Duodecim; Laaketieteellinen Aikakauskirja[JOURNAL]
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200 papers
Update on Current Care Guideline: Psoriasis (skin and joints).
Duodecim · 2017 · PMID 29243903
Psoriasis is a chronic, immune-mediated, inflammatory disorder of the skin and joints. Moderate-to-server cases are associated with an independent risk of comorbidity (cardiovascular diseases and diabetes) even after adj...
Psoriasis is a chronic, immune-mediated, inflammatory disorder of the skin and joints. Moderate-to-server cases are associated with an independent risk of comorbidity (cardiovascular diseases and diabetes) even after adjusting for risk factors, known to be more prevalent in psoriatics compared to normal population. The systemic underlying inflammation, analogous to that observed in rheumatoid arthritis, calls for a long-term effective treatment. Screening and treatment of cardiovascular risk factors is highly recommended. The biologic drug arsenal has new additions. Long term treatment data from clinical study extensions and independent registries are reviewed.
FOUR score in monitoring the level of consciousness of an intensive care patient: first experience of the use of the Finnish language version.
Sivula A, Luoto T, Heinilä J … +4 more , Huhtala H, Karlsson S, Yli-Hankala A, Långsjö J
Duodecim · 2017 · PMID 29243901
BACKGROUND: The goal was to increase the knowledge of Full Outline of UnResponsiveness (FOUR) score in Finland, release its Finnish version and to evaluate its usefulness in Finnish ICU patients. MATERIALS AND METHODS: T...
BACKGROUND: The goal was to increase the knowledge of Full Outline of UnResponsiveness (FOUR) score in Finland, release its Finnish version and to evaluate its usefulness in Finnish ICU patients. MATERIALS AND METHODS: The highest FOUR and Glasgow Coma Scale (GCS) scores of the adult ICU patients treated in Tampere University Hospital between 1st January and 31st October 2015 were analyzed retrospectively. In-hospital and 1-month mortality were the primary end-points. RESULTS: The Finnish version of FOUR performed comparably to previous studies. The ability of FOUR to predict mortality was equal to GCS. CONCLUSIONS: FOUR is at least equal to GCS in predicting mortality of ICU patients.
Discussing a serious illness with a patient and family.
Laaksovirta H
Duodecim · 2017 · PMID 29243899
Learning of a serious illness is unique news. Nothing certain can be known about how it will affect the hearer's outlook on the future before a conception is established about the hearer's expectations and how he/she has...
Learning of a serious illness is unique news. Nothing certain can be known about how it will affect the hearer's outlook on the future before a conception is established about the hearer's expectations and how he/she has understood the issue. For example, a person who has been expecting muscle tension to be an explanation for back pain but hearing that a cancer metastasis is the underlying cause, will inevitably be in shock. The healthcare system is not able to influence everything, but is usually given one possibility to make a good first impression when telling about a serious diagnosis. Various lists of issues to be taken into account have been devised to help this. They do not, however, replace effective interaction, which is a matter of skill but can also be practiced. It is possible to anticipate the reactions of the hearers, as long as they remember that feelings are feelings and facts are facts.
Invasive treatment of superficial veins of the lower extremities.
Saarinen J
Duodecim · 2017 · PMID 29243898
Modern invasive treatment of superficial venous insufficiency of the lower extremities is largely based on the use of intravenous procedures under ultrasound guidance. The first-line treatment is thermoablation, in which...
Modern invasive treatment of superficial venous insufficiency of the lower extremities is largely based on the use of intravenous procedures under ultrasound guidance. The first-line treatment is thermoablation, in which the insufficient superficial vein, typically vena saphena magna or parva, is constricted by using laser or radio frequency energy under ultrasound guidance. The procedure is nearly always successful under local anesthesia and can be performed as an outpatient operation. When necessary, visible collateral varices can be treated with foam sclerotherapy or by surgical excision. The need for associated medication or longer follow-up is limited and recovery is fast. The patients can be mobilized immediately, and only a couple of days of sick leave are usually required.
When should a drain be left in the abdominal cavity upon surgery?
