Narratives and experience in an occupational transition: a longitudinal study of the retirement process

This article presents the results from a longitudinal study of retirement. Data were collected through interviews with 12 Swedish participants over a 7-year period, beginning when they were still working and continuing through their early years of retirement. The findings show that the participants' narrative anticipations of retirement interacted with the events of ongoing life. Sometimes these events influenced the outcomes of the retirement process unpredictably. Consequently, retirement was often full of surprises and temporary periods of turbulence. Although some participants managed a transition into a satisfying pattern of retirement, others found it an ongoing process of frustration and dissatisfaction. Evidence from this longitudinal study indicates that a special type of occupation--engaging occupation with six constituents--was an important determinant of retirement satisfaction. This key finding is discussed with regard to its implications for theory development as well as its practical implications related to the importance of differentiating occupations and attending to the interaction between internal motivation and external expectations in the occupational pattern.

Service screening with mammography in Sweden--evaluation of effects of screening on breast cancer mortality in age group 40-49 years

The aim of the study was to develop a model for estimating the effect of the nation-wide service screening program with mammography on breast cancer mortality in Sweden. In 1997, the introduction of population-based service screening had been completed in all 26 counties. In approximately half of the counties suitable for evaluation, the lower age limit for invitation was 40 years (study population) and in the other half the age limit was 50 years (control population). The numbers of females aged 40 49 years for the two populations were 202,152 and 237,279, respectively (1988). The study and control populations were compared for the period 1986-1996 with regard to refined breast cancer mortality. To adjust for geographical differences, the period 1976 1986 was used as reference. With a mean follow-up time of 8 years, the estimated relative risk of breast cancer death in relation to invitation to service screening among women aged 40-49 years at breast cancer diagnosis was 0.91 (95% confidence interval 0.72-1.15). These findings were compatible with those presented in the previous overview of the Swedish randomized studies.

Posterior stabilization of the cervical spine with hooks and screws. A clinical evaluation of 26 patients with traumatic, degenerative or metastatic lesions, using a new implant system

We operated on 26 patients with cervical spine disorders (13 with traumatic lesions, 3 with spinal stenosis and myelopathy, 1 with osteomyelitis and 9 with metastasis) with posterior stabilization. A new implant system (Cervi-Fix) based on rods, enabling a choice of either screw or laminar hook fixation in a free combination, was used. The system was evaluated for ease of use, for safety, regarding complications related to the system, and for efficacy, regarding loss of correction and signs of instability. The patients were followed for a mean period of 11 months, with ordinary and flexion/extension radiographs and clinical examination. No complications related to the implant system were observed. Loss of correction was observed in one patient. We found constructs with few vertebral fixation points, especially with screws, easy to handle, whereas multiple-claw constructs were time consuming. This implant system seems to be versatile, safe and efficient, but could be improved by the development of instruments for the insertion of the hooks.

Does the house hold? History and the shape of Mien (Yao) society

This article reexamines accounts of Mien (Yao) ethnic minority populations in northern Thailand, in particular generalizations about social structure in terms of household formations. Two ethnographic accounts from the same province of Thailand during the 1960s suggest opposite tendencies in Mien household dynamics, but each makes a case for Mien society. This restudy proposes that the dynamics of the 1960s were largely specific to engagements with the regional political economy and a reworking of social relations, which led to the prominence of the household in social life. These dynamics were in and of the twentieth century, and this article draws on a contrast with the two generations immediately prior to what the ethnographies describe to situate households in relation to the shape of Mien social formations.

Theoretical studies of atomic-scale processes relevant to crystal growth

The study of adsorption, diffusion, island formation, and interlayer transport of atoms on a growing surface has been an active field in the past decade, because of both experimental and theoretical advances. Experiments can give detailed images of patterns formed on growing surfaces. An important challenge to the theoretical studies is the identification of dynamical processes controlling the pattern formation and overall surface morphology. This can be achieved by accurate modeling of the atomic interactions, a thorough search for active atomic-scale processes, and simulation of the growth on the experimental timescale to allow for detailed comparison with the experimental measurements. An overview of some of the theoretical methodology used in these studies and results obtained for one of the most extensively studied systems, Pt(111), is given here. A remarkable richness of phenomena has emerged from these studies, where apparently small effects can shift the balance between competing molecular processes and thereby change the morphology of a growing surface. The article concludes with a discussion of possible future directions in this research area.

Evolving narratives in the course of retirement: a longitudinal study

This paper presents results from the second phase of a longitudinal study of retirement. Data were gathered through interviews with 29 participants (65 to 66 years of age) who had previously been interviewed when they were 63 to 64 years of age and still working. Data were analyzed by characterizing each subject's narrative about retirement in terms of its narrative slope--progressive, stability, or regressive. These current narratives also were compared with the earlier narratives these participants told. It was found that, while anticipatory narratives may predispose persons toward action, they are not so much a fixed "script for action" as an orientation to act within circumstances. While participants' narratives anticipating retirement often turned out as expected, they were sometimes reshaped as a consequence of personal action, external events, and unexpected experiences within new retirement occupations. The study suggests that, while narratives play a role in shaping the direction of persons lives, they also interweave with and change directions as a result of ongoing life events and experiences.

Diffusion of Ge below the Si(100) surface: theory and experiment

We have studied diffusion of Ge into subsurface layers of Si(100). Auger electron diffraction measurements show Ge in the fourth layer after submonolayer growth at temperatures as low as 500 degrees C. Density functional theory predictions of equilibrium Ge subsurface distributions are consistent with the measurements. We identify a surprisingly low energy pathway resulting from low interstitial formation energy in the third and fourth layers. Doping significantly affects the formation energy, suggesting that n-type doping may lead to sharper Si/Ge interfaces.

