The limited value of three pathogen species in predicting healing of periodontal pockets

Baseline level of Actinobacillus actinomycetemcomitans has been suggested as being predictive of periodontal treatment outcome. We analyzed the presence of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Prevotella intermedia in 55 deep periodontal pockets of 29 patients (18 men, 11 women, 37-75 years) before and after periodontal treatment. At baseline and after treatment, 62% and 33%, respectively, of the subjects presented with 1, 2, or a combination of all 3 pathogens. The mean pocket depth of 6.6 mm (0.4 mm) before treatment decreased to 2.2 mm (0.4 mm) in response to treatment (P<0.001). The treatment plan of non-surgical or surgical treatment was based on pocket depths and tooth morphology only. No antimicrobial medications were used during the treatment. Eighty-two percent of the deep pockets healed satisfactorily to < or = 4 mm. The presence of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, or Prevotella intermedia at baseline was not associated with the outcome of the periodontal therapy. In conclusion, we found that the presence of the 3 periodontopathogen species had little or no value in predicting healing of periodontal pockets.

Matrix metalloproteinase 2 (gelatinase A) is related to migration of keratinocytes

The role of matrix metalloproteinases (MMPs) in cell migration was studied by measuring cell growth, migration, and production of MMP-2 and -9 in oral mucosal and skin keratinocytes cultured in the presence of synthetic MMP inhibitors. MMP-2 was the major gelatinolytic MMP produced by these cells while MMP-9 was produced at a low basal level. Inhibitor effects on MMP-9 production were therefore studied in keratinocytes stimulated by tumor necrosis factor alpha (TNFalpha). Tetracycline analogues at concentrations that inhibited the production of MMP-2 but not MMP-9 were able to drastically inhibit migration of both mucosal and skin keratinocytes. Tetracycline analogues also inhibited keratinocyte growth, an effect not found for the other inhibitors tested. Heterocyclic carbonate-derived compounds (LWs) that inhibited MMP-9 but not MMP-2 production had no effect on cell migration. Batimastat, a potent MMP inhibitor, did not have any effect on MMP production or cell growth but did inhibit keratinocyte migration. Tumor growth factor beta (TGFbeta) increased keratinocyte migration as well as both cell-associated and secreted MMP-2 production in wounded cell cultures. The secreted enzyme was partially converted into an active form. In this model batimastat totally blocked TGFbeta-promoted keratinocyte migration. Immunostaining of keratinocytes advancing into the wound revealed that MMP-2 was localized in extracellular matrix contactlike structures against the endogenously produced laminin-5-rich matrix. MMP-9 was localized diffusely along the cell membranes. Using in situ hybridization we observed that in chronically inflamed human gingiva MMP-2 is expressed in epithelium extending into subepithelial connective tissue. These results suggest that MMP-2 plays a specific role in epithelial migration, possibly by detaching the advancing cells from the pericellular matrix or by activating other MMPs.

Changing doctor prescribing behaviour

The aim of this overview was to identify interventions that change doctor prescribing behaviour and to derive conclusions for practice and further research. Relevant studies (indicating prescribing as a behaviour change) were located from a database of studies maintained by the Cochrane Collaboration on Effective Professional Practice. This register is kept up to date by searching the following databases for reports of relevant research: DHSS-DATA; EMBASE; MEDLINE; SIGLE; Resource Database in Continuing Medical Education (1975-1994), along with bibliographies of related topics, hand searching of key journals and personal contact with content area experts. Randomised controlled trials and non-equivalent group designs with pre- and post-intervention measures were included. Outcome measures were those used by the study authors. For each study we determined whether these were positive, negative or inconclusive. Positive studies (+) were those that demonstrated a statistically significant change in the majority of outcomes measured at level of p < or = 0.05 between the intervention and control groups. Negative studies (-) showed a significant change in the opposite direction and inconclusive studies (approximately) showed no significant change compared to control or no overall positive findings. We identified 79 eligible studies which described 96 separate interventions to change prescribing behaviour. Of these interventions, 49 (51%, 41%-61%) showed a positive significant change compared to the control group but interpretation of specific interventions is limited due to wide and overlapping confidence intervals.

Shoulder joint impairment among Finns aged 30 years or over: prevalence, risk factors and co-morbidity

OBJECTIVES

To describe the prevalence, risk factors and consequences of shoulder joint impairment in the population.

METHODS

A representative sample (n = 7217) of the Finnish population aged > or = 30 yr participated in a health examination survey (the Mini-Finland Health Survey). The design of the survey allowed an independent assessment of disability, reported shoulder pain, shoulder joint impairment and major chronic co-morbidity.

RESULTS

Shoulder impairment was observed in 8.8%, while pain was reported by 30%. The prevalence of shoulder pain decreased among the elderly, whereas impairments increased up to 20% of those aged 75-80 yr. In addition to age, sex, previous injury to the shoulder joint and a history of physically heavy work, diabetes was associated with shoulder impairment (OR 1.6, 95% CI 1.2-2.1). Shoulder impairment was associated with disability (adjusted OR 2.0, CI 1.6-2.5).

CONCLUSIONS

Shoulder impairment is an important component of ill health among the elderly, and cannot be reduced to reported pain alone.

MMP-9 from TNF alpha-stimulated keratinocytes binds to cell membranes and type I collagen: a cause for extended matrix degradation in inflammation?

Activated keratinocytes synthesize increased amounts of matrix metalloproteinases during inflammation. Incubation of mucosal keratinocytes with TNFalpha (24 h) increased their expression of MMP-9 mRNA, which was followed by the corresponding increase in the expression of MMP-9 protein. This stimulation was dose dependent and continued for several days after the initial exposure to TNFalpha. In contrast, the expression of MMP-2 was not influenced by TNFalpha. IFNgamma caused a significant dose-dependent inhibition in the TNFalpha-stimulated expression of MMP-9. TNFalpha did not markedly influence keratinocyte growth, while INFgamma potently inhibited cell growth. Cytokine-stimulated keratinocytes secreted most MMP-2 and MMP-9 extracellularly into the culture medium, but MMP-9 was also found in the membrane extract of keratinocytes. Furthermore, wild-type and recombinant MMP-9 were bound to noncollageneous and nonintegrin components of the mucosal keratinocyte cell surface. MMP-9 was not, however, found in the extracellular matrix deposited by the keratinocytes in culture. Type I and IV collagens and gelatin but no other purified extracellular matrix nor basement membrane proteins (types I and IV collagen, laminin-1 and -5, fibronectin) were able to bind MMP-9 from the conditioned medium. Binding of MMP-9 from keratinocyte conditioned medium was demonstrated along the collagen fibers using immunoelectron microscopy. These phenomena may participate in extended matrix degradation in chronic inflammation.

