Predictors of improvement in quality of life of long-term mentally ill individuals receiving case management

One hundred and thirteen long-term mentally ill clients receiving case management were investigated with regard to psychosocial and clinical predictors of changes in subjective quality of life during an 18-month follow-up. Better psychosocial functioning and fewer psychiatric symptoms at baseline predicted a greater improvement in quality of life. A larger decrease in symptom severity and a greater improvement in the social network during the follow-up were identified as the most important predictors of a greater improvement in subjective quality of life. The results of the study suggest that an emphasis should be put on effective symptom management, a reduction of needs for care and social support in order to fulfill the aims of improving subjective quality of life in patients receiving case management.

Characteristics of 15,314 hypertensive patients at high coronary risk. The VALUE trial. The Valsartan Antihypertensive Long-term Use Evaluation

Valsartan is an orally active, selective antagonist of the angiotensin II-1 (AT1) receptor developed for the treatment of hypertension. The Valsartan Antihypertensive Long-term Use Evaluation (VALUE) Trial of Cardiovascular Events in Hypertension is a double-blind, randomized prospective, parallel group study designed to compare the effects of valsartan with those of the calcium-antagonist amlodipine on the reduction of cardiac morbidity and mortality. Patients with essential hypertension, aged 50 years and older, and at particularly high risk of coronary events were enrolled. 18,119 patients were screened and 15,314 patients in 31 countries were randomized mainly between January 1998 and December 1999. These hypertensives had a mean blood pressure of 154.7/87.5 mmHg at the time of their randomization to blinded medication. The population comprises both genders (men 57.6%), Caucasians (89.1%), mean age 67.2 years, mean body mass index 28.6 kg/m2, coronary heart disease (45.8%), high cholesterol (33.0%), type 2 diabetes mellitus (31.7%) and smokers (24.0%). More than 92% of the randomized participants had been treated for high blood pressure for at least 6 months when screened for the study. The randomized population is now being treated (goal blood pressure < 140/90 mmHg) in adherence with the protocol until at least 1450 patients experience primary cardiac endpoint defined as clinically evident or aborted myocardial infarction, hospitalization for heart failure or death caused by coronary heart disease.

[Are newer antihypertensive agents better than the older ones? Results of trials (CAPPP, STOP-2, NORDIL, INSIGHT and ALLHAT) with newer antihypertensive agents]

Until recently, no morbidity-mortality study had examined the effects of "newer" drugs, like angiotensin-converting enzyme inhibitors, calcium antagonists, and alpha-blockers compared to "old", but well-proven, thiazide diuretics, and beta-blockers in the treatment of essential hypertension. The prospective and randomised clinical trials, CAPPP, STOP-2, NORDIL, INSIGHT, and one arm of ALLHAT, with a total of about 58,000 middle-aged or elderly hypertensive patients have now been published. The primary outcome, composite cardiovascular (CV) death, cerebral stroke, and myocardial infarction, or composite fatal coronary heart disease and myocardial infarction, was the same, irrespective of the drug in all trials. Thus, prevention of CV complications depends on the lowering of blood pressure with well-tolerated medication, irrespective of class.

Reduced cardiovascular morbidity and mortality in hypertensive diabetic patients on first-line therapy with an ACE inhibitor compared with a diuretic/beta-blocker-based treatment regimen: a subanalysis of the Captopril Prevention Project

OBJECTIVE

The Captopril Prevention Project (CAPPP) evaluated the effects of an ACE inhibitor-based therapeutic regimen on cardiovascular mortality and morbidity in hypertension. One planned subanalysis of the CAPPP was to evaluate the outcome in the diabetic patient group.

RESEARCH DESIGN AND METHODS

In the CAPPP, 572 (4.9% of 10,985 hypertensive patients) had diabetes at baseline and were studied according to a prospective, randomized, open, blinded, end point trial design. Patients aged 25-66 years with diastolic blood pressure > or =100 mmHg were included and randomized to receive either captopril or conventional antihypertensive treatment (diuretics and/or beta-blockers).

RESULTS

The primary end point, fatal and nonfatal myocardial infarction and stroke as well as other cardiovascular deaths, was markedly lower in the captopril than in the conventional therapy group (relative risk [RR] = 0.59; P = 0.018). Specifically, cardiovascular mortality, defined as fatal stroke and myocardial infarction, sudden death, and other cardiovascular death, tended to be lower in the captopril group (RR = 0.48; P = 0.084), and no difference was observed between the study groups for stroke (RR = 1.02; P = 0.96). Myocardial infarctions were less frequent in the captopril group than in the conventional therapy group (RR = 0.34; P = 0.002). Furthermore, total mortality was lower in the captopril as compared with the conventional therapy group (RR = 0.54; P = 0.034). Patients with impaired metabolic control seemed to benefit the most from ACE inhibitor-based therapy.

