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

OBJECTIVES: Perceived pain is a multi-factorial subjective variable, commonly measured by numeric rating scales, verbal descriptive scales (VDS), or by a position on an analogue line (VAS). A major question is whether an individual's VAS and VDS pain assessments, on the same occasion, could be comparable. The aim was to compare continuous and discretized VAS pain data with verbal descriptive pain datasets from the Oswestry Disability Index (ODI) and the European Quality of Life Scale (EQ-5D) in paired pain datasets. METHODS: The measurement level of data from any type of scale assessments is ordinal, having rank-invariant properties only. Non-parametric statistical methods were used. Two ways of discretizing the VAS-line to VAS-intervals to fit the number of the comparing VDS-categories were used: the commonly used (equidistant VAS,VDS)-pairs and the (unbiased VAS,VDS)-pairs of pain data. The comparability of the (VAS,VDS)-pairs of data of perceived pain was studied by the bivariate ranking approach. Hence, each pair will be regarded as ordered, disordered, or tied with respect to the other pairs of data. The percentage agreement, PA, the measures of disorder, D, and of order consistency, MA, were calculated. Total interchangeability requires PA = 1 and MA = 1. RESULTS: The wide range of overlapping of (VAS,VDS)-pairs indicated that the continuous VAS data were not comparable to any of the VDS pain datasets. The percentage of agreement, PA; in the (equidistant VAS,ODI) and (equidistant VAS, EQ-5D) pairs were 38 and 49%, and the order consistency, MA, was 0.70 and 0.80, respectively. Corresponding results for the (unbiased VAS,VDS)-pairs of pain data were PA: 54 and 100%, and MA: 0.77 and 1.0. CONCLUSION: Our results confirmed that perceived pain is the individual's subjective experience, and possible scale-interchangeability is only study-specific. The pain experience is not possible to be measured univocally, but is possible for the individual to rate on a scale.

Conversion of the MDHAQ to the HAQ score: a simple algorithm developed and validated in a cohort of 13 391 real-world patients.

OBJECTIVES: To develop and validate in real-world patients a conversion algorithm from the Multidimensionel Health Assessment Questionnaire physical function scale (MDHAQ) to the Stanford Health Assessment Questionnaire disability index physical function scale (HAQ) score. METHODS: From the DANBIO registry, 13 391 patients with RA (n = 8983), PsA (n = 2649) and axial spondyloarthritis (axSpA, n = 1759) with longitudinal data on HAQ and MDHAQ were included, stratified by diagnosis, and randomized 1:1 into development and validation cohorts. Conversion algorithms were developed by linear regression and applied in validation cohorts. From MDHAQ, the HAQ was calculated (cHAQ) and validated against the observed HAQ for criterion, correlational and construct validity. RESULTS: For RA, we developed the conversion algorithm cHAQ = 0.15+MDHAQ*1.08, and validated it in the RA validation cohort. Criterion validity: HAQ and cHAQ had comparable discriminative power to distinguish between high and low patient global scores (standardized mean difference: HAQ:-1.29, cHAQ:-1.35). Kappa value between HAQ and cHAQ functional states indicated good agreement (0.83). Correlational validity: baseline HAQ and cHAQ, respectively, correlated well with patient global scores (r = 0.65/0.67). Bland-Altman plots showed good agreement across all functional states. Construct validity: HAQ and cHAQ discriminated equally well between patients reporting symptom state as acceptable vs not, and across responses to an external anchor. Aiming for a common algorithm, the RA conversion algorithm was validated for PsA and axSpA with similar results. CONCLUSION: This study suggests that in observational datasets with only the MDHAQ available, a simple algorithm allows valid conversion to HAQ on the group level in RA, PsA and axSpA.

Roux-en-Y gastric bypass versus sleeve gastrectomy: nationwide data from the Danish quality registry for treatment of severe obesity.

