The effects of diabetes clubs on peer-support, disclosure of diabetes status, and sources of information regarding diabetes management: results of a pilot-intervention in rural Vietnam.

OBJECTIVES: To measure the effects of diabetes clubs on peer support, disclosure of diabetes status, and the source of information regarding the management of diabetes among persons living with type-2 diabetes (T2D) in rural Vietnam. STUDY DESIGN: A pre- and post-pilot intervention study was carried out in Thai Binh Province, Vietnam (n = 222). RESULTS: Post-intervention, 57.7 % reported using experiences shared by other persons with T2D during the diabetes club sessions. Compared to pre-intervention, there was an increase in the proportion of persons with T2D who disclosed their diabetes status to friends and/or community members (an increase of 15.3 and 13.8 percentage points, respectively). The proportion of persons who reported gathering their own information regarding diabetes management without any support from others decreased from 15.7 % to 6.3 %. Those who reported a relative inside their home or a relative outside their household as their primary source of T2D-relevant information increased from 10.8 % to 18.6 % and from 2.7 % to 9.5 %, respectively. Persons who mentioned that they did not have a need for further support for their diabetes care increased from 18.5 % to 32.0 %. Specific support regarding diabetes-related knowledge received from family members, friends, and/or community members increased from 27.5 % to 62.2 % CONCLUSIONS: These findings suggest a promising potential for the implementation of diabetes clubs to enhance diabetes-relevant knowledge and the quality of self-management among persons living with T2D diabetes in rural areas of Vietnam.

GPs' prescription patterns, experience, and attitudes towards medicinal cannabis-a nationwide survey at the early stage of the Danish test scheme.

BACKGROUND: On 1 January 2018 a four-year test scheme concerning use of medicinal cannabis (MC) was enacted. It has recently been extended for four more years by the Danish Parliament permitting all Danish physicians to prescribe MC to their patients. Previous studies have shown that general practitioners (GPs) have varying prescription experience, little knowledge, and mixed attitudes about MC. However, the present evidence is still limited, and no studies exist about Danish GPs' prescription experience, knowledge, and attitudes towards MC. Therefore, our aim was to examine Danish GPs' prescription experience, knowledge, and attitudes towards MC. METHODS: A national online survey-based study addressing Danish GPs was performed from September 2018 to July 2019. We performed separate multivariable logistic regression analyses including GPs' prescription experience, knowledge, and attitudes towards MC as outcome variables. RESULTS: A total of 427 (38.4%) of 1112 GPs completed the questionnaire. Of these, 37 (8.7%) had experience in prescribing MC. The majority had little or no knowledge about MC (80.6%) as well as a negative view on prescription of MC (71.4%) to patients. Factors associated with prescribing MC to patients were: Single-handed practices (OR = 1.6, 95% CI 1.1;1.8) and perception of having quite some knowledge about MC (OR = 4.8, 95% CI 2.2;10.4). Factors associated with having quite some knowledge about MC were: having a positive attitude towards prescribing MC (OR = 5.2, 95% CI 1.9;14.0), being male (OR = 1.7, 95% CI 1.4;1.8), and being at least 60 years of age (OR = 2.8, 95% CI 1.3;6.0). Factors associated with having a positive attitude towards prescribing MC were: having quite some knowledge about MC (OR = 5.2, 95% CI 2.2;12.5) and GPs being male (OR = 1.7, 95% CI 1.1;1.9). CONCLUSION: In this first study on prescription experience, knowledge, and attitudes about MC among Danish GPs, conducted one year after the Danish test scheme was enacted, we find a very low proportion of prescribers, little knowledge, and an overall negative attitude towards MC. Among the prescribing GPs, four in ten have little to no knowledge and a negative attitude towards MC. We stress that prescribing patterns, knowledge, and attitudes may change throughout the remaining time of the test scheme.

Chronic opioid use before and after exercise therapy and patient education among patients with knee or hip osteoarthritis.

