A man in his seventies with fatigue and renal failure. / En mann i 70-årene med utmattelse og nyresvikt.

A man in his seventies underwent routine heart examinations as part of workup for kidney transplantation. Unexpected findings led to more extensive investigations and revealed two rare systemic diseases as causes of his heart failure.

Association of excessive daytime sleepiness with migraine and headache frequency in the general population.

BACKGROUND: Some previous studies have postulated an association between migraine and excessive daytime sleepiness (EDS). This study evaluated the association of EDS with migraine and headache frequency in a general population, after adjusting for potential confounding variables. METHODS: The study was a postal survey of a random age and gender-stratified sample of 40,000 persons aged 20 to 80 years old drawn by the National Population Register in Norway. The questionnaire included questions about migraine, headache, the Epworth sleepiness scale (ESS) and various comorbidities. EDS was defined as ESS > 10. The association of EDS and migraine/headache were analysed by bivariate and multivariable logistic regression analyses. RESULTS: A total of 21,177 persons responded to the ESS and were included in the analyses. The odds ratio (OR) for EDS was increased for migraineurs (1.42 (95% CI 1.31─1.54), p < 0.001) compared to non-migraineurs; however, this finding was not significant after adjustment for a number of possible confounders. EDS increased with increasing headache frequency, with an OR of 2.74 (95% CI 2.05─3.65), p < 0.001) for those with headache on >179 days per year compared to those without headache in multivariable analysis. CONCLUSIONS: In a general population, the odds for EDS increased significantly with the headache frequency, irrespective of migraine status. EDS was not associated with reported migraine in multivariable analysis.

Redetermined crystal structure of α-dl-me-thio-nine at 340†K.

Two forms, α and ß, are known for the racemic amino acid dl-me-thio-nine, C5H11NO2S. The phase transition between them, taking place around 326 K, is associated with sliding at the central inter-faces of the hydro-phobic regions in the crystal, leaving the hydrogen-bonding pattern unperturbed. For the high-temperature α phase, only a structure of rather low quality has been available [R factor = 0.118, no H-atom coordinates; Taniguchi et al. (1980 ▶). Bull. Chem. Soc. Jpn, 53, 803-804]. We here present accurate structural data for this polymorph [R(F) = 0.049], which are compared with other related amino acid structures with similar properties. We report for the first time that the side chain of this phase has a minor disorder component [occupancy 0.0491 (18)] with a gauche+ rather than a gauche- conformation for the N-C-C-C group. In the crystal of the title compound, N-H⋯O hydrogen bonds link the mol-ecules into (100) sheets.

Eltrombopag in Good's Syndrome.

Good's syndrome is a rare acquired immunodeficiency associated with thymoma. Eltrombopag is a thrombopoietin receptor agonist and has been shown to be a valuable supplement to the treatment of several types of refractory cytopenias. In this paper, we describe a male patient suffering from Good's syndrome with immune-mediated T-cell driven pancytopenia and absence of megakaryopoiesis. He was successfully treated with eltrombopag resulting in a multilineage clinical response.

Headache in sleep apnea syndrome: epidemiology and pathophysiology.

This review investigates the relation between obstructive sleep apnea and sleep apnea headache, migraine and tension-type headache. Focus is made on studies from the general population with interviews conducted by a physician and obstructive sleep apnea confirmed by polysomnography. Obstructive sleep apnea syndrome is observed in 3% of the middle-aged population. The prevalence of sleep apnea headache in this population is 12%-18%, while morning headache with similar symptomatology as sleep apnea headache occur in 5%-8% of the general population. People with sleep apnea headache did have significantly more minutes below 90% oxygen saturation (23.1 min vs. 1.9 min, p = 0.002), higher level of average oxygen desaturation (5.9% vs. 4.5%, p < 0.001) and lower average of the lowest oxygen saturation (80.9% vs. 88.5%, p < 0.001) than people with morning headache. A comparison of those with obstructive sleep apnea with or without sleep apnea headache showed no significant differences. Thus, oxygen desaturation alone cannot explain the pathophysiology of sleep apnea headache. Obstructive sleep apnea and migraine, and obstructive sleep apnea and tension-type headache are not related in the general population. The cause of sleep apnea headache remains to be elucidated.

Type D personality is associated with increased prevalence of ventricular arrhythmias in community-residing persons without coronary heart disease.

