Neurological prognostication tools in out-of-hospital cardiac arrest patients in Danish intensive care units from 2005 to 2013.

BACKGROUND: Neurological prognostication is an essential part of post-resuscitation care in out-of-hospital cardiac arrest (OHCA). This study aims to assess the use of computed tomography (CT) and magnetic resonance imaging (MR) of the head, electroencephalography (EEG), and somatosensory evoked potentials (SSEP) in neurological prognostication in resuscitated OHCA patients and factors associated with their use in Danish tertiary and non-tertiary centers from 2005 to 2013 and associations with outcome. METHODS: We used the Danish Cardiac Arrest Registry to identify patients ≥18 years of age admitted to intensive care units due to OHCA of presumed cardiac etiology. CT 0-20 days and MR, SSEP, and EEG ≥2-20 days post OHCA were considered related to prognostication. Incidence and factors associated with procedures were assessed by multiple Cox regression with death as competing risk. RESULTS: Use of CT, MR, EEG, and SSEP increased during the study period (CT: 51%-67%, HRCT : 1.06, CI: 1.03-1.08, MR: 2%-5%, P = .08, EEG: 6%-33%, HREEG : 1.25, CI: 1.19-1.30, SSEP: 4%-15%, HRSSEP : 1.23, CI: 1.15-1.32). EEG and SSEP were more used in tertiary centers than non-tertiary (HREEG : 1.86, CI: 1.51-2.29, HRSSEP : 4.44, CI: 2.86-6.89). Use of CT, SSEP, and EEG were associated with higher 30-day mortality, and MR was associated with lower (HRCT : 1.15, CI: 1.01-1.30, HRMR : 0.53, CI: 0.37-0.77, HRSSEP : 1.90, CI: 1.57-2.32, HREEG : 1.75, CI: 1.49-2.05). CONCLUSION: Use of neurological prognostication procedures increased during the study period. EEG and SSEP were more used in tertiary centers. CT, EEG and SSEP were associated with increased mortality.

Electromechanical mapping for detection of myocardial viability in patients with ischemic cardiomyopathy.

BACKGROUND: We evaluated the ability of electromechanical mapping of the left ventricle to distinguish between nonviable and viable myocardium in patients with ischemic cardiomyopathy. METHODS AND RESULTS: Unipolar voltage amplitudes and local endocardial shortening were measured in 31 patients (mean+/-SD age, 62+/-8 years) with ischemic cardiomyopathy (ejection fraction, 30+/-9%). Dysfunctional regions, identified by 3D echocardiography, were characterized as nonviable when PET revealed matched reduction of perfusion and metabolism and as viable when perfusion was reduced or normal and metabolism was preserved. Mean unipolar voltage amplitudes and local shortening differed among normal, nonviable, and viable dysfunctional segments. Coefficient of variation for local shortening exceeded differences between groups and did not allow distinction between normal and dysfunctional myocardium. Optimum nominal discriminatory unipolar voltage amplitude between nonviable and viable dysfunctional myocardium was 6.5 mV, but we observed a great overlap between groups. Individual cutoff levels calculated as a percentage of electrical activity in normal segments were more accurate in the detection of viable dysfunctional myocardium than a general nominal cutoff level. The optimum normalized discriminatory value was 68%. Sensitivity and specificity were 78% for the normalized discriminatory value compared with 69% for the nominal value (P:<0.02). CONCLUSIONS: Endocardial ECG amplitudes in patients with ischemic cardiomyopathy display a wide scatter, complicating the establishment of exact nominal values that allow distinction between viable and nonviable areas. Individual normalization of unipolar voltage amplitudes improves diagnostic accuracy. Electroanatomic mapping may enable identification of myocardial viability.

Effect of anticoagulant therapy on the hypercoagulable state in patients carrying the factor V Arg506Gln mutation.

Resistance to activated protein C, caused by a single point mutation in the factor V gene (Arg506Gln or FV Leiden), is the most prevalent single risk factor associated with venous thromboembolic disease. The aim of this study was to investigate the effectiveness of standard oral anticoagulant therapy (OAT) in patients with the Arg506Gln mutation compared with a matched control group. The study compared selected variables in 27 patients carrying the Arg506Gln mutation with 27 sex- and age-matched controls in steady state oral anticoagulant treatment (OAT). The study showed that similar doses of vitamin K antagonists in carriers and noncarriers suppress and generate a uniform distribution of coagulation markers in steady state OAT. Thus, it seems that OAT with standard treatment doses is just as effective in patients with the Arg506Gln mutation as in comparable controls without the mutation.

