Developmental pathways in infants from 4 to 24 months.

BACKGROUND: There has been limited epidemiological research describing population-based samples regarding developmental pathways throughout infancy, and the research that exists has revealed substantial diversity. Identifying predictors for developmental pathways can inform early intervention services. METHODS: The Ages and Stages Questionnaire was used to measure communication, gross motor, fine motor, problem-solving and personal-social skills longitudinally in a large, population-based sample of 1555 infants recruited from well-baby clinics in five municipalities in southeast Norway. We conducted latent class analyses to identify common pathways within the five developmental areas. RESULTS: Our results indicated that most classes of infants showed generally positive and stable normative developmental pathways. However, for communication and gross motor areas, more heterogeneity was found. For gross motor development, a class of 10% followed a U-shaped curve. A class of 8% had a declining communication pathway and did not reach the level of the high stable communication class at 24 months. Low gestational age, low Apgar score, male sex, maternal depression symptoms, non-Scandinavian maternal ethnicity and high maternal education significantly predict less beneficial communication pathways. CONCLUSION: The results suggest that infants with low gestational age, low Apgar score, male sex and a mother with depression symptoms or non-Scandinavian ethnicity may be at risk of developing less beneficial developmental pathways, especially within the communication area. Targeting these infants for surveillance and support might be protective against delayed development in several areas during a critical window of development.

Cognitive rehabilitation in multiple sclerosis: a randomized controlled trial.

BACKGROUND: The evidence base in cognitive rehabilitation in multiple sclerosis (MS) is still sparse. OBJECTIVE: The aim of the study was to investigate the effects of cognitive rehabilitation on cognitive and executive coping, psychological well-being and psychological aspects of health-related quality of life (HRQoL) in patients with MS. METHODS: One hundred and twenty patients with cognitive complaints, taking part in a 4-week multidisciplinary rehabilitation, were randomized to an intervention group (n = 60) and a control group (n = 60). Both groups underwent neuropsychological assessment with subsequent feedback and took part in general multidisciplinary MS rehabilitation. Additionally, the intervention group participated in cognitive group sessions as well as individual sessions. The main focus was to formulate Goal Attainment Scaling goals for coping with cognitive challenges. For 3 months past rehabilitation, the intervention group received biweekly telephone follow-up, focusing on goal attainment. RESULTS: Executive functioning improved significantly from baseline to four and 7 months in both groups. Improvements in psychological well-being and psychological aspects of HRQoL occurred only in the intervention group. CONCLUSION: Multicomponent cognitive rehabilitation administered within the context of multidisciplinary rehabilitation can improve psychological well-being and psychological aspects of HRQoL.

Children are reliable reporters of common symptoms: results from a self-reported symptom diary for primary school children.

BACKGROUND: Collecting information on subjective symptoms in children by parental reports or physician's interview is indirect and not suited for prospective data collection over extended time periods. AIM: To examine the reliability of a diary for symptom self-reports by primary school children. METHODS: Children aged 7-8 or 11-12 were recruited from primary school and a paediatric outpatient department. A picture-based symptom diary was completed individually. Children were asked about presence of 10 specified subjective symptoms for five time periods covering the previous 24 h. The diary was completed twice for test-retest and answers were compared with semi structured physician's interviews. RESULTS: Test-retest reliability for reporting a symptom during the previous 24 h gave reliable kappa values of 0.64-0.91. Comparison with physician's interview gave kappas of 0.18-0.68. Requiring correct time of day for each symptom reduced reliability and validity. Kappa values for test-retest and child-physician agreement for the individual symptoms were respectively: sneezing, 0.80 and 0.30; sore throat, 0.89, 0.30; tiredness, 0.88, 0.65; headache, 0.64, 0.66; runny nose, 0.91, 0.68; sore eyes, 0.67, 0.18; cough, 0.73, 0.58; stomach ache, 0.69, 0.45. CONCLUSION: Our symptom diary gives reliable self-report data from primary school children. It may be used for prospective symptom monitoring.

White matter lesion severity is associated with reduced cognitive performances in patients with normal CSF Abeta42 levels.

