Accuracy of surgical complication rate estimation using ICD-10 codes

Background

The ICD‐10 codes are used globally for comparison of diagnoses and complications, and are an important tool for the development of patient safety, healthcare policies and the health economy. The aim of this study was to investigate the accuracy of verified complication rates in surgical admissions identified by ICD‐10 codes and to validate these estimates against complications identified using the established Global Trigger Tool (GTT) methodology.

Methods

This was a prospective observational study of a sample of surgical admissions in two Norwegian hospitals. Complications were identified and classified by two expert GTT teams who reviewed patients' medical records. Three trained reviewers verified ICD‐10 codes indicating a complication present on admission or emerging in hospital.

Results

A total of 700 admissions were drawn randomly from 12 966 procedures. Some 519 possible complications were identified in 332 of 700 admissions (47·4 per cent) from ICD‐10 codes. Verification of the ICD‐10 codes against information from patients' medical records confirmed 298 as in‐hospital complications in 141 of 700 admissions (20·1 per cent). Using GTT methodology, 331 complications were found in 212 of 700 admissions (30·3 per cent). Agreement between the two methods reached 83·3 per cent after verification of ICD‐10 codes. The odds ratio for identifying complications using the GTT increased from 5·85 (95 per cent c.i. 4·06 to 8·44) to 25·38 (15·41 to 41·79) when ICD‐10 complication codes were verified against patients' medical records.

Conclusion

Verified ICD‐10 codes strengthen the accuracy of complication rates. Use of non‐verified complication codes from administrative systems significantly overestimates in‐hospital surgical complication rates.

Code correctly

Risk Factors for Complications following Introduction of Radical Surgery for Colon Cancer: A Consecutive Patient Series

BACKGROUND

Rectal cancer surgery is standardized, resulting in improved survival. Colon cancer has fallen behind and therefore more radical surgical techniques have been introduced. One technique is complete mesocolic excision. The aim of this article was to study the complications after the introduction of standardized complete mesocolic excision in a single center.

METHODS

Complete mesocolic excision was introduced in 2007, and data were collected from 286 patients prior to surgery (2007-2010). The surgeon decided on open or laparoscopic surgery. Follow-up information was recorded until 31 December 2015. Complications were classified according to a modified Clavien-Dindo classification.

RESULTS

Complications occurred in 47%, severe complications (grade III and IV) in 15%. In-hospital mortality was 3.5%. A total of 142 patients (49.7%) were operated by open surgery. Logistic regression revealed anemia (p = 0.001), open surgery (p < 0.001), and long operating time (p < 0.001) as significant factors for complications in general. Multinomial logistic regression revealed that severe complications occurred more often in males (odds ratio: 2.56; 95% confidence interval: 0.98-6.68), patients with anemia (odds ratio: 3.49; 95% confidence interval: 1.27-9.60), elevated body mass index (odds ratio: 1.14; 95% confidence interval: 1.02-1.28), and in open surgery (odds ratio: 9.95; 95% confidence interval: 2.58-38.35). Age was not associated with severe complications. Survival was not significantly influenced by complications. Overall survival (5 years) was 90% among patients with complications and 92% among those without complications.

CONCLUSION

Severe complications following the introduction of complete mesocolic excision are patient dependent and related to open surgery. Patients selected for laparoscopy had less number of complications; therefore, introducing complete mesocolic excision by laparoscopy is justified. Identification of these factors can improve selection of appropriate surgical approach and postoperative patient safety.

Measured acoustic intensities for clinical diagnostic ultrasound transducers and correlation with thermal index

OBJECTIVES

To investigate if the thermal index for bone (TIB) displayed on screen is an adequate predictor for the derated spatial-peak temporal-average (I_SPTA.3 ) and spatial-peak pulse-average (I_SPPA.3 ) acoustic intensities in a selection of clinical diagnostic ultrasound machines and transducers.

METHODS

We calibrated five clinical diagnostic ultrasound scanners and 10 transducers, using two-dimensional grayscale, color Doppler and pulsed-wave Doppler, both close to and far from the transducer, with a TIB between 0.1 and 4.0, recording 103 unique measurements. Acoustic measurements were performed in a bespoke three-axis computer-controlled scanning tank, using a 200-μm-diameter calibrated needle hydrophone.

RESULTS

There was significant but poor correlation between the acoustic intensities and the on-screen TIB. At a TIB of 0.1, the I_SPTA.3 range was 0.51-50.49 mW/cm² and the I_SPPA.3 range was 0.01-207.29 W/cm² . At a TIB of 1.1, the I_SPTA.3 range was 19.02-309.44 mW/cm² and the I_SPPA.3 range was 3.87-51.89 W/cm² .

CONCLUSIONS

TIB is a poor predictor for I_SPTA.3 and I_SPPA.3 and for the potential bioeffects of clinical diagnostic ultrasound scanners. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Population-based study on resection rates and survival in patients with colorectal liver metastasis in Norway

Background

Detailed knowledge about the proportion of patients with colorectal liver metastases (CLM) undergoing resection is sparse. The aim of this study was to analyse cumulative resection rates and survival in patients with CLM.

Methods

For this population-based study of patients developing CLM during 2011–2013, data were extracted from the Norwegian Patient Registry and the Cancer Registry of Norway.

Results

A total of 2960 patients had CLM; their median overall survival was 10·9 months. Liver resection was performed in 538 patients. The cumulative resection rate was 20·0 per cent. The cumulative resection rate was 23·3 per cent in patients aged less than 40 years, 31·1 per cent in patients aged 40–59 years, 24·7 per cent in those aged 60–74 years, 17·9 per cent in those aged 75–79 years and 4·7 per cent in patients aged 80 years or more (P &lt; 0·001). In multivariable analysis, resection rate was associated with age, extrahepatic metastases, disease-free interval and geographical region. Overall survival after diagnosis of CLM was affected by liver resection (hazard ratio (HR) 0·54, 95 per cent c.i. 0·34 to 0·86), rectal cancer (HR 0·82, 0·74 to 0·90), metachronous disease (HR 0·66, 0·60 to 0·74), increasing age (HR 1·32, 1·28 to 1·37), region, and extrahepatic metastases (HR 1·90, 1·74 to 2·07). Three- and 4-year overall survival rates after hepatectomy were 73·2 and 54·8 per cent respectively.

Conclusion

The cumulative resection rate in patients with CLM in Norway between 2011 and 2013 was 20 per cent. Resection rates varied across geographical regions, and with patient and disease characteristics.

Subjective health complaints predict functional outcome six months after stroke

OBJECTIVES

Cerebrovascular stroke is a main cause of lasting disability in older age, and initial stroke severity has been established as a main determinant for the degree of functional loss. In this study, we searched for other predictors of functional outcome in a cohort of stroke patients participating in an early supported discharge randomised controlled trial.

METHODS

Thirty candidate variables related either to premorbid history or to the acute stroke were examined by ordered logistic regression in 229 stroke patients. Dependent variables were modified Rankin Scale (mRS) at 6 months and mRS change from baseline to 6 months.

RESULTS

For mRS at 6 months, Barthel Index at stable baseline post-stroke was the main predictor, with sex, age, previous cerebrovascular disease, previous peripheral artery disease and the necessity for tube feeding in the acute phase also contributing to the final model. For mRS change, only age and previous cerebrovascular disease were significant predictors. Prestroke subjective health complaints added significantly to all final models concurrently with sex losing its predictive power.

CONCLUSIONS

Initial stroke severity was the main predictor of functional outcome. Subjective health complaints score was a potent predictor for both outcome and improvement from baseline to 6 months and at the same time ameliorated the predictive impact of sex. The poorer functional prognosis for women after stroke may therefore be related to their higher load of subjective health complaints rather than to their sex itself. Treating these complaints may possibly improve the functional prognosis.

