The Danish Civil Registration System as a tool in epidemiology

Diagnostic flow for all patients referred with non-specific symptoms of cancer to a diagnostic centre in Denmark: A descriptive study

BACKGROUND

Since 2012, Cancer Patient Pathways for Non-specific Symptoms and Signs of Cancer (NSSC-CPP) have been implemented in Scandinavia and UK.

OBJECTIVES

This study aimed to describe the diagnostic flow for all patients referred from 1 January to 30 June 2020 to the NSSC-CPP in the Diagnostic Centre in Farsø (DC-F), Denmark.

METHODS

During the study period, we prospectively recorded information on the diagnostic flow, including: pathway trajectory, symptoms and findings leading to referral, diagnostic procedures and diagnoses at the end of DC Farsø work-up and within 6-months for all patients referred to the NSSC-CPP in DC Farsø using electronic patient files and the Danish National Patient Registry (DNPR).

RESULTS

Of the 314 referrals to DC Farsø, 227 had diagnostic work-up in DC Farsø, the remaining were redirected to other CPPs (n = 11), outpatient clinics (n = 45) or redirected to general practice (n = 25). Of total referrals, 25 (8%) received a malignant diagnosis, 20 (6%) a non-malignant but clinically relevant diagnosis with initiation of treatment, 16 (5%) a non-malignant diagnosis but no treatment needed and in 253 (81%) referrals no severe new condition was diagnosed. Two (1%) additional malignancies were diagnosed within a 6-month follow-up period.

CONCLUSION

By tracking all patients referred to the NSSC-CPP in DC Farsø, including those redirected, this is the first study to describe the diagnostic flow for all patients referred to a diagnostic centre in Denmark. This knowledge is important for further organisation and planning of the NSSC-CPP.

Risk of post-injection endophthalmitis peaks within the first three injections of anti-vascular endothelial growth factor therapy: A nationwide registry-based study

PURPOSE

To report the incidence of post-injection endophthalmitis (PIE) and the cumulative risk associated with repeated injections of intravitreal anti-vascular endothelial growth factor (anti-VEGF).

METHODS

We employed nationwide registries in Denmark to include all individuals aged ≥40 years who received at least one intravitreal anti-VEGF injection in 2007-2022. Our primary endpoint PIE was identified using specific diagnostic codes for endophthalmitis and procedure codes for vitreous biopsy within 10 days prior to and 120 days post-injection. Patients were stratified according to the underlying diagnoses for which they received the treatment. The relative risk (RR) for PIE was calculated between groups based on the number of injections received by the patients.

RESULTS

We identified 60 825 patients who received intravitreal anti-VEGF treatment during study time, with a median age of 77.2 years and females constituting 58.1%. We identified 232 cases of PIE after 1 051 549 injections during follow-up, resulting in an incidence of 0.022% [95% CI 0.019%-0.025%]. Despite a linear growth in annual anti-VEGF use, the incidence remained stable at 0.020% [95% CI 0.017%-0.023%] from 2013 to 2022. Compared to patients receiving 1-3 injections, RR for patients receiving 4-20, 21-40, and >40 injections were 0.46 [95% CI 0.34-0.63], 0.32 [95% CI 0.21-0.50], and 0.54 [95% CI 0.36-0.81], respectively. Findings were similar across the different diagnoses.

CONCLUSIONS

Based on 16 years of nationwide registry data, this study identified a low and stable incidence of PIE. Notably, the highest risk of endophthalmitis was within the first three anti-VEGF injections.

Primary and incisional hernias should be considered separately in clinical decisions and research: A nationwide register-based cohort study

BACKGROUND

Ventral hernias of umbilical, epigastric, and incisional types pose varied surgical challenges. Recent debates and research suggest that treatment strategies and outcomes may vary significantly based on hernia type and width. This study investigated whether differences in the risk of surgical outcomes among primary and incisional hernias are solely due to the hernia type. The primary outcome was reoperation for recurrence, and the secondary outcome was 90-day postoperative readmission.

METHODS

This study was based on prospectively collected data from the Danish Ventral Hernia Database linked with the Danish Civil Registration system and the National Patient Register. Data spanned from 2007 to 2022 and included patients with umbilical, epigastric, or incisional hernias. The 3 hernia types were analyzed for the risk of reoperation for recurrence, adjusted for sex, age, emergency repair, width, use of mesh, and Charlson comorbidity index.

RESULTS

We included 57,312 hernias: 34,147 umbilical, 9,433 epigastric, and 13,722 incisional hernias. Compared with patients with umbilical hernias, patients with epigastric hernias had a lower risk of reoperation (hazard ratio: 0.88, 95% confidence interval: 0.79-0.99) and those with incisional hernias had an increased risk (hazard ratio: 2.93, 95% confidence interval: 2.57-3.33). Postoperative 90-day readmission rates were also higher for patients with incisional hernias than for patients with umbilical and epigastric hernias.

CONCLUSION

Incisional hernias exhibited a higher risk of reoperation for recurrence and 90-day postoperative readmission, underscoring their unique nature in terms of both origin and clinical behavior. The findings suggest that primary and incisional hernias should be separate entities in medical practice and research.

Risk of recurrence in early-onset versus late-onset non-metastatic colorectal cancer, 2004-2019: a nationwide cohort study

Background

The incidence of colorectal cancer (CRC) in individuals younger than 50 years of age (early-onset CRC) is increasing. Early-onset CRC often present at advanced stage, suggesting a more aggressive cancer course compared to late-onset CRC (age 50-79). This nationwide cohort study estimates the incidence of recurrence following early-onset CRC and late-onset CRC.

Methods

The study included all Danish patients <80 years old operated for first-time Union for International Cancer Control (UICC) stage I-III CRC between January 2004 and December 2019. Recurrence status was determined by applying a validated algorithm to individual-level data from nationwide health registries. The 5-year cumulative incidence functions (CIF) of recurrence were reported for early-onset versus late-onset CRC. The difference in time to recurrence was estimated as a time ratio (TR) using an accelerated failure time model.

Findings

Among 25,729 CRC patients, 1441 (5.6%) had early-onset CRC. Compared to late-onset CRC, early-onset was associated with advanced disease stages and higher treatment intensity. The 5-year CIF of recurrence was 29% (95% CI: 26%-31%) in early-onset versus 21% (95% CI: 21%-22%) in late-onset CRC. The higher CIF of recurrence for early-onset patients persisted in stage-stratified analysis. Time to recurrence was shorter in early-onset versus late-onset patients with TR = 0.76 (95% CI: 0.67-0.85). The 5-year CIF of recurrence decreased from 2004 to 2019 for both early- and late-onset patients-most prominent for early-onset patients.

Interpretation

Early-onset CRC was associated with higher incidence of recurrence at all disease stages. Indicating that the increased risk is not explained by delayed diagnosis. The excess risk diminished from 2004 to 2019, suggesting that early-onset CRC may achieve a similar recurrence risk as late-onset CRC in a contemporary setting.

Funding

Aarhus University, Novo Nordisk Foundation, Innovation Fund Denmark, and the Danish Cancer Society.

Trends in papillary thyroid cancer mortality in Denmark according to stage and education

OBJECTIVE

Few studies exist on trends in papillary thyroid cancer (PTC) survival and mortality according to stage and level of socioeconomic status.

DESIGN

Nationwide cohort study.

PATIENTS AND MEASUREMENTS

Patients diagnosed with PTC during 2000-2015 in Denmark were identified from the Danish Cancer Registry and followed until the end of 2020. We evaluated 5-year all-cause mortality and relative survival according to stage and 5-year mortality rates with corresponding average annual percentage changes (AAPCs) according to stage and education. Finally, we assessed the association between several factors and mortality of PTC using Cox regression.

RESULTS

For the 2006 cases of PTC diagnosed during 2000-2015, relative survival tended to increase and mortality rates tended to decrease for all stages. For localized PTC, mortality rates tended to decrease among individuals with medium education (AAPC = -7.0, 95% confidence interval [CI]: -14.7 to 1.5), but showed an increasing pattern among individuals with long education (AAPC = 19.8, 95% CI: -4.2 to 50.0). For nonlocalized PTC, mortality rates showed a decreasing tendency among individuals with medium and long education (AAPC = -5.5, 95% CI: -13.2 to 2.9, and AAPC = -10.4, 95% CI: -20.8 to 1.4, respectively). Being diagnosed with PTC in a more recent calendar period and long education were associated with a lower mortality rate in the Cox regression analysis.

CONCLUSIONS

A pattern of an increasing relative survival and decreasing mortality rates of PTC across all stages was seen in Denmark during 2000-2015. The decreasing pattern in mortality rates was most evident in individuals with localized stage and medium education, and in individuals with nonlocalized stage and medium or long education.

Body image and depressive symptoms in Danish adolescents: A cross-sectional national study

BACKGROUND

Depressive symptoms are prevalent in adolescents. We aimed to investigate the association between body image and depressive symptoms, and how Body Mass Index (BMI) affects this.

METHODS

Survey data from 2017 with 9963 9th-grade Danish adolescents. Information from the survey about the exposure, body image, was divided into 3 categories: too fat, too thin, and adequate. Depressive symptoms, was measured with Center for Epidemiological Studies Depression Scale for Children (CES-DC4). BMI was categorized as underweight, normal weight and overweight. We used logistic regression and examined for effect modification by sex and BMI and adjusted for self-esteem and bullying.

RESULTS

An association was found between body image and depressive symptoms, when adjusting for BMI, sex, self-esteem, and bullying. The association was strongest for adolescents feeling too fat compared with adolescents feeling adequate OR:1.61(1.45-1.78), for adolescents feeling to thin compared to adequate: OR:1.21 (1.06-1.37). No effect modification by either BMI or sex was found, but those who perceive their bodies in contrast to their reported BMI faced the highest odds of depressive symptoms, and the results were confounded by self-esteem and bullying, that reduced the estimates after adjusting.

LIMITATIONS

This is a cross-sectional study with limited information regarding drop-out, with risk of selection bias.

CONCLUSION

We found an association between negative body image and depressive symptoms among Danish adolescents. This confirms previous studies and is a relevant aspect to adolescents' mental health, especially the contrast between BMI and perceived body image, and the confounding by self-esteem and bulling, with potential for prevention.

SGLT-2 inhibitors and mortality among patients with heart failure with reduced ejection fraction: linked database study

OBJECTIVE

To investigate the association between sodium-glucose cotransporter-2 (SGLT-2) inhibitor use and risk of all cause mortality among patients with heart failure with reduced ejection fraction.

DESIGN

Linked database study.

SETTING

National registers in Denmark, July 2020 to June 2023.

PARTICIPANTS

Patients with heart failure, aged ≥45 years, with left ventricular ejection fraction ≤40%.

MAIN OUTCOME MEASURES

The primary outcome was all cause mortality comparing initiation and continued treatment with SGLT-2 inhibitors versus continued treatment with other standard-of-care heart failure drugs and non-use of SGLT-2 inhibitors; secondary outcomes were the composite of cardiovascular mortality or admission to hospital with heart failure and its individual components. Hazard ratios were estimated using Cox regression adjusted using inverse probability of treatment weighting based on propensity scores.

