Assessment of fetal growth trajectory identifies infants at high risk of perinatal mortality

OBJECTIVE

To analyze perinatal risks associated with three distinct scenarios of fetal growth trajectory in the latter half of pregnancy compared with a referent group.

METHODS

This cohort study included women with singleton pregnancies that birthed between 32+0 and 41+6 gestational weeks and had two or more ultrasound scans at least four weeks apart from 18+0 weeks. We evaluated three different scenarios of fetal growth against a referent, defined as appropriate for gestational age-sized fetuses with appropriate forward growth trajectories. The comparator growth trajectories were categorized as Group 1: Small for gestational age (SGA) fetuses (EFW or AC <10th centile) with appropriate forward growth; Group 2: Decreased growth trajectory fetuses (decrease of ≥50 centiles) with EFW or AC ≥10th centile (i.e., non-SGA) at their final scan; and Group 3: Decreased growth trajectory fetuses with EFW or AC <10th centile (i.e., SGA) at their final scan. The primary outcomes were perinatal mortality (stillbirth or neonatal death). Secondary outcomes included stillbirth, birth of an SGA infant, preterm birth, emergency cesarean section (CS) for non-reassuring fetal status (NRFS), and composite severe neonatal morbidity. Associations were analyzed using logistic regression.

RESULTS

The final study cohort comprised 5319 pregnancies. Compared to the referent group, the adjusted odds of perinatal mortality were significantly increased in Group 2 (odds ratio [OR] 4.00, 95%CI 1.36-11.22) and Group 3 (OR 7.71, 95%CI 2.39-24.91). Only Group 3 had increased odds of stillbirth (OR 5.69, 95%CI 1.55-20.93). In contrast, infants in Group 1 did not have significantly increased odds of demise. The odds of an SGA infant at birth increased in all three groups but were highest in Group 1 (OR 111.86, 95%CI 62.58-199.95) and Group 3 (OR 40.63, 95%CI 29.01-56.92). In both groups, more than 80% of infants were born SGA, and nearly half had a birth weight <3rd centile. Likewise, the odds of preterm birth were increased in all three groups, being the highest in Group 3 with an OR of 4.27 (3.23-5.64). Lastly, the odds of severe neonatal morbidity were increased in Groups 1 and 3, whereas the odds of emergency CS for NRFS were only increased in Group 3.

CONCLUSIONS

Assessing the fetal growth trajectory in the latter half of pregnancy can help identify infants at increased risk of perinatal mortality and birth weight <3rd centile for gestation. This article is protected by copyright. All rights reserved.

The diagnosis of cerebral palsy in two Danish national registries: a validation study

AIMS

To determine the quality of prospectively collected data from the highly specialized Danish Cerebral Palsy Follow-up Program (CPOP), and to establish the validity of a reported cerebral palsy (CP) diagnosis in the Danish National Patient Registry (NPR), regularly used as a proxy for neurodevelopmental disorders in epidemiological research.

METHODS

We compared data from the two registries on children with registered CP, born in Denmark between 2008 and 2009, with information from medical records verified by two experienced physicians specializing in pediatric neurology. Data accuracy was estimated by completeness, correctness, and reliability. Completeness was calculated as the number of cases with correctly registered CP diagnoses divided by the total number of true CP diagnoses (similar to sensitivity). Correctness was calculated as the number of cases with correct registrations divided by the total number of cases (similar to positive predictive value). Reliability was estimated using kappa statistics.

RESULTS

Registered CP diagnoses in the CPOP had high accuracy, with 94% correctness and 91% completeness. Furthermore, most key variables in the CPOP showed excellent reliability, especially variables defining the severity of the condition. In the Danish NPR, only 225 of 348 children with a noted CP diagnosis fulfilled the diagnostic criteria for CP, resulting in 65% correctness.

CONCLUSIONS

Danish CPOP data are a valid source for epidemiological research. Conversely, a noted CP diagnosis in the Danish NPR was, at best, correct in only two out of three patients.

Children in Denmark with cerebral palsy rarely complete elementary school

AIM

To investigate how children with cerebral palsy (CP) perform in the Danish school system and which factors are associated with school performance.

METHOD

This was a population-based cohort study including 463 126 children born from 1997 to 2003. Data were extracted from seven national registries. The study encompassed 818 children with CP (483 [59.0%] males, 335 [41.0%] females) and 417 731 without CP (214 535 [51.4%] males, 203 196 [48.6%] females). We evaluated two primary outcomes: not completing 10 years of elementary school, defined as attending fewer than eight final mandatory exams; and grade point averages (GPAs). Mann-Whitney U tests were used to analyse differences in GPAs and logistic regressions were used to calculate odds ratios (ORs).

RESULTS

Among children with and without CP, 62.6% and 12.4% did not complete elementary school respectively (OR = 11.85 [10.28-13.66]). Additionally, children with CP who attended all final exams achieved lower overall GPAs than children without CP (6.6 vs 7.3, p = 0.001). In children with CP, comorbidities, maternal education, severity of motor impairments, and intellectual deficits were associated with increased odds of not completing elementary school. Notably, one-third of children with CP with apparent normal intelligence did not complete school, despite special educational measures.

INTERPRETATION

Danish children with CP rarely complete elementary school despite initiatives for a more supportive educational system. The complexity of individual needs in children with CP may be challenging for an inclusive school environment.

WHAT THIS PAPER ADDS

Children with cerebral palsy (CP) have a high risk of not completing elementary school. Children with CP achieve lower overall grades than children without CP. Motor impairment, comorbidities, and maternal education are associated with poor school performance. Intellectual impairment is the most important predictor of poor school performance.

The effect of gestational age on major neurodevelopmental disorders in preterm infants

BACKGROUND

Preterm infants have an increased risk of neurodevelopmental disorders. We established a direct quantitative comparison of the association between the degree of prematurity and three different neurodevelopmental disorders.

METHODS

In this cohort study, we combined data from 995,498 children in the Danish Medical Birth Register, from birth years 1997-2013, with information on cerebral palsy, epilepsy, and special educational needs. We estimated the gestational week-specific prevalence and risk for each of the disorders.

RESULTS

The risk ratio of cerebral palsy at gestational weeks 21-24, compared to term birth, was more than ten times higher than for the two other disorders. The prevalence of epilepsy and special educational needs declined almost parallel, with 9.2% (4.6%-13.5%) and 12.5% (11.2%-13.7%), respectively, per week of gestation toward term birth. Cerebral palsy did not decline similarly: from gestational weeks 21-24 until week 29 the prevalence declined insignificantly by 0.6% (-11.1%-11.0%) per week; whereas from week 29 until term, the prevalence declined markedly by 36.7% (25.9%-45.9%) per week.

CONCLUSIONS

The prevalence and risk of cerebral palsy are affected differently by the degree of prematurity compared with epilepsy and special educational needs, possibly reflecting important differences in cerebral pathophysiology.

IMPACT

For each week of gestation toward term birth, there was a clear log-linear decline in the prevalence of early childhood epilepsy and special educational needs. In contrast, the risk of cerebral palsy was high at the earliest gestational age, and the prevalence did not decline significantly until gestational week 29, from where it declined notably by nearly 40% for each week of gestation until term birth. Our results indicate important differences in the pathophysiological processes that associate preterm birth with these three neurodevelopmental disorders.

