Seasonal patterns of sickness absence due to diagnosed mental disorders: a nationwide 12-year register linkage study

AIMS

Although seasonality has been documented for mental disorders, it is unknown whether similar patterns can be observed in employee sickness absence from work due to a wide range of mental disorders with different severity level, and to what extent the rate of change in light exposure plays a role. To address these limitations, we used daily based sickness absence records to examine seasonal patterns in employee sickness absence due to mental disorders.

METHODS

We used nationwide diagnosis-specific psychiatric sickness absence claims data from 2006 to 2017 for adult individuals aged 16-67 (n = 636,543 sickness absence episodes) in Finland, a high-latitude country with a profound variation in daylength. The smoothed time-series of the ratio of observed and expected (O/E) daily counts of episodes were estimated, adjusted for variation in all-cause sickness absence rates during the year.

RESULTS

Unipolar depressive disorders peaked in October-November and dipped in July, with similar associations in all forms of depression. Also, anxiety and non-organic sleep disorders peaked in October-November. Anxiety disorders dipped in January-February and in July-August, while non-organic sleep disorders dipped in April-August. Manic episodes reached a peak from March to July and dipped in September-November and in January-February. Seasonality was not dependent on the severity of the depressive disorder.

CONCLUSIONS

These results suggest a seasonal variation in sickness absence due to common mental disorders and bipolar disorder, with high peaks in depressive, anxiety and sleep disorders towards the end of the year and a peak in manic episodes starting in spring. Rapid changes in light exposure may contribute to sickness absence due to bipolar disorder. The findings can help clinicians and workplaces prepare for seasonal variations in healthcare needs.

Nurse understaffing and short work experience as predictors of healthcare-associated infections

Background

Healthcare-associated infections (HAIs) are a serious risk factor for hospital patients leading to more than 90 000 deaths each year in European countries. It has been evaluated that 7% of patients in European acute care hospitals acquire an HAI, and that a large part of cases could be prevented. Good hand hygiene is central in preventing HAIs, which may be compromised under high work pressure. The aim of this study was to analyse the associations between nurse understaffing and short work experience with the risk of HAIs at patient-level. Prior evidence on this topic remains inconclusive due to a reliance on imprecise measurement of these exposures.

Methods

We utilized administrative data on employees’ working hours and patient records from one hospital district in Finland from years 2013-2019. The data included in total 281,672 inpatient periods. We used mixed-effects survival analyses to predict the overall risk of HAIs, and four types of HAIs: bloodstream, Clostridium difficile, surgical-site and pneumonia. To consider the incubation time, exposure to nurse understaffing and short work experience were measured in preceding days in moving time windows when the patients were in the hospital.

Results

Preliminary results showed that exposure to nurse understaffing within two days, measured as low nursing hours relative to planned hours, was associated with increased risk of HAIs (hazard ratio was 1.23, 95% CI 1.05-1.45). Additional analyses showed that this risk was especially pronounced in surgical-site infections, which were also carefully monitored in the hospital district. We did not find associations between exposure to short work experience among nurses and HAI risk.

Conclusions

This study showed that nurse staffing below planned levels was associated with an increased overall risk of HAIs, particularly surgical-site infections, among patients. Adequate levels of nursing staff in hospitals may be important for preventing HAIs.

Key messages

Hospital nurse understaffing and short work experience: associations with mortality among patients

Background

Determining and maintaining optimal staffing level in hospitals is crucial, as understaffing may have serious consequences and even increase mortality risk among patients. There is no consensus, however, on the optimal way to determine staffing requirements in hospitals as patients’ care needs vary between wards and days. Nurse work experience may also affect quality of care and ultimately patients’ survival but research on this topic is scarce.

Methods

Administrative register data on patients (N = 254,308) and employees of 40 hospital units was used in one hospital district in Finland from years 2013-2019. Both nurse understaffing and nurse work experience were measured with two different indicators in each unit-day. Mixed-effects survival models were used to analyse the associations of these exposures with mortality at patient-level, when adjusted for patients’ characteristics, such as age, sex and comorbidities.

Results

Preliminary results showed that every one percent increase in the cumulative proportion of understaffed days - measured as low nursing hours relative to planned - was associated with 1.002-fold mortality risk among patients (95% CI, 1.000-1.004, p-value=0.044). Short work experience was not associated with increased risk of death.

Conclusions

This study supports previous findings on the associations between nurse understaffing and increased mortality risk among patients in Finland although no association with mortality was found for the other three staffing characteristics. However, the average daily shares of actualized nursing hours relative to planned hours were quite high in hospital units. An indicator based on actualized relative to planned working hours in routine administrative data could be useful in evaluating understaffing in hospitals.

Key messages

• Adequate level of nursing professional in hospitals is related to patient survival.

• It is also crucial of develop efficient ways to evaluate understaffing in hospitals.

Psychotherapy – A Sound Investments In (Mental) Health Capital?

Introduction

The concept of health capital views health as a form of capital that produces healthy time to individual. This stock of capital - health that is - can decrease or increase. The potential of psychotherapy as individual's investment to (mental) health capital has been rarely studied in population level.

Objectives

The aim of our study is to shed light on the returns on individual-level investments in health capital. We consider the use of psychotherapy as an investment in health capital. This investment offers potential returns for individual as a higher level of subsequent income. However, these returns are potentially heterogenous: we aim to show to whom the use of psychotherapy is a sound investment in health capital.

Methods

We model the effects of mental health, and subsequent treatments such as the use of psychotropics and psychotherapy on income using two-way fixed effects regression.

Results

Preliminary results show that different parts of working-age population seem to have different potential returns related to the use of psychotherapy. These heterogenous effects are related to previously reported socioeconomic status related disparities: the level of human capital i.e. income and education play a role in the profitability of the individual level investment made in the health capital by the use of psychotherapy.

Conclusions

The use of psychotherapy has heterogenous effects on the income of individuals. The potential of this investment to produce health capital varies with education, the level of income prior to the use of psychotherapy.

Assessing Cut-off Points of Eosinophils, Nasal Polyp, and Lund-Mackay Scores to Predict Surgery in Nasal Polyposis: A Real-World Study

Background

Developing tools to identify chronic rhinosinusitis with nasal polyps (CRSwNP) patients requiring surgical treatment would help clinicians treat patients more effectively. The aim of this retrospective cross-sectional study was to identify cut-off values ​​for eosinophil percentage, nasal polyps (NP), and Lund-Mackay (LM) scores that may predict the need for surgical treatment in Finnish CRSwNP patients.

