Social network analysis reveals the failure of between-farm movement restrictions to reduce Salmonella transmission

An increasing number of countries are investigating options to stop the spread of the emerging zoonotic infection Salmonella (S.) Dublin, which mainly spreads among bovines and with cattle manure. Detailed surveillance and cattle movement data from an 11-year period in Denmark provided an opportunity to gain new knowledge for mitigation options through a combined social network and simulation modeling approach. The analysis revealed similar network trends for non-infected and infected cattle farms despite stringent cattle movement restrictions imposed on infected farms in the national control program. The strongest predictive factor for farms becoming infected was their cattle movement activities in the previous month, with twice the effect of local transmission. The simulation model indicated an endemic S. Dublin occurrence, with peaks in outbreak probabilities and sizes around observed cattle movement activities. Therefore, pre- and post-movement measures within a 1-mo time-window may help reduce S. Dublin spread.

Remote dielectric sensing detects pulmonary congestion in emergency patients with dyspnoea

Background

Immediate diagnosis of acute decompensated heart failure (ADHF) is essential in patients with dyspnoea. Remote Dielectric Sensing (ReDS), an electromagnetic non-invasive technology, estimates lung fluid content fast and observer-independently. In previous studies, ReDS discriminated congested heart failure patients from normal subjects with high accuracy. But not all ADHF patients have pulmonary interstitial congestion in the real world, and it is unknown if ReDS detects ADHF in consecutive patients with acute dyspnoea.

Purpose

To examine if ReDS can detect ADHF in consecutive dyspnoeic emergency patients and to compare ReDS with other diagnostic methods.

Method

This prospective observational study included consecutive patients with dyspnoea from the emergency departments. The exclusion criteria were age below 50 years, acute coronary syndrome, conditions prohibiting a supine CT scan, and no informed consent. We examined all patients immediately with ReDS, low-dose chest CT, echocardiogram, lung ultrasound (LUS), NT-proBNP, and Boston score. The Boston score used chest X-ray and clinical signs such as orthopnoea, jugular venous elevation, lung crackles and pedal oedema, and a score ≥8 equalled definite ADHF. A “LUS-score” ≥3 with at least 3 B-lines in one zone bilaterally equalled ADHF. ReDS values >35% lung fluid content were positive for pulmonary congestion, according to previous studies.

According to ESC guidelines, an expert panel adjudicated the ADHF diagnosis based on clinical signs, chest X-ray image, NT-proBNP, echocardiographic cardiac dysfunction (HFvhd, HFrEF, HFmrEF, HFpEF), and elevated LV filling pressure. Importantly, the panel was blinded to the ReDS values. For sub-analyses, we divided ADHF patients into a “CT-congested” ADHF subgroup if an independent chest CT showed interstitial congestion. We classified ADHF patients without congestion on CT, as the “mildly-congested” subgroup.

Results

97 included patients were examined within a median of 4.8 hours from admittance: 39 (40%) had ADHF, and 25 (26%) were ReDS-positive. ADHF patients had median LVEF 48%, NT-proBNP 347 pmol/l, and 85% had echocardiographic elevated LV filling pressure. ReDS detected ADHF with 46% sensitivity, 88% specificity, and 71% accuracy. The AUC for ReDS to detect ADHF (Figure 1), on a continuous scale, was similar to the Boston score (p=0.88) and the LUS score (p=0.74), but lower than NT-proBNP (p=0.02). The 21 (22%) CT-congested ADHF patients had higher ReDS values than the 18 (19%) mildly-congested ADHF patients (Figure 2, median 38% vs 30%, p<0.001). Furthermore, the mildly-congested ADHF patients had ReDS values similar to non-ADHF patients (median 30% vs 28%, p=0.36).

Conclusion

ReDS detects ADHF similarly to the Boston score and lung ultrasound but is inferior to NT-proBNP. This study suggests that ReDS primarily identifies CT-congested ADHF patients, but not the ADHF patients without interstitial congestion.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This work was supported by the research fund of Bispebjerg University Hospital and Holger & Ruth Hesse's Mindefond. Sensible Medical Ltd made the ReDS device available for free and provided an unrestricted grant to specifically collect the ReDS measurements. The sponsors did not affect the statistical analyses, study design, data collection, or writing of the paper.

Dose-dependency of diclofenac's cardiovascular risks: a series of nationwide emulated trials

Background

The dose dependency of the adverse effects of diclofenac remains poorly understood.

Purpose

To examine the dose-related cardiovascular risks associated with diclofenac initiation

Methods

We used Danish nationwide health registries (1999–2018) to conduct a series of emulated trials (n=285). Eligible adults had no recent NSAID fillings, contraindications, or conditions with low adherence. Individuals eligible for inclusion were ≥18 years with (1) ≥90 days continuous prescription records prior to diclofenac initiation (baseline); (2) no NSAID prescriptions ≤90 days before enrollment, and (3) no exclusion criteria. Exclusion criteria reflected likelihood of low adherence to treatment (dementia, schizophrenia, or antipsychotic drug use) and labeled contraindications (ulcer disease/anti-ulcer drugs, gastrointestinal bleeding, inflammatory bowel disease, thrombocytopenia, or heart failure). Initiators of diclofenac were compared to healthcare-seeking non-initiators, but also head-to-head for initiators of high (≥75 mg pills as proxy for ≥150 mg/daily) vs. low dose (≤50 mg pills as proxy for <150 mg/daily). Cox proportional-hazards regression was used to compute the intention-to-treat hazard ratio, as measure of the incidence rate ratio (IRR), of major adverse cardiac and cerebrovascular events (MACCE) within 30 days from initiation.

Results

Among 3,177,484 diclofenac initiatiors, 31% used high and 69% used low dose. Compared with non-initiators, diclofenac initiatiors had a 70% increased rate for MACCE (IRR 1.70, 95% CI: 1.55–1.86), reflecting for the individual MACCE components an increased IRRs of 1.66 (95% CI: 1.54–1.79) for myocardial infaction, 1.32 (1.20–1.45) for ischemic stroke, and 1.69 (1.54–1.86) for cardiac death. The effect for MACCE did not differ between initiators of high (IRR 1.73, 95% CI: 1.51–1.97) and low dose (IRR 1.68, 95% CI: 1.52–1.86) (Figure 1). When comparing high and low dose diclofenac head-to-head, we found no meaningful difference in the IRR for MACCE (1.03, 95% CI: 0.89–1.19), MI (0.99, 0.87–1.11), ischemic stroke (0.95, 0.81–1.11) or cardiac death (1.04, 0.90–1.21) (Figure 2).

Conclusion

Initiation of low- and high-dose diclofenac was associated with a consistent and comparable increase in cardiovascular risk.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation

Antithrombotic therapy and bleeding complications in patients with atrial fibrillation and active cancer

Background

Little is known about the extent to which an active cancer diagnosis increases bleeding and thromboembolic risks in atrial fibrillation (AF) patients. Data on major bleeding rates per antithrombotic management strategy are lacking in AF patients with active cancer.

Purpose

To examine the incidence rates of major bleeding per antithrombotic treatment in AF patients with active cancer and to examine whether cancer type impacts major bleeding and thromboembolic risks.

