Coeliac disease--associated disorders and survival

The associated diseases in 335 coeliac patients diagnosed 1980-90 were compared with age and sex matched control patients with various gastrointestinal symptoms. Endocrine disorders were found in 11.9% of coeliac and 4.3% of control patients (p = 0.0003). Coeliac patients had insulin dependent diabetes mellitus significantly (p = 0.0094) more often (5.4%) than control patients (1.5%). connective tissue diseases were found in 7.2% of coeliac and in 2.7% of control patients (p = 0.011). Sjögren's syndrome occurred in 3.3% of coeliac patients and in 0.3% of controls (p = 0.0059). Autoimmune thyroid diseases were found in 5.4% and asthma in 3.6% of coeliac patients, but also in 2.7% and 3.6%, respectively, among control patients. The incidences of malignant diseases and the survival rate in coeliac patients were compared with those in the Finnish population. Ten coeliac patients developed a cancer during the follow up (mean 5.3 years, range 1-12) but none had a lymphoma. The risk of malignant diseases in coeliac patients did not differ from that in the Finnish population in general. Eleven coeliac patients died during the follow up. The five year survival rates of coeliac patients did not differ from those in the general population. At least 83% of the coeliac patients adhered strictly to the gluten free diet, which may explain the favourable outcome.

Longitudinal study of maternal depressive symptoms and child well-being

OBJECTIVE

To investigate whether prenatal, postnatal, and/or current maternal depressive symptoms are associated with low level of psychosocial functioning or high level of emotional/behavioral problems in school-age children.

METHOD

As part of a prospective longitudinal study, maternal depressive symptoms were screened with the Edinburgh Postnatal Depression Scale prenatally, postnatally, and when the children were 8 to 9 years old. The original sample of 349 mothers was collected in 1989-1990 in Tampere, Finland. Of the 270 mother-child pairs at the latest stage of the study in 1997-1998, 188 mother-child pairs participated and 147 were included. The associations between maternal depressive symptoms at different points in time and the level of children's psychosocial functioning and problems reported on the Child Behavior Checklist and Teacher's Report Form were examined.

RESULTS

Children's low social competence and low adaptive functioning were associated with concurrent maternal depressive symptoms. Maternal postnatal depressive symptoms predicted low social competence. The presence of prenatal depressive symptoms in the mother was a strong predictor of child's high externalizing and total problem levels (odds ratio 3.1, 95% confidence interval 1.1-8.9 and odds ratio 8.5, 95% confidence interval 2.7-26.5). Prenatal as well as recurrent maternal depressive symptoms were associated with the least favorable child outcome.

CONCLUSIONS

Maternal depressive symptomatology at any time, especially prenatally, is a risk factor for the child's well-being. This should be noted already in prenatal care. The timing and the recurrence of maternal depressive symptoms affect the outcome for the child.

Prevalence of symptoms suggestive of gastro-oesophageal reflux disease in an adult population

Symptoms suggestive of gastro-oesophageal reflux disease are very common. The aim of the study was to assess the prevalence of these symptoms and factors influencing them in an unselected adult population. A questionnaire was mailed to a random sample of 2500 people aged > or = 20 years. The questions concerned heartburn, regurgitation, dysphagia, chest and upper abdominal pain, as well as medication and medical consultations for these symptoms. Of the 1700 (68%) responders, 9% had experienced heartburn on the day of response and 15%, 21% and 27% during the preceding week, month and year, respectively. The corresponding figures for regurgitation were 5, 15, 29 and 45%. During the past year 43% of the study group had had no such symptoms. Age, overweight, pregnancy and cigarette smoking significantly influenced the prevalence of symptoms. Using daily heartburn and/or regurgitation as dominant indicators 10.3% (95% CI 12-11.7) of the responders had gastro-oesophageal reflux disease. Medication (most commonly antacids) was used by only 16% of the symptomatic people, and only 5.5% had sought medical advice for symptoms during the past year. Thus, despite commonness of symptoms suggestive of gastro-oesophageal reflux disease only a minority of the individuals suffering from such symptoms use medication or have medical consultation.

New biomarker evidence of oxidative DNA damage in patients with non-insulin-dependent diabetes mellitus

Urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG) has been reported to serve as a sensitive biomarker of oxidative DNA damage and also of oxidative stress. We have investigated oxidative DNA damage in patients with non-insulin-dependent diabetes mellitus (NIDDM) by urinary 8-OHdG assessments. We determined the total urinary excretion of 8-OHdG from 24 h urine samples of 81 NIDDM patients 9 years after the initial diagnosis and of 100 non-diabetic control subjects matched for age and gender. The total 24 h urinary excretion of 8-OHdG was markedly higher in NIDDM patients than in control subjects (68.2 +/- 39.4 microg vs. 49.6 +/- 37.7 microg, P = 0.001). High glycosylated hemoglobin was associated with a high level of urinary 8-OHdG. The increased excretion of urinary 8-OHdG is seen as indicating an increased systemic level of oxidative DNA damage in NIDDM patients.

