Social Participation Considered as Meaningful in old age - the Perceptions of Senior Housing Residents in Finland

As populations across the world age, there is a recognised need for promoting social participation in older adults. Previous studies related to social participation have addressed that interactions perceived as meaningful may improve quality of life in old age. However, what is less clear is the nature of such participation from the perspective of older adults, as the vast majority of studies have been quantitative. The present study aimed to explore what characterises social participation that contributes to a meaningful everyday life, from the viewpoint of independently living Finnish older adults. Thematic analysis was used as an interpretative method drawing on semi-structured in-depth interviews with six residents aged 82 to 97 years from one senior housing facility. The analysis showed that social participation perceived as meaningful involved caring reciprocal interactions with people they connected with; having the freedom to make autonomous decisions and influence matters that affected their own or others' everyday life; and, on a more abstract level, feeling significant as a person. It furthermore fostered independence and companionship as well as reduced loneliness. To describe social participation that is perceived as meaningful from a theoretical perspective, we used Levasseur and colleagues' (2010) taxonomy and found that such involvement creates a sense of connectedness, a sense of belonging and relates to the concepts of social integration, social networking and social engagement. This type of involvement is associated with enhanced quality of life and a more meaningful life, highlighting the importance of creating environments where older adults can socially connect.

Social relations and exclusion among people facing death

In line with current policies and service developments related to palliative care, more people are dying at home. This situation has provoked discussions about the importance of non-medical issues related to death. The process of dying is often long, with many phases, and the social aspect is a major part of it. Our focus in this article is on dying as a social process. Social relationships are significant and play a meaningful role in enhancing the well-being of older adults approaching the end of life. Meaningful social relationships tend to change over time; however, and the process of dying may exacerbate such changes in and challenge these relationships. The aim of our study was to examine how social relationships are experienced and (re)constructed among older adults (70-83 years old) during the process of dying, in a Finnish context. We were interested in the nature and type of these relationships, and in the possible new forms of expression that may emerge during this process. Our empirical data were based on interviews with seven older adults who were close to death. The analysis revealed processes of exclusion from existing relations. At the same time, we observed new and unexpected relations being initiated, which sometimes became meaningful and supportive. The results highlighted the role of expectations and importance of analysing exclusion from a life-course perspective.

eConsultation between health care professionals in primary health care and specialized medical care

The synchronous eConsultation is provided by a specialist in a hospital to a GP appointment either by pre-set request or without scheduling. The patient participates in the session. The eConsultation employs video or chat and the program integrated into Health Village service platform enables also sharing x-rays, still photos and other EHR material. Health Village delivers public health services for general public, digital care pathways for patients with specific diagnoses and digital tools for professionals.

The eConsultation project started in 2018, after interviewing the member municipalities (n = 24, 1 600 000 inhabitants) of the Hospital District of Helsinki and Uusimaa (HUS) in Finland. The municipalities gave a high priority to eConsultation as a way of further integration of service chains and dissemination of common practices between and within the specialized and primary health care services.

Funded by the HUS and supported by the HUS IT Department eHealth Services, eConsultation pilots started in 2018 in close collaboration between the public specialized and primary health care organizations in neurology, orthopedics and wound treatment. The pilots indicated that eConsultation are more efficient than traditional consultation methods (e.g., the time used by a neurologist in eConsultation dropped by 87% vs. a face-to-face consultation visit). Almost all of patients and 84% of primary care professionals reported high level of satisfaction. The consultants found that the presence of a patient fostered, if needed, additional clinical interview and diagnostic procedures by proxy, as well as assessment of individual needs of a GP. The primary care professionals appreciated queue-free response (45 seconds in eConsultation with no pre-set appointment time) and augmented educational validity.

Scaling of eConsultation across the whole hospital district and more specialties is going on. eConsultation will be explored in depth in two starting scientific studies.

Key messages

Synchronous eConsultation. more efficient than traditional consultation methods.

Systematic Screening of Adverse Reactions to Metal Debris after Recap-M2A-Magnum Metal-on-Metal Total Hip Arthroplasty

Background and Aims:

An adverse reaction to metal debris is a known complication after large diameter head metal-on-metal total hip arthroplasty. However, the failure rate varies depending on the implant design. Therefore, we investigated the prevalence of adverse reaction to metal debris, as well as the symptoms and risk factors after undergoing a ReCap-M2a-Magnum large diameter head metal-on-metal total hip arthroplasty.

Materials and Methods:

Between 2005 and 2012, 1188 patients (1329 hips) underwent ReCap-M2a-Magnum total hip arthroplasty at our institution. Systematic screening for adverse reaction to metal debris was arranged using the Oxford Hip Score questionnaire, hip and pelvic radiographs, and assessments of the serum chromium and cobalt ion levels. Clinical evaluation and magnetic resonance imaging were performed for the symptomatic patients, as well as those with either chromium or cobalt ion levels ⩾5 µg/L. The prevalence of adverse reaction to metal debris after ReCap-M2a-Magnum total hip arthroplasty was assessed, and the risk factors for adverse reaction to metal debris were evaluated using logistic regression. The mean follow-up time was 5.2 (0.003–9.1) years. This study was an extension of a previous study conducted at our institution with 80 patients.

