Time trends in preeclampsia and gestational diabetes in Denmark and Alberta, Canada, 2005-2018-A population-based cohort study

INTRODUCTION

Preeclampsia and gestational diabetes mellitus share risk factors such as obesity and increased maternal age, which have become more prevalent in recent decades. We examined changes in the prevalence of preeclampsia and gestational diabetes between 2005 and 2018 in Denmark and Alberta, Canada, and investigated whether the observed trends can be explained by changes in maternal age, parity, multiple pregnancy, comorbidity, and body mass index (BMI) over time.

MATERIAL AND METHODS

This study was a register-based cohort study conducted using data from the Danish National Health Registers and the provincial health registers of Alberta, Canada. We included in the study cohort all pregnancies in 2005-2018 resulting in live-born infants and used binomial regression to estimate mean annual increases in the prevalence of preeclampsia and gestational diabetes in the two populations across the study period, adjusted for maternal characteristics.

RESULTS

The study cohorts included 846 127 (Denmark) and 706 728 (Alberta) pregnancies. The prevalence of preeclampsia increased over the study period in Denmark (2.5% to 2.9%) and Alberta (1.7% to 2.5%), with mean annual increases of 0.03 (95% confidence interval [CI] 0.02-0.04) and 0.06 (95% CI 0.05-0.07) percentage points, respectively. The prevalence of gestational diabetes also increased in Denmark (1.9% to 4.6%) and Alberta (3.9% to 9.2%), with average annual increases of 0.20 (95% CI 0.19-0.21) and 0.44 (95% CI 0.42-0.45) percentage points. Changes in the distributions of maternal age and BMI contributed to increases in the prevalence of both conditions but could not explain them entirely.

CONCLUSIONS

The prevalence of both preeclampsia and gestational diabetes increased significantly from 2005 to 2018, which portends future increases in chronic disease rates among affected women. Increasing demand for long-term follow up and care will amplify the existing pressure on healthcare systems.

The prognostic value of lymph node ratio in a national cohort of rectal cancer patients

OBJECTIVE

To analyze the prognostic implications of the lymph node ratio (LNR) in curative resected rectal cancer.

SUMMARY BACKGROUND DATA

It has been proposed that the LNR has a high prognostic impact in colorectal cancer, but the lymph node ratio has not been evaluated exclusively for rectal cancer in a large national cohort study.

METHODS

All 6793 patients in Denmark diagnosed with stage I to III adenocarcinoma of the rectum, and so treated in the period from 2003 to 2011, were included in the analysis. The cohort was divided into two groups according to whether or not neo-adjuvant treatment had been given.

RESULTS

In a multivariate analysis the pN status, ypN status and lymph node yield were found to be independent prognostic factors for overall survival, irrespective of neo-adjuvant therapy. The LNR was also found to be a significant prognostic factor with a Hazard Ratio ranging from 1.154 (95% CI: 0.930-1.432) (LNR: 0.01-0.08) to 2.974 (95% CI: 2.452-3.606) (LNR > 0.5) in the group of patients who had surgery to begin with and from 1.381 (95% CI: 0.891-2.139) (LNR: 0.01-0.08) to 2.915 (95% CI: 2.244-3.787) (LNR > 0.5) in the group of patients who had neo-adjuvant treatment.

CONCLUSIONS

The LNR reflects the influence on survival from N-status and the lymph node yield and since LNR was shown to be a significant prognostic predictor for overall survival in patients with curatively resected stage III rectal cancer irrespective of neo-adjuvant therapy we recommend that the introduction of LNR should be considered for rectal cancer in a revised TNM classification.

Tumour stage and preoperative chemoradiotherapy influence the lymph node yield in stages I-III rectal cancer: results from a prospective nationwide cohort study

AIM

The study aimed to determine whether the lymph node yield (LNY) in rectal cancer is influenced by patient-related and histopathological factors and the use of preoperative chemoradiotherapy (CRT).

METHOD

An analysis was carried out of the LNY in a nationwide Danish cohort of 7950 patients, treated by curative resection of Stage I-III rectal cancer during the period 2001-2011. The impact of year of diagnosis, age, gender, pathological stage of the tumour (pT-stage) and preoperative CRT on LNY was analysed.

