Characteristics associated with non-initiation and non-completion of human papillomavirus vaccination among Danish girls: a nationwide register-based cohort study.

AIM: The aim was to identify maternal and paternal socioeconomic and demographic characteristics for non-initiation and non-completion of the human papillomavirus (HPV) vaccination among Danish girls including time-trends. METHODS: This nationwide register-based cohort study included all girls residing in Denmark who were offered free-of-charge HPV vaccination as a part of the childhood vaccination program between 2009 and 2018 (birth cohorts 1996-2005). The study samples included 296,461 daughter-mother dyads and 291,025 daughter-father dyads. Data from the Danish Vaccination Register were linked with socioeconomic and demographic data from Statistics Denmark. HPV vaccination status was classified as 'non-initiation' for girls who received no HPV vaccine and as 'non-completion' for girls who initiated the HPV vaccination program but did not receive all the scheduled HPV vaccines. Data were analyzed using logistic regression models. RESULTS: Non-initiation of HPV vaccination was 13.7%, and non-completion was 24.2% among girls who initiated the HPV vaccination program. Girls of parents who were descendants of immigrants (adjusted odds ratio: 1.50; 95% confidence interval: 1.35-1.68), were at least 35-years old at time of birth, had basic or no education, had a low income, were not in the labor market, and were unmarried had the highest non-initiation and non-completion odds. The associations between socioeconomic and demographic characteristics and HPV vaccination uptake were similar for mothers and fathers. CONCLUSIONS: Despite free-of-charge availability to HPV vaccination in Denmark, we found disparities in non-initiation and non-completion of HPV vaccination among Danish girls by both mothers' and fathers' socioeconomic and demographic characteristics.

Do school-based smoking preventive interventions have unintended effects? Post hoc analysis of the Focus cluster randomised controlled trial.

OBJECTIVES: Public health interventions are designed to improve specific health-related outcomes; however, they may also produce negative side effects, such as substitution use, psychological or social harms. Knowledge about the unintended effects of school-based smoking preventive interventions is sparse. Hence, this study examined these potential unintended effects of the smoking-reducing intervention, Focus, among students in the vocational education and training setting. DESIGN: Cluster randomised controlled trial stratified by school type with 5 months follow-up. SETTING AND PARTICIPANTS: Across Denmark, eight schools were randomised to the intervention group (n=844 students, response proportion 76%) and six schools to the control group (n=815 students, response proportion 75%). This study focused solely on students who smoked at baseline (N=491). INTERVENTIONS: The intervention was developed systematically based on theory and a thoroughly mixed-methods needs assessment. Intervention components included a comprehensive school tobacco policy (smoke-free school hours) supported by a 3-day course for school staff and launched by an edutainment session for students; class-based lessons and a quit-and-win competition; and individual telephone smoking cessation support. OUTCOMES: Alternative tobacco and nicotine products (regular use of smokeless tobacco, hookah and e-cigarettes), regular cannabis use, boredom and loneliness at school, stress and perceived stigmatisation among smokers. RESULTS: We found no statistically significant unintended effects of the intervention. Nonetheless, insignificant findings indicated that students in the intervention group were less likely to be bored during school hours (OR 0.59, 95% CI 0.32 to 1.10) and experience stress (OR 0.62, 95% CI 0.35 to 1.10), but more likely to report feeling stigmatised compared with the control group (OR 1.55, 95% CI 0.71 to 3.40). CONCLUSIONS: Overall, findings suggested no unintended effects of the Focus trial with respect to substitution use, psychological, nor group or social harms. Future research is encouraged to report potential harmful outcomes of smoking preventive interventions, and interventions should be aware of the possible stigmatisation of smokers. TRIAL REGISTRATION NUMBER: ISRCTN16455577.

Trends in smoking-related diseases by socioeconomic position following a national smoking ban in 2007: a nationwide study in the Danish population.

