DSAM’s publikationsinformation om seneste resultater inden for almenmedicinsk forskning i Danmark.

En social gradient i deltagelse i brystkræftscreening

Line Flytkjær Jensen, Berit Andersen og Peter Vedsted
Tidsskrift for Dansk Sundhedsvæsen 

Det danske sundhedsvæsen har valgt at indføre screening for brystkræft. Undersøgelsen tilbydes hvert andet år til alle kvinder mellem 50 og 69 år og på landsbasis involverer det over 700.000 kvinder om året. Når samfundet stiller så omfattende et tilbud til rådighed, sker det på baggrund af en lang række faglige og organisatoriske overvejelser.

Læs artiklen

Use of primary care during the year before childhood cancer diagnosis: a nationwide population-based matched comparative study

Jette M. Ahrensberg, Morten Fenger-Grøn og Peter Vedsted
PLoS ONE

I dette registerstudie beskrives brugen af almen praksis i året op mod en kræftdiagnose. Undersøgelsen var baseret på børn med en primær kræftdiagnose (2002-2008) og inkluderede i alt 1278 børn og 10 gange så mange kontrolpersoner af samme køn og alder, men uden en kræftdiagnose.

Fra seks måneder før diagnosen fik børn, der senere fik konstateret kræft, en hyppigere og tiltagende søgning til almen praksis sammenlignet med jævnaldrende kontrolpersoner. Børn med leukæmi havde tiltagende kontakt til almen praksis fra tre måneder før diagnosen, mens børn med lymfom, knogletumor og andre solide tumorer havde en hyppigere kontakt til almen praksis fra fem måneder før diagnosen sammenlignet med børn uden kræft. Lidt overraskende fandt vi, at børn, der senere fik konstateret en hjernetumor, havde en hyppigere kontakt til almen praksis i alle 12 måneder før diagnosen.

Børn med kræft går således hyppigere til læge end raske jævnaldrende i månederne før diagnosen stilles.  At kontakten til almen praksis stiger umiddelbart inden diagnosetidspunktet er forventeligt, men at denne stigning ses måneder før, at diagnosen bliver stillet, antyder, at der allerede på dette tidspunkt kan være tegn sygdom og derved et muligt grundlag for at optimere diagnostikken af kræftsygdom hos børn.

Læs artiklen

Childhood cancer and factors related to prolonged diagnostic intervals - a Danish population-based study

Jette M. Ahrensberg, Frede Olesen, Rikke Pilegaard Hansen, Henrik Schrøder og Peter Vedsted
British Journal of Cancer

Formålet med dette studie var at undersøge om særlige symptomer, lægens tolkning af symptomerne og overleveringen til hospitalet var af betydning for det diagnostiske interval (dvs. fra symptompræsentation i almen praksis til diagnose). Artiklen er baseret på data fra henholdsvis forældre- og læge-spørgeskemaer.

Den praktiserende læge tolkede barnets symptomer som vage i 25,4 % af tilfældene, som alvorlige, men ikke cancer-relaterede i 50,0 % og som alarmsymptom i 19,0 % af tilfældene. Diagnosen blev stillet hurtigst hos børn med alarmsymptomer og i de tilfælde, hvor der i henvisningen specifikt var angivet en mistanke om kræftsygdom. Resultaterne viste også, at symptomet “opkast” var associeret med et kortere diagnostisk interval ved børn med CNS-tumorer, og at symptomet ”smerte” var associeret med et længere diagnostisk interval ved børn med leukæmi. Undersøgelsen viser, at alment praktiserende læger spiller en vigtig rolle i vurdering af børn med kræft (symptomtolkning og henvisningens ordlyd) og for, hvornår den specialiserede udredning sættes i gang.

