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BACKGROUND: Adequate pain management of preterm and sick newborn infants is a critical issue in the neonatal intensive care unit, as the infants are small and vulnerable with limited resources to deal with pain and stressful experiences. The use of pain assessment instruments, however, must be applied correctly to achieve consistency and improve continuity in care and treatment among clinicians. PURPOSE: To assess the development of neonatal intensive care unit nurses' interrater agreement in using the COMFORTneo pain assessment tool 5 years after initial implementation, and to identify items needing further development through analysis of discrepancies among nurses' COMFORTneo scores. METHODS: An evaluation study with a pre- and postdesign comparing nurses' interrater reliability in assessing infant pain using the COMFORTneo pain assessment tool at baseline and 5-year follow-up. RESULTS: Eighty-five percent of the nurses in the follow-up group (n = 26) had improved their skills 5 years after the implementation, and the improvement was significant (P < .000). We also found that interrater reliability was satisfactory (κ scores ≥0.65) for all the items of the COMFORTneo tool. However, to obtain "very good" interrater reliability (κ scores ≥0.80) 3 items were identified needing increased focus. IMPLICATIONS FOR PRACTICE: A thorough implementation of a national clinical guideline has been partially effective in ensuring that nurses used the COMFORTneo in their daily practice, which increased their competence in pain assessment. IMPLICATIONS FOR RESEARCH: Further research into the education of nurses on the efficacy of pain scales, nonpharmacologic and pharmacologic therapies, and individualized pain assessment is needed to better address pain management.

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OBJECTIVES: To investigate the effect of work pressure and job influence on the development of ischaemic heart disease (IHD) in women. METHODS: The effect of work pressure and job influence on the 15-year incidence of IHD in women participating in the Danish Nurse Cohort Study was prospectively studied. A total of 12 116 participants, aged 45-64 years, were examined in 1993 using a questionnaire and were followed by individual linkage in the National Register of Hospital Discharges to the beginning of 2008. Work pressure, job influence, occupational characteristics, demographic factors and known biological and behavioural risk factors for IHD were collected at baseline. RESULTS: During follow-up, 580 participants were hospitalised with IHD. In the fully adjusted model, nurses who reported work pressure to be much too high had a 1.4-fold increased risk of incident IHD (95% CI 1.04 to 1.81) compared with nurses who reported work pressure to be suitable. A tendency towards a dose-response effect was found. Age-stratified analysis showed that this effect was significant only among the younger nurses (<51 years old at baseline). No association was found between job influence and IHD. CONCLUSIONS: In this study we find that work pressure that is too high is a significant risk factor for IHD in younger female employees (<51 years of age). The results should be taken into account in the planning of primary prevention.

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PURPOSE: Many studies which investigate the effect of drugs categorize the exposure variable into never, current, and previous use of the study drug. When prescription registries are used to make this categorization, the exposure variable possibly gets misclassified since the registries do not carry any information on the time of discontinuation of treatment.In this study, we investigated the amount of misclassification of exposure (never, current, previous use) to hormone therapy (HT) when the exposure variable was based on prescription data. Furthermore, we evaluated the significance of this misclassification for analysing the risk of breast cancer. MATERIALS AND METHODS: Prescription data were obtained from Danish Registry of Medicinal Products Statistics and we applied various methods to approximate treatment episodes. We analysed the duration of HT episodes to study the ability to identify discontinuation of therapy from prescription data. Furthermore, we compared to results based on self-reported duration of HT from the Danish Nurse Cohort.Finally, we analysed the effect of HT exposure on time to breast cancer for the different prescription based exposure variables as well as for self-reported HT use. RESULTS: The results of time to discontinuation varied strongly across the different HT assessments. However, misclassification of HT exposure at baseline was limited and hence analysis of the effect of HT on time to breast cancer showed stability across the different exposure assessments with Hazard Ratios ranging from 1.68 to 1.78 for current use compared to never use. CONCLUSIONS: The findings suggest that it is possible to estimate the effect of never, current and previous use of HT on breast cancer using prescription data.

