Intensive care doctors' preferences for arterial oxygen tension levels in mechanically ventilated patients.

BACKGROUND: Oxygen is liberally administered in intensive care units (ICUs). Nevertheless, ICU doctors' preferences for supplementing oxygen are inadequately described. The aim was to identify ICU doctors' preferences for arterial oxygenation levels in mechanically ventilated adult ICU patients. METHODS: In April to August 2016, an online multiple-choice 17-part-questionnaire was distributed to 1080 ICU doctors in seven Northern European countries. Repeated reminder e-mails were sent. The study ended in October 2016. RESULTS: The response rate was 63%. When evaluating oxygenation 52% of respondents rated arterial oxygen tension (PaO2 ) the most important parameter; 24% a combination of PaO2 and arterial oxygen saturation (SaO2 ); and 23% preferred SaO2 . Increasing, decreasing or not changing a default fraction of inspired oxygen of 0.50 showed preferences for a PaO2 around 8 kPa in patients with chronic obstructive pulmonary disease, a PaO2 around 10 kPa in patients with healthy lungs, acute respiratory distress syndrome or sepsis, and a PaO2 around 12 kPa in patients with cardiac or cerebral ischaemia. Eighty per cent would accept a PaO2 of 8 kPa or lower and 77% would accept a PaO2 of 12 kPa or higher in a clinical trial of oxygenation targets. CONCLUSION: Intensive care unit doctors preferred PaO2 to SaO2 in monitoring oxygen treatment when peripheral oxygen saturation was not included in the question. The identification of PaO2 as the preferred target and the thorough clarification of preferences are important when ascertaining optimal oxygenation targets. In particular when designing future clinical trials of higher vs lower oxygenation targets in ICU patients.

Increased risk of atrial fibrillation among elderly Norwegian men with a history of long-term endurance sport practice.

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The prevalence increases with increasing age. In middle-aged men, endurance sport practice is associated with increased risk of AF but there are few studies among elderly people. The aim of this study was to investigate the role of long-term endurance sport practice as a risk factor for AF in elderly men. A cross-sectional study compared 509 men aged 65-90 years who participated in a long-distance cross-country ski race with 1768 men aged 65-87 years from the general population. Long-term endurance sport practice was the main exposure. Self-reported AF and covariates were assessed by questionnaires. Risk differences (RDs) for AF were estimated by using a linear regression model. After multivariable adjustment, a history of endurance sport practice gave an added risk for AF of 6.0 percent points (pp) (95% confidence interval 0.8-11.1). Light and moderate leisure-time physical activity during the last 12 months reduced the risk with 3.7 and 4.3 pp, respectively, but the RDs were not statistically significant. This study suggests that elderly men with a history of long-term endurance sport practice have an increased risk of AF compared with elderly men in the general population.

A complicated simple fall--an atypical case of serogroup Y meningococcal pneumonia with secondary septicaemia and literature review.

An elderly lady was admitted for pain management and rehabilitation following a fall. During her stay she developed a new heart murmur and sepsis. Subacute bacterial endocarditits was excluded, empirical ciprofloxacin was initiated and later converted to aztreonam with gentamicin for clinical deterioration. Subsequent investigations revealed meningococcal Y septicaemia secondary to pneumonia, with a possible oropharynx focus. Upon discharge she had returned to baseline state. The case reflects an unusual and increasing cause of pneumonia. A steady increase of infective serogroup Y isolates over the past 12-years in England, with tendency towards elderly makes it a significant differential among the general medical population. This trend corresponds with the US, but is yet unknown whether to be a periodic cycle or true change in dominance and, or, virulence among serogroups. If the latter were true, it would support the inclusion of serogroups beyond menigitides C in the vaccination program.

Changes in physical activity behavior and the development of body mass index during the last 30 years in Norway.