Methods

Data of CRSwNP patients (N = 378) undergoing consultation for ESS in 2001–19 were used. Data was collected from patient records and Lund-Mackay scores were determined from sinus computed tomography scans. The percentage of eosinophils was microscopically evaluated from the polyp samples available (n = 81). Associations were analyzed by Mann Whitney U test, and cut-off values by the area under the receiver operating characteristic curve (AUROC).

Results

ESS was performed to 293 (77.5%) of patients. Polyp eosinophilia was associated significantly with ESS (p = 0.001), whereas peripheral blood eosinophil count, LM- score and endoscopic NP- score were not (p > 0.05). AUROC values (95% CI) for detecting those needing ESS were for polyp eosinophilia 0.71 (0.60–0.83), p = 0.001, for LM score 0.59 (0.50–0.67), p = 0.054; for NP score 0.56 (0.48–0.64), p = 0.17, and for blood eosinophil count 0.68 (0.46–0.90), p = 0.08. With the threshold value of polyp eosinophilia (>25%), the sensitivity and specificity were optimal for detecting the group needing ESS from the group not undergoing ESS. The cut-off value of blood eosinophil count (>0.26 × 10⁹/L) had relatively good, yet statistically insignificant (underpowered), predictive potential. Moderate cut-off values were found for endoscopic LM score (≥14/24) and NP score (≥4/8).

Conclusions

Polyp eosinophilia (>25%) predicted ESS among Finnish hospital-level CRSwNP patients. A future challenge would be to find less invasive and cost-effective clinical factors predicting uncontrolled CRSwNP.

Age-group differences in associations of working hour characteristics and short sickness absences

Background

Working-hour characteristics are linked to disturbed sleep, but little is known about their association with short sickness absences (SA). We investigated the association between working hour characteristics in shift work and the incidence of short (1-3 days) SA in three age groups.

Methods

The data was from the hospitals’ electronic working time records. The final sample was restricted to the first incidence of short SA (1-3 days) from 2008 to 2015 and to shift working employees (n = 12156, 89% women). Age groups were < 35 (n = 5652), 35-49 (n = 3592) and ≤ 50 years (n = 2545). Work shifts (morning, day, evening, and night), quick returns (< 11 hours between two work shifts), length of work shift and weekly working time were calculated for case-crossover study design to compare the working hour characteristics of the 28 days preceding SA (exposure window) and those of the 28 days before the exposure window (control window). Conditional logistic regression models were run for odds ratios (OR) with 95% Confidence Intervals (95%CI).

Results

Working hour characteristics, especially length of working hours, played the clearest role among those < 35 years of age. In this age group, exposure to > 25% of > 40 weekly working hours associated with an increased likelihood of short SA (OR 1.30, 95%CI 1.17-1.44), whereas weekly working hours had OR 1.02 (95%CI 1.02-1.03). Having only a few (≤ 4) quick returns decreased the likelihood of SA (ORs 0.31-0.54), whereas having ≥25 quick returns increased it (OR 2.75, 95%CI 2.44-3.11). The results showed mostly similar trends among those of 35-49 years of age whereas among older workers (≤ 50 years) only an association for quick returns was observed.

Conclusions

Long working hours increase the risk of short SA among those ≤ 49 years of age and several quick returns among all age groups. These working-hour characteristics should be avoided to minimize SA and increased costs for the employer, but also to maintain public health.

Key messages

Unhealthy working-hour characteristics should be paid special attention in shift scheduling to avoid sickness absence. Good shift scheduling could assist in maintaining workability and therefore public health.

Labor market outcomes before and after first episode of part-time sickness absence

Background

Previous research suggests that part-time sickness absence (PTSA) results in better work participation compared to full-time sickness absence (FTSA), but few studies have examined trends in FTSA and unemployment before and after PTSA.

Methods

This Finnish population-based cohort study included 3406 individuals with first episode (>30 days) of PTSA in 2011 (=PTSA group), 42 510 individuals with FTSA (>30 days) in 2011 (=FTSA group), and 25 167 individuals with no sickness absence (>30 days) in 2011 from the general working-age population. Annual days of FTSA from 2007 to 2015 and unemployment from 2012 to 2015 were measured for the participants of each group. We modeled trends and relative risks for these labor market outcomes using negative binomial regression with generalized estimation equations.

Results

For the PTSA group, the adjusted mean annual number of FTSA days was 3 in the beginning of the follow-up, 15 a year before the index year, and 8-10 after the index year. The adjusted risk ratio (RR) of FTSA days after versus before PTSA was 1.95 (95% CI 1.75-2.17). For the FTSA group, mean of sickness absence days was 4 in the beginning, 13 a year before the index year and 9-19 after the index year. The mean of FTSA was 1-2 throughout the follow-up in the general population. An increasing slope in unemployment after the index year was observed in all groups, the absolute level of unemployment being highest among FTSA group and lowest among the general population group.

Conclusions

Long-term PTSA marks a decline in labour market participation. In absolute terms this decline is smaller than that in employees with long-term FTSA.

Key messages

Part-time sickness absence lasting >30 days marked an increase in full-time sickness absence although the absence levels did not reach those observed after full-time sickness absence of > 30 days. Our results show smaller impairment in labour market outcomes in employees granted a long-term part-time sickness absence than in those with long-term full-time sickness absence.

Central injection of oxytocin reduces food intake and affects hypothalamic and adipose tissue gene expression in chickens

