How to play the game of medical education: Sociocultural analyses of educational difficulties among medical residents

This article was migrated. The article was marked as recommended. Medical residents in difficulty struggle to comply with educational requirements. They pose a liability to patient safety and they have problems to adapt to the professional role of a doctor. Consequently, being a resident in difficulty may cause identity crisis and have the potential to disrupt the resident's professional identity as a doctor. Only few studies explore the tipping point between becoming a resident in difficulty or not, and these studies rarely reflect the surrounding sociocultural aspects of the residents' difficulties such as organisational culture in the workplace. This article explores how medical residency training culture influence on residents' risk of ending in difficulty. Our study was based on six focus-group interviews with residents (n=28) and in-depth interviews with residents in difficulty (n=10). The interpretation of data employed sociologist Pierre Bourdieu's theoretical framework around dispositions. Across the data, we identified four themes: Conflicting games in the field of medical education, altruism, organisational hierarchy, and coping with stress. We found a (mis)match between legitimate rules in the field of medicine and the residents' dispositions to appreciate those rules. These results can inform clinical supervisors and consultants in their decisions for supporting residents in difficulty and increasing educational achievement among struggling residents.

Early Assessment of Cost-effectiveness of Gastric Electrical Stimulation for Diabetic Nausea and Vomiting

Background/Aims

Recurrent nausea and/or vomiting are common complications of diabetes mellitus. The conditions severely impact the quality of life of patients and often cause repeated admissions to hospital incurring significant healthcare costs. If standard treatment fails, gastric electrical stimulation (GES) may be offered in selected cases, as a minimally invasive, but expensive, therapeutic option. Our aims are to evaluate the clinical effect and the cost-utility of GES as a treatment for severe diabetic recurrent nausea and/or vomiting.

Methods

Among 33 diabetes patients implanted with GES because of recurrent nausea and/or vomiting, 30 were available for evaluation. The effect of treatment was assessed prospectively using symptom-diaries and the SF-36 questionnaires at baseline, after 6 and 12 months, and thereafter yearly. The number of days in hospital due to symptoms related to gastrointestinal dysfunction was calculated using hospital records 12 months prior to and 12 months after implantation.

Results

The surgical procedures were performed without mortality or major complications. Six months after surgery 78% of the respondents had at least 50% reduction in time with nausea and 48% had at least 50% reduction in days with vomiting. Symptom relief persisted at follow-up after at least 4 years. Quality adjusted life years improved after GES, which was cost-effective after 24 months.

Conclusions

GES reduces symptoms and improves quality of life in diabetes patients with recurrent nausea and/or vomiting. The procedure is supposed as cost-effective over a 2-year time horizon.

Residents in difficulty: a mixed methods study on the prevalence, characteristics, and sociocultural challenges from the perspective of residency program directors

BACKGROUND

The majority of studies on prevalence and characteristics of residents in difficulty have been conducted in English-speaking countries and the existing literature may not reflect the prevalence and characteristics of residents in difficulty in other parts of the world such as the Scandinavian countries, where healthcare systems are slightly different. The aim of this study was to examine prevalence and characteristics of residents in difficulty in one out of three postgraduate medical training regions in Denmark, and to produce both a quantifiable overview and in-depth understanding of the topic.

METHODS

We performed a mixed methods study. All regional residency program directors (N = 157) were invited to participate in an e-survey about residents in difficulty. Survey data were combined with database data on demographical characteristics of the background population (N = 2399) of residents, and analyzed statistically (Chi-squared test (Χ (2)) or Fisher's exact test). Secondly, we performed a qualitative interview study involving three focus group interviews with residency program directors. The analysis of the interview data employed qualitative content analysis.

RESULTS

73.2 % of the residency program directors completed the e-survey and 22 participated in the focus group interviews. The prevalence of residents in difficulty was 6.8 %. We found no statistically significant differences in the prevalence of residents in difficulty by gender and type of specialty. The results also showed two important themes related to the workplace culture of the resident in difficulty: 1) belated and inconsistent feedback on the resident's inadequate performance, and 2) the perceived culturally rooted priority of efficient patient care before education in the workplace. These two themes were emphasized by the program directors as the primary underlying causes of the residents' difficulty.

CONCLUSIONS

More work is needed in order to clarify the link between, on the one hand, observable markers of residents in difficulty and, on the other hand, immanent processes and logics of practice in a healthcare system. From our perspective, further sociological and pedagogical investigations in educational cultures across settings and specialties could inform our understanding of and knowledge about pitfalls in residents' and doctors' socialization into the healthcare system.

Restorative proctocolectomy for ulcerative colitis: development and validation of a new scoring system for pouch dysfunction and quality of life

AIM

The purpose of this study was to develop and validate a pouch dysfunction score that could identify the aspects of function which have the greatest impact on quality of life as perceived by the patient.

METHOD

All (n = 1757) patients having restorative proctocolectomy in Denmark between 1980 and 2010 were identified. Of these, 1229 were available for study and were sent a questionnaire on bowel function and quality of life (QoL) designed specifically for this study. Function was correlated with QoL in a multivariate model using ordinal logistic regression with QoL as a dependent variable. The pouch dysfunction score was developed from a randomly selected half of the study population and the validity was tested on the other half.

RESULTS

1047 (85%) patients returned the questionnaire. On multivariate analysis, the symptom domains of 'incomplete emptying', 'severity of urgency', 'number of bowel movements/24 h', 'major incontinence' and 'use of anti-diarrhoeal medication' were associated with reduced QoL. The score was divided into three categories including 'none', 'minor' and 'some/major' pouch dysfunction. The corresponding coefficients gave the score a range from 0 to 7.5. There was a highly significant difference (P < 0.001) in score between the categories. The area under the receiver operating curve was 0.81.

CONCLUSION

Urgency, incomplete emptying, number of bowel movements/24 h, major incontinence and use of anti-diarrhoeal medication have a major impact on QoL. There was a high accuracy for the score, demonstrating its potential clinical usefulness in relating symptoms to QoL.

Liraglutide suppresses postprandial triglyceride and apolipoprotein B48 elevations after a fat-rich meal in patients with type 2 diabetes: a randomized, double-blind, placebo-controlled, cross-over trial

AIMS

Postprandial triglyceridaemia is a risk factor for cardiovascular disease (CVD). This study investigated the effects of steady-state liraglutide 1.8 mg versus placebo on postprandial plasma lipid concentrations after 3 weeks of treatment in patients with type 2 diabetes mellitus (T2DM).

METHODS

In a cross-over trial, patients with T2DM (n = 20, 18-75 years, BMI 18.5-40 kg/m²) were randomized to once-daily subcutaneous liraglutide (weekly dose escalation from 0.6 to 1.8 mg) and placebo. After each 3-week period, a standardized fat-rich meal was provided, and the effects of liraglutide on triglyceride (primary endpoint AUC(0-8h)), apolipoprotein B48, non-esterified fatty acids, glycaemic responses and gastric emptying were assessed. ClinicalTrials.gov ID: NCT00993304.

FUNDING

Novo Nordisk A/S.