BACKGROUND: Type D personality may be a risk factor for poor outcome in patients with cardiovascular disease. The biological mechanisms underlying this association are poorly understood. The objective of the study was to test the hypotheses that Type D personality is associated with biological markers for sympathetic dysregulation. DESIGN: Cross-sectional community-based study. METHODS: Type D personality was evaluated by DS-14 in 450 persons (46% men), aged between 30 and 65 years. From a Holter-recording, (mean length 18.3 hours), long-term heart rate, ventricular arrhythmias, and heart rate variability (HRV) were registered as markers of sympathetic dysregulation. Traditional cardiovascular risk factors, apnoea-hypopnoea index, medication, and anxiety symptoms were adjusted for. RESULTS: Type D persons had higher long-term averaged heart rate (74 vs. 71 beats/min, p = 0.003), but this difference was attenuated and not significant in the multivariate model (p = 0.078)). There was an increased prevalence of complex ventricular ectopy (bigeminy, trigeminy, or non-sustained ventricular tachycardia; 14 vs. 6%, p = 0.005 in multivariate model). HRV indices did not differ significantly between those with or without Type D personality. Anxiety symptoms did not confound these associations. CONCLUSIONS: Type D personality is independently associated with a higher likelihood of ventricular arrhythmias, which may be implicated in the increased cardiovascular risk observed in persons with Type D personality.

Novel cardiovascular risk markers in depression: no association between depressive symptoms and osteoprotegerin or adiponectin in persons at high risk for sleep apnea.

BACKGROUND: Inflammation is believed to play a role in the pathogenesis of both cardiovascular disease and depressive disorders. We hypothesized that circulating concentrations of the novel inflammatory and cardiovascular biomarkers osteoprotegerin (OPG) and adiponectin as well as high sensitivity C-reactive protein (hsCRP) are associated with the severity of depressive symptoms and presence of major depressive disorder (MDD). METHODS: In a cross-sectional population-derived study (Akershus Sleep Apnea Project) 520 persons underwent clinical examination and venous blood sampling. Medical history was obtained and the participants completed the Beck Depression Inventory (BDI). Structured clinical interviews for axis-I disorders including MDD were performed in a subgroup of 288 participants. OPG and adiponectin concentrations were determined by in-house time-resolved immunofluorometric assays. RESULTS: Despite significant correlation with hsCRP (r=0.162, p<0.001), the sum-score of BDI did not correlate with OPG or adiponectin levels (r=0.011, p=0.811 and r=0.055, p=0.210, respectively). Neither circulating OPG nor adiponectin differed between persons with (n=34) and without (n=246) MDD (median±interquartile range: 1.18 (0.96-1.49) vs. 1.17 (0.93-1.57) ug/l and 7.26 (5.13-9.91) vs. 7.39 (5.23-11.37) mg/l, respectively). LIMITATIONS: Causal considerations are not possible, and results in the sub-group of diagnosed participants need careful interpretation due to small sample size. CONCLUSIONS: hsCRP was independently associated with depressive symptoms, but no association between depression severity or presence of MDD and OPG- or adiponectin concentrations was observed in community-residing persons at high risk for obstructive sleep apnea.

Sleep apnoea headache in the general population.

BACKGROUND: The objective was to investigate the prevalence and clinical characteristics of sleep apnoea headache. METHODS: A postal questionnaire was received by 40,000 Norwegians from the general population. A total of 376 and 157 persons with high and low risk of sleep apnoea according to the Berlin Questionnaire had a polysomnography, and a clinical interview and examination by physicians. RESULTS: Sleep apnoea headache was diagnosed in 11.8% of the participants with obstructive sleep apnoea (OSA), while morning headache with similar symptomatology was diagnosed in 4.6% of the participants without OSA (p = 0.002). After adjusting for potential confounders the odds ratio for OSA remained significantly increased among participants with morning headache with an adjusted odds ratio of 2.92 (1.31-6.51). When using a cut-off of moderate (apnoea hypopnea index, AHI ≥ 15) and severe (AHI ≥ 30) OSA, the prevalence of sleep apnoea headache was 11.6% and 13.3%, respectively. Average oxygen desaturation and lowest oxygen saturation was not significantly different in participants with OSA with and without morning headache. CONCLUSION: Morning headaches were significantly more frequent among participants with OSA than those without OSA. Sleep apnoea headache is less common in the general population than has previously been reported in clinic populations. The relation of hypoxia and morning headache is questioned.

Prevalence of cardiovascular risk factors and concentration of C-reactive protein in Type D personality persons without cardiovascular disease.

