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Early life determinants of musculoskeletal sickness absence in a cohort of Norwegians born in 1967-1976.

In order to investigate the extent to which musculoskeletal sickness absence was influenced by a range of circumstances concerning family background and health in early life, we established a register-based cohort of all live-born in Norway between 1967 and 1976. Personal data on parental factors and health early in life were recorded prospectively from birth onward in the Medical Birth Registry of Norway, the National Insurance Administration, Statistics Norway, and the Central Population Register. We collected data in the National Insurance Administration on the first spell of medically certified long-term (>16 days) musculoskeletal (International Classification of Primary Care group L) sickness absence in 2000-2003 among 378, 356 participants who were considered to be at risk of sickness absence on January 1st, 2000. The 4-year musculoskeletal absence risk was 0.264 for women and 0.156 for men. Parental education level was associated with musculoskeletal sickness absence, with increasing adjusted relative risks by decreasing educational level for both genders. Associations with other early determinants (birth weight, childhood disease, parental survival, parental disability, parental income, and parental marital status) were all close to unity. Parental education level attributed 36% (95% confidence interval 33-38) to the population risk for women and 67% (64-70) for men. The parental education association was partly mediated through own educational attainment, which was strongly associated with musculoskeletal sickness absence in itself. Our data suggest that mechanisms acting early in life could influence later risk of musculoskeletal sickness absence.

Adult↗

Changes in body weight and onset of hypertension in perimenopausal women.

We assessed the determinants of onset of hypertension in a large, prospective population-based study of perimenopausal women from the Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) study. The data collection started in 1989, when a baseline postal inquiry was sent to all women aged 47-56 years (n=14 220) residing in the Kuopio Province in Eastern Finland. Names, social security numbers and addresses were obtained from the Population Register Centre of Finland. A total of 11 798 women responded at baseline and at 5-year follow-up in 1994. After the exclusion of 1777 women with prevalent hypertension at baseline and women with missing height or weight information, the study population consisted of 9485 without established hypertension at baseline. New cases of established hypertension during the follow-up (n=908) were ascertained with the Registry of Specially Refunded Drugs of the Finnish Social Insurance Institution (SII). According to the National Health Insurance, the SII granted 90% reimbursement for drug costs in defined chronic illnesses necessitating continuous medication, like arterial hypertension. Weight and weight gain both raised the risk by 5% per kg (P<0.001). Weight gain of 4-6 kg increased the risk of hypertension 1.25 times and a gain of more than 7 kg 1.65 times compared with the control (zero) group. To conclude, the onset of hypertension in peri- and early postmenopausal women was related to an increase in body weight despite controlling for initial body weight, reported physical activity and use of HRT. Therefore, preventing weight gain by dietary means and exercise is of great importance at menopausal age.

Age Factors↗

Farming, rural lifestyle and atopy in adults from southern Germany--results from the MONICA/KORA study Augsburg.

BACKGROUND AND OBJECTIVE: The increasing urbanization and the decrease in the numbers of farms in southern Germany might be associated with an increasing prevalence of allergic diseases. We compared the prevalence of allergic diseases in farmers, and rural, suburban and urban residents in the small geographical area of Augsburg in southern Germany. METHODS: In a cross-sectional survey adults, aged 25-75 years selected from the community population register were investigated. Rural, suburban and urban residents were defined by community size and farmers by occupation. Allergic respiratory disorders were assessed by self-administered questionnaires and specific IgE antibodies to five common aeroallergens. RESULTS: In comparison to rural residents the urban population had an increased risk of allergic rhinitis (OR = 1.5; 95% CI: 1.2-1.9), atopic sensitization (OR = 1.2; 95% CI: 1.0-1.4) and sensitization against pollen (OR = 1.5; 95% CI: 1.2-1.9). There was no difference in the risk of asthma (OR = 1.0; 95% CI: 0.6-1.6) and a decreased risk in the sensitization against house dust mite (OR = 0.8; 95% CI: 0.7-1.0). The suburban residents did not differ from urban residents. Farmers had lower risks in allergic rhinitis, atopic sensitization, sensitization against pollen and mites (OR = 0.63; 0.86; 0.51 and 0.80, respectively) than rural non-farming residents, however, these differences were statistically not significant. Reported allergic rhinitis with sensitization to pollen was 2.5 times (95% CI: 1.8-3.6) more prevalent in urban than in rural residents. CONCLUSION: A farming environment and rural lifestyle might be associated with unknown protective factors impacting the prevalence of allergies.

