UNASSIGNED: Most patients with pancreatic cancer who have undergone surgical resection eventually develop disease recurrence. ‍This study aimed to investigate whether there is evidence to support routine surveillance after pancreatic cancer surgery, with a secondary aim of analyzing the implementation of surveillance strategies in the Nordic countries.
UNASSIGNED: A scoping review was conducted to identify clinical practice guidelines globally and research studies relating to surveillance after pancreatic cancer resection. This was followed by a survey among 20 pancreatic units from four Nordic countries to assess their current practice of follow-up for operated patients.
UNASSIGNED: Altogether 16 clinical practice guidelines and 17 research studies were included. The guidelines provided inconsistent recommendations regarding postoperative surveillance of pancreatic cancer. The clinical research data were mainly based on retrospective cohort studies with low level of evidence and lead-time bias was not addressed. Active surveillance was recommended in Sweden and Denmark, but not in Norway beyond the post-operative/adjuvant period. Finland had no national recommendations for surveillance. The Nordic survey revealed a wide variation in reported practice among the different units. About 75% (15 of 20 units) performed routine postoperative surveillance. Routine CA 19-9 testing was used by 80% and routine CT by 67% as part of surveillance. About 73% of centers continued follow-up until 5 years postoperatively.
UNASSIGNED: Evidence for routine long-term (i.e. 5 years) surveillance after pancreatic cancer surgery remains limited. Most pancreatic units in the Nordic countries conduct regular follow-up, but protocols vary.

OBJECTIVE: Acromegaly is associated with increased morbidity and mortality if left untreated. The therapeutic options include surgery, medical treatment, and radiotherapy. Several guidelines and recommendations on treatment algorithms and follow-up exist. However, not all recommendations are strictly evidence-based. To evaluate consensus on the treatment and follow-up of patients with acromegaly in the Nordic countries.
METHODS: A Delphi process was used to map the landscape of acromegaly management in Denmark, Sweden, Norway, Finland, and Iceland. An expert panel developed 37 statements on the treatment and follow-up of patients with acromegaly. Dedicated endocrinologists (n = 47) from the Nordic countries were invited to rate their extent of agreement with the statements, using a Likert-type scale (1-7). Consensus was defined as ≥80% of panelists rating their agreement as ≥5 or ≤3 on the Likert-type scale.
RESULTS: Consensus was reached in 41% (15/37) of the statements. Panelists agreed that pituitary surgery remains first line treatment. There was general agreement to recommend first-generation somatostatin analog (SSA) treatment after failed surgery and to consider repeat surgery. In addition, there was agreement to recommend combination therapy with first-generation SSA and pegvisomant as second- or third-line treatment. In more than 50% of the statements, consensus was not achieved. Considerable disagreement existed regarding pegvisomant monotherapy, and treatment with pasireotide and dopamine agonists.
CONCLUSIONS: This consensus exploration study on the management of patients with acromegaly in the Nordic countries revealed a relatively large degree of disagreement among experts, which mirrors the complexity of the disease and the shortage of evidence-based data.

OBJECTIVE: To document current practice and develop consensus recommendations for the assessment and treatment of paroxysmal sympathetic hyperactivity (PSH) during rehabilitation after severe acquired brain injury.
METHODS: Delphi consensus process with three rounds, based on the Guidance on Conducting and REporting DElphi Studies (CREDES) guidelines, led by three convenors (the authors) with an expert panel. Round 1 was exploratory, with consensus defined before round 2 as agreement of at least 75% of the panel.
METHODS: A working group within the Nordic Network for Neurorehabilitation.
UNASSIGNED: Twenty specialist physicians, from Sweden (9 participants), Norway (7) and Denmark (4), all working clinically with patients with severe acquired brain injury and with current involvement in clinical decisions regarding PSH.
RESULTS: Consensus was reached for 21 statements on terminology, assessment and principles for pharmacological and non-pharmacological treatment, including some guidance on specific drugs. From these, an algorithm to support clinical decisions at all stages of inpatient rehabilitation was created.
CONCLUSIONS: Considerable consensus exists in the Nordic countries regarding principles for PSH assessment and treatment. An interdisciplinary approach is needed. Improved documentation and collation of data on treatment given during routine clinical practice are needed as a basis for improving care until sufficiently robust research exists to guide treatment choices.

Denmark has recently entered a collaboration with other Nordic countries to ensure a common strategy in the management of burn mass casualties. The collaboration is based upon the guideline Emergency Management of Severe Burns originating from the Australian and New Zealand Burn Association. The desire to establish a common Nordic strategy has led to a number of changes in the national guidelines for the treatment of burn injuries. The new guidelines recently implemented at the national university hospital of Denmark, Rigshospitalet, are presented in this review.

