Parents' and neonatal healthcare professionals' views on barriers and facilitators to parental presence in the neonatal unit: a qualitative study

BACKGROUND

Parent and infant separation in the neonatal unit is associated with adverse health outcomes. Family-integrated care has several advantages and the potential to reduce these adverse outcomes but requires parental presence. This study aimed to explore the views of parents and neonatal healthcare professionals (nHCPs) on barriers and facilitators to parental presence in a Swiss neonatal unit and to identify possible differences between nHCPs and parents, and between mothers and fathers.

METHODS

Data were collected through semi-structured interviews with parents and focus group discussions with nHCPs. Inductive content analysis was used to identify barriers and facilitators to parental presence in the neonatal unit.

RESULTS

Twenty parents (10 mothers and 10 fathers) and 21 nHCPs (10 nurses and 11 physicians) participated in the study. Parents and nHCPs experienced barriers and facilitators related to: (1) Structural factors of the institution, such as infrastructure or travel and distance to the neonatal unit. (2) Organization and time management of parental presence, daily activities, and work. (3) Resources, which include factors related to the legal situation, support services, family, and friends. (4) Physical and psychological aspects, such as pain, which mainly affected mothers, and aspects of emotional distress, which affected both parents. Self-care was an important physical and psychological facilitator. (5) Parent-professional interaction. Parental presence was influenced by communication, relationship, and interaction in infant care; and (6) Cultural aspects and language. Some perspectives differed between mothers and fathers, while the overall views of parents and nHCPs provided complementary rather than conflicting insights. Using visit plans to support the organization, educating nHCPs in knowledge skills and available resources to improve encouragement and information to parents, strengthening parent self-care, and improving nHCPs' attitudes towards parental presence were seen as possible improvements.

CONCLUSIONS

Multifactorial barriers and facilitators determine parental presence and experience in the neonatal unit. Parents and nHCPs made specific recommendations to improve parental presence.

Long-term trajectories of densely reported depressive symptoms during an extended period of the COVID-19 pandemic in Switzerland: Social worries matter

Previous mental health trajectory studies were mostly limited to the months before access to vaccination. They are not informing on whether public mental health has adapted to the pandemic. The aim of this analysis was to 1) investigate trajectories of monthly reported depressive symptoms from July 2020 to December 2021 in Switzerland, 2) compare average growth trajectories across regions with different stringency phases, and 3) explore the relative impact of self-reported worries related to health, economic and social domains as well as socio-economic indicators on growth trajectories. As part of the population-based Corona Immunitas program of regional, but harmonized, adult cohorts studying the pandemic course and impact, participants repeatedly reported online to the DASS-21 instrument on depressive symptomatology. Trajectories of depressive symptoms were estimated using a latent growth model, specified as a generalised linear mixed model. The time effect was modelled parametrically through a polynomial allowing to estimate trajectories for participants' missing time points. In all regions level and shape of the trajectories mirrored those of the KOF Stringency-Plus Index, which quantifies regional Covid-19 policy stringency. The higher level of average depression in trajectories of those expressing specific worries was most noticeable for the social domain. Younger age, female gender, and low household income went along with higher mean depression score trajectories throughout follow-up. Interventions to promote long-term resilience are an important part of pandemic preparedness, given the observed lack of an adaptation in mental health response to the pandemic even after the availability of vaccines in this high-income context.

Seroprevalence trends of anti-SARS-CoV-2 antibodies and associated risk factors: a population-based study

PURPOSE

We aimed to assess the seroprevalence trends of SARS-CoV-2 antibodies in several Swiss cantons between May 2020 and September 2021 and investigate risk factors for seropositivity and their changes over time.

METHODS

We conducted repeated population-based serological studies in different Swiss regions using a common methodology. We defined three study periods: May-October 2020 (period 1, prior to vaccination), November 2020-mid-May 2021 (period 2, first months of the vaccination campaign), and mid-May-September 2021 (period 3, a large share of the population vaccinated). We measured anti-spike IgG. Participants provided information on sociodemographic and socioeconomic characteristics, health status, and adherence to preventive measures. We estimated seroprevalence with a Bayesian logistic regression model and the association between risk factors and seropositivity with Poisson models.

RESULTS

We included 13,291 participants aged 20 and older from 11 Swiss cantons. Seroprevalence was 3.7% (95% CI 2.1-4.9) in period 1, 16.2% (95% CI 14.4-17.5) in period 2, and 72.0% (95% CI 70.3-73.8) in period 3, with regional variations. In period 1, younger age (20-64) was the only factor associated with higher seropositivity. In period 3, being aged ≥ 65 years, with a high income, retired, overweight or obese or with other comorbidities, was associated with higher seropositivity. These associations disappeared after adjusting for vaccination status. Seropositivity was lower in participants with lower adherence to preventive measures, due to a lower vaccination uptake.

CONCLUSIONS

Seroprevalence sharply increased over time, also thanks to vaccination, with some regional variations. After the vaccination campaign, no differences between subgroups were observed.

Interplay of Digital Proximity App Use and SARS-CoV-2 Vaccine Uptake in Switzerland: Analysis of Two Population-Based Cohort Studies

Objectives: Our study aims to evaluate developments in vaccine uptake and digital proximity tracing app use in a localized context of the SARS-CoV-2 pandemic. Methods: We report findings from two population-based longitudinal cohorts in Switzerland from January to December 2021. Failure time analyses and Cox proportional hazards regression models were conducted to assess vaccine uptake and digital proximity tracing app (SwissCovid) uninstalling outcomes. Results: We observed a dichotomy of individuals who did not use the SwissCovid app and did not get vaccinated, and who used the SwissCovid app and got vaccinated during the study period. Increased vaccine uptake was observed with SwissCovid app use (aHR, 1.51; 95% CI: 1.40-1.62 [CI-DFU]; aHR, 1.79; 95% CI: 1.62-1.99 [CSM]) compared to SwissCovid app non-use. Decreased SwissCovid uninstallation risk was observed for participants who got vaccinated (aHR, 0.55; 95% CI: 0.38-0.81 [CI-DFU]; aHR, 0.45; 95% CI: 0.27-0.78 [CSM]) compared to participants who did not get vaccinated. Conclusion: In evolving epidemic contexts, these findings underscore the need for communication strategies as well as flexible digital proximity tracing app adjustments that accommodate different preventive measures and their anticipated interactions.

Changes in Healthcare Utilization During the COVID-19 Pandemic and Potential Causes-A Cohort Study From Switzerland

Objectives: To describe the frequency of and reasons for changes in healthcare utilization in those requiring ongoing treatment, and to assess characteristics associated with change, during the second wave of the pandemic. Methods: Corona Immunitas e-cohort study (age ≥20 years) participants completed monthly questionnaires. We compared participants reporting a change in healthcare utilization with those who did not using descriptive and bivariate statistics. We explored characteristics associated with the number of changes using negative binomial regression. Results: The study included 3,190 participants from nine research sites. One-fifth reported requiring regular treatment. Among these, 14% reported a change in healthcare utilization, defined as events in which participants reported that they changed their ongoing treatment, irrespective of the reason. Reasons for change were medication changes and side-effects, specifically for hypertension, or pulmonary embolism treatment. Females were more likely to report changes [Incidence Rate Ratio (IRR) = 2.15, p = 0.002]. Those with hypertension were least likely to report changes [IRR = 0.35, p = 0.019]. Conclusion: Few of those requiring regular treatment reported changes in healthcare utilization. Continuity of care for females and chronic diseases besides hypertension must be emphasized.

