The effects of low to moderate alcohol consumption and binge drinking in early pregnancy on selective and sustained attention in 5-year-old children.

OBJECTIVE: The aim was to examine the effects of low to moderate maternal alcohol consumption and binge drinking in early pregnancy on children's attention at 5 years of age. DESIGN: Prospective follow-up study. SETTING: Neuropsychological testing in four Danish cities 2003-2008. POPULATION: A cohort of 1628 women and their children sampled from the Danish National Birth Cohort. METHODS: Participants were sampled based on maternal alcohol consumption during pregnancy. At 5 years of age, the children were tested with the recently developed Test of Everyday Attention for Children at Five (TEACh-5). Parental education, maternal IQ, maternal smoking in pregnancy, the child's age at testing, gender, and tester were considered core confounding factors, whereas the full model also controlled the following potential confounding factors: maternal binge drinking or low to moderate alcohol consumption, age, body mass index (BMI), parity, home environment, postnatal smoking in the home, child's health status, and indicators for hearing and vision impairments. MAIN OUTCOME MEASURES: TEACh-5 attention scores. RESULTS: There were no significant effects on test performance in children of mothers drinking up to 8 drinks per week compared with children of mothers who abstained, but there was a significant association between maternal consumption of 9 or more drinks per week and risk of a low overall attention score (OR 3.50, 95% CI 1.15-10.68). No consistent or significant associations were observed between binge drinking and attention test scores. CONCLUSIONS: The findings suggest an effect of maternal consumption of 9 or more drinks per week on attention functions in children, but the study detected no effects of lower levels of maternal consumption and no consistent effects of maternal binge drinking.

Migraine without aura: comparison with cervicogenic headache. Vågå study of headache epidemiology.

OBJECTIVES: To study migraine without aura (MwoA) prevalence in the commune of Vågå, Norway; 1838 (18- to 65-year-old) individuals were included. A special search was made for cervicogenic characteristics in MwoA, as it has been claimed that such characteristics may frequently be present. A comparison with cervicogenic headache (CEH) was made. METHODS: The MwoA and tension-type headache (T-TH) diagnosis was based on IHS criteria. CEH diagnosis was based on the principles of The Cervicogenic Headache International Study Group. RESULTS: There were 562 cases of MwoA; prevalence: 31%. There were 425 cases of 'pure' MwoA, i.e. without coexisting T-TH. These 'pure' cases were used for extracting MwoA symptoms. The female/male ratio was 1.69, the corresponding ratio in CEH being 0.71. Typical MwoA symptoms such as nausea/photophobia were most frequently found in migraine. This difference amounted to a factor of > or =2.6. On the other hand, typical CEH traits, like mechanical pain provocation and 'posterior' onset of exacerbations, occurred more frequently in CEH than in MwoA. The difference amounted to a factor of two or more. CONCLUSIONS: MwoA and CEH have clearly different characteristics. The differences between MwoA and CEH are staggering. It is unlikely that migraine and CEH are linked in a nosological sense.

Prevalence of cervicogenic headache: Vågå study of headache epidemiology.

OBJECTIVES: To describe the prevalence and various clinical characteristics of cervicogenic headache (CEH) in the population at large. METHODS: CEH was searched for in Vågå, Norway, where 1838 18 to 65-year-old citizens, i.e. 88.6% of this age group, underwent an interview/clinical examination. The Cervicogenic Headache International Study Group criteria include: (I) unilaterality of head pain, (II) reduction, range of movement, neck, (III/IV) ipsilateral shoulder/arm discomfort, (V/VI) mechanical provocation of similar pain, objectively or subjectively. RESULTS: A prevalence of 4.1% was found. In 41 cases with the highest number of CEH criteria ('core' cases), there was a male preponderance (F/M: 0.71). While cervicogenic traits (mechanical precipitation etc.) were frequently present in CEH, 'migraine traits', like nausea, vomiting, and throbbing seemed to be rarely present. In 97% of the cases, pain exacerbations began in the neck/occipital region. CONCLUSIONS: CEH may be one of the three large, recurrent headaches. In this series, there was no female preponderance. Nuchal onset of pain is a characteristic trait.

Neck pain and associated head pain: persistent neck complaint with subsequent, transient, posterior headache.