Is cellulose sponge degradable or stable as implantation material? An in vivo subcutaneous study in the rat

The long-term behaviour of cellulose sponge implants, 10 x 10 x 5 mm in size, and tissue reactions in and around them were examined in the subcutaneous tissue of the rat from 1 to 60 weeks after implantation. The cellulose sponge used was filled up with connective tissue 4 to 8 weeks after implantation. Histologically, moderate foreign body tissue reaction inside the implant, the appearance of cracks and fissures, spotty colouration, and softening of the pore walls were observed up to 16 weeks after implantation. Later, the foreign body reaction inside the sponge became milder, the spotty colouration disappeared and micropores enlarged in the viscose cellulose matrix. Histomorphometrically, the cross-sectional area of the implants and the size of the pore wall fragments decreased, and the number of pore wall fragments increased significantly. The cellulose sponge used can be regarded as a slowly degradable implantation material. However, the time needed for the total disappearance of the cellulose sponge from subcutaneous tissue is longer than the 60 weeks.

Prognosis of diastolic and systolic orthostatic hypotension in older persons

BACKGROUND

Orthostatic hypotension (OH) predicts mortality in hypertensive persons with diabetes mellitus, but no increase in mortality has been found among random samples of home-dwelling persons with OH. We examined the risks of nonvascular and vascular deaths according to different definitions of OH among home-dwelling elderly persons.

SUBJECTS AND METHODS

The study population consisted of all persons aged 70 years or older living in 5 rural municipalities (N=969), of whom 833 (86%) participated. Orthostatic tests were successfully carried out in 792 persons by nurse examiners. Orthostatic hypotension was defined as a systolic blood pressure (BP) drop of 20 mm Hg or more or a diastolic BP drop of 10 mm Hg or more 1 minute or 3 minutes after standing up. Nonvascular and vascular deaths during the follow-up period were recorded. Data on diseases, symptoms, medications, the results of clinical examinations and tests, functional ability, and health behavior were collected at the beginning of the follow-up period.

RESULTS

Of the sample, 30% had OH: the prevalence of systolic OH 1 minute and 3 minutes after standing up was 22% and 19%, respectively; that of diastolic OH 1 minute and 3 minutes after standing up was 6% for each. No differences in the occurrence of nonvascular deaths were found according to any of these definitions. By Cox multivariate regression analysis, the hazard ratio of vascular death associated with a diastolic BP reduction of 1 mm Hg 1 minute after standing up was 1.02 (P=.03), adjusted for systolic BP postural changes at 1 and 3 minutes and a diastolic BP change at 3 minutes. Adjusted for other significant factors associated with vascular death, the hazard ratio for vascular death associated with diastolic OH 1 minute after standing up was 2.04 (95% confidence interval, 1.01-4.15). The corresponding hazard ratio for systolic OH 3 minutes after standing up was 1.69 (95% confidence interval, 1.02-2.80). Using a cutoff point of 7 mm Hg or greater for a diastolic BP change 1 minute after standing up, the hazard ratio for vascular death was highest: 2.20 (95% confidence interval, 1.23-3.93). By logistic regression analysis, the baseline associates of diastolic OH 1 minute after standing up were dizziness when turning the neck (odds ratio [OR], 2.44), the use of a calcium antagonist (OR, 2.31), the use of a diuretic medication (OR, 2.29), a high systolic BP (OR, 2.23), and a low body mass index (OR, 2.26). The baseline associates of systolic OH 3 minutes after standing up were male sex (OR, 1.52), diabetes mellitus (OR, 1.92), a high systolic BP (OR, 2.91), and a low body mass index (OR, 1.68).

CONCLUSIONS

The presence of diastolic OH 1 minute and systolic OH 3 minutes after standing up predict vascular death in older persons. They differ from each other in their prevalence and in several associates, suggesting different pathophysiologic backgrounds. Clinicians should prescribe vasodilating and volume-depleting medications with caution for elderly persons with diastolic OH 1 minute after standing up. Appropriate treatment of hypertension might be the best means to manage the different types of OH with poor vascular prognoses.

