Reproductive history and cigarette smoking as risk factors for thyroid cancer in women: a population-based case-control study

A population-based case-control study was conducted in Northern Norway and Central Sweden to investigate hormonal and reproductive factors and cigarette smoking as determinants of papillary and follicular thyroid carcinoma in women. Information on 191 histologically confirmed cases and 341 age-matched controls was included. No clear association was found with regard to the number of live births, number of pregnancies, a history of incomplete pregnancies, or the use of oral contraceptives or hormonal replacement therapy. However, an early first childbirth (before 20 years of age, or less than 5 years after menarche) was associated with an increased risk of thyroid cancer. There was an increased risk of thyroid cancer among women with a history of artificial menopause compared to those with a spontaneous menopause [odds ratio (OR), 2.52; 95% confidence interval (CI), 0.96-6.62], which was more pronounced for the papillary carcinoma and after adjustment for age at menopause and use of replacement therapy. Cigarette smokers had a decreased risk of borderline statistical significance compared to nonsmokers (OR, 0.69; 95% CI, 0.47-1.01), particularly among premenopausal women (OR, 0.60; 95% CI, 0.38-0.96). This negative association persisted after adjustment for parity, hormonal treatments, and education. Women who started smoking before the age of 15 experienced a marked reduction in risk (OR, 0.38%; 95% CI, 0.18-0.80¿). Moreover, there was a suggestion of a dose-response effect with the amount of cigarettes smoked daily and with duration of the habit. Both the increased risk of artificial menopause and the negative association with smoking are compatible with a relation between levels of estrogens and thyroid cancer among women.

Remikiren (Ro 42-5892)--an orally active renin inhibitor in essential hypertension. Effects on blood pressure and the renin-angiotensin-aldosterone system

Remikiren (Ro 42-5892) is a new orally active renin inhibitor with high potency and specificity in vitro. In the present study, the drug was given in a short-term study in patients with essential hypertension, either as monotherapy or with added hydrochlorothiazide. Following a wash-out period of at least 3 weeks and then 8 days of single-blind placebo, 29 patients with essential hypertension were given remikiren 600 mg orally for 8 days. After 4 days of remikiren, hydrochlorothiazide 12.5 mg or 25 mg or placebo was added in double-blind fashion for the last 4 days. There were no significant changes in blood pressure in patients given remikiren alone. In patients given additional hydrochlorothiazide for 4 days, a marked reduction in blood pressure was observed. Remikiren effectively inhibited the plasma renin activity 24 h post-dose, whereas angiotensin II was reduced only during the first hours after drug administration. It is concluded that remikiren is orally effective. Its antihypertensive effect during short-term administration was not significant, but when given with a diuretic, a marked potentiation occurred. Further studies are needed to establish the long-term effects of remikiren alone and in combination therapy.

The Nordic comparative study on sectorized psychiatry. Part IV. The influence of patient social characteristics on treated incidence

As part of a Nordic comparative study on sectorized psychiatry, sociodemographic characteristics (gender, age and marital status) were studied in relation to treated incidence in eight diagnostic subgroups. One-year incidence cohorts in seven sectorized psychiatric services were used. Women with a neurosis diagnosis had a significantly higher relative probability of contact with all services. Men with a dependence diagnosis had a significantly higher relative probability of contact with four of the seven services. Older people had a significantly higher relative risk for affective psychosis in six of the seven centres, and younger individuals had a significantly higher relative risk for personality disorders in six of the seven centres. Unmarried people showed a higher relative risk for functional psychosis and personality disorders in five of the seven services.

The case for a greater blood pressure fall

Several large intervention trials in hypertension have shown that treated hypertensive patients are at increased risk of cardiovascular morbidity and mortality in spite of being treated. One possible explanation for this is the fact that the treated blood pressure rarely if ever is brought down to strictly normotensive levels. Against this view is the J-curve argument that suggests that too vigorous lowering of blood pressure may increase cardiovascular risks. Two prospective intervention trials have addressed this problem, the BBB Study, which has been published, and the much larger HOT Study which is still ongoing. Some of the findings in these two trials will be discussed with an emphasis on giving an up-date of the HOT Study.

Estrogen and progestagen modify the hemodynamic response to mental stress in young women

OBJECTIVE

To evaluate separately the effects of estrogen and progestagen on the cardiovascular response to a standardized mental stress test.

