Exposure to chlorpyrifos and pyrethroid insecticides and symptoms of Attention Deficit Hyperactivity Disorder (ADHD) in preschool children from the Odense Child Cohort

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood psychiatric disorder with severe and lifelong impact on mental health and socioeconomic achievements. Environmental factors may play a role in the increasing incidens rates. Previous studies on associations between prenatal and childhood exposure to organophosphate and pyrethroid insecticides and ADHD symptoms have yielded mixed findings.

OBJECTIVES

To investigate associations between prenatal and childhood exposure to chlorpyrifos and pyrethroids and ADHD symptoms in 5-year-old children from the Odense Child Cohort.

METHODS

Spot urine samples from pregnant women in gestational week 28 (n = 614) and offspring at 5 years of age (n = 814) were collected and analyzed for the specific metabolite of chlorpyrifos, TCPY (3,5,6-trichloro-2-pyridinol), as well as the generic pyrethroid metabolite, 3-PBA (3-phenoxybenzoic acid). Offspring ADHD symptoms were assessed at age 5 years using the parent reported "ADHD scale" from the "Child Behavior Checklist 1½-5" (n = 1114). Associations between insecticide exposure variables and an ADHD score ≥90th percentile were analyzed using logistic regression for all children and stratified by sex.

RESULTS

Most pregnant women had detectable concentrations of 3-PBA (93%) and TCPY (91%) with median concentrations of 0.20 μg/L and 1.62 μg/L, respectively. In children, 3-PBA and TCPY concentrations were detectable in 88% and 82% of the samples, and the median concentrations were 0.17 and 1.16 μg/L. No statistically significant associations were observed between insecticide metabolites and an ADHD score ≥90th percentile at age 5.

CONCLUSION

In this relatively large Danish birth cohort study with mainly low dietary insecticide exposure, we found no statistically significant associations between prenatal or childhood exposure to chlorpyrifos or pyrethroids, and excess ADHD-symptom load, in 5-year-old children. Prospective studies with multiple urine samples across vulnerable windows of neurodevelopment is warranted to improve assessment of safe exposure levels, which is particularly relevant for pyrethroids, since their use is increasing.

Outpatients with psychotic disorders need physical health-promoting treatment: A cross-sectional multisite study

Introduction

Impaired quality of life (QoL) and premature death in patients with primary non-affective psychotic disorders is related to lifestyle-induced comorbidities. Current municipal health-promoting treatment and care do not embrace the challenges of living with psychotic disorders.

Aim

This cross-sectional study aimed to identify the proportion of outpatients diagnosed with primary psychotic disorders who need health-promoting treatment and care, and who receive municipal health-promoting interventions.

Methods

Of 206 eligible invited outpatients from three psychiatric services clinics in Southern Denmark, 165 participated. Demographic and health characteristics, and use of alcohol, cannabis, drugs, and cigarettes were identified via a screening tool. Blood test information, body measurements, and medication status were extracted from the outpatients' medical records. The need for health promotion was assessed based on body mass index (BMI), and use of alcohol, cannabis, drugs, and cigarettes.

Results

Seventy-three percent of outpatients needed health promotion, of whom 61 % were not offered municipal health-promoting treatment and care. Thirty-six percent had one or more somatic comorbidities, including diabetes mellitus (15 %) and cardiovascular disease (10 %); 41 % smoked a mean (SD) of 19 (10) cigarettes daily. Mean (SD) BMI was 34 (8) kg/m2 for women and 29 (7) kg/m2 for men.

Conclusion

The majority of outpatients with non-affective psychotic disorders need health-promoting interventions, but only about 40 % of these patients receive such municipal health-promoting treatment and care. Future studies should clarify the impact of these interventions on the health status, QoL, and life expectancy of these patients.

Cognitive performance in hospitalized patients with severe or extreme anorexia nervosa

PURPOSE

Severe malnourishment may reduce cognitive performance in anorexia nervosa (AN). We studied cognitive functioning during intensive nutritional and medical stabilization in patients with severe or extreme AN and investigated associations between weight gain and cognitive improvement.

METHODS

A few days after admission to a specialized hospital unit, 33 patients with severe or extreme AN, aged 16-42 years, completed assessments of memory, cognitive flexibility, processing speed, and attention. Mean hospitalization was 6 weeks. Patients completed the same assessments at discharge (n = 22) following somatic stabilization and follow-up up to 6 months after discharge (n = 18).

RESULTS

The patients displayed normal cognitive performance at admission compared to normative data. During nutritional stabilization, body weight increased (mean: 11.3%; range 2.6-22.2%) and memory, attention, and processing speed improved (p values: ≤ 0.0002). No relationship between weight gain and cognitive improvement was observed at discharge or follow-up.

CONCLUSIONS

Cognitive performance at hospital admission was normal in patients with severe or extreme AN and improved during treatment although without association to weight gain. Based on these results, which are in line with previous studies, patients with severe or extreme AN need not be excluded from cognitively demanding tasks, possibly including psychotherapy. As patients may have other symptoms that interfere with psychotherapy, future research could investigate cognitive functioning in everyday life in patients with severe AN.

TRIAL REGISTRATION NUMBER

The study is registered at clinicaltrials.gov (NCT02502617).

LEVEL OF EVIDENCE

Level III, cohort study.

A survey exploring the practices of smoking cessation support among hospital-based healthcare providers

BACKGROUND

Hospital visits constitute a 'window of opportunity' for initiating smoking cessation attempts, and healthcare providers (HCPs) play an important role in supporting patients to stop smoking. Yet, the current practices of supporting smoking cessation in the hospital setting are largely unexplored. The aim of this study was to explore practices of smoking cessation support among hospital-based HCPs.

METHODS

HCPs working in a large hospital in the secondary care sector completed an online, cross-sectional survey, including sociodemographic and work-related factors as well as 21 questions assessing practices of smoking cessation support based on the "five As" framework. Descriptive statistics were computed, and predictors of HCPs giving patients advice to stop smoking were explored using logistic regression analysis.

RESULTS

All employees (N = 3998) in the hospital received a survey link; 1645 (41.1%) HCPs with daily patient contact completed the survey. Smoking cessation support in the hospital setting was limited with regard to assessment of smoking; providing information and advice; planning and referral for further support; and follow-up on smoking cessation attempts. Almost half (44.8%) of participating HCPs with daily patient contact never or rarely advise their patients to stop smoking. Physicians were more likely than nurses to advice patients to stop smoking, and HCPs in outpatient clinics were more likely to give advice than inpatient clinic HCPs.

CONCLUSION

Smoking cessation support is very limited in the hospital-based healthcare setting. This is problematic, as hospital visits can be windows of opportunity to help patients change their health behaviour. An intensified focus on the implementation of hospital-based smoking cessation support is needed.

Mentalization-oriented psychodynamic group therapy for patients with personality disorders: a naturalistic prospective cohort study

OBJECTIVES

Patients with personality disorders (PDs) are often treated with non-manualized psychodynamic group therapy (PDT) lasting for several years. Non-manualized PDT often combines a variety of therapeutic approaches from different PDT traditions, including mentalization-based therapy. Currently, little is known about the effect of this long-term, costly treatment. This study investigated the extent to which patients with different PDs benefit from mentalization-oriented PDT as it is implemented in clinical practice in terms of symptom severity, interpersonal problems, and general functioning.

METHODS

The design was a naturalistic, prospective cohort study. Seventy-five consecutive PD patients were assessed before treatment with the Symptom Checklist-90 Revised (SCL-90-R) as the primary outcome measure and the Inventory of Interpersonal Problems (IIP) and Global Assessment of Functioning (GAF) as secondary outcome measures. The sample was repeatedly assessed every 12 months for up to 36 months. Paired t-tests were applied to examine the effectiveness of the intervention.

RESULTS

Among completers (n = 42; 56%), improvement was observed on the SCL-90-R: Global Severity Index (mean change = -0.45 [95% CI = -0.72, -0.19]; Cohen's d = -0.55), Positive Symptom Distress Index (-0.40 [-0.63, -0.17]; -0.56); Positive Symptoms Total (-10.70 [-17.31, -4.09]; -0.52). Secondary outcomes also improved: IIP-total (mean change = -0.50 [95%CI = -0.74, -0.25]; Cohen's d = -0.66); GAF-Functioning (8.79 [6.32, 11.27]; 1.15); and GAF-Symptoms (10.67 [8.09, 13.25]; 1.34).