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AIMS AND OBJECTIVES: To gain information about the effects of implementation of a written food and meal policy and to evaluate to what extent systematic nutritional assessment and intervention would result in weight stability among the residents. BACKGROUND: Studies have shown that aged residents living in institutions suffer from malnutrition or are at risk of malnutrition. Health policies have pointed out that more attention should be given to individualised nutritional care. Several techniques are available to identify malnourished nursing home residents, but very few studies have reported findings of studies based on systematic nutritional assessment. DESIGN AND METHODS: A quasi-experimental study based on a time series design used the residents as their own controls. The study included all 20 residents who resided at the nursing home at baseline in September 2004. Five residents died during the study period (mean age 84.4 years, range 62-91 years). Altogether 15 residents (75%) were assessed all five times during the study period. RESULTS: The proportion of weight-stable residents increased significantly over the study from 52.6% (CI 99%: 23.1-80.2) at baseline to 87.7% (p < 0.01) at the end of the study. The proportion of weight losers significantly decreased from 42% (CI 99%: 23.1-80.8) to 13.3% (p < 0.01). The weight ranges indicate substantial weight changes, but over time the weight ranges became narrower, indicating a tendency towards weight stability. CONCLUSIONS: Although the nursing home had a formulated food and meal policy, this study shows the importance of a regular nutritional assessment combined with an individualised care planning. Relevance to clinical practice. Regular weighing combined with individualised care planning results in weight stability in nursing home residents. Individualised approach for nutritional care led by a qualified nurse is just as important in nursing homes as it is in hospitals.

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BACKGROUND: Denmark is facing a shortage of nurses and this trend is anticipated to worsen within the next decades. The major reason for this shortage is that only very few nurses remain employed until the general retirement age. Every year several nurses are expelled from the labour market prematurely which causes a problem not only for the disabled nurses but also because it can affect the morale and productivity among the remaining personnel while new staff members are hired and trained. AIM: The aim of the study was to analyse the relationship between lifestyle, working environment, socio-demographic factors and disability pension (DP) among nurses. METHODS: The study was based on 12,028 nurses above the age of 44 who in 1993 completed a questionnaire. The survey information was combined with longitudinal data from a register compiled by Statistics Denmark. The follow-up period was from 1993 to 2002. RESULTS: Nurses with relatively low gross incomes were more likely to become disability pensioners compared to nurses with high incomes (hazard ratio, HR 1.33 and HR 2.17). Also, nurses who were singles had a higher probability of entering DP (HR 1.63). Nurses who worked fixed evening or night shifts had higher risks of DP than nurses who worked daytime exclusively (HR 1.51 and HR 1.45). Smoking, obesity and having a sedentary lifestyle were also risk indicators for DP (HR 1.42, HR 1.63 and HR 1.50). Furthermore, low influence and high physical demands at work increased the probability of entering DP (HR 1.39 and HR 1.22). CONCLUSION: DP among nurses is influenced by a number of factors. Nurses who have poor working environments and/or unhealthy lifestyles have higher risks of becoming disability pensioners. Also, nurses who are singles and/or have low gross incomes have higher probability of entering DP.

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OBJECTIVE: To assess the relation between work-related stressors and breast cancer incidence and prognostic characteristics (estrogen receptor status, grade, lymph node status, size, stage) at the time of diagnosis. METHODS: The 18,932 women included in the Danish Nurse Cohort reported work-related stressors in 1993 and again in 1999 and were followed until the end of 2003 in national registries. Prognostic characteristics were obtained from a clinical database and fewer than 0.1% were lost to follow up. RESULTS: During follow-up, 455 women were diagnosed with breast cancer. Neither women with high work pressure (HR = 1.17; 95% CI: 0.79, 1.73) nor women with self-reported low influence on work organization (0.98; 0.69, 1.39) or long working hours (0.93; 0.54, 1.58) were at higher risk of breast cancer than women with no such stressors. Women with high work tempo had a slightly higher risk of breast cancer (1.25; 1.02, 1.54) than women with a suitable work tempo, but there was no dose-response effect. There were no clear differences in the prognostic characteristics of breast tumors diagnosed in women with and without work-related stressors. CONCLUSIONS: Work-related stressors do not affect breast cancer risk or the prognostic characteristics of incident breast cancers at the time of diagnosis. These results may be a comfort to working women and can hopefully prevent self-blaming among women who develop breast cancer.

