Tom-Harald Edna

Association between blood transfusion and infection in injured patients.

The association between red blood cell transfusions and infectious complications in 484 patients with acute injuries was studied in 1989. The median age was 62 years (0.5-97) and the median stay 7 days (3-141). Infectious complications developed in 46 (9.5%) patients. A number of potential risk factors, except blood transfusion, were analyzed in a logistic regression model to determine significant predictors of infectious complications. Blood transfusion as a cofactor was then added to this model. The final logistic regression analysis showed a relationship between blood transfusions and infectious morbidity that was independent of the other significant factors; Injury Severity Score, age, and surgical procedure. The corrected odds ratios for infection were 1.6 (95% confidence interval: 0.7-3.7) when 1-4 units of blood were given and 6.4 (95% CI: 2.3-18.3) when more than 4 units were used.

Association between transfusion of stored blood and infective bacterial complications after resection for colorectal cancer.

OBJECTIVE To examine the association between blood transfusion and bacterial infective complications after resection for colorectal adenocarcinoma. DESIGN Retrospective cohort study. SETTING District hospital; Norway. SUBJECTS 446 consecutive patients having resection of colorectal adenocarcinoma. MAIN OUTCOME MEASURES Postoperative bacterial infective morbidity in hospital. RESULTS 112 patients (25%) developed postoperative infections in hospital. Univariate analysis showed that the development of infection was significantly associated with increasing age (p=0.02), rectal compared with colonic cancer (p=0.002), preoperative radiotherapy (p=0.005), blood loss during operation (p=0.001), the extent of the primary tumour (T stage): T4 compared with T1-T3 (p=0.004), the presence of regional lymph node metastasis (N stage): N1-N3 compared with N0 (p=0.01), operating surgeon 1 (p=0.009), operating surgeon 2 (p=0.03), and blood transfusion (p < 0.001). Multivariate logistic regression analysis showed that the following variables were independent predictors of infection: age, rectal compared with colonic cancer, T stage, N stage, and blood transfusion. The corrected odds ratios for infection were 1.5 (95% CI 0.8 to 2.8) when 1-3 units of blood were given and 3.1 (95% CI 1.6 to 6.0) when more than three units were given. Storage time did not affect the rate of postoperative infections in patients given transfusions. CONCLUSION Transfusion of non-filtered stored allogeneic blood suspended in saline-adenine-glucose-mannitol is an independent risk factor for the development of postoperative infections in hospital in patients having a resection of colorectal cancer.

Small bowel obstruction in patients previously operated on for colorectal cancer

OBJECTIVE To find out the incidence, aetiology, and outcome of patients operated on for small bowel obstruction after previous operation for colorectal cancer. DESIGN Retrospective cohort study. SETTING District hospital serving a defined population, Norway. SUBJECTS 472 consecutive patients operated on for colorectal cancer, followed up for a median of 5.5 years (range 2.0-16.8) or until death; 351 had had a resection with curative intent, and 121 a palliative operation. MAIN OUTCOME MEASURES Incidence and aetiology of small bowel obstruction, postoperative mortality, and long term survival. RESULTS Small bowel obstruction necessitated operation in 36/351 (10%) after resection with curative intent, and in 5/121 (4%) after a palliative operation. The causes of obstruction were benign adhesions (n=21), local recurrence (n=17) and peritoneal carcinomatosis (n=3). One patient died of a myocardial infarction and six of cancer within 30 days of the operation for small bowel obstruction. The estimated median survival after the operation for small bowel benign obstruction was 1.9 years (SE=0.6) compared with 0.36 years (SE=0.04) for malignant obstruction (p=0.0007, logrank test). Late small bowel obstruction by adhesions was associated with higher blood loss during the primary operation (p=0.02). None of the 62 patients who took thiazide diuretics at the time of the primary operation later developed obstructive adhesions. CONCLUSION 41/472 patients (9%) developed small bowel obstruction after the primary operation for colorectal cancer. The aetiology was benign in 21 and malignant in 20 patients. Survival after operation for the obstruction was far better with benign than with malignant obstruction.

Colon cancer incidence, presentation, treatment and outcomes over 25 years

Aim  The aim of this study was to evaluate changes in the incidence, presentation, treatment and outcome of colon cancer in a complete cohort of patients treated at a single institution over a 25‐year period.

