New reference limits for cardiac troponin T and N-terminal b-type natriuretic propeptide in elders

BACKGROUND AND AIMS

Our aim was to define reference limits for cardiac troponin T (cTnT) and N-terminal pro B-type natriuretic peptide (proBNP) that would better reflect their concentrations in older people. In addition, the incidence of acute myocardial infarctions (AMIs) was studied using these reference limits in an older population with and without previous heart diseases.

MATERIALS AND METHODS

A population-based study with a ten-year follow-up. The reference population was formed by 763 individuals aged over 64 years, with no diagnoses of heart or kidney diseases.

RESULTS

There was a significant increase in cTnT and proBNP concentrations with age. The 99 % reference limits for cTnT were 25 ng/L, 28 ng/l, 38 ng/l, and 71 ng/l for men in five-year-intervals starting from 64 to 69 years to 80 years and older, and 18 ng/L, 22 ng/l, 26 ng/l, and 52 ng/L for women, respectively. The 97.5 % reference limits for proBNP were 272 ng/L, 287 ng/l, 373 ng/l and 686 ng/L for men, and 341 ng/L, 377 ng/l, 471 ng/l, and 794 ng/L for women, respectively. Elevated proBNP was statistically significantly associated with future AMIs in subjects with and without a previous heart disease.

CONCLUSIONS

Age-specific reference limits for cTnT and proBNP are needed to better evaluate cardiac symptoms.

Chronic conditions and multimorbidity associated with institutionalization among Finnish community-dwelling older people: an 18-year population-based follow-up study

Aim

The aim of the study is to assess the association of chronic conditions and multimorbidity with institutionalization in older people.

Findings

Having dementia, mood or neurological disorder and/or five or more chronic conditions were associated with a higher risk of institutionalization.

Message

These risk factors should be recognized in primary care when providing and targeting care and support for home-dwelling older people.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00535-y.

Purpose

The ageing population is increasingly multimorbid. This challenges health care and elderly services as multimorbidity is associated with institutionalization. Especially dementia increases with age and is the main risk factor for institutionalization. The aim of this study was to assess the association of chronic conditions and multimorbidity with institutionalization in home-dwelling older people, with and without dementia.

Methods

In this prospective study with 18-year follow-up, the data on participants’ chronic conditions were gathered at the baseline examination, and of conditions acquired during the follow-up period from the municipality’s electronic patient record system and national registers. Only participants institutionalized or deceased by the end of the follow-up period were included in this study. Different cut-off-points for multimorbidity were analyzed. Cox regression model was used in the analyses. Death was used as a competing factor.

Results

The mean age of the participants (n = 820) was 74.7 years (64.0‒97.0). During the follow-up, 328 (40%) were institutionalized. Dementia, mood disorders, neurological disorders, and multimorbidity defined as five or more chronic conditions were associated with a higher risk of institutionalization in all the participants. In people without dementia, mood disorders and neurological disorders increased the risk of institutionalization.

Conclusion

Having dementia, mood or neurological disorder and/or five or more chronic conditions were associated with a higher risk of institutionalization. These risk factors should be recognized when providing and targeting care and support for older people still living at home.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00535-y.

Subjective and objective health predicting mortality and institutionalization: an 18-year population-based follow-up study among community-dwelling Finnish older adults

BACKGROUND

Objective health measures, such as registered illnesses or frailty, predict mortality and institutionalization in older adults. Also, self-reported assessment of health by simple self-rated health (SRH) has been shown to predict mortality and institutionalization. The aim of this study was to assess the association of objective and subjective health with mortality and institutionalization in Finnish community-dwelling older adults.

METHODS

In this prospective study with 10- and 18-year follow-ups, objective health was measured by registered illnesses and subjective health was evaluated by simple SRH, self-reported walking ability (400 m) and self-reported satisfaction in life. The participants were categorized into four groups according to their objective and subjective health: 1. subjectively and objectively healthy, 2. subjectively healthy and objectively unhealthy, 3. subjectively unhealthy and objectively healthy and 4. subjectively and objectively unhealthy. Cox regression model was used in the analyses. Death was used as a competing factor in the institutionalization analyses.