RESULTS

After 3 weeks, mean postprandial triglyceride (AUC(0-8h) liraglutide/placebo treatment-ratio 0.72, 95% CI [0.62-0.83], p = 0.0004) and apolipoprotein B48 (AUC(0-8h) ratio 0.65 [0.58-0.73], p < 0.0001) significantly decreased with liraglutide 1.8 mg versus placebo, as did iAUC(0-8h) and C(max) (p < 0.001). No significant treatment differences were observed for non-esterified fatty acids. Mean postprandial glucose and glucagon AUC(0-8h) and C(max) were significantly reduced with liraglutide versus placebo. Postprandial gastric emptying rate [assessed by paracetamol absorption (liquid phase) and the ¹³C-octanoate breath test (solid phase)] displayed no treatment differences. Mean low-density lipoprotein and total cholesterol decreased significantly with liraglutide versus placebo.

CONCLUSIONS

Liraglutide treatment in patients with T2DM significantly reduced postprandial excursions of triglyceride and apolipoprotein B48 after a fat-rich meal, independently of gastric emptying. Results indicate liraglutide's potential to reduce CVD risk via improvement of postprandial lipaemia.

Effects of an isocaloric healthy Nordic diet on insulin sensitivity, lipid profile and inflammation markers in metabolic syndrome -- a randomized study (SYSDIET)

BACKGROUND

Different healthy food patterns may modify cardiometabolic risk. We investigated the effects of an isocaloric healthy Nordic diet on insulin sensitivity, lipid profile, blood pressure and inflammatory markers in people with metabolic syndrome.

METHODS

We conducted a randomized dietary study lasting for 18-24 weeks in individuals with features of metabolic syndrome (mean age 55 years, BMI 31.6 kg m(-2) , 67% women). Altogether 309 individuals were screened, 200 started the intervention after 4-week run-in period, and 96 (proportion of dropouts 7.9%) and 70 individuals (dropouts 27%) completed the study, in the Healthy diet and Control diet groups, respectively. Healthy diet included whole-grain products, berries, fruits and vegetables, rapeseed oil, three fish meals per week and low-fat dairy products. An average Nordic diet served as a Control diet. Compliance was monitored by repeated 4-day food diaries and fatty acid composition of serum phospholipids.

RESULTS

Body weight remained stable, and no significant changes were observed in insulin sensitivity or blood pressure. Significant changes between the groups were found in non-HDL cholesterol (-0.18, mmol L(-1) 95% CI -0.35; -0.01, P = 0.04), LDL to HDL cholesterol (-0.15, -0.28; -0.00, P = 0.046) and apolipoprotein B to apolipoprotein A1 ratios (-0.04, -0.07; -0.00, P = 0.025) favouring the Healthy diet. IL-1 Ra increased during the Control diet (difference -84, -133; -37 ng L(-1) , P = 0.00053). Intakes of saturated fats (E%, beta estimate 4.28, 0.02; 8.53, P = 0.049) and magnesium (mg, -0.23, -0.41; -0.05, P = 0.012) were associated with IL-1 Ra.

CONCLUSIONS

Healthy Nordic diet improved lipid profile and had a beneficial effect on low-grade inflammation.

PET hypoxia imaging with FAZA: reproducibility at baseline and during fractionated radiotherapy in tumour-bearing mice

PURPOSE

Tumour hypoxia is linked to treatment resistance. Positron emission tomography (PET) using hypoxia tracers such as fluoroazomycin arabinoside (FAZA) may allow identification of patients with hypoxic tumours and the monitoring of the efficacy of hypoxia-targeting treatment. Since hypoxia PET is characterized by poor image contrast, and tumour hypoxia undergoes spontaneous changes and is affected by therapy, it remains unclear to what extent PET scans are reproducible. Tumour-bearing mice are valuable in the validation of hypoxia PET, but identification of a reliable reference tissue value (blood sample or image-derived muscle value) for repeated scans may be difficult due to the small size of the animal or absence of anatomical information (pure PET). Here tumour hypoxia was monitored over time using repeated PET scans in individual tumour-bearing mice before and during fractionated radiotherapy.

METHODS

Mice bearing human SiHa cervix tumour xenografts underwent a PET scan 3 h following injection of FAZA on two consecutive days before initiation of treatment (baseline) and again following irradiation with four and ten fractions of 2.5 Gy. On the last scan day, mice were given an intraperitoneal injection of pimonidazole (hypoxia marker), tumours were collected and the intratumoral distribution of FAZA (autoradiography) and hypoxia (pimonidazole immunohistology) were determined in cryosections.

RESULTS

Tissue section analysis revealed that the intratumoral distribution of FAZA was strongly correlated with the regional density of hypoxic (pimonidazole-positive) cells, even when necrosis was present, suggesting that FAZA PET provides a reliable measure of tumour hypoxia at the time of the scan. PET-based quantification of tumour tracer uptake relative to injected dose showed excellent reproducibility at baseline, whereas normalization using an image-derived nonhypoxic reference tissue (muscle) proved highly unreliable since a valid and reliable reference value could not be determined. The intratumoral distribution of tracer was stable at baseline as shown by a voxel-by-voxel comparison of the two scans (R = 0.82, range 0.72-0.90). During treatment, overall tracer retention changed in individual mice, but there was no evidence of general reoxygenation.

CONCLUSION

Hypoxia PET scans are quantitatively correct and highly reproducible in tumour-bearing mice. Preclinical hypoxia PET is therefore a valuable and reliable tool for the development of strategies that target or modify hypoxia.

R-CHOEP-14 improves overall survival in young high-risk patients with diffuse large B-cell lymphoma compared with R-CHOP-14. A population-based investigation from the Danish Lymphoma Group

BACKGROUND

Optimal treatment of young patients with high-risk diffuse large B-cell lymphoma (DLBCL) remains a matter of debate and requires improvement. The combination chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) with addition of etoposide (CHOEP) has in other patient groups been shown to be effective. Further improvement has been accomplished with the use of rituximab in combination with the regimens every 2 weeks (R-CHOP-14, R-CHOEP-14). The aim of the present retrospective population-based study was to compare R-CHOP-14 with R-CHOEP-14 in a cohort of high-risk patients aged 18-60 years with two or more risk factors (stage III-IV, elevated lactate dehydrogenase levels, performance status 2-4). To our knowledge, this is the first study comparing these two regimens in this patient group.

METHODS

We obtained data for the period 2004-2009 from the Danish Lymphoma Database. One hundred and fifty-nine patients were eligible to enter the study. Primary end point was overall survival (OS) and secondary end points were response to treatment, progression-free survival (PFS) and safety.

RESULTS

Four-year OS was superior in the R-CHOEP-14 group: 75% compared with 62% for R-CHOP-14 (P=0.04). This superiority was also seen for PFS: 4-year PFS was 70% for the R-CHOEP-14 group compared with 58% for the R-CHOP-14 group (P=0.02).

CONCLUSION

R-CHOEP-14 is a promising regimen for young patients with high-risk DLBCL with improved OS and PFS compared with R-CHOP-14.

Atrial fibrillation and upper limb thromboembolectomy: a national cohort study

BACKGROUND

The risk factors associated with, and the incidence of systemic embolism in patients with atrial fibrillation (AF) are poorly understood.

OBJECTIVES

We studied the association between AF and upper limb thromboembolectomy involving brachial, ulnar or radial artery in a national cohort study that included all individuals aged 40-99 years with incident AF.

METHODS

Data were retrieved from the Danish National Vascular Registry, the National Registry of Patients, the Danish Civil Registration System and Statistics Denmark.