The effects of chemically modified tetracyclines (CMTs) on human keratinocyte proliferation and migration

Chemically modified non-antimicrobial tetracycline derivatives and other low-molecular-weight synthetic matrix metalloproteinase (MMP) inhibitors inhibited keratinocyte migration. Since 72-kDa gelatinase-A (MMP-2) was the major gelatinase in our culture conditions, the results suggest that this MMP may be important in the regulation of keratinocyte mobility. On the other hand, we measured only gelatinase activities (MMP-2 and -9) present in culture medium, and therefore the results do not reveal how the inhibitors affect other MMPs as well as MMP levels close to the cell membranes. Overall, CMTs were found to be efficient in the inhibition of keratinocyte migration.

Physicians' patterns of using a computerized collection of guidelines for primary care

Physician's Desk Reference and Database is a Finnish collection of computerized primary care guidelines. The program has been in clinical use since 1989. For this study, a function producing a log file of all searches was added to the program. Two hundred twenty-seven users returned log files that contained 15,267 searches. The users made 3.12 (range 1-10.4) searches per day. The average time needed to find and read an article was 4.9 minutes. Sufficient facts were found in 71% of the searches. Dermatology was the most popular field of interest, followed by infectious diseases and cardiology.

Determination of a common genetic variant of luteinizing hormone using DNA hybridization and immunoassays

OBJECTIVE

An immunologically anomalous form of LH, due to two point mutations in codons 8 and 15 of the LH beta gene, has previously been described. LH status, i.e. the discrimination between wild-type (WT) and variant (V) LH, is usually determined by immunoassays, which can be unreliable at low serum concentrations of LH. A DNA hybridization assay was therefore developed to score the LH genotype in all subjects, independent of their serum LH concentrations. To evaluate the performance of the hybridization method, and to expand our observations of the worldwide occurrence of the V-LH, we determined its frequency in additional populations. To confirm the connection between the anomalous immunoreactivity and the V-LH beta gene, we also sequenced the LH beta subunit gene of a homozygous person.

DESIGN

According to the ratio of two immunoassays, one detecting only WT-LH and the other detecting equally WT and V-LH, individuals can be classified as homozygotes for the V-LH beta allele, heterozygotes or WT. DNA samples from persons with known LH status, according to the immunoassays, were used for the development and evaluation of a new allele-specific DNA hybridization assay. This assay, and PCR and restriction fragment length polymorphism analysis, were used to determine the frequency of the V-LH beta allele in DNA samples obtained from eight populations.

PATIENTS

Ambulatory adult men and women, apparently healthy and with no endocrine disorders.

RESULTS

The LH genotyping by immunoassays and by the new hybridization method gave identical results with all samples analysed (n = 25). The V-LH beta subunit was observed to always have the two point mutations, and to be identical with the ones previously reported. The V-LH beta carrier frequency in the DNA samples collected from various populations varied between 0 and 53.5%.

CONCLUSIONS

The immunoassay technique and the hybridization assay can be used as alternatives to determine the LH status. A great variation in carrier frequency of the V-LH beta allele is observed in different populations.

An implementation study of the PDRD primary care computerized guidelines

OBJECTIVE

To study the implementation of electronic guidelines designed for general practitioners (GPs).

DESIGN

A descriptive 3-year follow-up study.

SUBJECTS

All new subscribers to Physician's Desk Reference and Database (PDRD) in 1992.

SETTING

Locations of computers, where PDRD software was installed for the first time in 1992.

MAIN OUTCOME MEASURES

Expectations of the program and changes in attitudes towards it, getting started with the system, frequency and continuity of use and estimated usefulness of the program.

RESULTS

The guidelines were expected to enhance diagnostic accuracy (60% of subscribers), save time (45%), and reduce costs (11%). After 1 year's use, the opinions of the users on these topics had become slightly more positive. Technical problems delayed starting to use the program in 27%. After 1 year 72% were using the program at least weekly. Using frequency was associated with having the computer in the office. The subscribers who renewed their subscription after one year often became regular users.

CONCLUSIONS

The study provides insight into the implementation phase of computer-based guidelines in a population of early adopters. Technical support was essential to overcome the barriers associated with computer technology. The perceived need for information was independent of the age and experience of the physicians.

Economic evaluation of rotavirus vaccinations in Finland: randomized, double-blind, placebo-controlled trial of tetravalent rhesus rotavirus vaccine

The cost-benefit ratio of tetravalent rhesus rotavirus vaccine (RRV-TV) in Finland for prevention of rotavirus gastroenteritis was assessed in a randomized, double-blind, placebo-controlled trial. Costs related to vaccination, side effects, and gastroenteritis were identified. Children received RRV-TV (n = 1,191) or placebo (n = 1,207) at 2, 3, and 5 months of age with other infant vaccinations. Prospective follow-up averaged 1.0 years per child. An intention-to-treat analysis was performed from the perspective of society. Nine cases of severe rotavirus gastroenteritis occurred in the RRV-TV group, versus 100 in the placebo group (P < .0001); mean cost per vaccinated child was 4 Finnish marks (FIM) in the RRV-TV group, versus 203 FIM in the placebo group. Side effects with related costs occurred after 11% and 7% of doses in the RRV-TV group and placebo group, respectively (P < .001); mean cost per child was 89 FIM vs. 75 FIM. The break-even cost (i.e., net benefit, excluding cost of vaccine) of RRV-TV in prevention of severe rotavirus gastroenteritis was 109 FIM (U.S. $19.60) per child.

