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Over the last decades, remarkable advances in survival in patients with congenital heart disease (CHD) have been reported. Currently, 90% of infants born with CHD can expect to reach adulthood. Moderate and severe CHD is associated with increased perioperative mortality. To ensure optimal management of CHD patients undergoing non-cardiac surgery, preoperative risk assessment is pivotal, along with a multidisciplinary approach and collaboration across hospitals. The objective of this review is to provide a simple model to identify CHD patients at risk prior to non-cardiac surgery.

This is a case report of a 56-year-old woman with a history of postmenopausal bleeding, who presented with an endometrioid adenocarcinoma and a co-existing non-gestational choriocarcinoma. We performed robotic assisted hysterectomy, bilateral oophorectomy and pelvic lymphadectomy, and histopathologic examination revealed a malignant tumour showing an endometrioid adenocarcinoma grade 2 with a minor component of choriocarcinoma incorporated into the adenocarcinoma. We compared data from exome sequencing of DNA from tumour and blood to show, that the choriocarcinoma component was most likely non-gestational.

This review summarises the knowledge of pain monitoring during surgery in Denmark. General anaesthesia consists of hypnosis, relaxation and analgesia. The first two can be objectively monitored, but analgesia is traditionally evalu-ated by the anaesthesiologist. Several monitors for as-sessing pain exist, and all types of pain monitoring are superior to traditional evaluation and seem to have several advantages but are still not used routinely in Denmark. The nociception level monitor is multimodal and incorporates movement, heart rate, heart rate variability, pulse plethysmography, skin temperature and galvanic skin response. It has been validated, but further research is needed.

In this case report a 28-year-old man had a six-year history of atraumatic wrist pain. X-ray and MRI showed an accessory ossicle dorsal to the lunate, near the scapholunate ligament: an os epilunatum. Os epilunatum is a rare ossicle of the hand, and only one clinical case and few cadaveric studies have previously been reported. Resection was performed through a dorsal approach, without damaging the scapholunate ligament. Three months post-operatively the patient had increased motility of the hand and no pain.

Bronchiectasis is characterised by chronic cough, airway inflammation, infection and bronchial dilatation. The disease may lead to impaired lung function and premature death. An underlying inflammatory disease or immunodeficiency may be present, but 40% of the cases are idiopathic. The diagnosis is based on high-resolution CT scan. Treatment is aimed at reducing symptoms and risk of exacerbations, and includes antibiotics, bronchodilators and pulmonary rehabilitation. Assessment of disease severity and individual phenotypes may help to modify treatment strategies in the future.

Rhabdomyolysis is a potential life-threatening condition characterized by a rapid destruction of striated muscle cells. Causes include trauma, muscle hypoxia, drugs, malignant hyperthermia, infections, toxins and metabolic myopathies. We report a case of a 52-year-old man with hereditary myoglobi-n-uria and gastroenteritis-induced rhabdomyolysis. Metabolic myopathy as a cause of rhabdomyolysis is rare but potential life-threatening if not diagnosed and treated promptly.

Pulmonary hypertension (PH) is classified into five groups. It is an important cause of dyspnoea. Echocardiography is the best non-invasive method for detecting PH and should be part of the evaluation of patients with dyspnoea. If signs of PH are detected on echocardiography, a number of other examinations should be undertaken to verify the diagnosis and classify PH correctly, as the treatment depends on the subtype of PH. The prognosis of PH is poor, but early detection and treatment can improve the course for some of the patients. Surgery can often cure chronic thromboembolic pulmonary hypertension.

Recent research has revealed the existence of a class of small non-coding RNAs, known as microRNAs. These microRNAs are deregulated in various cancers including gliomas. MicroRNAs have been suggested to be important in cancer stem cell biology and in proliferation and chemosensitivity of cancer cells. This makes microRNAs obvious targets for novel therapeutic strategies. In the present article we focus on the role of microRNAs in cancer cells and cancer stem cells as well as the possible therapeutic approaches exploiting this knowledge to improve future glioma therapy.