UNASSIGNED: High-quality clinical practice guidelines are necessary for effective use of resources both at an individual patient- and national-level. Nordic clinical practice guidelines recommendations for orthotic treatment of knee osteoarthritis vary and little is known about their quality.
UNASSIGNED: The aim of the study was to critically evaluate the quality of clinical practice guidelines in orthotic management of knee osteoarthritis in the Nordic countries.
UNASSIGNED: Systematic review.
UNASSIGNED: Four national clinical practice guidelines for treatment of knee osteoarthritis were assessed for methodological rigour and transparency by four independent assessors using the AGREE II instrument. Summary domain scores and inter-rater agreement (Kendall\'s W) were calculated.
UNASSIGNED: Domain scores indicate that many guidelines have not sufficiently addressed stakeholder involvement (average score: 55%), applicability (20%) and editorial independence (33%) in the development process. Inter-rater agreement for assessors indicated \'good\' agreement for clinical practice guidelines from Finland, Norway and Sweden (W = 0.653, p < 0.001; W = 0.512, p = 0.003 and W = 0.532, p = 0.002, respectively) and \'strong\' agreement for the clinical practice guideline from Denmark (W = 0.800, p < 0.001).
UNASSIGNED: Quality of clinical practice guidelines for orthotic treatment of knee osteoarthritis in the Nordic region is variable. Future guideline development should focus on improving methodology by involving relevant stakeholders (e.g. certified prosthetist/orthotists (CPOs)), specifying conflicts of interest and providing guidance for implementation.
CONCLUSIONS: The current review suggests that, for the Nordic region, there are areas of improvement which can be addressed, which ensure clinical practice guidelines are developed under stringent conditions and based on sound methods. These improvements would ensure knee osteoarthritis patients are receiving orthotic interventions based on appropriate guidance from published guidelines.

The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults (Scandinavian guidelines) are the first to incorporate serum measurement of the S100 astroglial calcium-binding protein B (S100B) to emergency department (ED) triage of patients with head injury (HI). This prospective validation study was conducted in the ED of the Tampere University Hospital, Finland, between November 2015 and November 2016. All consecutive adult patients with HI presenting to the ED within 24 h from injury were eligible for inclusion. Venous blood for S100B sampling was drawn from all patients, and the result was available at the ED. Computed tomography (CT) scans of the head were performed according to the on-call physician\'s evaluation. Only the samples collected within 6 h after injury were used. A one-week follow-up was conducted to identify possible HI-related complications. A total of 295 patients (median age, 67.0 years, range, 18-100; women, 48.8%) were enrolled. Of those, 196 (66.4%) underwent scanning. Acute traumatic lesions were detected on 31 (15.8%) of the scans. Two of the CT-positive patients were scanned without a guidelines-based indication. These lesions did not require any specific treatment or repeated imaging. The guidelines-based sensitivity was 0.94 (95% confidence interval [CI], 0.77-0.99) and specificity 0.19 (95% CI, 0.13-0.26) for predicting traumatic intracranial CT abnormalities. The positive and negative predictive value for positive head CT was 0.18 (95% CI, 0.12-0.25) and 0.94 (95% CI, 0.78-0.99), respectively. In the mild-low risk group, no false negative S100B values were recorded. Thirteen patients (4.4%) were re-admitted to the ED, and two patients (0.7%) died one week after the primary HI. The deaths were unrelated to the injury. None of these adverse events were directly caused by a primarily undiagnosed intracranial injury. The Scandinavian guidelines incorporated with S100B are a valid means of screening clinically significant acute traumatic lesions after HI and have the potential to reduce unnecessary CT scanning.

Clinical practice guidelines from other organizations or societies with assumed clinical and contextualized relevance for Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) members, may trigger a formal evaluation by The Clinical Practice Committee (CPC) for possible SSAI endorsement. This avoids unnecessary duplicate processes and minimizes resource-waste. Identified guidelines are assessed for endorsement using the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument. The SSAI CPC utilizes the AGREE II online coordinated group appraisal platform to assess the methodological rigor and transparency in which the guideline was developed. The results of the assessment, including the decision to endorse or not, are presented to the SSAI Board for sanctioning. This document briefly outlines the process for evaluation of non-SSAI guidelines by the CPC for possible SSAI endorsement.

In 2013 the Scandinavian Neurotrauma Committee (SNC) published updated guidelines for the initial management of minimal, mild and moderate traumatic head injuries (MTHI) that included serum analysis of protein S100B as a marker for brain tissue damage. This study reviews the effectiveness of the new guidelines in a clinical setting.
For all patients admitted to Akershus University Hospital (AHUS) from June 30th 2014 to December 15th 2014 with MTHI a separate form was filled in recording the time, indication and result of any S100B sampling and/or head computer tomography (CT) examinations. Data from these forms were compared to information derived from the electronic patient records for patients with MTHI and related diagnoses and data from the laboratory for all patients that had undergone the S100B analysis within the same period.
Five hundred seventy-five patients were identified with MTHI, S100B sampling was indicated for 223 (38.8%) patients and carried out for 188 (84.3%) of these patients. 69 (36.7%) of the patients had a negative S100B test, but a head CT scan was still performed in 31 cases despite the negative S100B test. In total the guidelines were followed for 362 of 575 patients (63.0%). 180 (31.3%) of the MTHI cases were discharged without further observation or CT examinations, including 38 (21.1%) as a direct result of S100B testing. No re-admissions or missed initial traumatic brain injuries were observed.
The implementation of the updated SNC guidelines resulted in direct discharge of more than one third of the MTHI cases without further observation or CT examinations. One in five of these discharges was a direct result of S100B testing. However, compliance to the guidelines were poor and the guidelines were only followed in 40%. While this study showed benefits of implementing SNC guidelines to reduce the number of CT scans, additional training is needed for optimal use.

