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1.  Validity of reaction to severe stress and adjustment disorder diagnoses in the Danish Psychiatric Central Research Registry 
Clinical Epidemiology  2015;7:235-242.
To assess the validity of reaction to severe stress and adjustment disorder diagnoses registered in the Danish Psychiatric Central Research Register (DPCRR), to examine the documentation of stressful and traumatic events in the medical records, and to investigate the occurrence of stress diagnoses among persons not registered in the DPCRR.
Among 101,633 patients diagnosed with International Classification of Diseases, 10th Edition (ICD-10) F43 diagnoses between 1995 and 2011, we selected 50 patients from two hospitals (100 total), comprising one above and one below median age for each diagnosis for five time periods, and reviewed their medical records. We calculated the positive predictive value, comparing registration in the DPCRR with the original medical records, and captured data on stressful life events. Two general practitioners were queried about 50 patients without a stress diagnosis in the DPCRR, regarding whether they had ever received a stress diagnosis.
The positive predictive value was 58% for acute stress reaction, 83% for posttraumatic stress disorder, 94% for adjustment disorder, 71% for other reactions to severe stress, and 68% for reaction to severe stress, unspecified. In 80% of the records, a stressful or traumatic event was noted. Of 100 patients without an F43 diagnosis in the DPCRR, seven had a stress diagnosis.
The DPCRR represents a valid and comprehensive resource for research on reaction to severe stress and adjustment disorders, particularly for posttraumatic stress disorder and adjustment disorder.
PMCID: PMC4381891  PMID: 25870515
validity (epidemiology); stress disorders; traumatic; Denmark
2.  Statin prescription patterns, adherence, and attainment of cholesterol treatment goals in routine clinical care: a Danish population-based study 
Clinical Epidemiology  2015;7:213-223.
To examine the annual rate and cumulative prevalence of statin use in Denmark 2004–10, including adherence of use and attainment of cholesterol targets.
We included all individuals aged 18–86 years with a first statin prescription in Northern Denmark in 2004–10. We calculated the annual rate and cumulative prevalence of statin use. We examined cholesterol values before and after start of statins and the proportion reaching targets according to European guidelines and cardiovascular risk group.
The study population consisted of 161,646 new statin users (51% men; median age 62 years). The peak rate of new statin initiators occurred in 2008, and a cumulative prevalence of 94 users per 1,000 population was reached in 2010. In total, 98% of new users started with simvastatin. Eighty-eight percent (142,897) did not switch statin type during follow-up. Overall persistence was 84%. The reduction in median total cholesterol in new statin users was 28% (from 6.3 mmol/L to 4.5 mmol/L), while it was 43% (from 4.0 mmol/L to 2.3 mmol/L) for low-density lipoprotein cholesterol. Among patients with very high cardiovascular risk, 66% attained the recommended total cholesterol target; corresponding figures were 74% among high-risk patients and 80% among low- to moderate-risk patients. Corresponding figures for low-density lipoprotein cholesterol were 54%, 82%, and 88%, respectively.
Statin use has become very prevalent in Danish adults, with high adherence. Cholesterol reduction after statin initiation is similar to that found in clinical trials, yet a substantial proportion of patients does not reach target cholesterol levels.
PMCID: PMC4345937  PMID: 25759601
statin; cholesterol attainment; Denmark; persistence
3.  Lifestyle Factors Associated with Type 2 Diabetes and Use of Different Glucose-Lowering Drugs: Cross-Sectional Study 
PLoS ONE  2014;9(11):e111849.
To examine the lifestyle profile among persons with and without Type 2 diabetes mellitus (DM) and among users of different glucose-lowering drugs.
We used questionnaire data from a Danish health survey and identified presence of Type 2 DM and use of medications through medical databases. We calculated age- and gender-standardized prevalence ratios (PRs) of lifestyle factors according to Type 2 DM and different glucose-lowering drugs.