BACKGROUND: National comprehensive smoke-free legislation has been found to decrease the incidence of several smoking-related diseases. In 2007, Denmark introduced a national smoking ban, which banned smoking indoor in workplaces and public places, although only partial restrictions were applied in certain settings. We examined the impact of the smoking ban on smoking-related diseases and whether this differed across socioeconomic groups. METHODS: Interrupted time series analyses of nationwide register data were performed using Poisson regression models to examine the differential impact of the smoking ban on monthly incidence rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers from 2002 to 2015. Immediate changes in incidence rates after the smoking ban and long-term changes in disease trends were estimated by comparing data from the pre- and post-ban period. Models were stratified by socioeconomic position. RESULTS: Overall, we found neither immediate changes in rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers following the smoking ban nor long-term post-ban changes in disease trends as compared to before the ban. Results did not differ across socioeconomic groups. A pronounced socioeconomic gradient in incidence rates was observed for all outcomes both before and after the smoking ban. CONCLUSION: The national smoking ban was not associated with a lower incidence of smoking-related diseases in the post-ban period compared to pre-ban levels and no differences between socioeconomic groups were observed. Future tobacco control in Denmark should consider which measures most effectively target the low socioeconomic groups to decrease the current strong socioeconomic inequality in health.

The association between education and fear of recurrence among breast cancer patients in follow-up - and the mediating effect of self-efficacy.

BACKGROUND: Major restructuring of surveillance after breast cancer treatment with less follow-up consultations may result in insecurity and fear of recurrence (FCR) among the less resourceful breast cancer patients. We investigate the association between breast cancer patients' education and FCR and if self-efficacy mediates the associations between education and FCR. MATERIAL AND METHODS: A questionnaire survey was conducted from 2017 to 2019, among 1773 breast cancer patients shortly after having their follow-up switched from regular outpatient visits with an oncologist to either nurse-led or patient-initiated follow-up, with a subsequent questionnaire after 12 months. Data on disease and treatment characteristics were extracted from medical records and the Danish Breast Cancer Group Database. Logistic regression analyses were used to examine the association between education and FCR. Separate analyses were conducted for patients ≤ and >5 years since diagnosis and all models were adjusted for age and cohabitation status. To explore potential mediation by self-efficacy, we conducted regression analyses on education and FCR further adjusting for self-efficacy. RESULTS: The participation rate was 57%, and after the exclusion of patients due to missing data, 917 were included in analyses. Patients with long education had significantly less FCR compared to patients with short education (OR (95% CI) 0.71 (0.51;0,99)). When separated by time since diagnosis, there was no association among patients >5 years since diagnosis while the OR was 0.51 (95% CI, 0.30;0.85) for patients ≤5 years since diagnosis. Further adjusting for self-efficacy among patients <5 years since diagnosis resulted in an OR of 0.56 (95% CI, 0.33;0.95) among patients with long compared to short education. CONCLUSION: Up to 5 years after diagnosis, breast cancer patients with long education are less likely to experience FCR than patients with short education. Self-efficacy mediated only a very small part of this association, indicating that other factors play a role in socioeconomic differences in FCR among breast cancer patients.

Effectiveness of the multi-component intervention 'Focus' on reducing smoking among students in the vocational education setting: a cluster randomized controlled trial.

