Pre-eclampsia screening in Denmark (PRESIDE): national validation study.

OBJECTIVES: To investigate the predictive performance of the Fetal Medicine Foundation (FMF) first-trimester screening algorithm for pre-eclampsia in a Danish population and compare screening performance with that of the current Danish strategy, which is based on maternal risk factors. METHODS: This was a prospective study of women with a singleton pregnancy attending for their first-trimester ultrasound scan and screening for aneuploidies at six Danish university hospitals between May 2019 and December 2020. Prenatal data on maternal characteristics and medical history were recorded, and measurements of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum pregnancy-associated plasma protein-A (PAPP-A) and serum placental growth factor (PlGF) were collected without performing a risk assessment for pre-eclampsia. Information on acetylsalicylic acid use was recorded. After delivery, pregnancy outcome, including gestational age at delivery and pre-eclampsia diagnosis, was recorded. Pre-eclampsia risk assessment for each woman was calculated blinded to outcome using the FMF screening algorithm following adjustment to the Danish population. Detection rates (DRs) of the FMF algorithm were calculated for a fixed screen-positive rate (SPR) of 10% and for the SPR achieved in the current Danish screening. RESULTS: A total of 8783 pregnant women were included, with a median age of 30.8 (interquartile range (IQR), 28.1-33.9) years. The majority were white (95%), naturally conceiving (90%), non-smokers (97%) and had no family history of pre-eclampsia (96%). The median body mass index was 23.4 (IQR, 21.2-26.6) kg/m2 . A complete risk assessment including maternal characteristics, MAP, UtA-PI, PlGF and PAPP-A was available for 8156 women (92.9%). In these women, UtA-PI was measured bilaterally with a median value of 1.58 (IQR, 1.27-1.94) and the median resting MAP of 80.5 (IQR, 76.1-85.4) mmHg in two consecutive measurements. Among these, 303 (3.7%) developed pre-eclampsia, including 55 (0.7%) cases of pre-eclampsia with delivery < 37 weeks of gestation and 16 (0.2%) cases of pre-eclampsia with delivery < 34 weeks. At a SPR of 10%, combined screening using the FMF algorithm based on maternal characteristics, MAP, UtA-PI, PlGF and PAPP-A had a DR of 77.4% (95% CI, 57.6-97.2%) for pre-eclampsia with delivery < 34 weeks, 66.8% (95% CI, 54.4-79.1%) for pre-eclampsia with delivery < 37 weeks and 44.1% (95% CI, 38.5-49.7%) for pre-eclampsia with delivery at any gestational age. The current Danish screening strategy using maternal risk factors detected 25.0% of women with pre-eclampsia with delivery < 34 weeks and 19.6% of women with pre-eclampsia with delivery < 37 weeks at a SPR of 3.4%. When applying the FMF algorithm including maternal characteristics, MAP, UtA-PI and PlGF at the fixed SPR of 3.4%, the DRs were 60.5% (95% CI, 36.9-84.1%) for PE with delivery < 34 weeks and 45.2% (95% CI, 32.0-58.5%) for PE with delivery < 37 weeks. CONCLUSION: In this large Danish multicenter study, the FMF algorithm based on maternal characteristics, MAP, UtA-PI, PlGF and PAPP-A predicted 77.4% of cases with pre-eclampsia with delivery < 34 weeks and 66.8% of cases with pre-eclampsia with delivery < 37 weeks of gestation at a SPR of 10%, suggesting that the performance of the algorithm in a Danish cohort matches that in other populations. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Late sensory changes following chest drain insertion during thoracotomy.

