisoners, Kauppakatu 39A, 70100, Kuopio, Finland.
| | - Anne Marika Lätti
- School of Medicine, Institute of Clinical Sciences, Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Heikki Olavi Koskela
- School of Medicine, Institute of Clinical Sciences, Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| |
Collapse
|
3
|
Kaunisto J, Salomaa ER, Koivisto M, Myllärniemi M. Overall drug treatment of idiopathic pulmonary fibrosis patients from national registries - a real-world study from Finland. BMC Pulm Med 2023; 23:364. [PMID: 37777734 PMCID: PMC10543307 DOI: 10.1186/s12890-023-02630-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 09/04/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Currently, two disease-modifying antifibrotic drugs are indicated for the treatment of idiopathic pulmonary fibrosis. The objective of this study was to analyse antifibrotic and overall prescription medication use of IPF patients in the real world. METHODS Data was collected from the FinnishIPF registry and the Registry of the Social Insurance Institution of Finland (SII). Purchases of all prescription medicines were assessed. The frequency, the initiation interval, the duration, and the breaks of the antifibrotic treatments were defined. The association between the prescription of antifibrotic therapy and different patient-related clinical parameters was studied. Accordingly, the relationships between the delay in starting therapy and patient-related variables were analysed. RESULTS Of the 263 IPF patients, 132 (50.2%) had started antifibrotic treatment during the study period 2011-2018. The mean interval from the diagnosis to the first purchase was 367 (SD 429) days. The antifibrotic drug was switched in 14% of patients. Discontinuation of therapy occurred most commonly during the first year of the treatment. The one-year persistence was 77.1% for pirfenidone and 78.9% for nintedanib. A tendency of treating patients under 75 years was noticed. Low forced vital capacity predicted earlier initiation of medication. CONCLUSIONS The initiation of antifibrotics after diagnosis was slow, probably due to reimbursement limitations. Younger age at diagnosis affected treatment initiation although it is unknown which patients benefit most from these medications. The reasons for discontinuation of the antifibrotic therapy during the first year should be a focus in clinical work and further studies.
Collapse
Affiliation(s)
- Jaana Kaunisto
- Department of Pulmonary Diseases, Division of Medicine, Turku University Hospital, Turku, Finland.
| | - Eija-Riitta Salomaa
- Department of Pulmonary Diseases and Clinical Allergology, University of Turku, Turku, Finland
| | - Mari Koivisto
- Department of Biostatistics, University of Turku, Turku, Finland
| | | |
Collapse
|
4
|
Helevä A, Murtomäki A, Huhtala H, Bousquet J, Luukkainen A, Karjalainen J, Lemmetyinen R, Haukka J, Torkki P, Nuutinen M, Toppila‐Salmi S. Risk factors of NSAID-exacerbated respiratory disease: A population-based study. Clin Transl Allergy 2023; 13:e12296. [PMID: 37632242 PMCID: PMC10442774 DOI: 10.1002/clt2.12296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/28/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Asthma with NSAID-exacerbated respiratory disease (NERD) is associated with uncontrolled or severe asthma. NERD patients are more prone to severe allergic reactions and their asthma exacerbations lead to hospitalisations twice as often compared to patients with non-NERD-asthma. NERD patients are prone to recurrent nasal polyposis requiring frequent endoscopic sinus surgeries. However, the early risk factors of NERD are not fully understood. The aim was to identify risk factors of NERD among patients with adult-onset asthma. METHODS We used data from 1350 population-based adult asthmatics with adult-onset asthma from Finnish national registers. NERD was defined as self-reported wheeze or other typical respiratory symptoms after ingestion of NSAIDs. Thirty-six covariates covering several domains (personal characteristics, life-style, early life factors, asthma characteristics and multimorbidities) were selected based on literature and were studied in association with NERD using logistic regressions. RESULTS The study population included 153 (11.3%) asthmatics with NERD. Thirty-six covariates were entered in univariate logistic regression analysis, in which 23 were associated with NERD (p < 0.05). These variables were entered in a multivariable logistic regression model in which allergic respiratory symptoms, female sex, osteoarthritis, difficult asthma, nasal polyps, second-hand smoke exposure at home, having 3 or more older siblings and being overweight were significantly associated with asthma with NERD (p < 0.05). Overweight decreased the risk of NERD, other factors increased it. CONCLUSION According to our study, risk factors of NERD in part are associated with female sex, BMI, exposure to tobacco smoke, allergy, orthopaedic disorders and infection history, and their early recognition might thus be important to manage the burden of NERD.