Molecular diagnosis of human rhinovirus infections: comparison with virus isolation

To compare the sensitivity and specificity of RT-PCR with that of virus isolation in the detection of human rhinoviruses, we tested nasopharyngeal aspirates from 200 patients on the 1st and 7th days after the onset of the common cold. An assay utilizing a short amplicon in the conserved 5' noncoding region was found highly sensitive. Of 192 positive samples altogether, 65 were found positive by RT-PCR only, 6 were positive by isolation exclusively, and 121 gave positive results in both tests.

Diagnosing acute maxillary sinusitis in primary care: a comparison of ultrasound, clinical examination and radiography

In primary care, acute maxillary sinusitis may be diagnosed by clinical examination, ultrasound or radiography. Previous studies on the diagnostic accuracy of these methods are from secondary care settings and may not be generalisable to primary care. In this study of 39 primary care patients we have compared ultrasound, clinical examination and radiography to sinus irrigation. The sensitivity of ultrasound performed by general practitioners is 61% and specificity is 53%. Diagnostic accuracy does not improve when the general practitioner bases the diagnosis on combination of clinical examination and ultrasound. The most accurate way to diagnose sinusitis is radiography and when the radiographs are interpreted by a radiologist (sensitivity: 61%; specificity: 98%). The accuracy of the ultrasound examination performed by general practitioners is poorer than earlier results from ENT practices. More attention should be paid to education and quality management in the use of ultrasound in primary care.

Functional assessment scales in detecting dementia

AIM

to evaluate the use of different functional scales in detecting dementia in a population study.

METHODS

the study is part of the Helsinki Ageing Study. A random sample of 795 subjects aged 75 (n = 274), 80 (n = 266) and 85 years (n = 255) was taken. The prevalences of dementia (DSM-III-R criteria) in these age groups were 4.6, 13.1 and 26.7% respectively. The functional scale scores were known for 71% of the non-demented and 66% of the demented subjects. A structured questionnaire completed by a close informant included four functional scales: the index of activities of daily living (ADL), the modified Blessed dementia scale (DS), the instrumental activities of daily living scale (IADL) and the Functional Assessment Questionnaire (FAQ).

RESULTS

all the functional scales discriminated demented from non-demented subjects. Based on receiver operating characteristics analysis, the area under the curve (95% confidence interval) was 0.90 (0.80-0.94) for the ADL, 0.94 (0.87-0.97) for the DS, 0.95 (0.90-0.98) for the IADL and 0.96 (0.92-0.98) for the FAQ. The effects of age, sex and education in detecting dementia were minor or non-existent in the ADL, DS and FAQ scales, but age had an effect on the performance of the IADL scale. All the scales detected even mild dementia adequately.

CONCLUSIONS

functional scales can be used in detecting dementia when functional assessment is already used for other purposes, such as among elderly primary care patients.

Osteoarthritis of the hip and knee and mechanical occupational exposure--a systematic overview of the evidence

OBJECTIVE

To clarify examine the epidemiologic evidence linking work related exposure to osteoarthritis (OA) of the hip and knee.

METHODS

We investigated MEDLINE and EMBASE 1966-1994 with search terms of osteoarthritis, osteoarthrosis, arthrosis; risk factors, exposure; occupational diseases, agricultural workers' diseases, work. From 123 original studies on risk factors for OA, 17 studies were identified as providing a comparison group and relating the presence or absence of radiologically diagnosed OA to occupational factors. The quality of the methodology of each study was evaluated independently by 4 reviewers using a standardized protocol.

RESULTS

Common methodological problems were encountered in areas such as representatives, recall of exposure, and evaluation of exposure and outcome. These problems often made a cause-effect relationship difficult to interpret. However, 7 of the 17 studies met our criteria for good methodological quality. A critical analysis of their results led to the following conclusions: (1) A consistently positive relationship exists between work involving knee bending and knee OA in men (range of odds ratio: 1.4-6). (2) The evidence suggesting a relationship between knee OA and occupational exposure in women is inconclusive. (3) A consistently positive but weak relationship exists between work related exposure (i.e., farming in particular) and hip OA in men. We felt we could not conclude with confidence that this relationship is strong due to the potential biases that exist in each of these studies. (4) No study attempted to investigate occupational exposure and hip OA in women.

CONCLUSION

Studies suggest a strong positive relationship between work related knee bending exposure and knee OA. The evidence between work related exposure, farming in particular, and hip OA is consistently positive but weak.

Ambient and biological monitoring of exposure to polycyclic aromatic hydrocarbons at a coking plant

The exposure to polycyclic aromatic hydrocarbons (PAH) was measured in a Finnish coking plant over a 7-year period (1988-1994), since the beginning of production. Hygienic measurements including dust and vapour sampling were performed and the correlations between the concentrations of airborne pyrene with the levels of pyrene metabolite 1-pyrenol in urine were calculated. The profile of measured 12 or 15 PAHs was very similar between mean concentrations of personal samples, which suggests that it is possible to calculate the concentrations of total PAH by using e.g. pyrene as a marker compound. Measurements suggest that the progress of working conditions has been very favourable because the mean exposure level of shift workers to benzo[a]pyrene has decreased from 2.5 micrograms/m3 to 0.3 micrograms/m3. This points to successful measures of technical prevention. The mean concentration of 1-pyrenol in urine has been 0.2-0.6 mumol/mol creatinine. The concentration increases slightly towards the end of the working day, but the correlation urinary pyrenol and air pyrene was weak. Therefore the usefulness of pyrenol level for predicting the pyrene concentration at low exposure level in the ambient air is very limited.

Practice guidelines in Finland: availability and quality

OBJECTIVE

To describe the quantity, quality, and availability of practice guidelines currently used in Finland.

DESIGN

Cross sectional survey.

METHODS

Guidelines from 1989 to 1995 were collected through a database search, through hand searches of the two Finnish general medical journals, and through an inquiry into hospitals, health centres, and medical societies. The content and source of evidence for guidelines was assessed.

