The patients' opinions about curative factors in involuntary treatment

The patients' opinions about their treatment are seldom solicited in psychiatry. We studied the opinions of 225 patients about curative factors in their treatment in a maximum security hospital: 90% answered the questions, which evaluated 38 forms of treatment. The patients received help from free walking in the hospital area in 98% of the patients, holidays in 93%, a personal psychiatric nurse in 91%, trips in 91%, communication in 88%, personnel's support in 87% and a psychiatrist in 86%. Medication was considered helpful in 77% and even restriction or isolation in 36% of the patients. If the patient experienced help from the psychiatrist, the cross-tabulation revealed that she or he also received help from many other treatment forms, even from the isolation. Help from the personal psychiatric nurse and medication depended on many other treatment forms. The most helpful treatment factors experienced were liberties and interactive treatment forms.

Validity assessment of a social support index

The purpose of this study was to reevaluate the psychometric properties of the social support sumindex used earlier in a Swedish longitudinal study. The results based on the data of a cross-sectional survey in 1992. A randomly selected cohort consisted of 212 men, aged 50 to 60 years. The population sample (n = 4853) was resident in Kuopio Province, Eastern Finland. The 34-item-index was stable. Item-total and item-item coefficients showed low internal consistency of the overall index and of most of the subindices. The index had good content validity. Limited evidence of construct validity was noticed. Index assessed well person's social network and support level, and association between the blood pressure and some of the subindices was noticed. The eight underlying subindices did not emerge in factor analysis. Before further using this index we propose its shortening with six items and re-grouping items into subindices.

DNA analysis in Finnish patients with hereditary neuropathy with liability to pressure palsies (HNPP)

Hereditary neuropathy with liability to pressure palsies (HNPP) is a dominantly inherited disorder that presents as recurrent mononeuropathies precipitated by apparently trivial traumas. The presence of a deletion in 17p11.2 was analysed in 13 Finnish families with HNPP. The deletion was found in all patients who were neurologically and neurophysiologically confirmed to have HNPP. In the problematic cases the detection of the gene defect is the method of choice in the diagnosis of HNPP. Analysis of DNA can also be used to detect clinically unaffected family members.

Psychosocial factors, female fertility and pregnancy: a prospective study--Part I: Fertility

The aim of the study was to determine prospectively whether psychosocial, personality-related or stress factors have influence on fertility. Initially 191 healthy nulliparas without a history of infertility who were planning to have children were studied gynecologically and by psychiatric examination. Life changes and changes in psychosocial stress were monitored throughout the study period of 6 months at regular intervals. The following factors turned out to be associated with higher than average fertility in the final follow-up sample of 180 women: looking younger than one's actual age, no fluctuation in body weight before pregnancy, low consumption of coffee, low score of psychosomatic symptoms, being the youngest sibling, low number of negative life changes, younger than spouse, having phobic traits, and customarily religious. There was no clearcut association between low fertility and deviations in personality factors.

Psychosocial factors, female fertility and pregnancy: a prospective study--Part II: Pregnancy

The aim of the study was to determine whether psychosocial factors have an influence on the progress and outcome of pregnancy and whether personality-related or stress factors are significant in this respect. One hundred and ninety-one nulliparas without a history of infertility were prospectively studied gynecologically and psychiatrically. Life changes and changes in stress factors were monitored throughout the study period and obstetric complications were registered. By the end of the study period 120 (63%) of the subjects had given birth, 38 (19%) had abortion, 22 (12%) did not conceive and the remaining 11 (6%) discontinued. Certain psychosocial factors (e.g. life changes, anxiety, subjectively estimated physically and mentally stressful work) were associated with complications of pregnancy. In the logistic regression analysis the psychosocial stress factors were more strongly associated with the outcome of pregnancy than the factors related to personality. Adjusting for the stress-buffering factors (personality, coping methods and social support) did not reduce the original association.

Lyme borreliosis associated with complete flaccid paraplegia

We report the case of a patient with concomitant Lyme borreliosis and acute paraplegia. The paraplegia was complete, flaccid and of upper motor neurone type. The diagnosis of borreliosis was based on the detection of large amounts of IgM and IgG borrelia antibodies in the acute phase serum and on the complete disappearance of IgM antibody during the review period. IgG borrelia antibodies were also detected in the CSF, but leakage of antibodies from the blood to the intrathecal space could not be ruled out. Lymphocytosis and increased total protein concentration in the CSF were signs compatible with neuroborreliosis. Ceftriaxone therapy effected dramatic recovery of the patient. This case suggests that borreliosis should be considered a possible cause of acute flaccid paraplegia.

