Cigarette smoking gives more respiratory symptoms among women than among men. The Nord-Trondelag Health Study (HUNT)

STUDY OBJECTIVE

Studies have indicated that women are more vulnerable to the effect of tobacco smoking compared with men. The aim of this study was to explore the prevalence of reported respiratory symptoms and diseases according to smoking burden, age and sex.

DESIGN

Questionnaire in a cross sectional population based study.

SETTING

The BONT (Bronchial obstruction in Nord-Trondelag) study is part of a comprehensive health survey of all inhabitants aged above 19 years in the county of Nord-Trondelag, Norway, which was carried out from 1995 to 1997.

PARTICIPANTS

A total of 65 717 subjects, 71.3% of the total population aged 20-100, answered the main questionnaire.

MAIN RESULTS

In all, 12.7% men and 12.1% women reported episodes of wheezing or breathlessness during the past 12 months, 8.8% men and 8.4% women reported that they had or had had asthma, 7.5% men and 8.2% women had ever used asthma medication, and 4.0% men and 3.0% women reported chronic bronchitis. Thirty per cent of men and 31% of women were smokers, and average pack years of smoking were 15.9 and 10.3, respectively. Among previous and current smokers, significant more women reported episodes of wheezing or breathlessness, current asthma and persistent coughing compared with men with the same smoke burden (pack years) and daily number of cigarettes.

CONCLUSION

The prevalence of reported asthma and use of asthma medication was higher than reported in previous Scandinavian studies. Respiratory symptoms increased by smoking burden. Comparing the prevalence of symptoms and current asthma among women and men with the same smoke burden or daily cigarette consumption, women seemed to be more susceptible to the effect of tobacco smoking than men.

Cardiovascular disease and risk factors in persons with type 2 diabetes diagnosed in a large population screening: the Nord-Trøndelag Diabetes Study, Norway

OBJECTIVE

To study cardiovascular status and risk factors in persons with newly diagnosed type 2 diabetes and controls in a large population.

DESIGN

Case-control study.

SETTING

Population screening.

SUBJECTS

The screening of 74 499 individuals (88.1%), aged 20 years and older, in Nord-Trøndelag County, Norway, during 1984-86 detected 428 persons with undiagnosed diabetes according to the 1980 WHO criteria, of whom 205 attended a clinical follow-up examination assessing cardiovascular status and risk factors.

METHODS

For each of 205 cases, one control person matched by age and sex underwent the same clinical examination. Lipids, body mass index, waist/hip ratio, blood pressure, pulse rate, blood pressure medication, kidney function, cardiovascular disease, family history and lifestyle were recorded.

RESULTS

At the screening prior to the diagnosis of diabetes, those with diabetes reported poorer general health, less physical activity, more siblings with diabetes and more frequent use of antihypertensive medication. They had higher body mass index, systolic and diastolic blood pressure and pulse rate compared with controls. At the clinical evaluation, diabetics had higher urine albumin levels, increased waist/hip ratio, and higher total cholesterol/HDL cholesterol ratios than the controls. They also reported a greater incidence of angina pectoris and had more ECG changes.

CONCLUSIONS

Diabetics presented with more cardiovascular risk factors, angina pectoris and ECG changes than the controls, and they had an established metabolic syndrome more often than controls. These results suggest that prevention of cardiovascular disease in diabetics requires earlier diagnosis of the diabetes.

Adolescent occasional smokers, a target group for smoking cessation? the Nord-Trøndelag Health Study, Norway, 1995-1997

BACKGROUND

Adolescent smokers are often unsuccessful in quitting and difficult to retain in cessation programs. In health promotion, focusing on the right target groups is essential. Aim. The aim was to examine if adolescent occasional smokers differ from daily smokers, and if possible differences could be useful for targeted smoking cessation programs.

METHODS

Ninety-one percent of all teenagers attending junior high or high schools participated in a cross-sectional study, conducted in Nord-Trøndelag County, Norway, 1995-1997, including 8,460 students 13-18 years old. Information on smoking habits, education, after school activities, and parents was obtained by self-administered questionnaires.