Lactobacillus mucosae sp. nov., a new species with in vitro mucus-binding activity isolated from pig intestine

A new Lactobacillus species from pig small intestine has been identified. In an attempt to isolate Lactobacillus reuteri strains carrying the putative colonization-factor gene (mub, for mucus binding) a mub-derived gene probe was used to screen pig intestinal material. A number of isolates were obtained and primary characterization showed that they were Gram-positive, catalase-negative, non-spore-forming, non-motile rods. Growth occurred at 45 degrees C but not at 15 degrees C and the DNA G+C content was 46 mol%. Cell wall analysis together with DNA-DNA hybridization and analysis of the 16S rRNA sequence revealed that the new isolates represent a previously undescribed Lactobacillus species closely related to L. reuteri, Lactobacillus fermentum and Lactobacillus pontis. The name Lactobacillus mucosae is proposed for this species and the type strain is S32T.

Autoaggregation of Lactobacillus reuteri is mediated by a putative DEAD-box helicase

We have cloned and sequenced a gene from Lactobacillus reuteri that encodes a 56 kDa protein, which mediates autoaggregation of the bacteria. Using an antiserum raised against extracellular proteins from the pig intestinal isolate L. reuteri 1063, we screened a genomic lambda library derived from the same strain. Affinity purification of recombinant protein from the isolated lambda clones showed that one type of clone expressed a protein that efficiently aggregated the parental strain when added to the bacteria. Subcloning and introduction of the corresponding gene, here denoted aggHinto the L. reuteri type strain markedly enhanced aggregation. Furthermore, insertional inactivation of aggH in strain 1063 resulted in an autoaggregation-deficient phenotype. Finally, an affinity-purified and cleaved fusion of AggH protein and the maltose-binding protein, MBP, strongly promoted aggregation of L. reuteri 1063, whereas the uncleaved fusion protein was inactive. Sequencing of aggH revealed that the corresponding protein has extensive sequence homology to the large family of ATP-dependent DEAD-box helicases. These results are intriguing in view of earlier data on the promotion of genetic exchange in Lactobacillus by aggregation.

Three-dimensional knee kinematics and stability in patients with a posterior cruciate ligament tear

The three-dimensional kinematics of the knee were studied from 5 months to 15 years after unilateral posterior cruciate ligament tears occurred in eight patients. All but two patients had signs of additional ligament injuries. Repeated radiostereometric examinations were conducted when the patients ascended a platform (step-up test) and during an instrumented anterior-posterior drawer test with the knee at 30 degrees of flexion. No changes in knee kinematics were observed during the step-up test, whereas increased anterior-posterior laxity (3.8-11.3 mm) was recorded for all patients. Four of the patients had an increased side-to-side difference (more than 2 mm) in anterior as well as posterior laxity. A rupture of the posterior cruciate ligament can be diagnosed at 30 degrees of knee flexion, but an increase in anterior laxity can erroneously be interpreted as an injury of the anterior cruciate ligament. The unaffected kinematics of the knee suggest that factors such as joint load and congruity and muscle activity can compensate for the absent posterior cruciate ligament during static examinations.

[The prevalence of fibromyalgia and chronic widespread musculoskeletal pain in Iceland.]

OBJECTIVE

To determine the prevalence of fibromyalgia and chronic widespread musculoskeletal pain (CWP) in Iceland in two demographic different areas.

MATERIAL AND METHODS

Population based prevalence study on 1200 females and 1200 males 18-79 years old in South-West- and South-Iceland. Established musculoskeletal pain questionnaire and telephone screening of nonresponders was used. Tender point examination was done on the subjects with CWP and the diagnosis of fibromyalgia was made in accordance with the American College of Rheumatology (ACR) 1990 criteria.

RESULTS

The prevalence of fibromyalgia in females based on 60.4% of the sample is 9.8%. The comparable prevalence in males based on 46.4% of the sample is 1.3%. The prevalence of CWP is 26.9% in females and 12.9% in males. A sharp increase in the prevalence of fibromyalgia and CWP in females is seen in the age group 31-40 compared with the age group 18-30. For female responders a statistical higher prevalence of CWP but not fibromyalgia is seen in South-West-Iceland, compared with South-Iceland. No regional differences were seen for males.

CONCLUSION

The prevalence of fibromyalgia and CWP is very high in Iceland. A matter of special concern is the high prevalence in young females. Possible causes are long working hours and stressful living conditions.

Re-used pacemakers--as safe as new? A retrospective case-control study

Re-use of pacemakers is of interest in an era of declining health care resources if it is proven safe and without risks to the patients. In order to investigate the safety of re-use of pacemakers we performed a retrospective case-control study. One hundred patients, who received a re-used pacemaker, were matched for date of implantation and mode (AAI; VVI; DDD) to 100 others who received a newly manufactured pacemaker and were followed for a mean of 32 +/- 11 months for complications defined as infections and signs of pacemaker malfunction and pacemaker replacement earlier than anticipated due to battery depletion. Patients who received re-used pacemakers were significantly older than those who received new units (79 +/- 9 vs 68 +/- 21 years; P < 0.0001). The number of complications did not differ significantly between groups. There were no early replacements due to battery depletion in either of the two groups. A cost-benefit analysis revealed a substantial economical advantage.

CONCLUSIONS

The re-use of pacemakers can be carried out without increased risk to the patients provided a proper routine for technical control and sterilization is followed. Re-use means substantial savings which possibly could make advanced pacemaker treatment available to all eligible patients irrespective of age. Whether re-use is feasible with implantable defibrillators remains to be determined.

Shot-gun phage display mapping of two streptococcal cell-surface proteins

We have used a phage display shot-gun cloning technique to map the binding domains in two cell surface proteins from animal group C streptococci. The proteins, MAG and ZAG, have affinity for alpha (2)-macroglobulin (alpha (2)M), serum albumin and IgG. In this work, parts of cloned i mag and zag genes were randomly cloned into a phagemid vector, and recombinant phages expressing alpha (2)-M- or albumin-binding activity were isolated through panning against immobilized alpha (2)M or albumin. Analysis of the clones revealed two distinct alpha (2)M-binding sites in protein MAG and two slightly overlapping binding sites in protein ZAG. The minimal albumin-binding domain in protein ZAG, as deduced from the affinity selected clones, consisted of 42 amino acids. These results show that the phage display shot-gun cloning is a rapid and convenient way to characterize the binding site(s) in receptor proteins without any prior knowledge of their number, size, and localization.

