Exploring diagnostic events and first referrals in cancer patient pathways in primary care. A questionnaire survey

BACKGROUND

Cancer diagnostic pathways in general practice are often nonlinear, and several events can delay timely diagnosis.

OBJECTIVES

To explore cancer diagnostic processes in general practice, examining how patients' symptom presentations, sex, and age are associated with the occurrence of predefined potentially delaying events and the first referrals.

METHOD

General practices in 3 Danish Regions were invited to participate in a questionnaire survey, addressing patient's symptom presentation, diagnostic process events, and first referral. The general practitioners (GPs) received a list of their incident cancer patients from the preceding 2 years.

RESULTS

In total 187 general practices participated, including 5,908 patients with the cancer diagnostic pathways initiated in general practice. Presenting with nonspecific symptoms was associated with potentially delaying events, even when the patient also had specific symptoms. Almost half of the patients were referred to a cancer patient pathway (CPP) first, men more often than women, and 10% were referred for acute hospitalization. In 23% of the diagnostic processes, GPs initially treated or referred patients on suspicion of another disease rather than cancer and waited due to normal examinations in 1 out of 20 patients. Excluding sex-specific cancers, these 2 events were more prevalent in women. Men less often complied to the follow-up agreement. Younger patients were less often first referred to a CPP and together with older patients more often first acutely hospitalized.

CONCLUSION

In cancer diagnostic processes in general practice, first referrals and the occurrence of potentially delaying events are associated with the patient's age, sex, and specificity of symptoms.

Exploring GPs' assessments of their patients' cancer diagnostic processes: a questionnaire study

BACKGROUND

Most cancer diagnostic pathways start from primary care and several factors affect the diagnostic processes.

AIM

To analyse the associations between patient characteristics, symptom presentation, and cancer type and the GP's assessment of the diagnostic processes.

DESIGN AND SETTING

General practices in the North, Central, and Southern regions of Denmark were invited to participate in a questionnaire survey.

METHOD

Participating GPs received a list of patients with incident cases of cancer in the period between 1 March 2019 and 28 February 2021 based on administrative hospital data. A questionnaire was completed for each patient, addressing symptom presentation and the GP's assessment of the diagnostic process both overall and in four subcategories (the patient's role, the GP's role, the transition between primary and secondary care, and the secondary sector's role).

RESULTS

A total of 187 general practices informed on 8240 patients. For 5868 patients, diagnostic pathways started in general practice. Almost half (48.3%, 2837/5868) presented with specific cancer symptoms. GPs assessed 55.6% (3263) and 32.3% (1897) of the diagnostic processes as 'very good' and 'predominantly good', respectively; 11.9% (700) were 'predominantly poor' or 'very poor' for these 5868 patients. Long symptom duration of ≥2 months prior to GP contact and presenting with non-specific or a combination of non-specific and specific symptoms were associated with a poor overall assessment of the diagnostic process. Assessment in the four subcategories showed that the patient's role was assessed less positively than the other three categories.

CONCLUSION

A longer symptom duration and presenting without cancer-specific symptoms were associated with GPs assessing the diagnostic process as poor.

Needs of multimorbid heart failure patients and their carers: a qualitative interview study and the creation of personas as a basis for a blended collaborative care intervention

Introduction

Involving patients and carers in the development of blended collaborative care (BCC) interventions for multimorbid heart failure (HF) patients is recommended but rarely practised, and research on the patient perspective is scarce. The aim of this study is to investigate patients' and carers' care-related needs and preferences to better customize a novel international BCC intervention.

Methods

A qualitative study design using framework analysis was employed. The study was performed in accordance with the EQUATOR standards for reporting qualitative research (SRQR). Patients aged at least 65 years with HF and at least two other physical diseases as well as their carers completed semistructured interviews in Germany, Italy, and Denmark. Based on these interviews, personas (prototype profiles of patients and carers) were created.

Results

Data from interviews with 25 patients and 17 carers were analysed. Initially, seven country-specific personas were identified, which were iteratively narrowed down to a final set of 3 personas: (a) the one who needs and wants support, (b) the one who has accepted their situation with HF and reaches out when necessary, and (c) the one who feels neglected by the health care system. Carers identifying with the last persona showed high levels of psychological stress and a high need for support.

Discussion

This is the first international qualitative study on patients' and carers' needs regarding a BCC intervention using the creation of personas. Across three European countries, data from interviews were used to develop three contrasting personas. Instead of providing "one size fits all" interventions, the results indicate that BCC interventions should offer different approaches based on the needs of individual patients and carers. The personas will serve as a basis for the development of a novel BCC intervention as part of the EU project ESCAPE (Evaluation of a patient-centred biopSychosocial blended collaborative CAre Pathway for the treatment of multimorbid Elderly patients).

Integrated care for older multimorbid heart failure patients: protocol for the ESCAPE randomized trial and cohort study

ESCAPE

Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multimorbid elderly patients.

THERAPEUTIC AREA

Healthcare interventions for the management of older patients with multiple morbidities.

AIMS

Multi-morbidity treatment is an increasing challenge for healthcare systems in ageing societies. This comprehensive cohort study with embedded randomized controlled trial tests an integrated biopsychosocial care model for multimorbid elderly patients.

HYPOTHESIS

A holistic, patient-centred pro-active 9-month intervention based on the blended collaborative care (BCC) approach and enhanced by information and communication technologies can improve health-related quality of life (HRQoL) and disease outcomes as compared with usual care at 9 months.

METHODS

Across six European countries, ESCAPE is recruiting patients with heart failure, mental distress/disorder plus ≥2 medical co-morbidities into an observational cohort study. Within the cohort study, 300 patients will be included in a randomized controlled assessor-blinded two-arm parallel group interventional clinical trial (RCT). In the intervention, trained care managers (CMs) regularly support patients and informal carers in managing their multiple health problems. Supervised by a clinical specialist team, CMs remotely support patients in implementing the treatment plan-customized to the patients' individual needs and preferences-into their daily lives and liaise with patients' healthcare providers. An eHealth platform with an integrated patient registry guides the intervention and helps to empower patients and informal carers. HRQoL measured with the EQ-5D-5L as primary endpoint, and secondary outcomes, that is, medical and patient-reported outcomes, healthcare costs, cost-effectiveness, and informal carer burden, will be assessed at 9 and ≥18 months.

CONCLUSIONS

If proven effective, the ESCAPE BCC intervention can be implemented in routine care for older patients with multiple morbidities across the participating countries and beyond.

Association of placental and umbilical cord characteristics with cerebral palsy: national cohort study

OBJECTIVES

Cerebral palsy (CP) is a group of movement disorders usually diagnosed in childhood. A substantial proportion are thought to be caused by antenatal events. Abnormalities of the umbilical cord and placenta are associated with an increased risk of adverse neonatal outcomes, but it is unclear whether these conditions also carry an increased risk of CP. We aimed to determine whether abnormalities of the umbilical cord or placenta are associated with CP and assess if these associations differ by sex of the child or gestational age at birth.

METHODS

We performed a national cohort study by linking data from The Medical Birth Registry of Norway with other national registries. All liveborn singletons born between 1999 and 2017 (n = 1 087 486) were included and followed up until the end of 2019. Diagnoses of CP were provided by the Norwegian National Insurance Scheme and the Norwegian Patient Register. We used generalized estimating equations and multilevel log binomial regression to calculate relative risks (RR), adjusted for year of birth, and stratified analyses were carried out based on sex and gestational age at birth. Exposures were abnormal umbilical cord (velamentous or marginal insertion, single umbilical artery (SUA), knots and entanglement), and placental abnormalities (retained placenta, placental abruption and previa).

RESULTS

A total of 2443 cases with CP (59.8% males) were identified. Velamentous cord insertion (adjusted RR (aRR), 2.11 (95% CI, 1.65-2.60)), cord knots (aRR, 1.53 (95% CI, 1.15-2.04)) and placental abnormalities (placenta previa (aRR, 3.03 (95% CI, 2.00-4.61)), placental abruption (aRR, 10.63 (95% CI, 8.57-13.18)) and retained placenta (aRR, 1.71 (95% CI, 1.32-2.22))) carried an increased risk of CP. Velamentous cord insertion was associated with CP regardless of gestational age or sex. A retained placenta was associated with a 2-fold increased risk for CP in males, while the associations of SUA and cord knot with CP were significant only among females.

