Amyloid diseases at old age : a pathological, epidemiological, and genetic study

Along with the increased life span of individuals, the burden of old age-associated diseases has inevitably increased. Alzheimer s disease (AD), probably the most well known geriatric disease, belongs to the old age-associated amyloid diseases. The purpose of this study was to investigate the frequency, genetic and health-associated risk factors, mutual association, and amyloid proteins in two old age-associated amyloid disorders senile systemic amyloidosis (SSA) and cerebral amyloid angiopathy (CAA) as part of the prospective population-based Vantaa 85+ autopsy study on a Finnish population aged 85 years or more (Studies I-III), completed with a case report on a patient with advanced AGel amyloidosis (Study IV). The numbers of patients investigated in the studies (I-III) were 256, 74, and 63, respectively. The diagnosis and grading of amyloid were based upon histological examination of tissue samples obtained post mortem and stained with Congo red. The amyloid fibril and associated proteins were characterized by immunohistochemical staining methods. The genotype frequencies of 20 polymorphisms in 9 genes and information on health-associated risk factors in subjects with and without SSA and CAA were compared. In a Finnish population ≥ 95 years of age, SSA and CAA occurred in 36% and 49% of the subjects, respectively. In total, two-thirds of these very elderly individuals had SSA, CAA, or both. However, in only 14% of the population these two conditions co-occurred. In subjects 85 years or older, the prevalence of SSA was 25%. In this population, SSA was associated with age at the time of death (p=0.002), myocardial infarctions (MIs; p=0.004), the G/G (Val/Val) genotype of the exon 24 polymorphism in the alpha2-macroglobulin (α2M) gene (p=0.042) and with the H2 haplotype of the tau gene (p=0.016). In contrast, the presence of CAA was strongly associated with APOE e4 (p=0.0003), with histopathological AD (p=0.0005), and with clinical dementia (p=0.01) in both e4+ (p=0.02) and e4- (p=0.06) individuals. Apart from demonstrating the amyloid fibril proteins, complement proteins 3d (C3d) and 9 (C9) were detected in the amyloid deposits of CAA and AGel amyloidosis, and α2M protein was found in fibrous scar tissue close to SSA. In conclusion, this first population based study on SSA shows that both SSA and CAA are common in very elderly individuals. Old age, MIs, the exon 24 polymorphism of the α2M gene, and H1/H2 polymorphism of the tau gene associate with SSA while clinical dementia and APOE ε4 genotype associate with CAA. The high prevalence of CAA, combined with its association with clinical dementia independent of APOE genotype, neuropathological AD, or SSA, also highlights its clinical significance in the very aged, among which the serious end stage complications of CAA, namely multiple infarctions and hemorrhages, are rare. The report on a patient having advanced AGel amyloidosis added knowledge on the disease and showed that this generally benign condition occasionally may lead to death. Further studies are warranted to confirm the findings in other populations. Also, the role of α2M and tau in the pathogenesis of SSA and the involvement of complement in the process of amyloid beta (Aβ) protein elimination from the brain remain to be clarified. Finally, the high prevalence of SSA in the elderly raises the need for prospective clinical studies to define its clinical significance.

Associations of gene polymorphisms and nutrition with calcium homeostasis and bone mineral density : Studies on skeletal nutrigenetics