CONCLUSIONS

Completers improved on symptom severity, interpersonal problems, and general functioning, with within-group effect sizes ranging from medium to large. Approximately half the sample dropped out, suggesting that mentalization-oriented PDT spanning several years may be unrealistic for many patients with PD. Significant outcomesThere are no clear guidelines for psychological interventions targeting personality disorders (PDs), and currently eclectic and non-manualized psychodynamic approaches lasting for up to 3 years are prevailing in some clinical practices.Although this treatment approach may have an effect on compliant patients, the high drop-out rate indicates that it may not be suitable for a large proportion of PD patients since it requires long-term commitment. Furthermore, it is difficult to identify the content of the non-manualized psychodynamic therapy and what helps the patients.More specific clinical guidelines emphasizing the application of evidence-based treatments or at least manualized treatments are warranted for the treatment of emotionally unstable PDs and other PDs. LimitationsThe naturalistic study design, without any control group, limits conclusions about mechanisms of action of the intervention.Since the intervention was not manualized, it is unknown exactly which treatment was actually administered, which reduces external validity.The outcomes are based on completer data of a relatively small sample size with high drop-out rate.

Health anxiety symptoms in Danish children during the first lockdown period of the COVID-19 pandemic: an Odense Child Cohort study

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic has a severe impact on the general population. During the pandemic, children may develop emotional and psychological symptoms, including increased worries about health and illness, known as health anxiety symptoms (HASs). We aimed to explore HAS in 7-9-year-old children from the Danish Odense Child Cohort (OCC) during the first COVID-19 lockdown period in Denmark, and to examine associations with potential risk factors.

MATERIAL AND METHODS

OCC is a cohort of children born between 2010 and 2012, which originally recruited 2874 of 6707 pregnancies (43%). Among the current OCC population of 2430 singleton children, 994 participated in this study (response rate 40%). Children and their parents filled out questionnaires about child HAS, family exposure to COVID-19 infection and parental HAS. Adjusted odds ratios (aORs) were calculated between high score child HAS (≥90th percentile) and covariates by use of logistic regression.

RESULTS

Most children (n = 686, 69%) reported few worries about their health. Children reporting high score HAS also had higher levels of internalizing symptoms at age 5; aOR 2.15 (1.20;3.85), p = .010, and higher levels of maternal and paternal HAS; aOR 2.40 (1.44;3.97), p = .001, and 2.00 (1.10;3.65), p = .023, whereas no association with child sex or familial exposure to COVID-19 was detected (n = 65, 6.5%).

CONCLUSIONS

High score child HAS during the first lockdown period of the COVID-19 pandemic was not associated with family exposure to COVID-19 infection, but to being a more anxious child a priori and to HAS in parents.

Sexual Activity in Couples Dealing With Breast Cancer. A Cohort Study of Associations With Patient, Partner and Relationship-Related Factors

Objective

Breast cancer may profoundly affect a couple’s sex life. The present study examines whether patient-, partner- and relationship-related characteristics are associated with sexual activity of couples following breast cancer diagnosis in the treatment phase and over time.

Methods

Women with breast cancer and their male cohabiting partners participated in a longitudinal study in Denmark. Logistic regression was used to examine associations of patient-, partner- and relationship-related characteristics at baseline (≤4 months following surgery) with couples’ sexual activity at baseline, 5 and 12 months later. The longitudinal analyses were stratified for couples’ sexual activity status at baseline.

Results

A total of 722, 533 and 471 couples were included in the analyses at baseline, 5- and 12-months follow-up, respectively. Older age, depressive symptoms and lower vitality of patients were associated with lower odds of couples’ sexual activity at baseline; chemotherapy treatment and older age of patients were associated with lower odds at 5-months follow-up in couples who were not sexually active at baseline. Higher ratings of emotional closeness, affectionate behavior and satisfaction with dyadic coping were associated with higher odds for sexual activity at baseline and over time in couples who were sexually active at baseline.

Conclusion

Sexual counseling during cancer treatment and rehabilitation should include a couple perspective. Relationship-related variables may be a protective factor for remaining sexually active after breast cancer diagnosis. Interventions could focus on strengthening these factors. Health professionals also need to consider the patients’ breast cancer treatment, vitality, and emotional distress in counselling on sexuality.

Multiple sclerosis impairment scale and brain MRI in secondary progressive multiple sclerosis

OBJECTIVE

To examine the Multiple Sclerosis Impairment Scale (MSIS) in secondary progressive MS (SPMS) in relation to the Expanded Disability Status Scale (EDSS), magnetic resonance imaging (MRI) outcomes, and mobility.

METHODS

In this observational single-center study, 68 secondary progressive multiple sclerosis (SPMS) patients were examined by MSIS, EDSS, functional mobility tests of upper/lower extremities, and multimodal MRI. Participants had EDSS ≥3.5, a decline in daily activities over the last year unrelated to relapses, and/or 6-month confirmed disability progression.

RESULTS

Mean disease duration was 23.1 ± 8.3 years and mean age 54.4 ± 8.1 years. MSIS, EDSS, and their corresponding motor, cerebellar, and sensory subscores correlated (p < .0001). Motor subscores of MSIS correlated stronger with Timed-25-Foot-Walk (T25FW) than pyramidal functional system score (FSS) (p = .03), but EDSS had a stronger correlation to T25FW than the total MSIS score (p = .01). MSIS cerebellar subscore correlated stronger with 9-Hole Peg Test (9-HPT) than cerebellar FSS (p = .04). The sensory MSIS subscore also showed correlation with 9-HPT in contrast to sensory FSS (p = .006). MSIS subscores had stronger correlations with MRI volumetry measures than FSS scores (lesion volume and putamen, thalamus, corpus callosum volumetry, p = .0001-0.0017).

CONCLUSION

In patients with SPMS, MSIS correlated with functional motor tests. MSIS showed stronger correlations with atrophy of central nervous system areas, and may be more sensitive to scale cerebellar and sensory function than EDSS.

Cortisol, Depression, and Anxiety Levels Before and After Short-Term Intensive Nutritional Stabilization in Patients With Severe Anorexia Nervosa

INTRODUCTION

Depression and anxiety are well-known comorbid conditions in patients with anorexia nervosa (AN). Hypercortisolemia in patients with AN may be pathogenic and contribute to depression and anxiety symptomatology.

OBJECTIVE

The aim of this study was to investigate short-term changes in cortisol levels and depression and anxiety symptomatology following intensive re-nutrition in patients with severe AN and hospitalized in a specialized unit. Furthermore, we investigated the potential association between cortisol levels and psychometric parameters.

METHODS

A total of 36 patients with AN were enrolled in the study. Nine dropped out before follow-up. Patients underwent paraclinical and psychometric examinations at admission and discharge. Measurements included plasma cortisol, cortisol binding globulin (CBG), 24-h urine cortisol, and self-report questionnaires regarding eating disorder, depression, anxiety, and stress symptoms. Patients were hospitalized in the unit for somatic stabilization and intensive re-nutrition. Mean admission length was 41 days. The study was registered at ClinicalTrials.gov (NCT02502617).

RESULTS

Cortisol levels in blood and urine did not change from admission to discharge in patients with severe AN. Symptoms of depression, anxiety, stress, and eating disorder remained elevated at discharge. There were no associations between changes in cortisol levels and changes in psychometrics.

DISCUSSION

Our results suggest that short-term intensive re-nutrition did not alter hypothalamic-pituitary-adrenal axis activity or mental health in patients with severe AN. Long-term stabilization and longer follow-up after hospital discharge may be needed to detect changes in cortisol levels and whether these changes are associated with depression and anxiety symptomatology. Greater knowledge about cortisol levels and mental health in patients with severe AN may help in the development of new treatment choices for the chronically ill patients. Future studies could investigate whether cortisol-lowering drugs have a therapeutic effect on mental health in AN.

