Amyloid-β deposits in human astrocytes contain truncated and highly resistant proteoforms

Alzheimer's disease (AD) is a neurodegenerative disorder that develops over decades. Glial cells, including astrocytes are tightly connected to the AD pathogenesis, but their impact on disease progression is still unclear. Our previous data show that astrocytes take up large amounts of aggregated amyloid-beta (Aβ) but are unable to successfully degrade the material, which is instead stored intracellularly. The aim of the present study was to analyze the astrocytic Aβ deposits composition in detail in order to understand their role in AD propagation. For this purpose, human induced pluripotent cell (hiPSC)-derived astrocytes were exposed to sonicated Aβ42 fibrils and magnetic beads. Live cell imaging and immunocytochemistry confirmed that the ingested Aβ aggregates and beads were transported to the same lysosomal compartments in the perinuclear region, which allowed us to successfully isolate the Aβ deposits from the astrocytes. Using a battery of experimental techniques, including mass spectrometry, western blot, ELISA and electron microscopy we demonstrate that human astrocytes truncate and pack the Aβ aggregates in a way that makes them highly resistant. Moreover, the astrocytes release specifically truncated forms of Aβ via different routes and thereby expose neighboring cells to pathogenic proteins. Taken together, our study establishes a role for astrocytes in mediating Aβ pathology, which could be of relevance for identifying novel treatment targets for AD.

Young adults looking back at their experiences of treatment and care for nonsuicidal self-injury during adolescence: a qualitative study

BACKGROUND

Nonsuicidal self-injury (NSSI) is associated with stigma, and negative attitudes among healthcare professionals toward NSSI have been reported. A person-centered approach that focuses on how individuals with lived experience of NSSI perceive the treatment and care they receive is invaluable in reducing barriers to help-seeking and improving treatment and mental healthcare services. The aim of the current qualitative study was to explore the perceptions of young adults when they look back upon their experiences of psychiatric treatment for NSSI during adolescence.

METHODS

Twenty-six individuals with lived experience of NSSI who were in contact with child and adolescent psychiatry during adolescence were interviewed. The interviews were analyzed using thematic analysis.

RESULTS

Three main themes were developed: Changed perceptions in retrospect, The importance of a collaborative conceptualization and Lasting impression of the relationship. Participants' perception of themselves as well as the treatment changed over time. The importance of a joint understanding of NSSI and an agreed-upon treatment focus was emphasized. The relationship to the mental health professionals, and experiences of how NSSI was communicated, were salient several years later.

CONCLUSIONS

Healthcare professionals need to communicate about NSSI in a respectful manner and include the perspective of the adolescent with lived experience of NSSI in a joint conceptualization of NSSI and treatment focus.

Painful differences between different pain scale assessments: The outcome of assessed pain is a matter of the choices of scale and statistics

OBJECTIVES

Perceived pain is a multi-factorial subjective variable, commonly measured by numeric rating scales, verbal descriptive scales (VDS), or by a position on an analogue line (VAS). A major question is whether an individual's VAS and VDS pain assessments, on the same occasion, could be comparable. The aim was to compare continuous and discretized VAS pain data with verbal descriptive pain datasets from the Oswestry Disability Index (ODI) and the European Quality of Life Scale (EQ-5D) in paired pain datasets.

METHODS

The measurement level of data from any type of scale assessments is ordinal, having rank-invariant properties only. Non-parametric statistical methods were used. Two ways of discretizing the VAS-line to VAS-intervals to fit the number of the comparing VDS-categories were used: the commonly used (equidistant VAS,VDS)-pairs and the (unbiased VAS,VDS)-pairs of pain data. The comparability of the (VAS,VDS)-pairs of data of perceived pain was studied by the bivariate ranking approach. Hence, each pair will be regarded as ordered, disordered, or tied with respect to the other pairs of data. The percentage agreement, PA, the measures of disorder, D, and of order consistency, MA, were calculated. Total interchangeability requires PA = 1 and MA = 1.

RESULTS

The wide range of overlapping of (VAS,VDS)-pairs indicated that the continuous VAS data were not comparable to any of the VDS pain datasets. The percentage of agreement, PA; in the (equidistant VAS,ODI) and (equidistant VAS, EQ-5D) pairs were 38 and 49%, and the order consistency, MA, was 0.70 and 0.80, respectively. Corresponding results for the (unbiased VAS,VDS)-pairs of pain data were PA: 54 and 100%, and MA: 0.77 and 1.0.

