Diabetic nephropathy is the most common cause of end-stage renal disease in the western world. Despite major improvements in both prevention and treatment of diabetic nephropathy, there is a continuous need to improve identification and treatment of "non-responders". In recent years, several experimental studies have shown that aldosterone plays a role in the development and progression of diabetic nephropathy, independent of angiotensin II and blood pressure levels. Blocking the renin-angiotensin-aldosterone system with an ACE-inhibitor (ACEI) and/or ambulatory blood pressure should theoretically inhibit the secretion of aldosterone. However, an increase in aldosterone during long-term treatment with ACEIs, so-called aldosterone escape or aldosterone breakthrough, has been described. In the present thesis, our studies evaluating the incidence and clinical impact (i.e. a faster rate of decline in kidney function) of aldosterone escape in type 1 diabetic patients with diabetic nephropathy, possible mechanisms of aldosterone escape, and finally the beneficial effect of blocking aldosterone on albuminuria, blood pressure and renal autoregulation is being reviewed, together with some aspects of the existing treatment recommendations.
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.
There are strong pragmatic and moral reasons for receiving societies to address access to healthcare for migrants. Receiving societies have a pragmatic interest in sustaining migrants' health to facilitate integration; they also have a moral obligation to ensure migrants' access to healthcare according to international human rights principles. The intention of this thesis is to increase the understanding of migrants' access to healthcare by exploring two study aims: 1) Are there differences in migrants' access to healthcare compared to that of non-migrants? (substudy I and II); and 2) Why are there possible differences in migrants' access to healthcare compared to that of non-migrants? (substudy III and IV). The thesis builds on different methodological approaches using both register-based retrospective cohort design, cross-sectional design and survey methods. Two different measures of access were used to explore differences: 1) cancer stage at diagnosis as a clinical outcome and 2) emergency room (ER) contacts as a utilisation measure. Both informal and formal barriers to access were studied to explore why possible differences existed including: 1) motivation for using ER; and 2) asylum seekers' healthcare entitlements. Different definitions of migration and ethnicity were investigated including: country of birth and residence status. Substudy I showed a tendency towards more advanced stage at diagnosis or unknown stage among most subgroups of migrant women with a history of cancer compared to non-migrant women. Sub-study II found that some migrants (those born in Somalia, Turkey and Ex-Yugoslavia) use ER services more frequently than do non-migrants whereas others have the same or lower utilisation levels. As a consequence, substudy III was undertaken, which documented that more migrant within all subgroups had considered contacting a primary caregiver before visiting the ER compared to non-migrants, but that migrants experienced communication problems herein. Additionally, more migrants had irrelevant ER visits as evaluated by caregivers. Substudy IV addressed formal and informal barriers to access and screening. According to the law asylum seekers are entitled to emergency care only in 10 out of 24 countries. Medical screening was carried out in all but one of the 24 EU countries; however, the content and extent of screening programmes vary. The thesis aimed to explore if there are differences in migrants' access to healthcare compared to that of non-migrants. Differences in utilisation and clinical outcome were identified between migrants and non-migrants. Reasons why disparities exist were also identified in relation to communication with primary care and on policy level. The thesis shows that various perspectives and scientific problems are important to get a full understanding of the process of access to healthcare for different migrant groups. Moreover, various complementary methodological approaches are needed when studying problems of migrants' access to healthcare.
Rotavirus infections are the most common cause of severe diarrhoea in children worldwide. Two internationally licensed rotavirus vaccines have proven to be efficacious in middle- and high-income countries and they could potentially be valuable tools for the prevention of rotavirus-associated diarrhoea in low-income countries where the disease burden is greatest. However, before the vaccines can be introduced into the national immunisation programmes in these countries, many challenges related to the financing of vaccine purchase, the cold chain capacity and vaccine efficacy must be overcome. There is also a need for political commitment to prevent rotavirus infections as well as a need for an overall strengthening of the health systems in low-income countries. If these challenges were met, rotavirus vaccination could substantially improve child health and survival from rotavirus-associated diarrhoea.
