Determinants of Acute Kidney Injury and Renal Function Decline After Endovascular Abdominal Aortic Aneurysm Repair.

OBJECTIVE/BACKGROUND: Endovascular aneurysm repair (EVAR) may be associated with renal injury and more insight is needed into potential risk factors. The aim was to identify clinical, anatomical, and peri-procedural parameters as potential risk factors for the occurrence of acute kidney injury (AKI) and to evaluate chronic kidney disease (CKD) after EVAR. METHODS: A cohort of 212 consecutive patients who underwent elective EVAR for abdominal aortic aneurysm from January 2009 to October 2016 was included. A subgroup of 149 patients with 2 years follow-up was compared with a set of 135 non-operated aneurysm patients with smaller aneurysms (similar cardiovascular risk profile) to assess CKD. Primary outcomes were AKI (Acute Kidney Injury Network criteria) and CKD measured by estimated glomerular filtration rate (Kidney Disease Improving Global Outcomes guidelines). For AKI, candidate risk factors were identified by univariate and multivariate logistic regression analysis; for chronic renal function decline, risk factors were identified using Cox regression analysis. RESULTS: AKI occurred in 30 patients (15%). On multivariate analysis, the use of angiotensin II blocker (odds ratio [OR] 4.08, 95% confidence interval [CI] 1.38-12.07) and peri-operative complications (OR 3.12, 95% CI 1.20-8.10) were independent risk factors for AKI, whereas statin use was a protective factor (OR 0.19, 95% CI 0.07-0.52). EVAR resulted in a significant increase (23.5%) in the occurrence of CKD compared with the control group (6.7%; p <.001). On univariate and multivariate Cox regression the risk factors: aortic neck diameter (per mm increase) (hazard ratio [HR] 1.13, 95% CI 1.02-1.25), renal artery stenosis >50% (HR 2.24, 95% CI 1.05-4.79), and the occurrence of AKI (HR 2.19, 95% CI 0.99-4.85) were significant predictors of CKD. CONCLUSION: This study identified use of angiotensin II blockers and peri-operative complications as risk factors for AKI. In addition, the problem of renal function decline after EVAR is highlighted, which indicates that prolonged protective measures (e.g., in those patients at high risk) over time are needed to improve patient outcomes.

Control of a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in a day-care institution.

This article describes an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in two institutions for multi-handicapped children in Copenhagen. The aim of the study was to determine whether it was possible to eradicate MRSA in a setting with multi-handicapped children and staff where there was a high degree of physical interaction. This was a prospective interventional uncontrolled cohort study that took place from January 2003 to March 2005. All individuals in close contact with the two institutions and/or in close contact with an MRSA-colonized subject from the outbreak were included in the study: 38 children, 60 staff members and 12 close relatives of colonized subjects. Infection control measures included screening all individuals. When MRSA infection or colonization was found, an attempt was made to eradicate MRSA, staff education was undertaken and attempts were made to determine the route of transmission. Eleven individuals were found to be positive for MRSA (10.0%). All isolates were identical by pulsed-field gel electrophoresis and harboured the staphylococcal cassette chromosome mec (SCCmec) type IV. All colonized and infected individuals were associated with a single room in one of the institutions. MRSA was eradicated from all the colonized and infected subjects. This study shows that it is possible to control an MRSA outbreak in institutions for multi-handicapped children where there is a high degree of physical contact.

Tuberculosis in a cohort of Vietnamese refugees after arrival in Denmark 1979-1982.

