Incidence and recurrence rate of sigmoid diverticulitis in patients requiring admission to hospital in Iceland from 1985 to 2014: nationwide population-based register study.

BACKGROUND: Diverticulitis is the most common complication of diverticular disease, affecting 10-25 per cent of patients with diverticula. A retrospective, nationwide, population-based cohort study was performed to analyse the incidence and recurrence rate of sigmoid diverticulitis requiring hospital admission. METHODS: All patients discharged from hospital in Iceland during 1985-2014 who were diagnosed with diverticular disease were included. The χ2 test was used to analyse the trend of the incidence in the period 2002-2014. The Kaplan-Meier method and the Cox model were used to analyse recurrence. RESULTS: Of 8660 admissions for diverticular disease, 4746 were due to diverticulitis, of which 2939 were for diverticulitis diagnosed for the first time. After the first attack, surgery was used to treat 661 patients. Of 2278 patients not treated by resection, 537 had a second attack (23·6 per cent). There was a significant decrease in the incidence of diverticulitis in patients aged 40-89 years during the period from 2002 to 2014 (P = 0·033). The risk of recurrence was associated with younger age at first attack and female sex (P < 0·001). CONCLUSION: There was a decline in the incidence of patients hospitalized with diverticulitis between 1995 and 2014, most prominent in older age groups. Different recurrence rates were reported in men and women, and in younger compared with older age groups.

ANTECEDENTES: La diverticulitis es la complicación más frecuente de la enfermedad diverticular y afecta al 10-25% de los pacientes con divertículos. Se realizó un estudio de cohortes retrospectivo de base poblacional a nivel nacional para analizar la incidencia y la tasa de recidiva de pacientes con diverticulitis sigmoidea que requieren ingreso hospitalario. MÉTODOS: Se incluyeron todos los pacientes dados de alta hospitalaria en Islandia durante el período de estudio entre 1985-2014 que fueron diagnosticados de enfermedad diverticular. Se utilizó el método de ji al cuadrado para analizar la tendencia de la incidencia en el período 2002-2014, y los métodos de Kaplan Meier y el modelo de Cox para analizar las recidivas. RESULTADOS: De 8.660 ingresos por enfermedad diverticular, 4.746 se debieron a diverticulitis, de los cuales 2.939 correspondían a un primer diagnóstico de diverticulitis. Después del primer episodio, se intervinieron 661 pacientes. De 2.278 pacientes que fueron tratados sin resección, 537 presentaron un segundo episodio (24%). Hubo una disminución significativa en la incidencia de diverticulitis en pacientes de 40 a 89 años durante el período 2002-2014 (P = 0,033). El riesgo de recidiva se asoció con una edad más joven en el primer episodio y con el sexo femenino (P < 0,001). CONCLUSIÓN: Se observó una disminución en la incidencia de diverticulitis que precisó hospitalización de 1995 a 2014, siendo más notoria en los grupos de mayor edad. Se observaron diferencias en las tasas de recidiva en los varones versus las mujeres y en los grupos de edad más joven versus los de mayor edad.

The NordICC Study: rationale and design of a randomized trial on colonoscopy screening for colorectal cancer.

BACKGROUND AND STUDY AIM: While colonoscopy screening is widely used in several European countries and the United States, there are no randomized trials to quantify its benefits. The Nordic-European Initiative on Colorectal Cancer (NordICC) is a multinational, randomized controlled trial aiming at investigating the effect of colonoscopy screening on colorectal cancer (CRC) incidence and mortality. This paper describes the rationale and design of the NordICC trial. STUDY DESIGN: Men and women aged 55 to 64 years are drawn from the population registries in the participating countries and randomly assigned to either once-only colonoscopy screening with removal of all detected lesions, or no screening (standard of care in the trial regions). All individuals are followed for 15 years after inclusion using dedicated national registries. The primary end points of the trial are cumulative CRC-specific death and CRC incidence during 15 years of follow-up. POWER ANALYSIS: We hypothesize a 50 % CRC mortality-reducing efficacy of the colonoscopy intervention and predict 50 % compliance, yielding a 25 % mortality reduction among those invited to screening. For 90 % power and a two-sided alpha level of 0.05, using a 2:1 randomization, 45 600 individuals will be randomized to control, and 22 800 individuals to the colonoscopy group. Interim analyses of the effect of colonoscopy on CRC incidence and mortality will be performed at 10-year follow-up. CONCLUSIONS: The aim of the NordICC trial is to quantify the effectiveness of population-based colonoscopy screening. This will allow development of evidence-based guidelines for CRC screening in the general population.

Risk factors and outcome in ICU-acquired infections.