RESULTS

Fifty-four percent of boys and 57% of girls had tried at least one cigarette. Of these, 36% of boys and 41% of girls were current smokers, half of whom reported occasional smoking. Students who had quit smoking had more often been occasional than daily smokers. Compared to daily smokers, occasional smokers participated in higher academic courses, were more engaged in organized activities and sports, had been drunk less often, and had better family role models.

CONCLUSION

Differences support potential utility of focusing on occasional smokers as a special target group in smoking cessation programs.

Prevalence of thyroid disease, thyroid dysfunction and thyroid peroxidase antibodies in a large, unselected population. The Health Study of Nord-Trondelag (HUNT)

OBJECTIVE

To examine the prevalence of thyroid disease and dysfunction including thyroid autoimmunity in Norway.

MATERIALS AND METHODS

All inhabitants 20 years and older (94009) in Nord-Trondelag were invited to participate in a health survey with a questionnaire and blood samples.

RESULTS

The prevalence of former diagnosed hyperthyroidism was 2.5% in females and 0.6% in males, hypothyroidism 4.8% and 0.9%, and goitre 2.9% and 0.4% respectively. In both sexes the prevalence increased with age. In individuals without a history of thyroid disease the median, 2.5 and 97.5 percentiles for TSH (mU/l) were 1.80 and 0.49-5.70 for females and 1. 50 and 0.56-4.60 for males. The TSH values increased with age. When excluding individuals with positive thyroid peroxidase antibodies (TPOAb) (>200U/ml), the 97.5 percentiles dropped to 3.60 mU/l and 3. 40 mU/l respectively. The prevalence of pathological TSH values in females and males were TSH >/=10mU/l 0.90% and 0.37%; TSH 4.1-9. 9mU/l 5.1% and 3.7%; and TSH</=0.05mU/l 0.45% and 0.20% respectively. The prevalence of positive TPOAb (>200U/ml) was 13.9% in females and 2.8% in males. In females the lowest percentage (7.9%) of positive TPOAb was seen with TSH 0.2-1.9mU/l and increased both with lower and higher levels of TSH. The percentage of males with positive TPOAb was lower than in females in all TSH groups except for those with TSH>10mU/l (85% TPOAb positive).

CONCLUSIONS

In spite of a high prevalence of recognised thyroid disease in the population a considerable number of inhabitants have undiagnosed thyroid dysfunction and also positive TPOAb.

[Pharmacological prevention of cardiovascular diseases in general practice]

BACKGROUND

In this paper the Norwegian College of General Practitioners, Working Group on Hypertension report recommendations for primary preventive drug treatment of elevated cardiovascular risk.

MATERIAL AND METHODS

Updated metaanalyses and randomised controlled trials are the main basis for the recommendations. The purpose of treating hypertension is prevention of cardiovascular diseases. Drug treatment with documented effect on morbidity and mortality is therefore recommended. We have also evaluated the cost effectiveness of drug treatment.

RESULTS

An estimate of the total risk of future cardiovascular disease is a necessary basis for treatment decisions. This paper presents tools for estimating total cardiovascular risk. Drug treatment is recommended if ten-year risk exceeds 20% or blood pressure equals or exceeds 170/100 mmHg. Drug treatments include antihypertensive, antithrombotic, antidiabetic and lipid-lowering drugs with documented effect on hard endpoints. Aspirin, thiazides, betablockers, metformin, calcium blockers, ACE inhibitors and statins are all drugs with documented effects on significant endpoints, but the costs of these treatments differ substantially.

INTERPRETATION

Drug treatment to prevent cardiovascular disease should be recommended for patients at significant risk of cardiovascular disease. Drugs with documented effect on morbidity and mortality should be used. Considerations of costs are important in treatment decisions.

[Life style advice provided by primary health care to prevent cardiovascular diseases]

BACKGROUND

The Working Group on Hypertension of the Norwegian College of General Practitioners reports in this paper on the documentation on behavioural advice in the prevention of cardiovascular disease. Emphasis is given to hypertension.

MATERIAL AND METHODS

The recommendations are mainly based on updated metaanalyses and randomised controlled trials. Hypertension is treated to prevent cardiovascular disease; that is why we put emphasis on documentation with significant end points. The validity of the documentation for general practice is assessed. We have also assessed whether certain methods or theories for behavioural change could be helpful to the general practitioner.

