Relapse risk of endometrial hyperplasia after treatment with the levonorgestrel-impregnated intrauterine system or oral progestogens.

OBJECTIVE: To investigate relapse rates after the successful treatment of patients with non-atypical endometrial hyperplasia who were randomised to either a levonorgestrel-impregnated intrauterine system (LNG-IUS; Mirena(®) ) or two regimens of oral medroxyprogesterone acetate (MPA) after primary histological response. DESIGN: A multicentre randomised trial. SETTING: Ten different outpatient clinics localised in hospitals and seven gynaecological private practices in Norway. POPULATION: One hundred and fifty-three women aged 30-70 years with low- or medium-risk endometrial hyperplasia met the inclusion criteria, and 153 completed the therapy. METHODS: Patients were randomly assigned to one of the following three treatment arms: LNG-IUS; 10 mg of oral MPA administered for 10 days per cycle for 6 months; or 10 mg of oral MPA administered daily for 6 months. The women were followed for 24 months after ending therapy. MAIN OUTCOME MEASURES: Histological relapse of endometrial hyperplasia. RESULTS: Histological relapse was observed in 55/135 (41%) women who had an initial complete treatment response. The relapse rates were similar in the three therapy groups (P = 0.66). In the multivariable analyses relapse was dependent on menopausal status (P = 0.0005) and estrogen level (P = 0.0007). CONCLUSIONS: The risk of histological relapse of non-atypical endometrial hyperplasia is high within 24 months of ceasing therapy with either the LNG-IUS or oral MPA. Continued endometrial surveillance and prolonging progestogen therapy should be considered. TWEETABLE ABSTRACT: Relapse of endometrial hyperplasia after successful treatment is independent of therapy regime.

Levonorgestrel-impregnated intrauterine device as treatment for endometrial hyperplasia: a national multicentre randomised trial.

OBJECTIVE: The purpose of this study was to investigate if the levonorgestrel-impregnated intrauterine device (LNG-IUS, Mirena(®) ) is safe and effective as therapy for low-risk and medium-risk endometrial hyperplasia compared with oral medroxyprogesterone (MPA). DESIGN: A multicentre randomised trial. SETTING: Norway. POPULATION: In all, 170 women aged 30-70 years with low- or medium-risk endometrial hyperplasia who met inclusion criteria. METHODS: Patients were randomly assigned to one of three treatment arms: LNG-IUS; oral MPA 10 mg administered for 10 days per cycle, or continuous oral MPA 10 mg daily, for 6 months. MAIN OUTCOME MEASURES: The primary outcome measure was normalisation or persisting hyperplasia. RESULTS: After 6 months all three treatment regimens showed significant effect when the outcome was evaluated as therapy response or not (P < 0.001). Responses were obtained for all the women in the LNG-IUS group (53/53, 95% CI 0.93-1.0) and for 96% of the women in the continuous oral group (46/48, 95% CI 0.86-0.99). Only 69% of the women in the cyclic oral group were responders (36/52, 95% CI 0.55-0.81). Adverse effects were relatively common with minimal differences between therapy groups. CONCLUSION: In the first trial of its kind, women treated with the LNG-IUS showed histologically normal endometrium after 6 months of therapy for endometrial hyperplasia. Cyclical progestogens are found to be less effective compared with continuous oral therapy and LNG-IUS and should not be used for this purpose.

Different labour outcomes in primiparous women that have been subjected to childhood sexual abuse or rape in adulthood: a case-control study in a clinical cohort.