BACKGROUND: Bariatric surgery as treatment of obesity is increasing worldwide. No guidelines exist on which type of bariatric procedure to choose for the individual patient. OBJECTIVES: This study aims to compare Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) with respect to weight loss, complications, comorbidities, and quality of life. SETTING: A nationwide multi-center register-based cohort study. METHODS: We identified 16,053 patients treated by bariatric surgery from 2008 to 2021 (RYGB, n = 13,075; SG, n = 2978) from the Danish quality registry for treatment of severe obesity (DBSO). We calculated risk ratios (RRs) and prevalence ratios (PRs) comparing surgical complications, weight loss, and medical comorbidities by type of procedure up to 2 years after surgery. RESULTS: Patients treated with RYGB experienced a greater weight loss than patients treated by SG both after 1 year (PR, .53; 95% confidence interval [CI], .48-.58) and 2 years (PR, .46; 95% CI, .39-.54). Compared with RYGB, SG yielded a lower risk of readmission (RR, .71; 95% CI, .60-.85). Likewise, the risk of reoperation between 30 days and 1 year (RR, .40; 95% CI, .30-.53) and 1 and 5 years (RR, .15; 95% CI, .12-.20]) were lower following SG. At 1-year follow-up, 76% of patients treated with RYGB and 63% of patients treated with SG experienced diabetes remission. Ten percent and 61% of patients were lost to follow-up after 1 and 2 years, respectively. CONCLUSION: The DBSO is an important resource in studying treatment of severe obesity. Weight loss is slightly greater after RYGB than after SG, but RYGB is associated with more frequent readmissions and reoperations.

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

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

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

Importance: Influenza has been associated with the risk of developing Parkinson disease, but the association is controversial. Objective: To examine whether prior influenza and other infections are associated with Parkinson disease more than 10 years after infection. Design, Setting, and Participants: This case-control study used data from 1977 to 2016 from the Danish National Patient Registry. All individuals with Parkinson disease, excluding those with drug-induced parkinsonism, were included and matched to 5 population controls on sex, age, and date of Parkinson diagnosis. Data were analyzed from December 2019 to September 2021. Exposures: Infections were ascertained between 1977 and 2016 and categorized by time from infection to Parkinson disease diagnosis. To increase specificity of influenza diagnoses, influenza exposure was restricted to months of peak influenza activity. Main Outcomes and Measures: Parkinson disease diagnoses were identified between January 1, 2000, and December 31, 2016. Crude and adjusted odds ratios (ORs) and 95% CIs were calculated by conditional logistic regression overall and stratified by time between infection and Parkinson disease (5 years or less, more than 5 to 10 years, more than 10 years). Results: Of 61 626 included individuals, 23 826 (38.7%) were female, and 53 202 (86.3%) were older than 60 years. A total of 10 271 individuals with Parkinson disease and 51 355 controls were identified. Influenza diagnosed at any time during a calendar year was associated with Parkinson disease more than 10 years later (OR, 1.73; 95% CI, 1.11-2.71). When influenza exposure was restricted to months of highest influenza activity, an elevated OR with a wider confidence interval was found (OR, 1.52; 95% CI, 0.80-2.89). There was no evidence of an association with any type of infection more than 10 years prior to Parkinson disease (OR, 1.04; 95% CI, 0.98-1.10). Several specific infections yielded increased odds of Parkinson disease within 5 years of infection, but results were null when exposure occurred more than 10 years prior. Conclusions and Relevance: In this case-control study, influenza was associated with diagnoses of Parkinson disease more than 10 years after infection. These observational data suggest a link between influenza and Parkinson disease but do not demonstrate causality. While other infections were associated with Parkinson disease diagnoses soon after infection, null associations after more than 10 years suggest these shorter-term associations are not causal.