Early development of treatment motivation predicts adherence and symptom reduction in an internet-based guided self-help program for binge eating disorder

OBJECTIVE

Lack of motivation is widely acknowledged as a significant factor in treatment discontinuity and poor treatment outcomes in eating disorders. Treatment adherence is lower in internet-based treatment. The current study aimed to assess the relationship between treatment motivation and treatment outcomes in an internet-based therapist-guided intervention for Binge Eating Disorder (BED).

METHOD

Adults (N = 153) with mild to moderate symptoms of BED participated in a 10-session internet-based treatment program. Baseline and between-session scores of "Readiness to change" and "Belief in change" were used to predict treatment completion and eating disorder symptom reduction (EDE-Q Global, BED-Q, and weekly number of binge eating episodes) at post-treatment.

RESULTS

Baseline treatment motivation could not predict treatment completion or symptom reduction. Early measures of treatment motivation (regression slope from sessions 1-5) significantly predicted both treatment completion and post-treatment symptom reduction. "Belief in change" was the strongest predictor for completing treatment (OR = 2.18, 95%-CI: 1.06, 4.46) and reducing symptoms (EDE-Q Global: B = -0.53, p = 0.001; number of weekly binge eating episodes: B = 0.81, p < 0.01).

DISCUSSION

The results indicated that patients entering online treatment for BED feel highly motivated. However, baseline treatment motivation could not significantly predict treatment completion, which contradicts previous research. The significant predictive ability of early measures of treatment motivation supports the clinical relevance of monitoring the development of early changes to tailor and optimize individual patient care. Further research is needed to examine treatment motivation in regard to internet-based treatment for BED with more validated measures.

Fibrocytes in early and long-standing rheumatoid arthritis: a 6-month trial with repeated synovial biopsy, imaging and lung function test

Objectives

To correlate the level of fibrocytes in peripheral blood, synovial tissue and in vitro culture in rheumatoid arthritis (RA) with changes in disease activity, imaging and pulmonary function.

Methods

Twenty patients with early RA (ERA) and 20 patients with long-standing RA (LRA) were enrolled in a 6-month prospective study. Sixteen patients undergoing wrist arthroscopy were healthy controls. Patients with RA underwent pulmonary function tests, ultrasound and synovial ultrasound-guided needle biopsy of the same wrist at baseline and 6 months. Wrist MRI was performed at baseline (all) and 6 months (ERA). Circulating fibrocytes were measured by flow cytometry, in vitro by the number of monocytes that were differentiated to fibrocytes and in synovial biopsies by counting in histological sections.

Results

Fibrocytes were primarily located around vessels and in the subintimal area in the synovium. Fibrocyte levels did not decline during the trial despite effective RA treatment. In the ERA group, increased synovitis assessed by ultrasound was moderate and strongly correlated with an increase in circulating and synovial fibrocyte levels, respectively. Increased synovitis assessed by MRI during the trial in the ERA group was moderately correlated with both increased numbers of circulating and cultured fibrocytes. Absolute diffusion capacity level was overall weakly negatively correlated with the level of circulating and synovial fibrocytes. The decline in diffusion capacity during the trial was moderately correlated with increased levels of synovial fibrocytes.

Conclusion

Our findings suggest that fibrocytes are involved in RA pathogenesis, both in the synovium and the reduction in lung function seen in a part of patients with RA.

Trial registration number

NCT02652299.

Time trends in treatment modes of anorexia nervosa in a nationwide cohort with free and equal access to treatment

BACKGROUND

Treating patients with anorexia nervosa (AN) remains a major challenge. The choice between an inpatient or an outpatient care setting is an essential issue for the patients and for their relatives with major health economic implications. However, health services-related studies are lacking. The present study was a descriptive exploration of time-trends in treatment modes of patients with free and equal access to health services.

METHODS

The study was based on a nationwide cohort of patients diagnosed for the first time with AN, each followed for 5 years in the registers covering the years 1994-2018. The per patient number of hospital admissions, cumulated number of days of hospitalization and number of outpatient visits during the first 5 years after initial diagnosis were considered.

RESULTS

The cohort of patients with AN with at least 5 years of follow-up amounted to N = 7,505. A clear trend was observed in the per patient five-year cumulated number of inpatient days, decreasing by 6% per year after adjustment for age at diagnosis, parental mental diagnosis, and family income. The five-year number of hospital admissions after initial diagnosis decreased by 2% per year, while no trend was observed for outpatient visits.

CONCLUSIONS

The per patient number of hospitalizations and cumulated days of hospitalization during 5 years after diagnosis were reduced for patients initially diagnosed with AN while there was no change in the number of outpatient visits. The factors contributing to these changes of treatment modes over time are in need of further study.

Prenatal Exposures to Perfluoroalkyl Acids and Associations with Markers of Adiposity and Plasma Lipids in Infancy: An Odense Child Cohort Study

BACKGROUND

Perfluoroalkyl acids (PFAA) are repellants that cross the placental barrier, enabling interference with fetal programming. Maternal PFAA concentrations have been associated with offspring obesity and dyslipidemia in childhood and adulthood, but this association has not been studied in infancy.

OBJECTIVES

We investigated associations between maternal PFAA concentrations and repeated markers of adiposity and lipid metabolism in infancy.

METHODS

In the prospective Odense Child Cohort, maternal pregnancy serum concentrations of five PFAA: Perfluorohexane sulfonic acid (PFHxS), perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), and perfluorodecanoic acid (PFDA) were measured in 649 women. Offspring were examined at birth (n=613) and at 3 months (n=602) and 18 months (n=503) of age. Total cholesterol, LDL, HDL, and triglyceride were evaluated at 3 months (n=262) and 18 months (n=198) of age. Mixed effects linear regression models estimated associations between PFAA and standardized (SDS) body mass index (BMI), ponderal index, and waist circumference. Associations between PFAA and body fat% (BF%) and plasma lipids SDS at 3 months and 18 months of age were investigated with linear regression models.

RESULTS

PFNA and PFDA were associated with higher BMI SDS [adjusted β=0.26; 95% confidence interval (CI): 0.03, 0.49 and β=0.58; 95% CI: -0.03, 1.19, respectively, for 1-ng/mL increases] and ponderal index SDS (β=0.36; 95% CI: 0.13, 0.59 and β=1.02; 95% CI: 0.40, 1.64, respectively) at 3 and 18 months of age (pooled) in girls. Corresponding estimates for boys were closer to the null but not significantly different from estimates for girls. In boys and girls (combined), PFNA and PFDA were associated with BF% at age 3 months (for 1-ng/mL PFDA, β=0.40; 95% CI: 0.04, 0.75), and PFDA was associated with total cholesterol SDS at 18 months (β=1.06; 95% CI: 0.08, 2.03) (n=83).

DISCUSSION

Prenatal PFAA were positively associated with longitudinal markers of adiposity and higher total cholesterol in infancy. These findings deserve attention in light of rising rates of childhood overweight conditions and dyslipidemia. https://doi.org/10.1289/EHP5184.

Six-month prospective trial in early and long-standing rheumatoid arthritis: evaluating disease activity in the wrist through sequential synovial histopathological analysis, RAMRIS magnetic resonance score and EULAR-OMERACT ultrasound score

Introduction

Standardised scoring systems for rheumatoid arthritis (RA) joint disease activity include Larsen score for radiographs, rheumatoid arthritis magnetic resonance imaging score (RAMRIS) for MRI and using the European League Against Rheumatisms-Outcome Measures in Rheumatology (EULAR-OMERACT) score for ultrasound (US) images. The aim of this prospective study was to investigate the relationship between histological synovitis and radiological synovitis, assessed by conventional X-ray, US and MRI of the wrist radiocarpal joint.

Methods

20 patients with treatment naive early RA (ERA) and 20 with long-standing RA (LRA) were enrolled in a 6-month prospective study. Patients with RA underwent US-guided synovial biopsy, X-ray and US of the wrist at enrolment and 6 months. MRI at baseline and also at 6 months for the ERA group, and scored with the RAMRIS system. X-ray was scored by Larsen score and US by the EULAR-OMERACT system. Synovial biopsy inflammation was determined by the Krenn score.