RESULTS

In total, 131,476 patients (68,042 men and 63,434 women) with AF without previous thromboembolectomy in the upper limb were registered. In the study cohort, 130 men underwent upper limb thromboembolectomy over 220,890 person-years of observation, whilst 275 women underwent thromboembolectomy over 197,777 patient-years. The incidence per 100,000 person-years was 58.9 (95% CI, 49.2-69.8) for men and 139.1 (95% CI, 123.1-156.5) for women. The relative risk of thromboembolectomy among patients with AF compared to the background population was 7.5 (95% CI, 6.3-8.9) for men, and 9.3 (95% CI, 8.3-10.5) for women. Women with AF had a relative thromboembolectomy risk of 1.8 (95% CI, 1.5-2.3) compared to men with AF. Among patients with AF, history of hypertension (HR 2.2-2.9), myocardial infarction (HR 2.9-3.9), heart failure (HR 1.6-1.9) and stroke (HR 2.2-3.8) were significantly associated with increased risk of thromboembolectomy in both men and women.

CONCLUSIONS

AF substantially increases the risk of upper limb thromboembolectomy. This risk is higher with increasing age, female gender, and associated with hypertension, myocardial infarction, heart failure and stroke.

Effects of different protein sources on plasminogen inhibitor-1 and factor VII coagulant activity added to a fat-rich meal in type 2 diabetes

BACKGROUND

Exaggerated postprandial triglyceride concentration is believed to be atherogenic, and to influence the risk of thrombosis. Both elevated plasminogen inhibitor 1 (PAI-1) and increased factor VII coagulant activity (FVIIc) are potential important contributors to the increased risk of cardiovascular disease in type 2 diabetes.

AIM

We aimed to investigate the effect of adding four different protein types (i.e. casein, whey, cod, and gluten) to a fat-rich meal on postprandial responses of PAI-1 and FVIIc in type 2 diabetic patients.

METHODS

Twelve type 2 diabetic patients ingested four isocaloric test meals in random order. The test meals contained 100 g of butter and 45 g of carbohydrate in combination with 45 g of casein (Cas-meal), whey (Whe-meal), cod (Cod-meal), or gluten (Glu-meal), respectively. Plasma concentrations of PAI-1 and FVIIc were measured before meal, and at regular intervals for 8-h postprandially.

RESULTS

The postprandial PAI-1 concentration decreased significantly by 49% to 56% in response to the four test meals. There were no significant differences between the outcomes from the four test-meals. The FVIIc levels decreased by 8% to 11% after the meals. Again, we observed no significant differences in outcomes between the four protein-enriched meals.

CONCLUSIONS

The four proteins casein, whey, cod, and gluten, added to a fat-rich meal, all decreased the PAI-1 and FVIIc concentrations postprandially in type 2 diabetic subjects. However, postprandial levels of PAI-1 and FVIIc were not acutely influenced by the protein source.

Educational climate seems unrelated to leadership skills of clinical consultants responsible of postgraduate medical education in clinical departments

BACKGROUND

The educational climate is crucial in postgraduate medical education. Although leaders are in the position to influence the educational climate, the relationship between leadership skills and educational climate is unknown. This study investigates the relationship between the educational climate in clinical departments and the leadership skills of clinical consultants responsible for education.

METHODS

The study was a trans-sectional correlation study. The educational climate was investigated by a survey among all doctors (specialists and trainees) in the departments. Leadership skills of the consultants responsible for education were measured by multi-source feedback scores from heads of departments, peer consultants, and trainees.

RESULTS

Doctors from 42 clinical departments representing 21 specialties participated. The response rate of the educational climate investigation was moderate 52% (420/811), Response rate was high in the multisource-feedback process 84.3% (420/498). The educational climate was scored quite high mean 3.9 (SD 0.3) on a five-point Likert scale. Likewise the leadership skills of the clinical consultants responsible for education were considered good, mean 5.4 (SD 0.6) on a seven-point Likert scale. There was no significant correlation between the scores concerning the educational climate and the scores on leadership skills, r = 0.17 (p = 0.29).

CONCLUSIONS

This study found no relation between the educational climate and the leadership skills of the clinical consultants responsible for postgraduate medical education in clinical departments with the instruments used. Our results indicate that consultants responsible for education are in a weak position to influence the educational climate in the clinical department. Further studies are needed to explore, how heads of departments and other factors related to the clinical organisation could influence the educational climate.

Upper-limb thrombo-embolectomy: national cohort study in Denmark

OBJECTIVES

We investigated the incidence of thrombo-embolectomy in upper-limb and prognosis with respect to arm amputation, stroke and death.

METHODS

We performed a national cohort study of individuals, aged 40-99 years, and undergoing first-time thrombo-embolectomy in the brachial, ulnar or radial artery in Denmark from 1990 to 2002. The data were retrieved from the National Vascular Registry and from the National Registry of Patients and the Civil Registration System. Patients were followed until 2006 to ascertain the occurrence of amputation and stroke and until 2007 with respect to death.

RESULTS

In total, 1377 incident cases of thrombo-embolectomy were registered, comprising 504 (36.6%) males with a mean age of 72.0 (standard deviation (SD) 12.4) years and 873 (63.4%) females with a mean age of 77.2 (SD 11.7) years. Incidence was 3.3 (95% confidence interval (CI): 3.1-3.7) for males and 5.2 (95% CI: 4.9-5.6) for females per 100000 person-years. After thrombo-embolectomy, upper-limb amputation was performed in 11 (incidence 2.2%; 95% CI: 1.2-3.4) males and 31 (3.6%; 95% CI: 2.5-4.9) females. Age- and sex-specific risk of stroke was 2-16 times higher, and risk of death 3-11 times higher, than in the general population.

CONCLUSIONS

Upper-limb thrombo-embolectomy is associated with an increased risk of limb amputation, stroke and death.

Differential effects of protein quality on postprandial lipemia in response to a fat-rich meal in type 2 diabetes: comparison of whey, casein, gluten, and cod protein

BACKGROUND

Enhanced and prolonged postprandial triglyceride responses involve increased cardiovascular disease risk in type 2 diabetes. Dietary fat and carbohydrates profoundly influence postprandial hypertriglyceridemia, whereas little information exists on the effect of proteins.

OBJECTIVE

The objective was to compare the effects of the proteins casein, whey, cod, and gluten on postprandial lipid and incretin responses to a high-fat meal in persons with type 2 diabetes.

DESIGN

A crossover study was conducted in 12 patients with type 2 diabetes. Blood samples were collected over 8 h after ingestion of a test meal containing 100 g butter and 45 g carbohydrate in combination with 45 g casein (Cas-meal), whey (Whe-meal), cod (Cod-meal), or gluten (Glu-meal). We measured plasma concentrations of triglycerides, retinyl palmitate (RP), free fatty acids, insulin, glucose, glucagon, glucagon-like peptide 1, and glucose-dependent insulinotropic peptide.

RESULTS

The incremental area under the curve for triglyceride was significantly lower after the Whe-meal than after the other meals. The RP response was lower after the Whe-meal than after the Cas-meal and Cod-meal in the chylomicron-rich fraction and higher after the Whe-meal than after Cod- and Glu-meals in the chylomicron-poor fraction. Free fatty acids were most pronouncedly suppressed after the Whe-meal. The glucose response was lower after the Whe-meal than after the other meals, whereas no significant differences were found in insulin, glucagon, glucagon-like peptide 1, and glucose-dependent insulinotropic peptide responses.

