Danish medical bulletin最新文献

Introduction: Formalized triage in the emergency department (ED) is not widely used in Denmark; this study explores the effects of introducing a five-level process triage system in a Danish ED.

Material and methods: Semi-structured qualitative interviews were conducted with 15 emergency nurses. The interviews were preceded by observations of the work of the ED nurses in which focus was on the triage process.

Results: Formalized triage was experienced to improve the overview of patients and resources at the ED, and the nurses described that they felt more assured when prioritizing between patients. Communication and coordination were also improved by the triage system. But more time spent on documentation and reevaluation may cause the nurses to feel professionally inadequate if adequate resources are not provided. Furthermore, the triage system has reduced the focus on the humanistic and psychosocial aspects of nursing. Difficulties were occasionally experienced when categorizing patients with diffuse symptoms according to the standardized triage symptoms and signs' algorithms.

Conclusion: Introducing a formalized triage system in the ED was experienced to give a better overview and more overall control of ED patients. Adequate resources are needed to ensure that a stronger focus on documentation and re-evaluation related to triage does not produce a feeling of professional inadequacy among the staff.

Funding: not relevant.

Trial registration: not relevant.

Introduction: Many pregnant women in Denmark have been advised that some alcohol intake is acceptable. In the 1999-2007-period, the Danish National Board of Health advised pregnant women that some alcohol intake was acceptable. From 2007, alcohol abstinence has been recommended. We aimed to describe the attitudes towards and knowledge about alcohol in pregnancy among general practitioners (GPs) in Denmark in 2000 and in 2009.

Material and methods: In 2000, we invited a representative sample of GPs in the catchment area of the Antenatal Care Centre in Aarhus to participate in the study. Participants were interviewed about their attitudes, beliefs, knowledge and information practice in relation to alcohol in pregnancy. Identical questions were sent to all GPs in the area in 2009.

Results: In 2000, most GPs (71%) considered that some alcohol intake in pregnancy was acceptable, mostly on a weekly level. There was considerable interperson variation in the participants' attitudes and recommendations to pregnant women. In 2009, significantly more GPs (51%) considered abstinence to be preferable, and significantly more GPs (53%) gave this advice to pregnant women than in 2000. Their knowledge about the official recommendations on alcohol was good. Older GPs were more likely to recommend abstinence.

Conclusion: The attitudes towards and knowledge about drinking in pregnancy among GPs have changed along with the change in official policy.

Funding: In 2000, data collection was funded by The Danish National Board of Health (J.no. 407-15-1999).

Trial registration: not relevant.

A fistula is defined as a pathological connection between the intestine and an inner (bladder or other intestine) or outer (vagina or skin) epithelial surface. Fistulas are discovered in up to 25% of all Crohn's disease patients during long-term follow-up examinations. Most are perianal fistulas, and these may be classified as simple or complex. The initial investigation of perianal fistulas includes imaging (MRI of the pelvis and rectum), examination under anaesthesia (EUA) with digital imaging, endoscopy, probing and anal ultrasound. Non-perianal fistulas require contrast imaging and/or CT/MRI for complete anatomical definition. Any abscess should be drained, and the disease extent throughout the entire gastrointestinal tract should be evaluated. Treatment goals for perianal fistulas include reduced fistula secretion or none, evaluated by clinical examination; the absence of abscesses; and patient satisfaction. MR imaging is required to demonstrate definitive fistula closure. Fistulotomy is considered for simple perianal fistulas. In complex perianal fistulas, antibiotics and azathioprine or 6-mercaptopurine, which are often combined with a loose seton, constitute the first-line medical therapy. In cases with persistent secretion, infliximab at 5 mg/kg is given at weeks 0, 2, and 6 and subsequently every 8 weeks. Adalimumab may improve fistula response in both infliximab-naïve patients and following infliximab treatment failure. Local therapy with fibrin glue or fistula plugs is rarely effective. Definitive surgical closure of perianal fistulas using an advancement flap may be attempted, but this procedure is associated with a high risk of relapse. Colostomy and proctectomy are the ultimate surgical treatment options for fistulas. Intestinal resection is almost always needed for the closure of symptomatic non-perianal fistulas.

Introduction: The emergency departments (EDs) handle approximately 1,000,000 contacts annually. Danish health care is undergoing reorganization that involves the creation of fewer and larger EDs to handle these contacts. There is therefore a need to prioritize the use of resources to optimize treatment. We thus wanted to investigate if Danish EDs are using triage systems and, if so, which systems they are using.

Material and methods: We performed a cross-sectional study on triage at all EDs in the 20 Danish hospitals that have been designated for emergency care.

Results: The response rate was 100% (n = 20). We found that triage was used at 75% (n = 15) of the EDs. Adaptive process triage (ADAPT) was the most frequently used validated triage system (25% (n = 5)), while 40% (n = 8) used non-validated systems. Triage was performed by nurses at 73% (n = 11) of the EDs using triage.

