Evaluation of the Development of Metacognitive Knowledge Supported by the KnowCat System

The aim of this study was to examine the development of the metacognitive knowledge of a group of higher education students who participated actively in an experiment based on a Computer Supported Collaborative Learning environment called KnowCat. Eighteen university students participated in a 12-month learning project during which the KnowCat learning environment was used to support scaffolding process among equals during problem-solving tasks. After using KnowCat, the students were interviewed over their work in this shared workspace. Qualitative analysis revealed that the educational application of KnowCat can favour and improve the development of metacognitive knowledge.

Alcohol expectancies and alcohol outcomes: effects of the use of protective behavioral strategies.

OBJECTIVE: Alcohol expectancies (AEs) are positively associated with drinking behaviors, whereas the use of protective behavioural strategies (PBS) is negatively related to alcohol outcomes among young adults. PBS have been shown to weaken relationships between some alcohol risk factors and alcohol outcomes. This study aimed to examine longitudinally the moderating effect of PBS on the relationships between AEs and alcohol outcomes among young adults. METHOD: Participants (N = 188; 61.7% female) were U.S. young adults participating in a larger longitudinal study. Measures of PBS, AEs, alcohol use, and related consequences were used from the baseline and 12-month follow-up assessments. RESULTS: Negative binomial hurdle models found that PBS (total score) significantly moderated the relationship between positive AEs and consequences, such that among high school seniors endorsing higher positive AEs, those using more PBS in high school reported fewer negative consequences 1 year later. PBS (Manner of Drinking) also moderated the relationship between negative AEs and alcohol use, revealing the use of PBS in high school as having a protective function against later drinking among participants with high positive AEs. Last, PBS (Serious Harm Reduction) significantly moderated the associations between positive AEs and alcohol use and between negative AEs and consequences, such that participants with higher AEs and higher PBS use in high school were at greatest risk for drinking and experiencing negative consequences later. CONCLUSIONS: Overall, these findings suggest that PBS use may be protective by weakening relationships between positive AEs and alcohol outcomes. Limitations and future directions are discussed.

Refractory intraretinal or subretinal fluid in neovascular age-related macular degeneration treated with intravitreal ranizubimab: Functional and Structural Outcome.

PURPOSE: To investigate the visual acuity results of eyes with neovascular age-related macular degeneration and refractory fluid despite monthly treatment with ranibizumab, and to investigate differences between refractory subretinal fluid and intraretinal cystic changes. METHODS: Retrospective chart review of consecutive treatment-refractory neovascular age-related macular degeneration, defined as persistent intraretinal or subretinal fluid despite monthly ranibizumab injections during 12 months or more. Data were evaluated for baseline characteristics, type and location of the refractory fluid, mean visual acuity change, number of injections, and the time point of first complete disappearance of all fluid on spectral domain optical coherence tomography. RESULTS: Seventy-six eyes (74 patients, mean age, 76.8 years) were identified. The mean follow-up was 33.6 months (range, 12-73 months). The mean number of injections was 11.4 in the first year and 27.7 over follow-up. The refractory fluid was located subfoveally in 61.8%. In 27 eyes (35.5%), the fluid resolved after a mean of 21.8 months (range, 13-49 months). Mean visual acuity increased by 9.0, 7.9, and 7.9 letters by Month 12, Month 24, and Month 36, respectively. Subgroup analysis revealed a higher risk for fibrosis (odds ratio, 3.30) or atrophy (odds ratio, 3.34) in patients with refractory cysts as compared with refractory subretinal fluid. Furthermore, refractory cysts showed a higher risk for a 10-letter visual acuity loss (P = 0.018). CONCLUSION: Fluid refractory to monthly treatment with ranibizumab for neovascular age-related macular degeneration still allowed for well-maintained visual improvement, even in subfoveal location. Late fluid resolution may occur. However, refractory cysts were associated with poorer anatomical and functional outcome than subretinal fluid.

Protective behavioral strategies and future drinking behaviors: Effect of drinking intentions.

