Treatment response of colorectal cancer liver metastases to neoadjuvant or conversion therapy: a prospective multicentre follow-up study using MRI, diffusion-weighted imaging and 1H-MR spectroscopy compared with histology (subgroup in the RAXO trial)

BACKGROUND

Colorectal cancer liver metastases respond to chemotherapy and targeted agents not only by shrinking, but also by morphologic and metabolic changes. The aim of this study was to evaluate the value of advanced magnetic resonance imaging (MRI) methods in predicting treatment response and survival.

PATIENTS AND METHODS

We investigated contrast-enhanced MRI, apparent diffusion coefficient (ADC) in diffusion-weighted imaging and 1H-magnetic resonance spectroscopy (1H-MRS) in detecting early morphologic and metabolic changes in borderline or resectable liver metastases, as a response to first-line neoadjuvant or conversion therapy in a prospective substudy of the RAXO trial (NCT01531621, EudraCT2011-003158-24). MRI findings were compared with histology of resected liver metastases and Kaplan-Meier estimates of overall survival (OS).

RESULTS

In 2012-2018, 52 patients at four Finnish university hospitals were recruited. Forty-seven patients received neoadjuvant or conversion chemotherapy and 40 liver resections were carried out. Low ADC values (below median) of the representative liver metastases, at baseline and after systemic therapy, were associated with partial response according to RECIST criteria, but not with morphologic MRI changes or histology. Decreasing ADC values following systemic therapy were associated with improved OS compared to unchanged or increasing ADC, both in the liver resected subgroup (5-year OS rate 100% and 34%, respectively, P = 0.022) and systemic therapy subgroup (5-year OS rate 62% and 23%, P = 0.049). 1H-MRS revealed steatohepatosis induced by systemic therapy.

CONCLUSIONS

Low ADC values at baseline or during systemic therapy were associated with treatment response by RECIST but not with histology, morphologic or detectable metabolic changes. A decreasing ADC during systemic therapy is associated with improved OS both in all patients receiving systemic therapy and in the resected subgroup.

Centralized repeated resectability assessment of patients with colorectal liver metastases during first-line treatment: prospective study

BACKGROUND

Metastasectomy is probably underused in metastatic colorectal cancer. The aim of this study was to investigate the effect of centralized repeated assessment on resectability rate of liver metastases.

METHODS

The prospective RAXO study was a nationwide study in Finland. Patients with treatable metastatic colorectal cancer at any site were eligible. This planned substudy included patients with baseline liver metastases between 2012 and 2018. Resectability was reassessed by the multidisciplinary team at Helsinki tertiary referral centre upfront and twice during first-line systemic therapy. Outcomes were resectability rates, management changes, and survival.

RESULTS

Of 812 patients included, 301 (37.1 per cent) had liver-only metastases. Of these, tumours were categorized as upfront resectable in 161 (53.5 per cent), and became amenable to surgery during systemic treatment in 63 (20.9 per cent). Some 207 patients (68.7 per cent) eventually underwent liver resection or ablation. At baseline, a discrepancy in resectability between central and local judgement was noted for 102 patients (33.9 per cent). Median disease-free survival (DFS) after first resection was 20 months and overall survival (OS) 79 months. Median OS after diagnosis of metastatic colorectal cancer was 80, 32, and 21 months in R0-1 resection, R2/ablation, and non-resected groups, and 5-year OS rates were 68, 37, and 9 per cent, respectively. Liver and extrahepatic metastases were present in 511 patients. Of these, tumours in 72 patients (14.1 per cent) were categorized as upfront resectable, and 53 patients (10.4 per cent) became eligible for surgery. Eventually 110 patients (21.5 per cent) underwent liver resection or ablation. At baseline, a discrepancy between local and central resectability was noted for 116 patients (22.7 per cent). Median DFS from first resection was 7 months and median OS 55 months. Median OS after diagnosis of metastatic colorectal cancer was 79, 42, and 17 months in R0-1 resection, R2/ablation, and non-resected groups, with 5-year OS rates of 65, 39, and 2 per cent, respectively.

CONCLUSION

Repeated centralized resectability assessment in patients with colorectal liver metastases improved resection and survival rates.

Incidence of lichen sclerosus and subsequent causes of death: a nationwide Finnish register study

OBJECTIVE

To assess the incidence of lichen sclerosus (LS) in women and the all-cause and cause-specific mortality of women with LS.

DESIGN

Population-based descriptive study.

SETTING

Finland.

POPULATION

All Finnish women, including 7790 women diagnosed with LS during the period 1969-2012.

METHODS

Information gathered from the Finnish Hospital Discharge Register on women with LS was combined with dates and causes of death from Statistics Finland and the Finnish Cancer Registry. Population statistics are from Statistics Finland.

MAIN OUTCOME MEASURES

Crude and age-adjusted incidence rates of LS and standardised mortality ratios (SMRs).

RESULTS

The incidence rate of LS adjusted for age (European Standard Population) increased from 14 per 100 000 woman-years in 2003 to 22 per 100 000 woman-years in 2010-2012. The age-specific incidence rate was highest in postmenopausal women (24-53 per 100 000) but was also elevated in girls aged 5-9 years (seven per 100 000). The all-cause mortality of women with LS was lower than in the general female population (SMR 0.84, 95% CI 0.78-0.90), mostly as a result of decreased mortality from circulatory diseases (SMR 0.80, 95% CI 0.72-0.89) and dementia and Alzheimer's disease (SMR 0.75, 95% CI 0.62-0.88). The cancer mortality equalled that of the population, but the vulvar cancer mortality was increased (SMR 28.1, 95% CI 19.3-39.4).

CONCLUSIONS

Lichen sclerosus is a common disease of elderly women. The overall mortality is decreased whereas the mortality as a result of vulvar cancer is increased.

TWEETABLE ABSTRACT

The likelihood of getting LS by age 80 years is 1.6%. The mortality of women with LS is reduced compared with that of the population.