Oxytocin (OT) is a well-characterized neurotransmitter that participates in a wide range of physiological processes including the inhibition of food intake. The avian ortholog, mesotocin (MT), differs from OT by a single amino acid. Little is known regarding the function of OT in regulating energy balance in birds; thus, this study was designed to determine the effects of central OT injection on food intake and adipose tissue physiology in chicks. At 4-d post-hatch, broiler chicks were fasted for 3 h and injected intracerebroventricularly with 0 (vehicle), 0.63, 2.5, 5.0, or 10 nmol OT. Oxytocin decreased food and water intake during the entire 180-min observation period. The reduction in water intake was likely not prandial because chicks that were food restricted after OT injection also drank less. There was increased c-Fos immunoreactivity in several appetite-associated hypothalamic nuclei in OT-injected chicks at 1 h, including the arcuate (ARC), dorsomedial nucleus (DMN), lateral hypothalamus (LH), paraventricular nucleus (PVN), and ventromedial hypothalamus (VMH). OT treatment was associated with reduced hypothalamic corticotropin-releasing factor (CRF) mRNA and increased cloacal temperature at 1 h post-injection. We then investigated appetite- and adipose tissue-associated effects of OT in chicks from lines that have undergone long-term selection for either low (LWS) or high (HWS) juvenile body weight. Central injection of OT decreased food intake in both lines with the magnitude of response greater in the HWS than LWS chicks. Adipose tissue abundance of fatty acid-binding protein 4, monoglyceride lipase (MGLL), MT, and perilipin-1 mRNA was greater in LWS than HWS chicks. Lipoprotein lipase, MGLL, and MT mRNAs increased in response to OT injection in LWS but not HWS chicks. In conclusion, central injection of OT induced anorexia, reduced water intake, increased body temperature, and was associated with activation of the ARC, DMN, LH, PVN, and VMH in the hypothalamus. The effects on appetite and body temperature may involve CRF signaling in the hypothalamus and lipolysis in the adipose tissue, respectively. There were differences in the appetite, and adipose tissue response to OT in body weight-selected lines of chicks supports that MT plays a role in energy balance regulation in chickens.

Diagnostic Accuracy of Symptoms, Endoscopy, and Imaging Signs of Chronic Rhinosinusitis Without Nasal Polyps Compared to Allergic Rhinitis

Objectives The diagnosis of chronic rhinosinusitis without nasal polyps (CRSsNP) and distinguishing it from allergic rhinitis is difficult. Yet, early detection of CRSsNP is important to prevent progressive and severe chronic rhinosinusitis. Our aim was to compare diagnostic accuracy of symptoms, endoscopy, and imaging signs of CRSsNP and allergic rhinitis -only phenotypes. Setting Prospective controlled follow-up study. Participants Forty-two nonsmoking patients visiting tertiary care due to CRSsNP and 19 nonsmoking volunteer controls with allergic rhinitis filled a symptoms questionnaire and underwent nasal endoscopy off-seasonally. All CRSsNP patients underwent computed tomography scans of paranasal sinuses. All the allergic rhinitis control subjects and 14 of the CRSsNP patients underwent sinus magnetic resonance imaging. Results Radiologic Lund-Mackay score, duration of symptoms, visual analogue scale scores of symptoms, and Sinonasal Outcome Test 22 were significantly higher in the CRSsNP group compared to allergic rhinitis control group. These factors also correlated in part with each other. Endoscopic score did not correlate with other factors, nor did it differ between CRSsNP and allergic rhinitis groups. The highest area under curve value was demonstrated for visual analogue scale score of facial pain/pressure (0.93) and score ≥4/10 showed 60% sensitivity and 95% specificity for detecting CRSsNP group ( P < .001). Radiologic sign of obstructed osteomeatal complex showed 100% specificity and 38% sensitivity for detecting CRSsNP group ( P < .001). Conclusions CRSsNP phenotype could be primarily distinguished from allergic rhinitis by higher facial pain/pressure score and secondarily by radiologic sings of obstructed ostiomeatal complex and higher Lund-Mackay score. Endoscopic score has limited value in distinguishing CRSsNP from allergic rhinitis.

Gestational hyperglycemia reprograms cardiac gene expression in rat offspring

BackgroundRat fetuses with maternal pregestational hyperglycemia develop cardiac dysfunction, and their cardiac gene expression differs from that of healthy control fetuses near term. We hypothesized that cardiac gene expression and morphologic abnormalities of rat fetuses with maternal pregestational hyperglycemia become normal after birth.MethodsNine rats were preconceptually injected with streptozotocin to induce maternal hyperglycemia and nine rats served as controls. The hyperglycemia group comprised 82 mice and the control group 74 offspring fed by euglycemic dams. Hearts of the offspring were collected on postnatal days 0, 7, and 14, and processed for histologic and gene expression analyses.ResultsOn day 0, heart weight was increased, and expression of cardiac genes involved in contractility, growth, and metabolism was decreased in the hyperglycemia group. On day 7, although cardiomyocyte apoptosis was enhanced, most of the changes in gene expression had normalized in the hyperglycemia group. By day 14, the expression of genes important for myocardial growth, function, and metabolism was again abnormal in the hyperglycemia group.ConclusionMost cardiac gene expression abnormalities become transiently normal during the first week of life of offspring to hyperglycemic rats. However, by day 14, cardiac expressions of genes involved in growth, function, and metabolism are again abnormal in relation to control offspring.

Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data

BACKGROUND

Adverse psychosocial working environments characterized by job strain (the combination of high demands and low control at work) are associated with an increased risk of depressive symptoms among employees, but evidence on clinically diagnosed depression is scarce. We examined job strain as a risk factor for clinical depression.

METHOD

We identified published cohort studies from a systematic literature search in PubMed and PsycNET and obtained 14 cohort studies with unpublished individual-level data from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium. Summary estimates of the association were obtained using random-effects models. Individual-level data analyses were based on a pre-published study protocol.

RESULTS

We included six published studies with a total of 27 461 individuals and 914 incident cases of clinical depression. From unpublished datasets we included 120 221 individuals and 982 first episodes of hospital-treated clinical depression. Job strain was associated with an increased risk of clinical depression in both published [relative risk (RR) = 1.77, 95% confidence interval (CI) 1.47-2.13] and unpublished datasets (RR = 1.27, 95% CI 1.04-1.55). Further individual participant analyses showed a similar association across sociodemographic subgroups and after excluding individuals with baseline somatic disease. The association was unchanged when excluding individuals with baseline depressive symptoms (RR = 1.25, 95% CI 0.94-1.65), but attenuated on adjustment for a continuous depressive symptoms score (RR = 1.03, 95% CI 0.81-1.32).

CONCLUSIONS

Job strain may precipitate clinical depression among employees. Future intervention studies should test whether job strain is a modifiable risk factor for depression.

Maternal diabetes induces changes in the umbilical cord gene expression

INTRODUCTION

Since maternal diabetes may affect fetal development and the umbilical cord provides an extension of the fetal vasculature, we decided to investigate cords' biological responses to maternal diabetic milieu.

METHODS

Using microarray analysis, we determined the gene expression profiles in the umbilical cords of six neonates born to type 1 diabetic mothers and in six control cords. Umbilical cord tissue was collected immediately after elective cesarean section. Expression data were confirmed by real-time polymerase chain reaction (11 genes). Additionally, the same umbilical cords were analyzed histologically.