BACKGROUND: Social inequality in smoking remains an important public health issue. Upper secondary schools offering vocational education and training (VET) comprise more students from lower socioeconomic backgrounds and have higher smoking prevalence than general high schools. This study examined the effects of a school-based multi-component intervention on students' smoking. METHODS: A cluster randomized controlled trial. Eligible participants were schools offering VET basic courses or preparatory basic education in Denmark, and their students. Schools were stratified by subject area and eight schools were randomly allocated to intervention (1,160 invited students; 844 analyzed) and six schools to control (1,093 invited students; 815 analyzed). The intervention program comprised smoke-free school hours, class-based activities, and access to smoking cessation support. The control group was encouraged to continue with normal practice. Primary outcomes were daily cigarette consumption and daily smoking status at student level. Secondary outcomes were determinants expected to impact smoking behavior. Outcomes were assessed in students at five-month follow-up. Analyses were by intention-to-treat and per protocol (i.e., whether the intervention was delivered as intended), adjusted for covariates measured at baseline. Moreover, subgroup analyses defined by school type, gender, age, and smoking status at baseline were performed. Multilevel regression models were used to account for the cluster design. Missing data were imputed using multiple imputations. Participants and the research team were not blinded to allocation. RESULTS: Intention-to-treat analyses showed no intervention effect on daily cigarette consumption and daily smoking. Pre-planned subgroup analyses showed statistically significant reduction in daily smoking among girls compared with their counterparts in the control group (OR = 0.39, 95% CI: 0.16, 0.98). Per-protocol analysis suggested that schools with full intervention had higher benefits compared with the control group (daily smoking: OR = 0.44, 95% CI: 0.19, 1.02), while no marked differences were seen among schools with partial intervention. CONCLUSION: This study was among the first to test whether a complex, multicomponent intervention could reduce smoking in schools with high smoking risk. Results showed no overall effects. There is a great need to develop programs for this target group and it is important that they are fully implemented if an effect is to be achieved. TRIAL REGISTRATION: https://www.isrctn.com/ISRCTN16455577 , date of registration 14/06/2018.

Long-term exposure to air pollution and mortality in a Danish nationwide administrative cohort study: Beyond mortality from cardiopulmonary disease and lung cancer.

BACKGROUND: The association between long-term exposure to air pollution and mortality from cardiorespiratory diseases is well established, yet the evidence for other diseases remains limited. OBJECTIVES: To examine the associations of long-term exposure to air pollution with mortality from diabetes, dementia, psychiatric disorders, chronic kidney disease (CKD), asthma, acute lower respiratory infection (ALRI), as well as mortality from all-natural and cardiorespiratory causes in the Danish nationwide administrative cohort. METHODS: We followed all residents aged ≥ 30 years (3,083,227) in Denmark from 1 January 2000 until 31 December 2017. Annual mean concentrations of fine particulate matter (PM2.5), nitrogen dioxide (NO2), black carbon (BC), and ozone (warm season) were estimated using European-wide hybrid land-use regression models (100 m × 100 m) and assigned to baseline residential addresses. We used Cox proportional hazard models to evaluate the association between air pollution and mortality, accounting for demographic and socioeconomic factors. We additionally applied indirect adjustment for smoking and body mass index (BMI). RESULTS: During 47,023,454 person-years of follow-up, 803,881 people died from natural causes. Long-term exposure to PM2.5 (mean: 12.4 µg/m3), NO2 (20.3 µg/m3), and/or BC (1.0 × 10-5/m) was statistically significantly associated with all studied mortality outcomes except CKD. A 5 µg/m3 increase in PM2.5 was associated with higher mortality from all-natural causes (hazard ratio 1.11; 95% confidence interval 1.09-1.13), cardiovascular disease (1.09; 1.07-1.12), respiratory disease (1.11; 1.07-1.15), lung cancer (1.19; 1.15-1.24), diabetes (1.10; 1.04-1.16), dementia (1.05; 1.00-1.10), psychiatric disorders (1.38; 1.27-1.50), asthma (1.13; 0.94-1.36), and ALRI (1.14; 1.09-1.20). Associations with long-term exposure to ozone (mean: 80.2 µg/m3) were generally negative but became significantly positive for several endpoints in two-pollutant models. Generally, associations were attenuated but remained significant after indirect adjustment for smoking and BMI. CONCLUSION: Long-term exposure to PM2.5, NO2, and/or BC in Denmark were associated with mortality beyond cardiorespiratory diseases, including diabetes, dementia, psychiatric disorders, asthma, and ALRI.

Perioperative fluid administration and complications in emergency gastrointestinal surgery-an observational study.