The Arg506Gln mutation (FV Leiden) among a cohort of 4188 unselected Danish newborns.

Resistance to activated protein C (APC) is the most prevalent single phenomenon associated with thromboembolic disease. It is caused by a single point mutation in the factor V gene (Arg506Gln or FV Leiden), replacing an Arg506 with a Gln at the APC-cleavage site in factor V. In this study we present a prevalence study of the Arg506Gln mutation in a large Danish cohort. By screening 4188 newborns (8376 alleles) we identified 3.4% alleles (95% CI: 3.0-3.8) of the Arg506Gln mutation, corresponding to a heterozygous prevalence of 6.6% (95% CI: 5.9-7.4) in Denmark. This is significantly lower than what has been reported from southern Sweden. The birth cohort has been selected from the entire country, providing representative and accurate estimates of the gene frequencies. Equal gender distribution was found, and the Arg506Gln mutation is probably not a considerable risk factor in fetal life in the general population.

Evaluation of a simple dosage scheme for transition from phenprocoumon to warfarin in oral anticoagulation.

Phenprocoumon, whose elimination half-time is 144 hours, has been the traditional oral anticoagulant of choice in Europe. However, today's most widely used drug is warfarin, whose elimination half-time is 40 hours. This study aims to evaluate a method for safe transition from phenprocoumon to warfarin, which is sometimes required. Hence, the large difference in their elimination rates may on occasion lead to serious overdosage upon transition from one drug to the other. According to average equipotent doses, a stepwise increase in warfarin dose was calculated based on the elimination half-times of the two drugs. The dosage scheme was subsequently tested in a pilot study including 35 patients. The conversion scheme was then adjusted based on the results from the pilot study. The new scheme was tested in 69 patients. The transition factor was 2.3, which implies that equipotency was achieved when the warfarin dose was 2.3 times larger than the phenprocoumon dose (in mg). This scheme proved optimal for 75% of the patients. However, the dose had to be adjusted individually in the remaining 25% of the patients to a level corresponding to the measured international normalised ratios. No patients experienced haemorrhages or thromboembolic complications during the period of changeover. In conclusion, the proposed scheme for changing medication from phenprocoumon to warfarin is safe and convenient.

Intravenous magnesium does not influence the activity of the coagulation cascade.

Experimental arterial thrombus formation is reduced during intravenous magnesium infusion. It is well documented that magnesium reduces platelet reactivity, but the antithrombotic effect could also originate from anticoagulant properties or increased fibrinolysis. We therefore evaluated the effect of intravenous magnesium on prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin III complex (TAT) concentrations, and fibrin degradation products (FbDP) in a randomized, cross-over study in 14 healthy volunteers. Citrated blood samples were collected at 0, 30, and 180 min. An additional in vitro study on magnesium's effect on the activity of different coagulation factors was carried out. A transient increase was seen in F1 + 2 and TAT after 30 min but without any significant difference between the placebo and magnesium period. FbDP did not change significantly between the two treatments. Increasing concentrations of magnesium dose-dependently decreased binding of activated factor X to activated factor VII (FVIIa), but the decrease was slight and probably without any significance for coagulation at the concentrations tested. No effect was observed on the activity of FVIIa or activated factor VIII. In conclusion, no significant differences were observed on markers of coagulation or fibrinolytic activity during intravenous magnesium infusion. These results indicate that the observed antithrombotic effect of magnesium is more likely to arise from the previously observed platelet inhibition.

[Ride-on rotary motor mowers--a new mechanism of injury. Home accidents]. / Bemandet rotorplaeneklipperulykke--en ny skademekanisme. Hjemmeulykker.

A hand injury caused by a ridding-on rotary motor mower is described. The injury was caused by a piece of wire caught by the rotar of the machine which projected and rotated from under the safety guard. This mechanism of injury is possible on account of the relatively large dimensions of the riding-on rotory motor mower. The user had climbed down from the machine to remove objects lying close to the motor mower and was hit on the dorsum of the left hand. He sustained severe traumatic lesions of the first and third fingers and traumatic amputation of the second finger corresponding to the distal phalynx. The authors suggest that a "dead man's grib" which acts via weight bearing on the driver's seat of the machine should be made legally compulsory in Denmark when the new safety measures for rotory motor mowers are drawn up.

[A new cause of accidents resulting from the use of air-powered tools]. / Ny skademekanisme ved brug af luftdrevet vaerktøj.

