11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study)

BACKGROUND

The introduction of second-generation antipsychotic drugs during the 1990s is widely believed to have adversely affected mortality of patients with schizophrenia. Our aim was to establish the long-term contribution of antipsychotic drugs to mortality in such patients.

METHODS

Nationwide registers in Finland were used to compare the cause-specific mortality in 66 881 patients versus the total population (5.2 million) between 1996, and 2006, and to link these data with the use of antipsychotic drugs. We measured the all-cause mortality of patients with schizophrenia in outpatient care during current and cumulative exposure to any antipsychotic drug versus no use of these drugs, and exposure to the six most frequently used antipsychotic drugs compared with perphenazine use.

FINDINGS

Although the proportional use of second-generation antipsychotic drugs rose from 13% to 64% during follow-up, the gap in life expectancy between patients with schizophrenia and the general population did not widen between 1996 (25 years), and 2006 (22.5 years). Compared with current use of perphenazine, the highest risk for overall mortality was recorded for quetiapine (adjusted hazard ratio [HR] 1.41, 95% CI 1.09-1.82), and the lowest risk for clozapine (0.74, 0.60-0.91; p=0.0045 for the difference between clozapine vs perphenazine, and p<0.0001 for all other antipsychotic drugs). Long-term cumulative exposure (7-11 years) to any antipsychotic treatment was associated with lower mortality than was no drug use (0.81, 0.77-0.84). In patients with one or more filled prescription for an antipsychotic drug, an inverse relation between mortality and duration of cumulative use was noted (HR for trend per exposure year 0.991; 0.985-0.997).

INTERPRETATION

Long-term treatment with antipsychotic drugs is associated with lower mortality compared with no antipsychotic use. Second-generation drugs are a highly heterogeneous group, and clozapine seems to be associated with a substantially lower mortality than any other antipsychotics. Restrictions on the use of clozapine should be reassessed.

FUNDING

Annual EVO Financing (Special government subsidies from the Ministry of Health and Welfare, Finland).

The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish Study Group for Antimicrobial Resistance

BACKGROUND

In the early 1990s there was an increase in erythromycin resistance among group A streptococci in Finland. In response, policies regarding outpatient antibiotic therapy were changed, and nationwide recommendations were issued that called for reductions in the use of macrolide antibiotics for respiratory and skin infections in outpatients. We studied the effect of this policy on the pattern of erythromycin resistance throughout Finland.

METHODS

From 1991 through 1996, a total of 39,247 group A streptococcal isolates from throat swabs (82 percent of the isolates) and pus samples (18 percent) and 290 isolates from blood cultures were studied in regional microbiology laboratories. The susceptibility of the isolates to erythromycin was tested by the disk-diffusion or the screening-plate method.

RESULTS

Consumption of macrolide antibiotics decreased from 2.40 defined daily doses per 1000 inhabitants per day in 1991 to 1.38 in 1992 (P=0.007) and remained near the lower level during the study period. The change in consumption was followed by a steady decrease in the frequency of erythromycin resistance among group A streptococcal isolates from throat swabs and pus samples, from 16.5 percent in 1992 to 8.6 percent in 1996 (odds ratio for 1996 as compared with 1992, 0.5; 95 percent confidence interval, 0.4 to 0.5).

CONCLUSIONS

In Finland, after nationwide reductions in the use of macrolide antibiotics for outpatient therapy, there was a significant decline in the frequency of erythromycin resistance among group A streptococci isolated from throat swabs and pus samples.

A 10 year asthma programme in Finland: major change for the better

BACKGROUND

A National Asthma Programme was undertaken in Finland from 1994 to 2004 to improve asthma care and prevent an increase in costs. The main goal was to lessen the burden of asthma to individuals and society.

METHODS

The action programme focused on implementation of new knowledge, especially for primary care. The main premise underpinning the campaign was that asthma is an inflammatory disease and requires anti-inflammatory treatment from the outset. The key for implementation was an effective network of asthma-responsible professionals and development of a post hoc evaluation strategy. In 1997 Finnish pharmacies were included in the Pharmacy Programme and in 2002 a Childhood Asthma mini-Programme was launched.

