Markku Järvinen

Effects of Reducing or Discontinuing Inhaled Budesonide in Patients with Mild Asthma

BACKGROUND In a previous study, we found that two years of treatment with an inhaled corticosteroid, budesonide, was more effective than treatment with an inhaled beta 2-agonist, terbutaline, in patients with newly diagnosed, generally mild asthma. We continued this study for a third year to investigate whether the steroid dose could be reduced or discontinued and what effect crossover of patients from beta 2-agonist therapy to corticosteroid therapy would have. METHODS A total of 37 patients treated for two years with inhaled budesonide at a dose of 1200 micrograms per day were randomly assigned to treatment with 400 micrograms of budesonide per day (19 patients) or placebo (18 patients) in a double-blind manner. Another 37 patients, who had received terbutaline during the first two years, were crossed over in an open-label manner to treatment with 1200 micrograms of budesonide per day during the third year. RESULTS Treatment with the reduced dose of budesonide was sufficiently effective in 74 percent of the patients to maintain bronchial responsiveness at a level similar to that achieved with the higher dose. In contrast, improvement was maintained in only 33 percent of the patients receiving placebo, and the differences in pulmonary function between the steroid and placebo groups were significant (for forced expiratory volume in one second, P = 0.007; for bronchial responsiveness to histamine, P = 0.025; and for peak expiratory flow in the morning, P = 0.040). The condition of patients who were crossed over from terbutaline therapy to treatment with 1200 micrograms of budesonide per day improved. However, the degree of improvement in these patients appeared to be less than in those who were treated with budesonide at the beginning of the three-year study. CONCLUSIONS Early treatment with inhaled budesonide results in long-lasting control of mild asthma. Maintenance therapy can usually be given at a reduced dose, but discontinuation of treatment is often accompanied by exacerbation of the disease.

Epidemiology of hip fractures.

There were an estimated 1.66 million hip fractures world-wide in 1990. According to the epidemiologic projections, this worldwide annual number will rise to 6.26 million by the year 2050. This rise will be in great part due to the huge increase in the elderly population of the world. However, the age-specific incidence rates of hip fractures have also increased during the recent decades and in many countries this rise has not leveled off. In the districts where this increase has either showed or leveled off, the change seems to especially concern womens cervical fractures. In men, the increase has continued unabated almost everywhere. Reasons for the age-specific increase are not known: increase in the age-adjusted incidence of falls of the elderly individuals with accompanying deterioration in the age-adjusted bone quality (strength, mineral density) may partially explain the phenomenon. The growth of the elderly population will be more marked in Asia, Latin America, the Middle East, and Africa than in Europe and North America, and it is in the former regions that the greatest increments in hip fracture are projected so that these regions will account for over 70% of the 6.26 million hip fractures in the year 2050. The incidence rates of hip fractures vary considerably from population to population and race to race but increase exponentially with age in every group. Highest incidences have been described in the whites of Northern Europe (Scandinavia) and North America. In Finland, for example, the 1991 incidence of hip fractures was 1.1% for women and 0.7% for men over 70 years of age. Among elderly nursing home residents, the figures can be as high as 6.2% and 4.9%. The lifetime risk of a hip fracture is 16%-18% in white women and 5%-6% in white men. At the age of 80 years, every fifth woman and at the age of 90 years almost every second woman has suffered a hip fracture. Since populations are aging worldwide, the mean age of the hip fracture patients are increasing rapidly, too. Between 1970 and 1991, the mean age of male Finnish patients increased dramatically from 52.9 years to 69.0 years. In women, the corresponding figures were 71.6 and 78.9 years. This change is likely to cause increasing problems in the treatment and rehabilitation of the patients. In 1990, 72% of the hip fractures worldwide occurred in women. All over the world, the hip fracture incidences are about two times higher in women than in men. Womens overrepresentation has been explained by womens lower bone mass and density and higher frequency of falling. Epidemiologic studies show that trochanteric fractures are an increasing problem since compared with cervical fractures their relative number increases progressively with age in women after the age of 60 years and since their incidence has been shown to increase in both sexes and all age groups during the recent decades. This may have direct public health implication since mortality, morbidity, and costs caused by trochanteric fractures are higher than those of the cervical fractures. Reduced bone density (strength) by age and over the recent decades has been the most frequently mentioned reason for the increase of trochanteric fractures. Also, the fall characteristics of the elderly may have changed during the recent decades resulting in increasing numbers of this type of hip fractures since the type of the hip fracture (cervical or trochanteric) also depends on the impact angle of the greater trochanter at the moment of the floor contact.

