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1.  Post-cholecystectomy symptoms were caused by persistence of a functional gastrointestinal disorder 
AIM: To classify gallstone disease as a basis for assessment of post-cholecystectomy symptoms.
METHODS: One hundred and fifty three patients with a clinical and ultrasonographic diagnosis of gallstones filled out a structured questionnaire on abdominal pain symptoms and functional gastrointestinal disorder (FGID) before and at six months after cholecystectomy. Symptom frequency groups (SFG) were categorized according to frequency of pain attacks. According to certain pain characteristics in gallstone patients, a gallstone symptom score was accorded on a scale from one to ten. A visual analogue scale was used to quantify pain. Operative specimens were examined for size and magnitude of stone contents as well as presence of bacteria. Follow-up took place after six months with either a consultation or via a mailed questionnaire. Results were compared with those obtained pre-operatively to describe and analyze symptomatic outcome.
RESULTS: SFG groups were categorized as severe (24.2%), moderate (38.6%), and mild (22.2%) attack frequency, and a chronic pain condition (15%). Pain was cured or improved in about 90% of patients and two-thirds of patients obtained complete symptom relief. Patients with the most frequent pain episodes were less likely to obtain symptom relief. FGID was present in 88% of patients pre-operatively and in 57% post-operatively (P = 0.244). Those that became asymptomatic or improved with regard to pain also had most relief from FGID (P = 0.001). No pre-operative FGID meant almost complete cure.
CONCLUSION: Only one third of patients with FGID experienced postoperative relief, indicating that FGID was a dominant cause of post-cholecystectomy symptoms.
PMCID: PMC3319963  PMID: 22493550
Gallstone symptoms; Functional gastrointestinal disease; Cholecystectomy; Post-cholecystectomy symptoms
2.  Early supported discharge after stroke in Bergen (ESD Stroke Bergen): three and six months results of a randomised controlled trial comparing two early supported discharge schemes with treatment as usual 
BMC Neurology  2014;14(1):239.
Stroke causes lasting disability and the burden of stroke is expected to increase substantially during the next decades. Optimal rehabilitation is therefore mandatory. Early supported discharge (ESD) has previously shown beneficial, but all major studies were carried out more than ten years ago. We wanted to implement and study the results of ESD in our community today with comparisons between ESD and treatment as usual, as well as between two different ESD models.
Patients with acute stroke were included during a three year period (2008–11) in a randomised controlled study comparing two different ESD models to treatment as usual. The two ESD models differed by the location of treatment: either in a day unit or in the patients’ homes. Patients in the ESD groups were followed by a multi-disciplinary ambulatory team in the stroke unit and discharged home as early as possible. The ESD models also comprised treatment by a multi-disciplinary community health team for up to five weeks and follow-up controls after 3 and 6 months. Primary outcome was modified Rankin Scale (mRS) at six months.
Three-hundred-and-six patients were included. mRS scores and change scores were non-significantly better in the two ESD groups at 3 and 6 months. Within-group improvement from baseline to 3 months was significant in the ESD 1 (p = 0.042) and ESD 2 (p = 0.001) groups, but not in the controls. More patients in the pooled ESD groups were independent at 3 (p = 0.086) and 6 months (p = 0.122) compared to controls and there also was a significant difference in 3 month change score between them (p = 0.049). There were no differences between the two ESD groups. Length of stay in the stroke unit was 11 days in all groups.
Patients in the ESD groups tended to be more independent than controls at 3 and 6 months, but no clear statistically significant differences were found. The added effect of supported discharge and improved follow-up seems to be rather modest. The improved stroke treatment of today may necessitate larger patient samples to demonstrate additional benefit of ESD.
Clinical trial registration
Unique identifier: NCT00771771
PMCID: PMC4301654  PMID: 25528166
Stroke; Randomised controlled trial; Rehabilitation; Early supported discharge; ESD; Community rehabilitation
3.  Surgery for colorectal liver metastases: the impact of resection margins on recurrence and overall survival 
Several reports have presented conflicting results regarding the association between resection margins (RMs) and outcome after surgery for colorectal liver metastases (CLM), especially in the era of modern chemotherapy. The purpose of this study was to evaluate the impact of RMs on overall survival (OS), time to recurrence (TTR) and local recurrence (LR) status, particularly for patients treated with preoperative chemotherapy.
A combined retrospective (1998 to 2008) and prospective (2008 to 2010) cohort study of consecutive patients with CLM without extrahepatic disease treated with primary resection at a medium volume centre.
A total of 253 patients with known R status and 242 patients with defined margin width were included in the study. Patients were stratified according to margin width; A: R1, <1 mm (n = 48, 19%), B: 1 to 4 mm (n = 77), C: 5 to 9 mm (n = 46) and D: ≥10 mm (n = 71). Median time to recurrence was 12.8 months, and after five years 21.5% had no recurrence. LR (inclusive combined recurrence in other hepatic sites or extrahepatic) occurred in 40 (16.5%) cases, most frequently seen with RMs below 5 mm. Five-year OS was 42.5% in R0 and 16.1% in R1 resections (P = 0.011). Patients were also stratified according to preoperative chemotherapy (n = 88), and the difference in five-year OS between R0 (45.1%) and R1 (14.7%) was maintained (P = 0.037). By multiple Cox regression analysis R1 resections tended to an adverse outcome (P = 0.067), also when adjusting for preoperative chemotherapy (P = 0.081).
R1 resections for colorectal liver metastases predict adverse outcome. RMs below 5 mm increased the risk for LR and shortened the time to recurrence. Preoperative chemotherapy did not alter an adverse outcome in R1 vs. R0 patients.