RESULTS

Two hundred eighty six genes were differentially expressed in the umbilical cords from diabetic pregnancies compared to the controls (fold change ±1.5 and P < 0.01). Maternal diabetes had a major effect on the expression of genes involved in vascular development (Bone morphogenetic protein 4, Delta-like 1, and Notch homolog 4), vessel wall integrity (Collagen type VIII alpha 1, Myocyte enhancer factor 2C, and Matrix metalloproteinase 2), and vascular function (Natriuretic peptide precursor B, Endothelin 1, Endothelin receptor B, Cyclooxygenase 1, and Phosphodiesterase 5A). Maternal diabetes was associated with thicker umbilical vein intima-media layers and larger umbilical vein and artery intima-media areas compared to the controls.

DISCUSSION

Maternal diabetic environment seems to alter umbilical cord expression of genes involved in the regulation of vascular development and function with simultaneous umbilical vessel muscle layer thickening. These alterations suggest vascular phenotypic modifications, which in turn may lead to long-term vascular consequences in various tissues in infants of diabetic mothers.

Job strain and the risk of severe asthma exacerbations: a meta-analysis of individual-participant data from 100 000 European men and women

Background

Many patients and healthcare professionals believe that work‐related psychosocial stress, such as job strain, can make asthma worse, but this is not corroborated by empirical evidence. We investigated the associations between job strain and the incidence of severe asthma exacerbations in working‐age European men and women.

Methods

We analysed individual‐level data, collected between 1985 and 2010, from 102 175 working‐age men and women in 11 prospective European studies. Job strain (a combination of high demands and low control at work) was self‐reported at baseline. Incident severe asthma exacerbations were ascertained from national hospitalization and death registries. Associations between job strain and asthma exacerbations were modelled using Cox regression and the study‐specific findings combined using random‐effects meta‐analyses.

Results

During a median follow‐up of 10 years, 1 109 individuals experienced a severe asthma exacerbation (430 with asthma as the primary diagnostic code). In the age‐ and sex‐adjusted analyses, job strain was associated with an increased risk of severe asthma exacerbations defined using the primary diagnostic code (hazard ratio, HR: 1.27, 95% confidence interval, CI: 1.00, 1.61). This association attenuated towards the null after adjustment for potential confounders (HR: 1.22, 95% CI: 0.96, 1.55). No association was observed in the analyses with asthma defined using any diagnostic code (HR: 1.01, 95% CI: 0.86, 1.19).

Conclusions

Our findings suggest that job strain is probably not an important risk factor for severe asthma exacerbations leading to hospitalization or death.

Resistin as a factor in osteoarthritis: synovial fluid resistin concentrations correlate positively with interleukin 6 and matrix metalloproteinases MMP-1 and MMP-3

OBJECTIVES

Resistin is an adipocytokine that has been related to inflammation and insulin resistance. Following knee injury, elevated levels of resistin have been found in synovial fluid (SF) while very little is known about the role of resistin in osteoarthritis (OA). The aim of the present study was to investigate resistin levels in OA joints and to determine if it is associated with inflammatory and catabolic factors in the joints.

METHOD

SF, plasma, and cartilage samples were collected from 88 OA patients undergoing knee replacement surgery. Resistin levels were measured by enzyme-linked immunosorbent assay (ELISA) in SF, plasma, and cartilage culture media.

RESULTS

Significant levels of resistin [0.75 (0.67) ng/mL; median (IQR)] were found in SF from OA patients. Resistin correlated positively with interleukin (IL)-6 (r = 0.39, p < 0.001) and with matrix metalloproteinases MMP-1 (r = 0.31, p = 0.004) and MMP-3 (r = 0.24, p = 0.024) in SF. Resistin was also released from cultured OA cartilage and it correlated with resistin levels in SF (r = 0.39, p < 0.001). In addition, resistin levels in plasma correlated positively with those in SF (r = 0.44, p < 0.001). There were no differences in SF or plasma resistin concentrations between females and males or between non-diabetic and diabetic patients, and resistin did not correlate with body mass index (BMI).

CONCLUSIONS

Resistin is present in OA joints and is released from OA cartilage. Levels of resistin in SF are associated with inflammatory and catabolic factors, suggesting that resistin has a role to play in the pathogenesis of, and as a possible drug target in, OA.

Delay in rat lung alveolarization after the combined exposure of maternal hyperglycemia and postnatal hyperoxia

BACKGROUND

Maternal diabetes interferes with fetal lung development and postnatal treatments may further disturb pulmonary growth. Therefore, we investigated the effect of postnatal oxygen exposure on alveolar development in neonatal rat lungs pre-exposed to intrauterine hyperglycemia.

METHODS

Diabetes was induced in Sprague-Dawley rats with streptozotocin injection before pregnancy. Hyperglycemia-exposed and control litters were randomized to breath room air or 85% oxygen for 7 days after birth. Lungs were analyzed on postnatal d7 for weight, morphology, apoptosis, proliferation, and biomarkers of oxidative stress.

RESULTS

Maternal hyperglycemia accelerated lung development as demonstrated by thinner alveolar walls and slightly increased secondary septation when compared to room air bred rats. Hyperoxia alone caused thin-walled and enlarged alveoli with few secondary septa. Interestingly, the dual exposure inhibited the thinning of alveolar walls and the disappearance of mesenchymal cells from the alveolar walls together with the delay in the formation of alveoli and secondary crests. While the lungs' oxidative stress was similar in all groups, pulmonary apoptosis and proliferation were altered.

CONCLUSION

Our results thus indicate that the hyperglycemic priming of the fetal lung modifies the deleterious effect of hyperoxia on alveolarization in neonatal rats.