Neoadjuvant chemotherapy with cisplatin and 5-fluorouracil in advanced squamous cell carcinoma of the head and neck: a randomized phase III study

BACKGROUND AND PURPOSE

In 1986 a prospective, randomized, multi-centre trial for evaluation of neoadjuvant chemotherapy with cisplatin and 5-fluorouracil in the treatment of advanced squamous cell carcinoma of the head and neck was initiated. As survival in this group of patients is poor the purpose was to find a possible survival benefit of the chemotherapy in addition to radiotherapy compared to radiotherapy only.

METHODS

Four-hundred sixty-one patients from Denmark, Norway and Sweden with tumors in oral cavity, oropharynx, hypopharynx and larynx were randomized to receive either standard treatment (radiotherapy or radiotherapy followed by surgery) or neoadjuvant chemotherapy followed by standard treatment. Chemotherapy included three courses of cisplatin 100 mg/m2 i.v. infusion on day 1 followed by 5-fluorouracil 1000 mg/m2 per day continuous i.v. infusion for 120 hours. Radiotherapy 64-70 Gy in 2 Gy per fraction, 5 times/week, was given to patients in both treatment arms.

RESULTS

Response rate was 71% for patients randomized to chemotherapy-radiotherapy and 66% for patients randomized to standard treatment (not statistically significant). Residual tumors were excised if possible. After surgery 62% of the patients randomized to chemotherapy-radiotherapy and 60% of the patients in the standard treatment group were clinically tumor free.

CONCLUSIONS

No statistically significant benefit in survival was observed for patients treated with neoadjuvant chemotherapy followed by radiotherapy. Nor was there any impact of chemotherapy on the number of patients achieving loco-regional tumor control after primary treatment.

IgA rheumatoid factor correlates with changes in B and T lymphocyte subsets and disease manifestations in rheumatoid arthritis

OBJECTIVE

To analyze the relationship between lymphocyte subsets, different rheumatoid factor (RF) isotypes, and clinical features in patients with rheumatoid arthritis (RA).

METHODS

Patients with established RA (n = 95) were examined clinically and blood samples were collected for measurements of RF by ELISA and for analysis of lymphocyte subsets by flow cytometry.

RESULTS

IgA RF positive patients had more severe disease and higher prevalence of extraarticular manifestations than the other patients. Patients with elevated IgA RF had a higher percentage of CD5+ B cells and of CD4+CD45RO+ T cells compared to the other patients with RA or controls. High percentage of CD4+CD45RO+ T cells was also significantly associated with extraarticular manifestations. Patients with the sicca syndrome had significantly higher ratio of CD5+ B cells than patients without or with other types of extraarticular manifestations.

CONCLUSION

Different disease manifestations in RA may be associated not only with certain RF isotypes and RF isotype combinations but also with changes in lymphocyte subsets in the blood. The relative increase of CD4+CD45RO+ T cells in the blood of IgA RF positive patients with RA might reflect preferential recruitment of CD8+CD45RO+ T cells to inflammatory sites.

Anticipating retirement: the formation of narratives concerning an occupational transition

OBJECTIVE

This study is the first part of a longitudinal investigation of the retirement process. This stage of the inquiry concerned how older persons anticipate their retirement.

METHOD

Thirty-two workers were randomly selected from all workers age 63 years in a suburb of Stockholm. They participated in semistructured interviews about their work and their expectations for retirement.

RESULTS

The participants narratives illustrated the complex work of interpreting the past and expected meaning in one's occupational life. The narratives, which anticipated widely different future trajectories, revealed many of the challenges and dilemmas of anticipating retirement and the close association of work experience to expectations for retirement. In particular, the narratives highlighted the participants' concerns about maintaining the quality of experience in activity. The findings also demonstrate the process by which persons anticipate and make choices about life change.

CONCLUSIONS

People anticipate retirement through volitional narratives in which they link together past, present, and future. Understanding this volitional process of interpreting, anticipating, and making choices is important to understanding how people adapt to life changes.

Excess mortality from breast cancer in relation to mammography screening in northern Sweden

OBJECTIVES

Previous randomised studies of mammography screening have shown a significant effect on breast cancer mortality, particularly in women aged 50-69 at randomisation. Breast cancer mortality has traditionally been studied by judgments on causes of death, either from cause of death registers or from medical records. In this study an alternative method was used, estimating the excess mortality associated with breast cancer.

SETTING

In 1990 two counties of northern Sweden started population based mammography screening of women aged 40-74. The unscreened population in the two other counties of the same region were selected as controls.

RESULTS

Excess mortality associated with breast cancer was lower in the screened population, and was discernible three to four years after the start of screening. The relative risk estimate, based on the cumulative excess number of deaths from breast cancer during 1990-95 in the screened versus the control population aged 40-74 (at diagnosis of breast cancer), was 0.72 (95% confidence interval (CI) 0.53 to 0.99). For women aged 50-69 it was 0.67 (95% CI 0.46 to 0.99). In the 50-69 age group the estimated excess number of deaths from breast cancer during 1995 was 17.0 per 100,000 women (95% CI 5.0 to 29.0) in the screened counties and 51.1 per 100,000 (95% CI 30.2 to 71.9) in the unscreened counties.

CONCLUSIONS

Population based routine screening has substantial effects on breast cancer mortality in women aged 50-69. Estimation of excess mortality can be used in future studies to evaluate the effects of mammography screening on breast cancer mortality.

A collagen binding protein from Lactobacillus reuteri is part of an ABC transporter system?