Background: The aim of the study was to investigate whether utilization of the emergency room differed between immigrant groups and Danish-born residents in Copenhagen, Denmark. Methods: The authors compared the number of emergency room contacts during 1997 among different ethnic groups in the study population. Data were provided by the Statistical Office of the Municipality of Copenhagen. The study population consisted of 183,478 citizens residing in the catchment area of Bispebjerg Hospital in Copenhagen on 1 January 1998. ``Contacts'' included 22,026 visits made to the emergency room at Bispebjerg Hospital during 1997. Both the study population and ``contacts'' were characterized by gender, age, income, and country of birth. The immigrants comprised nine ethnic groups according to country of birth. Data were analysed by Poisson regression comparing rate ratios. Results: Persons born in Somalia, Turkey, and ex-Yugoslavia had higher utilization rates of emergency room than Danish-born residents. All other non-Western-born residents had utilization rates similar to Danish-born residents. Persons born in other Western and European countries showed a tendency towards less utilization. Conclusion: Higher utilization rates among some immigrant groups may be explained by disparities in health or lack of knowledge about the Danish healthcare system as well as barriers to seeking primary care including language, fear of discrimination, and low satisfaction with primary care. The challenge remains to identify these causal relations, and to find out why utilization patterns vary between immigrant groups.
National Danish guidelines for the diagnosis and treatment of Helicobacter pylori (Hp) infection have been approved by the Danish Society for Gastroenterology. All patients with peptic ulcer disease, gastric cancer, and MALT lymphoma should be tested for Hp. We also recommend testing in first degree relatives to patients with gastric cancer, in NSAID-naive patients, who need long-term NSAID therapy, and in patients presenting with dyspepsia and no alarm symptoms. Non-endoscoped patients can be tested with a urea-breath test or a faecal antigen test. Endoscoped patients can be tested with a rapid urease test. Proton pump inhibitor therapy should be stopped at least 1 week prior to Hp testing. All infected patients should be offered Hp eradication therapy. First-line treatment is 7-day triple therapy with a proton pump inhibitor and clarithromycine in combination with metronidazole or amoxicilline. Quadruple therapy for 2 weeks with bismuthsubsalicylate, tetracycline, metronidazole and a proton pump inhibitor is recommended in case of treatment failure. Hp testing should be offered to all patients after eradication therapy but is mandatory in patients with ulcer disease, noninvasive gastric cancer or MALT lymphoma. Testing after eradication should not be done before 4 weeks after treatment has ended.
BACKGROUNDWe investigated the extent to which immigrants and patients of Danish origin have different motivations for seeking emergency room (ER) treatment, and differences in the relevance of their claims.METHODSData were obtained from a questionnaire survey of walk-in patients and their caregivers at four Copenhagen ERs. The patient survey was available in nine languages, and addressed patient-identified reasons for using the ER. Caregivers were asked if the claim was appropriate to the ER. 3809 patients and 3905 caregivers responded. The response rate among patients was 54%. Only questionnaires in which both patient and caregiver had responded, and in which data on the patient's nationality were available, were included in the analyses (n = 3426). The effect of region of origin was examined using bivariate, stratified analyses and tested for independence.RESULTSMore among immigrant patients than among patients of Danish origin had considered contacting a primary caregiver before visiting the ER, and more immigrants reported going to the ER because they could not contact a general practitioner, or could not explain their problem on the telephone. Compared to immigrants, more patients of Danish origin explained that the ER was most relevant to their need. A higher proportion of claims among immigrants were seen by caregivers as not being appropriate to the ER.CONCLUSIONMigrants have more irrelevant ER claims, presumably because of barriers in access to primary care. Access to primary care should be facilitated for these groups. Alternatively, ERs could include primary care activities as part of their services.