Collapse
Affiliation(s)
- Alma Helevä
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
- MD PhD Programme of the Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
| | - Aada Murtomäki
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
| | - Heini Huhtala
- Faculty of Social SciencesTampere UniversityTampereFinland
| | - Jean Bousquet
- Institute for AllergologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPAllergology and ImmunologyBerlinGermany
- University Hospital of MontpellierMontpellierFrance
| | - Annika Luukkainen
- Infectious Disease UnitSouth Karelia Central HospitalLappeenrantaFinland
| | - Jussi Karjalainen
- Allergy CentreTampere University HospitalTampereFinland
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Riikka Lemmetyinen
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
- Department of Public HealthUniversity of HelsinkiHelsinkiFinland
| | - Jari Haukka
- Department of Public HealthUniversity of HelsinkiHelsinkiFinland
| | - Paulus Torkki
- Department of Public HealthUniversity of HelsinkiHelsinkiFinland
| | - Mikko Nuutinen
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
- Haartman InstituteMedicumUniversity of HelsinkiHelsinkiFinland
| | - Sanna Toppila‐Salmi
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
- Haartman InstituteMedicumUniversity of HelsinkiHelsinkiFinland
- Department of Pulmonary MedicineHeart and Lung CenterHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| |
Collapse
|
5
|
Mäki-Heikkilä R, Koskela H, Karjalainen J, Parkkari J, Huhtala H, Valtonen M, Lehtimäki L. Cross-country skiers often experience respiratory symptoms during and after exercise but have a low prevalence of prolonged cough. BMJ Open Sport Exerc Med 2023; 9:e001502. [PMID: 37342789 PMCID: PMC10277524 DOI: 10.1136/bmjsem-2022-001502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/23/2023] Open
Abstract
Background Cross-country skiers train and compete during the winter for long periods of time in subfreezing conditions, which strains the airways and provokes respiratory symptoms. This study aimed to compare the prevalence of exercise-related symptoms and prolonged cough in competitive cross-country skiers versus the general population and to investigate the association between these symptoms and asthma. Methods A questionnaire was sent to Finnish cross-country skiers (n=1282) and a random sample of the general population (n=1754), with response rates of 26.9% and 19.0%, respectively. Results Both groups were mostly asymptomatic at rest, but symptoms were increased in both groups during and after exercise. Cough was more prevalent after exercise in skiers and phlegm production was more common during and after exercise in skiers. Asthma did not provoke specific symptoms, but symptom prevalence was higher in asthmatic individuals. Skiers had a higher prevalence of cough after exercise (60.6% vs 22.8%, p<0.001) compared with controls, but controls had a higher prevalence of prolonged cough (4.1% vs 9.6%, p=0.004). In participants without asthma, cold air triggered symptoms more often in skiers than controls, while strong odours triggered symptoms more often in asthmatic controls than skiers. Chronic cough lasting more than 8 weeks was rare, reported by 4.8% of controls and 2.0% of skiers. Conclusion Cross-country skiers, especially those with asthma, experience a higher burden of exercise-related respiratory symptoms compared with controls. However, repeated exposure to cold air does not appear to result in long-term hypersensitivity of the cough reflex arc.
