A nationwide structure for valid long-term oxygen therapy: 29-year prospective data in Sweden.

BACKGROUND: Long-term oxygen therapy (LTOT) improves prognosis in COPD with severe hypoxemia. However, adherence to criteria for eligibility and quality of LTOT is often insufficient and varies between countries. The aim of this study was to evaluate a national structure for prescription and management of LTOT over three decades in Sweden. METHODS: The study was a prospective, population-based study of 23,909 patients on LTOT from 1987 to 2015 in the Swedish National Register of Respiratory Failure (Swedevox). We assessed the prevalence, incidence, and structure of LTOT; completeness of registration in Swedevox; and validity of prescription and management of LTOT in Sweden according to seven published quality indicators. RESULTS: LTOT was prescribed by 48 respiratory or medicine units and managed mainly by specialized oxygen nurses. Swedevox had a stable completeness of 85% of patients starting LTOT since 1987. The national incidence of LTOT increased from 3.9 to 14.7/100,000 inhabitants over the time period. In 2015, 2,596 patients had ongoing therapeutic LTOT in the registry, a national prevalence of 31.6/100,000. Adherence to prescription recommendations and fulfillment of quality criteria was stable or improved over time. Of patients starting LTOT in 2015, 88% had severe hypoxemia (partial pressure of arterial oxygen [PaO2] <7.4 kPa) and 97% had any degree of hypoxemia (PaO2 <8.0 kPa); 98% were prescribed oxygen ≥15 hours/day or more; 76% had both stationary and mobile oxygen equipment; 75% had a mean PaO2 >8.0 kPa breathing oxygen; and 98% were non-smokers. CONCLUSION: We present a structure for prescription, management, and follow-up of LTOT. The national registry effectively monitored adherence to prescription recommendations and most likely contributed to improved quality of care.

Impact of preoperative serum albumin on 30-day mortality following surgery for colorectal cancer: a population-based cohort study.

OBJECTIVE: Surgery is the only potentially curable treatment for colorectal cancer (CRC), but it is hampered by high mortality. Human serum albumin (HSA) below 35 g/L is associated with poor overall prognosis in patients with CRC, but evidence regarding the impact on postoperative mortality is sparse. METHODS: We performed a population-based cohort study including patients undergoing CRC surgery in North and Central Denmark (1997-2011). We categorised patients according to HSA concentration measured 1-30 days prior to surgery date. We used the Kaplan-Meier method to compute 30-day mortality and Cox regression model to compute HRs as measures of the relative risk of death, controlling for potential confounders. We further stratified patients by preoperative conditions, including cancer stage, comorbidity level, and C reactive protein concentration. RESULTS: Of the 9339 patients undergoing first-time CRC surgery with preoperative HSA measurement, 26.4% (n=2464) had HSA below 35 g/L. 30-day mortality increased from 4.9% among patients with HSA 36-40 g/L to 26.9% among patients with HSA equal to or below 25 g/L, compared with 2.0% among patients with HSA above 40 g/L. The corresponding adjusted HRs increased from 1.75 (95% CI 1.25 to 2.45) among patients with HSA 36-40 g/L to 7.59 (95% CI 4.95 to 11.64) among patients with HSA equal to or below 25 g/L, compared with patients with HSA above 40 g/L. The negative impact associated with a decrement of HSA was found in all subgroups. CONCLUSIONS: A decrement in preoperative HSA concentration was associated with substantial concentration-dependent increased 30-day mortality following CRC surgery.

Coexisting liver disease is associated with increased mortality after surgery for diverticular disease.