Results:

In total, 33 patients (33 hips, 2.5% of all hips) required a revision operation due to adverse reaction to metal debris. Moreover, 157 hips exhibited definitive adverse reaction to metal debris, but a revision operation was not performed (157 of 1329 hips, 11.8% of all hips). Overall, 190 out of 1329 (14.3%) hips had definitive adverse reaction to metal debris. Pain, subluxation sensation, clicking, swelling, a small head size, and a fair/poor Oxford Hip Score were associated with definitive adverse reaction to metal debris.

Conclusion:

We found a high prevalence of adverse reaction to metal debris in the ReCap-M2a-Magnum total hip arthroplasty patients in this study; however, most of the patients did not require revision operations.

Whole body PET/CT in the follow-up of asymptomatic patients with stage IIB-IIIB cutaneous melanoma. Acta Oncol 2016;55:1355-1359. [PMID: 27553064 DOI: 10.1080/0284186x.2016.1213879]

BACKGROUND

Whole body positron emission tomography (PET)/computed tomography (CT) is a sensitive imaging technique in patients with metastatic melanoma, but its role in the follow-up of asymptomatic high-risk patients is unclear. The aim was to study the role of PET/CT as a routine surveillance imaging tool in asymptomatic high-risk patients at the early stage of follow-up combined with a sufficient follow-up over several years.

MATERIAL AND METHODS

A total of 110 asymptomatic patients with clinically local American Joint Committee on Cancer (AJCC) stage IIB-IIIB melanoma underwent routine whole body PET/CT scanning after a mean interval of seven months after initial surgery. Clinical data were retrospectively analyzed after a median follow-up time of 4.6 years.

RESULTS

Recurrent melanoma was detected in 45 patients (41%) and 36 (33%) died of melanoma. In 11 asymptomatic patients (10%) occult disease was detected with a single PET/CT. In seven of these patients (64%), positive PET/CT finding had major influence in treatment decisions. Four patients underwent surgical metastasectomy and two of them remained disease-free. In 34 patients (31%) PET/CT revealed no disease, but recurrence was detected at a median time of 19 months after negative PET/CT scan. In 50 patients (45%) PET/CT finding was true negative. In 15 patients (14%) scan was false positive leading to additional management or repetitive imagings.

CONCLUSION

A single PET/CT could detect 24% of all recurrences in asymptomatic melanoma patients at the early stage of follow-up, but an earlier detection of occult metastases did not improve survival.

Freedom Constrained Liner for the Treatment and Prevention of Dislocation in Total Hip Arthroplasty

BACKGROUND AND PURPOSE

Dislocation is one of the most common complications following total hip arthroplasty. The aim of our study was to assess failure rate of the Biomet Freedom constrained liner (Biomet, Warsaw, IN, USA) either in revision surgery for recurrent dislocation, or as a preventive method in high dislocation risk patients.

PATIENTS AND METHODS

We assessed retrospectively 105 consecutive surgical procedures in 103 patients where a Freedom constrained liner or cup was used in Turku University Hospital over a 7-year period from 2007 to 2014. The mechanical failure rate of the device was assessed based on medical records. The average age of the patients was 73.4 years. The number of male patients was 53 (51%). Mean follow-up time was 2.5 years. The association between failure of the device and potential risk factors-age, gender, indication, and approach-was analyzed with logistic regression. Results were expressed by odd ratios and 95% confidence intervals.

RESULTS

The mechanical failure rate of the Freedom device was 6 out of 105 (5.7%). None of the 11 preventive primary THAs against dislocation failed, 4 out of 52 (7.7%) preventive revision THAs against dislocation failed, and 2 out of 42 (4.8%) of the treated dislocation cases failed. Four out of six failures were dislocations due to impingement and failure of the locking mechanism. Two liners failed because of loosening. The risk factors assessed were not associated with failure of the device.

INTERPRETATION

We found out that the mechanical failure rate of a Freedom constrained device was low. These results encourage us to continue using the device.

Acetabular reconstruction with impaction bone grafting and cemented polyethylene socket in total hip revision arthroplasty

Background and aims:

Bone deficiency in revision total hip arthroplasty is a challenge to the surgeon. One option for restoration of the bone stock is impaction bone grafting and use of a cemented socket. The aim of this study was to evaluate the mid-term clinical outcome of impaction bone grafting and cemented socket revisions.

Material and methods:

A total of 59 patients (60 hips) underwent revision arthroplasty with impaction bone grafting and application of a cemented socket on the acetabular side in the Turku University Hospital from 1999 to 2004. The study end-point was re-revision for any reason. The cumulative percentages for survival were followed and estimated with Kaplan–Meier curves. Associations between occurrence of re-revision and potential risk factors were analyzed with logistic regression. Results were quantified by odd ratios and 95% confidence intervals. The mean age of the patients was 69 years (33% male). A total of 3% of the patients had a class I Paprosky acetabular defect, 38% had class II, and 55% had class III.

Results:

The overall survival rate was 73%. The mean follow-up time was 7 years. The most common reason for re-revision was aseptic loosening of the acetabular component (13 patients, 81% of re-revisions). Cox’s regression analysis did not identify any risk factors for re-revision.

