Glottic and supraglottic laryngeal carcinoma: differences in epidemiology, clinical characteristics and prognosis

In order to evaluate differences in epidemiology, clinical characteristics and prognosis, 166 glottic and 127 supraglottic cases of laryngeal squamous cell carcinoma diagnosed between 1962 and 1991 at Tampere University Hospital, Finland, were reviewed. The annual age-adjusted incidence in males decreased from 6.7/100,000 to 2.6/100,000 and the proportion of glottic tumours increased from one-third to two-thirds during the study period. The proportion of early stage lesions was greater among glottic tumours, and patients with a supraglottic tumour presented more often with neck node metastases. Hoarseness was the most common symptom, being more prevalent in patients with a glottic tumour. The symptom pattern of supraglottic carcinoma was altogether more diffuse. The 5-year disease-specific survival was 81% in glottic and 70% in supraglottic disease, but the difference in survival was not statistically significant. In the multivariate Cox regression analysis, higher T-category and presence of neck node metastases had adverse prognostic effect, while location of the tumour did not significantly affect the prognosis. Favourable changes in smoking habits seem to be the main reason for the incidence decrease and obviously also for the decrease in the proportion of supraglottic tumours.

Factors underlying changes in bone mineral during postpartum amenorrhea and lactation

To determine the physiologic and habitual factors that may modulate changes in bone mineral density (BMD) postpartum, dual-energy X-ray absorptiometry was performed at the lumbar spine, right femoral neck and dominant distal radius immediately after delivery, after resumption of menses, and 1 year thereafter in a cohort of 41 healthy postpartum Finnish women aged 31.5 (SD 4.6) years. Mean durations of lactation and postpartum amenorrhea (PPA) were 7.7 (3.7) and 5.9 (2.9) months, respectively. After PPA, significant bone losses of 2%-4% were observed at the lumbar spine and femoral neck. Duration of PPA and different lactational variables explained (adjusted R2) from 21% to 27% of the variability in changes in BMD during PPA. A recovery to postpregnancy BMD levels was observed at the lumbar spine; in contrast BMD at the femoral neck showed only a partial recovery. The duration of unsupplemented lactation was weakly (adjusted R2 = 0.13) associated with recovery at the lumbar spine, while a long duration of total lactation also showed a weak association (adjusted R2 = 0.02) with delayed recovery at the femoral neck. In conclusion, a systematic bone loss occurs during PPA, and after resumption of menstruation BMD recovers despite continued lactation. However, the time of bony recovery back to postpregnancy level seems to be modulated slightly by lactation habits. It is obvious that the control of postpartum BMD changes is a multifactorial process that may be specific to the skeletal site of interest.

First-time mothers and child care when the child is 8 months old

The aim of the present study was to examine those resources and strengths that mothers find helpful for coping with child care when the child was 8 months old. This study is part of a more extensive longitudinal study project in which the growth into motherhood of first-time mothers was followed for 8 months postpartum. Data were collected by using structured questionnaires between August 1995 and March 1996. The sample comprised 254 first-time mothers and 248 mothers returned the questionnaires by mail. The multivariate method used was a stepwise regression analysis. Predictors included in the multivariate method to explain coping with child care were as follows: the mother's competence, mother's attachment to the child, mother's self-concept, relation to the spouse, breastfeeding, decision-making support from the public health nurse and activity of the child. The strongest predictor was competence as a mother. The more competent the mother felt and the more attached the mother was to her child, the better her coping. The better the mother's self-concept and relationship with the spouse were, the better she succeeded in taking care of the child. If the mother still breastfed her child and received decision-making support from public health nurses, she coped better in child care. Finally the more active the child was, the more the risk for unsuccessful child care increased. The results indicate that the first-time mother's successful coping with child care when the child is 8 months old is associated with her own resources and attachment to the child as well as activity of the child and breastfeeding. A good relationship between the spouses and support for decision making from the public health nurse also contribute to coping with child care.

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.

Very low birthweight, bronchopulmonary dysplasia and health in early childhood

The impact of very low birthweight (<1500g) and bronchopulmonary dysplasia (BPD) on respiratory morbidity, on need of medical resources and rehabilitation at 2-8 y of age, and on the everyday life of the child's family was evaluated by means of a questionnaire addressed to parents of 143 very low birthweight children, 36 of whom had had BPD at 28 d postnatal age, and 131 term controls. In the preceding year, respiratory symptoms provoked by exercise, use of inhaled medications, regular follow-up visits and hospitalizations, need for physiotherapy, occupational therapy, technical aids and financial support from society had been more common in the very low birthweight groups compared to children born at term. Children with BPD suffered respiratory infections and needed antibiotic courses more frequently than term controls. Repeated antibiotic courses, physiotherapy and occupational therapy were more common among very low birthweight children with BPD than among those without. Concern for the child and the impact of the child's health on his or her everyday life and the parents' work and education were more often reported in target families than in term controls. Compared to term families, more parents in the BPD group felt that the child's health affected the pasttimes of other family members. To the families concerned, very low birthweight and BPD constitute a significant burden far beyond the neonatal period. Validated scales for the assessment of their quality of life are needed to develop supportive measures and to evaluate the effects of such interventions.

Grief and social support after the death of a spouse

The death of a spouse is one of the most stressful events in a person's life. Social support has been shown to be widely beneficial in moderating the effects of both chronic and acute stress. The answers of Finnish widows and widowers (n=318) were analysed in order to investigate the sources of social support, what is the nature of support received, and whether social support is connected with coping with grief. The Hogan Grief Reactions Checklist was used to describe the grief as well as answers to open-ended questions about what helped the widowed persons cope with their grief. Kahn's theory of social support was used as a framework in the content analysis of the open-ended answers. The results showed that Finnish widows and widowers receive social support most often from their own family and friends. They perceived the received support most helpful, but also the support that the grieving person can give to other family members is seen as important. Results suggest that those who had had social support were able to grieve by allowing themselves to disorganize and experience panic behaviour.

The GPIIIa Pl(A) polymorphism in the progression of abdominal aortic atherosclerosis

Glycoprotein IIIa is expressed in platelets as part of the fibrinogen receptor and also in vascular endothelium where it mediates smooth muscle cell proliferation. The association between the glycoprotein GPIIIa Pl(A) polymorphism and the stage of atherosclerosis in the abdominal aorta was studied in a prospective autopsy study series of 300 middle-aged men (33-69 years). The Pl(A) genotype was determined by RFLP-PCR. The stage of atherosclerosis in the abdominal aorta was determined by computer-assisted morphometry. Elevated, fibrous lesions were more frequently (P=0.05) found in the abdominal aortas of men with the Pl(A1) homozygous genotype compared to men with the A2 allele (OR 2.3; 95% CI 0.99-5.2). The area of complicated lesions was significantly greater in men with Pl(A2)-positive genotypes compared to A1 homozygotes. The association with complicated lesions was especially strong in men over 60 (P=0.002). These results suggest that Pl(A) polymorphism is involved in the progression of atherosclerosis in the abdominal aorta. The association of men possessing the Pl(A2) allele with slower development of fibrous lesions and with greater area of complicated lesions in the abdominal aorta may result from genotypic differences in the smooth muscle cell proliferation after slight injuries to the endothelium mediated by glycoprotein IIIa or from genotypic differences in platelet fibrinogen binding or both.