CONCLUSION

The data suggest that as a supplement to a fat-rich meal in patients with type 2 diabetes, whey protein seems to outperform other proteins in terms of postprandial lipemia improvement, possibly because of the formation of fewer chylomicrons or increased clearance of chylomicrons. The trial was registered at ClinicalTrials.gov as NCT00817973.

Can the Glycemic Index (GI) be used as a tool in the prevention and management of Type 2 diabetes?

The large increase in type 2 diabetes (T2DM), the considerable lifetime risk of diabetes and the loss of lifetime call for concerted action to prevent T2DM and its complications. Since diabetes is characterized by abnormal glucose metabolism, the question arises of whether a high intake of carbohydrates that are rapidly absorbed as glucose may increase the risk and worsen the course of T2DM. To quantify the impact of carbohydrates on blood glucose the glycemic index (GI) and the glycemic load (GL) have been applied. The GI of a food is a method of ranking carbohydrate rich foods according to their glycemic responses. GI is defined as the incremental area under the blood glucose curve of 50g carbohydrate of a test food expressed as a percentage of the area of the response to an equivalent amount of a reference food (glucose or white bread). In relation to GI/GL and prevention of T2DM there is insufficient information from observational studies to determine whether a positive association exists or not. Only randomized controlled clinical intervention studies will be able to provide the final answer. From meta-analyses of randomised controlled clinical trials comparing low and high GI diets in the treatment of diabetes it has been found that low GI diets improve the glycemic control. Labeling of foods with GI would be helpful for persons with diabetes, but the usefulness for healthy subjects remains to be clarified. At present it seems premature to introduce GI labeling for the entire population.

Long-Term Parathyroid- and c-Cell Function after Radioiodine for Benign Thyroid Diseases

The study examined static and dynamic parathyroid hormone and calcitonin secretion after radioiodine, and was a retrospective study of patients having received radioiodine for benign conditions 8-12 years earlier. In one group of patients parathyroid hormone and calcium were measured as single blood tests, in a second group of patients parathyroid hormone and calcitonin secretion capacity were measured during a hypocalcaemic citrate-clamp and a hypercalcaemic stimulation test. Baseline calcium and parathyroid hormone were normal within expected ranges 8-12 years after radioiodine. Stimulated parathyroid hormone or calcitonin secretion did not differ from an age- and gender-matched control group. Radioiodine in doses used for benign thyroid diseases appears safe with regard to parathyroid hormone and calcitonin secretion.

Recovery of autonomic nervous activity after myocardial infarction demonstrated by short-term measurements of SDNN

OBJECTIVE

Heart rate variability (HRV) has been demonstrated to be a risk factor after acute myocardial infarction (AMI). In the present study serial measurement of SDNN (standard deviation of the mean of qualified NN-interval) in short intervals was used to assess HRV changes after AMI, and determine the role of these as independent risk factors compared to clinical, arrhythmic, ischemic and anamnestic variables. Measurements from a normal healthy middle-aged male population were used as reference (n = 63).

METHODS

SDNN from a five-minute period during day and night-time, respectively, was examined in 103 patients 1 week (n = 54), 1 month (n = 72) and 12-16 months (n = 54) after infarction.

RESULTS

Day SDNN did not change during one-and-a-half years after AMI, and was significantly reduced compared with healthy males. Night SDNN, low after 1 week, with recovery 1 month after AMI, was significantly reduced compared with healthy males early, but not late after AMI. Thus, the study indicated during day-time a continuous abnormal sympathetic preponderance in the course of 16 months after AMI, and during night-time a gradual recovery of parasympathetic preponderance beginning early after AMI.

CONCLUSION

One week after AMI day-time SDNN of <30 ms, and night-time SDNN of < 18 ms, age > or =60 years, and myocardial ischemia (Holter monitoring) were independent predictors of 9 years' mortality. One and 12-16 months after AMI reduced day and night-time SDNN had no prognostic implication.

[Prognosis after late versus early nonfatal myocardial infarction]

Many recent studies have identified nonfatal recurrent myocardial infarction (RNMI) as the most significant predictor for later outcome. Almost all of these studies have been based on the studies of RNMI in the first year after the index infarction. The prognosis after late RNMI has not been studied properly. In 3,867 nonselected patients below 76 years of age with an acute myocardial infarction we studied the prognosis after a first RNMI depending on the year of its occurrence after the index infarction. Mortality was estimated by the method of Kaplan-Meier and the differences were evaluated by means of the Tarone-Ware test. Four hundred and ninety-three (13.6%) patients had a first RNMI in the first, 151 (5.4%) in the second, 105 (4.2%) in the third, and 71 (3.8%) in the fourth year after the index infarction (group 1-4). One-year mortality rate after RNMI was 23.7% in the first group, 24.1% in the second, 17.5% in the third, and 22.8 in the fourth group. When all the groups were compared with each other no significant difference was found between the mortality rates (p = 0.12) or Standardised Mortality Rates. We concluded that late and early RNMIs have almost the same grave prognosis.

[Effect of specific physiotherapy on chronic pain, functional level and quality of life in osteoporosis. A prospective randomized single-blind placebo-controlled study]

Patients suffering from osteoporotic vertebral fractures are handicapped by pain and reduced quality of life. Our aim was to investigate the effect of a short training program for osteoporotic patients with regard to pain level, use of analgetics and quality of life. We performed a prospective randomized single-blinded placebo-controlled study. The training program included general training of balance and muscle strength and stabilization of the back. The participants were randomised to 10 weeks of ambulatory training. Controls and training participants were tested weekly by registration of pain level and analgetic intake. Questionnaires on daily level of function and quality of life were given at the start and after five and 10 weeks. After three months both groups filled out the questionnaires at home. The training group had a significant reduction in pain score and use of analgetics. The distribution of functional score improved during training. Quality of life score improved significantly throughout the study and after three months. In conclusion, this ambulatory training program is effective for training osteoporotic patients with moderately severe pain and the training should be continued.

Clinical significance of cyclin-dependent kinase inhibitor p27Kip1 expression and proliferation in non-Hodgkin's lymphoma: independent prognostic value of p27Kip1

The cyclin-dependent kinase inhibitor p27Kip1 is a negative cell cycle regulator linking extracellular growth-regulatory signals to the cell cycle machinery in G1. We investigated the pattern and prognostic value of p27Kip1 expression in a population-based group of 203 non-Hodgkin's lymphoma (NHL) patients. The expression of p27Kip1 was identified by immunohistochemistry and correlated with Ki-67 expression and clinical features. Correlation with outcome was determined using uni- and multivariate analysis stratified by clinical grade. Except for very aggressive NHL, there was a negative correlation between p27Kip1 and Ki-67 expression. Low expression of p27Kip1, defined as nuclear p27Kip1 expression in <40% of malignant cells, was predictive of poor survival in indolent and aggressive NHL. However, even in this regard, very aggressive lymphomas behaved differently as those with low p27Kip1 expression tended to do better. Likewise, a high proliferation rate (Ki-67 >40%) was associated with poor survival in indolent and aggressive lymphomas. Multivariate analysis using the proportional hazards model showed that only p27Kip1, and not Ki-67, maintained independent prognostic significance in indolent and aggressive lymphomas (relative risk = 2. 0; P = 0.0095). The low cost and simplicity of this standard immunohistochemistry analysis makes p27Kip1 a promising and suitable prognostic marker in routine diagnostic laboratories in a standard diagnostic panel.