Air-powered tools are employed increasingly frequently in industry and involve new possibilities for occupational accidents. A new mechanism of trauma is described where the cause is failure of the snap connection between the tool and the air pipeline. The pipeline and the connection are hurled away from the tool with great force and can hit persons in the vicinity. During the period 1.1.1984 to 31.12.1986, 33 accidents of this type were registered with the workers' supervision authorities. 63% of these consisted to trauma to the neck, head and eyes. As prophylaxis, the present authors suggest a safety chain between the tool and the pipeline and a valve which interrupts the air supply when the pressure in the system falls.

[A non-immobilizing regimen following meniscal suturing]. / Ikke-immobiliserende regime efter menisksuturering.

Vertical lesions in the peripheral third of the meniscus were sutured in 13 patients. The patients were treated with restricted activity postoperatively instead of immobilization. The patients were kept in bed until they could lift the leg with extended knee, which they were allowed up with careful support (and support with crutches) until the sutures were removed on the loth day. After removal of the sutures, patients were permitted to bear weight with the knee extended until limited by pain and were permitted unlimited flexion of the knee. From the 21st day, rehabilitation with weight-bearing with the flexed knee was permitted until they could be discharged with normal mobility and quadriceps power after an average of 6.4 weeks. Re-rupture was demonstrated in one patient. At the time of examination after a period of observation of 25.5 months, the patients had an average score of 78 points on Lysholm's functional scale from 0-100. These results are apparently similar to the results obtained following immobilizating regimens. The authors therefore conclude that it is ethically justifiable to carry out an extensive comparative investigation of the results after immobilizing and nonimmobilizating regimens, respectively, following suture of menisci. An investigation of this type appears to be necessary.

[Corkscrew esophagus]. / "Proptraekkeresophagus".

"Corkscrew oesophagus" is characterised on the basis of two case reports and attention is drawn to thoracic pain of oesophageal origin. Corkscrew oesophagus is a radiological diagnosis and is characterised by twisted segments in the distal third of the oesophagus. The condition can sometimes be demonstrated endoscopically and it is due to a basic disturbance in the motility of the oesophagus. Painful conditions in the oesophagus are most frequently caused by gastro-oesophageal reflux or disturbances in motility and the latter is frequently complicated by reflux oesophagitis. Pain of oesophageal origin is frequently a diagnosis by exclusion and requires exclusion of ischaemic heart disease. The initial treatment should be directed to the reflux oesophagitis. The diagnosis and information about the origin of the pain and the benign course of the condition will calm the majority of the patients and remove their fear of a possible fatal heart disease.

[Consumption of psilocybin-containing hallucinogenic mushrooms by young people]. / Unges brug af hallucinogene psilocybinholdige svampe.

The aim of this questionnaire survey was to investigate the extent of hallucinogenic mushroom consumption among students from a high school in the county of Aarhus, Denmark and among students at the University of Aarhus and students from the Danish school of journalism in Aarhus, Denmark. 3% of the high school students had used psilocybine-containing mushrooms as a hallucinogen. Only 1% had experience with LSD. Of the students at the University of Aarhus, and students from the Danish school of journalism in Aarhus, 333 persons (83%) returned the anonymous questionnaire. 9% had experience with hallucinogenic psilocybine containing mushrooms while only 2% had LSD experience. The use of hallucinogenic mushrooms was surprisingly high. This suggest that mushrooms are the most commonly used hallucinogenic substance in Denmark and that the use has exceeded that of LSD. Compared to non-users mushrooms users had significant more friends with mushroom experience. Furthermore, the study shows that the intention to use mushroom is commoner in persons who have friends with HPS experience. We find that the use of mushroom takes place in minor groups known to each other. Compared to non-users, mushroom-users are significant more experienced with marijuana and other substances. Unfortunately, our data do not permit us to show whether mushroom users are more inclined to try other drugs or whether persons with a high drug experience use mushrooms as well. Further investigation on the subject is recommended.

[Examination and treatment of dyslipemia after myocardial infarction--are the goals achieved?]. / Udredning og behandling af dyslipidaemi efter akut myokardieinfarkt--opnås målene?