RESULTS

The value of advice against smoking, dietary advice (increased intake of grain products, vegetables, fruit, poultry and fish), and advice about exercise are well documented and applicable in general practice. Respect for the patient's autonomy and interest in the patients and their health-related habits seem to be important factors for improving doctor's chances of influencing patient behaviour.

INTERPRETATION

The value of life-style advice is well documented and should play an important role in clinical strategies to prevent cardiovascular disease in high-risk patients.

Implementing clinical guidelines in the treatment of diabetes mellitus in general practice. Evaluation of effort, process, and patient outcome related to implementation of a computer-based decision support system

OBJECTIVES

To evaluate the implementation of clinical guidelines for diabetes mellitus in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention.

METHODS

Randomized study with health center as unit. General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants. Seventeen health centers with 24 doctors and 499 patients with diabetes mellitus were in the intervention group and 12 health centers with 29 doctors and 535 patients were in the control group. Main outcome measures were group differences in fractions of patients without registrations (process evaluation) and mean group differences for the same variables (patient outcome evaluation).

RESULTS

Statistically significant group differences were experienced for fractions of patients without registration of cigarette smoking (intervention group, 82.6%; control group 94.5%), body mass index (78.2% vs. 93.0%), and sufficient registrations for calculation of risk score for myocardial infarction (91.1% vs. 98.3%); all during 18 months. Large center variations were shown for all variables. The only statistically significant group difference was -2.3 mm Hg (95% CI, -3.8, -0.8) in diastolic blood pressure in favor of the intervention group. Statistically insignificant differences in favor of the intervention group were HbA1c, -0.1% (95% CI, -0.4, 0.1), systolic blood pressure, -1.2 mm Hg (95% CI, -4.4, 2.0). Statistically insignificant differences in favor of the control group were fractions of smokers, +3.0% (95% CI, -4.0, 10.0), body mass index, +0.3 kg/m2 (95% CI, -0.8, 1.4), risk score in female +0.1 (95% CI, -5.1, 5.2), and risk score in male +2.6 (95% CI, -14.2, 19.5).

CONCLUSIONS

Implementation of clinical guidelines for diabetes mellitus in general practice, by means of a CDSS and several procedures for implementation, did not result in a clinically significant change in doctors' behavior or in patient outcome.

[Treatment of children with asthma--ideals and reality]

Children with bronchial asthma are the largest group of children with chronic disease in general practice. The aim of this study was to obtain information on morbidity, examination, and treatment in children with bronchial asthma. 102 children with current asthma, aged 7-15 years, participated in this study, which used a questionnaire, flow volume spirometry with beta2-agonist reversibility test, and two weeks of registrations of peak flow and symptom score. Most children had mild to moderate asthma; 60% had acceptable asthma control defined by a morbidity index. 64 children used either inhaled steroids or dinatriumcromoglycate prophylactic. 76 children had been examined by a paediatrician. Lung function measurements had been performed in 57 of 69 children with follow-up in general practice during the last 12 months. Allergy tests had been taken of 87 children. With respect to allergen exposure at home, only 30 children reported having an optimal home environment. Despite the extensive follow-up of children with asthma, our study indicates that the asthma control is not up to the standard set by current guidelines. By use of written treatment plans, and increasing knowledge of the disease, triggers and of the treatment of children and their parents, we probably would exploit the potential better. The recommendations and goals of the guidelines should, however, also be evaluated.

Health problems in teenage daily smokers versus nonsmokers, Norway, 1995-1997: the Nord-Trøndelag Health Study

Increased morbidity among teenage smokers has been reported, but specific current health problems and medication use other than of alcohol and narcotics have received less attention. The aim of this study was to examine the association between health problems and daily smoking in teenagers. Ninety percent of all teenagers attending junior high or high schools participated in a cross-sectional study conducted in Nord-Trøndelag County, Norway, 1995-1997; included were 8,040 students aged 13-18 years. Information on smoking habits, health problems, medication use, and use of health services was obtained in schools by self-administered questionnaire and by interview. Fifty-five percent of boys and 57% of girls had tried smoking, and 9% and 11%, respectively, reported current daily smoking. When compared with boys and girls who had never smoked, daily smoking among both sexes and all age groups was associated with significantly poorer perceived health, respiratory symptoms, headache, neck and shoulder pain, stomachache, nausea, frequent heartbeats, nervousness/restlessness, and sleep problems. Daily smokers used more medications and health services. Daily smoking by adolescents is already associated with multiple somatic health problems. Whether or not the association is causal, daily smoking identifies a group of adolescents with health problems for whom preventive strategies should also include medical and social support.

