Gender affirming treatment and employment rate in 3,812 Danish transgender persons and 38,120 controls

OBJECTIVE

Gender affirming care could be associated with higher employment rate. We assessed employment rates in transgender persons compared to controls and demographic, health and treatment-related factors associated with employment in transgender persons.

METHODS

National register-based cohort study in Danish persons with diagnosis code of gender dysphoria during year 2000-2021. Five age-matched controls of the same sex at birth and five age-matched controls of the other sex at birth were included. The date of study inclusion was the first date of transgender diagnosis. Employment was the primary study outcome.

RESULTS

The cohort included 3,812 transgender persons and 38,120 cisgender controls. The median age (interquartile range) was 19 (15; 24) years for transgender men, n = 1,993 and 23 (19; 33) years for transgender women, n = 1,819. In transgender men compared to control cisgender women, the odds ratio (95% confidence interval) for employment was 0.33 (0.29; 0.38) before study inclusion and 0.24 (0.20; 0.29) in the fifth calendar year after index; in transgender women compared to control cisgender men, corresponding ORs were 0.30 (0.70; 0.34) and 0.21 (0.18; 0.25). Similar findings were found between transgender persons and cisgender controls of other sex. Use of gender affirming hormone in transgender men increased probability of employment at all time points with odds ratio after 5 years: 1.61 (1.08; 2.42), p = 0.02 (95% confidence interval). In transgender women, use of hormone treatment was not associated with changed employment rates, 5 years odds ratio 1.31 (0.94; 1.82), p = 0.11.

CONCLUSION

Masculinizing hormone treatment was associated with higher probability of employment.

Gender-affirming treatment and mental health diagnoses in Danish transgender persons: a nationwide register-based cohort study

IMPORTANCE

Gender affirming treatment aims to improve mental health.

OBJECTIVE

To investigate longitudinal mental health outcomes in Danish transgender persons.

DESIGN

National register-based cohort study in Danish transgender persons with diagnosis code of "gender identity disorder" during the period 2000-2021.

PARTICIPANTS

Five age-matched controls of the same sex at birth and five age-matched controls of the other sex at birth were included for each transgender person.

MAIN OUTCOMES

Diagnosis codes of mental and behavioral disorders and/or prescription of psychopharmacological agents until June 2022.

RESULTS

The cohort included 3812 transgender persons with median age (interquartile range) 19 (15; 24) years for persons assigned female at birth (AFAB, N = 1993) and 23 (19; 33) years for persons assigned male at birth (AMAB, N = 1819) and 38 120 controls. Follow up duration was up to 10 years with mean (standard deviation) 4.5 (4.3) years. In transgender persons AFAB compared to control women, the odds ratio (OR) (95% confidence interval) for mental and behavioral disorders was 6.7 (5.5; 8.1) before the index date, 9.9 (8.4; 11.7) at 1 year, 5.8 (4.4; 7.7) at 5 years, and 3.4 (2.1; 7.5) at 8 years follow up. In transgender persons AMAB compared to control men, corresponding ORs were 5.0 (4.0; 6.4), 11.3 (9.3; 13.7), 4.8 (3.5; 6.5), and 6.6 (4.2; 10.3) at 8 years follow up (all P < .001).

CONCLUSION

The OR for mental health disorders was higher in transgender persons compared to controls and remained elevated throughout follow up, especially in transgender persons AMAB.

Cardiovascular risk in Danish transgender persons: a matched historical cohort study

BACKGROUND

Cardiovascular risk could be increased in transgender persons, but the mechanism is undetermined.

AIM

The aim of this study was to assess the risk of cardiovascular outcomes in Danish transgender persons compared to controls.

METHODS

The study design was a historical register-based cohort study in Danish transgenders and age-matched controls. The main outcome measure was cardiovascular diagnosis (any CVD) including medicine prescriptions for CVD during 2000-2018. The transgender cohort (n = 2671) included persons with International Classification of Diseases-10 diagnosis code of 'gender identity disorder' (n = 1583) and persons with legal sex change (n = 1088), 1270 were assigned female at birth (AFAB) and 1401 were assigned male at birth (AMAB). Controls (n = 26 710) were matched by age (n = 5 controls of same and n = 5 controls of other birth sex) of the respective transgender.