OBJECTIVE: To identify possible associations between white matter lesions (WML) and cognition in patients with memory complaints, stratified in groups with normal and low cerebrospinal fluid (CSF) Abeta42 values. MATERIAL AND METHODS: 215 consecutive patients with subjective memory complaints were retrospectively included. Patients were stratified into two groups with normal (n = 127) or low (n = 88) CSF Abeta42 levels (cut-off is 450 ng/l). Cognitive scores from the Mini-Mental State Examination (MMSE) and the Neurobehavioral Cognitive Status Examination (Cognistat) were used as continuous dependent variables in linear regression. WML load was used as a continuous independent variable and was scored with a visual rating scale. The regression model was corrected for possible confounding factors. RESULTS: WML were significantly associated with MMSE and all Cognistat subscores except language (repetition and naming) and attention in patients with normal CSF Abeta42 levels. No significant associations were observed in patients with low CSF Abeta42. CONCLUSIONS: WML were associated with affection of multiple cognitive domains, including delayed recall and executive functions, in patients with normal CSF Abeta42 levels. The lack of such associations for patients with low CSF Abeta42 (i.e. with evidence for amyloid deposition), suggests that amyloid pathology may obscure cognitive effects of WML.

Modelling and prediction of weekly incidence of influenza A specimens in England and Wales.

We propose a rather simple model, which fits well the weekly human influenza incidence data from England and Wales. A standard way to analyse seasonally varying time-series is to decompose them into different components. The residuals obtained after eliminating these components often do not reveal time dependency and are normally distributed. We suggest that conclusions should not be drawn only on the basis of residuals and that one should consider the analysis of squared residuals. We show that squared residuals can reveal the presence of the remaining seasonal variation, which is not exhibited by the analysis of residuals, and that the modelling of such seasonal variations undoubtedly improves model fit.

Hospital quality improvement in context: a multilevel analysis of staff job evaluations.

OBJECTIVE: To investigate how much of the variance in data on nurse evaluation of different aspects of hospital work can be attributed to individual, ward, department and hospital levels, and to discuss the implication of the findings on quality improvement strategies. DESIGN AND METHOD: National survey data of work experiences were collected from hospital nurses working at 124 hospital wards in 36 departments in 15 hospitals across Norway during the autumn of 1998. The multilevel structure of the variation of nine indices of job satisfaction was explored by fitting four-level random intercept models (nurse, ward, department and hospital). RESULTS: A total of 2606 nurses (66%) responded. The indices showed varying clustering to organizational units. Intraclass correlations (ICCs) varied from 0.05 to 0.38, representing considerable higher level variation. The ward level was the dominating level for the clustering of nurses' job aspect evaluations. CONCLUSION: Multilevel modelling of staff work experiences may identify which improvement goals can be addressed at which organizational level. Improvement efforts should be directed specifically towards each aspect of work and at its most relevant organizational level. Strategies aimed at the micro-organizational level (ward management) rather than the individual level or the macro level (hospital top management) might prove worthwhile.

Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit.

PROBLEM: Need for improved sedation strategy for adults receiving ventilator support. DESIGN: Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative. BACKGROUND AND SETTING: A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours. KEY MEASURES FOR IMPROVEMENT: Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes. STRATEGIES FOR CHANGE: Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial. EFFECTS OF CHANGE: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified. LESSONS LEARNT: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.

Intercommunity and temporal variation of eleven essential and five toxic elements in human placentas from deliveries in thirteen arctic and sub-arctic areas of Russia and Norway.

