Predictors of health-related quality of life in patients with Crohn's disease receiving biological therapy

BACKGROUND AND AIM

Health-related quality of life (HRQoL) is impaired in patients with Crohn's disease (CD). This study aimed to identify the impact of clinical disease activity on HRQoL in CD patients treated with biological agents.

METHODS

Patients with moderate to severe active CD treated with biological agents in Denmark were included from 2016-2018. Disease related symptoms were assessed via the Harvey Bradshaw Index. HRQoL was measured on the Short Health Scale (SHS). Multivariable linear regression models were conducted separately for each SHS item and average SHS score stratified for sex, adjusting for clinical manifestation and age.

RESULTS

In total, 1,181 CD patients were included. The mean age was 33 years and 56% were women. Abdominal pain (range of regression coefficients 1.18-1.42), number of liquid stools (0.33-0.58), and the appearance of a new rectal fistula (0.91-1.32) affected all domains in the SHS negatively for men and women. Arthralgia (0.47-0.67) and abdominal mass (0.54-0.62) affected 4 out of 5 items on SHS negatively for women and men, respectively. Female sex was found a predictor of lower HRQoL across all SHS items, whereas age and fistulizing disease, as phenotype, were not associated with lower HRQoL.

CONCLUSIONS

Abdominal pain, number of liquid stools, a new rectal fistula, arthralgia for women, clinically assessed abdominal mass for men as well as female sex, were all found to be predictors of decreased HRQoL.

The reliability of the Danish version of the Canadian Occupational Performance Measure

Introduction

This study aims to assess the reliability of the Danish version of the Canadian Occupational Performance Measure (COPM).

Method

151 clients, 42.4% male, mean age 66.9 years ( SD: 14.4, range: 16–90), from two hospitals and two rehabilitation centres were interviewed twice with the COPM over a ten-day mean interval ( SD: 4.9, range: 2–27) either by the same (intra-rater) or two different occupational therapists (inter-rater). Data were analysed with intra-class correlation coefficients, coefficient of repeatability, and Bland–Altman plots.

Results

823 occupational performance issues were prioritized of which 41%, 338 occupational performance issues (95% CI: 37.7–44.5), were mentioned in both interviews. The intra-class correlation coefficients were 59.8 (95% CI-intra-class correlation coefficients: 49.3–69.5) (COPM), 73.5 (95% CI intra-class correlation coefficients: 65.5-80.2) (COPM-Performance), and 71.8 (95% CI intra-class correlation coefficients: 63.4–78.8) (COPM-Satisfaction). The limits of agreement were −2.83 to 3.05 for the COPM-Performance and −3.50–3.53 for the COPM-Satisfaction. The COPM-Importance scores were highest when obtained by two raters, but opposite for the scores of the COPM-Performance and COPM-Satisfaction. The coefficient of repeatability roughly showed a change in +/- three points (COPM-Importance: 2.67; COPM-Performance: 2.94; and COPM-Satisfaction: 3.52). Correspondingly, Bland–Altman plots showed limits of agreement for the mean values of −2.71 and 3.53, respectively.

Conclusions

The intra-rater and inter-rater reliability of the COPM were moderate across settings, clients and rater experiences.

New onset anxiety and depression in patients with an implantable cardioverter defibrillator during 24 months of follow-up (data from the national DEFIB-WOMEN study)

OBJECTIVE

To examine the cumulative incidence of and covariates' association with new onset anxiety and depression in implantable cardioverter defibrillator (ICD) patients during 24 months of follow-up in patients without depression and anxiety at implant.

METHODS

Patients (n = 1040; 155 (14.9%) women; mean age: 64.2 ± 10.6) with a first-time ICD enrolled in the national, multi-center prospective observational DEFIB-WOMEN study comprised the study cohort. We obtained information on demographic and clinical data from the Danish Pacemaker and ICD Register.

RESULTS

During 24 months of follow-up, 138 (14.5%) patients developed new onset anxiety and 109 (11.3%) new onset depression. Age ≥ 60 [HR:0.60;95%CI:0.40-0.90] and an anxiety score between 3 and 4 [HR:2.85; 95%CI:1.71-4.75] and 5-7 [HR:5.97; 95%CI:3.77-9.45] on the Hospital Anxiety and Depression Scale (HADS) were associated with different hazards of new onset anxiety during follow-up. Age ≥ 60 [HR:0.62;95%CI:0.42-0.93] and a HADS depression score between 3 and 4 [HR:2.99;95%CI:1.80-4.95] and 5-7 [HR:6.45; 95%CI:4.12-10.10] were associated with different hazards of new onset depression.

