Has the attempt to reduce psychiatric inpatient treatment been successful in Finland?

The deinstitutionalisation process in Finland's psychiatric healthcare did not start until the late 1980s. Our aim is to evaluate how the use of psychiatric inpatient treatment was associated with deinstitutionalisation given the changes in the modality of treatment ideology (years 1987--1991) as well as being due to economic pressures (years 1991--1995). Special emphasis is given on the inpatient treatment of schizophrenia and other psychotic disorders. Data was retrieved using the national hospital discharge register of all treatment periods in psychiatric hospitals and treatment periods due to psychiatric disorders in other hospitals. Three years (1987, 1991, and 1995) were compared. Four healthcare districts in northern Finland were studied. Resource use was measured by number of treatment periods and inpatient days in relation to population. Psychiatric inpatient treatment was reduced in 1987--1991, when resources in community care increased. During the period of economic pressures (1991--1995), when community care resources no longer increased, inpatient treatment started to rise again. Over the whole period, psychiatric treatment in primary care institutions increased. Reduction of psychiatric beds results in increasing inpatient treatment in non-specialist institutions, especially when community care fails to serve the patients. In the future it is important to evaluate whether the quality of care remains in the standard of specialised services when treatment shifts away from the specialist level.

Allele 2 of interleukin-1 receptor antagonist gene increases the risk of thyroid peroxidase antibodies in subacute thyroiditis

Subacute granulomatous thyroiditis (SAT) is a self-limiting systemic inflammatory disorder with possible transient expression of thyroid antibodies. Persistent hypothyroidism is uncommon. The interleukin-1 receptor antagonist IL-1ra is an inhibitor of IL-1 activity and allele 2 of the IL-1ra gene is associated with inflammatory diseases and IL-1ra production. Forty-eight subjects with SAT were investigated. Polymorphisms of IL-1ra, IL-1beta-511 and TNFalpha genes were studied with respect to thyroid peroxidase antibodies (TPOab), thyroglobulin antibodies, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Serum IL-1ra levels were measured. An increased allelic frequency (43% vs 22%, p=0.039) and carriage rate (79% vs 41%, p=0.018) for IL-1ra allele 2 were observed with expression of TPOab in 14 (29.2%) subjects compared with those with negative findings. The carriage rate for both IL-1ra allele 2 and IL-1beta-511 allele 2 was also increased with TPOab expression (71% vs 27%, p=0.004, respectively). No difference in allele frequency or carriage rate was found compared with healthy controls. Serum IL-1ra levels correlated with S-CRP (r=0.41, p=0.004) and ESR (r=0.34, p=0.016), but the association with genes or thyroid antibodies was statistically insignificant. S-CRP levels and ESR were lower and negatively correlated with expression of TPOab (r=-0.27, p=0.046 and r=-0.32, p=0.017). This study describes the multiplicity of the mechanisms responsible for the severity of the acute-phase response during the course of SAT. IL-1ra may have a significant anti-inflammatory role in SAT. Presence of IL-1ra allele 2 increases the risk of developing TPOab.

Development of a patient-orientated instrument to measure service quality in outpatient departments

AIMS OF THE STUDY

To describe three stages in the development of an instrument to measure service quality from the patients' perspective in hospital outpatient departments.

RATIONALE

A reliable and valid service quality instrument is a valuable tool for collecting feedback from patients when improving outpatient services.

DESIGN

A multiphase process with several versions of the questionnaire testing its validity and reliability. The first version of the questionnaire was constructed from information collected in a previous interview study of patients' service experiences. Using this version (47 questions) information was collected in 15 outpatient departments (314 patients) and the second version of the questionnaire was developed. At this stage, a survey of employees (n=111) was included in the development process. This second version of the questionnaire (43 questions) was used to collect more data in three outpatient departments of a university hospital and in two outpatient departments of two regional hospitals on three different occasions (1416, 369 and 124 patients) within a period of 2 years. The reliability of the instrument was tested in terms of stability by using three repeated measurements, and using the Cronbach's alpha coefficient as an indicator of internal consistency. Content validity was assessed by means of percentage agreement between staff and patients. Logistic regression analysis was performed to assess construct validity.

