Reconstruction of the anterior cruciate- and anterolateral ligament deficient knee with a modified iliotibial graft reduces instability more than with an intra-articular hamstring graft.

PURPOSE: To compare knee kinematics before and after anterior cruciate ligament ACL reconstruction (ACL-R) using hamstring graft (HG) and a double-stranded iliotibial tract graft attached to Gerdy's tubercle (providing an extra-articular anterolateral tenodesis) (named the modified iliotibial tract graft = MIT). METHOD: Eighteen cadaveric knees were tested in a 6 degree of freedom kinematics rig. An optical tracking system recorded kinematics of the knee from 0 to 80 degrees of flexion applying no load, internal/external rotation (IR/ER), valgus/varus rotation (VGR/VRR), simulated pivot shift (SPS), anterior translation (AT) and posterior translation loads. The knee was tested before and after resection of the ACL and the anterolateral ligament (ALL), respectively; then after HG-ACL-R and MIT-ACL-R. Grafts were fixed at 20° of flexion. Results were compared to the intact knee. RESULTS: ACL resection resulted in a significant increase in AT (p < 0.05) over the entire range of motion, peaking at 20° of flexion, mean difference 6.6 ± 2.25 mm (p = 0.0007). ACL-R with HG-ACL and MIT-ACL restored AT. Resection of the ALL increased IR in the fully extended knee, mean difference 2.4 ± 2.1° (p = 0.024). When compared to the intact knee and the knee after HG-ACL-R, MIT-ACL-R knee reduced IR/SPS significantly (p < 0.05) in deep flexion angles (60°-80°), peaking at 80° of flexion. The MIT-ACL-R caused significantly less VRR at 80° flexion (p = 0.02). CONCLUSION: MIT-ACL-R restored AT equally to the HG-ACL-R. The MIT-ACL-R reduced IR and SPS in deep flexion, resulting in overconstraint. MIT-ACL-R can be used as an alternative to standard reconstruction methods.

Dementia and road traffic accidents among non-institutionalized older people in Denmark: A Danish register-based nested case-control study.

AIM: We used register-based data to estimate the effect of all-type dementia on road traffic accidents (RTAs) risk, combined with comorbidities or sedative medicines, among non-institutionalized older people in Denmark. METHODS: The source population was all residents in Denmark aged 65 years and older, alive as of January 1, 2008 ( n = 853,228). Cases were those who had any type of RTA in 2009-2014. Each case was matched for age, sex and geographic location to 4-6 controls. All-type dementia was ascertained using the International Classification of Diseases version 10 (ICD-10) diagnosis supplemented with prescribed medicine records. Eight chronic diseases were selected to assess comorbidities. Four types of medicines were categorized as sedative medicines for analysis. Conditional logistic regression with adjustment for education and marital status as well as either the number of comorbidities or sedative medications use was performed using STATA software. RESULTS: Older people with dementia had lower RTAs risk compared to their controls (odds ratio = 0.43, 95% confidence interval (0.32-0.60), p < 0.001). Significant interaction was observed between dementia and the number of comorbidities for RTAs estimation. CONCLUSIONS: The significantly lower RTAs risk for older individuals with dementia observed in our study may be due to people with dementia living at home having a lower frequency of outdoor activities; that is, less exposure to traffic. However, this, together with the interaction between dementia and comorbidities as well as sedative medications, should be investigated further.

Measuring bothersome menopausal symptoms: development and validation of the MenoScores questionnaire.

BACKGROUND: The experience of menopausal symptoms is common and an adequate patient-reported outcome measure is crucial in studies where women are treated for these symptoms. The aims of this study were to identify a patient-reported outcome measure for bothersome menopausal symptoms and, in the absence of an adequate tool, to develop a new measure with high content validity, and to validate it using modern psychometric methods. METHODS: The literature was reviewed for existing questionnaires and checklists for bothersome menopausal symptoms. Relevant items were extracted and subsequently tested in group interviews, single interviews, and pilot tests. A patient-reported outcome measure was drafted and completed by 1504 women. Data was collected and psychometrically validated using item-response theory Rasch Models. RESULTS: All questionnaires identified in the literature lacked content validity regarding bothersome menopausal symptoms and none were validated using item-response theory. Our content validation resulted in a draft measurement encompassing 122 items across eight domains. Following psychometrical validation, the final version of our patient-reported outcome measure, named the MenoScores Questionnaire, encompassed 51 items, including one single item, covering 11 scales. CONCLUSION: Menopausal symptoms are multidimensional with some symptoms unquestionably related to the menopausal transition. We identified four constructs of importance: hot flushes, day-and-night sweats, general sweating, and menopausal-specific sleeping problems. The MenoScores Questionnaire is condition-specific with high content validity and adequate psychometrical properties. It is designed to measure bothersome menopausal symptoms and all scales are developed and psychometrically validated using item-response theory Rasch Models. TRIAL REGISTRATION: Approved by the Danish Data Agency (J.nr. 2015-41-4057). Ethics Committee approval was not required.