Mammography screening is offered healthy women, and a high standard on professional and organizational level is mandatory not only in the screening programme but even in the diagnostic work-up and treatment. The main goal is to achieve a substantial reduction in disease specific mortality, but it is not possible to evaluate the effect on mortality until several years later, and continuously monitoring of the quality of all aspects of a screening programme is necessary. Based on other European guidelines, 11 quality indicators have been defined, and guidelines concerning organizational requirements for a Danish screening programme as well as recommendations for the radiographic and radiological work have been drawn up.
INTRODUCTION: Necrotizing external otitis (NEO) is a devastating and life-threatening infection in the external auditory canal and the temporal bone. The aim of this paper is to evaluate the diagnostics and treatment of NEO and to recommend new guidelines. MATERIAL AND METHODS: Eleven patients were retrospectively enrolled under the code DH609 otitis externa without specification from 1 January 2000 to 31 December 2009. Records were reviewed to register: age, symptoms, clinical findings, comorbidity, imaging, microbiology and treatment. RESULTS: The median age was 75 years and the median time of therapy at the hospital was 6.3 months. All patients belonged to a risk group. A diagnostic delay was found resulting in further progression of the disease. In contrast to current international recommendations, the treatment consisted mostly of local antibiotics in combination with surgery. All patients survived, but most patients were left with hearing loss and psychiatric problems. CONCLUSION: A greater awareness of diagnostic criteria and a shift from local antibiotics to prolonged systemic monotherapy with ciprofloxacin in accordance with international concepts is recommended. Surgery should be left for extensive and refractory cases only. A list of diagnostic criteria and treatment guidelines is presented. FUNDING: Not relevant. TRIAL REGISTRATION: Not relevant.
INTRODUCTION The epidemiology of appendicitis seems to be changing; the proportion of complicated appendicitis cases is growing. The outcome of childhood appendectomy in Denmark has not previously been evaluated nationwide in Denmark. MATERIAL AND METHODS Data on all Danish children treated for appendicitis were obtained from the National Patient Registry. Reoperation, readmittance or length of hospital stay (LOS) exceeding five days were considered nonsatisfactory outcomes. RESULTS A total of 2,617 children, 55% boys and 45% girls, were operated at 32 hospitals. Their mean age was 11.1 years. Mortality was 0%. A laparoscopic procedure was used in 34% of the cases. The medians of the postoperative LOS were one day for both the open and laparoscopic appendectomy groups, the corresponding means were 2.5 and 2.0 days (p<0.05). 4.5% had one or more reoperations. 18% had a LOS>5 days or readmittance. The typical reasons were wound infection, need for prolonged antibiotics treatment and simple, prolonged recovery. CONCLUSION The Danish practice for appendicitis has acceptable rates of reoperation, medians and means of LOS, and a rate of readmission which is comparable to that reported in other studies. However, a nonsatisfactory outcome after appendectomy in about 20% calls for improvement and further studies. FUNDING Not relevant. TRIAL REGISTRATION Not relevant.
INTRODUCTION Studies show that university students are at risk for eating disorders. However, risk behaviour has not been studied among Danish medical students, nor have the gender differences in risk behaviour been described in a Danish context. MATERIAL AND METHODS All first-year medical students (n = 979) received a questionnaire related to body perception, exercise habits, eating habits, height and weight in the fall of 2006 and 2007. The response rate was 57% (n = 561). The gender distribution of the study population was 71.8% females and 28.2% males and the average age was 21.5 years. RESULTS More males (89.8%) than females (73.1%) were satisfied with their body and more females (34.8%) than males (10.9%) felt too fat. More females (42.7%) than males (19.9%) felt guilty when eating unhealthy food. 2.3% (all females) claimed to feel anxiety when they were about to eat. More males (48.4%) than females (28.6%) stated that they could not keep themselves from exercising. 13.5% of the underweight females (body mass index < 20 kg/m²) felt too fat, while none of the underweight males had this perception. In average, females and males displayed 2.8 and 2.1 risk behaviours, respectively. CONCLUSION Female medical students have a drive for thinness and male medical students want to be muscular. More female than male students have a negative body perception. Female medical students are estimated to have a higher risk for developing eating disorders than male students. Future research in this area should address the causes of such behaviour.
