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Background and aims: Some studies point to sex differences in cardiovascular preventive practices. The aim of this study was to investigate differences in achievement of secondary preventive targets and long-term outcome in men and women after a coronary heart event. Methods: This study was a subanalysis from a randomized controlled trial of hospital-based versus primary care-based secondary preventive follow-up at Sorlandet Hospital, Norway, 2007–2022 and included both groups. The main outcome was achievement of treatment targets two years after the index event. Event-free survival was calculated based on the composite of mortality, coronary intervention, stroke, or myocardial infarction during follow-up. Participants were followed-up for up to 10 years after the index event through out-patient consultations. Results: In total, 337 women and 1203 men were eligible for the study. Due to loss of follow-up during the first two years after the index coronary event 106 (7%) participants were excluded from further analysis (53% withdrawal of consent, 12% death, and 35% other causes) leaving 307 (21%) women and 1127 (79%) men. After two years of follow-up we found no differences between women and men in achievement of blood pressure targets (61% vs. 59%; p = 0.57), LDL-cholesterol goals (64% vs. 69%; p = 0.15), HbA1c-goal in patients with diabetes (49% vs. 45%; p = 0.57), non-smoking (79% vs. 81%; p = 0.34), healthy diets (14% vs. 13%, p = 0.89), physical activity (55% vs. 58%; p = 0.38), use of acetylsalicylic acid (93% vs. 94%; p = 0.39), and use of lipid lowering therapy (92% vs. 94%; p = 0.15). After a median follow-up time of 5.0 [SD 3.2] years there were no differences between women and men regarding composite endpoint (89 [30.0%] vs. 345 [30.6]; p = 0.58), and composite endpoint-free survival did not differ between women and men (hospital-based follow-up HR for women versus men, 0.87, 95% CI 0.62–1.23; p = 0.44 and primary care service HR for women versus men 0.95, 95% CI 0.69–1.31; p = 0.78). Conclusions: The study show no sex differences in achievement of secondary preventive targets or composite endpoint after coronary heart events. However, many women and men did not achieve treatment goals, and further improvement in secondary prevention is needed. Trial registration: The study is registered in ClinicalTrials.gov (NCT00679237). [ABSTRACT FROM AUTHOR]

Introduction: A rupture of the anterior cruciate ligament (ACL) is a common knee injury in athletes, often followed by surgical reconstruction. A high percentage returns to high-impact sports, however, up to 25% of those athletes sustain an ACL reinjury.1 Objectives: To summarize evidence-based training modalities as secondary prevention measures after ACL recon- struction Study design: Evidence summary based on a systematic literature review. Methods: Systematic literature search in the databases PubMED and Web of Science with the keywords «ACL, anterior cruciate ligament, reconstruction, reinjury, second injury, rerupture, secondary, prevention, sports» from 2013 to May 2023. Two authors screened the hits independently for title and abstract, followed by full-text reading. Predefined inclusion (adults, professional and amateur athletes after ACL reconstruction), and exclusion criteria (conservative treatment, ACL suture, concomitant or secondary injuries, cadaver or animal study) were used. Injury of the contralateral side, rerupture of the reconstructed ACL and modification of risk factors for ACL reinjury were chosen as outcomes. The final study selection was made by consensus. Included studies were assessed for risk of bias by using the Critical Appraisal Skills Programme checklist.2 Results: From 923 hits, seven studies with a total of 560 athletes, one systematic literature review, three randomized controlled trials and three cohort studies were included for qualitative analysis. The included literature showed moderate to high quality. Secondary prevention programs with neuromuscular training, eccentric training and plyometric exercises and core strenghtening showed a positive impact on spine, knee and hip joint biomechanics, functional and clinical outcomes in patients after ACL reconstruction. Conclusions: The interventions in the included literature were shown to reduce various risk factors for ACL reinjury. However, the included studies were heterogeneous regarding interventions and outcomes. As ACL reinjury is multifactorial, it is recommended not to focus on one specific risk factor or outcome. [ABSTRACT FROM AUTHOR]

Background and aims: Identification of high-risk patients in secondary cardiovascular prevention may be challenging, although risk stratification tools are available. Cardiac troponins might have predictive value in identification of high-risk patients. The aim of this study was to investigate the association between cardiac Troponin T (cTnT) levels following a coronary event and long-term outcomes. Methods: This study was carried out as a subanalysis from a randomized controlled trial conducted at Sørlandet Hospital, Norway, where patients hospitalized with myocardial infarction (MI) or scheduled percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG) were included between 2007 and 2017. Participants were followed-up for up to 10 years after the index event through out-patient consultations. cTnT was assessed at each consultation as well as information regarding new cardiovascular events or death. Results: A total of 1278 patients (18–80 years) with complete measurements of cTnT were included. cTnT was elevated (≥ 14 ng/L) one year after the primary event in 241 (19%) of participants. Median follow-up was 5.7 [SD 2.7] years. Cox regression analyses showed reduced survival (adjusted HR 0.37, 95% CI 0.19–0.72; p = 0.003) and composite endpoint-free survival (adjusted HR 0.73, 95% CI 0.55–0.98; p = 0.04) in participants with elevated cTnT versus participants with low cTnT after adjustment for risk factors at inclusion and randomization assignment. Conclusions: Assessment of cTnT after coronary heart events may help identify patients at high risk of poor outcomes and might contribute to more focused secondary preventive treatment. Trial registration: The study is registered in ClinicalTrials.gov (NCT00679237). [ABSTRACT FROM AUTHOR]

Background: Machine learning (ML) is increasingly used to predict suicide deaths but their value for suicide prevention has not been established. Our first objective was to identify risk and protective factors in a general population. Our second objective was to identify factors indicating imminent suicide risk. Methods: We used survival and ML models to identify lifetime predictors using the Cohort of Norway (n=173,275) and hospital diagnoses in a Saskatoon clinical sample (n=12,614). The mean follow-up times were 17 years and 3 years for the Cohort of Norway and Saskatoon respectively. People in the clinical sample had a longitudinal record of hospital visits grouped in six-month intervals. We developed models in a training set and these models predicted survival probabilities in held-out test data. Results: In the general population, we found that a higher proportion of low-income residents in a county, mood symptoms, and daily smoking increased the risk of dying from suicide in both genders. In the clinical sample, the only predictors identified were male gender and older age. Conclusion: Suicide prevention probably requires individual actions with governmental incentives. The prediction of imminent suicide remains highly challenging, but machine learning can identify early prevention targets. [ABSTRACT FROM AUTHOR]

Background and Aims: Despite established guidelines on secondary prevention of cardiovascular disease, practical implementation of treatment targets is deficient even in high-income countries. This study compared long-term hospital-based treatment with follow-up at primary health care regarding new cardiovascular events and achievement of treatment targets.Methods: This randomized controlled trial at Sørlandet Hospital, Norway 2007-2021 included patients hospitalized due to myocardial infarction (n = 760) or after scheduled percutaneous coronary intervention (PCI) (n = 677) or coronary artery bypass grafting (n = 103). Patients were randomized to hospital-based secondary preventive care with consultations 2 weeks, 3 months, 6 months and 1 year after the index event and annually for up to 5 years, or follow-up at primary health care. Final data was collected after 10 years and hazard ratios were calculated using Cox regression analyses.Results: Composite endpoint-free survival due to a lower rate of PCI improved in patients with hospital-based follow-up (n = 788) compared to patients followed-up at primary health care (n = 752) (HR 0.80, 95% CI 0.66-0.96; p = 0.02) but all-cause mortality was not reduced (HR 0.96, 95% CI 0.59-1.56; p = 0.86). At 1 year, LDL-cholesterol (2.1 [SD 0.7] versus 2.3 [SD 0.8] mmol/l; p < 0.001) and systolic blood pressure (132 [SD 16] versus 142 [SD 20] mm/Hg; p < 0.001) were lower in the hospital-based group, and the differences remained significant during the first 5 years. Other secondary preventive measures (smoking cessation, physical activity, body weight, glucose control, drug adherence) did not differ.Conclusions: Long-term hospital-based secondary preventive follow-up improved composite endpoint-free survival, but not mortality. Substantial risk factors remained unaddressed. The beneficial effects on blood pressure and LDL-cholesterol disappeared after annual consultations ceased.Trial Registration: The study is registered in ClinicalTrials.gov (NCT00679237) May 16, 2008. [ABSTRACT FROM AUTHOR]

