Danish singles have a twofold risk of acute coronary syndrome: data from a cohort of 138 290 persons.

STUDY OBJECTIVE: Atherosclerosis of the coronary and other arteries is an important health problem in virtually all countries of the world, and thus there is a persisting need for the development of preventive programmes including population risk group identification. The aim of the study was to identify sociodemographic population risk indicators of an initial episode of acute coronary syndrome (ACS), including unstable angina pectoris (UAP), myocardial infarction (MI), and sudden cardiac death (SCD). DESIGN: Cohort study of 138 290 residents of the municipality of Aarhus, Denmark, aged 30-69 years. Information on population members' individual age, sex, social background, and eventual death was obtained from Danish Population Registers. SETTING: University hospital. PATIENTS: The study prospectively identified 646 victims of ACS from 1 April 2000 to 31 March 2002. MAIN RESULTS: Based on multiple logistic regression, age and single living were found to be positively associated with incident ACS in both sexes. Women >60 years living alone and men >50 years living alone were at especially high risk. They constituted only 5.4% and 7.7% of the source population, respectively, but they accounted for 34.3% and 62.4% of ACS patients dying within 30 days. CONCLUSIONS: Single living is associated with an increased risk of ACS. Thus, risk groups identified by use of information on their age and family structure may be targets for future more focused and cost effective preventive strategies. In Western populations, such high risk groups will constitute comparatively limited parts of the population, and in Denmark they are easily identifiable in routine population registers.

Risk of postpartum urinary incontinence associated with pregnancy and mode of delivery.

AIM: The aim was to estimate the postpartum urinary incontinence (PP UI) impact of precursory UI during pregnancy (PR UI) and delivery performed by cesarean section (CS) vs. vaginal childbirth (VC). METHODS: Among the members of two population samples, in total 8610 women aged 20-59 years, 1232 had their first childbirth and 642 their second childbirth within 13-120 months prior to responding to a questionnaire that included information on PR UI occurrence, mode of delivery and PP UI occurrence. RESULTS: CS was applied in 12.2% of first childbirths, and 87.8% thus delivered vaginally; PR UI during the pregnancy leading to the first childbirth was reported by 15.6%, and a total of 26.3% reported PP UI. An increased PP UI occurrence was reported following VC (28.3% vs. 12.0% in women undergoing CS, p < 0.001) and after PR UI (first childbirth, 66.7% vs. 18.8% in women not reporting PR UI, p < 0.0001). Among cases of PP UI following the first childbirth, 56.1% and 69.5% of cases could be attributed to PR UI and VC, respectively. CONCLUSIONS: The highest PP UI risks were found among women complaining of PR UI, which manifested itself as a crucial, independent precursor of PP UI. Because of the high frequency of VC, more than seven out of 10 cases of UI following the first childbirth, however, seemed to be attributable to VC. The present data did not lend significant support to the assumption that the PP UI risk is also lowered after a subsequent delivery by CS.

Anesthesiologists in prehospital care make a difference to certain groups of patients.

BACKGROUND: Knowledge of the population using prehospital emergency services is scarce except for selected subgroups. Interventions are often made without evaluation. The aim of this study was (1) to describe mortality, hospitalization and the diagnostic pattern among emergency ambulance users and (2) to evaluate the impact of one mobile emergency care unit (MECU) staffed by an anesthesiologist. DESIGN AND METHODS: A descriptive and quasi-experimental study of consecutive emergency ambulance users during two 3-month periods: before the MECU (Period 1) and after (Period 2). Hospitalization, diagnostic and 0-180-day mortality data were requested from national registers. Diagnoses were according to the International Classification of Diseases (ICD). RESULTS: Periods 1 and 2 included 2950 and 2869 users, respectively. The MECU attended 27.7% in Period 2. Fewer users were brought to hospital in Period 2 (87.9% vs. 93.8%, P < 0.0001), especially MECU users (76.5% MECU users vs. 92.3% other users; P < 0.001). Diagnoses included all main ICD-groups. Overall mortality of all users was 10.2%; no difference between the periods. Cardiovascular and respiratory diseases were among the most frequent and were associated with high mortality. In Period 2 mortality was lower in subgroups: acute myocardial infarction (AMI; n = 177, day 0-180, 13.3% vs. 40.5%, P < 0.001); and respiratory diseases, only short-term mortality (n = 388, day 0-1 mortality, 0.0% vs. 2.4%, P < 0.05). CONCLUSION: The diagnostic pattern among emergency ambulance users included all main groups of diseases. After the MECU fewer were brought to hospital. The overall mortality for all ambulance users was not influenced by the MECU. For the subgroups, especially AMI, mortality was lower after the introduction of the MECU.

