A follow-up of cognitive performance and diurnal salivary cortisol changes in former burnout patients.

The purpose of this study was to determine whether recovery from burnout is associated with improved cognitive functioning, and whether such improvement is associated with changes in hypothalamic-pituitary-adrenal axis activity and return to work. Forty-five former burnout patients were followed up after 1.5 years with a neuropsychological examination, diurnal salivary cortisol measurements, dexamethasone suppression test (DST), and self-ratings of cognitive problems. At follow-up, improved cognitive performance was observed on several tests of short-term memory and attention. Self-rated cognitive problems decreased considerably, but this decrease was unrelated to the improvement on neuropsychological tests. Diurnal salivary cortisol concentrations at awakening, 30 min after awakening, and in the evening, did not change from baseline to follow-up, nor did the cortisol awakening response. However, slightly, but significantly, stronger suppression of cortisol in response to the DST was observed at follow-up. Improvements in subjective or objective cognitive functioning and changes in diurnal cortisol concentration were unrelated to the extent of work resumption. However, a decreased DST response at follow-up was partially related to improved cognitive performance and work resumption. The clinical implications are that burnout seems to be associated with slight and significantly reversible cognitive impairment, and that self-rated cognitive change during recovery poorly reflects objective cognitive change.

A relationship between migraine and biliary tract disorders: findings in two Swedish samples of elderly twins.

OBJECTIVES: To investigate whether there is a relationship between the clinical occurrence of migraine and biliary tract disorders (BTD) and to study whether there is a genetic influence on such an association. MATERIALS AND METHODS: The near lifetime morbidity for migraine and BTD was examined in two Swedish twin-samples: OCTO-Twin (149 MZ and 202 DZ pairs; 234 men, 468 women; 80 years of age or older at inclusion), and the GENDER study (249 unlike-sex DZ-pairs; 70-80 years of age at inclusion). The diagnosis of BTD was established by perusal of medical records from the last twenty years. The diagnosis of migraine was based on iterated questionnaires and personal interviews. RESULTS: The odds ratio (OR) of BTD among OCTO-Twin subjects suffering from migraine was 3.5 (1.9-6.7) in monozygotic pairs and 1.7 (1.0-2.9) in dizygotic pairs The corresponding figures among the GENDER unlike-sex DZ-pairs was 2.7 (1.6-4.5). Migraine was associated with female sex and waist circumference. CONCLUSIONS: There is a relationship between the occurrence of migraine and BTD, also when controlling for the fact that both disorders are more frequent in women. The association appears to be partly attributable to genetic influences.

Who will become malnourished? A prospective study of factors associated with malnutrition in older persons living at home.

OBJECTIVES: To describe the nutritional status of older persons living at home, to investigate factors of importance for nutritional status, and to describe possible relationships between nutritional status and health-related quality of life (HRQoL). DESIGN: A longitudinal study using data from older persons born between 1916 and 1925. Data were collected at three occasions separated by four-year intervals. SETTING: Data collection was carried out in the participants' own homes. An experimenter administered all tests and conducted the interviews. PARTICIPANTS: A randomized selection from the Swedish Twin Register included 258 persons, all still living at home. MEASUREMENTS: Nutritional status was assessed using the Mini Nutritional Assessment (MNA), cognitive function using the Mini-Mental State Examination (MMSE) and HRQoL using the Nottingham Health Profile (NHP). Questions covering physical, psychological and social factors that may have an impact on nutritional status were also posed. RESULTS: Approximately 17% of participants were assessed as being at risk for malnutrition or as being malnourished. Cognitive impairment, reduced perceived health, recent hospital stay and receiving meals-on-wheels were factors associated with being at risk for malnutrition. CONCLUSION: Being at risk for malnutrition is common in older persons living at home, and many factors related to frailty increase this risk in later life. Making use of knowledge of these factors when giving care to older persons may be important in preventing nutritional problems.

Water resource use and management by the United States forest products industry.

The connections between forest products operations and water resources in the United States is considered and, where possible, quantified. Manufacture of wood, pulp, and paper products and the influences of forest management and forest products manufacture on water quality are discussed. Most fresh water in the US originates in forested areas. Responsible harvesting strategies, best management practices, and forest re-growth combine to minimize or eliminate changes in water availability and degradation of water quality due to harvesting. Relative to alternative land uses and large-scale disturbance events, forested areas produce the highest quality of fresh water. Water inputs for the manufacture of forest products total about 5.8 billion m(3) per year, an amount equal about 0.4% of the surface and groundwater yield from timberland. Approximately 88% of water used in manufacturing is treated and returned directly to surface waters, about 11% is converted to water vapor and released during the manufacturing process, and 1% is imparted to products or solid residuals. Extensive study and continued monitoring of treated effluents suggest few or no concerns regarding the compatibility of current effluents with healthy aquatic systems.

