Recurrence of Subdural Haematoma in a Population-Based Cohort – Risks and Predictive Factors

<div><p>Objectives</p><p>To estimate the risks of and identify predictors for recurrent subdural haematoma in surgically and conservatively treated patients.</p><p>Methods</p><p>The cohort comprised all individuals diagnosed with a first-time subdural hematoma in Denmark 1996–2011. Information on potential predictors was retrieved from the Danish health registers. Cumulative recurrence risks were estimated using the Aalen-Johansen estimator. Rate ratios (RR) were estimated using Poisson regression.</p><p>Results</p><p>Among 10,158 individuals with a subdural hematoma, 1,555 had a recurrent event. The cumulative risk of recurrent subdural hematoma was 9% at 4 weeks after the primary bleeding, increasing to and stabilising at 14% after one year. Predictors associated with recurrence were: Male sex (RR 1.60, 95% CI:1.43–1.80), older age (>70 years compared to 20–49 years; RR 1.41, 95% CI: 1.21–1.65), alcohol addiction (RR 1.20, 95% CI:1.04–1.37), surgical treatment (RR 1.76, 95% CI:1.58–1.96), trauma diagnoses (RR 1.14, 95% CI:1.03–1.27), and diabetes mellitus (RR 1.40, 95% CI:1.11–1.74). Out of a selected combination of risk factors, the highest cumulative 1-year recurrence risks for subdural hematoma of 25% (compared to 14% for all patients) was found in surgically treated males with diabetes mellitus.</p><p>Conclusions</p><p>The recurrence risk of subdural hematoma is largely limited to the first year. Patient characteristics including co-morbidities greatly influence the recurrence risk of SDH, suggesting that individualized prognostic guidance and follow-up is needed.</p></div

Inflammatory Bowel Disease and Risk of Adverse Pregnancy Outcomes

<div><p>Background and Objectives</p><p>Existing data on pregnancy complications in inflammatory bowel disease (IBD) are inconsistent. To address these inconsistencies, we investigated potential associations between IBD, IBD-related medication use during pregnancy, and pregnancy loss, pre-eclampsia, preterm delivery, Apgar score, and congenital abnormalities.</p><p>Methods</p><p>We conducted a cohort study in >85,000 Danish National Birth Cohort women who were pregnant in the period 1996-2002 and had information on IBD, IBD-related medication use (systemic or local corticosteroids, 5-aminosalicylates), pregnancy outcomes and potential confounders. We evaluated associations between IBD and adverse pregnancy/birth outcomes using Cox regression and log-linear binomial regression.</p><p>Results</p><p>IBD was strongly and significantly associated with severe pre-eclampsia, preterm premature rupture of membranes and medically indicated preterm delivery in women using systemic corticosteroids during pregnancy (hazard ratios [HRs] >7). IBD was also associated with premature preterm rupture of membranes in women using local corticosteroid medications (HR 3.30, 95% confidence interval [CI] 1.33-8.20) and with medically indicated preterm delivery (HR 1.91, 95% CI 0.99-3.68) in non-medicated women. Furthermore, IBD was associated with low 5-minute Apgar score in term infants (risk ratio [RR] 2.19, 95% CI 1.03-4.66). Finally, Crohn’s disease (but not ulcerative colitis) was associated with major congenital abnormalities in the offspring (RR 1.85, 95% CI 1.06-3.21). No child with a congenital abnormality born to a woman with IBD was exposed to systemic corticosteroids in utero.</p><p>Conclusion</p><p>Women with IBD are at increased risk of severe pre-eclampsia, medically indicated preterm delivery, preterm premature rupture of membranes, and delivering infants with low Apgar score and major congenital malformations. These associations are only partly explained by severe disease as reflected by systemic corticosteroid use.</p></div

The cumulative risks in percent of recurrent subdual haematoma and intracerebral haemorrhage up to 5 years after the primary bleeding event.