RESULTS

The incidence of asthma is still increasing, but the burden of asthma has decreased considerably. The number of hospital days has fallen by 54% from 110 000 in 1993 to 51 000 in 2003, 69% in relation to the number of asthmatics (n = 135 363 and 207 757, respectively), with the trend still downwards. In 1993, 7212 patients of working age (9% of 80 133 asthmatics) received a disability pension from the Social Insurance Institution compared with 1741 in 2003 (1.5% of 116 067 asthmatics). The absolute decrease was 76%, and 83% in relation to the number of asthmatics. The increase in the cost of asthma (compensation for disability, drugs, hospital care, and outpatient doctor visits) ended: in 1993 the costs were 218 million euro which had fallen to 213.5 million euro in 2003. Costs per patient per year have decreased 36% (from 1611 euro to 1031 euro).

CONCLUSION

It is possible to reduce the morbidity of asthma and its impact on individuals as well as on society. Improvements would have taken place without the programme, but not of this magnitude.

Use of medications and polypharmacy are increasing among the elderly

To assess changes in medicine use and polypharmacy, two cross-sectional surveys were carried out among community-dwelling persons aged 64 years or over in 1990-91 (n = 1,131) and 1998-99 (n = 1,197) in the municipality of Lieto in southwestern Finland. In addition to drug use, the questionnaire included items on social background, quality of life, and home nursing services. Among those surveyed, 78% in 1990-1991 and 88% in 1998-1999 (P =.001) used prescription drugs during 7 days prior to the interview. The most commonly used medications were for the cardiovascular and central nervous systems. The number of medications per person increased from 3.1 (SD 2.8) to 3.8 (SD 3.1) (P =.0001), and polypharmacy (concominant use of over five medications) increased from 19 to 25% (P =.006). These changes were most prominent among persons aged 85 years or over, especially among women. Polypharmacy is a complex and worrying phenomenon that merits more research.

Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study

OBJECTIVE

To study the association between prescribed antipsychotic drugs and outcome in schizophrenia or schizoaffective disorder in the community.

DESIGN

Prospective cohort study using national central registers.

SETTING

Community care in Finland.

PARTICIPANTS

Nationwide cohort of 2230 consecutive adults hospitalised in Finland for the first time because of schizophrenia or schizoaffective disorder, January 1995 to December 2001.

MAIN OUTCOME MEASURES

Rates of discontinuation of drugs (all causes), rates of rehospitalisation, and mortality associated with monotherapy with the 10 most commonly used antipsychotic drugs. Multivariate models and propensity score methods were used to adjust estimates of effectiveness.

RESULTS

Initial use of clozapine (adjusted relative risk 0.17, 95% confidence interval 0.10 to 0.29), perphenazine depot (0.24, 0.13 to 0.47), and olanzapine (0.35, 0.18 to 0.71) were associated with the lowest rates of discontinuation for any reason when compared with oral haloperidol. During an average follow-up of 3.6 years, 4640 cases of rehospitalisation were recorded. Current use of perphenazine depot (0.32, 0.22 to 0.49), olanzapine (0.54, 0.41 to 0.71), and clozapine (0.64, 0.48 to 0.85) were associated with the lowest risk of rehospitalisation. Use of haloperidol was associated with a poor outcome among women. Mortality was markedly raised in patients not taking antipsychotics (12.3, 6.0 to 24.1) and the risk of suicide was high (37.4, 5.1 to 276).

CONCLUSIONS

The effectiveness of first and second generation antipsychotics varies greatly in the community. Patients treated with perphenazine depot, clozapine, or olanzapine have a substantially lower risk of rehospitalisation or discontinuation (for any reason) of their initial treatment than do patients treated with haloperidol. Excess mortality is seen mostly in patients not using antipsychotic drugs.

Resistance to erythromycin in group A streptococci

BACKGROUND

The use of erythromycin in Finland nearly tripled from 1979 to 1989. In 1988, we observed an unusually high frequency of resistance to erythromycin in group A streptococci in one geographic region. Because routine testing does not detect the sensitivity of these organisms to antibiotics, we initiated a national study to evaluate the extent of this resistance.