Menstrual cycle, female hormone use and urinary incontinence in premenopausal women.

Our aim was to study the association between menstrual cycle characteristics, the use of female hormones and urinary incontinence (UI) in an age-stratified random population sample of 2158 premenopausal women who answered a questionnaire on urinary incontinence. Episodes of UI during 1997 were reported by 18.3% and one or more episodes of UI the preceding year by 3.9%. Based on multiple logistic regression, self-reported UI the day before answering the questionnaire was found to be associated with current hormone use for menstrual disorders (OR 2.7, 95% CI 1.2-6.6), a recent decrease in bleeding duration (OR 2.2, 95% CI 1.3-3.7), being on days 11-15 before the expected end of the menstrual cycle the preceding day (OR 2.6, 95% CI 1.3-5.0), and with general UI risk factors, i.e. vaginal childbirth, childhood enuresis, BMI >/=530 and exposure to abdominal and/or gynecologic surgery. The findings are in accordance with a hypothesis of hormonal variation being a risk indicator of UI in premenopausal women.

Acute myocardial infarction: does pre-hospital treatment increase survival?

The aim of this study was to assess the impact of a mobile emergency care unit (MECU) staffed with an anaesthetist, in terms of increased survival among patients with acute myocardial infarction (MI). The setting was an urban area with 330 000 inhabitants. This was a quasi-experimental before-and-after-study including consecutive emergency calls during September to November 1996 (Period 1, without the MECU) and September to November 1997 (Period 2, including the MECU). Fifty-four ambulance patients had their MI diagnosis confirmed at hospital during Period 1, and another 54 in Period 2. The 28-day mortality was collected from relevant registers. Twenty-four (44%) of Period 2 patients were transported by the MECU. MECU patients had lower systolic blood pressure (SBP) than other patients, both before and after hospital admission. Nitroglycerine treatment was relatively frequent in MECU patients, and cardioversion, anaesthesia and intubation was applied exclusively in these patients. After arrival at hospital, MECU patients had thrombolysis relatively often (46% versus 23% in other Period 2 patients) but percutaneous transluminal coronary angioplasty (PTCA) relatively infrequently (21% vs 30%). The total mortality was significantly lower in Period 2 than in Period 1 patients (11% vs 21%, <0.025), irrespective of differences in the distribution of age, gender, pulse and SBP, measured at hospital. Also, the more specific MECU use, alone and in combination with subsequent PTCA treatment, was found to be associated with prolonged survival. Pre-hospital treatment by an MECU staffed by an anaesthetist and/or having a PTCA seems to be associated with prolonged survival in acute MI patients. It must be underscored that these observations have been based on quasi-experimental rather than randomized experimental data.

Correlates of urinary incontinence in pregnancy.

In a population sample, the period prevalence of urinary incontinence (UI) during pregnancy was found to be 19.9% and 24.1% among 352 nulliparous and 290 primiparous women, respectively. The first UI episode ever was experienced by 16.7% and 7.0% during the two last trimesters of the first and second pregnancies, respectively. None of the pregnancy-specific risk factors, such as emesis and birthweight, was significantly associated with UI during pregnancy. Previous UI was a significant risk factor for period prevalent UI during pregnancy, explaining 34% and 83% of pregnancy UI for the nulliparous and the primiparous, respectively. The present data suggest pregnancy UI not to be provoked by the mere onset of pregnancy, but by increasing hormonal concentrations or local tissue changes caused by hormones, whereas there was no support for a theory based on increasing pressure on the bladder caused by the weight of the fetus.

Determinants of acceptance of a community-based program for the prevention of falls and fractures among the elderly.

BACKGROUND: Low-energy fractures among the elderly may be prevented by measures aimed at reducing the risk of falling or increasing the strength of the skeleton. Acceptance of these interventions in the target population is necessary for their success. METHODS: The total elderly population in a Danish municipality 7,543 community-dwelling persons aged 66+ years, were offered participation in one of three intervention programs: 2,550 persons were offered a home safety inspection, evaluation of prescribed medicine, and identification of possible health and food problems (Program I); 2,445 persons were offered 1000 mg of elemental calcium and 400 IU (10 microg) of vitamin D(3) per day in combination with evaluation of prescribed medicine (Program II); and 2,548 persons were offered a combination of the two programs (Program III). Acceptance was defined as willingness to receive an introductory visit by a nurse. RESULTS: Acceptance of Program I was 50%; of Program II, 56% (P < 0.00005 as contrasted with Program I); and of Program III, 46% (P < 0.005). Acceptance was associated with gender (females, 53%; males, 47%) and did not change from ages 66 to 84 but decreased significantly after the age of 85. Widows aged 66-84 had the highest acceptance (57%) and never married males aged 66-84 the lowest (30%). An important determinant, however, was the individual social service center that communicated the specific program. Acceptance varied from 39 to 66% between the social centers. CONCLUSIONS: Acceptance of a fall and fracture prevention program varies with intervention type; with gender, age, and social status of the target population; and with the motivation and attitude of the health workers involved in the implementation of the program.