Physiological restitution after night-call duty in anaesthesiologists: impact on metabolic factors.

BACKGROUND: Several studies have shown impaired mental well-being and performance in physicians work on call, but knowledge of the physiological effects is scarce. The aims of the present study were to investigate if there was a metabolic stress response in the restitutional phase after night-call duty, indicating potential negative health effects, and determine whether there were differences between physician specialities. METHODS: Anaesthesiologists (n = 19) were compared with paediatricians/ear, nose and throat (ENT) surgeons (n = 18). On an ordinary workday, 1 and 3 days after work on night call, blood samples were taken for analysis of glucose, thyroid-stimulating hormone (TSH), free thyroxine, testosterone, insulin growth factor-1 (IGF-1), high- and low-density lipoprotein cholesterol (HDL and LDL), triglycerids (TG) and insulin. Saliva cortisol was sampled on an ordinary working day, a day including 16-h night call, the third day following, and for anaesthesiologists also on a day off work. RESULTS: TSH differed significantly between days in both groups, with a 26% lower level 1 day after on-call duty (P < 0.001). A 48% cortisol rise in the morning preceding night duty was found for paediatricians/ENT surgeons (P < 0.01). CONCLUSION: The significant dip in TSH level 24 h after night-call duty indicates a metabolic effect of working on night call and should be studied further. However, the levels were within the normal range and the overall results do not imply any serious metabolic changes and only minor differences were seen between specialist groups.

Serum C-reactive protein in elderly men and women: association with mortality, morbidity and various biochemical values.

OBJECTIVE: The primary aim of this study was to define the distribution and the prognostic value of serum C-reactive protein (s-CRP) measured by a high-sensitivity method in elderly subjects of both genders with special reference to the distribution below 10 mg/l. As a secondary aim, a possible gender difference of s-CRP was examined. MATERIAL AND METHODS: Baseline s-CRP was described in a population-based sample of opposite-sex, twin-pairs (197 F, 189 M available for blood-sampling) aged 71-80 years (mean age 74.5 years), considering mortality through the next 4 years, morbidity (myocardial infarction, angina pectoris, congestive heart failure, arterial hypertension, venous thromboembolism, stroke, diabetes, gout, psoriasis, rheumatoid arthritis) before and after blood sampling, biochemical values (serum levels of urate, urea, ApoA1, ApoB, folate, FSH, LH, oestradiol, progesterone, testosterone, cortisol) and anthropometric measurements (body mass index (BMI), circumference of waist, buttocks and hips). RESULTS: The level of s-CRP did not deviate substantially from what has been reported for younger subjects. Higher values indicated an increased risk of cardiovascular morbidity and diabetes in women but not in men. The s-CRP level was associated with serum levels of urate, progesterone, folate, ApoA1, ApoB and the quotient ApoB/ApoA1 as well as with BMI and waist circumference. CONCLUSIONS: For the 71-80 years age group, s-CRP below the 80th percentile (4.3 mg/l) seems to have prognostic capacity mainly in women. The highest association with mortality as well as with cardiovascular diseases, diabetes and rheumatoid arthritis is found for s-CRP above 10 mg/l, which is the arbitrary lower level for the earlier routine low-sensitivity s-CRP methods. The association of s-CRP with serum urate, folate and the ApoB/ApoA1 quotient should be considered.

Gender differences in heritability of depressive symptoms in the elderly.

BACKGROUND: The present study aimed to investigate the relative importance of genetic and environmental influences on depressive symptoms in the elderly. METHOD: Depressive symptoms were assessed through the Center for Epidemiological Studies-Depression (CES-D) scale. The CES-D scale was administered to 959 twin pairs (123 female MZs, 90 male MZs, 207 same-sex female DZs, 109 same-sex male DZs and 430 opposite-sex DZs) aged 50 years or older (mean age 72 years). A dichotomous depressed state variable was constructed based on CES-D cut-offs and self-reported use of antidepressant medication. Structural equation models were fitted to the data to dissect genetic and environmental variance components. RESULTS: The sex-specific heritability estimates for depressive symptoms were 14% for males and 29% for females and 23% when constrained to be equal for men and women. The prevalence of clinically significant depressive symptoms was 16% for men and 24% for women. Heritability estimates for the dichotomous depressed state measure were 7% for males and 49% for females in the full model and 33% when constrained to be equal. CONCLUSION: Our results suggest that depressive symptoms in the elderly are moderately heritable, with a higher heritability for women than men, although differences in heritability estimates were not statistically significant.