Alcohol use is common among United States and Swedish high school students and is related to negative consequences. Whereas drinking intentions are associated with future drinking behaviors, the use of protective behavioral strategies (PBS) is associated with decreased alcohol-related harm among young adults. The interactive effect of PBS and drinking intentions in predicting alcohol outcomes has not been examined. Further, because most PBS studies have been conducted among U.S. college students, PBS research among other populations is needed. The aims of this study were to evaluate longitudinally (a) the relationships between drinking intentions, PBS and alcohol outcomes, and (b) the moderating roles of drinking intentions and country in these relationships among United States and Swedish high school drinkers. Data were collected at baseline, 6- and 12-month follow-ups on 901 Swedish and 288 U.S. high school drinkers. Drinking intentions were associated with more alcohol use and consequences, and use of certain PBS was related to fewer alcohol-related consequences over time. Additionally, the negative prospective relationship between use of PBS and alcohol use, but not alcohol-related consequences, was moderated by intentions, such that the relationship was stronger among participants endorsing high drinking intentions. Country did not moderate these relationships. These results provide initial support for the generalizability of PBS college research to United States and Swedish high school students and suggest that interventions targeting the use of PBS may be most effective among high school drinkers endorsing high drinking intentions. (PsycINFO Database Record

Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing.

OBJECTIVE: To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health. DESIGN: Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not. SETTING: General practices in metropolitan and rural Victoria, Australia. PARTICIPANTS: General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients. INTERVENTION: This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. OUTCOME MEASURES: Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients' sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data. RESULTS: 42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0·52, CI 0·28 to 0·96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0·66, CI 0·46 to 0·96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1; OR 0·40, CI 0·20 to 0·80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool. CONCLUSIONS: A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits. TRIAL REGISTRATION: ISRCTN.com ISRCTN16059206.

Role of microRNAs in the age-associated decline of pancreatic beta cell function in rat islets.

AIMS/HYPOTHESIS: Ageing can lead to reduced insulin sensitivity and loss of pancreatic beta cell function, predisposing individuals to the development of diabetes. The aim of this study was to assess the contribution of microRNAs (miRNAs) to age-associated beta cell dysfunction. METHODS: The global mRNA and miRNA profiles of 3- and 12-month-old rat islets were collected by microarray. The functional impact of age-associated differences in miRNA expression was investigated by mimicking the observed changes in primary beta cells from young animals. RESULTS: Beta cells from 12-month-old rats retained normal insulin content and secretion, but failed to proliferate in response to mitotic stimuli. The islets of these animals displayed modifications at the level of several miRNAs, including upregulation of miR-34a, miR-124a and miR-383, and downregulation of miR-130b and miR-181a. Computational analysis of the transcriptomic modifications observed in the islets of 12-month-old rats revealed that the differentially expressed genes were enriched for miR-34a and miR-181a targets. Indeed, the induction of miR-34a and reduction of miR-181a in the islets of young animals mimicked the impaired beta cell proliferation observed in old animals. mRNA coding for alpha-type platelet-derived growth factor receptor, which is critical for compensatory beta cell mass expansion, is directly inhibited by miR34a and is likely to be at least partly responsible for the effects of this miRNA. CONCLUSIONS/INTERPRETATION: Changes in the level of specific miRNAs that occur during ageing affect the proliferative capacity of beta cells. This might reduce their ability to expand under conditions of increased insulin demand, favouring the development of type 2 diabetes.

Low-fat dairy products and blood pressure: follow-up of 2290 older persons at high cardiovascular risk participating in the PREDIMED study

High blood pressure (BP) has been ranked as the most important risk factor worldwide regarding attributable deaths. Dietary habits are major determinants of BP. Among them, frequent intake of low-fat dairy products may protect against hypertension. Our aim was to assess the relationship between low-fat dairy product intake and BP levels and their changes after 12 month follow-up in a cohort of asymptomatic older persons at high cardiovascular risk recruited into a large-scale trial assessing the effects of Mediterranean diets on cardiovascular outcomes. Data from 2290 participants, including 1845 with hypertension, were available for analyses. Dairy products were not a specific part of the intervention; thus, data were analysed as an observational cohort. Dietary information was collected with validated semi-quantitative FFQ and trained personnel measured BP. To assess BP changes, we undertook cross-sectional analyses at baseline and at the end of follow-up and longitudinal analyses. A statistically significant inverse association between low-fat dairy product intake and systolic BP was observed for the 12-month longitudinal analysis. In the longitudinal analysis, the adjusted systolic and diastolic BP were significantly lower in the highest quintile of low-fat dairy product intake ( 2 4·2 (95% CI 2 6·9, 2 1·4) and 2 1·8 (95% CI 2 3·2, 2 0·4) mmHg respectively), whereas the point estimates for the difference in diastolic BP indicated a modest non-significant inverse association. Intake of low-fat dairy products was inversely associated with BP in an older population at high cardiovascular risk, suggesting a possible protective effect against hypertension.