Methods

We used Danish population-based health care databases to conduct this cohort study. We included all incident AF (including atrial flutter) patients aged ≥50 years between January 1st 1995 and December 31st 2016, out of whom we identified AF patients who subsequently developed cancer. We used International Classification of Diseases 10th Revision codes to identify data on cancer type and outcomes (i.e. major bleeding, arterial and venous thromboembolism). We used Anatomical Therapeutic Chemical codes to provide information on antithrombotic treatment (e.g. no anticoagulant treatment, platelet inhibitors, vitamin K antagonists, direct oral anticoagulants, or a combination of antithrombotic drugs) which was evaluated as a time-dependent variable. The follow-up started from the incident cancer diagnosis until the occurrence of an outcome, death or the end of the two year follow-up. Incidence rates per 100 patient-years and adjusted hazard ratios were computed.

Results

22,996 AF patients with a subsequent incident cancer diagnosis were included in the study. These patients had higher major bleeding and thromboembolic risk compared to those without cancer, with adjusted HRs of 2.11 (1.99–2.23) and 1.36 (1.27–1.44), respectively (Figure 1). Highest bleeding risk was observed for intracranial and respiratory cancer, while haematological and respiratory cancer were associated with highest thromboembolic risk. Bleeding risk increased with increasing number of antithrombotic drugs and was higher in AF patients with active cancer compared to those without, across all exposure categories (Figure 2).

Conclusions

Patients with AF and active cancer are at increased risk of major bleeding and thromboembolisms than those without cancer. Treatment with dual or triple antithrombotic therapy in AF patients with active cancer showed very high bleeding rates.

Funding Acknowledgement

Type of funding sources: None.

Atrial fibrillation in patients with a history of cancer and risk of bleeding complications associated with antithrombotic therapy

Background

Up to one in four patients with atrial fibrillation (AF) has a cancer diagnosis. It is largely unknown to which extent a prior cancer diagnosis affects major bleeding and thromboembolic risk in AF patients. Moreover, data on major bleeding rates per antithrombotic treatment type are lacking in these patients.

Purpose

To examine the incidence rates of major bleeding per antithrombotic treatment in AF patients with prior cancer and to examine whether cancer type and the time-interval between AF and cancer influence major bleeding and thromboembolic risks.

Methods

This nationwide population-based cohort study included incident Danish AF patients aged ≥50 years between 01–01–1995 and 31–12–2016. Data on prior cancer, major bleeding and thromboembolisms (i.e. arterial and venous) were obtained from Danish health registries via International Classification of Diseases 10th Revision codes. We stratified according to prior cancer and by time between the AF and cancer diagnosis (i.e. <1 year, 1–3 years, >3 years), and cancer type. Data on antithrombotic exposure (e.g. no anticoagulant treatment, platelet inhibitors, vitamin K antagonists, direct oral anticoagulants, or combination of antithrombotic drugs) were evaluated as a time-dependent variable. We computed incidence rates per 100 patient-years and adjusted hazard ratios in a Cox regression model.

Results

We identified 39,178 AF patients with a prior cancer diagnosis. Bleeding risk increased with increasing number of antithrombotic drugs and was higher in AF patients with a history of cancer compared to those without, across all exposure categories (Figure 1). The increased bleeding risk was similar across different time intervals between cancer and AF diagnosis. The increased thromboembolic risk steeply declined with increasing time intervals between AF and cancer diagnosis (Figure 2). Prior gastrointestinal, intracranial, haematological, respiratory and urogenital cancers were associated with an increased bleeding risk. The two latter cancer types were also associated with increased thromboembolic risks.

Conclusion

We showed that patients with atrial fibrillation and a prior history of cancer experience higher rates of bleeding than those without cancer. Both respiratory and urogenital cancers had the highest rates of bleeding and thromboembolisms.

Funding Acknowledgement

Type of funding sources: None.

Value of a chest X-ray and CT to diagnose acute heart failure in acute patients with dyspnoea: a prospective comparative diagnostic study in the emergency department

Background and purpose

Diagnosing heart failure (HF) remains difficult in the acute setting where multiple diagnoses are in play. Objective evidence of pulmonary congestion by chest X-ray (CXR) is one criteria for the recent universal definition of heart failure (UniHF). But, since CXR is known to have a low diagnostic value, we hypothesized that a chest CT (CT) would outdo the CXR to diagnose decompensated HF in acute breathless patients. This study's primary objective was to examine if the CT has higher accuracy than the CXR to diagnose HF in the acute setting; and, secondly, to identify what pre-test characteristics would predict a false negative CXR or CT.

Methods

We performed a single-centre, prospective observational study and included consecutive adult patients with dyspnoea in the emergency department. Patients underwent immediate clinical examination, blood tests, CXR, CT and an echocardiogram. Congestion on CXR and CT was defined as the congruent verdict by two expert thorax radiologists, blinded to each others reading and all other clinical data. The absence of congestion was defined as the congruent verdict of “no congestion”.

Congestion of CXR and CT was held up against UniHF ascertained by an expert panel of cardiologists where the pulmonary congestion component primarily was based on elevated filling pressures from the simultaneous comprehensive echocardiogram. Univariate- and multivariate logistic analyses identified factors associated with a false negative chest x-ray and CT.

Results

Of 228 patients with a mean age of 74,5 years, 129 (56,5%) were male, 98 (43%) had UniHF, and 139 (61.0%) had pulmonary disease. Congestion on the CXR diagnosed UniHF with a 54% sensitivity and 95% specificity, with almost similar figures for the CT with 54% and 99% respectively. A marginally better performance of the CT was shown by a significantly lower Akaike Information Criterion for pulmonary congestion by CT than for CXR. However, the net reclassification improvement by CT was 4% (p:0.5586). The CXR and CT were false negative for UniHF in 46% (45/98) for both modalities (Table 1). The only independent pre-test predictor of a false negative radiology examination in multivariable logistic regression analysis was NT-proBNP (CXR: OR 1.670 per log(BNP), p: <0.001) and CT: OR 1.693 per log(BNP), p: <0.001).

Conclusions

For the first time, CT has been directly compared with CXR to diagnose HF in consecutive breathless patients from the emergency department. The chest CT was marginally more specific than the CXR to diagnose HF, but with a similar sensitivity. Approximately half the patients obeying the universal definition of HF have no definite congestion on CXR nor CT, and these can only be identified by a high proBNP.

Funding Acknowledgement

Type of funding sources: None. Table 1

Antidepressant use in pregnancy and severe cardiac malformations: Danish register-based study

OBJECTIVE

Studies restricted to live births may underestimate severe teratogenic effects. We address the limitation by including data from both prenatal and postnatal diagnoses of cardiac malformations.

DESIGN

Register-based study.

SETTING

Denmark.

POPULATION

364 012 singleton pregnancies from 2007 to 2014.

METHODS

We used data from five nationwide registries. Exposure to antidepressants was measured using redeemed prescriptions.

MAIN OUTCOME MEASURES

Pregnancies with cardiac malformations that end in miscarriage, termination, stillbirth, postnatal death or cardiac surgery <1 year of birth were classified as severe cardiac malformations (SCM). Propensity scores with adjusted prevalence ratios (PRs) were calculated.

RESULTS

SCM were reported in 972 of 364 012 pregnancies overall and in 16 of 4105 exposed. For venlafaxine, the PR for SCM was 2.13 (95% confidence interval [CI] 0.89-5.13), 1.73 (95% CI 1.08-2.77) for other cardiac malformations, and there was a cluster of hypoplastic left heart syndromes (HLHS) (crude PR 17.4 [95% CI 6.41-47.2]), none of which ended in a live birth. For HLHS, the absolute risk increase was 4.4/1000 and the number needed to harm was 225. For selective serotonin reuptake inhibitors, the PRs were 1.09 (95% CI 0.52-2.30) and 1.38 (95% CI 1.00-1.92) for SCM and other cardiac malformations, respectively.

