Deaths In Denmark Research Articles

Nationwide burden of sudden cardiac death among patients with a psychiatric disorder

BackgroundPatients with psychiatric disorders have increased all-cause mortality compared with the general population. Previous research has shown that there is a fourfold increased risk of sudden cardiac death (SCD) among...

Criteria for brain death in Denmark

In 1990, the Danish brain death legislation was adopted by the Danish Parliament. Each year, around 100 patients in Denmark fulfil criteria for brain death/death by neurological criteria (BD/DNC). In this review of current Danish criteria including the indication for ancillary investigation, which in Denmark is digital subtraction angiography (DSA), we conclude that the time has come to revise the national BD/DNC criteria. We propose that visible anoxic-ischaemic encephalopathy on brain CT after cardiac arrest does not require evaluation by ancillary testing, and that CT-angiography can be used instead of DSA.

Sudden cardiac death as first manifestation of cardiovascular disease - a Danish nationwide study

Abstract Background and objective Sudden cardiac death (SCD) is a leading cause of death and previous studies have shown that approximately half of all cases have no known history of cardiovascular disease (CVD). Epidemiological studies of SCD cases of all ages are sparse. The aim of this study was to examine differences in incidence rates, clinical characteristics, comorbidities, and socioeconomic status between SCD cases with and without a known history of cardiovascular disease. Methods All 54,028 deaths in Denmark in 2010 were reviewed. Autopsy reports, death certificates, discharge summaries, and nationwide health and social registries were reviewed to identify cases of SCD. Information on previous history of CVD was extracted from the comprehensive Danish nationwide health and social registries. Results A total of 6,867 SCD cases were identified, of which 3,056 (44.5%) had no history of cardiovascular disease and 3,811 (55.5 %) had a history of CVD. Incidence rates of SCD increased with age and were higher in cases of SCD with a history of CVD across all age groups. The difference in incidence of SCD between persons with and without history of cardiovascular disease decreased with increasing age with incidence rate ratios ranging from 11.7 (95 % CI: 5.51 – 25.00) to 3.19 (95 % CI: 2.79-3.64) in those age 0-29 years and >90 years, respectively. Persons living in a low-income household (OR: 0.76, 95 % CI: 0.58-0.98, p=0.037), persons living in rural municipalities (OR: 0.87, 95 % CI: 0.78-0.98, p=0.021), and persons living in single-person households (OR: 0.73, 95 % CI: 0.66-0.82, p=0.037) had a lower likelihood of having a CVD prior to SCD. Conclusion This is the first nationwide study of SCD cases with and without history of CVD across all ages. SCD cases with no known CVD were significantly younger, more female and had less comorbidities. Although a substantial amount of SCD cases occur in persons with no known CVD, SCD is more common in the populations of persons with a history of CVD. Socioeconomic factors such as low income, living alone and living in rural communities were associated with a lower risk of having a cardiovascular diagnosis prior to SCD.Crude numbers and incidence rates of SCDIncidence rate ratios

Nationwide burden of sudden cardiac death among patients with a psychiatric disorder

Abstract Background and aim Patients with psychiatric disorders have increased all-cause mortality compared to the general population. Previous research has shown that they have a 4-fold increased risk of sudden cardiac death (SCD) among the young. However, the risk across all age groups remains unknown. Purpose To investigate the incidence of SCD in patients with psychiatric disorders aged 18-90 years in the Danish population by systematically reviewing all deaths in one year. Methods We examined all deaths in Denmark among residents aged 18-90 years in 2010 by reviewing death certificates and autopsy reports. All deaths were categorized as non-SCD, or SCD, based on the available information. Psychiatric disorder was defined according to ICD-10 criteria, or by redemption of a prescription for psychotropic medication within one year prior to death. Results Out of 4.3 million residents in 2010 aged 18-90 years, we observed 45 703 deaths of which 6 002 were SCD. Overall, the incidence of SCD was 4.35 times (CI: 4.20-4.50, p-value <0.001) higher among patients with psychiatric disorders than in the general population and was age dependent (p-value <0.001). When adjusting for age, sex, and comorbidities, psychiatric disorders were independently associated with SCD, with a hazard ratio (HR) of 2.46 (2.33-2.60, p-value: <0.001), with highest SCD risk among patients suffering from schizophrenic disorders with a HR of 5.27 (4.23-6.56 p-value <0.001). Furthermore, patients with psychiatric disorders had an expected 10-year excess loss of life of which 13% was caused by SCD. Conclusion The rate of SCD in patients with psychiatric disorders was 4 times higher than in the general population. Having a psychiatric disorder is independently associated with SCD. Life-expectancy for an 18-year-old with a psychiatric disorder is projected to be 10-years shorter in comparison.Incidence rate of SCD by age groupExcess loss of life-years