BACKGROUND: Type D personality is associated with poor cardiovascular outcome in patients with coronary or peripheral arterial disease. Whether Type D personality is associated with cardiovascular risk in persons without overt cardiovascular disease remains unknown. We hypothesized that Type D personality is associated with higher prevalence of traditional cardiovascular risk factors and higher concentration of C-reactive protein. DESIGN: Cross-sectional study. METHODS: Type D personality was assessed in 453 participants without cardiovascular disease derived from an epidemiological study of obstructive sleep apnoea. An evaluation of obesity, lipid status, diabetes, blood pressure, heart rate, smoking, leisure-time physical activity and high-sensitivity C-reactive protein was performed. RESULTS: Smoking (43% vs. 21%, P < 0.001) and low leisure-time physical activity (<3 hours/week, 57% vs. 40%, P = 0.003) were more prevalent, and heart rate (mean (standard deviation), 75 (10) vs. 71 (9), P = 0.001) and body mass index was higher (29.8 (6.0) vs. 28.4 (4.5) kg/m2, P = 0.009) in Type D compared to non-Type D participants. The total number of risk factors was significantly higher in Type D than non-Type D participants (3.4 (1.3) vs. 3.0 (1.2), P = 0.004). The concentration of C-reactive protein was higher in participants with Type D personality (median, interquartile range 1.6, 0.7-3.4 vs. 1.1, 0.6-2.6, P = 0.047), although not statistically significant after adjustment for possible mediating factors. CONCLUSIONS: Among participants at high risk of cardiovascular disease, presence of Type D personality was associated with elevated body mass index and unhealthy behaviour such as smoking and low physical activity, which may have mediated the elevated concentration of C-reactive protein.

A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea. The Akershus Sleep Apnea Project (ASAP).

The Berlin Questionnaire (BQ) is a widely used screening tool for obstructive sleep apnea (OSA), but its performance in the general population setting is unknown. The prevalence of OSA in middle-aged adults is not known in Norway. Accordingly, the aims of the current study were to evaluate the utility of the BQ for OSA screening in the general population and to estimate the prevalence of OSA in Norway. The study population consisted of 29,258 subjects (aged 30-65 years, 50% female) who received the BQ by mail. Of these, 16,302 (55.7%) responded. Five-hundred and eighteen subjects were included in the clinical sample and underwent in-hospital polysomnography. Screening properties and prevalence were estimated by a statistical model that adjusted for bias in the sampling procedure. Among the 16,302 respondents, 24.3% (95% confidence interval (CI)=23.6-25.0%) were classified by the BQ to be at high-risk of having OSA. Defining OSA as an apnea-hypopnea index (AHI) ≥5, the positive predictive value of the BQ was estimated to be 61.3%, the negative predictive value 66.2%, the sensitivity 37.2% and the specificity 84.0%. Estimated prevalences of OSA were 16% for AHI≥5 and 8% for AHI≥15. In conclusion, the BQ classified one out of four middle-aged Norwegians to be at high-risk of having OSA, but the screening properties of the BQ were suboptimal. The estimated prevalence of OSA was comparable to previous estimates from general populations in the USA, Australia and Europe.

Tension-type headache and sleep apnea in the general population.

The main objective of this study is to investigate the relationship between tension-type headache and obstructive sleep apnea in the general population. The method involves a cross-sectional population-based study. A random age and gender stratified sample of 40,000 persons aged 20-80 years residing in Akershus, Hedmark or Oppland County, Norway were drawn by the National Population Register. A postal questionnaire containing the Berlin Questionnaire was used to classify respondents to be of either high or low risk of obstructive sleep apnea. Included in this study were 297 persons with high risk and 134 persons with low risk of sleep apnea, aged 30-65 years. They underwent an extensive clinical interview, a physical and a neurological examination by physicians, and in-hospital polysomnography. Those with apnea hypopnoea index (AHI) ≥5 were classified with obstructive sleep apnea. Tension-type headache was diagnosed according to the International Classification of Headache Disorders. Results showed the prevalence of frequent and chronic tension-type headache was 18.7 and 2.1% in the participants with obstructive sleep apnea. The logistic regression analyses showed no significant relationship between tension-type headache and obstructive sleep apnea, with adjusted odds ratios for frequent tension-type headache of 0.95 (0.55-1.62) and chronic tension-type headache of 1.91 (0.37-9.85). The results did not change when using cut-off of moderate (AHI ≥15) and severe (AHI ≥30) obstructive sleep apnea. Thus, we did not find any significant relationship between tension-type headache and the AHI. The presence and severity of sleep apneas seem not to influence presence and attack-frequency of tension-type headache in the general population.

Migraine and sleep apnea in the general population.

Objective is to investigate the relationship between migraine and obstructive sleep apnea in the general population. A cross-sectional population-based study. A random age and gender stratified sample of 40,000 persons aged 20-80 years residing in Akershus, Hedmark or Oppland County, Norway, were drawn by the National Population Register. A postal questionnaire containing the Berlin Questionnaire was used to classify respondents to be of either high or low risk of obstructive sleep apnea. 376 persons with high risk and 157 persons with low risk of sleep apnea aged 30-65 years were included for further investigations. They underwent an extensive clinical interview, a physical and a neurological examination by physicians, and in-hospital polysomnography. Those with apnea hypopnoea index (AHI) ≥5 were classified with obstructive sleep apnea. Migraine without aura (MO) and migraine with aura (MA) was diagnosed according to the International Classification of Headache Disorders. MO and MA occurred in 12.5 and 6.8% of the participants with obstructive sleep apnea. The logistic regression analyses showed no relationship between the two types of migraine and obstructive sleep apnea, with adjusted odds ratios for MO 1.15 (0.65-2.06) and MA 1.15 (0.95-2.39). Further, estimates using cutoff of moderate (AHI ≥ 15) and severe (AHI ≥ 30) obstructive sleep apnea, did not reveal any significant relationship between migraine and the AHI. Migraine and obstructive sleep apnea are unrelated in the general population.

