Factors affecting women's participation in mammography screening in Nordic countries: A systematic review.

INTRODUCTION: Mammography screening programs have been implemented in European countries as prevention tools aimed at reducing breast cancer mortality through early detection in asymptomatic women. Nordic countries (Denmark, Finland, Iceland, Norway, Sweden, the Faroe Islands, and Greenland) demonstrated high participation rates; however, breast cancer mortality could be limited by further optimizing screening. This review aimed to explore factors that affect women's participation in mammography screening in Nordic countries. METHOD: A systematic review of segregated mixed research synthesis using a deductive approach was conducted. The following databases and platforms were searched to identify relevant studies: CINAHL with Full Text (EBSCOHost), MEDLINE (EBSCOHost), PsycInfo (ProQuest), Scopus (Elsevier) and Web of Science Core Collection (SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, and ESCI). The Critical Appraisal Skills Program was used for quality assessment. The Health Promotion Model was applied to integrate findings from qualitative and qualitative research. All methodological steps followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: The final selection (16 articles) included studies from three Nordic countries: Denmark (four quantitative studies), Norway (one qualitative and four quantitative studies), and Sweden (three qualitative and seven quantitative studies). Sixty-three factors were identified as barriers, facilitators, or factors with no influence. CONCLUSION: A substantial number of obtained factors, spread across a wide spectrum, describe (non-)participation in mammography screening as a versatile phenomenon. IMPLICATIONS FOR PRACTICE: The findings of this review could benefit the mammography staff and providers regarding possible interventions aimed at improving screening participation rates.

Epstein-Barr virus is not detected in mucosal lichen planus.

BACKGROUND: Lichen planus (LP) is a chronic inflammatory, immunological, mucocutaneous disease can affect skin, genital and oral mucosa. Oral lichen planus (OLP) is the most common noninfectious, chronic inflammatory oral disease affecting 1-2% of the general adult population. World Health Organization (WHO) classifies OLP as a potentially malignant disorder. Epstein Barr virus or human herpesvirus-4, is a member of the herpes virus family and one of the most ubiquitous viruses known to human, infecting approximately 90% of the world's adult population. The virus often infects B lymphocytes resulting in a wide spectrum of mucocutaneous and systemic diseases, ranging from mild lesions to aggressive malignancies. The aim of this study was to investigate expression of the EBV encoded RNAs EBER1 and EBER2 in oral and genital lichen planus and compare results with normal tissues in situ hybridization which is considered the golden standard for detection of EBER. MATERIAL AND METHODS: A total of 68 biopsies, 25 oral LP, 26 genital LP, 10 oral controls and finally 7 genital controls were analysed using situ hybridization. RESULT: All samples had RNA as shown by the control slide, whereas no case contained neither EBER1 nor EBER2. CONCLUSIONS: Based on results from our study EBV is not involved in aetiology of lichen planus.

Increased expression of p16 in both oral and genital lichen planus.

BACKGROUND: Lichen Planus, LP, is an inflammatory disease of possible autoimmune origin affecting mainly oral and genital mucosa and skin. According to the WHO oral LP is considered a potentially malignant disorders. The p16 tumour suppressor protein can act as an inhibitor of cyclin dependent kinases 4 and 6 and thus down regulate cell cycle progression. Since the discovery of p16 several studies have evaluated its expression in various forms of human cancers. The aim of this study was to evaluate and compare the expression of p16 in oral and genital LP and corresponding healthy mucosa. MATERIAL AND METHODS: A total of 76 cases of oral LP (OLP), 34 cases of genital LP (GLP), 12 cases of healthy oral and 9 cases of healthy genital mucosa were analysed by the use of immunohistochemistry. RESULTS: Data showed p16 to be highly expressed in both oral and genital LP, higher than in oral (p=0.000), and genital controls (p=0.002). CONCLUSIONS: Results suggest that the over-expression of p16 seen in LP play a part in the histopathology of the disease.

Autoantibodies and decreased expression of the transcription factor ELF-3 together with increased chemokine pathways support an autoimmune phenotype and altered differentiation in lichen planus located in oral mucosa.

