Functional outcome and associations with prehospital time and urban-remote disparities in trauma: A Norwegian national population-based study.

BACKGROUND: There is a lack of knowledge regarding the functional outcomes of patients after trauma. Remote areas in Norway has been associated with an increased risk of trauma-related mortality. However, it is unknown how this might influence trauma-related morbidity. The aim of this study was to assess the functional outcomes of patients in the Norwegian trauma population and the relationship between prehospital time and urban-remote disparities on functional outcome. METHODS: This registry-based study included 34,611 patients from the Norwegian Trauma Registry from 2015 - 2020. Differences in study population characteristics and functional outcomes as measured on the Glasgow Outcome Scale (GOS) at discharge were analysed. Three multinomial regression models were performed to assess the association between total prehospital time and urban-remote disparities and morbidity reported as GOS categories. RESULTS: Ninety-four per cent of trauma patients had no disability or moderate disability at discharge. Among patients with severe disability or vegetative state, 81 % had NISS > 15. Patients with fall-related injuries had the highest proportion of severe disability or vegetative state. Among children and adults, every minute increase in total prehospital time was associated with higher odds of moderate disability. Urban areas were associated with higher odds of moderate disability in all age groups, whereas remote areas were associated with higher odds of severe disability or vegetative state in elderly patients. NISS was associated with a worse functional outcome. CONCLUSIONS: The majority of trauma patients admitted to a trauma hospital in Norway were discharged with minimal change in functional outcome. Patients with severe injuries (NISS > 15) and patients with injuries from falls experienced the greatest decline in function. Every minute increase in total prehospital time was linked to an increased likelihood of moderate disability in children and adults. Furthermore, incurring injuries in urban areas was found to be associated with higher odds of moderate disability in all age groups, while remote areas were found to be associated with higher odds of severe disability or vegetative state in elderly patients.

Pain prevalence in hospitalized children: a prospective cross-sectional survey in four Danish university hospitals.

BACKGROUND: Pain management in hospitalized children is often inadequate. The prevalence and main sources of pain in Danish university hospitals is unknown. METHODS: This prospective mixed-method cross-sectional survey took place at four university hospitals in Denmark. We enrolled 570 pediatric patients who we asked to report their pain experience and its management during the previous 24 hours. For patients identified as having moderate to severe pain, patient characteristics and analgesia regimes were reviewed. RESULTS: Two hundred and thirteen children (37%) responded that they had experienced pain in the previous 24 hours. One hundred and thirty four (24%) indicated moderate to severe pain and 43% would have preferred an intervention to alleviate the pain. In children hospitalized for more than 24 hours, the prevalence of moderate/severe pain was significantly higher compared to children admitted the same day. The single most common painful procedure named by the children was needle procedures, such as blood draw and intravenous cannulation. CONCLUSION: This study reveals high pain prevalence in children across all age groups admitted to four Danish university hospitals. The majority of children in moderate to severe pain did not have a documented pain assessment, and evidence-based pharmacological and/or integrative ('non-pharmacological') measures were not systematically administered to prevent or treat pain. Thus, practice changes are needed.

FGFR3 mutations and the skin: report of a patient with a FGFR3 gene mutation, acanthosis nigricans, hypochondroplasia and hyperinsulinemia and review of the literature.

Fibroblast growth factor receptor 3 (FGFR3) gene mutations in the germline are well-known causes of skeletal syndromes. Somatic FGFR3 mutations have been found in malignant neoplasms and more recently in several cutaneous elements. We present a 14-year-old girl with mild hypochondroplasia who developed acanthosis nigricans. The report of a K650Q mutation in the FGFR3 gene in a similar case prompted us to conduct a point mutation analysis. The K650Q mutation was confirmed, but in contrast to the previous case, we additionally report findings of hyperinsulinemia. In the recent literature, an increasing number of different cutaneous elements have been found to harbor mutations of FGFR3, suggesting that FGFR3 plays a role in the pathogenesis of these elements. We review the present literature, describing studies in which FGFR3 mutations have been investigated in skin lesions: primarily seborrheic keratoses and epidermal nevi, but also other benign skin tumors and a single case of a squamous cell carcinoma. In addition, an overview of the FGFR3 point mutations in relation to each cutaneous element is given. Based on the current knowledge, it seems likely that these cutaneous lesions have a common genetic background. Our case shows that FGFR3 mutation analysis should be considered in case of the coexistence of acanthosis nigricans and a skeletal dysplasia. Testing for hyperinsulinemia is essential, also if a gene mutation is confirmed.

Increased prevalence of autoimmunity in Turner syndrome--influence of age.