Quality specifications for ordinal scale measurements with multiproperty (multiple) urine test strips

Analytical quality specifications for ordinal scale measurements have not been presented so far. Criteria are suggested for multiproperty (multiple) urine test strips based on upper limits of healthy reference intervals, analytical performance and statistical tests applicable to ordinal scales. Trueness (accuracy) can be evaluated against an acceptable comparison method by applying sensitivity and specificity concepts, and defining a grey zone with a lower detection limit and an upper confirmation limit. Concordance (agreement) of two or more ordinal scale categories should be evaluated by subtracting random agreement, using Kappa statistics. Repeatability (precision) can be calculated for categorized results using binomial statistics.

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.

Prognostic factors in controlled ovarian hyperstimulation

OBJECTIVE

To determine whether the number of retrieved oocytes and the required amount of gonadotropins per oocyte in IVF treatment can be predicted with use of the following independent predictive variables: age, parity, cause of infertility, body mass index, day 3-5 FSH, E2, inhibin B, ovarian volume, the number of follicles, and intraovarian and uterine artery vascular resistance measured by ultrasonography before ovarian hyperstimulation.

DESIGN

A retrospective analysis.

SETTING

University hospital infertility clinic.

PATIENT(S)

Seventy-four consecutive women attending the university hospital infertility clinic for IVF treatment.

INTERVENTION(S)

The investigated factors were measured on day 3-5 of the cycle, in which luteal phase suppression was begun before ovarian hyperstimulation preparatory to IVF.

MAIN OUTCOME MEASURE(S)

The amount of gonadotropins required per oocyte and the number of retrieved oocytes were correlated with the predictive factors in stepwise regression analysis.

RESULT(S)

The best predictive factors for the number of oocytes retrieved were FSH, inhibin B, and parity, explaining 25% of the ovarian response. Intraovarian vascular resistance, parity, FSH, and inhibin B best predicted the amount of gonadotropins needed, explaining 44% of the variation.

CONCLUSION(S)

FSH, inhibin B, and parity were the independent predictive factors for the number of retrieved oocytes. The same factors and intraovarian vascular resistance predicted the required amount of gonadotropins per oocyte. The main part of the ovarian response cannot be predicted using the factors investigated.

Expression of HSP-65 in jejunal epithelial cells in patients clinically suspected of coeliac disease

BACKGROUND

Coeliac disease (CD) can be classified both clinically and biologically an autoimmune disease. A close relationship obtains between heat shock proteins (HSPs) and numerous autoimmune diseases. HSPs are overexpressed when protecting the host against environmental insult. We sought here to establish whether dietary gluten is such a stress stimulus in patients clinically suspected of CD, and whether the expression of HSP-65 associates with densities of intraepithelial gammadelta+ T cells and/or with expression of mucosal HLA-DR.

METHODS

Seventy-eight children with clinical suspicion of CD underwent a jejunal biopsy. Monoclonal antibodies were used to stain jejunal epithelial HSP-65, intraepithelial lymphocytes and mucosal HLA-DR. Serum IgA-class endomysial autoantibodies (EMA) were measured by an indirect immunofluorescence method. CD susceptibility HLA DQA1*0501 and DQB1*0201 alleles (HLA DQ2) were determined.

RESULTS

Enhanced expression of epithelial cell mitochondrial HSP-65 was found in 80% (16/20) of coeliacs and in 24% (14/58) of children excluded for the disease, but in only 7% (2/28) of control subjects (p < 0.001, p = 0.049, respectively). Children with enhanced expression of HSP-65 had significantly higher gammadelta+ T cell densities than those with normal HSP-65 expression. A clear association between HSP-65 and serum IgA-class EMA were also ascertained in patients with normal jejunal mucosal morphology. HLA DQ2 positivity did not correlate with the HSP-65 expression.

CONCLUSIONS

Gluten might be an environmental insult not only in CD patients but also in some patients excluded for the disease on biopsy. Enhanced expression of epithelial cell stress proteins might be an indicator of such an insult.

Glycoprotein IIIa Pl(A) polymorphism associates with progression of coronary artery disease and with myocardial infarction in an autopsy series of middle-aged men who died suddenly

Glycoprotein IIIa (GPIIIa) has a key role in the aggregation of thrombocytes, and it also mediates intimal hyperplasia after endothelial injuries; the possible association of the Pl(A1/A2) polymorphism of the gene for GPIIIa with coronary thrombosis and with the progression of coronary artery disease (CAD) is still to be confirmed. Therefore, the association of the Pl(A) polymorphism with the development of coronary atherosclerosis, coronary narrowing, and myocardial infarction (MI) was studied in a prospective, consecutive autopsy series of 300 middle-aged, white Finnish men (33 to 69 years) suffering sudden out-of-hospital or violent death. Coronary atherosclerosis was measured morphometrically and the coronary stenosis percentage determined from a cast rubber model of the coronary tree. We found a significant inverse relation (P=0.01) between the Pl(A2)-positive genotype and coronary artery stenosis. The frequency of possessing the Pl(A2) allele was significantly (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.22 to 0.98) lower among men with >50% coronary stenosis (18.3%) than among those with <25% stenosis (32.9%). Although the Pl(A) polymorphism was not directly associated with MI, the Pl(A2) allele was present in 11 of the 22 men (50%) with MI and coronary thrombosis (OR 6.6, 95% CI 2.1 to 22.8) but in only 6 of the 47 (12.8%) with MI associated with severe stenosis in the absence of thrombosis. In line with this result, men possessing the Pl(A2) allele also had a larger area of fissured and ulcerated complicated lesions in their coronary arteries (P<0.05). The present results suggest that the Pl(A) polymorphism is involved in the development of CAD and MI. Men with the Pl(A2) allele may harbor more thin-walled, vulnerable coronary plaques, plaques prone to rupture, leading to massive, fatal thrombosis. In contrast, men homozygous for the Pl(A1) allele may more often show stable plaques and present with infarction caused by progressive coronary stenosis.

Patients' fears in coronary arteriography

This study was concerned with the objects of fear and the intensity of fears related to coronary arteriography (CA) in 378 patients scheduled for coronary arteriography at a university hospital. Intensity of fear was measured on a 10-point Likert-type scale which listed 26 objects of fear. The patients were asked to assess the intensity of their fears both before and after CA. The results showed that the intensity of fear varied depending upon the object of fear. The highest intensity was recorded for fear of coronary artery bypass surgery. A significant increase was found in fear of lying flat in bed after CA and fear of not receiving social support. Fears of uncertainty about the illness, the CA procedure, results of CA, pain, coronary artery bypass surgery and coronary angioplasty decreased significantly after CA. Significant associations were found between objects of fear and patient demographics. It is concluded that patients' fears should be assessed individually both before and after CA. Special attention should be paid to the fears of women, patients under 45 years, upper and lower level employees and the unemployed.

