Effects of prepartum concentrate feeding on reticular pH, plasma energy metabolites, acute phase proteins, and milk performance in grass silage-fed dairy cows

We investigated how concentrate feeding during the last 21 d of pregnancy affects reticular pH, inflammatory response, dry matter (DM) intake, and production performance of dairy cows. We hypothesized that adding concentrates to dairy cows' diet before calving reduces the decrease in reticular pH postpartum and thus alleviates inflammatory response. We also hypothesized that prepartum concentrate feeding increases DM intake postpartum and consequently improves milk performance. Two feeding experiments were conducted using a randomized complete block design. In each experiment, 16 multiparous Finnish Ayrshire cows were paired based on parity, expected calving date, body weight, and milk yield of the previous lactation. Within the pairs, cows were randomly allocated on one of the 2 dietary treatments 21 d before expected calving. In experiment 1 (Exp1), diets were ad libitum feeding of grass silage as a sole feed or supplemented with increasing amounts of concentrate offered separately (increased to 4 kg/d by d -7). In experiment 2 (Exp2), diets were ad libitum feeding of a total mixed ration containing either grass silage, barley straw, and rapeseed meal (64%, 28%, and 8% on DM basis, respectively) or grass silage, barley straw, and cereal-based concentrate mixture (49%, 29%, and 30% on DM basis, respectively). Following calving, all the cows were fed similarly and observed until d 56 postpartum. Feed intake and milk yield were recorded daily, and reticular pH was monitored continuously by reticular pH bolus. Blood samples were collected at the beginning of the experiments, 7 d before the expected calving date, 1 d (in Exp1) or 5 d (in Exp2), 10 d, and 21 d postpartum. In Exp1, concentrate feeding increased metabolizable energy intake and tended to increase DM and crude protein intake prepartum. Moreover, prepartum concentrate feeding increased the concentrations of plasma β-hydroxybutyrate and insulin, but differences in nonesterified fatty acids, glucose, or acute phase proteins were not observed. After calving, prepartum diet did not affect DM or nutrient intake, plasma energy metabolites, or milk production in Exp1. Although prepartum concentrate feeding increased reticular pH on the first day of lactation, it elevated plasma concentrations of serum amyloid-A and haptoglobin postpartum in the grass silage-based diet. In Exp2, adding concentrates to the diet based on a mixture of grass silage and straw did not affect prepartum DM intake or plasma concentrations of nonesterified fatty acids, glucose, or insulin. Adding concentrates to prepartum diet increased plasma concentration of β-hydroxybutyrate before calving as in Exp1. After calving, prepartum concentrate feeding increased DM and nutrient intake during the second week of lactation in Exp2, but no effects were observed thereafter. In contrast to our hypothesis, prepartum concentrate feeding decreased reticular pH after calving in Exp2, but no differences in inflammatory markers were observed. Based on this study, close-up concentrate feeding in diets based on grass silage with or without straw does not alleviate the decrease in reticular pH or mitigate inflammatory response postpartum.

Effects of forage and grain legume-based silages supplemented with faba bean meal or rapeseed expeller on lactational performance, nitrogen utilization, and plasma amino acids in dairy cows

The objective of this experiment was to investigate the effect of forage type [red clover (51%)-grass silage, i.e., RCG; vs. faba bean (66%)-grass silage, i.e., FBG] and concentrate type (faba bean, FB; vs. rapeseed expeller, RE) on lactational performance, milk composition and nitrogen (N) utilization in lactating dairy cows. Eight lactating multiparous Nordic Red cows were used in a replicated 4 × 4 Latin Square experiment, with 21-d periods, in a 2 × 2 factorial arrangement of treatments. The experimental treatments were as follows: (1) RCG with RE, (2) RCG with FB, (3) FBG with RE, and (4) FBG with FB. Inclusion rates of RE and FB were isonitrogenous. Crude protein contents of the experimental diets were 16.3, 15.9, 18.1, and 17.9% of dry matter, respectively. All diets included oats and barley and were fed ad libitum as total mixed rations with forage-to-concentrate ratio of 55:45. Dry matter intake and milk yield were recorded daily, and spot samples of urine, feces, and blood were collected at the end of each experimental period. Dry matter intake did not differ across diets, averaging 26.7 kg/d. Milk yield averaged 35.6 kg/d and was 1.1 kg/d greater for RCG versus FBG, and milk urea N concentration was lower for RCG compared with FBG. Milk yield was 2.2 kg/d and milk protein yield 66 g/d lower for FB versus RE. Nitrogen intake, urinary N, and urinary urea N excretions were lower, and milk N excretion tended to be lower for RCG compared with FBG. The proportion of the dietary N excreted as fecal N was larger in cows fed RCG than for those fed FBG, and the opposite was true for urinary N. We detected an interaction for milk N as percentage of N intake: it increased with RE compared with FB for RCG-based diet, but only a marginal increase was observed for FBG-based diet. Plasma concentration of His and Lys were lower for RCG than for FBG, whereas His tended to be greater and Lys lower for FB compared with RE. Further, plasma Met concentration was around 26% lower for FB than for RE. Of milk fatty acids, saturated fatty acids were decreased by RCG and increased by FB compared with FBG and RE, respectively, whereas monounsaturated fatty acids were increased by RCG versus FBG, and were lower for FB than for RE. In particular, 18:1n-9 concentration was lower for FB compared with RE. Polyunsaturated fatty acids, such as 18:2n-6 and 18:3n-3, were greater for RCG than for FBG, and 18:2n-6 was greater and 18:3n-3 was lower for FB versus RE. In addition, cis-9,trans-11 conjugated linoleic acid was lower for FB compared with RE. Faba bean whole-crop silage and faba bean meal have potential to be used as a part of dairy cow rations, but further research is needed to improve their N efficiency. Red clover-grass silage from a mixed sward, without inorganic N fertilizer input, combined with RE, resulted in the greatest N efficiency in the conditions of this experiment.

Socioeconomic factors and regional differences in mental disorder-based disability pensioning in Finland

Introduction

Prior literature has indicated low socioeconomic status (SES) and regional differences as epidemiological risk factors for disability pension (DP) due to mental disorders.

Objectives

Our studies aimed to examine these associations and differences in greater detail, with separate consideration of the risk factors for mood disorders (F30–39) and non-affective psychotic disorder (F20–29) DP.