CONCLUSIONS

Captopril is superior to a diuretic/beta-blocker antihypertensive treatment regimen in preventing cardiovascular events in hypertensive diabetic patients, especially in those with metabolic decompensation.

The relevance of tissue angiotensin-converting enzyme: manifestations in mechanistic and endpoint data

Angiotensin-converting enzyme (ACE) is primarily localized (>90%) in various tissues and organs, most notably on the endothelium but also within parenchyma and inflammatory cells. Tissue ACE is now recognized as a key factor in cardiovascular and renal diseases. Endothelial dysfunction, in response to a number of risk factors or injury such as hypertension, diabetes mellitus, hypercholesteremia, and cigarette smoking, disrupts the balance of vasodilation and vasoconstriction, vascular smooth muscle cell growth, the inflammatory and oxidative state of the vessel wall, and is associated with activation of tissue ACE. Pathologic activation of local ACE can have deleterious effects on the heart, vasculature, and the kidneys. The imbalance resulting from increased local formation of angiotensin II and increased bradykinin degradation favors cardiovascular disease. Indeed, ACE inhibitors effectively reduce high blood pressure and exert cardio- and renoprotective actions. Recent evidence suggests that a principal target of ACE inhibitor action is at the tissue sites. Pharmacokinetic properties of various ACE inhibitors indicate that there are differences in their binding characteristics for tissue ACE. Clinical studies comparing the effects of antihypertensives (especially ACE inhibitors) on endothelial function suggest differences. More comparative experimental and clinical studies should address the significance of these drug differences and their impact on clinical events.

The relationship of personality dimensions as measured by the temperament and character inventory and quality of life in individuals with schizophrenia or schizoaffective disorder living in the community

The influence of personality factors on the appraisal of subjective quality of life in individuals with schizophrenia or schizoaffective disorder is not much investigated. The present study examined this relationship in a sample of 104 patients living in the community. The temperament and character inventory was used to assess personality and the Lancashire quality of life profile was used to assess quality of life. The results showed that lower levels of harm avoidance and higher levels of self-directedness were significantly correlated to a better subjective quality of life. Regression analyses controlling for psychopathology revealed that a higher level of self-directedness was significantly associated with a better subjective quality in all aspects measured and explained the variance in the latter in the range of 4-12%. It is concluded that personality factors are involved in severely mentally ill individuals' assessment of their quality of life and should be accounted for in evaluations of quality of life assessments. The strength and directions of this influence require further studies.

The relationship of personality dimensions as measured by the temperament and character inventory and quality of life in individuals with schizophrenia or schizoaffective disorder living in the community

The influence of personality factors on the appraisal of subjective quality of life in individuals with schizophrenia or schizoaffective disorder is not much investigated. The present study examined this relationship in a sample of 104 patients living in the community. The temperament and character inventory was used to assess personality and the Lancashire quality of life profile was used to assess quality of life. The results showed that lower levels of harm avoidance and higher levels of self-directedness were significantly correlated to a better subjective quality of life. Regression analyses controlling for psychopathology revealed that a higher level of self-directedness was significantly associated with a better subjective quality in all aspects measured and explained the variance in the latter in the range of 4-12%. It is concluded that personality factors are involved in severely mentally ill individuals' assessment of their quality of life and should be accounted for in evaluations of quality of life assessments. The strength and directions of this influence require further studies.

Bracing versus nonbracing in rehabilitation after anterior cruciate ligament reconstruction: a randomized prospective study with 2-year follow-up

This study prospectively randomized 62 patients to rehabilitation programs either with or without postoperative brace for 6 weeks following bone-tendon-bone anterior cruciate ligament reconstruction. The nonbraced group had a smaller knee circumference 2 weeks after surgery. At 6-month follow-up the nonbraced group had a better Tegner score. At 2 years there was no difference between the groups. There was one partial rupture of the graft in the nonbraced group after a new trauma 1 year after surgery. There were no differences between the groups in either subjective or objective knee stability at 2 or 6 weeks or at follow-up 3, 6, and 24 months after surgery. This study found no benefit of using a postoperative knee brace on patients' knee function at any stage up to 24 months after surgery. Furthermore, the braced group was not more stable than the nonbraced group, indicating that the brace does not contribute to a more stable knee during rehabilitation or 2-year follow-up.

Relation between drug treatment and cancer in hypertensives in the Swedish Trial in Old Patients with Hypertension 2: a 5-year, prospective, randomised, controlled trial

BACKGROUND

Is cancer related to hypertension and blood pressure? Do antihypertensive drugs promote cancer? Do antihypertensive drugs protect against cancer? We previously analysed the frequency of cardiovascular mortality and morbidity in elderly people who participated in the Swedish Trial in Old Patients with Hypertension 2 (STOP-Hypertension-2). We have also looked at the frequency of cancer in these patients.