Factors Associated With COVID-19 Non-Vaccination in Switzerland: A Nationwide Study

Objectives: We compared socio-demographic characteristics, health-related variables, vaccination-related beliefs and attitudes, vaccination acceptance, and personality traits of individuals who vaccinated against COVID-19 and who did not vaccinate by December 2021. Methods: This cross-sectional study used data of 10,642 adult participants from the Corona Immunitas eCohort, an age-stratified random sample of the population of several cantons in Switzerland. We used multivariable logistic regression models to explore associations of vaccination status with socio-demographic, health, and behavioral factors. Results: Non-vaccinated individuals represented 12.4% of the sample. Compared to vaccinated individuals, non-vaccinated individuals were more likely to be younger, healthier, employed, have lower income, not worried about their health, have previously tested positive for SARS-CoV-2 infection, express lower vaccination acceptance, and/or report higher conscientiousness. Among non-vaccinated individuals, 19.9% and 21.3% had low confidence in the safety and effectiveness of SARS-CoV-2 vaccine, respectively. However, 29.1% and 26.7% of individuals with concerns about vaccine effectiveness and side effects at baseline, respectively vaccinated during the study period. Conclusion: In addition to known socio-demographic and health-related factors, non-vaccination was associated with concerns regarding vaccine safety and effectiveness.

Worries and anxiety in parents of adult survivors of childhood cancer: A report from the Swiss Childhood Cancer Survivor Study-Parents

OBJECTIVE

Having a child diagnosed with cancer is distressing for parents. We aimed to compare worries and anxiety in parents of adult childhood cancer survivors with parents of the Swiss general population (GP-parents), and to evaluate characteristics associated with worry in parents of survivors.

METHODS

We conducted a nationwide, population-based study in parents of survivors (survivors aged ≥20 years at study, ≤16 years at diagnosis, >5 years post diagnosis) and GP-parents (≥1 child aged ≥20 years at study). We used the Worry and Anxiety Questionnaire (WAQ), and computed the WAQ total score (worries; possible range 0-80) and caseness for generalized anxiety disorder (anxiety), cognitive, somatic, and any criteria. We used multilevel, multivariable linear regression to identify characteristics associated with worries in parents of survivors.

RESULTS

We included 787 parents of 513 survivors (41.0% fathers) and 478 GP-parents (42.3% fathers). Parents of survivors and GP-parents did not differ regarding worries (16.6 vs. 17.1, p = .977), anxiety (2.7% vs. 3.6%, p = .536), cognitive (p = .440), and somatic criteria (p = .067). Less parents of survivors met any criteria (17.7% vs. 24.0%, p = .039). Half of parents reported current cancer-related worries. Higher cancer-related worries were reported by mothers (β = 4.1; 95% CI: 2.0-6.2), parents with one child (β = 5.9; 95% CI: 2.0-9.7), currently experiencing disadvantages because of their child's former disease (β = 7.3; 95% CI: 4.0-10.6), or with support needs (β = 9.0; 95% CI: 3.9-14.2; p = .001).

CONCLUSIONS

It is encouraging that most parents of adult survivors report similar worries and anxiety as GP-parents, but cancer-related worries are still prevalent. Efforts should be made to empower parents to seek psycho-social support if required.

Changes in socioeconomic resources and mental health after the second COVID-19 wave (2020-2021): a longitudinal study in Switzerland

BACKGROUND

During the 2020/2021 winter, the labour market was under the impact of the COVID-19 pandemic. Changes in socioeconomic resources during this period could have influenced individual mental health. This association may have been mitigated or exacerbated by subjective risk perceptions, such as perceived risk of getting infected with SARS-CoV-2 or perception of the national economic situation. Therefore, we aimed to determine if changes in financial resources and employment situation during and after the second COVID-19 wave were prospectively associated with depression, anxiety and stress, and whether perceptions of the national economic situation and of the risk of getting infected modified this association.

METHODS

One thousand seven hundred fifty nine participants from a nation-wide population-based eCohort in Switzerland were followed between November 2020 and September 2021. Financial resources and employment status were assessed twice (Nov2020-Mar2021, May-Jul 2021). Mental health was assessed after the second measurement of financial resources and employment status, using the Depression, Anxiety and Stress Scale (DASS-21). We modelled DASS-21 scores with linear regression, adjusting for demographics, health status, social relationships and changes in workload, and tested interactions with subjective risk perceptions.

RESULTS

We observed scores above thresholds for normal levels for 16% (95%CI = 15-18) of participants for depression, 8% (95%CI = 7-10) for anxiety, and 10% (95%CI = 9-12) for stress. Compared to continuously comfortable or sufficient financial resources, continuously precarious or insufficient resources were associated with worse scores for all outcomes. Increased financial resources were associated with higher anxiety. In the working-age group, shifting from full to part-time employment was associated with higher stress and anxiety. Perceiving the Swiss economic situation as worrisome was associated with higher anxiety in participants who lost financial resources or had continuously precarious or insufficient resources.

CONCLUSION

This study confirms the association of economic stressors and mental health during the COVID-19 pandemic and highlights the exacerbating role of subjective risk perception on this association.

Is living in a household with children associated with SARS-CoV-2 seropositivity in adults? Results from the Swiss national seroprevalence study Corona Immunitas

BACKGROUND

We aimed to determine whether living in a household with children is associated with SARS-CoV-2 seropositivity in adults and investigated interacting factors that may influence this association.

METHODS

SARS-CoV-2 serology testing was performed in randomly selected individuals from the general population between end of October 2020 and February 2021 in 11 cantons in Switzerland. Data on sociodemographic and household characteristics, employment status, and health-related history was collected using questionnaires. Multivariable logistic regression was used to examine the association of living with children <18 years of age (number, age group) and SARS-CoV-2 seropositivity. Further, we assessed the influence of reported non-household contacts, employment status, and gender.

RESULTS

Of 2393 working age participants (18-64 years), 413 (17.2%) were seropositive. Our results suggest that living with children and SARS-CoV-2 seropositivity are likely to be associated (unadjusted odds ratio (OR) 1.22, 95% confidence interval [0.98-1.52], adjusted OR 1.25 [0.99-1.58]). A pattern of a positive association was also found for subgroups of children aged 0-11 years (OR 1.21 [0.90-1.60]) and 12-17 years (OR 1.14 [0.78-1.64]). Odds of seropositivity were higher with more children (OR 1.14 per additional child [1.02-1.27]). Men had higher risk of SARS-CoV-2 infection when living with children than women (interaction: OR 1.74 [1.10-2.76]).

CONCLUSIONS

In adults from the general population living with children seems associated with SARS-CoV-2 seropositivity. However, child-related infection risk is not the same for every subgroup and depends on factors like gender. Further factors determining child-related infection risk need to be identified and causal links investigated.

TRIAL REGISTRATION

https://www.isrctn.com/ISRCTN18181860 .

Recommendations for the surveillance of mental health problems in childhood, adolescent, and young adult cancer survivors: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Survivors of childhood, adolescent, and young adult (diagnosed when <25 years of age) cancer are at risk of mental health problems. The aim of this clinical practice guideline is to harmonise international recommendations for mental health surveillance in survivors of childhood, adolescent, and young adult cancer. This guideline was developed by a multidisciplinary panel of experts under the sponsorship of the International Guideline Harmonization Group. We evaluated concordance among existing survivorship clinical practice guidelines and conducted a systematic review following evidence-based methods. Of 7249 studies identified, 76 articles from 12 countries met the inclusion criteria. Recommendations were formulated on the basis of identified evidence in combination with clinical considerations. This international clinical practice guideline strongly recommends mental health surveillance for all survivors of childhood, adolescent, and young adult cancers at every follow-up visit and prompt referral to mental health specialists when problems are identified. Overall, the recommendations reflect the necessity of mental health surveillance as part of comprehensive survivor-focused health care.

The Corona Immunitas Digital Follow-Up eCohort to Monitor Impacts of the SARS-CoV-2 Pandemic in Switzerland: Study Protocol and First Results

Objectives: To describe the rationale, organization, and procedures of the Corona Immunitas Digital Follow-Up (CI-DFU) eCohort and to characterize participants at baseline.