OBJECTIVE: To investigate changes in opioid use after supervised exercise therapy and patient education among knee or hip osteoarthritis patients with chronic opioid use. METHOD: In this cohort study, we linked data from the Good Life with osteoArthritis in Denmark register (GLA:D®; standardised treatment program for osteoarthritis; January 2013 to November 2018) with national health registries. Among 35,549 patients, 1,262 were classified as chronic opioid users based on amount and temporal distribution of dispensed opioids the year before the intervention. We investigated changes in opioid use, measured as mg oral morphine equivalents (OMEQs), from the year before the intervention to the year after using generalized estimating equations. RESULTS: We found a 10% decrease in mg OMEQs from the year before to the year after the intervention (incidence rate ratio [IRR]: 0.90, 95% confidence interval [CI]: 0.86, 0.94). Additional analyses suggested this decrease to be mainly attributable to regulatory actions targeting opioid prescribing during the study period (IRR among patients participating in the intervention before: 0.98 [95% CI: 0.89, 1.07] vs after: 0.83 [0.74, 0.93] regulatory actions). In a random general population sample of matched chronic opioid users, a similar opioid use pattern was observed over time, further supporting the impact of regulatory actions on the opioid use in the study population. CONCLUSION: Among patients with knee or hip osteoarthritis and chronic opioid use, a standardised treatment program did not change opioid use when regulatory changes in opioid prescribing were taken into account.

Challenges in the cross-sectoral collaboration on vulnerable pregnant women: a qualitative study among Danish general practitioners.

BACKGROUND: Vulnerable pregnant women, defined as women threatened by social, psychological, or physical risk factors, need special support during pregnancy to prevent complications in pregnancy, birth, and childhood. Proper cross-sectoral collaboration in antenatal care is paramount to delivering sufficient supportive care to these women. General practitioners (GPs) often face barriers when assessing vulnerable pregnant women and may; as a result, under-identify and underreport child abuse. Little is known about how the cross-sectoral collaboration in antenatal care affects the GP's opportunities of managing vulnerable pregnant women. This study explores GPs' perceived barriers and facilitators in the antenatal care collaboration on vulnerable pregnant women and in the reporting of these women to social services. METHODS: A qualitative study with semi-structured focus group interviews among twenty GPs from the Region of Southern Denmark. A mixed inductive and deductive analytic strategy was applied, structured according to the Theoretical Domains Framework (TDF). RESULTS: Three themes emerged: I) collaborative experience, II) motivation, and III) organizational working conditions. Barriers were lacking experience, i.e. knowledge, skills, and attention to antenatal care collaboration and reporting, inadequate organizational working contexts, i.e. insufficient pathways for communication between health care and social care systems, and laws restricting feedback on the consequences of reporting. This decreased the GPs motivation, i.e. poor confidence in navigating the system, fear of breaking the patient alliance when collaborating in antenatal care and reporting with the social services. GPs motivation to collaborate and report was increased by knowing the working contexts of their collaborative partners in the antenatal care and social services system and by a strong doctor-patient relationship enabling them to describe the vulnerability to collaborators. CONCLUSIONS: GPs experience system-related barriers to collaborating and reporting on vulnerable pregnant women within the health care sector and in the interplay with the social services sector. Organizational development of cross-sectoral antenatal care collaboration should imply user involvement of all collaborative partners. Results suggest that health authorities should consider establishing accessible communication pathways between the GPs and the social services to improve options for proper cross-sectoral communication and feedback to GPs, thereby improving care trajectories of vulnerable pregnant women.

Assessing and addressing vulnerability in pregnancy: General practitioners perceived barriers and facilitators - a qualitative interview study.