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

BACKGROUND: There are sparse real-world data on severe asthma exacerbations (SAE) in children. This multinational cohort study assessed the incidence of and risk factors for SAE and the incidence of asthma-related rehospitalization in children with asthma. METHODS: Asthma patients 5-17 years old with ≥1 year of follow-up were identified in six European electronic databases from the Netherlands, Italy, the UK, Denmark and Spain in 2008-2013. Asthma was defined as ≥1 asthma-specific disease code within 3 months of prescriptions/dispensing of asthma medication. Severe asthma was defined as high-dosed inhaled corticosteroids plus a second controller. SAE was defined by systemic corticosteroids, emergency department visit and/or hospitalization all for reason of asthma. Risk factors for SAE were estimated by Poisson regression analyses. RESULTS: The cohort consisted of 212 060 paediatric asthma patients contributing to 678 625 patient-years (PY). SAE rates ranged between 17 and 198/1000 PY and were higher in severe asthma and highest in severe asthma patients with a history of exacerbations. Prior SAE (incidence rate ratio 3-45) and younger age increased the SAE risk in all countries, whereas obesity, atopy and GERD were a risk factor in some but not all countries. Rehospitalization rates were up to 79% within 1 year. CONCLUSIONS: In a real-world setting, SAE rates were highest in children with severe asthma with a history of exacerbations. Many severe asthma patients were rehospitalized within 1 year. Asthma management focusing on prevention of SAE is important to reduce the burden of asthma.

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

BACKGROUND: Data on the risk of death following an asthma exacerbation are scarce. With this multinational cohort study, we assessed all-cause mortality rates, mortality rates following an exacerbation, and patient characteristics associated with all-cause mortality in asthma. METHODS: Asthma patients aged ≥18 years and with ≥1 year of follow-up were identified in 5 European electronic databases from the Netherlands, Italy, UK, Denmark and Spain during the study period January 1, 2008-December 31, 2013. Patients with asthma-COPD overlap were excluded. Severe asthma was defined as use of high dose ICS + use of a second controller. Severe asthma exacerbations were defined as emergency department visits, hospitalizations or systemic corticosteroid use, all for reason of asthma. RESULTS: The cohort consisted of 586,436 asthma patients of which 42,611 patients (7.3%) had severe asthma. The age and sex standardized all-cause mortality rates ranged between databases from 5.2 to 9.5/1000 person-years (PY) in asthma, and between 11.3 and 14.8/1000 PY in severe asthma. The all-cause mortality rate in the first week following a severe asthma exacerbation ranged between 14.1 and 59.9/1000 PY. Mortality rates remained high in the first month following a severe asthma exacerbation and decreased thereafter. Higher age, male gender, comorbidity, smoking, and previous severe asthma exacerbations were associated with mortality. CONCLUSION: All-cause mortality following a severe exacerbation is high, especially in the first month following the event. Smoking cessation, comorbidity-management and asthma-treatment focusing on the prevention of exacerbations might reduce associated mortality.

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

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

Validation study of the population included in the Danish Schizophrenia Registry.

INTRODUCTION: We aimed to assess the validity of the schizophrenia diagnoses registered in the Danish Schizophrenia Registry (DSR) by comparing with information from medical records. METHODS: The study included a random sample of 390 subjects from the DSR who were representative of each geographic region of Denmark. For each subject in the sample, a medical record review was performed by local psychiatrists to confirm or disconfirm the schizophrenia diagnosis and to give a qualified estimate of the date of diagnosis. Only register data and medical record information were used, and thus the individuals in the sample were not approached. We calculated the positive predictive value, comparing registrations in the DSR with the original medical records as a reference. RESULTS: A total of 325 out of 390 (83%) medical records were reviewed. The positive predictive value was 91% (95% confidence interval (CI): 88-94%), varying between geographic regions from 85% to 100%. The classification of incident versus prevalent disease corresponded with the reference in 93% (95% CI: 80-97%) of cases diagnosed in 2014-2015. CONCLUSIONS: The DSR includes the intended patient population and represents a valid and valuable source for improving quality of care and for research. FUNDING: The study was financed by the Danish Regional Development Fund for Clinical Quality. TRIAL REGISTRATION: not relevant.