METHODS

We randomly assigned 6614 elderly patients with hypertension (mean age 76 years, median time of follow-up 5.3 years) to one of three treatment strategies: conventional drugs (diuretics or b-blockers), calcium antagonists, or ACE inhibitors. We matched the patients to the Swedish Cancer Registry and compared our findings with expected values based on age, sex, and calendar-year-specific reference frequencies for the general Swedish population. We also compared the number of cancers between the three treatment groups.

FINDINGS

At baseline, 607 (9%) patients had previous malignant disease. Diagnoses were closely similar to the distribution of cancer types that might be seen in elderly patients. During follow-up, there were 625 new cases of cancer in 590 patients. The frequency of cancer did not differ significantly between the treatment strategies, including all cancers and those at individual sites. The standardised incidence ratios (SIRs) for all cancers were also close to unity: 0.92 (95% CI 0.80-1.06) for conventional drugs, 0.96 (0.83-1.10) for calcium antagonists, and 0.99 (0.86-1.13) for ACE inhibitors.

INTERPRETATIONS

No difference in cancer risk was seen between patients randomly assigned to conventional drugs, calcium antagonists, or ACE inhibitors. Thus, the general message to the practising physician is that more attention should be given to getting the blood pressure down than to the risk of cancer.

Perceptions of the real and the ideal ward atmosphere among trainees and staff before and after the introduction of a new work rehabilitation model

Changes in the ward atmosphere of a psychiatric work rehabilitation unit were investigated. Both trainees and staff filled in the Community-Oriented Programs Environment Scale (COPES) before and after a new rehabilitation model was implemented. It was hypothesised that the levels of autonomy and practical orientation would increase from both the trainees' and staff's perspective concerning the real ward atmosphere and that the staff's perceptions of an ideal ward atmosphere would change in the same way. The staff perceived an increased level of autonomy with respect to both the real ward atmosphere and to what constitutes an ideal ward atmosphere, which partly confirmed the hypotheses, but the level of practical orientation was stable. Concerning the staff's estimate of an ideal ward atmosphere, further changes were an increased level of involvement and a decrease in spontaneity, which was not hypothesised, but was not in conflict with the philosophy behind the new model. From the trainee's perspective there was no change of either autonomy or practical orientation. Instead, there was a decrease in personal problem orientation. Compared to an optimal profile, the ward atmosphere was beneficial, before as well as after implementation of the new programme. Differences were found between the staff and the trainees, but they were not large enough to separate the groups according to what is considered an optimal profile. The few changes found support earlier conclusions that the ward atmosphere is a stable phenomenon over time.

Effects of individual risk factors on the incidence of cardiovascular events in the treated hypertensive patients of the Hypertension Optimal Treatment Study. HOT Study Group

BACKGROUND

The Hypertension Optimal Treatment (HOT) Study has provided information about cardiovascular events in 18790 hypertensives, subjected to pronounced blood pressure (BP) lowering for a mean of 3.8 years. The HOT study data have subsequently been analysed after stratification of the patients according to global cardiovascular risk, and it has been found that, despite intensive blood pressure lowering in all risk strata, morbid event rates increased with increasing risk stratum.

OBJECTIVES

Previously analysed global risk strata were based on combinations of risk factors. The analyses presented here were intended to provide information on the relative role that the presence of each individual factor may have in increasing cardiovascular risk, despite good BP control.

METHODS

Risk ratios (RR) for patients with and those without a risk factor were calculated with 95% confidence intervals (CI) using a Cox proportional hazard model, and adjusted for all variables except the one under examination.

RESULTS

For all risk factors considered and for all types of event, RR were always greater than 1, indicating a greater risk in the presence, compared with that in the absence of each factor. The male gender was a statistically significant risk for cardiovascular (CV) events, CV and total mortality and particularly for myocardial infarction (MI); age > or = 65 years for CV events, stroke, CV and particularly total mortality; smoking for all events analysed, but particularly for total mortality (twice higher in smokers than in non-smokers); high serum cholesterol (> 6.8 mmol/l) for CV events, MI and CV mortality; high serum creatinine (> 155 micromol/l) for CV events, stroke, CV and total mortality; diabetes for CV events, stroke, total mortality and particularly CV mortality; and ischaemic heart disease for all events analysed. Adjusted RR were often close to or greater than 2.

CONCLUSIONS

Each of the risk factors considered was found to be an important cause of residual risk, despite good BP control. These findings emphasize the importance of addressing other correctable risk factors, e.g. smoking, hypercholesterolaemia and diabetes, as well as rigorous control of blood pressure, and of initiating antihypertensive therapy before cardiovascular and renal damage becomes manifest.