BACKGROUND: Coexistence of liver disease in patients undergoing surgery for diverticular disease (DD) may increase the risk of postoperative complications, but the evidence is limited. AIM: To investigate the impact of liver disease on mortality and reoperation rates following surgery for DD. METHODS: We performed a cohort study based on medical databases of all patients undergoing surgery for DD in Denmark during 1977-2011, categorizing them into three cohorts according to history of liver disease: patients with non-cirrhotic liver disease, those with liver cirrhosis, and those without liver disease (comparison cohort). Using the Kaplan-Meier method, we computed mortality in each cohort for 0-30, 31-60, and 61-90 days following surgery for DD. We used a Cox regression model to compute hazard ratios as measures of the relative risk (RR) of death, controlling for potential confounders, including other comorbidities. In addition, we assessed the reoperation rate within 30 days of initial surgery. RESULTS: Of 14,408 patients undergoing surgery for DD, 233 (1.6 %) had non-cirrhotic liver disease and 91 (0.6 %) had liver cirrhosis. Thirty-day mortality was 9.9 % in patients without liver disease and 14.6 % in patients with non-cirrhotic liver disease [adjusted RR = 1.64 (95 % confidence interval [CI] 1.16-2.31)]. Among patients with liver cirrhosis, mortality was 24.2 % [adjusted RR = 2.70 (95 % CI 1.73-4.22)]. Liver cirrhosis had an impact on mortality up to 60 days after surgery for DD. The reoperation rate was approximately 10 % in each cohort. CONCLUSION: Preexisting liver disease has a major impact on postoperative mortality following surgery for DD.

Long-term mortality and recurrence after colorectal cancer surgery with preoperative stenting: a Danish nationwide cohort study.

BACKGROUND AND STUDY AIMS: Self-expanding metal stents (SEMS) used as a bridge to surgery for obstructive colorectal cancer (CRC) have fallen under suspicion for inducing tumor dissemination, and thereby increasing recurrence risk and long-term mortality. The aim of this study was to compare overall mortality and CRC recurrence in patients receiving preoperative SEMS vs. patients undergoing urgent resection. PATIENTS AND METHODS: This was a Danish, nationwide, population-based cohort study (2005 - 2010). For patients with CRC who survived the first 30 days after resection, the long-term survival in terms of mortality rate ratios was assessed using Cox regression with adjustment for important covariates. For patients with Dukes' A - C disease only, recurrence risk was similarly assessed using incidence rate ratios. RESULTS: The 5-year survival was 49 % among 581 patients with preoperative SEMS and 40 % among 3333 patients undergoing urgent resection, corresponding to an adjusted mortality rate ratio of 0.98 (95 % confidence interval [CI] 0.90 to 1.07). For patients with Dukes' stage A - C disease, the 5-year recurrence risk was 39 % among 286 patients after preoperative SEMS and 30 % among 1627 patients after urgent resection, corresponding to an adjusted incidence rate ratio of 1.12 (95 %CI 0.99 to 1.28). CONCLUSIONS: Long-term mortality associated with the use of SEMS as a bridge to surgery was comparable to that of urgent resection. SEMS use may be associated with an increased CRC recurrence risk.

Validity of the Danish National Registry of Patients for chemotherapy reporting among colorectal cancer patients is high.

BACKGROUND: The Danish National Registry of Patients (DNRP) is a potentially valuable resource for monitoring national trends in the use of chemotherapy and evaluating the benefits and harms of alternative treatments among colorectal cancer (CRC) patients in Denmark. However, the validity of chemotherapy reporting in the DNRP is unknown. In this study, we evaluated the validity of the DNRP for identifying the receipt of chemotherapy and specific treatments, and the timing and number of treatments among CRC patients, using medical records and pharmacy data as the reference standard. METHODS: We selected a random sample of CRC patients with lymph node involvement who were diagnosed at Aarhus University Hospital (n = 25) or Aalborg University Hospital (n = 25) from 2009 to 2010. Administration dates, specific treatments, and number of treatment courses were abstracted for the 180 days post diagnosis from the DNRP, medical records, and pharmacy production databases. The prevalence of chemotherapy, timing of first administration, and number of courses were described. DNRP data were compared with the reference standard for each hospital, and the kappa, sensitivity, specificity, positive and negative predictive values, and 95% confidence intervals were calculated for the receipt of any chemotherapy and specific treatments. RESULTS: The prevalence of chemotherapy was 72% and 68% among CRC patients treated in Aarhus and Aalborg, respectively, with >90% of patients without distant metastasis receiving treatment within 90 days from diagnosis. Patients received on average 4.6 and 4.7 treatment courses in Aarhus and Aalborg, respectively. Kappa, sensitivity, and specificity of chemotherapy reporting in the DNRP was high (≥0.88), but the sensitivity of individual chemotherapies varied by hospital. CONCLUSION: The validity of chemotherapy reporting in the DNRP was high, although some variation by hospital exists. The DNRP represents a population-based nationwide resource that can be used to provide timely and accurate evaluations of chemotherapy use among CRC patients in Denmark.