Conclusion:

Our results were inferior compared to some previous studies. Impaction bone grafting of acetabular defects in revision total hip arthroplasty may not always provide a reliable bone stock in long-term.

Risk of donor-site lymphatic vessel dysfunction after microvascular lymph node transfer

BACKGROUND

Microvascular lymph node transfer has been used to improve lymphatic function in patients with lymphoedema. We previously reported changes in the lymphatic function of the donor limb after lymph node transfer. For this reason, we modified our surgical method to be more conservative.

SUBJECTS AND METHODS

Microvascular lymph node transfer was performed in 13 patients using the previously reported original method. Sixteen patients were operated upon using the more conservative modified method. Lymphatic function in the donor limb was evaluated using volumetry, lymphoscintigraphy and tissue water percentage.

RESULTS

In the original method group, the donor-limb volume was on average greater (199 ± 540 ml) than in the non-operated control limb. The volume difference between the limbs was smaller (151 ± 463 ml) in the modified method group. Two patients in the original method group had abnormal transport index (Ti) values in lymphoscintigraphy indicating decreased lymphatic function of the donor limb. In the modified method group, the Ti-values remained normal. The tissue water percentage of the donor limb was on average 40% ± 4% in the original method group and 40% ± 3% in the modified method group. Importantly, none of the patients in either group developed clinical lymphoedema in the donor limb during the 11-84-month follow-up.

CONCLUSIONS

Even with the more conservative lymph node transfer method, we can observe slight, subclinical signs of lymphatic dysfunction in the donor limb. These results highlight the importance of minimizing the surgical exploration in the inguinal area and avoiding damage to the lymphatic vessels or sentinel nodes draining the lower limb.

Experience of structural onlay allografts for the treatment of bone deficiency in revision total hip arthroplasty

Background and Aims:

Loss of femoral bone stock in elective revision total hip arthroplasty poses unique and substantial challenges. Structural onlay allografts may provide mechanical stability for the cementless revision prosthesis and increase bone stock.

Material and methods:

At least one cortical onlay allograft was used in 40 elective total hip arthroplasty revisions (40 patients) to reconstruct femoral bone defects. The operations were performed between January 1999 and August 2010 in the Turku University Hospital, Finland. The mean follow-up time was 52 months (range: 12–125 months).

Results:

The allografts were incorporated into the bone tissue in 37 of 40 (92.5%) patients. Cementless revision stems healed in 36 of 40 (90.0%) patients, but these patients were not exactly the same patients whose allografts were successfully incorporated. One or more surgical complications were experienced by 14 of 40 (35.0%) patients during follow-up. In all, 4 of 40 (10.0%) patients (all women) had hip infections during follow-up. Of the 7 patients with rheumatoid arthritis, 4 (57.1%) had at least one complication.

Conclusions:

The use of the cortical onlay allografts provides a feasible option for restoring the integrity of the proximal femur in revision total hip arthroplasty, but the complication rate is high, particularly in female patients with rheumatoid arthritis.

Early results of large head metal-on-metal hip arthroplasties

BACKGROUND AND AIMS

Total hip arthroplasty significantly improves patient's life quality. However, total joint replacement is associated with possible complications, such as dislocations, infections, fractures and periprosthetic osteolysis. The goal of this study was to evaluate a large head metal-on-metal total hip arthroplasties and analyse short term complications related to them.

MATERIAL AND METHODS

Between 9/2005 and 6/2009, a total of 691 hip replacements were performed on 635 patients with the use of Magnum M2 large head cementless metal-on-metal prosthesis in Turku University Hospital. All patients had a scheduled follow-up at two to three months, and at one year. The results were evaluated using X-rays, Harris Hip Score (HHS), and evaluating post-operative complications and reasons for re-operations.

RESULTS

During our follow-up the HHS median raised from its preoperative value of 59.8 to 86.4 two to three months after the operation, and to 93.9 one year after the operation. As a complication we had five infections requiring single open debridement (early infection) or a two stage revision. Seven patients had a periprosthetic femoral fracture that was operated and 11 patients were reoperated because of acetabular component malposition, fracture or early loosening. We did not observe any dislocations, n. ischiadicus damages, squeeking or complications related to high metal ion release (ALVAL-reactions (Aseptic Lymphocyte-dominated Vasculitis-Associated Lesion) or pseudotumours).

CONCLUSIONS

The metal-on-metal bearing pair allows large femoral head size, which decreases the risk for dislocation. It may also decrease the risk for osteolysis and aseptic loosening in a long run. Early complication rate related to the bearing surface is minimal. Metal-on-metal prosthesis is a good choice for young and active patients with good bone quality.

Sentinel lymph node biopsy and survival in elderly patients with cutaneous melanoma

BACKGROUND

Sentinel lymph node biopsy (SNB) is a widely adopted staging procedure in patients with cutaneous melanoma. The benefits of SNB have not been evaluated thoroughly in older age groups.

METHODS

This was a two-centre retrospective observational study of patients with melanoma aged at least 70 years undergoing SNB.

