Readmission and mortality in patients discharged with a diagnosis of medical observation and evaluation (Z03*-codes) from an acute admission unit in Denmark: a prospective cohort study

Background

We assessed the 30-day risk of readmission and mortality among patients receiving an International Classification of Diseases 10th edition diagnosis of medical observation and evaluation (Z03*) following admission to an acute medical admission unit (AMAU), stratified on any further specification of diagnosis during hospital stay.

Methods

We used Central Denmark’s (Midt)-Electronic Patient Journal to identify patients with a Z03*-diagnosis among patients admitted to the AMAU, Aarhus University Hospital Nørrebrogade from April 2012 to March 2013, and noted any specification of diagnosis. Patients were followed from hospital discharge until death, emigration, or completion of 30 days follow-up.

Results

Of 409 patients with an initial Z03* diagnosis at the AMAU, 55% (n = 226) received a more specific discharge diagnosis after transferral to other departments. Among patients discharged to home with a Z03*-diagnosis, 30% were readmitted within 30 days, while the corresponding figure was 23% for patients receiving a specific diagnosis (p = 0.06). In contrast, corresponding figures for 30-day mortality were 3% for Z03*-diagnosed patients and 10% for those who obtained a specific diagnosis (p = 0.003).

Conclusions

Patients diagnosed with Z03* at hospital discharge have a substantially lower 30-day mortality, but a higher readmission-rate, compared to patients who obtain a specific diagnosis during the entire hospital stay.

Patient-level predictors of achieving early glycaemic control in Type 2 diabetes mellitus: a population-based study

AIMS

To identify individual predictors of early glycaemic control in people with Type 2 diabetes mellitus after initiation of first glucose-lowering drug treatment in everyday clinical practice.

METHODS

Using medical registries, we identified a population-based cohort of people with a first-time glucose-lowering drug prescription in Northern Denmark in the period 2000-2012. We used Poisson regression analysis to examine patient-level predictors of success in reaching early glycaemic control [HbA_1c target of < 53 mmol/mol (7%)] < 6 months after treatment start.

RESULTS

Among the 38 418 people (median age 63 years), 27 545 (72%) achieved early glycaemic control. The strongest predictor of achieving early control was pre-treatment HbA_1c level; compared with a pre-treatment HbA_1c level of ≤ 58 mmol/mol (7.5%), the adjusted relative risks of attaining early control were 0.63 (95% CI 0.61-0.64) for baseline HbA_1c levels of > 58 and ≤ 75 mmol/mol (> 7.5 and ≤ 9%), and 0.58 (95% CI 0.57-0.59) for a baseline HbA_1c level of > 9% (> 75 mmol/mol). All other examined predictors were only weakly associated with the chance of achieving early control. After adjustment, the only characteristics that remained independently associated with early control (in addition to high baseline HbA_1c ) were being widowed (adjusted relative risk 0.95; 95% CI 0.93-0.97) and having a high Charlson comorbidity index score (score ≥ 3; adjusted relative risk 0.94; 95% CI 0.90-0.97).

CONCLUSIONS

In a real-world clinical setting, people with Type 2 diabetes mellitus initiating glucose-lowering medication had a similar likelihood of achieving glycaemic control, regardless of sex, age, comorbidities and other individual factors; the only strong and potentially modifiable predictor was HbA_1c before therapy start.

Overall and cause-specific mortality after Roux-en-Y gastric bypass surgery: A nationwide cohort study

BACKGROUND

Few population-based studies provide data on mortality after bariatric surgery. We hypothesized that hypoglycemia could be an underdiagnosed cause of death.

OBJECTIVES

To examine perioperative, all-cause, and cause-specific long-term mortality in Roux-en-Y gastric bypass (RYGB) patients versus population comparisons.

SETTING

Danish nationwide population-based cohort study.

METHODS

We included all 9895 patients who underwent RYGB during 2006-2010, and a 1:25 age- and gender-matched comparison cohort (n = 247,366) (0.3% lost to follow up). We compared mortality rates and computed mortality rate ratios (MRR) for all-cause and cause-specific mortality using Cox regression analysis. For deceased RYGB patients (n = 91), we conducted a detailed medical record audit.