Collapse
Affiliation(s)
| | - Heikki Koskela
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland
- Institute of Clinical Sciences, Faculty of Health Sciences, University of Eastern Finland School of Medicine, Kuopio, Pohjois-Savo, Finland
| | - Jussi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Pirkanmaa, Finland
| | - Jari Parkkari
- Tampere Research Center of Sports Medicine, UKK Institute, Tampere, Pirkanmaa, Finland
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyvaskyla, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Pirkanmaa, Finland
| | - Maarit Valtonen
- Finnish Institute of High Performance Sport KIHU, Jyväskylä, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Pirkanmaa, Finland
| |
Collapse
|
6
|
Nuutinen M, Haukka J, Virkkula P, Torkki P, Toppila-Salmi S. Using machine learning for the personalised prediction of revision endoscopic sinus surgery. PLoS One 2022; 17:e0267146. [PMID: 35486626 PMCID: PMC9053825 DOI: 10.1371/journal.pone.0267146] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Revision endoscopic sinus surgery (ESS) is often considered for chronic rhinosinusitis (CRS) if maximal conservative treatment and baseline ESS prove insufficient. Emerging research outlines the risk factors of revision ESS. However, accurately predicting revision ESS at the individual level remains uncertain. This study aims to examine the prediction accuracy of revision ESS and to identify the effects of risk factors at the individual level. METHODS We collected demographic and clinical variables from the electronic health records of 767 surgical CRS patients ≥16 years of age. Revision ESS was performed on 111 (14.5%) patients. The prediction accuracy of revision ESS was examined by training and validating different machine learning models, while the effects of variables were analysed using the Shapley values and partial dependence plots. RESULTS The logistic regression, gradient boosting and random forest classifiers performed similarly in predicting revision ESS. Area under the receiving operating characteristic curve (AUROC) values were 0.744, 0.741 and 0.730, respectively, using data collected from the baseline visit until six months after baseline ESS. The length of time during which data were collected improved the prediction performance. For data collection times of 0, 3, 6 and 12 months after baseline ESS, AUROC values for the logistic regression were 0.682, 0.715, 0.744 and 0.784, respectively. The number of visits before or after baseline ESS, the number of days from the baseline visit to the baseline ESS, patient age, CRS with nasal polyps (CRSwNP), asthma, non-steroidal anti-inflammatory drug exacerbated respiratory disease and immunodeficiency or suspicion of it all associated with revision ESS. Patient age and number of visits before baseline ESS carried non-linear effects for predictions. CONCLUSIONS Intelligent data analysis identified important predictors of revision ESS at the individual level, such as the frequency of clinical visits, patient age, Type 2 high diseases and immunodeficiency or a suspicion of it.
Collapse
Affiliation(s)
- Mikko Nuutinen
- Haartman Institute, University of Helsinki, Helsinki, Finland
- Nordic Healthcare Group, Helsinki, Finland
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Paula Virkkula
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Paulus Torkki
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Haartman Institute, University of Helsinki, Helsinki, Finland
- Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- * E-mail:
| |
Collapse
|
7
|
Salonen J, Kreus M, Lehtonen S, Vähänikkilä H, Purokivi M, Kaarteenaho R. Decline in Mast Cell Density During Diffuse Alveolar Damage in Idiopathic Pulmonary Fibrosis. Inflammation 2021; 45:768-779. [PMID: 34686945 PMCID: PMC8956519 DOI: 10.1007/s10753-021-01582-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/12/2021] [Indexed: 11/30/2022]
Abstract
Mast cells (MCs) are known to be involved in the pathogenesis of idiopathic pulmonary fibrosis (IPF), although their role in acute exacerbations of IPF has not been investigated. The aims of the study were to evaluate the numbers of MCs in fibrotic and non-fibrotic areas of lung tissue specimens of idiopathic pulmonary fibrosis (IPF) patients with or without an acute exacerbation of IPF, and to correlate the MC density with clinical parameters. MCs of IPF patients were quantified from surgical lung biopsy (SLB) specimens (n = 47) and lung tissue specimens taken at autopsy (n = 7). MC density was higher in the fibrotic areas of lung tissue compared with spared alveolar areas or in controls. Female gender, low diffusion capacity for carbon monoxide, diffuse alveolar damage, and smoking were associated with a low MC density. MC densities of fibrotic areas had declined significantly in five subjects in whom both SLB in the stable phase and autopsy after an acute exacerbation of IPF had been performed. There were no correlations of MC densities with survival time or future acute exacerbations. The MC density in fibrotic areas was associated with several clinical parameters. An acute exacerbation of IPF was associated with a significant decline in MC counts. Further investigations will be needed to clarify the role of these cells in IPF and in the pathogenesis of acute exacerbation as this may help to identify some potential targets for medical treatment for this serious disease.
