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Journal of Evaluation in Clinical Practice 05/2012; 18(4):927-8. · 1.23 Impact Factor
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ABSTRACT: Aims To estimate the potential gain of national screening programmes for colorectal cancer (CRC) by stool occult blood testing in the Nordic countries, with comparative reference to the burden of other causes of premature death. Methods Implementation of national screening programmes for CRC was modelled among people 55-74 years in accordance with the 2011 Cochrane review of biannual screening, using the faecal occult blood test (FOBT) for 10 years, resulting in 15% relative risk reduction in CRC deaths among all those invited [intention-to-treat; relative risk 0.85; confidence interval (CI) 0.78 to 0.92]. Our calculations are based on the World Health Organization and national databanks on death causes (ICD-10) and the mid-year number of inhabitants in the target group. For Finland, Denmark, Norway and Sweden, we used data for 2009. For Iceland, due to the population's small size, we calculated mean mortality for the period 2005-2009. Results Invitation to a CRC screening programme for 10 years could influence 0.5-0.9% (95%CI 0.4-1.2) of all deaths in the age group 65-74 years. Among the remaining 99% of premature deaths, around 50% were caused by lung cancer, other lung diseases, cardiovascular diseases and accidents, with some national variations. Conclusions and implications Establishment of a screening programme for CRC for people aged 55-74 can be expected to affect only a minor proportion of all premature deaths in the Nordic setting. From a public health perspective, prioritizing preventive strategies targeting more prevalent causes of premature death may be a superior approach.
Journal of Evaluation in Clinical Practice 04/2012; · 1.23 Impact Factor
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Journal of Evaluation in Clinical Practice 12/2011; · 1.23 Impact Factor
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ABSTRACT: Many clinical guidelines for cardiovascular disease (CVD) prevention contain risk estimation charts/calculators. These have shown a tendency to overestimate risk, which indicates that there might be theoretical flaws in the algorithms. Total cholesterol is a frequently used variable in the risk estimates. Some studies indicate that the predictive properties of cholesterol might not be as straightforward as widely assumed. Our aim was to document the strength and validity of total cholesterol as a risk factor for mortality in a well-defined, general Norwegian population without known CVD at baseline.
We assessed the association of total serum cholesterol with total mortality, as well as mortality from CVD and ischaemic heart disease (IHD), using Cox proportional hazard models. The study population comprises 52 087 Norwegians, aged 20-74, who participated in the Nord-Trøndelag Health Study (HUNT 2, 1995-1997) and were followed-up on cause-specific mortality for 10 years (510 297 person-years in total).
Among women, cholesterol had an inverse association with all-cause mortality [hazard ratio (HR): 0.94; 95% confidence interval (CI): 0.89-0.99 per 1.0 mmol L(-1) increase] as well as CVD mortality (HR: 0.97; 95% CI: 0.88-1.07). The association with IHD mortality (HR: 1.07; 95% CI: 0.92-1.24) was not linear but seemed to follow a 'U-shaped' curve, with the highest mortality <5.0 and ≥7.0 mmol L(-1) . Among men, the association of cholesterol with mortality from CVD (HR: 1.06; 95% CI: 0.98-1.15) and in total (HR: 0.98; 95% CI: 0.93-1.03) followed a 'U-shaped' pattern.
Our study provides an updated epidemiological indication of possible errors in the CVD risk algorithms of many clinical guidelines. If our findings are generalizable, clinical and public health recommendations regarding the 'dangers' of cholesterol should be revised. This is especially true for women, for whom moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial.
Journal of Evaluation in Clinical Practice 09/2011; 18(1):159-68. · 1.23 Impact Factor
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BMJ (Clinical research ed.). 01/2011; 343:d7826.
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ABSTRACT: Distribution of body fat is more important than the amount of fat as a prognostic factor for life expectancy. Despite that, body mass index (BMI) still holds its status as the most used indicator of obesity in clinical work.