Proarrhythmic drugs, drug levels, and polypharmacy in victims of sudden arrhythmic death syndrome: An autopsy-based study from Denmark

BackgroundSudden arrhythmic death syndrome (SADS), characterized by an unknown or inconclusive cause of death at autopsy together with a negative or nonlethal toxicology screening result, is the most common cause of sudden cardiac death in victims younger than 35 years. The complete causality of SADS remains unclear, with drugs being a potential risk factor. ObjectiveThis study aimed to describe the toxicologic profiles of SADS victims, focusing on proarrhythmic drugs, drug levels, and polypharmacy. MethodsAll deaths in Denmark of those aged 1–35 years in 2000–2019 and 36–49 years in 2007–2019 were examined through death certificates, national registries, and autopsy reports with toxicology screenings. We investigated all sudden unexpected death victims with an autopsy performed, including negative or nonlethal drug findings, where cause of death was unknown or inconclusive (SADS). ResultsWe identified 477 SADS victims; 313 (66%) had a positive toxicology screening result (adjudicated nonlethal), with an average of 2.8 drugs per case. More than half of the SADS victims with a positive toxicology screening result had QT-prolonging or brugadogenic drugs present. Polypharmacy was present in 66%, psychotropic polypharmacy in 37%, and QT-prolonging polypharmacy in 22%, with the most frequent overall and QT-prolonging drug combination being an antipsychotic and a psychoanaleptic drug. QT-prolonging drugs were more often present at suprapharmacologic levels than non–QT-prolonging drugs. ConclusionThe majority of the SADS population had a positive toxicology screening result, with a notably large proportion having proarrhythmic drugs and polypharmacy. This highlights the need for future focus on drugs as a risk factor for SADS.

AUD-DSS: a decision support system for early detection of patients with alcohol use disorder

BackgroundAlcohol use disorder (AUD) causes significant morbidity, mortality, and injuries. According to reports, approximately 5% of all registered deaths in Denmark could be due to AUD. The problem is compounded by the late identification of patients with AUD, a situation that can cause enormous problems, from psychological to physical to economic problems. Many individuals suffering from AUD never undergo specialist treatment during their addiction due to obstacles such as taboo and the poor performance of current screening tools. Therefore, there is a lack of rapid intervention. This can be mitigated by the early detection of patients with AUD. A clinical decision support system (DSS) powered by machine learning (ML) methods can be used to diagnose patients’ AUD status earlier.MethodsThis study proposes an effective AUD prediction model (AUDPM), which can be used in a DSS. The proposed model consists of four distinct components: (1) imputation to address missing values using the k-nearest neighbours approach, (2) recursive feature elimination with cross validation to select the most relevant subset of features, (3) a hybrid synthetic minority oversampling technique-edited nearest neighbour approach to remove noise and balance the distribution of the training data, and (4) an ML model for the early detection of patients with AUD.Two data sources, including a questionnaire and electronic health records of 2571 patients, were collected from Odense University Hospital in the Region of Southern Denmark for the AUD-Dataset. Then, the AUD-Dataset was used to build ML models. The results of different ML models, such as support vector machine, K-nearest neighbour, decision tree, random forest, and extreme gradient boosting, were compared. Finally, a combination of all these models in an ensemble learning approach was selected for the AUDPM.ResultsThe results revealed that the proposed ensemble AUDPM outperformed other single models and our previous study results, achieving 0.96, 0.94, 0.95, and 0.97 precision, recall, F1-score, and accuracy, respectively. In addition, we designed and developed an AUD-DSS prototype.ConclusionIt was shown that our proposed AUDPM achieved high classification performance. In addition, we identified clinical factors related to the early detection of patients with AUD. The designed AUD-DSS is intended to be integrated into the existing Danish health care system to provide novel information to clinical staff if a patient shows signs of harmful alcohol use; in other words, it gives staff a good reason for having a conversation with patients for whom a conversation is relevant.