The Nordic Study on schizophrenic patients living in the community. Subjective needs and perceived help

In a community sample of 418 persons diagnosed with schizophrenia, subjective needs and perceived help was measured by the Camberwell Assessment of Need (CAN). The mean number of reported needs was 6.2 and the mean number of unmet needs 2.6. The prevalence of needs varied substantially between the need areas from 3.6% ('telephone') to 84.0% ('psychotic symptoms'). The rate of satisfaction estimated as the percentage of persons satisfied with the help provided within an area varied between 20.0% ('telephone') and 80.6% ('food'). The need areas concerning social and interpersonal functioning demonstrated the highest proportion of unmet to total needs. In a majority of need areas the patients received more help from services than from relatives, but in the areas of social relations the informal network provided substantial help. In general the patients reported a need for help from services clearly exceeding the actual amount of help received. In a linear regression model symptom load (BPRS) and impaired functioning (GAF) were significant predictors of the need status, explaining 30% of the variance in total needs and 20% of the variance in unmet needs. It is concluded that the mental health system fails to detect and alleviate needs in several areas of major importance to schizophrenic patients. Enhanced collaboration between the care system and the informal network to systematically map the need profile of the patients seems necessary to minimise the gap between perceived needs and received help.

Outcome assessment in psychiatric service evaluation

BACKGROUND

The present paper gives an overview of outcome assessment issues in psychiatric service evaluation, based on seven proposals concerning the content and methodology of outcome assessment. It is stressed that outcome assessments should be performed on both the system and the patient level and that multiple outcome domains should be used, reflecting multiple perspectives of the services. It is also argued that outcome studies benefit from incorporating service use measures in order to enable analyses of costs and cost-effectiveness of services. Outcome studies of community-based psychiatric services have so far mainly investigated service models or programs.

CONCLUSIONS

It is concluded that there is a need to investigate the relationship between particular parts and content of services and outcome, in order to increase knowledge of what is effective in community-based psychiatric services.

[Comparison of preventive effect of "new" and "old" antihypertensive agents]

BACKGROUND

Until recently no morbidity-mortality study had examined the effects of newer drugs like angiotensin-converting enzyme inhibitors, calcium-antagonists and alpha-blockers compared to "old" but well-proven thiazide diuretics and beta-blockers in the treatment of essential hypertension.

MATERIAL AND METHODS

The prospective and randomized clinical trials CAPPP, STOP-2, NORDIL, INSIGHT and one arm of ALLHAT, with a total of approximately 58,000 middle-aged or elderly hypertensive patients have been assessed.

RESULTS

The primary outcome, composite cardiovascular (CV) death, cerebral stroke and myocardial infarction, in one study with heart failure, or composite fatal coronary heart disease and myocardial infarction, was equal in all trials.

INTERPRETATION

According to current evidence, prevention of cardiovascular disease in hypertension is the same irrespective of the class of drug.

Ward atmosphere, client satisfaction, and client motivation in a psychiatric work rehabilitation unit

This study investigated the ward atmosphere of a psychiatric work rehabilitation unit and its relationships to clients' satisfaction with the unit and client motivation, operationalised as proneness to set personal goals for their rehabilitation. The Community-oriented Programs Environment Scale was used and 52 clients participated. Their report of the ward atmosphere was in accordance with recommended levels on 5 sub-scales out of 10. A regression analysis revealed that optimal levels of order-and-organization and support were of importance for satisfaction with the unit. An optimal level of support was associated with a high rating of personal goals. This study added two therapeutically interesting factors-satisfaction and motivation-to the flora of factors that have been related to perceptions of the ward atmosphere.

Risk assessment and treatment benefit in intensively treated hypertensive patients of the hypertension Optimal Treatment (HOT) study

BACKGROUND

The Hypertension Optimal Treatment (HOT) Study provided information about cardiovascular events in 18,790 hypertensives, subjected to pronounced blood pressure lowering for a mean of 3.8 years.

METHODS AND RESULTS

The HOT Study data have been further analysed after risk stratification of the patients (1999 World Health Organization and International Society of Hypertension guidelines criteria): (i) no patients of the HOT Study were classified as low risk, 50% were classified as medium risk, 20.2% as high risk and 29.8% as very high risk; (ii) incidence of cardiovascular events in these patients with excellent blood pressure control [92% had diastolic blood pressure (DBP) < or = 90 mmHg] remained proportional to pretreatment risk. The relative risk of very high- versus medium-risk strata was between two and three both when HOT Study patients were considered independently of, or within the DBP target group they had been randomized to; and (iii) event rates in all risk strata were calculated to be much lower (possibly 60% lower) than rates expected from baseline risk calculated approximately by the Framingham equation.

CONCLUSIONS

The low event rate in HOT Study patients is likely to result from pronounced blood pressure lowering, and is not explained by a lower risk profile than in previous controlled trials of antihypertensive treatment. The persistence of a risk gradient despite intensive blood pressure lowering suggests a combination of blood pressure control with other strategies of risk correction and the need to initiate antihypertensive therapy before complications develop.