BACKGROUND: During the Vågå headache epidemiology study, there were indications that various types of work, such as carpentry and hairdressing, frequently seemed to be linked to a combination of neckache and headache. OBJECTIVES: A post hoc study was conducted among 1838, 18- to 65-year-old Vågå citizens, looking for patients with combined neck/headache. DESIGN: Face-to-face interview was conducted. RESULTS: Combined neckache and headache were detected in 121 (6.6%) individuals. The bilateral headache originated in the neck; it was mild/moderate, symptom-poor, and frequently provoked by awkward neck positions. No such headache occurred without a neckache. Headache in this group of patients resembles tractor drivers' headache, except for the provoking factor itself. CONCLUSIONS: This headache is not listed in headache classification systems/textbooks on headache. This headache must be distinguished from the unilateral cervicogenic headache proper because of the different treatment perspectives.

Hydrogen sulphide headache and other rare, global headaches: Vågå study.

One aim of the Vågå study of headache epidemiology was to depict the total panorama of headaches in a small-sized, Norwegian community at the end of the 20th century. In the present part of the study, a search was made for the rare, global headaches. Various, relatively unknown headache categories were observed, such as hydrogen sulphide intoxication (n = 2) after exposure to H(2)S ambient air concentrations of >or=100 p.p.m. In Vågå, nitroglycerine headache ('dynamite headache') proved to be a relatively frequent disorder (n = 13). This represents approximately 0.7% of the study group. A main reason for this, in all probability unusually high frequency is that there previously have been soapstone mines within the precincts of the parish. Another relatively frequently occurring headache followed exposure to wind (n = 7; 0.38%). Ice-cream headache was rare (n = 3; 0.16%), when only the general question was asked: 'other headaches?'. Approximately 7 years later, an ad hoc procedure was adopted: 50 parishioners who did not answer positively concerning ice-cream headache on the first examination were asked specific questions concerning ice-cream headache. Four had had such an experience, i.e. prevalence of 8%, which is 50 times higher than the original result, but still a rather low prevalence when compared with the mean prevalence from other studies: 39%. This demonstrates that the result as regards prevalence, even for a headache such as ice-cream headache, to a large degree depends upon the interview technique used.

Neck-tongue syndrome and related (?) conditions.

A search has been made for the neck-tongue syndrome. It started out with a systematic inquiry during the Vågå study of headache epidemiology during the years 1995-97. Two cases were detected relatively early during the study. This led to a scrutiny of such cases also in our hospital headache practice. The origin - and the basis of the study, nevertheless, was the Vågå study. In the Vågå study, where 1838 18-65-year-old parishioners were examined, there were four neck-tongue syndrome cases (N-TS), i.e. a prevalence of approximately 0.22%. N-TS may be more frequent than hitherto surmised. A variant was observed in one case; a young male: instead of numbness, a 'spasm' seemed to occur in the tongue. None of the four had at any time consulted their physician for their complaints. In our regular headache practice, two new cases were detected. In one of them and in one of the Vågå cases, there was a combination with ipsilateral cervicogenic headache (CEH). In N-TS, there may be both ipsilateral headache and upper extremity sensory phenomena, a constellation reminiscent of CEH. The possible pathogenetic relationship between N-TS and CEH is therefore discussed in some detail.

Defining cancer patients as being in the terminal phase: who receives a formal diagnosis, and what are the effects?

PURPOSE: Physicians either do not define cancer patients as being terminal, or their prognostic estimates tend to be optimistic. This might affect patients' appropriate and timely referral to specialist palliative care services or can lead to unintended acute hospitalization. PATIENTS AND METHODS: We used the Danish Cancer Register and four administrative registers to perform a retrospective cohort study in 3,445 patients who died as a result of cancer. We used the Danish "terminal declaration" issued by a physician as a proxy for a formal terminal diagnosis (prognosis of death within 6 months). The terminal declaration gives right to economic benefits and increased care for the dying. We investigated patient-related factors of receiving an explicit terminal diagnosis by logistic regression and then analyzed the effects of such a diagnosis on admission rate per week and place of death. RESULTS: Thirty-four percent of patients received a formal terminal diagnosis. Age of > or = 70 years (odds ratio [OR], 0.44; 95% CI, 0.34 to 0.56; P < .001), women (OR, 0.81; 95% CI, 0.69 to 0.96; P = .02), hematologic cancer (OR, 0.20; 95% CI, 0.09 to 0.41; P < .001), and a less than 1-month survival time (OR, 0.10; 95% CI, 0.07 to 0.15; P < .001) were associated with a lesser likelihood of receiving a formal terminal diagnosis. Explicit terminal diagnosis was associated with lower admission rate and an adjusted OR of hospital death of 0.25 (95% CI, 0.21 to 0.29). CONCLUSION: Women and the elderly were less likely to receive a formal terminal diagnosis. The formal terminal diagnosis reduced hospital admissions and increased the possibilities of dying at home.