Results

In the ERA group at baseline, Krenn score was correlated strongly with both US combined score (r = 0.77 p < 0.001) and MRI synovitis score (r = 0.85 p < 0.001), while uncorrelated at 6 months. In the LRA group at baseline, these scores correlated strongly (r = 0.83, p < 0.001) to moderately (r = 0.61, p = 0.002), and persisted at 6 months for US score (r = 0.81 p < 0.001). For all patients with RA, change in Krenn score between baseline and 6 months was correlated with both change in US combined score (r = 0.65, p < 0.001) and change in MRI synovitis score (r = 0.50, p = 0.03).

Conclusion

The MRI RAMRIS synovitis score and EULAR-OMERACT US scoring system are sensitive measures of histological synovitis in LRA and ERA. After 6 months, this correlation persists in the established RA group, but not in the ERA group. Overall, decreases in MRI/US synovitis are associated with reductions in histological synovitis. The study validates the use of MRI RAMRIS and EULAR-OMERACT US scores as surrogate markers of histological synovitis in established RA and early untreated RA.

Patient-reported outcomes and safety in patients undergoing synovial biopsy: comparison of ultrasound-guided needle biopsy, ultrasound-guided portal and forceps and arthroscopic-guided synovial biopsy techniques in five centres across Europe

Background

We present a European multicenter study, comparing safety data and patient-reported outcomes (PRO) from patients undergoing synovial biopsy using ultrasound-guided needle biopsy (US-NB), ultrasound-guided portal and forceps (US-P&F) or arthroscopic-guided (AG) procedures.

Objectives

To describe safety and PRO data on joint indices of pain, stiffness and swelling before and after biopsy, procedural discomfort, joint status compared with before biopsy and willingness to undergo a second biopsy for each technique and compare the three techniques. To evaluate the impact on PRO and safety data of corticosteroid therapy as part of the biopsy procedure and sequential biopsy procedures.

Methods

Data were collected on the day of biopsy and 7-14 days postprocedure. Joint pain, swelling and stiffness indices were recorded as 0-100  mm Visual Analogue Scale; qualitative outcome variables on five-point Likert scales. Groups were compared with linear regression, adjusting for disease activity, corticosteroid therapy and prebiopsy PRO value and accounting for repeated measurements.

Results

A total of 524 synovial biopsy procedures were documented (402 US-NB, 65 US-P&F and 57 AGSB). There were eight adverse events (1.5%) with no difference between biopsy methods (p=0.55). All PROs were improved 2  weeks postprocedure, and there were no differences in postbiopsy change in PROs between biopsy methods. Corticosteroid administration, whether intramuscular (n=62) or intra-articular (n=38), did not result in more adverse events (p=0.81) and was associated with reduction in postbiopsy swelling (p<0.01). Sequential biopsy procedures (n=103 patients) did not result in more adverse events (p=0.61) or worsening in PRO data.

Conclusion

Overall, our results do not suggest a significant difference in safety or patient tolerability between US-NB, US-P&F and AGSB sampling. Further, corticosteroid therapy as part of the biopsy procedure and sequential biopsies is safe and well tolerated in patients.

Barriers to lifestyle changes for prevention of cardiovascular disease - a survey among 40-60-year old Danes

Background

Elimination of modifiable risk factors including unhealthy lifestyle has the potential for prevention of 80% of cardiovascular disease cases. The present study focuses on disclosing barriers for maintaining specific lifestyle changes by exploring associations between perceiving these barriers and various sociodemographic and health-related characteristics.

Methods

Data were collected through a web-based questionnaire survey and included 962 respondents who initially accepted treatment for a hypothetical cardiovascular risk, and who subsequently stated that they preferred lifestyle changes to medication. Logistic regression was used to analyse associations between barriers to lifestyle changes and relevant covariates.

Results

A total of 45% of respondents were identified with at least one barrier to introducing 30 min extra exercise daily, 30% of respondents reported at least one barrier to dietary change, and among smokers at least one barrier to smoking cessation was reported by 62% of the respondents. The perception of specific barriers to lifestyle change depended on sociodemographic and health-related characteristics.

Conclusion

We observed a considerable heterogeneity between different social groups in the population regarding a number of barriers to lifestyle change. Our study demonstrates that social inequality exists in the ability to take appropriate preventive measures through lifestyle changes to stay healthy. This finding underlines the challenge of social inequality even in populations with equal and cost-free access to health care. Our study suggests supplementing traditional public campaigns to counter cardiovascular disease by using individualized and targeted initiatives.

Determinants of preferences for lifestyle changes versus medication and beliefs in ability to maintain lifestyle changes. A population-based survey

Preferences for medication treatment versus lifestyle changes are of major importance in the management of chronic diseases. This study aims to investigate determinants of preference for lifestyle changes versus medication for prevention of cardiovascular disease as well as determinants of respondents' beliefs in their ability to maintain lifestyle changes. A representative sample of 40-60-year old Danish inhabitants was in 2012 invited to a survey and were asked to imagine that they had been diagnosed as being at increased risk of heart disease. Subsequently they were presented with a choice between a preventive medical intervention versus lifestyle change. The study population for the present paper comprises 1069 participants. A total of 962 participants preferred lifestyle changes to medication treatment. Significant determinants for preferring lifestyle changes were female gender and high level of physical activity. Significant determinants for not opting for lifestyle changes were being self-employed, poor self-rated health and smoking. Low educational attainment, lifestyle risk factors, self-reported health-related challenges and prior experience with heart disease were associated with a low belief in ability to maintain lifestyle changes. For conclusion we found a pervasive preference for lifestyle changes over medical treatment when individuals were promised the same benefits. Lifestyle risk factors and socioeconomic characteristics were associated with preference for lifestyle changes as well as belief in ability to maintain lifestyle changes. For health professionals risk communication should not only focus on patient preferences but also on patients' beliefs in their own ability to initiate lifestyle changes and possible barriers against maintaining changes.

Alarm symptoms of upper gastrointestinal cancer and contact to general practice--A population-based study

INTRODUCTION

Survival of upper gastrointestinal (GI) cancer depends on early stage diagnosis. Symptom-based guidelines and fast-track referral systems have been implemented for use in general practice. To improve diagnosis of upper GI cancer, knowledge on prevalence of alarm symptoms in the general population and subsequent healthcare-seeking is needed.

MATERIAL AND METHODS

A nationwide study of 100,000 adults, who were randomly selected from the general population were invited to participate in an internet-based survey. People aged ≥45 years were included in this study. Items regarding experience of specific and nonspecific alarm symptoms of upper GI cancer within the preceding 4 weeks and contact to general practitioner (GP) were included.

RESULTS

Of the 60,562 subjects aged ≥45 years, 33,040 (54.6%) completed the questionnaire. The prevalence of the specific alarm symptoms ranged between 1.1% ("repeated vomiting") and 3.4% ("difficulty swallowing"). Women had higher odds of experiencing "repeated vomiting" and "persistent and recent-onset abdominal pain", but lower odds of experiencing "upper GI bleeding". The proportion of people contacting their GP with each of the four specific alarm symptoms ranged from 24.3% ("upper GI bleeding") to 39.9% ("repeated vomiting"). For each combination of two specific alarm symptoms, at least 52% contacted their GP.

CONCLUSION

The specific alarm symptoms of upper GI cancer are not very prevalent in the general population. The proportion of GP contacts with each of the four specific symptoms varied between 24.3% and 39.9%. The proportion of GP contacts was higher in the older age and with combinations of two symptoms.

Live birth and adverse birth outcomes in women with ulcerative colitis and Crohn's disease receiving assisted reproduction: a 20-year nationwide cohort study

OBJECTIVE

To examine the chance of live births and adverse birth outcomes in women with ulcerative colitis (UC) and Crohn's disease (CD) compared with women without inflammatory bowel disease (IBD) who have undergone assisted reproductive technology (ART) treatments.

METHODS

This was a nationwide cohort study based on Danish health registries, comprising all women with an embryo transfer during 1 January 1994 through 2013. The cohorts comprised 1360 ART treatments in 432 women with UC, 554 ART treatments in 182 women with CD and 148,540 treatments in 52,489 women without IBD. Our primary outcome was live births per ART treatment cycle. We controlled for multiple covariates in the analyses. Our secondary outcomes were adverse birth outcomes.