The gene coding for a collagen binding protein from Lactobacillus reuteri NCIB 11951 was cloned and sequenced. A genomic lambda library was constructed and recombinant plaques were screened using antisera raised against purified collagen binding proteins from the same L. reuteri strain. The positive plaques were subjected to sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blot analysis, which revealed the expression of a 29 kDa protein, which reacted with the antisera and bound 125I-labelled type I collagen. The sequence of the corresponding gene, cnb showed that the collagen binding protein has sequence similarities to the solute binding component of bacterial ABC transporters.

Healthy houses--perspective on well-being in rural Cambodia

In a remote area of north-east Cambodia, health is seen more as a matter of living in a spiritually favourable house than of preventing and controlling diseases in individuals. However, this way of seeing things is being influenced towards a more collective view on the one hand, and a more individualistic one on the other.

Pulmonary artery abnormalities in tetralogy of Fallot and relation to late physical performance

Preoperative angiograms were reviewed in 86 (52%) of 165 patients who underwent intracardiac repair of tetralogy of Fallot in 1966-1976. The median age at repair was 7 years (range 9 months-55 years). Hypoplasia, stenosis or atresia of the pulmonary and aortopulmonary collateral arteries were present in 58 patients (67%). Hypoplasia of the main pulmonary artery was associated with hypoplasia of the pulmonary artery branches. In patients who received a transannular patch the pulmonary arteries were smaller than in those without patch. Three of five pulmonary artery branch stenoses were located at the site of a previous palliative shunt. The postrepair right ventricular/left ventricular systolic pressure ratio (PRV/LV) measured in the operating room was compared with a predicted ratio based on pulmonary artery dimensions. High PRV/LV was associated with poor prognosis. In survivors the postrepair PRV/LV had fallen significantly 13-26 years later. Work capacity and pulmonary function at follow-up were not influenced by presence of pulmonary artery abnormalities. We conclude that such abnormalities, although common in patients with tetralogy of Fallot, did not per se influence physical performance in long-term survivors.

Prospective analysis of C1 dissociation and complement activation in patients with systemic lupus erythematosus

OBJECTIVE

To evaluate the results of complement analysis for assessment of disease activity and severity, and prediction of flares in systemic lupus erythematosus (SLE).

METHODS

Patients with mild extra-renal flares, severe extra-renal flares or flares of lupus glomerulonephritis were followed for eight months, with investigations being performed every second month. Findings in initial samples four months before the flares were compared with findings in a control group with stable disease. C-reactive protein, and circulating C1q, C4 and C3 were determined together with two types of complexes containing C1 inhibitor (C1 INH), C1 INH-C1r-C1s and C1 INH-C1r-C1s-C1 INH, and the C3 breakdown product C3d.

RESULTS

Enhanced formation of C1 INH-C1r-C1s appeared to be a marker of low specificity and was mainly seen in patients with extra-renal disease. Concentrations of C1 INH-C1r-C1s-C1 INH, C3d, C1q and C3 clearly varied according to disease activity in patients with severe disease. Interestingly, high C1 INH-C1r-C1s-C1 INH values were found four months before the flares in all but one patient with lupus glomerulonephritis. Assessment of the relative predictivity for a subsequent flare indicated low C1q to be the most reliable marker, the predictivity of the complexes being: low C1q > high C1 INH-C1r-C1s-C1 INH > low C3 > high C3d > low C4.

CONCLUSION

The importance of C1q and C1-related events in SLE may be underestimated. In addition, our results demonstrate the relevance of serial complement analysis for the assessment of disease activity and severity.

Echocardiographic findings in 83 patients 13-26 years after intracardiac repair of tetralogy of Fallot

Doppler echocardiography was performed in 83 patients, 13-26 (median 19) years after repair of tetralogy of Fallot. Median age at repair was 7 years (range 9 months-42 years). An outflow patch restricted to the right ventricle was used in 29%, a transannular patch in 27% and the right ventricle was closed without a patch in 44%. Ninety-six percent of the patients were asymptomatic at follow-up. Patients with a transannular patch were younger, had a larger right ventricle and a higher right ventricle to pulmonary artery pressure difference than those without a patch. The average end-diastolic diameter of the right ventricle was larger than normal regardless of type of repair. The thickness of the right ventricular wall was increased in 50%. In 43% of the patients there was persistent hypertrophy of the right ventricular wall despite normalized systolic pressure. The average size and function of the left ventricle were normal although fractional shortening was reduced in 30% of the patients. The aortic root was abnormally large in 48%. Thirty-four percent had moderate or severe pulmonary valve regurgitation. Symptom-limited work capacity was 87% of predicted and was inversely related to age, systolic pressure in the right ventricle. E/A ratio of the left ventricle and use of the transannular patch. We conclude that right ventricular dysfunction and right ventricular outflow obstruction and/or incompetence were common even in asymptomatic long-term survivors after repair of tetralogy of Fallot.

A protein G-related cell surface protein in Streptococcus zooepidemicus

This work describes the cloning and sequencing of a gene encoding a plasma protein receptor from Streptococcus zooepidemicus. This receptor, termed protein ZAG, is a 45-kDa protein that binds alpha 2-macroglobulin (alpha 2M), serum albumin, and immunoglobulin G (IgG). The IgG-binding activity is located in the C-terminal part of the molecule and is mediated by two repeated domains highly homologous to each other as well as to the corresponding domains in streptococcal type III Fc receptors. The IgG-binding profile of protein ZAG is similar to that previously reported for S. zooepidemicus. Binding to serum albumin is mediated by a short amino acid sequence in the middle of the molecule. This domain shows homology to previously described albumin-binding proteins from streptococci, and the albumin-binding profile of protein ZAG is similar to that of streptococcal protein G. The N-terminal part of protein ZAG, which mediates binding to the plasma proteinase inhibitor alpha 2M, is composed of a unique stretch of amino acids. Protein ZAG competes for the same, or nearby, binding site(s) in alpha 2M as do two recently described Streptococcus dysgalactiae receptors, although the sequences of the alpha 2M-binding domains in these three receptors show only minor sequence similarities.