Maternal hyperglycemia leads to fetal cardiac hyperplasia and dysfunction in a rat model

Accelerated fetal myocardial growth with altered cardiac function is a well-documented complication of human diabetic pregnancy, but its pathophysiology is still largely unknown. Our aim was to explore the mechanisms of fetal cardiac remodeling and cardiovascular hemodynamics in a rat model of maternal pregestational streptozotocin-induced hyperglycemia. The hyperglycemic group comprised 107 fetuses (10 dams) and the control group 219 fetuses (20 dams). Fetal cardiac function was assessed serially by Doppler ultrasonography. Fetal cardiac to thoracic area ratio, newborn heart weight, myocardial cell proliferative and apoptotic activities, and cardiac gene expression patterns were determined. Maternal hyperglycemia was associated with increased cardiac size, proliferative, apoptotic and mitotic activities, upregulation of genes encoding A- and B-type natriuretic peptides, myosin heavy chain types 2 and 3, uncoupling proteins 2 and 3, and the angiogenetic tumor necrosis factor receptor superfamily member 12A. The genes encoding Kv channel-interacting protein 2, a regulator of electrical cardiac phenotype, and the insulin-regulated glucose transporter 4 were downregulated. The heart rate was lower in fetuses of hyperglycemic dams. At 13-14 gestational days, 98% of fetuses of hyperglycemic dams had holosystolic atrioventricular valve regurgitation and decreased outflow mean velocity, indicating diminished cardiac output. Maternal hyperglycemia may lead to accelerated fetal myocardial growth by cardiomyocyte hyperplasia. In fetuses of hyperglycemic dams, expression of key genes that control and regulate cardiomyocyte electrophysiological properties, contractility, and metabolism are altered and may lead to major functional and clinical implications on the fetal heart.

Sensitization to Malassezia in children with atopic dermatitis combined with food allergy

BACKGROUND

The yeast Malassezia belongs to our normal cutaneous flora, but is capable of sensitizing individuals with atopic dermatitis (AD). Our objective was to investigate the prevalence of sensitization to Malassezia with a 10-yr follow-up among children suffering from AD combined with food allergy (FA) in relation to the extent of AD in infancy.

METHODS

One hundred and eighty seven infants diagnosed with AD and milk/wheat allergy before 1 yr of age were included in the study. The area of AD was estimated from patient records of the first visit and measured with SCORAD at the 10-yr follow-up. Specific IgE against Malassezia was determined with ImmunoCAP™ at 11 yr of age.

RESULTS

In infancy, 24 children (13%) were allergic to milk, 71 (38%) to wheat, and 92 (49%) to both milk and wheat, and 94 (50%) children had mild, 57 (30%) moderate and 36 (19%) severe AD. At the 10-yr follow-up visit, 19 (10%) of the children had ongoing milk and/or wheat allergy; 147 children (79%) had mild AD and 30 (16%) had SCORAD index of 0. Specific IgE against Malassezia mix was positive (≥0.35 kU/l) in 27% and specific IgE against M. sympodialis in 20% of the 187 children. The area of AD in infancy was associated with a greater risk of having allergen-specific IgE to Malassezia at the 10-yr follow-up. The risk ratio for FA was 3.11 (95% CI: 2.05-4.72; p < 0.001) if specific IgE to Malassezia was positive.

CONCLUSIONS

Infants with severe AD and FA seem to have a greater risk of becoming sensitized to Malassezia during a 10-yr follow-up.

Fetal hyperglycemia alters lung structural development in neonatal rat

Maternal diabetes is associated with increased risk for abnormal fetal organogenesis, but its effects on the developing lungs are still insufficiently known. To determine the effect of maternal hyperglycemia on postnatal lung development, we studied lung structural and cellular changes in newborn rats exposed to intrauterine hyperglycemia. We induced hyperglycemia in Sprague-Dawley rats with i.p. streptozotocin before pregnancy and allowed the hyperglycemic and control dams deliver at term. Lungs were obtained on postnatal day (d) 0, d7, and d14 and analyzed for lung weight and morphology, as well as cellular apoptosis (TUNEL staining) and proliferation (PCNA staining). Quantitative micro-CT analysis of the lung vasculature was additionally performed at d14. At birth, maternal hyperglycemia resulted in decreased relative lung weight, thinner alveolar septa and increased cellular apoptosis and proliferation, when compared to controls. At 1 and 2 weeks of age pulmonary cell apoptosis and alveolar chord length remained unchanged, but cell proliferation and number of secondary crests were increased in the hyperglycemia-exposed neonatal lungs in comparison with the controls. Density of small arterioles on histological examination and the structure of pulmonary arterial vasculature in micro-CT analysis of the neonatal lungs were not influenced by maternal hyperglycemia. Our results suggest, that maternal hyperglycemia is related to developmental structural alterations in postnatal rat lungs. These early changes may reflect aberrant maturational adaptation in response to the hyperglycemic fetal environment.

Adiponectin associates with markers of cartilage degradation in osteoarthritis and induces production of proinflammatory and catabolic factors through mitogen-activated protein kinase pathways

Introduction

Adiponectin is an adipokine that regulates energy metabolism and insulin sensitivity, but recent studies have pointed also to a role in inflammation and arthritis. The purpose of the present study was to investigate the association and effects of adiponectin on inflammation and cartilage destruction in osteoarthritis (OA).

Methods

Cartilage and blood samples were collected from 35 male OA patients undergoing total knee replacement surgery. Preoperative radiographs were evaluated using Ahlbäck classification criteria for knee OA. Circulating concentrations of adiponectin and biomarkers of OA, that is, cartilage oligomeric matrix protein (COMP) and matrix metalloproteinase 3 (MMP-3), were measured. Cartilage samples obtained at the time of surgery were cultured ex vivo, and the levels of adiponectin, nitric oxide (NO), IL-6, MMP-1 and MMP-3 were determined in the culture media. In addition, the effects of adiponectin on the production of NO, IL-6, MMP-1 and MMP-3 were studied in cartilage and in primary chondrocyte cultures.

Results

Plasma adiponectin levels and adiponectin released from OA cartilage were higher in patients with the radiologically most severe OA (Ahlbäck grades 4 and 5) than in patients with less severe disease (Ahlbäck grades 1 to 3). Plasma adiponectin concentrations correlated positively with biomarkers of OA, that is, COMP (r = 0.55, P = 0.001) and MMP-3 (r = 0.34, P = 0.046). Adiponectin was released by OA cartilage ex vivo, and it correlated positively with production of NO (r = 0.43, P = 0.012), IL-6 (r = 0.42, P = 0.018) and MMP-3 (r = 0.34, P = 0.051). Furthermore, adiponectin enhanced production of NO, IL-6, MMP-1 and MMP-3 in OA cartilage and in primary chondrocytes in vitro in a mitogen-activated protein kinase (MAPK)-dependent manner.

Conclusions

The findings of this study show that adiponectin is associated with, and possibly mediates, cartilage destruction in OA.