CONCLUSION

Our results confirmed that perceived pain is the individual's subjective experience, and possible scale-interchangeability is only study-specific. The pain experience is not possible to be measured univocally, but is possible for the individual to rate on a scale.

OUP accepted manuscript

OBJECTIVES

To develop and validate in real-world patients a conversion algorithm from the Multidimensionel Health Assessment Questionnaire physical function scale (MDHAQ) to the Stanford Health Assessment Questionnaire disability index physical function scale (HAQ) score.

METHODS

From the DANBIO registry, 13 391 patients with RA (n = 8983), PsA (n = 2649) and axial spondyloarthritis (axSpA, n = 1759) with longitudinal data on HAQ and MDHAQ were included, stratified by diagnosis, and randomized 1:1 into development and validation cohorts. Conversion algorithms were developed by linear regression and applied in validation cohorts. From MDHAQ, the HAQ was calculated (cHAQ) and validated against the observed HAQ for criterion, correlational and construct validity.

RESULTS

For RA, we developed the conversion algorithm cHAQ = 0.15+MDHAQ*1.08, and validated it in the RA validation cohort. Criterion validity: HAQ and cHAQ had comparable discriminative power to distinguish between high and low patient global scores (standardized mean difference: HAQ:-1.29, cHAQ:-1.35). Kappa value between HAQ and cHAQ functional states indicated good agreement (0.83). Correlational validity: baseline HAQ and cHAQ, respectively, correlated well with patient global scores (r = 0.65/0.67). Bland-Altman plots showed good agreement across all functional states. Construct validity: HAQ and cHAQ discriminated equally well between patients reporting symptom state as acceptable vs not, and across responses to an external anchor. Aiming for a common algorithm, the RA conversion algorithm was validated for PsA and axSpA with similar results.

CONCLUSION

This study suggests that in observational datasets with only the MDHAQ available, a simple algorithm allows valid conversion to HAQ on the group level in RA, PsA and axSpA.

Reconstructing the diet, trophic level and migration pattern of mysticete whales based on baleen isotopic composition

Baleen from mysticete whales is a well-preserved proteinaceous material that can be used to identify migrations and feeding habits for species whose migration pathways are unknown. Analysis of δ13C and δ15N values from bulk baleen have been used to infer migration patterns for individuals. However, this approach has fallen short of identifying migrations between regions as it is difficult to determine variations in isotopic shifts without temporal sampling of prey items. Here, we apply analysis of δ15N values of amino acids to five baleen plates belonging to three species, revealing novel insights on trophic position, metabolic state and migration between regions. Humpback and minke whales had higher reconstructed trophic levels than fin whales (3.7-3.8 versus 3-3.2, respectively) as expected due to different feeding specialization. Isotopic niche areas between baleen minima and maxima were well separated, indicating regional resource use for individuals during migration that aligned with isotopic gradients in Atlantic Ocean particulate organic matter. Phenylanine δ15N values confirmed regional separation between the niche areas for two fin whales as migrations occurred and elevated glycine and threonine δ15N values suggested physiological changes due to fasting. Simultaneous resolution of trophic level and physiological changes allow for identification of regional migrations in mysticetes.

Long-term Risk of Parkinson Disease Following Influenza and Other Infections

Importance

Influenza has been associated with the risk of developing Parkinson disease, but the association is controversial.

Objective

To examine whether prior influenza and other infections are associated with Parkinson disease more than 10 years after infection.

Design, Setting, and Participants

This case-control study used data from 1977 to 2016 from the Danish National Patient Registry. All individuals with Parkinson disease, excluding those with drug-induced parkinsonism, were included and matched to 5 population controls on sex, age, and date of Parkinson diagnosis. Data were analyzed from December 2019 to September 2021.

Exposures

Infections were ascertained between 1977 and 2016 and categorized by time from infection to Parkinson disease diagnosis. To increase specificity of influenza diagnoses, influenza exposure was restricted to months of peak influenza activity.

Main Outcomes and Measures

Parkinson disease diagnoses were identified between January 1, 2000, and December 31, 2016. Crude and adjusted odds ratios (ORs) and 95% CIs were calculated by conditional logistic regression overall and stratified by time between infection and Parkinson disease (5 years or less, more than 5 to 10 years, more than 10 years).