Nationwide improvement of rectal cancer treatment outcomes in Norway, 1993–2010

Background. The Norwegian Rectal Cancer Project was initated in 1993 with the aims of improving surgery, decreasing local recurrence rates, improving survival, and establishing a national rectal cancer registry. Here we present results from the Norwegian Colorectal Cancer Registry (NCCR) from 1993 to 2010. Material and methods. A total of 15 193 patients were diagnosed with rectal cancer in Norway 1993–2010, and were registered with clinical data regarding diagnosis, treatment, locoregional recurrences and distant metastases. Of these, 10 796 with non-metastatic disease underwent tumour resection. The results were stratified into five time periods, and the treatment outcomes were compared. Recurrence rates are presented for the 9785 patients who underwent curative major resection (R0/R1). Results. Among all 15 193 patients, relative five-year survival increased from 54.1% in 1993–1997 to 63.4% in 2007–2010 (p < 0.001). Among the 10 796 patients with stage I–III disease who underwent tumour resection, from 1993–1997 to 2007–2010, relative five-year survival improved from 71.2% to 80.6% (p < 0.001). An increasing proportion of these patients underwent surgery at large-volume hospitals; and 30- and 100-day mortality rates, respectively, decreased from 3.0% to 1.4% (p < 0.001) and from 5.1% to 3.0% (p < 0.011). Use of preoperative chemoradiotherapy increased from 6.5% in 1993 to 39.0% in 2010 (p < 0.001). Estimated local recurrence rate after major resection (R0/R1) decreased from 14.5% in 1993–1997 to 5.0% in 2007–2009 (p < 0.001), and distant recurrence rate decreased from 26.0% to 20.2% (p < 0.001). Conclusion. Long-term outcomes from a national population-based rectal cancer registry are presented. Improvements in rectal cancer treatment have led to decreased recurrence rates of 5% and increased survival on a national level.

Prevalence of anaemia at diagnosis of colorectal cancer: assessment of associated risk factors.

BACKGROUND/AIMS The aim of this study was to report the prevalence of anaemia in patients with cancer located in different anatomical segments of the colon and rectum and to assess possible risk factors for this anaemia. METHODOLOGY The study included 1189 patients referred during 1980-2004 with a colorectal adenocarcinoma. Data were obtained from hospital records and from the Norwegian Cancer Registry. Risk factors for anaemia were analyzed in multivariable logistic regression analysis. The WHO definition of anaemia was used. RESULTS The prevalence of anaemia diminished gradually and linearly as the location of the tumours was more distal towards the rectum. Anaemia was found in 74.7% (215/288) of the patients with cancer in the coecum or ascending colon, 57.1% (48/84) in the transverse colon, 40.0% (180/300) in the sigmoid and 30.5% (114/374) in the rectum. In the multivariable analysis, age, location of the tumour and T-stage remained associated with anaemia, whereas the histological differentiation of the tumour, N-stage, M-stage, period of admission, duration of symptoms and rectal bleeding were not. CONCLUSIONS Anaemia was common, especially in patients with proximal colon cancer. T-stage but not N-stage or M-stage was associated with anaemia.

Trends in cholecystectomy rates in a defined population during and after the period of transition from open to laparoscopic surgery

Abstract Objective. To evaluate cholecystectomy rates in a Norwegian county during the transition time from open to laparoscopic surgery, with focus on the incident rate of laparoscopic operations, sex differences, age at operation, and indications for cholecystectomy. Material and methods. All 2615 patients living in North Trondelag County and operated with cholecystectomy for benign biliary disease between 1990 and 2011 were identified. Poisson regression was used to analyze factors associated with cholecystectomy incidence rate ratios (IRRs). Results. The proportion of completed laparoscopic cholecystectomies was 8% in 1992, 50% in 1994, 94% in 2003 and 99% in 2011. The incidence of cholecystectomy increased from 6.2 per 10 000 person-years in 1990–1992, 8.0 in 1993–1997, to 10.0 in 1998–2003 and remained at this level with a rate of 10.7 during 2004–2011. Adjusting for age at each year of surgery the IRR for females compared with males was 2.3(2.1–2.5) p < 0.001. The median age at operation was 60.2 years (13–90) in males, 50.1 years (12–93) in females p < 0.001. The median age diminished by 5 years in both males and females. A conversion from laparoscopic to open surgery decreased significantly by calendar year of surgery, increased with age of the patient, and was less often in surgery for gallstone colic than for other indications. Conclusions. During the introduction of laparoscopic surgery, the rates of cholecystectomy increased and remained stable at a higher level during the later years of the study. The rate of completed laparoscopic operations increased from 8% in 1992 to 99% in 2011.