RESULTS

Twenty-nine per cent of the patients received preoperative CRT. The median LNY was 13 [interquartile range (IQR): 8-19]. A total of 43.4% of the patients had an LNY of < 12. The median LNY increased from 8 (IQR: 5-12) to 20 (IQR: 13-28) LNs over the years of the study period (P < 0.0001). Gender and body mass index (BMI) had no impact on the median LNY. Age had a minor impact, with a range of 12 (IQR: 8-18) to 13 (IQR: 9-20) (P < 0.0001). The LNY ranged from 9 (IQR: 6-14) to 16 (IQR: 10-26), according to pT-stage (pT0-pT4) (P < 0.0001). Median LNY, according to preoperative CRT or no preoperative CRT, was 10 (IQR: 6-16) and 14 (IQR: 8-18), respectively (P < 0.0001). The percentages of patients with an LNY of < 12, according to preoperative CRT or no preoperative CRT, were 58.7% and 37.1%, respectively (P < 0.0001).

CONCLUSION

An increase in the LNY over the period of the study was observed, probably reflecting improved quality of surgery and histopathology. A minor significant reduction of LNY was found with increasing age of the patient. LNY was significantly related to pT-stage and to the use of preoperative chemoradiotherapy. For these reasons the minimum harvest of 12 LNs as a surrogate marker for the oncological quality of surgery should be questioned.

The relation between lymph node status and survival in Stage I-III colon cancer: results from a prospective nationwide cohort study

AIM

This study involved a large nationwide Danish cohort to evaluate the hypothesis that a high lymph node harvest has a positive effect on survival in curative resected Stage I-III colon cancer and a low lymph node ratio has a positive effect on survival in Stage III colon cancer.

METHOD

Analysis of overall survival was conducted using a nationwide Danish cohort of patients treated with curative resection of Stage I-III colon cancer. All 8901 patients in Denmark diagnosed with adenocarcinoma of the colon and treated with curative resection in the period 2003-2008 were identified from the Danish Colorectal Cancer Group (DCCG). The impact of lymph node count and lymph node ratio was analysed.

RESULTS

Overall 5-year survival was 56.8 and 66.6%, (P < 0.0001) for lymph node counts of fewer than 12 and 12 or more, respectively. The percentages of lymph node positive patients in the two groups were 29.8 and 40.3% (P < 0.0001), respectively. When putting the Stage III patients into four subgroups according to the lymph node ratio (cut-off points 1/12, 1/4 and 1/2) we found an overall 5-year survival rate of 68.1, 57.2, 49.3 and 32.4% (P < 0.0001). Lymph node count and lymph node ratio were independent prognostic factors in multivariate analysis.

CONCLUSION

High lymph node count was associated with improved overall survival in colon cancer. Lymph node ratio was superior to N-stage in differentiating overall survival in Stage III colon cancer. Stage migration was observed.

Parent-offspring conflict and the persistence of pregnancy-induced hypertension in modern humans

Preeclampsia is a major cause of perinatal mortality and disease affecting 5–10% of all pregnancies worldwide, but its etiology remains poorly understood despite considerable research effort. Parent-offspring conflict theory suggests that such hypertensive disorders of pregnancy may have evolved through the ability of fetal genes to increase maternal blood pressure as this enhances general nutrient supply. However, such mechanisms for inducing hypertension in pregnancy would need to incur sufficient offspring health benefits to compensate for the obvious risks for maternal and fetal health towards the end of pregnancy in order to explain why these disorders have not been removed by natural selection in our hunter-gatherer ancestors. We analyzed >750,000 live births in the Danish National Patient Registry and all registered medical diagnoses for up to 30 years after birth. We show that offspring exposed to pregnancy-induced hypertension (PIH) in trimester 1 had significantly reduced overall later-life disease risks, but increased risks when PIH exposure started or developed as preeclampsia in later trimesters. Similar patterns were found for first-year mortality. These results suggest that early PIH leading to improved postpartum survival and health represents a balanced compromise between the reproductive interests of parents and offspring, whereas later onset of PIH may reflect an unbalanced parent-offspring conflict at the detriment of maternal and offspring health.