Results

Of 61 626 included individuals, 23 826 (38.7%) were female, and 53 202 (86.3%) were older than 60 years. A total of 10 271 individuals with Parkinson disease and 51 355 controls were identified. Influenza diagnosed at any time during a calendar year was associated with Parkinson disease more than 10 years later (OR, 1.73; 95% CI, 1.11-2.71). When influenza exposure was restricted to months of highest influenza activity, an elevated OR with a wider confidence interval was found (OR, 1.52; 95% CI, 0.80-2.89). There was no evidence of an association with any type of infection more than 10 years prior to Parkinson disease (OR, 1.04; 95% CI, 0.98-1.10). Several specific infections yielded increased odds of Parkinson disease within 5 years of infection, but results were null when exposure occurred more than 10 years prior.

Conclusions and Relevance

In this case-control study, influenza was associated with diagnoses of Parkinson disease more than 10 years after infection. These observational data suggest a link between influenza and Parkinson disease but do not demonstrate causality. While other infections were associated with Parkinson disease diagnoses soon after infection, null associations after more than 10 years suggest these shorter-term associations are not causal.

Incidence, risk factors and re-exacerbation rate of severe asthma exacerbations in a multinational, multidatabase pediatric cohort study

BACKGROUND

There are sparse real-world data on severe asthma exacerbations (SAE) in children. This multinational cohort study assessed the incidence of and risk factors for SAE and the incidence of asthma-related rehospitalization in children with asthma.

METHODS

Asthma patients 5-17 years old with ≥1 year of follow-up were identified in six European electronic databases from the Netherlands, Italy, the UK, Denmark and Spain in 2008-2013. Asthma was defined as ≥1 asthma-specific disease code within 3 months of prescriptions/dispensing of asthma medication. Severe asthma was defined as high-dosed inhaled corticosteroids plus a second controller. SAE was defined by systemic corticosteroids, emergency department visit and/or hospitalization all for reason of asthma. Risk factors for SAE were estimated by Poisson regression analyses.

RESULTS

The cohort consisted of 212 060 paediatric asthma patients contributing to 678 625 patient-years (PY). SAE rates ranged between 17 and 198/1000 PY and were higher in severe asthma and highest in severe asthma patients with a history of exacerbations. Prior SAE (incidence rate ratio 3-45) and younger age increased the SAE risk in all countries, whereas obesity, atopy and GERD were a risk factor in some but not all countries. Rehospitalization rates were up to 79% within 1 year.

CONCLUSIONS

In a real-world setting, SAE rates were highest in children with severe asthma with a history of exacerbations. Many severe asthma patients were rehospitalized within 1 year. Asthma management focusing on prevention of SAE is important to reduce the burden of asthma.

FRI0586 HOW TO GET FROM THE MULTIDIMENSIONAL HEALTH ASSESSMENT QUESTIONNAIRE TO STANFORD HEALTH ASSESSMENT QUESTIONNAIRE DISABILITY INDEX SCORES IN PATIENTS WITH RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS AND AXIAL SPONDYLOARTHRITIS: DEVELOPMENT AND VALIDATION OF A CONVERSION ALGORITHM

Background:

In the DANBIO quality registry in Denmark, patients with rheumatoid arthritis (RA) psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) have reported Patient Reported Outcomes (PROs) including the Stanford Health Assessment Questionnaire Disability Index (HAQ-DI) for nearly twenty years as part of routine care. Patients’ feedback have stressed a need for a shorter registration of disability (1). While the shorter Multidimensional Health Assessment Questionnaire (MDHAQ) is preferred by patients, the original HAQ-DI is the preferred tool in observational studies. Thus, a conversion algorithm between the MDHAQ and HAQ-DI scores is warranted.

Objectives:

To develop and validate a simple conversion algorithm between MDHAQ and HAQ-DI scores in RA, PsA and axSpA patients.

Methods:

Patients registered in DANBIO with a diagnosis of RA, PsA or axSpA who had completed both HAQ-DI and MDHAQ simultaneously at a visit +/- 30 days from start of conventional synthetic (cs)DMARD or biological (b)DMARD were eligible for the analysis, and randomly divided into development and validation cohorts stratified by diagnosis. The conversion algorithm was developed in the RA development cohort using linear regression with HAQ-DI as the dependent variable and MDHAQ as the independent variable. The predicted HAQ (pHAQ) scores were then calculated by applying the conversion algorithm to the MDHAQ scores in the RA, PsA and axSpA validation cohorts. The pHAQ was validated against the HAQ-DI in the validation cohorts regarding criterion, correlational and construct validity.

Results:

We included 8983/4410/1760 patients with RA/PsA/axSpA, respectively. The conversion algorithm pHAQ=0.15+MDHAQ*1.08 had the best fit (R2=0.83) in the RA development cohort.