BACKGROUND: The fluid balance associated with a better outcome following emergency surgery is unknown. The aim of this study was to explore the association of the perioperative fluid balance and postoperative complications during emergency gastrointestinal surgery. METHODS: We retrospectively included patients undergoing emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 2.5 L divided the cohort in a conservative and liberal group. Outcome was Clavien-Dindo graded complications registered 90 days postoperatively. We used logistic regression adjusted for age, sex, American Society of Anesthesiologists' classification, use of epidural analgesia, use of vasopressor, type of surgery, intraabdominal pathology, and hospital. Predicted risk of complications was demonstrated on a continuous scale of the fluid balance. RESULTS: We included 342 patients operated between July 2014 and July 2015 from three centers. The perioperative fluid balance was 1.6 L IQR [1.0 to 2.0] in the conservative vs. 3.6 L IQR [3.0 to 5.3] in the liberal group. Odds ratio of overall 2.6 (95% CI 1.5 to 4.4), p < 0.001, and cardiopulmonary complications 3.2 (95% CI 1.9 to 5.7), p < 0.001, were increased in the liberal group. A perioperative fluid balance of 0-2 L was associated with minimal risk of cardiopulmonary complications compared to 1.5-3.5 L for renal complications. CONCLUSION: We found a perioperative fluid balance above 2.5 L to be associated with an increased risk of overall and cardiopulmonary complications following emergency surgery for gastrointestinal obstruction or perforation. A perioperative fluid balance of 0-2 L was associated with the lowest risk of cardiopulmonary complications and 1.5-3.5 L for renal complications.

Cardiovascular Rehabilitation Increases Walking Distance in Patients With Intermittent Claudication. Results of the CIPIC Rehab Study: A Randomised Controlled Trial.

OBJECTIVE: To examine whether a cardiac rehabilitation programme in a community based setting for patients with intermittent claudication (IC) affects walking ability, quality of life, and changes in health behaviour. The trial investigated a cross sector cardiovascular rehabilitation programme compared with usual care for patients having non-operative management. METHODS: The trial allocated 118 patients, with 1:1 individual randomisation to either an intervention or control group. Data were collected at a department of vascular surgery and at a healthcare centre in Denmark. The rehabilitation intervention consisted of usual care plus 12 weeks of exercise training, pedometer, health education, and text messages. The primary outcome was maximum walking distance at six months measured by treadmill walking test. The secondary outcomes were maximum walking distance at 12 months and pain free walking distance measured by treadmill walking test, healthy diet, level of physical activity, and quality of life (QoL) at six and 12 months. RESULTS: In the intervention group, 46 participants were analysed, with 47 in the control group. Following three months of rehabilitation, a 37% difference (95% CI 1.10 - 1.70; p = .005) was found between groups in maximum walking distance at six and 12 months, in favour of the intervention group. The same positive effect was found in physical activity, QoL, and healthy diet, but was not statistically significant in pain free walking distance and smoking. CONCLUSION: A specialised community based cardiac rehabilitation programme for patients with IC showed statistically and clinically significant effects on maximum walking distance, physical activity, quality of life, and healthy diet, but not on pain free walking distance and smoking, compared with usual care without rehabilitation.

Size and composition of family networks of decedents: A nationwide register-based study.

BACKGROUND: Seriously ill individuals rely heavily on family caregivers at the end of life. Yet many do not have family support. AIM: To characterize the size and composition of decedents' family networks by cause of death, demographic, clinical, socioeconomic, and geographic characteristics. DESIGN: A cross-sectional population-level study with data collected from nation-wide registers. SETTING/PARTICIPANTS: All adults in Denmark born between 1935 and 1998 who died of natural causes between 2009 and 2016 were linked at the time of death to living adult spouses/partners, children, siblings, parents, and grandchildren. RESULTS: Among 175,755 decedents (median age: 68 years, range: 18-81 years), 61% had a partner at the time of death and 78% had at least one adult child. Ten percent of decedents had no identified living adult family members. Decedents with family had a median of five relatives. Males were more likely to have a spouse/partner (65%) than females (56%). While 93% of decedents dying of cancer had adult family, only 70% of individuals dying of dementia had adult family at the time of death. The majority of cancer decedents co-resided or lived within 30 km of family (88%), compared to only 65% of those dying from psychiatric illness. CONCLUSIONS: While the majority of adults had an extensive family network at the time of death, a substantial proportion of decedents had no family, suggesting the need for non-family based long-term service and support systems. Assessment of family networks can expand our understanding of the end-of-life caregiving process and inform palliative care delivery.

