Showing papers in "Ugeskrift for Læger in 2006"

Postoperative nausea and vomiting

Abstract: During the last years huge amounts of literature have been reviewed systematically. Recently, guidelines have been proposed. For the first time a large prospective study has been performed on the effect of combining antiemetics. In this review we try to propose a rational approach to postoperative nausea and vomiting. The scoring of patients at risk, rational anaesthetic agents, prophylactic administration of antiemetics to patients at risk and effective postoperative antiemetic treatment are suggested.

Health effects of migration

Abstract: The proportion of citizens with an ethnic minority background in Denmark is rising and considerations about how to adapt health care services to the needs of this part of the population are becoming increasingly relevant. To do this, knowledge is needed about the factors influencing the health of these population groups. Migration is one of these factors. The process of migration influences the somatic and mental health of migrants and is described in this article. Ethnicity, social position and aspects related to communication also influence migrants’ health; however, we do not discuss these factors [1]. DEFINITION Migration is a process of social change during which a person moves from one cultural setting to another in order to settle for a longer period of time or permanently [2]. People may migrate from rural to urban areas, between neighbouring countries or over longer distances; migration therefore covers a broad variety of processes [3]. The migration process includes conditions in the country of origin, during the journey, and in the recipient country. Migrants can be defined in various ways, e.g., as internally displaced, asylum seekers, refugees, or immigrants [4]. It is difficult to distinguish between forced and voluntary migration; the reasons for migration often include both elements [4, 5]. Reasons for migration can be divided into push factors (driving the individual out of the country of origin) and pull factors (attracting the individual towards the recipient country). Push factors include war, poverty, hunger etc., while pull factors include employment opportunities and political and religious freedom [1, 6]. These factors affect both the nature of the migration and the migrants’ health [3]. There are large differences in both the reasons for migrating and the conditions related to the migration. Migrants constitute a very diverse group with different ethnic and socioeconomic backgrounds and disease patterns in the countries of origin etc. Thus, migrants’ health is influenced by a broad range of factors [2, 4-6].

[Acute pesticide poisoning--a global public health problem].

Abstract: Acute pesticide poisoning has become a major public health problem worldwide, following the intensification of agriculture and the promotion of agrochemicals in low and middle income countries, with more than 300.000 deaths each year. The easy availability of highly toxic pesticides in the homes of farming communities has made pesticides the preferred means of suicide with an extremely high case fatality. Similarly, the extensive use of pesticides exposes the community to both long-term and acute occupational health problems. A concerted effort is urgently needed to address the situation.

The genetics of obesity

Abstract: Although environmental factors clearly play a role, studies of twins and adoptees show that obesity is a familial trait which to a large degree can be ascribed to genetic factors. According to evolutionary models, obesity-causing variants may originally have had an evolutionary benefit, whereas in a modern environment they pose a risk. Despite a clear genetic cause, the molecular genetic variations underlying common forms of obesity are not clear. Out of many hundred candidates, only a few hold up, and only variations in the MC4R gene have been found with a prevalence which may lead to common forms of obesity.

Colorectal foreign bodies

Abstract: A patient with a retained anally introduced colorectal foreign body or complications hereof needs appropriate treatment The patient may be in danger and is certainly in discomfort The problem is relatively rare; however, its incidence may be expected to increase Guidelines for handling of the situation are lacking in many textbooks Here, a suggestion for handling of a patient with a retained colorectal foreign body or complications hereof is presented

Drug treatment of obesity

Abstract: Acceptable adverse effects and a clinical relevant weight loss of 3 to 5 kilograms have been found in long-term randomized clinical trials for sibutramine (Reductil) and orlistat (Xenical); these drugs may be prescribed for treatment of obesity for a duration of one and four years, respectively. This also seems to be the case for rimonabant (Acomplia), which is expected to receive approval in 2005 or 2006. However, until data on morbidity and mortality are available from RCTs, there is no absolute indication for prescribing drugs for treatment of obesity.

Medication overuse headache

Abstract: Frequent use of symptomatic headache drugs may induce medication overuse headache. In primary care settings, medication overuse headache is the third common diagnosis of headache, next to migraine and tension-type headache. The pathophysiologic mechanisms are unknown. It is a severely disabling condition that has a huge economic impact on society. Treatment includes complete drug withdrawal, and the prognosis is good. Preventive measures and providing information to the patients are very important.