RESULTS

The final version of the questionnaire contained 12 items. Agreement between patient and staff ratings was found to be acceptable for most questions (content validity). Two measurements on different occasions yielded a similar structure (construct validity). Internal consistency was acceptable (Cronbach's alpha = 0.67-0.93 in the first and 0.71-0.94 in the second survey). The variance of the alpha coefficients was small in the retest (stability).

CONCLUSIONS

The instrument developed is general to the extent that it is suitable for assessing service quality improvement needs in individual units and for making cross-departmental comparisons.

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.

Quality assurance in radiotherapy of breast cancer--variability in planning target volume delineation

The inter-physician and inter-patient variability in planning target volume delineation for the radiotherapy of breast cancer after conservative surgery is presented. Eleven experienced radiation oncologists determined the planning target volume (PTV) for four breast cancer patients. Delineation was based on CT slices taken at intervals of 15 mm. The variability in target volume delineation was determined by measuring the volumes in units of cc and the position of the drawn PTVs. Statistical analysis was based on X/R-charts and on Pareto chart and analysis. The maximum range in PTV for one patient was from 670 to 1,200 cc. The observations of three physicians were in excess of the warning limit altogether 18 times. The methods used in this study clearly reveal inter-physician variability in PTV delineation and widest variations found are not acceptable. Training targeted to some physicians and more detailed and unambiguous protocols for PTV delineation are needed.

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.

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.

Subjective daytime sleepiness and its predictors in Finnish adolescents in an interview study

The purpose of this study is to evaluate the predictors of subjective daytime sleepiness (SDS) and its chronicity in adolescents. Two groups of adolescents (107 with SDS and 107 without SDS) from our first questionnaire study were invited to an interview after 3 y. A follow-up questionnaire had been sent to them one year earlier. The interview included questions about sleep, daytime sleepiness, living habits, physical and mental health, and progress at school. The adolescents were also examined clinically. Interviews were conducted with 66 out of 107 subjects with SDS and 64 out of 107 without SDS (age range 12 to 19 y). In this interview 42 out of the 130 adolescents had SDS. A total of 20 adolescents reported SDS in both questionnaire studies and in the interview (chronic SDS). In a multivariate analysis (logistic regression) sleep disorders, frequent medication and depressive emotions were significantly associated with SDS. Chronic SDS was connected in a bivariate analysis (Pearson's chi-square) with excessive night waking, difficulty in falling asleep, dreaming, frequent medication, frequent alcohol drinking, and irregular breakfast eating, and in our previous studies also with delayed sleep rhythm.

CONCLUSION

Sleep disorders and health problems were more common causes of SDS than undesirable living habits. However, alcohol drinking and delayed sleep rhythm were associated with chronic SDS in addition to sleep disorders and medication.

Pancreatic carcinoma and fast MR imaging: technical considerations for signal intensity difference measurements

The aim of the study was to find the fast magnetic resonance imaging (MRI) sequence with the best conspicuity of pancreatic lesions at 1.0 T and 1.5 T. A total of 51 patients were studied. At 1.0 T, 22 patients with verified malignant pancreatic lesions were studied using the T1-weighted breath-hold spoiled Gradient Echo 2D FLASH(75) or FLASH(80) sequences, both non-enhanced and enhanced with gadolinium. The relative signal intensity difference (SIDR) between lesion and pancreas was measured. At 1.5 T, 20 patients with primary malignant lesions of the pancreas, and nine patients with 13 benign cystic lesions were examined with the breath-hold T2-weighted TrueFISP, HASTE, T1-weighted 2D FLASH(80) and FLASH(50) fat saturation sequences, the latter also enhanced. The signal intensity (SI) values of the pancreas and lesions as well as the pancreatic standard deviation (S.D.) were assessed, and the contrast-to-noise ratio (C/N) was determined. Statistical significances were calculated using an analysis of variance. No statistically significant difference between the sequences used in the conspicuity of cancer was found, either at 1.0 T or at 1.5 T. At 1.5 T, the T2-weighted TrueFISP and HASTE sequences could differentiate benign, cystic lesions from malignant lesions.