Role of cage material, working style and hearing sensitivity in perception of animal care noise

During daily care, laboratory animals are exposed to a variety of sounds which may have effects on welfare and also cause physiological and behavioural changes. So far, almost no attention has been paid to individual sounds or the sound level caused by animal care or the sound level inside the animal cage. In this study, sounds from selected rat care procedures were recorded: pulling cage out of the rack, placing it onto a table and replacing the cage back into the rack; with measurements made inside the rat cage and in the adjacent cage. Diet was poured into the food hopper and sounds were recorded inside the cage and also the adjacent cage. The work was repeated in a calm and also in a hurried style, using stainless steel and polycarbonate cages. Finally, the sounds produced by running tap water were recorded. Differences between rat and human hearing were compared using novel species-specific sound level weightings: R-weighting for rats dB(R) and H-weighting for human dB(H). Hurried work with steel caused sound exposure levels exceeding 90 dB(R) when the cages were placed into the rack and about 80 dB(R) when pulling them out of the rack or placing onto a table. With polycarbonate, the levels were 10–15 dB(R) lower. Unhurried calm working produced lower sound exposure levels than hurried working in many procedures. When the procedures were repeated with measurements in the adjacent cage, the sound exposure levels were lower, but the results were similar. Pouring food pellets into a hopper above the rat's head caused 15 dB(R) higher sound exposure levels than pouring food to an adjacent cage. In general, humans hear these sounds about 10–15 dB louder than rats. In conclusion, cage material, working style and hearing sensitivity all have an impact on the sound exposure level in the rodent cage. With correct working methods, high sound levels can be efficiently avoided in most cases.

Altered TUBB3 expression contributes to the epothilone response of mitotic cells

Background:

Epothilones are a novel group of microtubule (mt) targeting cancer drugs that bind to the β-subunit of the αβ-tubulin dimer. Epothilones inhibit cell proliferation and induce cell death by interfering with the normal mt function. In this study, we examined the consequences of altered expression of human β-tubulin isotypes in terms of the epothilone drug response in human lung and breast cancer cell lines.

Methods:

The β-tubulin isotypes TUBB2A–C, TUBB3 and TUBB were silenced or overexpressed in A549, A549EpoB40 and MCF7 cell lines in the presence or absence of epothilones. The drug effects on cell proliferation, mitosis and mt dynamics were determined using live cell microscopy and immunofluorescence assays.

Results:

Loss of TUBB3 enhanced the action of epothilones. TUBB3 knockdown increased the severity of drug-induced mitotic defects and resulted in stabilisation of the mt dynamics in cells. Moreover, exogenous expression of TUBB3 in the epothilone resistant cell line conferred the response to drug treatments. In contrast, reduced levels of TUBB2A–C or TUBB had not apparent effect on the cells’ response to epothilones.

Conclusion:

Our results show that the expression of TUBB3 contributes to the cellular response to epothilones, putatively by having an impact on the mt dynamics.

Continuous wound infusion with ropivacaine fails to provide adequate analgesia after caesarean section

BACKGROUND

Continuous wound infusion with local anaesthetic has been used in post-caesarean pain management with conflicting results. We carried out a study comparing three groups: continuous ropivacaine wound infusion, intrathecal morphine with saline wound infusion and saline wound infusion only.

METHODS

Sixty-six women undergoing elective caesarean section under combined spinal-epidural anaesthesia were randomly allocated to receive intrathecal morphine with saline wound infusion or 48 h continuous wound infusion with either ropivacaine or saline. All parturients received oral ketoprofen and intravenous oxycodone patient-controlled analgesia. Consumption of oxycodone, visual analogue scale pain scores (0-10 cm), patient satisfaction, side effects and recovery parameters were recorded for 48 h in a double-blind manner.

RESULTS

Continuous wound infusion with ropivacaine failed to reduce oxycodone consumption or pain scores compared with saline control. In the first 24 h intrathecal morphine reduced mean oxycodone consumption compared to the ropivacaine wound infusion group (26 mg vs. 48 mg, P=0.007) and saline wound infusion group (26 mg vs. 45 mg, P=0.021). The first 24-h mean pain score was also lower in the intrathecal morphine group vs. the saline wound infusion group (1.3 vs. 2.2, P=0.021). Pain scores were not significantly different between intrathecal morphine and ropivacaine wound infusion groups. Pruritus was more common with intrathecal morphine.

CONCLUSION

Compared to saline control, continuous wound infusion with ropivacaine failed to reduce the use of intravenous oxycodone patient-controlled analgesia or pain scores. Intrathecal morphine decreased oxycodone consumption by 46% in the first 24 h after surgery when compared to continuous ropivacaine wound infusion.

Spacer prostheses in two-stage revision of infected knee arthroplasty

At present, no consensus exists on the best spacer alternative for the management of two-stage exchange arthroplasty of infected knee arthroplasties. In this retrospective study, patient records of 24 patients, who had undergone two-stage revisions in which resterilised prosthetic components were used as spacers, were reviewed. The outcome was compared to that of operations performed during the same period (1993-2003) using cement spacers (n=10). With an average follow-up of 32 months, control of infection was achieved in 26 cases (76%), with good or excellent clinical outcome in 19 cases (56%). Treatment failed and resulted in amputation at the level of the thigh before reimplantation in one case. Three patients did not undergo reimplantation. In four cases (12%) infection relapsed. The reinfection rate did not differ between the two spacer groups. Patients treated with resterilised components had a superior range of motion during the period between the two stages. Operative time was shorter and there was less blood loss in the reimplantation arthroplasty when a prosthetic spacer was used. We consider resterilised prosthetic components a safe and effective alternative to cement spacers in the management of infected knee arthroplasties.