BACKGROUND: The pathogenesis of oral lichen planus (OLP), a chronic inflammatory disease, is not fully understood. It is known that OLP has autoimmune features, and it is suggested to be an autoimmune disease. ELF-3 is involved in differentiation of keratinocytes and deregulated in different tumours and inflammatory diseases. CXCR-3 and its ligands CXCL-10 and CXCL-11 are increased in autoimmune diseases and linked to Th-1 immune response. OBJECTIVES: To analyse and compare expression of ELF-3, CXCR-3, CXCL-10 and CXCL-11 in OLP lesions and controls in whole and microdissected epithelium. METHODS: Tissue biopsies from 20 patients clinically and histologically diagnosed with OLP and 20 healthy controls were studied using whole tissues or microdissected epithelium. By the use of qRT-PCR, mRNA levels of ELF-3, CXCR-3, CXCL-10 and CXCL-11 were studied. Western blot was used for analysis of ELF-3 protein expression. Sera from 19 OLP patients and 20 controls were analysed with ELISA in search for autoantibodies. Results The upregulation of CXCR-3, CXCL-10 and CXCL-11 found in OLP is similar to previous findings showing an autoimmune phenotype in lichen planus (LP) and lichen sclerosus. Decreased expression of the differentiation-related transcription factor ELF-3 was also seen in OLP lesions, and we further demonstrate presence of circulating autoantibodies against the ELF-3 protein in sera from 3 of 19 (16%) LP patients tested. CONCLUSIONS: On the basis of these findings, we confirm that OLP shows features of an autoimmune disease and suggest deregulated differentiation of keratinocytes to be one of the causes of the disease phenotype.

Sudden cardiac death in young athletes: time for a Nordic approach in screening?

In 2005, the European Society of Cardiology published recommendations for cardiovascular screening in athletes. Discussion on whether screening is beneficial is ongoing. Recently, the first prospective results on effectiveness of screening in preventing sudden deaths were published from Italy. The results were supportive of screening, but did not provide conclusive evidence. Our suggestion for a Nordic approach on this issue is a directed cardiovascular examination initially involving elite athletes, because this is feasible with respect to the Nordic health care systems and the organization and logistics of elite competitive sports, but also because of the negative aspects of screening large populations. This directed cardiovascular examination would include personal and family history, clinical examination, and electrocardiography (ECG). Further examinations should thereafter be carried out in athletes with suggestive findings in the initial evaluation. The directed cardiovascular examination should be voluntary. It should be conducted at least once, with information on alarming symptoms (syncope, chest pain or dizziness during exercise) and heredity (sudden cardiac death or hereditary heart disease in near relatives) stressed to the athlete as indications for necessary check-ups in the future. The examination would also provide the athlete with an ECG recording, which is valuable as a reference at a later time.

Unspecific elevation of plasma troponin-T and CK-MB after coronary surgery.

OBJECTIVE: Biochemical markers of myocardial injury are frequently elevated after cardiac surgery. It is generally accepted that release unrelated to permanent myocardial damage explains a proportion of these elevations. However, little is known about the magnitude and temporal characteristics of this diagnostic noise. One way to address this issue would be to study a group without permanent myocardial injury. DESIGN: The unique release kinetics of troponin-T (permanent myocardial injury causes a sustained release of structurally bound troponin) were used to identify patients with no or minimal permanent myocardial injury. Blood was sampled from patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) before surgery, 3 and 8 h after unclamping the aorta, and each morning until postoperative day 4, for analysis of enzymes and troponin-T. From 302 consecutive patients a subgroup was identified that fulfilled the following criteria: (a) normalized troponin-T levels < or = postoperative day 4; (b) no ECG changes indicating myocardial injury. RESULTS: Seventy-seven patients fulfilled the criteria above and in this subgroup troponin-T (2.08 +/- 1.42 microg/l; range 0.35-8.99 microg/l) peaked at the 3 h recording and creatine kinase monobasic (CK-MB) (28.6 +/- 11.3 microg/l; range 11.9-86.0 microg/l) peaked at the 8 h recording after unclamping the aorta. CONCLUSION: Substantial early elevations of plasma CK-MB and troponin-T occurred in patients with no or minimal permanent myocardial injury after CABG. Unspecific release was most pronounced during the timeframe that is usually studied to evaluate myocardial protective strategies or to compare revascularization procedures.

Early identification of permanent myocardial damage after coronary surgery is aided by repeated measurements of CK-MB.