Individuals with Turner syndrome (TS) are prone to develop autoimmune conditions such as coeliac disease (CD), thyroiditis and type 1 diabetes (T1DM). The objective of the present study was to examine TS of various karyotypes for autoantibodies and corresponding diseases. This was investigated in a prospective cross-sectional study of Danish TS patients (n = 107, median age 36.7 years, range: 6-60 years). A medical history was recorded and a blood sample was analysed for autoantibodies against gliadin, transglutaminase, adrenal cortex, intrinsic factor, anti-thyroid peroxidase (anti-TPO) and glutamic-acid-decarboxylase 65 (GAD-65). Autoantibodies were present in 58% (n = 61) of all patients, whereof 18% (11) had autoantibodies targeting more than one organ. Patients with autoantibodies were significantly older than those without (P = 0.001). Anti-TPO was present in 45% (48) of patients, of whom 33% (16) were hypothyroid. Overall, 18% (19) presented with CD autoantibodies, of whom 26% (five) had CD. Anti-TPO and CD autoantibodies co-existed in 9% (10). Immunoglobulin A deficiency was found in 3% (three) of patients, who all had CD autoantibodies without disease. Among four patients with anti-GAD-65 none had T1DM, but two were classified as having T2DM. One patient had adrenocortical autoantibodies but not adrenal failure. Autoantibodies against intrinsic factor were absent. Anti-GAD-65 was increased in isochromosomal karyotypes (3/23 versus 1/84, P = 0.008) with no other association found between autoantibodies and karyotype. In conclusion, TS girls and women face a high prevalence of autoimmunity and associated disease with a preponderance towards hypothyroidism and CD. Thus, health care providers dealing with this patient group should be observant and test liberally for these conditions even before clinical symptoms emerge.

Functional ecology and palaeolimnology: using cladoceran remains to reconstruct anthropogenic impact.

The field of lake palaeoecology has undergone significant changes. Powerful quantitative techniques have been developed to investigate anthropogenic impacts on lakes. Inclusion of zooplankton and benthic chydorid cladocerans has provided previously unavailable information on the historical development of planktivorous fish populations, submerged macrophytes and lake production, and has been used to document exotic species introductions, rapid genetic evolution and human disturbance of lakes. In particular, new techniques now allow a more complete evaluation of changes in past and present trophic structure to be made, and provide insights on the rapid evolutionary responses of aquatic invertebrate communities to anthropogenic perturbation of lakes.

Retention and internal loading of phosphorus in shallow, eutrophic lakes.

This paper gives a general overview of the nature and important mechanisms behind internal loading of phosphorus (P), which is a phenomenon appearing frequently in shallow, eutrophic lakes upon a reduction of the external loading. Lake water quality is therefore not improved as expected. In particular summer concentrations rise and P retention may be negative during most of the summer. The P release originates from a pool accumulated in the sediment when the external loading was high. In most lake sediments, P bound to redox-sensitive iron compounds or P fixed in more or less labile organic forms constitute major fractions--forms that are potentially mobile and eventually may be released to the lake water. The duration of the recovery period following P loading reduction depends on the loading history, but it may last for decades in lakes with a high sediment P accumulation. During the phase of recovery, both the duration and net P release rates from the sediment seem to decline progressively. Internal P loading is highly influenced by the biological structure as illustrated by lakes shifting from the turbid to the clearwater state as a result of, for example, biomanipulation. In these lakes P concentrations may be reduced to 50% of the pre-biomanipulation level and the period with negative retention during summer can thus be reduced considerably. The duration of internal loading can be reduced significantly by different restoration methods such as dredging to remove accumulated P or addition of iron or alum to elevate the sorption capacity of sediments. However, an important prerequisite for achieving long-term benefits to water quality is a sufficient reduction of the external P loading.

Deep-vein thrombosis prophylaxis in orthopedic surgery: hip surgery.

Hip replacement surgery carries a high risk of thromboembolic complications, and pharmacological prophylaxis is routinely adopted in clinical practice. Meta-analyses have indicated that low molecular weight heparins (LMWHs) are clinically superior to conventional prophylaxis with unfractionated heparin. These analyses have regarded LMWHs as one chemical entity, despite differences in their physicochemical, biological, and pharmacodynamic properties. Comparing data from trials of different LMWHs is difficult despite standardization in trial design, patient selection criteria, and efficacy assessments, as the influences of concurrent disease and variation in venogram interpretation are difficult to interpret. Furthermore, variations in bleeding assessment limit conclusions on the safety profile of different LMWHs. Two clinical trials have compared enoxaparin with tinzaparin and reviparin respectively. Efficacy equivalence was demonstrated despite differences in the anti-Xa activities of the doses given. These trials support the position of the United States Food and Drug Administration and the World Health Organization that LMWHs are distinct, noninterchangeable compounds and cannot be therapeutically substituted based upon anti-factor Xa levels. The extent of clinical experience with each LMWH is an important factor influencing clinical use.

