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The primary purpose of treating chronic hepatitis C (HCV) is to prevent the development of liver fibrosis, cirrhosis, and cancer. In the last decade, direct-acting antiviral medicine (DAA) has been approved to treat children with HCV. This treatment has a higher efficacy, shorter duration, and milder side effects than the previously approved treatment. In this review, it is recommended to track down children who might be infected with HCV to enhance early treatment to prevent transmission of the virus and the possible complications., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Managing critically ill children is a rare and challenging event requiring training to ensure adequate and timely quality of care. Thus, health professionals train for pediatric emergencies in a simulated setting. Virtual reality (VR) is a promising modality for simulation, and current evidence highlights the potential of VR for simulating pediatric emergencies. However, more studies are needed to determine the aspects of VR design and implementation that support transfer of learning.

Bite wounds are common in the emergency departments in Denmark. As a result of the Covid-19 pandemic, more people are adopting pets and the number of hours spent at home with pets are increasing. This will probably result in more bite wounds and therefore, it is as important as ever for emergency doctors to be able to treat bite wounds appropriately. In this review, we summarise the most common types of bite wounds, how to make a thorough physical examination, what to focus on in the anamnesis, and how to treat bite wounds including when to suture and the indications for prophylactic antibiotics.

The COVID-19 pandemic may not only increase mortality due to the virus but also due to the indirect effects. The disease continues to ravage health and economic metrics globally, which is likely to increase maternal and under five-year child mortality in low- and middle-income countries. This review highlights key areas of concern for maternal and under five-year child mortality due to the indirect effects of the COVID-19 pandemic in low- and middle-income countries.

Acute heart failure is a common and severe condition in Danish emergency hospitals. Hypertensive pulmonary oedema, cardiogenic shock and congestive heart failure are the most common phenotypes. The aim of this review is to summarise the most recent international guidelines for acute triage and treatment of acute heart failure. Afterload is reduced with nitrates, congestion is treated with intravenous loop-diuretics, and in selected patients, cardiac output could be increased by inotropic drugs or mechanical support devices.

Snakebite envenoming is a neglected tropical disease killing more than 100,000 people every year. Reducing the mortality and morbidity of snakebite envenoming depends on the accessibility of healthcare and antivenom, but also on sufficient knowledge on correct first aid treatment. In this review, we summarise the indications for antivenom treatment and which first-aid measures have proven effective, and which methods should be avoided, since many traditional methods of first-aid treatment of snakebites have been proven to be ineffective or even harmful.

In an advanced emergency medical service all parts of the advanced life support (ALS) algorithm can be provided. This evidence-based algorithm outlines resuscitative efforts for the first 10-15 minutes after cardiac arrest, whereafter the algorithm repeats itself. Restoration of spontaneous circulation fails in most cases, but in some circumstances the patient may benefit from additional interventional approaches, in which case transport to hospital with ongoing cardiopulmonary resuscitation is indicated. This paper has summarized treatments outside the ALS algorithm, which may be beneficial, but are not supported by firm scientific evidence.

Out-of-hospital cardiac arrest is associated with high mortality and morbidity. Treatment options remain few in refractory cases, but extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly applied to improve the outcome. This article summarizes the use, experience and outcome of eCPR focussing on current knowledge of criteria for selection of relevant patients for treatment.

Survival from out-of-hospital cardiac arrest in Denmark has increased significantly since 2001, and important improvements have been made in the post-resuscitation care. The aim of this article is to summarize the most recent international guidelines for post-resuscitation care in a Danish perspective. The main aspects concern securing haemodynamic and respiratory functions and performing urgent coronary catheterization and targeted temperature management in selected patients. In prognostication a multi-modal approach should be applied.

Conducted electrical weapons (CEW) were invented in the 1970s and are now widely used by more than 16,000 military and law enforcement agencies worldwide. Recent studies have sug-gested that a causal relation of cardiac arrest in humans and utilization of CEW may exist and cardiac capture and fatal arrhythmia have been documented in animal studies. We believe, based on current knowledge, that CEW use may have caused human fatalities. Users should be aware of potential serious side effects and be able to provide basic life support.

