Total and cause-specific mortality rates in a prospective study of community-acquired hepatitis C virus infection in northern Norway.

Knowledge of the natural course and especially the total and cause-specific mortality of community-acquired chronic HCV infection is limited. The aims of our study were to determine the total and cause-specific mortality in patients infected with chronic hepatitis C in a community-based setting in northern Norway. This prospective cohort study included 1010 HCV-positive patients diagnosed with recombinant immunoblot assay between 1 January 1990 and 1 January 2000, with a median observation time from diagnosis to follow-up of 7 years. Data were collected from medical records in the period between 1 January 2004 and 30 June 2006. Time and cause of death were ascertained from the Norwegian Causes of Death Register. Age-adjusted death rates and standardised mortality ratios (SMRs) were compared with those of the general Norwegian population. In total, 122 deaths were recorded. The Kaplan-Meier estimate of survival was 88% at 14 years. The SMR in the cohort relative to the general population was 6.66. Most of the excess deaths in both genders were because of liver-related causes, those associated with a drug-using lifestyle and suicide. The statistically significant increase in SMRs ranged from 4.2 for death by cancer in women to 64.6 for liver disease in women. There was no statistically significant increase in SMRs from cardiovascular disease in either gender or from cancer in men. In conclusion, our study shows that the death rate in patients infected with hepatitis C is 6.66 times higher than in the general Norwegian population.

Does admission to a medical department improve patient life expectancy?

Doubts about the effectiveness of medical care in improving patient health have been raised by epidemiological studies and by studies of geographical variation and inappropriate use of health care. To investigate this problem, the life expectancy gain (LEG) from consecutive admissions to a department of internal medicine during a six-week period was assessed by two expert panels, each consisting of an internist, a surgeon, and a general practitioner. The mean LEG for all admissions was 2.25 years (n = 422). Sixty-one percent had a LEG of 0.10 years or less, while 5% had a LEG of more than 9.98 years. In a probabilistic sensitivity analysis, the mean LEG remained greater than zero under assumptions of overestimated positive LEG and underestimated negative LEG. We conclude that the life expectancy of the majority of the patients was not influenced by the admission, but that a minority had substantial gains, resulting in a high overall mean LEG.

Effectiveness of antihypertensive treatment in chronic renal failure: to what extent and with which drugs do patients treated by nephrologists achieve the recommended blood pressure?

Adequate control of blood pressure (BP) is important to slow the progression of chronic renal failure (CRF). The Joint National Committee (JNC) VI recommends BP <130/85 mmHg, or <125/75 mmHg if urinary protein excretion exceeds 1 g/d. Angiotensin converting enzyme inhibitors (ACE-I) are considered as first-line agents. The current study is a survey of the degree of goal achievement and prescription patterns of antihypertensive (AHT) medication according to the JNC guidelines in clinical nephrology practice. All patients with CRF, not on renal replacement therapy, treated by nephrologists at the University Hospital of North-Norway were included in this retrospective cross-sectional study. Data on protein:creatinine ratio (PC ratio), BP and AHT drugs prescribed were extracted from the hospital's databases and medical records. A total of 144 patients were included. The patients' age was 62+/-16 years and the serum creatinine value was 210+/-92 micromol/l (mean+/-s.d.). In all, 74 patients (51%) had PC ratio < or =1, 36 (25%) >1, and for 34 (24%) PC ratio had not been measured; 23 (31%) of the patients with PC ratio < or =1 had BP < or =130/85 (139+/-21/78+/-12), and 5 (14%) of those with PC ratio >1 had BP < or =125/75 (145+/-22/85+/-14). Failure to achieve the goal was most commonly due to elevated SBP. In all, 55 % of the patients were prescribed ACE-I or angiotensin receptor blocker (ARB). In conclusion, the recommended BP goals may be difficult to achieve for a high proportion of patients in clinical practice due to difficulty in lowering SBP. There is a potential for improved treatment of hypertension in CRF patients, including increased prescription of ACE-I and ARB.

Lipoma of the breast: a diagnostic dilemma.

Lipoma of the breast often causes diagnostic and therapeutic uncertainty. Clinically it may be difficult to distinguish a lipoma from other conditions. Fine-needle aspiration cytology (FNAC) is often not helpful. Both mammography and ultrasound scanning are often negative. For the present study, 108 women with a clinical diagnosis of lipoma were enrolled prospectively. The clinical diagnosis of lipoma was found to be incorrect in 25.0% of these cases. Mammography and ultrasound revealed a lipoma in only 3.0% and 21.0%, respectively. FNAC revealed only fat cells in 74.0% of cases. In all, only 9 patients (11.4%) fulfilled the triple diagnostic criteria, theoretically making tumour excision mandatory in the remaining cases. Our proposal for management is for any clinical diagnosis of lipoma to be confirmed by either FNAC revealing fat cells or a core biopsy consistent with a lipoma. The mammogram and the ultrasound need not necessarily demonstrate a lipoma, but obviously must not show anything to raise the suspicion of malignancy at the site. If these criteria are met it is not necessary to excise the tumour.

