Toxic acute hepatitis and hepatic fibrosis after consumption of chaparral tablets

In this report we describe a young, previously healthy woman who developed severe acute hepatitis after consumption of chaparral tablets, a commonly used herbal product. In this case, the elimination-rechallenge event and the exclusion of other possible aetiologic factors strongly supported true causality between the herbal product and the liver damage. Primary liver biopsy showed severe toxic hepatitis consistent with previous reports of chaparral-induced liver damage. Later, 6 months after the liver function tests had normalized, permanent hepatic fibrosis could still be seen.     

Comparison of two budesonide powder inhalers,Easyhaler and Turbuhaler,in steroid-naïve asthmatic patients

The objective of this multicenter study was to compare the clinical efficacy, safety, and acceptability of Easyhaler and Turbuhaler for the delivery of budesonide 200 micrograms/dose twice daily in steroid-na?ve asthmatic patients. Three hundred and twenty-six newly diagnosed, steroid-na?ve adult patients with mild-to-moderate asthma were recruited into this randomized, double-blind, double-dummy, parallel-group study, comprising a 2-week run-in period and 8 weeks of treatment. Patients received budesonide inhalation powder 400 micrograms/day either via Easyhaler (n = 159) or via Turbuhaler (n = 167), plus salbutamol inhalation powder (100 micrograms/dose) via Easyhaler as rescue therapy. The study was completed by 292 patients: 143 in the Easyhaler group and 149 in the Turbuhaler group. The primary outcome variable, mean morning peak expiratory flow (PEF), improved significantly and almost similarly by 36.3 and 30.6 l/min, respectively, from run-in to weeks 7-8. At weeks 7-8, the mean (SE) difference in morning PEF between the two treatments was 7.1 (9.4) l/min (90% CI from -8.4 to 22.6) on per protocol analysis, which was within the defined limits for therapeutic equivalence. There were no significant differences between treatments in terms of secondary efficacy variables or adverse events. However, patients found Easyhaler more acceptable than Turbuhaler. The results show that budesonide via Easyhaler is clinically as effective as Pulmicort Turbuhaler when equal daily doses of budesonide are delivered to steroid-na?ve asthmatic patients. Moreover, patients found Easyhaler more acceptable than Turbuhaler, and a majority would prefer Easyhaler if given a choice.     

Humoral immunity induced by a live Francisella tularensis vaccine. Complement fixing antibodies determined by an enzyme-linked immunosorbent assay (CF-ELISA)

A complement-fixing enzyme-linked immunosorbent assay (CF-ELISA) with bacterial sonicate as the antigen, human AB serum as the source of complement and alkaline-phosphatase-labelled anti-(human C3e) as the conjugate was developed for detecting antibodies to Francisella tularensis. Humoral responses after inoculation with a live attenuated tularemia vaccine were studied in 13 subjects by this method. Twelve responded with CF antibodies, which in most cases appeared 4 weeks after vaccination, the response time varying from 1 week to 2 months. The highest individual CF titres, of 140–9990, were reached 1–4 months after vaccination (average 2.4 months). The CF titres tended to decrease with time, and at 10 months two of the 12 subjects with an earlier CF positive response were negative again. CF antibodies were nevertheless still detectable in all three subjects studied 1.5 years after vaccination.     

Pluralistic task shifting for a more timely cancer diagnosis. A grounded theory study from a primary care perspective

ObjectiveTo explore how cancer could be diagnosed in a more timely way.DesignGrounded theory analysis of primary care physicians’ free text survey responses to: ‘How do you think the speed of diagnosis of cancer in primary care could be improved?’. Secondary analysis of primary care physician interviews, survey responses, literature.SettingPrimary care in 20 European Örenäs Research Group countries.SubjectsPrimary care physicians: 1352 survey respondents (2013-2016), 20 Spanish and 7 Swedish interviewees (2015–2019).Main outcome measuresConceptual explanation of how to improve timeliness of cancer diagnosis.ResultsPluralistic task shifting is a grounded theory of a composite strategy. It includes task sharing – among nurses, physicians, nurse assistants, secretaries, and patients – and changing tasks with cancer screening when appropriate or cancer fast-tracks to accelerate cancer case finding. A pluralistic dialogue culture of comprehensive collaboration and task redistribution is required for effective pluralistic task shifting. Pluralistic task shifting relies on cognitive task shifting, which includes learning more about slow analytic reasoning and fast automatic thinking initiated by pattern recognition; and digital task shifting, which by use of eHealth and telemedicine bridges time and place and improves power symmetry between patients, caregivers, and clinicians. Financial task shifting that involves cost tracking followed by reallocation of funds is necessary for the restructuring and retraining required for successful pluralistic task shifting. A timely diagnosis reduces expensive investigations and waiting times. Also, late-stage cancers are costlier to treat than early-stage cancers. Timing is central to cancer diagnosis: not too early to avoid overdiagnosis, and never too late.ConclusionsWe present pluralistic task shifting as a conceptual summary of strategies needed to optimise the timeliness of cancer diagnosis.