According to guidelines, medical treatment of dyslipidaemia in post-AMI patients should await assessment of underlying lipid disorders and the outcome of dietary treatment. The risk of patients not being treated with lipid-lowering therapy because of lack of follow-up has led to more aggressive guidelines recommending statin treatment even before discharge from hospital. In a study comprising 730 patients, we have shown that, although most patients were discharged from the coronary care unit without statin treatment, a traditional rehabilitation programme succeeded in assessing more than 95% of the patients for underlying lipid disorders, and more than 75% of patients with plasma cholesterol > or = 5.5 mmol/l received lipid-lowering therapy within the first year. Most patients were treated with statins. Statins, however, were given in smaller doses than those used in the clinical trials, and only 52% of the treated patients reached the recommended goal of plasma cholesterol lower than 5 mmol/l.

[Insect stings. A prospective study of complications and injury mechanisms]. / Insektstik. En prospektiv opgørelse af komplikationer og skademekanismer.

The aim of the study was to evaluate complications to insect stings, and to describe the circumstances in which the patients were stung. During a one year period (1.1.-31.12.1991) a total of 178 hospital and emergency room contacts due to insect stings were registered. All patients afterwards received a mailed questionnaire concerning insect stings. Nearly 3/4 of the patients were able to identify the stinging insect by use of an identification chart. One hundred and forty-five patients had mild symptoms, 33 patients had moderate symptoms and three presented severe symptoms with anaphylactic shock. Eleven percent of the patients required admission and another 21% were seen in out-patient clinics. More children than adults could after a physical examination be discharged from the hospital without treatment. More than 3/4 of the stings occurred in July, August and September and more than 3/4 were during the day and evening. We found that most of the insect stings were due to either wasps or bees and that no one stung by insects other than wasps or bees needed admission to hospital. We conclude that a major part of insect stings could be avoided by following ordinary precautions.

[Cross-sectional therapeutic programs--an example of a cooperative health care system. A review with comments]. / Tvaersektorielle behandlingsprogrammer--et eksempel på det samarbejdende sundhedsvaesen. En kommenteret oversigt.

There is no tradition for sharing the responsibility for episodes of care between the primary and secondary sectors in the Danish health care system. Concurrently with increased international experience with shared care programmes, there is also a growing interest in Denmark in cooperation between the sectors. Based on literature research, shared care programmes are presented as a method of ensuring continuity and quality in treatment of chronic diseases. Experiences in the areas of diabetes, asthma, rheumatoid arthritis, and cancer are described. It is concluded that the Danish health care system is well prepared for the implementation of shared care programmes; there are only few sources of payment in the system, and an extensive continuing medical education system ensures that general practitioners can participate in relevant education. The implementation of shared care programmes in Denmark should be followed by scientific evaluation and documentation of the quality of the treatment programmes.

[Diagnostic value of C-reactive protein in bacterial infections. Review of the literature]. / Diagnostisk vaerdi af C-reaktivt protein ved bakterielle infektioner. En litteraturoversigt.

Conflicting data for predictive values for C-reactive protein (CRP) in its ability to distinguish between viral and bacterial diseases are reviewed. Study designs regarding setting, patient-mix, severity of disease and prevalence seem to determine the magnitude of predictive values. We have calculated predictive values for patients suspected of septicaemia, meningitis, appendicitis, cholecystitis, upper- and lower respiratory disease, acute sinusitis and acute otitis media, and revealed the highest predictive values among patients suspected for severe and generalized infections. More localized diseases have lower predictive values. We emphasize the importance of a study design where the circumstances resemble the real situations in which the test is supposed to be used. This will ensure the clinical applicability of predictive values for a diagnostic test.

[Hallucinogenic psilocybine containing mushrooms. Toxins contained in Danish wild mushrooms]. / Hallucinogene psilocybinholdige svampe. Dansk vildtvoksende rusgift.

A number of the wild Danish mushrooms contain the hallucinogenic agent psilocybin which resembles LSD in many ways. The commonest of these are the "liberty cap" or "magic mushrooms" (Psilocybe semilanceata). On the basis of experience from USA and western Europa, increase in employment of this mushrooms as a hallucinogenic intoxicant may be anticipated in Denmark. The history, epidemiology, botany and pharmacology of the mushroom are reviewed. Clinical pictures and treatment are described for: 1) Acute poisoning with psilocybin-containing fungi, 2) Late sequelae of consumption of psilocybin-containing fungi and 3) Poisoning with more poisonous fungi on account of incorrect identification. General practitioners, duty roster doctors, doctors in casualty departments and in acute psychiatric departments should be aware of these problems. Intoxication with psilocybin may be confused with panic anxiety or euphoria in persons with mydriasis and other sympathomimetic symptoms. The possibility of more serious mushroom poisoning on account of incorrect identification should be borne in mind.