Body mass index (BMI; kg/m(2)) has increased markedly in the last decades. We hypothesized that highly physically active persons both at work and at leisure would be resistant to weight gain. The hypothesis was tested by analyzing Norwegian cross-sectional data collected in the period 1972-2002. Participants were 214,449 men and 206,136 women (aged 20-70 years). During the last 30 years in men and the last 15 years in women, a systematic larger BMI increase per year was observed in the sedentary [regression coefficients (SE) in men 0.060 (0.004) kg/m(2) and women 0.137 (0.012) kg/m(2)] compared with highly physically active groups [regression coefficients (SE) in men 0.036 (0.00 4) kg/m(2), and in women -0.001 (0.039) kg/m(2)]. Analyses were robust to adjustments for age, smoking and education. There was a larger absolute net increase in the prevalence of obesity among the sedentary compared with persons performing light, moderate or heavy physical activity (PA) at leisure. PA level in women both at work and in leisure was not associated with weight gain during the last decades. This association was less evident among men. Men and women who were lightly, moderately or highly active at leisure were less likely to be obese compared with those who were sedentary.

Rose angina predicts 23-year coronary heart disease mortality in women and men aged 40-49 years.

OBJECTIVE: To determine the long-term coronary heart disease (CHD) mortality in women and men with symptoms, according to the Rose Angina Questionnaire at a relatively young age. DESIGN: Cohort study with the baseline survey conducted during 1974-8. Information on symptoms was collected by a short, three-item version of the Rose Angina Questionnaire. Participants were re-invited to a similar survey five years later and followed for mortality throughout 2000. SETTING: Three counties in Norway (the Norwegian Counties Study). PARTICIPANTS: 16 616 men and 16 265 women aged 40-49 years and denying CHD in 1974-8. MAIN OUTCOME MEASURE: CHD mortality during 23 years. RESULTS: By the end of follow-up 1316 men (7.9%) and 310 women (1.9%) had died from CHD, including 16% (66/406) of men and 4% (24/563) of women with Rose angina in 1974-8. Rose angina implied an elevated mortality from CHD with adjusted hazard ratios 1.50 (95% CI 1.16 to 1.93) in men and 1.98 (95% CI 1.30 to 3.02) in women. According to calculations based on the Cox model these increases in risk are similar to those associated with elevations of total cholesterol by 1.8 mmol/l (men) and 2.5 mmol/l (women) or elevations of systolic blood pressure by 21 mm Hg (men) or 31 mm Hg (women). CONCLUSIONS: Angina symptoms in ages as low as 40-49 years were associated with elevated long-term CHD mortality in Norwegian women and men. This indicates that the three-item version of the Rose Angina Questionnaire, although a screening tool rather than a diagnostic test, adds information on undiagnosed CHD in both sexes.

Simultaneous quantitation of homocysteine, cysteine and methionine in plasma and urine by liquid chromatography-tandem mass spectrometry.

BACKGROUND: A method utilizing liquid chromatography-electrospray tandem mass spectrometry (LC-MS/MS) has been developed and evaluated for the determination of total homocysteine, cysteine and methionine in plasma and urine. The simultaneous measurement of homocysteine and methionine concentrations may help explain the underlying mechanism responsible for hyperhomo-cysteinaemia. METHODS: Samples were prepared by simple protein precipitation after reduction of disulphides by dithiothreitol. Reduced analyte signal caused by ionization suppression effects, seen with plasma samples, was compensated for with matrix-matched standards, and the use of isotopically labelled internal standards. Recovery for each analyte was better than 94%. RESULTS: Concentrations of plasma homocysteine determined by LC-MS/MS were compared with those obtained by two automated commercially available FDA-approved procedures: (i) high-performance liquid chromatography (HPLC) with pre-column derivatization and fluorescence detection and (ii) by fluorescence polarization immunoassay (FPIA). Agreement with the LC-MS/MS method is given by the Deming regression equations LC-MS/MS = 1.062 HPLC-0.01 and LC-MS/MS = 1.104 FPIA-0.43. CONCLUSION: Low reagent costs together with the relative simplicity of sample preparation make the LC-MS/MS method well suited, not only for research work but also in those laboratories with a tandem mass spectrometer, for the measurement of routine clinical samples.

Behavioural and psychological symptoms of Alzheimer type dementia are not correlated with plasma homocysteine concentration.