More than half of all sudden cardiac deaths occur in persons without a history of cardiovascular disease: A study of 54,028 deaths in Denmark

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Copenhagen University Hospital, Rigshospitalet Background Sudden cardiac death (SCD) is a major public health problem accounting for a large proportion of global mortality. Previous studies suggest that SCD often occurs in the general population in persons not previously diagnosed with cardiovascular disease. It is evidently challenging to identify high-risk persons in an overwhelmingly large population of mainly healthy individuals and studies are needed to further characterize these SCD cases. Purpose To estimate SCD burden in patients not previously diagnosed with cardiovascular disease and to characterize these SCD cases. Methods All deaths in Denmark (population of 5.5 million) in 2010 were manually reviewed case-by-case. Autopsy reports, death certificates, and information from nationwide health registries were systematically examined to identify all SCD in 2010. The Danish National Patient Register contains information on all in- and outpatient activities at Danish hospitals and emergency departments and was used to identify all SCD cases with a previous cardiovascular diagnosis. Results There were 54,028 deaths in Denmark in 2010, of which 6,867 (13%) were categorized as SCD. Overall incidence rate of SCD was 124 (95%-CI: 121-127) per 100,000 person-years. Of all SCD, 59% were not diagnosed with cardiovascular disease prior to death. SCD incidence in persons with and without a history of cardiovascular disease was 790 (95%-CI: 762-820) and 78 (95%-CI: 75-80) per 100,000 person-years, respectively. This corresponds to an incidence rate ratio of 10 (95%-CI: 10-11). SCD cases with no previously diagnosed cardiovascular diseases were younger (median age 75 vs. 80 years, p<0.001), more often female (45 vs. 42%, p=0.019), and on average had a lower household income (p=0.002) (Table 1). SCD cases not diagnosed with cardiovascular disease prior to death in general had fewer comorbidities, except for psychiatric diseases, which were more common in the undiagnosed group (Table 1). Conclusion In this large and nationwide study of all SCD in Denmark in 2010, more than half of all SCD occurred in persons without a history of cardiovascular disease. This suggests that SCD is often first manifestation of disease. We currently do not have accurate tools for SCD risk stratification in the general population and future research is needed to identify modifiable and easily measured risk factors of SCD in the general population.

Diagnostic Age, Age at Death and Stage Migration in Men Dying with or from Prostate Cancer in Denmark.

The impact of changes in diagnostic activity and treatment options on prostate cancer epidemiology remains a subject of debate. Newly published long-term survival outcomes may not represent contemporary patients and new perspectives are in demand. All men dying in Denmark with prostate cancer diagnosis during a 10-year period were analyzed to address the stage migration of and time lived with prostate cancer diagnosis. All male deaths in Denmark between 2007 and 2016 (n = 261,657) were obtained and crosslinked with The Danish Prostate Cancer Registry (DaPCaR) and the Danish Cancer Registry. Correlation in diagnostic age and stage (localized, locally advanced, metastatic), age at death and cause of death were investigated by Kruskal-Wallis test and linear regression in 15,692 men diagnosed with prostate cancer. Prostate cancer mortality remained stable during the study period. Among the men who died of prostate cancer, 65% had locally advanced or metastatic disease at diagnosis. Age at diagnosis declined in men diagnosed with localized disease and remained constant in men with locally advanced or metastatic disease. Age at death increased in all men. Despite increased efforts to detect prostate cancer early, two-thirds of men who die from prostate cancer still have advanced prostate cancer at the time of diagnosis. Our data show increased life-expectancy in men diagnosed with prostate cancer, however, this benefit must be weighed against increased time of living with the disease and overdiagnosis. The intensified treatment of elderly men and men with advanced disease may be the key to lower prostate cancer mortality.