PMCID: PMC4029814  PMID: 24767422
Colorectal liver metastases; Resection margin; Overall survival; Local recurrence; Time to recurrence; Preoperative chemotherapy
4.  Birth after preeclamptic pregnancies: association with allergic sensitization and allergic rhinoconjunctivitis in late childhood; a historically matched cohort study 
BMC Pediatrics  2014;14:101.
The development of allergic sensitization and allergic disease may be related to factors during intrauterine life, but the role of maternal preeclampsia is not known.
We studied if maternal preeclampsia is associated with long-term allergic sensitization, allergic rhinoconjunctivitis, atopic dermatitis, asthma and with altered lung function in late childhood.
617 children participated in a 1:2 matched and controlled historical cohort study; 230 born after preeclamptic pregnancies and 387 born after normotensive pregnancies. Specific IgE in serum and lung function were measured at the age of 12.8 years and questionnaires on maternal and adolescent data were completed at the ages of 10.8 years (girls) and 11.8 years (boys), and at 12.8 years (both genders). The association between birth after preeclampsia and the main outcome measures allergic sensitization, allergic rhinoconjunctivitis, atopic dermatitis, asthma and lung function in late childhood were analysed with multiple regression analyses, including possible confounders.
Severe maternal preeclampsia was associated with high level allergic sensitization (sum of specific IgE in serum ≥ 3.9 kU/l; the 25 percentile for all children being sensitized); odds ratio (OR): 3.79; 95% confidence interval (CI): (1.54, 9.32); p = 0.015 and with allergic rhinoconjunctivitis in offspring; OR: 2.22, 95% CI: (1.19, 4.14), p = 0.047. Preeclampsia was not associated with atopic dermatitis, asthma or altered lung function in late childhood.
Maternal preeclampsia was associated with allergic sensitization and allergic rhinoconjunctivitis in offspring in late childhood, but not with other atopic diseases.
PMCID: PMC3995723  PMID: 24725676
Childhood; Allergy; Allergic rhinoconjunctivitis; Allergic sensitization; Asthma; Atopic dermatitis; Atopy; Child; Lung function; Preeclampsia
5.  A survey of surgical team members’ perceptions of near misses and attitudes towards Time Out protocols 
BMC Surgery  2013;13:46.
Medical errors are inherently of concern in modern health care. Although surgical errors as incorrect surgery (e.g., wrong patient, wrong site, or wrong procedure) are infrequent, they are devastating events to experience. To gain insight about incidents that could lead to incorrect surgery, we surveyed how surgical team members perceive near misses and their attitudes towards the use of Time Out protocols in the operating room. We hypothesised that perceptions of near-miss experiences and attitudes towards Time Out protocols vary widely among surgical team members.
This cross-sectional study (N = 427) included surgeons, anaesthetists, nurse anaesthetists, and operating room nurses. The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses on an ordinal scale (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members’ experience of near misses or mistakes; their strategies for verifying the correct patient, site, and procedure; questions about whether they believed that these mistakes could be avoided using the Time Out protocol; and how they would accept the implementation of the protocol in the operating room.
In the operating room, 38% of respondents had experienced uncertainty of patient identity, 81% had experienced uncertainty of the surgical site or side, and 60% had prepared for the wrong procedure. Sixty-three per cent agreed that verifying the correct patient, site, and procedure should be a team responsibility. Thus, only nurse anaesthetists routinely performed identity checks prior to surgery (P ≤ 0.001). Of the surgical team members, 91% supported implementation of a Time Out protocol in their operating rooms.
The majority of our surgical personnel experienced near misses with regard to correct patient identity, surgical site, or procedure. Routines for ensuring the correct patient, site, and surgical procedure must involve all surgical team members. We find that the near-miss experiences are a wake-up call for systematic risk reducing efforts and the use of checklists in surgery.
PMCID: PMC3851944  PMID: 24106792
Surgery; Operating room; Near misses; Medical errors; Checklist
6.  Fever in the tropics: aetiology and case-fatality - a prospective observational study in a tertiary care hospital in South India 
BMC Infectious Diseases  2013;13:355.
The objective of this study was to describe aetiology and case fatality of fever among inpatients in a tertiary care hospital in South India.
This was an observational, prospective study conducted in a tertiary care hospital in Vellore, Tamil Nadu, India. Between July 2nd 2007 and August 2nd in 2007, adult patients admitted to the hospital with temperature ≥ 38.0°C were included consecutively and followed during the hospitalisation period. Demographic and clinical data were collected and analysed for each patient. Associations were sought between death and various clinical and demographic variables.
One hundred patients were included, 61 male and 39 female. Mean age was 37.5 (range: 16 to 84) years. Mean fever duration was 5.4 (range: 0.1 to 42.9) weeks.
The following infectious aetiologies were recorded: tuberculosis (19%), lower respiratory infection (11%) including three with sepsis, urinary tract infection (10%) including three with E. coli sepsis, Plasmodium falciparum malaria (5%) including three patients with mixed P. vivax infection, scrub typhus (5%), typhoid fever (4%), cryptococcal meningitis (4%) including three HIV positive patients, endocarditis (3%) including two patients with Staphylococcus aureus sepsis, spleen abscess (2%), amoebic liver abscess (2%), sepsis undefined focus (1%), HIV infection (1%), hepatitis B (1%), rubella (1%), peritonitis (1%) and cholecystitis (1%).
