The Helsinki approach to face transplantation

Aim

We herein describe the establishment of the Helsinki Vascularized Composite Allotransplantation (VCA) program and its execution in the first two face transplant cases.

Gestational diabetes identifies women at risk for permanent type 1 and type 2 diabetes in fertile age: predictive role of autoantibodies

OBJECTIVE: Our aim was to evaluate the predictive value of gestational diabetes mellitus (GDM), diabetes-associated autoantibodies, and other factors for development of clinical diabetes later in life. RESEARCH DESIGN AND METHODS: In this case-control study the presence of autoantibodies was studied in 435 women with GDM and in healthy matched control subjects. The need for exogenous insulin during GDM was recorded. In the GDM group, the mean follow-up period was 5.7 years and in the control group 6.1 years. RESULTS: Among the subjects with GDM, 20 (4.6%) developed type 1 diabetes and 23 (5.3%) developed type 2 diabetes, whereas none of the control subjects became diabetic. Two-thirds of those who developed type 1 diabetes tested positive initially for islet cell antibodies (ICAs), whereas 56% of them had autoantibodies to GAD (GADAs) and 38% to the protein tyrosine phosphatase-related IA-2 molecule. Only 2 of the 23 women who presented later with type 2 diabetes tested positive for autoantibodies. According to multivariate analysis, initial age < or =30 years, the need for insulin treatment for GDM, and antibody positivity for ICAs and GADAs were associated with increased risk for clinical type 1 diabetes. CONCLUSIONS: Pregnancy seems to identify women who are at risk of developing diabetes later in life. About 10% of Finnish women with GDM will develop diabetes over the next 6 years; nearly half of them develop type 1 diabetes and the other half type 2 diabetes. Age < or =30 years, the need for insulin treatment during pregnancy, and positivity for ICAs and GADAs confer a high risk of subsequent progression to type 1 diabetes in women affected by GDM.     

Determinants for preventive oral health care need among community‐dwelling older people: a population‐based study

The aim was to study the determinants of preventive oral health care need among community‐dwelling old people. The study population consisted of 165 participants, a subpopulation in the Geriatric Multidisciplinary Strategy for Good Care of Elderly People (GeMS) study. Fifty‐five percent of the edentate participants with full dentures and 82% of the dentate had a need for preventive oral health care. In the total study population, the need for preventive care was associated with co‐morbidity (measured by means of the Modified Functional Co‐morbidity Index) odds ratios (OR) 1.2 (confidence intervals [CI] 1.0–1.5), being pre‐frail or frail, OR 2.5 (CI 1.2–5.1), presence of natural teeth, OR 4.8 (CI 2.2–10.4), and among dentate participants, the use of a removable partial denture, OR 12.8 (CI 1.4–114.4). Primary care clinicians should be aware of the high need for preventive care and the importance of nonoral conditions as determinants of preventive oral health care need.     

Inflammatory response to surgical trauma in patients with minilaparotomy cholecystectomy versus laparoscopic cholecystectomy: a randomised multicentre study

Objective The aim of the study was to evaluate the inflammatory response to surgical trauma in minilaparotomy cholecystectomy (MC) compared to laparoscopic cholecystectomy (LC). Assessment of inflammatory response to surgical trauma in MC has not been addressed properly. Therefore, we investigated five interleukins (IL) and C-reactive protein (CRP) in MC versus LC group in a prospective randomised trial. Methods Initially, 106 patients with non-complicated symptomatic gallstone disease were randomised into MC (n?=?56) or LC (n?=?50) groups. Plasma levels of five interleukins (IL-1β, IL-1ra, IL-6, IL-8, IL-10) and hs-CRP were measured at three time points; before operation (PRE), immediately after operation (POP1) and six hours after operation (POP2). The primary end-point of the study was to compare the plasma levels of five interleukins and CRP in LC versus MC group. Results The demographic variables and the surgical data were similar in the study groups. The patients in the MC group had higher elevation of the CRP mean values post-operatively (p?=?0.01). However, the patients in the MC group had higher elevation of the IL-1ra mean values post-operatively, the mean pre-/post-operative IL-1ra values being 299/614?pg/ml in the MC group versus 379/439?pg/ml in the LC group (p?=?0.003). There was no statistical significance in IL-6 mean values between the MC and LC groups pre- and post-operatively (POP1). However, the patients in the MC group had higher IL-6 mean values six hours post-operatively (POP2), the mean IL-6 values being 27.6?pg/ml in the MC group versus 14.8?pg/ml in the LC group (p?=?0.037). In addition, the patients in the MC group had higher elevation of the IL-6 mean values post-operatively, the mean pre-/post-operative IL-6 values being 4.1/27.6?pg/ml in the MC group versus 3.8/14.8?pg/ml in the LC group (p?=?0.04). There was no statistical significance in IL-8, IL-10, and IL-1β mean values between the MC and LC groups pre- and post-operatively. Conclusion Our results suggest that the inflammatory response in MC versus LC groups was similar based on the IL-8, IL-10, and IL-1β values. A new finding with possible clinical relevance in the present work is higher relative elevation of the IL-1ra and IL-6 mean values post-operatively in the MC group.     

