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PubMed1990

Breast-feeding and diarrheal morbidity.

This study used a unique longitudinal survey of more than 3000 mother-infant pairs observed from pregnancy through infancy. The sample is representative of infants from the Cebu region of the Philippines. The sequencing of breast-feeding and diarrheal morbidity events was carefully examined in a longitudinal analysis which allowed for the examination of age-specific effects of feeding patterns. Because the work controlled for a wide range of environmental causes of diarrhea, the results can be generalized to other populations with some confidence. The addition to the breast-milk diet of even water, teas, and other nonnutritive liquids doubled or tripled the likelihood of diarrhea. Supplementation of breast-feeding with additional nutritive foods or liquids further increased significantly the risk of diarrhea; most benefits of breast-feeding alone or in combination with nutritive foods/liquids became small during the second half of infancy. Benefits of breast-feeding were slightly greater in urban environments.

Breast Feeding↗
PubMed2002

On changing a long-term clinical trial midstream.

Clinical triallists are often reluctant to alter the protocol or the design of an ongoing study in part because of concern that changes may affect the integrity of the study. This paper encourages considering changes in long-term clinical trials when the medical environment changes or when the accruing data from the trial lead to questioning the assumptions underlying the original design. One must make such changes in a way that will not cast doubt on the integrity of the trial. An important aspect of the design is choice of sample size. Methodology for sample size recalculation has matured over the decade. Several techniques are now available for the usual types of endpoints - continuous, discrete and time-to-failure - as well as for longitudinal analysis. Published papers describe the choices of variance at the time of recalculation, approaches to estimation and testing at the end of the study, and the time of recalculation. In a study with a sponsor, a Data Safety Monitoring Board (DSMB) and an Executive Committee, one or more of these three groups is responsible for recommending increases in sample size when the accruing data indicate that the assumed variance underestimated the true variance. Sometimes a statistician independent of all three bodies performs the relevant calculations and sends the recommendation to the sponsor. This paper argues that the DSMB should not generally be the responsible body because knowledge of treatment effect can place it in an uncomfortable position.

Aspirin↗
PubMed2006

Frequency of family dinner and adolescent body weight status: evidence from the national longitudinal survey of youth, 1997.

OBJECTIVE: To explore associations between overweight status and the frequency of family dinners (FFD) for adolescents and how those associations differ across race and ethnicity. RESEARCH METHODS AND PROCEDURES: A sample of 5014 respondents between 12 and 15 years of age from the 1997 wave of the National Longitudinal Survey of Youth 1997 (NLSY97) was used. BMI was calculated using self-reported height and weight; 13.3% of respondents qualified as overweight, 16.4% qualified as at-risk-of-overweight, and 1.9% qualified as underweight. The remainder were normal weight. FFD was defined as the number of times respondents had dinner with their families in a typical week in the past year. Multinomial logistic regression models were estimated separately for non-Hispanic whites vs. blacks and Hispanics for odds of belonging to the other weight categories compared with normal weight. A supplementary longitudinal analysis estimated the odds of change in overweight status between 1997 and 2000. RESULTS: In 1997, the FFD distribution was as follows: 0, 8.3%; 1 or 2, 7.3%; 3 or 4, 13.4%; 5 or 6, 28.1%; 7, 42%. For whites, higher FFD was associated with reduced odds of being overweight in 1997, reduced odds of becoming overweight, and increased odds of ceasing to be overweight by 2000. No such associations were found for blacks and Hispanics. DISCUSSION: Reasons for racial and ethnic differences in the relationship between FFD and overweight may include differences in the types and portions of food consumed at family meals. More research is needed to verify this.

Adolescent↗
PubMed1989

Fetal and infant lead exposure: effects on growth in stature.

The growth of a cohort of 260 infants was prospectively followed up from birth. Blood lead and stature measurements were obtained every 3 months until 15 months of age. Fetal lead exposure was indexed by measuring lead in maternal blood during pregnancy. A longitudinal analysis revealed that covariate adjusted growth rates in stature were negatively related to the infants' postnatal blood lead concentration, as indexed by increase in average blood lead values from 3 to 15 months. However, this relationship between growth rate and change in blood lead concentration was evidenced only among those infants whose mothers had prenatal blood lead levels greater than the maternal cohort median of 7.7 micrograms/dL is about 2 cm shorter at 15 months of age if, postnatally, the infant incurred a 10-micrograms/dL blood lead increase during the 3- to 15-month interval of life, compared with an infant who has no increase.