Objective. To determine longitudinal changes in lifestyle behaviour and lipid management in a chronic coronary heart disease (CHD) population. Design. A multi-centre cohort study consecutively included 1127 patients at baseline in 2014–2015, on average 16 months after a CHD event. Data were collected from hospital records, a questionnaire and clinical examination. Seven hundred and seven of 1021 eligible patients participated in a questionnaire-based follow-up in 2019. Data were analysed with univariate statistics. Results. After a mean follow-up of 4.7 years (SD 0.4) from baseline, the percentage of current smokers (15% versus 16%), obesity (23% versus 25%) and clinically significant symptoms of anxiety (21% versus 17%) and depression (13% versus 14%) remained unchanged, whereas the proportion with low physical activity increased from 53% to 58% (p <.001). The proportions with reduced physical activity level were similar in patients over and under 70 years of age. Most patients were still taking statins (94% versus 92%) and more patients used high-intensity statin (49% versus 54%, p <.001) and ezetimibe (5% versus 15%, p <.001) at follow-up. 73% reported ≥1 primary-care consultation(s) for CHD during the last year while 27% reported no such follow-up. There were more smokers among participants not attending primary-care consultations compared to those attending (19% versus 14%, p =.026). No differences were found for other risk factors. Conclusions. We found persistent suboptimal risk factor control in coronary outpatients during long-term follow-up. Closer follow-up and intensified risk management including lifestyle and psychological health are needed to improved secondary prevention and outcome of CHD. Trial registration: Registered at ClinicalTrials.gov: NCT02309255. Registered at 5 December 2014, registered retrospectively. [ABSTRACT FROM AUTHOR]

Background: Vocational support is recommended for patients in cardiac rehabilitation (CR), as returning to work is important in patients social readjusting after an acute coronary event. Information is lacking on whether CR leads to higher long-term employment after percutaneous coronary intervention (PCI). Aims: The aims of this study were to determine employment status three years after PCI, to compare employment status between CR participants and CR non-participants and to assess predictors for employment. Methods: We included first-time PCI patients from the NorStent trial, who were of working age (<63 years; n = 2488) at a three-year follow-up. Employment status and CR participation were assessed using a self-report questionnaire. Propensity score method was used in comparing employment status of CR participants and CR non-participants. Results: Seventy per cent of participants who were <60 years of age at the index event were employed at follow-up and CR participation had no effect on employment status. Being male, living with a partner and attaining higher levels of education were associated with a higher chance of being employed, while being older, prior cardiovascular morbidity and smoking status were associated with lower chance of being employed at follow-up. Conclusion: Because a significant number of working-age coronary heart disease patients are unemployed three years after coronary revascularization, updated incentives should be implemented to promote vocational support. Such programmes should focus on females, patients lacking higher education and patients who are living alone, as they are more likely to remain unemployed. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease (CVD) mortality is substantially higher in Russia than in neighbouring Norway. We aimed to compare blood pressure- and lipid-lowering medication use and proportion meeting treatment targets between general population samples in the two countries in those with CVD and diabetes.Methods: The study population was adults aged 40-69 years reporting a diagnosis of myocardial infarction (MI), stroke and/or diabetes participating in cross-sectional population-based studies in Russia (Know Your Heart (KYH) 2015-18 N = 626) and Norway (The Tromsø Study 2015-16 (Tromsø 7) N = 1353). Reported medications were coded according to the 2016 WHO Anatomical Therapeutic Chemical Classification system. Treatment targets were defined using the Joint European Societies guidelines for CVD prevention in clinical practice (2016).Results: Age- and sex-standardized prevalence of use of lipid-lowering medications was higher in Tromsø 7 for all three conditions with a disproportionately large difference in those reporting MI (+ 48% (95% CI 39, 57%)). Proportion meeting treatment targets for LDL cholesterol was poor in both studies (age- and sex-standardized prevalence of control KYH vs Tromsø 7: MI 5.1% vs 10.1%; stroke 11.6% vs 5.8%; diabetes 24.9% vs 23.3%). Use of antihypertensive medication was higher in KYH for stroke (+ 40% (95% CI 30, 50%)) and diabetes (+ 27% (95% CI 19, 34%)) groups but approximately equal for the MI group (- 1% (95% CI -1, 1%)). Proportion meeting blood pressure targets was lower in KYH vs Tromsø 7 (MI 51.8% vs 76.3%; stroke 49.5% vs 69.6%; diabetes 51.9% vs 63.9%).Conclusions: We identified different patterns of medication use in people with CVD and diabetes. However despite higher use of lipid-lowering medication in the Norwegian study treatment to target for total cholesterol was poor in both Russian and Norwegian studies. In contrast we found higher levels of use of antihypertensive medications in the Russian study but also that less participants met treatment targets for blood pressure. Further work should investigate what factors are responsible for this seeming paradox and how management of modifiable risk factors for secondary prevention could be improved. [ABSTRACT FROM AUTHOR]

Aim: The purpose of this study was to estimate the proportion of Norwegian coronary heart disease patients participating in cardiac rehabilitation programmes after percutaneous coronary intervention, and to determine predictors of cardiac rehabilitation participation. Methods: Participants were patients enrolled in the Norwegian Coronary Stent Trial. We assessed cardiac rehabilitation participation in 9013 of these patients who had undergone their first percutaneous coronary intervention during 2008–2011. Of these, 7068 patients (82%) completed a self-administered questionnaire on cardiac rehabilitation participation within three years after their percutaneous coronary intervention. Results: Twenty-eight per cent of the participants reported engaging in cardiac rehabilitation. Participation rate differed among the four regional health authorities in Norway, varying from 20%–31%. Patients undergoing percutaneous coronary intervention for an acute coronary syndrome were more likely to participate in cardiac rehabilitation than patients with stable angina (odds ratio 3.2; 95% confidence interval 2.74–3.76). A multivariate statistical model revealed that men had a 28% lower probability (p<0.001) of participating in cardiac rehabilitation, and the odds of attending cardiac rehabilitation decreased with increasing age (p<0.001). Contributors to higher odds of cardiac rehabilitation participation were educational level >12 years (odds ratio 1.50; 95% confidence interval 1.32–1.71) and body mass index>25 (odds ratio 1.19; 95% confidence interval 1.05–1.36). Prior coronary artery bypass graft was associated with lower odds of cardiac rehabilitation participation (odds ratio 0.47; 95% confidence interval 0.32–0.70) Conclusion: The estimated cardiac rehabilitation participation rate among patients undergoing first-time percutaneous coronary intervention is low in Norway. The typical participant is young, overweight, well-educated, and had an acute coronary event. These results varied by geographical region. [ABSTRACT FROM AUTHOR]

