Pharmacological approach to acute pancreatitis

The aim of the present review is to summarize the current knowledge regarding pharmacological prevention and treatment of acute pancreatitis （AP） based on experimental animal models and clinical trials. Somatostatin （SS） and octreotide inhibit the exocrine production of pancreatic enzymes and may be useful as prophylaxis against Post Endoscopic retrograde cholangiopancreatography Pancreatitis （PEP）. The protease inhibitor Gabexate mesilate （GM） is used routinely as treatment to AP in some countries, but randomized clinical trials and a meta-analysis do not support this practice. Nitroglycerin （NGL） is a nitrogen oxide （NO） donor, which relaxes the sphincter of Oddi. Studies show conflicting results when applied prior to ERCP and a large multicenter randomized study is warranted. Steroids administered as prophylaxis against PEP has been validated without effect in several randomized trials. The non-steroidal anti-inflammatory drugs （NSAID） indomethacin and diclofenac have in randomized studies showed potential as prophylaxis against PEP. Interleukin 10 （IL-10） is a cytokine with anti-inflammatory properties but two trials testing IL-10 as prophylaxis to PEP have returned conflicting results. Antibodies against tumor necrosis factor-alpha （TNF-α） have a potential as rescue therapy but no clinical trials are currently being conducted. The antibiotics beta- lactams and quinolones reduce mortality when necrosis is present in pancreas and may also reduce incidence of infected necrosis. Evidence based pharmacological treatment of AP is limited and studies on the effect of potent anti-inflammatory drugs are warranted.     

Long-term follow-up in patients treated by stent implantation for post-ablation pulmonary vein stenosis

Purpose

Symptomatic severe pulmonary vein stenosis (PVS) after catheter ablation of atrial fibrillation (AF) is a rare but well-recognized complication. Treatment options include pulmonary vein angioplasty with or without drug eluting balloons or angioplasty with stent implantation. The treatment of choice is unclear. In our center, pulmonary vein stenting is the treatment of choice for significantly stenotic veins. We present the long-term clinical outcome of 9 patients treated with stent implantation.

Methods

Between 2001 and 2015, 3048 patients with AF were treated with catheter ablation at our institution, of which 9 developed symptomatic PVS. A total of 11 PVS were treated. Pre-procedural imaging (CT, MR, transesophageal echocardiography, angiography) was performed in all patients.

Results

Mean time from ablation to stenting was 18 months. Three patients had recurrent pneumonia and the remaining reduced functional capacity (NYHA 2). All patients were in functional capacity NYHA 1 (p?<?0.05) after a mean follow-up of 64 (18–132) months. Three patients still had paroxysmal AF, of which two have undergone repeated ablation.

Conclusions

Symptomatic PVS after AF ablation can be successfully treated by stent implantation with durable results and good clinical outcome. AF ablation is still a feasible option after stent deployment.

     

Space perception,movement, and insight: attuning to the space of everyday life after major weight loss

Physiotherapists are well placed to help people adjust and engage meaningfully with the world following major weight loss. Recent research indicates that the body size a patient has lived with for years can continue to affect movement and perception even after largescale weight loss. This article explores this discrepancy in depth from the perspective of phenomenology and space perception and through the concepts of body image, body schema, and affordances. It draws on an empirical example in which a nautical engineer described his lived experience of returning to work following bariatric surgery and the discrepancies he experienced while adjusting to his new situation, particularly when moving his smaller body around the ship’s engine room, previously inaccessible to him. Analysis of this empirical example suggests that transitions in weight and size following bariatric surgery are both highly explicit in awareness (i.e., body image) and outside awareness (i.e., body schema). Major weight loss can open up new affordances and possibilities of being in the world, but only after adjustments in body image and body schema. The article suggests ways in which such insights can contribute to physiotherapists’ clinical development and practice when working with patients undergoing major weight loss.     