Methods: Participants of Corona Immunitas, a population-based nationwide SARS-CoV-2 seroprevalence study in Switzerland, were invited to join the CI-DFU eCohort in 11 study centres. Weekly online questonnaires cover health status changes, prevention measures adherence, and social impacts. Monthly questionnaires cover additional prevention adherence, contact tracing apps use, vaccination and vaccine hesitancy, and socio-economic changes.

Results: We report data from the 5 centres that enrolled in the CI-DFU between June and October 2020 (covering Basel City/Land, Fribourg, Neuchâtel, Ticino, Zurich). As of February 2021, 4636 participants were enrolled and 85,693 weekly and 27,817 monthly questionnaires were collected. Design-based oversampling led to overrepresentation of individuals aged 65+ years. People with higher education and income were more likely to enroll and be retained.

Conclusion: Broad enrolment and robust retention of participants enables scientifically sound monitoring of pandemic impacts, prevention, and vaccination progress. The CI-DFU eCohort demonstrates proof-of-principle for large-scale, federated eCohort study designs based on jointly agreed principles and transparent governance.

"I don't take for granted that I am doing well today": a mixed methods study on well-being, impact of cancer, and supportive needs in long-term childhood cancer survivors

PURPOSE

With increasing numbers of childhood cancer survivors (CCS), it is important to identify the impact of cancer and CCS' needs for support services that can mitigate the long-term impact on psychosocial wellbeing, including health-related quality of life (HRQOL). We aimed (1) to describe survivors' wellbeing, impact of cancer, and supportive care needs and (2) to determine how socio-demographic or clinical characteristics and impact of cancer relate to survivors' unmet needs.

METHOD

In this mixed methods study, a quantitative survey was used to assess HRQOL, psychological distress, impact of cancer, and supportive care needs. Qualitative interviews were conducted to explore the meaning of wellbeing, health, and impact of cancer.

RESULTS

Overall, 69 CCS participated in the survey of which 28 participated in qualitative interviews (aged ≥ 18 years, diagnosed with cancer ≤ 18 years). Few CCS (13%) reported poor physical HRQOL, but almost half reported poor mental HRQOL (49%) and psychological distress (42%). Health was considered to encompass both: physical and emotional aspects of wellbeing. Cancer positively impacted CCS' ability to care and attitude towards life, whereas relationships and insurance were negatively impacted. Risks for unmet needs increased in CCS with self-reported low health status, late effects, psychological distress, with older age at study or longer time since end of treatment.

CONCLUSION

In our study, many CCS experienced various psychosocial, psychological and informational unmet needs, indicating that survivors' needs are currently not duly addressed. Current efforts to provide supportive psychosocial care in Switzerland should be further operationalized to provide adequate support.

The long shadow of childhood cancer: a qualitative study on insurance hardship among survivors of childhood cancer

BACKGROUND

The long-term consequences of childhood cancer have received increasing attention due to the growing number of survivors over the past decades. However, insurance hardships of survivors are mostly unknown. This study explored qualitatively, in a sample of childhood cancer survivors (CCS), (i) the experiences and needs of CCS living in Switzerland with a special focus on hardships related to insurance; and (ii) the views of insurance and law experts with experience on childhood cancer.

METHODS

Semi-structured interviews were conducted with 28 childhood cancer survivors and 3 experts (one legal expert, two insurance experts). Data was analysed using qualitative content analysis.

RESULTS

Three key themes emerged from the interviews with the CCS: 1) experiences with insurance, 2) perception of discrimination, and 3) needs and barriers for support. The interviewed experts provided further detailed clarification of CCS' concerns. Our findings indicated that some CCS can move past their cancer history, while others continue to face hardships. CCS reported confusion about the opportunities and services within the social security system and most relied on their personal contacts for guidance. Finally, CCS expressed a strong need for socio-economic and legal support for social insurance questions, especially related to disability insurance.

CONCLUSIONS

With the growing population of CCS, it is essential to further assess the interplay between medical and psychosocial health and socio-economic hardship. Supportive psychosocial services should aim to ameliorate insurance hardships. Better understanding of the relationship between childhood cancer and insurance hardships during survivorship will inform efforts to improve long-term financial security and health outcomes for survivors. We call for the public, lawmakers, researchers, insurers, and patient organizations to come together and discuss future perspectives to avoid the risk of discrimination for cancer survivors.

The unmet needs of childhood cancer survivors in long-term follow-up care: A qualitative study

OBJECTIVE

Evidence suggests benefits of long-term follow-up care attendance for childhood cancer survivors, but studies show poor inclusion of survivorship issues and needs. While information needs of childhood cancer survivors have been addressed previously, few studies specifically investigated the supportive care needs of survivors beyond the domain of information and communication. Therefore, this qualitative study aimed to assess the unmet needs of childhood cancer survivors with regards to their long-term survivorship.

METHODS

Childhood Cancer Switzerland invited survivors of childhood cancer to participate in our study. We used semistructured interviews to assess survivors' experiences regarding the impact of their disease and the (un)met needs during their survivorship. Data analysis followed the principles of qualitative content analysis.

RESULTS

Interviews were conducted with 28 childhood cancer survivors (mean age 31 years, age at diagnosis 9 years, time since end of treatment 19 years). Key themes in relation to unmet needs of survivors were (1) lacking psychosocial support, (2) lacking collaboration and decentralization of care, (3) starting from zero, and (4) need for centralized, specialized, and individualized services.

CONCLUSIONS

Our findings revealed a demand for integrating psychosocial support in long-term follow-up care and a strong need for personalized, centralized, and interdisciplinary long-term follow-up care. Current established interdisciplinary clinics should be further extended to provide centralized, personalized, and evidence-based long-term follow-up care including adequate psychosocial support for all childhood cancer survivors.

Healthcare professionals' opinions on psychological screening in follow-up care for childhood cancer survivors

INTRODUCTION

Implementation of screening for psychological distress in populations at risk, as recommended in existing guidelines, can be challenging on different levels: structural, organisational and personal (provider and patient). A specific group at risk for psychological distress, including anxiety and depression, is the growing population of childhood cancer survivors (CCS). In many countries, including Switzerland, the standardised assessment of psychological late effects during follow-up care is not yet established. The emotion thermometer, a short and validated assessment tool to screen for psychological distress, might facilitate implementation of psychological screening in Swiss CCS follow-up care.

AIMS OF THE STUDY

To inform implementation strategy and assess readiness of centres to integrate standardised psychological screening, we conducted a cross-sectional survey. We describe healthcare professionals&rsquo; opinions on (i) the current standard of psychological screening in follow-up care, (ii) their experience using the emotion thermometer, and (iii) perceived barriers and facilitators of possible implementation of psychological screening, including the emotion thermometer.

METHODS

We contacted 49 healthcare professionals involved in CCS follow-up care in all nine paediatric oncology clinics in Switzerland. The electronic survey included closed and open questions.

RESULTS

A majority of the healthcare professionals (17/24, 71%) stated that assessment of psychological distress is currently not standard in follow-up care. On the contrary, about half of them (11/24, 46%) think that psychological distress is adequately assessed in follow-up care. None of the participants had any previous experience with the emotion thermometer. After being informed about the emotion thermometer, nearly 80% (19/24) agree that it appears to be a good screening instrument and support the idea of regular application during follow-up care. Facilitators of implementation included the instrument&rsquo;s brevity, its ability to visualise psychological topics and raising awareness of the need to think about the psychological side of follow-up care. Barriers included lack of time, the additional effort and the perception that instead an informal assessment would be sufficient. Concerns about using an artificial assessment, rather than a natural conversation, were also expressed.

CONCLUSIONS

There is overall agreement that screening for psychological late effects is not yet standard in follow-up care in Switzerland. It is important to mitigate perceived barriers and concerns of healthcare professionals to enable a successful implementation of psychological distress screening according to the established standards of care.

