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Salpe Malkon,1 Björn Wettermark,1 Thomas Kahan,2 Pia Bastholm-Rahmner,3 Jan Hasselström,4 Miriam Qvarnström1 1Department of Pharmacy, Uppsala University, Uppsala, Sweden; 2Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden; 3Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; 4Department of Neurobiology and Care Sciences and Society, Karolinska Institutet, Stockholm, SwedenCorrespondence: Miriam Qvarnström, Department of Pharmacy, Faculty of Pharmacy, Uppsala University, Box 580, Uppsala, 751 23, Sweden, Email miriam.qvarnstrom@farmaci.uu.sePurpose: Few studies explored what patients initiated on blood pressure medication in primary care think about their disease and their medications. The aim of this study was to gain an understanding of hypertensive patients’ views on and experiences of hypertension and the use of antihypertensive medications.Methods: A qualitative study based on open-ended questions from a survey on medication adherence, which captured treated hypertensive patients’ perspective on their condition and treatment. Data were collected for 219 patients on antihypertensive medication, ≥ 30 years old, who consulted 25 primary health care centers in Stockholm, Sweden, during 2016. Thematic analysis with both inductive and deductive approach was applied.Results: We identified 21 codes from the data and grouped them under the World Health Organization’s five dimensions of adherence: condition-, therapy-, health care team and system-, patient-, and socioeconomic-related factors. The analyses revealed that many patients with hypertension have limited knowledge of their disease, are afraid of drug side effects and experience various issues in primary health care that may negatively impact adherence, including short doctor appointments, prescribing without communication and room for improvement in individualization of therapy and a person-centered approach.Conclusion: Many patients with hypertension have limited understanding of their hypertension and fear of adverse events from their antihypertensive medications. There is also room for improvement in how the patients are managed in primary health care. Interventions should focus on these issues to promote a better blood pressure target achievement.Plain Language Summary: Few studies have explored what patients initiated on blood pressure medication in primary care think about their disease and their medications.In this study, we analyzed free comments collected from 219 patients responding to a survey on medication adherence. Those who responded used antihypertensive medication, were ≥ 30 years old, and consulted primary health care centers in Stockholm, Sweden.The analyses revealed that many patients with hypertension have limited knowledge of their disease, are afraid of drug side effects and experience various issues in primary health care that may negatively impact adherence, including short doctor appointments, prescribing without communication and room for improvement in individualization of therapy and a person-centered approach.Interventions to promote a better blood pressure treatment would likely benefit from targeting these problems raised by patients.Keywords: hypertension, antihypertensive treatment, medication adherence, patient perspectives, primary health care, qualitative studies

Aims: While medication adherence (MA) is a key prerequisite for achieving optimal clinical and economic outcomes, nonadherence is highly prevalent. Assessing how healthcare professionals (HCPs) in Europe manage MA, focusing on measurement, reporting and interventions, is the subject of this study., Methods: A cross-sectional study was conducted among 40 European countries and quantitative analysis was conducted via an online survey. The multi-language online survey was created using Webropol 3.0 survey and reporting tool. Descriptive statistics and chi-squared tests were applied., Results: In total, 2875 HCPs (pharmacists: 39.9%; physicians: 36.7%; nurses: 16.4%) from 37 European countries participated. The most used methods for MA assessment were direct communication with patients (86.4%) and referring to personal patient records (56.7%) (P < 0.0001). Physicians (74.9%) and nurses (58.8%) were more aware of problems related to MA in contrast to pharmacists (48.6%) (P < 0.001). Almost all HCPs (92.6%) indicated that MA-enhancing interventions involved mainly direct communication with nonadherent patients (93.3%) and their caregivers (55.7%). Medication review and related optimization of therapy were mainly performed in Western European countries (46.8%). Technological solutions were ranked as one of the less applied approaches (10-15%) (P < 0.001)., Conclusions: HCPs in all European regions recognize MA management as an integral element of overall patient-centred care. More efforts are needed to ensure timely, adequate and relevant MA assessment, reporting and improvement and involvement of all HCPs, especially among pharmacists who were generally less aware of MA issues. Promotion and use of digital technological solutions should be the focus of current and future clinical practice to optimize MA management processes., (© 2024 The Author(s). British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Cardiovascular diseases are the main causes of death, and statins can reduce the risk of major vascular events. Lithuania is among the European countries with the highest cardiovascular mortality despite a rapidly increasing use of statins. Previous reviews have shown the problem of poor patient adherence, but there are limited studies from Eastern European countries. The aim of this study was to evaluate treatment persistence in new users of statins in Lithuania and to investigate factors associated with persistence. Dispensed prescriptions from patients aged >18 years old initiated on statins in 2018-2019 were included, and data were obtained from a national health insurance fund. Persistence was assessed by the proportion of patients who still had statins dispensed 1 year after the first dispensing. Factors associated with persistence were assessed using logistic regression. A total of 104 726 patients (41.3% men) were initiated on statin treatment. Only 41% of them continued statin use 1 year after initiation. Factors associated with higher persistence rate were older age, higher dose of statin, use of other medicines and use of statins as secondary prevention. Low persistence to statin therapy needs to be recognized by healthcare workers, pharmacists and policy makers to address this problem., (© 2024 The Authors. Basic & Clinical Pharmacology & Toxicology published by John Wiley & Sons Ltd on behalf of Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).)