Adult↗

Is nocturia equally common among men and women? A population based study in Finland.

PURPOSE: We assessed the prevalence of nocturia and its association with sociodemographic factors. MATERIALS AND METHODS: Information was collected with a questionnaire mailed to a random sample of 6,000 subjects 18 to 79 years old, identified from the Finnish Population Register Centre. Nocturia was defined as 1 or more, or 2 or more voids per night. Information was collected using the DAN-PSS questionnaire with an additional question from the AUA-SI questionnaire. Age standardized prevalence was calculated using the European standard population. Logistic regression was used for multivariate analysis. RESULTS: Of the 6,000 subjects 62.4% responded and 97.9% of the participants provided information on all nocturia questions. The age standardized prevalence of nocturia (1 or more voids per night) was 37% (95% CI 34%-40%) among men and 43% (95% CI 40%-46%) among women. With criterion of 2 or more voids per night prevalence was 12% (95% CI 10%-14%) for men and 13% (95% CI 11%-14%) for women. Women 18 to 49 years old had more nocturia than men. At 50 to 59 years old half of men and women reported nocturia. In older age groups nocturia was more frequent among men than women. The prevalence of nocturia increased at a constant rate with age. It increased twice as rapidly in men as among women (increase in OR 7.3% [95% CI 6.5%-8.2%] and 3.5% [95% CI 2.9%-4.1%] per year among men and women, respectively). CONCLUSIONS: The age standardized prevalence of nocturia (1 or more voids per night) was approximately 40% for both genders. In men the prevalence of nocturia increases more rapidly with age than in women. Nocturia is more common among women at a younger age but the differences disappear by middle age. In the elderly nocturia is more frequent among men.

Adolescent↗

Ethnic inequalities in age- and cause-specific mortality in The Netherlands.

BACKGROUND: By describing ethnic differences in age- and cause-specific mortality in The Netherlands we aim to identify factors that determine whether ethnic minority groups have higher or lower mortality than the native population of the host country. METHODS: We used data for 1995-2000 from the municipal population registers and cause of death registry. All inhabitants of The Netherlands were included in the study. The mortality of people who themselves or whose parent(s) were born in Turkey, Morocco, Surinam, or the Dutch Antilles/Aruba was compared with that of the native Dutch population. Mortality differences were estimated by Poisson regression analyses and by directly standardized mortality rates. RESULTS: Compared with native Dutch men, mortality was higher among Turkish (relative risk [RR] = 1.21, 95% CI: 1.16, 1.26), Surinamese (RR = 1.24, 95% CI: 1.19, 1.29), and Antillean/Aruban (RR = 1.25, 95% CI: 1.15, 1.36) males, and lower among Moroccan males (RR = 0.85, 95% CI: 0.81, 0.90). Among females, inequalities in mortality were small. In general, mortality differences were influenced by socio-economic and marital status. Most minority groups had a high mortality at young ages and low mortality at older ages, a high mortality from ill-defined conditions (which is related to mortality abroad) and external causes, and a low mortality from neoplasms. Cardiovascular disease mortality was low among Moroccan males (RR = 0.51, 95% CI: 0.44, 0.59) and high among Surinamese males (RR = 1.13, 95% CI: 1.05, 1.21) and females (RR = 1.14, 95% CI: 1.06, 1.23). Homicide mortality was elevated in all groups. CONCLUSION: Socio-economic factors and marital status were important determinants of ethnic inequalities in mortality in The Netherlands. Mortality from cardiovascular diseases, homicide, and mortality abroad were of particular importance for shifting the balance from high towards low all-cause mortality.

Adolescent↗

Do changes in cardiovascular risk factors explain changes in mortality from stroke in Finland?