Revision total knee arthroplasty with the Total Condylar III system in inflammatory arthritis

We report a consecutive series of 16 revision total knee arthroplasties using the Total Condylar III system in 14 patients with inflammatory arthritis which were performed between 1994 and 2000. There were 11 women and three men with a mean age of 59 years (36 to 78). The patients were followed up for 74 months (44 to 122). The mean pre-operative Knee Society score of 37 points (0 to 77) improved to 88 (61 to 100) at follow-up (t-test, p < 0.001) indicating very good overall results. The mean range of flexion improved from 62 degrees (0 degrees to 120 degrees) to 98 degrees (0 degrees to 145 degrees) (t-test, p < 0.05) allowing the patients to stand from a sitting position. The mean Knee Society pain score improved from 22 (10 to 45) to 44 (20 to 50) (t-test, p < 0.05). No knee had definite loosening, although five showed asymptomatic radiolucent lines. Complications were seen in three cases, comprising patellar pain, patellar fracture and infection. These results suggest that the Total Condylar III system can be used successfully in revision total knee arthroplasty in inflammatory arthritis.

The C/C-13910 genotype of adult-type hypolactasia is associated with an increased risk of colorectal cancer in the Finnish population

BACKGROUND AND AIMS

The role of nutrition in the pathogenesis of colorectal cancer is not fully understood. Milk products are an essential part of human nutrition in Western countries. Absorption of lactose, the main sugar of milk, is regulated by the activity of the lactase enzyme in the gut wall. The activity of lactase is genetically determined and is associated with a C/T single nucleotide polymorphism residing 13910 bp upstream of the lactase coding sequence. Here we have studied the relationship between the C/T(-13910) polymorphism and colorectal cancer in Finnish, British, and Spanish populations.

PATIENTS AND METHODS

A total of 2766 subjects, including 963 Finnish, 283 British, and 163 Spanish subjects with colorectal cancer, and 773 Finnish, 363 British, and 221 Spanish control subjects, were genotyped for the C/T(-13910) variant by polymerase chain reaction minisequencing.

RESULTS

The C/C(-13910) genotype, which is a robust molecular marker of low lactase activity (lactase non-persistence), was found to significantly associate with the risk of colorectal cancer (p = 0.015) in the Finnish subjects, with an odds ratio of 1.40 (95% confidence interval 1.07-1.85). No association was found with site, histology, or stage of the tumour. No significant risk was detected in the British or Spanish populations.

CONCLUSION

Low lactase enzyme activity, defined by genotyping of the C/T(-13910) variant, may increase the risk of colorectal cancer. Further studies are warranted to investigate the role of milk and other dairy products in the pathogenesis of colon cancer in different populations.

Advances in the diagnosis of respiratory virus infections

Background: Advances have been made in selecting sensitive cell lines for isolation, in early detection of respiratory virus growth in cells by rapid culture assays, in production of monoclonal antibodies to improve many tests such as immunofluorescence detection of virus antigens in nasopharyngeal aspirates, in highly sensitive antigen detections by time-resolved fluoroimmunoassays (TR-FIAs) and biotin-enzyme immunoassays (BIOTH-E), and, finally, in the polymerase chain reaction (PCR) detection of respiratory virus DNA or RNA in clinical specimens. All of these advances have contributed to new or improved possibilities for the diagnosis of respiratory virus infections.

Objectives and study design: This review summarizes our experiences during the last 15 years in the development of diagnostic tests for respiratory virus infections, and in use of these tests in daily diagnostic work and in epidemiological studies.

Results: Immunofluorescence tests based on monoclonal antibodies, all-monoclonal TR-FIAs, and biotin-enzyme immunoassays (EIAs) have about the same sensitivities and specificities. They compare well with the sensitivity of virus culture. PCR followed by liquid-phase hybridization is a sensitive method for detecting adenovirus DNA and enterovirus and rhinovirus RNA in clinical specimens. IgG EIA on paired acute and convalescent phase sera is the most sensitive serological test for respiratory virus infections and is a valuable reference method when evaluating the sensitivity of new diagnostic tests. The IgG avidity test can distinguish primary infections from re-infections at least in respiratory syncytial virus (RSV) infections. IgM antibody assays, on the other hand, had low sensitivities in our studies.

Conclusions: The choice of diagnostic methods for respiratory virus infections depends on the type and location of the laboratory, the number of specimens tested, and the previous experience of the laboratory. Virus culture, whenever possible, should be the basic diagnostic method; the results, including identification of the virus, should be available no more than 24 h later than the results of rapid diagnostic tests. In small laboratories, especially in hospitals where specimen transportation is well organized, immunofluorescence may be the best choice for antigen detection with the provision that an experienced microscopist and a good UV microscope are available. If the laboratory receives a large number of specimens and has previous experience with EIAs, then biotin-EIAs or TR-FIAs may be the most practical techniques. Their advantages include the stability of the antigens in clinical samples since intact, exfoliated epithelial cells are not required, treatment of specimens is practical, testing of large numbers of specimens is possible, and reading the printed test result is less subjective than reading fluorescence microscopy. The larger role of PCR in the diagnosis of respiratory virus infections depends on future developments such as practical methods to extract DNA or RNA and to purify the extracts from nonspecific inhibitors, plus further improvements to minimize cross-contamination. Group-specific detection of enteroviruses and rhinoviruses is an example of the potential for PCR technology. In experienced laboratories. EIA IgG antibody tests should be available. Recombinant antigens may be a useful part of such assays.

Patient-controlled epidural technique improves analgesia for labor but increases cesarean delivery rate compared with the intermittent bolus technique

BACKGROUND

We tested the hypothesis that patient-controlled epidural analgesia for labor (PCEA) provides better analgesia and satisfaction than the intermittent bolus technique (bolus) without affecting the mode of delivery.

