Danish medical bulletin最新文献

Introduction: Treatment of newly diagnosed immune thrombocytopenia (ITP) is controversial and guidelines vary internationally. At the Paediatric Department, Aalborg Hospital, a "watchful waiting" approach was adopted in the early 2000s. We aimed to investigate whether this change in strategy had any adverse effects on the subsequent clinical outcomes.

Material and methods: Medical records were reviewed for children with ITP presenting with a platelet count < 30 billion/l in the 1990s (n = 22) and in the 2000s (n = 47). Management during the initial admission and events during the first 12 months after diagnosis were recorded.

Results: The rate of initial treatment with immunoglobulin or steroids was reduced from 64% in the 1990s to 15% in the 2000s. The percentage of children with ITP lasting more than three months did not increase (30% versus 32%). Nor did the occurrence of ITP lasting > 12 months (15% versus 27%). The proportion of children requiring readmission (19% versus 27%) or receiving therapy during follow-up (19% versus 23%) was unchanged. Serious bleeding requiring immediate intervention was equally rare (one episode in the 1990s, two in the 2000s). Cusum plots usefully depicted the changes in management and confirmed that the rate of adverse events did not increase.

Conclusion: A watchful waiting strategy for children with newly diagnosed ITP has been implemented without adverse effects on the duration or the morbidity of ITP.

Reduced skeletal muscle mitochondrial function has been proposed to lead to insulin resistance and type 2 diabetes. It has been known for several years that oxidative capacity of skeletal muscle is reduced in patients with type 2 diabetes compared to weight matched controls. The reduction in oxidative capacity supposedly leads to the accumulation of intramyocellular lipid which inhibits insulin signalling and causes insulin resistance. It is not known whether this reduction in mitochondrial capacity is the cause or the effect of type 2 diabetes. This PhD-thesis describes the effect of different pharmacological interventions on mitochondrial function in type 2 diabetes and describe whether mitochondrial function is uniformly distributed to both upper and lower extremities. Furthermore, a hypothesis on the molecular mechanism for weight gain observed with anthyperglycaemic treatment will be presented.

Introduction: The sentinel lymph node (SLN) procedure has emerged as a safe staging method with a low morbidity. The objective of the present study was to examine the recurrence rates including especially the axillary recurrence rate in SLN-negative patients after a long follow-up period.

Material and methods: A total of 344 breast cancer patients were referred to SLN biopsy at our department from January 2000 to May 2005. Lymphoscintigraphy with (99m)Tc-nanocolloid was followed by same-day radioprobe-guided surgery. Among the 344 patients, 181 were SLN-negative. The group of SLN-negative patients was followed with regard to recurrence in general and axillary recurrence in particular by reviewing their respective medical files from control visits.

Results: The identification rate (IR) was 99% (340/344). Extra-axillary SLNs were detected in seven patients (4%). One patient had an axillary recurrence 39 months after the primary operation, corresponding to an axillary recurrence rate of 0.6% after a median follow-up of 60 months (range 7-93).

Conclusion: With a high IR and an axillary recurrence rate of 0.6% after five years of follow-up, our data suggest that the SLN procedure is a valid and accurate method for the staging of breast cancer patients.

Introduction: The study objective was to describe demographic and clinical characteristics among HIV late presenters in a Danish university hospital.

Material and methods: Patients > 15 years of age were enrolled in this retrospective study. Data from the medical patient records were analyzed in accordance with the CD4 count at the time of HIV diagnosis.

Results: Among 194 HIV patients (138 men and 56 women), 63 (33%) were diagnosed with a CD4 count below 200 cells/microlitre (late presenters). Heterosexuals constituted a larger proportion of patients in the late presenter group than did homosexual men (MSM) (p = 0.02), whereas a higher proportion of MSM than heterosexuals were diagnosed with HIV during primary infection (p < 0.01). Half of the late presenters had consulted a general practitioner three to 12 months prior to their HIV diagnosis. HIV antibody testing had not been performed although complaints consistent with possible underlying immune deficiency had been reported. Twenty per cent of the late presenters had a persistently low CD4 count below 200 cells/microlitre at follow-up despite having received HAART therapy for more than two years.