OBJECTIVE: To compare the duration and outcome of the first labour in women who have been subjected to childhood sexual abuse (CSA) and women who have been raped in adulthood (RA). DESIGN: Case-control study in a clinical cohort. SETTING: University Hospital of North Norway. SAMPLE: In all, 373 primiparas: 185 subjected to CSA, 47 to RA and 141 controls without a history of abuse. METHODS: Data on birth outcomes were retrieved from the patient files. Information on sexual abuse was reported in consultation with specialised midwives in the mental health team. Birth outcomes were analysed by multinominal regression analysis. MAIN OUTCOME MEASURES: Vaginal births, delivery by caesarean section, operative vaginal delivery and duration of labour. RESULTS: As compared with controls, the RA group showed a significantly higher risk for caesarean section (adjusted OR 9.9, 95% CI 3.4-29.4) and operative vaginal delivery (adjusted OR 12.2, 95% CI 4.4-33.7). There were no significant differences between the CSA and the control group. The RA group displayed significantly longer duration of labour in all phases as compared with the control and CSA groups. CONCLUSIONS: There were major differences in the duration of labour and birth outcomes in the two abuse groups. Despite a higher proportion of obstetric risk factors at onset of labour in the CSA group, women subjected to CSA had shorter labours and less risk for caesarean section and operative vaginal deliveries than women subjected to RA. The best care for birthing women subjected to sexual abuse needs to be explored in further studies.

Validity and predictive ability of the juvenile arthritis disease activity score based on CRP versus ESR in a Nordic population-based setting.

OBJECTIVE: To compare the juvenile arthritis disease activity score (JADAS) based on C reactive protein (CRP) (JADAS-CRP) with JADAS based on erythrocyte sedimentation rate (ESR) (JADAS-ESR) and to validate JADAS in a population-based setting. METHODS: The CRP and ESR values and the corresponding JADAS scores (JADAS10/27/71) were compared in a longitudinal cohort study of 389 children newly diagnosed with juvenile idiopathic arthritis (JIA) in the Nordic JIA study. The construct validity and the discriminative and predictive ability of JADAS were assessed during a median disease course of 8 years by comparing JADAS with other measures of disease activity and outcome. RESULTS: At the first study visit the correlation between JADAS27-CRP and JADAS27-ESR was r=0.99 whereas the correlation between CRP and ESR was r=0.57. Children with higher JADAS scores had an increased risk of concomitant pain, physical disability and use of disease-modifying antirheumatic drugs (DMARDs). A higher JADAS score at the first study visit also significantly predicted physical disability, damage and no remission off medication at the final study visit, and also use of DMARDs during the disease course. Sensitivity to change, demonstrated as change in JADAS score compared with the American College of Rheumatology paediatric measures of improvement criteria, mostly showed excellent classification ability. CONCLUSION: The JADAS-CRP and JADAS-ESR correlate closely, show similar test characteristics and are feasible and valid tools for assessing disease activity in JIA.

Birth outcomes in primiparous women who were raped as adults: a matched controlled study.

OBJECTIVE: To compare the duration of labour and the birth outcome in a group of primiparous women who had been raped after the age of 16, with a control group from the same birth cohort. DESIGN: Cohort study. SETTING: University Hospital of North Norway. SAMPLE: Fifty women raped as adults and 150 controls. METHODS: Data about birth outcomes in the first pregnancy were collected from the patient files and data concerning the assault were obtained in a subsequent pregnancy through consultations with the women who had been raped. Birth outcomes in the group of women who had been raped were compared with matched controls using a multivariable logistic regression model. MAIN OUTCOME MEASURES: Caesarean section, operative vaginal delivery and duration of labour. RESULTS: During their first delivery, the women who had been raped had an increased risk for caesarean section (adjusted odds ratio 15.7, 95% CI 5.0-49.1) and for assisted vaginal delivery (adjusted odds ratio 13.1, 95% CI 4.9-34.5) when compared with controls. The group of women who had been raped had a longer second stage of labour than the control group (120 versus 55 minutes, P < 0.01). They were more often single mothers, unemployed and smokers, and had a higher body mass index and more previous pregnancy terminations and miscarriages than the control group. CONCLUSIONS: The women who had been raped had a longer second stage of labour, and an increased risk of caesarean section and operative vaginal delivery compared with controls from the general birth cohort. These findings indicate that the consequences for delivery for women who had been raped as adults could be specific and may warrant particular attention. The birth experience of women who had been raped should also be illuminated in future studies.

Multisite musculoskeletal pain in adolescence as a predictor of medical and social welfare benefits in young adulthood: The Norwegian Arctic Adolescent Health Cohort Study.