Heredity explains a major part of the variation in calcium homeostasis and bone strength, and the susceptibility to osteoporosis is polygenetically regulated. Bone phenotype results from the interplay between lifestyle and genes, and several nutritional factors modulate bone health throughout life. Thus, nutrigenetics examining the genetic variation in nutrient intake and homeostatic control is an important research area in the etiology of osteoporosis. Despite continuing progress in the search for candidate genes for osteoporosis, the results thus far have been inconclusive. The main objective of this thesis was to investigate the associations of lactase, vitamin D receptor (VDR), calcium sensing receptor (CaSR) and parathyroid hormone (PTH) gene polymorphisms and lifestyle factors and their interactions with bone health in Finns at varying stages of the skeletal life span. Markers of calcium homeostasis and bone remodelling were measured from blood and urine samples. Bone strength was measured at peripheral and central bone sites. Lifestyle factors were assessed with questionnaires and interviews. Genetic lactase non-persistence (the C/C-13910 genotype) was associated with lower consumption of milk from childhood, predisposing females in particular to inadequate calcium intake. Consumption of low-lactose milk and milk products was shown to decrease the risk for inadequate calcium intake. In young adulthood, bone loss was more common in males than in females. Males with the lactase C/C-13910 genotype may be more susceptible to bone loss than males with the other lactase genotypes, although calcium intake predicts changes in bone mass more than the lactase genotype. The BsmI and FokI polymorphisms of the VDR gene were associated with bone mass in growing adolescents, but the associations weakened with age. In young adults, the A986S polymorphism of the calcium sensing receptor gene was associated with serum ionized calcium concentrations, and the BstBI polymorphism of the parathyroid gene was related to bone strength. The FokI polymorphism and sodium intake showed an interaction effect on urinary calcium excretion. A novel gene-gene interaction between the VDR FokI and PTH BstBI gene polymorphisms was found in the regulation of PTH secretion and urinary calcium excretion. Further research should be carried out with more number of Finns at varying stages of the skeletal life span and more detailed measurements of bone strength. Research should concern mechanisms by which genetic variants affect calcium homeostasis and bone strength, and the role of diet-gene and gene-gene interactions in the pathogenesis of osteoporosis.

The importance of a precise definition, comprehensive model, and critical discussion of successful aging at work

It is crucial to advance understanding of the concept of successful aging at work to guide rigorous future research and effective practice. Drawing on the gerontology and life-span developmental literatures, I recently proposed a definition and theoretical framework of successful aging at work that revolve around employees increasingly deviating from average developmental trajectories across the working life span. Based on sustainability, person–job fit, and proactivity theories, Kooij suggested an alternative perspective that emphasizes the active role of employees for successful aging at work. In this article, I compare the 2 approaches and attempt a partial integration. I highlight the importance of a precise definition, comprehensive model, and critical discussion of successful aging at work. Furthermore, I suggest that person–environment fit variables other than person–job fit (e.g., person–organization fit) and adapting to person–environment misfit may also contribute to successful aging at work. Finally, I argue that proactive behaviors must have age-differential effects on work outcomes to be considered personal resources for successful aging at work.

Successful aging at work

The expression successful aging at work and related terms such as active, healthy, and productive aging at work are frequently used by organizational researchers and practitioners. However, there are no concrete definitions or theoretical frameworks that explain their meaning, assumptions, and underlying processes. In this paper, I first review conceptualizations of successful aging in the fields of gerontology and life span psychology. Second, I propose a working definition of successful aging at work based on four key elements: criteria, explanatory mechanisms, facilitating and constraining factors, and temporal patterns. I distinguish successful aging at work from usual and unsuccessful aging and from other age-related developments in the work context. Third, I introduce a theoretical framework organized around 5 principles on intraindividual age-related change over time, person and contextual mediators and moderators, and work outcomes. Fourth, I review theoretical and empirical research on age in the workplace published in the past decade through the lens of the proposed theoretical framework. Finally, I conclude this paper by outlining suggestions for future research on successful aging at work, including methodological considerations.

Yksilöllisyys ja yhteisöllisyys K. E. Nipkowin uskonnonpedagogisen teorian kehityksessä 1960-1990

