Danish medical journal
-
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.
-
Danish medical journal · Apr 2015
Comparative StudyDiagnosis and treatment of unexplained anemia with iron deficiency without overt bleeding.
A general overview is given of the causes of anemia with iron deficiency as well as the pathogenesis of anemia and the para-clinical diagnosis of anemia. Anemia with iron deficiency but without overt GI bleeding is associated with a risk of malignant disease of the gastrointestinal tract; upper gastrointestinal cancer is 1/7 as common as colon cancer. Benign gastrointestinal causes of anemia are iron malabsorption (atrophic gastritis, celiac disease, chronic inflammation, and bariatric surgery) and chronic blood loss due to gastrointestinal ulcerations. ⋯ Oral treatment with a 100-200 mg daily dose of elemental iron is recommended (lower dose if side effects), but 3-6 months of oral iron therapy is often required to achieve therapeutic goals. Intravenous iron therapy is used if oral treatment lacks efficacy or causes side effects or in the presence of intestinal malabsorption or prolonged inflammation. Three algorithms are given for the following conditions: a) the paraclinical diagnosis of anemia with iron deficiency; b) the diagnostic work-up for unexplained anemia with iron deficiency without overt bleeding; and c) how to proceed after negative bidirectional endoscopy of the gastrointestinal tract.
-
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.
-
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.
-
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.