CONCLUSIONS

The detection of placental and umbilical cord abnormalities may help identify children at increased risk of CP. The associations between placental or umbilical cord abnormalities and the risk of CP do not vary substantially with gestational age at birth or sex of the child. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Coping strategies among individuals with multiple physical symptoms: A general population-based cross-sectional study

OBJECTIVE

Coping has been suggested as a perpetuating factor for physical symptoms. The aim of this study was to examine the use of the coping strategies approach, resignation, and diversion in individuals with multiple physical symptoms according to the construct of Bodily Distress Syndrome (BDS).

METHODS

This cross-sectional study was part of the nationwide web-based survey Danish Symptom Cohort (DaSC). In total, 100,000 individuals were invited to participate, and individuals eligible for the present study were respondents aged 20-64 years without a current or recent pregnancy. Multiple physical symptoms were identified using the BDS checklist, and coping was assessed by the Brief Approach/Avoidance Coping Questionnaire. Statistical analyses included descriptive statistics and multinomial and logistic regression.

RESULTS

A total of 35,810 respondents were included in the study, of which 8512 (23.8%) fulfilled the criteria for having multiple physical symptoms. This group of respondents had lower coping scores on approach and higher coping scores on resignation and diversion compared with the non-BDS group. The regression analyses showed that high scores on approach were associated with a lower probability of having multiple symptoms (adjusted OR 0.92, 95% CI: 0.91-0.92), whereas high scores on diversion and resignation were associated with a higher probability of having multiple symptoms (adjusted OR 1.10; 95% CI: 1.09-1.11 and adjusted OR 1.19; 95% CI: 1.18-1.20, respectively).

CONCLUSION

The study supports the hypothesis that experiencing multiple physical symptoms is associated with certain coping strategies. This is relevant knowledge for health care professionals who will be treating this patient group.

Developing and Validating a Lung Cancer Risk Prediction Model: A Nationwide Population-Based Study

Lung cancer can be challenging to diagnose in the early stages, where treatment options are optimal. We aimed to develop 1-year prediction models for the individual risk of incident lung cancer for all individuals aged 40 or above living in Denmark on 1 January 2017. The study was conducted using population-based registers on health and sociodemographics from 2007-2016. We applied backward selection on all variables by logistic regression to develop a risk model for lung cancer and applied the models to the validation cohort, calculated receiver-operating characteristic curves, and estimated the corresponding areas under the curve (AUC). In the populations without and with previously confirmed cancer, 4274/2,826,249 (0.15%) and 482/172,513 (0.3%) individuals received a lung cancer diagnosis in 2017, respectively. For both populations, older age was a relevant predictor, and the most complex models, containing variables related to diagnoses, medication, general practitioner, and specialist contacts, as well as baseline sociodemographic characteristics, had the highest AUC. These models achieved a positive predictive value (PPV) of 0.0127 (0.006) and a negative predictive value (NPV) of 0.989 (0.997) with a 1% cut-off in the population without (with) previous cancer. This corresponds to 1.2% of the screened population experiencing a positive prediction, of which 1.3% would be incident with lung cancer. We have developed and tested a prediction model with a reasonable potential to support clinicians and healthcare planners in identifying patients at risk of lung cancer.

Associations between smoking status and involvement of personal and professional relations among individuals reporting symptoms related to a diagnosis of lung cancer: a population-based study

BACKGROUND

Smoking is the leading cause of lung cancer, but individuals who currently smoke seek healthcare less frequently. This study of individuals reporting symptoms related to diagnosis of lung cancer has the following aims: 1) to explore the involvement of personal and professional relations; 2) to analyse whether age, sex and smoking status are associated with involving personal and professional relations; and 3) to analyse whether involving a personal relation is associated with healthcare-seeking.

METHODS

Data was extracted from a Danish population-based survey from 2012 with 100,000 randomly selected invitees 20 years or older. We describe the involvement of personal and professional relations among individuals experiencing four predefined symptoms indicative of lung cancer: prolonged coughing, prolonged hoarseness, shortness of breath and haemoptysis, either alone or in combination. Using multivariate logistic regression, we analyse the associations between involving personal or professional relations and various covariates (sex, age, smoking status). Moreover, we analyse the association between involving a personal relation and healthcare-seeking.

RESULTS

A total of 35,958 individuals over 40 years old completed the questionnaire. Of these, 5,869 individuals reported at least one lung cancer symptom. A higher percentage of participants with prolonged hoarseness and prolonged coughing reported no involvement of personal and professional relations (27.6% and 22.7%, respectively) compared to shortness of breath (12.4%). The most involved personal and professional relations were the spouse (46.2-62.5%) and the general practitioner (GP) (31.3-54.5%), respectively. Women and individuals in the oldest age group had higher odds of involving personal and professional relations. Individuals who currently smoke involved all relations less frequently than individuals who formerly,- and never smoked. Odds of contacting the GP or another doctor were three to seven-fold higher when a personal relation was also involved.

CONCLUSION

Women and the oldest age group had higher odds of involving relations, whereas individuals who currently smoked tended to be less likely to contact any personal or professional relations. Involving a personal relation was associated with higher odds of healthcare-seeking. The findings could be useful for GPs in terms of identifying patients at risk of postponing relevant healthcare-seeking with potential lung cancer symptoms.

A population-based study on social inequality and barriers to healthcare-seeking with lung cancer symptoms

Healthcare-seeking with lung cancer symptoms is a prerequisite for improving timely diagnosis of lung cancer. In this study we aimed to explore barriers towards contacting the general practitioner (GP) with lung cancer symptoms, and to analyse the impact of social inequality. The study is based on a nationwide survey with 69,060 individuals aged ≥40 years, randomly selected from the Danish population. The survey included information on lung cancer symptoms, GP contacts, barriers to healthcare-seeking and smoking status. Information about socioeconomics was obtained by linkage to Danish Registers. Descriptive statistics and multivariate logistic regression model were used to analyse the data. “Being too busy” and “Being worried about wasting the doctor’s time” were the most frequent barriers to healthcare-seeking with lung cancer symptoms. Individuals out of workforce and individuals who smoked more often reported “Being worried about what the doctor might find” and “Being too embarrassed” about the symptoms. The social inequality in barriers to healthcare-seeking with lung cancer symptoms is noticeable, which emphasises the necessity of focus on vulnerable groups at risk of postponing relevant healthcare-seeking.

Involvement of personal and professional relations when experiencing colorectal cancer symptoms - a cross sectional study

OBJECTIVE

As part of improving early diagnosis of colorectal cancer (CRC), knowledge about involvement of personal and professional relations, when experiencing CRC symptoms, is important. This study aimed to analyse involvement of personal and professional relations and whether age, sex, number of symptoms and available social network are associated with involving family, non-family and professional relations amongst individuals experiencing CRC symptoms.

METHODS

Some, 100 000 Danes over 20 years were randomly selected and invited to a cross sectional survey comprising questions about involvement of relations regarding four predefined CRC symptoms (abdominal pain, rectal bleeding and change in stool texture and frequency).

RESULTS

In total, 35 801 respondents over 40 years answered all relevant items and 9346 (26.1%) had experienced at least one CRC symptom in the preceding 4 weeks. Abdominal pain was more often than stool-related symptoms discussed with relations. Respondents with >1 symptom had higher odds of reporting general practitioner (GP) contact compared to respondents with single symptoms. Age ≥60 years was associated with higher odds of GP contact and involving family relations. Spouse/partner was the most frequently involved relation. Involving a personal relation increased the odds of GP contact. Having an available social network decreased GP contact for some symptoms.

CONCLUSION

Odds of involving professional relations, e.g. the GP, were higher amongst individuals experiencing multiple CRC symptoms and those involving personal relations. Having an available social network was associated with lower odds of GP contact, suggesting that individuals with no available social network are more prone to use their GP.

Can National Registries Contribute to Predict the Risk of Cancer? The Cancer Risk Assessment Model (CRAM)

Simple Summary

Early identification of individuals with an increased risk of cancer is an important challenge. Danish administrative registers may be useful in this respect because they cover the entire population and include comprehensive and consistently coded long-term data. We aimed to develop a predictive model based on Danish administrative registers to facilitate the automated identification of individuals at risk of any type of cancer. In addition to age, almost all the included factors contributed statistically significantly, but also only marginally, to the prediction models, which means that we have not overlooked obvious information available in the register. Future prediction studies should focus on specific cancer types where more precise risk estimations might be expected. It is our ultimate ambition that an effective model can be used at the point of care, integrated into electronic patient record systems to alert physicians of patients at a high risk of cancer.