Postinfectious and sporadic functional gastrointestinal disorders have different prevalences and rates of overlap: results from a controlled cohort study 3 years after acute giardiasis

BACKGROUND

Irritable bowel syndrome (IBS) is a common complication following gastroenteritis, and a high prevalence of postgiardiasis IBS has previously been reported. This study aims to investigate the prevalence, adjusted relative risk (RRadj), and overlap of different functional gastrointestinal disorders (FGID) according to Rome III criteria following infection with Giardia lamblia.

METHODS

All patients ≥18 years of age with verified giardiasis during an outbreak in 2004, and a control group matched by age and gender, were mailed a questionnaire 3 years later.

KEY RESULTS

The prevalence of functional dyspepsia (FD) was 25.9% in the exposed and 6.9% in the control group, RRadj: 3.9 (95% confidence intervals [CI]: 3.1-4.8). The prevalence of IBS was 47.9% and 14.3%, respectively, with RRadj: 3.4 (95% CI: 3.0-3.8). Prevalence of other gastrointestinal symptoms ranged from 70.0% vs 39.7% for bloating (RRadj: 1.8) to 8.3% vs 2.9% for nausea (RRadj: 3.0) in the Giardia and the control group, respectively. Among individuals fulfilling criteria for IBS 44% in the exposed group and 29% in the control group also fulfilled criteria for FD. IBS subtypes based on Rome III criteria (stool consistency) showed poor agreement with subtypes based on frequency of bowel movements (Kappa-values: 0.17 and 0.27).

CONCLUSIONS & INFERENCES

There were high prevalences and RRs of IBS, FD and other gastrointestinal symptoms following acute giardiasis, and a high degree of overlap between the disorders. The agreement between different IBS subtype criteria varied, and there were also differences between the exposed and control group.

Quality of Life and Pain in Patients with Acute Cholecystitis

Background:

Acute cholecystitis carries a higher risk of subsequent gallstone related events than symptomatic, non-complicated disease. However, it is largely unknown to what extent non-operative treatment will affect the patient's well-being as no trial has studied the possible consequences on pain and quality of life. Our aim was to study in a randomized trial how observational treatment (watchful waiting) compared to cholecystectomy.

Methods:

Sixty-four patients with acute cholecystitis were randomized to observation or cholecystectomy. All gallstone related events were registered and patients answered questionnaires on quality of life (PGWB and NHP) and pain (Pain score and VAPS) at randomization and at 6, 12 and 60 months later.

Results:

Patients were followed-up for a median of 67 months. Ten of 33 patients (30 %, 95 % CI 15 %−46 %) patients randomized to observation and 27 of 31 (87 %, 95 % CI 75 %−99 %) of patients randomized to operation had a cholecystectomy. Twelve of 33 (36 %, 95 % CI 20 %−53 %) patients in the observation group had a gallstone related event compared to 6 of 31 (19 %, 95 % CI 5%−33 %) patients in the operation group, but the difference was not significant. When patients were grouped according to randomization or actual operative outcome (+/− cholecystectomy), we did not find any significant differences in pain or quality of life measurements.

Conclusion:

Although conservative treatment of AC carried a certain but not significantly increased risk of subsequent gallstone related events, this did not influence the symptomatic outcome as assessed by quality of life and pain measurements. Thus, we argue that conservative (non-operative) treatment and observation of AC is an acceptable option and should at least be considered in elderly and frail patients.

Strain Elastography Evaluation of Rectal Tumors: Inter- and Intraobserver Reproducibility

PURPOSE

Elastography is a promising method for the identification and differentiation of malignant tissue in several organ systems. The primary aim was to evaluate the inter- and intraobserver reproducibility of endorectal strain elastography differentiation of adenomas and adenocarcinomas. The secondary aim was to compare the performance of strain elastography to endorectal ultrasonography (ERUS) examinations.

MATERIALS AND METHODS

Consecutive inclusion of 95 ERUS examinations and 110 elastography video loops with ERUS overlay mode. Video loops were randomized and evaluated by eight observers on two separate occasions. Observers were blinded to all clinical information except the circumferential location of the tumor. A continuous visual analog scale (VAS) and a categorical scale (W-score) were used for elastography evaluation. ERUS loops were T-staged according to the TNM classification system. Histopathological evaluation of surgical resection specimen was used as the reference standard.

RESULTS

Strain elastography visual evaluation yielded intraobserver variability from 0.86 to 0.97 and interobserver variability of 0.99. VAS strain elastography differentiation of adenomas (pT0) and adenocarcinomas (pT1 - 4) yielded sensitivity, specificity, accuracy, positive and negative predictive values of 0.94, 0.71, 0.89, 0.92 and 0.78, respectively. The corresponding ERUS values were 0.83, 0.64, 0.79, 0.88 and 0.54, respectively.

CONCLUSION

Visual evaluation of elastography loops is highly reproducible in an offline setting with blinded observers, and correlates significantly with pT-stages. Strain elastography performs better than ERUS and might consequently improve staging.

Can the cardiovascular family history reported by our patients be trusted? The Norwegian Stroke in the Young Study

Background and purpose

Family history (FH) is used as a marker for inherited risk. Using FH for this purpose requires the FH to reflect true disease in the family. The aim was to analyse the concordance between young and middle‐aged ischaemic stroke patients' reported FH of cardiovascular disease (CVD) with their parents' own reports.

Methods

Ischaemic stroke patients aged 15–60 years and their eligible parents were interviewed using a standardized questionnaire. Information of own CVD and FH of CVD was registered. Concordance between patients and parents was tested by kappa statistics, sensitivity, specificity, predictive values and likelihood ratios. Regression analyses were performed to identify patient characteristics associated with non‐concordance of replies.

Results

There was no difference in response rate between fathers and mothers (P = 0.355). Both parents responded in 57 cases. Concordance between patient and parent reports was good, with kappa values ranging from 0.57 to 0.7. The patient‐reported FH yielded positive predictive values of 75% or above and negative predictive values of 90% or higher. The positive likelihood ratios (LR+) were 10 or higher and negative likelihood ratios (LR−) were generally 0.5 or lower. Interpretation regarding peripheral arterial disease was limited due to low parental prevalence. Higher age was associated with impaired concordance between patient and parent reports (odds ratio 1.05; 95% confidence interval 1.01–1.09; P = 0.020).

Conclusions

The FH provided by young and middle‐aged stroke patients is in good concordance with parental reports. FH is an adequate proxy to assess inherited risk of CVD in young stroke patients.

Interferon gamma (IFN-γ)-mediated inflammation and the kynurenine pathway in relation to risk of hip fractures: the Hordaland Health Study

The cytokine interferon gamma (IFN-γ) stimulates neopterin release and tryptophan degradation into kynurenines through the kynurenine pathway. High levels of neopterin were associated with increased hip fracture risk, as were some of the kynurenines, suggesting a role of IFN-γ-mediated inflammation in the processes leading to hip fracture.

INTRODUCTION

Low-grade systemic inflammation has been associated with bone loss and risk of fractures. Interferon gamma (IFN-γ) initiates macrophage release of neopterin and also stimulates degradation of tryptophan along the kynurenine pathway as part of cell-mediated immune activation. Plasma neopterin and the kynurenine/tryptophan ratio (KTR) are thus markers of IFN-γ-mediated inflammation. Risk of hip fracture was investigated in relation to markers of inflammation and metabolites in the kynurenine pathway (kynurenines).

METHODS

Participants (71 to 74 years, N = 3,311) in the community-based Hordaland Health Study (HUSK) were followed for hip fractures from enrolment (1998-2000) until 31 December 2009. Plasma C-reactive protein (CRP), neopterin, KTR, and six kynurenines were investigated as predictors of hip fracture, using Cox proportional hazards regression analyses.

RESULTS

A hazard ratio (HR) of 1.9 (95% confidence interval (CI) 1.3-2.7) for hip fracture was found in the highest compared to the lowest quartile of neopterin (p trend across quartiles <0.001). CRP and KTR were not related to hip fracture risk. Among the kynurenines, a higher risk of fracture was found in the highest compared to the lowest quartiles of anthranilic acid and 3-hydroxykynurenine. For subjects in the highest quartiles of neopterin, CRP, and KTR compared to those in no top quartiles, HR was 2.5 (95% CI 1.6-4.0).

