When does subluxation of the first carpometacarpal joint cause swan-neck deformity of the thumb in rheumatoid arthritis: A 20-year follow-up study

The aim of our study was to assess the incidence of subluxation of the first carpometacarpal joint (CMC I) and to evaluate which degree of subluxation produces swan-neck deformity of the thumb in rheumatoid arthritis (RA) occurring over 20 years. The hands of 83 rheumatoid factor (RF)-positive RA patients with recent (6 months) arthritis were evaluated radiographically at onset and at 1, 3, 8 and 15 years; 68 patients were evaluated at 20 years from entry. Subluxation was assessed in millimetres and compared with the MCP-I angle measurement to evaluate the thumb deformity. A statistical end-point analysis was performed between two different grades of subluxation. Subluxation of 2–3 mm was non-specific and only one third of these thumbs showed swan-neck deformity. At the end-point, subluxation of 4 mm was present in 17% of the thumbs, 81% of which had the swan-neck deformity; only five thumbs did not show this deformity, but presented deformed and unstable MCP I and interphalangeal joints. The frequency of swan-neck deformity was highly significantly (p<0.0001) increased in the thumbs with severe CMC I subluxation (4 mm) compared with lesser subluxation (<4 mm). When subluxation of the CMC I exceeds 4 mm, the swanneck deformity of the thumb is a common consequence. This deformity is often progressive, and the hand function of such patients should be followed up carefully, both clinically and radiographically.     

Morphological alterations in experimental esophagitis

The morphology of esophagitis, both in the presence and absence of acid, was studied by light microscopy and transmission and scanning electron microscopy. For this purpose the rabbit esophagus was isolated in situ and perfused with agents known to cause esophageal mucosal damage (HCl, pepsin, taurocholate, and deoxycholate). In addition, changes in the permeability of the plasma membrane of the esophageal epithelial cells were assessed by staining the esophageal epithelium with trypan blue and antinuclear antibodies. The results indicate that HCl alone causes relatively few changes in the esophageal epithelium. However, when combined with pepsin or taurocholate, severe ulcerative changes were caused within an hour. Deoxycholate, which is formed in the upper gastrointestinal tract under nonacidic conditions, also causes severe damage. Further, it was shown that the esophagitis caused by pepsin and bile salts are clearly morphologically different. Bile salts affect primarily the cell membrane and intracellular organelles, while pepsin seems to affect the intercellular substance causing the epithelial cells to be shed. In contrast, the presence or absence of acid per se does not seem to influence the nature of the epithelial damage, since the lesions caused by the two bile salts (deoxycholate vs taurocholate + HCl) were morphologically similar.     

Long-term prognosis of pigmentary glaucoma.

Outcome, prognosis and course of pigmentary glaucoma were studied in 38 patients (75 eyes). The mean age of the subjects at the time of diagnosis was 34.0 years and at the time of the study 44.1 years. The follow-up time ranged from 2 to 30 years with a mean follow-up time of 10.1 years. At the time of the study eighty-nine percent of the eyes had normal vision (0.7 or better), 3% slight impairment of vision (0.6-0.3), 5% low vision (0.2-0.05) and 3% were blind. Visual field defects were mild in 78%, moderate in 13% and severe in 8% of the eyes. One eye (1%) had normal fields. In 8 patients the stage of the field defects was asymmetrical between the two eyes. All were able to read at least monocularly with glasses. No one was blind, retired early or professionally limited because of pigmentary glaucoma. Thirty-nine eyes were on topical treatment. Fifteen eyes had additionally been treated with laser trabeculoplasty when the glaucoma could not be stabilized with topical treatment combined with systemic acetazolamide. Further twenty eyes had undergone trabeculectomy, 18 of them when medical treatment had failed and 2 following LTP. The non-involved eye of a patient suffering from a monocular disease was without treatment. The mean intraocular pressure at the time of the diagnosis was 33.5 mmHg (SD 10.4 mmHg) and at the final visit 17.5 mmHg (SD 3.4 mmHg). Four eyes were operated for cataracts and one for retinal detachment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Five-year risk of developing clinical diabetes after first myocardial infarction; the FINAMI study.

