Vibeke Backer

Bispebjerg Hospital, Copenhagen University, København, Capital Region, Denmark

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Publications (236)777.54 Total impact

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    ABSTRACT: Background: Chronic rhinosinusitis (CRS) is a common health problem that is subclassified as CRS with nasal polyps (CRSwNPs) or CRS without NPs (CRSsNP). In accordance with the united airways concept, CRSwNPs frequently coexists with asthma but to date, this association remains unexplained and its strength is uncertain. Here, we aimed to examine the association between CRSwNPs and asthma in collaboration between the neighboring specialities: otorhinolaryngology and respiratory medicine. Methods: A prospective clinical study was performed comprising 40 CRS patients scheduled for functional endoscopic sinus surgery and 21 control persons. We performed nasal endoscopy, peak expiratory flow, spirometry, and bronchodilation tests. In selected cases, additional pulmonary tests were performed. Atopy was assessed by skin-prick test or by measuring specific IgE in serum. Results: Asthma was diagnosed in 26 patients with CRSwNPs (65%; odds ratio = 5.9 [1.79, 19.65]; p = 0.003), and 5 control persons (24%). Twenty-five percent of the CRSwNP patients had undiagnosed asthma. Atopy was not significantly associated with CRSwNPs (p = 0.39) or with coexisting asthma within the CRSwNP group (p = 0.50). Conclusion: Compared with previous studies, we found a very high prevalence of asthma and, frequently, asthma was undiagnosed. Furthermore, CRSwNPs was associated with chronic bronchitis and, in those with asthma, lower airway obstruction. These results call for a closer collaboration between otorhinolaryngology and respiratory medicine in relation to patients with CRSwNPs, in research as well as in clinical practice.
    American journal of rhinology & allergy 10/2014; 28(5). · 1.74 Impact Factor
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    ABSTRACT: Elite athletes frequently suffer from asthma and airway hyperresponsiveness (AHR). We aimed to investigate predictors of airway pathophysiology in a group of unselected elite summer-sport athletes, training for the summer 2008 Olympic Games, including markers of airway inflammation, systemic inflammation and training intensity.
    Medicine and science in sports and exercise. 09/2014;
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    ABSTRACT: Exercise-induced bronchoconstriction (EIB) describes the phenomenon of transient airway narrowing in association with physical activity. Although it may seem likely that EIB would have a detrimental impact on athletic performance, this has yet to be established.
    Sports medicine (Auckland, N.Z.). 08/2014;
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    ABSTRACT: The purpose of the present study was to investigate the effect of high-dose inhaled terbutaline on muscle strength, maximal sprinting, and time-trial performance in trained men.
    European journal of applied physiology. 08/2014;
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    ABSTRACT: Our objective was to investigate effects of acute and 2-week administration of oral salbutamol on repeated sprint ability, exercise performance, and muscle strength in elite endurance athletes. Twenty male elite athletes [VO2max: 69.4 ± 1.8 (Mean ± SE) mL/min/kg], aged 25.9 ± 1.4 years, were included in a randomized, double-blinded and placebo-controlled parallel study. At baseline, after acute administration, and again after 2-week administration of the study drugs (8 mg salbutamol or placebo), subjects' maximal voluntary contraction (MVC) of m. quadriceps and isometric endurance of m. deltoideus were measured, followed by three repeated Wingate tests. Exercise performance at 110% of VO2max was determined on a bike ergometer. Acute administration of salbutamol increased peak power during first Wingate test by 4.1 ± 1.7% (P < 0.05). Two-week administration of salbutamol increased (P < 0.05) peak power during first and second Wingate test by 6.4 ± 2.0 and 4.2 ± 1.0%. Neither acute nor 2-week administration of salbutamol had any effect on MVC, exercise performance at 110% of VO2max or on isometric endurance. No differences were observed in the placebo group. In conclusion, salbutamol benefits athletes' sprint ability. Thus, the present study supports the restriction of oral salbutamol in competitive sports.
