Self-report dieting and long-term changes in body mass index and waist circumference.

OBJECTIVE: This prospective study explores whether dieting attempts and previous changes in weight predict changes in body mass index (BMI) and waist circumference (WC). METHODS: The study was based on the representative Finnish Health 2000 Survey and on its follow-up examination 11 years later. The sample included 2,785 participants, aged 30-69. BMI and WC were determined at health examinations. Information on dieting attempts and previous changes in weight was collected using a questionnaire including questions on whether participant had tried to lose weight (no/yes), gained weight (no/yes) or lost weight (no/yes) during the previous year. RESULTS: At baseline, 32.8% were dieters. Of these, 28.4% had lost weight during the previous year. Dieters had higher BMI and WC than non-dieters. During the follow-up, the measures increased more in dieters and in persons with previous weight loss. The mean BMI changes in non-dieters versus dieters were 0.74 (standard deviation [SD] 2.13) kg/m2 and 1.06 (SD 2.77) kg/m2 (P = 0.002), respectively. The corresponding numbers for those with no previous weight change versus those who had lost weight were 0.65 (SD 2.07) kg/m2 and 1.52 (SD 2.61) kg/m2. The increases in BMI and WC were most notable in dieters with initially normal weight. CONCLUSIONS: The increases in BMI and WC were greater in dieters than in non-dieters, suggesting dieting attempts to be non-functional in the long term in the general population.

The outcome of short- and long-term psychotherapy 10 years after start of treatment.

BACKGROUND: Empirical evidence on whether patients' mental health and functioning will be more improved after long-term than short-term therapy is scarce. We addressed this question in a clinical trial with a long follow-up. METHOD: In the Helsinki Psychotherapy Study, 326 out-patients with mood or anxiety disorder were randomly assigned to long-term psychodynamic psychotherapy (LPP), short-term psychodynamic psychotherapy (SPP) or solution-focused therapy (SFT) and were followed for 10 years. The outcome measures were psychiatric symptoms, work ability, personality and social functioning, need for treatment, and remission. RESULTS: At the end of the follow-up, altogether 74% of the patients were free from clinically elevated psychiatric symptoms. Compared with SPP, LPP showed greater reductions in symptoms, greater improvement in work ability and higher remission rates. A similar difference in symptoms and work ability was observed in comparison with SFT after adjustment for violations of treatment standards. No notable differences in effectiveness between SFT and SPP were observed. The prevalence of auxiliary treatment was relatively high, 47% in SFT, 58% in SPP and 33% in LPP, and, accordingly, the remission rates for general symptoms were 55, 45 and 62%, respectively. CONCLUSIONS: After 10 years of follow-up, the benefits of LPP in comparison with the short-term therapies are rather small, though significant in symptoms and work ability, possibly due to more frequent use of auxiliary therapy in the short-term therapy groups. Further studies should focus on the choice of optimal length of therapy and the selection of factors predicting outcome of short- v. long-term therapy.

Therapists' professional and personal characteristics as predictors of outcome in long-term psychodynamic psychotherapy and psychoanalysis.

BACKGROUND: Whether long-term psychodynamic therapy (LPP) and psychoanalysis (PA) differ from each other and require different therapist qualities has been debated extensively, but rarely investigated empirically. METHODS: In a quasi-experimental design, LPP was provided for 128 and PA for 41 outpatients, aged 20-46 years and suffering from mood or anxiety disorder, with a 5-year follow-up from start of treatment. Therapies were provided by 58 experienced therapists. Therapist characteristics, measured pre-treatment, were assessed with the Development of Psychotherapists Common Core Questionnaire (DPCCQ). General psychiatric symptoms were assessed as the main outcome measure at baseline and yearly after start of treatment with the Symptom Check List, Global Severity Index (SCL-90-GSI). RESULTS: Professionally less affirming and personally more forceful and less aloof therapists predicted less symptoms in PA than in LPP at the end of the follow-up. A faster symptom reduction in LPP was predicted by a more moderate relational style and work experiences of both skillfulness and difficulties, indicating differences between PA and LPP in the therapy process. CONCLUSIONS: Results challenge the benefit of a classically "neutral" psychoanalyst in PA. They also indicate closer examinations of therapy processes within and between the two treatments, which may benefit training and supervision of therapists.

Psychological predictors on the outcome of short-term psychodynamic psychotherapy and solution-focused therapy in the treatment of mood and anxiety disorder.