Clinical limitations of risk assessment models.

Appropriate thromboprophylaxis in hospital patients is effective in preventing clinically important venous thromboembolic events, including deep vein thrombosis (DVT) and fatal pulmonary embolism. Due to the risk of bleeding associated with pharmacological prophylaxis and the cost of administering prophylactic drugs, the clinical benefit and cost-effectiveness of thromboprophylaxis may be optimized by providing prophylaxis only to patients at risk of thrombosis, and tailoring the intensity of prophylaxis to the level of risk. Accurate assessment of patients' thromboembolic risk is therefore highly necessary. Thromboembolic risk is influenced by numerous factors. Several risk factor indices based on clinical risk factors and laboratory variables have been proposed since the 1970s, but these have not been widely adopted due to their complexity and lack of prospective validation. The method of deriving risk data on which these indices are based is questioned, and older prognostic indices excluded recently identified risk factors, particularly molecular factors such as the clotting factor V Leiden mutation, further undermining their clinical value. A number of much simpler risk assessment models (RAMs) have now been developed which stratify patients into low-, moderate- and high-risk categories. However, no RAM currently available provides comprehensive guidance for all patient groups. Use of poorly designed RAMs may fail to identify some patients at risk, leading to omission of prophylaxis and preventable thrombotic events. Certain patient groups develop DVT despite prophylaxis. Current RAMs are not validated to identify these patients. Well-designed and well-validated RAMs, incorporated into standard practice guidelines in hospitals, should contribute to improved clinical outcomes and economic benefits of prophylaxis.

[Diet for heart patients. A questionnaire study at Danish coronary care units]. / Kost til hjertepatienter. En spørgeskemaundersøgelse på danske hjerteafdelinger.

A questionnaire survey of Danish hospitals showed that 70% of patients admitted for acute ischaemic heart disease were served the ordinary menu during their stay at the hospital. About 10% had a diabetic menu, while 20% had different kinds of lipid lowering diets. The ordinary menu contained 17 energy percent (E%) protein, 38 E% fat, and 46 E% carbohydrate. The amount of fibre was 3.1 g/MJ, the ratio of polyunsaturated to saturated fatty acids (P/S) was 0.4, and the total energy in a day's menu was 8.1 MJ. The ordinary high-fat hospital diets differ markedly from diets believed to be cardioprotective, contrast with the dietary counselling given during admission, and should be replaced by lipid lowering diets in most cases of acute ischaemic heart disease for educational and therapeutic reasons.

[Obstetric health care offered to Turkish immigrant women--a quality assessment]. / Sundhedsvaesenets omsorg for tyrkiske indvandrerkvinders graviditet og fødsel--en kvalitetsvurdering.

The object of this investigation was to make a quality-assessment of the care offered to pregnant and delivering Turkish immigrant women by the Danish health care system. The quality-assessment was made as a Medical Audit using data obtained from relevant medical records as well as from semi-structured interviews with the women. Thirteen cases were evaluated among the 65 Turkish women included in the project by having delivered at Aarhus Kommunehospital in the period between April 1 and December 15 1989. In this material no severe obstetrical deficiencies were found, but other types of deficiencies were observed. Bad communication due to insufficient use of trained interpreters and to the health personnel's lack of knowledge about cultural background often resulted in mutual misunderstandings. Most of the women were examined by many different doctors and midwives during pregnancy and delivery. It is demonstrated, that the lack of continuity was an additional strain of these women. It is concluded that the difficulties in communication are potentially dangerous, increasing the risk of delayed or missing obstetrical intervention. The insufficient communication demonstrated causes insecurity and inappropriate care.

Alternative equilibria in shallow lakes.

The turbidity of lakes is generally considered to be a smooth function of their nutrient status. However, recent results suggest that over a range of nutrient concentrations, shallow lakes can have two alternative equilibria: a clear state dominated by aquatic vegetation, and a turbid state characterized by high algal biomass. This bi-stability has important implications for the possibilities of restoring eutrophied shallow lakes. Nutrient reduction alone may have little impact on water clarity, but an ecosystem disturbance like foodweb manipulation can bring the lake back to a stable clear state. We discuss the reasons why alternative equilibria are theoretically expected in shallow lakes, review evidence from the field and evaluate recent applications of this insight in lake management.