For almost 100 years the bacille Calmette-Guérin (BCG) vaccine has been the primary prophylaxis of tuberculosis (TB). Recent studies suggest that reintroduction of the vaccine might be beneficial from a general child health perspective. Studies from West-Africa report that BCG vaccination at birth reduces child mortality and morbidity. We recently started "The Calmette Study" in Denmark to conduct a randomised clinical trial and collect firm evidence of the suggested hypothesis, that BCG vaccination at birth has beneficial unspecific effect on child health also in a high-income TB low-incidence country.

Dabigatran has been approved for prevention of thromboembolic complications in nonvalvular atrial fibrillation. We present a case of thrombosis of a mechanical prosthetic mitral valve during anticoagulation with dabigatran, switched from warfarin. The patient presented with cardiogenic shock, was treated with thrombolytic therapy and discharged with warfarin therapy. Dabigatran in patients with mechanical valve prosthesis should be avoided and echocardiography is indicated if dyspnoea develops in such patients.

Guidelines suggest that acute coronary angiography (CAG) is considered in patients resuscitated from out-of-hospital cardiac arrest with presumed cardiac aetiology. Since specialized post-resuscitation care, including therapeutic hypothermia, has proved beneficial in randomized studies, CAG should be offered to patients with a high likelihood of thrombotic coronary lesions, i.e. patients with ST-segment elevation in electrocardiogram (ECG) following resuscitation. This article suggests a triage and referral based on electronic transmission of ECG and teleconference with specialized centres in all patients.

Introduction: There are substantial differences in long-term survival of patients resuscitated from out-of-hospital cardiac arrest, and the level of care during hospitalization may be a contributing factor. The purpose of this study was to determine if a difference in long-term prognosis between hospitals could be detected in patients surviving cardiac arrest in Copenhagen., Material and Methods: The mobile emergency care unit attempted resuscitation in 1,098 patients with out-of-hospital cardiac arrest in the period 2002 to 2006, among whom return of spontaneous circulation occurred in 336 (30%) of the patients admitted to hospital. Survival was determined using the Central Population Registry through Statistics Denmark., Results: Patients admitted to a tertiary facility were younger, more frequently male, they had more commonly ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) as their initial rhythm, and they had more frequently received bystander cardiopulmonary resuscitation. Survival at 4.6 years was 41% in patients admitted to the tertiary hospital and 10% in patients admitted to other hospitals, p < 0.0001. After adjustment for other known risk factors, patients admitted to other hospitals had a hazard ratio of 1.8 for death (95% confidence interval: 1,4-2,5) compared with patients admitted to a tertiary facility., Conclusion: The survival rate after out-of-hospital cardiac arrest was significantly higher in patients admitted to a tertiary facility than among patients admitted to less specialized hospitals. Further studies are needed to identify causal factors.

Most hospital work can be seen as linked processes. Designed to examine process performance, control charts allow distinction between two types of variation. While processes that exhibit special cause variation are unstable and should be improved by eliminating special causes, processes exhibiting only common cause variation are predictable and should be improved by fundamental redesign. Control charts are also key tools to monitor such intended changes. This paper provides an overview of the most common types of control charts and the most important interpretation rules.

Induced hypothermia in comatose patients resuscitated from cardiac arrest improves survival and neurological outcome when the initial rhythm is ventricular fibrillation. Results from 26 patients treated with early prehospital cooling, continued in hospital with cold fluids and body surface cooling, are presented. Sixteen patients had no or only minor neurological defects at discharge. Thirteen of 17 patients treated for ventricular fibrillation had a good cerebral outcome at discharge. Two patients had minor complications resulting from the treatment.

With the increasing possibilities of and clinical demand for diagnostic imaging in the management of acute cardiovascular disease, the probability of uncovering complicated cases increases. These cases are often challenging to the clinician in determining the best method of treatment. We present a case of pulmonary embolism in which an intracardiac thrombus entrapped in a patent foramen ovale without penetrating it was discovered. The patient received thrombolytic therapy without complications and was discharged in good condition six days after thrombolysis.