BACKGROUND: Vulnerability due to low psychosocial resources increases among women in the fertile age. Undetected vulnerability in pregnancy is a major contributor to inequality in maternal and perinatal health and constitutes a risk of maternal depression, adverse birth outcomes,-i.e. preterm birth, low birth weight, and adverse outcomes in childhood such as attachment disorders. General practitioners (GPs) have a broad understanding of indicators of vulnerability in pregnancy. However, less than 25% of pregnant women with severe vulnerability are identified in Danish general practice. The aim was to explore GPs' perceived barriers and facilitators for assessing and addressing vulnerability among pregnant women. METHODS: A qualitative study with semi-structured focus group interviews with twenty GPs from urban and rural areas throughout the Region of Southern Denmark. A mixed inductive and deductive analytic strategy was applied, structured according to the Theoretical Domains Framework (TDF). RESULTS: Five themes emerged covering twelve TDF domains: (I)knowledge and attention, (II)professional confidence, (III)incentives, (IV)working conditions and (V)behavioral regulations. Prominent barriers to assessment were lack of continuity of care and trust in the doctor-patient relation. Other barriers were inattention to indicators of vulnerability, time limits, unavailable information on patients' social support needs from cross-sectoral collaborators, and lack of reimbursement for the use of extra time. Fear of damaging the doctor-patient relation, ethical dilemmas and time limits were barriers to addressing vulnerability. Facilitators were increased attention on vulnerability, professionalism and a strong and trustful doctor-patient relation. Behavioral regulations ensuring continuity of care and extra time for history taking enabled assessing and addressing vulnerability, especially when a strong doctor-patient relation was absent. CONCLUSIONS: The TDF disclosed several barriers, especially in the absence of a strong doctor-patient relation. A behavior change intervention of restructuring the organization of antenatal care in general practice might reduce the GPs' barriers to assessing and addressing vulnerability in pregnancy. The findings may serve as a guide for commissioners and policymakers of antenatal care on the GPs' support needs when providing antenatal care to vulnerable pregnant women.

Sialic acid blockade in dendritic cells enhances CD8+ T cell responses by facilitating high-avidity interactions.

Sialic acids are negatively charged carbohydrates that cap the glycans of glycoproteins and glycolipids. Sialic acids are involved in various biological processes including cell-cell adhesion and immune recognition. In dendritic cells (DCs), the major antigen-presenting cells of the immune system, sialic acids emerge as important regulators of maturation and interaction with other lymphocytes including T cells. Many aspects of how sialic acids regulate DC functions are not well understood and tools and model systems to address these are limited. Here, we have established cultures of murine bone marrow-derived DCs (BMDCs) that lack sialic acid expression using a sialic acid-blocking mimetic Ac53FaxNeu5Ac. Ac53FaxNeu5Ac treatment potentiated BMDC activation via toll-like receptor (TLR) stimulation without affecting differentiation and viability. Sialic acid blockade further increased the capacity of BMDCs to induce antigen-specific CD8+ T cell proliferation. Transcriptome-wide gene expression analysis revealed that sialic acid mimetic treatment of BMDCs induces differential expression of genes involved in T cell activation, cell-adhesion, and cell-cell interactions. Subsequent cell clustering assays and single cell avidity measurements demonstrated that BMDCs with reduced sialylation form higher avidity interactions with CD8+ T cells. This increased avidity was detectable in the absence of antigens, but was especially pronounced in antigen-dependent interactions. Together, our data show that sialic acid blockade in BMDCs ameliorates maturation and enhances both cognate T cell receptor-MHC-dependent and independent T cell interactions that allow for more robust CD8+ T cell responses.

General practitioners' perceived indicators of vulnerability in pregnancy- A qualitative interview study.