Methods

Subjects (N = 36 879) were all those granted DP due to a mental disorder for the first time between 2010 and 2015 in Finland. All the subjects were matched with three controls. Education, income and occupational status were used as measures of SES. Conditional logistic regression models were used to study SES differences. Negative binomial regression analysis was used to study the levels of DP risk in the Finnish hospital districts.

Results

DP recipients had low educational and income levels and often lived alone. The risk of DP was greater in white-collar occupational groups compared with blue-collar workers. Students had the greatest risk of DP for all mental and mood disorders. Significant differences in the regional mental disorder DP risks did not appear to follow the traditional Finnish health differences.

Conclusions

We found evidence of SES factors and regional variation associating with mental disorder-related severe loss of working and studying ability in a disorder-specific way. The increased risk of white-collar worker DP could be related to the psychosocially demanding contemporary working life. Regional variation in DP may at least partly relate to differences in regional mental health service systems.

Disclosure

No significant relationships.

Costs after hip fracture in independently living patients: a randomised comparison of three rehabilitation modalities

OBJECTIVE

To evaluate costs and cost-effectiveness of physical and geriatric rehabilitation after hip fracture.

DESIGN

Prospective randomised study (mean age 78 years, 105 male, 433 female) in different rehabilitation settings: physically oriented (187 patients), geriatrically oriented (171 patients), and healthcare centre hospital (control, 180 patients).

MAIN MEASURES

At 12 months post-fracture, we collected data regarding days in rehabilitation, post-rehabilitation hospital treatment, other healthcare service use, number of re-operations, taxi use by patient or relative, and help from relatives.

RESULTS

Control rehabilitation (4945,2€) was significantly less expensive than physical (6609.0€, p=0.002) and geriatric rehabilitation (7034.7€ p<0.001). Total institutional care costs (primary treatment, rehabilitation, and post-rehabilitation hospital care) were lower for control (13,438.4€) than geriatric rehabilitation (17,201.7€, p<0.001), but did not differ between control and physical rehabilitation (15659.1€, p=0.055) or between physical and geriatric rehabilitation ( p=0.252). Costs of help from relatives (estimated as 30%, 50% and 100% of a home aid's salary) with physical rehabilitation were lower than control ( p=0.016) but higher than geriatric rehabilitation ( p=0.041). Total hip fracture treatment costs were lower with physical (36,356€, 51,018€) than control rehabilitation (38,018€, 57,031€) at 50% and 100% of salary ( p=0.032, p=0.014, respectively). At one year post-fracture, 15D-score was significantly higher in physical rehabilitation group (0.697) than geriatric rehabilitation group (0.586, p=0.008) and control group (0.594, p=0.009).

CONCLUSIONS

Considering total costs one year after hip fracture the treatment including physical rehabilitation is significantly more cost-effective than routine treatment. This effect could not be seen between routine treatment and treatment including geriatric rehabilitation.

The labor supply of registered nurses in Finland: the effect of wages and working conditions

Many countries report, to varying degrees, of suffering from a shortage of nurses. We examined both pecuniary and non-pecuniary factors that may be associated with nurses' labor supply. We approximated a classical labor supply model and calculated the wage elasticities of hours of work and participation. Even though the wage elasticity was quite small, the effect on the hours supplied was significant. However, wages alone may not sufficiently increase the labor supply from the current stock of nurses; other elements, such as contractual conditions, seem to play an important role as well.

Nurses' intentions to leave nursing in Finland

The shortage of nurses is a problem in many countries. We examined how factors related to wage, work, job satisfaction/dissatisfaction, and workplace or demographic factors were associated with nurses' intentions to switch from health care to non-health-care roles. Wage and share of income from shift work were negatively and statistically significantly related to nurses' intention to leave the health care sector. However, some non-pecuniary variables, such as Possibility for Specialisation gained a positive, statistically significant association with job satisfaction and thereby decreased intention to change work sector. Therefore, not only economic factors influence the labour supply of nurses.

Fatal injuries in Finnish agriculture, 1988-2000

Agriculture is one of the most hazardous industries in Finland. The aim of this study was to describe and analyze fatal farm injuries in Finland in 1988 to 2000. The information regarding farm-related fatalities was collected by the Kuopio Regional Institute of Occupational Health. The material of this study consisted of all fatal injuries that occurred on a farm or away from a farm in the course of agricultural work. A total of 217 farm-related fatalities occurred in Finland between 1988 and 2000. Of these, 120 were tractor-related, and 97 were other fatal farm injuries. Most of the injuries involved middle-aged or older male farmers. The most typical fatalities with tractors were tractor overturns during driving on a road or working in a field. Other fatal farm incidents occurred mainly in construction work, animal husbandry, or forest work. Elderly farmers and children proved to be risk groups for fatal injuries.

Cost-effectiveness of screening for familial abdominal aortic aneurysms

BACKGROUND

Screening for familial abdominal aortic aneurysms (AAA) is widely recommended. To analyze cost-effectiveness of screening for familial AAAs incremental cost-effectiveness (C/E) analysis based on an ultrasound screening among relatives and a decision model of screening program was compared to a baseline situation without systematic screening.

PATIENTS AND METHODS

74% (238/322) of first-degree relatives of 150 consecutive AAA patients were screened at HUCH (Helsinki University Central Hospital). Effectiveness and costs of treatment were assessed using the Finnish Hospital Discharge Register and from survival analysis of 1130 AAA patients who underwent elective or emergency surgery in HUCH. To form incremental C/E-ratios the existing clinical practice was compared to a screening program for male siblings. Hypothetical screened and control cohorts of 1000 male relatives were used to create the decision model. Parameters in C/E-analyses were derived from our own data except for growth and rupture rates. A sensitivity analysis was carried out.

RESULTS

The incremental effectiveness in life-years gained by the screening of male siblings was 92 years with incremental C/E-ratio of FIM 33,000 ($6200). According to sensitivity analysis the C/E-ratios were robust for all variables tested.

CONCLUSIONS

Screening of male siblings of AAA patients produces incremental life-years at low cost thus screening of male siblings is highly recommended.

Cardiac parasympathetic activity is increased by weight loss in healthy obese women

OBJECTIVE

We studied the effect of weight reduction on cardiac parasympathetic activity (PSA) in obese women. We also studied the relationship between the changes of PSA, resting energy expenditure (REE), and major cardiovascular risk factors.