    Scandinavian Journal of Medicine and Science in Sports 08/2014; · 3.21 Impact Factor
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    ABSTRACT: trefoil factor peptides (TFF) are secreted onto mucosal surfaces together with mucins and occur in high concentrations in pulmonary secretions from patients with chronic obstructive pulmonary disease (COPD). In the present study, we aimed to explore the concentrations of the peptides in serum and sputum in patients with COPD. thirty-five individuals were included in the study, including 11 healthy individuals, 13 with asthma and 11 with COPD. TFF1, TFF2 and TFF3 were measured by ELISA in sputum induced by hypertonic saline inhalation and in serum. Total protein content in sputum was also determined. in the sputum samples from COPD patients, we observed an eight-fold higher concentration of TFF1 and a five-fold higher concentration of TFF3 compared to controls. In the serum samples from COPD patients, we observed three-, three- and two-fold higher concentrations of TFF1, TFF2 and TFF3, respectively, compared to controls. there is increased secretion of TFF peptides in the lungs of patients with COPD, as well as significant increases in serum levels. This suggests a role for TFF peptides in the pathogenesis of pulmonary diseases with mucus hypersecretion.
    The Clinical Respiratory Journal 04/2014; · 1.66 Impact Factor
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    ABSTRACT: Patterns of health-care use and comorbidities present in patients in the period before diagnosis of chronic obstructive pulmonary disease (COPD) are unknown. We investigated these factors to inform future case-finding strategies. We did a retrospective analysis of a clinical cohort in the UK with data from Jan 1, 1990 to Dec 31, 2009 (General Practice Research Database and Optimum Patient Care Research Database). We assessed patients aged 40 years or older who had an electronically coded diagnosis of COPD in their primary care records and had a minimum of 3 years of continuous practice data for COPD (2 years before diagnosis up to a maximum of 20 years, and 1 year after diagnosis) and at least two prescriptions for COPD since diagnosis. We identified missed opportunites to diagnose COPD from routinely collected patient data by reviewing patterns of health-care use and comorbidities present before diagnosis. We assessed patterns of health-care use in terms of lower respiratory consultations (infective and non-infective), lower respiratory consultations with a course of antibiotics or oral steroids, and chest radiography. If these events did not lead to a diagnosis of COPD, they were deemed to be missed opportunities. This study is registered with ClinicalTrials.gov, number NCT01655667. We assessed data for 38 859 patients. Opportunities for diagnosis were missed in 32 900 (85%) of 38 859 patients in the 5 years immediately preceding diagnosis of COPD; in 12 856 (58%) of 22 286 in the 6-10 years before diagnosis, in 3943 (42%) of 9351 in the 11-15 years before diagnosis; and in 95 (8%) of 1167 in the 16-20 years before diagnosis. Between 1990 and 2009, we noted decreases in the age at diagnosis (0·05 years of age per year, 95% CI 0·03-0·07) and yearly frequency of lower respiratory prescribing consultations (rate ratio 0·982 opportunities per year, 95% CI 0·979-0·985). Prevalence of all comorbidities present at COPD diagnosis increased except for asthma and bronchiectasis, which decreased between 1990 and 2007, from 281 (33·4%) of 842 patients to 451 of 1465 (30·8%) for asthma, and from 53 of 842 (6·3%) to 53 of 1465 (3·6%) for bronchiectasis. In the 2 years before diagnosis, of 6897 patients who had had a chest radiography, only 2296 (33%) also had spirometry. Opportunities to diagnose COPD at an earlier stage are being missed, and could be improved by case-finding in patients with lower respiratory tract symptoms and concordant long-term comorbidities. UK Department of Health, Research in Real Life.
    The lancet. Respiratory medicine. 04/2014; 2(4):267-76.
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    ABSTRACT: Abstract Background: Several studies have suggested a relationship between the age at menarche and risk of asthma. Objective: To conduct a systematic review and meta-analysis of the relationship between the age at menarche and the risk of asthma. Methods: This systematic review and meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). A pre specified literature search strategy was used to identify studies of potential relevance and independent reviews were carried out by two authors. Raw data was pooled using the software package RevMan to calculate summary odds ratios. The risk of publication bias was assessed graphically by using a funnel plot and the robustness of the overall estimate obtained was assessed by using sensitivity analyses. Results: The searches identified 61 potentially relevant articles of which seven matched the inclusion criteria required for the meta-analysis, with a total of 22,859 subjects. Pooling of the seven studies showed that girls with early menarche (<12 years) had an increased risk of asthma relative to girls with late menarche; random effects odds ratio=1.37 (1.15-1.64), (p=0.0005). Substantial heterogeneity was revealed (I(2)=55%). Sensitivity analysis showed that the risk estimate was not markedly changed when excluding any of the studies. The funnel plot did not indicate publication bias. Conclusions: Early menarche appears to be associated with increased risk of asthma. Hormonal, immunological, genetic, and environmental factors may act in a developmental context to explain this relationship. Future studies are warranted to further determine the mechanisms responsible for this observation.