METHODS

We studied 272 isolates of group A streptococci obtained from blood cultures from 1988 through 1990. In 1990 we collected from six regional laboratories 3087 consecutive isolates from throat swabs and 1349 isolates from pus samples. Resistance was indicated by growth on blood agar containing 2 micrograms of erythromycin per milliliter after incubation in 5 percent carbon dioxide. We also evaluated the clinical importance of erythromycin resistance in a retrospective study of consecutive patients with pharyngitis.

RESULTS

The frequency of resistance to erythromycin in group A streptococci from blood cultures increased from 4 percent in 1988 to 24 percent in 1990. From January to December 1990, the frequency of resistance in isolates from throat swabs increased from 7 percent to 20 percent, and resistance in isolates from pus increased from 11 percent to 31 percent. In four communities within 50 km of each other, the frequency of erythromycin resistance ranged from 2 to 5 percent to 26 to 44 percent. Several distinct DNA restriction profiles and serotypes were found among resistant isolates from the same area, suggesting a multiclonal origin. The treatment of pharyngitis with erythromycin failed in 9 of 19 patients infected with erythromycin-resistant group A streptococci, as compared with 1 of 26 patients with erythromycin-susceptible isolates (47 percent vs. 4 percent, P = 0.008).

CONCLUSIONS

In Finland since 1988 there has been a rapid and substantial increase in resistance to erythromycin in group A streptococci. The extent of this resistance is particularly serious since there are only a few alternative antibiotics available for peroral treatment of group A streptococcal infections.

Reliability and validity of interview data on chronic diseases. The Mini-Finland Health Survey

The Mini-Finland Health Survey was designed to obtain a comprehensive picture of health and of the need for care in Finnish adults, and to develop methods for monitoring health in the population as a whole. Out of a nationally representative sample of 8000 people aged 30 or over, 7217 (90%) were both interviewed at home by local public health nurses using simple open-ended questions and, independently of this interview, subsequently examined in a two-phase health examination. The estimate of chronic morbidity based on the health interview (56%) was close to the prevalence of definite somatic diseases diagnosed in the health examination (54%), and the agreement between the two methods was moderate (kappa = 0.53). The estimated prevalence of cardiovascular diseases was the same (23%) in the health interview and in the health examination; the agreement was substantial (kappa = 0.74). The prevalence of respiratory and musculoskeletal diseases and mental disorders was underestimated in the interview by 52, 25 and 78%, respectively; the agreement between results of the two methods was relatively low (kappa = 0.43, 0.38 and 0.30, respectively). These results suggest that both the health examination and the health interview methods, as used in this survey, have useful applications in monitoring the population's health.

Risks associated with selective serotonin reuptake inhibitors in pregnancy

OBJECTIVE

To study the effects of selective serotonin reuptake inhibitors (SSRIs) on pregnancy outcome.

METHODS

We performed a population-based study of women exposed to SSRIs during pregnancy (n = 1782). Data were derived from a national project in Finland, established by 3 governmental organizations. In that project, the Drug Reimbursement Register, the Medical Birth Register, the Register of Congenital Malformations, and the Register of Induced Abortions have been linked. Comparisons were made between women with SSRI purchases to matched controls and between women with purchases in different trimesters. Only singleton pregnancies were included. Primary outcomes were major malformations, preterm birth, small for gestational age, low birth weight, and treatment in neonatal special or intensive care unit. Analyses were based on logistic models.

RESULTS

Major malformations were not more common in infants or fetuses of women with first trimester SSRI purchases (n = 1,398) when compared with controls with no drug purchases (P = .4). Of infants born to mothers with SSRI purchases in the 3rd trimester, 15.7% were treated in special or intensive care unit compared with 11.2% of infants exposed only during the 1st trimester (P = .009, adjusted odds ratio 1.6, 95% confidence interval 1.1-2.2). We found no increased risk of preterm birth (< 37 weeks), birth 32 weeks of gestation or less, small for gestational age, or low birth weight in women with purchases in each trimester or during the 2nd and 3rd trimesters when compared with women with only 1st trimester purchases.

CONCLUSION

Use of SSRIs during pregnancy is not independently associated with increased risk of adverse perinatal outcome other than need for treatment in neonatal special or intensive care unit.