Long-lasting cephalic jabs (?) The Vågå study of headache epidemiology.

Jabs (stabs) usually last < or = 3 s and are located in the skull area, mostly anteriorly. In many cases, there are only a few jabs during lifetime. With this definition, jabs are frequent, thus at 35.2% in the Vågå study of headache epidemiology. Long-lasting jabs (?), i.e. paroxysms lasting 10-120 s, were present in six out of 1779 parishioners. These pain paroxysms seemed mainly to be side-locked, but could not be provoked. Possibly, these long-lasting jabs after all mainly are regular jabs. To include the < or = 2-minute-long paroxysms among the jabs will necessitate a rather drastic change of criteria. This group of jabs may, nevertheless, be heterogeneous. In two parishioners, the paroxysms were associated with a migraine-like pain. The paroxysms occasionally became most intense (2-10 times the basal pain), and then, and only then, were they combined with stark, visual phenomena: wave-like movements ('undulation'), anopsia, but also: immense dizziness, nausea/vomiting. The nature of the side-locked basal pain, although migraine-like, remains unsolved.

Supraorbital neuralgia. Vågå study of headache epidemiology.

In a recent, hospital-based report, we described a small series of 5 patients with unilateral, more or less chronic, severe forehead pain, that could be transitorily abated by anaesthetic blockade of the supraorbital nerve and more permanently abated by 'liberation' operation directed towards the nerve exit area at the supraorbital notch. However, epidemiological data on supraorbital neuralgia are lacking. Among 1838 18-65-year-old inhabitants in Vågå (88.6% of the eligible ones), there were 10 who presented the following clinical picture: (1) Unilateral forehead/ocular pain, not diagnosed or diagnosable as any other, particular, unilateral headache; (2) Steadfast unilaterality; (3) Increased tenderness upon pressure over the exit site of the supraorbital nerve (incisura frontalis) on that side--in those who were in an active phase; (4) Foregoing trauma in the forehead/supraorbital rim area, ipsilaterally. In approximately half the cases, there was a moderate, ipsilateral sensory loss. A striking finding was the occurrence of jabs in the symptomatic area, and in synchrony with the neuralgia pain. These 10 inhabitants correspond to a prevalence of 0.5% (or 0.65% if two nontrauma cases are included).

Caffeine-withdrawal headache. The Vågå study of headache epidemiology.

In connection with the Vågå study of headache epidemiology, a search was made for caffeine-withdrawal headache in 1741 parishioners. Female to male ratio 1.05; mean age 44.2 years (range 18-65 years). A face-to-face interview technique was used. The mean consumption of coffee was 4.7 cups a day. Males on an average consumed more coffee (5.1 +/- 3.3 cups/day) than females (4.4 +/- 3.1 cups/day). Neither in those with a high consumption of coffee: > or =10 cups a day (n = 134), nor in those with a considerable variation in consumption: > or =10 cups/day (n = 31) did there seem to be a definite increase in headache resembling caffeine-withdrawal headache, for instance during weekends. In seven parishioners, however, there did seem to be such a headache, and in two of them, the evidence was rather convincing. This headache generally seemed to be mild and global and occurred mainly in the morning hours on weekends. There was no nausea, no throbbing quality of the pain, and no reported use of analgesics. Coffee seemed to abate the headache. This frequency (0.4%) should, clearly, be regarded as a minimum figure. Caffeine-withdrawal headache at the grassroots level may be a rather rare, generally vague, symptom-poor headache.

Psychosocial factors at work in relation to low back pain and consequences of low back pain; a systematic, critical review of prospective cohort studies.

Relevant studies of low back pain (LBP) published between 1990 and 2002 were systematically retrieved via electronic databases and checking of reference lists. Forty papers fulfilled the inclusion criteria; 10 were of high quality. A wide variety of instruments had been used for collection of data on work related psychosocial factors, many of which had not undergone any form of validation. Moderate evidence was found for no association between LBP and perception of work, organisational aspects of work, and social support at work. There was insufficient evidence for a positive association between stress at work and LBP. No conclusions could be drawn regarding perception of work and consequences of LBP. There was strong evidence for no association between organisational aspects of work and moderate evidence for no association between social support at work and stress at work and consequences of LBP.

Cluster headache prevalence. Vågå study of headache epidemiology.