Criterion validity: The correlation coefficients between HAQ-DI/pHAQ and patient global score at baseline were 0.66/0.65. In groups of patients with high and low disability (defined as patient global score ≥50), standardized mean difference was -1.4 for HAQ-DI, and -1.4 for pHAQ.

Correlational validity: Correlation coefficients between HAQ-DI/pHAQ and ΔHAQ-DI/ΔpHAQ between baseline and first follow-up visit were r=0.91 and r=0.87, respectively. Correlation coefficients between HAQ-DI/pHAQ and pain score, DAS28CRP and physician global score were 0.63/0.64, 0.55/0.55 and 0.34/0.34, respectively. A Bland-Altman plot showed good agreement of HAQ-DI and pHAQ across all functional states.

Construct validity: HAQ-DI/pHAQ at the first follow-up visit after baseline was comparable between Patient Acceptable Symptom State groups (PASS=No: mean 1.17 vs 1.18/PASS=Yes: 0.55 vs 0.60). Similar results were seen for the external anchor (Figure 1).

In PsA and axSpA validation cohorts, similar results were found.

Conclusion:

A conversion algorithm from MDHAQ to HAQ-DI was developed in ≈ 4500 RA patients. In separate large validation cohorts of RA, PsA and axSpA patients, the predicted HAQ calculated from the MDHAQ scores showed good criterion, correlational and construct validity comparable to the original HAQ-DI. The results suggest that for research purposes the MDHAQ can be converted to HAQ-DI if a full HAQ-DI has not been performed.

References:

[1] Primdahl J. et al. Arthritis Care Res 2019 (in press).

Acknowledgments:

The authors thank all Danish patients and Departments of Rheumatology, who conscientiously report to the DANBIO registry.

Disclosure of Interests:

Elisabeth Svensson: None declared, Katja Løngaard: None declared, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Rikke Meincke: None declared, Jens Kristian Pedersen: None declared, Lene Dreyer: None declared, Niels Steen Krogh: None declared, Dorte Vendelbo Jensen: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis

The Associations Between Pre- and Postnatal Maternal Symptoms of Distress and Preschooler's Symptoms of ADHD, Oppositional Defiant Disorder, Conduct Disorder, and Anxiety

Objective: The objective of this article is to examine the associations between pre- and postnatal maternal distress and preschooler's symptoms of ADHD, Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and anxiety, by timing and gender. Method: Children, aged 3.5 years (N = 1,195), recruited from the Norwegian Mother and Child Cohort Study, were assessed with a semistructured parental psychiatric interview. Perinatal maternal symptoms of distress were assessed by Symptom Checklist (SCL-5); Poisson regression was used to examine the associations. Results: Mid-gestational maternal distress significantly increased the average number of child symptoms, ranging between 3.8% for ADHD hyperactive-impulsive (ADHD-HI) and 8.7% for anxiety. The combination of high maternal scores of distress both pre- and postnatally were associated with increased risk of child symptoms of anxiety (relative risk [RR] = 2.10; 95% confidence interval [CI] = [1.43, 3.07]), CD (RR = 1.83; 95% CI = [1.33, 2.51]), and ODD (RR = 1.30; 95% CI = [1.03, 1.64]), with minor sex differences. Conclusion: Maternal distress during mid-gestation was associated with ADHD, behavioral, and emotional symptoms in preschool children. Continued exposure into the postnatal period may further increase these risk associations .

Multinational cohort study of mortality in patients with asthma and severe asthma

BACKGROUND

Data on the risk of death following an asthma exacerbation are scarce. With this multinational cohort study, we assessed all-cause mortality rates, mortality rates following an exacerbation, and patient characteristics associated with all-cause mortality in asthma.

METHODS

Asthma patients aged ≥18 years and with ≥1 year of follow-up were identified in 5 European electronic databases from the Netherlands, Italy, UK, Denmark and Spain during the study period January 1, 2008-December 31, 2013. Patients with asthma-COPD overlap were excluded. Severe asthma was defined as use of high dose ICS + use of a second controller. Severe asthma exacerbations were defined as emergency department visits, hospitalizations or systemic corticosteroid use, all for reason of asthma.

RESULTS

The cohort consisted of 586,436 asthma patients of which 42,611 patients (7.3%) had severe asthma. The age and sex standardized all-cause mortality rates ranged between databases from 5.2 to 9.5/1000 person-years (PY) in asthma, and between 11.3 and 14.8/1000 PY in severe asthma. The all-cause mortality rate in the first week following a severe asthma exacerbation ranged between 14.1 and 59.9/1000 PY. Mortality rates remained high in the first month following a severe asthma exacerbation and decreased thereafter. Higher age, male gender, comorbidity, smoking, and previous severe asthma exacerbations were associated with mortality.