Extent of fussing and colic type crying preceding atopic disease

In a prospective follow up of 116 high risk infants, a 24 hour behavioural chart on seven consecutive days was analysed at seven and 12 weeks of age. Of children who manifested atopic disease at 2 years, 44/116 (38%), had shown significantly more fussing during the seventh, and colic type cry during the twelfth week than those who remained healthy (72/116, 62%).

A study of interleukin-1 cluster genes in susceptibility to and severity of multiple sclerosis

In this explorative study, interleukin-1 (IL-1) receptor antagonist (IL-1RA; polymorphism of variable number of tandem repeats: VNTR), IL-1alpha (-889), IL-1beta (-511) and IL-1beta (+3953) polymorphisms were studied in relation to susceptibility to and severity of multiple sclerosis (MS), in 93 MS patients and 400 normal controls. No associations were found for any polymorphisms, alone or in combination. However, in our MS cohort, females were found to be IL-1RA allele 2 carriers more frequently than males (33/49 vs. 16/44, p = 0.0028). Using a cohort of 109 controls, IL-1RA allele 2 carriers were more frequently women with MS than control women (33/49 vs. 23/43, odds ratio (OR) = 2.19, 95% confidence interval (CI) 1.02-4.72, p = 0.043, P(C) = ns). The data suggest that the IL-1 cluster genes make no major contribution to MS, but the tentative association between IL-1RA allele 2 and susceptibility of MS in women warrants further studies.

Kidney ultrasound and Doppler ultrasound findings during and after acute urinary retention

OBJECTIVE

To evaluate changes in kidney ultrasound and Doppler ultrasound images during and subsequent to acute urinary retention (AUR).

METHODS

Twenty-five men with a mean age of 69 years suffering AUR for a mean of 31 h were studied by measuring serum creatinine, creatinine clearance and renal ultrasound. Renal Doppler ultrasound was applied in 19 of these cases and all patients were followed for 6 months after acute retention was relieved.

RESULTS

During AUR hydronephrosis was noted in three patients; this disappeared during follow-up. During the acute period, after 1 month and after 6 months the average resistive indexes (RI) were 0.71, 0.70 and 0.69, respectively. The changes were not statistically significant. During follow-up, the proportion of patients with normal RI increased from 42 to 64%. Median serum creatinine was normal during retention and follow-up. Median creatinine clearance was reduced during retention and became normal during follow-up (P < 0.05). No correlation was found between RI and serum creatinine at any time-point, nor was any correlation noted between RI and creatinine clearance during retention or at the 1-month follow-up; at 6 months, however, there was a significant inverse correlation between them (P = 0.01).

CONCLUSION

AUR caused elevation of RI, which may be interpreted as diminished renal blood flow. Although in the majority of patients it recovered after treatment, elevated RI was still found in one third of the patients, possibly due to previous chronic bladder outlet obstruction. Our findings stress the importance of both fast release of AUR and effective treatment of its cause.

Experimental follow-up model for clinical frontal sinus obliteration with bioactive glass (S53P4)

Bioactive glass S53P4 (BG) is an osteoconductive allograft material. Since 1990, BG has been used in the obliteration of frontal sinuses in more than 30 consecutive patients. The patients have been monitored regularly with clinical examinations, computer tomography (CT) scans, laboratory tests and, in a few cases, biopsies have also been obtained. The material has been well tolerated and no loss of volume of obliteration material has been seen in the obliterated sinuses. However, in repeated CT monitoring and with Region of Interest (ROI) analysis, a decrease in the density of the obliteration material inside the frontal sinuses has been seen. In the present study, the clinical conditions after an obliteration operation were simulated and the behaviour of the BG in the obliterated area was observed. The aim was to study whether it is possible indirectly to estimate the resorption of a massive amount of BG with ROI analysis for monitoring the clinical success of the treatment. Thus two sizes of granules (0.63-0.8 mm and 0.8-1.0 mm) in eight separate BG amounts, weight 25 g, were tested in simulated body fluid (SBF) in standard conditions. The dissolution of silicon (Si) and phosphate (P) was detected with direct plasma atom emission spectroscopy (DCP-AES) monthly up to 6 months. The BG amounts were scanned with CT and the slices analysed using the ROI technique at 1, 3 and 6 months. The cumulative loss of Si and P in SBF was significant during the study (p < 0.0001) and it was stronger with smaller than with larger granules (p < 0.0001). This was shown correspondingly by the decrease of Hounsfield units (p < 0.0001) in ROI analysis. The method seems reliably to reveal the resorption of BG for clinical purposes.