Work capacity and central hemodynamics thirteen to twenty-six years after repair of tetralogy of Fallot

Exercise tests and cardiac catheterization were performed in 53 patients, 13 to 26 years after intracardiac repair of tetralogy of Fallot. At the time of repair, the median age was 7 years, and 60% of patients with cyanosis had had a previous palliative procedure. The right ventriculotomy was closed without a patch in 21 patients (40%), a patch restricted to the right ventricle was inserted in 18 patients (34%), and in 14 (26%) the patch extended across the pulmonary anulus. At follow-up, 94% of the patients were free of symptoms. Symptom-limited work capacity was 87% of the predicted value (95% confidence limits, 82% to 94%). Work capacity was inversely related to age at follow-up, to right ventricular systolic pressure at rest, and to presence of moderate or severe pulmonary valve regurgitation. Cardiac output in relation to oxygen uptake was reduced in 74% of patients during exercise. In 12 patients (23%), systolic pressure at rest in the right ventricle was 50 mm Hg or higher. Systolic pressure during exercise in the right ventricle was lower in patients without a patch than in those with a patch and was abnormally high in all groups compared with healthy subjects. The ratio of right to left ventricular pressure was significantly lower than measurements taken immediately after repair. An intracardiac left-to-right shunt was present in 6 patients (11%). Three patients required invasive treatment as a result of our follow-up. We conclude that work capacity was moderately reduced 13 to 26 years after repair of tetralogy of Fallot and was adversely influenced by right ventricular hypertension and pulmonary valve regurgitation. Intermittent lifelong surveillance is advocated, because patients without symptoms may have hemodynamic abnormalities that necessitate intervention.

Streptococcal protein MAG--a protein with broad albumin binding specificity

Protein MAG is a cell surface protein from Streptococcus dysgalactiae which binds alpha 2-macroglobulin (alpha 2M), serum albumin and immunoglobulin G (IgG). In this work protein MAG was expressed in Escherichia coli, purified and analysed for its albumin-binding specificity. The binding of protein MAG to serum albumins of different species origin was studied in a dot-blot assay and compared with the binding of streptococcal protein G, so far the best studied bacterial albumin receptor. The albumin-binding of protein MAG was also characterized using real-time biospecific interaction analysis (BIA), and the ka, kd and the Kaff values for different albumins were determined. Amino acid sequence alignment revealed homology between the albumin-binding domain of protein MAG and earlier described streptococcal albumin receptors including protein G. However, the MAG protein was reactive with serum albumin from bovine, dog, goat, horse, human, mouse, pig, rat and sheep origin and therefore displays a broader albumin-binding profile than protein G concerning the albumins tested in this work. Comparison of the albumin-binding spectrum of protein MAG with the earlier described albumin receptors of various S. dysgalactiae strains and other streptococci, suggests that protein MAG is a new type of albumin receptor.

Survival and clinical results up to 26 years after repair of tetralogy of Fallot

Repair of tetralogy of Fallot was performed on 165 patients (median age 7 years, range 4 months-54 years) in 1966-1976. The 30-day mortality rate was 15%. High postrepair right ventricular/left ventricular pressure ratio (P(RV/LV)) was a predictor of early mortality. Complete atrioventricular block of varying duration, though associated with 42% of the early deaths, was not an independent risk factor in multivariate analysis. The 20-year survival rate (excluding early deaths) was 84%. Reoperation was done in ten patients. Of the 16 late deaths, eight were sudden. Old age at repair and use of transannular patch correlated with risk of late death. Complete atrioventricular block, acyanosis, year of surgery, sex, and P(RV/LV) did not significantly influence long-term survival. Follow-up (median 19, range 13-26 years) comprised 110 survivors, 95% of whom were asymptomatic, 77% in employment, 65% had participated in school athletics and 58% regularly exercised, but 40% did not have regular medical examinations. Operation at age 3-5 years had the most favourable prognosis.

Late sudden deaths after repair of tetralogy of Fallot. Electrocardiographic findings associated with survival

Of 141 hospital survivors after intracardiac repair of tetralogy of Fallot, eight died suddenly 6-23 years later. Compared with the other 133 patients, these eight were older at operation, with higher post-repair systolic right ventricular pressure and more often complete atrioventricular block; ventricular arrhythmia was diagnosed before death in three cases. In follow-up totalling 2255 patient years, the linearized rate of sudden death was 0.35%/year. The instantaneous risk of sudden death showed continuous increase with the length of follow-up. Of 80 survivors electrocardiographically evaluated 13-26 (median 20) years postoperatively, none had complete block, but 79 had complete right bundle branch block, including seven with left anterior hemiblock. Ventricular extrasystoles were recorded in 1% at rest, in 34% during exercise and in 83% during 24-hour ambulatory monitoring, with Lown Grade > or = II in 27%. Old age and possibly presence of fibrosis and/or fibroelastosis in right ventricular outflow Lown Grade. A patient with Lown grade III died suddenly 2 years after our follow-up. Old age at repair thus was associated with increased risk of late sudden death and with frequent ventricular arrhythmia in long-term survivors.

Social support and the development of immune function in human immunodeficiency virus infection

A psychosocial investigation offered to all human immunodeficiency virus (HIV)-infected men with moderately severe or severe hemophilia in Sweden was made in 1986. Most of these men had been infected in the years 1980 to 1984 and told about their infections in 1985. Forty-nine subjects had answered questions in regard to sources of emotional support in their life situation. Based on the responses to these questions a score of "availability of attachment" (AVAT) was calculated, and two groups of patients were identified: one with high AVAT and one with low AVAT scores. The subjects were followed with regard to the state of their immune system, as reflected by CD4 counts, until 1990. The results indicated that a low AVAT score in 1985 was associated with a significantly more rapid progressive deterioration in CD4 count during subsequent years. The mechanism behind this association is unknown. Several possible confounders were not studied. However, if the association between a poor AVAT score and rapid CD4 deterioration after HIV infection is replicated in other samples, it could be important to the future clinical care of HIV-infected subjects.