RESULTS

A total of 423 patients were included. SNB was successful in 405 patients (95·7 per cent), of whom 88 (21·7 per cent) had sentinel node metastasis. During a median follow-up of 2·5 years, recurrence developed in 80 patients (18·9 per cent). Nodal recurrence developed in eight sentinel node-negative patients, giving a false-negative rate of 8·3 per cent, a sensitivity of 91·7 per cent and an overall diagnostic accuracy of 98·0 per cent. A total of 46 patients (10·9 per cent) died from melanoma and 42 (9·9 per cent) from other causes. At 5 years, the relapse-free survival rate was 80·0 per cent in sentinel node-negative patients and 39 per cent in node-positive patients; cancer-specific survival rates were 88·6 per cent and 46 per cent respectively (P < 0·001). In multivariable analysis, sentinel node metastasis (P < 0·001), a Breslow thickness of at least 2·0 mm (P = 0·007) and presence of ulceration (P = 0·012) were independent prognostic factors for cancer-specific survival.

CONCLUSION

SNB is a feasible and accurate technique for detecting nodal metastases in older patients with melanoma. Sentinel node status is the most important predictor of cancer-specific outcome in the elderly.

Up to 10 Years Follow up of the Use of 71 Cortical Allografts (Strut-Grafts) for the Treatment of Periprosthetic Fractures

Backround and Aims:

Periprosthetic fractures are often located in areas of poor bone quality. There are multiple strategies to manage these fractures. Stable fixation in areas of low bone quality may require the use of cortical bone strut allografts.

Material and Methods:

Cortical allograft struts were used in the treatment of 71 patients with periprosthetic fractures between a 10 year period from 1/1999 untill 12/2008. 18 patients had a periprosthetic fracture around the knee implant, 52 around the hip implant and 1 in between the hip and knee prosthesis. The average follow-up time was 943 days ranging from 90 days to 3428 days.

Results and Conclusions:

The overall union rate was 91%. 20 patients died during the follow-up, 6 of them during the first six month after operation. 8 patients (12%) had an diagnosed infection during the follow-up time. The specific strategy chosen to periprostehetic fracture treatment should depend on the quality of the remaining bone stock, type of the implant, location and classification of the fracture and on patients related factors, such age age and comorbidities. Use of cortical bone struts is a good option in fractures associated with poor bone quality. Use of allograft strut combined with a nonlocking plate, which offers the highest stiffness known, may provide superior biomechanical stability compared with other methods in some situations.

The effect of loneliness and change in loneliness on self-rated health (SRH): a longitudinal study among aging people

The association between adverse health and loneliness among aging people is known, but most of the studies are cross-sectional. In addition, the associations between changes in loneliness with health are less well known, especially in the case of aging people. The present study examined whether absence of loneliness in 2005 predicted subsequent good SRH in 2008, and whether changes in loneliness were associated with SRH in 2008. Longitudinal, questionnaire-based data were collected from three age cohorts (born in 1926-30, 1936-40, and 1946-50) living in southern Finland. Baseline data was collected in 2002 (n = 2815, 66%); the follow-ups were done in 2005 (n = 2476, 60%) and 2008 (n =2 064, 73%). Logistic regression analyses were used to derive the results. Never or seldom experiencing loneliness was a strong predictor for good SRH. In addition, good health was common among those who never felt lonely. Among men the group experiencing decreasing loneliness had the highest OR of good health. Thus, loneliness is a significant contributor to poor SRH among aging people. In addition, favorable SRH is indicated not only by the absence of loneliness at both measurement points, but also by decreased loneliness. Preventing loneliness is important for health promotion.

Clinical PET imaging of insulinoma and beta-cell hyperplasia

Persistent hyperinsulinemic hypoglycemia (PHH) is caused by solitary benign insulinoma or hyperplasia of pancreatic beta cells. In infants, PHH is caused by functionally defective hyperplastic beta cells, which are either diffusely or focally distributed in the pancreas. In adults, insulinoma is the most common cause of PHH, but recently, an increasing number of beta-cell hyperplasias has been reported among adults. The cause of adult beta-cell hyperplasia is not known. Whether the increased use of bariatric surgery in the treatment of severe obesity plays a role here is under investigation. Accurate localization of disease focus in both insulinoma and focal beta-cell hyperplasia provides an important support for surgery, especially as the use of laparoscopic surgery has increased. Conventional imaging of these challenging pancreatic lesions has evolved during recent years, but current imaging methods still lack sufficient sensitivity or are invasive. In most pancreatic NETs, the usefulness of positron emission tomography (PET) with fluorine-labeled fluorodeoxyglucose ([(18)F]FDG) for lesion detection is limited because of the low glucose turnover of these tumors. Based on the capacity of pancreatic beta cells to take up and decarboxylate amine precursors, several investigators have studied patients with pancreatic NETs using aminoacid precursors, such as [(18)F]dihydroxyphenylalanine (DOPA) and [(11)C]hydroxytryptophan (5-HTP), in an attempt to increase the sensitivity of PET scanning. Another characteristic of NETs is the expression of somatostatin receptors, and thus encouraging studies with somatostatin receptor imaging with [(18)Ga]-labeled somatostatin analogs have emerged as a new interesting imaging tool for the diagnosis of pancreatic NETs. This article provides an overview of our experiences and the current literature on PET imaging in patients with PHH caused by insulinoma or beta-cell hyperplasia.

