Several researchers have determined the tumor length to be an important prognostic indictor of esophageal cancer (EC). However, controversy exists concerning the optimal cut-off points for tumor length to predict overall survival. The aim of this study was to determine the prognostic value of tumor length and propose the optimum cut-off point for tumor length in predicting survival difference in elderly patients with esophageal squamous cell carcinoma (ESCC).
From January 2001 to December 2009, a retrospective analysis of 132 consecutive patients older than 70 years with ESCC was conducted. A receiver-operating characteristic (ROC) curve for survival prediction was plotted to verify the optimum cut-off point for tumor length. Univariate and multivariate analyses were performed to evaluate prognostic parameters for survival.
A ROC curve for survival prediction was plotted to verify the optimum cut-off point for tumor length, which was 4.0 cm. Patients with tumor length ≤4.0 cm had significantly better 5-year survival rate than patients with a tumor length >4.0 cm (60.7% versus 31.6%, P = 0.007). Multivariate analyses showed that tumor length (>4.0 cm versus ≤4.0 cm, P = 0.036), differentiation (poor versus well/moderate, P = 0.032), N staging (N1-3 versus N0, P = 0.018), and T grade (T3-4 versus T1-2, P = 0.002) were independent prognostic factors.
Tumor length is a predictive factor for long-term survival in elderly patients with ESCC, especially in T3-4 grade or nodal-negative patients. We conclude that 4.0 cm may be the optimum cut-off point for tumor length in predicting survival in elderly patients with ESCC.
Esophageal cancer; esophagectomy; prognostic factor; squamous cell carcinoma; survival; tumor length
Glycosylation and glycan composition are of fundamental importance for the biological properties of FSH and LH. The aim of this study was to determine the glycosylation, sialylation, and sulfonation of serum FSH and LH throughout the normal menstrual cycle.
Serum samples were collected from 79 healthy women with regular menstrual cycles. The mean numbers of anionic monosaccharide (AMS), sialic acid (SA), and sulfonated N-acetylgalactosamine (SU) residues per FSH and LH molecule were estimated for all sera with methods based on electrophoreses, neuraminidase treatments, and fluoroimmunoassays of the gonadotrophins.
Di-glycosylated glycoforms (FSHdi, LHdi) were detected in serum in addition to tetra-glycosylated FSH (FSHtetra) and tri-glycosylated LH (LHtri). FSHdi exhibited two peaks: one on day 5 to 7 and one, more pronounced, at midcycle. FSHtetra plateaued at a high concentration from day 5 to 15, without a midcycle peak. There were lower concentrations of LHdi than LHtri, except at midcycle when the opposite occurred. The mean numbers of SA and SU residues per molecule of FSH and LH in serum showed four different patterns during the cycle, all with highly significant (P < 0.0001) differences between levels at different phases of the cycle. The pattern of SA residues on FSH was ‘M’-shaped, and that of SU on LH ‘V’-shaped.
Serum FSH and LH governing the natural ovarian stimulation process exhibited dynamic changes of glycosylation and glycan composition. This new information on the FSH and LH molecular structures may lead to more successful mono-ovulatory treatment regimens for ovulation induction in anovulatory women.
di-glycosylated FSH; di-glycosylated LH; glycoforms; isoforms; ovulation induction; sialic acid; sulfonated N-acetylgalactosamine
Pentraxin 3 (PTX3) is an acute phase marker, which is produced at the site of infection or inflammation in contrast to CRP that is mainly synthesized by the liver. The aim of the present study was to see if lifestyle interventions/weight loss would lead to decreased blood plasma concentrations of PTX3.
Study subjects (n = 31) were recruited to a lifestyle intervention program aiming at increased physical activity, improved eating habits, and weight loss. High-sensitivity C-reactive protein (CRP) and PTX3 methods were used for analysis of CRP and PTX3 in plasma samples collected at inclusion and after 4 and 8 weeks of treatment.
