Stroke and Risk of Epilepsy: A Danish Nationwide Register-Based Study.

BACKGROUND: Stroke is associated with a risk of epilepsy, but associations with age, sex, stroke type and severity, time trends, and mortality are uncertain. We studied the risk of epilepsy after stroke while accounting for sex, age, stroke types and severity, calendar time, and death. METHODS: This was a prospective nationwide register-based, matched cohort study of patients admitted with a validated first stroke in Denmark from April 1, 2004, to December 16, 2018, excluding those with prior epilepsy. Patients with stroke were matched 10:1 on age, sex, and calendar time with reference people without prior epilepsy or stroke. We estimated the cumulative incidence of an epilepsy diagnosis in the Danish National Patient Registry (International Classification of Diseases Tenth Revision: G40) with death as a competing risk using competing risk regression and estimated adjusted hazard ratios by Cox regression models. RESULTS: We identified 101 034 patients with stroke (46.5% female; mean age, 70.4 years) who survived 14 days after stroke along with 1 010 333 matched reference people. Two years after the stroke, the cumulative incidence of epilepsy was 3.0% (95% CI, 2.9-3.2) after ischemic stroke and 8.6% (95% CI, 8.0-9.2) after intracerebral hemorrhage versus 0.7% (95% CI, 0.7-0.7) in the matched references. Compared with the reference population, the 2-year hazard ratio of epilepsy was 21.7 (95% CI, 20.3-23.2) after ischemic stroke and 61.3 (95% CI, 51.1-73.4) after intracerebral hemorrhage. The risk of epilepsy increased with stroke severity; the 2-year cumulative incidence of epilepsy was 10.5% (95% CI, 9.5-11.4) for very severe ischemic stroke and 13.1% (95% CI, 11.1-15.1) after very severe intracerebral hemorrhage. CONCLUSIONS: In this population-based study of patients with validated stroke, the absolute and relative risk estimates of poststroke epilepsy were lower compared with previous studies. Reasons for the lower risk estimates include accounting for the high mortality associated with stroke, which had a significant impact on risk especially for severe stroke.

Effect of Remote Ischemic Conditioning in Ischemic Stroke Subtypes: A Post Hoc Subgroup Analysis From the RESIST Trial.

BACKGROUND: Remote ischemic conditioning (RIC) is a simple and noninvasive procedure that has proved to be safe and feasible in numerous smaller clinical trials. Mixed results have been found in recent large randomized controlled trials. This is a post hoc subgroup analysis of the RESIST trial (Remote Ischemic Conditioning in Patients With Acute Stroke), investigating the effect of RIC in different acute ischemic stroke etiologies, and whether an effect was modified by treatment adherence. METHODS: Eligible patients were adults (aged ≥18 years), independent in activities of daily living, who had prehospital stroke symptoms with a duration of less than 4 hours. They were randomized to RIC or sham. The RIC treatment protocol consisted of 5 cycles with 5 minutes of cuff inflation alternating with 5 minutes with a deflated cuff. Acceptable treatment adherence was defined as when at least 80% of planned RIC cycles were received. The analysis was performed using the entire range (shift analysis) of the modified Rankin Scale (ordinal logistic regression). RESULTS: A total of 698 had acute ischemic stroke, 253 (36%) were women, and the median (interquartile range) age was 73 (63-80) years. Median (interquartile range) overall adherence to RIC/sham was 91% (68%-100%). In patients with a stroke due to cerebral small vessel disease, who were adherent to treatment, RIC was associated with improved functional outcome, and the odds ratio for a shift to a lower score on the modified Rankin Scale was 2.54 (1.03-6.25); P=0.042. The association remained significant after adjusting for potential confounders. No significant associations were found with other stroke etiologies, and the overall test for interaction was not statistically significant (χ2, 4.33, P=0.23). CONCLUSIONS: In patients with acute ischemic stroke due to cerebral small vessel disease, who maintained good treatment adherence, RIC was associated with improved functional outcomes at 90 days. These results should only serve as a hypothesis-generating for future trials. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03481777.

Type 2 diabetes mellitus in patients with ischemic stroke - A nationwide study.