RESULTS

The mean age of the participants (n = 1259) was 73.5 years (range 64.0-100.0). During the 10- and 18-year follow-ups, 466 (37%) and 877 (70%) died, respectively. In the institutionalization analyses (n = 1106), 162 (15%) and 328 (30%) participants were institutionalized during the 10- and 18-year follow-ups, respectively. In both follow-ups, being subjectively and objectively unhealthy, compared to being subjectively and objectively healthy, was significantly associated with a higher risk of institutionalization in unadjusted models and with death both in unadjusted and adjusted models.

CONCLUSIONS

The categorization of objective and subjective health into four health groups was good at predicting the risk of death during 10- and 18-year follow-ups, and seemed to also predict the risk of institutionalization in the unadjusted models during both follow-ups. Poor subjective health had an additive effect on poor objective health in predicting mortality and could therefore be used as part of an older individual's health evaluation when screening for future adverse outcomes.

A practical laboratory index to predict institutionalization and mortality - an 18-year population-based follow-up study

Background

Previously, several indexes based on a large number of clinical and laboratory tests to predict mortality and frailty have been produced. However, there is still a need for an easily applicable screening tool for every-day clinical practice.

Methods

A prospective study with 10- and 18-year follow-ups. Fourteen common laboratory tests were combined to an index. Cox regression model was used to analyse the association of the laboratory index with institutionalization and mortality.

Results

The mean age of the participants (n = 1153) was 73.6 (SD 6.8, range 64.0–100.0) years. Altogether, 151 (14.8%) and 305 (29.9%) subjects were institutionalized and 422 (36.6%) and 806 (69.9%) subjects deceased during the 10- and 18-year follow-ups, respectively. Higher LI (laboratory index) scores predicted increased mortality. Mortality rates increased as LI scores increased both in unadjusted and in age- and gender-adjusted models during both follow-ups. The LI did not significantly predict institutionalization either during the 10- or 18-year follow-ups.

Conclusions

A practical index based on routine laboratory tests can be used to predict mortality among older people. An LI could be automatically counted from routine laboratory results and thus an easily applicable screening instrument in clinical settings.

Predictive factors for the outcome of a multidisciplinary pain rehabilitation programme on sick-leave and life satisfaction in patients with whiplash trauma and other myofascial pain: a follow-up study

OBJECTIVE

To evaluate the effects of a multidisciplinary rehabilitation programme on sick-leave, coping resources and life satisfaction in whiplash patients and other pain patients.

SUBJECTS

Forty patients suffering from symptoms after whiplash trauma and 33 patients with musculoskeletal pain in the neck or back were recruited for this study. Ninety-seven consecutive patients admitted to the Department of Neurosurgery with cervical pain, cervical disc herniation or symptomatic spondylosis served as a control group.

RESULTS

Decreased coping resources and poorer life satisfaction were observed for whiplash subjects at the beginning of the rehabilitation programme compared to the control group from the Department of Neurosurgery. After the rehabilitation period 49% of the patients had improved their coping resources totalling to 63% after 2 years. At that follow-up 46% of patients had increased their life satisfaction. Furthermore, the group with whiplash injury showed a significant increase in sick absenteeism whereas the group without whiplash trauma had decreased their sick-leave. Eighty-eight per cent of the subjects could be correctly classified according to their vocational outcome by means of discriminant function. The elapse of time since working, low life satisfaction, lack of increase in coping resources during the rehabilitation programme, ethnic origin of the patient and living in the countryside predicted poor vocational outcome.

CONCLUSION

Our results suggest variables from the social environment and coping resources as useful predictors for treatment outcome.

Somatosensory evoked magnetic fields from primary sensorimotor cortex in juvenile neuronal ceroid lipofuscinosis

The present study evaluated neurophysiologic function of the primary sensorimotor cortex in juvenile neuronal ceroid lipofuscinosis. A 122-channel magnetometer, which allowed studies of the somatosensory system in millimeter and millisecond precision, was used to record somatosensory evoked magnetic fields to median nerve stimulation from 10 patients and their matched control subjects. In both patients and controls, the somatosensory evoked magnetic fields from primary sensorimotor area typically consisted of N20m, P35m, and P60m deflections. In the patients, N20m was significantly delayed, whereas P35m peaked earlier than in the control subjects. The source strengths for N20m and P35m were greater in the patients than in the controls. Both deflections showed a significant positive correlation with the disease duration: the sources were stronger in the older patients than in the younger ones. P60m deflections were normal or reduced in the patients. The results indicated increased thalamocortical excitability in the sensorimotor cortex in juvenile neuronal ceroid lipofuscinosis.