SETTING: Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark. OBJECTIVE: To study the occurrence of tuberculosis (TB) in a cohort of immigrants from a high incidence country during the years following arrival in a low incidence country. DESIGN: Follow-up analysis in a cohort of 1983 Vietnamese refugees who arrived in Denmark during the period 1979-1982. The civil registration number could be identified for 1936 (98%) individuals from the original cohort. Date of possible death, emigration and the development of tuberculosis were determined by checking the refugees' civil registration number in the National Civil Register and the National Infectious Disease Registry for Tuberculosis. RESULTS: Tuberculosis notification for the 1936 individuals fell from 1.14% for the first 12 months to a mean of 0.08% per year during the following 5-year period. During the 16 years of follow up, 36 of the refugees developed tuberculosis, of whom 14 (39%) had had abnormal chest X-ray on arrival and 14 (39%) (including one with normal chest X-ray) had been identified as having active tuberculosis through screening on arrival. CONCLUSION: Decline in tuberculosis incidence for immigrants is very rapid if the tuberculosis infection rate is low following arrival. With a very limited TB screening programme (chest X-ray on arrival) and a passive diagnosis policy without preventive chemotherapy, it is possible to control tuberculosis among high prevalence immigrants in a low incidence country.

Infant BCG vaccination study in Lithuania.

SETTING: Infants identified in maternity hospitals in Vilnius, Lithuania. OBJECTIVES: To test the capacity of the BCG vaccine, Danish strain 1331 (Danish vaccine), to induce tuberculin reactivity and scar formation in neonates compared to the WHO International Reference Preparation of BCG (IRP vaccine), and to study the effect of dose and of age at vaccination. DESIGN: A randomized four-armed study: 1) normal dose, 0.05 ml Danish vaccine given to neonates at birth, 2) half the normal dose of Danish vaccine given at birth, 3) IRP vaccine given at birth at normal infant dose, and 4) the normal infant dose of Danish vaccine given at 3 months of age. RESULTS: Larger tuberculin reactions, as well as an increased frequency and larger scars, were seen when Danish vaccine was given at 3 months of age in comparison to neonatal vaccination. Halving the dose resulted in smaller reactions, but the difference was not significant. The IRP vaccine resulted in borderline significantly larger reactions in comparison to the Danish vaccine. The number of infants receiving very early vaccination (0-2 days) was not evenly distributed in all groups, however, which is believed to explain the observed difference.

Increased number of sporadic nosocomial group A streptococcal bacteraemias during a community epidemic.

An increased morbidity rate due to Lancefield group A streptococci (GAS) in the Scandinavian countries, beginning late in 1987, led to the present retrospective survey of bacteraemias with GAS in Denmark. Among 242 reported cases from January 1987-December 1989, 94 were found to have been nosocomially acquired, and their occurrence mirrored the pattern of the epidemic with T-type 1 and the seasonal variation of other serotypes in the community. The 27 nosocomial cases from 1988 were studied further. Eighty percent were associated with postoperative wound infection, erysipelas, puerperal or neonatal infection. Of the 52 community-acquired cases in 1988, 80% comprised erysipelas, respiratory tract infection, meningitis, gastrointestinal disease or arthritis. The bacteraemic patients were promptly treated with antibiotics, but the use of penicillin was in some cases delayed because the clinical signs of streptococcal infection were misinterpreted by the attending clinician. Ideally, the nosocomial infections should have been prevented by hygienic measures in the hospitals. When an epidemic situation of this type exists in the community, handwashing routines become vitally important. A warning for epidemics should be extended to the hospital.

Gastroenteritis: a waterborne outbreak affecting 1600 people in a small Danish town.

STUDY OBJECTIVE: To examine (i) the extent of illness caused by contamination of a waterworks with waste water due to overflow, and its correlation with precipitation; (ii) the potential secondary spread; (iii) economic losses due to sick leave. DESIGN: A historical follow up study with structured postal questionnaires. SETTING: A small community on the outskirts of greater Copenhagen at the end of 1991 and the beginning of 1992. PARTICIPANTS: The main study group comprised all 703 households supplied by the waterworks (response rate: 89% of households). There was a control group of 200 randomly chosen households in neighbouring communities with a different water supply source (response rate: 64% of households). A day care group of all 149 children (response rate: 78%) and 30 teachers (response rate: 83%) who lived in central Copenhagen, but spent the day in four day care centres supplied by the waterworks, and members of their household was also studied. MEASUREMENTS AND MAIN RESULTS: Altogether 1455 people (88% of respondents in the main study group) reported having had symptoms of gastroenteritis, particularly diarrhoea (83%) and vomiting (55%). In the control group, 10% had had symptoms of gastroenteritis. The onset of episodes with diarrhoea correlated well with precipitation (Spearman's correlation coefficient: 0.75; p = 0.0002). The secondary attack rate in household contacts was 12%. No pathogens were found. Affected people stayed home from work for a total of 1658 days. The cost of loss of production because of sick leave amounted to 1,600,000 Danish kroner (180,000 pounds). CONCLUSIONS: The outbreak caused extensive illness correlated with precipitation, showed secondary spread, and was associated with major economic losses. Increased awareness among local physicians and waterworks personnel of the possibility of contamination of the water could have led to earlier intervention and reduced the extent of illness. Outbreaks are often caused by several factors, many of a technical nature, which in this case acted together. It is recommended that attention be paid to each factor.