Aims: Self-reported information from questionnaires is frequently used in clinical epidemiological studies, but few provide information on the reproducibility of instruments applied in secondary coronary prevention studies. This study aims to assess the test–retest reproducibility of the questionnaire applied in the cross-sectional NORwegian CORonary (NOR-COR) Prevention Study. Methods: In the NOR-COR study 1127 coronary heart disease (CHD) patients completed a self-report questionnaire consisting of 249 questions, of which there are both validated instruments and de novo questions. Test–retest reliability of the instrument was estimated after four weeks in 99 consecutive coronary patients. Intraclass Correlation Coefficient (ICC) and Kappa (κ) were calculated. Results: The mean interval between test and retest was 33 (±6.4) days. Reproducibility values for questions in the first part of the questionnaire did not differ from those in the latter. A good to very good reproducibility was found for lifestyle factors (smoking: κ = 1.0; exercise: ICC = 0.90), medical factors (drug adherence: ICC = 0.74; sleep apnoea: ICC = 0.87), and psychosocial factors (anxiety and depression: ICC = 0.95; quality of life 12-Item Short-Form Health Survey (SF12): ICC = 0.89), as well as for the majority of de-novo-created variables covering the patient’s perceptions, motivation, needs, and preferences. Conclusions: The present questionnaire demonstrates a highly acceptable reproducibility for all key items and instruments. It thus emerges as a valuable tool for evaluating patient factors associated with coronary risk factor control in CHD patients. [ABSTRACT FROM AUTHOR]

Background: Risk factor control after a coronary event in a recent European multi-centre study was inadequate. Patient selection from academic centres and low participation rate, however, may underscore failing risk factor control in routine clinical practice. Improved understanding of the patient factors that influence risk factor control is needed to improve secondary preventive strategies. The objective of the present paper was to determine control of the major risk factors in a coronary population from routine clinical practice, and how risk factor control was influenced by the study factors age, gender, number of coronary events, and time since the index event.Methods: A cross-sectional study determined risk factor control and its association with study factors in 1127 patients (83% participated) aged 18-80 years with acute myocardial infarction and/or revascularization identified from medical records. Study data were collected from a self-report questionnaire, clinical examination, and blood samples after 2-36 months (median 16) follow-up.Results: Twenty-one percent were current smokers at follow-up. Of those smoking at the index event 56% continued smoking. Obesity was found in 34%, and 60% were physically inactive. Although 93% were taking blood-pressure lowering agents and statins, 46% were still hypertensive and 57% had LDL cholesterol >1.8 mmol/L at follow-up. Suboptimal control of diabetes was found in 59%. The patients failed on average to control three of the six major risk factors, and patients with >1 coronary events (p < 0.001) showed the poorest overall control. A linear increase in smoking (p < 0.01) and obesity (p < 0.05) with increasing time since the event was observed.Conclusions: The majority of coronary patients in a representative Norwegian population did not achieve risk factor control, and the poorest overall control was found in patients with several coronary events. New strategies for secondary prevention are clearly needed to improve risk factor control. Even modest advances will provide major health benefits.Trial Registration: Registered at ClinicalTrials.gov (ID NCT02309255 ). [ABSTRACT FROM AUTHOR]

Background: Secondary preventive drug therapy following acute myocardial infarction (AMI) is recommended to reduce the risk of new cardiovascular events. The aim of this nationwide cohort study was to examine the initiation and long-term use of secondary preventive drugs after AMI.Methods: The prescription of drugs in 42,707 patients < 85 years discharged alive from hospital after AMI in 2009-2013 was retrieved by linkage of the Norwegian Patient Register, the Norwegian Prescription Database, and the Norwegian Cause of Death Registry. Patients were followed for up to 24 months.Results: The majority of patients were discharged on single or dual antiplatelet therapy (91 %), statins (90 %), beta-blockers (82 %), and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor II blockers (ARB) (60 %). Patients not undergoing percutaneous coronary intervention (PCI) (42 %) were less likely to be prescribed secondary preventive drugs compared with patients undergoing PCI. This was particular the case for dual antiplatelet therapy (43 % vs. 87 %). The adherence to prescribed drugs was high: 12 months after index AMI, 84 % of patients were still on aspirin, 84 % on statins, 77 % on beta-blockers and 57 % on ACEI/ARB. Few drug and dose adjustments were made during follow-up.Conclusion: Guideline-recommended secondary preventive drugs were prescribed to most patients discharged from hospital after AMI, but the percentage receiving such therapy was significantly lower in non-PCI patients. The long-time adherence was high, but few drug adjustments were performed during follow-up. More attention is needed to secondary preventive drug therapy in AMI patients not undergoing PCI. [ABSTRACT FROM AUTHOR]

Background and purpose Exercise adherence in general is reported to be problematic after cardiac rehabilitation. Additionally, vigorous exercise is associated with impaired exercise adherence. As high-intensity interval training (HIT) is frequently used as a therapy to patients with coronary artery disease in cardiac rehabilitation, the objective was to assess long-term exercise adherence following an HIT cardiac rehabilitation programme. Methods A multicentre randomized study was carried out. Eligible participants were adults who had previously attended a 12-week HIT cardiac rehabilitation programme, as either a home-based or hospital-based HIT (treadmill exercise or group exercise). The primary outcome was change in peak oxygen uptake; secondary outcomes were self-reported and objectively measured physical activity. Results Out of 83 eligible participants, 76 were available for assessment (68 men/8 women, mean age 59 (8) years) at a one-year follow-up. Peak oxygen uptake was significantly elevated above baseline values, (treadmill exercise: 35.8 (6.4) vs. 37.4 (7.4) ml kg−1 min−1, group exercise: 32.7 (6.5) vs. 34.1 (5.8) ml kg−1 min−1 and home-based exercise: 34.5 (4.9) vs. 36.7 (5.8) ml kg−1 min−1 at baseline and follow-up, respectively), with no significant differences between groups. The majority of the participants (>90%) met the recommended daily level of 30 minutes of moderate physical activity. The home-based group showed a strong trend towards increased physical activity compared with the hospital-based groups. Discussion The results from this study have shown that both home-based and hospital-based HIT in cardiac rehabilitation induce promising long-term exercise adherence, with maintenance of peak oxygen uptake significantly above baseline values at a one-year follow-up. The implication for physiotherapy practice is that HIT in cardiac rehabilitation induces satisfactory long-term exercise adherence. Copyright © 2015 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: This project aims to identify socio-demographic, medical and psychosocial factors (study factors) associated with coronary risk control and prognosis, and to test their impact in a representative sample of coronary heart disease (CHD) patients.Design: The first phase includes a cross-sectional study designed to explore the association between the study factors and coronary risk factor control in CHD patients. Data from hospital records, a questionnaire, clinical examination and blood samples were collected. The independent effects of study factors on subsequent coronary events will be explored prospectively by controlling for baseline coronary risk factors. In the second phase, we will test the effect of tailored interventions to modify the study factors associated with unfavourable risk profile in phase I.Results: In all 1366 patients (21% women), aged 18-80 years with a coronary event on average 17 (2-38) months prior to study participation were identified (83% participation rate). Of the 239 patients who refused participation, 229 patients consented to analysis of hospital record data (non- participants).Conclusions: If the study variables contribute to CHD risk factors and prognosis, the present project may be important for the development of prevention programs by tailoring these to the patients perceived needs and behaviour profiles. [ABSTRACT FROM AUTHOR]