METHODS

Seven women were studied during the early follicular phase (day 1-4) of three different menstrual cycles after randomized oral administration of either 6 mg estradiol valerate or 15 mg norethisterone acetate or placebo. Heart rate and blood pressure were recorded at rest for 2 hours after administration and throughout the stress test. Forearm plethysmography was recorded at rest and during stress.

RESULTS

Estrogen had no effect on heart rate or blood pressure at rest. After estrogen administration the increases in heart rate (delta 14 bpm/10 bpm; p < 0.01) and diastolic blood pressure (delta 14 mmHg/9 mmHg: p = 0.06) from baseline to stress were augmented compared to those observed after placebo administration. Heart rate, systolic and diastolic blood pressures reached higher levels during stress after estrogen administration compared to placebo (delta 5 bpm, and delta 7 mmHg and delta 5 mmHg respectively; p < 0.05). Estrogen administration also caused a prolongation of the diastolic blood pressure response to stress. Progestagen compared to placebo induced an increase in heart rate already at rest (delta 4 bpm; p < 0.01), and heart rate was maintained on a higher level throughout the stress test (p < 0.05). Blood pressure at rest and pressor responses to stress were not significantly changed after progestagen administration.

CONCLUSIONS

The results indicate that estrogen is responsible for the enhanced cardiovascular responses to stress, whereas progestagen provokes a parallel upward shift of basal heart rate which is independent of level of activation.

Psychiatric morbidity in primary public health care: a Nordic multicentre investigation. Part I: method and prevalence of psychiatric morbidity

The prevalence of mental illness in five different Scandinavian primary care populations was investigated in this study. Patients consecutively consulting their general practitioner a particular week-day were included in the study. Initially the SCL-25 was applied and next the high scores and a sample of the low scores were interviewed by the PSE. In the analysis the screening procedure was first validated. The internal validity of the SCL was tested by means of Rasch latent structure analysis and the external validity tested by ROC/QROC analysis. Based on this, a short 8-item version of the SCL was developed. The prevalence of mental illness in all centres was 0.26 with a minimum of 0.14 in Nacka and a maximum of 0.34 in Turku.

What is important in psychiatric outpatient care? Quality of care from the patient's perspective

The development of quality assurance programmes for psychiatric care has increased the interest in quality of care and accountability from the patient's perspective. The aims of this study were threefold. First, to map descriptive characteristics of ideal outpatient psychiatric care through open-ended patient interviews, using a sample of 94 psychiatric outpatients, second, to have another sample of 84 outpatients rank the importance of 57 treatment characteristics extracted from the qualitative analysis of the interviews, and third to make comparisons with a previously performed investigation on quality of care of psychiatric inpatients. Results of the content analysis showed that characteristics of ideal outpatient treatment could be classified in eight content categories: accessibility of care, treatment content, staff-patient relationship, continuity of care, staff's professionalism, patient information/co-influence, treatment environment and cost of care. Results from the patients' rating of the importance of treatment characteristics showed that patients put the highest emphasis on staff's empathetic qualities in being interested, understanding, listening and respecting patients. Comparisons with the previously studied inpatient sample, showed great similarities in what was considered important to reach a satisfactory care situation. It is concluded that in order to secure content validity of investigations of the quality of psychiatric care from the patient's perspective, effort should be put into including the areas of staff-patient relationship and patient information and co-influence.

Differences in the glycosylation of recombinant and native human milk bile salt-stimulated lipase revealed by peptide mapping

The milk of some mammals contains a bile salt-stimulated lipase (BSSL). Human milk BSSL is heavily glycosylated (30-40% carbohydrate) and present at a concentration of approximately 100-200 mg/l, thereby being one of the most abundant human whey proteins. BSSL has been shown to have an important role in the uptake of energy from human milk. The risk of HIV contamination has restricted the use of banked human milk for nutritional purposes. This has evoked an interest in the production of a recombinant form of the protein for supplementation of formula. We have produced BSSL in mouse C127 and hamster CHO cells, and used chromatographic methods for the characterization of the products. This study was focused on study of the glycosylation of the protein by using peptide mapping and isolation of glycosylated fragments. The results show how human BSSLs from different sources differ both in extent of glycosylation, in glycan heterogeneity, and in lectin binding.