Results of the STOP-Hypertension-2 trial

The second Swedish Trial in Old patients with Hypertension (STOP-Hypertension-2) was conducted to compare the effects of "newer" antihypertensive therapies (angiotensin converting enzyme [ACE] inhibitors and calcium antagonists) and established therapies (beta-blockers and diuretics) on cardiovascular mortality and morbidity in elderly hypertensive patients. A total of 6614 patients were randomized to receive conventional treatment, ACE inhibitors or calcium antagonists, and followed for a mean of 5 years. The primary endpoint was a combination of fatal stroke, fatal myocardial infarction and other fatal cardiovascular disease; secondary endpoints were a combination of fatal or non-fatal stroke or myocardial infarction, and other cardiovascular mortality. The three treatments produced similar reductions in supine systolic blood pressure. There were no significant differences in the risk of cardiovascular events between patients receiving conventional therapy and those receiving newer therapies. All three treatments were well tolerated. The STOP-Hypertension-2 results thus add to the extensive literature showing the benefits of blood pressure reduction in elderly hypertensive patients. Moreover, they are consistent with current management guidelines which emphasise the importance of the achieved blood pressure reduction in the prevention of cardiovascular events.

Molecular analysis of commensal host-microbial relationships in the intestine

Human beings contain complex societies of indigenous microbes, yet little is known about how resident bacteria shape our physiology. We colonized germ-free mice with Bacteroides thetaiotaomicron, a prominent component of the normal mouse and human intestinal microflora. Global intestinal transcriptional responses to colonization were observed with DNA microarrays, and the cellular origins of selected responses were established by laser-capture microdissection. The results reveal that this commensal bacterium modulates expression of genes involved in several important intestinal functions, including nutrient absorption, mucosal barrier fortification, xenobiotic metabolism, angiogenesis, and postnatal intestinal maturation. These findings provide perspectives about the essential nature of the interactions between resident microorganisms and their hosts.

Renal function and intensive lowering of blood pressure in hypertensive participants of the hypertension optimal treatment (HOT) study

This article reports further analyses of the Hypertension Optimal Treatment (HOT) Study data with the aim to describe (1) the value of baseline serum creatinine and its clearance (estimated by Cockroft and Gault formula) as predictors of cardiovascular events, (2) the effects of intensive lowering of BP on cardiovascular events and renal function in patients with reduced renal function, and (3) the effects on cardiovascular events of adding acetylsalicylic acid to antihypertensive therapy in patients with reduced renal function. The results show that (1) baseline elevation in serum creatinine and a reduction in estimated creatinine clearance are powerful predictors of cardiovascular events and death. (2) Reduced renal function at baseline did not preclude the desired control of BP. In contrast to patients with normal renal function, the incidence of major cardiovascular events did not differ in the three groups of patients with mild renal insufficiency randomized to different diastolic BP targets. No significant changes in serum creatinine were seen at the end of the 3.8-yr treatment period in the great majority of patients. However, there was a small group of patients (0.58% of the total study population) whose renal function deteriorated (increase > or =30% over baseline and final serum creatinine concentration > or =2 mg/dl) despite satisfactory reduction of diastolic BP. (3) The results of this reanalysis of the HOT Study suggest though do not prove that the association of acetylsalicylic acid with intensive antihypertensive therapy offers additional benefit in hypertensive patients with reduced renal function.

Relationships between satisfaction with occupational factors and health-related variables in schizophrenia outpatients

BACKGROUND

The purpose of this study was to explore relationships between satisfaction with occupational factors, operationalized as occupational status and the total daily occupational situation, and health-related variables among people with schizophrenia. The health-related variables included quality of life, perceived control, sense of coherence, and psychopathology. Gender differences in these relationships were explored as well.

METHODS

A sample of 74 individuals, aged 20-55 years, from outpatient psychiatric services were recruited to the study. A variety of interviews and self-rating scales were used in the data collection.

RESULTS

When controlling for depressive symptoms, the results showed that satisfaction with employment status was of significance for health among patients with schizophrenia, but satisfaction with the total daily occupational situation seemed to be even more important to quality of life and other health-related aspects. In particular, satisfaction with daily occupations constituted an important dimension for self-rated quality of life. Some minor sex differences could be discerned in the pattern of associations.

CONCLUSIONS

The strong association between satisfaction with daily occupations and self-rated quality of life adds a new dimension to the understanding of quality of life for this group of subjects, and suggests that helping to organise an individual's daily occupations ought to be a significant task in planning for psychiatric services.

The validity of Antonovsky's Sense of Coherence measure in a sample of schizophrenic patients living in the community

AIM OF THE STUDY

To examine the construct and predictive validity of Antonovsky's Sense of Coherence (SOC) concept in a sample of schizophrenic persons living in the community.