INTRODUCTION:As we found no recent published reports on the amount and kind of research published from Danish hospitals without university affiliation, we have found it relevant to conduct a bibliometric survey disclosing these research activities.MATERIAL AND METHODS:We retrieved all scientific papers published in the period 2000-2009 emanating from all seven Danish non-university hospitals in two regions, comprising 1.8 million inhabitants, and which were registered in a minimum of one of the three databases: PubMed MEDLINE, Thomson Reuters Web of Science and Elsevier's Scopus.RESULTS:In 878 of 1,252 papers, the first and/or last author was affiliated to a non-university hospital. Original papers made up 69% of these publications versus 86% of publications with university affiliation on first or last place. Case reports and reviews most frequently had authors from regional hospitals as first and/or last authors. The total number of publications from regional hospitals increased by 48% over the 10-year period. Publications were cited more often if the first or last author was from a university hospital and even more so if they were affiliated to foreign institutions. Cardiology, gynaecology and obstetrics, and environmental medicine were the three specialities with the largest number of regional hospital publications.CONCLUSION:A substantial number of scientific publications originate from non-university hospitals. Almost two thirds of the publications were original research published in international journals. Variations between specialities may reflect local conditions.FUNDING:not relevant.TRIAL REGISTRATION:not relevant.
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.
UNLABELLEDCochrane systematic reviews with meta-analyses of randomised trials provide guidance for clinical practice and health-care decision-making. In case of disagreements between research evidence and clinical practice, high quality systematic reviews can facilitate implementation or deimplementation of medical interventions into clinical practice. This applies especially to treatment of critically ill patients where interventions are most often costly and the clinical conditions are associated with high mortality.OBJECTIVESTo assess the potential benefits or harms of 1) antithrombin III (AT III) for critically ill patients; 2) inhaled nitric oxide (INO) for acute respiratory distress syndrome (ARDS) and acute lung injury (ALI); 3) aerosolized prostacyclin for ARDS and ALI; 4) thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion.METHODSWe performed four systematic reviews of relevant randomised clinical trials. To quantify the estimated effect of various interventions, we conducted meta-analyses, where appropriate, to determine intervention effects using the Cochrane Collaboration methodology, trial sequential analyses (TSA), the GRADE, and the PRISMA-guidelines when conducting our systematic reviews. All reviews were performed according to published protocols following the recommendations of the Cochrane Handbook for systematic reviews of interventions. We performed multiple subgroup and sensitivity analyses with regard to methodological quality and various clinical outcomes. Trials were identified through Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE Science Citation Index-Expanded, The Chinese Biomedical Database and LILACS. We included all randomized clinical trials. We hand-searched reference lists, reviews, and contacted authors and experts for additional trials. We searched ClinicalTrials.gov, Centre Watch Clinical Trials Listing Service and ControlledTrials.com for missed, unreported, or ongoing trials. We screened bibliographies of relevant articles and conference proceedings and wrote to trialists and pharmaceutical companies producing the drugs in question.RESULTSFour systematic reviews included a total of 44 trials with 5,551 patients. Only 15 of the trials were classified as trials with low risk of bias (high methodological quality) regarding generation of the allocation sequence, allocation concealment, blinding, follow-up and other types of bias. 1) Compared with placebo or no intervention, AT III did not significantly affect overall mortality (relative risk (RR) 0.96, 95% confidence interval (CI) 0.89 to 1.03). No subgroup analyses on risk of bias, populations of patients, or with and without adjuvant heparin yielded significant results. AT III significantly increased the risk of bleeding events (RR 1.52, 95% CI 1.30 to 1.78). 