Antidepressants and the risk of suicide, attempted suicide, and overall mortality in a nationwide cohort

BACKGROUND

It is unknown if antidepressant treatment is associated with either increased or decreased risk of suicide.

OBJECTIVE

To estimate the risk of suicide, attempted suicide, and overall mortality during antidepressant treatments in a real-life setting with high statistical power.

DESIGN AND SETTING

A cohort study in which all subjects without psychosis, hospitalized because of a suicide attempt from January 1, 1997, to December 31, 2003, in Finland, were followed up through a nationwide computerized database.

PARTICIPANTS

A total of 15 390 patients with a mean follow-up of 3.4 years.

MAIN OUTCOME MEASURES

The propensity score-adjusted relative risks (RRs) during monotherapy with the most frequently used antidepressants compared with no antidepressant treatment.

RESULTS

In the entire cohort, fluoxetine use was associated with the lowest risk (RR, 0.52; 95% confidence interval [CI], 0.30-0.93), and venlafaxine hydrochloride use with the highest risk (RR, 1.61; 95% CI, 1.01-2.57), of suicide. A substantially lower mortality was observed during selective serotonin reuptake inhibitor use (RR, 0.59; 95% CI, 0.49-0.71; P<.001), and this was attributable to a decrease in cardiovascular- and cerebrovascular-related deaths (RR, 0.42; 95% CI, 0.24-0.71; P=.001). Among subjects who had ever used any antidepressant, the current use of medication was associated with a markedly increased risk of attempted suicide (39%, P<.001), but also with a markedly decreased risk of completed suicide (-32%, P=.002) and mortality (-49%, P<.001), when compared with no current use of medication. The results for subjects aged 10 to 19 years were basically the same as those in the total population, except for an increased risk of death with paroxetine hydrochloride use (RR, 5.44; 95% CI, 2.15-13.70; P<.001).

CONCLUSIONS

Among suicidal subjects who had ever used antidepressants, the current use of any antidepressant was associated with a markedly increased risk of attempted suicide and, at the same time, with a markedly decreased risk of completed suicide and death. Lower mortality was attributable to a decrease in cardiovascular- and cerebrovascular-related deaths during selective serotonin reuptake inhibitor use.

Use of oral antimicrobials decreases serum enterolactone concentration

The lignan enterolactone, a phytoestrogen, may protect against hormone-dependent cancers and cardiovascular diseases. It is produced by the intestinal microflora from dietary precursors. Because of the pronounced impact of antimicrobials on the intestinal microflora, the authors examined whether serum enterolactone concentration is affected by previous use of oral antimicrobials. Enterolactone was measured by time-resolved fluoroimmunoassay in 2,753 Finnish men and women aged 25--64 years who participated in a cross-sectional national survey in 1997. Background information was collected by self-administered questionnaire, and data on antimicrobial treatment were gathered from the nationwide prescription database of the Social Insurance Institution. Serum enterolactone concentration was significantly lower in those who had used oral antimicrobials up to 12--16 months before serum sampling than in nonusers (16.4 vs. 19.3 nmol/liter). The concentration was associated with the number of treatments and the time from the last treatment. Modest differences were present between various antimicrobials. The authors' findings support the crucial role of gut microflora in the metabolism of lignans. Furthermore, recent use of antimicrobials should be considered when the association between serum enterolactone concentration and risk of chronic diseases is studied.

Incidence of cancer and statin usage--record linkage study

The consumption of statins (HMG-CoA reductase inhibitors) has been increasing, and a substantial part of the middle-aged and elderly population use them continuously. Because a large fraction of the population is exposed, even a small excess of risk with respect to cancer should be considered. We carried out a record-linkage study in Finland utilizing nationwide databases of reimbursed statin medication and cancer. The study population included all statin users in Finland who had purchased at least 1 prescription between 1996 and 2005 and who had no cancer diagnosis at the date of first purchase. A control population without statin usage was also included. Data consisted of 472,481 pairs of individuals that cumulated 4.2 million person years with an average of 8.8 years of follow-up. Fifty thousand two hundred ninety-four cancer cases were observed. Simvastatin and atorvastatin were the most used substances. The most frequent cancers were prostate, breast, lung, colon, and rectum cancer. In general, no association between the utilization of statins and cancer could be detected. In conclusion, this study adds large-scale, population-based results about the association between statin utilization and the incidence of cancer. We found neither beneficial nor harmful associations between the usage of statins and cancer.