Background: There is a lack of studies on the knowledge and skills needed for patient education of individuals with coronary heart disease. Better understanding of what competencies health professionals see as necessary for patient education in secondary prevention can contribute to improved education of educators, and thus, improved patient education. Aim: The purpose of this study was to investigate health professionals’ views on the knowledge and skills necessary in conducting high-quality patient education for adults recently diagnosed with coronary heart disease. Methods: A qualitative study was conducted using individual interviews with health professionals with experience from different types of patient education in cardiac care. The interviews were analysed using systematic text condensation. Results: The informants were 19 Icelandic and Norwegian registered nurses, physiotherapists and cardiologists. Sound updated theoretical and clinical knowledge, along with advanced communication skills, was considered essential for patient education. This includes being able to establish interpersonal relationships with patients, capturing their learning needs, facilitating an effective dialogue and providing individualised patient centred education and lifestyle counselling. Conclusions: Evidence-based patient education requires knowledgeable health professionals with advanced communication skills and pedagogical competences that enable them to motivate patients and provide effective patient centred lifestyle counselling. [ABSTRACT FROM AUTHOR]

Objective - To examine changing trends in the field of secondary prevention of atherosclerotic disease in Norwegian general practice. Design - A multipractice survey of consecutive patients with atherosclerotic disease consulting general practitioners in 1994/95 compared with a similar survey in 1996/97. Setting - Primary health care. Subjects - 707 patients attending 31 general practitioners in 1994/95 and 1353 patients attending 63 general practitioners in 1996/97. Main outcome measures - The patients were examined and interviewed for risk factors and pharmacological treatment. Results - In 1994/95, 18% of the patients had been prescribed a lipid-lowering agent as opposed to 55% in the later survey. Consequently, the average level of LDL cholesterol in the 1996/97 population was 19% lower than in the 1994/95 population (3.8 mmol/l vs 4.7 mmol/l), which may imply a marked risk reduction. Aspirin and beta-blockers were prescribed to approximately 50% of the patients in both surveys. Diabetic patients had the same drug prescription rate and lipid profile as non-diabetics. In both surveys, about 25% of the patients were smokers. Conclusion – Secondary prevention in the majority of patients with atherosclerotic disease though ameliorating is still unsatisfactory. More attention is needed to achieve and sustain treatment goals. [ABSTRACT FROM AUTHOR]

Study Objectives: The aim of this study was to determine the prevalence of insomnia and its association with clinical and psychosocial factors in a large sample of outpatients with coronary heart disease., Methods: The sample comprised 1,082 patients, mean age 62 years (21% female), who participated in the cross-sectional NORwegian CORonary Prevention Study. Patients who were hospitalized with myocardial infarction and/or a coronary revascularization procedure in 2011-2014 responded to a self-report questionnaire and participated in a clinical examination with blood samples 2-36 (mean, 16) months later. Insomnia was assessed using the Bergen Insomnia Scale, a questionnaire based on the criteria for the clinical diagnosis of insomnia as described in the Diagnostic and Statistical Manual of Mental Disorders, fourth version. We performed bivariate logistic regressions for crude analysis and backward stepwise logistic regressions for multiadjusted odds ratios (OR)., Results: In total, 488 patients (45%) reported insomnia, and 24% of these patients had used sleep medication in the previous week. Anxiety symptoms (OR: 5.61) were the strongest determinants of insomnia, followed by female sex (OR: 1.88), diabetes (OR: 1.83), eating fish fewer than three times a week (OR: 1.69), type D personality (OR: 1.69), and C-reactive protein ≥ 2 mg/L (OR:1.58), in multiadjusted analyses., Conclusions: Insomnia was highly prevalent in coronary heart disease outpatients. Psychological factors, lifestyle factors, and subclinical inflammation were associated with insomnia. Our results emphasize the need to identify patients with insomnia and provide appropriate management of insomnia in outpatients with coronary heart disease., (© 2021 American Academy of Sleep Medicine.)

Background: Studies regarding adequacy of secondary stroke prevention are limited. We report medication adherence, risk factor control and factors influencing vascular risk profile following ischaemic stroke., Methods: A total of 664 home-dwelling participants in the Norwegian Cognitive Impairment After Stroke study, a multicenter observational study, were evaluated 3 and 18 months poststroke. We assessed medication adherence by self-reporting (4-item Morisky Medication Adherence Scale) and medication persistence (defined as continuation of medication(s) prescribed at discharge), achievement of guideline-defined targets of blood pressure (BP) (<140/90 mmHg), low-density lipoprotein cholesterol (LDL-C) (<2.0 mmol L -1 ) and haemoglobin A1c (HbA1c) (≤53 mmol mol -1 ) and determinants of risk factor control., Results: At discharge, 97% were prescribed antithrombotics, 88% lipid-lowering drugs, 68% antihypertensives and 12% antidiabetic drugs. Persistence of users declined to 99%, 88%, 93% and 95%, respectively, at 18 months. After 3 and 18 months, 80% and 73% reported high adherence. After 3 and 18 months, 40.7% and 47.0% gained BP control, 48.4% and 44.6% achieved LDL-C control, and 69.2% and 69.5% of diabetic patients achieved HbA1c control. Advanced age was associated with increased LDL-C control (OR 1.03, 95% CI 1.01 to 1.06) and reduced BP control (OR 0.98, 0.96 to 0.99). Women had poorer LDL-C control (OR 0.60, 0.37 to 0.98). Polypharmacy was associated with increased LDL-C control (OR 1.29, 1.18 to 1.41) and reduced HbA1c control (OR 0.76, 0.60 to 0.98)., Conclusion: Risk factor control is suboptimal despite high medication persistence and adherence. Improved understanding of this complex clinical setting is needed for optimization of secondary preventive strategies., (© 2020 The Authors. Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.)

Background: Secondary prophylactic drugs are important for avoiding further cardiovascular events after myocardial infarction. We have examined whether patients collect these drugs from pharmacies and whether there are differences in survival between those who collect versus do not collect the drugs., Material and Method: All patients <80 years registered in the Norwegian Myocardial Infarction Registry in 2013-16 were included in the study. The Norwegian Prescription Database was used to determine whether patients collected their prescriptions from pharmacies., Results: During the study period, 32 328 patients under the age of 80 were registered in the Norwegian Myocardial Infarction Registry, of whom 96 % were discharged alive. The proportion of patients who were prescribed acetylsalicylic acid was 95 %, two antiplatelet agents, 83 %; a statin, 90 %; beta-blockers, 76 %; and ACE inhibitors/AII receptor blockers, 55 %. The proportions of patients who collected each of these drugs from a pharmacy within six months were 94 %, 90 %, 96 %, 95 % and 94 %, respectively. The combined incidence of death, stroke and myocardial infarction during the follow-up period (median 944 days) was higher among patients who did not collect all of their prescribed drugs (adjusted HR 1.7; 95 % CI 1.6-1.8). Among patients who died, the median time to death was 509 days for those who collected all of their prescribed drugs versus 126 days for those who did not (p <0.001)., Interpretation: Most patients do collect prescribed drugs from a pharmacy after myocardial infarction. A shorter time to death among patients who do not collect the drugs may suggest a high degree of general morbidity in this group.