Pulmonary function thirteen to twenty-six years after repair of tetralogy of Fallot

Lung function was evaluated in 68 patients 13 to 26 (median 19) years after repair of tetralogy of Fallot. Age at repair was 7 years (9 months to 42 years) and 51% had a palliative shunt. An outflow patch was inserted in 56%. Median vital capacity was 84% of predicted, forced expiratory volume in 1 second 83%, maximal voluntary ventilation at 40 breaths/min 70%, and diffusing capacity for carbon monoxide 77% of predicted. Scintigraphy demonstrated abnormal pulmonary perfusion in 86%. Average right lung perfusion was 57% (predicted 52%). Regional hypoperfusion could in some patients be explained by previous palliative shunt, pulmonary artery obstruction, or presence of aortopulmonary collaterals. Median symptom-limited work capacity was 82% (95% confidence limits 78% to 90%) of predicted. Twenty-eight physically active patients had high values for symptom-limited work capacity, vital capacity, forced expiratory volume in 1 second, and maximal voluntary ventilation at 40 breaths/min compared with those of inactive patients. Lung function variables were related to physical exercise and previous palliative shunt. Moderate or severe pulmonary valve incompetence had negative but not significant influence on lung function. There was no significant influence of acyanosis before repair, use of transannular patch, duration of follow-up, or smoking. We found moderately reduced work capacity and lung function late after repair of tetralogy of Fallot that did not cause symptoms. Lung function variables were high in young active male patients and low in patients with previous palliative shunt. A better lung function in active patients indicates that physical activity should be encouraged after repair of tetralogy of Fallot.

Three-dimensional knee joint movements during a step-up: evaluation after anterior cruciate ligament rupture

The three-dimensional motions of the knee were analysed during closed kinetic chain knee extension in 13 patients with unilateral chronic injury of the anterior cruciate ligament. The patients ascended a platform, and serial stereophotogrammetric roentgenograms were exposed from about 100 degrees of flexion to full extension. From a position of about 100 degrees of knee flexion and 20 degrees of internal rotation, the tibia rotated externally during the extension. Almost no tibial adduction or abduction was observed. The tibial intercondylar eminence translated laterally, distally, and anteriorly relative to the femur. In knees with absence of the anterior cruciate ligament, the intercondylar eminence had a more posterior position compared with the contralateral normal knees. The proximal tibia was used as a fixed reference segment to evaluate the anteroposterior translations of a central point in the femoral condyles. The femoral point was more anteriorly displaced in the injured than in the contralateral knees. This difference might reflect increased activity of the hamstrings in the injured knees, because it was most pronounced at 80 degrees of flexion and decreased with increasing extension. In the sagittal plane, the mean helical axis was positioned close to the femoral insertion of the ligament at 80 degrees of flexion and was displaced distally and anteriorly during extension. In the frontal plane, the axis had a transverse direction at 80 degrees of flexion. At close to full extension, the axis was positioned distally in the lateral condyle and proximally in the medial condyle. In the horizontal plane, the helical axes ran slightly more anteriorly in the medial than in the lateral femoral condyle but changed inclination at close to full extension and became almost parallel to the transverse axis.

Patient age as a prognostic factor in prostate cancer

Whether patient age per se is a prognostic factor of significance in prostate cancer is controversial. To investigate this issue age-specific relative survival was analyzed, and the number of years lost due to this disease was calculated in a large and unselected cohort of 6,890 prostate cancer patients diagnosed between 1971 and 1987 in the northern region of Sweden. The tumor grade was derived from filed notification forms, which showed 26.4% well (grade 1), 40.0% moderately (grade 2) and 17.7% poorly (grade 3) differentiated tumors. There was an overrepresentation of grade 3 tumors among the youngest patients. The age-specific relative survival rate did not differ significantly among different age groups and slight differences almost vanished when adjusting for tumor grade. This finding does not support the view that tumors appearing in younger patients are more aggressive per se. However, loss of life expectancy differed significantly among all age classes and in all 3 grades. In patients with grade 1 tumors the years lost due to prostate cancer ranged from 11.0 to 1.2 in the youngest and oldest age strata, even though the relative survival was approximately 0.70 in all age classes. It was concluded that even if relative survival is constant with patient age, the absolute impact of prostate cancer at different ages varied substantially as indicated by loss of life expectancy. This finding might indicate that younger prostate cancer patients should be given more aggressive treatment than older patients.

Effects of dietary intervention on serum lipids in factory workers

OBJECTIVE

To assess the effect of workplace-oriented dietary intervention on serum lipids.

DESIGN

A cohort study. Screening for blood lipids and subsequent dietary intervention performed at a ferro-alloy factory where all the workers have at least one meal per working day served by the factory kitchen.

SETTING

Employees at Grundartangi ferro-alloy factory, Iceland.

SUBJECTS

From 1 June 1989 to 1 June 1991, 155 workers participated in the screening and prevention programme.

INTERVENTION

Changing the food served by the kitchen to 200 workers by lowering the total number of calories and increasing the content of fibre and unsaturated fats in the diet.

RESULTS

The mean serum cholesterol was lowered from 6.64 to 6.09 mmol/l or by -8.28% for the whole group (p < 0.001) after two years of intervention. In the subgroups studied, serum high density lipoprotein (HDL) increased (p < 0.001), whereas serum low density lipoprotein (LDL) decreased. Cholesterol/HDL and LDL/HDL ratios were reduced. General dietary habits seemed to change in a favourable way. No significant change occurred in body mass index or smoking habits, and there was little effect on exercise habits.

CONCLUSION

Workplace dietary intervention seems to be effective in reducing cardiovascular risk factors. Information provided to the kitchen staff is of importance, as well as information given to the employees, in order to obtain beneficial results from dietary change.