Work is related to a substantial portion of adult-onset asthma incidence in the Finnish population

There are no population-based follow-up studies to estimate the fraction of asthma incidence that is attributable to work. In Finland, individuals with clinically well-established persistent asthma are registered for reimbursement of medication from the national health insurance scheme. We combined, at an individual level, these data with the population census data of 1985, 1990, and 1995 to estimate the attributable fraction of work in adult-onset persistent asthma. Our follow-up study covered the entire 25- to 59-yr-old employed population of Finland in 1986-1998. Relative risks (RR) for occupational categories were estimated in comparison to those employed in administrative work. There were 49,575 incident cases of asthma. The attributable fraction of occupation was 29% (95% CI 25-33%) for men and 17% (95% CI 15-19%) for women. The risk was increased especially in agricultural work, manufacturing work, and service work. In addition to already established risk occupations of occupational asthma, such as food and beverage work, the analysis identified a large number of occupations with significant excess of asthma incidence. The results indicate that the impact of occupational factors in the inception of adult-onset persistent asthma, and consequently the potential for prevention, is much larger and more widely spread than generally assumed.

NSAID use and the risk of hospitalization for first myocardial infarction in the general population: a nationwide case-control study from Finland

AIMS

To evaluate the risk of first myocardial infarction (MI) associated with the use of various non-steroidal anti-inflammatory drugs (NSAIDs) in the general population.

METHODS AND RESULTS

We conducted a population-based matched case-control study over the years 2000-3 in outpatient residents of Finland. In the nationwide Hospital Discharge Register 33 309 persons with first time MI were identified. A total of 138 949 controls individually matched for age, gender, hospital catchment area, and index day were selected from the Population Register. For combined NSAIDs, the adjusted odds ratio for the risk of first MI with current use was 1.40 (95% CI, 1.33-1.48). The risk was similar for conventional (1.34; 1.26-1.43), semi-selective (etodolac, nabumetone, nimesulide, and meloxicam) (1.50; 1.32-1.71), and cyclo-oxygenase-2 (COX-2) selective NSAIDs (rofecoxib, celecoxib, valdecoxib, and etoricoxib) (1.31; 1.13-1.50). Age of current user did not consistently modify the risk. No NSAID was associated with an MI-protective effect. All durations from 1 to 180 days of conventional NSAIDs and from 31 to 90 days duration of COX-2 selective NSAIDs were associated with an elevated risk of MI.

CONCLUSION

Current use of all NSAIDs is associated with a modest risk of first time MI.

Reliability of perceived health by sex and age

The aim of this study was to assess the test-retest reliability of a measure of perceived general health by sex and age. The study analyzed data from the nationally representative Mini-Finland Health Survey of 8000 adults aged 30 and over. The subjects were invited to attend a personal health interview and a health examination in 1978-1980. Altogether 7217 persons participated. Perceived general health was measured at the personal health interview and in the self-administered questionnaire 1-6 weeks apart. The identical questions were: how would you assess your current health? The response alternatives were good, fairly good, intermediate, fairly poor, poor and cannot say. This study showed that among men and women unweighted agreement of the 'good-intermediate-poor' categorization of perceived health was around 70% and unweighted kappa-values were around 0.5. Only in the oldest age-group (75+) reliability declined below these levels. The fair or good reliability of perceived health observed in this study gives additional confidence for using this general measure of overall health status in future research.

Outpatient use of erythromycin: link to increased erythromycin resistance in group A streptococci

Resistance to erythromycin in group A streptococci has become an important problem among outpatients in Finland. The prevention of such problems requires information about the relationship between antimicrobial consumption and antimicrobial resistance. Having found considerable variation among health authority areas in the proportions of group A streptococci resistant to erythromycin, we investigated the potential impact of local differences in the consumption of this agent on the development of resistance. In 1992, 10,162 group A streptococcal isolates (nearly 100% were from outpatients) collected from 206 health authority areas were tested for erythromycin resistance; 1,647 isolates (16%) were resistant. Logistic regression analysis showed that the proportion of isolates resistant to erythromycin clearly increased with increasing local erythromycin consumption by outpatients in 1991 (P = .006). This positive association indicates that a prudent policy for the treatment of outpatients is essential to maintenance of the effectiveness of antimicrobial agents.

