Management of chronic obstructive pulmonary disease in general practice in Denmark.

INTRODUCTION: In recent years, increased awareness and focus on chronic obstructive pulmonary disease (COPD) has evolved. Alongside, a growing interest has emerged in quality of care including early diagnosis, smoking cessation, rehabilitation and relevant medication as tools for achieving a better prognosis. METHODS: The aim of this study was to analyse the quality of real-life management of COPD in a representative sample of Danish general practices. Our main focus was to measure the fulfilment of ten specific quality-of-care indicators at the annual control visit for management of COPD, as suggested by the Danish Society of General Practitioners (DSAM), by extracting relevant data from the electronic patient medical records (PMR) of the general practitioners' (GP) electronic patient filing systems. RESULTS: In total, 82 GP clinics participated in the study. Approximately half were solo clinics and the rest were various types of partnership clinics. The records of 1,556 COPD patients (51.3% males) with an average age of 69.7 years (range: 36-97 years) were included. We found the level of registration of the quality-of-care standards to be very low, as only 11.1% (95% confidence interval: 7.9-15.8%) of the PMR recorded an acceptable (80-99%) or excellent (100%) registration. Conclutions: Improvement of adherence to COPD guidelines among GPs is of paramount importance to improve management and reduce the overall burden of COPD. However, this study demonstrates that substantial room for improvement remains. FUNDING: This study was sponsored by Boehringer Ingelheim, Denmark, and the authors have all received payment for their contribution to the study. TRIAL REGISTRATION: The trial was approved by the Danish Health Authority and the Danish Data Protection Agency.

The distress thermometer in survivors of gynaecological cancer: accuracy in screening and association with the need for person-centred support.

PURPOSE: Unrecognised psychological distress among cancer survivors may be identified using short screening tools. We validated the accuracy of the distress thermometer (DT) to detect psychological distress on the Hospital Anxiety and Depression Scale (HADS) among early stage gynaecological cancer survivors and whether the women's DT and HADS scores were associated with the need of an individualised supportive intervention. METHODS: One hundred sixty-five gynaecological cancer survivors answered DT and HADS before randomisation in a trial testing a nurse-led, person-centred intervention using supportive conversations. The number of conversations was decided in the woman-nurse dyad based on the woman's perceived need. Nurses were unaware of the women's DT and HADS scores. We validated DT's accuracy for screening using HADS as gold standard and receiver operating characteristic curves. Associations between DT and HADS scores and the number of conversations received were investigated. RESULTS: For screening of distress (HADS ≥ 15), a DT score ≥ 2, had a sensitivity of 93% (95% CI 82-98%), a specificity of 40% (32-49%), and positive and negative predictive values of 36% (28-45%), and 94% (84-98%), respectively; area under curve was 0.73 (0.64-0.81). Higher DT and HADS scores were associated with more interventional conversations. CONCLUSIONS: In gynaecological cancer survivors, DT may perform fairly well as a first stage screening tool for distress, but a second stage is likely needed due to a high number of false positives. DT and HADS scores may predict the number of supportive conversations needed in an individualised intervention in gynaecological cancer survivors.

Prognostic Factors and Treatment Results After Bleomycin, Etoposide, and Cisplatin in Germ Cell Cancer: A Population-based Study.

BACKGROUND: First-line treatment for patients with disseminated germ cell cancer (GCC) is bleomycin, etoposide, and cisplatin (BEP). A prognostic classification of patients receiving chemotherapy was published by the International Germ Cell Cancer Collaborative Group (IGCCCG) in 1997, but only a small proportion of the patients received BEP. OBJECTIVE: To estimate survival probabilities after BEP, evaluate the IGCCCG prognostic classification, and propose new prognostic factors for outcome. DESIGN, SETTING, AND PARTICIPANTS: Of a Danish population-based cohort of GCC patients (1984-2007), 1889 received first-line BEP, with median follow-up of 15 yr. Covariates evaluated as prognostic factors were age, year of treatment, primary site, non-pulmonary visceral metastases, pulmonary metastases, and tumor markers. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcomes measured were 5-yr progression-free survival (PFS), 5-yr disease-specific survival (DSS), and 5-yr overall survival (OS) as calculated using the Kaplan-Meier method and the Cox proportional hazards model. RESULTS AND LIMITATIONS: The 5-yr PFS, DSS, and OS were 87%, 95%, and 93%, respectively, for patients with seminomatous GCC (SGCC) and good prognosis. For nonseminomatous GCC (NSGCC) with good, intermediate, and poor prognosis, the 5-yr probabilities were 90%, 76%, and 55% for PFS; 97%, 87%, and 66% for DSS; and 95%, 85%, and 64% for OS, respectively. For SGCC patients, new adverse prognostic factors not included in the IGCCCG classification were higher age and lactate dehydrogenase ≥1.5 times the upper limit of normal. For NSGCC patients, higher age and pulmonary metastases were additional adverse prognostic factors. Treatment in earlier years was associated with higher mortality. Limitations include the small number of patients in the prognostic groups, and the inability to adjust for performance status and comorbidity. CONCLUSIONS: Our study reveals improved survival for disseminated GCC throughout the study period. We propose new prognostic factors for outcome for validation in larger cohorts of patients. PATIENT SUMMARY: In this study of testicular cancer patients, we evaluated prognostic factors for outcome and calculated survival after standard chemotherapy. We find that survival has improved over the years and we propose new prognostic factors for outcome for validation in larger patient cohorts.