Laine M, Mentula P, Koskenvuo L … +2 more , Nordin A, Sallinen V
Duodecim · 2017 · PMID 29243897
Passive or active drainage can be used after abdominal surgery. Drains aim at eradicating infected or inflammatory tissue fluids and to alarm of undesired events such as bile, pancreatic, or bowel leak. Drains may, howev...
Passive or active drainage can be used after abdominal surgery. Drains aim at eradicating infected or inflammatory tissue fluids and to alarm of undesired events such as bile, pancreatic, or bowel leak. Drains may, however, occlude or be situated away from the postoperative dilemma. Furthermore, drains themselves are susceptible to cause or maintain infection by retrograde contamination, may irritate the peritoneum causing excess ascites formation, and cause pain. Recent scientific evidence suggests that drains are unnecessary after most abdominal operations. Thus, drains should be used only in certain specific operation types such as pancreatic and emergency surgery. In other operations drains can be omitted if no clear risk factors are present.
Diagnostics and current care of myasthenia gravis.
Atula S, Pfau K, Salmi T … +4 more , Sihvo E, Haapio M, Saarela M, Auranen M
Duodecim · 2017 · PMID 29243896
Myasthenia gravis (MG) is the most common neuromuscular transmission disorder, causing weakness of skeletal muscles on exertion. The course of the disease is highly variable, symptoms and signs may change rapidly due to...
Myasthenia gravis (MG) is the most common neuromuscular transmission disorder, causing weakness of skeletal muscles on exertion. The course of the disease is highly variable, symptoms and signs may change rapidly due to infection or pregnancy. MG is classified using serological, electrophysiological and pharmaceutical tools. A precise diagnosis allows for the choice of right treatment, predicts the course of disease and hence helps with the follow-up. In this review we present Finnish guidelines for diagnostics, treatment and follow-up of MG patients.
Thoracic outlet syndrome.
Arokoski J, Karppinen J, Lindgren KA … +4 more , Vastamäki H, Vastamäki M, Ristolainen L, Laimi K
Duodecim · 2017 · PMID 29243895
It is important to remember the possibility of nonspecific thoracic outlet syndrome (TOS) when treating patients with neck and upper extremity symptoms. There are no specific diagnostic criteria for the syndrome. Diagnos...
It is important to remember the possibility of nonspecific thoracic outlet syndrome (TOS) when treating patients with neck and upper extremity symptoms. There are no specific diagnostic criteria for the syndrome. Diagnosis is based on symptoms, clinical examination and the ruling out of other causes. The first-line option of clinical care is conservative treatment, which in most cases is sufficient for the patient to regain normal functioning. However, some of the most difficult TOS patients need surgical treatment, especially when persistent symptoms have already begun in adolescence, and if compression of neural or vascular structures is thought to result from anatomical structures. Conservative treatment options are essential also for surgically treated patients.
Preliminary appraisal of clinical drug trials is changing.
Konttinen O, Närhi U
Duodecim · 2017 · PMID 29243893
The EU Clinical Trials Regulation will change the preliminary appraisal of trials and lighten the bureaucracy. Routines of the member states will be standardized, processing of applications provided with tighter time lim...
The EU Clinical Trials Regulation will change the preliminary appraisal of trials and lighten the bureaucracy. Routines of the member states will be standardized, processing of applications provided with tighter time limits, and the licensing procedure made more flexible by using a common European portal. At the same time, definitions will be provided for low intervention trials subject to more flexible rules of follow-up, requirements of master file content, and traceability of test drugs. Implementation of the regulation depends on the completion of the EU portal, currently estimated to take place in the autumn of 2018. Preparations for execution in Finland are carried out by a working group appointed by the Ministry of Social Affairs and Health. On the national level, preparations are in progress to e.g. reorganize ethical evaluation, because the deadlines of evaluation of applications cannot be met with the current structure. Furthermore, regulations concerning insurances and collaterals, language requirements and possibilities of petitioning relating to the applications will also be decided on a national basis.
New study designs in clinical drug development.