Muscle Injuries Biology and Treatment

Muscle injuries are one of the most common traumas occurring in sports. Despite their clinical importance, few clinical studies exist on the treatment of these traumas. Thus, the current treatment principles of muscle injuries have either been derived from experimental studies or been tested only empirically. Although nonoperative treatment results in good functional outcomes in the majority of athletes with muscle injuries, the consequences of failed treatment can be very dramatic, possibly postponing an athletes return to sports for weeks or even months. Moreover, the recognition of some basic principles of skeletal muscle regeneration and healing processes can considerably help in both avoiding the imminent dangers and accelerating the return to competition. Accordingly, in this review, the authors have summarized the prevailing understanding on the biology of muscle regeneration. Furthermore, they have reviewed the existing data on the different treatment modalities (such as medication, therapeutic ultrasound, physical therapy) thought to influence the healing of injured skeletal muscle. In the end, they extend these findings to clinical practice in an attempt to propose an evidence-based approach for the diagnosis and optimal treatment of skeletal muscle injuries.

Prevention of Hip Fracture in Elderly People with Use of a Hip Protector

BACKGROUND Hip fractures are common in frail elderly adults worldwide. We investigated the effect of an anatomically designed external hip protector on the risk of these age-related fractures. METHODS We randomly assigned 1801 ambulatory but frail elderly adults (1409 women and 392 men; mean age, 82 years), in a 1:2 ratio, either to a group that wore a hip protector or to a control group. Fractures of the hip and all other fractures were recorded until the end of the first full month after 62 hip fractures had occurred in the control group. The risk of fracture in the two groups was compared, and in the hip-protector group the risk of fracture was also analyzed according to whether the protector had been in use at the time of a fall. RESULTS During follow-up, 13 subjects in the hip-protector group had a hip fracture, as compared with 67 subjects in the control group. The respective rates of hip fracture were 21.3 and 46.0 per 1000 person-years (relative hazard in the hip-protector group, 0.4; 95 percent confidence interval, 0.2 to 0.8; P=0.008). The risk of pelvic fracture was slightly but not significantly lower in the hip-protector group than in the control group (2 subjects and 12 subjects, respectively, had pelvic fracture) (relative hazard, 0.4; 95 percent confidence interval, 0.1 to 1.8; P > or = 0.05). The risk of other fractures was similar in the two groups. In the hip-protector group, four subjects had a hip fracture (among 1034 falls) while wearing the protector, and nine subjects had a hip fracture (among 370 falls) while not wearing the protector (relative hazard, 0.2; 95 percent confidence interval, 0.05 to 0.5; P=0.002). CONCLUSIONS The risk of hip fracture can be reduced in frail elderly adults by the use of an anatomically designed external hip protector.

The Fixation Strength of Six Hamstring Tendon Graft Fixation Devices in Anterior Cruciate Ligament Reconstruction Part I: Femoral Site

