Impact of Mesh and Fixation on Chronic Inguinal Pain in Lichtenstein Hernia Repair: 5-Year Outcomes from the Finn Mesh Study

OBJECTIVE

To find out the mesh fixation technique that minimises chronic pain in Lichtenstein hernioplasty. Mesh fixation may affect chronic pain and recurrence after inguinal hernia surgery, but long-term results of comparative trials are lacking.

METHODS

Lichtenstein hernioplasty was performed under local anaesthesia on 625 patients in day care units. The patients were randomised to receive either a cyanoacrylate glue (n = 216), self-gripping mesh (n = 202) or non-absorbable 3-0 polypropylene sutures (n = 216) for the fixation of mesh. A standardised telephone interview or postal questionnaire was conducted 5 years after the index operation. The patients with complaints suggesting recurrence or chronic pain (visual analogue scale ≥ 3, 0-10) were examined clinically. The rate of occasional pain, chronic severe pain, recurrence, re-operations, daily use of analgesics, overall patient satisfaction and sensation of a foreign object were recorded.

RESULTS

A total of 82% of patients (n = 514) completed the 5-year audit including 177, 167 and 170 patients in the glue, self-fixation and suture groups, respectively. There were no significant differences in the incidence of pain (7-8%), operated recurrences (2-4%), overall re-operations (4-5%), need for analgesics (1-2%), patient's satisfaction (93-97%) or in the feeling of a foreign object (11-18%) between the study groups.

CONCLUSION

The choice of the mesh or fixation method had no effect on the overall long-term outcome, pain or recurrence of hernia. Less penetrating fixation (glue or self-gripping mesh) is a safe option for the fixation of mesh in Lichtenstein hernia repair.

Optimising the antibiotic treatment of uncomplicated acute appendicitis: a protocol for a multicentre randomised clinical trial (APPAC II trial)

BACKGROUND

Based on epidemiological and clinical data acute appendicitis can present either as uncomplicated (70-80%) or complicated (20-30%) disease. Recent studies have shown that antibiotic therapy is both safe and cost-effective for a CT-scan confirmed uncomplicated acute appendicitis. However, based on the study protocols to ensure patient safety, these randomised studies used mainly broad-spectrum intravenous antibiotics requiring additional hospital resources and prolonged hospital stay. As we now know that antibiotic therapy for uncomplicated acute appendicitis is feasible and safe, further studies evaluating optimisation of the antibiotic treatment regarding both antibiotic spectrum and shorter hospital stay are needed to evaluate antibiotics as the first-line treatment for uncomplicated acute appendicitis.

METHODS

APPAC II trial is a multicentre, open-label, non-inferiority randomised controlled trial comparing per oral (p.o.) antibiotic monotherapy with intravenous (i.v.) antibiotic therapy followed by p.o. antibiotics in the treatment of CT-scan confirmed uncomplicated acute appendicitis. Adult patients with CT-scan diagnosed uncomplicated acute appendicitis will be enrolled in nine Finnish hospitals. The intended sample size is 552 patients. Primary endpoint is the success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without the need for surgical intervention and no recurrent appendicitis during one-year follow-up. Secondary endpoints include post-intervention complications, late recurrence of acute appendicitis after one year, duration of hospital stay, pain, quality of life, sick leave and treatment costs. Primary endpoint will be evaluated in two stages: point estimates with 95% confidence interval (CI) will be calculated for both groups and proportion difference between groups with 95% CI will be calculated and evaluated based on 6 percentage point non-inferiority margin.

DISCUSSION

To our knowledge, APPAC II trial is the first randomised controlled trial comparing per oral antibiotic monotherapy with intravenous antibiotic therapy continued by per oral antibiotics in the treatment of uncomplicated acute appendicitis. The APPAC II trial aims to add clinical evidence on the debated role of antibiotics as the first-line treatment for a CT-confirmed uncomplicated acute appendicitis as well as to optimise the non-operative treatment for uncomplicated acute appendicitis.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT03236961, retrospectively registered on the 2nd of August 2017.

Blood Transfusions in Major Pancreatic Surgery: A 10-Year Cohort Study Including 1404 Patients Undergoing Pancreatic Resections in Finland

Background:

Despite guidelines on blood transfusion (TF) thresholds, there seems to be great variation in transfusion policies between hospitals and surgeons. In order to improve and unify blood transfusion policies, the Finnish Red Cross Blood Service carried out a project concerning the optimal use of blood products (Verivalmisteiden optimaalinen käyttö) between 2002 and 2011. In this study, we determined the blood transfusion trends in major pancreatic surgery in Finland.

Methods:

Initially, 1337 patients who underwent major pancreatic resections between 2002 and 2011 were classified into the TF+ or TF− groups. Centers were divided into high-, medium-, and low-volume centers. The blood transfusion trends and the trigger points for blood transfusions in these patients were determined.

Results:

There were no differences between high-, medium- and low-volume centers in blood usage, trigger points or the use of reserved blood units after pancreatoduodenectomy or total pancreatectomy. However, the trigger points were lowered significantly during the study period at high-volume centers (p = 0.003), and a better use of reserved blood units was found in high- (p < 0.001) and medium-volume (p = 0.043) centers. In addition, a better use of reserved blood units was found in high-volume centers after distal pancreatectomy (p = 0.020)

Conclusion:

Although only minor changes in blood transfusion trends after pancreatoduodenectomy or total pancreatectomy were found generally, the lowering of the transfusion trigger point and the best use of reserved blood units during the study period occurred in high-volume centers.