Individuality and the Community in the Development of K. E. Nipkow's Theory of Religious Education from 1960 to 1990 The purpose of this study was to describe and analyze the development occurred between 1960 and 1990 of the theory of religious education as proposed by K. E. Nipkow, the German Religious Education specialist, from the point of view of individuality and the community. Nipkow's methodological approach of dialectic convergence theory resulted in a dialogue between theological and educational factors, which supported the thirty-year development of Nipkow's models, theoretical foundations, and theory of religious education. Nipkow's doctoral dissertation, published in 1960, deals with individuality in the thinking of Pestalozzi, Humboldt and Schleiermacher. Nipkow regarded individuality as one of the basic concepts of education, which were to be interpreted anew as social and historical situations changed. In the late 1960s Nipkow developed the so-called experiential hermeneutically oriented context model for the needs of religious education. In this model, individuality is expressed in the attention paid to pupils' life situations and the educational reality. The multi-dimensional theoretical framework of religious education in 1975 emphasized supporting identity as a fundamental task of religious education. The concept of individuality was thus given a new form, in accordance with contemporary theories of developmental psychology. Other fundamental tasks, such as the socio-ethical task, the task of critical religious thinking, and that of ecumenical learning, meant a more specific emphasis on the community. It was an outline of a liberating education, which faced the individualistic-existential and social-ecclesiastical challenges of the time with a critical attitude. The further development of the theoretical outline in 1982 continued to uphold the perspectives of both individuality and the community, as Nipkow combined a historical-social dimension with theories of developmental psychology, especially that of life-span research. According to him, the development of the individual and communal life-reality belonged together. The fundamental task of religious education came to be learning to live and believe together. Nipkow transferred the idea of dialogue into inter-generational learning and developed elementarization as a methodology of Religious Education, which takes into account the point of departure of each age group. His theory of educational responsibility in the church (1990) contained the tasks of walking alongside the individual and the renewal of church communities as prerequisites of communicating the Christian faith in an era characterized by multifaceted Christianity. The "geisteswissenschaftliche" school and its concepts (Ger. Individualität; Bildung) were found to be the explanatory factor of the concepts of individuality and the community in the development of Nipkow's theory of religious education. The concept of education employed by Nipkow (Ger. Bildung) implies, on one hand, the individuality, autonomy, freedom and personal responsibility of people of different ages, and on the other hand, the dialogical nature of education in the community facilitated by this concept. Theologically, Nipkow associates himself in his views on individuality and the community with Schleiermacher's understanding of faith, of which openness towards the world was characteristic. The significance of individuality and the community in Nipkow's thinking was, furthermore, deepened by his participation, as a member of working parties, in the educational discussions of the World Council of Churches.

Stalinismin lyhyt kurssi : Suomalaiset Moskovan Lenin-koulussa 1926-1938

This study of the Finns at the International Lenin School (ILS) reflects history of the Soviet Union during Stalin's era, history of the Communist International (Comintern) as well as history of Finnish communism. The life span of the ILS (1926-1938) matches up with creating and establishing the power structures of Stalinism. Both the ILS and Finnish Communism in the USSR became casualties of the Great Terror (1937-1938). After the WW2, however, the Soviet education was appreciated inside the Communist Party of Finland (CPF). If Finland would have become People's Democracy, the former ILS students would have composed the inner circle of the new "democratic" government. The Finnish teachers of the ILS were leaders of the CPF that was headquartered in Moscow. At the ILS studied in total 141 Finnish communists. The purpose of the ILS was to educate the communist parties' leading stratum of functionaries. They were supposed to internalize current values, methods and discipline of the Bolsheviks. This study evaluates the effects of the total school experience on the Finns that often ended in another total institution in Finland: prison. The curricula of the ILS consisted of theory of Marxism-Leninism, party history, political economics and themes of campaigns of Stalinism. The ILS year included participation in Bolshevik party life and practical work. During summer excursions (praktikas) the students could acquaint themselves with building of socialism in the Soviet Republics. At the ILS, intention to ideological moulding was not hidden. The students were supposed to adopt the Stalinist identity of the professional revolutionaries of the era. The ILS was saturated with ideology and propaganda. This study analyzes especially uses of history as vehicle of ideological standardisation and as instrument of power. Stalin contributed personally to shortcomings of history writing of the communist party. Later he supervised writing of the inclusive handbook of communism, "History of the All-Union Communist Party. Short Course". Special attention will be paid to the effects of Stalin's intervention at the ILS and inside the CPF. The life of the Finns at the ILS and outside the school is described at grass roots. The dividing line between personal and political is analyzed by charting emotional, intimate and bodily experiences of the Finns of the ILS. The fates of the ILS Finns after the studying or teaching period in Moscow are explored in detail. The protagonist among the teachers is Yrjö Sirola that was called "father of the CPF cadres". The Finnish ILS teachers and the formed students that had remained in the USSR were most severely hit by the Great Terror. The Soviet education had most importance in Finland of post WW2 period. The training at the ILS, however, did not contribute to revolution in Finland. The main heading of the study, "A Short Course of Stalinism", crystallises interpretation of the ILS as seat of learning of ideological unity of Stalinism. On the other hand, the title includes a statement of incompleteness of the Stalinist education if the schooling at the ILS had remained in one year.