Sex differences in sudden cardiac death in a nationwide study of 54 028 deaths

ObjectiveSudden cardiac death (SCD) is a leading cause of death and is more common among males than females. Epidemiological studies of sex differences in SCD cases of all ages are...

Sex differences in sudden cardiac death: a nationwide study of 54,028 deaths in Denmark

Abstract Background Sudden cardiac death (SCD) is a leading cause of death. SCD is more common among males. In women SCD is, however, still the leading cause of death. The SCD epidemiology among women is less studied. Purpose The aim of this study was to examine how incidence rates, clinical characteristics and causes of SCD vary between males and females. Methods All deaths in Denmark in the 2010 (54,028) were included in the study. Autopsy reports, death certificates, discharge summaries and nationwide health registries were reviewed to identify cases of SCD. Sex and age specific SCD incidence rates in the general population were calculated, and age-adjusted clinical characteristics were compared using logistic regression. Results A total of 6,867 SCD cases were identified, of which 3,859 (56%) were males and 3,008 (44%) were females. Incidence rates increased with age and was higher for males across all age groups in the adult population. Average age of SCD was 71.3±14.3 years among males compared to 79.4±13.3 among females (mean ± standard deviation, p<0.0001). The greatest difference in incidence between males and females was found among the 35–50-year group with an incidence rate ratio of 3.7 (95% confidence interval: 2.8–4.8). Although the males were younger, males more often had cardiovascular diseases and diabetes mellitus prior to SCD. Among autopsied cases, coronary artery disease (CAD) was the leading cause of death among both sexes. Structural causes of SCD, other than CAD, were more common among women (p<0.01). Conclusion In this nationwide study of sex differences in SCD across all age groups, the differences in incidence rates between males and females were greatest among young adults and the middle-aged. Incidence rates of SCD among older females approached that of the male population, despite significantly more cardiovascular disease and diabetes mellitus in the male population in the 10 years prior to SCD. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark

Prevalence and incidence rates of atrial fibrillation in Denmark 2004–2018

Abstract Background Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with substantial morbidity and mortality. Its prevalence is currently rising partly due to population ageing. However, reported trends in incidence rates are conflicting, and the comparability of existing reports is limited due to methodological inconsistencies across studies. Purpose The main purpose of the current study was to investigate the prevalence of AF in the Danish adult population and time trends in incidence rates from 2004 through 2018. As a secondary purpose, the prevalence and incidence were compared to corresponding Norwegian estimates from 2004 through 2014 derived using the same methodology. Methods A register-based study was conducted including all individuals aged ≥18 years in Denmark from 2004–2018. AF cases were identified in the National Patient Register and the Cause of Death Register, which comprise information on all hospital contacts and deaths in Denmark, respectively. The prevalence of AF was calculated as the number of individuals alive at the end of the study period with at least one registered diagnosis from 1994 through 2018 divided by the number of Danish residents aged ≥18 years. Incidence rates were calculated as the number of annual AF cases with no previous diagnosis noted in the past 10 years divided by the person-time contributed by the population free of AF on 1 January in the same calendar year. All incidence rates were standardized according to a Nordic standard population. The comparison of the Danish and Norwegian incidence estimates focused solely on AF hospitalizations and deaths from 2004 through 2014. Results The cumulative prevalence of AF was 3.0% in the Danish adult population. The incidence increased from 391 per 100,000 person-years in 2004 to 481 per 100,000 person-years in 2015, after which it declined to 367 per 100,000 person-years in 2018 (Figure 1). On average, the incidence increased by 1.7% annually until 2015 (IRR: 1.017 (95% CI: 1.016–1.018); p<0.001) and then declined by 8.5% (IRR: 0.915 (95% CI: 0.909–0.921); p<0.001). Although the incidence rates generally were higher among men and older individuals, a similar time trend was observed in both men and women irrespective of age. Focusing solely on AF hospitalizations and deaths did not change the interpretation of the results. The comparable Norwegian estimates will be presented at the conference. Conclusions The prevalence of AF is currently around 3.0% in the Danish adult population, but the incidence rate has declined steeply since 2015. The observed decline in new cases is promising from a public health perspective and its underlying causes warrant further investigation. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation Figure 1