Collapse
Affiliation(s)
- Johanna Salonen
- Respiratory Medicine, Research Unit of Internal Medicine, University of Oulu, P.O. Box 8000, 90014 Oulu, Finland
- Medical Research Center (MRC) Oulu, Oulu University Hospital, P.O. Box 20, 90029 OYS Oulu, Finland
| | - Mervi Kreus
- Respiratory Medicine, Research Unit of Internal Medicine, University of Oulu, P.O. Box 8000, 90014 Oulu, Finland
- Medical Research Center (MRC) Oulu, Oulu University Hospital, P.O. Box 20, 90029 OYS Oulu, Finland
| | - Siri Lehtonen
- Medical Research Center (MRC) Oulu, Oulu University Hospital, P.O. Box 20, 90029 OYS Oulu, Finland
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Oulu University Hospital, University Hospital of Oulu, P.O. Box 23, 90029 OYS Oulu, Finland
| | - Hannu Vähänikkilä
- Infrastructure for Population Studies, Faculty of Medicine, Northern Finland Birth Cohorts, University of Oulu, Arctic Biobank, P.O. Box 8000, 90014 Oulu, Finland
| | - Minna Purokivi
- The Center of Medicine and Clinical Research, Division of Respiratory Medicine, Kuopio University Hospital, P.O. Box 100, 70029 KYS Kuopio, Finland
| | - Riitta Kaarteenaho
- Respiratory Medicine, Research Unit of Internal Medicine, University of Oulu, P.O. Box 8000, 90014 Oulu, Finland
- Medical Research Center (MRC) Oulu, Oulu University Hospital, P.O. Box 20, 90029 OYS Oulu, Finland
| |
Collapse
|
8
|
Kreus M, Lehtonen S, Skarp S, Kaarteenaho R. Extracellular matrix proteins produced by stromal cells in idiopathic pulmonary fibrosis and lung adenocarcinoma. PLoS One 2021; 16:e0250109. [PMID: 33905434 PMCID: PMC8078755 DOI: 10.1371/journal.pone.0250109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/30/2021] [Indexed: 11/29/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) and lung cancer share common risk factors, epigenetic and genetic alterations, the activation of similar signaling pathways and poor survival. The aim of this study was to examine the gene expression profiles of stromal cells from patients with IPF and lung adenocarcinoma (ADC) as well as from normal lung. The gene expression levels of cultured stromal cells derived from non-smoking patients with ADC from the tumor (n = 4) and the corresponding normal lung (n = 4) as well as from patients with IPF (n = 4) were investigated with Affymetrix microarrays. The expression of collagen type IV alpha 1 chain, periostin as well as matrix metalloproteinase-1 and -3 in stromal cells and lung tissues were examined with quantitative real-time reverse transcriptase polymerase chain reaction and immunohistochemistry, respectively. Twenty genes were similarly up- or down-regulated in IPF and ADC compared to control, while most of the altered genes in IPF and ADC were differently expressed, including several extracellular matrix genes. Collagen type IV alpha 1 chain as well as matrix metalloproteinases-1 and -3 were differentially expressed in IPF compared to ADC. Periostin was up-regulated in both IPF and ADC in comparison to control. All studied factors were localized by immunohistochemistry in stromal cells within fibroblast foci in IPF and stroma of ADC. Despite the similarities found in gene expressions of IPF and ADC, several differences were also detected, suggesting that the molecular changes occurring in these two lung illnesses are somewhat different.
