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Introduction: Herpes zoster (HZ or shingles) and its complication post-herpetic neuralgia (PHN) are common in persons above 50 years of age. A vaccine that decreases the incidence and morbidity associated with HZ was licensed for use in 2006 and will be marketed in Denmark as from 2013. This study aimed to explore the relations between illness perceptions of shingles and attitudes towards zoster vaccination.

Material and methods: Three qualitative focus group interviews were conducted with 22 patients, relatives and individuals with no personal experiences with HZ. Semi-structured interview guides were applied including questions identified in a literature study. The data were analysed using a medical anthropological approach.

Results: The study showed that HZ and PHN, in particular, have severe impacts on patients' quality of life (QoL) and often affect their relatives' daily lives as well. Nevertheless, people who have no experience with HZ underrate both its prevalence and its QoL impacts. Such misperceptions often result in delayed treatment and may lead to a low uptake of zoster vaccination.

Conclusion: Individual attitudes towards zoster vaccination are closely related to subjective perceptions of HZ and views on vaccination in general. Vaccination recommendations to target groups are necessary, but individual choice is determined by knowledge about the disease, personal risk assessment and the recommendations of the general practitioner.

Funding: The study was funded by a research grant from Sanofi Pasteur MSD.

Trial registration: not relevant.

Introduction: Multi-dose drug dispensing (MDDD) signifies that the patient's medicine is packed in disposable bags corresponding to the dose that should be taken. The purpose of the present study was to investigate how a hospital MDDD instruction was followed.

Material and methods: All patients receiving MDDD on admission to the acute medical admission ward at Bispebjerg Hospital in the period from 1 January to 30 June 2010 were prospectively included in the study. An audit of the medication lists and hospital case records covering the period from admission to discharge was performed. A proportion of patients received a post-discharge home visit. An interview in both sectors was carried out to determine whether the instructions had been followed.

Results: Almost 9% of the patients were receiving MDDD on admission. Information on MDDD was recorded in the physician case record for 3.4% of the patients and in the nurse case record for 12.9% of the patients. Changes in MDDD during hospitalization were made for 58.3% of the patients. General practitioners and/or the community pharmacy were notified of changes in MDDD at discharge for 13.6% of the patients. The post-discharge visits and the interview revealed potential issues of concern regarding patient safety.

Conclusion: MDDD is frequent. Identification and registration of MDDD is only performed sporadically. Changes in MDDD are frequent, but they are rarely accompanied by information to the general practitioner or the community pharmacy.

Funding: The project was partly funded by the Ministry of Health and Prevention 2009.

Trial registration: The study was approved by the Danish Data Protection Agency.

The present thesis consists of one published article and one draft manuscript. Interest in the incretin hormone glucose-dependent insulinotropic polypeptide (GIP) was reignited by the discovery that GIP receptor deficient mice were unable to gain weight in response to high fat feeding. However, the path from processing of the prohormone to regulation of secretion and establishment of its role in the complicated network of mediators involved in energy mobilization is not fully understood. The biologically active GIP1-42 was found in vivo to be dependent on processing from the immature prohormone by proprotein convertase 1/3 (PC1/3) in the intestinal K-cell. Even so, ~50% of GIP immunoreactive cells do not express PC1/3 raising the possibility that subsets of K-cells exist in which the precursor may be cleaved at alternative sites. Cell line studies did demonstrate that another convertase in endocrine cell types, PC2, mediated cleavage at alternative sites liberating larger and smaller GIP fragments. It was possible to detect fragments of similar size in gel filtration extracts of murine upper jejunum, but the identity, mechanism of processing and function of these immunoreactivities remains uncertain. Once correctly processed GIP1-42 is secreted in response to food intake. The K-cell is believed to directly sense and respond to nutrients in the intestine, but as the molecular profiling of this cell type has just begun, the nutrient sensing machinery and possible feedback regulation are still poorly characterized. When secreted to the blood stream, GIP acts as a mediator of energy mobilization in a complex network with other hormones. An acute and established function of GIP is to exert its incretin function thereby enhancing glucose stimulated insulin secretion necessary for prompt disposal of nutrients, yet GIP also stimulates glucagon secretion to increase blood glucose. In the diabetic state the insulinotropic effect of GIP is impaired and an early inexpedient glucagon stimulation in response to a meal further counteracts effects of insulin and worsens glycaemic control. A demonstration that GIP receptor deficient mice were resistant to diet induced obesity let to the categorization of GIP as a fat promoting hormone and direct insulin-mimetic effects in adipose tissue has been proposed. We were able to demonstrate a redundancy for the GIP receptor in incorporation of lipids into adipocytes. We also observed that GIP receptor deficient mice could respond normally to high fat feeding with increased fat mass, but failed to increase lean mass. Mice with rescue of the GIP receptor in adipose tissue normalized the body composition in response to high fat diet, but the mice had a lower total body weight. In contrast, the GIP receptor expressed in the pancreatic beta-cell was able to promote lean mass gain on a low fat diet, but not on a high fat diet. Overall, we have established principal requirements for GIP maturation. Furthermore,

Introduction: Treatment of pilonidal sinuses with Bascom's pit-pick operation can easily be performed under local analgesia. We describe pain during and after the operation, time to return to work, time to healing and success rate.