Does Nissen Fundoplication Provide Lifelong Reflux Control? Symptomatic Outcome After 31-33 Years

BACKGROUND

A substantial number of people are suffering from gastroesophageal reflux disease (GERD). The indication for surgical treatment is the failure of medical treatment in patients with objectively verified GERD. The use of PPIs has been noted to increase with the length of follow-up after fundoplication, raising questions concerning the durability of surgical results. The aim of the study was to investigate the results of open Nissen fundoplication (ONF) over a follow-up of more than 31 years.

METHODS

ONF was performed for 38 consecutive patients. Questionnaires concerning long-term outcome were sent on December 14, 2015, to the 24 patients still living. Long-term symptom evaluation was carried out using the Gastrointestinal Symptom Rating Scale (GSRS), Visick grading, a Visual Analog Scale (VAS), the DeMeester-Johnson reflux scale, and the 15D tool.

RESULTS

Seventeen (70.8%) of the 24 patients still living participated in the study. The typical symptoms of GERD had resolved significantly. Dysphagia was graded as none or minimal by 13 (81.3%) patients. The mean 15D score of the patient group was clinically and statistically the same (0.896 vs. 0.899) as that of the age- and sex-standardized general population (p = 0.912). Six (15.8%) patients had used antireflux medication after the operation and 4 of them (10.6%) continuously.

CONCLUSIONS

Patients in the present study used PPIs less frequently than what has been reported in previous long-term follow-up studies. Our results indicate that successful surgery may provide lifelong relief of GERD symptoms and normalize the health-related quality of life in GERD patients.

Outcomes of High-Frequency Gastric Electric Stimulation for the Treatment of Severe, Medically Refractory Gastroparesis in Finland

Background and Aims:

Severe, medically uncontrollable gastroparesis is a rare entity, which can be treated using a high-frequency gastric electric stimulator implanted surgically. Previous follow-ups have proven positive outcomes with gastric electric stimulator in patients with gastroparesis. The aim of this study was to evaluate the efficacy and safety of gastric electric stimulator in patients, in whom gastroparesis could not be controlled by conservative means in our country.

Materials and Methods:

This is a retrospective multi-center cohort comprising all patients who had been implanted gastric electric stimulator for severe, medically refractory gastroparesis during 2007–2015 in Finland.

Results:

Fourteen patients underwent implantation of gastric electrical stimulator without any postoperative complications. Laparoscopic approach was used in 13 patients (93%). Prior implantation, all patients needed frequent hospitalization for parenteral feeding, 13 had severe nausea, 11 had severe vomiting, 10 had notable weight loss, and 6 had frequent abdominal pain. After operation, none of the patients required parenteral feeding, 11 patients (79%) gained median of 5.1 kg in weight (P < 0.01), and symptoms were relieved markedly in 8 and partially in 3 patients (79%). Of partial responders, two continued to experience occasional vomiting and one mild nausea. Five patients needed medication for gastroparesis after the operation. One patient did not get any relief of symptoms, but gained 6 kg in weight. No major late complications occurred.

Conclusion:

Gastric electrical stimulator seems to improve the nutritional status and give clear relief of the symptoms of severe, medically uncontrollable gastroparesis. Given the low number of operations, gastric electrical stimulator seems to be underused in Finland.

Long-term mortality and causes of death in endoscopically verified upper gastrointestinal bleeding: comparison of bleeding patients and population controls

OBJECTIVE

Upper gastrointestinal bleeding (UGIB) is a common emergency, with in-hospital mortality between 3 and 14%. However, the long-term mortality and causes of death are unknown. We investigated the long-term mortality and causes of death in UGIB patients in a retrospective single-centre case-control study design.

METHODS

A total of 569 consecutive patients, aged ≥18 years, admitted to Kuopio University Hospital for their first endoscopically verified UGIB during the years 2009-2011 were identified from hospital records. For each UGIB patient, an age, sex and hospital district matched control patient was identified from the Statistics Finland database. Data on endoscopy procedures, laboratory values, comorbidities and medication were obtained from patient records. Data on deaths and causes of death were obtained from Statistics Finland.

RESULTS

In-hospital mortality of UGIB patients was low at 3.3%. The long-term (mean follow-up 32 months) mortality of UGIB patients was significantly higher than controls (34.1 versus 12.1%, p < .001). During the 6 months following UGIB, the risk of death compared to controls was highest (HR 19.2, 95% CI 7.0-52.4, p < .001) and remained higher up to 3 years after the bleeding. Beyond 3 years' follow-up, there was no difference in mortality between the groups (HR 0.7, 95% CI 0.4-1.6, p = .436). During the first 3 months after the UGIB episode, mortality was related to gastrointestinal diseases; after 3 months, the causes of death were related to comorbidities and did not differ from causes of death in controls.

CONCLUSIONS

UGIB patients have three times higher long-term mortality than population controls.

The Accuracy of the Computed Tomography Diagnosis of Acute Appendicitis: Does the Experience of the Radiologist Matter?

Background and Aims:

To assess the accuracy of computed tomography in diagnosing acute appendicitis with a special reference to radiologist experience.