Gender differences in depression: a study of older unlike-sex twins.

Gender differences in depressive symptoms, in the diagnosis of major/minor depression, and in the use of antidepressant medication were investigated. The sample included 249 pairs of unlike-sex twins, who were between 70 and 80 years of age at the initial, baseline assessment. A follow-up, in which both members of 145 twin pairs participated, was carried out four years later. Participants completed the Centre for the Epidemiologic Studies Depression Scale (CES-D) for depressive symptoms. Current use of antidepressant medicine was assessed. Medical records of major/minor depression from the period 1985-1998, including a summary of those diagnoses in earlier years, were gathered from several sources. Women had a higher frequency of depressive symptoms and depression diagnoses than their twin brothers. Depressive symptoms and diagnosis of depression increased over time, slightly more among men. The gender difference and increase over time in the depressive symptoms were related to differences in socio-economic status and physical functioning in men and women. No gender difference was found in the use of antidepressant medication.

Association between depressed mood in the elderly and a 5-HTR2A gene variant.

The aim of this study was to investigate any possible association between depressed mood in the elderly and two candidate SNPs in the serotonin system: one in the 5-HTR2A gene promotor (-1438 G/A) and one in the 5-HT transporter gene (-925 C/A). DNA from a population-based Swedish twin sample (N = 1,592; mean age = 73) was genotyped using Pryosequencing trade mark. An association was found between the 5-HTR2A gene promotor polymorphism and depressed mood (OR: 1.5, CI: 1.1-2.1) for the A/A genotype in the total sample. When the sample was analyzed by gender, a significant association (OR: 2.4, CI: 1.4-4.4) was found for males and the A/A genotype, but not for females. The 5-HT transporter gene was not associated with depressed mood in this elderly population. These results suggest that there might be different genetic mechanisms for males and females contributing to the development of depressed mood in the elderly.

Health effects of occupational exposure to acrylamide using hemoglobin adducts as biomarkers of internal dose.

OBJECTIVES: This study assessed the health effects of occupational acrylamide exposure using hemoglobin (Hb) adducts as biomarkers of internal dose. METHODS: Two hundred and ten tunnel workers exposed for about 2 months to a chemical-grouting agent containing acrylamide and N-methylolacrylamide underwent a health examination. Blood samples were drawn for the analysis of Hb adducts of acrylamide. Fifty workers claiming recently developed or deteriorated symptoms of the peripheral nervous system (PNS) were referred to a neurophysiological examination. Workers with Hb-adduct levels exceeding 0.3 nmol/g globin attended follow-up examinations 6, 12, and 18 months after exposure cessation. RESULTS: Forty-seven workers had Hb-adduct levels within the normal background range (0.02-0.07 nmol/g globin), while the remaining 163 had increased levels up to a maximum of 17.7 nmol/g globin. Clear-cut dose-response associations were found between the Hb-adduct levels and PNS symptoms. Thirty-nine percent of those with Hb-adduct levels exceeding 1 nmol/g globin experienced tingling or numbness in their hands or feet. A no-observed adverse effect level of 0.51 nmol/g globin was estimated for numbness or tingling in the feet or legs. For 23 workers there was strong evidence of PNS impairment due to occupational exposure to acrylamide. All but two had recovered 18 months after the cessation of exposure. CONCLUSIONS: Occupational exposure to a grouting agent containing acrylamide resulted in PNS symptoms and signs. The use of Hb adducts of acrylamide as a biomarker of internal dose revealed strong dose-response associations. The PNS symptoms were, however, generally mild, and in almost all cases they were reversible.

Powdering floor polish and mucous membrane irritation in secondary school pupils.