CONCLUSIONS

Pregnancy exposure to venlafaxine is associated with an increased risk of severe cardiac malformations but with a low absolute risk. Potential mechanisms include direct effects or confounding by indication. Venlafaxine exposure is a marker for risk pregnancies for which fetal echocardiography may be considered.

TWEETABLE ABSTRACT

Exposure to venlafaxine is associated with an increased risk of cardiac malformations but with a low absolute risk. TWEETABLE ABSTRACT.

Comparative cardiovascular safety of strontium ranelate and bisphosphonates: a multi-database study in 5 EU countries by the EU-ADR Alliance

Strontium ranelate use, compared with oral bisphosphonates, is not associated with increased risk of AMI in patients with no contraindications for SR use. However, current strontium ranelate (compared with current bisphosphonate) appears associated with 25-30% excess risk of VTE and 35% excess risk of CVDeath.

INTRODUCTION

Evaluate the risk of cardiac and thromboembolic events among new users of SR and oral BPs without contraindications for SR.

METHODS

We conducted three multi-national, multi-database (Aarhus-Denmark, HSD-Italy, IPCI-Netherlands, SIDIAP-Spain, THIN-UK) case-control studies nested within a cohort of new users of SR/BP. We matched cases of acute myocardial infarction (AMI), venous thromboembolism (VTE), and cardiovascular death (CVDeath), up to 10 controls on gender, year of birth, index date, and country. Conditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CIs) according to current SR vs current BP use and current vs past SR use, adjusting for potential confounders. Data were pooled using random effects meta-analysis.

RESULTS

No excess risk of AMI (5477 cases/54,674 controls) was found with current SR vs current BP (OR 0.89 (95%CI 0.70, 1.12)) nor with current vs past SR use (0.71(0.56, 0.91)). For VTE (5614 cases/6036 controls), an excess risk was found with current SR compared with current BP use, 1.24 (0.96, 1.61), and current vs past SR use, 1.30 (1.04, 1.62). For CVDeath (3019 cases/29,871 controls), an increased risk was seen with current SR vs current BP use, 1.35 (1.02, 1.80), but not with current vs past SR use (0.68 (0.48, 0.96)).

CONCLUSION

In patients without contraindications for SR, we found no evidence of an increased risk of AMI but a 25-30% excess risk of VTE and a 35% excess risk of CVDeath with current SR vs current BP users. This is despite a reduction in risk in CVDeath with current vs past SR users. The latter disparity could still be partially explained by cessation of preventative therapies in end-of-life or residual confounding by indication.

Correction to: Impact of risk minimisation measures on the use of strontium ranelate in Europe: a multi-national cohort study in 5 EU countries by the EU-ADR Alliance

The original version of this article, published on 26 November 2019 contained a mistake.

Impact of risk minimisation measures on the use of strontium ranelate in Europe: a multi-national cohort study in 5 EU countries by the EU-ADR Alliance

INTRODUCTION

In May 2013 and March 2014, the European Medicines Agency (EMA) issued two decisions restricting the use of strontium ranelate (SR). These risk minimisation measures (RMM) introduced new contraindications and limited the indications of SR therapy. The EMA required an assessment of the impact of RMMs on the use of SR in Europe. Methods design: multi-national, multi-database cohort Setting: electronic medical record databases based on hospital (Denmark) and primary care provenance (Italy, Spain, the Netherlands, UK).

PARTICIPANTS

the database source populations were included for population-based analyses, and SR users for patient-level analyses.

INTERVENTION

New RMMs included contraindications (ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, uncontrolled hypertension) and restricted SR indication to severe osteoporosis with initiation by experienced physician and not as first line anti-osteoporosis therapy.

METHODS

Prevalence and incidence rates of SR use in the population; prevalence of contraindications and restricted indications in SR users, plus 1-year therapy persistence. Drug use measures were calculated in three periods for comparison: reference (2004 to May 2013), transition (June 2013 to March 2014) and assessment (from April 2014 to end 2016).

RESULTS

The study population included 143 million person-years(PY) of follow-up and 76,141 incident episodes of SR treatment. Average monthly prevalence rates of SR use dropped by 86.4% from 62.6/10,000 PY (95 CI 62.4-62.9) in the reference to 8.5 (8.5-8.6) in the assessment period. Similarly, the incidence rate of SR use fell by 97.3% from 7.4/10,000 PY (7.4-7.4) to 0.2 (0.2-0.2) between the reference and assessment period. The prevalence of any contraindication decreased, whilst the prevalence of restricted indications increased in these periods. One-year persistence decreased in the assessment compared with reference period.

CONCLUSIONS

Our study demonstrates a substantial impact of the regulatory action to restrict use of SR in Europe: SR utilisation overall decreased strongly. The proportion of patients fulfilling the restricted indications, without contraindications, increased after the proposed RMMs.

Self-Disorders in Asperger Syndrome Compared to Schizotypal Disorder: A Clinical Study

OBJECTIVE

There are historical and theoretical indications of a difference in subjective experience between autism spectrum disorder (ASD) and the schizophrenia spectrum. However, this difference has not been empirically explored. Therefore, to explore potential differences in subjective experience between the 2 spectra, we examined the presence/absence of self-disorders in Asperger syndrome/autism spectrum disorder (As/ASD) compared to schizotypal disorder (Sd). Self-disorders represent changes in basic self-awareness which have been found to accumulate within the schizophrenia spectrum.

METHODS

All participants were recruited from clinical units and interviewed with a focus on the exploration of presence/absence of self-disorders, with the Examination of Anomalous Self-Experience (EASE) scale, and a general assessment of present psychopathology, with Schedules for Clinical Assessment in Neuropsychiatry (SCAN).

RESULTS

A total of 51 participants (As/ASD, n = 22; Sd, n = 29) were included in the statistical analyses. When controlling for age, gender, years of education, mental problems before the age of 16, and special needs school attendance, there was a clear difference in presence/absence of self-disorders between the 2 groups, with significantly higher levels in the Sd group. Further, there was an overlap in SCAN-rated symptoms between the 2 groups.

CONCLUSION

Our results indicate a significant difference between As/ASD and Sd at the level of the basic self, which, in turn, indicates that an exploration of anomalous self-experience is a valuable supplement in the clinical differentiation between As/ASD and Sd.

Arguments for a Phenomenologically Informed Clinical Approach to Autism Spectrum Disorder

OBJECTIVE

The aim of this paper is to provide arguments for a phenomenologically informed clinical approach to autism spectrum disorder (ASD), including a plea for clinical attention to the self in ASD.

METHODS

Central concepts of continental phenomenology, phenomenological psychopathology, and the phenomenological interview are presented, with an emphasis on the potential unifying qualities of an approach which includes the exploration of subjective and intersubjective experience. These phenomenological concepts and methods are contrasted with the current conceptualization of ASD, where the first-person perspective is not in focus.

RESULTS

Contemporary phenomenological papers on ASD address key concepts like intersubjectivity, intercorporeality, and intentionality. However, insights from this theoretical field have not been followed up in clinical research and practice. Consequently, there is (to our knowledge) still a lack of phenomenologically informed clinical explorations of experience of self, others, and the world in ASD.

CONCLUSION

A phenomenologically informed focus on the form and structure of subjective experience, including a focus on self-experience in ASD, can lead to new and important insights in relation to clinical differentiation between ASD and schizophrenia spectrum disorder.