BACKGROUND

The salutogenic model of Antonovsky proposes that the individual's sense of coherence, which is a personal orientation towards life, determines the health experience. The salutogenic perspective might in several advantageous aspects contribute to the care and support for patients with a long and persistent mental illness like schizophrenia.

DESIGN

The study is a 18-month follow-up study. Structured interviews were used to interview 120 patients with a diagnosis of schizophrenia or a schizoaffective disorder. Pearlin's mastery scale, Rosenberg's self-esteem scale, the Interview Schedule for Social Interactions (ISSI) and the Brief Psychiatric Rating Scale (BPRS) were used as construct validity measures of the SOC scale. Health related measures such as quality of life, global well-being, satisfaction with health assessed by the Lancashire Quality of Life Profile (LQOLP) and global psychosocial functioning (GAF) were used in calculations of the predictive validity of SOC.

RESULTS

The SOC was positively related to mastery, self-esteem and social support but negatively associated to psychopathology. In total, mastery, self-esteem and adequacy of social integration explained 61.1% of the variance in SOC, and mastery contributed with the greatest part of the variance, 46.3% SOC was positively associated to all health related measures and changes in SOC during an 18-month follow-up was positively correlated to changes in overall subjective quality of life, general health, global well-being and global psychosocial functioning.

CONCLUSION

The results gave support to the construct and predictive validity of the SOC measure in individuals suffering from a diagnosis of schizophrenia.

Predictors of social relations in persons with schizophrenia living in the community: a Nordic multicentre study

BACKGROUND

Deinstitutionalisation has led to persons with serious mental illness spending most of their time outside psychiatric institutions. Not much is known about their social life. The paper presents the results of structured interviews with non-institutionalised persons with schizophrenia about treatment, care and social network. The network data are analysed from three perspectives: finding predictors of the number and of the quality of social contacts, and establishing the respective variables that characterise persons with high, and those with low, scores on both the quantity and quality dimensions of social integration.

METHODS

Random samples of persons with schizophrenia receiving outpatient services in ten psychiatric centres in the four Nordic countries were interviewed. The following instruments were used: Interview Schedule for Social Interaction (ISSI), Camberwell Assessment of Needs, Lancashire Quality of Life Profile, General Assessment of Functioning (GAF) and Brief Psychiatric Rating Scale (BPRS), in addition to a checklist covering the utilisation of different services. The ISSI provided the main data for this paper. A restricted number of possible predictors were used in General Linear Model (GLM) factorial analysis and discriminant analysis.

RESULTS

A total of 418 persons took part in the study. The overall participation rate was 55%. Social integration in terms of number of contacts was related to a high GAF score, few BPRS negative and hostility symptoms, having contact with user organisations and living in urban (in contrast to rural) areas. Availability of emotional relations was predicted by female sex, low scores on the BPRS hostility dimension, high GAF score, having contact with one's family more than once a month, and living in urban areas. Work, adequate leisure activities and GAF score discriminated between the best and worst integrated groups.

CONCLUSIONS

Living in urban areas, being female, having a high GAF score and low scores on hostility predicted better integration in terms of number of contacts and emotional relations.

Baseline Characteristics and Early Blood Pressure Control in the CONVINCE Trial

-Blood pressure (BP) control rates around the world are suboptimal. Part 2 of the National Health and Nutrition Educational Survey (NHANES) III indicates that only 27.4% of hypertensive Americans aged 18 to 74 years have a BP of <140/90 mm Hg. We wanted to assess BP control during the first 2 years and to describe the baseline characteristics of patients enrolled in the Controlled ONset Verapamil INvestigation of Cardiovascular Endpoints (CONVINCE) Study, an international clinical trial that compares outcomes in hypertensive patients randomized to initial treatment with either controlled-onset extended-release verapamil or the investigator's choice of atenolol or hydrochlorothiazide. At randomization, BP was <140/90 mm Hg in only 20.3% of the 16 602 subjects (average+/-SD age 65.6+/-7.4 years; 56% women, 84% white/7% black/7% Hispanic). The average BP at enrollment was 148/85 mm Hg for patients taking BP medications (n=13 879) and 161/94 mm Hg for previously untreated patients (n=2723). After medication titration, with a transtelephonic computer that recommended an increase in the dose or number of antihypertensive agents whenever the BP was 140/90 mm Hg, 84.8% of the subjects attained the goal BP. During 2 years of treatment, BP control was maintained in 67% to 69% of the subjects (69% to 71% for systolic BP of <140 mm Hg and 90% for diastolic BP of <90 mm Hg). These data suggest that the control of systolic BP is more difficult than the control of diastolic BP. The US national goal of having 50% of hypertensives with a BP of <140/90 mm Hg may be achievable if a forced titration strategy is used. Interested investigators, free care and medications, and well-educated subjects may make the attainment of such a goal easier in the CONVINCE study than in the general population.