OBJECTIVE: ECG diagnosis of myocardial infarction after cardiac surgery is associated with major pitfalls and enzyme diagnosis is interfered by unspecific elevation unrelated to permanent myocardial injury. Sustained release of troponin-T is a marker of permanent myocardial injury if renal function is maintained. However, early identification of perioperative myocardial infarction is desirable and therefore the usefulness of creatine kinase monobasic (CK-MB) kinetics to detect myocardial injury early after coronary surgery was investigated. DESIGN: Two hundred and eighty-six patients undergoing coronary surgery were studied with respect to release of enzymes and troponin-T preoperatively and postoperatively 3 and 8 h after unclamping the aorta, and every morning postoperative days 1-4. RESULTS: CK-MB peak was found at 3 h (n = 145), 8 h (n = 103) and 16-20 h after unclamping (n = 38). Depending on when the CK-MB peak was recorded different demographic and perioperative characteristics were found. A sustained release of troponin-T was characteristic for the group with the CK-MB peak at 16-20 h after unclamping. CONCLUSION: If CK-MB is measured only once it may be advisable to do it on the first postoperative morning as these measurements provided the best discrimination between patients with and without sustained elevation of troponin-T. However, repeated sampling provides additional information that aids in the early identification of permanent myocardial injury particularly in patients with borderline elevations of CK-MB.

Aortic valve replacement with pericardial valves in patients with small aortic roots. Clinical results in a consecutive series of patients receiving 19 and 21 mm prostheses.

OBJECTIVE: To determine how second generation pericardial valves perform in patients with small aortic roots. DESIGN: Ninety patients who underwent isolated aortic valve replacement (AVR) with 19 or 21 mm Mitroflow or Carpentier-Edwards (Perimount) valves between 1989 and 1996 were studied. Mean age was 78 years. Concomitant coronary bypass surgery was performed in 41%. RESULTS: Thirty-day mortality was 5.6%. Ninety-seven percent had acceptable transprosthetic mean pressure gradients (25 mmHg or less) 1 week after surgery. Follow-up was 100% complete and 76% of the patients were alive after a mean of 5 years. There was no structural valve failure or valve thrombosis. One patient required reoperation for perivalvular leak. Four patients had transient ischemic attacks and seven had strokes. These figures are, however, within the expected range for the age. CONCLUSION: Second generation pericardial valves perform well in elderly patients with small aortic roots. Postoperative hemodynamics are acceptable, valve durability of up to 8 years adequate, and the clinical results good, considering the age of the patients.

Vectorcardiography is superior to conventional ECG for detection of myocardial injury after coronary surgery.

OBJECTIVE: The reliability of conventional scalar ECG for diagnosis of perioperative myocardial infarction (PMI) in cardiac surgery has been questioned. For the diagnosis of myocardial infarction in general vectorcardiography (VCG) is superior to ECG. Therefore, the usefulness of conventional VCG and computerized analysis of spatial VCG changes for diagnosis of PMI were studied. DESIGN: VCG registrations were obtained from 218 patients undergoing coronary surgery. The spatial QRS vector loop area of each VCG registration was calculated and the loop area before surgery compared with the loop area after surgery. Conventional VCG criteria for myocardial infarction and set values for loop area reduction were related to sustained elevation of plasma troponin-T and clinical course. RESULTS: Both conventional VCG criteria and spatial changes translated better than Q-waves on scalar ECG into elevation of biochemical markers of myocardial injury and impaired clinical course. CONCLUSION: VCG appears superior to conventional ECG as regards detection of myocardial injury in coronary surgery. Computerized programs have facilitated the registration and the interpretation of VCG and this methodology deserves further evaluation in cardiac surgery.

Are electrocardiographic Q-wave criteria reliable for diagnosis of perioperative myocardial infarction after coronary surgery?

