Evaluation of a nasal surgical questionnaire designed for monitoring surgical outcomes and comparing different techniques.

OBJECTIVE: This study evaluated a nasal surgical questionnaire designed for monitoring surgical outcomes and comparing different techniques. METHODS: Eighty-three healthy volunteers answered the same questionnaire twice with a minimum interval of five weeks. Three visual analogue scale items were used to assess nasal obstruction during the day, at night and during exercise. Respondents rated nasal obstruction severity by marking on a 10 cm line, with scores ranging from 0 to 100 (measured in millimetres). Other nasal symptoms, considered secondary outcomes, were graded using four-point Likert scales. RESULTS: Mean visual analogue scale scores for nasal obstruction severity experienced during the day, at night and during exercise at initial assessment were 9.99, 12.95 and 11.67, respectively. Thirty-eight per cent of scores indicated no obstruction (scores of 0), 47 per cent indicated mild obstruction (scores 1-30), 13 per cent indicated moderate obstruction (scores 31-70) and 2 per cent indicated severe obstruction (scores 71-100). Males had higher scores than females. The scores for the first and second assessment did not differ, except at night for obstruction in allergic individuals which was considered clinically unimportant. CONCLUSION: The questionnaire reliably assesses nasal symptoms and may be useful for prospective studies of nasal surgery.

Prospective randomized study of routine intraoperative cholangiography during open cholecystectomy: long-term follow-up and multivariate analysis of predictors of choledocholithiasis.

A prospective randomized study was performed to assess the value of routine intraoperative cholangiography (IOC) during cholecystectomy for gallstone disease. Four hundred and fifty-seven consecutive patients were screened for the presence of 11 predefined clinical criteria assumed to indicate choledocholithiasis. Two hundred and eighty patients who had no positive criteria and in whom preoperative endoscopic retrograde cholangiography had not been performed were randomized at the operating table to the IOC or no-IOC group. Follow-up was performed 6 to 8 years after the operation with a questionnaire and by use of clinical, biochemical, and radiologic investigations as indicated. Multivariate analysis was used to identify independent predictors of choledocholithiasis and the combination of criteria having the best predictive ability. The frequency of common bile duct calculi at operation was significantly correlated with age and with all clinical criteria except recent or present pancreatitis. However, only serum bilirubin level, cystic duct diameter, demonstration of common bile duct calculi on preoperative imaging or intraoperative palpation, and age at operation were independent predictors of choledocholithiasis. The overall best subset of clinical indicators contained all criteria with the exception of pancreatitis and alkaline phosphatase level. Negative predictive ability of the set of criteria was 100% for patients up to 60 years of age and 97% for patients older than 60 years at the time of operation. No case of residual common bile duct calculi was present in the IOC and no-IOC groups at follow-up. Our data strongly support a policy of performing IOC during cholecystectomy only when clinical criteria suggest the presence of common bile duct abnormalities or to clarify ductal anatomy.

On the occurrence of focal, occult in situ and invasive carcinoma in 250 mastectomy specimens.

In 1982, a total of 250 breasts were removed for cancer in the surgical departments of the Oslo City Health Department, comprising 81% of all new breast cancers reported in Oslo in 1982. Invasive ductal carcinoma (68%) and invasive lobular carcinoma (12.4%) were the predominant types. Special attention was given to the presence of occult in situ or invasive carcinomas more than 1 cm from the periphery of the main carcinoma. In 24.8% of the specimens, carcinoma in situ was found in such locations, and an additional 6.9% showed a second, occult invasive carcinoma. Carcinoma in situ was equally common in invasive ductal and invasive lobular carcinoma. Occult invasive carcinoma was predominantly found in specimens with invasive lobular carcinoma. There was a significantly increased number of lymph node metastases in patients with carcinoma in situ or second, occult primary carcinoma more than 1 cm from the periphery of the main carcinoma.

Nuclear morphometry of benign and malignant breast lesions.

The mean nuclear area (MNA) of mammary gland epithelium was measured in 403 breast specimens, comprising 239 invasive carcinomas, 49 carcinomas in situ, 45 cases of fibrocystic disease (f.c.d.) with intraductal epithelial hyperplasia, and 60 cases of f.c.d. without intraductal hyperplasia. Normal breast tissue adjacent to other benign or malignant lesions was measured in 170 specimens. Statistical analysis revealed no difference between the MNA of invasive ductal carcinoma and ductal carcinoma in situ. The MNA of lobular and ductal carcinomas were significantly different. Significant differences were also found between ductal carcinoma and the two classes of f.c.d. The MNA of f.c.d. with and without intraductal hyperplasia were also significantly different, the former having the highest MNA. All breast lesions showed MNA significantly higher than that of normal breast epithelium. These findings show that there is a gradual increase in MNA from the baseline value of normal breast epithelium, via fibrocystic disease without and with intraductal proliferation to invasive carcinomas. Measurement of MNA may aid in pinpointing cases of intraductal epithelial hyperplasia with malignant potential.

