Home Blood Pressure Measurement ��� Epidemiology and Clinical Application

<b>Verenpaineen kotimittaus ��� epidemiologia ja kliininen k��ytt��</b> Kohonnutta verenpainetta, maailmanlaajuisesti merkitt��vint�� ennenaikaiselle kuolemalle altistavaa riskitekij����, ei voida tunnistaa tai hoitaa ilman tarkkoja ja k��yt��nn��llisi�� verenpaineen mittausmenetelmi��. Verenpaineen kotimittaus on saavuttanut suuren suosion potilaiden keskuudessa. L����k��rit eiv��t ole kuitenkaan viel�� t��ysin hyv��ksyneet verenpaineen kotimittausta, sill�� riitt��v�� todistusaineisto sen toimivuudesta ja eduista on puuttunut. T��m��n tutkimuksen tarkoituksena oli osoittaa, ett�� kotona mitattu verenpaine (kotipaine) on perinteist�� vastaanotolla mitattua verenpainetta (vastaanottopaine) tarkempi, ja ett�� se on tehokas my��s kliinisess�� k��yt��ss��. Tutkimme kotipaineen k��ytt���� verenpainetaudin diagnosoinnissa ja hoidossa. Lis��ksi tarkastelimme kotipaineen yhteytt�� verenpainetaudin aiheuttamiin kohde-elinvaurioihin. Ensimm��inen aineisto, joka oli edustava otos Suomen aikuisv��est��st��, koostui 2 120 45���74-vuotiaasta tutkimushenkil��st��. Tutkittavat mittasivat kotipainettaan viikon ajan ja osallistuivat terveystarkastukseen, johon sis��ltyi kliinisen tutkimuksen ja haastattelun lis��ksi syd��nfilmin otto ja vastaanottopaineen mittaus. 758 tutkittavalle suoritettiin lis��ksi kaulavaltimon sein��m��n intima-mediakerroksen paksuuden (valtimonkovettumataudin mittari) mittaus ja 237:lle valtimon pulssiaallon nopeuden (valtimoj��ykkyyden mittari) mittaus. Toisessa aineistossa, joka koostui 98 verenpainetautia sairastavasta potilaasta, hoitoa ohjattiin satunnaistamisesta riippuen joko ambulatorisen eli vuorokausirekister��innill�� mitatun verenpaineen tai kotipaineen perusteella. Vastaanottopaine oli kotipainetta merkitt��v��sti korkeampi (systolisen/diastolisen paineen keskiarvoero oli 8/3 mmHg) ja yksimielisyys verenpainetaudin diagnoosissa kahden menetelm��n v��lill�� oli korkeintaan kohtalainen (75 %). 593 tutkittavasta, joilla oli kohonnut verenpaine vastaanotolla, 38 %:lla oli normaali verenpaine kotona eli ns. valkotakkiverenpaine. Verenpainetauti voidaan siis ylidiagnosoida joka kolmannella potilaalla seulontatilanteessa. Valkotakkiverenpaine oli yhteydess�� liev��sti kohonneeseen verenpaineeseen, matalaan painoindeksiin ja tupakoimattomuuteen, muttei psykiatriseen sairastavuuteen. Valkotakkiverenpaine ei kuitenkaan vaikuttaisi olevan t��ysin vaaraton ilmi�� ja voi ennustaa tulevaa verenpainetautia, sill�� siit�� k��rsivien syd��n- ja verisuonitautien riskitekij��profiili oli normaalipaineisten ja todellisten verenpainetautisten riskitekij��profiilien v��liss��. Kotipaineella oli vastaanottopainetta vahvempi yhteys verenpainetaudin aiheuttamiin kohde-elinvaurioihin (intima-mediakerroksen paksuus, pulssiaallon nopeus ja syd��nfilmist�� todettu vasemman kammion suureneminen). Kotipaine oli tehokas verenpainetaudin hoidon ohjaaja, sill�� kotipaineeseen ja ambulatoriseen paineeseen, jota on pidetty verenpainemittauksen ���kultaisena standardina���, perustuva l����kehoidon ohjaus johti yht�� hyv����n verenpaineen hallintaan. T��m��n ja aikaisempien tutkimusten tulosten pohjalta voidaan todeta, ett�� verenpaineen kotimittaus on selke�� parannus perinteiseen vastaanotolla tapahtuvaan verenpainemittaukseen verrattuna. Verenpaineen kotimittaus on k��yt��nn��llinen, tarkka ja laajasti saatavilla oleva menetelm��, josta voi tulla jopa ensisijainen vaihtoehto verenpainetautia diagnosoitaessa ja hoitaessa. Verenpaineen mittausk��yt��nt����n tarvitaan muutos, sill�� n��ytt����n perustuvan l����ketieteen perusteella vaikuttaa, ett�� vastaanotolla tapahtuvaa verenpainemittausta tulisi k��ytt���� vain seulontatarkoitukseen.