BACKGROUND: Nosocomial infections are common in intensive care units (ICU). The objectives of this study were to determine risk factors of ICU-acquired infections, and potential mortality attributable to such infections. METHODS: An observational study was performed in a 10-bed multidisciplinary ICU. For a period of 27 months, all patients admitted for >or=48 h were included. Infections were diagnosed according to Centers for Disease Control and Prevention definitions. Airway colonization was explored by molecular typing. Risk factors for infection were determined by multivariable logistic regression. Survival was analyzed with time-varying proportional hazards regression. RESULTS: Of 278 patients, 81 (29%) were infected: urinary tract infections in 39 patients (14%), primary bloodstream infections in 25 (9%), surgical site infections in 22 (8%) and pneumonia in 21 (8%). Of the total of 147 episodes, Gram-negative bacilli were isolated in 90, Gram-positive cocci in 49 and Candida sp. in 25. Risk factors for pneumonia were mechanical ventilation [odds ratio (OR=7.9, CI 1.8-35), lack of enteral nutriment (OR=8.0, CI 1.4-45) and length of time at risk (OR=1.8, CI 1.2-2.8), while gastric acid inhibitors did not affect the risk (OR=0.99, CI 0.32-3.0). Transmission of bacteria from the stomach to the airway was not confirmed. The risk of death was increased as patients were infected with pneumonia [hazard ratio (HR)=3.6; CI: 1.6-8.1], or primary bloodstream infection (HR=2.5; CI: 1.2-5.4), independent of age and disease severity. CONCLUSIONS: Mortality was increased by ICU-acquired pneumonia and primary bloodstream infections. Our findings did not support the gastro-pulmonary hypothesis of ICU-acquired pneumonia. The proposition that blood transfusions increase the risk of ICU-acquired nosocomial infections was not supported.

Association between sigmoid diverticulitis and left-sided colon cancer: a nested, population-based, case control study.

BACKGROUND: An increased risk of left-sided colon cancer in patients with diverticular disease of the sigmoid colon has been reported. The aim of this study was to investigate to what extent patients with diverticulitis of the sigmoid colon differ in long-term risk of colon cancer compared to patients with diverticulosis of the colon without any clinical signs of diverticulitis. METHODS: A total of 7159 patients (2478 M, 4681 F) discharged with a diagnosis of diverticulosis or diverticulitis in 1965-83 in the Uppsala Health Care Region were followed-up with the Swedish Cancer Registry. Sixty-four cases with colon cancer were identified and compared with 123 controls without cancer matched for sex, age and year of first discharge. Based on information from the patients' charts, an independent observer blinded to the outcome assigned a clinical diagnosis of diverticulitis or not diverticulitis to cases and controls. RESULTS: In patients classified as having sigmoid diverticulitis there was an increased risk of left-sided colon cancer compared with patients with diverticulosis without any clinical signs of diverticulitis (odds ratio = 4.2, 95% CI 1.3-13.0) which remained after mutually adjusting for several clinical parameters in a multivariate conditional logistic regression analysis. CONCLUSION: The results of the study indicate a causal association between sigmoid diverticulitis and a long-term increased risk of left-sided colon cancer.

Diverticulitis of the sigmoid colon. A comparison of CT, colonic enema and laparoscopy.

PURPOSE: To evaluate the use of laparoscopy, CT, colonic enema (CE), and laboratory tests (white blood cell count (WBC), sedimentation rate (SR), and C-reactive protein (CRP) in diagnosing diverticulitis of the sigmoid colon. MATERIAL AND METHODS: The diagnostic methods were prospectively evaluated in 88 patients, 30 of whom were referred for laparoscopy. RESULTS: Fifty-two patients were found to have sigmoid diverticulitis: 20 patients by laparoscopy, 21 by CT, and 11 by CE combined with one positive laboratory test. Laparoscopy proved to be superior to the other diagnostic methods in diagnosing diverticulitis of the sigmoid colon. CT had a high specificity (1.0; 95% CI: 0.92-1.0) but low sensitivity (0.69; 95% CI: 0.56-0.79) in detecting diverticulitis. CE had a higher sensitivity (0.82; 95% CI: 0.71-0.90) but a lower specificity (0.81; 95% CI: 0.67-0.91) than CT. CONCLUSION: CT was the best method for diagnosing abdominal pathology outside the colon. CT can be recommended as the first examination in seriously ill patients where abscesses and other causes of the symptoms than diverticulitis must first be ruled out. Laparoscopy is probably the most accurate method in diagnosing diverticulitis.

[Nosocomial infections in the Intensive Care Unit at Landspitalinn.].