Conclusion: One third of the HIV patients in this study were diagnosed as late presenters, and this group featured a higher proportion of heterosexuals than of MSM. The HIV antibody test should be performed more consistently on solid clinical ground by general practitioners.

Introduction: Rheumatoid arthritis (RA) is a chronic disease with autoimmune traits of unknown aetiology which primarily affects synovial joints. Glucocorticoids (GCs) are still widely used in RA treatment despite the expanding use of targeted and very efficient agents. The objective of this study was to assess the impact of treatment with tumour necrosis factor-α inhibitors (TNFi) on GC utilization in real-life practice among Danish RA patients.

Material and methods: The DANBIO registry is a nationwide rheumatologic database which collects demographic and clinical data. This retrospective study included RA outpatients from a tertiary rheumatologic department recruited from the DANBIO registry who initiated their first TNFi treatment between January 2000 and February 2010 (n = 171). GC dosing during the year before and the year after TNFi initiation were compared. Patients acted as their own control.

Results: The median daily prednisolone dose was significantly decreased after initiation of TNFi treatment (p < 0.01). At TNFi initiation, 78 patients (46%) received prednisolone compared with 53 (31%) by the end of follow-up. After TNFi initiation, 30 patients (38%) discontinued prednisolone and in 34 (44%) prednisolone dose was reduced. Similarly, the number of GC injections decreased significantly at 13, 26 and 52 weeks following TNFi initiation (p < 0.01).

Conclusion: GC utilization is significantly reduced after initiation of TNFi treatment. Among patients on prednisolone at TNFi onset, prednisolone was withdrawn in one third and the dose was reduced in nearly half. Furthermore, the need for GC injections decreased.

Introduction: At 2.7% in 1970, the Danish medico-legal autopsy frequency was lower than recent frequencies observed in the Nordic countries (4-24%). The aim of this study was to analyse trends in the number and frequency of Danish medico-legal autopsies.

Material and methods: Data were collected from the computerized archives in the Danish departments of forensic medicine, Statistics Denmark and the Danish National Board of Health.

Results: During the 1996-2005 study period, a total of 14,990 medico-legal autopsies were performed. This yielded a medico-legal autopsy frequency of between 2.4% and 2.8%. Our results revealed a certain constancy in the number of medico-legal autopsies and frequency of autopsy with regard to manner of death, sex and number, but we also observed changes in the age composition which involved a decrease in the proportion of young (20-39 years) and an increase in the proportion of middle-aged persons (40-59 years).

Conclusion: Denmark has a lower autopsy frequency than other Nordic countries and this may constitute a problem for quality of death-statistics and research based on autopsy results. If the patterns in medico-legal autopsy frequencies continue, a decrease in the number of medico-legal autopsies is to be expected. As a consequence, education and training of forensic pathologists may be impaired.

Introduction: The immune system is suppressed during chemotherapy. This makes diagnosis of severe life-threatening infections more difficult and it also intensifies the clinical course of such infections. Hence, empirical use of broad-spectrum antibiotics is mandatory. We investigated if procalcitonin (PCT) measurement may improve diagnostic accuracy.

Material and methods: In a prospective observational study, we included all admissions due to febrile episodes in a cohort of children below 16 years of age. PCT and C-reactive protein (CRP) were analyzed using LUMI test and VITROS CRP slides, respectively.

Results: We recorded 230 febrile episodes in 85 children. Severe systemic infection was found in 61 (27%) of these episodes. PCT performed better than CRP (p value ≤ 0.01). The discriminative power of PCT was significant already from admission. For CRP, discriminative power was significant after 48 hours. The cut-offs for PCT and CRP were 0.4 ng/ml and 336 nmol/ml to achieve sensitivities of 93%. The specificities for PCT and CRP were 45% and 22%, respectively. Severely infected patients were not found, either by PCT or by CRP in four (7%) cases. PCT levels rose in response to infection in the neutropenic population.

Conclusion: PCT measurement considerably improves biochemical information; however, the sensitivity is too low to safely alter the recommended administration of empirical antibiotics at admission.