Tissue inhibitor of metalloproteinase-1 levels in plasma from tumour arteries and veins of patients with rectal cancer

OBJECTIVE

Tissue inhibitor of metalloproteinase-1 (TIMP-1) plays a major role in the regulation of tissue growth, including cancer growth. The TIMP-1 protein can be determined in plasma, and increased plasma levels of TIMP-1 are associated with a poor prognosis of colorectal cancer patients. The aim of the present study was to evaluate whether tumour tissue release of the TIMP-1 protein contributes to the increased plasma levels of TIMP-1 observed in patients with colorectal cancer.

MATERIAL AND METHODS

Preoperative blood samples from a peripheral vein and intraoperative blood samples from a tumour artery, a tumour vein and from a peripheral vein were drawn from 24 patients undergoing elective, intended curative surgery for primary rectal cancer. TIMP-1 levels were determined concurrently in plasma from all samples using a validated ELISA method. Counts of white blood cells and platelets were also carried out.

RESULTS

No significant differences between plasma TIMP-1 levels could be demonstrated in any compartment. In particular, there was no significant difference in TIMP-1 levels in plasma from tumour arteries and tumour veins. However, there was a significant decrease in neutrophil cell counts from tumour arteries to tumour veins (p<0.001).

CONCLUSIONS

The present results do not support the current hypothesis that tumour cells contribute substantially to increased plasma TIMP-1 levels observed in patients with colorectal cancer.

Toxic encephalopathy and noise-induced hearing loss

In several laboratory animal studies, it has been documented that the hearing, vision, and brain can be injured due to exposure to organic solvents. This finding formed the background for a pilot study (n=16) aimed at identifying new ways of qualifying diagnostics, treatment, and rehabilitation of patients suffering from brain injury due to exposure to organic solvents, also referred to as toxic encephalopathy. Diagnosing toxic encephalopathy is complicated because the symptoms of this type of diffuse brain injury are non-specific. So, it was initially hypothesised that some of the difficulties involved in diagnosing toxic encephalopathy could be minimized by extending the diagnostic procedure. Apart from clinical interviewing and neuropsychological testing, the diagnosis should include the examination of hearing and vision. This will help in achieving new measures that could improve in diagnosing toxic encephalopathy with more certainty. On the basis of ranking, only one patient in the pilot study was considered to have a normal neuropsychological test profile, which was defined as a test profile without any marked deviations when compared with a normal population. A total of 10 patients were considered to have "discrete problems." These patients had a test profile showing either a few strikingly negative results or an array of results slightly below the expected level when compared with a normal population. A total of four patients were considered to suffer from "moderate problems" and one patient from "severe problems." The patients with "moderate problems" and "severe problems" showed consistent negative results and an unambiguous negative test profile. However, the overall results of all neuropsychological examinations performed revealed a dispersed picture. Quite remarkably, all the 13 patients who had their hearing examined showed a loss of hearing, 7 patients complained about tinnitus, and all patients had a history of exposure to both noise and organic solvents, which had not been observed at the initial examination, but seemed to have serious implications for their prognosis and future life.

Influence of major surgery on the mannan-binding lectin pathway of innate immunity

The mannan-binding lectin (MBL) pathway of complement activation is important in host defence against pathogens and possibly against cancer. We investigated the effect of major surgery on two central components of the MBL pathway; MBL and the MBL-associated serine protease MASP-2, and for comparison also measured the interleukin (IL)-6 and C-reactive protein (CRP) levels. Serial blood samples were obtained from patients belonging to two different cohorts. Cohort 1 comprised 60 patients undergoing open or laparoscopic colectomy for benign disease (n = 12) or colon cancer (n = 48). Cohort 2 comprised 27 patients undergoing elective, open surgery for colorectal cancer, and was included in order to cover blood sampling between days 2 and 6. As expected, the surgical stress induced a marked acute phase response, as evidenced by a large increase in IL-6 (18-fold) and CRP (13-fold) levels with maximum at 12 h and 2 days, respectively. However, in both cohorts the levels of MBL and MBL-associated serine protease 2 (MASP-2) were largely unaffected, except for a minor but significant increase around day 8 in cohort 1. The preoperative levels of IL-6 and CRP were correlated significantly in both cohorts (r = 0.71, P < 0.0001 and r = 0.65, P = 0.005, respectively). Preoperative MASP-2 correlated with preoperative CRP (r = 0.59, P = 0.001) and IL-6 (r = 0.55, P = 0.02) in cohort 2 only. In contrast to the marked effects on the levels of IL-6 and CRP, the surgery influenced only marginally the two proteins of the MBL pathway.