RESULTS

The study included 6776 patients who started SGLT-2 inhibitors (79% dapagliflozin; 21% empagliflozin) and 14 686 patients who remained on other standard-of-care heart failure drugs and did not use SGLT-2 inhibitors. Most SGLT-2 inhibitor users were male (70%), the mean age was 71.2 (standard deviation 10.6) years, and 20% had type 2 diabetes. During follow-up, 374 deaths occurred among SGLT-2 inhibitor users (incidence rate 5.8 per 100 person years) and 1602 among non-users (8.5 per 100 person years). The weighted hazard ratio for all cause mortality was 0.75 (95% confidence interval 0.66 to 0.85); the weighted incidence rate difference was -1.6 (95% confidence interval -2.5 to -0.8) per 100 person years. Secondary outcomes showed a weighted hazard ratio of 0.94 (0.85 to 1.04) for cardiovascular mortality or hospital admission with heart failure, 0.77 (0.64 to 0.92) for cardiovascular mortality, and 1.03 (0.92 to 1.15) for hospital admission with heart failure. The weighted hazard ratios for all cause mortality were consistent in patients with and without diabetes (0.73 (0.58 to 0.91) and 0.73 (0.63 to 0.85); P=0.99).

CONCLUSIONS

In this large database study among patients with heart failure with reduced ejection fraction, SGLT-2 inhibitor use was associated with a 25% lower risk of all cause mortality, supporting their effectiveness in routine clinical practice.

Long-term aspirin adherence following myocardial infarction and risk of cardiovascular events

AIMS

Aspirin is considered mandatory after myocardial infarction (MI). However, its long-term efficacy has been questioned. This study investigated the effectiveness of long-term aspirin after MI.

METHODS AND RESULTS

Patients ≥40 years with MI from 2004 to 2017 who were adherent to aspirin 1 year after MI were included from Danish nationwide registries. At 2, 4, 6, and 8 years after MI, continued adherence to aspirin was evaluated. Absolute and relative risks of MI, stroke, or death at 2 years from each time point were calculated using multivariable logistic regression analysis with average treatment effect modelling standardized for age, sex, and comorbidities. Subgroup analyses were stratified by sex and age > and ≤65 years. Among 40 116 individuals included, the risk of the composite endpoint was significantly higher for non-adherent patients at all time points. The absolute risk was highest at 2-4 years after MI for both adherent [8.34%, 95% confidence interval (CI): 8.05-8.64%] and non-adherent patients (10.72%, 95% CI: 9.78-11.66%). The relative risk associated with non-adherence decreased from 4 years after index-MI and onwards: 1.41 (95% CI: 1.27-1.55) at 4-6 years and 1.21 (95% CI: 1.06-1.36) at 8-10 years (Ptrend = 0.056). Aspirin non-adherence in women and individuals >65 years was not associated with increased risk. Pinteraction at each of the time points: Age - <0.001, <0.001, 0.002, 0.51; Sex - 0.25, 0.02, 0.02, 0.82.

CONCLUSION

Non-adherence to long-term aspirin was associated with increased risk of MI, stroke, or death, but not in women or individuals >65 years. The risk decreased from 4 years after MI with near statistical significance.

Morbidity Burden in Patients With Ebstein Anomaly: The Natural History

BACKGROUND

The lifetime morbidity burden of patients with Ebstein anomaly (EA) has not been well described.

METHODS AND RESULTS

Through an extensive 2-country register-based collaboration, patients diagnosed with EA who were born between 1930 and 2017 were identified in Danish and Swedish nationwide medical registries. Each patient was matched by age and sex with 10 control subjects from the general population. Cox proportional-hazards regression, Fine-Gray competing risk regression, and Kaplan-Meier failure function were used to estimate the morbidity burden. The study included 794 patients diagnosed with EA and 7940 controls, with a median follow-up period of 33 years. Among patients with EA, approximately half (n=442) had isolated EA, and 28% (n=218) had concomitant atrial septal defect. Patients with complex anatomy demonstrated the highest cardiovascular morbidity burden, followed by those with concomitant atrial septal defect and isolated EA. The lifetime cumulative incidence of supraventricular arrhythmia and ventricular preexcitation in patients with EA, with or without atrial septal defect, was approximately 70% and 19%, respectively. Supraventricular arrhythmia substantially increased the risk of ischemic stroke (hazard ratio [HR] 22.6 [95% CI, 11.1-45.9]). Presence of atrial septal defect significantly affected arrhythmia and heart failure burden compared with isolated EA. In the total cohort of patients with EA, supraventricular arrhythmia onset led to an immediate high incidence of heart failure, with a 10-year cumulative incidence of 18%.

CONCLUSIONS

The natural history of EA, whether isolated or not, involves a substantial burden of cardiovascular morbidity and thus a highly vulnerable long-term prognosis.

Breast cancer in women with previous gestational diabetes: a nationwide register-based cohort study

BACKGROUND

Gestational diabetes mellitus (GDM) is a common pregnancy complication characterized by insulin resistance. A link has been suggested between insulin resistance and breast cancer, which is the most common cancer in women. Hence, women with previous GDM may be at increased risk of developing breast cancer, yet, the existing evidence is conflicting. This study explored the association between GDM and incident breast cancer, including age at cancer diagnosis. Additionally, we investigated the potential impact of severity of insulin resistance during pregnancy and of subsequent diabetes development on the breast cancer risk.

METHODS

We conducted a nationwide, register-based cohort study including all women giving birth in Denmark from 1997 to 2018. We defined GDM and breast cancer based on ICD-10 codes. Premenopausal and postmenopausal breast cancer was pragmatically defined as age at outcome < 50 years and ≥ 50 years, respectively. A proxy for severity of insulin resistance during pregnancy was based on insulin treatment; subsequent diabetes was defined as presence of ICD-10 codes and/or antidiabetic medication after pregnancy. The statistical analyses included Cox regression, logistic regression and t-test.

RESULTS

Of 708,121 women, 3.4% had GDM. The median follow-up period was 11.9 years (range 0-21.9). The overall breast cancer risk was comparable in women with and without previous GDM (adjusted hazard ratio 0.96 [95% CI 0.83-1.12]). Premenopausal and postmenopausal breast cancer risk also did not differ; however, women with previous GDM had a breast cancer diagnosis at younger age (42.6 vs. 43.5 years, p-value 0.01). All-cause mortality was similar regardless of GDM history. Severity of insulin resistance during pregnancy and subsequent diabetes did not affect breast cancer risk.

CONCLUSIONS

This large, population-based cohort study showed no higher risk of incident breast cancer in women with previous GDM compared to women without previous GDM after a median of almost 12 years of follow-up. This was evident irrespective of menopausal state. The breast cancer risk was not influenced by the severity of insulin resistance during pregnancy and by subsequent diabetes development. Regardless of GDM history, attention towards prevention, early detection and treatment of breast cancer should be prioritized.

Inflammatory Bowel Disease in Adults and Elderly: The Use of Selected Non-IBD Medication Examined in a Nationwide Cohort Study

BACKGROUND

Real-world data on medications used for conditions other than inflammatory bowel disease (IBD) are sparse. We examined how the onset of IBD affects the prescription pattern of selected non-IBD medication and the risk of becoming an incident user.

METHODS

This nationwide cohort study utilized data from Danish health registers. We included incident patients with young adult-onset IBD (18-39 years of age), adult-onset IBD (40-59 years of age), and elderly-onset IBD (60+ years of age), from 1998 to 2018 and followed all for 3 years. We examined redeemed prescriptions before and after the onset of IBD and estimated the risk of becoming a user of non-IBD medications using logistic regression models.

RESULTS

We identified 36165 patients, 16 771 (46%) with young adult onset, 10615 (29%) with adult onset, and 8779 (24%) with elderly onset. The onset of IBD increased the use of antidepressants, antipsychotics, sedatives/hypnotics, opioids, nonopioid analgesics, antidiabetics, and proton pump inhibitors, even in patients with no other underlying comorbid diseases. The adjusted odds ratio for using antidepressants 1 year after the onset of IBD in elderly was 1.50 (95% confidence interval [CI], 1.14-1.82), in opioids 1.69 (95% CI, 1.45-1.95), in nonopioid analgesics 2.10 (95% CI, 1.77-2.48), in cardiovascular medication 2.20 (95% CI, 1.86-2.61), and in proton pump inhibitors 1.51 (95% CI, 1.31-1.74) compared with adults.

CONCLUSIONS

In all 3 age groups, the proportions of patients with redeemed prescriptions for several groups of non-IBD medication were significantly increased after the IBD diagnosis compared with before. The risk of becoming an incident user for several groups of non-IBD medication was increased in elderly patients.

Time trends in incidence of pilonidal sinus disease from 1996 to 2021: A Danish population-based cohort study

AIM

Pilonidal sinus disease (PSD) is a common condition, but no data on disease occurrence exist outside highly selected settings. The aim of this study was to assess time trends in the incidence of PSD in a nationwide setting.

METHOD

Using data from nationwide Danish registries, we identified 48 247 patients recorded with diagnostic or surgical procedure codes representing PSD between 1996 and 2021. We stratified by sex and computed the age-adjusted and age-specific incidence rate, comparing 5-year intervals with the incidence rate ratio (IRR).

RESULTS

The overall incidence of PSD increased from 26.1 to 39.6/100 000 person-years (PY) from the period 1996-2000 to the period 2016-2021 (IRR 1.52, 95% CI 0.78-2.94). The incidence increased from 35.8 to 56.9/100 000 PY (IRR 1.59, 95% CI 0.52-4.89) in male patients and from 16.4 to 22.5/100 000 PY (IRR 1.37, 95% CI 0.68-2.76) in female patients. The peak of age-specific incidence was 215.7/100 000 PY (95% CI 206.1-245.4) among 20-year-old men and 107.9/100.000 PY (95% CI 100.0-114.0) among 18-year-old women. Over the study period, the median age at first hospital contact decreased from 27 years [interquartile range (IQR) 22-34 years) to 25 years (IQR 20-34 years) in men but remained stable around 23 years (IQR 18-32 years) in women. However, for both sexes, the highest increase in incidence was seen in early adolescence.

CONCLUSION

The incidence of PSD has increased significantly over the last decades. The increase is driven primarily by men and boys, with the highest increase in incidence seen in early adolescence. The increased burden of disease is not reflected in the literature, and more studies are warranted to understand the drivers of this development.

Use of proton pump inhibitors after laparoscopic gastric bypass and sleeve gastrectomy: a nationwide register-based cohort study

BACKGROUND/OBJECTIVES

L-RYGB and L-SG are the dominant bariatric procedures worldwide. While L-RYGB is an effective treatment of coexisting gastroesophageal reflux disease (GERD), L-SG is associated with an increased risk of de-novo or worsening of GERD. The study aimed to evaluate the long-term use of proton pump inhibitors (PPI) following laparoscopic Roux-en-Y gastric bypass (L-RYGB) and sleeve gastrectomy (L-SG).

SUBJECTS/METHODS

This nationwide register-based study included all patients undergoing L-RYGB or L-SG in Denmark between 2008 and 2018. In total, 17,740 patients were included in the study, with 16,096 and 1671 undergoing L-RYGB and L-SG, respectively. The median follow up was 11 years after L-RYGB and 4 years after L-SG. Data were collected through Danish nationwide health registries. The development in PPI use was assessed through postoperative redeemed prescriptions. GERD development was defined by a relevant diagnosis code associated with gastroscopy, 24 h pH measurement, revisional surgery or anti-reflux surgery. The risk of initiation of PPI treatment or GERD diagnosis was evaluated using Kaplan-Meier plots and COX regression models. The risk of continuous PPI treatment was examined using logistic regression modeling.

