Clinicopathological characteristics and non-adhesive organ culture of insulinomas.

BACKGROUND AND AIMS: Insulinoma is a very rare type of islet cell tumour, but nevertheless the most common endocrine tumour of the pancreas. We aimed at reviewing our clinical experience with this tumour type and to assess whether organ culture could be obtained from surgically resected insulinoma material. MATERIAL AND METHODS: All patients with insulinomas (6 men and 10 women) referred to Haukeland University Hospital between 1986 and 2006 were included in the study. Median age of onset was 53 years (range 21-74). Biochemical diagnosis was established during a 72 h fast test. Imaging and localization of the tumours were performed with intra-operative ultrasonography, endoscopic ultrasonography, CT-scan and/or transcutaneous ultrasonography. For six patients, organ cultures were set up from tumour tissue fragments. RESULTS: The annual incidence of insulinoma was 0.8 per million. The patients generally presented with non-specific, episodic symptoms, which often were mistaken for cardiovascular, neurological or diabetic disease and in some cases delayed the diagnosis with several years. Two patients had diabetes prior to the diagnosis of insulinoma. Patient weight gain was probably due to increased food intake, compensating for the hypoglycemia. Intra-operative ultrasonography detected all tumours correctly, whereas 73% were detected by endoscopic ultrasonography and 38% by CT scan. Five insulinomas were located in the head, eight in the body and three in the tail of the pancreas. All were removed by open-access surgery, eleven cases by resection and five by enucleation. One tumour was malignant with liver metastases and two patients had tumours defined as borderline. Insulinoma tissue fragments developed into spheroids during the first week of culturing and insulin secretion into the media was demonstrated. CONCLUSIONS: Insulinomas are rare and diagnostically challenging tumours. Intra-operative ultrasonography was superior to other imaging modalities to locate the lesion. In organ culture, insulinomas readily form spheroids which may be used to yield insight into beta-cell biology.

Enhanced detection of mutations in BRCA1 exon 11 using restriction endonuclease fingerprinting-single-strand conformation polymorphism.

A novel approach to mutation screening in the large exon 11 (comprising 3427 bp) of the human BRCA1 gene is presented. Restriction endonuclease fingerprinting single-strand conformation polymorphism (REF-SSCP) is based on repeated detection of DNA sequence variants in different restriction endonuclease fragments, and we evaluated the method using blood samples from 25 Norwegian patients with hereditary breast/ovarian cancer. We compared REF-SSCP to constant denaturant gel electrophoresis (CDGE) and to the protein truncation test (PTT). REF-SSCP detected 12 different DNA variants. Four of these were not detected by CDGE, and only one variant detected by CDGE was missed by REF-SSCP. PTT detected 4 of these 13 variants. REF-SSCP was subsequently applied to a second patient series (Swedish, n=20). A total of 14 different DNA variants were detected by REF-SSCP, 6 of which were truncating mutations (PTT detected only 4). Nonsense and frameshift mutations that are putative breast/ovarian cancer mutations, were detected in 7 of the 25 Norwegian and 9 of the 20 Swedish patients.

Mammography: influence of departmental practice and women's characteristics on patient satisfaction: comparison of six departments in Norway.

OBJECTIVE: To investigate how departmental practice and women's characteristics are related to low patient satisfaction with mammography. DESIGN: Survey of patients by means of self administered questionnaires before and after mammography. PATIENTS: 488 women (89% of those invited), aged 23-86 years, at six departments. MAIN OUTCOME MEASURES: Low level of satisfaction measured on psychometric scales of physical pain, psychological distress, staff punctuality and technical skills, information provided, and physical surroundings. RESULTS: Satisfaction varied by department on the scales for pain, punctuality, information, and surroundings. After adjustment for women's characteristics an attributable risk of negative outcome by department was identified on the scales for pain, distress, punctuality, information, and surroundings. Adjusted odds ratio (ORs) ranged from 0.3 (95% confidence interval (95% CI) 1.2 to 6.0) on the pain scale, to 6.0 (2.9 to 12.3) on the punctuality scale. After adjustment for confounding variables, higher risk of dissatisfaction was associated with age < 50, nervousness about mammography, expected pain, lack of knowledge about mammography, and distrust in mammography (adjusted OR (95% CI) ranged from 1.6 (1.0 to 2.7) to 3.7 (2.0 to 7.3)). CONCLUSION: Departmental practices differed for breast compression, information, punctuality, and facilities and were associated with a low level of satisfaction irrespective of patient characteristics. Women's lack of knowledge about mammography and distrust in the procedure were confirmed as risk factors for dissatisfaction. All these factors might be helped by training the staff, improving facilities, and informing the women.