Non-infectious causes of fever were diagnosed in 15%, including systemic lupus erythematosus in four and malignancy in six patients. Cause of fever remained unknown in 13%.
Case fatality during hospitalisation was 7% (7/100). Six of those who died were male. Five fatalities had bacterial sepsis, one spleen abscess and malignancy, and one had lymphomalignant disorder.
Diabetes and increasing age were significant risk factors for fatal outcome in unadjusted analyses, but only increasing age was a risk factor for death in adjusted analysis.
A high number of tuberculosis and bacterial infections and a high case fatality rate from sepsis were found in this cohort, underlining the importance of microbiological diagnostics and targeted antimicrobial treatment in the management of fever. P. falciparum was identified in all malaria cases, and this rapidly fatal infection should be considered in patients with acute undifferentiated fever in India.
PMCID: PMC3750507  PMID: 23899336
Fever; Aetiology; Tropics; Case-fatality; Sepsis; Malaria; Tuberculosis
7.  The Norwegian Stroke in the Young Study (NOR-SYS): Rationale and design 
BMC Neurology  2013;13:89.
Ischemic stroke in young adults is a major health problem being associated with a higher vascular morbidity and mortality compared to controls, and a stroke recurrence rate of 25% during the first decade. The assumed cause of infarction and the detected risk factors determine the early- and long-term treatment. However, for many patients the cause of stroke remains unknown. Risk factor profile and etiology differ in young and elderly ischemic stroke patients, and atherosclerosis is the determined underlying condition in 10 to 15%. However, subclinical atherosclerosis is probably more prevalent and may go unrecognized.
Ultrasound imaging is a sensitive method for the detection of arterial disease and for measurement of adipose tissue. The relationship between intima-media thickness (IMT), plaques, cardiovascular risk factors including visceral adipose tissue (VAT) and ischemic events has repeatedly been shown.
We have established The Norwegian Stroke in the Young Study (NOR-SYS) as a three-generation research program with the goal to increase our knowledge on heredity and the development of arterial disease and ischemic stroke. Extended standardized ultrasound examinations are done in order to find subclinical vessel disease for early and better prophylaxis.
NOR-SYS is a prospective long-term research program. Standardized methods are used for anamnestic, clinical, laboratory, imaging, and ultrasound data collection in ischemic stroke patients aged ≤60 years, their partners and joint adult offspring. The ultrasound protocol includes the assessment of intracranial, carotid and femoral arteries, abdominal aorta, and the estimation of VAT. To date, the study is a single centre study with approximately 400 patients, 250 partners and 350 adult offspring expected to be recruited at our site.
NOR-SYS aims to increase our knowledge about heredity and the development of arterial vascular disease in young patients with ischemic stroke and their families. Moreover, optimization of diagnostics, prophylaxis and early intervention are major targets with the intention to reduce stroke recurrence and other clinical arterial events, physical disability, cognitive impairment and death.
NOR-SYS is reviewed and approved by the Regional Committee for Medical and Health Research Ethics, Western-Norway (REK-Vest 2010/74), and registered in NCT01597453.
PMCID: PMC3721997  PMID: 23865483
Ischemic stroke; Stroke in the young; Atherosclerosis; Arterial disease; Ultrasound; Heredity; Vascular risk; Long-term outcome; Mortality
8.  Possible relation between maternal consumption of added sugar and sugar-sweetened beverages and birth weight – time trends in a population 
BMC Public Health  2012;12:901.
High birth weight (BW) is a risk factor for later obesity. In Norway, mean BW and proportion of large newborns increased from 1989 to 2000 and subsequently decreased to the 1989 level by 2010. The purpose of the study was to explore causes of this temporary increase.
From a regional prospective database pregnancy and newborn data were extracted for all 33088 singleton pregnancies resulting in live infants born at term without malformations during 1989–2010. Trends in BW, ponderal index and proportion of large newborns were related to individual prenatal exposures, including pre-pregnancy body mass index (PP-BMI) and gestational weight gain (GWG) for the years 2001–2010, and thereafter related ecologically to national population data on consumption of nutrients and physical activity.
For the regional cohort mean (standard deviation) BW increased from 3580 (453) grams in 1989/90 to 3633 (493) grams in 2001/02 (p<0.001), and decreased to 3583 (481) grams in 2009/10 (p<0.001). The proportion with BW>4500 grams increased from 2.6% to 4.8% (p<0.001) and subsequently decreased to 3.3% (p=0.002). The trends remained after adjustment for relevant exposures. For the years 2001/02 to 2009/10 (n= 15240) mean (SD) PP-BMI increased from 24.36 (4.44) to 24.85 (5.02) kg/m2 (p<0.001) while GWG decreased from 14.79 (5.85) to 13.86 (5.79) kg (p<0.001). The estimated net effect of changes in PP-BMI, GWG and other known exposures was a 6 grams reduction in BW from 2001/02 to 2009/10, leaving 44 grams reduction unexplained. National consumption of major nutrients did not change, but consumption of sucrose, in large part as sugar-sweetened beverages (SSB) changed in parallel to the BW trends.
The temporary increase in BW and large babies in the regional cohort was identical to that reported for Norway. Individual level data on known pregnancy related predictors for BW could not explain these changes, but the parallel time trend in national consumption of sucrose, in particular as SSB, may lend support to a hypothesis that intake of sugar may have a direct effect on BW and infant body proportions independent of effects through PP-BMI and GWG.