Predicting recurrence after unprovoked venous thromboembolism: prospective validation of the updated Vienna Prediction Model.

The updated Vienna Prediction Model for estimating recurrence risk after an unprovoked venous thromboembolism (VTE) has been developed to identify individuals at low risk for VTE recurrence in whom anticoagulation (AC) therapy may be stopped after 3 months. We externally validated the accuracy of the model to predict recurrent VTE in a prospective multicenter cohort of 156 patients aged ≥65 years with acute symptomatic unprovoked VTE who had received 3 to 12 months of AC. Patients with a predicted 12-month risk within the lowest quartile based on the updated Vienna Prediction Model were classified as low risk. The risk of recurrent VTE did not differ between low- vs higher-risk patients at 12 months (13% vs 10%; P = .77) and 24 months (15% vs 17%; P = 1.0). The area under the receiver operating characteristic curve for predicting VTE recurrence was 0.39 (95% confidence interval [CI], 0.25-0.52) at 12 months and 0.43 (95% CI, 0.31-0.54) at 24 months. In conclusion, in elderly patients with unprovoked VTE who have stopped AC, the updated Vienna Prediction Model does not discriminate between patients who develop recurrent VTE and those who do not. This study was registered at www.clinicaltrials.gov as #NCT00973596.

Posterior Sub-Tenon Triamcinolone Injection for Chronic Macular Oedema Associated With Non-Ischemic Branch or Central Retinal Vein Occlusion

Aims: To evaluate the effectiveness and safety of Posterior Sub-Tenon (PST) Triamcinolone Acetonide (TA) injection for persistent macular oedema associated with non-ischemic Central Retinal Vein Occlusion (CRVO) or Branch Retinal Vein Occlusion (BRVO) in non-vitrectomized eye. Methods: Fourteen consecutive eyes of 14 patients characterized by macular oedema lasting more than 3 months and with a visual acuity of less than 20/40 were enrolled. Six eyes presented with BRVO, 8 eyes with CRVO. PST injection of 40 mg TA was performed in topical anaesthesia. All patients were phakic, and followed for at least 6 months. Snellen visual acuity converted to LogMAR units and anatomic responses were evaluated before, and at 1, 3, 6, and 12 (if required) months after injections and re-injection considered. Results: In the BRVO group, mean foveal thickness was 548.2±49.50 μm preoperatively, and 452.8±56.2 μm and 280.8±62.5 μm at 1 and 12 month follow-up, respectively. Statistical analysis showed significant differences between preoperative and postoperative measurements (P<.05, paired t test) 3 months after injections. Improvement of visual acuity by at least 0.2 LogMAR was seen in 3(50%) of the 6 eyes. No re-injection was needed. In the CRVO group, mean foveal thickness was 543.7±34.4 μm preoperatively, and 283.0±29.0 μm and 234.8±23.6 μm at 1 and 12 month follow-up, respectively. Statistical analysis showed significant differences between preoperative and postoperative measurements (P<.05, paired t test). Improvement of visual acuity by at least 0.2 LogMAR was seen in 7 eyes (88%). Mean number of re-injection was of 2.1±0.3. Intraocular pressure elevation of 22 mm Hg or higher was found in 2/14 eyes (14%). Cataract progression was noted in 5/14 eyes (36%). Conclusions: PST injection of TA appears to be as safe and effective treatment for chronic macular oedema associated due to both non-ischemic BRVO or CRVO, with a better efficacy in BRVO.