OBJECTIVES: Acrylate-styrene copolymer polish has been used to protect the surface of linoleum flooring since the 1960s. Problems with powdering of floor polish were observed at an early stage. In a secondary school in Linköping, Sweden, this phenomenon occurred in the winter of 1994-1995 and the pupils frequently reported irritative symptoms from the eyes and airways. This study was undertaken to assess the potential effect of powdering floor polish on the mucous membranes of the eyes and respiratory tract. METHODS: Repeated questionnaire-based surveys were conducted with identical questions in the spring of 1995 (during the powdering period) and in the autumn of 1995 (after the polish was removed). The questions dealt with irritative symptoms from the nose, eye, throat and lower respiratory tract. RESULTS: A preventive effect related to the removal of polish was found for irritative symptoms in all locations mentioned above, but was particularly clear for the lower respiratory tract (prevalence rate ratio = 0.37, 95% CI = 0.23-0.59). CONCLUSIONS: The results of this study indicate that the powdering of floor polish may cause irritative symptoms from the eyes and airways in school children.

Semantic modeling of a traditional classification: results and implications.

A primary health care version of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), together with a three-dimensional model for classification of diseases according to location, origin, and type has been semantically represented. The resulting computer-based version is made available via the World Wide Web.

Caregiver's burden of patients 3 years after stroke assessed by a novel caregiver burden scale.

OBJECTIVE: To assess burden of caregivers to stroke patients three year after primary stroke and to test validity and reliability of a novel caregiver burden scale (CB scale). DESIGN: A longitudinal community-based 3-year follow-up study of 35 consecutive primary stoke patients initially admitted to an Acute Medical Unit (mean age 82 yr). The validity of the CB scale was studied in 150 patients (mean age 77 yr): 83 demented outpatients with stroke from a general geriatric day-care unit. Reliability was studied in another 23 outpatients (mean age 72 yr) with stroke from the same unit. METHODS: A 22-item CB scale for different types of caregiver burden and scales for neuroticism and extroversion (Eysenck Personality Inventory) and quality of life (11-item scale). Activities of daily life were assessed by a 6-item, scale, initially and 3 years later. OUTCOME MEASURE: Reliability and validity of the CB scale. Improvements of activities of daily life of stroke patients. RESULTS: Factor analyses of the CB scale gave five indices--general strain, isolation, disappointment, emotional involvement, and environment--having good kappa values, .89 to 1.00 and Cronbach's alpha, .70 to .87, except for environment. A higher burden was related to a closer relationship but not to the living situation. The highest caregiver burden was found among patients showing the greatest improvements of ADL, when divided into tertiles. The patient's degree of extroversion and quality of life were negatively correlated to caregiver burden, -.46(p < .05) and .59(p < .01). CONCLUSIONS: The CB scale proved to be a valid and reliable instrument to assess caregiver burden. To improve the caregiver situation, individual patient personality characteristics, like extroversion, feeling of quality of life, and progression of the disease, must be considered.

Changes in functional competency in the oldest old. A longitudinal study.

Changes in everyday functioning and cognitive abilities are studied longitudinally in a representative sample of the oldest old. Respondents were selected by using census records from all people aged 84, 86, 88, and 90 years old living in an area of South Central Sweden, and then were assessed at 2-year intervals. The findings show high base rates for disabilities and high incidence of cognitive and functional deficits among survivors. Mortality is associated with higher rates of disability at the previous time of assessment. Because of this increased mortality rate among disabled individuals, prevalence does not rise as much as would be expected from the high incidence. Instead, new cases of disabled are partly replacing disabled individuals who died since the previous evaluation.

Group homes for people with dementia: a Swedish example.

We describe the development and evaluation of group homes for dementia patients in Sweden. Group homes have been established on a social model of care to provide a better quality of life than in institutional settings, while making a small savings on cost. An enriched program of activities uses familiar, everyday household tasks, with staff trained to model appropriate behaviors. An evaluation of four homes indicated that residents could be well accommodated in the setting, even as their disabilities increased. Although there were some initial problems, staff satisfaction was high and turnover low.

Stress management in the treatment of essential hypertension in primary health care.

The present study was a pilot project to determine the feasibility of a stress management program for treatment of hypertension in the Swedish primary health care system. Those patients in the catchment area of the primary health care center at Tumba hospital who were under 45 years old and diagnosed with primary hypertension during 1979-1981, were chosen to participate if they had had at least one measurement of 150 mmHg systolic and/or 95 mmHg diastolic during 1981. Patients on diuretic medication were included but those being medicated with beta-blockers were excluded for ethical reasons. Of the 21 people who fulfilled these criteria, 13 took part in the treatment, which lasted ten weeks. Both systolic and diastolic blood pressure decreased significantly (151.1 to 124.7 and 96.4 to 89.3, respectively). The conclusions drawn were that stress management may offer a viable alternative to medication of mild hypertension in primary health care and that it should be tested on a larger scale with systematic blood pressure measurements performed during daily activities, serving as a basis for baseline determination.