AIMS: Type 2 diabetes (T2D) is a risk factor for ischemic stroke (IS) and associated with an adverse prognosis. Both stroke and diabetes care has evolved substantially during the last decade. This study aimed to determine the prevalence of T2D among IS patients along with time trends in the risk profile, use of glucose-lowering medications, quality-of-care and clinical outcomes, including stroke severity; length-of-stay; mortality, readmission and recurrent stroke in a large national cohort. METHODS: Registry-based cohort study including all IS events in Denmark from 2004 to 2020. IS with co-morbid T2D were compared to IS without diabetes while adjusting for age, sex, stroke severity, co-morbidity and socio-economic factors. RESULTS: The study included 169,262 IS events; 24,479 with co-morbid T2D. The prevalence of T2D in IS increased from 12.0% (2004-2006) to 17.0% (2019-2020). The adjusted absolute 30-day mortality risk in IS with T2D decreased from 9.9% (2004-2006) to 7.8% (2019-2020). The corresponding adjusted risk ratios (aRR) were 1.22 95% confidence interval (1.09-1.37) and 1.29 (1.11-1.50), respectively. The aRR of 365-day mortality was in 2004-2006: 1.20 (1.12-1.29) and in 2019-2020: 1.34 (1.22-1.47). The 30- and 365-day readmissions rates were also consistently higher in IS with T2D. CONCLUSIONS: The prevalence of T2D in IS increased over time. The 30- and 365-day mortality rates decreased over the time-period but were consistently higher in IS with co-morbid T2D. Readmissions were also higher in IS with T2D. This highlights an urgent need for strategies to further improve the prognosis in IS patients with co-morbid T2D.

Regional variation in incidence and prognosis of acute kidney injury.

BACKGROUND: Examining regional variation in acute kidney injury (AKI) and associated outcomes may reveal inequalities and possibilities for optimization of the quality of care. Using the Danish medical databases, we examined regional variation in the incidence, follow-up and prognosis of AKI in Denmark. METHODS: Patients with one or more AKI episodes in 2017 were identified using population-based creatinine measurements covering all Danish residents. Crude and sex-and-age-standardized incidence rates of AKI were estimated using census statistics for each municipality. Adjusted hazard ratios (aHR) of chronic kidney disease (CKD), all-cause death, biochemical follow-up and outpatient contact with a nephrology department after AKI were estimated across geographical regions and categories of municipalities, accounting for differences in demographics, comorbidities, medication use, lifestyle and social factors, and baseline kidney function. RESULTS: We identified 63 382 AKI episodes in 58 356 adults in 2017. The regional standardized AKI incidence rates ranged from 12.9 to 14.9 per 1000 person-years. Compared with the Capital Region of Denmark, the aHRs across regions ranged from 1.04 to 1.25 for CKD, from 0.97 to 1.04 for all-cause death, from 1.09 to 1.15 for biochemical follow-up and from 1.08 to 1.49 for outpatient contact with a nephrology department after AKI. Similar variations were found across municipality categories. CONCLUSIONS: Within the uniform Danish healthcare system, we found modest regional variation in AKI incidence. The mortality after AKI was similar; however, CKD, biochemical follow-up and nephrology follow-up after AKI varied across regions and municipality categories.

Glucagonlike peptide-1 receptor agonists versus dipeptidyl peptidase-4 inhibitors in ischemic strokes with diabetes 2.

BACKGROUND AND PURPOSE: Cardiovascular outcome trials demonstrate that glucagonlike peptide-1 receptor agonists (GLP-1RAs) reduce the risk of major adverse cardiovascular events in patients with type 2 diabetes (T2D), whereas dipeptidyl peptidase-4 inhibitors (DPP-4is) have not shown cardiovascular benefits. We compared acute ischemic stroke (AIS) with T2D treated with either a GLP-1RA or DPP-4i prior to the index stroke. METHODS: This national cohort study included AIS patients with T2D from 2017 to 2020 in Denmark who were users of a GLP-1RA or DPP-4i. To be categorized as a user, we required at least 12 months of exposure and no concurrent treatment with another newer glucose-lowering medication during the last 3 months prior to the index stroke. GLP-1RA users were compared to users of DPP-4i while adjusting for the calendar year of index stroke, age, sex, comorbidity, and socioeconomic factors. RESULTS: The study included 1567 AIS events with T2D; 593 were users of GLP-1RA and 974 of DPP-4i. The absolute risk of a very severe stroke was 2.4% (95% confidence interval [CI] = 1.2-3.7) in GLP-1RA users and 6.1% (95% CI = 4.6-7.7) in DPP-4i users. The corresponding adjusted risk ratio (aRR) of GLP-1RA versus DPP-4i was 0.49 (95% CI = 0.24-1.00). The aRRs of 30-day and 365-day mortality were 0.55 (95% CI = 0.32-0.94) and 0.72 (95% CI = 0.53-0.98), respectively. CONCLUSIONS: The risk of a very severe stroke as well as the 30-day and 365-day poststroke mortality rates were lower among the AIS patients with comorbid T2D receiving GLP-1RA prior to the index stroke compared to those receiving DPP-4i. Hence, GLP-1RA may improve stroke outcomes in comparison with DPP-4i.