Of 21,637 survey participants aged 25–79 years, 680 (3%) had Type 2 DM (median age 63 years) with a median diabetes duration of 5 years. Participants with Type 2 DM had a substantially higher prevalence of obesity (36% vs. 13%, PR: 3.1, 95% confidence interval (CI): 2.8–3.6), yet more reported to eat a very healthy diet (25% vs. 21%, PR: 1.2, 95% CI: 1.0–1.4) and to exercise regularly (67% vs. 53%, PR: 1.3, 95% CI: 1.2–1.4). Also, fewer were current smokers or had high alcohol intake. When compared with metformin users, obesity was substantially less prevalent in users of sulfonylurea (PR: 0.5, 95% CI: 0.4–0-8), and insulin and analogues (PR: 0.4, 95% CI: 0.3–0.7). Tobacco smoking was more prevalent in sulfonylurea users (PR: 1.4, 95% CI: 0.9–2.1) compared with metformin users. We found no material differences in physical exercise, diet or alcohol intake according to type of glucose-lowering drug.
Type 2 DM patients are substantially more obese than other individuals, but otherwise report to have a healthier lifestyle. Metformin use is strongly associated with obesity, whereas sulfonylurea use tends to be associated with tobacco smoking.
PMCID: PMC4219789  PMID: 25369331
4.  Lifestyle and clinical factors associated with elevated C-reactive protein among newly diagnosed Type 2 diabetes mellitus patients: a cross-sectional study from the nationwide DD2 cohort 
We aimed to examine the prevalence of and modifiable factors associated with elevated C-reactive Protein (CRP), a marker of inflammation, in men and women with newly diagnosed Type 2 Diabetes mellitus (DM) in a population-based setting.
CRP was measured in 1,037 patients (57% male) with newly diagnosed Type 2 DM included in the prospective nationwide Danish Centre for Strategic Research in Type 2 Diabetes (DD2) project. We assessed the prevalence of elevated CRP and calculated relative risks (RR) examining the association of CRP with lifestyle and clinical factors by Poisson regression, stratified by gender. We used linear regression to examine the association of CRP with other biomarkers.
The median CRP value was 2.1 mg/L (interquartile range, 1.0 – 4.8 mg/L). In total, 405 out of the 1,037 Type 2 DM patients (40%) had elevated CRP levels (>3.0 mg/L). More women (46%) than men (34%) had elevated CRP. Among women, a lower risk of elevated CRP was observed in patients receiving statins (adjusted RR (aRR) 0.7 (95% confidence interval (CI) 0.6-0.9)), whereas a higher risk was seen in patients with central obesity (aRR 2.3 (95% CI 1.0-5.3)). For men, CRP was primarily elevated among patients with no regular physical activity (aRR 1.5 (95% CI 1.1-1.9)), previous cardiovascular disease (aRR1.5 (95% CI 1.2-1.9) and other comorbidity. For both genders, elevated CRP was 1.4-fold increased in those with weight gain >30 kg since age 20 years. Sensitivity analyses showed consistent results with the full analysis. The linear regression analysis conveyed an association between high CRP and increased fasting blood glucose.
Among newly diagnosed Type 2 DM patients, 40% had elevated CRP levels. Important modifiable risk factors for elevated CRP may vary by gender, and include low physical activity for men and central obesity and absence of statin use for women.
PMCID: PMC4161271  PMID: 25163828
C-reactive protein; Lifestyle factors; Obesity; Physical activity
5.  The functional barometer –a self-report questionnaire in accordance with the international classification of functioning, disability and health for pain related problems; validity and patient-observer comparisons 
The International Classification of Functioning, Disability and Health, (ICF) provides a unified, international standardized framework for describing and classifying health and health-related functioning and disability. Based on an ICF core sets the Functional Barometer, (FB), was developed for assessments of perceived pain-related problems with functions, activity and quality-of-life by patients suffering from long-term pain. The aim was to evaluate the construct validity, and to compare the assessments of a patient’s problems from the perspectives of the patient and of the examining professional when using the validated FB and corresponding ICF-classification form, respectively.
Patients with long-term pain for more than 3 months that visited one of four pain clinics during specified time periods of data collections were eligible. The self-report Balanced Inventory for Spinal disorders was used for validation of the FB. Correspondingly to the validated FB an ICF-classification form for professional’s assessment was developed. The data sets for these inter-scale and the patient-professional comparisons were collected adjacent to the clinical examination. By the statistical method used for evaluation of the pairs of ordinal data presence of systematic disagreement was identified and measured separately from additional individual variations.
