Operative Treatment of Ovarian Cancer and Borderline Tumors in Different Hospital Categories in Finland

Surgery is the cornerstone of ovarian cancer treatment and maximal cytoreduction is important. In the early 1980’s primary surgical treatment of ovarian cancer was performed in over 80 hospitals in Finland. The significance of the operative volume of the hospital, of the training of the surgeons and of centralization of surgical treatment has been widely discussed. The aim of the present study was to evaluate the outcome of surgical treatment of ovarian cancer in different hospital categories retrospectively and prospectively, and to analyze if any differences are reflected in survival. The retrospective study included 3851 ovarian cancer patients operated between 1983 and 1994 in Finland. The data was analyzed according to hospital category (university, central, and other) and by quartiles of the hospital operative volume. The results showed that patients operated in the highest operative volume hospitals had the best relative survival. When stratifying the analysis by the period of diagnosis (1983-1988 and 1989-1994), the university hospitals improved their performance the most. The prospective part of the thesis was initiated in 1999 and included 307 patients with invasive ovarian cancer and 65 patients with an ovarian borderline tumor. The baseline and 5-year surveys used a questionnaire that was filled in by the operating surgeons. For analysis of the 5-year followup data, the hospitals were divided into three categories (<10, 10-20, or >20 patients operated in 1999). The effect of the surgical volume was analyzed also as a continuous variable (1-47 operations per year). In university hospitals, pelvic lymphadenectomy was performed in 88 %, and para-aortic lymphadenectomy in 73 %, of the patients with stage I disease. The corresponding figures ranged from 11 % to 21 % in the other hospitals. For stage III ovarian cancer patients operated by gynecological oncologists, the estimated odds ratio for no macroscopic residual tumor was 3.0 times higher (95 % CI 1.2-7.5) than for those operated by general gynecologists. In the university and other hospitals 82% of the patients received platinum-based chemotherapy. Platinum + taxane combination was given to 63 % of the patients in the university and in 49 % in the other hospitals (p = 0.0763). Only a minority of the patients with tumors of borderline malignancy were staged according to recommendations, most often multiple peritoneal biopsies and omentectomy were neglected. FIGO stage, patient age, and residual tumor were independent prognostic factors of cancer-specific 5-year survival. A higher hospital operative volume was also a significant prognostic factor for better cancer-specific survival (p = 0.036) and disease-free survival (p = 0.048). In conclusion, ovarian cancer patients operated in high-volume university hospitals were more often optimally debulked and had a significantly better cancer-specific survival than patients operated in other hospitals. These results favor centralization of primary surgical treatment of ovarian cancer.

Use of GRADE for assessment of evidence about prognosis : rating confidence in estimates of event rates in broad categories of patients.

Main concepts : The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach defines quality of evidence as confidence in effect estimates; this conceptualization can readily be applied to bodies of evidence estimating the risk of future of events (that is, prognosis) in broadly defined populations In the field of prognosis, a body of observational evidence (including single arms of randomized controlled trials) begins as high quality evidence. The five domains GRADE considers in rating down confidence in estimates of treatment effect-that is, risk of bias, imprecision, inconsistency, indirectness, and publication bias-as well as the GRADE criteria for rating up quality, also apply to estimates of the risk of future of events from a body of prognostic studies Applying these concepts to systematic reviews of prognostic studies provides a ful approach to determine confidence in estimates of overall prognosis in broad populations.

Anàlisi del bloc de fonaments individuals per demarcació (fid) corresponent a la defensa de l'espai per la posició dels laterals en el futbol: comparació entre categories amateur i semi-professional