How well do general practitioners know their elderly patients' social relations and feelings of loneliness?

BACKGROUND: Social relationships are important to people and affect their quality of life, morbidity and mortality. The aim of this study was to examine the correlation between elderly patients' descriptions of their social relations and feelings of loneliness, and their general practitioners' assessments of these. METHODS: Cross-sectional study in 12 general practices in the Capital Region of Denmark. During a three-week period each practice asked their patients aged 65 and older to fill out a questionnaire regarding health, social relations and loneliness; the general practitioner (GP) filled out a matching questionnaire regarding their perception of the patient's social relations and loneliness. Data were collected from February to September 2014. RESULTS: Of the 767 eligible patients 476 were included in the study. For 447 patients both GP and patient had answered at least one question on loneliness or social participation. The correlations between patients' and GPs' answers regarding social participation and loneliness were low (0.04-0.26). While GPs were less able to identify lonely patients and patients with low social participation, they were better at identifying not-lonely patients or those with high social participation. It was especially difficult for GPs to identify lonely patients when they were not living alone or if the GP believed the patient had high social participation. CONCLUSION: GPs have difficulty identifying patients who are lonely or have low social participation and this ability is further diminished when the patients do not live alone or if the GP believes them to have high social participation. Given the consequences of loneliness and limited social participation on patients' health and well-being, and GPs' limited ability to identify these patients, GPs' obligations and resources in this area need to be clarified.

KNEES-ACL has superior responsiveness compared to the most commonly used patient-reported outcome measures for anterior cruciate ligament injury.

PURPOSE: For clinical trials, it is essential that measures are sensitive to change. The aim of this study was to conduct a head-to-head comparison of responsiveness of four PROMs used to measure outcome after anterior cruciate ligament (ACL) reconstruction. The PROMs compared were the knee injury osteoarthritis outcome score (KOOS), the international knee documentation committee subjective form (IKDC), the Lysholm score, and the knee numeric-entity evaluation score (KNEES-ACL). We hypothesized that KNEES-ACL would be more responsive than the other PROMs, as KNEES-ACL was created based on patient interviews and validated using Rasch analysis. METHODS: One-hundred and sixty-six consecutive adults completed the four PROMs before and 3, 6, and 12 months after ACL-reconstructive surgery. Responsiveness was calculated as Cohen's Effect Size and Standardized Response Means. Bootstrapping was used to generate 95% confidence intervals for comparisons of responsiveness across PROMs. Repeated-measures ANOVA was also computed for each PROM. RESULTS: The largest effect sizes at 12 months were seen for KNEES-ACLSports-Behaviour (1.35, p < 0.001) and KNEES-ACLSports-Physical (1.19, p < 0.001), the smallest for KOOSADL (0.35, p < 0.001) and KOOSSymptoms (0.39, p < 0.001). IKDC and Lysholm lay between these with IKDC slightly more responsive. Head-to-head comparisons of similar subscales of KOOS and KNEES-ACL showed substantial differences in effect size in the domains of symptoms (0.69, p < 0.001), daily activities (0.31, p = 0.005), and Sports activity (0.63, p = 0.013) all in favour of KNEES-ACL. CONCLUSION: These results demonstrate superior responsiveness for KNEES-ACL, which is the only PROM that has been constructed through exhaustive patient feedback and validated for patients with ACL deficiency using the most stringent psychometric methods (Rasch analysis). KNEES-ACL is the most precise and accurate PROM for patients with ACL injury and the most trustworthy instrument for clinicians and clinical researchers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Sample Size in Qualitative Interview Studies: Guided by Information Power.

