Treatment of acute myocardial infarction in the sub-arctic region of Norway. Do we offer an equal quality of care?

Patients, relatives, healthcare workers and administrators are concerned about the quality of care offered. We aimed to explore the treatment of acute myocatrdial infarction (AMI) in Northern Norway, compare it with the national figures, and document whether there is an equal quality of care or not. The retrospective study included data on patients' treatment for AMI. The following sources were employed. The Norwegian Patient Registry, National Quality of Care Database, Norwegian Myocardial Infarction Registry and data from the National Air Ambulance Services of Norway. The period 2012-2014/15 was studied and the variables were: incidence of AMI, gender and age adjusted rates of AMI and revascularization (PCI, CABG) based on patient's place of living (according to hospital catchment area) and 30-day survival rate. The annual incidence of AMI was 9% higher in the northern region. Significant incidence variations (2.7-5.9 AMI/1000 inhabitants) between the hospitals' catchment areas were revealed. The 30-day survival rate varied between 85.1-92.1% between hospitals. The variation in revascularization/AMI rate was 0.72-1.54. Air amublance services' availability varied through the day. In conclusion, significant variations in the AMI rate and an unequal service within the region was revealed.

Caries experience and quantification of Streptococcus mutans and Streptococcus sobrinus in saliva of Sudanese schoolchildren.

Streptococcus mutans and Streptococcus sobrinus are among the most commonly isolated bacterial species implicated as etiological agents of dental caries. Details of the composition of the oral microflora related to dental caries should aid in assessing the prevalence and risk of disease at an individual level. The aim of the present study was to determine the presence and relative amounts of S. mutans and S. sobrinus in the saliva samples obtained from schoolchildren in Khartoum State, the Sudan, and to study the association of the amounts of S. mutans and S. sobrinus with caries experience, socioeconomic status and sugar-sweetened snacks in this population. 140 samples, 30 of which were from individuals with caries experience, were examined using quantitative real-time polymerase chain reaction (qRT-PCR) with specific oligonucleotide primers. The mean ratio of fold differences of S. mutans to S. sobrinus was 0.77 (SD 5.4) and 2.29 (SD 6.0) for samples obtained from caries-free and caries-active individuals, respectively. This suggested that the proportion of S. sobrinus was higher than S.mutans in the caries-active group when compared to the caries-free group. An association was found between children with caries-active lesions and the frequent consumption of sticky desserts and higher socioeconomic status. S. sobrinus seems to be associated with caries experience in the studied population. A proposal of caries screening programs designed to test for S. sobrinus in this population may be developed.

Do tooth gaps matter? Evaluation of self-assessments: a pilot study.

This study aimed to test the hypothesis stating no difference in number of teeth or tooth gaps counted by the dentist or the patient. The sample consisted of 49 randomly selected regular patients and their dentists (response rate 10%, 53% males). Mean age of the patients was 53.6 +/- 11.9 years. The mean number of teeth was 26.5, 20/49 reported tooth gaps (excluding second and third molars) and 12/20 had visible gaps. The calculation of patients' detection of gaps showed a sensitivity = 79%, specificity = 96% and a positive predictive value of 95%. The patients reported more teeth in the maxilla and fewer teeth in the mandible compared with their dentists. More teeth were misdiagnosed as the number of teeth increased in the mandible. Patients reported more gaps than dentists in both jaws (NS); an average of 0.04, 0.18 and 0.22 misdiagnosed gaps in the maxilla, mandible and for both jaws respectively. Agreement on tooth present/missing in the maxilla was 91.3% (+/-9.82) and in the mandible 88.2% (+/-10.44). Correlation between self-report and dentist's report of the number of teeth present and the number of gaps in the maxilla was (Pearson's r) 0.94 and 0.83. One person with self-perceived visible gaps and five persons with non-visible gaps were recommended treatment; two persons agreed about a treatment need. Self-assessments of tooth gaps show limited but acceptable sensitivity and excellent specificity. No significant differences in tooth counting were found when comparing self-reports and dentists' reports. The study should be tried on a larger scale.

Assessment of the reliability and validity of the Dental Neglect Scale in Norwegian adults.