Abstract

Purpose: To develop a predictive model based on Danish administrative registers to facilitate automated identification of individuals at risk of any type of cancer. Methods: A nationwide register-based cohort study covering all individuals in Denmark aged +20 years. The outcome was all-type cancer during 2017 excluding nonmelanoma skin cancer. Diagnoses, medication, and contact with general practitioners in the exposure period (2007–2016) were considered for the predictive model. We applied backward selection to all variables by logistic regression to develop a risk model for cancer. We applied the models to the validation cohort, calculated the receiver operating characteristic curves, and estimated the corresponding areas under the curve (AUC). Results: The study population consisted of 4.2 million persons; 32,447 (0.76%) were diagnosed with cancer in 2017. We identified 39 predictive risk factors in women and 42 in men, with age above 30 as the strongest predictor for cancer. Testing the model for cancer risk showed modest accuracy, with an AUC of 0.82 (95% CI 0.81–0.82) for men and 0.75 (95% CI 0.74–0.75) for women. Conclusion: We have developed and tested a model for identifying the individual risk of cancer through the use of administrative data. The models need to be further investigated before being applied to clinical practice.

Effects of once-weekly semaglutide on coronary outcomes in patients with type 2 diabetes mellitus with or at high risk for cardiovascular disease: insights from the SUSTAIN-6 trial

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Nordisk A/S

Background/introduction

In the randomised, double-blind, placebo-controlled SUSTAIN-6 cardiovascular (CV) outcomes trial, once-weekly (OW) semaglutide (a glucagon-like peptide-1 receptor agonist), compared with placebo, reduced the risk of major adverse CV events (CV death, non-fatal myocardial infarction [MI], or non-fatal stroke) and the risk for revascularisation (pre-specified secondary outcome) in patients with type 2 diabetes mellitus (T2DM) with or at high risk for CV disease (CVD). However, the effects of OW semaglutide on composite coronary-specific outcomes have not been explored.

Purpose

The aim of these post-hoc, exploratory analyses was to assess the effects of OW semaglutide, compared with placebo, on composite coronary outcomes in the SUSTAIN-6 trial population.

Methods

In these post-hoc analyses of the SUSTAIN-6 trial, the following coronary outcomes were assessed with OW semaglutide (0.5 and 1.0 mg doses pooled) vs placebo, both in addition to standard of care: the main coronary outcome (composite of MI [both fatal and non-fatal] or coronary revascularisation [defined as coronary artery bypass graft surgery or percutaneous coronary intervention]); and the expanded coronary outcome (composite of MI, coronary revascularisation, or unstable angina). Coronary outcomes were assessed overall, as well as in subgroups with or without a prior coronary event (MI or coronary revascularisation) at baseline. Cox proportional hazards regression models were used to analyse time to first event for the outcomes.

Results

Overall, 3,297 patients were included in these analyses. Key cohort characteristics included a mean age of 64.6 ± 7.4 years with an average T2DM duration of 13.9 ± 8.1 years; 39.3% were female and 48.3% had prior MI or coronary revascularisation (32.5% and 40.3% for each prior event, respectively). The median follow-up duration was 2.1 years. The proportion of patients experiencing a first event was lower with OW semaglutide vs placebo for the main coronary outcome (6.1% vs 8.1%; hazard ratio [HR] 0.74 [95% confidence interval (CI) 0.57–0.97]) and the expanded coronary outcome (6.3% vs 8.6%; HR 0.73 [95% CI 0.56–0.94]) (Figure 1). The time to the first main coronary outcome event is shown in Figure 2. Prior coronary event status at baseline did not modify the treatment effects of semaglutide (all p-interaction >0.05) (Figure 1).

Conclusions

In these post-hoc analyses of the SUSTAIN-6 trial, OW semaglutide reduced the risk of composite coronary outcomes vs placebo in patients with T2DM with or at high risk for CVD, irrespective of prior MI or revascularisation status. These findings support the beneficial effects of OW semaglutide in this high risk population.

[Social inequality in health]

Social inequality is a significant challenge in the Danish healthcare system, and in general practice the inequality has many faces. To give more to those who need most is a difficult task, and research shows the diversity of the challenges experienced in the primary healthcare sector. However, as argued in this review, through innovative research we may be able to find new directions in how to provide patient centered healthcare, and in taking on this task general practice is centrally positioned as the place at which most patients are seen on a regular basis.

Is concern for gynaecological alarm symptoms associated with healthcare-seeking? A Danish population-based cross-sectional study

Background

Diagnosing cancer at an early stage increases survival, and for most gynaecological cancers the diagnostic pathway is initiated, when women seek medical attention with symptoms. As many factors influence healthcare-seeking, knowledge about these factors is important. Concern can act as a barrier or a trigger for women experiencing gynaecological alarm symptoms. This study aimed to examine whether concern for the symptom or the current health was associated with healthcare-seeking among women with gynaecological alarm symptoms.

Methods

Some 100,000 randomly selected Danish citizens were invited to a national web-based survey. The questionnaire included items regarding symptom experiences, healthcare-seeking and concern for the experienced symptoms and current health. This study included 5019 women with self-reported gynaecological alarm symptoms (pelvic pain, pain during intercourse, bleeding during intercourse and postmenopausal bleeding). Concern was reported on a 5-point Likert scale from ‘not at all’ to ‘extremely’. Data were analysed using multivariate logistic regression models.

Results

Women who were ‘extremely’ concerned about a gynaecological alarm symptom had two to six times higher odds of reporting healthcare-seeking compared to women who were ‘not at all’ concerned. Symptom concern was associated with higher odds of healthcare-seeking for all four gynaecological alarm symptoms and the odds increased with increasing levels of concern. Additionally, concern for current health was associated with higher odds of healthcare-seeking. Concern for current health as expressed by others was positively associated with healthcare-seeking but had only minor influence on the association between concern for current health and healthcare-seeking.

Conclusions

Concern for a gynaecological alarm symptom and for current health was positively associated with healthcare-seeking. The results can be used for future informational health campaigns targeting individuals at risk of postponing warranted healthcare-seeking.

Neutrophil-to-lymphocyte ratio predicts cardiovascular events in patients with type 2 diabetes: post hoc analysis of SUSTAIN 6 and PIONEER 6

Background

Inflammation plays an important role in atherosclerosis. The neutrophil-to-lymphocyte ratio (NLR) may serve as a clinically useful biomarker of inflammation and cardiovascular (CV) disease, although this relationship has not been studied in people with type 2 diabetes (T2D).

Purpose

This post hoc analysis investigated the relationship between NLRs and CV outcomes in T2D CV outcomes trials for two formulations of semaglutide, a glucagon-like peptide-1 receptor agonist.

Methods

In pooled analyses of the SUSTAIN 6 and PIONEER 6 trials, 6,480 patients with T2D at high CV risk received placebo or semaglutide (once-weekly subcutaneously up to 1.0 mg, or once-daily orally up to 14 mg). NLRs were calculated from complete blood counts at randomisation. Adjudicated outcomes included 3-point major adverse CV events (MACE: composite of CV death, non-fatal myocardial infarction [MI] or non-fatal stroke; primary outcome), expanded MACE, CV death and all-cause death (secondary outcomes). Patient characteristics and CV outcomes were analysed according to baseline NLR tertiles using pooled trial data. Estimation of hazard ratios (HRs) for all outcomes across NLR tertiles used a Cox proportional hazards model. A Cox spline regression with continuous NLR as covariate adjusted for treatment was used to predict the event rate of first MACE at 2 years.

Results

Overall, baseline NLR was recorded in 6,364 patients. Mean baseline NLRs were 1.5, 2.2 and 3.6 in the low, middle and high tertiles, respectively. Patients in the high NLR tertile were older (66.6 years), more likely to be male (70.0%), had longer duration of diabetes (15.3 years), higher body weight (93.3 kg), lower diastolic blood pressure (75.5 mmHg) and estimated glomerular filtration rate (70.4 mL/min/1.73m2) vs those in the lower NLR tertiles (all p<0.0001). Higher NLR was associated with an increased risk of MACE (HR [95% confidence interval (CI)]: 1.37 [1.05; 1.80; p=0.02] and 1.86 [1.45; 2.41; p<0.0001] for the middle and high tertiles, respectively, vs the low tertile). The high NLR tertile was also associated with a 74% increased risk of expanded MACE and twofold risk for CV death and all-cause death vs the low NLR tertile (Figure 1). Spline regression indicated that NLR values >5 increased the risk of first MACE substantially (Figure 2). Further analysis of NLR and MACE by tertiles showed a more pronounced association in patients without prior MI and/or stroke (HR [95% CI]: 1.64 [1.07; 2.56]; p=0.03 and 2.09 [1.38; 3.21]; p=0.0006 in the middle and high tertiles, respectively, vs the low tertile).