Research is described that constitutes an extension of an earlier paper (J. Environ. Monit., 2001, 3, 177-184), in which concentrations were measured in 263 human placentas of 11 essential elements (P, Ca, Mg, Cu, S, Na, Fe, Zn, K, Se, Mn) and 5 toxic elements (Ba, Sr, Pb, Ni, Cd). The additional data considered derive from earlier visits to 4 of the original 6 communities and 3 others, all but one of which are located in northern Norway and neighbouring areas of Russia. This more than doubled the number of placental samples available (263 to 571). Unfortunately, the personal, life-style and morphometric information obtained for the first study group was not available for the additional mothers. Country differences were evident for all elements except Ba, Fe and Zn; Cd, Cu, Mn, Na, Se, Ni, Pb, Sr and S were higher and K, P, Ca and Mg were lower in Russia (p < 0.03). Not unexpectedly, the highest median lead concentration was observed for the largest city in the western arctic region of Russia, namely Murmansk. Similarly, the higher median nickel level observed for Russia reflects the established observation that urinary nickel concentrations are higher in the Russian than in the Norwegian communities. Even though sampling was performed at different times of the year and before and after a 3-year interval in four centres, inter-collection differences were of relatively small magnitude and appear not to be linked to seasonal or temporal changes. Principal component analysis (PCA) confirmed the prominence of Factor 1, which grouped those metals that are known to form insoluble phosphate complexes and whose concentrations showed a dependence on gestational age and maternal smoking in the earlier study. It is concluded that PCA is a powerful statistical tool for exploring and identifying fundamental pathways and processes involved in governing the inorganic elemental composition of placental tissue. It also has the potential of identifying study limitations and quality assurance shortfalls. Further our findings show promise that placental concentrations of toxic elements may serve as an index of exposure and of nutritional intake for selected essential micro-elements.

The self-perceived health status of Norwegian physicians compared with a reference population and foreign physicians.

AIMS: To compare the self-perceived health status of a representative sample of Norwegian physicians with a general reference population; and to investigate differences in health status among groups of physicians. METHODS: A cross-sectional postal survey was carried out of 1,126 Norwegian physicians and 1,742 subjects in a general reference population, using the widely used general health status questionnaire--Short Form 36 (SF-36). Scores were adjusted for differences in age, gender and education where applicable. RESULTS: The health status of Norwegian physicians was better than that of subjects with a lower level of education in the four dimensions of the SF-36 related to physical health. Male physicians scored better on the physical functioning scale and lower on vitality and social functioning than comparable university graduates. Older physicians scored better than younger in dimensions related to mental health and social functioning. Norwegian general practitioners reported better health status than colleagues in Sweden and the UK. CONCLUSIONS: The self-perceived health status of Norwegian physicians was as good or better than that of the general population. The cross-national differences could be caused by cultural differences, or be related to practice style or job strain.

Factor analysis of essential and toxic elements in human placentas from deliveries in arctic and subarctic areas of Russia and Norway.

Concentrations in human placenta of 11 essential elements (P, Ca, Mg, Cu, S, Na, Fe, Zn, K, Se, Mn) and 5 toxic elements (Ba, Sr, Pb, Ni, Cd) are compared for each of two arctic communities in eastern Norway and western Russia, and for another in each country located at more southerly latitudes. All but Mg, Fe, P and K were present in higher concentrations in the Russian study group. The observed inter-element correlations are reflected by the four major factors identified in a principal component analysis. The total variation explained was 67.3%, of which more than half (35.3%) was contributed by Factor 1. P, Ca, Mg, Ba, Sr, Pb, and Ni were major contributors to this factor. The placental concentrations of these elements depended strongly on gestational age, increasing from about week 35 and peaking near weeks 39 and 40, and exhibited skewed frequency distributions and a dependence on maternal smoking. The gestational-dependent mineralization of the placenta is interpreted to reflect the deposition of metal phosphates coinciding with smoking-induced tissue damage. The loadings of the remaining three factors are reviewed in the context of common uptake mechanisms, similar biochemistries and unique transport pathways. The inter-element relationships and grouping of the elements observed should constitute a scientific base for the use of placenta composition in environmental monitoring and epidemiological studies.

[How much money are we willing to spend on health services?]. / Hvor mye penger vil vi bruke på helsevesenet?