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.

Increased prevalence of atopy among children exposed to mold in a school building

BACKGROUND

The purpose of this study was to assess the occurrence of immunoglobulin E sensitization to common environmental allergens (atopy) and new allergic diseases among schoolchildren after starting school in a water-damaged school building. The staff and pupils of a Finnish elementary school with visible water damage and mold complained of respiratory and skin symptoms. The school building was examined and widespread moisture damage was found. A control school with no visible water damage was also examined. No indication of exceptional microbial growth was found in the samples taken from this school.

METHODS

History of allergic diseases and the year of diagnosis were established by a questionnaire. IgE antibodies to the common environmental allergens were determined from randomly selcted groups from both schools.

RESULTS

Elevated IgE values were significantly more common among the exposed children, as was the occurrence of new allergic diseases after the children started at the school.

CONCLUSIONS

The odds ratios for the IgE values of the study groups indicated a possible relationship between exposure to microorganisms and IgE sensitization. Exposure to spores, toxins, and other metabolites of molds may have complex results with unknown immunogenic effects that may act as a nonspecific trigger for allergic sensitization leading to the development of atopy.

Coronary artery disease modifies left ventricular remodelling due to heavy alcohol consumption

BACKGROUND

Coronary artery disease (CAD) and excessive alcohol use can both damage the myocardium. Their combined effect on the heart muscle has not been characterized. We set out to assess whether the presence of CAD modifies the effects of chronic alcohol consumption on the left ventricular (LV) structure in middle-aged men.

METHODS

A postmortem examination was performed on 700 Finnish men (age range, 33-70 years) who experienced a sudden, nonhospital death. A coronary arteriography and measurement of the LV wall thickness, cavity area, and ratio by planimetry of transversal ventricular slices were done at the autopsy. The men were grouped by the most severe coronary artery diameter stenosis (<30%, 30-60%, >60%) and by daily alcohol dose (<12 g, 12-72 g, 72-180 g, >180 g) estimated by a structured interview of their lifetime partner.

RESULTS

Analysis by ANCOVA, adjusted for age, body size, smoking, hypertension, and diabetes, showed a statistically significant interaction between the effects of coronary artery stenosis and daily alcohol dose on the LV cavity area (p = 0.037) and on the LV wall thickness/cavity area ratio (p = 0.018). In the group with <30% stenosis, the LV wall thickness/cavity area ratio (mean +/- SEM) increased from 1.6 +/- 0.2 mm/cm2 in men drinking <12 g/day to 6.2 +/- 1.4 mm/cm2 in men drinking 72-180 g/day (p = 0.021). A similar trend was seen in men with 30-60% coronary stenosis (p = 0.32). By contrast, in men with >60% coronary stenosis, the LV wall thickness/cavity area ratio decreased with increasing daily alcohol use from 2.2 +/- 0.3 to 1.4 +/- 0.1 mm/cm2 (p = 0.27).

CONCLUSIONS

CAD modulates the effects of alcohol on the heart muscle. Heavy drinking results in concentric LV remodelling in men with no or only mild coronary artery stenoses whereas an opposite trend is seen in men with severe coronary artery obstructions. The mechanism of the interaction remains unknown.

Correlation between serum inhibin B and other indicators of the ovarian function

OBJECTIVE

To investigate the correlation between the early follicular phase serum inhibin B levels and other indicators of ovarian reserve.