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

AIM: To evaluate the validity and responsiveness of a questionnaire developed to measure the impact of a high-fidelity simulation intervention. DESIGN: A pre- and postintervention design. METHODS: In August 2017, 107 participants completed a questionnaire measuring knowledge and perceived self-confidence pre- and postintervention. Validity of the questionnaire was determined by expert reviews, individual interviews and estimates of the changes in knowledge and perceived self-confidence. The changes were estimated by the differences between paired proportions of participants. The responsiveness of the ordered categorical item scores on self-confidence was evaluated by the measure of systematic group change and individual variations. RESULTS: The analysis of the interviews resulted in three themes: item content, item style and the administration of the questionnaire. An intervention effect on knowledge assessments was shown by the changes in paired proportions of participants with increased or decreased correct assessments (ranging from -25.5 - 24.8 percentage units). The responsiveness of the self-confidence scale was confirmed by evidence of post-intervention systematic group changes towards higher levels. CONCLUSION: This study provides useful experience for a forthcoming randomized controlled study to evaluate the effect of high-fidelity simulation on undergraduate nursing students' knowledge and self-confidence when assessing patient deterioration. IMPACT: Cause-and-effect relationship between simulation and learning is required to improve nursing education. A statistically significant rise in students' knowledge and levels of self-confidence after simulation were identified in this study. The study provided important aspects of future research study designs.

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

BACKGROUND AND AIMS: Whiplash-Associated Disorders (WAD) are characterized by great variability in long-term symptoms. Patients with central neck and movement-induced stabbing pain participated in a randomized study comparing cervical fusion and multimodal rehabilitation. As reported in our previous paper, more patients treated by cervical fusion than by rehabilitation experienced pain relief. Although patient reported outcome measures are a core component of outcome evaluation, independent examiner has been recommended. Because of the heterogeneity of WAD complaints the patients in our study were examined at baseline and follow-up by four experts representing neurology, orthopedics, psychology and physical medicine. The aim was to compare the professional assessments of change both regarding the possible impact of the different examiners' perspectives on individual patient's outcome, and also on the analysis of possible outcome differences between the treatment groups. METHODS: WAD patients with long-term neck pain as the predominant symptom after a traffic accident were eligible. The neck pain origin should be in the midline and perceived as dull and aching, with sudden movement inducing midline stabbing pain. Of the 1,052 patients in contact with our team, 49 were eligible. The overall treatment effect was evaluated on a global outcome transitional scale. The criteria for the scale categories were defined by each expert's professional perspective on change in the whiplash complaints. Statistical methods that take account of the non-metric properties of ordered categorical data were used. Observed inter-expert disagreement was evaluated by the Svensson method that identifies and measures systematic group-related disagreement separately from disagreement caused by individual variation. Possible differences in the distributions of assessments on the expert-specific outcome scales between the treatment groups were analyzed by the Kruskal-Wallis test. RESULTS: The per-protocol evaluation showed that a majority of the 18 patients who underwent fusion surgery were assessed as somewhat or much better, ranging from 67% to 78% depending on the expert. Corresponding proportions of improvement in the 17 patients treated by multimodal rehabilitation ranged from 29% to 53%. The statistical analyses confirmed better outcomes in the patients treated by fusion surgery, with p-values ranging from 0.003 to 0.04. The experts' assessments of intra-patient change disagreed more or less for all patients. The analyses of the paired comparisons confirmed that these disagreements could most probably be explained by the different profession-specific operational definitions of the outcome scales rather than by individual variations in data. CONCLUSIONS: The multi-dimensional complexity of WAD-related complaints was comprehensively demonstrated by the inter-disciplinary disagreements in assessing intra-patient outcomes. The superiority of positive treatment effects in patients who underwent cervical fusion compared with multimodal rehabilitation was evident to all experts. IMPLICATIONS: The results strengthen our previous opinion that neck pain in this subgroup of WAD patients has a somatic origin. More than one examiner is recommended for multi-dimensional outcome assessments.

Rate of Acute Hospital Admissions Before and After Roux-en-Y Gastric Bypass Surgery: A Population-based Cohort Study.