BACKGROUND: Like most other countries, Norway spends increasing sums of money on health care. The purpose of this study is to elicit people's views on whether society should spend more, and if so, their willingness to contribute to the financing of an expanded health service. MATERIAL AND METHODS: A random sample of the Norwegian population (2,089) were approached regarding a questionnaire study. 716 returned completed questionnaires (34%). Different versions of a questionnaire were used on three sub-samples in order to analyze the extent to which the distribution of answers depends on the wording of the questions. Variation in answers are sought explained by sociodemographic variables and political preferences. RESULTS: 70-80% held that society should spend more on health care. Their willingness to pay more in terms of "earmarked health care taxes" varied between the sub-samples. The mean annual figures were between NOK 1,314 and NOK 1,972. The proportions not willing to pay more varied between 39% and 46%. INTERPRETATION: It appears to be wide support for the idea that society should spend more on health care, but limited support for the idea of having to finance the desired expansion. One should be very cautious to generalize from preference surveys of this kind, because answers depend on the wording of the questions.

Physician in conflict: a survey study of individual and work-related characteristics.

Relationship of individual and work-related factors to interpersonal conflicts at work was studied, using data from a nationwide survey in 1993 of the work environment and living conditions of physicians in Norway. The survey included a total of 1,800 questions spread over 16 questionnaires, which were distributed according to an 'overlapping questionnaire design'. Questionnaires were mailed to a random sample of 9,266 physicians, of whom 6,652 responded (72%). The results suggest that personality factors such as 'intensity' and 'reality weakness' are related to conflict with one's immediate superior, but not to conflict with others at work. Respondents reporting conflict with friends, relatives and spouse tended to report more conflict at work both with immediate superiors and others. The frequency of interpersonal conflict at work was not related to gender.

[PS-RESKVA (Patient Satisfaction, Results and Quality)--patient satisfaction in hospitals]. / PS-RESKVA--pasienttilfredshet i sykehus.

The reliability and acceptability of a 39-question patient-satisfaction questionnaire (PS-RESKVA) for use in hospitals is assessed. Postal questionnaires were sent to 19,395 patients, aged between 15 and 100 years, who were discharged from the medical, surgical, gynaecological, and neurological wards of two Norwegian hospitals; they were followed up with one reminder. The response rate was 59% for all patients, and 71% among those who were considered medically capable of answering. Six underlying factors were identified in the PS-RESKVA profile, which contained 11 different aspects satisfaction. The PS-RESKVA satisfied the psychometric criteria for internal consistency. Results indicate that the PS-RESKVA is a possible measure of patient satisfaction after discharge from hospital. It seems acceptable to patients in general, and is a reliable measure of satisfaction for a wide range of patients. Further studies on its validity are warranted.

[Norwegian physicians--affluent and reputed, but not particularly happy]. / Norske leger--velstående og velansette, men ikke spesielt lykkelige.

Norwegian doctors enjoy a high standard of living. A comparison of doctors' work environment and living conditions with those of the general population (Survey of Norwegian physicians' work environment and living conditions 1993 (Nord-Trøndelag Health survey 1986, Survey of work environment 1989, General Household Survey 1991) shows that doing better does not necessarily mean feeling better. In almost all sex and age groups doctors score significantly lower than the rest of the population do on all our quality-of-life indicators. The mismatch may reflect the nature of their work. Although a larger share of doctors than others consider their work interesting and not physically tiresome, they work longer hours, and more them report feeling worn out, and that they have sleeping problems. Fewer of them describe their sociopsychological work environment as good. Possibly, as much effort should be put into improving doctors' jobs as into raising their salaries.

[Time stress among Norwegian physicians]. / Tidspress blant norske leger.

In this paper perceived stress at work is examined in a nationwide representative sample of Norwegian physicians. Four questions were asked about how often the doctors experienced their working conditions as hectic and bothersome, that the work load was unacceptable, that the large number of duties prevented them form working effectively and that they had difficulty in working reasonably undisturbed. 28% of the respondents stated that their work load was often or fairly often unacceptable, while 43% often or fairly often found it difficult to carry out various tasks without being disturbed. While 19% of the physicians perceived their working situation as often hectic and bothersome, the corresponding figure among other academics was 5%. When the four questions were combined to form a measure of stress, about one fifth of the doctors proved to be highly stressed. In a multiple linear regression analysis (N = 2,304) the physician's perceived autonomy was the strongest predictor of stress, i.e. doctors who feel they can substantially influence the planning and organization of their work achieve the lowest scores for stress. Heads of hospital departments are more stressed than physicians who work outside hospital. Stress also increases with increasing frequency of overtime and with increasing amounts of voluntary overtime.

