Hospitalised patients with unexplained chest pain: incidence and prognosis.

BACKGROUND: The prognosis of unexplained chest pain patients provides valuable information for evaluation of health services. OBJECTIVE: To examine prognosis of unexplained chest pain. METHODS: Using data from in- and outpatient hospital visits in Norway of patients discharged with a main diagnosis of unexplained chest pain (ICD-10: R072-R074) in 2010-2012, the 1-year incidence of coronary heart disease (CHD), any cardio-vascular disease (CVD) and mortality was evaluated. Cases with prior 2-year history of CVD or chest pain were excluded. Cox proportional hazards evaluated outcomes by patient characteristics and standardized mortality ratios evaluated observed versus expected mortality. RESULTS: Of 59 569 patients identified (20-89 years of age), the majority (86%) were referred to hospital by out-of-hours emergency care centres. Subsequent CHD was noted for 12.5%, 19.5% and 25.0% of men and 7.2%, 11.0%, 14.0% of women aged 45-64, 65-74 and 75-89 years, respectively. The per cent of deaths attributed to CVD were greatest within the first 2 months of postdischarge. Total mortality rates (per 1000 person-years) were 6.6 in men and 4.7 in women aged 45-64 and 69.2 in men and 39.5 in women aged 75-89 years. Relative to the general population, mortality was 53% and 45% higher for men and women under 65 years of age, respectively, attributed primarily to non-CVD causes. CONCLUSION: Patients in Norway discharged with unexplained chest pain are an at-risk group in terms of incident CHD, any CVD and mortality, including non-CVD mortality during the first-year postdischarge. The results suggest that unexplained chest pain patients may benefit from greater healthcare coordination between medical disciplines.

Trends in 28-day and 1-year mortality rates in patients hospitalized for a first acute myocardial infarction in Norway during 2001-2009: a "Cardiovascular disease in Norway" (CVDNOR) project.

OBJECTIVE: The aim of this study was to investigate the trends in 28-day and 1-year mortality rates in patients hospitalized for a first acute myocardial infarction (AMI) in Norway during the period 2001-2009. Potential age group and gender differences in these trends were also examined. DESIGN, SUBJECTS AND SETTING: In this retrospective nationwide cohort study, patients hospitalized for a first AMI between 2001 and 2009 were identified in the Cardiovascular Disease in Norway 1994-2009 (CVDNOR) project and followed for 1 year. MAIN OUTCOME MEASURES: Trends in 28-day and 1-year mortality [both all-cause and cardiovascular disease (CVD) mortality] were investigated. RESULTS: A total of 115,608 patients (60.6% men) were hospitalized for a first AMI during the study period. Mortality at 28 days was reduced annually by 3.8% overall and by 6.7%, 4.1% and 2.6% in patients aged 25-64, 65-84 and ≥85 years, respectively (all Ptrend < 0.001). In addition, 1-year all-cause mortality was reduced annually by 2.0% overall (Ptrend < 0.001) and by 3.7% (Ptrend = 0.02), 2.5% (Ptrend < 0.001) and 1.1% (Ptrend < 0.001) in patients aged 25-64, 65-84 and ≥85 years, respectively. Furthermore, 1-year CVD mortality was reduced overall by 6.2% annually; a reduction was observed in all age groups. Finally, 1-year non-CVD mortality increased annually overall by 3.9% due to an increase in patients aged ≥65 years. CONCLUSION: Mortaity at 28 days after the first AMI declinedin Norway between 2001 and 2009 in both men and women and in all age groups. All-cause mortality at 1 year also declined both in men and women due to decreases in CVD mortality rates, whilst non-CVD mortality rates increased amongst patients ≥65 years of age.

Combined analyses and extended follow-up of two randomized controlled homocysteine-lowering B-vitamin trials.

OBJECTIVES: In the Norwegian Vitamin Trial and the Western Norway B Vitamin Intervention Trial, patients were randomly assigned to homocysteine-lowering B-vitamins or no such treatment. We investigated their effects on cardiovascular outcomes in the trial populations combined, during the trials and during an extended follow-up, and performed exploratory analyses to determine the usefulness of homocysteine as a predictor of cardiovascular outcomes. DESIGN: Pooling of data from two randomized controlled trials (1998-2005) with extended post-trial observational follow-up until 1 January 2008. SETTING: Thirty-six hospitals in Norway. SUBJECTS: 6837 patients with ischaemic heart disease. INTERVENTIONS: One capsule per day containing folic acid (0.8 mg) plus vitamin B12 (0.4 mg) and vitamin B6 (40 mg), or folic acid plus vitamin B12, or vitamin B6 alone or placebo. MAIN OUTCOME MEASURES: Major adverse cardiovascular events (MACEs; cardiovascular death, acute myocardial infarction or stroke) during the trials and cardiovascular mortality during the extended follow-up. RESULTS: Folic acid plus vitamin B12 treatment lowered homocysteine levels by 25% but did not influence MACE incidence (hazard ratio, 1.07; 95% CI, 0.95-1.21) during 39 months of follow-up, or cardiovascular mortality (hazard ratio, 1.12; 95% CI, 0.95-1.31) during 78 months of follow-up, when compared to no such treatment. Baseline homocysteine level was not independently associated with study outcomes. However, homocysteine concentration measured after 1-2 months of folic acid plus vitamin B12 treatment was a strong predictor of MACEs. CONCLUSION: We found no short- or long-term benefit of folic acid plus vitamin B12 on cardiovascular outcomes in patients with ischaemic heart disease. Our data suggest that cardiovascular risk prediction by plasma total homocysteine concentration may be confined to the homocysteine fraction that does not respond to B-vitamins.