OBJECTIVE: A major assumption in cardiovascular medicine is that Q-waves on the electrocardiogram indicate major myocardial tissue damage. The appearance of a new Q-wave has therefore been considered the most reliable criterion for diagnosis of perioperative myocardial infarction (PMI) in cardiac surgery. In a study, originally intended to evaluate troponin-T as a marker of PMI, analysis of our data aroused the need to address the reliability of Q-wave criteria for diagnosis of PMI. METHODS: In 302 consecutive patients undergoing coronary surgery, Q-wave and other electrocardiogram (ECG) criteria were compared with biochemical markers of myocardial injury and the postoperative course. All ECGs were analysed by a cardiologist blinded to the biochemical analyses and the clinical course. RESULTS: The incidence of positive Q-wave criteria was 8.1%. Combined biochemical (CK-MB > or = 70 microg/l) and Q-wave criteria were found in 1.0%. Patients with new Q-waves did not have CK-MB or troponin-T levels significantly different from those without Q-waves. More than 25% of the Q-waves were associated with plasma troponin-T below the reference level (< 0.2 microg/l) on the fourth postoperative day. Q-wave criteria alone did not influence the postoperative course. In contrast, biochemical markers correlated with clinical outcome. CONCLUSIONS: The majority of Q-waves appearing after coronary surgery were not associated with major myocardial tissue damage, and according to troponin-T one-fourth of the Q-waves were not associated with myocardial necrosis. Furthermore, the appearance of Q-waves had little influence on short term clinical outcome. Therefore, the use of Q-wave criteria as the gold standard for diagnosis of PMI may have to be questioned.

Quantitative digital evaluation of myocardial exercise thallium-201 single-photon emission tomography in post-menopausal women.

Quantitative computerized analysis of data from myocardial thallium-201 (201Tl) single-photon emission tomography (SPET) may improve the diagnostic accuracy of coronary heart disease. The reference ranges for post-menopausal women are, however, limited and obtained mainly from patients. To compare reference values from healthy post-menopausal women and to improve the quantitative analysis, 20 women (10 patients with coronary heart disease and previous infarction and 10 age-matched healthy volunteers) were examined immediately post exercise and after a delay. A nine-segment 'bull's-eye' model was used for analysis. At visual evaluation, reproducibility was high (93%), no false-positive results were obtained and in 70% of the patients the SPET was interpreted as abnormal. Using reported reference values for quantitative analysis, all the healthy women had an abnormal result. New reference values based on three different methods of 'normalization' were calculated: the relative activity of segment 3 set to 100%, the segment with the highest activity set to 100% and a least-squares method. They all differed significantly from those that had previously been reported. The frequencies of agreement between visual and quantitative analysis were 84-92% and were highest when segment 3 was used as a reference, but in this case only 40% of the patients with coronary heart disease had an abnormal SPET. Using the least-squares method for handling digital information, the SD of the normal values decreased and 90% of the patients with coronary heart disease were accurately diagnosed. These results provide quantitative digital reference values for healthy post-menopausal women. They verify that quantitative analysis is in diagnostic agreement with visual evaluation, stress the need for local verification of reference ranges and suggest a least-square normalization method for the analysis.

Biplane transoesophageal echocardiography, transthoracic Doppler, and magnetic resonance imaging in the assessment of coarctation of the aorta.

This study compared flow-sensitive magnetic resonance imaging with biplane transoesophageal echocardiography in combination with continuous wave Doppler from the suprasternal notch in patients with native coarctation or after surgical repair. Twenty patients (mean age 33 years, range 17-60) were investigated, of whom 15 had undergone surgery at mean age 13 years, range 5-43. Peak and mean flow in the ascending and descending aorta as well as coarctation peak velocity were determined with the magnetic resonance imaging phase contrast technique. Coarctation peak velocity was also measured by Doppler from the jugulum. Magnetic resonance imaging axial sections as well as biplane transoesophageal echocardiography were used to measure the smallest diameter of the constricted segment. Sixteen healthy volunteers, mean age 36 years, range 22-63, provided reference values for magnetic resonance imaging determined volume of flow in the aorta. Peak flow in the descending aorta was 9.2 +/- 3.7 l. min-1 (reference 13.0 +/- 2.5, P < 0.01) and mean flow 3.1 +/- 0.9 l. min-1 (reference 3.4 +/- 0.8, P > 0.05). The ratio of descending-to-ascending peak flow was 0.54 +/- 0.17 (reference 0.69 +/- 0.10, P < 0.01) and mean flow 0.68 +/- 0.15 (reference 0.69 +/- 0.08, P > 0.05). The coarctation velocity was slightly higher with Doppler than with magnetic resonance imaging (+0.24 +/- 0.44 m. s-1, 95% confidence interval +0.45 to +0.02 m. s-1, P = 0.05). The coarctation diameter was slightly larger with magnetic resonance imaging than with transoesophageal echocardiography (1.4 +/- 3.5 mm, 95% confidence interval +3.1 to -0.3 mm, P = 0.11). Both methods are suitable for the assessment and follow-up of coarctation of the aorta. Flow assessment with magnetic resonance imaging provides a hitherto unavailable measure with which to assess the severity of obstruction.