CSF and MRI findings in patients with acute herpes zoster

OBJECTIVE

To explore MRI and CSF findings in patients with herpes zoster (HZ) and to correlate the findings with clinical manifestations of the disease.

METHODS

Fifty immunocompetent patients (mean age, 59 years; range, 17 to 84 years) with HZ of fewer than 18 days duration participated. None had clinical signs of meningeal irritation, encephalitis, or myelitis. In 42 patients (84%), the symptoms constituted pain and rash only. Six patients (12%) had motor paresis, and three patients (6%) had ocular complications. One to three CSF samples were obtained from 46 patients (the first sampling taken 1 to 18 days from onset of rash), and 16 patients (all with either trigeminal or cervical HZ) underwent MRI of the brain. The clinical follow-up continued at least 3 months.

RESULTS

CSF was abnormal in 28/46 patients (61%): pleocytosis (range, 5 to 1,440 microL) was detected in 21, elevated protein concentration in 12, varicella zoster virus (VZV) DNA in 10, and immunoglobulin G antibody to VZV in 10. These changes were more common in patients with acute complications, although they did not predict development of postherpetic neuralgia (PHN). In 9/16 patients (56%), MRI lesions attributable to HZ were seen in the brainstem and cervical cord. At 3 months, 5/9 patients (56%) with abnormal MRI had PHN, whereas none of the 7 patients with no HZ-related lesions on MRI had any remaining pain.

CONCLUSIONS

Subclinical extension of viral inflammation into the CNS occurs commonly in HZ. This finding may have implications for treatment of HZ and prevention of various associated complications.

Physiological factors and medications as predictors of injurious falls by elderly people: a prospective population-based study

To determine the physiological factors and medications predicting injurious falls among the elderly population, the authors conducted a prospective study in a rural home-dwelling population aged 70 years or over, initially 979 persons (377 men and 602 women), from 1 January 1991 to 31 December 1992, in Northern Finland. The independent risk factors for all falling injuries, falls leading to minor injuries and ones leading to major injuries were determined. In men, the independent risk factors for all injuries were gait disturbances [odds ratio (OR) = 3.5] and the use of digitalis (OR = 2.2), those for minor injuries were gait disturbances (OR = 2.7) and the use of calcium blockers (OR = 3.0), and those for major injuries were the absence of a quadriceps reflex (OR = 4.8), gait disturbances (OR = 2.8) and the use of digitalis (OR = 2.9). In women, the corresponding independent risk factors were short step length (OR = 32.1), the use of calcium blockers (OR = 2.5) and the use of medications for improving peripheral circulation (OR = 3.7) for all injurious falls, path deviation (OR = 2.3) the use of calcium blockers (OR = 2.8) and the use of anti-inflammatory drugs (OR = 2.1) for minor injuries, and foot deformity (OR = 2.0), short step length (OR = 15.8), the use of long-acting benzodiazepines (OR = 4.0) and the use of calcium blockers (OR = 2.4) for major injuries. In order to prevent injurious falls, attention should be given to the prescription of tranquillizers, cardiovascular medications and anti-inflammatory drugs. The walking abilities of elderly people should be maintained and chronic diseases leading to peripheral neuropathy should be treated adequately.

Visual neglect as a predictor of functional outcome one year after stroke

OBJECTIVE

The aim was to study the role of visual neglect in acute right hemisphere brain infarct as a predictor of poor functional outcome during the first year after stroke. In particular, we were interested in the additional value of neglect measures besides hemiparesis, hemianopia, cognitive deficits and age.

PATIENTS AND METHODS

A consecutive series of 57 patients with a neuroradiologically verified right hemisphere infarct was examined within 10 days of the stroke. Fifty patients were followed up for 1 year. Neglect was measured with the Conventional and the Behavioural subtests of the Behavioural Inattention Test (BITC and BITB, respectively). The predictors were determined at the 10-day examination. Functional outcome was assessed 3, 6 and 12 months after the onset with the Frenchay Activities Index.

RESULTS

Neglect in BITB was the best single predictor, which together with high age formed the best combination of predictors for poor functional outcome at each follow-up. Hemiparesis was also included in this prediction model at the 3-month follow-up, but hemianopia, BITC, or visuoconstructional and memory deficits showed no additional predictive value. However, neglect usually recovered soon. When neurological and cognitive deficits were assessed at the same time as the outcome, hemiparesis rather than neglect was the strongest correlate of poor outcome.

CONCLUSION

Neglect in acute stroke is an important predictor of poor functional recovery. Residual neglect, which could be compensated in the follow-up tests, may nevertheless restrict patients' real-life activities and hobbies.