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.

Nursing staffs self-perceived outcome from a rehabilitation 24/7 educational programme - a mixed-methods study in stroke care

Background

During the past two decades, attempts have been made to describe nurses’ contributions to the rehabilitation of inpatients following stroke. There is currently a lack of interventions that integrate the diversity of nurses’ role and functions in stroke rehabilitation and explore their effect on patient outcomes. Using a systematic evidence- and theory-based design, we developed an educational programme, Rehabilitation 24/7, for nursing staff working in stroke rehabilitation aiming at two target behaviours; working systematically with a rehabilitative approach in all aspects of patient care and working deliberately and systematically with patients’ goals. The aim of this study was to assess nursing staff members’ self-perceived outcome related to their capability, opportunity and motivation to work with a rehabilitative approach after participating in the stroke Rehabilitation 24/7 educational programme.

Methods

A convergent mixed-method design was applied consisting of a survey and semi-structured interviews. Data collection was undertaken between February and June 2016. Data from the questionnaires (N = 33) distributed before and after the intervention were analysed using descriptive statistics and Wilcoxon sign rank test. The interviews (N = 10) were analysed using deductive content analysis. After analysing questionnaires and interviews separately, the results were merged in a side by side comparison presented in the discussion.

Results

The results from both the quantitative and qualitative analyses indicate that the educational programme shaped the target behaviours that we aimed to change by addressing the nursing staff’s capability, opportunity and motivation and hence could strengthen the nursing staff’s contribution to inpatient stroke rehabilitation. A number of behaviours changed significantly, and the qualitative results indicated that the staff experienced increased focus on their role and functions in rehabilitation practice.

Conclusion

Our study provides an understanding of the outcome of the Rehabilitation 24/7 educational programme on nursing staff’s behaviours. A mixed-methods approach provided extended knowledge of the changes in the nursing staff members’ self-percived behaviours after the intervention. These changes suggest that educating the nursing staff on rehabilitation using the Rehabilitation 24/7 programme strengthened their knowledge and beliefs about rehabilitation, goal-setting as well as their role and functions.

Reduction of calprotectin and phosphate during testosterone therapy in aging men: a randomized controlled trial

OBJECTIVES

To investigate the effect of testosterone treatment on biomarkers calprotectin, fibroblast growth factor 23 (FGF23), soluble Klotho, phosphate, calcium, parathyroid hormone, creatinine and estimated glomerular filtration rate.

DESIGN

Randomized, double-blinded, placebo-controlled study.

SETTING

Odense Androgen Study-the effect of Testim and training in hypogonadal men.

PARTICIPANTS

Men aged 60-78 years old with a low normal concentration of free of bioavailable testosterone <7.3 nmol/L and waist circumference >94 cm recruited from 2008 to 2009 (N = 48) by advertisement.

INTERVENTION

Participants were randomized to receive 5-10 g gel/50-100 mg testosterone (Testim^®, Ipsen, France) or 5-10 g gel/placebo.

RESULTS

The plasma levels of calprotectin and phosphate were significantly reduced in the group receiving testosterone therapy (gel) compared to the placebo group (p < 0.05). Testosterone treatment did not have any significant effect on plasma levels of FGF23 or soluble Klotho. The reduction in phosphate levels was inversely associated with bioavailable testosterone.

CONCLUSION

Compared to the placebo group, 6 months of testosterone therapy (gel) reduced calprotectin and phosphate levels suggesting decreased inflammation and decreased cardiovascular risk.

Mortality and cardiovascular diseases risk in patients with Barrett's oesophagus: a population-based nationwide cohort study

BACKGROUND

Patients with Barrett's oesophagus may be at increased risk of mortality overall, and cardiovascular disease has been suggested as the main underlying cause of death.

AIM

To examine cause-specific mortality and risk of cardiovascular events among patients with Barrett's oesophagus.

METHODS

Utilising existing Danish data sources (1997-2011), we identified all patients with histologically verified Barrett's oesophagus (n = 13 435) and 123 526 members of the general population matched by age, sex and individual comorbidities. We calculated cause-specific mortality rates and incidence rates of cardiovascular diseases. We then compared rates between patients with Barrett's oesophagus and the general population comparison cohort, using stratified Cox proportional hazard regression.

RESULTS

Patients with Barrett's oesophagus had a 71% increased risk of overall mortality. The cause-specific mortality rate per 1000 person-years for patients with Barrett's oesophagus was 8.5 for cardiovascular diseases, 14.7 for non-oesophageal cancers, and 5.4 for oesophageal cancer. Compared to the general population cohort, corresponding hazard ratios were 1.26 (95% confidence interval (CI): 1.15-1.38), 1.77 (95% CI: 1.65-1.90), and 19.4 (95% CI: 16.1-23.4), respectively. The incidence rates of cardiovascular diseases per 1000 person-years for Barrett's oesophagus patients and for persons from the general population cohort, respectively, varied from 0.4 and 0.2 for subarachnoid bleeding (hazard ratio 1.10, 95% CI: 0.87-1.39) to 8.1 and 5.9 for congestive heart failure (hazard ratio 1.33, 95% CI: 1.21-1.46).

CONCLUSION

Prophylactic measures targeted at cardiovascular diseases and non-oesophageal cancers potentially could be more important than measures against oesophageal cancer, for improving prognosis among patients with Barrett's oesophagus.

Effectiveness of intensification therapies in Danes with Type 2 diabetes who use basal insulin: a population-based study

AIMS

To examine the usage and real-life effectiveness of intensification therapies in people with Type 2 diabetes treated with basal insulin.

METHODS

We used population-based healthcare databases in Denmark during 2000-2012 to identify all individuals with a first basal insulin prescription (with or without oral drugs), and evaluated subsequent intensification therapy with bolus insulin, premixed insulin or glucagon-like peptide-1 (GLP-1) receptor agonists. Poisson regression was used to compute the adjusted relative risks of reaching glycaemic control targets.

RESULTS

We included 7034 initiators of basal insulin (median age 64 years, diabetes duration 5.3 years, 84% with oral co-medication and median (interquartile range) pre-insulin HbA_1c level 77 (65-92) mmol/mol [9.2% (8.1-10.6%)]. Of these, 3076 (43.7%) received intensification therapy after a median of 11 months: 58.5% with premixed insulin, 29.0% with bolus insulin, 10.6% with GLP-1 receptor agonists, and 1.9% with more than one add-on. Overall, 22% had attained an HbA_1c level of < 53 mmol/mol (< 7%) by 3-6 months after intensification, while 38% attained an HbA_1c < 58 mmol/mol (< 7.5%). Compared with premixed insulin intensification, attainment of HbA_1c < 53 and < 58 mmol/mol was similar with bolus insulin add-on [adjusted relative risk 1.03 (95% CI 0.86-1.24) and 1.02 (95% CI 0.91-1.15), and higher for GLP-1 receptor agonist add-on [adjusted relative risk 1.56 (95% CI 1.27-1.92) and 1.27 (1.10-1.47)].

CONCLUSIONS

Among people with Type 2 diabetes, 22 and 38% reached a target HbA_1c < 53 mmol/mol (< 7%) or < 58 mmol/mol (< 7.5%), respectively, after intensification of their basal insulin therapy. Compared with premixed insulin, target attainment was similar with bolus insulin and higher with GLP-1 receptor agonists.