Cohort Studies↗
PubMed2002

Increase in the prevalence of allergen skin sensitization in successive birth cohorts.

BACKGROUND: Little is known about longitudinal trends in the prevalence of allergen skin sensitization in the general population. OBJECTIVE: We sought to measure the change in prevalence of allergen skin sensitization over a 9-year period in a cohort of adults and hence to determine whether cross-sectional differences in prevalence between age groups are due to an aging or cohort effect. METHODS: In 1991 and 2000, we measured skin sensitization, defined as a wheal diameter of 3 mm or larger than that elicited by a saline control, to Dermatophagoides pteronyssinus, cat fur, mixed grass, Aspergillus fumigatus, and Cladosporium herbarum in a cohort of 1339 adults from Nottingham aged between 18 and 71 years in 1991. Subjects were divided into six 9-year successive birth cohorts, and the effects of birth cohort and the within-subject change from 1991 to 2000 were analyzed in a generalized estimating equation logit model. RESULTS: The unadjusted prevalence of sensitization to any allergen was 30.5% in 1991 and 31.8% in 2000. In cross-sectional analyses the prevalence of sensitization decreased with increasing age at both surveys (risk ratio, 2.15; 95% confidence interval [CI], 1.45-3.17 for 18- to 26-year-old patients relative to 63- to 70-year-old patients in the 1991 survey). In longitudinal analysis there was no within-subject change in sensitization from 1991 to 2000 (adjusted odds ratio, 1.07; 95% CI, 0.97-1.19), but there was a significant cohort effect (adjusted odds ratio per successive 9 year cohort, 1.27; 95% CI, 1.18-1.37). CONCLUSION: The cross-sectional decrease in allergen sensitization with age in the general population arises predominantly from a secular increase in sensitization prevalence with successive birth cohorts and not to a loss of sensitization within subjects over time. As a result of this cohort effect, the prevalence of allergic sensitization has increased in this general adult population sample.

Adolescent↗
PubMed2001

Antibody response to IR6, a conserved immunodominant region of the VlsE lipoprotein, wanes rapidly after antibiotic treatment of Borrelia burgdorferi infection in experimental animals and in humans.

Invariable region (IR)(6), an immunodominant conserved region of VlsE, the antigenic variation protein of Borrelia burgdorferi, is currently used for the serologic diagnosis of Lyme disease in humans and canines. A longitudinal assessment of anti-IR(6) antibody levels in B. burgdorferi-infected rhesus monkeys revealed that this level diminished sharply after antibiotic treatment (within 25 weeks). In contrast, antibody levels to P39 and to whole-cell antigen extracts of B. burgdorferi either remained unchanged or diminished less. A longitudinal analysis in dogs yielded similar results. In humans, the anti-IR(6) antibody titer diminished by a factor of > or =4 in successfully treated patients and by a factor of <4 in treatment-resistant patients. This result suggests that the quantification of anti-IR(6) antibody titer as a function of time should be investigated further as a test to assess response to Lyme disease therapy or to determine whether a B. burgdorferi infection has been eliminated.

Adult↗
PubMed1997

Predictors of severity of acne vulgaris in young adolescent girls: results of a five-year longitudinal study.

OBJECTIVES: The objectives of this study were to determine which factors in early pubertal girls might be predictive of later, severe facial acne. STUDY DESIGN: The study was a 5-year longitudinal cohort study, with yearly visits from 1987 through 1991, in a volunteer sample of 439 black and 432 white fourth- and fifth-grade girls with consent from their legal guardians. The subjects were recruited from public and parochial schools in Cincinnati, Ohio. The degree of facial acne was classified annually as mild, moderate, or severe. Blood samples were obtained at the first, third, and fifth years of the study. Using the acne status during the fifth year of the study as the outcome variable, we determined the contributions from the prior acne status and the serum levels of dehydroepiandrosterone sulfate (DHEAS), testosterone, free testosterone (FT), estradiol (E2), progesterone, and testosterone-estrogen binding globulin (TEBG) and compared the results at various ages and at times before and after menarche. RESULTS: No racial differences in acne or hormone levels were found. There was a progressive increase in the number of acne lesions with age and maturation. The girls exhibited many more comedonal than inflammatory acne lesions, regardless of age. The girls in whom severe acne developed by the fifth year of the study had significantly more comedones and inflammatory lesions than girls with mild or moderate acne, as early as age 10 years, approximately 2 h years before menarche, a time when their degree of acne was mild. Girls with mild comedonal acne had significantly later onset of menarche (12.5 compared with 12.2 years) than girls with severe comedonal acne. Girls in whom severe comedonal acne developed had significantly higher levels of serum DHEAS and, in a longitudinal analysis, somewhat higher levels of testosterone and FT in comparison with girls who had mild or moderate comedonal acne. Serum E2, testosterone/E2, progesterone, and TEBG values were no different in girls with severe compared with mild or moderate comedonal acne. CONCLUSIONS: The early development of comedonal acne may be one of the best predictors of later, more severe disease. The adrenal hormone DHEAS appears to play an important role in the initiation of acne. DHEAS, testosterone, and FT are associated with the perpetuation of severe comedonal acne. Early recognition of young girls at risk of having severe comedonal acne may enable the clinician to intervene and thus prevent unwanted sequelae.