AIMS: To evaluate the reliability and construct validity of the Dental Neglect Scale (DNS) and to estimate the level of dental neglect in the adult Norwegian population. METHODS: A questionnaire containing socio-demographics, oral health attitude variables, self-reported service use and a translated version of the original DNS was tested in two samples: 1) a convenience sample of University employees (n=263) and 2) a proportionate random sample (n=2000) drawn from the national population register (age 16-79 years). The reliability assessment of the instrument was by internal consistency (Cronbach's alpha) and factor analysis (principal component) (n=1309). The test-retest comparisons (n=108) were analyzed by Spearman's rho for the sum-scores, and kappa statistics for single items. Logistic regression analyses were used to evaluate the construct validity of the DNS. RESULTS: The Cronbach's alpha coefficient for the overall construct of DNS was 0.67 (n=173) and 0.57 (n=1301). Only one factor was extracted, explaining a total of 36% of the scale variance (n=1301). Cohen's kappa for the test-retest comparisons ranged from 0.21-0.79 (n=108), and Spearman's rho for the test-retest sum-scores was 0.60. Higher neglect scores were positively related to a negative opinion about own dental health (OR=3.3), last dental appointment because of pain or other problems (OR=2.3), less than 20 teeth (OR=2.2), drinking soft drinks with sugar every day (OR=2.1), non-regular dental service use (OR=2.2) and using floss or toothpicks seldom or never (OR=1.6). The prevalence of high dental neglect was 20%. CONCLUSIONS: The analyses indicated construct validity for the Dental Neglect Scale but low reliability for some of its items. One fifth of this representative sample of Norwegian adults reported a high level of dental neglect.

Sugar snack consumption in Ugandan schoolchildren: Validity and reliability of a food frequency questionnaire.

OBJECTIVES: This study assessed the reproducibility and relative validity of an eight-item self-administered food frequency questionnaire (FFQ) on intake of sugared snacks in Ugandan schoolchildren. A 5-day precoded food behaviour checklist (FBC) was used as validation criteria. Sociodemographic correlates of a sum frequency sugar score were explored. METHODS: The study was conducted in Kampala, Uganda, in 2004. Six hundred and fourteen schoolchildren (mean age 12.4 years) completed the FFQ on cakes/biscuits, chocolate, ice sticks, soft drinks, coffee, tea, sugared desserts and sweets/candies at school. They were examined clinically for dental caries. Forty students completed the FFQ twice, 1 week apart and 325 students completed the 5 day FBC at school. RESULTS: The mean decayed, missing and filled tooth index score was 0.98 (SD 1.6, range 0-15). Reproducibility scores (Cohen's kappa) for the sugar items ranged from 0.17 (ice sticks) to 0.55 (biscuits). No differences were seen between the average intakes at test and retest. Higher intake was reported in FFQ than in FBC across all sugar items. Crude agreement between students reporting intake at least 3-5 times a week/less than three times a week ranged from 50% to 55% (e.g. biscuits, chocolate) to 87% (tea). Spearman's correlation coefficients ranged from 0.14 (desserts) to 0.27 (sweets). anova revealed significant increase (P = 0.001) in the mean FBC sum scores by increasing quartiles of the FFQ sum scores. The average sum FFQ sugar scores were higher in girls than in boys and higher in older than in younger students. CONCLUSION: Fair reproducibility was established for the FFQ sugar items. The FFQ was acceptable in classifying individuals into broad categories of low and high sugar consumption.

Oral Impacts on Daily Performance in Norwegian adults: the influence of age, number of missing teeth, and socio-demographic factors.

This study investigates the relationships among socio-demographic factors, dental status, and impaired oral health-related quality of life (OHRQoL) using a translation into Norwegian of the Oral Impacts on Daily Performance (OIDP) inventory. Data were collected as part of the Central Bureau of Statistics (CBS) OMNIBUS survey in Norway. The CBS drew a two-stage proportionate random sample, comprising 2,000 residents aged 16-79 yr, from the national population register. Information was available for 1,309 individuals (response rate 66.0%) who completed telephone interviews in November and December 2003. A total of 18.3% (95% confidence interval: 16.2-20.4) reported that an oral problem had affected at least one daily oral performance during the 6 months preceding the survey. The proportion of adults who confirmed impacts varied from 11.3% (eating) to 2.1% (social contact). Multiple logistic regression analysis revealed statistically significant disparities regarding respondents' age, residential area, dental attendance, and number of remaining teeth. The prevalence of OIDP in the Norwegian population was modest, but varied systematically with both socio-demographic and oral health-related factors. The consistently declining OIDP with increasing age after controlling for dental status suggests age-related changes of participants' values and expectations.

Oral Impacts on Daily Performance in Norwegian adults: validity, reliability and prevalence estimates.