BACKGROUND Tibial fixation is more problematic than femoral fixation in anterior cruciate ligament reconstruction. HYPOTHESIS There is no difference in initial fixation strength among hamstring tendon graft tibial fixation devices. STUDY DESIGN Randomized experimental study. METHODS Each of six devices used to fix 120 quadrupled human semitendinosus-gracilis tendon grafts into porcine tibiae was tested 10 times with a single-cycle load-to-failure test and 10 times with a 1500-cycle loading test. Specimens surviving cyclic loading were subjected to a single-cycle load-to-failure test. RESULTS Intrafix (1332 N) was the strongest in the single-cycle load-to-failure test, followed by WasherLoc (975 N), tandem spiked washer (769 N), SmartScrew ACL (665 N), BioScrew (612 N), and SoftSilk (471 N). After cyclic-loading tests, Intrafix showed the lowest residual displacement (1.5 mm) and was also strongest (1309 N) in the single-cycle load-to-failure test after the cyclic-loading test, followed by WasherLoc (3.2 mm; 917 N). CONCLUSION The Intrafix provided clearly superior strength in the fixation of hamstring tendon grafts to the tibial drill hole. CLINICAL RELEVANCE Some caution may be warranted when using the implants that showed increased residual displacement, especially if aggressive rehabilitation is to be used. Preconditioning of the hamstring tendon graft-implant complex before tibial fixation is needed.Background: Strength of graft fixation is the weakest link in anterior cruciate ligament reconstruction. Hypothesis: There is no difference in initial fixation strength between different hamstring tendon graft femoral fixation devices. Study Design: Randomized experimental study. Methods: Each of six devices was used in the fixation of 10 quadrupled human semitendinosus-gracilis tendon grafts in tunnels drilled in porcine femora and tested 10 times with a single-cycle load-to-failure test at a rate of 50 mm/min and 10 times with a 1500-cycle loading test between 50 and 200 N at one cycle every 2 seconds. The specimens that survived the cyclic loading were subjected to a single-cycle load-to-failure test. Results: The Bone Mulch Screw (1112 N) was strongest in the single-cycle load-to-failure test, followed by EndoButton CL (1086 N), RigidFix (868 N), SmartScrew ACL (794 N), BioScrew (589 N), and RCI screw (546 N). It also showed the lowest residual displacement (2.2 mm) and was strongest in the single-cycle load-to-failure test after cyclic loading. Conclusions: The Bone Mulch Screw was superior to all other devices. Clinical Relevance: Caution may be warranted in employing aggressive rehabilitation after reconstruction with these devices. Preconditioning of the graft-implant complex before fixation is important.

Effect of a vibration exposure on muscular performance and body balance. Randomized cross-over study

This randomized cross‐over study was designed to investigate the effects of a 4‐min vibration bout on muscle performance and body balance in young, healthy subjects. Sixteen volunteers (eight men, eight women, age 24–33 years) underwent both the 4‐min vibration‐ and sham‐interventions in a randomized order on different days. Six performance tests (stability platform, grip strength, isometric extension strength of lower extremities, tandem‐walk, vertical jump and shuttle run) were performed 10 min before (baseline), and 2 and 60 min after the intervention. The effect of vibration on the surface electromyography (EMG) of soleus, gastrocnemius and vastus lateralis muscles was also investigated. The vibration‐loading, based on a tilting platform, induced a transient (significant at the 2‐min test) 2·5% net benefit in the jump height (P=0·019), 3·2% benefit in the isometric extension strength of lower extremities (P=0·020) and 15·7% improvement in the body balance (P=0·049). In the other 2‐min or in the 60‐min tests, there were no statistically significant differences between the vibration‐ and sham‐interventions. Decreased mean power frequency in EMG of all muscles during the vibration indicated evolving muscle fatigue, while the root mean square voltage of EMG signal increased in calf muscles. We have shown in this study that a single bout of whole body vibration transiently improves muscle performance of lower extremities and body balance in young healthy adults.

Majority of Hip Fractures Occur as a Result of a Fall and Impact on the Greater Trochanter of the Femur: A Prospective Controlled Hip Fracture Study with 206 Consecutive Patients

Abstract. The objectives of this study were to learn how hip fracture patients fall, and to compare the mechanics of their falls with those falls that did not result in hip fracture. In this way we sought to obtain reliable insight into the etiology and pathogenesis of hip fracture and fracture prevention. A total of 206 consecutive patients with fresh hip fracture and 100 controls were interviewed and examined between October 1994 and May 1996. The only inclusion criterion was that the fracture had occurred within 24 hours of hospital admittance. The control subjects were admitted from the same community after an accidental fall that did not result in hip fracture. The characteristics of the accident were determined by personal interview and examination of the patients within 24 hours of the event. In 98% of the hip fracture patients, the fracture was a result of a fall. The majority of the patients (76%) reported that they had fallen directly to the side. Forty-eight fracture cases had one or more eyewitnesses and their reports supported this observation. In 56% of the hip fracture patients, a fresh subcutaneous hematoma was seen on the greater trochanter of the proximal femur; such a hematoma was rare in the controls (6%) (P < 0.001), and this gave evidence for the direct impact of the greater trochanter during the fall of the hip fracture subjects. Most of the elderly fallers who fractured a hip did not manage to break the fall, e.g., with an outstretched arm. In conclusion, our results suggest that a typical hip fracture is the result of a fall and a subsequent impact on the greater trochanter of the proximal femur. The clinical implication of this finding is that effective prevention of hip fractures could be achieved by the diminution of the number and severity of falls of the elderly. We suggest that the severity of the falls (impacts on the greater trochanter) could be decreased by an external hip protector.