RESEARCH METHODS AND PROCEDURES

Changes of cardiac vagal tone, an index of PSA, REE, and major cardiovascular risk factors, were measured in 52 healthy obese women after a 6-month weight reduction. Ten of the women were remeasured at 12 and 24 months. Cardiac vagal tone was assessed by a vagal tone monitor and REE by indirect calorimeter.

RESULTS

Cardiac vagal tone increased significantly (p = 0.046), averaging a 9.5% weight loss in 6 months. The vagal tone increased further with weight loss during the following 6 months, and thereafter, it declined with weight regain. The increase of cardiac vagal tone correlated significantly with decreases of body weight, fat mass, waist circumference, serum insulin, and heart rate. REE adjusted for fat-free mass and age did not change with weight loss and was not related to cardiac vagal tone at any time-point.

DISCUSSION

Cardiac PSA activity increases with weight loss in obese women. This increase may not be maintained long-term if body weight is regained. The rise of cardiac PSA is correlated with decreases of body fat mass, abdominal fat, serum insulin, and heart rate. Cardiac PSA is not related to REE.

Weight change and blood coagulability and fibrinolysis in healthy obese women

OBJECTIVES

To study the effect of weight loss and subsequent weight maintenance or weight regain on the activities of FVII and plasminogen activator inhibitor 1 (PAI-1) and the concentration of fibrinogen over 12 months in obese women consuming a hypoenergetic, low-fat diet with or without orlistat. In addition, the relation between the changes of the activities of PAI-1 and FVII with the changes of other cardiovascular risk factors were examined.

METHODS AND PROCEDURES

Design-a 12-month randomized double-blind weight reduction trial of placebo and orlistat. Subjects-51 healthy obese women (age 44+/-0.7 y, BMI 36.2+/-0.5 kg/m(2), mean+/-s.e.m.) Treatment-the participants were on a hypoenergetic diet (-600 kcal daily). The diet was adjusted for actual body weight (-300 kcal) at 6 months. Women were randomized to receive either orlistat 120 mg three times daily (n=25) or placebo three times daily (n=26) for 12 months according to a double-blind protocol after a 1 month run-in period. Measurements-changes of body weight, body composition, haemostatic and other cardiovascular risk factors were measured at 3-6 month intervals. The activity of plasma PAI-1 was measured by a chromogenic method, fibrinogen by the PT-derived method and the activity of FVII by the one-stage method.

RESULTS

The changes in body weight between orlistat and placebo groups were not statistically significantly different. Orlistat did not influence haemostatic factors beyond its effect on weight loss. Therefore, the results of the orlistat and placebo groups were pooled. The average weight loss at 3, 6 and 12 months was 7.6, 9.5 and 10.0 kg, respectively (P<0.001). Between 6 and 12 months, 35% of women regained weight, 24% had stable weight and 41% continued to lose weight. No changes in the mean plasma fibrinogen concentration were observed at any time point during the trial. During the first 3 months the activities of PAI-1 and FVII decreased. The decline depended on the magnitude of weight loss. Between months 6 and 12 the changes of PAI-1 and FVII activities paralleled the changes of body weight. The activities rose with weight rebound but remained below the 6-month values if weight loss was sustained or continued. The changes of serum insulin were significantly correlated with the changes of both PAI-1 and FVII at 6 months and with PAI-1 at 12 months.

CONCLUSIONS

The maintenance of modest weight loss is associated with long-term benefits in PAI-1 and FVII in obese women. The change of serum insulin is associated with the changes of PAI-1 activities. Fibrinogen is not affected by modest weight loss.

Quality of life and cost-effectiveness of levonorgestrel-releasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomised trial

BACKGROUND

Heavy menstrual blood loss is a common reason for women to seek medical care. The levonorgestrel-releasing intrauterine system (IUS) is an effective medical treatment for menorrhagia. We report a randomised comparison of this approach with hysterectomy in terms of the quality of life of women with menorrhagia and cost-effectiveness.

METHODS

Of 598 women referred with menorrhagia to five university hospitals in Finland, 236 were eligible and agreed to take part. They were randomly assigned treatment with the levonorgestrel-releasing IUS (n=119) or hysterectomy (n=117). The amount of menstrual blood loss was objectively measured. The primary outcome measure was health-related quality of life at 12-month follow-up. Analyses were by intention to treat.

FINDINGS

In the group assigned the levonorgestrel-releasing IUS, 24 (20%) women had had hysterectomy and 81 (68%) continued to use the system at 12 months. Of the women assigned to the hysterectomy group, 107 underwent the operation. Health-related quality of life improved significantly in both the IUS and hysterectomy groups (change 0.10 [95% CI 0.06-0.14] in both groups) as did other indices of psychological wellbeing. There were no significant differences between the treatment groups except that women with hysterectomy suffered less pain. Overall costs were about three times higher for the hysterectomy group than for the IUS group.

INTERPRETATION

The significant improvement in health-related quality of life highlights the importance of treating menorrhagia. During the first year the levonorgestrel-releasing IUS was a cost-effective alternative to hysterectomy in treatment of this disorder.

Effect of orlistat treatment on body composition and resting energy expenditure during a two-year weight-reduction programme in obese Finns

OBJECTIVE

To examine the effect of orlistat (Xenical) treatment on body composition and resting energy expenditure (REE) during a 2 y weight-reduction programme in obese Finns.

SUBJECTS

Of initially 96 obese subjects who participated in the weight-reduction programme, those 72 subjects (13 men, 59 women, body mass index (BMI) 35.9 +/- 3.9 kg/m2, age 43.4 +/- 6.0 y, mean +/- s.d.) with the complete set of data for 2 y were included in the study.

DESIGN

After a 4-week lead-in period, subjects were randomized with either orlistat 120 mg t.i.d. or placebo t.i.d. in conjunction with a mildly hypoenergetic balanced diet for 1 y. This was followed by 1 y double-blind period with the subjects within each treatment group re-assigned to receive orlistat 120 mg t.i.d. or placebo t.i.d. in conjunction with a weight maintenance diet.

MEASUREMENTS

Body composition and REE were measured after an overnight fast by a bioelectrical impedance method and indirect calorimeter, respectively. The measurements were performed at the beginning and at 3, 6, 12 and 24 months.