The Oral Impacts on Daily Performance (OIDP) instrument was translated into Norwegian and reviewed for cultural and conceptual equivalence by a group of bilingual academics. A sample of employees from the University of Bergen completed the Norwegian OIDP frequency questionnaire twice. A total of 173 and 108 subjects participated in the first and the second administration, respectively, of this questionnaire. A two-stage proportionate random sample, comprising 2,000 residents (age-range 16-79 yr), was drawn from the national population register by the Central Bureau of Statistics. Information became available for 1,309 persons who completed telephone interviews. The Norwegian OIDP preserved the overall concept of the English version. Test-retest reliability, in terms of Cohen's kappa, was 0.65, and Cronbach's alpha was high (> or = 0.80). In both samples, variations in the OIDP scores were apparent in relation to self-reported oral health and number of remaining teeth, supporting construct and criterion validity of the inventory. Only three of the OIDP interviews were discarded, which supports face validity. A total of 18.3% confirmed that they had at least one oral impact. Age-specific rates were 17.5%, 19.0%, 17.9% and 18.4% among 16-24, 24-44, 45-66 and 67-79-yr-old participants. The satisfactory psychometric properties provide evidence for the cross-cultural use of the OIDP. The presence of a distinct floor effect indicates poor sensitivity of the OIDP to detect improvements of oral health-related quality of life at a population level. Prevalence estimates were low, suggesting that the current oral health status has little impact on the daily performance of the Norwegian adult population.

Dental caries experience and its relationship to social and behavioural factors among 3-5-year-old children in Uganda.

OBJECTIVE: The aim of this study was to assess the socio-demographic and behavioural correlates of caries experience and sugar intake patterns among pre-school children in Uganda. METHODS: Five hundred and eighty-nine, 3-5-year-old children (51% boys, response rate = 85%), attending nursery schools in urban and peri-urban settings in central Kampala and Nakawa, respectively, were clinically examined for dental caries using the dmft index. Visible plaque on the labial surfaces of their maxillary incisors was recorded as a proxy for oral hygiene habits. A questionnaire designed to assess socio-demographic factors and sugar habits was completed by their caregivers in face-to-face interviews. RESULTS: The mean dmft scores were 1.7, 2.4 and 3.1, and 42%, 44% and 42% had visible plaque among 3-, 4- and 5-year-olds, respectively. In Nakawa, a total of 64%, 62% and 22% of the subjects had dmft > 0, decayed teeth (dt) > 0 and missing teeth > 0, respectively. The corresponding rates in central Kampala were 56%, 55% and 17%. Multivariate analyses revealed that attending school in Nakawa, having a mother with a lower level of education, reporting the intake of cough syrup, visiting a dentist and scoring positively for plaque were associated with higher odds (1.6, 1.5, 3.7 and 2.7) for having dmft > 0. The adjusted mean frequency sugar scores varied systematically between mothers with low and high levels of education (mean scores = 11.0 vs. 10.4), and for children with negative and positive plaque scores (mean scores = 10.6 vs. 10.9). CONCLUSION: The caries experience was highest among children attending nursery schools in Nakawa and those who had had longer periods of cough syrup consumption, whereas children from the two locations were equally exposed to sugar consumption generally. Both caries experience and frequency of sugar consumption was highest among children of less-well-educated mothers.

Trends in reasons for tooth extractions in Norway from 1968 to 1998.

The aims of this study were (i) to determine the reasons for extraction of permanent teeth in Norway in 1998 and (ii) to describe changes in reasons for extraction in time-trend and quasi-longitudinal perspectives over 30 years based on three cross-sectional studies. The 1998 data were obtained from questionnaires distributed to a national random sample of 1,500 dentists, of whom 1,008 responded (67%). A total of 1,495 teeth were extracted for 1,164 patients (age 10-92 years) during a period of 2 weeks. Caries accounted for 40% of the extractions and periodontal diseases for 24%. Caries was the primary reason in patients 10-45 years old, while periodontal diseases dominated among adults > 45 years old. In a time-trend perspective, among patients > or = 21 years, a significant decrease in the proportion of extractions because of caries was observed between 1968 and 1988, while non-significant changes were found between 1988 and 1998. Extractions because of periodontal disease accounted for about 26% in all surveys. Followed longitudinally, the three cohorts born 1923-32, 1933-42, 1943-52 showed a decrease in the proportion of extractions due to caries, and an increase in the proportion of periodontal extractions during the period, more so between 1968 and 1988 than between 1988 and 1998. The three cohorts showed a variable trend of change, which may indicate that period and age effects do not necessarily operate in the same direction.

Return of beta-adrenergic sensitivity in a patient with insulinoma after removal of the tumour.