Background: Medication adherence is essential for the achievement of therapeutic goals. Yet, the World Health Organization estimates that 50% of patients are nonadherent to medication and this has been associated with 125 billion euros and 200,000 deaths in Europe annually., Objective: This study aimed to unravel barriers and unmet training needs regarding medication adherence management across Europe., Design: A cross-sectional study was conducted through an online survey. The final survey contained 19 close-ended questions., Participants: The survey content was informed by 140 global medication adherence experts from clinical, academic, governmental, and patient associations. The final survey targeted healthcare professionals (HCPs) across 39 European countries., Main Measures: Our measures were barriers and unmet training needs for the management of medication adherence across Europe., Key Results: In total, 2875 HCPs (pharmacists, 40%; physicians, 37%; nurses, 17%) from 37 countries participated. The largest barriers to adequate medication adherence management were lack of patient awareness (66%), lack of HCP time (44%), lack of electronic solutions (e.g., access to integrated databases and uniformity of data available) (42%), and lack of collaboration and communication between HCPs (41%). Almost all HCPs pointed out the need for educational training on medication adherence management., Conclusions: These findings highlight the importance of addressing medication adherence barriers at different levels, from patient awareness to health system technology and to fostering collaboration between HCPs. To optimize patient and economic outcomes from prescribed medication, prerequisites include adequate HCP training as well as further development of digital solutions and shared health data infrastructures across Europe., (© 2024. The Author(s).)

Purpose: This study aims to determine initiation and persistence for patients with type 2 diabetes receiving their first prescription of an antidiabetic agent and the associations with socioeconomic factors., Methods: A cohort study including 8515 patients with type 2 diabetes who were prescribed their first antidiabetic medication between 2012 and 2019 in Uppsala, Sweden, was followed during 2 years. Medical records were linked to national registers on dispensed drugs and socioeconomic data. Adherence was assessed based on patients' medication claims within 30 days of prescription (initiation) and continued claims after 24 months (persistence). Multivariable logistic regression was used to determine the associations with the socioeconomic factors age, sex, living status, country of birth, education, occupation, and income., Results: Within 30 days, 92.4% of the patients claimed their first prescription, and 64.0% were still being dispensed the initially prescribed medication after 24 months. Unemployed patients had lower initiation rates, and women had lower persistence rates. Factors associated with both low initiation and persistence were low income, young or old age, birth outside Europe, and being prescribed other diabetes drugs than metformin monotherapy., Conclusion: Socioeconomic factors have different impact on the initiation of a new medication and the persistence to treatment in type 2 diabetes. It is important to acknowledge these differences to develop appropriate interventions to improve medication nonadherence., (© 2023. The Author(s).)