AIM: To investigate the incidence of clinical diabetes as determined by the incidence of diabetes drug reimbursements within a 5-year period after the first myocardial infarction (MI) in patients who were non-diabetic at the time of their first MI. RESEARCH DESIGN AND METHODS: A population-based MI register, FINMONICA/FINAMI, recorded all coronary events in persons of 35-64 years of age between 1988 and 2002 in four study areas in Finland. These records were used to identify subjects sustaining their first MI (n = 2632). Participants of the population-based risk factor survey FINRISK (surveys 1987, 1992, 1997 and 2002), who did not have diabetes or a history of MI, served as the control group (n = 7774). The FINMONICA/FINAMI study records were linked with the National Social Security Institute's drug reimbursement records, which include diabetes medications, using personal identification codes. The records were used to identify subjects who developed diabetes during the 5-year follow-up period (n = 98 in the MI group and n = 79 in the control group). RESULTS: Sixteen per cent of men and 20% of women sustaining their first MI were known to have diabetes and thus were excluded from this analysis. Non-diabetic men having a first MI were at more than twofold {hazard ratio (HR) 2.3 [95% confidence interval (CI) 1.6-3.4]}, and women fourfold [HR 4.3 (95% CI 2.4-7.5)], risk of developing diabetes mellitus during the next 5 years compared with the control population without MI. CONCLUSIONS: Many patients who do not have diabetes at the time of their first MI develop diabetes in the following 5 years.     

Bronchoscopy in the diagnosis and surveillance of respiratory infections in lung and heart–lung transplant recipients

Fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) and transbronchial biopsies (TBB) is a widely used method to detect respiratory infections and to differentiate them from other postoperative complications in lung transplant (LTX) recipients, but the usefulness of surveillance FOBs is not yet established. The aim of this study was to evaluate the usefulness of FOB in the diagnosis and surveillance of infections in LTX recipients. We reviewed all the consecutive 609 FOBs performed on 40 lung or heart-LTX recipients between February 1994 and November 2002. The overall diagnostic yield was 115/190 (61%) and 43/282 (15%) for clinically indicated and surveillance FOBs respectively (P < 0.001). Infection was established by bronchoscopic samples in 96/190 (50.5.%) of the clinically indicated FOBs and 34/282 (12.1%) of the surveillance FOBs (P < 0.001). The diagnostic yield of the clinically indicated FOBs was highest (72%) from 1 to 6 months post-transplant (P = 0.04). Pneumocystis carinii was detected in 23 (4.9%) of the bronchoscopic specimens and 15 (65%) of the P. carinii infections were detected during adequate chemoprophylaxis. To conclude, in LTX recipients clinically indicated FOB has a good diagnostic yield in detecting infections and other postoperative complications, whereas the information received from surveillance FOB has remained less significant. With current prophylaxis and screening strategies FOB is still required to detect P. carinii infections.     

Musculoskeletal symptoms of dentists assessed by a multidisciplinary approach

Musculoskeletal health was studied as part of a comprehensive health examination in 131 professionally active dentists. 42% of dentists had experienced pain and disability (interference with daily activities) by neck-shoulder problems during the preceding year, with a tendency to greater prevalence in salaried dentists than in private practitioners. For the lower back, this percentage was 37. Somatic symptoms of stress, perceiving dentistry as physically too heavy or mentally too straining and a poorer general health status rating were all associated with a greater 1-yr prevalence of neck-shoulder and lower back pain and disability and with poorer general physical fitness. Age, weekly work hours, working posture, use of an assistant, or radiographic degenerative changes in the dentist's skeleton were not associated with 1-yr prevalence of neck-shoulder or lower back pain and disability. The results provide evidence that physical exercise should be recommended to dentists and might also be applicable to subjects in other occupations with similar requirements.     

A new definition for myocardial infarction: what difference does it make?

AIMS: As a response to changing diagnostic tools of myocardial infarction (MI), new case definitions for acute coronary events were published in 2003 as the American Heart Association Scientific Statement. We assessed the new definition in hospitalized patients in a large population-based MI register study. METHODS AND RESULTS: We identified all suspected acute coronary syndromes with data either on troponin T or on troponin I and at least one of the enzymatic markers of myocardial injury (n=6104). The 2003 definition with the use of troponins identified 83% more definite MIs than the WHO MONICA definition using cardiac enzymes. The additional patients were older, had more often diabetes, and received less often thrombolysis and revascularization than those having MI by both definitions. Adjusting for age, sex, study area, and study year, the additional patients with their first MI aged 25-74 had a higher risk of cardiovascular death within 1 year than patients having definite MI by both definitions (hazard ratio 1.6, 95% CI 1.1-2.2). CONCLUSION: The changing diagnostic criteria present a considerable challenge for the assessment of long-term trends in MI events in the community as well as for longitudinal studies of the natural history of MI. The 2003 definition, when applied using troponins, identified a sizable new group of MI patients, among persons with suspected acute coronary syndrome, at high risk of a recurrent event.     

An analysis of ophthalmology services in Finland - has the time come for a Public-Private Partnership?

Background  

We studied the prerequisites for Public-Private Partnership (PPP) in the context of the Finnish health care system and more specifically in the field of ophthalmology. PPP can be defined as a more or less permanent cooperation between public and private actors, through which the joint products or services are developed and in which the risks, costs and profits are shared.