RESULTS

The median (interquartile range) age at study inclusion was 22 (18; 29) years for AFAB and 26 (21; 39) years for AMAB. The mean (s.d.) follow-up time was 4.5 (4.2) years for AFAB and 5.7 (4.8) years for AMAB. The hazard ratio (HR) for any CVD was significantly higher in transgenders vs controls of same and other birth sex, with highest adjusted HR in transgenders AFAB vs control men: 2.20 (95% CI: 1.64;2.95), P < 0.001. Gender-affirming hormone treatment (GAHT) explained part of elevated risk of CVD in transgenders AFAB, whereas GAHT did not contribute to the elevated risk of CVD in transgenders AMAB.

CONCLUSIONS

The risk of cardiovascular diagnosis was increased in transgenders. The mechanism should be further investigated.

Gender affirming hormonal treatment in Danish transgender persons. A nationwide register-based study

BACKGROUND

Gender affirming hormonal treatment (GAHT) is a cornerstone in transgender care. National data are sparse regarding use of hormonal treatment by transgender persons.

AIM

To assess use of GAHT in transgender persons.

DESIGN

National register-based cohort study in Danish transgender persons followed from 2000 until 2018. The main outcome measure was prescription and purchase of GAHT. Persons with ICD-10 diagnosis code of "gender identity disorder" (CGI-cohort) and persons with legal sex change but without diagnosis (CPR-cohort) were included. In the CGI-cohort, transgender women were defined by prescription of estrogen and/or cyproterone acetate and/or testosterone-5-alpha reductase inhibitors and transgender men were defined by prescription of testosterone after study inclusion. Discontinuation of GAHT was defined as no purchase of GAHT ≥ 13 months or shift from feminizing to masculinizing hormone treatment, or vice versa.

RESULTS

The cohort included 2789 transgender persons (n = 1717, CGI-cohort and n = 1072, CPR-cohort). The median age (interquartile range) at study inclusion was 26.1 (17.7) years for persons assigned male at birth (n = 1447) and 22.5 (10.5) years for persons assigned female at birth (n = 1342). In the CGI-cohort, the event rate for GAHT in transgender women increased from 4.0 (95% CI: [3.1; 5.2]) events per 100 person in year 2000-2005 to 20.6 [17.8; 23.7] between 2014 -2018. In transgender men, the event rate of GAHT increased from 4.2 [2.8; 6.2] to 18.8 [16.4; 21.6]. The rate of discontinuation of GAHT was 0.06 (95% CI 0.049; 0.071) per person year.

CONCLUSIONS

The event rate of GAHT increased during 2000-2018. Our data suggested high adherence to GAHT. This article is protected by copyright. All rights reserved.

Socioeconomic status in Danish transgender persons: a nationwide register-based cohort study

BACKGROUND

Gender dysphoria could be associated with low socioeconomic status (SES). SES could be modified by age, ethnic background, and medical morbidity.

AIM

To determine SES in a national study population including transgender persons in Denmark.

METHODS

National register-based cohort study in Danish transgender persons and age-matched controls. The transgender study cohort included persons with ICD-10 diagnosis code of 'gender identity disorder' and/or persons with legal sex change and persons who fulfiled the inclusion criteria during 2000-2018. The main outcome measure was SES including personal income, occupational status, and education.

RESULTS

The cohort included 2770 transgender persons and 27,700 controls. In the transgender study cohort, 1437 were assigned male at birth (AMAB), median age (interquartile range, IQR) 26.0 (17.3) years, and 1333 were assigned female at birth (AFAB), median age 22.5 (10.3) years. Adjusting for age and sex, the relative risk ratio (RRR) of low vs high personal income was 5.6 (95% CI: 4.9; 6.3) in transgender persons compared to controls. The RRR of low vs high income was 6.9 (5.8; 8.3) in persons AMAB compared to control males and 4.7 (3.9; 5.6) in persons AFAB compared to control females. The RRR of low vs high income was 3.7 (3.2; 4.3) in transgender persons of Danish origin compared to controls. The Charlson comorbidity index was comparable in transgender persons vs controls.

CONCLUSIONS

Being transgender was negatively associated with SES. In transgender persons, the risk of low vs high income could be more pronounced in transgender persons of foreign origin.

Gender incongruence in Denmark, a quantitative assessment

INTRODUCTION

The number of persons with gender incongruence referred to health care is increasing, but national data on the incidence of gender incongruence are lacking. The aim of this study was to quantify the development in number of individuals with gender incongruence over time and to estimate the national incidence in Denmark.