Literacy teacher research in high poverty schools: Why it matters

Teachers who work in contexts in which their students’ lives are affected by poverty take up the challenge of learning to teach diverse students in ways that teachers in other contexts may not be required to do. And they do this work in contexts of immense change. Students’ communities change, neighborhoods change, educational policies change, literate practices and the specific effects of what it means to be poor in particular places also change. What cannot change is a commitment to high-equity, high-quality education for the students in these schools. Teachers need to analyze situations and make ongoing ethical decisions about pedagogy and curriculum. To do this, they must be able to continuously gauge the effects of their practices on different students. Hence, we argue that building teacher-researcher dispositions and repertoires is a key goal for teacher education across the teaching life-span. Drawing on a range of recent and ongoing collaborative research projects in schools situated in areas of high poverty, we draw out some principles for literacy teachers’ education.

Regulation of Growth by Drosophila FoxO Transcription Factor

Forkhead box class O (FoxO) transcription factors are members of the forkhead box transcription factor superfamily, with orthologues in various species such as human, worm and fly. FoxO proteins are key regulators of growth, metabolism, stress resistance and, consequently, life span. FoxOs integrate signals from different pathways, e.g. the growth controlling Insulin-TOR signaling pathway and the stress induced JNK and Hippo signaling pathways. FoxO proteins have evolved to guide the cellular response to varying energy and stress conditions by inducing the expression of genes involved in the regulation of growth and metabolism. This work has aimed to deepen the understanding of how FoxO executes its biological functions. A particular emphasis has been laid to its role in growth control. Specifically, evidence is presented indicating that FoxO restricts tissue growth in a situation when TOR signaling is high. This finding can have implications in a human condition called Tuberous sclerosis, manifested by multiple benign tumors. Further, it is shown that FoxO directly binds to the promoter and regulates the expression of a Drosophila Adenylate cyclase gene, ac76e, which in turn modulates the fly s development and growth systemically. These results strengthen FoxOs position among central size regulators as it is able to operate at the level of individual cells as well as in the whole organism. Finally, an attempt to reveal the regulatory network upstream of FoxO has been carried out. Several putative FoxO activity regulators were identified in an RNAi screen of Drosophila kinases and phosphatases. The results underscore that FoxO is regulated through an elaborate network, ensuring the correct execution of key cellular processes in metabolism and response to stress. Overall, the evidence provided in this study strengthens our view of FoxO as a key integrator of growth and stress signals.

Effect of Nucleic Acid Reactive Antibodies on Tumor Cells Grown in Vivo

Nucleic acid reactive antibodies have been reported to inhibit various nucleio acid mediated functions in cell free systems. These antibodies were also shown to inhibit the growth of transformed cells in culture due to the high rate of endocytosis in transformed cells as compared to normal cells. In this report, we have tested the possibility of nucleic acid reactive antibodies inhibiting the growth of tumor cells in vivo. The life span of mice bearing Dalton's lymphoma ascites tumor cells was increased, when they were immunized with conjugates of guanosine-BSA, GMP-BSA and tRNA-MBSA complex before transplanting the tumor cells. A similar effect was also observed when mice were injected intraperitoneally with antibodies to guanosine oi GMP along with the tumor cells. The specificity was ascertained, as immunization with non-specific antigens did not show any significant effect on tumor bearing mice. The results shows that nucleic acid. reactive antibodies inhibit the growth of tumor cells in vivo.

Short- and long-term consequences of food resources on Ural owl Strix uralensis reproduction

