Clinical review

Tick-borne encephalitis in children

Clinical review

21.09.2023: The incidence of tick-borne encephalitis in Norway is increasing. The risk of infection shows considerable geographical variations, with clusters of cases in certain municipalities in the counties of Agder, and Vestfold and Telemark. There is also a major variation in clinical presentation. Only a small number of cases of tick-borne encephalitis in children have been reported in Norway, and the condition may be underdiagnosed. We present a clinical review, including two case studies, that focuses on the clinical presentation and diagnosis of tick-borne encephalitis in children. Tick-borne...

Late effects after breast cancer treatment

Clinical review

03.08.2023: Breast cancer is the most common cancer among women in Norway. Nine out of ten will become long-term survivors. Being cancer-free does not necessarily mean feeling healthy, and many experience troublesome late effects, such as fatigue, pain and fear of recurrence. General practitioners represent the most important medical support for the majority of these women. This clinical review article summarises up-to-date knowledge about late effects after breast cancer treatment. Non-pharmacological interventions can have a positive effect on many of the most common late effects. In 2021, more than...

Suture materials

Clinical review

28.06.2023: Suture materials are of crucial importance for most surgical procedures, and knowledge about these is useful for all doctors. This clinical review article gives an introduction to the most common suture materials and their properties. Lastly, recent trends in suture technology are presented. Suture materials have been used in surgical procedures for thousands of years (1). Both the materials and their usage have changed over time (2). Previously, needles were made of bone, and sutures were made of silk, tendon and hair (3). Today, we largely use metal needles and synthetic suture materials...

Chronic neutropenia in adults

Clinical review

12.06.2023: Neutrophils are an important component of the innate immune system, and they prevent bacterial and fungal infections by phagocytosis and killing of pathogens. Neutropenia is defined as an abnormally low number of circulating neutrophils, and the term chronic neutropenia is used when it lasts more than three months. The objective of this clinical review is to raise awareness among doctors in Norway of chronic neutropenia and possible causes. A patient with severe neutropenia and fever requires immediate admission to hospital and initiation of empiric sepsis treatment before the cause of...

Recurrent pericarditis

Clinical review

31.05.2023: Pericarditis is an important differential diagnosis in patients with chest pain. The two most common causes in the developed world are idiopathic pericarditis and inflammation following cardiac surgery or myocardial infarction. Recurrence of pericarditis affects up to 30 % of patients, half of whom experience multiple episodes, and approximately 10 % develop steroid-dependent and colchicine-refractory pericarditis. Recurrence is due to autoinflammatory processes in the pericardium. Advanced diagnostic imaging and treatment with colchicine and interleukin-1 inhibitors has helped reduce...

Vascular parkinsonism

Clinical review

08.05.2023: Parkinsonism can have many causes, among them cerebrovascular disease. Vascular parkinsonism can be caused by infarction or haemorrhage in the nigrostriatal pathway, resulting in hemiparkinsonism, or by widespread small vessel disease in the white matter, leading to the gradual development of bilateral symptoms in the lower extremities. Compared to patients with Parkinson's disease, individuals with vascular parkinsonism have earlier onset of gait disturbance, are more likely to have urinary incontinence and cognitive impairment, and have poorer treatment response and prognosis; however, they...

Treatment of motor symptoms in Parkinson's disease

Clinical review

05.05.2023: In recent years, the development of new therapies and improvements in our understanding of older therapies have led to changes in the management of Parkinson's disease. However, current Norwegian and international therapy recommendations present a range of different options as being equally viable. In this clinical review, we propose an updated algorithm for the medical treatment of motor symptoms in Parkinson's disease, based on evidence-based recommendations and our own personal experience and opinions. The treatment of Parkinson's disease can be complicated. Many different options are...

Keratosis pilaris

Clinical review

16.03.2023: Keratosis pilaris, or 'plucked chicken skin', is a very common condition. It is caused by keratin accumulation in the hair follicles. Although mild cases of the condition can be considered to be a normal variant, it can lead to multiple appointments with general practitioners and dermatologists. In rare cases, keratosis pilaris can form part of specific syndromes or be associated with other diseases. The aim of this article is to give an overview of the different variants of keratosis pilaris and discuss the pathogenesis and treatment options. Keratosis pilaris, often referred to as 'plucked...