PMCID: PMC3607934  PMID: 23095173
Pregnancy; Body mass index; Weight gain; Birth weight; Macrosomia; Large for gestational age; Glucose; Sugar; Sugar-sweetened beverages; Norway
9.  Feasible and simple exclusion criteria for pulmonary reference populations 
Thorax  2007;62(9):792-798.
International guidelines recommend that pulmonary reference populations consist of never‐smokers without respiratory diseases or symptoms, but the diseases and symptoms are not clearly specified. The present study aimed to identify simple exclusion criteria for defining pulmonary reference populations.
Based on a random sample from a general population (the parent population), 2358 subjects aged 26–82 years performed spirometric tests. From this sample, subjects were stepwise excluded according to self‐reported obstructive lung diseases, symptoms and smoking history. Four increasingly more healthy respiratory reference populations were formed. Prediction equations for the median and lower limit of normal lung function were derived using quantile regression analysis.
Subjects without self‐reported obstructive lung diseases or the cardinal respiratory symptoms of breathlessness, cough or wheeze (population B), never‐smokers without cardinal symptoms (population C) and never‐smokers without any respiratory symptoms (population D) constituted 50% (n = 1184), 23% (n = 539) and 14% (n = 331) of the parent population (population A), respectively. The largest discrepancy between prediction equations was found between the parent population and the population without cardinal respiratory symptoms (population B) (p<0.05). Minor changes in the reference equations were also seen when excluding ever‐smokers (population C). There was no additional change with exclusion of other respiratory symptoms (population D). Age‐related decline in lung function was steepest in the parent population.
Obstructive lung diseases, smoking history, breathlessness, cough and wheeze are optimal exclusion criteria for a pulmonary reference population. Further validation of the exclusion criteria identified in this study is recommended with identical wording in other and larger multinational populations.
PMCID: PMC2117321  PMID: 17389756
10.  Health status in patients at risk of inherited arrhythmias and sudden unexpected death compared to the general population 
BMC Medical Genetics  2010;11:27.
The possibilities in the molecular genetics of long QT syndrome (LQTS) and hypertrophic cardiomyopathy (HCM) has made family screening, with diagnostic and predictive genetic testing part of the health care offer in genetic counselling of inherited arrhythmias, potentially affecting the subjective health among these individuals. The study compared health status among patients at risk of arrhythmia because of family history or clinical diagnosis of LQTS and HCM with reference health status scores of the general population.
In the period 2005-2007, 127 patients (mean age 45 years, 53.5% women), with a family history of arrhythmia (n = 95) or a clinical diagnosis of LQTS (n = 12) or HCM (n = 19) referred for genetic counselling at the medical genetic departments in Norway filled in a questionnaire (Short Form Health Survey SF-36) measuring health status on eight domains. The patient SF-36 scores were compared to expected scores of the general population by t-test, and the relationship between the socio-demographic variables, clinical status, and SF-36 domains were analysed by multiple linear regression.
The total sample reported significant lower SF-36 score as compared to the general population scores for the domain of general health (mean difference -7.3 (<0.001). When analysing the sample in subgroups according to clinical status, the general health was still significant lower for the group of family risk and in the group of HCM. In addition the physical functioning, role physical, vitality and role emotional domains were reduced for the latter group. In general, employment, higher education and being referred to genetic counselling through a family member were associated with better scores on the health status domains.
Having a genetic risk of arrhythmia affects general health significantly. In addition, patients with a clinical diagnosis of HCM demonstrate a significantly poorer health in both physical and mental domains.
PMCID: PMC2836315  PMID: 20163700
11.  Severity of Giardia infection associated with post-infectious fatigue and abdominal symptoms two years after 
A high rate of post-infectious fatigue and abdominal symptoms two years after a waterborne outbreak of giardiasis in Bergen, Norway in 2004 has previously been reported. The aim of this report was to identify risk factors associated with such manifestations.
All laboratory confirmed cases of giardiasis (n = 1262) during the outbreak in Bergen in 2004 received a postal questionnaire two years after. Degree of post-infectious abdominal symptoms and fatigue, as well as previous abdominal problems, was recorded. In the statistical analyses number of treatment courses, treatment refractory infection, delayed education and sick leave were used as indices of protracted and severe Giardia infection. Age, gender, previous abdominal problems and symptoms during infection were also analysed as possible risk factors. Simple and multiple ordinal logistic regression models were used for the analyses.
The response rate was 81% (1017/1262), 64% were women and median age was 31 years (range 3-93), compared to 61% women and 30 years (range 2-93) among all 1262 cases. Factors in multiple regression analysis significantly associated with abdominal symptoms two years after infection were: More than one treatment course, treatment refractory infection, delayed education, bloating and female gender. Abdominal problems prior to Giardia infection were not associated with post-infectious abdominal symptoms. More than one treatment course, delayed education, sick leave more than 2 weeks, and malaise at the time of infection, were significantly associated with fatigue in the multiple regression analysis, as were increasing age and previous abdominal problems.
Protracted and severe giardiasis seemed to be a risk factor for post-infectious fatigue and abdominal symptoms two years after clearing the Giardia infection.
PMCID: PMC2808308  PMID: 20003489
12.  Long-term symptoms in dizzy patients examined in a university clinic 
The long-term course of dizziness was investigated combining medical chart and survey data. The survey was undertaken median (interquartile range (IQR)) 4.6 (4.3) years after the initial medical examination.
Chart data comprised sex, age, diagnosis, symptom duration, postural sway and neck pain. Survey data comprised symptom severity assessed by the Vertigo Symptom Scale – Short Form (VSS-SF), and data regarding current state of dizziness, medication, neck pain and other chronic conditions.