STUDY DESIGN

Seventy-four women aged 24-40 years (mean 32) with different infertility etiologies were investigated in the early follicular phase of a spontaneous mentrual cycle. The volume of the ovaries was measured and the total number of follicles <5 mm in size counted by ultrasound. Serum levels of FSH, estradiol (E2) and inhibin B were measured on the same day. In stepwise regression analysis inhibin B levels were correlated with age, body-mass-index, the ultrasound measurements, cause of infertility, parity, FSH and E2.

RESULTS

FSH, BMI and the number of follicles proved to be statistically significant independent predictive factors for the inhibin B levels, FSH and BMI correlating negatively and the number of follicles positively with inhibin B serum concentrations.

CONCLUSION

The number of small follicles reflect the inhibin B production of the ovaries. BMI being as strong predictive factor of inhibin B levels as FSH could in part explain the impaired likelihood of conceiving in obese patients.

Unawareness of deficits after right hemisphere stroke: double-dissociations of anosognosias

OBJECTIVES

The aim was to study whether anosognosia for hemiparesis, anosognosia for neglect and general unawareness of illness double-dissociate, indicating that anosognosias are specific and independent impairments of awareness. On the other hand, anosognosias may be associated with one another and with general cognitive dysfunction, which decreases awareness of deficits. The persistence and predictive value of anosognosias was examined during a 1-year follow-up.

PATIENTS AND METHODS

Fifty-seven consecutive patients with acute right hemisphere infarction underwent neurological and neuroradiological examinations, neuropsychological testing and an interview 10 days, 3 months and 1 year after onset.

RESULTS

Anosognosia for neglect and anosognosia for hemiparesis double-dissociated, as did unawareness of illness and anosognosia for neglect. Patients showing unawareness of illness or anosognosia for neglect and anosognosia for hemiparesis had poorer orientation and verbal memory than patients who were aware of these defects. Unawareness of illness and anosognosia for hemiparesis disappeared during 3-month follow-up.

CONCLUSION

Double-dissociations demonstrate that anosognosias for different defects are independent and specific impairments of awareness, although general cognitive disorder may also reduce awareness of defects. Unawareness of illness and anosognosia for hemiparesis disappear rapidly and can hardly be direct causes of poor long-term recovery. However, transient anosognosia may be associated with persistent disorders which result in poor outcome.

The impact of supportive telephone call intervention on grief after the death of a family member

This study describes the impact of a supportive telephone call on grief 4 months after the death of a family member. The study design involved a quasi-experimental intervention group (n = 70) and a control group (n = 155). The intervention was a supportive telephone call after the death of a family member. Grief reactions were measured with the Hogan Grief Reactions Checklist. Results were completed by content analysis of family members' experiences of the intervention. Chi-square and t tests were used to compare the associations with demographic data, and logistic regression analysis was used to compare the responses. The results pointed to differences in despair and personal growth between the groups. The participants experienced the supportive telephone call positively for the most part. Negative experiences were associated with promises to call in which the call never reached the participant. Grieving family members' positive experiences of the call indicate that there is a need for individual support after the death, given by nurses of the wards in which the deceased received care.

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.

Chromosome imbalances in familial gliomas detected by comparative genomic hybridization

Familial occurrence of gliomas, in the absence of well-defined hereditary multisystem disorders, is reported occasionally. We describe 17 families that have been afflicted with two or more gliomas but do not raise suspicion of other inheritable syndromes. The families were identified among 369 consecutive glioma patients operated at the Tampere University Hospital during 1983-1994. We applied comparative genomic hybridization (CGH) analysis on 21 gliomas occurring in these 17 families. The most frequent genetic alterations, detected in over 20% of the tumors, were losses of 6q, 10, 4q, 9p and gains of 7, 19, 20q, 1p. We compared the chromosomal alterations detected in the familial gliomas to those reported previously on 209 sporadic gliomas in nine different CGH studies. In this comparison, the familial gliomas more often showed losses of chromosome arms 4q and 6q and gains of 1p and 22q. The most frequent losses (9/21 tumors) in the familial gliomas resided on chromosome arm 6q (P = 0.005, Fisher's exact test; with Bonferroni correction, P = 0.04). The loss of 6q was also the most common intrafamilial aberration, present in four separate gliomas belonging to two families. The minimal common area of loss on this chromosome resided at 6q14-16. In conclusion, we have found several characteristic aberrations by CGH in the familial gliomas and we present new chromosomal regions possibly involved in the familial predisposition to gliomas.