CONVERSION TO AFLIBERCEPT THERAPY VERSUS CONTINUING WITH RANIBIZUMAB THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION DEPENDENT ON MONTHLY RANIBIZUMAB TREATMENT.

PURPOSE: To compare the effects of converting to aflibercept therapy with continuing ranibizumab therapy in eyes with neovascular age-related macular degeneration requiring monthly ranibizumab treatment. METHODS: Patients were selected from the 104 patients (115 eyes) already enrolled in an "Observe and Plan" prospective case series that included treating neovascular age-related macular degeneration with ranibizumab for 24 months. Patients who still needed monthly retreatment at the end of a 2-year study were randomized to either continue ranibizumab therapy or to convert to aflibercept therapy. Outcome measures included average interval between treatments, resolution of exudative signs, number of retreatments, and change in visual acuity over 12 months (the third treatment year). RESULTS: Nineteen patients (21 eyes) met the inclusion criteria. Ten eyes were randomized to receive aflibercept, and 11 eyes remained on ranibizumab. Groups were balanced for baseline characteristics. Outcomes were similar in the 2 groups over a 12-month study duration, with no statistical difference. CONCLUSION: This comparative pilot study suggests that neovascular age-related macular degeneration requiring monthly retreatment with ranibizumab may respond in similar ways to both ranibizumab and aflibercept treatment. Larger sample sizes would be needed to confirm this observation.