Conclusion: Triage systems were used in 75% of Danish EDs. ADAPT was the primary triage system in 25% of the EDs, while 40% used non-validated triage systems. An improvement in the quality of health care in Danish EDs may possibly be achieved by implementing validated triage, i.e. ADAPT.

Funding: not relevant.

Trial registration: not relevant.

Introduction: Queue models are effective tools for framing management decisions and Danish hospitals could benefit from awareness of such models. Currently, as emergency departments (ED) are under reorganization, we deem it timely to empirically investigate the applicability of the standard "M/M/1" queue model in order to document its relevance.

Material and methods: We compared actual versus theoretical distributions of hourly patient flow from 27,000 patient cases seen at Frederiksberg Hospital's ED. Formulating equations for arrivals and capacity, we wrote and tested a five equation simulation model.

Results: The Poisson distribution fitted arrivals with an hour-of-the-day specific parameter. Treatment times exceeding 15 minutes were well-described by an exponential distribution. The ED can be modelled as a black box with an hourly capacity that can be estimated either as admissions per hour when the ED operates full hilt Poisson distribution or from the linear dependency of waiting times on queue number. The results show that our ED capacity is surprisingly constant despite variations in staffing. These findings led to the formulation of a model giving a compact framework for assessing the behaviour of the ED under different assumptions about opening hours, capacity and workload.

Conclusion: The M/M/1 almost perfectly fits our. Thus modeling and simulations have contributed to the management process.

Funding: not relevant.

Trial registration: not relevant.

Introduction: Early outcome after elective ventral hernia repair is unsatisfactory, but detailed analyses are lacking. The aim of this study was to describe the aetiology of prolonged hospital stay (LOS), readmission and death < 30 days after elective ventral hernia repair.

Material and methods: The present study was a nationwide case-control study based on prospective results from elective ventral hernia repairs (incisional, umbilical/epigastric, parastomal and other rare ventral hernia repairs) performed in Denmark during 2008. The exclusion criteria were emergency operation and ventral hernia repair in addition to another surgical procedure. The study group were patients with poor outcome (a LOS ≥ 5 days and/or readmission and/or death ≤ 30 days) and the control group were patients without a poor outcome. Major complications were defined as severe and potentially fatal complications.

Results: The cohort included 2,258 patients (a study group counting 258 patients (259 repairs) and a control group comprising 2,000 patients (2,016 repairs)). Patients in the study group underwent repair significantly more often for incisional (76% versus 28%, p < 0.001), parastomal (3% versus 1%, p = 0.001) and recurrent hernia (21% versus 12%, p < 0.001). Furthermore, hernia defects were significantly larger (median 8 cm versus 2 cm, p < 0.001) in the study group than in the control group. Prolonged LOS was mainly due to pain (27%), major complications (19%), and seroma formation (9%). Readmissions were primarily caused by wound infections and pain.

Conclusion: Readmissions and prolonged hospital stay after ventral hernia repair were mainly due to pain, major complications, wound infections and seroma formation.

Funding: The foundation of Engineer Johs. E. Ormstrup and wife Grete Ormstrup and Region Zealand"s foundation for health-care research provided funding for this study.

Trial registration: The study was registered with the Danish Data Protection Agency (ref. no. 2008-58-0020) and www.clinicaltrials.gov (ref. no. NCT01388634).

In late stage Parkinson's disease (PD), medical treatment may not control the symptoms adequately, and the patient may become eligible for bilateral high frequency deep brain stimulation (DBS) in the subthalamic nucleus (STN). The effect of STN DBS on gait and postural instability is not always as predictable as the effect on clinical symptoms tremor, rigidity and bradykinesia. This may relate to the type of gait disorder or the stimulating electrode localization in the STN. We sought to evaluate the effect of STN DBS on gait performance during overground walking and gait initiation--assessed with 3D optokinetic movement analyses--and to compare the DBS effect with stimulation site localized on peri-operative MRI. The stimulation sites were grouped according to STN borders visualised on pre-operative MRI, and the active stimulation site was compared with clinical improvement and gait parameters. STN DBS is associated with improved movement amplitude while movement duration may be unaffected by both disease and stimulation. This may imply an improvement primarily on hypokinesia including gait hypokinesia.

Introduction: Epilepsy is often misdiagnosed and approximately one in every four patients diagnosed with refractory epilepsy does not have epilepsy, but instead non-epileptic seizures. Video electroencephalography monitoring (VEM) is the gold standard for differentiation between epileptic and non-epileptic seizures. The purpose of this study was to investigate the effectiveness of VEM as a diagnostic tool.