2) INO showed no statistically significant effect on overall mortality (RR 1.06, 95% CI 0.93 to 1.22) and in several subgroup and sensitivity analyses, indicating robust results. Limited data demonstrated no effect of INO on duration of ventilation, ventilator-free days, and length of stay in the intensive care unit and hospital. We found a statistically significant, but transient improvement in oxygenation in the first 24 hours, expressed as the ratio of PO2 to fraction of inspired oxygen (mean difference (MD) 15.91, 95% CI 8.25 to 23.56). However, INO appears to significantly increase the risk of renal impairment among adults (RR 1.59, 95% CI 1.17 to 2.16) but did not significantly affect the risk of bleeding or methaemoglobin or nitrogen dioxide formation. 3) We found only one small low risk of bias paediatric trial examining the role of aerosolized prostacyclin in ALI or ARDS. Based on this limited amount of data, we were unable to support or refute the routine use of this intervention in ALI or ARDS. 4) Compared with standard treatment, TEG or ROTEM showed no statistically significant effect on overall mortality (RR 0.77, 95% CI 0.35 to 1.72) but only five trials provided data on mortality. Our analyses demonstrated a statistically significant effect of TEG or ROTEM on the amount of bleeding (MD -85.05 ml, 95% CI -140.68 to -29.42) but failed to show any statistically significant effect on other predefined outcomes. However, whether this reduction has implication for the patient's clinical condition is still uncertain.CONCLUSIONWe did not find reliable evidence to support the clinical use of the assessed immuno-coagulatory interventions for general use in critical care based on the available evidence. A large proportion of the trials had serious methodological shortcomings, small number of patients, and short trial duration. The sparse data provided in the included trials may be or may not be promising but is not necessarily evidence of absence of a beneficial or harmful effect, because many of the outcome measures have not been adequately addressed so far. There is an urgent need for several randomised clinical trials with low risk of bias and low risk of random error to evaluate the use of the assessed interventions.
INTRODUCTION: The aims of this study were to determine the prevalence of women with gestational diabetes mellitus (GDM) not obtaining HbA(1c) within the normal range (<= 5.6%) before delivery and to examine whether elevated HbA1c values are associated with an increased risk of large-for gestational age (LGA) infants.MATERIAL AND METHODS: A population of 148 women with singleton pregnancies who had been diagnosed with GDM < 34 weeks, and who had a minimum of two HbA(1c) tests with a >= 3 week interval. They were divided into those obtaining a HbA(1c) <= 5.6%, and those who did not before delivery and further stratified according to baseline HbA(1c) <= or > 5.6%. The primary outcome was LGA infants.RESULTS: A total of 51 (34%) women did not obtain a HbA(1c) <= 5.6% before delivery. The median HbA(1c) before delivery was 5.9% versus 5.3% in the two groups. At baseline, body mass index and HbA(1c) were higher in the women not obtaining the goal (30.9 versus 27.8 kg/m(2); 5.9% versus 5.1%, both p < 0.01). Women with an elevated HbA(1c) before delivery had a higher prevalence of LGA infants (adjusted odds ratio (OR) 3.1 (95% confidence interval (CI) 1.3-7.6) and neonatal hypoglycaemia (adjusted OR 6.2 (95% CI 1.3-29.0). Other pregnancy outcomes were similar in the two groups. Stratification according to baseline HbA(1c) did not seem to change the result.CONCLUSION: Women with GDM not obtaining HbA(1c) within the normal range before delivery had a three-fold increased risk of having an LGA infant and a six-fold increased risk of neonatal hypoglycaemia.
