Danish medical bulletin最新文献

Introduction: Parents of a young child with severe disabilities are facing a large range of new challenges; furthermore, most of these families have extended social needs regarding information, financial support, day care facilities, disability aids, etc. Many parents with disabled children have been found to be dissatisfied with social services. This study explores parents' experiences with Danish social services during their transition to a new daily life after the birth of a severely disabled child.

Material and methods: Repeated qualitative interviews were performed individually with 16 parents of a severely disabled young child during the first two years after the diagnosis of the child's disabilities. Data were analysed using grounded theory.

Results: We found that the encounter with the social services increased stress in the families. Parental expectations were not met, especially regarding information; parents felt clientized, and obtaining social support was very resource consuming. Parents' needs regarding practical support and empathic case-working were not met and they spent much time and effort due to lacking continuity between sectors.

Conclusion: Parents have specific needs when becoming clients in the social service system whose organisation of social services needs improvement. Health care professionals are advised to identify problems and support cooperation between the parents and the social service system, as well as to report the health-related consequences of prolonged and inefficient case-working for the child and its parents.

Funding: was received from Socialministeriet, Landsforeningen LEV, Ronald McDonalds Børnefond, Susie og Peter Robinsohns fond, Rosalie Petersens fond, PLU-fonden, Ville Heises fond, Sygesikringens forskningsfond, Helsefonden, Elsass fonden.

Trial registration: not relevant.

Introduction: The Danish Poison Information Centre (DPIC) provides information to the public and health care professionals on acute poisonings. The DPIC received 41,000 enquiries during the first three years of its existence as an open 24h telephone service. The aim of this data register study was to classify all substance exposures, to gain knowledge of the status and trends in poisonings (toxico-surveillance) and to evaluate the development in the number of contacts.

Material and methods: Information and inquiries were continuously entered into a poison-centre database. A new classification system was established during the study to ensure that all agents were properly classified. A total of 41,139 calls were divided into 18 substance categories, each consisting of 3-11 subgroups.

Results: The number of contacts per year increased by 70% from 2007 to 2009. Three contacts per thousand individuals in the Danish population were registered in 2009. For all groups, except drugs of abuse, the data showed an increase in the actual number of exposures from 2008 to 2009. Pharmaceuticals represent one third of substance exposures, and analgesics constitute a third of these poisonings. A relative increase in contacts concerning household substances, plants and vitamins was observed.

Conclusion: The classification gave detailed knowledge of the current poisoning status. Evaluation of subgroups showed a need for a larger number of subgroups to ensure a sufficient level of toxico-surveillance. Compared to other national poison centres, we predict a doubling in enquiries during the next ten years, mainly from the public.

Multiple myeloma is a fatal B cell neoplasm often resulting in focal and in some cases more diffuse destruction of bone. The bone destruction is a result of increased activity of bone resorbing cells--multinucleated osteoclasts emerging through of multiple fusions. In multiple myeloma, clonally expanding cancer cells provide a stimulatory signal for osteoclast recruitment, differentiation and excessive bone resorption. The stimulatory actions of myeloma cells are believed to be mediated via the production of cytokines and local factors or by modulating bone microenvironment in order to stimulate osteoclastic bone resorption. However, our recent study revealed potentially a novel and more intimate contribution of myeloma cells to the bone destruction. Our analysis of the bone biopsies from myeloma patients showed fully integrated malignant nuclei inside osteoclasts, which were transcriptionally active. As a result, about 30% of the osteoclasts in the bone marrow biopsies from myeloma patients were in fact osteoclast-myeloma cell hybrids. As the functional relevance of this novel cell type remained uncertain, the aim of my PhD study became to 1) strengthen the evidence of the existence of hybrid cells, 2) elucidate the functional differences between hybrid cells and non-hybrid OCs and 3) relate these findings to the pathogenesis of osteolytic disease in multiple myeloma. To this end, I developed a culture model of osteoclast-myeloma cell fusion between (pre)osteoclasts already committed to fuse and myeloma cells selected for adherence. The model was applied for testing of the bone resorptive properties of hybrid cells identified by labelling with green fluorescence. When comparing the highly fluorescent and non-fluorescent OCs on bone slices, it seemed that the frequency of highly fluorescent osteoclasts actively resorbing bone was increased as compared with non-fluorescent osteoclasts. This was assessed in two independent ways. Furthermore, these fluorescent osteoclasts appear to resorb deeper compared to non-fluorescent osteoclasts. The preliminary data that need to be confirmed suggest that formation of hybrid cells by fusion of myeloma cells with osteoclasts may result in reprogramming of the osteoclasts and contribute to the more aggressive bone resorption by osteoclasts as it is typically seen in myeloma patients. Another aspect of multiple myeloma and associated bone disease is the unmet need for novel and more efficient therapeutic regiments. Resveratrol (trans-3, 4', 5-trihydroxystilbene; RSV) is a natural compound shown to target the key players of myeloma bone disease: bone resorbing osteoclasts, bone forming osteoblasts and myeloma cells. Our in vitro study on RSV showed that it possessed this ideal triad of properties appearing and thus might be of interest as a potential drug for the treatment of multiple myeloma. RSV suppresses the growth and survival of myeloma cells, inhibits osteoclasts and stimulates the formation of osteob