We assessed the association of five different anthropometric measures with mortality in general and cardiovascular disease (CVD) mortality in particular using Cox proportional hazards models. Predictive properties were compared by computing integrated discrimination improvement and net reclassification improvement for two different prediction models. The measures studied were BMI, waist circumference, hip circumference, waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR). The study population was a prospective cohort of 62,223 Norwegians, age 20-79, followed up for mortality from 1995-1997 to the end of 2008 (mean follow-up 12.0 years) in the Nord-Trøndelag Health Study (HUNT 2).
After adjusting for age, smoking and physical activity WHR and WHtR were found to be the strongest predictors of death. Hazard ratios (HRs) for CVD mortality per increase in WHR of one standard deviation were 1.23 for men and 1.27 for women. For WHtR, these HRs were 1.24 for men and 1.23 for women. WHR offered the greatest integrated discrimination improvement to the prediction models studied, followed by WHtR and waist circumference. Hip circumference was in strong inverse association with mortality when adjusting for waist circumference. In all analyses, BMI had weaker association with mortality than three of the other four measures studied.
Our study adds further knowledge to the evidence that BMI is not the most appropriate measure of obesity in everyday clinical practice. WHR can reliably be measured and is as easy to calculate as BMI and is currently better documented than WHtR. It appears reasonable to recommend WHR as the primary measure of body composition and obesity.
PLoS ONE 01/2011; 6(10):e26621. · 4.09 Impact Factor
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Scandinavian journal of primary health care 06/2010; 28(2):65-6. · 2.21 Impact Factor
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ABSTRACT: Objectives: To determine the incidence of herpes zoster (HZ) and frequency of complications, mainly the incidence of postherpetic neuralgia (PHN). Design: Prospective follow-up study. Setting: Primary health care in Iceland. Main outcome measures: Incidence of HZ, age and sex distribution of patients and discomfort or pain 1, 3 and 12 months after the rash. Results: During an observation period of 229,547 person years, 462 episodes of acute zoster developed (incidence equals; 2.0/1,000/year) in 457 patients. End points were gained for all (100%) after 12 months follow up. Those still having pain after 12 months were followed further, 23 to 57 months more. Systemic acyclovir was used in less than 4%. A fourth of all HZ cases occurred in children and teenagers. PHN was rare in patients younger than 60 years of age; 2% and 1% experienced only mild pain at 3 and 12 months respectively. No patient had moderate or severe pain in this age group at these time points. In contrast pain was experienced by 19% and 8% of patients 60 years of age and older at 3 and 12 months respectively. However, after 12 months only two patients (0.4%) had moderate pain, none had severe pain. Potential immuno-modulating conditions (diabetes mellitus, cancer, HIV-infection, steroid treatment) were present in 24 patients (5%), 4 (1%) of whom were diagnosed with a malignancy within 6 months of contracting HZ. Conclusions: HZ is more common in younger age groups than has previously been reported. In patients younger than 60, the probability of PHN is very low. Malignancy is seldom associated with zoster rash in the primary care setting. The use of routine computerised medical records increases the possibility of collecting epidemiological information on the clinical course of a disease.
07/2009; 2(1):12-16.
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ABSTRACT: Clinicians are generally advised to consider several risk factors when evaluating patients' cardiovascular disease (CVD) risk. Our aim was to study whether combined assessment of five traditional risk factors might help doctors demarcate a relatively distinct and manageable group of high-risk individuals. We selected five modifiable risk factors and estimated the proportion of a well-defined population with 'unfavourable' levels of at least two of them, as defined by four internationally renowned guidelines. The impact of including so-called 'prehypertension' among the risk factors was specifically addressed, and the results are discussed in a wider perspective.
Guideline implementation was modelled on data from a cross-sectional Norwegian population study comprising 62 104 adults aged 20-79 years (The Nord-Tröndelag Health Study 1995-7). Total, age- and gender-specific point prevalences of individuals with zero, one, two, three or more factors, in addition to established disease, were calculated.