MAG, a novel plasma protein receptor from Streptococcus dysgalactiae

The gene encoding a plasma protein receptor from Streptococcus dysgalactiae has been cloned and sequenced. The gene product, with a predicted molecular mass of approx. 44 kDa, binds alpha 2-macroglobulin (alpha 2 M), serum albumin and immunoglobulin G (IgG). By subcloning and expressing various parts of the gene as fusion proteins, we found that the three binding activities reside in discrete domains of the protein. The single IgG-binding domain, localized in the C-terminal part of the molecule, shows high homology to streptococcal type-III Fc receptors. In the middle of the molecule, there is a stretch of 50 amino acids (aa) mediating albumin binding. This region has partial homology with the albumin-binding domains of streptococcal protein G. The alpha 2 M-binding domain is located in the N terminus of the molecule and is composed of a unique aa sequence. We call this trifunctional plasma protein receptor, MAG (binds alpha 2 M, albumin and IgG).

The type-III Fc receptor from Streptococcus dysgalactiae is also an alpha 2-macroglobulin receptor

We have cloned and sequenced the gene for a type-III Fc receptor from a Streptococcus dysgalactiae strain isolated from bovine mastitis and report here the complete sequence of the gene. The 1992-nucleotides-long open reading frame codes for a protein of 664 amino acids with a predicted molecular mass of 72 kDa (including the signal peptide). The C-terminal part of the protein is very similar to other streptococcal type-III receptors but contains five homologous IgG-binding domains compared to two or three in earlier reported Fc receptors of this type. Upstream of the IgG-binding domains, there is a unique sequence containing short repeated motifs. Subcloning different parts of the gene and expressing them as maltose-binding fusion proteins revealed that the upstream part is mediating binding to the plasma proteinase inhibitor alpha 2-macroglobulin after its complex formation with proteases. In contrast to earlier described type-III Fc receptors, this molecule does not bind human serum albumin.

Pap smear screening and changes in cervical cancer mortality in Sweden

OBJECTIVES

Age-adjusted incidence of cervical carcinoma has fallen dramatically in Sweden in recent decades. This investigation is an attempt to evaluate the effectiveness of the gynecologic Pap smear screening program in terms of reduction of mortality from cervical cancer.

METHODS

Cervical cancer mortality trends in relation to age, calendar period, county and degree of screening activities in the population were analyzed. Multiplicative Poisson regression models were utilized. The reduction of mortality was attributed to the activities of cervical screening.

RESULTS

The analysis gave a calculated 53% reduction in cervical cancer mortality (95% confidence limits 23-72%), attributable to screening.

CONCLUSIONS

The study supports the hypothesis that gynecological Pap smear screening has had an important impact on the reduction in cervical cancer mortality.

Chronic lymphocytic leukemia: a retrospective study of 122 cases

During the period 1978-1982 in the three northernmost countries of Sweden all 143 patients with a registered diagnosis of chronic lymphocytic leukemia (CLL) were retrospectively analyzed. After re-evaluation, 122 cases remained in the study. The mean age was 71 years and the male/female ratio was 2.2:1. Sixty-one patients were Binet stage A, 29 stage B and 32 stage C. The diagnosis CLL was made after routine check-up for other diseases in most of the patients and they had no symptoms from the CLL. The median survival was 51 months and there were no differences in crude survival according to stage or other prognostic factors such as hemoglobin, lymphocytes or thrombocytes in peripheral blood. Analysis of CLL as a cause of specific mortality showed the stage of CLL to have a slight prognostic significance. This could be due to the fact that many of the patients suffered from other serious diseases, allowing the detection of early stage or advanced CLL with no symptoms.

Over-the-top or tunnel reconstruction of the anterior cruciate ligament? A prospective randomised study of 54 patients

We report a review of 54 patients with chronic anterior cruciate ligament rupture treated by patellar-quadriceps tendon graft augmented with polypropylene braid (Kennedy-LAD). The femoral placement of the graft was randomised to either a modified over-the-top (OTT) or a tunnel position obtained by an isometric drill guide (ISO). At the two-year follow-up both procedures had resulted in improvement of subjective knee function and activity level. Stereoradiographic measurements showed reduction of anteroposterior laxity to near normal in about one-third of the patients, but muscle strength and objective functional performance showed little or no changes. The OTT group had better subjective knee function. We were unable to confirm the theoretical advantages of the use of the drill guide, partly because it provided a tibial tunnel which was too anterior.

Kinematics of successful knee prostheses during weight-bearing: three-dimensional movements and positions of screw axes in the Tricon-M and Miller-Galante designs

Using roentgen stereophotogrammetric analysis we recorded the three-dimensional movements in six knees with implanted Tricon-M prostheses and ten knees with Miller-Galante prostheses as the patients ascended a platform. Fourteen patients with normal knees were used as controls. The two prosthetic designs displayed decreased internal tibial rotation and the Tricon-M increased valgus rotation. A central point on the tibial articular surface had a more lateral position in the Tricon-M design and a more distal one in the Miller-Galante design compared to normal knees. Increased posterior displacement with increasing flexion was observed in both designs. When the normal knees were extended at full weight-bearing the helical axes mainly shifted inclination in the frontal plane. In the prosthetic knees there was a tendency to anterior-posterior displacement of the axes as extension proceeded, especially in the Miller-Galante design. Translations along the helical axes were larger than normal in the Miller-Galante and smaller in the Tricon-M knees, reflecting differences in constraint of the two designs.

Over-the-top or tunnel reconstruction of the anterior cruciate ligament? A prospective randomised study of 54 patients

We report a review of 54 patients with chronic anterior cruciate ligament rupture treated by patellar-quadriceps tendon graft augmented with polypropylene braid (Kennedy-LAD). The femoral placement of the graft was randomised to either a modified over-the-top (OTT) or a tunnel position obtained by an isometric drill guide (ISO). At the two-year follow-up both procedures had resulted in improvement of subjective knee function and activity level. Stereoradiographic measurements showed reduction of anteroposterior laxity to near normal in about one-third of the patients, but muscle strength and objective functional performance showed little or no changes. The OTT group had better subjective knee function. We were unable to confirm the theoretical advantages of the use of the drill guide, partly because it provided a tibial tunnel which was too anterior.

