Rasmus Køster-Rasmussen

The role of diseases, risk factors and symptoms in the definition of multimorbidity – a systematic review

Abstract Objective is to explore how multimorbidity is defined in the scientific literature, with a focus on the roles of diseases, risk factors, and symptoms in the definitions. Design: Systematic review. Methods: MEDLINE (PubMed), Embase, and The Cochrane Library were searched for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diagnoses, risk factors, and symptoms. We reviewed 163 articles. In 61 articles (37%), the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions, with diabetes as the most frequent. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways. The definition of multimorbidity is heterogeneous and risk factors are more often included than symptoms. The severity of conditions is seldom included. Since the number of people living with multimorbidity is increasing there is a need to develop a concept of multimorbidity that is more useful in daily clinical work. Key Points The increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice. Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4–147 different conditions. Diseases are included in all definitions of multimorbidity. Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included.

Adjunctive steroid treatment: Local guidelines and patient outcome in adult bacterial meningitis

Our objective was to evaluate local guidelines regarding early steroid treatment in adult community acquired bacterial meningitis, and assess the actual treatment given and its correlation to clinical outcome. Patient outcome was obtained retrospectively from the medical records of 210 adults admitted to 47 hospitals in Denmark during 2002–2004 (population 5.4 million) and was combined with results from a questionnaire regarding treatment guidelines in these hospitals. In 36 of 47 departments responding to the questionnaire, 21 recommended early steroid treatment, but none did so initially during 2002. Early steroid treatment was given to 15% of patients and was given more often when recommended locally (41% vs 11%, OR =5.7 (2.4–13.5)). Unfavourable outcome was demonstrated rarely in patients treated with early steroids compared to the non-steroid group (17% vs 42%, p<0.05). In the 32 cases with petechial skin lesions, these were caused by pneumococci (15), meningococci (15), Staphylococcus aureus (1) and enterococci (1), and thus the presence of such lesions should not make the clinician abstain from early steroid treatment of bacterial meningitis. In conclusion, concordance with the new consensus of early steroid treatment was poor on a national basis, and better (41%) when adequate local guidelines were available. Early steroid treatment was associated with favourable outcome, and improved implementation of adequate guidelines may contribute to better patient outcome in bacterial meningitis.

Weight Changes following the Diagnosis of Type 2 Diabetes: The Impact of Recent and Past Weight History before Diagnosis. Results from the Danish Diabetes Care in General Practice (DCGP) Study

Aims The association between recent and more distant weight changes before and after the diagnosis of type 2 diabetes has been little researched. The aim of this study is to determine the influence of patients’ weight history before diabetes diagnosis on the observed 6-year weight changes after diagnosis. Methods A clinical cohort study combined with self-reported past weight history. In total 885 patients aged ≥40 years and newly diagnosed with clinical type 2 diabetes were included. Body weight was measured immediately after diabetes diagnosis and again at the 6-year follow up examination (median, 5.7 years). At diagnosis patients reported their weight 1 year and 10 years previously, and also at the age of 20. Multivariate linear regression analyses controlled for 20 baseline patient characteristics. Results The median (interquartile range) age at diagnosis was 63.2 (53.9; 71.4) years. Median body weight was 80.0 (72.0; 90.0) kg 10 years before diagnosis, 85.0 (75.0; 95.0) kg 1 year before diagnosis, 82.4 (72.0; 94.0) kg at diagnosis, and 80.0 (70.0; 91.1) kg at 6-year follow up. Each kg of weight gain during the year preceding the diagnosis was associated with a weight change (95% CI) of -0.20 (-0.28; -0.13) kg during the follow up period. In all models age and body mass index at diagnosis predicted future weight changes, while the weight at age 20 (-0.01 (-0.06; 0.03) kg/kg), and the weight change from 10 years to 1 year before diagnosis (-0.01 (-0.06; 0.04) kg/kg), did not predict weight change after diagnosis. Conclusions During the first on average 5.7 years after diagnosis of type 2 diabetes, patients generally follow a course of declining average weight, and these weight developments are related primarily to recent weight changes, body mass index, and age, but not to the more distant weight history.

Intentional Weight Loss and Longevity in Overweight Patients with Type 2 Diabetes: A Population-Based Cohort Study.

