Dyslipidemia and hyperglycemia predict coronary heart disease events in middle-aged patients with NIDDM.

Patients with NIDDM are at increased risk for coronary heart disease (CHD). However, information on the predictive value of cardiovascular risk factors and the degree of hyperglycemia with respect to the risk for CHD in diabetic patients is still limited. Therefore, we carried out a prospective study on risk factors for CHD, including a large number of NIDDM patients. At baseline, risk factor levels of CHD were determined in 1,059 NIDDM patients (581 men and 478 women), aged from 45 to 64 years. These patients were followed up to 7 years with respect to CHD events. Altogether, 158 NIDDM patients (97 men [16.7%] and 61 women [12.8%]) died of CHD and 256 NIDDM patients (156 men [26.8%] and 100 women [20.9%]) had a serious CHD event (death from CHD or nonfatal myocardial infarction). A previous history of myocardial infarction, low HDL cholesterol level (<1.0 mmol/l), high non-HDL cholesterol (> or =5.2 mmol/l), high total triglyceride level (>2.3 mmol/l), and high fasting plasma glucose (>13.4 mmol/l) were associated with a twofold increase in the risk of CHD mortality or morbidity, independently of other cardiovascular risk factors. High calculated LDL cholesterol level (> or =4.1 mmol/l) was significantly associated with all CHD events. The simultaneous presence of high fasting glucose (>13.4 mmol/l) with low HDL cholesterol, low HDL-to-total cholesterol ratio, or high total triglycerides further increased the risk for CHD events up to threefold. Our 7-year follow-up study provides evidence that dyslipidemia and poor glycemic control predict CHD mortality and morbidity in patients with NIDDM.

Factors associated with fasting and postglucagon plasma C-peptide levels in middle-aged insulin-treated diabetic patients.

We studied fasting and postglucagon plasma C-peptide levels and factors associated with them in two representative studies of middle-aged insulin-treated diabetic patients whose diabetes had been diagnosed after the age of 30 yr. Altogether, 75 men and 79 women from East Finland and 83 men and 62 women from West Finland aged 45-64 yr were studied. Of these patients, 44.4% had undetectable fasting and 38.5% undetectable postglucagon C-peptide concentrations. The phi-coefficient expressing the concordance of fasting and postglucagon C-peptide concentrations in the classification of diabetic patients into nonresponders and responders was .75 in men and .91 in women. In multiple stepwise regression analyses, body mass index (BMI) and the period between diabetes diagnosis and the initiation of insulin treatment were positively and duration of diabetes inversely associated with fasting and postglucagon C-peptide levels in both sexes. We concluded that 1) insulin deficiency is not uncommon in middle-aged insulin-treated diabetic patients whose diabetes has been diagnosed after the age of 30 yr; 2) fasting C-peptide levels contain basically the same information as postglucagon C-peptide levels; and 3) a low BMI, a need for insulin treatment soon after the diagnosis of diabetes, and a long duration of diabetes are predictive of insulin deficiency.

Atherosclerotic vascular disease and its risk factors in non-insulin-dependent diabetic and nondiabetic subjects in Finland.

A cross-sectional study on the prevalence of atherosclerotic vascular disease (ASVD) and its risk factors in non-insulin-dependent diabetic and nondiabetic subjects was carried out from 1982 to 1984 in East Finland (Kuopio) and West Finland (Turku), two areas known to differ markedly in prevalence of ASVD in the nondiabetic population. A total of 510 diabetic and 649 nondiabetic subjects aged 45-64 yr were examined in East Finland and 549 diabetic and 724 nondiabetic subjects of the same age in West Finland. In both areas and in both sexes the prevalence of coronary heart disease (CHD), stroke, and intermittent claudication was higher in diabetic than in nondiabetic subjects. Both in diabetic and nondiabetic subjects the prevalence of ASVD was higher in East Finland than in West Finland. In men, the East-West difference in the prevalence of symptomatic CHD and claudication was greater in diabetic than in nondiabetic subjects. In both areas and in both sexes the serum lipid pattern was more atherogenic and hypertension was more frequent in diabetic than in nondiabetic subjects. In both diabetic and nondiabetic subjects, serum total-cholesterol level was somewhat higher and hypertension was more frequent in East Finland than in West Finland. The East-West difference in serum total-cholesterol was greater in diabetic than in nondiabetic subjects. In multiple logistic analyses including cardiovascular risk factors, diabetes status, and area of residence, residence in East Finland was found to be, in addition to diabetes, a strong independent factor associated with CHD, particularly in men.