Coping style in relation to the consumption of factor concentrate in HIV-infected hemophiliacs during the years after their infection became known

A psychosocial investigation offered to all HIV-infected men with moderately severe or severe hemophilia in Sweden was made in 1986. Most of these men had been infected in the years 1980-1984 and told about their own infection in 1985. A noninfected group of hemophiliacs was used as a reference group in the psychosocial investigation. A psychosocial prognosis was made on the basis of the coping style observed by means of the Coping Wheel. Among subjects who showed evidence of a passive-pessimistic copying style, there was a significant decrease in the number of factor concentrate units received in 1987 and 1988. Among subjects in the group with a more active-optimistic coping style, there was a tendency of increasing the use of factor concentrate during the years after the HIV-infection became known. This result indicates that awareness of HIV-infection may influence specific hemophilia behavior among subjects with passive-depressed copying style.

Prostate cancer in northern Sweden. Incidence, survival and mortality in relation to tumour grade

In order to study changes in incidence, survival and mortality of prostate cancer in relation to morphological grade, we analysed all incident cases of prostate cancer in Northern Sweden during three 2-year periods (1974-1975, 1980-1981 and 1986-1987). The age-adjusted incidence increased by 35% from 1974-1975 to 1986-1987, but there was only a minor increase in the mortality rates. The increase in incidence was mainly due to well-differentiated (G1) and moderately differentiated (G2) tumours, whereas the incidence of poorly differentiated (G3) tumours remained stable. The 5-year relative survival rate increased significantly from 1974-1975 to 1986-1987. The relative survival rate for each tumour grade was, however, almost stable over the studied time period. After adjustment for tumour grade the differences in relative survival rate diminished. We believe that the most likely explanation for these changes in incidence, survival and mortality is enhanced detection of tumours with more favourable histology as a result of a more frequent use of the diagnostic tools available.

Psychosocial self-prognosis in relation to mortality and morbidity in hemophiliacs with HIV infection

HIV-infected hemophiliacs participated in a psychosocial prognosis study. The Coping Wheel was filled out 1-2 years after the subjects had been told that they were HIV-infected and between 1 and 7 years after they had become infected. The number of significant signs of disease as well as mortality were recorded during the years following the psychosocial measurements. These measures were related to three measures of anticipated future activities derived from the Coping Wheel, namely 'number of activities for oneself', 'number of activities with others' and a combined measure 'number of activities for oneself in relation to number of activities with others'. The results indicated that the subject's own psychosocial prognosis added to the prediction of mortality. The most important psychosocial factor was the combined measure: those with few anticipated activities for oneself in relation to activities with others had a greater likelihood of dying soon during follow-up. The latter prediction was true even after adjustment for age and condition of the immune system (CD4 count) at the start of follow-up. The conclusion is that the Coping Wheel, applied as in the present examination, may be of help in prognosis and in identifying psychosocial needs in patients with HIV infection.

Laxity after cruciate ligament injury in 94 knees. The KT-1000 arthrometer versus roentgen stereophotogrammetry

We examined 94 knees with chronic anterior cruciate ligament injuries, 55 of which had been operated with ligament reconstruction, using the KT-1000 arthrometer (89 N anterior force) and roentgen stereophotogrammetry (RSA, 150 N anterior, 80 N posterior force). In intact knees the tibial displacement did not differ between the methods. In injured knees, operated or not, the KT-1000 recorded smaller AP translations and side-differences than RSA. Thus, the stabilizing effect of reconstructive surgery may be overrated, if evaluated with the standard KT-1000 technique.

Clustering of neutrophil leucocytes in serum: possible role of C1q-containing immune complexes

Clustering activity for neutrophil granulocytes was generated in pooled normal human serum (NHS) by incubation of the serum with preformed IgG aggregates, but not in heat-treated NHS (56 degrees C, 30 min), indicating that the function was complement-dependent. Judging from results of experiments with complement-deficient sera, and serum depleted of C1q, factor D and properdin, recruitment of the complement system beyond C1 was not required for induction of the activity. Zymosan treatment of NHS resulted in some neutrophil clustering activity, but recombinant C5a had a limited effect. C1q added to heat-treated NHS in conjunction with performed IgG aggregates supported neutrophil clustering in a dose-dependent manner. The serum C1q inhibitor, a chondroitin 4-sulphate proteoglycan known to interact with the collagenous part of C1q, clearly reduced neutrophil clustering in heat-treated NHS supplemented with C1q and IgG aggregates. The C1q inhibitor also reduced the inherent neutrophil clustering activity of some sera from patients with systemic lupus erythematosus (SLE). Neutrophil clustering activity in SLE serum was earlier shown to be inversely related to the number of circulating neutrophils in vivo. Although the precise mechanisms remain unclear, we propose that C1q-containing immunoglobulin complexes mediate neutrophil clustering through C1q receptors, and that this might contribute to pathogenesis of immune complex diseases such as SLE.

Surgical treatment of vertebral metastases

Metastatic tumors often spread to the vertebral column. When the mechanical strength of a vertebra is decreased as a result of tumor-induced bone destruction, a pathologic fracture may occur. Such a fracture is often associated with severe pain. If it occurs in the thoracic or upper lumbar region, there is a major risk of paraplegia if the fractured vertebral body is displaced into the spinal canal. Metastases in the vertebral column also can cause neurologic symptoms due to direct infiltration of the tumor into the spinal canal. Due to recent advances in spinal surgery, effective help often can be provided to these patients. The extent and type of surgical intervention, however, must be carefully considered in each individual case.