RESULTS

719 practice guidelines were found. 578 guidelines (80%) were retrieved by the inquiry, the database search identified 27 (4%) and hand searches 106 (15%). There were 150 guidelines (21%) developed nationally, 120 (17%) regionally, and 449 (62%) locally. The structure and quality of evidence supporting the guidelines was variable and only two guidelines were based on meta-analysis. The references were significantly more often (P < 0.001) documented in the national guidelines (n = 129, 86%) than in the regional or local guidelines (n = 65, 11%).

CONCLUSIONS

There are many ways of disseminating guidelines and it may be difficult for end users to find the appropriate guidelines. Sources of evidence were seldom documented in the regional and local guidelines and even some national guidelines lacked all references. More attention should be paid to documenting the level of evidence, structuring the guidelines, and creating optimal strategies for development and dissemination of guidelines.

One-year risk of institutionalization in demented outpatients with caretaking relatives

In order to determine the factors associated with good and poor 1-year prognosis of demented patients, the caretakers of 100 home-based patients attending a specialist memory clinic were interviewed. After the follow-up, 71% continued to live at home. Mild dementia, independence in activities of daily living, fair independence in functions of instrumental activities of daily living, and lack of depression were clear signs for a good prognosis. Some patients with severe dementia and poor functional capacity continued to live at home. Continuing home care was also more likely if memory impairment, as opposed to functional problems, was expressed as the main concern. The proportion of caretakers mentioning memory decline as the main problem decreased during 1 year from 38% to 9% and the proportion mentioning functional problems increased from 48% to 64% among those continuing in home care. Memory disturbances are the first to appear and cause problems, but only functional decline threatens living at home.

Influenza vaccination among healthy employees: a cost-benefit analysis

The cost of influenza vaccination and influenza infections was evaluated in a controlled study among healthy municipal homemakers. Acute respiratory infections were followed clinically and with laboratory samples for 8 months. Full follow-up was achieved in 351 persons in the intervention group, of whom 47% obtained vaccination, and 492 controls. Influenza infection was confirmed in 10 employees (8 of these in the control group) and other viral infections in 6 employees (5 of them controls). All infections occurred in non-vaccinated persons. The relative risk of infection in the control group was 2.9 (95% CI 0.6-13.4) for influenza and 3.1 (0.9-10.8) for all respiratory infections. The mean sick leave for influenza was 4.9 days. The cost per immunization was FIM 141, and the average cost per influenza infection FIM 1183. The cost per infection averted was FIM 6270, and the equivalent cost for immunization FIM 26.52. Influenza vaccination had a slight protective effect against both influenza and other respiratory infections. The cost of vaccination programmes exceeded the benefit from averted infections. Optimal vaccination strategies for healthy adults need to be planned individually with minimal loss of working time.

One-step all-in-one dry reagent immunoassays with fluorescent europium chelate label and time-resolved fluorometry

The availability of an intrinsically fluorescent, inert, and stable Eu chelate label made it feasible to design one-step all-in-one immunoassays with time-resolved fluorometry for detection. Both competitive and noncompetitive immunoassays are performed in microtitration wells containing all assay-specific components in a stable dry form. Only the sample and one assay buffer common for all analytes need to be added. Model assays for human chorionic gonadotropin (hCG), alpha-fetoprotein (AFP), and progesterone all reached equilibrium in 15 min or less without compromising the performance characteristics of the measurements, all of which perform at least equivalent to state-of-the-art assays. The detection limits for hCG, AFP, and progesterone were 0.3 IU/L, 0.1 microgram/L, and 0.5 nmol/L, respectively. The assay ranges for hCG and AFP were linear to 5000 IU/L and 1200 micrograms/L, respectively. The immunoassay format can be readily implemented in a fully automated random-access immunoassay system with optimal performance characteristics and no handling of analyte-specific assay components.

One-step all-in-one dry reagent immunoassays with fluorescent europium chelate label and time-resolved fluorometry

The availability of an intrinsically fluorescent, inert, and stable Eu chelate label made it feasible to design one-step all-in-one immunoassays with time-resolved fluorometry for detection. Both competitive and noncompetitive immunoassays are performed in microtitration wells containing all assay-specific components in a stable dry form. Only the sample and one assay buffer common for all analytes need to be added. Model assays for human chorionic gonadotropin (hCG), alpha-fetoprotein (AFP), and progesterone all reached equilibrium in 15 min or less without compromising the performance characteristics of the measurements, all of which perform at least equivalent to state-of-the-art assays. The detection limits for hCG, AFP, and progesterone were 0.3 IU/L, 0.1 microgram/L, and 0.5 nmol/L, respectively. The assay ranges for hCG and AFP were linear to 5000 IU/L and 1200 micrograms/L, respectively. The immunoassay format can be readily implemented in a fully automated random-access immunoassay system with optimal performance characteristics and no handling of analyte-specific assay components.

Diagnosis of maxillary sinusitis in Finnish primary care. Use of imaging techniques

OBJECTIVE

To observe the effect of imaging techniques on the diagnostic pattern of sinusitis in primary care.

DESIGN

A multicentre survey.

SETTING

14 health centres with varying facilities for clinical imaging.

SUBJECTS

446 adult patients with a suspicion of acute maxillary sinusitis. Ultrasound or radiography facilities existed in 337 cases while 109 could only be judged clinically. MAIN outcome measures--The use of ultrasound, radiography, laboratory tests, irrigation and control visits. The final number of patients with sinusitis in different facility groups.

RESULTS

When available, ultrasound was used in 82-92% and radiography in 6-32% of cases. The ultrasound finding showed mucosal thickening or was difficult to interpret in every third case; one half of these were interpreted as sinusitis and the rest were considered healthy. In total, sinusitis was diagnosed in 84-88% when ultrasound or radiography only could be used, and in 77% when both techniques were available (p < 0.01). Simultaneously the general practitioners' confidence in the correctness of their diagnosis increased from 39% to 66%.

CONCLUSION

When possible, ultrasound is widely used in diagnosing sinusitis in Finnish primary care. The use of ultrasound slightly diminished the numbers of sinusitis diagnoses but the techniques of using and interpreting ultrasound findings need to be improved.

