Persistent cough - A rare presentation of hepatocellular carcinoma.

Coughing is a very common condition, accounting for frequent visits in general practice. In this case report, we found the cause of persisting cough to be hepatocellular carcinoma, located in close proximity to the diaphragm. After the tumor had been treated with chemoembolization the coughing disappeared. After the common causes for persistent cough has been ruled out, the clinician could consider other, rarer, conditions as the cause of the coughing, including affection of the diaphragm.

Alcohol and substance abuse, depression and suicide attempts after Roux-en-Y gastric bypass surgery.

BACKGROUND: Small studies suggest that subjects who have undergone bariatric surgery are at increased risk of suicide, alcohol and substance use disorders. This population-based cohort study aimed to assess the incidence of treatment for alcohol and substance use disorders, depression and attempted suicide after primary Roux-en-Y gastric bypass (RYGB). METHODS: All patients who underwent primary RYGB in Sweden between 2001 and 2010 were included. Incidence of hospital admission for alcohol and substance use disorders, depression and suicide attempt was measured, along with the number of drugs prescribed. This cohort was compared with a large age-matched, non-obese reference cohort based on the Swedish population. Inpatient care and prescribed drugs registers were used. RESULTS: Before RYGB surgery, women, but not men, were at higher risk of being diagnosed with alcohol and substance use disorder compared with the reference cohort. After surgery, this was the case for both sexes. The risk of being diagnosed and treated for depression remained raised after surgery. Suicide attempts were significantly increased after RYGB. The adjusted hazard ratio for attempted suicide in the RYGB cohort after surgery compared with the general non-obese population was 2·85 (95 per cent c.i. 2·40 to 3·39). CONCLUSION: Patients who have undergone RYGB are at an increased risk of being diagnosed with alcohol and substance use, with an increased rate of attempted suicide compared with a non-obese general population cohort.

Changes in eating behaviour and food choices in families where the mother undergoes gastric bypass surgery for obesity.

BACKGROUND/OBJECTIVES: There is a lack of research exploring the effects of Roux-en-Y gastric bypass (RYGB) surgery on the patient's family's eating behaviour and food choices. The aim of the current study was to investigate changes in partners' and children's eating behaviour and food choices following maternal RYGB. SUBJECTS/METHODS: Sixty-nine women and their families were recruited from RYGB waiting lists at five Swedish surgical clinics. Data were collected during home visits 3 months before and 9 months after RYGB. Anthropometrical measures were taken, the adults completed the Three-Factor Eating Questionnaire and the children completed the Children's Eating Attitudes Test (ChEAT). All participants also completed a short food frequency questionnaire. RESULTS: Changes in scores were analysed using paired t-tests for unadjusted estimates or linear regression models with robust variance (General Estimating Equations) in order to enable age- and sex-adjusted estimates for the children. There were no meaningful differences in the partners' eating behaviour or food choices. The boys, but not the girls, improved their ChEAT scores, as did the overweight/obese children in comparison with the normal-weight children. The boys, unlike the girls, also decreased their intake of soft drinks, as did the normal-weight children when compared with the overweight/obese children. CONCLUSIONS: No clear-cut changes were found in partners' eating behaviour and food choices. Eating attitudes and soft drinks intake were improved among boys but not among girls. Differing modelling behaviour may partially explain these findings, but available data did not allow us to understand the underlying mechanisms.

Differences in gestational weight gain between pregnancies before and after maternal bariatric surgery correlate with differences in birth weight but not with scores on the body mass index in early childhood.

BACKGROUND: Large maternal gestational weight gain (GWG) is associated with increased birth weight and increased risk of obesity in offspring, but these associations may be confounded by genetic and environmental factors. The aim was to investigate the effects of differences in GWG in all three trimesters on differences in birth weight and in body mass index (BMI) scores at 4 and 6 years of age, within siblings born before and after bariatric surgery. METHOD: Women with at least one child born before and one after bariatric surgery were identified in national Swedish registers. Series of weight (and height) measurements were collected from antenatal medical records, with data on the nearest pregnancies before and after bariatric surgery. RESULTS: The age-adjusted means of pre- and post-operative GWG of 124 women were 11.3 (standard deviation [SD] 7.2) and 8.3 (SD 6.4) kg, respectively (P = 0.01). Adjusted fixed effects regression models showed positive associations of differences in mean total GWG with differences in siblings' birth weight, 0.023 kg per 1-kg greater weight gain (95% confidence interval [CI]: 0.014-0.069) and for second trimester 0.53 kg for each 1-kg greater weight per week (95% CI: 0.32-1.61), whereas no associations were found with BMI in pre-school age. CONCLUSION: This study showed positive associations between differences in total and second trimester maternal GWG and differences in children's birth weight, but no association with BMI scores in pre-school age. Maternal genetic, social and lifestyle factors fixed from one pregnancy to the next were taken into account in the analyses by the study design.