FACTORS ASSOCIATED WITH MET AND UNMET REHABILITATION NEEDS AFTER STROKE: A MULTICENTRE COHORT STUDY IN DENMARK AND NORWAY

ObjectivesTo examine patient-reported needs for care and rehabilitation in a cohort following different subacute pathways of rehabilitation, and to explore factors underpinning met and unmet needs.DesignObservational multicentre cohort study.Patients and methodsA total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered questions from the Norwegian Stroke Registry about perceived met, unmet or lack of need for help and training during the first 3 months post stroke. The term “training” in this context was used for all rehabilitative therapy offered by physiotherapists, occupational or speech therapists. The term “help” was used for care and support in daily activities provided by nurses or health assistants.ResultsNeed for training: 15% reported unmet need, 52% reported met need, and 33% reported no need. Need for help: 10% reported unmet need, 58% reported met, and 31% reported no need. Participants from both Norway and Denmark had similar patterns of unmet/met need for help or training. Unmet need for training was associated with lower functioning, (odds ratio (OR) = 0.32, p < 0.05) and more anxiety (OR = 0.36, p < 0.05). Patients reporting unmet needs for help more often lived alone (OR = 0.40, p < 0.05) and were more often depressed (OR = 0.31, p < 0.05).ConclusionSimilar levels of met and unmet needs for training and help at 3 months after stroke were reported despite differences in the organization of the rehabilitation services. Functioning and psychological factors were associated with unmet rehabilitation needs.LAY ABSTRACTThe aim of this study was to examine patient-reported needs for care and rehabilitation among selected patients with stroke in Norway and Denmark. A total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered the following 2 questions from the Norwegian Stroke Registry: Have you received enough help after the stroke? Have you received as much training as you wanted after the stroke? The term “training” in this context was used for all rehabilitative therapy offered by physio-, occupational or speech therapists. The term «help» was used for care and support in daily activities provided by nurses or health assistants. Levels of anxiety and depression were investigated. With regard to training needs, 15% of all participants reported unmet needs, 52% reported that their needs had been met, and 33% reported that they had no need for training. Regarding the need for help, 10%, 58% and 31% reported unmet needs, that needs had been met, and that they had no need for care, respectively. Participants in the 2 countries had similar patterns of unmet/met needs for help or training. Unmet need for training was associated with low function and anxiety. Patients reporting an unmet need for help more often lived alone and were more often depressed. There was no difference in met or unmet needs between Norwegian and Danish participants.Different rehabilitative follow-up after stroke did not affect levels of met and unmet rehabilitation needs. Health services should pay special attention to patients at risk, including those who are anxious or depressed, live alone or have functional deficits after stroke.Key words: stroke, rehabilitation, unmet needs, rehabilitation pathways

Stroke is a major cause of death, with an increasing number of patients affected worldwide (1). Stroke survivors often have varying degrees of physical, psychosocial and cognitive disabilities, which may substantially affect their functional ability in daily and working life (2). Treatment offered by specialized stroke units (3), inpatient multidisciplinary rehabilitation teams (4) and community-based rehabilitation services adapted to patients’ home environment (5) are key elements to successful rehabilitation. At all intervention levels, the identification of patients’ individual needs is crucial for the optimization of rehabilitation outcomes. The definition of a need is, however, not unambiguous (6). A pragmatic approach is to adopt the most commonly used definition of healthcare needs and define rehabilitation needs as the needs that can be fulfilled by rehabilitation interventions and services (7). From the patient’s perspective, a need represents the perception of a situation in which help or support is desired. If adequate help is not offered, the provision of services does not fit the needs, gaps occur and needs become unmet (8).A perceived need for therapy, comprehensive care, pscyhological support or information are examples of commonly reported unmet needs post-stroke (9).Unmet rehabilitation needs may persist for years after stroke (10). According to a UK study, they are more often reported by people with disabilities, those belonging to ethnic minorities, and those living in the most deprived areas (10). According to a recent systematic review of 19 studies, mostly cross-sectional in design, 74% of stroke survivors experienced at least one unmet need. The studies revealed heterogeneous levels of unmet needs, ranging between 5% and 40% for care and between 2% and 36% for therapy (9). In most studies, unmet needs were assessed by using different multi-item questionnaires, such as the Longer-term Unmet Need after Stroke (11) and the Greater Manchester Stroke Assessment Tool (12), or by the self-report of long-term needs after stroke (10).In a Swedish registry study evaluating perceived unmet or partly met rehabilitation needs with a single question, 21.5% of patients reported unmet needs one year after stroke. Important underpinning factors were older age, dependency on others, pain and depressive/ affective symptoms (13).Rehabilitation practices are formulated and enacted in a cultural and historical context aligned to the development of healthcare services (14). Specialized stroke rehabilitation is integrated in the public healthcare systems in Nordic countries (15), but, whereas the Norwegian study region mainly emphasizes inpatient rehabilitation, the Danish region has developed an additional and more specialized, community-based rehabilitation programme (16). Although some studies have reported different rehabilitation pathways in the early subacute phase of stroke (17), no previous studies have, to our knowledge, compared unmet needs post stroke in participants with different subacute rehabilitation pathways.The primary aim of this study was to examine patient-reported needs for healthcare and rehabilitation services in a cohort with different rehabilitation pathways recruited from 2 Nordic country-regions. Secondary aims were to assess to what extent these needs were met or unmet 3 months post stroke and to explore factors associated with met and unmet needs.     