METHODS

We randomized 187 parturients to receive labor analgesia using either the PCEA or bolus technique. The PCEA group received a starting bolus of 14 mg of bupivacaine and 60 micro g of fentanyl in a 15-ml volume, followed by a background infusion (bupivacaine 0.08% and fentanyl 2 microg ml(-1)) 5 ml h(-1) with a 5-ml bolus and 15-min lock-out interval. The bolus group received boluses of 20 mg of bupivacaine and 75 micro g of fentanyl in a 15-ml volume.

RESULTS

Parturients in the PCEA group had significantly (P < 0.05-0.01) less pain during the first and second stages of labor. There was no difference in the spontaneous delivery rate between the groups, but the cesarean delivery rate was significantly (P < 0.05) higher (16.3% vs. 6.7%) in the PCEA group than in the bolus group. Bupivacaine consumption was significantly (P < 0.01) higher (11.2 mg h(-1) vs. 9.6 mg h(-1)) and the second stage of labor was significantly (P < 0.01) longer (70 min vs. 54 min) in the PCEA group than in the bolus group. Patient satisfaction was equally good in both groups.

CONCLUSION

The PCEA technique provided better pain relief. This was associated with higher bupivacaine consumption, prolongation of the second stage of labor, and an increased rate of cesarean section.

Prediction of mobilisation failure in patients with non-Hodgkin's lymphoma

Factors affecting progenitor cell mobilisation in patients with non-Hodgkin's lymphoma (NHL) are incompletely understood. We have analysed factors predicting mobilisation failure in 97 consecutive patients with NHL (59 males, 38 females; median age 49 years) who received mobilisation with intermediate-dose CY (4 g/m(2)) followed by G-CSF. The histology included large cell B (N=50), mantle cell (N=16), follicular (N=16) and other NHL (N=15). The disease status was 1CR/PR/primary refractory in 66 patients and >1 CR/PR in 31 patients. The minimum criterion for successful mobilisation was the collection of >or=1.5 x 10(6)/kg CD34(+) cells. In all, 18 patients (19%) failed to reach this threshold. In univariate analysis, premobilisation factors associated with mobilisation failure included BM involvement at the time of diagnosis (P=0.001) or prior to mobilisation (P=0.001) and low platelet count just prior to mobilisation (P=0.001). In multivariate analysis, only BM involvement at diagnosis (P=0.004) and platelet count just prior to mobilisation (P=0.01) were associated with mobilisation failure. A mathematical model based on these two factors and presented in the form of a receiver operating characteristics curve showed a sensitivity of 0.71 and a specificity of 0.77 in the prediction of mobilisation failure. Patients at a high risk of mobilisation failure may benefit from novel approaches.

Effects of gestational age and prenatal and perinatal events on the coagulation status in premature infants

OBJECTIVE

To study prospectively the effects of prematurity and perinatal events on the coagulation status of premature infants.

PATIENTS AND MAIN OUTCOME MEASURES

Blood samples from premature infants born before 37 gestational weeks were taken for analysis of coagulation factors II, V, VII, and X and platelet count.

RESULTS

A total of 125 premature infants, 71 boys, were studied at the median postnatal age of 40 minutes (range 12-100). The lowest median activities of coagulation factors II, V, VII, and X and the platelet count were observed, as expected, in infants (n = 21) born at 24-27 weeks gestation. Twin B (n = 14) had lower median activities of coagulation factors II, V, VII, and X than twin A. Infants with evidence of mild asphyxia (Apgar score at 5 minutes < 7 or cord pH < 7.26) had significantly (p < 0.05) lower levels of coagulation factors II, V, VII, and X and platelet counts than infants without asphyxia. Infants who were small for gestational age (SGA) had significantly (p < 0.05) lower levels of coagulation factors V and VII and platelet counts than infants of appropriate size for gestational age. Other prenatal and perinatal variables examined (sex, maternal hypertension and/or pre-eclampsia, antenatal steroid use, mode of delivery, Apgar scores) did not show any significant associations with coagulation status, which may be explained by the small number of infants studied.

CONCLUSIONS

The data strongly suggest that there are distinct differences in specific coagulation tests in different patient populations, which could assist in the identification of extremely preterm, SGA, or asphyxiated preterm infants who may be susceptible to haemorrhagic problems perinatally.

Investigation of the mechanisms of therapy-related hypoglycaemia in children with acute lymphoblastic leukaemia

AIM

To determine the mechanisms of fasting hypoglycaemia occurring during maintenance therapy (MT) for childhood acute lymphoblastic leukaemia (ALL).

METHODS

Thirty-five children and adolescents with ALL, aged 2.4-17.4 y, were fasted for up to 16 h during MT. Nineteen of the children developed hypoglycaemia after 11 to 16 h of fasting. Blood samples for determination of metabolic changes were taken on completion of fasting. Nineteen patients underwent a glucagon stimulation test after 4 to 16 h of fasting during MT. Erythrocyte concentrations of the metabolites of methotrexate (E-MTX) and 6-mercaptopurine (E-TGN) were measured at the time of fasting. Fifteen out of 19 patients who became hypoglycaemic were re-studied 3 to 4 mo after cessation of therapy.

RESULTS

In the hypoglycaemia group, plasma levels of gluconeogenic amino acids alanine and glutamine were lower (medians 117 vs 190 micromol L(-1), p = 0.009, and medians 396 vs 448 micromol L(-1), p = 0.031, respectively) than in the normoglycaemia group. Serum levels of free carnitine were lower (medians 20.3 vs 29.8 micromol L(-1), p = 0.027), free fatty acids higher (medians 3.09 vs 1.23 mmol L(-1), p < 0.001) and marked dicarboxylic aciduria was more common in the patients with hypoglycaemia (in 14/16 vs in 2/14, p < 0.001). Impaired responses to glucagon stimulation occurred in 36% (4/11) in the hypoglycaemia group and in 12.5% (1/8) in the normoglycaemia group (p = 0.243). No significant differences were detected in E-MTX and E-TGN between the groups. Most of the metabolic abnormalities returned to normal after cessation of chemotherapy.