Impairment of Social Function in Young Females With Recent-Onset Anorexia Nervosa and Recovered Individuals

PURPOSE

A subgroup of individuals with anorexia nervosa (AN) displays social difficulties; however, it is not clear if individuals with comorbid autism spectrum disorders account for these difficulties.

METHODS

We compared social function using the Autism Diagnostic Observation Schedule in 43 young females with first-episode AN who did not have comorbid autism spectrum disorder, 28 individuals recovered from adolescent-onset AN, and 41 healthy comparison individuals (age range 14-22 years). We measured adaptive behavior with the Vineland-II parent questionnaire, and aspects of social cognition with psychological tests, such as the Reading-the-Mind-in-the-Eyes test, Profile of Nonverbal Sensitivity short version, The Awareness of Social Inference Test, Animated Triangles, and the CANTAB Affective Go/No-go task.

RESULTS

Participants with first-episode AN and those recovered from AN displayed difficulties in social function, which were not associated with body mass index or other state factors of the disorder in those with first-episode AN. Mood problems and anxiety were not associated with these difficulties. Parents rated participants with first-episode AN lower than recovered and control participants on the Socialization Domain of Vineland-II. Finally, only participants recovered from AN demonstrated deficits in specific domains of social cognition: perceiving nonverbal bodily gesture and vocal prosody.

CONCLUSIONS

Young females with first-episode AN and those recovered from AN displayed impairments in social function, which may represent more stable traits of the disorder. Only participants recovered from AN demonstrated deficits in social cognition.

Fast diffusion kurtosis imaging of fibrotic mouse kidneys

Diffusion kurtosis imaging (DKI) is sensitive to tissue microstructure and may therefore be useful in the diagnosis and monitoring of disease in brain and body organs. Generally, diffusion magnetic resonance imaging (dMRI) in the body is challenging because of the heterogeneous body composition, which can cause image artefacts as a result of chemical shifts and susceptibility differences. In addition, the abdomen possesses physiological factors (e.g. breathing, heartbeat, blood flow) which may severely reduce image quality, especially when echo planar imaging is employed, as is typical in dMRI. Collectively, these challenging measurement conditions impede the use and exploration of DKI in the body. This impediment is further exacerbated by the traditionally large amount of data required for DKI and the low signal-to-noise ratio at the b-values needed to effectively probe the kurtosis regime. Recently introduced fast DKI techniques reduce the challenge of DKI in the body by decreasing the data requirement substantially, so that, for example, triggering and breath-hold techniques may be applied for the entire DKI acquisition without causing unfeasible scan times. One common pathological condition for which body DKI may be of immediate clinical value is kidney fibrosis, which causes progressive changes in organ microstructure. With its sensitivity to microstructure, DKI is an obvious candidate for a non-invasive evaluation method. We present preclinical evidence indicating that the rapidly obtainable tensor-derived mean kurtosis ( W̅) distinguishes moderately fibrotic kidneys from healthy controls. The presence and degree of fibrosis are confirmed by histology, which also indicates fibrosis as the main driver behind the DKI differences observed between groups. We therefore conclude that fast kurtosis is a likely candidate for an MRI-based method for the detection and monitoring of renal fibrosis. We provide protocol recommendations for fast renal DKI in humans based on a b-value optimisation performed using data acquired at 3 T in normal human kidney.

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.

Perceived stress and risk of any osteoporotic fracture

Perceived stress is associated with several adverse health outcomes; however, little is known about the impact of stress on fracture risk. In this population-based cohort study, persons with high perceived stress have an increased 5-year risk of any osteoporotic fracture, in particular hip fracture.

INTRODUCTION

We conducted a population-based cohort study in Denmark to examine the association between perceived stress and risk of subsequent osteoporotic fracture.

METHODS

A 2006 population-based health survey in the Central Danish Region (with 1.25 million inhabitants) was used to identify 7943 persons who were 55 years or older on the survey date and completed the Perceived Stress Scale. Individuals were categorized into two groups: high level of stress and low level of stress (including no stress). We obtained information on all osteoporotic fractures through linkage to the Danish National Registry of Patients. We used Cox regression to compute hazard ratios (HRs) with 95 % confidence interval (CI) adjusted for a number of lifestyle factors, socioeconomic data, perceived general health, and prescription history, comparing high- and low-stress persons.

RESULTS

A total of 1799 persons (22.6 %) reported high level of perceived stress, whereas 6144 (77.4 %) reported low level or no stress. The 5-year risk of any osteoporotic fracture was 7.4 and 5.4 % in persons with high and low perceived stress, respectively, corresponding to adjusted HR of 1.37 (CI 1.00-1.89). The adjusted HR for hip fracture within 5 years associated with high perceived stress was 1.68 (CI 1.04-2.72). The associations weakened with increasing follow-up time.

CONCLUSIONS

Persons with high perceived stress have an increased risk of any osteoporotic fracture, in particular risk of hip fracture within 5 years of stress assessment even after adjusting for differences in lifestyle, comorbidities, osteoporosis presence, medication use, and socioeconomic status at the time of stress level evaluation. The association attenuated after longer follow-up time.

Preconception venous thromboembolism and placenta-mediated pregnancy complications

BACKGROUND

Placenta-mediated complications are leading causes of maternal and fetal morbidity and mortality. We hypothesized that a preconception history of venous thromboembolism (VTE) is associated with increased risk of placenta-mediated pregnancy complications.

METHODS

A nationwide population-based cohort study of all singleton pregnancies leading to delivery from 1997 to 2012 (n = 964 967). We obtained data on placenta-mediated pregnancy complications from the Danish Medical Birth Registry and data on VTE before pregnancy from the Danish National Patient Registry. We computed absolute risks, crude and adjusted risk differences (RDs) using a binomial regression model, and crude and adjusted risk ratios (RRs) from a modified Poisson regression model.

RESULTS

Overall, 1419 women had a preconception history of VTE, while 578 112 did not. Preeclampsia occurred in 4.2% of pregnancies in the VTE group and in 2.7% of pregnancies in a comparison cohort (adjusted RD = 1.3%, 95% confidence interval (CI) 0.6-2.0%; adjusted RR = 1.5, 95% CI 1.3-1.8). Stillbirth occurred in 0.7% of pregnancies in the VTE group and in 0.4% of pregnancies in the comparison cohort (adjusted RD = 0.3%, 95% CI 0.02-0.6%; adjusted RR = 1.8, 95% CI 1.1-3.0). Placental abruption occurred in 0.8% of pregnancies in the VTE group and in 0.5% of pregnancies in the comparison cohort (adjusted RD = 0.3%, 95% CI - 0.05-0.6%; adjusted RR = 1.6, 95% CI 1.1-2.4). Small-for-gestational-age infants accounted for 10.9% of live births in the VTE group and 9.8% of live births in the comparison cohort (adjusted RD = 0.6%, 95% CI - 0.5-1.7%; adjusted RR = 1.1, 95% CI 0.9-1.3).

CONCLUSION

Women with a history of VTE were at increased risk of placenta-mediated complications.

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.

Preadmission use of ACE inhibitors or angiotensin receptor blockers and short-term mortality after stroke

BACKGROUND AND AIM

The prognostic impact of ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) on stroke mortality remains unclear. We aimed to examine whether prestroke use of ACE-Is or ARBs was associated with improved short-term mortality following ischaemic stroke, intracerebral haemorrhage (ICH) and subarachnoid haemorrhage (SAH).