Chlamydial antibodies in an elderly Finnish population

The characteristic feature of Chlamydia is its tendency to cause chronic infections. It has been hypothesized that prior exposure to C. pneumoniae may lead to chronic infection and the development of associated chronic cardiopulmonary disease. Few studies have so far addressed the occurrence of chlamydial antibodies in an elderly, unselected population. This information is important for the development of possible treatment strategies. Chlamydial antibodies were analysed from 1179 serum samples obtained from 481 men and 698 women, aged 64 y and over, who participated in an epidemiological survey carried out in a Finnish rural district. Specific IgG and IgA antibodies were measured by the microimmunofluorescence (micro-IF) test. The criterion for seropositivity was defined as a titre of > or =32 for both IgG and IgA, independently of each other. C. pneumoniae IgG antibodies occurred in 91% of the men and 75% of the women. The respective figures for C. pneumoniae IgA antibodies were 57% and 28%. The geometric mean titres (GMT) rose with increasing age and were higher in men than in women. The prevalences of C. trachomatis IgG antibodies were 13% in men and 18% in women, and for IgA antibodies, 2% and 1%, respectively. C. psittaci antibodies were rare. Only 3% of the men and women were IgG seropositive, whereas the respective figures for IgA seropositivity were 0.4% and 0.1%. C. pneumoniae antibodies indicative of recurrent or chronic infection were common in the elderly. The geometric mean titres correlated positively with age and were higher in men than in women. Other chlamydial antibodies occurred in low titres.

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.

Increased density of jejunal gammadelta+ T cells in patients having normal mucosa--marker of operative autoimmune mechanisms?

Both from a clinical and a biological point of view, coeliac disease can be classified among the autoimmune diseases, or one could suspect autoimmune mechanisms to be operative in the disease. The aim of the present study was to find evidence for mucosal markers of coeliac disease latency in patients clinically suspected but on routine biopsy excluded for the disease. Monoclonal antibodies were used to stain jejunal intraepithelial lymphocytes and mucosal HLA-DR. Serum IgA-class reticulin autoantibodies were measured by an indirect immunofluorescence and gliadin antibodies by an enzyme-linked immunosorbent assay method. The DQA1*0501 and DQB1*0201 alleles were determined. Twenty-seven of 107 consecutive patients had coeliac disease. Altogether 39 of 79 (49%) children with normal jejunal mucosa had an increased density of intraepithelial gammadelta+ T cells (> or = 4.4 cells/mm). IgA-class reticulin autoantibodies were positive in 18 (23%) of the children excluded for coeliac disease. The antibody positivity was mostly seen in patients carrying the DQAI 0501 and DQB1*0201 alleles. Also, reticulin autoantibody-positive children having normal jejunal mucosal morphology had significantly higher densities of intraepithelial gammadelta+ T cells than antibody negative ones. On 1.5-4.5 year follow-up four out of 18 (22%) children primarily excluded for coeliac disease showed mucosal deterioration and coeliac disease. Many patients clinically suspected of coeliac disease but having normal jejunal mucosa show markers of coeliac disease latency which may be gluten-induced indicating autoimmune mechanisms to be operative in the gut.

Growth of prepubertal children with juvenile chronic arthritis

The height and height velocity standard deviation scores (HSDS and HVSDS) of 64 prepubertal children with mild to moderate chronic arthritis were calculated at the time of diagnosis and then annually during treatment and follow-up of 4 y. Preceding the diagnosis, children with chronic arthritis were as a group slightly taller than their healthy peers. During the year before the diagnosis they had grown faster than their peers. During the first year of treatment their growth velocity decreased (change in the mean HVSDS from +0.63 to -0.52), but during further follow-up it returned to the pretreatment level (the mean HVSDS being +0.53 four years after the diagnosis). The growth was influenced more by polyarticular than by pauciarticular disease. The cumulative total dose of glucocorticosteroids did not have statistically significant influence on growth. In conclusion, growth retardation in prepubertal children with chronic arthritis was seen following the diagnosis and initiation of treatment, more so in polyarticular disease. During further follow-up, growth velocity increased. This reflected the growth promoting effect of inflammatory process control.

Quality control in health care: an experiment in radiotherapy planning for breast cancer patients after mastectomy

PURPOSE

The importance of evaluating and improving quality in clinical practice is now generally acknowledged. In this study we estimated different sources of variation in radiotherapy planning for breast cancer patients after mastectomy and sought to test the applicability of a reproducibility and repeatability (R&R) study in a clinical context.

METHODS

Eleven radiation oncologists planned radiotherapy three times for three different kinds of breast cancer patients without knowing they were handling the same patient three times. Variation was divided into different components: physicians as operators, patients as parts, and repeated measurements as trials. Variation due to difference across trials (repeatability), that across the physicians (reproducibility), and that across the patients (variability) were estimated, as well as interactions between physicians and patients. Calculation was based on the sum of squares, and analysis was supported by various graphical presentations such as range charts and box plots.

RESULTS

Some parts of the planning process were characterized by higher and different kinds of variation than the others. Interphysician variation (i.e., reproducibility) was not high but there were some clearly outlying physicians. The highest variation was in repeatability (= intraphysician variation). The major part of the variation was, however, that from patient to patient: 33% of the total in Parameter 1 and 85% of the total in Parameter 2.

CONCLUSIONS

R&R studies are applicable and are needed to evaluate and improve quality in clinical practice. This kind of analysis provides opportunities to establish which kinds of patients require particularly careful attention, which points in the process are most critical for variation, which are the most difficult aspects for each physician and call for more careful description in documents, and which physicians need further training.

Changing jejunal gamma delta T cell receptor (TCR)-bearing intraepithelial lymphocyte density in coeliac disease

The function of jejunal intraepithelial gamma delta+ T cells is obscure, but they are commonly implicated as playing a role in inflammatory and autoimmune conditions. In coeliac disease (CoD), there are controversial reports as to gluten dependency of these cells. We have now studied the small bowel mucosal intraepithelial T cell densities, and the ratios of gamma delta+ to CD3+ T cells and gamma delta+ to alpha beta+ T cells during early disease development and on a gluten-free diet. Nine children initially excluded for CoD were followed up and rebiopsy after 0.8-4.5 years showed mucosal deterioration. Further, 21 biopsy specimens from newly diagnosed CoD patients were studied, together with 20 specimens taken from children on a gluten-free diet. During CoD development the density of gamma delta+ and alpha beta+ T cells as well as the ratios of gamma delta+ to CD3+ T cells and gamma delta+ to alpha beta+ T cells increased. In the latent stage of CoD when the small bowel mucosal architecture was still normal, two children had clearly normal densities of gamma delta+ (< 2.5 cells/100 epithelial cells) and alpha beta+ (< 25.0 cells/100 epithelial cells) T cells, and low ratios as well. In patients with newly diagnosed CoD the densities decreased significantly on a long-term gluten-free diet. We conclude that the density of intraepithelial gamma delta+ T cells as well as alphabeta+ T cells in CoD is gluten-dependent. CoD can develop in a child ingesting normal amounts of gluten and having normal jejunal mucosal morphology on biopsy and a normal density of gamma delta+ T cells.