Dynamic contrast-enhanced CT in suspected lung cancer: quantitative results.

OBJECTIVES: To examine whether dynamic contrast-enhanced CT (DCE-CT) could be used to characterise and safely distinguish between malignant and benign lung tumours in patients with suspected lung cancer. METHODS: Using a quantitative approach to DCE-CT, two separate sets of regions of interest (ROIs) in tissues were placed in each tumour: large ROIs over the entire tumour and small ROIs over the maximally perfused parts of the tumour. Using mathematical modelling techniques and dedicated perfusion software, this yielded a plethora of results. RESULTS: First, because of their non-normal distribution, DCE-CT measurements must be analysed using log scale data transformation. Second, there were highly significant differences between large ROI and small ROI measurements (p<0.001). Thus, the ROI method used in a given study should always be specified in advance. Third, neither quantitative parameters (blood flow and blood volume) nor semi-quantitative parameters (peak enhancement) could be used to distinguish between malignant and benign tumours. This was irrespective of the method of quantification used for large ROIs (0.13

Infrequent attention to dietary and physical activity behaviours in conversations in Swedish child health services.

AIM: To investigate conversations between nurses and parents in Swedish child health services and to assess to what extent attention is directed towards dietary and physical activity behaviours in children. METHODS: Twenty-three nurses audio-recorded one session each. Recordings were assessed and topics were classified according to predetermined categories. RESULTS: The three most frequent topics of conversation concerned physical examinations of the child (30% of session time), talking to the child to establish or maintain contact and interest (15%), and development of language skills (12%). Dietary habits came on fourth place (10%), and physical activity ranked 14 (4%). CONCLUSION: Attention to dietary and physical activity behaviours in children is infrequent in Swedish child health services. Concern is raised about the efficacy of prevention efforts against childhood obesity.

Limited value of 99mTc depreotide single photon emission CT compared with CT for the evaluation of pulmonary lesions.

OBJECTIVES: A contrast-enhanced multidetector CT (MDCT) scan is the first choice examination when evaluating patients with suspected lung cancer. However, while the clinical focus is on CT, research focus is on molecular biological methods whereby radiolabelled pharmaceuticals are injected into participants and target malignant lung tumours. We examined whether a contrast-enhanced MDCT scan supplied with an additional non-contrast enhanced high-resolution CT scan, or a newer but more expensive (99m)Tc depreotide single photon emission CT (SPECT) scan, was the better first-choice examination for the work-up of pulmonary lesions. Furthermore, we examined whether a (99m)Tc depreotide SPECT scan was an appropriate second-choice examination for patients with indeterminate lesions. METHODS: 140 participants were included in the analysis. CT images were given a malignancy potential rating of 1, 2 or 3 with higher rating being indicative of disease. (99m)Tc depreotide SPECT images were graded either positive or negative. Histopathology and CT follow-up were used as reference standard. Sensitivity, specificity and diagnostic accuracy were calculated. RESULTS: Overall sensitivity, specificity and diagnostic accuracy of CT were 97%, 30% and 84%, respectively. Overall sensitivity, specificity and diagnostic accuracy of (99m)Tc depreotide SPECT were 94%, 58% and 76%, respectively. For indeterminate lesions sensitivity, specificity and diagnostic accuracy of (99m)Tc depreotide SPECT were 71%, 68% and 69%, respectively. CONCLUSION: Both CT and (99m)Tc depreotide SPECT made valuable contributions to the evaluation of pulmonary lesions. (99m)Tc depreotide SPECT results were not superior to CT results and did not contribute further to the diagnostic work-up. Regarding indeterminate lesions,( 99m)Tc depreotide SPECT sensitivity was too low.

Impact of mental health problems on case fatality in male cancer patients.

BACKGROUND: Although mortality rates are elevated in psychiatric patients relative to their healthy counterparts, little is known about the impact of mental health on survival in people with cancer. METHODS AND RESULTS: Among 16 498 Swedish men with cancer, survival was worse in those with a history of psychiatric hospital admissions: multiply-adjusted hazard ratio (95% confidence interval) comparing cancer mortality in men with and without psychiatric admissions: 1.59 (1.39, 1.83). CONCLUSION: Survival in cancer patients is worse among those with a history of psychiatric disease. The mechanisms underlying this association should be further explored.