Tibial muscular dystrophy. Late adult-onset distal myopathy in 66 Finnish patients

OBJECTIVE

To clarify the classification of two previously reported groups of patients with anterior tibial distal dystrophy, to find additional patients with the disease, and to describe the clinical features of this disease.

DESIGN

National survey of the records of patients with neuromuscular diseases in Finland. Findings of selected patients were compared with those of previously reported cases.

PATIENTS

Thirty-six previously described patients and 30 additional patients from the current survey, with 41 symptomatic patients and 25 subjectively asymptomatic affected relatives.

RESULTS

There were 66 patients with late adult-onset tibial muscular dystrophy. Symptoms appear after the age of 35 years with reduced ankle dorsiflexion, and progress is slow without marked disability. Facial muscles, upper extremities, and proximal muscles are usually spared. Muscle biopsy results reveal nonspecific dystrophic changes in clinically affected muscles, and frequently severe adipose replacement in the anterior tibial muscles occurs. Asymptomatic muscles have mild myopathic changes only. Vacuolar degeneration is detected in a minority of patients. Electromyography shows profound myopathic changes in the anterior tibial muscle, but extensor brevis muscles are well preserved. Computed tomography or magnetic resonance imaging of muscles discloses marked involvement of tibial extensor muscles and focal patches of fatty degeneration in various asymptomatic muscles. Pedigree data suggest autosomal dominant inheritance.

CONCLUSIONS

Tibial muscular dystrophy might represent a new form of distal myopathy and it is rather common, at least in Finland.

Fatal encephalitis caused by concomitant infection with tick-borne encephalitis virus and Borrelia burgdorferi

We describe a 38-year-old farmer from the southwestern archipelago of Finland where both tick-borne encephalitis (TBE) virus and Borrelia burgdorferi are endemic. He presented with fever and headache, developed severe meningoencephalitis in 3 days, and, after 1 month, died without regaining consciousness. High titers of IgG and IgM antibodies to TBE virus were present in both serum and CSF. Serology for Borrelia was negative. Autopsy revealed necrotizing encephalitis and myelitis with involvement of the dorsal root ganglion. With use of polymerase chain reaction tests, segments of two separate genes of B. burgdorferi were amplified from the patient's CSF. This case demonstrates that the possibility of dual infection should be considered for patients residing in geographic areas where Ixodes ticks may carry both the TBE virus and B. burgdorferi. We believe that the most severe damage in this case was caused by TBE virus rather than by B. burgdorferi. Nevertheless, the coinfection might have contributed to the fatal outcome that has not been previously observed in Finnish patients with TBE.

Antigen and antibody assays in the aetiological diagnosis of respiratory infection in children

The diagnostic efficacy of two methods--demonstration of seroconversion in paired sera and detection of antigen in clinical specimens--was evaluated in 183 children with respiratory syncytial, parainfluenza or adenoviral, or pneumococcal respiratory tract infection. Viral infection was diagnosed in 46 (37%) of the 125 cases by antigen assay alone, in 36 (29%) by antibody assay alone and in 43 (34%) by both methods. In respiratory syncytial viral infections, antigen assays were more often positive than antibody assays; 80% of the cases were antigen positive and 63% solely antigen positive. In parainfluenza and adenoviral infections, antigen assays were not as useful; a positive result was seen in 59% and 44% of cases, respectively. Pneumococcal infection was diagnosed in 25 (30%) of the 84 cases by antigen assay alone, in 54 (64%) by antibody assay alone and in only 5 (6%) by both methods. Thus nearly all pneumococcal infections were diagnosed by only one method. The efficacy of antigen and antibody assay was clearly dependent on the age of the patients. In infants less than six months of age, nearly all (27 (90%)) of the 30 infections were diagnosed by antigen detection; 25 solely by antigen detection. In older patients, antigen and antibody assays supplemented each other. We conclude that antigen detection should be used as the primary method for the diagnosis of viral or pneumococcal respiratory tract infection. In infants, antigen detection is the only reliable method of microbial diagnosis. In addition, antigen detection is the method of rapid microbial diagnosis. In pneumococcal infections, the sensitivities of antigen detection methods are not sufficient; this is an important area for further research.