[Positive feedback for good medical work--a short-supply commodity?]. / Anerkjennelse for godt legearbeid--en mangelvare?

In a nationwide survey of the working environment of Norwegian physicians every second respondent reported seldom or never being appreciated or praised for good work by their superiors. Nurses, colleagues and auxiliaries are more frequent sources of such appreciation. Very little of the variance in doctors' experience of positive feedback is explained by job variables: a doctor who does not receive supportive feedback cannot attribute this to unwise choice of specialty or type of employer, or to age, sex or position in the hierarchy. The experiences of male and female doctors are very much the same. Whether the doctors are appreciated and praised for good work seems to depend rather on certain traits of their personality.

[Patients' stories about their hospital stay. "Of course one special physician was responsible for me--what a question?"]. / Pasientfortellinger om sykehusopphold. "Selvfølgelig var det én lege som hadde hovedansvaret for meg--hvordan skulle det ellers ha gått?"

Data on patients' experiences are usually collected by questionnaires with fixed response categories. An analysis of 3,600 questionnaires showed that almost every fifth responder elaborated on his/her multiple choice answers by writing additional comments. Nearly all the comments were related to topics in the questionnaire. However, the number of comments relating to each of the questions varied. The patients' additional comments may give a clearer indication of what experiences they were anxious to provide feedback on than their multiple choice answers. Additional comments to the questionnaires provide the health service with supplementary information on which its quality assurance efforts can be based.

[Physicians' own control of their working situation--a myth?]. / Legers kontroll over egen arbeidssituasjon--en myte?

The idea that physicians have more autonomy than others in regard to their work does not match the physicians' own experience. In 1993, Norwegian physicians experienced less control over their own work than other professionals and employees in Norwegian society did. However, large variations exist between groups of physicians. Hospital doctors report less autonomy than other physicians do. Among specialists, surgeons report the lowest degree of job control. Female physicians report having less autonomy than their male colleagues, regardless of where or with what they work. Job control increases with age, both for female and for male physicians.

[Physicians and the mass media. Opinion of physicians on the coverage of medicine, health policy and the medical profession by the mass media]. / Leger og massemedier. Legeoppfatninger om massemedienes omtale av medisin, helsepolitikk og legene som yrkesgruppe.

Every fourth physician disapproves of mass media coverage of health policy questions. Four out of ten physicians are dissatisfied with the way scientific medical issues are covered, and seven out of ten are dissatisfied with articles and programmes about the medical profession. The physicians' dissatisfaction was predicted by a low level of perceived job autonomy and a high level of perceived unrealistic expectations from patients, families, superiors and politicians. The doctors' disapproval of press coverage of the medical profession increased with perceived stress. The dissatisfaction was clearly greater among younger than among older physicians. Internists and surgeons tended to be more dissatisfied than physicians in other specialties. Dissatisfaction with mass media was not, however, a question of personal grudge: respondents who felt that they themselves had been unfairly spoken of by the media did not disapprove of the media coverage of health issue, or of the medical profession in general, to any greater degree than did doctors who had no such personal complaints.

[Is gender of significance for specialization of physicians? An analysis of specialization degree among female and male physicians]. / Har kjønn betydning for om legen blir spesialist? En analyse av spesialiseringsgrad blant kvinnelige og mannlige leger.

Although there has been a substantial increase in the number of women in medicine, we still find strong gender differences in career patterns. Female physicians specialize to a lower degree than their male colleagues do, although the percentage who do so has increased in recent years. The gender difference in frequency of specialization is not an effect of female physicians' spending a longer time on specialist training. Our results indicate that female physicians, to a greater extent than their male colleagues have to choose between family and career. A larger percentage of female than of male physicians live alone, perhaps indicating that career demands a higher price for the former. However, the percentage of singles is, larger among older than among younger female physicians. We interpret this as indicating that the necessity to choose between career and family is not as strong as it used to be.