Material and methods: In this retrospective study, we have investigated the diagnostic outcome of 155 in patients undergoing VEM at Copenhagen University Hospital (Rigshospitalet) over a two-year period.

Results: The study showed that VEM revealed a diagnosis in 80%. Epilepsy was diagnosed in 38% and epilepsy was rejected in 43% of cases. In the remaining 20% of cases, epilepsy could not be excluded. Among patients who were referred in antiepileptic drug treatment, 29% did not have epilepsy. The highest diagnostic yield was obtained when patients had seizures with ictal electroencephalography paroxysms during VEM.

Conclusion: Several patients without epilepsy are treated as if they had epilepsy. VEM is a costly method, but with a large diagnostic yield and should therefore be used when there is doubt about the diagnosis in patients with relatively frequent seizures. The use of VEM is expedient to make the correct diagnosis, optimize medical treatment of patients with epilepsy and to avoid unnecessary treatment in patients without epilepsy.

Funding: not relevant.

Trial registration: not relevant.

Introduction: Primary joint replacements generally function well with excellent clinical results. However, failure rates for young patients are still high and increasing in number. The longterm survival of an uncemented prosthesis is influenced by multiple factors depending on host physiology as well as properties of implanted material, initial mechanical stability, early osseointegration, and the surrounding bone. Parathyroid hormone is the principal regulator of calcium homeostasis and involved in the control of bone remodelling. Parathyroid hormone administered intermittently increases bone formation and mass by osteoblast stimulation. Early osseointegration and implant fixation could potentially be enhanced with adjuvant parathyroid hormone treatment. The aim of the studies in this PhD thesis was to determine if implant fixation of experimental implants can be improved with adjuvant intermittent administration of parathyroid hormone.

Studies: All studies used an experimental canine model of early implant fixation inserting porous coated titanium alloy implants with no weight bearing in a bed of cancellous bone. The study design was un-paired. Test animals were randomised to PTH (1-34) 5 μm/kg daily for 4 weeks. Implant fixation was defined by mechanical stability and osseointegration. Study I investigated the effect of parathyroid hormone on implant fixation of implants inserted press fit with surrounding bone in the proximal tibia of 20 canines. Histomorphometric analysis showed increased amount of new bone in contact with the implant. No improvement was observed in the surrounding bone. PTH did not increase mechanical fixation in pushout test. Study II investigated the effect of parathyroid hormone on implant fixation of implants surrounded by a critical 1 mm gap. Implants where inserted in the tibia of 20 canines. Bone density was increased in the inner gap and outer gap with PTH treatment. Bone at implant interface improved with PTH but did not achieve significance. Push-out testing showed that PTH Increased mechanical implant fixation in shear stiffness and total energy absorption. Shear strength was not significantly increased. Study III investigated the effect on implant fixation of implants surrounded by a 2.5 mm gap in which morsellised allograft was impacted. Implants were inserted in 20 Canines in the humerus. Histomorphometric analysis showed that PTH increased the amount of new bone within the gap, but not in contact the implant. There were no differences in amount of allograft. The push-out testing showed no differences in mechanical parameters.

Conclusion: The studies in this PhD thesis demonstrated that parathyroid hormone increases bone healing around implants in situations of insertion in press-fit or in more challenging environments of empty and grafted gaps. Early fixation was increased in implants with gaps, in which pure gap bone stimulation improved fixat

Introduction: Computed tomography (CT) was proven to be superior to preoperative abdominal ultrasound in the preoperative setting for detection of hepatic metastases from colorectal cancer (CRC). The higher sensitivity of CT has resulted in a number of unexpected abdominal findings of varying importance; an issue that was previously studied in relation to CT colonography, but not in relation to staging CT with intravenous contrast in CRC patients. The aim of the present study was to evaluate the number and significance of such unexpected findings on staging CTs in CRC patients.

Material and methods: The study comprises a retrospective analysis of 247 consecutive patients who underwent colorectal cancer surgery at Roskilde Hospital, Denmark, in 2009. A preoperative abdominal staging CT was performed in 245 of these patients. All CT scans and patient records were reviewed by the authors. The unexpected CT findings were classified as being of high, moderate or low clinical importance according to whether they required treatment relatively promptly, later or did not require treatment at all, respectively.

Results: Overall, 114 patients (47%) had unexpected findings. Nineteen of the 137 findings (14%) or 8% in all patients were considered to be of high importance. Three per cent of all patients had abdominal aortic aneurysms, 2% had CRC metastases to the adrenal glands, 2% primary kidney tumours and 1% gynaecologic tumours. Twenty per cent of the patients had findings of moderate importance and 29% findings of low importance.

Conclusion: Staging CT in CRC patients showed nearly 8% of unexpected abdominal findings of high clinical importance requiring relatively prompt treatment.

Funding: not relevant.

Trial registration: not relevant.