Collapse
Affiliation(s)
- Mervi Kreus
- Research Unit of Internal Medicine, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
- * E-mail:
| | - Siri Lehtonen
- Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
- Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland
| | - Sini Skarp
- Northern Finland Birth Cohorts, Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Riitta Kaarteenaho
- Research Unit of Internal Medicine, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
9
|
Vähätalo I, Kankaanranta H, Tuomisto LE, Niemelä O, Lehtimäki L, Ilmarinen P. Long-term adherence to inhaled corticosteroids and asthma control in adult-onset asthma. ERJ Open Res 2021; 7:00715-2020. [PMID: 33585657 PMCID: PMC7869602 DOI: 10.1183/23120541.00715-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/12/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND In short-term studies, poor adherence to inhaled corticosteroids (ICS) has been associated with worse asthma control, but the association of long-term adherence and disease control remains unclear. OBJECTIVE To assess the relationship between 12-year adherence to ICS and asthma control in patients with adult-onset asthma. METHODS As part of the Seinäjoki Adult Asthma Study, 181 patients with clinically confirmed new-onset adult asthma and regular ICS medication were followed-up for 12 years. Adherence (%) to ICS was assessed individually ((µg dispensed/µg prescribed)×100) during the follow-up. Asthma control was evaluated after 12 years of treatment according to the Global Initiative for Asthma 2010 guideline. RESULTS Asthma was controlled in 31% and not controlled (partly controlled or uncontrolled) in 69% of the patients. Patients with not-controlled asthma were more often male, older, nonatopic and used higher doses of ICS than those with controlled disease. The mean±sd 12-year adherence to ICS was 63±38% in patients with controlled asthma and 76±40% in patients with not-controlled disease (p=0.042). Among patients with not-controlled asthma, those with lower 12-year adherence (<80%) had more rapid decline in forced expiratory volume in 1 s (-47 mL·year-1) compared to patients with better adherence (≥80%) (-40 mL·year-1) (p=0.024). In contrast, this relationship was not seen in patients with controlled asthma. CONCLUSIONS In adult-onset asthma, patients with not-controlled disease showed better 12-year adherence to ICS treatment than those with controlled asthma. In not-controlled disease, adherence <80% was associated with more rapid lung function decline, underscoring the importance of early recognition of such patients in routine clinical practice.
Collapse
Affiliation(s)
- Iida Vähätalo
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Tampere University Respiratory Research Group, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Hannu Kankaanranta
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Tampere University Respiratory Research Group, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Krefting Research Centre, Institute of Medicine, Dept of Internal Medicine and Clinical Nutrition, University of Gothenburg, Gothenburg, Sweden
| | - Leena E. Tuomisto
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Tampere University Respiratory Research Group, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Onni Niemelä
- Tampere University Respiratory Research Group, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Dept of Laboratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Lauri Lehtimäki
- Tampere University Respiratory Research Group, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Pinja Ilmarinen
- Dept of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Tampere University Respiratory Research Group, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| |
Collapse
|
10
|
Kotanen P, Kreivi HR, Vainionpää A, Laaksovirta H, Brander P, Siirala W. Home invasive mechanical ventilation in Finland in 2015-2019. ERJ Open Res 2020; 6:00223-2020. [PMID: 33263031 PMCID: PMC7682663 DOI: 10.1183/23120541.00223-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/01/2020] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The prevalence of long-term invasive mechanical ventilation via tracheostomy in chronic respiratory insufficiency is largely unknown. We aimed to clarify prevalence and aetiology of the use of home invasive mechanical ventilation (HIMV) in Finland in 2015-2019. METHODS Information on HIMV patients was collected yearly from all Finnish Hospital District patient registries between 1 January 2015 and 1 January 2019. Data included underlying diagnosis, time from diagnosis to HIMV initiation, treatment length, mortality and basic sociodemographic data. RESULTS In 2015, we had 107 HIMV patients. During the follow-up we received 34 new patients (24.1%) and 46 patients (32.6%) died. In 2019, we had 95 HIMV patients and the prevalence in Finland was 2.0 in 100 000. The most common diagnoses were motor neurone disease (29.1%) and spinal cord injuries (19.9%). Mean duration of HIMV among all patients on 1 January 2019 was 12.3 years and among deceased patients, 11.2 years. Treatment durations ranged from 7.7 years for motor neurone disease patients to 47.3 years for post-polio syndrome patients. Most patients (81.6%) used HIMV 24 h·day-1. CONCLUSIONS HIMV is a rare, long-lasting treatment, most often used in chronic hypoventilation caused by chronic neurological disease. Based on our 4 year follow-up the prevalence of HIMV seems to be diminishing in Finland. Treatment duration and survival vary greatly depending on the underlying diagnosis. Most of the patients were totally dependent on HIMV, requiring 24-h care.