Tuberculosis and water pipes as source of infection

Abstract: Since 1990 the incidence rate of tuberculosis has been increasing in Storstroem County, both in persons born in Denmark and in immigrants/fugitives. The increase in patients born in Denmark has been seen mainly among younger males. Subtypes LC2 and C2 were selected for further investigation of the sources and modes of infection, as the number of infected patients was increasing and the index patients were well known. All contacts were traced and investigated according to the Danish recommendations. In total, 49 patients were treated, and 63 other persons shared their households. By comparison of infected contacts in households with infected patients who had shared a water pipe with a known patient, risk rates of 0.76 and 0.73 were found. When a positive Mantoux test was included, the figures were 0.60 and 0.64, respectively. As risk rates for the two modes of infection were the same, we recommend that the use of water pipes should be included in the routine search for carriers of infection.

Heparin and cancer

Abstract: The association between cancer and venous thromboembolism is well described. Several studies indicate that elements of the haemostatic system participate in tumour genesis. During the last decade a number of post-hoc analyses of trials not primarily designed to evaluate the effect of low molecular weight heparins (LMWH), on cancer survival, have indicated an increased survival. This has recently been supported by results from several prospective trials with LMWH. The possible anti-cancer effect of LMWH is not known in details. Treatment regimes with LMWH have to be performed.

[Barthel Index for evaluation of function: a Danish consensus on its use].

Abstract: The Barthel Index is widely used in the evaluation of function. In Denmark at least three versions are used without a consensus of their specific formulation. The term ''Modified Barthel Index'' is used for several versions. A Barthel Index score without version has no meaning since a maximum score in one version indicates very poor function in another. This paper describes the proper usage of the Barthel Index and suggests the terminology ''Barthel-20'' and ''Barthel-100'' for the recommended versions published by Collin et al and Shah et al. The number after ''Barthel-'' indicates the maximum score.

[Length of stay in total hip and knee arthroplasty in Danmark I: volume, morbidity, mortality and resource utilization. A national survey in orthopaedic departments in Denmark].

Abstract: INTRODUCTION: The goal of this study was to evaluate hospital stays for patients operated on with primary total hip- and knee-arthroplasty (THA and TKA) in Denmark in order to focus on the relationship between duration of hospital stay, surgical volume, morbidity and mortality and resources. MATERIALS AND METHODS: According to the National Register on Patients in 2004 concerning postoperative length of hospital stay, readmissions (30 days) and mortality (30 and 90 days), departments with short and long hospital stay were compared and potential economical savings were estimated if all departments reduced their stays to match the departments with the shortest hospital stay. RESULTS: Postoperative hospital stay varied between departments from 4.5 to 12 days. Two-thirds of the departments had stays of more than seven days. A high surgical volume tended to correlate with short hospital stay and reduced mortality. A nation-wide reduction of hospital stay after THA and TKA to five days would free 28,000 hospital beds and produce economic savings of approx. 13 million Euro. CONCLUSION: Nation-wide implementation of fast-track THA and TKA would result in a significant decrease in the needed number of hospital beds and generate economic savings with similar or better outcome.

[Alcohol consumption by middle-aged and elderly Danes from 1987 to 2003].

Abstract: INTRODUCTION: The trend in alcohol consumption by middle-aged and elderly Danes has received little attention, but earlier studies indicated increased consumption. Social factors may influence the trend. Our objective was to investigate the trend in alcohol consumption by the middle-aged and elderly and inquire about significant trends among specific social subgroups. MATERIALS AND METHODS: In the Danish Health and Morbidity Survey carried out in 1987, 1994, 2000 and 2003, a total of 11,754 people aged 50 and older were asked about their alcohol consumption. The mean alcohol intake and the number of heavy drinkers were compared from year to year. RESULTS: The mean intake per day increased from 1.5 drinks in 1987 to 2.1 drinks in 2003 for men and from 0.5 drink in 1987 to 1.0 drink in 2003 for women. The percentage of elderly drinking above the sensible drinking limits increased from 15.2% to 20.4% for men and from 10.7% to 13.6% for women. The strongest increasing trend in the number of heavy drinkers was in the lowest socio-economic groups and among those married or cohabiting. CONCLUSION: The increased number of heavy drinkers among the middle-aged and elderly is of great importance to their general state of health. The increase has possibly been caused by a social and cultural development which has led to a generation of elderly who used to drink alcohol earlier in their lives and continue drinking in old age. More focus on alcohol consumption among the middle-aged and elderly in health policy initiatives is needed. Language: da

[Accelerated versus conventional hospital stay in total hip and knee arthroplasty III: patient satisfaction].