Insulin-like growth factor-I in type 2 (non-insulin-dependent) diabetics with myocardial infarction and without macroangiopathy.

In order to evaluate whether insulin-like growth factor-I (IGF-I) is associated with the development of diabetic macroangiopathy, we measured its plasma concentration in type 2 diabetics with definite myocardial infarction (MI), in type 2 diabetics without macroangiopathy (MA), and in non-diabetic healthy controls. We also compared plasma IGF-I concentration in non-diabetics with definite MI to that in non-diabetics without MA. There was a large interindividual variation in plasma IGF-I concentration in all groups of subjects studied. The median values were as follows: 0.60 IU/ml in diabetics with MI, 0.59 IU/ml in diabetics without MA, 0.48 IU/ml in non-diabetics with MI and 0.76 IU/ml in non-diabetic healthy controls. The only statistically significant difference between the groups was that between non-diabetics with MI and non-diabetics without MA. In diabetics, irrespective of MA, no significant correlation existed between plasma IGF-I level and the degree of glycemic control, renal function or various risk factors for atherosclerosis. The results of this study suggest that the high prevalence of macroangiopathy in type 2 diabetics cannot be imputed to IGF-I.

Can treatment outcome of chronic low back pain be predicted? Psychological disease consequences clarifying the issue.

OBJECTIVE: To search for generalizable, psychological predictors of chronic pain treatment outcome. DESIGN: The prognostic power of the psychological predictors, classified into subareas of function, i.e., impairments, disabilities, and handicaps, was compared in predictive situations varying with the quality of patient samples, programs, and outcome measures. SETTING: Four rehabilitation centers in Finland providing "functioning activation" or more passive "spa resort" treatment programs for low back pain patients. PATIENTS: 173 low back pain patients for whom the inpatient rehabilitation program was funded by the Finnish Social Insurance Institution. OUTCOME MEASURES: The measures were panel assessment of global functioning (DSM III Axis V), self-report of handicap (Million), panel assessment of handicap (WHO index), panel assessment of adherence (four rating scales), and self-report of well-being (Faces scale). RESULTS: Multivariate, stepwise regression analyses suggested that the disability and handicap measures of functioning may be more effective predictors than impairment measures, which, however, add to the variance explained by the former. However, the predictive power of psychological impairments, disabilities, and handicaps varied with differences in patient group, outcome measure, and program. CONCLUSION: The "general predictors" of chronic pain treatment outcome may be difficult to find. Therefore, planning treatment for the individual patient may always have to be based on accurate multiaxial and multidimensional assessment of patient functioning.

Intensive physical and psychosocial training program for patients with chronic low back pain. A controlled clinical trial.

STUDY DESIGN: The authors conducted a controlled clinical trial with 1-year follow-up to define the effectiveness of an intensive physical and psychosocial training program on patients with low back pain. SUMMARY OF BACKGROUND DATA: The intervention group included 152 patients (mean age 40.5 yr, Million index 45.1/100), and the reference group included 141 patients (mean age 40.4 yr, Million-index 44.5/100). METHODS: The progressive intervention program consisted of intensive physical training and psychosocial activation. The outcomes were physical and psychosocial measures, the pain and disability index (Million), sick leaves, and occupational handicap. RESULTS: The intervention was more efficient with respect to physical measures and pain and disability index. There were only mild or no differences in changes between the study groups in psychologic variables, sick leaves, or retirement. CONCLUSIONS: The intervention program could improve physical disability, but to improve occupational handicap, activities of the whole society (social legislation, labor market policy) are needed.

A prospective study of patients with sciatica. A comparison between conservatively treated patients and patients who have undergone operation, Part I: Patient characteristics and differences between groups.