Quantitative and qualitative aspects of the social network in schizophrenic patients living in the community. Relationship to sociodemographic characteristics and clinical factors and subjective quality of life

Quantitative and qualitative aspects of the social network were investigated in a sample of 120 schizophrenic out-patients. Sociodemographic and clinical factors as well as subjective quality of life were investigated as to their relationship to the social network. The Interview Schedule for Social Integration (ISSI) was used to assess social network and Lancashire Quality of Life Profile was used to assess subjective quality of life. Psychopathology was measured by BPRS and psychosocial functioning by GAF. The patients reported a significantly worse social network compared to a normal sample both regarding quantitative and qualitative aspects of the network. Almost half of the patients wanted access to more social contacts. Relatives and friends turned out to be the patient's main source of supportive contacts. More severe negative and positive symptoms were related to a worse social network. Support was found for an association between characteristics of the social network, such as satisfaction with social contacts, and quality of life. The results give reason to suggest that the care system should consider the informal caregivers' situation and focus on interventions, which enhance the patient's satisfaction with social contacts.

Comparison of key worker and patient assessment of needs in schizophrenic patients living in the community: a Nordic multicentre study

OBJECTIVE

The present study is part of a Nordic multicentre study investigating the life and care situation of community samples of schizophrenic patients. The specific aim of the present part of the study was to examine the agreement between patients and their key worker concerning the presence of met and unmet needs in a number of life domains, and help or support given in these domains.

METHOD

The comparisons were based on 300 matched pairs of assessments of need using the Camberwell Assessment of Need interview.

RESULTS

The results showed that key workers identified slightly more needs, 6.17 vs. 5.76, a significant difference. There was a moderate or better agreement on the presence of a need in 17 of 22 life domains investigated, but in only 11 life domains concerning the presence of an unmet need. Disagreement concerning whether the patient was given the right kind of help or support was even more substantial.

CONCLUSION

It is concluded that key workers and patients disagree particularly concerning unmet needs and that this is potentially related to a number of factors associated with the key worker and patient. It is also concluded that further research is needed to increase the knowledge concerning the sources of this disagreement if need assessment is to become a valid basis for service planning and individual treatment planning.

Determinants of satisfaction with community-based psychiatric services: a cross-sectional study among schizophrenia outpatients

This was a cross-sectional study investigating factors related to satisfaction with care among long-term mentally ill patients diagnosed with schizophrenia, selected from an outpatient register. Demographic factors, personality variables, and health-related factors were related to their satisfaction with care. Satisfaction with care showed no relationships to demographic factors such as age, living conditions, or civil status. However, significant associations indicated that patients who had never been hospitalized for mental illness, who were native Swedes, or who had an independent living rated their satisfaction with care higher. Personality, measured with the Temperament and Character Inventory, showed a relationship to satisfaction with care on only one dimension, self-directedness, of seven. Some of the results indicated a relationship between subjective measures and satisfaction with care, and some did not, but, taken together, the findings suggested a partial influence from a subjective factor on both subjective measures of well-being and on satisfaction with care. However, associations between interviewer-rated measures of health-related variables and satisfaction with care proposed that the better-functioning patients were more satisfied with the care, in turn indicating that the services better suited these patients. Thus, assuming that the influence of treatment was controlled for through the selection of long-term mentally ill subjects, this study pointed to two determinants of satisfaction with care: a selectively working subjective factor and the services being better designed for the better-functioning patients.

Comparison of antihypertensive treatments in preventing cardiovascular events in elderly diabetic patients: results from the Swedish Trial in Old Patients with Hypertension-2. STOP Hypertension-2 Study Group

BACKGROUND

The benefits of treating hypertension in elderly diabetic patients, in terms of achieving reductions in cardiovascular morbidity and mortality, have been documented in several recent prospective trials. There has, however, been some controversy regarding the effect of different antihypertensive drugs on the frequency of myocardial infarction in this group of patients.

DESIGN

STOP Hypertension-2 was a prospective, randomized, open trial with blinded endpoint evaluation.

METHODS

We studied 6614 elderly patients aged 70-84 years; 719 of them had diabetes mellitus at the start of the study (mean age 75.8 years). Patients were randomly assigned to one of three treatment strategies: conventional antihypertensive drugs (diuretics or beta-blockers), calcium antagonists, or angiotensin converting enzyme (ACE) inhibitors.

RESULTS

Reduction in blood pressure was similar in the three treatment groups of diabetics. The prevention of cardiovascular mortality was also similar; the frequency of this primary endpoint did not differ significantly between the three groups. There were, however, significantly fewer (P = 0.025) myocardial infarctions during ACE inhibitor treatment (n = 17) than during calcium antagonist treatment (n = 32; relative risk 0.51, 95% confidence interval 0.28-0.92); but a (non-significant) tendency to more strokes during ACE inhibitor treatment (n = 34 compared with n = 29; relative risk 1.16, 95% confidence interval 0.71-1.91).

