Incidence of diverticular bleeding: a population-based study.

OBJECTIVE: To determine the incidence of diverticular bleeding (DB) and examine the time trend of the incidence. Furthermore to study prognosis with regard to therapy and rebleeding. METHODS: A retrospective, population-based study of patients with DB in a National University Hospital from 2006 to 2016. Patients were identified in an electronically stored colonoscopy database. Definite diverticular bleeding was defined as active bleeding, a nonbleeding visible vessel or adherent clot. Presumptive diverticular bleeding was defined as acute painless rectal bleeding leading to hospitalization with visible diverticula but no evidence of bleeding and no other colonic lesions or bleeding sites identified on endoscopy. A 30-day re-bleeding was determined after discharge. RESULTS: A total of 3683 colonoscopy reports were reviewed, including 345 patients (males 51%) with presumptive 95% (n = 327) or definitive 5% (n = 18) diverticular bleeding. Overall 96% were treated conservatively, 3% endoscopically and 0.3% surgically. Only 5.8% of patients had a 30-day rebleed. After exclusion, 315 patients were included in the incidence calculations. The mean cumulative incidence of diverticular bleeding was 14/100,000 inhabitants per year. A time trend analysis of the incidence of DB revealed no significant change in incidence during the study period. CONCLUSIONS: The mean incidence of colonic diverticular bleeding was found to be approximately 14 cases per 100,000 inhabitants and year. The incidence does not seem to have changed in the past decade. The vast majority of patients with diverticular bleeding did not require endoscopic therapy and could be managed with conservative treatment.

Health economic aspects of vertebral augmentation procedures.

We reviewed all peer-reviewed papers analysing the cost-effectiveness of vertebroplasty and balloon kyphoplasty for osteoporotic vertebral compression fractures. In general, the procedures appear to be cost effective but are very dependent upon model input details. Better data, rather than new models, are needed to answer outstanding questions. Vertebral augmentation procedures (VAPs), including vertebroplasty (VP) and balloon kyphoplasty (BKP), seek to stabilise fractured vertebral bodies and reduce pain. The aim of this paper is to review current literature on the cost-effectiveness of VAPs as well as to discuss the challenges for economic evaluation in this research area. A systematic literature search was conducted to identify existing published studies on the cost-effectiveness of VAPs in patients with osteoporosis. Only peer-reviewed published articles that fulfilled the criteria of being regarded as full economic evaluations including both morbidity and mortality in the outcome measure in the form of quality-adjusted life years (QALYs) were included. The search identified 949 studies, of which four (0.4 %) were identified as relevant with one study added later. The reviewed studies differed widely in terms of study design, modelling framework and data used, yielding different results and conclusions regarding the cost-effectiveness of VAPs. Three out of five studies indicated in the base case results that VAPs were cost effective compared to non-surgical management (NSM). The five main factors that drove the variations in the cost-effectiveness between the studies were time horizon, quality of life effect of treatment, offset time of the treatment effect, reduced number of bed days associated with VAPs and mortality benefit with treatment. The cost-effectiveness of VAPs is uncertain. In answering the remaining questions, new cost-effectiveness analysis will yield limited benefit. Rather, studies that can reduce the uncertainty in the underlying data, especially regarding the long-term clinical outcomes of VAPs, should be conducted.

The impact of different health dimensions on overall quality of life related to kyphoplasty and non-surgical management.

UNLABELLED: This study uses data from a previously published randomised trial where balloon kyphoplasty was compared to non-surgical management. Of the improved overall quality of life, 60 % was caused by decreased pain. However, ignoring other dimensions of quality of life would underestimate the procedure's effect. INTRODUCTION: Acute back pain has been viewed as the most important factor lowering quality of life (QoL) for patients suffering vertebral fractures. The objective of this study was to quantify the impact of different health dimensions on overall QoL using patient-reported outcome measurements (PROMs) collected in Fracture Reduction Evaluation (FREE) trial. METHODS: The analysis was based on patients included in the 2-year-long randomised controlled FREE trial studying the efficacy and safety of balloon kyphoplasty procedure (BKP) compared to non-surgical management (NSM). The PROMs included were EQ-5D, Short Form (SF)-36, visual analogue scale (VAS) pain and the Roland-Morris Disability Questionnaire (RMDQ). The health dimensional contribution to the overall QoL improvements was analysed by isolating the impact of each dimension on QoL in the SF-36 and EQ-5D, respectively. A correlation analysis of the QoL improvement was performed to investigate the relationships between the four instruments. RESULTS: Changes in pain explained 60 % of the quality-adjusted life years (QALY) gained in BKP vs. NSM followed by self-care (17 %), mobility (16 %) and usual activities (10 %) (EQ-5D). Health dimensions capturing the mental state had little impact on the QALY gained. The SF-36 dimensional analysis showed similar results. The correlation analysis showed that the correlation between VAS pain, RMDQ and QALY improvement was fairly weak. CONCLUSIONS: Changes in the pain dimension of health are the most important drivers for changes of overall QoL in patients treated with BKP or NSM. However, ignoring the impact of other dimensions would lead to an underestimation of the actual improvement in overall QoL.

