Effects of growth and aging on the reference values of pulmonary nitric oxide dynamics in healthy subjects.

The lung just like all other organs is affected by age. The lung matures by the age of 20 and age-related changes start around middle age, at 40-50 years. Exhaled nitric oxide (FENO) has been shown to be age, height and gender dependent. We hypothesize that the nitric oxide (NO) parameters alveolar NO (CANO), airway flux (JawNO), airway diffusing capacity (DawNO) and airway wall content (CawNO) will also demonstrate this dependence. Data from healthy subjects were gathered by the current authors from their earlier publications in which healthy individuals were included as control subjects. Healthy subjects (n = 433) ranged in age from 7 to 78 years. Age-stratified reference values of the NO parameters were significantly different. Gender differences were only observed in the 20-49 age group. The results from the multiple regression models in subjects older than 20 years revealed that age, height and gender interaction together explained 6% of variation in FENO at 50 ml s-1 (FENO50), 4% in JawNO, 16% in CawNO, 8% in DawNO and 12% in CANO. In conclusion, in this study we have generated reference values for NO parameters from an extended NO analysis of healthy subjects. This is important in order to be able to use these parameters in clinical practice.

Thalidomide therapy and polyneuropathy in myeloma patients.

Thalidomide is today an increasingly used therapy in advanced and refractory myeloma patients, especially in patients relapsing after high dose therapy. One important and well-known side effect of thalidomide is polyneuropathy (PNP). The purpose of this study was to investigate 1) how severe the thalidomide-induced PNP is in patients treated for myeloma 2) which neurophysiological tests and parameters are most sensitive in detecting the thalidomide-induced PNP and 3) how neuropathic symptoms correlate with neurophysiological changes. Twelve patients received thalidomide for treatment of relapsed multiple myeloma for at least 5 months. Prior to the thalidomide treatment, all patients had been treated with chemotherapy including vincristine, and seven patients had also received cisplatin. PNP symptoms, clinical findings and neurophysiological tests before and after the therapy were evaluated. Prior to thalidomide treatment, 7 patients had minimal and one patient slight PNP. After thalidomide treatment, 4 patients had minimal, 4 patients slight, and 3 patients moderate PNP. Thalidomide-induced PNP mainly affected sensory myelinated axons, but also alpha motor neuron axons were affected to some extent. Thermal thresholds were not altered, indicating that thin myelinated and unmyelinated axons are spared. The most sensitive parameter for detecting thalidomide-induced PNP was the sensory nerve compound action potential amplitude. The neuropathic symptoms deteriorated significantly during the therapy, but clinically, no patient developed a disabling PNP that would have required interrupting the therapy. The neuropathic side effects of thalidomide seem to be acceptable in myeloma patients.

Plasma cell leukemia 3 months after autologous blood cell transplantation for multiple myeloma.

We describe a patient with multiple myeloma who was treated with intensive therapy and autologous blood cell transplantation as her first-line treatment. The disease relapsed 3 months after the transplant as plasma cell leukemia and the patient succumbed in 4 weeks. We suggest that an aggressive plasma cell clone may be selected during the course of intensive treatment. Complex karyotypic findings are also presented.

Allogeneic bone marrow transplantation in multiple myeloma: a report of four cases.

Allogeneic bone marrow transplantation offers a new and promising form for treatment of multiple myeloma incurable with chemotherapy. We present four cases of advanced multiple myeloma given bone marrow transplantation from HLA-identical and MLC-negative sibling donors. One patient had a recurrent plasmacytoma 8 months later and one died 12 days after the transplantation whereas the other two are in good clinical remission 15 and 19 months post-transplantation.

VAD regimen in the treatment of resistant multiple myeloma: slow or fast infusion?