Cold-induced vasospasm after digital replantation does not improve with time. A 12-year prospective study.

The incidence of cold-induced vasospasm after hand injuries has been reported to be as high as 100%, following replanted digital amputations. The exact cause of this problem is obscure, no specific treatment is available and little is known about the long-term prognosis. Further knowledge is therefore needed in order to advise patients concerning future job potential at an early stage. In a previous paper we evaluated the incidence and severity of cold intolerance 2 years after digital replantation. The incidence of cold-induced vasospasm then was high as well as the discomfort experienced by the patients. We carried out a follow-up of patients previously examined 10 years ago. Our results show that cold induced vasospasm in replanted digits does not improve with time. Patients with moderate symptoms may perceive improvement, probably due to a change of habits. Patients with severe problems did not experience improvement and should be given early advice to seek work in warm surroundings to reduce the discomfort.

Arm-ankle systolic blood pressure difference at rest and after exercise in the assessment of aortic coarctation.

OBJECTIVE: To evaluate the difference in systolic blood pressure at the arm and ankle at rest and after various exercise tests for the assessment of aortic coarctation. METHODS: 22 patients (mean age 33 years, range 17-66) were investigated on the suspicion of having haemodynamically significant aortic coarctation. Eight had undergone previous coarctation surgery, of whom five had received vascular grafts and three end to end anastomoses. The patients exercised submaximally while supine, seated on a bicycle, and walking on a treadmill, as well as exercising maximally on a treadmill. Arm and ankle blood pressure were measured with a cuff at rest and 1-10 minutes after exercise. Invasive pressures and cardiac output by thermodilution were recorded during catheterisation while patients were at rest and during and after supine bicycle exercise. The degree of constriction was assessed by angiography. Twelve healthy volunteers (mean age 32 years, range 17-56) provided reference values for cuff pressures after exercise. RESULTS: All patients with a difference in cuff pressure at rest of 35 mm Hg or more had a difference in invasive pressure of 35 mm Hg or more. Increasing severity of constriction on angiography correlated with larger pressure gradients at rest and during exercise (P < 0.0001). When cuff measurements after exercise were considered singly or combined to form a predictor they did not improve the prediction of the invasive pressure gradients at rest or after maximal exercise. A pressure gradient between arm and ankle also developed in normal subjects after maximal but not after submaximal exercise. CONCLUSION: In most patients with suspected haemodynamically significant coarctation the difference in cuff pressure between arm and ankle at rest is sufficient to select patients in need of further evaluation. If exercise is performed submaximal exercise is preferable.

Nutritional assessment and muscle energy metabolism in severe chronic congestive heart failure--effects of long-term dietary supplementation.

In order to investigate nutritional status in relation to the metabolic state of skeletal muscle in patients with severe congestive heart failure, and to explore the influence of long-term dietary supplementation, 22 patients were randomized in a double-blind study to receive either a placebo (n = 13) or high caloric fluid (n = 9). Before treatment, the muscle content of adenosine triphosphate (ATP), creatine and glycogen was lower than in healthy individuals, and muscle biopsies revealed an excess of water. Two patients were found to be malnourished according to nutritional assessment criteria. Following study treatment, no significant changes occurred, either within or between the two subgroups. Thus, patients with severe congestive heart failure displayed metabolic derangement in skeletal muscle which did not seem to be explained by malnutrition.

Cold sensitivity after replantation in relation to arterial circulation and vasoregulation.

Cold intolerance is a common problem after injuries to the hand. To elucidate the mechanism of this cold sensitivity, eight patients with successful replantations of amputations of the thumb or index finger were studied one and half years later. In six patients the Doppler signal from the anastomosed arteries was normal and in two patients signs of mild stenosis were found. All patients had normal or slightly reduced basal finger systolic pressure in the replanted finger. Six had signs of marked vasospasm. Alpha-receptor blockade had no effect on the cold-induced decrease in finger systolic pressure in the replanted finger. It is concluded that cold intolerance after hand injuries results from a defect in vasoregulation and is not caused by organic insufficiency of the circulation.