MATERIAL AND METHODS

Historical descriptive cohort study. Individuals older than 18 years with legal sex-change in their person registration number were achieved from Statistics Denmark, and the National Health Register provided data on contact diagnoses related to gender-identity conditions. By combining these two data sources, we made estimates on incidence and incidence rates for individuals with gender incongruence in Denmark through a 41-year period 1980-2020.

RESULTS

Through 1980-2020, the annual number of legal sex-changes increased in individuals assigned female at birth from 5 to approximately 170 and among individuals assigned male at birth from 10 to approximately 150. The cumulative number of legal sex-changes at the end of 2019 was 1275 assigned female at birth and 1422 assigned male at birth and 66% of the legal sex-changes were in individuals below 30 years. Correspondingly, the annual number of contacts with the healthcare system due for gender-identity-related conditions increased from 30 during 1990-1999 to around 500 in 2017 (both genders combined), with a 10-fold increase from 2010 to 2017.

CONCLUSIONS

The number of legal sex-changes and healthcare contacts due to gender-identity-related diagnoses increased substantially over the last 40 years with a more than 10-fold increase during the last decade. This calls for research on possible explanations for this increase, for research on the short-term and long-term health consequences of hormonal and surgical treatment regimens and for ensuring adequate healthcare facilities.

[Sex reassignment surgery in Denmark]

This review summarises the knowledge of sex reassignment surgery in Denmark. Sex reassignment surgery aims at confirming a transgender person's gender identity and can consist of surgery on breasts, genitals, thyroid cartilage, vocal cords as well as facial and body contours. In Denmark, most procedures are performed at a highly specialised level after referral to Center for Gender Identity. Some choose to get procedures performed abroad. Depending on the surgical procedure additional surgery can be necessary, however, patient satisfaction is generally high. Surgery has been shown to increase patients' quality of life and decrease gender dysphoria.

Treatment of Factor XIII Deficiency with Cryoprecipitate

In in vitro and in vivo investigations of two patients with congenital factor XIII-deficiency it was demonstrated that cryoprecipitate contains a high factor XIII-activity. Cryoprecipitate in small amounts, given as intravenous injections every 3 or 4 weeks seems to be useful as a prophylactic treatment of patients with severe haemorrhagic due to factor XHI-deficiency.

Sexual assault: a descriptive study of 2500 female victims over a 10-year period

OBJECTIVE

To describe the victims of sexual assault and the circumstances in which the assaults occur.

DESIGN

Descriptive case study.

SETTING

Centre for Victims of Sexual Assault (CVSA), Rigshospitalet, Copenhagen, Denmark.

POPULATION OR SAMPLE

A total of 2541 women attending CVSA from 2001 to 2010.

METHODS

All women attending CVSA underwent a standardised data collection procedure. Descriptive bivariate analysis and logistic regression analysis were performed.

MAIN OUTCOME MEASURES

Associations between different assault characteristics and (1) the age of the victim and (2) the relationship between victim and perpetrator.

RESULTS

Two-thirds of the victims were aged 15-24 years. Seventy-five percent had met the perpetrator before the sexual assault and 70% reported the assault to the police. A physical injury was found in 53, and 27% sustained an anogenital lesion. Alcohol was involved in 60% of the cases. One-third of the victims had experienced a previous sexual assault(s). Women were more likely to report to the police when they were assaulted by a stranger (odds ratio [OR] 1.9, 95% confidence interval [95% CI] 1.3-2.6) and sustained a physical injury (OR 1.7, 95% CI 1.4-2.2) or anogenital lesion (OR 1.5, 95% CI 1.1-2.0). Women aged 45 years or older were more likely to sustain a physical injury (OR 2.0, 95% CI 1.2-3.2) or an anogenital lesion (OR 2.1, 95% CI 1.4-3.2).

CONCLUSIONS

Our results challenge the typical stereotype of a violent rape attack by a stranger, which is important in creating an environment where women are not reluctant to seek help after a sexual assault. Young age and drinking alcohol were risk factors for sexual assault, and we need to address this when considering preventive strategies.