Increase of antimicrobial resistance of faecal aerobic gram-negative bacteria in a geriatric hospital

Antimicrobial resistance of faecal aerobic Gram-negative bacteria to eight different antimicrobials was determined by a velvet replica-plating method in 1988 and 1933. Faecal samples were taken from 131 geriatric inpatients in the Turku City Hospital with a hospitalization of more than 7 days. From 1987 to 1992 the use of first and second generation cephalosporins and ciprofloxacin increased from 3.32 defined daily doses (DDD) per bed to 24.25 DDD/bed and from 0.63 DDD/Bed to 28.11 DDD/bed, respectively. A statistically significant increase was observed in the frequency of samples resistant (with >= 1% of resistant colonies) to cefuroxime (p = 0.0004) and ceftazidime (p = 0.037) in patients who received antimicrobial therapy and to ampicillin (p = 0.046) in patients who had not received antimicrobial therapy. In addition, despite the decreased use of sulphonamides and trimethoprim (from 17.11 DDD/bed to 5.54 DDD/bed) no significant changes in the frequency of resistant faecal samples were observed. Use of ciprofloxacin has been found to cure resistance plasmids from bacteria in vitro. However, despite the increased use of ciprofloxacin, no decrease in faecal bacteria resistant to any of the other antimicrobials (i.e. trimethoprim) studied was observed.

Circadian rhythm studies in neuronal ceroid-lipofuscinosis (NCL)

Sleep disorders are common in NCL patients. The patients have problems such as frequent awakenings, difficulties with sleep onset, nightmares, and night terrors. The aim of the study was to examine whether the sleep disturbance in NCL can be explained on the basis of desynchronised circadian rhythms. Therefore we studied diurnal patterns of melatonin, cortisol, body temperature, and motor activity of 14 patients. The group consisted of 8 JNCL patients, 5 INCL children, and one boy with Jansky-Bielschowsky disease of the variant type. There were healthy age- and sex-matched control subjects. The blood samples for serum melatonin and cortisol were collected every 2 hours during 24-hour periods. Body temperature was recorded continuously for a 24-hour period by a polygraph. Diurnal motor activity was measured by wrist actigraphy for 5 days. In most of our patients sleep was fragmented and the sleep phase was irregular. Disturbances in the daily hormonal rhythms occurred only in the minority of the patients and only at an advanced stage of the disease. Although disturbances in the body temperature rhythm were found in about half of the patients, a general failure in the circadian regulatory system does not explain the frequent disturbances of the sleep-wake cycle of the NCL patients.

A new dhfrVIII trimethoprim-resistance gene, flanked by IS26, whose product is remote from other dihydrofolate reductases in parsimony analysis

A new plasmid-borne gene, dhfrVIII, encoding high-level trimethoprim resistance (TpR) was found in an intestinal Escherichia coli. It seems to be a widely occurring mediator of TpR. Among 973 examined TpR E. coli, the new resistance gene was found in 13 (1.3%) isolates from Sweden, Finland and Nigeria. The new gene was sequenced and found to code for a dihydrofolate reductase (DHFR) of 169 amino acids (M(r) 19005). The dhfrVIII gene on the studied plasmid pLMO226 was observed to be flanked by IS26 elements. The dhfrVIII gene and a 3' unidentified open reading frame (ORF) seem to be borne on a compound transposon with IS26 at its ends, since the configuration of two IS26 flanking dhfrVIII and the unidentified ORF was conserved among the isolates that were probe-positive for the gene. Phylogeny parsimony analysis showed the dhfrVIII-encoded enzyme to be only remotely related to other known plasmid-mediated, drug-resistant DHFR. Only a few of the latter form well-supported monophyletic groups.