Material of the antiarch placoderm Bothriolepis from the middle Givetian of the Valentia Slate Formation in Iveragh Peninsula, Ireland, is described and attributed to a new species, B. dairbhrensis sp. nov. A revision of the genus Bothriolepis is proposed, and its taxonomic content and previous phylogenetic analyses are reviewed, as well as the validity of morphologic characteristics considered important for the establishment of the genus, such as the shape of the preorbital recess of the neurocranium. A series of computerised phylogenetic analyses was performed, which reveals that our new species is the sister taxon to the Frasnian Scottish form B. gigantea. New phylogenetic and biogeographic analyses of the genus Bothriolepis together with comparisons between faunal assemblages reveal a first northward dispersal wave from Gondwana to Euramerica at the latest in the mid Givetian. Other Euramerican species of Bothriolepis seem to belong to later dispersal waves from Gondwana, non-excluding southward waves from Euramerica. Questions remain open such as the taxonomic validity and stratigraphic constraints for the most ancient forms of Bothriolepis in China, and around the highly speciose nature of the genus., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Dupret et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The Triassic was a crucial period for the early evolution and diversification of insects, including Coleoptera 1-3 -the most diverse order of organisms on Earth. The study of Triassic beetles, however, relies almost exclusively on flattened fossils with limited character preservation. Using synchrotron microtomography, we investigated a fragmentary Upper Triassic coprolite, which contains a rich record of 3D-preserved minute beetle remains of Triamyxa coprolithica gen. et sp. nov. Some specimens are nearly complete, preserving delicate structures of the legs and antennae. Most of them are congruent morphologically, implying that they are conspecific. Phylogenetic analyses suggest that T. coprolithica is a member of Myxophaga, a small suborder of beetles with a sparse fossil record, and that it represents the only member of the extinct family Triamyxidae fam. nov. Our findings highlight that coprolites can contain insect remains, which are almost as well preserved as in amber. They are thus an important source of information for exploring insect evolution before the Cretaceous-Neogene "amber time window." Treated as food residues, insect remains preserved in coprolites also have important implications for the paleoecology of insectivores, in this case, likely the dinosauriform Silesaurus opolensis., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate the reliability of clinician-based perceptual assessment of voice and computerized acoustic voice analysis as screening tests for vocal fold paresis or paralysis (VFP) after thyroid and parathyroid surgery., Methods: This was a prospective study of 181 patients undergoing thyroid or parathyroid procedure with pre and postoperative laryngoscopic vocal fold inspection, perceptual voice assessment using grade, roughness, breathiness, asthenia, and strain (GRBAS) scale and acoustic voice analysis using the multi-dimensional voice program (MDVP). Patients were divided into 2 groups for comparison; those with new postoperative VFP and those without. Potential screening tools were evaluated using the receiving operating characteristic (ROC) analysis., Results: Fourteen (6.6%) patients had a new postoperative VFP. Postoperative GRBAS scores were significantly (P < 0.05) higher in patients with VFP compared to those without. However, there were no statistically significant differences in MDVP values between the groups. Postoperative GRBAS grade score (cut off > 0) had the best sensitivity, 93%, for predicting VFP, but the specificity was only 50%. Postoperative jitter (cut off > 1.60) in MDVP had a good specificity, 90%, but only 50% sensitivity. Combining all the GRBAS and MDVP variables with P < 0.05 in the ROC analysis yielded a test with 100% sensitivity and 55% specificity., Conclusions: Physician-based perceptual voice assessment has a high sensitivity for detecting postoperative VFP, but the specificity is poor. The risk of VFP is low in patients with completely normal voice at discharge. However, routine laryngoscopy after thyroid and parathyroid surgery is still the most reliable exam for VFP screening.

Purpose: To study the differences in attitudes towards hypertension and drug treatment between patients persistent and non-persistent to antihypertensive drug treatment. Materials and methods: Cross-sectional study on patients with hypertension treated at 25 primary healthcare centres in Stockholm, Sweden. Questionnaires were sent to the patients 3-12 months after initiation of antihypertensive drug treatment. Persistent medication users, defined as patients with less than 30 days without tablet supply between prescription refills, were compared with non-persistent users by scores from Likert scales: Brief-Illness Perception Questionnaire (Brief IPQ, 0-10) and Beliefs about Medicines Questionnaire (BMQ General, 4-20 and BMQ Specific, 5-25). Results: A total of 711 patients were included in the final analyses (mean age: 62 years; 50% women), of whom 609 (86%) were classified as persistent and 102 (14%) as non-persistent by analyses of their filled prescriptions. Likert scales from the Brief-IPQ showed (all p  < 0.02) that persistent patients believed that hypertension was a chronic condition (median 6 vs. 4), that hypertension had less consequences on their life (median 2 vs. 3) and that they can prevent cardiovascular disease by taking antihypertensive treatment (median 7 vs. 5). Likert scales from the BMQ General showed (all p  < 0.02) that persistent patients believed that there are potential benefits from taking the treatment (median 16 vs. 16), and they did not believe that the doctors put too much trust in drugs (median 12 vs. 13). Further, results from the BMQ Specific showed that they believed that the antihypertensive drugs are necessary for them in order to maintain or improve their own health (median 17 vs. 16). Conclusions: Primary healthcare providers should further emphasize the chronicity of hypertension diagnosis and the benefits of treatment, to improve the patients' medication persistence to antihypertensive treatment.