<p>The cumulative risks in percent of recurrent subdual haematoma and intracerebral haemorrhage up to 5 years after the primary bleeding event.</p

Risk, treatment duration, and recurrence risk of postpartum affective disorder in women with no prior psychiatric history: A population-based cohort study

<div><p>Background</p><p>Some 5%–15% of all women experience postpartum depression (PPD), which for many is their first psychiatric disorder. The purpose of this study was to estimate the incidence of postpartum affective disorder (AD), duration of treatment, and rate of subsequent postpartum AD and other affective episodes in a nationwide cohort of women with no prior psychiatric history.</p><p>Methods and findings</p><p>Linking information from several Danish national registers, we constructed a cohort of 457,317 primiparous mothers with first birth (and subsequent births) from 1 January 1996 to 31 December 2013 (a total of 789,068 births) and no prior psychiatric hospital contacts and/or use of antidepressants. These women were followed from 1 January 1996 to 31 December 2014. Postpartum AD was defined as use of antidepressants and/or hospital contact for PPD within 6 months after childbirth. The main outcome measures were risk of postpartum AD, duration of treatment, and recurrence risk. We observed 4,550 (0.6%) postpartum episodes of AD. The analyses of treatment duration showed that 1 year after the initiation of treatment for their first episode, 27.9% of women were still in treatment; after 4 years, 5.4%. The recurrence risk of postpartum AD for women with a PPD hospital contact after first birth was 55.4 per 100 person-years; for women with postpartum antidepressant medication after first birth, it was 35.0 per 100 person-years. The rate of postpartum AD after second birth for women with no history of postpartum AD was 1.2 per 100 person-years. After adjusting for year of birth and mother’s age, women with PPD hospital contact after first birth had a 46.4 times higher rate (95% CI 31.5–68.4) and women with postpartum antidepressant medication after their first birth had a 26.9 times higher rate (95% CI 21.9–33.2) of a recurrent postpartum episode after their second birth compared to women with no postpartum AD history. Limitations include the use of registry data to identify cases and limited confounder control.</p><p>Conclusions</p><p>In this study, an episode of postpartum AD was observed for 0.6% of childbirths among women with no prior psychiatric history. The observed episodes were characterized by a relatively short treatment duration, yet the women had a notably high rate of later AD and recurrent episodes of postpartum AD. The recurrence risk of postpartum AD was markedly higher among women with PPD hospital contact after first birth compared to women with postpartum antidepressant medication after first birth. Our results underline the necessity of measures targeted at specific vulnerable groups, such as women who experience PPD as a first psychiatric episode.</p></div

Rate ratio (RR) of recurrent subdural haematoma (SDH) in surgically- and conservatively treated patients, according to potential predictors in Denmark 1996–2011.

<p>* 95% Confidence interval</p><p>** Rate ratios adjusted for age, gender, calendar period, time since admittance for first SDH, length of hospital stay for the primary SDH, and the potential predictors for recurrent SDH listed in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0140450#pone.0140450.t001" target="_blank">Table 1</a>.</p><p>⁺ P-value: test for similar RR’s for surgically vs conservatively treated patients for each predictive factor.</p><p>^† Trauma diagnosis less than 2 years before the primary SDH</p><p>^†† PDMD: Pre-packaged Daily Medication Doses.</p><p>Rate ratio (RR) of recurrent subdural haematoma (SDH) in surgically- and conservatively treated patients, according to potential predictors in Denmark 1996–2011.</p

The cumulative risks in percent of recurrent subdual haematoma and intracerebral haemorrhage up to 1 year after the primary bleeding event.

<p>The cumulative risks in percent of recurrent subdual haematoma and intracerebral haemorrhage up to 1 year after the primary bleeding event.</p

The estimated proportion of women in antidepressant treatment by number of months since the initiation of treatment for a postpartum episode of affective disorder (AD).

<p>Primiparous Danish women with a postpartum AD, 1996–2013, with no prior psychiatric disorders.</p

Associations between inflammatory bowel disease, medication use during pregnancy and overall rates of preterm delivery in the Danish National Birth Cohort, 1996–2003.