CONCLUSIONS

Low levels of gluconeogenic amino acids, especially of alanine, are associated with hypoglycaemia. Reduced hepatic glycogen stores may also be involved in the aetiology.

Emotional reactions and life changes of caregivers of demented patients when home caregiving ends

Many studies indicate that the cessation of caregiving of demented patients has positive effects on caregivers' lives but contradictory findings have also been reported. The aim of this study was to investigate how the caregivers of demented patients experienced the cessation of caregiving, how caregivers' lives changed after this event, and which factors predicted emotional reactions and life changes. Data were collected from 64 caregivers of demented patients, recruited from a previous controlled intervention study. The semi-structured telephone interviews sought (1) sociodemographic data, (2) emotional reactions the caregivers recalled from the point of cessation of caregiving, and (3) life changes experienced after that time point. At the point of cessation of caregiving, spouse caregivers had higher risk for loneliness, depressive feelings and sorrow than non-spouse caregivers. Feelings of relief were associated with non-spouses. Community care support obtained during the previous intervention study had protected the caregivers from loneliness, depressive feelings and sorrow. After the end of caregiving, spouse caregivers tended to experience more negative life changes. The increased number of leisure activities was associated with the support during community care.

A double-blinded, randomized comparison of intrathecal and epidural morphine for elective cesarean delivery

We randomized 150 parturients into a double-blinded trial to receive intrathecal (IT) 100 microg (IT 100 group) or 200 microg (IT 200 group) or epidural 3 mg (Epidural group) of morphine for elective cesarean delivery with a combined spinal/epidural technique. The patients additionally received ketoprofen 300 mg/d. Postoperative pain relief and side effects were registered every 3 h up to 24 h, and all patients were interviewed on the first postoperative day. Pain control was equally good, but the parturients in the IT 100 group requested rescue analgesics more often compared with the other groups (P < 0.05). Itching was a common complaint and was reported by 74% of the parturients in the Epidural group and 65% and 91% in the IT 100 and IT 200 groups, respectively (P < 0.01). Medication for itching was requested by 44%, 24%, and 45% of the patients, respectively (P < 0.05). There was no difference in postoperative nausea or vomiting. The pain relief was perceived as good by >90% of the patients in all groups. In conclusion, because of the decreased incidence of and lesser requirements of medication for itching, IT morphine 100 microg with ketoprofen is recommended in cesarean deliveries. Rescue analgesics nevertheless need to be prescribed.

IMPLICATIONS

Spinal morphine is an effective analgesic after cesarean delivery, but it has several side effects. The purpose of this study was to compare the prevalence of side effects and the level of analgesia of epidural morphine with two different doses of spinal morphine after elective cesarean delivery. Although rescue analgesics may be required, intrathecal morphine 100 microg is suggested for postoperative analgesia after cesarean delivery.

Factors related to non-compliance with antihypertensive drug therapy

The objectives were to study the associations of perceived health care-related and patient-related factors with self-reported noncompliance with antihypertensive treatment. General practitioners identified all of their hypertensive patients in 26 health centres during 1 week in 1996 (n = 2219). A total of 1782 (80%) patients participated in the study, of whom 1561 were on antihypertensive medication. Based on 82 opinion statements in two questionnaires, 14 problem indices were formed by using factor analysis. Out of these, summary variables concerning problems related to the health care system and the patients were formed. Logistic regression models, including interaction analyses, were used to study the associations with non-compliance. The results were that the majority of patients had at least one perceived health care system-related (88%) and patient-related problem (92%). A high number of both perceived health care system-related problems (adjusted OR 4.77; 95% CI 2.76, 8.26) and patient-related problems (adjusted OR 3.23; 95% CI 1.79, 5.81) were associated with self-reported non-compliance. The experience of adverse drug effects was also associated with non-compliance (adjusted OR 1.41; 95% CI 1.03, 1.94). In conclusion self-reported non-compliance was associated with multiple risks of both perceived health care system-related and patient-related problems.

Apolipoprotein E gene promoter (-219G/T) polymorphism is associated with premature coronary heart disease

The relationship of two apolipoprotein (apo) E gene polymorphisms and coronary heart disease (CHD) was investigated in 118 Finnish families with premature CHD and in 110 healthy control subjects. Affected siblings and probands with premature CHD had higher frequencies of the T allele of the -219G/T promoter polymorphism and the epsilon 4 allele (genotypes epsilon 4/3 or epsilon 4/4) of the apo epsilon 2/epsilon 3/ epsilon 4 polymorphism than those of healthy control subjects. Additionally, when the two apo E gene polymorphisms were combined, affected siblings and probands had a higher frequency of the -219T allele and the epsilon 4 allele combinations than did healthy controls. The -219T and the epsilon 4 alleles both separately and together were associated with higher levels of 2-h glucose in an oral glucose tolerance test. These results indicate that the two polymorphisms of the apo E gene have similar effects on the risk of coronary atherosclerosis in families with premature CHD. This risk was not explained by the effect of apo E gene polymorphisms on cholesterol metabolism, but their effect on cardiovascular risk factor clustering with insulin resistance may be of importance. We conclude that in addition to the epsilon 4 allele, also the -219G/T promoter polymorphism of the apo E gene is associated with early onset CHD.