Sample sizes must be ascertained in qualitative studies like in quantitative studies but not by the same means. The prevailing concept for sample size in qualitative studies is "saturation." Saturation is closely tied to a specific methodology, and the term is inconsistently applied. We propose the concept "information power" to guide adequate sample size for qualitative studies. Information power indicates that the more information the sample holds, relevant for the actual study, the lower amount of participants is needed. We suggest that the size of a sample with sufficient information power depends on (a) the aim of the study, (b) sample specificity, (c) use of established theory, (d) quality of dialogue, and (e) analysis strategy. We present a model where these elements of information and their relevant dimensions are related to information power. Application of this model in the planning and during data collection of a qualitative study is discussed.

Diagnostic invasiveness and psychosocial consequences of false-positive mammography.

PURPOSE: We undertook a study to assess whether women with false-positive mammography have worse psychosocial consequences if managed with a workup that involves a biopsy (invasive group) than if managed with only additional imaging (noninvasive group). METHODS: We performed subgroup analysis of a cohort study of 454 women with abnormal screening mammography and 908 matched control women with normal results. Using a condition-specific questionnaire (Consequences of Screening in Breast Cancer), we assessed 12 psychosocial consequences at 5 time points (0, 1, 6, 18, and 36 months after final diagnosis) and compared the 2 groups of women with false-positives (invasive and noninvasive management groups). RESULTS: Among the 252 women with false-positive mammography eligible for this study, psychosocial consequences were similar for those managed invasively and those managed noninvasively during the 36 months of follow-up. In 60 comparisons (12 scales and 5 time points), differences between the groups were never statistically significant (P <.01) and the point estimates for the differences were always close to zero. The psychosocial consequences of women with false-positive results, regardless of management, fell between those of women with normal mammography and those of women determined to have breast cancer. CONCLUSIONS: We found no evidence that use of more invasive diagnostics was associated with worse psychosocial consequences. It is therefore reasonable to pool subgroups of women with false-positives in a single analysis. The invasiveness of subsequent diagnostic procedures does not help to identify women at higher risk for adverse psychosocial consequences of false-positive mammography.

Comparing the effect of non-medical mechanical restraint preventive factors between psychiatric units in Denmark and Norway.

BACKGROUND: The use of mechanical restraint (MR) is controversial, and large differences regarding the use of MR are often found among countries. In an earlier study, we observed that MR was used twice as frequently in Denmark than Norway. AIMS: To examine how presumed MR preventive factors of non-medical origin may explain the differing number of MR episodes between Denmark and Norway. METHODS: This study is a cross-sectional survey of psychiatric units. Linear regression was used to assess the confounding effects of the MR preventive factors, i.e. whether a difference in the impact of these factors is evident between Denmark and Norway. RESULTS: Six MR preventive factors confounded [∆exp(B)> 10%] the difference in MR use between Denmark and Norway, including staff education (- 51%), substitute staff (- 17%), acceptable work environment (- 15%), separation of acutely disturbed patients (13%), patient-staff ratio (- 11%), and the identification of the patient's crisis triggers (- 10%). CONCLUSIONS: These six MR preventive factors might partially explain the difference in the frequency of MR episodes observed in the two countries, i.e. higher numbers in Denmark than Norway. One MR preventive factor was not supported by earlier research, the identification of the patient's crisis triggers; therefore, more research on the mechanisms involved is needed. CLINICAL IMPLICATIONS: None of the six MR preventive factors presents any adverse effects; therefore, units in Denmark and Norway may consider investigating the effect of implementing, the identification of the patient's crisis triggers, an increased number of staff per patient, increased staff education, a better work environment and reduced use of substitute staff in practice.

Eosinophilia in routine blood samples as a biomarker for solid tumor development - A study based on the Copenhagen Primary Care Differential Count (CopDiff) Database.