CONCLUSION

All-cause mortality following a severe exacerbation is high, especially in the first month following the event. Smoking cessation, comorbidity-management and asthma-treatment focusing on the prevention of exacerbations might reduce associated mortality.

Validation study of the population included in the Danish Schizophrenia Registry

INTRODUCTION

We aimed to assess the validity of the schizophrenia diagnoses registered in the Danish Schizophrenia Registry (DSR) by comparing with information from medical records.

METHODS

The study included a random sample of 390 subjects from the DSR who were representative of each geographic region of Denmark. For each subject in the sample, a medical record review was performed by local psychiatrists to confirm or disconfirm the schizophrenia diagnosis and to give a qualified estimate of the date of diagnosis. Only register data and medical record information were used, and thus the individuals in the sample were not approached. We calculated the positive predictive value, comparing registrations in the DSR with the original medical records as a reference.

RESULTS

A total of 325 out of 390 (83%) medical records were reviewed. The positive predictive value was 91% (95% confidence interval (CI): 88-94%), varying between geographic regions from 85% to 100%. The classification of incident versus prevalent disease corresponded with the reference in 93% (95% CI: 80-97%) of cases diagnosed in 2014-2015.

CONCLUSIONS

The DSR includes the intended patient population and represents a valid and valuable source for improving quality of care and for research.

FUNDING

The study was financed by the Danish Regional Development Fund for Clinical Quality.

TRIAL REGISTRATION

not relevant.

Validity of a questionnaire developed to measure the impact of a high-fidelity simulation intervention: A feasibility study

AIM

To evaluate the validity and responsiveness of a questionnaire developed to measure the impact of a high-fidelity simulation intervention.

DESIGN

A pre- and postintervention design.

METHODS

In August 2017, 107 participants completed a questionnaire measuring knowledge and perceived self-confidence pre- and postintervention. Validity of the questionnaire was determined by expert reviews, individual interviews and estimates of the changes in knowledge and perceived self-confidence. The changes were estimated by the differences between paired proportions of participants. The responsiveness of the ordered categorical item scores on self-confidence was evaluated by the measure of systematic group change and individual variations.

RESULTS

The analysis of the interviews resulted in three themes: item content, item style and the administration of the questionnaire. An intervention effect on knowledge assessments was shown by the changes in paired proportions of participants with increased or decreased correct assessments (ranging from -25.5 - 24.8 percentage units). The responsiveness of the self-confidence scale was confirmed by evidence of post-intervention systematic group changes towards higher levels.

CONCLUSION

This study provides useful experience for a forthcoming randomized controlled study to evaluate the effect of high-fidelity simulation on undergraduate nursing students' knowledge and self-confidence when assessing patient deterioration.

IMPACT

Cause-and-effect relationship between simulation and learning is required to improve nursing education. A statistically significant rise in students' knowledge and levels of self-confidence after simulation were identified in this study. The study provided important aspects of future research study designs.

Hyperkalaemia in people with diabetes: occurrence, risk factors and outcomes in a Danish population-based cohort study

AIMS

To examine the incidence, risk factors and clinical outcomes of hyperkalaemia in people with diabetes in a real-world setting.

METHODS

Using Danish health registries, we identified a population-based cohort of people with first-time drug-treated diabetes, in the period 2000-2012. First, the cumulative incidence of hyperkalaemia, defined as first blood test with potassium level >5.0 mmol/l after diabetes treatment initiation, was ascertained. Second, in a case-control analysis, risk factors were compared in people with vs without hyperkalaemia. Third, clinical outcomes were assessed among individuals with hyperkalaemia in a before-after analysis, and among people with and without hyperkalaemia in a matched cohort analysis.

RESULTS

Of 68 601 individuals with diabetes (median age 62 years, 47% women), 16% experienced hyperkalaemia (incidence rate 40 per 1000 person-years) during a mean follow-up of 4.1 years. People who developed hyperkalaemia had a higher prevalence of chronic kidney disease [prevalence ratio 1.74 (95% CI 1.68-1.81)], heart failure [prevalence ratio 2.35 (95% CI 2.18-2.54)], use of angiotensin-converting enzyme inhibitors [prevalence ratio 1.24 (95% CI 1.20-1.28)], use of spironolactone [prevalence ratio 2.68 (95% CI 2.48-2.88)] and potassium supplements [prevalence ratio 1.59 (95% CI 1.52-1.67)]. In people with diabetes who developed hyperkalaemia, 31% were acutely hospitalized within 6 months before hyperkalaemia, increasing to 50% 6 months after hyperkalaemia [before-after risk ratio 1.67 (95% CI 1.61-1.72)]. The 6-month mortality rate after hyperkalaemia was 20%. Compared with matched individuals without hyperkalaemia, the hazard ratio for death was 6.47 (95% CI 5.81-7.21).