Opsonising immunoglobulins and mannan-binding lectin in chronic lymphocytic leukemia

We investigated the influence of plasma concentrations of immunoglobulin G (IgG), IgA, IgM, IgG subclasses and mannan-binding lectin (MBL) on susceptibility to infection in patients with chronic lymphocytic leukemia (CLL). Of 28 patients with CLL, increased susceptibility to infection was recorded in nine. Four of them (44%) had hypogammaglobulinemia as opposed to only one (5%) of the 19 patients without increased susceptibility to infection (OR 14.4; 95% CI, 1.6-130). When the effect of IgG subclasses contributing to hypogammaglobulinemia was studied, only the decreased concentrations of IgG4 and IgG2 were associated with increased susceptibility to infection. They, in turn, were intercorrelated and also highly correlated with the concentration of IgA. In fact, when these parameters were studied by a multivariable model, only the decreased concentration of IgA was shown as an independent risk factor for infection (P = 0.03). The mean concentration of MBL was significantly higher in patients with infections than in those without (6.54 mg/l and 2.75 mg/l, respectively; P = 0.001). The monitoring of its concentrations might be useful in the follow-up of infectious morbidity in CLL.

Pain and somatosensory dysfunction in acute herpes zoster

OBJECTIVE

To determine the nature of sensory change and its association with pain and allodynia in acute herpes zoster.

DESIGN

Prospective clinical study.

PATIENTS

One hundred thirteen immunocompetent patients with acute herpes zoster.

METHODS

Onset, intensity, and quality of pain and severity of rash were recorded. Quantitative somatosensory testing for tactile and thermal thresholds, qualitative pinprick testing, and testing of dynamic and static allodynia were performed within the affected dermatome, its mirror-image dermatome, and in an adjacent dermatome bilaterally.

RESULTS

Acute pain was reported as severe in 50%, moderate in 29%, mild in 12%, and absent in 9% of patients. Preherpetic pain (median = 4 days, range = 1-60 days) was experienced by 71%. Mechanical allodynia, dynamic, static, or both, was found in 37% of patients and was noted to extend one or more dermatomes outside the rash in 12%. In the affected dermatomes, thresholds were elevated for warmth and cold, lowered for heat pain, and unchanged for touch when compared with the contralateral side. Logistic regression analyses showed that compression-evoked allodynia, brush-evoked allodynia, and the history of preherpetic pain were more frequently encountered in patients with severe pain. Sensory threshold changes were not associated with the severity of pain or rash or with the presence of allodynia.

CONCLUSION

Pain, allodynia, and altered sensation are common features of acute herpes zoster. They are likely to result primarily from widespread neural inflammation within the affected afferent system. The sensory changes found in acute herpes zoster are different from those reported in published studies on postherpetic neuralgia and suggest sensitization phenomena and preservation of tactile functions rather than major neural damage. The exact mechanisms for acute herpes zoster pain, however, remain speculative.

Retinopathy is independently related to microalbuminuria in type 2 diabetes mellitus

AIM, SUBJECTS AND METHODS: To evaluate whether microalbuminuria is related to retinopathy in type 2 diabetes, we studied a sample of 125 known diabetic subjects with a mean disease duration of 11 years (range 5-22 years), aged 46-71 years, by ophthalmoscopy, fundus photography and fluoresceine angiography. Urinary albumin excretion rate (UAER) was measured by nephelometry and the fractional clearance of albumin, i.e. in relation to creatinine was calculated from spot samples. The subjects were classified into groups based on the UAER/24 h.

RESULTS

Microalbuminuria was present if UAER was 30-300 mg/24 h and overt nephropathy when UAER > or = 300 mg/24 h. Background (> or = 2 microaneurysms or > or = 2 hemorrhages or > or = 1 more advanced lesions, except proliferative changes) and proliferative retinopathies were found in 21% and in 3%, respectively. Subjects with microalbuminuria (p = 0.026) and overt nephropathy (p = 0.002) had more frequently background retinopathy than their counterparts with a normal UAER (chi2-test). A multivariate logistic regression model was obtained for background retinopathy (chi2 = 37.5, p = 0.0000039, OR 14.9, correct prediction of negative outcome in 97% and of positive outcome in 30.4%) including the following variables. The fractional clearance of albumin independently explained background retinopathy (OR 3.9, 95% CI 1.3-12, p = 0.028). Insulin therapy (p = 0.0017), diabetes duration (p = 0.048), blood glucose at 2 h in standard oral glucose tolerance test (p = 0.009) and low fasting serum HDL cholesterol (p = 0.023) also independently explained retinopathy. Age, gender, BMI, systolic blood pressure, ACE inhibitor therapy, fasting serum total cholesterol and triglyceride, blood glucose or insulin, hemoglobin A1c, glucagon-stimulated C peptide response, glomerular filtration rate or smoking habits did not independently explain retinopathy.

CONCLUSION

We conclude that microalbuminuria is related to background retinopathy in type 2 diabetes.

The significance of IgG subclasses and mannan-binding lectin (MBL) for susceptibility to infection in apparently healthy adults with IgA deficiency

The aim of this study was to investigate the significance of IgG subclasses and MBL for susceptibility to infection in association with IgA deficiency. The study population consisted of 139 apparently healthy adult blood donors with IgA deficiency and normal serum levels of IgG and IgM, and an increased susceptibility to infection demonstrated at a population level. Additionally, 216 controls matched for age and sex were investigated. IgG4 deficiency was more common and the mean level of IgG4 lower in persons with IgA deficiency than in the controls. No significant associations could be demonstrated between overt IgG subclass deficiencies and increased susceptibility to infection. However, when the mean concentrations of IgG subclasses were analysed with regard to medical history, that of IgG1 was lower in persons who reported recurrent viral respiratory infections, that of IgG3 in persons who had episodes of severe infection in their history, and that of IgG4 in persons who had recurrent mild respiratory infections, compared with those who had no particular history of infections. In contrast, MBL deficiency-alone or combined with that of the IgG subclass-was not associated with increased susceptibility to infection in persons with IgA deficiency. The results indicate that the proneness to infections observed in a population of otherwise healthy persons with IgA deficiency can only for a small part be accounted for by concomitant deficiencies of IgG subclasses. Contrary to expectations, no synergism between the deficiencies of IgA and MBL could be demonstrated.

Orthostatic hypotension and cognitive decline in older people

OBJECTIVES

To establish the role of orthostatic hypotension (OH) as a risk factor for cognitive decline among home-dwelling and institutionalized older people and to describe other predictors of cognitive decline.

DESIGN

Follow-up study with two clinical examinations.

SETTING

A community-based setting in northern Finland.

PARTICIPANTS

All of the 1159 people aged 70 or more living in five rural municipalities around the town of Oulu in Northern Finland in 1991. At the time of the follow-up examination, 2.5 years later, 884 of the original participants were alive and 651 were re-examined.