Based on a prospective study on 342 sciatica patients examined with rhizography, the aim was to determine which factors others than the rhizography finding and the grade and duration of symptoms were related to the selection of patients to undergo operation. Compared with surgically treated patients, conservatively treated patients who did not undergo operation and who had pathologic rhizography findings had pessimistic attitudes to possible surgery, often expressed a desire to retire, and considered their work as physically stressful. The women in this group were older and had lower pain indices than women who underwent operation. Conservatively treated patients with negative rhizography had more severe occupational handicaps, minor expectations of possible surgery, physically more strenuous jobs requiring difficult physical positions, and lower indices for pain and ADL than did the operated patients. The social and ergonomic background problems are emphasized in sciatica patients conservatively treated after rhizography.

A prospective study of patients with sciatica. A comparison between conservatively treated patients and patients who have undergone operation, Part II: Results after one year follow-up.

The prospective study included 122 sciatica patients who had not undergone operation (NOPs) and 220 sciatica patients who had undergone operation (OPs); all had been examined by rhizography. The follow-up study was done on 110 (90%) of the NOPs and 212 (96%) of the OPs. The NOPs were divided into two groups: 30 patients with pathologic rhizography (PR) and 80 patients with negative rhizography (NR). Pain-, ADL-, and occupation-handicap indices showed that after the 1 year follow-up the OP group had the best result and the NR group the lowest result. The PR group had nearly as good a result as the OP group. Thus, sciatica patients are candidates for conservative therapy, even though they have pathologic findings in rhizography, if the symptoms are mild. To improve therapeutic outcome, more accurate diagnostic tools are needed to develop specific therapy especially for those sciatica patients with negative rhizography.

Prevalence of handicapping hearing loss in an aging population.

The mean hearing thresholds of 369 Finnish inhabitants, 65 years, and born in 3 consecutive years on two elected days each year, were studied in high standard measurement conditions. Eighty-nine of these subjects were reexamined 3 years later. They represented a typical partly industrialized white population with a high standard of living. With the criteria for hearing rehabilitation for presbycusis set at a mean hearing threshold of 30 dB or worse at 500 to 1,000 to 2,000 Hz, and/or 50-dB hearing loss at 2,000 Hz, the prevalence of rehabilitation need was 3.2%. Conductive hearing losses were found in 6% of the subjects.

Mental health and functioning: a case analysis of rehabilitation patients.

The relationship between mental health and functioning has been inconsistently described. Here, the role of mental health in determining functioning was studied from a large multi-axial (biopsychosocial) and multi-dimensional (impairments, disabilities and handicaps) point of view. Case-analysis of rehabilitation patients indicated that inconsistent findings may be due to an incorrect linearity assumption. Results indicated that: (1) good mental health may aid the patient to benefit from rehabilitation. However, (2) it does not guarantee good future functioning, because the impact of mental health on functioning varies in interaction with other functional aspects. On the other hand, (3) poor mental health does not necessarily impede good future functioning, whereas (4) poor mental health, associated with other aspects of poor functioning, quite reliably predicts poor functioning after rehabilitation. It was concluded that single psychological factors cannot predict functioning. To improve prediction, broader models of functional assessment in rehabilitation should be used.

The biopsychosocial disease consequence model in rehabilitation: model development in the Finnish 'work hardening' programme for chronic pain.

To compare the effectiveness of diverse rehabilitation programmes, comparable data about their effects on maintaining or improving the residual function of the rehabilitation patients should be gathered. Current rehabilitation theories and assessment procedures for functioning are not consistent enough for valid comparisons. The rehabilitation theory should be developed to produce coherence and generalizability to the rehabilitation process. The biopsychosocial disease consequence (BPSDC) model for functioning is presented for this purpose. The model describes the rehabilitation process of patients with chronic pain as a three-axial (biopsychosocial) and three-dimensional (disease consequences) assessment and intervention grid for functioning. It emphasizes the strict mutual relationship between the assessment procedures and intervention plans. Application of the BPSDC model in the Finnish AKSELI project studying the effects of two different programmes on patients with chronic low-back pain is described. Although the AKSELI studies indicated that in addition to the assessment procedures other factors also contributed to valid evaluation of outcomes, and it is hoped that the BPSDC model will encourage researchers to look for definitions of functioning, to assess functioning according to theoretical assumptions about the sub-areas of functioning, and to provide comparable outcome data for the evaluation of various programmes.