CONCLUSIONS

One in six newly diagnosed people with diabetes experienced a hyperkalaemic event, which was associated with severe clinical outcomes and death.

Superior outcomes following cervical fusion vs. multimodal rehabilitation in a subgroup of randomized Whiplash-Associated-Disorders (WAD) patients indicating somatic pain origin-Comparison of outcome assessments made by four examiners from different disciplines

BACKGROUND AND AIMS

Whiplash-Associated Disorders (WAD) are characterized by great variability in long-term symptoms. Patients with central neck and movement-induced stabbing pain participated in a randomized study comparing cervical fusion and multimodal rehabilitation. As reported in our previous paper, more patients treated by cervical fusion than by rehabilitation experienced pain relief. Although patient reported outcome measures are a core component of outcome evaluation, independent examiner has been recommended. Because of the heterogeneity of WAD complaints the patients in our study were examined at baseline and follow-up by four experts representing neurology, orthopedics, psychology and physical medicine. The aim was to compare the professional assessments of change both regarding the possible impact of the different examiners' perspectives on individual patient's outcome, and also on the analysis of possible outcome differences between the treatment groups.

METHODS

WAD patients with long-term neck pain as the predominant symptom after a traffic accident were eligible. The neck pain origin should be in the midline and perceived as dull and aching, with sudden movement inducing midline stabbing pain. Of the 1,052 patients in contact with our team, 49 were eligible. The overall treatment effect was evaluated on a global outcome transitional scale. The criteria for the scale categories were defined by each expert's professional perspective on change in the whiplash complaints. Statistical methods that take account of the non-metric properties of ordered categorical data were used. Observed inter-expert disagreement was evaluated by the Svensson method that identifies and measures systematic group-related disagreement separately from disagreement caused by individual variation. Possible differences in the distributions of assessments on the expert-specific outcome scales between the treatment groups were analyzed by the Kruskal-Wallis test.

RESULTS

The per-protocol evaluation showed that a majority of the 18 patients who underwent fusion surgery were assessed as somewhat or much better, ranging from 67% to 78% depending on the expert. Corresponding proportions of improvement in the 17 patients treated by multimodal rehabilitation ranged from 29% to 53%. The statistical analyses confirmed better outcomes in the patients treated by fusion surgery, with p-values ranging from 0.003 to 0.04. The experts' assessments of intra-patient change disagreed more or less for all patients. The analyses of the paired comparisons confirmed that these disagreements could most probably be explained by the different profession-specific operational definitions of the outcome scales rather than by individual variations in data.

CONCLUSIONS

The multi-dimensional complexity of WAD-related complaints was comprehensively demonstrated by the inter-disciplinary disagreements in assessing intra-patient outcomes. The superiority of positive treatment effects in patients who underwent cervical fusion compared with multimodal rehabilitation was evident to all experts.

IMPLICATIONS

The results strengthen our previous opinion that neck pain in this subgroup of WAD patients has a somatic origin. More than one examiner is recommended for multi-dimensional outcome assessments.

Posttraumatic Stress Disorder and Gastrointestinal Disorders in the Danish Population

BACKGROUND

Evidence for the association between posttraumatic stress disorder (PTSD) and gastrointestinal (GI) disorders is mixed, owing in part to methodologic differences across studies. Furthermore, studies which have combined GI disorders or symptoms for examination as one overall category may potentially obscure associations between PTSD and individual GI diagnoses.

METHODS

This nationwide cohort study examined the incidence of all major nonmalignant GI disorders in patients with a prior PTSD diagnosis (n = 4,076), compared with the general population incidence from 1995 to 2013, using Danish medical registry data. We examined differences by sex, age, marital status, psychiatric and somatic comorbidity, and follow-up time. Risks, standardized incidence rates (SIRs), and confidence intervals (95% CIs) were calculated.