Low back pain and subsequent cardiovascular mortality

STUDY DESIGN

This was a prospective cohort study based on data of the Mini-Finland Health Examination Survey collected between 1978 and 1980, with follow-up until the end of 1991.

OBJECTIVE

A number of studies have revealed associations between smoking, cardiovascular diseases, and low back pain. Therefore, it has been suggested that atherosclerosis could be involved in the etiology of low back pain. Low back pain was studied for its prediction of mortality and, in particular, deaths from cardiovascular disease.

SUMMARY OF BACKGROUND DATA

Of a nationally representative sample of 8000 people older than 29 years, 7217 (90%) participated in a comprehensive health examination. At interviews, 5459 (76%) had a history of low back pain. In a standardized clinical examination, 1253 (17%) were diagnosed as having chronic low back pain.

METHODS

The follow-up information on mortality and causes of death was obtained from the Central Statistical Office of Finland.

RESULTS

By the end of 1991, 1487 of the examinees had died, 815 from any cardiovascular disease and 501 from coronary heart disease. Neither the history of back complaints nor chronic low back pain predicted mortality.

CONCLUSION

That low back pain does not affect longevity disagrees with the hypothesis that atherosclerosis resulting in death from cardiovascular disease is etiologically linked to low back pain.

Expression of epithelial adhesion proteins and integrins in chronic inflammation

Epithelial cell behavior in chronic inflammation is poorly characterized. During inflammation of tooth-supporting structures (periodontal disease), increased proliferation of epithelial cells into the inflamed connective tissue stroma is commonly seen. In some areas ulceration and degeneration take place. We studied alterations in the expression of adhesion molecules and integrins during chronic periodontal inflammation. In inflamed tissue, laminin-1 and type IV collagen were still present in the basement membrane and surrounding blood vessels, but they were also found extravascularly in inflamed connective tissue stroma. Type VII collagen and laminin-5 (also known as kalinin, epiligrin, or nicein) were poorly preserved in the basement membrane zone, but both were found in unusual streak-like distributions in the subepithelial connective tissue stroma in inflamed tissue. Both fibronectin and tenascin were substantially decreased in chronically inflamed connective tissue, showing only punctate staining at the basement membrane zone. Integrins of the beta 1 family showed two distinct staining patterns in epithelial cells during chronic inflammation; focal losses of beta 1 integrins (alpha 2 beta 1 and alpha 3 beta 1) were found in most areas, while in other areas the entire pocket epithelium was found to be strongly positive for beta 1 integrins. No members of the alpha v integrin family were found in any epithelia studied. Expression of the alpha 6 beta 4 integrin was high in basal cells of healthy tissue, but weak in epithelium associated with chronic inflammation. Chronic inflammation therefore involves alterations in both adhesion proteins and integrins expressed by epithelial cells. Basement membrane components found at abnormal sites in stroma in chronic inflammation might serve as new adhesive ligands for various cell types in inflamed stroma.

Prediction of severe rheumatoid arthritis using Epstein-Barr virus

One of the immunological abnormalities in patients with RA is increased synthesis of immunoglobulins (Ig) in cultures of Epstein-Barr virus (EBV-) stimulated lymphocytes. We set out to investigate whether this feature, seen early in the disease, associated with later severe RA. We studied prospectively 45 patients with recent onset RA and, 41 healthy individuals. From 0-6 months after admission, blood lymphocytes were cultured in the presence of EBV for 4 weeks and Ig in the supernatants were assayed. To assess the severity of disease, clinical, laboratory and radiological evaluations were performed every 6 months for 2 yr. The association of increased Ig production with the severity of RA was then analysed. During the follow-up period, 30 of the original 45 patients developed erosive disease. At onset, these 30 patients did not differ from the 15 with non-erosive disease when assessed by several parameters reflecting rheumatoid activity. However, EBV-induced production of Ig was significantly higher in the erosive compared with the non-erosive group of patients (P < 0.001). Using Ig synthesis, it was possible to identify a subgroup of 9-14 patients, depending on the isotype studied, who would later develop severe erosive disease (PVpos = 90-100%). These results show that high EBV-induced production of Ig early in RA associates with later severe disease, particularly with joint erosions. This feature identifies, with over 90% likelihood, the third of patients who will later develop most severe disease.

Matrix metalloproteinases (MMP-2 and MMP-9) of the oral cavity: cellular origin and relationship to periodontal status

Proteolytic enzymes released by the host cells are associated with the tissue destruction in periodontal diseases. Matrix metalloproteinases (MMPs) have the primary role in this process, since, in concert, they can degrade most of the extracellular matrix components. In the present study, we investigated MMP-2 and MMP-9 in oral fluids of healthy subjects and periodontitis patients and the contributions of different oral cells to the enzyme production. The enzymograms revealed that the main gelatinase in oral rinses, crevicular fluid, and whole saliva migrated at 92 kDa. Activity was also detected at 200 kDa and 130 kDa and minor activity at 86 kDa, 72 kDa, and 40 kDa. Traces of gelatinolytic activity were also detected in pure parotid secretions. The 92-kDa enzyme was identified to MMP-9 and the 200-kDa gelatinase to MMP-2, by means of specific anti-72-kDa antiserum. Gingival keratinocytes produced mainly MMP-9, while gingival and granulation tissue fibroblasts expressed MMP-2. Glandular tissue contained mainly MMP-9, and mRNA for MMP-9 was also found in acinar epithelial cells. Periodontitis patients had significantly higher levels of MMP-9 than healthy subjects. Also, MMP-2 was elevated in periodontitis patients. Periodontal treatment reduced the amount of gelatinases dramatically. This study shows that gelatinases are produced by various cells in the oral cavity. The amount of gelatinases is elevated during periodontal disease, while conventional periodontal treatment efficiently reduces the levels these enzymes. We suggest that MMP-2 and MMP-9 could participate in tissue destruction in periodontitis.

Expression of matrix metalloproteinase-2 and -9 during early human wound healing

BACKGROUND

During wound healing, keratinocytes detach from the basement membrane and migrate to cover the exposed connective tissue. Subsequently, the wound clot is degraded gradually and replaced by the epithelial cells and the granulation tissue. Both of these processes are likely to be affected by matrix-modifying enzymes. Type IV collagenases are members of the matrix metalloproteinase family (MMP), which are known to degrade several matrix components. The aim of this study was to investigate the expression of MMP-2 and MMP-9 (72-kd and 92-kd type IV collagenases, respectively) during early human wound healing.