Post-traumatic stress in parents of long-term childhood cancer survivors compared to parents of the Swiss general population

BACKGROUND

We describe post-traumatic stress symptoms (PTSS) and post-traumatic stress disorder (PTSD) in parents of long-term childhood cancer survivors (CCS-parents) and compare them to parents of similar-aged children (comparison-parents) of the Swiss general population (SGP). We compare type of reported stressful event, prevalence of PTSS and PTSD, and psychosocial and cancer-related characteristics associated with PTSS. We further describe the respective normative data for the SGP.

METHODS

We conducted a nationwide cross-sectional questionnaire survey in a population-based sample of long-term CCS-parents (survivors aged ≤16 years at diagnosis, ≥20 years at study, >5 years post-diagnosis) and in the SGP. Using the Impact of Event Scale-Revised, we measured PTSS regarding the most stressful event experienced, and computed probable cases of PTSD.

RESULTS

Participants included 663 CCS-parents (39.4% fathers) and 1035 individuals of the SGP (40.0% male), of which we identified 391 comparison-parents (41.2% fathers). Illness was most often indicated as stressful event (CCS-parents: 49.5%, comparison-parents: 27.6%, SGP: 25.3%). Prevalence of PTSS and PTSD (CCS-parents: 4.8%, comparison-parents: 6.7%, SGP: 5.6%) did not significantly differ. Lower education was associated with higher intrusion, avoidance, and hyperarousal in all samples (all P ≤ .003). Parents of children with a chronic illness reported higher intrusion (all P ≤ .004). We found no associations with cancer-related characteristics.

CONCLUSIONS

No increased risk for PTSS or PTSD was found among CCS-parents. Individuals with lower education and those with a chronically ill child might benefit from additional support to help manage and resolve the stress symptoms in the long term.

Genotyping of clinically relevant human adenoviruses by array-in-well hybridization assay

A robust oligonucleotide array-in-well hybridization assay using novel up-converting phosphor reporter technology was applied for genotyping clinically relevant human adenovirus types. A total of 231 adenovirus-positive respiratory, ocular swab, stool and other specimens from 219 patients collected between April 2010 and April 2011 were included in the study. After a real-time PCR amplification targeting the adenovirus hexon gene, the array-in-well assay identified the presence of B03 (n = 122; 57.5% of patients), E04 (29; 13.7%), C02 (21; 9.9%), D37 (14; 6.6%), C01 (12; 5.7%), C05 (5; 2.4%), D19 (4; 1.9%), C06 (2; 0.9%), D08 (1; 0.5%), A31 (1; 0.5%) and F41 (1; 0.5%) genotypes among the clinical sample panel. The typing result was obtained for all specimens that could be amplified (n = 223; 97%), and specificity of the typing was confirmed by sequencing specimens representing each of the different genotypes. No hybridization signal was obtained in adenovirus-negative specimens or specimens with other viruses (n = 30). The array-in-well hybridization assay has great potential as a rapid and multiplex platform for the typing of clinically relevant human adenovirus genotypes in different specimen types.

Flow cytometry in comparison with mitotic index in predicting disease outcome in transitional-cell bladder cancer

The DNA content and S-phase fraction were measured by flow cytometry in 448 tumour biopsy specimens from transitional-cell bladder cancer (TCC). The samples were also analyzed for mitotic index, WHO grade and papillary status, and histological and flow cytometric data were then correlated to clinical behaviour of tumours during a mean follow-up period of 9.9 years. TNM classification, WHO grade, papillary status, mitotic index, DNA ploidy and S phase fraction were significantly interrelated. Twenty-four percent of tumours showed heterogeneous DNA indices when measured from multiple samples (measured in 94 cases). Of the histological parameters, independent predictors of progression in superficial tumours were the S-phase fraction and mitotic index. In superficial tumours, S-phase fraction and the mitotic index included all the available independent prognostic information in survival analysis, whereas in muscle-invasive tumours T category was the most important prognostic factor. The results suggest that DNA ploidy has no independent prognostic value in transitional-cell bladder cancer, whereas proliferation indices (SPF, mitotic index) are important prognostic factors. Accordingly, malignancy classification of papillary bladder tumours can be based on proliferation indices alone. Nodular tumours run an unfavourable course and their malignancy grading by flow cytometry or by mitotic index is not relevant.

Grading of superficial bladder cancer by quantitative mitotic frequency analysis

A cohort of 270 superficial (stages Ta to T1) transitional cell bladder tumors was followed for more than 8 years. World Health Organization (WHO) grade, papillary status and 2 mitotic indexes were related to progression, recurrence-free survival and bladder cancer related survival during followup. Mitotic activity index and volume corrected mitotic index were significantly related to WHO grade and papillary status (p < 0.0001). WHO grade, papillary status and mitotic indexes were related significantly to progression in univariate analysis (p < 0.001) whereas in a multivariate analysis only volume corrected mitotic index included independent prognostic information (p < 0.001). Recurrence-free survival was related to volume corrected mitotic index in the entire cohort (p = 0.03) and in papillary tumors (p = 0.07). Bladder cancer related survival was related to WHO grade, papillary status, mitotic activity index and volume corrected mitotic index (all p < 0.0001). In papillary tumors mitotic activity index (p < 0.0001), volume corrected mitotic index (p < 0.0001) and WHO grade (p = 0.0036) predicted survival. In multivariate analysis mitotic activity index predicted independently recurrence-free survival in the entire cohort (p = 0.043) and in papillary tumors (p = 0.012). Bladder cancer survival in the entire cohort and in papillary tumors was related independently to volume corrected mitotic index (p < 0.001). The results show that superficial transitional cell bladder tumors can be efficiently categorized into prognostic groups by quantitative mitotic frequency analysis and the results provide a new classification system for superficial transitional cell bladder tumors.

Prediction of superficial bladder cancer by nuclear image analysis

A cohort of 270 superficial transitional cell bladder tumours (Ta-T1) was followed-up for over 8 years. WHO grade, papillary status and six nuclear factors were related to progression, recurrence-free survival (RFS) and bladder cancer-related survival (BS) during the follow-up period. Mean nuclear area (NA), standard deviation of nuclear area (SDNA), nuclear perimetry (PE), standard deviation of nuclear perimetry (SDPE), shortest nuclear axis (Dmin) and longest nuclear axis (Dmax) were significantly related to WHO grade and papillary status (P < 0.0001). All the nuclear factors were related significantly to progression in univariate analysis (P < 0.01) whereas in a multivariate analysis WHO grade (P < 0.0001) and papillary status (P = 0.048) included independent prognostic information. RFS was related to PE (P = 0.009), SDPE (P = 0.013), Dmin (P = 0.021), Dmax (P = 0.028) and SDNA (P = 0.029). In papillary tumours SDPE (P = 0.007) and Dmin (P = 0.024) predicted RFS. BS was related to WHO grade, papillary status, NA, SDNA, PE, Dmax, Dmin (all P < 0.0001) and to SDPE (P = 0.003). In papillary tumours PE (P < 0.0001), Dmax (P = 0.0022), Dmin (P = 0.0027), WHO grade (P = 0.0036), NA (P = 0.0005), SDNA (P = 0.0355) and SDPE (P = 0.0718) predicted BS. In multivariate analysis SDPE (P = 0.029) predicted RFS and survival was related to WHO grade (P < 0.001) and PE (P = 0.014) independently. In papillary tumours only Dmax (P = 0.001) predicted survival independently. The results show that superficial papillary transitional cell bladder tumours can be efficiently categorised into prognostic groups by nuclear image analysis and the results provide a new classification system for superficial papillary bladder tumours. Tumours with high nuclear factor values should be considered for radical primary therapy and adjuvant therapy after transurethral resections.

