Deep sclerectomy

This study was undertaken to determine outcome of deep sclerectomy (DS) with and without mitomycin C (MMC), especially in patients with normal tension glaucoma (NTG). Intraocular pressure (IOP) lowering effect of DS to NTG eyes with low preoperative IOP has not been studied previously. When aiming for low postoperative IOP, MMC may introduce postoperative adverse effects. Majority of glaucoma patients scheduled for surgery have primary open angle glaucoma (POAG), but exfoliation glaucoma (EXG) is common in Nordic countries. IOP lowering with DS results in a decrease in best corrected visual acuity (BCVA) during the first postoperative weeks, the reasons for which are not thoroughly known. The aims of this thesis were to investigate 1) the effect of DS in NTG eyes, 2) the possible additional IOP-lowering effect and adverse effects of MMC use, 3) the effect of DS in POAG and EXG eyes and 4) changes to BCVA, and anterior and posterior structures of the eye after DS. DS reduced IOP efficiently in NTG eyes, an effect that could be noticed throughout our follow-up: postoperative IOP with and without MMC was 9 to 10 mmHg respectively, after 6 to 9 years of follow-up. Hypotony was more common during the first postoperative months when MMC was used. IOP was lower until 5 years postoperatively in the MMC group. In the MMC group 87%, and the non-MMC group 100% of eyes needed GP during follow-up. Needling was needed in 16 of 34 eyes. Four eyes lost two or more lines of best-corrected visual acuity (BCVA). The rate of serious postoperative complications was low. DS lowered IOP efficiently also in POAG and EXG eyes. Mean postoperative IOP was 16.8 mmHg in POAG, and 16.5 mmHg in EXG after 3 years´ follow-up. GP and re-operations were more common in EXG. IOP of 2 to 14 mmHg one week postoperatively indicated a lower rate of losing surgical success. BCVA decreased when IOP was lowered with DS, but had returned to its preoperative level 4 weeks postoperatively. Axial length was shortened by 0.1 mm, and a steeper corneal meridian changed from 44.6 to 44.9 D. Thickness of the central cornea decreased 6 μm when measured with Scheimpflug. Changes in macular structures in optical coherence tomography (OCT) were small: four patients initially developed macular folds and two persisted until 4 weeks postoperatively, but visual acuities remained good. Based on these studies, we demonstrated that DS is effective in lowering IOP in NTG, EXG, and POAG. Even very low IOP between 9 to 10 is achievable. Use of MMC results in lower IOP and fewer postoperative interventions. MMC use was without significant risk of serious complications or adverse effects. Rate of GP is close to 100% when follow-up is long. EXG eyes may have altered fibrotic response to DS, which may favor MMC use. DS is a safe procedure, with only relatively small changes in anterior and posterior structures and a low rate of irreversible decrease in BCVA.Syvä sklerektomia on glaukoomakirurginen leikkausmenetelmä, jolla on pyritty vähentämään leikkauksen aiheuttamia komplikaatioita. Syvän sklerektomian tehoa matalapaineglaukoomaa sairastavilla ei ole aiemmin tutkittu. Glaukoomakirurgiassa käytetään usein mitomysiiniä parantamaan leikkauksen tehoa. Suomessa yleisen eksfoliaatioglaukooman leikkaustuloksia on julkaistu vähän. Glaukoomaleikkausten jälkeen näöntarkkuus alenee muutaman viikon ajaksi, mutta syitä tähän ei täysin tiedetä. Väitöskirjassani tutkin syvän sklerektomian vaikutusta silmänpaineeseen matalapaineglaukoomaa sairastavilla sekä mitomysiinin käyttöön liittyviä hyötyjä ja mahdollisia sivuvaikutuksia. Lisäksi tutkin syvän sklerektomian tehoa eksfoliaatioglaukoomaa ja avokulmaglaukoomaa sairastavilla sekä syvän sklerektomian aiheuttamia muutoksia näöntarkkuuteen ja silmän rakenteisiin. Syvän sklerektomian teho matalapaineglaukoomassa osoittautui merkittäväksi. Keskimääräinen silmänpaine leikkauksen jälkeen oli 9-10 mmHg seuranta-ajan ulottuessa 9 vuoteen asti. Mitomysiinin käyttö johti matalampaan silmänpaineeseen viiden ensimmäisen vuoden ajaksi. Pitkäaikaisseurannassa leikkauskomplikaatiot ja mitomysiinin käytön sivuvaikutukset olivat harvinaisia. Myös eksfoliaatioglaukoomassa syvän sklerektomian teho oli hyvä kolmen vuoden aikana. Eksfoliaatioglaukoomaa sairastavat joutuivat kuitenkin useammin uusintaleikkaukseen ja goniopunktuuraan verrattuna tavallista avokulmaglaukoomaa sairastaviin. Mikäli silmänpaine oli 2-14 mmHg välillä viikko leikkauksen jälkeen, tällä havaittiin olevan merkitystä ennustettaessa leikkauksen onnistumista. Syvän sklerektomian jälkeen keskimääräinen näöntarkkuus aleni merkittävästi, mutta palautui neljään viikkoon mennessä. Silmän pituus lyheni 0,1 mm ja sarveiskalvon kaarevuus jyrkkeni vähän, mutta nämä eivät selittäneet näöntarkkuuden alenemaa. Ensimmäisinä viikkoina silmänpohjassa havaittiin verkkokalvon hentoa poimuttumista, mutta tämä väheni ensimmäisen kuukauden aikana, eikä vaikuttanut näöntarkkuuteen. Ensimmäistä kertaa voitiin osoittaa, että syvällä sklerektomialla saavutetaan matalapaineglaukoomassa merkittävä silmänpaineen alennus ja vaikutus ulottui 6-9 vuoteen asti leikkauksen jälkeen. Mitomysiinin käyttöön ei havaittu liittyvän kohonnutta komplikaatioriskiä. Suomessa yleisessä eksfoliaatioglaukoomassa syvän sklerektomian teho oli hyvä. Näöntarkkuus palautui leikkauksen jälkeen ensimmäisen kuukauden aikana ja silmän etuosaan tai silmänpohjaan ei aiheutunut merkittäviä näöntarkkuuteen vaikuttavia muutoksia

