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BACKGROUND: Prevention of persistent pain after breast cancer surgery, via early identification of patients at high risk, is a clinical need. Psychological factors are among the most consistently proposed predictive parameters for the development of persistent pain. However, repeated use of long psychological questionnaires in this context may be exhaustive for a patient and inconvenient in everyday clinical practice. METHODS: Supervised machine learning was used to create a short form of questionnaires that would provide the same predictive performance of pain persistence as the full questionnaires in a cohort of 1000 women followed up for 3 yr after breast cancer surgery. Machine-learned predictors were first trained with the full-item set of Beck's Depression Inventory (BDI), Spielberger's State-Trait Anxiety Inventory (STAI), and the State-Trait Anger Expression Inventory (STAXI-2). Subsequently, features were selected from the questionnaires to create predictors having a reduced set of items. RESULTS: A combined seven-item set of 10% of the original psychological questions from STAI and BDI, provided the same predictive performance parameters as the full questionnaires for the development of persistent postsurgical pain. The seven-item version offers a shorter and at least as accurate identification of women in whom pain persistence is unlikely (almost 95% negative predictive value). CONCLUSIONS: Using a data-driven machine-learning approach, a short list of seven items from BDI and STAI is proposed as a basis for a predictive tool for the persistence of pain after breast cancer surgery.

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BACKGROUND: Ensuring patient involvement in health technology assessments (HTAs) and clinical practice guidelines (CPGs) is important. However, the goals and methods of such involvement are not always clear. OBJECTIVES: The aim of this study was to 1) discover ways to involve patients in HTA and CPG processes, 2) describe challenges, and 3) find ways of informing patients about HTAs and CPGs in Finland. METHODS: As part of a one-day seminar targeted at representatives of patient organizations (POs), 3, 1-h focus group discussions were held (n = 20, with 14 PO representatives). PO representatives included real patients and health care professionals working in the organizations. The discussions were tape-recorded, transcribed, and thematically analyzed. RESULTS: Focus group participants highlighted the importance of gathering patient views from a group of patients, rather than individuals. Surveys through POs were the most frequently mentioned means of gathering patients' views. PO representatives reported interest in cooperating in HTA and CPG processes. The most often mentioned challenges were finding appropriate representatives for the target group and conveying information about HTAs and CPGs to patients. Multichannel communication was seen as essential. Furthermore the information should be readable, comprehensible, tailored, reliable, reusable, complementary, and timely. CONCLUSIONS: Possible strategies to involve patients in HTA and CPG processes were incorporating patient representatives in the CPG and HTA groups, offering timely possibility to participate, and ensuring reporting with clear and unambiguous language. The main identified challenge was finding appropriate representatives of the target group. The role of POs was seen as important particularly when informing the patients.

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BACKGROUND: Persistent postsurgical pain can have a significant effect on the quality of life of women being treated for breast cancer. The aim of this prospective study was to develop a screening tool to identify presurgical demographic, psychological and treatment-related factors that predict persistence of significant pain in the operated area after 6 months from surgery. METHODS: Background and self-reported questionnaire data were collected the day before surgery and combined with treatment-related data. Pain in the operated area was assessed 6 months after surgery with a questionnaire. The Bayesian model was used for the development of a screening tool. RESULTS: Report of preoperative chronic pain, more than four or more previous operations, preoperative pain in the area to be operated, high body mass index, previous smoking and older age were included in the six-factor model that best predicted significant pain at the follow-up in the 489 women studied. CONCLUSION: A six-factor risk index was developed to estimate the risk of developing significant pain after breast cancer surgery. Neither treatment- nor mood-related variables were included in the model. Identification of risk factors may lead to prevention of persistent postsurgery pain. This tool could be used for target prevention to those who are at the highest risk of developing persistent postsurgery pain.

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OBJECTIVE: To approximate the workload of blood pressure (BP) measurements and lifestyle counselling in primary healthcare when the related guidelines are followed. To evaluate the impact of facilitated guideline implementation with respect to workloads. DESIGN: Modelling study after cross-sectional audit process. SETTING: Thirty-one municipal health stations. Intervention Intrinsic facilitation in implementation of hypertension guideline. MAIN OUTCOME MEASURES: Number and level (normal <140/85 mmHg, slightly 140-160/85-95 mmHg or markedly elevated >160/95 mmHg) of BP measurements at nurses' appointments, approximation of time allocated for measurements and lifestyle counselling before and 1 year after the intervention. RESULTS: A total of 3119 BP measurements were recorded during the audit week in 2002. BP level measurements were "normal" in 1214 (38.9%), slightly elevated in 1371 (44.0%) and markedly elevated in 534 (17.1%). According to the modelling, 12% of a nurse's workday consisted of BP recordings and counselling. After intervention, the corresponding figures were 2330 measurements (828 (35.5%) normal, 990 (42.5%) slightly and 512 (22.0%) markedly elevated) corresponding to 6.3% of the workday. CONCLUSIONS: Through facilitation programmes, it is possible to change working practices according to the related guidelines, agree on the division of tasks and empower patients to engage with their own treatment. These changes can lead to considerable decreases in the workload of health centre personnel with consequent redistribution of personnel resources to patients in true need for services.