Survival outcomes and healthcare utilization between immigrant patients and Danish-born patients with hematological cancers: a Danish population-based study.

Overall survival (OS) for patients with a hematological cancer may differ between immigrant and Danish-born patients due to disparities in socioeconomic status, health literacy, and language proficiency. This cohort study aimed to investigate survival and hospitalization according to immigrant status while controlling for confounders. Patients with newly diagnosed hematological cancer in 2000-2020 were identified in the Danish nationwide hematological registers and stratified into Danish-born, Western, and non-Western patients. Patients were followed from diagnosis until death, 31st December 2021, or emigration, whichever came first. Crude OS, standardized OS, and 5-years OS differences were computed using flexible parametric models and hazard ratios using Cox regression. Number of hospitalization days in the year before and after diagnosis, respectively, were calculated using Poisson regression. A total of 2,241 immigrants and 41,519 Danish-born patients with a hematological cancer were included. Standardized 5-years OS was similar between groups with 58% (95% confidence interval 57-58%) for Danish-born patients, 57% (55-60%) for Western, and 56% (53-58%) for non-Western immigrant patients. Subgroup analyses identified OS differences in selected subgroups. Non-Western immigrant patients had 1.3 (0.5-2.1) more hospitalization days in the year before diagnosis and an adjusted incidence rate ratio of hospitalization days of 1.14 (1.13-1.15) in the year after diagnosis compared with Danish-born patients. In conclusion, there were no overall differences in survival when comparing immigrant patients to Danish-born patients after controlling for relevant confounders. Healthcare utilization was slightly higher among non-Western immigrant patients before and after diagnosis, but differences were small on an individual patient level.

Long-term risk factors of recurrent stroke, myocardial infarction and death in patients leaving hospital with a diagnosis of ischemic stroke or TIA.

Objectives. The prevalence of patients with prior stroke is increasing globally. Accordingly, there is a need for up-to-date evidence of patient-related prognostic factors for stroke recurrence, post stroke myocardial infarction (MI) and death based on long-term follow-up of stroke survivors. For this purpose, the RIALTO study was established in 2004. Design. A prospective cohort study in which patients diagnosed with ischemic stroke (IS) or transient ischemic attack (TIA) in three Copenhagen hospitals were included. Data were collected from medical records and by structured interview. Data on first stroke recurrence, first MI and all-cause death were extracted from the Danish National Patient Registry and the Danish Civil Registration System. Results. We included 1215 patients discharged after IS or TIA who were followed up by register data from April 2004 to end of 2018 giving a median follow-up of 3.5-6.9 years depending on the outcome. At the end of follow-up 406 (33%) patients had been admitted with a recurrent stroke, 100 (8%) had a MI and 822 (68%) had died. Long-term prognostic predictors included body mass index, diabetes, antihypertensive and lipid lowering treatment, smoking, a sedentary lifestyle as well as poor self-rated health and psychosocial problems. Conclusions. Long-term risk of recurrent stroke and MI remain high in patients discharged with IS or TIA despite substantial improvements in tertiary preventive care in recent decades. Continued attention to the patient risk profile among patients surviving the early phase of stroke, including comorbidities, lifestyle, and psychosocial challenges, is warranted.

Incidence of atrial fibrillation and flutter in Denmark in relation to country of origin: a nationwide register-based study.

BACKGROUND: Atrial fibrillation and flutter (AF) is the most common sustained arrhythmia with an increasing prevalence in Western countries. However, little is known about AF among immigrants compared to non-immigrants. AIM: To examine the incidence of hospital-diagnosed AF according to country of origin. METHOD: Immigrants were defined as individuals born outside Denmark by parents born outside Denmark. AF was defined as first-time diagnosis of AF. All individuals were followed from the age of 45 years from 1998 to 2017. The analyses were adjusted for sex, age, comorbidity, contact with the general practitioner and socioeconomic variables. Adjustment was conducted using standardised morbidity ratio weights, standardised to the Danish population in a marginal structural model. RESULTS: The study population consisted of 3,489,730 Danish individuals free of AF and 108,914 immigrants free of AF who had emigrated from the 10 most represented countries. A total of 323,005 individuals of Danish origin had an incident hospital diagnosis of AF, among the immigrants 7,300 developed AF. Adjusted hazard rate ratios (HRRs) of AF for immigrants from Iran (0.48 [95%CI:0.35;0.64]), Turkey (0.74 [95%CI:0.67;0.82]) and Bosnia-Herzegovina (0.42 [95%CI:0.22;0.79]) were low compared with Danish individuals. Immigrants from Sweden, Germany and Norway had an adjusted HRR of 1.13 [95%CI:1.03;1.23], 1.12 [95%CI:1.05;1.18] and 1.11 [95%CI:1.03;1.21], respectively (Danish individuals as reference). CONCLUSIONS: Substantial variation in the incidence of hospital-diagnosed AF according to country of origin was observed. The results may reflect true biological differences but could also reflect barriers to AF diagnosis for immigrants. Further efforts are warranted to determine the underlying mechanisms.