Success in Weight Management Among Patients with Type 2 Diabetes : Do Perceived Autonomy Support, Autonomous Motivation, and Self-Care Competence Play a Role?

Based on self-determination theory (SDT), this study investigated whether the three central SDT variablesperceived autonomy support (from a physician), autonomous motivation and self-care competencewere associated with success in weight management (SWM) among primary care patients with type 2 diabetes when the effect of other important life-context factors was controlled for. Patients participated in a mail survey in 2011. Those who had tried to change their health behavior during the past two years in order to lose weight, either with or without success (n = 1433, mean age 63years, 50% men), were included in this study. The successors were more autonomously motivated and energetic than the non-successors. Moreover, male gender, younger age, taking oral medication only, and receiving less social support in diabetes care predicted better success. Autonomous motivation predicted SWM; self-care competence also played a role by partly mediating the effect of autonomous motivation on SWM. These results support the idea of SDT that internalizing the value of weight management and its health benefits is necessary for long-term maintenance of health behavior change. Perceived autonomy support was not directly associated with SWM. However, physicians can promote patients' weight management by supporting their autonomous motivation and self-care competence.Peer reviewe

Empowerment among adult patients with type 2 diabetes : age differentials in relation to person-centred primary care, community resources, social support and other life-contextual circumstances