Allergic- and non-allergic rhinitis are very common diseases in childhood in industrialized countries. Although these conditions are widely trivialized by both parents and physicians they induce a major impact on quality of life for the affected children and a substantial drainage of health care resources. Unfortunately, diagnostic specificity is hampered by nonspecific symptom history and lack of reliable diagnostic tests which may explain why the pathology behind such diagnoses is poorly understood. Improved understanding of the pathophysiology of allergic- and non-allergic rhinitis in young children may contribute to the discovery of new mechanisms involved in pathogenesis and help direct future research to develop correctly timed preventive measures as well as adequate monitoring and treatment of children with rhinitis. Asthma is a common comorbidity in subjects with allergic rhinitis and epidemiological surveys have suggested a close connection between upper and lower airway diseases expressed as the "united airways concept". Furthermore, an association between upper and lower airway diseases also seems to exist in non-atopic individuals. Nevertheless, the nature of this association is poorly understood and there is a paucity of data objectivizing this association in young children. The aim of this thesis was to describe pathology in the upper and lower airways in young children from the COPSAC birth cohort with investigator-diagnosed allergic- and non-allergic rhinitis. Nasal congestion is a key symptom in both allergic- and non-allergic rhinitis, and eosinophilic inflammation is a hallmark of the allergic diseases. In paper I, we studied nasal eosinophilia and nasal airway patency assessed by acoustic rhinometry in children with allergic rhinitis, non-allergic rhinitis and healthy controls. Allergic rhinitis was significantly associated with nasal eosinophilia and irreversible nasal airway obstruction suggesting chronic inflammation and structural remodeling of the nasal mucosa in children already at age 6 years. Non-allergic rhinitis exhibited no change in the nasal airway patency, but some nasal eosinophilia albeit less than children with allergic rhinitis. These findings suggest different pathology in allergic- and non-allergic rhinitis which may have important clinical implications for early pharmacological treatment of rhinitis in young children. In paper II, we utilized the nasal airway patency end-points derived from paper I to examine whether upper and lower airway patency are associated. Upper airway patency was assessed by acoustic rhinometry before and after intranasal α-agonist and lower airway patency by spirometry before and after inhaled β2-agonist. Upper and lower airway patencies were strongly associated and independent of body size, rhinitis and asthma. The association was consistent for both baseline values and for decongested nasal airway patency and post-β2 FEV1. Blood and nasal eosinophilia were also associated

Introduction: Regular breakfast habits are important for the health and well-being of young people. The family is an important setting for developing regular breakfast habits. The objectives of the present study are to study the association between family structure and the regularity of breakfast habits among children and adolescents, and to analyse whether such potential association is modified by gender.

Material and methods: Data are from the Danish contribution to the international study entitled Health Behaviour in School aged Children, 2006. Participants are school children aged 11, 13 and 15 drawn from a random sample of Danish schools. The response rate was 88.8%, n = 6,269. Family structure was categorized into traditional family, single-parent family and reconstructed family. Irregular breakfast habits (IBH) were defined as having breakfast 0-1 times per week.

