Immediate Breast Reconstructions in the Treatment of Breast Cancer

Breast cancer is the most common form of potentially fatal cancer in women in the Western world. Better understanding of the breast cancer disease process together with developments in treatments have led to improved survival and reduced risk of recurrence, significantly influencing the acceptance of breast reconstructions as part of breast cancer treatment. Skin-sparing mastectomy followed by immediate breast reconstruction has proved superior to other forms of breast reconstruction in terms of aesthetic outcome. However, due to the relatively recent introduction of skin-sparing mastectomy concerns on the surgical and oncological safety of the operation persist. The aim of the present study is to evaluate the surgical and oncological safety of skin-sparing mastectomy and immediate breast reconstruction in a consecutive patient series with ensuing follow-up. Subsequent aims of the study are to examine possibilities of reducing surgical complications of the operation and to assess the feasibility of sentinel node biopsy together with immediate breast reconstruction. The study population comprises a consecutive series of patients having undergone skin-sparing mastectomy followed by immediate breast reconstruction at the Helsinki University Central Hospital between 1992 and 2006. In Study I, the hospital records of 207 patients, operated between 1992 and 2001, were analyzed for surgical complications and recurrences of breast cancer during follow-up. In Study II, 60 consecutive patients were randomized into either conventional diathermy or radiofrequency coagulation groups to examine possibilities of reducing skin-flap complications. Study III consists of 62 consecutive breast cancer patients evaluated for the feasibility of sentinel node biopsy simultaneously with immediate breast reconstruction. In Study IV, hospital records were analyzed to examine local recurrence of breast cancer in a consecutive series of 146 patients with Stage I or II disease. Post-operative complications in Study I included native skin-flap necrosis (10.1%), hematoma (10.1%), anastomose thrombosis (5.3%), infection (3.4%), hernia (2.6%) and loss of one microvascular flap (0.7%). The Stage I and II patients in Study IV had a local recurrence rate of 2.7%, an isolated regional lymph node recurrence rate of 2.1% and a systemic recurrence rate of 2.7%, during a mean follow-up time of 51 months. The Stage III patients in study I had a locoregional recurrence rate of 31.3% during follow-up. Radiofrequency coagulation in Study II did not decrease skin-flap complications when compared with conventional diathermy. An increased skin-flap complication rate in Study II was associated with smoking and the type of skin incision used. In Study III, eleven patients had tumor positive sentinel nodes, nine of which were detected intraoperatively. Skin-sparing mastectomy followed by immediate breast reconstruction is a safe procedure both surgically and oncologically, especially for early stage breast cancer. Tennis racket type incision is associated with an increased skin-flap complication rate. Sentinel node biopsy with intraoperative assessment of sentinel node metastases is feasible in patients undergoing immediate breast reconstruction.

Adjuvant Arteriovenous Fistula for Infrapopliteal Bypass Patency

A lack of suitable venous graft material or poor outflow is an increasingly encountered situation in peripheral vascular surgery. Prosthetic grafts have clearly worse patency than vein grafts in femorodistal bypass surgery. The use of an adjuvant arteriovenous fistula (av-fistula) at the distal anastomosis has been postulated to improve the flow and thus increase prosthetic graft patency. In theory the adjuvant fistula might have the same effect in a compromised outflow venous bypass. A free flap transfer also augments graft flow and may have a positive effect on an ischaemic limb. The aim of this study was to evaluate the possible benefit of an adjuvant av-fistula and an internal av-fistula within a free flap transfer on the patency and outcome of an infrapopliteal bypass. The effect of the av-fistula on bypass haemodynamics was also assessed along with possible adverse effects. Patients and methods: 1. A prospective randomised multicentre trial comprised 59 patients with critical leg ischaemia and no suitable veins for grafting. Femorocrural polytetrafluoroethylene (PTFE) bypasses with a distal vein cuff, with or without an adjuvant av-fistula, were performed. The outcome was assessed according to graft patency and leg salvage. 2. Haemodynamic measurements were performed to a total of 50 patients from Study I with a prolonged follow-up. 3. Nine critically ischaemic limbs were treated with a modified radial forearm flap transfer in combination with a femorodistal bypass operation. An internal av-fistula was created within the free flap transfer to increase flap artery and bypass graft flow. 4. The effect of a previous free flap transfer on bypass haemodynamics was studied in a case report. 5. In a retrospective multicentre case-control study, 77 infrapopliteal vein bypasses with an adjuvant av-fistula were compared with matched controls without a fistula. The outcome and haemodynamics of the bypasses were recorded. Main results: 1. The groups with and without the av-fistula did not differ as regards prosthetic graft patency or leg salvage. 2. The intra- and postoperative prosthetic graft flow was significantly increased in the patients with the av-fistula. However, this increase did not improve patency. There was no difference in patency between the groups, even in the extended follow-up. 3. The vein graft flow increased significantly after the anastomosis of the radial forearm flap with an internal av-fistula. 4. A previously performed free flap transfer significantly augmented the flow of a poor outflow femoropedal bypass graft. 5. The adjuvant av-fistula increased the venous infrapopliteal bypass flow significantly. The increased flow did not, however, lead to improved graft patency or leg salvage. Conclusion: An adjuvant av-fistula does not improve the patency of a femorocrural PTFE bypass with a distal vein cuff despite the fact that the flow values increased both in the intraoperative measurements and during the immediate postoperative surveillance. The adjuvant av-fistula increased graft flow significantly also in a poor outflow venous bypass, but regardless of this the outcome was no improved. The adjuvant av-fistula rarely caused adverse effects. In a group of diabetic patients, the flow in a vascular bypass graft was augmented by an internal av-fistula within a radial forearm flap and similarly in a patient with a previous free flap transfer, a high intraoperative graft flow was achieved due to the free flap shunt effect.