RESULTS

Risk of any GI disorder among PTSD patients was 25% (95% CI: 21%, 29%); the SIR for any GI disorder was 1.8 (95% CI: 1.7, 2.0). Risk and SIRs varied by disorder (e.g., no association with diverticula of the intestines [SIR: 1.1, 95% CI: 0.83, 1.5]; stronger association with peptic ulcer, site unspecified [SIR: 3.3, 95% CI: 1.8, 5.5]). Stratified analyses revealed that some associations were stronger for persons ages 16-39 or unmarried at PTSD diagnosis, persons with comorbid psychiatric diagnoses, and in the year following PTSD diagnosis.

CONCLUSIONS

This study documents associations between clinician-diagnosed PTSD and all major nonmalignant GI disorders in an unselected nationwide cohort with long follow-up. Differences in associations across GI disorders and important modifiers may account for previous conflicting research findings.

Tonsillectomy and risk of Parkinson's disease: A danish nationwide population-based cohort study

BACKGROUND

We hypothesized that tonsillectomy modifies the risk of PD.

OBJECTIVES

To test the hypothesis in a nationwide population-based cohort study.

METHODS

We used Danish medical registries to construct a cohort of all patients in Denmark with an operation code of tonsillectomy 1980-2010 (n = 195,169) and a matched age and sex general population comparison cohort (n = 975,845). Patients were followed until PD diagnosis, death, censoring, or end of follow-up 30 November 2013. Using Cox regression, we computed hazard ratios for PD and corresponding 95% confidence intervals, adjusting for age and sex by study design, and potential confounders.

RESULTS

We identified 100 and 568 patients diagnosed with PD among the tonsillectomy and general population comparison cohort, respectively, finding similar risks of PD (adjusted hazard ratio = 0.95 [95% confidence interval: 0.76-1.19]; for > 20 years' follow-up (adjusted hazard ratio = 0.96 [95% confidence interval: 0.64-1.41]).

CONCLUSION

Tonsillectomy is not associated with risk of PD, especially early-onset PD. © 2017 International Parkinson and Movement Disorder Society.

Trends and differences in tuberculosis incidences and clustering among natives in Denmark, Sweden and Finland: comparison of native incidences and molecular epidemiology among three low-incidence countries

OBJECTIVES

To compare the epidemiology of tuberculosis (TB) in Denmark, Sweden and Finland, by focusing on the native population in order to identify epidemiologic differences and thus indirectly possible differences in TB control.

METHODS

TB incidence trends from 1990 through 2015 were compared among the countries. In addition, for the periods 2012-2013 and 2014-2015, genotyping data were compared. Genotyping was performed using the 24-locus mycobacterial interspersed repetitive unit-variable number of tandem repeat (MIRU-VNTR) method in Denmark and Sweden. For Finland, spoligotyping in conjunction with the 15-locus MIRU-VNTR method was used for 2012-2013 and translated into the 24-locus MIRU-VNTR when feasible, and for 2014-2015 only MIRU-VNTR was used. Both incidence trends and molecular epidemiology were assessed for native cases.

RESULTS

The average annual rate of change in TB incidence for native Danes was -2.4% vs. -6.1% and -6.9% for native Swedes and Finns respectively. In 2012-2013 Denmark had 52 native cases in the largest transmission chain vs. three cases in Sweden and ten in Finland, and during the same period the clustering rate for native Danes was 48.8% vs. 6.5% and 18.2% for native Swedes and Finns respectively. For 2014-2015, a similar pattern was seen.

CONCLUSIONS

The decline of TB among natives in Denmark is slower than for Sweden and Finland, and it seems Denmark has more active transmission among natives. The focused assessment on basic native TB epidemiology reveals striking differences in TB transmission among otherwise similar low-TB-incidence countries.

Survival after bone metastasis by primary cancer type: a Danish population-based cohort study

OBJECTIVE

In the 10 most common primary types with bone metastases, we aimed to examine survival, further stratifying on bone metastases only or with additional synchronous metastases.

METHODS

We included all patients aged 18 years and older with incident hospital diagnosis of solid cancer between 1994 and 2010, subsequently diagnosed with BM until 2012. We followed patients from date of bone metastasis diagnosis until death, emigration or 31 December 2012, whichever came first. We computed 1-year, 3-year and 5-year survival (%) and the corresponding 95% CIs stratified on primary cancer type. Comparing patients with bone metastasis only and patients with other synchronous metastases, we estimated crude and adjusted HRs and corresponding 95% CI for mortality.

