Validity and utilization of epidemiological data: a study of ischaemic heart disease and coronary risk factors in a local population.

OBJECTIVES: To calculate the burden of ischaemic heart disease (IHD) and coronary risk factors in a defined population using data from all public providers of health care, i.e. inpatient and outpatient care in all settings. STUDY DESIGN: Cross-sectional, 1-year retrospective study. METHODS: The main outcome measures were the number of individuals by diagnosis and by care setting, and gender- and age-specific event rates by diagnosis. RESULTS: Less than half of the individuals who visited any care provider for IHD or coronary risk factors were identified in the hospital discharge register. Calculation of the actual burden of disease in the population showed that when hospital discharge data were combined with outpatient data, there were no or slight differences in the age-specific rates of acute myocardial infarction (AMI), while the rates of angina were between two-fold and four-fold higher, and unspecified IHD was between three-fold and ten-fold higher in individuals aged > or =50 years compared with using hospital discharge data alone. The rates of hypertension, diabetes and lipid disorders increased in all age groups when outpatient data were added to hospital discharge data. The differences in the rates were more pronounced in women aged 50-79 years. However, the age-specific rates were higher in men except for hypertension which was higher in older women. CONCLUSION: Data for epidemiological analyses of diseases are often based on hospital discharge data. This study found that hospital discharge data provide limited information on patients treated for IHD and coronary risk factors, except for AMI. These findings suggest that hospital discharge data should be combined with outpatient care data to provide a more comprehensive estimate of the burden of IHD and its risk factors.

Lack of integration, and seasonal variations in demand explained performance problems and waiting times for patients at emergency departments: a 3 years evaluation of the shift of responsibility between primary and secondary care by closure of two acute hospitals.

In 1996, Stockholm County decided to reduce the costs of health care in order to release resources for upcoming medical needs. The method was both structural changes and transfer of low technology care from hospitals to other settings. The effects of interventions on service quality for patients and organisational performance of departments of internal medicine, orthopaedics and surgery were evaluated. Three cross-sectional studies were performed for comparison over time. Details on all individuals who visited A&E departments during 1 week in May 1997, May 1998 and May 1999 were recorded prospectively, and 16246 visits were registered. From 1995 to 1999 the total number of visits increased by 21% according to annual statistics. The utilisation of emergency care rose by 40/1000, and was not associated with the growth of population by 4.5%. Hospitals responded to peaks of demand by stringent prioritisation. Median waiting times were unchanged, but mean waiting times were prolonged over time, in particular for younger, not-referred patients. There was a direct correlation between waiting times and number of visitors. Total length of stay at A&E departments was related mainly to the waiting time for the first examination by a physician and cycle time for X-rays. Increased number of visits strained the capacity of hospitals and led to temporary loss of service quality for patients. The expected chain-reaction of integrated care did not take place, since providers outside hospitals were resistant to the shift of responsibility. Hospitals were utilised as primary care centres. The sub-optimal integration and fragmented care with an inappropriate balance between providers seems a universal problem.

Implementation of service screening with mammography in Sweden: from pilot study to nationwide programme.

Establishment of mammography screening in Sweden has progressed logically from pilot study through clinical trials to service screening. Screening with mammography for early detection of breast cancer has been provided by all Sweden's 26 county councils since 1997. It took 23 years from the initial pilot study through clinical trials to the establishment of mammography service screening throughout Sweden. In the screening rounds completed by 1995-96, and provided by all but one county council, 1040000 women participated, corresponding to 81% of those invited. The national average recall rate was 2.2%, and consequently 23000 women were recalled for additional investigations. Eleven county councils invited women aged 40-74, six invited women aged 50-69, the remaining eight invited women between both these age intervals. Mammography outside screening programmes-clinical mammography-is available throughout Sweden. About 100000 women a year were referred for clinical mammography and about 50% of these were either younger or older than those invited for screening. A negative relation between the use of clinical mammography and participation in the screening programmes was noticed.