BackgroundRising prevalence of type 2 diabetes (T2D), also among younger adults, constitutes a growing public health challenge. According to the person-centred Chronic Care Model, proactive care and self-management support in combination with community resources enhance quality of healthcare and health outcomes for patients with T2D. However, research is scarce concerning the importance of person-centred care and community resources for such outcomes as empowerment, and the relative impact of various patient support sources for empowerment is not known. Moreover, little is known about the association of age with these variables in this patient-group. This study, carried out among patients with T2D, examined in three age-groups (27-54, 55-64 and 65-75years) whether person-centred care and diabetes-related social support, including community support and possibilities to influence community health issues, are associated with patient empowerment, when considering possible confounding factors, such as other quality of care indicators and psychosocial wellbeing. We also explored age differentials in empowerment and in the proposed correlates of empowerment.MethodIndividuals from a register-based sample with T2D participated in a cross-sectional survey (participation 56%, n=2866). Data were analysed by descriptive statistics and multivariate logistic regression analyses.ResultsRespondents in the youngest age-group were more likely to have low empowerment scores, less continuity of care, and lower wellbeing than the other age-groups, and to perceive less social support, but a higher level of person-centred care than the oldest group. Community support, including possibilities to influence community health issues, was independently and consistently associated with high empowerment in all three age-groups, as was person-centred care in the two older age-groups. Community support was the social support variable with the strongest association with empowerment across age-groups. Moreover, vitality was positively and diabetes-related distress negatively associated with high empowerment in all age-groups, whereas continuity of care, i.e. having a family/regular nurse, was independently associated in the youngest age-group only.ConclusionPerson-centred care and community support, including possibilities to influence community health issues, supports empowerment among adults with T2D. Findings suggest that age is related to most correlates of empowerment, and that younger adults with T2D have specific healthcare needs.Peer reviewe

Determinants of physical activity among patients with type 2 diabetes : the role of perceived autonomy support, autonomous motivation and self-care competence

Peer reviewe

Patients' assessment of chronic illness care : a validation study among patients with type 2 diabetes in Finland

Background: To meet the challenges of the rising prevalence of chronic diseases, such as type 2 diabetes, new approaches to healthcare delivery have been initiated; among these the influential Chronic Care Model (CCM). Valid instruments are needed to evaluate the public health impact of these frameworks in different countries. The Patient Assessment of Chronic Illness Care (PACIC) is a 20-item quality of care measure that, from the perspective of the patient, measures the extent to which care is congruent with the CCM. The aim of this study was to evaluate the psychometric properties of the Finnish translation of the PACIC questionnaire, in terms of validity and reliability, in a large register-based sample of patients with type 2 diabetes. Method: The PACIC items were translated into Finnish in a standardized forward-backward procedure, followed by a cross-sectional survey among patients with type 2 diabetes (response rate 56%; n = 2866). We assessed the Finnish version of the PACIC scale for the following psychometric properties: content validity, internal consistency reliability, convergent and construct validity. We also present descriptive data on total scale as well as predetermined subscale levels. Results: The item-response on the PACIC scale was high with only small numbers of missing data (0.5-1.1%). Ceiling effects were low (0.3-5.3%) whereas floor effects were over 20% for two of the predetermined subscales (problem solving and follow-up/coordination). The total PACIC scale showed a reasonable distribution and excellent internal consistency (alpha 0.94) while the internal consistency of the subscales were at least acceptable (0.74-0.86). The principal component analysis identified a two-or three-factor solution instead of the proposed five-dimensional. In other respects, the PACIC scale showed the hypothesized relationships with quality of care and outcome measures, thus demonstrating convergent and construct validity. Conclusion: A Finnish version of the PACIC scale is now validated in the primary care setting among patients with type 2 diabetes. The findings suggest comparable psychometric properties of the Finnish scale as of the original English instrument and earlier translations, and reasonable levels of validity and reliability.Peer reviewe

Health care climate, perceived self-care competence and glycemic control among patients with type 2 diabetes in primary care.