Material and methods: The study comprised a cohort of 75 primary pit-pick (PP) operations performed at our department between August 2007 and December 2009. The median age was 30 years (range 15-64 years) and 57 (76%) were male. A total of 55 patients were interviewed daily by phone for one week with a view to registering their ability to return to work and their scoring of maximum pain on a numerical rating scale with a pain score ranging from 0 (no pain) to 10.

Results: The mean maximum pain during the first post-operative day was 2.2 (95% confidence interval (CI) 1.8-2.7) and at day four 1.0 (CI 0.7-1.3). Within 24 hours, 51% could return to work and the mean time was 3.2 (CI 1.8-4.5) days. Postoperative infection was related to the presence of secondary sinus (p = 0.03) and increasing number of midline sinus excisions (p = 0.02). Complete wound healing was achieved in 84% of the patients after a mean period of 3.5 (CI 3.1-3.9) weeks. Incomplete wound healing was significantly related to a small number of PPs (p < 0.05), increasing number of midline sinus excisions (p < 0.05) and no postoperative infection (p = 0.01). At one-year follow-up 80% were considered successfully treated.

Conclusion: The majority of patients with simple pilonidal sinuses can be treated successfully with Bascom's PP procedure as out-patients. This regimen causes only mild postoperative pain and patients can resume work after a few days.

Funding: not relevant.

Trial registration: not relevant.

Severe pain is usual after laparoscopic ventral hernia repair (LVHR). Mesh fixation with titanium tacks may play a key role in the development of acute and chronic pain and alternative fixation methods should therefore be investigated. This PhD thesis was based on three studies and aimed too: 1) assess the intensity and impact of postoperative pain by detailed patient-reported description of pain and convalescence after LVHR (Study I), 2) evaluate the feasibility of fibrin sealant (FS) for mesh fixation in an experimental pig model (Study II), and 3) investigate FS vs. tacks for mesh fixation in LVHR in a randomised, double-blinded, clinical controlled study with acute postoperative pain as the primary outcome (Study III). In Study I - a prospective descriptive study - 35 patients were prospectively included and underwent LVHR. Scores of pain, quality of life, convalescence, fatigue, and general well-being were obtained from each patient. Follow-up was six months. Average pain from postoperative day (POD) 0-2 and POD 0-6 measured on a 0-100 mm visual analogue scale (VAS) was 61 and 48, respectively. Pain scores reached preoperative values at POD 30. The incidence of severe chronic pain was 7%. No parameter predicted postoperative pain significantly. Significant correlations were found between pain, and general well-being (rS= -0.8, p < 0.001), satisfaction (rS= -0.67, p < quality of life score (rS= -0.63, p < 0.001) six months postoperatively. Patients resumed normal daily activity at POD 14. In Study II - a randomised experimental study in pigs - nine pigs were operated laparoscopically with insertion of two different meshes fixed with either FS or tacks. All pigs were euthanized on POD 30. The primary outcome parameter was strength of ingrowth between the mesh and the anterior abdominal wall. A mechanical peel test was performed for each tissue sample. The secondary outcome parameters were grade and strength of adhesions to the mesh, shrinkage and displacement/folding of the mesh and histological parameters. All nine pigs survived without complications until sacrifice. No meshes were displaced from their initial position at autopsy, but in two cases mesh folding was observed. No significant difference in strength of ingrowth was found between different fixation methods or mesh types. Furthermore, no significant difference was found in grade or strength of adhesions or any histological parameters. In Study III - a randomised, controlled, double-blinded, multicenter trial - 40 patients with umbilical hernia defects between 1.5-5 cm, were randomly assigned to receive FS or titanium tacks for mesh fixation in LVHR. Patients, care givers and those assessing the outcomes were blinded to group assignment. The primary outcome was average pain from POD 0-2 (VAS score). Secondary outcome parameters were fatigue, general well-being and time to resume normal daily activity. Follow-up was one month for all. Patients in the FS group reported

Introduction: Only limited data are available on subtotal laparoscopic colectomy (STC) in patients with in inflammatory bowel disease. We present the first Danish experiences with intended laparoscopic STC for inflammatory bowel disease (IBD). The primary outcome was 30-day morbidity.

Material and methods: The present study is a retrospective single-centre study with consecutive enrolment of patients undergoing intended STC for IBD from 1 January 2005 to 31 July 2009. The results were analysed as either emergency or elective operations. Only the most severe complication was noted for each patient. Data on medical treatment, blood tests and complications and death within 30 days were registered.