Acne Vulgaris↗
PubMed2001

Chernobyl fallout and outcome of pregnancy in Finland.

Possible effects of Chernobyl fallout on outcome of pregnancy in Finland were evaluated in a nationwide follow-up study. The outcomes were the rate of live births and stillbirths, pregnancy loss, and induced abortions by municipality. Exposure was assessed based on nationwide surveys of radiation dose rate from the Chernobyl fallout, from both external and internal exposures. Using these measurements, we estimated the monthly dose rate for each of the 455 Finnish municipalities. On average, the dose rate from Chernobyl fallout reached 50 microSv per month in May 1986--a doubling of the natural background radiation. In the most heavily affected area, 4 times the normal background dose rates were recorded. Given the underlying regional differences in live birth, stillbirth, and abortion rates, we used longitudinal analysis comparing changes over time within municipalities. A temporary decline in the live birth rate had already begun before 1986, with no clear relationship to the level of fallout. A statistically significant increase in spontaneous abortions with dose of radiation was observed. No marked changes in induced abortions or stillbirths were observed. The decrease in the live birth rate is probably not a biological effect of radiation, but more likely related to public concerns of the fallout. The effect on spontaneous abortions should be interpreted with caution, because of potential bias or confounding. Further, there is little support in the epidemiologic literature on effects of very low doses of radiation on pregnancy outcome.

Abortion, Spontaneous↗
PubMed2006

Influence of neoadjuvant radiochemotherapy combined with hyperthermia on the quality of life in rectum cancer patients.

PURPOSE: The present study compares quality of life (QoL) after neoadjuvant radiochemotherapy with or without hyperthermia in patients with advanced rectal cancer. METHODS: Between April 1994 and May 1999, 137 patients were treated by neoadjuvant radiochemotherapy with (69 patients (50.4%)) or without (68 patients (49.6%)) hyperthermia. Forty-six patients (33.6%) filled-out a 'Gastrointestinal Quality of Life Index' (GIQLI) questionnaire at four time points (before and after neoadjuvant therapy, early after surgery and after long-term follow-up) and were included in the present study. RESULTS: There were no statistically significant differences in the global GIQLI index between patients treated with neoadjuvant radiochemotherapy with and without hyperthermia at any time point. The longitudinal analysis of GIQLI values in both treatment groups showed specific profiles that were identical in both treatment groups. Occurrence of severe toxicity during the neoadjuvant therapy in both arms lead to a significant temporary reduction of QoL scores at TP2 without any detrimental long-term effects. Patients with sphincter preservation and patients with sphincter resection reported similar QoL scores during long-term follow-up. CONCLUSION: Neoadjuvant radiochemotherapy with and without hyperthermia has similar effects on the QoL of patients with locally advanced rectal cancer. The addition of hyperthermia during the neoadjuvant therapy with the potentially associated inconveniences has no negative effects on QoL.

Adult↗
PubMed2003

Frequency and predictive value of a mammographic recommendation for short-interval follow-up.