A personal-computer semiautomated report-coding system for diagnostic mammography.

A computerized report-coding system for diagnostic mammography using a personal computer was developed. Four years' experience with the radiologist-oriented system is presented. The data input time for report generation is in most cases less than 30 seconds by radiologists familiar with keyboard entry. Suspicious and malignant findings are dictated in the conventional way. About 80% of the mammographic examinations at the university Breast Imaging Center were suitable for standardized reporting. Radiologist-generated reports using a personal computer might be an alternative to transcriptionist-oriented systems.

The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam.

To study the natural history of acute sciatica, 208 patients with obvious symptoms and signs of a lumbar radiculopathy (L5 and S1) were examined within 14 days of onset. A concomitant double-blind investigation of the effect of the nonsteroidal anti-inflammatory drug piroxicam was performed. The results measured by visual analog scale and Roland's functional tests showed a satisfactory improvement throughout the 4 weeks of observation. The piroxicam-treated group had same results as the control group. Based on questionnaires at months 3 and 12 approximately 30% of the patients still complained about back trouble and 19.5% were out of work after 1 year. Four patients underwent surgery during this period.

Treatment of acute low-back pain with piroxicam: results of a double-blind placebo-controlled trial.

Twenty-seven investigators participated in a double-blind, parallel placebo-controlled trial of piroxicam involving 278 patients with acute low back pain. Therapy commenced within 48 hours of the injury and continued for 7 days. The drug was given in the recommended regimen of 40 mg once daily for the first 2 days and 20 mg once daily thereafter. After 3 days of therapy, piroxicam patients showed a statistically greater amount of pain relief in the lying (P less than 0.001), sitting (P less than 0.01), and standing (P less than 0.01) positions, but after 7 days the difference between treatments was no longer significant. After 1 week's therapy, however, the requirement for additional analgesic was significantly lower in the piroxicam group (P less than 0.05), and more piroxicam than placebo patients (42 versus 28) had returned to work (P less than 0.05). Toleration was excellent in most patients, with only 13% of the piroxicam and 17% of the placebo group reporting adverse effects of mainly mild or moderate severity. The profile of the adverse effects was similar for both treatments. Piroxicam can provide effective relief of acute low-back pain with good toleration; it should be considered for use in the initial treatment of this condition.

[Accomplish more for less--a status report from Lovisenberg hospital]. / Gjør mer for mindre--statusrapport fra Lovisenberg sykehus.

In 1988 the local authorities increased the catchment area and reduced the budget for Lovisenberg hospital in Oslo. The hospital has met this challenge by improving its productivity. Despite a 20% cut in the acute bed capacity, the number of discharged patients was increased by 19 and 16%, and the length of stay for hospital care was shortened by 33 and 26%, at the medical and surgical departments respectively. The shorter period of hospitalization did not affect mortality or frequency of readmissions. We conclude that the present budget cuts have led to valuable changes at our hospital. The number of acute beds is now well balanced with the size of the catchment area (2.5 beds per 1000 inhabitants). However, further reduction is not advisable.

Incidence of cancer among workers in a Norwegian nitrate fertiliser plant.

The incidence of cancer among 2023 male fertiliser workers has been investigated in a historical cohort study. Workers who had been employed for more than one year in work with possible exposure to dust containing nitrate between 1945 and 1979 were included. An individual cumulated exposure to dust expressed in level-years was calculated for each participant. The cohort was followed up from 1953 to the end of 1988, and the incidence of cancer was compared with the national rates. There were 467 deaths v 504.8 expected (standardised mortality ratio (SMR) = 0.93), and 185 cases of cancer v 195.5 expected (standardised incidence ratio (SIR) = 0.95). Thirty cases of lung cancer were found v 27.5 expected (SIR = 1.09). No overall excess of gastric cancer was found (15 cases v 17.0 expected; SIR = 0.89). No association was found between cumulated exposure to nitrate and gastric cancer, and there was no association between duration of employment or time since first employment and incidence of gastric cancer.

A comparison of actual registered costs and costs derived from diagnosis-related groups (DRGs) for patients undergoing heart transplantation, lung transplantation, and thoracotomy for other lung diseases.