Discontinuation of diabetes medication in the 10 years before death in Denmark: a register-based study

Discontinuation of diabetes medication in the last years of life has been suggested to improve quality of life while deemed safe to implement. However, the extent, patterns, and secular changes in discontinuation of glucose-lowering medication in older people with type 2 diabetes have been scarcely described. We therefore aimed to describe the trends in the use of glucose-lowering medication during the last 10 years of life of older people and explore how key clinical and socioeconomic covariates are associated with these patterns. In this register-based cohort study, all individuals with type 2 diabetes who died aged 80 years or older between Jan 1, 2006, and Dec 31, 2018, were identified through the Danish Diabetes Register and linked to the Danish National Prescription Registry. We followed the population backwards in time from death to date of last medication intake. To estimate the cumulative proportion of people on glucose-lowering medication, a Poisson regression model for the rate of medication as a function of time before death (0 to 10 years before death) and calendar year of death (2006-18) was fitted. Both single-substance and combination glucose-lowering medications were included and categorised as insulins, sulfonylureas, metformin, DPP-4 inhibitors, GLP-1 analogues, SGLT2 inhibitors, acarbose, and thiazolidinediones. Insulin was further subdivided into four groups: fast-acting, intermediate-acting, long-acting, and mixed insulin. To identify which covariates were associated with discontinuation, estimates were adjusted for sex, age at death, diabetes duration at time of death, the total number of diabetes complications at time of death (from no complications to four or more), level of education, immigrant status, and income quartile. 52 523 individuals (28 746 [54·7%] females and 23 777 [45·3%] males) were identified, with a mean age at type 2 diabetes diagnosis of 77 years (SD 8), median age at death of 86 years (IQR 83-90), and median diabetes duration at death of 9 years (IQR 5-14). We found a considerable discontinuation of glucose-lowering medication during the last 10 years of life, with the proportion of people on glucose-lowering medication starting at between 89% (95% CI 87-91) in 2006 and 87% (86-88) in 2018 at 10 years before death and decreasing to between 52% (50-54) in 2006 and 38% (37-39) in 2018 at the time of death. Specifically, we found that the proportion of people on sulfonylureas, at any time before death, decreased substantially from 2006 to 2018, whereas the proportion on metformin and DPP-4 inhibitors increased with calendar year of death. Changes were less pronounced for the remaining medications. The overall discontinuation patterns changed with increasing calendar year of death, such that discontinuation rates increased and occurred earlier (further away from time of death) with increasing calendar year. Discontinuations were generally more pronounced during the last year of life. Proportions of people on medication and patterns of discontinuation, as well as the association with covariates, varied with medication class. Covariates most frequently associated with changes in discontinuation rates were sex, age at death, type 2 diabetes duration at death, and number of complications. For example, females were less likely to receive metformin than males at all years before death (rate ratio 0·91 (95% CI 0·89-0·94, p<0·0001), and there was a negative association between the proportion of individuals on metformin and increasing age at death (rate ratio per year increase 0·96 [0·96-0·96], p<0·0001) and type 2 diabetes duration (0·95 per year increase [0·94-0·95], p<0·0001). Our results suggest that increased focus on and implementation of discontinuation of glucose-lowering medication in recent years might have had an effect on discontinuation patterns, particularly during the last year of life. None.