RESULTS

The risk of initiating PPI treatment was significantly higher after L-SG compared with L-RYGB (HR 7.06, 95% CI 6.42-7.77, p < 0.0001). The risk of continuous PPI treatment was likewise significantly higher after L-SG (OR 1.45, 95% CI 1.36-1.54, p < 0.0001). The utilization of PPI consistently increased after both procedures. The risk of GERD diagnosis was also significantly higher after L-SG compared with L-RYGB (HR 1.93, 95% CI 1.27-2.93, p < 0.0001).

CONCLUSIONS

The risk of initiating and continuing PPI treatment was significantly higher after L-SG compared with L-RYGB, and a continuous increase in the utilization of PPI was observed after both procedures.

Rheumatoid arthritis and risk of osteoarticular infection and death following Staphylococcus aureus bacteraemia: a nationwide cohort study

OBJECTIVES

Osteoarticular infection (OAI) is a feared complication of Staphylococcus aureus bacteraemia (SAB) and is associated with poor outcomes. We aimed to explore the risk of OAI and death following SAB in patients with and without rheumatoid arthritis (RA) and to identify risk factors for OAI in patients with RA.

METHODS

Danish nationwide cohort study of all patients with microbiologically verified first-time SAB between 2006-18. We identified RA, SAB, comorbidities, and RA-related characteristics (e.g. orthopaedic implants and antirheumatic treatment) in national registries including the rheumatology registry DANBIO. We estimated the cumulative incidence of OAI and death and adjusted hazard ratios (HRs, multivariate Cox regression).

RESULTS

We identified 18 274 patients with SAB (n = 367 with RA). The 90-day cumulative incidence of OAI was 23.1% (95% CI 18.8; 27.6) for patients with RA and 12.5% (12.1; 13.0) for patients without RA (non-RA) [HR 1.93 (1.54; 2.41)]. For RA patients with orthopaedic implants cumulative incidence was 29.4% (22.9; 36.2) [HR 1.75 (1.08; 2.85)], and for current users of tumor necrosis factor inhibitors (TNFi) it was 41.9% (27.0; 56.1) [HR 2.27 (1.29; 3.98) compared with non-users]. All-cause 90-day mortality following SAB was similar in RA [35.4% (30.6; 40.3)] and non-RA [33.9% (33.2; 34.5), HR 1.04 (0.87; 1.24)].

CONCLUSION

Following SAB, almost one in four patients with RA contracted OAI corresponding to a doubled risk compared with non-RA. In RA, orthopaedic implants and current TNFi use were associated with approximately doubled OAI risk. One in three died within 90 days in both RA and non-RA. These findings encourage vigilance in RA patients with SAB to avoid treatment delay of OAI.

Effectiveness of R-CHOP versus R-CHOEP for treatment of young patients with high-risk diffuse large B-cell lymphoma: A Danish observational population-based study

PURPOSE

Etoposide to standard R-CHOP is used for high-risk diffuse large B-cell lymphoma (DLBCL) in some countries. Due to the lack of randomized trials, a real-world data study using matching methods was used to test the potential effectiveness of R-CHOEP over R-CHOP.

PATIENTS AND METHODS

This study included patients from the Danish Lymphoma Register diagnosed between 2006 and 2020 at the age of 18-60 years with de novo DLBCL and age-adjusted IPI ≥2. R-CHOEP treated patients were matched 1:1 without replacement to R-CHOP treated patients using a hybrid exact and genetic matching technique. Primary endpoints were progression-free survival (PFS) and overall survival (OS).

RESULTS

In total, 396 patients were included; 213 received R-CHOEP and 183 received R-CHOP. Unadjusted 5-year PFS and OS for R-CHOEP were 69% (95% Confidence intervals [CI]; 63%-76%) and 79% (CI;73%-85%) versus 62% (CI;55%-70%) and 76% (CI;69%-82%) for R-CHOP (log-rank test, PFS p = .25 and OS p = .31). A total of 127 patients treated with R-CHOEP were matched to 127 patients treated with R-CHOP. Matching-adjusted 5-year PFS and OS were 65% (CI; 57%-74%) and 79% (CI; 72%-84%) for R-CHOEP versus 63% (CI; 55%-73%) and 79% (CI;72%-87%) for R-CHOP (log-rank test, PFS p = .90 and OS p = .63).

CONCLUSION

The present study did not confirm superiority of R-CHOEP over R-CHOP for young patients with high-risk DLBCL.

Associations Between Mental Disorders in Donors and Matched Recipients of Hematopoietic Stem Cell Transplants: A Population-Based Cohort Study

Background

Immunological mechanisms have been implicated in the development of mental disorders, and interestingly, case reports have suggested that hematopoietic stem cell transplantation (HSCT) can both transmit and cure psychotic disorders by replacing immune progenitor cells.

Methods

Using Danish registers, we followed patients who received HSCT from donors with a psychiatric diagnosis or psychotropic medication use. We assessed risk of incident mental disorders or psychotropic medication use compared with recipients with unaffected donors. We identified 464 donor-recipient pairs (51.3% male recipients). All donor-recipient pairs were related.

Results

Receiving HSCT from a donor with a psychiatric history was not significantly associated with incident psychiatric diagnoses (hazard rate ratio [HRR] 2.79, 95% CI, 0.83-9.39; p = .098) or incident use of psychotropics (HRR 1.43, 95% CI, 0.91-2.24; p = .118). Subgroup analysis showed an increased risk of antipsychotic use, which remained significant after adjusting for confounders (HRR 4.73, 95% CI, 1.26-17.78; p = .021); however, this was based on a small number of cases. For depression and antidepressant use, data were available to perform a meta-analysis of our and one additional study, which showed no significant difference (HRR 1.24, 95%, CI 0.66-2.35).

Conclusions

Receiving HSCT from a donor with a psychiatric history did not affect risk of mental disorders. An increased risk of antipsychotic use was observed only in subgroup analyses; however, the exploratory nature of the study, the limited sample size, and family relationship between donors and recipients do not allow for causal conclusions, and external replication studies are warranted.

Presence and development of diabetic retinopathy in 16 999 patients with type 1 diabetes in the Danish Registry of Diabetic Retinopathy

PURPOSE

To evaluate the five-year incidence of diabetic retinopathy (DR) and associated risk markers in patients with type 1 diabetes in the national Danish DR-screening programme.

METHODS

Based on national data, we included all 16 999 patients with type 1 diabetes in the Danish Registry of Diabetic Retinopathy, who attended the national screening programme in the period 2013-2018. According to the worse eye at first screening, DR was classified (levels 0-4) and linked with various national health registries to retrieve information on diabetes duration, systemic comorbidity, and medication.

RESULTS

At first screening, median age and duration of diabetes were 45.0 and 16.7 years, and 57.5% were males. The prevalence and five-year incidences for DR and progression to proliferative DR (PDR) were 44.2%, 8.9% and 2.0%, respectively. In multivariable Cox models, the incidence endpoints were associated with duration of diabetes (hazard ratio [HR] 1.76, 95% confidence interval [CI] 1.63-1.89, and HR 2.04, 95% CI 1.73-2.40 per 10 years), moderately low Charlson Comorbidity Index score (HR 1.27, 95% CI 1.10-1.47, and HR 2.80, 95% CI 2.23-3.51), and use of blood pressure lowering medication (HR 1.20, 95% CI 1.05-1.36, and HR 1.98, 95% CI 1.53-2.57).

CONCLUSION

In a study of all patients with type 1 diabetes from the Danish DR-screening programme, we identified duration of diabetes, systemic disease and use of anti-hypertensive treatment as consistent risk markers for incident and progressive DR.

Incidence of depression in patients with cardiovascular disease and type 2 diabetes: a nationwide cohort study

BACKGROUND

Estimating how type 2 diabetes (T2D) affects the rate of depression in cardiovascular disease (CVD) can help identify high-risk patients. The aim is to investigate how T2D affects the rate of depression according to specific subtypes of CVD.

METHODS

Incident CVD patients, free of psychiatric disease, with and without T2D, were included from nationwide registries between 2010 and 2020. We followed patients from CVD diagnosis until the first occurrence of depression, emigration, death, 5 years, or end of study (December 31, 2021). We used time-dependent Poisson regression to estimate the incidence rates and rate ratios (IRR) of depression following subtypes of CVD with and without T2D. The model included age, sex, comorbidities, calendar year, T2D duration, educational level, and living situation as covariates.

RESULTS

A total of 165,096 patients were included; 45,845 had a myocardial infarction (MI), 63,691 had a stroke, 19,959 had peripheral artery disease (PAD), 35,568 had heart failure (HF), and 979 were diagnosed with 2 or more CVD subtypes (= > 2 CVD's). Baseline T2D in each CVD subtype ranged from 11 to 17%. The crude incidence rate of depression per 1000 person-years (95% confidence intervals) was: MI + T2D: 131.1 (109.6;155.6), MI: 82.1 (65.3;101.9), stroke + T2D: 287.4 (255.1;322.6), stroke: 222.4(194.1;253.6), PAD + T2D: 173.6 (148.7;201.4), PAD:137.5 (115.5;162.5), HF + T2D: 244.3 (214.6;276.9), HF: 199.2 (172.5;228.9), =  > 2 CVD's + T2D: 427.7 (388.1;470.2), =  > 2 CVD's: 372.1 (335.2;411.9). The adjusted IRR of depression in MI, stroke, PAD, HF, and =  > 2 CVD's with T2D compared to those free of T2D was: 1.29 (1.23;1.35), 1.09 (1.06;1.12), 1.18 (1.13;1.24), 1.05 (1.02;1.09), and 1.04 (0.85;1.27) (p-value for interaction < 0.001).

CONCLUSION

The presence of T2D increased the rate of depression differently among CVD subtypes, most notable in patients with MI and PAD.

Traumatic spinal cord injury and its correlation to risk of autoimmune/-inflammatory disease

STUDY DESIGN

Nationwide epidemiological open cohort study.

OBJECTIVES

To evaluate whether individuals with traumatic spinal cord injury (TSCI) are more prone to develop autoimmune diseases compared to a general non-TSCI population.

SETTING

Danish public national registries.

METHODS

An open nationwide cohort, including individuals born in Denmark from or alive during 1945-2018 was collected and the study period was 1980-2018. Poissons Log-linear regression estimated the incidence rate ratio (IRR) for developing eight groups of autoimmune diseases. A dose-response relationship based on the cervical/thoracic level of injury was assessed by stratification.

RESULTS

The cohort included 3,272 individuals with TSCI and 4.8 million background individuals, accounting for 50,865 and 140 million person-years respectively. The TSCI population had an overall IRR of 1.81 (95% CI, 1.59 to 2.05) of getting any autoimmune disease. Subgroup analysis found positive associations for; a) Other neurologic IRR 5.19 (95% CI, 2.79 to 9.65), b) multiple sclerosis IRR 3.70 (95% CI, 2.54 to 5.40), c) Dermatologic IRR 2.57 (95% CI, 1.86 to 3.55), d) Type 1 diabetes mellitus IRR 2.01 (95% CI, 1.54 to 2.61), e) Systemic 1.92 (95% CI, 1.44 to 2.55), and f) Gastroenterologic IRR 1.42 (95% CI, 1.05 to 1.92). Cervical levels of TSCI showed an IRR of 1.70 (95% CI, 1.43 to 2.02), while thoracic levels had an IRR 1.98 (95% CI, 1.63 to 2.39).

CONCLUSIONS

TSCI may be an individual risk factor of developing an autoimmune disease. There does not appear to exist a dose-response relationship from the level of injury.

SPONSORSHIP

None.