Background: The aim of this study was to determine the incidence, risk factors, and spontaneous recovery rate of vocal fold paresis (VFP) with routine laryngoscopy before and after thyroid surgery., Methods: All consecutive patients undergoing primary or redo thyroid surgery between years 2011-2016 were prospectively registered in an electronic database, and scheduled for pre- and postoperative laryngoscopic vocal fold inspection by otolaryngologists independently of the surgical team., Results: A total of 920 thyroid operations with 1296 nerves at risk were performed in 866 patients. Pre- and postoperative laryngoscopy was done in 95% and 98%, respectively. Preoperative VFP was detected in 24 (2.8%) patients. New postoperative VFP was found in 53 of 920 operations (5.8%) and in 55 of 1296 nerves at risk (4.2%). After 12 months, 14 had recovered full vocal fold function and eight had near-complete recovery. VFP was permanent after 29 operations (3.2%); two patients were lost to follow-up with uncertain outcome. Of the 1296 nerves at risk, injury was permanent in 30 (2.3%). In multivariate analysis, patients operated for recurrent goiter had nearly nine times higher risk of new VFP (23% rate), whereas patients with malignant histology had three times higher risk of postoperative VFP (up to 22% rate)., Conclusion: VFP continues to be a serious complication of thyroid surgery, especially in operations for redo goiter and thyroid malignancy. The incidence of VFP may be underestimated unless laryngoscopic examinations are performed routinely.

Diets of pterosaurs have mainly been inferred from indirect evidence such as comparative anatomy, associations of co-occurring fossils, and functional morphology. Gut contents are rare, and until now there is only a single coprolite (fossil dropping), with unidentified inclusions, known. Here we describe three coprolites collected from a palaeosurface with numerous pterosaur tracks found in early Kimmeridgian (Hypselocyclum Zone) intertidal deposits of the Wierzbica Quarry, Poland. The specimens' morphology and association to the tracks suggest a pterosaur producer. Synchrotron scans reveal numerous small inclusions, with foraminifera making up the majority of the identifiable ones. Other small remains include shells/carapaces (of bivalves, ostracods, and other crustaceans/arthropods) and bristles (some possibly of polychaete worms). The high density of the small shelly inclusions suggest that they were not accidently ingested, but constituted an important food source for the pterosaur(s), perhaps together with unpreserved soft-bodied animals. The combined evidence from the tracks and coprolites suggest a filter-feeding ctenochasmatid as the most likely tracemaker. If true, this significantly expands the bromalite record for this pterosaur group, which was previously only known from gastroliths. Moreover, this study also provides the first direct evidence of filter feeding in Jurassic pterosaurs and shows that they had a similar diet to the recent Chilean flamingo ( Phoenicopterus chilensis )., Competing Interests: The authors declare there are no competing interests.

Diets of extinct animals can be difficult to analyse if no direct evidence, such as gut contents, is preserved in association with body fossils. Inclusions from coprolites (fossil faeces), however, may also reflect the diet of the host animal and become especially informative if the coprolite producer link can be established. Here we describe, based on propagation phase-contrast synchrotron microtomography (PPC-SRμCT), the contents of five morphologically similar coprolites collected from two fossil-bearing intervals from the highly fossiliferous Upper Triassic locality at Krasiejów in Silesia, Poland. Beetle remains, mostly elytra, and unidentified exoskeleton fragments of arthropods are the most conspicuous inclusions found in the coprolites. The abundance of these inclusions suggests that the coprolite producer deliberately targeted beetles and similar small terrestrial invertebrates as prey, but the relatively large size of the coprolites shows that it was not itself a small animal. The best candidate from the body fossil record of the locality is the dinosauriform Silesaurus opolensis Dzik, 2003, which had an anatomy in several ways similar to those of bird-like neotheropod dinosaurs and modern birds. We hypothesize that the beak-like jaws of S. opolensis were used to efficiently peck small insects off the ground, a feeding behaviour analogous to some extant birds., Competing Interests: The authors declare no competing interests.