L’objectiu d’aquest estudi va ser analitzar un element del component tàctic com a factor determinant en el rendiment del futbol, és a dir, comprovar si hi ha diferències en l’execució del bloc de Fonaments Individuals per Demarcació (FID) corresponent a la defensa de l’espai per la posició dels laterals en el futbol, entre les categories amateur i semi-professional. Es van enregistrar un total de 18 partits, on 9 dels quals feien referència a l’equip de l’Arbúcies Club de Futbol i la resta a l’equip de la Unió Esportiva Llagostera. Les variables estudiades van ser les següents: cobertures al central que defensa al possessor de la pilota, evitar passades interiors que guanyin l’esquena, defensa individual dels jugadors que intenten passar per l’esquena del segon central (entrar-sortir) i eliminar l’espai de desmarcada en profunditat, mantenint la línia amb el central. Per analitzar-les es va utilitzar el programa Longomatch i el Excel on hi vam configurar un instrument d’avaluació. Els principals resultats del treball van ser que l’equip de la Unió Esportiva Llagostera va fer menys errors en l’execució dels FID, tot i que va seguir tenint errors en el compliment d’aquests fonaments.

Positive predictive values of Breast Imaging Reporting and Data System (BI-RADS®) categories 3, 4 and 5 in breast lesions submitted to percutaneous biopsy

Objective To evaluate the BI-RADS as a predictive factor of suspicion for malignancy in breast lesions by correlating radiological with histological results and calculating the positive predictive value for categories 3, 4 and 5 in a breast cancer reference center in the city of São Paulo. Materials and Methods Retrospective, analytical and cross-sectional study including 725 patients with mammographic and/or sonographic findings classified as BI-RADS categories 3, 4 and 5 who were referred to the authors' institution to undergo percutaneous biopsy. The tests results were reviewed and the positive predictive value was calculated by means of a specific mathematical equation. Results Positive predictive values found for categories 3, 4 and 5 were respectively the following: 0.74%, 33.08% and 92.95%, for cases submitted to ultrasound-guided biopsy, and 0.00%, 14.90% and 100% for cases submitted to stereotactic biopsy. Conclusion The present study demonstrated high suspicion for malignancy in lesions classified as category 5 and low risk for category 3. As regards category 4, the need for systematic biopsies was observed.

A Threat to a virtual hand elicits motor cortex activation

We report an experiment where participants observed an attack on their virtual body as experienced in an immersive virtual reality (IVR) system. Participants sat by a table with their right hand resting upon it. In IVR, they saw a virtual table that was registered with the real one, and they had a virtual body that substituted their real body seen from a first person perspective. The virtual right hand was collocated with their real right hand. Event-related brain potentials were recorded in two conditions, one where the participant"s virtual hand was attacked with a knife and a control condition where the knife only struck the virtual table. Significantly greater P450 potentials were obtained in the attack condition confirming our expectations that participants had a strong illusion of the virtual hand being their own, which was also strongly supported by questionnaire responses. Higher levels of subjective virtual hand ownership correlated with larger P450 amplitudes. Mu-rhythm event-related desynchronization in the motor cortex and readiness potential (C3-C4) negativity were clearly observed when the virtual hand was threatened as would be expected, if the real hand was threatened and the participant tried to avoid harm. Our results support the idea that event-related potentials may provide a promising non-subjective measure of virtual embodiment. They also support previous experiments on pain observation and are placed into context of similar experiments and studies of body perception and body ownership within cognitive neuroscience.

A Threat to a virtual hand elicits motor cortex activation

We report an experiment where participants observed an attack on their virtual body as experienced in an immersive virtual reality (IVR) system. Participants sat by a table with their right hand resting upon it. In IVR, they saw a virtual table that was registered with the real one, and they had a virtual body that substituted their real body seen from a first person perspective. The virtual right hand was collocated with their real right hand. Event-related brain potentials were recorded in two conditions, one where the participant"s virtual hand was attacked with a knife and a control condition where the knife only struck the virtual table. Significantly greater P450 potentials were obtained in the attack condition confirming our expectations that participants had a strong illusion of the virtual hand being their own, which was also strongly supported by questionnaire responses. Higher levels of subjective virtual hand ownership correlated with larger P450 amplitudes. Mu-rhythm event-related desynchronization in the motor cortex and readiness potential (C3-C4) negativity were clearly observed when the virtual hand was threatened as would be expected, if the real hand was threatened and the participant tried to avoid harm. Our results support the idea that event-related potentials may provide a promising non-subjective measure of virtual embodiment. They also support previous experiments on pain observation and are placed into context of similar experiments and studies of body perception and body ownership within cognitive neuroscience.