Beta-adrenergic sensitivity and counterregulatory hormone and symptomatic responses to hypoglycaemia were studied in a 22-year-old man before and 3 and 34 weeks after removal of an insulinoma. The beta-adrenergic sensitivity was measured by the effect of an isoprenaline infusion on the heart rate, and the dose needed to increase the heart rate by 25 beats min(-1) (I25) calculated from regression lines. The glucose thresholds for the hormonal responses and symptoms were studied during a gradual fall in plasma glucose using a hypoglycaemic clamp technique. As compared with preoperative values, beta-adrenergic sensitivity was unchanged 3 weeks after surgery, but showed a marked improvement after 34 weeks, the I25 (in microg isoprenaline) being 0.96, 0.86, and 0.56, respectively. The hormone responses to hypoglycaemia were earlier, but with no improvement in symptom generation at 3 weeks. After 34 weeks, the thresholds for both hormone release and symptom generation occurred at a plasma glucose approximately 1 mmol l(-1) higher than before surgery. Thus, in our patient, there was a marked improvement in beta-adrenergic sensitivity, an earlier release of counterregulatory hormones, and an earlier recognition of hypoglycaemic symptoms after surgery. However, the restoration of these responses took more than 3 weeks.

Altered cAMP response after isoprenaline stimulation of mononuclear leucocytes from insulin-dependent diabetic patients with hypoglycaemia unawareness.

Loss of adrenergic hypoglycaemic symptoms is the most distinctive feature in insulin-dependent diabetes mellitus (IDDM) patients with hypoglycaemia unawareness. Previous reports from in vivo studies show reduced heart rate responsiveness both to adrenergic agonists and antagonists in these patients. This study was carried out to investigate whether the reduced adrenergic sensitivity in IDDM patients with hypoglycaemia unawareness (IDDM-unaware) also could be demonstrated as reduced increase in cAMP production in mononuclear leucocytes induced by isoprenaline stimulation, or reduced inhibition by ICI-118551 (a selective beta 2-adrenergic receptor blocker) of isoprenaline induced cAMP production. We found that the slope of the concentration-response curves of isoprenaline/cAMP and the maximal cAMP concentrations obtained after isoprenaline stimulation were reduced in IDDM-unaware compared to control and IDDM patients with normal hypoglycaemia awareness (IDDM-aware). We did not find any significant differences in the response to ICI-118551 between control, IDDM-aware and IDDM-unaware. This study supports the reports of reduced sensitivity of adrenergic agonists as a part of the pathophysiological changes in hypoglycaemia unawareness, but we have not been able to confirm the reports of an association between hypoglycaemia unawareness and reduced effect of adrenergic antagonists.

Reduced beta-adrenergic sensitivity in healthy volunteers induced by hypoglycemia.

A single causative mechanism for development of hypoglycemia unawareness in insulin-dependent diabetes mellitus (IDDM) is not yet apparent. Reduced adrenergic sensitivity may be part of the explanation. This study was carried out to investigate the effect of hypoglycemia on beta-adrenergic sensitivity. Ten healthy male subjects (age 19-23 years) gave informed consent to take part in the study. They were hospitalized overnight at the University Hospital of Tromsø, Department of Clinical Research, on two occasions. Isoprenaline and metoprolol sensitivity tests were performed the morning after hospitalization: once after an intravenous (iv) injection of placebo (0.9% NaCl), and once after an iv injection of insulin (0.15 IU insulin/kg body weight) to induce hypoglycemia. The dose of isoprenaline needed to increase heart rate (HR) by 25 beats per minute (bpm) (I25), and the dose of metoprolol (M-12.5) needed to inhibit I25 with 50% or 12.5 bpm, when injected simultaneously, were used as determinants of isoprenaline and metoprolol sensitivity. In this study, there was a significant (p < 0.05) increase both in I25 and M-12.5 after hypoglycemia. The dose-response curve of isoprenaline/HR was significantly shifted to the right after hypoglycemia. This study shows that acute hypoglycemia induces a reduction in beta-adrenergic sensitivity, and it supports the hypothesis of reduced beta-adrenergic sensitivity as an important pathophysiological mechanism in hypoglycemia unawareness in IDDM.

Dysfunction in the beta 2-adrenergic signal pathway in patients with insulin dependent diabetes mellitus (IDDM) and unawareness of hypoglycaemia.