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In this study, we compared the response rates of blood, saliva, and buccal cell samples in a pilot study on the Danish nurse cohort and examined the quantity and quality of the purified genomic DNA. Our data show that only 31% of the requested participants delivered a blood sample, whereas 72%, 80%, and 76% delivered a saliva sample, buccal cell sample via mouth swabs, or buccal cell sample on FTA card, respectively. Analysis of purified genomic DNA by NanoDrop and agarose gel electrophoresis revealed that blood and saliva samples resulted in DNA with the best quality, whereas the DNA quality from buccal cells was low. Genotype and PCR analysis showed that DNA from 100% of the blood samples and 72% to 84% of the saliva samples could be genotyped or amplified, whereas none of the DNA from FTA cards and only 23% of the DNA from mouth swabs could be amplified and none of the DNA from swabs and 94% of the DNA from FTA cards could be genotyped. Our study shows that the response rate of self-collection saliva samples and buccal cell samples were much higher than the response rate of blood samples in our group of Danish nurses. However, only the quality of genomic DNA from saliva samples was comparable with blood samples as accessed by purity, genotyping, and PCR amplification. We conclude that the use of saliva samples is a good alternative to blood samples to obtain genomic DNA of high quality and it will increase the response rate considerably in epidemiologic studies.

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OBJECTIVE: To identify risk factors for hip fracture and to examine whether hormone replacement therapy (HRT) modifies the effect of these risk factors. DESIGN: Prospective cohort study. SETTING: The Danish Nurse Cohort Study. PARTICIPANTS: 14,015 female nurses aged 50 years and above who in 1993 completed a questionnaire on general health and lifestyle issues, reproductive history including information on HRT, and family history of osteoporosis and personal history of a wrist fracture. OUTCOME MEASURES: End-point was the first-ever hip fracture registered in the Danish National Hospital Register during the period from 1993 to 1999. RESULTS: During the follow-up period 245 hip fractures were identified. Ever users of HRT had a lower risk of hip fracture (hazard ratio 0.69; 0.50-0.94). Women reporting a poor health (hazard ratio 2.01; 1.30-3.11), restrictions in daily activities (hazard ratio 1.52; 1.05-2.21), low body mass index (hazard ratio 1.65; 0.98-2.77), and leisure time sedentary physical activity (hazard ratio 1.88; 1.30-2.70) were main identified risk factors for hip fracture. HRT did not modify the effect of risk factors on the risk of hip fracture. CONCLUSION: This study confirms that women with a frail health are at increased hip fracture risk and that ever use of HRT decreases the risk of hip fracture. HRT did not modify the effect of these risk factors, indicating that the preventive effect of this therapy is independent of risk factors.

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BACKGROUND: The authors compared self-reported non-spine fractures obtained from a cohort of Danish female nurses with fracture diagnoses registered in the Danish National Hospital Register (DNHR). METHOD: The self-reported fracture history was obtained from a questionnaire and was related to fracture information registered with the DNHR by means of the unique person identification code of Danish citizens. A total of 166 self-reported hip fractures, 391 self-reported wrist fractures, and 121 self-reported upper arm fractures were available for the comparison. The self-reported fractures were initially compared with the anatomic specific fracture diagnoses registered in the DNHR. Second, the comparison also included fracture diagnoses of adjacent skeletal sites (unspecific fracture diagnoses). RESULTS: The positive predictive value of a positive report of hip fracture was 89%. Inclusion of unspecific registered hip fractures increased the positive predictive value to 94%. The same figures for wrist fractures were 75% and 84%, respectively, and for upper arm fractures 54% and 83%, respectively. The predictive value of a negative report of hip fracture was 99.5%. The fracture year was correctly reported in 76% of the hip fracture cases, 81% of the wrist fracture cases, and 82% of the upper arm fracture cases. Predictors of false-positive report of fractures were young age ( < 60 years), report of indoor falls in the previous year, and use of hormone replacement therapy (HRT). CONCLUSION: The authors conclude that self-report of hip, wrist, or upper arm fractures among Danish nurses is relatively accurate but varies by the site of fracture. False positive reports of fracture introduce only modest bias fracture risk estimates and tend to dilute the association between exposures and fracture.