The VAD regimen is effective in the treatment of resistant and relapsing multiple myeloma. In the original VAD regimen, vincristine (V) and doxorubicin (A) are given as continuous infusions together with peroral dexamethasone (D). For practical reasons, we have shortened the infusion times: 8 hours for vincristine and 1 hour for doxorubicin. In this retrospective analysis, we have compared the efficacy and toxicity of the original and modified VAD protocols in the treatment of myeloma patients at our institution. Of the 31 consecutive patients with myeloma, primarily or secondarily resistant to alkylating agents, 16 were treated by the original and 15 by the modified VAD protocol. We found no significant difference in the response rates (good responses 31% and 20% respectively), survival times (17 and 9 months respectively) or toxicity between the two protocols. VAD may well be modified so as to consist of short infusions of V and A. The overall efficacy of the traditional and modified regimens is, however, rather unsatisfactory in patients with advanced myeloma.

The asthma programme of Finland: an evaluation survey in primary health care.

OBJECTIVE: To evaluate the basic structures and processes of asthma care 6 years after the launch of the Finnish Asthma Programme. The evaluation will serve as the baseline for the implementation of the evidence-based guidelines for asthma published in 2000. DESIGN: A descriptive type-2 evaluation (managerial monitoring of a policy implementation), based on operationalised statements of the Asthma Programme. RESULTS: A co-ordinating doctor for asthma, usually a general practitioner (GP), was interviewed in 248 (91%) health centres; 83% of the health centres have at least one GP nominated as the local asthma co-ordinator and 94% have a nurse. Asthma education for the professionals had been organised in 71% of the health centres in the previous 2 years. First-line treatment consists of an inhaled corticosteroid. Guided self-management is used in 98% of the health centres, but its components were not clear to the doctors. CONCLUSION: The basic structure of equipment and organisation for the diagnosis and treatment of asthma has been set up in the primary health care services.

Implementation of the DOTS strategy for tuberculosis in the Leningrad Region, Russian Federation (1998-1999).

SETTING: The DOTS pilot project for tuberculosis control in the Leningrad Region of the Russian Federation, supported by the Finnish Lung Health Association and the World Health Organization (WHO). OBJECTIVE: To assess the efficacy of WHO-recommended standard short-course chemotherapy in newly detected pulmonary tuberculosis cases positive by smear or with extensive lung lesions suggestive of culture positivity, under project conditions. METHODS: Analysis of data on case detection, sputum smear conversion and treatment outcome based on standardised (WHO) registers from districts and a central computerised database. RESULTS: Of 859 adult pulmonary tuberculosis cases (292 smear-positive) notified in the Leningrad Region in the study period, 312 new cases were included in the project. The sputum conversion rate at the end of the second month was 82.8% and 91.1% at the end of the third month. Of bacteriologically confirmed cases, 71.3% were successfully treated, 4.9% died, 11.7% defaulted and 8.1% failed. CONCLUSION: In the first year of the pilot project in the Leningrad Region, the DOTS strategy revealed feasibility and moderate efficacy among new pulmonary tuberculosis cases who were either smear-positive or showed extensive lung lesions on chest X-ray, and who were therefore of high epidemiological and medical priority.

Chronic bronchitis and chronic obstructive pulmonary disease: Finnish National Guidelines for Prevention and Treatment 1998-2007.