Imaging follow-up of RF ablation of lung tumours.

Imaging is important in the decision-making process of how to treat a lung tumour, which ideally should be a multi-disciplinary team decision. Imaging is important during radiofrequency ablation (RFA) treatment with regard to optimal placement of the electrode, the immediate post-treatment criteria and very early detection of complications of the procedure. Imaging is very important in the treatment follow-up. In lung RFA, as in many other interventional procedures, the traditional morphological imaging techniques to evaluate treatment response have difficulties and functional imaging techniques may potentially be more useful. However, larger studies showing this impact have not yet been performed.

Contrast-enhanced ultrasound in oncology.

In patients with known malignant disease, 51% of liver lesions less than 1.5 cm turn out to be benign. Whether the probability of malignancy is high or low, further investigations are often necessary to definitely exclude malignancy. Contrast-enhanced ultrasonography has a prominent role in lesion characterization with a diagnostic accuracy comparable with computed tomography and magnetic resonance imaging. Anti-angiogenic treatment is common in most oncological institutions and the response evaluation is a new challenge with a research focus on the change in tumour vasculature and perfusion. In planning biopsies, CEUS can identify necrotic and viable areas of tumours and improve the diagnostic accuracy.

Morbidity and mortality before and after bariatric surgery for morbid obesity compared with the general population.

BACKGROUND: Bariatric surgery reduces morbidity and mortality in obese subjects, but it is unclear how rates compare with those in the population. The aim was to assess the risk of admission to hospital for obesity-related co-morbidities and overall mortality after bariatric surgery in relation to the general population. METHODS: A nationwide, population-based cohort study was conducted of all patients who underwent bariatric surgery in Sweden between 1980 and 2006. Each patient was compared with ten age- and sex-matched controls randomly selected from the Total Population Register. Hospital admission for co-morbidities was identified through the Patient Register. Cox proportional regression was used to calculate hazard ratios (HRs). RESULTS: A total of 13 273 patients underwent bariatric surgery between 1980 and 2006. After surgery, the overall adjusted HR remained increased for myocardial infarction (HR 1·56, 95 per cent confidence interval 1·35 to 1·81), angina pectoris (HR 2·05, 1·84 to 2·31), stroke (HR 2·13, 1·88 to 2·42), hypertension (HR 2·80, 2·61 to 3·01), diabetes (HR 2·44, 2·23 to 2·67) and death (HR 1·24, 1·15 to 1·34) in these patients compared with the general population. The 4161 patients who underwent gastric bypass surgery no longer had a higher risk of diabetes (HR 1·23, 0·88 to 1·72) or myocardial infarction (HR 0·78, 0·42 to 1·45), whereas morbidity remained increased after restrictive surgery in 7855 patients. The adjusted mortality remained higher after both gastric bypass and restrictive surgery. CONCLUSION: Gastric bypass, but not restrictive surgery, in patients with morbid obesity seems to reduce the risk of diabetes and myocardial infarction to population levels, but the risk of death remains increased.

Nationwide cohort study of post-gastric bypass hypoglycaemia including 5,040 patients undergoing surgery for obesity in 1986-2006 in Sweden.

AIMS/HYPOTHESIS: Symptomatic hypoglycaemia with related confusion, syncope, epilepsy or seizures is a newly recognised complication of gastric bypass surgery for obesity. The incidence of these conditions is not known. We therefore studied the incidence of post-gastric bypass hypoglycaemia and related symptoms in patients who have undergone gastric bypass and a reference cohort from the general population of Sweden. METHODS: This is a nationwide cohort study based on national registries with 5,040 persons who underwent gastric bypass, vertical banded gastroplasty or gastric banding for obesity in Sweden between 1 January 1986 and 31 December 2006 and a cohort of ten referents per patient matched for sex and age randomly sampled from the general population. The incidence rates of hospitalisation for hypoglycaemia, confusion, syncope, epilepsy or seizures before and after dates of surgery or inclusion in the reference cohort were studied. RESULTS: Preoperative incidences of hospitalisation for hypoglycaemia were similar in the surgical and referent cohorts. After gastric bypass surgery, the adjusted hazard ratios were significantly elevated for hypoglycaemia (2.7 [95% CI 1.2-6.3]), confusion (2.8 [1.3-6.0]), syncope (4.9 [3.4-7.0]), epilepsy (3.0 [2.1-4.3]) and seizures (7.3 [5.0-10.8]). The proportions of gastric bypass patients and reference participants affected by hypoglycaemia were very low (0.2% and 0.04%, respectively). There was no increased risk of hypoglycaemia after vertical banded gastroplasty or gastric banding compared with the referent population. CONCLUSIONS/INTERPRETATION: Obese persons who have undergone gastric bypass have an increased risk of hospitalisation for diagnoses associated with post-gastric bypass hypoglycaemia, although few patients are affected.