Immunogenicity and safety of a combination of two serogroup B meningococcal outer membrane vesicle vaccines

MenBvac and MeNZB are safe and efficacious vaccines against serogroup B meningococcal disease. MenBvac is prepared from a B:15:P1.7,16 meningococcal strain (strain 44/76), and MeNZB is prepared from a B:4:P1.7-2,4 strain (strain NZ98/254). At 6-week intervals, healthy adults received three doses of MenBvac (25 microg), MeNZB (25 microg), or the MenBvac and MeNZB (doses of 12.5 microg of each vaccine) vaccines combined, followed by a booster 1 year later. Two-thirds of the subjects who received a monovalent vaccine in the primary schedule received the other monovalent vaccine as a booster dose. The immune responses to the combined vaccine were of the same magnitude as the homologous responses to each individual vaccine observed. At 6 weeks after the third dose, 77% and 87% of the subjects in the combined vaccine group achieved serum bactericidal titers of > or = 4 against strains 44/76 and NZ98/254, respectively, and 97% and 93% of the subjects achieved a fourfold or greater increase in opsonophagocytic activity against strains 44/76 and NZ98/254, respectively. For both strains, a trend of higher responses after the booster dose was observed in all groups receiving at least one dose of the respective strain-specific vaccine. Local and systemic reactions were common in all vaccine groups. Most reactions were mild or moderate in intensity, and there were no vaccine-related serious adverse events. The safety profile of the combined vaccine was not different from those of the separate monovalent vaccines. In conclusion, use of either of the single vaccines or the combination of MenBvac and MeNZB may have a considerable impact on the serogroup B meningococcal disease situation in many countries.     

Does the low FODMAP diet improve symptoms of radiation-induced enteropathy? A pilot study

Rationale: Patients with radiation-induced enteropathy (RE) after cancer treatment show similar symptoms as patients with irritable bowel syndrome (IBS). The low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet (LFD) is a widespread management strategy for IBS. We aimed to investigate if there may be a positive effect of LFD on symptoms and health-related quality of life (HRQOL) in patients with RE.

Methods: In an open non-controlled pilot study, 11 patients (all female) with RE-related IBS symptoms were recruited largely based on own initiative. All followed LFD for four weeks. IBS Severity Scoring System (IBS-SSS) and IBS Symptom Questionnaire (IBS-SQ) were used to assess symptoms. Short Form Nepean Dyspepsia Index (SF-NDI) and 12-item Short Form Health Survey (SF-12) evaluated HRQOL. A three day food record was used to estimate baseline intake of FODMAPs and to reveal dietary changes.

Results: FODMAP intake was successfully reduced, although LFD was found a burdensome intervention. IBS symptoms improved significantly based on mean total score of IBS-SSS and IBS-SQ, which changed from 310.2?±?60.7 to 171.4?±?107.2 (p?=?.001) and 27.4?±?4.1 to 15.7?±?10.1 (p?=?.002). HRQOL improved based on SF-NDI total score (30.5?±?9.4 to 18.3?±?8.2, p?=?.001) and based on mental (p?=?.047) and physical (p?=?.134) score of SF-12. Main additional dietary changes were reduced intake of energy, carbohydrates, and fiber.

Conclusion: Our findings from this small-scaled pilot study indicate that the LFD may alleviate symptoms and improve HRQOL in patients with RE. Further controlled studies with larger sample size should be conducted to verify our results and hopefully enable implementation of LFD as a future part of the management strategy for RE.     

