Understanding adherence to official guidelines on statin prescribing in primary health care--a multi-level methodological approach.

OBJECTIVE: The aim was to investigate the role that municipalities and out-patient health care centres (HCCs) have in understanding adherence to official guidelines on statin prescribing. Our hypothesis was that after guideline publication, adherence to recommended statin prescription would increase and variance among HCCs and municipalities would decrease. Since multi-level regression analysis (MLRA) is a relatively new methodology in pharmacoepidemiology, we also aimed to explore the application of MLRA in our investigation. METHODS: We obtained data from the Swedish Corporation of Pharmacies record of sales regarding all initial prescriptions of statins issued between April and December 2003. We applied multi-level analysis on 34,514 individual prescriptions (level 1) nested within 226 HCCs (level 2), which in turn were nested within 33 municipalities (level 3). Temporal trends and gender differences were investigated by means of random slope analysis. Variance was expressed using median odds ratio (MOR) and interval odds ratio. RESULTS: HCCs appeared to be more relevant than municipalities for understanding the physicians' propensity to prescribe a recommended statin (MOR(HCC) = 1.96 and MOR(Municipality) = 1.41). Overall prevalence of adherence was very low (about 20%). After publication of the guidelines, prescription of recommended statins increased, and variance among HCCs decreased but only during the first 4 months of the observation period. CONCLUSION: The publication of official guidelines in the county of Scania exerted a positive influence on statin prescription but, at the end of the observation period, adherence was still low and practice variation high. These facts may reflect inefficient therapeutic traditions and suggest that more intensive interventions may be necessary to promote rational statin prescription.

Emergence of imipenem resistance in Klebsiella pneumoniae owing to combination of plasmid-mediated CMY-4 and permeability alteration.

Klebsiella pneumoniae BM2974 isolated from an abdominal abcess was resistant to high concentrations of all available beta-lactams, including recently developed third-generation cephalosporins and carbapenems. Isoelectric focusing of beta-lactamases and amplification, cloning and sequencing of the corresponding genes, together with conjugation and transformation experiments, indicated that, in addition to the chromosomally encoded beta-lactamase, the strain produced three plasmid-mediated beta-lactamases with pIs of 5.4, 8.2 and 9.0, which corresponded to TEM-1, SHV-5 and AmpC-type CMY-4, respectively. Strain BM2974 also lacked a major outer membrane protein of c. 40 kDa which was present in the spontaneous imipenem-susceptible revertant BM2974-1. We suggest that imipenem resistance in strain BM2974 is attributable to production of CMY-4 beta-lactamase combined with permeability alteration.

Abdominal vessel enhancement with an ultrasmall, superparamagnetic iron oxide blood pool agent: evaluation of dose and echo time dependence at different field strengths.

RATIONALE AND OBJECTIVES: The purpose of the study was to determine the dose and echo time dependence of abdominal vessel enhancement at magnetic resonance (MR) imaging after injection of a blood pool contrast agent at two field strengths. MATERIALS AND METHODS: Sixteen healthy volunteers received NC100150 Injection at three dose levels (1.0 mg, 2.5 mg, and 4.0 mg of iron per kilogram of body weight). Images of the aorta and inferior vena cava (IVC) were obtained at 0.5 or 1.5 T. Four sequences with varying echo times were used with each subject. Signal intensities were recorded from the aorta, IVC, vessel vicinity, air, and a marker outside the patient. Contrast-to-noise ratios (CNRs) were calculated for the vessels. Aortic delineation was subjectively evaluated. RESULTS: Images with the highest mean vessel signal intensities, subjectively assessed as satisfactory for aortic delineation, were obtained with 2.5-4.0 mg of iron per kilogram of body weight at both field strengths. The highest CNR was found with 4.0 mg of iron per kilogram of body weight at 1.5 T. An increase in echo time caused larger signal intensity loss at larger dose levels. The signal intensity from the IVC was higher than that of the aorta at all dose levels, echo times, and field strengths. CONCLUSION: NC100150 Injection is an efficient T1-reducing agent at both 0.5 and 1.5 T. A positive dose response for CNR of the aorta and IVC was seen at 1.5 T.

Oral carriage of Candida species in children and adolescents with Down's syndrome.

Oral carriage of Candida albicans was studied in 55 children and adolescents with Down's syndrome (DS), aged between 7 months and 20 years 6 months, and compared with an age- and sex-matched control group of subjects. Twenty-two of the DS subjects were diagnosed as having congenital cardiovascular malformations. Compared to controls, the DS subjects were more prone to infections. The number of subjects colonized with C. albicans in the oral cavity was significantly higher in the DS group (69%) than in the control group (35%). Colonization with C. albicans and simultaneous erythematous or white pseudomembranous lesions of the oral mucosa were diagnosed in 22 (40%) of the DS groups and in only one of the control group. In both the DS and the healthy control subjects the frequency of colonization with C. albicans was positively correlated to age. The DS subjects were significantly more densely colonized by C. albicans than the controls. Abnormalities of the immune response in DS children may contribute to the increased oral carriage of C. albicans.

