Estimated Number of Symptomatic Lyme Borreliosis Cases in Adults in Finland in 2021 Using Seroprevalence Data to Adjust the Number of Surveillance-Reported Cases: A General Framework for Accounting for Underascertainment by Public Health Surveillance.

Background: Finland conducts public health surveillance for Lyme borreliosis (LB) based on clinically diagnosed and laboratory-confirmed cases. We used data from seroprevalence studies to determine the extent to which LB cases were underascertained by public health surveillance. Methods: The numbers of incident symptomatic LB cases in 2011 in six regions in Finland were estimated using (1) data from Borrelia burgdorferi sensu lato seroprevalence studies, (2) estimates of the proportion of LB infections that are asymptomatic, and (3) estimates of the duration of LB antibody detection. The numbers of estimated incident symptomatic LB cases were compared with the numbers of surveillance-reported LB cases to estimate regional underascertainment multipliers. Underascertainment multipliers were applied to the numbers of surveillance-reported LB cases in each region in 2021 and summed to estimate the number of symptomatic LB cases in Finland among adults in 2021. A sensitivity analysis evaluated the impact of different durations of antibody detection. Results: Using an asymptomatic proportion of 50% and a 10-year duration of antibody detection, the estimated regional underascertainment multipliers in Finland ranged from 1.0 to 12.2. Applying the regional underascertainment multipliers to surveillance-reported LB cases in each region and summing nationally, there were 19,653 symptomatic LB cases in Finland among adults in 2021 (526/100,000 per year). With 7,346 surveillance-reported LB cases in Finland among adults in 2021, the estimated number of symptomatic LB cases indicate that there were 2.7 symptomatic LB cases for every surveillance-reported LB case among adults. With a 5- or 20-year duration of antibody detection, there were an estimated 36,824 or 11,609 symptomatic LB cases among adults in 2021, respectively. Discussion: Finland has robust public health surveillance for LB, but cases are underascertained. This framework for estimating LB underascertainment can be used in other countries that conduct LB surveillance and have conducted representative LB seroprevalence studies.

Attitudes and actions: A survey to assess statin use among Finnish patients with increased risk for cardiovascular events.

BACKGROUND: Statins are the first-line treatment for lowering serum cholesterol and preventing coronary artery disease (CAD). Patients who fail to comply with the prescribed statin treatment face a markedly increased risk for cardiovascular events. OBJECTIVE: The aim of the article was to study the subjective factors, which modulate persistence with and adherence to statin therapy among Finnish patients at high risk for cardiovascular events. METHODS: A total of 1022 Finnish adults diagnosed with CAD, diabetes, hypertension, or severe hereditary dyslipidemia completed an electronic questionnaire survey during a visit in 1 of the 84 community pharmacies participating in the study. RESULTS: Thirty-four percent of the survey respondents were diagnosed with CAD or severe hereditary dyslipidemia and 82% were current or former statin users. Prevalence of nonpersistence with statin therapy was 15% among CAD patients and 17% among respondents without the diagnosis. Most of the nonpersistent statin users had discontinued the medication without consultation of a physician. None of the studied sociodemographic background factors were associated with persistence with statin therapy. Instead, experienced adverse effects, fear of adverse effects, perceived lack of need, and difficulties in use of a statin emerged as powerful predictors of nonpersistence. Awareness of treatment goals was low, and strikingly, public discussion about adverse effects of statins had induced nearly every third discontinuation of statin treatment. CONCLUSION: Several subjective, potentially modifiable reasons for nonpersistence were identified from the patient perspective. Improved utilization of patient-centered approaches in pharmacologic management of cardiovascular risks is necessary to improve adherence, and ultimately, treatment outcomes.

Characteristics of first-time varenicline users - A cross-sectional study in Finnish quitters.