1. A national recommendation for the promotion of prevention, treatment and rehabilitation in relation to chronic bronchitis and COPD from 1998 to 2007 has been prepared on the basis of extensive collaboration by order of the Ministry of Social Affairs and Health. The Programme needs to be revised as necessary, because of rapid developments in medical knowledge, and in drug therapy in particular. 2. COPD is a disease characterized by slowly progressing, irreversible airways obstruction. Over 5% of the population suffer from symptomatic forms of the disease. It is estimated that a further 5% of the population may suffer from latent COPD. Most patients (75%) suffer from mild forms of the disease. The disease is often preceded by chronic bronchitis. A total of 400,000 Finns suffer from chronic bronchitis or COPD. Occurrence of these diseases in future will be particularly affected by decreased smoking by men, increased smoking by the young and by women, and aging of the population. 3. In 1997, the annual treatment costs of chronic bronchitis and COPD were estimated to be FIM 1.5 thousand million, total costs FIM 5 thousand million. Without intensification of measures to prevent and treat the diseases, costs will rise significantly. Costs arising from severe COPD (5% of patients with COPD) account for roughly 65% of costs overall and are primarily related to hospitalizations. 4. The goals of the Programme for the Prevention and Treatment of Chronic Bronchitis and COPD are as follows: (a) to decrease the incidence of chronic bronchitis; (b) to ensure that as many patients as possible with chronic bronchitis recover; (c) to maintain capacity for work and functional capacity of patients with COPD; (d) to reduce the percentage of patients with moderate to severe COPD; (e) to decrease the number of hospitalization days of COPD patients by 25% overall; and (f) to decrease annual costs per patient. 5. The following means are suggested for achieving the goals: (a) reduction in smoking; (b) reduction in work-related and outdoor air pollutants and improvement of quality of indoor air; (c) enhancement of knowledge about risk factors and treatment of the diseases is in key groups; (d) promotion of early diagnosis and active treatment, in smokers in particular; (e) improvement of guided self-care; (f) early commencement of rehabilitation, individual planning and implementation, primarily as an element in treatment; and (g) encouragement of scientific research. 6. COPD and exacerbation of its symptoms can be prevented through choices relating to life habits, such as not smoking, maintaining good general condition, and protection against exposure to dusts. The Programme gives examples of such measures and appeals to various authorities and voluntary organizations to increase their cooperation. Preventive methods should be individualized, and based on due consideration. 7. Chronic bronchitis and COPD should be diagnosed at early stages, and treated appropriately from the outset. Treatment consists of: (a) treatment according to causes, such as stopping smoking and work hygiene; (b) early rehabilitation such as patient education and guided self-care: (c) drug therapy; (d) hospital treatment; and (e) rehabilitation. 8. The hierarchy of referrals in the treatment of COPD should be revised to accord a greater role to the primary health care sector. Good exchanges of information and cooperation between the primary health care and specialized medical care sectors will all be necessary if this hierarchial model is to have the desired effect. 9. Hospital districts and health centres should ensure that different levels of the health-care system are capable of fulfilling the tasks assigned to them appropriately. One specialist in each hospital district should be given charge of prevention and assembly of know-how relating to treatment, and of quality of treatment at regional level. (ABSTRACT TRUNCATED)

Sleep apnoea: Finnish National guidelines for prevention and treatment 2002-2012.