The patient perspective survey. Can consultations for complex health problems be enhanced?

BACKGROUND: Patients with complex health problems pose particular difficulties due to the interaction between psychosocial factors and physical disease. The aim of this study is to investigate the usefulness of a paper based instrument (the Patient Perspective Survey, or PPS) to enhance general practitioner-patient communication and patients' self reported coping skills. METHODS: A previously validated questionnaire was modified and distributed to a self selected group of 21 GPs. They recruited 77 patients with complex health problems and asked them to complete a PPS questionnaire. The patients then returned for an extended consultation to discuss the results of the questionnaire with the GP. Patients and GPs subsequently completed PPS evaluation forms. RESULTS: The PPS was useful for patients with chronic conditions with mixed physical and psychological components. It appeared to enhance the GP-patient relationship and gave patients a better understanding of their coping skills. DISCUSSION: Patients with complex health problems can use paper based questionnaires to improve the quality of communication between themselves and their GPs.

Which hurts the most? A comparison of pain rating during double-contrast barium enema examination and colonoscopy.

PURPOSE: To study the degree of pain caused by double-contrast barium enema examination and colonoscopy and to compare pain ratings by patients and medical personnel. MATERIALS AND METHODS: In a random sample, 190 patients (aged 45-79 years) (mean, 63.1 years) recorded their experiences of pain during each procedure and the medical staff recorded their impressions of the patients' pain, on a 10-point progressive scale. The data were analyzed with the Wilcoxon rank test, Spearman rank correlation, and generalized kappa value. RESULTS: Patients' pain ratings were significantly higher during colonoscopy than during double-contrast barium enema examination (P < .0001). Pain was rated significantly higher by patients than by personnel for both procedures (P < .0001). CONCLUSION: In the choice of procedure, patients' high level of pain during colonoscopy should be remembered. The medical staff frequently underestimated patients' pain during both procedures, and this study documents a need for more extensive pain relief measures during potentially painful examinations of the large bowel.

Referrals for radiological examination of the large bowel. Pre-radiological examinations, tests and referral letters.

The aims of the present study were to assess the frequency of examinations or tests before referral for a barium enema, to identify predictors for the use of such examinations or tests and to evaluate the quality of the referral letters. 1852 patients completed a questionnaire on symptoms and examinations or tests performed before referral. Symptoms, examination procedures, laboratory data and reason for referral were registered in 1781 referral letters and were compared with the information given by the patients. Serum haemoglobin was measured in 76%, per-rectal examination in 45%, faecal occult blood tests in 37% and proctosigmoidoscopy in only 16% of the patients. High age was a significant predictor for all examinations, and patients with rectal bleeding and rectal pain were more often examined rectally, although this was omitted in several patients with such symptoms. All evaluated information was reported significantly more frequently by the patients than by the doctors in the referral letters. The very low figures for rectal examinations and the lack of completeness and adequacy of the information in the referral letters underline the need for efforts to change doctors' behaviour when investigating and referring patients with possible colorectal disease.

White coat hypertension in a general practice. Prevalence, cardiovascular risk factors and clinical implications.

OBJECTIVE: To examine the prevalence of white coat hypertension (WCH) and white coat effect (WCE) in a general practice. Background and biochemical characteristics, triglycerides, total cholesterol, HDL cholesterol, fasting blood glucose, microalbuminuria, ECG, smoking habits, height and weight of patients with white coat hypertension were compared to patients with sustained hypertension. DESIGN: Blood pressure measurements among mild hypertensives in clinic visits by doctor and at home by the patients. SETTING: A primary health centre in Oslo, Norway. SUBJECTS: Sixty-eight patients with mild hypertension (41 females and 27 males) aged 20-75 years. MAIN OUTCOME MEASURES: Patients had their blood pressure measured in clinic visits by general practitioners and by themselves at home to study the prevalence of WCH and the WCE. WCH was defined as a consistently increased blood pressure in the clinic and a normal home-measured blood pressure. WCE was defined as a difference in mean systolic blood pressure measured by physician and patients of 10 mmHg, or more. An individual risk score for myocardial infarction was calculated. Subjects with and without WCH/WCE were compared in relation to background characteristics and biochemical differences. RESULTS: Fourteen patients (21%) were found with WCH, while 25 (37%) had WCE. Patients with WCH differed significantly from hypertensives in age, total cholesterol, and heart rate. In multivariate analysis, increasing age and heart rate were significant negative predictors for WHC. CONCLUSION: WCH may be a significant clinical challenge in general practice, especially among younger patients.