Otitis media history, surgery and allergy in 60-year perspective: a population-based study.

OBJECTIVES: To assess the relationship between recurrent otitis media (OM), OM surgery and allergy in a 60-years perspective in the general population. METHODS: A cross-sectional questionnaire study of 40,000 randomly selected Norwegians aged 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75 and 80 years stratified by age and gender in 2005, i.e. each age group 30-60 years included 2000 and the remaining age groups 1000 persons of each gender. Main outcome measures were recurrent childhood OM, childhood myringotomy, ventilation tubes or adenoidectomy and lifetime allergy. RESULTS: The prevalence of recurrent OM was 24.3% (n=4823) and OM surgery 12.4% (n=2499). An increase in the proportion of OM surgery by age cohort was found, with the highest surgery rate of 0.52 for the 1955 age cohort, followed by a gradual decrease until the 1980 age cohort, when surgery stabilized at 0.42. Recurrent OM and OM surgery was more common in respondents with allergy. Among the latter, the probability for OM surgery was almost threefold when the age cohort 1945 was compared to 1920, OR(adj) at 2.95 (1.59-5.48). The latter tendency remained strong until 1965. Among non-allergics, the increase in surgery probability by age cohort showed the same tendency, but the relationship was less strong than for those with allergy. CONCLUSIONS: Despite a twofold increase in recurrent OM and OM surgery from 1925 to 1945, the proportion of OM and OM surgery have been stable since 1945. Our findings suggest a shift in clinical practice, most likely indicating a change in surgery from acute infections to otitis media with effusion (OME).

A cross-sectional population-based survey of migraine and headache in 21,177 Norwegians: the Akershus sleep apnea project.

The objective was to investigate the prevalence and interrelation of migraine and headache in the general population. Forty thousand men and women aged 20-80 years from the Norwegian general population received a mailed questionnaire with questions about migraine and headache. The questionnaire response rate was 54.5%. The lifetime prevalence of migraine was 26.5% (95% CI 25.9-27.1%), i.e., 18.1% (95% CI 17.3-18.9%) in men and 34.1% (95% CI 33.2-35.0%) in women. The prevalence of migraine decreased slightly in both men and women after an age of 45. The 1 year prevalence of headache was 77.2%, i.e., 69.6% (95% CI 68.7-70.6%) in men and 84.0% (95% CI 83.3-84.7%) in women. The frequency of headache decreased with age, but some of the elders aged 70 or above experienced more frequent headache. The prevalence of being headache free increased from 19.1% (95% CI 14.2-25.6%) to 74.7% (95% CI 70.0-78.8%) in 20 and 80 years old men without co-occurrence of migraine, and from 5.1% (95% CI 2.9-8.8%) to 61.4% (95% CI 54.9-67.6%) in 20 and 80 years old women without co-occurrence of migraine. Co-occurrence of migraine significantly increased the frequency of headache and decreased the prevalence of being headache free.

[Profylactiv cholesystectomy after bile duct stones?]. / Profylaktisk kolecystektomi etter gallegangsstein?

BACKGROUND: Endoscopic sphincterotomy (EPT) is well established as a treatment of bile duct stones, often performed to reduce the frequency of complications. We wanted to evaluate the complication rates after preventive cholecystectomy compared with expectative follow up. MATERIAL AND METHODS: In this retrospective study we have registered the outcome for 63 patients treated with cholecystectomy and 298 patients followed up expectatively. Allocation to the groups was based on clinical evaluation without randomization, hence the groups are not similar, a fact which should be taken into consideration when results are evaluated. For both groups we have registered events due to biliary complications. RESULTS: The patients submitted to cholecystectomy were somewhat younger with higher comorbidity than the non-operated patients. In the expectative group, 27% had one or more late complications as opposed to 6.3% in the cholecystectomy group. There was no relative difference in mortality. INTERPRETATION: The study confirms that prophylactic cholecystectomy may actually contribute to a lower complication rate and is an option for treatment in low-risk patients. Prophylactic cholecystectomy cannot, however, be recommended as a routine procedure. The study is based on clinically selected patient groups and results must be interpreted with care.