Introduction: Endobronchial ultrasound (EBUS) is a minimally invasive diagnostic modality, by which it is possible to visualize and do biopsy of structures adjacent to the trachea and the central bronchial system. EBUS is mostly used for staging of lung cancer patients, but EBUS is now used worldwide as a diagnostic tool in patients with mediastinal tumours or adenopathy., Material and Methods: In this paper, we report of the result of the first 100 EBUS patients referred for further investigation of mediastinal adenopathy or tumour found via CT. All 100 patients underwent EBUS in general anaesthesia, and 95 patients had transbronchial needle aspiration biopsy performed (TBNA)., Results: A total of 46 patients were known to have or have had cancer; in 20 of these patients we found cancer in the mediastinum by EBUS-TBNA, 24 patients had lymph node aspirates without cancer and in two patients the aspirate was inconclusive. The remaining 49 patients all had a record of non-malignant medical disease; 22 of these patients were found to have cancer in the mediastinum, one patient had cancer-suspect EBUS-TBNA, 24 had lymph node aspirates without malignancy and in two patients the aspirate was inconclusive. All patients were followed for 6-30 months. The sensitivity was roughly calculated to 94%. No patients suffered any complications., Conclusion: We conclude that EBUS-TBNA is a safe and accurate diagnostic tool in the evaluation of mediastinum in patients with cancer as well as in patients with non-malignant disease.

The development of stump and phantom pain after limb amputation in patients with complex regional pain syndrome (CRPS) is very frequent. Stump pain is typically recurred CRPS and the possibilities for effective pharmacological pain relief are often limited. Spinal cord stimulation (SCS) has a well-documented pain relieving effect in patients with CRPS. This case story summarises the long term effect of SCS in a patient with CRPS after two amputations of the right leg. Pharmacological pain therapies as well as Guanethidine blockade were found to be ineffective.

This is a case report concerning a patient with traumatic uncontrolled bleeding. The patient was admitted with a severe head injury and facial fractures. During neurosurgery, the bleeding became life-threatening and there was a request for recombinant factor VIIa therapy (NovoSeven). Before the treatment, thromboelastography was performed. This showed platelet insufficiency, and after infusion of platelets, the bleeding was under control and there was no longer a need for recombinant factor VIIa therapy. We therefore recommend thromboelastography to evaluate coagulation status before treatment with recombinant factor VIIa.

Stimulation techniques (SB) include manipulation, acupuncture, acupressure, physiotherapy, transcutaneous electrical nerve stimulation, reflexotherapy, laser treatment and epidural stimulation technique. The purpose of this paper is to investigate the scientific evidence for these techniques. The Cochrane Library and Medline were searched for all techniques from 2000 to date. Only randomised controlled studies written in English were included. Search words were used, such as; acupuncture and neck pain, shoulder pain, etc. In total 587 papers were identified for the following diseases; headache, neck pain, shoulder pain, elbow pain, low back pain and knee pain. 415 papers were excluded, and the remaining 172 papers, a total of 20,431 patients, are the basis for this study. The effect of acupuncture and epidural stimulation technique is scientifically well-supported. For the remaining techniques, the scientific evidence is dubious.

A 68-year-old woman was admitted for open heart surgery. She had no history of allergy, but had suffered acute heart failure after having received protamine twice. Possible predisposition to adverse reactions is discussed and ways of reducing adverse reactions to protamine are suggested.

The medical treatment of various cancers may, as long-term sequelae, cause infertility in girls and young women. In order to preserve the fertility of such women, techniques to cryopreserve ovarian tissue have gained considerable interest during recent years. The ovarian tissue is cryopreserved before cancer treatment is commenced, and first replaced when the woman has been cured. Based on the successful results from the use of this technique in test animals, where normal live young have been born, cryopreservation of human ovarian tissue has been initiated in a number of fertility clinics worldwide over the last few years. So far, only two women have experienced transplantation of cryopreserved ovarian tissue. Menstrual cycles and oestradiol production were restored in both women, but restoration of fertility have not yet been demonstrated. This review describes the technique and its present possibilities and limitations. The legal aspects in Denmark are presented and some ethical aspects described.