METHODS

We conducted a nationwide population-based cohort study using medical registries in Denmark. We identified all first-time stroke patients during 2004-2012 and their comorbidities. We defined ACE-I/ARB use as current use (last prescription redemption <90 days before admission for stroke), former use and non-use. Current use was further classified as new or long-term use. We used Cox regression modelling to compute 30-day mortality rate ratios (MRRs) with 95% CIs, controlling for potential confounders.

RESULTS

We identified 100 043 patients with a first-time stroke. Of these, 83 736 patients had ischaemic stroke, 11 779 had ICH, and 4528 had SAH. For ischaemic stroke, the adjusted 30-day MRR was reduced in current users compared with non-users (0.85, 95% CI 0.81 to 0.89). There was no reduction in the adjusted 30-day MRR for ICH (0.95, 95% CI 0.87 to 1.03) or SAH (1.01, 95% CI 0.84 to 1.21), comparing current users with non-users. No association with mortality was found among former users compared with non-users. No notable modification of the association was observed within sex or age strata.

CONCLUSIONS

Current use of ACE-Is/ARBs was associated with reduced 30-day mortality among patients with ischaemic stroke. We found no association among patients with ICH or SAH.

New Interview and Observation Measures of the Broader Autism Phenotype: Description of Strategy and Reliability Findings for the Interview Measures

Clinical genetic studies confirm the broader autism phenotype (BAP) in some relatives of individuals with autism, but there are few standardized assessment measures. We developed three BAP measures (informant interview, self-report interview, and impression of interviewee observational scale) and describe the development strategy and findings from the interviews. International Molecular Genetic Study of Autism Consortium data were collected from families containing at least two individuals with autism. Comparison of the informant and self-report interviews was restricted to samples in which the interviews were undertaken by different researchers from that site (251 UK informants, 119 from the Netherlands). Researchers produced vignettes that were rated blind by others. Retest reliability was assessed in 45 participants. Agreement between live scoring and vignette ratings was very high. Retest stability for the interviews was high. Factor analysis indicated a first factor comprising social-communication items and rigidity (but not other repetitive domain items), and a second factor comprised mainly of reading and spelling impairments. Whole scale Cronbach's alphas were high for both interviews. The correlation between interviews for factor 1 was moderate (adult items 0.50; childhood items 0.43); Kappa values for between-interview agreement on individual items were mainly low. The correlations between individual items and total score were moderate. The inclusion of several factor 2 items lowered the overall Cronbach's alpha for the total set. Both interview measures showed good reliability and substantial stability over time, but the findings were better for factor 1 than factor 2. We recommend factor 1 scores be used for characterising the BAP.

Pneumonia and the incidence of cancer: a Danish nationwide cohort study

OBJECTIVES

To examine the risk of a subsequent pulmonary or extra-pulmonary cancer diagnosis following a first-time hospital-based diagnosis of pneumonia.

DESIGN

Population-based cohort study using Danish medical registries.

SETTING

All hospitals in Denmark.

SUBJECTS

A total of 342,609 patients with a first-time hospital-based (inpatient, emergency room or outpatient clinic) diagnosis of pneumonia between 1995 and 2011.

MAIN OUTCOME MEASURES

We quantified the excess risk of various cancers amongst pneumonia patients compared to the expected risk in the general population, using relative [standardised incidence ratios (SIRs)] and absolute risk calculations. Follow-up started 1 month after a hospital-based diagnosis of pneumonia and ended on 31 December 2011.

RESULTS

A total of 28,496 cancers were observed, compared with 21,625 expected, amongst 342,609 pneumonia patients followed for a median of 4.2 years. The absolute risk of a cancer diagnosis 1 to <6 months following a pneumonia diagnosis was 1.4%, with a corresponding SIR of 2.48 [95% confidence interval (CI) 2.41-2.55]. This was mainly due to an increased risk of lung cancer (eightfold) and haematological cancers (fourfold). The SIR for any cancer remained increased at 1.35 (95% CI 1.30-1.40) during 6-12 months of follow-up, and 1.20 (95% CI 1.18-1.22) during 1-5 years of follow-up. Beyond 5 years, an increased risk was maintained for lung, oesophageal, liver and bladder cancers, squamous cell carcinoma of the skin, lymphoma and multiple myeloma.

CONCLUSIONS

A hospital-based pneumonia diagnosis was associated with an increased risk of a cancer diagnosis, especially in the ensuing months, but the absolute risk was small.

Chronic liver disease and 90-day mortality in 21,359 patients following peptic ulcer bleeding--a Nationwide Cohort Study

BACKGROUND

Bleeding is a serious and frequent complication of peptic ulcer disease. Hepatic dysfunction can cause coagulopathy and increases the risk of peptic ulcer bleeding. However, whether chronic liver disease increases mortality after peptic ulcer bleeding remains unclear.

AIM

To examine the prognostic impact of chronic liver disease on mortality after peptic ulcer bleeding.

METHODS

We used population-based medical registries to conduct a cohort study of all Danish residents hospitalised with incident peptic ulcer bleeding from 2004 through 2011. We identified patients diagnosed with liver cirrhosis or non-cirrhotic chronic liver disease before their admission for peptic ulcer bleeding. We then computed 90-day mortality after peptic ulcer bleeding based on the Kaplan-Meier method (1 - survival function) and used a Cox regression model to estimate mortality rate ratios (MRRs), controlling for potential confounders.

RESULTS

We identified 21,359 patients hospitalised with peptic ulcer bleeding. Among these, 653 (3.1%) had a previous diagnosis of liver cirrhosis and 474 (2.2%) had a history of non-cirrhotic chronic liver disease. Patients with liver cirrhosis and non-cirrhotic chronic liver disease had a cumulative 90-day mortality of 25.3% and 20.7%, respectively, compared to 18.3% among patients without chronic liver disease. Liver cirrhosis was associated with an adjusted 90-day MRR of 2.38 (95% CI: 2.02-2.80), compared to 1.49 (95% CI: 1.22-1.83) among patients with non-cirrhotic chronic liver disease.

CONCLUSION

Patients with chronic liver disease, particularly liver cirrhosis, are at increased risk of death within 90 days after hospitalisation for peptic ulcer bleeding compared to patients without chronic liver disease.

Biogas production from vietnamese animal manure, plant residues and organic waste: influence of biomass composition on methane yield

Anaerobic digestion is an efficient and renewable energy technology that can produce biogas from a variety of biomasses such as animal manure, food waste and plant residues. In developing countries this technology is widely used for the production of biogas using local biomasses, but there is little information about the value of these biomasses for energy production. This study was therefore carried out with the objective of estimating the biogas production potential of typical Vietnamese biomasses such as animal manure, slaughterhouse waste and plant residues, and developing a model that relates methane (CH4) production to the chemical characteristics of the biomass. The biochemical methane potential (BMP) and biomass characteristics were measured. Results showed that piglet manure produced the highest CH4 yield of 443 normal litter (NL) CH4 kg(-1) volatile solids (VS) compared to 222 from cows, 177 from sows, 172 from rabbits, 169 from goats and 153 from buffaloes. Methane production from duckweed (Spirodela polyrrhiza) was higher than from lawn grass and water spinach at 340, 220, and 110.6 NL CH4 kg(-1) VS, respectively. The BMP experiment also demonstrated that the CH4 production was inhibited with chicken manure, slaughterhouse waste, cassava residue and shoe-making waste. Statistical analysis showed that lipid and lignin are the most significant predictors of BMP. The model was developed from knowledge that the BMP was related to biomass content of lipid, lignin and protein from manure and plant residues as a percentage of VS with coefficient of determination (R-square) at 0.95. This model was applied to calculate the CH4 yield for a household with 17 fattening pigs in the highlands and lowlands of northern Vietnam.