Temporal lobe epilepsy

Clinical review

30.01.2023: The temporal lobes are the part of the brain most likely to give rise to epileptic seizures. Seizures originating in the temporal lobes vary greatly in character; some may be so unusual that they are not even recognised as epileptic. For patients who have been diagnosed with hippocampal sclerosis and whose seizures cannot be controlled with drugs, epilepsy surgery may be a good treatment option. In this brief clinical review, we summarise the key features of epilepsy and highlight the importance of accurate and early diagnosis for achieving good clinical outcomes. All patients who have had a...

High levels of lipoprotein(a) – assessment and treatment

Clinical review

12.01.2023: Approximately 5 % of the population have highly elevated levels of lipoprotein(a) (Lp(a)), which is a genetically determined risk factor for cardiovascular disease. Measuring lipoprotein(a) can improve cardiovascular risk stratification and have consequences for preventive measures. Treatment is targeted at reducing modifiable cardiovascular risk factors, but Lp(a)-lowering drugs are being trialled. This article reviews the management of lipoprotein(a) in clinical practice. Lipoprotein(a), abbreviated as Lp(a) and often referred to as lipoprotein little a, was first identified in 1963 by the...

Primary progressive aphasia

Clinical review

23.11.2022: Neurodegenerative dementia may, in rare cases, initially manifest as isolated language impairments in the absence of other cognitive symptoms. These impairments are often somewhat imprecisely referred to as difficulties with 'word finding'. There are several variants of this form of dementia, each caused by different underlying neuropathologies. Occasionally problems with speech rather than language predominate. Patients may have exclusively language or speech-related symptoms for several years, but eventually all will progress to generalised dementia. This clinical review describes primary...

Melanoma – investigation and primary treatment

Clinical review

24.10.2022: Melanoma is a relatively common diagnosis, both in the primary and specialist health service. Ongoing research and new evidence base means that the recommendations for investigation and treatment are continually changing. This can lead to uncertainty among doctors who do not treat this patient group regularly. In this clinical review we give a summary of the latest recommendations, primarily aimed at general practitioners, dermatologists and doctors in local hospitals. Melanoma is one of the most common forms of cancer in Norway, and its incidence has been rising sharply since the 1960s. After...

Long-term post-concussion symptoms

Clinical review

22.08.2022: Concussion is common and usually resolves without complications. However, persistent symptoms occur in 10–15 % of patients. These post-concussion symptoms are predominantly somatic, cognitive and emotional. The condition is most common in those with previous somatic and mental health issues. The causes underlying long-term post-concussion symptoms are unclear, but a biopsychosocial explanatory model is currently regarded as the most appropriate basis for diagnosis and treatment. This clinical review article is based on key literature and our own clinical experiences with patients who have...

Merkel cell carcinoma

Clinical review

14.06.2022: Merkel cell carcinoma is an uncommon but aggressive tumour with a high metastatic potential. A rapidly growing, non-tender cutaneous tumour on sun-exposed areas of the body in older patients should raise suspicion of the condition. It may be necessary to combine the patient history with clinical, radiological and pathological findings in order to make the correct diagnosis. Excision with a 1–2 cm margin, direct closure and simultaneous sentinel-node biopsy should be performed without delay. Adjuvant radiation therapy of the tumour site may be relevant. After the diagnosis is made, assessment...

Skin grafting

Clinical review

30.05.2022: Skin grafting involves covering an area of missing skin with healthy skin tissue harvested from another part of the body. The aim of this clinical overview is to give a short introduction to the procedure. Burns, scalds, trauma and cancer surgery can result in major defects in the skin that must be covered and reconstructed. The reconstructive ladder is a well-known principle within reconstructive surgery that arranges the various treatment strategies for skin defects in order of increasing complexity (Figure 1) (1). The idea behind this principle is to choose the most efficient treatment...