Age-dependent association of apolipoprotein E genotype with coronary and aortic atherosclerosis in middle-aged men: an autopsy study

BACKGROUND

Apolipoprotein E (apoE) polymorphism is one of the genetic determinants of serum cholesterol values. The apoE epsilon4 allele has been associated with advanced coronary heart disease (CHD) diagnosed by angiography, but the role of the apoE genotype in atherosclerosis has not been confirmed at vessel-wall level, nor is any age-dependent effect of the apoE genotype on the development of CHD known.

METHODS AND RESULTS

The right and left anterior descending coronary arteries (RCA and LAD) and the aorta from 700 male autopsy cases (Helsinki Sudden Death Study) in 1981-1982 and 1991-1992 (average age 53 years, range 33 to 70 years) were stained for fat, and all areas covered with fatty streaks, fibrotic plaques, and complicated lesions were measured. In the RCA and LAD, the apoE genotype was significantly associated with the area of total atherosclerotic lesions in men <53 years old but not with that in older men (P=0.0085 and P=0.041, respectively, for age-by-genotype interaction). Men <53 years old with the epsilon4/3 genotype showed 61% larger total atherosclerotic lesion area in the RCA (P=0.0027) and 26% larger area in the LAD (P=0.12) than did men with the epsilon3/3. The apoE epsilon4/3 was also associated with atherosclerotic lesions in the abdominal (P=0.014) and thoracic (P=0.12) aorta, but this effect, unlike that of the coronary arteries, was not age-related.

CONCLUSIONS

In men, the apoE epsilon4 allele is a significant genetic risk factor for coronary atherosclerosis in early middle age. This suggests that at older age, other known risk factors of CHD play a more important role in the atherosclerotic process than apoE polymorphisms.

Strong prediction of fractures among older adults by the ratio of carboxylated to total serum osteocalcin

We examined serum total osteocalcin (TOC), carboxylated osteocalcin (COC), and their ratio (COC/TOC) by one-step two-site immunofluorescent assays in 87% (n = 792) of all home-dwelling persons of 70 years or older living in a defined area in northern Finland. Other baseline subject-related risk factors of fractures were assessed by postal questionnaires, interviews, clinical examinations, and tests. During a 5-year follow-up period, all falls and fractures (n = 106) were recorded by regular phone calls and by examining all the medical records yearly. Serum TOC and COC concentrations increased with advancing age and were higher in women than in men, but corresponding differences were not found in the case of COC/TOC. The adjusted relative risk of fracture was elevated in association with low (< or =-1 SD from the mean) COC; hazard ratio (HR, 95% CI) 2.00 (1.20-3.36) and low COC/TOC; HR 5.32 (3.26-8.68), the relative risk being highest in the population older than 80 years; and HR 7.02 (2.42-20.39). The predictive value of low COC/TOC lasted 3 years. The multivariable-adjusted relative risk of hip fracture (n = 26) in regard to low COC/TOC ratio was 3.49 (1.12-10.86), as compared with the persons who did not suffer hip fractures. Our results suggest that serum COC concentrations and, more strongly, COC/TOC, predict the occurrence of fractures in older community-dwelling adults. The risk of fracture associated with low COC/TOC equals the hip fracture risk previously verified for concomitant high serum undercarboxylated OC concentrations and low bone mineral density.

Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled trial

CONTEXT

Hallux valgus is a common foot deformation in adults, but evidence for effectiveness of surgical and conservative treatments for this condition is limited.

OBJECTIVE

To compare the effectiveness of surgical and orthotic treatment with no treatment in patients with hallux valgus.

DESIGN AND SETTING

Randomized controlled trial conducted in 4 general community hospitals in Finland in 1997-1998, with a follow-up period of 12 months.

PARTICIPANTS

Two hundred nine consecutive patients (mean age, 48 years; 93% women) with a painful bunion and a hallux valgus angle 35 degrees or less.

INTERVENTIONS

Patients were randomly assigned to surgery (distal chevron osteotomy; n = 71), orthosis (n = 69), or a 1-year waiting list (control group, n = 69).

MAIN OUTCOME MEASURES

Pain intensity during walking on a visual analog scale (0-100), patient assessment of global improvement, number of painful days, cosmetic disturbance, footwear problems, functional status, and treatment satisfaction, compared among treatment groups.