Bariatric surgery reduces mortality in Swedish men.

BACKGROUND: Mortality is lower in obese patients who have undergone surgery for obesity than in those who have not. The majority of patients in these studies have been women. Perioperative mortality is known to be higher among men, and this may counterbalance the survival advantage seen after surgery. This cohort study compared mortality among operated obese patients, non-operated obese patients and a general control cohort of men. METHODS: The study was based on record linkage between Swedish registries. An operated obese, a non-operated obese and a general control cohort were created. The two non-operated cohorts were assigned pseudosurgery dates. Data regarding preoperative and postoperative morbidity were collected, as well as mortality data. RESULTS: Hazard ratios were calculated for mortality between the cohorts adjusting for preoperative morbidity and age. Comparison of all-cause mortality for the obese surgical and non-surgical cohorts gave an adjusted mortality risk of 0.7 (95 per cent confidence interval (c.i.) 0.5 to 1.0) (P = 0.039); the adjusted mortality risk was 1.5 (95 per cent c.i. 1.1 to 2.0) (P = 0.011) when the obese surgical cohort was compared with the general control cohort. CONCLUSION: Bariatric surgery reduces overall mortality in obese men.

The combined effects of overweight and smoking in late adolescence on subsequent disability pension: a nationwide cohort study.

BACKGROUND: Smoking and obesity are two of the most important risk factors for chronic disease today. Their combined effect on the risk of disability pension is not known. METHODS: A nationwide cohort of 45 920 Swedish men (18.7 + or - 0.5 years) were followed for 38 years. The body mass index (BMI), based on measured height and weight, was used to define underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9) and obesity (> or = 30.0). The hazard ratios (HRs) associated with BMI and smoking status at baseline for receiving disability pension were adjusted for socio-economic index (SEI), muscular strength, geographic region and place of residence. RESULTS: During 1.6 million person-years, 4631 disability pensions and 2897 deaths occurred. After adjustment, overweight (HR 1.34, 95% CI 1.19-1.51) and obesity (HR 1.55, 1.18-2.05) were associated with an increased risk of disability pension, independent of smoking, whereas underweight (18.5; HR 1.07, 0.97-1.17) was not compared with normal weight. Similarly, smoking 1-10 (HR 1.37, 1.27-1.49) or >10 cigarettes per day (HR 2.01, 1.86-2.17) showed independent risk increases versus non-smoking. Although obese individuals smoking >10 daily cigarettes were at greatly increased risk (HR 2.98, 1.98-4.47), no evidence of interaction between the two risk factors could be detected. CONCLUSIONS: Both increased adiposity and smoking are strong and independent predictors of disability pension, but they do not act synergistically.

Extension of the calibration curve for the PGRA facility in Petten.

At the boron neutron capture therapy (BNCT) facility in Petten, the Netherlands, (10)B concentrations in biological materials are measured with the prompt gamma ray analyses facility that is calibrated using certified (10)B solutions ranging from 0 to 210 ppm. For this study, newly certified (10)B solutions ranging up to 1972 ppm are added. MCNP simulations of the setup range to 5000 ppm. A second order polynomial (as already used) will fit (10)B-concentrations less than 300 ppm. Above 300 ppm a fitted third order polynomial is needed to describe the calibration curve accurately.

High-sensitive C-reactive protein is associated with reduced lung function in young adults.

Systemic inflammation has been associated with reduced lung function. However, data on the interrelationships between lung function and inflammation are sparse, and it is not clear if low-grade inflammation leads to reduced lung function. Associations between high-sensitive C-reactive protein (CRP) and spirometric lung function were assessed in a population-based cohort of approximately 1,000 Danes aged 20 yrs. In males, the average decline in forced expiratory volume in one second (FEV(1)) in the highest CRP quintile was 23 mL.yr(-1) versus 1.6 mL.yr(-1) in the lowest quintile. In females, the average decline was 6.2 mL.yr(-1) in the highest CRP quintile versus an increase of 1.8 mL.yr(-1) in the lowest CRP quintile. In a multiple regression analysis adjusted for sex, body mass index, cardiorespiratory fitness, smoking, asthma, airway hyperresponsiveness and serum eosinophil cationic protein, higher levels of CRP at age 20 yrs were associated with a greater reduction in both FEV(1) and forced vital capacity between ages 20 and 29 yrs. The findings show that higher levels of C-reactive protein in young adults are associated with subsequent decline in lung function, suggesting that low-grade systemic inflammation in young adulthood may lead to impaired lung function independently of the effects of smoking, obesity, cardiorespiratory fitness, asthma and eosinophilic inflammation.