OBJECTIVE: To determine the nosocomial infection rate, pathogens, colonisation and hospital mortality in the Intensive Care Unit (ICU) at Landspitalinn, which is a ten bed, general medical-surgical ICU. METHODS: Patients admitted for more than 48 hours were included. Surveillance- cultures were performed on admission and thereafter three times a week (tracheal aspirate, oropharyngeal swab, gastric aspirate, urine and other specimens as indicated). ICU infections were defined by the criteria of CDC, USA. In the first 12 months 140 patients met the inclusion criteria at 150 admissions. The study is ongoing. RESULTS: Eighty-seven ICU-acquired infections were diagnosed in 48 of the 150 admissions (32%), the mean age was 58 years (0-87) and 60% were males. The most common infections were: UTI 27 (31%), pneumonia 18 (21%), septicemia 15 (17%), wound infections eight (9%) and tracheitis seven (8%). Etiologic agents of the 87 infections were E. coli (15), Klebsiella sp. (7) and other Enterobacteriacae (9), Enterococcus sp. (12), Candida sp. (12), S. epidermidis (7), P. aeruginosa (7) and other/unknown pathogens (18). Infected patients stayed for a mean of 15.0 days and uninfected patients 4.2 days (p<0.05). Every patient staying for more than three weeks had at least one infection. The mean age of infected patients was 63 years and of uninfected patients 56 years (p<0.05). Neither APACHE-II nor TISS score on admission differed significantly between the infected and uninfected groups. Mortality in the ICU was 10.4% (5/48) in the infected group and 19.6% (20/102) in the uninfected group (p=0.24). CONCLUSION: Nosocomial infections in patients admitted to the ICU were common and associated with extended stay. Most of the infections were caused by Gram-negative bacilli.

Cancers among patients diagnosed as having diverticular disease of the colon.

OBJECTIVE: To assess the incidence of underlying malignancy in patients with a diagnosis of diverticular disease of the colon. DESIGN: Retrospective cohort study. SETTING: University hospital, Sweden. SUBJECTS: 7159 patients discharged from hospital with a first diagnosis of diverticulosis or diverticulitis in central Sweden 1965-1983. INTERVENTION: The cohort was followed up for two years for the occurrence of cancer. MAIN OUTCOME MEASURE: Cancer incidence. RESULTS: A total of 372 cancer cases were identified standard incidence ratio = 2.4; 95% confidence interval 2.2 to 2.7). Sites at excess risk during the first year were: colon and rectum, pancreas, prostate, stomach, lymphatic and haemopoietic tissue, liver and bile ducts, ovary and lung, with the highest excess risk in the left colon (standard incidence ratio = 17.8; 95% CI 12.7 to 24.1). CONCLUSION: Malignant diseases, especially colorectal cancer, are relatively common among patients with a clinical diagnosis of diverticulosis or diverticulitis of the colon. This may indicate a need for a change in current clinical practice.

Laparoscopic suture rectopexy.

PURPOSE: This article describes a technique for laparoscopic suture rectopexy and assesses the postoperative results. METHODS: The rectum was fixed to the presacral fascia with five to six sutures. The procedure was performed using a laparoscope in four patients. RESULTS: There were no postoperative complications. In one patient a large enterocele was observed during the operation. This patient developed a recurrence about one month postoperatively. CONCLUSION: Laparoscopic suture rectopexy might be an alternative to open rectopexy for patients with isolated rectal prolapse.

Accuracy of double contrast barium enema and sigmoideoscopy in the detection of polyps in patients with diverticulosis.

The sensitivity between double contrast barium enema (DCBE) and sigmoideoscopy in diagnosing neoplastic lesions in the sigmoid colon was compared in patients with diverticulosis. In 52 patients with severe diverticulosis (> or = 15 diverticulas) the DCBE detected one out of 4 polyps found by sigmoideoscopy. In the remaining 54 patients with mild diverticulosis (< 15 diverticulas) DCBE detected 7 out of 10 polyps found by sigmoideoscopy. Successful bowel preparation did not influence the outcome of the DCBE. Sigmoideoscopy was incomplete in 17 (16%) of the patients; females were more difficult to examine than males (p = 0.012), as were those with a previous pelvic operation (p = 0.032). We conclude that neither DCBE nor sigmoideoscopy alone is sufficient to detect all neoplastic lesions in the sigmoid colon in patients with sigmoid diverticulosis of the colon.

Increased risk of left sided colon cancer in patients with diverticular disease.

Certain similar epidemiological characteristics suggest a common aetiology for colon cancer and diverticulosis of the colon. The hypothesis that patients with diverticulosis are at increased risk of developing colon cancer was tested in a retrospective, population based, cohort study in Sweden. A total of 7159 patients (2478 men and 4681 women) who had been given a hospital discharge diagnosis of diverticulosis or diverticulitis of the colon between 1965 and 1983 were followed up during 1985 by means of record linkage procedures. After excluding the first 2 years of follow up, there was not a significant increase in risk (SIR) overall for colon cancer (SIR = 1.2; 95% confidence intervals (CI) 0.9, 1.6) or for rectal cancer (SIR = 1.1; 95% CI 0.7, 1.7). The observed number of right sided colon cancers was as expected (SIR = 0.9; 95% CI 0.5, 1.5). In contrast, an increased risk of left sided colon cancer was found both overall (SIR = 1.8; 95% CI 1.1, 2.7) and consistently in men and women as well as in different age groups. This risk increased the longer the follow up (p value for trend < 0.001). These results do not support the hypothesis of a common aetiology in diverticular disease and colonic cancer but suggest a causal relationship between diverticular disease and cancer of the left colon.