Supplementing prediction by EuroSCORE with social and patient-reported measures among patients undergoing cardiac surgery.

OBJECTIVES: The risk of poor outcomes is traditionally attributed to biological and physiological processes in cardiac surgery. However, evidence exists that other factors, such as emotional, behavioral, social, and functional, are predictive of poor outcomes. Objectives were to evaluate the predictive value of several emotional, social, functional, and behavioral factors on four outcomes: death within 90 days, prolonged stay in intensive care, prolonged hospital admission, and readmission within 90 days following cardiac surgery. METHODS: This prospective study included adults undergoing cardiac surgery 2013-2014, including information on register-based socioeconomic factors and self-reported health in a nested subsample. Logistic regression analyses to determine the association and incremental value of each candidate predictor variable were conducted. Multiple regression analyses were used to determine the incremental value of each candidate predictor variable, as well as discrimination and calibration based on the area under the curve (AUC) and Brier score. RESULTS: Of 3217 patients, 3% died, 9% had prolonged intensive care stay, 51% had prolonged hospital admission, and 39% were readmitted to hospital. Patients living alone (odds ratio, 1.19; 95% confidence interval, 1.02-1.38), with lower educational levels (1.27; 1.04-1.54) and low health-related quality of life (1.43; 1.02-2.01) had prolonged hospital admission. Analyses revealed living alone as predictive of prolonged intensive care unit (ICU) stay (Brier, 0.08; AUC, 0.68), death (0.03; 0.71), and prolonged hospital admission (0.24; 0.62). CONCLUSION: Living alone was found to supplement EuroSCORE in predicting death, prolonged hospital admission, and prolonged ICU stay following cardiac surgery. Low educational level and impaired health-related quality of life were, furthermore, predictive of prolonged hospital admission.

Emergency Laparotomy in Denmark: A Nationwide Descriptive Study.

BACKGROUND: The term 'emergency open abdominal surgery' covers a range of common procedures with high complication and mortality risks; however, previous studies have not included descriptive analyses of the patients undergoing the procedures. The aim of this study is to present a nationwide description of all patients who undergo an emergency bowel resection, ostomy placement or drainage involving laparotomy at Danish hospitals and to report the 30- and 365-day mortality risks. METHOD: We identified all of the patients in the Danish National Patient Register aged 18 + who underwent emergency open abdominal surgery in the form of a laparotomy during the period 2003-14. Using Poisson and logistic regression models, we analyzed incidence rates and mortality risk. RESULT: The sample consisted of 15,680 patients, with an overall open abdominal surgery incidence rate of 30.4 cases per 100,000 person-years. The 30-day mortality risk was 19.3% for both sexes, and increased with age (at 80-89, mortality risk was 39.4% for males and 34.5% for females). The 30-day mortality risk fell by 5.4% during the study period, from 22.2% to 16.7%. CONCLUSION: Open abdominal surgery is a common, high-risk procedure with a high incidence rate and mortality risk, especially for elderly patients. The incidence rate and mortality risk fell during the period studied. In Denmark, there is no standard post-discharge care program for patients who undergo emergency laparotomies. Our results support the need to investigate standardized post-operative follow-up and rehabilitation plans to reduce mortality.

Descriptive study of all Danish patients undergoing emergency exploratory laparotomies in the period 2003-2014.