Disrupted p53 function as predictor of treatment failure and poor prognosis in B- and T-cell non-Hodgkin's lymphoma

Mutation of the p53 gene has been associated with treatment failure and poor outcome in various malignancies. It has been suggested that immunohistochemical analysis of p53 and p21Waf1, a downstream target, can be used to screen for p53 gene mutations. We determined the value of immunohistochemical screening for p53 gene mutations as a prognostic marker in a population-based group of B- and T-cell non-Hodgkin's lymphomas (NHLs). On the basis of p53 gene mutation status and immunohistochemically detected p53 and p21Waf1 expression in 34 lymphomas, we established an immunophenotype (delta p53) correlating with p53 gene mutation. The immunohistochemical analysis was extended to encompass 199 lymphomas from a population-based registry and was correlated with clinical parameters. Delta p53 showed 100% concordance with p53 gene mutation and was detected in 42 cases (21%). Multivariate analysis of advanced stage lymphomas showed that delta p53 was independently associated with treatment failure (relative risk, 3.8; P = 0.001). Delta p53 predicted poor survival when analyzing all patients (P = 0.0001), as well as B-cell (P = 0.04) and T-cell NHL (P = 0.000002). In multivariate analysis, delta p53 (relative risk, 2.2; P = 0.001) maintained prognostic significance. The impact on prognosis of delta p53 was highly significant in the low-intermediate-risk group (P = 0.00002). Comparing survival of the aggressive lymphoma patients in this group showed that the 8 delta p53 patients died within 1 year, whereas the median survival of the 28 non-delta p53 patients was 36 months. These results suggest that immunohistochemically assessed p53 status may predict treatment response and outcome in B- and T-cell NHL patients.

Nonsteroidal anti-inflammatory drugs after acute myocardial infarction. DAVIT Study Group. Danish Verapamil Infarction Trial

The effect of nonsteroid anti-inflammatory drugs (NSAIDs) after acute myocardial infarction was studied in a retrospective study of 88 patients who were receiving regular NSAID treatment at randomization in the Danish Verapamil Infarction Trial II. There were no significant differences in mortality or major events between NSAID-treated patients versus controls (1,687); however, in a multivariate analysis a nonsignificant beneficial trend in favor of NSAIDs was observed.

Temporal pattern of the effect of verapamil on myocardial reinfarction. DAVIT Study Group. Danish Verapamil Infarction Trial

The purpose of this study was to compare the effects of verapamil on early versus late reinfarction after an index myocardial infarction. A total of 1775 consecutive patients < 76 years of age, with acute myocardial infarction, included in the Danish Verapamil Infarction Trial II, were followed for 18 months. Reinfarctions during the observation period were retrospectively divided into the 50% earliest occurring and the 50% latest occurring (early and late reinfarction, respectively). Cox regression analysis was applied to assess the significance of clinical baseline variables and treatment group (verapamil vs. placebo) on early, late, and total reinfarction. One hundred and ninety-one reinfarctions were registered during the 18-month observation: 96 in the first 5 months (early) and 95 in the last 13 months (late). On univariate analysis verapamil significantly reduced the rate of total reinfarction (P = 0.04, hazard ratio [HR] = 0.77; 95% confidence Interval [CI] 0.58-1.03) and early reinfarction (P = 0.007, HR 0.56; 95% CI 0.37-0.86), but not late reinfarction (P = 0.99, HR = 1.05; 95% CI 0.70-1.56). In a multivariate model, only the rate of early reinfarction was reduced by verapamil (P = 0.012, HR = 0.59, 95% CI 0.39-0.90). Additionally, predictors of early and late reinfarction were quite different in this model. After an index myocardial infarction verapamil reduces the rate of early but not late reinfarction.

Comparison of the prognosis after early versus late recurrent nonfatal myocardial infarction. DAVIT Study Group. Danish Verapamil Infarction Trial

BACKGROUND

Recurrent nonfatal myocardial infarction (RNMI) is the most significant risk factor for later outcome after an index infarction. However, little is known about the prognosis after RNMIs that occur beyond the first year after the index infarction.

METHODS AND RESULTS

In 3867 nonselected patients <76 years old with an acute myocardial infarction, we studied the rate of and prognosis after a first RNMI, depending on the year of its occurrence after the index infarction. Mortality rate was estimated by the method of Kaplan-Meier, and the differences were evaluated by means of the Tarone-Ware test. Four hundred ninety-three (13.6%) patients had a first RNMI in the first, 151 (5.4%) in the second, 105 (4.2%) in the third, and 71 (3.8%) in the fourth year after the index infarction (groups 1 through 4). One-year mortality rate after RNMI was 23.7% in the first group, 24.1% in the second group, 17.5% in the third group, and 22.8 in the fourth group. When all the groups were compared with each other, no significant difference was found between the mortality rates (p = 0.12) or standardized mortality rates.

CONCLUSIONS

Late RNMIs have almost the same grave prognosis as do early RNMIs.

5993 survivors of suspected myocardial infarction. 10 year incidence of later myocardial infarction and subsequent mortality

AIMS

To evaluate the 10-year incidence of later infarction and subsequent mortality, as well as predictors of later infarction, in patients with suspected myocardial infarction and alive on day 15 after admission.

METHODS AND RESULTS

5993 patients admitted with suspected myocardial infarction and alive on day 15 after admission were registered in The First Danish Verapamil Infarction Trial database in 1979-81. 2586 had definite infarction, 402 probable infarction and 3005 no infarction as they fulfilled 3, 2 and 1 criteria for infarction. They were followed for 10 years with respect to later infarction and death, i.e., including death after later infarction. The 10 year infarction rate after index admission was 48.8% in definite, 47.3% in probable and 24.6% in no infarction patients (P < 0.0001). The subsequent 10-year mortality was 82.3% in primary definite, 74.7% in primary probable, and 77.9% in primary no infarction patients (ns), Cox regression analysis with sex, age group, and definite, probable or no infarction as independent variables showed that females aged < 50 years without a primary infarction had the lowest hazard ratio (0.13 relative to males, aged 50-65 years with definite/probable infarction at index admission) for a later infarction, in contrast to the highest hazard ratio (1.17) for males aged > 65 years with definite or probable infarction.

CONCLUSION

The 10-year infarction rate in patients with suspected myocardial infarction in whom the diagnosis is ruled out is lower than in those with definite or probable infarction, but the mortality after a later infarction is similar in all three groups.

[Prognosis after AMI--are there gender differences?]

To examine the prevailing hypothesis that females fare worse than males after acute myocardial infarction, we compared short-term (15 days) and long-term (ten year) prognosis after acute myocardial infarction for the two sexes. Three thousand and seventy-three consecutive patients with acute myocardial infarction were followed for 10 years after a first registration in the Danish Verapamil Infarction Trial database in 1979-81. Early mortality increased significantly with age (p < 0.0001), but was not significantly related to sex, with a 15 days mortality of 17% in females and 16% in males. Ten year mortality in patients alive day 15 was 58.8%. Hazard ratio for females versus males after adjustment for age was 0.90 (0.80-1.01). Ten year reinfarction rate was 48.8% with age adjusted hazard ratio for females versus males of 0.90 (0.78-1.04) and ten year mortality after reinfarction was 82.3%, with age adjusted hazard ratio in females versus males of 0.98 (0.82-1.16). No difference in cause of death was found between the two sexes. We conclude that sex by itself is not a risk indicator after acute myocardial infarction.