Social drivers in atrial fibrillation occurrence, screening, treatment, and outcomes: systematic-narrative hybrid review.

The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

'There are things I have learned the hard way' Patient experiences on lasting challenges 4 months after Transient Ischemic Attack: A qualitative study.

BACKGROUND: Fatigue, depression, anxiety and cognitive difficulties are reported by 1/3 of patients following transient ischemic attack (TIA). AIMS: To explore the timeline and how the diagnosis impacts individuals experiencing lasting challenges after TIA. Furthermore, to identify what they believed facilitated return to everyday life. DESIGN: Qualitative exploratory study with a phenomenological-hermeneutic approach. METHODS: Individual semi-structured interviews and thematic analysis. RESULTS: Fifteen patients were included. Four themes were identified; (1) 'They say it is transient - no, not for me' where all participants described lasting challenges emphasizing invalidating fatigue and impaired social participation, (2) 'I am a changed person; how does this impact my future?' which reflects altered identity and elevated alertness to symptoms, (3) 'Time has been my ally and new perspectives have evolved' where most participants described improvement over time and a few considered the diagnosis a wake-up call to change lifestyle. Lastly (4) 'What would have helped me recover?' which unfolds that close, trustful relations influence positively. In addition, the system often failed to support. Participants described pressure to return to work and lack of trust and negative experiences when involving their general practitioner. CONCLUSIONS: During the 4 months since diagnosis, participants experienced limitations impacting physical, psychological and social domains. They felt uninformed that lasting challenges could affect them. Different coping strategies were activated, and participants with close, supportive relations managed better. A pressure to return to work and a lack of trust in the general practitioner affected their recovery negatively. Overall, return to everyday life after TIA was considered stressful and appropriate support lacking. RELEVANCE TO CLINICAL PRACTICE: To be able to support patients with challenges following TIA, we as healthcare professionals need to understand the identified impact and life changing circumstances. Currently the system seemingly is not able to provide timely, sufficient and competent support. IMPACT (ADDRESSING): WHAT PROBLEM DID THE STUDY ADDRESS?: We know from the literature that up to 1/3 of patients following transient ischemic attack experience lasting challenges measured on a variety of questionnaires. This is paradoxical to a diagnosis defined by focal neurological symptoms that resolve within 24 h. It is unknown how patients with lasting challenges experience the timeline from diagnosis and until 4 months after, how the diagnosis impacts the lives of these individuals, and what they believe as beneficial in returning to their everyday life. WHAT WERE THE MAIN FINDINGS?: These participants with self-reported lasting challenges experienced substantial impacts on physical, psychological and social domains. Further, they felt alone with their struggles and when in need of support from the healthcare system, it failed to provide this. A pressure to return to work and a lack of trust in the general practitioner affected return to everyday life negatively, whereas close and supportive relations facilitated positively. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: This study will have an impact on the healthcare professionals that provide support and the (limited) follow-up services to patients after TIA. These healthcare professionals are often specialized nurses who need to know what these patients experience and need in order to act upon their struggles and provide timely support. REPORTING METHOD: The Standards of Reporting Qualitative Research (SRQR). PATIENT OR PUBLIC CONTRIBUTION: Patients with TIA was involved in planning this study. They participated in a panel to plan a prospective observational cohort study and emphasized the importance of exploring the subjective perspectives of impact and prognosis for those patients struggling in a longer term (through qualitative interviews).

Rasch analysis of a patient-reported outcome measure for self-perceived health among psychiatric patients in Denmark.