    Journal of Asthma 03/2014; · 1.85 Impact Factor
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    Kristian Aasbjerg, Vibeke Backer
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    ABSTRACT: Treatment for seasonal allergic rhinitis induced by airborne allergens can be divided into two major groups: symptom-dampening drugs, such as antihistamines and corticosteroids, and disease-modifying drugs in the form of immunotherapy. It has been speculated that depot-injection corticosteroids given once or twice a year are a safe and patient-friendly alternative to the time-consuming immunotherapy. Our data indicate otherwise.
    Expert Review of Clinical Immunology 02/2014; 10(2):171-3. · 2.89 Impact Factor
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    ABSTRACT: Abstract Objective: Ongoing airway inflammation measured by fractional exhaled nitric oxide (FENO) and airway hyperresponsiveness (AHR) to mannitol are associated in selected asthma patients, but no evidence exists of this association in unselected asthma patients. The aim was to investigate the association between FENO and AHR to mannitol in unselected individuals with possible asthma. Methods: A real-life study on patients with possible asthma referred to a specialized asthma clinic. Data on asthma history, FEV1, FENO, atopy, smoking, treatment and AHR to mannitol were collected. Results: In 217 unselected patients with symptoms suggestive of asthma, FENO and response to mannitol were tested. Of the 141 who underwent both tests, 32 (23%) had FENO > 25 ppb, and 58 (41%) had AHR to mannitol. A significant association between high FENO and AHR was found (p < 0.001); 26% responded to mannitol despite a normal NO, and 8% had a high FENO but no AHR. Additionally, a weak association was found between log FENO and log response to mannitol (r = 0.32, p < 0.01). The area under the ROC curve for FENO as a predictor of AHR was 0.66 (95% CI 0.6-0.8) and for mannitol for having high FENO was 0.73 (95%CI 0.6-0.9). Conclusion: In a large sample of patients referred to an asthma clinic, an association was found between FENO and AHR to mannitol. However, a significant proportion of asthma patients had a normal FENO despite having AHR, suggesting that in some patients, AHR to mannitol is not driven by eosinophilic airway inflammation.
    Journal of Asthma 01/2014; · 1.85 Impact Factor
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    ABSTRACT: The development of atopic diseases early in life suggests an important role of perinatal risk factors. To study whether early life exposures modify the genetic influence on atopic diseases in a twin population. Questionnaire data on atopic diseases from 850 monozygotic and 2,279 like-sex dizygotic twin pairs, 3-9 years of age, from the Danish Twin Registry were cross-linked with data on prematurity, Caesarean section, maternal age at birth, parental cohabitation, season of birth, and maternal smoking during pregnancy, from the Danish National Birth Registry. Significant predictors of atopic diseases were identified with logistic regression and subsequently tested for genetic effect modification using variance components analysis. After multivariable adjustment, prematurity (gestational age below 32 weeks) (OR=1.93, CI=1.45-2.56); Caesarean section (OR=1.25, CI=1.05-1.49); and maternal smoking during pregnancy (OR=1.70, CI=1.42-2.04) significantly influenced the risk of asthma, whereas none of the factors were significantly associated with atopic dermatitis and hay fever. Variance components analysis stratified by exposure status showed no significant change in the heritability of asthma according to the identified risk factors. In this population-based study of children there was no evidence of genetic effect modification of atopic diseases by several identified early life risk factors. The causal relationship between these risk factors and atopic diseases may therefore be mediated via mechanisms different from gene-environment interaction.