A novel dihydrofolate reductase cassette inserted in an integron borne on a Tn21-like element

In this study, a 498-bp dhfrXII gene coding for trimethoprim resistance was found inserted in a cassette-like manner in the recombinationally active locus, the integron, borne on a transposon Tn21-like element. The dhfrXII cassette is distinct from those cassettes earlier observed in integrons and was found here upstream of two similarly inserted cassettes. The second one carried the new unidentified orfF, which is 85% identical to the orfD cassette in R46. The third cassette contained the aadA2 gene mediating spectinomycin resistance. The plasmid carrying this Tn21-like element was originally isolated from a trimethoprim-resistant urinary tract pathogen, Escherichia coli, from Turku City Hospital, Turku, Finland. By colony hybridization and polymerase chain reaction, this group of three cassettes, including dhfrXII, was detected in four additional E. coli strains of similar origin and in four Shigella strains isolated in Finland but originating from Asia. The dihydrofolate reductase produced from dhfrXII showed an unusual drug resistance in that 50% of the enzymatic activity remained at a trimethoprim concentration of 1 mM.

Analysis of genetic localization of the type I trimethoprim resistance gene from Escherichia coli isolated in Finland

Among a collection of clinical Escherichia coli isolates, the type I dihydrofolate reductase (DHFR) mediating trimethoprim resistance was generally observed to be chromosomally determined. Only a minority of isolates carried the type I DHFR gene simultaneously on a plasmid. The majority of E. coli isolates studied also hybridized with a probe specific for the transposition gene tnsC of transposon Tn7; and in most of these isolates, Tn7 was found to be inserted into a preferred site in the E. coli chromosome. A minority of isolates that harbored the type I DHFR gene in the chromosome lacked a complete Tn7. Some of these harbored the type I DHFR gene inserted in a structure similar to that containing the gene for streptomycin resistance in Tn21. In the other isolates that were negative for a complete Tn7, the sequences upstream of the type I DHFR gene were demonstrated to be homologous to those flanking the type I DHFR gene in Tn7. This could indicate that the antibiotic resistance region of Tn7 may occur independently of this transposon. In two isolates, no sequences resembling Tn7 or Tn21 were found adjacent to the type I DHFR gene.

Trimethoprim resistance in Escherichia coli isolates from a geriatric unit

The frequency of trimethoprim resistance among Escherichia coli isolates from urine samples collected at Turku City Hospital, Turku, Finland, remained at 40% during 1984 to 1988. The proportion of highly resistant (MIC, greater than or equal to 1,024 micrograms/ml) isolates increased, however, and most of these harbored the type I dihydrofolate reductase gene. Only a few isolates possessed type II or VII genes.

Increase of trimethoprim resistance among Shigella species, 1975-1988: analysis of resistance mechanisms

Trimethoprim (TMP) resistance among Shigella species isolated from Finnish travelers increased from 3.0% in 1975-1982 to 42.0%-43.8% in 1987-1988. Of the 317 TMP-resistant Shigella isolates identified during 1975-1988, 175 (55%) collected in 1985-1987 and in 1988 were tested further. Almost all (98%) were highly resistant to TMP, suggesting a plasmid-mediated origin. The type I dihydrofolate reductase (DHFR) gene was detected in 85% of the isolates studied. Twenty-three percent of the type I DHFR-positive isolates failed to hybridize with a probe detecting only Tn7-derived sequences, suggesting that the type I DHFR gene may occur independently of transposon Tn7. Four of the five Shigella species isolated from travelers to Sri Lanka hybridized with the probe for type V DHFR gene, implying a local distribution of the type V DHFR gene. The type II and type III DHFR genes were not found among the isolates studied. Only 12% of the TMP-resistant Shigella isolates failed to hybridize with any of the DHFR gene probes used.

The emergence and mechanisms of trimethoprim resistance in Escherichia coli isolated from outpatients in Finland

Trimethoprim (TMP), either alone or in combination with sulphonamides, is commonly used for treating urinary tract infections. In Finland, TMP alone has been in clinical use since 1973. TMP resistance in the major outpatient urinary tract pathogen, Escherichia coli, increased during 1978-1988 from 5% to 16% in the Turku area, during 1980-1988 from 3% to 19% in the Helsinki area and also during 1980-1988 from 3% to 14% in the Rovaniemi area. The majority (91%) of TMP-resistant strains were highly-resistant to TMP (MIC greater than or equal to 1024 mg/l). The most common (57%) TMP resistance gene, detected by DNA hybridization, was the type I dihydrofolate (DHFR) gene. The type II DHFR genes were found in less than 3% of the strains studied. No positive hybridizations were detected with the type III DHFR probe, and only a few positive hybridizations were found with the type V DHFR probe. Forty percent of the isolates did not hybridize with any of the DHFR probes used, suggesting additional unknown resistance mechanisms responsible for the high-level TMP resistance. These unknown TMP resistance mechanisms, together with the type I DHFR-mediated resistance, were responsible for the increase of TMP resistance among the E. coli strains studied.