Abstract: Introduction The goal of this study was to evaluate patient satisfaction with the hospital stay in relation to the length of stay for patients operated on with primary total hip- and knee-arthroplasty (THA and TKA). Materials and methods According to the National Register on Patients, the three departments with the shortest and the three departments with the longest postoperative hospital stay at the end of 2003 were chosen for evaluation. The patients, operated on with THA or TKA from September 2004 to April 2005, from the selected departments answered a questionnaire regarding satisfaction with elected parts of their stay, co-morbidity, sex and age. Results The patients from the departments with the shortest stay were not younger nor had they less co-morbidities than patients from departments with longer stays. Apart from staying a significantly shorter time, they were either as satisfied--or sometimes more satisfied--with all parts of their stay compared to patients from the departments with longer hospital stay. Conclusion Patients in accelerated stays are not less satisfied with their hospital stay (or any part of it) compared to patients with longer and more conventional hospital stays. These results support the implementation of fast-track total hip- and knee arthroplasty.

[Health economic analysis of smoking cessation prior to surgery--based on a randomised trial].

Abstract: Smoking is a risk factor for postoperative complications such as pneumonia, infections and impaired wound healing. These can be reduced by preoperative stop-smoking intervention six to eight weeks before surgery. The aim of this study was to evaluate the costs and benefits of a stop-smoking intervention program by means of cost consequence analysis (CCA). A total of 120 smokers scheduled for hip or knee alloplasty were randomised to either a control group or an intervention group. The intervention group received an intensive stop-smoking intervention six to eight weeks before surgery. The focus of the economic analysis was on direct costs. Diagnosis-related group (DRG) costs were used for estimating the costs of secondary surgery. In all, 64% of the patients in the intervention group stopped smoking before surgery, as opposed to 8% in the control group. In the intervention group, 5.4% of the patients had wound complications, and 3.6% needed secondary surgery. In the control group, 30.8% had wound complications and 15.4% needed secondary surgery. The direct costs were almost the same in the two groups, whereas the overall costs in the intervention group were lower than in the control group. The economic analysis shows that a preoperative smoking intervention program is beneficial to society and the patient alike. Based on these calculations, we recommend that all patients scheduled for hip or knee alloplasty be given preoperative stop-smoking intervention.

Osteoarthritis and obesity

Abstract: Epidemiological studies show an increased prevalence of osteoarthritis of the knee and hand with increased body mass index [BMI]. Osteoarthritis of the hip joint is not related to BMI. The connection between obesity and osteoarthritis cannot exclusively be explained by genetic factors or by the accumulation of tear and wear. Overweight occurs prior to knee joint degeneration, not as a result of diminished activity due to joint degeneration. Weight control seems to be an influential tool in the prophylaxis of overweight-specific joint degeneration.

[OPUS: a randomised multicenter trial of integrated versus standard treatment for patients with a first-episode psychosis--secondary publication].

Abstract: A total of 547 patients with first-episode psychosis were included in a randomised clinical trial comparing integrated treatment with standard treatment The integrated treatment consisted of assertive community treatment with programmes for family involvement and social skills training Patients in integrated treatment had significantly fewer psychotic and negative symptoms, less comorbid substance abuse, better adherence to treatment and more satisfaction with treatment at one-year and two-year follow-ups

[Suicide and suicidal behavior among asylum seekers in Denmark during the period 2001-2003. A retrospective study].