(1) After negotiations with the Finnish Ministry of Social Affairs and Health, a national programme to promote prevention, treatment and rehabilitation of sleep apnoea for the years 2002-2012 has been prepared by the Finnish Lung Health Association on the basis of extensive collaboration. The programme needs to be revised as necessary, because of the rapid development in medical knowledge, and in appliance therapy in particular. (2) Sleep apnoea deteriorates slowly. Its typical features are snoring, interruptions of breathing during sleep and daytime tiredness. Sleep apnoea affects roughly 3% of middle-aged men and 2% of women. In Finland, there are approx. 150,000 sleep apnea patients, of which 15,000 patients have a severe disease, 50,000 patients are moderate and 85,000 have a mild form of the disease. Children are also affected by sleep apnea. A typical sleep apnea patient is a middle-aged man or a postmenopausal woman. (3) The obstruction of upper airways is essential in the occurrence of sleep apnoea. The obstruction can be caused by structural and/or functional factors. As for structural factors, there are various methods of intervention, such as to secure children's nasal respiration, to remove redundant soft tissue, as well as to correct malocclusions. It is possible to have an effect on the functional factors by treating well diseases predisposing to sleep apnoea, by reducing smoking, the consumption of alcohol and the use of medicines impairing the central nervous system. The most important single risk factor for sleep apnoea is obesity. (4) Untreated sleep apnoea leads to an increase morbidity and mortality through heart circulatory diseases and through accidents by tiredness. Untreated or undertreated sleep apnoea deteriorates a person's quality of life and working capacity. (5) The goals of the Programme for the prevention and treatment of sleep apnoea are as follows: (1) to decrease the incidence of sleep apnoea, (2) to ensure that as many patients as possible with sleep apnoea recover, (3) to maintain capacity for work and functional capacity of patients with sleep apnoea, (4) to reduce the percentage of patients with severe sleep apnoea, (5) to decrease the number of sleep apnoea patients requiring hospitalisation and (6) to improve cost effectiveness of prevention and treatment of sleep apnoea. (6) The following means are suggested for achieving the goals: (1) to promote prevention of obesity, weight loss and weight control; (2) to promote securing of nasal respiration in child patients and removal of obstructing redundant soft tissues; (3) to promote the correction of children's malocclusions, (4) to enhance knowledge about risk factors and treatment of sleep apnoea in key groups, (5) to promote early diagnosis and active treatment, (6) to commence rehabilitation early and individually as a part of treatment and (7) to encourage scientific research. (7) On the national level, the occurrence of sleep apnoea can be prevented, for example, by encouraging weight control. The programme gives examples of such measures and appeals to various authorities and voluntary organisations to reinforce their collaboration. Preventive measures should be individualised, and based on due consideration. (8) The efficacy of diagnosing sleep apnoea should be increased. Attention should be paid to the symptoms of risk group patients at different units of the primary and occupational health care. Even mild forms of the disease should be treated appropriately. Diagnosis and treatment of the disease involve cooperation between the primary and specialised health-care sectors. Methods of treatment are (1) treatment of obesity, (2) positional therapy, (3) reduction of the use of medicines impairing the central nervous system, (4) reduction of smoking and the consumption of alcohol, (5) devices affecting the position of the tongue and lower jaw, (6) treatment with Continuous Positive Airway Pressure (CPAP-treatment), (7) surgical methods of treatment and (8) rehabilitation. (9) The hierarchy of referrals in the prevention and treatment of sleep apnoea should be revised to accord a greater role to the primary health-care sector. Good exchanges of information and cooperation between the primary health care and specialised medical-care sectors should be developed. Hospitals districts in cooperation with provincial governments and municipalities should ensure that different levels of the health-care system are capable of fulfilling the tasks assigned to them appropriately. (10) Rehabilitation of sleep apnoea should be goal-orientated and cover all forms of rehabilitation: medical, occupational and social. Rehabilitation should prevent the effects caused by the disease. Thus, it is possible to support self-care, increase the patient's resources and improve quality of life. (11) Information and training should be directed primarily towards health-care personnel, patients and their families. Organisations should produce materials for health and patient education as well as organising training events. To support the activities. financing will be needed from organisations such as Finland's Slot Machine Association. The Social Insurance Institution should disseminate information about questions of social security. Regional direction and training will mainly be the responsibilities of hospital districts, provincial governments and local health centres. The media will play an important role in the dissemination in-depth information about prevention and treatment of sleep apnoea.

A television format for national health promotion: Finland's "Keys to Health".

A series of televised risk reduction and health promotion programs have been broadcast in Finland since 1978. The five series of programs were the product of a cooperative effort by Finland's television channel 2 and the North Karelia Project. The series has featured a group of volunteers who are at high risk of diseases because of their unhealthful habits and two health educators who counsel the studio group and the viewers to make changes in health behaviors. The "Keys to Health 84-85" was the fifth of the series and consisted of 15 parts, 35 minutes viewing time each. Results of the evaluation surveys, which are presented briefly, indicate that viewing rates were high. Of the countrywide sample, 27 percent of men and 35 percent of women reported that they had viewed at least three parts of the series. Reported changes in behaviors were substantial among the viewers who had seen several parts of the series and were meaningful, overall, for the entire population. Of the countrywide sample, 7.1 percent of smoking viewers reported an attempt to stop smoking--this number was 3.6 percent of all smokers. The percentages of weight loss among viewers and the total population sample were 3.9 for men and 2.1 for women. The reported reductions in fat consumption were 27.2 percent for men and 15.0 percent for women. The reported effects in the demonstration area of North Karelia were even higher, mainly because of higher viewing rates.

