Anne Helms Andreasen

Randomised controlled trial of structured personal care of type 2 diabetes mellitus

Abstract Objective: To assess the effect of a multifaceted intervention directed at general practitioners on six year mortality, morbidity, and risk factors of patients with newly diagnosed type 2 diabetes. Design: Pragmatic, open, controlled trial with randomisation of practices to structured personal care or routine care; analysis after 6 years. Setting: 311 Danish practices with 474 general practitioners (243 in intervention group and 231 in comparison group). Participants: 874 (90.1%) of 970 patients aged ≥40 years who had diabetes diagnosed in 1989-91 and survived until six year follow up. Intervention: Regular follow up and individualised goal setting supported by prompting of doctors, clinical guidelines, feedback, and continuing medical education. Main outcome measures: Predefined clinical non-fatal outcomes, overall mortality, risk factors, and weight. Results: Predefined non-fatal outcomes and mortality were the same in both groups. The following risk factor levels were lower for intervention patients than for comparison patients (median values): fasting plasma glucose concentration (7.9 v 8.7 mmol/l, P=0.0007), glycated haemoglobin (8.5% v 9.0%, P<0.0001; reference range 5.4-7.4%), systolic blood pressure (145 v 150 mm Hg, P=0.0004), and cholesterol concentration (6.0 v 6.1 mmol/l, P=0.029, adjusted for baseline concentration). Both groups had lost weight since diagnosis (2.6 v 2.0 kg). Metformin was the only drug used more frequently in the intervention group (24% (110/459) v 15% (61/415)).Intervention doctors arranged more follow up consultations, referred fewer patients to diabetes clinics, and set more optimistic goals. Conclusions: In primary care, individualised goals with educational and surveillance support may for at least six years bring risk factors of patients with type 2 diabetes to a level that has been shown to reduce diabetic complications but without weight gain. What is already known on this topic Evidence is increasing that control of hyperglycaemia, hypertension, and dyslipidaemia may postpone the development of diabetic complications in patients with type 2 diabetes Maintaining good control over a long period can be difficult What this study adds Structured individualised personal care with educational and surveillance support for general practitioners reduced levels of risk factors in type 2 diabetic patients after six years Risk factors were reduced to a level that has been shown to have a beneficial effect on diabetic complications Participants also showed modest weight loss

Anastomotic leakage after anterior resection for rectal cancer: risk factors

Objective  The study aimed to identify risk factors for clinical anastomotic leakage (AL) after anterior resection for rectal cancer in a consecutive national cohort.

Epidemiology of renal involvement in newly-diagnosed middle-aged and elderly diabetic patients. Cross-sectional data from the population-based study “Diabetes Care in General Practice”, Denmark

SummaryWe report on a study in which 487 Danish general practitioners participated with the purpose of including all newly-diagnosed diabetic patients aged 40 years or more from a well-defined catchment population during a welldefined time period. A, total of 1267 diabetic patients with a median age of 65.3 years were included. Renal involvement was assessed from the albumin/creatinine ratio in a morning urine sample. Albumin/creatinie ratio was <2/2<20/≥20 mg/mmol in 59.8/33.6/6.6% of male and 66.6/28.8/4.6% of female patients. The level of albumin/creatinine ratio increased with age and the observed overall male predominance was almost confined to diabetic patients with an albumin/creatinine ratio of 5 mg/mmol or greater. By taking into account the confounding effect of age and sex, a positive association between smoking and albumin/creatinine ratio was disclosed. Moreover, high systolic blood pressure, hypertriglyceridaemia, hypercholesterolaemia (males only) and high HbA1c, but not body mass index or diastolic blood pressure were identified as correlates of elevated albumin/creatinine ratio. Glucosuria was positively correlated with albumin/creatinine ratio even when the influence of HbA1c, sex and age was taken into account. A positive correlation between serum creatinine and albumin/creatinine ratio was seen in males, but not in females. In addition, renal involvement was associated with the presence of peripheral angiopathy and diabetic retinopathy and with high resting heart rate. The cross-sectional data presented highlight the importance of reducing the overall burden of modifiable risk factors in newly-diagnosed Type 2 diabetic patients.