OBJECTIVE: Patient's pre-treatment suitability for short-term psychodynamic psychotherapy (STPP) and solution-focused therapy (SFT) has not been compared. The aim of this study was to compare the prediction of psychological suitability measures on outcome of STPP vs. SFT. METHOD: Altogether 198 patients with mood or anxiety disorder were randomized to STPP or SFT. A 7-item Suitability for Psychotherapy Scale (SPS) was assessed at baseline and a cumulative SPS score was formed. Psychiatric symptoms were measured using SCL-90-GSI at baseline and seven times during a 3-year follow-up. RESULTS: The SPS score predicted the outcome of both short-term psychotherapies; for patients with a good score short-term therapies seemed beneficial, whereas for patients with a poor score they did not seem sufficient. There was no difference between STPP and SFT in the prediction of the SPS score. CONCLUSIONS: Psychological suitability measures may apparently be useful in the prediction of overall short-term psychotherapy outcomes.

Prediction of the outcome of short- and long-term psychotherapy based on socio-demographic factors.

BACKGROUND: Socio-demographic factors predict the outcome of short-term psychotherapy (STT) in the treatment of mood and anxiety disorders, but information on the prediction for long long-term therapy (LPP) is lacking. We aimed to compare the prediction of changes in psychiatric symptoms afforded by socio-demographic factors across two treatment conditions, short- versus long-term psychotherapy. METHODS: In the Helsinki Psychotherapy Study, 326 outpatients with mood or anxiety disorders, aged 20-46 years, were randomly assigned to STT or LPP. Socio-demographic factors (i.e. age, gender, education, employment status, marital status, and living arrangement) were self-reported. Psychiatric symptoms were measured by the Symptom Check List, Global Severity Index (SCL-90-GSI) and Anxiety scale (SCL-90-Anx), and the Beck Depression Inventory (BDI) at baseline and seven times during a three-year follow-up period. RESULTS: Socio-demographic factors were found to predict symptom development during follow-up irrespective of the baseline symptom level. Patients in a relatively good position, i.e. married and highly educated patients benefited from STT, whereas patients in less advantaged positions, i.e. homemakers, lone parents, and divorced patients needed LPP or did not benefit from either therapy. In several categories of socio-demographic factors, the extent to which a patient's background predicted the outcome of the psychotherapy varied according to whether general, anxiety or depressive symptoms were studied. LIMITATIONS: We were unable to assess widows and pensioners. For ethical reasons, a no-treatment control group with a long follow-up could not be included in the study design. CONCLUSIONS: Socio-demographic factors may need to be considered in the selection of patients for short- and long-term therapy.

Changes in lifestyle for psychiatric patients three years after the start of short- and long-term psychodynamic psychotherapy and solution-focused therapy.

OBJECTIVES: Lifestyle is less favourable among individuals suffering from psychiatric disorders. We studied whether psychotherapy brings along changes in lifestyle and whether these changes differ between short-term and long-term psychodynamic psychotherapy (SPP and LPP) and solution-focused therapy (SFT). METHODS: A total of 326 outpatients, 20-46 years of age, with mood or anxiety disorder were randomly assigned to LPP, SPP and SFT. The lifestyle variables considered were alcohol consumption, smoking, body mass index (BMI), leisure time exercise and serum cholesterol. The patients were monitored for three years from the start of treatment. RESULTS: During the three-year follow-up, BMI and serum cholesterol rose statistically significantly although no statistically significant trends were shown for alcohol consumption, smoking or exercise. SPP showed a disadvantage of increased alcohol consumption and serum cholesterol level when compared with LPP. SFT showed an advantage of reduced smoking in comparison with SPP. DISCUSSION: Small therapy-specific changes in lifestyle may be a result from psychotherapy treatment. These lifestyle changes are apparently more common in short-term therapy. More studies are needed to verify these findings.

Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up.