Complement and c4 null alleles in severe chronic adult periodontitis

Severe forms of chronic periodontitis affect up to 10% of adults. Tumour necrosis factor and lymphotoxin-alpha genes in the major histocompatibility complex are associated with severe periodontitis. Complement factor C4 is a nearby, polymorphic, functionally relevant gene region. Although associated with chronic mucosal infections, C4 deficiencies have not been assessed in adult periodontitis patients. We tested whether complement levels are systemically altered and C4 deficiencies associated with severe chronic periodontitis. In a case-control study, we analysed levels of plasma C3, and C4, serum classical pathway haemolytic activity, C4 allotypes and C4 gene numbers in 37 patients with severe chronic periodontitis and in 150 voluntary controls. Plasma levels of C3 were higher, and classical pathway haemolytic activity was lower in patients than in controls. Partial C4 gene deficiencies were more frequent in patients than in controls (odds ratio 2.4, 95% confidence interval 1.1-5.5, P = 0.032). Changes in complement levels may reflect chronic, recurring inflammation. C4 gene deficiencies are associated with predisposition to chronic periodontitis.

Human MHC region harbors both susceptibility and protective haplotypes for coronary artery disease

Aiming to study the role of human major histocompatibility complex (MHC) region on coronary artery disease (CAD), we enrolled two separate patient materials and controls. First, heart transplantation recipients (n = 276) were divided into three subgroups according to the severity of atherosclerosis. The human leukocyte antigen (HLA)-A-B-DR haplotype and gene frequencies were compared between groups. Second, patients with acute coronary syndrome (ACS) (n = 100) and healthy controls (n = 74) were assessed by nine genetic MHC markers (HLA-A, HLA-B, HLA-DRB1, LTA+253(a/g), LTA+496(C/T), LTA+633(c/g), LTA+724(C/A), C4A and C4B), and the frequencies were compared. In the heart transplantation recipients, HLA-DR1 was strongly associated with CAD [severe vs no evidence, odds ratio (OR) 2.37; 95% confidence interval (CI) 1.33-4.25; P = 0.003]. Similarly, in the patients with ACS, HLA-DRB1*01 was associated with CAD (patients vs controls, OR 2.36; 95% CI 1.25-4.44; P = 0.007). HLA-DRB1*01 was associated with low-density-lipoprotein cholesterol (OR 5.32; 95% CI 1.64-17.26; P = 0.005) and smoking habit (OR 3.13; 95% CI 1.09-9.03; P = 0.035) as risk factors. The strongest protective gene was HLA-B*07 alone (OR 0.46; 95% CI 0.24-0.88; P = 0.02) or together with the haplotype LTA+253a-LTA+633g-C4A3-C4B1 (OR 0.36; 95% CI 0.22-0.57; P = 0.00001). In conclusion, human MHC region harbors genes that protect from and predispose to CAD.

Practice strategies of musicians modulate neural processing and the learning of sound-patterns

Previous studies suggest that pre-attentive auditory processing of musicians differs depending on the strategies used in music practicing and performance. This study aimed at systematically revealing whether there are differences in auditory processing between musicians preferring and not-preferring aural strategies such as improvising, playing by ear, and rehearsing by listening to records. Participants were assigned to aural and non-aural groups according to how much they employ aural strategies, as determined by a questionnaire. The change-related mismatch negativity (MMN) component of event-related brain potentials (ERPs) was used to probe pre-attentive neural discrimination of simple sound features and melody-like patterns. Further, the musicians' behavioral accuracy in sound perception was tested with a discrimination task and the AMMA musicality test. The data indicate that practice strategies do not affect musicians' pre-attentive neural discrimination of changes in simple sound features but do modulate the speed of neural discrimination of interval and contour changes within melody-like patterns. Moreover, while the aural and non-aural groups did not differ in their initial neural accuracy for discriminating melody-like patterns, they differed after a focused training session. A correlation between behavioral and neural measures was also obtained. Taken together, these results suggest that auditory processing of musicians who prefer aural practice strategies differs in melodic contour and interval processing and perceptual learning, rather than in simple sound processing, in comparison to musicians preferring other practice strategies.

Immunoglobulins and complement factor C4 in adult rhinosinusitis

We assessed whether complement and its factor C4 or abnormal immunoglobulin levels are associated with chronic or recurrent rhinosinusitis. We used multiple patient and control groups to obtain clinically meaningful data. Adult chronic or recurrent rhinosinusitis and acute purulent rhinosinusitis patients were compared with unselected adults and controls without previous rhinosinusitis. Associated clinical factors were reviewed. Levels of immunoglobulins, plasma C3, C4 and classical pathway haemolytic activity were analysed. C4 immunophenotyping was used to detect C4A and C4B deficiencies as null alleles. Complement was up-regulated in rhinosinusitis. C4A nulls and low IgA, IgG, IgG1, IgG2, IgG3 and IgG4 levels were all more common in chronic or recurrent rhinosinusitis patients than in unselected and healthy controls. We searched for relevant differences between the patient groups. According to stepwise logistic regression analysis, nasal polyposis [odds ratio (OR) 10.64, 95% confidence interval (CI) 2.5-45.7, P = 0.001], bronchial asthma (OR 8.87, 95% CI 2.3-34.9, P = 0.002), C4A null alleles (OR 5.84, 95% CI 1.4-24.9, P = 0.017) and low levels of IgG4 together with either IgG1 or IgG2 (OR 15.25, 95% CI 1.4-166.8, P = 0.026) were more common in chronic or recurrent rhinosinusitis than in acute rhinosinusitis patients. Isolated low IgG subclasses had limited value in patient assessment. C4A null alleles are associated with chronic or recurrent rhinosinusitis, potentially through their effect on immune defence and inflammation control. Multiple clinical and immunological parameters may need to be evaluated when searching for prognostic variables.