The sample consisted of 503 patients, the mean (standard deviation (SD)) age was 50.0 (11.6) years, women being slightly overrepresented (60%). Severe problems with dizziness (VSS-SF mean (SD) 13.9, (10.8)) were indicated in the total group and in 5 of 6 diagnostic sub-groups. Vertigo/balance- and autonomic/anxiety-related symptoms were present in all groups. Current dizziness was confirmed by 73% who had significantly more severe problems than the non-dizzy (VSS-SF mean (SD): 17.2 (10.1) versus 5.0 (7.3)). Symptoms were related to vertigo/balance more than to autonomic/anxiety (test of interaction p < 0.001).
Based on simple logistic regression analysis, sex, symptom duration, neck pain, sway and diagnoses predicted dizziness. Symptom duration and neck pain remained predictors in the adjusted analysis. Age, symptom duration, neck pain, sway and diagnoses predicted vertigo/balance-related dizziness in both regression analyses. Sex, neck pain and sway predicted development of autonomic/anxiety-related dizziness according to simple regression analysis, while only neck pain remained a significant predictor in the adjusted analysis. With respect to diagnosis, simple regression analysis showed significant reduced likelihood for development of dizziness in all vestibular sub-groups when compared to the non-otogenic dizziness group. With respect to vertigo/balance- and autonomic/anxiety-related symptoms, the implication of diagnostic belonging varied. No effect of diagnoses was seen in adjusted analyses.
The majority of patients had persistent and severe problems with dizziness. The wait-and-see attitude before referral to specialist institutions may be questioned. Early, active movements seem necessary, and attention should be paid to the presence of neck pain. Diagnoses had limited prognostic value. Questionnaire-based evaluations could assist in classification and identification of type of dizziness and thereby provide a better basis for specific rehabilitation.
PMCID: PMC2693507  PMID: 19445693
13.  Cardiovascular autonomic function tests in an African population 
Diabetes mellitus is becoming increasingly common in sub-Saharan Africa. Autonomic dysfunction contributes to morbidity and mortality in diabetic patients. Data on autonomic dysfunction in the African population is scarce, and no reference values for standardized autonomic function tests are available. The aim of this study was to establish cut off values for five easy-to-use cardiovascular autonomic function tests that may be suitable for resource-poor settings.
We recruited 276 healthy African individuals, 156 men and 120 women, aged > 20 years. Participants were tested for (1) resting heart rate (HR), (2) HR variation in response to deep breathing, (3) HR response to standing, and (4) postural changes in systolic and diastolic blood pressure (SBP and DBP). Respective cut-off values were calculated according to the 95th or 5th percentile.
Taking an association of the autonomic test results with gender and age into consideration, we defined the following cut-off values: resting HR (bpm) ≥ 89 for men and ≥ 97 for women; HR (bpm) in response to deep breathing ≤ 13, ≤ 11, ≤ 9, ≤ 8, and ≤ 7 for age groups 20–29, 30–39, 40–49, 50–59, and 60+ years, respectively; HR (bpm) in response to standing ≤ 14 for 20–29 years, and ≤ 11 for 30+ years; postural decreases in SBP ≥ 17 mmHg for all age groups; and postural decreases in DBP (mmHg) ≥ 2 for men and ≥ 5 for women.
The test battery revealed cut-off values different from those measured in Caucasians. Further studies are recommended a) to assess whether these cut off values are generally applicable, and b) to establish population specific reference values for Africans.
PMCID: PMC2646733  PMID: 19115999
14.  Sense of coherence as a resource in relation to health-related quality of life among mentally intact nursing home residents – a questionnaire study 
Sense of coherence (SOC) is a strong determinant of positive health and successful coping. For older people living in the community or staying in a hospital, SOC has been shown to be associated with health-related quality of life (HRQOL). Studies focusing on this aspect among nursing home (NH) residents have been limited. This study investigated the relationship between SOC and HRQOL among older people living in NHs in Bergen, Norway.
Based on the salutogenic theoretical framework, we used a descriptive correlation design using personal interviews. We collected data from 227 mentally intact NH residents for 14 months in 2004–2005. The residents' HRQOL and coping ability were measured using the SF-36 Health Survey and the Sense of Coherence Scale (SOC-13), respectively. We analyzed possible relationships between the SOC-13 variables and SF-36 subdimensions, controlling for age, sex, marital status, education and comorbidity, and investigated interactions between the SOC and demographic variables by using multiple regression.
SOC scores were significantly correlated with all SF-36 subscales: the strongest with mental health (r = 0.61) and the weakest with bodily pain (r = 0.28). These did not change substantially after adjusting for the associations with demographic variables and comorbidity. SOC-13 did not interact significantly with the other covariates.
These findings suggest that more coping resources improve HRQOL. This may indicate the importance of strengthening the residents' SOC to improve the perceived HRQOL. Such knowledge may help the international community in developing nursing regimens to improve HRQOL for older people living in NHs.
PMCID: PMC2607268  PMID: 18940001
15.  Psychometric properties of the Vertigo symptom scale – Short form 
The aim of the study was to examine the psychometric properties of the Vertigo symptom scale – short form (VSS-SF), a condition-specific measure of dizziness, following translation of the scale into Norwegian.
A cross-sectional survey design was used to examine the factor structure, internal consistency and discriminative ability (sample I, n = 503). A cross-sectional pre-intervention design was used to examine the construct validity (sample II, n = 36) of the measure and a test-retest design was used to examine reliability (sub-sample of sample II, n = 28).