Peer reviewe

The importance of and satisfaction with sex life among breast cancer survivors in comparison with healthy female controls and women with mental depression or arterial hypertension : results from the Finnish nationwide HeSSup cohort study

Introduction Breast cancer (BC) and its treatment is associated with several physical and psychosocial changes that may influence sexuality for years after treatment. Women with BC show significantly greater rates of sexual dysfunction than do healthy women. The purpose of the study was to evaluate how a BC diagnosis associates with women's perceived sexuality and sexual satisfaction. Material and methods The data of the ongoing prospective Health and Social Support (HeSSup) survey was linked with national health registries. Respondents with registry data confirmed BC (n = 66), mental depression (n = 612), arterial hypertension (n = 873), and healthy women (n = 9731) formed the study population. The importance of and satisfaction with sex life were measured by a self-report questionnaire modified from the Schover's and colleagues' Sexual History Form. Results Women with BC considered sex life less important than did healthy women (p <0.001). They were significantly less satisfied with their sex life than healthy women (p = 0.01) and women with arterial hypertension (p = 0.04). Living single or educational level did not explain the differences between the groups. Conclusions BC survivors depreciate their sex life and experience dissatisfaction with it. Sexuality can be a critical issue for the quality of life of women surviving from BC, and hence, the area deserves major attention in BC survivorship care. Health care professionals should regularly include sexual functions in the assessment of BC survivors' wellbeing.Peer reviewe

A named GP increases self-reported access to health care services

Background Continuity of care strengthens health promotion and decreases mortality, although the mechanisms of these effects are still unclear. In recent decades, continuity of care and accessibility of health care services have both decreased in Finland. Objectives The aim of the study was to investigate whether a named and assigned GP representing continuity of care is associated with the use of primary and hospital health care services and to create knowledge on the state of continuity of care in a changing health care system in Finland. Methods The data are part of the Health and Social Support (HeSSup) mail survey based on a random Finnish working age population sample of 64,797 individuals drawn in 1998 and follow-up surveys in 2003 and 2012. The response rate in 1998 was 40% (n = 25,898). Continuity of care was derived from the 2003 and 2012 data sets, other variables from the 2012 survey (n = 11,924). The principal outcome variables were primary health care and hospital service use reported by participants. The association of the explanatory variables (gender, age, education, reported chronic diseases, health status, smoking, obesity, NYHA class of any functional limitation, depressive mood and continuity of care) with the outcome variables was analysed by binomial logistic regression analysis. Results A named and assigned GP was independently and significantly associated with more frequent use of primary and hospital care in the adjusted logistic regression analysis (ORs 1.53 (95% CI 1.35-1.72) and 1.19 (95% CI 1.08-1.32), p < 0.001). Conclusion A named GPs is associated with an increased use of primary care and hospital services. A named GP assures access to health care services especially to the chronically ill population. The results depict the state of continuity of care in Finland. All benefits of continuity of care are not enabled although it still assures treatment of population in the most vulnerable position.Peer reviewe

Trends in high life satisfaction among adolescents in five Nordic countries 2002–2014

Life satisfaction is an important indicator when assessing positive mental health aspects in populations, including among adolescents. The aim of this study was to investigate trends over time in prevalence of high life satisfaction among adolescents from five Nordic countries: Denmark, Iceland, Finland, Norway and Sweden. We used data from four waves of the Health Behaviour in School-Aged Children study from 2002, 2006, 2010 and 2014 (n=109,847). HBSC is a school-based study examining social circumstances, health and health behaviour among 11-, 13- and 15-years olds every four years in many European and North American countries. The Cantril Ladder, an 11-step visual analogue scale, was used as the measure of life satisfaction, and was dichotomised into two groups: high life satisfaction (scoring 9 or 10 on the scale) and medium/low life satisfaction (scoring <9). Over the 12-year period studied, between 28.6 and 44.8% of adolescents in the five countries rated their life satisfaction as high. Relatively large changes in prevalence levels occurred at the country level over the period. Denmark and Finland showed a steady, significant decline in the prevalence of high life satisfaction over the years. Iceland showed the highest prevalence in 2010. Norway and Sweden showed similar development until 2010, followed by a clear increase for Norway and a sharp decline in adolescent high life satisfaction for Sweden up until 2014. In all countries, high life satisfaction was most prevalent in 11-year- olds and least prevalent in almost all surveys among 15-year-old girls.peerReviewe