BACKGROUND: Pain in adolescence is associated with mental health problems, the main reason for work disability in young adults. This study explores the relationship between multisite musculoskeletal pain in adolescence and later medical (sickness and medical rehabilitation benefits) and social welfare benefits, adjusted for sociodemographic, adolescent psychosocial and mental health problems. METHODS: Data were obtained by linkage between the National Insurance Registry (2003-11) and the Norwegian Arctic Adolescent Health Study, a school-based survey in North Norway (2003-05), accepted by 3987 fifteen- to sixteen-year-olds (68% of the total population). The start of the follow-up time was July 1st of the corresponding year the participants responded to the health study. Musculoskeletal pain was measured by the number of musculoskeletal pain sites. RESULTS: We found a positive linear relationship between adolescent musculoskeletal pain sites and the occurrence of medical and social welfare benefits in young adulthood (p ≤ 0.001). Adolescent musculoskeletal pain was a significant predictor of sickness (p < 0.001) and social welfare benefits in females (p = 0.036), when adjusted for adolescent psychosocial and mental health problems. The most important adolescent psychosocial predictors were externalizing problems, less parental involvement and adverse life events. CONCLUSION: Adolescent multisite musculoskeletal pain was found to be an important predictor of later sickness and social welfare benefit receipt from adolescence to young adulthood. SIGNIFICANCE: Adolescents with multisite musculoskeletal pain are at substantially increased risk of health and social difficulties into young adulthood. Identification and interventions for these adolescent problems could alleviate this risk and be a sound socioeconomic investment.

Maternal anti-HLA class I antibodies are associated with reduced birth weight in thrombocytopenic neonates.

In this comparative cross-sectional study, possible associations between maternal anti-HLA class I antibodies and birth weight in neonatal thrombocytopenia are explored. Although commonly detected in pregnancies and generally regarded as harmless, it has been suggested that such antibodies might be associated with fetal and neonatal alloimmune thrombocytopenia (FNAIT). As a link between FNAIT due to human platelet antigen 1a-specific antibodies and reduced birth weight in boys has previously been demonstrated, we wanted to explore whether maternal anti-HLA class I antibodies might also affect birth weight. To examine this, suspected cases of FNAIT referred to the Norwegian National Unit for Platelet Immunology during the period 1998-2009 were identified. Pregnancies where the only finding was maternal anti-HLA class I antibodies were included. An unselected group of pregnant women participating in a prospective study investigating maternal-fetal hemodynamics at the University Hospital North Norway during the years 2006-2010 served as controls. Twenty-nine percent of controls had anti-HLA class I antibodies. The thrombocytopenic neonates had a significantly lower adjusted birth weight (linear regression, P=0.036) and significantly higher odds of being small for gestational age (OR=6.72, P<0.001) compared with controls. Increasing anti-HLA class I antibody levels in the mother were significantly associated with lower birth weight and placental weight among thrombocytopenic neonates, but not among controls. These results indicate that maternal anti-HLA class I antibodies in thrombocytopenic neonates are associated with reduced fetal growth. Further studies are needed to test if placental function is affected.

Effect of time, temperature and additives on a functional assay of C1 inhibitor.

There are different recommendations for the handling of blood samples for analyses of the kallikrein-kinin or complement system, respectively. C1 inhibitor (C1-INH) takes a crucial part in both systems. In order to establish recommendations for blood specimen collection and transport for making the diagnosis of hereditary angioedema (HAE), the effect of time, temperature and different additives on C1-INH function and antigen was determined. We used blood samples from normals and patients suffering from HAE type I. Plasma containing EDTA, heparin, sodium citrate or polybrene-EDTA, and serum were assayed after incubations at 4 degrees C or 37 degrees C for 6 or 24 h. In addition, pooled serum was incubated for up to 5 days at room temperature. A modest decrease in C1-INH function was observed as an effect of storage-time in samples from normals (p = 0.039) and a substantial decrease was seen for the HAE patients (p = 0.0002). No significant effect of temperature (4 degrees C or 37 degrees C) was found. Clotting did not reduce C1-INH activity. Plasma containing heparin or polybrene interfered with the functional assay, yielding falsely high and low values, respectively. C1-INH functional assay performed within 24 h in serum, EDTA-treated or citrated plasma discriminated well between HAE patients and normals. This was also the case for serum kept at room temperature for up to 5 days, although a modest fall in C1-INH function was seen in the incubation period. For practical purposes we recommend serum as the sample of choice, preferably received within 48 h.