OBJECTIVES: To estimate the extent to which the changes in the main cardiovascular risk factors (blood pressure, smoking, and serum cholesterol concentration) can explain the observed changes in mortality from stroke in Finland during the past 20 years. DESIGN: Predicted changes in mortality from cerebrovascular disease mortality were calculated by a proportional hazards model from data obtained in cross sectional population surveys in 1972, 1977, 1982, 1987, and 1992. Predicted changes were compared with the observed changes in mortality statistics. SETTING: North Karelia and Kuopio provinces, Finland. SUBJECTS: 16,741 men and 16,389 women aged 30-59 randomly selected from the national population register, of whom 14,054 men and 14,546 women participated. MAIN OUTCOME MEASURES: Levels of risk factors and predicted and observed changes in mortality from cerebrovascular disease. RESULTS: The observed changes in diastolic blood pressure, total serum cholesterol concentration, and smoking in the population from 1972 to 1992 predicted a 44% fall in mortality from stroke in men and changes in diastolic blood pressure and smoking predicted a 34% fall in women. The observed fall in mortality from stroke was 66% in men and 60% in women. CONCLUSIONS: Two thirds of the fall in mortality from stroke in men and half in women can be explained by changes in the three main cardiovascular risk factors.

Adult↗

Choice of contraceptive modality by women in Norway.

STUDY OBJECTIVE: To investigate the use of contraception in a representative sample of Norwegian women. OUTCOME MEASURES: Frequency distribution of contraceptive methods by age, marital status and partly strata. MATERIAL: A sample of 4,933 women were selected at random from the Central Population Register as participants in the second Norwegian fertility study (1988). The response rate was 81% (n = 4,019) and personal interviews of contraceptive use were carried out among 2,782 women who were fecund, sexually active and not pregnant. These women comprise the study population. RESULTS: 2,782 women were sexually active during the last month prior to the interview and thus in potential need of contraception. More than 50% of the women used either oral contraceptives (21%) or IUDs (30%). The use of oral contraceptives decreased linearly with age from a user rate of 60% among women 20-24 years old to 1.5% among women 40-44 years of age. The use of IUDs increased from 6% in the youngest age group to nearly 40% among women aged 30-39 years of age. Oral contraceptives were preferentially used by childless women or those with only one child, while IUDs were most often used by women with two or more children. The sterilisation rate increased by age and in the 40-44 age group one out of every three women was sterilised. Non-use was most frequent among the subgroups of women who planned children in the future. Use of condoms and other coitus-dependent contraceptives varied less with age, marital status and parity than did the use of OC, IUDs or sterilisation. CONCLUSION: The user pattern concerning different contraceptive methods reflects the general guidelines for contraceptives in Norway. The fact that nearly 70% of the women were in one of the three categories--OC or IUD users, or one of the partners was sterilised--reveals that the awareness and knowledge of modern contraception is high in Norwegian society.

Adult↗

Population dynamics of Cosmoclopius nigroannulatus Stal (Hemiptera, Reduviidae) in tobacco culture.

The role of predators influencing populations of insects considered as pests is extremely important for agroecosystems. The population ecology of Cosmoclopius nigroannulatus, a predatory reduvid associated with the tobacco culture was investigated aiming to study the population dynamics of adults, along the culture cycle. In an experimental plot of approximately 300 m2, in Porto Alegre (30 degrees 0'S; 51 degrees 13'W), RS, Brazil, 270 tobacco plants were grown; each plant identified by alphanumeric coordinates. Using the mark-release-recapture method, daily samplings were done from August to December 1999, and three times a week from this date until April 2000. The adults were captured by hand, marked, sexed and released on the same plant they were captured. The individual number and plant coordinate were registered. Population estimates were analyzed by the Fisher-Ford method. In 107 sampling occasions, 604 individuals were marked, 273 males and 331 females. Three generations of C. nigroannulatus were registered during the culture cycle. The colonizing generation was represented by 14 males and 15 females (a sex ratio of 0.48), the first by 109 males and 137 females (0.44) and the second by 150 males and 179 females (0.46). The estimated daily survival rate varied between generations decreasing from 98% in the colonizing generation to 87% in the second. The observed longevity or permanence time in the experimental area varied significantly among generations, being at about 40 days in the colonizing generation, 13 days in the first and 5 days in the second. It was observed that as the population increases, the survival and/or permanence time in the area decreases, suggesting a relation between this and a decline in the available resources probably with an associated increase in intra-specific competition.

Animals↗

[Netherlands Fertility Survey, September 1977].

"By means of a sample survey information has been gathered on the number of live-born children, the number of additionally expected children and the exposure status of married women born in the period 1928-1961, with the Dutch nationality and living in the Netherlands. Approximately 7,000 women have been asked to participate. About those women who did/could not participate a few demographic data were gathered from the municipal population registers. This article gives some important results of the survey but does not analyse those results profoundly."