EXPERIMENTAL DESIGN

Experimental wounds were created in human oral mucosa and biopsies were taken 1, 3, and 7 days after wounding. In situ hybridization on paraffin sections was used for the detection of messenger RNAs coding for MMP-2 and MMP-9, and the secretion of MMPs into the oral cavity after wounding was followed by zymography. Regulation of MMP-2 and MMP-9 expression by cytokines was studied using cultured mucosal keratinocytes, gingival fibroblasts, and wound granulation tissue fibroblasts.

RESULTS

By in situ hybridization, the expression of MMP-2 was localized in the connective tissue fibroblasts and endothelial cells during all phases of wound healing. Mucosal epithelium was practically negative for MMP-2 expression. MMP-9 messenger RNA was found in mucosal epithelium on days 1, 3, and 7. A strong signal was localized in basal and suprabasal cell layers in the nonwounded area, while only the basal cell layer was MMP-9 positive in the migrating epithelial sheet. Seven days after wounding, granulation tissue exhibited an unusually strong signal for MMP-9 messenger RNA. Wound fluid contained mainly MMP-9, the amount of which was highest in two- to four-day-old secretions. None of the cytokines tested (transforming growth factor beta-1, interleukin-1 beta, basic fibroblast growth factor, tumor necrosis factor-alpha, interferon-gamma) were able to regulate MMP-2 expression in cultured wound fibroblasts. However, keratinocyte MMP-9 production was enhanced by interleukin-1 beta, transforming growth factor beta-1, and tumor necrosis factor-alpha.

CONCLUSIONS

During wound healing, MMP-9 is suggested to be involved in keratinocyte migration and granulation tissue remodelling. Expression of MMP-2 remains stable during wound healing.

Association of overweight, trauma and workload with coxarthrosis. A health survey of 7,217 persons

In a population sample health survey, body mass, previous trauma and physical stress were studied for associations with coxarthrosis. A sample of 8,000 persons representative of the Finnish population aged 30 or over was invited for examination, and 90 percent participated. On the basis of a standardized clinical examination, a physician diagnosed coxarthrosis in 6 percent of the women and 4 percent of the men. The prevalence rose with age. In persons with a past traumatic lower-limb injury, the odds ratio of unilateral coxarthrosis was 2.1 and of bilateral coxarthrosis 1.5, as adjusted for sex, age and other determinants using logistic regression. The sum index reflecting self-reported features of physical stress in present or previous occupations was directly proportional to the prevalence of coxarthrosis. Body mass index (kg/m2) was closely associated with bilateral coxarthrosis; the adjusted odds ratio (95 percent confidence intervals) for indices > 35, compared to those < 25, was 2.8 (1.4-5.7). In terms of the population attributable fraction, prior trauma, physical stress and body mass were estimated to explain 59 percent of the prevalence of coxarthrosis. The potential for primary prevention may be great, but longitudinal population studies are necessary to elucidate causal significance of the risk factors.

Anti-integrin antibodies induce type IV collagenase expression in keratinocytes

During wound healing, pericellular proteolysis is thought to be essential for the detachment of keratinocytes from basement membrane and in their migration into the wound bed. We have characterized integrin-type cell adhesion/migration receptors in human mucosal keratinocytes and examined their function in the regulation of type IV collagenase gene expression. Two major integrins of the beta 1 class, alpha 2 beta 1 and alpha 3 beta 1, were found to function as collagen and fibronectin receptors, respectively. Antibodies against beta 1 and alpha 3 integrin subunits were found to stimulate the expression of the 92 kDa type IV collagenase severalfold in a dose-dependent manner. Keratinocytes expressed also the 72 kDa type IV collagenase, the synthesis of which remained, however, unchanged in keratinocytes treated with anti-integrin antibodies. Stimulation of 92 kDa enzyme was found to be caused directly by antibody binding to integrins, since Fab-fragments of anti-beta 1 antibodies alone were able to induce collagenase expression in the absence of secondary, clustering antibodies. Antibodies against alpha 2 beta 1 integrin caused no stimulation. Keratinocytes seeded on different substrata (plastic, collagen, fibronectin, laminin, or vitronectin) showed equal induction of type IV collagenase expression. Expression of 92 kDa type IV collagenase could not be induced by peptides (GRGDS, GRGES), proteins (fibronectin, laminin, fibrinogen, albumin), or antibodies to fibronectin. We suggest that proteolytic processes around keratinocytes can be regulated by extracellular factors signalling through integrin-type receptors.

Musculoskeletal disorders as determinants of disability in Finns aged 30 years or more

The relationship between disability and various musculoskeletal disorders was investigated in 7217 men and women representative of the Finnish population aged 30 years or more. They participated in the Mini-Finland Health Survey and were first screened by interview and questionnaire about limitations in daily activities. The outcome variables were reduced working capacity, an occasional need for assistance in daily activities, and a regular need for assistance in daily activities. In a two-phase medical examination, all cases fulfilling predetermined diagnostic criteria of musculoskeletal, cardiovascular, respiratory and mental disorders and diabetes were recorded independently. In multivariate logistic regression analyses, inflammatory arthritis was the strongest determinant of all forms of disability. Osteoarthritis, especially in the hip, was a strong determinant of both occasional and regular need for assistance, and chronic low back pain was a strong determinant of reduced working capacity and occasional need for assistance among those aged 30-64 years. Other musculoskeletal disorders also determined the prevalence disability, but these relationships were reduced by taking comorbidity into account. A low level of education and a low (less than 20 kg/m2) or very high (at least 35 kg/m2) body mass index represented independent determinants of all forms of disability, and a history of physically strenuous work an independent determinant of reduced working capacity, when disabling illness was adjusted for. The proportion of all forms of disability attributable to musculoskeletal disorders, in models including, age, sex, other disabling illness and significant non-medical determinants of disability, was close to 20%. The disorders with the highest community impact were chronic low back pain among those aged 30-64, osteoarthritis of the hips and knees and inflammatory arthritis.