A nationwide study on anastomotic leakage after colonic cancer surgery

Aim  Anastomotic leakage (AL) is a major challenge in colorectal cancer surgery due to increased morbidity and mortality. Possible risk factors should be investigated differentially, distinguishing between rectal and colonic surgery in large‐scale studies to avoid selection bias and confounding.

The Danish National Health Survey 2010.: Study design and respondent characteristics.

Aims: In 2010 the five Danish regions and the National Institute of Public Health at the University of Southern Denmark conducted a national representative health survey among the adult population in Denmark. This paper describes the study design and the sample and study population as well as the content of the questionnaire. Methods: The survey was based on five regional stratified random samples and one national random sample. The samples were mutually exclusive. A total of 298,550 individuals (16 years or older) were invited to participate. Information was collected using a mixed mode approach (paper and web questionnaires). A questionnaire with a minimum of 52 core questions was used in all six subsamples. Calibrated weights were computed in order to take account of the complex survey design and reduce non-response bias. Results: In all, 177,639 individuals completed the questionnaire (59.5%). The response rate varied from 52.3% in the Capital Region of Denmark sample to 65.5% in the North Denmark Region sample. The response rate was particularly low among young men, unmarried people and among individuals with a different ethnic background than Danish. Conclusions: The survey was a result of extensive national cooperation across sectors, which makes it unique in its field of application, e.g. health surveillance, planning and prioritizing public health initiatives and research. However, the low response rate in some subgroups of the study population can pose problems in generalizing data, and efforts to increase the response rate will be important in the forthcoming surveys.

Hormone therapy and risk of myocardial infarction: a national register study.

AIM To assess the risk of myocardial infarction (MI) as a result of hormone therapy (HT), with focus on the influence of age, duration of HT, various regimens and routes, progestagen type, and oestrogen dose. METHODS AND RESULTS All healthy Danish women (n = 698,098, aged 51-69) were followed during 1995-2001. On the basis of a central prescription registry, daily updated national capture on HT was determined. National Registers identified 4947 MI incidents. Poisson regression analyses estimated rate ratios (RRs). Overall, we found no increased risk [RR 1.03 (95% CI: 0.95-1.11)] of MI with the current HT compared with women who never used HT; age-stratified RR among women aged 51-54, 55-59, 60-64, and 65-69 years were 1.24 (1.02-1.51), 0.96 (0.82-1.12), 1.11 (0.97-1.27), and 0.92 (0.80-1.06), respectively. An increasing risk with longer duration was found for younger women, which was not observed with older age groups. In all age groups, the highest risk of MI was found with continuous HT regimen. No increased risk was found with unopposed oestrogen, cyclic combined therapy, or tibolone. Significantly lower risk was found with dermal route than oral unopposed oestrogen therapy (P = 0.04). No associations were found with progestagen type or oestrogen dose. CONCLUSION In a National cohort study, we found that HT regimen and route of application could modify the influence of HT on the risk of MI.

Assessment of habitual energy and macronutrient intake in adults: comparison of a seven day food record with a dietary history interview

Objective: To examine the quantitative agreement between a 7 day food record and a diet history interview when these are conducted under the same conditions and to evaluate whether the two methods assess habitual diet intake differently among subgroups of age and body mass index (BMI).Design: Cross-sectional study.Setting: Population study, Denmark.Subjects: A total of 175 men and 173 women aged 30–60 y, selected randomly from a larger population sample of Danish adults.Interventions: All subjects had habitual diet intake assessed by a diet history interview and completed a 7 day food record within 3 weeks following the interview. The diet history interview and coding of records were performed by the same trained dietician.Main outcome measure: Median between-method difference in assessment of total energy intake, absolute intake of macronutrients, and nutrient energy percentages. Difference between reported energy intake from both methods and estimated energy expenditure in different subgroups.Results: Energy and macronutrient intake was assessed slightly higher by the 7 day food record than by the diet history interview, but in absolute terms the differences were negligible. The between-method difference in assessment of total energy intake appeared to be stable over the range of age and BMI in both sexes. As compared to estimated total energy expenditure, both diet assessment methods underestimated energy intake by approximately 20%. For both methods the under-reporting increased by BMI in both sexes and by age in men.Conclusions: Energy and macronutrient intake data collected under even conditions by either a 7 day food record or a diet history interview may be collapsed and analysed independent of the underlying diet method. Both diet methods, however, appear to underestimate energy intake dependent on age and BMI.Sponsorship: Danish Medical Research Council, the FREJA programme.