Treatment trajectories for Danish individuals with type 2 diabetes in the era of emerging glucose-lowering therapies

AIM

To analyse patterns of glucose-lowering therapies among people with type 2 diabetes (T2D) in Denmark from 2016 to 2023.

MATERIALS AND METHODS

We examined time trends in the clinical profiles of people with T2D who initiated different glucose-lowering therapy classes for the first time. We furthermore investigated individual-level treatment trajectories following first-ever glucose-lowering therapy in people with or without cardiorenal disease. The study utilized data from the nationwide Danish health registries and included all individuals who filled a first-ever prescription for metformin, dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs), sodium-glucose co-transporter-2 inhibitors (SGLT-2is) or insulin, excluding those without HbA1c-confirmed T2D or probable type 1 diabetes.

RESULTS

We included 260 393 individuals initiating a new glucose-lowering therapy class from 2016 to 2023, during which there were 6- and 3-fold increases in initiators of GLP-1RAs and SGLT-2is, respectively. The median HbA1c level at treatment initiation with GLP-1RAs or SGLT-2is decreased, from 67-68 mmol/mol in 2016-2017 to 57-58 mmol/mol in 2022-2023. Among individuals who initiated metformin as first-line therapy, the proportion who started additional glucose-lowering therapy within 2 years increased from 25% in 2016 to 40% in 2021. Among the 38% of individuals who had established cardiorenal disease when they initiated first-ever glucose-lowering therapy in 2020, 22% used SGLT-2is and 18% GLP-1RAs after 2.5 years, compared with 17% and 21% among initiators without cardiorenal disease, respectively.

CONCLUSIONS

Our study documents a trend towards earlier T2D treatment intensification and an increase in the use of GLP-1RAs and SGLT-2is in Denmark. However, optimal T2D treatment is still not received by most individuals with early T2D and established cardiorenal disease.

GLP-1 Receptor Agonist Use and Risk of Suicide Death

Importance

Concerns have been raised regarding a link between use of glucagon-like peptide-1 (GLP-1) receptor agonists and increased risk of suicidality and self-harm.

Objective

To assess the association between use of GLP-1 receptor agonists and the risk of suicide death in routine clinical practice.

Design, Setting, and Participants

This active-comparator new-user cohort study used nationwide register data from Sweden and Denmark from 2013 to 2021. Adults 18 to 84 years old who initiated treatment with GLP-1 receptor agonists or the comparator sodium-glucose cotransporter-2 (SGLT2) inhibitors were included. Data were analyzed from March to June 2024.

Exposure

Initiation of treatment with a GLP-1 receptor agonist or SGLT2 inhibitor.

Main Outcomes and Measures

The primary outcome was suicide death recorded in the cause of death registers. Secondary outcomes were the composite of suicide death and nonfatal self-harm and the composite of incident depression and anxiety-related disorders. Using propensity score weighting, hazard ratios (HRs) with 95% CIs were calculated separately in the 2 countries and pooled in a meta-analysis.

Results

In total, 124 517 adults initiated a GLP-1 receptor agonist and 174 036 initiated an SGLT2 inhibitor; among GLP-1 receptor agonist users, the mean (SD) age was 60 (13) years, and 45% were women. During a mean (SD) follow-up of 2.5 (1.7) years, 77 suicide deaths occurred among users of GLP-1 receptor agonists and 71 suicide deaths occurred among users of SGLT2 inhibitors: weighted incidences were 0.23 vs 0.18 events per 1000 person-years (HR, 1.25; 95% CI, 0.83-1.88), with an absolute difference of 0.05 (95% CI, -0.03 to 0.16) events per 1000 person-years. The HR was 0.83 (95% CI, 0.70-0.97) for suicide death and nonfatal self-harm, and the HR was 1.01 (95% CI, 0.97-1.06) for incident depression and anxiety-related disorders.

Conclusions and Relevance

This cohort study, including mostly patients with type 2 diabetes, does not show an association between use of GLP-1 receptor agonists and an increased risk of suicide death, self-harm, or incident depression and anxiety-related disorders. Suicide death among GLP-1 receptor agonist users was rare, and the upper limit of the confidence interval was compatible with an absolute risk increase of no more than 0.16 events per 1000 person-years.

Opioid use after surgical treatment in the Danish population-Protocol for a register-based cohort study

BACKGROUND

Over the past 25 years, global opioid consumption has increased. Denmark ranks fifth in opioid use globally, exceeding other Scandinavian countries. Postsurgical pain is a common reason for opioid prescriptions, but opioid use patterns after patient discharge from the hospital are unclear. This study examines trends in opioid prescription among Danish surgical patients over a year.

METHODS

This register-based cohort study will use data from Danish governmental databases related to patients undergoing the 10 most frequent surgical procedures in 2018, excluding cancer-related and minor procedures. The primary outcome will be the dispensed postoperative opioid prescriptions at retail pharmacies over four quarters. Secondary analyses will include associations with sex, age, education attainment, and oral morphine equivalent quotient. Surgical treatments and diagnoses will be identified using NOMESCO procedure codes and ICD-10 codes. Opioids will be identified by ATC codes N02A and R05DA04. Subjects will be classified as preoperative opioid consumers or non-opioid consumers based on opioid prescriptions redeemed in the 6 months before surgery.

DISCUSSION

The study will use extensive national register-based data, ensuring consistent data collection and enhancing the generalizability of the findings to similar healthcare systems. The study may identify high-risk populations for long-term opioids and provide information to support opioid prescribing guidelines and public health policies.

Comparative Cardiovascular Effectiveness of Empagliflozin Versus Dapagliflozin in Adults With Treated Type 2 Diabetes: A Target Trial Emulation

BACKGROUND

Empagliflozin and dapagliflozin have proven cardiovascular benefits in people with type 2 diabetes at high cardiovascular risk, but their comparative effectiveness is unknown.

METHODS

This study used nationwide, population-based Danish health registries to emulate a hypothetical target trial comparing empagliflozin versus dapagliflozin initiation, in addition to standard care, among people with treated type 2 diabetes from 2014 through 2020. The outcome was a composite of myocardial infarction, ischemic stroke, heart failure (HF), or cardiovascular death (major adverse cardiovascular event). Participants were followed until an outcome, emigration, or death occurred; 6 years after initiation; or December 31, 2021, whichever occurred first. Logistic regression was used to compute inverse probability of treatment and censoring weights, controlling for 57 potential confounders. In intention-to-treat analyses, 6-year adjusted risks, risk differences, and risk ratios, considering noncardiovascular death competing events, were estimated. Analyses were stratified by coexisting atherosclerotic cardiovascular disease and HF. A per-protocol design was performed as a secondary analysis.

RESULTS

There were 36 670 eligible empagliflozin and 20 606 eligible dapagliflozin initiators. In the intention-to-treat analysis, the adjusted 6-year absolute risk of major adverse cardiovascular event was not different between empagliflozin and dapagliflozin initiators (10.0% versus 10.0%; risk difference, 0.0% [95% CI, -0.9% to 1.0%]; risk ratio, 1.00 [95% CI, 0.91 to 1.11]). The findings were consistent in people with atherosclerotic cardiovascular disease (risk difference, -2.3% [95% CI, -8.2% to 3.5%]; risk ratio, 0.92 [95% CI, 0.74 to 1.14]) and without atherosclerotic cardiovascular disease (risk difference, 0.3% [95% CI, -0.6% to 1.2%]; risk ratio, 1.04 [95% CI, 0.93 to 1.16]) and in people with HF (risk difference, 1.1% [95% CI, -6.5% to 8.6%]; risk ratio, 1.04 [95% CI, 0.79 to 1.37]) and without HF (risk difference, -0.1% [95% CI, -1.0% to 0.8%]; risk ratio, 0.99 [95% CI, 0.90 to 1.09]). The 6-year risks of major adverse cardiovascular event were also not different in the per-protocol analysis (9.1% versus 8.8%; risk difference, 0.2% [95% CI, -2.1% to 2.5%]; risk ratio, 1.03 [95% CI, 0.80 to 1.32]).

CONCLUSIONS

Empagliflozin and dapagliflozin initiators had no differences in 6-year cardiovascular outcomes in adults with treated type 2 diabetes with or without coexisting atherosclerotic cardiovascular disease or HF.

ABO Blood Type and Short-Term Mortality in Patients With Infection-Associated Disseminated Intravascular Coagulation

BACKGROUND

Disseminated intravascular coagulation (DIC) is a devastating disease of the coagulation system. We examined the association between ABO blood type and short-term mortality in patients with infection-associated DIC.

METHODS

The study cohort was drawn from the Danish Disseminated Intravascular Coagulation (DANDIC) cohort. Our subcohort was restricted to patients with infection-associated DIC. All-cause 30-day and 90-day mortality were computed by Kaplan-Meier estimates and odds ratios between ABO blood types were examined using logistic regression analysis adjusted for age, sex, comorbidity, and location of infection. Blood type O was used as a reference.

RESULTS

The DANDIC cohort included 3023 patients with DIC. Among these, 1853 (61%) had infection-associated DIC. Data on ABO blood type were unavailable in 34 patients (1.8%), who were excluded. The median age was 68 years and 58.2% were males. The 30-day mortality ranged between 38.6% and 42.5% and the 30-day mortality odds ratios were 1.15 (95% confidence interval (CI), 0.92-1.42) for blood type A; 0.84 (95% CI, 0.49-1.43) for AB; and 0.95 (95% CI, 0.67-1.33) for B compared to blood type O.

CONCLUSIONS

We found no clinically meaningful difference in short-term mortality between the various ABO blood types in patients with infection-associated DIC.

Validation of Fetal Medicine Foundation charts for fetal growth in twins: nationwide Danish cohort study

OBJECTIVE

To assess the validity of the Fetal Medicine Foundation (FMF) chorionicity-specific models for fetal growth in twin pregnancy.

METHODS

This was an external validation study of the FMF models using a nationwide Danish cohort of twin pregnancies. The cohort included all dichorionic (DC) and monochorionic diamniotic (MCDA) twin pregnancies with an estimated delivery date between 2008 and 2018, which satisfied the following inclusion criteria: two live fetuses at the first-trimester ultrasound scan (11-14 weeks' gestation); biometric measurements available for the calculation of estimated fetal weight (EFW) using the Hadlock-3 formula; and delivery of two liveborn infants. Validation involved assessing the distributional properties of the models and estimating the mean EFW Z-score deviations. Additionally, the models were applied to pregnancies that delivered preterm and attended non-scheduled visits (complicated pregnancies).

RESULTS

Overall, 8542 DC and 1675 MCDA twin pregnancies met the inclusion criteria. In DC twins, 17 084 fetuses were evaluated at a total of 95 346 ultrasound scans, of which 44.5% were performed at scheduled visits in pregnancies carried to 37 + 0 weeks or later. The median number of growth scans per DC twin fetus from 20 + 0 weeks onwards was four. The model showed good agreement with the validation cohort for scheduled visits in DC twins delivered at 37 + 0 weeks or later (mean EFW Z-score, -0.14 ± 1.05). In MCDA twins, 3350 fetuses underwent 31 632 eligible ultrasound scans, of which 59.5% were performed at scheduled visits in pregnancies carried to 36 + 0 weeks or later. The median number of growth scans per MCDA twin fetus from 16 + 0 weeks onwards was 10. The model showed favorable agreement with the validation cohort for scheduled visits in MCDA twins delivered at 36 + 0 weeks or later (mean EFW Z-score, -0.09 ± 1.01). Non-scheduled visits and preterm delivery before 37 + 0 weeks for DC twins and before 36 + 0 weeks for MCDA twins corresponded with smaller weight estimates, which was consistent with the study's definition of complicated pregnancy.