Multiuse of medicines in Finland

The purpose of this study was to investigate the occurrence of multiuse of prescription drugs and its major determinants among Finnish adults. The data were based on three nationally representative and intercomparable health surveys in 1976, 1978-80, and 1987. The study populations were 16,413 in 1976, 13,138 in 1987, and 7,217 in 1978-80. The simultaneous use of at least five prescription drugs was the main outcome measure. In 1976, 4.7% of the study population, and 6.3% in 1987 were multiusers. Of all users of prescription drugs, the proportion of multiusers was 14% both in 1976 and 1987. In 1987, the elderly comprised 55% of all multiusers, whereas their share in 1976 was 44%. The strongest predictor of the multiuse was, as expected, chronic morbidity. Of the various diagnostic groups, the main determinants were cardiac insufficiency, hypertension, asthma, mental disorders, and coronary heart disease. Even allowing for chronic morbidity, age was significantly associated with multiuse, but sex was not. The number of visits to a primary care physician correlated also independently with the multiuse. These findings indicate that the elderly may in part get prescriptions indiscriminately.

Prevalence, determinants, and consequences of chronic neck pain in Finland

Chronic neck pain is a relatively mild musculoskeletal condition, but common enough to be a possible public health problem. The distribution, determinants, and consequences of chronic neck pain have hitherto been described inadequately. In the Mini-Finland Health Survey, a representative population sample of 8,000 Finns aged greater than or equal to 30 years was invited to participate in a comprehensive health examination comprising an interview and a clinical examination; 90.2% complied. Predetermined criteria were used to diagnose major cardiovascular, musculoskeletal, respiratory, mental, and other disorders, regardless of other simultaneous disorders. Chronic neck syndrome was diagnosed in 9.5% of the men and 13.5% of the women. When adjusted for age and sex, the prevalence of the neck syndrome was associated with a history of injury to the back, neck, or shoulder and with mental and physical stress at work. Among those aged 30 to 64 years, overweight and parity were also significant determinants. Other musculoskeletal and mental disorders were associated with neck syndrome, and the association persisted after working conditions, injuries, overweight, and parity were adjusted for. There was some independent association between neck syndrome and disabilities, use of physician services, and use of pain killers.

Protein composition of crevicular fluid before and after treatment

Crevicular fluid (CF) analysis is a potential tool for site-specific diagnosis of periodontal disease activity. In this study, CF was collected using a novel washing method from 91 sites in 18 adult periodontitis patients both before and after conventional periodontal treatment. The sites studied were classified according to their clinical status and the number of polymorphonuclear leukocytes (PMN's) in CF samples. CF proteins were analyzed from individual sites with gel electrophoresis (SDS-PAGE). Furthermore, both the cell-bound and soluble neutral proteolytic activities of the samples were determined. Albumin was the main protein both in healthy and slightly inflamed sites. The most severely inflamed sites were characterized by high levels of low molecular weight (LMW) proteins (mol. weight ca. 12,000) and strong cell-bound neutral proteolytic activity. Scaling and root planing reduced both the LMW proteins and neutral proteolytic activity markedly in pockets responding well to treatment. The levels of the LMW proteins in CF correlated with the cell-bound neutral proteolytic activity, which reflected the number of PMN's in the sample. The present results suggest that the appearance of the LMW proteins in CF is associated with the periodontal inflammatory status of the site.

Prevalence of primary fibromyalgia in the Finnish population

OBJECTIVE

To obtain descriptive epidemiological data on fibromyalgia and its components in a representative sample of the Finnish population.

DESIGN

Cross sectional study of 8000 Finns aged 30 or more invited for screening and a main examination for musculoskeletal disorders and other major disorders.

SETTING

A mobile clinic.

POPULATION

7217 subjects who attended the screening phase; 3434 subjects positive on screening who attended the main examination for musculoskeletal disorders.

MAIN OUTCOME MEASURES

Musculoskeletal, mental, and other symptoms detected by interview and questionnaire; results of standardised clinical examination of the musculoskeletal system; operational definition of fibromyalgia; mortality at 10 years.

RESULTS

The prevalence of fibromyalgia was low (54 cases; 0.75%) and related to age (peak prevalence at 55-64 years), female sex (twice as prevalent in women), occupation (no cases among 1596 white collar professionals), level of education (strong inverse gradient), and high levels of physical stress at work. No significant associations were found with body mass index, smoking, or mental stress at work. The prevalence of fibromyalgia was sensitive to even minor modifications of the definition. Fibromyalgia was strongly coincident with many other disorders, especially musculoskeletal conditions. Fibromyalgia did not predict mortality.

CONCLUSION

Descriptive epidemiological data offer little support for the concept of fibromyalgia.

Determinants of sciatica and low-back pain

Several factors were studied for their association with the prevalence of chronic low-back syndromes, sciatica, and unspecified low-back pain (LBP) in 2,946 women and 2,727 men (age range, 30-64 years) participating in the Mini-Finland Health Survey, a project aimed at comprehensive evaluation of the population's health. On the basis of a standardized clinical examination, a physician diagnosed sciatica in 5.1% and LBP in 11.6% of the subjects. Those with a previous traumatic back injury had a 2.5-fold risk of having sciatica or LBP. The fractions of sciatica and LBP attributable to such back injuries were estimated to be 16.5% and 13.7%, respectively. Sum indices of both physical and mental stress at work were found to be directly proportional to the prevalence of sciatica and LBP. Smokers had an increased risk of LBP, and body height was related positively to the prevalence of sciatica. These associations, however, were inconsistent between sex and age subgroups. In the presence of osteoarthritis in the knee, hip, or hand, LBP was prevalent (adjusted odds ratio [OR], 5.3; 95% confidence interval [CI], 4.1-6.9), but sciatica was not (OR, 1.1; 95% CI, 0.7-1.7). Diabetics were found to have a significantly decreased prevalence of LBP (OR, 0.4; 95% CI, 0.3-0.8). Many factors, independent of each other, determine the occurrence of chronic low-back syndromes. The determinants of sciatica and LBP are different to some extent.