Birth Rate↗

A population-based study of congenital diaphragmatic hernia outcome in New South Wales and the Australian Capital Territory, Australia, 1992-2001.

PURPOSE: The aim of the study was to describe the incidence and survival of infants born with congenital diaphragmatic hernia (CDH) in the state of New South Wales (NSW) and the Australian Capital Territory (ACT), Australia. METHODS: A population-based cohort study of all infants inclusive up to 1 month of age diagnosed with CDH in NSW and the ACT between 1992 and 2001 was conducted. Data sources were the NSW and ACT Neonatal Intensive Care Data Collection (Neonatal Intensive Care Units Study), NSW Birth Defects Register, Population Health Research Centre of ACT Health, and NSW Midwives Data Collection. Individual risk factors for mortality were assessed using the chi(2) test with P < .05 being considered statistically significant. Multivariate analysis was performed using logistic regression to adjust for potential confounding variables. RESULTS: From the databases used, the incidence of CDH in NSW and the ACT was 1 per 3800 births. Of 242 infants identified with CDH, 8% underwent termination of pregnancy, 10% were stillborn after 20 weeks' gestation, and 82% were liveborn. Most liveborn infants (70%) were delivered at term with a 64% survival, whereas 30% were preterm with a 35% survival. For liveborn infants, the overall preoperative mortality was 35% with 56% surviving to discharge. Logistic regression identified a low 5-minute Apgar score, prematurity, and air leak as independent risk factors for mortality. CONCLUSIONS: This population-based study of CDH provides us with baseline data for our states. Mortality is high in preterm infants and in the preoperative period. Avoiding preterm delivery and improving preoperative stabilization are the measures most likely to improve survival.

Abortion, Induced↗

Alcohol drinking may increase risk of breast cancer in men: a European population-based case-control study.

OBJECTIVE: It has been estimated that alcohol drinking increases the risk of breast cancer in women by approximately 7% for each increment of 10 g alcohol per day. However, the few studies conducted on breast cancer among men have failed to detect an association with quantitative measures of alcohol drinking, even if the alcohol intake is generally higher in men than in women. On the other hand, increased risks of male breast cancer were inconsistently reported in alcoholics or patients with liver cirrhosis. We have investigated the role of alcohol drinking in male breast cancer using data collected in a population-based case-control study on seven rare cancers, conducted in Denmark, France, Germany, Italy, and Sweden. METHODS: The cases were 74 histologically verified male breast cancer patients aged 35-70 years. The controls (n = 1432) were selected from population registers, and frequency-matched to the cases by age group and geographic area. To check for consistency, a separate analysis was conducted using as controls the patients with a rare cancer other than male breast recruited simultaneously in the European study (n = 519 men). RESULTS: Based on population controls, the risk of developing breast cancer in men increased by 16% (95% CI: 7-26%) per 10 g alcohol /day (p < 0.001). An odds ratio of 5.89 (95% CI: 2.21-15.69) was observed for alcohol intake greater than 90 g per day, as compared with light consumers (< 15 g per day). Similar associations were observed when other rare cancers patients were used as controls. CONCLUSION: We found that the relative risk of breast cancer in men is comparable to that in women for alcohol intakes below 60 g per day. It continues to increase at high consumption levels not usually studied in women.

Adult↗

Prevalence of tuberculosis in a rural area by an alternative survey method without prior radiographic screening of the population.

SETTING: Mass miniature radiography (MMR) is the usual tool for population screening in tuberculosis case prevalence surveys. However, this facility is not available at most centres in India. OBJECTIVE: The feasibility of conducting a survey without MMR screening was therefore investigated. DESIGN: The study was carried out in Bangalore rural district during 1984-1986. The area was the same as for six earlier prevalence surveys conducted since 1961. The population aged up to 44 years was tuberculin tested. Persons with test induration size of > or = 10 mm were eligible for sputum examination, besides all those aged over 45 years who were eligible without discrimination. RESULTS: Reduction of workload was not adequately achieved through screening, as 78.4% of the registered population (29,400) was still eligible for sputum examination. The changed screening procedure in this survey also made comparison with earlier data difficult. In spite of more liberal and comprehensive screening, the observed prevalence rate of cases (438/100,000 population aged 10+ years) was similar to earlier surveys. The prevalence rate of smear-positive cases, however, was much lower (68/100,000 population aged 10+ years). CONCLUSION: In conclusion, the candidate screening procedure was not suitable. The findings nevertheless conformed to the overall declining trend for the area, as reported earlier.