Perinatal factors and the risk of asthma in childhood--a population-based register study in Finland

The aim of the study was to assess whether perinatal factors are associated with the risk of asthma in childhood in a register-based, nested case-control study in Finland. All children born between January 1, 1996, and April 30, 2004, who were entitled to a special reimbursement for antiasthmatic drugs (i.e., had diagnosed asthma by 2006 and had purchased inhaled corticosteroids or montelukast at least once), were identified (n = 21,038). For each case, one matched control child was selected. The associations between perinatal factors, derived from the Finnish Medical Birth Register, and the risk of asthma were analyzed by conditional logistic regression. In the final multivariate model, maternal asthma, young age, smoking, previous miscarriages, and a high number of previous deliveries, as well as cesarean section, low gestational age, and low ponderal index, were associated with an increased risk of asthma in children diagnosed before the age of 3 years. Among children diagnosed at the age of 3 years or later, maternal asthma, low gestational age, and low ponderal index were associated with an increased risk, and a high number of previous deliveries was associated with a decreased risk of asthma. In conclusion, perinatal factors play a role in the development of asthma in childhood, but the etiology may differ in early and late-onset asthma.

Antibiotic use predicts an increased risk of cancer

Antibiotic use has been hypothesized to be associated with the risk of cancer but the evidence is sparse and inconsistent. The aim of the present study was to determine whether antibiotic use predicts the development of various cancers. This nationwide cohort study included 3,112,624 individuals, aged 30-79 years, with no history of cancer. Information on their antibiotic use between 1995 and 1997 was obtained from the Drug Prescription Registry. During the period 1998-2004, 134,070 cancer cases were ascertained from the Finnish Cancer Registry. Cox proportional hazards regression was used to estimate the relative risks (RRs) with 95% confidence intervals (95% CIs). Antibiotic use was associated with an increased risk of cancer: for categories of increasing antibiotic use (0-1, 2-5 and >/=6 prescriptions), RRs (95% CIs) for cancer were 1.0 (reference), 1.27 (1.26-1.29) and 1.37 (1.34-1.40). RRs (for comparison of lowest and highest exposure group) for the most common primary sites i.e. prostate, breast, lung and colon were 1.39 (1.31-1.48), 1.14 (1.09-1.20), 1.79 (1.67-1.92), and 1.15 (1.04-1.26), respectively. RRs for other primary sites varied between 0.90 (0.76-1.05) for ovary to 2.60 (1.60-4.20) for endocrine gland (excluding thyroid). In conclusion, antibiotic use predicts an increased risk of cancer. Because of the design of our study the possibility of residual confounding cannot be excluded and further studies are required to confirm the results.

Social inequalities in antidepressant treatment and mortality: a longitudinal register study

BACKGROUND

Despite an increased prevalence of depression among people of low socio-economic position, it remains unclear whether their treatment with antidepressants appropriately matches their increased need compared with people from more affluent backgrounds. This study examined socio-economic differences in antidepressant prescriptions and mortality related to depressive disorders.

METHOD

A longitudinal register study of 17947 male and 47458 female local government employees with linked information on socio-economic indicators (education and occupational status) and data on antidepressant use and mortality associated with depressive disorder (suicide, alcohol-related deaths) during the years 1994 to 2000.

RESULTS

In men, antidepressant treatment was less common among low educational groups than among high educational groups (OR 0.87, 95% CI 0.76-0.99) and a corresponding difference was seen between occupational statuses (OR for manual v. upper non-manual 0.72, 95% CI 0.62-0.84). In women, socio-economic position was not associated with antidepressant use. However, both among the men and women, employees with low socio-economic position had increased risk for mental-health-related mortality, as indicated by suicides, deaths from alcohol-related causes, and all-cause mortality.

CONCLUSIONS

These data suggest a mismatch in the treatment of depression relative to apparent clinical need, with the lowest levels of treatment concentrated in the lower socio-economic groups, despite evidence of their increased prevalence of depression and suicide.