Material and Methods:

Data were collected prospectively in our randomized controlled trial comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (APPAC trial, NCT01022567). We evaluated 1065 patients who underwent computed tomography for suspected appendicitis. The on-call radiologist preoperatively analyzed these computed tomography images. In this study, the radiologists were divided into experienced (consultants) and inexperienced (residents) ones, and the comparison of interpretations was made between these two radiologist groups.

Results:

Out of the 1065 patients, 714 had acute appendicitis and 351 had other or no diagnosis on computed tomography. There were 700 true-positive, 327 true-negative, 14 false-positive, and 24 false-negative cases. The sensitivity and the specificity of computed tomography were 96.7% (95% confidence interval, 95.1–97.8) and 95.9% (95% confidence interval, 93.2–97.5), respectively. The rate of false computed tomography diagnosis was 4.2% for experienced consultant radiologists and 2.2% for inexperienced resident radiologists (p = 0.071). Thus, the experience of the radiologist had no effect on the accuracy of computed tomography diagnosis.

Conclusion:

The accuracy of computed tomography in diagnosing acute appendicitis was high. The experience of the radiologist did not improve the diagnostic accuracy. The results emphasize the role of computed tomography as an accurate modality in daily routine diagnostics for acute appendicitis in all clinical emergency settings.

Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial

BACKGROUND

An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis. The objective of this study was to compare the costs of antibiotics alone versus appendicectomy in treating uncomplicated acute appendicitis within the randomized controlled APPAC (APPendicitis ACuta) trial.

METHODS

The APPAC multicentre, non-inferiority RCT was conducted on patients with CT-confirmed uncomplicated acute appendicitis. Patients were assigned randomly to appendicectomy or antibiotic treatment. All costs were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis during the 1-year follow-up. The cost estimates were based on cost levels for the year 2012.

RESULTS

Some 273 patients were assigned to the appendicectomy group and 257 to antibiotic treatment. Most patients randomized to antibiotic treatment did not require appendicectomy during the 1-year follow-up. In the operative group, overall societal costs (€5989·2, 95 per cent c.i. 5787·3 to 6191·1) were 1·6 times higher (€2244·8, 1940·5 to 2549·1) than those in the antibiotic group (€3744·4, 3514·6 to 3974·2). In both groups, productivity losses represented a slightly higher proportion of overall societal costs than all treatment costs together, with diagnostics and medicines having a minor role. Those in the operative group were prescribed significantly more sick leave than those in the antibiotic group (mean(s.d.) 17·0(8·3) (95 per cent c.i. 16·0 to 18·0) versus 9·2(6·9) (8·3 to 10·0) days respectively; P < 0·001). When the age and sex of the patient as well as the hospital were controlled for simultaneously, the operative treatment generated significantly more costs in all models.

CONCLUSION

Patients receiving antibiotic therapy for uncomplicated appendicitis incurred lower costs than those who had surgery.

Validity of a single question to assess habitual physical activity of community-dwelling older people

The aim is to determine concurrent validity of a single self-report habitual physical activity (PA) question against accelerometer-based PA and mobility variables, and corresponding changes in self-reported PA and mobility. Cross-sectional and longitudinal data of the "Life-space mobility in old age" (LISPE) cohort and its substudy on PA were utilized. At baseline, 848 community-dwelling, 75- to 90-year-old people living independently in central Finland participated in home-based interviews. One and 2 years later, 816 and 761 of them were reassessed by phone, respectively. Tri-axial accelerometer data over 7 days were collected following the baseline assessments in a subsample of 174. Self-reported habitual PA was assessed based on intensity and duration using a single question with seven response options (range: mostly resting to competitive sports). Mobility variables were as follows: life-space mobility, walking difficulty over 500 m, and short physical performance battery. Statistically significant correlations were found between self-reported habitual PA and mobility (Spearman correlation coefficient Rs = 0.40-0.61) and accelerometer-based PA variables [step counts (Rs = 0.49), time in moderate (Rs = 0.49) and low intensity (Rs = 0.40) PA, and time in sedentary behavior (Rs = -0.28)]. A decline in self-reported habitual PA over time was associated with 5-10p decline in life-space mobility (PA improvement with 0-3p increase) and with developing a higher degree of walking difficulty (in 35-44% of participants). In conclusion, based on these results, the self-report question to assess habitual PA is valid and responsive to change and thus useful for epidemiological research in community-dwelling older people, also in follow-up studies.

Association between mid- to late life physical fitness and dementia: evidence from the CAIDE study

OBJECTIVES

This study investigated the association between perceived physical fitness at midlife, changes in perceived fitness during the three decades from mid- to late life and dementia risk.

DESIGN

Prospective cohort study.

SETTING

Cardiovascular risk factors, ageing and incidence of dementia (CAIDE) study.

SUBJECTS

Subjects were selected from four independent, random samples of population-based cardiovascular surveys and were first examined in 1972, 1977, 1982 or 1987, when they were on average 50 years old. The CAIDE target population included 3559 individuals. A random sample of 2000 individuals still alive in 1997 was drawn for re-examinations (performed in 1998 and 2005-2008) that consisted of cognitive assessments, with 1511 subjects participating in at least one re-examination. Dementia diagnoses were also confirmed from national registers for the entire target population.

MAIN OUTCOME MEASURE

All-cause dementia.