BACKGROUND: Varenicline is an efficacious medicine for smoking cessation (SC) but little is known about the characteristics of varenicline users. This study examined the characteristics of first-time (naïve) varenicline users in Finland and compared those who had previously used SC pharmacotherapy to those who were trying SC pharmacotherapy for the first time. METHODS: A cross-sectional survey was conducted in Finnish community pharmacies between February 2014 and January 2015. Pharmacy customers purchasing a varenicline starter package for the first time ever were asked to complete a questionnaire or to participate in a structured interview conducted by the pharmacist (identical questions). The questionnaire included questions about demographic characteristics, smoking habits, previous cessation attempts and factors associated with varenicline use. RESULTS: Altogether 98 people completed the survey. The majority were daily smokers (96%, n = 94), with a history of over 10 years of regular smoking (94%, n = 92), and a strong/very strong nicotine dependence (67%, n = 66). Half of the participants (54%, n = 53) were trying a SC pharmacotherapy for the first time. Demographic characteristics and smoking habits were similar between first-time and previous users of SC medications (p > 0.05). Health centers (42%, n = 41) and occupational health care clinics (37%, n = 36) were the most common sources of varenicline prescriptions. The majority of participants received the prescription for varenicline after mentioning their desire for quitting to a physician (70%, n = 69). CONCLUSIONS: Considering the relatively large proportion of SC naïve medicine users among new users of varenicline, smokers who have previously been reluctant to quit smoking, to use other pharmacological SC interventions, or perhaps unaware of these options may be interested in attempting cessation with varenicline. Most participants made the initiative to discuss their smoking with the physician, which led to varenicline prescribing. This suggests that physicians may not satisfactorily recognize their patients' nicotine dependence and desire to quit, and they should more actively support patients' smoking cessation.

A survey on the medication adherence to methotrexate among rheumatoid arthritis patients treated with self-administered biologic drugs.

OBJECTIVES: Methotrexate (MTX) is the most widely used co-therapy among rheumatoid arthritis (RA) patients using biological disease-modifying anti-rheumatic drugs (bDMARDs). However, adherence to MTX treatment remains a concern with estimates of adherence ranging from 59 to 63%. The objective of this study was to assess the self-reported use and adherence to MTX among RA patients treated with self-administered bDMARDs. METHODS: An electronic questionnaire survey was conducted in 68 community pharmacies in Finland. To be included in the present study patients had to be at least 18 years old, be currently using a self-administered bDMARD and be diagnosed with RA. The results are presented as medians with their respective interquartile ranges (IQR) or percentages. RESULTS: Of the 158 pharmacy customers asked to participate, 135 (85%) consented to complete the questionnaire. The included respondents were predominantly female (72%) with a median age of 55 (IQR 44-65) and rheumatic activity of 3 out of 10 (IQR 2-6.5). The majority (91%) of the included respondents were using TNF-inhibitors and 27% of all patients were on biologic monotherapy. MTX was currently used by 45% of the respondents while 50% were past users. Of the current MTX users, 6.8% identified themselves moderately non-adherent to the treatment. MTX-related adverse events were important factors associated with nonadherence and discontinuation of the treatment. CONCLUSIONS: Only 45% of the respondents were currently using MTX co-therapy, but the ones who did were adherent to their treatment. Self-reported adherence may however be subject to social desirability bias and recall bias.

The role of community pharmacies in counseling of personal medical devices and drug-delivery products in Estonia.

OBJECTIVES: To evaluate the current situation on medical technology at community pharmacies in Estonia, looking into the availability, dispensing and counseling of personal medical devices/drug-delivery products (PMDs/DDPs) and related professional knowledge of community pharmacists. METHODS: A descriptive cross-sectional questionnaire-based study using an internet-based eFormular study platform. RESULTS: In total, 137 community pharmacies responded to the study. Of the pharmacies, 51.8% dispensed and 32.1% counseled PMDs/DDPs several times a day. 55.4% of the respondents assessed their professional knowledge on PMDs/DDPs as good to medium and 44.6% as satisfactory to poor. Of the respondents, 79.6% reported a need for systematic education about named devices. CONCLUSION: Community pharmacies are a frequent source for the dispensing and counseling of PMDs/DDPs in Estonia. However, community pharmacists admitted a strong need for continuing education about general and practical aspects related to the use of PMDs/DDPs for the provision of more professional services in the future.