RESULTS

During the first year, the orlistat-treated group had greater reduction of body weight and fat mass but not of fat-free mass or REE as compared to placebo. During the second year, orlistat treatment was associated with smaller regain of body weight and fat mass with no significant differences in the changes of fat-free mass or REE as compared to placebo.

CONCLUSION

In addition to better weight loss and maintenance of reduced weight, orlistat treatment is associated with beneficial changes in body composition but with no excess decrease in resting energy expenditure as compared to that achieved during placebo with a dietary therapy alone.

Do QOL instruments agree? A comparison of the 15D (Health-Related Quality of Life) and NHP (Nottingham Health Profile) in hip and knee replacements

OBJECTIVES

Several instruments for measuring health-related quality of life (HRQOL) have been developed, and others are under construction. The problem is whether the different HRQOL measures show comparable results. We first compared the functional relationship of the Nottingham Health Profile (NHP) and the 15-dimensional measure of HRQOL (15D) in hip and knee replacement patients. The hypothesis was that condition or intervention does not affect the functional relationship between NHP and 15D changes.

METHODS

We assessed the agreement of the instruments by comparing observed changes in the 15D and its fitted values derived by regressing the 15D by the NHP dimensions. Patients (n = 452) were recruited consecutively from seven Finnish orthopedic departments during April 1991-May 1992. HRQOL was measured prior to surgery and 6, 12, and 24 months postoperatively.

RESULTS

There was a different functional relationship between the HRQOL instruments in hip and knee patients; they agreed upon the direction of changes in HRQOL in 84% and showed opposite signs in 12%. The NHP showed significantly more improvement in quality of life than the 15D.

CONCLUSIONS

The two instruments were in slight but significant disagreement. Estimates of effectiveness can vary according to the instrument used. Comparisons of effectiveness in healthcare programs measured by differing instruments need information on the functional discrepancies between the instruments in the conditions and interventions in which they are applied.

Cost-effectiveness of targeted screening for abdominal aortic aneurysm. Monte Carlo-based estimates

OBJECTIVES

This article reports a cost-effectiveness analysis of targeted screening for abdominal aortic aneurysm (AAA). A major emphasis was on the estimation of distributions of costs and effectiveness.

METHODS

We performed a Monte Carlo simulation using C programming language in a PC environment. Data on survival and costs, and a majority of screening probabilities, were from our own empirical studies. Natural history data were based on the literature.

RESULTS

Each screened male gained 0.07 life-years at an incremental cost of FIM 3,300. The expected values differed from zero very significantly. For females, expected gains were 0.02 life-years at an incremental cost of FIM 1,100, which was not statistically significant. Cost-effectiveness ratios and their 95% confidence intervals were FIM 48,000 (27,000-121,000) and 54,000 (22,000-infinity) for males and females, respectively. Sensitivity analysis revealed that the results for males were stable. Individual variation in life-year gains was high.

CONCLUSIONS

Males seemed to benefit from targeted AAA screening, and the results were stable. As far as the cost-effectiveness ratio is considered acceptable, screening for males seemed to be justified. However, our assumptions about growth and rupture behavior of AAAs might be improved with further clinical and epidemiological studies. As a point estimate, females benefited in a similar manner, but the results were not statistically significant. The evidence of this study did not justify screening of females.

Reoperations after lumbar disc surgery: a population-based study of regional and interspecialty variations

STUDY DESIGN

A follow-up study using nationwide administrative databases.

OBJECTIVES

To explore rates of reoperation after lumbar disc surgery and their regional and interspecialty variations.

SUMMARY OF BACKGROUND DATA

In many Western countries, rates of lumbar disc surgery display significant geographic variations suggesting varying treatment criteria among operating surgeons. Few population-based studies have explored the risk of reoperation after disc surgery, and regional or interspecialty variations in the reoperations are unknown.

METHODS

Patients who underwent lumbar spine surgery from January 1, 1987 through December 31, 1995, were identified in the Finnish Hospital Discharge Register. Data on the patients' initial disc operations, subsequent operations, and cause-of-death records were linked using personal identification codes. The Kaplan-Meier method and proportional hazard model were used to analyze risks of reoperation after initial surgery, according to hospital catchment area rates of disc surgery and for neurosurgical and orthopedic patients of university hospitals.

RESULTS

12.3% of 25,359 surgical patients with herniated lumbar discs underwent subsequent lumbar operations corresponding to the cumulative risk of 18.9% in the 9-year follow-up. Reoperation rates increased during the study period with the recent patient cohorts exhibiting risks. The reoperation risk showed a systematic geographic variation: the higher the regional disc surgery rate, the higher the reoperation risk. Overall, neurosurgical patients had a higher reoperation risk than orthopedic patients (relative risk [RR]: 1.57, 95% confidence interval [CI]: 1.17-2.10), but this was not a uniform finding.

CONCLUSIONS

The reoperation risk after disc surgery increased during the study period and was higher in hospital catchment areas with higher overall discectomy rates. The reoperation risks varied among the university hospitals but tended to be higher for neurosurgical rather than for orthopedic patients.

Priority-setting in Finnish healthcare

The characteristics which affect priority setting in the Finnish healthcare system include strong municipal (local) administration, no clear separation between producers and purchasers, a duality in funding, and the potential for physicians in public hospitals to practice in the private sector. This system has its strengths, such as the possibility to effectively co-ordinate social and healthcare services, and a strong incentive to take care of local needs, because of municipal responsibility to finance these services largely through local taxes. However, the municipalities are typically too small to take advantage of these potentials, their knowledge is scarce especially of secondary care and their negotiating power with respect to hospitals is low. Local politicians also have a dual role: they represent the needs of the local population but simultaneously they are decision-makers in hospitals. Full-time physicians are allowed to act in a dual role as well; they can run a private practice, which is paid for on a fee-for-service basis, while the hospital pays (mostly) a fixed monthly salary. The share of financing which flows from the National Sickness Insurance system to healthcare users may have adverse effects on the local use of resources. The broad national consensus statement on patient-level priorities did not reach any general rules on priorities. Strong support was given to citizens' equal right to access all healthcare services. In healthcare practice, this general rule has some exemptions. First, the reimbursement schemes for prescribed drugs vary depending on the severity and chronic nature of the disease. Secondly, the tax-financed dental services for the young are clearly prioritised over those of older citizens. In the consensus statement, emphasis was put on improving the efficiency of producing health services in order to avoid having to impose patient-level priorities.

