Lise Lund Håheim

Risk factors of stroke incidence and mortality. A 12-year follow-up of the Oslo Study.

Background and Purpose The objective of this study was to determine the risk factors of stroke incidence and mortality. Methods Our data are based on a prospective cohort study of men aged 40 to 49 years after 12 years of follow-up. Results In age-adjusted Cox proportional-hazards regression analysis of 14 403 healthy men, diastolic blood pressure was a stronger predictor for stroke incidence and mortality than systolic blood pressure. Smoking was a stronger predictor of mortality than of incidence. However, there was no dose-response relation among smokers by increased cigarette consumption. Total serum cholesterol was a significant (P < .05) risk factor for stroke mortality and of borderline significance (P=.08) for stroke incidence. Increased physical activity at leisure was associated with reduced stroke incidence but not mortality. The myocardial infarction risk score comprising systolic blood pressure, total serum cholesterol, and daily cigarette smoking was a strong predictor of mortality and incidence. Body mass index, triglycerides, blood glucose, and physical activity at work were not found to be risk factors for stroke. Conclusions Reduction of blood pressure, cessation of smoking, lowered cholesterol, and increased physical activity at leisure are individual measures to reduce the risk of stroke.

Lung cancer and air pollution: a 27 year follow up of 16 209 Norwegian men

Background: The well documented urban/rural difference in lung cancer incidence and the detection of known carcinogens in the atmosphere have produced the hypothesis that long term air pollution may have an effect on lung cancer. The association between incidence of lung cancer and long term air pollution exposure was investigated in a cohort of Oslo men followed from 1972/73 to 1998. Methods: Data from a follow up study on cardiovascular risk factors among 16 209 40 to 49 year old Oslo men in 1972/73 were linked to data from the Norwegian cancer register, the Norwegian death register, and estimates of average yearly air pollution levels at the participants’ home address in 1974 to 1998. Survival analyses, including Cox proportional hazards regression, were used to estimate associations between exposure and the incidence of lung cancer. Results: During the follow up period, 418 men developed lung cancer. Controlling for age, smoking habits, and length of education, the adjusted risk ratio for developing lung cancer was 1.08 (95% confidence interval, 1.02 to 1.15) for a 10 µg/m3 increase in average home address nitrogen oxide (NOx) exposure between 1974 and 1978. Corresponding figures for a 10 µg/m3 increase in sulphur dioxide (SO2) were 1.01 (0.94 to 1.08). Conclusions: Urban air pollution may increase the risk of developing lung cancer.

Association of Cardiometabolic Multimorbidity With Mortality.

IMPORTANCE The prevalence of cardiometabolic multimorbidity is increasing. OBJECTIVE To estimate reductions in life expectancy associated with cardiometabolic multimorbidity. DESIGN, SETTING, AND PARTICIPANTS Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates. EXPOSURES A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI). MAIN OUTCOMES AND MEASURES All-cause mortality and estimated reductions in life expectancy. RESULTS In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy. CONCLUSIONS AND RELEVANCE Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

Association of Cardiometabolic Multimorbidity With Mortality The Emerging Risk Factors Collaboration

IMPORTANCE The prevalence of cardiometabolic multimorbidity is increasing. OBJECTIVE To estimate reductions in life expectancy associated with cardiometabolic multimorbidity. DESIGN, SETTING, AND PARTICIPANTS Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates. EXPOSURES A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI). MAIN OUTCOMES AND MEASURES All-cause mortality and estimated reductions in life expectancy. RESULTS In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy. CONCLUSIONS AND RELEVANCE Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

Use of β-blockers is associated with prostate cancer-specific survival in prostate cancer patients on androgen deprivation therapy.

Experimental evidence suggests a role for the β2‐adrenergic receptor pathway in prostate cancer (PCa). We have investigated the association of β‐blocker use with PCa incidence and survival in a Norwegian cohort.

Leisure time physical activity in middle age predicts the metabolic syndrome in old age: results of a 28-year follow-up of men in the Oslo study

BackgroundData are scarce on the long term relationship between leisure time physical activity, smoking and development of metabolic syndrome and diabetes. We wanted to investigate the relationship between leisure time physical activity and smoking measured in middle age and the occurrence of the metabolic syndrome and diabetes in men that participated in two cardiovascular screenings of the Oslo Study 28 years apart.MethodsMen residing in Oslo and born in 1923–32 (n = 16 209) were screened for cardiovascular diseases and risk factors in 1972/3. Of the original cohort, those who also lived in same area in 2000 were invited to a repeat screening examination, attended by 6 410 men. The metabolic syndrome was defined according to a modification of the National Cholesterol Education Program criteria. Leisure time physical activity, smoking, educational attendance and the presence of diabetes were self-reported.ResultsLeisure time physical activity decreased between the first and second screening and tracked only moderately between the two time points (Spearmans ρ = 0.25). Leisure time physical activity adjusted for age and educational attendance was a significant predictor of both the metabolic syndrome and diabetes in 2000 (odds ratio for moderately vigorous versus sedentary/light activity was 0.65 [95% CI, 0.54–0.80] for the metabolic syndrome and 0.68 [0.52–0.91] for diabetes) (test for trend P < 0.05). However, when adjusted for more factors measured in 1972/3 including glucose, triglycerides, body mass index, treated hypertension and systolic blood pressure these associations were markedly attenuated. Smoking was associated with the metabolic syndrome but not with diabetes in 2000.ConclusionPhysical activity during leisure recorded in middle age prior to the current waves of obesity and diabetes had an independent predictive association with the presence of the metabolic syndrome but not significantly so with diabetes 28 years later in life, when the subjects were elderly.