OBJECTIVE: To explore general practitioners' (GPs') perceived indicators of vulnerability among pregnant women in primary care. DESIGN: A qualitative study with semi-structured in-depth focus group interviews. SETTING: General practices located in a mixture of urban, semi-urban and rural practices throughout the Region of Southern Denmark SUBJECTS: Twenty GPs. MAIN OUTCOME MEASURES: Through qualitative analysis with systematic text condensation of the interview data, the following themes emerged: (1) obvious indicators of vulnerability-i.e. somatic or psychological illnesses, or complex social problems and 2) intangible indicators of vulnerability - i.e. identification depended on the GPs' gut-feeling. From the GPs' perspective, the concept of vulnerability in pregnancy were perceived as the net result of risk factors and available individual and social resources, with a psychosocial etiology as the dominant framework. CONCLUSIONS: The GPs demonstrated a broad variety of perceived indicators of vulnerability in pregnancy; most importantly, the GPs were aware of a group of pregnant women with intangible vulnerability mainly representing low resilience. Despite not fitting into the GPs' perceived concept of vulnerability, the GPs had a strong gut feeling that these women might be vulnerable. Misjudging the resources of pregnant women due to their physical appearance could delay the GPs' identification of vulnerability. Future studies should explore the challenges GPs experiences when assessing vulnerability among pregnant women.

Development in Danish medical students' empathy: study protocol of a cross-sectional and longitudinal mixed-methods study.

BACKGROUND: Clinical empathy has been associated with positive outcomes for both physicians and patients such as: more accurate diagnosis and treatment, increased patient satisfaction and compliance, and lower levels of burnout and stress among physicians. International studies show mixed results regarding the development of empathy among future physicians associating medical education with decline, stability or increase in empathy levels. These mixed results are due to several study limitations. In Denmark, no investigation of Danish medical students' empathy trajectory has yet been conducted wherefore such a study is needed that optimizes the study design of earlier studies. METHODS: The aim of the study is to examine and analyze empathy levels and empathy changes among Danish medical students from the four medical faculties in Denmark, employing a cross-sectional and longitudinal mixed-methods design including a control group of non-medical students. By supplementing cross-sectional and longitudinal questionnaire studies with a focus group interview study it is the aim to identify and analyze factors (including educational) that are perceived by medical students to influence the development of empathy and its expression in clinical care. DISCUSSION: The results of the study will provide insight into the trajectory of medical students' empathy and in undergraduate and graduate students' experiences with and perceptions of empathy development. In addition, the study will provide evidence to support further research on how targeted educational programmes can best be designed to educate empathic and patient-centered physicians.

Primary health care: an opportunity for early identification of people living with undiagnosed HIV infection.

OBJECTIVES: We aimed to determine the fraction of HIV-diagnosed individuals who had primary health care (PHC) contacts 3 years prior to HIV diagnosis and whether the risk of HIV diagnosis and degree of immunodeficiency were associated with the frequency of visits or procedures performed. METHODS: We used data from national registries to conduct a population-based nested case-control study. Cases were individuals diagnosed with HIV infection in Denmark from 1998 to 2016. Population controls were extracted from the general population matched 13:1 on gender and age. We used conditional logistic regression. As there was a statistically significant interaction, analyses were further stratified by gender and Danish/non-Danish origin. RESULTS: We identified 2784 cases and 36 192 controls. Ninety-three per cent of cases and 88% of controls attended PHC at least once in the 3 years prior to diagnosis, with a higher median number of visits to PHC (NVPC) for cases. We found a statistically significant positive association between NVPC and risk of subsequent HIV diagnosis in men and non-Danish women. A U-shaped association between NVPC and risk of HIV diagnosis among Danish women. No substantial association between NVPC and degree of immunodeficiency was found. Risk of HIV diagnosis and degree of immunodeficiency were weakly associated with type of procedures performed. CONCLUSIONS: For most HIV-infected individuals, there seem to be many opportunities for earlier diagnosis in PHC. In men and non-Danish women, the risk of HIV diagnosis but not the degree of immunodeficiency was related to NVPC. The results suggest that the type of medical procedure performed cannot not be used as a guide by the primary physician to indicate which patients to test.