Physical activity and stroke mortality in women. Ten-year follow-up of the Nord-Trondelag health survey, 1984-1986

BACKGROUND AND PURPOSE

Few studies have reported a protective effect of physical activity on stroke in women, particularly among elderly women. This study was conducted to examine the association between different levels of leisure-time physical activity and stroke mortality in a large prospective study of middle-aged and elderly women.

METHODS

We conducted a 10-year mortality follow-up of women aged >/=50 years, free from stroke at baseline (n=14 101), who participated in the Nord-Trondelag Health Survey in Norway during 1984-1986. Main outcome measures were relative risk of stroke mortality according to increasing levels of physical activity, with the least active group used as reference.

RESULTS

In groups aged 50 to 69, 70 to 79, and 80 to 101 years, the relative risk of dying decreased with increasing physical activity, after adjustment for potentially confounding factors. In groups aged 50 to 69 and 70 to 79 years, the most active women had an adjusted relative risk of 0. 42 (95% CI, 0.24 to 0.75) and 0.56 (95% CI, 0.36 to 0.88), respectively. In the group aged 80 to 101 years, there was a consistent negative association with physical activity; the adjusted relative risk for the most active was 0.57 (95% CI, 0.30 to 1.09).

CONCLUSIONS

Physical activity was associated with reduced risk of death from stroke in middle-aged and elderly women. This association persisted after we excluded individuals with prevalent cardiovascular and cerebrovascular disease at baseline and women who died during the first 2 years of follow-up. These observations strengthen the evidence that physical activity should be part of a primary prevention strategy against stroke in women.

Rapid changes in the prevalence of obesity and known diabetes in an adult Norwegian population. The Nord-Trøndelag Health Surveys: 1984-1986 and 1995-1997

OBJECTIVE

To determine whether changes in mean BMI and the prevalence of obesity in a total adult population during a short (11-year) period were associated with changes in the prevalence of diabetes.

RESEARCH DESIGN AND METHODS

This study involved cross-sectional surveys of all inhabitants aged > or = 20 years of the county of Nord-Trøndelag from 1984 to 1986 (n = 85,100) and from 1995 to 1997 (n = 92,434). Attendance rates were 88.1 and 71.3%, respectively, and 90.0% in an additional survey of people aged 13-19 years from 1995 to 1997 (n = 9,593). Main outcome measures were age-specific mean BMI for the diabetic and nondiabetic subgroups and the prevalence of obesity and diabetes. For comparison, mean BMIs from 18 of 19 Norwegian counties for the group aged 40-42 years were examined.

RESULTS

Mean BMI increased from 27.2 to 29.0 kg/m2 in the diabetic population and from 25.1 to 26.3 kg/m2 in the nondiabetic population. The BMI distribution curve shifted to the right, but homogeneity was also reduced. A comparison with other Norwegian counties indicated that this increase occurred during the last 6 years between the surveys. The prevalence of obesity (BMI > or = 30 kg/m2) increased from 7.5 to 14% in nondiabetic men and from 13 to 18% in nondiabetic women. The increase was particularly great in men aged < 60 years and in women aged < 50 years. The overall prevalence of known diabetes increased between the two surveys (from 2.9 to 3.2%) but only in men. The largest increase was observed in the corresponding younger sex and age-groups.

CONCLUSIONS

A substantial increase in mean BMI and the prevalence of obesity occurred in the younger age-groups at the same time as an increase in the prevalence of diabetes. A greater increase in diabetes prevalence in this ethnically stable Western European population may follow if effective primary preventive strategies are not undertaken.

Implementing clinical guidelines in the treatment of hypertension in general practice. Evaluation of patient outcome related to implementation of a computer-based clinical decision support system

OBJECTIVE

To evaluate the implementation of clinical guidelines for hypertension in general practice by use of a computer-based clinical decision support system (CDSS) and a specific implementation strategy. Evaluation of patient outcome.