Objective This study examined the influence of weight loss on long-term morbidity and mortality in overweight (BMI≥25kg/m2) patients with type 2 diabetes, and tested the hypothesis that therapeutic intentional weight loss supervised by a medical doctor prolongs life and reduces the risk for cardiovascular disease in these patients. Methods This is a 19 year cohort study of patients in the intervention arm of the randomized clinical trial Diabetes Care in General Practice. Weight and prospective intentions for weight loss were monitored every third month for six years in 761 consecutive patients (≥40 years) newly diagnosed with diabetes in general practices throughout Denmark in 1989–92. Multivariable Cox regression was used to estimate the association between weight change during the monitoring period (year 0 to 6) and the outcomes during the succeeding 13 years (year 6 to 19) in 444 patients who were overweight at diagnosis and alive at the end of the monitoring period (year 6). The analysis was adjusted for age, sex, education, BMI at diagnosis, change in smoking, change in physical activity, change in medication, and the Charlson comorbidity 6-year score. Outcomes were from national registers. Results Overall, weight loss regardless of intention was an independent risk factor for increased all-cause mortality (P<0.01). The adjusted hazard ratio for all-cause mortality, cardiovascular mortality, and cardiovascular morbidity attributable to an intentional weight loss of 1 kg/year was 1.20 (95%CI 0.97–1.50, P = 0.10), 1.26 (0.93–1.72, P = 0.14), and 1.06 (0.79–1.42, P = 0.71), respectively. Limiting the analysis to include only those patients who survived the first 2 years after the monitoring period did not substantially change these estimates. A non-linear spline estimate indicated a V-like association between weight change and all-cause mortality, suggesting the best prognosis for those who maintained their weight. Conclusions In this population-based cohort of overweight patients with type 2 diabetes, successful therapeutic intentional weight loss, supervised by a doctor over six years, was not associated with reduced all-cause mortality or cardiovascular morbidity/mortality during the succeeding 13 years.

Mercury Pollution from Small-Scale Gold Mining Can Be Stopped by Implementing the Gravity-Borax Method – A Two-Year Follow-Up Study from Two Mining Communities in the Philippines:

Mercury is used globally to extract gold in artisanal and small-scale gold mining. The mercury-free gravity-borax method for gold extraction was introduced in two mining communities using mercury in the provinces Kalinga and Camarines Norte. This article describes project activities and quantitative changes in mercury consumption and analyzes the implementation with diffusion of innovations theory. Activities included miner-to-miner training; seminars for health-care workers, school teachers, and children; and involvement of community leaders. Baseline (2011) and follow-up (2013) data were gathered on mining practices and knowledge about mercury toxicology. Most miners in Kalinga converted to the gravity-borax method, whereas only a few did so in Camarines Norte. Differences in the nature of the social systems impacted the success of the implementation, and involvement of the tribal organization facilitated the shift in Kalinga. In conclusion, the gravity-borax method is a doable alternative to mercury use in artisanal and small-scale gold mining, but support from the civil society is needed.

Back on track—Smoking cessation and weight changes over 9 years in a community-based cohort study

OBJECTIVE To examine the impact of smoking cessation on body weight compared with normal long-term weight development. METHODS Of 1970 adults (20-69 years) in a rural town in Denmark invited to take part in the study in 1998-2000, 1374 (70%) participated. After 9 years, 1121 participated in the follow-up study. Weight changes were compared using multivariable regression models. RESULTS The mean baseline weight of never-smokers was 76.4 kg (SD 16.0). The adjusted weight of smokers and ex-smokers differed by -4.2 kg (95% CI: -5.9, -2.6), and -0.7 kg (95% CI: -2.5, 1.1), respectively. The adjusted weight gain rate (kg/year) of never-smokers, smokers, and ex-smokers was 0.213, 0.127, and 0.105, respectively. The absolute post cessation weight gain (PCWG) was 5.0 kg (SD 7.0), and the adjusted PCWG was 2.8 kg (95% CI: 1.7, 3.9) compared with never-smokers, and 3.5 kg (95% CI: 2.3, 4.8) compared with smokers. The follow-up weight did not differ between quitters and never-smokers (0.1 kg; 95% CI: -2.4, 2.6). CONCLUSION Smokers weigh less than never-smokers. By quitting, they gain weight and end up weighing the same as comparable never-smokers. Weight gain rates differ by smoking status. Consequently, PCWG depends on the length of follow-up. Our graphical model indicates that smoking cessation results in a return to normal weight development.

Identifying practice-related factors for high-volume prescribers of antibiotics in Danish general practice

Objectives In Denmark, general practice is responsible for 75% of antibiotic prescribing in the primary care sector. We aimed to identify practice-related factors associated with high prescribers, including prescribers of critically important antibiotics as defined by WHO, after accounting for case mix by practice. Methods We performed a nationwide register-based survey of antibiotic prescribing in Danish general practice from 2012 to 2013. The unit of analysis was the individual practice. We used multivariable regression analyses and an assessment of relative importance to identify practice-related factors driving high antibiotic prescribing rates. Results We included 98% of general practices in Denmark ( n  =   1962) and identified a 10% group of high prescribers who accounted for 15% of total antibiotic prescriptions and 18% of critically important antibiotic prescriptions. Once case mix had been accounted for, the following practice-related factors were associated with being a high prescriber: lack of access to diagnostic tests in practice (C-reactive protein and urine culture); high use of diagnostic tests (urine culture and strep A throat test); a low percentage of antibiotic prescriptions issued over the phone compared with all antibiotic prescriptions; and a high number of consultations per 1000 patients. We also found that a low number of consultations per 1000 patients was associated with a reduced likelihood of being a high prescriber of antibiotics. Conclusions An apparent underuse or overuse of diagnostic tests in general practice as well as organizational factors were associated with high-prescribing practices. Furthermore, the choice of antibiotic type seemed less rational among high prescribers.