The role of the microRNAs in the age-associated oancreatic β-cell dysfunction

Le corps humain emploie le glucose comme source principale d'énergie. L'insuline, sécrétée par les cellules ß-pancreatiques situées dans les îlots de Langerhans, est l'hormone principale assurant un maintien constant du taux de glucose sanguin (glycémie). Les prédispositions génétiques, le manque d'activité physique et un régime déséquilibré peuvent entraîner une perte de sensibilité à l'insuline et des taux de glucose dans le sang élevé (hyperglycémie), une condition nommée diabète de type 2. Cette maladie est initiée par une sensibilité diminuée à l'insuline dans les tissus périphériques, entraînant une demande accrue en insuline. Cette pression continue finie par épuiser les cellules ß-pancreatiques, qui sécrètent alors des niveaux d'insuline insuffisant en trainant l'apparition du diabète. Le vieillissement est un facteur de risque important pour les maladies métaboliques dont le diabète de type 2 faits partis. En effet la majeure partie des diabétiques de type 2 ont plus de 45 ans. Il est connu que le vieillissement entraine une perte de sensibilité à l'insuline, une sécrétion altérée d'insuline, une baisse de réplication et une plus grande mort des ß-cellules pancréatiques. Le but de ma thèse était de mieux comprendre les mécanismes contribuante au dysfonctionnement des cellules ß- pancréatiques lors du vieillissement. Les travaux du « Human Genome Project » ont révélés que seulement 2% de notre génome code pour des protéines. Le reste non-codant fut alors désigné sous le nom de « ADN déchets ». Cependant, l'étude approfondie de cet ADN non-codant ces dernières deux décennies a démontré qu'une grande partie code pour des «MicroARNs », des ARNs courts (20-22 nucleotides) découverts en 1997 chez le vers C.elegans. Depuis lors ces molécules ont été intensivement étudiées, révélant un rôle crucial de ces molécules dans la fonction et la survie des cellules en conditions normales et pathologiques. Le but de cette thèse était d'étudier le rôle des microARNs dans le dysfonctionnement des cellules ß lors du vieillissement. Nos données suggèrent qu'ils peuvent jouer un rôle tantôt salutaire, tantôt nocif sur les cellules ß. Par exemple, certains microARNs réduisent la capacité des cellules ß à se multiplier ou réduisent leur survie, alors que d'autres protègent ces cellules contre la mort. Pour conclure, nous avons démontré les microARNs jouent un rôle important dans le dysfonctionnement des cellules ß lors du vieillissement. Ces nouvelles découvertes préparent le terrain pour la conception de futures stratégies visant à améliorer la résistance des cellules ß pancréatiques afin de trouver de nouveaux traitements du diabète de type 2. -- Le diabète de type 2 est une maladie métabolique due à la résistance à l'action de l'insuline des tissus cibles combinée à l'incapacité des cellules ß pancréatiques à sécréter les niveaux adéquats d'insuline. Le vieillissement est associé à un déclin global des fonctions de l'organisme incluant une diminution de la fonction et du renouvellement des cellules ß pancréatiques. Il constitue ainsi un risque majeur de développement des maladies métaboliques dont le diabète de type 2. Le but de cette thèse était d'étudier le rôle des microARNs (une classe d'ARN non- codants) dans le dysfonctionnement lié au vieillissement des cellules ß. L'analyse par microarray des niveaux d'expression des microARN dans les îlots pancréatiques de rats Wistar mâles âgés de 3 et 12 mois nous a permis d'identifier de nombreux changements d'expression de microARNs associés au vieillissement. Afin d'étudier les liens entre ces modifications et le déclin des cellules ß, les changements observés lors du vieillissement ont été reproduits spécifiquement dans une lignée cellulaire, dans des cellules ß primaires de jeune rats ou de donneurs humains sains. La diminution du miR-181a réduit la prolifération des cellules ß, tandis que la diminution du miR-130b ou l'augmentation du miR-383 protège contre l'apoptose induite par les cytokines. L'augmentation du miR-34a induit l'apoptose et inhibe la prolifération des cellules ß en réponse aux hormones Exendin-4 et prolactine et au facteur de croissance PDGF-AA. Cette perte de capacité réplicative est similaire à celle observée dans des cellules ß de rats âgés de 12 mois. Dans la littérature, la perte du récepteur au PDGF-r-a est associée à la diminution de la capacité proliférative des cellules ß observée lors du vieillissement. Nous avons pu démontrer que PDGF-r-a est une cible directe de miR- 34a, suggérant que l'effet néfaste de miR-34a sur la prolifération des cellules ß est, du moins en partie, lié à l'inhibition de l'expression de PDGF-r-a. L'expression de ce miR est aussi plus élevée dans le foie et le cerveau des animaux de 1 an et augmente avec l'âge dans les ilôts de donneurs non-diabétiques. Ces résultats suggèrent que miR-34a pourrait être non seulement impliqué dans l'affaiblissement des fonctions pancréatiques associé à l'âge, mais également jouer un rôle dans les tissus cibles de l'insuline et ainsi contribuer au vieillissement de l'organisme en général. Pour conclure, les travaux obtenus durant cette thèse suggèrent que des microARNs sont impliqués dans le dysfonctionnement des cellules ß pancréatiques durant le vieillissement. -- Type 2 diabetes is a metabolic disease characterized by impaired glucose tolerance, of the insulin sensitive tissues and insufficient insulin secretion from the pancreatic ß-cells to sustain the organism demand. Aging is a risk factor for the majority of the metabolic diseases including type 2 diabetes. With aging is observed a decline in all body function, due to decrease both in cell efficiency and renewal. The aim of this thesis was to investigate the potential role of microRNAs (short non- coding RNAs) in the pancreatic ß-cell dysfunction associated with aging. Microarray analysis of microRNA expression profile in pancreatic islets from 3 and 12 month old Wistar male rats revealed important changes in several microRNAs. To further study the link between those alterations and the decline of ß-cells, the changes observed in old rats were mimicked in immortalized ß-cell lines, primary young rat and human islets. Downregulation of miR-181a inhibited pancreatic ß-cell proliferation in response to proliferative drugs, whereas downregulation of miR-130b and upregulation of miR-383 protected pancreatic ß-cells from cytokine stimulated apoptosis. Interestingly, miR-34a augmented pancreatic ß-cell apoptosis and inhibited ß-cell proliferation in response to the proliferative chemicals Exendin-4, prolactin and PDGF-AA. This loss of replicative capacity is reminiscent of what we observed in pancreatic ß-cells isolated from 12 month old rats. We further observed a correlation between the inhibitory effect of miR-34a on pancreatic ß-cell proliferation and its direct interfering effect of this microRNA on PDGF-r-a, which was previously reported to be involved in the age-associated decline of pancreatic ß-cell proliferation. Interestingly miR-34a was upregulated in the liver and brain of 1 year old animals and positively correlated with age in pancreatic islets of normoglycemic human donors. These results suggest that miR-34a might be not only involved in the age-associated impairment of the pancreatic ß-cell functions, but also play a role in insulin target tissues and contribute to the aging phenotype on the organism level. To conclude, we have demonstrated that microRNAs are indeed involved in the age-associated pancreatic ß-cell dysfunction and they can play both beneficial and harmful roles in the context of pancreatic ß-cell aging.