Aetiology of community-acquired pneumonia in children treated in hospital

Viral and bacterial antigen and antibody assays were prospectively applied to study the microbial aetiology of community-acquired pneumonia in 195 hospitalised children during a surveillance period of 12 months. A viral infection alone was indicated in 37 (19%), a bacterial infection alone in 30 (15%) and a mixed viral-bacterial infection in 32 (16%) patients. Thus, 46% of the 69 patients with viral infection and 52% of the 62 patients with bacterial infection had a mixed viral and bacterial aetiology. Respiratory syncytial virus (RSV) was identified in 52 patients and Streptococcus pneumoniae in 41 patients. The next common agents in order were non-classified Haemophilus influenzae (17 cases), adenoviruses (10 cases) and Chlamydia species (8 cases). The diagnosis of an RSV infection was based on detecting viral antigen in nasopharyngeal secretions in 79% of the cases. Pneumococcal infections were in most cases identified by antibody assays; in 39% they were indicated by demonstrating pneumococcal antigen in acute phase serum. An alveolar infiltrate was present in 53 (27%) and an interstitial infiltrate in 108 (55%) of the 195 patients. The remaining 34 patients had probable pneumonia. C-reactive protein (CRP), erythrocyte sedimentation rate and total white blood cell count were elevated in 25%, 40% and 36% of the patients, respectively. CRP was more often elevated in patients with bacterial infection alone than in those with viral or mixed viral-bacterial infections. No other correlation was seen between the radiological or laboratory findings and serologically identified viral, bacterial or mixed viral-bacterial infections.(ABSTRACT TRUNCATED AT 250 WORDS)

Report of a workshop on respiratory viral infections: epidemiology, diagnosis, treatment, and prevention

An international workshop to review the epidemiology, diagnosis, treatment, and prevention of respiratory viral infections was held in Turku, Finland, in May 1991. This workshop emphasized the following points. (1) In epidemiological studies of influenza virus, serological, clinical, and gene-sequencing methods have been used to produce a full picture of genetic evolution. Less complete information exists about other viruses, although new data on respiratory syncytial virus are emerging. (2) Tools for the diagnosis of respiratory viral infections have been developed in conjunction with the use of solid-phase immunoassays. A role remains for tissue culture in surveillance and epidemiological studies. Detection of bacterial involvement in respiratory infections has been more difficult. (3) Treatment of infections due to respiratory viruses has advanced with the use of amantadine and aerosolized ribavirin. On the other hand, many viruses remain refractory to treatment. Means for preventing influenza are established, but barriers to the development of other viral vaccines--including the existence of multiple serotypes, imperfect natural immunity, and paradoxical hypersensitivity--have proven difficult to surmount.

Comparison of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin, with or without dihydroergotamine, in abdominal hysterectomy

The effects of administration of low-molecular-weight heparin (enoxaparin 20 mg) once a day, of unfractionated heparin (5000 IU twice a day, and of unfractionated heparin (2500 IU) plus dihydroergotamine (0.5 mg) twice a day were assessed in 100 patients undergoing abdominal hysterectomy. The test medications were given subcutaneously 2 hours before operation and for 3 days thereafter. There were no thromboembolic complications. Intraoperative blood loss, wound haematomas and blood loss via drains during four days after operation were similar in the three groups. None of the 37 patients receiving enoxaparin experienced major postoperative bleeding. Six out of 31 patients receiving unfractionated heparin without dihydroergotamine and two out of 32 patients receiving dihydroergotamine in addition experienced major bleeding necessitating re-operation and/or blood transfusion, (P < 0.05). Enoxaparin caused less major bleeding than unfractionated heparin with or without dihydroergotamine in patients undergoing hysterectomy.

Shedding of infectious virus and virus antigen during acute infection with respiratory syncytial virus

Shedding of respiratory syncytial virus (RSV) in nasopharyngeal aspirates (NPA) of hospitalized children with acute respiratory infection was studied using direct antigen detection by time-resolved fluoroimmunoassay, rapid identification of infectious virus in centrifugally inoculated cell cultures by immunoperoxidase staining and conventional virus culture. Sequential NPAs, in which also local RSV-specific IgA response was measured, were collected from children with proven RSV infection. The shedding pattern was similar for both infectious virus and viral antigen. The overall agreement of the three methods was good (81%) in diagnostic specimens collected on admission, but markedly reduced (46%) in follow-up specimens. Secretory IgA was abundant in specimens giving discrepant or negative results only. The proportion of patients who shed RSV was high (> or = 87%) in the first week after onset of symptoms, and decreased sharply in the second week. An opposite temporal pattern was found in the proportion of patients with detectable RSV-IgA in their secretions. Sequentially isolated strains were antigenically stable as determined by their reactivity with a large panel of monoclonal antibodies. The findings suggest that RSV shedding should be monitored by using more than one method for virus detection.