Psychologists' role in functional assessment of rehabilitation patients.

In this study attention was paid to the psychological criteria that clinicians may use when assessing global functioning of rehabilitation patients. Global functioning was understood to be determined by physical, psychological and social factors and was operationally defined as performance in three different areas of life: work, daily activities and human relations. The psychological factors whose relationships to global functioning were studied were three components of personality dynamics:--mental health, cognitive skills and motivation. Patients' mental health, cognitive abilities, motivation and global functioning were clinically rated on the basis of data given by psychological interview, psychological test-results and other information. Correlation analysis showed that the clinicians tend to use the mental health state, the level of cognitive performance and the degree of motivation as criteria when assessing the functioning of rehabilitation patients during the rehabilitation examination. However, multiple regression analysis showed that these psychological variables explained as little as 32% of the variance in follow-up functioning. This is in agreement with the biopsychosocial view that psychological factors are only one class of events manifesting in illness, functioning and behavior.

Rehabilitation after surgery for lumbar disc herniation: results of a randomized clinical trial.

The aim of this prospective study was to examine the one-year postoperative results in patients operated on for lumbar disc herniation randomized in two groups: one with comprehensive rehabilitation and the other taken care of by normal care facilities. A total of 212 patients without any previous spinal operations comprised the final study group. The physiatrist, the surgeon, the social worker, and the psychologist performed the handicap evaluation according to the occupation handicap scales of the WHO. The handicap was evaluated for two phases: before the onset of acute sciatica leading to operation and one year after operation. No significant differences in handicap distribution between the intervention and normal care groups were seen. The postoperative handicap correlated highly significantly with preoperative handicap for both groups. More than half (57%) of all the patients returned to work within two months of the operation. The amount of sick leaves did not differ significantly between the intervention and normal care groups. A total of 15 persons (7%) retired during the postoperative year.

Resource support and heart patient recovery.

This prospective study examines the effects of resources utilized by myocardial infarction (MI) and coronary artery bypass (BY) patients in the recovery process. The resource support model incorporates formal (institutionalized) and semi-formal (mutual aid) services along with informal assistance (social networks). Patient interview data were collected on 147 MI and 159 BY patients at hospitalization and at 3 months. Sociodemographic, illness and resource data were obtained, and hospital records were abstracted. Two outcomes were evaluated: activity limitations and work capacity. Bivariate and multivariate analyses were used to assess individual and resource effects. Multivariate analyses revealed that, for MI patients, a higher level of activity prior to hospitalization and a shorter hospital stay were significantly related to recovery. A smaller social network with greater frequency of contact enhanced recovery. For BY patients, recovery was significantly associated with higher social class higher level of activity prior to hospitalization and fewer health care visits. Outcome based on work capacity revealed that MI patients who were younger in age, male sex and who had fewer prescribed medications were more likely to recover. By patients had a similar pattern as that observed for MI patients in terms of age and sex. Co-morbidity had a negative effect on recovery. Those with less affective informal support were more likely to have recovered. The resource support model employed in this prospective study proved to have mixed results. However, the model may be a useful multifactorial framework for examining the effects on patient recovery over a longer duration.

Community phase of cardiac rehabilitation.

Although their effects cannot be shown to statistically alter coronary heart disease mortality or morbidity, voluntary health organizations throughout the world clearly play an important role in bringing about favorable changes in the natural history of this disease and in the community phase of its management. In particular, voluntary organizations are able to conduct research surveys and field trials and by so doing favorably influence state health administration. They are able to correct temporary deficiencies in health services, particularly in the form of psychosocial support and cardiac health education. Observers note that the major change in community phase management has occurred with the wider use of coronary bypass surgery since 1975. More objective data, especially relating to psychosocial factors, can be expected when further research (especially the MONICA Study) is completed. Throughout the world, however, existing voluntary health organizations could be more active in the community phase of cardiac rehabilitation. It would seem an area where such organizations could well do more. A challenging question that should be constantly reviewed is 'Can we do more to reduce the effects of invalidism in cardiac patients?'