RESULTS

Poor physical fitness at midlife was associated with increased dementia risk in the entire target population [hazard ratio (HR), 1.5; 95% confidence interval (CI), 1.1-2.0]. In participants, odds ratio (OR) was 2.0 (95% CI, 0.9-4.0). This association was significant in apolipoprotein E ε4 allele (APOEε4) noncarriers (OR, 4.3; 95% CI, 1.4-13.3), men (HR, 1.8; 95% CI, 1.1-3.0) and people with chronic conditions (HR, 2.9; 95% CI, 1.3-6.6). A decline in fitness after midlife was also associated with dementia (OR, 3.0; 95% CI, 1.7-5.1), which was significant amongst both men and women and more pronounced in APOEε4 carriers (OR, 4.4; 95% CI, 2.1-9.1).

CONCLUSIONS

Perceived poor physical fitness reflects a combination of biological and lifestyle-related factors that can increase dementia risk. A simple question about perceived physical fitness may reveal at-risk individuals who could benefit from preventive interventions.

Associations between muscle strength, spirometric pulmonary function and mobility in healthy older adults

Pathological obstruction in lungs leads to severe decreases in muscle strength and mobility in patients suffering from chronic obstructive pulmonary disease. The purpose of this study was to investigate the interdependency between muscle strength, spirometric pulmonary functions and mobility outcomes in healthy older men and women, where skeletal muscle and pulmonary function decline without interference of overt disease. A total of 135 69- to 81-year-old participants were recruited into the cross-sectional study, which was performed as a part of European study MyoAge. Full, partial and no mediation models were constructed to assess the interdependency between muscle strength (handgrip strength, knee extension torque, lower extremity muscle power), spirometric pulmonary function (FVC, FEV1 and FEF50) and mobility (6-min walk and Timed Up and Go tests). The models were adjusted for age, sex, total fat mass, body height and site of enrolment. Partial mediation models, indicating both direct and pulmonary function mediated associations between muscle strength and mobility, fitted best to the data. Greater handgrip strength was significantly associated with higher FVC, FEV1 and FEF50 (p < 0.05). Greater muscle power was significantly associated with better performance in mobility tests. Results suggest that decline in mobility with aging may be caused by decreases in both muscle strength and power but also mediated through decreases in spirometric pulmonary function. Future longitudinal studies are warranted to better understand how loss of function and mass of the respiratory muscles will affect pulmonary function among older people and how these changes are linked to mobility decline.

The impact of fibrin glue in the prevention of failure after Nissen fundoplication

BACKGROUND AND AIMS

Good long term result after Nissen fundoplication is achieved in most of the patients in specialized centres. Still failure occurs in some cases and reoperation after failed conservative treatment is done in 3-6% of the cases. Reoperation is more dangerous and results worse than after primary fundoplication. Therefore we wanted to analyze factors related to failure of Nissen fundoplication with special emphasis on utilization of crural closure, anchor-ing of the fundic wrap and the use of fibrin glue.

MATERIAL AND METHODS

Patients records of 258 patients were analyzed by an independent ob-server. Defective fundic wrap, recurrent oesophagitis and hiatal hernia were defined as failure.

RESULTS

Failure after Nissen fundoplication was found in 29 patients (14.9%). Crural closure (p = 0.021), anchoring of the wrap (p = 0.020) and fibrin glue (p = 0.029) decreased the incidence of failure. However, only crural closure (p = 0.010) and fibrin glue (p = 0.019) were independent factors in the prevention of failure.

CONCLUSIONS

Fibrin glue as a new method might be worth utilizing to further decrease the incidence of failure after Nissen fundoplication. Because our study was retrospective, prospective randomized study should be performed before universal use of fibrin glue in the prevention of failure after fundoplication.

Effect of age on the association between body fat percentage and maximal walking speed

OBJECTIVE

To study the effect of age on the association between body fat percentage and maximal walking speed in older people.

DESIGN AND PARTICIPANTS

Cross-sectional analysis of data collected in the Finnish population-based Health 2000 Survey involving 916 men and 1 222 women aged 55 years and older with complete data on body composition and a walking speed test.

METHODS

Body fat percentage was assessed using bioelectrical impedance analysis and maximal walking speed based on a timed walking test over a distance of 6.1 meters. Linear regression models were used to study the effect of age on association between body fat percentage and maximal walking speed.

RESULTS

The association between body fat percentage quartiles and maximal walking speed differed significantly between persons of different ages (p for age interaction = 0.027). In the age-stratified analyses, the association between body fat percentage and maximal walking speed remained significant among 60-69-year olds and 70-79-year-olds, but disappeared among 55-59-year-olds and 80-year and older after adjustment for potential covariates. Body fat percentage explained 11% of the variation in maximal walking speed among 55-59-year-olds, 21% among 60-69-year-olds, 17% among 70-79-year-olds and 11% among 80-year and older.

CONCLUSION

Association between body fat percentage and maximal walking speed was strongest between the ages of 60 and 79 years. The results suggest that the effects of excess body fatness are especially harmful for physical functioning among adults in their sixties and seventies and they could benefit from interventions.