Persistence of noncancer-related musculoskeletal chronic pain among community-dwelling older people: a population-based longitudinal study in Finland.

OBJECTIVE: To determine the persistence of chronic pain among community-dwelling older persons and to identify factors related to persistent chronic pain. METHODS: In this prospective longitudinal study, a random sample of Finnish community-dwelling people aged 76 years and older (n=256) were interviewed annually by a trained nurse at 3 time points. Data on prevalence, duration, location, and intensity of musculoskeletal pain, analgesic use, demographics, and health characteristics were collected during the interviews. RESULTS: Chronic pain was reported by 48.9% of the participants at baseline, with 74.4% of them experiencing persistent chronic pain, that is, they reported chronic pain at all 3 study points. Persistent chronic pain was associated with poor self-rated health (adjusted odds ratio [AOR]=2.26, 95% confidence interval [95% CI] 1.03-4.98), mobility difficulties (AOR=2.80, 95% CI, 1.22-6.43), and arthrosis or rheumatoid arthritis (AOR=3.07, 95% CI, 1.47-6.42) when compared with persons without chronic pain. However, only 15% of the persons with persistent chronic pain were using analgesics on a regular basis, and one out of every 5 was not taking any analgesics. CONCLUSIONS: Chronic musculoskeletal pain is a highly persistent condition among community-dwelling older persons and it is related to poor health and mobility difficulties. In addition, the use of daily analgesic is low despite the continuous nature of chronic pain.

More attention to pain management in community-dwelling older persons with chronic musculoskeletal pain.

BACKGROUND: persistent pain is a major problem in older people, but little is known about older persons' opinion about the treatment of persistent pain. OBJECTIVE: the objective of this study was to investigate the factors associated with older participants having chronic musculoskeletal pain and hoping persistently that physician would pay more attention to the pain management. METHODS: this 3-year follow-up study was a part of large population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study. The population sample (n = 1000) of the GeMS study was randomly selected from older inhabitants (≥75 years) of Kuopio city, Finland, and participants were interviewed annually in the municipal health centre or in the participant's current residence by three study nurses. The current substudy included participants with chronic musculoskeletal pain (n = 270). Participants were asked specifically whether they hoped that more attention would be paid to pain management by the physician. RESULTS: at baseline, 41% of the community-dwelling older participants with chronic musculoskeletal pain hoped the physician would pay more attention to pain management. Of those participants, 49% were still continuing to hope after 1 year and 31% after 2 years. A persistent hope to receive more attention to pain management was associated with poor self-rated health (OR: 2.94; 95% CI: 1.04-8.30), moderate-to-severe pain (OR: 3.46; 95% CI: 1.42-8.44), and the daily use of analgesics (OR: 4.16; 95% CI: 1.08-16.09). CONCLUSION: physicians need to take a more active role in the process of recognising, assessing and controlling persistent pain in older people.

First insights into community pharmacy based buprenorphine-naloxone dispensing in Finland.

BACKGROUND: Finnish community pharmacies have been permitted to dispense buprenorphine-naloxone since February 2008. This study explored the dispensing practices, service experiences, problems encountered and opportunities for future development. METHODS: In August 2011, a questionnaire was mailed to all Finnish community pharmacies dispensing buprenorphine-naloxone (n=69). RESULTS: Sixty-four pharmacies responded (93%), of which 54 had dispensed buprenorphine-naloxone to 155 clients since 2008. Forty-eight pharmacies had 108 current clients (10% of all buprenorphine-naloxone clients in Finland). Overall satisfaction with buprenorphine-naloxone dispensing was high, with all respondents indicating dispensing had gone 'well' or 'very well'. Fourteen pharmacies (26%) had experienced one or more problems, predominately in relation timing or non-collection of doses. Problems were more common in pharmacies with more than one buprenorphine-naloxone client (odds ratio 1.39, 95% confidence interval 1.05-1.86). Most pharmacies (n=43, 80%) identified opportunities for improvement, including the need for more education and financial remuneration. Forty-six pharmacies (85%) were willing to dispense buprenorphine-naloxone to more clients; however, 43 pharmacies (80%) perceived that supervision of buprenorphine-naloxone dosing is not a suitable task for pharmacists in Finland. CONCLUSION: Provision of buprenorphine-naloxone in Finnish community pharmacies has remained relatively small-scale. As experiences have been generally positive and problems rare, it may be possible to expand these services.