Choosing the optimal antihypertensive dose regimen

THE OPTIMAL DOSE-RESPONSE CURVE: From a pharmacological point of view the optimal dose regimen of an antihypertensive agent is relatively easy to define. By constructing dose-response curves the most effective dose can usually be identified. From a clinical point of view the problem is more complicated. FACTORS THAT INFLUENCE THE IDEAL CLINICAL DOSE: The most important consideration is the relationship between efficacy and adverse effects. Ideally, dose-response curves for both antihypertensive efficacy and adverse effects should be produced. From these curves the optimal dose may be established. Drugs such as lacidipine that demonstrate a good overlap between efficacy and tolerability provide a wide therapeutic window. PRACTICAL CONSIDERATIONS: It may be less effective to increase the dose of a single drug until the desired effect is obtained; the addition of another therapeutic agent is often preferable. Cost is also a factor. If the dose-response curve flattens, it may not be cost-effective to recommend a higher dose, even if the higher dose is slightly more effective. Furthermore, if an unnecessarily high dose has been recommended, doctors will soon learn to prescribe half the dose or less, which may have budgetary implications for the manufacturer. The choice of the optimal dose regimen is a complicated, multifactorial problem. The aim is to find a reasonable balance between efficacy and adverse effects, at a competitive cost.

The future role of losartan

The past few decades have seen a remarkable development in the field of pharmacological therapy, one of the most notable examples being the treatment of arterial hypertension. Some of the early anti-hypertensive agents were relatively crude by today's standards, but gradually efficacy, tolerability, or both, of blood pressure-lowering (BP) drugs have been improved. It is presently possible to choose from a number of effective and well-tolerated compounds for the treatment of hypertension. The latest additions to the anti-hypertensive armamentarium are the angiotensin II receptor antagonists, the most advanced of these being losartan. It is perhaps most relevant to compare losartan to the angiotensin converting enzyme (ACE) inhibitors, another class of anti-hypertensive agents which acts mainly by interfering with the renin-angiotensin-aldosterone system (RAAS). Studies have shown that losartan lowers BP at least as effectively as ACE inhibitors. However, the side-effect profile of losartan is more favourable. In particular cough, a relatively common side-effect of ACE inhibitors, has been shown to be significantly less common during losartan treatment. This is probably because losartan does not interfere with bradykinin metabolism, unlike the ACE inhibitors. Regarding the reversal of left ventricular hypertrophy (LVH), a powerful risk indicator for cardiovascular disease, we have shown that losartan is more effective in this regard than treatment with the beta-blocker atenolol. It appears, based on these and other findings, that interference with the RAAS is particularly useful in causing reversal of the cardiovascular hypertrophic changes. The prognostic implications remain to be demonstrated, but it would be logical to expect a benefit from this effect. It was recently shown that polymorphism of the ACE gene is associated with increased risk of coronary heart disease even in the absence of conventional risk factors. If these findings are confirmed the interest in interfering with the RAAS as a therapeutic modality in hypertension would obviously be strengthened. It is not easy to predict the future role of any new therapeutic modality. The positive relation between efficacy and tolerability of losartan, as well as the fact that several observations suggest that interference with the RAAS could be favourable from a prognostic point of view, suggest that losartan may come to play an important role in the future treatment of hypertension.

Human milk kappa-casein and inhibition of Helicobacter pylori adhesion to human gastric mucosa

Readily digested caseins, which account for almost half of the protein content in human milk, are important as nutritional protein for breast-fed infants. It has also been advocated that part of the antimicrobial activity of human milk resides in the caseins, most likely the glycosyated K-casein. Top explore this possibility, we purified K-casein from human milk to homogeneity by a two-step size-exclusion chromatography procedure. Purified human K-casein, in contrast to K-casein purified from bovine milk, effectively inhibited the cell lineage-specific adhesion of fluoroisothiocyanate-labeled Helicobacter pylori to human gastric surface mucous cells. The inhibitory activity was abolished by metaperiodate oxidation and considerably reduced by preincubation with alpha-L-fucosidase but not with alpha-N-acetylneuraminidase or endo-beta-galactosidase. These results strongly support the view that fucose containing carbohydrate moieties of human K-casein are important for inhibition of H. pylori adhesion and, thus, infection. They also suggest that breastfeeding may protect from infection by H. pylori during early life and that species-specific glycosylation patterns, as illustrated by human bovine K-casein, partly determine both the narrow host spectrum of this human gastric pathogen and the capacity to resist infection.

Cardioprotective potential of antihypertensives

The main reason for treating arterial hypertension is obviously to reduce hypertension-induced cardiovascular morbidity and mortality. Numerous studies have demonstrated a preventive effect against stroke when elevated blood pressure has been lowered by pharmacological intervention. A preventive effect of such therapy has also been shown with regard to coronary heart disease (CHD). However, the issue here is much less clear, perhaps because diuretics have been the main therapy in the majority of the large intervention trials. There are reasons to believe that newer therapy, e.g., the angiotensin converting enzyme inhibitors, would be more effective in preventing CHD in hypertensive patients. Some of this evidence will be reviewed in this paper.