Different worlds, different tasks for health promotion: comparisons of health risk profiles in Chinese and Finnish rural people

The aim of this study was to compare cardiovascular risk factors of working-aged people in Chinese and Finnish rural villages. The surveys were carried out in 1989 in Tianjin, China, and in Kuopio, Finland. Altogether, 897 Chinese inhabitants and 795 Finnish subjects participated in the surveys. Health behaviours were recorded, and height, weight, blood pressure, heart rate and serum lipids were measured. Generally Finns had a significantly higher mean body-mass index, systolic and diastolic blood pressures, and serum total cholesterol, low-density lipoprotein cholesterol, and total cholesterol/high-density lipoprotein ratio than the Chinese. However, no difference was seen between Chinese and Finnish women in diastolic blood pressure and serum triglycerides. Lower high-density lipoprotein cholesterol levels were observed in Finnish men than in Chinese men, whereas a higher mean level was shown in Finnish women than in Chinese women. There were significantly higher mean heart rates and prevalence of smoking in Chinese than in Finnish populations. More people who were overweight, obese and hypertensive were found in the Finnish than in the Chinese populations. Most of the Finns had two or more cardiovascular risk factors compared with the Chinese, the majority of whom were in the group with less than two risk factors. In conclusion, the risk profiles are clearly somewhat different in these two countries. A major task for the Chinese health policy and health care system is to decrease smoking and to prevent obesity and hypertension. In Finland, the biggest task seems to be the reduction of weight and lipid abnormalities, and the prevention of hypertension.

Prevalence of subjective dry mouth and burning mouth in hospitalized elderly patients and outpatients in relation to saliva, medication, and systemic diseases

OBJECTIVE

The purpose of this study was to investigate the prevalence of self-reported symptoms of dry mouth and burning mouth in the frail elderly. We expected to find the studied symptoms more frequently in the frail elderly than in those who were healthier.

STUDY DESIGN

We examined 175 home-living elderly patients (mean age with SD, 82 +/- 5.7 years) hospitalized because of sudden worsening of their general health. For comparison, 252 elderly outpatients (mean age with SD, 77 +/- 5.7 years) from the same community were studied. The subjects' medical diagnoses and prescribed drugs used daily were recorded, their oral health examined, and saliva samples taken for analyses of flow rates, yeasts, and a variety of biochemical factors.

RESULTS

The results showed that 63% of the hospitalized patients and 57% of the outpatients complained of dry mouth. The respective percentages of burning mouth were 13% in the hospitalized and 18% in the outpatients. The dentate status affected the feeling of dry mouth and burning mouth, but there were no consequent differences in concentrations of salivary biochemical constituents, yeast counts, and buffering capacity between patients with or without the symptoms except that hospitalized patients complaining of dry mouth more often had low salivary buffering than those without the symptom. Dry mouth was also more prevalent among the hospitalized patients who used several drugs daily, whereas no such association was found with the burning-mouth symptom. Use of analgesics appeared to safeguard against both the symptoms. Dry mouth and burning mouth were seldom reported simultaneously, although low salivary flow rate was a common finding in patients with burning mouth. The strongest explanatory factors for burning mouth were psychiatric disease among the outpatients (OR 8.7, CI 1.4-54.1, P <.05) and use of psychiatric drugs among the hospitalized (OR 4.2, CI 0.9-20.0, P =.07). For dry mouth, the strongest explanatory factors were respiratory disease in the outpatients (OR 2.0, CI 1.0-3.8, P <.05) and low salivary flow rate in the hospitalized elderly (OR 3.7, CI 1.4-10, P <.05). In all patients (n = 427), use of psychiatric drugs was the strongest explanatory factor for dry mouth (OR 2.1, CI 1.2-3.5, P <.01), whereas analgesic medication was found to protect against burning mouth (OR 0.5, CI 0.3-0.9, P <.05).

CONCLUSION

The subjective feelings of dry mouth and burning mouth appeared to be a complex issue among the elderly population studied. The 2 symptoms were seldom reported at the same time. The appearance of symptoms did not directly correlate with general health, except in the case of psychiatric diseases and medications, which should be taken into account.

Free L-tryptophan plasma levels in antisocial violent offenders

RATIONALE

Several studies have shown that impulsive violent behavior is associated with reduced serotonin metabolism in the brain, but no data exist on possible alterations of the serotonin precursor (free L-tryptophan) levels among violent offenders.

OBJECTIVES

To study free L-tryptophan and kynurenine plasma levels among antisocial violent offenders.

METHODS

Free L-tryptophan and competing amino acid (CAA) plasma levels were measured among 19 male impulsive antisocial violent offenders and 19 age-matched healthy male controls.

RESULTS

Mean free L-tryptophan/(CAA) plasma levels were 160% (95% CI 116%-204%) higher among offenders than controls (P=0.000). Seventeen of the 19 offenders (89.5%) had values of more than 2 SD above the mean value of controls. The levels of kynurenine, the major metabolite of tryptophan, were slightly increased in offenders.

CONCLUSION

Free plasma L-tryptophan/CAA levels were markedly increased among antisocial violent offenders indicating a disturbed tryptophan metabolism.

Cardiovascular risk factors associated with insulin resistance cluster in families with early-onset coronary heart disease

Coronary heart disease (CHD) is a multifactorial disease caused by environmental and genetic factors. CHD clusters in families, but it is not known whether susceptibility to early-onset CHD is associated with the clustering of cardiovascular risk factors. Therefore, we determined the levels of cardiovascular risk factors among siblings with and without severe early-onset CHD drawn from 101 Finnish families. Probands with CHD, compared with their siblings without CHD, had, respectively, higher 2-hour insulin levels (475.7 versus 331.8 pmol/L, P=0.011) and 2-hour insulin areas (796.2 versus 640.4 pmol/L per hour, P=0.031) in an oral glucose tolerance test, lower high density lipoprotein cholesterol levels (1.22 versus 1.42 mmol/L, P=0.001), higher total triglyceride levels (1.91 versus 1.68 mmol/L, P=0.018), higher very low density lipoprotein triglyceride levels (1.25 versus 1.06 mmol/L, P=0.011), and higher fibrinogen levels (3.8 versus 3.4 g/L, P= 0.008). No significant differences were found in cardiovascular risk factors between affected siblings and probands with CHD. Environmental or lifestyle factors did not differ between siblings with or without early-onset CHD. We conclude that cardiovascular risk factors associated with the insulin resistance syndrome (hyperinsulinemia, low high density lipoprotein cholesterol, high total and very low density lipoprotein triglycerides, and high fibrinogen) are likely to contribute indirectly to early-onset CHD.