Tumour infiltrating lymphocytes as an independent prognostic factor in transitional cell bladder cancer

The prognostic value of tumour infiltrating lymphocytes (TIL) was assessed in a cohort of 514 patients with a transitional cell bladder cancer (TCC) during a follow up period of over 9 years. The density of TIL were positively correlated to WHO grade (P < 0.0001), non-papillary growth architecture (P < 0.0001), morphometric nuclear factors (P < 0.007) and volume corrected mitotic index (M/V index) (P < 0.0001). Dense TIL predicted progression in Ta-T1 tumours (P < 0.0006) whereas in a multivariate analysis they had no independent predictive value. Dense TIL were related to short recurrence-free survival in Ta-T1 tumours in a univariate analysis (P = 0.06) as well as in a multivariate analysis (P = 0.005). Dense TIL predicted unfavourable prognosis in the entire cohort (P = 0.0316) and in papillary tumours (P = 0.062) whereas in nodular tumours TIL were a sign of good prognosis (P = 0.0141). Also in T3-T4 tumours TIL were related to less aggressive behaviour of TCC (P = 0.0259). In a multivariate analysis including clinical stage (T-category), WHO grade, papillary status, six morphometric nuclear factors and M/V index dense TIL were a highly significant indicator of a favourable prognosis (P = 0.007). Particularly TIL categorized rapidly proliferating TCC into prognostic groups (P = 0.001). The results show that TIL are a sign of efficient host defence mechanisms in TCC and TIL predict a favourable prognosis in invasive TCC.

Clinical prognostic factors in transitional cell cancer of the bladder

A cohort of 537 patients with transitional cell cancer of the bladder (TCC) were followed up for a mean of 9 years and the clinicopathological data were related to prognosis. The T category (p < 0.0001), N category (p < 0.0001) and M category (p < 0.0001) were the most important clinical prognostic factors, followed by the age of the patient (p < 0.0001). Of the histological variables the WHO grade (p < 0.0001), papillary status (p < 0.0001) and the presence of R3-4 cells in voided urine (p = 0.0061) predicted unfavorable prognosis. In Ta-T1 tumors the WHO grade (p < 0.0001), papillary status (p < 0.0001) and the age of the patient (p < 0.0001) had a prognostic value in univariate analysis. In Cox's analysis independent predictors of survival were the T category (p < 0.0001), WHO grade (p < 0.0001), patient age (p < 0.0001), papillary status (p = 0.012) and the presence of symptoms before diagnosis (p = 0.033). In superficial tumors the WHO grade (p < 0.0001) and patient age (p < 0.0001) were independent predictors of survival.

Prognostic factors in nodular transitional cell bladder tumours

A cohort of 106 nodular transitional cell bladder cancers (TCC) were followed up for a mean of 9 years. Clinical stage, WHO grade, six morphometric nuclear factors and volume corrected mitotic index (M/V index) were correlated to progression and survival during the follow-up period. Nuclear factors were related to WHO grade with a borderline significance (p = 0.01-0.3) whereas the M/V index showed a highly significant relation to WHO grade. Neither nuclear factors nor the M/V index were related significantly to T-, N- or M-categories at the time of diagnosis. Progression in N- and M-categories was related independently to WHO grade whereas progression in T-category could not be predicted significantly by none of the variables included in this analysis. Survival was predicted by T-category (p = 0.0028), N-category (p = 0.0001), M-category (p = 0.0057) and M/V index (p = 0.010). In T1-T2N0M0 tumours survival was predicted by the Dmax (p = 0.015) and by the M/V index (p = 0.039). In multivariate survival analysis T-category (p < 0.001) had independent prognostic value. In T1-T2N0M0 tumours only the M/V index predicted survival independently (p = 0.007). The results show that only the proliferation rate in addition to T-category have prognostic significance in nodular TCC.

Prognostic factors in WHO grade 2 transitional-cell bladder cancer (TCC); a novel two-grade classification system for TCC based on mitotic index

A retrospective histological analysis has been carried out on 537 cases of transitional-cell bladder carcinoma, followed-up over a period of 9 years. In the first part of the study WHO grade 2 tumours were analysed and a number of independent factors predictive for survival identified. In a multivariate analysis the T category and M/V index (number of mitotic figures/mm2 neoplastic epithelium) were the most important prognostic factors. In a subsequent analysis of the whole series of 537 cases, overall the M/V index was not as important in predicting survival as the stage of the tumour. However, in superficial tumours (Ta-T1) subsequent analysis showed that the M/V index alone could be used to predict survival.

Transmediastinal esophagectomy and colon interposition without thoracotomy

In the Central Hospital of Central Finland (responsibility for 250,000 inhabitants) the technique of transmediastinal esophagectomy and colon interposition without thoracotomy was used on 19 consecutive patients in the years 1983-1988. Fourteen of the patients had a malignant and five a benign disease. The type of cancer was squamous cell cancer in 13, and adenocancer in 1 case. All five patients with a benign disease had an etiology of corrosion by various agents. Two of them had a spontaneous rupture. In three cases the perforation occurred as a complication of endoscopic dilatation. There were no peroperative but one postoperative death. Six minor complications were well under control. The survival rate of cancer patients is comparable with the results reported by other authors. All five patients with a benign disease are in excellent condition with a follow up time from 4 to 100 months (mean 44 mo).

Independent clinical, histological and quantitative prognostic factors in transitional-cell bladder tumours, with special reference to mitotic frequency

A cohort of 537 transitional-cell bladder cancers (TCC) was followed up for a mean of 9 years. Clinical stage, WHO grade, papillary status, 6 nuclear factors and volume-corrected mitotic index (M/V index) were related to progression and survival. Classic and quantitative prognostic factors were significantly interrelated (p less than 0.001). In Ta-Tl tumours M/V index predicted progression independently (p less than 0.001) and in the entire cohort progression was related independently to the M/V index (p = 0.0001) and to the WHO grade (p = 0.0022). In survival analysis, clinical stage (p less than 0.0001), M/V index (p less than 0.0001), WHO grade (p less than 0.0001), papillary status (p less than 0.0001) and nuclear factors (p less than 0.0001) were significant predictors. In papillary tumours, clinical stage (p less than 0.0001), M/V index (p less than 0.0001), WHO grade (p less than 0.0001) and nuclear factors (p = 0.0001-0.0133) were related to survival. In a multivariate analysis T-category (p less than 0.001), WHO grade (p less than 0.001), M/V index (p = 0.002) and papillary status (p = 0.034) predicted survival independently in the entire cohort whereas in papillary tumours T-category (p less than 0.001) and M/V index (p less than 0.001) were independent predictors. If tumours with pelvic lymph-node metastases or distant metastases at diagnosis were excluded from the analysis, T-category (p less than 0.001), M/V index (p less than 0.001) and WHO grade (p less than 0.001) were independent predictors. In papillary tumours T-category (p less than 0.001), M/V index (p less than 0.001) and WHO grade (p = 0.048) predicted survival. The results emphasize the importance of mitotic activity as a most important histological prognostic factor in TCC, second only to clinical stage. In Ta-TI tumours quantitative mitotic frequency analysis includes all the available independent prognostic information. Accordingly, TCC can be graded by mitotic frequency analysis in place of subjective grading systems.

Treatment with antioxidant and other nutrients in combination with chemotherapy and irradiation in patients with small-cell lung cancer

Eighteen non-randomized patients with small cell lung cancer (4 women and 14 men, mean age 60.4, SD 7.8 years) received in addition to conservation small cell lung cancer treatment antioxidant treatment with vitamins, trace elements and fatty acids. All patients were out-patients who, except for one were also treated with chemotherapy and/or irradiation at regular intervals at a university of central hospital. Five patients (28%) were in an advanced stage of the disease. At the end of the follow-up period (31.7.90) the median survival time for the whole group was 505 days. Fourteen (77%) of the patients survived for more than 12 months and six patients (33%) for more than two years. One patient (5%) survived more than five years. Eight patients (44%) were still alive with a mean survival time of 32 months at the end of the study. Ten patients succumbed earlier from progression of the disease. Antioxidant treatment, in combination with chemotherapy and irradiation, prolonged the survival time of patients with small cell lung cancer compared to most published combination treatment regimens alone. We also noticed that the patients receiving antioxidants were able to tolerate chemotherapy and radiation treatment well. Surviving patients started antioxidant treatment in general earlier than those who succumbed.