The levels of the major risk indicators of cardiovascular diseases in Eastern Finland rior to a community-based intervention programme. (The North Karelia project).

The design, implementation and the major results of a study for measuring the prevalent CHD risk indicators in Eastern Finland are presented. The study formed the baseline survey of the North Karelia Project and was conducted in 1972 for a representative random sample of the population aged 25-59 in the county of North Karelia and a matched reference area. Altogether 11.992 persons were examined with a participation rate of 93% in North Karelia and 90% in the reference area. The prevalence rates of the "hard" CHD risk indicators (blood pressure, cholesterol, smoking and triglycerides) are presented and reference is made to the prevalence rates of some other "softer" risk indicators. In general, the level of the "hard" risk indicators is high and this is especially true for the younger males. The two areas resemble each other closely in these respects as was anticipated. In the discussion the results are reviewed from the point of view of the primary preventive programme.

Smart Habit Xylitol campaign, a new approach in oral health promotion.

A national 'Smart Habit' Xylitol campaign was organised in Finland in autumn 1992. The aim of the campaign was to increase consumption of xylitol chewing gum in 13-year-old school children, to promote their oral health. The campaign was conducted in elementary schools in the form of a quiz and lesson related to xylitol. Seventh form children from schools in 12 local health authority areas in 10 provinces took part in the campaign. Six thousand seven hundred children were involved. Data were collected with a series of three separate postal questionnaires. The study group consisted of 1,281 children exposed to the campaign. A control group was formed from 1,227 children in the same provinces not exposed to it. Questionnaires were distributed before and after the campaign. A third one was sent out a month later. A high number of the children had consumed xylitol chewing gum even before the campaign. The majority of the respondents reported no changes in consumption of xylitol chewing gum after meals in the first two questionnaires. The results showed that the consumption of xylitol chewing gum after meals increased more in the group exposed to the campaign than in the control group (P = 0.002). Girls in the study group increased their consumption of xylitol chewing gum more than boys (P = 0.016). Also an increase in the daily use of xylitol chewing gum was achieved by the campaign; differences between the study and the control group being significant (P < 0.05). Even though there was knowledge about the beneficial properties of xylitol beforehand, an increase in knowledge was achieved by the campaign. There seems to be potential for positive oral health promotion by means of this type of xylitol campaign.

Interaction in health education.

The usefulness of the application of the psychodynamic frame of reference in person-to-person health education is examined in the present study. The health educator's proper understanding of his client through an integrative use of his own cognitive and emotional responses to the client is first discussed. Depending on the level of maturity of their personalities, and on the nature of their formative relations, the clients will develop different modes of interaction in their relationships with the health educator. Learning to adequately recognize and meet clients showing different interactional modes is considered to substantially increase the prospects of the health educator helping his clients to accomplish a change in health behaviour. Four levels of interaction and their proper encountering are described and discussed. It is concluded that health education and individual health educators would benefit from an increased familiarity with, and use of, the psychodynamic body of knowledge.

The impact of unemployment on psychosomatic symptoms and mental well-being.

The relationship between psychosomatic symptoms and mental well-being among unemployed (N = 132) and employed (N = 187) personnel of two similar wood-processing factories was studied. Mental well-being was measured by means of the 12-item General Health Questionnaire (GHQ-score) and the 13-item Beck Depression Inventory (BDI-score). The 13-item questionnaire assessing psychosomatic symptoms was used (PS-score). The 33 and 66 percentiles (tertiles) were formed on the basis of PS-score of the two groups separately. The highest PS-score percentile was compared with the combined first and second percentile. Higher PS-score implied impaired mental well-being especially in the unemployed but also in the control group. Insufficient social support and uncertainty about the future was associated with highest PS-score in the study group but not in the control group. High PS-score was associated with subjective mental problems in both groups. Impaired health and PS-score were associated in both groups. Our results suggest that unemployment is a powerful external stress factor and that psychosomatic symptoms were associated with impaired mental well-being.