Quality of life after prolonged intensive care

OBJECTIVE

To assess the subjective health status, quality of life, and functional ability of patients whose intensive care stay was prolonged and to compare their quality of life with that of the general population.

DESIGN

Inception cohort study.

SETTING

Twenty-three-bed multidisciplinary intensive care unit (ICU) in a tertiary care center.

PATIENTS

A consecutive sample of 718 patients aged > or = 18 yrs who required intensive care > or = 4 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The Nottingham Health Profile was used to compare the ICU patients with a random sample (n = 2,595) of the general population. The quality of life and functional ability of 368 respondents (78.3% of 470 survivors) were assessed at 6 months after ICU admission. The length of the ICU stay was 13.6+/-11.8 (median, 9; maximum, 81) days. The quality of life and its various dimensions were influenced by the diagnosis for ICU admission and age. Although problems in physical mobility and energy were prevalent among all patient groups, only a small proportion was dependent on others for the management of daily activities. Patients with trauma or respiratory failure experienced the most limitations. The quality of life of elderly patients and patients who had undergone cardiac surgery was comparable with the general population regarding emotional reactions, social isolation, and pain.

CONCLUSIONS

The quality of life of survivors after a prolonged intensive care stay is fairly good, although not comparable with that of the general population. The psychosocial aspects of the quality of life are restored more rapidly than physical performance.

Effect of weight loss and regional fat distribution on plasma leptin concentration in obese women

OBJECTIVES

To investigate how circulating leptin concentrations are related to regional fat distribution and whether moderate weight loss alters these relationships.

DESIGN

A 6 month, clinical weight reduction trial with measurements before and after weight loss.

SUBJECTS

38 healthy, obese women (age: 44.3+/-9.9 y, BMI: 34.0+/-4.0 kg/m2).

MEASUREMENTS

The following measurements were made. 1. indices of obesity and fat distribution: weight, body mass index (BMI), hip circumference (peripheral fat), waist circumference, total body fat (bioelectrical impedance), abdominal fat distribution: visceral fat and abdominal subcutaneous fat (ultrasonography); and 2. Biochemical measurements: plasma leptin and serum insulin.

RESULTS

Baseline plasma leptin concentrations were three-fold higher in obese women than in normal weight controls. After weight loss averaging 8.4 kg (9.0%), plasma leptin decreased by a mean of 22.3% (P < 0.001), corresponding to body fat decrease of 16.6% (P < 0.001), abdominal subcutaneous fat decrease of 17.4% (P < 0.001) and visceral fat decrease of 18.7% (P < 0.001). The total amount of body fat correlated with plasma (serum) leptin before (r = 0.64, P < 0.001) and after (r = 0.75, P < 0.001) weight loss. Plasma leptin concentrations expressed per kg of body fat did not change significantly during weight loss. After controlling for body fat, baseline leptin concentrations were significantly associated with hip circumference (r = 0.57, P < 0.001) but not with any indices of abdominal fat distribution. After weight loss the associations became significant for hip and waist circumference as well as for visceral and abdominal subcutaneous fat. Changes in leptin correlated with changes in all indices of obesity except visceral fat.

CONCLUSIONS

Plasma leptin concentrations reflect not only total fat mass but also adipose tissue distribution, especially peripheral fat. Plasma leptin values per kilogram of fat mass do not change significantly with modest weight loss.

Costs and cost-effectiveness in hip and knee replacements. A prospective study

The extensive benefits of the total hip (THA) and knee (TKA) replacements are well documented, but surprisingly little is known about their economics. We assessed costs, cost-effectiveness (C/E), and patient-related C/E variances in THA and TKA from data on 276 THA and 176 TKA patients. Patients with primary arthrosis, primary operation, and total joint replacement were recruited from seven hospitals between March 1991 and June 1992. Their use of health and other welfare services together with health-related quality of life (HRQoL) were measured before the surgery and at 6, 12, and 24 months postoperatively. HRQoL was assessed by the 15D, a 15-dimensional HRQoL instrument, and the Nottingham Health Profile. Costs were assessed from questionnaire responses, the Finnish Hospital Discharge Register, and Finnish Arthroplasty Register. Total hospital costs per patient were 45,000 FIM (US $10,500) for THA and 49,600 FIM (US $11,500) for TKA. Prosthesis costs comprised 21% of these costs in THA and 24% in TKA. On average, hip patients gained more in terms of HRQoL, and the operations were more cost-effective. The C/E ratio for younger (< or = 60 years) knee patients did not differ from those in all age groups of hip patients, whereas TKAs in those over 60 years had a worse C/E ratio compared with all other patient subgroups. It was concluded that allocation efficiency can be improved by considering not only the intervention but also patient characteristics such as age. Indeed, the C/E ratio varied more across age groups of knee patients than between average THA and TKA patients.

Relationship of metabolic variables to abdominal adiposity measured by different anthropometric measurements and dual-energy X-ray absorptiometry in obese middle-aged women

OBJECTIVES

To investigate how abdominal adiposity assessed by different anthropometric measurements and dual-energy X-ray absorptiometry measurements is associated with metabolic risk factors for cardiovascular disease and non-insulin-dependent diabetes mellitus in obese women.

DESIGN

Cross-sectional study.

SUBJECTS

Forty-three healthy, obese, middle-aged women (age: 29-64 y, BMI: 28-42 kg/m2).

MEASUREMENTS

(1) Anthropometry: waist circumference, waist-to-hip ratio, waist-to-height ratio, abdominal sagittal and transverse diameters and their ratio. (2) Dual-energy X-ray absorptiometry: the amount of total and regional abdominal fat. (3) Metabolic measurements: serum total, VLDL, LDL, HDL cholesterol, triglycerides, fasting and postglucose serum insulin and glucose.

RESULTS

After adjustment for age and BMI, all the anthropometric measurements except waist-to-hip ratio and waist-to-height ratio related significantly to HDL and LDL cholesterol. On the other hand, waist-to-hip ratio and waist-to-height ratio showed an association with triglycerides. In addition, all the anthropometric measurements except transverse diameter correlated significantly with fasting insulin and fasting glucose. Waist-to-hip ratio was the only measure that associated with 2 h glucose concentration. The differences between the correlation coefficients were not statistically significant in the z-transformed correlation coefficient test. As to dual-energy X-ray absorptiometry results, the region from the dome of diaphragm to the top of femur ('abdominal fat') and the area between the first and the fourth lumbal vertebrae ('upper lumbal fat') inversely related to HDL cholesterol and positively to triglycerides. Both of these regions correlated significantly with fasting insulin, and "upper lumbal fat' associated also with fasting glucose even after adjustment for age and BMI.