BACKGROUND/AIMS: Vitamin B12 and folate deficiencies have been associated with cognitive impairment and various psychiatric symptoms but not specifically with behavioural and psychological symptoms of dementia (BPSD). A limitation of previous studies in dementia was lack of concurrent homocysteine measurement especially as it may provide a better indicator of tissue activities of these vitamins. This study was designed to clarify whether a relationship exists between plasma homocysteine concentration and BPSD. METHODS: Plasma homocysteine, serum vitamin B12 and folate were measured in 23 Alzheimer's disease (AD) patients with BPSD and 27 AD patients without BPSD as determined through the use of the Neuropsychiatric Inventory (NPI). Blood levels of measured substances were also correlated with individual NPI scores and with cumulative NPI scores for different cluster of symptoms. RESULTS: There was no significant difference (p = 0.956) in the mean plasma homocysteine levels between AD patients with BPSD (17.48 micromol/l) and AD patients without BPSD (17.34 micromol/l). Similarly, there was no significant difference between the two groups in the mean serum B12 (382.61 and 391.60 pg/ml, respectively) and folate (7.95 and 10.02 ng/ml, respectively). Mean levels for both vitamins were well within the laboratory reference range. Neither individual nor cluster NPI scores correlated significantly with plasma homocysteine. CONCLUSION: This study shows for the first time that BPSD are not associated with hyperhomocysteinaemia in Alzheimer dementia. Although previous studies have identified homocysteine as an independent risk factor in AD, the results reported here do not lend weight to an aetiological role for homocysteine specifically in BPSD.

Ethnicity and sex are strong determinants of diabetes in an urban Western society: implications for prevention.

AIMS/HYPOTHESIS: This study was conducted to investigate the prevalence of diabetes and its association with ethnicity and sex, to identify subgroups at special risk. METHODS: We performed a population-based cross-sectional survey of 30- to 67-year-olds in an area of Oslo with low socio-economic status, and collected data using questionnaires, physical examinations and serum analyses for the 2,513 participants (attendance rate 49.3%). RESULTS: In the age group 30-59 years, mean BMI was 28.5 (95% CI: 27.5-29.6) for South Asian women, 26.1 (25.9-26.4) for Western women, 26.7 (26.1-27.4) for South Asian men and 27.2 (26.9-27.5) for Western men. The diabetes prevalence rates were 27.5% (18.1-36.9) for South Asian women, 2.9% (1.9-3.4) for Western women, 14.3% (8.0-20.7) for South Asian men and 5.9% (4.2-7.5) for Western men. The age-adjusted odds ratio (OR) for diabetes for women vs men was 1.9 (0.9-4.1) for South Asians, and 0.4 (0.3-0.6) for the Western population (p<0.001). The age-adjusted OR for diabetes for South Asians vs Westerners was 11.0 (5.8-21.1) for women and 3.0 (1.6-5.4) for men, and after adjustment for WHR the ORs were 7.7 (3.9-15.3) for women and 2.6 (1.4-4.9) for men. After additional adjustments for physical activity, education, body height and fertility for women, the OR was 6.0 (2.3-15.4) for women and 1.9 (0.9-4.0) for men. CONCLUSIONS/INTERPRETATION: The alarmingly high prevalence of diabetes among South Asian women in Norway needs further investigation, as it has considerable public health implications. Ethnic differences in OR for diabetes persisted after adjustment for age, adiposity, physical activity and education. These differences were still present for women after additional adjustment for body height and fertility.

Hormone therapy and mortality during a 14-year follow-up of 14 324 Norwegian women.

OBJECTIVES: We evaluated mortality from cardiovascular disease (CVD), coronary heart disease (CHD) and all causes in relation to use of any hormone therapy (HT) and HT with oestradiol and norethisterone or levonorgestrel. DESIGN: Population-based cohort study. SETTING AND SUBJECTS: Women in three Norwegian counties were invited to a health survey in 1985-88 and 82.8% participated. In all 14 324 post- or perimenopausal women aged 35-62 years, including 702 HT users with a mean age of 48.8 years, were followed for 14 years. RESULTS: Women using HT had mortality from all causes and CVD comparable with that of nonusers. The relative risk (RRs) for CVD mortality amongst all women were 0.69 (95% CI: 0.35-1.33) for users of HT, and 0.96 (95% CI: 0.43-2.17) for users of HT with norethisterone or levonorgestrel. Amongst women free of self-reported cardiovascular health problems at baseline all-cause, CVD and CHD mortality tended to be lower amongst users of HT whilst HT use was linked with increased mortality amongst women with cardiovascular health problems. CONCLUSIONS: In this cohort of women around the usual age of menopause all-cause or CVD mortality amongst users of HT, most often oestradiol combined with norethisterone or levonorgestrel, was not markedly different from that of nonusers. Early CHD events amongst HT users prior to the baseline survey, together with selective inclusion of healthy subjects, may in part explain protective effects of HT on CHD reported from previous observational studies.