Is it possible to reduce the number of cerebral complications in carotid endarterectomy?

An effort was made to reduce the number of cerebral complications in carotid endarterectomy by focusing attention on the perioperative prevention of embolism and thrombosis in a prospective series of carotid endarterectomies (group I, n = 62) performed during a 24 months' period 1982-1984 in Tampere University Hospital. Controls were two other series of carotid endarterectomies (group II, n = 60, and group III, n = 60) comprising all 120 carotid endarterectomies carried out by other trained vascular surgeons in the same hospital during the years 1976-1984. During the first 30 postoperative days there were no deaths, one stroke and one TIA in group I. On the other hand there were three deaths, seven strokes and five TIAs in group II and four deaths, two strokes and three TIAs in group III. The number of cerebral complications in carotid endarterectomy was significantly less in the study group than in the control groups, and thus it was possible to reduce the perioperative complications in carotid endarterectomy possibly by pre- and postoperative drug treatment and routine intraoperative heparinization.

The protective effect of guar gum against stress-induced gastric ulcers in the rat

After the methodology had been studied and pilot studies conducted, nine groups of rats (10 rats per group) were fed solutions of different compositions via orogastric tube during induction of stress ulcers by resistant and a cold ambient temperature. The first group was a control group and received no feeding. Group 2 rats received distilled water, group 3 rats guar gum in distilled water, group 4 rats wheat flour (placebo) in distilled water, group 5 rats a 10% solution of glucose in distilled water, group 6 rats guar gum in the 10% glucose solution, group 7 rats wheat flour in the 10% glucose solution, group 8 rats a 30% glucose solution and group 9 rats cimetidine, intraperitoneally. Cimetidine provided the best protection against stress-induced ulcers. Guar gum in distilled water was almost as effective as cimetidine. Slightly fewer rats (30%) exhibited ulcers in the guar gum group than in the cimetidine group (40%). However, the ulcers in the guar gum group were larger than those in the cimetidine groups. The percentage of rats with ulcers and the percentage of the largest category of ulcers decreased as the energy content of the solutions changed from 10% to 30% glucose and from the control percentages. The protective effect of guar gum in distilled water was reduced when it was infused in a 10% glucose solution. In the latter solution, the effect of guar gum was similar to that in the rats given wheat flour (placebo) in a 10% glucose solution.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosing mammary cancer among an unselected Finnish population. Proposal for practical improvements

A total of 309 new mammary cancer patients were found in three successive years among 250,000 unselected Finns showing an annual rate of 1.08 cancers per 1000 women over 20 years of age. The main preoperative examinations were palpation and mammography. Palpation alone was performed preoperatively in 158 (51 percent) patients, palpation and mammography in 120 (38 percent), and the tumor was nonpalpable and found only in mammography in 31 (10 percent) patients. Fine-needle biopsy with palpation was performed in 191 (62 percent) patients and it confirmed definite malignancy in 89 cases, that is in 47 percent of the biopsied patients and in 29 percent of all patients. Mammography was most valuable in small tumors and fine-needle biopsy in large ones. The number of mammographies performed in the whole population per each new cancer case was 50; it seems unreasonable to increase the number of mammographies performed. It seems that the best way to improve the present preoperative evafuation of mammary cancer patients would be to perform a fine-needle biopsy under stereotactic guidance in every patient, and especially in those with a small tumor.

Patient satisfaction among day surgery patients in a central hospital

Satisfaction among patients treated one year before day surgery in a central hospital was studied by questionnaires, sent to 100 and returned by 70 patients. The satisfaction before surgery was positive in 74% and negative in 6% of the patients. Based on their experiences from surgery, patients satisfaction improved in 59%, and did not decline. The preferred waiting times to the out-patients examination and also between this and the operation day was 8-10 weeks. Except for patients unable to work (mostly orthopedic patients) very short waiting times were difficult. Hospital arrangements during the treatment day (before, during and after the operation) were considered very good by 56 to 62%, good by 31-40%, satisfactory by 1-6%, and weak by 0-1% of the patients. In all, 96% of the patients would be ready to return to day surgery. The two patients who would refuse had difficulties at discharge. Thus day surgery has had a positive effect on surgical patient satisfaction. The most important improvement was increased surgical availability. In order to improve satisfaction further, patients unable to work as a result of their surgical problem should be treated almost immediately.

Immediate effect of vagotomy on pancreatic insulin secretion

The effect of vagotomy and gastric resection on insulin secretion was examined by the glucagon stimulated C-peptide test in gastrectomy patients (n = 11) without truncal vagotomy and in total gastrectomy patients (n = 10) with truncal vagotomy. The test was performed twice in each patient: 10 minutes after the midline incision was made and then 60 to 90 minutes later when gastric resection or total gastrectomy was completed, during the reconstructive phase of the operation. Gastric resection without truncal vagotomy was followed by a higher increase (48%) in serum C-peptide concentration caused by glucagon stimulation than total gastrectomy with truncal vagotomy (13%). There was a significant (p less than 0.05) increase in the glucagon stimulated glucose-related C-peptide concentration in patients without truncal vagotomy, whereas truncal vagotomy inhibited this increase. These results suggest that truncal vagotomy will produce a reduction in stimulated insulin secretion in humans.

Postprandial blood concentrations of insulin-independent carbohydrate, galactose, in oral test after gastric surgery

In order to examine the postprandial blood concentrations of insulin-independent carbohydrates after gastric surgery oral galactose test (1.65 g/kg body weight in water, 33%, w/v) was performed in 55 symptomatic patients and in 5 healthy subjects. There were patients after total gastrectomy (TG) (n = 17), gastric resection with (GRS, n = 17) or without (GR; n = 12) selective vagotomy, and after proximal selective vagotomy (PSV, n = 9). The patients had immediately after drinking the test solution a 2- to 5-fold higher blood galactose concentration than the healthy subjects. The TG patients had the most rapid, the healthy subjects the slowest and the GR and GRS patients an intermediate rapid, immediate increase of blood galactose concentration. The TG patients showed a plateau 40-60 min and a decrease 60-90 min after the start of the test. The PSV patients showed a plateau 60-90 min after the commencement of the test. The GR and GRS patients and the healthy subjects had a continuous increase in blood galactose concentration during the whole test period, but the maximal point 90 min after the drinking of the solution was lower in the GRS than in the GR patients and lowest in the healthy subjects. The PSV patients had a lower blood galactose curve than the TG, GRS and GR patients but higher than the healthy subjects except the plateau 60-90 min postprandially.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and metabolic effects and wound healing metabolism in controlled total parenteral nutrition with high vs. low nitrogen content for seven days after abdominoperineal rectum resection for carcinoma

The clinical, metabolic and anthropometric effects and wound healing metabolism of two regimens of total parenteral nutrition with different amount of nitrogen low, 0.1 g, and high, 0.3 g/body weight kg/day were examined in this prospective double-blind study in two groups of ten patients subjected to abdominoperineal rectum resection for carcinoma for seven postoperative days. The results showed that the high nitrogen infusion associated with metabolic stress indicated by high excretion of urea, high level of serum urea and by a higher frequency of complications. Five patients of the high and one of the low nitrogen group showed complications (p less than 0.05). Further, the metabolic load, complications and high nitrogen infusion associated with higher body temperature, degree of fatigue, levels of C-reactive proteins, leukocytosis and lower of hand pressure force than found in those with low nitrogen infusion. The patient with low or high nitrogen infusion had similar parameters in wound healing metabolism of incision and stoma. The patients with complications showed a reduced stomal hydroxyproline concentration on the third postoperative day (p less than 0.05) and an increase of stomal and wound hydroxyproline and DNA on the seventh postoperative day (p less than 0.05). It is concluded that nitrogen amount of 0.1 g body weight kg/day is a better and a good alternative as compared to 0.3 g in total parenteral nutrition after major abdominal surgery for carcinoma.