Here we present evidence for osteophagy in the Late Triassic archosaur Smok wawelski Niedźwiedzki, Sulej and Dzik, 2012, a large theropod-like predator from Poland. Ten medium to large-sized coprolites are matched, by their dimensions and by association with body fossils and footprints, to S. wawelski. The coprolites contain fragments of large serrated teeth as well as up to 50 percent by volume of bone fragments, with distinct fragmentation and angularity, from several prey taxa. This suggests pronounced osteophagy. Further evidence for bone-crushing behaviour is provided by isolated worn teeth, bone-rich regurgitalites (fossil regurgitates) and numerous examples of crushed or bite-marked dicynodont bones, all collected from the same bone-bearing beds in the Lipie Śląskie clay-pit. Several of the anatomical characters related to osteophagy, such as a massive head and robust body, seem to be shared by S. wawelski and the tyrannosaurids, despite their wide phylogenetic separation. These large predators thus provide evidence of convergence driven by similar feeding ecology at the beginning and end of the age of dinosaurs.

Purpose: To assess drug adherence in patients treated with ≥3 antihypertensive drug classes, with both controlled and uncontrolled blood pressure and describe associated factors for nonadherence., Methods: Patients with hypertension, without cardiovascular comorbidity, aged >30 years treated with ≥3 antihypertensive drug classes were followed for 2 years. Both patients with treatment resistant hypertension (TRH) and patients with controlled hypertension were included. Clinical data were derived from a primary care database. Pharmacy refill data from the Swedish Prescribed drug registry was used to calculate proportion of days covered (PDC). Patients with a PDC level ≥ 80% were included., Results: We found 5846 patients treated ≥3 antihypertensive drug classes, 3508 with TRH (blood pressure ≥ 140/90), and 2338 with controlled blood pressure (<140/90 mm Hg). TRH patients were older (69.1 vs 65.8 years, P < .0001) but had less diabetes (28.5 vs 31.7%, P < .009) compared with patients with controlled blood pressure. The proportion of patients with PDC ≥ 80% declined with 11% during the first year in both groups. Having diabetes was associated with staying adherent at 1 year (RR 0.82; 95% CI, 0.68-0.98) whilst being born outside Europe was associated with nonadherence at one and (RR 2.05; 95% CI, 1.49-2.82)., Conclusions: Patients with multiple antihypertensive drug therapy had similar decline in adherence over time regardless of initial blood pressure control. Diabetes was associated with better adherence, which may imply that the structured caregiving of these patients enhances antihypertensive drug treatment., (Copyright © 2018 John Wiley & Sons, Ltd.)

Opinions differ on whether the evolution of tetrapods (limbed vertebrates) from lobe-finned fishes was directly linked to terrestrialization. The earliest known tetrapod fossils, from the Middle Devonian (approximately 390 million years old) of Zachełmie Quarry in Poland, are trackways made by limbs with digits; they document a direct environmental association and thus have the potential to help answer this question. However, the tetrapod identity of the tracks has recently been challenged, despite their well-preserved morphology, on account of their great age and supposedly shallow marine (intertidal or lagoonal) depositional environment. Here we present a new palaeoenvironmental interpretation of the track-bearing interval from Zachełmie, showing that it represents a succession of ephemeral lakes with a restricted and non-marine biota, rather than a marginal marine environment as originally thought. This context suggests that the trackmaker was capable of terrestrial locomotion, consistent with the appendage morphology recorded by the footprints, and thus provides additional support for a tetrapod identification.

Coprolites (fossil faeces) reveal clues to ancient trophic relations, and contain inclusions representing organisms that are rarely preserved elsewhere. However, much information is lost by classical techniques of investigation, which cannot find and image the inclusions in an adequate manner. We demonstrate that propagation phase-contrast synchrotron microtomography (PPC-SRμCT) permits high-quality virtual 3D-reconstruction of coprolite inclusions, exemplified by two coprolites from the Upper Triassic locality Krasiejów, Poland; one of the coprolites contains delicate beetle remains, and the other one a partly articulated fish and fragments of bivalves.

We describe the first known occurrence of a Devonian coelacanth specimen from the lower Famennian of the Holy Cross Mountains, Poland, with a conodont element preserved in its digestive tract. A small spiral and phosphatic coprolite (fossil excrement) containing numerous conodont elements and other unrecognized remains was also found in the same deposits. The coprolite is tentatively attributed to the coelacanth. Although it is unclear whether the Late Devonian coelacanth from Poland was an active predator or a scavenger, these finds provide the first direct evidence of feeding on conodont animals by early coelacanth fish, and one of the few evidences of feeding on these animals known to date. It also expands our knowledge about the diet and trophic relations between the Paleozoic marine animals in general.