OBJECTIVE: To examine rates of acute inpatient hospital admissions patients undergoing Roux-en-Y gastric bypass (RYGB) surgery and a matched population-based comparison cohort. SUMMARY BACKGROUND DATA: Little is known about the admission rates before and after RYGB. METHODS: Nationwide population-based cohort study, including all 9985 patients undergoing RYGB in Denmark during 2006 to 2010, and 247,375 matched general population comparisons. We calculated cumulative incidence of surgical complications after RYGB and incidence rate ratios (RRs) of hospital admission in RYGB patients versus comparisons before and after RYGB. RESULTS: Admissions for surgical complications occurred in 3.3% (n = 328) of RYGB patients <30 days after surgery and in 23.9% (n = 2367) during entire follow-up (median 4.2 yrs). Fifteen percent (n = 1486) were admitted with abdominal pain, 5.2% (n = 518) with intestinal obstruction during follow-up. Overall admission rates in RYGB patients versus comparisons were 11.5 versus 5.9 per 100 person-years before RYGB [RR = 1.95 (95% confidence interval (CI): 1.89-2.01)], increasing to 24.9 versus 7.1 per 100 person-years after RYGB [RR = 3.38 (95% CI; 3.30, 3.47)]. RRs of cardiovascular and chronic pulmonary disease admissions decreased considerably. RRs increased for alcohol abuse [0.59 (95% CI; 0.39-0.88) to 2.17 (95% CI; 1.72-2.72)], self-harm (suicide attempts, medication overuse) [1.72 (95% CI; 1.32-2.25) to 3.61 (95% CI; 2.88-4.52)], anemia [0.84 (95% CI; 0.39-1.78) to 17.92 (95% CI; 14.94-21.48)], and osteoporosis [1.19 (95% CI; 0.93-1.53) to 1.65 (95% CI; 1.35-2.02)]. CONCLUSIONS: Short-term surgical complications occurred in 3% and long-term complications in one-fourth of RYGB patients. Compared with the general population, the RR for any inpatient admission increased after RYGB.

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

BACKGROUND: We hypothesized that tonsillectomy modifies the risk of PD. OBJECTIVES: To test the hypothesis in a nationwide population-based cohort study. METHODS: We used Danish medical registries to construct a cohort of all patients in Denmark with an operation code of tonsillectomy 1980-2010 (n = 195,169) and a matched age and sex general population comparison cohort (n = 975,845). Patients were followed until PD diagnosis, death, censoring, or end of follow-up 30 November 2013. Using Cox regression, we computed hazard ratios for PD and corresponding 95% confidence intervals, adjusting for age and sex by study design, and potential confounders. RESULTS: We identified 100 and 568 patients diagnosed with PD among the tonsillectomy and general population comparison cohort, respectively, finding similar risks of PD (adjusted hazard ratio = 0.95 [95% confidence interval: 0.76-1.19]; for > 20 years' follow-up (adjusted hazard ratio = 0.96 [95% confidence interval: 0.64-1.41]). CONCLUSION: Tonsillectomy is not associated with risk of PD, especially early-onset PD. © 2017 International Parkinson and Movement Disorder Society.

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

OBJECTIVE: In the 10 most common primary types with bone metastases, we aimed to examine survival, further stratifying on bone metastases only or with additional synchronous metastases. METHODS: We included all patients aged 18 years and older with incident hospital diagnosis of solid cancer between 1994 and 2010, subsequently diagnosed with BM until 2012. We followed patients from date of bone metastasis diagnosis until death, emigration or 31 December 2012, whichever came first. We computed 1-year, 3-year and 5-year survival (%) and the corresponding 95% CIs stratified on primary cancer type. Comparing patients with bone metastasis only and patients with other synchronous metastases, we estimated crude and adjusted HRs and corresponding 95% CI for mortality. RESULTS: We included 17 251 patients with bone metastasis. The most common primary cancer types with bone metastasis were prostate (34%), breast (22%) and lung (20%). One-year survival after bone metastasis diagnosis was lowest in patients with lung cancer (10%, 95% CI 9% to 11%) and highest in patients with breast cancer (51%, 50% to 53%). At 5 years of follow-up, only patients with breast cancer had over 10% survival (13%, 11% to 14%). The risk of mortality was increased for the majority of cancer types among patients with bone and synchronous metastases compared with bone only (adjusted relative risk 1.29-1.57), except for cervix, ovarian and bladder cancer. CONCLUSIONS: While patients with bone metastases after most primary cancers have poor survival, one of ten patients with bone metastasis from breast cancer survived 5 years.

