Characteristics and Outcomes of 79 Patients with an Insulinoma: A Nationwide Retrospective Study in Finland

OBJECTIVE

Insulinomas are rare pancreatic tumours. Population-based data on their incidence, clinical picture, diagnosis, and treatment are almost nonexistent. The aim of this study was to clarify these aspects in a nationwide cohort of insulinoma patients diagnosed during three decades.

DESIGN AND METHODS

Retrospective analysis on all adult patients diagnosed with insulinoma in Finland during 1980-2010.

RESULTS

Seventy-nine patients were diagnosed with insulinoma over the research period. The median follow-up from diagnosis to last control visit was one (min 0, max 31) year. The incidence increased from 0.5/million/year in the 1980s to 0.9/million/year in the 2000s (p = 0.002). The median diagnostic delay was 13 months and did not change over the study period. The mean age at diagnosis was 52 (SD 16) years. The overall imaging sensitivity improved from 39% in the 1980s to 98% in the 2000s (p < 0.001). Seventy-one (90%) of the patients underwent surgery with a curative aim, two (3%) had palliative surgery, and 6 (8%) were inoperable. There were no significant differences in the types of surgical procedures between the 1980s, 1990s, and 2000s; tumour enucleations comprised 43% of the operations, distal pancreatic resections 45%, and pancreaticoduodenectomies 12%, over the whole study period. Of the patients who underwent surgery with a curative aim, 89% had a full recovery. Postoperative complications occurred in half of the patients, but postoperative mortality was rare.

CONCLUSIONS

The incidence of insulinomas has increased during the past three decades. Despite the improved diagnostic options, diagnostic delay has remained unchanged. To shorten the delay, clinicians should be informed and alert to consider the possibility of hypoglycemia and insulinoma, when symptomatic attacks are investigated in different sectors of the healthcare system. Developing the surgical treatment is another major target, in order to lower the overall complication rate, without compromising the high cure rate of insulinomas.

[Should school children receive pertussis vaccine?]

BACKGROUND

A study comparing diphtheria immunity in Norwegian and Russian schoolchildren indicated low immunity against diphtheria in Norwegian children before the booster dose given at age 11 years. The pertussis epidemic in Norway 1997-98 demonstrated decreasing vaccine immunity from age 5-6 years. The possibility of improving immunity against both diseases by a booster dose during early school age is therefore under consideration.

MATERIAL AND METHODS

Immune response and adverse events were studied after a combined vaccine against diphtheria, tetanus, pertussis (acellular) and poliomyelitis (DTPa-IPV) given at seven years of age, and a combined vaccine against diphtheria, tetanus and pertussis (acellular) (DTPa) at 11 years of age, in two parallel trials including 124 and 83 participants respectively.

RESULTS

The trials confirmed that the diphtheria immunity is lower than it ideally should be in more than 40% of children before the booster dose at age 11. Pertussis immunity is difficult to assess because there is no clear relationship between antibody levels and protection. All study participants responded well to all vaccine components. The 11-year-old children reported higher occurrence of adverse events than the 7-year-olds. All adverse events were brief and none were serious.

INTERPRETATION

The results indicate that a booster dose of DTPa-IPV in early school age would give better protection against diphtheria and pertussis in Norwegian schoolchildren, without unacceptable side effects.

[Physicians as leaders. Evaluation of a leadership training program for physicians (Medled)]

In September 1990, 40 doctors started a two year management training programme consisting of six one week courses organised by the Norwegian Medical Association. The programme was evaluated, and this article presents the results of two of the methods, used for evaluation: the first an interview with 12 participants, and the second a questionnaire answered by participants, colleagues at the same department and colleagues at other hospitals (a control group) before and after the course. Compared with colleagues from the same department and from the control group the participants had changed their attitude towards important questions of management. They had become more concerned about the importance of motivating the staff, that the department should give priority to the hospital's objectives in preference to own interests, and that the ultimate responsibility for the department should reside in one person and this person should be a doctor with a relevant specialty. The results of the questionnaire survey are confirmed by the results of the interviews. In addition the results of the interviews suggest that, during the management training programme, the participants had changed from an individual-oriented to a more group-oriented style of management.

[Quality assurance of municipal health services]

The article describes what can be done to improve quality in the Norwegian primary health services, seen from the point of view of the municipal health officer. Quality assurance is particularly important in the primary health services for the following reasons: They, i.e. the primary health services constitute a major part of the total health services, and they are unique by being a basic front-line service consisting of many small units. Compared with the rest of the health services, many of the personnel employed at these units are not fully qualified. As a consequence, we argue that setting quality standards and ensuring and improving quality in patient care must be an integrated part of the work of all primary health care personnel. Ensuring quality has been a major issue for the national health authorities in recent years, but has not yet been incorporated as a routine in the services. We give six examples where quality assurance is relevant, with references from research.