The aim was to study persistence to, and switching between, antihypertensive drug classes and to determine factors associated with poor persistence.This was an observational cohort study. The Swedish Primary Care Cardiovascular Database includes data from medical records, socioeconomic data, filled prescriptions, and hospitalizations from national registries for 75,000 patients with hypertension. Patients included in the study were initiated on antihypertensive drug treatment in primary healthcare in 2006 to 2007. We defined class persistence as the proportion remaining on the initial drug class, including 30 days of gap. Patients with a filled prescription of another antihypertensive drug class after discontinuation of the initial drug, including 30 days of gap, were classified as switchers. Persistence to the various drug classes were compared with that for diuretics.We identified 4997 patients (mean age 60 ± 12 years in men and 63 ± 13 years in women). Out of these, 95 (2%) filled their first prescription for fixed combination therapy and 4902 (98%) for monotherapy, including angiotensin converting enzyme inhibitors (37%), angiotensin receptor blockers (4%), beta blockers (21%), calcium channel blockers (8%), and diuretics (28%). Persistence to the initial drug class was 57% after 1 year and 43% after 2 years. There were no differences in persistence between diuretics and any of the other antihypertensive drug classes, after adjustment for confounders. Discontinuation (all adjusted) was more common in men (P = 0.004), younger patients (P < 0.001), those with mild systolic blood pressure elevation (P < 0.001), and patients born outside the Nordic countries (P < 0.001). Among 1295 patients who switched drug class after their first prescription, only 21% had a blood pressure recorded before the switch occurred; and out them 69% still had high blood pressures.In conclusion, there appears to be no difference in drug class persistence between diuretics and other major antihypertensive drug classes, when factors known to be associated with poor persistence are taken into account., Competing Interests: The authors have no conflicts of interest to disclose.

Objective: To describe the Swedish Primary Care Cardiovascular Database, SPCCD. Design. Longitudinal data from electronic medical records, linked to national registers. Setting. 48 primary healthcare centres in urban (south-western Stockholm) and rural (Skaraborg) regions in Sweden. Subjects. Patients diagnosed with hypertension 2001-2008., Main Outcome Measures: Blood pressure (BP) and impact of retrieval of data on BP levels, clinical characteristics, co-morbidity and pharmacological treatment., Results: The SPCCD contains 74 751 individuals, 56% women. Completeness of data ranged from > 99% for drug prescriptions to 34% for smoking habits. BP was recorded in 98% of patients during 2001-2008 and in 63% in 2008. Mean BP based on the last recorded value in 2008 was 142 ± 17/80 ± 13 mmHg. Digit preference in BP measurements differed between the two regions, p < 0.001. Antihypertensive drugs were prescribed in primary healthcare to 88% of the patients in 2008; however, when all prescribers were included 96% purchased their drugs. Cardiovascular co-morbidity and diabetes mellitus were present in 28% and 22%, respectively., Conclusion: This large and representative database shows that there is room for improvement of BP control in Sweden. The SPCCD will provide a rich source for further research of hypertension and its complications.

Purpose: To determine factors associated with low persistence in patients initiated on drug treatment for hypertension., Methods: Cohort study using medical records for patients with hypertension in 48 Swedish primary healthcare centres. Data were linked to national registers on dispensed drugs, hospitalizations, outpatient hospital consultations, deaths, migration, and socioeconomy. We identified 5225 patients (55 % women, mean age 61 years) initiated on antihypertensive drug treatment during 2006-2007. Persistence was measured for two years by the dispensed drugs. Patients with a gap of >30 days between end of dispensed supply and the next dispensed prescription were classified as non-persistent. This was calculated by Kaplan-Meier analysis. Cox proportional hazard regression was used to estimate hazard ratios for discontinuation. Potential predictors included age, gender, blood pressure before initiation of therapy, cardiovascular comorbidity, educational level, country of birth, and income., Results: Among patients with a dispensed first prescription, 26 % discontinued treatment during the first year, and a further 9 % discontinued during the second year. Discontinuation (all adjusted) was more common in men (P = 0.002) and in younger patients (30-49 years, P < 0.001). Systolic (P < 0.001) but not diastolic blood pressure was positively associated with persistence. Native-born Swedish citizens and patients born in the other Nordic countries had lower discontinuation rates than those born outside the Nordic countries (P < 0.001)., Conclusion: Major determinants of discontinuation of antihypertensive drug treatment are male sex, young age, mild-to-moderate systolic blood pressure elevation, and birth outside of Sweden.