Adolescent↗

Increasing age does not decrease risk of schizophrenia up to age 40.

It is well established that at the population level the age-specific incidence of schizophrenia is highest in the early 20s and decreases with age. We present new findings showing that this is not the case when we assume that only part of the population is susceptible. The study population consisted of birth cohorts born in Finland from 1950 to 1968. These were identified from the Population Register Center, which provided the data as multidimensional tables with sex, and year, month, and place of birth as marginals. Each cohort was followed-up until 1991, up to age 40. Data analyses were based on a compound Poisson statistical model, which assumed that only part of the population is susceptible to develop schizophrenia. The method detects the proportion of susceptibles in population level, but does not identify susceptible individuals. The model was able to reveal the basic hazard distribution, which showed increasing risk of developing schizophrenia with higher age at the individual level among the susceptible part of the population. The increase in risk was more rapid among males, but the susceptible part of the population was of similar size among both sexes. The proportion of susceptibles seemed to be lower in younger cohorts. We conclude that when an individual belongs to the susceptible part of the population, his/her individual risk of developing schizophrenia increases with age, at least up to age 40. This increase is more rapid among males. The reasons behind the lower proportion of susceptibles in younger birth cohorts, as well reasons for differences in risk between sexes remained unclear and need more research.

Adult↗

Impairment, disability and handicap as risk factors for depression in old age. The Gospel Oak Project V.

BACKGROUND: An association between disablement and late-life depression is often reported in cross-sectional studies. However, many lack effect sizes, and do not control for confounding. Therefore, it is difficult both to quantify the overall impact of poor health on depression and to understand which aspects are most salient. METHODS: A catchment area survey of all over 65-year-old residents of an electoral district in London, UK, using a population register derived from a door-to-door census was undertaken. Depression was measured using SHORT-CARE, and the consequences of disease classified according to the WHO International Classification of Impairments, Disabilities and Handicaps. RESULTS: Six hundred and fifty-four subjects were interviewed out of an older population of 889. The prevalence of SHORT-CARE pervasive depression was 17%. Impairment, disability and, particularly, handicap were strongly associated with depression. The adjusted odds ratio for depression in the most handicapped quartile compared with the least was 24.2 (8.8-66.6). The population attributable fraction (PAF) for depression attributable to handicap was 0.78. The PAFs for recent life events and female gender were much lower. Handicap explained most of the depression associated with individual impairments and disabilities. Adjusting for handicap abolished or weakened the associations between depression and social support, income, older age, female gender and living alone. CONCLUSIONS: Even given some uncertainty in distinguishing handicap and depression as constructs, and the impossibility of deciding direction of causality, it seems likely that handicap is of central significance to late-life depression. Handicap may be more amenable to intervention than either impairment or disability.

Activities of Daily Living↗

Testicular cancer and parental use of fertilizers in agriculture.

Testicular cancer incidence is increasing rapidly in several countries. Environmental causes acting early in life are suspected but have not yet been identified. We conducted a cohort study to identify parental risk factors for testicular cancer among farmers' sons. Children born in 1952-1991 to parents who were farm holders at the time of the agricultural censuses in 1969-1989 were identified in the Central Population Register (Oslo, Norway). The resulting cohort of male offspring (n = 166,291) were followed up in the Cancer Registry of Norway (Oslo, Norway) for 1965-1991. Exposure indicators were derived from census information on activities on the farm. The cancer incidence was compared with that of the total rural population, and potential risk factors were analyzed by Poisson regression. In a follow-up of 2,924,663 person-years, 158 incident cases of testicular cancer were identified. The study population had a higher incidence of testicular cancer than did the total rural population, particularly at ages 15-19 years and in western Norway. Specific fertilizer regimens on the farm were associated with testicular cancer (rate ratio = 2.44; 95% confidence interval = 1.66-3.56), in particular nonseminoma (rate ratio = 4.21; 95% confidence interval = 2.13-8.32). The rate ratio estimates were highest for boys ages 15-19 years and for a subset of study subjects who were considered more likely to have grown up on a farm. Nondifferential misclassification and bias toward unity are likely because exposure information was available only at the farm level and only for census years. The fertilizer indicators were not available early in life for most subjects, and precise interpretations are difficult. A hypothesis worth considering is that excess nutrient run-off from agriculture constitutes a risk. However, inferences concerning the biological basis of our observations can scarcely be made.