Mini-Mental State Examination score and B-type natriuretic peptide as predictors of cardiovascular and total mortality in an elderly general population

INTRODUCTION. The aim of the present study was to examine the power of B-type natriuretic peptide (BNP) and mild cognitive impairment as independent predictors of total and cardiovascular mortality in combination with established cardiovascular risk markers in an elderly general population without severe cognitive impairment. METHODS. A total of 499 individuals, aged more than 75 years, were examined and followed up for a median of 7.9 years in a prospective population-based stratified cohort study carried out in eastern Finland. The Cox proportional hazards regression model was used to determine the impact of multiple factors on total and cardiovascular mortality. RESULTS. In a multivariable model including established cardiovascular risk factors and conditions, both continuous BNP (adjusted hazard ratio (HR) 1.44 for a 1-SD change; 95% confidence interval (CI) 1.22-1.77; P < 0.001) and continuous MMSE score (HR 0.81 for a 1-SD change; 95% CI 0.70-0.94; P = 0.007) were independently associated with all-cause mortality. In a multivariable model, BNP remained a significant predictor of cardiovascular mortality, while MMSE score lost its significance. CONCLUSIONS. BNP, a measure of cardiovascular burden, and MMSE score 18-23, an indicator of mild cognitive impairment, are both independent predictors of total mortality. BNP and MMSE score may potentially be useful in screening elderly patients for elevated risk of mortality.     

Analyzing atopic and non-atopic asthma

There is a need to better define phenotypes of asthma. However, many studies have data available only on asthma and atopy, so they are often used to define ‘atopic’ and ‘non-atopic’ asthma. We discuss and illustrate the problems of analyzing such outcomes. We used the 31 year follow-up of the Northern Finland Birth Cohort 1966 (n=5,429). ‘Atopic asthma’ and ‘non-atopic asthma’ were defined based on presence or absence of atopy (any skin prick test ≥3 mm) at age 31. Gender and ownership of cat in childhood were used as risk factors. Simple calculations on hypothetical datasets were used to support the conclusions. ‘Atopic asthma’ and ‘non-atopic asthma’, are not well separated disease entities. The association of a risk factor with ‘atopic asthma’ and ‘non-atopic asthma’ is determined both by its association with asthma and with atopy. E.g. if a risk factor is not associated with asthma, but is protective for atopy, this will produce a protective association with ‘atopic asthma’, but an opposite association with ‘non-atopic asthma’. This is the result from the typical analysis, which uses all non-asthmatics as the comparison group. Valid results, unconfounded by atopy, can be gained by comparing asthmatics to nonasthmatics separately among atopics and non-atopics, i.e. by doing the analysis stratified by atopy. If data only on asthma and atopy are available, asthma and atopy should be analyzed at first as separate outcomes. If atopic and nonatopic asthma are used as additional outcomes, valid results can be gained by stratifying the analysis by atopy.     

Systemic and regional effects of experimental gradual splanchnic ischemia

We evaluated the effects of gradual intestinal ischemia on systemic and regional haemodynamics and oxygen transport. Superior mesenteric artery (SMA) blood flow was decreased by 40%, 70%, and 100% for 60-minute periods and thereafter released in 12 pigs. Hemodynamic changes were monitored continuously, and the intestinal perfusion was evaluated by changes in portal vein-arterial lactate gradient, intramucosal pH, tonometric Pco₂, tonometric-portal vein Pco₂ gradient, and regional oxygen extraction. Local signs of intestinal hypoperfusion developed during the SMA occlusion. Intramucosal pH and portal vein pH decreased from 7.18 ± 0.04 to 6.81 ± 0.04 (P < .01) and from 7.36 ± 0.01 to 7.25 ± 0.03 (P < .05), respectively. Intramucosal Pco2 and tonometric-portal vein Pco2 gradient increased from 12.4 ± 1.3 to 21.2 ± 1.8 kPa (P < .01) and from 6.0 ± 1.3 to 14.0 ± 1.9 kPa (P < .05), respectively. Portal vein-arterial lactate gradient and splanchnic oxygen extraction increased from 0.02 ± 0.07 to 2.32 ± 0.47 mmol/L (P < .01) and from 0.44.-k 0.03 to 0.60 ± 0.03 (P < .05), respectively. Systemic changes observed during the SMA occlusion were reduction of cardiac index (161 ± 12 to 114 ± 8 mL/min/kg, P < .01) and pulmonary capillary wedge pressure (4 ± 1 to 3 ± 1 mm Hg) and increase in heart rate (124 ± 5 to 173 ± 11 beats/ min, P < .01) and mean arterial pressure (79 ± 3 to 104 ± 5 mm Hg, P < .01). Systemic oxygen extraction increased (P < .05), arterial pH increased (P < .05), and arterial lactate decreased (P < .01) during the SMA occlusion. Splanchnic ischemia defined as an increase in portal vein-arterial lactate gradient above mean +2 SD of the baseline occurred at 93 ± 15 minutes corresponding 70% SMA occlusion. We conclude that signs of tissue hypoperfusion started to develop at 70% SMA occlusion and that regional tissue hypoperfusion in the splanchnic region may develop without any systemic signs of oxygen supply/demand mismatch.