Ultrastructural aspects of liver injury with special reference to small bile ducts in patients with ulcerative colitis

Liver tissue specimens taken at colectomy from 29 patients with chronic ulcerative colitis were studied by electron microscope. The fine-structural alterations were correlated with light microscopy and with biochemical liver function tests. The purpose was to identify ultrastructural features which could explain the pathogenesis of sclerosing cholangitis. Severely injured bile-duct epithelial cells were seen in three out of the eight light-microscopically diagnosed cholangitis cases, in the two cases of non-specific reactive hepatitis, and in the two fatty livers. Four cholangitis cases had, in heavily thickened bile-duct basement membranes, translucent areas containing bile-like material. Bile-duct microvilli were often blunted, and reduced in number. Intracanalicular bile thrombi and bile inclusions in hepatocytes were seldom seen, mostly but not exclusively in cholangitis. The fine-structural alterations apparently represent various stages of liver injury. These findings do not appear to be specific, but their prominence seems to correlate with the progression of the disease, at least in the case of histological parameters, but also in serum enzyme activities indicative of cholestasis. The bile-like electron-dense material found in proliferating basement membranes, very possibly regurgitated into the injured bile-duct wall after epithelial injury, could enhance the development of periductal fibrosis, leading to progression of sclerosing cholangitis.

Muscle pathology in idiopathic cricopharyngeal dysphagia. Enzyme histochemical and electron microscopic findings

The structural changes in the cricopharyngeal muscle (CM) were examined ultrastructurally and by enzyme histochemistry in five patients suffering from idiopathic cricopharyngeal dysphagia (ICD). Diagnosis was established by fiberoptic esophagoscopy, esophageal manometry and cineradiography. Cricopharyngeal myotomy was performed with marked improvement in all patients. Intraoperatively, a biopsy was taken from the CM. Additionally, all patients underwent neurological examination for possible generalized muscle disease, and a biopsy was taken from a limb muscle. CM from nine cadavers without known history of dysphagia served as control. The control samples disclosed structural changes which were considered to be pathological in other skeletal muscles, and required that the criteria for CM pathology we modified accordingly. In three patients changes in CM histology suggested specific pathogenesis: one patient had evidence for a generalized myositis but was only symptomatic for dysphagia. Another patient had muscle fiber atrophy and slight inflammation in her CM, possibly due to alcohol abuse. The third patient had loss of CM fibers with replacement by connective tissue enough to cause functional disturbances. In two patients no cause for dysphagia was found in either immunohistochemistry or electron microscopic studies. These results demonstrate the special structural features of the CM and indicate that ICD can have multiple etiologies.

Identification of health status dimensions in a working-age population. An exploratory study

With regard to health care there is a growing demand for comprehensive and reliable instruments of general health status measurement. In the Finnish Healthy Village Study, 427 men and 366 women of working age participated in a comprehensive health examination that included more than 120 physical, psychological, and social health status variables. On the basis of minimum correlation values, 37 health status variables were chosen for factor analytic study. Principal component factor analysis with varimax rotation identified six dimensions of health status: physical functioning, emotional state, perceived health, anthropometric state and blood pressure, social functioning, and biochemical state. These six factors accounted for 46% of the total variance of health status variables. Health profile analysis of both men and women revealed the same dimensions but in different order. Men ranked their self-rated general health more closely with their physical functioning, whereas women ranked it with perceived health. The identification of general health status dimensions has implications for planning health promotion programs and evaluating their outcomes.

Detection of tick-borne encephalitis virus in ixodid ticks collected in natural foci by time-resolved fluoroimmunoassay

Time-resolved fluoroimmunoassay (TR-FIA) was used for the first time for evaluation of infestation of ixodid ticks with tick-borne encephalitis virus. Comparison of TR-FIA results with those obtained in enzyme immunoassay and by virus isolation confirmed the high efficacy of the method in question. Positive results of TR-FIA coincided with the data of virus isolation in 83.6% cases, the level of false-negative results did not exceed 1.2%, the overall time consumption amounted to about 1.2 hr.

[The strain-specific diagnosis of influenza by using lanthanide immunofluorescence analysis based on monoclonal antibodies to the hemagglutinin of the influenza A virus]

Nine monoclonal antibodies (MCA) to hemagglutinin of influenza A/Taiwan/1/86 (H1N1) virus and 5 MCA to influenza A/Mississippi/1/85 (H3N2) virus were generated and characterized. The MCA were used for the development of diagnostic test systems on the basis of time-resolved fluoroimmunoassay. The same MCA were used as primary and detecting antibodies in the test system specific for HA of the H1 serosubtype, whereas in the test system specific for influenza A serosubtype H3 virus MCA of different epitope appurtenance were used as primary and secondary antibodies. The sensitivity of the test system for HA of serosubtype H1 was found to be 10 ng/ml and that for serosubtype H3 5 nh/ml. The developed test systems were tried on the clinical material collected during the epidemic periods of 1983-1989.