Antibody responses to tetanus and diphtheria vaccine in chronic and recurrent rhinosinusitis

OBJECTIVES: Chronic rhinosinusitis may be accompanied by impaired immunity despite normal levels of serum immunoglobulins. Immune responses in sinusitis patients have previously been evaluated using polysaccharide vaccines. Our AIM was to assess the immune status by evaluating responses to diphtheria and tetanus vaccine. METHODS: Specific antibodies were measured before and 2 weeks after vaccination in 25 patients with chronic or recurrent sinusitis and in 30 healthy individuals. The mean age of the patients was 46 years and that of healthy controls 43 years. RESULTS: After vaccination the patients had on average 4.08-fold lower responses to diphtheria toxoid and 2.20-fold lower responses to tetanus than the controls. Fourteen out of 25 patients had antibody levels that did not reach the 95% normal distribution range of healthy controls after either diphtheria or tetanus vaccination. All the patients had normal levels of serum immunoglobulins. CONCLUSIONS: A significant proportion of patients with persisting symptoms of rhinosinisitis may have impaired responses to protein vaccines. Responses to protein vaccines may be used to evaluate immune function of sinusitis patients.

Leptin enhances MMP-1, MMP-3 and MMP-13 production in human osteoarthritic cartilage and correlates with MMP-1 and MMP-3 in synovial fluid from OA patients

OBJECTIVES

In the present study, we investigated the role of adipocytokine leptin in the pathogenesis of osteoarthritis (OA) by measuring its effects on matrix metalloproteinase (MMP) production in human OA cartilage. In addition, the correlations between leptin and MMP concentrations in synovial fluid from OA patients were studied.

METHODS

Cartilage tissue obtained from leftover pieces of total knee replacement surgery from patients with OA was used in the experiments. Production of collagenases MMP-1, MMP-8 and MMP-13, and stromelysin-1 (MMP-3) in the cartilage was measured by immunoassay and the signalling pathways were explored by pharmacological means. In addition, synovial fluid samples were collected from 84 OA patients undergoing knee replacement surgery. The concentrations of leptin and MMPs in synovial fluid were measured by immunoassay.

RESULTS

Leptin alone and in combination with IL-1β enhanced production of MMP-1, MMP-3, and MMP-13 in human OA cartilage, while MMP-8 concentrations remained undetectable. The effects of leptin on MMP-1, MMP-3 and MMP-13 production were mediated through transcription factor NF-κβ, and through protein kinase C and MAP kinase pathways. Interestingly, leptin concentrations in synovial fluid from OA patients correlated positively with MMP-3 (r=0.51, p<0.001) and MMP-1 (r=0.41, p<0.001) levels.

CONCLUSIONS

To our knowledge, this is the first study to show that leptin up-regulates MMP-1 and MMP-3 production in human OA cartilage and correlates positively to MMP-1 and MMP-3 in synovial fluid from OA patients. The findings suggest that leptin has catabolic effects in OA joints by increasing MMP production in cartilage.

Maternal hyperglycemia modifies extracellular matrix signaling pathways in neonatal rat lung

BACKGROUND

Maternal diabetes is associated with numerous adverse effects in fetal and neonatal organs, including the lungs.

OBJECTIVE

To investigate the effects of intrauterine hyperglycemia on neonatal lung biological signaling, we performed a microarray analysis in the lungs of four 14-day-old rat pups born to a hyperglycemic dam and in four age mate control pup lungs.

METHODS

Total RNA was isolated and cDNA was hybridized to the Illumina Sentrix® RatRef-12 BeadChip. A total of 22,000 genes were analyzed for expression profiles and functional gene clustering. Ten selected genes differentially expressed in microarray were additionally analyzed by the real-time polymerase chain reaction.

RESULTS

Two hundred twenty-seven genes were differentially expressed in neonatal rat lungs exposed to intrauterine hyperglycemia when compared to normoglycemic controls (fold change > 1.2, p < 0.001). Functional clustering analysis revealed increased expression in signaling pathways involved with extracellular matrix regulation. The most significantly downregulated functions were cell proliferation, extracellular region, cell adhesion and reactive oxygen species metabolism.

CONCLUSION

We found significant hyperglycemia-induced gene expression alterations in neonatal rat pulmonary tissue which may interfere with lung growth and biological signaling pathways.

Occupational burnout and chronic work disability: an eight-year cohort study on pensioning among Finnish forest industry workers

BACKGROUND

The objective was to explore if burnout, a syndrome from chronic work stress, predicts work disability during eight years among industrial employees. We investigated whether burnout would predict disability in initially healthy employees and all subgroups by the most common causes for disability.

METHODS

Of the participants in a company-wide survey (n=9705, 63%) performed in 1996, 8371 employees were identified and 7810 provided full information. The impact of burnout and its sub-dimensions, assessed with the Maslach Burnout Inventory-General Survey, on being granted register-based new disability pension till 2004 was analysed with Cox hazard regression and multinomial regression. The analyses were adjusted for socio-demographic factors, registered medication use, and self-reported chronic illness at baseline.

RESULTS

The hazard ratio (HR) for new disability pension was 3.8 (95% confidence interval CI 2.7-5.4) with severe burnout. The risk of severe burnout and severe exhaustion for work disability attenuated but remained significant after adjustments. The association between severe burnout and work disability was significant also in the subpopulation of employees without registered medication at baseline but not among employees healthy by self-report. Crude associations between burnout and all categories of cause-specific disability were significant. The exhaustion dimension predicted work disability due to mental and miscellaneous disorders after adjustments.

LIMITATIONS

A non-random one-branch sample was used. The final sample covered 50% of eligible employees.

CONCLUSIONS

In industrial work, burnout-related chronic work disability is general in nature. Burnout predicts work disability among healthy employees when health is assessed with registered use of medication but not when it is determined by self-report.

Job strain as a predictor of disability pension: the Finnish Public Sector Study

OBJECTIVE

To examine whether high job strain (a combination of high job demands and low job control) is a risk factor for disability pension.

SETTING

Ten municipalities and 21 hospitals in Finland.

DESIGN AND PARTICIPANTS

A prospective cohort study of 20 386 female and 4 764 male Finnish public sector employees aged 19-50 using data from two surveys (baseline in 2000-2 and follow-up in 2005) and employers' registers. In addition to self-reported job strain, we computed work unit-aggregated job strain for each participant (the average of scores of all workers of participant's work unit except the participant him/herself).