Generally, the use of clinical databases for quality development in the hospital sector has not been satisfactory. A substantial problem attaches to the IT systems used hitherto. This article describes a number of requirements which the National Indicator Project has specified for a forthcoming second generation of clinical database system. Besides, the second generation system Clinical Performance Measurements which is used in the Copenhagen Hospital Corporation for several disease areas and for The Danish Vascular Registry is described. This experience emphasizes the need for central management of development initiatives within clinical quality databases. The management must allow for coordination, rational management and experience-based further development of IT systems for the clinical databases and integration with present and forthcoming systems including electronic patient record systems. The management should also allow for the decisive interaction between clinical quality development and medical informatics.

This review states the work which has been done in Denmark on clinical indicators and large databases containing clinical data with nationwide coverage. The aim of the work was to obtain valid and reliable information on clinical quality to be used by clinicians, leaders, and the public. Nationally we have: 1) The needed experience related to identification and development of clinical indicators and construction of databases. 2) The necessary partners (scientific societies, hospital owners, primary care sector, and health authorities) are motivated and involved in a collaborative organisation. Nationally we lack: 1) Experience with implementation and use of clinical indicators. 2) An overview of the needed investments to ensure coverage of all important diseases, continuity in patient care, and improvement of the existing databases. 3) Fully integrated information systems.

Introduction: The aim was to analyse incidence rates and to predict the future number of cases of malignant mesothelioma in Denmark., Methods: We analysed the 1912 cases of malignant mesothelioma reported to the Danish Cancer Register, 1943-1993, in order to describe the current incidence rates. The relative risks of synthetic birth cohorts were estimated by a Poisson regression model and used to predict the future number of cases in males., Results: The incidence rate increased to 1.33 per 100,000 person years in men in 1983-1987, and to 0.51 in women in 1973-1977. According to a Poisson regression model, the risk in birth cohorts in males peaked in the 1940-1944 cohort and decreased to 0.57 in the 1950-1954 cohort. The age-specific incidence rate peaked at 246 per 100,000 person years in the age group of 80-84. The future annual number of mesothelioma cases is expected to peak around 2015 with 93 cases in men born before 1955., Discussion: The fit of the model was not ideal, but with careful interpretation of the results we conclude that a further increase in the number of mesothelioma cases can be expected, and the effect of regulating the environmental exposure to asbestos cannot be expected within the next 10-15 years.

From 1990 through 1997 the working schedules for staff surgeons underwent gradual changes. The aim was to comply with patient demands to receive care from few surgeons during hospital care. To evaluate the effect, four controlled or cross sectional studies were conducted. Quality of care was assessed by surgical audit. Patient and surgeon satisfaction was examined with questionnaires and interviews. Changes in costs were evaluated by administrative data. The number of different specialists providing care was reduced by 50%, initially during inpatient care and later also during outpatient care. The patients experienced this change as very satisfying. Hospital stay was reduced, as was time used by specialists on out-of-hours duty. The quality of care did not change neither did the use of diagnostic tests. The specialists appraised the increased individual responsibility in patient care as satisfying. Initiatives should be taken to examine whether other ways of organising work for hospital employed doctors have similar effect.

In a modern health care system continuing measurement and monitoring of relevant clinical data comprise the base of documentation for the quality of care. Internationally there has been increasing focus on monitoring and measuring the quality of care using principals from clinical epidemiology, including quality monitoring using clinical indicators. Indicators can be derived with regard to structure, process and outcome. The indicators should be in a form which can be used within the individual department and for comparison between hospitals nationally and internationally. The idea of professional indicators is to be able to track developments over time, as well to be able to respond at relevant times. The work with quality indicators will support continuing work with quality development in the medical specialities as well as giving a possibility for dialogue between politicians, the management system and the medical specialities about priority of resources and the structure of the hospital system, which extend further than the simpler issues of finance, which have been dominating until now.

The impact on quality of ward care provided by surgeons within two continuity schedules was assessed by explicit and implicit audit. In one schedule one surgeon provided care and in another a staff of surgeons provided care. The study included 214 consecutive inpatients. The study demonstrated that quality of ward care was unaffected by continuity schedule. In the single surgeon continuity schedule, however, nearly twice as many discharge letters were posted within four days (p < 0.001). Likewise, twice as many contained information that the patients had been informed about the diagnosis (p < 0.05). In both continuity schedules about 20% of the patients received inadequate care. Analysis of this finding demonstrated that more patients had been subject to inadequate follow-up in the single surgeon continuity schedule, whereas more patients had been subject to inadequate postoperative observation in the staff continuity schedule. In both schedules an equal number of patients had been subject to incomplete diagnoses and inadequate medical care.