Results: A total of 32 patients underwent surgery (15 elective and 17 emergency procedures). Patients in the emergency group had significantly more severe disease activity than elective patients. Severe complications were recorded in 47% and 20% of the patients undergoing emergency and elective STC, respectively (p = 0.15). The overall morbidity was 72%. One emergency patient died. Five of eight emergency patients and one of three elective patients underwent conversion and experienced a major complication (p = 0.55). The overall conversion rate was 32% (p = 0.15).

Conclusion: We found high morbidity and conversion rates in patients undergoing SLC for IBD. A prospective national Danish survey on early postoperative outcome is suggested.

Funding: not relevant.

Trial registration: not relevant.

The clinical epidemiological studies included in this thesis fall into three parts. The first part includes studies on birth outcome in women with ulcerative colitis. The second part includes pharmacoepidemiological studies on birth outcome after anti-inflammatory drug therapy in pregnancy, including patients with ulcerative colitis and Crohn's disease. The third part (and the latest publications) includes birth outcome in women with Crohn's disease; and the methods of cohort establishment in these studies are developed and improved due to the knowledge gathered from conducting the earlier studies. The birth outcomes in women with ulcerative colitis are examined in a nationwide, Danish, cohort of women based on data from the Danish National Hospital Discharge Registry and the Danish Medical Birth Registry, and within a Hungarian case-control data set. Our data suggest: 1) Significantly increased risk of preterm birth when women give birth 0-6 months after establishment of the diagnosis. It is considered whether the increased risk may be influenced by disease activity around the time of establishing the diagnosis. 2) No increased risk of giving birth to children with low birth weight, intrauterine growth retardation or congenital abnormalities (evaluated overall). 3) Significantly increased risk of some selected congenital abnormalities (limb deficiencies, obstructive urinary and multiple congenital abnormalities). No other studies have examined the risk of selected congenital abnormalities in children born by women with ulcerative colitis. The pharmacoepidemiological studies on birth outcomes after use of anti-inflammatory drug therapy in pregnancy, including women with ulcerative colitis and Crohn's disease, are based on data from the Hungarian case-control data set, a countywide Danish prescription Database, the Danish National Hospital Discharge Registry, the Danish Medical Birth Registry, and review of selected medical records. After exposure to sulfasalazine during pregnancy our data suggest. No significantly increased overall relative risk of congenital abnormalities and no significantly increased risks of selected congenital abnormalities. After exposure to 5-aminosalicylic acid during pregnancy our data suggest. No significantly increased relative risk of low birth weight, intrauterine growth retardation or congenital abnormalities (evaluated overall). A significantly increased relative risk of preterm birth and stillbirth in ulcerative colitis women, compared to women with no prescription of reimbursed medicine in pregnancy - and also after comparing with women with chronic inflammatory bowel disease not taking 5-aminosalicylic acid during pregnancy. It is not clear whether these associations are causal or influenced by confounding by disease activity in particular. After maternal exposure to azathioprine/6-mercaptopurine during pregnancy our data suggest. An increased relative risk of preterm birth, congenital abnormalit

Introduction: We analyzed the trend in body mass index (BMI) as well as in the prevalence of overweight and obesity among Danish adults, mainly women, from 1997/1998 to 2004/2005 and evaluated any regional differences.

Material and methods: Data were drawn from two cross-sectional population-based studies conducted in parallel in Aalborg and Copenhagen from 1997/1998 and 2004/2005. Height and weight were measured in a total of 7,487 participants in the two cohorts.

Results: In the total cohort, we found no significant difference in BMI from 1997/1998 to 2004/2005 (p = 0.828). There was an increase in BMI in Aalborg of 0.32 (p = 0.030), while in Copenhagen we observed a statistically significant decrease in BMI of 0.30 (p = 0.017). The difference in change over time in BMI between the two regions was significant (p = 0.002). Also the difference in the trend in prevalence of overweight and obesity was statistically significant between the two cities (p = 0.010).

Conclusion: Our results indicate that the obesity epidemic is leveling off - at least among women - and that it may even be receding in Copenhagen. Nevertheless, the absolute average BMI values and the prevalence of overweight and obesity in both cities are high which underlines the need for further initiatives to prevent obesity-related health risks in the future.

Funding: The DanThyr studies were supported by funding from the Tømmerhandler Vilhelm Bang Foundation, the Copenhagen Corporation Research Foundation, the 1991 Pharmacy Foundation, the Danish Medical Foundation, the Health Insurance Foundation, the Agnes and Knut Mørk Foundation, the Wedel Wedelsborg Foundation, the Ortho-Clinical Foundation and BRAHMS Diagnostica.

Trial registration: not relevant.