Prevalence of knee instability in relation to sports activity.

The objective was to estimate the prevalence of knee instability among active athletes and to investigate potential associations to type, amount and duration of sports participation. Based on a questionnaire, 339 athletes provided information about different features of occupation, sports activity and knee instability. The 12-month period prevalence of knee instability and constant or recurrent knee instability, and absence from sport and absence from work due to knee instability, was 22%, 14%, 5% and 1%, respectively. Knee instability as such, and constant or recurrent knee instability were found to be positively associated with female gender and different features of occupational work. In conclusion, knee instability is a commonly reported phenomenon among active athletes. It was found to be independent of the type and the amount of sports activity but highly dependent on female gender, type and amount of occupational work.

Assessment of dementia in nursing home residents by nurses and assistants: criteria validity and determinants.

OBJECTIVES: To describe the criterion validity of nursing home staff's assessment of organic disorder compared with ICD-10 criteria, and to identify determinants of staff assessment of organic disorder. METHOD: Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. Nursing staff members were interviewed about the residents' activities of Daily Living, behavioural problems, orientation in surroundings and communication skills, and asked if the resident had an organic disorder. Multiple logistic regression was used to select the items that most strongly determined staff assessment of organic disorder. RESULTS: Sixty-two per cent of the residents were diagnosed by GMS-AGECAT as having organic disorder, 78% of these were correctly identified by the staff. Whether analysed among residents with or without organic disorder, or in the total group of residents, the staff assessment of the presence of organic disorder depended on a limited set of behavioural characteristics of the resident, namely 'going to the toilet in inappropriate places', 'saying things that do not make sense' and impairment in orientation. CONCLUSIONS: Staff comprehension of organic disorder resulted in over- as well as under-labelling of residents, a tendency that will affect communication with medical personnel and may lead to inadequate or wrong medical treatment and to negative performance as well as negative role expectations in everyday life in nursing homes.

Use of a national database for strategic management of municipal oral health services for Danish children and adolescents.

OBJECTIVE: To evaluate the use of a national register for strategic management of dental health services for 0-17-year-old Danish children and to identify determinants for their use of the system as a strategic tool in management of the services. METHODS: During the period December 1997 to January 1998, the leaders of 268 private and public dental services were mailed a self-administered postal questionnaire on their use of the dental health reporting system of the Danish National Board of Health, the so-called SCOR-system. Ninety-six percent responded. The questionnaire contained questions about the use of SCOR (dependent variable) and the following independent variables: 1) the dental service in the municipality; and 2) the leader of the dental service, including his/her assessment of and knowledge related to the SCOR-system. Information concerning other independent variables such as: 1) the population and the socio-economic, cultural and political environment of the municipality; and 2) dental morbidity was collected as antecedent data from various official sources. RESULTS: Seventy-seven percent of municipalities with public clinics and 68% of municipalities without public clinics used SCOR-tables for planning purposes and preventive intervention. Forty percent reported data for all age groups to the SCOR-system and 36% used non-obligatory special codes in order to monitor more specific questions. Use of SCOR data was positively associated with the dental health services being organized in public clinics, with a high number of public clinics in the municipality, and with a positive assessment among the dental leaders of the reporting system as a planning tool. Special codes for precavitated lesions and/or fissure sealants were used more frequently in municipalities where DMFS in 15-year-olds had decreased from 1995 to 1996. Otherwise no associations between dental health and use of the system could be demonstrated. CONCLUSIONS: SCOR is widely used as a strategic planning instrument concerning the Danish dental services for children and adolescents. The predictors associated with its use are partly structural characteristics of the municipality and its dental service and factors partly related to a leader's knowledge about and assessment of the system. These factors might be amenable to change through training of the users of the system.

Determinants for the use of psychotropics among nursing home residents.