Use of antacids in a general population: the impact of health-related variables, lifestyle and sociodemographic characteristics.

Self-medication with antacids is very common in patients with less severe forms of dyspepsia, but we know very little about the users of antacids and their incentive to take them. The aim of this study was to analyze the relationship between self-reported use of antacids and health-related variables, lifestyle, and sociodemographic characteristics in order to characterize the use of antacids in a general population. The use of antacids was assessed by a questionnaire answered by men and women aged 20-62 years (n = 15,986; response rate 75.9%). Logistic regression analysis was used to quantify the relationships between the use of antacids and health-related variables, lifestyle, and sociodemographic characteristics. Approximately 10% of the population had used antacids during the preceding 14 days. There was no overall gender difference. Among those who had no dyspeptic symptoms, 1.5% reported use of antacids, whereas among those who had all three dyspeptic symptoms (heartburn, epigastric pain, peptic ulcer), 46.5% had used antacids. Heartburn was the most important predictor for antacid use in both men (odds ratio [OR] = 8.57 [6.65-11.04]) and women (OR = 9.35 [7.16-12.221) followed by self-reported epigastric pain and peptic ulcer (both: OR = approximately 2). The importance of these self-reported health conditions remained unchanged after adjusting for lifestyle and sociodemographic variables. There were fewer antacid users among unmarried women than married women, and coffee-drinking was inversely associated with antacid use. These findings were consistent in both bivariate and multivariate analysis. The present study provides population-based information showing that self-medication with antacids in Norway appeared to be appropriate. Because dyspeptic symptoms play a major role in the consumption of antacids, this study shows the importance of including information about specific clinical variables in the analysis and interpretation of patterns of drug use.

Legal drug use in a general population: association with gender, morbidity, health care utilization, and lifestyle characteristics.

Legal drug use was assessed by a questionnaire to 15,986 men and women participating in the Finnmark Health Survey 1987-1988. Logistic regression analysis was used to quantify the relationships between legal drug use and gender, morbidity, utilization of health services, and lifestyle and sociodemographic characteristics. Drug use was higher in women than men, but the gender difference decreased with age. Women used more drug groups than men, and the gender difference increased with number of drugs used. Participating in outdoor activities was associated with lower use of drugs in both men and women. The data support the notion that alcohol use plays a more important role in the prediction of drug use in men compared with women. A significant gender difference in the consumption of legal drugs do persist after adjusting for co-morbidity and utilization of health services. Overall, this analysis shows that drug use depends on need (morbidity), followed by use of health services and lifestyle. Sociodemographic variables were shown to have minor influence.

Changing incidence of peptic ulcer--facts or artefacts? A cohort study from Tromsø.

STUDY OBJECTIVE: The aim was to estimate the age and sex specific incidences of duodenal and gastric ulcers censored for death and migration. DESIGN: A population based cohort was followed seven years through records of x ray examinations, endoscopies, and operations in the only hospital serving the area. SETTING: The study was conducted in the municipality of Tromsø, Northern Norway, where all men aged 20 to 54 years and women aged 20 to 49 years in 1980, a total of 21,440, were included. MAIN RESULTS: We found an incidence of 1.47 (95% CI 1.21-1.76) and 0.88 (0.67-1.14) per 1000 person-years for gastric and 1.98 (1.69-2.31) and 0.85 (0.64-1.11) for duodenal ulcers in men and women, respectively. A small and insignificant sex difference for gastric ulcer was noted. The duodenal preponderance in men was only recognised among the ulcers identified by x ray, not among ulcers diagnosed by endoscopy. CONCLUSIONS: This population based study has, in contrast to recent studies from other areas, revealed an unchanged high incidence of gastric and duodenal ulcer in both sexes. Compared to earlier studies from this area it indicates a preponderance of duodenal ulcers. The study also shows the impact of attendance rate, death, and migration, and of diagnostic methods on the incidence estimates. Ignoring these potential biases may lead to conclusions on peptic ulcer trends that reflect artefacts rather than real changes in peptic ulcer occurrence.