RESULTS

Follow-up rates at 6 and 12 months were 99% and 98%, respectively. At 6 months, pain intensity decreased more in the surgical group than in the control group (adjusted mean differences, -20 [95% confidence interval (CI), -28 to -12]) and more in orthosis than in the control groups (adjusted mean difference, -14 [95% CI, -22 to -6. At 1 year, pain intensity decreased more in the surgical than in the control groups (adjusted mean difference, -19 [95% CI, -28 to -10]) and more than in the surgical and orthosis groups (adjusted mean difference, -14 [95% CI, -22 to -5]). At 1 year, 83%, 46%, and 24% in the surgery, orthosis, and control groups, respectively, thought they had improved compared with baseline (number needed to treat), 1.7 between surgical and control groups). Number of painful days, cosmetic disturbance, and footwear problems were least and functional status and satisfaction with treatment were best in the surgical group.

CONCLUSIONS

Surgical osteotomy is an effective treatment for painful hallux valgus. Orthoses provide short-term symptomatic relief.

Mutations at the mitochondrial DNA polymerase (POLG) locus associated with male infertility

Human mitochondrial DNA polymerase, encoded by POLG, contains a polyglutamine tract encoded by a CAG microsatellite repeat. Analysis of POLG genotypes in different populations identified an association between absence of the common, ten-repeat allele and male infertility typified by a range of sperm quality defects but excluding azoospermia.

Risk factors for major injurious falls among the home-dwelling elderly by functional abilities. A prospective population-based study

BACKGROUND

In order to identify the risk factors essential for preventing major injurious falls, the associations between injurious falls and certain factors were assessed among disabled and independent elderly, respectively, who had fallen during a 2-year period.

METHODS

A prospective population-based study was conducted in five rural northern Finnish municipalities. The series consisted of all inhabitants aged 70 years or over, initially 979 persons. During a 2-year follow-up period, all injurious falls were recorded on the basis of telephone contacts, diary reporting and a review of the medical records of the participants.

RESULTS

Thirty percent of the subjects having fallen sustained a major injury. The multivariate model applied to the disabled elderly showed the following variables to be related to a high risk for major injurious falls: divorced, widowed or unmarried marital status (odds ratio = 2.2), a low body mass index (odds ratio = 3.1), incomplete step continuity (odds ratio = 2.2), poor distant visual acuity (odds ratio = 2.3) and the use of long-acting benzodiazepines (odds ratio = 2.4). Among the independent elderly, the risk of a fall resulting in major injury was high among the subjects who had peripheral neuropathy (odds ratio = 2.5) or were suffering from insomnia (odds ratio = 4.1).

CONCLUSIONS

The risk factors for major injuries in fall occurrences differ between the disabled and independent elderly. Preventive measures should be targeted according to the disabilities of the population.

Death rates and causes of death in patients with rheumatoid arthritis: a population‐based study

OBJECTIVE

To assess the mortality and causes of death in a cross-sectional population-based study of 1042 patients with rheumatoid arthritis (RA).

METHODS

In 1988, 604 RA patients [470 females (F), 134 males (M)] and 457 age- and sex-matched controls (352 F, 105 M) were examined prospectively (participants) and 438 (183 F, 81 M) non-participant RA patients retrospectively. In 1999, vital status and causes of death were determined. Mortality in the total RA population was compared to that in the general population, and that among participant RA patients to their matched controls.

RESULTS

A total of 384 (37%) RA patients and 71 (16%) controls died. RA patients had increased mortality compared to the general population (standardized mortality ratios SMR 2.64) or controls (1.71). This was observed in both sexes. Over 40% of deaths in all groups were due to cardiovascular diseases. RA patients were at increased risk of dying of urogenital, gastrointestinal, respiratory and cardiovascular diseases, infections, and cancers when compared to the general population or controls.

CONCLUSIONS

Our results show that a cross-sectional cohort of RA patients had an increased risk of death from various causes.

Fracture risk associated with a fall according to type of fall among the elderly

The kinetic energy and direction of a fall contribute to the occurrence of fracture. However, the fracture risk associated with different types of fall, different amounts of energy and different landing directions is poorly understood. We recorded all falls and fall-related fractures over 7 years in an aged semi-rural home-dwelling population (n = 980), using intensive fall recording. The falls were classified according to type and place of occurrence into slip falls (SLFs), trip falls (TRFs), other extrinsic falls on the level (OEFs), intrinsic falls on the level (IFs), stair falls (STFs), falls from an upper level (ULFs) and nondefined falls (NDFs) occurring indoors or outdoors. Incidences of falls and fractures were calculated for the whole follow-up period. The population was clinically examined to assess general risk factors of fracture, after which the risk of fracture was determined in the first fall according to the different fall types. Comparison was made with intrinsic falling on the level. The overall incidences of indoor and outdoor falls were 328 (95% CI 314-345) and 198 (186 210) per 1000 person-years (PY), respectively, and those of fractures 23 (19-27) and 11 (8-4) per 1000 PY, respectively. Indoor SLFs, TRFs, OEFs, IFs, STFs, ULFs and NDFs occurred relatively evenly throughout the study period. The crude and adjusted relative fracture risks were greater in SLFs, OEFs and STFs compared with IFs. Indoor falls and fractures are more common than those occurring outdoors in aged home-dwelling persons. The kinetic energies produced in SLFs, OEFs and STFs may be higher than those generated in IFs, leading to increased risk of fracture.