Prolonged total extracorporeal lung assistance without systemic heparinization.

A 16-year-old female developed severe ARDS in her single remaining lung following pneumonectomy for blunt trauma. Total extracorporeal lung assist (ECLA) for 40 days using a covalently heparin-coated circuit proved lifesaving. Systemic heparinization was not applied, as the heparinized surface by itself prevented clotting of the extracorporeal circuit. Systemic primary fibrinolysis developed but was not associated with major bleeding. A veno-right ventricular cannulation technique was used and maximum venous drainage for the extracorporeal circulation was achieved by elevating the bed 50 cm from the floor. This allowed extracorporeal blood flow (ECBF) approaching cardiac output (CO) and complete extracorporeal replacement of lung function. After 40 days, lung recovery allowed discontinuation of ECLA. Five days later the patient suffered serious lung collapse and was operated for a bronchopleural fistula. The patient was extubated 4 weeks after terminating ECLA and discharged in good condition 5 weeks later.

Portal vein thrombosis in Crohn's disease.

Thromboembolic complications of inflammatory bowel disease are a well-recognized occurrence. Portal vein thrombosis has been reported in patients with ulcerative colitis but to date has not been reported in patients with Crohn's disease. We present the first case of portal vein thrombosis in a patient with Crohn's disease.

[Polymyalgia rheumatica. A disease in general practice]. / Polymyalgia rheumatica. En sygdom i almen praksis.

In retrospective investigation from a group practice with 4,100 registered patients, the number of cases of giant cell arthritis (polymyalgia rheumatica and temporal arteritis) diagnosed during the period 1978-1988 was calculated. Possible diagnostic criteria and a proposal for a therapeutic plan are discussed. Twenty-eight patients (40% men and 60% women) participated in the investigation. This gives an incidence of 0.56/1,000 which is higher than in previous Danish investigations. Problems involved in excluding infectious diseases and malignant conditions are illustrated by means of a review of the reasons for consultation, the examinations performed and the treatments during a period of six months prior to commencement of steroid therapy. The diagnostic delay was found to be two months. 35% of the patients were hospitalized in the course of the disease. The average duration of treatment was 22.5 months. The importance of good information to the patients and the necessary of good cooperation between general practice and the hospital sector is emphasized.

Beta-adrenoceptor agonists and hypoxia in sheep fetuses.

Sheep fetuses, near term, were studied to test the influence of a tocolytic beta agonist, terbutaline, on fetal responses to hypoxia. After fetal exteriorization the drug was administered intravenously to the mother in three different doses: The max group comprised 11 ewes receiving 67-134 micrograms min-1. Seven ewes were given 30 micrograms min-1 and eight ewes were infused with 10 micrograms min-1. Seventeen fetuses served as controls. Hypoxia was induced by intermittent complete occlusions of the maternal abdominal aorta. Maternal terbutaline levels were high (range 50-748 nmol l-1) in the max group and the 30-micrograms group, whereas those in the 10-micrograms group were in the clinical range (range 11-58 nmol l-1). Fetuses in the max and 30-micrograms groups reacted to moderate hypoxia with excessive responses of heart rate, blood pressure myocardial contractility and ST waveform changes and a 50% mortality rate during severe hypoxia as compared with 12% in the control animals. Ten micrograms min-1 did not decrease the survival but caused an increase in myocardial workload and a negative energy balance during severe hypoxia.

Material thrombogenicity in central venous catheterization III. A comparison between soft polyvinylchloride and soft polyurethane elastomer, long, antebrachial catheters.

Soft venous catheters, 36 made of polyurethane (PU) and 37 made of polyvinylchloride (PVC), were inserted in 73 patients via basilic and cephalic veins punctured at the cubital fossa, and compared regarding their thrombogenicity. The mean duration of catheterization was 12.5 days. Two patients with PU- and six patients with PVC-catheters developed clinical thrombophlebitis 4-36 days after insertion. The radiological thrombi were rather small with both PU- and PVC-catheters in both peripheral and central veins with no significant difference between the catheters. Also, the incidence of thrombosis and the rate of catheter occlusions were similar. The surface topography of the PVC-catheters was relatively smoother, but less uniform than that of the PU-catheters. Platelet adhesion in vitro to the catheter surfaces, expressed as ATP-concentration in relation to catheter area after contact with human blood, was relatively low with both catheters. The results suggest that soft PU- and PVC-catheters have a similar thrombogenicity.