Cost-effectiveness of oral triptans for acute migraine: mixed treatment comparison.

BACKGROUND: The cost-effectiveness of triptans in the treatment of migraine has not been assessed since generic sumatriptan entered the Finnish market in 2008. METHODS: Using systematic review and mixed treatment comparison, the effectiveness of triptans was estimated with regard to 2-hour response, 2-hour pain-free, recurrence, and any adverse event, using published clinical data. Direct and indirect costs (2010 EUR, societal perspective) and quality-adjusted life-years (QALYs) were evaluated over one acute migraine attack using a decision-tree model. RESULTS: The meta-analysis combined data from fifty-six publications. The highest probability of achieving the primary outcome, "sustained pain-free, no adverse event" (SNAE), was estimated for eletriptan 40 mg (20.9 percent). Sumatriptan 100 mg was the treatment with lowest estimated costs (€20.86), and the incremental cost-effectiveness ratio of eletriptan 40 mg compared with sumatriptan 100 mg was €43.65 per SNAE gained (€19,659 per QALY gained). CONCLUSION: Depending on the decision-maker's willingness-to-pay threshold, either sumatriptan 100 mg or eletriptan 40 mg is likely to be cost-effective.

Sponsorship-related outcome selection bias in published economic studies of triptans: systematic review.

BACKGROUND: Economic studies funded by the pharmaceutical industry are more likely to report favorable results and recommendations for the sponsor's product than are studies funded by nonindustry establishments. PURPOSE: To determine whether clinical outcome data obtained from the same meta-analyses are used differently in various economic studies of oral triptans and whether there is an association between the study sponsorship and the choice of clinical outcome measure. DATA SOURCES: Economic studies of triptans were identified by updating a previously published systematic review. STUDY SELECTION: Twelve studies that used the same meta-analyses as the source of clinical outcome data were identified. DATA EXTRACTION: Two independent reviewers extracted the essential data from the identified studies. DATA SYNTHESIS: In the 12 appraised studies, 9 alternative measures of effectiveness were derived from the same meta-analyses. Eleven studies were industry-related, and in these the selected clinical outcome consistently favored the sponsor's product. Also the reported results suggested that the sponsor's product was more cost-effective than the competitors' products. LIMITATIONS: The cost-effectiveness of triptans is dependent on both the definition of clinical effectiveness and the treatment-related costs. Only bias related to the selection of the clinical outcome measure has been taken into account in this review. CONCLUSIONS: The results of published economic studies of triptans are conflicting and biased. There is a tendency to select clinical outcome measures that support the sponsor's product. This leads to concern about the possible poor applicability of these results in decision making.

Dual role of FoxA1 in androgen receptor binding to chromatin, androgen signalling and prostate cancer.

High androgen receptor (AR) level in primary tumour predicts increased prostate cancer-specific mortality. However, the mechanisms that regulate AR function in prostate cancer are poorly known. We report here a new paradigm for the forkhead protein FoxA1 action in androgen signalling. Besides pioneering the AR pathway, FoxA1 depletion elicited extensive redistribution of AR-binding sites (ARBs) on LNCaP-1F5 cell chromatin that was commensurate with changes in androgen-dependent gene expression signature. We identified three distinct classes of ARBs and androgen-responsive genes: (i) independent of FoxA1, (ii) pioneered by FoxA1 and (iii) masked by FoxA1 and functional upon FoxA1 depletion. FoxA1 depletion also reprogrammed AR binding in VCaP cells, and glucocorticoid receptor binding and glucocorticoid-dependent signalling in LNCaP-1F5 cells. Importantly, FoxA1 protein level in primary prostate tumour had significant association to disease outcome; high FoxA1 level was associated with poor prognosis, whereas low FoxA1 level, even in the presence of high AR expression, predicted good prognosis. The role of FoxA1 in androgen signalling and prostate cancer is distinctly different from that in oestrogen signalling and breast cancer.