Conclusion

Baseline NLR predicts MACE, CV death and all-cause death in patients with T2D and high CV risk. NLR is readily accessible from routinely obtained and inexpensive blood counts; it could offer a convenient, clinically useful inflammatory biomarker for CV risk prediction in this population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novo Nordisk A/S Figure 1Figure 2

Prediction of preterm pre-eclampsia according to NICE and ACOG criteria: descriptive study of 597 492 Danish births from 2008 to 2017

OBJECTIVE

The aim of this national study was to examine the incidence of preterm pre-eclampsia (PE) and the proportion of women with risk factors for PE, according to the criteria suggested by the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG), during a 10-year period in Denmark.

METHODS

Data from The Danish National Patient Registry and the Danish Medical Birth Registry were used to obtain the incidence of preterm PE with delivery < 37 weeks' gestation and risk factors for PE for all deliveries in Denmark from 1 January 2008 to 31 December 2017. The proportion of women with at least one high-risk factor and/or at least two moderate-risk factors for PE, according to the NICE and ACOG criteria, and the detection rate for preterm PE were examined. Race, socioeconomic status and the woman's weight at birth were not available from the registries used, and information on Type-2 diabetes was found to be invalid.

RESULTS

Of the 597 492 deliveries during the study period, any PE was registered in 3.2%, preterm PE < 37 weeks in 0.7% and early-onset PE < 34 weeks' gestation in 0.3%. These proportions remained largely unchanged from 2008 to 2017. Overall, the NICE criteria were fulfilled in 7.5% of deliveries and the ACOG criteria in 17.3%. In the total population, the NICE criteria identified 47.6% of those with preterm PE and the ACOG criteria identified 60.5%. The current criteria for offering aspirin treatment in Denmark largely correspond to having at least one NICE high-risk factor. In 2017, a total of 3.5% of deliveries had at least one NICE high-risk factor, which identified 28.4% of cases that later developed preterm PE.

CONCLUSIONS

The incidence of preterm PE remained largely unchanged in Denmark from 2008 to 2017. Prediction of PE according to high-risk maternal factors could be improved by addition of moderate-risk factors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Women's barriers for contacting general practice when experiencing gynecological cancer symptoms: a population-based study

BACKGROUND

A prerequisite for general practitioners (GPs) being able to refer patients with gynecological cancer alarm symptoms for further investigations is that individuals present the symptoms to the GP. Not all symptoms are presented to the GP, and knowledge of barriers for healthcare-seeking is sparse. The aim of this study was to analyze associations between age, socioeconomic status, and common barriers ("being too embarrassed", "being too busy", "worried about wasting the doctors time" and "worried what the GP might find") towards GP contact with gynecological alarm symptoms.

METHODS

Nationwide population-based study in Denmark based on a random sample of 51 090 women aged 20 years or older. A web-based questionnaire regarding experience of four predefined alarm symptoms of gynecological cancer, decisions about contact to GPs, and barriers towards GP contact was distributed. Information about socioeconomic status was collected from Statistics Denmark.

RESULTS

A total of 26 466 women (54.5%) completed the questionnaire. The proportion of women with no contact to the GP varied between 64.6% and 78.1% for postmenopausal bleeding and pain during intercourse, respectively. Between 32.3% (bleeding during intercourse) and 45.3% (postmenopausal bleeding) of the women reported no barriers for GP contact. The proportions of reported barriers ranged from 7.5% for being too embarrassed (pelvic pain) to 26.8% for being too busy (bleeding during intercourse). Women aged 40-59 years had lower odds of reporting "being too embarrassed" and "worried about wasting the GP´s time", while women aged 60 + years of age had lower odds of reporting "being too busy" compared to the youngest age group. Women in the highest income groups had lower odds of reporting "being too embarrassed" and "wasting the GP´s time" compared to those with a low income, while those with high educational level had lower odds of reporting "being too embarrassed" and "worried what the GP might find" compared to those with low educational level.

CONCLUSIONS

More than half of the respondents with no contact to the GP, reported one or more barriers towards GP contact. Lower age and socioeconomic status were significantly associated with higher odds of reporting barriers. As this may explain the differences in healthcare seeking behavior, healthcare planners, policy makers and clinicians should be aware of these findings.

Women's barriers for contacting their general practitioner when bothered by urinary incontinence: a population-based cross-sectional study

Background

Urinary incontinence (UI) is a frequently occurring condition among women and increases with age. Effective treatments exist but many women hesitate to contact their general practitioner (GP) regarding UI. Therefore, it is important to generate knowledge regarding barriers for healthcare-seeking. Several factors such as age, duration and number of symptoms are associated with healthcare-seeking. How socioeconomic status (SES) is associated with experiencing barriers for healthcare-seeking for UI has not been explored. The objectives of this study were to: (1) analyze frequencies of barriers for healthcare-seeking, and (2) investigate associations between SES and barriers for contacting the GP, among women reporting bothersome UI.

Method

A cross-sectional web-based questionnaire study of symptoms occurrence among 51,090 randomly selected women. This study investigates reported symptoms of three types of UI (stress UI, urge UI and UI without stress or urge) and reported barriers for GP contact combined with register data on SES.

Results

A total of 4,051 (16.4%) women reported to be bothered by either stress UI (9.1%), urge UI (4.0%) or incontinence without stress or urge (2.4%) and 76.3%, 70%, and 64% respectively, had not contacted their GP regarding the symptom(s). The most frequently reported barriers were ‘being too embarrassed’ (19.3%) and ‘being too busy’ (18.4%) for stress incontinence, and ‘being too embarrassed (19.0%) or ‘worried about wasting the doctor’s time’ (16.9%) for women with bothersome urge UI or UI without stress or urge. Younger women had higher odds of reporting barriers and the barriers embarrassment and being worried about what the doctor might find were significantly associated with lower educational level.

Conclusion

Women with lower educational level have an increased risk of not seeking healthcare for UI symptoms. The GP should be aware of identifying women bothered by UI for whom effective treatment options to alleviate the symptoms are available.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00864-x.

When does proton pump inhibitor treatment become long term? A scoping review

Objective

Proton pump inhibitor (PPI) use has risen substantially, primarily driven by ongoing use over months to years. However, there is no consensus on how to define long-term PPI use. Our objectives were to review and compare definitions of long-term PPI use in existing literature and describe the rationale for each definition. Moreover, we aimed to suggest generally applicable definitions for research and clinical use.

Design

The databases PubMed and Cochrane Library were searched for publications concerning long-term use of PPIs and ClinicalTrials.gov was searched for registered studies. Two reviewers independently screened the titles, abstracts, and full texts in two series and subsequently extracted data.

Results

A total of 742 studies were identified, and 59 met the eligibility criteria. In addition, two ongoing studies were identified. The definition of long-term PPI use varied from >2 weeks to >7 years. The most common definition was ≥1 year or ≥6 months. A total of 12/61 (20%) of the studies rationalised their definition.

Conclusion

The definitions of long-term PPI treatment varied substantially between studies and were seldom rationalised.

In a clinical context, use of PPI for more than 8 weeks could be a reasonable definition of long-term use in patients with reflux symptoms and more than 4 weeks in patients with dyspepsia or peptic ulcer. For research purposes, 6 months could be a possible definition in pharmacoepidemiological studies, whereas studies of adverse effects may require a tailored definition depending on the necessary exposure time. We recommend to always rationalise the choice of definition.

Effects of liraglutide and semaglutide on stroke subtypes in patients with type 2 diabetes: a post hoc analysis of the LEADER, SUSTAIN 6 and PIONEER 6 trials

Introduction

Diabetes is an independent risk factor for stroke, with approximately a two-fold excess risk in people with versus those without diabetes. Accumulating evidence suggests glucagon-like peptide-1 (GLP-1) analogues (including liraglutide and semaglutide) may reduce the risk of stroke in patients with type 2 diabetes (T2D).

Purpose

We examined the effect of liraglutide and semaglutide on stroke and its subtypes based on pooled data from LEADER, SUSTAIN 6 and PIONEER 6.