Declining prevalence of cerebral palsy in children born at term in Denmark

AIM

To investigate reasons for the declining prevalence of cerebral palsy (CP) in children born at term in Denmark by evaluating obstetric and neonatal factors associated with CP, and their changes over time.

METHOD

In this cohort study, we included 987 495 children (504 600 [51.1%] males and 482 895 [48.9%] females) born after 37 completed gestational weeks during birth years 1997 to 2013. Risk ratios of CP for each factor were calculated with log-binominal regression analyses. Significant factors were evaluated concerning their development in prevalence over time.

RESULTS

In the antenatal period, there were significant associations with an increased risk of CP and high maternal body mass index (BMI), smoking during pregnancy, nulliparity, male sex, gestational age, and low birthweight. In the study period, fewer females smoked during pregnancy and fewer children were born post-term, dropping from 22.6% to 11.4% and 9.4% to 2.5% respectively. Conversely, the proportion of females with high BMI increased. Most significant risk factors were found in the neonatal period, with an increase in children with diagnosed birth defects and children admitted to neonatal care.

INTERPRETATION

Reasons for the declining prevalence of CP appear to be multifactorial and likely include the decline in maternal smoking and children born post-term along with centralization and advances in neonatal treatment.

Cardiac rehabilitation do not diminish the socioeconomic and ethnical disparity in patients with coronary heart disease

Aims

Cardiac patients with low socioeconomic status and non-western ethnic background have worse outcomes. The aim of this nationwide study was to determine whether the immediate effect of CR differs between groups defined by socioeconomic status and ethnic background, and whether disparity in the prognosis of cardiac patients is diminished by CR participation.

Methods

We included all patients in Denmark with myocardial infarction and/or coronary revascularization from August 2015 until March 2018. Level of education, as a marker for socioeconomic status, was divided into four groups, and ethnicity into Danish, non-Western and Western. Participation in CR was identified through the Danish Cardiac Rehabilitation Database (DHRD) and the Danish National Patient Register. Primary outcome was achievement of CR quality indicators, including risk factor control and medication, from DHRD, and secondary outcome a composite endpoint of cardiovascular disease hospitalization and all-cause mortality (MACE).

Results

We identified 34,511 patients of whom 19,383 had participated in CR and 9,882 provided information on CR data from DHRD. Higher education was associated with greater improvement in VO2peak and non-western patients were less likely to be screened for depression or receive dietary consulting. No other significant disparity in CR quality indicators, was found across education and ethnicity. There was a strong socioeconomic gradient in MACE irrespective of CR participation, medication and risk factor control (adjusted HR 0.71 (0.58–0.86) for high versus low education). Similarly, non-western origin was associated with higher risk of MACE (adjusted HR 1.2 (1.1–1.4).

Conclusion

We found strong socioeconomic and ethnic disparity in prognosis of CHD patients which were unaffected by CR participation. The results indicate that CR, conventional risk factor control and medical treatment have limited impact on these disparities.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Figure 1Figure 2

Lower perception of pharmacological treatment increases risk of non-adherence to medication

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation

Background

A large proportion of patients fail to reach optimal adherence to medication following incident ischemic heart disease (IHD) despite amble evidence of the beneficial effect of medication. Non-adherence to medication increases risk of disease-related adverse outcomes but none has explored how perception about pharmacological treatment detail on non-adherence using register-based follow-up data.

Purpose

To investigate the association between patients’ perception of pharmacological treatment and risk of non-initiation and non-adherence to medication in a population with incident IHD.

Methods

This cohort study followed 871 patients until 365 days after incident IHD. The study combined patient-reported survey data on perception about pharmacological treatment (categorised by ‘To a high level’, ‘To some level’, and ‘To a lesser level’) with register-based data on reimbursed prescription of cardiovascular medication (antithrombotics, statins, ACE-inhibitors/angiotensin receptor blockers, and β-blockers). Non-initiation was defined as no pick-up of medication in the first 180 days following incident IHD and analysed by Poisson regression. Two different measures evaluated non-adherence in patients initiating treatment: 1) proportion of days covered (PDC) analysed by Poisson regression, and 2) risk of discontinuation analysed by Cox proportional hazard regression. All analyses were adjusted for confounding variables (age, sex, ethnicity, income, educational level, civil status, occupation, charlson comorbidity index, supportive relatives, and individual consultation in medication) identified by directed acyclic graph and obtained from national registers and the survey. Item non-response was handled by multiple imputation and item consistency was evaluated by McDonalds omega.

Results

Lower perceptions about pharmacological treatment was associated with increased risk of non-initiation and non-adherence to medication irrespectively of drug class and adherence measure in the multiple adjusted analyses (please see figure illustrating results on antithrombotics). A dose-response relationship was observed both at 180- and 365-days of follow-up, but the steepest decline in adherence differed when comparing the two adherence measures (results not shown). Moderate internal consistency was found for the summed measure of perception (McDonalds omega = 0.67).

Conclusion

Lower perception of pharmacological treatment was associated with subsequent non-initiation and non-adherence to medication, irrespectively of measurement method and drug class.

Abstract Figure. Figre: Multiple adjusted analyses

Dormancy dampens the microbial distance-decay relationship

Much of Earth's biodiversity has the capacity to engage in dormancy, a reversible state of reduced metabolic activity. By increasing resilience to unfavourable conditions, dormancy leads to the accumulation of 'seed banks'. These reservoirs of genetic and phenotypic diversity should diminish the strength of environmental filtering and increase rates of dispersal. Although prevalent among single-celled organisms, evidence that dormancy influences patterns of microbial biogeography is lacking. We constructed geographical and environmental distance-decay relationships (DDRs) for the total (DNA) and active (RNA) portions of bacterial communities in a regional-scale 16S rRNA survey of forested ponds in Indiana, USA. As predicted, total communities harboured greater diversity and exhibited weaker DDRs than active communities. These observations were robust to random resampling and different community metrics. To evaluate the processes underlying the biogeographic patterns, we developed a platform of mechanistic models that used the geographical coordinates and environmental characteristics of our study system. Based on more than 10⁶ simulations, our models approximated the empirical DDRs when there was strong environmental filtering along with the presence of long-lived seed banks. By contrast, the inclusion of dispersal generally decreased model performance. Together, our findings support recent theoretical predictions that seed banks can influence the biogeographic patterns of microbial communities. This article is part of the theme issue 'Conceptual challenges in microbial community ecology'.

Socioeconomic consequences for adults with atrial septal defect: A register based follow-up study

Background

Atrial Septal Defect (ASD) is considered one of the most benign defects among congenital heart disease. The very good short and midterm outcomes after closure in the recent decades has led to believe that the ASD population is almost comparable to the background population after treatment. However, recent studies indicate that these patients are much more affected by their disease than first assumed. In this nationwide cohort study, we report the first long-term follow-up of use of permanent social security benefits and work participation in adults with ASD.

Methods

All Danish patients born before 1994 and diagnosed with ASD between 1959-2013 (n = 2,277) were identified from the Danish registries. A comparison cohort was created using the Danish Civil Registration System, matching every verified ASD patient with 10 persons from the general population on gender and birth year. We used Cox proportional hazards regression to compare the risk of receiving permanent social security benefits in the ASD patients compared with the matched cohort. Using the DREAM database we calculated the proportion of patients and controls not working at the age of 30 years.