Aetiology of peptic ulcer: a prospective population study in Norway.

STUDY OBJECTIVE: To analyse simultaneously the effect of several risk factors for peptic ulcer. DESIGN: Cohort study where all patients with new or incident peptic ulcers in a well defined population were registered for a seven year period. The follow up started with a comprehensive health survey including a questionnaire on diet, lifestyle, psychological and social conditions, and health. Relative risks, both sex specific and separate, for gastric and duodenal ulcers were estimated from proportional hazard regression analysis. SETTING: A population based survey conducted in the municipality of Tromsø, northern Norway. PARTICIPANTS: In 1980, a total of 21,440 men and women, aged 20 to 54 years and 20 to 49 years respectively, were invited to participate. A total of 14,667 people attended and returned the questionnaire. MAIN RESULTS: A total of 328 people had their first peptic ulcer in the follow up period. Age, cigarette smoking, first degree relatives with peptic ulcer, and low educational level were shared risk factors for peptic ulcer in both men and women. In men, frequent upper respiratory infections increased the risk of gastric ulcer and drinking a great deal of milk increased the risk of duodenal ulcer. None of the other dietary variables, including coffee and alcohol consumption, contributed significantly to the risk. Use of analgesics was not a risk factor, and none of the psychological indicators analysed carried any significant risk. CONCLUSIONS: Age, inheritance, and cigarette smoking are all important risk factors for peptic ulcer. The increased risk associated with low educational background indicate that social strains, comprising lifestyle and diet habits, are part of the multifactorial aetiology of peptic ulcer. No support was found for the assumption that peptic ulcer disease is a psychosomatic disorder. This study did not support the view that duodenal and gastric ulcers have different aetiologies-rather it showed a similarity in risk patterns.

Amelioration of reperfusion injury following hypothermic, ischemic cardioplegia in isolated, infarcted rat hearts.

The left coronary artery was ligated and myocardial infarction developed in 28 rats. Three weeks later, the hearts were excised and mounted in an apparatus for perfusion of non-working isolated hearts (Langendorff). Hypothermic (15 degrees C), ischemic cardioplegia was induced for either 2 or 3 1/2 h followed by reperfusion for 45 min. Half of the hearts were reperfused with an initially gradual rise in temperature and pressure of the perfusion fluid, whereas the other half was reperfused directly with the perfusate at 37 degrees C and 100 cm H2O pressure. The hearts were examined by transmission electron microscopy and randomized for stereological analysis based on point counting on electron micrographs. Cardioplegia of 2 h duration was tolerated better than cardioplegia for 3 1/2 h (interstitial edema; P = 0.03, fraction of altered mitochondria; P = 0.001). Particularly in the hearts undergoing the longest cardioplegia, myocardial injury was less severe following a gentle reperfusion as compared with those exposed to the clinically common abrupt technique (fraction of mitochondria in the myocyte; P = 0.03, fraction of altered mitochondria; P = 0.008). In the interstitium, the luminal area of capillaries was significantly increased and the endothelial swelling less pronounced in the groups undergoing the gentle reperfusion technique, (luminal/endothelial fraction; P = 0.01). The study shows that previously infarcted hearts are susceptible to ischemic damage even after 2 h of regular hypothermic, ischemic cardioplegia and that a gentle reperfusion technique significantly ameliorates reperfusion injury.

Myocardial and microvascular injury following coronary surgery and its attenuation by mode of reperfusion.