BACKGROUND: Eosinophilia may represent an early paraclinical sign of malignant disease and a host anti-tumor effect. The association between eosinophilia and the development of solid tumors has never before been examined in an epidemiological setting. The aim of the present study was to investigate eosinophilia in routine blood samples as a potential biomarker of solid tumor development in a prospective design. MATERIAL AND METHODS: From the Copenhagen Primary Care Differential Count (CopDiff) Database, we identified 356 196 individuals with at least one differential cell count (DIFF) encompassing the eosinophil count during 2000-2007. From these, one DIFF was randomly chosen and categorized according to no (< 0.5 × 10(9)/l), mild (≥ 0.5-1.0 × 10(9)/l) or severe (≥ 1.0 × 10(9)/l) eosinophilia. From the Danish Civil Registration System and the Danish Cancer Registry we ascertained all-cause death and solid tumors within the first three years following the DIFF. Using multivariable logistic regression, odds ratios (OR) were calculated and adjusted for previous eosinophilia, sex, age, year, month, C-reactive protein, previous cancer and Charlson's Comorbidity Index. RESULTS: The risk of bladder cancer was increased with mild eosinophilia [OR 1.93 (CI 1.29-2.89), p = 0.0013]. No associations with eosinophilia were observed for the remaining solid cancers. CONCLUSION: We demonstrate that eosinophilia in routine blood samples associates with an increased risk of bladder cancer. Our data emphasize that additional preclinical studies are needed in order to shed further light on the role of eosinophils in carcinogenesis, where it is still unknown whether the cells contribute to tumor immune surveillance or neoplastic evolution.

Educational intervention and functional decline among older people: the modifying effects of social capital.

AIM: To analyse if social capital modifies the effect of educational intervention of home visitors on mobility disability. Earlier studies have found that educational intervention of home visitors has a positive effect of older peoples' functional decline, but how social capital might modify this effect is still unknown. METHODS: We used the Danish Intervention Study on Preventive Home Visits - a prospective cohort study including 2863 75-year-olds and 1171 80-year-olds in 34 Danish municipalities - to analyse the modifying effect of different aspects of social capital on the effect of educational intervention of home visitors on functional decline. The three measures of social capital (bonding, bridging, and linking) were measured at contextual level. Data was analysed with multivariate linear regression model using generalised estimating equations to account for repeated measurements. RESULTS: We found that 80-year-olds living in municipalities with high bonding (B=0.089, p=0.0279) and high linking (B=0.0929; p=0.0217) had significant better mobility disability in average at 3-year follow up if their municipality had received intervention. CONCLUSIONS: With the unique design of the Danish Intervention Study on Preventive Home Visits and with theory-based measures of social capital that distinguish between three aspects of social capital with focus on older people, this study contributes to the literature about the role of social capital for interventions on mobility disability.

The effectiveness of a semi-tailored facilitator-based intervention to optimise chronic care management in general practice: a stepped-wedge randomised controlled trial.

BACKGROUND: The Danish health care sector is reorganising based on disease management programmes designed to secure integrated and high quality chronic care across hospitals, general practitioners and municipalities. The disease management programmes assign a central role to general practice; and in the Capital Region of Denmark a facilitator-based intervention was undertaken to support the implementation of the programmes in general practice. The purpose of the study was to assess the effectiveness of this semi-tailored facilitator-based intervention. METHOD: The study was a stepped-wedge, randomised, controlled trial among general practices in the Capital Region of Denmark. The intervention group was offered three one-hour visits by a facilitator. The intervention was semi-tailored to the perceived needs as defined by each general practice, and the practices could choose from a list of possible topics. The control group was a delayed intervention group. The primary outcome was change in the number of annual chronic disease check-ups. Secondary outcomes were: changes in the number of annual check-ups for type 2 diabetes (DM2) and chronic obstructive pulmonary disease (COPD); changes in the number of spirometry tests, changes in the use of ICPC diagnosis coding and patient stratification; sign-up for a software program for patient overview; and reduction in number of practices with few annual chronic disease check-ups. RESULTS: We randomised 189 general practices: 96 practices were allocated to the intervention group and 93 to the delayed intervention group. For the primary outcome, 94 and 89 practices were analysed. Almost every outcome improved from baseline to follow-up in both allocation groups. At follow-up there was no difference between allocation groups for the primary outcome (p = 0.1639). However, some secondary outcomes favoured the intervention: a higher reported use of ICPC diagnosis coding for DM2 and COPD (p = 0.0050, p = 0.0243 respectively), stratification for COPD (p = 0.0185) and a faster initial sign-up rate for the software program. CONCLUSION: The mixed results from this study indicate that a semi-tailored facilitator-based intervention of relatively low intensity is unlikely to add substantially to the implementation of disease management programmes for DM2 and COPD in a context marked by important concurrent initiatives (including financial incentives and mandatory registry participation) aimed at moving all practices towards changes in chronic care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01297075.