MEASUREMENTS

In 1991, 907 people (78.3% of the total population) were tested for orthostatic hypotension, and their cognitive capacity was assessed with the Mini-Mental State Examination (MMSE). The calculation/spelling tasks were excluded from the final version used in the statistical analysis. The re-assessment of cognitive capacity was made on 651 subjects (73.6% of those alive) who had participated in the first examination. The data were analyzed using polychotomous and linear regression analysis models.

RESULTS

The prevalence of OH was 28.7%, with no age or sex differences. The mean sum score for the shortened MMSE in 1991 was 21.6 (+/-3.98) for persons with OH and 21.1 (+/-4.08) for non-OH persons. During the follow-up, the sum score declined in the OH group by .44 (+/-2.81) points and in the non-OH group by .83 (+/-3.61) points. No type of OH (systolic or diastolic 1- or 3-minute values or their combination) predicted cognitive decline; the only predictors were old age and low level of formal education.

CONCLUSIONS

Orthostatic hypotension is a common clinical condition that affects every fourth person aged 70 years or older. By temporarily inducing cerebral hypoperfusion, it may cause or exacerbate cognitive dysfunction. In an unselected population, OH was not associated with cognitive deterioration, nor did it predict cognitive decline during a 2-year follow-up.

Frequency and risk factors in bronchopulmonary dysplasia in a cohort of very low birth weight infants

Frequency and perinatal risk factors in bronchopulmonary dysplasia (BPD) were retrospectively evaluated in a cohort of 242 infants with birth weights less than 1501 g born in one hospital in 1990-1994. At 28 days' postnatal age, 30.7% (59/192) of the infants alive received oxygen supplementation and showed typical radiological changes in chest X-rays. At 36 weeks' corrected gestation, 13.0% (24/184) of the survivors fulfilled these criteria. In multivariate analysis, low birth weight and gestational age, male sex, packed red cell infusions and long duration of ventilator therapy were correlated with an increased risk of BPD at 28 days' postnatal age. Only 49% of the infants with BPD had had respiratory distress syndrome, and 49% of them recovered from BPD by 36 weeks' corrected gestational age. Preeclampsia, low birth weight, rapid birth weight recovery, packed red cell infusions, long duration of ventilator therapy, patent ductus arteriosus and hyperoxia were associated with BPD beyond 36 weeks' corrected gestation. No infant born small for gestational age recovered from BPD before 36 weeks' corrected gestation. The frequency of BPD at 28 days' postnatal age seems to be increasing, but half of the patients recover before term. Factors other than respiratory distress syndrome, especially small birth weight, early weight gain and possibly intrauterine growth retardation are becoming more important risk factors of BPD beyond 36 weeks' corrected gestation.

Social support provided by public health nurses and the coping of first-time mothers with child care

The purpose of this study was to look at the factors related to the first-time mother's coping with child care when her child is 3 months old. This study is part of an extensive longitudinal project in which the development of mothering skills of first-time mothers was followed up for 8 months postpartum. The data were collected with a questionnaire between March and September 1995, in a sample of 271 first-time mothers. The mothers filled in the questionnaire when their babies were 3 months old. Coping with child care was assessed using Spearman correlation coefficient and stepwise regression analysis. Positive correlation was found between the mother's competence, attachment to the child, health, depression, relationship with the spouse, sense of isolation and role restriction, and the mother's coping with child care. The strongest correlation existed between the mother's competence and her coping. Positive correlation was also found between the child's mood, demandingness and acceptability, and the mother's coping with child care, with the child's demandingness having the strongest correlation. Positive correlation was again found between social support--the average functional support the mother received from her own social network, plus affect, affirmation, and aid from the public health nurses--and the mother's coping with child care. The predictors included in the multivariate method were the mother's competence, health, depression, and attachment to her child; the child's mood and ease or difficulty of care; and the affect and affirmation from the public health nurse. The results show that the first-time mother's coping with child care, when the child is 3 months old, is affected by the characteristics of both mother and child, as well as by the social support received from their social network and from the public health nurses at the child welfare clinic.

Cranio-caudal differences in granulation tissue formation: an experimental study in the rat

This study examined potential regional differences in the deposition of granulation tissue in cellulose sponges placed in the dorsum of rats. Four cellulose sponge implants, 10 x 10 x 5 mm in size, two in cranial and two in caudal positions, were used to induce granulation tissue formation in the back of the rat. A cranio-caudal difference in connective tissue formation was assessed from 1 to 24 weeks after implantation. Granulation tissue ingrowth, measured histomorphometrically, was enhanced at 2 weeks and the surrounding capsule was thinner from 1 to 3 weeks in implants located in the cranial part of the back. In the cranial position, the number of fibroblasts, assessed semiquantitatively, was higher and the ratio of inflammatory cells to fibroblasts lower at 2-3 weeks. Also, the ratio of hydroxyproline content to total nitrogen content was higher after the first week in cranial specimens. Thus, a distinct cranio-caudal difference in the proliferative phase was observed. These results show the obvious practical considerations underlying the need for randomization or comparison between implants from exactly corresponding cranio-caudal locations.

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.

A new visual performance test offers new variables for assessing daytime vigilance: short pauses in performance

A new visual performance test, VigiMouse, was evaluated with the aid of 6 volunteering pediatry residents. The results were compared with a visual analogue scale in differentiating four different states: mild sleep deprivation, low blood alcohol level, a combination of both, and the normal state. A normal night shift at a busy pediatric ward was chosen to represent sleep deprivation. A new set of parameters based on short pauses in performance proved to be more sensitive in detecting small changes in performance than parameters based on reaction times.

Head injuries and cognitive decline among older adults: a population-based study

OBJECTIVE

To examine the relationship between minor and major head injuries caused by fall accidents and cognitive decline among a cohort of adults age 70 years or older (n = 588).

BACKGROUND

Even a mild brain injury may affect cognitive functions. Among older adults, results from case-control studies suggest that the occurrence of head injury is positively associated with the onset of AD.

METHODS

The shortened version of the Mini-Mental State Examination (sMMSE) was performed and a set of demographic and clinical variables were collected at the beginning of the study. All falls were recorded during a period of 2.5 years, after which the sMMSE tests were repeated. The risk of falls causing head injury in terms of a defined cognitive decline was examined during another follow-up period of approximately 2.5 years.

RESULTS

There was no association between the occurrence of minor head injuries and decline in sMMSE scores. A positive relationship existed between the occurrence of major head injuries and a decline in sMMSE scores. The risk of cognitive decline increased linearly as higher cut-off points were used to define the decline in sMMSE scores-with relative risks (95% CI) of 0.94 (0.47 to 1.90), 1.35 (0.64 to 2.85), 1.75 (0.78 to 3.91), 2.38 (1.02 to 5.52), and 3.72 (1.64 to 8.44)-for a decline of > or =1, > or =2, > or =3, > or =4, and > or =5 points in the sMMSE score. The high risk remained unchanged after adjustment for other potential factors contributing to cognitive decline or dementia. The risk factors associated with falls causing major head injury during the second follow-up period were high age, OR (95% CI) 3.58 (1.87 to 6.85); use of psychotropic medication, 2.04 (1.09 to 3.83); diagnosis of hypertension, 1.80 (0.96 to 3.37); and decline in sMMSE score of >5 points, 2.41 (0.86 to 6.76).