One single CVD risk factor was exhibited by 12.4% of the population; two factors by 21.5%; and three or more by 49.7%. Established CVD or diabetes mellitus was reported by 12.5%. In total, 83.7% of the population exhibited a risk or disease profile with at least two factors, if prehypertension was included.
If guideline recommendations are literally applied, as many as 84% of adults in Norway could exhibit two or more CVD or risk factors and thus be considered in need of individual, clinical attention. This challenges the widely held presumption that 'the net will close' around a manageable group of individuals-at-risk if several risk factors are jointly considered. As the finding of this study arises in one of the world's most long- and healthy-living populations, it raises several practical as well as ethical questions.
Journal of Evaluation in Clinical Practice 03/2009; 15(1):103-9. · 1.23 Impact Factor
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ABSTRACT: Previous studies indicate that clinical guidelines using combined risk evaluation for cardiovascular diseases (CVD) may overestimate risk. The aim of this study was to model and discuss implementation of the current (2007) hypertension guidelines in a general Norwegian population.
Implementation of the current European Guidelines for the Management of Arterial Hypertension was modelled on data from a cross-sectional, representative Norwegian population study (The Nord-Trøndelag Health Study 1995-97), comprising 65,028 adults, aged 20-89, of whom 51,066 (79%) were eligible for modelling.
Among individuals with blood pressure >or=120/80 mmHg, 93% (74% of the total, adult population) would need regular clinical attention and/or drug treatment, based on their total CVD risk profile. This translates into 296,624 follow-up visits/100,000 adults/year. In the Norwegian healthcare environment, 99 general practitioner (GP) positions would be required in the study region for this task alone. The number of GPs currently serving the adult population in the study area is 87 per 100,000 adults.
The potential workload associated with the European hypertension guidelines could destabilise the healthcare system in Norway, one of the world's most long- and healthy-living nations, by international comparison. Large-scale, preventive medical enterprises can hardly be regarded as scientifically sound and ethically justifiable, unless issues of practical feasibility, sustainability and social determinants of health are considered.
BMC Family Practice 01/2009; 10:70. · 1.80 Impact Factor
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Scandinavian Journal of Primary Health Care 01/2007; 24(4):196-8. · 2.05 Impact Factor
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ABSTRACT: The relative effects of risk factors on the prevalence of resistant pneumococcal clones are hard to determine. Our aim was to evaluate the effect of risk factors on the prevalence of resistant pneumococci in Iceland in 2003 and compare these data with results of identical studies performed in 1993 and 1998. A randomized sample of 1,107 children was chosen from all 2,532 children 1 to 6 years old living in four communities. Pneumococci were carried by 64% of the 824 children enrolled and 9.5% were penicillin nonsusceptible (PNSP), as opposed to 8.1% (1998) and 8.5% (1993), and multiresistant strains of serotype 6B were 2.5% compared to 7.5% and 7.7% (p < 0.001). Antimicrobial use had declined in 10 years from 1.5 to 1.0 courses/child per year. The only significant risk factor for carriage of PNSP and erythromycin-resistant pneumococci was antimicrobial consumption. The multiresistant type 6B strains disappeared from the areas with the lowest antimicrobial use but maintained unchanged prevalence in the area with the highest use. The number of erythromycin- resistant, penicillin-susceptible strains of all pneumococci (37/475, 7.8%) increased significantly from the previous studies (7/353, 2.0%, 1998, and 2/390, 0.5%, 1993). This observation is associated with increased use of macrolides, especially azithromycin, in one of the study areas. Spread of novel resistant clones appears to be the main reason for rapid and significant changes in pneumococcal resistance rates. The choice of antimicrobial class appears to influence the selective environment favoring particular resistant clones.