CONCLUSION

During 24 months of follow-up, respectively 14.5% and 11.3% of patients developed new onset anxiety and depression, suggesting that screening patients at several timepoints, and in particular those with even minimally elevated HADS scores at baseline, may be warranted to identify patients at risk for poor health outcomes.

Anxiety and depression symptoms in Danish patients with an implantable cardioverter-defibrillator: prevalence and association with indication and sex up to 2 years of follow-up (data from the national DEFIB-WOMEN study)

AIMS

To investigate (i) the prevalence of anxiety and depression and (ii) the association between indication for implantable cardioverter-defibrillator (ICD) implantation and sex in relation to anxiety and depression up to 24 months' follow-up.

METHODS AND RESULTS

Patients with a first-time ICD, participating in the national, multi-centre, prospective DEFIB-WOMEN study (n = 1496; 18% women) completed the Hospital Anxiety and Depression Scale at baseline, 3, 6, 12, and 24 months. Data were analysed using linear mixed modelling for longitudinal data. Patients with a secondary prophylactic indication (SPI) had higher mean anxiety scores than patients with a primary prophylactic indication (PPI) at baseline, 3, and 12 months and higher mean depression scores at all-time points, except at 24 months. Women had higher mean anxiety scores as compared to men at all-time points; however, only higher mean depression scores at baseline. Overall, women with SPI had higher anxiety and depression symptom scores than men with SPI. Symptoms decreased over time in both women and men. From baseline to follow-up, the prevalence of anxiety (score ≥8) was highest in patients with SPI (13.3-20.2%) as compared to patients with PPI (range 10.0-14.7%). The prevalence of depression was stable over the follow-up period in both groups (range 8.5-11.1%).

CONCLUSION

Patients with a SPI reported higher anxiety and depression scores as compared to patients with PPI. Women reported higher anxiety scores than men, but only higher depression scores at baseline. Women with SPI reported the highest anxiety and depression scores overall.

Association of Socioeconomic Status With Dementia Diagnosis Among Older Adults in Denmark

IMPORTANCE

Low socioeconomic status (SES) has been identified as a risk factor for the development of dementia. However, few studies have focused on the association between SES and dementia diagnostic evaluation on a population level.

OBJECTIVE

To investigate whether household income (HHI) is associated with dementia diagnosis and cognitive severity at the time of diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This population- and register-based cross-sectional study analyzed health, social, and economic data obtained from various Danish national registers. The study population comprised individuals who received a first-time referral for a diagnostic evaluation for dementia to the secondary health care sector of Denmark between January 1, 2017, and December 17, 2018. Dementia-related health data were retrieved from the Danish Quality Database for Dementia. Data analysis was conducted from October 2019 to December 2020.

EXPOSURES

Annual HHI (used as a proxy for SES) for 2015 and 2016 was obtained from Statistics Denmark and categorized into upper, middle, and lower tertiles within 5-year interval age groups.

MAIN OUTCOMES AND MEASURES

Dementia diagnoses (Alzheimer disease, vascular dementia, mixed dementia, dementia with Lewy bodies, Parkinson disease dementia, or other) and cognitive stages at diagnosis (cognitively intact; mild cognitive impairment but not dementia; or mild, moderate, or severe dementia) were retrieved from the database. Univariable and multivariable logistic and linear regressions adjusted for age group, sex, region of residence, household type, period (2017 and 2018), medication type, and medical conditions were analyzed for a possible association between HHI and receipt of dementia diagnosis.

RESULTS

Among the 10 191 individuals (mean [SD] age, 75 [10] years; 5476 women [53.7%]) included in the study, 8844 (86.8%) were diagnosed with dementia. Individuals with HHI in the upper tertile compared with those with lower-tertile HHI were less likely to receive a dementia diagnosis after referral (odds ratio, 0.65; 95% CI, 0.55-0.78) and, if diagnosed with dementia, had less severe cognitive stage (β, -0.16; 95% CI, -0.21 to -0.10). Individuals with middle-tertile HHI did not significantly differ from those with lower-tertile HHI in terms of dementia diagnosis (odds ratio, 0.92; 95% CI, 0.77-1.09) and cognitive stage at diagnosis (β, 0.01; 95% CI, -0.04 to 0.06).

CONCLUSIONS AND RELEVANCE

The results of this study revealed a social inequality in dementia diagnostic evaluation: in Denmark, people with higher income seem to receive an earlier diagnosis. Public health strategies should target people with lower SES for earlier dementia detection and intervention.