PURPOSE: To characterise the prescription pattern of psychotropics in Danish nursing homes and to identify diagnostic, behavioural, cognitive and performance characteristics associated with prevalent psychotropic drug use. METHODS: Prescribed daily medication was recorded from nurses' files. Based on the Anatomical Therapeutical Chemical (ATC) classification index, psychotropics were categorised into neuroleptics, benzodiazepines and antidepressants. Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. One hundred and eighteen staff members were interviewed about the residents's Activities of Daily Living (ADL), behavioural problems (Nursing Home Behavior Problem Scale), orientation, communication skills and if the resident had any psychiatric disorder. Multiple logistic regression was used to select the items that determined the use of psychotropics. RESULTS: Fifty-six percent of the residents received a psychotropic, 21% received neuroleptics, 38% received benzodiazepines and 24% received antidepressants. In the multivariate analysis, staff assessment of the resident's mental health was a determinant for the use of all types of specific psychotropics, whereas a GMS-AGECAT diagnosis only determined the use of neuroleptics. Behavioural problems were a determinant for the use of neuroleptics and the use of benzodiazepines irrespective of the psychiatric diagnosis of the resident. Use of antidepressants was associated with male gender and increasing age. CONCLUSIONS: Staff perceptions of psychiatric morbidity and norms have a greater impact on the prescription of psychotropics than standardised clinical criteria.

Traumatic experience and sleep disturbance in refugee children from the Middle East.

BACKGROUND: Sleep disturbance is frequently reported in children after traumatic experiences associated with organised violence. The aim of this study was to identify specific traumatic risk indicators and modifying factors for sleep disturbance among recently arrived refugee children from the Middle East. METHODS: The study group comprises 311, 3-15 year old refugee children from the Middle East. On arrival in Denmark, their parents participated in a structured interview about their childrens' health and history of exile and eventual exposure to war, organised violence and human rights violation. RESULTS: A family history of violence (grandparent's violent death before the birth of the child or parental exposure to torture) as well as a stressful present family situation (father scolds the child more than previously) were the strongest predictors of prevalent sleep disturbance in the children. Arriving in Denmark with both parents rather than one was a modifying factor, so the effect of traumatic experience on sleep patterns later in childhood was mediated through parental presence and behaviour. CONCLUSION: This study indicates that the family environment is of primary importance for childhood sleep disturbance following traumatic experiences connected with war and other organised violence.

Empirical weighting of the Standardized Mini Mental State Examination items among nursing home residents.

Missing items in the Mini Mental State examination are dealt with in different ways. The main aims of this study were to calculate a weighted item score for organic disorder on the basis of the item score of the Standardized Mini Mental State Examination (SMMSE) test regardless of the completeness of the test and to compare the criterion validity of the weighted scores with the ordinal scores for the SMMSE test. With a participation of 91%, the study included 100 nursing residents. All residents were tested with the SMMSE test and concurrently diagnosed in accordance with the ICD-10 by a consultant psychiatrist. The two assessments were mutually blinded. Multiple conditional forward logistic regression was used to select the items that most strongly predicted organic disorder as assessed by the psychiatrist. The weighted score had significantly better validity parameters, performed better on a receiver operating curve (ROC), and was better at dichotomizing the population into organic disorder than the commonly used ordinal score. We propose that missing items in the SMMSE should be scored as missing and included in empirical weighting on SMMSE items, which will then be substantially more valid than the SMMSE score itself.

Criterion-validity-based assessment of four scale constructs.

BACKGROUND: The aim of this study was to discuss, in general, selected crucial aspects of the appropriate methodology for the development and validation of scales indicating health status, and to illustrate this empirically by within-material comparison of the accuracy of four different scale constructs based on identical raw data. METHODS: The empirical example was based on information from the parents of 99 refugee children, aged 3-15 years, from the Middle East, who participated in a structured interview on their children's mental health. Following this, they were exposed to a blinded semi-structured psychological interview. Four anxiety scales were constructed based on answers to 12 anxiety symptom questions in the structured interview: Scale 1, by cumulation of original item scores, each ranging from 0 to 3; Scale 2, by counting the number of symptoms being present; Scale 3, by counting the number of frequent or intense anxiety symptoms; Scale 4, by estimation of the multivariate probability of the child being anxious, as assessed by the psychological interview. The scales were compared for their accuracy in the identification of children assessed as anxious by psychological interview. RESULTS: The four scales correlated mutually, and each of them was significantly associated with anxiety, as assessed by psychological interview. The weighted scale, however, performed significantly better than the unweighted scales for sensitivity but not for specificity. In the present data set the overall amount of misclassification was, however, significantly less than in the unweighted scales. CONCLUSION: As expected from theory, the weighted scale was found to be superior to the unweighted scales, in identifying the anxious children of the empirical example. In the presence of a blinded criterion measurement, empirical regression-based weighting of scale items thus constitutes an accessible and valid alternative to traditional methods of health and social scaling.