In the Vågå study of headache epidemiology, a search was made also for cluster headache. Of the available 18-65-year-old dalesmen, 1838 (88.6%) could be examined personally (O.S.) - 51.3% females and 48.7% males. Based on current International Headache Society criteria, cluster headache seemed to be present in seven dalesmen, one female and six males (corresponding to a total prevalence of 381 per 100 000; 95% confidence interval (CI) 153-783 per 100 000). Except for the female gender, the female case was fairly typical. In one case, there were short-lasting bouts ('minibouts'). It was felt that this also was a genuine case of cluster headache. If one excluded the latter case, there would be one female and five males [a prevalence of 106 per 100 000 for females, and 558 per 100 000 for males, giving a prevalence in the total population of 326 per 100 000 (95% CI 120-709 per 100 000)]. The confidence interval was considerable. This study therefore does not give a clear indication as to prevalence.

Exertional headache--II. Clinical features Vågå study of headache epidemiology.

In connection with a large-scale study of headache epidemiology in the parish of Vågå, Norway (n = 1838), a prevalence of exertional headache (EH) of 12.3% was recently reported (n = 202). The principal aim of the present report is to have a closer look at various clinical features: particular attention has been given to the coexistence of EH and migraine. EH seemed to coexist with migraine in 46% of the cases. In spite of that finding, there was generally no plentitude of 'migraine features' in the EH attacks per se. The predominant 'migraine feature' in EH attacks was throbbing. EH attacks were generally more short-lasting and seemed to be more lenient than the corresponding migraine attacks. Nausea/vomiting, and unilaterality of pain were generally not inherent features of EH attacks. EH attacks in all probability are not abortive migraine attacks--rather, they seem to be 'migraine-like'.

Prolonged benign exertional headache. The Vågå Study of headache epidemiology.

OBJECTIVE: To explore in detail the duration of exertional headache attacks and explicitly to identify cases of prolonged exertional headache. BACKGROUND: The prevalence of exertional headache in general population samples may exceed 10%. The prevalence and distinguishing clinical characteristics of prolonged exertional headache are not well delineated. METHODS: One author (O.S.) personally interviewed 1838 parishioners (88.6%) of ages 18 to 65 years living in a southern Norwegian commune. Questions relevant to exertional headache were included. RESULTS: As recently reported elsewhere, exertional headache was present in 12.3% of those questioned. With 1 hour set as a tentative border for short- versus long-duration exertional headache, there were approximately equal numbers with short- and long-lasting attacks; prevalence of short-lasting attacks was 6.3% and long-lasting attack prevalence was 6.0%. In regards to other epidemiologic and clinical features, the long-lasting cases did not seem to deviate from the short-lasting cases; both categories had a moderate female preponderance and similar age of onset. There was a somewhat higher mean number of "migrainelike features" in the long-lasting than in the short-lasting variety of exertional headache. Exertional headache attacks could last up to 24 hours. CONCLUSIONS; There seems to be little reason to subdivide exertional headache into 2 separate varieties according to attack duration. Exertional headache attacks have "migrainelike" features but do not seem to be "form fruste" migraine attacks. The long-lasting variety is not uncommon.

Extracephalic jabs/idiopathic stabs. Vågå study of headache epidemiology.

Ultrashort cephalic paroxysms are well known. In the parish of Vågå, Norway, 35.2% of the 18-65-year-old subjects (n = 1779) were recently found to have such jabs. In the present work, a search has been made for extracephalic 'jabs'. A questionnaire was in its entirety administered by the same investigator (O.S.) in a 'semistructured' way. Facial jabs were present in three women, and in one of them the pain spread to the head. Four subjects had jabs occurring at random throughout the body, also including the cephalic area. Pure nuchal jabs were present in 12 subjects, 10 of whom were males. This sex preponderance difference differs significantly from that in jabs in general (with 40.2% males). The characteristics of the extracephalic jabs, i.e. the duration and temporal pattern, do not seem to differentiate them essentially from jabs in general. The subjects were not asked specific questions regarding extracranial jabs. Most of the affected individuals gave information spontaneously about their jabs. For these reasons, this study is not a proper prevalence study. It does show, however, that extracranial jabs exist, and it gives some indications as to their frequency.

Ambiguous relation between physical workload and low back pain: a twin control study.

AIMS: To examine the association between self reported physical workload and low back pain (LBP) in younger twins. To investigate whether genetic factors interact with physical workload in relation to LBP. METHODS: A twin control study was performed within a population based twin register using 1910 complete monozygotic (MZ) and same sexed dizygotic (DZ) twin pairs aged 25-42 and discordant for LBP. LBP in the affected twins was divided into two groups: "LBP for 30 days during the past year". Physical workload was divided into four categories: "sitting", "sitting/walking", "light physical", and "heavy physical". Data were analysed in a matched design using conditional logistic regression. MZ and DZ twins were analysed separately and together in order to determine possible genetic influences in relation to physical workload and LBP. RESULTS: Statistically significant graded relations were found for increasing workload and LBP of longer duration but not for LBP of shorter duration (

Suboptimal care and perinatal mortality in ten European regions: methodology and evaluation of an international audit.