RESULTS

The chance of a live birth for each embryo transfer was significantly reduced in ART treatments in women with UC (OR=0.73, 95% CI 0.58 to 0.92), but not significantly reduced in the full model of ART treatments in women with CD (OR=0.77, 95% CI 0.52 to 1.14). Surgery for CD before ART treatment significantly reduced the chance of live birth for each embryo transfer (OR=0.51, 95% CI 0.29 to 0.91). In children conceived through ART treatment by women with UC, the OR of preterm birth was 5.29 (95% CI 2.41 to 11.63) in analyses including singletons and multiple births; restricted to singletons the OR was 1.80, 95% CI 0.49 to 6.62.

CONCLUSIONS

Our results suggest that women with UC and CD receiving ART treatments cannot expect the same success for each embryo transfer as other infertile women. Women with CD may seek to initiate ART treatment before needing CD surgery. Increased prenatal observation in UC pregnancies after ART should be considered.

Associations between patients' risk attitude and their adherence to statin treatment - a population based questionnaire and register study

Background

Poor adherence to medical treatment may have considerable consequences for the patients’ health and for healthcare costs to society. The need to understand the determinants for poor adherence has motivated several studies on socio-demographics and comorbidity. Few studies focus on the association between risk attitude and adherence. The aim of the present study was to estimate associations between patients’ adherence to statin treatment and different dimensions of risk attitude, and to identify subgroups of patients with poor adherence.

Methods

Population-based questionnaire and register-based study on a sample of 6393 persons of the general. Danish population aged 20–79. Data on risk attitude were based on 4 items uncovering health-related as well as financial dimensions of risk attitude. They were collected through a web-based questionnaire and combined with register data on redeemed statin prescriptions, sociodemographics and comorbidity. Adherence was estimated by proportion of days covered using a cut-off point at 80 %.

Results

For the dimension of health-related risk attitude, “Preference for GP visit when having symptoms”, risk-neutral and risk-seeking patients had poorer adherence than the risk-averse patients, OR 0.80 (95 %-CI 0.68–0.95) and OR 0.83 (95 %-CI 0.71–0.98), respectively. No significant association was found between adherence and financial risk attitude. Further, patients in the youngest age group and patients with no CVD were less adherent to statin treatment.

Conclusion

We find some indication that risk attitude is associated with adherence to statin treatment, and that risk-neutral and risk-seeking patients may have poorer adherence than risk-averse patients. This is important for clinicians to consider when discussing optimal treatment decisions with their patients. The identified subgroups with the poorest adherence may deserve special attention from their GP regarding statin treatment.

Self-reported symptoms and healthcare seeking in the general population--exploring "The Symptom Iceberg"

BACKGROUND

Research has illustrated that the decision-making process regarding healthcare seeking for symptoms is complex and associated with a variety of factors, including gender differences. Enhanced understanding of the frequency of symptoms and the healthcare seeking behaviour in the general population may increase our knowledge of this complex field. The primary objective of this study was to estimate the prevalence of self-reported symptoms and the proportion of individuals reporting GP contact, in a large Danish nationwide cohort. A secondary objective was to explore gender differences in GP contacts in response to experiencing one of the 44 predefined symptoms.

METHODS

A Danish nationwide cohort study including a random sample of 100,000 individuals, representative of the adult Danish population aged 20 years or above. A web-based questionnaire survey formed the basis of this study. A total of 44 different symptoms covering a wide area of alarm symptoms and non-specific frequently occurring symptoms were selected based on extensive literature search. Further, items regarding contact to the GP were included. Data on socioeconomic factors were obtained from Statistics Denmark.

RESULTS

A total of 49,706 subjects completed the questionnaire. Prevalence estimates of symptoms varied from 49.4% (24,537) reporting tiredness to 0.11% (54) reporting blood in vomit. The mean number of reported symptoms was 5.4 (men 4.8; women 6.0). The proportion of contact to the GP with at least one symptom was 37%. The largest proportion of GP contacts was seen for individuals reporting blood in the urine (73.2%), whereas only 11.4% of individuals with increase in waist circumference reported GP contact. For almost 2/3 of the symptoms reported, no gender differences were found concerning the proportion leading to GP contacts.

CONCLUSION

Prevalence of symptoms and GP contacts are common in this overview of 44 different self-reported symptoms. For almost 2/3 of the reported symptoms no gender differences were found concerning the proportion leading to GP contacts. An enhanced understanding of healthcare seeking decisions may assist healthcare professionals in identifying patients who are at risk of postponing contact to the GP and may help development of health campaigns targeting these individuals.

Overlap of symptoms of gastroesophageal reflux disease, dyspepsia and irritable bowel syndrome in the general population

INTRODUCTION

Gastroesophageal reflux disease (GERD), functional dyspepsia (FD) and irritable bowel syndrome (IBS) are common functional gastrointestinal conditions with significant impact on the daily lives of individuals. The objective was to investigate the prevalence and overlap of the three conditions in a Western general population.

MATERIAL AND METHODS

A nationwide study of 100,000 individuals 20 years and above, randomly selected in the general population. A web-based questionnaire survey formed the basis of this study. Questions regarding FD and IBS were extracted from the ROME III adult questionnaire. Questions regarding GERD were developed based on the Montreal definition. Prevalence estimates for GERD, FD IBS were calculated in total and for each sex separately and for four age groups. A Venn diagram was constructed, illustrating the overlap between the three conditions.

RESULTS

The overall response rate was 52.2%. The prevalence of GERD, FD and IBS was 11.2%, 7.7% and 10.5%, respectively, and overlap between two or three of these conditions was seen among 6.5% of the respondents. Among individuals meeting the criteria of one or more of the conditions GERD, FD and IBS, 30.7% had overlap between two or all three conditions.

CONCLUSION

GERD, FD and IBS are common conditions in the general population and the overlap between these conditions is also quite common. When diagnosing patients with GERD, FD and IBS, physicians should keep in mind that these patients could be suffering from more than one of these conditions.

General practitioners' knowledge and concern about electromagnetic fields

Our aim is to explore general practitioners’ (GPs’) knowledge about EMF, and to assess whether different knowledge structures are related to the GPs’ concern about EMF. Random samples were drawn from lists of GPs in Germany in 2008. Knowledge about EMF was assessed by seven items. A latent class analysis was conducted to identify latent structures in GPs’ knowledge. Further, the GPs’ concern about EMF health risk was measured using a score comprising six items. The association between GPs’ concern about EMF and their knowledge was analysed using multiple linear regression. In total 435 (response rate 23.3%) GPs participated in the study. Four groups were identified by the latent class analysis: 43.1% of the GPs gave mainly correct answers; 23.7% of the GPs answered low frequency EMF questions correctly; 19.2% answered only the questions relating EMF with health risks, and 14.0% answered mostly “don’t know”. There was no association between GPs’ latent knowledge classes or between the number of correct answers given by the GPs and their EMF concern, whereas the number of incorrect answers was associated with EMF concern. Greater EMF concern in subjects with more incorrect answers suggests paying particular attention to misconceptions regarding EMF in risk communication.

Participation in questionnaire studies among couples affected by breast cancer

OBJECTIVE

Participation bias may be a problem in couple-based psychosocial studies. Therefore, it is important to investigate the characteristics associated with participation. The aim of this study was to analyze whether participation in a longitudinal psychosocial questionnaire study among couples affected by breast cancer was associated with socioeconomic, breast cancer-specific, and other health-related characteristics of the patients and partners.

METHODS

The analyzes are based on 2254 couples who were invited to participate in a nationwide survey on psychosocial adjustment among couples dealing with breast cancer. Participating couples (N = 792) were compared with non-participating couples (N = 1462) with regard to socioeconomic and health-related characteristics obtained from nationwide clinical and administrative registers.