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BACKGROUND: Recent findings from randomized clinical trials on the effects of hormone replacement therapy (HRT) among postmenopausal women contradict findings from observational studies indicating a protective effect on the development of cardiovascular disease. Most observational studies on HRT are based on self-reported data, although data on the validity of HRT in postmenopausal women are sparse. METHODS: We examined self-reported HRT use from questionnaires administered in 1993 (n = 2694) and again in 1999 (n = 2666) to a cohort of Danish nurses living in two Danish counties compared with prescription-reimbursement data from two administrative databases through the Danish National Health Service. RESULTS: The sensitivity and specificity of the self-reported, current HRT use in 1993 were 78.4%[95% confidence interval (95% CI) 75.4-81.4] and 98.4% (95% CI 97.8-98.9), respectively. In 1999, the estimates were 74.8% (95% CI 72.0-77.7) and 98.0% (95% CI 97.3-98.8), respectively. None of the factors examined--including age, alcohol intake, physical activity, smoking, presence of hypertension, and body mass index--was strongly associated with validity. We found a relatively high validity of self-reported data on HRT use. Furthermore, agreement between self-reported and registry-based data was not strongly associated with a range of demographic and lifestyle factors. CONCLUSION: These findings suggest that use of self-reported data is not an important contributor to the apparent discrepancy between observational studies and randomized trials on the cardiovascular effects of HRT use.

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Epidemiologic studies have shown an increased risk of breast cancer following hormone replacement therapy (HRT). The aim of this study was to investigate whether different treatment regimens or the androgenecity of progestins influence the risk of breast cancer differently. The Danish Nurse Cohort was established in 1993, where all female nurses aged 45 years and above received a mailed questionnaire (n = 23,178). A total of 19,898 women returned the questionnaire (86%). The questionnaire included information on HRT types and regimens, reproductive history and lifestyle-related factors. Breast cancer cases were ascertained using nationwide registries. The follow-up ended on 31 December 1999. Women with former cancer diagnoses, women with missing information on HRT, surgical menopause, premenopausal, as well as hysterectomized women were excluded, leaving 10,874 for analyses. Statistical analyses were performed using Cox proportional hazards model. A total of 244 women developed breast cancer during follow-up. After adjustment for confounding factors, an increased risk of breast cancer was found for the current use of estrogen only (RR = 1.96; 95% CI = 1.16-3.35), for the combined use of estrogen and progestin (RR = 2.70; 95% CI = 1.96-3.73) and for current users of tibolone (RR = 4.27; 95% CI = 1.74-10.51) compared to the never use of HRT. In current users of combined HRT with testosterone-like progestins, the continuous combined regimens were associated with a statistically significant higher risk of breast cancer than the cyclical combined regimens (RR = 4.16, 95% CI = 2.56-6.75, and RR = 1.94, 95% CI = 1.26-3.00, respectively). An increased risk of breast cancer was noted with longer durations of use for the continuous combined regimens (p for trend = 0.048). The European traditional HRT regimens were associated with an increased risk of breast cancer. The highest risk was found for the use of continuous combined estrogen and progestin.