BACKGROUND: A recommendation for short-interval follow-up of "probably benign finding" is associated with up to 11% of screening mammograms, but its predictive value for breast cancer is unclear. We examined the predictive values (i.e., the percentage of women with a diagnosis of breast cancer 2 years after a short-interval follow-up recommendation) and likelihood ratios (derived from the pretest and post-test odds of breast cancer in the Women's Health Initiative sample) for breast cancer that are associated with a recommendation for short-interval follow-up among postmenopausal women. METHODS: We performed a longitudinal analysis of a prospective cohort of 68 126 postmenopausal women (aged 50-79 years) who were participating in clinical trials as part of the Women's Health Initiative at 40 centers across the United States. Eligible participants had screening mammograms at baseline and at least 2 years of follow-up that included a repeat mammography. Outcomes measured were breast cancer events at 1 and 2 years after baseline and the results of subsequent mammograms. All P values were two-sided. RESULTS: A total of 2927 (5%) of the 58 408 eligible women had baseline mammograms that included recommendations for short-interval follow-up. The incidence of breast cancer for women with a short-interval follow-up recommendation was 1.0% at 2 years after the baseline mammogram compared with breast cancer incidences of 0.6% and 0.5% for women whose baseline mammograms were described as "benign" and "negative," respectively. Across the 40 participating centers, the prevalence of short-interval follow-up recommendations among baseline mammograms varied from 1.2% to 9.8% (P<.001), even when the analysis was adjusted for key variables in regression models. Centers reporting higher frequencies of such recommendations did not have lower positive predictive values for breast cancer than centers reporting lower frequencies. The likelihood ratio for breast cancer after a recommendation for short-interval follow-up on a subsequent mammogram was 2.20 (95% confidence interval = 1.65 to 2.86). CONCLUSION: Having a mammographic recommendation for short-interval follow-up was associated with a low positive predictive value for breast cancer among postmenopausal women during a 2-year follow-up. This result suggests that the current criteria for this recommendation-repeat mammography within 6 months-should be reconsidered.

Aged↗
PubMed1998

Neutralizing antibodies are positively associated with CD4+ T-cell counts and T-cell function in long-term AIDS-free infection.

OBJECTIVES: To assess the dynamics of neutralizing antibodies (NAb) in long-term AIDS-free HIV-1-infected subjects and establish correlations with known markers of disease progression. DESIGN: Cross-sectional study using sera collected from long-term non-progressors (LTNP) 8 years after seroconversion or study entry. Longitudinal study using sera collected from LTNP at 0, 0.5, 1, 2, 4, 6, 8 and 10 years after seroconversion and, as controls, from rapid progressors. METHODS: Individuals with documented AIDS-free HIV-1 infection for at least 8 years were evaluated for NAb against five heterologous HIV-1 primary isolates. In the cross-sectional study, serum viral RNA levels, CD4+ T-cell numbers and T-cell function were determined on samples collected during the eighth year of follow-up. For the longitudinal study, NAb were assessed in sequential sera taken from LTNP and rapid progressors. RESULTS: Serum neutralization titres found in individual sera differed from one HIV-1 isolate to another, were detected in 49-76% of LTNP, without correlation with the coreceptor usage of the isolate, and were positively associated with CD4+ T-lymphocyte counts (P = 0.0041) and T-cell function (P = 0.04). No correlation was found between NAb and the level of viral RNA in serum or the rate of CD4+ T-cell decline. Longitudinal analysis of sera from LTNP and rapid progressors showed that although several subjects in both groups had neutralizing activity at seroconversion, it thereafter became lower or no longer detectable. NAb were again found 1-4 years later and stably persisted in LTNP, but remained undetectable or at low levels in rapid progressors. CONCLUSIONS: NAb were preferentially found in subjects with relatively preserved T-cell function and CD4+ T-cell numbers. In these individuals, neutralizing activity against heterologous isolates increased with time. These data suggest that the capacity to produce broadly NAb is a function of the integrity of the immune system.

CD4 Lymphocyte Count↗
PubMed1996

Lack of influence of menopause on blood pressure and cardiovascular risk profile: a 16-year longitudinal study concerning a cohort of 568 women.