BACKGROUND: It is well known that chest drains are associated with severe movement-related acute pain. These noxious stimuli could play a significant role in development and maintenance of persistent post-operative pain. Therefore we studied chest drain sites in post-thoracotomy pain syndrome (PTPS) patients, in regard to pain and sensory dysfunction. METHODS: We quantified thermal and pressure thresholds on both the chest drain side and the contralateral side in 11 PTPS patients and 10 pain-free post-thoracotomy patients 33 months after the thoracotomy. On average, each patient had two chest drains inserted during surgery. RESULTS: At follow up, two patients experienced pain at the chest drain sites, but had maximal pain near or at the thoracotomy scar. Comparison between chest drain side and control side for all 21 patients demonstrated significantly elevated thresholds for warmth detection and heat pain on the chest drain side (P < 0.01), but not for cool detection or pressure. No significant differences between chest drain side and control side were observed within PTPS or pain-free patients. Comparing PTPS and pain-free patients (chest drain-to-control side), no significant differences in thresholds were found. Although all 11 PTPS patients suffered from incisional pain, only two patients had pain from chest drains. CONCLUSION: Increased thresholds for thermal detection suggest that chest drain insertion is associated with late nerve injury. Because no significant differences in sensory thresholds between PTPS and pain-free patients were found, the pathophysiological role of small fibre nerve injury from chest drains in relation to PTPS remains unclear.

Consequences of persistent pain after lung cancer surgery: a nationwide questionnaire study.

BACKGROUND: post-thoracotomy pain syndrome (PTPS) and its social consequences have been inconsistently investigated as most studies were either small sized, focused on a limited number of risk factors or included heterogeneous surgical procedures. The current objectives were to obtain detailed information on the consequences of PTPS after thoracotomy and video-assisted thoracic surgery (VATS) from homogenous unselected nationwide data, and to suggest mechanisms for the development of PTPS. METHODS: data from 1327 patients were collected using a prospective national database and combined with a detailed questionnaire. RESULTS: the response rate was 81.5%, resulting in 546 patients without prior thoracic surgery for the final analysis. Follow-up was 22 months (range 12-36). PTPS occurred in 33% thoracotomy patients and 25% VATS patients. Clinically relevant pain was present in 11-18% of the patients and severe pain in 4-12% depending on the level of physical activity. In PTPS patients, 64% also had pain from other locations on the body. Perceived sensory changes in the thoracic area were present in 63% of PTPS patients vs. 25% in pain-free patients (P<0.001). When comparing VATS with thoracotomy, no consistent differences in the prevalence, distribution of pain, sensory changes or effect of pain on daily activities were observed although clinically relevant and severe pain was reduced after VATS. CONCLUSIONS: this nationwide study corroborates that PTPS is a clinically relevant problem influencing daily activities a long time after thoracotomy and VATS. Nerve injury and increased pain responsiveness may explain the majority of symptoms, the prevalence and distribution of pain including perceived sensory sensations.

Donor Smoking and Older Age Increases Morbidity and Mortality After Lung Transplantation.

BACKGROUND: The lack of lung transplant donors has necessitated the use of donors with a smoking history and donors of older age. We have evaluated the effects of donor smoking history and age on recipient morbidity and mortality with baseline values of pulmonary function and survival free of chronic lung allograft dysfunction (CLAD) as morbidity variables. METHODS: This is a retrospective analysis of 588 consecutive lung transplant recipients and their corresponding 454 donors. Donors were divided into three groups: group 1 included smokers, group 2 nonsmokers, and group 3 had unknown smoking status; these were further divided into three age groups: group A: 0 to 39 years; group B: 40 to 54 years; and group C: ≥55 years. RESULTS: One hundred fifty-one donors were former or actual smokers, 175 were nonsmokers, and 128 had unknown smoking histories. Baseline forced expiratory volume in 1 second, forced vital capacity, and diffusion capacity of carbon monoxide were lowest in the groups who received lungs from a smoking donor. CLAD-free survival was identical in all smoking groups, and overall survival was better both for lungs from nonsmoking donors and donors with unknown smoking status compared to lungs from smoking donors. One hundred sixty-nine donors were in age group A, 203 in B, and 82 in C. Baseline forced expiratory volume in 1 second, forced vital capacity, and diffusion capacity of carbon monoxide were lowest in the groups who received lungs from donors older than 55 years. Overall survival as well as CLAD-free survival was significantly lower with donors ≥55 years. CONCLUSIONS: Donor smoking history and older donor age impact lung function, mortality, and CLAD-free survival after transplantation. Because of a shortage of organs, extended donor criteria may be considered while taking waiting list mortality into account.