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OBJECTIVE: To examine the effect of oestrogen alone and in combination with progestin on the risk of low-energy, hip, wrist, and upper arm fractures. Additionally, to examine to what extent previous use, duration of use as well as recency of discontinuation of hormone replacement therapy (HRT) influences the fracture risk. DESIGN: Prospective cohort study. SETTING: The Danish Nurse Cohort Study PARTICIPANTS: 7082 female nurses aged 50-69, who completed a questionnaire on lifestyle and use of HRT in 1993. OUTCOME MEASURES: Self-reported low-energy, hip, wrist, and upper arm fractures between 1993--1999 obtained at a re-examination in 1999. RESULTS: Compared to never users, current users of HRT, either oestrogen alone or combined with progestin, had a lower risk of low-energy, hip, wrist, and upper arm fractures (hazard ratio 0.60, 0.39-0.93 and hazard ratio 0.44, 0.30-0.66, respectively). The protective effect of HRT appeared to be significantly restricted to users who used the therapy for 10 years or more (hazard ratio 0.27, 0.14-0.51). Women who previously used hormones experienced no protective effect on fracture risk regardless of duration of therapy and recency of discontinuation. CONCLUSION: Only long-term HRT (10 years or more) offers a protective effect against low energy, hip, wrist, and upper arm fractures. In women with risk factors or established osteoporosis, benefits and risks of this therapy should be balanced when considering its use as a first line treatment for prevention of these fractures.

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BACKGROUND: Recent randomized clinical trials suggest an increased risk of stroke with hormone therapy (HT), whereas observational studies have suggested mixed results. Differences in design, definitions of HT exposure, and stroke outcome may explain these discrepancies. Little attention has been paid to identifying subgroups of women who are particularly sensitive to HT. OBJECTIVES: To investigate the risk of various stroke outcomes among women using HT based primarily on estradiol-17beta (unopposed or combined with norethisterone acetate) and to assess the potential modifying effect by presence of risk factors for stroke. DESIGN: Prospective cohort study. SETTING: In 1993, the Danish Nurse Study was established, and questionnaires on lifestyle and HT use were sent to all Danish nurses older than 44 years, of whom 19,898 (85.8%) replied. PARTICIPANTS: Postmenopausal women (n = 13,122) free of previous major cardiovascular and cerebrovascular disease and cancer. MAIN OUTCOME MEASURE: Ischemic or hemorrhagic stroke (n = 144) identified in the national registries of hospital discharges and cause of deaths in the total follow-up through December 31, 1998. RESULTS: In 1993, 28.0% of the 13 122 were current HT users, 14.3% were past users, and 57.7% were never users. Overall, HT exposure was not consistently associated with stroke. However, subdivision based on the presence of hypertension showed a significantly increased risk of stroke among hypertensive women. Compared with hypertensive never HT users, an increased risk of total stroke was found with current use (hazard ratio, 2.35; 95% confidence interval, 1.16-4.74) and especially with current use of estrogen-progestin (hazard ratio, 3.00; 95% confidence interval, 1.33-6.76). Normotensive women had no increased risk of stroke with HT. CONCLUSIONS: We found an increased risk of stroke among hypertensive but not normotensive women using HT. The present study suggests that HT should be avoided in hypertensive women.

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Observational studies and recent randomized trials have shown that postmenopausal hormone replacement therapy (HRT) may reduce the risk of osteoporotic fractures by about 30 to 40%. In this study we used a log linear graphical model to determine whether women with a known increased risk of osteoporosis were more likely to use HRT than other women and to examine whether women at increased risk modified this risk through their lifestyle. Cox regression analysis was used to analyze if women at risk of osteoporosis used HRT longer than women not at risk. Participants were Danish female nurses who, in 1993, were between 50 and 69 years of age (N=14,865). Data were collected from postal questionnaires. We concluded that nurses with a known family history of osteoporosis more often used HRT than nurses without this risk. No other direct associations were found between biological risk factors and ever use of HRT. The presence of biological risk factors of osteoporosis was not consistently modified by a healthier lifestyle. Nurses with a low body mass index (BMI) with a known family history of osteoporosis continued to use HRT longer than nurses without these risk factors.

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