<p>HR, hazard ratio; CI, confidence interval.</p><p>All estimates were adjusted for parity (0, 1, ≥2), socioeconomic status (6 categories: master’s degree or higher and currently employed, or leader of a business with ≥10 employees; bachelor’s degree and currently employed, or leader of a business with <10 employees; skilled worker (completed vocational training with apprenticeship) and currently employed; unskilled worker or unemployed (short-term); current student; unemployed (long-term)), pre-pregnancy BMI (<20, 20–25, >25), and smoking (non-smoker, smoker) and alcohol consumption (non-drinker, <1 drink/week, ≥1 drink/week) during pregnancy, in strata within the models.</p><p>^a Delivery before 37 weeks’ gestation.</p><p>^b The medication use sub-categories do not sum to the total number of women with IBD and CD because 6 women with CD who used AZA were excluded from the medication type-specific analyses.</p><p>^c Registered pregnancy complications and other potentially relevant conditions in OCS-using women with IBD who delivered prematurely: preterm premature rupture of membrances (five women); severe pre-eclampsia (four women); maternal chronic disease other than IBD (four women, one with spontaneous preterm delivery and three with indicated Caesarian deliveries; the degree to which these conditions, rather than IBD activity, influenced the decision to deliver the fetus early in the medically indicated deliveries, is unclear); breech presentation of fetus (one woman with medically indicated preterm delivery).</p><p>Associations between inflammatory bowel disease, medication use during pregnancy and overall rates of preterm delivery in the Danish National Birth Cohort, 1996–2003.</p

Risk of postpartum affective disorder (AD)—Distribution of number of births, women with prior history of postpartum AD, and postpartum AD episodes according to parity, year of birth, and age.

<p>Risk of postpartum affective disorder (AD)—Distribution of number of births, women with prior history of postpartum AD, and postpartum AD episodes according to parity, year of birth, and age.</p

Recurrent Intracerebral Hemorrhage: Associations with Comorbidities and Medicine with Antithrombotic Effects

<div><p>Background</p><p>Intracerebral hemorrhage (ICH) is a disease with high mortality and a substantial risk of recurrence. However, the recurrence risk is poorly documented and the knowledge of potential predictors for recurrence among co-morbidities and medicine with antithrombotic effect is limited.</p><p>Objectives</p><p>1) To estimate the short- and long-term cumulative risks of recurrent intracerebral hemorrhage (ICH). 2) To investigate associations between typical comorbid diseases, surgical treatment, use of medicine with antithrombotic effects, including antithrombotic treatment (ATT), selective serotonin reuptake inhibitors (SSRI’s), and nonsteroidal anti-inflammatory drugs (NSAID’s) with recurrent ICH.</p><p>Methods</p><p>The cohort consisted of all individuals diagnosed with a primary ICH in Denmark 1996–2011. Information on comorbidities, surgical treatment for the primary ICH, and the use of ATT, SSRI’s and NSAID’s was retrieved from the Danish national health registers. The cumulative recurrence risk of ICH was estimated using the Aalen-Johansen estimator, thus taking into account the competing risk of death. Associations with potential predictors of recurrent ICH were estimated as rate ratios (RR’s) using Poisson regression. Propensity score matching was used for the analyses of medicine with antithrombotic effects.</p><p>Results</p><p>Among 15,270 individuals diagnosed with a primary ICH, 2,053 recurrences were recorded, resulting in cumulative recurrence risk of 8.9% after one year and 13.7% after five years. Surgical treatment and renal insufficiency were associated with increased recurrence risks (RR 1.64, 95% CI 1.39–1.93 and RR 1.72, 95% CI 1.34–2.17, respectively), whereas anti-hypertensive treatment was associated with a reduced risk (RR 0.82, 95% CI 0.74–0.91). We observed non-significant associations between the use of any of the investigated medicines with antithrombotic effect (ATT, SSRI’s, NSAID’s) and recurrent ICH.</p><p>Conclusions</p><p>The substantial short-and long-term recurrence risks warrant aggressive management of hypertension following a primary ICH, particularly in patients treated surgically for the primary ICH, and patients with renal insufficiency.</p></div