MAIN RESULTS

93 employees (0.4%) retired because of disability during the follow-up. In multilevel logistic regression analysis adjusted for demographic characteristics and health risk behaviour, odds for disability pension was 2.60 (95% CI 1.26 to 5.34) times higher for employees with high self-assessed job strain than for those with low self-assessed job strain at baseline. The corresponding OR for passive job versus low job strain was 2.82 (95% CI 1.34 to 5.96). Analysis of work unit-aggregated scores replicated the association for high job strain, OR 2.25 (95% CI 1.17 to 4.35), but not that for passive job. The association between work unit job strain and disability pension remained significant after further adjustment for prevalent diseases, psychological distress and perceived health status.

CONCLUSIONS

Job strain is associated with risk of subsequent disability pension. If causal, this association suggests that organisational interventions to reduce job strain may also reduce early exit from work.

Successful liver-kidney transplantation in two children with aHUS caused by a mutation in complement factor H

A 12-month-old boy and his 16-year-old aunt became acutely ill 6 months apart and were diagnosed to have atypical hemolytic uremic syndrome (aHUS). Genetic analysis revealed heterozygous R1215Q mutation in complement factor H (CFH) in both patients. The same mutation was found in five healthy adult relatives indicating incomplete penetrance of the disease. The patients developed terminal renal failure and experienced reversible neurological symptoms in spite of plasma exchange (PE) therapy. In both cases, liver-kidney transplantation was successfully performed 6 months after the onset of the disease. To minimize complement activation and prevent thrombotic microangiopathy or overt thrombotic events due to the malfunctioning CFH, extensive PE with fresh frozen plasma was performed pre- and perioperatively and anticoagulation was started a few hours after the operation. No circulatory complications appeared and all four grafts started to function immediately. Also, no recurrence or other major clinical setbacks have appeared during the postoperative follow-up (15 and 9 months) and the grafts show excellent function. While more experience is needed, it seems that liver-kidney transplantation combined with pre- and perioperative PE is a rational option in the management of patients with aHUS caused by CFH mutation.

Effects of homeopathic treatment on salivary flow rate and subjective symptoms in patients with oral dryness: a randomized trial

Twenty-eight patients with xerostomia participated in a blind, placebo-controlled longitudinal study of the possible effects of homeopathic medicines on oral discomfort. All patients were first divided in two groups according to their medication. After that the two groups were randomly assigned according to a coin-toss to the experimental or control group. Most patients had systemic diseases, such as rheumatoid arthritis and/or Sjögren's syndrome, and frequent daily medications. The randomly selected experimental group (n=15) got an individually prescribed homeopathic medicine and the control group (n=13) a placebo substance (sugar granules), both for 6 weeks. Neither group knew of the nature of the medicine. Oral dryness was evaluated by measurement of unstimulated and wax-stimulated salivary flow rates and visual analogue scale. With only two exceptions, the experimental group experienced a significant relief of xerostomia whereas no such effect was found in the placebo group. Stimulated salivary flow rate was slightly higher with homeopathy than placebo but no consistent changes occurred in salivary immunoglobulin (IgA, IgG) levels. In an open follow-up period those receiving homeopathic medicine continued treatment and the placebo group patients were treated with individually prescribed homeopathic medicines. The symptoms of xerostomia improved in both groups. Our results suggest that individually prescribed homeopathic medicine could be a valuable adjunct to the treatment of oral discomfort and xerostomic symptoms.

Effect of adjuvant androgen deprivation on thyroid function tests in prostate cancer patients

Androgen deprivation (AD) used in the treatment of prostate cancer is known to alter concentrations of sex hormones and their binding globulins. Less is known as to its effect on thyroid hormones. In this prospective study the effects of AD on thyroid function were clarified. Levels of serum thyroid stimulating hormone (TSH), free thyroxine (FT4) and thyroid binding globulin concentrations were measured in prostate cancer patients treated with either radical radiotherapy and androgen deprivation for 12 months (AD) or radical radiotherapy alone (RT). Measurements were made at baseline, and at 3, 6 and 12 months. At baseline and at 3 months the results of thyroid function tests did not differ significantly between groups. A significant decline in serum testosterone in the AD group was accompanied by a significant decline in FT4 at 6 and 12 months, while no significant changes in thyroid function were observed in the RT group. The decline in FT4 among AD patients did not evoke a normal TSH response. Prolonged use of AD hampers the interpretation of thyroid test results. This finding has substantial implications for the follow-up of patients in hormonally treated prostate cancer.

Binding of CGRP analogs and their effect on adenylate cyclase activity in porcine iris-ciliary body

The structure-activity relationship of the calcitonin gene-related peptide (CGRP) in the porcine iris-ciliary body was studied using different CGRP analogs. The receptor binding affinity is located mainly in the carboxyterminal end of the CGRP peptide while the ability to stimulate adenylate cyclase (AC) enzyme is mainly in the aminoterminal end of the peptide. The binding of CGRP analogs was also found to be temperature-dependent. Changes in the alpha-helical region or in the beta-turn, as well as replacements of threonine-4, asparagine-25 or asparagine-26, reduce the binding affinity already at +4 degrees C. Truncated aminoterminus, changes in the loop region between cysteines 2 and 7, and especially in threonine 6, have for their part an important role in maintaining AC-stimulating activity.

A novel T cell-regulated mechanism modulating allergen-induced airways hyperreactivity in BALB/c mice independently of IL-4 and IL-5

The immunoregulatory functions of IL-4 and IL-5 have identified these cytokines as primary targets for the resolution of airways inflammation and bronchial hyperreactivity in asthma. However, the individual contribution of each of these cytokines and of IL-5-regulated eosinophilia to the induction of airways hyperreactivity in mouse models of asthma remains highly controversial. In this investigation, we have used IL-4- and IL-5-deficient mice of the same genetic background in combination with inhibitory mAbs to these cytokines to identify unequivocally the contribution of these factors to the induction of airways hyperreactivity. Sensitization and aeroallergen challenge of wild-type mice with OVA induced pathological changes to the respiratory epithelium, airways eosinophilia, and hyperreactivity to beta-methacholine. Inhibition of the actions of IL-4 and/or IL-5 did not abolish airways hyperreactivity, and in the case of IL-4-deficient mice pretreated with anti-IL-5 mAb, airways hyperreactivity persisted in the absence of pronounced airways inflammation. Airways hyperreactivity was abolished only by anti-CD4+ mAb treatment. However, aeroallergen challenge of IL-5-/- mice showed that morphologic changes to the airways were critically linked to IL-5 and eosinophilia. This investigation demonstrates the existence in BALB/c mice of a novel CD4+ T cell pathway for modulating airways hyperreactivity. These findings may provide an explanation for the dissociation of airways eosinophilia from the development of airways hyperreactivity observed in some cases of asthma and in animal models of this disease.