Læs artiklen

Evidence of increasing mortality with longer diagnostic intervals for five common cancers: A cohort study in primary care

(Dansk titel: Bevis for øget dødelighed ved længere diagnostiske intervaller for fem hyppige kræftformer: et kohortestudie i den primære sundhedssektor)

Marie Louise Tørring, Morten Frydenberg, Rikke P. Hansen, Frede Olesen og Peter Vedsted
European Journal of Cancer

Danske kræftpatienter har en dårligere overlevelse og diagnosticeres på et senere stadie i deres sygdomsforløb sammenlignet med kræftpatienter resten af Norden. Det har skabt øget fokus på ventetid i udredningen for kræft i Danmark. Da det ikke er muligt at undersøge ventetidens betydning eksperimentelt, så beror evidensen på observationelle studier, hvor patienterne ikke har fået tildelt ventetiden tilfældigt. Mange af disse studier viser det modsatte af, hvad vi forventer: Patienter med kort udredningstid har højere dødelighed end resten. Det har tidligere ført til konklusioner om, at tiden til diagnose er uden betydning.

Formålet med denne undersøgelse var at analysere sammenhængen mellem længden af det diagnostiske interval (defineret som tiden fra egen læges konstatering af symptomer til kræftdiagnosen) og femårsdødeligheden for de fem hyppigste kræftformer i Danmark. Vores analytiske sigte var at tage højde for fejl eller skævheder i studiedesignet, der kan føre til effektforveksling og dermed fejlkonklusioner vedr. ventetidens betydning.

Vi analyserede data fra en dansk befolkningsundersøgelse af 1.128 patenter med tyk- og endetarms-, lunge-, modermærke-, bryst- og prostatakræft. For at tydeliggøre effektforveksling undlod vi at antage en monoton sammenhæng mellem ventetid og dødeligheden, og vi opdelte analyserne efter lægernes tolkning af patienternes symptomer ved første henvendelse i praksis.

Vi så en U-formet sammenhæng mellem længden af det diagnostiske interval og femårsdødeligheden blandt patienter med tyk- og endetarms-, lunge-, modermærke- og prostatakræft, der havde præsenteret alarmsymptomer eller alvorlige symptomer i almen praksis. Vi så en modsat, konkavformet sammenhæng for tyk- og endetarms-, lunge-, modermærke-, brystkræftpatienter, der havde præsenteret uspecifikke symptomer i almen praksis. Denne sidste sammenhæng var dog ikke statistisk signifikant.

Overordnet fandt vi, at patienter med kort ventetid har højere dødelighed (det såkaldte ventetidsparadoks) samt en øget dødelighed ved længere diagnostiske intervaller for de 40-50 % af patienterne, der havde ventet længst. Effektforveksling som følge af klinisk sortering af patienterne kan forklare de kontraintuitive fund, men det kan ikke forklare den øgede dødelighed ved længere diagnostiske intervaller. Studiet tilbageviser således mange tidligere studier, der formentlig ubegrundet har konkluderet, at diagnostisk ventetid er uden betydning.

Læs artiklen

Health care experiences in infancy and subsequent frequent illness in 1-year old children*

Ruth Ertmann, Volkert Siersma, Susanne Reventlow, Margareta Söderström
Health Vol.5, No.2, 259-266 (2013) Health doi:10.4236/health.2013.52035

ABSTRACT

Background: Parents of infants suffering from frequent episodes of illness demand more ac- knowledgement from general practice with re- gard to their observations of these illnesses, which is evident from their tendency to book multiple consultations. Aim: To identify factors relating to illness and health-care experiences in infancy that predict frequent episodes of illness in toddlers.

Design of study: A retrospective questionnaire and a prospective diary study in- cluding 183 infants born in February 2001 in a district of the capital region of Denmark. Setting: Denmark, primary care.

Methods: Infants were recruited from a birth cohort and experiences of illness from birth until the age of 11 months were collected using a questionnaire. Thereafter the infants were followed prospectively from the age of 11 to 14 months using diary cards. The diary data consisted of 1) selected symptoms, 2) doctor-contacts and 3) parent-rated illness se- verity, information used to form three aspects of a frequently ill child. The analyses explore as- sociations from the infant data with the three indicators of frequent illness.

Results: Experi- ences of restless sleep, earache, otitis media, penicillin usage and use of medicine associated with illness in infancy were highly associated with factors of excess illness during the follow up period. Disturbed sleep in infancy was the factor with the highest probability of frequent illness as a toddler—an unexpected finding. Experiences of acute otitis media (earache, fre- quent visits to the doctor and antibiotic treat- ment) were strongly related to frequent illnesses. Asthma or giving the child medicine correlated with a higher parent-rated frequency of illness later on.