Outcome of renal transplantation in patients over the age of 60: a case-control study.

The outcome of kidney transplantation in 70 consecutive patients aged 60 years or more was compared to that of matched contemporary controls aged 18-54 years. Although the elderly patients were a positive selection from a much larger population in dialysis their first-year mortality was significantly increased (8 versus one of the controls, P = 0.016). Morbidity in bronchopneumonia was also increased (11 versus 2, P = 0.009). In the group of elderly patients six grafts were lost due to the death of the patient. Neither the rate of irreversible rejection nor the need for extra antirejection therapy differed between the groups. The increased mortality and morbidity suggest that the selection had not been too restricted. Thus kidney transplantation should only be offered to a minority of elderly uraemic patients.

Cost-effectiveness studies of renal transplantation.

This study analyzes opportunity costs for the treatment of end-stage renal disease. Kidney transplantation remains the most cost-effective treatment for uremia and is one of the most cost-effective technologies in health care. Improved survival of grafts and increased numbers of transplants have the potential to reduce costs for dialysis programs. To support organ donation activities, the public and concerned health professionals should be informed about the opportunity cost of "unnecessary" dialysis. These resources could be reallocated from dialysis to other programs. Among patients in dialysis, a more common use of chronic ambulatory peritoneal dialysis instead of institution-based hemodialysis would greatly increase cost-utility and further reduce the program costs of renal replacement therapy.

Influence of zymosan (a non-specific macrophage stimulator) and of indomethacin on liver tumours--an experimental study in rats.

Zymosan--a non-specific macrophage-stimulating agent--reduces tumour take in the liver. The mechanism for this effect is not clear, but it may be mediated via the Kupffer cells and prostaglandins. On the other hand, the Prostaglandin-synthesis inhibitor, indomethacin, inhibits tumour growth. Pretreatment with zymosan (3 mg 100 g-1) for 3 days of two different strains of rats, inoculated in the liver with a hepatoma or an adenocarcinoma cell suspension respectively, reduced tumour take and also initial tumour growth. The effect on tumour take and initial growth was inhibited by concomitant administration of indomethacin (0.2 mg 100 g-1). When zymosan was administered after tumour cell inoculation the growth rate of the hepatoma was retarded, but this effect was not abrogated by indomethacin. Pretreatment with indomethacin had no significant effect on tumour take or initial growth. When given after the tumour was established in the liver, indomethacin reduced the growth rate of the hepatoma, but not of the adenocarcinoma. These results suggest that there are different mechanisms for the effects of zymosan on tumour take and on growth of an established tumour. In immunoincompetent nude mice the effect on the hepatoma was similar to the effect in the rat. In vitro both tumours were insensitive to zymosan and indomethacin. This study confirms that pretreatment with a non-specific macrophage stimulator (zymosan) diminishes tumour take and growth in the liver, that the effect of zymosan on tumour take in the liver is abrogated by indomethacin and that the zymosan effect on tumour take in the liver is at least partly mediated by the Kupffer cells and prostaglandins.

Insulin sensitivity, hormonal levels and skeletal muscle protein metabolism in tumour-bearing exercising rats.

