Stroke identification by criteria based dispatch - a register based study.

BACKGROUND: Rapid and precise dispatch of resources is a key element in pre-hospital emergency medicine. Emergency medical communication centres (EMCCs) dispatch resources based on protocols and guidelines, balancing the acute need of the individual and the resource allocation of the pre-hospital emergency medical system. The aim of this study was to determine the validity of stroke identification by the Norwegian dispatch guidelines. METHOD AND MATERIAL: This was a register-based study where patients suspected for stroke were compared to those with the final diagnosis of stroke as an indicator group for the guideline validation. One EMCC and its three associated hospitals participated with 13 months of data. Four subcodes of the stroke dispatch code were defined as suspicious of stroke and further analysed. Factors associated with stroke identification were explored. RESULTS: The sensitivity for identifying a stroke patient at initial EMCC contact was 57.9% (51.5, 64.1), specificity was 99.1% (98.9, 99.2), positive predictive value was 45.7% (40.1, 51.4) and negative predictive value was 99.4% (99.3, 99.5). The emergency medical access telephone (113) was initial EMCC contact line in only 48% of the cases. Paralyses and admittance to a smaller hospital were associated with increased probability for stroke (OR 2.6, P = 0.001 and OR 2.7, P = 0.01), respectively. CONCLUSION: The sensitivity for identification of stroke patients by the dispatch guidelines is modest, while the specificity is high. The 113 telephone line was initial EMCC access point for less than half of the stroke patients.

Factors associated with disallowance of compulsory mental healthcare referrals.

OBJECTIVE: Norwegian studies report that a substantial amount of referrals for compulsory mental health care are disallowed at specialist assessment, at a rate that varies with referring agent. Knowledge on factors associated with disallowance could improve the practice of compulsory mental health care. This study aims to examine such factors, placing particular emphasis on the impact of referring agents. METHOD: This study utilized data from the prospective, longitudinal cohort study 'Suicidality in Psychiatric Emergency Admissions' conducted at a Norwegian psychiatric emergency unit which served approximately 400 000 inhabitants. Data on referral, admission and patient characteristics were retrieved on compulsory admissions conducted between 1 May 2005 and 30 April 2008. Bivariate and logistic regression analyses and structural multilevel modelling were performed. RESULTS: Among 2813 compulsory admissions, 764 were disallowed. Low competence in the referring agent, high GAF S score, observed alcohol or drug intoxication, reported suicide risk, and the presence of neurotic, stress-related and somatoform disorders, personality disorders and other non-specified diagnoses were associated with above average disallowance frequency. Non-Norwegian ethnicity and schizophrenia spectrum disorders were associated with below average disallowance rates. CONCLUSION: Among several factors associated with disallowance, low symptom load was the strongest, whilst referring agent competence modestly affected disallowance rate.

Initial prescription of antipsychotics and antidepressants in general practice and specialist care in Norway.

OBJECTIVE: To examine the incidence rates of antipsychotic (AP) and antidepressant (AD) drug treatment in Norway and the proportions initiated in general practice and specialist care respectively. METHOD: Data on all prescriptions of APs and ADs dispensed to the general population in Norway from 1 January 2004 until 31 August 2009 were extracted from the Norwegian Prescription Database. This information was merged with data about general practitioners (GPs) from the Norwegian Regular General Practitioner Scheme. RESULTS: One-year incidence rates per 1000 inhabitants were 3.4 for APs and 8.6 for ADs. GPs initiated 58% of APs and 73% of ADs, while psychiatrists initiated 15% and 6% respectively. Psychiatrists initiated treatment more often among younger patients, and they prescribed relatively newer drugs more commonly than GPs. A large share of incident users did not refill their prescriptions for APs (57%) or ADs (33%). CONCLUSION: GPs have a key role as regards initiating treatment with APs and ADs in Norway, while psychiatrists' influence seems limited, particularly among older patients. Efforts for quality improvement of mental health care need to involve primary health care. In addition, an increased focus from psychiatrists towards the increasingly ageing part of the population seems requisite.