Life-history theory states that although natural selection would favour a maximisation of both reproductive output and life-span, such a combination can not be achieved in any living organism. According to life-history theory the reason for the fact that not all traits can be maximised simultaneously is that different traits compete with each other for resources. These relationships between traits that constrain the simultaneous evolution of two or more traits are called trade-offs. Therefore, during different life-stages an individual needs to optimise its allocation of resources to life-history components such as growth, reproduction and survival. Resource limitation acts on these traits and therefore investment in one trait, e.g. reproduction, reduces the resources available for investment in another trait, e.g. residual reproduction or survival. In this thesis I study how food resources during different stages of the breeding event affect reproductive decisions in the Ural owl (Strix uralensis) and the consequences of these decisions on parents and offspring. The Ural owl is a suitable study species for such studies in natural populations since they are long-lived, site-tenacious, and feed on voles. The vole populations in Fennoscandia fluctuate in three- to four-year cycles, which create a variable food environment for the Ural owls to cope with. The thesis gives new insight in reproductive costs and their consequences in natural animal populations with emphasis on underlying physiological mechanisms. I found that supplementary fed Ural owl parents invest supplemented food resources during breeding in own self-maintenance instead of allocating those resources to offspring growth. This investment in own maintenance instead of improving current reproduction had carry-over effects to the following year in terms of increased reproductive output. Therefore, I found evidence that reduced reproductive costs improves future reproductive performance. Furthermore, I found evidence for the underlying mechanism behind this carry-over effect of supplementary food on fecundity. The supplementary-fed parents reduced their feeding investment in the offspring compared to controls, which enabled the fed female parents to invest the surplus resources in parasite resistance. Fed female parents had lower blood parasite loads than control females and this effect lasted until the following year when also reproductive output was increased. Hence, increased investment in parasite resistance when resources are plentiful has the potential to mediate positive carry-over effects on future reproduction. I further found that this carry-over effect was only present when potentials for future reproduction were good. The thesis also provides new knowledge on resource limitation on maternal effects. I found that increased resources prior to egg laying improve the condition and health of Ural owl females and enable them to allocate more resources to reproduction than control females. These additional resources are not allocated to increase the number of offspring, but instead to improve the quality of each offspring. Fed Ural owl females increased the size of their eggs and allocated more health improving immunological components into the eggs. Furthermore, the increased egg size had long-lasting effects on offspring growth, as offspring from larger eggs were heavier at fledging. Limiting resources can have different short- and long-term consequences on reproductive decisions that affect both offspring number and quality. In long-lived organisms, such as the Ural owl, it appears to be beneficial in terms of fitness to invest in long breeding life-span instead of additional investment in current reproduction. In Ural owls, females can influence the phenotypic quality of the offspring by transferring additional resources to the eggs that can have long-lasting effects on growth.

Generation and Characterization of the Cation-Chloride Cotransporter KCC2 Hypomorphic Mouse

The cation-Cl- cotransporter (CCC) family comprises of Na+-Cl- cotransporter (NCC), Na+-K+-2Cl- cotransporters (NKCC1-2), and four K+-Cl- cotransporters (KCC1-4). These proteins are involved in several physiological activities, such as cell volume regulation. In neuronal tissues, NKCC1 and KCC2 are important in determining the intracellular Cl- levels and hence the neuronal responses to inhibitory neurotransmitters GABA and glycine. One aim of the work was to elucidate the roles for CCC isoforms in the control of nervous system development. KCC2 mRNA was shown to be developmentally up-regulated and follow neuronal maturation, whereas NKCC1 and KCC4 transcripts were highly expressed in the proliferative zones of subcortical regions. KCC1 and KCC3 mRNA displayed low expression throughout the embryogenesis. These expression profiles suggest a role for CCC isoforms in maturation of synaptic responses and in the regulation of neuronal proliferation during embryogenesis. The major aim of this work was to study the biological consequences of KCC2-deficiency in the adult CNS, by generating transgenic mice retaining 15-20% of normal KCC2 levels. In addition, by using these mice as a tool for in vivo pharmacological analysis, we investigated the requirements for KCC2 in tonic versus phasic GABAA receptor-mediated inhibition. KCC2-deficient mice displayed normal reproduction and life span, but showed several behavioral abnormalities, including increased anxiety-like behavior, impaired performance in water maze, alterations in nociceptive processing, and increased seizure susceptibility. In contrast, the mice displayed apparently normal spontaneous locomotor activity and motor coordination. Pharmacological analysis of KCC2-deficient mice revealed reduced sensititivity to diazepam, but normal gaboxadol-induced sedation, neurosteroid hypnosis and alcohol-induced motor impairment. Electrophysiological recordings from CA1-CA3 subregions of the hippocampus showed that KCC2 deficiency affected the reversal potentials of both the phasic and tonic GABA currents, and that the tonic conductance was not affected. The results suggest that requirement for KCC2 in GABAergic neurotransmission may differ among several functional systems in the CNS, which is possibly due to the more critical role of KCC2 activity in phasic compared to tonic GABAergic inhibition.