[Fetal chylothorax]. / Føtal chylothorax.

Foetal chylothorax was diagnosed in female foetus by ultrasound scanning on account of suspected twin pregnancy at the 34th week. No other signs of hydrops foetalis were found. The chylothorax reformed rapidly following intrauterine thoracocentesis which was therefore repeated immediately before Cesarean section at the 38th week in order to facilitate the perinatal cardiopulmonary adjustment. Pulmonary maturation was found to be normal. Postnatally, marked chylous effusion in the pleural cavity continued. Conservative treatment with pleural drainage and total parenteral nutrition was attempted initially. On account of the absence of response and supervening infection, it was decided to operate after the elapse of three weeks. Pleural decortication was performed with good result.

In chronic kidney disease staging the use of the chronicity criterion affects prognosis and the rate of progression.

The Kidney Disease Outcomes Quality Initiative definition and staging of chronic kidney disease (CKD) have been adopted by most nephrologists but include a criterion of chronicity that has not been investigated. This criterion specifies that renal structural damage and/or reduction in glomerular filtration rate (GFR) should be present for periods lasting longer than 3 months. We examined the effects of changing this criterion to 6, 9, or 12 months on the prognosis and the rate of progression in population-based cohorts with CKD stages 3 and 4. A 12-month chronicity criterion significantly reduced the number of CKD patients relative to the 3-month criterion for both stages 3 and 4. For both stages, there were statistically significant differences in 5-year mortality between the 6- and 9-month cohorts. For stage 4, the 5-year cumulative incidence of renal failure significantly increased from 6 to 9 months, and the rate of change in GFR significantly decreased between the same two cohorts. The 5-year cumulative incidence of improvement in GFR lasting 1 year or more was significantly higher for the 3-month cohort than for the 12-month cohort in the stage 3 group. Hence, we suggest that the chronicity criterion is an important determinant of the characteristics of the population of patients with CKD stages 3 and 4. This may have practical consequences in both research and clinical work.

Proinsulin:insulin and insulin:glucose ratios as predictors of carotid plaque growth: a population-based 7 year follow-up of the Tromsø Study.

AIMS/HYPOTHESIS: Proinsulin is increased in persons at cardiovascular risk. Increased secretion of proinsulin relative to insulin has been suggested as a sign of defective conversion of proinsulin to insulin and C-peptide and is associated with beta cell dysfunction. It has also been suggested that proinsulin has more of a pro-atherogenic effect than insulin, the levels of which are also increased in the insulin resistance state. In this prospective population-based study, we examined whether the proinsulin:insulin ratio (PIR) or insulin:glucose ratio (IGR, an insulin resistance surrogate) predicted carotid plaque size in nondiabetic participants. MATERIALS AND METHODS: The study included 1,859 men and 1,998 women aged 25-82 years from the Tromsø Study, who were examined with B-mode high resolution ultrasound at baseline in 1994-1995 and at follow-up in 2001-2002. All images were computer processed to yield mm(2) measures of plaque. Proinsulin and insulin were measured at baseline. All analyses were stratified for sex. RESULTS: After adjusting for age, baseline plaque area, BMI, cholesterol, HDL-cholesterol, HbA(1c), IGR, albumin:creatinine ratio, fibrinogen, BP and lifestyle factors (tobacco smoking, alcohol consumption, physical activity), PIR was significantly associated with plaque size at follow-up in women but not men. For each SD in the PIR in women, the mean plaque area increased by 0.97 mm(2) (95% CI 0.44-1.50). IGR was not associated with carotid plaque size. CONCLUSIONS/INTERPRETATION: The PIR is associated with progressive carotid artery plaque size in women.

The progression of chronic kidney disease: a 10-year population-based study of the effects of gender and age.

The increase in demand for renal replacement therapy makes it important to investigate the prognosis of the earlier stages of chronic kidney disease (CKD). We examined the change in glomerular filtration rate (GFR), and patient and renal survival in CKD stage 3 in the municipality of Tromsø, a well-defined European community with a population of 58,000. All patients with estimated GFR between 30 and 59 ml/min/1.73 m(2) for more than 3 months during a 10-year study period were identified from a complete database of all 248 560 measurements of serum creatinine made in the community in the study period. Change in GFR was estimated for each patient using a multilevel model. A complete follow-up with respect to patient and renal survival was obtained from hospital databases. A total of 3047 patients was included. The median number of measurements of creatinine for each patient was 9, and the median observation time was 44 months. Mean estimated change in GFR was--1.03 ml/min/1.73 m(2)/year. Seventy-three percent of the patients experienced a decline in GFR. The 10-year cumulative incidence of renal failure was 0.04 (95% CI 0.03-0.06) and mortality 0.51 (95% CI 0.48-0.55). Female gender was associated with slower decline in GFR and better patient and renal survival. In this population-based study, the decline in GFR in CKD was slower than in previously studied selected patient groups. A high mortality pre-empted the development of renal failure in many patients. The prognosis of CKD depended strongly on gender.