The effect of urinary incontinence status during pregnancy and delivery mode on incontinence postpartum. A cohort study.

OBJECTIVE: The objectives of this study were to investigate prevalence of urinary incontinence at 6 months postpartum and to study how continence status during pregnancy and mode of delivery influence urinary incontinence at 6 months postpartum in primiparous women. DESIGN: Cohort study. SETTING: Pregnant women attending routine ultrasound examination were recruited to the Norwegian Mother and Child Cohort Study (MoBa). POPULATION: A total of 12,679 primigravidas who were continent before pregnancy. METHODS: Data are from MoBa, conducted by the Norwegian Institute of Public Health. Data are based on questionnaires answered at week 15 and 30 of pregnancy and 6 months postpartum. MAIN OUTCOME MEASURES: Urinary incontinence 6 months postpartum is presented as proportions, odds ratios and relative risks (RRs). RESULTS: Urinary incontinence was reported by 31% of the women 6 months after delivery. Compared with women who were continent during pregnancy, incontinence was more prevalent 6 months after delivery among women who experienced incontinence during pregnancy (adjusted RR 2.3, 95% CI 2.2-2.4). Adjusted RR for incontinence after spontaneous vaginal delivery compared with elective caesarean section was 3.2 (95% CI 2.2-4.7) among women who were continent and 2.9 (95% CI 2.3-3.4) among women who were incontinent in pregnancy. CONCLUSION: Urinary incontinence was prevalent 6 months postpartum. The association between incontinence postpartum and mode of delivery was not substantially influenced by incontinence status in pregnancy. Prediction of a group with high risk of incontinence according to mode of delivery cannot be based on continence status in pregnancy.

Norwegian regular general practitioners' experiences with out-of-hours emergency situations and procedures.

OBJECTIVE: To study the participation of Norwegian regular general practitioners (RGPs) in the out-of-hours system in 2006 and what kind of emergency situations and procedures they experienced in the past 12 months. RGPs' confidence in performing certain emergency procedures was also mapped. METHODS: In May 2006 all 3804 RGPs taking part in the RGP scheme in Norway were sent a questionnaire dealing with several aspects of the emergency out-of-hours duty. The RGPs who had participated were asked about 14 pre-selected emergency situations, experiences with different pre-selected emergency procedures and their self-confidence with these in the past 12 months. RESULTS: After two reminders 2913 (78%) answered and 1832 (63%) confirmed they had taken part in emergency out-of-hours services in the past 12 months. 95% of participating RGPs answered questions about emergency situations, 74-78% about emergency procedures. The most common situations were chest pain, psychiatric problems and asthma, experienced by 94%, 92% and 88%, respectively. The number of occasions the doctors had experienced the most frequent emergency procedures (presented as median 25-75% percentiles) were: intravenous medication, three (1-10); oxygen mask, three (1-10); venous access, four (1-10). The doctors reported almost no experiences with other procedures. The doctors reported a high self-confidence in performing the emergency procedures. Male doctors working four or more shifts per month and doctors working in rural areas reported more experiences both in emergency situations and procedures. CONCLUSION: Approximately two-thirds of RGPs in Norway took part in the out-of-hours service. A wide variety of emergency cases was experienced by the RGPs. Despite this, experiences with most emergency procedures during a 12-month period are low. Regular training is therefore necessary to maintain good skill levels.

Confidence in Procedural Skills before and after a Two-Year Master's Programme in Family Medicine in Gezira State, Sudan.