Epidemiology of Cytochrome P450-mediated Drug-Drug Interactions

Drug-drug interactions (DDIs) comprise an important cause of adverse drug reactions leading to excess hospitalizations. Drug metabolism is catalyzed by 75% by cytochrome P450 (CYP) enzymes and thus they are often involved in pharmacokinetic DDIs. In general, DDIs are studied in randomized controlled clinical trials in selected study populations. The overall aim of the present studies was to perform observational pharmacoepidemiological surveys on CYP-mediated DDIs in diseases important at the population level. The prevalence of co-administrations of four prodrugs (losartan, codeine, tramadol, and clopidogrel), three sulphonylureas (glibenclamide, glimepiride, and glipizide), or two statins (lovastatin and simvastatin) with well established agents altering CYP activity, as well as of statins with fibrates, was studied in Finland utilizing data from a university hospital medication database (inpatients) and the National Prescription Register of the Social Insurance Institution of Finland, Kela (outpatients). Clinical consequences of potential DDIs were estimated by reviewing laboratory data, and information from hospital care and cause-of-death registers. Concomitant use of study substrates with interacting medication was detected in up to one fifth of patients in both hospital and community settings. Potential CYP3A4 interactions in statin users did not manifest in clear adverse laboratory values but pharmacodynamic DDIs between statins and fibrates predisposed patients to muscular toxicity. Sulphonylurea DDIs with CYP2C9 inhibitors increased the risk of hypoglycaemia. CYP3A4 inhibitor use with clopidogrel was not associated with significant changes in mortality but non-fatal thrombosis and haemorrhage complications were seen less often in this group. Concomitant administration of atorvastatin with clopidogrel moderately attenuated the antithrombotic effect by clopidogrel. The overall mortality was increased in CYP3A4 inducer and clopidogrel co-users. Atorvastatin used concomitantly with prodrug clopidogrel seems to be beneficial in terms of total and LDL cholesterol concentrations, and overall mortality compared with clopidogrel use without interacting medication. In conclusion, CYP-mediated DDIs are a common and often unrecognized consequence of irrational drug prescribing.

Epidemiology, management and outcome of facial injuries

Dental injuries are common and the incidence of maxillofacial injuries has increased over the recent decades in Finland. Accidental injuries are the global leading cause of death among children over the age of one year and among adults under the age of 40 globally. Significant resources and costs are needed for the treatment of these patients. The prevention is the most economical way to reduce trauma rates and costs. For the prevention it is crucial to know the prevalences, incidences and risk factors related to injuries. To improve the quality of treatment, it is essential to explore the causes, trauma mechanisms and management of trauma. The above mentioned was the aim of this thesis. With a large epidemiological cohort study (5737 participants) it was possible to estimate lifetime prevalence of and risk factors for dental trauma in general population (Study I). The prevalence of dental fractures was 43% and the prevalence of dental luxations and avulsions was 14%. Male gender, a history of previous non-dental injuries, mental distress, overweight and high alcohol consumption were positively associated with the occurrence of dental injuries Study II was conducted to explore the differences in type and multiplicity of mandibular fractures in three different countries (Canada, Finland and Kuwait). This retrospective study showed that the differences in mandibular fracture multiplicity and location are based on different etiologies and demographic patterns. This data can be exploited for planning of measures to prevent traumatic facial fractures. The etiology, management and outcome of 63 pediatric skull base fracture (Study III) and 20 pediatric frontobasal fracture patients (Study IV) were explored. These retrospective studies showed that, both skull base fracture and frontobasa fracture are rare injuries in childhood and although intracranial injuries and morbidity are frequent, permanent neurological or neuropsychological deficits are infrequent. A systematic algorithm (Study V) for computer tomography (CT) image review was aimed at clinicians and radiologists to improve the assessment of patients with complex upper midface and cranial base trauma. The cohort study was cross sectional and data was collected in the Turku and Oulu University Hospitals. A novel image-reviewing algorithm was created to enhance the specificity of CT for the diagnosis of frontobasal fractures. The study showed that an image-viewing algorithm standardizes the frontobasal trauma detection procedure and leads to better control and assessment. The purpose of the retrospective subcranial craniotomy study (VI) was to review the types of frontobasal fractures and their management, complications and outcome when the fracture is approached subcranially. The subcranial approach appears to be successful and have a reasonably low complication rate. It may be recommended as the technique of choice in multiple and the most complicated frontal base fractures where the endoscopic endonasal approach is not feasible.