    The Clinical Respiratory Journal 01/2014; · 1.66 Impact Factor
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    ABSTRACT: Introduction: Asthma is one of the most widespread chronic diseases worldwide. In spite of numerous detrimental effects on asthma, smoking is common among asthma patients. These smoking-induced aggravations of asthma may be attributed to changes in airway inflammation, which is characterized by a higher degree of neutrophilic inflammation than in non-smokers. A state of neutrophilic inflammation may lead to increased steroid resistance and an accelerated loss of lung function owing to tissue destruction. The aim of the present study was to elucidate predictors of neutrophilic inflammation in young asthmatic smokers not on steroid treatment, including analysis of tobacco history and bacterial colonization. Methods: In a cross-sectional study, 52 steroid-free, current smokers with asthma were examined with induced sputum, fractional exhaled nitric oxide (FeNO), lung function, ACQ6 score, mannitol and methacholine challenge. A sample from the sputum induction was taken for bacterial analysis using 16S gene PCR technique and sequencing. Results: Using one-way ANOVA and binary and linear regression models, only age and ACQ6 score were found to be significant predictors for airway neutrophilia. The investigation also included analysis for effect of pack years, current tobacco consumption, body mass index, lung function, FeNO; methacholine and mannitol responsiveness, atopy, gender, asthma history and presence of bacteria. The most common potentially pathogenic bacteria found were Streptococcus spp., Haemophilus spp. and Mycoplasma spp. Conclusion: In the present study, no tobacco related predictors of airway neutrophilia were found, indicating that in the younger years of asthma patients who smoke, the amount of tobacco smoked in life does not influence the degree of neutrophilia. Conversely, for asthmatic smokers neutrophilia may be induced when a certain threshold of tobacco consumption is reached.
    Journal of Asthma 01/2014; · 1.85 Impact Factor
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    ABSTRACT: Background Smoking is a major risk factor for lung diseases and lower respiratory symptoms, but since not all smokers develop chronic bronchitis and since chronic bronchitis is also diagnosed in never-smokers, it has been suggested that some individuals are more susceptible to develop chronic bronchitis due to genetics. Objective To study the relative influence of genetic and environmental factors on the variation in the susceptibility to chronic bronchitis. Methods In a population-based questionnaire study of 13,649 twins, 50-71 years of age, from the Danish Twin Registry, we calculated sex-specific concordance rates and heritability of chronic bronchitis. The response rate was 75%. Results The prevalence of chronic bronchitis was 9.3% among men and 8.5% among women. The concordance rate for chronic bronchitis was higher in monozygotic twins than in dizygotic twins among women; 0.30 vs. 0.17, but not among men; 0.15 vs. 0.18. The heritability of chronic bronchitis adjusted for smoking and age was 55% (36-71%) in women, whereas the susceptibility to chronic bronchitis in men for 25% (8-41%) was ascribable to familial environment but not to genetic factors. Conclusions Chronic bronchitis shows a moderate familial aggregation, particularly in women. Increased susceptibility to respiratory disease among female smokers relative to male smokers may have a genetic origin.
    Respiratory Medicine. 01/2014;
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    ABSTRACT: Background The prevalence of severe asthma is unknown. However, international expert statements estimate that severe asthma represents 5% to 10 % of the entire asthma population. Objective Based on register data from a nationwide population, we wanted to investigate the prevalence of severe asthma, the extent of asthma control, and contact with specialist care. Methods A descriptive cross-sectional register study was performed. By using a nationwide prescription database, we identified current patients with asthma (age, 18-44 years) in 2010. Severity was classified as severe versus mild-moderate asthma according to the level of antiasthma treatment. We investigated prescription drug use, hospitalizations, emergency department visits, and outpatient clinic visits according to severity. Results Among a nationwide population, we identified 61,583 current patients with asthma. Based on the level of antiasthma treatment, 8.1% of identified patients was classified as having severe asthma. Low asthma control (dispensed prescriptions of prednisolone, emergency department visits, hospitalization, or excessive short-acting β2-agonist use) was more frequent in subjects with severe asthma (36.4% vs 25.2%, P < .0001); 63.8% with severe asthma and low asthma control were not managed by specialist care. Patients with severe asthma with specialist contact more frequently had impaired asthma control compared with subjects not treated by a specialist (44.4% vs 33.1%, P < .0001). Conclusion Based on the level of treatment, 8.1% of a nationwide population of current patients with asthma was classified as having severe asthma. Low asthma control was more frequent among subjects with severe asthma, and only a minority had access to specialist care. There is room for optimizing asthma management, particularly among patients with severe disease.