A longitudinal cohort study of Finnish patients with primary Sjögren's syndrome: clinical, immunological, and epidemiological aspects

OBJECTIVE

To evaluate outcome in a cohort of Finnish patients with primary Sjögren's syndrome (pSS).

METHODS

Clinical and laboratory data from the time of diagnosis and follow up were collected from 110 patients with pSS (107 women, three men) diagnosed in 1977-1992 in central Finland. The standardised incidence ratio for cancers was determined as the ratio of the observed number of cases to the expected number based on regional population rates. Eighty one of the 93 patients still alive were interviewed, and clinical and laboratory examinations performed in 1994-1997.

RESULTS

The mean (SD) erythrocyte sedimentation rate (33 (22) v 45 (28) mm/1st h), serum IgG (18.8 (7.4) v 22.5 (8.5) g/l), and serum IgM (1.6 (1.1) v 2.0 (1.2) g/l) at the control visit were significantly (p<0.0001) lower than those at baseline. A similar change was observed in a subgroup of patients never treated with glucocorticosteroids or disease modifying antirheumatic drugs. Three non-Hodgkin's lymphomas were diagnosed (standardised incidence ratio 13; 95% confidence interval 2.7 to 38). In a logistic regression model, the patients with pSS with subsequent lymphoma were found to have higher baseline levels of serum beta2 microglobulin than the others (odds ratio 1.9; 95% confidence interval 1.1 to 3.4).

CONCLUSION

The results suggest that mean concentrations of serum IgG and IgM in patients with pSS decline with time, possibly reflecting diminishing inflammatory activity. As in previous studies, the incidence of non-Hodgkin's lymphomas in this cohort of patients with pSS was significantly higher than in the reference population.

Predictors for recurrent falls among the home-dwelling elderly

OBJECTIVE

Scant attention has been paid to the risk factors for recurrent falls among the home-dwelling elderly, although there are remarkable age and sex differences according to whether or not the falls recur. In this report we describe and analyse the risk factors for recurrent falls by selected clinical variables and the history of falling during the previous year.

DESIGN

A community-based prospective study covering two years.

SETTING

All home-dwelling persons (N = 1016) aged 70 years or older living in five municipalities in northern Finland.

OUTCOME MEASURES

The risk factors of recurrent falling by selected clinical variables using cross-tabulations and multivariate analyses.

RESULTS

Previous falls, peripheral neuropathy, use of psychotropic medication and slow walking speed were independent risk factors for recurrent falling. The risk of recurrent falling increased with an increasing number of previous falls.

CONCLUSIONS

Early preventive measures should be taken among the elderly persons who are prone to falling. In order to reduce the risk of recurrent falls among the elderly, the attending physician should take a critical view of the use of psychotropic medications, and attempts should be made to treat conditions underlying peripheral neuropathies and abnormal gait.

High incidence and prevalence of adult coeliac disease. Augmented diagnostic approach

BACKGROUND

The diagnosis of coeliac disease is easily overlooked as patients can present with mild or atypical symptoms, or the condition can even be clinically silent. Our aim was to detect coeliac disease patients with such atypical or no symptoms as well as those with typical features.

METHODS

The incidence of adult coeliac disease in Tampere was calculated from 1975 to 1994 and the prevalence as of 31 December 1994. Open-access endoscopy was available for general practitioners, and small-bowel biopsy was done routinely. Serologic screening was applied to patients with an increased risk of coeliac disease.

RESULTS

The incidence of coeliac disease increased tenfold, and the prevalence was 270 per 100,000 inhabitants in 1994. Twenty per cent were found by serologic screening and 10% as a result of routine biopsy; 24% had dermatitis herpetiformis.

CONCLUSIONS

Our diagnostic approach gave a coeliac prevalence similar to that found in population screening studies. One-third had silent coeliac disease.