Meningiomas are classified according to WHO (1993), and include eleven subtypes of benign meningiomas, two semi-malignant and one anaplastic. In most cases meningiomas exhibit modifications or deletions in chromosome 22. Increasing knowledge of the natural history concerning growth rate and the treatment of incidental meningiomas is accumulating. Meningiomas formerly classified as surgically inaccessible are now often operable due to a continuing refinement of the surgical techniques and the study of possible new routes of intracranial tumour removal.

Meningeal melanocytomas are rare benign neoplasms of meningeal melanocytes, and are most frequently located in the posterior fossa and along the cervical spinal cord. We report a case of a 16 year-old girl with a melanocytoma located in the upper cervical part of the spinal canal. The patient presented severe neurological signs, but had a very good outcome following surgery.

Two cases of electricity failure in an operation theatre during open heart surgery are discussed. The fuse for the patient monitor, ventilator, surgery instruments and heart lung machine was blown. Short-circuit was established because of humidity in the plug of the heater for fluid and blood. We recommend sealed or founded plugs and that anaesthesia equipment should not be used as an electrical supply for other electronic apparatus.

Several studies of patients with chronic obstructive pulmonary disease (COPD) have shown that pulmonary rehabilitation three to seven times a week improves exercise performance and well being. This study investigates feasibility, effect and economic aspects of a programme consisting of two sessions a week. Twenty-four patients were randomized to rehabilitation and twenty-one to placebo. In an outpatient setting patients were assigned to an eight-week programme of exercise plus education twice a week (Exercise group) or conventional community cares (Placebo group). Seven patients did not complete the rehabilitation. The characteristics of the thirty-eight COPD patients at baseline (mean +/- SD): forced expiratory volume in one second (FEV-1) 1.1 +/- 0.4 L, six-minute walk distance (6MWD) 413 +/- 75 m. Rehabilitation resulted in an insignificant improvement in well being and the 6MWD (29 m ¿95% confidence interval: -8-66 m¿. Rehabilitation session twice a week for eight weeks had no effect in patients with moderate COPD.

Primary pulmonary hypertension (PPH) is defined as continuing increase of the blood pressure in the pulmonary arteries without any known reason. The expected incidence in Western Europe is one to two per one million inhabitants, which in Denmark is around five to ten new cases each year. The diagnosis PPH is established by excluding other known reasons for secondary pulmonary hypertension. Primary pulmonary hypertension is a progressive and incurable disease. The treatment of PPH is with vasodilatory agents and anti-coagulants with supplementary diuretics, digoxin and oxygen as second-line of treatment. The most important vasodilators are calcium-antagonist and Epoprostenol (prostacyclin PGI2). Lung transplantation or combined heart and lung transplantation is at the moment the only possible treatment for progressive PPH disease in Denmark. The one year survival after lung- or heart and lung transplantation for PPH are not as good as the survival among other patients who are heart and lung transplanted.

En-bloc double lung transplantation with tracheal anastomosis and direct revascularization of the bronchial arteries to the left internal mammary artery has been carried out in Denmark since June 1992. Forty-seven patients (32 with alfa-1 antitrypsin deficiency, 11 with chronic obstructive pulmonary disease, two with cystic fibrosis and two with primary pulmonary hypertension), 25 men and 22 women, average age 39 years (17-64 years), have received their first double-lung transplant with bronchial artery revascularization. Arteriography of the internal mammary artery and bronchial arteries was performed in 42 (89%) of the patients from 1-150 days after the operation. Successful bronchial artery revascularization was demonstrated arteriographically in 40 patients, in two patients the arteriography failed to show bronchial artery revascularization. Arteriography was not performed in five patients due to early complications and death. Bronchoscopy showed rapid, uncomplicated airway healing in 42 patients. Mucosal necrosis under the tracheal anastomosis was found in three patients, and severe obstructive endobronchial growth of the fungus Aspergillus fumigatus was diagnosed in the last two patients. The one- and two-year survival is 83% (Kaplan-Meier). Eleven patients are dead, five due to pulmonary causes and six due to extra-pulmonary causes. Pulmonary function became normal in nearly all surviving patients between three to six months after the transplantation. In conclusion, en-bloc double-lung transplantation with bronchial artery vascularization has shown good short-term results, and the one- and two-year survival gives hope that a successful bronchial artery revascularization will improve the long-term survival following lung transplantation.