The Norwegian health care system, like other health care systems in the world, is in the midst of a changing financial environment for hospital reimbursement for patient care. Since 1997 the Norwegian government has introduced a new financing model of block grant and activity-based financing. In this model, diagnosis-related groups (DRGs) play an important role in hospital financing. The initial motive for developing the DRGs was to improve hospital productivity and efficiency and to develop a tool to control increasing hospital costs better. We raised the question as to whether the DRG system in fact covers actual costs in patient groups undergoing heart transplantation (n = 12), lung transplantation (n = 4), and thoracotomy for other diseases (n = 10). A new prospective cost model was developed to measure actual costs related to individual patients. The patients were closely observed and the related data collected during the hospital stay. Each patient's hospital stay was divided into four different categories of resource requirements, defined as heavy intensive care, light intensive care, intermediate care, and ordinary care. In addition, the number of staff involved and the duration of surgery and procedures were recorded, as were medicine costs and material costs. Based on these data, the actual costs for each patient were calculated. These were then compared with the respective DRG reimbursement (100 % coverage) for the corresponding group. We found that the median cost for heart transplantation was US$ 50,590 (1 US$ = 7.5 NOK based on the exchange rate at the time of the study), while the respective DRG reimbursement was US$ 65,662. For lung transplantation, the respective figures were US$ 46,668 vs US$ 65,662, and for thoracotomy, US$ 24,307 vs. US$ 11,004. We found that our method was applicable to a hospital setting. DRG coverage for heart and lung transplantation seems to overestimate the actual costs. For the thoracotomy procedure, the DRG coverage did not cover the actual costs.

[Diagnosis-related groups and neonatal surgical patients]. / Diagnoserelaterte grupper og neonatalkirurgiske pasienter.

Diagnose Related Groups (DRG) are defined on the basis of the principal diagnosis, secondary diagnoses, procedures, age, sex and discharge status, and were developed to improve hospital productivity and efficacy. Existing code systems do not cover all medical specialties equally well; examples are neonatal medicine, cancer treatment and rehabilitation. We have developed a prospective method to measure actual costs related to patients individually. The major element in this method is based upon the hospital stay being divided into types of treatment with different resource requirements: heavy intensive care, light intensive care, intermediate care and ordinary care. In addition, costs related to surgery and other procedures are measured. Our method was used to calculate costs related to neonatal surgery due to various inborn diseases in the gastrointestinal tract and the urinary system. All patients needed immediate care and competent medical intervention. Mean costs for the group was NOK 291,181 while total reimbursement to the hospital was NOK 100,390, resulting in a net negative balance of NOK 190,970. Neonatal surgery does not seem to be adequately covered by the DRG system. This complex patient group provides a comprehensive test of the prospective method, and after evaluation we feel that it can be used in most other patient groups to verify actual cost.

Macrophage heterogeneity in thromboplastin response.

The procoagulant activities of non-elicited mouse monocytes/macrophages from four anatomical localizations were compared. These cell populations were further examined for their ability to increase their procoagulant activity on exposure to endotoxin or phytohaemagglutinin (PHA). Peritoneal macrophages exhibited the highest basal procoagulant activity. Their activity was further enhanced by stimulation with endotoxin and PHA, but marked strain differences were noted. This procoagulant has been identified as tissue thromboplastin. Isolated adherent spleen cells, peripheral blood monocytes or lung alveolar macrophages had a low basal procoagulant activity that did not increase on exposure to PHA or endotoxin. The identity of the weak procoagulant in these cells is uncertain. The presence of lymphocytes in the macrophage cultures (4:1 ratio) enhanced slightly (1.3 to 1.5-fold) the response of peritoneal macrophages to endotoxin or PHA but did not significantly influence the procoagulant activity of the other macrophage subpopulations under the conditions tested. These results demonstrate heterogeneity among different macrophage subpopulations with regard to cellular procoagulant expression.

[Determination of estrogen receptors in aspirates from needle biopsies of breast carcinomas. Correlation to a biochemical method]. / Bestemmelse av østrogenreseptorer i finnålsaspirat fra mammakarsinom. Korrelasjon til biokjemisk metode.

Several methods exist for determining oestrogen receptor status in breast carcinomas. Biochemical methods have been widely used for many years, but recently immunocytochemical methods have become available. We have compared the outcome of the biochemical and immunocytological analysis in 274 breast cancer patients. Fine needle aspirates from all the patients were investigated immunocytologically and 214 tumours were positive (78%) and 60 negative (22%). Biochemical data were available in 155 patients, and the concordance between the two methods was 88%. Most of the 119 carcinomas (43%) that were only investigated cytologically were too small to allow both histological and biochemical analysis. A minority of patients were not operated on because of high age, and/or impaired health, or because the tumour was inoperable. In our opinion, biochemical and immunocytological methods are equally sensitive and specific in detecting oestrogen receptor in breast tumour tissue. In fine needle aspirates there is the additional advantage of morphological assessment of malignant nuclei and the possibility of obtaining material from small lesions.