The majority of the impaired symptoms in hypoglycaemia unawareness, such as palpitations, tachycardia and tremor, are caused by increased release of adrenaline (ADR) and noradrenaline (NA), and induced by stimulation of beta-adrenergic receptors. Binding of ADR or NA to the beta-adrenergic receptor generates a signal, transmitted via a guanine nucleotide binding protein complex (G-protein), which in turn activates adenylate cyclase with increased production of cAMP. The aim of this study was to show whether IDDM-patients with hypoglycaemia unawareness had deficient coupling between beta2-adrenergic receptors and G-proteins compared to IDDM-patients with hypoglycaemia unawareness and healthy controls. The IDDM-patients were subgrouped as hypoglycaemia aware or unaware based on questionnaire answers, clinical information and the results of isoprenaline sensitivity tests. Mononuclear leukocytes (MNL) were isolated from venous blood. By saturation binding experiments, using [125I]-(-)-iodopindolol ((-)-IPIN), total receptor number (Bmax) and affinity (Kd) were determined. By displacement experiments the relative number of low- and high-affinity receptors for the beta-adrenergic agonist (-)-isoprenaline ((-)-ISO) were determined. We found no difference in Bmax- or Kd-values. for (-)-IPIN between the subgroups. However, there was a reduced capability to form high-affinity binding complexes with (-)-ISO in MNL from IDDM-patients with hypoglycaemia unawareness. It was concluded that hypoglycaemia unawareness in IDDM was associated with dysfunction of the proximal beta2-adrenergic signal pathway.

Reduced sensitivity to beta-adrenoceptor stimulation and blockade in insulin dependent diabetic patients with hypoglycaemia unawareness.

Nine IDDM-patients with hypoglycaemia unawareness, seven IDDM-patients with hypoglycemia awareness and a control group of nine healthy persons were included in this study. The patients were recruited from the medical out-patients' department of the University Hospital of Tromsø. The pathophysiological changes which cause hypoglycaemia unawareness are today not clear. Reduced peripheral tissue sensitivity to catecholamines is suggested as one of several mechanisms which may contribute. For further investigation of beta-adrenergic sensitivity an isoprenaline/metoprolol sensitivity test was performed. Isoprenaline and metoprolol were administered intravenously, and the effects on heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and plasma levels of adrenaline (ADR) and noradrenaline (NA) were measured. All subjects were given the same doses of isoprenaline (0.25-8 micrograms) and metoprolol (0.5-8 mg). Metoprolol was given together with the dose of isoprenaline which increased heart rate by 25 beats min-1. The dose/response curves of both isoprenaline/HR and metoprolol/HR were significantly shifted to the right in IDDM-patients with hypoglycaemia unawareness compared with controls and IDDM-patients with hypoglycaemia awareness (P < 0.05). Reduced sensitivity of isoprenaline stimulation has also been shown before, whereas reduced sensitivity of a blocking agent has not earlier been shown. These findings support the hypothesis of reduced beta-adrenergic sensitivity as one pathophysiological component in hypoglycaemia unawareness.

Plasma protein binding of catecholamines, prazosin and propranolol in diabetes mellitus.

In the present study equilibrium dialysis has been used to determine the degree of protein binding of the catecholamines adrenaline and noradrenaline and the adrenergic receptor blockers, prazosin and propranolol in diabetics. The binding of the catecholamines in plasma from Type I and II diabetic patients was not significantly different from that of healthy subjects. The ratio of the bound and free catecholamine concentrations was correlated with the level of albumin (HSA). Significantly reduced protein binding of prazosin was observed in Type I and II diabetic subjects compared to healthy volunteers. The binding of propranolol was significantly reduced in Type I patients. The ratios between the bound and unbound concentrations of prazosin and propranolol were significantly correlated with the levels of alpha 1-acid glycoprotein (AAG). The results suggest that non-enzymatic glycosylation of plasma proteins may increase the unbound fraction of the adrenergic blockers prazosin and propranolol.

Catecholamine binding and concentrations in acute phase plasma after surgery.

The present study was undertaken to decide whether the bound fractions and/or total concentrations of catecholamines were determinative for the variability of biologically active concentrations in human plasma. The binding and concentrations of noradrenaline (NA) and adrenalin (Adr) were determined in acute phase plasma after major hip surgery in five subjects. The bound fractions before surgery were 23.0% and 18.4% for NA and Adr, respectively. The binding of catecholamines increased in the post-operative period. Five days after surgery the binding of NA and Adr was 30.9% and 24.0%, respectively. The surgical trauma induced an acute phase reaction in plasma with a decrease of albumin (HSA) concentrations whereas the concentrations of alpha-1 acid glycoprotein (AAG) increased. The catecholamine concentrations showed a considerable inter- and intraindividual variability. However, the present work shows that the variability of the biologically active catecholamine concentrations is mainly dependent on the total plasma concentrations and not the plasma protein binding.