[Indirect comparison and network meta-analyses--new tools for the assessment of evidence on the relative efficacy of drugs]. / Epäsuora vertailu ja verkostometa-analyysit --uudet työkalut lääkkeiden suhteellisen tehon ja vaikuttavuuden arviointiin.

Meta-analysis allows the quantitative combination of results of multiple studies that address similar research questions. Traditional meta-analysis of studies involving a direct comparison of two treatment alternatives can be applied to estimate the overall relative efficacy of these two treatment alternatives. All treatment options relevant to practical treatment decisions are, however, not always compared directly against each other in clinical studies, but indirect comparison via a common comparator may be possible. To use all relevant evidence from both direct and indirect comparisons of treatment options, advanced methods of meta-analysis have been developed. These so-called network meta-analyses extend the traditional meta-analysis to cases where a network of studies enables different pair-wise direct and indirect comparisons between multiple treatment alternatives, thereby forming a network of relevant evidence.

[Are there enough medical scientists in Finland?]. / Riittääkö suomessa lääkäritutkijoita?

Discussion within the scientific society and hospital communities has raised concerns of the current status and future of clinical research in Finland. One of the crucial future challenges is whether there are enough medical scientists that are able to perform clinical research and comprehend and manage medicine as a whole. In the article, the authors present suggestions for solving the problematic issues.

Short-course adjuvant trastuzumab therapy in early stage breast cancer in Finland: cost-effectiveness and value of information analysis based on the 5-year follow-up results of the FinHer Trial.

BACKGROUND: Trastuzumab is a standard treatment of HER2-positive early breast cancer in many countries, and it is usually given as a one year adjuvant treatment. However, its cost-effectiveness has not been assessed in Finland. The Finland Herceptin (FinHer) trial has compared a shorter 9-week treatment protocol against no trastuzumab with promising results. The aim of this study was to assess the potential cost-effectiveness of the 9-week treatment based on the recently published five-year follow-up results of the FinHer trial. METHODS: An evaluation model of breast cancer treatment was constructed using fitted survival estimates and a long-term Markov model. The cost-effectiveness of 9-week adjuvant treatment was assessed in a Finnish setting, compared to treatment without trastuzumab. The analysis was performed from a societal perspective, and a 3% discount rate was applied for future costs and outcomes. Value of information analysis was performed to estimate the potential value of further research. RESULTS: According to the probabilistic analysis, the incremental cost-effectiveness ratio was €12 000 per quality adjusted life year (QALY), and €9300 per life year gained (LYG), when comparing adjuvant trastuzumab therapy to standard treatment without trastuzumab. The modelled incremental outcomes for trastuzumab treatment were 0.66 QALY and 0.85 LYG for a lifetime perspective. Value of information analysis showed that additional research on treatment effects would be most valuable for reducing uncertainty in the adoption decision. CONCLUSIONS: Adjuvant 9-week trastuzumab is likely to be a cost-effective treatment in the Finnish setting. Results from an ongoing trial comparing adjuvant 9-week treatment with the 12-month treatment will play a key role in addressing the uncertainty related to the treatment effect and potential cost-effectiveness of these two treatment protocols.

Cellular characteristics of non-allergic eosinophilic conjunctivitis.