Results

ASD patients had a higher risk of receiving permanent social security benefits (hazard ratio 2.3 (95% confidence interval 2.1-2.6)) compared with the comparison cohort; 24% of the ASD patients was receiving permanent social security benefits at the end of follow up compared with 12% of the comparison cohort. At the age of 30 years, the proportion not working was 28% in the ASD cohort and 18% in the comparison cohort. Of patients not working 23% had a psychiatric diagnose compared to 6.8% of the controls.

Conclusions

The risk of receiving permanent social security benefits was twice as high in patients with ASD and the work participation was reduced compared with the background population.

Key messages

The poor affiliation to the work force and high prevalence of psychiatric morbidity is worrying. It demands for an increased psychosocial support by professionals caring for patients with ASD.

Children with dyskinetic cerebral palsy are severely affected as compared to bilateral spastic cerebral palsy

AIM

We aimed at describing clinical findings in children with dyskinetic as compared to bilateral spastic cerebral palsy (CP).

METHODS

Data were extracted from the Danish nationwide CP register. Participants were born in 1999-2007 and were 5-6 years at ascertainment.

RESULTS

The total number of CP cases was 1165 of which 92 had dyskinetic and 540 bilateral spastic CP. Prevalence of dyskinetic CP was 0.16 per 1000 live births. In participants with dyskinetic compared to bilateral spastic CP, there was more frequently an Apgar level less than five at five minutes (22.7% vs. 11.2%) and neonatal seizures (43.5% vs. 28.5%), but less respiratory deficiency, hyperbilirubinaemia and sepsis. Impairment based on gross motor function classification was more severe in dyskinetic CP (level III-V 90.0% vs. 66.0%). In dyskinetic CP, there was a high rate of reduced developmental quotient (68.1%), visual impairment (39.3%) and epilepsy (51.6%). Basal ganglia lesions were more prevalent in dyskinetic compared to bilateral spastic CP (27.7% vs. 12.8%).

CONCLUSION

Cases of dyskinetic CP had overlapping clinical features with cases of bilateral spastic CP, but differed significantly in several perinatal risk factors. The children with dyskinetic CP had experienced more peri- or neonatal adverse events, and neurodevelopmental impairment was severe.

P631Socioeconomic status; how does it influence referral to cardiac rehabilitation after acute myocardial infarction?

Background

The number of patients with low socioeconomic status who are referred to cardiac rehabilitation (CR) has been documented to be relative lower than patients with high SES among all patients hospitalised with acute myocardial infarction (AMI).

Purpose

The aims of this study were to evaluate the referral process to CR and how it is influenced by socioeconomic variables.

Methods

In 2011–2014, 1229 patients were hospitalised with AMI at Department of Cardiology of our University Hospital, Denmark. All were evaluated for participation to CR. Socioeconomic status was measured by personal income, educational level, marital status, and employment and obtained from national registers. Multiple logistic regression assessed socioeconomic determinants in three phases of the referral process to CR: 1. information about CR, 2. wish to participate in CR, and 3. referral to specialiced- or municipality-based CR. All analyses were adjusted for sex, age, and comorbidities.

Results

A total of 1123 (91.4%) patients received information regarding CR. Of these, 854 (69.5%) patients wished to participate in the programme. Income was the most important socioeconomic variable when looking at who were informed about CR (OR 2.17, 95%-CI: 1.0- 4.64) and who wished to participate in CR (OR 1.55, 95%-CI: 1.02–2.35).

Characteristics of study participants Characteristics All participants STEMI NSTEMI UAP n=1229 n=402 n=711 n=116 Male (n, %) 907 (73.8) 322 (80.1) 503 (70.7) 82 (70.7) Age Group (yrs)   <65 591 (48.1) 227 (56.5) 308 (43.3) 56 (48.3)   65–74 371 (30.2) 116 (28.9) 215 (30.2) 40 (34.5)   ≥75 267 (21.7) 59 (14.7) 188 (26.4) 20 (17.2) Baseline Comorbidity   Hypertension 241 (19.6) 62 (15.4) 148 (20.8) 31 (26.7)   Diabetes 14 (1.1) <5 (<1) 8 (1.1) <5 (<1) Charlson Comorbidity Index   Low (0 points) 1088 (88.5) 358 (89.1) 630 (88.6) 100 (86.2)   Moderate/High (>0) 141 (11.5) 44 (10.9) 81 (11.4) 16 (13.8) Civil status (n, %)   Married/Partnership 793 (64.5) 253 (62.9) 449 (63.2) 91 (78.4)   Divorced/Unmarried/Widow 436 (35.5) 149 (37.1) 262 (36.8) 25 (21.6) Occupational status (n, %)   Employed 479 (39.0) 195 (48.5) 240 (33.8) 44 (37.9)   Unemployed/Retired 750 (61.0) 207 (51.5) 471 (66.2) 72 (62.1) Educational status (n, %)   Low 516 (42.0) 144 (35.8) 322 (45.3) 50 (43.1)   Medium 539 (43.9) 201 (50.0) 293 (41.2) 45 (38.8)   High 174 (14.2) 57 (14.2) 96 (13.5) 21 (18.1) Gross income, tertile (n, %)   Low 405 (33.0) 113 (28.1) 251 (35.3) 41 (35.3)   Medium 406 (33.0) 124 (30.8) 247 (34.7) 35 (30.2)   High 418 (34.0) 165 (41.0) 213 (30.0) 40 (34.5) STEMI: ST-elevated myocardial infarction; NSTEMI: non-ST-elevated myocardial infarction; UAP: unstable angina pectoris.

Conclusion

Two out of three patients received referral to CR. However, higher income was proportional with the likelihood of receiving information about CR and willingness to participate in the programme.

Acknowledgement/Funding

the Danish Heart Foundation

Inhibition of Activated Coagulation Factor VII by Normal Human Plasma

An amidolytic assay system with tissue thromboplastin (Tpl), purified coagulation factors VII and X, and the chromogenic substrate S-2222 was developed. Antithrombin III (AT) accounts for about one third of the total inhibition exerted by normal plasma in this test system. This effect of AT was prevented by adding purified AT blocking antibodies. Normal plasma and serum showed approximately similar inhibitory effects. The inhibition was probably directed against activated factor VII (F VIIa). Gel filtration of adsorbed normal plasma on Ultrogel AcA 34 showed three inhibitory peaks which were different from AT.

Reproducibility of 3-Dimensional Ultrasound Measurements of Placental Volume at Gestational Ages 11 - 14 Weeks

OBJECTIVE

To evaluate the reproducibility of placental volume using three-dimensional ultrasound.

METHODS

The VOCAL (Virtual Organ Computer-aided AnaLysis) technique involves rotating an image of an object along an established axis using predefined angles. This provides a number of sections to measure manually, resulting in the object being displayed with an estimated placental volume. Four predefined angles 30°, 15°, 9°, and 6°, creating 6, 12, 20 and 30 sections, respectively. Measurements of placenta volumes in 21 women with singleton pregnancies were performed at gestational age 11-14 weeks by a single consultant in Foetal Medicine and later processed by two observers. The intraobserver reproducibility between all four angles was calculated as the mean Coefficient of Variation. Interobserver reproducibility was assessed by Interclass Correlation Coefficient (ICC), Limits of Agreement (LOA) and illustrated in Bland-Altman plots.