Threat Simulation- The Function of Dreaming?

Dreaming is a pure form of phenomenality, created by the brain untouched by external stimulation or behavioral activity, yet including a full range of phenomenal contents. Thus, it has been suggested that the dreaming brain could be used as a model system in a biological research program on consciousness (Revonsuo, 2006). In the present thesis, the philosophical view of biological realism is accepted, and thus, dreaming is considered as a natural biological phenomenon, explainable in naturalistic terms. The major theoretical contribution of the present thesis is that it explores dreaming from a multidisciplinary perspective, integrating information from various fields of science, such as dream research, consciousness research, evolutionary psychology, and cognitive neuroscience. Further, it places dreaming into a multilevel framework, and investigates the constitutive, etiological, and contextual explanations for dreaming. Currently, the only theory offering a full multilevel explanation for dreaming, that is, a theory including constitutive, etiological, and contextual level explanations, is the Threat Simulation Theory (TST) (Revonsuo, 2000a; 2000b). The empirical significance of the present thesis lies in the tests conducted to test this specific theory put forth to explain the form, content, and biological function of dreaming. The first step in the empirical testing of the TST was to define exact criteria for what is a ‘threatening event’ in dreams, and then to develop a detailed and reliable content analysis scale with which it is possible to empirically explore and quantify threatening events in dreams. The second step was to seek answers to the following questions derived from the TST: How frequent threatening events are in dreams? What kind of qualities these events have? How threatening events in dreams relate to the most recently encoded or the most salient memory traces of threatening events experienced in waking life? What are the effects of exposure to severe waking life threat on dreams? The results reveal that threatening events are relatively frequent in dreams, and that the simulated threats are realistic. The most common threats include aggression, are targeted mainly against the dream self, and include simulations of relevant and appropriate defensive actions. Further, real threat experiences activate the threat simulation system in a unique manner, and dream content is modulated by the activation of long term episodic memory traces with highest negative saliency. To sum up, most of the predictions of the TST tested in this thesis received considerable support. The TST presents a strong argument that explains the specific design of dreams as threat simulations. The TST also offers a plausible explanation for why dreaming would have been selected for: because dreaming interacted with the environment in such a way that enhanced fitness of ancestral humans. By referring to a single threat simulation mechanism it furthermore manages to explain a wide variety of dream content data that already exists in the literature, and to predict the overall statistical patterns of threat content in different samples of dreams. The TST and the empirical tests conducted to test the theory are a prime example of what a multidisciplinary approach to mental phenomena can accomplish. Thus far, dreaming seems to have always resided in the periphery of science, never regarded worth to be studied by the mainstream. Nevertheless, when brought to the spotlight, the study of dreaming can greatly benefit from ideas in diverse branches of science. Vice versa, knowledge learned from the study of dreaming can be applied in various disciplines. The main contribution of the present thesis lies in putting dreaming back where it belongs, that is, into the spotlight in the cross-road of various disciplines.

Foodstuffs and medicines as legal categories in the EU and China. Functional foods as a borderline case