CONCLUSION

Treatment of hypertensive diabetic patients with conventional antihypertensive drugs (diuretics, beta-blockers, or both) seemed to be as effective as treatment with newer drugs such as calcium antagonists or ACE inhibitors.

Influence of gender on prevention of myocardial infarction by antihypertensives and acetylsalicylic acid: the HOT study

OBJECTIVE

The aims of the Hypertension Optimal Treatment (HOT) Study were to investigate the relationship between three levels of target office diastolic blood pressure (BP; < or = 90, < or = 85, and < or = 80 mm Hg) and cardiovascular death, myocardial infarction (MI), and stroke in hypertensive patients, and to examine the effects of 75 mg of acetylsalicylic acid (ASA) daily versus placebo.

DESIGN

Randomized, double-blind study. This substudy assessed the influence of gender on the incidence of MI.

SUBJECTS

A total of 18,790 patients (mean age, 61.5 years; range, 50-80 years).

METHODS

Patients were randomized and followed for an average of 3.8 years until 71,051 patient-years had elapsed and 683 events, including 215 MIs, had occurred.

RESULTS

There were significantly fewer MIs in the lowest diastolic BP target group (P = .034) in women (n = 8883); a similar but smaller trend was not statistically significant in men. The effect of ASA on preventing MI was also influenced by gender (P = .38 in women; P = .001 in men [lowered by 42%]).

CONCLUSION

Lowering diastolic BP to about 80 mm Hg in hypertensive women and administering 75 mg of ASA daily to well-treated hypertensive men reduces MI in patients with essential hypertension.

Study on COgnition and Prognosis in the Elderly (SCOPE): baseline characteristics

The Study on COgnition and Prognosis in the Elderly (SCOPE) is a multi-centre, prospective, randomized, double-blind, parallel-group study. The primary objective of SCOPE is to assess the effect of the angiotensin II type 1 (AT1) receptor blocker, candesartan cilexetil 8-16 mg once daily, on major cardiovascular events in elderly patients (70-89 years of age) with mild hypertension (DBP 90-99 and/or SBP 160-179 mmHg). The secondary objectives of the study are to test the hypothesis that antihypertensive therapy can prevent cognitive decline (as measured by the Mini Mental State Examination, MMSE) and dementia, and to assess the effect of therapy on total mortality, myocardial infarction (MI), stroke, renal function, and hospitalization. A total of 4964 patients from 15 participating countries were recruited during the randomization phase of SCOPE, exceeding the target population of 4000. The mean age of the patients at enrolment was 76 years, the ratio of male to female patients was approximately 1:2, and 52% of patients were already being treated with an antihypertensive agent at enrolment. The majority of patients (88%) were educated to at least primary school level. At randomization, mean sitting blood pressure values were SBP 166 mmHg and DBP 90 mmHg, and the mean MMSE score was 28. Previous cardiovascular disease in the study population included myocardial infarction (4%), stroke (4%) and atrial fibrillation (4%). Men, more often than women, had a history of previous MI, stroke and atrial fibrillation. A greater percentage of men were smokers (13% vs 6% in women) and had attended university (11% vs 3% of women). Of the randomized patients, 21% were 80 years of age. In this age group smoking was less common (4% vs 10% for 70-79-year-olds) and fewer had attended university (4% vs 7% for 70-79-year-olds). The incidence of MI was similar in both age groups. However, stroke and atrial fibrillation had occurred approximately twice as frequently in the older patients. The patients' mean age at baseline was similar in the participating countries, and most countries showed the approximate 1:2 ratio for male to female patients. There was also little inter-country variation in terms of mean SBP, DBP or MMSE score. However, there was considerable regional variation in the percentage of patients on therapy prior to enrolment.

Influence of glutathione metabolising enzymes in rats with gram-negative sepsis

OBJECTIVE

To evaluate the role of glutathione metabolising enzymes in rats with Gram-negative sepsis.

SETTING

University hospital, Sweden.

ANIMALS

61 male Sprague Dawley rats.

INTERVENTIONS

Animals were divided into two groups, one of which was given tert-butyl-4-hydroxyanisole (BHA), a powerful inducer of glutathione metabolising enzymes. A gelatine capsule containing bacteria and adjuvant substances was placed in the abdomen. In one group it contained only adjuvant substances, and the controls underwent sham laparotomy.

MAIN OUTCOME MEASURES

Activities of glutathione metabolising enzymes, and histological effect on pulmonary tissue.

RESULTS

Activities of glutathione metabolising enzymes were reduced in lung tissue after the induction of sepsis. Pre-treatment with BHA increased enzyme activity and reduced the histological changes.

CONCLUSION

Glutathione metabolising enzymes may have a role in sepsis, and pre-treatment with BHA seems to prevent histological changes in pulmonary tissue in septic rats.