Does routine blood bone biochemistry predict vitamin D insufficiency in elderly patients with low-velocity fractures?

PURPOSE: Vitamin D deficiency impairs bone mineralisation and can predispose individuals to fractures. This study aimed at testing whether measurement of plasma calcium, alkaline phosphatase, and phosphate levels could detect vitamin D insufficiency. METHODS: During a 10-week winter period from December 2000 to February 2001, all elderly patients presenting to a general hospital in Brighton--British seaside town--with a fracture of the proximal femur and without known bone mineralisation problems were invited to participate in the study. RESULTS: 23 (63.9%) of the 36 eligible patients had insufficient levels of vitamin D, with a plasma concentration of less than 30 nmol/L. The mean parathyroid hormone level was 56 pg/mL (range, 12-193 pg/mL). 11 of the 36 patients had an elevated level of parathyroid hormone were insufficient in vitamin D. The mean plasma concentration of calcium was 2.30 mmol/L (range, 2.05-2.98 mmol/L). The mean phosphate level was 0.98 mmol/L (range, 0.40-1.79 mmol/L), and the mean alkaline phosphatase level was 91 IU/L (range, 46-127 IU/L). There was poor correlation between vitamin D insufficiency and plasma calcium, alkaline phosphatase, or phosphate levels. CONCLUSION: Plasma calcium, alkaline phosphatase, and phosphate testing cannot detect vitamin D insufficiency. We recommend that vitamin D and calcium supplementation be considered for patients with low-energy hip fractures.

Defining a left-lateralized response specific to intelligible speech using fMRI.

Functional imaging studies of language have shown bilateral superior temporal activations in response to 'passive' perception of speech when the baseline condition did not control for the acoustic complexity of speech. Controlling for this complexity demonstrates speech-specific processing lateralized to the left temporal lobe, and our recent positron emission tomography study has emphasized a role for left anterolateral temporal cortex in speech comprehension. This contrasts with the more usual view that relates speech comprehension to left temporal-parietal cortex, the ill-defined area of Wernicke. This study attempted to reconcile these differences, using a more sensitive 3 T functional magnetic resonance imaging system, and a sparse sampling paradigm. We found left lateralized activations for intelligible speech with two distinct foci, one in the anterior superior temporal sulcus and the other on the posterior temporal lobe. Therefore, the results demonstrate that there are neural responses to intelligible speech along the length of the left lateral temporal neocortex, although the precise processing roles of the anterior and posterior regions cannot be determined from this study.

Towards understanding language organisation in the brain using fMRI.

Functional magnetic resonance imaging (fMRI), which allows non-invasive mapping of human cognitive functions, has become an important tool for understanding language function. An understanding of component processes and sources of noise in the images is contributing to increased confidence in the reproductability of studies. This allows clinical applications, e.g., for pre-surgical lateralisation of language functions in patients with temporal lobe epilepsy. fMRI is a sensitive method for mapping regions involved in language functions. We recently have applied it to study the effect of word surface form on reading with a comparison of responses to Chinese characters or alphabetical Pinyin. Interpretation of fMRI activations must be made with caution; fMRI suggests task-associated activation, but does not independently confirm that such activity is necessary. However, complementary studies can be performed using transcranial magnetic stimulation (TMS), which can be used to interfere with brain activity in a specific region transiently for characterisation of the behavioural effects. We describe how TMS combined with fMRI has confirmed a role for the left inferior frontal cortex in semantic processing.

Selective cytotoxic lesions of the retrohippocampal region produce a mild deficit in social recognition memory.