Wilcoxon paired samples test showed a significant decrease in PTX3 concentrations from 2068 pg/mL at start to 2007 pg/mL at 4 weeks (P = 0.002) and 1748 pg/mL at 8 weeks (P = 0.003). The PTX3 decrease was not significantly correlated with a corresponding decrease in CRP or weight reduction.
The lifestyle intervention program resulted in a significant reduction of circulating concentrations of pentraxin 3 already after 4 and 8 weeks of treatment.
Adult; body weight; CRP; human; inflammation; pentraxin 3; plasma
To improve neurointensive care (NIC) and outcome for traumatic brain injury (TBI) patients it is crucial to define and monitor indexes of the quality of patient care. With this purpose we established the web-based Uppsala TBI register in 2008. In this study we will describe and analyze the data collected during the first three years of this project.
Data from the medical charts were organized in three columns containing: 1) Admission data; 2) Data from the NIC period including neurosurgery, type of monitoring, treatment, complications, neurological condition at discharge, and the amount of secondary insults; 3) Outcome six months after injury. Indexes of the quality of care implemented include: 1) Index of improvement; 2) Index of change; 3) The percentages of ‘Talk and die' and ‘Talk and deteriorate' patients.
Altogether 314 patients were included 2008–2010: 66 women and 248 men aged 0–86 years. Automatic reports showed that the proportion of patients improving during NIC varied between 80% and 60%. The percentage of deteriorated patients was less than 10%. The percentage of Talk and die/Talk and deteriorate cases was <1%. The mean Glasgow Coma Score (Motor) improved from 5.04 to 5.68 during the NIC unit stay. The occurrences of secondary insults were less than 5% of good monitoring time for intracranial pressure (ICP) >25 mmHg, cerebral perfusion pressure (CPP) <50 mmHg, and systolic blood pressure <100 mmHg. Favorable outcome was achieved by 64% of adults.
The Uppsala TBI register enables the routine monitoring of NIC quality indexes.
Database; neurointensive care; outcome; quality register; secondary insults; traumatic brain injury
Chronic obstructive pulmonary disease (COPD) is a common cause of death. Despite the heavy symptom burden in late stages, these patients are relatively seldom referred to specialist palliative care.
A web-based survey concerning medical and organizational aspects of palliative care in COPD was distributed to respiratory physicians in Sweden. There were 93 respondents included in the study.
Palliative care issues were regularly discussed with the patients according to a third of the respondents. About half of the respondents worked in settings where established routines for co-operation with palliative units were available at least to some extent. Less than half of the respondents (39%) were aware of current plans to develop palliative care, either as a co-operative effort or within the facility. Palliative care is focused on physical, psychological, social, and existential dimensions, and the proportions of respondents providing support within these dimensions, ‘always' or ‘often', were 83%, 36%, 32%, and 11%, respectively. Thus, to treat the physical dimensions was perceived as much more obvious than to address the other dimensions.
The survey indicates that the priorities and resources for palliative care in COPD are insufficient in Sweden. The data, despite limitations, reveal a lack of established team-work with specialized palliative care units and actual plans for such co-operation.
Care management; COPD; holistic care; palliative care; survey
When performing in-vitro fertilization (IVF), more embryos than needed are often derived. These embryos are usually frozen and stored, but as ruled by Swedish law they have to be discarded after 5 years. In other countries it is legal to donate the excess embryos to other infertile couples who for different reasons cannot undergo the procedure of IVF. The aim of the present study was to investigate public opinion in Sweden regarding different aspects of embryo donation.
A questionnaire regarding attitudes towards aspects of embryo donation was sent to a randomized sample of 1,000 Swedish women and men of reproductive age.
A total of 34% responded to the questionnaires. A majority of the respondents (73%) were positive towards embryo donation. Seventy-five per cent agreed that it should be possible to donate embryos to infertile couples. Approximately half of the participants (49%) supported embryo donation to single women. A majority of the participants emphasized that demands should be imposed on the recipient's age (63%), alcohol addiction (79%), drug addiction (85%), and criminal record (67%). Forty-seven per cent of the respondents agreed that the recipient should be anonymous to the donor, and 38% thought that the donor should remain anonymous to the child.