Socioeconomic position and mental health care use before and after first redeemed antidepressant and time until subsequent contact to psychologist or psychiatrists: a nationwide Danish follow-up study

PURPOSE

The purpose was to investigate inequalities in access to care among people with possible depression.

METHOD

In this nationwide register-based cohort study of 30,593 persons, we observed the association between socioeconomic position (SEP, education/income) and mental health care use (MHCU) four months before the date of first redeemed antidepressant (Index Date/ID) and 12 months afterwards-and time to contact to psychologist/psychiatrist (PP). Logistic, Poisson, and Cox regression models were used, adjusted for sex, age, cohabitation, and psychiatric comorbidity.

RESULTS

Before ID, high SEP was associated with less GP contact (general practitioner), higher odds ratios for GP-Mental Health Counseling (GP-MHC), psychologist contact, and admissions to hospital. This disparity decreased the following 12 months for GP-MHC but increased for contact to psychologist; same pattern was seen for rate of visits. However, the low-income group had more contact to private psychiatrist. For the 25,217 individuals with no MHCU before ID, higher educational level was associated with almost twice the rate of contact to PP the following 12 months; for the high-income group, the rate was 40% higher. 10% had contact to PP within 40 days after ID in the group with higher education; whereas, 10% of those with a short education would reach PP by day 120. High-income group had faster access as well.

CONCLUSION

Being in high SEP was positively associated with MHCU, before and after ID, and more rapid PP contact, most explicit when measured by education. Co-payment for psychologist may divert care towards private psychiatrist for low-income groups.

Clinical management of hip fractures in elderly patients with dementia and postoperative 30-day mortality: A population-based cohort study

OBJECTIVES

Patients with dementia have an increased 30-day mortality after hip fracture. We investigated clinical management including time to surgery, out-of-hours admission and surgery, surgery on weekends, surgery volume per ward, and anesthesia technique for this excess mortality risk.

METHOD

This register- and population-based study comprised 12,309 older adults (age 70+) admitted to hospital for a first-time hip fracture in 2013-2014, of whom 11,318 underwent hip fracture surgery. Cox proportional hazards regression models were applied for the analysis.

RESULTS

The overall postoperative 30-day mortality was 11.4%. Patients with dementia had a 1.5 times increased mortality risk than those without (HR = 1.50 [95% CI 1.31-1.72]). We observed no time-to-surgery difference by patient dementia status; additionally, the excess mortality risk in patients with dementia could not be explained by the clinical management factors we examined.

CONCLUSIONS

Increased mortality in patients with dementia could not be explained by the measured preoperative clinical management. Suboptimal handling of postoperative complication and rehabilitation are to be investigated for their role in the witnessed increased mortality for patients with dementia.

Does socioeconomic status make a difference? A register-based study on the extent to which cardiovascular screening in patients with inflammatory arthritis leads to recommended follow-up in general practice

OBJECTIVE

To investigate to what extent patients with inflammatory arthritis (IA) follow recommendations given in a secondary care nurse-led cardiovascular (CV) risk screening consultation to consult their general practitioner (GP) to reduce their CV risk and whether their socioeconomic status (SES) affects adherence.

METHODS

Adults with IA who had participated in a secondary care screening consultation from July 2012 to July 2015, based on the EULAR recommendations, were identified. Patients were considered to have high CV risk if they had risk Systematic COronary Risk Evaluation (SCORE) ≥5%, according to the European SCORE model or systolic blood pressure ≥145 mmHg, total cholesterol ≥8 mmol/L, LDL cholesterol ≥5 mmol/L, HbA1c ≥42 mmol/mol or fasting glucose ≥6 mmol/L. The primary outcome was a consultation with their GP and at least one action focusing on CV risk factors within 6 weeks after the screening consultation.

RESULTS

The study comprised 1265 patients, aged 18-85 years. Of these, 336/447 (75%) of the high-risk patients and 580/819 (71%) of the low-risk patients had a GP consultation. 127/336 (38%) of high-risk patients and 160/580 (28%) of low-risk patients received relevant actions related to their CV risk, for example, blood pressure home measurement or prescription for statins, antihypertensives or antidiabetics. Education ≥10 years increased the odds for non-adherence (OR 0.58, 95% CI 0.0.37 to 0.92, p=0.02).

CONCLUSIONS

75% of the high-risk patients consulted their GP after the secondary care CV risk screening, and 38% of these received an action relevant for their CV risk. Higher education decreased adherence.