RESULTS

The perioperative (30-days) mortality after RYGB was .04% (4/9895). After 4.2 years, RYGB-related mortality (deaths due to intestinal obstruction/intra-abdominal leakage) was .15% (16/9895). All-cause mortality was very similar in the 2 cohorts (median age, 40.2 years; 21.7% men): RYGB cohort, .89% (n = 91); comparison cohort, .92% (n = 2204); MRR = 1.03 (95% confidence interval [CI], .84-1.27). Mortality due to suicide (2.78; 95% CI, 1.44-5.33), accidents (2.29; 95% CI, 1.16-4.54), gastrointestinal diseases (2.01; 95% CI, 1.06-3.84), and infectious diseases (1.75; 95% CI, .98-3.17) was higher in the RYGB cohort versus comparison groups, but mortality from cancer was lower (0.43; 95% CI, .27-.70). Our medical record audit indicated that 8% of deaths after RYGB (n = 7) were possibly hypoglycemia related.

CONCLUSION

Perioperative mortality after RYGB is low in Denmark, and subsequent all-cause mortality is similar to that of matched comparisons. After RYGB, patients have substantially increased mortality due to external causes such as suicide, accidents, and possibly hypoglycemia.

Appendectomy and risk of Parkinson's disease: A nationwide cohort study with more than 10 years of follow-up

OBJECTIVES

The appendix may be a key site for the initiation of Parkinson's disease (PD) pathology. We examined the hypothesis that appendectomy is associated with lower PD risk.

METHODS

We used Danish medical and administrative registries to construct a cohort of all patients in Denmark with an operation code of appendectomy during 1980-2010 (n = 265,758) and a matched general population comparison cohort (n = 1,328,790). Using Cox regression, we computed hazard ratios and corresponding 95% confidence intervals for PD, adjusting for potential confounders and stratifying on age at appendectomy (≤45 years / > 45 years), sex, and follow-up time.

RESULTS

During follow-up ( > 10 years), PD incidence was 0.19 and 0.15 per 1,000 person-years at risk in the appendectomy cohort and in the general population comparison cohort, respectively, yielding a slightly increased risk of PD (adjusted hazard ratio = 1.14; 95% confidence interval 1.03-1.27). Findings were consistent after more than 20 years of follow-up and when stratified on age of appendectomy and sex.

CONCLUSION

Appendectomy was associated with a small increase in PD risk 10 or more years after surgery. © 2016 International Parkinson and Movement Disorder Society.

Bowel wall visualisation at CT colonography

Purpose: To evaluate the quality of bowel wall visualisation at CT colonography and the impact of examination in the supine and prone positions.

Material and Methods: After bowel preparation, 111 patients underwent CT colonography. Air distension, degree of fluid redistribution with change in body position (supine and prone), influence of residual stool on bowel wall assessability, and quality of overall colon visualisation were evaluated using scales.

Results: Thirty of 110 patients (27%) had complete overall visualisation of the colon wall and 52 (47%) had subtotal visualisation of a limited part of the colon. The entire colon was more often air-filled in the prone position (46%) than in the supine position (18%). Joint review of supine and prone data showed that for all colon segments, except the sigmoid (86%), ≥95% of the patients had complete air filling. All patients had residual fluid. In 75% to 99%, depending on segment, fluid did not interfere with the bowel wall visualisation in the combined evaluation of supine and prone data sets. Thirty-one patients had residual stool with potential negative influence on polyp detection.

Conclusions: The colon wall was completely, or almost completely, visualised in 75% of the patients, and examination in the supine and prone positions was necessary for complete visualisation.

Hand function in Charcot Marie Tooth: test retest reliability of some measurements

Objective: To evaluate the reliability of some measurements of hand function in people with Charcot Marie Tooth disease.

Design: Test retest study.

Setting: University, hospitals/clinics in northern Sweden.

Subjects: Twenty people with Charcot Marie Tooth disease.

Main outcome measures: Measures of (1) dexterity; Box and Block Test and Nine-Hole Peg Test, (2) strength; Grippit instrument (grip and pinch), (3) tactile sensation; Shape Texture Identification Test. Statistics used: intraclass correlation (ICC 2.1), limits of agreement, coefficient of repeatability, coefficient of variation, and linear weighted kappa.