DESIGN

Randomised study with health centres as units. The intervention group had the CDSS installed and made ready for use, doctors and assistants were trained and received a user-manual, the doctors were offered telephone repetitions, a seminar in risk intervention and, at the same seminar, further demonstration of the CDSS. The doctors received baseline registrations with information of how they treated their own hypertensive patients, and use of the CDSS was checked repeatedly.

SETTING

General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants.

PARTICIPANTS

Seventeen health centres with 24 doctors and 984 patients in the intervention group. Data from 879 patients used in the final analyses. Twelve health centres with 29 doctors and 1255 patients in the control group. Data from 1119 patients used in the final analyses.

MAIN OUTCOME MEASURES

After an intervention period of 18 months, group differences in level of systolic and diastolic blood pressure, serum cholesterol, body mass index, and risk score for myocardial infarction were calculated, as well as group differences in fractions of smokers.

RESULTS

Significant group difference in favour of intervention group: diastolic blood pressure 1 mmHg (95% CI -1.89, -0.17). However, a significant baseline difference in systolic blood pressure in favour of control group of 2.7 mmHg (95% CI 1.0, 4.5) had been reduced to 1.2 mmHg (95% CI -0.6, 3.0) after intervention.

CONCLUSION

Implementation of clinical guidelines in the treatment of hypertensive patients in general practice by means of a CDSS and several other procedures for implementation did not affect patient outcome in any clinically significant way.

Case report: paraarticular soft-tissue osteoma of the hip

A case of paraarticular soft-tissue osteoma of the hip is presented. The patient is a 30-year-old white male with a two year history of progressive left hip pain. Plain film and cross-sectional imaging in conjunction with pathologic correlation are used to make the diagnosis. The lesion lacks the typical zoning pattern of myositis ossificans, shows no direct communication with native bone, and is extraarticular in location as opposed to synovial osteochondromatosis. Soft tissue osteomas most commonly occur around the knee, the foot, and the ankle. Soft tissue osteomas are rare tumors and this case is unusual in that it occurs around the hip.

Identification of incident stroke in Norway: hospital discharge data compared with a population-based stroke register

BACKGROUND AND PURPOSE

The validity of hospital discharge diagnoses is essential in improving stroke surveillance and estimating healthcare costs of stroke. The aim of this study was to assess sensitivity, positive predictive value, and accuracy of discharge diagnoses compared with a stroke register.

METHODS

A record linkage was made between a population-based stroke register and the discharge records of the hospital serving the population of the stroke register (n=70 000). The stroke register (including patients aged 15 and older and with no upper age limit), applied here as a "gold standard," was used to estimate sensitivity, positive predictive value, and accuracy of the discharge diagnoses classification. The length of stay in hospital by stroke patients was measured.

RESULTS

Identifying cerebrovascular diseases by hospital discharge diagnoses (International Classification of Diseases, 9th Revision [ICD-9], codes 430 to 438.9, first admission) lead to a substantial overestimation of stroke in the target population. Restricting the retrieval to acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436) gave an incidence estimate closer to the "true" incidence rate in the stroke register. Selecting ICD-9 codes 430 to 438 of cerebrovascular diseases gave the highest sensitivity (86%). The highest positive predictive value (68%) was achieved by selecting acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436), at the expense of a lower sensitivity (81%). Accuracy of ICD codes 430 to 438.9 (n=678) revealed the highest proportion of incident strokes identified by the acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436). Seventy-four percent of hospital discharge diagnoses classified as first-ever stroke kept the original diagnosis. Only 4.6% of the discharge diagnoses were classified as nonstroke diagnoses after validation. The estimation of length of stay in the hospital was improved by selection of acute stroke diagnoses from hospital discharge data (ICD-9 codes 430, 431, 434, and 436), which gave the same estimate of length of stay, a median of 8 days (2.5 percentile=0 and 97.5 percentile=56), compared with a median of 8 days (2.5 percentile=0 and 97.5 percentile=51) based on the stroke register.

CONCLUSIONS

Hospital discharge data may overestimate stroke incidence and underestimate the length of stay in the hospital, unless selection routines of hospital discharge diagnoses are restricted to acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436). If supplemented by a validation procedure, including estimates of sensitivity, positive predictive value, and accuracy, hospital discharge data may provide valid information on hospital-based stroke incidence and lead to better allocation of health resources. Distinguishing subtypes of stroke from hospital discharge diagnoses should not be performed unless coding practices are improved.