Predictors of health-related quality of life in patients with moderate to severely active ulcerative colitis receiving biological therapy

Background and aims: Patients with ulcerative colitis have reduced health-related quality of life compared to the general population. Current treatment strategy aims to reduce patients' symptoms and increase health-related quality of life. We investigated which symptoms of ulcerative colitis correlate to decreased health-related quality of life.Methods: Among 743 patients with moderate to severely active ulcerative colitis receiving biological therapy in a cross-sectional national study, we determined which disease-related symptoms, as measured by the Simple Clinical Colitis Activity Index, worsened health-related quality of life scores across the Short Health Scale dimensions, while adjusting for treatment, age, and clinical manifestation, and stratifying for sex, by means of multiple linear regression.Results: Patients with active disease had decreased health-related quality of life compared to those with inactive disease (median 5.8 (range 4.5-7.5) vs. 2 (0.8-3.3)). Both sexes had decreased health-related quality of life in all dimensions for the symptoms: bowel frequency during daytime (0.37-0.86 and 0.46-0.84), urgency of defecation (0.54-0.79 and 0.49-0.65) and blood in stool (0.50-0.75 and 0.36-0.54) for men and women respectively. Women were more often negatively affected by bowel frequency during night-time (4 domains vs. 1) and arthritis (5 domains vs. 3). In non-stratified analysis female sex is an independent predictor of lower health-related quality of life for 3 domains (0.38-0.53).Conclusions: Health-related quality of life was most prominently associated with bowel frequency during daytime, urgency of defecation, and blood in stool. Other symptoms associated for some health-related quality of life dimensions, and appear to vary between the sexes.

Looking into the Content of the Canadian Occupational Performance Measure (COPM): A Danish Cross-Sectional Study

PURPOSE

To examine the content validity of the Danish version of the Canadian Occupational Performance Measure (COPM-DK).

MATERIALS AND METHODS

This cross-sectional study was performed in a hospital and a community rehabilitation centre. The content validity of the COPM was assessed by relating the clients' prioritized occupational performance issues (OPIs) to the conceptual model of the Canadian Model of Occupational Performance and Engagement (CMOP-E) and the levels of the Taxonomic Code of Occupational Performance (TCOP). Six occupational therapy lecturers participated in classifying the OPIs using the TCOP.

RESULTS

A total of 112 clients from a regional and community-based rehabilitation participated. The 56% regional participants came from a hospital's hand and knee surgery department. The remaining 44% participants came from a community-based rehabilitation centre with in- and outpatient departments. There were 44% males, with a mean age of 65.2 years. They prioritized 495 OPIs, of which 40% concerned self-care, 32% productivity, and 28% leisure. The prioritized OPIs were divided into a total of 224 different OPIs. There were significant differences in which areas were prioritized in the various population groups. Of the OPIs, 64.3% could be classified into the TCOP levels of occupation and activity, i.e., 1/3 of the OPIs were related to tasks and actions, and thus beyond the scope of the COPM. The interrater agreement of the OPI classification was only fair (kappa 0.3).

CONCLUSION

The content validity of the COPM seems to depend on how and with which clients it is administered. Caution must be taken to secure OPIs on the higher levels of the TCOP, while maintaining the clients' right to nominate OPI preferences. Therefore, an introductory course and on-going support are recommendable. Bearing this in mind, the COPM seems useful to identify individual clients' prioritized OPIs in a Danish context.

The Validity of the Danish Version of the Canadian Occupational Performance Measure

PURPOSE

To establish the construct validity of the Danish version of the Canadian Occupational Performance Measure (COPM).

METHODS

A cross-sectional study was performed in two settings, a regional hospital and a rehabilitation centre in a community. Including adult clients with a variety of diagnoses, we assessed construct validity by correlating the COPM to the Occupational Self-Assessment (OSA), the five-item World Health Organization Well-Being Index (WHO-5), and the EuroQol-five domain-five level questionnaire (EQ-5D-5L). Further examination of the comparability of the OSA and the COPM was performed in two ways. First, an interrater agreement of the theoretical correlation of the 21 OSA items and the three areas of the COPM was conducted. Secondly, we examined the compliance between the prioritized occupational performance issues (OPIs) and items of the OSA prioritized for change.