The results of the present study indicate support for embryo donation among a subset of the Swedish population of reproductive age. If embryo donation were to be allowed in Sweden, strategies for treatment and counselling need to be developed.
Attitudes; disclosure; embryo donation; gender; Swedish population
Neoplastic pericarditis represents approximately 5%–7% of the cases with acute pericarditis and is rarely the initial manifestation of malignancy. The most common cause is lung cancer, followed by breast cancer, lymphomas, leukemia, and esophageal cancer. Neoplastic pericardial disease is extremely rare in thyroid cancer, especially as the first manifestation. Here, we present a papillary thyroid carcinoma that was manifested with pericarditis and cardiac tamponade in a 49-year-old female.
Cardiac tamponade; neoplastic pericarditis; pericardial effusion; thyroid cancer
Shoulder external rotation braces used for patients with a first-time shoulder dislocation are designed with a variety of arm positions in abduction as well as external rotation. However, few studies have focused on their immobilizing performance, comfort, or user-friendliness. Especially, there have been no robust data of shoulder abduction-external rotation (A-ER) braces in comparison to those of external rotation (ER) braces.
Four types of commercially available shoulder braces (two ER and two A-ER braces) were tested in 30 healthy participants. The angles of external rotation and abduction were measured for each brace at initial application, after simulated daily activities, and after reapplication. Then, subjects were asked to assess the discomfort of bracing and difficulty of reapplication using a visual analogue scale. Data were compared between the two ER braces and two A-ER braces as well as among the four braces.
For both external rotation angle and subjective assessment, there were no significant differences between the ER and A-ER braces. Among the four braces, the measurement of arm position demonstrated no significant differences, except the external rotation angles between the two ER braces. The A-ER braces were assessed to be significantly less comfortable than the ER braces in the subjective assessment.
Immobilization using the A-ER braces could maintain the arm position in abduction-external rotation with comparable user-friendliness, although they tended to be less comfortable during daily activities compared to the ER braces.
Abduction; conservative treatment; external rotation; immobilization; shoulder brace; shoulder instability
Our knowledge about atopy as a longitudinal predictor of asthma is limited. The purpose of this study was to investigate the prognosis of asthma and risk factors for asthma onset, especially sensitization of specific allergens in a population sample.
Material and methods
A cohort responded to a respiratory questionnaire in 1990 and 2003. At baseline, 2,060 subjects who, in the screening questionnaire, reported respiratory symptoms and 482 controls were investigated with interviews, spirometry, and skin-prick test. A total of 721 asthmatics and 976 subjects without respiratory disease were clinically verified. At follow-up in 2003, 340 subjects with persistent asthma and 186 subjects with asthma remission were identified, while 76 subjects reported new asthma onset.
Sensitization to pets and a high symptom score were significant determinants of persistent asthma (odds ratio (OR) 3.2 (95% CI 1.9–5.6) and 5.7 (2.5–13.3), respectively) and onset of asthma (OR 2.6 (1.1–6.0), and 1.7 (1.2–2.3)). A high self-reported responsiveness to airway irritants (OR 1.6 (1.1–2.2)), and more asthma medications (OR 2.0 (1.3–2.9)) were additional indicators of persistent asthma at the follow-up. Belonging to the older age group decreased the risk both of having persistent asthma and asthma onset.
Asthmatics sensitized to pets have a more severe outcome than asthmatics not sensitized to pets. Sensitization to pets was also a strong predictor for onset of asthma. Special attention should be given to asthmatics who report having severe symptoms and problems with airway irritants as such patients are more likely to have persistent problems.
Allergens; allergy tests; asthma; longitudinal study; prognosis; skin-prick test
Different reasons influence the current low birth-rate and the postponement of the birth of the first child throughout Europe. The aim of this study was to explore how highly educated women and men in Sweden reflect on fertility and postponed parenthood.