A prospective Danish multicentre study was conducted to evaluate the incidence of retinal detachment after cataract extraction in myopic eyes (axial length, > or = 25.5 mm). Two hundred and forty-seven cataract extractions in myopic eyes were reported during a period of 13 months. Two hundred and forty-one eyes underwent extracapsular and six eyes intracapsular cataract extraction. The mean follow-up time for 158 eyes was seven months (ranging from 1-30 months). In five cases a retinal detachment was observed, one case was probably present preoperatively, this person had undergone intracapsular cataract extraction. The incidence of retinal detachment was thus 1.62-2.02% in the total material and 1.66% in eyes operated with extracapsular cataract extraction.

The most common indication for oocyte donation is ovarian insufficiency due to premature menopause or resistant ovarian syndrome and ovarian dysgenesis with either normal or abnormal (e.g. Turner's syndrome) karyotype. In Denmark, oocyte donation must be anonymous, and the donors have to be other infertile patients undergoing in vitro fertilisation (IVF), treatment. It is suggested, that the National Health Service offers oocyte donation to hypergonadotropic women with ovarian insufficiency, as well as to a few other groups who fulfil the criteria for IVF treatment, but where this treatment cannot be completed. Oocyte donors must be less than 35 years old, physically and mentally healthy and without major genetic diseases in the family. The donor must be screened for HIV, hepatitis, syphilis, chlamydia and gonorrhoea. We propose that those patients who have more than six oocytes aspirated, allowing "surplus" oocytes to be donated. It is also proposed that the departmental order from the Ministry of Health be changed, so that normally fertile women are allowed to donate oocytes. Oocyte donation should be reported to a central authority.

In Denmark, legislation has made cryopreservation of human oocytes and embryos possible since October 1992. The legislation is reviewed. Cryopreservation of embryos constitutes a significant improvement of infertility treatment. The number of oocyte pick-ups and the number of embryos transferred can be reduced without compromising the total likelihood of success of in-vitro fertilization (IVF) treatment. According to Danish law, frozen embryos can only be stored for one year. This limit will interfere with patient expectations in numerous cases, and the time limit should be expanded. Moreover, freezing of embryos should be allowed in connection with oocyte donation programmes.

Medical indications for in vitro fertilization and embryo transfer (IVF-ET) internationally and in Denmark are reviewed. Reports from large international centres document that tubal infertility, unexplained infertility, endometriosis and male infertility are equally good indications for IVF. Traditionally, tubal infertility has been the only medical indication qualifying for IVF treatment within the National Health Service in Denmark. Thus, in this country, couples with unexplained and male infertility and with endometriosis have to pay up to 25,000 D.Kr. per IVF-ET treatment in private fertility clinics. Since there is no scientific basis for this discrimination, it is urged that the present rules are changed, so that couples with unexplained and male infertility and endometriosis are also allowed IVF treatment free of charge in the public fertility clinics.

The aim of the present study was to evaluate the diagnostic value of electron microscopy (EM) performed on Surecut biopsies from patients without known primary tumour. The material consisted of 108 consecutive biopsies, obtained over a period of two years, from patients with tumour(s) in the liver or lymph nodes (on the neck, in the axilla or retroperitoneum). From each patient fine needle aspirations and Surecut biopsies for light microscopy and electron microscopy were taken. Only biopsies in which material for both electron microscopy and light microscopy was sufficient were included (60%). Immunohistochemical reactions were performed on paraffin sections when indicated. Final diagnoses were confirmed on surgically removed specimens and/or autopsies. Electron microscopy was necessary for obtaining the final histological diagnosis in 15% of the cases. It is therefore recommended to obtain additional ultrasound guided biopsies for EM from cancer patients with tumours in the liver or lymph nodes in cases where the primary origin of the tumour is unknown.

Transfusion-associated graft-versus-host disease (TA-GVHD) is a serious complication of blood transfusion which is caused by immunocompetent donor lymphocytes reacting against recipient antigens. We report a case of TA-GVHD in a male patient with Hodgkin's disease who had received several units of non-irradiated blood components. TA-GVHD was diagnosed by histological examination of affected skin and demonstration of engrafted lymphocytes of female phenotype by in situ hybridization using a Y-chromosome specific probe. The need to irradiate blood components given to patients in defined risk-groups is stressed.