Walking ability and all-cause mortality in older women

In this study self-reported ability to walk 2 km and six-minute walking test (6MWT) performance were examined as predictors of all-cause mortality in 434 women, aged 63-76 years. The primary outcome measure was all-cause mortality (follow-up: 8 years). Predictors were self-reported difficulties in walking 2 km and 6-min walking distance tertiles of ≤495, 496-560 and ≥561 m, and no test result due to refusal by the physician to grant permission to perform the test or participant's inability or unwillingness to perform the test. During the follow-up, 39 participants died. Participants reporting minor (age- and body mass index-adjusted hazard ratio 2.53, 95% confidence interval 1.12-5.69) or major (7.93, 3.49-18.05) difficulties in walking 2 km had increased risk of death compared with those reporting no difficulties. Participants with no 6MWT result (6.99, 2.46-19.86) were at an increased risk of death when compared with participants who walked ≥561 m. A similar trend (2.47, 0.81-7.56) was found for participants with walking distance of ≤495 m during the 6MWT. The trends remained similar after adjustments for other confounders. In conclusion, self-reported difficulties in walking 2 km are associated with an increased risk of death in older community-dwelling women. Objectively measured walking ability gives similar results.

Altered expression of HSP27 and HSP70 in distal oesophageal mucosa in patients with gastro-oesophageal reflux disease subjected to fundoplication

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is a risk factor for oesophageal adenocarcinoma. Although fundoplication cures reflux symptoms and oesophagitis, it remains controversial whether it is capable of preventing the development of oesophageal adenocarcinoma. Hsp27 and Hsp70 are associated with the development of cancer, whereas the effect of fundoplication on them is not known.

METHODS

The expression of Hsp27 and Hsp70 was assessed semiquantitatively from biopsies of oesophageal mucosa for a prospective cohort of 19 patients with GERD treated with fundoplication and 7 controls without GERD. Upper gastrointestinal endoscopy with biopsies from the oesophagogastric junction (EGJ) and the distal and proximal oesophagus were performed preoperatively (19 patients) and after recovery from GERD at 6 (19 patients) and 48 months (16 patients) postoperatively.

RESULTS

The expressions of both Hsp27 (p = 0.001) and Hsp70 (p = 0.002) in the distal oesophagus were lower in patients preoperatively and at 48 months postoperatively (p < 0.001 for both) than in controls. The patients' Hsp27 and Hsp70 levels were lower preoperatively in the proximal oesophagus (p = 0.048 for both) than in controls. Both Hsp27 (p = 0.002) and Hsp70 (p = 0.003) were lower in the distal oesophagus preoperatively and at 48 months postoperatively (p = 0.003 for Hsp27, p = 0.004 for Hsp70) than in the proximal oesophagus.

CONCLUSIONS

Our results indicate that there may be some factor interfering with the mucosal defence system of the distal oesophagus in GERD that is uninfluenced by fundoplication and not associated with the acid-reflux-normalizing effect.

Definition of treatment goals for moderate to severe psoriasis: a European consensus

Patients with moderate to severe psoriasis are undertreated. To solve this persistent problem, the consensus programme was performed to define goals for treatment of plaque psoriasis with systemic therapy and to improve patient care. An expert consensus meeting and a collaborative Delphi procedure were carried out. Nineteen dermatologists from different European countries met for a face-to-face discussion and defined items through a four-round Delphi process. Severity of plaque psoriasis was graded into mild and moderate to severe disease. Mild disease was defined as body surface area (BSA) ≤10 and psoriasis area and severity index (PASI) ≤10 and dermatology life quality index (DLQI) ≤10 and moderate to severe psoriasis as (BSA > 10 or PASI > 10) and DLQI > 10. Special clinical situations may change mild psoriasis to moderate to severe including involvement of visible areas or severe nail involvement. For systemic therapy of plaque psoriasis two treatment phases were defined: (1) induction phase as the treatment period until week 16; however, depending on the type of drug and dose regimen used, this phase may be extended until week 24 and (2) maintenance phase for all drugs was defined as the treatment period after the induction phase. For the definition of treatment goals in plaque psoriasis, the change of PASI from baseline until the time of evaluation (ΔPASI) and the absolute DLQI were used. After induction and during maintenance therapy, treatment can be continued if reduction in PASI is ≥75%. The treatment regimen should be modified if improvement of PASI is <50%. In a situation where the therapeutic response improved ≥50% but <75%, as assessed by PASI, therapy should be modified if the DLQI is >5 but can be continued if the DLQI is ≤5. This programme defines the severity of plaque psoriasis for the first time using a formal consensus of 19 European experts. In addition, treatment goals for moderate to severe disease were established. Implementation of treatment goals in the daily management of psoriasis will improve patient care and mitigate the problem of undertreatment. It is planned to evaluate the implementation of these treatment goals in a subsequent programme involving patients and physicians.

Genetic contribution to the relationship between personality and depressive symptoms among older women

BACKGROUND

Prior studies suggest that certain types of personality are at higher risk for developing depressive disorders. This study examined the relationship between old age depressive symptoms and two middle-age personality dimensions, neuroticism and extraversion.

METHOD

The present study is part of the Finnish Twin Study on Aging, where altogether 409 female twins who had completed the Eysenck Personality Inventory at the age of 38-51 years were studied for depressive symptoms 28 years later using Center for the Epidemiologic Studies Depression Scale. Logistic regression analysis suitable for dependent data and univariate and Cholesky models for decomposing the genetic and environmental factor were used.