Results: The ICC for the Box and Block Test was very high (0.95). The limits of agreement, coefficient of repeatability (CR) (11.5 blocks/min) and coefficient of variation (CV) (8.4%) were acceptable. There was bias towards a better result on the second occasion. For the Nine-Hole Peg Test, the reliability was good if performance was within 2 min (ICC =0.99, CR = 4.3 s, CV = 3.9%). Grip strength proved to be reliable (ICC = 0.99, CR = 26.7 N, CV = 6.6%), while pinch strength was less reliable. The kappa value of the Shape Texture Identification Test was 0.87, which was considered very good although the test has limitations in terms of how well it can describe patients either performing very well or very poorly.

Conclusions: The tested instruments can all be used to evaluate hand function in people with Charcot Marie Tooth. Certain factors, however, like limited time aspects for the Nine-Hole Peg Test and the number of trials used, should be taken into consideration. Pinch strength evaluation should be interpreted with caution.

Health-Related Quality of Life in Pacemaker Patients: A Single and Multidimensional Self-Rated Health Comparison Study

Since implantation of the first permanent pacemaker in 1958, significant advances have been made in pacemaker technology. To date, however, health-related quality of life (HRQoL) in a large pacemaker population has not been investigated. With dwindling clinical resources, it is important to study HRQoL in a pacemaker population in a reliable and straightforward manner. This study aimed to determine and compare single and multidimensional self-rated health (SRH) in a pacemaker population in terms of sociodemographic characteristics, pacemaker mode and symptoms. The findings showed that irrespective of whether the perspective was single or multidimensional, this Swedish pacemaker population (n=697) with a mean age of 76 years had an acceptable HRQoL. Men, aged 65-84 years, persons who were cohabiting, who had their own dwelling, who had a DDD or who had a pacemaker for <or=3 and 4-7 years experienced better HRQoL. Efforts need to be made for women, single persons, the elderly and retired persons. In conclusion, the SRH of a pacemaker population can be trustworthy established by means of a single-dimensional SRH question.

Prevalence, severity, and predictors of symptoms of dumping and hypoglycemia after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) results in pronounced weight loss in morbidly obese patients but may also cause adverse effects like early dumping and hypoglycemia. Prevalence data on these complications and their potential predictors are sparse.

OBJECTIVE

To assess the prevalence and possible predictors of early dumping and hypoglycemia in a population-based cohort of RYGB patients.

SETTING

University Hospital, Denmark.

DESIGN

A questionnaire survey was performed in the Central Denmark Region including RYGB-operated patients (years 2006-2011, n = 2238) and a nonoperated comparison cohort (n = 89). The Dumping Rating Scale and the Edinburgh Hypoglycemia Scoring System, together with demographic and clinical characteristics, were used, and possible predictors were examined by logistic regression.

RESULTS

The response rate was 64% (1429/2238). In total, 9.4% (134/1429) and 6.6% (95/1429) experienced moderate or severe symptoms of early dumping and hypoglycemia, respectively, which were significantly higher than in the comparison cohort. Because 3.4% (95% CI: 2.5-4.4) of the RYGB group experienced both early dumping and hypoglycemia, the total prevalence of 1 or both conditions was 12.6 (95% CI 10.9-14.4). Possible predictors for both conditions were body mass index (BMI)<25 kg/m² (odds ratio [OR] 1.70 (95% CI: 0.98-2.95) and OR 1.60 (95% CI: .83-3.06), respectively) compared with patients with BMI 25-30 kg/m². Younger age seemed to increase the risk of both conditions (<35 yr: OR 1.75 (95% CI: 1.11-2.75) and OR .59 (95% CI: .93-2.72), respectively) compared with patients>45 years.

CONCLUSION

Symptoms of early dumping and hypoglycemia were rather common with a prevalence of 1 or both conditions of 12.6% after RYGB. Predictors included younger age and a lower BMI.

Adjustment disorder and risk of Parkinson's disease

BACKGROUND AND PURPOSE

It has been postulated that stress is part of the etiological process of Parkinson's disease (PD). The risk of PD was examined in a cohort of patients with adjustment disorders, a diagnosis made in the presence of a severe response to a stressful life event.