Group A streptococcal bacteraemias in Denmark 1987-89.

A retrospective study of laboratory-verified cases of Group A Streptococcal bacteraemias in Denmark was conducted for the period 1987-1989 after a sudden increase occurred during the winter 1988-1989. The aim of the study was to describe the epidemiology in the period and to compare cases during the outbreak period with cases in a period with a baseline risk. Based on isolates, a total of 242 cases in 240 patients were included in the study and information on previous health of the patients, source of infection (community-acquired or nosocomial) and outcome were obtained from hospital records. During the epidemic period the total incidence increased three-fold. The frequency of type 1 increased from 1 in 5 to 1 in 2. The number of previously healthy individuals falling ill with type 1 increased 25-fold. The relative increase was higher among patients with community-acquired infection than among patients with nosocomial infection. The lethality rate was 48% during the epidemic in which 38% of the cases occurred. As early diagnosis and treatment are the two most important measures to prevent serious outcome, effectiveness and timeliness of surveillance systems are of extreme importance.

Reported side effects to chloroquine, chloroquine plus proguanil, and mefloquine as chemoprophylaxis against malaria in Danish travelers.

BACKGROUND: The aim of the study was to provide data on the relative frequency of reported symptoms in travelers using chloroquine, chloroquine plus proguanil, and mefloquine. METHOD: The study was an open, nonrandomized study recording self-reported events in travelers recruited consecutively from two travel clinics in Copenhagen, Denmark. The main outcome measures were the relative proportion of travelers reporting particular symptoms in the three prophylaxis groups, compliance, hospitalization and premature termination of the travel. RESULTS: From May 1996 to April 1998 5, 446 travelers were included and 4,158 questionnaires (76.3%) returned. Compliance was significantly better in mefloquine users with 83.3% of short term travelers compared to 76.3% in chloroquine plus proguanil users. Also, 84.8%, 59.3% and 69.5% using chloroquine, chloroquine plus proguanil, and mefloquine respectively reported no symptoms and 0.6%, 1.1% and 2.8% reported "unacceptable" symptoms. Compared to chloroquine, mefloquine users had a significantly higher risk of reporting depression, RR 5.06 (95% CI 2.71 - 9.45), "strange thoughts," RR 6.36 (95% CI 2.52 - 16.05) and altered spatial perception, RR 3.00 (95% CI 1.41 - 6.41). CONCLUSION: Overall mefloquine is tolerated at least as well as chloroquine plus proguanil and shows better compliance, however, symptoms related to the central nervous system are more prevalent in mefloquine users and when symptoms develop, they are perceived as more severe.

The EUVAC-NET project: creation and operation of a surveillance community network for vaccine preventable infectious diseases.

The EUVAC-NET network is in charge of the epidemiological surveillance and control of vaccine preventable diseases. It is coordinated by the SSI in Denmark, in collaboration with the ISS in Italy. The two main diseases targeted by the network are measles and pertussis. A collaboration is planned with the PHLS for the monitoring of Haemophilus influenzae b. EUVAC-NET includes the Member States of the European Union, and Iceland, Norway and Switzerland.