RESULTS

Middle age extraversion protected from later depressive symptoms while neuroticism increased the risk. Twin modeling indicated that the association between neuroticism and depressive symptoms resulted from shared genetic risk factors common to both traits. However, a substantial proportion of the genetic vulnerability was specific to old age depressive symptoms and was not shared with neuroticism. Middle age extraversion had no genetic relationship with old age depressive symptoms.

CONCLUSIONS

The relationship between middle age neuroticism and old age depressive symptoms is strong but only partly the result of genetic factors that predispose to both neuroticism and depressive symptoms. Extraversion, by contrast, has no genetic relationship with depressive symptoms experienced in old age.

Self-reported preclinical mobility limitation and fall history as predictors of future falls in older women: prospective cohort study

We studied if self-reported preclinical mobility limitation, described as modification of task performance without perception of difficulty, predicts future falls in older women with and without fall history. Our results suggest that combined measure of self-reported preclinical mobility limitation and fall history may offer one possibility for inexpensive fall-risk evaluation in clinical practice.

INTRODUCTION

We studied if self-reported preclinical mobility limitation predicts future falls in older women with and without fall history.

METHODS

The study population consisted of 428 community-living 63-76-year-old women. At baseline, those who expressed no difficulty walking 2 km but reported that it took longer than before or that they did it less often were categorized as having preclinical mobility limitation. Those reporting difficulty in 2-km walk were categorized as having manifest mobility limitation. Fall history was recalled for previous 12 months and dichotomized. The incidence of future falls over 12 months was followed up with fall calendars.

RESULTS

During the fall follow-up, a total of 440 falls were reported by 201 participants. Among those with fall history, women with preclinical mobility limitation had almost 4-fold (incidence rate ratios 3.77; 95% CI 1.02-13.92) and those with manifest mobility limitation almost 15-fold (14.66; 2.72-79.00) adjusted risk for future falls compared to those with no mobility limitation and no previous falls. Among women without fall history, preclinical and manifest mobility limitation did not predict future falls nor did fall history without mobility limitation.

CONCLUSIONS

Already, early signs of mobility decline with history of falls increase the risk of further falls and should be considered as indications for fall prevention interventions.

European S3-guidelines on the systemic treatment of psoriasis vulgaris

Of the 131 studies on monotherapy or combination therapy assessed, 56 studies on the different forms of phototherapy fulfilled the criteria for inclusion in the guidelines. Approximately three-quarters of all patients treated with phototherapy attained at least a PASI 75 response after 4 to 6 weeks, and clearance was frequently achieved (levels of evidence 2 and 3). Phototherapy represents a safe and very effective treatment option for moderate to severe forms of psoriasis vulgaris. The onset of clinical effects occurs within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term use, the consequences of high, cumulative UV doses (such as premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicability of the therapy is limited by spatial, financial, human, and time constraints on the part of the physician, as well as by the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs for, and time required of, the patient must be considered.

Imprecision of cardiac marker analyses among laboratories on the basis of external quality assurance results: Finnish experience

The purpose of this report was to evaluate the reproducibility and harmonization of cardiac marker tests and to describe the current situation concerning quality of assays for cardiac markers on the basis of the results of the external quality control schemes (EQAS) of Labquality Ltd., Helsinki, Finland in the period 2002 to 2005. Finnish EQAS surveys obtained for proficiency samples at low marker concentration indicated that the overall coefficient of variation (CV) between laboratories for CK-MBmass and troponin I exceeded 10 %, while for cardiac troponin T the CV was 8.6 %. Intra-laboratory reproducibility was investigated in a single laboratory using concomitant testing in the same EDTA plasma samples to establish cut-off limits for one CK-MBmass and three troponin assays. The 10 % imprecision limit obtained from the concomitant testing in the same samples for CK-MBmass was (by Elecsys) 8.5 microg/L, for cardiac troponin T (by Elecsys) 0.023 microg/L and for cardiac troponin I (by AxSYM) and by Immulite 2000) 0.85 microg/L and 0.63 microg/L. At present, it is recommended that laboratories determine the concentration at which the 10 % imprecision for a specific cardiac marker assay is reached, because the assays generally do not reach that imprecision at the level of the 99th percentile value, usually taken as decisional level. However, common efforts of scientific societies and professional diagnostic industry associations internationally are needed if consensus is to be reached on standardization of immunoassays for cardiac markers and uniform results obtained among laboratories.

Factors affecting the increased risk of physical inactivity among older people with depressive symptoms

The purpose of this study was to investigate the association between depressive symptoms and physical inactivity, and whether motives for and barriers to exercise explain the potential association between depressive symptoms and physical inactivity in older people. The design of the study was cross-sectional. The study population comprised 645 people born between 1922 and 1928 who were residents in a city-center area of Jyväskylä in central Finland. Depressive symptoms were assessed using Center for the Epidemiologic Studies Depression Scale, physical activity using Grimby's (1986) validated scale, and motives for and barriers to exercise using a questionnaire and mobility limitation with a test of walking time over 10 m. The results demonstrated that the risk of physical inactivity was more than twofold among persons with depressive symptoms compared with non-depressed people. A higher prevalence of perceived barriers to physical activity, such as poor health, fear and negative experiences, together with lack of knowledge, explained part of the increased risk of physical inactivity among those with depressive symptoms while differences in motives for physical activity did not have a material effect. Adjustment for walking time over 10 m attenuated the increased risk of inactivity further. When planning exercise promotion programs, finding ways to overcome fear and negative experiences and providing information may help to increase physical activity among people with depressive symptoms. Additionally, difficulties caused by poor mobility should not be ignored.