The scree plot indicated a two factor structure accounting respectively for 41% and 12% of the variance prior to rotation. The factors were related to vertigo-balance (VSS-V) and autonomic-anxiety (VSS-A). Twelve of the items loaded clearly on either of the two dimensions, while three items cross-loaded. Internal consistency of the VSS-SF was high (alpha = 0.90). Construct validity was indicated by correlation between path length registered by platform posturography and the VSS-V (r = 0.52), but not with the VSS-A. The ability to discriminate between dizzy and not dizzy patients was excellent for the VSS-SF and sub-dimension VSS-V (area under the curve 0.87 and 0.91, respectively), and acceptable for the sub-dimension VSS-A (area under the curve 0.77). High test-retest reliability was demonstrated (ICC VSS-SF: 0.88, VSS-V: 0.90, VSS-A: 0.90) and no systematic change was observed in the scores from test to retest after 2 days.
Using a Norwegian translated version of the VSS-SF, this is the first study to provide evidence of the construct validity of this instrument demonstrating a stable two factor structure of the scale, and the identified sub-dimensions of dizziness were related to vertigo-balance and autonomic-anxiety, respectively. Evidence regarding a physical construct underlying the vertigo-balance sub-scale was provided. Satisfactory internal consistency was indicated, and the discriminative ability of the instruments was demonstrated. The instrument showed satisfactory test-retest reliability.
PMCID: PMC2329601  PMID: 18371190
16.  Health-related quality of life and emotional and behavioral difficulties after extreme preterm birth: developmental trajectories 
PeerJ  2015;3:e738.
Background. Knowledge of long-term health related outcomes in contemporary populations born extremely preterm (EP) is scarce. We aimed to explore developmental trajectories of health-related quality of life (HRQoL) and behavior from mid-childhood to early adulthood in extremely preterm and term-born individuals.
Methods. Subjects born at gestational age ≤28 weeks or with birth weight ≤1,000 g within a region of Norway in 1991–92 and matched term-born control subjects were assessed at 10 and 18 years. HRQoL was measured with the Child Health Questionnaire (CHQ) and behavior with the Child Behavior Checklist (CBCL), using parent assessment at both ages and self-assessment at 18 years.
Results. All eligible EP (n = 35) and control children participated at 10 years, and 31 (89%) and 29 (83%) at 18 years. At 10 years, the EP born boys were given significantly poorer scores by their parents than term-born controls on most CHQ and CBCL scales, but the differences were minor at 18 years; i.e., significant improvements had occurred in several CHQ (self-esteem, general health and parental impact-time) and CBCL (total problem, internalizing and anxious/depressed) scales. For the girls, the differences were smaller at 10 years and remained unchanged by 18 years. Emotional/behavioral difficulties at 10 years similarly predicted poorer improvement on CHQ-scales for both EP and term-born subjects at 18 years. Self-assessment of HRQoL and behavior at 18 years was similar in the EP and term-born groups on most scales.
Conclusions. HRQoL and behavior improved towards adulthood for EP born boys, while the girls remained relatively similar, and early emotional and behavioral difficulties predicted poorer development in HRQoL through adolescence. These data indicate that gender and a longitudinal perspective should be considered when addressing health and wellbeing after extremely preterm birth.
PMCID: PMC4304859  PMID: 25653912
Adolescent; Development; Preterm infant; Health-related quality of life; Behavior
17.  Repeated Acetylcholine Receptor Antibody-Concentrations and Association to Clinical Myasthenia Gravis Development 
PLoS ONE  2014;9(12):e114060.
We aimed to examine the longitudinal association between Myasthenia Gravis (MG) clinical severity and concentration of acetylcholine receptor (AChR)-antibodies to evaluate if AChR-antibody variations correlate to disease severity. A positive AChR-antibody test is specific for MG.
Material and Methods
All patients from western Norway who had two or more AChR- antibody tests in the period 1983–2013 were identified. The Myasthenia Gravis Foundation of America (MGFA) Clinical Classification was used to grade disease development. Multiple ordinal logistic regression analysis was used to estimate a possible predictive effect for AChR-antibody concentration on MGFA classification result.
In 67 patients two or more AChR-antibody tests with a corresponding MGFA-score were performed, with a total of 309 tests. 56 patients were treated with immunosuppressive drugs and 11 by pyridostigmine only. There was a positive association between concentration of AChR-antibodies and longitudinal MGFA-score for the subgroup with immunosuppressive treatment, but not for those treated with pyridostigmine only. This association between AChR-antibody concentration and MGFA score declined with increasing time since onset (p = 0.005 for the interaction of group×time×concentration).
For MG patients with immunosuppressive treatment, repeated AChR-antibody measurements give information about clinical development, and can therefore be of support in therapeutic decisions.
PMCID: PMC4252099  PMID: 25464006
18.  How Important Are Social Support, Expectations and Coping Patterns during Cardiac Rehabilitation 
Purpose. To investigate the predictive role of relevant social and psychosocial determinants on emotional distress among patients after cardiac rehabilitation. Methods. A longitudinal prospective study examined short-term (6 months) and long-term (2 years) impact of predictors on anxiety and depression complaints in 183 patients with 6-months follow-up data attending a four-week rehabilitation stay at the Krokeide Centre in Bergen, Norway. The patients mainly suffered from coronary heart disease. Emotional distress, coping, social support, socioeconomic status, and negative expectations were measured by means of internationally validated questionnaires. A composite score of anxiety and depression complaints was used as the outcome measure in the study. Results. This study revealed that task-oriented coping improved emotional status in long-term followup, and negative expectations were associated with emotional distress in short-term followup. A higher socioeconomic status and more social support predicted improved emotional status in short- as well as long-term followup. Conclusions. Fewer negative expectations and functional coping along with social support are important factors for the prevention of emotional distress after cardiac disease. Such elements should be addressed and encouraged in patients during cardiac rehabilitation.