Many postgraduate family medicine training programmes have been developed to meet the worldwide dire need for practicing family physicians. This study was conducted in Gezira state of Sudan in a "before-and-after" design in the period of 2010-2012 with the aim to assess improvements in candidates' confidence in performing certain clinical skills. A self-evaluation questionnaire was used with a five-grade scale (1-5) to assess candidates' confidence in performing 46 clinical skills. A group of 108 participants responded for both the "before" and the "after" questionnaire: the response rate was 91% (before) and 90% (after). In general, a positive progress trend was detected. The mean skill value for all skills was 3.23 (before) and 3.93 (after) with a mean increase of 21.7% (P < 0.001). Male students scored constantly higher than females both before and after completing the master's programme, while females showed a higher percentage in progress. Scores in certain medical disciplines were higher than others. However, disciplines with low scores in the beginning, such as psychiatry and ophthalmology, showed the highest progress percentage. The results show a significant increase in confidence in performing procedural skills designed in the curriculum of the GFMP master's programme.

Tx-discs--no effect against subjective health complaints: a randomised controlled study.

BACKGROUND: Dowsers claim unhealthy effects of 'earth rays', and the producer of TX-discs claims that these discs may shield a person from the influence of 'earth rays', thereby relieving most illness in the person shielded. OBJECTIVES: To compare the effects of the TX-disc versus a placebo disc in patients with longstanding muscular-skeletal complaints. SETTING: Self-recruited community living persons in the Bergen area, Western Norway. PATIENTS: 67 women and 13 men with longstanding muscular-skeletal complaints, recruited by advertisements in local newspapers. DESIGN: A randomised and double-blinded controlled trial with a 6 months follow-up period. MAIN OUTCOME MEASUREMENT: The Subjective Health Complaints (SHC) questionnaire. RESULTS: We found a substantial reduction on the mean SHC sub-scale scores of muscular-skeletal, pseudo-neurological, gastro-intestinal, and allergic complaints, mainly occurring from baseline to 6 weeks (28-45%, P < 0.05-0.001). There were however no statistically significant differences for these variables between the TX group and the placebo group at any time point. IMPLICATIONS: TX-discs used in accordance with the instructions had no clinically or statistically significant effect on muscular-skeletal pain, pseudo-neurological complaints, gastro-intestinal, or allergic complaints during this study.

Telemedicine and E-Learning in a Primary Care Setting in Sudan: The Experience of the Gezira Family Medicine Project.

Information and communication technology (ICT) is progressively used in the health sector (e-health), to provide health care in a distance (telemedicine), facilitate medical education (e-learning), and manage patients' information (electronic medical records, EMRs). Gezira Family Medicine Project (GFMP) in Sudan provides a 2-year master's degree in family medicine, with ICT fully integrated in the project. This cross-sectional study describes ICT implementation and utilization at the GFMP for the years 2011-2012. Administrative data was used to describe ICT implementation, while questionnaire-based data was used to assess candidates' perceptions and satisfaction. In the period from April 2011 to December 2012, 3808 telemedicine online consultations were recorded and over 165000 new patients' EMRs were established by the study subjects (125 candidates enrolled in the program). Almost all respondents confirmed the importance of telemedicine. The majority appreciated also the importance of using EMRs. Online lectures were highly rated by candidates in spite of the few challenges encountered by combining service provision with learning activity. Physicians highlighted some patients' concerns about the use of telemedicine and EMRs during clinical consultations. Results from this study confirmed the suitability of ICT use in postgraduate training in family medicine and in service provision.

Test-dependent changes in nociception after administration of the putative serotonin antagonist metitepin in mice.

Intraperitoneal administration of the putative serotonin receptor antagonist metitepin (0.06-1.0 mg/kg) in mice induced dose-dependent antinociception in the increasing temperature hot-plate test and the formalin test, but elicited hyperalgesia in the tail-flick test. Reduced motor activity was observed after injection of the largest dose of metitepin, but did not influence the behavioural responses in the tests. Selective lesions of ascending serotonergic pathways induced by administration of the neurotoxin p-chloroamphetamine 5 and 6 days before testing (40 mg/kg each day) did not directly affect the responsiveness in any of the tests but enhanced the metitepin-induced antinociception in the hot-plate and formalin tests. The hyperalgesia in the tail-flick test was not affected by the lesions. The results suggest that metitepin may alter nociception in mice by exhibiting both agonist and antagonist properties on central serotonergic receptors.