The effect of obesity combined with low muscle strength on decline in mobility in older persons: results from the InCHIANTI study

OBJECTIVE

Both obesity and muscle impairment are increasingly prevalent among older persons and negatively affect health and physical functioning. However, the combined effect of coexisting obesity and muscle impairment on physical function decline has been little studied. We examined whether obese persons with low muscle strength experience significantly greater declines in walking speed and mobility than persons with only obesity or low muscle strength.

DESIGN

Community-dwelling adults aged > or = 65 years (n = 930) living in the Chianti geographic area (Tuscany, Italy) were followed for 6 years in the population-based InCHIANTI study.

MEASUREMENTS

On the basis of baseline measurements (1998-2000), obesity was defined as body mass index (BMI) > or = 30 kg/m(2) and low muscle strength as lowest sex-specific tertile of knee extensor strength. Walking speed and self-reported mobility disability (ability to walk 400 m or climb one flight of stairs) were assessed at baseline and at 3- and 6-year follow-up.

RESULTS

At baseline, obese persons with low muscle strength had significantly lower walking speed compared with all other groups (P < or = 0.05). In longitudinal analyses, obese participants with low muscle strength had steeper decline in walking speed and high risk of developing new mobility disability over the 6-year follow-up compared with those without obesity or low muscle strength. After the age of 80, the differences between groups were substantially attenuated. The differences seen in walking speed across combination of low muscle strength and obesity groups were partly explained by 6-year changes in muscle strength, BMI and waist circumference.

CONCLUSIONS

Obesity combined with low muscle strength increases the risk of decline in walking speed and developing mobility disability, especially among persons < 80 years old.

Genetic influences on adult body mass index followed over 29 years and their effects on late-life mobility: a study of twin sisters

BACKGROUND

The rise in body mass index (BMI) during adulthood increases the risk for metabolic disorders, functional limitations and disability in old age. This twin study examined prospectively whether genetic and environmental influences on women's BMI also account for mobility 29 years later.

METHODS

The sample consisted of 103 monozygotic and 114 dizygotic pairs of twin sisters reared together. Body mass index was initially evaluated in 1975, when the women were aged 42.6+/-3.4 years, and was followed-up in 1981, 1990, 2001 and 2004. Mobility was evaluated using the standardised 6-minute walking test in 2001, when the women were aged 68.6+/-3.2 years, and followed-up 3 years later. An investigation was made into how genetic and environmental influences on adult BMI accounted for mobility in old age using a genetic latent growth modelling approach.

RESULTS

During the follow-up period, BMI increased by 17%. Midlife BMI was a significant predictor of mobility 29 years later. Genetic influences on BMI level and its rate-of-change accounted for 37% and 25% respectively, of the genetic influences on mobility later in life. The corresponding environmental influences on BMI level and its rate-of-change were 35% and 22%.

CONCLUSION

Genes predisposing to higher BMI across middle age increase the risk for poorer mobility in old age. Identifying those genes could lead to interventions targeted at preventing obesity and mobility loss later in life. However, modification of environmental factors, eg exercise and nutrition, remain the most feasible ways of influencing BMI and mobility across the life span.

Longitudinal changes in genetic and environmental influences on older women's walking ability

This study examined the stability and change over time in genetic and environmental influences on walking ability among older women. Maximal walking speed over 10 m and 6-min walking endurance test were measured under standard conditions at baseline and 3 years later. At both times, 63 monozygotic (MZ) and 67 dizygotic (DZ) twin pairs were measured for walking speed and 58 MZ and 56 DZ pairs for walking endurance. Participants were twin sisters reared together and aged 63-75 years at baseline. Genetic and environmental influences were examined using longitudinal genetic modelling. The results showed that walking speed was preserved from baseline to follow-up. Genetic influences on walking speed were also similar at baseline (56%) and follow-up (60%). Walking endurance declined from baseline to follow-up, while genetic influences for walking endurance increased from baseline (40%) to follow-up (60%). Most of the genetic influences identified at baseline were also present at follow-up for walking speed (r(g)=0.72) and endurance (r(g)=0.71). In conclusion, among relatively healthy older women, genetic influences on walking speed and endurance were moderate at baseline, while at 3-year follow-up a moderate increment was observed in walking endurance. Newly expressed genetic influences were recognized at follow-up.

The cause of the Chinese sofa/chair dermatitis epidemic is likely to be contact allergy to dimethylfumarate, a novel potent contact sensitizer

BACKGROUND

A small epidemic of severe contact dermatitis cases related to newly acquired sofas and chairs has surpassed the news threshold in Finland and the U.K.

OBJECTIVES

To study affected patients and to identify the cause.

METHODS

Five patients with contact dermatitis related to a newly purchased chair or sofa were studied. Furniture samples were analysed by gas chromatography-mass spectrometry. Compounds were identified using a mass spectrum library and measured semiquantitatively. Patch tests were performed with commercial standard allergens, furniture upholstery and chemicals found in the analysis.

RESULTS

Patch tests with commercial allergens did not solve the problem. Up to 470 microg kg(-1) of dimethylfumarate was found in chairs. The patients showed strong positive patch test reactions to upholstery fabric samples and to dimethylfumarate, down to a level of 1 p.p.m. in the most severe case.