Methods

LEADER (NCT01179048), SUSTAIN 6 (NCT01720446) and PIONEER 6 (NCT02692716) were global randomised cardiovascular (CV) outcomes trials of liraglutide, subcutaneous semaglutide and oral semaglutide, respectively, in patients with T2D at high CV risk. In this post hoc analysis, we evaluated the effect of these GLP-1 analogue treatments (pooled) on time to first occurrence of all strokes and subtypes of stroke. Ischaemic stroke was subcategorised according to the TOAST classification, based on aetiology by an external blinded reviewer. A Cox proportional hazards model stratified by trial with pooled treatment as a factor was used to examine treatment effects.

Results

Across the three trials, 216/7907 (2.7%) patients in the GLP-1 analogue group and 262/7913 (3.3%) in the placebo group had a stroke. The risk of first occurrence of all strokes was significantly reduced in the GLP-1 analogue versus placebo group (HR 0.82, 95% CI 0.68–0.98; p=0.030). Treatment effects were consistent across stroke subtypes: ischaemic (HR 0.84, 95% CI 0.69–1.02; p=0.08), haemorrhagic (HR 0.72, 95% CI 0.42–1.22; p=0.22) and undetermined (HR 0.71, 95% CI 0.32–1.60; p=0.41; Figure 1). Across TOAST subcategories, there was a trend that GLP-1 analogue treatment had the greatest benefit versus placebo in small vessel occlusion strokes compared with large artery disease or cardioembolic strokes; however, no statistically significant effects were found in any subcategory.

Conclusion

In this post hoc analysis of the LEADER, SUSTAIN 6 and PIONEER 6 trials, GLP-1 analogue treatment reduced the risk of stroke in patients with T2D and high CV risk, with an indication using TOAST criteria of the strongest effect on stroke caused by small vessel occlusion.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novo Nordisk A/S. WDS is supported by the NIHR Exeter Clinical Research Facility. MAJ is supported by the NIHR SW Peninsula Applied Research Collaboration. This abstract does not necessarily reflect the views of the NIHR, the Exeter Clinical Research Facility, the NHS or the UK Department of Health.

Socioeconomic status and barriers for contacting the general practitioner when bothered by erectile dysfunction: a population-based cross-sectional study

BACKGROUND

Erectile dysfunction (ED) is common and impacts psychosocial wellbeing negatively. Many do not seek medical attention and several barriers for healthcare seeking with ED exist. Little is known about the association between socioeconomic characteristics of the patient and barriers for healthcare-seeking for men bothered by ED. The objectives of the study were 1) to estimate the proportion of men bothered by ED, who do not contact the GP, 2) to analyse the frequencies of selected barriers for healthcare seeking and 3) to analyse associations between socioeconomic factors and barriers for contacting the GP.

METHODS

Data derive from a nationwide survey of symptom experiences among 100,000 randomly selected individuals aged 20 years and above. The questionnaire comprises, among other, questions about ED. This study focuses on men who reported bothersome ED and further reported, that they did not contact a GP regarding the symptom. Questions addressing barriers regarding GP contact included embarrassment, worrying about wasting the doctor's time, being too busy, and worrying about what the doctor might find. Information about socioeconomic characteristics was obtained from Statistics Denmark.

RESULTS

A total of 4072 men (18.3%) reported that they had experienced ED within the past four weeks. Of those, 2888 (70.9%) were categorized as having bothersome ED. In the group of men with bothersome ED 1802 (62.4%) did not contact the GP and 60.5% reported barriers for GP-contact. Of the reported barriers, the most frequent was 'being too embarrassed' (29.7%). In general, respondents in the older age groups were less likely to report embarrassment, business and worrying what the doctor might find. Respondents with highest attained educational level were less likely to report embarrassment and worrying.

CONCLUSION

Nearly two third of the respondents with bothersome ED had not contacted their GP. More than half of those reported barriers towards GP contact with embarrassment as the most frequent barrier. In general, respondents in the older age groups and with high educational level were less likely to report barriers.

Sex-specific reference ranges of cerebroplacental and umbilicocerebral ratios: longitudinal study

OBJECTIVES

Observational studies have shown that low cerebroplacental ratio (CPR) values predict an increased risk of adverse perinatal outcome. The inverse ratio, i.e. the umbilicocerebral ratio (UCR), has been suggested to be a better predictor as it rises with increasing degree of fetal compromise. However, longitudinal reference ranges for UCR have not been established, and whether gestational-age-dependent changes in CPR or UCR differ between male and female fetuses has not been studied. Thus, the aims of this study were to investigate sex-specific, gestational-age-associated serial changes in CPR and UCR during the second half of pregnancy and to establish longitudinal reference ranges.

METHODS

This was a secondary analysis of prospectively collected data from a dual-center longitudinal observational cohort study of low-risk singleton pregnancies. Doppler blood-flow velocity waveforms were obtained serially from the umbilical artery (UA) and fetal middle cerebral artery (MCA) from 19-41 weeks' gestation, and pulsatility indices (PIs) were determined. CPR and UCR were calculated as the ratios MCA-PI/UA-PI and UA-PI/MCA-PI, respectively. The course and outcome of pregnancies were recorded, and the sex of the fetus was determined after delivery. Reference intervals for CPR and UCR were constructed using multilevel modeling, and gestational-age-specific Z-scores in male and female fetuses were compared.

RESULTS

Of a total of 299 pregnancies enrolled, 284 (148 male and 136 female fetuses) were included in the final analysis, and 979 paired measurements of UA-PI and MCA-PI were used to construct sex-specific longitudinal reference intervals. The relationship of both CPR and UCR with gestational age was U-shaped, but in opposite directions. There was a small but significant difference in Z-scores of CPR and UCR between male and female fetuses throughout the second half of pregnancy (P = 0.007).

CONCLUSIONS

We have established longitudinal reference ranges for CPR and UCR suitable for serial monitoring, with the possibility of refining assessment by using fetal sex-specific ranges and conditioning by a previous measurement. The clinical significance of such refinements needs further evaluation. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Cost-effectiveness of 12 weeks of supervised treatment compared to written advice in patients with knee osteoarthritis: a secondary analysis of the 2-year outcome from a randomized trial

OBJECTIVE

To assess the 24-month cost-effectiveness of supervised treatment compared to written advice in knee osteoarthritis (OA).

DESIGN

100 adults with moderate-severe OA not eligible for total knee replacement (TKR) randomized to a 12-week individualized, supervised treatment (exercise, education, diet, insoles and pain medication) or written advice. Effectiveness was measured as change in quality-adjusted life years (QALYs) from baseline to 24 months, including data from baseline, 3, 6, 12 and 24 months, while healthcare costs and transfer payments were derived from national registries after final follow-up. Incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated. A sensitivity analysis resampling existing data was conducted and the probability of cost-effectiveness was estimated using a 22,665 Euros/QALY threshold. In a sensitivity analysis, cost-effectiveness was calculated for different costs of the supervised treatment (actual cost in study; cost in private practice; and in-between cost).

RESULTS

Average costs were similar between groups (6,758 Euros vs 6,880 Euros), while the supervised treatment were close to being more effective (incremental effect (95% CI) of 0.075 (-0.005 to 0.156). In the primary analysis excluding deaths, this led the supervised treatment to be cost-effective, compared to written advice. The sensitivity analysis demonstrated that the results were sensitive to changes in the cost of treatment, but in all scenarios the supervised treatment was cost-effective (ICERs of 6,229 to 20,688 Euros/QALY).

CONCLUSIONS

From a 24-month perspective, a 12-week individualized, supervised treatment program is cost-effective compared to written advice in patients with moderate-severe knee OA not eligible for TKR.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT01535001.

Involvement of personal and professional relations among men bothered by lower urinary tract symptoms: a population-based cross-sectional study

Background

Lower urinary tract symptoms (LUTS) are common among men worldwide and despite frequently of benign origin, the symptoms often influence quality of life. Most men experiencing LUTS manage their symptoms in private settings without consulting their general practitioner (GP). Therefore, the purpose of this study was to identify who in the personal and professional relations Danish men discussed their bothersome LUTS with, to analyse factors associated with discussing LUTS with personal and professional relations, and to analyse how having a social network influenced healthcare seeking.

Methods

A nationwide population-based, cross-sectional survey representative of the Danish population. A total of 46,647 randomly selected men aged 20+ were invited to participate. Data were collected in 2012. The main outcome measures were odds ratios between involvement of personal and professional relations, GP contact and different characteristics (age, number of symptoms, available social network, and involvement of personal relations) among men experiencing bothersome LUTS. We used multivariate logistic regression models.