Ohjauksen ja neuvonnan vaikutukset sepelvaltimoiden ohitusleikkauspotilaiden terveyskäyttäytymiseen, terveyteen ja toimintakykyyn

Effects of counseling and guidance on health behavior, health, and functional abilities of coronary artery bypass (cab) patients Hospital periods of heart patients are brief and full of activity today, and for that reason, the meaning of counseling and guidance becomes emphasized. The present intervention study started based on observations of staff members at the heart organization. According to these observations, there were gaps in counseling and guidance intended for coronary artery bypass (CAB) patients. The purpose of the present intervention study was to describe and evaluate the program on counseling and guidance organized for patients who were referred to CAB operations. More specifically, the study was to assess its short-term (3-month), intermediate (6-month), and long-term (12-month) effects on health behavior, health, and functional abilities of CAB patients of any age on one hand and elderly on the other, as well as on their mortality. The data consisted of those individuals having coronary heart disease (CHD) and living in Uusimaa (n = 365) who went through their first CAB operation at the Helsinki University Hospital between May 7th, 1998 and December 31st, 2001. Based on the need of urgency, they were divided into two groups: 1) surgery with regular referral procedure (non-acute) or 2) surgery in the acute phase of CHD. Randomization into an intervention and a control group was separately carried out within these two groups. A subgroup was formed by including those 65 years or older who were operated on with regular referral procedure. Data on health behavior, health, and functional abilities were gathered with survey questionnaires. Times and causes of death were examined January 1st, 1998 through December 31st, 2004. Intervention included counseling and guidance in small groups. The intervention of the non-acutely operated patients was implemented prior to and following surgery, whereas the intervention of the acutely operated patients was implemented after surgery alone. The control group received regular health care services. Counseling and guidance contributed in positive terms to the frequency of alcohol use among non-acutely operated men and to the frequencies of exercise and functional ability among women. The intervention was also capable of having an effect on the exercise frequencies of elderly and acutely operated men. The present intervention did not have an effect on the body mass index, whereas it had barely a slight effect on the health status of the CAB patients. The findings of the intervention and generalizations resulting from them must be viewed critically because the data analysis utilized a multi-testing situation, many variables, and several subgroups. The study did not involve intention to treat analysis. Additionally, a loss of patients was great especially among the elderly and acutely operated patients.

Elämänlaatu ja iäkkäiden kaatumisten ehkäisy

Quality of life and fall prevention among the aged Improvement of quality of life is considered to be one of the most important goals of prevention, treatment and rehabilitation among the aged. The study aimed to describe and assess fall prevention interventions as a quality of life indicator, and to describe the social dimension of health-related quality of life among the aged. In addition, it aimed to assess the effects of fall prevention intervention on quality of life among the aged. The study was implemented by using a methodological triangulation. The data in the systematic review was retrieved from the databasis of medical and nursing sciences. Home-dwelling aged (n=19) participated in the qualitative study of a social dimension of quality of life. The data was gathered by the thematic interview method. The quantitative multifactorial fall prevention study comprised 591 participants, either the aged living at home or in sheltered housing, showing an increased risk of falling. Participants were randomized into an intervention or a control group. Follow-up measurements were carried out after a 12 month intervention. The data was collected by the 15D quality of life instrument and a structured questionnaire. Based on the systematic review, only in a few studies fall prevention produced positive effects on dimensions of quality of life (physical function, social function, vitality, mental health, environmental domain). Based on the thematic interview the social dimension of quality of life consisted of three themes: personal values, personal milieu and personal daily life. Based on the fall prevention program, depressive symptoms and distress decreased, managing in usual activities improved, sexual activity and phone contacts increased among men. In women, managing in usual activities improved, socializing increased and discomfort and symptoms decreased. Within the groups, self-perceived health improved among women in the intervention group and among men in the control groups. In addition, fear of falling and feelings of insecurity reduced among women in the intervention group. Personal daily life with its activities opened up new perspectives into the social dimension of good quality of life, which was emphasized especially in the interviews of the oldest participants. Multifactorial fall prevention can affect positively some physical and psychosocial dimensions of quality of life among the community-dwelling aged. Additional studies with larger sample sizes, longer follow-up periods and multiple outcome measures are needed. Fall prevention intervention may affect quality of life by different mechanisms, and the quantitative and qualitative assessment of its effects should also be included in the interventions of randomized controlled trials.