Background: The relative importance of lifestyle, medical and psychosocial factors on the risk of recurrent major cardiovascular (CV) events (MACE) in coronary patients' needs to be identified. The main objective of this study is to estimate the association between potentially preventable factors on MACE in an outpatient coronary population from routine clinical practice., Methods: This prospective follow-up study of recurrent MACE, determine the predictive impact of risk factors and a wide range of relevant co-factors recorded at baseline. The baseline study included 1127 consecutive patients 2-36 months after myocardial infarction (MI) and/or revascularization procedure. The primary composite endpoint of recurrent MACE defined as CV death, hospitalization due to MI, revascularization, stroke/transitory ischemic attacks or heart failure was obtained from hospital records. Data were analysed using cox proportional hazard regression, stratified by prior coronary events before the index event., Results: During a mean follow-up of 4.2 years from study inclusion (mean time from index event to end of study 5.7 years), 364 MACE occurred in 240 patients (21, 95% confidence interval: 19 to 24%), of which 39 were CV deaths. In multi-adjusted analyses, the strongest predictor of MACE was not taking statins (Relative risk [RR] 2.13), succeeded by physical inactivity (RR 1.73), peripheral artery disease (RR 1.73), chronic kidney failure (RR 1.52), former smoking (RR 1.46) and higher Hospital Anxiety and Depression Scale-Depression subscale score (RR 1.04 per unit increase). Preventable and potentially modifiable factors addressed accounted for 66% (95% confidence interval: 49 to 77%) of the risk for recurrent events. The major contributions were smoking, low physical activity, not taking statins, not participating in cardiac rehabilitation and diabetes., Conclusions: Coronary patients were at high risk of recurrent MACE. Potentially preventable clinical and psychosocial factors predicted two out of three MACE, which is why these factors should be targeted in coronary populations., Trial Registration: Registered at ClinicalTrials.gov: NCT02309255. Registered at December 5th, 2014, registered retrospectively.

Background: Patients with established coronary artery disease (CAD) have an increased risk of new cardiovascular events. An underuse of secondary preventive drugs has been observed, and many patients may not attain the treatment goals for secondary prevention. The aims of the present nationwide register-based cohort study were to assess the degree of risk factor control and long-term outcomes in patients < 80 years with Type 1 myocardial infarction (MI) with and without prior CAD., Methods: Data concerning all patients with MI admitted to hospitals in Norway from 2013 to 2016 were retrieved from the Norwegian Myocardial Infarction Register (NORMI). Long-term mortality was obtained through linkage with the Norwegian Cause of Death Registry., Results: In total, 47,204 patients were registered in the NORMI from 2013 to 2016. Prior CAD was recorded in 7219 (25.2%) of the 28,607 patients < 80 years old with Type 1 MIs. On average, 3 of the 6 defined treatment targets for secondary preventive therapy were attained, and only 1% of the patients achieved all targets. Patients with MI and prior CAD had increased risk of death or new MI compared to patients without prior CAD during long-term follow-up (adjusted HR 1.6, 95% CI 1.5-1.7)., Conclusions: Prior CAD was frequent in patients with acute MI. The attainment of secondary preventive treatment targets in patients with MI and prior CAD was not optimal, and the long-term outcomes were reduced compared to patients without prior CAD. Increased efforts to improve risk factor control are needed.

Background: After a stroke, a person has an increased risk of recurrent strokes. Effective secondary prevention can provide significant gains in the form of reduced disability and mortality. While considerable efforts have been made to provide high quality acute treatment of stroke, there has been less focus on the follow-up in general practice after the stroke. One strategy for the implementation of high quality, evidence-based treatment is the development and distribution of clinical guidelines. However, from similar fields of practice, we know that guidelines are often not adhered to. The purpose of this study was to investigate to what degree patients who have suffered a stroke are followed up in general practice, if recommendations in the national guidelines are followed, and if patients achieve the treatment goals recommended in the guidelines. Methods: The study included patients with cerebral infarction identified by the ICD-10 discharge diagnoses I63.0 trough I63.9 in two Norwegian local hospitals. In total 51 patients participated. They were listed with general practitioners in 18 different clinics. The material consists of the general practitioners' (GPs') medical records for these patients in the first year of follow-up; in total 381 consultations. Results: Of the 381 consultations during the first year of follow-up, 71 (19%) had stroke as the main topic. The blood pressure (BP) target value < 140/90 mmHg was reached by 24 patients (47%). The low density lipoprotein (LDL) cholesterol target value < 2.0 mmol/L was reached by 14 (27%) of the 51 patients. In total six patients (12%) got advice on physical activity and three (6%) received dietary advice. No advice about alcohol consumption was recorded. Conclusions: The findings support earlier claims that the development and distribution of guidelines alone is not enough to implement a certain practice. Despite being a serious condition, stroke gets limited attention in the first year of follow-up in general practice. This can be explained by the complexity of general practice, where even a serious condition loses the competition for attention to other apparently equally important issues. [ABSTRACT FROM AUTHOR]

Background: Understanding the determinants associated with prediabetes and type 2 diabetes in coronary patients may help to individualize treatment and modelling interventions. We sought to identify sociodemographic, medical and psychosocial factors associated with normal blood glucose (HbA1c < 5.7%), prediabetes (HbA1c 5.7-6.4%), and type 2 diabetes., Methods: A cross-sectional explorative study applied regression analyses to investigate the factors associated with glycaemic status and control (HbA 1c level) in 1083 patients with myocardial infarction and/or a coronary revascularization procedure. Data were collected from hospital records at the index event and from a self-report questionnaire and clinical examination with blood samples at 2-36 months follow-up., Results: In all, 23% had type 2 diabetes, 44% had prediabetes, and 33% had normal blood glucose at follow-up. In adjusted analyses, type 2 diabetes was associated with larger waist circumference (Odds Ratio 1.03 per 1.0 cm, p = 0.001), hypertension (Odds Ratio 2.7, p < 0.001), lower high-density lipoprotein cholesterol (Odds Ratio 0.3 per1.0 mmol/L, p = 0.002) and insomnia (Odds Ratio 2.0, p = 0.002). In adjusted analyses, prediabetes was associated with smoking (Odds Ratio 3.3, p = 0.001), hypertension (Odds Ratio 1.5, p = 0.03), and non-participation in cardiac rehabilitation (Odds Ratio 1.7, p = 0.003). In patients with type 2 diabetes, a higher HbA 1c level was associated with ethnic minority background (standardized beta [β] 0.19, p = 0.005) and low drug adherence (β 0.17, p = 0.01). In patients with prediabetes or normal blood glucose, a higher HbA 1c was associated with larger waist circumference (β 0.13, p < 0.001), smoking (β 0.18, p < 0.001), hypertension (β 0.08, p = 0.04), older age (β 0.16, p < 0.001), and non-participation in cardiac rehabilitation (β 0.11, p = 0.005)., Conclusions: Along with obesity and hypertension, insomnia and low drug adherence were the major modifiable factors associated with type 2 diabetes, whereas smoking and non-participation in cardiac rehabilitation were the factors associated with prediabetes. Further research on the effect of individual tailoring, addressing the reported significant predictors of failure, is needed to improve glycaemic control., Trial Registration: Retrospectively registered at ClinicalTrials.gov: NCT02309255 , December 5th 2014.