Aim: Emergency exploratory laparotomy is a high-risk procedure, but most studies are based on small sample sizes, and no nationwide studies have reported the number of patients and the mortality risk. This descriptive study reports the prevalence, incidence and 30- and 365-day mortality of all patients undergoing emergency exploratory laparotomies in Denmark from 2003 to 2014. Methods: The study population is based on the Danish National Patient Register, which includes all patient contacts with Danish hospitals, including patients undergoing emergency surgery. All patients were followed in registers on mortality. Rates and proportions were estimated using Poisson and logistic regression models. Results: The number of prevalent patients was 15,330 through the period (2003-2014) of whom 13,795 were incident patients. Prevalence increased with age and peaked at 1% for the 80- to 84-year-old age group. The overall incidence was 27 per 100,000 person-years, which strongly increased with age (87 per 100,000 person-years among men and 85 per 100,000 person-years among women). The 30-day mortality was 16.5% and the 365-day mortality was 23.1%. Both increased strongly with age and did not improve over the study period. Both 30- and 365-day mortality were higher among unmarried patients compared to married patients. Conclusions: Emergency exploratory laparotomies are common high-risk procedures especially for the elderly population. These results can be used to focus on better postoperative care to reduce the mortality.

The challenge of non-adherence to early rehabilitation after coronary artery bypass surgery: Secondary results from the SheppHeartCABG trial.

BACKGROUND: Attending and maintaining a cardiac rehabilitation programme is a challenge. AIMS: The purpose of this study was to explore associations between non-adherence to early coronary artery bypass graft rehabilitation and sociodemographic and clinical baseline data. METHODS: Coronary artery bypass graft patients were randomised 1:1 to either four weeks of comprehensive early rehabilitation or usual care. Outcomes were assessed at three time-points points: baseline, discharge and four weeks post-coronary artery bypass graft. Differences in sociodemographic and clinical baseline data in adherent versus non-adherent patients were tested using the Pearson χ2 test for categorical variables. To test associations between non-adherence to exercise training and sociodemographic and clinical baseline data, multivariate logistic regression was used to estimate the odds ratio for in-hospital training and post-discharge training adjusted for age, sex and left ventricular ejection fraction. RESULTS: Non-adherence to in-hospital versus post-discharge exercise training was 31% (n=48) versus 53% (n=81). Female non-adherence was 20% versus 70%. Non-adherence to in-hospital versus post-discharge mindfulness was 87% versus 70%. Male non-adherence to mindfulness was 85% versus 70%. Non-adherence to psycho-educational consultations was 3%, most of whom were men. Patients with university level education were more adherent to in-hospital exercise training than patients with lower educational level (odds ratio=3.14 (95% confidence interval; 1.16-8.51), p=0.02). Diabetic patients were more non-adherent to exercise training after discharge (3.74 (1.54-9.08), p=0.004) as were overweight patients (0.37 (0.17-0.80), p=0.01). CONCLUSIONS: This study demonstrated wide acceptance of psycho-educational consultations in post-coronary artery bypass graft patients. Adherence to physical rehabilitation was low especially after discharge from hospital and the opportunity to attend a mindfulness programme was not used.

Finasteride Use and Risk of Male Breast Cancer: A Case-Control Study Using Individual-Level Registry Data from Denmark, Finland, and Sweden.

BACKGROUND: In case reports, concerns have been raised as to whether finasteride use increases the risk of male breast cancer. Previous epidemiologic evidence on the potential link is conflicting. This study aimed to assess whether an association between finasteride use and male breast cancer exists after accounting for potential confounders. METHODS: The source population consisted of all men (≥35 years) from Denmark (1995-2014), Finland (1997-2013), and Sweden (2005-2014). Cases with incident male breast cancer were identified in the cancer registries and matched with 50 density-sampled, age, and country-matched male population controls per case. Exposure information on finasteride use was derived from the prescription registries. Potential confounders were identified using the directed acyclic graph methodology and measured by use of information from nation-wide registries. RESULTS: The study population comprised 1,005 male breast cancer cases and 43,058 controls. Confounder-adjusted odds of finasteride exposure were not statistically significantly increased [OR, 1.09; 95% confidence interval (CI), 0.77-1.54] in breast cancer cases relative to controls. There was no evidence of a dose-response relationship, as the group with greatest exposure to finasteride was associated with lowest OR of male breast cancer [OR, 0.72 (95% CI, 0.40-1.30)]. Sensitivity analyses did not reveal marked changes in results with different exposure definitions or for specific subgroups. CONCLUSIONS: Results from this study provided no evidence that finasteride use was associated with male breast cancer. IMPACT: This large confounder-adjusted study supports the view that exposure to finasteride is not associated materially with male breast cancer risk.