Association between obesity status in young adulthood and disability pension.

OBJECTIVE: Obesity and underweight in young adulthood are associated with greater risk of future disability pension. Neither underlying causes of disability pension nor whether overweight confers excess risk is established in this age group. The aim of this study was to investigate risk of future disability pension according to body mass index (BMI) in young adulthood. DESIGN: BMI was measured at military conscription (1969-1994; n=1 191 027; mean age 18.3+/-0.5 years). Date and cause of disability pension, death and emigration dates were collected from national registers (1971-2006). Muscular strength, age, municipality, socioeconomic position, testing center and year were adjusted for in Cox regressions. RESULTS: During 28.4 million person-years, 60 024 subjects were granted disability pension. The hazard ratios (HRs) for underweight (1.14, CI 95% 1.11-1.17), overweight (1.36, 1.32-1.40), moderate (BMI 30-34.9; 1.87, 1.76 to 1.99) and morbid obesity (BMI>or=35; 3.04, 2.72-3.40) were elevated compared to normal weight. Not adjusting for muscular strength led to overestimation of the risk in underweight (1.27, 1.24-1.31), but underestimation in overweight (1.29, 1.25-1.33), moderately (1.72, 1.62-1.82) and morbidly obese subjects (2.77, 2.48-3.09). For circulatory and musculoskeletal causes, respectively, HRs were elevated only for overweight (2.06; 1.82-2.34; 1.47; 1.39-1.55) and obesity (3.51; 2.79-4.40; 2.15; 1.94-2.38). The same applied for tumors and nervous system, but not psychiatric causes, for which underweight (1.20; 1.16-1.24) displayed similar HR as overweight (1.21; 1.16-1.27), whereas the risk in obese subjects was higher (1.60; 1.46-1.75). CONCLUSION: The risks in overweight and obese, but not underweight, subjects were significantly elevated for each cause investigated. Although causality cannot be inferred, productivity losses associated with adverse BMI in young adulthood appear to be large.

Set-up and calibration of a triple ionization chamber system for dosimetry in mixed neutron/photon fields.

The aim of this study is to introduce a triple ionization chamber system to separate dose components of mixed neutron/photon fields. Fast and thermal neutron dose components have a different biological effectiveness than gamma dose components. If boron neutron capture is used to enhance the dose in certain areas of a patient, the precise knowledge of the thermal neutron flux is essential. A tissue equivalent and two magnesium ionization chambers have been prepared for use in a triple chamber system for this purpose. One of the magnesium chambers is coated with (10)B on the inside to enhance its response to thermal neutrons. All three chambers have been calibrated at a cobalt source, medical linear accelerators and several neutron sources. The chambers have been studied in Monte Carlo simulations and the results are compared with measurements.

IQ in early adulthood and later cancer risk: cohort study of one million Swedish men.

BACKGROUND: While several studies have reported an inverse relation between IQ and total mortality rates, little is known about the association, if any, between IQ and disease-specific outcomes, particularly cancer. METHODS: A cohort of 959,540 Swedish men who underwent IQ testing at military conscription at around 19 years of age, and who were followed for incident cancer. Hazards ratios for the relation between IQ and 20 cancer outcomes were computed using Cox regression. RESULTS: During an average of 19.5 years of follow-up, there were 10 273 new cancer cases. IQ showed few associations with the cancer end points studied. There was a suggestion that IQ was positively associated with lung cancer, and inversely related to stomach, oesophageal and liver malignancies, although effects were modest. The only robust gradient was found for IQ in relation to skin cancer (HRper one standard deviation advantage in IQ; 95% confidence interval 1.18; 1.13, 1.24; P value for trend across categories: <0.01), which was attenuated but retained statistical significance after adjustment for indices of socioeconomic position across the life course. CONCLUSIONS: In this large cohort of Swedish men followed into middle age, IQ was related to very few of the cancer outcomes under investigation. This indicates that the recent observation that low IQ is related to increased mortality rates may not be generated by an IQ-cancer gradient. Given that the present analyses are among the first to examine these associations, replication is required.