RESULTS

There was no significant difference in intraobserver variability between the four angles, p = 0.19, but a trend towards a lower coefficient of variation with the smallest angle was observed. A high intraobserver reproducibility was found using the 6° angle (ICC = 0.918 (0.812 - 0.966) and 0.983 (0.960- 0.993), LOA = [-22.9- 22.5] and [-14.3 - 12.1]), but interobserver reproducibility showed a wide range of agreement (LOA = [-50.5- 34.8]), particularly in cases with u-shaped placentas.

CONCLUSION

The low interobserver reproducibility of VOCAL measurements of placentae requires significant differences between normal and abnormal cases if the technique should be implemented for clinical use.

Socio-economic status influences blood pressure control despite equal access to care

OBJECTIVE

Denmark has a health care system with free and equal access to care irrespective of age and socio-economic status (SES). We conducted a cross-sectional study to investigate a possible association between SES and blood pressure (BP) control of hypertensive patients treated in general practice.

METHODS

We enrolled 184 general practices and 5260 hypertensive patients. The general practitioners reported information about BP and diagnosis of diabetes. Information about education, income, antihypertensive drug treatment and other co-morbidity was retrieved from relevant registers from Statistics Denmark. The outcome measure was BP control defined as BP <140/90 mmHg in general and <130/80 mmHg in diabetics.

RESULTS

Patients <65 years and with an educational level of 10-12 years had increased odds ratio (OR) of BP control compared to patients with an educational level <10 years. Patients ≥65 years had increased OR of BP control if they were married/cohabiting as compared to being single, whereas education and income had no impact in this age group. Diabetics had significantly reduced odds of BP control irrespective of age, educational or income level.

CONCLUSIONS

Despite equal access to care for all patients, SES had significant impact on BP control in this survey. Diabetes and cardiovascular disease also had a substantial influence irrespective of age, educational and income level.

Treatment of 5413 hypertensive patients: a cross-sectional study

BACKGROUND

Most hypertensive patients are managed in primary care in Denmark, but previous studies have shown that only 21-43% of hypertensive patients achieve optimal blood pressure (BP) control. Antihypertensive drug treatment, risk factors and cardiovascular disease (CVD) are some of the important factors to consider when optimizing the individual treatment strategy in hypertensive patients.

OBJECTIVE

To examine treatment of BP according to Danish guidelines (BP < 140/90 mmHg generally and <130/80 mmHg for diabetics) in a population from general practice in relation to risk factors, CVD and diagnosis of diabetes.

METHODS

A cross-sectional study comprising 184 practices and 5413 hypertensive patients was carried out in Denmark. The general practitioners filled in information on each patient's risk factors, CVD and antihypertensive drug treatment. Patients filled in a questionnaire on risk factors. The outcome measures were optimal BP control according to Danish guidelines and antihypertensive drug treatment.

RESULTS

Mean patient age was 65.9 years [95% confidence interval (CI): 65.6-66.1]. Optimal BP control was achieved in 29.1% (95% CI: 27.9-30.3) of the study population. Among 842 diabetics with or without CVD, optimal BP control was achieved in 10.9% (95% CI: 8.8-10.3), while 38.7% (35.5-41.9) of patients with CVD achieved optimal BP control. The majority of all patients were treated with 1 (32.5%, 95% CI: 32.5 (31.3-33.8)) or two antihypertensive drugs (39.0%, 95% CI: 38.2-40.8). In hypertensive diabetics, 17.7% were not treated with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker.

CONCLUSION

In general practice, the proportion of hypertensive patients achieving optimal BP control is inadequate. The majority of hypertensive patients are treated with only one or two antihypertensive drugs.

Cardiovascular outcomes and their relationships to lipoprotein components in patients with and without chronic kidney disease: results from the IDEAL trial

OBJECTIVES

In Incremental Decrease in Endpoints through Aggressive Lipid-lowering (IDEAL), we compared cardiovascular outcomes in patients with and without chronic kidney disease (CKD) (estimated glomerular filtration rate <60 mL min(-1) 1.73 m(-2)) and analysed relationships between lipoprotein components (LC) and major coronary events (MCE) and other cardiovascular (CV) events.

DESIGN

Exploratory analysis of CV endpoints in a randomized trial comparing high dose of atorvastatin to usual dose of simvastatin on MCE.

SETTINGS

Patients with CKD were compared with the non-CKD patients. Cox regression models were used to study the relationships between on-treatment levels of LC and incident MCE.

FINDINGS

Chronic kidney disease was strongly associated with cardiovascular end-points including total mortality. In patients with CKD, a significant benefit of high dose atorvastatin treatment was found for any CV events, stroke and peripheral artery disease, but not for MCE. However, all cardiovascular end-points except stroke and CV mortality were reduced in the non-CKD group. Differential changes in LC or relationships to LC could not explain the different treatment outcomes in MCE in the two groups.

INTERPRETATION

Chronic kidney disease was a powerful risk factor for all cardiovascular end-points. The reason why the significant reductions achieved by high-dose statin treatment in most CV end-points in the non-CKD group were only in part matched by similar reductions in the CKD patients is not apparent. This difference did not result from differential changes in or relations to LC, but limited power may have increased the possibility of chance findings.

Effects of cisapride on gastroparesis in patients with insulin-dependent diabetes mellitus. A double-blind controlled trial

Fourteen insulin-dependent diabetics with symptoms and signs of delayed gastric emptying were treated with a new prokinetic agent, cisapride. In a placebo-controlled cross-over trial no significant differences from placebo was found regarding overall symptomatic effects and effects on gastric emptying of a mixed solid/liquid isotope marked test meal. Solid emptying was most markedly delayed in diabetics compared with healthy controls, but the emptying rate was not correlated to the severity of symptoms as observed for liquid emptying. During active treatment with cisapride the amelioration of symptoms was correlated to increased emptying rates assessed by combined measure of liquid/solid gastric emptying.

Danish singles have a twofold risk of acute coronary syndrome: data from a cohort of 138 290 persons

STUDY OBJECTIVE

Atherosclerosis of the coronary and other arteries is an important health problem in virtually all countries of the world, and thus there is a persisting need for the development of preventive programmes including population risk group identification. The aim of the study was to identify sociodemographic population risk indicators of an initial episode of acute coronary syndrome (ACS), including unstable angina pectoris (UAP), myocardial infarction (MI), and sudden cardiac death (SCD).

DESIGN

Cohort study of 138 290 residents of the municipality of Aarhus, Denmark, aged 30-69 years. Information on population members' individual age, sex, social background, and eventual death was obtained from Danish Population Registers.

SETTING

University hospital.

PATIENTS

The study prospectively identified 646 victims of ACS from 1 April 2000 to 31 March 2002.

MAIN RESULTS

Based on multiple logistic regression, age and single living were found to be positively associated with incident ACS in both sexes. Women >60 years living alone and men >50 years living alone were at especially high risk. They constituted only 5.4% and 7.7% of the source population, respectively, but they accounted for 34.3% and 62.4% of ACS patients dying within 30 days.