Cardiac event rates after acute myocardial infarction in patients treated with verapamil and trandolapril versus trandolapril alone. Danish Verapamil Infarction Trial (DAVIT) Study Group

Angiotensin-converting enzyme (ACE) inhibitors improve survival in patients with congestive heart failure (CHF) after an acute myocardial infarction (AMI), but mortality may be as high as 10% to 15% after 1 year. Verapamil prevents cardiac events after an AMI in patients without CHF. We hypothesized that in postinfarct patients with CHF already prescribed diuretics and an ACE inhibitor, additional treatment with verapamil may reduce cardiac event rate. In this multicenter, double-blind study, patients with CHF receiving diuretic treatment were consecutively randomized to treatment with trandolapril 1 mg/day for 1 month and 2 mg/day the following 2 months (n = 49), or to trandolapril as mentioned plus verapamil 240 mg/day for 1 month and 360 mg/day for 2 months (n = 51). Trial medication started 3 to 10 days after AMI. All patients were followed for 3 months. End points in the trandolapril/trandolapril-verapamil groups were death 1/1, reinfarction 7/1, unstable angina 9/3, and readmission for CHF 6/2. The 3-month first cardiac event rate was 35% in trandolapril-treated patients and 14% in trandolapril-verapamil-treated patients (hazard ratio 0.35, 95% confidence interval 0.15 to 0.85, p = 0.015). These data suggest that verapamil reduces cardiac event rates in post-AMI patients with CHF when added to an ACE inhibitor and a diuretic.

On the importance of sensitivity to the dose-effect relationship in chemotherapy

The dose effect relationship of cytostatics is discussed from a theoretical point of view. Assuming tumour cell sensitivity as a continuum and an exponential distribution of cell probability density as a function of sensitivity the 'log kill' concept has been extended to a model describing the relation between dose and effect in malignant tumours. The model is based on only 3 parameters: The ratio between maximum and minimum sensitivity, the ratio between maximum and minimum cell probability density according to sensitivity and finally the product of dose and (minimum) sensitivity. The model demonstrates that the fractional tumour reduction intended is of major importance for the resulting curves. Dose effect curves describing a small fractional cell kill (0.5) are much steeper than curves describing a high one (to 10(-3)). Possible clinical implications of the model are discussed.

[Prognostic values of echocardiography compared with clinical variables in suspected heart disease. Multivariate analysis of long-term prognosprognosis in 456 patients]

The aim of the study was to evaluate the prognostic significance of clinical and echocardiographic data in patients referred for echocardiography in a retrospective analysis. Four hundred and fifty-six patients from a district hospital were studied. Survival after three years was 64%. Multivariate analysis identified five factors with independent prognostic information (relative risks of death are shown in brackets): left ventricular wall motion index (WMI) < or = 1.2 by echocardiography (2.5), status as in-patient (2.1), age > 65 years (1.7), clinical heart failure (1.9) and atrial fibrillation (1.5). When information on age, hospitalisation status, heart failure and heart rhythm had already been entered in the Cox model, echocardiographic results such as decreased WMI and dilated right ventricle still gave further prognostic information. We conclude that among conventional clinical and echocardiographic data WMI was the strongest predictor of long-term survival, and, despite prior knowledge of major clinical features, echocardiography provided further prognostic information.

Sex related differences in short and long-term prognosis after acute myocardial infarction: 10 year follow up of 3073 patients in database of first Danish Verapamil Infarction Trial

OBJECTIVE

To re-examine the prevailing hypothesis that women fare worse than men after acute myocardial infarction.

DESIGN

10 year follow up of all patients with confirmed acute myocardial infarction registered in the database of the Danish verapamil infarction trial in 1979-81.

SETTING

16 coronary care units, covering a fifth of the total Danish population.

PATIENTS

3073 consecutive patients with acute myocardial infarction, 738 (24%) women and 2335 (76%) men.

MAIN OUTCOME MEASURES

Early mortality (before day 15). For patients alive on day 15: mortality, cause of death, admission with recurrent infarction, and mortality after reinfarction.

RESULTS

Early mortality increased significantly with age (P < 0.0001) but was not significantly related to sex, with a 15 day mortality of 17% in women and 16% in men. Adjustment for age and sex simultaneously revealed a significant interaction (P = 0.02) between these variables, with a greater increase with age in early mortality for men than for women (early mortality was equal for the two sexes at age 64 years). Ten year mortality in patients alive on day 15 was 58.8%. The overall age adjusted hazard ratio (95% confidence interval) for women versus men was 0.90 (0.80 to 1.01); 0.90 (0.78 to 1.04) for 10 year reinfarction (48.8%); and 0.98 (0.82 to 1.16) for 10 year mortality after reinfarction (82.3%). No difference in cause of death was found between the sexes. With a follow up of up to 10 years for patients alive on day 15 mortality, rate of reinfarction, and mortality after reinfarction increased with increasing age (P < 0.0001).

CONCLUSION

Sex by itself is not a risk factor after acute myocardial infarction.

Prognostic value of echocardiography in 190 patients with chronic congestive heart failure. A comparison with New York Heart Association functional classes and radionuclide ventriculography

Survival in 190 consecutive patients with congestive heart failure, discharged from a general hospital, was studied. Sixteen patients were in New York Heart Association (NYHA) class I, 87 in II, 83 in III and 4 in IV. Median left ventricular ejection fraction (LVEF) from radionuclide ventriculography was 0.30 (range 0.06-0.74). Two-year survival was 68%. Wall motion index was the only echocardiographic variable with significant, independent, prognostic information on survival. The 2-year survival in NYHA classes I and II was 90.7% for wall motion index > or = 1.3, and 78.6% when < 1.3. In classes III and IV survival was 68.9% for wall motion index > or = 1.3 and 39.9% when < 1.3. Addition of LVEF gave further information about survival. This study demonstrates that echocardiography is of great value in determining prognosis in congestive heart failure patients, and that wall motion index contains the majority of the information. Wall motion index is closely correlated to LVEF, however prognostication is improved when information about LVEF is added.

Epstein-Barr virus genome in non-Hodgkin's lymphomas occurring in immunocompetent patients: highest prevalence in nonlymphoblastic T-cell lymphoma and correlation with a poor prognosis. Danish Lymphoma Study Group, LYFO