Late results of surgical and nonoperative treatment of carotid stenosis. Eighty-four patients documented by angiography in 1974-1976

The long-term results of carotid endarterectomy are controversial. Here we report the late results of 44 surgically and 40 non-surgically treated patients with carotid stenosis documented by angiography in 1974-1976. The groups were similar with respect to sex-distribution, age, length of follow-up time (median 123.0 and 130.0 months in the surgical and non-surgical groups, respectively) and the occurrence of risk factors. Hypertension was more frequent (p less than 0.05) in the surgical group, as was medical treatment, mostly anticoagulants (p less than 0.06). The angiographic findings were also more severe in this group (p less than 0.001). During the follow-up period the occurrence of cerebrovascular complications (death, stroke and/or TIA) was more frequent in the nonoperated than in the operated group; however, survival of the patients was similar, as the cardiovascular deaths were an equalizing factor. The quality of life in patients alive examined for clinical and neurologic status and by neuropsychological tests and interview was similar, except that the operated patients were more satisfied. The progression of atherosclerosis in the carotid artery assessed by Duplex scanning was more frequent in the nonoperated group. Differences in medical treatment did not explain the results. Thus it is concluded that the late results were better in the operated patients with carotid stenosis than in the nonoperated ones.

Early cerebral complications in carotid endarterectomy: risk factors

Three hundred and thirty one carotid endarterectomies were performed on 279 patients during a period of twenty years from 1965 to 1984. The indication for surgery was transient ischemic attack in 67.4%, stroke in 22.7% and asymptomatic carotid stenosis in 10.0% of the operations. The overall major cerebral complication rate attending the operation was 9.6%. During the last four years' period from 1981 to 1984 the procedure morbidity was 3.6% and there was no mortality. Postoperative complications comprised 31 ipsilateral strokes and one contralateral stroke; the complications occurred during the first 24 hours in 28 cases and on the fourth or fifth day in four cases. Of these patients 11 succumbed to internal carotid thrombosis, one to cerebral infarction without thrombosis and one to intracerebral hemorrhage. The associated factors for major complications were analyzed retrospectively in the light of 32 parameters. Patients of advanced age, patients with type II diabetes mellitus, elevated serum triglycerides, high-grade stenosis or occlusion of the contralateral carotid artery, negative smoking history and those undergoing a second operation proved to be at high risk of early postoperative cerebral complications. These complications can be reduced by intraoperative use of heparin, preoperative ASA treatment and a short clamping time. Also peroperative use of shunt is obviously of benefit.

Metabolic problems after gastric surgery

The findings on dumping syndrome (DS) are not consistent considering its relations with age, sex, weight/height, smoking habits, race, dose of oral glucose, the time elapsed since surgery, the function of exocrine pancreas nor the duration of ulcer symptoms. The patients after total gastrectomy (TG) may present relative postprandial lack of insulin. As a sign of long-term hyperglycemia elevated HbA1 has been measured in DS patients. Oral galactose test may reveal new features of DS. Abnormalities in splanchnic blood circulation as well as release of intestinal hormones are involved with DS. Dietary habits including fibers, pectin and guar gum, play a central role in the prevention and treatment of DS. In unresponsive cases several operative methods have been applied with success. Alkaline reflux gastritis is most often seen after B II and I reconstructions and after pyloroplasty. Chronic diarrhea follows mostly after truncal vagotomy. Ten to 50% of patients after gastrectomy (GE) waste 10 to 20% of their body weight because of decreased food, energy, vitamin and mineral intake caused by eating-related symptoms. Vitamin and mineral supplements, a small snack 20 min before the major meal, digestive enzymes, treatment of colonization with antibiotics and protein foods may help. About 50% of GE patients show iron deficiency anemia. Easily dissolved iron between meals with ascorbic acid give the most effective response. Deficiency of vitamin B12 or of folate may develop as megaloblastic anemia. B12 supplement and antibiotics are effective in bacterial overgrowth, but surgical correction is necessary in troublesome blind loop. Folic acid deficiency is corrected by oral folic acid.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical pharmacokinetics of iron preparations

The principle of iron conservation is the basis of iron metabolism; the normal basal loss of iron from the body is about 1 mg daily in a 70 kg man and 0.8 mg in a 55 kg woman. Iron is lost mainly by the menstrual and gastrointestinal routes. The total iron requirement during pregnancy is 800 mg; in the last month the requirement may amount to 7 to 8 mg/day. Supplementary iron is recommended for many menstruating women, and during the latter part of pregnancy. Correct fetal iron metabolism is ensured by proper maternal iron status, although there are contradictory opinions and findings about the relationship between maternal and fetal iron metabolism. Preterm infants fed on breast milk have a negative iron balance, and require an iron intake of about 0.6 mg/kg/day, and 3.4 mg/1 g haemoglobin, to compensate for intestinal and venesection iron losses, respectively. The absorption of supplementary iron by the preterm infant is a linear function of intake. Preterm infants do not require iron supplements when given repeated blood transfusions. During lactation the total iron losses of the mother are 1 mg/day, and thus no supplementary iron is needed if the iron metabolism has been in balance during the pregnancy. Serum ferritin concentration decreases continuously when iron stores in the body are reduced, and totally empty iron stores are the only known reasons for low serum ferritin concentration. Despite depleted iron stores, serum ferritin concentration can be normal or higher than normal in protein-energy malnutrition, up to 3 months after major surgery, in acute liver damage, in some patients with prolonged hyperglycaemia due to diabetes mellitus, in acute lobar pneumonia, active pulmonary tuberculosis and rheumatoid arthritis on gold therapy, in sepsis secondary to marrow hypoplasia induced by chemotherapy, in heavy drinkers and for a few days after myocardial infarction. In haemochromatosis, iron is deposited in liver (producing fibrosis), pancreas, endocrine glands and heart. The rise in the level of iron in the body is due to increased absorption and/or increased intake. This pathology may occur in transfusions, in alcoholism (especially when alcoholic beverages are contaminated with iron and the diet is low-protein), in several liver diseases, in congenital transferrin deficiency and in idiopathic disease. Patients susceptible to haemochromatosis should receive a low-iron diet. Serum ferritin determination may be helpful in early identification of susceptible members of a family with idiopathic familial haemochromatosis, but transferrin saturation is not a good indicator of either iron depletion or iron overload.(ABSTRACT TRUNCATED AT 400 WORDS)

Mammographic and palpation findings in the irradiated spared breast

Between 1983 and 1987, 22 women underwent breast-preserving treatment for T1 (n = 19) or T2 (n = 3) cancer. Axillary surgery was performed in 17 patients and axillary node "sampling" in one patient, while 4 patients had no axillary surgery. Radiotherapy was begun no later than six weeks after operation. The patients had the first post-treatment follow-up examination at 1 month to 41 months after irradiation. Six of the patients had more than one follow-up examination. According to the length of the follow-up period, there were two different groups of patients. Fourteen patients had the first follow-up examination at 1 month to 10 months after completion of radiation treatment. Eleven breasts (79%) had solid consistency as well as radiological edema. Six of the breasts had signs of severe edema seen during the first 6 months. At the second or third examination, if made after 10 months, the signs of edema decreased or disappeared. Eight patients examined for the first time at 12 to 41 months after radiation treatment had no radiological signs of breast edema and only 3 of the breasts were solid. The present results suggest that post-treatment mammograms are not useful during the first 6 months after irradiation and that the value of palpation is limited to at least 10 months; in selected patients these periods can be considerably longer.