Reliability and consistency of a validated sun exposure questionnaire in a population-based Danish sample.

An important feature of questionnaire validation is reliability. To be able to measure a given concept by questionnaire validly, the reliability needs to be high. The objectives of this study were to examine reliability of attitude and knowledge and behavioral consistency of sunburn in a developed questionnaire for monitoring and evaluating population sun-related behavior. Sun related behavior, attitude and knowledge was measured weekly by a questionnaire in the summer of 2013 among 664 Danes. Reliability was tested in a test-retest design. Consistency of behavioral information was tested similarly in a questionnaire adapted to measure behavior throughout the summer. The response rates for questionnaire 1, 2 and 3 were high and the drop out was not dependent on demographic characteristic. There was at least 73% agreement between sunburns in the measurement week and the entire summer, and a possible sunburn underestimation in questionnaires summarizing the entire summer. The participants underestimated their outdoor exposure in the evaluation covering the entire summer as compared to the measurement week. The reliability of scales measuring attitude and knowledge was high for majority of scales, while consistency in protection behavior was low. To our knowledge, this is the first study to report reliability for a completely validated questionnaire on sun-related behavior in a national random population based sample. Further, we show that attitude and knowledge questions confirmed their validity with good reliability, while consistency of protection behavior in general and in a week's measurement was low.

Early-onset type 2 diabetes: Age gradient in clinical and behavioural risk factors in 5115 persons with newly diagnosed type 2 diabetes-Results from the DD2 study.

AIM: To examine the association between early onset of type 2 diabetes mellitus (DM) and clinical and behavioural risk factors for later complications of diabetes. METHODS: We conducted a cross-sectional study of 5115 persons with incident type 2 DM enrolled during 2010-2015 in the Danish Centre for Strategic Research in Type 2 Diabetes-cohort. We compared risk factors at time of diagnosis among those diagnosed at ≤45 years (early onset) with diagnosis age 46 to 55, 56 to 65 (average onset = reference), 66 to 75, and >75 years (late onset). Prevalence ratios (PRs) were computed by using Poisson regression. RESULTS: Poor glucose control, ie, HbA1c ≥ 75 mmol/mol (≥9.0%) in the early-, average-, and late-onset groups was observed in 12%, 7%, and 1%, respectively (PR 1.70 [95% confidence intervals (CI) 1.27, 2.28] and PR 0.17 [95% CI 0.06, 0.45]). A similar age gradient was observed for severe obesity (body mass index > 40 kg/m2 : 19% vs. 8% vs. 2%; PR 2.41 [95% CI 1.83, 3.18] and 0.21 (95% CI 0.08, 0.57]), dyslipidemia (90% vs. 79% vs. 68%; PR 1.14 [95% CI 1.10, 1.19] and 0.86 [95% CI 0.79, 0.93]), and low-grade inflammation (C-reactive protein > 3.0 mg/L: 53% vs. 38% vs. 26%; PR 1.41 [95% CI 1.12, 1.78] and 0.68 [95% CI 0.42, 1.11]). Daily smoking was more frequent and meeting physical activity recommendations less likely in persons with early-onset type 2 DM. CONCLUSIONS: We found a clear age gradient, with increasing prevalence of clinical and behavioural risk factors the younger the onset age of type 2 DM. Younger persons with early-onset type 2 DM need clinical awareness and support.

One year effectiveness of neuromuscular exercise compared with instruction in analgesic use on knee function in patients with early knee osteoarthritis: the EXERPHARMA randomized trial.

