From biomedical teaching to biopsychosocial education: a process of change in a Finnish medical school

A group of clinicians, teachers and researchers in the University of Oulu have been worried for years about the predominantly biomedical orientation in the local Faculty of Medicine. Therefore, a project group was founded in 1992 to develop the medical degree programme towards a more comprehensive model. This article introduces the main strategies used in the process of change and describes the challenges encountered during the process. There are still many problems in the education of medical students towards a patient and family orientation and in the effort to change the whole medical culture of the university from a biomedical to a biopsychosocial approach. However, in the postgraduate education of general practitioners, we no longer prefer to teach only doctors, but education on the biopsychosocial model will also be arranged to the interdisciplinary teams working in the municipalities in the Province of Oulu in Finland.     

Scintigraphy in prediction of the salivary gland function after gland-sparing intensity modulated radiation therapy for head and neck cancer

BACKGROUND AND PURPOSE: To evaluate salivary gland scintigraphy in prediction of salivary flow following radiation therapy. PATIENTS AND METHODS: Twenty patients diagnosed with head and neck cancer were treated with intensity modulated radiation therapy with an intention to spare the salivary gland function. The total quantitative saliva secretion was measured prior to and 6 and 12 months after therapy, and the function of the major salivary glands was monitored using Tc-99m-pertechnetate scintigraphy. Two models were designed for prediction of the post-treatment salivary flow: an average model, based on the average proportions of saliva produced by each of the four major glands in healthy subjects, and an individual model, based on saliva produced by each gland as measured by scintigraphy prior to therapy. These models were compared with volume-based (Lyman) normal tissue complication probability models using two published sets of model parameters. RESULTS: The D(50) for the parotid and the submandibular gland function assessed at 6 and 12 months after radiotherapy was approximately 39Gy. The scintigraphy-based individual model predicted well the measured post-treatment saliva flow rates. The correlation coefficient between the predicted stimulated and the measured saliva flow rate was 0.77 (p<0.0001) at 6 months and 0.55 (p=0.034) at 12 months after completion of radiotherapy. The relative changes in unstimulated and stimulated salivary flow rates showed similar dependency on the cumulative radiation dose. CONCLUSIONS: Salivary gland function assessed by scintigraphy prior to radiotherapy is useful in prediction of the residual salivary flow after radiotherapy.     

Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease.

OBJECTIVE: To evaluate transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease (PID). METHODS: We studied 51 outpatients with a mean age of 26.8 years (range 16-52) who had a history of low abdominal pain, negative pregnancy test, and no gynecologic procedures performed during the last month. Endometrial biopsy was used for the histopathologic diagnosis. The presence of plasma cell endometritis was used as the criterion standard for the diagnosis of PID. Sonography was performed before biopsy in a blinded fashion without knowledge of the clinical findings and laboratory results except for the pregnancy test. Repeat pelvic and ultrasound examinations were performed 4 weeks after antimicrobial therapy. RESULTS: Endometrial biopsy revealed plasma cell endometritis in 13 cases (25%). Thickened fluid-filled tubes were seen in 11 of 13 patients (85%) with plasma cell endometritis and in none of those without. Other sonographic findings associated with plasma cell endometritis were polycystic-like ovaries and free pelvic fluid. A sonogram suggestive of PID, ie, thickened fluid-filled tube with or without free pelvic fluid, had a sensitivity of 85% and a specificity of 100% for the diagnosis of plasma cell endometritis. None of the patients with a normal sonogram or simple cyst had plasma cell endometritis. Repeat examination after 4 weeks showed that the sonographic findings had resolved in 60% of the patients who had had histologic evidence of infection. CONCLUSION: Transvaginal sonography can facilitate the outpatient management of patients with suspected PID.     

Diagnosis and management of tubal pregnancy: effect on fertility outcome

We analysed 188 ectopic pregnancies seen during a 2-year period. They represented 2.2% of the live births that occurred during the same time interval. Overall, 53% of the tubal pregnancies had ruptured at the time of examination. Location was ampullary in 51% of the cases, isthmic in 28%, and 10% had aborted. Sixty-nine (38%) patients had an IUD. Diagnostic sensitivity was 58%-93% for pregnancy tests, 79% for culdocentesis, 41% for ultrasound examination, 43% for dilatation and curettage, and 100% for laparoscopy. Salpingectomy was performed in 47% of the cases, salpingotomy in 27%, and tubal resection in 19%. During a follow-up of 116 women (mean 1.5 years, range 0.5-3 years) 49% delivered, 10% had repeat ectopic pregnancy, 10% had abortion, 17% were infertile and 15% practised birth control. Among those who delivered no difference was found between those who underwent salpingectomy and those who underwent conservative surgery.     

Endometritis and acute salpingitis associated with Chlamydia trachomatis and herpes simplex virus type two

A patient who had endometritis confirmed by endometrial biopsy and acute salpingitis confirmed by laparoscopy is reported. Chlamydia trachomatis and herpes simplex virus type two were isolated from the endometrial cavity and the fallopian tube. The histopathologic findings of the endometritis were similar to those frequently seen in chronic chlamydial eye disease or chlamydial cervicitis.     