SLNB and the importance of micrometastases in vulvar squamous cell carcinoma

With the exception of patients with tumors smaller than 2cm and infiltration less than 1mm, standard treatment for squamous cell carcinomas of the vulva includes ipsi- or bilateral inguinofemoral lymph node dissection. However, with only 20% of early stage patients presenting with lymph node metastases in the groin, the majority of these patients do not gain from the procedure, but are at risk of its complications and detriments. The sentinel lymph node biopsy (SLNB) method targets the lymph nodes most likely to contain metastasis and has proven high accuracy in predicting the absence of metastasis in non-sentinel lymph nodes when found negative on pathologic examination. The SLNB further provides for a more thorough examination of the harvested lymph nodes and hence increases the detection of micrometastases. Although the clinical significance of micrometastases is controversial, reports on patients with micrometastasis suffering recurrence emerge, making the importance of detecting micrometastases in the pathologic examination of the sentinel lymph nodes evident. Appreciating its limitations, the sentinel lymph node procedure shows evidence of evolving into a feasible and safe procedure in the hands of experienced surgeons, pathologists and nuclear medicine physicians in early stage vulvar carcinoma patients. Still, larger multicenter trials are needed to assess its accuracy and safety.     

Vegans,Vegetarians and Pescatarians Are at Risk of Iodine Deficiency in Norway

Low iodine intakes have been documented in different population groups in Norway. We aimed to assess iodine status, dietary intake, supplement and macroalgae use, and iodine knowledge in vegans, vegetarians and pescatarians. In this study, 115 vegans, 55 vegetarians and 35 pescatarians from the Oslo region of Norway, aged 18–60 years, participated. A spot urine sample was collected along with a dietary assessment of iodine intake, supplement and macroalgae use. The median urinary iodine concentration (MUIC) in vegans was 43 µg/L (moderate iodine deficiency), in vegetarians 67 µg/L and in pescatarians 96 µg/L (mild iodine deficiency). In multiple linear regression analysis, use of iodine supplements was one of the strongest predictors of UIC. About half of the participants had median 24-h iodine intakes below estimated average requirement (EAR) of 100 µg/day. Fifty percent had low knowledge score, while 27% had very low knowledge score. Vegans, vegetarians and possibly pescatarians in Norway, are unable to reach the recommended iodine intake merely from food and are dependent on iodine supplements. There is an urgent need for dietary guidance targeting vegans, vegetarians and pescatarians to avoid inadequate iodine intake in non-supplement users, as well as avoiding excess iodine intake in macroalgae users.     

Weight loss surgery as a tool for changing lifestyle?

This article critically explores the tension between perceptions of weight loss surgery as a last resort and as a tool. This tension stems from patients’ doubt and insecurity whether expectations for a healthy life will come through. Thus, even after surgery, traditional weight loss methods, including diets and exercise, are considered paramount. Drawing on a series of interviews with Norwegian women, we argue that the commercialization of weight loss surgeries as well as the moral stigmas attached to such operations serve to perpetuate this tension. More specifically, the women were advised to leave their old habits behind, and embrace a healthier and more active lifestyle. In such a climate, we argue that undergoing surgery without subsequently embodying dietary and exercise norms is hardly an option. On the contrary, these become a moral obligation that modern women need to relate to—and perhaps negotiate—in order to repudiate stigmas attached to weight loss surgeries as a quick fix for those incapable of losing weight in the “proper” manner.     

“Then I Can Become Very Ill”: Women's Experiences of Living With Irreversible Changes in Their Viscera

Over the past 5 years, interest in weight-loss surgery has increased in tandem with the growing obesity epidemic in both Western and developing countries. In particular, scholars have documented the health promoting aspects of weight-loss surgery. Nevertheless, few researchers have explored the side effects, most prominently “dumping,” that frequently accompany weight-loss surgery. Building on the one previous qualitative study of dumping, I focused my research for this article on the challenges associated with limiting food intake. Based on interviews with 22 Norwegian women, all of whom had undergone the gastric-bypass procedure, I concluded that the women who had a history of struggling with overeating found adjusting their food intake after the surgery particularly challenging. Appropriate personalized support for individuals struggling to establish new eating habits after the surgery requires a thorough understanding of the challenges associated with adjusting food intake. In this context, the findings of this article should be of interest to an international audience.