The hepatic conversion of vitamin D in alcoholics with varying degrees of liver affection

The seasonal variations in circulating 25-hydroxycholecalciferol (25-HCC) were studied in 102 alcoholics with fatty liver disease without histologic signs of cirrhosis and in 35 patients with alcoholic cirrhosis. The mean levels were compared with those of normal persons. Alcoholics had generally lower 25-HCC values than the controls, particularly in the summer. This was primarily explained by insufficient diet and reduced exposure to sunshine. The ability of the liver to hydroxylate in the 25-position was studied in three groups of alcoholics with 1) fatty liver disease without cirrhosis, 2) compensated cirrhosis, 3) severely incompensated liver cirrhosis. All three groups exhibited a significant increase in serum 25-HCC following the peroral administration of cholecalciferol at a dose of 1 200 U daily for 7 days. Similar rises were seen 7 days after a single injection of 10 000 U cholecalciferol. This indicates a normal intestinal absorption of vitamin D, even in advanced alcoholic liver disease, and is inconsistent with a severely damaged 25-hydroxylation capacity in these patients. Osteomalacia due to impaired liver hydroxylation of vitamin D can hardly explain the increased fracture rate and the decreased bone mass, which have been described in alcoholics.

Acute hepatitis: a prognostic study with observation time up to 37 years. A follow-up of the Iversen/Roholm liver biopsy material

Re-evaluation of 890 consecutive liver biopsies from 1939-59 gave the diagnosis of acute hepatitis in 147 patients. A follow-up study of these patients was performed 15-37 years after the diagnostic biopsy, based on repeated liver biopsies, biochemical liver tests, autopsy reports and death certificates. Two patients died from acute liver failure, and development of cirrhosis was documented or strongly suspected in 22 patients (15 percent). A comparison between these 24 patients with a malignant course of hepatitis and 86 patients with a well documented uncomplicated disease, revealed a significantly larger number of women, a higher age, and more cases with piece-meal necrosis, confluent necrosis and marked portal inflammation in the intitial liver biopsy in the group with the poor prognosis.

Patients’ experiences of abuse in health care: a Nordic study on prevalence and associated factors in gynecological patients

BACKGROUND

In an earlier Swedish study conducted with The NorVold Abuse Questionnaire, we found that one-third of female patients who had experienced adult abuse in health care (AAHC) had a background of childhood emotional, physical and/or sexual abuse (EPSA) ('revictimised'). But since the majority of women with AAHC were 'new victims' without such a background, there might be other factors associated with AAHC. The present study aimed to map prevalence of abuse in health care (AHC), and associated variables among new victims and revictimised patients.

METHODS

We carried out a cross-sectional questionnaire study at 5 Nordic gynecological clinics. Associations between AAHC and other variables were tested in a multivariate model in 4 groups of women with adult EPSA, childhood EPSA, childhood and adult EPSA, and no EPSA.

RESULTS

The response rate was 77% (n=3,641). The overall prevalence of any lifetime experience of AHC was 13-28%. High educational level, physical complaints, post-traumatic stress symptoms, and sleeping problems were associated with AAHC in women without EPSA (new victims). Poor self-rated health was strongly associated with AAHC in the 3 groups of women with EPSA.

CONCLUSION

AHC is commonly reported by gynecological patients in the Nordic countries, but not yet properly explored or understood. The most important factors associated with AAHC were high educational level and poor self-rated health.

Genitoanal injury in adult female victims of sexual assault

OBJECTIVES

To evaluate the presence and extFent of genitoanal injury among sexually assaulted women and to estimate the risk of injury in subgroups according to the type of assault and to the sexually assaulted women's susceptibility to injury.

STUDY DESIGN

A case-control study of 249 women exposed to sexual assault. Injury identified by gross visualization. Women with and without injury were compared. Logistic regressions analyses were performed to calculate the risk of injury.

RESULTS

Thirty-two percent sustained genitoanal injury. Anal penetration and assaults on women without prior sexual experience were associated with genitoanal injury.

CONCLUSIONS

Most women do not have visible genitoanal injuries. The risk of sustaining genitoanal injury during a sexual assault is higher among women without prior sexual intercourse experience and among women exposed to anal penetration. The severity of the assault is a poor predictor of genitoanal injury.

Women's perceived experiences of abuse in the health care system: their relationship to childhood abuse

OBJECTIVES

The aim of this study was to determine whether there was an association between any lifetime experiences of emotional, physical and/or sexual abuse and perceived abuse in the health care system. Furthermore, we wanted to ascertain if adult victims of perceived abuse in the health care system reported exposure to childhood emotional, physical and/or sexual abuse more often than non-victims did.