Key points

• Cancer diagnosis is under-researched in primary care, especially theoretically. Thus, inspired by classic grounded theory, we analysed and conceptualised the field:
• Pluralistic task shifting is a conceptual explanation of how the timeliness of cancer diagnosis could be improved, with data derived mostly from primary care physicians.
• This includes task sharing and changing tasks including screening and cancer fast-tracks to accelerate cancer case finding, and requires cognitive task shifting emphasising learning, and digital task shifting involving the use of eHealth and telemedicine.
• Financial task shifting with cost tracking and reallocation of funds is eventually necessary for successful pluralistic task shifting to happen.

     

The effect of high-fiber rye bread enriched with nonesterified plant sterols on major serum lipids and apolipoproteins in normocholesterolemic individuals

Background and aimsPlant sterols are naturally occurring cholesterol-lowering compounds which are industrially incorporated in various foods. A novel food carrier is rye bread, the intake of which can be monitored in trials utilizing newly defined plasma biomarkers. Our aim was to determine the effects of plant sterols incorporated into high-fiber rye bread on serum total and LDL cholesterol, apoB/apoA1 and total cholesterol/HDL cholesterol ratios and lipophilic (pro)vitamins in healthy free-living normocholesterolemic individuals.Methods and resultsIn this double-blind, dietary intervention trial the subjects (n = 68) were randomized to receive a rye bread (9.3 g/d fiber) with added plant sterols (2 g/d) (active) or without (control). In the second phase of the study the amount of rye bread was doubled providing 18.6 g/d fiber and in the active group 4 g/d plant sterols. Compliance was monitored utilizing 3-day food diaries and a novel rye fiber-derived biomarker in plasma. Intake of rye bread enriched with 2 g/d of plant sterols during two weeks reduced significantly serum total and LDL cholesterol, apoB/apoA1 and total cholesterol/HDL cholesterol ratios by 5.1%, 8.1%, 8.3% and 7.2%, respectively, compared to controls. Correspondingly, the following two-week treatment with 4 g/d of plant sterols resulted in 6.5%, 10.4%, 5.5% and 3.7% difference compared to controls, being most pronounced for LDL (0.33 mmol/L). The treatments did not affect lipophilic (pro)vitamin levels.ConclusionRye bread enriched with 2–4 g/d of nonesterified plant sterols beneficially modifies cardiovascular lipid risk factors in normocholesterolemic subjects compared to controls.     

Ten-year results of a community-based anti-smoking program (as part of the North Karelia Project in Finland

The North Karelia Project was launched in 1972 to carry outa comprehensive community-based programme to reduce the highrates of cardiovascular disease (CVD) in North Karelia, Finland.Among the main intermediate objectives was the reduction ofsmoking rates, especially among the male population which hadmuch higher CVD and smoking rates than the female populationof the area. The intervention was based on the application ofbehavioral and social theories in a community setting, withemphasis upon a broad range of activities and upon communityparticipation. The programme was evaluated by standardized examinationof large representative cross-sectional population samples in1972, 1977 and 1982, in North Karelia and in a matched referencearea. The proportion of current smokers among 30- to 59-year-oldmen in North Karelia decreased from 52% in 1972 to 44% in 1977,and to 38% in 1982. In the reference area the respective smokingrates were 50, 45 and 45%. About 27% of male smokers in NorthKarelia stopped smoking during the project period, while inthe reference area the proportion was 10% (P<0.001). Amongwomen the initially low smoking rates increased in both areasby 7%—due to new birth cohorts with higher smoking ratesentering the age group of the study. At the same time, the prevalenceof ex-smokers among women at the outset.     