Two cases of extracardial rhabdomyomata are described. One case was discovered incidentally at autopsy while the other was primarily examined by needle aspiration biopsy. As far as the authors are aware, this is the first case to be reported.

Since August 1988, in Odense Hospital, electric spinal cord stimulation (SCS) has been employed for the treatment of pain in patients with confirmed ischaemic heart disease who suffer from incapacitating angina pectoris despite maximal medical/surgical treatment. The object of the present investigation was to assess not only the social economic consequences of SCS treatment (cost-utility analysis) but also altered quality of life in SCS patients (perception of pain, mobility, function in daily life and physical activity). Sixteen consecutive SCS patients all of whom were resident in the County of Funen and who were submitted to implantation of an SCS system during the period August 1988 to December 1989, participated in this investigation. The results are based on data from the year prior to SCS implantation compared with the subsequent time with SCS treatment. Saving was found at hospital level (reduction in number of admissions) og 40,200 Danish crowns/annum/patient (approximately IJ 3,000) (1989 prices), and for non-hospital related expenses a corresponding saving of 16,289 Danish crowns/annum/patient (approximately IJ 1,600) was found mainly on account of reduction in the amount of home nursing required. The total saving was found to constitute 56,489 Danish crowns/annum/patient (approximately IJ 5,600). In addition, improvements were registered in all respects which constituted assessment of the quality of life of the patients.

In the treatment of infertility employing in vitro fertilisation and embryo transfer (IVF-EF), oocytes, spermatozoa and pre-embryos are cultured for 48 hours outside the woman's body before they are introduced into the uterus. In addition to the necessary salts, the media in which this culture takes place, also consists of a source of protein. In order to eliminate the variability of patient sera, a prospective, randomized investigation was performed to elucidate whether a well-defined source of protein such as human serum albumin (hSA-hSA 200 mg/ml, Statens Seruminstitute) can replace patient serum as source of protein in the culture of oocytes, spermatozoa and pre-embryos in IVF-ET treatment. The pregnancy rate per transplantation was increased from 30% in the serum group (21 pregnant out of 69 transplantations) to 39% in the albumin group (26 pregnant out of 66 transplantations) but the difference is not significant. On the other hand, the quality of the pre-embryos as assessed by morphological criteria became significantly better and the implantation rate per transplanted pre-embryo was found to be significantly increased in the albumin group. On the basis of this investigation, hSA is recommended as the source of protein, rather than the patient's own serum in the culture of oocytes, spermatozoa and pre-embryos in IVF-ET treatment.

Employment of alternative therapeutic measures is increasing in Denmark. Some of this equipment employs magnetic fields in the therapeutic strategy. This may involve interference with the function of electronic equipment. Electronic interference may, in certain situations, influence pace-maker function. In the worst cases, it may be imagined that the situation may endanger life for persons who are dependent on pace-makers. When a pace-maker is exposed to a magnetic field of a certain strength, the type of pacing is changed to a fixed frequency. Some pace-maker types carry out a built-in test programme when exposed to magnetic influence (vario- or threshold test). The magnetic influence may involve discomfort for the wearer of the pace-maker, but does not endanger life. Investigation of stationary magnetic fields from alternative medical equipment resulted in disturbance of pace-maker function in an isolated case. Pulsating magnetic fields may result in possible induction of electric current which may be wrongly interpreted by the pacemaker. The results of this may be that the pace-maker does not send out pace impulses. As protection from continuous electric noise, pace-makers have a built-in electronic safety circuit (dual-demand). When this is activated, the pace-maker will stimulate with a basic frequency. It is recommended that equipment which employs magnetic fields in treatment should be measured before being employed on pace-maker wearers.

Various electrical devices are implanted for cardiac-, diaphragma-, pain- and musclestimulation. The stimulator/pacemaker can be implanted in locations, different from that of ordinary cardiac pacemakers. All electric stimulation equipment containing batteries must be removed before cremation on account of the risk of explosion.