Although a number of studies have implicated the hippocampal formation in social recognition memory in the rat, a recent study in this laboratory has demonstrated that selective cytotoxic lesions, confined to the hippocampus proper (encompassing the four CA subfields and the dentate gyrus), are without effect on this behaviour. This finding suggests that the hippocampus proper does not subserve social recognition memory in the rat, but does not preclude the possibility that other areas of the hippocampal formation, such as the entorhinal cortex or subiculum, could support this form of learning. The present study addressed this issue by examining the effects of selective cytotoxic retrohippocampal (RHR) lesions (including both the entorhinal cortex and subiculum) on social recognition memory in the rat. RHR lesions produced a mild social recognition memory impairment, although lesioned animals still displayed a reduction in investigation time between the first and second exposure to the juvenile. This result is consistent with other studies which have implicated the retrohippocampal or parahippocampal area in olfactory recognition memory processes. It also suggests, however, that other areas, out with the retrohippocampal region, are also likely to play an important role in social recognition memory.

Predicting success: stakeholder readiness for home telecare diabetic support.

Readiness to adopt a new technology is one factor that contributes to the success of a telehealth programme. Since one goal of telehealth is to improve care, it is appropriate to determine its success through a quality-of-care framework that addresses structure, process and outcome. A qualitative case study of home care in the Calgary Health Region in Alberta set out to understand how clients, nurses, physicians and managers perceived their readiness to use video-visits for home care. Focus groups, home visits, and telephone and face-to-face interviews were used to collect data. Readiness to adopt home telecare was compared between groups, as well as with behaviour predicted in the literature. Differences in perceptions were identified among the four participant groups. Clients and managers identified a higher degree of readiness-clients because of the potential to support independence in their homes and managers because of the potential efficiencies in the system.

Upper reference limit, analytical quality specifications and clinical use of haemoglobin A1C.

Haemoglobin A1c (HbA1c) is now the key component for monitoring glycaemic control in diabetes mellitus (DM), especially for its close relation to diabetes complications. However, treatment goals in terms of HbA1c concentrations have been difficult to define and compare because of lack of international standardization and lack of common reference values of HbA1c concentrations. The aims of our study were to document our HbA1c analysis and make it traceable to international reference laboratories with the aid of current reference preparations, to establish a reference interval based on a low-risk population, and to evaluate the analytical quality specifications, which could meet clinical needs. The s(analytical) of our method (Tosoh) was < 0.3 HbA1c%, and the mean bias as estimated from Dr Cas Weykamp's reference preparation was below 0.3 HbA1c. This was the same as that for participating Scandinavian and international reference laboratories. The concentrations were made traceable to results from the Diabetes Control and Complication Trial (DCCT) and the UK Prospective Diabetes Study (UKPDS). Risk groups for DM were ruled out from a randomly selected population in Vejle County, which isolated a "low-risk" reference population. The 97.5 reference interval in this population (N=430) was from 5.07 HbA1c% (95% CI: 5.02-5.11) to 6.24 HbA1c% (95% CI: 6.19-6.30), and the 99.9 centile was 6.62 HbA1c% (95%) CI 6.55-6.71). Body mass index, age and gender contributed marginally to the level of HbA1c concentrations. A 10% delta risk estimate of DM complications was detectable with a probability of Type I error of 40%, while adoption of a significance level of 95% and consideration to biological variation needed a risk difference of at least 33% to be detected. The critical difference was 11% for changes in either direction at s(analytical) < or = 0.2 HbA1c% and a s(biological) of 0.3 HbA1c%. Based on criteria for sharing common reference intervals and clinical utility, we accepted that the bias and s(analytical) should both be < 0.3 HbA1c% at the level of 7.0 HbA1c%.

Predicting success: stakeholder readiness for home telecare diabetic support.

Readiness to adopt a new technology is one factor that contributes to the success of a telehealth programme. Since one goal of telehealth is to improve care, it is appropriate to determine its success through a quality-of-care framework that addresses structure, process and outcome. A qualitative case study of home care in the Calgary Health Region in Alberta set out to understand how clients, nurses, physicians and managers perceived their readiness to use video-visits for home care. Focus groups, home visits, and telephone and face-to-face interviews were used to collect data. Readiness to adopt home telecare was compared between groups, as well as with behaviour predicted in the literature. Differences in perceptions were identified among the four participant groups. Clients and managers identified a higher degree of readiness - clients because of the potential to support independence in their homes and managers because of the potential efficiencies in the system.