Second Malignant Neoplasms and Cause of Death in Patients With Germ Cell Cancer: A Danish Nationwide Cohort Study.

IMPORTANCE: Patients given systemic treatment for testicular germ cell cancer (GCC) are at increased risk for a second malignant neoplasm (SMN). Previous studies on SMN and causes of death lacked information on the exact treatment applied or were based on patients receiving former treatment options. OBJECTIVE: To evaluate the treatment-specific risks for SMN and death in a nationwide population-based cohort of patients with GCC treated with current standard regimens. DESIGN, SETTING, AND PARTICIPANTS: This study examined a Danish nationwide cohort of 5190 men with GCC who entered the Danish Testicular Cancer database between January 1, 1984, and December 31, 2007. Treatment results were compared with a randomly sampled, age-stratified, population-based control group. Cases of gonadal and extragonadal primary were included in the nationwide cohort. The treatments were surveillance only; retroperitoneal radiotherapy (RT); bleomycin, etoposide, and cisplatin (BEP); or more than 1 line of treatment (MTOL). MAIN OUTCOMES AND MEASURES: Cumulative incidence and hazard ratios (HRs) for SMN and death calculated by the Cox proportional hazards model were compared with those of age-matched controls. RESULTS: The study population comprised 2804 patients with seminoma and 2386 with nonseminoma. The median follow-up was 14.4 years (interquartile range, 8.6-20.5 years). The 20-year cumulative incidence of SMN with death as a competing risk was 7.8% (surveillance), 7.6% (BEP), 13.5% (RT), 9.2% (MTOL), and 7.0% (controls). We found no increased risk for SMN after surveillance, while the HRs were 1.7 (95% CI, 1.4-2.0), 1.8 (95% CI, 1.5-2.3), and 3.7 (95% CI, 2.5-5.5), respectively, after BEP, RT, and MTOL. Mortality owing to non-GCC causes was decreased after surveillance, but increased by 1.3 times after BEP and RT and by 2.6 times after MTOL. Excess mortality due to SMN was found after BEP (HR, 1.6; 95% CI, 1.2-2.2), RT (HR, 2.1; 95% CI, 1.5-2.9), and MTOL (HR, 5.8; 95% CI, 3.6-9.6). CONCLUSIONS AND RELEVANCE: We found no increased risk for SMN or death among patients undergoing surveillance only. The risks for SMN and death due to SMN were increased after BEP alone, RT alone, and MTOL. Approaches to define patients who might benefit from less intensive treatment are needed.

The combined predictive capacity of rat models of algogen-induced and neuropathic hypersensitivity to clinically used analgesics varies with nociceptive endpoint and consideration of locomotor function.

Different neurobiological mechanism(s) might contribute to evoked and non-evoked pains and to limited translational drug discovery efforts. Other variables including the pain model and sensory testing method used, dose/route/preadministration time of compound(s), lack of adverse effect profiling and level of observer experience might also contribute. With these points in mind, we tested three mechanistically distinct analgesics in rat models of algogen-induced and neuropathic pain. In chronic constriction injury (CCI) rats evoked hindpaw mechanical hypersensitivity and spontaneous weight bearing deficits developed quickly and persisted for at least 3 weeks post-injury. In contrast, evoked cold hypersensitivity, or movement-associated behavioural deficits (rotarod, beam-walking) were less manifested or dissipated rapidly post-injury. Mechanical hypersensitivity was dose-dependently reversed by morphine (3-10 mg/kg, s.c.) and gabapentin (50-200 mg/kg, i.p.). Weight bearing deficits and cold hypersensitivity were reversed only by high doses of each drug. Surprisingly, duloxetine (10-60 mg/kg, s.c.) was largely ineffective in neuropathic rats although it partially reduced formalin-induced spontaneous nocifensive behaviours; especially during interphase, a period associated with activation of descending monoaminergic inhibition. Morphine and gabapentin markedly attenuated second phase formalin- and in addition capsaicin-induced nocifensive behaviours; indicative of effects on central sensitization and nociceptor hyperexcitability mechanisms. Only gabapentin consistently attenuated nociceptive behaviours at a dose that did not impair exploratory locomotor behaviour in naïve rats. Accordingly, this comparative analysis indicates that the pharmacological sensitivity of evoked and non-evoked pain indices does not necessarily correlate within models, perhaps reflecting differing underlying mechanisms. Conversely, the pharmacological specificity of non-evoked pain indices to selected drugs was conserved across models indicative of similar underlying mechanisms enduring in the face of differing aetiology. Finally, although the predictive capacity of these models was largely unaffected by observer-related experience, it was putatively compromised when adverse event profiling of each drug was considered in parallel.