Indication for resuscitative thoracotomy in thoracic injuries-Adherence to the ATLS guidelines. A forensic autopsy based evaluation.

BACKGROUND: The appropriate indications for Resuscitative Thoracotomy (RT) are still debated in the literature and various guidelines have been proposed. This study aimed to evaluate whether Advanced Trauma Life Support (ATLS) guidelines for RT were applied correctly and to evaluate the proportion of deceased patients with potentially reversible thoracic lesions (PRTL). METHODS: The database at the Department of Forensic Medicine at Copenhagen University was queried for autopsy cases with thoracic lesions indicated by the SNOMED autopsy coding system. Patients were included if thoracic lesions were caused by a traumatic event with trauma team activation. Patient cases were blinded for any surgical intervention and evaluated independently by two reviewers for indications or contraindications for RT as determined by the ATLS guidelines. Second, autopsy reports were evaluated for the presence of PRTL. RESULTS: Sixty-seven patients met the inclusion criteria. Two were excluded due to insufficient data. The overall agreement with guidelines was 86% and 77% for blunt and penetrating trauma, respectively. For patients submitted to RT the overall agreement with guidelines was 63% being 45% and 74% for blunt and penetrating trauma, respectively. For patients who did not undergo RT the agreement with guidelines was 100%. In all cases where RT was performed in agreement between guidelines and the clinical decision the autopsy reports showed PRTL in 16 (84%) patients. In cases of non-agreement PRTL were found in 9 (82%) patients. CONCLUSIONS: Agreement with ATLS guidelines for RT was 63% for intervention and 100% for non-intervention in deceased patients with thoracic trauma. Agreement was higher for penetrating trauma than for blunt trauma. The adherence to guidelines did not improve the ability to predict autopsy findings of PRTL. Although the study has methodical limitations it represents a novel approach to the evaluation of the clinical use of RT guidelines.

Effect of prolonged alveolar hypoxia on pulmonary arterial pressure and segmental vascular resistance.

The time course of hypoxic pulmonary vasoconstriction and its segmental distribution were studied during prolonged (150 min) alveolar hypoxia in in vivo dog lungs at constant-flow perfusion. With the pulmonary and the systemic circulations separated by two extracorporeal circuits, adequate systemic oxygenation was achieved throughout the experiments. The pulmonary circulation exhibited a time-related biphasic hypoxic vasoconstrictor response: an initial rapid contraction [79 +/- 11% (SE) above control level] was followed by a partial relaxation when a second slow and sustained vasoconstriction (92 +/- 13% above control level) superseded. We partitioned the pulmonary circulation into two segments by arterial occlusion: an upstream arterial segment and a downstream segment consisting of a middle and a venous segment. Measurements were performed at baseline and during the late sustained vasoconstrictor response. Prolonged alveolar hypoxia increased pulmonary capillary pressure by 90 +/- 18%, the site of pulmonary vasomotion being the arterial upstream and downstream middle and venous segments.

Pregnancy and progeny after long-term contraceptive treatment with low-dose progestogens.

Sixteen women who had used a low-dose progestogen-only oral contraceptive preparation ('Exluton'), containing 0.5 mg. lynestrenol per tablet, for periods of at least a year were studied. All had normal pregnancies after discontinuing the preparation and gave birth to healthy infants: 11 girls and 5 boys. No complications were found at subsequent routine examinations of the infants.

Proprioception at the ankle: the effect of anaesthetic blockade of ligament receptors.

Seven subjects with normal joints were tested for active and passive position sense of ankle inversion, peroneal reflex reaction time to sudden ankle inversion, and postural stability during single-leg stance. The tests were performed before and after regional block of the ankle and foot with local anaesthetic. Passive position sense, assessed with the muscles relaxed, was greatly impaired by anaesthesia but active position sense, with the calf muscles activated, was preserved, and the peroneal reaction time to sudden ankle inversion was not altered. The magnitude of postural sway during single-leg stance was also unchanged by anaesthesia of the ankle and foot. The results suggest that the afferent input from intact lateral ankle ligaments is important in sensing correct placement of the foot at heel-strike, but that this input can be replaced by afferent information from active calf muscles. Afferent input from these muscles seems also to be responsible for dynamic ankle protection against sudden ankle inversion and is adequate to allow stable single-leg stance.