The EUVAC-NET survey: national measles surveillance systems in the EU, Switzerland, Norway, and Iceland.

The EUVAC-NET network undertook a questionnaire study on measles surveillance systems in EU member countries, Switzerland, Norway and Iceland. All questionnaires were completed. Surveillance systems for measles are implemented in 16 of the 18 countries. Most countries have some case based data and in all countries the shift is towards case based surveillance for measles, though there are differences between countries concerning case definitions and classifications. A two-dose MMR vaccination schedule is implemented in all the EUVAC-NET countries but methods used for estimation of vaccination coverage are diverse.

[Changes in measles, mumps and rubella (MMR) immunity until the year of 2002 after the introduction of MMR vaccination]. / Aendringer i maeslinge-, fåresyge- og røde hunde-(MFR)-immuniteten frem til år 2002 efter indførelse af MFR-vaccination.

In order to decide whether vaccination for measles, mumps and rubella should be introduced at the age of five years, calculations of the immunities in various age groups were performed until the year 2002 with and without vaccination at the age of five years. These calculations are based on the knowledge of immunity in the various age groups before the MMR vaccination programme was instituted in 1987 and knowledge of the compliance with vaccination obtained to date. Future predictions reveal that it is of decisive significance that compliance with vaccination among 12-year-olds is increased as rapidly as possible to 0.7 and to 0.8 in the subsequent year, if the level of immunity present prior to institution of the vaccination programme is to be maintained. The second vaccination given at a shorter interval after the first would prevent about 150 cases of illness in all per annum among 6-12 years-old. However, this should not be introduced at the expense of vaccination at the age of 12 years, which should be continued for at least 10-15 years yet. Possible abandoning of vaccination at the age of 12 years 10-15 years hence presupposes that adequate numbers of the children have been vaccinated twice at an early age and that it is sufficiently certain that secondary failure of vaccination does not occur to any significant extent.

[Duration of immunity and occurrence of secondary vaccine failure following vaccination against measles, mumps and rubella]. / Varighed af immunitet og forekomst af sekundaert vaccinesvigt efter vaccination mod maeslinger, fåresyge og røde hunde.

The present article illustrates the extent of secondary vaccine failure after vaccination for measles, mumps and rubella (MMR). Secondary vaccine failure means loss of the immunity induced by vaccination to such an extent that infection becomes possible. Serological investigations carried out with follow-up periods of up to 16 years after vaccination for measles, 21 years after vaccination for rubella and 12 years after vaccination for mumps reveal that loss of antibodies occurs with the elapse of time but that the clinical significance of this is probably very limited. Where all three types of vaccination are concerned, secondary vaccine failure has hitherto been very seldom. Infection with measles after secondary vaccine failure is generally described as running a milder course. In rare cases, rubella re-infection has resulted in infection in utero, so that a slight risk of congenital rubella cannot be entirely excluded after successful vaccination. No extensive systematic investigations of the effect of revaccination have been carried out and, similarly, the optimal interval between two or more vaccinations has not been illustrated in more detail in the literature. Subclinical infection is not uncommon after all three vaccines. Where measles is concerned, immunity may possibly be regarded as a continuum which, depending upon the antibody level, protects the individual from various degrees of clinical disease. If wild virus can be spread via individuals with subclinical infections, it is doubtful whether population immunity (herd immunity), which is necessary to eliminate the three diseases, can be attained in large populations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Occurrence of hepatitis A infection in Denmark]. / Forekomst af hepatitis A-infektion i Danmark.

Hepatitis A is a mandatory notifiable disease in Denmark. The number of notified cases of hepatitis A was compiled over a period of 16 years, 1980-1995. A total of 3790 were included in the study. The average incidence was 4.6 per 100,000 population per year, but the number of cases declined slightly through the period. Median age among Danes were 27 years and among immigrants seven years. The male to female ratio was 1.5 among Danes and 1.1 among foreigners. The incidence was highest in the capital area. Two-thirds of the notified persons were infected in Denmark, among whom the source of infection was unknown for half of the cases. The two most important sources of infection were household contracts and i.v. drug abuse. A total of 73 persons were infected in connection with their occupation in Denmark. Workers in day care centres, sewage workers and cleaners may be particularly at risk, although the risk is still low. The relevance of vaccination recommendations for special groups is considered.