[Anticoagulant and thrombolytic therapy in deep venous thrombosis and pulmonary embolism]. / Antikoagulansbehandling og trombolyse ved dyb venøs trombose og lungeemboli.

During the last 10 years anticoagulant (AC) therapy and thrombolytic treatment of venous thromboembolism (VT) have been evaluated in randomized studies. Adjusted subcutaneous (s.c.) heparin and low molecular weight heparin (LMWH) are found at least as effective as intravenous (i.v.) infusion of heparin in deep venous thrombosis (DVT) without an increased bleeding risk. In pulmonary embolism (PE) randomized trials assessing the efficacy of s.c. heparin and LMWH are missing. Oral AC-treatment can be initiated from the first or second day in VT. The recommended duration is three months for medical patients, and 4 weeks seem appropriate for surgical patients that are completely mobilized and without persisting predisposing factors. Long-term efficacy of thrombolytic treatment of DVT has only been assessed in small trials showing a trend towards reduced risk of developing chronic venous insufficiency. Short-term thrombolytic treatment of DVT is evaluated in ongoing trials. In the treatment of PE short-term thrombolysis with either t-PA or urokinase is found to be as effective as long-term thrombolytic treatment with a reduced bleeding risk. Thrombolytic therapy rapidly reduces embolic mass and stabilizes haemodynamics, but mortality and long-term efficacy of thrombolysis and AC-treatment versus AC-treatment alone in PE are being assessed in ongoing studies.

[Is the randomized controlled trial overvalued as a basis for clinical decision-making? A review with comments]. / Er det randomiserede forsøg overvurderet som klinisk beslutningsgrundlag? En Kommenteret oversigt.

The randomized controlled trial (RCT) may have considerable limitations in clinical research. Lacking the possibility of blinding impairs the internal validity of the trials. The external validity is often impaired, as results of RCTs obtained in an ideal situation, may be difficult to generalize to a clinical routine situation. Pragmatic randomized trials move from ideal situations towards routine situations, and by modifying the design it is possible to reduce selection bias due to patient and physician preferences. Quasi-experimental studies have varying degrees of problems with internal validity but are necessary contributions to our knowledge of the effect of treatment in clinical routine situations. Limitations of the usefulness of RCTs as well as pragmatic and quasi-experimental studies in clinical research make it necessary to recognise that different methods complement one another. Research in development of RCTs and new methods in clinical research should be encouraged.

[Resistance to activated protein C. The most common cause of familial thrombophilia]. / Resistens mod aktiveret protein C. Den hyppigste årsag til familiaer trombofili.

Resistance to activated protein C (APC) is caused by the most prevalent single gene defect associated with thromboembolic disease so far described. The majority of cases are caused by a single point mutation in the Factor V gene, which predicts replacement of Arg506 in the APC-cleavage site with a Gln. APC resistance is found in 20-60% of patients with venous thrombosis and in 3-10% of the normal population among Caucasians. In its heterozygous state, the mutation is associated with a 5-10-fold increased risk of thrombosis. Homozygosity is associated with more severe APC resistance, and a higher risk of developing thrombosis. By the age of 33 years, 8% of normals, 20% of heterozygotes, and 40% of homozygotes have had manifestations of venous thrombosis. APC resistance has been described in 60% of women with thromboembolic complications during pregnancy and in approximately 30% of women with thromboembolic complications using oral contraceptives. Development of clinical episodes of thrombosis in patients with APC resistance is likely to occur on a multifactorial basis. Hypercoagulable states may result from multigene interactions, and prothrombotic insults in patients with an inherited predisposition may precipitate thrombotic complications. In this review we present and discuss results from the recent medical literature.

[Differences in the use of C-reactive protein analysis and erythrocyte sedimentation in general practice and hospitals. Development from 1986 to 1995]. / Forskelle i brugen af C-reaktivt protein og saenkningsreaktion i almen praksis og på sygehus. Udvikling fra 1986 til 1995.

Analysis for C-reactive protein (CRP) was introduced in the Vejle Hospital catchment area in 1987. During the next ten year period the use of CRP has increased to reach a stable level both on hospital wards, out-patient clinics and in general practice. While the use of erythrocyte sedimentation rate on wards has decreased correspondingly, this is not seen in out-patient clinics or in general practice. There are medical as well as practical reasons for this discrepancy. It is believed that the possibility of performing a CRP as a point-of-care test in the GPs office in the future will lead to a reduction in the number of analyses of erythrocyte sedimentation rate performed in general practice as well.