Collapse
Affiliation(s)
- Petra Kotanen
- HUH Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Doctoral Programme in Clinical Research, University of Helsinki, Helsinki, Finland
| | - Hanna-Riikka Kreivi
- HUH Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Aki Vainionpää
- Department of Rehabilitation, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Hannu Laaksovirta
- HUH Neurocenter, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirkko Brander
- HUH Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Waltteri Siirala
- Dept of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland
| |
Collapse
|
11
|
Ala-Seppälä HM, Ukkonen MT, Lehtomäki AI, Pohja ES, Nieminen JJ, Laurikka JO, Khan JA. High Occurrence of Thrombo-Embolic Complications During Long-Term Follow-up After Pleural Infections-A Single-Center Experience with 536 Consecutive Patients Over 17 Years. Lung 2020; 198:671-678. [PMID: 32607673 PMCID: PMC7374478 DOI: 10.1007/s00408-020-00374-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022]
Abstract
Purpose Pleural infections are associated with significant inflammation, long hospitalizations, frequent comorbidities, and are often treated operatively—all of which are consequential risk factors for thrombo-embolic complications. However, their occurrence following the treatment of pleural infection is still unknown. The aim of the study was to ascertain the early and long-term occurrence of thrombo-embolic events in patients treated for pleural infections. Methods The study included all patients that were treated for pleural infections in Tampere University Hospital between January 2000 and December 2016. Data regarding later treatment episodes due to pulmonary embolisms and/or deep vein thromboses as well as survival data were requested from national registries. The rates were also compared to a demographically matched reference population adjusted for age, sex, and the location of residence. Results The final study population comprised 536 patients and 5318 controls (median age 60, 78% men). The most common etiology for pleural infection was pneumonia (73%) and 85% underwent surgical treatment for pleural infection. The occurrence of thrombo-embolic complications in patients and controls was 3.8% vs 0.1% at three months, 5.0% vs 0.4% at one year, 8.8% vs 1.0% at three years, and 12.4% vs 1.8% at five years, respectively, p < 0.001 each. Female sex, advanced age, chronic lung disease, immunosuppression, video-assisted surgery, and non-pneumonic etiology were associated with a higher incidence of thrombo-embolism. Conclusions The occurrence of thrombo-embolic events—particularly pulmonary embolism but also deep vein thrombosis—was significant in patients treated for pleural infections, both initially and during long-term follow-up.
Collapse
Affiliation(s)
- Henna Maria Ala-Seppälä
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Ensitie 4, 33520, Tampere, Finland
| | - Mika Tapani Ukkonen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland
- Faculty of Medicine and Life Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Antti Ilmari Lehtomäki
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Ensitie 4, 33520, Tampere, Finland
| | - Emilia Susanna Pohja
- Faculty of Medicine and Life Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Jaakko Juhani Nieminen
- Faculty of Medicine and Life Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Jari Olavi Laurikka
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Ensitie 4, 33520, Tampere, Finland
- Faculty of Medicine and Life Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Jahangir Ari Khan
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Ensitie 4, 33520, Tampere, Finland.