The thesis discusses the regulation of foodstuffs and medicines, and particularly the regulation of functional foods. Legal systems investigated are the EU and China. Both are members of the WTO and Codex Alimentarius, which binds European and Chinese rules together. The study uses three Chinese berries as case examples of how product development faces regulation in practice. The berries have traditional uses as herbal medicines. Europe and China have similar nutrition problems to be resolved, such as obesity, cardiovascular disease, and diabetes. The three berries might be suitable raw materials for functional foods. Consumer products with health-enhancing functions, such as lowering blood pressure, might legally be classifi ed either as foodstuffs or medicines. The classifi cation will depend on functions and presentation of the product. In our opinion, food and medicine regulation should come closer together so the classifi cation issue would no longer be an issue. Safety of both foodstuffs and medicines is strictly regulated. With medicines, safety is a more relative concept, where benefi ts of the product are compared to side-effects in thorough scientifi c tests and trials. Foods, on the other hand, are not allowed to have side-effects. Hygiene rules and rules on the use of chemicals apply. In China, food safety is currently at focus as China has had several severe food scandals. Newly developed foods are called novel foods, and are specifi cally regulated. The current European novel food regulation from 1997 treats traditional third country products as novel. The Chinese regulation of 2007 also defi nes novel foods as something unfamiliar to a Chinese consumer. The concepts of novel food thus serve a protectionist purpose. As regards marketing, foods are allowed to bear health claims, whereas medicines bear medicinal claims. The separation is legally strict: foods are not to be presented as having medicinal functions. European nutrition and health claim regulation exists since 2006. China also has its regulation on health foods, listing the permitted claims and how to substantiate them. Health claims are allowed only on health foods. The European rules on medicines include separate categories for herbal medicines, traditional herbal medicines, and homeopathic medicines, where there are differing requirements for scientifi c substantiation. The scientifi c and political grounds for the separate categories provoke criticism. At surface, the Chinese legal system seems similar to the European one. To facilitate trade, China has enacted modern laws. Laws are needed as the country moves from planned economy to market economy: ‘rule of law’ needs to replace ‘rule of man’. Instead of being citizens, Chinese people long were subordinates to the Emperor. Confucius himself advised to avoid confl ict. Still, Chinese people do not and cannot always trust the legal system, as laws are enforced in an inconsistent manner, and courts are weak. In China, there have been problems with confl icting national and local laws. In Europe, the competence of the EU vs. the competence of the Member States is still not resolved, even though the European Commission often states that free trade requires harmonisation. Food and medicine regulation is created by international organisations, food and medicine control agencies, standards agencies, companies and their organisations. Regulation can be divided in ‘hard law’ and ‘soft law’. One might claim that hard law is in crisis, as soft law is gaining importance. If law is out of fashion, regulation certainly isn’t. In the future, ‘law’ might mean a process where rules and incentives are created by states, NGOs, companies, consumers, and other stakeholders. ‘Law’ might thus refer to a constant negotiation between public and private actors. Legal principles such as transparency, equal treatment, and the right to be heard would still be important.