Late carotid restenosis: aetiologic factors for recurrent carotid artery stenosis during long-term follow-up

During a fourteen-year-period 257 patients underwent carotid endarterectomy in an unselected population of 700,000 inhabitants. The incidence of haemodynamically significant restenosis was 13.5% in 133 vessels in 116 patients studied by duplex scanning 28 to 209 months following carotid endarterectomy. The most striking differences between patent and restenosed cases were in serum cholesterol, triglyceride and HDL-cholesterol levels. The patients with a long-term low cholesterol (less than 6.5 mmol/l), low triglyceride (less than 1.42 mmol/l) and high HDL cholesterol (greater than 1.0 mmol/l) levels had significantly less high grade restenosis (P less than 0.05). Apolipoprotein A-I and B had no significant effect, but if the lowest limit of normal apolipoprotein A-I level was considered as 1.27 g/l the difference was significant. The frequency of a high-grade restenosis in patients with diabetes mellitus and coronary heart disease was not significantly increased, but supports the view that these are risk factors in the development of atherosclerotic changes in an operated carotid artery. The incidence of recurrent stenosis appears to be unrelated to hypertension, claudication, obesity, smoking, operative factors or to the indication for surgery. Men were more prone than women to get a high-grade restenosis. Postoperative treatment with acetylsalicylic acid was most effective, the incidence was only half of that expected, whereas the anticoagulants or a combination of acetylsalicylic acid and dipyridamole were of no benefit. Haematocrit, RBC, platelet count and thrombocrit were contradictory.

Malignancies in the families of patients with gastric polyps

The present series consists of 155 patients with gastric polyps who attended the Central University Hospital of Tampere/between 1972 and 1983/but who did not develop gastric malignancies during the follow-up. 93 patients with non-ulcer dyspepsia served as controls. Both the experimental and control patients were interviewed with the help of a schedule as to the occurrence of malignancies among their family. The family was defined as parents, grand parents, brothers, sisters and children. There was a total of 961 members in the families of the study patients and 755 in the families of controls. In the families of the men with gastric polyps, the frequency of intestinal malignancies as a percentage of all malignancies was higher than in the controls, 10.3 and 2.9 percent, respectively (p less than 0.01). The frequency of gastric malignancies in the families of the women with gastric polyps was higher than in the controls and in men, 6.2, 3.1 and 2.4 percent, respectively (p less than 0.05, and p less than 0.025). The frequencies of all malignancies were similar in the study and control families. Thus there seems to be some family -related accumulation of intestinal malignancies in men and of gastric malignancies in women with gastric polyps.

Vitamin D and calcitonin treatment in patients with femoral neck fracture: a prospective controlled clinical study

The effects on general and bone metabolism of femoral neck fracture patients of 0.25 micrograms alpha-calcoid given orally twice daily (n = 9) and 25 micrograms calcitonin given subcutaneously 30 times (n = 10) in 10 weeks were studied against a control (n = 11). Bone histology and histomorphometry showed non-age related osteoporosis in 30% and osteomalacia in 22% of the patients studied. Impaired serum vitamin D status was found in 47-88% of patients, secondary hyperparathyroidism and increased serum parathyroid hormone in 59% and decreased serum calcitonin levels in 69%. On histology, normal findings and non-age related osteoporosis on histology were associated with low serum levels of 25-hydroxyvitamin D3, 1,25- and 24,25-dihydroxyvitamin D3. Very high serum levels of 1,25-dihydroxyvitamin D3 and low levels of 25-hydroxyvitamin D3 occurred in fracture patients with osteomalacia. Calcitonin improved calcium balance, reduced osteoporosis and increased the serum 1,25- and 24,25-dihydroxyvitamin D3 levels but had no effect on osteomalacia. Vitamin D reduced osteomalacia, slightly increased the serum 1,25-dihydroxyvitamin D3 concentration and decreased serum levels of parathyroid hormone. Both treatments gave a similar slight decrease in serum calcitonin concentrations. A mechanism of action for the treatments is suggested.

High serum lactic acid concentration after laparotomy and peritonitis in iron stores depletion. An experimental study on the rat

Total depletion of iron stores with a moderately decreased blood hemoglobin concentration (114 x 10 vs. 155 x 12 g/l in controls, n = 28) was produced in rats (n = 28) by rearing them for six weeks on an iron free diet, in iron free cages, starting at two weeks of age. The controls were treated at the same time in same conditions, except that they were given a normal supply of dietary iron. In all rats laparotomy and peritonitis by ligation and puncture of the caecum were carried out with ether anesthesia. Postoperative mortality and blood lactic acid concentration were followed for 120 minutes after the procedure. Postoperative mortality (8 of 28, 29% vs. 1 of 28, 4%) and blood lactic acid concentration (3.3 x 0.3 to 3.6 x 0.5 vs. 1.4 x 0.1 to 1.8 x 0.2 mmol/l) were higher (p less than 0.001) in the experimental group than in the control animals. The surviving rats (2.0 x 0.1 to 2.1 x 0.2 mmol/l) had a lower (p less than 0.001) blood lactic acid concentration than those who died (5.6 x 0.5 to 6.1 x 1.1). The results suggest that total lack of iron producing a moderate decrease of blood hemoglobin concentration creates a significant risk in abdominal surgery and focus the activation of the anaerobic energy yielding process.

Empty iron stores as a significant risk factor in abdominal surgery

The mortality and morbidity in abdominal surgery were investigated in two groups of patients, one with empty (N = 228) and the other with normal (N = 220) iron stores before operation. The estimation of body iron stores by measurements of serum ferritin concentration assumes that the only reason for a low ferritin value is an empty iron store. The results showed that the period of hospital treatment was shorter and the number of complications, especially infections, fewer, in patients with normal as compared to empty iron stores before the operation (p less than 0.001). These differences were especially striking in patients subjected to gastric or large bowel surgery. The results were not explained by differences in sex, age, serum albumin, or clinical anemia. The complications were not predictable from preoperative serum albumin, alkaline phosphatase, or alanine amino transferase levels. Among patients with postoperative complications those with preoperative empty iron stores also had a lower preoperative blood hemoglobin concentration (127 +/- 10 g/liter) than those with normal preoperative iron stores (136 +/- 9 g/liter). Thus it is speculated that the mechanisms behind postoperative complications due to preoperative empty iron stores might be a decrease in tissue oxygenation, resulting in an increased fatigue while working, decreased contractile capacity of the respiratory muscles, and a decrease in immune function. Thus a measurement of serum ferritin concentration and correction of empty iron stores is recommended before abdominal surgery.

Nutritional state after colon interposition for benign oesophageal disease

The nutritional state of 32 patients after (mean 66 months) colon interposition due to benign oesophageal disease was examined. Forty-four per cent of the patients had depleted iron stores (low serum ferritin concentration). Serum iron and blood haemoglobin concentrations were lower (P less than 0.001) in those with low than in those with normal serum ferritin concentration (115 +/- 12 g/l and 15 +/- 5 mumol/l vs 135 +/- 12 g/l and 23 +/- 9 mumol/l). Most very low blood haemoglobin concentrations (less than 110 g/l) were found in patients with depleted iron stores. Eighteen patients had serum albumin concentrations slightly below (35-39 g/l) the normal range, and two other patients had values less than 35 g/l. The patients had less dietary iron (13 +/- 6 mg/d) than age- and sex-matched controls (19 +/- 7 mg/d), but the intake of patients with depleted iron stores (12 +/- 5 mg/d) was similar to that of patients with normal iron stores (14 +/- 6 mg/d). Symptoms and/or the replacement of colon graft anti- or isoperistaltically did not have any significant association with the nutritional status, only slightly reduced blood haemoglobin and serum albumin concentration were found among the symptomatic patients and the patients with an antiperistaltic graft. Iron therapy and protein supplements, eg, from milk, egg, soy and meat, are recommended as the dietary treatment. To improve the nutritional status a short intra-abdominal colon graft loop anastomosed to the proximal stomach instead of long loop with an antral anastomosis of the present patients is suggested.