Adolescent↗

Cancer mortality among licensed herbicide applicators.

This retrospective cohort study investigated the cancer mortality of 1341 herbicide applicators licensed before 1 January 1980. The cohort was followed for mortality until 1 January 1988 by means of the Dutch system of population registers. For the subjects who died before 1 January 1988 the cause of death was obtained from the Central Bureau of Statistics. The cause of death was obtained for 98.4% of the deceased subjects. The total mortality was lower than expected according to mortality rates of the total male Dutch population. The total number of deaths from cancer was however slightly higher than expected [standardized mortality ratio (SMR) 114]. Mortality from several subtypes of cancer was also higher than expected, that for multiple myeloma being statistically significantly higher than unity (SMR 815, 95% confidence interval 164-2382). Occupational exposure to herbicides appears to increase the risk for multiple myeloma and possibly other malignant neoplasms.

Cohort Studies↗

Prevalence of nasal polyps in adults: the Skövde population-based study.

Patients with nasal polyps present repeatedly in otorhinolaryngology practices, but the prevalence of nasal polyps in the general population is not known. Our objective was to investigate the prevalence of nasal polyps in an adult Swedish population in relation to age, gender, asthma, and aspirin intolerance. A random sample of 1,900 inhabitants over the age of 20 years, stratified for age and gender, was drawn from the municipal population register in Skövde, Sweden, in December 2000. The subjects were called to clinical visits that included questions about rhinitis, asthma, and aspirin intolerance and examination by nasal endoscopy. In total, 1,387 volunteers (73% of the sample) were investigated. The sample size was adequate, with a good fit to the whole population. The prevalence of nasal polyps was 2.7% (95% confidence interval, 1.9-3.5), and polyps were more frequent in men (2.2 to 1), the elderly (5% at > or = 60 years of age), and asthmatics. Subjective symptoms of aspirin intolerance were not found to correlate with polyps. Nasal polyps were more common in adults than was stated by the a priori estimate. The Skövde population-based study is considered representative for the Swedish population.

Adult↗

Demographics of the UK cystic fibrosis population: implications for neonatal screening.

The objective was to determine the composition of the Cystic Fibrosis (CF) Population attending specialist UK CF centres in terms of age, gender, age at diagnosis, genotype and ethnicity. With the planned introduction of the national CF screening programme in the UK, cystic fibrosis transmembrane regulator (CFTR) mutations were compared between different ethnic groups enabling a UK-specific frequency of mutations to be defined. Data were analysed from the patient biographies held in the UK CF Database (see www.cystic-fibrosis.org.uk). The currently registered population of 5,274 CF patients is 96.3% Caucasian with a male preponderance that significantly increases with age. The majority of the 196 non-Caucasian CF patients are from the Indian Subcontinent (ISC), of which one in 84 UK CF patients are of Pakistani origin. The commonest CFTR mutation, deltaF508, is found in 74.1% of all CF chromosomes. In the Caucasian CF population, 57.5% are deltaF508 homozygotes but the UK ISC CF population with only 24.7%, has significantly fewer deltaF508 homozygotes patients (95% confidence interval (CI) 0.2-0.4). The distribution of Caucasian patients with deltaF508/deltaF508, deltaF508/Other and Other/Other does not fit the expected distribution with a Hardy-Weinberg model unless those patients without a detected mutation are excluded (P<0.001). The UK CF Database has shown the UK CF population to have distinct characteristics separate from the North American and European CF Registries. The ISC group contains many mutations not recognised by current genetic analysis, and one in four ISC patients have no CFTR mutations identified. The CFTR analysis proposed for the screening programme would detect 96% of patients registered in the database, but is unlikely to achieve the desired >80% detection rates in the ethnic minority groups. Screen-positive, non-Caucasian infants without an identifiable CFTR mutation should be referred for a sweat test and genetic counselling when serum trypsinogen concentrations remain elevated after birth.

Adolescent↗