The assessment of needs in psychiatric patients. Interrater reliability of the Swedish version of the Camberwell Assessment of Needs instrument and results from a cross-sectional study

The assessment of needs has been put forth as an important dimension in both the planning, development and evaluation of psychiatric services. A needs assessment tool for routine use should ideally be brief, not require additional staff, be valid and reliable with respect to setting, gender and culture, and also be sensitive to changes in needs and differences in needs between subgroups of patients. In this study, the interrater reliability of the Swedish version of the Camberwell Assessment of Needs instruments (CAN), measuring needs in 22 areas, was investigated in a cross-sectional sample consisting of 119 psychiatric inpatients and outpatients. The prevalence and severity of needs, prevalence of unmet needs, as well as current help received was also investigated. The interrater reliability of the instrument was found to be good both measured as total percentages of agreement in ratings, where an agreement of 80% or above was found in 90% of the comparisons, and as measured by Cohen's kappa. Predominant needs in the sample were in addition to clinical needs concerning psychological distress and psychotic symptoms, social needs such as the need for company, daytime activities and information concerning condition and treatment. The CAN seems to be a instrument with a high interrater reliability also when used under routine conditions as in this study. It also seems to have a high degree of feasibility with regard to different types of patients and settings and a sensitivity concerning differences in needs in subgroups of patients.

The Nordic comparative study on sectorized psychiatry. II. Resources of the psychiatric services and treated incidence

As a part of a Nordic comparative study on sectorized psychiatry, treated incidence was related to the resources and dynamic qualities of psychiatric services in 7 catchment areas. One-year treated incidence cohorts were used. Data was collected concerning number of beds and staff, number of long-term patients and turnover rate of patients in the services and availability of specialized services. A positive correlation was found between rates of outpatient staff and treated incidence. No statistically significant correlation was found between the dynamic qualities of the services and treated incidence. Treated incidence of dependence was the highest in a center that had a special service unit for abusers. Special services for young and old people were not clearly reflected in treated incidence in respective patient groups.

The Hypertension Optimal Treatment (HOT) Study: 12-month data on blood pressure and tolerability. With special reference to age and gender

The Hypertension Optimal Treatment (HOT) Study is an ongoing prospective, randomized, multicenter trial conducted in 26 countries. Its two main aims are to evaluate the relationship between three levels of target diastolic blood pressure (< or = 90, < or = 85 or < or = 80 mmHg) and the incidence of cardiovascular morbidity and mortality in hypertensive patients and the effects on morbidity and mortality of a low dose, 75 mg daily, of acetylsalicylic acid (ASA, aspirin) compared with placebo. Altogether 19,193 patients have been recruited and randomized and one-year data are now available for all patients. This is a report on the blood pressures achieved, the tolerability and other available data after 12 months of follow-up of all patients. Special reference will be given to the subgroup of elderly patients (> or = 65 years, n = 6,113) as compared to younger patients (< 65 years, n = 13,080). On average, the target group < or = 90 mmHg in diastolic blood pressure has reached 86 mmHg, the target group < or = 85 mmHg has reached 83 mmHg and the target group < or = 80 mmHg has reached 81 mmHg. The percentage of patients that has obtained their target blood pressures is 84% in the target group < or = 90 mmHg, 72% in the target group < or = 85 mmHg and 57% in the target group < or = 80 mmHg at 12 months of follow-up. In the elderly subgroup (> or = 65 years of age) the percentage of patients at target is higher for all target groups, being 86, 76 and 61%, respectively, at 12 months. Antihypertensive treatment is initiated with a calcium antagonist, felodipine, at a dose of 5 mg once daily. If target blood pressure is not reached, additional antihypertensive therapy, with either an angiotensin converting enzyme (ACE) inhibitor or a beta-adrenoceptor blocking agent, is given. Further dose adjustments are made in accordance with a set protocol. As a fifth and final step a diuretic may be added. Side effects have been relatively few in this large multinational series of intensively treated hypertensive patients. Only ankle edema, 2.6% and 3.0%, and coughing, 1.3% and 0.8%, in young and elderly patients, respectively, exceed a frequency of 1%, and 88% of all patients are still taking their baseline therapy felodipine after one year. The one-year data presented here indicate that it should be possible to fulfill the primary aims of the HOT Study.