DESIGN

A cross sectional questionnaire study. The first hypothesis was tested in the total sample, and the second hypothesis in a case-control analysis. The cases were those women who reported perceived experiences of abuse in the health care system as adults. Exposure was defined as experience of emotional, physical and/or sexual abuse in childhood.

SETTINGS

Three Swedish gynaecological clinics.

SAMPLE

A total of 2439 gynaecology patients (response rate 81%).

METHODS

Postal questionnaire.

MAIN OUTCOME MEASURE

Associations between experiences of emotional, physical and/or sexual abuse, and perceived abuse in the health care system; all operationalised in The NorVold Abuse Questionnaire (NorAQ).

RESULTS

A general association was found between lifetime experiences of emotional, physical and/or sexual abuse and perceived abuse in the health care system. Adult victims of abuse in the health care system reported experiences of emotional, physical and/or sexual abuse in childhood more often than non-victims did. These findings also held after adjustment for age and educational level.

CONCLUSIONS

We found associations between experiences of any lifetime abuse and perceived abuse in the health care system. Adult victimisation in the health care system was associated with childhood exposure to emotional, physical and/or sexual abuse. These associations call for attention and need to be further investigated.

A history of sexual abuse and health: a Nordic multicentre study

OBJECTIVES

To determine if a history of sexual abuse is associated with objective and subjective indicators of health and if certain abusive incidents had a stronger impact on health than others.

DESIGN

A cross-sectional, multicentre study.

SETTING

Five gynaecological departments in the five Nordic countries.

SAMPLE

Three thousand five hundred and thirty-nine gynaecology patients.

METHODS

The NorVold Abuse Questionnaire (NorAQ) on abuse history and current health was mailed to all patients who consented to participate.

MAIN OUTCOME MEASURES

Reason for index visit at the gynaeocological clinic as well as several questions on health were recorded. General health status was measured as self-estimated health, psychosomatic symptoms (headache, abdominal pain, muscle, weakness, dizziness), number of health care visits and number of periods on sick leave.

RESULT

A history of sexual abuse was reported by 20.7% of respondents. A history of sexual abuse was significantly associated with chronic pelvic pain as reason for index visit (P < 0.01), laparoscopic surgery (P < 0.01), psychosomatic symptoms (P < 0.01), self-estimated poor health (P < 0.01), many health care visits (P < 0.01) and high incidence of sick leave (P < 0.01). Several subgroups within the group of sexually abused women were more likely to report poor health: women abused as both children and adults, women who experienced additional emotional and/or physical abuse and women abused by a person they knew.

CONCLUSION

Sexual abuse has a profound impact on women's health. Taking a history of sexual abuse seems particularly warranted when the patient presents with chronic pelvic pain or symptoms of a vague and diffuse nature.

Are sociodemographic and regional and sample factors associated with prevalence of abuse?

BACKGROUND

The aims of the present study were: 1) to estimate the prevalence of emotional, physical and sexual abuse and abuse in the health care system, and 2) to study the associations between prevalence of abuse and sociodemographic and sample variables.

METHODS

This cross-sectional study used a validated postal questionnaire in four Swedish samples; patients at three gynecologic clinics with different character and in different regions (n = 2439) and women in one randomized population sample (n = 1168).

RESULTS

Any lifetime emotional abuse was reported by 16.8-21.4% of the women; physical abuse by 32.1-37.5%; sexual abuse by 15.9-17.0%; and abuse in the health care system by 14.0-19.7%. For 7-8% abuse had included life threats and 9-20% of all women in the study currently suffered from their experiences of abuse. Most women had not disclosed their background of abuse to the gynecologist. There were differences in sociodemographic variables between the four samples. Generally, in the multivariate analyses we found associations between prevalence of abuse and age, educational level, civil status and occupation, but no consistent association between prevalence of abuse and sample variables.

CONCLUSION

Lifetime prevalence rates of the four kinds of abuse were high in all samples as measured by the NorVold Abuse Questionnaire (NorAQ), and 1/10-1/5 women in the study suffered currently from abusive experiences. In multivariate analyses prevalence of abuse was consistently associated with sociodemographic but not to sample variables.

Women's experiences of the gynecologic examination: factors associated with discomfort

BACKGROUND

The aim of this study was to evaluate how women experience the gynecologic examination and to assess possible factors associated with experiencing discomfort during the gynecologic examination.