    The Journal of Allergy and Clinical Immunology: In Practice. 01/2014;
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    ABSTRACT: Background Long-term longitudinal studies of lung function from childhood to adulthood are important in linking our understanding of childhood risk factors to adult disease. Airway hyperresponsiveness has been shown to independently affect lung function growth in studies of adolescence. The objective of the study was to test the hypothesis that airway hyperresponsiveness has an independent deleterious effect on lung function in adolescence that extends into adulthood. Methods A random population sample (n=983) aged 7-17 from Copenhagen was followed longitudinally for 20 years with four examinations. Results A total of 780 (79.3%) subjects contributed with lung function measurements and bronchial provocation testing. Among these, 170 (21.8%) had airway hyperresponsiveness at one examination or more during the study period. There was no difference in initial FEV1 levels between subjects with and without airway hyperresponsiveness. In a repeated measures regression model with adjustment for asthma and smoking, airway hyperresponsiveness was independently associated with reduced rates of growth in lung function in both sexes of 23 ml/year. Reduced growth rates resulted in deficits in maximal attained level of lung function at age 18, which persisted throughout the follow-up until the last examination at age 27-37 years. Conclusion Airway hyperresponsiveness has an independent deleterious effect on lung function development from 7 to 37 years resulting in a lower maximal attained lung function and persistent deficits in lung function in adulthood.
    Respiratory medicine 01/2014; · 2.33 Impact Factor
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    ABSTRACT: Reproductive changes such as impaired fertility and adverse pregnancy outcomes have been related to female asthma. We recently found that time to pregnancy is prolonged in asthmatic females especially in women with moderate to severe asthma and in those above 30 years of age. Despite their reproductive difficulties the asthmatics ultimately conceived just as many biological children as healthy throughout their reproductive lives. This knowledge therefore raises questions about how asthma affects fertility pathophysiologically. The purpose of this review is to describe the existing knowledge in this field and suggest hypotheses of causal relationships, which may form the basis for future studies in this field. The aim is, in particular, in the literature to examine whether there is any evidence to suggest that the systemic inflammation that characterizes asthma, can affect fertility. The issue is potentially clinically important for asthmatic, infertile individuals and society because treatment of the general systemic inflammation associated with the asthmatic disease combined with hormone stimulation might be the optimal target for an effective infertility therapy, possibly decreasing the need for in vitro fertilization.
    ISRN allergy. 01/2014; 2014:131092.
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    ABSTRACT: Background Late onset asthma is associated with more severe disease and higher morbidity than in younger asthma patients. This may in part relate to under recognition of asthma in older adults, but evidence on the impact of patient age on diagnostic assessment of asthma in a specialist setting is sparse. Aim To examine the impact of patient age on the type and proportion of diagnostic tests performed in patients undergoing specialist assessment for asthma. Methods Data from a clinical population consisting of all patients consecutively referred over a 12 months period to a specialist clinic for assessment of asthma were analysed. Results A total of 224 patients with asthma or suspected asthma were referred during the 12 month period; 86 adults aged < 35 years, 95 aged 35-55 years and 43 aged > 55 years. Symptom characteristics were similar, but adults > 35 years had a lower lung function than younger adults, and were more frequently smokers. However, a regression analysis showed that older age was associated with a lower likelihood of diagnostic assessment with a reversibility test, a bronchial challenge test, or measurement of exhaled NO, independently of a known diagnosis of asthma, smoking habits and lung function at referral. Conclusion A lower level of diagnostic assessment was observed already after the age of 35 years, indicating a risk for under diagnosis of asthma at an earlier patient age than previously thought.
    Respiratory Medicine. 01/2014;
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    ABSTRACT: The mannitol test was developed as an easy-to-use, safe, standardized bronchial challenge test for diagnosing asthma in a wide range of clinical settings. The mannitol test has a moderate sensitivity and will only detect approximately 60% of asthma cases. Hence, a negative mannitol test cannot be used to rule out asthma. The advantage of the mannitol test is a high specificity. In an individual with symptoms suggestive of asthma, a positive test indicates a high likelihood of asthma with ongoing airway inflammation and seems useful for detecting asthma requiring regular anti-inflammatory therapy. In this review, the current knowledge on the usefulness of the mannitol in a clinical setting as well as in clinical trials is presented and outstanding questions on the usefulness of the test are discussed.
    Expert Review of Respiratory Medicine 12/2013; 7(6):655-63.