PMCID: PMC4180384  PMID: 25302122
19.  Irritable Bowel Syndrome and Chronic Fatigue 6 Years After Giardia Infection: A Controlled Prospective Cohort Study 
Giardia infection in a nonendemic setting is associated with an increased risk for irritable bowel syndrome and chronic fatigue 6 years later. These conditions should be considered a differential diagnosis in patients with persisting symptoms after eradication of the parasite.
Background. Functional gastrointestinal disorders and fatigue may follow acute infections. This study aimed to estimate the persistence, prevalence, and risk of irritable bowel syndrome and chronic fatigue 6 years after Giardia infection.
Methods. We performed a controlled prospective study of a cohort of 1252 individuals who had laboratory-confirmed Giardia infection during a waterborne outbreak in 2004. In total, 748 cohort cases (exposed) and 878 matched controls responded to a postal questionnaire 6 years later (in 2010). Responses were compared to data from the same cohort 3 years before (in 2007).
Results. The prevalences of irritable bowel syndrome (39.4%) by Rome III criteria and chronic fatigue (30.8%) in the exposed group 6 years after giardiasis were significantly elevated compared with controls, with adjusted relative risks (RRs) of 3.4 (95% confidence interval [CI], 2.9–3.9) and 2.9 (95% CI, 2.3–3.4), respectively. In the exposed group, the prevalence of irritable bowel syndrome decreased by 6.7% (RR, 0.85 [95% CI, .77–.93]), whereas the prevalence of chronic fatigue decreased by 15.3% from 3 to 6 years after Giardia infection (RR, 0.69 [95% CI, .62–.77]). Giardia exposure was a significant risk factor for persistence of both conditions, and increasing age was a risk factor for persisting chronic fatigue.
Conclusions. Giardia infection in a nonendemic setting is associated with an increased risk for irritable bowel syndrome and chronic fatigue 6 years later. The prevalences of both conditions decrease over time, indicating that this intestinal protozoan parasite may elicit very long-term, but slowly self-limiting, complications.
PMCID: PMC4207419  PMID: 25115874
Giardia; irritable bowel syndrome; chronic fatigue; postinfectious
20.  Balance and walking after three different models of stroke rehabilitation: early supported discharge in a day unit or at home, and traditional treatment (control) 
BMJ Open  2014;4(5):e004358.
To compare the effects on balance and walking of three models of stroke rehabilitation: early supported discharge with rehabilitation in a day unit or at home, and traditional uncoordinated treatment (control).
Group comparison study within a randomised controlled trial.
Hospital stroke unit and primary healthcare.
Inclusion criteria: a score of 2–26 on National Institutes of Health Stroke Scale, assessed with Postural Assessment Scale for Stroke (PASS), and discharge directly home from the hospital stroke unit.
Two intervention groups were given early supported discharge with treatment in either a day unit or the patient's own home. The controls were offered traditional, uncoordinated treatment.
Outcome measures
Primary: PASS. Secondary: Trunk Impairment Scale—modified Norwegian version; timed Up-and-Go; 5 m timed walk; self-reports on problems with walking, balance, ADL, physical activity, pain and tiredness. The patients were tested before randomisation and 3 months after inclusion.
From a total of 306 randomised patients, 167 were tested with PASS at baseline and discharged directly home. 105 were retested at 3 months: mean age 69 years, 63 men, 27 patients in day unit rehabilitation, 43 in home rehabilitation and 35 in a control group. There were no group differences, either at baseline for demographic and test data or for length of stroke unit stay. At 3 months, there was no group difference in change on PASS (p>0.05). Some secondary measures tended to show better outcome for the intervention groups, that is, trunk control, median (95% CI): day unit, 2 (0.28 to 2.31); home rehabilitation, 4 (1.80 to 3.78); control, 1 (0.56 to 2.53), p=0.044; and for self-report on walking, p=0.021 and ADL, p=0.016.
There was no difference in change between the groups for postural balance, but the secondary outcomes indicated that improvement of trunk control and walking was better in the intervention groups than in the control group.
Trial registration
This study is part of the Early Supported Discharge after Stroke in Bergen, (NCT00771771).
PMCID: PMC4025466  PMID: 24833680
21.  Two Valid Measures of Self-rated Physical Activity and Capacity 
Questionnaires on physical activity (PA) and physical capacity (PC) are valuable tools, as they are cost beneficial, and have high response rates. The validity of short versions of such questionnaires has not been examined satisfactorily. Therefore, we aimed at examining the validity of a set of questions coding for PA and PC.
The questions were administered to 217 men and women attending a cardiac rehabilitation program. Participants also gave blood samples, measuring HDL cholesterol, triglycerides (TG), insulin, glucose, and microCRP. The relations between PA and PC and biological markers were examined by linear regression analyses.
Measures for PC and for PA were identified by factor analysis, which proved internally consistent. TG, homeostatic model assessment (HOMA) score, and mCRP were all significantly associated with the measures of PC and PA.
The measures of PA and PC are valid compared with biological markers, allowing cost-beneficial and time-efficient evaluation of important measures for cardiovascular health.
PMCID: PMC3551239  PMID: 23346259
Cardiac rehabilitation; motor activities; outcome assessment; physical fitness; questionnaires.