CONCLUSIONS

Single living is associated with an increased risk of ACS. Thus, risk groups identified by use of information on their age and family structure may be targets for future more focused and cost effective preventive strategies. In Western populations, such high risk groups will constitute comparatively limited parts of the population, and in Denmark they are easily identifiable in routine population registers.

Synchronization and beam forming in an array of repulsively coupled oscillators

We study the dynamics of an array of Stuart-Landau oscillators with repulsive coupling. Autonomous network with global repulsive coupling settles on one from a continuum of synchronized regimes characterized by zero mean field. Driving this array by an external oscillatory signal produces a nonzero mean field that follows the driving signal even when the oscillators are not locked to the external signal. At sufficiently large amplitude the external signal synchronizes the oscillators and locks the phases of the array oscillations. Application of this system as a beam-forming element of a phase array antenna is considered. The phase dynamics of the oscillator array synchronization is used to reshape the phases of signals received from the phase array antenna and improve its beam pattern characteristics.

Forearm plethysmography in the assessment of vascular tone and resistance vasculature design: new methodological insights

AIM

High peripheral resistance and structural alteration in resistance arteries are central phenomena in essential hypertension and have been widely examined by forearm venous occlusion plethysmography; at rest for studying vascular tone, and during reactive hyperaemia for studying vascular structure. This work concerns the influence of venous pressure on hyperaemic vascular resistance (Rmin), the reproducibility of hyperaemic and resting vascular resistances (Rrest) and the relation between forearm and total peripheral vascular resistance (TPR).

METHODS

In four healthy subjects, intravenous and intra-arterial blood pressures were measured simultaneously with plethysmographic recordings of hyperaemic and resting forearm blood flows. Reproducibility was examined in 15 young and 14 middle-aged healthy subjects and in 21 untreated hypertensive patients.

RESULTS

Rmin remained low in the first recorded cardiac cycle, but rose in the second, even though corrected for the venous pressure rise, suggesting vascular tone recovery along with venous congestion. Between-day reproducibility of Rmin was high in middle-aged normotensive (8.7%) and hypertensive subjects (10.6%), but Rmin fell significantly between successive days in the young subjects. Rrest correlated with TPR, but required up to 40 min to reach steady state and showed high day-to-day variation in young (21.8%) and hypertensive subjects (16.2%).

CONCLUSIONS

During hyperaemia, vascular resistance should be measured in the first cardiac cycle following venous occlusion to minimize influences of venous pressure rise and possible tone recovery. Rrest seems to reflect TPR. About 20 subjects may be needed to detect 15% changes between days in Rrest, fewer when concerning Rmin and TPR.

Repulsive synchronization in an array of phase oscillators

We study the dynamics of a repulsively coupled array of phase oscillators. For an array of globally coupled identical oscillators, repulsive coupling results in a family of synchronized regimes characterized by zero mean field. If the number of oscillators is sufficiently large, phase locking among oscillators is destroyed, independently of the coupling strength, when the oscillators' natural frequencies are not the same. In locally coupled networks, however, phase locking occurs even for nonidentical oscillators when the coupling strength is sufficiently strong.

Quality of lipid-lowering therapy in patients with ischaemic heart disease: a register-based study in 3477 patients

OBJECTIVE

To develop a method to evaluate routine management practices concerning lipid-lowering treatment in patients with ischaemic heart disease (IHD) in a large geographic area.

DESIGN

A register-based study linking information on IHD with cholesterol levels and prescriptions on lipid-lowering medications by personal registration number. Plasma cholesterol levels were collected from the electronic laboratory information system (LIS), and information on IHD from the Danish National Hospital Register (LPR). The extent of treatment was evaluated by information on prescriptions on lipid-lowering medications from the Danish National Health Service.

SETTING

Evaluates treatment in both hospitals and primary care.

SUBJECTS

Patients with IHD.

RESULTS

In total 3477 patients <75 years were identified, and 43.7% had claimed prescriptions on lipid-lowering medications (01.01.2000-31.07.2000). In the whole population, 42% reached the goal for total cholesterol lower than 5 mmol L-1 set by European guidelines. In the 1521 patients treated with lipid-lowering medications 55% reached the goal.

CONCLUSION

By use of registers it was possible to develop a method to evaluate and monitor current treatment practice for dyslipidaemia in a large geographic area. The method makes it possible to evaluate the impact of guidelines, changes in treatment procedures and to provide feedback to physicians. The study revealed that lipid-lowering treatment is still not sufficiently implemented in clinical practice even in patients with known IHD, and the used doses of statins are lower than those used in randomized clinical trials.

Statins decrease bone turnover in postmenopausal women: a cross-sectional study

BACKGROUND

Statins have been suggested as potential agents in the management of osteoporosis. Reviews of medical records have shown an increased bone mass and some studies have shown a reduced occurrence of fractures in subjects on long-term treatment with statins. We studied the effects of treatment with statins on calcium homeostasis, bone turnover and bone mineral density.

DESIGN

In a cross-sectional design, plasma levels of parathyroid hormone (PTH) and biochemical markers of bone turnover, bone mineral density (BMD) and body composition (fat- and lean tissue-mass) were measured in 140 postmenopausal women who had been treated with a statin for more than 2 years (median 4 years) and compared to 140 age- and gender-matched, population-based controls.

RESULTS

Plasma levels of bone turnover markers were lower in the statin-treated subjects than in the controls: osteocalcin (-9%, P = 0.03), bone-specific alkaline phosphatase (-14%, P < 0.01), and C-terminal telopeptide of type I collagen (-11%, P < 0.01). On the other hand, plasma PTH levels were 16% higher in the statin-treated subjects than in the controls (P < 0.01). However, body composition and BMD at the lumbar spine, hip, forearm and whole body did not differ between the two groups. No correlation could be demonstrated between changes in biochemical quantities and dose or duration of statin use.

CONCLUSION

Our data show that statins affect the function of bone cells. Most likely, the effect is antiresorptive.

[Examination and treatment of dyslipemia after myocardial infarction--are the goals achieved?]

According to guidelines, medical treatment of dyslipidaemia in post-AMI patients should await assessment of underlying lipid disorders and the outcome of dietary treatment. The risk of patients not being treated with lipid-lowering therapy because of lack of follow-up has led to more aggressive guidelines recommending statin treatment even before discharge from hospital. In a study comprising 730 patients, we have shown that, although most patients were discharged from the coronary care unit without statin treatment, a traditional rehabilitation programme succeeded in assessing more than 95% of the patients for underlying lipid disorders, and more than 75% of patients with plasma cholesterol > or = 5.5 mmol/l received lipid-lowering therapy within the first year. Most patients were treated with statins. Statins, however, were given in smaller doses than those used in the clinical trials, and only 52% of the treated patients reached the recommended goal of plasma cholesterol lower than 5 mmol/l.

Willingness to pay for arthritis symptom alleviation. Comparison of closed-ended questions with and without follow-up

OBJECTIVE

To compare two methods of measuring willingness to pay (WTP): closed-ended questions with and without follow-up.