Background Anxiety and depression are related to coronary heart disease, and psychological support is recommended in cardiac rehabilitation. Purpose The aims of this study were: to compare the prevalence of anxiety and depression with respect to cardiac rehabilitation participation among patients who have been treated with percutaneous coronary intervention; to examine prevalence of anxiety and depression among percutaneous coronary intervention patients compared to the general population; and to identify predictors of symptomatic anxiety and depression among percutaneous coronary intervention patients. Methods We included 9013 patients undergoing first-time percutaneous coronary intervention. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale in a representative sample of 775 patients at baseline and after three years of follow-up, and in the entire cohort at three-year follow-up. Results Cardiac rehabilitation participants had more anxiety and depression than cardiac rehabilitation non-participants at baseline, and both groups had a more anxiety than the general population. The levels of anxiety and depression fell significantly during three years of follow-up, but the changes did not differ between cardiac rehabilitation participants and cardiac rehabilitation non-participants. Three years after percutaneous coronary intervention the prevalence of anxiety was 32% ( p < 0.001), higher among cardiac rehabilitation participants compared to cardiac rehabilitation non-participants. Female gender and younger age were associated with anxiety, whereas older age, lower levels of education and cardiovascular morbidity were associated with depression. Conclusion The levels of anxiety and depression were prevalent among percutaneous coronary intervention patients and the levels were not affected by cardiac rehabilitation participation. Anxiety is prevalent among female and younger patients, whereas depression is related to older age and cardiovascular co-morbidity.

Objective An interleukin-beta antagonist reduces the risk of subsequent cardiovascular events in coronary patients with high-sensitivity C-reactive protein (hs-CRP) ≥2 mg/L. It remains to be defined how large the coronary population at inflammatory risk is, and what the predictors of elevated risk are. Methods A cross-sectional study investigated the proportion of patients with elevated hs-CRP (i.e. ≥2 mg/L) and the respective demographic and clinical predictors in 971 patients without concomitant inflammatory diseases who had been hospitalized with myocardial infarction (80%) and/or a revascularization procedure. Data were collected from hospital records, a self-report questionnaire and a clinical examination with blood samples. Results After 2-36 month follow-up, 39% ( n = 378) had hs-CRP ≥ 2 mg/L, among whom 64% ( n = 243) had low-density lipoprotein cholesterol (LDL-C) ≥1.8 mmol/L and 47% ( n = 176) used a low-intensity statin regime. Only 24% had both LDL and hs-CRP at target range, 27% had elevation of both, whereas 12% had hs-CRP ≥ 2 mg/L and LDL-C < 1.8 mmol/L. Somatic comorbidity (odds ratio (OR) 1.3/1.0 point on the Charlson score), ≥1 previous coronary event (OR 2.4), smoking (OR 2.2), higher body mass index (OR 1.2/1.0 kg/m 2 ), high LDL-C (OR 1.4/1.0 mmol/L) and higher anxiety scores (OR 1.1/1.0 point increase on the Hospital Anxiety and Depression Scale-Anxiety subscale score) were significantly associated with hs-CRP ≥2 mg/L in adjusted analyses. Conclusions Elevated hs-CRP was frequently observed after a coronary event and associated with unfavourable LDL-C and unhealthy lifestyles and psychosocial distress. Intensified statin therapy and strategies to target these modifiable factors are the encouraged first steps to reduce inflammation and improve LDL-C in these patients.

Objective Understanding the determinants of low-density lipoprotein cholesterol (LDL-C) control constitutes the basis of modelling interventions for optimal lipid control and prognosis. We aim to identify medical and psychosocial (study) factors associated with unfavourable LDL-C control in coronary patients. Methods A cross-sectional explorative study used logistic and linear regression analysis to investigate the association between study factors and LDL-C in 1095 patients, hospitalized with myocardial infarction and/or a coronary revascularization procedure. Data were collected from hospital records, a comprehensive self-report questionnaire, clinical examination and blood samples after 2-36 months follow-up. Results Fifty-seven per cent did not reach the LDL-C target of 1.8 mmol/l at follow-up. Low socioeconomic status and psychosocial factors were not associated with failure to reach the LDL-C target. Statin specific side-effects (odds ratio 3.23), low statin adherence (odds ratio 3.07), coronary artery by-pass graft operation as index treatment (odds ratio 1.95), ≥ 1 coronary event prior to the index event (odds ratio 1.81), female gender (odds ratio 1.80), moderate- or low-intensity statin therapy (odds ratio 1.62) and eating fish < 3 times/week (odds ratio 1.56) were statistically significantly associated with failure to reach the LDL-C target, in adjusted analyses. Only side-effects (standardized β 0.180), low statin adherence ( β 0.209) and moderate- or low-intensity statin therapy ( β 0.228) were associated with LDL-C in continuous analyses. Conclusions Statin specific side-effects, low statin adherence and moderate- or low-intensity statin therapy were the major factors associated with unfavourable LDL-C control. Interventions to improve LDL-C should ensure adherence and prescription of sufficiently potent statins, and address side-effects appropriately.

Background: Treatment of hypertension post-stroke preserves cognition through prevention of recurrent stroke, but it is not clear whether it prevents cognitive decline through other mechanisms. We aimed to describe changes in blood pressure from baseline to 1 year post-stroke and to evaluate the association between achieved blood pressure targets and cognitive function, mild cognitive impairment (MCI), and dementia., Methods: We included patients with first-ever stroke, and defined achieved blood pressure goals as systolic blood pressure (SBP) in the categories ≤125 mmHg, ≤140 mmHg, and ≤160 mmHg, SBP reduction of ≥10 mmHg, and diastolic blood pressure (DBP) reduction of ≥5 mmHg. The main outcome variables were cognitive assessments 1 year post stroke. Secondary outcomes were diagnoses of MCI or dementia., Results: Forty-one of 166 patients (25%) reached SBP ≤125 mmHg after 1 year, 92/166 (55%) reached SBP ≤140 mmHg, and 150/166 (90%) reached SBP ≤160 mmHg. SBP was reduced by ≥10 mmHg in 44/150 (29%) and DBP by ≥5 mmHg in 57/150 (38%). We did not find any statistically significant associations between cognitive test performances and different blood pressure goals (P=0.070-1.0). Nor was there any significant association between achieved goal blood pressure or blood pressure reduction after 1 year and the diagnoses of MCI or dementia (P=0.32-0.56)., Conclusion: Treatment of hypertension is important for primary and secondary prevention of stroke. Showing a potential beneficial effect of blood pressure control on cognitive function, however, probably needs longer follow-up.

Intensive statin therapy is a central component of secondary prevention after acute myocardial infarction (AMI), particularly among high-risk patients, such as those with diabetes mellitus (DM). However, the frequency and predictors of intensive statin therapy use after AMI among patients with DM have not been described. We examined patterns of intensive statin therapy use (defined as a statin with expected low-density lipoprotein cholesterol lowering of >50%) at discharge among patients with AMI with known DM enrolled in a 24-site US registry. Predictors of intensive statin therapy use were evaluated using multivariable hierarchical Poisson regression models. Among 1,300 patients with DM after AMI, 22% were prescribed intensive statin therapy at hospital discharge. In multivariable models, ST-elevation AMI (risk ratio [RR] 1.48, 95% confidence interval [CI] 1.29 to 1.70), insurance for medications (RR 1.28, 95% CI 1.00 to 1.63), and higher low-density lipoprotein cholesterol levels (RR 1.05 per 1 mg/dl, 95% CI 1.02 to 1.07) were independent predictors of intensive statin therapy, whereas higher Global Registry of Acute Coronary Events scores were associated with lower rates of intensive statin therapy (RR 0.94 per 10 points, 95% CI 0.91 to 0.98). In conclusion, only 1 in 5 patients with DM was prescribed intensive statin therapy at discharge after an AMI. Predictors of intensive statin therapy use suggest important opportunities to improve quality of care in this patient population., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The aim of this study was to explore and reflect upon mental health nursing and first-episode psychosis. Seven multidisciplinary focus group interviews were conducted, and data analysis was influenced by a grounded theory approach. The core category was found to be a process named 'working behind the scenes'. It is presented along with three subcategories: 'keeping the patient in mind', 'invisible care' and 'invisible network contact'. Findings are illuminated with the ethical principles of respect for autonomy and paternalism. Nursing care is dynamic, and clinical work moves along continuums between autonomy and paternalism and between ethical reflective and non-reflective practice. 'Working behind the scenes' is considered to be in a paternalistic area, containing an ethical reflection. Treating and caring for individuals experiencing first-episode psychosis demands an ethical awareness and great vigilance by nurses. The study is a contribution to reflection upon everyday nursing practice, and the conclusion concerns the importance of making invisible work visible.