[Late diagnosis of advanced breast cancer--a challenge for health services]. / Sent oppdaget cancer mammae en utfordring for helsevesenet.

From 1982 to 1987, 1,637 cancers of the breast were diagnosed in Oslo. 235 were classified as advanced according to one or more of the following criteria: tumour size greater than or equal to 5 cm (T3) or T4, metastasis within 4 months, pathological diagnosis pT3, pT4 or pN2. These were further studied. The distribution of women with advanced cancer mammae was uneven. For no obvious reason, incidence was significantly higher in one out of four hospitals in Oslo. 169 of the patients discovered the tumour themselves. Many patients delayed seeking help. 93 waited for more than eight weeks before doing so. For patients with metastasis at time of diagnosis, survival was slightly more than one year, and for patients without metastasis it was four and a half year. The length of stay in hospital increased with increasing admissions.

[Investigation of palpable breast tumours. Patient flow and quality assessment of the tripple diagnostic procedure]. / Utredning av palpabel tumor mammae. Pasientstrøm og kvalitetsvurdering av trippeldiagnostikken.

The evaluation of patients with a palpable breast lump includes physical examination, mammography, and fine needle aspiration cytology. Combined use of these diagnostic procedures (triple diagnostic) gives nearly the same degree of accuracy as excisional biopsy with a sensitivity of 97-99% in patients with palpable breast carcinomas. Ultrasonography is a valuable adjunct when mammography is normal or nonconclusive and should be the primary imaging modality in patients under 35 years of age with benign findings on physical examination. Ongoing quality assessment of mammography and ultrasonography is mandatory, since the imaging modalities play a central role in the evaluation of patients with lumps in the breast. There are considerable practical problems associated with the medical audit of the triple diagnostic procedure. Aspects of the evaluation of breast lumps and organization of breast imaging centres are discussed in the light of our own experiences.

[From a registry to a clinical information system. Development of the Datacor system at the surgery department A, Rikshospitalet]. / Fra virksomhetsregistrering til klinisk informasjonssystem. Utvikling av Datacor-systemet ved Kirurgisk avdeling A, Rikshospitalet.

Based on a simple register for thoracic and cardiovascular operations a modulated system has been built up at Department of Surgery A. The register covers waiting list, a basic patient record, extensive operative data, the postoperative course and the final outcome. A local area network includes 36 microcomputers with approximately 75 users. Owing to lack of commercially available programs, local applications based on dBase have been developed. In this article we discuss our positive experiences from use of the local system with respect to administration, quality assurance and local research, its future place within a larger hospital system interconnected via a backbone, the need for better support and graphic user interface.

Predictive ability of choledocholithiasis indicators. A prospective evaluation.

To assess the predictive ability of various indicators of common bile duct calculi, 457 patients undergoing cholecystectomy for gallstone disease were prospectively screened for the presence of 11 predefined criteria of possible choledocholithiasis. The predictive ability of the criteria, individually and in combinations, was determined. For all criteria, except a history of pancreatitis, a significantly increased incidence of choledocholithiasis was found. The number of positive criteria correlated positively with the frequency of common bile duct calculi. The negative predictive value and sensitivity of the total set of criteria were 98% and 89.5%, respectively. Following common duct exploration, the number of complications and the duration of postoperative hospitalization were significantly increased as compared with simple cholecystectomy. Peroperative cholangiography with cholecystectomy is recommended in all patients, with one or more criteria of possible choledocholithiasis. Routine peroperative cholangiography in patients with no positive criteria does not seem to be necessary.

Assessing estrogen and progesterone receptor status in fine needle aspirates from breast carcinomas. Results on six years of material and correlation with biochemical assay.

OBJECTIVE: To evaluate the usefulness of immunocytochemical staining on breast fine needle aspiration (FNA) cytology as a routine procedure for determination of estrogen (ER) and progesterone (PR) receptor status. STUDY DESIGN: FNA cytology material from 864 patients was immunostained for ER and PR using Abbott ER/PR-ICA kits. Percentage of stained nuclei, staining intensity and staining pattern was evaluated. In 259 cases comparison with biochemical assay was possible. RESULTS: Of the cases, 75.6% were ER positive and 65% PR positive, and 61.6% were both ER and PR positive. Approximately 4% of the smears were inconclusive because of scant cellularity. Concordance between the immunostaining and biochemical method was 84% for ER and 71% for PR. Kappa values were 0.61 and 0.4, respectively. Major discrepancies were found in 7.7% of the specimens. CONCLUSION: Inconclusive smears due to scant cellularity is a minor problem. Technical difficulties are few, and false negative and positive staining is rarely seen. The results are comparable to those from the biochemical method, and immunostaining of ER/PR on breast cancer FNA cytology smears is useful as a routine procedure for receptor determination.