We interviewed women (n = 22) and men (n = 18) who had started their professional careers and still had no children. Data were analysed with qualitative content analysis.
Fertility was perceived as an unconsidered capacity, sometimes unpredictable, and different for women and men, but nevertheless taken for granted. The participants were of the opinion that fertility could be restored by assisted reproductive technologies or replaced by alternatives to a biological child. Postponed parenthood was described as an adaptation to societal changes and current discourses about parenthood as well as a consequence of a contemporary lifestyle with many competing priorities.
Highly educated young women and men in contemporary Sweden have competing priorities when planning and setting goals for their lives, and having children is one of them. They describe fertility as an imperceptible and retrievable capacity and postponed parenthood as a rational adaptation to changes in society. These findings suggest that increased information about the limitations of human reproduction is needed, but also that societal support for younger parents is of utmost importance.
Content analysis; fertility; interviews; parenthood; reproduction
We here report a case of diabetic ketoacidosis at onset of type 1 diabetes after a prolonged period of starvation due to anorexia nervosa. A 53-year-old female with a history of anorexia nervosa was admitted to the psychiatric clinic due to psychotic behaviour and inability to take care of herself. Twenty-four hours after admission she was transferred to the clinic of internal medicine due to altered mental status, and laboratory screening revealed a pH of 6.895 and blood glucose concentration of 40 mmol/L. Due to the unusual combination of prolonged starvation and diabetic ketoacidosis we implemented some modifications of existing treatment guidelines and some special considerations regarding nutrition in order to prevent a re-feeding syndrome.
Anorexia nervosa; diabetic ketoacidosis; starvation; type 1 diabetes
There has been only one reported case of neuromuscular scoliosis following chronic inflammatory demyelinating polyneuropathy (CIDP). However, no cases of scoliosis that were treated with surgery secondary to CIDP have been previously described. A 16-year-old boy with CIDP was consultant due to the progression of scoliosis with the coronal curve of 86° from T8 to T12. Posterior correction and fusion with segmental pedicle screws were performed under intraoperative spinal cord monitoring with transcranial electric motor-evoked potentials. Although the latency period was prolonged and amplitude was low, the potential remained stable. Coronal curve was corrected from 86° to 34° without neurological complications. We here describe scoliosis associated with CIDP, which was successfully treated with surgery under intraoperative spinal cord monitoring.
Chronic inflammatory demyelinating polyneuropathy; intraoperative spinal cord monitoring; scoliosis; transcranial electric motor-evoked potentials
Prostaglandin E1 (alprostadil) is widely used for maintaining the patency of ductus arteriosus in ductus-dependent congenital heart defects in neonates to improve oxygenation. Among more common side effects are fever, rash, apnoea, diarrhoea, jitteriness, and flushing. More severe side effects are brown fat necrosis, cortical hyperostosis, and gastric outlet obstruction, most commonly the result of antral foveolar hyperplasia or hypertrophic pyloric stenosis. We report on an infant with a ductus-dependent congenital heart defect who developed symptoms and sonographic evidence of focal foveolar hyperplasia and hypertrophic pyloric stenosis after prolonged treatment with prostaglandin E1. Gastrointestinal symptoms persisted after corrective cardiac surgery, and pyloromyotomy was required. Study of the case and of available literature showed an association between the total dose of prostaglandin E1 administered and duration of treatment and the development of gastric outlet obstruction. We conclude that if patients are treated with a prostaglandin E1 infusion, careful monitoring for symptoms and signs of gastric outlet obstruction is required.
Alprostadil; focal foveolar hyperplasia; gastric outlet obstruction; hypertrophic pyloric stenosis; neonates; prostaglandin E1
This study investigated the effects of short-term intermittent hypoxia (IH) preconditioning on cardiac structure and function in rats and the influence of ischemia reperfusion (I/R) injury. Special attention was then paid to the involvement of hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF).