RESULTS

Associations were seen between various socioeconomic variables and couple participation. The patient characteristics older age (OR = 0.15 [95% CI = 0.07-0.55]), low education (OR = 1.95 [95% CI = 1.46-2.68]), disability pension (OR = 0.59 [95% CI = 0.39-0.55]), or non-western ethnicity (OR = 0.36 [95% CI = 0.15-0.82]) reduced couple participation. The partner characteristics older age (OR = 0.23 [95% CI = 0.15-0.43]), low education (OR = 1.67 [95% CI = 1.25-2.22]), receiving disability pension (OR = 0.46 [95% CI = 0.25-0.82]), non-western ethnicity (OR = 0.17 [95% CI = 0.06-0.49]), or high morbidity (OR = 0.76 [95% CI = 0.60-0.96]) also reduced couple participation. Furthermore, couples with low income (OR = 1.49 [95% CI = 1.16-1.95]) had reduced participation. No associations were found between couple participation and breast cancer-related variables.

CONCLUSIONS

Socioeconomic characteristics of patients and partners, and morbidity of partners may influence participation in couple-based psychosocial breast cancer research. Breast cancer-related characteristics do not seem to influence participation.

The Danish Symptom Cohort: Questionnaire and Feasibility in the Nationwide Study on Symptom Experience and Healthcare-Seeking among 100 000 Individuals

Introduction. In order to develop strategies to prevent delay in diagnosis, it is important to gain knowledge of symptoms and healthcare-seeking processes in the population. This paper describes a combined survey and register-based study with (1) focus on development of a questionnaire concerning experience of symptoms and subsequent consequences and (2) feasibility of the study. Methods. The study is a nationwide cohort study of 100 000 individuals randomly selected from the Danish general population. A comprehensive questionnaire concerning experience of symptoms and subsequent consequences was developed. The methodological framework for the development included defining the domains to be measured, identification of previous items, scales and questionnaires in the literature, and pilot and field testing. Results. A total of five domains and 16 subdomains were defined covering the area of symptom experience, symptom characteristics, reaction in response to symptom experience, external factors, and personality characteristics with potential influence on the symptom experience. In total, 49 706 questionnaires were completed, yielding a response rate of 52.2%. Conclusion. We developed a comprehensive questionnaire used in a large combined survey and register-based study concerning experience of symptoms and subsequent consequences of symptom experiences. We succeeded in conducting a large survey providing the groundwork for The Danish Symptom Cohort.

Relational coordination and organisational social capital association with characteristics of general practice

Background. Relational coordination (RC) and organisational social capital (OSC) are measures of novel aspects of an organisation's performance, which have not previously been analysed together, in general practice. Objectives. The aim of this study was to analyse the associations between RC and OSC, and characteristics of general practice. Methods. Questionnaire survey study comprising 2074 practices in Denmark. Results. General practitioners (GPs) rated both RC and OSC in their general practice higher than their secretaries and nurses. The practice form was statistically significantly associated with high RC and OSC. RC was positively associated with the number of patients listed with a practice per staff, where staff is defined as all members of a practice including both owners and employees. Conclusion. The study showed that RC and OSC were significantly associated with type of profession and practice type. RC was also found to be significantly positively associated with number of patients per staff. However, the low response rate must be taken into consideration when interpreting the self-reported results of this study.

Danish General Practitioners' Use of Prostate-Specific Antigen in Opportunistic Screening for Prostate Cancer: A Survey Comprising 174 GPs

Background. The use of prostate-specific antigen test has markedly increased in Danish general practice in the last decade. Despite the national guidelines advice against PSA screening, opportunistic screening is supposed to be the primary reason for this increased number of PSA tests performed. Aims. Based on the increase in the amount of PSA conducted, we aimed to analyse how GPs in Denmark use the PSA test. Methods. A self-administrated questionnaire concerning symptomatic and asymptomatic patient cases was developed based on the national and international guidelines and the extensive literature review, and an in-depth interview conducted with a GP was performed. Results. None of the GPs would do a PSA measurement for an asymptomatic 76-year-old man. For asymptomatic 55- and 42-year-old men, respectively, 21.9% and 18.6% of GPs would measure PSA. Patient request and concern could be potential reasons for measuring PSA for asymptomatic patients. Almost all GPs stated that a PSA measurement is indicated for symptomatic 49- and 78-year-old men, respectively, 98.9% and 93.8%. Conclusion. Opportunistic PC screening is being performed in general practice to a high degree. Hence, current guidelines are not followed, and intense focus should be on more effective implementation strategies in order to avoid overuse of PSA.

A survey of cancer patients' unmet information and coordination needs in handovers--a cross-sectional study

Background

The care responsibilities for cancer patients are frequently handed over from one healthcare professional to another. These handovers are known to pose a threat to the safety of patients and the efficiency of the healthcare system. Little is known about specific needs of cancer patients in handovers. The objectives of this study were to examine cancer patients’ unmet needs for information and coordination in handovers and to analyse the association between patients’ demographic and clinical characteristics and unmet information and coordination needs.

Methods

Cancer patients treated in an oncology and a surgery outpatient setting completed a questionnaire developed to examine unmet information and coordination needs of cancer patients in handovers. Associations between unmet needs and comorbidity, treatment type, time since diagnosis, gender, age, and education in various handover situations were analysed.

Results

Of 250 eligible patients 131 participated (response rate of 52%). Overall, 18% of patients had unmet coordination needs and 18% had unmet information needs.

Hospital discharge was the type of handover where patients most frequently reported unmet information needs (18%). Unmet coordination needs were most frequently reported in handovers between different hospitals (19%) and in handovers between hospital and general practice (18%). In general, age and education were statistically significantly associated with reporting unmet needs, where patients younger than 60 years and patients with a higher education were more likely to express unmet needs.

Conclusions

The findings indicate room for improvements regarding exchange of information and coordination between healthcare professionals, and between healthcare professionals and patients.

Patients suspected of irritable bowel syndrome--cross-sectional study exploring the sensitivity of Rome III criteria in primary care

OBJECTIVES

The Rome III criteria for irritable bowel syndrome (IBS) are recommended by guidelines to help identify the syndrome. The majority of IBS patients are managed in primary care, where a pragmatic approach to diagnosis is usually adopted, using clinical judgment and knowledge about the patient. Many general practitioners (GPs) have no or limited knowledge of the diagnostic criteria, few use them, and many consider IBS a diagnosis of exclusion. The aim of this study is to explore the sensitivity of the Rome III criteria in relation to a GP-based clinical diagnosis of IBS, to identify differences between Rome III-positive and -negative patients, and to describe the agreement between the various symptom-based criteria.

METHODS

Patients aged 18-50 years, presenting in primary care with gastrointestinal complaints and identified as IBS patients by their GP, were referred for enrollment. The Manning and Rome I-III criteria were evaluated through interviews and patients completed the questionnaires The Gastrointestinal Symptom Rating Scale (GSRS)/The Gastrointestinal Symptom Rating Scale modified for use in patients with IBS (GSRS-IBS), Short Form 36, Irritable Bowel Syndrome Quality of Life measurement, Work Productivity and Activity Impairment questionnaire-irritable bowel version, and a questionnaire on use of health-care resources.

RESULTS

A total of 604 patients were referred and 499 were included (mean age 32.8 (s.d. 9.5) years, 75% were female). The Rome III criteria were fulfilled by 376 patients (sensitivity 0.75, 95% CI 71-79%). Rome III-positive patients more frequently reported disturbed defecation, had a higher symptom burden, and lower disease-specific health-related quality of life compared with Rome III-negative patients. The various symptom-based criteria identified slightly different subpopulations with the highest agreement between the Rome II and III criteria.

CONCLUSIONS

The Rome III criteria identified three in four patients labeled with IBS in primary care. The relevance of the Rome III for IBS in primary care is supported.

A randomised controlled trial to improve general practitioners' services in cancer rehabilitation: effects on general practitioners' proactivity and on patients' participation in rehabilitation activities

Few studies have evaluated initiatives targeting implementation of cancer rehabilitation. In this study we aim to test the effects of a complex intervention designed to improve general practitioners' (GPs) involvement in cancer rehabilitation. Outcomes were proactive contacts to patients by their GP reported by the patients and GPs, respectively, and patients' participation in rehabilitation activities.