Tenhunen O, Turpeinen M, Kurki P
Duodecim · 2017 · PMID 29243892
Clinical development of a novel drug has traditionally been seen as a series of four phases, each having its own objectives in establishing the efficacy and safety of the drug. Increasingly individualized medicine and th...
Clinical development of a novel drug has traditionally been seen as a series of four phases, each having its own objectives in establishing the efficacy and safety of the drug. Increasingly individualized medicine and the changing mechanisms of drug action are also changing the designs of clinical drug testing. The borders of development phases become blurred and the traditional large, controlled multicenter studies may in part be replaced by individual and risk-based approaches. The indications for drugs are more precisely targeted from biological starting points, and a target-oriented development may guide the designs of clinical testing at all stages of development. Utilization of data from registries along with modeling will become more common in clinical drug testing.
Biobanks and Comprehensive Cancer Center Finland (FICAN) as institutions enabling clinical drug testing.
Carpén O, Helander T
Duodecim · 2017 · PMID 29243869
Clinical trials aiming at developing targeted drug therapies require the identification of appropriate patient groups, utilizing both clinical information and the biological profile of the disease. The Finnish healthcare...
Clinical trials aiming at developing targeted drug therapies require the identification of appropriate patient groups, utilizing both clinical information and the biological profile of the disease. The Finnish healthcare system provides exceptional possibilities for utilizing health data in identifying patient groups, planning of clinical sample studies and recruiting patients. Biobanks established at university hospitals together with the regional cancer centers play a central role in collecting biological specimens and attaching health data to the specimens. Combined with longitudinal health data, the collections of tissue specimens obtained in connection with the diagnosis offer versatile possibilities for the development of companion diagnostics of targeted drugs. Specimens collected on the basis of informed consent in connection with diagnosis and treatment enable the identification of patients suitable for drug trials, and a contact according to the consent. In the development of new functions, national collaboration - both geographical and between research infrastuctures - becomes of paramount importance. Combining the resources of biobanks, the genome strategy and the Comprehensive Cancer Center, an enabling legislation and, above all, patients with a positive attitude towards examinations, offer excellent possibilities for Finland to become the model country of individualized treatment.
Hope for better treatment in participating clinical drug trials.
Keränen T, Pasternack A, Halkoaho A
Duodecim · 2017 · PMID 29243475
An informed consent is a prerequisite for participating in medical trials, whereby the person asked to take part in the trial shall understand what he is committing himself to, and that the consent is given voluntarily....
An informed consent is a prerequisite for participating in medical trials, whereby the person asked to take part in the trial shall understand what he is committing himself to, and that the consent is given voluntarily. Voluntariness can be undermined by so-called therapeutic optimism, i.e. belief in personal benefit brought about by the trial, as well as the difficulty of understanding how conventional treatment and the trial differ from each other, i.e. the so-called therapeutic misconception. The investigator, especially if he is also the attending physician, may influence the development of therapeutic misconception, because the participant may assume that the physician works as an investigator for the best benefit of the patients. It is important to recognize unrealistic optimism and therapeutic misconception of the trial, because for the participant they may result in disappointment and loss of confidence during the trial.
Preliminary ethical appraisal of a trial - what's it all about?
Siipi H
Duodecim · 2017 · PMID 29243472
Preliminary ethical appraisal of medical trials is often based on the following four principles: respect for autonomy, beneficence, non-maleficence, and justice. Preliminary ethical appraisal should, however, not be unde...
Preliminary ethical appraisal of medical trials is often based on the following four principles: respect for autonomy, beneficence, non-maleficence, and justice. Preliminary ethical appraisal should, however, not be understood solely as application of these four principles to practice. Ethical committees will inevitably interpret the principles and make decisions about their reciprocal importance in connection with each trial. Reasoning does not always proceed from above towards practical recommendations of action, but can instead also be based on a moral rule or practice relating to a certain action. A good preliminary ethical appraisal will also take into account everyday standards of morality, law and shared moral values of the society.
Update on Current Care Guideline: Venous insufficiency of the lower limb.
Duodecim · 2017 · PMID 29243470
Venous insufficiency of the lower limb is a common disease. Diagnosis is based on symptoms, clinical findings and duplex ultrasound. Consideration and planning of invasive treatment cannot be performed without ultrasound...