BACKGROUND: Insufficient evidence exists for a viable choice between long- and short-term psychotherapies in the treatment of psychiatric disorders. The present trial compares the effectiveness of one long-term therapy and two short-term therapies in the treatment of mood and anxiety disorders. METHOD: In the Helsinki Psychotherapy Study, 326 out-patients with mood (84.7%) or anxiety disorder (43.6%) were randomly assigned to three treatment groups (long-term psychodynamic psychotherapy, short-term psychodynamic psychotherapy, and solution-focused therapy) and were followed up for 3 years from start of treatment. Primary outcome measures were depressive symptoms measured by self-report Beck Depression Inventory (BDI) and observer-rated Hamilton Depression Rating Scale (HAMD), and anxiety symptoms measured by self-report Symptom Check List Anxiety Scale (SCL-90-Anx) and observer-rated Hamilton Anxiety Rating Scale (HAMA). RESULTS: A statistically significant reduction of symptoms was noted for BDI (51%), HAMD (36%), SCL-90-Anx (41%) and HAMA (38%) during the 3-year follow-up. Short-term psychodynamic psychotherapy was more effective than long-term psychodynamic psychotherapy during the first year, showing 15-27% lower scores for the four outcome measures. During the second year of follow-up no significant differences were found between the short-term and long-term therapies, and after 3 years of follow-up long-term psychodynamic psychotherapy was more effective with 14-37% lower scores for the outcome variables. No statistically significant differences were found in the effectiveness of the short-term therapies. CONCLUSIONS: Short-term therapies produce benefits more quickly than long-term psychodynamic psychotherapy but in the long run long-term psychodynamic psychotherapy is superior to short-term therapies. However, more research is needed to determine which patients should be given long-term psychotherapy for the treatment of mood or anxiety disorders.

A case study in comparing therapies involving informative drop-out, non-ignorable non-compliance and repeated measurements.

Virtually no comparisons of different psychotherapies with long follow-up times have been carried out until now. The Helsinki Psychotherapy Study is a randomized clinical trial, where patients were monitored for 12 months after the onset of study treatments, of which each lasted approximately 6 months. The patients' psychiatric status was measured at five pre-determined time points during the follow-up period. In general, the analyses of trials are complicated in cases where compliance with the given treatment is incomplete or the drop-out from the follow-up is non-ignorable. In the present study, the quality of the treatment deviated from the protocol for some patients and some patients took auxiliary treatments which had similar effects to the study treatment during the study treatment or follow-up period. This might have resulted in standard intention-to-treat analyses providing excessively conservative or liberal conclusions. Non-compliance may have been non-ignorable in some cases, so subject-specific latent factors may have influenced the outcome both directly and indirectly via compliance behaviour. The most and least healthy patients are the most likely to dropout from the follow-up a priori, so the missing data process is informative. The missing data can partly be augmented with surrogate information collected during interviews with patients who dropped out. A Bayesian hierarchical as-treated model, which uses random-effects-based selection models to account for non-ignorable missing data and non-compliance, was compared with different mixed effects models.

Distal pulse palpation: is it reliable?

The aim of this study was to evaluate the reliability of distal pulse palpation. The dorsalis pedis and the tibialis posterior arteries of 25 patients with suspected lower limb arterial disease were independently palpated by three vascular surgeons and three medical students in the outpatient clinic and by two vascular nurses and one physician in the vascular laboratory. The palpation findings were compared to the ankle/brachial index (ABI). Palpable and unpalpable pulses were best separated with ABI 0.76 as the cutoff point. The degree of misdiagnosis was unacceptably high, with an underdiagnosis of more than 30%. The agreement was highest (kappa 0. 68, good) among the vascular laboratory personnel in the peaceful vascular laboratory and lowest (kappa 0.38, fair) among the vascular surgeons in the busy outpatient clinic. The poor agreement and the high proportion of misdiagnosis obtained in the outpatient clinic argue against the use of pulse palpation as a single diagnostic method. Palpable pulses with low ABIs clearly state the need for more objective measurements whenever ischemia is suspected. Yet, by carefully palpating both pedal arteries under good, nonhurried conditions the reproducibility and accuracy of pulse palpation can be tolerable.

Aortofemoral surgery and sexual function.

OBJECTIVES: To determine the incidence and pathophysiology of erectile dysfunction (ED) in patients with aortoiliac occlusive disease (AIOD) and the effects of aortofemoral surgery, including endarterectomy (E) and reconstruction (R), on erectile function (EF). DESIGN: Evaluation of EF before and 3 months after surgery. METHODS: 31 out of 40 male patients scheduled for aortofemoral surgery were given multiple choice questionnaires and penile dynamic Colour Doppler Ultrasonography. RESULTS: Of the 31 who agreed to enter the study five (16%) were found to be potent and 26 (84%) to suffer from ED. This was purely arteriogenic in 8% of the cases, purely venogenic in 23%, combined arteriogenic and venogenic in 53%, and neurogenic in 16%. Twenty patients returned for postoperative evaluation of EF, nine who had undergone E and 11 who had undergone R. Improvement of EF, in terms of increased penile arterial inflow, occurred in seven patients, six who had undergone E and one who had undergone R. EF remained unchanged in nine patients, three who had undergone E and six who had undergone R. Deterioration of EF occurred in four patients, all who had undergone R, and was attributable to decreased arterial inflow in two cases and to neurogenic surgical injury in the other two. CONCLUSIONS: The majority of patients with AIOD suffers from ED. Reduced penile arterial inflow and cavernovenous leakage are equally important in the pathophysiology of ED in patients with AIOD, suggesting that atherosclerosis may also compromise the penile veno-occlusive mechanism. Endarterectomy seems more likely than reconstruction to improve or maintain EF.