| |
Collapse
|
12
|
Kotisalmi E, Hakulinen A, Mäkelä M, Toppila-Salmi S, Kauppi P. A comparison of biologicals in the treatment of adults with severe asthma - real-life experiences. Asthma Res Pract 2020; 6:2. [PMID: 32467765 PMCID: PMC7222440 DOI: 10.1186/s40733-020-00055-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Anti-IgE (omalizumab) and anti-IL5/IL5R (reslizumab, mepolizumab and benralizumab) treatments are available for severe allergic and eosinophilic asthma. In these patients, studies have shown beneficial effects in oral corticosteroid use and exacerbations. The aim of this retrospective single-center study was to evaluate the effect of biological therapy on severe asthma and to compare different therapies. METHODS We collected and analysed results of anti-IL5/IL5R and anti-IgE therapies for asthma from January 2009 until October 2019 in specialized care. We compared number of exacerbations, asthma symptoms and use of per oral corticosteroids and antimicrobics because of asthma before and during biological therapy, and in a separate analysis need for per oral corticosteroids, antimicrobics or surgery due to upper respiratory tract diseases in asthmatics receiving biologicals. The analyses were done using the Chi square test, T-test or Mann-Whitney U -test, the Kruskall-Wallis test or the Wilcoxon test. RESULTS Of 64 patients, 40 used continuous per oral corticosteroid therapy prior to biological therapy. The mean daily dose of per oral corticosteroid was reduced in those with anti-IL5/IL5R therapy (- 3.0 mg, p = 0.02). The number of annual per oral corticosteroid courses decreased in both the anti-IL5/IL5R (- 2.8 courses, p < 0.05) and anti-IgE groups (- 1.3 courses, p < 0.05). The number of annual antibiotic courses (- 0.7 courses, p = 0.04) and total number of exacerbation events (- 4.4 events/year, p < 0.05) were reduced in the anti-IL5/IL5R group. In the 55 asthma patients analysed for upper respiratory tract findings, the results suggested a reduction in need for chronic rhinosinusitis surgery during biological therapy. CONCLUSIONS Results with biological therapies in this real-life clinical setting are comparable to those reported in clinical trials. Biological therapy reduces exacerbations and per oral corticosteroid use. TRIAL REGISTRATION NCT04158050, retrospectively registered 6.11.2019.
Collapse
Affiliation(s)
- Emma Kotisalmi
- Respiratory Diseases and Allergology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Meilahdentie 2, FI-00029 HUS, P.O. Box 160, Helsinki, Finland
- Respiratory Diseases and Allergology, University of Helsinki and Helsinki University Hospital, Heart and Lung Center, Helsinki, Finland
| | - Auli Hakulinen
- Respiratory Diseases and Allergology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Meilahdentie 2, FI-00029 HUS, P.O. Box 160, Helsinki, Finland
| | - Mika Mäkelä
- Respiratory Diseases and Allergology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Meilahdentie 2, FI-00029 HUS, P.O. Box 160, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Otorhinolaryngology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Helsinki, Finland
| | - Paula Kauppi
- Respiratory Diseases and Allergology, University of Helsinki and Helsinki University Hospital, Inflammation Center, Meilahdentie 2, FI-00029 HUS, P.O. Box 160, Helsinki, Finland
| |
Collapse
|
13
|
Salonen J, Purokivi M, Bloigu R, Kaarteenaho R. Prognosis and causes of death of patients with acute exacerbation of fibrosing interstitial lung diseases. BMJ Open Respir Res 2020; 7:e000563. [PMID: 32265195 PMCID: PMC7254157 DOI: 10.1136/bmjresp-2020-000563] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of this study was to compare the clinical characteristics, causes of death and factors impacting on the prognosis of patients with idiopathic pulmonary fibrosis (IPF) and other fibrosing interstitial lung disease (FILD) with a history of acute exacerbation (AE) of IPF or FILD. METHODS Retrospective data of hospital treatment periods caused by AE-IPF and AE-FILD were collected from medical records. Clinical features and survival data of IPF and non-IPF cases were evaluated and compared. The underlying and immediate causes of death were gathered from death certificates. RESULTS A total of 128 patients fulfilled the criteria for inclusion. IPF (n=79/62%), rheumatoid arthritis-associated interstitial lung disease (RA-ILD; n=17/14%) and asbestosis (n=11/8.6%) were the most common FILD subgroups in the study. The median survival after hospitalisation in AE-IPF was 2.6 months compared with 21 months in other AE-FILDs (p<0.001). The survival difference was not explained by age, gender or pulmonary function test results at the time of hospitalisation. Patients with non-specific interstitial pneumonia and RA-ILD had the most favourable prognosis. ILD was the most common underlying cause of death in both patients with IPF and with other FILD accounting for 87% and 78% of deaths, respectively. CONCLUSIONS We detected a significantly longer survival in AE of patients with non-IPF compared with that of AE-IPFs. The prognosis of patients was affected by the underlying lung disease since pulmonary fibrosis was the underlying cause of death in the majority of all patients with FILD having experienced an AE.