OBJECTIVE: Guidelines of the European Society of Cardiology (ESC) recommend that ferritin and transferrin saturation should be tested in chronic heart failure (HF) and state that iron treatment with ferric carboxymaltose should be considered in HF patients with iron deficiency to alleviate symptoms and improve exercise tolerance and quality of life. This study evaluates the cost effectiveness of the implementation of this recommendation in four Nordic countries (Denmark, Finland, Norway, and Sweden).
METHODS: We performed a cost-utility analysis comparing ferric carboxymaltose treatment with placebo over a one-year time period in each country. Data on healthcare resource use and health outcomes were taken from the CONFIRM-HF study and combined with country-specific unit costs. Differences in per-patient costs and quality-adjusted life years (QALYs) were calculated.
RESULTS: QALYs were higher (increase of 0.050 QALYs per patient) in the iron-treated group compared with placebo. Per-patient costs were lower in all countries (with reductions ranging from €36 to €484). Fewer hospitalizations were one key driver of these results. Another important driver was how well the new routines for iron treatment can be integrated into the current healthcare management of HF. A sensitivity analysis confirmed the results to be robust.
CONCLUSIONS: Iron deficiency therapy in HF with ferric carboxymaltose compared with placebo is estimated to both improve health-related quality of life and save healthcare costs in all Nordic countries. A well-organized healthcare management of HF patients can enable the implementation of ESC-recommended treatment of iron deficiency without need for additional resources.

Background and objective: Irrational use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the main cause of adverse effects-associated hospitalizations among all medication groups leading to extremely increased costs for health care. Pharmacoepidemiological studies can partly reveal such issues and encourage further decisions. Therefore, the aim of our study was to evaluate the utilization of non-opioid analgesics (ATC classification N02B and M01A) in Lithuania, and to compare it with that of other Baltic and Scandinavian countries in terms of compliance to the WHO pain treatment guidelines and the EMA safety recommendations on NSAID use. Materials and methods: The dispensing data were obtained from the sales analysis software provider in the Baltic countries (SoftDent, Ltd., Kaunas, Lithuania); State Medicine Control Agencies of Lithuania, Latvia, and Estonia; Norwegian Prescription Database; Swedish Database for Medicines; and Danish Prescription Database. Data included the utilization of both prescription and over-the-counter drugs. Utilization was expressed in defined daily doses (DDD)/1000 inhabitants/day. Results: During the 11-year period, the utilization of drugs belonging to the N02B and M01A groups increased by 22.8%, from 58.37 in 2005 to 71.68 DDD/1000 inhabitants/day in 2016 in Lithuania. Contrary to the WHO guidelines on pain management, all Baltic countries were more likely to use NSAIDs than other analgesics and antipyretics: in 2015, the drugs of the M01A group were used 6.04, 5.79, and 6.11 times more than those of N02B in Lithuania, Estonia, and Latvia, respectively, whereas the Scandinavian countries preferred the N02B to the M01A group: in Denmark and Sweden, the utilization of other analgesics and antipyretics was 2.33 and 1.24, respectively, times higher than that of NSAIDs. In Norway, the use of both groups was similar. In the Scandinavian countries, paracetamol was the analgesic of first choice, whereas, in Lithuania, it took only the third place. The most popular drug in Lithuania was diclofenac, and its utilization accounted for 30.04% of all non-opioid analgesics in 2016. Although the European Medicines Agency (EMA) restricted the use of certain NSAIDs, i.e., cyclooxygenase-2 (COX-2) inhibitors, nimesulide, and diclofenac, their use consistently increased by 15.91, 2.83, and 1.41 times, respectively, showing incompliance with the international guidelines. Conclusions: Neither the EMA safety policy on NSAID use nor the WHO pain treatment guidelines had a sufficient impact on the rational use of NSAIDs in Lithuania. The use of NSAIDs restricted by the EMA (diclofenac, COX-2 inhibitors, nimesulide, and piroxicam) remains high or even increases, while the utilization of safer alternatives (paracetamol and naproxen) remains relatively low as compared with the Scandinavian countries. Incompliance with international guidelines may result in increased morbidity, mortality and higher costs for health care.