CONCLUSIONS

The FMF models provide a good fit for EFW measurements in our Danish national cohort of uncomplicated twin pregnancies assessed at routine scans. Therefore, the FMF models establish robust criteria for subsequent investigations and potential clinical applications. Future research should focus on exploring the consequences of clinical implementation, particularly regarding the identification of twins that are small-for-gestational age, as they are especially susceptible to adverse perinatal outcome. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Long-term exposure to ambient air pollution and risk of lung cancer - A comparative analysis of incidence and mortality in four administrative cohorts in the ELAPSE study

BACKGROUND

Studies have linked air pollution to lung cancer incidence and mortality, but few have compared these associations, which may differ due to cancer survival variations. We aimed to evaluate the association between long-term air pollution exposure and lung cancer incidence and compare findings with previous lung cancer mortality analyses within the same cohorts.

METHODS

We analyzed four population-based administrative cohorts in Denmark (2000-2015), England (2011-2017), Norway (2001-2016) and Rome (2001-2015). We assessed residential exposure to annual average fine particulate matter (PM2.5), nitrogen dioxide (NO₂), black carbon (BC), and warm-season ozone (O3) using Europe-wide land use regression models. We used Cox proportional hazard models to evaluate cohort-specific hazard ratios (HRs) and 95% confidence intervals (CIs) for lung cancer incidence identified using hospital admission records (English and Roman cohorts) or cancer registries (Danish and Norwegian cohorts). We evaluated the associations at low exposure levels using subset analyses and natural cubic splines. Cohort-specific HRs were pooled using random-effects meta-analyses, separately for incidence and mortality.

RESULTS

Over 93,733,929 person-years of follow-up, 111,949 incident lung cancer cases occurred. Incident lung cancer was positively associated with PM2.5, NO2 and BC, and negatively associated with O3. The negative O3 association became positive after adjustment for NO2. Associations were almost identical or slightly stronger for lung cancer incidence than mortality in the same cohorts, with respective meta-analytic HRs (95% CIs) of 1.14 (1.06, 1.22) and 1.12 (1.02, 1.22) per 5 μg/m3 increase in PM2.5, and 1.10 (1.04, 1.16) and 1.09 (1.02, 1.16) per 10 μg/m3 increase in NO2. Positive associations persisted for both incidence and mortality at low pollution levels with similar magnitude.

CONCLUSIONS

We found similarly elevated risks of lung cancer incidence and mortality in association with residential exposure to PM2.5, NO2 and BC in meta-analyses of four European administrative cohorts, which persisted at low pollution levels.

Patient characteristics and mortality across diagnostic settings in COPD

BACKGROUND

Many patients with chronic obstructive pulmonary disease (COPD) are diagnosed late, e.g., at first acute exacerbation of COPD (AECOPD). AECOPD increases the risk of death. We aim to investigate patient characteristics and mortality across diagnostic settings among patients with COPD.

METHODS

This nationwide Danish study allocated 107,023 patients with a first-time registered COPD-related hospital contact between 2010 and 2018 based on diagnostic setting: primary care (prior inhalation medication use), hospital outpatient clinic or hospital admission. Multivariable logistic regression was employed to investigate patient characteristics and mortality across these diagnostic settings.

RESULTS

In total, 81,035 (75.7 %) patients were diagnosed in primary care, median age 63 years (interquartile range (IQR) 53-71); 11,302 (10.6 %) at an outpatient clinic, median age 68 years (IQR 60-76), and 14,686 (13.7 %) during hospital admission, median age 73 years (IQR 65-81). Patient characteristics associated with diagnosis during hospital admission encompassed age (odds ratio (OR) 1.05, 95 % confidence interval (CI) 1.05-1.05, p < 0.001), male sex (OR 1.14, CI 1.10-1.19, p < 0.001), and number of comorbidities, which increased from one comorbidity (OR 2.64, CI 2.50-2.79, p < 0.001) to six or more comorbidities (OR 12.37, CI 11.26-13.60, p < 0.001). Diagnosis during hospital admission due to AECOPD was associated with increased one-year mortality (OR 1.24, CI 1.16-1.33, p < 0.001) compared to diagnosis in primary care.

CONCLUSION

Patients diagnosed with COPD in hospital settings were generally older, predominantly male, and had more comorbidities. Patients diagnosed in primary care prior to their first AECOPD admission had higher one-year survival.

Algorithm for forming hospital care episodes by combining attendance contacts in the Danish National Patient Register: A methodological consensus-driven study

BACKGROUND

Studying complete hospital care episodes from register data, for instance when assessing length of stay, discharges and readmissions, can cause methodological difficulties due to the lack of a contact linkage identifier. We aimed to develop an algorithm combining sequential attendance contacts in the Danish National Patient Register (DNPR) into hospital care episodes, spanning the entire duration and all contacts from hospital arrival to departure.

METHODS

The algorithm was developed under the consensus of experts from research institutions across Denmark. It reads in second and third version DNPR data, deletes contacts without attendance, duplicates elective outpatient contacts corresponding to attendance dates and modifies contact types (e.g. repeated acute contacts), among others. Thereafter, sequential contacts within 4 h are marked as the same hospital care episode, consisting of one or more DNPR contact. We tested the algorithm in a data set of adults living in Denmark during 2013-2021 and compared different hourly cut-offs.

RESULTS

For the demonstration, we included 120.2 m contacts from 5.7 m persons, combined into 105.9 m hospital care episodes. Of the hospital care episodes, 6.4% were acute inpatients, 8.3% were acute outpatients, 2.0% were elective inpatients and 83.3% were elective outpatients. Using 4 h as our recommendation, 3-h, 5-h and 6-h cut-offs for contact combining revealed only minor differences in the number of hospital care episodes (<0.4%), whereas 12-h (<1.7%) and 24-h cut-offs (<43.1%) had a larger impact.

CONCLUSIONS

The algorithm automates data reading, modification and linkage of sequential attendance contacts. The algorithm can be initiated as a SAS macro and is available from an online repository.

Evaluating the effect of BCG vaccination for non-specific protection from infection in senior citizens during the COVID-19 pandemic: A randomised clinical trial

OBJECTIVES

The Bacillus Calmette-Guérin (BCG) vaccine may induce non-specific protection against unrelated infections. We tested the effect of BCG on the risk of infections among Danish senior citizens.

METHODS

Single-blinded randomised controlled trial including 1676 volunteers >65 years. Participants were randomised 1:1 to BCG or placebo and followed for 12 months. The primary outcome was acute infection leading to medical contact. Secondary outcomes were verified SARS-CoV-2 infection, self-reported respiratory symptoms, and all-cause hospitalisation. Data was analysed using Cox regression models, estimating hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

The incidence of acute infection was 52.1 and 58.2 per 100 person-years for BCG and placebo, respectively (HR=0.89, 95% CI=0.78-1.02). There was no effect of BCG on SARS-CoV-2 infections (0.97, 0.75-1.26) or all-cause hospitalisations (1.10, 0.80-1.50), but BCG was associated with more respiratory symptoms (1.21, 1.10-1.33). BCG reduced the incidence of acute infections among participants <75 years (0.82, 0.70-0.95) but not among those >75 years (1.14, 0.88-1.47). In participants, who were COVID-19 vaccinated before enrolment, BCG was associated with lower incidence of acute infections (0.65, 0.50-0.85).

CONCLUSION

BCG did not reduce risk of acute infections among Danish seniors overall, but the effect was modified by age group and COVID-19 vaccination.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04542330) and EU Clinical Trials Register (EudraCT number 2020-003904-15). Full trial protocol is available at ClinicalTrials.gov.

SUMMARY

In a randomised clinical trial among Danish senior citizens, BCG vaccination did not reduce the overall risk of acute infection, but BCG was associated with reduced risk in participants <75 years and participants who received COVID-19 vaccines prior to enrolment.

Urticaria and the risk of cancer: a Danish population-based cohort study

BACKGROUND

Urticaria has been tentatively linked to cancer, but epidemiological evidence supporting this link is sparse and conflicting. We conducted a population-based cohort study using healthcare databases covering the Danish population (January 1980-December 2022). We followed 87 507 people for a median of 10.1 years after their first hospital contact for urticaria.

OBJECTIVES

To examine associations of a hospital diagnosis of urticaria with incident cancer.

METHODS

We computed the absolute risk of cancer and standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) standardized to Danish national cancer rates. In a cross-sectional analysis, we examined whether the extent of cancer spread differed between people with vs. without a previous urticaria diagnosis.

RESULTS

The overall SIR for all types of cancer was 1.09 (95% CI 1.06-1.11) based on 7788 observed vs. 7161 expected cases. The risk for any cancer was 0.7% (95% CI 0.6-0.7) for the first year of follow-up. Cancer was diagnosed in 588 people with urticaria during the first year of follow-up (SIR 1.49, 95% CI 1.38-1.62) and in 7200 people thereafter (SIR 1.06, 95% CI 1.04-1.09). During the first year of follow-up, we found strong associations with haematological cancers (e.g. non-Hodgkin lymphoma; SIR 2.91, 95% CI 1.92-4.23). Cancer stage was similar in people with vs. without a previous urticaria diagnosis.

CONCLUSIONS

At the time of urticaria diagnosis, or in the first year afterward, we found a large increase in the risk of cancer. In subsequent years, a persistent 6% increase in risk remained. Diagnostic efforts may partly explain the elevated short-term risk, but occult cancer may promote urticaria, or cancer and urticaria share common risk factors.

Preoperative Psychopharmacological Treatment Is Not a Risk Factor for Poorer Patient-Reported Improvements 12 months After Hip or Knee Arthroplasty: A Multicenter Registry-Based Cohort Study of 7,247 Procedures

BACKGROUND

Preoperative psychopharmacological treatment (PPT) has been associated with increased hospital length of stay and readmission rate after hip and knee arthroplasty. However, little is known regarding the association between PPT and improvements in patient-reported outcomes postoperatively in a multicenter fast-track setting. Thus, the primary objective was to investigate whether PPT is a risk factor for poorer patient-reported improvements 12 months after surgery. Secondary objectives included assessment of additional time points and subgroups of PPT.

METHODS

This multicenter registry-based cohort study included 4,021 primary hip and 3,226 primary knee arthroplasties performed from 2016 to 2020 at three fast-track departments in Denmark due to primary osteoarthritis. The Oxford Hip Score/Oxford Knee Score (OHS/OKS), EuroQol-5 Dimensions-3 Levels/EuroQol-5 Dimensions-5 Levels, and EuroQol visual analog scale were collected at baseline and 3, 6, 12, and 24 months after surgery. Exposure status was assigned using the Danish National Prescription Registry. Marginal mean differences (MD) with 95% confidence intervals (CIs) were estimated using multilevel Tobit regression and adjusted for age, sex, and the Charlson Comorbidity Index obtained from the Danish National Patient Register.

RESULTS

No associations were found between PPT and improvements in OHS (MD -0.5, CI -1.4 to 0.4) or OKS (MD -0.3, CI -1.2 to 0.5) after 12 months. However, PPT was associated with lower baseline OHS (MD -1.4, CI -2.2 to -0.6) and OKS (MD -2.1, CI -2.9 to -1.3), and 12 months follow-up OHS (MD -1.9, CI -2.8 to -1.1) and OKS (MD -2.4, CI -3.2 to -1.6). Similar findings were observed at other time points, using EuroQol-5 Dimensions-3 Levels/EuroQol-5 Dimensions-5 Levels or EuroQol visual analog scale, and when evaluating PPT subgroups.