BACKGROUND: A European concerted action (the EuroNatal study) investigated differences in perinatal mortality between countries of Europe. This report describes the methods used in the EuroNatal international audit and discusses the validity of the results. METHODS: Perinatal deaths between 1993 and 1998 in regions of ten European countries were identified. The categories of death chosen for the study were singleton fetal deaths at 28 or more weeks of gestational age, all intrapartum deaths at 28 or more weeks of gestational age and neonatal deaths at 34 or more weeks of gestational age. Deaths with major congenital anomalies were excluded. An international audit panel used explicit criteria to review all cases, which were blinded for region. Subjective interpretation was used in cases of events or interventions where explicit criteria did not exist. Suboptimal factors were identified in the antenatal, intrapartum and neonatal periods, and classified as 'maternal/social', due to 'infrastructure/service organization', or due to 'professional care delivery'. The contribution of each suboptimal factor to the fatal outcome was listed and consensus was reached on a final grade using a procedure that included correspondence and plenary meetings. RESULTS: In all regions combined, 90% of all known or estimated cases in the selected categories were included in the audit. In total, 1619 cases of perinatal death were audited. Consensus was reached in 1543 (95%) cases. In 75% of all cases, the grade was based on explicit criteria. In the remaining cases, consensus was reached within subpanels without reference to predefined criteria. There was reasonable to good agreement between and within subpanels, and within panel members. CONCLUSIONS: The international audit procedure proved feasible and led to consistent results. The results that relate to suboptimal care will need to be studied in depth in order to reach conclusions about their implications for assessing the quality of perinatal care in the individual regions.

Exertional headache. I. Vågå study of headache epidemiology.

The aim was to assess the prevalence ('life-time') and manifestations of exertional headache and to validate some of the clinical diagnostic criteria. This study is part of the Vågå headache epidemiology study, where 1838 18-65-year-old dalesmen were personally examined in a 'semistructured' interview. With the criteria used, the prevalence was 12.3%. There was a slight but significant female preponderance (F/M ratio 1.38). There was a mixture of short- and more long-lasting attacks. Attacks followed long-lasting and strenuous effort/exhaustion. The precipitation mechanisms differed essentially from the cough/sneezing type of provocation. Blinded recheck of records (n = 100) as well as recheck of dalesmen (n = 41) showed high kappa values. The clinical manifestations differed essentially from Rooke's (1968) description (that mainly dealt with the 'cough headache'-type). The present findings were similar to those in Pascual's description of exertional headache from 1996.

The epidemiology of syphilis in pregnancy.

This study evaluated the magnitude, risk factors and outcomes of syphilis in pregnancy in a large cohort of women in four countries participating in the World Health Organization (WHO) antenatal care trial. All women attending the first prenatal care at each selected clinic were enrolled. Screening at the first antenatal visit was routinely performed with either rapid plasma reagin or Venereal Disease Research Laboratory and confirmed by fluorescent treponemal antibody absorption. All women also had the same syphilis tests after delivery. The initial prevalence, the incidence during pregnancy and the overall prevalence of syphilis at delivery were 0.9%, 0.4% and 1.3% respectively. Risk factors for syphilis during pregnancy were younger age for the incidence and older age and a history of stillbirth for the prevalence. Women with syphilis during pregnancy had significantly more adverse outcomes. We support the recommendation that in addition to the initial testing, a second routine test for syphilis ought to be established early in the third trimester even in low prevalence areas.

Tractor drivers' head- and neck-ache: Vågå study of headache epidemiology.

The main aim was to study the occurrence of neck- and headache in farmers exposed to seasonal tractor work which involves prolonged, continuous neck rotation. As an integral part of the Vågå study of headache epidemiology, 109 farmers were interviewed according to a set scheme in a 'semistructured' interview, concerning complaints in the wake of tractor work. No appreciable headache/neck-ache was found in 13 farmers; neck-ache alone was present in 66 farmers; headache/neck-ache was present in 15 farmers. For the remaining 15, the information was inadequate. Headache appeared only in connection with neck-ache. Only in those with headache did there seem to be a prevalence of nuchal features (such as reduced range of motion in the neck and positive skin-roll test). In 45% of cases, there was a carry-over effect after the chores, mostly of 1-3 days duration. Head- and neck-pain seem to be frequent in tractor drivers during chores.