Quaternary structure and metal ion requirement of family II pyrophosphatases from Bacillus subtilis, Streptococcus gordonii, and Streptococcus mutans

Pyrophosphatase (PPase) from Bacillus subtilis has recently been found to be the first example of a family II soluble PPase with a unique requirement for Mn2+. In the present work, we cloned and overexpressed in Escherichia coli putative genes for two more family II PPases (from Streptococcus mutans and Streptococcus gordonii), isolated the recombinant proteins, and showed them to be highly specific and active PPases (catalytic constants of 1700-3300 s(-)1 at 25 degrees C in comparison with 200-400 s(-)1 for family I). All three family II PPases were found to be dimeric manganese metalloenzymes, dissociating into much less active monomers upon removal of Mn2+. The dimers were found to have one high affinity manganese-specific site (K(d) of 0.2-3 nm for Mn2+ and 10-80 microm for Mg2+) and two or three moderate affinity sites (K(d) approximately 1 mm for both cations) per subunit. Mn2+ binding to the high affinity site, which occurs with a half-time of less than 10 s at 1.5 mm Mn2+, dramatically shifts the monomer <--> dimer equilibrium in the direction of the dimer, further activates the dimer, and allows substantial activity (60-180 s(-)1) against calcium pyrophosphate, a potent inhibitor of family I PPases.

Association of angiotensin converting enzyme and plasminogen activator inhibitor-1 promoter gene polymorphisms with features of the insulin resistance syndrome in patients with premature coronary heart disease

Polymorphisms of the angiotensin-converting enzyme (ACE) (insertion/deletion (I/D) in intron 16) and of the plasminogen activator inhibitor-1 (PAI-1) (promoter 4G/5G) genes have been linked with coronary heart disease (CHD) and/or myocardial infarction (MI). We studied the association of polymorphisms in these genes with CHD with linkage and association analyses in 118 families with premature and severe CHD and in 110 healthy controls. In linkage analysis there was no evidence for a linkage of the ACE or PAI-1 loci with CHD. However, in quantitative linkage analysis the ACE locus was linked with fasting glucose (P=0. 047) and fasting free fatty acid levels (P=0.029). In association analysis the ACE genotype frequencies of probands with CHD did not differ from those of healthy controls. Normoglycemic probands with MI and with the ACE polymorphism DD genotype had characteristics of the insulin resistance syndrome. They had higher levels of 1-h glucose (P=0.008) and 2-h free fatty acids (P=0.011) in an oral glucose tolerance test and higher levels of total (P=0.005) and very-low-density lipoprotein triglycerides (P=0.006) than probands with the ID or the II genotypes. The PAI-1 gene polymorphism was not associated with any of the variables of glucose or lipid metabolism. In conclusion, the ACE and PAI-1 gene polymorphisms are not linked with early-onset CHD. However, the ACE gene polymorphism is associated with features of the insulin resistance syndrome.

Ligand binding sites in Escherichia coli inorganic pyrophosphatase: effects of active site mutations

Type I soluble inorganic pyrophosphatases (PPases) are well characterized both structurally and mechanistically. Earlier we measured the effects of active site substitutions on pH--rate profiles for the type I PPases from both Escherichia coli (E-PPase) and Saccharomyces cerevisae (Y-PPase). Here we extend these studies by measuring the effects of such substitutions on the more discrete steps of ligand binding to E-PPase, including (a) Mg(2+) and Mn(2+) binding in the absence of added ligand; (b) Mg(2+) binding in the presence of either P(i) or hydroxymethylbisphosphonate (HMBP), a competitive inhibitor of E-PPase; and (c) P(i) binding in the presence of Mn(2+). The active site of a type I PPase has well-defined subsites for the binding of four divalent metal ions (M1--M4) and two phosphates (P1, P2). Our results, considered in light of pertinent results from crystallographic studies on both E-PPase and Y-PPase and parallel functional studies on Y-PPase, allow us to conclude the following: (a) residues E20, D65, D70, and K142 play key roles in the functional organization of the active site; (b) the major structural differences between the product and substrate complexes of E-PPase are concentrated in the lower half of the active site; (c) the M1 subsite is functionally isolated from the rest of the active site; and (d) the M4 subsite is an especially unconstrained part of the active site.

Delirium in the non-demented oldest old in the general population: risk factors and prognosis

BACKGROUND

The oldest old are prone to develop delirium. Studies into risk factors for delirium have been carried out predominantly in younger age groups. The aim of this population-based follow-up study was to investigate the risk factors for delirium requiring medical attention and subsequent prognosis in the non-demented general population aged > or = 85 years.

METHOD

The study included the non-demented subjects in the population-based Vantaa 85+ study. After the 3-year observation period, 199 subjects (91% of those surviving) were re-examined and their medical records were evaluated for episodes of delirium. The subjects were followed up with respect to mortality for another 2 years.

RESULTS

During the 3-year observational period, 20 subjects (10%) had been diagnosed as having had an episode of delirium. A Mini-Mental State Examination score of < 24 (odds ratio (OR) 3.44, confidence interval (CI = 95%) 1.27-9.32) and high systolic blood pressure (OR 3.08, CI 1.08-8.79) were identified as independent risk factors for delirium. The association between the delirium episode and a new diagnosis of dementia was significant ( p = 0.001). The mortality rate was greater among those subjects who experienced delirium than among subjects without this syndrome ( p = 0.008).

CONCLUSIONS

Mild cognitive impairment and high systolic blood pressure were found to be risk factors for delirium requiring medical attention in the general non-demented population aged > or = 85 years. The study also highlights the significant association between delirium and a new dementia diagnosis in this age group.