Antinociceptive effects of serotonergic reuptake inhibitors in mice.

The antinociceptive effects of three predominantly serotonergic reuptake inhibitors, alaproclate, citalopram and clomipramine, were examined in mice using the hot-plate, formalin and substance P tests. The effects were compared with those of the noradrenergic reuptake inhibitor, desipramine. Different profiles in the three nociceptive tests were found for all four drugs, using doses of 10 and 40 mg/kg. The selective serotonergic reuptake inhibitor, alaproclate, seemed to have the least antinociceptive effects, and was the only drug that was ineffective in the hot-plate test. The other selective drug, citalopram, had a stronger effect than alaproclate in the substance P test, but in the formalin test, both drugs were approximately equally effective. Clomipramine differed from citalopram by being more effective in the formalin test. These findings thus indicate that selective inhibitors of the uptake of 5-HT have weaker antinociceptive effects than less selective drugs. Desipramine seemed to be no less effective than the serotonergic drugs and was the most potent drug in the hot-plate test.

Intrathecal injection of capsaicin can be used as a behavioural nociceptive test in mice.

Intrathecal injections in mice of substance P (SP), capsaicin and kainic acid elicited a behavioural response similar to that caused by noxious stimulation. Although the agents have different mechanisms of action, they showed a similar response, consisting of biting, scratching and licking the caudal parts of the body. Activation of adenosine receptors in the spinal cord with 5-N-ethylcarboxamide adenosine (NECA) had no effect on the response to substance P or to kainic acid, but reduced the response to capsaicin. It is concluded that different substances, injected intrathecally, can be used to differentiate between pre- and postsynaptic induced nociceptive behaviour, and that this assay may be valuable in assessing central antinociceptive effects of various drugs, especially those affecting systems modulated by substance P.

A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trøndelag.

OBJECTIVES: The aim was to assess the prevalence of any urinary leakage in an unselected female population in Norway, and to estimate the prevalence of significant incontinence. METHODS: The EPINCONT Study is part of a large survey (HUNT 2) performed in a county in Norway during 1995-97. Everyone aged 20 years or more was invited. 27,936 (80%) of 34,755 community-dwelling women answered a questionnaire. A validated severity index was used to assess severity. RESULTS: Twenty-five percent of the participating women had urinary leakage. Nearly 7% had significant incontinence, defined as moderate or severe incontinence that was experienced as bothersome. The prevalence of incontinence increased with increasing age. Half of the incontinence was of stress type, 11% had urge and 36% mixed incontinence. CONCLUSIONS: Urinary leakage is highly prevalent. Seven percent have significant incontinence and should be regarded as potential patients.

Diagnostic classification of female urinary incontinence: an epidemiological survey corrected for validity.

Diagnostic questions about stress and urge incontinence were validated against a final diagnosis made by a gynecologist after urodynamic evaluation. Thereafter, an epidemiological survey was performed, using similar questions, and correcting the answers for lack of validity. Included were 250 incontinent women at the out-patient clinic and 535 women who reported incontinence in the epidemiological survey. The sensitivity for stress incontinence was 0.66 (95% confidence interval +/- 0.08), specificity 0.88 (+/- 0.06). The corresponding values for urge incontinence were 0.56 (+/- 0.15) and 0.96 (+/- 0.03), and for mixed incontinence 0.84 (+/- 0.10) and 0.66 (+/- 0.07). Using these indices of validity as corrective measures for the diagnostic distribution reported in the epidemiological survey, the percentage of stress incontinence increased from 51 to 77%, while mixed incontinence was reduced from 39 to 11%. Pure urge incontinence increased from 10 to 12%. Mixed incontinence will be overreported in epidemiological surveys. Correction for validity indicates that a larger majority than hitherto reported may have pure stress incontinence.