The validation process resulted in a revised FB(2.0) that meets the requirements of good construct and content validity. The professionals’ ICF-classifications of the patients’ problems disagreed with the patients’ assessments on the FB(2.0); the percentage agreements ranged from 18% to 51%. The main reason was that the practitioners systematically underestimated the patients’ levels of problems but the different professionals contributed also to a large individual variability (noise) in assessment.
This study presents an ICF-based validated self-report questionnaire, The FB, to be used for identifying and describing pain-related problems with current functioning, activities and quality-of-life as perceived by patients suffering from long-term pain. The strong evidences of underestimation of the patients’ problems and the variability in the professionals’ ICF-classifications demonstrated the importance of describing the patient’s problems both from the patient’s and the professional’s perspective beneficial for the patient’s rehabilitation.
PMCID: PMC4002556  PMID: 24758709
Disagreement measures; ICF; Ordinal data; Pain; Patient-professional disagreement; Questionnaire; Rehabilitation; Validity
6.  Does marriage protect against hospitalization with pneumonia? A population-based case-control study 
Clinical Epidemiology  2013;5:397-405.
To reduce the increasing burden of pneumonia hospitalizations, we need to understand their determinants. Being married may decrease the risk of severe infections, due to better social support and healthier lifestyle.
Patients and methods
In this population-based case-control study, we identified all adult patients with a first-time pneumonia-related hospitalization between 1994 and 2008 in Northern Denmark. For each case, ten sex- and age-matched population controls were selected from Denmark’s Civil Registration System. We performed conditional logistic regression analysis to estimate the odds ratios (ORs) for pneumonia hospitalization among persons who were divorced, widowed, or never married, as compared with married persons, adjusting for age, sex, 19 different comorbidities, alcoholism-related conditions, immunosuppressant use, urbanization, and living with small children.
The study included 67,162 patients with a pneumonia-related hospitalization and 671,620 matched population controls. Compared with controls, the pneumonia patients were more likely to be divorced (10% versus 7%) or never married (13% versus 11%). Divorced and never-married patients were much more likely to have previous diagnoses of alcoholism-related conditions (18% and 11%, respectively) compared with married (3%) and widowed (6%) patients. The adjusted OR for pneumonia-related hospitalization was increased, at 1.29 (95% confidence interval [CI]: 1.25–1.33) among divorced; 1.15 (95% CI: 1.12–1.17) among widowed; and 1.33 (95% CI: 1.29–1.37) among never-married individuals as compared with those who were married.
Married individuals have a decreased risk of being hospitalized with pneumonia compared with never-married, divorced, and widowed patients.
PMCID: PMC3797619  PMID: 24143123
marital status; risk; mortality; immune function
7.  Existing data sources for clinical epidemiology: Danish registries for studies of medical genetic diseases 
Clinical Epidemiology  2013;5:249-262.
Denmark has an extensive collection of national and regional medical registries. There are many advantages to registry-based research when investigating genetic diseases which, due to their rarity, can be difficult to identify. In this study, we aimed to provide an updated overview of Danish registries for medical genetic conditions and describe how data linkage across registries can be used to collect data on genetic diseases at the individual level and at the family level. We present a list of medical genetic registries in Denmark at the national level, data sources from the departments of clinical genetics and other specialized centers, and project-specific data sources. We also summarize key general registries, such as the Danish National Registry of Patients, the Danish Medical Birth Registry, and the Civil Registration System, which are renowned for their comprehensive and high quality data, and are useful supplemental data sources for genetic epidemiology research. We describe the potential for data linkage across multiple registries, which allows for access to medical histories with follow-up time spanning birth to death. Finally, we provide a brief introduction to the Danish epidemiological research setting and legalities related to data access. The Danish collection of medical registries is a valuable resource for genetic epidemiology research.
PMCID: PMC3745287  PMID: 23966801
epidemiology; registry-based research; genetic disorders
8.  Sleep problems in Parkinson's disease: a community-based study in Norway 
BMC Neurology  2012;12:71.
The purpose of this study was to examine the prevalence of sleep problems in a community-based sample of patients with Parkinson’s disease (PD) in Norway, and their associated factors.
176 consecutive PD outpatients (41% females) were included in a study of non-motor symptoms, including sleep problems. All participants responded to the Parkinson’s Disease Sleep Scale (PDSS), where an overall score below 82 or a score below 5 on a sub-item indicate possible sleep problem. Factors associated with sleep were also investigated, with special emphasis on severity of PD, fatigue, mental health and restless legs syndrome (RLS).