Liver disease and 30-day mortality after colorectal cancer surgery: a Danish population-based cohort study.

BACKGROUND: Colorectal cancer (CRC) is common, with surgery as the main curative treatment. The prevalence of chronic liver disease has increased, but knowledge is limited on postoperative mortality in patients with liver disease who undergo CRC surgery. Hence, we examined 30-day mortality after CRC surgery in patients with liver disease compared to those without liver disease. METHODS: We used medical databases to conduct a nationwide cohort study of all patients undergoing CRC surgery in Denmark from 1996 through 2009. We further identified patients diagnosed with any liver disease before CRC surgery and categorized them into two cohorts: patients with non-cirrhotic liver disease and patients with liver cirrhosis. Patients without liver disease were defined as the comparison cohort. Using the Kaplan-Meier method, we computed 30-day mortality after CRC surgery in each cohort. We used a Cox regression model to compute hazard ratios as measures of the relative risk (RR) of death, controlling for potential confounders including comorbidities. In order to examine the impact of liver disease in different subgroups, we stratified patients by gender, age, cancer stage, cancer site, timing of admission, type of surgery, comorbidity level, and non-hepatic alcohol-related disease. RESULTS: Overall, 39,840 patients underwent CRC surgery: 369 (0.9%) had non-cirrhotic liver disease and 158 (0.4%) had liver cirrhosis. Thirty-day mortality after CRC surgery was 8.7% in patients without liver disease and 13.3% in patients with non-cirrhotic liver disease (adjusted RR of 1.49 95% confidence interval (CI): 1.12-1.98). Among patients with liver cirrhosis, mortality was 24.1%, corresponding to an adjusted RR of 2.59 (95% CI: 1.86-3.61). The negative impact of liver disease on postoperative mortality was found in all subgroups. CONCLUSIONS: Pre-existing liver disease was associated with a markedly increased 30-day mortality following CRC surgery.

Effects of 17ß-estradiol on galanin(1-29)- and galanin(1-16)-like immunoreactivities.

There are reasons to believe that the galanin neuropeptide family could include more than the two hitherto known members (galanin(1-29) and galanin-like peptide), such as the existence of at least three galanin receptors and the fact that synthetic short-chain homologues have effects and binding sites that are distinct from those of galanin(1-29). The current study uses a radioimmunoassay based on a polyclonal rabbit antiserum raised against galanin(1-16) to study the concentrations of galanin(1-16) like immunoreactivity (LI) in the various parts of the brain and gut of ovariectomized female rats, and investigates the effects of different concentrations of estradiol on these concentrations in relation to galanin(1-29)-LI. Galanin(1-29) concentrations were increased by 17ß-estradiol administration in almost all examined tissues whereas galanin(1-16)-LI was increased by 17ß-estradiol treatment in most of the gut, but only in the pituitary of the brain. Furthermore, the relation between galanin(1-29)-LI and galanin(1-16)-LI varied substantially from tissue to tissue. The main hypothesis, that galanin(1-16)-LI would be affected by 17ß-estradiol in brain and/or gut, was confirmed in addition to the secondary hypothesis, stating that the pattern of galanin(1-16)-LI changes would differ from that of galanin(1-29). The study indicates that galanin(1-16)-LI is estrogen-responsive but that its concentrations are regulated differently from that of galanin(1-29). This is strongly indicative of a biological relevance of this potentially new member of the galanin neuropeptide family.