Natural history of celiac disease-associated antibodies and progression to overt disease in children at increased genetic risk

Background: Celiac disease is a lifelong, gluten-sensitive, autoimmune-mediated chronic enteropathy, tightly associated with risk alleles at the HLA class II genes. Aims: This study was carried out as a part of the population-based Type 1 Diabetes Prediction and Prevention (DIPP) Project. The first aim was to study the natural history of celiac disease-associated antibodies before the diagnosis of celiac disease was made. The second aim was to describe when and in which order celiac disease-associated and type 1 diabetes-associated antibodies appeared in children with genetic risk for both diseases. Subjects and Methods: Antibodies against tissue transglutaminase (TGA) and other celiac disease-associated antibodies were measured in serum samples collected at 3- to 12-month intervals of children at genetic risk for celiac disease who participated in the DIPP project. Celiac disease was confirmed by duodenal biopsy. Type 1 diabetes-associated antibodies were measured in all samples that had been collected. Overt disease was diagnosed according to World Health Organization criteria. Follow-up continued until a diagnosis of type 1 diabetes or until the end of a defined follow-up period. Results: TGA appeared in children at genetic risk for celiac disease only after the first year of life, but anti-gliadin antibodies often emerged significantly earlier, at age 6 months. The data show that spontaneous disappearance of celiac disease-associated antibodies, transient or persisting, is a common phenomenon, at least in prepubertal children. In children with genetic susceptibility to type 1 diabetes and celiac disease, celiac disease-associated antibodies usually develop earlier than the type 1 diabetes-associated antibodies. Conclusions: The transient nature of celiac disease-associated antibodies emphasizes the significance of establishing seropositivity repeatedly in screening detected celiac disease before gastroscopy and duodenal biopsy are considered and emphasized the importance of duodenal biopsy for diagnosing celiac disease.

A Comparative Study of the Effectiveness of a Prefabricated Appliance and a Stabilization Appliance in the Treatment of Myofascial pain and Headache

The aim of this thesis was to evaluate the short- and long-term effectiveness of a prefabricated occlusal appliance (R) on patients with myofascial pain and headache by comparing it with the treatment of the stabilization appliance (S). Another aim was to evaluate the effect of appliance treatment on stress-related salivary parameters like cortisol and IgA, as well as on flow rate values in these patients. Sixty-five patients diagnosed with myofascial temporomandibular disorder (TMD) pain, of whom 94% suffered concomitantly from headache, at two centres for Stomatognathic Physiology, one in Sweden and one in Finland, were included in this randomized controlled trial using Research Diagnostic Criteria for TMD (RDC/TMD), with history questionnaires and clinical examinations performed at baseline and at 6- and 10-weeks, and 6- and 12-month follow-ups. Patients were randomly assigned either to the R or the S group. Treatment outcome was measured according to IMMPACT (Initiative on Methods, Measurements, and Pain Assessment in Clinical Trials), i.e. four chronic pain outcome domains: pain intensity, overall improvement, physical and emotional functioning. Changes in frequency and intensity of headache were recorded. Thirty-nine patients participated in the saliva study. Salivary analyses were performed at 6 and 10 weeks. The results revealed no differences between groups at baseline. At all follow-ups, all four outcome measures, as well as frequency and intensity of headache, showed statistically significant within-group improvement compared to baseline, without significant differences between groups. No treatment-induced changes in saliva parameters could be registered. In conclusion, the effectiveness of the prefabricated appliance seemed to be similar to that of the stabilization appliance in alleviating myofascial pain, and frequency and intensity of headache, in the short as well as the long term. However, no changes in salivary parameters were observed during treatment.