Validation and recommendation of methods to measure biogas production potential of animal manure

In developing countries, biogas energy production is seen as a technology that can provide clean energy in poor regions and reduce pollution caused by animal manure. Laboratories in these countries have little access to advanced gas measuring equipment, which may limit research aimed at improving local adapted biogas production. They may also be unable to produce valid estimates of an international standard that can be used for articles published in international peer-reviewed science journals. This study tested and validated methods for measuring total biogas and methane (CH₄) production using batch fermentation and for characterizing the biomass. The biochemical methane potential (BMP) (CH₄ NL kg⁻¹ VS) of pig manure, cow manure and cellulose determined with the Moller and VDI methods was not significantly different in this test (p>0.05). The biodegradability using a ratio of BMP and theoretical BMP (TBMP) was slightly higher using the Hansen method, but differences were not significant. Degradation rate assessed by methane formation rate showed wide variation within the batch method tested. The first-order kinetics constant k for the cumulative methane production curve was highest when two animal manures were fermented using the VDI 4630 method, indicating that this method was able to reach steady conditions in a shorter time, reducing fermentation duration. In precision tests, the repeatability of the relative standard deviation (RSDr) for all batch methods was very low (4.8 to 8.1%), while the reproducibility of the relative standard deviation (RSD_R) varied widely, from 7.3 to 19.8%. In determination of biomethane concentration, the values obtained using the liquid replacement method (LRM) were comparable to those obtained using gas chromatography (GC). This indicates that the LRM method could be used to determine biomethane concentration in biogas in laboratories with limited access to GC.

Deep phenotyping of the unselected COPSAC2010 birth cohort study

Background

We hypothesize that perinatal exposures, in particular the human microbiome and maternal nutrition during pregnancy, interact with the genetic predisposition to cause an abnormal immune modulation in early life towards a trajectory to chronic inflammatory diseases such as asthma and others.

Objective

The aim of this study is to explore these interactions by conducting a longitudinal study in an unselected cohort of pregnant women and their offspring with emphasis on deep clinical phenotyping, exposure assessment, and biobanking. Exposure assessments focus on the human microbiome. Nutritional intervention during pregnancy in randomized controlled trials are included in the study to prevent disease and to be able to establish causal relationships.

Methods

Pregnant women from eastern Denmark were invited during 2008–2010 to a novel unselected ‘COPSAC₂₀₁₀’ cohort. The women visited the clinic during pregnancy weeks 24 and 36. Their children were followed at the clinic with deep phenotyping and collection of biological samples at nine regular visits until the age of 3 and at acute symptoms. Randomized controlled trials of high‐dose vitamin D and fish oil supplements were conducted during pregnancy, and a trial of azithromycin for acute lung symptoms was conducted in the children with recurrent wheeze.

Results

Seven hundred and thirty‐eight mothers were recruited from week 24 of gestation, and 700 of their children were included in the birth cohort. The cohort has an over‐representation of atopic parents. The participant satisfaction was high and the adherence equally high with 685 children (98%) attending the 1 year clinic visit and 667 children (95%) attending the 2 year clinic visit.

Conclusions

The COPSAC₂₀₁₀ birth cohort study provides longitudinal clinical follow‐up with highly specific end‐points, exposure assessments, and biobanking. The cohort has a high adherence rate promising strong data to elucidate the interaction between genomics and the exposome in perinatal life leading to lifestyle‐related chronic inflammatory disorders such as asthma.

Proton pump inhibitor use may not prevent high-grade dysplasia and oesophageal adenocarcinoma in Barrett's oesophagus: a nationwide study of 9883 patients

BACKGROUND

Proton pump inhibitors (PPI) may potentially modify and decrease the risk for development of oesophageal adenocarcinoma in Barrett's oesophagus (BO).

AIM

To investigate if the intensity and adherence of PPI use among all patients with BO in Denmark affected the risk of oesophageal adenocarcinoma.

METHODS

We performed a nationwide case-control study in Denmark among 9883 patients with a new diagnosis of BO. All incident oesophageal adenocarcinomas and high-grade dysplasias were identified, and risk ratios were estimated on the basis of prior use of PPIs. Sex- and age-matched BO patients without dysplasia or malignancies in a 10:1 ratio were used for comparison. Conditional logistic regression was used for analysis, adjusting for low-grade dysplasia, gender and medication.

RESULTS

We identified 140 cases with incident oesophageal adenocarcinomas and/or high-grade dysplasia, with a median follow-up time of 10.2 years. The relative risk of oesophageal adenocarcinoma or high-grade dysplasia was 2.2 (0.7-6.7) and 3.4 (95% CI: 1.1-10.5) in long-term low- and high-adherence PPI users respectively.

CONCLUSIONS

No cancer-protective effects from PPI's were seen. In fact, high-adherence and long-term use of PPI were associated with a significantly increased risk of adenocarcinoma or high-grade dysplasia. This could partly be due to confounding by indication or a true negative effect from PPIs. Until the results from future studies hopefully can elucidate the association further, continuous PPI therapy should be directed at symptom control and additional modalities considered as aid or replacement.

Data mining the ScanBrit study of a gluten- and casein-free dietary intervention for children with autism spectrum disorders: behavioural and psychometric measures of dietary response

We previously reported results based on the examination of a gluten- and casein-free diet as an intervention for children diagnosed with an autism spectrum disorder as part of the ScanBrit collaboration. Analysis based on grouped results indicated several significant differences between dietary and non-dietary participants across various core and peripheral areas of functioning. Results also indicated some disparity in individual responses to dietary modification potentially indicative of responder and non-responder differences. Further examination of the behavioural and psychometric data garnered from participants was undertaken, with a view to determining potential factors pertinent to response to dietary intervention. Participants with clinically significant scores indicative of inattention and hyperactivity behaviours and who had a significant positive changes to said scores were defined as responders to the dietary intervention. Analyses indicated several factors to be potentially pertinent to a positive response to dietary intervention in terms of symptom presentation. Chronological age was found to be the strongest predictor of response, where those participants aged between 7 and 9 years seemed to derive most benefit from dietary intervention. Further analysis based on the criteria for original study inclusion on the presence of the urine compound, trans-indolyl-3-acryloylglycine may also merit further investigation. These preliminary observations on potential best responder characteristics to a gluten- and casein-free diet for children with autism require independent replication.

Antibiotic use during pregnancy alters the commensal vaginal microbiota

Antibiotics may induce alterations in the commensal microbiota of the birth canal in pregnant women. Therefore, we studied the effect of antibiotic administration during pregnancy on commensal vaginal bacterial colonization at gestational week 36. Six hundred and sixty-eight pregnant women from the novel unselected Copenhagen Prospective Studies on Asthma in Childhood (COPSAC2010 ) pregnancy cohort participated in this analysis. Detailed information on oral antibiotic prescriptions during pregnancy filled at the pharmacy was obtained and verified prospectively. Vaginal samples were obtained at pregnancy week 36 and cultured for bacteria. Women who received oral antibiotics during any pregnancy trimester had an increased rate of colonization by Staphylococcus species in the vaginal samples as compared with samples obtained from women without any antibiotic treatment during pregnancy (adjusted OR 1.63, 95% CI 1.06-2.52, p 0.028). Oral antibiotic administration in the third trimester were also associated with increased colonization by Staphylococcus species (adjusted OR 1.98, 95% CI 1.04-3.76, p 0.037). These bacteriological changes were associated with urinary tract infection antibiotics. Women treated in the third trimester of pregnancy were more often colonized by Escherichia coli than women without antibiotic treatment in the third trimester (adjusted OR 1.91, 95% CI 1.04-3.52, p 0.038). This change was associated with respiratory tract infection (RTI) antibiotics. We did not observe any significant changes in vaginal Streptococcus agalactiae (group B streptoccocus) or Staphylococcus aureus colonization following antibiotic treatment in pregnancy. Antibiotic administration during pregnancy leads to alterations in the vaginal microbiological ecology prior to birth, with potential morbidity, and long-term effects on the early microbial colonization of the neonate.