RESULTS

The study included a total sample of 112 participants with more than half of the participants (56%) recruited from the hospital. 109 participants had measurements for both COPM and OSA (44% males) with a mean age of 64.7 years (range 16-96 years). All correlations, between the COPM and the OSA, the WHO-5, and the EQ-5D-5L, were low or negligible (r < 0.50). Manual examination confirmed a difference in the constructs of the OSA and the COPM. This was demonstrated by a negligible interrater agreement between the items of the OSA and the areas of the COPM, and differences in the prioritized OPIs and OSA items, even if there were some resemblances, were found.

CONCLUSIONS

This study suggests that the construct of the COPM provides data different to those obtained with the standardized measurements included for comparison. The present study supports the assumption that the COPM can detect unique OPIs that clients want to do, need to do, must do, or are not satisfied with the way they do.

Development in Danish medical students' empathy: study protocol of a cross-sectional and longitudinal mixed-methods study

BACKGROUND

Clinical empathy has been associated with positive outcomes for both physicians and patients such as: more accurate diagnosis and treatment, increased patient satisfaction and compliance, and lower levels of burnout and stress among physicians. International studies show mixed results regarding the development of empathy among future physicians associating medical education with decline, stability or increase in empathy levels. These mixed results are due to several study limitations. In Denmark, no investigation of Danish medical students' empathy trajectory has yet been conducted wherefore such a study is needed that optimizes the study design of earlier studies.

METHODS

The aim of the study is to examine and analyze empathy levels and empathy changes among Danish medical students from the four medical faculties in Denmark, employing a cross-sectional and longitudinal mixed-methods design including a control group of non-medical students. By supplementing cross-sectional and longitudinal questionnaire studies with a focus group interview study it is the aim to identify and analyze factors (including educational) that are perceived by medical students to influence the development of empathy and its expression in clinical care.

DISCUSSION

The results of the study will provide insight into the trajectory of medical students' empathy and in undergraduate and graduate students' experiences with and perceptions of empathy development. In addition, the study will provide evidence to support further research on how targeted educational programmes can best be designed to educate empathic and patient-centered physicians.

Therapeutic Use of the Human Papillomavirus Vaccine on Recurrent Respiratory Papillomatosis: A Systematic Review and Meta-Analysis

BACKGROUND

Recurrent respiratory papillomatosis is a benign condition caused by human papillomavirus (HPV). Surgery is the mainstay of treatment, but numerous adjuvant therapies have been applied to improve surgical outcome. Recently, HPV vaccination has been introduced, but only smaller studies of its effect have been published. The present meta-analysis is intended as a possible substitute for a proposed but not yet realized multicenter randomized controlled trial.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed, Embase, and Cochrane were systematically searched. All retrieved studies (n = 593) were reviewed and qualitatively assessed. In addition, 2 previously unpublished data sets were included. The systematic review included 11 studies, comprising 133 patients, of whom 63 patients from 5 studies were eligible for meta-analysis. A random-effects meta-analysis was conducted for the mean difference in number of surgical procedures per month before and after vaccination.

RESULTS

The number of surgical procedures per month was significantly reduced after HPV vaccination compared with before vaccination (estimated mean, 0.06 vs 0.35). The mean intersurgical interval increased from 7.02 months (range, 0.30-45 months) before to 34.45 months (2.71-82 months) after HPV vaccination.

CONCLUSION

The present study supports the continued use of the HPV vaccine as an adjuvant treatment for recurrent respiratory papillomatosis.

The Risk of Elective Abortion in Women With Crohn's Disease and Ulcerative Colitis: A Nationwide Cohort Study

BACKGROUD

Women with inflammatory bowel disease (IBD) might have an increased tendency to choose an elective abortion due to a fear that their fetus could be harmed by use of medications, disease flares during pregnancy, or for genetic reasons. We examined the risk of elective abortions in women with ulcerative colitis (UC) and Crohn's disease (CD) compared with women without IBD.

METHODS

This nationwide cohort study, based on Danish health registries, comprises all registered pregnancies from 1996 through 2015. The 2 exposed groups constituted pregnancies of women with UC or CD, and the unexposed group constituted all pregnancies of women without IBD. Our outcome was elective abortion by maternal request up until the end of the 12th completed week of gestation. We used logistic regression models and calculated the odds ratio (OR) for an elective abortion, controlling for confounders.

RESULTS

The overall prevalence rates of elective abortions in women with UC and CD and without IBD were 12.4% (898 elective abortions/7250 pregnancies), 14.9% (978 elective abortions/6559 pregnancies), and 16.9% (285,251 elective abortions/1,691,857 pregnancies), respectively. In women with UC and CD, the adjusted ORs for an elective abortion (95% confidence interval) were 0.80 (0.74-0.86) and 0.96 (0.89-1.04), respectively.