CONCLUSIONS

In hip and knee arthroplasty, PPT was not a risk factor for poorer patient-reported improvements 12 months after surgery. However, PPT was associated with marginally poorer baseline and follow-up scores. Thus, arthroplasties remain effective treatments despite PPT from a patient-centered perspective.

Use of antithrombotic therapy and the risk of cardiovascular outcomes and bleeding in cancer patients at the end of life: a Danish nationwide cohort study

BACKGROUND

Despite uncertain benefit-risk profile near the end of life, antithrombotic therapy (ATT) is prevalent in patients with terminal cancer.

OBJECTIVES

To examine adherence and persistence with ATT in terminally ill cancer patients and investigate risks of major and clinically relevant bleeding, venous thromboembolism (VTE), and arterial thromboembolism (ATE) by ATT exposure.

METHODS

Using a Danish nationwide cohort of terminal cancer patients, ATT adherence in the year following terminal illness declaration was measured by the proportion of days covered (PDC) by prescription. Discontinuation was defined as a treatment gap of ≥30 days between prescription renewals. One-year cumulative incidences of bleeding complications, VTE, and ATE were calculated, considering the competing risk of death.

RESULTS

During 2013-2022, 86 732 terminally ill cancer patients were identified (median age, 75 years; 47% female; median survival, 57 days). At terminal illness declaration, 37.5% were receiving ATT (66.6% platelet inhibitors, 23.0% direct oral anticoagulants, and 10.4% vitamin K antagonists [VKAs]). The mean PDC with ATT was 88% (SD, 30%), highest among platelet inhibitor users (mean PDC, 89%) and lowest among VKA users (73%). One-year ATT discontinuation incidence was 7.9% (95% CI, 7.7%-8.1%). Most patients continued ATT until death (74.8% platelet inhibitors, 58.8% direct oral anticoagulants, and 61.6% VKAs). Patients receiving ATT had a lower 1-year VTE risk but higher risks of ATE and major bleeding.

CONCLUSION

Despite uncertain benefit-risk profile, most terminally ill cancer patients continue ATT until the end of life. These findings provide insights into current ATT utilization and discontinuation dynamics in the challenging context of terminal illness.

Incidence of Graves' Disease with Validation and Completeness of the Diagnosis for Registry Extracts in the Danish National Patient Register

Purpose

Graves' disease (GD) is one of the most common causes of thyrotoxicosis. It has been proposed to identify incident GD by using the GD-specific code, E05.0, of the 10th revision of the International Classification of Disease (ICD-10) in the Danish National Patient Register (DNPR). We aimed to report the incidence of GD and to investigate the validity and completeness of E05.0 registration using Aalborg University Hospital (AaUH) as a single centre-sample.

Patients and Methods

The study included registry data from 2020 to 2022. The study population (n=2,893) comprised all people (15-99 years) in the catchment area of AaUH (n=244,872) with either positive anti-thyroid stimulating hormone receptor antibodies (TRAb), or registered with a thyroid disease related ICD-10 code E03.0-E07.9, O99.2 or O90.5 at the Department of Endocrinology, AaUH. To identify incident cases, all subjects occurring for the first time in 2020 were excluded (n=2,339). The incident subjects were categorized into a general practice (n=63) or hospital care group (n=491) and underwent GD verification by biochemical tests and thyroid imaging. Validity was evaluated by positive (PPV) and negative (NPV) predictive values and completeness of E05.0 registration was estimated to the total number of verified GD subjects in hospital care only and in overall (groups combined).

Results

One hundred thirty-one incident GD subjects were identified corresponding to an incidence of 26.8 per 100,000/year. E05.0 had a PPV of 90% [95% CI: 81;96] and a NPV of 90% [95% CI: 85;93] to identify incident cases of GD. Completeness was estimated to be 73% [95% CI: 63;82] in hospital care and 50-60% [95% CI: 41;68] in overall.

Conclusion

We report on a similar incidence of GD as previous studies in Denmark. Despite a high PPV, incident cases of GD could not adequately be identified by E05.0 in DNPR due to low completeness. Researchers should rely on biochemical test results to identify incident GD.

Is development and persistence of multiple physical symptoms associated with coping? A longitudinal study over a decade

OBJECTIVE

To examine the development and persistence of multiple physical symptoms (MPS) over a decade including the associations with sociodemographics and coping strategies.

METHOD

A longitudinal study of 16,405 individuals aged 20-64 years participating in the Danish Symptom Cohort (DaSC) was conducted in 2012 with follow-up data in 2022 (DaSC II). MPS were assessed according to the unifying diagnostic construct of bodily distress syndrome, and coping was measured with the Brief Approach/Avoidance Coping Questionnaire. Descriptive statistics and multivariable logistic regression analyses were performed.

RESULTS

Among individuals not having MPS in 2012, 17 % had developed MPS in 2022. Among individuals having MPS in 2012, 57 % had persistence of MPS in 2022. Individuals who developed or had persistence of MPS at follow-up were more likely to be female, have lower educational level, be immigrant, redeem antidepressants, have lower approach scores as well as higher diversion and resignation scores.

CONCLUSIONS

Individuals responding to stressful situations with low approach, high diversion, and high resignation may be at higher risk of developing MPS and have persistence of MPS. As coping can be targeted through psychotherapy, it is important to focus on maladaptive strategies, especially in high-risk groups for developing and maintaining MPS.

Evaluation of Two Different Approaches for Selecting Patients for Postoperative Radiotherapy in Deep-Seated High-Grade Soft Tissue Sarcomas in the Extremities and Trunk Wall

Two national sarcoma centers have had different approaches for selecting patients with grade 2-3 deep-seated soft tissue sarcomas (STS) for postoperative radiotherapy (RT). We evaluated potential differences in local recurrence in patients treated at the two centers. At Sarcoma Center 1 (SC1), RT was the standard treatment for all tumors except certain small tumors excised with a margin wider than 1 cm. Sarcoma Center 2 (SC2) avoided RT for tumors regardless of tumor size if removed with a margin wider than 1 cm and/or a solid barrier. We included 386 patients (SC1/SC2 = 196/190) over 18 years of age diagnosed with a non-metastatic grade 2-3, deep-seated STS of the extremities or trunk wall, who underwent primary surgical treatment (only tumors excised with a negative margin) from 1 January 2000, to 31 December 2016. Kaplan-Meier survival analysis, competing risk analysis, and cause-specific Cox regression were applied. A total of 284 patients received primary RT, 163 (83%) at SC1 and 121 (64%) at SC2 (p < 0.001). The cumulative incidence of local recurrence at five years was 15% (95% CI: 10-19%) at SC1 and 14% (95% CI: 9-19%) at SC2. Multivariate analysis showed no significant differences in local recurrence between the centers. We concluded that when entering all available patients into the analysis using an intention-to-treat principle, a more selective approach to postoperative RT in patients with grade 2-3 deep-seated STS did not lead to a higher local recurrence rate. However, with this study design, we cannot rule out if the local recurrence rate could have been lower if RT was administered to all tumors removed with a margin wider than 1 cm and/or a solid barrier.

Risk of Ischemic Stroke After Patent Foramen Ovale Closure

BACKGROUND

Transcatheter patent foramen ovale (PFO) closure is the recommended treatment for patients age 18 to 60 years with cryptogenic stroke having a high probability of being PFO-related. Limited data exist on stroke recurrence after PFO closure outside clinical trials.

OBJECTIVES

The purpose of this study was to examine stroke recurrence after PFO closure in routine clinical practice.

METHODS

We used nationwide population-based Danish registries to conduct a cohort study of all patients with PFO closure during 2008 to 2021 (n = 1,162) and a birth year and sex-matched comparison cohort from the general population (n = 11,620). We calculated absolute and relative risks of ischemic stroke within 4 years after PFO closure. We used weighted Cox regression to estimate adjusted HRs of the association between PFO closure vs the general population and ischemic stroke.

RESULTS

The absolute risks of ischemic stroke in patients with PFO closure and in the general population, respectively, were 1.4% (95% CI: 0.8%-2.3%) and 0.1% (95% CI: 0.0%-0.1%) at 1 year, 1.4% (95% CI: 0.8%-2.3%) and 0.2% (95% CI: 0.2%-0.4%) at 2 years, 2.2% (95% CI: 1.3%-3.5%) and 0.4% (95% CI: 0.2%-0.5%) at 3 years, and 2.5% (95% CI: 1.5%-4.0%) and 0.4% (95% CI: 0.3%-0.6%) at 4 years. Thus, the absolute 4-year risk of ischemic stroke was 2.1% (95% CI: 0.9%-3.3%) higher in patients with PFO closure than in the general population, corresponding to an adjusted HR of 6.3 (95% CI: 3.1-12.6).

CONCLUSIONS

The 4-year risk of ischemic stroke after routine PFO closure for cryptogenic stroke was comparable to that observed in clinical trials, but remained higher than in the general population.

Socioeconomic status and emergency department visits in adults with a history of severe childhood asthma: a register-based study

Background and Objective

Our knowledge of socioeconomic status (SES) and emergency department (ED) visits in adults with a history of severe childhood asthma is limited. Our aim was, therefore, to investigate these variables in individuals with a history of severe childhood asthma compared to a control population.

Methods

The Kongsberg cohort comprises Danish individuals with a history of severe childhood asthma and a previous 4-month stay at an asthma care facility in Kongsberg, Norway, between 1950 and 1979. The cohort was compared 1:1 to sex and age matched controls with no previous diagnosis of or treatment for obstructive airway disease (OAD). Data from the national Danish health registries were used for comparing cases and controls.

Results

A total of 1394 adults from the Kongsberg cohort were alive and residing in Denmark (mean age 63 years, 43% females) at the index date (June 2022). A Charlson comorbidity index score of ≥1 was higher in the study cohort compared to controls (7% versus 3%) (p < 0.01). Cases had a 1.5-fold increased likelihood of having a high educational level (p < 0.001) compared to controls. Compared to the controls, cases had a higher risk of all-cause ED visits, with individuals having lower educational levels showing the highest proportion of ED visits. Furthermore, 31.2% and 22.9%, respectively, of cases and controls with high educational levels had had ED visits. Compared to controls, logistic regression analysis revealed a 1.7-fold higher risk of all-cause ED visits in cases (p < 0.001).

Conclusions

In adults with a history of severe childhood asthma, educational level, comorbidity burden, and risk of ED visit were higher compared to matched controls with no history of obstructive airway disease.

Does LDL-C determination method affect statin prescribing for primary prevention? A register-based study in Southern Denmark

AIMS

Examine whether the low-density lipoprotein cholesterol (LDL -C) determination method influences the rate of statin initiation for primary prevention of cardiovascular disease.

METHODS AND RESULTS

We conducted a register-based retrospective study in the Region of Southern Denmark. Two hospital-based laboratories in the region directly measure LDL -C whereas four laboratories calculate LDL -C using Friedewald's formula. Physicians do not choose which method is used. We included all statin-naïve patients ≥40 years with no history of cardiovascular disease, diabetes, or chronic kidney disease, who had their LDL -C determined during 2018-2019. There were 202 807 people who had LDL -C determined during the study period (median age 59 years, 44% women) of which 37% had a direct LDL -C measurement. The median reported LDL -C was 3.40 mmol/L [interquartile range (IQR) 2.90-4.00] for those with a direct measurement vs. 3.00 mmol/L (IQR 2.40-3.50) for those with calculated LDL -C. For those with direct measurement, re-calculated LDL -C (using Friedewald's formula) was 0.35 mmol/L lower than the reported direct LDL -C measurement. Among those with directly measured LDL -C, 3.6% initiated statins compared with 2.7% of those with a calculated LDL -C. Direct LDL -C measurement led to higher odds of having a statin initiated compared with calculated LDL -C (adjusted odds ratio 1.23, 95% CI 1.17-1.30); for those with triglycerides >1.7 mmol/L the adjusted odds ratio was 1.41 (95% CI 1.30-1.52).