OBJECTIVE: To test long-term effectiveness of neuromuscular exercise (NEMEX) with instructions in optimized pharmacological treatment (PHARMA) on activities of daily living (ADL) in patients with early knee osteoarthritis. DESIGN: 12-months follow-up from a randomized controlled trial. Participants with mild-to-moderate medial tibiofemoral knee osteoarthritis were randomly allocated to 8 weeks NEMEX or PHARMA. The primary outcome measure was the ADL-subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcome measures included the other four KOOS-subscales, the University of California Activity Score (UCLA) and the European Quality of Life-5 Dimensions. RESULTS: Ninety-three patients (57% women, 58 ± 8 years, body mass index 27 ± 4 kg/m2) were randomized to NEMEX (n = 47) or PHARMA group (n = 46) with data from 85% being available at 12-months follow-up. Good compliance was achieved for 49% of the participants in NEMEX (≥12 sessions) and 7% in PHARMA (half the daily dose of acetaminophen/NSAIDs ≥ 28 days). Within-group improvements in NEMEX were considered to be clinically relevant (≥10 points) for all KOOS-subscales, except Sport/Rec whereas, no between-groups difference in the primary outcome KOOS ADL (3.6 [-2.1 to 9.2]; P = 0.216) was observed. For KOOS Symptoms, a statistically significant difference of 7.6 points (2.6-12.7; P = 0.004) was observed in favor of NEMEX with 47% improving ≥10 points. CONCLUSIONS: No difference in improvement in difficulty with ADL was observed. NEMEX improved knee symptoms to a greater extent with half of patients reporting clinically relevant improvements. CLINICALTRIALS. GOV IDENTIFIER: NCT01638962 (July 3, 2012). ETHICAL COMMITTEE: S-20110153.

The effect of instruction in analgesic use compared with neuromuscular exercise on knee-joint load in patients with knee osteoarthritis: a randomized, single-blind, controlled trial.

OBJECTIVE: To investigate the effect of a neuro-muscular exercise (NEMEX) therapy program compared with instructions in optimized analgesics and anti-inflammatory drug use (PHARMA), on measures of knee-joint load in people with mild to moderate knee osteoarthritis (OA). We hypothesized that knee joint loading during walking would be reduced by NEMEX and potentially increased by PHARMA. DESIGN: Single-blind, randomized controlled trial (RCT) comparing NEMEX therapy twice a week with PHARMA. Participants with mild-to-moderate medial tibiofemoral knee OA were randomly allocated (1:1) to one of two 8-week treatments. Primary outcome was change in knee load during walking (Knee Index, a composite score from all three planes based on 3D movement analysis) after 8 weeks of intervention. Secondary outcomes were frontal plane peak knee adduction moment (KAM), Knee Injury and Osteoarthritis Outcome Scores (KOOS) and functional performance tests. RESULTS: Ninety three participants (57% women, 58 ± 8 years with a body mass index [BMI] of 27 ± 4 kg/m2 (mean ± standard deviation [SD])) were randomized to NEMEX group (n = 47) or PHARMA (n = 46); data from 44 (94%) and 41 (89%) participants respectively, were available at follow-up. 49% of the participants in NEMEX and only 7% in PHARMA demonstrated good compliance. We found no difference in the primary outcome as evaluated by the Knee Index -0.07 [-0.17; 0.04] Nm/%BW HT. Secondary outcomes largely supported this finding. CONCLUSIONS: We found no difference in the primary outcome; knee joint load change during walking from a NEMEX program vs information on the recommended use of analgesics and anti-inflammatory drugs. ClinicalTrials.gov Identifier: NCT01638962 (July 3, 2012). Ethical Committee: S-20110153.

Faith Moves Mountains-Mountains Move Faith: Two Opposite Epidemiological Forces in Research on Religion and Health.

Research suggests opposite epidemiological forces in religion and health: (1). Faith seems to move mountains in the sense that religion is associated with positive health outcomes. (2). Mountains of bad health seem to move faith. We reflected on these forces in a population of 3000 young Danish twins in which all religiosity measures were associated with severe disease. We believe the reason for this novel finding is that the sample presents as a particularly secular population-based study and that the second epidemiological force has gained the upper hand in this sample. We suggest that all cross-sectional research on religion and health should be interpreted in light of such opposite epidemiological forces potentially diluting each other.