During the period 1.2.1988-31.1.1989, a prospective investigation was undertaken of the intensive prehospital treatment in Odense. Comparison was undertaken between a medically staffed ambulance (2 months), a motorized doctor (rendez-vous, model 4 months) and the heart ambulance (recommended by the Danish National Board of Health (6 months]. Out of 28 patients brought in by the medically staffed ambulance, two (7%) were discharged alive. Out of 57 patients brought in the phase with the motorized doctor nine (16%) were discharged alive. Out of 78 patients brought in by heart ambulance one (1%) was discharged alive. The results of this investigation reveal that the prehospital treatment of cardiac arrest in Odense can be improved by participation of a doctor in the treatment, (particularly the rendezvous model). Suggested improvements consist of 1) improved alarm system, 2) intensification of training laymen in treatment of cardiac arrest and 3) increased information to the population.

Psychological assessment in the form of a test for dementia was carried out in 69 individuals. Thirty of these were survivors of cardiac arrest outside hospital. Seven of these were brought to hospital in ordinary emergency ambulances, 14 in heart ambulances and nine in medically staffed ambulances. In addition, 28 patients with acute myocardial infarction (AMI) and 11 control persons were examined. The result of the investigation demonstrates that the more intensive the prehospital treatment of cardiac arrest, the more patients survive with good cerebral function. In particular, the percentage of cerebral damage was least in cases where a medically staffed ambulance was employed.

In connection with participation of doctors in the emergency ambulance service in Odense, the number of cases of observed cardiac arrest outside hospital was registered during a period of six months. The object was to assess how often primary treatment for cardiac arrest was instituted by passers-by before arrival of the ambulance. Seventy-four cases of observed cardiac arrest occurred. In 11 of these (15%) primary resuscitation was attempted outside hospital. In only three (4%) cases the primary resuscitation was undertaken by lay persons. Treatment of cardiac arrest before arrival of the ambulance increases survival. It is therefore essential to increase the number of courses in the treatment of cardiac arrest for lay persons, if mortality is to be reduced.

Two cases of compression of the deep peroneal nerve by a ganglion cyst in the region of the proximal tibio-fibular joint are reported. In order to prevent recurrence, the importance of excision of the ganglion and its stalk is emphasized.

Mediastinal emphysema following facial trauma in the absence of neck, chest or abdominal injury is a rare entity. Mediastinal emphysema associated with fractures of the facial bones or odontological surgery has only been reviewed previously in case reports. This article reviews the etiological and pathogenetic mechanisms of subcutaneous facial/cervical emphysema and mediastinal emphysema associated with fractures of the facial bones. Complications and risk factors in treating fractures of the facial bones when mediastinal emphysema is present are discussed with emphasis on anaesthesiological complications.

The results of treatment of infertility by in vitro fertilization and embryo transfer (IVF-ET) in Rigshospitalet, Copenhagen, are reviewed for 143 patients in whom treatment was completed during the period 1.9.1985-21.2.1988 and for 100 pregnancies during the period 1.9.1985-15.11.1988. Among the 143 patients in whom treatment was completed, 48 became pregnant on one or more occasions as pregnancy occurred in 53 cycles. A total of 44 women delivered 55 infants. There were 35 singleton deliveries, seven twin deliveries and two triplet deliveries. One woman became biochemically pregnant, four aborted before the 12th week of pregnancy an one woman aborted on two occasions in the second trimester. Three women were treated operatively for extrauterine pregnancies. A total of 33.6% of the patients became pregnant, the baby-take-home rate per patient was 30.8%, the pregnancy rate per ET was 23.5% and the delivery rate per transplantation was 19.6%. Non-completed pregnancies per pregnant woman were 20.8%. Only preliminary account of the 100 pregnancies can be given as treatment has not been completed in all of these patients. Among the 100 pregnancies, there were 59 singleton pregnancies, ten twin pregnancies and three triplet pregnancies and 29 pregnancies which were not completed. The age distribution of the pregnant and non-pregnant women (23% over 34 years became pregnant and 53% under 29 years became pregnant) emphasizes the importance of commencing treatment as early as possible.