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OBJECTIVES: Evaluation of the effect of a quality improvement programme on cardiovascular disease (CVD) risk factor recording and risk factor levels in a controlled study at two primary health care centres serving 26,000 inhabitants in Northern Helsinki. METHODS: From a random sample of patient records from 1995 (n=1,066), 1996 (n=1,042), and 1997 (n=1,040) the frequency of CVD risk factor recording was measured and the changes in mean levels of total cholesterol, blood glucose, blood pressure, and body weight were monitored during the follow up period. The intervention programme (1995-1996) consisted of lectures and meetings of multiprofessional teams, development of local guidelines, and introduction of a structured risk factor recording sheet as part of the patient records. RESULTS: After the quality improvement period all risk factors were better recorded at the intervention station than at the control station (p<0.001). More high risk CVD patients were detected from the general population at the intervention station. The mean values of most measured risk factors changed during the intervention. During the follow up period differences were observed between the two health stations in the time trends for body weight, body mass index (BMI), total cholesterol, and glucose levels. Risk factor levels of high risk patients receiving CVD treatment decreased during the intervention. CONCLUSIONS: A simple quality improvement programme improved the practice of recording risk factors for CVD which resulted in earlier detection of patients with a high risk of developing the disease.

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In order to assess the effectiveness of lifestyle interventions in reducing cardiovascular disease risk factors, morbidity and mortality among working-age adults, we undertook a systematic review of randomized controlled trials of various lifestyle interventions (diet, exercise, smoking cessation, alcohol intake reduction) in adults followed for 1 year or longer. Twenty-one single-factor and 21 multifactorial interventions were analysed by outcome. Changes in cardiovascular morbidity and mortality and total mortality were considered as main outcomes. Changes in weight, total cholesterol, blood pressure, sodium excretion, smoking and alcohol consumption were also analysed, and numbers needed to treat were calculated for smoking, morbidity and mortality. In secondary prevention, both single and multifactorial lifestyle interventions were shown to reduce morbidity and mortality, and multifactorial approaches reduced cholesterol levels. Primary prevention was found to reduce risk factors efficiently, especially when the intervention is multifactorial. Effect sizes were heterogeneous with wide confidence intervals. Standardized ways of describing interventions, measuring their effects and reporting outcomes systematically would facilitate effect-size evaluations. Interventions should optimally be multifactorial and targeted at high-risk patients with multiple risk factors for cardiovascular disease.

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Aluminium and iron overload is often seen among long-term haemodialysis patients. Untreated non-de-aluminized dialysis water or the intake of large amounts of aluminium hydroxide as phosphate binders are the most common reasons for hyper-aluminaemia. Iron overload is mainly a result of multiple blood transfusions given to correct renal anaemia. In chronic dialysis patients, hypochromic anaemia is one of the clinical manifestations of a long-term overload of aluminium and perhaps of other metals, e.g. iron. We used deferoxamine (DFO) to chelate aluminium and excessive iron in 17 patients on chronic haemodialysis. Two grams of DFO was administered weekly in the form of an i.v. infusion during the last hour of the dialysis session. The mean serum aluminum concentration decreased from 407.3 micrograms/l to 184.2 micrograms/l within 3 years of treatment, the mean serum ferritin concentration from 1,563 micrograms/l to 487 micrograms/l within 2 years. Anaemia was corrected concomitantly with an increase in the haemoglobin level, which rose from 71.7 g/l to 80.8 g/l. The mean corpuscular volume increased from 83.8 fl to 91.3 fl. The need for blood transfusion also decreased significantly in all patients after the institution of DFO therapy. The clinical manifestations of aluminium and iron overload disappeared and the quality of life improved. No major side-effects were observed.

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The outbreak of paralytic poliomyelitis in Finland in 1984 was halted by nationwide oral poliovirus vaccination campaign. Immunocompromised patients, including those with chronic uraemia and on continuous dialysis, were excluded from the oral vaccination group and instead were given a dose of the new enhanced-potency inactivated poliovirus vaccine before the campaign. We studied the antibody response to this vaccine in 49 patients on chronic dialysis, using conventional antigen of all three serotypes and two additional type 3 strains. It was observed that 86% (42 of 49) of patients either had a satisfactory concentration of neutralising poliovirus antibodies against all three serotypes prior to vaccination, or responded with at least a four-fold increase of antibodies. Fourteen of 21 patients originally seronegative to at least one of the five virus strains used showed a striking seroconversion. One patient remained seronegative to type 1 poliovirus while two and four other patients were left with low (less than 8) titres of type 1 and 3 antibodies respectively. The latter seven patients showed moderate or good responses to the other two serotypes. We conclude that the enhanced-potency inactivated poliovirus vaccine produces a good antibody response in uraemic patients.

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To study the urinary kallikrein excretion before the delivery of term pregnancy we measured its excretion preterm (between 32-36 gestational week) in 13 patients with normotensive pregnancy and 17 patients with pregnancy-induced hypertension and one to five days before the delivery at term in 18 and 22 patients, respectively. In normotensive pregnancy urinary kallikrein excretion remained unchanged during the late third trimester until delivery (12.6 +/- 1.7 ncat in 24 hours in preterm, 10.8 +/- 1.2 before delivery). In pregnancy-induced hypertension and particularly in pre-eclampsia urinary kallikrein excretion was lower than in normotensive pregnancy and the decrease became more marked as the time of delivery approached (respective values: in pregnancy induced hypertension 9.2 +/- 1.2 and 7.0 +/- 0.7; in pre-eclampsia 7.6 +/- 1.3 and 7.3 +/- 0.9). The decrease in urinary kallikrein excretion suggests progressive disturbances in the interactions of renal vasoactive systems (the kallikrein-kinin system, the renin-angiotensin system and prostaglandins) with resultant changes in renal hemodynamics.

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An impairment of the renal function was observed in three patients who received azapropazone for various rheumatic disorders with simultaneous hyperuricaemia. A distinct increase in serum creatinine occurred in all patients. In one case the renal biopsy suggested a hypersensitivity reaction with a consequent acute tubulo-interstitial nephritis as the mechanism of the impaired renal function. The renal insufficiency was reversible in all cases after the withdrawal of azapropazone.

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