Microbial Drug Resistance 01/2006; 12(3):169-76. · 2.15 Impact Factor
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ABSTRACT: To investigate potential links between antimicrobial drug use for acute otitis media (AOM) and tympanostomy tube placements, and the relationship between parental views and physician antimicrobial prescribing habits.
Cross-sectional community study repeated after five years.
Representative samples of children aged 1-6 years in four well-defined communities in Iceland, examined in 2003 (n = 889) and 1998 (n = 804).
Prevalence of antimicrobial treatments for AOM, tympanostomy tube placements, and parental expectations of antimicrobial treatment. Results. Tympanostomy tubes had been placed at some time in 34% of children in 2003, as compared with 30% in 1998. A statistically significant association was found between tympanostomy tube placement rate and antimicrobial use for AOM in 2003. In the area where antimicrobial use for AOM was lowest in 1998, drug use had further diminished significantly. At the same time, the prevalence of tympanostomy tube placements had diminished from 26% to 17%. Tube placements had increased significantly, from 35% to 44%, in the area where antimicrobial use for AOM was highest. Parents in the area where antimicrobial consumption was lowest and narrow spectrum antimicrobials were most often used were less likely to be in favour of antimicrobial treatment.
Comparison between communities showed a positive correlation between antimicrobial use for AOM and tympanostomy tube placements. The study supports a restrictive policy in relation to prescriptions of antibiotics for AOM. It also indicates that well-informed parents predict a restrictive prescription policy.
Scandinavian Journal of Primary Health Care 10/2005; 23(3):184-91. · 2.05 Impact Factor
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ABSTRACT: To estimate the high risk group for cardiovascular disease in a well defined Norwegian population according to European guidelines and the systematic coronary risk evaluation system.
Modelling study.
Nord-Tröndelag health study 1995-7 (HUNT 2), Norway.
5548 participants of the Nord-Tröndelag health study 1995-7, aged 40, 50, 55, 60, and 65.
Distribution of risk categories for cardiovascular disease, with emphasis on the high risk group.
At age 40, 22.5% (95% confidence interval 19.3% to 25.7%) of women and 85.9% (83.2% to 88.6%) of men were at high risk of cardiovascular disease. Corresponding numbers at age 50 were 39.5% (35.9% to 43.1%) and 88.7% (86.3% to 91.0%) and at age 65 were 84.0% (80.6% to 87.4%) and 91.6% (88.6% to 94.1%). At age 40, one out of 10 women and no men would be classified at low risk for cardiovascular disease.
Implementation of the 2003 European guidelines on prevention of cardiovascular disease in clinical practice would classify most adult Norwegians at high risk for fatal cardiovascular disease.
BMJ (Clinical research ed.). 10/2005; 331(7516):551.
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Scandinavian Journal of Primary Health Care 07/2005; 23(2):65-7. · 2.05 Impact Factor
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ABSTRACT: Our first objective is to describe total, age- and gender-specific prevalences of subjects in a well-defined population for whom medical follow-up is indicated due to unfavourably high blood pressure and/or cholesterol levels, as defined by the 2003 European guidelines on cardiovascular disease prevention in clinical practice. Our second objective is to highlight scientific questions and ethical dilemmas relating to implementation of the guidelines.
Cross-sectional population study comprising 62104 adult Norwegians aged 20-79 years who participated in The Nord-Tröndelag Health Study 1995--97.
Total, age- and gender-specific point prevalences of individuals with total cholesterol > or =5 mmol/l and/or systolic blood pressure > or =140 mmHg and/or diastolic blood pressure > or =90 mmHg, or taking antihypertensive medication.
In total, 76% of individuals aged 20-79 years have an "unfavourable" cardiovascular disease risk profile, according to guideline definitions. The point prevalence of individuals with cholesterol and/or blood pressure above the recommended cut-off points increases with age. By age 24, the prevalence reaches 50%. By age 49, it reaches 90%. Men below 50 years of age have higher combined risk prevalence than women.