CONCLUSIONS

This may indicate a role for low-grade immune activation in the pathogenic processes leading to hip fracture.

Interferon (IFN)-γ-mediated inflammation and the kynurenine pathway in relation to bone mineral density: the Hordaland Health Study

The risk of osteoporosis increases in inflammatory disorders. In cell-mediated immune activation, interferon (IFN)-γ stimulates macrophage release of neopterin and increases the activity of indoleamine 2,3-dioxygenase (IDO), thereby stimulating tryptophan degradation along the kynurenine pathway. Plasma levels of neopterin and the kynurenine/tryptophan ratio (KTR) are thus markers of IFN-γ-mediated inflammation. Several kynurenine pathway metabolites (kynurenines) possess immunomodulatory properties. The aim of this study was to investigate associations between markers of IFN-γ-mediated inflammation and kynurenines with bone mineral density (BMD). The community-based Hordaland Health Study (HUSK), with middle-aged (46–49 years) and older (71–74 years) participants, was conducted from 1998 to 2000 (n = 5312). Hip BMD in relation to neopterin, KTR and kynurenines were investigated, using linear and logistic regression analyses. In the oldest group, neopterin (P ≤ 0·019) and KTR (P ≤ 0·001) were associated inversely with BMD after multiple adjustment. Comparing the highest to the lowest quartiles, the odds ratios of low BMD (being in the lowest quintile of BMD) in the oldest cohort were for neopterin 2·01 among men and 2·34 among women (P ≤ 0·007) and for KTR 1·80 for men and 2·04 for women (P ≤ 0·022). Xanthurenic acid was associated positively with BMD in all sex and age groups while 3-hydroxyanthranilic acid was associated positively with BMD among women only (P ≤ 0·010). In conclusion, we found an inverse association between BMD and markers of IFN-γ-mediated inflammation in the oldest participants. BMD was also associated with two kynurenines in both age groups. These results may support a role of cell-mediated inflammation in bone metabolism.

Acute hospital admission for nursing home residents without cognitive impairment with a diagnosis of cancer

Studies of hospitalisation of cognitively intact nursing home (NH) residents with cancer are scarce. Knowledge about associations between socio-demographic, medical and social support variables and hospital admissions aids in preventing unnecessary admissions. This is part of a prospective study from 2004 to 2005 with follow-up to 2010 for admission rates. We studied whether residents with cancer have more admissions and whether socio-demographic and medical variables and social support subdimensions are associated with admission among cognitively intact NH residents with (n = 60) and without (n = 167) cancer aged ≥65 years scoring ≤0.5 on the Clinical Dementia Rating Scale and residing ≥6 months. We measured social support by face-to-face interview. We identified all respondents through NH medical records for hospital admission, linking their identification numbers to the hospital record system to register all admissions. We examined whether socio-demographic and medical variables (medical records) and social support subscales were associated with the time between inclusion and first admission. Residents with cancer had more admissions (25/60) than those without (53/167) (odds ratio 1.7). Social integration was correlated with admission (P = 0.04) regardless of cancer diagnosis. Residents with cancer had more hospital admissions than those without. Higher social integration gave more admissions independent of cancer diagnosis.

Short term results of complete (D3) vs. standard (D2) mesenteric excision in colon cancer shows improved outcome of complete mesenteric excision in patients with TNM stages I-II

BACKGROUND

The aim of the present study was to investigate whether the new method of complete mesocolic excision (CME) with a high (apical) vascular tie (D3 resection) had an immediate effect compared with a conventional (standard) approach even in those patients without lymph node metastases.

METHODS

A cohort of 189 consecutive patients with tumour-nodal-metastasis (TNM) stages I-II and a mean age of 73 years were operated on in the period from January 2007 to December 2008 in three community teaching hospitals. The CME approach (n = 89), used in hospital A, was compared to the standard technique used (n = 105) in two other hospitals, B and C. Lymph node yields from the specimens were used as a surrogate measure of radical resections. Outcome was analysed after a median follow-up of 50.2 months.

RESULTS

In-hospital mortality rate was 2.8 % in the CME group and 8.6 % in the standard group. The 3-year overall survival (OS) in the CME group was 88.1 versus 79.0 % (p = 0.003) in the standard group, and the corresponding disease-free survival (DFS) was 82.1 versus 74.3 % (p = 0.026). Cancer-specific survival was 95.2 % in the CME group versus 90.5 % in the standard group (p = 0.067). Age, operative technique, and T category were significant in multiple Cox regressions of OS and DFS.

CONCLUSIONS

Compared with the standard (D2) approach, introduction of CME surgical management of colon cancer resulted in a significant immediate improvement of 3-year survival for patients with TNM stage I-II tumours as assessed by OS and DFS.

Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study

Background

Positive changes in safety culture have been hypothesized to be one of the mechanisms behind the reduction in mortality and morbidity after the introduction of the World Health Organization's Surgical Safety Checklist (SSC). We aimed to study the checklist effects on safety culture perceptions in operating theatre personnel using a prospective controlled intervention design at a single Norwegian university hospital.

Methods

We conducted a study with pre- and post-intervention surveys using the intervention and control groups. The primary outcome was the effects of the Norwegian version of the SSC on safety culture perceptions. Safety culture was measured using the validated Norwegian version of the Hospital Survey on Patient Safety Culture. Descriptive characteristics of operating theatre personnel and checklist compliance data were also recorded. A mixed linear regression model was used to assess changes in safety culture.

Results

The response rate was 61% (349/575) at baseline and 51% (292/569) post-intervention. Checklist compliance ranged from 77% to 85%. We found significant positive changes in the checklist intervention group for the culture factors ‘frequency of events reported’ and ‘adequate staffing’ with regression coefficients at −0.25 [95% confidence interval (CI), −0.47 to −0.07] and 0.21 (95% CI, 0.07–0.35), respectively. Overall, the intervention group reported significantly more positive culture scores—including at baseline.

Conclusions

Implementation of the SSC had rather limited impact on the safety culture within this hospital.

Ischaemic stroke at a young age is a serious event--final results of a population-based long-term follow-up in Western Norway

BACKGROUND AND PURPOSE

Our population-based long-term follow-up of young ischaemic stroke patients and controls showed 10-fold increased mortality and fivefold increased arterial event rate nearly 12 years after study inclusion. We now assess memory, anxiety, depression and sleep in relation to employment and functional outcome, treatment goals and results from a last alive-dead survey.

METHODS

Patients (n = 232) ≤ 49 years with an index-stroke between 1988 and 1997 were retrospectively selected and compared with age- and sex-matched controls (n = 453). At follow-up from 2004 to 2005, 144 (77%) of 187 patients were clinically examined. Self-assessment information about memory problems, anxiety, depression, sleeping problems, education and employment was compared with answers from standardized questionnaires from 167 controls. Functional outcome was measured by the modified Rankin Scale (mRS).

RESULTS

Patients compared with controls had more memory problems (41.0% vs. 5.4%, P < 0.001), anxiety (19.4% vs. 9%, P = 0.009), depression (29.2% vs. 13.2%, P = 0.001) and sleeping problems (36.1% vs. 19.2%, P = 0.001). In the multiple regression analysis male gender (OR 9.3, 95%CI 0.10-0.61, P = 0.002), normal memory (OR 12.7, 95%CI 0.07-0.47, P < 0.001) and mRS 0-1 (OR 15.7, 95%CI 0.002-0.12, P < 0.001) were factors for full-time employment. Blood pressure was < 140/90 mmHg in 39% of patients, 49% stopped smoking and 38.2% used statins. After a mean observation time of 18.3 years, 63 (27.2%) of 232 patients were dead.