Abstract: INTRODUCTION: Our aim was to examine suicidal behaviours among asylum seekers in Denmark. MATERIALS AND METHODS: A retrospective quantitative analysis of data from reports to the Danish Red Cross Asylum Department on suicidal behaviours among persons over 15 years of age in the period 2001-2003 and from 54 medical records of suicidal asylum seekers in Denmark in 2001 was carried out. RESULTS: The number of suicide attempts by asylum seekers in 2001 was 3.4 times higher than by Danish residents. Furthermore, the rate of suicide attempts by asylum seekers grew in the following two years. Suicidal behaviours are most frequent among asylum seekers between 30 and 39 years of age. There are national differences. The preferred method of suicide attempt is intake of medicine. Stress-related diagnoses constitute three fourths of all diagnoses. One analysis suggests that the long waiting time (average 20.8 months) faced by asylum seekers combined with rejection of asylum cases may trigger a rapid suicidal reaction. Other factors may also be active, as 44% of suicide attempts occur within six months after arrival in the country. DISCUSSION: The results are discussed in relation to other research on the vulnerability of refugees, immigrants and asylum seekers and also in relation to length of waiting time, growing mental morbidity and the increasing number of rejections of asylum applications during recent years, a period characterized by a reduction of staff at the asylum centers. It is recommended that prevention of suicidal behaviour shall be given higher legal and administrative priority. Language: da

Surfactant treatment of newborn infants receiving continuous positive airway pressure treatment

Abstract: INTRODUCTION The purpose of this study was to examine the efficiency of a single dose of fast-acting exogenous surfactant (Curosurf) given to premature babies with progressive respiratory insufficiency. Curosurf was given as early rescue therapy during a brief intubation (INSURE method: INtubation-SURfactant-Extubation) during treatment with nasal Continuous Positive Airway Pressure (CPAP). MATERIALS AND METHODS Retrospective study of 115 premature infants with respiratory distress syndrome born and treated at Odense University Hospital during the years 1999 to 2004. The criterion for surfactant treatment was a decrease in the arterial/alveolar oxygen tension ratio (or corresponding values for the fraction of inspired oxygen) below 0.36 in infants with gestational age (GA) 29 weeks the effect was 87%, and all survived. CONCLUSION The effect of surfactant therapy administered per the INSURE method is GA-dependent, and the method works best after GA week 25. The question is whether earlier therapy will increase its efficiency or the method has reached its limit.

Telemedicine in the transmission of prehospitalisation ECGs of patients with suspected acute myocardial infarction

Abstract: INTRODUCTION Time to reperfusion is critical to the outcome of patients with ST-elevation myocardial infarction (MI). Other studies have indicated that wireless transmission of prehospital ECGs can reduce the time to reperfusion. This study evaluated the effect on time to treatment using prehospitalisation ECG transmission to a cardiologist's handheld device in patients with acute chest pain, as well as the potential effect of direct transfer of patients to the closest appropriate cardiological facility. MATERIALS AND METHODS During a one-year study period, prehospitalisation ECGs were transmitted for all patients with symptoms indicative of acute coronary syndrome. The ECGs were received on a handheld device by an attending cardiologist, and the patient was referred to PCI treatment if ST-elevation was found. RESULTS 152 transmissions were registered; 27 of these patients underwent primary PCI treatment. 135 (89%) of the attempted transmissions were successful. Compared to historic controls, there was an increased on-scene time usage of 7 minutes, including transfer. The median time spent from arrival at the hospital to the start of invasive treatment was low, 22 minutes. Compared to historic controls, we found a total reduction in time spent of 72 minutes (p< 0.01). DISCUSSION The results indicate that it is possible to minimize the time delay to primary PCI treatment by direct transfer through consultation and use of wireless transmission of prehospitalisation-acquired ECGs to a handheld device carried by an attending cardiologist.

[Length of stay after primary total hip and knee arthroplasty in Denmark, 2001-2003].