OBJECTIVE: To analyse the effect of menopause on blood pressure and cardiovascular risk. DESIGN: From an Italian general population, 568 women (408 pre- and 160 post-menopausal) were screened twice, in 1978 and 16 years later. METHODS: Cross-sectional analyses both in 1978 and in 1994, and longitudinal analysis in the 1978-1994 period. RESULTS: For the general analysis the cohort was reduced to 525 women with paired data in 1978 and 1994. In both cross-sectional studies, unadjusted blood pressure and cardiovascular risk were higher after than they were before menopause, but any difference disappeared after adjustment or matching for age. In 1994 we studied three groups of women: those who were still premenopausal, those who were fertile in 1978 but postmenopausal in 1994 and those who were already postmenopausal in 1978. The 16-year blood pressure increment was similar in all three groups. The incidence of myocardial infarction and angina pectoris was greater in those who were already postmenopausal than it was in those who had their menopause during the study period. An analysis of mortality was performed for all of the 568 women. Forty-three of them died, 14 from cardiovascular causes (six before and eight after menopause), 18 from neoplasia (two before and 16 after menopause) and 11 from other diseases. Menopausal status was rejected from the Cox equations both of overall and of cardiovascular mortality, showing a significantly predictive value only for neoplastic mortality. CONCLUSION: Menopause has no influence on high blood pressure and cardiovascular risk. The greater blood pressure levels, mortality and morbidity observed in postmenopausal women are simply attributable to their older age and are no longer detectable in an age-matched sample.

Adult↗
PubMed2005

Body mass index in Bengali adolescents.

We describe a mixed longitudinal analysis of body mass index (BMI) in a group of Bengali adolescents (age 11-17 years) from a middle income family background and compare this against existing national and international data. Healthy school children, comprising of 416 boys and 343 girls were consented for annual repeat measurements of weight, height and pubertal staging between the years 1998 and 2001. The LMS method was used to construct smoothed BMI mean and standard deviation (SD) curves. Bengali adolescents have lower BMI than affluent Indian children and are -1 to -2 SD below US children. BMI increases in adolescence (boys: r = 0.49, p < 0.001, girls: r = 0.54, P < 0.001) with age but SMR does not have an independent effect on BMI.

Adolescent↗
PubMed1988

Guillain-Barré syndrome: a model of random conduction block.

In the Guillain-Barré syndrome clinical deficit is caused by failure of conduction in nerve fibres. Immunological mechanisms are generally held responsible, but the mechanism has not yet been elucidated. A recent longitudinal analysis of the distribution of lesions along the nerve trunks suggested two main patterns. In one of them, motor conduction block dispersed over the length of the nerve trunk was found, whereas sensory fibres were usually spared. For further pathogenetic studies of this subgroup, it is important to know whether conduction block occurs randomly or at preferred sites. As a tool to establish this, a model for conduction block is presented, based on a random distribution of lesions in the peripheral nerves. It is applicable to compound muscle action potentials (CMAP) obtained in routine EMG studies. Comparison of predicted and measured CMAPs in a first group of seven Guillain-Barré patients with evidence of conduction block supports the concept of a random distribution of lesions in this subgroup.

Electric Stimulation↗
PubMed2006

Directly measured secondhand smoke exposure and COPD health outcomes.

BACKGROUND: Although personal cigarette smoking is the most important cause and modulator of chronic obstructive pulmonary disease (COPD), secondhand smoke (SHS) exposure could influence the course of the disease. Despite the importance of this question, the impact of SHS exposure on COPD health outcomes remains unknown. METHODS: We used data from two waves of a population-based multiwave U.S. cohort study of adults with COPD. 77 non-smoking respondents with a diagnosis of COPD completed direct SHS monitoring based on urine cotinine and a personal badge that measures nicotine. We evaluated the longitudinal impact of SHS exposure on validated measures of COPD severity, physical health status, quality of life (QOL), and dyspnea measured at one year follow-up. RESULTS: The highest level of SHS exposure, as measured by urine cotinine, was cross-sectionally associated with poorer COPD severity (mean score increment 4.7 pts; 95% CI 0.6 to 8.9) and dyspnea (1.0 pts; 95% CI 0.4 to 1.7) after controlling for covariates. In longitudinal analysis, the highest level of baseline cotinine was associated with worse COPD severity (4.7 points; 95% CI -0.1 to 9.4; p = 0.054), disease-specific QOL (2.9 pts; -0.16 to 5.9; p = 0.063), and dyspnea (0.9 pts; 95% CI 0.2 to 1.6 pts; p < 0.05), although the confidence intervals did not always exclude the no effect level. CONCLUSION: Directly measured SHS exposure appears to adversely influence health outcomes in COPD, independent of personal smoking. Because SHS is a modifiable risk factor, clinicians should assess SHS exposure in their patients and counsel its avoidance. In public health terms, the effects of SHS exposure on this vulnerable subpopulation provide a further rationale for laws prohibiting public smoking.