Short- and long-term mortality in major non-cardiac surgical patients admitted to the intensive care unit.

BACKGROUND: The aim of this register-based cohort study was to characterize patients admitted to the intensive care unit (ICU) following non-cardiac surgery and identify risk factors associated with 30-days, 90-days and 1-year mortality after ICU admission. METHODS: Patients aged 18+ years admitted to the intensive care unit within 30-days of non-cardiac surgery at four Capital Region hospitals in Denmark between January 2005 and December 2014 were included. Patients were identified through the Danish National Patient Register. The outcomes were 30-days, 90-days and 1-year mortality after ICU admission. Unadjusted and multivariate logistic regression analyses were performed to identify independent risk factors of mortality. RESULTS: The study included 3311 ICU patients. Gastrointestinal surgery accounted for 71.3%, orthopaedic surgery for 18.4% and urologic surgery for 10.2% of the population. For the total population, the median length of stay in hospital was 18 days (9-36, 25th-75th percentile) and 2 days (1-4, 25th-75th percentile) in the ICU. Thirty-days, 90-days and 1-year mortality were 37.8%, 44.5% and 51.2% respectively. Mortality within the ICU was 22.3% while the post-ICU in-hospital mortality was 19.4%. Higher age, comorbidity, delayed ICU admission, acute surgery, and gastrointestinal and orthopaedic surgery increased 30-days, 90-days and 1-year mortality. CONCLUSIONS: Short- and long-term mortality in non-cardiac surgical patients admitted to the ICU is very high, especially among the elderly comorbid patients undergoing acute surgery. Future research should focus on targeting clinically modifiable risk factors and performing tailored treatment for these high-risk patients.

Measuring HRQoL following heart valve surgery: the HeartQoL questionnaire is a valid and reliable core heart disease instrument.

PURPOSE: Patient-reported health-related quality of life is a complementary healthcare outcome and important when assessing treatment efficacy. Using COSMIN methodological recommendations, this study evaluates the validity and reliability of a core heart disease-specific health-related quality of life questionnaire, the HeartQoL questionnaire (Danish version) in a sample of patients following heart valve surgery. DESIGN: This project involved a cross-sectional validity study and a test-retest reliability study. METHODS: Eligible patients completed the HeartQoL, the SF-36 health survey questionnaire, and the Hospital Anxiety and Depression Scale following heart valve surgery. Construct validity was tested using a priori hypotheses. Internal consistency reliability was assessed with Cronbach's alpha. An independent sample of patients participated in the test-retest study and reproducibility was determined with relative [intra-class correlation coefficient (ICC)] and absolute reliability [standard error of measurement (SEM) and smallest detectable change (SDC)]. RESULTS: Internal consistency was high with Cronbach's alpha ≥ 0.87. ICC was 0.86-0.92. SEM ranged from 0.17 to 0.26 points and SDC ranged from 0.5 to 0.7 points. Construct validity was confirmed with 87% of all a priori hypotheses for predicted variables. CONCLUSIONS: The HeartQoL questionnaire demonstrates acceptable construct validity, internal consistency, and test-retest reproducibility in patients following heart valve surgery. Future studies should focus on assessing the responsiveness of the HeartQoL questionnaire over time and following heart valve surgery.

Evaluation of the smoking intervention X:IT after the second year: A randomized controlled trial.