[Urinary incontinence and pregnancy, vaginal childbirth and obstetric interventions]. / Urininkontinens og graviditet, vaginal fødsel og obstetriske indgreb.

The aim was to examine the association between pregnancy, vaginal childbirth (VC) and obstetric techniques, and the prevalence of urinary incontinence (UI). A cross-sectional survey enrolled a random population sample of 6240 women aged 20-59 years, who were mailed a self-administered questionnaire on UI and, among other things, experience of VC and obstetric intervention. More than 75% responded. The present analysis includes 4345 women. Multivariate UI prevalence odds ratios were increased in relation to UI during pregnancy, UI following immediately after a VC, and age 30 or more at the second VC. No multivariate association was found in relation to forceps delivery or vacuum extraction delivery, episiotomy or perineal suturing. In conclusions, not only the process of childbirth itself but also processes during pregnancy seem to be strongly associated with prevalent UI. Perineal suturing may be associated with prevalent UI, whereas other obstetric techniques inspected do not seem to be so.

[Nursing home residents in Northern Jutland]. / Plejehjemsbeboere i Nordjylland.

The purpose of the study was to describe a Danish nursing home population. The study consists of 288 nursing home residents (median age 84.6 years, 68% females). The psychiatric morbidity of the residents was diagnosed with the GMS-AGECAT. The staff was interviewed about the residents' ADL, disturbing behaviour and therapeutic measures. Seventy-one percent had a psychiatric disorder, with organic disorder as the most frequent (61%). Demented residents received significantly less hypnotics, were more often physically restrained and had lower ADL levels compared to other residents. The situation in Denmark can be seen as a paradox. While substantial effort has been made to increase the possibility of choice and to "deinstitutionalize" nursing homes, the majority of the residents are demented and thus not capable of making valid choices.

Active knee joint flexibility and sports activity.

The aim of the study was to estimate active knee flexion and active knee extension in athletes and to investigate the potential association of each to different types of sports activity. Active knee extension and active knee flexion was measured in 339 athletes. Active knee extension was significantly higher in women than in men and significantly positively associated with weekly hours of swimming and weekly hours of competitive gymnastics. Active knee flexion was significantly positively associated with participation in basketball, and significantly negatively associated with age and weekly hours of soccer, European team handball and swimming. The results point to sport-specific adaptation of active knee flexion and active knee extension.

Dynamic strength of the quadriceps muscle and sports activity.

The study objectives were to examine the dynamic strength of the quadriceps muscle in athletes, and investigate its association with participation in sport. The study comprised 168 active competitive non-pregnant athletes, aged 14-24 years. The dynamic strength of their quadriceps muscle was measured, and they answered a questionnaire about sports activity and occupation. The dynamic strength of the quadriceps muscle was significantly higher in men than in women, and was positively associated with body weight, years of jogging, years of soccer, and weekly hours of basketball. In conclusion, the dynamic strength of the quadriceps muscle seems to be associated with sports activity. The results suggest sport specific adaptation, which may reflect high levels of running and jumping activity.

Prevalent urinary incontinence as a correlate of pregnancy, vaginal childbirth, and obstetric techniques.

OBJECTIVES: This study examined the association between pregnancy, vaginal childbirth and obstetric techniques, and the prevalence of urinary incontinence among adult women aged 20 to 59 years. METHODS: A cross-sectional survey enrolled a random sample of 6240 women aged 20 to 59 years who were mailed a self-administered questionnaire focusing on urinary incontinence and other health variables. More than 75% of the women responded. The present analysis includes 4345 women who were not pregnant and did not experience a vaginal childbirth during 1994. RESULTS: Multivariate prevalence odds ratios showed increases in relation to urinary incontinence during pregnancy, urinary incontinence immediately after a vaginal childbirth, and age of 30 years or more at the second vaginal childbirth. No multivariate associations were found for forceps delivery or vacuum extraction delivery, episiotomy, or perineal suturing. CONCLUSION: Not only the process of childbirth itself but also processes during pregnancy seem to be strongly associated with prevalent urinary incontinence. Perineal suturing may be associated with prevalent urinary incontinence, whereas other obstetric techniques inspected do not seem to be so.