Prevalence and manifestations of endometritis among women with cervicitis

Thirty-five women referred from a clinic treating sexually transmitted diseases, because of suspected cervicitis, were studied for the presence of endometritis by transcervical endometrial biopsies and cervical and endometrial cultures. Fourteen (40%) of the patients had histologic evidence of endometritis. Findings that significantly correlated with endometritis included a history of intermenstrual vaginal bleeding, the presence of Chlamydia trachomatis, Neisseria gonorrhoeae, or Streptococcus agalactiae in the cervix, and the presence of serum antibodies to C. trachomatis or to Mycoplasma hominis.     

Randomized Controlled Trial of Back School With and Without Peer Support

The aim of this trial was to determine whether social interaction between patients with long-lasting nonspecific back pain reduces subjective or objective disability. The participants were selected from persons visiting an occupational health care unit because of back pain. After a clinical examination in a university clinic, subjects without a specific diagnosis and having no disabilities preventing active rehabilitation were selected for study. The subjects (n = 108) were randomized into treatment (n = 54) and control groups (n = 54). Altogether 18 study groups, 9 treatment groups and 9 groups for controls, were formed. Before starting the back schools altogether 15 subjects dropped out. Both the treatment groups (n = 47) and the controls (n = 46) attended a back school consisting of 10 lessons and demonstrations supervised by a physiotherapist. The participants in treatment groups, but not the controls, had physical exercise and social intercourse with other members within the group. The clinical examination was repeated after 6 and 12 months. Both the treatment groups and the controls showed improvement in perceived functional capacity (assessed with Oswestry disability questionnaire) and in perceived life quality (assessed with 15D score). At the 6-month follow-up life quality had improved statistically significantly more among the participants in treatment groups than among the controls, and at the 12-month follow-up the Oswestry index showed corresponding improvement. Among subjects suffering from nonspecific back pain, social support improves the results of active rehabilitation.     

Economic evaluation of a risk-based caries prevention program in preschool children

We have previously reported that, in young children, a risk-based caries prevention program compared with conventional prevention has a good caries-preventive effect. The present study aimed to assess the economic aspects of this program. We used the presence of mutans streptococci in plaque (Dentocult-SM) and/or the presence of incipient carious lesions at 2 years of age for risk assessment, and measured the outcome of caries (yes/no) at the age of 5 years. Dental assistants carried out the screening and preventive work. The economic analysis included the actual running costs of the program during the 3-year follow-up based on the time spent on dental visits. The costs per child per 3 years were significantly lower in the risk-based group (54 euros) than in the conventional prevention group (69 euros) (Student's t test, P = 0.004). If a dentist with an assistant had done all the work, the costs would have been twice as high. Compared to conventional prevention, the results suggest that risk-based prevention can be effective in reducing both costs and dental caries in preschool children, provided that the screening and preventive measures are delegated to preventive dental assistants.     

Effects of a betaine-containing toothpaste on subjective symptoms of dry mouth: a randomized clinical trial

Our aim was to study the effects of mildly flavoured sodium lauryl sulphate (SLS)-containing and detergent-free toothpastes with and without betaine (BET) on subjective symptoms of dry mouth in a randomised clinical trial. BET is an osmoprotectant that reacts with molecules to supply the surface with a water coating that protects cells from surfactants. Twenty-seven xerostomic patients and 18 healthy controls took part in the randomised, double-blind clinical trial with a crossover design. Three mildly flavoured toothpastes: (1) 4% BET, (2) 1% SLS and 4% BET, and (3) 1% SLS were used for six weeks each. The reference or washout paste contained neither SLS nor BET. The subjects' dental appointments were at the beginning of the trial and before and after the use of each toothpaste. At each appointment, the subjects were interviewed about subjective sensations of dry mouth (Visual Assessment Scoring (VAS) Index). The subjects did not report any adverse effects in connection with the use of the toothpastes. The VAS scores for lip dryness and eating difficulties were significantly lower for the BET paste (lip dryness: BET相似文献   

Genetic risk determines the emergence of diabetes-associated autoantibodies in young children

Timing of onset of autoimmunity is a prerequisite for unmasking triggers and pathogenesis of type 1 diabetes. We followed 4,590 consecutive newborns with 8 or 3% HLA-DQB1 conferred risk for type 1 diabetes at 3-, 6-, or 12-month intervals up to 5.5 years of age. Islet cell autoantibodies (ICAs) and, in the 137 children with ICAs, insulin autoantibodies (IAAs), GAD65 autoantibodies (GADAs), and IA-2 protein autoantibodies (IA-2As) were measured. Children with high genetic risk developed ICAs more often than those with moderate risk (log-rank P = 0.0015); 85 and 91% remained ICA negative by 5 years of age, respectively. The time of appearance of biochemical autoantibodies was then compared with the appearance of ICAs. IAAs and GADAs emerged usually before ICAs (means -1.8 and -1.5 months, respectively) and IA-2As after ICAs (mean 2.0 months). Ninety-five percent of all IAAs, GADAs, and IA-2As seroconversions occurred in a cluster (-12 to 8 months) around the ICA seroconversion. We conclude that diabetes-associated autoantibodies emerged in children with predisposing HLA-DQB1 alleles after 3 months of age at a constant tempo, determined by the genetic risk level, usually in the order of IAA, GADA, ICA, and IA-2A. Seroconversion to multiple autoantibody positivity usually occurred tightly clustered in time.