CONCLUSIONS

Pregnant women with IBD are not more likely to choose an elective abortion compared with women without IBD. These results are reassuring as they suggest that women with IBD are not so worried about a negative impact of their disease, disease activity, or medications that they would choose to terminate a pregnancy.

Socioeconomic position, symptoms of depression and subsequent mental healthcare treatment: a Danish register-based 6-month follow-up study on a population survey

OBJECTIVE

Examine whether the severity of symptoms of depression was associated with the type of mental healthcare treatment (MHCT) received, independent of socioeconomic position (SEP).

DESIGN

Register-based 6-month follow-up study on participants from the Danish General Suburban Population Study (GESUS) 2010-2013, who scored the Major Depression Inventory (MDI).

PARTICIPANTS

Nineteen thousand and eleven respondents from GESUS.

INTERVENTIONS

The MHCT of the participants was tracked in national registers 4 months prior and 6 months after their MDI scores. MHCT was graduated in levels. SEP was defined by years of formal postsecondary education and income categorised into three levels. Data were analysed using logistic and Poisson regression analyses.

OUTCOMES

MHCT included number of contacts with: general practitioner (GP), GP mental health counselling, psychologist, psychiatrist, emergency contacts, admissions to psychiatric hospitals and prescriptions of antidepressants.

RESULTS

For 547 respondents with moderate to severe symptoms of depression there was no difference across SEP in use of services, contact (y/n), frequency of contact or level of treatment, except respondents with low SEP had more frequent contact with their GP. However, of the 547 respondents , 10% had no treatment contacts at all, and 47% had no treatment beyond GP consultation. Among respondents with no/few symptoms of depression, postsecondary education ≥3 years was associated with more contact with specialised services (adjusted OR (aOR) 1.92; 95% CI 1.18 to 3.13); however, this difference did not apply for income; additionally, high SEP was associated with fewer prescriptions of antidepressants (education aOR 0.69; CI 0.50 to 0.95; income aOR 0.56, CI 0.39 to 0.80) compared with low SEP.

CONCLUSION

Participants with symptoms of depression were treated according to the severity of their symptoms, independent of SEP; however, more than half with moderate to severe symptoms received no treatment beyond GP consultation. People in low SEP and no/few symptoms of depression were more often treated with antidepressants. The study was approved by The Danish Data Protection Agency Journal number 2015-41-3984. Accessible at: https://www.datatilsynet.dk/fortegnelsen/soeg-i-fortegnelsen/.

Causes of death among full term stillbirths and early neonatal deaths in the Region of Southern Denmark

OBJECTIVE

We examined the causes of death amongst full term stillbirths and early neonatal deaths.

METHODS

Our cohort includes women in the Region of Southern Denmark, who gave birth at full term to a stillborn infant or a neonate who died within the first 7 days from 2010 through 2014. Demographic, biometric and clinical variables were analyzed to assess the causes of death using two classification systems: causes of death and associated conditions (CODAC) and a Danish system based on initial causes of fetal death (INCODE).

RESULTS

A total of 95 maternal-infant cases were included. Using the CODAC and INCODE classification systems, we found that the causes of death were unknown in 59/95 (62.1%). The second most common cause of death in CODAC was congenital anomalies in 10/95 (10.5%), similar to INCODE with fetal, genetic, structural and karyotypic anomalies in 11/95 (11.6%). The majority of the mothers were healthy, primiparous, non-smokers, aged 20-34 years and with a normal body mass index (BMI).

CONCLUSION

Based on an unselected cohort from an entire region in Denmark, the cause of stillbirth and early neonatal deaths among full term infants remained unknown for the vast majority.

Risk factors and between-hospital variation of caesarean section in Denmark: a cohort study

OBJECTIVES

The aim of this study was to estimate the effects of risk factors on elective and emergency caesarean section (CS) and to estimate the between-hospital variation of risk-adjusted CS proportions.

DESIGN

Historical registry-based cohort study.

SETTINGS AND PARTICIPANTS

The study was based on all singleton deliveries in hospital units in Denmark from January 2009 to December 2012. A total of 226 612 births by 198 590 mothers in 29 maternity units were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated (1) OR of elective and emergency CS adjusted for several risk factors, for example, body mass index, parity, age and size of maternity unit and (2) risk-adjusted proportions of elective and emergency CS to evaluate between-hospital variation.