Does vagotomy protect against multiple sclerosis?

OBJECTIVES: To examine the association between vagotomy and multiple sclerosis. METHODS: We conducted a matched cohort study of all patients who underwent truncal or super-selective vagotomy and a comparison cohort, by linking Danish population-based medical registries (1977-1995). Hazard ratios (HRs) for multiple sclerosis, adjusting for potential confounders were computed by means of Cox regression analysis. RESULTS: Median age of multiple sclerosis onset corresponded to late onset multiple sclerosis. No association with multiple sclerosis was observed for truncal vagotomy (0-37 year adjusted HR=0.91, 95% confidence interval [CI]: 0.48-1.74) or super-selective vagotomy (0-37 year adjusted HR=1.28, 95% CI: 0.79-2.09) compared with the general population. INTERPRETATION: We found no association between vagotomy and later risk of late onset multiple sclerosis.

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

OBJECTIVE: We investigated the association of early achieved HbA1c level and magnitude of HbA1c reduction with subsequent risk of cardiovascular events or death in patients with type 2 diabetes who initiate metformin. RESEARCH DESIGN AND METHODS: This was a population-based cohort study including all metformin initiators with HbA1c tests in Northern Denmark, 2000-2012. Six months after metformin initiation, we classified patients by HbA1c achieved (<6.5% or higher) and by magnitude of HbA1c change from the pretreatment baseline. We used Cox regression to examine subsequent rates of acute myocardial infarction, stroke, or death, controlling for baseline HbA1c and other confounding factors. RESULTS: We included 24,752 metformin initiators (median age 62.5 years, 55% males) with a median follow-up of 2.6 years. The risk of a combined outcome event gradually increased with rising levels of HbA1c achieved compared with a target HbA1c of <6.5%: adjusted hazard ratio (HR) 1.18 (95% CI 1.07-1.30) for 6.5-6.99%, HR 1.23 (1.09-1.40) for 7.0-7.49%, HR 1.34 (1.14-1.57) for 7.5-7.99%, and HR 1.59 (1.37-1.84) for ≥8%. Results were consistent for individual outcome events and robust by age-group and other patient characteristics. A large absolute HbA1c reduction from baseline also predicted outcome: adjusted HR 0.80 (0.65-0.97) for Δ = -4, HR 0.98 (0.80-1.20) for Δ = -3, HR 0.92 (0.78-1.08) for Δ = -2, and HR 0.99 (0.89-1.10) for Δ = -1 compared with no HbA1c change (Δ = 0). CONCLUSIONS: A large initial HbA1c reduction and achievement of low HbA1c levels within 6 months after metformin initiation are associated with a lower risk of cardiovascular events and death in patients with type 2 diabetes.

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

BACKGROUND: We assessed the 30-day risk of readmission and mortality among patients receiving an International Classification of Diseases 10th edition diagnosis of medical observation and evaluation (Z03*) following admission to an acute medical admission unit (AMAU), stratified on any further specification of diagnosis during hospital stay. METHODS: We used Central Denmark's (Midt)-Electronic Patient Journal to identify patients with a Z03*-diagnosis among patients admitted to the AMAU, Aarhus University Hospital Nørrebrogade from April 2012 to March 2013, and noted any specification of diagnosis. Patients were followed from hospital discharge until death, emigration, or completion of 30 days follow-up. RESULTS: Of 409 patients with an initial Z03* diagnosis at the AMAU, 55% (n = 226) received a more specific discharge diagnosis after transferral to other departments. Among patients discharged to home with a Z03*-diagnosis, 30% were readmitted within 30 days, while the corresponding figure was 23% for patients receiving a specific diagnosis (p = 0.06). In contrast, corresponding figures for 30-day mortality were 3% for Z03*-diagnosed patients and 10% for those who obtained a specific diagnosis (p = 0.003). CONCLUSIONS: Patients diagnosed with Z03* at hospital discharge have a substantially lower 30-day mortality, but a higher readmission-rate, compared to patients who obtain a specific diagnosis during the entire hospital stay.