CONCLUSIONS

Our results suggest that the occurrence of major head injury increases the risk of cognitive decline. The cause of cognitive decline may be dementia, but this assumption remains to be elucidated in future studies.

Relationships between family dynamics of Finnish child-rearing families, factors causing strain and received support

The aim of this study was to determine the relationships between family dynamics, the factors causing strain on child-rearing parents and the support available to families from public health nurses. Family dynamics was defined as the family's unique way of functioning and was conceptualized by means of six different dimensions. Questionnaires were sent to 118 families, and of these 85 mothers and 79 fathers participated in the study. According to the findings the majority of parents involved in bringing up children aged 3-4 years assessed their families to be well-functioning. There was a correlation between a low level of factors causing strain on the family and a positive evaluation of family dynamics based on the various dimensions. According to the mothers the support, i.e. emotional, appraisal and instrumental support, received from public health nurses, along with a small number of strain-causing factors on the partner relationship, correlated well with their positive assessments of the mutuality and flexibility of their families.

Gender differences in fears related to coronary arteriography

OBJECTIVE

To compare levels of fear and the intensity of specific fears in women and men related to coronary arteriography (CA).

DESIGN

Prospective survey.

SETTING

A 1360-bed university hospital. Data were collected before, during, and after CA, and again 6 months later.

SUBJECTS

The sample consisted of 54 women and 166 men undergoing scheduled CA.

METHODS

To compare fear levels at different points of evaluation; two analyses of covariance for repeated measures were performed.

RESULTS

On average, women had significantly higher mean scores of fear across the points of evaluation on the Visual Analogue Scale than men (P <.001). During the hospital stay, the most intense fear for both women and men was the fear of coronary artery bypass grafting and the uncertainty about the illness, whereas at home it was the fear of myocardial infarction. On average, women reported significantly intense fears more frequently than men across time. On average, men experienced more intensive fear of problems in their sex life than women (P =. 032). The changes in intensity of fears over time were not significantly different by gender, except in fear of pain (P =.013), health care staff not having enough time to care for the patient (P =.039), and health care staff discussing the patient's condition without the patient being present (P =.048). Age and prior CA were found to be significantly related to most of the fears at different points of evaluation, and to the changes of fears over time.

CONCLUSION

There existed differences in the tendency to report intensity of fears by gender; however, the intensity of fears changed in a similar way over time. The results suggest that the few gender differences in fears that existed may be explained by the treatment chosen for the patients and the patients' acceptance of it. Therefore, it is important to adapt information and support according to the treatment chosen for the patient.

Factors related to successful breast feeding by first-time mothers when the child is 3 months old

The aim of the reported study was to gain information on those factors which contribute to the success of breast feeding in first-time mothers when the child is 3 months old. The study is part of a wider longitudinal project which follows-up the growth to motherhood of first-time mothers in Finland over a period of 8 months postpartum. Data collection was by questionnaires distributed between March and September 1995. The sample comprised 271 first-time mothers. The mothers completed the questionnaires when their infants were 3 months old. The analysis applied was a polychotomic logistic regression analysis. When the child was 3 months old those mothers who perceived themselves competent as mothers and who felt that society appreciated motherhood appropriately coped better with breast feeding. Also, those mothers who had worked at home prior to the birth of the child and who felt that breast feeding was important in motherhood coped better with breast feeding. Those mothers whose state of mind was more balanced after the birth coped better with breast feeding. The more affirmation the mother received from members of her social network the better she coped with breast feeding. The research findings suggest that factors influencing successful breast feeding in first-time mothers at 3 months postpartum are the mother's own resources and attitude to breast feeding, support from the social network and the current appreciation of breast feeding in society.

Dopexamine unloads the impaired right ventricle better than iloprost, a prostacyclin analog, after coronary artery surgery

OBJECTIVE

To evaluate the ventricle-unloading properties of dopexamine and iloprost and to compare their effects on right ventricular (RV) function and oxygen transport in patients with low RV ejection fraction (RVEF) after cardiac surgery.

DESIGN

A prospective, randomized, double-blind, cross-over, clinical study.

SETTING

University hospital.

PARTICIPANTS

Twenty patients with proximal total stenosis of the right coronary artery studied immediately after coronary artery surgery.

INTERVENTIONS

Treatment drugs were administered in a random order in doses equipotent with respect to cardiac output response. Infusion rates were increased stepwise to induce a 25% increase in cardiac index. A washout period of 60 minutes was allowed between treatments.

MEASUREMENTS AND MAIN RESULTS

Central hemodynamics, RV function assessed by the EF (fast-response thermodilution), end-systolic and end-diastolic volumes, and systemic oxygenation were measured before and after the first drug, after the washout period, and after the second drug. Central filling pressures remained constant during treatments. Both drugs decreased pulmonary vascular resistance index, but iloprost was more effective (p < 0.05). Iloprost decreased mean arterial and pulmonary artery pressure, which were unaffected by dopexamine. Dopexamine increased EF significantly more than iloprost (p < 0.001). End-systolic volume index decreased subsequent to dopexamine only (p < 0.001). Iloprost increased intrapulmonary shunt more than dopexamine (p < 0.001). Changes in oxygen delivery, consumption, and extraction were similar.

CONCLUSION

The findings suggest that dopexamine is more effective than iloprost for support and unloading of the postoperatively disturbed RV in terms of RVEF and end-systolic volume. The reduction of pulmonary vascular resistance after administration of iloprost without a decrease in end-systolic volume might not be considered a reduction of RV afterload. Iloprost increases the pulmonary shunt fraction, however, more than dopexamine, indicating a more prominent vasodilator effect.

Increase in paediatric acute otitis media diagnosed by primary care in two Finnish municipalities--1994-5 versus 1978-9

In recent decades, several epidemiological studies have been published on acute otitis media (AOM), indicating that the occurrence of AOM is increasing. However, the comparison between the surveys is complicated and biased by several factors, e.g. variable study demography and design and dissimilar diagnostic criteria. The present study was performed with an identical set-up in 1978-9 and 1994-5 to find out potential changes in the occurrence of AOM. All the attacks of AOM among children under 10 years diagnosed by a physician during the 12-month periods 1 June, 1978 to 31 May 1979 and 1 June 1994 to 31 May 1995 were registered retrospectively in two Finnish municipalities. The incidence rate (total number of AOM attacks per 100 child years) was 19 (95% CI 18-21) in 1978-9 and 32 (95% CI 30-34) in 1994-5. The increase in the occurrence of AOM was 68% (95% CI 53-79%, P < 0001).