[Evaluation of the General Practitioner Scholarship--small seed, rich harvest]. / Evaluering av allmennpraktikerstipendordningen--lite frø, rik avling.

In 1976 the Norwegian Medical Association instituted the General Practitioner Scholarship. A total of 36 scholarship months is granted each year, available for small scientific projects lasting a maximum of six months. This article presents the results of an evaluation based on data from the recipients of the scholarships (n = 107) and from rejected applicants (n = 76) during the period 1986-94, and from the four University Departments of General Practice in Norway. 85 (80%) recipients, involved in 95 projects, responded to a mailed questionnaire. 60 (72%) had published one scientific article or more from their project. 64 (70%) of the projects had evolved from questions raised in the recipients' own daily practice, the main topics being clinical issues and community medicine. More than two thirds of the recipients were still doing scientific work. All informants recognised the importance of the General Practice Scholarship for research and development in Norwegian primary health care.

Age and sex: underestimated selection criteria for referral to x-ray examination of the colon?

An analysis was made of 2416 consecutive patients who underwent a double-contrast barium enema at the Central Roentgen Institute in Oslo. Age, sex, and radiological findings were registered. The age and sex distribution among patients consulting in general practice and in our study was surprisingly similar. This suggests that age as a risk factor for colorectal neoplasms did not play a prominent role among the referring doctors. Colorectal cancer was more frequent in males (4%) than females (2%) (p = 0.03). Odds ratio adjusted for age was 2.1 (1.3-3.8). This may be due to few examinations performed in old age, and different patient behaviour when experiencing colorectal symptoms. The overall polyp frequency was 11%. The frequency increased significantly from the age group 40-49.

[Home blood pressure measurement in general practice patients]. / Hjemmemåling av blodtrykk hos pasienter i allmennpraksis.

In 68 consecutive patients with mild hypertension, blood pressure was measured by general practitioners during visits to the clinic, by nurse and by the patients at home. Mean age was 50 years (SD: 11) for both genders and 60% were women. Blood pressure and heart rate were significantly higher when measured by physicians than by nurse and patient (p < 0.01). During the study period of six weeks a significant decrease in blood pressures was registered by both physicians and patients. The study demonstrates the feasibility of home blood pressure monitoring as a part of the practice to diagnose hypertension in general practice.

[What is the most important for the patient in the meeting with a general practitioner?]. / Hva er viktig for pasienten i møtet med allmennpraktikeren?

Efficient medical communication depends on an understanding of the patient perspective. The purpose of this study was to characterise the most important consultation elements as perceived by primary care patients. The experience of 31 patients regarding their most recent medical encounter were recorded in six focus groups. All groups were audiotaped and analysed by qualitative methodology. Five consultation themes emerged spontaneously in all groups: Interaction between doctor and patient (e.g. communication, emotional experiences, and personal relationship with the doctor) and consultation outcome were the most important elements. Information, continuity of care, and time with the doctor were considered reasonably important. Six other themes received limited attention in a few groups only (e.g. availability, doctor's gender, time in the waiting room, auxiliary personnel, the clinical examination, and technical skills). Patients value the personal, attentive, and listening doctor. The feeling of not having to hurry during the consultation is more important than the actual number of minutes. Patients' level of emotional involvement and their specific expectations are often undisclosed. There are large individual differences with regard to the meaning of and need for information.

[Words and language used by patients when describing consultation with general practitioners]. / Pasienters ordvalg og uttrykksmåter om siste konsultasjon hos allmennpraktiker.

Increased knowledge of how patients express their experiences may help physicians to capture their patients' perceptions and agenda. The aim of the present study was to examine words and language used by patients when describing specific primary care consultation experiences. Six focus group sessions with a total of 31 patients were conducted shortly after a general practice consultation. All group sessions were audiotaped and analysed by qualitative ethnographic methodology. Seven distinct grammatical and verbal characteristics were found: The consultations were recited in the first person with little recollection of the doctors' talk or actions. Subjectivity was constantly underlined by the verbs "feel" or "think". When expressing negative emotions, the personal pronoun constantly was changed from the personal singular to the impersonal or plural form. Language tended to be evasive in connection with possible criticism. Negative emotions were diminished by the use of limiting expressions and modest wording. Non-committal expressions, with a wide range of possible meanings, were frequent, and were possible to decipher only by close attention to non-verbal cues. We conclude that doctors may capture more of their patients' hidden emotional messages in the consultation by increased awareness of specific verbal characteristics and non-verbal cues.