METHODS

Cluster randomised controlled trial. All general practices in Denmark were randomised to an intervention group or to a control group (usual procedures). Patients were subsequently allocated to the intervention or the control group based on randomisation status of their GP. Between May 2008 and February 2009, adult patients treated for incident cancer at Vejle Hospital, Denmark, were assessed for eligibility. A total of 323 general practices were included, allocating 486 patients to an intervention and 469 to a control group. The intervention included a patient interview about rehabilitation with a rehabilitation coordinator at the hospital, comprehensive information to the GP about individual needs for rehabilitation, and an encouragement to the GP to contact the patient proactively. Questionnaires were administered to patients and GPs at 14 months after inclusion.

RESULTS

At baseline average age of patients was 63 years and 72% were female. The most frequent cancer localisations were breast (43%), lung (15%), and malignant melanoma (8%). The intervention had no effect on either patient- or GP-reported extent of GP proactivity. Further, no effect was observed on patient participation in rehabilitation activities during the 14-month follow-up period.

DISCUSSION

The intervention had no effect on GP proactivity or on patient participation in rehabilitation activities. However, analyses showed a significant association between proactivity and participation and we, therefore, conclude that increased GP proactivity may facilitate patient participation in rehabilitation activities.

Association between unmet needs and quality of life of cancer patients: a population-based study

BACKGROUND

Two conceptually different morbidity outcomes unmet needs and health-related quality of life are used to identify cancer patients in need of clinical attention and to evaluate rehabilitation programmes. The knowledge on the interrelation between unmet needs and health-related quality of life is scarce. This paper studies the hypothesis that patient-perceived unmet needs of rehabilitation during the cancer trajectory are associated with decreased quality of life.

MATERIAL AND METHODS

Based on registers, a Danish population-based cohort of adult, incident, mixed-site cancer patients diagnosed between 1 October 2007 and 30 September 2008 was established. At 14 months following diagnosis participants completed a questionnaire including health-related quality of life (EORTC QLQ C-30), psychological distress (POMS-SF), and unmet needs with regard to physical, emotional, family-oriented, sexual, work-related, and financial problems. Unmet needs were assessed through six ad hoc questions.

RESULTS

Questionnaires were received from 3439 of 4947 patients, resulting in a response rate of 70%. The three most frequent cancer types were breast (28.4%), prostate (14.6%) and colorectal cancer (15.2%). Overall, 60.1% expressed an unmet need of rehabilitation in at least one area, physical and emotional problems being the most frequent (40.0% and 37.5%). For all scales of the EORTC QLQ C-30 and POMS, significant adjusted mean differences were observed between patients with unmet needs in at least one area and patients with no unmet needs (p-values < 0.001). These differences were well above levels usually considered clinically relevant. Further, impairment increased with increasing number of areas in which unmet needs were reported.

DISCUSSION

We confirmed the hypothesis that patient-perceived unmet needs of rehabilitation during the cancer trajectory are associated with decreased quality of life. This study supports the use of unmet needs questions to identify patients in need of clinical attention. Interventions reducing cancer patients' perceived needs of rehabilitation may enhance quality of life.

Social inequality in cancer rehabilitation: a population-based cohort study

OBJECTIVES

In a healthcare system with equal access we analysed possible associations between cancer survivors' socioeconomic status (SES) and their: 1) need for rehabilitation; 2) participation in rehabilitation activities; and 3) unmet needs for rehabilitation in a 14-month period following date of diagnosis.

METHODS

A population-based cohort study including incident cancer patients diagnosed from 1 October 2007 to 30 September 2008 in Denmark. Fourteen months after diagnosis participants completed a mailed out questionnaire developed to measure different aspects and dimensions of rehabilitation. Individual information on cohabitation status, education, income and labour market status was retrieved from national registers. Logistic regression analyses were used to explore associations between socioeconomic status and rehabilitation outcomes.

RESULTS

A total of 3439 patients responded (70%). Significant interactions between SES and sex were demonstrated and further analyses were therefore stratified for gender. In general, women and to a lesser extent men with short education and low income participated less often in activities and had in some areas more unmet needs. Women living alone more often expressed a rehabilitation need in the physical, emotional and financial area and had to a higher extent unmet needs in a number of areas. Men living alone and men outside the workforce had increased odds of unmet needs in the physical area.

CONCLUSIONS

Despite equal access to care, SES had a significant impact on cancer survivors' rehabilitation. In general, the associations were most pronounced for female cancer patients. We suggest that special attention should be paid to socioeconomically disadvantaged groups by taking into account differences in SES in a clinical setting and when developing targeted rehabilitation programmes.

A randomised controlled trial to improve the role of the general practitioner in cancer rehabilitation: effect on patients' satisfaction with their general practitioners

OBJECTIVE

To test whether a complex intervention facilitating early cancer rehabilitation by involvement of the general practitioner (GP) soon after diagnosis improves patients' satisfaction with their GPs.

DESIGN

A cluster randomised controlled trial. All general practices in Denmark were randomised to an intervention or a control group before the start of the study. Patients included those with cancer who were subsequently allocated to either group based on the randomisation status of their GP.

PARTICIPANTS

Adult patients with cancer treated for incident cancer at the public regional hospital (Vejle Hospital, Denmark) were included between May 2008 and February 2009. A total of 955 patients registered with 323 practices were included, of which 486 patients were allocated to the intervention group and 469 to the control group.

INTERVENTION

The intervention included a patient interview assessing the need for rehabilitation, improved information from the hospital to GPs including information on the patients' current needs along with information about needs of patients with cancer in general. Further, GPs were encouraged to proactively contact the patients and facilitate the patients' rehabilitation course.

OUTCOME MEASURES

6 months after inclusion of the patient, patient satisfaction with their GP during the last 12 months in five different dimensions of GP care was assessed using the Danish version of the EuroPEP (European Patients Evaluate General Practice Care) questionnaire (DanPEP). 14 months after inclusion, patient satisfaction with the GP regarding the cancer course and GP's satisfaction with own contribution to the patients' rehabilitation course were assessed using ad hoc questions specifically designed for this study.

RESULTS

No overall effect of the intervention was observed. Subgroup analysis of the patients with breast cancer showed statistically significant improvement of satisfaction with the GP in two of the five DanPEP dimensions.

CONCLUSIONS

This complex intervention aiming at improving GPs' services in cancer rehabilitation had no impact on patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov, registration ID number NCT01021371.

Is a targeted intensive intervention effective for improvements in hypertension control? A randomized controlled trial

BACKGROUND

High blood pressure (BP) is one of the most important risk factors for stroke, and antihypertensive therapy significantly reduces the risk of cardiovascular morbidity and mortality. However, achieving a regulated BP in hypertensive patients is still a challenge.

OBJECTIVE

To evaluate the impact of an intervention targeting GPs' management of hypertension.

METHODS

A cluster randomized trial comprising 124 practices and 2646 patients with hypertension. In the Capital Region of Denmark, the participating GPs were randomized to an intensive or to a moderately intensive intervention group or to a control group and in Region Zealand and Region of Southern Denmark, practices were randomized into a moderately intensive intervention and to a control group. The main outcome measures were change in proportion of patients with high BP and change in systolic BP (SBP) and diastolic BP (DBP) from the first to the second registration.

RESULTS

The proportion of patients with high BP in 2007 was reduced in 2009 by ~9% points. The mean SBP was reduced significantly from 2007 to 2009 by 3.61 mmHg [95% confidence interval (CI): -4.26 to -2.96], and the DBP was reduced significantly by 1.99 mmHg (95% CI: -2.37 to -1.61). There was no additional impact in either of the intervention groups.

CONCLUSION

There was no impact of the moderate intervention and no additional impact of the intensive intervention on BP.

Socio-economic status influences blood pressure control despite equal access to care

OBJECTIVE

Denmark has a health care system with free and equal access to care irrespective of age and socio-economic status (SES). We conducted a cross-sectional study to investigate a possible association between SES and blood pressure (BP) control of hypertensive patients treated in general practice.

METHODS

We enrolled 184 general practices and 5260 hypertensive patients. The general practitioners reported information about BP and diagnosis of diabetes. Information about education, income, antihypertensive drug treatment and other co-morbidity was retrieved from relevant registers from Statistics Denmark. The outcome measure was BP control defined as BP <140/90 mmHg in general and <130/80 mmHg in diabetics.