CONCLUSIONS

Our data show a heterogeneous prognosis and high mortality even for long-time survivors of ischaemic stroke at a young age. Prospective studies of young stroke patients and controls are necessary for direct comparison.

Gastrointestinal wall thickness measured with transabdominal ultrasonography and its relationship to demographic factors in healthy subjects

PURPOSE

To describe the gastrointestinal (GI) wall thickness and the thickness of individual wall layers in healthy subjects using ultrasound and to determine whether demographic factors, the ultrasound transducer frequency, or a fasting state influences these measurements.

MATERIALS AND METHODS

After overnight fasting, the GI wall thickness and wall layers were measured in several regions with transabdominal, high-frequency ultrasound. 122 healthy subjects aged 23 - 79 were included. All measurements were performed with both 8 and 12-MHz transducers except for the rectum measurement (4 MHz). 23 patients were given a 300 Kcal test meal and re-examined after 30 minutes.

RESULTS

Wall thickness measurements of the GI tract with transabdominal ultrasonography are dependent on transducer frequency (p < 0.001), weight (p < 0.001) and age (p < 0.018). The thickness of individual wall layers in the ileum and the sigmoid colon was found to be dependent on both age (p = 0.007) and weight (p < 0.001). The mean wall thickness from the jejunum to the sigmoid colon ranged from 0.9 to 1.2 mm with standard deviations (SD) of 0.3 mm or less. The mean (SD) was 2.9 (0.8) mm in the gastric antrum, 1.6 (0.3) mm in the duodenum, and 2.1 (0.5) mm in the rectum. The gastric antrum was thinner and the ileum and sigmoid colon were thicker after the test meal (p < 0.05).

CONCLUSION

GI wall thickness depends on weight and age. Provided adequate measurement, an abnormal GI wall should be suspected if the thickness exceeds 2 mm except for in the gastric antrum, duodenum and rectum. Reference values for wall thickness can be used regardless of fasting state or probe frequency except for in the gastric antrum.

Flow cytometry technique for analysing Leishmania promastigote phagocytosis by human polymorphonuclear leucocytes and monocytes

In this study, we developed a flow cytometry technique for studying Leishmania (L.) mexicana phagocytosis by human polymorphonuclear leucocytes (PMNs) and monocytes. Leishmania promastigotes are elongated in shape and flagellated. This influences the light scatter when phagocytosis is measured by flow cytometry. Accordingly, we developed an oxidative burst method for measuring the phagocytic process. As this is an indirect marker of phagocytosis, we used confocal, light and electron microscopy to verify that promastigotes were, indeed, internalized by the phagocytes. For both PMNs and monocytes, the optimal conditions for achieving high sensitivity in flow cytometry detection were 5% pooled human serum and 15 min. incubation time. Incubations at 35, 37 and 39°C were also equally efficient for both PMNs and monocytes. Optimal parasite ratios were 10 parasites per PMN and 20 parasites per monocyte. Under these conditions, Leishmania were readily phagocytosed by human PMNs and monocytes and the effects of other influences, such as treatment, would be readily detectable. This indicated that these cells may play a role in the immune response against Leishmania.

Ultrasound safety in early pregnancy: reduced energy setting does not compromise obstetric Doppler measurements

OBJECTIVES

We hypothesized that first-trimester Doppler ultrasonography can be carried out at lower output energies than the currently advocated limits without compromising clinically important information.

METHODS

We recruited 42 pregnant women for an ultrasound examination at 12 weeks' gestation. Twenty-one women were examined with a transvaginal transducer, the rest with a transabdominal transducer. We used pulsed Doppler to measure pulsatility index (PI) and peak systolic velocity (PSV) in five clinically relevant fetal and maternal blood vessels. The energy indicator thermal index for bone (TIb) was set at 1.0, 0.5 and 0.1. Each measurement was repeated three times. A mixed linear regression model accounting for correlation between measurements was used to assess the effect of different TIb levels and transducers.

RESULTS

We were able to visualize the vessels by color Doppler and measure PI and PSV in all vessels at all energy levels in all the participants with the exception of the ductus venosus in two participants, yielding 1872 recordings for statistical analysis. A reduction in TIb from 1.0 to 0.5 and 0.1 had no effect on the PI or PSV values, nor was there any trend towards higher parameter variance with decreasing TIb. There was no difference between measured values of PI and PSV between the transducers, but the transabdominal technique was associated with a greater parameter variance.

CONCLUSION

Reliable first-trimester Doppler data can be obtained with output energy reduced to a TIb of 0.5 or 0.1.

Endorectal elastography in the evaluation of rectal tumours

AIM

Real-time elastography visualizes tissue compliance using an ultrasound platform. Elastography has been used, particularly in the breast, to characterize indeterminate lesions on B-mode imaging as either benign or malignant. The primary aim of this study was to assess the feasibility of routine endorectal elastography to evaluate rectal neoplasia. The secondary aim was to correlate elastography data with histopathological end-points.

METHOD

Sixty-nine patients referred to the outpatient clinic of the Department of Colorectal Surgery at Haukeland University Hospital for the evaluation of rectal tumours were included in this prospective cohort study. All patients underwent digital rectal examination, rigid rectoscopy with biopsy, endorectal ultrasonography and endorectal elastography. In each case a strain ratio was calculated, comparing the tumour tissue with adjacent reference tissue that appeared normal on ultrasound scanning.

RESULTS

Histopathologically there were 23 adenomas and 45 adenocarcinomas. One patient died before surgical treatment. Adequate elastography images were obtained in 66/69 (96%) patients. Optimal discrimination of malignant and benign lesions was obtained using a strain ratio cut-off value of 1.25 (sensitivity, 0.93; specificity, 0.96; and accuracy, 0.94).

CONCLUSION

Endorectal elastography can be performed as an integral part of the clinical evaluation of rectal tumours and has good patient compliance. The method is a promising modality for the discrimination between adenocarcinoma and adenoma of the rectum.

Selectively reduced posterior corpus callosum size in a population-based sample of young adults born with low birth weight

BACKGROUND AND PURPOSE

Several studies suggest that VLBW is associated with a reduced CC size later in life. We aimed to clarify this in a prospective, controlled study of 19-year-olds, hypothesizing that those with LBWs had smaller subregions of CC than the age-matched controls, even after correcting for brain volume.

MATERIALS AND METHODS

One hundred thirteen survivors of LBW (BW <2000 grams) without major handicaps and 100 controls underwent a 3T MR examination of the brain. The cross-sectional area of the CC (total callosal area, and the callosal subregions of the genu, truncus, and posterior third) was measured. Callosal areas were adjusted for head size.

RESULTS

The posterior third subregion of the CC was significantly smaller in individuals born with a LBW compared with controls, even after adjusting for size of the forebrain. Individuals who were born with a LBW had a smaller CC (mean area, 553.4 mm(2)) than the controls (mean area, 584.1 mm(2)). Differences in total area, however, did not remain statistically significant after adjusting for FBV.

CONCLUSIONS

The uncorrected callosal size in 19-years-olds born with LBW was smaller than that of normal controls. However, after adjusting for FBV, the group difference was restricted to the posterior third. The clinical impact of a smaller posterior part needs further investigation.

Traumatic spinal cord injury and concomitant brain injury: a cohort study

OBJECTIVE

To assess the temporal trends in the incidence and demographic characteristics of traumatic spinal cord injury (TSCI) with clinical concomitant traumatic brain injury (TBI), in an unselected, geographically defined cohort, 1952-2001.

MATERIAL AND METHODS

The patients were identified from hospital records. TBI was classified as none, mild, moderate, and severe.

RESULTS

Of 336 patients, 157 (46.7%) patients had a clinical concomitant TBI. Clinical TBI was classified as mild in 30.1%, moderate in 11.0% and severe in 5.7%. The average annual incidence increased from 3.3 per million in the first decade to 10.7 per million in the last. Alcohol was the strongest risk factor of clinical TBI (OR = 3.69) followed by completeness of TSCI (OR = 2.18).