Hand eczema influences the quality of life. Management strategies include the use of moisturizers. In the present study the time to relapse of eczema during treatment with a barrier-strengthening moisturizer (5% urea) was compared with no treatment (no medical or non-medicated preparations) in 53 randomized patients with successfully treated hand eczema. The median time to relapse was 20 days in the moisturizer group compared with 2 days in the no treatment group (p = 0.04). Eczema relapsed in 90% of the patients within 26 weeks. No difference in severity was noted between the groups at relapse. Dermatology Life Quality Index (DLQI) increased significantly in both groups; from 4.7 to 7.1 in the moisturizer group and from 4.1 to 7.8 in the no treatment group (p < 0.01) at the time of relapse. Hence, the application of moisturizers seems to prolong the disease-free interval in patients with controlled hand eczema. Whether the data is applic-able to moisturizers without barrier-strengthening properties remains to be elucidated.

Background: Naltrexone has considerable potential in helping to prevent relapse in heroin dependency. A longer-lasting formulation for naltrexone treatment is desirable to further reduce non-adherence and relapse during treatment of opiate dependence., Aims: To evaluate the safety and effectiveness of a 6-month naltrexone implant in reducing opioid use after in-patient treatment., Method: A group of 56 abstinence-oriented patients who completed in-patient treatment for opioid dependence were randomly and openly assigned to receive either a 6-month naltrexone implant or their usual aftercare. Drug use and other outcomes were assessed at 6-month follow-up., Results: Patients receiving naltrexone had on average 45 days less heroin use and 60 days less opioid use than controls in the 180-day period (both P<0.05). Blood tests showed naltrexone levels above 1 ng/ml for the duration of 6 months. Two patients died, neither of whom had received an implant., Conclusions: Naltrexone implant treatment safely and significantly reduces opioid use in a motivated population of patients.

Background: The primary objective of this study was to investigate if supplementary lactobacilli treatment could improve the initial cure rate after vaginal clindamycin therapy, and secondly, if lactobacilli as repeated adjunct treatment during 3 menstrual cycles could lengthen the time to relapse after initial cure., Methods: Women (n = 100) with bacterial vaginosis diagnosed by Amsel criteria were after informed consent offered vaginal clindamycin therapy followed by vaginal gelatine capsules containing either 109 freeze-dried lactobacilli or identical placebo capsules for 10 days during 3 menstrual cycles in a double-blind, randomized, placebo-controlled trial., Results: The initial intent to treat (ITT) analysis for the one-month cure rate was 64% in the lactobacilli group and 78% in the placebo group (p > 0.05). However, any patient with missing or unclassified smears at the initial visit who continued the study and whose next smear indicated a cure was included in the cured group; the study also excluded two of the patients in the lactobacilli group who reported that they did not take any vaginal capsules. With consideration to these population changes, the initial cure rate would be 77% in the lactobacilli group. The 76 cured women were followed for 6 menstrual cycles or until relapse within that time span. At the end of the study, 64.9% (24/37) of the lactobacilli treated women were still BV-free compared to 46.2% (18/39) of the placebo treated women. Comparison of the two groups regarding "Time from cure to relapse" was statistically significant (p = 0.027) in favour of the lactobacilli treatment. Adjuvant therapy with lactobacilli contributed significantly to avoidance of relapse with a proportional Hazard Risk ratio (HR) of 0.73 (0.54-0.98) (p < 0.05), Conclusion: The study shows that supplementary treatment combining two different strains of probiotic lactobacilli does not improve the efficacy of BV therapy during the first month of treatment, but for women initially cured, adjunct treatment of lactobacilli during 3 menstrual cycles lengthens the time to relapse significantly in that more women remained BV free at the end of the 6-month follow up., Trial Registration Number: ISRCTN62879834.

Population-based data that cover reproductive health outcomes across two complete generations have recently become available in the Nordic countries. Such data enable estimation of recurrence risks from one generation to the next of different conditions such as birth defects or pre-eclampsia. Risks related to a singleton pregnancy involve the contribution of three individuals: the mother, the father and the fetus. A paternal contribution is mainly through the father's contribution of half of the alleles of the fetus. A maternal contribution may occur in three fundamentally different ways. First, the mother provides half of the genomic alleles to the fetus, with contribution of paternal alleles completing the whole genome. Second, the mother provides the fetal environment and possible susceptibility to complications during pregnancy which she may have inherited from her mother. Finally, she provides the fetal mitochondria. Because of these different contributions, recurrence from mother to offspring is fundamentally different from recurrence from father to offspring. How recurrence risks reflect and shape the underlying contributions to overall perinatal risk is illustrated through a review of published data from Norway on gestational age, pre-eclampsia and birth defects.

Predictors for repetition of suicide attempts were evaluated among 92 adolescent suicide attempters 9 years after an index suicide attempt (90% females). Five were dead, two by suicide. Thirty-one (42%) of 73 had repeated a suicide attempt. In multiple Cox regression analysis, four factors had an independent predictive effect: comorbid disorders, hopelessness, having ever received treatment for mental or behavior problems, and having a father exerting control without affection. Prediction on an individual level was difficult. Since almost half repeated a suicidal act, the best strategy is to evaluate all adolescent suicide attempters thoroughly and provide treatment as needed.

Purpose: It has not been decided to what extent the results from statin trials should be transferred to clinical practice in the very old. The aim of the study was to assess the use of cardiovascular drugs after an acute myocardial infarction (MI), with particular focus on statins, in very old patients as compared to younger patients., Method: A sample of 901 acute MI patients was drawn from 16 hospitals in 1999/2000; the patients were followed up for 2.5 years. Information on demographic variables and drug therapy was obtained from hospital records, and in the follow-up period by direct patient contact or questionnaire. The main indications for prescribing the various cardiovascular drugs were recorded., Results: At discharge, drug use in patients >or=80 and <80 years, respectively, was as follows: ACE-inhibitors 48 versus 32%, nitrates 55 versus 32%, diuretics 64 versus 26%, aspirin 72 versus 86%, and beta-blockers 67 versus 85%. A striking difference was found for statins: 9% in the very old and 72% in younger patients. The pattern of drug use generally remained unchanged after 2.5 years. Survival rates for patients >or=80 and <80 years: at discharge 72 versus 90%, after 2.5 years 34 versus 73%., Conclusions: Drug therapy was widely accepted for the indication secondary prevention after MI in patients above 80 years of age. The various cardiovascular drugs were prescribed to about the same extent for very old and younger patients. The exception was lipid lowering drugs which, despite the physicians' recognition of the indication secondary prevention in the very old patients, were prescribed to a limited extent., (Copyright (c) 2005 John Wiley & Sons, Ltd.)