Recovery of astaxanthin from seafood wastewater utilizing fish scales waste.

The paper presents basic data on astaxanthin adsorption from fisheries wastewater to fish scales. This process has been proposed to be applicable in fisheries and shrimp waste management [Helgason, Recovery of compounds using a natural adsorbent, Patent WO 01/77230, 2001]. The innovative feature of the method is the application of a solid waste (fish scales) as a natural adsorbent for a carotenoid pigment (astaxanthin) from the seafood industry wastewater. The model investigations were performed with pure synthetic carotenoids to exclude the role of matrix in which astaxanthin is present in the wastewater. Under the experimental conditions used, the maximum loading capacity of astaxanthin onto the scales is 360 mg kg(-1) dry wt. Studies of the thus formed value added product indicated that drying causes significant loss of astaxanthin activity. Due to the effective filtration characteristics of the studied sorption material, we suggest the scale/astaxanthin sorption process to be suitable for treatment of wastewater from different industries.

Greater intima-media thickness in the carotid bulb is associated with reduced baroreflex sensitivity.

The aim of this study was to evaluate the association between resting baroreflex sensitivity (BRS) and carotid intima-media thickness (IMT), a putative marker of subclinical atherosclerosis. Participants were 64 men and 18 women (median age, 57 years; range, 40 to 70 years), who did not have a previous history of coronary artery disease or treatment for hypertension. Resting BRS was measured during a 9-min baseline period using the noninvasive sequence technique; carotid IMT was subsequently determined using ultrasonography. Hierarchical multiple regression analyses showed that greater IMT in the carotid bulb (an area with a high density of baroreceptors) was associated with reduced BRS. These findings remained after adjusting BRS for resting mean arterial pressure, age, body mass index, gender, and smoking history, R2 = 0.06, P = .03. In contrast, IMT in the common and internal carotid regions (areas with presumably lower baroreceptor densities) did not account for a significant proportion of the variance in BRS. These results suggest that subclinical atherosclerosis, specifically in a region with high baroreceptor density, is associated with a reduced sensitivity of the baroreflex.

Out-of-hours service in rural areas. An observational study of accessibility, attitudes and quality standards among general practitioners in Iceland.

OBJECTIVES: To examine the access, workload, duties, commitments and quality standards of primary care physicians (GPs) resulting from out-of-hours service. SETTING: All GPs (n = 96) in rural Iceland. MAIN OUTCOME MEASURES: Answers to a postal survey. RESULTS: The participation rate was 80%. The GPs estimated that in 97% of the cases they could be contacted within 5 minutes in an emergency. Under usual circumstances (weather conditions) and within a distance of 10 km, 70% of them could reach the patient within 30 minutes of receiving the call. In severe weather conditions, 50% of the GPs in smaller districts (650-6000 inhabitants) estimated that it could take up to 5 hours or more to reach the patient (which could happen once a year). In the least populated districts, 84% of the GPs had to be on call 14 days or more per month. Serious emergencies (involving special training such as cardiac resuscitation or tracheal intubation) were relatively rare, and GPs expressed the necessity for regular refresher courses in such fields. CONCLUSIONS: Modern telecommunication networks guarantee good access to out-of-hours service. The workload and on-call duties are great and do not comply with European Union (EU) recommendations regarding minimal rest time. If GPs in rural areas are to be expected to provide frontline health care, including in severe emergency situations, regular training courses are needed.

[Out of hours service in the Icelandic primary health care sector: an observational study.].