CONCLUSIONS

The incidence of TSCI with concomitant TBI has increased during the last 50 years. Alcohol and completeness of injury are strong risk factors. Increased awareness of dual diagnoses is necessary.

Enkle spirometrimålinger i en generell mannlig befolkning

 SAMMENDRAGFormålet var å evaluere deltagelsen ved enkle spirometrimålinger utført av menn fra den generelle befolkningenog å studere mulige prediktorer for ikke å oppnå godkjent test.Alle menn i alderen 29-46 år bosatt i Hordaland fylke samt Sauda kommune (N=45 380) ble invitert til entverrsnittsundersøkelse i 1988-90. Luftveissymptomer, røykevaner og sivil status ble besvart via spørreskjemaog målinger av forsert ekspiratorisk volum ved ett sekund (FEV 1) og forsert vital kapasitet (FVC) bleutført med Vitalograph belg-spirometre.I alt deltok 29 611 menn (65%) i studien. Spirometrimålinger ble utført hos 91% av de fremmøtte og avdisse var det kun 1,6% som ikke klarte å oppnå tre godkjente registreringer med ≤300 ml mellom de tohøyeste FVC verdiene. Andelen uten tre godkjente målinger var hyppigere hos aldri-røykere, ugifte og hospersoner med luftveissymptomer enn hos hhv. røykere, gifte og asymptomatiske menn.Konklusjon  Simple spirometry in a general male population.Nor J Epidemiol ENGLISH SUMMARYIn this general population study we wanted to evaluate the participation of simple spirometry and to identifypredictors of spirometric test failure.All men aged 29-46 years living in western Norway (N=45,380) were invited to a cross sectional communitysurvey. Respiratory symptoms, smoking habits and marital status were obtained from self-administeredquestionnaires and measurements of FEV 1 and FVC were performed using dry-wedge bellow spirometers.Altogether 29,611 subjects (65%) participated in this survey. Spirometric recordings were obtained in91% of the attendants (n=26,803) of whom 1.6% failed the acceptability criterion of ≤300 ml between thetwo highest of three FVC values. Spirometric failures were more prevalent in never smokers, single men andsubjects with respiratory symptoms than in ever-smokers, married and asymptomatic subjects, respectively.Conclusions  : In men aged 29-46 years, spirometric test failures occurred more frequently in neversmokers than in smokers and ex smokers after adjusting for other covariables. The higher failure ratesobserved in never smokers, in single men and in subjects1997; 7 (2): 243-248.: Hos menn i alderen 29-46 år var risikoen for mislykket spirometri større hos aldri-røykere,ugifte og hos personer med luftveissymptomer enn hos hhv. røykere, gifte og asymptomatiske personer.Humerfelt S, Eide GE, Gulsvik A. 

Quantitative computed tomography: emphysema and airway wall thickness by sex, age and smoking

We investigated how quantitative high-resolution computed tomography (HRCT) measures of emphysema and airway wall thickness (AWT) vary with sex, age and smoking history. We included 463 chronic obstructive pulmonary disease (COPD) cases and 431 controls. All included subjects were current or ex-smokers aged > or = 40 yrs, and all underwent spirometry and HRCT examination. The HRCT images were quantitatively assessed, providing indices on lung density and airway dimensions. The median (25-75th percentile) %LAA950 (% low-attenuation area < -950 HU) was 8.9 (3-19) and 4.7 (1-16) in male and female COPD cases, respectively, and 0.71 (0.3-1.6) and 0.32 (0.1-0.8) in male and female controls, respectively. %LAA950 was higher in ex-smokers and increased with increasing age and with increasing number of pack-years. The mean+/-SD standardised AWT was 0.504+/-0.030 and 0.474+/-0.031 in male and female COPD cases, respectively, and 0.488+/-0.028 and 0.463+/-0.025 in male and female controls, respectively. AWT decreased with increasing age in cases, and increased with the degree of current smoking in all subjects. We found significant differences in quantitative HRCT measures of emphysema and AWT between varying sex, age and smoking groups of both control and COPD subjects.

Neonatal bronchopulmonary dysplasia predicts abnormal pulmonary HRCT scans in long-term survivors of extreme preterm birth

BACKGROUND

There is an increasing understanding that extreme preterm birth carries a risk of long-term pulmonary sequelae. A study was undertaken to investigate if, and in what way, neonatal factors were associated with subsequent abnormalities on pulmonary high-resolution CT (HRCT) scanning and if pulmonary function was related to these abnormalities.

METHODS

HRCT scanning and pulmonary function tests were performed less than 2 weeks apart in 74/86 eligible subjects (86%) born at a gestational age of < or =28 weeks or with a birth weight of < or =1000 g within a defined area in Western Norway in 1982-5 (n = 42) or 1991-2 (n = 32). Mean age at examination was 18 and 10 years, respectively. HRCT scans were interpreted by a paediatric radiologist blinded to the clinical data using a structured system allowing scores from 0 to 50.

RESULTS

Lung parenchymal abnormalities were found in 64 subjects (86%), the median (interquartile range) score being 3.0 (1.75-5.0) points. Prolonged neonatal requirement for oxygen treatment predicted poor outcome, and an increase of 100 days increased the average HRCT score by 3.8 points (p<0.001). There was also a positive association of the severity of pulmonary function abnormalities with the extent of HRCT abnormalities, exemplified by the relation between forced expiratory volume in 1 s and total HRCT score (beta = -0.090; p<0.001).

CONCLUSIONS

In area-based cohorts of long-term survivors of extremely preterm birth, prolonged neonatal requirements for oxygen treatment predicted subsequent structural abnormalities on HRCT scans and in pulmonary function, and these two outcome measures were interrelated.

Characteristics of generalised epileptiform activity

OBJECTIVE

To study the age-related occurrence of specific features of generalised epileptiform activity (GEA), their correlation with EEG background activity (BA), and their internal correlation.

METHODS

17,723 consecutive routine EEGs from 12,511 patients were annotated and categorised into a database. The first EEG containing GEA from all 325 patients with such activity were selected and categorised for GEA features. The BA was studied in multivariable fractional polynomial regression models including intervening variables. The GEA features were studied in similar models for age-dependency and internal correlation.

RESULTS

High GEA-amplitude and low GEA-frequency correlated with BA slowing. The occurrence of 'irregular spike/sharp slow wave' pattern increased with age (p=0.003). Hyperventilation sensitivity was not age-related. There was no correlation between hyperventilation sensitivity and photoparoxysmal response. The age-related probability for specific GEA-types was established.

CONCLUSIONS

High GEA-amplitude and low GEA-frequency correlate with BA slowing, indicating cerebral cortical dysfunction. Hyperventilation sensitivity and photoparoxysmal response independently increase the yield of EEG. There is no age-dependency for hyperventilation sensitivity showing that an upper age threshold for hyperventilation provocation is inappropriate.

SIGNIFICANCE

The results extend our understanding of GEA and help the electroencephalographer in weighing the various GEA components.

Ultrasound, atherosclerosis and stroke at a young age: a cross-sectional long-term follow-up in western Norway

BACKGROUND AND PURPOSE

Previous studies have shown significantly higher mortality and vascular morbidity amongst patients with ischaemic stroke onset at a young age compared with controls after a mean observation time of more than 11 years.

METHODS

In the present cross-sectional study, we measured the carotid intima-media thickness (IMT) in 140 (75%) of 187 survivors of ischaemic stroke after a mean observation time of 11.9 years. Their mean age when included was 41.1 years. IMT was measured by B-mode ultrasonography.

RESULTS

Total maximum IMT <1.0 mm was found in 34 (24%) patients, [1.0-1.2 mm) in 29 (21%) patients, [1.2-1.5 mm) in 29 (21%) patients and >or=1.5 mm in 48 (34%) patients. Increasing total maximum IMT was related to increasing age, male gender, recurrent ischaemic stroke, coronary atherosclerosis, peripheral atherosclerosis, smoking, hypertension and diabetes mellitus.