Nationwide burden of sudden cardiac death: A study of 54,028 deaths in Denmark.

A large proportion of all deaths are sudden cardiac deaths (SCDs). Reliable estimates of nationwide incidence of SCD, however, are missing. The goals of this study were to estimate SCD burden across all age groups in Denmark and to compare it with the estimates of other common causes of death. All deaths in Denmark (population of 5.5 million) in 2010 were manually reviewed case by case. Autopsy reports, death certificates, and information from nationwide health registries were systematically examined to identify all SCD cases in 2010. According to the level of detail of the available information, all deaths were categorized as either non-SCD, definite SCD, probable SCD, or possible SCD. There were 54,028 deaths in Denmark in 2010, of which 6867 (13%) were categorized as SCD (591 (9%) definite SCD, 1568 (23%) probable SCD, and 4708 (68%) possible SCD). The incidence rate of definite SCD was 11 (95% confidence interval 10-12) per 100,000 person-years. Including definite, probable, and possible SCD cases, the highest possible overall SCD incidence rate was 124 (95% confidence interval 121-127) per 100,000 person-years. Estimated SCD burden was similar to or greater than the estimates of all other common causes of death. Of all SCD cases, 49% were not diagnosed with cardiovascular disease before death. SCD accounted for up to 13% of all deaths. Almost half of all SCD cases occurred in persons without a history of cardiovascular disease. Consequently, the optimization of risk stratification and prevention of SCD in the general population should be given high priority.

Social and ethnic disparities in stillbirth and infant death in Denmark, 2005\u20132016

Ethnic disparity in stillbirth and infant death has been demonstrated in Europe. As the relation between migration and health change over time, this population based register study investigated the recent figures and explored if potential differences could be explained by the well-known educational and income inequalities in stillbirth and infant death using a novel approach. Stillbirth and infant mortality varied considerably according to country of origin, with only immigrants from China, Norway, and Poland having an overall lower risk than Danish women. Women of Pakistani, Turkish, and Somali origin had a particularly high risk of both outcomes. Women from recent high conflict areas displayed a pattern with increased stillbirth risk. An observed excess risks across generations was found, which is disturbing and rule out factors related to language barriers or newness. Differences in educational level and household income explained only part of the observed inequalities. Strengthening of the maternity care system to better understand and meet the needs of immigrant women seems needed to mitigate the disparities.

A review of deadly accidents involving fireworks in Denmark.

The aim of this study was to describe the circumstances surrounding firework-related deaths in Denmark, locate similarities and compare findings to the other known literature. Autopsy files, including police reports, located through searches in the archives of the three Danish institutes of forensic medicine were accessed. Data describing the age, gender, toxicology findings, circumstances of the accident, cause of death, autopsy findings and type of fireworks were examined. Eight cases involving firework-related deaths matched the search criteria, two of which occurred on New Year's Eve. An unknown number of cases that had not been autopsied were confirmed to exist. Data from the included cases suggested that using illegal fireworks, being male and handling fireworks directly played a key role in deaths. Most notably, illegal fireworks account for few injuries overall but caused the most deaths found in this study. Firework-related deaths are a rare occurrence. Autopsy findings often reveal blast wave injury to be the cause of death. Only one of the eight decedents included in this study were intoxicated with alcohol. Thus it can be assumed that powerful illegal fireworks are, by themselves, a risk factor for a deadly accident, independent of alcohol intoxication.

Sudden cardiac death among persons with diabetes aged 1-49 years: a 10-year nationwide study of 14 294 deaths in Denmark.