Respiratory morbidity among children following renovation of a water-damaged school

The authors sought to determine whether exposure to molds, resulting from moisture damage in a school, was associated with increased respiratory symptoms and morbidity among schoolchildren and whether the renovation of this building resulted in a decrease in prevalence of respiratory symptoms and morbidity. The study was a follow-up (1-y interval) of children between the ages of 7 and 12 y from two elementary schools in a Finnish suburb. In addition to a questionnaire completed by the parents, the authors assessed the respiratory health of children by examining the health records of a local health center. In the cross-sectional study, the prevalence of symptoms and infections were higher in the exposed group, as were visits to a physician and use of antibiotics. The school was renovated, after which all prevalence decreased and no significant differences remained, except for visits to a physician (according to questionnaire responses). Therefore, moisture damage and exposure to molds increased the indoor air problems of schools and affected the respiratory health of children.

Wheezing in early life and asthma at school age: predictors of symptom persistence

Early childhood wheezing is associated with asthma later in life. However, the high spontaneous recovery rate and the lack of firm predictors for persistence of wheezing complicates the development of evidence-based guidelines for long-term management of wheezy infants and toddlers. Our aim was to define variables that could be used to identify wheezy individuals younger than 3 years of age who would continue to be symptomatic at school age. The method used was a questionnaire-based cross-sectional survey of 2,027 randomly chosen, 6-13-year-old school children. Altogether 1,829 (90%) questionnaires were returned. Emergency medical care had been sought for 186 (10.2%) children for wheezing during the first 3 years of life, and only 17.2% of these children had received similar emergency treatment during the 12 months preceding the survey. The total proportion of children with current asthma at school age was 11.4%. A logistic regression analysis indicated that for the early wheezers, a family history of asthma, an itchy rash or food allergy, and exposure to tobacco smoke at home before the age of 3 years, were all independently associated with symptom persistence until school age. Among all wheezy children younger than 3 years, those who have a history of food allergy, itchy rash, asthma occurrence in a sibling or parent, or are exposed to tobacco smoke during the first years of life are at highest risk for symptom persistence until school age.

Apolipoprotein E polymorphism and atherosclerosis: association of the epsilon4 allele with defects in the internal elastic lamina

The defects in the internal elastic lamina (IEL) have been proposed to be important for the migration of smooth muscle cells into the intima during atherosclerosis. We investigated the association of a genetic factor--apolipoprotein E (apoE) genotype--with the number of gaps in the IEL of the artery wall in 123 consecutive autopsy cases (90 male, 33 female) aged 18-93. At autopsy, the circumference of the IEL and the number of gaps in the IEL were measured in circular samples of the coeliac; (CA), superior mesenteric (SMA) and inferior mesenteric (IMA) arteries. In the series, the number of gaps per millimetre in the IEL of CA, SMA and IMA were associated with intimal thickening (P<0.0001, P=0.01 and P=0.005, respectively). In men, apoE genotype was significantly associated with the number of gaps in the IEL of the CA and IMA (P=0.033 and P=0.041, respectively). The carriers of epsilon4/3 or epsilon4/4 genotype had higher number of gaps in CA than the carriers of epsilon3/3 genotype (2.30+/-2.63 vs. 1.38+/-1.83 gaps/mm, P=0.035) and also higher number of gaps in IMA than the carriers of epsilon3/2 (2.18+/-1.71 vs. 0.66+/-0.60 gaps/mm, P=0.041). The results suggest that the apoE varepsilon4 allele may be involved with IEL fragmentation in men. This may be mediated through higher serum cholesterol associated with the varepsilon4 allele.