DISCUSSION

IMT changes confirm increased vascular morbidity in patients who suffered ischaemic stroke at a young age.

Clinical data discriminating between adults with positive and negative results on bronchodilator testing

OBJECTIVE

To evaluate how spirometry, symptoms and smoking discriminate between subjects who are responsive to bronchodilator testing and those who are non-responsive, and to examine how cut-off points of positive tests are related to symptoms of chronic obstructive pulmonary disease (COPD) and asthma.

METHODS

Subjects aged 47-48 and 71-73 years living in Bergen, Norway, were recruited. The 3506 participants (69%) filled in questionnaires and performed a bronchodilator test using salbutamol.

RESULTS

Tests were positive (forced expiratory volume in 1 s [Delta FEV1] >or=200 ml and >or=12%) in 107 subjects (3%). In logistic regression, spirometry (FEV1 < 80%, OR 6.0, 95%CI 3.6-10.2, and FEV1/FVC < 0.70, OR 3.1, 95%CI 1.9-5.2) and pack-years >or= 20 (OR 0.3, 95%CI 0.2-0.7), but not symptoms, predicted the test outcome. FEV1% and FEV1/forced volume capacity (FVC) discriminated equally well between positive and negative tests (area under the receiver operating characteristic [ROC] curve 0.81, 95%CI 0.77-0.85 vs. 0.77, 95%CI 0.72-0.82). The largest likelihood ratio for positive tests was 5.4 (95%CI 3.8-7.8) using FEV1 < 80% and FEV1/FVC < 0.70.

CONCLUSIONS

Spirometry and to a lesser extent smoking, but not symptoms, are useful in discriminating between middle-aged and elderly patients with positive and negative bronchodilator tests. Acute responses to salbutamol, expressed by commonly used Delta FEV1 cut-off points, are poorly related to COPD- and asthma-like symptoms.

Islet cell autoantibodies in African patients with Type 1 and Type 2 diabetes in Dar es Salaam Tanzania: a cross sectional study

Background

The aim of the present study was to assess the occurrence of glutamic acid decarboxylase autoantibodies (GADA) and insulinoma antigen 2 autoantibodies (IA2A) among patients of African origin in Dar es Salaam, Tanzania and to compare the occurrence of autoimmune mediated Type 1 diabetes with findings previously reported from the same place and from other African diabetic populations.

Methods

Two hundred and forty five patients from the diabetic clinic at Muhimbili Hospital were recruited for a cross sectional study. Patients were clinically classified into groups with Type 1 (T1D) and Type 2 diabetes (T2D); there were 94 patients with T1D and 151 with T2D. Autoantibodies for GAD and IA2 were measured with an assay based on radioligand binding. Fasting and random blood glucose, HbA1c, and C-peptide levels were also determined.

Results

Of the patients with T1D, 28 (29.8%) were GADA positive and 20 (21.3%) were IA2A positive. The overall occurrence of any autoantibody was 42.6%. The GAD and IA2 autoantibodies were detected more frequently among patients with T1D than among patients with T2D (P < 0.001). A higher autoantibody prevalence was observed with combined GADA and IA2A measurements compared to individual autoantibody measurements; 40 (42.6%) patients with T1D versus 11 (7.3%) with T2D had at least one positive autoantibody titer. There was no correlation between duration of disease and detection of autoantibodies in patients with T1D. There was a strong association with family history of diabetes among the autoantibody positive versus autoantibody negative patients with T1D (p < 0.01).

Conclusion

The prevalence of GAD and IA2 autoantibodies among African patients with T1D in Dar es Salaam was the same as that reported previously for South Africa and Ethiopia. It was much higher than the prevalence of islet cell autoantibodies (ICA) reported from the same clinic about 15 years ago. For unknown reasons the prevalence of pancreatic related autoantibodies in this African population is lower than the prevalence found among Caucasian populations.

Overweight and obesity in Norwegian children: secular trends in weight-for-height and skinfolds

AIM

The prevalence of overweight and obesity in paediatric populations has been rapidly increasing in many countries over the past decades. The aims of the present study were to provide new data on weight-for-height and skinfolds, and to compare these to growth references for children between 3 and 17 years, collected in the same city between 1971 and 1974.

MATERIAL

The present study is based on cross-sectional data of 4115 children (2086 boys and 2029 girls) aged 4-15 years measured in 2003-6.

RESULTS

Overall, 18.0% of the boys and 20.1% of the girls were above the 90th weight-for-height percentile of the 1971-1974 references, 8.0% and 7.2% were above the 97.5th percentile, indicating an upward shift in weight-for-height. An even more prominent increase was observed for skinfold thicknesses; for triceps skinfolds about 30% of the boys and 28% of the girls were above the 90th percentile of the 1971-1974 references, and corresponding values for subscapular skinfolds were 26.5% and 25.9%. Using international cut-off values for body mass index, the overall prevalence of overweight and obesity was 12.5% and 2.1% in boys, and 14.8% and 2.9% in girls.

CONCLUSIONS

Our study has demonstrated a significant increase in weight-for-height in Norwegian children over the last 30 years, and that these changes are caused by an increase in fat tissue, as shown by skinfold measurements. The current prevalence of overweight and obesity is comparable to recent estimates from most Western and Northern European countries.

Long-term mortality among young ischemic stroke patients in western Norway

OBJECTIVES

To obtain data on long-term mortality among young ischemic stroke patients compared with controls in this population-based study.

MATERIAL AND METHODS

We used Kaplan-Meier survival analysis to compare 232 patients aged 15-49 years with first-ever cerebral infarction in 1988-1997 and 453 controls followed from inclusion to death or 1 August 2005 for 2515 and 5558 person-years respectively. In a subanalysis of 192 patients, we compared risk factor variables using the Kaplan-Meier method and log-rank testing. We applied a Cox proportional hazards model to adjust for multiple risk factors.

RESULTS

Forty-five patients and nine controls died during follow-up (P < 0.0005). Independent risk factors for mortality were active tumor disease (P < 0.0005), high consumption of alcohol (P < 0.0005), coronary atherosclerosis (P < 0.001), living alone (P < 0.02), seizures (P < 0.04) and smoking (P = 0.08).

CONCLUSIONS

Long-term mortality was significantly increased among young stroke patients, mainly due to such lifestyle factors as high consumption of alcohol and tobacco.

Changes in bone and lipid metabolism in postmenopausal women with early breast cancer after terminating 2-year treatment with exemestane: a randomised, placebo-controlled study

Aromatase inhibitors improve relapse-free survival in early breast cancer, but there is concern about possible detrimental effects on bone mineral density (BMD) and plasma lipids. This paper presents the results of a 2-year study evaluating the effects of exemestane versus placebo on BMD, bone markers, plasma lipids and coagulation factors, including a 1-year follow-up after termination of treatment in 147 patients. During treatment, the mean annual rate of loss of BMD in the lumbar spine was 2.17% in the exemestane group versus 1.84% in the placebo group (n.s.) and 2.72% versus 1.48%, respectively, in the femoral neck (P=0.024). A loss of BMD above that expected in both arms of this study could be due to low vitamin D status (88% of all patients had vitamin D levels <30 ng/ml). The changes observed with exemestane were partially reversed during a 1-year follow-up, with no significant difference between the two arms. Similarly, the moderate decrease in high-density lipoprotein (HDL)-cholesterol was reversed. The bone marker values decreased, although a difference at 6 months of follow-up was still recorded, in particular for the markers of bone synthesis.