After a mean of 6 years, the frequencies of later vascular events (recurrent ischemic stroke or myocardial infarction) in 232 young ischemic stroke patients (younger than 50 years) with none to five traditional risk factors were 2.1%, 6%, 19%, 26%, 30%, and 67% (p < 0.001). Long-term secondary preventive medication may not be indicated in young ischemic stroke patients with no risk factor.

Background: Periodontal therapy coupled with active maintenance has been shown to be effective in maintaining periodontal health, however, the question of re-treatment is rarely alluded to in the literature., Aim: To quantify the type and extent of re-treatment in a group of patients who had completed a definitive course of periodontal treatment in a Norwegian specialist periodontal practice. The study also investigated factors associated with the provision of periodontal surgery as a re-treatment modality., Methods: A consecutive group of patients who had comprehensive periodontal treatment, which included periodontal surgery, and were subsequently maintained for between 10 and 17 years were studied., Results: One hundred and one patients with an average age at reassessment of 59.4 (standard deviation (SD) 9.0) years were studied. The average length of the review period was 13.1 (SD 1.9) years. In addition to routine maintenance, 50 patients had further re-treatment and 40 of those who were re-treated had periodontal surgery in the study period. Logistic regression showed that independent predictors of surgical re-treatment, with the effects adjusted for other variables in the model, were uncertain or poor prognosis at baseline, erratic or poor post baseline compliance and a family history of periodontal disease., Conclusion: Considerable amounts of re-treatment, including in many cases extensive non-surgical treatment or periodontal surgery, were provided for patients who had surgical periodontal treatment and were subsequently maintained for least 10 years in a specialist periodontal practice.

Objective: The first aim of this study was to estimate the impact of anal sphincter laceration during the first delivery on the risk of recurrence in the second delivery. The second aim was to estimate the absolute risk of anal sphincter laceration in the second delivery according to the history of anal sphincter laceration and birth weight., Methods: In this population-based cohort study, the study sample comprised all women included in the Norwegian Medical Birth Registry with 2 consecutive singleton vaginal deliveries during the period 1967-1998 (n = 486,463). The impact of prior anal sphincter laceration on recurrent anal sphincter laceration was estimated as crude and adjusted odds ratios (ORs)., Results: Anal sphincter laceration during first delivery increased the risk for a sphincter laceration in the next delivery, (adjusted OR 4.3, 95% confidence interval [CI] 3.8-4.8). Other risk factors were birth weight (adjusted OR 23.6, 95% CI 16.5-33.6, birth weight > 5,000 g versus birth weight < 3,000 grams), use of forceps (adjusted OR 5.1, 95% CI 4.3-6.0), use of vacuum (adjusted OR 1.4, 95% CI 1.1-1.7), and period of delivery (adjusted OR 4.3, 95% CI 3.7-5.0 for 1995-1998 versus 1967-1975). The absolute risks for anal sphincter laceration at second delivery for women with prior laceration were 1.3% (95% CI 0.4-3.2%) for birth weight less than 3,000 g and 23.3% (95% CI 11.8-38.6%) for birth weight more than 5,000 g., Conclusion: Only 10% of women with anal sphincter laceration at second delivery had a history of prior laceration. Prior anal sphincter laceration is associated with increased risk of laceration in second delivery, in particular in women who carry children with high birth weight., Level of Evidence: II-2.

The relationship of surgical castration to sexual recidivism in a sexually violent predator/sexually dangerous person (SVP/SDP) population is reviewed. A review of the literature on castrated sex offenders reveals a very low incidence of sexual recidivism. The low sexual recidivism rates reported are critiqued in light of the methodologic limitations of the studies. Better designed testicular/prostate cancer studies have demonstrated that, while sexual desire is reduced by orchiectomy, the capacity to develop an erection in response to sexually stimulating material is not eliminated. The relevance of this literature to SVP/SDP commitment decisions and ethics is discussed. Two vignettes of castrated, high-risk sex offenders illustrate how to address risk reduction. Two tables are presented: the first outlines individual case data from a difficult-to-obtain report, and the second summarizes the most frequently cited castration studies on sexual recidivism. Orchiectomy may have a role in risk assessments; however, other variables should be considered, particularly as the effects can be reversed by replacement testosterone.

To test the hypothesis that a statin could reduce the recurrence rate of atrial fibrillation after electrical cardioversion (EC), we performed an open, controlled multicenter study. Patients (n = 114) who had atrial fibrillation >48 hours and who were scheduled for EC were randomized to receive 40 mg of pravastatin once daily for 3 weeks before and 6 weeks after EC or no drug in addition to standard therapy. Pravastatin did not reduce the recurrence rate of atrial fibrillation after EC.

The purpose of this study was to compare two clinical samples of women substance abusers, one from Iowa and one from Norway, along several dimensions: "substance abuse" history, current "abuse" pattern, parental and spouse drinking history, symptoms of psychological distress, and "vulnerability" to relapse. A higher percentage of women substance abusers from Iowa were divorced and lived alone, were "vulnerable" to relapse, and reported more life problems secondary to their substance use than women from Norway. The Iowa women had used more substances in addition to alcohol than had the Norwegian women. The Norwegian women reported greater intensity of emotional distress than the women from Iowa.

Objective: To evaluate the effect of acupuncture in the prevention of recurrent lower urinary tract infection (UTI) in adult women., Design: A controlled clinical trial with three arms: an acupuncture group, a sham-acupuncture group, and an untreated control group. Patients were followed for 6 months., Setting: An acupuncture clinic in Bergen, Norway., Subjects: Sixty-seven adult women with a history of recurrent lower UTI., Main Outcome Measures: Acute lower UTIs during the 6-month observation period., Results: Eighty-five percent were free of lower UTI during the 6-month observation period in the acupuncture group, compared with 58% in the sham group (p < 0.05), and 36% in the control group (p < 0.01). There were half as many episodes of lower UTI per person-half-year in the acupuncture group as in the sham group, and a third as many as in the control group (p < 0.05)., Conclusion: Acupuncture seems a worthwhile alternative in the prevention of recurring lower UTI in women.

Objective: To study infectious pathology at index ectopic pregnancy and to determine what other factors predispose a woman to repeat ectopic pregnancy., Methods: All women (n = 697) with their first (index) ectopic pregnancy histologically verified between January 1, 1978, and December 31,1993, at the only two hospitals in one Norwegian county were eligible. Included were permanent residents of the county who were 37 years of age or younger and who had not had tubal surgery before the index pregnancy. When the study closed on November 1, 1994, the participants had been observed prospectively for fertility events from approximately 1 to 17 years. Included in the final analyses were 353 women who had from one to five natural conceptions, for a total of 555 pregnancies. Chi-square test was used in univariate analysis, and the generalized estimating equations approach was used to analyze correlated responses and covariates that changed over time., Results: Pregnancy order is the stronger correlate of subsequent ectopic pregnancy. The frequency of repeat ectopic pregnancy decreased by one-third for each pregnancy from the first to the third pregnancy. The odds of having another ectopic pregnancy were nearly three times higher for women with a diagnosis of infectious pathology than for women who had no infectious pathology. Other correlates of repeat ectopic pregnancy include age 24 years or younger at first ectopic pregnancy, history of repeat ectopic pregnancy, initiation of infertility work-up, and conception with an intrauterine device at index pregnancy. Method of surgery was not associated with repeat ectopic pregnancy., Conclusion: The most crucial reproductive event after first ectopic pregnancy is the first event to occur. Women who have experienced two ectopic pregnancies should be considered candidates for assisted reproduction.