Wistar rats were given IH treatment for 1, 7, 14, or 28 days. Some of them were thereafter subject to myocardial infarction surgery. Right ventricle systolic pressure (RVSP), myocardial capillary density (CD), and mRNA/protein expression of HIF-1α, VEGF, and Bcl-2 in rat myocardial tissue were determined. Apoptotic cell number was determined by TUNEL staining, and concentrations of malondialdehyde (MDA) and superoxide dismutase (SOD) were measured.
IH treatment for 1, 7, 14, and 28 days reduced the myocardial infarction size, whereas IH for 28 days increased the RVSP, ratio of right to left ventricle weight (RV/LV+S), and CD. IH up-regulated the mRNA and protein levels of HIF-1α, VEGF, and Bcl-2 both under normal and I/R conditions. The induced expression of HIF-1α and VEGF by IH reached a peak after 7 days of treatment. Moreover, IH for 28 days induced cardiomyocyte apoptosis, whereas prior treatment with IH for 1, 7, 14, and 28 days all markedly attenuated the apoptosis effected by the subsequent I/R injury. IH also decreased the concentrations of MDA but increased those of SOD in myocardial tissue of both in normal rats and following I/R.
The present study demonstrates that short-term IH protects the heart from I/R injury through inhibiting apoptosis and oxidative stress. The up-regulation of HIF-1α and VEGF by short-term IH may participate in the cardioprotective effect of IH.
apoptosis; HIF-1α; intermittent hypoxia; myocardial infarction; VEGF
To estimate the possible economic benefit of a sequential testing strategy with NT-proBNP to reduce the number of echocardiographies.
Retrospective study in a third-party payer perspective. The costs were calculated from three Swedish counties: Blekinge, Östergötland, and Uppland. Two cut-off levels of NT-proBNP were used: 400 and 300 pg/mL. The cost-effectiveness of the testing strategy was estimated through the short-term cost avoidance and reduction in demand for echocardiographies.
The estimated costs for NT-proBNP tests and echocardiographies per county were reduced by 33%–36% with the 400 pg/mL cut-off and by 28%–29% with the 300 pg/mL cut-off. This corresponded to a yearly cost reduction of approximately €2–5 million per million inhabitants in these counties.
The use of NT-proBNP as a screening test could substantially reduce the number of echocardiographies in the diagnostic work-up of patients with suspected cardiac failure, as well as the associated costs.
Cost; echocardiography; health economics; heart failure; laboratory test; NT-proBNP
We studied the relationship between systolic blood pressure and hemodynamics using impedance cardiography in elderly Han residents in order to evaluate how different hemodynamic variables are altered with normal aging and with hypertension superimposed on aging.
A total of 670 subjects, aged 60–93 years, were evaluated with impedance cardiography for non-invasive hemodynamic variables. The subjects were categorized as hypertensives or normotensives, and then they were also divided into six subgroups according to actual systolic blood pressure values.
Hypertensive patients had significantly lower values of cardiac output (4.4 ± 1.5 L/min) and cardiac index (2.6 ± 1.0 L/min/m2) than those in the normotensive group (4.7 ± 1.5 L/min, and 2.8 ± 0.8 L/min/m2, respectively; P < 0.05 for both). Compared to the normotensive group, stroke volume and stroke index values were also lower and systemic vascular resistance and systemic vascular resistance index were higher in the hypertensive group. There were no significant differences in left ventricular stroke work and left ventricular stroke work index between the two groups. When all 670 subjects were stratified to actual blood pressure, cardiac output of group 6 patients (systolic blood pressure ≥180 mmHg) was 19% lower than that of group 1 subjects (SBP <140 mmHg; P < 0.05). Similarly, systemic vascular resistance of group 6 patients was 56% higher than that of group 1 subjects (P < 0.05).