Abstract: INTRODUCTION We studied length of stay (LOS) after operation with total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Denmark from 2001 to 2003 to determine whether experiences from published accelerated tracks had been implemented in Denmark, resulting in reduced LOS. MATERIALS AND METHODS Through the National Patient Registry (Landspatientregistret) we obtained information on numbers, sex, age and LOS for each year during the period 2001-2003, inclusive. RESULTS In 2003 the male-female sex ratios for THA and TKA were 1:1.4 and 1:1.7, respectively. In 2003, the mean age at operation with THA was 66.0 years for men and 69.9 years for women; 66.9 years for men and 69.0 years for women operated on with TKA. During the period studied, LOS was reduced for both operations: 16% for THA, to a mean of 8.1 days, and 17% for TKA, to a mean of 8.6 days, in 2003. LOS increased with age for both THA and TKA. Men had shorter LOS than women. DISCUSSION The LOS shows that accelerated tracks - with accompanying shorter LOS in the area of 4 to 6 days - have not been implemented on a nationwide basis, and we find a need to review the principles for rehabilitation after operation with THA and TKA in the direction of accelerated tracks. This could be expected not only to generate large savings in LOS but also to reduce the need for rehabilitation and possibly reduce morbidity.

[Self-reported stress and risk of breast cancer--a secondary publication].

Abstract: A possible association between stress and risk of breast cancer has been assessed in different study designs with conflicting results. We prospectively followed 6,689 women from the Copenhagen City Heart Study for 18 years for a first-time diagnosis of primary breast cancer. The women were asked about stress intensity and frequency at baseline in 1981-83. Women reporting high levels of stress were at lower risk of breast cancer (hazard ratio = 0.60; 95% CI: 0.37-0.97) than women reporting low levels of stress. This association was most pronounced among women who received hormone therapy.

Access to health care for migrants

Abstract: Migrants include a broad category of individuals moving from one place to another, either forced or voluntarily Ethnicity and migration are interacting concepts which may act as determinants for migrants' health and access to health care This access to health care may be measured by studying utilisation patterns or clinical outcomes like morbidity and mortality Migrants' access to health care may be affected by several factors relating to formal and informal barriers Informal barriers include economic and legal restrictions Formal barriers include language and psychological and sociocultural factors

[Alternative therapies in Denmark--use, users and motives for the use].

Abstract: INTRODUCTION The purpose of this study was to examine the use of complementary and alternative medicine (CAM) in Denmark, possible associations between the use of CAM and various socio-economic variables, and motives for the use of CAM. MATERIALS AND METHODS Our data derived from the Danish Health and Morbidity Survey, 2003. The sample consisted of 4,000 Danish citizens aged 18 years or older, of whom 2,593 (65%) completed the interviews. Multivariate logistic regression analysis was used to examine the association between the use of CAM and various socio-economic variables. RESULTS The survey revealed that 40.2% had ever used CAM and 20.1% had used CAM within the last year. Of those reporting having used CAM ever, reflexology (22.7%), massage/osteopathy/other manipulative techniques (16.5%) and acupuncture (16.2%) were the most frequently used. The use of CAM was more common among women than men, among people aged 30-66 years and among people with 13-14 years of education. There was no association between marital status and CAM. Thirty-nine percent of those having ever used CAM stated that CAM is a supplement to the treatment received in the conventional Danish health care system. CAM was used mainly to treat mild symptoms/diseases (39%) and as prevention or for increased well-being (22%). More women than men stated that they wished to take an active part in their own treatment (30% versus 14%) and cited the unwanted side effects of conventional medicine (16% versus 7%) as a motive for using CAM. CONCLUSION This study shows that the use of CAM is not a hot trend but the continuation of a trend that shows no signs of slowing down.

Kvaliteten af diagnose- og procedurekodning i Ortopædkirurgi Nordjylland

Abstract: INTRODUCTION When the aim is for high quality, efficiency and a balanced allocation of resources in health services, there is a constant demand for optimisation of the quality of registration regarding diagnosis, treatment and DRG-values (DRG = Diagnosis Related Groups). Since the mid-nineties the DRG-system has been used to shed light on productivity in Danish hospitals. This study investigates the quality of registrations after the introduction of an organization for registrations in the county of Northern Jutland. MATERIAL AND METHODS The registrations from 554 orthopaedic patients, both in-patient and day case surgery, during a two-week period, were scrutinised critically and changed as appropriate, based on a thorough examination of the medical records. RESULTS In 37% of the courses registrations were found insufficient or incorrect. In 27% of the cases there was a need for a change in either the diagnosis taken action on, a secondary diagnosis or the treatment registration. 10% had two or three changes. In 11% of the courses of treatment the DRG-value was changed. On average DKK 974 were added, constituing in total only 0.4% of the total DRG-value. But single variations from deductions of DKK 56,000 to an addition of DKK 39,000 were observed. The gravest mistakes are elucidated. CONCLUSION Locally, there is a need for continuous instruction of both doctors and secretaries regarding correct registration of diagnosis and treatment as well as an improvement of the registration facilities. On a national basis more precise recommendations are required within the medical specialist areas in order to secure an unambiguous registration.