Are resistance patterns in uropathogens published by microbiological laboratories valid for general practice?

During 7 months from August 1994, 171 urine samples were collected consecutively in general practice in Western Norway from female patients with suspected lower urinary tract infection. For each of the 171 samples, 2 samples from adult females received from general practice at the microbiological laboratory on the same day were selected using a predetermined system. Samples noted as treatment controls and samples from pregnant patients were discarded. Bacteriuria was found in 101/171 (59.1%) vs 220/342 (64.3%) of the samples. The general practice material contained more bacteriuric samples with Escherichia coli (83.2% vs 71.8%, p<0.05) and Staphylococcus saprophyticus (11.9 vs 6.4%), and fewer with other Gram-negative rods (4.0% vs 15.9%, p<0.01) and enterococci (1.0% vs 5.9%, p<0.01). The frequency of resistant isolates was substantially lower in the samples from general practice for all antibacterial agents tested: amoxycillin 18.9% vs 23.9%, mecillinam 1.1% vs 4.7%, trimethoprim 12.9% vs 18.5%, cotrimoxazole 12.0% vs 15.4%, sulphonamide 20.0% vs 28.4%, nitrofurantoin 3.0% vs 9.7% (p<0.05). Data from local laboratories exaggerate the resistance problems among uropathogens found in urine samples in general practice.

The quality of life in women with urinary incontinence as measured by the sickness impact profile.

The objectives of this paper were to assess the quality of life of community-living women with urinary incontinence according to age, symptom group, amount of leakage, and duration, by use of the Sickness Impact Profile (SIP). Thirty-six women aged between 40 and 60 years and 40 women aged 70 years or more were randomly selected from the clients attending an incontinence clinic and interviewed using the SIP questionnaire. Urge and stress incontinence subgroups were defined by means of a symptom questionnaire. Total, psychosocial, and physical dysfunctions were moderate (8%, 7%, and 8% respectively) in general, but major differences were found when age and symptom groups were analysed. Urge symptoms were associated with more impairment than symptoms of stress incontinence. The elderly women with symptoms of stress incontinence were relatively little affected, while their younger counterparts were severely affected, especially in the categories of emotional behavior and recreation and pastimes. We conclude that urinary incontinence in women adversely affects quality of life to a significant degree; the extent depends on the nature of incontinence and the age of the person.

Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study.

OBJECTIVE: To investigate the association between parity and urinary incontinence, including subtypes and severity of incontinence, in an unselected sample, with special emphasis on age as a confounder or effect modifier. METHODS: This was a cross-sectional study (response rate 80%) with 27,900 participating women. Data on parity and urinary leakage, type, frequency, amount, and impact of incontinence were recorded by means of a questionnaire. A validated severity index was used. Relative risks (RR) with nulliparous women as reference were used as an effect measure. RESULTS: Incontinence was reported by 25% of participants. Prevalences among nulliparous women ranged from 8% to 32%, increasing with age. Parity was associated with incontinence, and the first delivery was the most significant. The association was strongest in the age group 20-34 years with RR 2.2 (95% confidence interval [CI] 1.8, 2.6) for primiparous women and 3.3 (2.4, 4.4) for grand multiparous women. A weaker association was found in the age group 35-64 years (RRs between 1.4 and 2.0), whereas no association was found among women over 65 years. For stress incontinence in the age group 20-34 years, the RR was 2.7 (2.0, 3.5) for primiparous women and 4.0 (2.5, 6.4) for grand multiparous women. There was an association with parity also for mixed incontinence, but not for urge incontinence. Severity was not clinically significantly associated with parity. CONCLUSION: Parity is an important risk factor for female urinary incontinence in fertile and peri- and early postmenopausal ages. Only stress and mixed types of incontinence are associated with parity. All effects of parity seem to disappear in older age.