Limitation of the Vitros dry-slide technique in measuring high concentrations of salicylate in plasma.

The linearity of the Vitros dry-slide method for plasma salicylate was assessed in two ways: serial concentrations of sodium salicylate were added to fresh lithium heparin plasma, and the salicylate was determined both neat and in dilution. Vitros salicylate results submitted to the Heathcontrol External Quality Assessment Scheme were compared to the spike value. Similar loss of linearity was observed in both cases. Serious salicylate overdosage requiring specific clinical treatment may have been underestimated.

Action levels for obesity treatment in 40 to 42-y-old men and women compared with action levels for prevention of coronary heart disease.

BACKGROUND: Guidelines for treating overweight and obesity have been suggested by the World Health Organization and other expert groups. We asked whether most men and women targeted in obesity guidelines would already be included in existing clinical recommendations for the prevention of coronary heart disease (CHD) or whether a new group of patients would be added to current workloads. SUBJECTS AND METHODS: In 1997 the Norwegian National Health Screening Service examined CHD risk factors in subjects aged 40-42 y living in three counties. We studied 6911 men and 7992 women who did not report treatment for diabetes, hypertension or the presence of cardiovascular disease. Estimated 10 y risk of CHD was calculated using the Framingham equation. RESULTS: The prevalence of single risk factors (systolic blood pressure > or =160 mmHg, diastolic blood pressure > or =95 mmHg, total cholesterol level > or =7.8 mmol/l and nonfasting glucose > or =11.1 mmol/l) ranged between 0 and 11% among subjects with body mass index > or =25 kg/m2. Adding low HDL cholesterol (<1.0 mmol/l for men, <1.1 mmol/l for women) and 10 y risk CHD risk to the classical risk factors increased prevalence to 16-50% (one or more risk factors or 10 y risk > or =10%). Sensitivities and specificities of using body mass index (BMI) or BMI and waist circumference as a screen for elevated CHD risk ranged between 22 and 91%. Screening for 10 y CHD risk of > or =10% or one or more risk factors among men and screening for one or more risk factors among women gave positive predictive values of 19-50%; however, the positive predictive value of screening for 10 y CHD risk of > or =10% was only 1-2% among women. Compared with men with BMI<30 kg/m2 or waist circumference <102 cm, those with measurements equal to or above these levels had statistically significantly higher adjusted odds ratios of elevated CHD risk (1.49, 95% CI 1.24-1.79 and 1.48, 95% CI 1.22-1.80, respectively); these associations were not observed among women. CONCLUSION: Using BMI and waist circumference to screen for CHD risk yields low positive prediction values, thus doubling the number of men and adding even more to the number of women seen by the practitioner for prevention of CHD.

The role of the entorhinal cortex in two forms of spatial learning and memory.

It is generally acknowledged that the rodent hippocampus plays an important role in spatial learning and memory. The importance of the entorhinal cortex (ERC), an area that is closely interconnected anatomically with the hippocampus, in these forms of learning is less clear cut. Recent studies using selective, fibre-sparing cytotoxic lesions have generated conflicting results, with some studies showing that spatial learning can proceed normally without the ERC, suggesting that this area is not required for normal hippocampal function. The present study compared cytotoxic and aspiration ERC lesions with both fimbria fornix (FFX) lesions and sham-operated controls on two spatial learning tasks which have repeatedly been shown to depend on the hippocampus. Both groups of ERC lesions were impaired during non-matching-to-place testing (rewarded alternation) on the elevated T-maze. However, neither of these lesions subsequently had any effect on the acquisition of a standard spatial reference memory task in the water maze. FFX lesions produced a robust and reliable impairment on both of these tasks. A second experiment confirmed that cytotoxic ERC lesions spared water maze learning but disrupted rewarded alternation on the T-maze, when the order of behavioural testing was reversed. These results confirm previous reports that ERC-lesioned animals are capable of spatial navigation in the water maze, suggesting that the ERC is not a prerequisite for normal hippocampal function in this task. The present demonstration that ERC lesions disrupt non-matching-to-place performance may, however, be consistent with the possibility that ERC lesions affect attentional mechanisms, for example, by increasing the sensitivity to recent reward history.