Low-intensity tensile loading increases intratendinous glucose uptake in the Achilles tendon

The metabolic activity of tendinous tissues has traditionally been considered to be of limited magnitude. However, recent studies have suggested that glucose uptake increases in the force-transmitting tissues as a response to contractile loading, which in turn indicates an elevated tissue metabolism. The purpose of the present study was to investigate whether such a mechanism could be observed for the human Achilles tendon following tensile loading. Six subjects participated in the study. Unilateral Achilles tendon loading was applied by 25-min intermittent voluntary plantar flexor contractions. A radioactive tracer ([18F]-2-fluoro-2-deoxy-D-glucose) was administered during muscle action, and glucose uptake was measured by use of PET. Regions of interest were defined on the PET images corresponding to the cross section of Achilles tendon at two longitudinally separated sites (insertion and free tendon). Glucose uptake index was determined within respective regions of interest for the active and resting leg. Tendon force during voluntary contractions was approximately 13% of maximal voluntary contraction force. Tendon loading induced an elevated glucose uptake index compared with that of the contralateral resting tendon in the region of tendon insertion (0.13 +/- 0.05 vs. 0.09 +/- 0.02; P < 0.05) and at the free tendon (0.12 +/- 0.01 vs. 0.08 +/- 0.02; P < 0.05). The present data suggest that tissue metabolism is elevated in the human Achilles tendon in response to low-intensity loading.

Complement C4 deficiency and HLA homozygosity in patients with frequent intraoral herpes simplex virus type 1 infections

Three consecutive patients with no apparent immunodeficiency who had frequent intraoral herpes simplex type 1 recurrences, a rare complication of herpes simplex virus infection, were found to have a total deficiency of either the A or B isotype of the complement component C4 and to be homozygous for the studied HLA antigens. A combination of HLA homozygosity, which may lead to impaired T cell recognition of viral peptides, and deficiency in the classical complement pathway, which can compromise virus neutralization, may predispose to severe and frequent herpes simplex virus infections.

Real-time PCR for detection and quantitation of hepatitis B virus DNA

A sensitive and reproducible real-time PCR assay based on TaqMan technology was developed for the detection and quantitation of hepatitis B virus (HBV) DNA in serum, and compared with an "in-house" qualitative PCR assay. HBV DNA was measured in 125 serum samples from 76 hepatitis B patients, consisting of 22 patients with an acute infection, 20 patients with a previous history of hepatitis B infection, and 34 patients with a chronic hepatitis B. Four patients with a chronic infection were treated with either an IFN-alpha monotherapy or a combination of IFN-alpha and lamivudine. Twenty-nine sera from healthy individuals and non-hepatitis B patients served as negative controls. The assay was validated by using a 10-fold dilution series of the World Virological Quality Control (VQC) sample containing 3.73 x 10(7) genome equivalents per ml. The detection limit for the real-time PCR was 3.73 x 10(2) genome equivalents per ml (geq/ml), while it was 3.73 x 10(3) geq/ml for the in-house PCR. The real-time PCR assay had an 8-logarithm dynamic range spanning from 10(2) to 10(10) geq/ml. In clinical serum samples, the real-time PCR and the in-house PCR detected HBV DNA in 81% (101/125) and 66% (83/125) of samples, respectively. HBV DNA was not detected among the negative controls by either of these assays. In conclusion, real-time PCR is a sensitive, specific, and a reproducible approach for the detection and quantitation of HBV DNA in clinical serum samples, useful also for monitoring the efficacy of antiviral treatment.

Activation of transcription factor NF-kappaB by growth inhibitory cytokines in vulvar carcinoma cells

Numerous investigations show that cytokines have a significant role in the regulation of cell growth. There is also increasing evidence for the role of transcription factors in cytokine-mediated growth-regulation of cancer cells. Our previous data demonstrate that several cytokines are able to inhibit DNA synthesis of vulvar carcinoma cells. The aim of this study was to investigate the effect of growth-inhibitory cytokines on the binding activity of transcription factor AP-1 and NF-kappaB in two vulvar carcinoma cell lines UM-SCV-6 and UM-SCV-1A in vitro. The effects of interferon gamma (IFN-gamma), interleukins 10 (IL-10) and 13 (IL-13), transforming growth factor beta(1) (TGF-beta(1)) and tumor necrosis factor alpha (TNF-alpha) on the DNA binding proteins were studied by electrophoretic mobility shift assay (EMSA). Our results showed that NF-kappaB and AP-1 were constitutively activated in both cell lines. The binding activity of NF-kappaB was found to be stimulated by TNF-alpha in both vulvar carcinoma cell lines while no effect on AP-1 was found by any of the cytokines. The binding activity of NF-kappaB was decreased by IL-10 and IL-13 in UM-SCV-1A cells suggesting that the pathway by which TNF-alpha activates NF-kappaB differs from that activated by interleukins.