Comparison of the Frejka pillow and the von Rosen splint in treatment of congenital dislocation of the hip

In southern Finland between 1966 through 1975, 920 newborns were treated with a Frejka pillow for dislocation of the hip. The treatment failed in 55 patients. The pillow was then rejected and replaced with the von Rosen splint. One hundred eighty patients were treated with the new method between 1978 and 1981. The treatment failed in one girl. At 3 years of age, one boy had slight features of avascular necrosis. Temporary skin irritation was found in 19% of patients. In two patients, the splint had to be replaced with a pillow because of skin problems. A treatment device which parents are allowed to take off between outpatient visits is not recommended.

The management of primary acetabular dysplasia. Its association with habitual side-lying

Fifty-one infants with limited abduction of the hip and acetabular dysplasia were, between 1969 and 1975, treated with abduction-adduction exercises, administered by the parents; no abduction devices were used. In 1983 a follow-up examination was carried out on 41 of these patients. Although at birth these children had characteristics similar to patients with congenital dislocation of the hip, none of their hips dislocated. At birth acetabular measurements showed that half the children had severe dysplasia and the other half slight dysplasia; the difference between the affected and the healthy hips was significant. At follow-up the gait was normal in all the patients. Movements at the hips were symmetrical and within normal limits in all but one patient. The acetabular angle, the centre-edge angle, the shaft-neck angle, the hip ratio, and the size of the femoral head were the same on the previously affected side as on the normal side. Nineteen of the children followed up had preferred lying on one side and dysplasia of the upper hip had developed. The significance of the sleeping position on the development of acetabular dysplasia is discussed.

Late diagnosis in congenital dislocation of the hip

In 1966-1975, congenital dislocation of the hip was diagnosed after the neonatal period in 115 children in Uusimaa county in southern Finland; the incidence was 0.76 per thousand liveborns. No decreasing tendency could be seen during the time of the investigation. In most children, the diagnosis was made during the first medical examination at the child welfare clinic at the average age of 3 months. The number of children diagnosed at walking age seemed to be decreasing. The numbers of boys and bilateral affections were smaller in this group than among cases diagnosed during the neonatal period. Dislocation was suspected in 23 per cent of the children even before the diagnosis was made. The reasons for the delay are given and discussed. In 1981, 66 per cent of the children were symptomless and no radiographic signs could be seen. Sixteen per cent of the children had minor residual signs with no need for follow-up, and in 18 per cent the outcome was still unclear.

Congenital dislocation of the hip in Finland. An epidemiologic analysis of 1035 cases

The incidence of congenital dislocation of the hip (CDH) and some birth characteristics of the population in Uusimaa county in southern Finland were investigated during the years 1966 through 1975. A total of 1035 babies with CDH was born during the time under review. This was 0.68 per cent of liveborns in the area. In 920 babies, the diagnosis was made during the first month of life, corresponding to 0.61 per cent of liveborns and 89 per cent of all children with CDH. The annual variation was great. The monthly variation of CDH in girls was significant, with a peak in June-July, differing from other investigations. Contrary to results of several other studies, the birth weight of the affected babies was normal. The sex distribution, number of first-born babies, side of the dislocation and associated calcaneovalgus foot were in accordance with findings in most other investigations.

Treatment of congenital dislocation of the hip after neonatal diagnosis

During 1966-1975, 920 infants with a congenital dislocation of the hip diagnosed neonatally were born in Uusimaa county in southern Finland. The first examination of the hips was made by a pediatrician, but the diagnosis was generally confirmed by a pediatric surgeon before treatment was started. The mean age of beginning treatment was 7 days. An abduction pillow was the only treatment in 852 cases, six of whom later developed complications, notably two with avascular necrosis. The duration of the pillow treatment shortened noticeably during the time under review but this caused no increase in the number of failures. In 64 cases the routine pillow treatment could not be carried through, mostly because the hip dislocated on the pillow. The most apparent reason for this was inappropriate control of the pillow by the parents. In this group bilateral dislocations and associated calcaneovalgus feet were found more often than in the rest of the neonatal group. Non-operative treatment was successful in 96 per cent of the 920 cases.