METHODS

Consecutive patients visiting the Department of Obstetrics and Gynecology at Glostrup County Hospital, Denmark, were invited to participate in the study, and received a postal questionnaire that included questions about the index visit, obstetric and gynecologic history and sexual abuse history. The response rate was 80% (n = 798). The degree of discomfort during the gynecologic examination was indicated on a scale from 0 to 10. Experiencing discomfort was defined as a score of 6 or more, based on the 75th percentile.

RESULTS

Discomfort during the gynecologic examination was strongly associated with a negative emotional contact with the examiner and young age. Additionally, dissatisfaction with present sexual life, a history of sexual abuse and mental health problems such as depression, anxiety and insomnia were significantly associated with discomfort.

CONCLUSION

The emotional contact between patient and examiner seemed to have great importance when focusing on discomfort during the gynecologic examination. Furthermore, we found that discomfort was associated with a number of factors that are seldom known to the gynecologists, such as sexual abuse history, mental health problems and patients' sexual life. Gynecologists need to focus on the emotional contact and to reevaluate issues for communication before the examination.

Emotional, physical, and sexual abuse in patients visiting gynaecology clinics: a Nordic cross-sectional study

BACKGROUND

Abuse against women causes much suffering for individuals and is a major concern for society. We aimed to estimate the prevalence of three types of abuse in patients visiting gynaecology clinics in five Nordic countries, and to assess the frequency with which gynaecologists identify abuse victims.

METHODS

We did a cross-sectional, multicentre study of women attending five departments of gynaecology in Denmark, Finland, Iceland, Norway, and Sweden. We recruited 4729 patients; 3641 (77%) responded and were included in the study. Participants completed a postal questionnaire (norvold abuse questionnaire) confidentially. Primary outcome measures were prevalences of emotional, physical, and sexual abuse, and whether abused patients had told their gynaecologist about these experiences. We assessed differences between countries with Pearson's chi(2) test.

FINDINGS

The ranges across the five countries of lifetime prevalence were 38-66% for physical abuse, 19-37% for emotional abuse, and 17-33% for sexual abuse. Not all abused women reported current ill-effects from the abusive experience. Most women (92-98%) had not talked to their gynaecologist about their experiences of abuse at their latest clinic visit.

INTERPRETATION

Despite prevalences of emotional, physical, and sexual abuse being high in patients visiting gynaecology clinics in the Nordic countries, most victims of abuse are not identified by their gynaecologists. This lack of discussion might increase the risk of abused patients not being treated according to their needs. Gynaecologists should always consider asking their patients about abuse.

[Sexually transmitted infections and sexual violence against women. Guidelines for examination, prophylactic treatment and follow-up]

Based upon a literature search, but also considering the situation in Denmark, guidelines for examination, prophylactic treatment and follow-up of female victims of sexual assault have been prepared. A pragmatic attitude, looking upon the victim's situation and fear of having acquired a sexually transmitted infection, has been prevailing in order to avoid unnecessary examinations and treatments. The guidelines are directed towards female victims in whom the assault has included vaginal, oral, and/or anal penetration or attempt of penetration. It is concluded that all victims should be screened for and offered prophylactic treatment for chlamydia. Screening for gonorrhea initially and at follow-up is recommended but treatment only if an infection has been established. All victims should be screened for hepatitis B initially and again after three months and vaccination offered if any information indicates that the assailant has an increased risk of hepatitis B. All victims should be screened for HIV initially and again after one and three months. In single cases antiviral HIV prophylaxis must be considered.

Carvedilol and atenolol once daily in the treatment of hypertension

Fifty milligrams of carvedilol and 100 mg atenolol were administered in a random order once a day for 2 months to 43 patients with mild to moderate hypertension, in a double-blind crossover study. Blood pressure, heart rate and peripheral blood flow parameters (n = 11) were recorded 2 and 24 h after the drug administration. Supine blood pressure was the same 2 h after both carvedilol and atenolol administration, but carvedilol caused a greater decrease in standing systolic blood pressure 2 h after the administration (P less than 0.05). The heart rate decreased less with carvedilol (P less than 0.01). There was no difference in the effects exerted by the two therapies on systolic blood pressure and the heart rate 24 h after drug administration, but the diastolic blood pressure was higher in patients given carvedilol (92 versus 88 mmHg; P less than 0.05). Forearm blood flow, forearm vascular resistance and calf blood flow did not change significantly with either of the therapies. In conclusion, 50 mg carvedilol once a day is an effective antihypertensive therapy, though its duration of action did not reach that of 100 mg atenolol once a day. Peripheral vasodilation was similar with both therapies.