BACKGROUND: Patient-reported outcome measures (PROMs) are valuable and necessary tools for establishing and maintaining patient-centred healthcare. The PRO-Psychiatry initiative was primarily initiated to support the patient's voice in treatment decision-making and secondarily to monitor patient-perceived quality of care. The result of the initiative is a patient-reported instrument developed in collaboration between patients and clinicians. We aimed to validate the PROM developed for measuring self-perceived health among psychiatric patients in North Denmark Region, in terms of internal consistency, criterion validity and responsiveness. METHOD: Patients in contact with a psychiatric hospital in the North Denmark Region from September 2018 to March 2021 were included in the study. The PROM constitutes a scale of 17 items covering various aspects of self-perceived health including well-being (7 items), lack of well-being (5 items) and social functioning (5 items), where the former domain entails the WHO-5 Well-Being Index. The potential range of the total scale score is 0-85. We applied McDonald's omega, average inter-item correlation (AIIC) and differential item functioning (DIF). In addition, we used mixed effects analyses to estimate temporal correlations. The instrument was compared with self-rated overall mental and psychiatric health. RESULTS: The patient population consisted of 1132 unique patients and a total of 2476 responses corresponding to one response per patient pathway. McDonald's omega was found to be 0.92 (95% CI 0.92 to 0.93), while the AIIC was found to be 0.42 (95% CI 0.39 to 0.44). For DIF, the largest systematic variation resulted in a maximum difference of 2.3 points on the total score when adjusting for the latent trait and was found when comparing initial measurements with follow-up measurements. The correlation between the total score and the outcomes regarding overall physical and mental health was 0.52 (95% CI 0.48 to 0.56) and 0.74 (95% CI 0.72 to 0.76). Similar correlations were found for the corresponding changes over time. CONCLUSION: The scale showed high consistency and little systematic variation between the comparison groups. The concurrent correlations and analyses of responsiveness coincided with the prespecified hypotheses. Overall, we deem the Danish PRO-Psychiatry instrument to possess suitable psychometric properties for measuring self-perceived health among a psychiatric population.

Birth cohort effects on diagnosed atrial fibrillation incidence: nationwide cohort study from 1980 to 2018.

BACKGROUND: The incidence of atrial fibrillation (AF) shows substantial temporal trends, but the contribution of birth cohort effects is unknown. These effects refer to the relationship between birth year and the likelihood of developing AF. We aimed to assess trends in cumulative incidence of diagnosed AF across birth cohorts and to disentangle the effects of age, birth cohort and calendar period by using age-period-cohort analyses. METHODS: In a Danish nationwide population-based cohort study, 4.7 million individuals were selected at a given index age (45, 55, 65 and 75 years) free of AF and followed up for diagnosed AF. For each index age, we assessed trends in 10-year cumulative incidence of AF across six 5-year birth cohorts. An age-period-cohort model was estimated using Poisson regression with constrained spline functions collapsing data into 1-year intervals across ages and calendar years. RESULTS: Cumulative incidence of AF diagnosis increased across birth cohorts for all index ages (ptrend<0.001). Compared with the first birth cohort, the diagnosed AF incidence rate ratio in the last birth cohort was 3.0 (95% CI 2.9 to 3.2) for index age 45 years, 2.9 (2.8 to 3.0) for 55 years, 2.8 (2.7 to 2.8) for 65 years and 2.7 (2.6 to 2.7) for 75 years. Age-period-cohort analyses showed substantial birth cohort effects independent of age, with no clear period effect. Compared with individuals born in 1930, the diagnosed AF incidence rate was 0.125 smaller among individuals born in 1885 and was four times larger among individuals born in 1975. CONCLUSION: Substantial birth cohort effects, independent of age and calendar period, influence trends in diagnosed AF incidence.

Quality of early stroke care and long-term mortality in patients with acute stroke: A nationwide follow-up study.

INTRODUCTION: High quality of early stroke care is essential for optimizing the chance of a good patient outcome. The quality of care may be monitored by process performance measures (PPMs) and previous studies have found an association between fulfilment of PPMs and short-term mortality. However, the association with long-term mortality remains to be determined. We aimed to evaluate the association between fulfilment of PPMs and long-term mortality for patients with acute stroke in Denmark. PATIENTS AND METHODS: We used data from Danish health care registers between 2008 and 2020 to identify all patients admitted with incident stroke (haemorrhagic (ICH) or ischaemic stroke). The quality of early stroke care was assessed using 10 PPMs. Mortality was compared using Cox proportional hazard ratios, risk ratios computed using Poisson regression, and standardized relative survival. RESULTS: We included 102,742 patients; 9804 cases of ICH, 88,591 cases of ischaemic stroke, and 4347 cases of unspecified strokes. The cumulative 10-year mortality risk was 56.8%. Fulfilment of the individual PPMs was associated with adjusted hazard rate ratios of death between 0.76 and 0.96. Patients with 100% fulfilment of all PPMs had a lower 10-year post-stroke mortality (adjusted risk ratio 0.90) compared to the patients with 0%-49% fulfilment and a standardized relative survival of 81.3%, compared to the general population. CONCLUSION: High quality of early stroke care was associated with lower long-term mortality following both ICH and ischaemic stroke, which emphasizes the importance of continued attention on the ability of stroke care providers to deliver high quality of early care.