Vitamin D deficiency: A threat to bone health in breast cancer patients during adjuvant treatment with aromatase inhibitors

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Background: To evaluate potential detrimental effects of the aromatase inactivator exemestane on bone, 147 postmenopausal women with early breast cancer were randomised to receive either exemestane for 2 years or placebo (J. Clin. Oncol. 23 [22], 5126–5137, 2005). Exemestane increased the annual bone loss from the femoral neck (2.72%) compared to placebo (1.48%; P = 0.024) with a non-significant increase in the lumbar spine (exemestane 2.17% versus placebo 1.84%). The annual bone loss was higher than expected in the placebo arm. Methods: Various biomarkers involved in bone metabolism (25-hydroxyvitamin D, parathormone, calcium, estrogens, androgens) were analysed to elucidate their influence on bone status at baseline and BMD loss during treatment with exemestane compared to placebo. Results: Using a cut-off value of 30 ng/ml for 25-hydroxyvitamin D (J. Clin. Endocrinol. Metab. 90 [6], 3800–3801, 2005), the majority of study participants suffered from vitamin D deficiency (56 of 62 patients in the placebo group and 52 of 59 in the exemestane group). The mean levels (95% confidence interval) of vitamin D were 22.6 ng/ml (21.2 - 24.1) in the placebo group and 21.6 ng/ml (20.0 - 23.3) in the treatment group, revealing no differences between these groups. Low serum calcium levels at baseline were found to be significantly correlated to low BMD in the femoral neck in the exemestane group. However, individual levels of vitamin D, parathormone and estradiol at baseline were not correlated significantly to BMD. Conclusions: Considering an annual bone loss of 0.5% to be representative for postmenopausal women (Osteoporos. Int. 15, 881–886, 2004), our data indicate that vitamin D deficiency could be the most important factor elevating bone loss among patients treated with exemestane as well as in the placebo group. These findings, together with the observation of a moderate additional effect of exemestane on bone loss, underlines the need for proper vitamin D substitution of postmenopausal women in general and in breast cancer patients during treatment with aromatase inhibitors in particular.

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Indoor exposures and respiratory symptoms in a Norwegian community sample

BACKGROUND

Limited data are available on the effect of a poor indoor climate on the respiratory health of adults. No data are available regarding the contribution of indoor exposures to the burden of respiratory symptoms in the population.

METHODS

In 1996-7 a community sample of 3181 adults aged 26-82 years was invited to participate in a survey on indoor climate and respiratory health in Hordaland County, Norway. 2401 subjects agreed to take part. Logistic regression was used to examine the relationship between eight markers of indoor exposure and physician diagnosed asthma and five respiratory symptoms, after adjustment for sex, age, smoking, educational level, smoking habits, pack years, and occupational airborne exposure.

RESULTS

Mould exposure was associated with all the respiratory symptoms; the adjusted odds ratios (OR) varied from 1.6 (95% confidence interval (CI) 1.0 to 2.4) for cough with phlegm to 2.3 (95% CI 1.4 to 3.9) for grade 2 dyspnoea. Keeping a cat or dog in childhood was associated with grade 2 dyspnoea and attacks of dyspnoea, with adjusted ORs of 1.3 (95% CI 1.0 to 1.7) and 1.4 (95% CI 1.1 to 1.8), respectively. Having a fitted carpet in the bedroom was negatively associated with three of the five respiratory symptoms. 3-5% of the frequency of the respiratory symptoms in the study population could be attributed to exposure to visible moulds.

CONCLUSION

Mould exposure is an independent risk factor for several respiratory symptoms in a general population covering a wide age span, but it makes only a small contribution to the respiratory symptom burden in the population at large.

The incidence of adult asthma: a review

In recent years, several new studies have estimated the incidence of adult asthma. These studies vary in design and quality. The current paper summarises the findings of major population studies in the adult incidence of asthma. The pooled estimate of the adult incidence of asthma was 4.6 per 1000 person-years in women and 3.6 per 1000 person-years in men. The estimate among only general population cohort studies was higher, respectively 5.9 and 4.4 per 1000 person-years in women and men. The adult incidence of asthma was slightly higher in women than men. In the few studies that allowed the incidence of asthma to be estimated among those aged >50 years, there was a trend towards a higher incidence with age. It is thought likely that this is at least partly explained by misclassification with COPD. However, the current findings from these studies may imply that the incidence of asthma in the elderly has previously been under-estimated. Finally, the review shows that estimates of adult asthma incidence have tended to be higher in later studies, implying a rise in asthma incidence in adults within the timeframe of observation.

Trends in symptoms of obstructive lung disease in Norway

SETTING

Evidence is accumulating that there has been an increase in the adult population burden of obstructive lung disease. Has this increased the burden of symptoms? It is possible that diagnostic efficiency has improved, so that milder asthma cases are being diagnosed.

OBJECTIVE

To investigate changes in symptom burden by asthma diagnosis, age and sex.

DESIGN

We performed two postal cross-sectional studies among adults aged 15-70 years in Oslo, Norway, in 1972 and again in 1998/1999 (total = 39998). Changes in 11 self-reported respiratory symptoms were investigated.

RESULTS

The prevalence of having at least one symptom increased from 50% to 60% (P < 0.001), and the distribution of symptoms showed an overall increase. Nine symptoms increased in prevalence. The increase was largest among the young and females, and was present in both those with and those without asthma. For any given number of reported symptoms, asthma prevalence was higher in 1998 than in 1972, suggesting increased case finding.

CONCLUSION

There has been an increase in the population burden of respiratory symptoms matching the observed increase in young adult asthma, together with a probable increase in the clinical willingness to give an asthma diagnosis.

Homocysteine Levels, Haemostatic Risk Factors and Patency Rates after Endovascular Treatment of the Above-Knee Femoro-Popliteal Artery

OBJECTIVES

To investigate the relationship between plasma homocysteine and other haemostatic variables and restenoses or reocclusions after endovascular treatment of symptomatic atherosclerosis of the above-knee femoro-popliteal artery.

DESIGN

Prospective observational study.

SETTING

University hospital.

PATIENTS AND METHODS

The study included 103 patients (116 limbs), treated with subintimal angioplasty in 58 cases (50%) and with intraluminal PTA in 58 (50%): 39 (34%) patients were treated for critical limb ischaemia. Blood samples for analyses of fasting plasma values of homocysteine, fibrinogen, D-dimer, activated protein C resistance were drawn upon admission. Median follow-up for all procedures was 11 months (range 0-42 months). Outcome events (arterial patency) were defined as > or =50% restenosis or reocclusion in the treated arterial segment. Patency rates were estimated with the product limit method and Kaplan-Meier curves. Variables found to be related significantly to patency were included in multivariate analysis performed with the Cox proportional hazard model.

RESULTS

The 1-year cumulative primary patency rate for all procedures was 48%. One-year limb salvage rate in cases of critical ischaemia was 74%. Multivariate analysis demonstrated significant independent associations between patency rates and plasma D-dimer, diabetes mellitus, the nature of the lesion treated (stenosis vs. occlusion) and antithrombotic therapy with aspirin after the procedure. Plasma levels of homocysteine, fibrinogen or activated protein C resistance were not associated with patency rates. Homocysteine levels were higher in patients with critical limb ischaemia than those with intermittent claudication.

CONCLUSIONS

Early restenosis or reocclusion after endovascular intervention of lesions in the above-knee femoro-popliteal artery was more frequent following treatment of occlusion (versus stenosis), for patients with diabetes, patients with elevated D-dimer and those without antithrombotic therapy after the procedure. Plasma homocysteine did not appear to influence the outcome of endovascular intervention.

Pulmonary outcome in adolescents of extreme preterm birth: a regional cohort study

AIMS

The pulmonary outcome of extreme prematurity remains to be established in adults. We determined respiratory health and lung function status in a population-based, complete cohort of young preterms approaching adulthood.

METHODS

Forty-six preterms with gestational age < or = 28 wk or birthweight < or = 1000 g, born between 1982 and 1985, were compared to the temporally nearest term-born subject of equal gender. Spirometry, plethysmography, reversibility test to salbutamol and methacholine bronchial provocation test were performed. Neonatal data were obtained from hospital records and current symptoms from validated questionnaires.