Violation of treatment guidelines — hazard for rectal cancer patients

AimThe aim of this study was to evaluate temporal trends in treatment and outcome in rectal cancer diagnosed during 1980–2004 at Levanger Hospital.Materials and methodsA protocol for prospective registration of rectal cancer treated with total mesorectal excision including operative strategy, radiotherapy and surveillance was established at Levanger Hospital in 1980. In this study, all rectal cancer patients treated during 1980–2004 were included.ResultsMore patients received preoperative radiotherapy during 2000–2004, but otherwise there were no significant differences in presentation or treatment during 1980–2004. The 5-year local recurrence rate after resection with curative intent was 4.5% (0–9.7), 18.7% (10.3–27.1) and 2.2% (0–6.7) in 1980–1989, 1990–1999 and 2000–2004 (p = 0.006), respectively. Out of a total of 23 cases of local recurrence, treatment guidelines, mainly with regard to radiotherapy, were violated in 19 cases. The 5-year overall survival after resection with curative intent was 65% (95% confidence interval [CI] 55–76) during 1980–1989, 58% (49–68) in 1990–1999 and 71% (59–83) in 2000–2004 (n.s). The 5-year relative survival was 83% (95% CI 69–95) during 1980–1989, 71% (59–81) in 1990–1999 and 84% (69–98) in 2000–2004 (n.s).ConclusionRectal cancer patients experienced excellent outcomes in the period 1980–1989 and 2000–2004. Due to violations of treatment guidelines, the rate of local recurrence was much too high in the period 1990–1999. This article illustrates the importance of continuous quality assurance in the treatment of rectal cancer to maintain optimized outcomes for the patients.

Prior statin use and 90-day mortality in Gram-negative and Gram-positive bloodstream infection: a prospective observational study.

In several studies on patients with bloodstream infection (BSI), prior use of statins has been associated with improved survival. Gram-positive and Gram-negative bacteria alert the innate immune system in different ways. We, therefore, studied whether the relation between prior statin use and 90-day total mortality differed between Gram-positive and Gram-negative BSI. We conducted a prospective observational cohort study of 1,408 adults with BSI admitted to Levanger Hospital between January 1, 2002, and December 31, 2011. Data on the use of statins and other medications at admission, comorbidities, functional status, treatment, and outcome were obtained from the patients’ hospital records. The relation of statin use with 90-day mortality differed between Gram-negative and Gram-positive BSI (p-value for interaction 0.01). Among patients with Gram-negative BSI, statin users had significantly lower 90-day total mortality [odds ratio (OR) 0.42, 95 % confidence interval (CI) 0.23–0.75, p = 0.003]. The association remained essentially unchanged after adjusting for the effect of sex, age, functional status before the infection, and underlying diseases that were considered confounders (adjusted OR 0.38, 95 % CI 0.20–0.72, p = 0.003). A similar analysis of patients with Gram-positive BSI showed no association of statin use with mortality (adjusted OR 1.22, 95 % CI 0.69–2.17, p = 0.49). The present study suggests that prior statin use is associated with a lower 90-day total mortality in Gram-negative BSI, but not in Gram-positive BSI.

Trends in antimicrobial resistance and empiric antibiotic therapy of bloodstream infections at a general hospital in Mid-Norway: A prospective observational study

BackgroundThe occurrence of bloodstream infection (BSI) and antimicrobial resistance have been increasing in many countries. We studied trends in antimicrobial resistance and empiric antibiotic therapy at a medium-sized general hospital in Mid-Norway.MethodsBetween 2002 and 2013, 1995 prospectively recorded episodes of BSI in 1719 patients aged 16–99 years were included. We analyzed the antimicrobial non-susceptibility according to place of acquisition, site of infection, microbe group, and time period.ResultsThere were 934 community-acquired (CA), 787 health care-associated (HCA) and 274 hospital-acquired (HA) BSIs. The urinary tract was the most common site of infection. Escherichia coli was the most frequently isolated infective agent in all three places of acquisition. Second in frequency was Streptococcus pneumoniae in CA and Staphylococcus aureus in both HCA and HA. Of the BSI microbes, 3.5% were non-susceptible to the antimicrobial regimen recommended by the National Professional Guidelines for Use of Antibiotics in Hospitals, consisting of penicillin, gentamicin, and metronidazole (PGM). In contrast, 17.8% of the BSI microbes were non-susceptible to cefotaxime and 27.8% were non-susceptible to ceftazidime.Antimicrobial non-susceptibility differed by place of acquisition. For the PGM regimen, the proportions of non-susceptibility were 1.4% in CA, 4.8% in HCA, and 6.9% in HA-BSI (p < 0.001), and increasing proportions of non-susceptibility over time were observed in HA-BSI, 2.2% in 2002–2005, 6.2% in 2006–2009, and 11.7% in 2010–2013 (p = 0.026), mainly caused by inherently resistant microbes. We also observed increasing numbers of bacteria with acquired resistance, particularly E. coli producing ESBL or possessing gentamicin resistance, and these occurred predominantly in CA- and HCA-BSI.ConclusionsGenerally, antimicrobial resistance was a far smaller problem in our BSI cohort than is reported from countries outside Scandinavia. In our cohort, appropriate empiric antibiotic therapy could be achieved to a larger extent by replacing second- and third-generation cephalosporins with penicillin-gentamicin or piperacillin-tazobactam.