CONCLUSION

None of the anthropometric measurements (waist circumference, waist-to-hip ratio, waist-to-height ratio or sagittal diameter) was significantly superior to others to assess the metabolic risk profile. 'Upper lumbal fat' (the area between the first and the fourth lumbal vertebrae) measured by dual-energy X-ray absorptiometry discerned obese women with elevated fasting insulin and fasting glucose.

Haematological toxicity: a marker of adjuvant chemotherapy efficacy in stage II and III breast cancer

Two hundred and eleven patients with node-positive stage II and III breast cancer were treated with eight cycles of adjuvant chemotherapy comprising cyclophosphamide, doxorubicin and oral ftorafur (CAFt), with and without tamoxifen. All patients had undergone radical surgery, and 148 patients were treated with post-operative radiotherapy in two randomized studies. The impact of haematological toxicity of CAFt on distant disease-free (DDFS) and overall survival (OS) was recorded. Dose intensity of all given cycles (DI), dose intensity of the two initial cycles (DI2) and total dose (TD) were calculated separately for all chemotherapy drugs and were correlated with DDFS and OS. Patients with a lower leucocyte nadir during the chemotherapy had significantly better DDFS and OS (P = 0.01 and 0.04 respectively). Dose intensity of the two first cycles also correlated significantly with DDFS (P = 0.05) in univariate but not in multivariate analysis, while the leucocyte nadir retained its prognostic value. These results indicate that the leucocyte nadir during the adjuvant chemotherapy is a biological marker of chemotherapy efficacy; this presents the possibility of establishing an optimal dose intensity for each patient. The initial dose intensity of adjuvant chemotherapy also seems to be important in assuring the optimal effect of adjuvant chemotherapy.

Quality of life and functional ability in hip and knee replacements: a prospective study

The impact of hip (THA) and knee arthroplasty (TKA) on patients' health-related quality of life (HRQOL), physical ability and functioning was assessed in a two year follow-up study of 276 hip and 176 knee patients. The eligibility criteria were a diagnosis of primary arthrosis, a primary operation, and total joint arthroplasty. Patients were interviewed by questionnaire prior to the operation and 6, 12 and 24 months after the surgery. Subjective health outcomes were assessed with the Nottingham Health Profile and the 15D, a fifteen dimensional HRQOL measure. Patients' physical ability was assessed using measures of activities of daily living, and of physical mobility. Patient related outcome variations were analyzed by regression models. Major improvements were observed for pain, sleep and physical mobility. On average, in most of the quality of life dimensions the patients attained a similar quality of life as the comparable general population and only 4.7% of hip and 9.7% of knee patients had a worse HRQOL score at all three post-operative measurements than at baseline. Naturally, those with the poorest HRQOL pre-operatively gained most from the operation. High age did not lessen HRQOL gains from THA, but in TKA the oldest patients gained least in terms of 15D scores. Hip, but not knee patients with a long education tended to have greater improvements in quality of life and functional ability.

Hospital- and patient-related characteristics determining length of hospital stay for hip and knee replacements

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most prestigious health care technologies. Their popularity has grown rapidly, and an increasing proportion of health care resources is allocated to them. We studied patient- and hospital-related factors that cause variation in a major determinant of hospital costs, the length of hospital stay (LOS) for THA and TKA. We gathered data on 10,288 hip and 5,173 knee patients with primary or secondary arthrosis from the Finnish Arthroplasty Register, which we linked with the Finnish Hospital Discharge Register. Patient- and hospital-related variations in LOS were explained using regression models. Of the patient-related factors, complications caused the greatest prolongation of hospital stay, but patient's age, gender, and charge category also influenced LOS. Hospital-related factors were major causes of LOS variation. In the hospitals the average case-mix-adjusted LOS ranged from less than a week to 3 weeks. The number of arthroplasties performed in hospital was inversely related to LOS. The within-hospital LOS figures for THA and TKA were strikingly similar and persistent.

Vinorelbine and epirubicin in metastatic breast cancer. A dose finding study

The aim of the study was to define the maximum tolerated dose (MTD) of vinorelbine given as one or two weekly doses in combination with epirubicin 60 mg/m2 every third week. The MTD was defined as the dose resulting in a WHO grade III or IV leucopenia exceeding 50% of patients. Patients were treated in groups of 10 at escalating doses of vinorelbine. The number of patients at the final dose level was expanded to 20. The dose of epirubicin was kept constant at 60 mg/m2 every third week. At dose level 1, 15 mg/m2 vinorelbine was given on day 1 at level 2, 20 mg/m2 was given on day 1 and at level 3, 20 mg/m2 was given on days 1 and 8. The MTD was reached at dose level 3. WHO haematological toxicity grade IV occurred in 0, 10 and 45% and grade III at 60, 30 and 30% of patients at dose levels 1, 2 and 3, respectively. Despite the common occurrence of grade IV haematological toxicity, only two serious infections were noted. Non-haematological toxicity of vinorelbine included neurotoxicity, manifesting as muscle weakness, constipation and paresthesias in the majority of patients. Neurotoxicity was usually mild and did not require treatment discontinuation. Phlebitis at the injection site was troublesome in many patients. Alopecia and nausea, probably due to epirubicin, occurred in most patients. The response rates were 22% (95% CI (confidence interval) 3-60%), 40% (12-74%) and 60% (36-81%) at levels 1, 2 and 3, respectively (non-significant).

The prognosis of stage III breast cancer treated with postoperative radiotherapy and adriamycin-based chemotherapy with and without tamoxifen. Eight year follow-up results of a randomized trial

Sixty-one patients with primary node positive stage III breast cancers were randomized to receive postoperative radiotherapy and doxorubicin-based chemotherapy (eight cycles of CAFt: cyclophosphamide, adriamycin, oral ftorafur) with or without tamoxifen as adjuvant treatment. The five-year overall survival for all patients was 49% (with tamoxifen 48% and without tamoxifen 50%) and disease-free survival 33% (with tamoxifen 27% and without 39%). Local control for all patients was only 64% despite the postoperative radiotherapy. There was no significant difference between these two treatment groups in overall and disease-free survival or local control. The prognosis of stage III breast cancer remains grim despite modern adjuvant therapy. In addition to more effective systemic treatment more effective local therapy is also needed in order to obtain satisfactory local control. The most important studies in stage III breast cancer with 5-year survival results are reviewed here.