Melioidosis presenting as urinary tract infection in a previously healthy tourist

Melioidosis is a tropical disease caused by Burkholderia pseudomallei, which is common in southeast Asia and Australia, but which is rarely diagnosed in Scandinavia. An increasing number of cases are being reported among tourists to infected areas. We report the first Finnish case of melioidosis, which presented as urinary tract infection in a previously healthy male tourist.

Regulation of UT-OC-3 ovarian carcinoma cells by cytokines: inhibitory effects on cell proliferation and activation of transcription factors AP-1 and NF-kappaB

The present study was designed to investigate the growth regulatory effects of cytokines in UT-OC-3 ovarian cystadenocarcinoma cells in vitro. The effects of interleukin-6 (IL-6), interferons alpha (IFN-alpha) and gamma (IFN-gamma), granulocyte-macrophage colony-stimulating factor (GM-CSF), tumour necrosis factor alpha (TNF-alpha), and transforming growth factor beta1 (TGF-beta1) were investigated by (125)I-deoxyuridine ((125)IUdR) incorporation assay. In order to understand better the molecular mechanisms of the observed effects, the activation of DNA-binding proteins was studied by electrophoretic mobility shift assay. In addition, cellular DNA was tested by fragmentation analysis to determine if the most growth inhibitory cytokines are able to induce programmed cell death (apoptosis). After 48h in culture, TGF-beta1, TNF-alpha, IFN-alpha and IL-6 showed a clear inhibitory effect on (125)IUdR incorporation (P<0.005), and IFN-gamma and GM-CSF caused even more significant inhibition (P<0.001). IFN-alpha and IFN-gamma were both growth inhibitory after 72h in culture (P<0.005). Similarly, GM-CSF induced a slight inhibition (P<0.05), whereas TGF-beta1 and TNF-alpha almost blocked DNA synthesis (P<0.001) after 72h. IL-6 had no statistically significant effect on cell proliferation after 72h. Transcription factors AP-1 and NF-kappaB were both constitutively expressed in UT-OC-3 cells. The binding activity of AP-1 was found to be stimulated by the growth inhibitory cytokines, TGF-beta1 and TNF-alpha, and the binding of NF-kappaB was stimulated by TNF-alpha. Apoptosis does not seem to be induced by any of these cytokines in the UT-OC-3 ovarian cancer cell model.

Inhibitory effects of cytokines on ovarian and endometrial carcinoma cells in vitro with special reference to induction of specific transcriptional regulators

In the present study, we have investigated the effects of interferons-alpha (IFN-alpha) and -gamma (IFN-gamma), interleukin-10 (IL-10) and -13 (IL-13), transforming growth factor-beta1 (TGF-beta1), granulocyte-macrophage colony-stimulating factor (GM-CSF), and tumor necrosis factor-alpha (TNF-alpha) on cell proliferation and induction of transcription factors AP-1 and NF-kappaB in UM-EC-3 human endometrial adenocarcinoma cells and UT-OC-5 ovarian carcinoma cells in vitro. In addition, cellular DNA was extracted to study if any of these factors is able to induce apoptosis. In UM-EC-3 cell line DNA synthesis was inhibited by GM-CSF, IL-10, IL-13, TGF-beta1, IFN-alpha, and IFN-gamma after 48 and 72 h in culture, whereas TNF-alpha had no significant effect on cell proliferation in any of the experiments. The inhibition of DNA synthesis was similarly observed in UT-OC-5 ovarian carcinoma cells by IL-10, TNF-alpha, and IFN-gamma after 48 and 72 h, whereas IFN-alpha had no statistically significant effect. An inhibitory effect of GM-CSF was observed only after 48 h and TGF-beta after 72 h in culture, respectively. Transcription factors AP-1 and NF-kappaB were both constitutively active in UM-EC-3 and UT-OC-5 cells. The binding activity of AP-1 was found to be stimulated by all growth-inhibitory cytokines studied in both cell lines, whereas the specific binding activity of NF-kappaB was affected moderately only by TNF-alpha in UT-OC-5 ovarian carcinoma cells. No signs of DNA fragmentation typical of apoptosis were observed in any of these studies.

Ethics in health care management: developing an instrument to assess humane caring

The care of patients should be professional, human and humane. This is an ethical issue. The words human (inhimillinen) and humane (ihmisläheinen) have different meanings in the Finnish language. At Kuopio University Hospital (1200 beds), in Finland, it was decided to provide patients with professional and humane caring. Ethical values differ for different groups of people. Therefore humane caring was assessed by questioning both hospital patients (n = 160) and staff (n = 196). The data were subjected to content analysis. The result was that the values obtained for both patients and staff were similar. Five descriptive categories of humane caring emerged. To discover what kind of caring was provided for patients, the categories were operationalized into 66 criteria and a questionnaire was drawn up on the basis of these criteria. The data for evaluation of the quality of caring were collected from patients (n = 1708). The data were analysed using cross-tabulations and the chi-squared test; sum variables were calculated for the five standards. The results suggest that special attention should be paid to vulnerable patient groups (e.g. the elderly and the young). One means of ethical management is to support our staff to care more humanely by discussing with them the results of this study, setting standards and criteria for humane caring and what this means in practice. It is hoped our caring will therefore be more humane.