Aims:Review studies on the long-term effects of school-based smoking interventions show mixed results. X:IT was a three-year cluster randomized controlled trial to prevent uptake of smoking among Danish students from age 13 years until age 15 years which previously proved effective in preventing smoking after the first year of intervention. The aim of this paper was to conduct the pre-planned analyses of the effects of the X:IT intervention on smoking after the second year. Methods: We used self-reported questionnaire data from students at baseline, first, second, and third follow-up (n at second follow-up=3269, response rate=79.4%). Data from third follow-up were not suitable for analysis. Outcome measure: 'current smoking', dichotomised into smoke daily, weekly, monthly or more seldom versus do not smoke. We performed multilevel, logistic regression analyses of available cases and intention-to-treat (ITT) analyses, replacing missing outcome values by multiple imputation. Results: The prevalence of smoking increased from 5.8% at baseline to 17.0% at second follow-up among students at intervention schools, and from 7.6% to 18.7% among students at control schools. Analyses of available cases and ITT analyses did not support X:IT being effective in preventing smoking after the second year of intervention. Conclusions: Although X:IT was effective after the first year of intervention, we were not able to demonstrate any effects after the second year. Implementation of the intervention was lower in the second year compared to the first year which indicates that the missing effect of the intervention at second follow-up is due to lack of implementation.

Long-Term Outcomes of Robot-Assisted Surgery in Patients with Colorectal Cancer.

BACKGROUND: Robotic technology has been proven to be a safe alternative to conventional laparoscopy with regards to the peri- and postoperative clinical outcomes. Oncological outcomes have been scarcely examined. The purpose of this study was to examine the disease-free survival in relation to the two surgical approaches: robot-assisted surgery and conventional laparoscopy. In addition, all-cause mortality and recurrence-free survival were investigated. METHODS: Between January 2010 and December 2015, patients, undergoing either laparoscopic or robot-assisted elective, curative-intended surgery for colorectal cancer were included. RESULTS: A total of 9184 patients underwent surgery in the study period: 5978 patients for colon cancer and 3206 patients for rectal cancer. Among patients with colon cancer, 331 patients (5.5%) underwent robot-assisted surgery, and 449 patients (14.0%) underwent robot-assisted surgery in the rectal cancer group. In the adjusted analyses, the hazard ratio (HR) for disease-free survival, for patients with colon cancer was 0.91 [95% confidence interval (CI) 0.71-1.18]. For patients with rectal cancer, the adjusted HR was 0.83 (95% CI 0.65-1.06). No difference in all-cause mortality and recurrence-free survival were observed. CONCLUSIONS: The study demonstrated comparable rates of disease-free survival, all-cause mortality, and recurrence-free survival when comparing robot-assisted surgery with conventional laparoscopy in patients with colorectal cancer.

Time to expand risk evaluation systems for cardiac surgery? Looking beyond physiological parameters.

Risk assessment in cardiac surgery traditionally consists of medical and physiological parameters. However, non-physiological factors have also been found to be predictive of poor outcomes following cardiac surgery. Therefore, the isolated focus on physiological parameters is questionable. This paper describes the emotional, behavioural, social and functional factors that have been established to play a role in outcomes following cardiac surgery. This forms a basis for future research, testing the value of these factors above and beyond the physiological parameters. By including such non-physiological factors, the accuracy of the existing risk scoring systems could potentially be improved.

Vascular invasion and survival after liver transplantation for hepatocellular carcinoma: a study from the European Liver Transplant Registry.

BACKGROUND: Studies suggest that vascular invasion may be a superior prognostic marker compared with traditional selection criteria, e.g. Milan criteria. This study aimed to investigate the prognostic value of micro and macrovascular invasion in a large database material. METHODS: Patients liver transplanted for HCC and cirrhosis registered in the European Liver Transplant Registry (ELTR) database were included. The association between the Milan criteria, Up-to-seven criteria and vascular invasion with overall survival and HCC specific survival was investigated with univariate and multivariate Cox regression analyses. RESULTS: Of 23,124 patients transplanted for HCC, 9324 had cirrhosis and data on explant pathology. Patients without microvascular invasion, regardless of number and size of HCC nodules, had a five-year overall survival of 73.2%, which was comparable with patients inside both Milan and Up-to-seven criteria. Patients without macrovascular invasion had an only marginally reduced survival of 70.7% after five years. Patients outside both Milan and Up-to-seven criteria without micro or macrovascular invasion still had a five-year overall survival of 65.8%. CONCLUSION: Vascular invasion as a prognostic indicator remains superior to criteria based on size and number of nodules. With continuously improving imaging studies, microvascular invasion may be used for selecting patients for transplantation in the future.