BACKGROUND: Decisive changes have occurred in out of hours service in recent years, prompted by technological and methodological progress, improved communications and public demand. Concurrently, physicians' leisure time has come under increasing pressure. AIMS: To examine the workload, duties and com notmitments of primary care physicians (GPs) resulting from out of hours service. Further, to assess the organisation and quality of out of hours service and possible differences between urban and rural areas. MATERIAL AND METHODS: A postal survey containing 58 questions was sent to all primary health care physicians holding posts for at least six months on March 1st 1996. Of a total of 143 GPs, answers were returned from 100 (70%). RESULTS: All GPs on call (100%) were equipped with radios, mobile phones or pagers. They estimated that in 95% of the cases they could be contacted within five minutes jn an emergency. In an emergency and bad weather conditions 82% of doctors in urban areas could attend their patients within 30 minutes, and 100% within 60 minutes. Similar figures for rural areas were 10% within 30 minutes and 18% within 60 minutes. In the least populated districts 84% of the practitioners had to be on call 14 days or more per month. Serious emergencies (involving special training such as cardiac resuscitation or tracheal intubation) were relatively rare, and GPs expressed the necessity for regular refreshing courses in such fields. CONCLUSIONS: Access to doctors is good in this country. Workload and on-call duties are significantly heavier here than abroad, to some extent owing to outdated organisation. Various possibilities exist for improvement in the quality and reliability of out of hours service, but to be effective they must be supplemented by professional counselling and support, and facilities for further training in these fields.

Plasma fatty acids and lipids in two separate, but genetically comparable, Icelandic populations.

Levels of serum lipids and lipoproteins, and the fatty acid composition of plasma phospholipids, were measured in two genetically comparable, but widely separated, populations. The 1975 mortality rates for ischemic heart disease were significantly higher in one of these populations, the Manitoban residents of pure Icelandic descent, than in the other, a rural population from Northeastern Iceland. Two study populations, Icelanders and Icelandic-Canadians, were drawn from these larger populations. The study populations were matched for age and sex and divided into three age groups, 20-39, 40-59, and 60-69 years. In comparison to the Icelandic-Canadians, the Icelanders exhibited significantly higher levels of total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol, but lower triglyceride levels. Their plasma phospholipids contained significantly lower levels of saturated fatty acids (SFA), monounsaturated fatty acids, and n-6 polyunsaturated fatty acids (PUFA); but their n-3 PUFA levels were three times as high. It was additionally found that fatty acid composition of plasma phospholipids differed among Icelanders of different ages. SFA levels were significantly lower, and n-6 PUFA levels significantly higher, in the 20-39 year group than in the 60-69 year group, possibly due to different dietary fat consumption patterns between generations. No corresponding age-related difference in the fatty acid composition of plasma phospholipids was found in the Icelandic-Canadian study population. As the Icelandic and Icelandic-Canadian groups are assumed to be genetically similar, the biochemical differences between them are evidently due to environmental, probably dietary, differences. The findings indicate that n-3 PUFA may be cardioprotective in the context of an otherwise atherogenic diet.

[Percutaneous nephrolithotomy (PCNL) in Reykjavik City Hospital 1985-1993.].

In the years 1985 to 1993, 92 patients, 61 men and 31 women, went to PCNL for stone removal at the Urology Department in the Reykjavik City Hospital, total 112 procedures. It was almost every patient who needed surgery for stone in the upper urinary tract. Most of the patients went home from the hospital in good health two or three days after the operation. Operation on the left kidney was more common (59%) than on the right one (41%). The stone size was 4-40 mm in diameter, mean 12 mm. In 70% of the operations there was one stone, but in 10% there were four stones or more. The procedure was done in two stages in 64% but in one stage in 36%. Stones in the upper ureter (26%) were first manipulated up into the renal pelvis. In 82% of the operations we did not have to disintegrate the stones but in 18% we used ultrasound or electrohydrolic-waves to do so. 87% of the patients needed only one operation. The results were that 87.5% of the patients were stonefree or had stonerests 4 mm or less after one procedure. Thirteen patients were taken more than once to PCNL, five of them got rid of their stones after repeated operations. Thus 90.2% of the 92 patients were managed successfully, that is stone-free or had stonerests smaller than 4 mm. No serious complications were noted. The most common complication was leakage of contrast media as a sign of perforation of the renal pelvis in 29 procedures. It always held without further complication within a few days with a nephrostomy.

[Autonomic nervous dysfunction in insulin-dependent (type 1) diabetic men.].