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    ABSTRACT: Smoking has been shown to have several detrimental effects on asthma, including poor symptom control, attenuated treatment response and accelerated decline in lung function. In spite of this, smoking is at least as common among asthma patients as in the rest of the population. The aggravations of smoking on asthma may be caused by effects on airway inflammation, which has been found to be changed in asthmatic smokers. It is not known whether these smoking-induced airway inflammation changes are reversible after smoking cessation. The aim of the present study was to assess airway changes in asthmatic smokers before and during smoking cessation. 46 smokers with asthma, all steroid-free (age range: 19-40), were recruited. All participants attempted smoking cessation over a period of 3 months. Visits were performed at weeks 0, 6 and 12 and included induced sputum, FeNO, methacholine challenge, lung function, asthma control questionnaire (ACQ6) and exhaled CO. 26 of 46 patients succeeded in quitting smoking. In the quitters, improvements in methacholine AHR (77% before and 52% after smoking cessation, respectively, p=0.016) and ACQ6 score (1.7 to 0.7, p<0.034) and FeNO (p=0.002) were observed, whereas no significant changes were found regarding eosinophils or lung function. A small but significant decrease in neutrophils (54.1% to 52.0%, p=0.003) was present in quitters compared with the non-quitters. Non-quitters experienced no changes in any parameters. Smoking cessation improved asthma control, but the changes were not be related to change in eosinophilic inflammation, and the reduction in neutrophils was small. Thus, airway inflammation with eosinophils and neutrophils may be less important drivers of asthma control in smokers than other factors. Smoking cessation may improve clinically important disease parameters such as AHR and symptom score, but likely unrelated to changes in airway inflammation. This article is protected by copyright. All rights reserved.
    Clinical & Experimental Allergy 11/2013; · 4.79 Impact Factor
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    ABSTRACT: Coexistence of infertility and asthma has been observed clinically. We therefore investigated the association between asthma and delayed pregnancy in a nationwide population-based cohort of twins.A cohort of 15250 twins living in Denmark (aged 12-41 years) participated in a questionnaire study including questions about the presence of asthma and fertility. Differences in time to pregnancy and pregnancy outcome were analysed in subjects with asthma, allergy and in healthy individuals using multiple regression analysis.Asthma was associated with increased time to pregnancy 27% vs. 21.6%, OR=1.31 (1.1-1.6), p=0.009. The association remained significant after adjustment for age, age at menarche, BMI and socioeconomic status (p=0.05 OR=1.25(1-1.6)), and was more pronounced in those above 30 years of age (32.2% vs. 24.9% p=0.04 OR=1.44 (1.1-1.9)). Untreated asthmatics had significant increased risk of prolonged TTP compared to healthy individuals (OR=1.79 (1.2-2.66) p=0.004), while asthmatics receiving any kind of treatment for asthma trended having a shorter TTP than untreated asthmatics (OR=1.40, p=0.134).Asthma prolongs time to pregnancy. The negative effect of asthma on fertility increases with age and is growing with disease intensity, indicating that a systemic disease characterized by systemic inflammation also can involve reproductive processes.
    European Respiratory Journal 11/2013; · 6.36 Impact Factor

Publication Stats

3k Citations
777.54 Total Impact Points

Institutions

  • 1995–2014
    • Bispebjerg Hospital, Copenhagen University
      • • Department of Clinical Physiology and Nuclear Medicine
      • • Department of Pulmonary Medicine
      København, Capital Region, Denmark
  • 2012
    • Uppsala University
      • Department of Medical Sciences
      Uppsala, Uppsala, Sweden
  • 2011
    • Roskilde Hospital
      Roskilde, Zealand, Denmark
  • 2004–2011
    • University of Copenhagen
      København, Capital Region, Denmark
  • 2009
    • Imperial College London
      • Section of Airway Disease
      Londinium, England, United Kingdom
    • Statens Serum Institut
      • Department of Epidemiology Research
      Copenhagen, Capital Region, Denmark
  • 1990–2007
    • Copenhagen University Hospital Hvidovre
      • • Department of Clinical Biochemistry
      • • Department of Infectious Diseases
      Hvidovre, Capital Region, Denmark
  • 2003
    • National Institute of Public Health
      København, Capital Region, Denmark
    • National Institute of Public Health, Denmark
      København, Capital Region, Denmark
  • 1999
    • Children's Heart Center
      Las Vegas, Nevada, United States
  • 1992–1996
    • Rigshospitalet
      • Department of Clinical Physiology, Nuclear Medicine and PET
      Copenhagen, Capital Region, Denmark
  • 1994
    • Glostrup Hospital
      • Department of Paediatrics
      København, Capital Region, Denmark
  • 1989–1994
    • The Ohio State University
      • • Division of Hospital Medicine
      • • Department of Internal Medicine
      Columbus, OH, United States
  • 1990–1993
    • Copenhagen University Hospital
      København, Capital Region, Denmark