Interleukin-10 gene promoter region polymorphism is associated with eosinophil count and circulating immunoglobulin E in adult asthma

BACKGROUND

IL-10 has several functional effects relevant to asthma. It can modulate IgE production and induce apoptosis in eosinophils. Polymorphisms of IL-10 gene have been shown to affect IL-10 production.

OBJECTIVE

To establish whether IL-10 polymorphisms are associated with asthma and phenotype-related characteristics.

METHODS

The frequency of three single base exchange polymorphisms (at positions - 1082, - 819 and - 592) and corresponding haplotypes of the IL-10 gene were analysed in 245 adult asthmatic subjects and 405 controls using PCR and restriction fragment length polymorphism (RFLP). The data were assessed for correlations with the eosinophil count, serum IgE and lung function.

RESULTS

The IL-10 haplotype frequencies were similar in asthmatics and controls. Eosinophil count median was 2.0- to 3.2-fold higher among asthmatics with rare ATA/ATA genotype than in asthmatics with other genotypes. No such difference was seen in the control group. When analysed by IL-10 haplotype carrier state and gender, male asthmatics with ATA haplotype had 2.8-fold higher serum IgE than those without ATA. A converse association was found in male controls with ATA haplotype, who had 1.9-fold lower serum IgE than their ATA-negative counterparts. The high IL-10-producing GCC haplotype was associated with impaired lung function in smoking male controls while in asthmatics no clear effect on lung function was found with any of the haplotypes studied.

CONCLUSION

These results suggest that the eosinophil counts and serum IgE are differently regulated by IL-10 genotype in asthmatic and in normal subjects. However, IL-10 polymorphism is not related to susceptibility in asthma.

Macrolide-resistant Streptococcus pneumoniae and use of antimicrobial agents

The prevalence of isolates of Streptococcus pneumoniae (pneumococcus) that are resistant to antimicrobial agents is increasing globally. We studied the connection between antimicrobial resistance of pneumococci and regional use of antimicrobial agents in Finland. In 1997, a total of 6106 pneumococcal isolates were identified in clinical microbiology laboratories in Finland. Most of the pneumococci were isolated from respiratory tract samples, 8% were from blood culture samples, and 0.5% were from cerebrospinal fluid samples. The regional levels of resistance for pneumococci in 1997 were compared with the regional rates of use of antimicrobial agents from 1995 through 1996. We found that resistance to macrolides correlated highly significantly with macrolide use (P=.006). A significant correlation was also found between resistance to trimethoprim-sulfamethoxazole and trimethoprim-sulfamethoxazole use (P=.043). We did not find a correlation between penicillin resistance and the use of any antimicrobial agent. The positive correlation between macrolide-resistant pneumococci and the use of macrolides is worrying, because macrolides are used worldwide in the treatment of patients with respiratory tract infections, which are often caused by pneumococci.

Mycobacterium tuberculosis infection and the subsequent development of asthma and allergic conditions

BACKGROUND

Epidemiologic studies have suggested that certain viral infections, as well as exposure to Mycobacterium tuberculosis in early life, could, at least to some extent, prevent the subsequent development of atopic disease.

OBJECTIVE

We investigated whether M tuberculosis infection in childhood or adolescence has any effect on the development of asthma and allergic conditions in later life.

METHODS

The study subjects (n = 1162) were individuals notified to the National Tuberculosis Registry between January 1, 1966, and December 31, 1969, who were 20 years of age or younger and had verified or justifiably probable new active tuberculosis of respiratory or other organs. The control subjects were age-matched, sex-matched, and geographically matched control pairs from the Population Registry of the Social Insurance Institution in Finland. The subjects were followed for 28 to 32 years. The prevalence of persistent asthma and allergic conditions among men and women at the end of 1997 were calculated on the basis of the Drug Reimbursement Registry of the Social Insurance Institution in the whole study population and in the subgroup of subjects aged 16 years or younger at the time of M tuberculosis infection.