METHODS

Using Danish medical registries, PD occurrence was examined in a nationwide population-based cohort of patients with adjustment disorder diagnosed between 1995 and 2011. The standardized incidence ratio of PD was calculated as the ratio of observed to expected cases, stratified by time and potential risk factors, including depression and anxiety.

RESULTS

Our adjustment disorder cohort (67 786 patients) was followed for a median of 8 years (interquartile range 4, 12.6 years). During follow-up, 119 patients developed PD, versus 64 expected, corresponding to a standardized incidence ratio of 1.84 (95% confidence interval 1.53, 2.20). Consistent results were observed after stratification on potential risk factors, including depression and anxiety.

CONCLUSION

Adjustment disorder, a diagnosis made in the presence of severe response to stressful life events, was associated with an increased risk of PD.

Association of parental history of type 2 diabetes with age, lifestyle, anthropometric factors, and clinical severity at type 2 diabetes diagnosis: results from the DD2 study

BACKGROUND

We investigated whether parental history of type 2 diabetes mellitus (T2D) is associated with age, lifestyle, anthropometric factors, and clinical severity at the time of T2D diagnosis.

METHODS

We conducted a cross-sectional study based on the Danish Centre for Strategic Research in Type 2 Diabetes cohort. We examined the prevalence ratios (PR) of demographic, lifestyle, anthropometric, and clinical factors according to parental history, using Poisson regression adjusting for age and gender.

RESULTS

Of 2825 T2D patients, 34% (n = 964) had a parental history of T2D. Parental history was associated with younger age at diagnosis [adjusted (a)PR 1.66, 95% confidence interval: 1.19, 2.31) for age <40 years; aPR 1.36 (95% confidence interval: 1.24, 1.48) for ages 40-59 years] and with higher baseline fasting plasma glucose [≥7.5 mmol/L, aPR 1.47 (95% confidence interval: 1.20, 1.80)], and also tended to be associated with lower beta cell function. In contrast, patients both with and without a parental history had similar occurrence of central obesity [91% vs. 91%], weight gain ≥30 kg since age 20 [52% vs. 53%], and lack of regular physical activity [60% vs. 58%]. Presence of diabetes complications or comorbidities at T2D diagnosis was not associated with parental history.

CONCLUSIONS

The lack of an association between parental history and adverse lifestyle factors indicates that T2D patients do not inherit a particular propensity for overeating or inactivity, whereas patients with a parental history may have more severe pancreatic beta cell dysfunction at diagnosis.

Evaluation of two instruments of perceived symptom intensity in palliative care patients in an outpatient clinic

AIMS AND OBJECTIVES

To evaluate the test-retest stability in assessments of perceived symptom intensity on the Edmonton Symptom Assessment System-revised and the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative. The possible interchangeability between the instruments and the patients' experiences of completing the instruments were also studied.

BACKGROUND

The two instruments assess the same symptoms, but the symptom intensity is assessed on 11-point numerical scales on the Edmonton Symptom Assessment System-revised and on four-point verbal descriptive scales on the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative. Both instruments are commonly used; however, uncertainty exists about which instrument should be recommended and about the interchangeability of the instruments.

DESIGN

This study used a test-retest design with inter-scale comparisons.

METHODS

Data from 54 patients with cancer who were receiving palliative care in an oncology outpatient clinic were self-reported by the patients in the clinic, at home and when patients returned to the clinic.

RESULTS

The assessments on the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative verbal rating scales showed a higher level of test-retest stability than the assessments on the Edmonton Symptom Assessment System-revised numerical scoring scales, indicating higher reliability. The correspondence between the verbal categories and the numerical scores of symptom intensity were low because different verbal categories were used by patients who assessed the same numerical score.

CONCLUSIONS

The test-retest stability in the assessments was higher on the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative and the results show that assessments on the two instruments could not be used interchangeably. Therefore, the symptom instrument chosen must be specified and unchanged within a patient to improve efficacy in clinical practice.