The Danish Centre for Strategic Research in Type 2 Diabetes (DD2) study: Collection of baseline data from the first 580 patients.

This paper provides an overview of the baseline data collected in the nationwide Danish Centre for Strategic Research in Type 2 Diabetes (DD2) project. The paper presents descriptive data from the first 580 patients enrolled in the DD2. The DD2 database will contain detailed interview data, clinical examination data, and urine and blood samples from up to 10,000 patients newly diagnosed with type 2 diabetes each year, collected from general practitioners and hospital outpatient clinics in all of Denmark. Of the first DD2 patients enrolled, blood and urine samples have been obtained from 97%. The median age of the first 580 patients was 59 years and 322 (56%) were men. Median weight gain from age 20 to maximum lifetime weight was 29 kg for men and 31 kg for women, and 364 patients (63%) did not currently participate in regular sports activities. Two hundred and ninety two patients (50%) had a known family history of diabetes. Two hundred fifty (43%) of the 580 DD2 patients have also been enrolled in the Danish Diabetes Database for Adults from which additional clinical data can be obtained. Among these 250 patients (154 of whom were men, 96 women), 75 (49%) men were currently obese, and 63 (41%) were overweight, whereas 62 (65%) women were obese, and another 21 (22%) were overweight. Twenty-nine patients (12%) received insulin, 164 patients (66%) received oral antidiabetics only, and 57 (23%) received no antidiabetic treatment. Glycemic regulation was modest (the glycosylated hemoglobin A of 46% was ≥7.5%). Two thirds of the patients received antihypertensive and hypolipidemic treatment. Self-reported daily tobacco smoking (23%) and alcohol overuse (6%) seemed comparable to occurrence in the general Danish population. One quarter of the patients with newly diagnosed diabetes had a history of hospital-diagnosed comorbidity at baseline as included in the Charlson comorbidity index, in particular prior myocardial infarction (5%), cerebrovascular disease (5%), peripheral vascular disease (4%), chronic pulmonary disease (6%), and previous solid cancer (6%). In the future, the DD2 database represents a valuable source for outcome studies in type 2 diabetes.

[Organisation of basic training in laparoscopic surgery]. / Organisering af basal uddannelse i laparoskopisk kirurgi.

INTRODUCTION: Training, development and implementation of minimally invasive surgery is resource-demanding. The new Danish specialist training programme combined with shorter employment periods and working hours have increased the need for a more efficient education, training and certification of surgery, gynaecology and urology trainees. MATERIAL AND METHODS: A total of 106 trainees who were non-specialised doctors from a region in Denmark underwent theoretical as well as practical specialised training in laparoscopy in the period 2006-2008. The training had several modules of which the two first are described. The training and evaluation methods used were objective, structured clinical examination (OSCE-test) and objective skill assessments tests (OSATS-test). RESULTS: Among the 108 trainees, a total of 80 physicians passed. On module 1, the distribution of participants with regards to speciality was: surgery 47 physicians, urology 14 physicians and gynaecology 45 physicians. Six physicians were not certified. We have registered OSATS-scores for 64 participants with a median score of 3.0 (range 1-4.4). To pass, the multiple choice test participants needed to answer 66% of the questions correctly. Below this level were 20 participants out of 57 (35%) on module 1 and 32 out of 60 (53%) on module 2. CONCLUSION: Thanks to political attention and sufficient financing a centre without physical premises has been established. It has been possible to offer training to young surgeons during their first year with both benchmark training and live operations in animal models. The concept may also be used by the trainee as guidance when making education and career choices.

Appetitive and aversive classical conditioning of female sexual response.