Hip fractures in Finland between 1970 and 1997 and predictions for the future.

BACKGROUND Hip fractures in elderly people are common worldwide, and the predicted ageing of populations is increasing the burden of these fractures on health-care systems. However, prediction of the true increases in number of patients needing treatment requires exact knowledge of whether the number of hip fractures is rising more rapidly than can be accounted for by demographic changes alone. We aimed to make such a prediction for people aged 50 years or more in Finland. METHODS All patients aged 50 years or more, who were admitted to hospitals in Finland during 1970-97 for primary treatment of first hip fracture were selected from the National Hospital Discharge Register. The age-specific and age-adjusted fracture incidences were expressed as the number of patients per 100,000 individuals per year, and prediction of the number, and incidence of hip fractures in Finland (population 5 million) until the year 2030 was calculated with a regression model. FINDINGS The number of hip fractures in Finnish people aged 50 or more rose during the study period, from 1857 in 1970 to 7122 in 1997. The corresponding fracture incidence (per 100,000 people) increased from 163 to 438. The age-adjusted incidence of hip fractures also showed a steady increase from 1970 to 1997: in women, from 292 to 467, and in men, from 112 to 233. If this trend continues, the number of hip fractures in Finland will be almost three-fold higher in the year 2030 than in 1997. INTERPRETATION The number of hip fractures in elderly Finnish men and women is increasing at a rate that cannot be explained merely by demographic changes. The precise reasons for this are not known, but deterioration in age-adjusted bone-mineral density and strength, with accompanying increase in the age-adjusted incidence of injurious falls of the elderly, could partly account for the development.

The role of recreational sport activity in Achilles tendon rupture A clinical, pathoanatomical, and sociological study of 292 cases

During the last few decades, the incidence of tendon ruptures has increased in civilized countries. Our ma terial comprises 749 patients who had 832 tendon ruptures treated surgically between 1972 and 1985. There were no competitive athletes among the patients studied. There were 292 single ruptures of the Achilles tendon, 274 of the proximal biceps brachii, 113 of the extensor pollicis longus, and 70 of other tendons. Forty- eight patients had multiple ruptures and 35 patients had reruptures. Achilles tendon ruptures often occurred in recreational sports activities (59%), in contrast to other tendon ruptures (2%; P < 0.001). The mean age for patients who had Achilles tendon rupture was 35.2 years and for patients with other ruptures, 50.7 years (P < 0.001). There was a connection between the high incidence of blood group O and tendon ruptures (P< 0.001). In cases of multiple ruptures and reruptures, the frequency of blood group O was 71%. Sixty-two point three percent of the patients with Achilles tendon rupture were professionals or white collar workers, which is markedly more than in the Hungarian popula tion (12.7%; P < 0.001). Two hundred and six Achilles tendon ruptures were studied histologically, and all cases displayed pathological alterations. The results indicate that complete rupture of the Achilles tendon is usually a sequel to a sedentary life-style and participa tion in sports activities.

Nationwide Decline in Incidence of Hip Fracture

This epidemiologic study determined the trend in the number and incidence (per 100,000 persons) of hip fracture among older adults in Finland, an EU country with a well‐defined white population of 5.2 million, between 1970 and 2004. The results show that the alarming rise in the fracture incidence from early 1970s until late 1990s has been now followed by declining fracture rates. Reasons for this are largely unknown, but a cohort effect toward a healthier aging population and increased average body weight and improved functional ability among elderly Finns could partly explain the phenomenon.