METHODS

A measurement experiment based on dichotomous choice contingent valuation survey data is reported. Marginal WTP estimates for alleviation of rheumatoid arthritis symptoms resulting from treatment with a novel anti-rheumatic agent, cA2 (TNF-alpha blockade), were calculated. Monte Carlo simulations were undertaken to evaluate the methods with respect to their statistical power.

RESULTS

The estimated marginal WTP values using closed-ended questions with and without follow-up were DKK 637 (US $91) and DKK 1,268 (US $181), respectively. A Wilcoxon's signed-rank test showed that the difference of DKK 631 was significant. Moreover, including a follow-up question increases the precision of the result. Monte Carlo simulations showed that trade-offs between power (i.e., the probability of a correct rejection of a false null hypothesis), efficiency, and size may exist in the two models.

CONCLUSIONS

There was a significant difference between the WTP estimates when using closed-ended questions with and without follow-up. When choosing between the models, however, power, efficiency, and size could be used as selection criteria.

Normolipidemia and hypercholesterolemia in persons heterozygous for the same 1592 + 5G --> A splice site mutation in the low-density lipoprotein receptor gene

In the present study, we have characterized a unique splice donor G to A substitution in the moderately conserved + 5 position in intron 10 of the low-density lipoprotein (LDL) receptor gene. In two Danish families, carriers of the 1592 + 5G --> A mutation display a clinical phenotype ranging from healthy normocholesterolemic persons to classical heterozygous familial hypercholesterolemia (FH) patients. Reverse transcription-polymerase chain reaction (RT-PCR) of RNA from Epstein Barr virus (EBV)-transformed lymphoblasts obtained from members of both families demonstrated abnormal splicing generating two aberrant mRNAs due to either alternative splicing and skipping of exon 10 or activation of a cryptic splice site in intron 10 inserting 66 intronic base pairs. These abnormally spliced mRNAs were predicted to encode two abnormal receptor proteins containing an in-frame deletion of 75 amino acids and an insertion of 22 novel amino acids, respectively. Results obtained by immunofluorescence staining, flow cytometry, and confocal microscopy of transfected Chang and COS-7 cells expressing normal and mutant LDL receptors were compatible with nearly complete retention of the mutant proteins in the endoplasmic reticulum. Quantitative measurements of LDL receptor mRNAs from EBV-transformed lymphoblasts, however, did not reveal any significant differences in variant mRNA contents between mutation carriers in the families that could be related to degree of hypercholesterolemia.

The clinical usefulness of glucated haemoglobin in diabetes care evaluated by use of a medical technology assessment strategy

With the introduction of measurements of glycated haemoglobin in a single blood sample as an index of long-term blood glucose control, the clinically usefulness of these measurements was questioned. The aim of this study was to evaluate measurements of glycated haemoglobin as a new test for metabolic regulation in diabetes management by use of a medical technology assessment strategy. Technology assessment in medicine has been defined as "the art and science of evaluating medical practices", but the strategy has to be adjusted to the medical technology in question always including the following three stages: (a) problem definition and identification of medical technology, (b) analysis by testing the technology with consideration to its benefit and harm, its costs, and its social consequences, and (c) synthesis of the accumulated knowledge about the technology. Based on the out-put from the problem definition we found it necessary to investigate some of the identified problems ourselves before implementation of routine measurements of glycated haemoglobin. Several studies were accomplished to validate the laboratory technology in terms of analytical reliability and its clinical usefulness. We wanted to (1) define goals of analytical quality of assays of glycated haemoglobin based on clinical goals, (2) establish a laboratory method for measurements of glycated haemoglobin fulfilling the defined goals, (3) investigate the ability of measurements of glycated haemoglobin to characterize impaired glucose tolerance, (4) evaluate the clinical usefulness of measurements of glycated haemoglobin in the assessment of metabolic regulation in non-insulin-dependent diabetes mellitus (NIDDM), (5) compare physicians' assessment of metabolic control in insulin-dependent diabetes mellitus (IDDM) with measurements of glycated haemoglobin and determine whether knowledge of glycated haemoglobin values would result in improved metabolic control, and (6) evaluate the organizational and economical consequences of introducing regular measurements of glycated haemoglobin. The analysis required a multi-disciplinary approach. Based on our own studies and the available data information we found that measurements of glycated haemoglobin should be regarded the most clinically appropriate test of long-term glycemia and should be introduced into routine management of adult patients with IDDM and NIDDM with the following guidelines concerning methodologies, clinical utility, organizational consequences. The individual laboratory has to establish and secure its own method since at present we are still without an internationally accepted reference method or reference material. The method should measure HbA1c without measuring the labile intermediate pre-HbA1c and provide separate detection of haemoglobin variants. We investigated the analytical goals for the performance characteristics of assays based on biological variation and on the clinical significance of a certain change in concentrations in the individual. Different strategies lead to different analytical goals of CVA between 2-4%. An oral glucose tolerance test is still required to establish the diagnosis of diabetes. Measurements of glycated haemoglobin have been suggested as an alternative but a considerable overlap between the WHO-defined groups of normal and impaired glucose tolerance was observed. In patients with IDDM our studies demonstrated the limitations of traditional clinical judgement and the laboratory procedures in providing an accurate assessment of blood glucose control and that knowledge of HbA1c values allowed the clinician to identify patients in poor glycemic control and lead to improvement in glycemic control. In patients with NIDDM our study showed that measurements of HbA1c provided information that was otherwise not obtainable in the usual clinical setting in primary health care. Measurements of glycated haemoglobin were easily accepted by patients with diabetes. (ABSTRACT TRUNCA

Dyslipidemia and coronary artery disease. Prevalence and treatment in patients referred for coronary arteriography

A reduction in serum total cholesterol (T-C) levels has been shown to reduce mortality in patients with coronary artery disease and to decrease the need for revascularization. To examine the prevalence and treatment of lipid disorders in patients referred for their first coronary angiogram, medical history and fasting blood samples were collected in 108 consecutive patients. Ninety-one patients (84.3%) fulfilled the criteria for dyslipidemia. Hypercholesterolemia had previously been demonstrated in 53 patients (49.1%), and 34 (64.2%) of these patients still had T-C > 6.0 mmol/l at the time of admission. Among 55 patients who were unaware of any lipid disorders at admission, 28 (50.9%) had T-C > 6.0 mmol/l.

CONCLUSION

The majority of patients referred for their first coronary angiogram and possible revascularization suffered from dyslipidemia. Many patients with previously recognized dyslipidemia were insufficiently treated.

Phenotypic presentation of the FH-Cincinnati type 5 low density lipoprotein receptor mutation

Familial hypercholesterolaemia (FH) is an autosomal dominant hereditary disease of lipid metabolism that in most families is caused by mutations in the low density lipoprotein receptor (LDLR) gene. Though more than 150 mutations are known, the clinical picture associated with most of these is not known. Genetic FH diagnosis may soon become routine in the setting of genetic counselling, and therefore thorough information on the phenotype-genotype relationship of different mutations is now important. In this study, index patients from each of 14 Danish FH families were screened for mutations in exon 2 of the LDLR gene using a denaturing gradient gel electrophoresis (DGGE)-based mutation screening assay. A deviating DGGE pattern identified two index patients, where subsequent sequencing revealed heterozygosity for the FH Cincinnati type 5 Trp23-to-Stop LDLR mutation. Data from three generations of the families allowed the first clinical and biochemical description of this mutation. Evidence that genetic analysis adds independent diagnostic information compared to traditional clinical/biochemical FH diagnosis was documented by demonstrating the presence of the FH Cincinnati mutation in a family member with a completely normal lipid profile. By comparison to non-FH family members, it was documented that carrier status for the FH Cincinnati mutation is associated with a significant risk of cardiovascular disease. Thus, genetic analysis may improve diagnostic precision and help to define more precisely which of the members of FH families are in need of preventive interventions and may aid in establishing phenotype-genotype relationships allowing more refined genetic counselling in FH.