Fasting hypoglycemia is common during maintenance therapy for childhood acute lymphoblastic leukemia

Nineteen of 35 children (54%) with acute lymphoblastic leukemia receiving maintenance therapy consisting of daily oral 6-mercaptopurine and weekly oral methotrexate developed hypoglycemia (blood glucose level <2.7 mmol/L [50 mg/dL] or <2.9 mmol/L [54 mg/dL] with symptoms) during 16 hours of overnight fasting. In 15 of 15 re-studied children, fasting tolerance had improved, and in 67% (10/15), it had become normal a few months after cessation of therapy.

Systematic intervention for supporting community care of elderly people after a delirium episode

OBJECTIVE

To investigate the effects of a systematic intervention with a case manager concept and rehabilitation periods compared to standard aftercare in elderly community-dwelling patients discharged from the hospital after a delirium episode.

DESIGN

Before/after intervention cohort study with 3-year follow-up.

SETTINGS

Acute geriatric wards of a city hospital and a private rehabilitation center.

SUBJECTS AND METHODS

The intervention group consisted of 51 community-dwelling people over 65 years of age without severe underlying disorders, who were consequently admitted as emergency cases to the hospital because of a delirious state or who were delirious immediately after admission. The intervention included continuous support and counseling by a nurse specialist and rehabilitation periods at a rehabilitation center. The control group consisted of 51 age- and gender-matched patients admitted to the same hospital for delirium fulfilling the same inclusion and exclusion criteria during preceding years. The main outcome measures were duration of community care, the use of long-term institutional care, the use of short-term hospitalizations during the follow-up, and the death of the patients.

RESULTS

Delirium even in the healthy community-dwelling subjects indicated a poor prognosis. After 3 years, 18 patients (35%) from the intervention group and 9 patients (18%) from the controls were in community care. The mean duration of community care was 671 days in the intervention group and 503 days in the control group, p = .025. A reduction of 19 years was achieved in the cumulative time spent in long-term institutionalized care. The use of short-duration hospitalization was similar in both groups.

CONCLUSION

The institutionalization of elderly patients after a delirious state could be delayed using rehabilitation periods and systematic intervention with the case manager concept.

Pain as a reason to visit the doctor: a study in Finnish primary health care

This study aims to demonstrate the prevalence of pain as a reason for seeing a physician in primary care. We also performed an analysis of the localization, duration and frequency of pains, as well as the diagnoses of patients having pain. A total of 28 physicians at 25 health centers in Finland collected the data, comprising 5646 patient visits. Pain was identified as the reason for 2237 (40%) of the visits. The most common localizations were in the lower back, abdomen and head. One-fifth of the pain patients had experienced pain for over six months. Analysis of the diagnoses revealed half of the pains to be musculoskeletal. Patients experienced considerable limitations in various activities of life due to pain. A quarter of the pain patients of active working age received sick leave. Our results confirm that pain is a major primary health care problem, which has an enormous impact on public health.

Delirium in elderly people without severe predisposing disorders: etiology and 1-year prognosis after discharge

BACKGROUND

The etiologic factors of delirium have been frequently studied in hospitalized elderly patients who usually have an underlying disorder, i.e., hip fracture or dementia predisposing to delirium. The etiologic factors of delirium and prognosis in healthy elderly remain unstudied. The aim of our study was to detect the primary and additional etiologic factors contributing to delirium among community-dwelling healthy elderly people without predisposing disorders to delirium and to evaluate 1-year prognosis after discharge to home.

METHOD

The study subjects consisted of 51 community-dwelling people over 65 years of age, without severe underlying disorders predisposing to delirium, admitted consecutively to the hospital because of a delirious state. The diagnosis of delirium was based on the DSM-III-R criteria. After discharge to home, the subjects were followed up for 1 year.

RESULTS

The most important primary causes of delirium were infections in 22 cases (43%) and cerebrovascular attacks in 13 cases (25%). After the 1-year follow-up period, 10 patients (20%) had been taken into long-term care and 5 patients (10%) had died.

DISCUSSION

The plausible etiologic factor of delirium was detected in all cases. Among healthy elderly people, infections and cerebrovascular attacks were the most important etiologic factors for delirium. After discharge to home, 30% of the patients had to be taken into long-term care or had died within 1 year of the delirium.

Serum lipid concentrations and growth characteristics in 12-year-old children born small for gestational age

According to Barker's hypothesis, children born small for gestational age (SGA) are at increased risk for cardiovascular diseases in adulthood. The aim of our study was to determine whether retarded fetal growth is associated with dyslipidemia in childhood and, if so, to find predictive factors in the growth characteristics of SGA children. We studied the serum lipid concentrations of 55 SGA children and their 55 appropriate for gestational age control subjects at the age of 12 y. Growth variables were recorded at birth, 5 y, and 12 y of age. The study group consisted of all full-term SGA children born at our university hospital during a 22-mo period in 1984-1986. Nearly half of the SGA children (47.3%) were in the highest quartile for serum total cholesterol of the appropriate for gestational age children (p = 0.038). In multiple logistic regression analysis, poor catch-up growth in height (odds ratio, 13. 8; 95% confidence interval, 2.0-97.5), female sex (odds ratio, 8.1; 95% confidence interval, 1.3-48.9), and early stage of puberty (odds ratio, 7.5; 95% confidence interval, 1.2-46.5) predicted high cholesterol level in the SGA children. By the age of 5 y, 20 (36.4%) SGA children showed catch-up growth of > or =2 SD scores in height, and 21 (38.2%) SGA children showed catch-up growth of > or =2 SD scores in weight from birth. At the age of 12 y, the SGA children were still significantly shorter (p<0.001) and lighter (p< 0.05) than the appropriate for gestational age children, even though their pubertal development was similarly advanced. In conclusion, to be born SGA has long-term consequences for later growth and may already influence the level of serum total cholesterol before the teens. SGA children with poor catch-up growth in height may be at the highest risk for hypercholesterolemia.