AimsThe aim of this study was to compare nationwide incidence rate (IR) of sudden cardiac death (SCD) in persons aged 1–49 years with and without diabetes mellitus (DM).Methods and resultsThe study population consisted of all persons in Denmark aged 1–49 years in 2000–09, which equals 27.1 million person-years. All 14 294 deaths in the 10-year period were included. By using the highly descriptive Danish death certificates, 1698 cases of sudden and unexpected death were identified. Through review of autopsy reports, discharge summaries, and the Danish registries, we identified 1363 cases of SCD. The Danish Register of Medicinal Product Statistics was used to identify persons with type 1 DM and type 2 DM. Among the 14 294 decedents, there were 669 with DM, of which 118 suffered SCD (9% of all SCD), making SCD the leading cause of death among young persons with DM. Among those aged 1–35 years, the IR of SCD-DM was 21.9 per 100 000 person-years compared to 2.6 per 100 000 person-years among persons without DM [IR ratio 8.6, 95% confidence interval (CI) 5.8–28.6]. Within the age range 36–49 years, the IR among persons with DM was 119.8 per 100 000 person-years compared to 19.7 per 100 000 person-years among persons without DM (IR ratio 6.1, 95% CI 4.7–7.8).ConclusionWe found that young persons with DM aged 1–35 years had >8-fold higher SCD IR compared to young persons without DM. Our study highlights the need for early cardiovascular risk monitoring and assessment in young persons with DM.

Workshop: The Danish MAMAACT trial as an example for discussing evaluation methods in complex interventions

Abstract Over recent years, immigration to Europe has risen significantly. This development has led to increasing birth rates by non-Western immigrant women. Maternity care systems are not yet adapted to this increased diversity of women. In Denmark, 13 % of all children are currently born by women originating from non-Western countries. Despite a publically funded antenatal care, non-Western immigrant women have lower utilization of Danish antenatal care compared to other women giving birth. Many non-Western immigrant women have an increased prevalence of severe maternal morbidity and higher risks of maternal death, stillbirth and infant death compared to the majority populations. Poor health status at birth can impair the cognitive, sensory and motor development and lead to learning disabilities during school age, and thus reduce equality in life chances. Suboptimal care is a contributing factor to these ethnic disparities. Provision of appropriate antenatal care is pivotal to reduce these serious disparities and challenges to public health, however little is known about models of care, which can overcome these barriers. The MAMAACT intervention was developed to increase response to symptoms of pregnancy complications among maternity care providers as well as non-Western immigrant women. The intervention consisted of postgraduate training of midwives in intercultural communication and health education materials (leaflet and an app) for non-Western immigrant women describing how to respond to warning signs during pregnancy in six different languages, The intervention was implemented at 10 out of 20 Danish maternity wards as part of a national trial from the year 2018 to 2019, potentially reaching 25.000 pregnant women, including 2500 of non-Western origin. This workshop shares insight into innovative ways of providing antenatal care for non-Western immigrant women and will focus on methodological aspects of scientific evaluation of complex interventions for vulnerable populations. The workshop includes an introduction, three presentations, and a discussion with the audience. Using quantitative data, the first presentation will give an overview of ethnic disparities in stillbirth and infant death in Denmark. The second presentation will present qualitative data from the implementation evaluation of the MAMAACT intervention with a focus on the interventions program theory, methodological considerations and evaluation results. Finally, the third presentation will illuminate how the concepts of Health Literacy and cultural health capital contribute to an understanding of mechanisms leading to ethnic disparities and how they can be used for evaluating the impact of the MAMAACT intervention. The final discussion will stimulate knowledge sharing between the participants on how to combine quantitative and qualitative insights in trials, how to build partnerships and recruit vulnerable populations in evaluations, and how to use sociological theory in evaluations. Key messages Reducing ethnic disparity in reproductive health requires maternity care systems to rethink their antenatal care services so they are better equipped to support non-Western immigrant women’s needs. Sharing knowledge on the use of mixed methods, recruitment of vulnerable populations, and the use of sociological theory can contribute to future approaches to evaluate complex interventions.

