Lakartidningen最新文献

Tularemia is a zoonotic disease caused by the contagious bacterium Francisella tularensis. In Sweden, the infection is primarily transmitted through mosquito bites with peak season from August to October. Depending on the infection site, tularemia has six different clinical variants. Patients are often presented with the ulceroglandular form - fever, inoculation site ulcer and regional lymphadenopathy - but oculoglandular, glandular, oropharyngeal, pneumonic and typhoidal forms also occur. Historically endemic to northern Sweden, tularemia has spread further south since the first case was described in 1931. Due to clinical diversity and sometime prolonged course, the awareness of tularemia  is important for multiple medical specialties. The diagnosis should be considered among patients with typical symptoms in Sweden during peak season.

The European Society of Cardiology has released new 2024 guidelines on chronic coronary syndrome. These guidelines emphasize that patients with this condition should be actively assessed and treated to reduce the risk of future events. Key updates include the introduction of a risk factor-based clinical probability model to aid in this process. Furthermore, the guidelines stress that coronary CT angiography is recommended as the first-line diagnostic method for patients with a low to moderate probability of coronary artery disease. In cases of moderate to high probability, functional tests such as stress echocardiography, PET-CT, or perfusion MRI are advised, depending on availability. The guidelines recommend that all patients with chronic coronary artery disease receive high-intensity lipid-lowering treatment, with a target LDL level of less than 1.4 mmol/L. For patients with non-obstructive coronary artery disease who continue to experience persistent angina pectoris, further investigation of the microcirculation is recommended.

The Swedish National Patient Register (NPR) is vital for epidemiological research. A 2010 review assessed the validity of inpatient diagnoses, but outpatient data were excluded. A recent review in the European Journal of Epidemiology examined validation studies for inpatient diagnoses post-2010 and outpatient data since 2001. Across 89 publications, median positive predictive value (PPV) was 84% for diagnoses (range: 18-100%) and 97% for surgical codes. Sensitivity was lower, median 73% (range: 45-80%). PPV and sensitivity varied depending on diagnosis, coding, reference standard, and data source. Different diagnostic criteria are needed depending on research question. Combining NPR with other registers can enhance accuracy. Limitations include incomplete outpatient data in early years, gaps in private healthcare reporting, and insufficient coverage of certain medical codes. Despite this, the NPR remains a reliable and central data source for medical research when limitations are considered.

Recent advancements in sequencing technologies have enabled both the identification of many monogenic diseases and the development of precision medicine, enabling tailored therapies for many patients. This case presentation describes four patients across three generations diagnosed with hyperkalemia of unclear origin. Genetic testing revealed a pathogenic variant in the KLHL3 gene, linked to familial hyperkalemic hypertension. Treatment with hydrochlorothiazide essentially normalised the potassium levels for all patients, and the oldest patient, with a resistant hypertension since a young age, had a dramatic improvement in blood pressure. This case underscores the importance of a detailed family history combined with genetic testing, which can lead to tailored and effective treatments.

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with gas embolism, which is often fatal when observed through clinical signs. Here we report the only case, to our knowledge, of a survivor of paradoxal gas embolism with a patent foramen ovale during ERCP. The patient suffered respiratory collapse with unmeasurable end-tidal carbon dioxide and severe hypoxemia. Total circulatory collapse was imminent, as demonstrated by severe hypotension and bradycardia with prominent S-T depressions on ECG. Transesophageal echocardiography (TEE) showed massive amounts of biventricular gas bubbles and a patent foramen ovale. After resuscitation with epinephrine, norepinephrine, crystalloid fluid boluses and a 100% fraction of inspired oxygen the patient's condition improved, and he was transferred to the intensive care unit. Repeat TEE showed that the gas bubbles had disappeared, and the patient was extubated that same evening. No neurological deficits were found before discharge. We want to highlight the importance of keeping gas embolism in mind when performing endoscopic procedures.

Neuroleptics are important for the treatment of serious psychiatric conditions. Few neuroleptics are approved for use in children and adolescents. Side effects are common, and children experience them more often than adults, particularly metabolic effects. The number of prescriptions of neuroleptics to children aged 5-17 years has increased (from 5 to 23 per 1000 children during 2004-2023). Most children were prescribed second-generation antipsychotics, which is in accordance with national recommendations. The most prescribed drugs were risperidone and aripiprazole, but regional differences exist. Children treated with neuroleptics need to be monitored more frequently, but adequate follow-up measures are used according to our survey of 85 prescribers. There is a need for an in-depth analysis of children's use of antipsychotics and the risk of serious side effects.

Acute suppurative thyroiditis (AST) is an extremely rare and potentially life-threatening condition, which can at first be difficult to differentiate from the far more common subacute thyroiditis (SAT). AST is most often described in patients with immunosuppression, or in patients with a pre-existing thyroid disease or anatomical structural defect, such as a pyriform sinus fistula. Here, we describe a case where a 37-year-old immunocompromised woman presented with intermittent fever, fatigue, erythema and tenderness of the anterior neck. TSH was suppressed and free T3 and T4 were elevated. She was prescribed Prednisolone 30 mg due to suspicion of SAT, but her symptoms from the anterior neck escalated. She developed a thyroid abscess, and was successfully treated with surgical drainage and oral antibiotics.

The daily regulatory work with pharmacovigilance includes requirements of risk minimisation measures (RMM). However, when it comes to evaluating the efficacy of RMM, methodological issues have been raised regarding commonly used surveys, and the updated Guideline on good pharmacovigilance practices, Module XVI Addendum II, proposes using mixed methods when RMM outcome is evaluated.    The Swedish Medical Products Agency has used aggregated national register data to evaluate compliance to the contraindication for cyproterone in patients with previous or current meningioma. Among 13 036 patients diagnosed with meningioma during the period 2005-2022, 21 to 63 individuals had filled a prescription of cyproterone ever after diagnosis. This is regarded as a resource-efficient method to assess compliance to contraindications, although anonymous aggregated statistics entail an uncertainty of measurement because the data must not be granular enough to be attributed to single individuals.

Cowpox is an infection caused by the cowpox virus, a zoonotic DNA virus belonging to the genus Orthopoxvirus. The infection presents as a febrile illness with a characteristic eschar-like lesion. Humans are typically infected through contact with rodents or cats who have been in contact with rodents. The diagnosis is made using PCR. In this case series, we present eight cases of cowpox contracted in Sweden.

Hormonal therapy is widely used to treat different conditions in humans; a well-known indication being the relief of menopausal symptoms in women. Transdermal delivery of hormonal drugs is common and may pose a risk to humans and animals through secondary exposure. This report raises awareness of risks associated with secondary exposure to transdermal hormone-containing drugs, based on evidence from spontaneous reporting of suspected adverse events. Clinical signs in humans included precocious puberty, unresolved virilisation, accelerated growth rate, alopecia, foetal death, and female infertility. In animals, clinical signs included persistent oestrus, poor growth rate and birth defects. Risks of secondary exposure must be acknowledged when prescribing hormonal drugs and as a possible aetiology of clinical signs in humans and animals.