[Which measures can increase research activity at Norwegian hospitals?]. / Hvilke tiltak kan øke forskningsaktiviteten ved universitetssykehusene?

BACKGROUND: Less medical research is carried out in Norway than in the other Nordic countries. In order to improve this situation, clinical research units have been established at the university hospitals. However, factors other than those remedied by such measures are known to hinder clinical research. We wanted to explore potential researchers' views on what factors are keeping them from doing research or increasing their research activity. MATERIAL AND METHODS: Questionnaires were sent to all physicians and psychologists at the University Hospital of Tromsø. They included questions about research background, ongoing research projects, and factors hindering research. RESULTS: The questionnaire was answered by 289 physicians and psychologists, a response rate of 74%. 38% were engaged in ongoing research projects. 81% responded that lack of time due to clinical work prevented them from doing research or increasing their research activity. 50% were hindered by factors that may be remedied by the clinical research units, but only 6% by such factors alone. INTERPRETATION: Establishing clinical research units is a necessary, but not sufficient precondition for increasing research activity at the University Hospital of Tromsø. Lack of time is experienced as the most important factor hindering research; little improvement can be expected if this problem is not addressed.

Is the general practitioner hospital a potential "patient trap"? A panel study of emergency cases transferred to higher level hospitals.

OBJECTIVES: 1. To find out whether a stay in local general practitioner hospitals (GP hospitals) prior to an emergency admission to higher level hospitals aggravated or prolonged the course of the disease, or contributed to permanent health loss for some patients. 2. To detect cases where a transitory stay in a GP hospital might have been favourable. DESIGN: A retrospective expert panel study based on records from GP hospitals and general hospitals. The included patients had participated in a previous prospective study of consecutive admissions to GP hospitals during 8 weeks. SETTING: Fifteen out of 16 GP hospitals in Finnmark county, Norway. SUBJECTS: Seventy-three patients transferred to higher level hospitals from a total of 395 admitted to GP hospitals. MAIN OUTCOME MEASURES: Three outcome categories were considered for each patient: "possible permanent health loss", "possible significantly prolonged or aggravated disease course", and "possible favourable effect on the disease course". RESULTS: There was agreement about the possibility of negative effects in two patients (2.7%), while a possible favourable influence was ascribed to six cases (8.2%). CONCLUSION: Negative health effects due to transitory stays in GP hospitals are uncommon and moderate, and balanced by benefits, particularly with regard to early access to life saving treatment for critically ill patients.

Prediction of five-year survival for patients admitted to a department of internal medicine.

OBJECTIVE: The effect of many common forms of therapy, as medication for mild hypertension or hypercholesterolaemia, only reaches clinical significance after years of treatment. The meaningful application of such therapy presupposes that physicians can, at least to some extent, predict the remaining lifetime of patients. We investigated whether clinicians from different disciplines were able to predict the 5-year survival of patients admitted to a department of internal medicine. DESIGN: The members of two groups, each consisting of an internist, a surgeon and a general practitioner, made individual predictions of the expected remaining lifetime of discharged patients from written summaries of clinical information. Each patient was randomized to be assessed by the members of either of the two groups. The predictions were compared with actual 5-year survival. SETTING: Department of internal medicine at a university hospital. SUBJECTS: Patients admitted consecutively during a 6-week period. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values and areas under the receiver operating characteristic (ROC) curves for predictions of 5-year survival for each of the six experts. RESULTS: A total of 402 patients were included. Five-year survival was 0.63. The sensitivity of the predictions ranged from 0.81 to 0.95, the specificity from 0.61 to 0.77, the positive predictive value from 0.78 to 0.87 and the negative predictive value from 0.68 to 0.87. The areas under the ROC curves ranged from 0.84 to 0.91. CONCLUSION: The quality of predictions of 5-year survival made by experienced clinicians should permit the rational use of treatments with long-term effects.

Peptic ulcer patterns in Arctic Norway.