Aged↗
PubMed2001

Concentrations of chondroitin sulfate epitopes 3B3 and 7D4 in synovial fluid after intra-articular and extracapsular reconstruction of the cranial cruciate ligament in dogs.

OBJECTIVE: To evaluate effects of intra-articular and extracapsular reconstruction of the cranial cruciate ligament (CCL) on metabolism of articular cartilage as reflected by concentrations of chondroitin sulfate epitopes 3B3 and 7D4 in synovial fluid. ANIMALS: 13 adult dogs. PROCEDURE: Each dog underwent unilateral CCL transection (CCLT). One month after CCLT, sham CCL reconstruction (3 dogs), intra-articular CCL reconstruction (5), or extracapsular CCL reconstruction (5) was performed. Synovial fluid was collected by direct arthrocentesis from CCLT and contralateral stifle joints immediately before (time 0) and 1, 3, and 5 months after CCLT. Fluid was examined for concentrations of 3B3 and 7D4 epitopes and total sulfated glycosaminoglycan (GAG) content. RESULTS: Concentrations of 3B3, 7D4, and GAG, 3B3:GAG, or 7D4:GAG in CCLT joints did not differ significantly among treatment groups nor in the ratios of these variables in CCLT joints to contralateral joints at 3 months. In a longitudinal analysis, concentrations of 3B3 and 7D4, 3B3:GAG, and 7D4:GAG in CCLT joints in all groups changed significantly with time, but we did not detect time X group interactions. CONCLUSIONS AND CLINICAL RELEVANCE: Transection of CCL resulted in significant perturbation in articular cartilage metabolism as reflected by alterations in concentrations of 3B3 and 7D4 in synovial fluid. These changes over time were not significantly influenced by method of CCL reconstruction. We did not find evidence that surgical stabilization of CCL-deficient joints by intra-articular or extracapsular techniques had any effect on preventing alterations in composition of synovial fluid that have been associated with secondary osteoarthritis.

Animals↗
PubMed1999

CC chemokine receptor 5 cell-surface expression in relation to CC chemokine receptor 5 genotype and the clinical course of HIV-1 infection.

CCR5 cell-surface expression was studied in relation to CCR5 genotype and clinical course of HIV-1 infection. HIV-1 infected CCR5+/+ individuals had higher percentages of CCR5-expressing CD4+ T cells as compared with HIV-1-infected CCR532/+ individuals. For both genotypic groups, the percentages of CCR5-expressing cells were higher than for the uninfected counterparts (CCR5+/+, HIV+ 28% and HIV- 15% (p < 0.0001); CCR532/+, HIV+ 21% and HIV- 10% (p = 0.001), respectively). In HIV-1-infected individuals, high percentages of CCR5-expressing cells were associated with low CD4+ T cell numbers (p = 0.001), high viral RNA load in serum (p = 0.046), and low T cell function (p = 0.054). As compared with nonprogressors with similar CD4+ T cell numbers, individuals who did progress to AIDS had a higher percentage of CCR5-expressing CD4+ T cells (32% vs 21% (p = 0.002). Longitudinal analysis of CCR5+/+ individuals revealed slight, although not statistically significant, increases in CCR5-expressing CD4+ T cells and CD4+ T cell subsets characterized by the expression of CD45 isoforms, during the course of HIV-1 infection. Preseroconversion, the percentage of CCR5-expressing CD4+ T cells was higher in individuals who subsequently developed AIDS (28%) than in those who did not show disease progression within a similar time frame (20%; p = 0.059). Our data indicate that CCR5 expression increases with progression of disease, possibly as a consequence of continuous immune activation associated with HIV-1 infection. In turn, CCR5 expression may influence the clinical course of infection.

Adult↗
PubMed2002

[Primary health care in Vestfold county prior and after the introduction of the primary health act].

A longitudinal analysis of the development of primary care in Norway focusing on Vestfold County shows that resources have increasingly been channelled to curative services, with less being spent on community-based preventive care. Vestfold, a county in the most densely populated area of Norway, with an expanding population and a growing economy, has seen a remarkable growth in private practice. There are several reasons for this. Socio-economic and demographic trends play a role; the provision of curative services is also more flexible and more profitable. Local municipalities seem to have given higher priority to curative services than to preventive tasks. Nation-wide, primary care has grown more slowly than specialised care. At the local level, care for the elderly, organised as a separate service, has been a winner.

Community Health Services↗