[Reduction of mortality in acute myocardial infarction with streptokinase and aspirin therapy. Results of ISIS-2]

This investigation includes 17,187 patients in 417 hospitals in 16 countries admitted within 24 hours of the commencement of symptoms of acute myocardial infarction (AMI). The patients were allotted at random to the following treatments 1) intravenous infusion of 1.5 million International Units streptokinase (SK) during one hour, 2) 160 mg acetyl salicylic acid (ASA) daily for 30 days, 3) both SK and ASA and 4) placebo treatment only. The five-week cardiovascular mortality was reduced by 25% following infusion of streptokinase from 12.0% to 9.2% and by 23% during ASA treatment from 11.8% to 9.4%. The combination of SK and ASA resulted in 42% reduction in the cardiovascular mortality after five weeks compared with the placebo. The effect of SK was greatest if treatment was instituted within six hours but effects were obtained after all of the first 24 hours. The preliminary results show that the reduction in mortality obtained by both SK and ASA appears to continue during the subsequent one to two years. SK treatment resulted in haemorrhage requiring treatment in 0.5% as compared with 0.2% in the placebo group, more cases of proved cerebral haemorrhage, 0.1% as compared with 0.0%, but fewer cases of cerebral apoplexy, 0.7% as compared with 0.8%. It is concluded that thrombolysis with SK combined with prophylaxis of repeated thrombosis with ASA is the indicated treatment in cases of AMI and less than 6-24 hours duration.

Erythropoietin-induced secondary polycythemia in a patient with a renal cell carcinoma. A case report

This study provides clear documentation of in vivo biogenesis of erythropoietin (Epo) by a human renal carcinoma. A middle-aged woman with a clear cell renal carcinoma of the left kidney developed severe polycythemia. This polycythemia was accompanied by markedly elevated levels of immunoreactive erythropoietin both in the peripheral venous blood, and in blood derived from the left renal vein during nephrectomy. Exstirpation of the non-invasive renal carcinoma was followed by complete restoration of both hematocrit and erythropoietin plasma concentration to normal levels. The fall in plasma erythropietin concentration immediately after nephrectomy (T/2 less than or equal to 3 hours) was probably a valid representation of plasma erythropoietin metabolism in this patient. Direct evidence of erythropoietin production in individual renal carcinoma cells was provided by immunoperoxidase studies demonstrating focal cytoplasmatic accumulation of immunoreactive erythropoietin in the tumor cells.

Liver histology in a 'normal' population--examinations of 503 consecutive fatal traffic casualties

The liver histology of 503 consecutive victims of fatal (within 24 hours) traffic accidents submitted to medico-legal autopsy are used as a standard of reference. In 370 persons (74%) no pathological changes in the liver biopsies were observed. Fatty liver was found in 120 persons (24%), non-specific portal inflammation in 7 persons, alcoholic hepatitis in 6, and portal fibrosis in 5. No cases of cirrhosis, chronic aggressive hepatitis, changes compatible with chronic persistent hepatitis, viral hepatitis, or other internationally accepted morphological diagnoses were found. A significant positive correlation between the frequency of steatosis and age groups was demonstrable. Fatty liver was found in 1% of persons below 20 years, in 18% between 20--40 years, and in 39% of persons more than 60 years in this normal material. The persons with fatty liver had a higher body weight, but the overweight was not correlated to age. It is concluded that fatty infiltration in the liver is a normal observation in aged persons.

Studies on the serum lipid and lipoproteins in steatosis of the liver

In a medical department, specialized in liver diseases, 45 patients (33 men and 12 women) suffering from steatosis of the liver have been examined with reference to serum lipid abnormalities. Twenty-eight of the patients were chronic alcoholics. Annual check-ups, including biopsy of the liver, were made to evaluate the development of the steatosis. The patients did not receive treatment with drugs or diet. Thirteen patients showed hypercholesterolemia, 16 increased serum triglyceride and 8 increased serum phosphorus lipid. Two showed a type I lipoprotein anomaly and 33 a type II-like pattern, defined as increased beta-lipoprotein associated with increase of serum cholesterol, was found in four cases. Three had a type III and three a type IV abnormal pattern, with increased pre-beta-lipoprotein and serum triglyceride levels. Correlation analysis revealed correlations between pre-beta-lipoprotein and serum triglyceride as well as between serum triglyceride and serum free fatty acid levels.