PURPOSE: This study examines the histology of conjunctival biopsy samples from patients with persistent allergic eosinophilic conjunctivitis (AEC) or non-allergic eosinophilic conjunctivitis (NAEC). METHODS: Fourteen patients with conjunctivitis and eosinophilia in cytology samples were included in the study. Seven had positive skin-prick tests (the AEC group) and seven had negative skin-prick tests (the NAEC group). Eight asymptomatic subjects with negative skin-prick tests served as a control group. In conjunctival biopsies eosinophils were identified with monoclonal antibodies. Mast cells were identified by specific immunostaining and tryptase-positive granules were counted around them. The percentage of degranulated mast cells was used as a measure of cell activation. Eosinophil and goblet cell numbers were counted, epithelial thickness was measured, and the symptoms were characterized and graded. RESULTS: The numbers of eosinophils in biopsies were higher in patients with AEC than in healthy controls (p = 0.010). The proportion of activated mast cells tended to be higher in AEC patients (65%) than in NAEC patients (48%) or control subjects (40%). Patients with AEC had more goblet cells than control subjects (p = 0.049) and their epithelial layer was thicker (p = 0.054). Patients with AEC had more severe symptoms than control subjects (p = 0.0005), whereas the symptoms of NAEC patients did not differ statistically from those of controls (p = 0.065). CONCLUSIONS: Patients with NAEC were characterized by mild eosinophilic inflammation and only minor structural conjunctival changes. The condition seems to run a relatively mild but persistent clinical course.

Amount of external CME in groups of specialties: a nation-wide survey among Finnish doctors.

BACKGROUND: Continuing medical education (CME) is an integral part of continuing professional development and a prerequisite for good quality in health care. We aimed to describe and analyse the number of days spent in formal CME outside the workplace by specialty among Finnish doctors of working age. FINDINGS: The number of days in formal CME outside the workplace in 2005 reported by specialists was obtained from an annual postal survey, conducted by the Finnish Medical Association in March 2006, of all working-age doctors. Those who had attained their specialist degree before 2005 were included in the study. The 49 specialties were re-categorised into 15 groups. The mean reported number of days and 95% confidence intervals were calculated. Differences were analysed by Poisson regression adjusted for relevant covariates. The response rate to the question about CME was 70.2% (7,374) among specialists. The median age (interquartile range) of the respondents was 49 years (from 44 to 55 years), and 51.7% (3,810) were female. The mean reported number of days in CME was 8.8 (95% CI 8.7-9.0). Neurologists and surgery specialists participated in CME the most frequently (10.3 and 10.4 days) and ophthalmologists the least (7.6 days). In comparison with anaesthesiology and intensive care specialists, most specialists reported having significantly more formal CME, and no group reported having less. CONCLUSIONS: Significant variation was observed, and we therefore suggest studies seeking to account for this variation. The results have originally been published in Finnish in the Finnish Medical Journal.

A comparison of three questionnaire-based measures of analgesic use over 11 years in adult males: a retrospective analysis of data from a prospective, population-based cohort study.

BACKGROUND: Few data are available on whether 3 commonly used, yet slightly different, questionnaire-based measures assessing the use of analgesics provide congruent and comparable results. OBJECTIVE: The objective of this study was to compare 3 different measures of analgesic use in 1 study population over an 11-year period. METHODS: Data for this study were gathered from a prospective, population-based cohort study in which 3 different measures were applied simultaneously for measuring use of analgesics at baseline, 4 years, and 11 years. The first measure was "weekly analgesic use in general," the second measure "analgesic use for pain symptoms within the past week," and the third measure "giving the name of any analgesic used within the past week." The subjects were Finnish men who completed 11 years of follow-up in the Kuopio Ischemic Heart Disease Risk Factor (KIHD) Study, conducted at the Research Institute of Public Health, University of Kuopio, Kuopio, Finland. Agreement between the 3 different measures was determined by Kappa statistics. RESULTS: A total of 829 men completed 11 years of follow-up (mean [SD] age, 51.4 [6.7] years at baseline; 62.4 [6.5] at study end). At baseline, the prevalence of weekly analgesic use varied from 12.3% to 17.4% and at 11 years from 16.5% to 25.9%, depending on which measure was being used. The third measure yielded the highest prevalence at all 3 points of time and the lowest was obtained using the first measure. The Kappa agreement between the 3 measures at the 3 time points varied from moderate (0.37) to good (0.71). CONCLUSIONS: The results of this study suggest that the measure being used influences the obtained prevalence of analgesic use. All 3 measures tested consistently throughout the course of the study. The best results, with regard to determining prevalence, were obtained by asking the respondents to name the medicines they had been using during the previous week.