Implementing clinical guidelines in the treatment of hypertension in general practice

Discrepancies between clinical guidelines and clinical practice call for practical implementation strategies. This study evaluates the implementation of clinical guidelines for hypertension in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. We carried out a randomized study of general practice health centres in Sør- and Nord-Trøndelag counties in Norway (population 380000). A total of 17 health centres were included, with 24 doctors and 984 patients in the intervention group. Data from 887 patients was used in the analyses. There were 12 health centres with 29 doctors and 1255 patients in the control group. Data from 1127 control patients was used in the analyses. The main outcome measures were doctor's behaviour, measured by adherence to registration of recommended variables in the Norwegian clinical guidelines for hypertension. The aim of the intervention was to lower the fractions of patients without registrations. However, there were no clinically significant differences between the intervention group and the control group for fractions of patients without registration of blood pressure (intervention group 14.3%, control group 14.2%) or serum cholesterol (62.3% vs. 56.8%) during 12 months, nor, during 18 months, for fractions of patients without a registration of cigarette smoking (82.9% vs. 87.1%), cardiovascular inheritance (79.5% vs. 73.4%) and body mass index (81.5% vs. 89.2%). One or several variables necessary for calculation of risk score for myocardial infarction were missing in 91.7% of patients in the intervention group and 91.9% of patients in the control group. Large centre variations were shown for all variables. Implementation of clinical guidelines in the treatment of hypertensive patients in general practice, by means of a CDSS and several procedures for implementation did not result in clinically significant changes in the doctors' behaviour. Of importance are both the lack of user-friendliness of the specific CDSS and problems in performing time-consuming multidimensional procedures.

[Drugs in the treatment of asymptomatic risk conditions--better documentation is required]

This paper points to the dilemmas posed by the lack of longitudinal studies of morbidity and mortality, or of side-effects, of several drugs widely used in treatment of asymptomatic risk factors. New drugs and new indications make large groups eligible for treatment, i.e. for mildly elevated blood pressure or cholesterol levels, impaired glucose tolerance and risk of osteoporosis. The treatment of people with asymptomatic elevated risk factors differs in point of principle from the treatment of diseases, symptoms or complaints: The patient has no subjective feeling about his or her condition; the health risk is usually lower; there are no good evaluation measures for the treatment; and the risk that side-effects outweigh the benefits is greater. This makes high quality treatment and good information to patients even more important than in ordinary practice. More knowledge about effects with regard to morbidity and mortality and about long-term side-effects is necessary. Doctors should prefer drugs for which the effects are documented, and give patients with the highest health risk top priority.

Correlates of subjective well-being in stroke patients

BACKGROUND AND PURPOSE

Data on survival and functioning after stroke needs to be supplemented by measures emphasizing the patients' subjective perception. We studied (1) subjective well-being (SWB) as a latent variable in a common-factor model with four items, (2) the reliability of these four items, and (3) variables related to SWB in stroke patients.

METHODS

Data on all stroke patients (n=1417) and a random subsample of stroke-free individuals of similar age (n=1439) were collected from the Nord-Trøndelag Health Survey, a cross-sectional study of 74977 persons. Based on a two-sample factor analysis model, scores of SWB were calculated, and variables explaining SWB were studied in a regression model.

RESULTS

Four items were a priori believed to measure SWB as a latent variable ("satisfaction," "strength," "calmness," and "cheerfulness"). This was confirmed by factor analysis. The reliability of these items (the proportion of the variance of the items that can be explained by the common factor) was between .42 and .53. Regression analyses showed a significant effect of having had a stroke, gender (lower SWB in men), age (increasing SWB with increasing age), perceived general health, nervousness, loneliness, sleep problems, social support, and use of analgesics. There was no statistical interaction between these variables and having had a stroke.

CONCLUSIONS

Higher SWB after stroke relates to female gender, older age, good general and mental health, and a firm social network.

Treatment of diabetes mellitus--physicians' adherence to clinical guidelines in Norway

OBJECTIVE

To assess general practitioners' current adherence to the Norwegian clinical guidelines for the treatment of diabetes mellitus.