Impact of Age and Gender on the Prevalence and Prognostic Importance of the Metabolic Syndrome and Its Components in Europeans. The MORGAM Prospective Cohort Project

Objective To investigate the influence of age and gender on the prevalence and cardiovascular disease (CVD) risk in Europeans presenting with the Metabolic Syndrome (MetS). Methods Using 36 cohorts from the MORGAM-Project with baseline between 1982–1997, 69094 men and women aged 19–78 years, without known CVD, were included. During 12.2 years of follow-up, 3.7%/2.1% of men/women died due to CVD. The corresponding percentages for fatal and nonfatal coronary heart disease (CHD) and stroke were 8.3/3.8 and 3.1/2.5. Results The prevalence of MetS, according to modified definitions of the International Diabetes Federation (IDF) and the revised National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATPIII), increased across age groups for both genders (P<0.0001); with a 5-fold increase in women from ages 19–39 years to 60–78 years (7.4%/7.6% to 35.4%/37.6% for IDF/NCEP-ATPIII) and a 2-fold increase in men (5.3%/10.5% to 11.5%/21.8%). Using multivariate-adjusted Cox regressions, the associations between MetS and all three CVD events were significant (P<0.0001). For IDF/NCEP-ATPIII in men and women, hazard ratio (HR) for CHD was 1.60/1.62 and 1.93/2.03, for CVD mortality 1.73/1.65 and 1.77/2.06, and for stroke 1.51/1.53 and 1.58/1.77. Whereas in men the HRs for CVD events were independent of age (MetS*age, P>0.05), in women the HRs for CHD declined with age (HRs 3.23/3.98 to 1.55/1.56; MetS*age, P = 0.01/P = 0.001 for IDF/NCEP-ATPIII) while the HRs for stroke tended to increase (HRs 1.31/1.25 to 1.55/1.83; MetS*age, P>0.05). Conclusion In Europeans, both age and gender influenced the prevalence of MetS and its prognostic significance. The present results emphasise the importance of being critical of MetS in its current form as a marker of CVD especially in women, and advocate for a redefinition of MetS taking into account age especially in women.

Anastomotic leakage after curative anterior resection for rectal cancer: short and long-term outcome.

Objective  The influence of symptomatic anastomotic leakage (AL) after anterior resection (AR) for rectal cancer on short and long‐term mortality and local and distant recurrence was analysed.

Hormone Therapy and Different Ovarian Cancers: A National Cohort Study

Postmenopausal hormone therapy use increases the risk of ovarian cancer. In the present study, the authors examined the risks of different histologic types of ovarian cancer associated with hormone therapy. Using Danish national registers, the authors identified 909,946 women who were followed from 1995-2005. The women were 50-79 years of age and had no prior hormone-sensitive cancers or bilateral oophorectomy. Hormone therapy prescription data were obtained from the National Register of Medicinal Product Statistics. The National Cancer and Pathology Register provided data on ovarian cancers, including information about tumor histology. The authors performed Poisson regression analyses that included hormone exposures and confounders as time-dependent covariates. In an average of 8.0 years of follow up, 2,681 cases of epithelial ovarian cancer were detected. Compared with never users, women taking unopposed oral estrogen therapy had increased risks of both serous tumors (incidence rate ratio (IRR) = 1.7, 95% confidence interval: 1.4, 2.2) and endometrioid tumors (IRR = 1.5, 95% confidence interval: 1.0, 2.4) but decreased risk of mucinous tumors (IRR = 0.3, 95% confidence interval: 0.1, 0.8). Similar increased risks of serous and endometrioid tumors were found with estrogen/progestin therapy, whereas no association was found with mucinous tumors. Consistent with results from recent cohort studies, the authors found that ovarian cancer risk varied according to tumor histology. The types of ovarian tumors should be given attention in future studies.