A series of 520 cases of non-Hodgkin's lymphoma (NHL; 374 of B-cell, 130 of T-cell, 5 of non-B/non-T-cell, and 11 of undetermined phenotype) was analyzed for the presence of Epstein-Barr virus (EBV) using RNA in situ hybridization (RISH). The aims of the study were to assess the frequency of EBV-encoded small nuclear RNAs 1 and 2 (EBER), abundant immediate early RNAs (BHLF), and latent membrane protein-1 (LMP-1) in cases covering the entire histologic spectrum of NHL, and to analyze whether EBV status had prognostic relevance with regard to patient survival. EBER positivity was found in 25 of 374 (7%) B-NHL and 40 of 130 (31%) T-NHL (P < .00005) cases, but in only 1 of 16 cases with non-B/non-T-cell or undetermined phenotype. Among T-NHL cases, EBER positivity was confined to angioimmunoblastic, lymphadenopathy-like lymphoma (11 of 13 cases, 85%), Lennert's lymphoma (five of seven cases, 71%), and pleomorphic T-NHL (24 of 67 cases, 36%). Mycosis fungoides, lymphoblastic, and CD30-positive anaplastic large T-cell NHL cases were consistently EBV-negative. Double-labeling by RISH and immunophenotyping demonstrated the presence of EBV in neoplastic T cells, but no CD21 expression was found in the EBER-positive T-NHL cases. LMP-1 was expressed in 12 of 40 (30%) EBER-positive T-NHL and 5 of 25 (20%) EBER-positive B-NHL cases. For both T- and B-NHL, no correlation was found for EBER positivity and age, sex, clinical stage, or serum level of lactate dehydrogenase (LDH) at diagnosis. However, in T-NHL but not B-NHL, EBER positivity correlated with the presence of constitutional symptoms and a poor performance score (PS < 1; scale, 0 to 4). EBER status did not have any prognostic significance in B-NHL, but it had a negative prognostic impact in high-grade T-NHL (7-year survival of EBER-negative v EBER-positive cases: 33% v 14%; P = .01). A multivariate analysis including all B- and T-NHL of intermediate-/high-grade histology showed that EBER positivity in T-NHL was one of the three most significant factors recognized by the final prognostic model, only surpassed by PS greater than 1 and age greater than 67 years, and more powerful than B symptoms, an elevated LDH, or disseminated disease (clinical stage greater than II). We conclude that patients with EBV-positive T-NHL have a very poor clinical outcome, that EBV status should be considered as additional useful information in the classification of T-NHL, and that EBV-positive T-NHL should be treated as a separate entity in the future.

[10-year mortality of patients admitted to coronary units with or without confirmed diagnosis of myocardial infarction. A relation to anamnesis and diagnosis at discharge]

The ten-year mortality in patients with suspected myocardial infarction with (AMI) and without (non-AMI) confirmed diagnosis was evaluated in 1897 non-AMI patients and 1401 AMI patients who were consecutively admitted to hospital during The Danish Verapamil Infarction Study. The following risk factors contained independent prognostic information about mortality for non-AMI patients: age, previous AMI, sex and diabetes. In patients with AMI the risk factors were: age, previous AMI, clinical heart failure, diabetes and angina pectoris. When the diagnosis at discharge for non-AMI patients was included in the Cox-analysis, only the diagnoses of bronchopneumonia, musculoskeletal disorders and observation only of added prognostic information. We conclude that non-AMI patients are at high risk for mortal events in the long-term. High risk patients can be identified from the medical history and should be carefully evaluated regarding coronary artery disease at the time of discharge in order to improve the risk stratification, treatment and prognosis.

Non-Hodgkin's lymphoma of the gastrointestinal tract: a population-based analysis of incidence, geographic distribution, clinicopathologic presentation features, and prognosis. Danish Lymphoma Study Group

PURPOSE

To evaluate incidence, time trends, geographic distribution, clinicopathologic presentation features, and prognostic factors for survival and relapse in gastrointestinal (GI) non-Hodgkin's lymphomas (NHLs).

PATIENTS AND METHODS

Over a 9-year period (1983 to 1991), 2,446 new NHL cases were recorded in a Danish population-based NHL registry (Danish Lymphoma Study Group [LYFO]). Of these, 306 (12.5%) were GI NHL (175 gastric, 109 intestinal, and 22 both sites). LYFO registry data were used for incidence rate (IR) assessment, and time-trend and geographic distribution analysis. Relative risk (RR) values for survival and relapse were identified by multivariate analysis.

RESULTS

The mean annual, age-standardized IRs for gastric and intestinal NHL were 0.71/10(5) and 0.48/10(5) per year, respectively. Age-specific IRs for both localizations showed an exponential increase as a function of age. Time-trend analysis for the period 1983 to 1991 showed stable IRs for both localizations. Intestinal NHL was more frequent in males (male-to-female ratio, 2.0 v 1.3), and had a higher occurrence of disseminated disease, constitutional symptoms, high-grade histology, and T-cell phenotype (10% v 2%). Gastric NHL had more low-grade cases (38% v 19%), and almost all were of the mucosa-associated lymphoid tissue (MALT) type. The cause-specific 5-year survival rate was 63% for gastric NHL and 49% for intestinal NHL. The Musshoff staging system was an excellent discriminator between truly localized (stage I and II1) and disseminated cases (stage II2 to IV), particularly for gastric NHL, for which no survival difference was found between surgically and conservatively stage localized cases.

CONCLUSION

(1) No increase in the incidence of GI NHL was found over a 9-year observation period; (2) nonrandom spatial distribution of new GI NHL cases was observed; (3) factors that significantly increased the risk of death in gastric cases were presence of B symptoms (RR = 3.3), clinical stage is more than II1 (RR = 3.0), age more than 72 years (RR = 2.4), and elevated serum lactate dehydrogenase (s-LDH) level (RR = 2.0); and factors that increased the risk of death in intestinal cases were presence of B symptoms (RR = 3.2), age more than 58 years (RR = 2.8), and clinical stage more than I (RR = 2.1); (4) factors that significantly increased the risk of relapse in gastric cases were male sex and no radiotherapy in primary treatment; and in intestinal cases were T-cell phenotype and no surgery in primary treatment; (5) surgical staging, as opposed to thorough noninvasive staging, did not improve staging accuracy and final outcome in localized gastric NHL.

Ten year mortality in patients with suspected acute myocardial infarction

OBJECTIVE

To describe the 10 year mortality in patients with suspected acute myocardial infarction.

DESIGN

Follow up of all patients below 76 years of age admitted with acute chest pain to 16 coronary care units participating in the Danish verapamil infarction trial in 1979-81.

SUBJECTS

Of the 5993 patients included, 2586 had definite infarction, 402 had probable infarction, and 3005 did not have infarction.

MAIN OUTCOME MEASURES

Death and cause of death. Standardised mortality ratio (observed mortality/expected mortality in background population).

RESULTS

The estimated 10 year mortalities were 58.8%, 55.5%, and 42.8% in patients with definite, probable, and no infarction, respectively (P < 0.0001). Stratified Cox's analysis identified a hazard ratio for mortality of 1.25 (95% confidence interval 1.08 to 1.44) for probable infarction compared with no infarction and of 1.15 (1.00 to 1.32) for definite compared with probable infarction. The standardised mortality ratio in the first year was 7.1 (6.5 to 7.8) for definite infarction, 5.0 (3.6 to 6.3) for probable infarction, and 4.7 (4.2 to 5.2) for no infarction. From the second year and onwards the annual standardised mortality ratio in the three groups did not differ significantly. Cardiac causes of deaths were recorded in 89%, 84%, and 71% of the deaths in patients with definite, probable, and no infarction, respectively.

CONCLUSIONS

The 10 year mortality of patients with and without infarction is significantly higher than in the background population. Most deaths are caused by coronary heart disease, and these patients should consequently be further evaluated at the time of discharge and followed up closely.