Mortality and disability among granite workers

The objective of the present study was to investigate the mortality, disability, and long-term morbidity of granite workers. The study included 1,026 workers hired between 1940 and 1971 and followed until the end of 1981. The total number of deaths was 235, and the expected number was 229.7. Excess mortality rates were observed for respiratory diseases (observed/expected = 28/13.9). The number of tumor deaths was 46 (expected 44.9). Excess lung cancer mortality was evident at 15 to 35 years of latency; the observed number of lung cancer deaths for the follow-up period of 25 to 29 years was 8, while 2.1 were expected. Mortality from cardiovascular diseases and violent deaths was slightly less than expected. The results for disability and long-term morbidity showed elevated incidence and prevalence rates for respiratory diseases and rheumatoid arthritis. The observed number of disability pensions due to rheumatoid arthritis in 1981 was 10 observed versus 1.8 expected, and the observed number of patients granted free medication was 19 versus 8.1 expected. The results indicate that granite dust exposure per se may be an etiologic and pathogenetic factor for lung cancer, cancer of the gastrointestinal tract, and some extrapulmonary nonmalignant chronic diseases.     

Mortality and disability among cotton mill workers

The mortality and disability of cotton mill workers were studied in five Finnish cotton mills. The population under study comprised all 1065 women exposed to raw cotton dust who had been hired between 1950 and 1971. The minimum exposure period was five years. For the study on disability, the cohort was followed up until the end of 1981. The follow up period for the mortality analysis was from 1950 to 1985. At the end of 1981 the observed number of prevalent disability pensions for respiratory disease was 15, whereas 3.9 were expected (p less than 0.01) on the basis of the national figures for women. There were 46 musculoskeletal diseases (27.7 expected, p less than 0.01), of which 24 were osteoarthritis (14.5 expected) and 13 rheumatoid arthritis (6.6 expected). The incidence rates of disability pensions were calculated for the period 1969-81. Comparison of incidence rates between cotton mill workers and the Finnish female population showed excessive rates for both respiratory diseases (p less than 0.001) and musculoskeletal diseases (p less than 0.01), with an excess of new cases of rheumatoid arthritis (p less than 0.05). By the end of 1985 the number of person-years was 31,678 and the number of deaths 95. The standardised mortality ratios for the total period of follow up (1950-85) showed no excess for respiratory diseases. Mortality from cardiovascular diseases was also lower than expected. The observed number of tumours was 33, the corresponding expected number 32.0. Thirteen tumours were in the digestive organs (6.6 expected, p<0.05) and three were lung cancers (1.9 expected). Five workers had died from renal disease; the expected number was 1.5 (p<0.05).     

National TV smoking cessation program and contest in Finland.

BACKGROUND. In the fall of 1986 the North Karelia Project in cooperation with Finnish TV 2 arranged an eight-part nationwide smoking cessation TV program. The Project, also arranged a smoking cessation contest coinciding with the TV program in cooperation with four major voluntary public health organizations and the national health service. The TV program featured two studio groups of local volunteers: one from Turku (southwestern Finland) and the other from North Karelia, where there was more intensive community support for the activity. RESULTS: Based on a national survey of a representative population sample, the reported viewing rates (at least one part) of the working-age population (15-64 years, smokers and nonsmokers) were 64% in North Karelia, 45% in Turku, and 46% nationally (P less than 0.001). Among smokers who had watched at least one session of the TV program, 7.7% reported to have tried to quit smoking in North Karelia, 4.1% in Turku, and 7.5% nationally. Altogether, 16,089 smokers participated in the contest; again the highest participation rate was in North Karelia. The 6-month success rate among the smokers who participated in the contest was 22% in North Karelia, 18% in Turku, and 17% nationally (P less than 0.05). Men were more likely to succeed in quitting: among men the 6-month success rate was 22% and among women 15% (P less than 0.001). CONCLUSIONS: The results and experiences indicate high viewing and participation and a beneficial cost-effect ratio. They also stress the importance of community support activities in enhancing the effects of a media-based health promotion program.