Positron emission tomography studies on D2 and 5-HT2 receptor binding in risperidone-treated schizophrenic patients.

By the use of positron emission tomography (PET), high central dopamine D2 receptor occupancy (70 to 90%) has been demonstrated in patients treated with conventional neuroleptics. In patients treated with the atypical antipsychotic clozapine, the D2 occupancy was low (20 to 67%). The effects of clozapine may thus be mediated by a mechanism distinct from D2 occupancy. The observation that low doses of clozapine (125 to 175 mg daily) induced more than 80% (5-hydroxytryptamine) 5-HT2 occupancy supports the view that 5-HT2 antagonism may be related to the atypical effects of clozapine. Risperidone is a new antipsychotic drug with high affinity in vitro for both central 5-HT2 and D2 receptors. In this study, we determined the D2 and 5-HT2 occupancy induced by clinical treatment with risperidone. Four patients with acute exacerbation of schizophrenia were examined by PET after 4 weeks of treatment with risperidone, 6 mg daily. The D2 occupancy in the striatum was 75 to 80%. The 5-HT2 occupancy in the neocortex was 78 to 88%. This study confirms that, in patients with schizophrenia, treatment with risperidone induces a high D2 and 5-HT2 occupancy. Risperidone is, accordingly, a suitable drug for the examination of the clinical benefit of combined serotonin and dopamine antagonism.

A carcinoid tumor of the ileum. A case report and a brief review of the relevant literature. Case report.

An unusual case of carcinoid tumor of the ileum is presented where a metastatic deposit in the spine was removed 10 years before the primary lesion could be detected. The primary tumor was 3 cm in diameter with a hepatic metastasis, however, the patient was completely asymptomatic, and the lesions were only discovered accidentally. The discussion illustrates the diagnostic difficulties of small bowel carcinoids and that surgery as the only curative treatment has a role to play even in advanced stages. Understanding the pathological basis of this uncommon tumor is essential for the choice of most appropriate treatment.

Four years' results of a prospective, randomized clinical trial comparing polytetrafluoroethylene and modified human umbilical vein for below-knee femoropopliteal bypass.

Polytetrafluoroethylene (PTFE) (Gore-Tex) and human umbilical vein (Biograft) arterial grafts were compared for below-knee femoropopliteal bypass grafting in a prospective randomized clinical trial. One hundred five patients (105 limbs) entered the trial. Seventy-six percent suffered from rest pain, ulceration, or gangrene. The median postoperative ankle-arm blood pressure index was 0.36. Twenty-three limbs had three patent tibial arteries, 46 limbs had two tibial arteries, 31 limbs had one patent artery, and five limbs had isolated popliteal segments. Thirty-four percent were repeat operations. Fifty-five patients were allocated to receive PTFE grafts and 50 to receive human umbilical vein grafts. The two groups were comparable as to preoperative risk factors and operative and postoperative treatment. During the first 4 years (maximum 1609 days) 40 PTFE grafts and 24 umbilical veins occluded. At 1 year the PTFE patency rate was 53% and at 4 years was 22%. For umbilical vein the corresponding figures were 74% and 42% (p = 0.005, Gehan test). During follow-up the incidence of PTFE failure was on the average 2.1 times higher than that of umbilical vein failure (95% confidence limits 1.2 to 3.4).

The oral glucose tolerance test in men under 55 years of age with intermittent claudication.

Blood glucose at sixty, ninety, and one hundred twenty minutes after a standardized oral glucose load was compared in healthy middle-aged men and patients with intermittent claudication. No difference was found when the authors compared blood glucose at zero and sixty minutes. At both ninety and one hundred twenty minutes, however, they found a relative hypoglycemia in patients with peripheral arteriosclerotic disease in an early stage.

Acute thrombogenicity of a compliant polyurethane urea graft compared with polytetrafluoroethylene: an experimental study in sheep.

The acute thrombogenicity of a new polyurethane urea graft has been compared with polytetrafluoroethylene (PTFE) grafts using labelled homologous platelets in the carotid arteries of sheep in a low-flow model. There was no difference in patency. Thrombus weight and thrombus free surface were the same in both types of graft after 4 h. The accumulation of homologous 32P platelets was measured at the 2 anastomoses and at a midgraft position. At no point was there any statistically significant difference between the 2 grafts, but the activity was always somewhat higher in the polyurethane grafts. Although more compliant, in this study polyurethane urea grafts behaved much like PTFE ones.