Venous insufficiency of the lower limb is a common disease. Diagnosis is based on symptoms, clinical findings and duplex ultrasound. Consideration and planning of invasive treatment cannot be performed without ultrasound. Vast majority of invasive treatments in superficial venous insufficiency can be done by ultrasound-guided endovenous methods with local anesthesia. Thermoablation (laser of radiofrequency) is the first-line treatment. There are promisisng endovenous methods for treatment of deep venous obstruction in selected cases.
High-resolution CT of the lungs: Indications and diagnosis.
Lauri H
Duodecim · 2017 · PMID 29243467
High-resolution computed tomography (HRCT) is a method of examination which is more precise than chest 2-rat in the diagnosis and monitoring of diseases of the lung tissue and the airways. Modern CT equipment enables a v...
High-resolution computed tomography (HRCT) is a method of examination which is more precise than chest 2-rat in the diagnosis and monitoring of diseases of the lung tissue and the airways. Modern CT equipment enables a volume HRCT scan covering the whole lung tissue. HRCT slices can also be constructed from contrast-enhanced CT scans of the chest of the whole body. HRCT of the lungs can be applied to the diagnosis of both acute and more chronic diffuse diseases of the lung tissue and the airways. The best-known indications for HRCT include idiopathic interstitial pneumonias, such as idiopathic pulmonary fibrosis. High-resolution computed tomography has also become established in the diagnostics of pneumoconiosis, such as asbestosis. More acute indications for HRCT include various inflammations, drug reactions and diffuse alveolar injury. Medical history plays a central role in the interpretation of lung HRCT, because a finding in imaging examination is often unspecific. A good test requisition is therefore important.
Atypical hemolytic-uremic syndrome.
Kaartinen K, Martola L, Meri S
Duodecim · 2017 · PMID 29243465
Atypical hemolytic-uremic syndrome (aHUS) is a rare form of thrombotic microagiopathy caused dysregulation of the alternative pathway of the complement resulting in tissue. In aHUS, activation of the alternative pathway...
Atypical hemolytic-uremic syndrome (aHUS) is a rare form of thrombotic microagiopathy caused dysregulation of the alternative pathway of the complement resulting in tissue. In aHUS, activation of the alternative pathway of the complement is in an aberrant way directed against endothelial cells and blood cells. This is either due to a mutation in a complement factor, most commonly factor H, or an autoantibody against a complement regulator. In some patients the underlying disorder is not identified despite thorough examinations. Typical aHUS-patients have acute kidney injury and microangiopathic hemolysis and, to a varying degree, disturbances of other organs. An effective inhibitor of the final product of complement, eculizumab, has revolutionized the treatment of these patients.
[Physicians' working conditions, health and working capacity].
Elovainio M, Virtanen M, Oksanen T
Duodecim · 2017 · PMID 29243461
Changes in the working environment will also influence the work of physicians. The greatest of these changes on the Finnish scale, the SOTE reform (the reform in social welfare and public health services), still lies ahe...
Changes in the working environment will also influence the work of physicians. The greatest of these changes on the Finnish scale, the SOTE reform (the reform in social welfare and public health services), still lies ahead. Labor shortage, on-call duties and patient record systems providing little support to work add to the burden. In surveys related to psychosocial working conditions, physicians' greatest work load factors have been rush, forced working pace and poor communication despite the fact that, on average, they consider their working conditions to be good, frequently better than those of other professional groups, and are committed to carry on with their work until retirement age. Although psychic symptoms and sleep disturbances are common among physicians, there are fewer disability pensions due to e.g. depression among physicians than in other professional groups. Among the municipal professions, physicians have nearly the lowest rate of job absenteeism due to sickness. Challenges brought about by the changes in physician's work can be met with fair management, development of the social capital of the work community, organization of tasks and flexibility of working hours.
[Update on Current Care Guideline: Neck pain (adults)].
Duodecim · 2017 · PMID 29243460
Neck pain is usually non-specific, but serious illness or specific reasons for neck pain need to be ruled out. Patients are encouraged to continue their daily activities. Acute neck pain often disappears without any spec...