The number of students requiring special education has been increasing in Finland all through the 2000s. Reading and writing problems are the most significant learning problems requiring supportive education among pupils of a lower form. Without a fluent ability to read and write a child's availability to information and learning are significantly restricted and the effect extends from social coping to getting on in working life. Although special education is the most important form of rehabilitation for dyslexia, home practice and support play an important role for the student's progress.

Data on saliva in coronary artery bypass graft (CABG) surgery patients are sparse. Understanding salivary parameters, however, may aid clinical decision making. We hypothesized that cardiac surgery might affect patients' salivary flow rates and buffering, salivary proteins, and microbial counts. A 3-year, open follow-up study was conducted examining salivary flow, its chemical composition, and acidogenic microbial counts in 89 CABG surgery patients. The changes in salivary flow and proteins between baseline and 3-year post-CABG surgery were assessed using paired t-test and, with respect to the median of number of drugs used daily, by use of a nonparametric rank sum test. The results showed no long-term change in salivary flow rates and buffering capacity. With the exception of salivary urea, IgA and IgM concentration, and lysozyme output, the differences in salivary proteins between baseline and 3-year post-CABG were not statistically significant. No difference was observed in saliva values between patients taking drugs below or above the median number of drugs. Acidogenic microbial counts remained the same throughout the study. In conclusion, the salivary flow rates and constituents did not practically change in patients who underwent CABG surgery during the 3-year follow-up.

The aim of the present study was to establish whether the early signs of various orofacial dysfunctions, malocclusions, or occlusal interferences can predict the development of temporomandibular dysfunction (TMD) in young adults. Forty-eight subjects referred for speech therapy and 49 controls participated in all four stages of this longitudinal study. The subjects were examined at the ages of 7, 10, 15, and 19 years. The phoniatrician diagnosed errors in place of articulation and problems in the movement and co-ordination of the speech articulators. Occlusion, TMD signs (palpatory tenderness of the masticatory muscles, and of temporomandibular joints (TMJ), jaw deviation on opening, and clicking), mandibular movement capacity and occlusal interferences were registered by the orthodontist. Multiple logistic regression models were applied in order to evaluate whether single signs of TMD at the age of 19 years were related to previous/present malocclusions or interferences, to misarticulations of speech, problems in oral motor skills, or other signs of TMD. The effect of gender was also considered. The results showed that excessive overjet was the only variable which seemed to consistently increase the risk of TMD. In addition, girls seemed to be more prone to the development of TMD than boys. Although, during growth, there were both local and central factors associated occasionally with TMD development, the predictive value of those variables in the estimation of the individual risk of TMD was rather small.

Objective: The objective of this study was to investigate if patients with severe heart disease (CHD patients) present more signs of dental infections than patients without heart disease (non-CHD patients), if serum inflammatory markers differ between the groups, and if there is a link between these and the oral health parameters., Methods: We performed clinical and radiologic dental examinations and collected serum samples of 256 patients with New York Heart Association class II-IV heart disease (CHD patients) and 250 non-CHD controls. Serum samples were analysed using pertinent methods in the clinical laboratory of the hospital, and the differences in serum biomarkers between CHD patients and non-CHD patients were examined using various statistical methods. A modified dental index (MDI) was constructed and used in the analyses., Results: CHD patients were significantly more likely to be edentulous (34.8% vs. 14.8%) and retain less natural teeth than non-CHD patients (8.6 vs. 17) (P <.001). In CHD patients the remaining teeth and supporting tissues were more often diseased. High MDI scores were significantly associated with CHD status (OR 1.31, CI 1.16-1.48), as was gingivitis (OR 3.37, CI 1.66-6.86), while the presence of deep periodontal pockets was not. Serum C-reactive protein and fibrinogen concentrations and blood erythrocyte sedimentation rates were higher in the CHD group. Also, H. pylori and Chlamydia antibodies were significantly higher in the CHD group., Conclusion: CHD patients presented with poorer oral health status than non-CHD patients. Serum inflammatory markers were significantly higher in the CHD patients compared to the non-CHD group. High MDI scores linked with risk of CHD.