CONCLUSION

Differences in the reporting of LDL -C from laboratories using different methods have a substantial influence on physician's decisions to prescribe statins.

Burden of disease and cost of illness of infants less than 6 months of age hospitalised with respiratory syncytial virus in Denmark - a 10-year national register-based study

BACKGROUND

Respiratory syncytial virus (RSV) is the most common cause of hospitalisation in infants aged ≤ 6 months in Western countries. Nearly 1,500 infants under six months of age are hospitalised with RSV annually in Denmark. This nationwide study describes the healthcare resource utilisation and costs related to RSV hospitalisation in this vulnerable age group.

METHODS

RSV cases were identified in the Danish National Patient Register. Infants were included if they at the age of 0-5 months had a (1) respiratory related hospital admission (duration > 12 h), (2) within 10 days of a positive RSV test, (3) between January 2013 and December 2022. Each case was matched with five individuals never diagnosed with RSV on age, sex, region of residence, birth (pre/full term), number of siblings < 7 years old, and parents' education. An episode of RSV was defined as the seven days prior to hospitalisation to 30 days after initial hospitalisation. Study outcomes included contacts with hospital and primary care, and total healthcare costs defined as the sum cost of hospital care, primary care, and prescription medicine. Cost and contacts attributable to RSV was calculated in a diff-in-diff framework, as the difference between case and reference group.

RESULTS

The study population comprised of 8,428 RSV cases and 41,725 reference individuals. Cases generated 1.58 (p < 0.001) attributable inpatient contacts, 0.84 (p < 0.001) outpatient contacts, and 1.19 (p < 0.001) primary care contacts during their RSV episode. An additional 0.6 (p < 0.001) inpatient, 1.08 (p < 0.001) outpatient and 2.42 (p < 0.001) primary care contacts were attributed to RSV in the year following the RSV episode. Total cost of an RSV episode was EUR 2,997 (p < 0.001) with an additional EUR 1,428 (p < 0.001) in the following year.

CONCLUSION

RSV hospitalisations of infants are associated with substantial healthcare utilisation and costs. The same pattern was observed in the year following the RSV episode. If the new RSV prevention options are introduced nationwide, the overall burden of RSV is expected to be substantially reduced in the future.

Implications of Age for the Diagnostic and Prognostic Value of Cardiac Troponin T and I

BACKGROUND

The influence of age on cardiac troponin is unclear and may vary between cardiac troponin T (cTnT) and I (cTnI). We aimed to compare the impact of age on the diagnostic and prognostic utility of cTnT and cTnI.

METHODS

This Danish nationwide, register-based cohort study included patients with at least one cardiac troponin (cTn) measurement from 2009 through June 2022, stratified into decades of age. We used peak cTn concentration during admission, dichotomized as positive/negative and normalized to the 99th percentile. Receiver operating characteristics for myocardial infarction (MI) and logistic regression were used to estimate the odds ratio (OR) for mortality at 1 year.

RESULTS

We included 541 817 patients; median age 66 years (interquartile range [IQR] 51-77) and 256 545 (47%) female. A total of 40 359 (7.4%) had an MI, and 59 800 (14.1%) patients died within 1 year of admission. The predictive ability of both cTns for MI were highest for patients 30 to 50 years. This was most pronounced for cTnT, the specificity of which fell from 83% among patients 40 to 49 years to 4% for patients ≥90 years. The prognostic ability of both cTns for 1-year mortality declined with age. cTnT had stronger prognostic ability for all age-groups; OR for a positive cTnT 28.4 (95% CI, 20.1-41.0) compared with 9.4 (95% CI, 5.0-16.7) for cTnI among patients <30 years.

CONCLUSIONS

The predictive and prognostic ability of cTnT and cTnI declined with age. cTnT had a low specificity for MI in elderly patients. However, cTnT was the strongest prognostic marker among all age groups.

The DANish Disseminated Intravascular Coagulation (DANDIC) Cohort Study: Time Trends in Incidence and Short-Term Mortality

Background: Disseminated intravascular coagulation (DIC) is a severe condition affecting the coagulation system. However, current knowledge regarding its incidence and mortality remains limited. In this study, we examined the incidence and mortality of DIC, including time trends, in Denmark. Methods: In this population-based cohort study, potential DIC cases were identified through the hospital laboratory database in the Central Denmark Region which has a population of approximately 1.3 million residents. Eligibility criteria were age above 18 years, a positive DIC score, and a disease associated with DIC. All eligible patients underwent a review of their medical records. Follow-up started on the date of a patient's first positive DIC score. Age- and sex-standardized incidence rates were calculated using year-specific DIC events as the numerator and the adult population of the Central Denmark Region as the denominator. All-cause 30-day mortality in the DIC cohort was computed based on Kaplan-Meier estimates and the mortality rates between subgroups were examined using logistic regression. Results: Among the 40,534 patients for whom all DIC biomarkers were measured on the same date, 6748 had a positive DIC score. Of these, 2565 were included in the cohort. The median age was 64 years, and 56.1% were men. The overall incidence rate per 100,000 person years declined during the study period, from 33.1 in 2013 to 24.0 in 2020. Thirty-day all-cause mortality was 35% in 2013 and 41.3% in 2020. Conclusions: The overall incidence rate of DIC declined between 2013 and 2020, mainly reflecting a declining incidence among patients with infection-associated DIC. Mortality did not improve.

Surgery in patients with infective endocarditis and prognostic importance of patient frailty

PURPOSE

Surgery is required in 20-50% of patients with infective endocarditis (IE). Frailty increases surgical risk; however, the prognostic implications of frailty in patients undergoing IE-related surgery remain poorly understood. We aimed to assess the association between frailty and all-cause mortality or rehospitalization after discharge (≥ 14 days).

METHODS

We identified all IE patients who underwent surgery during admission (2010-2020) in Denmark. The Hospital Frailty Risk Score was used to categorize patients into two frailty risk groups, patients with low frailty scores (< 5 points) and frail patients (≥ 5 points). We analyzed time hospitalized after discharge and all-cause mortality from the date of surgery with a one-year follow-up. Statistical analyses utilized the Kaplan-Meier estimator, Aalen-Johansen estimator, and the Cox regression model.

RESULTS

We identified 1282 patients who underwent surgery during admission, of whom 967 (75.4%) had low frailty scores, and 315 (24.6%) were frail. Frail patients were characterized by advanced age, a lower proportion of males, and a higher burden of comorbidities. Frail patients were more hospitalized (> 14 days) in the first post-discharge year (19.1% vs.12.3%) compared to patients with low frailty scores. Additionally, frail patients had higher rates of all-cause mortality including in-hospital deaths (27% vs. 15%) and rehospitalizations (43.5% vs 26.1%) compared to patients with low frailty scores. This was also evident in the adjusted analysis (hazard ratio 1.36 [CI 95% 1.09-1.71]).

CONCLUSION

Frailty was associated with an ≈40% increased rate of rehospitalization (≥ 14 days) or death. Further studies are needed to assess the effectiveness of surgery with a focus on frailty to improve prognostic outcomes in these patients.

Risk and Epidemiology of Periprosthetic Knee Fractures After Primary Total Knee Arthroplasty: A Nationwide Cohort Study

BACKGROUND

Periprosthetic knee fractures (PPKFs) following total knee arthroplasty (TKA) are uncommon, but potentially serious injuries. We analyze the risk and risk factors for a PPKF in standard primary TKA patients who have osteoarthritis and a minimally (cruciate-retaining TKAs without a femoral box cut) or posterior-stabilized TKA. In addition, we report the risk for patients who have other underlying knee disorders and/or a higher level of TKA constraint.

METHODS

All primary TKAs were identified from the Danish National Patient Register and the Danish Knee Arthroplasty Register using data between 1997 and 2022. Subsequent fractures were identified through the International Classification of Diseases diagnosis code, Nordic Medico-Statistical Committee procedure code, or indication for revision TKA.

RESULTS

We included 120,642 standard primary TKA patients who had 1,659 PPKFs. The cumulated proportions were 0.4% (95% confidence interval (CI) 0.3 to 0.4) at 2 years 0.8% (0.7 to 0.8) at 5 years. At 10 years, the cumulated proportion was 1.7% (1.6 to 1.8), with 1.3% in the femur, 0.2% in the patella, and 0.2% in the tibia. Significant risk factors were (hazard ratio [HR] [95% CI]); ipsilateral hip arthroplasty (2.3 [2.0 to 2.6]); women (2.1 [1.8 to 2.4]), osteoporosis (1.4 [1.2 to 1.7]); age 80+ (1.4 [1.3 to 1.6]), uncemented TKA (1.3 (1.1 to 1.5) and Charlson Comorbidity Index score 3+ (1.4 [1.1 to 1.8]). An additional 22,624 primary TKA patients who had other underlying knee disorders and/or a higher level of implant constraint were included with 633 PPKFs. The 10-year cumulated proportions were 8.3% (95% CI 6.9 to 9.8) when the underlying disorder was a previous fracture, 2.8% (2.2 to 3.5) for rheumatic disorders, and 5.2% (2.6 to 10.6) for osteonecrosis. In patients who had condylar constrained knees, it was 6.9% (5.1 to 9.4), and 12.4% (8.0 to 16.04) for hinges.

CONCLUSIONS

In standard primary TKA patients, the 10-year cumulated proportion of PPKFs was 1.7%, and ipsilateral hip arthroplasty, women, osteoporosis, advanced age, uncemented TKA and higher Charlson Comorbidity Index increased the risk. Higher risks were observed in non-osteoarthritis patients and/or patients who had a higher level of TKA constraint.

Anaphylaxis: first clinical presentation, subsequent referral practise, and suspected elicitor-an observational study

Anaphylaxis is an allergic manifestation characterised by rapid onset and progression. Rapid treatment may be challenging in patients with atypical symptoms or no previous history of anaphylaxis. This study aimed to describe the clinical prehospital presentation of first-time anaphylactic patients. To help target educational initiatives, we sought to identify which groups of medical professionals are most likely to encounter first-time anaphylactic patients and investigated the referral pattern for suspected anaphylactic patients for specialised treatment. A retrospective register-based study from the Region of Southern Denmark. Patients referred to the Allergy Centre, Odense University Hospital, from 2019 to 2021 were included. The medical records were manually reviewed for first contact with the emergency departments or the emergency medical service. 444 patients with suspected anaphylaxis were referred. 226 patients had grade 3-5 systemic allergic reactions as classified by the World Allergy Organisation; 90% had cutaneous symptoms, 63% symptoms from the central nervous system, 42% gastrointestinal symptoms, 40% cardiovascular symptoms, 36% had upper-airway symptoms, and 36% had lower-airway symptoms. Patients treated prehospitally had a significantly more severe degree of anaphylaxis than patients only treated within the hospital. More than half of the patients with suspected anaphylaxis were referred to the Allergy Centre from the emergency departments. Patients with allergies progressing to severe anaphylaxis most often are treated prehospitally before transport to emergency departments. From the emergency departments, they are referred to the allergy centre. Education concerning the immediate treatment of severe anaphylaxis should primarily be targeted towards prehospital care providers.