Health and quality of life before and after hip or knee arthroplasty

The impact of hip and knee arthroplasty based on the patients' own evaluations of their health, quality of life, and physical ability was assessed using a cross-sectional study design. The eligibility criteria were a diagnosis of primary arthrosis, primary operation, and total joint arthroplasty. Preoperative hip and knee patient groups were compared with similar groups who underwent arthroplasty 2 or 5 years previously. Subjective health outcome was assessed with the Nottingham health profile and a 15-dimensional, health-related quality of life measure. Patients' physical ability was assessed using a measure of activities of daily living. Major improvements were observed for pain, sleep, range of motion, and physical ability. However, after surgery, patients were less healthy than the general population of the same age. The health status of patients operated on 2 or 5 years ago was similar, suggesting that health gains persist for several years.

Salvage therapies in women who fail to respond to first-line treatment with fluorouracil, epirubicin, and cyclophosphamide for advanced breast cancer

PURPOSE

We studied all salvage therapies given until death or the end of follow-up evaluation in women who failed to respond to the same first-line cytotoxic therapy for metastatic breast cancer.

PATIENTS AND METHODS

The study cohort consisted of 140 women who had received the fluorouracil, epirubicin, and cyclophosphamide (FEC) regimen for metastatic breast cancer. Eight patients were excluded. No exclusions with respect to disease site, performance status, or biochemical abnormalities were made. The median follow-up time was 29 months for surviving patients.

RESULTS

Most patients (88%) died during the follow-up period. Patients received a median of three salvage therapies (range, zero to eight) during the course of disease. Most courses (52%) were not assessable for response. Fifty-percent of courses consisted of chemotherapy: 35% of hormonal and 15% of combination of cytotoxic and hormonal therapies. The median duration of therapy (DT) ranged from 4 to 1 months, and decreased with advancing stages of therapy. Similarly, median time to treatment failure (TTF) ranged from 3 to 0.5 months. For unknown causes, patients who received second-line hormonal therapy fared better than those who received other forms of therapy. Of 366 analyzed courses, only one complete response (CR) and 18 partial responses (PRs) were observed (response rate, 11% for assessable and 5% for all courses). Stable disease for at least 3 months was found in 20% to 25% of courses. Most responses (n = 10) occurred during first salvage therapy, and no responses were observed after third salvage therapy.

CONCLUSIONS

Response rates for salvage therapies were low, and median treatment times short. The value of offering more than two salvage chemotherapy regimens to an unselected group of patients is questionable.

Renal cell carcinoma in a natural remaining kidney after two kidney transplantations. Case report

A 57-year-old woman with nephropathy following a streptococcal infection had received a kidney transplant in 1980 and 1986 and immunosuppressive treatment since 1980. Renal cell carcinoma was found in the right native kidney in 1991, with skeletal metastases. Nephrectomy was performed and radiotherapy given. Removal of non-functioning kidneys would prevent development of such cancer.

Sudden tumour regression with enhanced natural killer cell accumulation in a patient with stage IV breast cancer

Spontaneous regression of advanced breast cancer is a rare phenomenon. Efforts have been made in order to explain it by means of immunological mechanisms. Corticosteroids have demonstrated important efficacy in the treatment of breast cancer. We present a patient with stage IV breast cancer in whom large tumour masses dramatically regressed during treatment with dexamethasone alone. In this patient, histological and hormonal findings, with results of analyses on surface and intracellular blood cells markers demonstrated significant redistribution of lymphocytes and accumulation of natural killer cells in tumour masses. It seems that dexamethasone has acted through the hypophyse against cancer.

Influence of treatment schedule on toxicity and efficacy of cyclophosphamide, epirubicin, and fluorouracil in metastatic breast cancer: a randomized trial comparing weekly and every-4-week administration

PURPOSE

To compare the effect on toxicity and efficacy of the fluorouracil 500 mg/m2, epirubicin 60 mg/m2, and cyclophosphamide 500 mg/m2 (FEC) regimen divided into 4 weekly doses with conventional every-4-week administration in metastatic breast cancer.

PATIENTS AND METHODS

The inclusion criteria demanded measurable or assessable metastases from breast cancer and a World Health Organization (WHO) performance index of 2 or less. One hundred seventy-three patients with metastatic breast cancer who had not been treated with anthracyclines were randomized to receive FEC once every 4 weeks or once a week. The scheduled monthly doses of the cytotoxic agents were identical in both groups. Three patients were excluded from analysis.

RESULTS

Hematologic toxicity, alopecia, nausea, and vomiting were significantly more severe in the group that received treatment every 4 weeks. The response rate was higher in the group that received FEC every 4 weeks than in the group treated weekly (47% v 30%, P = .02). Time to progression was significantly (P = .005) longer with every-4-week FEC treatment (median, 9.2 months v 5.4 months for weekly treatment). Patients in the group treated every 4 weeks lived significantly (P = .01) longer than patients treated weekly (median survival times, 21.2 months v 11.8 months, respectively). The actually delivered monthly dose levels and treatment duration were similar in the two groups.

CONCLUSION

Both efficacy and toxicity of FEC were greater when treatment was administered every 4 weeks rather than once a week, despite identical dose intensity.

The combination of radiotherapy, adjuvant chemotherapy (cyclophosphamide-doxorubicin-ftorafur) and tamoxifen in stage II breast cancer. Long-term follow-up results of a randomised trial

Two hundred patients with node positive stage II breast cancer were randomised to four groups after radical mastectomy and axillary evacuation: (1) Postoperative radiotherapy, (2) Adjuvant chemotherapy with eight courses of CAFt (cyclophosphamide 500 mg m-2 + doxorubicin 40 mg/m-2 + ftorafur 20 mg kg-1 orally day 1-14) every fourth week, (3) Postoperative radiotherapy and adjuvant chemotherapy and (4) postoperative radiation, adjuvant chemotherapy and tamoxifen 40 mg daily for 2 years. Thirty-two per cent of the patients discontinued treatment due to GI-toxicity, while 26% required dose reductions due to leukopenia. Radiation pneumonitis was more frequent after the combination of postoperative radiotherapy with chemotherapy. There was a better relapse-free survival in the groups receiving chemotherapy compared to radiotherapy alone (P = 0.05), which was highly significant in a multivariate Cox analysis (P = 0.004). No significant survival differences were seen. Tamoxifen had no clear overall effect but there were better relapse-free (P = 0.04) and overall (P = 0.004) survival with tamoxifen in estrogen receptor positive patients, while estrogen receptor negative patients had a somewhat poorer survival (P = 0.07) after tamoxifen. Local control was better (NS) after the combination (93%) radiotherapy and chemotherapy compared to either treatment alone (76% with radiotherapy and 74% with chemotherapy at 5 years).