Nurses' ability to perceive patients' fears related to coronary arteriography

This study describes the congruence of the perceptions of 180 patient-nurse dyads concerning patients' fears related to coronary arteriography (CA). The perceptions were measured with a purpose-designed instrument which listed 26 objects of fear. t-Tests and chi-square tests were used to compare the responses and the associations with demographic data. The results pointed to inconsistencies between patients' and nurses' perceptions. Nurses and patients had congruent perceptions of the 10 most intense fears related to CA. Otherwise nurses tended to overestimate patients' fears. Nurses' perceptions of the intensity of individual patients' fears were incongruent so that before CA there was a tendency to overestimate the intensity of fears and after CA to underestimate it. The results suggest that nurses need to pay more attention to the assessment of individual patients' fears and to avoid stereotypical views of patient fears. The use of an assessment instrument is recommended as one way of enhancing the quality of care.

Prevalence of coronary heart disease, associated manifestations and electrocardiographic findings in elderly Finns

OBJECTIVE

to study the prevalence of coronary heart disease (CHD) and its clinical manifestations among Finnish elderly people in a cross-sectional epidemiological survey in the rural district of Lieto, southwestern Finland, with special emphasis on the overlap of CHD manifestations with electrocardiogram (ECG) findings and factors associated with CHD.

DESIGN

observational population-based study.

SETTING

Health Centre in Lieto, Finland, 1990-91.

SUBJECTS

488 men and 708 women aged 64-97 years.

MAIN OUTCOME MEASURES

angina pectoris (AP) and dyspnoea were recorded using the London School of Hygiene cardiovascular questionnaires. Resting ECG findings were analysed and coded. Minnesota codes 1.1-1.3, 4.1-4.4, 5.1-5.3 or 7.1 were interpreted as ischaemic. The medical history of cardiovascular diseases was based on medical records.

RESULTS

the prevalence of AP was 9.1% [95% confidence interval (CI): 6.7-12.0] among men and 4.9% (3.5-6.8) among women. The respective figures for myocardial infarction (MI) were 13.9% (10.9-17.0) and 6.5% (4.8-8.6). Ischaemic ECG findings were common: 32.9% (28.7-37.1) of men and 39.3% (35.7-43.0) of women had such changes, whereas only a minority of them reported typical AP. The total prevalence of CHD, including AP, MI, past coronary artery by-pass operation or angioplasty or ischaemic ECG findings, was 37.7% (33.4-42.0) in men and 42.0% (38.3-45.6) in women. Among men, a higher prevalence of CHD was associated with increasing age [odds ratio (OR) 1.81; 95% .CI: 1.20-2.73] and a history of having smoked in the past (OR 1.66; 1.06-2.59), whereas among women it was associated with increasing age (OR 2.02; 1.48-2.77) and a lower educational level (OR 2.30; 1.37-3.86).

CONCLUSION

the prevalence of CHD among elderly people is high and the clinical picture of the disease is variable. The nature of CHD seems to be less severe among elderly women compared with men. Minor ECG changes, especially in the ST and T segments, are common with ageing and should not necessarily be interpreted as ischaemic. However, these findings combined with atypical chest pain or dyspnoea in an elderly person may indicate the possibility of CHD.

Prerequisites for quality improvement in nursing

AIM

This study examines how the characteristics of nurses, working communities and leadership affect the prerequisites for quality improvement in nursing.

BACKGROUND

Knowledge of the phenomena affecting nurses' action is needed, since quality of care is seen as a result of an individual carer's professional skills, work motivation and commitment to work.

METHODS

Material for the study was collected using a questionnaire. The respondents were 723 nursing practitioners from two special level hospitals. The main instrument used was the Managerial Abilities instrument developed by the researchers.

FINDINGS

The results of the statistical analyses showed that exhaustion experienced by the nurses is the most important obstacle to quality improvement in nursing. The education of nurses, good team work and the ward sister's managerial abilities have a positive influence on quality improvement in nursing.

CONCLUSION

Nurses' exhaustion should be reduced in order to improve quality of care.

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.

Follow-up of asbestosis patients and predictors for radiographic progression

OBJECTIVE

We followed a group of 85 Finnish asbestosis patients radiographically for an average of 6.5 (range 2-10) years to examine the progression of the disease and to assess possible explanations for the progression.

METHODS

The examinations included full-size chest radiographs and a blood specimen analysis. The radiographs were classified according to the 1980 International Labor Office (ILO) classification. Progression was accepted if the second or third radiography was estimated (in a side-by-side comparison) to have more profusion of small opacities qualitatively than the first, even if the radiographs were classified into the same profusion category.

RESULTS

In all, 38% of the patients showed progression during the follow-up period. The average progression of small opacities ranged from ILO 1/1 to ILO 2/2 (0.4 minor ILO categories/year). The asbestosis was progressive more often among the sprayers than among the insulators and asbestos factory workers [cross-tabulation, odds ratio (OR) 5.0, 95% confidence interval (95% CI) 1.2-20]. In the logistic regression model the ILO classification category at the beginning of the follow-up (OR 1.54; 95% CI 0.96-2.47), the fibronectin (OR 1.01; 95% CI 1.00-1.01) and angiotensin-converting enzyme (ACE; OR 1.10; 95% CI 1.00-1.20) levels, and the erythrocyte sedimentation rate (ESR; OR 1.05; 95% CI 1.00-1.10) were statistically associated with the radiographic progression of small opacities. Abnormalities of the pleura were found to progress more often among the patients with progressive parenchymal opacities.

CONCLUSION

For the progression of small-opacity profusion the significant predictors in the logistic regression model were the ILO profusion category at the beginning of the follow-up period, the fibronectin level, the ACE value, and the ESR. The model correctly classified 94% of the patients with progression and 65% of those without progression. The differences in the mean values recorded for the biomarkers between the progressors and nonprogressors, however, were small and may therefore not be of any importance to the clinician.

What contributes to breastfeeding success after childbirth in a maternity ward in Finland?

BACKGROUND

The study objective was to gain information about factors that contribute to the successful establishment of breastfeeding in first-time mothers while they are still in the maternity hospital. The study was part of a wider longitudinal project that examined the development of first-time mothers into motherhood during eight months after the birth.

METHODS

Data were collected by a questionnaire distributed between January and May 1995. The sample comprised 326 first-time mothers, who completed the questionnaires on about the fifth day after childbirth. A polychotomic logistic regression analysis was applied.

RESULTS

Mothers who had a positive experience of breastfeeding in the maternity ward and who began lactating 2 to 3 days postpartum coped better with breastfeeding than those whose experience was less positive and who lactated later. Moreover, the greater the emotional (affect) and concrete (aid) support received by the mother from members of her support network, the better she coped with breastfeeding. By contrast, those mothers who were upset while in the maternity ward coped less well with breastfeeding.

CONCLUSIONS

Establishing successful breastfeeding in first-time mothers requires the professional guidance and support of the maternity staff and paying attention to the person closest to the new mother, who in this study was the spouse or father of the child.

Does abstinence from smoking or a transdermal nicotine system influence atracurium-induced neuromuscular block?