RELEVANCE TO CLINICAL PRACTICE

The Edmonton Symptom Assessment System-revised or the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative can be used for initial assessments of patients, but should not be compared or used interchangeably. It is vitally important to have individual follow-up for all patients who score an instrument.

Compound-specific stable isotope analysis of nitrogen-containing intact polar lipids

RATIONALE

Compound-specific isotope analysis (CSIA) of nitrogen in amino acids has proven a valuable tool in many fields (e.g. ecology). Several intact polar lipids (IPLs) also contain nitrogen, and their nitrogen isotope ratios have the potential to elucidate food-web interactions or metabolic pathways. Here we have developed novel methodology for the determination of δ(15)N values of nitrogen-containing headgroups of IPLs using gas chromatography coupled with isotope-ratio mass spectrometry.

METHODS

Intact polar lipids with nitrogen-containing headgroups were hydrolyzed and the resulting compounds were derivatized by (1) acetylation with pivaloyl chloride for compounds with amine and hydroxyl groups or (2) esterification using acidified 2-propanol followed by acetylation with pivaloyl chloride for compounds with both carboxyl and amine groups. The δ(15)N values of the derivatives were subsequently determined using gas chromatography/combustion/isotope-ratio mass spectrometry.

RESULTS

Intact polar lipids with ethanolamine and amino acid headgroups, such as phosphatidylethanolamine and phosphatidylserine, were successfully released from the IPLs and derivatized. Using commercially available pure compounds it was established that δ(15)N values of ethanolamine and glycine were not statistically different from the offline-determined values. Application of the technique to microbial cultures and a microbial mat showed that the method works well for the release and derivatization of the headgroup of phosphatidylethanolamine, a common IPL in bacteria.

CONCLUSIONS

A method to enable CSIA of nitrogen of selected IPLs has been developed. The method is suitable for measuring natural stable nitrogen isotope ratios in microbial lipids, in particular phosphatidylethanolamine, and will be especially useful for tracing the fate of nitrogen in deliberate tracer experiments.

Associations between stress disorders and cardiovascular disease events in the Danish population

OBJECTIVES

Post-traumatic stress disorder (PTSD) is a well-documented risk factor for cardiovascular disease (CVD). However, it is unknown whether another common stress disorder-adjustment disorder--is also associated with an increased risk of CVD and whether gender modifies these associations. The aim of this study was to examine the overall and gender-stratified associations between PTSD and adjustment disorder and 4 CVD events.

DESIGN

Prospective cohort study utilising Danish national registry data.

SETTING

The general population of Denmark.

PARTICIPANTS

PTSD (n=4724) and adjustment disorder (n=64,855) cohorts compared with the general population of Denmark from 1995 to 2011.

PRIMARY OUTCOME MEASURES

CVD events including myocardial infarction (MI), stroke, ischaemic stroke and venous thromboembolism (VTE). Standardised incidence rates and 95% CIs were calculated.

RESULTS

Associations were found between PTSD and all 4 CVD events ranging from 1.5 (95% CI 1.1 to 1.9) for MI to 2.1 (95% CI 1.7 to 2.7) for VTE. Associations that were similar in magnitude were also found for adjustment disorder and all 4 CVD events: 1.5 (95% CI 1.4 to 1.6) for MI to 1.9 (95% CI 1.8 to 2.0) for VTE. No gender differences were noted.

CONCLUSIONS

By expanding beyond PTSD and examining a second stress disorder-adjustment disorder-this study provides evidence that stress-related psychopathology is associated with CVD events. Further, limited evidence of gender differences in associations for either of the stress disorders and CVD was found.

Prescribing practices and clinical predictors of glucose-lowering therapy within the first year in people with newly diagnosed Type 2 diabetes

AIM

To examine prescribing practices and predictors of glucose-lowering therapy within the first year following diagnosis of Type 2 diabetes mellitus in a clinical care setting.

METHODS

We followed people enrolled in the Danish Centre for Strategic Research in Type 2 Diabetes (DD2) cohort from outpatient hospital clinics and general practices throughout Denmark in 2010-2013. We used Poisson regression to compute age- and gender-adjusted risk ratios (RRs).