Effect of functional bracing, quadriceps and hamstrings on anterior tibial translation in anterior cruciate ligament insufficiency: a preliminary study.

Anterior tibial translation was measured in six patients with anterior cruciate ligament insufficiency. The tests were done in 15, 45, and 90 degrees of knee flexion, partly with activated quadriceps or hamstrings, and partly with subjects wearing a 4-point functional DonJoy brace. The translation was evaluated with a computerized electrogoniometer (Acufex KSS). The anterior tibial translation was significantly reduced by use of the hamstrings in all three degrees of knee flexion. The effect of the 4-point brace was only significant in 15 and 45 degrees of flexion. The quadriceps did not reduce the anterior tibial translation.

[Lung volume reduction surgery. A new surgical therapeutic possibility for patients with emphysema]. / Lungevolumenreducerende kirurgi. Et nyt kirurgisk behandlingstilbud til patienter med emfysem.

Lung volume reduction surgery is a new surgical procedure for treatment of patients with pulmonary emphysema. At the operation the most peripheral parts of the lung are resected. Only 15-20% of the patients admitted for lung volume reduction surgery are suitable for operation. The preliminary results have demonstrated improvement in lung function in the majority of the patients. Most of the reports comprise small numbers of patients and have a short time of observation. The longest reported period of observation for a larger number of patients is 24 months and shows a continuing improvement in lung function, dyspnoea and six minute walk test. Because of the high incidence of emphysema, lung volume reduction is a procedure that could reach large extension in the future. However, better definition of criteria of inclusion and better evaluation of the operative procedures are needed.

[Cannulation of the radial artery. Risks, effective examination methods and monitoring of the circulation in the hand during the procedure]. / Kanylering af a. radialis. Risici, relevante undersøgelsesmetoder og monitorering af håndens kredsløb i forbindelse med proceduren.

Cannulization of the radial artery with the object of continuous measurement of the blood pressure or repeated analyses of the arterial blood gases is an easy and relatively safe procedure. Thrombosis is observed in 25-40% of the cases. The frequency depends upon the condition of the patient, the cannula and technique of cannulization and duration of this. Permanent ischaemic damage resulting from thrombosis is, however, rare. Other complications of clinical significance are infections and vascular lesions which are, similarly, rare. Allen's test for assessing the collateral circulation of the hand has a high negative predictive value while the positive predictive value is so low that a positive test result does not exclude cannulization. In these cases, better assessment of the perfusion of the hand may be obtained by combining the test with pletysmography. After cannulization, it should be possible to monitor perfusion distal to the site of cannulization employing more recent pulse oximeters with the aid of the pletysmographic curve.

Emergency thoracotomies in the largest trauma center in Denmark: 10 years' experience.

AIM: The aim of our study was to investigate the outcome in terms of 30-day survival and to determine whether preoperative factors could predict the outcome. METHODS: All patients who underwent an emergency thoracotomy (ET) during the period 2000 to 2009 were included. The patients were divided into two groups: emergency department thoracotomy and operating room thoracotomy. Data on demographics, mechanism of injury, intraoperative data, Injury Severity Scores (ISS), probability of survival, signs of life, transportation time, indications, and outcome were collected. RESULTS: Forty-four ETs were performed. The mechanisms of injury were penetrating in 28 (64%) and blunt in 16 (36%) cases. In the emergency department thoracotomy group, the survival was 45 versus 20% for penetrating and blunt trauma, respectively. The total survival was 33%. In the operating room thoracotomy group, the survival was 83%. The survivors had a significantly lower ISS and a higher calculated probability of survival. The calculated mean probability of survival was 44 and 84% in the emergency department thoracotomy and operating room thoracotomy groups, respectively. The actual survival was similar, with 33% in the emergency department thoracotomy group and 83% in the operating room thoracotomy group. CONCLUSIONS: The probability of survival and ISS are good predictors of survival in these patients and should be included in the future in order to make upcoming studies easier to compare. Patients with very high ISS or low probability of survival survived, justifying the procedure in our center.