Conclusions: Sleep problems in infancy can predict frequent illness episodes later on. In clinical practice the GP may benefit from talking about sleep in the consultations in order to learn something more. The three different indicators of frequent illness applied to different aspects of being a frequently ill child.

Læs artiklen

The majority of sick children receive paracetamol during the winter

Ruth Kirk Ertmann, Janne Julie Møller, Frans Boch Waldorff, Volkert Siersma, Susanne Reventlow & Margareta Söderström
Danish Medical Journal, Dan Med J 59/12:A4555, december 2012

ABSTRACT

INTRODUCTION: Even though fever is a common symptom in childhood, it often worries parents and they may try to reduce discomfort by giving the child paracetamol, which is currently the most commonly sold over-the-counter medicine. The objective of this study was to investigate parentadministered paracetamol in toddlers during a winter period in relation to symptoms, doctor contacts and severity-rated illness.

MATERIAL AND METHODS: The study was conducted as aprospective diary study covering a three-month winter period. It comprised a cohort of 183 infants born in February 2001 in a district of the capital area in Denmark.

RESULTS: According to the parents, a total of 119 toddlers (65%) received paracetamol at least once during the study period; 9.3% of the toddlers received paracetamol for more than ten days. The administration of paracetamol rose as the number of symptoms increased. Paracetamol was given in 37% of days with fever. The most frequent combinations of symptoms to trigger paracetamol administration were fever and earache with a probability of 64%. For the symptoms of vomiting and earache, the probability was 60%. In the rare cases with monosymptomatic fever, some 23% used paracetamol.

CONCLUSION: The majority of ill toddlers received paracetamol if they had several symptoms. However, paracetamol was administrated in 37% of days with fever. This use of paracetamol seems reasonable as the parents differentiate between degrees of illness and withhold paracetamol until the second day of the illness episode

FUNDING: not relevant.

TRIAL REGISTRATION: The Danish Research Foundation for General Practice. The Ethical Committee of Frederiksborg County. Journal number 2001-1-62G.

Læs artiklen

Long-Term Psychosocial Consequences of False-Positive Screening Mammography

John Brodersen, PhD, Volkert Dirk Siersma, PhD
Ann Fam Med 2013;11:106-115. doi:10.1370/afm.1466.

ABSTRACT

PURPOSE Cancer screening programs have the potential of intended beneficial effects, but they also inevitably have unintended harmful effects. In the case of screening mammography, the most frequent harm is a false-positive result. Prior efforts to measure their psychosocial consequences have been limited by shortterm follow-up, the use of generic survey instruments, and the lack of a relevant benchmark—women with breast cancer.

METHODS In this cohort study with a 3-year follow-up, we recruited 454 women with abnormal findings in screening mammography over a 1-year period. For each woman with an abnormal finding on a screening mammogram (false and true positives), we recruited another 2 women with normal screening results who were screened the same day at the same clinic. These participants were asked to complete the Consequences of Screening in Breast Cancer—a validated questionnaire encompassing 12 psychosocial outcomes—at baseline, 1, 6, 18, and 36 months.

RESULTS Six months after final diagnosis, women with false-positive findings reported changes in existential values and inner calmness as great as those reported by women with a diagnosis of breast cancer (Δ = 1.15; P = .015; and Δ = 0.13; P = .423, respectively). Three years after being declared free of cancer, women with false-positive results consistently reported greater negative psychosocial consequences compared with women who had normal findings in all 12 psychosocial outcomes (Δ >0 for 12 of 12 outcomes; P <.01 for 4 of 12 outcomes).

CONCLUSION False-positive findings on screening mammography causes longterm psychosocial harm: 3 years after a false-positive finding, women experience psychosocial consequences that range between those experienced by women with a normal mammogram and those with a diagnosis of breast cancer.

Læs artiklen

Structured personal care of type 2 diabetes: a 19 year follow-up of the study Diabetes Care in General Practice (DCGP)

L. J. Hansen, V. Siersma, H. Beck-Nielsen, N. de Fine Olivarius
Diabetologia april 2013

Abstract

Aims/hypothesis: This study is a 19 year observational follow-up of a pragmatic open multicentre cluster-randomised controlled trial of 6 years of structured personal diabetes care starting from diagnosis.