Ability to work after arterial surgery for chronic incapacitating ischaemia of the lower limb in middle-aged patients.

OBJECTIVE: To assess the efficacy of arterial surgery in restoring ability to walk and working capacity. DESIGN: Retrospective follow up study. SETTING: Fourth Department of Surgery, Helsinki University Central Hospital. SUBJECTS: 67 middle-aged patients (mean age 53 years) with chronic incapacitating ischaemia of the lower limb. INTERVENTIONS: Arterial reconstruction. MAIN OUTCOME MEASURES: Clinical outcome, vascular laboratory assessments, mortality, morbidity, return to work, and retirement. RESULTS: According to objective vascular laboratory criteria a primary positive effect was achieved in 63/67 (94%). Fourty-eight of the 65 surviving patients (74%) were free of symptoms on treadmill testing three months after the operation. Working capacity was restored in 41/50 of the patients not yet retired (82%). Three years postoperatively 77% of the surviving patients still fared objectively better than before operation. The 10-year survival rate was 67%. Fourteen of the 22 patients who died did so of cardiovascular diseases (64%). Advanced distal ischaemia (indicated by a preoperative ankle-brachial index of 0.5 or less) was associated with increased risk of death. Altogether 251 working years were achieved of the 435 that could have potentially been gained. The most common reason for retirement during follow up was progression of peripheral arterial disease in the lower limbs in 13/41 patients (32%). At the end of the study there were nine patients still working with potentially 73 working years left. CONCLUSION: These results indicate that arterial surgery can restore working capacity in middle aged patients with threatening or temporary invalidity. Long term outcome, especially mortality, is mostly affected by other signs of cardiovascular disease, whereas working capacity is dependent on a wider variety of factors.

Cardiac arrhythmias and myocardial ischemia after thoracotomy for lung cancer.

The records of 598 patients undergoing a thoracic surgical procedure for lung cancer from 1975 through 1989 were reviewed for occurrence of cardiac arrhythmias and myocardial ischemic events. Atrial tachycardias occurred in 16% (94/598); atrial fibrillation was preponderant (87%), followed by supraventricular tachycardia and atrial flutter. Patients with recurrent episodes of dysrhythmias had a significantly higher mortality rate than those without episodes or with a single episode only (17% versus 2.4%; p less than 0.01). Transient ischemic electrocardiographic changes were documented in 23 patients (3.8%) and myocardial infarction in 7 (1.2%). An abnormal preoperative exercise test result and intraoperative hypotension were strongly associated with both dysrhythmia and ischemia (p less than 0.01). Pneumonectomy, ischemic changes on the electrocardiogram, and cardiac enlargement were also associated with arrhythmias (p less than 0.01). A weaker association (p less than 0.05) was found between postoperative arrhythmias and old myocardial infarction (greater than 6 months), arterial hypertension, and heart failure. Pulmonary function had no predictive value in this respect. A history of angina or old myocardial infarction was predictive of transient postoperative myocardial ischemia but not myocardial infarction. Despite improved anesthetic and monitoring techniques and more frequent use of the intensive care unit postoperatively in the last decade, the incidence of arrhythmias after thoracotomy has not decreased. More effective prevention is needed, particularly for patients with defined preoperative and perioperative risk factors.

The effect of acetylsalicylic acid on the outcome after lower limb arterial surgery with special reference to cigarette smoking.