RESULTS

In women a significantly lower prevalence of persistent asthma was found among those aged 16 years or younger at the time of M tuberculosis infection than among the control subjects (3.7% vs 8.3%, respectively; P =.035). The women with a history of tuberculosis also showed a significantly lower prevalence of allergic conditions than the control subjects (8.3% vs 14.0%, respectively; P =.003) when the whole study population of women was considered. In men, however, the only significant difference between the cases and control subjects was found for persistent asthma, with the cases showing a significantly higher prevalence than the control subjects (4.4% and 1.8%, respectively; P =.008).

CONCLUSION

M tuberculosis infection in childhood significantly reduced the occurrence of subsequent asthma in women. Moreover, this infection was also found to reduce the occurrence of allergic conditions in later life in women. By contrast, no suppressive effect of M tuberculosis infection in childhood or adolescence on the later development of asthma or allergic conditions could be observed in men. The differences in the natural history of atopic disease between the sexes and the occurrence of tuberculosis mostly in later childhood and adolescence may largely explain our findings.

Risk of asthma among Finnish patients with occupational rhinitis

STUDY OBJECTIVES

To determine the risk of asthma among patients with occupationally induced rhinitis.

DESIGN

Patients with confirmed occupational rhinitis were followed for asthma incidence through register linkage. Patients with other occupational diseases were used as a reference population.

SUBJECTS

Patients entered into the Finnish Register of Occupational Diseases in from 1988 to 1999 for occupational rhinitis (n = 3,637) or other occupational disease (n = 31,457) were observed until December 31, 2000, through two national registers of individuals who were eligible for the reimbursement of asthma medication and the Population Register Center.

METHODS

Incidence rates of asthma were calculated, and a log-linear model, adjusted for age, gender, and occupation, was used to estimate the relative risks (RRs) of asthma among those with occupational rhinitis compared to those with other occupational diseases.

RESULTS

There were 420 and 972 incident cases of asthma, respectively, among those with occupational rhinitis and the reference population. The crude RR of asthma was 4.8 (95% confidence interval [CI], 4.3 to 5.4) for all patients with occupational rhinitis, 5.4 (95% CI, 4.8 to 6.2) for those with occupational rhinitis accepted for compensation, and 3.7 (95% CI, 3.1 to 4.5) for patients with unaccepted occupational rhinitis. The RR varied according to occupation and was the highest among farmers and wood workers, both groups having a sevenfold risk. The risk was especially high during the year following notification, but a roughly threefold risk persisted several years thereafter.

CONCLUSIONS

Patients with occupationally induced rhinitis have a high risk of asthma, but further studies are needed to establish the effect of preventive interventions.

Psychotropics among the home-dwelling elderly--increasing trends

OBJECTIVE

To assess the level of and changes in the use of psychotropics among the home-dwelling elderly in the 1990s.

METHODS

A descriptive analysis based on data from two cross-sectional interview and health examination surveys of elderly persons aged 64 years or over conducted in Lieto, a typical semi-rural Finnish municipality, in 1990-91 and 1998-99. National prescription data were utilized to compare the use of psychotropics in the late 1990s by all Finnish home-dwelling elderly and the elderly in Lieto. In Lieto drug information was obtained from 1131 persons in 1990-91 and from 1197 in 1998-99, and the mean age of the informants was 73 years in both surveys. The brand names of the prescription drugs (both irregular and regular medication) taken by each interviewee during seven days prior to the interview were recorded and categorized by the Anatomical Therapeutic Chemical (ATC) classification system.

RESULTS

Every fourth person was taking at least one psychotropic drug in both surveys. Most users were on regular psychotropic medication. The use of hypnotics and antidepressants increased most during the study period. Polypharmacy and the use of psychotropics were most prevalent among those aged 85 years or over, with women predominating. Concomitant use of two or more psychotropics increased statistically significantly from 7% to 10% between the surveys. The young elderly, aged 64-71 years, used cyclic antidepressants equally commonly in both surveys. None of the young elderly used new atypical antipsychotics in 1998-99.

CONCLUSIONS

Psychotropics tend to be overprescribed and overused among the elderly, a group at the highest risk of adverse drug reactions. The tendency of prescribing for the elderly is not going in a better direction. New-generation psychotropics were not used. The need for long-standing use of psychotropics should be assessed regularly.