Objective: Little is known about the dental health and health behavior of patients referred for open-heart surgery because of severe heart disease. Yet, coronary atherosclerosis has been suggested to be an inflammatory disease in which chronic dental infections may trigger pathogenic mechanisms in the walls of arteries. In epidemiological studies periodontal disease in particular has been linked with coronary heart disease (CHD)., Study Design: We set out to investigate by means of clinical examination, x-ray, and questionnaire the oral health status, health-related behavior, and conceptions of 256 CHD patients referred for open-heart surgery in the Kuopio University Hospital. The patients' heart disease was New York Heart Association grades II-IV. For comparison, 250 age- and sex-matched non-CHD patients were also studied. Differences between groups were analyzed conventionally and with the Total Dental Index (TDI), which uses linear modeling and logistic regression analyses to summarize periodontal factors and other signs of oral infections. We expected to find neglected dental care and worse oral health situation among the CHD patients., Results: Edentulousness was seen in 35% of the CHD group and in 15% of the non-CHD group (P < .001). The CHD group had significantly lower number of teeth (8.8 +/- 9.1) than the non-CHD group (17 +/- 10.5; P < .001). No dental appointment in the past 10 years was reported in 66% of the CHD patients and 35% of the non-CHD patients. Forty-nine percent of the CHD group and 69% of the non-CHD group had had a dental visit within the past 2 years (P < .001). Daily tooth brushing was reported by 46% of the CHD group and 56% of the non-CHD group (P < .05). Only 2% of the CHD group and 8% of the non-CHD group flossed daily (P < .001). TDI scores were significantly higher in the edentulous than in the dentate study groups (P < .001), but no difference was observed between CHD and non-CHD patients of the same dentate or edentulous status. Mean TDI score was 3.2 +/- 0.8 in edentulous CHD patients and 3.1 +/- 0.4 in edentulous non-CHD patients; the scores in the dentate patients were 2.5 +/- 0.9 in the CHD group and 2.4 +/- 2.0 in the non-CHD group. The TDI score appeared almost significant a predictor of CHD when used as a dependent variable in logistic regression analysis (P = .08)., Conclusion: Worse oral health status and less satisfactory oral health behavior were observed in the CHD patients than among the cardiologically healthy.

Changes in the morphology and functioning of the speech articulators were assessed in 118 children monitored from the age of 7 to 10 years, and associations between these variables and misarticulations were analyzed. The accuracy of articulatory movements and their coordination improved markedly. There was a relative delay in development of the motor coordination of boys who produced sounds too far posteriorly. Difficulties in tongue movements and their coordination increased the risk for the category of other misarticulations. Difficulties in motor coordination contributed to a lesser extent to articulatory speech disorders in 10-year-olds compared to 7-year-olds. Some new cases of inaccuracy of coordinating the movements refer to the liability of muscle coordination still at the age of 10.

Associations between different types of misarticulations and morphology as well as function of the speech articulators were assessed in 287 first-grade children. Sounds produced too far anteriorly evidently were due to immaturity of the articulatory speech movements, which showed a tendency to improve spontaneously with age. Sounds produced too far posteriorly correlated positively with problems in coordinating the movements of different muscles of the tongue, indicating a possible dyspractic origin. Children who had problems with lip tonus were prone to have laterally produced misarticulations.

Associations among several orofacial dysfunctions such as articulatory speech disorders, craniomandibular disorders (CMD) and problems in coordinating the orofacial muscles were examined in two groups of Finnish first-graders, i.e. children with and without speech disorders. In the whole sample of 287 subjects the mean age was 7.5 yr. A speech therapist diagnosed articulatory speech disorders and a phoniatrician examined the morphology and function of the articulators. Signs and symptoms of CMD, capacity for mandibular movement, and prevalence of occlusal interferences were examined by a dentist. Deviations in motor skills, but not in morphology of the articulators, were associated with speech disorders. The findings also suggested that capacity for mandibular movement, deviation of the jaw during maximal mouth opening and occlusal interferences were related to certain speech disorders among these 6-8 yr olds. Different orofacial dysfunctions appear to be associated with each other during growth.

Occurrence and type of articulatory speech disorders were studied in 157 7-year-old first-graders found to have articulatory disorders at school and referred for further treatment to the Department of Phoniatrics, University Central Hospital. The control group consisted of all 130 first-graders in two elementary schools in Kuopio. About one third of the control group had articulatory speech disorders, one fifth of them expressing need for speech therapy. In both groups distortions of the /s/-sound were the most common disorders, distortions of the /r/-sound being rather uncommon and those of the /l/-, /d/- and /t/-sounds very rare. Occurrence of articulatory speech disorders did not vary systematically with sex nor was it associated with handedness. Some spontaneous correction of /s/-disorders occurred, while /r/-disorders were rather resistant to early treatment. The results suggest the need for reevaluation of differential diagnostics and timing of speech therapy during kindergarten and elementary school.