DESIGN

Descriptive, retrospective registration of information from patient records of one year; 7 November 1993 to 7 November 1994. In addition, mailed questionnaire to examine the representativeness of the participating doctors.

SETTING

General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants.

PARTICIPANTS

In one year 1119 patients were registered with the diagnosis of diabetes mellitus in the records of 56 general practitioners. The patients were 53% women and 47% men; 51% were 70 years or older.

MAIN OUTCOME MEASURES

Levels of HbA1c and blood pressure in accordance with the recommendations of the Norwegian clinical guidelines for diabetes mellitus. Fractions of patients with a measured HbA1c, blood pressure, and serum cholesterol in one year.

RESULTS

At least one HbA1c was recorded in 77% of the diabetic patients during the specified year. In patients under 70 years of age, 56% had HbA1c above the recommended treatment level of 7.5%. In patients 70 years of age or older, 36% were above the recommended limit of 8.5%. At least one blood pressure was recorded in 79% of the patients during the specified year. In patients under 70 years of age, 53% had a systolic blood pressure above the recommendations of 140 mmHg, and 22% had a diastolic blood pressure above the recommendations of 90 mmHg. Serum cholesterol was not recorded during the specified year in 75% of the patients.

CONCLUSION

There are still major discrepancies between current practice and the intentions laid down in the Norwegian clinical guidelines. A discussion of alternative methods for implementation and evaluation of the efficacy of clinical guidelines is needed.

Epidemiology of stroke in Innherred, Norway, 1994 to 1996. Incidence and 30-day case-fatality rate

BACKGROUND AND PURPOSE

In Norway, as well as other industrialized countries, mortality from stroke has declined over the past decades. Data on stroke morbidity are lacking. This study was conducted to determine the incidence, case fatality, and risk factors of stroke in a defined Norwegian population.

METHODS

During the period 1994 to 1996, a population-based stroke registry collected uniform information about all cases of first-ever and recurrent stroke occurring in people aged > or = 15 years in the region of Innherred in the central part of Norway (target population 70,000), where the prevalence of cardiovascular risk factors was screened in 1984 to 1986 and 1995 to 1997.

RESULTS

During the 2 years of registration (September 1, 1994, to August 31, 1996), 432 first-ever (72.8%) and 161 recurrent (27.2%) strokes were registered. The crude annual incidence rate was 3.12/1000 (2.85/1000 for males and 3.38/1000 for females). Adjusted to the European population, the annual incidence rate of first-ever stroke was 2.21/1000. The annual incidence rate of cerebral infarction was 2.32/1000, intracerebral hemorrhage 0.32/1000, subarachnoid hemorrhage 0.19/1000, and unspecified stroke 0.38/1000. The 30-day case-fatality rate was 10.9% for cerebral infarction, 37.8% for intracerebral hemorrhage, and 50.0% for unspecified stroke. Fourteen percent of the patients were found outside the hospital, and only 50% of the suspected stroke cases in the hospital (at admission or reviewed discharge diagnosis of ICD-9 codes 430 to 438) fitted the final inclusion criteria.

CONCLUSIONS

This first population-based stroke register in Norway revealed incidence rates of stroke similar to other Scandinavian countries, and comparison between other European countries did not indicate regional variations within Western Europe.

BRCA1 sequence analysis in women at high risk for susceptibility mutations. Risk factor analysis and implications for genetic testing

CONTEXT

A mutation in the BRCA1 gene may confer substantial risk for breast and/or ovarian cancer. However, knowledge regarding all possible mutations and the relationship between risk factors and mutations is incomplete.

OBJECTIVES

To identify BRCA1 mutations and to determine factors that best predict presence of a deleterious BRCA1 mutation in patients with breast and/or ovarian cancer.

DESIGN

A complete sequence analysis of the BRCA1 coding sequence and flanking intronic regions was performed in 798 women in a collaborative effort involving institutions from the United States, Italy, Germany, Finland, and Switzerland.

PARTICIPANTS

Institutions selected 798 persons representing families (1 person for each family) thought to be at elevated a priori risk of BRCA1 mutation due to potential risk factors, such as multiple cases of breast cancer, early age of breast cancer diagnosis, and cases of ovarian cancer. No participant was from a family in which genetic markers showed linkage to the BRCA1 locus.