Intraepithelial gamma delta T-cell-receptor lymphocytes and genetic susceptibility to coeliac disease

Although the proportion of gamma delta T-cell-receptor (TCR)-bearing intraepithelial lymphocytes is increased in the jejunum of patients with active coeliac disease, an abnormality thought to be specific among those with gluten-sensitive enteropathy, the factors influencing gamma delta TCR expression remain uncertain. We examined the relation between genetic factors associated with coeliac disease and intraepithelial gamma delta T lymphocyte distribution in both coeliac patients and their healthy first-degree relatives. 41% (45/109) of healthy relatives had an increased density of gamma delta T cells in their mucosa and 66% had an increased density of alpha beta T cells. By contrast with alpha beta T cells, the density of gamma delta cells was significantly associated with genetic markers for coeliac disease susceptibility (DR3, DQA, and DQB). We also found a dose effect of DQA and DQB genes on the number of intraepithelial gamma delta T cells. An increased density of gamma delta T cells in normal jejunal mucosa of a healthy individual with appropriate genetic determinants might be necessary for the development of the typical lesions of coeliac disease. Routine jejunal histological studies should include gamma delta T-cell counts, thus allowing early detection of coeliac disease latency.

Polymorphisms within the tumor necrosis factor locus and prevalence of coronary artery disease in middle-aged men

Tumor necrosis factor (TNF) is an important cytokine in the inflammation process of atherosclerosis and is also involved in lipid metabolism. Two biallelic polymorphisms within TNF gene locus-TNFA at the position -308 in the promoter region of the TNF gene and TNFB in the first intron of the lymphotoxin-alpha (LT-alpha) have been reported to be associated with TNF production and with susceptibility to inflammatory diseases. We studied the association of these polymorphisms within the major histocompatibility complex (MHC) III region with coronary atherosclerosis and its manifestations. The autopsy series comprised 700 Caucasian Finnish men, aged 33-70 years (The Helsinki Sudden Death Study). Coronary stenosis and surface area of atherosclerotic changes (fatty streaks, fibrous plaques, complicated lesions and calcification) were measured and the presence of myocardial infarction and coronary thrombosis recorded. TNFA and TNFB genotypes were determined by the PCR-RFLP technique. The allele frequencies were TNFA1/TNFA2=0.88/0.12 and TNFB1/TNFB2=0.30/0.70. There was a strong linkage disequilibrium between the two polymorphisms. There were no differences in coronary stenosis and in the frequency of old or recent myocardial infarction or coronary thrombosis between men with different genotype status in either locus. Men with TNFA22 or TNFB11 genotype tended to have more fibrous lesions and calcification in their coronary arteries. TNFA and TNFB polymorphisms are unlikely to contribute to progression of atherosclerosis in a way clinically important.

Effect of an oats-containing gluten-free diet on symptoms and quality of life in coeliac disease. A randomized study

BACKGROUND

Evidence suggests the acceptability of oats in a gluten-free diet in coeliac disease. We investigated the impact of an oats-containing diet on quality of life and gastrointestinal symptoms.

METHODS

Thirty-nine coeliac disease patients on a gluten-free diet were randomized to take either 50 g of oats-containing gluten-free products daily or to continue without oats for 1 year. Quality of life was assessed using the Psychological General Well-Being questionnaire and gastrointestinal symptoms using the Gastrointestinal Symptom Rating Scale. Small-bowel mucosal villous architecture, CD3+, alphabeta+, gammadelta+ intraepithelial lymphocytes, serum endomysial and tissue transglutaminase antibodies were investigated.

RESULTS

Twenty-three subjects were randomized to the oats-containing diet and 16 to the traditional gluten-free diet. All adhered strictly to their respective diet. Quality of life did not differ between the groups. In general, there were more gastrointestinal symptoms in the oats-consuming group. Patients taking oats suffered significantly more often from diarrhoea, but there was a simultaneous trend towards a more severe average constipation symptom score. The villous structure did not differ between the groups, but the density of intraepithelial lymphocytes was slightly but significantly higher in the oats group. The severity of symptoms was not dependent on the degree of inflammation. Antibody levels did not increase during the study period.

CONCLUSION

The oats-containing gluten-free diet caused more intestinal symptoms than the traditional diet. Mucosal integrity was not disturbed, but more inflammation was evident in the oats group. Oats provide an alternative in the gluten-free diet, but coeliac patients should be aware of the possible increase in intestinal symptoms.

Cancer of the tongue in patients younger than 40 years. A distinct entity?

BACKGROUND

An increase in the incidence of oral cancer among patients younger than 40 years has been reported worldwide. It has been suggested that the disease behaves more aggressively among young people.

OBJECTIVE

To evaluate the clinical and biologic behavior of tongue cancer among younger patients.