Results

Overall, 22,297 men completed the questionnaire. Of those, 4885 (21.9%) had experienced at least one LUTS, 23.5% had not discussed their symptoms with either personal nor professional relations and 59.1% had not discussed their LUTS with any professional relation. The symptoms were most often discussed with personal relations, primarily the spouse/partner who was involved in more than half of the cases. Odds of consulting the GP, another doctor and other healthcare professionals were two to four-fold higher when the symptoms were discussed with a personal relation. Having an available social network was significantly associated with lower odds of consulting the GP regarding frequent urination.

Conclusions

Despite the high prevalence of bothersome LUTS more than one-fifth of men did not discuss their symptoms with either personal nor professional relations, and more than half did not discuss the symptoms with any professional relations. Discussing the symptoms with personal relations was generally associated with higher odds of seeking professional help, and for frequent urination, having an available social network was associated with lower odds of consulting the GP. The results may be useful for detecting and treating men bothered by LUTS.

Imprinting disorders in children born after ART: a Nordic study from the CoNARTaS group

STUDY QUESTION:

Is the risk of imprinting disorders increased in children conceived after

SUMMARY ANSWER:

We found an adjusted odds ratio (AOR) of 2.84 [95% CI: 1.34–6.01] for Beckwith–Wiedemann syndrome in ART children, while the risk of Prader–Willi syndrome, Silver–Russell syndrome or Angelman syndrome was not increased in children conceived after ART.

WHAT IS KNOWN ALREADY:

Earlier studies, most of them small, have suggested an association between ART and imprinting disorders.

STUDY DESIGN, SIZE, DURATION:

This was a binational register-based cohort study. All children conceived by ART in Denmark (n = 45 393, born between 1994 and 2014) and in Finland (n = 29 244, born between 1990 and 2014) were identified. The full background populations born during the same time periods in the two countries were included as controls. Odds ratios of imprinting disorders in ART children compared with naturally conceived (NC) children were calculated. The median follow-up time was 8 years and 9 months for ART children and 11 years and 9 months for NC children.

PARTICIPANTS/MATERIALS, SETTING, METHODS:

From the national health registries in Denmark and Finland, we identified all children diagnosed with Prader–Willi syndrome (n = 143), Silver–Russell syndrome (n = 69), Beckwith–Wiedemann syndrome (n = 105) and Angelman syndrome (n = 72) born between 1994/1990 and 2014, respectively.

MAIN RESULTS AND THE ROLE OF CHANCE:

We identified a total of 388 children diagnosed with imprinting disorders; 16 of these were conceived after ART. The overall AOR for the four imprinting disorders in ART children compared with NC children was 1.35 [95% CI: 0.80–2.29], but since eight ART children were diagnosed with Beckwith–Wiedemann syndrome, the AOR for this specific imprinting disorder was 2.84 [95% CI: 1.34–6.01]. The absolute risk of Beckwith–Wiedemann syndrome in children conceived after ART was still low: 10.7 out of 100 000 newborns. The risks of Prader–Willi syndrome, Silver–Russell syndrome and Angelman syndrome were not increased in children conceived after ART.

LIMITATIONS, REASONS FOR CAUTION:

Imprinting disorders are rare events and our results are based on few ART children with imprinting disorders. The aetiology is complex and only partly clarified, and the clinical diagnoses are challenged by a broad phenotypic spectrum.

WIDER IMPLICATIONS OF THE FINDINGS:

In the existing studies, results on the risk of imprinting disorders in children conceived after ART are ambiguous. This study adds that the risk of imprinting disorders in ART children is very small and perhaps restricted to Beckwith–Wiedemann syndrome.

STUDY FUNDING/COMPETING INTEREST(S):

This work was supported by the Nordic Trial Alliance: a pilot project jointly funded by the Nordic Council of Ministers and NordForsk (grant number: 71450), the Nordic Federation of Obstetrics and Gynecology (grant numbers: NF13041, NF15058, NF16026 and NF17043) and the Interreg Öresund-Kattegat-Skagerak European Regional Development Fund (ReproUnion project). The authors have no conflicts of interest related to this work.

TRIAL REGISTRATION NUMBER:

N/A

Is healthcare-seeking with gynaecological alarm symptoms influenced by personal and professional relations? A Danish population-based, cross-sectional study

OBJECTIVES

To identify the personal and professional relations of women experiencing gynaecological alarm symptoms, to analyse if involving a personal relation is related to healthcare-seeking with gynaecological alarm symptoms, and to analyse if having an available social network is associated with involvement of this relation.

DESIGN

Web-based, population-based, cross-sectional questionnaire survey.

SETTING

The general population in Denmark.

PARTICIPANTS

The study invited 100 000 individuals randomly drawn from the Danish Civil Registration System. Pregnant women and women who did not answer relevant questions about social network were excluded. A total of 5053 women who experienced at least one gynaecological alarm symptom were included in the study. PRIMARY AND SECONDARY OUTCOMES: (1) Personal and professional relations that women experiencing gynaecological alarm symptoms involve; (2) the association between involving a personal relation and healthcare-seeking; and (3) the association between having an available social network and involvement of this relation.

RESULTS

The general practitioner (GP) was the most involved professional relation, while the spouse/partner was the most involved personal relation. When experiencing gynaecological alarm symptoms, more than 50% of women did not involve a professional relation and 20% did not involve a personal relation. For all four gynaecological alarm symptoms, the odds of involving the GP were higher in the oldest age group. Women were two to seven times more likely to involve their GP if they had personal relation involvement. No statistically significant association was found between having an available social network and involving the GP.

CONCLUSION

Involving a personal relation in healthcare-seeking was associated with increased involvement of the GP, who consequently was the most involved professional relation when experiencing gynaecological alarm symptoms. Spouse/partner was the most involved personal relation. The oldest age group had the highest odds of involving the GP. No association was found between having an available social network and involving the GP.

Single umbilical artery and risk of congenital malformation: population-based study in Norway

OBJECTIVES

Single umbilical artery (SUA) is associated with congenital malformations in most organ systems, but reported findings have not been consistent. While it has been suggested that genetic and persisting environmental factors influence the development of SUA, it is not known whether there is an increased risk of recurrence in a subsequent pregnancy of the same woman. The aims of this study were to investigate the occurrence of, and risk factors for, SUA in Norway, to assess its association with congenital malformations and trisomies 13, 18 and 21 and to study the risk of recurrence of SUA in subsequent pregnancies.

METHODS

This was a population-based study of all (n = 918 933) singleton pregnancies of > 16 weeks' gestation recorded in the Medical Birth Registry of Norway from 1999 to 2014. To identify risk factors and congenital malformations associated with SUA, generalized estimating equations and logistic regression were used to calculate odds ratios (OR) with 95% CIs. ORs were also calculated for the recurrence of SUA in subsequent pregnancy.

RESULTS

The occurrence of SUA in our population was 0.46% (4241/918 933). Parity ≥ 4, smoking, maternal pregestational diabetes, epilepsy, chronic hypertension, previous Cesarean delivery and conception by assisted reproductive technology increased the odds of having SUA. There was a particularly strong association between SUA and gastrointestinal atresia or stenosis in the neonate, with ORs of 25.8 (95% CI, 17.0-39.1) and 20.3 (95% CI, 13.4-30.9) for esophageal and anorectal atresia or stenosis, respectively, followed by an OR of 5.9 (95% CI, 1.9-18.5) for renal agenesis. SUA was associated with an up to 7-8 times increased risk of congenital heart defects. There was an association with microcephaly, congenital hydrocephalus and other congenital malformations of the brain and spinal cord. Diaphragmatic hernia, limb reductions and cleft lip or palate had a weaker association with SUA, with ORs ranging from 4.8 to 2.8. The associations with trisomy 18 and 13 were equally strong (OR 14.4 (95% CI, 9.3-22.4) and OR 13.6 (95% CI, 6.7-27.8), respectively), and the risk of trisomy 21 was doubled (OR 2.1 (95% CI, 1.2-3.6)). Pregnancies with SUA, with or without an associated malformation, had a 2-fold increased risk for SUA in a subsequent pregnancy.