Formalin test in mice, a useful technique for evaluating mild analgesics.

A modification of the formalin test appropriate for testing of mice is described. Formalin 1 or 5% was injected into the dorsal surface of a hindpaw, and the time the animal spent licking the paw was recorded. On the basis of the response pattern, two distinct periods of intensive licking activity were identified; an early (0-5 min after injection) and a late response (20-30 min after injection). The following analgesics were investigated (dose range): acetylsalicylic acid (100-400 mg/kg), paracetamol (100-400 mg/kg) and morphine (0.6-10 mg/kg). Acetylsalicylic acid (200-400 mg/kg early response, 300-400 mg/kg late response), paracetamol (200-400 mg/kg early response, 300-400 mg/kg late response) and morphine (2.5-10 mg/kg) inhibited the responses in a dose-dependent manner. The results indicate that the test is useful for evaluating mild analgesics. It may have advantages over some of the tests that are commonly used for testing analgesics.

A modified hot-plate test sensitive to mild analgesics.

The present study compares a modified hot-plate test in which the temperature is slowly increased from non-noxious levels with a standard constant temperature hot-plate test. In both tests, hindpaw lick was found to be a more reliable criterion response than forepaw lick, and was employed throughout the experiments. In the constant temperature hot-plate test, 1-min exposure to the test apparatus the day before testing significantly reduced the response latencies of both rats and mice. No effect of pre-exposure was found in the increasing temperature test. In both tests and in both species, sessions of repeated testing were conducted with only insignificant alterations in responsiveness between trials. In both rats and mice, dose-related increases in response temperature were obtained in the increasing temperature hot-plate test after administration of morphine, paracetamol and acetylsalicylic acid, whereas only morphine had consistent effects in the constant temperature test. Thus, the increasing temperature hot-plate is a useful analgesimetric test in both rats and mice, superior to the conventional hot-plate test with regard to consistency of results and sensitivity to non-narcotic analgesics.

Antinociceptive effects of orphenadrine citrate in mice.

The antinociceptive effect of orphenadrine citrate, a muscle relaxant, was investigated in mice. Four different pain tests were selected to involve different noxious stimuli. Clear antinociceptive effects were found in the formalin test. The increasing temperature hot-plate test showed a biphasic dose-response relationship with slight hyperalgesia after low doses and hypoalgesia after higher doses. No significant effects of orphenadrine (0-25 mg/kg) were found in the tail flick and constant temperature hot-plate tests. The data suggest that orphenadrine may reduce, enhance or leave unaffected different types of nociceptive transmission. Orphenadrine may also possess analgesic properties in conditions not involving muscle spasm.

Mechanisms of orphenadrine-induced antinociception in mice: a role for serotonergic pathways.

The possible involvement of central serotonergic pathways in the mechanism of action of orphenadrine citrate was investigated in male albino mice. Orphenadrine (20 mg/kg) did not alter the concentration of 5-hydroxytryptamine (5-HT) or its metabolite 5-hydroxyindole acetic acid in the frontal cortex or spinal cord, nor did it, in moderate concentrations, inhibit the uptake of [14C]5-HT, [3H]noradrenaline ([3H]NA) or [3H]dopamine ([3H]DA) into crude synaptosomal preparations from the cortex. The antinociceptive effect of orphenadrine was studied in the formalin test and in the increasing temperature hot plate test. No sensorimotor impairment was observed for doses of 30 mg/kg or lower. A general depletion of serotonin by means of p-chlorophenylalanine significantly reduced the effect of orphenadrine in both tests, while lesion of the ascending serotonergic systems by means of p-chloroamphetamine did not affect the analgesia. It is concluded that the antinociceptive effect of orphenadrine may be mediated in part via the raphe-spinal serotonergic systems.