INTRODUCTION: There is only limited evidence for appetitive classical conditioning of female sexual response, and to date modulation of female sexual response by aversive conditioning has not been studied. AIM: The aim of this article is to study appetitive and aversive classical conditioning of sexual responses in women. MAIN OUTCOME MEASURES: Vaginal pulse amplitude was assessed by vaginal photoplethysmography and ratings of affective value were obtained. METHOD: Two differential conditioning experiments were conducted. In Experiment 1, on appetitive conditioning, neutral pictures served as conditional stimuli (CSs) and genital vibrotactile stimulation as the unconditional stimulus (US). In Experiment 2, on aversive conditioning, erotic pictures served as CSs and a pain stimulus as US. In both experiments, only one CS (the CS+) was followed by the US during the acquisition phase. Conditioned responses were assessed during the extinction phase. RESULTS: In Experiment 1, during the extinction phase, as expected vaginal pulse amplitude was higher in response to the CS+ than during the CS-. Also, the CS+ was rated as marginally more positive than the CS-. In Experiment 2, during the extinction phase, as expected vaginal pulse amplitude was lower in response to the CS+ than during the CS-, and the CS+ was rated as more negative than the CS-. CONCLUSIONS: The results provide evidence for appetitive classical conditioning of sexual response in women, and are the first to show attenuation of sexual response in women by aversive conditioning.

Clinical practice and evidence in endoscopic treatment of bleeding peptic gastroduodenal ulcer.

OBJECTIVE: To investigate treatment practice in non-variceal upper gastrointestinal bleeding (NVUGIB) caused by gastroduodenal ulcer and how it adheres to the best evidence as documented in randomized studies and meta-analyses. MATERIAL AND METHODS: The literature was surveyed to identify appropriate practices, and a structured multiple choice questionnaire developed and mailed to all departments in Denmark treating UGIB. RESULTS: All 42 departments responded. All had therapeutic gastroscopes and equipment necessary for endoscopic haemostasis; 90% of departments had written guidelines. Adjuvant pharmacologic treatment included tranexamic acid in 38%. Proton-pump inhibitors (PPIs) were used by all departments, with 29% starting prior to endoscopic treatment. Eight departments (19%) used continuous PPI infusion, three of them starting with a bolus dose. In 50% of departments an anaesthesiologist was always present regardless of whether endotracheal intubation (routinely used by 10%) was used or not. Ten percent did not treat Forrest IIa and IIb ulcers, while IIc ulcers were treated by 36%. In 10% of departments clots were never removed, while in 2/3 attempts were made to remove resistant clots by mechanic means. Seven departments (17%) used monotherapy with epinephrine, while 59% always used dual therapy; 19% injected less than 10 ml. In rebleeding, 92% attempted endoscopic treatment before surgery, and used epinephrine in 79% of cases, while the remainder used epinephrine or polidocanol at the discretion of the endoscopist. Two out of three departments used high-dependency or intensive-care units for surveillance. Seventeen percent applied scheduled second-look gastroscopy. CONCLUSIONS: Practice is variable, even in areas with established evidence based on randomized controlled studies, such as dosage and way of administration and duration of PPI treatment, injection treatment used as monotherapy and the volume used, including ulcers with clots for treatment, and the use of scheduled second-look endoscopy. Since the rebleeding rate has remained unchanged for decades, and rebleeding implies increased surgery and mortality rates, appropriate practices must be promoted in order to improve results. Development and implementation of national guidelines may facilitate the process.

[Palliative cancer care is an important part of urology. A study of the last year of life of patients who died because of urologic cancer]. / Palliativ cancervård är en betydande del av urologin. Studie av det sista levnadsåret för patienter som dog av urologisk cancer.

A total of 330 in-patient episodes at the urology ward, with a mean duration of 9.8 days, were registered in a study of 100 patients who died from urological cancer. Twelve patients spent more than two months of their last year of life at the urology ward. As many as 82% of the admittances were on an emergency basis. A total of 101 operations were performed on 84 patients; 47 patients received palliative radiotherapy. This patient category needs a great deal of palliative care--at short notice--in order to get an optimal quality of life. Although many symptoms could have been alleviated outside hospital, the majority of patients needed specialised urological hospital care during their last year of life.