Hemodynamic control of atrial natriuretic peptide plasma levels in neonatal respiratory distress syndrome

To evaluate the contribution of the pulmonary and ductal hemodynamics on the cardiac atrial natriuretic peptide (ANP) synthesis and release in neonatal respiratory distress syndrome, serial blood samples for plasma C-terminal end, and the more stable N-terminal end (NT-proANP) of the propeptide were obtained. Simultaneous evaluation of the systolic pulmonary artery pressure (PAP) and magnitude of ductal shunting by the Doppler method were made of 37 distressed infants during the first 4 days of life. Both plasma ANP and NT-proANP rose after birth, peaked at 48 hours of age, and correlated significantly (r = 0.66; p < 0.001; n = 78) with each other. The initially high systolic PAP and, since the systemic arterial pressure (SAP) did not change, the PAP/SAP ratio declined slowly during the study period, as did the magnitude of ductal left-to-right shunting after an initial increase during the first hours after birth. Plasma NT-proANP had a positive correlation to the magnitude of ductal left-to-right shunting both during the first 2 and 4 days of life, but did not correlate with PAP, SAP, or PAP/SAP ratio during the same time periods. Eight infants with delayed closure of the ductus maintained elevated plasma NT-proANP values after the second day of life.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute effects of synthetic surfactant replacement on pulmonary blood flow in neonatal respiratory distress syndrome

To assess the acute effects of surfactant replacement therapy on the pulmonary blood flow in neonatal respiratory distress syndrome (RDS), 23 distressed infants were studied before and for 1 hour after either synthetic surfactant instillation (n = 13) or endotracheal suctioning (n = 10). Doppler ultrasound was used to measure blood flow velocity and flow velocity integral, representing volumetric flow, of the left pulmonary artery branch, ductal left-to-right shunt, and ascending aorta. Surfactant instillation increased the left pulmonary artery and ductal shunt flow velocity and flow velocity integral for 1 hour in 10 of 13 treated infants, whereas no change was found after endotracheal suctioning. There was a significant (P < 0.05) correlation between the changes in the pulmonary artery and ductal flow values at 1 hour after surfactant treatment. The mean increase during 1 hour after treatment in the pulmonary artery flow ranged from 15 to 25% and in the ductal left-to-right shunt from 28 to 33%. No change in the aortic flow or heart rate was found in either group. Our results thus suggest that synthetic surfactant therapy may acutely increase pulmonary blood flow and ductal left-to-right shunting in infants with RDS.

Pulmonary hemodynamics after synthetic surfactant replacement in neonatal respiratory distress syndrome

To evaluate the acute effects of surfactant replacement therapy on pulmonary circulation in neonatal respiratory distress syndrome, we studied 25 infants before and for 1 hour after either synthetic surfactant administration (n = 15) or endotracheal suctioning (n = 10). The noninvasive Doppler method was used to estimate systolic pulmonary artery pressure from tricuspid regurgitant flow velocity and to measure blood flow velocity of the left-to-right shunt through the ductus arteriosus. Pulmonary artery pressure decreased significantly within 15 minutes after surfactant administration and remained low throughout the study period, whereas suctioning did not change pulmonary artery pressure levels. No changes in systemic pressure were found in either group. Velocity of the ductal left-to-right shunting increased and remained elevated for 1 hour only in surfactant-treated infants. In addition, right-to-left ductal shunting disappeared in four infants after surfactant administration. Our data thus indicate that administration of synthetic surfactant to infants with respiratory distress syndrome reduces pulmonary vascular resistance, resulting in a decrease in pulmonary artery pressure and an increase in ductal flow velocity.

Magnetic fields produced by eye blinking

Magnetic signals produced by voluntary eye blinking were recorded. The maximal signals were found over the posterior parts of the orbits. The polarity of the signal reversed over each eye and in the frontal midline. The amplitude increases with light and amplitude decreases with darkness were similar in the electrical and magnetic blink and eye movement signals. Three different simulation models were used in the interpretation of the results. It is concluded that the primary current source of the blink signal is the transretinal current density. Lid movements change the geometry of the volume conductor resulting in changes in the measured electrical and magnetic field patterns.

Cerebral magnetic fields preceding self-paced plantar flexions of the foot

Cerebral magnetic fields preceding self-paced plantar flexions of the feet were studied with a SQUID gradiometer in 4 subjects. A slow magnetoencephalographic (MEG) shift was observed to begin as early as 1 sec before the movement. The shift changed its polarity between frontal and parietal areas. The MEG shifts preceding right and left foot movements were similar in shape, but their polarities differed at many recording locations. Simultaneous movements of both feet were preceded by shifts approximately equal to the sum of the shifts preceding the unilateral foot movements at the same recording location. The results suggest that the EEG and MEG shifts preceding foot movements are largely generated by tangential current sources on the mesial surface of the contralateral hemisphere around the motor representation area of the foot.