RESULTS

When entering the study at a mean age of 17.7 (SD: 1.2) y, a doctor's diagnosis of asthma and use of asthma inhalers were significantly more prevalent among preterms than controls (one asthmatic control compared to nine preterms, all but one using asthma inhalers). Peak expiratory flow (PEF) and forced expiratory volume in 1 s (FEV1) were decreased and the discrepancies relative to controls increased parallel to increased severity of neonatal lung disease. Parameters of increased neonatal oxygen exposure significantly predicted FEV1. Adjusted for height, gender and age, FEV1 was reduced by a mean of 580 ml/s in subjects with a history of bronchopulmonary dysplasia. Fifty-six percent of preterms had a positive methacholine provocation test compared to 26% of controls.

CONCLUSION

A substantially decreased FEV1, increased bronchial hyperresponsiveness and a number of established risk factors for steeper age-related decline in lung function were observed in preterms. A potential for early onset chronic obstructive pulmonary disease is present in subsets of this group.

Homocysteine Levels, Haemostatic Risk Factors and Restenosis after Carotid Thrombendarterectomy

OBJECTIVES

To investigate the effect of elevated serum homocysteine and haemostatic as well as clinical risk factors on the tendency to restenosis after carotid artery thrombendarterectomy.

DESIGN

A prospective, observational study.

PATIENTS AND METHODS

In the period from October 1999 to October 2002, 86 patients were subjected to 96 carotid endarterectomies because of internal carotid artery stenoses. The carotid stenoses were symptomatic in 86 cases (90%). Fasting plasma homocysteine, fibrinogen, D-dimer and activated protein C resistance were measured the day before surgery. Follow-up was done 1, 3, 6, 12 and 18 months postoperatively and yearly thereafter with clinical assessment and triplex ultrasonography. The median follow-up time was 17 months (range 9-42 months). Freedom from restenosis was estimated with Kaplan-Meier curves, using log-rank test for comparison between groups. Variables found to be significantly related to restenosis rates were included in a multivariate analysis performed with the Cox proportional hazards model. Comparison of means of continuous data between two groups was done with Student's t-test and more than two groups with one-way analysis of variance.

RESULTS

Restenoses within 12 months of the operation occurred in 11 cases (11%). Univariate analysis revealed that plasma homocysteine values < or =10 micromol/l and freedom from ischaemic heart disease were both significantly associated with an increased risk of restenosis (p=0.0076 and 0.0059). However, multivariate analysis showed that only plasma homocysteine values <10 micromol/l were independently and significantly associated with an increased risk of restenosis (p=0.046). There were no associations between the degree of atherosclerotic affection of the precerebral circulation or symptoms on one hand and the levels of homocysteine, fibrinogen, D-dimer and activated protein C resistance on the other.

CONCLUSION

There seems to be an independent, significant association between homocysteine values within the lower two thirds of the normal range and restenosis after carotid endarterectomy. Studies on the biological properties of human endothelial cells from different types of vasculature and different locations, specifically with respect to homocysteine metabolism and its effect, are warranted.

Bias in retrospective studies of trends in asthma incidence

There is evidence for an increase in adult asthma prevalence. Several retrospective studies have shown an increase in asthma incidence by year of birth, consistent with an increasing trend in asthma incidence. The validity of this retrospective approach is unknown. Retrospective and prospective asthma incidence by year of birth were compared in the same community, during the same time period, from two independent studies; a cohort study and a cross-sectional study in Western Norway. In the prospective study, subjects without asthma were followed from 1985-1996/1997. In the retrospective study in 1998, subjects reported the age at which the disease started. Analyses of incident asthma in the period 1985-1996 were compared between the studies. The retrospective analysis showed a large increase in asthma incidence by year of birth, with an odds ratio (OR) of 2.9 comparing those born in 1969 with those born in 1927. The prospective study showed the opposite, with an OR of 0.2 comparing those born in 1969 with those born in 1927. There was only a 20% difference in the cumulative incidence of asthma. To conclude, retrospective estimates of trends in asthma incidence are likely to be severely biased by differential recall.

Pulmonary gas exchange and educational level: a community study

Socio-economic status (SES) is related to increased risk of airway disease in terms of forced expiratory volume in one second (FEV1) and forced vital capacity. No data are available as to what extent SES predicts alveolar function in a general population. In this cross-sectional study, 1,275 subjects aged 18-73 yrs underwent pulmonary testing, including the single-breath carbon monoxide transfer capacity of the lungs (TL,CO). Educational level was used as an index for SES. Mean +/- SD TL,CO % predicted was 97% among those with primary school education, 99% among those with secondary school education and 104% among those with a university degree. In a multiple linear regression analysis, adjusting for age, height, haemoglobin, carboxyhaemoglobin, smoking habits, occupational exposure, FEV1 and body mass index, TL,CO was significantly related to educational level in males but not in females. Occupational exposure was not significant. In this study, socio-economic status was found to be an independent determinant of TL,CO. Even in an affluent country such as Norway, socio-environmental risk factors may differ based on individuals' SES. Such risk factors may, for instance, be higher exposure to airborne pollutants, poorer housing conditions, or lower consumption of fruit and vegetables. Further exploration is called for.

Remission of respiratory symptoms by smoking and occupational exposure in a cohort study

Few studies have estimated the remission rates of respiratory symptoms in general populations. No community cohort studies have examined the impact of smoking cessation and previous dust or fumes exposure on the remission of respiratory symptoms. In the Hordaland County Study, an 11-yr community cohort (1985-1996/1997) from Western Norway, data from 2,819 subjects were used to examine the remission of six respiratory symptoms. The measured cumulative remission varied from 42.3% for morning cough to 58.4% for chronic cough. Smoking cessation was a significant predictor of remission of the cough symptoms and wheezing, with odds ratios (OR) (95% confidence intervals (CI)) varying from 2.2 (1.3-3.7) for wheezing to 6.2 (3.5-11.2) for morning cough, after adjustment for sex, age, pack-years smoked, previous dust or fumes exposure, and educational level. In those not previously exposed to dust or fumes, the adjusted OR (95% CI) for the remission of morning cough, phlegm cough, dyspnoea grade 2, attacks of dyspnoea and wheezing varied from 1.5 (0.9-2.5) for attacks of dyspnoea to 2.1 (1.1-3.9) for dyspnoea grade 2, as compared to those previously exposed to dust or fumes. This study suggests a beneficial effect of smoking cessation and an adverse effect of occupational exposure on the remission of respiratory symptoms.

Pain and quality of life in patients with symptomatic, non-complicated gallbladder stones: results of a randomized controlled trial

BACKGROUND

Cholecystectomy is intended to relieve symptoms of gallstones, but unfortunately some patients will experience postcholecystectomy symptoms, including pain. There is limited information in the literature on gallstone-related pain and its influence on quality of life. The aim of this study was to examine how pain and quality of life in patients with symptomatic, uncomplicated gallbladder stones were affected by observation of their condition compared with removal of the gallbladder.

METHODS

One-hundred and thirty-seven patients were randomized to observation (watchful waiting; n = 69) or cholecystectomy (n = 68) and answered questionnaires on pain, quality of life (PGWB index and NHP Part II) at randomization and fixed intervals (6, 12 and 60 months). All gallstone-related events (hospital admission for pain, complications of gallstone disease and cholecystectomy) and crossover between treatment groups were recorded.

RESULTS

Of patients randomized to observation, 35 of 69 patients (51%) eventually underwent a cholecystectomy. Significant improvements in quality of life and pain scores were detected regardless of surgical treatment. Patients that subsequently experienced gallstone-related events had significantly higher pain scores at randomization than patients that did not experience any subsequent events, and this difference was maintained throughout follow-up.

CONCLUSIONS

Unexpectedly, in the majority of patients symptoms did abate without any significant differences between groups in pain and quality of life. Patients that had high intensity and frequency of pain at randomization had a higher risk of experiencing subsequent events.