Kädestä suuhun : Makro- ja mikrotaloudellinen tarkastelu suomalaisten kotitalouksien säästämisestä ja sen mittaamisesta 1950-luvulla

This study is divided into two parts: a methodological part and a part which focuses on the saving of households. In the 1950 s both the concepts as well as the household surveys themselves went through a rapid change. The development of national accounts was motivated by the Keynesian theory and the 1940 s and 1950 s were an important time for the development of the national accounts. Before this, saving was understood as cash money or money deposited in bank accounts but the changes in this era led to the establishment of the modern saving concept. Separate from the development of national accounts, household surveys were established. Household surveys have been conducted in Finland from the beginning of the 20th century. At that time surveys were conducted in order to observe the working class living standard and as a result, these were based on the tradition of welfare studies. Also a motivation for undertaking the studies was to estimate weights for the consumer price index. A final reason underpinning the government s interest in observing this data regarded whether there were any reasons for the working class to become radicalised and therefore adopt revolutionary ideas. As the need for the economic analysis increased and the data requirements underlying the political decision making process also expanded, the two traditions and thus, the two data sources started to integrate. In the 1950s the household surveys were compiled distinctly from the national accounts and they were virtually unaffected by economic theory. The 1966 survey was the first study that was clearly motivated by national accounts and saving analysis. This study also covered the whole population rather than it being limited to just part of it. It is essential to note that the integration of these two traditions is still continuing. This recently took a big step forward as the Stiglitz, Sen and Fitoussi Committee Report was introduced and thus, the criticism of the current measure of welfare was taken seriously. The Stiglitz report emphasises that the focus in the measurement of welfare should be on the households and the macro as well as micro perspective should be included in the analysis. In this study the national accounts are applied to the household survey data from the years 1950-51, 1955-56 and 1959-60. The first two studies cover the working population of towns and market towns and the last survey covers the population of rural areas. The analysis is performed at three levels: macro economic level, meso level, i.e. at the level of different types of households, and micro level, i.e. at the level of individual households. As a result it analyses how the different households saved and consumed and how that changed during the 1950 s.

"Säästän ja tuhlaan, mutta en osta mitään turhaa tai ylimääräistä" : helsinkiläislasten oma raha ja sen käyttö

Nykylapsuudesta on tullut varsin kulutuskeskeistä. Tämän päivän lapset kasvavat valtaisan tavara- ja elämysmaailman ympäröimänä ja he osallistuvat myös kuluttajina yhteiskuntaan. He ovat huomispäivän aikuiskouluttajia, joiden arvot ja asenteet kuluttamista kohtaan muotoutuvat osin jo lapsuudessa. Lapset ovat myös markkinoinnille kiinnostava kohderyhmä ja yhä nuoremmat tunnistavat mainoksista tuttuja brändejä. Tässä tutkimuksessa käsitellään helsinkiläislasten omaa rahaa heidän omasta näkökulmastaan. Useimmiten tämä oma raha on joko viikkorahaa tai kuukausirahaa. Näkökulma tutkimukseen on kulutussosiologinen. Teoreettisena viitekehyksenä on käytetty Viviana Zelizerin teoriaa rahan luokittelusta ja korvamerkitsemisestä. Kiinnostuksen kohteena ovat myös olleet lasten rahaan ja sen käyttöön liittyvät arvot. Tutkitut lapset ovat iältään 9.-13.- vuotiaita. Tutkimuksen pohjana on valmis aineisto, joka on kerätty Survey-tutkimuksena keväällä 2008. Aineiston analyysissä on käytetty sekä kvantitatiivista että kvalitatiivista lähestymistapaa. Analyysimenetelminä on käytetty ristiintaulukointia ja sisällönanalyysiä. Vaikka lapsuuteen ja nuoruuteen liitetään usein huoli holtittomasta kulutuksesta ja materialistisista arvoista, aineiston pohjalta voi väittää, että huoli on ainakin osittain aiheeton. Tutkimuksesta käy ilmi, että 9- 13-vuotiaiden helsinkiläislasten kulutustavat ovat yleisesti ottaen säästäväisyyttä ihannoivat, joskin myös materialistisia asenteita tulee ilmi. Helsinkiläislapset ovat omaksuneet aikuisyhteiskunnan luomat ja ylläpitämät asenteet "järkevästä" rahankäytöstä. Rahankäytössään lapset eivät näe minkäänlaista ristiriitaa, vaan sekä kuluttaminen, että säästäminen on lapsille hyvin luontevaa. Lapset, jotka ovat pienestä pitäen tottuneet mainoksiin ja markkinointiin suhtautuvat rahankäyttöön mutkattomasti ja järkevästi. Tutkimuksessa ei noussut missään vaiheessa ilmi, että lapset ihannoisivat kerskakulutusta tai ylenpalttista rahankäyttöä, vaan säästäväisyyden normi heijastui myös lasten retoriikassa. Kaiken kaikkiaan vaikutelma lasten suhteesta rahaan oli hyvin realistinen. He myös näyttivät ymmärtävän rahan arvon ja olivat valmiita säästämään päästäkseen tavoitteeseensa. Alueellisesti Helsinki näyttäytyy hyvin homogeenisena, eikä mittavia eroja lasten oman rahan määrässä esiinny.