RESULTS

The CS proportion was stable at 20%-21%, but showed wide variation between units, even in adjusted models. Large units performed significantly more elective CSs than smaller units, and the risk of emergency CS was significantly reduced compared with smaller units. Many of the included risk factors were found to influence the risk of CS. The most important risk factors were breech presentation and previous CS. Four units performed more CSs and one unit fewer CSs than expected.

CONCLUSION

The main risk factors for elective CS were breech presentation and previous CS; for emergency CS they were breech presentation and cephalopelvic disproportion. The proportions of CS were stable during the study period. We found variation in risk-adjusted CS between hospitals in Denmark. Although exhaustive models were applied, the results indicated the presence of systematic variation between hospital units, which was unexpected in a small, well-regulated country such as Denmark.

Risk of Ectopic Pregnancy in Women With Inflammatory Bowel Disease: A 22-Year Nationwide Cohort Study

BACKGROUND & AIMS

Few data are available on adverse events of pregnancy in women with inflammatory bowel diseases (IBD), such as ectopic pregnancy. We assessed the risk of ectopic pregnancy in pregnancies of women in Denmark with IBD compared with those without IBD over a 22-year period. We also examined the disease-specific risks of ectopic pregnancies in pregnancies of women with ulcerative colitis (UC) or Crohn's disease (CD) who underwent IBD-related surgical procedures.

METHODS

We performed a retrospective study of all women of child-bearing age (ages, 15-50 y) registered in the Danish National Patient Registry with at least 1 pregnancy during the period from January 1994 through December 31, 2015. We collected data on all women with an ectopic pregnancy, hydatidiform mole, miscarriages (spontaneous and other abortions, including abnormal pregnancy products, missed abortion, and pregnancy without a fetus), induced abortions, and births in women with and without IBD. Our study population included 7548 pregnancies in women with UC, 6731 pregnancies in women with CD, and 1,832,732 pregnancies in women without IBD. We controlled for multiple covariates, including pelvic and abdominal surgery.

RESULTS

Women with CD had a greater risk of ectopic pregnancy, per pregnancy, than women without IBD (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.01-1.49), whereas women with UC did not (OR, 0.98; 95% CI, 0.80-1.20). In pregnancies of women with CD and UC who underwent IBD-related surgery before pregnancy, there was a nonsignificant increase in risk of ectopic pregnancy compared with pregnancies in women with IBD who did not have surgery (OR, 1.49; 95% CI, 0.91-2.44 for CD, and OR, 1.17; 95% CI, 0.54-2.52 for UC).

CONCLUSIONS

We found a statistically significant increased risk of ectopic pregnancy in pregnancies of women with CD compared with pregnancies of women without IBD. Surgery for IBD before pregnancy increased the risk of ectopic pregnancy, although this increase was not statistically significant.

Retrospective evaluation of a national guideline to prevent neonatal hypoglycemia

BACKGROUND

Hypoglycemia is common in neonates and may cause adverse neurological outcomes. Guidelines should aim to prevent repeated hypoglycemic episodes in risk groups, but they are not usually stratified according to the severity of hypoglycemia risk, which may lead to inappropriate and redundant interventions. We evaluated the effect of a national prevention guideline stratified according to mild, moderate, and severe risks of hypoglycemia.

METHODS

From national registers, a population cohort of 22,725 neonates was identified retrospectively before and after implementation of a national guideline. Of these, 1900 had World Health Organization International Classification of Diseases 10 discharge diagnoses of hypoglycemia. Diagnoses indicating hypoglycemia risk [small/large for gestational age (SGA/LGA), asphyxia, prematurity, maternal insulin-treated diabetes mellitus] were recorded. Neonatal ward files were evaluated to validate hypoglycemia diagnoses. Adjusted odds ratios (aORs) were calculated, adjusting for sex, parity, SGA, LGA, preterm birth, and asphyxia, where relevant.

RESULTS

Primiparity and male sex were associated independently with hypoglycemia diagnosis [aORs, 1.29 (1.17-1.42) and 1.14 (1.03-1.26), respectively]. Overall incidence of hypoglycemia at discharge decreased from 9.4% to 5.5% after guideline implementation [aOR_change, 0.57 (0.50-0.64)]. Overall incidence of validated hypoglycemia decreased from 2.1% to 1.2% [aOR 0.59 (0.46-0.77), p<0.001]. By risk group, the hypoglycemia incidence decreased from 30.5% to 18.6% [aOR 0.52 (0.36-0.75)] among SGA neonates, from 25.8% to 16.4% [aOR 0.57 (0.42-0.76)] among preterm infants, and from 27.4% to 16.6% [aOR 0.63 (0.34-0.83)] among those with asphyxia. LGA neonates showed a decreased incidence in obstetric wards only. No significant change was observed for the diabetes group.