Patient satisfaction and quality of care at four diagnostic imaging procedures: mammography, double-contrast barium enema, abdominal ultrasonography and vaginal ultrasonography.

The objective of this study was to measure patient satisfaction and to investigate the practical implications of monitoring the quality of care at four radiology procedures. A survey was conducted immediately after the examinations in eight radiology departments: 550 patients attending for mammography, 110 for double-contrast barium enema (DCBE), 97 for abdominal ultrasonography and 90 for vaginal ultrasonography. Outcome measures were seven questionnaire scales: pain, emotional distress, information received, staff's punctuality and technical ability, facilities, and general satisfaction. Response rate was 87 %. Multivariate regression analysis showed significant differences between procedures on all scales (p < 0.001). Differences considered to be of practical importance, i. e. >/= 7 scale points, were detected on five of the scales. Mammography and DCBE caused the most pain, and vaginal US and DCBE caused the most distress. The US procedures entailed dissatisfaction with information about the procedures. The DCBE patients recorded dissatisfaction with the staff's lack of punctuality, and these and the mammography patients recorded dissatisfaction with the facilities. The findings indicate a potential for improving patients' experiences. Several aspects of care, i. e. pain management, attention to the patient's emotional concerns, explanation of procedures, punctuality and quality of the facilities, can be improved.

A new, brief questionnaire (PEQ) developed in primary health care for measuring patients' experience of interaction, emotion and consultation outcome.

BACKGROUND: A deepened understanding of patients' perspectives is essential in order to improve medical communication. By changing focus from patient satisfaction to patient experiences, more immediate, personal and affective responses may be captured. OBJECTIVE: Our aim was to develop a new consultation-specific questionnaire on patient experiences. METHODS: The questionnaire was developed in Norwegian primary care in three main phases. Phase 1: focus groups with patients in order to identify important aspects of patients' experiences, and their words and language when describing such experiences. Phase 2: a questionnaire survey with 110 items including 660 patients. Extensive testing resulted in a reduction to 25 items on six dimensions. Phase 3: a questionnaire survey with 25 items including 1092 patients. Psychometric analyses and feedback from patients and physicians involved dimensionality and tests of validity and reliability. RESULTS: A final questionnaire was produced with 18 items on five dimensions: communication; emotions; short-term outcome; barriers; and relations with the auxiliary staff. The validity and reliability estimates were highly satisfactory. Three scales were skewed while two were more equally distributed. Forty-eight per cent of the patients described less than optimal communication experiences; some communication barriers were detected in 70% of the visits and less helpful experiences with the staff were reported in 55% of the visits. Twenty-four per cent of patients left with no positive feelings, and 48% scored low on the outcome scale (knowledge, perceived result). CONCLUSIONS: The patient experience questionnaire (PEQ) emphasizes what patients value the most, i.e. interaction, emotions and outcome, and may represent a valuable tool for doctors who want feedback from their patients on the function of their doctor-patient relationships.

Smoking cessation. A comparative, randomised study between management in general practice and the behavioural programme SmokEnders.

OBJECTIVE: To compare the effectiveness of two different stop smoking interventions. DESIGN: A randomised, controlled trial. Results based on intention to treat. SETTING: Three towns in the south-eastern part of Norway. INTERVENTIONS: Visits to GP for "practice as usual" (GP group) or participation in the behavioural programme SmokEnders (SE group) with follow-up 2 weeks, 2 months and 1 year after an agreed stopping date. SUBJECTS: 139 smokers recruited through open invitation. MAIN OUTCOME MEASURE: Self-reported smoking stop rate 2 weeks, 2 months and 1 year after an agreed stopping date, completed with biochemical indicators by the 1-year registration. RESULTS: Two weeks after the agreed cessation date, 10/70 (14%) of the GP group and 46/69 (67%) of the SE group had stopped smoking. After 2 months, 9/70 (13%) in the GP group and 37/69 (54%) in the SE group were non-smokers. One year after cessation 5/70 (7%) in the GP group and 21/69 (30%) in the SE group were non-smokers. CONCLUSIONS: Both interventions were effective as measured by the smoking cessation rate. However, the intervention in the SE group was considerably more effective than in the GP group, which suffered from a sizeable number of drop-outs.

Predictors of enhanced well-being after coronary artery bypass surgery.