Medication errors on hospital admission

Abstract: INTRODUCTION This study investigated the number of medication errors on hospital admission and the clinical relevance of these errors. The new personal electronic medicine profile (PEM) was tested to establish whether it can contribute further information about the patient's medication on admission. MATERIALS AND METHODS This cross-sectional study included patients admitted to an acute medical admissions ward. In addition to the ward's usual admission procedure, a clinical pharmacist created an extra medication history by carrying out semi-structured interviews and obtaining additional information from the patient's GP. Information was then obtained from the PEM. A clinical expert panel assessed the potential clinical relevance of the discrepancies. RESULTS Of 67 patients admitted, 48 were interviewed. The patients' average age was 71, and they used an average of 6.4 medications each. There were 309 prescriptions registered, producing 85 errors: the extra medication history highlighted 73 of these errors, and the subsequent check of the PEM revealed a further 12 errors. Thirty-three patients (69%) were affected by one or more errors, of which the expert panel considered six (18%) to be potentially serious. CONCLUSION Medication errors on admission to hospital reduce the quality of treatment and can lead to adverse events. The PEM cannot replace the traditional medication history, but the use of a PEM and the increased focus on medication histories can contribute to an improved hospital stay.

Antioxidants and health

Abstract: The Danish Fitness and Nutrition Council has evaluated the basis for recommendations on the intake of antioxidants and has found limited basis for increasing the recommended intake levels for the antioxidants vitamin C and E. Evidence was insufficient to support recommendations for polyphenol or carotenoid supplementation. Supplementation with high doses of vitamin E and beta-carotene may present a health risk. A high intake of fruit and vegetables is associated with a reduced risk of lifestyle diseases, but there is no evidence that this association is due to an antioxidant effect.

[Global burden of disease--a race against time].

Abstract: Low-income communities will within the next decades undergo rapid changes. The burden of non-communicable diseases (NCDs), such as diabetes, cardio-vascular disease and cancer, will comprise an increasing proportion of the total disease burden. The results of projections indicate that the already constrained health systems will face a double burden of disease, in which HIV/AIDS and other common infectious diseases will co-exist with the new NCDs. In order for preventive measures directed towards NCD to be cost-effective, these have to be implemented within the next 10-20 years.

The attitude of doctors and nurses towards reporting and handling errors and adverse events

Abstract: Introduction Few studies have been published about the attitudes of doctors and nurses towards reporting and handling adverse events. However, knowledge about staff attitudes is relevant and may be essential to dealing with potential problems and barriers that staff might have, as well as to supporting cultural change in relation to reporting and learning. Materials and methods From February to March 2002, a questionnaire comprising 133 questions was distributed to 4019 doctors and nurses in four counties in Denmark. This paper deals with only a subset of the results of the survey. Results Responses were obtained from 703 doctors and 881 nurses, yielding an overall response rate of 51%. Statistical analysis was performed with non-parametric tests (Mann-Whitney, Kruskal-Wallis). The survey shows large differences in attitudes among different staff groups towards reporting adverse events, and errors, in their reasons for not reporting and their degree of distress at the prospect of making mistakes. Doctors are more reluctant (34%) than nurses (21%) to bring up adverse events and errors, indicating as their main reasons: lack of tradition, fear of the press, and the risk of being reprimanded. In contrast to consultants, "non-consultants" (staff specialists and junior doctors), and especially the female members of this group, show a greater agreement with each of the proposed reasons. The thought that one may cause injury to a patient induces 35% of "non-consultants" to consider giving up their job "now and then/often". Discussion Efforts to improve patient safety culture can become more effective via knowledge about similarities and differences among staff groups that have been uncovered in this survey.