The development in incidence rates and survival in Denmark, and the rate-ratio in selected municipalities that had industries utilizing asbestos was studied in 1865 cases of malignant mesothelioma identified in the Danish Cancer Registry 1943-1992. For men a steady increase in the incidence to 1.6 per 100,000 personyears in 1992 was found, while the rate for women decreased to 0.28 per 100,000 personyears. Age-specific incidence rates were highest for the older age-groups. An unexplained difference in the distribution of pleural and peritoneal cancers was seen between men and women. The average survival was 6.9 months for men and 7.8 for women and had not changed during the period of observation. The average rate-ratio for the selected municipalities was 1.97 (95% confidence intervals: 1.73-2.24) for men and 1.35 (1.08-1.69) for women. Improvements in working conditions in terms of minimizing asbestos exposure were introduced in 1980. Considering the latency period from exposure to diagnosis of 25-30 years, the impact of this measure on the rate of incidence cannot be expected before the year 2000.

Unlabelled: In order to investigate the educational value of trainee surgeons' work, all work done by trainees at a Department of Surgery was recorded in a prospective and consecutive way for four weeks. It was recorded as fixed categories divided into intervals of 15 minutes. The work could be classified in three dimensions: Character, educational value and geography. The youngest trainees performed routine work without educational value. They had some practical jobs which could be done by other personnel. The work did not fulfil the educational claims for a trainee surgeon in phase I. The second group of trainees performed much routine work without educational value. They had no practical jobs that could have been performed by non-doctors. They had some work with educational value but not enough to fulfil the goals of a trainee surgeon in phase II., Conclusion: Doctors' clinical education could be improved by giving them work with educational value and supervision. Supervision should be performed by specialists who should also contribute to the routine work without educational value.

Nation-wide incidence rates are presented of colorectal cancer in Denmark from 1943 to 1988. In Denmark notification of malignant and related diseases is mandatory. The percentage of histologically confirmed tumours is now 95. The annual incidence rate of colon cancer in Denmark has been increasing among men and women combined from 684 cases in 1943-1947 to 2020 cases in 1988. In the same period the incidence of rectal cancer has increased from 762 cases in 1943-1947 to 1108 cases in 1988. We analyzed the effects of age, calender time, and birth cohort with multiplicative Poisson models. We did not find consistent period effects in the models. We suggest an etiologic distinction between carcinoma of the rectum, the left colon and the right colon.

Ninety-five participants in five theoretical courses on colorectal cancers were prior to the course asked to attend a multiple choice examination about colorectal cancer. All participants were under education in general surgery. Their experience in years as doctors was registered as was the time each participant had used for preparation before this course. For thirty-six of the participants the course ended with an examination and the participants had knowledge of that before they attended the course. We found a statistically significant relation between the amount of time spent in preparation and the results obtained in the multiple choice examination. There was no relation between results obtained and experience as a doctor. Participants who knew that an examination was to be held used significantly longer time for preparation and obtained a significantly better results than participants who did not attend any examination at the end of the course. It is concluded that the reading of text books extends the knowledge on colorectal cancer and that doctors during education are more eager to prepare when they know that an examination is waiting.

This retrospective study included all patients over a five-year period who underwent the Hartmann's procedure because of a malignant left-sided large bowel obstruction. Twenty-nine patients were treated with this procedure. The cumulative operative mortality was 14%, and the five-year survival was 31%. Intestinal continuity was restored in seven patients (24%). There were no anastomotic leakages. The treatment resulted in a permanent colostomy in 62% of the patients. The Hartmann's procedure can be employed as a treatment of malignant left-sided large bowel obstruction, but will cause a high frequency of permanent colostomy.