PATIENTS AND METHODS

Data on all patients younger than 40 years in whom tongue cancer was diagnosed in Finland between 1980 and 1989 (34 cases) were collected; pertinent clinical data were available for risk factor screening. A follow-up of at least 5 years or until death was available for all 34 patients. Immunocytochemical staining techniques were used to assess the expression of p53 and bcl-2 proteins, and p53 mutation analysis was performed by using the nonradioactive single-strand conformation polymorphism technique.

RESULTS

The incidence of tongue cancer in this age group in Finland did not change during the study period. The clinical behavior of tongue cancer in young people was not more aggressive compared with that of older patients in general, with the overall 5-year survival being as good as 70.6%. Altogether, p53 mutations were found in 17 of 33 tumors (51.5%). The p53 and bcl-2 protein expression was strong or moderate in 33.3% and 30.3% of the samples, respectively. Intense p53 protein expression was associated with the larger tumor size (P < .05). The poorest prognosis was found in patients with tumors greater than 4 cm in diameter (P = .01) or moderately or poorly differentiated cancer (P = .01). There was a trend for the adverse prognosis to accumulate in patients with moderately or poorly differentiated carcinoma and mutations in p53 (P = .09).

CONCLUSIONS

The cause of tongue cancer in patients younger than 40 years seems to be multifactorial. Those patients had a similar clinical course, prognosis, and function of p53 as found in the reports of a normal age variation. Mutations of p53 seemed to be an additional prognostic marker that was associated with moderate or poor differentiation of the tumors.

Adolescent depression: the role of discontinuities in life course and social support

OBJECTIVE

To study sociodemographic determinants of depression among 14-16 years old girls and boys, and the role of perceived social support in mediating the effects of the background variables.

METHOD

16464 adolescents aged 14-16 participated the School Health Promotion Study, a survey about health, health behaviour and school behaviour. Depression was measured by the Finnish modification of the 13-item Beck Depression Inventory. Moderate to severe symptoms in this scale were recorded as depression.

RESULTS

Depression was associated with family structure in both sexes. Among girls, having moved recently and low parental education increased the risk for depression, among boys, unemployment in the family. Accumulating number of discontinuities in life course increased the proportion of the depressed among both girls and boys. Perceived lack of social support had the same effect. Lack of support did not explain the effect on depression of the discontinuities in life course.

CONCLUSION

To detect risk groups for adolescent depressive disorders, health services should pay attention to adolescents who have experienced life changes. Perceived social support should be enquired.

Moderate alcohol consumption and loss of cerebellar Purkinje cells

OBJECTIVE

To examine the dose-response effect of alcohol consumption on the number of cerebellar Purkinje cells.

DESIGN

A prospective necropsy study combined with detailed reports on use of alcohol from a relative or friend. The number of Purkinje cells was counted in the anterior midsagittal section of the cerebellar vermis, the area of which was measured by computer assisted morphometry.

SETTING

Department of forensic medicine, University of Helsinki.

SUBJECTS

66 men, aged 35 to 69 years, subjected to medicolegal necropsy because of sudden or violent death. The average all year daily alcohol consumption over the year was 0 to 10 g in 17 men, 11 to 80 g in 24 men, and more than 80 g in 25 men.

MAIN OUTCOME MEASURES

Number of Purkinje cells, alcohol consumption.

RESULTS

The numbers and density of Purkinje cells in the cross section of vermis showed a consistent but weak decrease with increasing daily alcohol intake but not with age. A wide variation in the cell counts was observed, especially in men drinking more than 80 g, suggesting differences in the susceptibility to effects of alcohol. Compared with men drinking 40 g or less, a long term moderate consumption of an average of 41 to 80 g daily was associated with a significant average loss of 242 (95% confidence interval 45 to 439) Purkinje cells (15.2%) from a mean of 1583 to 1341 cells. In those drinking 81 to 180 g the average loss was 535 (259 to 811) cells (33.4%) to a mean of 1048 cells. The density of cells in the cross section of vermis also fell significantly by 0.9 cell/mm (0.1 to 1.7) when the daily consumption exceeded 40 g and by 1.4 cell/mm (0.3 to 2.5) when the intake was 81 to 180 g. Only three cases (4.5%) in the series showed macroscopical cerebellar atrophy.

CONCLUSION

Long term intake of moderate doses of alcohol daily for 20-30 years may damage the cerebellum before the onset of macroscopical atrophy. Despite distinct individual differences an all year average daily alcohol intake of 41-80 g results in a risk of significant loss of Purkinje cells.