We have previously shown that spontaneous physical exercise can delay onset of experimental anorexia and cachexia, and retard tumour growth; we now report the effects on insulin sensitivity, hormonal levels and skeletal muscle protein metabolism. Insulin sensitivity determined with a euglycaemic hyperinsulinaemic clamp revealed a normalised glucose disposal rate in tumour-bearing exercising (TBE) versus sedentary (TBS) animals (TBE 15.55 +/- 2.71 versus TBS 2.47 +/- 2.12 mg/kg/min; P < 0.05). Both TBE and TBS animals had decreased levels of corticosterone during the clamp. Serum levels of insulin during tumour progression were unaffected by exercise, but the insulin: glucagon ratio increased and the progressive decrease in rT3 was attenuated. The concentration of glucagon decreased in both tumour-bearing groups during the experiment, while TBE animals showed a relative reduction in corticosterone. Capacity for skeletal muscle protein synthesis, expressed as RNA: protein ratio, was normalised in TBE animals in two tumour protocols (TBE 5.9 +/- 0.6 versus TBS 4.7 +/- 0.3; TBE 2.9 +/- 0.4 versus TBS 1.8 +/- 0.2; P < 0.05, respectively). Incorporation rate of 14C-phenylalanine into skeletal muscle protein was increased in the TBE group in vitro and in vivo. In the postexercise period, protein degradation evaluated by tyrosine release in vitro was increased, but decreased over time. This study has confirmed a positive skeletal muscle protein balance in exercising tumour-bearing animals, partly explained by the increased insulin sensitivity. This conclusion was further supported by the less catabolic pattern indicated by hormonal levels.

Glomerular filtration rate after liver transplantation with a low-dose cyclosporin protocol.

Cyclosporin nephrotoxicity is a well-known complication in organ transplantation. In successful liver transplantation, a moderate degree of renal impairment is accepted. Whether this impairment is continuously progressive, stabilizes with time, or is reversible is not known. We have prospectively evaluated the glomerular filtration rate (GFR) using 51CrEDTA plasma clearance in 29 liver transplant patients (11 males and 18 females) with a mean age of 49 years (range 22-62 years). The 51CrEDTA plasma clearance measurements were performed preoperatively and at 3, 6, 12, 24, and 36 months after the liver transplantation. All but six patients were given sequential, quadruple drug therapy with antithymocyte globulin, azathioprine, steroids, and cyclosporin. Intravenous cyclosporin was avoided and oral cyclosporin started when renal function was stable. Cyclosporin was started in a dose of 8 mg/kg body weight, aiming at whole blood through levels (specific monoclonal technique) of 200 micrograms/l in the postoperative period; thereafter, the dosage was rapidly tapered down, aiming at whole blood trough levels of less than 100 micrograms/l at 3 months (1.5-2 mg/kg body weight). From a mean preoperative GFR of 89 +/- 3 ml/min per 1.73 m2, all patients declined in renal function after transplantation to a mean of 64 +/- 4 ml/min per 1.73 m2 3 months after transplantation, and starting in the 3rd month the renal function was stable at about 70% of the preoperative value. No correlations were found between cyclosporin peak level or accumulated cyclosporin dose and renal impairment. We conclude that liver transplantation with cyclosporin immunosuppression will induce renal impairment even if cyclosporin blood levels are carefully monitored and kept low.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of adenine nucleotide and water content of cold-stored rat livers to serve as graft viability indices for transplantation.

A study was undertaken to determine whether the cellular viability of the liver graft and posttransplantation outcome could the assessed by the graft energy status or change in water content prior to the transplantation procedure. These measurements were performed in a rat liver transplantation model. In a first set of experiments, the time for 50% survival of grafts preserved with UW solution or saline solution was determined. Grafts preserved with UW solution could be cold-stored for 19.9 h and grafted with a 50% success rate. The corresponding figure for saline-preserved grafts was 6.2 h. The energy status and water content of liver grafts preserved with UW solution for 19.9 h and livers preserved with saline solution for 6.2 h were compared. There were significant differences between livers preserved with UW solution and saline solution for ATP (p < 0.01), total adenine nucleotides (p < 0.05), ATP/ADP (p < 0.05) and energy charge levels (p < 0.05). ATP concentrations in the donor livers did not decrease significantly during cold storage when the success rate decreased from 100 to 0% after liver transplantation. The livers preserved with NaCl solution took up water during preservation. In contrast, the water content was reduced slightly in the livers preserved with UW solution and the differences were significant at all times. During cold storage using either the UW solution or saline solution for preservation, there were no significant time-related changes in the water content of the liver graft when the posttransplantation success rate decreased from 100 to 0% after liver transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)