Temporal trends in lifetime risks of atrial fibrillation and its complications between 2000 and 2022: Danish, nationwide, population based cohort study.

OBJECTIVES: To examine how the lifetime risks of atrial fibrillation and of complications after atrial fibrillation changed over time. DESIGN: Danish, nationwide, population based cohort study. SETTING: Population of Denmark from 1 January 2000 to 31 December 2022. PARTICIPANTS: 3.5 million individuals (51.7% women and 48.3% men) who did not have atrial fibrillation at 45 years of age or older were followed up until incident atrial fibrillation, migration, death, or end of follow-up, whichever came first. All 362 721 individuals with incident atrial fibrillation (46.4% women and 53.6% men), but with no prevalent complication, were further followed up until incident heart failure, stroke, or myocardial infarction. MAIN OUTCOME MEASURES: Lifetime risk of atrial fibrillation and lifetime risks of complications after atrial fibrillation over two prespecified periods (2000-10 v 2011-22). RESULTS: The lifetime risk of atrial fibrillation increased from 24.2% in 2000-10 to 30.9% in 2011-22 (difference 6.7% (95% confidence interval 6.5% to 6.8%)). After atrial fibrillation, the most frequent complication was heart failure with a lifetime risk of 42.9% in 2000-10 and 42.1% in 2011-22 (-0.8% (-3.8% to 2.2%)). Individuals with atrial fibrillation lost 14.4 years with no heart failure. The lifetime risks of stroke and of myocardial infarction after atrial fibrillation decreased slightly between the two periods, from 22.4% to 19.9% for stroke (-2.5% (-4.2% to -0.7%)) and from 13.7% to 9.8% for myocardial infarction (-3.9% (-5.3% to -2.4%). No evidence was reported of a differential decrease between men and women. CONCLUSION: Lifetime risk of atrial fibrillation increased over two decades of follow-up. In individuals with atrial fibrillation, about two in five developed heart failure and one in five had a stroke over their remaining lifetime after atrial fibrillation diagnosis, with no or only small improvement over time. Stroke risks and heart failure prevention strategies are needed for people with atrial fibrillation.

Umbilical Cord pH Levels and Neonatal Morbidity and Mortality.

Importance: Umbilical cord pH (UC-pH) level is an important objective indicator of intrapartum fetal hypoxia and is used to predict neonatal morbidity and mortality. A UC-pH value of less than 7.00 is often defined as a threshold for severe acidosis, but existing evidence is divergent and largely based on UC-pH measurements from selected populations; consequently, the results are challenging to interpret. Objective: To investigate the association between UC-pH levels and the risk of adverse neonatal outcomes in a national setting with universal UC-pH measurement. Design, Setting, and Participants: This national, population-based cohort study included all liveborn, singleton, full-term infants without malformations born in Denmark from January 1, 2012, to December 31, 2018. Data were analyzed from January 1, 2023, to March 1, 2024. Exposure: Umbilical cord pH level categorized as less than 7.00, 7.00 to 7.09, 7.10 to 7.19 and 7.20 to 7.50 (reference group). Main Outcomes and Measures: The primary outcome was a composite of severe adverse neonatal outcomes: neonatal death, therapeutic hypothermia, mechanical ventilation, treatment with inhaled nitric oxide, or seizures. Secondary outcomes were individual components of the primary outcome, Apgar score, respiratory outcomes, and hypoglycemia. Data are presented as adjusted risk ratios (ARRs) with 95% CIs. Results: Among the 340 431 infants included, mean (SD) gestational age was 39.9 (1.6) weeks; mean (SD) birth weight was 3561 (480) g; and 51.3% were male. Umbilical cord pH of less than 7.20 was observed more often among infants with a gestational age of 40 or 41 weeks (31.6%-33.6% compared with 18.2%-20.2% at a gestational age of 39 weeks) and among male infants (53.9%-55.4% vs 44.6%-46.1% among female infants). Compared with the pH reference group (576 of 253 540 [0.2%]), the risk for the primary outcome was increased for the groups with UC-pH levels of less than 7.00 (171 of 1743 [9.8%]), 7.00 to 7.09 (101 of 11 904 [0.8%]), and 7.10 to 7.19 (259 of 73 244 [0.4%]). Comparable patterns were observed for the individual outcomes, except for neonatal death, which was only increased in the group with UC-pH levels of less than 7.10. The risk of treatment with continuous positive airway pressure was increased when UC-pH levels were less than 7.20, and the risk of hypoglycemia was 21.5% if UC-pH levels were less than 7.10. Conclusions and Relevance: In this cohort study of 340 431 newborn infants, results support and extend previous studies indicating a higher risk of adverse outcomes even at UC-pH levels above 7.00. The threshold for more intensive observation and treatment may be reconsidered.