Changes in Prescription Drug Use After Gastric Bypass Surgery: A Nationwide Cohort Study.

OBJECTIVES: To evaluate changes over time in drug use among patients undergoing Roux-en-Y gastric bypass (RYGB) surgery and a matched population-based comparison cohort. BACKGROUND: A little is known about the prescription drug use before and after RYGB surgery. METHODS: Nationwide population-based cohort study included 9908 patients undergoing RYGB in Denmark during 2006 to 2010 and 99,080 matched general population members. We calculated prevalence ratios (PRs) comparing prescription drug use 36 months after RYGB/index date with use 6 months before this date (baseline). RESULTS: At baseline, more RYGB patients (median 40 years, 22% males) used a prescription drug (81.5% vs 49.1%). After 3 years, the use had decreased slightly among RYGB patients [PR = 0.93; 95% confidence interval (CI) = (0.91, 0.94)], but increased in the comparison cohort (PR = 1.05; 95% CI = 1.04-1.06). In the RYGB cohort, large, sustained decreases occurred for treatment of metabolic syndrome-related conditions, such as any glucose-lowering drug (PR = 0.28; 95% CI = 0.25-0.31) and lipid-modifying drugs PR = 0.50; 95% CI = 0.46-0.55). Use of inhalants for obstructive airway diseases (PR = 0.79; 95% CI = 0.74-0.85) also decreased. Use of neuropsychiatric drugs was two-fold higher at baseline in the RYGB cohort (22.8% vs 10.9%) and increased further after RYGB-that is, antidepressants (PR = 1.13; 95% CI = 1.07-1.19), antipsychotics (PR = 1.39; 95% CI = 1.21-1.60), and potential treatment of neuropathy (PR = 1.39; 95% CI = 1.28-1.51). CONCLUSIONS: Three years after RYGB surgery, we found large reductions in the use of treatment of metabolic syndrome-related conditions, inhalants for obstructive airway diseases and glucocorticoid use. In contrast, frequent use of neuropsychiatric drugs further increased after RYGB.

Posttraumatic Stress Disorder and Gastrointestinal Disorders in the Danish Population.

BACKGROUND: Evidence for the association between posttraumatic stress disorder (PTSD) and gastrointestinal (GI) disorders is mixed, owing in part to methodologic differences across studies. Furthermore, studies which have combined GI disorders or symptoms for examination as one overall category may potentially obscure associations between PTSD and individual GI diagnoses. METHODS: This nationwide cohort study examined the incidence of all major nonmalignant GI disorders in patients with a prior PTSD diagnosis (n = 4,076), compared with the general population incidence from 1995 to 2013, using Danish medical registry data. We examined differences by sex, age, marital status, psychiatric and somatic comorbidity, and follow-up time. Risks, standardized incidence rates (SIRs), and confidence intervals (95% CIs) were calculated. RESULTS: Risk of any GI disorder among PTSD patients was 25% (95% CI: 21%, 29%); the SIR for any GI disorder was 1.8 (95% CI: 1.7, 2.0). Risk and SIRs varied by disorder (e.g., no association with diverticula of the intestines [SIR: 1.1, 95% CI: 0.83, 1.5]; stronger association with peptic ulcer, site unspecified [SIR: 3.3, 95% CI: 1.8, 5.5]). Stratified analyses revealed that some associations were stronger for persons ages 16-39 or unmarried at PTSD diagnosis, persons with comorbid psychiatric diagnoses, and in the year following PTSD diagnosis. CONCLUSIONS: This study documents associations between clinician-diagnosed PTSD and all major nonmalignant GI disorders in an unselected nationwide cohort with long follow-up. Differences in associations across GI disorders and important modifiers may account for previous conflicting research findings.