CONCLUSIONS

SUA is associated strongly with gastrointestinal atresia or stenosis, suggesting common developmental mechanisms. The increased risk of recurrence of SUA suggests that genetic and/or persisting environmental factors influence the risk. We found that SUA had equally strong associations with trisomies 13 and 18. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Multiple physical symptoms and individual characteristics - A cross-sectional study of the general population

OBJECTIVE

Multiple physical symptoms not attributable to known organic disease are common in all medical fields and associated with major personal and social consequences. This study investigated multiple physical symptoms according to the construct of bodily distress syndrome (BDS) and associated individual characteristics in the general adult population.

METHODS

A nationwide, population-based study of 100,000 randomly selected individuals aged 20 years and older, conducted in 2012. A web-based questionnaire formed the basis of the study and was combined with Danish national registry data on socioeconomic factors and medication and healthcare use.

RESULTS

49,706 individuals completed the questionnaire. After exclusion of women indicating pregnancy, respondents reporting chronic disease and respondents over 65 years of age, 23,331 remained for analysis. Of these 23,331 individuals, 15.5% fulfilled the criteria for BDS. BDS positives were more often younger (20-40 years) and female. Self-rated health and self-reported functional capacity were impaired among these individuals. Fulfilling the BDS criteria was significantly associated with current or former smoking, overweight and obesity, low educational level and income, and unemployment. Moreover, individuals with BDS were more often from ethnic minorities and had higher use of healthcare and medication.

CONCLUSION

Multiple physical symptoms, as captured by the concept of BDS, are common in the general adult population, especially among younger women. Fulfilling the BDS criteria is associated with substantial negative impact on self-perceived health and socioeconomic parameters. Fulfilling BDS criteria is positively associated with health risk behaviors (smoking, overweight and obesity) and higher use of healthcare and medication.

P4628A multiple biomarker approach for risk assessment after ST-segment elevation myocardial infarction

Background

Several biomarkers independently predict outcome following ST-segment elevation myocardial infarction (STEMI). We hypothesized that combining information from multiple circulating biomarkers with numerous pathophysiological pathways may improve biomarker risk stratification following a STEMI.

Method

This was a prospective study of 735 patients with STEMI treated with primary percutaneous coronary intervention. Seventeen biomarkers were drawn before revascularization, including adrenalin, noradrenalin, C-reactive protein (CRP), neutrophil gelatinase-associated lipocalin (NGAL), pro-atrial natriuretic peptide (pro-ANP), alfa-defensin, adiponectin, troponin I, hemoglobin, thrombocyte, and total leukocyte count. The primary outcome was a composite of cardiovascular death or heart failure (CVD/HF) identified by national registries. In the effort to identify the best model, the population was randomly split into two equally sized groups, a derivation cohort and a validation cohort. We used classification and regression tree (CART) analysis to develop a risk model. The identified risk model was hereafter applied to the whole cohort.

Results

Mean age was 63 years, 74% were male and 33% had hypertension. During a median follow-up time of 5.0 years (3.2; 5.0), we observed 185 primary events. After including all biomarkers in the initial model, the CART analysis created a risk model including pro-ANP, NGAL, and CRP (Figure 1a). The risk of CVD/HF increased incrementally with increasing risk group (Figure 1b). The risk remained significantly higher in groups 3 and 4 after multivariable adjustments (hazard ratio (HR)=3.38 [95% confidence interval (CI): 1.60; 7.16] p=0.001 and HR=6.55 [95% CI: 2.73; 15.76] p<0.001, respectively) when compared with group 1.

Figure 1

Conclusion

We developed a risk model based on multiple biomarkers (NGAL, CRP, and pro-ANP) determined from a CART analysis which may ease risk stratification after STEMI.

Acknowledgement/Funding

Sif Rasmussen received a scholarship grant from Herlev & Gentofte Hospital and the P. Carl Petersens Fond during preparation of this manuscript.

Reduced focal fiber collinearity in the cingulum bundle in adults with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a disabling condition, often associated with a chronic course. Given its role in attentional control, decision-making, and emotional regulation, the anterior cingulate cortex is considered to have a key role in the pathophysiology of the disorder. Notably, the cingulum bundle, being the major white matter tract connecting to this region, has been historically a target for the surgical treatment of intractable OCD. In this study, we aimed to identify the extent to which focal-more than diffuse-abnormalities in fiber collinearity of the cingulum bundle could distinguish 48 adults with OCD (mean age [SD] = 23.3 [4.5] years; F/M = 30/18) from 45 age- and sex-matched healthy control adults (CONT; mean age [SD] = 23.2 [3.8] years; F/M = 28/17) and further examine if these abnormalities correlated with symptom severity. Use of tract-profiles rather than a conventional diffusion imaging approach allowed us to characterize white matter microstructural properties along (100 segments), as opposed to averaging these measures across, the entire tract. To account for these 100 different segments of the cingulum bundle, a repeated measures analysis of variance revealed a main effect of group (OCD < CONT; F_[1,87] = 5.3; P = 0.024) upon fractional anisotropy (FA, a measure of fiber collinearity and/or white matter integrity), in the cingulum bundle, bilaterally. Further analyses revealed that these abnormalities were focal (middle portion) within the left and right cingulum bundle, although did not correlate with symptom severity in OCD. Findings indicate that focal abnormalities in connectivity between the anterior cingulate cortex and other prefrontal cortical regions may represent neural mechanisms of OCD.

Predictive values of colorectal cancer alarm symptoms in the general population: a nationwide cohort study

Background

Alarm symptoms are used in many cancer referral guidelines. The objectives were to determine the 1-year predictive values (PVs) of colorectal cancer (CRC) alarm symptoms in the general population and to describe the proportion of alarm symptoms reported prior to diagnosis.

Methods

A nationwide prospective cohort of 69,060 individuals ≥40 years randomly selected from the Danish population was invited to complete a survey regarding symptoms and healthcare-seeking in 2012. Information on CRC diagnoses in a 12-month follow-up came from the Danish Cancer Registry. PVs and positive and negative likelihood ratios were calculated.

Results

A total of 37,455 individuals participated (response rate 54.2%). Sixty-four individuals were diagnosed with CRC. The single symptom with the highest positive PVs (PPV) and LR+ was rectal bleeding. PPVs were generally higher among individuals aged ≥75 years and highest among those reporting at least one specific alarm symptom that led to a GP contact.

Conclusion

In general, the PPVs of CRC alarm symptoms are low and the NPVs high, especially in the youngest age groups. The LR +  show a relative association with specific symptoms like rectal bleeding. Future campaigns on early diagnosis of CRC should focus on healthcare-seeking when experiencing rectal bleeding and target older people with the highest incidence.

Increased postural stiffness during challenging postural tasks in patients with knee osteoarthritis with high pain sensitization

BACKGROUND

Postural stability is affected in knee osteoarthritis patients who present with pain but the link to pain sensitization is unclear.

METHODS

Patients with knee osteoarthritis completed the Knee Injury and Osteoarthritis Outcome Score and pressure pain thresholds were assessed bilaterally at the knee, lower leg and forearm prior to standing quietly (1 min) on a force platform in four conditions: Firm surface with open eyes, firm surface with closed eyes, soft surface with open eyes, and soft surface with closed eyes. Pain intensity during standing was assessed via numerical rating scale. Postural stability was assessed by the range, velocity, and standard deviation of the Center of Pressure (CoP) extracted from the force platform. The means of three repeated measures per standing condition were analysed. High-sensitization and low-sensitization groups were defined based on bilateral pressure pain thresholds from leg and arm.

FINDINGS

Fifty-six patients were included. Compared with the low-sensitization group, the high-sensitization group demonstrated 1) smaller pressure pain thresholds at the knee (P < 0.05) although the Knee Injury and Osteoarthritis Outcome Score and pain intensity were not significantly different between groups, and 2) smaller range of the CoP in the anterior-posterior direction during the soft surface with closed eyes condition (P < 0.05).

INTERPRETATION

Smaller CoP range suggest that patients with more widespread pain sensitivity have increased postural stiffness compared with the low-sensitization group. The greater stiffness found in high-sensitization patients under sensory restrictions (closed eyes and reduced proprioception) might relate to restricted integration of sensory information due to widespread pain sensitization.

Academic performance in adolescents aged 15-16 years born after frozen embryo transfer compared with fresh embryo transfer: a nationwide registry-based cohort study

OBJECTIVE

To assess academic performance in singletons aged 15-16 years conceived after frozen embryo transfer (FET) compared with singletons born after fresh embryo transfer (ET) in Danish cohorts born from 1995 to 2001.

