Danish medical journal
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Danish medical journal · Apr 2015
Review Meta AnalysisThe role of fibrinogen and haemostatic assessment in postpartum haemorrhage: preparations for a randomised controlled trial.
Pregnancy is a state of hypercoagulobility that might be an evolutionary way of protecting parturients from exsanguination following child birth. Observational studies suggest an association between a low level of fibrinogen (coagulation factor I) at the start of postpartum haemorrhage (PPH) and subsequent severity of bleeding. Fibrinogen concentrate may be prescribed to correct acquired hypofibrinogenaemia, but evidence is lacking regarding the treatment efficacy. ⋯ Paper IV includes recommendations of the European Society of Anaesthesiology regarding the use of fibrinogen concentrate in PPH, and is based on very weak (GRADE 2) evidence and low confidence in estimates of effect (GRADE C). Paper V describes the protocol for a RCT of early fibrinogen supplementation in women with severe postpartum haemorrhage. Several practical, ethical and trial management challenges need to be addressed when conducting independent clinical research involving parturients with severe bleeding, placebo-controlled and blinded administration of a drug in a multicenter set-up with enrolments during the entire day and with many personnel involved.
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Danish medical journal · Apr 2015
ReviewMechanisms of improved glycaemic control after Roux-en-Y gastric bypass.
Roux-en-Y gastric bypass (RYGB) surgery induces weight loss of 20-30% that is maintained for 20 years. In patients with type 2 diabetes, the glucose-lowering effect of RYGB is superior to conventional antidiabetic therapy and often occurs within days after surgery. The aim of the thesis was to investigate the physiological mechanisms responsible for improved glycaemic control with special focus on the early postoperative period. ⋯ Changes in alpha-cell function did not seem to contribute substantially to the improved glycaemic control after RYGB, as glucagon secretion increased paradoxically after oral glucose, and suppression of glucagon in response to iv infusions of glucose, GIP, GLP-1 and insulin was largely unchanged postoperatively. In conclusion, improved glycaemic control after Roux-en-Y gastric bypass can be explained by early enhancements of hepatic insulin sensitivity and later improvements in peripheral insulin sensitivity in combination with increased postprandial insulin secretion linked to exaggerated postprandial GLP-1 secretion. Surgical changes in gut anatomy are likely to explain the increased GLP-1 secretion and hence the increased postprandial insulin secretion, whereas calorie restriction and subsequent weight loss may be the major cause of improved insulin sensitivity.
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Danish medical journal · Apr 2015
ReviewOxidative and inflammatory biomarkers of ischemia and reperfusion injuries.
Ischemia-reperfusion injuries occur when the blood supply to an organ or tissue is temporarily cut-off and then restored. Even though the restoration of blood flow is absolutely essential in preventing tissue death, the reperfusion of oxygenated blood to the oxygen-deprived areas may in itself augment the tissue damage in excess of that produced by the ischemia alone. The process of ischemia-reperfusion is multifactorial and there are several mechanisms involved in the pathogenesis. ⋯ We are currently still awaiting the results of the IMPACT-trial - a randomized, placebo-controlled, clinical trial exploring the effect of intracoronary and systemic melatonin given to patients suffering from AMI and undergoing primary percutaneous coronary intervention (pPCI) (paper 5). Though pPCI is undisputedly life-saving, it holds a built-in consequence of aggravating the ischemic injury, paradoxically due to the reperfusion. The optimization of existing treatments and the exploring of new suitable interventions, such as melatonin, for minimizing the ischemia-reperfusion injuries is therefore of great interest.
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Danish medical journal · Apr 2015
ReviewMigration and health: exploring the role of migrant status through register-based studies.
This thesis aims to explore migrant status as a determinant in register-based studies on migrant health. It is based on eight studies that investigate the following three main issues: 1) What is the importance of migrant status for morbidity patterns among migrants compared with Native Danes? 2) Do migrant status and ethnicity affect clinical indicators of access among migrants compared with native Danes? 3) What is the importance of migrant status for mortality patterns among migrants compared with Native Danes? The thesis builds on a register-based historical prospective cohort design. Through Statistics Denmark, all refugees (n = 29,174) and family reunification immigrants (n = 33,287) who received residence permits in Denmark from 1 January 1993 to 31 December 1999 were included and matched 4:1 on age and sex with Native Danes. ⋯ It also demonstrates the role of migrant status as a useful variable in migrant studies in addition to ethnicity. Across all three sub-themes, inequalities in morbidity patterns were sometimes in favour of migrants and sometimes in favour of native Danes. Finally, inequalities in health were more pronounced for the refugee group, which was consistently more at risk compared with native Danes or which apparently benefited less from the protective factors of being a migrant compared with family reunification immigrants.
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Danish medical journal · Apr 2015
ReviewDanish national sedation strategy. Targeted therapy of discomfort associated with critical illness. Danish Society of Intensive Care Medicine (DSIT) and the Danish Society of Anesthesiology and Intensive Care Medicine (DASAIM).
Sedation of critically ill patients undergoing mechanical ventilation should be minimized or completely avoided. Only in selected situations is sedation indicated as first line therapy (increased intracranial pressure or therapeutic hypothermia). ⋯ If sedation is used a validated sedation scale is recommended. On a daily basis sedation should be interrupted and only restarted after a thorough search for reversible causes of discomfort and stress.