The development of autonomic nervous dysfunction (AND) in subjects with diabetes influences life expectancy and may cause sudden death. The present study evaluates disturbances of AND in 41 men with type 1 diabetes mellitus, but without heart symptoms, and the relationship with other long term diabetic complications and blood sugar control. Their age ranged 18-50 years (mean 34 +/-8 years) and the duration of diabetes 1-43 years (mean 13 +/-10 years). A control group consisted of 18 healthy men of similar age. Heart rate and blood pressure responses during standard autonomic tests were assessed by a computer program, vibration sensibility by a Biothesiometer, and an exercise test was performed. AND was more frequent in diabetics than controls (39% versus 6%, p<0.01), and increased with the duration of diabetes (r=0.34, p<0.05), but not significantly with HbAl-levels (r=0.21, p=0.19). Diabetics with AND had an earlier onset p<0.05) and a longer duration of (p<0.01) diabetes, decreased vibration sense (p<0.05), more frequent hypoglycaemic episodes (p<0.05), intermittent claudication (p<0.01), a higher resting heart rate (p<0.05), and a shorter treadmill time (p<0.05). Consequently, at maximal exercise their systolic (p<0.05) and diastolic (p=0.08) blood pressure increased less. With longer duration of diabetes, retinopathy (p

Influence of colour Doppler echocardiography on the ultrasonic assessment of congenital heart disease: a prospective study.

OBJECTIVE: To evaluate the additional information provided by colour Doppler in the ultrasonic assessment of congenital heart disease. PATIENTS AND METHODS: A prospective study of 215 children (age range 1 day-16 years) presenting with clinical signs of congenital heart disease. RESULTS: Colour Doppler was essential for the diagnosis of an anomalous left coronary artery and altered the management of a patient initially diagnosed as having cardiomyopathy. Colour Doppler provided extra information, but without major impact on management, in the following: the diagnosis of ventricular septal defects associated with other defects, of multiple ventricular septal defects, of anomalous pulmonary venous drainage, and of mild mitral regurgitation; the demonstration of site of coarctation, of stenotic or hypoplastic pulmonary artery branches, of unobstructed flow through a right atrial membrane, and of left ventricle to right atrium regurgitation; the assessment of the width of the duct and of flow through the patent foramen ovale in transposition and tricuspid atresia; the differentiation of pulmonary atresia from critical pulmonary stenosis and the measurement of maximum velocity of tricuspid regurgitation. CONCLUSIONS: Ideally all patients should undergo colour Doppler studies before cardiac surgery to ensure a more accurate diagnosis. However, since the additional information provided does not affect the management in most patients, machines without colour Doppler can provide a satisfactory service in paediatric cardiology centres in countries where resources are limited.

Some structural aspects of vanadium bromoperoxidase from Ascophyllum nodosum.

The stability of the vanadium containing bromoperoxidase from Ascophyllum nodosum was studied. The enzyme was very resistant against chemical denaturation. Denaturation did not occur upon incubation in 4 M guanidine hydrochloride. Circular dichroism measurements showed that the secondary structure was not affected upon incubation in 4% sodium dodecyl sulphate. The sedimentation coefficient and the molecular mass, determined by ultracentrifugation were 6.96 S and 97 kDa, respectively, indicating a very compact molecule. The protein molecule contained 16 cysteine residues, all of which participated in the formation of disulfide bridges. Circular dichroism-measurements in the far ultraviolet region revealed that the protein consisted of a large amount of alpha-helix (74%), and no beta-pleated sheet. The dissociation constant of the apoprotein vanadium-complex was 55 nM (at pH 8.5), and rapidly increased at lower pH. The data suggest that the protonation of a group with a pKa higher than 8.5 prevents the binding of vanadate. Structural analogues of vanadate (phosphate and arsenate) were competitive inhibitors with respect to the reconstitution of the bromoperoxidase. The inhibition constants were 60 and 120 microM for phosphate and arsenate, respectively. The binding of hydrogen peroxide to the enzyme was visualized by optical spectroscopy. Upon addition of H2O2 the optical absorption spectrum showed a small, but significant, decrease in absorption in the 315 nm region, which was restored upon addition of bromide, or by allowing the solution to stand for several hours. These changes are ascribed to the formation of a stable enzyme-peroxo-intermediate, in line with a previous analysis of the steady-state kinetics.

Computed tomography, angiography and ultrasound in staging of renal carcinoma.

Preoperative evaluation of the extent of the renal tumor is of value in determining the prognosis of the patient and the most suitable therapy. CT and angiography were reviewed in 27 cases of renal carcinoma to evaluate tumor involvement of lymph nodes, renal vein, vena cava, and the perinephric space. In 26 of these cases the ultrasound examination was similarly reviewed. Comparison of ultrasound, CT, and angiography demonstrated that staging of renal tumors with ultrasound is mainly limited by its inability to demonstrate extrarenal infiltration. Both CT and ultrasound proved reliable in the demonstration of tumor spread to the renal vein and inferior vena cava. CT and angiography were equally effective in the evaluation of tumor extension; since CT is easier to perform, less invasive and less time consuming than angiography it should be the primary method for staging of renal neoplasms. Angiography offers detailed information on the vascular supply of the tumor important for the choice of surgical approach and should be performed only on special indications.