In 14 patients undergoing coronary surgery, repeated atrial biopsies were obtained before and at the end of ischemia, and at 20 and 60 min of reperfusion. In half of the patients reperfusion was initiated with an abrupt rise in blood temperature and pressure, in the other half with a gradual rise. The biopsies were prepared for transmission electron microscopy and analyzed by stereological technique. In all biopsies, myocytic injury, as revealed by mitochondrial changes and intracellular edema, occurred following ischemia (P = 0.0003 and 0.007, respectively). The intracellular edema regressed following 20 min of reperfusion (P = 0.008). The myocytic mitochondrial changes persisted during reperfusion towards the end of the observation period (P = 0.0001). Interstitial edema increased following ischemia (P = 0.007) and persisted following 60 min of reperfusion (P = 0.009). The capillary part was significantly reduced after 20 min of reperfusion (P = 0.003), probably reflecting interstitial edema. Most changes were reversible in nature, although foci of irreversible changes were shown. In patients with a gradual start of reperfusion there was a significant regression of interstitial edema (P = 0.005) at 60 min reperfusion compared to the patients with an abrupt start, where the same changes seemed to persist or even increase. The study demonstrates that "reperfusion injury" occurs in human myocardium. It can be discerned from "ischemic" injury, and it may be reduced by a gentle mode of reperfusion.

Effects of low dose propranolol after coronary bypass surgery.

This study was performed to record the occurrence of clinically important supraventricular tachyarrhythmias (SVA) during the first eight days following coronary bypass surgery after preoperative withdrawal of various betablockers and to investigate whether low dose propranolol medication postoperatively could reduce the occurrence of such arrhythmias. Forty patients with stable angina pectoris were postoperatively randomly assigned to either a group (B) receiving low doses of propranolol or to a group (A) not receiving this medication. The number of patients having episodes of clinically important SVA was recorded. Two out of sixteen patients in the propranolol group had such episodes compared with nine out of twenty without postoperative betablockade (p = 0.07). Thus among patients treated with various betablockers which were withdrawn prior to coronary surgery, the occurrence of postoperative clinically important SVA could not be significantly reduced by postoperative low dose propranolol administration.

Is Helicobacter pylori the cause of dyspepsia?

OBJECTIVE: To determine the association between infection with Helicobacter pylori and dyspepsia. DESIGN: Cross sectional study of dyspeptic subjects and age and sex matched controls identified by a questionnaire survey of all inhabitants aged 20-69. (Endoscopy, histological examination, and microbiological examinations of biopsies from the gastric mucosa were performed blind.) SETTING: Population based survey in Sørreisa, Norway. SUBJECTS: All 782 dyspeptic subjects (excluding those with a previous history of peptic ulcer, gall stones or kidney stones, and coronary heart disease) and controls were offered an endoscopy, of whom 309 dyspeptic subjects and 310 controls attended. MAIN OUTCOME MEASURES: Prevalences of endoscopic and histological diagnoses and of cultures positive for H pylori. RESULTS: A high prevalence of positive cultures, increasing with age, was found in both dyspeptic subjects (48%) and non-dyspeptic controls (36%) (p = 0.004). Positive cultures in both dyspeptic subjects and controls were strongly associated with histological gastritis (70%, 95% confidence interval 65.5 to 85.3; 60%, 52.7 to 67.7, respectively) and peptic ulcer (92%, 61.5 to 99.8; 64.1, 9.4 to 99.2, respectively). Only 3% of subjects with a histologically non-inflamed gastric mucosa had this infection (dyspeptic subjects 2%, 0.2 to 7.0; controls 4%; 1.2 to 8.8). CONCLUSIONS: The relation between dyspeptic symptoms and H pylori is dubious; H pylori seems to have a pathogenetic role in gastritis and may be a contributing factor but not a cause of peptic ulcer.

Prevalences of endoscopic and histological findings in subjects with and without dyspepsia.