A prospective controlled study of 144 patients with peripheral obstructive arterial disease was undertaken to evaluate the efficacy of acetylsalicylic acid (ASA) treatment (250 mg daily) on the outcome after lower limb arterial surgery which mainly involved endarterectomy. By random enrollment, 2 groups of 72 patients were formed after the surgery. Patients with ASA treatment for 3 months, starting from the seventh postoperative day, were compared with patients who were not treated with ASA. The patients in both groups had similar characteristics as to sex ratio, age, concomitant diseases, preoperative arm-ankle systolic blood pressure index, and type and primary success of the reconstruction. Forty-seven of the ASA-treated and 48 of the untreated patients reported to continue cigarette smoking. Postoperative ASA-treatment protected against local adverse events which occurred in 15 patients (21%) of the ASA-treated group compared with 31 patients (43%) of the untreated group (p less than 0.01). Among heavy smokers (greater than 15 cigarettes/day) the efficacy of antiplatelet treatment was not detectable. These results imply that, in patients with peripheral arterial disease, ASA prevents platelet interaction to endarterectomized and atherosclerotic lower limb arteries thereby affecting the subsequent risk of occlusion; however, heavy cigarette smoking, which is very common among patients with peripheral arterial disease, counteracts the local antithrombotic potency of ASA.

How many projections are really needed in angiographic assessment of the femoral bifurcation?

The purpose of this study was to analyze how many angiographic projections are needed in the diagnosis of hemodynamically significant stenoses of the femoral bifurcation. A total of 134 femoral bifurcations were examined with triplanar angiography in 67 patients (45 men and 22 women). The patients, ranging in age from 42 to 81 years (mean 63), suffered from incapacitating symptoms of peripheral arterial disease. The contralateral posterior oblique projection proved to be the most valuable in the assessment of hemodynamically significant arterial stenoses of the femoral bifurcation. An AP projection added information on stenoses of the inlets of the deep femoral artery in 9% of cases and on stenoses of the inlets of the superficial femoral artery in 6% of cases. An arteriographic examination should be started with a contralateral posterior oblique projection and this view will suffice in most cases.

[Vascular surgery in Finland]. / Kärlkirurgi i Finland.

The number of vascular operations performed in Finland correspond to those in Europe as a whole but is less than in the other Nordic countries. Unlike the practice in the other Nordic countries vascular surgery in Finland is included in other heart and thorax surgery, which means that it receives fewer resources.

Long term outcome after resection of the first rib for thoracic outlet syndrome.

A total of 112 first ribs in 103 patients were resected over 11 years for thoracic outlet syndrome. Seventy-seven patients (84 operations) were followed up for 2.5 years or more to assess the long term results of this procedure and the factors affecting them. One month after surgery 52 per cent of limbs were asymptomatic and 77 per cent were at least improved. A follow-up examination was performed, on average 6.1 years after the operation, by two independent examiners. This evaluation showed a permanent success rate of 37 per cent among 84 limbs examined. These long term results compare unfavourably with previously published data. The reason for the poor final outcome seemed to be difficulty in selecting patients for the operation. This was not aided by any of the preoperative tests. Patients in this study were evaluated by independent examiners, and only a total absence of preceding symptoms was accepted as the criterion for success. We emphasize the importance of unbiased evaluation and long term follow-up.

Late results and prognosis after carotid artery surgery.

Carotid reconstruction was performed on 75 patients (84 operations) mainly because of transient ischemic attacks (TIA) and/or amaurosis fugax (67%) or TIA with incomplete recovery (20%). The operative mortality was 2.4%. The incidence of permanent postoperative neurologic deficit was 6.0%. The postoperative observation time was 1 year to 13 years 5 months (mean 66 months). At follow-up 87% of the survivors were symptom-free. Three new strokes, one of them not related to the operated side, occurred follow-up, and 26 more patients died. The relative cumulative 5-year survival was 87.3%. Of the total 28 deaths, 16 were due to myocardial infarction. Mortality was significantly heightened and cumulative 5-year survival reduced when preoperative ECG had indicated coronary heart disease. The high incidence of deaths from myocardial disease during long-term follow-up was directly related to preoperative presence of coronary heart disease.

Personality factors as predictors of compliance with and the outcome of supervised self-care program for patients with intermittent claudication.

Personality factors related to the outcome of supervised self-care treatment program were studied in 56 patients with intermittent claudication. Psychological methods used were: structured interviews, the Rorschach Test, the Thematic Apperception Test, Beck's Depression Inventory, the Beth Israel Hospital Inventory of alexithymic behavior and Sauri's Creativity Inventory of psychic flexibility and adaptability. The patients who had no apparent signs of psychic disorders and were also capable of coping with disease-related psychic problems showed the best recovery. Alexithymic patients with a low level of psychic adaptability were likely to find the supportive relationship rewarding, but optimal recovery was not achieved. The results indicated that paranoid tendencies may be obstacles to a satisfying doctor-patient relationship and should be controlled.