Neck pain is usually non-specific, but serious illness or specific reasons for neck pain need to be ruled out. Patients are encouraged to continue their daily activities. Acute neck pain often disappears without any special treatment. Patient information is important. If pain medication is needed, paracetamol is the primary choice. Multidisciplinary treatment is recommended if disabling pain does not improve during the first two months. Neck-specific exercises are recommended in the chronic phase.
Adrenomyeloneuropathy due to mutation in the ABCD1 gene as underlying factor in spastic paraparesis.
Ylikallio E, Rahikkala E, Keski-Filppula R … +2 more , Auranen M, Tyynismaa H
Duodecim · 2017 · PMID 29243459
We present a Finnish family in which adrenomyeloneuropathy (AMN) caused by the mutation in the ABCD1 gene was revealed as the cause of spastic paraparesis. . Two patients had hypoadrenalism, which is in some cases some a...
We present a Finnish family in which adrenomyeloneuropathy (AMN) caused by the mutation in the ABCD1 gene was revealed as the cause of spastic paraparesis. . Two patients had hypoadrenalism, which is in some cases some associated with the disease . AMN is a hereditary disease manifested both in men and women. but owing to the location of the gene in the X chromosome the symptoms are usually more severe in male patients. . Diagnoses was trucked down with gene-panel sequencing and confirmed through detection of an elevated level of very long-chain fatty acids in the serum of the patients. Specific molecular genetic diagnosis is beneficial, because it enables precise genetic counseling as well as recognition and treatment of associated symptoms, such as severe cortisol deficiency.
Prevalence of life-supporting prolonged invasive ventilation support in Finland.
Siirala W, Vainionpää A, Kainu A … +3 more , Korpela J, Olkkola K, Aantaa R
Duodecim · 2017 · PMID 29243458
BACKGROUND: There is no comprehensive data in our country on the prevalence of life-supporting prolonged invasive ventilation support. The objective of the survey was to clarify in all hospital districts of continental F...
BACKGROUND: There is no comprehensive data in our country on the prevalence of life-supporting prolonged invasive ventilation support. The objective of the survey was to clarify in all hospital districts of continental Finland the prevalence of patients who were dependent on invasive ventilation support, and the disease leading to the treatment. PATIENTS AND METHODS: The KOTIVEHNO 2015 survey was carried out as population-based cross-sectional study by sending a questionnaire to all doctors in charge of prolonged invasive ventilation support. The questionnaires were used to collect data on the patients within care on 1st January, 2017. RESULTS: The prevalence of life-supporting prolonged invasive ventilation support in Finland among the population aged over 16 years or more was 2/4 patients/100,000 habitants. Altogether 107 patients were within the care. There was variation in the prevalence among the hospital districts. Of the patients, 24% were affected with a motoneuron disease, in 18% the cause was spinal cord injury, 15% suffered from Duchenne's muscular dystrophy, and the rest had some other rare neurological disease. CONCLUSIONS: Life-supporting prolonged invasive ventilation support is rare in Finland. The treatment is associated with neuromuscular diseases causing respiratory insufficiency, and with spinal cord injuries.
[New self-assessment tools for evaluating work ability].
Vuokko A, Tuisku K
Duodecim · 2017 · PMID 29243453
Assessment and support of the work ability and function is an elementary responsibility of health care. The focus of assessment lies in the remaining functional capacity and its sufficiency with respect to occupational d...
Assessment and support of the work ability and function is an elementary responsibility of health care. The focus of assessment lies in the remaining functional capacity and its sufficiency with respect to occupational demands. Objective and subjective perspectives, personal resources and limitations, and the subject's relationship to the environment are taken into account according to biopsychosocial models of work ability. We recommend three useful self-report measurement tools for work ability and function. Return-to-Work-Readiness Questionnaire (RTW-RQ), Return-to-Work Self-Efficacy (RTW-SE) and Sheehan Disability Scale (SDS). These tools structure an interactive evaluation providing possibilities for follow-up. They provide means to discuss one's personal resources and limitations and to promote return-to-work.
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