DESIGN

Danish national registry-based cohort study.

SETTING

Danish national registries.

POPULATION

All 6495 singletons conceived after assisted reproductive technology (ART) treatment in Denmark from 1995 to 2001 [FET (n) = 423; fresh ET (n) = 6072].

METHODS

Mean test scores on a national standardised and international comparable grading-scale. Comparisons of test score were first made in univariate analysis (Model 1) and secondly in a multivariate linear model (Model 2) adjusting for relevant reproductive and socio-demographic covariates such as the occupational and educational level of the parents. Sensitivity analyses on FET-IVF (in vitro fertilisation) versus fresh ET-IVF and FET-ICSI (intracytoplasmic sperm injection) versus fresh ET-ICSI were made. Linear mixed models were used to account for the correlation in test scores of siblings for continuous outcome.

MAIN OUTCOME MEASURES

Mean overall test score and test score in Danish, mathematics, English, and physics/chemistry.

RESULTS

Crude and adjusted mean test scores were similar for adolescents conceived after FET compared with fresh ET. The crude mean difference was +0.11 (95% CI -0.11; 0.34), and the adjusted mean difference was +0.12 (95% CI -0.09; 0.34).

CONCLUSIONS

Adolescents conceived after FET had similar academic performance at 15-16 of years of age compared with children conceived after fresh ET.

TWEETABLE ABSTRACT

Using frozen embryos in fertility treatment does not affect school performance in Danish adolescents aged 15-16 years.

Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials

OBJECTIVES

To compare 2-year outcomes of total knee replacement (TKR) followed by non-surgical treatment to that of non-surgical treatment alone and outcomes of the same non-surgical treatment to that of written advice.

DESIGN

In two randomized trials, 200 (mean age 66) adults with moderate to severe knee osteoarthritis (OA), 100 eligible for TKR and 100 not eligible for TKR, were randomized to TKR followed by non-surgical treatment, non-surgical treatment alone, or written advice. Non-surgical treatment consisted of 12 weeks of supervised exercise, education, dietary advice, use of insoles, and pain medication. The primary outcome was the mean score of the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, activities of daily living (ADL), and quality of life (QOL).

RESULTS

Patients randomized to TKR had greater improvements than patients randomized to non-surgical treatment alone (difference of 18.3 points (95% CI; 11.3 to 25.3)), who in turn improved more than patients randomized to written advice (difference of 7.0 points (95% CI; 0.4 to 13.5)). Among patients eligible for TKR, 16 (32%) from the non-surgical group underwent TKR during 2 years and among those initially ineligible, seven patients (14%) from the non-surgical group and ten (20%) from the written advice group underwent TKR.

CONCLUSIONS

TKR followed by non-surgical treatment is more effective on pain and function than non-surgical treatment alone, which in turn is more effective than written advice. Two out of three patients with moderate to severe knee OA eligible for TKR delayed surgery for at least 2 years following non-surgical treatment.

TRIAL REGISTRATION

ClinicalTrials.gov numbers NCT01410409 and NCT01535001.

Barriers to contacting general practice with alarm symptoms of colorectal cancer: a population-based study

BACKGROUND

A prerequisite for general practitioners (GPs) being able to refer patients with cancer alarm symptoms for further investigations is that individuals present to the GP. Knowledge of barriers to help-seeking is, however, sparse. Objectives. The aim of this study was to analyse associations between the experience of recent-onset alarm symptom of colorectal cancer and four different barriers towards GP contact.

METHODS

A nationwide web-based cohort survey was conducted in 100000 individuals aged 20 years or above, randomly selected from the Danish Civil Registration System. Items regarding experience of four predefined alarm symptoms of colorectal cancer (rectal bleeding, abdominal pain, change in stool texture and change in stool frequency), decisions about contact to GPs and barriers towards GP contact were included.

RESULTS

A total of 37455 respondents over 40 years (51.8%) completed the questionnaire. The proportion of individuals with no contact to the GP varied between 69.8% and 79.8% for rectal bleeding and change in stool frequency, respectively. The most widely reported barriers were being worried about wasting the doctor's time and being too busy to make time to visit the doctor. Men with rectal bleeding significantly more often reported being worried about what the doctor might find. The proportion of individuals who reported barriers was, in general, higher among the youngest age group.

CONCLUSION

Barriers to contacting the GP were frequent when experiencing alarm symptoms of colorectal cancer. Reporting the different barriers was significantly associated with gender and age.

Lifestyle, socioeconomic status and healthcare seeking among women with gynaecological cancer alarm symptoms: a combined questionnaire-based and register-based population study

OBJECTIVES

To determine the proportion of contacts to general practitioner (GP) with recent onset gynaecological cancer alarm symptoms (pelvic pain, postmenopausal bleeding, bleeding during intercourse or pain during intercourse) and to analyse the associations between lifestyle factors, socioeconomic status and GP contact for these symptoms.

DESIGN

Cross-sectional survey combined with data from national registers.

SETTING

The general Danish population.

PARTICIPANTS

A total of 25 866 non-pregnant women ≥20 years completed the survey. Women reporting at least one of four gynaecological alarm symptoms within the preceding 6 months form the study base (n=2957).

RESULTS

The proportion of women reporting GP contact ranged from 21.1% (pain during intercourse) to 32.6% (postmenopausal bleeding). Women aged 60+ years had higher odds of reporting GP contact for at least one of the four gynaecological cancer alarm symptoms compared with those aged 20-39 years (OR 2.56, 95% CI 1.69 to 3.89), and immigrants had higher odds of reporting GP contact for at least one of the symptoms (OR 1.56, 95% CI 1.13 to 2.15) compared with ethnic Danish individuals. Among those reporting postmenopausal bleeding and/or bleeding during intercourse, women in the age group 60+ years had higher odds of reporting GP contact compared with those aged 20-39 years (OR 2.79, 95% CI 1.33 to 5.87). A high educational level (>12 years) was positively associated with reporting GP contact for postmenopausal bleeding and/or bleeding during intercourse compared with a low educational level (<10 years) (OR 2.23, 95% CI 1.19 to 4.19). No associations were found with lifestyle factors.

CONCLUSIONS

Few women contacted their GP with recent onset gynaecological cancer alarm symptoms. Higher age, being immigrant and higher educational level increased the odds of GP contact. Future studies should explore the reasons for these findings as this may aid in prompting early diagnosis and thereby improve the prognosis of gynaecological cancer.

Predictive values of upper gastrointestinal cancer alarm symptoms in the general population: a nationwide cohort study

BACKGROUND

Survival rates for upper gastrointestinal (GI) cancer are poor since many are diagnosed at advanced stages. Fast track endoscopy has been introduced to prompt diagnosis for patients with alarm symptoms that could be indicative of upper GI cancer. However, these symptoms may represent benign conditions and little is known about the predictive values of alarm symptoms of upper GI cancer in the general population.

METHODS

The study is a nationwide cohort study of 60,562 individuals aged 45 years or above randomly selected from the Danish general population. Participants were invited to complete a survey comprising of questions on several symptom experiences, including alarm symptoms for upper GI cancer within the past four weeks. The participants were asked about specific symptoms (repeated vomiting, difficulty swallowing, signs of upper GI bleeding or persistent and recent-onset abdominal pain) and non-specific symptoms (nausea, weight loss, loss of appetite, feeling unwell and tiredness). We obtained information on upper GI cancer diagnosed in a 12-month period after completing the questionnaire from the Danish Cancer Registry. We calculated positive predictive values and positive likelihood ratios for the association between alarm symptom and subsequent upper GI cancer.

RESULTS

A total of 33,040 individuals above 45 years completed the questionnaire, yielding a response rate of 54.6%. Respondents were fairly respresentative of the study sample. During the follow-up period, 18 people were diagnosed with upper GI cancer. The number of incident cancers was similar among eligible non-respondents. Two thirds of the respondents with an upper GI malignancy had experienced one or more alarm symptoms. The positive predictive value for being diagnosed with upper GI cancer after reporting a least one alarm symptom was 0.1% (95% CI:0.0-0.1%). The positive likelihood ratio was 4.4 for specific alarm symptoms and 1.1 for non-specific alarm symptoms.

CONCLUSIONS

We found that positive predictive values of alarm symptoms of upper GI cancer experienced in the general population are low. It is important knowledge that despite denoted alarm symptoms even patients with specific alarm symptoms of upper GI cancer have a low risk of being diagnosed with upper GI cancer.