RESULTS

We included 17 251 patients with bone metastasis. The most common primary cancer types with bone metastasis were prostate (34%), breast (22%) and lung (20%). One-year survival after bone metastasis diagnosis was lowest in patients with lung cancer (10%, 95% CI 9% to 11%) and highest in patients with breast cancer (51%, 50% to 53%). At 5 years of follow-up, only patients with breast cancer had over 10% survival (13%, 11% to 14%). The risk of mortality was increased for the majority of cancer types among patients with bone and synchronous metastases compared with bone only (adjusted relative risk 1.29-1.57), except for cervix, ovarian and bladder cancer.

CONCLUSIONS

While patients with bone metastases after most primary cancers have poor survival, one of ten patients with bone metastasis from breast cancer survived 5 years.

Co-Occurrence of ODD and CD in Preschool Children With Symptoms of ADHD

OBJECTIVE

Patterns of co-occurrence between ADHD, Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD) were examined in a sample of non-referred preschool children. ADHD subtypes and sex differences were also explored.

METHOD

Children aged 3.5 years ( n = 1,048) with high scores on ADHD characteristics were recruited from the Norwegian Mother and Child Cohort Study and clinically assessed, including a semi-structured psychiatric interview.

RESULTS

In children with ADHD, concurrent ODD was present more often than CD (31% vs. 10%), but having ADHD gave higher increase in the odds of CD than of ODD (ODD: odds ratio [OR] = 6.7, 95% confidence interval [CI] = [4.2, 10.8]; CD: OR = 17.6, 95% CI = [5.9, 52.9]). We found a greater proportion of children having the combined ADHD subtype as well as more severe inattentiveness among children with co-occurring CD compared with ODD. Sex differences were minor.

CONCLUSION

There are important differences in co-occurring patterns of ODD and CD in preschool children with ADHD.

Early Glycemic Control and Magnitude of HbA1c Reduction Predict Cardiovascular Events and Mortality: Population-Based Cohort Study of 24,752 Metformin Initiators

OBJECTIVE

We investigated the association of early achieved HbA_1c level and magnitude of HbA_1c reduction with subsequent risk of cardiovascular events or death in patients with type 2 diabetes who initiate metformin.

RESEARCH DESIGN AND METHODS

This was a population-based cohort study including all metformin initiators with HbA_1c tests in Northern Denmark, 2000-2012. Six months after metformin initiation, we classified patients by HbA_1c achieved (<6.5% or higher) and by magnitude of HbA_1c change from the pretreatment baseline. We used Cox regression to examine subsequent rates of acute myocardial infarction, stroke, or death, controlling for baseline HbA_1c and other confounding factors.

RESULTS

We included 24,752 metformin initiators (median age 62.5 years, 55% males) with a median follow-up of 2.6 years. The risk of a combined outcome event gradually increased with rising levels of HbA_1c achieved compared with a target HbA_1c of <6.5%: adjusted hazard ratio (HR) 1.18 (95% CI 1.07-1.30) for 6.5-6.99%, HR 1.23 (1.09-1.40) for 7.0-7.49%, HR 1.34 (1.14-1.57) for 7.5-7.99%, and HR 1.59 (1.37-1.84) for ≥8%. Results were consistent for individual outcome events and robust by age-group and other patient characteristics. A large absolute HbA_1c reduction from baseline also predicted outcome: adjusted HR 0.80 (0.65-0.97) for Δ = -4, HR 0.98 (0.80-1.20) for Δ = -3, HR 0.92 (0.78-1.08) for Δ = -2, and HR 0.99 (0.89-1.10) for Δ = -1 compared with no HbA_1c change (Δ = 0).

CONCLUSIONS

A large initial HbA_1c reduction and achievement of low HbA_1c levels within 6 months after metformin initiation are associated with a lower risk of cardiovascular events and death in patients with type 2 diabetes.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

SETTING

Danish nationwide population-based cohort study.

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bowel wall visualisation at CT colonography

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

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

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

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

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

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

Design: Test retest study.

Setting: University, hospitals/clinics in northern Sweden.

Subjects: Twenty people with Charcot Marie Tooth disease.

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

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

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

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

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

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

BACKGROUND

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

OBJECTIVE

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

SETTING

University Hospital, Denmark.

DESIGN

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

RESULTS

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

CONCLUSION

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

Adjustment disorder and risk of Parkinson's disease

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

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

RATIONALE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

DESIGN

Prospective cohort study utilising Danish national registry data.

SETTING

The general population of Denmark.

PARTICIPANTS

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

PRIMARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Vagotomy and subsequent risk of Parkinson's disease

OBJECTIVE

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

METHODS

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

RESULTS

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

INTERPRETATION

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

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

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

Posttraumatic stress disorder and cancer risk: a nationwide cohort study

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