Ischemic Stroke in Young Adults

Stroke is the second leading cause of death and the leading cause of disability worldwide. Of all strokes, up to 80% to 85% are ischemic, and of these, less than 10% occur in young individuals. Stroke in young adults—most often defined as stroke occurring under the age of 45 or 50—can be particularly devastating due to long expected life-span ahead and marked socio-economic consequences. Current basic knowledge on ischemic stroke in this age group originates mostly from rather small and imprecise patient series. Regarding emergency treatment, systematic data on use of intravenous thrombolysis are absent. For this Thesis project, we collected detailed clinical and radiological data on all consecutive patients aged 15 to 49 with first-ever ischemic stroke between 1994 and 2007 treated at the Helsinki University Central Hospital. The aims of the study were to define demographic characteristics, risk factors, imaging features, etiology, and long-term mortality and its predictors in this patient population. We additionally sought to investigate, whether intravenous thrombolysis is safe and beneficial for the treatment of acute ischemic stroke in the young. Of our 1008 patients, most were males (ratio 1.7:1), who clearly outnumbered females after the age of 44, but females were preponderant among those aged <30. Occurrence increased exponentially. The most frequent risk factors were dyslipidemia (60%), smoking (44%), and hypertension (39%). Risk factors accumulated in males and along aging. Cardioembolism (20%) and cervicocerebral artery dissection (15%) were the most frequent etiologic subgroups, followed by small-vessel disease (14%), and large-artery atherosclerosis (8%). A total of 33% had undetermined etiology. Left hemisphere strokes were more common in general. Posterior circulation infarcts were more common among those aged <45. Multiple brain infarcts were present in 23% of our patients, 13% had silent infarcts, and 5% had leukoaraiosis. Of those with silent brain infarcts, majority (54%) had only a single lesion, and most of the silent strokes were located in basal ganglia (39%) and subcortical regions (21%). In a logistic regression analysis, type 1 diabetes mellitus in particular predicted the presence of both silent brain infarcts (odds ratio 5.78, 95% confidence interval 2.37-14.10) and leukoaraiosis (9.75; 3.39-28.04). We identified 48 young patients with hemispheric ischemic stroke treated with intravenous tissue plasminogen activator, alteplase. For comparisons, we searched 96 untreated control patients matched by age, gender, and admission stroke severity, as well as 96 alteplase-treated older controls aged 50 to 79 matched by gender and stroke severity. Alteplase-treated young patients recovered more often completely (27% versus 10%, P=0.010) or had only mild residual symptoms (40% versus 22%, P=0.025) compared to age-matched controls. None of the alteplase-treated young patients had symptomatic intracerebral hemorrhage or died within 3-month follow-up. Overall long-term mortality was low in our patient population. Cumulative mortality risks were 2.7% (95% confidence interval 1.5-3.9%) at 1 month, 4.7% (3.1-6.3%) at 1 year, and 10.7% (9.9-11.5%) at 5 years. Among the 30-day survivors who died during the 5-year follow-up, more than half died due to vascular causes. Malignancy, heart failure, heavy drinking, preceding infection, type 1 diabetes, increasing age, and large-artery atherosclerosis causing the index stroke independently predicted 5-year mortality when adjusted for age, gender, relevant risk factors, stroke severity, and etiologic subtype. In sum, young adults with ischemic stroke have distinct demographic patterns and they frequently harbor traditional vascular risk factors. Etiology in the young is extremely diverse, but in as many as one-third the exact cause remains unknown. Silent brain infarcts and leukoaraiosis are not uncommon brain imaging findings in these patients and should not be overlooked due to their potential prognostic relevance. Outcomes in young adults with hemispheric ischemic stroke can safely be improved with intravenous thrombolysis. Furthermore, despite their overall low risk of death after ischemic stroke, several easily recognizable factors—of which most are modifiable—predict higher mortality in the long term in young adults.