OBJECTIVES: To assess patients' perception of the therapeutic outcome after coronary artery bypass surgery, and to find predictors for increased well-being. DESIGN: Self-administered questionnaires (Family APGAR and GHQ-30) were completed on admission and at the follow-up after 12 months, together with functional classification according to the NYHA index. SETTING: Ullevål University Hospital, Oslo, Norway, 1990-1992. SUBJECTS: Two hundred and thirteen patients with stable angina admitted for elective coronary artery bypass surgery. INTERVENTION: Elective coronary artery bypass surgery. MAIN OUTCOME MEASURES: Improved physical and psychosocial functioning after one year. RESULTS: One hundred and ninety-seven (92%) patients improved their NYHA class, while it remained stable or declined in 16 (8%) patients. Significantly fewer patients with mental distress were found at the follow-up than at the baseline examination (49 patients [23%] versus 80 patients [38%], respectively, P < 0.0001). One hundred and forty-six patients (69%) reported enhanced psychosocial well-being, while it was reduced (n = 60) or unchanged (n = 7) in 67 patients (31%). Predictors for improved psychosocial well-being following coronary artery bypass surgery were mental distress before surgery (odds ratio 2.8) and being a male patient (odds ratio 2.8). CONCLUSIONS: The majority of the patients reported significant improvement in their physical and psychosocial functioning one year after coronary artery bypass surgery. Mental distress and male sex were significant predictors of enhanced well-being. Questionnaires on psychosocial well-being such as the GHQ-30 may, in addition to health status measurements, offer additional useful information when coronary artery bypass surgery is considered.

[Occurrence of senile dementia among elderly in need of support in the municipality of Grimstad]. / Forekomst av aldersdemens blant hjelptrengende eldre i Grimstad kommune.

The background for this study is the common belief in the community of Grimstad that aluminium is related to dementia; the high aluminium content in the local water supply is an ongoing source of concern. In this study we show that the prevalence of dementia among elderly in Grimstad is not higher than in the city of Bergen. We also discuss the demands the community must meet to care for the growing population of demented elderly.

Indicators of childhood sexual abuse in gynaecological patients in a general practice.

OBJECTIVE: To find indicators of a history of childhood sexual abuse in patients consulting for a gynaecological examination in a general practice. DESIGN: Semistructured interview after a consultation. SETTING: General practice in the city of Oslo, Norway. PARTICIPANTS: Of 117 women aged 20-49 with a gynaeco- logical problem, 85 were interviewed. MAIN OUTCOME MEASURE: History of childhood sexual abuse. RESULTS: 24 (28%) of 85 women interviewed by their female GP when consulting for a gynaecological problem reported childhood sexual abuse. In total they reported 32 abusive events, quite different as to the type of assault, the relation to the offender, and the duration. A history of pelvic pain or gynaecological surgery showed a significant association with reported childhood sexual abuse with odds ratios of 4.0 (CI 1.0-15.8) and 4.1 (CI 1.0-17.0), respectively. As adverse sexual experiences may lead to somatization as a coping strategy, certain findings might be indicators of unknown childhood sexual abuse in patients presenting for gynaecological disorders. CONCLUSION: A history of pelvic pain and gynaecological surgery may be indicators of sexual abuse in childhood.

A new instrument to measure patient satisfaction with mammography. Validity, reliability, and discriminatory power.

OBJECTIVES: The benefit of mammography depends on repeated use. Therefore, surveying the mammographic quality as judged by the users addresses an important topic. The authors assess the practicality, validity, reliability, and discriminatory power of a new, brief, multidimensional questionnaire for measuring patient satisfaction with mammography. Items measuring discomfort and attitudes toward repeat adherence were included. METHODS: A self-administered questionnaire was given to women from six radiology departments in Norway. Four hundred eighty-eight out of 550 women referred for screening or diagnostic mammography were included. Seventy-seven patients also completed the test/retest study, and 44 women additionally completed an Australian questionnaire. Scores for patient satisfaction on the structure, process, discomfort, and general satisfaction scales of the questionnaire were used as the main outcome measures. RESULTS: Response rate was 89%, and rate of completion was more than 95%. Strict psychometric criteria for construct validity and reliability were satisfied. Because lower levels of satisfaction were detectable with the new questionnaire but not with the Australian questionnaire and because an acceptable degree of variability in response was detected, support for discriminatory power was found. CONCLUSIONS: The discomfort dimension contributed substantially to validity and discriminatory power. Patient behavior with time may be monitored with the new questionnaire, thus representing a valuable tool for scientific and practical purposes.