This study included patients who underwent elective curative resection of adenocarcinoma of the large bowel with primary suture of the anastomosis. The overall incidence of clinical anastomotic leakage was 5%. The incidence of anastomotic leakage was significantly higher in men than in women after low anterior resection. The three-layer anastomosis has no advantage in large bowel surgery when compared with data from other sutured anastomoses reported in the literature.

In March 1986, a questionnaire investigation was sent to 250 general practitioners chosen at random in Denmark. In this questionnaire, general practitioners were asked about their assessment of the total activity involved in letters of discharge. Out of the practitioners questioned, 188 replied to the questionnaire (75.2%). 74% of the practitioners considered that changes were necessary in discharge letters. Most dissatisfaction was expressed about late receipt of discharge letters. 34% of the practitioners found that these letters should be received 0-3 days after discharge of the patient while 61% considered that 4-7 days after discharge could be accepted. A total of 92% considered that, on an average, they received letters of discharge later than seven days after discharge of the patient. As regards the contents of the letters of discharge, 68% of the practitioners considered that these were usually satisfactory. Practitioners appreciated substantial letters with emphasis on conditions of significance for the post-hospital treatment. The most important information was considered to be: medicine on discharge, information given to the patient, reasons for possible changes in medication, information about the subsequent treatment in addition to medicine and information about patho-anatomical findings at operation or biopsy. This investigation has provided a general consumer review of the form of discharge letters, the language, content, use and time of sending.

In September 1986, a questionnaire about letters of discharge was sent to 250 physicians-in-charge i 250 clinical hospital departments in Denmark. Out of these, 214 replied to the questionnaire (85.6%). Only 110 (51%) of the physicians-in-charge stated that there was a definite time (number of days) by which the letter of discharge should be sent after the discharge of the patient. In 99 departments (46%), the letters of discharge were, on an average, sent later than the physician-in-charge found acceptable. 50% of the physician-in-charge found that the acceptable time of sending the letter of discharge after discharge of the patient was 0-3 days. 43% of the physicians-in-charge found that 4-7 days after discharge of the patient could be accepted. Formalized teaching in writing letters of discharge only took place in 24 departments (11%). Only few physicians-in-charge stated that they often or fre quently received negative or positive feed-back from general practitioners about letters of discharge. The following concrete proposals to improve the quality of letters of discharge and to shorten the time until sending are discussed: simplifying the passage from dictation of the letter to dispatch, increased formalized teaching of house officers and generally higher priority for letters of discharge.

In September 1986, a questionnaire about letters of discharge was sent to 250 house officers in 250 clinical departments in Denmark. Out of these 197 replied to the questionnaire (78%). 32% of the house officers found that an acceptable time for the general practitioner to receive the letter of discharge was 0-3 days after discharge of the patient, while 53% of the house officers found that 4-7 days time was acceptable. 23% of the house officers stated that they had now or previously received formalized teaching about how to write letters of discharge. 44% of the house officers stated that they never received criticism or advice about writing of letters of discharge from their physicians-in-charge. The house officers considered that the most important information in the letter of discharge was, in general: medication on discharge, recommended follow-up treatment apart from medicine, information about possible outpatient visits, pathological findings at operation or biopsy and information about the treatment during hospitalization. 88% of the house officers considered that the letter of discharge was a good form of communication. 29% of the house officers considered that alterations of the work in toto of the letters of discharge were necessary and remarked that this was particularly important as regards early dispatch of letters of discharge to general practitioners. A description of the function of letters of discharge as seen by house officers is attempted in this investigation.

During a period of 17 years, 135 patients with acute left-sided obstructive cancer of the colon were admitted to two hospitals in the County of Copenhagen. Primary decompression by means of coecostomy was performed. The plan was to perform resection of the tumour after some weeks and colocolic anastomosis and closure of the coecostomy either spontaneously or operatively after some months. The total mortality was 24%. A total of 84 patients (62%) completed the planned therapeutic course, 21 without complications. Eighteen patients survived with permanent coecostomies. The mortality in this material was similar to those in materials where other therapeutic regimes were employed. The prolonged therapeutic programme and considerable morbidity thus do not result in reduction in the mortality. The authors cannot therefore recommend primary decompressive coecostomy. This method can only be recommended as an emergency measure under local anaesthesia for patients in such poor general condition that other forms of treatment are not possible.