Results: Analyses of the total population show an increased, significant odds ratio (OR) of 1.56 for IBH among children from single-parent families. Among children from reconstructed families, an insignificant OR of 1.27 was observed. Further, the results suggest that girls living in a reconstructed family may also have an increased risk of IBH.

Conclusion: The breakfast habits of adolescent boys and girls are influenced by family structure.

Introduction: The purpose of this article was to assess our experience with the facial artery musculomucosal (FAMM) flap technique for reconstruction of the oral cavity after tumour ablation. We also introduce new surgical developments for this technique.

Material and methods: We retrospectively examined 22 cases involving FAMM flap surgery during the period from July 2007 to December 2009, focusing on postoperative complications and flap survival. We describe a new method for closing the donor defect using the buccal fat pad, as well as a method for harvesting a broader flap than is traditionally described.

Results: Among the 22 cases studies, seven (32%) experienced postoperative complications. However, 57% of these cases had undergone preoperative radiotherapy. The complications we observed included problems relating to integration, partial necrosis and bleeding. There were no reported complications relating to the donor site.

Conclusion: The FAMM flap is a suitable technique for reconstruction following tumour ablation. Our study also suggests that while preoperative radiotherapy is a contraindication for this treatment, neck dissection surgery is not.

Introduction: Hypovolaemic shock is a major course of death in trauma patients. The mortality in patients in profound shock at the time of arrival is extremely high and we wanted to investigate the outcome of patients undergoing laparotomy at the Trauma Care Unit (TCU).

Material and methods: Forty-four emergency laparotomies performed at the TCU at Rigshospitalet between January 2003 and December 2009 were registered. The indication for surgical intervention was based on persisting, unstable haemodynamics and either positive findings at focused abdominal sonography in trauma (FAST) or penetrating injury. In some patients, laparotomy was performed despite a negative FAST because of ongoing instability. The patients were stratified according to their systolic blood pressure (BP).

Results: After 24 hours, 46% (20 patients) of the patients were alive. The survival after 30 days was 41% (18 patients). Stratifying the patients into three categories according to the systolic BP at the time of arrival (BP > 80 mmHg (n = 14), 80 mmHg ≥ BP > 60 mmHg (n = 10) and BP ≤ 60 mmHg (n = 20) revealed a 64%, 50% and 34% survival rate within the first 24 hours (p = 0.04). In the group of patients with BP ≤ 60 mmHg, the survival decreased to 20% after 30 days. Stratification by penetrating or blunt trauma showed no significant difference in survival (40% versus 50% survival after 30 days) (p = 0.40). However, in those patients arriving with BP ≤ 60 mmHg (five penetrating and 15 blunt injuries), we found that the survival rate after laparotomy was 60% and 13%, respectively.

Conclusion: The present study shows that haemodynamically unstable patients with abdominal or suspected abdominal injuries undergoing emergency laparotomy have a high mortality, especially those with BP ≤ 60 mmHg. Patients with a penetrating trauma have a far better prognosis than those with a blunt trauma.

Introduction: This study describes unsedated transnasal oesophagogastroduodenoscopy (UT-OGD) in the office setting. Evaluation of national guidelines regarding primary endoscopy for the investigation of upper gastrointestinal (GI) symptoms was also a focus of this study.

Material and methods: Retrospective registration of 2,000 cases regarding demographics, symptoms, pre-endoscopic treatment, feasibility and findings.

Results: The proportion of males was 42%. 19% of the patients were referred due to alarm symptoms. The transnasal feasibility was 97%. Endoscopic findings: No abnormal findings (NAF) 53%, hiatal hernia 25%, oesophagitis 11%, gastric inflammation 11%, ulcer 10%, cancer 1% and others 1%. Alarm symptoms (AS) versus non-alarm symptoms (NAS): 35% of patients with AS had NAF versus 58% in the NAS group (p < 0.001). Cancer was present in 4% of the cases in the AS group versus 0.1% in the NAS group (p < 0.001). < 45 years versus ≥ 45 years: 69% of patients < 45 years had NAF versus 45% of patients ≥ 45 years (p < 0.001). Cancer was present in 0% of the cases in those < 45 years versus 1.4% in those ≥ 45 years (p = 0.002).