Bacterial antigen induced release of soluble vascular endothelial growth factor (VEGF) and VEGFR1 before and after surgery

OBJECTIVE

The influence of surgery on release of soluble vascular endothelial growth factor (sVEGF) and the soluble inhibitory receptor (sVEGFR1) is unknown. The effect of major and minor surgery on variations in sVEGF and sVEGFR1 concentrations in vivo was studied, and on bacterial antigen-induced release of sVEGF and sVEGFR1 from whole blood in vitro.

MATERIAL AND METHODS

Sixty-one patients with abdominal diseases undergoing five different surgical procedures were included in the study. Blood samples were drawn from patients before and after the operation. White blood cells and platelets were counted, and plasma sVEGF and sVEGFR1 were determined. Whole blood from each blood sample was stimulated in vitro with bacteria-derived antigens (lipopolysaccharides or protein A) and sVEGF and sVEGFR1 levels were subsequently determined in the supernatants.

RESULTS

Neither sVEGF nor sVEGFR1 concentrations in plasma changed during surgery. In vitro stimulation of blood samples with bacteria-derived antigens resulted in a significant increase in sVEGF (p < 0.0001) and a less pronounced but still significant increase in sVEGFR1 (p < 0.01). Bacterial antigen-induced release of sVEGF correlated significantly with neutrophil cell counts (0.53 < r < 0.78; p < 0.0001). Bacterial antigen-induced sVEGFR1 release did not correlate with cell counts.

CONCLUSIONS

Plasma sVEGF and sVEGFR1 concentrations did not change during surgery. In vitro bacterial stimulation led to increased release of sVEGF, which was not compensated for by an equivalent increase in sVEGFR1. There was a positive impact of major abdominal surgery on release of sVEGF. The bacterial antigen-induced changes in sVEGF may be related to the number of circulating neutrophils.

The role of tissue factor in colorectal cancer

The possible role of tissue factor (TF) in colorectal cancer (CRC) is reviewed. A correlation between TF expression and advanced stages of malignancy, and a correlation between TF expression and overall survival have been suggested in CRC. This is supported by experimental studies indicating that TF plays a key role in growth, invasion and dissemination of tumour cells, and in tumour related angiogenesis as well. In addition, the activation of TF in CRC patients in relation to the surgical trauma, perioperative blood transfusion and development of postoperative bacterial infectious complications are discussed. Finally, future directions for the development of anticancer modalities directed against regulation of TF are considered.

Death and injury caused by land mines in Burma

One hundred and eighty-eight Burmese refugees in Thailand were interviewed. One hundred and five of those interviewed had knowledge of a total of 313 persons who had been exposed to land mine explosions. Twenty-three of the interviewed were land mine survivors. They were all male, aged between eight and 68 years, and all except one had been injured between 1986 and 1997. Fifteen of the 23 were civilians, eight were guerilla soldiers who were injured either in battle or while deploying or disarming land mines. Those who had stepped on land mines were all crus or femur amputated and had several scars on the lower limbs, abdomen and some also on the forearms. Those who had handled a land mine had lost either fingers or hands and one also lost both eyes. This study shows that the frequency of land mine accidents in Burma has been underestimated and that the mortality is high. The study also supports the general impression that many victims are civilians.

[Spread of methicillin-resistant Staphylococcus aureus. Are our hygienic precautions sufficient?]

A patient was transferred from Pakistan to a Danish orthopaedic ward. In Denmark he was tested MRSA-positive. Two months after he was discharged, similar MRSA strains were found in another patient. The two patients had been on the same ward for one week. All hygienic precautions had been taken. Staff and other patients on the ward at the relevant time all tested MRSA-negative.

Results of medical examination of refugees from Burma

OBJECTIVES

To describe exposure to human rights violations among refugees from rural Burma; to compare exposure experienced by an ethnic Burmese minority group, the Shans, with that of the rest of the study population; and to compare exposure of those who had fled Burma recently with that of refugees who had arrived in Thailand earlier.

DESIGN

Cross-sectional interview and clinical examination.

SETTING

Refugee settlements and refugee camps in Northern Thailand near the border to Burma in November 1997.