Late results after paediatric cardiac surgery

Background: Congenital heart defects include a wide range of inborn malformations. Depending on the defect, the life expectancy of a newborn with cardiac anomaly varies from a few days to a normal life span. In most instances surgery, is the only treatment available. The late results of surgery have not been comprehensively investigated. Aims: Mortality, morbidity and the life situation of all Finnish patients who had been operated on for congenital heart defect during childhood were investigated. Methods: Patient and surgical data were gathered from all hospitals that had performed heart surgeries on children. Late mortality and survival data were obtained from the population registry, and the causes of deaths from Statistics Finland. Morbidity of patients operated on during 1953-1989 was assessed by the usage of medicines. The pharmacotherapy data of patients and controls were obtained from the Social Insurance Institute. The life situation of patients was surveyed by mailed questionnaire. Survival, causes of deaths and life situation of patients were compared with those of the general population. Results: A total of 7240 cardiac operations were performed on 6461 children during the first 37 years of cardiac surgery (1953-1989). The number of procedures constantly rose during this period, and the increase continued in later years. The patient material varied over time, as more defects became surgically treatable. During 1953-1989 the operative mortality (death within 30 days of surgery) was 6.9%. In the 1990s a slight rise occurred in early mortality, as increasingly complicated patients were surgically treated. During 2000-2003 practically no defects were beyond the operative range. Thus, the operative mortality of 4.4% was excellent, decreasing even further to 2.0% in 2004-2007. The overall 45-year survival of patients operated on in 1953-1989 was 78%, and the corresponding figure for the general population was 93%. Survival depended on the defect, being worst among patients with univentricular heart. Late survival was also better during the 1990s and at the beginning of the 21st century. Of the 6028 early survivors, 592 died late (>30 days) after surgery. A total of 397 deaths (67%) were related and 185 (31%) unrelated to congenital heart defect. The cause of death was unknown in 10 cases. Of those 5774 patients who survived their first operation and had complete follow-up, 16% were operated on several times. Seventeen percent of patients used medicines for cardiac symptoms (heart failure, arrhythmia, hypertension and coronary disease). Patients risk of using cardiac medicines was 2.16 (Cl 1.97-2.37) times higher than that of controls. Patients also had more genetic syndromes and mental retardation and more often used medicines for asthma and epilepsy. Adult patients who had been operated on as children had coped surprisingly well with their defects. Their level of education was similar and their employment level even higher than expected, and they were living in a steady relationship as often as the general population. Conclusions: Cardiac surgery developed rapidly, and nowadays practically all defects can be treated. The overall survival of all operated patients was 78%, 16% less than that of the general population. However, it was significantly better than the anticipated natural survival. However, many patients had health problems; 16% needed reoperations and 17% cardiac medicines to maintain their condition. Most of the patients assessed their general health as good and lived a normal life.

Active and break spells of the Indian summer monsoon

In this paper, we suggest criteria for the identification of active and break events of the Indian summer monsoon on the basis of recently derived high resolution daily gridded rainfall dataset over India (1951-2007). Active and break events are defined as periods during the peak monsoon months of July and August, in which the normalized anomaly of the rainfall over a critical area, called the monsoon core zone exceeds 1 or is less than -1.0 respectively, provided the criterion is satisfied for at least three consecutive days. We elucidate the major features of these events. We consider very briefly the relationship of the intraseasonal fluctuations between these events and the interannual variation of the summer monsoon rainfall. We find that breaks tend to have a longer life-span than active spells.While, almost 80% of the active spells lasted 3-4 days, only 40% of the break spells were of such short duration. A small fraction (9%) of active spells and 32% of break spells lasted for a week or longer. While active events occurred almost every year, not a single break occurred in 26% of the years considered. On an average, there are 7 days of active and break events from July through August. There are no significant trends in either the days of active or break events. We have shown that there is a major difference between weak spells and long intense breaks. While weak spells are characterized by weak moist convective regimes, long intense break events have a heat trough type circulation which is similar to the circulation over the Indian subcontinent before the onset of the monsoon. The space-time evolution of the rainfall composite patterns suggests that the revival from breaks occurs primarily from northward propagations of the convective cloud zone. There are important differences between the spatial patterns of the active/break spells and those characteristic of interannual variation, particularly those associated with the link to ENSO. Hence, the interannual variation of the Indian monsoon cannot be considered as primarily arising from the interannual variation of intraseasonal variation. However, the signature over the eastern equatorial Indian Ocean on intraseasonal time scales is similar to that on the interannual time scales.