The purpose of the present study was to investigate the interaction of chronic smoking and the actions of atracurium (ATR). Twenty nonsmokers (NON-SMOK) were compared with 80 smokers, who were randomized into three groups: 30 patients received 21 mg/d transdermal nicotine system > or = 10 h before fentanyl/thiopental/N2O/O2/isoflurane anesthesia (TD-NICO), whereas the abstinent group received a placebo transdermal system (ABST, n = 30). The TD-NICO and ABST groups refrained from smoking for at least 10 h before the induction of anesthesia. A third group was allowed to smoke until 1-3 h before anesthesia (SMOK, n = 20). Neuromuscular block was monitored using a Relaxograph (Datex, Helsinki, Finland). The electromyographic response was recorded from the first dorsal interosseus muscle of the hand. The inspiratory isoflurane concentration was kept constant at 0.7 vol% in all patients. After an initial bolus dose of 0.5 mg/kg ATR, no significant difference was observed among the groups regarding onset time and maximal neuromuscular block. In Group ABST, the duration of block until 25% recovery of T1 was 48.2 +/- 10.1 min, which was significantly longer (analysis of variance post hoc tests) than in Groups TD-NICO, SMOK, and NON-SMOK (42.7 +/- 7.1, 41.4 +/- 10.4, and 42.8 +/- 7.3 min, respectively). The maintenance dose of ATR in Group ABST (0.23 +/- 0.03 mg x kg(-1) x h(-1)) was smaller than in Groups TD-NICO, SMOK, and NON-SMOK (0.30 +/- 0.07, 0.32 +/- 0.06, and 0.32 +/- 0.05 mg x kg(-1) x h(-1), respectively). We conclude that abstinence from smoking increases the duration of ATR-induced neuromuscular block and reduces the maintenance dose of ATR in smokers. Perioperative use of a transdermal nicotine system prevents these abstinence-induced changes in duration and maintenance-dose.

IMPLICATIONS

The purpose of the present study was to investigate the interaction of chronic smoking and atracurium. Smokers who refrain from smoking for > 10 h require a smaller maintenance dose of atracurium than nonsmokers. However, using a transdermal nicotine system prevents the decrease in maintenance dose during abstinence.

The level of autoantibodies against oxidized LDL is not associated with the presence of coronary heart disease or diabetic kidney disease in patients with non-insulin-dependent diabetes mellitus

Oxidation of low-density lipoprotein (LDL) may be an important factor in the development of diabetic macrovascular and renal complications. The level of autoantibodies against oxidized LDL (oxLDL-Ab) can be used as an index of LDL oxidation in vivo. The purpose of this study was to investigate the association between the level of oxLDL-Ab and the presence of coronary heart disease and renal dysfunction in patients with non-insulin-dependent diabetes mellitus (NIDDM). We determined the plasma levels of oxLDL-Ab in 46 NIDDM patients and 48 well matched nondiabetic control subjects. NIDDM patients had a moderately higher level of oxLDL-Ab than control subjects (0.083 +/- 0.051 vs. 0.062 +/- 0.045, p = 0.04). However, there was no difference in the level of oxLDL-Ab between subjects with and without coronary heart disease, and the level of oxLDL-Ab was not associated with indices of glomerular filtration rate or urinary albumin excretion.

Fear of patients related to coronary arteriography

The purpose of this paper is to describe and evaluate the ability of instruments to produce information about the presence and intensity of fear before, during and after coronary arteriography. Information about patient fear was measured from cognitive, physiological and behavioural dimensions. The sample of the study was 243 patients who were due to have a scheduled coronary arteriography in a university hospital in Finland. Fear was measured by the Visual Analogy Scale (VAS), Hospital Anxiety and Depression (HAD) Scale and State-Trait Anxiety Inventory (STAI). Physiological measurements (blood pressure and heart rate) were obtained. The VAS was given to 46 nurses and seven nurse assistants to measure nurses' perception of patient fear. Over 80% of the patients reported fears. Nurses perceived that the patients had more fears than they reported. Changes in physiological measurements were small but significant. One-third of the patients felt increased fear after the coronary arteriography. VAS, STAI and HAD produced reliable information about the patient fear. The correlations between the instruments suggest that each is a valid and appropriate measure of fear. Nurses need to develop their communication and observation skills in order to develop their recognition of the patients' fear.

Survival of elderly Finns suffering from dysthymic disorder: a community study

The survival of aged Finns suffering from dysthymic disorder (DSM-III criteria) was assessed in two cohorts (60+ yrs and 65+ yrs) in a longitudinal epidemiological study conducted in Ahtäri in western Central Finland from 1984 onwards. The mortality of dysthymic persons (N = 214 and N = 115) was compared to that of the non-depressed population living in the same municipality (N = 982 and N = 853). Two follow-up periods (6 yrs and 11.5 yrs) were used for the first cohort, and one (6 yrs) for the second cohort. The Kaplan-Meier procedure and Mantel-Cox statistics followed by Cox proportional hazards models were used in the analyses. The occurrence of dysthymic disorder in men was related to higher mortality in both cohorts during all follow-up periods. In women, the occurrence of dysthymic disorder was related to higher mortality in the first cohort during the follow-up of 11.5 years, and in the second during the follow-up of 6 years. When age, sex, marital status, education, smoking, physical health and functional abilities were taken into account in the Cox proportional hazards models, high age, male sex, smoking, low educational level, the use of more than two medicines and lowered functional abilities emerged as predictors of mortality in the first cohort during both follow-up periods. In the second cohort, high age male sex, smoking, poor physical health and lowered functional abilities emerged as predictors. The results suggest that the higher mortality of the aged suffering from dysthymic disorder is explained by the high occurrence of somatic diseases and disabilities in dysthymic persons. They do not suggest that there might exist biochemical factors in the aetiology of dysthymic disorders that would increase mortality. Nor do they give any evidence to suggest that dysthymic disorders might be precursors of somatic diseases increasing mortality.

Changes in the oral health of adolescents treated by the Finnish public dental services between the ages of 13 and 15 years

Oral cavity health was monitored in 2422 young people aged 13-15 years attending four health centres in Finland between 1992 and 1995. Assessments were made in terms of DMF, D and CPITN indices at clinical examinations. Of those who had no carious teeth at the initial examination, 60% did not develop cavities during the whole period, whereas half of those who had at least two carious teeth at the initial examination developed at least three new carious teeth. The treatment time needed by the latter accounted for half of the total time expended by the researchers until the end of the period. Costs can be saved or new patients brought into the dental care system by reorganizing the treatment of the patients who suffer from abundant caries and by reducing the resources devoted to the treatment of healthy patients.

Normal growth of prepubertal nephrotic children during long-term treatment with repeated courses of prednisone

The growth of 21 prepubertal children with steroid-dependent frequently relapsing nephrotic syndrome was studied before and during treatment with repeated courses of oral prednisone for 4 y. The height and height velocity standard deviation scores (HSDS and HVSDS) of the nephrotic children were -0.11 and -0.06, respectively, at the onset of the disease and -0.12 and +0.05, +0.14 and +1.02, +0.21 and +0.78 and +0.17 and +0.66, respectively, thereafter yearly during the treatment. The mean yearly cumulative dose of prednisone was 6300, 3459, 2677 and 2081 mg/body area (m2) at the first, second, third and fourth year, respectively. The nephrotic children grew normally for their age before onset of the disease and growth remained normal despite prednisone treatment.