Incidence and Prevalence of Concussion in Denmark from 1999-2018: A Nationwide Cohort Study.

Concussion is a common diagnosis in emergency rooms, yet contemporary incidence and prevalence estimates are sparse and rely on self-reported data. A nationwide cohort study was conducted to provide up-to-date information, covering the entire Danish population from 1999 to 2018. Hospital contacts with a concussion diagnosis, including emergency room visits, hospital admissions, and outpatient contacts, were retrieved from the Danish National Patient Registry (DNPR), and incidence rates were age-standardized and stratified. The 20-year prevalence was defined as the percentage of Danes alive in 2018 who had experienced a concussion since 1999. The diagnostic codes used were the ICD-10 code S06.0 and a local Danish code for 'observation for concussion' (DZ033D). Additional data on activities related to concussion injuries were obtained from the Accident Analysis Group at Odense University Hospital through DNPR. Findings from the study indicated that during the period 1999-2018, the total age-standardized concussion incidence rate increased by 10% to 308 per 100,000 person-years (95% confidence interval (CI): 304-313). Notable time trends included 1) a reduced sex difference from 40% to 6% (95% CI: 3%-9%), 2) a doubled incidence rate in children aged 0-1 and in seniors aged over 80, 3) an increased utilization of head imaging across all age groups, except children, 4) a decline in the proportion of traffic-related concussions, and 5) a prevalence of concussion of 4.9% (95% CI: 4.89% - 4.93%) in 2018. The increasing incidence of concussions among the elderly is concerning in light of an aging population, and warrants further investigation, as evidence-based preventive interventions for falls exist. Additionally, the increased utilization of head imaging across all age groups except children calls for attention toward avoidance of unnecessary radiation exposure. Despite a drop in traffic-related cases, concussions remain highly prevalent. In conclusion, these findings indicate that concussions are an important public health concern, necessitating ongoing surveillance, research, and targeted resource allocation to address concussion management and prevention effectively.

Prevalence and impact of SARS-CoV-2 infection among patients with acute ischaemic stroke: a nationwide register-based cohort study in Denmark.

OBJECTIVES: An increased risk of stroke has been reported among patients with COVID-19 caused by SARS-CoV-2. We aimed to investigate the nationwide prevalence of SARS-CoV-2 among patients with acute ischaemic stroke and to study the impact on stroke severity, quality of care and mortality on an individual patient level. DESIGN: This was a nationwide register-based cohort study. SETTING: We used data from several Danish registers which were linked at an individual patient level using the unique civil registration number assigned to all Danish citizens. Patients were identified from the Danish Stroke Registry and information on SARS-CoV-2 infection status was collected from the Danish National COVID-19 Registry. Concurrent SARS-CoV-2 infection was defined as a positive PCR test within 31 days prior to, and 1 day after, stroke admission. Information on comorbidity was collected from the Danish National Patient Registry and information on vital status was collected from the Danish Civil Registration System. PARTICIPANTS: A total of 11 502 patients admitted with acute ischaemic stroke from 10 March 2020 to 31 May 2021 were included in the study. RESULTS: Among the included patients, the majority (84.6%) were tested for SARS-CoV-2, but only 68 had a positive test. These patients were more prone to have atrial fibrillation and were more often treated with reperfusion therapy. They had a significantly increased risk of severe stroke (adjusted relative risk (aRR) 1.93, 95% CI: 1.22 to 3.04) and a significantly increased 30-day mortality risk (aRR 2.29, 95% CI: 1.19 to 4.39). There was no difference in the proportion of patients fulfilling relevant performance measures on quality of care. CONCLUSION: In this nationwide study, only 0.6% of patients with acute ischaemic stroke were tested positive for a concurrent SARS-CoV-2 infection. The patients with SARS-CoV-2 presented with more severe strokes.