The causes of hospital-treated acute lower respiratory tract infection in children

OBJECTIVE

To determine the etiologic agents in children with acute lower respiratory infection.

DESIGN

A survey of a series of patients.

SETTING

General pediatric hospital serving an urban population with and without referrals in Helsinki, Finland.

PARTICIPANTS

135 Finnish children aged 2 months to 15 years (mean, 1.75 years), with clinically defined acute lower respiratory infection (with difficulty of breathing), or found to have fever and a pneumonic infiltrate on chest roentgenogram.

SELECTION PROCEDURES

Consecutive sample on voluntary basis.

INTERVENTIONS

None.

MAIN RESULTS

Of 121 children with adequate samples, an etiologic diagnosis could be established in 84 (70%): 30 (25%) had bacterial, 30 (25%) viral, and 24 (20%) mixed infections. Antibody assays alone identified the agent in 91% of positive cases.

CONCLUSIONS

Bacterial infections are common but generally underestimated in acute lower respiratory infection; serologic methods add significantly to their detection.

Influenza vaccination in the prevention of acute otitis media in children

We studied a new approach to the prevention of acute otitis media through the administration of influenza vaccine to 187 day-care center children aged 1 to 3 years before the influenza A epidemic of 1988-1989. The control group consisted of 187 unvaccinated children of similar age and background. During the 6-week study period, influenza A infection was diagnosed in five (3%) of 187 vaccinees and in 29 (16%) of 187 controls. Acute otitis media developed in three (60%) of five vaccinees with an influenza A infection compared with 18 (67%) of 27 controls (excluded were two children with a double viral infection). The incidence of acute otitis media associated with influenza A was reduced by 83% in the vaccinees. The total number of children with acute otitis media in the vaccine group was 35, compared with 55 in the control group, disclosing a 36% reduction among the vaccinees. We conclude that influenza vaccination decreases the incidence of acute otitis media in children during an influenza A epidemic, suggesting also that other vaccines against respiratory viruses may be an effective way to reduce the incidence of acute otitis media.

Inclusion body myositis and paramyxoviruses

Inclusion body myositis (IBM) is a distinct type of muscle disease. The characteristic electron microscopic findings, intranuclear or intracytoplasmic inclusions composed of microtubular filaments, morphologically resemble paramyxovirus nucleocapsids. These findings and the reported immunoreactivity of the inclusions with mumps virus antibodies have suggested that inclusion body myositis is a chronic virus infection. We analyzed skeletal muscle specimens from three patients with characteristic light microscopic features and electron microscopically verified inclusions of IBM by immunocytochemistry using antibodies raised against members of the paramyxovirus group, and by in situ hybridization with a cRNA probe representing the mumps virus nucleocapsid gene. The specificity of the reactions was demonstrated with infected and uninfected cultured cells. No immunocytochemical staining or hybridization signal was observed in biopsy specimens from IBM patients. These findings speak against a paramyxovirus etiology of IBM.

Treatment of acute exacerbations in early multiple sclerosis: cyclosporin A or prednisolone?

Twenty-six acute exacerbations in 26 patients with early definite multiple sclerosis (MS) were treated with oral cyclosporin-A (CyA) or oral prednisolone in a double-blind, controlled and randomized trial. The duration of the treatment was 6 weeks. All of the patients showed improvement during the treatment. There were no differences in outcome between patients on CyA (7.5 mg/kg) or prednisolone (decreasing doses from 0.8 mg/kg) during the 6 week treatment. However, the improvement of clinical signs 3 months after the treatment was slightly greater in the prednisolone group. The drugs did not have significant side-effects. There was no fluctuation in the CD4/CD8 ratio during the follow-up. The two treatment groups did not differ from each other in respect to the number of CD3 (T3), CD4 (T4), CD8 (T8), CD14 (monocytes), CD20 (B cells) or CD25 (interleukin-2 receptor positive cells). The number of active T cells with the interleukin-2 receptor was high in the beginning of the exacerbation but it decreased during the treatment. To conclude, the effects of CyA and prednisolone were comparable in the treatment of acute MS relapses.