RESULTS

Patients <65 years and with an educational level of 10-12 years had increased odds ratio (OR) of BP control compared to patients with an educational level <10 years. Patients ≥65 years had increased OR of BP control if they were married/cohabiting as compared to being single, whereas education and income had no impact in this age group. Diabetics had significantly reduced odds of BP control irrespective of age, educational or income level.

CONCLUSIONS

Despite equal access to care for all patients, SES had significant impact on BP control in this survey. Diabetes and cardiovascular disease also had a substantial influence irrespective of age, educational and income level.

Associations between reporting of cancer alarm symptoms and socioeconomic and demographic determinants: a population-based, cross-sectional study

Background

Reporting of symptoms which may signal cancer is the first step in the diagnostic pathway of cancer diseases. Cancer alarm symptoms are common in the general population. Public awareness and knowledge of cancer symptoms are sparse, however, and many people do not seek medical help when having possible cancer symptoms. As social inequality is associated with cancer knowledge, cancer awareness, and information-seeking, our hypothesis is that social inequality may also exist in the general population with respect to reporting of cancer alarm symptoms. The aim of this study was to investigate possible associations between socioeconomic and demographic determinants and reporting of common cancer alarm symptoms.

Methods

A cross-sectional questionnaire survey was performed based on a stratified sample of the Danish general population. A total of 13 777 randomly selected persons aged 20 years and older participated. Our main outcome measures were weighted prevalence estimates of self-reporting one of the following cancer alarm symptoms during the preceding 12 months: a lump in the breast, coughing for more than 6 weeks, seen blood in urine, or seen blood in stool. Logistic regression models were used to calculate unadjusted and adjusted odds ratios with 95% confidence intervals for the associations between each covariate and reporting of cancer alarm symptoms.

Results

A total of 2 098 (15.7%) of the participants reported one or more cancer alarm symptoms within the preceding 12 months.

Women, subjects out of the workforce, and subjects with a cancer diagnosis had statistically significantly higher odds of reporting one or more cancer alarm symptoms. Subjects with older age and subjects living with a partner had lower odds of reporting one or more cancer alarm symptoms. When analysing the four alarm symptoms of cancer separately most tendencies persisted.

Conclusions

Socioeconomic and demographic determinants are associated with self-reporting of common cancer alarm symptoms.

Participation in cancer rehabilitation and unmet needs: a population-based cohort study

Purpose

To investigate associations between cancer survivors’ sex, age, and diagnosis in relation to their (1) need for rehabilitation, (2) participation in rehabilitation activities, and (3) unmet needs for rehabilitation in a 14-month period following date of diagnosis.

Methods

A population-based cohort study was performed on incident cancer patients diagnosed from 1 October 2007 to 30 September 2008. Fourteen months after diagnosis, participants completed a questionnaire developed to measure the aspects of rehabilitation. Logistic regression analyses were used to explore the association between sex, age, and diagnosis, and the outcome variables for rehabilitation.

Results

A total of 3,439 patients participated, yielding an overall response rate of 70%. One third of the cancer patients reported a need for physical rehabilitation and one third for psychological rehabilitation. Half of the patients participated in at least one activity. Unmet needs were most often reported in psychological, sexual, and financial areas. Women expressed more needs, participated more often in rehabilitation activities, and had, to a higher extent, their emotional needs fulfilled. Breast cancer patients participated more often in physical rehabilitation. Elderly who expressed rehabilitation needs more often had them unresolved.

Conclusions

A substantial variation in rehabilitation needs, participation in activities, and unmet needs in relation to sex, age, and cancer type was observed. Cancer care ought to systematically address the wide range of needs in all groups through integration of systematic needs assessment and targeted supply of offers.

Enhanced involvement of general practitioners in cancer rehabilitation: a randomised controlled trial

OBJECTIVE

To test the hypothesis that a multimodal intervention giving the general practitioner (GP) an enhanced role in cancer rehabilitation improves patients' health-related quality of life and psychological distress.

DESIGN

Cluster randomised controlled trial. All general practices in Denmark were randomised to an intervention group or to a control group. Patients were subsequently allocated to intervention or control (usual procedures) based on the randomisation status of their GP.

SETTING

All clinical departments at a public regional hospital treating cancer patients and all general practices in Denmark.

PARTICIPANTS

Adult patients treated for incident cancer at Vejle Hospital, Denmark, between 12 May 2008 and 28 February 2009. A total of 955 patients (486 to the intervention group and 469 to the control group) registered with 323 general practices were included.

INTERVENTION

The intervention included an interview about rehabilitation needs with a rehabilitation coordinator at the regional hospital, information from the hospital to the GP about individual needs for rehabilitation and an encouragement of the GP to contact the patient to offer his support with rehabilitation.

MAIN OUTCOME MEASURES

The primary outcome was health-related quality of life measured 6 months after inclusion using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Secondary outcomes included quality of life at 14 months and additional subscales of the EORTC QLQ-C30 at 6 and 14 months and psychological distress at 14 months using the Profile of Mood States Scale.

RESULTS

No effect of the intervention was observed on primary and/or secondary outcomes after 6 and 14 months.

CONCLUSION

A multimodal intervention aiming to give the GP an enhanced role in cancer patients' rehabilitation did not improve quality of life or psychological distress.

TRIAL REGISTRATION

ClinicalTrials.gov, registration ID number NCT01021371.

Treatment of 5413 hypertensive patients: a cross-sectional study

BACKGROUND

Most hypertensive patients are managed in primary care in Denmark, but previous studies have shown that only 21-43% of hypertensive patients achieve optimal blood pressure (BP) control. Antihypertensive drug treatment, risk factors and cardiovascular disease (CVD) are some of the important factors to consider when optimizing the individual treatment strategy in hypertensive patients.

OBJECTIVE

To examine treatment of BP according to Danish guidelines (BP < 140/90 mmHg generally and <130/80 mmHg for diabetics) in a population from general practice in relation to risk factors, CVD and diagnosis of diabetes.

METHODS

A cross-sectional study comprising 184 practices and 5413 hypertensive patients was carried out in Denmark. The general practitioners filled in information on each patient's risk factors, CVD and antihypertensive drug treatment. Patients filled in a questionnaire on risk factors. The outcome measures were optimal BP control according to Danish guidelines and antihypertensive drug treatment.

RESULTS

Mean patient age was 65.9 years [95% confidence interval (CI): 65.6-66.1]. Optimal BP control was achieved in 29.1% (95% CI: 27.9-30.3) of the study population. Among 842 diabetics with or without CVD, optimal BP control was achieved in 10.9% (95% CI: 8.8-10.3), while 38.7% (35.5-41.9) of patients with CVD achieved optimal BP control. The majority of all patients were treated with 1 (32.5%, 95% CI: 32.5 (31.3-33.8)) or two antihypertensive drugs (39.0%, 95% CI: 38.2-40.8). In hypertensive diabetics, 17.7% were not treated with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker.

CONCLUSION

In general practice, the proportion of hypertensive patients achieving optimal BP control is inadequate. The majority of hypertensive patients are treated with only one or two antihypertensive drugs.

Nonlocal description of X waves in quadratic nonlinear materials

We study localized light bullets and X waves in quadratic media and show how the notion of nonlocality can provide an alternative simple physical picture of both types of multidimensional nonlinear waves. For X waves we show that a local cascading limit in terms of a nonlinear Schrödinger equation does not exist-one needs to use the nonlocal description, because the nonlocal response function does not converge toward a function. Also, we use the nonlocal theory to show that the coupling to the second harmonic is able to generate an X shape in the fundamental field despite having anomalous dispersion, in contrast to the predictions of the cascading limit.

Bubble generation in a twisted and bent DNA-like model

The DNA molecule is modeled by a parabola embedded chain with long-range interactions between twisted base pair dipoles. A mechanism for bubble generation is presented and investigated in two different configurations. Using random normally distributed initial conditions to simulate thermal fluctuations, a relationship between bubble generation, twist and curvature is established. An analytical approach supports the numerical results.

Energy funneling in a bent chain of Morse oscillators with long-range coupling

A bent chain of coupled Morse oscillators with long-range dispersive interaction is considered. Moving localized excitations may be trapped in the bending region. Thus chain geometry acts like an impurity. An energy funneling effect is observed in the case of random initial conditions.