Adjuvant hormone therapy in breast cancer

Recent results from controlled trials of adjuvant tamoxifen and oophorectomy in early breast cancer are reviewed. The results of the statistical overview performed by the Early Breast Cancer Trialists Collaborative Group are summarised, and some important questions left open by this overview are discussed. These include the choice of patients for adjuvant endocrine treatment, long term results of tamoxifen, interaction with postoperative radiotherapy, the effect of tamoxifen on non-cancer deaths, and interaction of the adjuvant effect of tamoxifen with concentrations of oestrogen receptor levels in the tumour.

Intra-arterial and intravenous use of 4' epidoxorubicin combined with 5-fluorouracil in primary hepatocellular carcinoma. A randomized comparison

Between October, 1986, and March, 1990, 20 consecutive untreated and noncirrhotic patients with measurable and histologically and/or cytologically confirmed unresectable primary liver cancer were randomly assigned to intravenous (10 patients) or intra-arterial (10 patients) therapy. Patients were treated every 4 weeks with a combination chemotherapy regimen containing 4' epidoxorubicin and 5-fluorouracil. A 3-min bolus injection of 4' epidoxorubicin was followed by 5-fluorouracil given in a 90-min infusion. The dose of 4' epidoxorubicin was escalated: the starting dose was 40 mg/m2, the second dose was 50 mg/m2, and thereafter 60 mg/m2 during subsequent cycles. The dose of 5-fluorouracil was always 800 mg/m2. Objective response rates (20%) were similar in both treatments; two patients had partial responses in the intra-arterially treated group and one complete and one partial response were recorded in the intravenously treated group. The median survival time was 15.2 months for the patients treated intra-arterially and 13.8 months for the patients treated intravenously. Toxicity was mainly mild in both groups with less hematopoietic toxicity in the I.A.-treated group. 4' epidoxorubicin combined with 5-fluorouracil given intra-arterially is not superior to the intravenous therapy, but it may diminish systemic toxicity.

FEC (5-fluorouracil-epirubicin-cyclophosphamide) monthly versus FEC weekly in metastatic breast cancer. First results of a randomized trial

Patients (n = 174) with metastatic breast cancer previously untreated with anthracycline cytotoxic agents were randomized into two groups: Group 1 received FEC (5-fluorouracil 500 mg/m2, epirubicin 60 mg/m2 and cyclophosphamide 500 mg/m2) once every fourth week and group 2 received the treatment once weekly in the same monthly dosage. Treatment was recommended to continue until disease progression or to a cumulative epirubicin dose of 1,000 mg/m2, but could be discontinued at any time at the patient's request or at the treating physician's judgement. An interim analysis was made when 131 patients were evaluable for response, and 128 patients for toxicity. Hematological toxicity was significantly more severe in the monthly group, as was nausea and vomiting. Of the monthly treated patients 76% had total alopecia compared to 14% in the weekly group. There were no statistically significant differences in the occurrence of mucositis. Monthly FEC gave significantly higher response rate than weekly treatment (52 vs 34%, p = 0.01). Time to progression was significantly (p = 0.004) longer with monthly FEC. Patients in the monthly treated group lived significantly (p = 0.02) longer than patients in the weekly group. These results indicate that both toxicity and efficacy of epirubicin-containing combination therapy in breast cancer is dependent on the treatment schedule, not merely on dosage. Both efficacy and toxicity increased when the treatment was given once monthly compared to the weekly schedule.

Postirradiation sarcoma. Analysis of a nationwide cancer registry material

Thirty-three cases of postirradiation sarcoma (PIS) from the files of the Finnish Cancer Registry were analyzed. The most frequent first primary tumors were cancers of the breast (seven cases) and female reproductive organs (13 cases). Five patients had a childhood cancer. The median total radiation dose at the site of the PIS was 3600 cGy (1600 cGy to 11200 cGy). The median interval from start of radiation therapy to detection of PIS was 13.2 years (3.4 to 22.8 years). The PIS was of soft tissue origin in 25 of 33 cases. The most frequent histologic types were osteosarcoma (ten cases, including four extraskeletal tumors), malignant fibrous histiocytoma (ten cases), and fibrosarcoma (six cases). The overall crude 5-year survival rate was 29% (calculated from the start of treatment for PIS), and for patients initially treated with either radical surgery or combined marginal surgery and postoperative irradiation it was 67%. The authors conclude that there is a chance for cure for radically treated patients with postirradiation sarcoma that emphasizes the importance of regular long-term follow-up of cancer patients.

Postirradiation sarcoma. Analysis of a nationwide cancer registry material

Thirty-three cases of postirradiation sarcoma (PIS) from the files of the Finnish Cancer Registry were analyzed. The most frequent first primary tumors were cancers of the breast (seven cases) and female reproductive organs (13 cases). Five patients had a childhood cancer. The median total radiation dose at the site of the PIS was 3600 cGy (1600 cGy to 11200 cGy). The median interval from start of radiation therapy to detection of PIS was 13.2 years (3.4 to 22.8 years). The PIS was of soft tissue origin in 25 of 33 cases. The most frequent histologic types were osteosarcoma (ten cases, including four extraskeletal tumors), malignant fibrous histiocytoma (ten cases), and fibrosarcoma (six cases). The overall crude 5-year survival rate was 29% (calculated from the start of treatment for PIS), and for patients initially treated with either radical surgery or combined marginal surgery and postoperative irradiation it was 67%. The authors conclude that there is a chance for cure for radically treated patients with postirradiation sarcoma that emphasizes the importance of regular long-term follow-up of cancer patients.