The acute thrombogenicity of a compliant polyurethane arterial graft compared with autologous vein. An experimental study in sheep.

The acute thrombogenicity of a new type of polyurethane urea graft was compared with that of autologous femoral vein graft in a sheep carotid artery interposition model. There was significantly more thrombus formation (as measured from thrombus weight and thrombus-free surface) and greater platelet accumulation in the polyurethane graft. Despite flow restriction to 25 ml/min, the patency rates after 4 hours were similar; all veins were patent and only one of the eight polyurethane grafts was occluded.

Reconstruction of the external carotid artery.

Reconstruction of a stenotic external carotid artery associated with occlusion of the ipsilateral internal carotid artery is described in four cases. In two of them there was also a significant stump of internal carotid artery following the occlusion, and the stump was oversewn at the reconstructive operation. All four patients improved after the operation. Two still required medication which, however, had been ineffective preoperatively but now was beneficial. Reconstruction of the external carotid artery is indicated in patients with ipsilateral occlusion of the internal carotid artery and symptoms of artery-to-artery embolization.

Leg blood flow in intermittent claudication--a comparison between non insulin dependent diabetics and non diabetics.

The influence of diabetes on leg blood flow in intermittent claudication has been assessed by comparing the systolic arm-ankle pressure gradient at rest and resistance to blood flow during reactive hyperemia in patients with non-insulin dependent diabetes and non-diabetic controls. Cases and controls were matched for age and sex. Smoking habits, blood pressure, and blood lipids didn't differ in the two groups. Diabetes was associated with a higher resistance to blood flow during reactive hyperemia and a greater arm-ankle pressure gradient at rest. Resistance to blood flow during reactive hyperemia was in the non-diabetics strongly correlated to the arm-ankle pressure gradient at rest (r = 0.84). Corresponding correlation coefficient was in diabetics 0.04. In one of four diabetic legs a high resistance to blood flow during reactive hyperemia didn't correspond to a big arm-ankle pressure gradient. The results in this study support the concept of both macro- and microvascular disease in diabetes.

Extraanatomic vascular reconstruction in patients with aorto-iliac arteriosclerosis.

During an 11-year period 117 extraanatomic reconstructions were made for aorto-iliac arteriosclerosis; 36 axillofemoral and 81 femorofemoral crossover bypasses. The patients were old and had several factors making them poor risks for surgery. Axillofemoral grafts were more often used in patients with malignant disease. Postoperative mortality was 10% without difference between the two types of reconstruction. Both early and late complications were significantly more frequent in patients with axillofemoral bypass. Reoperations for occlusion and symptoms from the donor side also were significantly more common among axillofemoral patients. Life table analysis showed a higher survival and patency rate among patients with crossover grafts.

Aneurysms of the popliteal artery.

A retrospective study of 13 patients with 18 popliteal artery aneurysms has been undertaken. The patients were seen under a period of 12 years. Six of the patients had extrapopliteal aneurysms as well. Seven of the popliteal aneurysms presented as vascular emergencies, due to occlusion of the popliteal artery. In this group the amputation rate was 57%. In the elective group no amputation was necessary nor did any patient suffer from claudication during follow-up. Ultrasonography is a good tool for demonstrating the nature of the disease. Usually a short exclusion bypass is enough to reconstruct the area. A popliteal aneurysm, if not occluded and asymptomatic, is an indication to operate because of the threat to the limb in case of embolism or thrombosis.

Vascular complications after total hip arthroplasty.

Four cases of vascular complications in connection with total hip replacement are reported and another 25 cases from the literature summarized. Acute intraoperative injuries most often give rise to severe haemorrhage. Delayed injuries with pseudoaneurysm formation or thrombosis give rise to hip pain, distal ischaemia or haemorrhage when a prosthesis is extracted. There is a dominance of female patients and left-sided operations and cases complicated with infections and reoperations. Aetiologic and therapeutic considerations are discussed.

A cubic protein-monoolein-water phase.

A cubic monoacylglycerol-protein-water phase has been identified by low-angle X-ray diffraction, and the main features of the ternary phase diagram monoolein/lysozyme/water are presented. The thermal stability of the protein in the lipid-protein cubic phase has been examined by differential scanning calorimetry. According to the physical properties of the phase it is proposed that the protein molecules are located in the water medium, i.e. in the water channel systems of the cubic structure earlier suggested. The ability of various proteins to form this cubic phase has been studied, and it was found that the formation of this phase is favoured by an isoelectric point (pI) far from pH 7 in a salt-free solution, thus by high electrostatic repulsive forces.