Genetic diagnosis with the denaturing gradient gel electrophoresis technique improves diagnostic precision in familial hypercholesterolemia

BACKGROUND

Familial hypercholesterolemia (FH) is an autosomal dominant inherited disorder of lipid metabolism caused by mutations in the LDL receptor gene. FH is characterized clinically by elevated LDL cholesterol level and premature coronary disease. Diagnosing FH on clinical grounds may be difficult, and previous genetic methods are too cumbersome for routine use except in the few populations with FH-founder mutations. A simple mutation screening technique based on denaturing gradient gel electrophoresis (DGGE) has been highly useful in detecting mutations in other genes, and in the present study we evaluated the diagnostic potential of this method for the diagnosis of FH.

METHODS AND RESULTS

Conditions for screening exon 3 of the LDL receptor gene using the DGGE technique were established and 14 Danish FH families were examined. An index patient from 1 family had an abnormal DGGE pattern; consequently, an examination of exon 3 of the LDL receptor gene in 21 members of this patient's family was done. The DGGE pattern was seen only in patients with a definite clinical diagnosis of FH. Subsequent sequencing of exon 3 of the LDL receptor gene in these individuals revealed the presence of the French-Canadian type 4 Trp66-Gly mutation. However, in 4 of 11 cases in which a definite clinical diagnosis of FH had been made, the inheritance of the French-Canadian type 4 mutation could be rejected on the basis of genetic analysis.

CONCLUSIONS

Introduction of a simple genetic analysis based on DGGE may improve the precision of diagnosis in FH families.

Detection of a single base deletion in codon 424 of the low density lipoprotein receptor gene in a Danish family with familial hypercholesterolemia

We performed a screening of exon 9 of the low density lipoprotein receptor (LDLR) gene in 14 Danish families with familial hypercholesterolemia (FH) using the denaturing gradient gel electrophoresis (DGGE) technique. In one of the probands from these families an abnormal band pattern in the gradient gel was detected. Subsequent DGGE analysis of the family of this index patient revealed that the DGGE pattern cosegregated with the disease in this family. Sequencing of the exon showed a deletion of a C in codon 424 of the LDLR gene resulting in a frame shift with the introduction of a stop codon 5 codons further downstream. The mutation is referred to as FH-Odense. The predicted truncated receptor protein consists of the 428 amino terminal amino acids. Consequently, the cytosolic and membrane spanning parts of the mature LDL receptor, which normally secure the receptor in the plasma membrane, are missing. The FH-Odense mutation results in severe premature coronary atherosclerosis as shown by the clinical expression in 5 generations of the affected family.

Comparative effects of gemfibrozil and clofibrate in type III hyperlipoproteinemia

Type III hyperlipoproteinemia (dysbetalipoproteinemia) is characterized by elevated concentrations of plasma cholesterol and triglycerides due to an increase in very low density lipoprotein (VLDL) remnant lipoproteins. In a retrospective analysis we observed that in 12 patients with this disorder, gemfibrozil reduced concentrations of total cholesterol, VLDL cholesterol and triglycerides by 48%, 72% and 68%, respectively. These changes were greater than those reported in a similar number of patients treated with clofibrate. Comparative data on the efficacy of different fibrates in this disorder are very limited; to assess this further we have compared the hypolipidemic effects of gemfibrozil (600 mg twice daily) and clofibrate (1 g twice daily) in six patients with well-characterized type III hyperlipoproteinemia. Baseline values were obtained after at least 8 weeks on diet and treatment values were obtained after 6 and 8 weeks of treatment with each drug. Treatment with clofibrate and gemfibrozil both resulted in significant reductions in the plasma concentrations of total cholesterol (40% and 54%), VLDL cholesterol (59% and 79%) and total triglycerides (48% and 70%), as well as a significant increase in HDL cholesterol (9% and 7%). Gemfibrozil was, however, significantly (P < 0.05) more effective in reducing plasma concentrations of total cholesterol, VLDL cholesterol and triglycerides than was clofibrate, in the same patients.

Intraventricular streptokinase increases cerebrospinal fluid D dimer in preterm infants with posthaemorrhagic ventricular dilatation

Failure to lyse multiple small blood clots in the cerebrospinal fluid (CSF) reabsorption pathways may be one of the mechanisms leading to posthaemorrhagic ventricular dilatation (PHVD). It has been suggested that intraventricular administration of streptokinase may resolve PHVD but it is not known whether such treatment produces an increase in fibrin degradation products in the CSF. Ventricular CSF was collected from six infants with PHVD before and during intraventricular treatment with streptokinase 1000 units/h. In all six infants, CSF D dimer increased during streptokinase treatment. Median D dimer before treatment was 1642 micrograms/l and during treatment 5440 micrograms/l (p < 0.05). Undetectable D dimer levels in plasma during streptokinase treatment ruled out the possibility that D dimer had merely diffused into the CSF. This augmentation of local fibrinolysis may have therapeutic potential. There was no evidence of systemic fibrinolysis.

Hypertriglyceridemia and low HDL: therapeutic considerations

The recently revised guidelines for cholesterol management in Europe and the USA have focused attention on triglycerides and HDL cholesterol as risk factors for coronary heart disease. In the present review, I shall discuss therapeutic considerations in the treatment of patients with hypertriglyceridemia or low HDL cholesterol in the context of these new recommendations. I shall also consider recent studies in which the effect of triglyceride-lowering drugs on the concentrations and metabolism of lipoproteins in patients with dyslipidemia are evaluated.

Drug treatment of dyslipoproteinemia

This article has focused on the appropriate indications for lipid-lowering drugs in adult patients with different lipoprotein disorders, which we have divided into primary hypercholesterolemia, combined hyperlipidemia,and hypertriglyceridemia. The mechanism of action, efficacy, and safety profile of the major drugs have been reviewed, and based on this information, we have presented our views on the appropriate drugs of first choice and appropriate second-choice agents for treatment of adult patients with different dyslipidemias. The rationale for the use of hypolipidemic drugs is strongest in patients with hyperlipidemia who concurrently have evidence for coronary or peripheral vascular disease, in whom the goal of secondary prevention is to retard further progression of atherosclerosis and potentially induce some regression, whereas in selected high-risk patients without evidence of atherosclerosis, the goals of therapy are to prevent the premature development of CAD or, in patients with severe hypertriglyceridemia, prevent the adverse sequelae of hepatomegaly, splenomegaly, and potentially pancreatitis. We have focused on the use of hypolipidemic drugs in adult patients, and the guidelines discussed are not appropriate for use in children with hyperlipidemia, in whom drug therapy should be undertaken selectively and in consultation with a lipid specialist. Many areas of controversy in the use of lipid-lowering drugs remain to be addressed by future studies; these include the use of lipid-lowering drugs in patients with secondary causes of hyperlipidemia (e.g., the nephrotic syndrome), the use of lipid-lowering drugs in women, and recommendations for drug therapy in older patients.