Orbital fractures

Clinical review

04.04.2022: Orbital fractures can occur as a result of direct trauma to the eye region or surrounding facial bones. The fractures can lead to significant functional impairment and cosmetic changes. Surgical treatment of orbital fractures aims to reconstruct the bony anatomy and restore the orbit's original volume. This clinical review article looks at the key factors regarding orbital fractures. Orbital fractures are fractures in the bones surrounding the eye socket (orbit), and the third most common type of facial fracture in adults and children (1, 2). The fractures are usually categorised by anatomical...

Which meniscus injuries require surgery?

Clinical review

22.03.2022: Degenerative and traumatic meniscus injuries should be considered two completely different pathologies requiring treatment based on entirely different principles. Degenerative tears are part of the development of osteoarthritis and should generally be treated conservatively, whereas surgery should be considered for traumatic tears to help prevent the development of osteoarthritis. In this article, we summarise which patients should be referred promptly to an orthopaedic surgeon, and which should be referred to a physiotherapist. Over the last few decades, increasing access to MRI has helped to...

Dry mouth in the seriously ill and dying

Clinical review

10.02.2022: Dry mouth constitutes a significant problem for most patients with grave illnesses and a need for palliative treatment. The main causes are pharmaceuticals, diseases and cancer treatment, which are often associated with increasing age. The condition may give rise to discomfort, pain, dysphagia, speech problems, increased caries activity, dehydration, malnutrition and loss of appetite. There are few evidence-based remedies against this condition. An apparently trivial problem like dry mouth may therefore cause deterioration of the clinical picture and a reduced quality of life. A study of a...

Superior semicircular canal dehiscence syndrome

Clinical review

24.01.2022: Superior semicircular canal dehiscence syndrome is a condition with troubling ear symptoms and vertigo caused by a defect in the bone between the inner ear and the middle cranial fossa. The disease is not dangerous, and for many patients it is sufficient to provide a thorough explanation for the symptoms and advice about coping strategies, balance exercises and, if necessary, use of assisted hearing devices. Surgical treatment may be appropriate for patients with severe symptoms. Superior semicircular canal dehiscence syndrome was first described in the late 1990s (1). It was shown that a...

Skin picking disorder

Clinical review

13.12.2021: Skin picking disorder is an under-recognised mental disorder that typically starts during adolescence and leads to considerable emotional distress and/or reduced functioning in important areas of life. Repeated picking at the skin happens despite efforts to stop. Feelings of lack of control and shame are prominent, and anxiety disorders and depression are common comorbidities. SSRIs and n-acetylcysteine may be beneficial, but cognitive behavioural therapy is probably more effective. Skin picking disorder is classified as an obsessive-compulsive and related disorder. The disorder is...

Amiodarone-induced thyrotoxicosis

Clinical review

08.11.2021: We see an increasing number of patients with amiodarone-induced thyrotoxicosis. This condition can be treated pharmacologically, but treatment over several months may give rise to adverse reactions. In most cases we recommend that amiodarone therapy be continued despite newly detected thyrotoxicosis. Particularly in cases of heart failure, one should not wait too long before considering thyroidectomy. Treatment of amiodarone-induced thyrotoxicosis must be delivered with close collaboration between endocrinologist and cardiologist. Amiodarone is the most potent drug available against cardiac...

Reconstruction of wound defects in the perineum

Clinical review

25.10.2021: Surgical procedures in the perineum can cause major soft-tissue defects that require reconstruction with plastic surgery. In this article we present plastic surgery principles for the reconstruction of wound defects and common methods used to reconstruct wound defects in the perineum. A need for reconstruction of defects in the perineum tends to arise as a result of surgery for gastrointestinal or gynaecological cancer. Techniques for reconstructing perineal defects range from simple methods, such as direct closure of wounds and local skin flaps, to more complex procedures such as pedicled or...

Anterior shoulder dislocation – assessment and treatment

Clinical review

05.08.2021: Anterior shoulder dislocation can occur in connection with a traumatic event or as a result of an anatomical predisposition. A traumatic dislocation can damage stabilising structures, which can predispose an individual to recurrent dislocations. People under the age of 30 and those who participate in contact sports are particularly susceptible, and can consequently incur further damage to the stabilising structures. Patients in these categories should be considered for surgical treatment at an early stage. The shoulder joint is the body's most mobile joint and is therefore particularly prone...