RESULTS

Among 1158 new Type 2 diabetes mellitus patients, 302 (26%) did not receive glucose-lowering therapy within the first year, 723 (62%) received monotherapy [685 (95%) with metformin], and 133 (12%) received more than one drug. Predictors of receiving any vs. no therapy and combination vs. monotherapy were: age < 40 years [RR: 1.29 (95% CI: 1.16-1.44) and 3.60 (95% CI: 2.36-5.50)]; high Charlson Comorbidity Index [RRs: 1.20 (95% CI: 1.05-1.38) and 2.08 (95% CI: 1.16-3.72)]; central obesity [RRs: 1.23 (95% CI: 1.04-1.44) and 1.93 (95% CI: 0.76-4.94)]; fasting blood glucose of ≥ 7.5 mmol/l [RRs: 1.25 (95% CI: 1.10-1.42) and 1.94 (95% CI: 1.02-3.71)]; and HbA1c ≥ 59 mmol/mol (≥ 7.5%) [RR: 1.26 (95% CI: 1.20-1.32) and 2.86 (95% CI: 1.97-4.14)]. Weight gain ≥ 30 kg since age 20, lack of physical exercise and C-peptide of < 300 pmol/l also predicted therapy.

CONCLUSIONS

Comorbidity, young age, central obesity and poor baseline glycaemic control are important predictors of therapy one year after Type 2 diabetes mellitus debut.

Trauma, comorbidity, and mortality following diagnoses of severe stress and adjustment disorders: a nationwide cohort study

Longitudinal outcomes following stress or trauma diagnoses are receiving attention, yet population-based studies are few. The aims of the present cohort study were to examine the cumulative incidence of traumatic events and psychiatric diagnoses following diagnoses of severe stress and adjustment disorders categorized using International Classification of Diseases, Tenth Revision, codes and to examine associations of these diagnoses with all-cause mortality and suicide. Data came from a longitudinal cohort of all Danes who received a diagnosis of reaction to severe stress or adjustment disorders (International Classification of Diseases, Tenth Revision, code F43.x) between 1995 and 2011, and they were compared with data from a general-population cohort. Cumulative incidence curves were plotted to examine traumatic experiences and psychiatric diagnoses during the study period. A Cox proportional hazards regression model was used to examine the associations of the disorders with mortality and suicide. Participants with stress diagnoses had a higher incidence of traumatic events and psychiatric diagnoses than did the comparison group. Each disorder was associated with a higher rate of all-cause mortality than that seen in the comparison cohort, and strong associations with suicide were found after adjustment. This study provides a comprehensive assessment of the associations of stress disorders with a variety of outcomes, and we found that stress diagnoses may have long-lasting and potentially severe consequences.

Early glycaemic control among patients with type 2 diabetes and initial glucose-lowering treatment: a 13-year population-based cohort study

AIM

To examine real-life time trends in early glycaemic control in patients with type 2 diabetes between 2000 and 2012.

METHODS

We used population-based medical databases to ascertain the association between achievement of glycaemic control with initial glucose-lowering treatment in patients with incident type 2 diabetes in Northern Denmark. Success in reaching glycated haemoglobin (HbA1c) goals within 3-6 months was examined using regression analysis.

RESULTS

Of 38 418 patients, 91% started with oral glucose-lowering drugs in monotherapy. Metformin initiation increased from 32% in 2000-2003 to 90% of all patients in 2010-2012. Pretreatment (interquartile range) HbA1c levels decreased from 8.9 (7.6-10.7)% in 2000-2003 to 7.0 (6.5-8.1)% in 2010-2012. More patients achieved an HbA1c target of <7% (<53 mmol/mol) in 2010-2012 than in 2000-2003 [80 vs 60%, adjusted relative risk (aRR) 1.10, 95% confidence interval (CI) 1.08-1.13], and more achieved an HbA1c target of <6.5% [(<48 mmol/mol) 53 vs 37%, aRR 1.07 95% CI 1.03-1.11)], with similar success rates observed among patients aged <65 years without comorbidities. Achieved HbA1c levels were similar for different initiation therapies, with reductions of 0.8% (from 7.3 to 6.5%) on metformin, 1.5% (from 8.1 to 6.6%) on sulphonylurea, 4.0% (from 10.4 to 6.4%) on non-insulin combination therapies, and 3.8% (from 10.3 to 6.5%) on insulin monotherapy.