The validated sun exposure questionnaire: association of objective and subjective measures of sun exposure in a Danish population-based sample.

BACKGROUND: Few questionnaires used in monitoring sun-related behaviour have been tested for validity. OBJECTIVES: We established the criteria validity of a questionnaire developed for monitoring population sun-related behaviour. METHODS: During May-August 2013, 664 Danes wore a personal electronic ultraviolet radiation (UVR) dosimeter for 1 week that measured their outdoor time and dose of erythemal UVR exposure. In the following week, they answered a questionnaire on their sun-related behaviour in the measurement week. RESULTS: Outdoor time measured by dosimetry correlated strongly with both outdoor time and the developed exposure scale measured in the questionnaire. Exposure measured in standard erythema dose (SED) by dosimetry correlated strongly with the exposure scale. In a linear regression model of UVR (SED) received, 41% of the variation was explained by skin type, age, week of participation and exposure scale, with exposure scale as the main contributor. The weekly sunburn fraction correlated strongly with the number of ambient sun hours (r = 0·73, P < 0·001). CONCLUSIONS: This criteria-validated questionnaire provides evidence of the exposure that the questionnaire aimed to measure. The evidence provided showed a strong link between the objectively measured behaviour and the behaviour measured by this survey construct. The questionnaire is the first validated tool to measure the UVR exposure in a national population-based sample.

Medical and non-medical predictors of initiating long-term use of proton pump inhibitors: a nationwide cohort study of first-time users during a 10-year period.

BACKGROUND: Studies of the increasing use of proton pump inhibitors (PPIs) have mainly focused on prevalent long-term use and associations with gastrointestinal morbidity and comedication. Little is known about non-medical characteristics of first-time users of PPI, and predictors of initiating long-term use of PPIs. AIMS: To describe medical and non-medical characteristics of first-time PPI users during a 10-year period and to analyse predictors of initiation of long-term use (>60 defined daily doses (DDDs) within 6 months) of PPIs. METHODS: A nationwide cohort study of first-time users of PPI. Data were collected from Danish national registers. Individuals redeeming their first prescription for a PPI (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole) in 2001 and 2011 were identified. Redemption of more than 60 DDDs of PPI within 6 months defined long-term use. Logistic regression models were used to determine the associations between previous diagnoses, comedication and socio-economic characteristics and initiation of long-term use of PPIs in 2011. RESULTS: From 2001 to 2011 incidence of first-time users increased with an incidence rate ratio of 1.53 and mean quantity of PPI redeemed at first prescription increased by 44.6%. In 2011 a total of 37.6% redeemed >60 DDDs within 6 months, and 96% of the long-term users did not have a diagnosis registered which indicated treatment. New onset long-term use was significantly associated with low income and low educational level when adjusting for other predisposing variables. CONCLUSIONS: Proton pump inhibitor treatment is increasingly initiated with larger quantities prescribed for indications that are unidentifiable from the registers. Morbidity and comedication seem to be the strongest predictors of new onset long-term use of PPIs. However, there is also an independent social gradient.

General practice variation when initiating long-term prescribing of proton pump inhibitors: a nationwide cohort study.

BACKGROUND: Suggestions of overprescribing of proton pump inhibitors (PPIs) for long-term treatment in primary care have been raised. This study aims to analyse associations between general practice characteristics and initiating long-term treatment with PPIs. METHODS: A nationwide register-based cohort study of patients over 18 years redeeming first-time prescription for PPI issued by a general practitioner in Denmark in 2011. Patients redeeming more than 60 defined daily doses (DDDs) of PPI within six months were defined first-time long-term users. Detailed information on diagnoses, concomitant drug use and sociodemography of the cohort was extracted. Practice characteristics such as age and gender of the general practitioner (GP), number of GPs, number of patients per GP, geographical location and training practice status were linked to each PPI user. Logistic regression analysis was used to determine associations between practice characteristics and initiating long-term prescribing of PPIs. RESULTS: We identified 90 556 first-time users of PPI. A total of 30 963 (34.2 %) met criteria for long-term use at six months follow-up. GPs over 65 years had significantly higher odds of long-term prescribing (OR 1.32, CI 1.16-1.50), when compared to younger GPs (<45 years). Furthermore, female GPs were significantly less likely to prescribe long-term treatment with PPIs (OR 0.87, CI 0.81-0.93) compared to male GPs. CONCLUSIONS: Practice characteristics such as GP age and gender could explain some of the observed variation in prescribing patterns for PPIs. This variation may indicate a potential for enhancing rational prescribing of PPIs.