Oral anticoagulation therapy initiation in patients with atrial fibrillation in relation to world region of origin: a register-based nationwide study.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia and results in a high risk of stroke. The number of immigrants is increasing globally, but little is known about potential differences in AF care across migrant populations. AIM: To investigate if initiation of oral anticoagulation therapy (OAC) differs for patients with incident AF in relation to country of origin. METHODS: A nationwide register-based study covering 1999-2017. AF was defined as a first-time diagnosis of AF and a high risk of stroke. Stroke risk was defined according to guidelines from the European Society of Cardiology (ESC). Poisson regression adjusted for sex, age, socioeconomic position and comorbidity was made to compute incidence rate ratios (IRR) for initiation of OAC. RESULTS: The AF population included 254 586 individuals of Danish origin, 6673 of Western origin and 3757 of non-Western origin. Overall, OAC was initiated within -30/+90 days relative to the AF diagnosis in 50.3% of individuals of Danish origin initiated OAC, 49.6% of Western origin and 44.5% of non-Western origin. Immigrants from non-Western countries had significantly lower adjusted IRR of initiating OAC according to all ESC guidelines compared with patients of Danish origin. The adjusted IRRs ranged from 0.73 (95% CI: 0.66 to 0.80) following the launch of the 2010 ESC guideline to 0.89 (95% CI: 0.82 to 0.97) following the launch of the 2001 ESC guideline. CONCLUSION: Patients with AF with a high risk of stroke of non-Western origin have persistently experienced a lower chance of initiating OAC compared with patients of Danish origin during the last decades.

Positive predictive value and sensitivity of cancer-associated venous thromboembolism diagnoses in the Danish National Patient Register.

INTRODUCTION: Hospital discharge diagnoses from administrative registries are frequently used in studies of cancer-associated venous thromboembolism, but the validity of International Classification of Diseases (ICD) codes for identifying such events is unknown. MATERIALS AND METHODS: Using patient samples from the Danish National Patient Register, we calculated positive predictive values (PPV), i.e., the proportion of registered ICD codes, which could be confirmed after manual search of the electronic health record. Sensitivity was estimated in a sample of patients with imaging-verified venous thromboembolism but without prior knowledge about their ICD coding status. Sensitivity was calculated as the proportion of these patients, who were discharged with an ICD code for venous thromboembolism. RESULTS: The overall PPV of an ICD-10 diagnosis of cancer-associated venous thromboembolism was 75.9 % (95 % confidence interval 71.3-80.0). In subgroups, the PPV was particularly low for recurrent venous thromboembolism (44.2 %), diagnoses in a secondary position (55.7 %), outpatient diagnoses (65.3 %), and diagnoses given at surgical (66.7 %), emergency wards (48.4 %), or via hospices/palliative teams (0 %). The overall sensitivity was 68 %, meaning 32 % of patients with cancer diagnosed in hospital with venous thromboembolism were discharged without any registered ICD code for venous thromboembolism. CONCLUSIONS: The positive predictive value of an ICD diagnosis of cancer-associated venous thromboembolism in the Danish Patient Register was overall adequate for research purposes, but with notable variation across subgroups. Sensitivity was limited, as 1/3 of patients with venous thromboembolism were discharged without any relevant ICD code. Cautious interpretation of incidence of cancer-associated venous thromboembolism based on administrative register-based data is warranted.

Disparities in prehospital and emergency surgical care among patients with perforated ulcers and a history of mental illness: a nationwide cohort study.

PURPOSE: To compare patients with and without a history of mental illness on process and outcome measures in relation to prehospital and emergency surgical care for patients with perforated ulcer. METHODS: A nationwide registry-based cohort study of patients undergoing emergency surgery for perforated ulcer. We used data from the Danish Prehospital Database 2016-2017 and the Danish Emergency Surgery Registry 2004-2018 combined with data from other Danish databases. Patients were categorized according to severity of mental health history. RESULTS: We identified 4.767 patients undergoing emergency surgery for perforated ulcer. Among patients calling the EMS with no history of mental illness, 51% were identified with abdominal pain when calling the EMS compared to 31% and 25% among patients with a history of moderate and major mental illness, respectively. Median time from hospital arrival to surgery was 6.0 h (IQR: 3.6;10.7). Adjusting for age, sex and comorbidity, patients with a history of major mental illness underwent surgery 46 min (95% CI: 4;88) later compared to patients with no history of mental illness. Median number of days-alive-and-out-of-hospital at 90-day follow-up was 67 days (IQR: 0;83). Adjusting for age, sex and comorbidity, patients with a history of major mental illness had 9 days (95% CI: 4;14) less alive and out-of-hospital at 90-day follow-up. CONCLUSION: One-third of the population had a history of mental illness or vulnerability. Patients with a history of major mental illness were less likely to be identified with abdominal pain if calling the EMS prior to arrival. They had longer delays from hospital arrival to surgery and higher mortality.