The impact of patients’ involvement in cooking on their mortality and morbidity: A 19-year follow-up of patients diagnosed with type 2 diabetes mellitus

Abstract Objective. This study explored the impact of involvement in cooking on long-term morbidity and mortality among patients newly diagnosed with type 2 diabetes mellitus (T2DM). Design and subjects. Data are from the population-based study Diabetes Care in General Practice. In baseline questionnaires, 1348 patients newly diagnosed with T2DM gave information on how frequently they consumed a warm main meal and how often they cooked it themselves. The selected patients were followed up for 19 years in the Danish National Patient Registry and the Danish Register of Causes of Death. Main outcome measures. This study analysed the association between involvement in cooking and each of seven pre-specified outcomes was analysed in Cox regression models with stepwise adjustment for possible confounders and mediators. Results. 92% of the patients with T2DM consumed a warm main meal = five times per week. Among these, women who cooked for themselves less than once a week had a higher risk of diabetes-related deaths (HR 1.86 [95% CI 1.03–3.35], p = 0.039) and stroke (HR 2.47 [95% CI 1.08–5.65], p = 0.033), after adjustment for confounders. For men, infrequent cooking was not related to increased risk for the outcomes investigated. Conclusions. In patients newly diagnosed with T2DM and with a regular intake of warm main meals, infrequent involvement in cooking was associated with an increased risk of diabetes-related death and stroke for women, but not for men. General practitioners should pay special attention to managing diabetes treatment in female patients newly diagnosed with T2DM who report infrequent involvement in cooking.

Urinary albumin and 8-oxo-7,8-dihydroguanosine as markers of mortality and cardiovascular disease during 19 years after diagnosis of type 2 diabetes - a comparative study of two markers to identify high risk patients

Urinary albumin is an important biomarker used to identify high risk patients with diabetes, but there is a need for new biomarkers that alone or in combination with urinary albumin could give an even better prediction of clinical patient outcomes. One promising biomarker is 8-oxo-7,8-dihydroguanosine (8-oxoGuo) that represents intracellular oxidative stress. We investigated the ability of microalbuminuria (MA) and urinary 8-oxoGuo, alone and in combination, to predict mortality and cardiovascular disease (CVD) in patients with type 2 diabetes. We used data from 1381 newly diagnosed diabetes patients, and urinary albumin and 8-oxoGuo were assessed in morning urine collected at the time of diabetes diagnosis and at a follow-up visit 6 years later. Associations between the urinary markers and mortality and CVD were assessed in Cox proportional hazards regression models. Test performance was assessed using sensitivity, specificity, positive predictive value and negative predictive value for 10-year mortality and 10-year incidence of CVD. Both 8-oxoGuo and urinary albumin were statistically significantly associated with all-cause mortality at diagnosis as well as at 6-year follow-up. At diagnosis only urinary albumin was associated with CVD. In contrast, only 8-oxoGuo was associated with CVD at 6-year follow-up. When investigating test performance, we found that by combining information from MA and 8-oxoGuo the ability to correctly identify patients at risk could be improved. The findings suggest that measurement of urinary 8-oxoGuo provides additional information about risk to that obtained from urinary albumin, and that the combined use of 8-oxoGuo and urinary albumin could be useful for a better identification of patients at risk of CVD and death.

The effect of structured personal care on diabetes symptoms and self-rated health over 14 years after diabetes diagnosis

AIMS To explore the effect of structured personal care on diabetes symptoms and self-rated health over 14 years after diabetes diagnosis while patients are gradually diagnosed with other chronic conditions (multimorbidity). METHODS Post hoc analysis of the Danish randomized controlled trial Diabetes Care in General Practice including 1381 patients newly diagnosed with type 2 diabetes. The effect of structured personal care compared with routine care on diabetes symptoms and self-rated health was analysed 6 and 14 years after diagnosis with a generalized multilevel Rasch model. RESULTS Structured personal care reduced the overall likelihood of reporting diabetes symptoms at the end of the intervention (OR 0.79; 95% CI: 0.64-0.97), but this effect was not explained by glycaemic control or multimorbidity. There was no effect of the intervention on diabetes symptoms after 14 years or on self-rated health after 6 years or 14 years. CONCLUSIONS Structured personal care had a beneficial effect on diabetes symptoms 6 years after diagnosis, but not on self-rated health at either follow up point. To optimally manage patients over time it is important to supplement clinical information by information provided by the patients.