Conclusion: UT-OGD in private practice had a higher proportion of females than similar procedures performed in hospital settings. Feasibility was high. Endoscopic findings were comparable to those reported by other studies, except for a lower prevalence of oesophagitis. Age < 45 years and absence of alarm symptoms were strong negative predictors for the presence upper GI cancer. Our data thus seem to confirm the Danish guideline regarding primary endoscopy for the investigation of upper GI symptoms.

Oral anticoagulation therapy (OAT) with coumarins (vitamin K-antagonists) is prescribed for both prophylactic and therapeutic use to patients at increased risk of thromboembolism. OAT has a narrow therapeutic index, and monitoring is based on the International Normalized Ratio (INR) conventionally determined on citrated plasma obtained by venepuncture. Based on the INR measurements, health care providers determine the appropriate dose of coumarins (e.g. warfarin (Marevan). Optimised management of OAT improves the quality of treatment. Patient self-management (PSM) is a new concept where the patient takes an active part in his or her own treatment. PSM in OAT implies that the patient analyses a drop of blood using a portable coagulometer (INR-monitor). The coagulometer displays the INR, which the patient uses for coumarins dosage. It is still not clarified which subset of patients (in terms of indication for OAT, age, co-morbidity etc.) that potentially will benefit from PSM, and how large this potential effect is. A precondition for a correct dosage of coumarins is a correct estimation of the INR, and the method and apparatus used for providing the INR measurements is in this context essential. The coagulometers used for PSM have not been investigated adequately in terms of precision and agreement, so this is warranted. INR has proven adequate for adjusting dosages. It is doubtful that the level of INR reflects the overall haemostatic capacity or thrombotic potential of individual patients. Measurement of continuous calibrated automated thrombin generation (CAT) and coagulation factors activities may serve as a more sensitive and global haemostatic parameter and potentially with better performance in predicting risk of complications in patients on OAT. We found that the clotting activity of coagulation factors II, VII, IX, and X and CAT exhibited no variability over a 6-week period. The activity of the coagulation factors and CAT was significantly associated with the INR, so these two tests can be used concomitantly and/or interchangeably with the INR. Approximately 50% of the total variability of the coagulation factor activities and CAT was reflected by the INR, whereas the remaining variability was within the subject (patient). Coagulation factor activities and CAT can therefore potentially be used to provide further information to the risk of bleeding and thromboembolism, since almost 50% of the variability within the subject is not displayed in the INR value. Yet it remains uncertain if this method can predict complications in individual patients on OAT. Larger clinical trials with a longer follow-up period, preferably using clinical endpoints, are needed in order to draw any firm conclusions regarding the clinical consequences. However, measurement of coagulation factor activities and CAT may improve measurement of coagulation activity in patients prescribed OAT beyond the parameters currently clinically available. The CoaguChek S and

Introduction: Perforation of the oesophagus into the thoracic cavity is a potentially life-threatening condition. The causes are numerous. Treatment for oesophageal perforation targets mediastinal and pleural contamination. Present knowledge about the causes of perforation and the types of treatment is poor.

Material and methods: A retrospective review was made between 1997 and 2005 based on extracts from the National Patient Registry.

Results: A total of 286 patients were diagnosed with perforation of the oesophagus (131 women and 155 men). Their average age was 60 years. A wide spectrum of causes was reported, e.g. instrumentation of the oesophagus 136 (47.6%), spontaneous rupture 89 (31.1%) or procedures otherwise related to surgical intervention 9 (3.1%). One third of the patients started conservative treatment 91 (31.9%). The majority of the patients were transferred to a thoracic surgery department for further treatment: about 25% of patients underwent surgery. The average hospitalization time was 18 days. The mortality rate was 21%.

Conclusion: Oesophageal perforation remains a diagnostic and therapeutic challenge and the condition requires aggressive treatment. Recent consensus in early treatment with thoracotomy, debridement, irrigation and subsequent parenteral nutrition has improved survival. In this material, most perforations were iatrogenic in nature. In the 2002-2005 period, the study showed that 29% of the iatrogenic perforations were caused by the use of a rigid endoscope which is risky and whose use should therefore be restricted. It is advisable to set up national guidelines for treatment of oesophageal perforation and to centralise treatment.