Collapse
Affiliation(s)
- Johanna Salonen
- Respiratory Medicine, Research Unit of Internal Medicine, University of Oulu, Oulu, Finland
- Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Minna Purokivi
- The Center of Medicine and Clinical Research, Division of Respiratory Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Risto Bloigu
- Medical Informatics and Statistics Research Group, University of Oulu, Oulu, Finland
| | - Riitta Kaarteenaho
- Respiratory Medicine, Research Unit of Internal Medicine, University of Oulu, Oulu, Finland
- Medical Research Center, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
14
|
Myllymäki H, Niskanen M, Oksanen KE, Sherwood E, Ahava M, Parikka M, Rämet M. Identification of novel antigen candidates for a tuberculosis vaccine in the adult zebrafish (Danio rerio). PLoS One 2017; 12:e0181942. [PMID: 28742838 PMCID: PMC5526617 DOI: 10.1371/journal.pone.0181942] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 07/10/2017] [Indexed: 12/31/2022] Open
Abstract
Tuberculosis (TB) remains a major global health challenge and the development of a better vaccine takes center stage in fighting the disease. For this purpose, animal models that are capable of replicating the course of the disease and are suitable for the early-stage screening of vaccine candidates are needed. A Mycobacterium marinum infection in adult zebrafish resembles human TB. Here, we present a pre-clinical screen for a DNA-based tuberculosis vaccine in the adult zebrafish using an M. marinum infection model. We tested 15 antigens representing different types of mycobacterial proteins, including the Resuscitation Promoting factors (Rpf), PE/PPE protein family members, other membrane proteins and metabolic enzymes. The antigens were expressed as GFP fusion proteins, facilitating the validation of their expression in vivo. The efficiency of the antigens was tested against a low-dose intraperitoneal M. marinum infection (≈ 40 colony forming units), which mimics a primary M. tuberculosis infection. While none of the antigens was able to completely prevent a mycobacterial infection, four of them, namely RpfE, PE5_1, PE31 and cdh, led to significantly reduced bacterial burdens at four weeks post infection. Immunization with RpfE also improved the survival of the fish against a high-dose intraperitoneal injection with M. marinum (≈ 10.000 colony forming units), resembling the disseminated form of the disease. This study shows that the M. marinum infection model in adult zebrafish is suitable for the pre-clinical screening of tuberculosis vaccines and presents RpfE as a potential antigen candidate for further studies.
Collapse
Affiliation(s)
- Henna Myllymäki
- BioMediTech Institute and Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- * E-mail:
| | - Mirja Niskanen
- BioMediTech Institute and Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Kaisa Ester Oksanen
- BioMediTech Institute and Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Eleanor Sherwood
- BioMediTech Institute and Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Maarit Ahava
- BioMediTech Institute and Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Mataleena Parikka
- BioMediTech Institute and Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Oral and Maxillofacial Unit, Tampere University Hospital, Tampere, Finland
| | - Mika Rämet
- BioMediTech Institute and Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, Oulu, Finland, and Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| |
Collapse
|