Sudden cardiac death caused by myocarditis in persons aged 1–49 years: a nationwide study of 14 294 deaths in Denmark

Myocarditis is associated with an increased risk of sudden cardiac death (SCD) in the young. However, information on nationwide burden of SCD caused by myocarditis (SCD-myocarditis) is sparse. For this study all deaths among persons in Denmark aged 1–35 years in 2000–2009 and 36–49 years in 2007–2009 (27.1 million person-years) were included. Autopsy reports, death certificates, discharge summaries, and nationwide registries were used to identify all cases of SCD-myocarditis. In the 10-year study period, there were 14 294 deaths, of which we identified 1 363 (10%) SCD. Among autopsied SCD (n = 753, 55%), cause of death was myocarditis in 42 (6%) cases corresponding to an SCD-myocarditis incidence of 0.16 (95%CI: 0.11–0.21) per 100 000 person-years. Males had significantly higher incidence rates of SCD-myocarditis compared to females with an incidence rate ratio of 2.2 (95%CI: 1.1–4.1). Myocarditis was not registered as cause of death in any of the non-autopsied SCD (n = 610, 45%). In conclusion, after nationwide unselected inclusion of 14 294 deaths, we found that 6% of all autopsied SCD was caused by myocarditis. No cases of SCD-myocarditis were reported in the non-autopsied SCD, which could reflect underdiagnosing of myocarditis in non-autopsied SCD. Furthermore, our data suggest a female protection towards SCD-myocarditis.

Age-Dependent Increase in Incidence of Staphylococcus aureus Bacteremia, Denmark, 2008-2015.

Staphylococcus aureus bacteremia (SAB) is a major cause of illness and death worldwide. We analyzed temporal trends of SAB incidence and death in Denmark during 2008-2015. SAB incidence increased 48%, from 20.76 to 30.37 per 100,000 person-years, during this period (p<0.001). The largest change in incidence was observed for persons >80 years of age: a 90% increase in the SAB rate (p<0.001). After adjusting for demographic changes, annual rates increased 4.0% (95% CI 3.0-5.0) for persons <80 years of age, 8.4% (95% CI 7.0-11.0) for persons 80-89 years of age, and 13.0% (95% CI 9.0-17.5) for persons >90 years of age. The 30-day case-fatality rate remained stable at 24%; crude population death rates increased by 53% during 2008-2015 (p<0.001). Specific causes and mechanisms for this rapid increase in SAB incidence among the elderly population remain to be clarified.

Decline in incidence of sudden cardiac death in the young: a 10-year nationwide study of 8756 deaths in Denmark.

Sudden cardiac death in the young (SCDY) accounts for a significant proportion of deaths among the young. The aim of this nationwide study was to examine temporal changes in incidence and causes of SCDY in Denmark in 2000-2009. During this 10-year period, several public and private health initiatives were undertaken to decrease morbidity and mortality in Denmark. All deaths among persons aged 1-35 years in Denmark in 2000-2009 (23.7 million person-years) were included. Death certificates, autopsy reports, discharge summaries, and data from nationwide administrative registries were used to identify SCDY cases. Sudden cardiac death in the young incidence rates were age-adjusted and sex-adjusted using direct standardization. Temporal changes in standardized SCDY incidence rates were reported as average annual percent changes. In the 10-year study period, there were 8756 deaths, of which we identified 635 (7%) SCDY cases. For these SCDY cases, median age at death was 29 years and 68% were men. Standardized incidence of SCDY decreased from 3.1 per 100000 person-years in 2000 [95% confidence interval (CI) 2.4-3.8] to 2.5 per 100000 person-years in 2009 (95% CI 1.9-3.2). This corresponds to an average annual percent change of -3.0% (95% CI -5.8 to -0.1). The distribution of major causes of SCDY did not change significantly throughout the study period. Incidence of SCDY decreased significantly from 2000 through 2009 in Denmark with an average annual percent change of -3%. Further research is needed to elucidate underlying causes of this development.