CONCLUSION

Stratification of hypoglycemia risk in a hypoglycemia prevention guideline was followed by decreased estimated hypoglycemia incidence, but no causative conclusion could be drawn. Prospective studies with risk stratification for hypoglycemia prevention are encouraged.

Impact of appropriate empirical antibiotic treatment on recurrence and mortality in patients with bacteraemia: a population-based cohort study

Background

Data on the impact of empirical antibiotic treatment (EAT) on patient outcome in a population-based setting are sparse. We assessed the association between EAT and the risk of recurrence within one year, short-term- (2–30 days) and long-term (31–365 days) mortality in a Danish cohort of bacteraemia patients.

Methods

A cohort study including all patients hospitalized with incident bacteraemia during 2007–2008 in the Copenhagen City and County areas and the North Denmark Region. EAT was defined as the antibiotic treatment given at the 1^st notification of a positive blood culture. The definition of recurrence took account of pathogen species, site of infection, and time frame and was not restricted to homologous pathogens. The vital status was determined through the civil registration system. Association estimates between EAT and the outcomes were estimated by Cox and logistic regression models.

Results

In 6483 eligible patients, 712 (11%) had a recurrent episode. A total of 3778 (58%) patients received appropriate EAT, 1290 (20%) received inappropriate EAT, while EAT status was unrecorded for 1415 (22%) patients. The 2–30 day mortality was 15.1%, 17.4% and 19.2% in patients receiving appropriate EAT, inappropriate EAT, and unknown EAT, respectively. Among patients alive on day 30, the 31–365 day mortality was 22.3% in patients given appropriate EAT compared to 30.7% in those given inappropriate EAT. Inappropriate EAT was independently associated with recurrence (HR 1.25; 95% CI = 1.03–1.52) and long-term mortality (OR 1.35; 95% CI = 1.10–1.60), but not with short-term mortality (OR 0.85; 95% CI = 0.70–1.02) after bacteraemia.

Conclusions

Our data indicate that appropriate EAT is associated with reduced incidence of recurrence and lower long-term mortality following bacteraemia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2233-z) contains supplementary material, which is available to authorized users.

Effects of lifestyle intervention in pregnancy and anthropometrics at birth on offspring metabolic profile at 2.8 years: results from the Lifestyle in Pregnancy and Offspring (LiPO) study

CONTEXT

Maternal obesity and gestational weight gain are linked to offspring adverse metabolic profiles, and lifestyle interventions during pregnancy in obese women may have long-term positive effects on their children. Furthermore, although the association between birth weight and later metabolic outcomes is well established, little is known about the predictive value of abdominal circumference at birth.

OBJECTIVES

The purpose of this study was to determine (1) the effects of lifestyle interventions during pregnancy in obese women on offspring metabolic risk factors and (2) predictive values of birth weight (BW) and birth abdominal circumference (BAC).

DESIGN

This was a follow-up of a randomized controlled trial, the Lifestyle in Pregnancy (LiP) study.

SETTING

The study was conducted in Odense and Aarhus University Hospitals, Denmark.

PARTICIPANTS

We studied the offspring of LiP study participants (n = 157) and offspring of normal-weight mothers (external reference group, n = 97).

INTERVENTION

INTERVENTIONs included dietary advice, coaching, and exercise during pregnancy.

MAIN OUTCOME MEASURES

The outcome measures were body mass index (BMI) Z-score, abdominal circumference, blood pressure, and fasting plasma glucose, insulin, high-density lipoprotein, and triglycerides at the age of 2.8 years.

RESULTS

No differences were detected in BMI Z-scores or metabolic risk factors between the LiP intervention and control groups or between the LiP and external reference groups. BAC and BW were associated (all P < .05) with BMI Z-score (0.19-0.23), abdominal circumference (0.57-0.70), plasma glucose (0.11-0.09), insulin (4.33-3.13), and triglycerides (0.07-0.07) but not with blood pressure or high-density lipoprotein (regression coefficients per increase in BAC and BW of 1 SD score).

CONCLUSIONS

Early childhood metabolic risk factors were unaffected by lifestyle interventions in obese pregnant women. Offspring of obese mothers who participated in the LiP study were comparable to offspring of normal-weight mothers, possibly indicating a general beneficial effect of trial participation. BAC and BW were both associated with later metabolic risk factors.