[The childhood vaccination program. Background, status and future]. / Børnevaccinationsprogrammet. Baggrund, status og fremtid.

Surveillance of the Danish childhood immunization programme has taken place at Statens Seruminstitut since 1980. A description of the prevalence of the diseases, which are included in the programme, is presented. The Danish childhood immunization programme has for many years been one of the best in the world although it differs markedly from other countries. The polio immunization programme with inactivated polio vaccine given first and then later live attennuated vaccine is probably the optimal polio immunization programme. The childhood immunization programme began in 1943 with free diphtheria vaccination, and tetanus immunization was added in 1949. There was a big polio epidemic in 1952/53 and the polio vaccine was introduced in 1955. All three vaccines have markedly reduced the prevalence of these diseases. Pertussis vaccine was introduced in 1961 and measles, mumps and rubella vaccination in 1987. Vaccination against Haemophilus Influenzae type b was introduced with success in 1993. In the future several changes will probably be made in the programme because of the possibility using new combined vaccines.

[The impact of postal invitations and user fee on influenza vaccination among the elderly. A randomized controlled trial in general practice]. / Betydning af indkaldelse og brugerbetaling for influenzavaccination blandt aeldre. Et randomiseret kontrolleret forsøg i almen praksis.

Influenza epidemics are accompanied by considerable excess morbidity and mortality especially among the elderly and the chronically ill. In the influenza season 1995 a controlled, randomized trial was carried out to examine the impact of postal invitations and user fee on influenza vaccination rates. Five hundred and eighty-five patients aged 65 years or older participated. They were all recognized by their general practitioner (GP) to be in the risk group to whom influenza vaccination is recommended. One third were invited to free influenza vaccination. Another third received postal invitations to influenza vaccination paying the usual fee ($40-$60 US). The last third served as a control group, being vaccinated on their own request and paying the usual fee. In the control group 25% (19-31%, 95% confidence interval) of the patients were vaccinated, compared to 49% (42-56%) in the group which received a postal reminder and paid the usual fee, and 72% (65-78%) in the group invited to be vaccinated free of charge.

[Knowledge of, attitudes toward and participation in the new vaccinations against measles, mumps and rubella during the first 2 years]. / Kendskab og holdninger samt tilslutning de første to år til de nye vaccinationer mod maeslinger, fåresyge og røde hunde.

The new vaccinations for measles, mumps and rubella (MMR) for children and the new vaccination for rubella for adult women were introduced in Denmark on 1.1.1987. An account is presented of 1) knowledge about and attitudes to the new vaccinations, investigated three months after commencement of the programme as assessed by means of a marketing investigation and 2) participation in vaccination during the first two years after introduction of the vaccination programme assessed by registration of services in the Danish National Health Service. The calculated participation in the MMR vaccination programme at the age of 15 months was found to be 72% and 31% at the age of 12 years. The calculated participation in the rubella vaccination programme at the age of 18 years was 13% in 1988 and even less for the remaining women. 95% of persons with children aged 0-12 years in the household who were questioned had heard about the new vaccinations for children and more than 50% had detailed knowledge about MMR vaccination. More than 10% were against MMR vaccination mainly because they considered that it was better for children to have these infections naturally. 90% of the women questioned knew why adult women were offered vaccination for rubella, although the percentage was less in the younger women. Compared with the goals established, participation in the MMR vaccination programme is insufficient. Participation in the rubella vaccination programme for adult women is entirely inadequate. The reasons for defective participation and proposed improvements are discussed. It is important that general practitioners and health nurses instruct parents about these possibilities.

[Contamination of a water system with sewage]. / Forurening af et vandvaerk med kloakvand.