Copper requirements of broiler breeder hens.

One-hundred-twenty Cobb 500 hens, 20 wk of age, were randomly allocated into individual cages with the objective of estimating Cu requirements. After being fed a Cu deficient diet for 4 wk, hens were fed diets with graded increments of supplemental Cu (0.0; 3.5; 7.0; 10.5; 14; and 17.5 ppm) from Cu sulfate (CuSO4 5H2O), totaling 2.67; 5.82; 9.38; 12.92; 16.83; and 20.19 ppm analyzed Cu in feeds for 20 weeks. Estimations of Cu requirements were done using exponential asymptotic (EA), broken line quadratic (BLQ), and quadratic polynomial (QP) models. Obtained Cu requirements for hen d egg production and total settable eggs per hen were 6.2, 7.3, and 12.9 ppm and 8.1, 9.0, and 13.4 ppm, respectively, using EA, BLQ, and QP models. The QP model was the only one having a fit for total eggs per hen with 13.1 ppm Cu as a requirement. Hemoglobin, hematocrit, and serum Cu from hens had requirements estimated as 13.9, 11.3, and 18.5, ppm; 14.6, 13.0, and 19.0 ppm; and 16.2, 14.6, and 14.2 ppm, respectively, for EA, BLQ, and QP models. Hatching chick hemoglobin was not affected by dietary Cu, whereas requirements estimated for hatching chick hematocrit and body weight and length were 10.2, 12.3, and 13.3 ppm using EA, BLQ, and QP models; and 6.8 and 7.1 ppm, and 12.9 and 13.9 ppm Cu using EA and BLQ models, respectively. Maximum responses for egg weight, yolk Cu content, and eggshell membrane thickness were 14.9, 12.7, and 15.1 ppm; 15.0, 16.3, and 15.7 ppm; and 7.3, 7.8, and 14.0 ppm Cu, respectively, for EA, BLQ, and QP models. Yolk and albumen percentage were adjusted only with the QP model and had requirements estimated at 11.0 ppm and 11.3 ppm, respectively, whereas eggshell mammillary layer was maximized with 10.6, 10.1, and 14.4 ppm Cu using EA, BLQ, and QP models, respectively. The average of all Cu requirement estimates obtained in the present study was 12.5 ppm Cu.

[Advance directives, a tool to humanize care]. / Les directives anticipées, un outil d'humanisation des soins.

The relationship between the patient and a medical care giver is complex specially as it implies to the human, juridical and practical points of view. It depends on legal and deontological considerations, but also on professional habits. Today, we are confronted to a fundamental modification of this relationship. Professional guidelines exist, but are rarely applied and rarely taught in universities. However, patients are eager to move from a paternalistic relationship to a true partnership, more harmonious and more respectful of individual values ("value based medicine"). Advance directives give us an opportunity to improve our practices and to provide care consistent with the needs and wishes of each patient.

[Community health for aged persons: the activities of the geriatric polyclinic in Geneva]. / Santé communautaire pour les personnes âgées: l'activité de la policlinique de gériatrie à Genève.

In addition to its mainly home-based clinical activity, the Geriatric Polyclinic has chosen to develop tree programmes with a specific activity. Their common objectives being promoting heath and maintaining home-based treatment in the best conditions and for as long as possible. This article describes these programmes.

[Medicine and humanism: clinical ethics and the community dimension of geriatrics]. / Médecine et humanisme: l'éthique clinique et la gériatrie à dimension communautaire.

Clinical ethics is generally related to the clinical bedside activity. Clinical ethics constitutes one aspect of bioethics. In particular, its aim consists in facilitating the solving of conflicts of values in practical care. By encouraging effective communication and discussion within the interdisciplinary team, geriatricians will be able to make adequate diagnostic and therapeutic interventions, in accordance with the fundamental desire of the patient and her or his family.