With aging, arterial systolic blood pressure is elevated as a result of increased arterial stiffness and increased systemic vascular resistance. With hypertension, these values are further elevated. Non-invasive impedance cardiography helps to characterize the hemodynamic mechanisms, which can improve hypertension management.
aging superimposed; arterial systolic blood pressure; elderly Han residents; hemodynamics; hypertension
Two hundred and forty patients were randomly allocated into six groups: Group I, anesthesia was maintained with sevoflurane; Group II, anesthesia was maintained with sevoflurane and 8 mg of ondansetron; Group III, anesthesia was maintained with propofol; Group IV, anesthesia was maintained with propofol and 8 mg of ondansetron; Group V, anesthesia was maintained with sevoflurane and propofol; Group VI, anesthesia was maintained with sevoflurane combined with propofol and 8 mg of ondansetron.
We found that the incidence of vomiting was lower in group II (17.5%), group IV (7.5%), and group VI (10%) compared with group I (55%), group III (27.5%), and group V (30%), respectively (P < 0.05). The incidence of vomiting was also lower in group III (27.5%) and group V (30%) when compared with group I (55%) (P < 0.05). The incidence of nausea was 55% in group I, 42.5% in group II, 30% in group III, 27.5% in group IV, 30% in group V, and 30% in group VI. Groups III and V had a lower incidence of nausea than group I (P < 0.05).
We conclude that compared with sevoflurane anesthesia alone, anesthesia with either propofol alone or propofol combined with sevoflurane resulted in a reduced incidence of vomiting and nausea during the first 24 h after surgery. Administration of ondansetron effectively reduced the incidence of vomiting but not that of nausea for all three types of general anesthesia.
general anesthesia; nausea; ondansetron; vomiting
Whole-body (WB) magnetic resonance imaging (MRI), including diffusion-weighted imaging (DWI), has been increasingly used for the detection of metastatic disease.
To assess the value of WB MRI including DWI compared to computed tomography (CT) for staging of malignant melanoma. A second aim was to assess the value of DWI in addition to conventional MR sequences for the detection of lesions.
Material and methods
WB MRI with DWI and CT chest, abdomen, and pelvis were performed in 23 patients with histologically confirmed malignant melanoma. CT before and after the MRI examinations and the clinical follow-up was utilized as the standard of reference.
WB MRI and WB DWI detected 345 and 302 lesions, respectively, compared to 397 lesions with CT. The sensitivity of WB MRI and WB DWI varied considerably in different regions of the body. In the lungs, WB MRI and WB DWI showed 63% and 47% true-positive lesions, respectively. WB MRI and WB DWI detected 56 bone lesions in 12 patients compared to 42 lesions in 8 patients with CT. In addition, WB MRI and WB DWI could detect 68 lesions outside the field of view of CT in six patients.
WB MRI is still not ready to replace CT for staging of malignant melanoma, especially in the thorax region. However, WB MRI is advantageous for detection of bone lesions and lesions outside the investigated volume of the conventional CT. When WB MRI is evaluated, both DWI and conventional MRI sequences must be scrutinized.
DWI; malignant melanoma; whole-body MRI
General practitioners (GPs) write about 80% of all antibiotic prescriptions, the greatest number of them for patients with respiratory tract infections. However, there is a lack of research targeting the influence of external factors on antibiotic prescribing by physicians. This study aimed to explore experiences of GPs in Lithuania and the Russian Federation with regard to antibiotic prescription for upper respiratory tract infections. By such means it might be possible to reveal external enabling factors that influence antibiotic prescribing in these countries.
Five focus groups were performed with 22 GPs from Lithuania and 29 GPs from the Kaliningrad Region of the Russian Federation; then, thematic analysis of data was performed.
Six thematic categories were identified that are related to external forces enabling antibiotic prescription: the necessity for political leadership to encourage clinically grounded antibiotic use; over-the-counter sale of antibiotics; designation of antibiotics as reimbursable medications; supervision by external oversight institutions; lack of guidelines for the treatment of upper respiratory tract infections; and pharmaceutical company activities.
Comprehensive efforts to reduce the burden of non-clinically grounded antibiotic prescription should go beyond addressing factors at the physician–patient level and take into account important factors in the enabling environment as well.
Antibiotic prescribing; general practitioners; Lithuania; Russian Federation; upper respiratory tract infections