While there are four times as many duodenal as gastric ulcers in Europe and the United States, previous studies have shown gastric ulcers to be more common in the Arctic regions of Norway. To investigate a possible change in the duodenal-to-gastric ulcer ratio, the incidence rate of first-time peptic ulcer in a well defined population in Northern Norway was studied by registration of all examinations of the upper digestive tract from 1983 to 1984. In this population, 5.3% were examined by endoscopy (52.5%) or a barium meal (47.5%). The incidence rates of duodenal and gastric ulcers were 1.4 and 0.8 per 1,000 per year, resulting in a duodenal-to-gastric ulcer ratio of 1.7:1. Although this ratio is higher than in a previous study (1.1:1), the pattern of peptic ulcer disease in northern Norway is still different from that in the rest of Europe.

The cost of inappropriate admissions: a study of health benefits and resource utilization in a department of internal medicine.

OBJECTIVES: High rates of inappropriate hospital admissions have been found in numerous studies, suggesting that a high percentage of hospital resources are, in effect, wasted. The degree to which this is true depends on how costly inappropriate admissions are compared to other admissions. This study aimed to estimate both the percentage and cost of inappropriate admissions. SETTING: Department of internal medicine at a teaching hospital. SUBJECTS: Consecutively admitted patients during a six-week study period. MAIN OUTCOME MEASURES: Assessments of inappropriateness were based on estimates of health benefit and necessary care level. These estimates were made by expert panels using a structured consensus method. Health benefit was estimated as gain in quality-adjusted life years, or degree of short-term improvement in quality of life during or shortly after the hospital stay. The direct costs to the hospital of each stay were estimated by allocating the costs of labour, 'hotel' and overhead according to length of stay and adding to this the cost of ancillary resources used by each individual patient. RESULTS: A total of 422 admissions were included. The 102 (24%) judged to be inappropriate had a lower mean cost (US$ 2532) than the other 320 (US$ 5800) (difference 3268; 95% confidence interval 1025-5511). The inappropriate admissions accounted for 12% of the total costs. CONCLUSIONS: Denying care for inappropriate admissions does not generate cost reductions of the same magnitude. Policy makers should be cautious in projecting the cost savings potential of excluding inappropriate admissions.

Cost savings and health losses from reducing inappropriate admissions to a department of internal medicine.

OBJECTIVES: Inappropriate hospital admissions are commonly believed to represent a potential for significant cost reductions. However, this presumes that these patients can be identified before the hospital stay. The present study aimed to investigate to what extent this is possible. METHODS: Consecutive admissions to a department of internal medicine were assessed by two expert panels. One panel predicted the appropriateness of the stays from the information available at admission, while final judgments of appropriateness were made after discharge by the other. RESULTS: The panels correctly classified 88% of the appropriate and 27% of the inappropriate admissions. If the elective admissions predicted to be inappropriate had been excluded, 9% of the costs would have been saved, and 5% of the gain in quality-adjusted life-years lost. The corresponding results for emergency admissions were 14% and 18%. CONCLUSIONS: The savings obtained by excluding admissions predicted to be inappropriate were small relative to the health losses. Programs for reducing inappropriate health care should not be implemented without investigating their effects on both health outcomes and costs.

Does admission to a department of internal medicine improve patients' quality of life?

OBJECTIVES: The Tromsø Medical Department Health Benefit Study was designed to estimate health gains from admissions to a department of internal medicine. We have previously reported that the hospital stays had no effect on the life expectancy of 61% of the patients. However, it has been claimed that modern medicine has a greater effect on quality of life (QoL) than on life expectancy. The aim of the present study was to investigate this issue by estimating gains in QoL for patients admitted to a department of internal medicine. DESIGN: The time trade-off method (TTO) was used for assessing QoL gain from consecutive admissions during a 6-week period. The assessments were made by one of two expert panels, each consisting of an internist, a surgeon and a general practitioner, on the basis of summaries of all relevant clinical information about the patients. Short-term improvements in QoL during the stay or shortly after discharge were scored on an ordinal scale. RESULTS: Of the admitted patients, 41% had gains in QoL measured with the TTO (mean gain = 0.06; 95% confidence interval = 0.05-0.07; n = 422), and eight of these had gains equal to or greater than 0.50. Another 40% had gains in health-related short-term QoL measured with the ordinal scale. In a multivariate linear regression analysis, emergency admissions, high age and the disease categories 'endocrinological diseases' and 'pneumonia and influenza', were associated with higher gain, and 'undiagnosed symptoms' and 'cerebrovascular diseases' with lower gain. CONCLUSIONS: As judged by the expert panels, the investigated department of internal medicine was effective in improving the QoL of 81% of the admitted patients. Whilst most of the patients achieved small gains, a minority had gains in QoL corresponding to the treatment of life-threatening diseases.

Assessing health benefit from hospitalization. Agreement between expert panels.

Agreement between two expert panels in assessing gain in life expectancy and quality of life from unselected stays in a department of internal medicine was investigated. Weighted kappa statistics of 0.45 for gain in life expectancy and 0.63 for gain in quality of life were found.