OBJECTIVE: To examine the association between dyspeptic symptoms and endoscopic and histological diagnoses. DESIGN: Cross sectional study of people with dyspepsia and controls matched for age and sex identified by questionnaire survey of all inhabitants aged 20 to 69. Endoscopy and histological examination was performed with the examiner blind to whether or not the patient had dyspepsia. SETTING: Population based survey in Sørreisa, Norway. SUBJECTS: All people with dyspepsia and age and sex matched people without dyspepsia were offered endoscopy. A total of 309 people with dyspepsia and 310 without dyspepsia underwent endoscopy, giving 273 matched pairs. MAIN OUTCOME MEASURES: Prevalences of endoscopic and histological diagnoses made according to internationally accepted standards. RESULTS: In all, 1802 of 2027 (88.9%) people returned the questionnaire. Of the 163 subjects who refused endoscopy, 114 were controls. Of five endoscopic and four histological diagnoses only peptic ulcer disease, endoscopic duodenitis, and active chronic gastritis were diagnosed significantly more often in people with dyspepsia. In all, 30% to 50% of the diagnoses of mucosal inflammation and peptic ulcer disease were made among subjects without dyspepsia, and only 10% of both those with and those without dyspepsia had normal endoscopic findings. CONCLUSIONS: The diagnostic findings, with possible exceptions of peptic ulcer disease and endoscopic duodenitis, showed no association of clinical value with dyspeptic symptoms. The small number of "normal" endoscopic findings in both those with and those without dyspepsia challenge well accepted endoscopic and histological diagnostic criteria with relation to the upper gastrointestinal tract.

Frequency of acute asymptomatic myocardial infarction and an estimate of infarct age in cases of abrupt sudden death observed in a forensic autopsy material.

The aim of this study is to determine the frequency of acute infarcts at autopsy in cases of unexpected abrupt deaths in persons with coronary heart disease. In addition, we want to estimate the time between onset of infarct and death based on evolving tissue changes in the infarct known to occur during the first hours. Thirty cases of unexpected, abrupt deaths were selected from a forensic autopsy material. Half of them had a preliminary diagnosis of coronary heart disease, the other half a preliminary diagnosis not involving the heart or chest area. Complete autopsies were performed. The myocardium and the coronary arteries were sampled and examined without knowledge of the gross findings or to which group the case belonged. Myocardial infarcts and acute coronary changes were found in both groups, less frequently in the non-coronary group. The age of the myocardial and coronary lesions was estimated by observing morphological characteristics changing with time, e.g. increasing polymorphonuclear leucocytes in the infarcted myocardium, and increasing amount of fibrin in thrombi. The majority of cases in the coronary group died with an extensive asymptomatic myocardial infarction, which probably had lasted 5-6 hrs or less. Acute changes in the right coronary artery and its area of supply prevailed. Acute myocardial infarcts were observed also in a minority of the non-coronary group, but myocardial infarction was not the cause of death in any of them. Abrupt coronary death is most often preceded by an extensive asymptomatic myocardial infarction within the last 5-6 hrs.

Oscillometric brachial mean artery pressures are higher than intra-radial mean artery pressures in intensive care unit patients receiving norepinephrine.

BACKGROUND: Norepinephrine is frequently used in intensive care unit (ICU) patients to raise and maintain an adequate mean arterial pressure (MAP). Conflict arises as to which MAP should guide vasopressor dose, as oscillometric MAP in the brachial artery often diverges from intra-radial MAP. We wanted to estimate the magnitude of this difference in ICU patients receiving norepinephrine, and to see whether the patient age, norepinephrine dose, age of radial catheter, ventilation treatment or severity of illness influenced the difference. METHODS: Prospective observational study comparing oscillometric MAP and intra-radial MAP performed in a central hospital-based surgical ICU during the period from February 2002 through to October 2003. Sixty-eight consecutive patients who received a norepinephrine infusion to maintain MAP above 70 mmHg were included. The mean arterial blood pressure was measured both oscillometrically and in the ipsilateral radial artery. RESULTS: Oscillometric MAP was on average 6.6 mmHg higher (95% CI 5.3-7.9) than intra-radial MAP in the 134 sets of measurements (P < 0.001). The patient's age (P = 0.319), norepinephrine dosage (P = 0.959) the age of the radial catheter (P = 0.992) were not significant. The difference in MAP was marginally greater in ventilated patients (P = 0.061) and significantly greater as the simplified acute physiology score (SAPS) score increased (P = 0.022). CONCLUSIONS: MAP measured oscillometrically over the brachial artery directly in the radial artery gave different results in an ICU population receiving norepinephrine. In more than one of four patients this difference is so large, and increases with illness severity, that the selection of any one method would influence treatment.