SUBJECTS

92 persons (group A) were examined according to the program. Fourty-six were Shans; 34 had migrated within the past five months. A further 96 person (group B), more randomly selected, were interviewed according to an abbreviated interview program; of these, 38 had fled recently.

MAIN OUTCOME MEASURES

A score was used to quantify the exposure. Testimonies of exposure to physical violence were validated, assessing the consistency between the reported exposure, reported ensuing symptoms and the result of the clinical examination.

RESULTS

Both groups reported massive exposure to the following human rights violations: forced labour (group A: 66%, group B: 35%), porter service (65%, 44%), forced relocation (51%, 51%), killing of family members (36%, 29%). In group A, there were twelve cases of self-reported torture. Moreover, there were reports of rape, disappearances and land mine accidents. In all cases of exposure to physical violence the testimonies were appraised to be valid.

CONCLUSION

The violations of human rights in Burma were massive. The Shans were exposed as heavily as the others. Those who had arrived recently were as heavily exposed as the other groups. Apart from the land mine problem, the Burmese army was held responsible for all the reported and documented human rights violations.

Radiation-induced skin injury after percutaneous transluminal coronary angioplasty. Case report

A 58-year-old man underwent percutaneous transluminal coronary angioplasties in June 1992 and May 1993. Approximately 3 weeks after the last procedure, a cutaneous lesion developed into an ulcer over the right scapular region. The ulcer failed to heal with conservative treatment; therefore, surgical excision was performed. The localization and the course of the development indicated injury caused by radiation, and this was confirmed by the histologic examination. To avoid such injury in interventional procedures with long fluoroscopic time, several precautions should be taken. These include continuous surveillance of the X-ray dosage, the use of different projections to avoid exposure to one skin area throughout the whole procedure, keeping the irradiated area as small as possible, and good planning of the procedure.

A fast, economical and efficient method for DNA purification by use of a homemade bead column

A fast, efficient and economical method for purification of DNA from various sources by the use of silica particles packed in homemade bead columns is described. The method is a further development of the method devised by Carter and Milton (1), improved by the introduction of a column operated with a vacuum system. The method is highly suitable for multiple sample handling in the preparation of DNA for sequencing and other purposes. Protocols are devised for plasmid minipreparation, gel elution and purification of DNA from solutions e.g. enzyme reactions.

[An alcoholic clientele and causes of death]

The object of this investigation was to describe the deaths in the Nordic groups and among Greenlanders from section 105 institution in Copenhagen. The investigation included 206 known patients. The median ages for Danes, Finns, Norwegians, Swedes and Greenlanders were 52 years, 45 years, 45 years, 56 years and 33 years, respectively. Nineteen deaths in women were included in the investigation. Socially, the majority of these were lonely and many of these had no fixed abode. The previously recognized somatic diseases in this group were dominated by alcohol misuse, malnutrition, poor housing conditions and sequelae of head injuries. Half of the previous conditions in the group were psychiatric. The deaths in the group were frequently violent and sudden. In 43% of the cases, deaths were not from natural causes, 35% of the deaths were from natural causes and in 22% the causes were unknown. In the group of Greenlanders, which differed considerably from the other groups with Nordic nationalities, 2/3 of the deaths were from violence.

Psychological effect of detailed preanesthetic information

Eighty-one patients admitted for minor surgery were followed with questionnaires and self-rating scales in the pre- and post-anesthetic period to evaluate the effect of giving either routine or detailed information. The patients were randomly allocated to two groups and received either routinely given information by the anesthetist for about 5 min or more detailed information for at least 20 min. The patients' experience of the effect of the preanesthetic visit was tranquillizing and adequate in both groups. The most significant difference with detailed information was a smaller number of side-effects like slow cerebration, nausea and a general feeling of discomfort compared to the routinely informed patients. Repetitive ratings on Spielberger's State of Anxiety Scale showed that the patients who had had previous anesthetic experience were less influenced by the degree of information given. In view of the considerable numbers of parameters investigated, there were relatively few significant differences between the groups, and it was concluded that there was no convincing benefit from expanding routine to detailed information.

Endometriosis of the vermiform appendix

The pathological findings and clinical aspects of 22 patients with endometriosis of the vermiform appendix are presented. The cases were found among 10,000 appendices examined from 1950 to 1981. During this period of 32 years, 800 cases of pelvic endometriosis were seen. In 10 patients no other locations of pelvic endometriosis were found.