European network for Health Technology Assessment, EUnetHTA: Planning, development, and implementation of a sustainable European network for Health Technology Assessment

OBJECTIVES The European network on Health Technology Assessment (EUnetHTA) aimed to produce tangible and practical results to be used in the various phases of health technology assessment and to establish a framework and processes to support this. This article presents the background, objectives, and organization of EUnetHTA, which involved a total of sixty-four partner organizations. METHODS Establishing an effective and sustainable structure for a transnational network involved many managerial, policy, and methodological tools, according to the objective of each task or Work Package. Transparency in organization, financial transactions, and decision making was a key principle in the management of the Project as was the commitment to appropriately involve stakeholders. RESULTS EUnetHTA activities resulted in a clear management and governance structure, efficient partnership, and transnational cooperation. The Project developed a model for sustainable continuation of the EUnetHTA Collaboration. CONCLUSIONS The EUnetHTA Project achieved its goals by producing a suite of practical tools, a strong network, and plans for continuing the work in a sustainable EUnetHTA Collaboration that facilitates and promotes the use of HTA at national and regional levels. Responsiveness to political developments in Europe should be balanced with maintaining a high level of ambition to promote independent, evidence-based information and well-tested tools for best practice based on a strong network of HTA institutions.

Nonfasting Serum Glucose and the Risk of Fatal Stroke in Diabetic and Nondiabetic Subjects: 18-Year Follow-up of the Oslo Study

BACKGROUND AND PURPOSE The association between nonfasting serum glucose and stroke mortality for diabetic and nondiabetic subjects is presented for participants of the Oslo Study. METHODS The study started in 1972; of 16,209 men aged 40 to 49 years, 16,172 had no previous history of stroke and 151 were known to be diabetic. Five diabetic and 80 nondiabetic subjects died of stroke during the 18 years of follow-up, giving a rate ratio of 7.87 (95% confidence interval [CI], 2.48 to 19.14). The rate of mortality for all causes in diabetic subjects was more than five times that of those who were nondiabetic. RESULTS Nonfasting serum glucose was a predictor of fatal stroke in all participants (diabetic subjects included) without a history of stroke in age-adjusted univariate analysis. The relative risk was 1.13 (CI, 1.03 to 1.25) by increase of 1 mmol/L of serum glucose according to results of proportional hazards regression analysis. Accordingly, relative risk for nondiabetic subjects was 1.02 (CI, 0.83 to 1.26) with no linear trend. The rate ratio of the fifth quintile to the rest was 1.57 (CI, 0.94 to 2.56) for all participants and 1.28 (CI, 0.72 to 2.18) for nondiabetics. CONCLUSIONS There was an interaction between glucose level and body mass index versus stroke for all participants but not for nondiabetic subjects, with an increased risk for men with above-median values of glucose and body mass index. Analysis of nondiabetic subjects failed to show glucose as a definite predictor of fatal stroke.

Ethics of palliative surgery in patients with cancer.

Surgery is an important palliative method for patients with advanced malignant disease. In addition to concerns related to clinical decision making, various moral challenges are encountered in palliative surgery. Some of these relate to the patients and their illness, others to the surgeons, their attitudes, skills and knowledge base.

Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team

Whether planned cesarean section is better than planned vaginal delivery for breech presentation at term (37–42 weeks) has been the subject of debate for some time. Apart from two small randomized controlled trials (1,2) from the early 1980s, the evidence on breech delivery was based on patient series and register studies, which have been considered to be of low scientific value. However, in October 2000 the randomized multicenter Term Breech Trial (TBT) was published in The Lancet (3), with a 3-month follow-up in 2002 (4). The study included 2083 deliveries from 121 obstetric departments in 26 countries. One Danish and one Finnish, but no Norwegian, obstetric departments took part in the study. The TBT concluded that planned cesarean section led to a significantly better perinatal outcome than planned vaginal delivery. The occurrence of maternal complications was similar for the two groups. Not surprisingly, the TBT ignited intense discussion among doctors, midwives and the public. Data from the Medical Birth Registry of Norway show a slight increase in the incidence of breech presentation among infants with a birthweight greater than 2499 g in the period 1981–98, and the incidence is 2.9% in 1998 (Fig. 1). In Norway, 40% of approximately 1500 annual term breech infants are currently delivered vaginally (Fig. 2). A change to routine use of cesarean section would have an unprecedented impact on clinical practice in Norway. The use of external cephalic version on the Norwegian population has not been studied previously. A review team was therefore assigned to review (5,25) all current literature on term breech deliveries as well as on external cephalic version, using predetermined standard literature review methodology.