Controlled trial on medical birth notification design

In a controlled trial, two different forms were compared with respect to thoroughness of completing medical data on procedures during pregnancy, labor, and in newborns. The contents of 547 forms filled in by hospital personnel were compared to data abstracted from hospital records by trained research assistants. Forms with open-ended questions lacked information on 29% of the most common procedures and forms with a check-box format 9%. The results support the use of the check-box format in routine collection of data on common medical procedures.

Core-periphery differences in children's health and use of general practitioner services in Finland from 1964 to 1987

Finland is a modern welfare state in Northern Europe especially proud of its development of programs for children's health. The aim of this study was to investigate the development of core-periphery differences in children's health and use of health services. The study material was obtained from the national health and social security interview survey carried out in 1964, 1968, 1976 and 1987. Age standardized prevalence of chronic diseases, number of restricted-activity days and physician contacts were presented for two age groups: 0-6-year-olds and 7-14-year-olds. The prevalence of chronic diseases was quite similar in the core and periphery in 1976 and 1987, but the number of restricted-activity days throughout the study period (1964-1987) was significantly higher in the core than in the periphery. The consistently higher frequency of physician contacts in the core in comparison with the periphery was spectacular; the welfare policy of the last decades seems to have had very little or no effect on this difference. The core-periphery division thus continues to have relevance with respect to the health of Finnish children.

Rationality and cost-effectiveness of diagnosis and treatment of group A streptococci in primary care patients with pharyngitis

Rationality and cost-effectiveness of several strategies for diagnosing and treating sore throat patients were evaluated in primary care. In an empirical material of 2016 patients, 3 different bacteriological methods (traditional culture, slide culture, and latex agglutination test) for the detection of group A beta-hemolytic streptococci (GAS) were compared. Sensitivity analyses were done for several variables, including GAS test performance, testing frequencies, medication rates, and accuracy of clinical evaluation. The amounts of unnecessary medication varied from 19 to 33%, and there were 2.2-8.9% of untreated GAS infections. Strategies based on bacteriology achieved more rational and economic results than treating no one, treating all patients, or using clinical evaluation without bacteriology. The cost-effectiveness of the latex agglutination test depended on the sensitivity of the test. The results were further sensitive to sick leave lengths, cost of antibacterials, and clinical accuracy, but not to GAS test cost. Rapid tests for GAS detection can be recommended, if the sensitivity of the test in the actual working conditions is acceptable.

Heart rate variability in infants subsequently suffering sudden infant death syndrome (SIDS)

To study the role of the autonomic cardiovascular control in SIDS the heart rate variability (HRV) was analysed from 24 tape recordings made from a prospective population-based study on 16 term and one preterm infant suffering SIDS and compared to similar data on 23 control infants matched on birthweight, gestation and postnatal age. The number of regular breathing segments was lower in the SIDS cases than in controls (P = 0.02). No significant differences were found between the SIDS cases and their controls for average heart rate, median breathing rate, indices of overall and beat-to-beat HRV. Neither were significant intergroup differences found when the subjects were divided into neonatal and postneonatal subgroups. Analysis of HRV by power-spectral techniques did not show any significant differences between SIDS cases and controls for the general distribution of power or for the respiratory HRV. Analysis of HRV did not differentiate infants destined to die of SIDS from surviving controls in the same population.

A study of the possible correlation of high salivary calcium levels with periodontal and dental conditions in young adults

The periodontal bone level and the number of erupted and intact teeth were assessed from the X-rays of 46 dental students (mean age 24.2 yr). Paraffin-stimulated whole saliva was collected in a standardized way and the salivary flow-rate was measured. The salivary concentration of calcium was analysed by atomic absorption spectrophotometry. The subjects were divided into 2 groups according to the salivary Ca level. Subjects with salivary Ca levels over the mean value (51.03 micrograms/ml) were included in the 'high salivary Ca group' (n = 20). Age- and sex-matched pairs showing Ca levels below the mean formed the 'low salivary Ca group' (n = 26). The results show that subjects in the high salivary Ca-group had significantly more intact teeth than their pairs in the low salivary Ca group (p less than 0.025). There was no difference in the total number of teeth present nor in the salivary flow rate. No periodontal breakdown could be detected in any of the X-rays. It seems that in young adults high salivary Ca content can be correlated with good dental health but not with periodontal bone destruction.

Descriptive epidemiology and public health aspects of low back pain

The prevalence of low back syndrome and its consequences in terms of disability, handicap, and need for medical care were studied as part of "the Mini-Finland Health Survey". A sample of 8000 persons representative of the Finnish population aged 30 or over was invited for examination, and 7217 (90%) participated. At interview 75% of the participants reported that they had experienced at least one episode of low back pain. Six or more episodes were reported by half of the population, and about 20% had suffered from pain during the previous month. On the basis of a standardised clinical examination, a physician diagnosed low back syndrome in 17.5% of men and 16.3% of women. The prevalence was highest in those aged 55-64 years. The use of health services was frequent among those suffering from low back pain. Nevertheless, their need for care was commonly unmet. Some disability was found in almost 60% of the subjects with low back pain, although severe functional limitations were rare. It was estimated that of the work disability the reduced capacity for everyday duties apart from work, and the reduced capacity for leisure time activities, in the population 18%, 16%, and 17%, respectively, were attributable to the low back syndrome. Thus low back syndrome has a strong impact on individuals and on society as a whole.

Effect of latex agglutination test on prescribing for group A streptococcal throat disease in primary care

Diagnosis and treatment of 849 sore throat patients in primary care was studied with regard to the utilization and accuracy of a latex test for group A beta-hemolytic streptococci. 78% were tested, but 11% of the rapid test results were uncertain, and 15% conflicted with traditional culture results. The negative predictive value of the test was 98%, and the positive predictive value only 59%. 52% of all patients received antibacterials, the rapid test result influencing the treatment decisions clearly but not solely. The nurses utilized the rapid test more often than the physicians. The study stresses the difficulties inherent in introducing new tests in primary care and illustrates the realities of overutilization of the test and overmedication despite test results.