The mean age was 68.5 years (range 35–90); the mean Hoehn and Yahr stage was 2.11 (SD 0.86), and the mean UPDRS part III was 22.3 (SD 11.7). Sleep problems were common among PD patients. While only 17% of the sample had an overall score below 82 on the PDSS, 70% of the patients had a score below 5 on one item. There was no significant association between PD severity and any of the sleep items in the PDSS; whereas fatigue, mental health problems, and RLS were associated with PDSS score.
The current findings call for increased awareness of sleep problems in PD patients, especially focusing on the association with mental health problems, fatigue and RLS.
PMCID: PMC3472275  PMID: 22883600
Sleep; Parkinson; Prevalence; Norway; Associated factors
9.  Changes in body mass index by age, gender, and socio-economic status among a cohort of Norwegian men and women (1990–2001) 
BMC Public Health  2007;7:269.
Consistent with global trends, the prevalence of obesity is increasing among Norwegian adults. This study aimed to investigate individual trends in BMI (kg/m2) by age, gender, and socio-economic status over an 11-year period.
A cohort of 1169 adults (n = 581 men; n = 588 women) self-reported BMI during a general health interview twice administered in two regions in Norway.
Average BMI increased significantly from 23.7 (SD = 3.4) to 25.4 (SD = 3.8), with equivalent increases for both genders. Proportion of obesity (BMI ≥ 30) increased from 4% to 11% for women and 5% to 13% for men. Of those already classified as overweight or obese in 1990, 68% had gained additional weight 10 years later, by an average increase of 2.6 BMI units. The greatest amount of weight gain occurred for the youngest adults (aged 20–29 years). Age-adjusted general linear models revealed that in 1990, women with a lower level of education had a significantly greater BMI than more educated women. In both 1990 and 2001, rural men with the highest level of household income had a greater BMI than rural men earning less income. Weight gain occurred across all education and income brackets, with no differential associations between SES strata and changes in BMI for either gender or region.
Results demonstrated significant yet gender-equivalent increases in BMI over an 11-year period within this cohort of Norwegian adults. Whereas socio-economic status exerted minimal influence on changes in BMI over time, young adulthood appeared to be a critical time period at which accelerated weight gain occurred.
PMCID: PMC2222164  PMID: 17903273
10.  Lack of interchangeability between visual analogue and verbal rating pain scales: a cross sectional description of pain etiology groups 
Rating scales like the visual analogue scale, VAS, and the verbal rating scale, VRS, are often used for pain assessments both in clinical work and in research, despite the lack of a gold standard. Interchangeability of recorded pain intensity captured in the two scales has been discussed earlier, but not in conjunction with taking the influence of pain etiology into consideration.
In this cross-sectional study, patients with their pain classified according to its etiology (chronic/idiopathic, nociceptive and neuropathic pain) were consecutively recruited for self-assessment of their actual pain intensity using a continuous VAS, 0–100, and a discrete five-category VRS. The data were analyzed with a non-parametric statistical method, suitable for comparison of scales with different numbers of response alternatives.
An overlapping of the VAS records relative the VRS categories was seen in all pain groups. Cut-off positions for the VAS records related to the VRS categories were found lower in patients with nociceptive pain relative patients suffering from chronic/idiopathic and neuropathic pain. When comparing the VAS records transformed into an equidistant five-category scale with the VRS records, systematic disagreements between the scales was shown in all groups. Furthermore, in the test-retest a low percentage of the patients agreed to the same pain level on the VAS while the opposite hold for the VRS.
The pain intensity assessments on VAS and VRS are in this study, not interchangeable due to overlap of pain records between the two scales, systematic disagreements when comparing the two scales and a low percentage intra-scale agreement. Furthermore, the lower VAS cut-off positions relative the VRS labels indicate different meaning of the rated pain intensity depending on pain etiology. It is also indicated that the scales have non-linear properties and that the two scales probably have different interpretation. Our findings are in favor of using the VRS in pain intensity assessments but if still the VAS is preferred, the VAS data should be analyzed as continuous using statistical methods suitable for ordinal data. Furthermore, our findings indicate a risk to over or under estimate the patient's perceived pain when interpreting condensed VAS data.
PMCID: PMC1274324  PMID: 16202149

Results 1-10 (10)