CONCLUSIONS

The cause of the Chinese sofa/chair dermatitis epidemic is likely to be contact allergy to dimethylfumarate, a novel potent contact sensitizer.

Prevalence and risk factors of PAD among patients with elevated ABI

OBJECTIVES

To assess the prevalence and clinical significance of elevated ankle-brachial index (ABI) in patients referred to vascular consultation.

DESIGN

Retrospective clinical study.

MATERIAL AND METHODS

In 1,762 patients referred with a suspicion of peripheral arterial disease (PAD), ABI and toe brachial index (TBI) were measured by photoplethysmography. ABI>/=1.3 was considered falsely elevated and TBI<0.60 was the diagnostic criterion for PAD.

RESULTS

The prevalence of elevated ABI was 8.4% and that of PAD among these patients 62.2%. PAD was significantly more prevalent among subjects with severe symptoms (rest pain, ulcers or gangrene) than in those with intermittent claudication (83.8% and 45.3%, respectively, p<0.001). The risk of PAD diagnosis was ten-fold (OR 10.31, 95% CI 2.07-51.30) among those with chronic renal failure, five-fold among patients with a history of smoking (OR 5.63, 95% CI 1.22-26.00) and over three-fold (OR 3.44, 95% CI 1.46-8.12) among those with coronary heart disease. The specificities of elevated ABI threshold levels (1.3, 1.4 and 1.5) in identifying PAD were 86%, 94% and 96%, respectively, the sensitivities being 44%, 38% and 36%, respectively.

CONCLUSIONS

The prevalence of elevated ABI in patients referred to vascular consultation is 8.4% and that of PAD among these 62.2%. PAD is significantly more probable among those with chronic renal failure, a history of smoking and coronary heart disease. Furthermore, the specificity of elevated ABI (>/=1.3) in recognizing PAD is good, whereas the sensitivity is only satisfactory.

Cost analysis of an exercise program for older women with respect to social welfare and healthcare costs: a pilot study

The aim of this study was to analyze social welfare and healthcare costs and fall-related healthcare costs after a group-based exercise program. The 10-week exercise program, which started after discharge from the hospital, was designed to improve physical fitness, mood, and functional abilities in frail elderly women. Sixty-eight acutely hospitalized and mobility-impaired women (mean age 83.0, SD 3.9 years) were randomized into either group-based (intervention) or home exercise (control) groups. Information on costs was collected during 1 year after hospital discharge. There were no differences between the intervention and control groups in the mean individual healthcare costs: 4381 euros (SD 3829 euros) vs 3539 euros (SD 3967 euros), P=0.477, in the social welfare costs: 3336 euros (SD 4418 euros) vs 4073 euros (SD 5973 euros), P=0.770, or in the fall-related healthcare costs: 996 euros (SD 2612 euros) vs 306 euros (SD 915), P=0.314, respectively. This exercise intervention, which has earlier proved to be effective in improving physical fitness and mood, did not result in any financial savings in municipal costs. These results serve as a pilot study and further studies are needed to establish the cost-effectiveness of this exercise intervention for elderly people.

Genetic effects in common on maximal walking speed and muscle performance in older women

The purpose was to examine whether maximal walking speed, maximal isometric knee extensor strength, and leg extensor power share genetic or environmental effects in common. The data was collected from 103 monozygotic and 114 dizygotic female twin pairs aged 63-76 years. Maximal walking speed over 10 m was measured in the laboratory corridor using photocells for timing. Isometric knee extensor strength and leg extensor power were measured using an adjustable dynamometer. The genetic models showed that strength, power, and walking speed had a genetic effect in common which accounted for 52% of the variance in strength, 36% in power, and 34% in walking speed. Strength and power had a non-shared environmental effect in common explaining 13% of variation in strength and 14% in power. The remaining variance was accounted for by trait-specific effects. Some people may be more prone to functional limitation in old age due to their genetic disposition, but this does not rule out that changes in the lifestyle of predisposed subjects may also have a major effect. Approximately half of the variation in each trait was explained by environmental effects, which suggests the importance of the physical activity to improve performance and prevent functional limitation.

Customer-oriented counseling for physical activity in older people: study protocol and selected baseline results of a randomized-controlled trial (ISRCTN 07330512)

The objective of this study is to describe the rationale, design and selected baseline results of a 2-year randomized-controlled trial (RCT) on the effects of physical activity counseling in community-living older people. After a four-phase screening and data-collection process targeting all independently living people in the city center of Jyväskylä, Finland, six hundred and thirty-two 75-81-year-old cognitively intact, sedentary persons who were able to move independently outdoors at least minimally and willing to take part in the RCT were randomized into intervention and control groups. At baseline, over half of the subjects exercised less than two to three times a month and two-thirds were willing to increase their physical activity level. The desire to increase physical activity was more common (86%) among subjects with mobility limitation compared with those without (60%, P=0.004). The intervention group received an individualized face-to-face counseling session, followed by phone contacts every 3 months throughout the intervention. The study outcomes include physical activity level, mobility limitation, functional impairments, disability, mood, quality of life, use of services, institutionalization and mortality. The screening and recruitment process was feasible and succeeded well, and showed that unmet physical activity needs are common in older people.