Interleukin-5-producing CD4+ T cells play a pivotal role in aeroallergen-induced eosinophilia, bronchial hyperreactivity, and lung damage in mice

Although activated CD4+ T cells have been implicated in the pathogenesis of asthma, the direct contribution of this leukocyte to the induction of aeroallergen-induced bronchial hyperreactivity and lung damage is unknown. In the present investigation, we have used a model of allergic airways inflammation, which displays certain phenotypic characteristics of late-phase asthmatic responses, together with interleukin-5-deficient (IL-5-/- ) mice and donor antigen-specific CD4+ TH2-type cells to obtain unequivocal evidence for a role of this T lymphocyte in the pathophysiology of allergic airways inflammation. Antigen-primed CD4+ T cells and CD4- cells (CD4+-depleted population) were purified from the spleens of ovalbumin (OVA)-sensitized wild-type mice and adoptively transferred to OVA-sensitized and nonsensitized IL-5-/- mice. In vitro stimulation of the purified cell populations with OVA resulted in the secretion of IL-4 and IL-5, but not interferon-gamma, from the CD4+ T cells, indicating that they were of the TH2 type. In contrast, interferon-gamma, but not IL-4 and IL-5, was produced by the CD4- T cells. The CD4+ TH2-type cells (but not the CD4 cells) reconstituted aeroallergen (OVA)-induced blood and airways eosinophilia, lung damage, and airways hyperreactivity to 1-methacholine in IL-5-/- mice. The reconstitution did not require prior sensitization of the mice, but it did not occur if they were aerosolized with saline instead of OVA. The circulating levels of OVA-specific -IgE and -IgG1 were not significantly altered by the adoptive transfer of either cell population. These investigations establish that IL-5-secreting CD4+ TH2-type cells play a pivotal role in generating blood and airways eosinophilia and in the subsequent development of bronchial hyperreactivity and lung damage that occurs in response to aeroallergens.

Interleukin-5 and eosinophils induce airway damage and bronchial hyperreactivity during allergic airway inflammation in BALB/c mice

The cytokines IL-4 and IL-5 secreted from antigen-activated CD4+ T cells are thought to play central roles in the clinical expression and pathogenesis of asthma. However, there is conflicting evidence in animal models of allergic airway inflammation as to the relative importance of IL-5 and eosinophils to the mechanisms underlying the induction of bronchial hyperreactivity and morphological changes to the airways in response to aeroallergen. In a recent investigation, the development of aeroallergen-induced bronchial hyperreactivity in BALB/c mice was thought to be exclusively regulated by IL-4, with no role for IL-5 or eosinophils being demonstrated. In contrast, allergic airway disease could not be induced in IL-5-deficient mice of the C57BL/6 strain. A model of allergic airway inflammation, which displays certain phenotypic characteristics of late-phase asthmatic responses, was used in the present investigation to establish a role for IL-5 and eosinophils in the initiation of bronchial hyperreactivity and in the pathogenesis of allergic airway disease in BALB/c mice. Sensitization and repetitive aerosolization of mice with ovalbumin resulted in a severe airway inflammatory response which directly correlated with the induction of extensive airway damage and bronchial hyperreactivity to beta-methacholine. Treatment of mice with anti-IL-5 mAb before aeroallergen challenge, abolished blood and airway eosinophilia, lung damage and significantly reduced bronchial hyperreactivity. These results show that IL-5 and eosinophilic inflammation play a substantial role in the pathophysiology of allergic airway disease and, moreover, that aeroallergen-induced bronchial hyperreactivity is not exclusively regulated by IL-4. These results also suggest that eosinophils are predominantly responsible for regulating aeroallergen-induced structural changes to the airways which contribute, in part, to the mechanism underlying the induction of bronchial hyperreactivity. Thus, there are at least two distinct pathophysiological mechanisms for the induction of aeroallergen-induced airway occlusion.

Nonmelanoma skin cancer in northern Finland

BACKGROUND AND OBJECTIVES

The incidence of nonmelanoma skin cancers is highest in those geographic areas where light-skinned people are exposed to large amounts of sunlight. The purpose of this study was to detect differences in nonmelanoma skin cancers diagnosed in Northern Finland compared to those from elsewhere. Another purpose was to estimate whether changes have occurred in clinical diagnosis, site distribution, and recurrence rate during the past 15 years.

METHODS

The material included patients treated at Oulu University Hospital in Northern Finland (64.6 degrees N) during the years 1976-1977 and 1991-1992. Information was collected from files on 334 patients with 428 different, histologically verified skin cancers.

RESULTS

In 1976-1977, the average age of men with basal cell carcinoma (BCC) was 61 years, whereas the women's average age was 66 years. In 1991-1992, the corresponding ages were 69 and 72 years. The site distribution did not show any obvious changes in the 15 years, but the differences between sexes had become more prominent. Men had more BCC on the ears and the trunk, whereas women had more BCC on the nose and the forehead. Most of the squamous cell carcinomas (SCC) were on the head and neck similar to BCC, but on the ears of men there occurred relatively more SCC than BCC.

CONCLUSIONS

The clinical diagnosis of BCC was fairly easy to make, whereas that of SCC seemed to be very difficult clinically and was only correct in 10% of the cases. The markedly decreased recurrence rate of BCC between 1976 and 1992 probably occurred because of changes in treatment practices.

Pregnane glycosides from fruits of Balanites aegyptiaca

From the mesocarp of Balanites aegyptiaca fruits, two pregnane glycosides were isolated. One is new and identified as pregn-5-ene-3 beta,16 beta,20(R)-triol 3-O-(2,6-di-O-alpha-L-rhamnopyranosyl)-beta-D-glucopyranoside (balagyptin), while the other is known and assigned as pregn-5-ene-3 beta,16 beta,20(R)-triol 3-O-beta-D-glucopyranoside.

The treatment of high enterocutaneous fistula with surgical drainage and total parenteral nutrition

High enterocutaneous fistulas occurred in 17 malnourished patients after abdominal surgery, performed in most cases for serious primary disease, and were treated with emergency surgical drainage, in 15 cases, early resuturation, in six patients, and total parenteral nutrition (12.6 MJ) in all cases. No elective reconstructions were carried out. The fistulas healed in 27 +/- 20 days, except in three patients, with carcinoma of the stomach or necrosis of the pancreas, who died in sepsis.