Methods to assess seasonal effects in epidemiological studies of infectious diseases--exemplified by application to the occurrence of meningococcal disease

Seasonal variation in occurrence is a common feature of many diseases, especially those of infectious origin. Studies of seasonal variation contribute to healthcare planning and to the understanding of the aetiology of infections. In this article, we provide an overview of statistical methods for the assessment and quantification of seasonality of infectious diseases, as exemplified by their application to meningococcal disease in Denmark in 1995-2011. Additionally, we discuss the conditions under which seasonality should be considered as a covariate in studies of infectious diseases. The methods considered range from the simplest comparison of disease occurrence between the extremes of summer and winter, through modelling of the intensity of seasonal patterns by use of a sine curve, to more advanced generalized linear models. All three classes of method have advantages and disadvantages. The choice among analytical approaches should ideally reflect the research question of interest. Simple methods are compelling, but may overlook important seasonal peaks that would have been identified if more advanced methods had been applied. For most studies, we suggest the use of methods that allow estimation of the magnitude and timing of seasonal peaks and valleys, ideally with a measure of the intensity of seasonality, such as the peak-to-low ratio. Seasonality may be a confounder in studies of infectious disease occurrence when it fulfils the three primary criteria for being a confounder, i.e. when both the disease occurrence and the exposure vary seasonally without seasonality being a step in the causal pathway. In these situations, confounding by seasonality should be controlled as for any confounder.

Urine and serum concentrations of inhaled and oral terbutaline

We examined urine and serum concentrations after therapeutic use of single and repetitive doses of inhaled and supratherapeutic oral use of terbutaline. We compared the concentrations in 10 asthmatics and 10 healthy subjects in an open-label, cross-over study with 2 mg inhaled and 10 mg oral terbutaline on 2 study days. Further, 10 healthy subjects were administrated 1 mg inhaled terbutaline in 4 repetive doses with total 4 mg. Blood samples were collected at baseline and during 6 h after the first inhalations. Urine samples were collected at baseline and during 12 h after the first inhalations. Median (IQR) urine concentrations peaked in the period 0-4 h after inhalation with Cmax 472 (324) ng/mL in asthmatics and 661 (517) ng/mL in healthy subjects, and 4-8 h after oral use with Cmax 666 (877) ng/mL in asthmatic and 402 (663) ng/mL in healthy subjects. In conclusion we found no significant differences in urine and serum concentrations between asthmatic and healthy subjects. We compared urine and serum concentrations after therapeutic inhaled doses and supratherapeutic oral doses and observed significant statistical differences in both groups but found it impossible to distinguish between therapeutic and prohibited use based on doping tests with urine and blood samples.

Urine concentrations of repetitive doses of inhaled salbutamol

We examined blood and urine concentrations of repetitive doses of inhaled salbutamol in relation to the existing cut-off value used in routine doping control. We compared the concentrations in asthmatics with regular use of beta2-agonists prior to study and healthy controls with no previous use of beta2-agonists. We enrolled 10 asthmatics and 10 controls in an open-label study in which subjects inhaled repetitive doses of 400 microgram salbutamol every second hour (total 1600 microgram), which is the permitted daily dose by the World Anti-Doping Agency (WADA). Blood samples were collected at baseline, 30 min, 1, 2, 3, 4, and 6 h after the first inhalations. Urine samples were collected at baseline, 0-4 h, 4-8 h, and 8-12 h after the first inhalations. Median urine concentrations peaked in the period 4-8 h after the first inhalations in the asthmatics and between 8-12 h in controls and the median ranged from 268 to 611 ng×mL (-1). No samples exceeded the WADA threshold value of 1000 ng×mL (-1) when corrected for the urine specific gravity. When not corrected one sample exceeded the cut-off value with urine concentration of 1082 ng×mL (-1). In conclusion we found no differences in blood and urine concentrations between asthmatic and healthy subjects. We found high variability in urine concentrations between subjects in both groups. The variability between subjects was still present after the samples were corrected for urine specific gravity.

Toward high-throughput drug screening on a chip-based parallel affinity separation platform

High-throughput screening of compound libraries, including the study of fragments, has become one of the cornerstones in modern drug discovery research. During this process hits are defined that may be developed into valuable leads and eventually into possible drug candidates. In this paper, we have demonstrated that parallel zonal weak affinity chromatography in microcolumns on a chip offers a possible screening format for weakly binding ligands toward a protein target. We used albumin as a model system because this transport protein is well established as a binder (both weak and strong) for drug substances. Bovine serum albumin was immobilized on microparticulate diolsilica particles and then packed into a 24-channel cartridge, which served as the separation platform. Analysis of the obtained chromatograms yielded information about affinity even in the millimolar range. Employing this approach, thousands of substances can be screened in just a day. We feel confident that zonal affinity chromatography will provide a useful technology in the future for performing high-throughput screening.

Rheumatoid arthritis and birth outcomes: a Danish and Swedish nationwide prevalence study

OBJECTIVES

To examine the prevalence of preterm birth, infants with low Apgar score, small for gestational age (SGA) birth, stillbirth and congenital abnormalities in women with rheumatoid arthritis (RA) compared with women without RA.

DESIGN

Prevalence study.

SETTING

Combined Sweden and Denmark nationwide from 1994 to 2006.

SUBJECTS

We included 871,579 women with a first-time singleton birth identified through population-based healthcare databases.

MAIN OUTCOME MEASURES

We compared the prevalence of preterm birth, low Apgar score (<7 at 5 min), SGA birth, stillbirth and congenital abnormalities amongst women with RA compared with women without RA using prevalence odds ratio (OR) with 95% confidence interval (95% CI), whilst controlling for maternal age, smoking, parental cohabitation and year. We stratified analyses by period of birth (1994-1997, 1998-2001 and 2002-2006).

RESULTS

Amongst 1199 women with RA, 7.8% gave birth between 32 and 36 gestational weeks (adjusted OR, 1.44; 95% CI, 1.14-1.82), 1.4% gave birth before gestational week 32 (adjusted OR, 1.55; 95% CI, 0.97-2.47), 1.6% had an infant with a low Apgar score (OR, 0.99; 95% CI, 0.95-1.65), 5.9% had an SGA birth (adjusted OR, 1.56; 95% CI, 1.2-2.01), 0.9% experienced stillbirth (adjusted OR, 2.07; 95% CI, 0.98-4.35) and 4.3% gave birth to an infant with congenital abnormalities (adjusted OR,1.32; 95% CI, 0.98-1.79). The OR for congenital abnormalities decreased from 2.57 (95% CI, 1.59-4.16) in 1994-1997 to 1.00 (95% CI, 0.64-1.56) in 2002-2006.

CONCLUSIONS

Women with RA had a high prevalence of most adverse birth outcomes. This could be due to inflammatory activity, medical treatment or other factors not controlled for.