22.  Can Electronic Tools Help Improve Nursing Home Quality? 
ISRN Nursing  2011;2011:208142.
Background. Nursing homes face challenges in the coming years due to the increased number of elderly. Quality will be under pressure, expectations of the services will rise, and clinical complexity will grow. New strategies are needed to meet this situation. Modern clinical information systems with decision support may be part of that. Objectives. To study the impact of introducing an electronic patient record system with decision support on the use of warfarin, neuroleptics and weighing of patients, in nursing homes. Methods. A prevalence study was performed in seven nursing homes with 513 subjects. A before-after study with internal controls was performed. Results. The prevalence of atrial fibrillation in the seven nursing homes was 18.8%. After intervention, the proportion of all patients taking warfarin increased from 3.0% to 9.8% (P = 0.0086), neuroleptics decreased from 33.0% to 21.5% (P = 0.0121), and the proportion not weighed decreased from 72.6% to 16.0% (P < 0.0001). The internal controls did not change significantly. Conclusion. Statistics and management data can be continuously produced to monitor the quality of work processes. The electronic health record system and its system for decision support can improve drug therapy and monitoring of treatment policy.
PMCID: PMC3191730  PMID: 22013540
23.  Long-Term Followup of Patients with Active J-Reservoirs after Restorative Proctocolectomy for Ulcerative Colitis with regard to Reservoir Function, Mucosal Changes, and Quality of Life 
ISRN Gastroenterology  2011;2011:430171.
Objective. Study the functional results and mucosal changes in the ileal pouch after restorative proctocolectomy with J-reservoir for ulcerative colitis. Material and Methods. Followup study of 125 patients with J-reservoir with one disease-specific- and one general (SF-36) quality of life-questionnaire, rectoscopy with biopsies, and stool samples to evaluate inflammation, dysplasia, presence of Helicobacter pylori and calprotectin level. Results. Fourteen J-reservoirs were removed or deactivated, leaving 111 patients for followup. The followup time was 6.8 (1–15) years. 87.4% of the patients were satisfied. 93.1% had some kind of functional restriction: food- (75.5%), social- (28.9%), physical- (37%) or sexual restriction (15.3%). 18.6% had often or sometimes faecal incontinence. Low daytime faecal frequency was associated with good quality of life. 13 patients (12.6%) had a less favourable result. There was no pouch-dysplasia. Calprotectin levels were increased in patients with visible pouch inflammation or history of pouchitis. HP was diagnosed by RUT in 42.3%, but was not associated with inflammation or pouchitis. Conclusions. Most patients were satisfied with the J-reservoir in spite of a high frequency of various restrictions. 12.6% (13 patients) had a less favourable functional result, partly due to a high frequency of defecations, pain, pouchitis and inflammation.
PMCID: PMC3168452  PMID: 21991508
24.  Long-Term Followup with Evaluation of the Surgical and Functional Results of the Ileal Pouch Reservoir in Restorative Proctocolectomy for Ulcerative Colitis 
ISRN Gastroenterology  2011;2011:625842.
Aims. Evaluate the early and long term surgical and functional results of the ileal pouch-reservoir (IPAA) in patients with intractable ulcerative colitis. Material and Methods. Followup of 134 consecutive patients with W-or J-ileal pouch by diseases-specific and general health (SF-36) questionnaire. In the first 44 patients, early and late followup was performed. Results. Followup was performed 7.4 years (0.5–17 years) after construction of W (n = 9) and J (n = 125) ileal pouch, which had similar results. There were 14.9% early and 43.6% late complications with 12.7% early and 19.5% late reoperations. Protecting loop-ileostomy used in 54 patients (43.9%), did not protect against complications. Thirteen reservoirs (9.8%) were resected (n = 8) or deactivated (n = 5) due to functional failure. Operation time, postoperative complications and pouchitis were determinators for reservoir failure and reduced quality of life. The functional results at followup of 44 patients at 2.5 years (0.8–6.7 years) and 11.5 years (8.2–19.2 years) were remarkably similar. Conclusions. IPAA is a good option for most patients when medication fails. 10% experience failure with inferior quality of life. Protective stoma will not reduce failure rates. After an initial time period, reservoir function will not change over time.
PMCID: PMC3168493  PMID: 21991523
25.  Hospital Admissions from Nursing Homes: Rates and Reasons 
Nursing Research and Practice  2011;2011:247623.
Hospital admissions from nursing homes have not previously been investigated in Norway. During 12 months all hospital admissions (acute and elective) from 32 nursing homes in Bergen were recorded via the Norwegian ambulance register. The principal diagnosis made during the stay, length of stay, and the ward were sourced from the hospital's data register and data were merged. Altogether 1,311 hospital admissions were recorded during the 12 months. Admissions from nursing homes made up 6.1% of the total number of admissions to medical wards, while for surgical wards they made up 3.8%. Infections, fractures, cardiovascular and gastri-related diagnoses represented the most frequent admission diagnoses. Infections accounted for 25.0% of admissions, including 51.0% pneumonias. Of all the admissions, fractures were the cause in 10.2%. Of all fractures, hip fractures represented 71.7. The admission rate increased as the proportion of short-term beds increased, and at nursing homes with short-term beds, admissions increased with increasing physician coverage. Potential reductions in hospitalizations for infections from nursing homes may play a role to reduce pressure on medical departments as may fracture prevention. Solely increasing physician coverage in nursing homes will probably not reduce the number of hospitalizations.
PMCID: PMC3170020  PMID: 21994816

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