Metabolic syndrome and patient-reported outcome two years after hip and knee arthroplasty

Aims

The influence of metabolic syndrome (MetS) on the outcome after hip and knee arthroplasty is debated. We aimed to investigate the change in patient-reported outcome measure (PROM) scores after hip and knee arthroplasty, comparing patients with and without MetS.

Methods

From 1 May 2017 to 30 November 2019, a prospective cohort of 2,586 patients undergoing elective unilateral hip and knee arthroplasty was established in Denmark. Data from national registries and a local database were used to determine the presence of MetS. Patients' scores on Oxford Hip Score (OHS) or Oxford Knee Score (OKS), EuroQol five-dimension five-level questionnaire (EQ-5D-5L), University of California, Los Angeles (UCLA) Activity Scale, and Forgotten Joint Score (FJS) at baseline, three, 12, and 24 months after surgery were collected. Primary outcome was the difference between groups from baseline to 12 months in OHS and OKS. Secondary outcomes were scores of OHS and OKS at three and 24 months and EQ-5D-5L, UCLA Activity Scale, and FJS at three, 12, and 24 months after surgery. Generalized linear mixed model was applied, adjusting for age, sex, Charlson Comorbidity Index, and smoking to present marginal mean and associated 95% CIs.

Results

A total of 62.3% (1,611/2,586) of the cohort met the criteria for MetS. Both groups showed similar increase in mean OHS (MetS group 22.5 (95% CI 21.8 to 23.1), non-MetS group 22.1 (21.3 to 22.8); p = 0.477) and mean OKS (MetS group 18.0 (17.4 to 18.6), non-MetS group 17.8 (17.0 to 18.7); p = 0.722) at 12 months' follow-up. Between groups, similar improvements were seen for OHS and OKS at three and 24 months postoperatively and for the mean EQ-5D-5L, EuroQol-visual analogue scale (EQ-VAS), UCLA Activity Scale, and FJS at every timepoint.

Conclusion

Patients meeting the criteria for MetS obtain the same improvement in PROM scores as individuals without MetS up to 24 months after hip and knee arthroplasty. This is important for the clinician to take into account when assessing and advising patients with MetS.

Burden of hospitalization during the first year following transcatheter and surgical aortic valve replacement

BACKGROUND

Hospitalizations are a major burden for both patients and society but are potentially preventable. We examined the one-year hospitalization burden in patients undergoing transcatheter aortic valve replacement (TAVR) and compared hospitalization rates and patterns with those undergoing isolated surgical aortic valve replacement (SAVR).

METHODS

Using Danish nationwide registries, we identified patients who underwent first-time TAVR and isolated SAVR (2008-2019), respectively. Subsequent hospitalizations were classified as cardiovascular or noncardiovascular according to discharge diagnosis codes.

RESULTS

Patients undergoing TAVR (N = 4,921) were older and had more comorbidities than those undergoing SAVR (N = 5,220). There were 5,725 and 4,426 hospitalizations within the first year after discharge in the TAVR and SAVR group, respectively. During the one-year follow-up period post-TAVR, 46.6% were not admitted, 25.4% were admitted once, 12.6% twice, and 15.4% 3 times or more. The corresponding proportions in patients undergoing SAVR were 55.3%, 25.1%, 10.0%, and 9.5%, respectively. Among patients with ≥1 hospitalization following TAVR, 50.3% had a total length of all hospital stays between 1 and 7days, 19.0% 8-14days, 18.0% 15-30days, 9.9% 31-60days, and 2.8% ≥61days. The corresponding proportions for patients undergoing SAVR were 58.6%, 17.2%, 13.1%, 7.4%, and 3.7%, respectively. Compared with patients undergoing SAVR, those undergoing TAVR had a lower early (day0-30: HR 0.89 [95% CI, 0.80-0.98]), but a higher late hospitalization rate (day 31-365: 1.46 [1.32-1.60]).

CONCLUSIONS

The 1-year hospitalization burden following TAVR is substantial. Compared with patients undergoing isolated SAVR, those undergoing TAVR had a lower early, but a higher late hospitalization rate - a difference that likely reflects unmeasured differences in the patient cohorts.

Risk of Cancer in Patients With Diverticular Disease: A Population-Based Cohort Study

BACKGROUND & AIMS

Several studies have investigated the association between diverticular disease (DD) and colorectal cancer. However, whether there is an association between DD and malignancies other than those in the colorectum remains uncertain.

METHODS

For the 1978-2019 period, we conducted a nationwide, population-based cohort study using national Danish health care data. We followed patients with DD for up to 20 years, beginning 1 year after the date of DD diagnosis until the first occurrence of incident cancer, emigration, death, 20 years of follow-up, or December 31, 2019. We calculated cumulative incidence proportions of cancer and standardized incidence ratios (SIRs) comparing cancer incidence among patients with DD with that in the general population.

RESULTS

We identified 200,639 patients with DD, of whom 20,498 were diagnosed with cancer during the 1-20 years after their DD diagnosis. The SIRs were increased for most cancer sites except for those in the colorectum (SIR, 0.75; 95% confidence interval, 0.72-0.78). The highest SIRs were observed for cancers of the lung, bronchi, and trachea (SIR, 1.20; 95% confidence interval, 1.15-1.24) and kidney (SIR, 1.27; 95% confidence interval, 1.16-1.39).

CONCLUSIONS

Our findings show an increased long-term relative risk of cancer following a diagnosis of DD. These findings are likely caused by prevalence of numerous risk factors in patients with DD that confer an increased risk of cancer. The decreased relative risk of colorectal cancer might be explained by an increased likelihood of patients with DD undergoing colonoscopy with polypectomy.

The combined impact of migraine and gestational diabetes on long-term risk of premature myocardial infarction and stroke: A population-based cohort study

OBJECTIVE

To examine the combined impact of migraine and gestational diabetes mellitus (GDM) on the risks of premature (persons aged ≤60 years) major adverse cardiovascular and cerebrovascular events (MACCE) based on a composite endpoint of fatal and non-fatal myocardial infarction (MI) and stroke.

BACKGROUND

Migraine and GDM are risk factors for cardiovascular disease. It is unknown how the combination of migraine and GDM may affect cardiovascular disease risk.

METHODS

In a Danish population-based cohort longitudinal study, we established four cohorts among women with at least one pregnancy during 1996-2018: women with migraine, women with GDM, women with both migraine and GDM, and women free of migraine and free of GDM. Risks of premature MACCE and component endpoints were assessed for each cohort.

RESULTS

We included 1,307,456 women free of migraine and free of GDM, 56,811 women with migraine, 24,700 women with GDM, and 1484 women with migraine and GDM. The 20-year absolute risk of MACCE was 1.3% (MI: 0.4%, ischemic stroke: 0.6%, hemorrhagic stroke: 0.3%) among women free of migraine and free of GDM, 2.3% (MI: 0.8%, ischemic stroke: 1.2%, hemorrhagic stroke: 0.5%) among women with migraine, 2.2% (MI: 1.0%, ischemic stroke: 1.0%, hemorrhagic stroke: 0.4%) among women with GDM, and 3.7% (MI: 1.7%, ischemic stroke: 1.7%, hemorrhagic stroke: 0.3%) among women with both migraine and GDM. The 20-year adjusted hazard ratio of premature MACCE was 1.65 (95% confidence interval [CI] 1.49-1.82) for women with migraine; 1.64 (95% CI 1.37-1.96) for women with GDM; and 2.35 (95% CI 1.03-5.36) for women with both GDM and migraine when compared with women free of migraine and free of GDM.

CONCLUSIONS

Migraine and GDM were each independently associated with an increased risk of MACCE. Risk of premature MACCE was greatest among women with both migraine and GDM, although this risk estimate was imprecise.

Treatment intensity level as a proxy for severity of chronic obstructive pulmonary disease: A risk stratification tool

BACKGROUND

Increasing severity of chronic obstructive pulmonary disease (COPD) is associated with increasing risk of poor outcomes. Using health registry data, we aimed to assess the association between treatment intensity levels (TIL), as a proxy for underlying COPD severity, and long-term outcomes.

METHODS

Using Danish nationwide registries, we identified patients diagnosed with COPD during 2001-2016, who were alive at index date of 1 January 2017. We stratified patients into exclusive TILs from least to most severe: no use, short term therapy, mono-, dual-, triple therapy, oral corticosteroid (OCS), and long-term oxygen treatment (LTOT). Survival analyses were used to assess 5-year outcomes by TIL.

RESULTS

We identified 53,803 patients with COPD in the study period (median age: 72 years [inter quartile range, 64-80], 48 % male). The three most severe TILs were associated with a significant incremental increase in all-cause mortality with an adjusted hazard ratio (aHR) for triple therapy, OCS and LTOT of 1.44 (95 % CI: 1.38-1.51), 1.67 (95 % CI: 1.59-1.75), and 2.91 (95 % CI: 2.76-3.07) compared with those receiving no therapy as reference. The same pattern was evident for the composite outcome of 5-year mortality or COPD-related hospitalization with an aHR for triple therapy, OCS and LTOT of 2.30 (95 % CI: 2.22-2.38), 2.85 (95 % CI: 2.74-2.96), and 4.00 (95 % CI: 3.81-4.20), respectively.

CONCLUSION

Increasing TILs were associated with increasing five-year mortality and risk of COPD-related hospitalization. TILs may be used as a proxy for underlying COPD severity in epidemiological studies.

Adverse health outcomes in offspring of parents with alcohol-related liver disease: Nationwide Danish cohort study

BACKGROUND

Parental drinking can cause harm to the offspring. A parent's diagnosis of alcohol-related liver disease (ALD) might be an opportunity to reach offspring with preventive interventions. We investigated offspring risk of adverse health outcomes throughout life, their association with their parent's educational level and diagnosis of ALD.

METHODS AND FINDINGS

We used nationwide health registries to identify offspring of parents diagnosed with ALD in Denmark 1996 to 2018 and age- and sex-matched comparators (20:1). We estimated the incidence rate ratios (IRRs) of hospital contacts with adverse health outcomes, overall and in socioeconomic strata. We used a self-controlled design to examine whether health outcomes were more likely to occur during the first year after the parent's ALD diagnosis. The 60,804 offspring of parents with ALD had a higher incidence rate of hospital contacts from age 15 to 60 years for psychiatric disease, poisoning, fracture or injury, alcohol-specific diagnoses, other substance abuse, and of death than comparators. Associations were stronger for offspring with low compared to high socioeconomic position: The IRR for admission due to poisoning was 2.2 versus 1.0 for offspring of an ALD parent with a primary level versus a highly educated ALD parent. Offspring had an increased risk for admission with psychiatric disease and poisoning in the year after their parent's ALD diagnosis. For example, among offspring whose first hospital contact with psychiatric disease was at age 13 to 25 years, the IRR in the first year after their parent's ALD diagnosis versus at another time was 1.29 (95% CI 1.13, 1.47). Main limitation was inability to include adverse health outcomes not involving hospital contact.

CONCLUSIONS

Offspring of parents with ALD had a long-lasting higher rate of health outcomes associated with poor mental health and self-harm that increased shortly after their parent's diagnosis of ALD. Offspring of parents of low educational level were particularly vulnerable. This study highlights an opportunity to reach out to offspring in connection with their parent's hospitalization with ALD.