CONCLUSIONS

Pretreatment HbA1c levels in patients with incident type 2 diabetes have decreased substantially, which is probably related to earlier detection and treatment in accordance with changing guidelines. Achievement of glycaemic control has improved, but 20% of patients still do not attain an HbA1c level of <7% within the first 6 months of initial treatment.

Vagotomy and subsequent risk of Parkinson's disease

OBJECTIVE

Parkinson's disease (PD) may be caused by an enteric neurotropic pathogen entering the brain through the vagal nerve, a process that may take over 20 years. We investigated the risk of PD in patients who underwent vagotomy and hypothesized that truncal vagotomy is associated with a protective effect, whereas superselective vagotomy has a minor effect.

METHODS

We constructed cohorts of all patients in Denmark who underwent vagotomy during 1977-1995 and a matched general population cohort by linking Danish registries. We used Cox regression to compute hazard ratios (HRs) for PD and corresponding 95% confidence intervals (CIs), adjusting for potential confounders.

RESULTS

Risk of PD was decreased in patients who underwent truncal (HR = 0.85; 95% CI = 0.56-1.27; follow-up of >20 years: HR = 0.58; 95% CI: 0.28-1.20) compared to superselective vagotomy. Risk of PD was also decreased after truncal vagotomy when compared to the general population cohort (overall adjusted HR = 0.85; 95% CI: 0.63-1.14; follow-up >20 years, adjusted HR = 0.53; 95% CI: 0.28-0.99). In patients who underwent superselective vagotomy, risk of PD was similar to the general population (HR = 1.09; 95% CI: 0.84-1.43; follow-up of >20 years: HR = 1.16; 95% CI: 0.80-1.70). Statistical precision of risk estimates was limited. Results were consistent after external adjustment for unmeasured confounding by smoking.

INTERPRETATION

Full truncal vagotomy is associated with a decreased risk for subsequent PD, suggesting that the vagal nerve may be critically involved in the pathogenesis of PD.

Insertion of exogenous epitopes in the E3-19K of oncolytic adenoviruses to enhance TAP-independent presentation and immunogenicity

Oncolytic adenoviruses can promote immune responses against tumors by expressing and/or displaying tumor-associated antigens. However, the strong immunodominance of viral antigens mask responses against tumor epitopes. In addition, defects in major histocompatibility complex class I antigen presentation pathway such as the downregulation of the transporter-associated with antigen processing (TAP) are frequently associated with immune evasion of tumor cells. To promote the immunogenicity of exogenous epitopes in the context of an oncolytic adenovirus, we have taken advantage of the ER localization of the viral protein E3-19K. We have inserted tumor-associated epitopes after the N-terminal signal sequence for membrane insertion of this protein and flanked them with linkers cleavable by the protease furin to facilitate their TAP-independent presentation. This strategy allowed an enhanced presentation of the exogenous epitopes in TAP-deficient tumor cells in vitro and the generation of higher specific immune responses in vivo that were able to significantly control tumor growth.

Posttraumatic stress disorder and cancer risk: a nationwide cohort study

The association between stress and cancer incidence has been studied for more than seven decades. Despite plausible biological mechanisms and evidence from laboratory studies, findings from clinical research are conflicting. The objective of this study was to examine the association between PTSD and various cancer outcomes. This nation-wide cohort study included all Danish-born residents of Denmark from 1995 to 2011. The exposure was PTSD diagnoses (n = 4131). The main outcomes were cancer diagnoses including: (1) all malignant neoplasms; (2) hematologic malignancies; (3) immune-related cancers; (4) smoking- and alcohol-related cancers; (5) cancers at all other sites. Standardized incidence ratios (SIR) were calculated. Null associations were found between PTSD and nearly all cancer diagnoses examined, both overall [SIR for all cancers = 1.0, 95 % confidence interval (CI) = 0.88, 1.2] and in analyses stratified by gender, age, substance abuse history and time since PTSD diagnosis. This study is the most comprehensive examination to date of PTSD as a predictor of many cancer types. Our data show no evidence of an association between PTSD and cancer in this nationwide cohort.