A biological modeling based comparison of two strategies for adaptive radiotherapy of urinary bladder cancer.

Background Adaptive radiotherapy is introduced in the management of urinary bladder cancer to account for day-to-day anatomical changes. The purpose of this study was to determine whether an adaptive plan selection strategy using either the first four cone beam computed tomography scans (CBCT-based strategy) for plan creation, or the interpolation of bladder volumes on pretreatment CT scans (CT-based strategy), is better in terms of tumor control probability (TCP) and normal tissue sparing while taking the clinically applied fractionation schedules also into account. Material and methods With the CT-based strategy, a library of five plans was created. Patients received 55 Gy to the bladder tumor and 40 Gy to the non-involved bladder and lymph nodes, in 20 fractions. With the CBCT-based strategy, a library of three plans was created, and patients received 70 Gy to the tumor, 60 Gy to the bladder and 48 Gy to the lymph nodes, in 30-35 fractions. Ten patients were analyzed for each adaptive plan selection strategy. TCP was calculated applying the clinically used fractionation schedules, as well as a rescaling of the dose from 55 to 70 Gy for the CT-based strategy. For rectum and bowel, equivalent doses in 2 Gy fractions (EQD2) were calculated. Results The CBCT-based strategy resulted in a median TCP of 75%, compared to 49% for the CT-based strategy, the latter improving to 72% upon rescaling the dose to 70 Gy. A median rectum V30Gy (EQD2) of 26% [interquartile range (IQR): 8-52%] was found for the CT-based strategy, compared to 58% (IQR: 55-73%) for the CBCT-based strategy. Also the bowel doses were lower with the CT-based strategy. Conclusions Whereas the higher total bladder TCP for the CBCT-based strategy is due to prescription differences, the adaptive strategy based on CT scans results in the lowest rectum and bowel cavity doses.

Are Cancer Patients' Socioeconomic and Cultural Factors Associated with Contact to General Practitioners in the Last Phase of Life?

Introduction. General practitioners (GPs) play an important role in end of life care, which should be offered regardless of socioeconomic position and cultural factors. The aim was to analyse associations between GP contacts at the end of life and socioeconomic and cultural characteristics of Danish cancer patients. Method. Population-based study identifying 599 adults who died of cancer from March to November 2006, in Aarhus County, Denmark. Associations between health register-based data on "total GP face-to-face contacts" and "GP home visits" during the last 90 days of life and patients' socioeconomic and cultural characteristics were calculated. Results. Having low income (RR: 1.18 (95% CI: 1.03; 1.35)) and being immigrants or descendants of immigrants (RR: 1.17 (95% CI: 1.02; 1.35)) were associated with GP face-to-face contacts. However, patients living in large municipalities had lower likelihood of having both GP face-to-face contacts in general (RR: 0.85 (95% CI: 0.77;0.95)) and GP home visits (RR: 0.89 (95% CI: 0.80; 0.99)). Conclusion. This study indicates higher proportion of GP contacts to economically deprived patients and immigrants/descendants of immigrants. These subgroups were, however, small and results should be looked upon with caution. Furthermore, palliative needs were not included and together with urban/rural the underlying causes need further investigation.

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.