Chronic congestive heart failure. Description and survival of 190 consecutive patients with a diagnosis of chronic congestive heart failure based on clinical signs and symptoms

The prognosis, and clinical findings related to prognosis, were examined in a consecutive series of 190 patients under 76 years of age (mean 64 years) with congestive heart failure (CHF). The aetiology of CHF was ischaemic heart disease in 66%, hypertension in 11% and cardiomyopathy in 23%. The 2-year mortality was 32%. Median left ventricular ejection fraction (LVEF) was 0.30, range 0.06 to 0.74. Eight per cent were in New York Heart Association (NYHA) class I, 46% in II, 44% in III and 2% in IV. Multivariate analysis, excluding exercise test variables, revealed seven variables with independent, significant prognostic information, (hazard ratios for death in brackets): ln (natural logarithm) (LVEF) (3.19), NYHA class III+IV (2.72), plasma urea > 7.6 mmol.l-1 (2.22), serum creatinine > 121 mumol.l-1 (2.05), serum sodium < or = 137 mmol.l-1 (2.03), pulmonary congestion on X-ray (1.86), and age > 65 years (1.86). Multivariate analysis, including exercise testing, showed the following variables to contain independent, significant prognostic information: increase in heart rate during maximal exercise < or = 35 min-1 (3.5), ln (LVEF) (3.7), serum creatinine > 121 mumol.l-1 (2.9), maximal exercise time < or = 4 min (2.3), serum sodium < or = 137 mmol.l-1 (2.5), ischaemic heart disease (2.0) and plasma urea > 7.6 mmol.l-1 (1.9). In conclusion, patients with CHF have a high risk of death despite intensive medical treatment. LVEF is a strong predictor of mortality. Both NYHA class and exercise variables have strong independent prognostic information as regards mortality in combination with LVEF, but are mutually exclusive.

The prognostic significance of post-infarction angina pectoris and the effect of verapamil on the incidence of angina pectoris and prognosis. The Danish Study Group on Verapamil in Myocardial Infarction

The prognostic significance of angina pectoris and the effect of intervention with verapamil on the incidence of angina pectoris were studied in patients recovering from myocardial infarction and included in the Danish Verapamil Infarction Trial II. During the second week after admission patients were doubly-blindly randomized to treatment with verapamil 360 mg.day-1 or placebo. Treatment was continued for up to 18 months. At discharge angina pectoris was reported in 11% of 869 patients randomized to verapamil and in 12% of 888 randomized to placebo (ns). One month after discharge a significant increase in the prevalance of angina pectoris was reported in both the verapamil (33%) (P < 0.001) and the placebo groups (39%) (P < 0.001). The one month prevalence of angina pectoris (P = 0.03) and the 18 months overall incidence of angina pectoris (P = 0.002) were both significantly lower in the verapamil group compared with placebo. Stable angina pectoris during the first month of follow-up was a significant predictor of major events (i.e. death or reinfarction) (hazard ratio = 1.45; 95% confidence limits: 1.10, 1.89). As verapamil significantly reduced the incidence of angina pectoris during daily activities, and thereby the number of patients at high risk, the beneficial effect of verapamil in reducing major events in patients recovering from myocardial infarction is likely to be due to abolishing myocardial ischaemia.

Ten-year mortality of patients admitted to coronary care units with and without myocardial infarction. Risk factors from medical history and diagnosis at discharge. DAVIT-Study Group. Danish Verapamil Infarction Trial

The purpose was to evaluate the 10-year mortality in patients with acute chest pain suspected of myocardial infarction with (AMI) and without (non-AMI) confirmed diagnosis and to determine risk factors from the medical history and the diagnosis at discharge. One-thousand eight-hundred and ninety-seven non-AMI patients and 1,401 patients with AMI consecutively admitted to 1 of 16 coronary care units participating in The Danish Verapamil Infarction Study were included. During follow-up, 630 deaths occurred among the non-AMI patients and 415 of these could be classified as cardiac deaths. Multivariate analysis identified the following risk factors containing independent prognostic information about mortality for non-AMI patients: age, previous AMI, sex, and diabetes. In patients with AMI the risk factors were: age, previous AMI, clinical heart failure, diabetes, and angina pectoris. By including the diagnosis at discharge for non-AMI patients in the Cox analysis, the prognostic significance was compared to the variables from the medical history. Only the diagnoses bronchopneumonia, musculoskeletal disorders and observatio sine indicatione therapiae added independent prognostic information. We conclude that non-AMI patients are at high risk for mortal events in the long term. High-risk patients can be identified from their medical history, whereas the diagnosis at discharge only adds limited prognostic information. All non-AMI patients should be carefully evaluated regarding coronary artery disease at the time of discharge in order to improve the risk stratification, treatment and prognosis.

Incidence, presenting features and prognosis of low-grade B-cell non-Hodgkin's lymphomas. Population-based data from a Danish lymphoma registry

During the period January 1983 to January 1988 1597 newly diagnosed cases of non-Hodgkin's lymphoma (NHL) were included in a Western Danish population-based NHL registry. Of these, 31% (N = 496) were low-grade NHL (LG-NHL) consisting of (Kiel): 9% lymphocytic (LY), 27% lymphoplasmacytic/-cytoid (IC), 53% follicular centroblastic/-centrocytic (CB/CCf) and 11% unclassifiable low-grade. LG-NHL (age range: 26-94 yrs, median: 64 yrs; M/F ratio: 0.8) had an age-standardised incidence rate (IR) of 2.7/10(5)/yr. Age-specific IR's showed an age-related exponential rise in all subtypes except for CB/CCf. Compared with the intermediate (IG)- and high-grade (HG) group, LG-NHL had more female cases (M/F ratio: 0.79 vs. 1.2; p = 0.0002), a higher frequency of stage III-IV disease (66% vs. 53%; p < 0.00005) and of bone marrow involvement (39% vs. 19%; p < 0.00005). A later revision of all IC cases (N = 132) distinguished 79 non-polymorphic (ICnp) from 25 polymorphic (ICp) cases; 28 cases were differently classified. In 34 LG-NHL patients histologic transformation was verified: CB/CCf to CB diffuse (22 pts) and LY to immunoblastic or CB type (6 pts). The 7-yr survival for LG-NHL was 63% (IG: 48%, HG: 38%; p < 0.00005). A Cox-regression analysis identified the following adverse prognostic factors for survival in LG-NHL: age > 50 with a relative risk (RR) of 3.2, hepatic involvement (RR = 2.1), elevated s-LDH (RR = 1.9), B-symptoms (RR = 1.8) and IC histology (ICnp+ICp) (RR = 1.7).(ABSTRACT TRUNCATED AT 250 WORDS)

Tuberous sclerosis and parathyroid adenoma

Very little is known about the pathogenesis of tuberous sclerosis. Over the past 10 years, however, increasing numbers of reports on adenomatous diseases in association with tuberous sclerosis have been published. A case of hypercalcaemia and parathyroid adenoma in association with tuberous sclerosis is presented, of which there has been one such report published previously. This association might be another manifestation of this complex disease: it is therefore recommended that plasma calcium concentrations should be measured in such patients.

[Thrombocyte concentrate infusions--a study of the frequency of contamination and its clinical significance]

Three hundred and twenty-four samples from platelet concentrate bags were examined for bacterial contamination. Blood cultures were made when platelet transfusion was followed by pyrexia to examine the frequency of platelet transfusion-induced septicemia. 6.5% of samples showed bacterial growth, mostly ordinary skin flora, but other bacteria were also demonstrated. Pyrexia followed 14% of the transfusion episodes, and in 58% of the febrile episodes this was associated with bacterial contamination of the bag. In one episode of post-transfusion pyrexia the same bacteria were found in cultures from both bag and blood. The case is presented here. Sources of bacterial contamination of platelet preparations are discussed. The use of platelet concentrates in treatment of thrombocytopenic patients is so important that the demonstrated rate of contamination does not alter the indication for platelet transfusion. Nevertheless, when platelet transfusion is followed by pyrexia, cultures from the bag and patient's blood should be performed to establish etiology and relevant antibiotic treatment.