Introduction: The management of complex fistula-in-ano remains a surgical challenge. Previously published studies on the treatment of fistula-in-ano with the anal fistula plug (AFP) have reported a success rate reaching 35-87%. The aim of this study was to assess the results of the AFP procedure in a group of Danish patients with complex fistulas, and to analyse if the results were compatible with previous international findings.

Material and methods: A retrospective analysis of prospectively collected data was performed for 37 consecutive patients treated with the Surgisis AFP plug for complex fistula-in-ano at the Surgical Department of Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark, between June 2006 and April 2010. Surgery and evaluation were performed by one of two specially trained proctologists.

Results: The success rate per patient was 45.9% (17/37) and the success rate per procedure was 44.7% (17/38). A total of 40 fistulas were treated with the AFP and the success rate per fistula was 47.5% (19/40). Plug dislodgement occurred after 28.9% of the procedures, thereby accounting for 52.4% of the failed AFP procedures (11/38). No patients experienced any change in continence after the procedure.

Conclusion: We found a patient cure rate of 45.9% which is in accordance with previously reported patient cure rates of 35-87%. Current knowledge suggests that the AFP is a good choice for first-line management of complex fistula-in-ano, but further evaluation is needed.

Introduction: It has been proposed that pre-diabetes may cause neuropathy. The aim of this study was to investigate whether cardiac autonomic neuropathy (CAN) in uraemic patients was related to the presence of pre-diabetes.

Material and methods: The study included 66 non-diabetic uraemic patients selected from a waiting list for kidney transplantation. They were on average 43 ± 12 years old, with a duration of uraemia of 32 ± 27 months in the pre-dialytic stage, or receiving either haemo-, or peritoneal dialysis. A control group of 14 healthy people matched by sex, age and body mass index were enrolled. Beat-to-beat variability was determined from the echocardiographic recording during deep inspiration and expiration. CAN was defined as a beat-to-beat value below 10 beats/min. Pre-diabetes was defined as presence of impaired fasting glucose and/or impaired glucose tolerance measured by oral glucose tolerance test (WHO/American Diabetes Association criteria 2007).

Results: The prevalence of CAN was 38% in uraemic patients compared with 8% in the controls (p < 0.005). Twenty-seven (41%) out of the 66 uraemic patients were pre-diabetic, while the remaining 39 had a normal glucose tolerance. The prevalence of CAN was comparable in uraemic patients with (44%) and without (33%) pre-diabetes. Uraemic patients with CAN were characterised by higher systolic blood pressure (p < 0.05) and higher age (p < 0.005) compared with uraemic patients without CAN.

Conclusion: The prevalence of CAN and impaired glucose tolerance is high in uraemic patients, but impaired glucose tolerance seems to play no significant role in the aetiology of CAN in uraemic patients.

Introduction: The objective of this study was to evaluate the clinical outcome of tuberculosis (TB) with regards to epidemiology, symptoms, delay, diagnostics, use of HIV-test, treatment, treatment outcome and mortality in the North Jutland Region from 2000 through 2008.

Material and methods: The present study is a retrospective study of all new TB cases in the 2000-2008 period.

Results: The period saw a total of 251 TB patients (an average of 28 per year). Almost 60% of the patients were not Danish-born, being mostly from Somalia and Greenland. The mean age was 43 years. 31% were alcohol abusers. 2% had AIDS. Cough was the most frequent symptom followed by weight loss, fever and fatigue. In 78.5% of the cases, it was possible to retrieve a positive culture, 53% had a positive sputum smear. However, in 8% of all patients, it was not possible to isolate Mycobacterium tuberculosis and these cases were diagnosed in accordance with the clinical signs. Almost all patients received the standard treatment comprising four antibiotics. 83% were treated successfully, while 5% ended their treatment prematurely. At the end of the study, 14% were dead. In all, 55% of all patients were HIV-tested. Two tested positive before their TB diagnosis and three after.

Conclusion: The incidence of TB did not seem to decrease over the course of the study period as seen in the rest of Europe. The relatively high rate of alcohol abusers as compared with earlier Danish literature seems to be due to previous underreporting. A treatment success of 83% is high. This first study of HIV testing in Danish TB patients revealed that it was an acceptable result compared with other studies in this field, but the result was not satisfactory because we may miss patients with HIV/TB co-infection when only half of the patients are tested.