[Treatment of primary hypercholesterolemia with pravastatin. A placebo-controlled trial]

We present the results of a multicentre, placebo-controlled, randomized double-blind comparison of the treatment of primary hypercholesterolaemia with pravastatin (Pravachol), an HMG-CoA-reductase inhibitor. The study was conducted in both general practice and hospital settings. Two hundred and eighty-six patients who despite oral and written dietary instructions and advice on healthy living had elevated total serum cholesterol levels of between six and eight mmol/l were randomized to treatment with either parvastatin (Pravachol) or placebo. The study showed a significant reduction in both total serum cholesterol (of 16%) and serum LDL-cholesterol among those treated with pravastatin (Pravachol), as well as a small increase tin serum HDL-cholesterol of six percent. Advice on diet and healthy living resulted in a reduction of serum cholesterol of only 1.5%. There were no important differences between those treated from the hospital and those treated in general practice. The incidence of side-effects was low and comparable to placebo levels, and only two percent of the pravastatin (Pravachol) treated patients had to have the treatment stopped. All side-effects were reversible. No side-effects relating to the central nervous system were registered, and no elevations of serum creatinine phosphokinase were observed amongst the pravastatin treated patients, presumably because of the drug's selective inhibitory effect on cholesterol synthesis in the liver.

Analytical Goal-Setting for Monitoring Patients When Two Analytical Methods are Used

Serial results from an individual are often obtained using more than one method. Results should be transferable over time and locale. Every method has inherent analytical error, and goals are required to delineate the maximum allowable random (imprecision) and systematic (inaccuracy, bias) errors to facilitate optimal patient care. Based on Harris's proposal [Am J Clin Pathol 1979;72:374-82] that desirable imprecision should be less than or equal to one-half the within-subject biological variation, if the methods have negligible imprecision, then the maximum allowable bias between two methods used for monitoring is one-third of the within-subject biological variation. A more general model has been developed that relates the analytical imprecisions of two methods, and the bias between them, to biological variation. Applying the general formula derived in specific clinical monitoring situations in which a known change in serial results (occurring at a stated probability) stimulates clinical action allows goals for the imprecisions of the two methods and allows the difference in bias between them to be determined quantitatively.

Analytical goal-setting for monitoring patients when two analytical methods are used

Serial results from an individual are often obtained using more than one method. Results should be transferable over time and locale. Every method has inherent analytical error, and goals are required to delineate the maximum allowable random (imprecision) and systematic (inaccuracy, bias) errors to facilitate optimal patient care. Based on Harris's proposal [Am J Clin Pathol 1979;72:374-82] that desirable imprecision should be less than or equal to one-half the within-subject biological variation, if the methods have negligible imprecision, then the maximum allowable bias between two methods used for monitoring is one-third of the within-subject biological variation. A more general model has been developed that relates the analytical imprecisions of two methods, and the bias between them, to biological variation. Applying the general formula derived in specific clinical monitoring situations in which a known change in serial results (occurring at a stated probability) stimulates clinical action allows goals for the imprecisions of the two methods and allows the difference in bias between them to be determined quantitatively.

[Leadership and professionalism]

In 1990 a new organizational structure based on decentralization and team leadership, where the leader (usually a doctor) is responsible for the final decision, was introduced at the regional and university hospital of Tromsø. This structure replaces the traditional dual structure of leadership where the leaders (a doctor and a nurse) did not share responsibility for the whole department. In order to analyze organizational practices after the reform we constructed three different organization models of the hospital: the hierarchical model, the professional model and the workshop model. Of five teams, one functioned hierarchically, three resembled the professional model, and the fifth came close to the workshop model. The leader of the hierarchical team behaves autocratically and the employees are dissatisfied. In the three remaining teams conditions have changed very little compared with the situation before the reorganization. In the workshop team decisions are reached jointly. This team functions in an innovative way. Even though the new organizational structure has quite divergent consequences and some leaders have problems, the majority of the hospital employees support the new structure.

Extrinsic pathway inhibitor (EPI) released to the blood by heparin is a more powerful coagulation inhibitor than is recombinant EPI

EPI released to the blood after injection of heparin, as well as recombinant EPI (r-EPI) added to normal plasma prolonged both the dilute Tissue Thromboplastin (TTP) time and the Activated Partial Thromboplastin Time (APTT). It is known that EPI inhibits both factor Xa and the factor VIIa-TTP complex. The prolongation of the APTT by EPI reflects only its inhibition of factor Xa. Addition of anti-EPI immunoglobulins (IgG) to normal plasma shortened the dilute TTP time 7.3 seconds (p less than 0.001) and the APTT by 0.7 seconds (p less than 0.001). In postheparin plasma, with polybrene added to neutralize the direct effect of heparin, the TTP was about 26 seconds longer and the APTT about 9 seconds longer than baseline values. These effects were completely abolished by anti-EPI IgG, as were the effects of r-EPI. The EPI activity (chromogenic substrate-assay) of this postheparin plasma was 1.7 U/ml. The EPI activity of the plasma spiked with r-EPI to obtain comparable effects on clotting were much higher; about 22 U/ml for the TTP effect and about 5 U/ml for the APTT effect. The findings indicate that r-EPI is considerably less potent than postheparin EPI as inhibitor of plasma coagulation. This is most striking when coagulation is initiated through the extrinsic pathway. Possibly, the anticoagulant effect of r-EPI mainly depends on its Xa inhibitory effect.

Chromogenic substrate assay of extrinsic pathway inhibitor (EPI): levels in the normal population and relation to cholesterol

A two-stage chromogenic substrate assay was standardized to measure extrinsic pathway inhibitor (EPI) activity in plasma and serum samples. In the first stage, diluted plasma or serum (0-0.8%) was incubated with factor VIIa (25 pM), tissue thromboplastin (tissue factor, TF, 1% v/v) with excess binding sites for factor VIIa, and factor Xa (0.8 nM). In the second stage, excess factor X and chromogenic substrate were added as substrate for residual TF/factor VIIa catalytic activity. Heating the samples at 56 degrees C for 15 min before assay removed greater than 95% of the factor VII amidolytic activity of the samples, defibrinated the plasma, and produced only slight reduction of EPI activity. The coefficient of variation for the same sample assayed on different days was 8.7-10.6% and the intra-assay coefficient of variation was 5.0%. Addition of anti-EPI immunoglobulin to normal plasma completely abolished the EPI activity of the sample. EPI activity was stable in plasma samples stored at -20 degrees C, but in serum, some samples lost greater than 50% activity after 3 months at -70 degrees C. Median EPI activity of umbilical cord blood was 45% (range 33-93%). In a cohort of healthy blood donors (n = 176) EPI activity was significantly correlated with age; the regression line was y = 68% + 0.60x (r = 0.39). The approximated standard deviation for the regression line was 17.9% and the age-adjusted reference limits were determined. Equal levels were seen in males and females.(ABSTRACT TRUNCATED AT 250 WORDS)