Methods: A total of 1,381 patients aged ≥40 years and newly diagnosed with type 2 diabetes were followed up in national registries for 19 years. Clinical follow-up was at 6 and 14 years after diabetes diagnosis. The original 6 year intervention included regular follow-up and individualised goal setting, supported by prompting of doctors, clinical guidelines, feedback and continuing medical education (ClinicalTrials.gov NCT01074762). The registry-based endpoints were: incidence of any diabetes-related endpoint; diabetes-related death; all-cause mortality; myocardial infarction (MI); stroke; peripheral vascular disease; and microvascular disease.

Results: At 14 year clinical follow-up, group differences in risk factors from the 6 year follow-up had levelled out, although the prevalence of (micro)albuminuria and level of triacylglycerols were lower in the intervention group. During 19 years of registry-based monitoring, all-cause mortality was not different between the intervention and comparison groups (58.9 vs 62.3 events per 1,000 patient-years, respectively; for structured personal care, HR 0.94, 95% CI 0.83, 1.08, p = 0.40), but a lower risk emerged for fatal and non-fatal MI (27.3 vs 33.5, HR 0.81, 95% CI 0.68, 0.98, p = 0.030) and any diabetes-related endpoint (69.5 vs 82.1, HR 0.83, 95% CI 0.72, 0.97, p = 0.016). These differences persisted after extensive multivariable adjustment.

Conclusions/interpretation: In concert with features such as prompting, feedback, clinical guidelines and continuing medical education, individualisation of goal setting and drug treatment may safely be applied to treat patients newly diagnosed with type 2 diabetes to lower the risk of diabetes complications.

Læs artiklen

Panel 7: Treatment and comparative effectiveness research

Marchisio P, Chonmaitree T, Leibovitz E, Lieberthal A, Lous J, Mandel E, McCormick D, Morris P, Ruohola A

Denne artikel er resultatet af en international arbejdsgruppes anstrengelser med at gennemse og læse alle artikler om behandling af otitis media fra perioden januar 2007 til juni 2011. Efter intensiv e-mail korrespondance mødtes gruppen i forbindelse med konferencen Recent Advances in Otitis media, New Orleans juni 2011. Vi fandt 114 relevant kvalitetsartikler som er refereret og kommenteret i artiklen. Der er i udvælgelse lagt vægt på den videnskabelige evidens. Andre syv grupper fokuserede i tilsvarende artikler på otitis medias Epidemiologi, patofysiologi, mikrobiologi og immunologi, genetik, molekylær biologi, effekt af vaccination, og endelig komplikation. Alle otte panel-artikler er publiceret som supplementum 4 (i alt 143 sider).  

Abstract

Background and Objectives: Otitis media (OM) is one of the most common reasons for antibiotic treatment in children. Controversies regarding antibiotic treatment for OM have accumulated in the past decade, and there seem to be more dilemmas than certainties. The objectives of this article are to provide the state-of-the art review on achievements in treatment of all different stages of OM, including acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media, and to outline the future research areas.
Data Sources. PubMed, Ovid Medline, the Cochrane Database, and Clinical Evidence (BMJ Publishing).

Review Methods: All types of articles related to OM treatment published in English between January 2007 and June 2011 were identified. A total of 286 articles related to OM treatment were reviewed by the panel members; 114 relevant quality articles were identified and summarized.

Results: New evidence emerged on beneficial results of antibiotic treatment, compared with observation of AOM in young children who were diagnosed based on stringent criteria. In OME, the main results were related to a nonsignificant benefit of adenoidectomy versus tympanostomy tube placement alone in the treatment of chronic OME in younger children. Other modalities of OM treatment were studied and described herein.

Conclusions and Implications for Practice: Significant progress has been made in advancing the knowledge on the treatment of OM. Areas of potential future research have been identified and outlined.

Keywords:
otitis media, treatment, antibiotics

Læs artiklen

DSAM, Stockholmsgade 55, 2100 København Ø

Telefon: 7070 7431 E-mail: dsam@dsam.dk