Metsäsääntely Suomessa ja Venäjällä. Näkökulmia kestävään metsätalouteen

Sustainability is the aim of forest management and forest regulation in many countries. Accordingly, forest management has been steered towards more environmentally friendly methods and new regulatory instruments have been introduced. At the same time, wood trade and forest industry have become a global business. Even if the importance of national forest legislation has not decreased, it has been widely acknowledged that national regulation of forest management is no longer sufficient. The movement of goods does not acknowledge boundaries, even though most negative environmental and social consequences stay in the country of origin of wood and other raw materials. As a partial solution to this dilemma, different kinds of regulations have been developed. Various forest certification schemes and wood trade regulation in the EU (995/2010) are examples of efforts to prevent illegal logging and unsustainable forestry. The Finland-based forest industry is to a varying extent dependent on wood trade from Russia. Especially in the 1990‟s, ethical questions concerning import of wood from Russian old growth forests near the Finnish border were widely discussed. Consequently, forest industry enterprises have developed systems to trace the origin of wood and to buy certified wood from Russia. The aim of the research has been to evaluate Finnish and Russian forest regulations in order to investigate what kind of forest management these regulations enhance, and to what extent ecologically sustainable forest management has been integrated into different forms of regulation. I have examined Finnish and Russian forest regulation in four separate articles based on the topics of the Russian Forest Code, forest certification and other voluntary forest protection measures in Russia, Finnish forest certification and Finnish forest legislation. One objective has been to analyse the roles voluntary forest certification plays in promoting sustainable forest management in different countries. In my research, I have mainly concentrated on ecological sustainability and protection of biodiversity, although other aspects of sustainable forest management have been touched upon in different articles. In the following I shall conclude the findings of my research. When the current Russian Forest Code (2006) was being adopted, the main emphasis was not on ecological issues, but on reorganizing forest governance. The role of ecological requirements was even slightly diminished during the legislative reform. There are, nevertheless, still stipulations aiming at ecological sustainability, such as the division of forests into different forest management categories and various protection zones. In 2000, FSC forest certification arrived in Russia, at present covering already 28 million hectares of forests. The PEFC scheme is now in use as well, but to a much lesser extent. If properly implemented, Russian forest certification schemes clearly improve the level of ecological and social sustainability of forestry in Russia. Certification criteria, however, are partly in conflict with the Russian forest legislation and certified enterprises have been forced to pay fines or to negotiate with forest authorities. This clearly indicates that even if Russian forest legislation has otherwise been liberalized to a certain extent, some significant paternalism still exists. Voluntary, hands-on biodiversity protection measures are not valued, and they are not part of the official protection policies as in many other countries. However, there have been some regional solutions to this dilemma. In the Republic of Karelia forest authorities have approved a set of forest biodiversity protection rules created by a local NGO and a forest industry enterprise. By following these local rules, an enterprise can avoid fines for protection measures. The current Finnish Forest Act was adopted in 1996. It brought forest legislation into a new era as some ecological aspects were integrated into forest legislation. The various soft-law forest management recommendations further increased the level of biodiversity protection. My evaluation of the overall legitimacy of the Finnish forest legislation and forest management paradigm revealed, however, several problematic issues. As part of this study I analysed the history of the current forest management paradigm. This analysis revealed the path dependency which still hinders the protection of biodiversity and clearly decreases the general legitimacy of forest management. Due to several historical reasons only even-structured forest management based on clear cuts has for decades been officially approved in Finland. Due to increasing demands of forest owners the legislation is finally being revised. Yet, the official approval of uneven-structured forest management would not be enough to fully improve ecological, social and cultural legitimacy. The latest ecological theories and knowledge of endangered species should be taken into account in the on-going reform of forest legislation as well as the modernisation. Forest legislation is one of the very few spheres of Finnish environmental legislation where openness and participation are still considered a threat. The first Finnish forest certification scheme, PEFC, was established in 2000. It now covers more than 20 million hectares, about 95% of the forests in Finland. PEFC Finland does not require a higher level of biodiversity protection than the recommendations by Tapio (the Development Centre for Forestry), but certification has unified forest management practices and requires more protection measures than mere forest legislation. The study suggests that in Finland PEFC has not functioned as an instrument which would substantially improve the level of forest management. Rather it has supported the status quo of the forest sector. While the ecological and social responsibility of Finland-based forest corporations was one impetus for this research, I want to conclude that there are problems related to forest legislation and non-state regulation in both Finland and Russia. If an enterprise buying wood from Russia buys only certified wood, and carefully avoids wood coming from high conservation value forests that are either ecologically or socially valuable, it can be claimed to be as sustainably produced as in Finland. However, there must be continuous scrutiny of the circumstances. In Russia, the level of the compliance of certification criteria varies considerably, and there are vast unprotected invaluable forest areas. The utilisation of these areas should not be based on short-sighted decisions or lack of consensus among stakeholders.

Distribution of HCV genotypes among different exposure categories in Brazil

Hepatitis C virus (HCV) infection is widespread and responsible for more than 60% of chronic hepatitis cases. HCV presents a genetic variability which has led to viral classification into at least 6 genotypes and a series of subtypes. These variants present characteristic geographical distribution, but their association with different responses to treatment with interferon and severity of disease still remains controversial. The aim of this study was to investigate the patterns of distribution of HCV genotypes among different exposure categories in Brazil. Two hundred and fifty anti-HCV positive samples were submitted to HCV-RNA detection by RT-PCR and their genotype was determined by restriction fragment length polymorphism (RFLP) analysis. In addition, the genotype/subtype of 60 samples was also determined by a reverse hybridization assay. HCV 1 was the most prevalent (72.0%), followed by type 3 (25.3%), HCV 2 (2.0%) and HCV 4 (0.7%). The HCV genotype distribution varied among the different exposure categories, with HCV 1 being more frequent among blood donors, hemophiliacs and hemodialysis patients. A high frequency of HCV 3 was observed in cirrhotic patients, blood donors from the South of Brazil and injecting drug users (IDUs). The general distribution of the HCV genotype in Brazil is similar to that in other regions of the world.