Implementation of the 2003 European guidelines on CVD prevention would label a large majority of Norwegian adults as having unfavourably high cholesterol and/or blood pressure levels. The current biomedical standards appear to invalidate demographic health statistics. The theoretical basis on which the guidelines rest should thereby be scrutinized with regard to scientific methodology and consistency. Important ethical dilemmas arise at the point of guideline implementation, relating to risk labelling and medicalization, as well as resource allocation and sustainability within the healthcare system.
Scandinavian Journal of Primary Health Care 12/2004; 22(4):202-8. · 2.05 Impact Factor
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Lakartidningen 05/2004; 101(15-16):1412-5.
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BMJ (Clinical research ed.). 09/2003; 327(7413):498-500.
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ABSTRACT: Widespread antimicrobial use is a risk factor for development of antimicrobial resistance. Antimicrobial treatment of acute otitis media (AOM) may not always be necessary. Little is known about the influence of parental expectations on physicians' decision-making in relation to treatment of AOM. Evidence is insufficient as to whether tympanostomy tube placement reduces antibiotic consumption.
We randomly selected 1,030 children 1 to 6 years old living in 4 geographic areas in Iceland to be invited to participate in the study. Information about sociodemographic factors, antimicrobial prescriptions and their indications during the preceding 12 months, tympanostomy tube placements and parental views on antimicrobial use and bacterial resistance were obtained from a questionnaire completed by the parents and medical records.
The incidence of AOM episodes resulting in antimicrobial prescription for 804 children recruited into the study was 0.7 (95% confidence interval, 0.6 to 0.8) per child per year, highest among children age 1 year, i.e. 1.8 prescriptions (95% confidence interval, 1.4 to 2.2). The cumulative incidence of tympanostomy tube placements was approximately 30%. Antimicrobial use during the preceding 8 weeks for children with and without tubes did not differ (P = 0.36). Fifteen percent of children with tubes had received antimicrobials during the preceding 8 weeks at last once for AOM compared with 14% of those without tubes (P = 0.97). Parents in the area where antimicrobial consumption was lowest were less likely to accept antimicrobial treatment than parents in the other areas (P = 0.005). Parents of children who had previously received antimicrobials for AOM were more likely to accept antimicrobials (P = 0.04).
Parental expectations to antimicrobial treatment and awareness about resistance development appear to influence treatment strategies for AOM. The high rate of tympanostomy tube placement in preschool children does not result in reduced antimicrobial consumption.
The Pediatric Infectious Disease Journal 01/2003; 21(12):1110-5. · 3.58 Impact Factor
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ABSTRACT: The effects of community-wide interventions to reduce resistance rates are poorly understood. This study evaluated the effect of reduced antimicrobial usage on the spread of penicillin-nonsusceptible pneumococci (PNSP) in four communities in Iceland. The study was performed after interventions to reduce antimicrobial usage and compared to an identical study performed 5 years before. A randomized sample of 953 children was chosen from all 2,900 1- to 6-year-old children living in four well-defined communities. The main outcome measures were nasopharyngeal carriage of PNSP and individual and community use of antimicrobials. Pneumococci were carried by 51.7% of the 743 children enrolled, and 8.1% of the pneumococci were PNSP as opposed to 8.5% in the previous study. The antimicrobial use of participants had been reduced from 1.5 to 1.1 courses/year and the overall use among children <7 years old living in the study areas from 13.6 to 11.1 defined daily dosages/1000 children per day. The prevalence of PNSP increased in the two areas furthest away from the capital area despite reduced consumption. The major risk factors for carriage of PNSP remained the same. Interventions can be effective in reducing antimicrobial use. Pandemic multiresistant clones can also spread fast in small communities with low antimicrobial use, where their appearance may be delayed compared to highly populated urban areas. Clonal spread and herd immunity are important factors to be considered in the evaluation of intervention effects.
Microbial Drug Resistance 01/2002; 8(3):187-92. · 2.15 Impact Factor