Spinal cord stimulation for the treatment of peripheral neuropathic pain

Clinical review

02.06.2021: Spinal cord stimulation with weak electric current is a neuromodulatory treatment suitable for subgroups of patients with chronic neuropathic pain and certain other pain conditions. Neuropathic pain can reduce quality of life, and the effectiveness of pharmacological treatment is often limited. Studies of spinal cord stimulation have shown significant pain relief and improved functioning at group level, and recent years have seen the development of new stimulation methods which are currently under evaluation. Pain relief upon electrical stimulation of the spinal cord, first described in a case...

Use of anticholinergic drugs in older patients

Clinical review

07.04.2021: Many medicines prescribed for older patients have an unintended anticholinergic effect in addition to the primary intended effect. This may lead to adverse reactions such as dizziness and memory loss, particularly in older people. Before prescribing new medicines, it is therefore important to assess the total anticholinergic burden by means of specific screening tools, such as AGS Beers Criteria® and the STOPP/START criteria. If the anticholinergic burden is high, drugs should be replaced or discontinued. Medicines with anticholinergic properties are regularly prescribed for older and often...

Thrombocytopaenia in the critically ill

Clinical review

11.01.2021: Thrombocytopaenia is defined as a platelet count of < 150 · 109/L and occurs frequently in the critically ill. The condition arises as a result of the reduced production or increased destruction or consumption of platelets. Thrombocytopaenia in critically ill patients is often the result of multiple pathophysiological mechanisms, and these must be identified if the prognosis is to be determined and appropriate treatment provided. Thrombocytopaenia occurs frequently in the critically ill, and often has several underlying causes. This article provides an overview of thrombocytopaenia in...

Thyroid nodules – investigation and follow-up

Clinical review

03.09.2020: Thyroid nodules are common. As a result of increased use of diagnostic imaging, more nodules are detected as incidental findings. The great majority of them are benign and need no treatment. Systematic ultrasonography performed by a skilled doctor, possibly combined with cytology sampling, will to a large extent determine which nodules require follow-up. Thyroid nodules are common. As a result of increased use of diagnostic imaging, more nodules are detected as incidental findings. The great majority of them are benign and need no treatment. Systematic ultrasonography performed by a skilled...

Excision of skin lesions

Clinical review

23.06.2020: Excision of skin lesions takes place regularly in general practice. The procedure is simple, but correct execution depends on a knowledge of skin anatomy and basic surgical principles. This article presents indications for excision of skin lesions and a recommended method based on clinical experience and relevant literature. The method can be used on both pigmented and non-pigmented lesions. Seborrheic keratoses are not discussed (1). The contents of the article apply to the primary health service. Indication Skin lesions are excised with a view to obtaining a histological diagnosis. Pigmented...

COVID-19 and venous thromboembolism – prophylaxis and treatment

Clinical review

17.06.2020: As the pandemic has been unfolding, reports have emerged of a relatively high incidence of coagulopathy and thromboembolic events in connection with COVID-19 infections. Raised awareness surrounding this issue, and appropriate antithrombotic prophylaxis and treatment, are therefore important for this group of patients. The COVID-19 pandemic has dominated the medical debate in recent months, and has impacted all aspects of society (1). SARS-CoV-2 is a virus of the Corona group which primarily attacks the respiratory epithelium and can result in acute respiratory distress syndrome. In extreme...

Bacterial odontogenic infections

Clinical review

28.04.2020: Odontogenic infections are infections that originate in the teeth and/or their supporting tissues. Such infections are common, and a large proportion of infections of the head and neck region are of odontogenic origin. Most odontogenic infections cause mild signs and symptoms, but they can also develop into serious conditions. This article provides an overview of the most common pathogenic microbes in the oral cavity, the most frequently occurring odontogenic infections, and the treatment and potential complications of the latter. The article is based on a non-systematic search in PubMed, plus...