MAJOR OUTCOME MEASURES

Sequence variants detected in this sample are presented along with analyses designed to determine predictive characteristics of those testing positive for BRCA1 mutations.

RESULTS

In 102 women (12.8%), clearly deleterious mutations were detected. Fifty new genetic alterations were found including 24 deleterious mutations, 24 variants of unknown significance, and 2 rare polymorphisms. In a subset of 71 Ashkenazi Jewish women, only 2 distinct deleterious mutations were found: 185delAG in 17 cases and 5382insC in 7 cases. A bias in prior reports for mutations in exon 11 was revealed. Characteristics of a patient's specific diagnosis (unilateral or bilateral breast cancer, with or without ovarian cancer), early age at diagnosis, Ashkenazi Jewish ethnicity, and family history of cancer were positively associated with the probability of her carrying a deleterious BRCA1 mutation.

CONCLUSIONS

Using logistic regression analysis, we provide a method for evaluating the probability of a woman's carrying a deleterious BRCA1 mutation for a wide range of cases, which can be an important tool for clinicians as they incorporate genetic susceptibility testing into their medical practice.

Fifteen years with clinical guidelines in the treatment of hypertension--still discrepancies between intentions and practice

OBJECTIVE

To assess physicians' current adherence to the Norwegian clinical guidelines for the treatment of hypertension.

DESIGN

Descriptive, retrospective registration of information from patient records of one specified year. In addition, mailed questionnaire to examine the representativeness of the participating doctors.

SETTING

General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants.

PATIENTS

In one year 2468 patients were registered with the diagnosis of hypertension in the records of 56 general practitioners. The patients were 57% women and 43% men; 41% were 70 years or older.

MAIN OUTCOME MEASURES

Levels of blood pressure in accordance with the recommendations of the Norwegian clinical guidelines for hypertension. Fractions of patients with a measured blood pressure and serum cholesterol in one year.

RESULTS

At least one blood pressure was recorded in 95% of the hypertensive patients during the specified year. The systolic blood pressure was 140 mmHg or less in 25% and 160 mmHg or less in 65%, while the diastolic blood pressure was 90 mmHg or less in 61%. According to the Norwegian clinical guidelines for systolic blood pressure, 29% of the women and 21% of the men were above recommended levels for treatment. With respect to the diastolic blood pressure, the figures were 38% for women and 40% for men. Patients under 60 years of age were often not treated according to the recommendations. Serum cholesterol was not recorded during the specified year in 68% of the total group, nor in 55% of patients aged 65 years or younger.

CONCLUSION

There are still major discrepancies between current practice and the intentions laid down in the Norwegian clinical guidelines. A discussion of alternative methods for implementation and for evaluation of the efficacy of clinical guidelines is needed.

Prevalence of known and previously unknown diabetes mellitus and impaired glucose tolerance in an adult Norwegian population. Indications of an increasing diabetes prevalence. The Nord-Trøndelag Diabetes Study

OBJECTIVE

To establish the prevalence of known and undiagnosed diabetes mellitus and impaired glucose tolerance in a representative Norwegian adult population according to the 1980 World Health Organization Expert Committee diagnostic criteria.

DESIGN

Screening survey applying questionnaire and non-fasting blood glucose followed by a fasting and an oral glucose tolerance test.

SETTING

The county of Nord-Trøndelag, Norway, 1984-86.

SUBJECTS

All inhabitants aged > or = 20 years (85,100); 90.3% participated. For previously unknown diabetes: all inhabitants > or = 40 years (53,001)--participation rate 84.7%.

MAIN OUTCOME MEASURE

Prevalence.

RESULTS

The prevalence of previously known diabetes was 2.6% in men and 3.2% in women. Total diabetes prevalence > or = 40 years was 4.8% in men and 5.6% in women. The prevalence increased continuously with age until 90 years. One patient in five was previously undiagnosed. Impaired glucose tolerance in those with an abnormal non-fasting value was rare; only 0.9% in men and 0.2% in women. The prevalence of known diabetes was three times higher than 20-30 years ago and four times higher than 50 years ago. Except for known diabetes in the very old the prevalence corresponded well with recent Nordic studies.

IMPLICATIONS

The present diabetes prevalence was so high that interested general practitioners will get sufficient experience in follow-up of diabetic patients to facilitate a good quality of the care.