The purpose of the study was to examine the extent of illness caused by contamination of a waterworks with waste water due to overflow. Structured questionnaires were mailed to all 703 households (the main study group) and four day-care centers supplied by the waterworks as well as a group of 200 randomly chosen households in neighbouring communities with a different water supply. Fourteen hundred and fifty-five persons (88% of respondents in the main study group) reported that they had had symptoms of gastroenteritis, particularly diarrhoea (83%) and vomiting (55%). In the control group, 10% of respondents had had symptoms of gastroenteritis. Onset of diarrhoea correlated well with precipitation (Spearman's correlation coefficient: 0.75; p = 0.0002). No pathogens were found. It is important to be aware of the possibility of water contamination when an increased number of cases of gastroenteritis are observed in a local area and to report even a suspicion of waterborne diseases to the county public health office.

[MMR-vaccination of children allergic to eggs]. / MFR-vaccination af børn med aegallergi.

To re-evaluate the recommendations for MMR-vaccination of children known to be allergic to eggs a descriptive study was carried out in which all reported allergic side effects for 1987-1996 were studied. During the 10 year period 1,200,000 MMR vaccinations were given. Eighteen were found with immediate type hypertensity, but only eight presented symptoms within 24 hours. One child with egg-allergy reacted within 15 min presenting rhinitis and respiratory difficulty. None had anaphylactic shock. It was concluded that MMR vaccine may be administered to children allergic to eggs when given in a paediatric ward where appropriate emergency treatment is available.

[Outbreak of serogroup C meningococcal disease among teenagers in Randers--preventive measures and examination of the meningococcal carrier conditions]. / Udbrud af serogruppe C-meningokoksygdom blandt teenagere i Randers--profylaktiske foranstaltninger og undersøgelse af meningokokboerertilstanden.

An outbreak involving 20 cases of serogroup C meningococcal disease, predominantly among teenagers, occurred over a seven-month period in the Randers area of Denmark. The cases were caused by a serogroup C:2a:P1.2 sulphonamide-resistant strain. The available evidence was against the transmission being related to particular schools. The outbreak was experienced as three clusters. At two schools involved in the first and the third cluster of the outbreak, 351 students were examined regarding pharyngeal carriage of meningococci, 282 of whom were tested again 17 weeks later; 308 students attending two similar schools in a nearby area were examined once. The majority of strains isolated from group C carriers in the high-risk area were serologically indistinguishable from the outbreak strain (13/14 = 95%), but less often sulphonamide-resistant (5/13 = 38%). In both areas, the overall carrier rate (30%), the overall group C rate (3%) and, the carrier rate for the outbreak strain (1%) were the same. The attack rate for the outbreak strain differed significantly: 1/40 in the high-risk area versus 1/2.500 in the normal risk area. No conditions that might explain this difference were revealed. Immediately after recognition of the first and the third cluster, 780 and 13,300 students, respectively, were vaccinated with meningococcal polysaccharide vaccine A+C. It was concluded that the definition of target groups for vaccination should be liberal, because the "at risk" population may be difficult to recognize at the onset of an outbreak.

[Tuberculosis in Denmark 1972-1996]. / Tuberkuloseudviklingen i Danmark 1972-1996.

The present study is based on notified cases of tuberculosis (TB) in the National tbc. register 1972-1996. A decline in Tb incidence was seen from 1972 and until the mid-1980's. Subsequently the trend has reversed due to an increasing number of TB cases in foreigners. In 1996, 60% of all cases of TB in Denmark were found in foreigners reflecting the rising number of refugees and their families arriving in Denmark from highly endemic areas, mainly Somalia. Among native Danes the TB incidence fell from 14 per 100,000 in 1972 to 4 per 100,000 in the 1980's and stabilized at this very low level. The unchanged incidence in Danes covers a falling incidence in the older and a rising incidence in the younger and middle-aged adult population, mainly in the capital. Approximately half of the cases occur in high-risk groups. The TB-epidemic is close to elimination in the indigenous Danish population, but the disease is maintained at a low level probably due to increased patient and doctor delay and resulting microepidemics primarily in high-risk populations.