INTRODUCTION: The aim of this pilot study was to evaluate glycaemic control in diabetic patients admitted to hospital.MATERIAL AND METHODS: Patients were prospectively identified at 11 consecutive Wednesdays in one medical and one surgery department and information from the previous three days of admission was collected, including: bedside p-glucose readings, scheduled and supplemental insulin treatment.RESULTS: In total, 111 observation days were included from 37 diabetic patients (27 medical and ten surgical). P-glucose was measured on average four and 2.5 times daily at the medical and the surgery department, respectively. The median p-glucose level was 8.6 mmol/l (range 4.0-22), with no obvious difference between the two departments and no trend towards improvement observed. Approximately one third of the patients had median p-glucose values > 10 mmol/l. 7% of the patients at the medical and none at the surgery department had a p-glucose < 3 mmol/l. Supplemental insulin was prescribed to the majority of patients at the medical department and to 30% at the surgery department with a median p-glucose threshold of 12 and 14 mmol/l at the two departments, respectively. Supplemental insulin was not given despite being indicated in 37% of the elevated glucose episodes. Increments in scheduled insulin dose were rarely observed despite being indicated.CONCLUSION: Despite acceptable median p-glucose levels, hyperglycaemia was frequent. The number of glucose readings was low and clinical inertia was observed, both with regard to intensification the scheduled insulin and with regard to administration of supplemental insulin.
THE EIGHT ORIGINAL PAPERS ARE 1. Astrup AS, Tarnow L, Rossing P, Pietraszek L, Hansen PR, Parving H-H. Improved prognosis in type 1 diabetic patients with nephropathy: A prospective follow-up study. Kidney Int 2005; 68(3):1250-1257. 2. Tarnow L, Astrup AS, Parving H-H. Elevated placental growth factor (PlGF) predicts cardiovascular morbidity and mortality in type 1 diabetic patients with diabetic nephropathy. Scand J Clin Lab Invest Suppl 2005; 240:73-79. 3. Astrup AS, Tarnow L, Rossing P, Hansen BV, Hilsted J, Parving H-H. Cardiac autonomic neuropathy predicts cardiovascular morbidity and mortality in type 1 diabetic patients with diabetic nephropathy. Diabetes Care 2006; 29(2):334-339. 4. Astrup AS, Tarnow L, Christiansen M, Hansen PR, Parving H-H, Rossing P. Pregnancy-associated plasma protein A in a large cohort of Type 1 diabetic patients with and without diabetic nephropathy-a prospective follow--up study. Diabet Med 2007; 24(12):1381-1385. 5. Astrup AS, Tarnow L, Pietraszek L et al. Markers of endothelial dysfunction and inflammation in type 1 diabetic patients with or without diabetic nephropathy followed for 10 years: association with mortality and decline of glomerular filtration rate. Diabetes Care 2008; 31(6):1170-1176. 6. Kim WY, Astrup AS, Stuber M et al. Subclinical coronary and aortic atherosclerosis detected by magnetic resonance imaging in type 1 diabetes with and without diabetic nephropathy. Circulation 2007; 115(2):228-235. 7. Astrup AS, Kim WY, Tarnow L et al. Relation of left ventricular function, mass, and volume to NTproBNP in type 1 diabetic patients. Diabetes Care 2008; 31(5):968-970. 8. Astrup AS, Nielsen FS, Rossing P et al. Predictors of mortality in patients with type 2 diabetes with or without diabetic nephropathy: a follow-up study. J Hypertens 2007; 25(12):2479-2485.
DANISH MEDICAL BULLETIN 1 This review has been accepted as a thesis together with four previously published papers by University of Copenhagen May 10th 2011 and defended on June 10th 2011. Tutors: Lena Specht, Stine Korreman, Per Munck af Rosenschöld and Anders Navr‐ sted Pedersen Official opponents: Dorte Nielsen, Matthias Guckenberger and Jan‐Jakob Sonke Correspondence: Department of Radiation Oncology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark E‐mail: gitte.persson@rh.regionh.dk
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 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.