Eosinophilia in routine blood samples and the subsequent risk of hematological malignancies and death.

Eosinophilia may represent an early paraclinical sign of hematological malignant disease, but no reports exist on its predictive value for hematological malignancies. From the Copenhagen Primary Care Differential Count (CopDiff) Database, we identified 356,196 individuals with at least one differential cell count (DIFF) encompassing the eosinophil count during 2000-2007. From these, one DIFF was randomly chosen and categorized according to no (<0.5 × 10(9) /L), mild (≥ 0.5-1.0 × 10(9) /L) or severe (≥ 1.0 × 10(9) /L) eosinophilia. From the Danish Cancer Registry and the Danish Civil Registration System, we ascertained hematological malignancies and death within 3 years following the DIFF. Using multivariable logistic regression odds ratios (ORs) were calculated and adjusted for previous eosinophilia in a DIFF, sex, age, year, month, C-reactive protein, previous cancer, and comorbidity. ORs for developing Hodgkin's lymphoma (HL) was significantly increased in individuals exhibiting severe eosinophilia, OR = 9.09 (C.I. 2.77-29.84), P = 0.0003. The association with classical myeloproliferative neoplasms (cMPNs) showed an increasing risk with OR = 1.65 (1.04-2.61) P = 0.0322 and OR = 3.87 (1.67-8.96) P = 0.0016 for mild and severe eosinophilia. Eosinophilia was in a similar fashion associated with chronic lymphatic leukemia (CLL), OR = 2.57 (1.50-4.43), P = 0.0006 and OR = 5.00 (1.57-15.94), P = 0.0065, and all-cause death, OR of 1.16 (1.09-1.24), P < 0.0001 and 1.60 (1.35-1.91), P < 0.0001. We confirm associations between eosinophilia and HL and cMPNs, and in addition for the first time demonstrate a dose-dependent association between eosinophilia and CLL as well as death. Unexplained eosinophilia should prompt clinicians to consider conditions where early diagnosis may improve prognosis.

Long-term psychosocial consequences of false-positive screening mammography.

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 short-term 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 long-term 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.

Eosinophilia in routine blood samples as a biomarker for solid tumor development - A study based on The Copenhagen Primary Care Differential Count (CopDiff) Database.

Background. Eosinophilia may represent an early paraclinical sign of malignant disease and a host anti-tumor effect. The association between eosinophilia and the development of solid tumors has never before been examined in an epidemiological setting. The aim of the present study was to investigate eosinophilia in routine blood samples as a potential biomarker of solid tumor development in a prospective design. Material and methods. From the Copenhagen Primary Care Differential Count (CopDiff) Database, we identified 356 196 individuals with at least one differential cell count (DIFF) encompassing the eosinophil count during 2000-2007. From these, one DIFF was randomly chosen and categorized according to no (< 0.5 × 10(9)/l), mild (≥ 0.5-1.0 × 10(9)/l) or severe (≥ 1.0 × 10(9)/l) eosinophilia. From the Danish Cancer Registry we ascertained solid tumors within the first three years following the DIFF. Using multivariable logistic regression, odds ratios (OR) were calculated and adjusted for previous eosinophilia, sex, age, year, month, C-reactive protein, previous cancer and Charlson's comorbidity index. Results. The risk for breast cancer was significantly lower in individuals exhibiting mild eosinophilia than in individuals with normal eosinophil counts [OR (95% confidence intervals) = 0.51 (0.35-0.76), p = 0.0005]. The risk of bladder cancer, however, increased with severity of eosinophilia [2.27 (1.53-3.39), p < 0.0001 and 2.62 (0.96-7.14), p = 0.0592 for mild and severe eosinophilia, respectively]. No associations with eosinophilia were observed for remaining solid cancers. Conclusion. We demonstrate that eosinophilia in routine blood samples associate with a decreased risk of breast cancer and an increased risk of bladder cancer. Our data emphasize that additional preclinical studies are needed in order to shed further light on the role of eosinophils in carcinogenesis, where it is still unknown whether the cells contribute to tumor immune surveillance or neoplastic evolution.

Risk factors for 48-hours mortality after prehospital treatment of opioid overdose.

INTRODUCTION: Opioid overdose is commonly treated by prehospital emergency services and the majority of the patients are discharged immediately after treatment and a short observation period. There is a minor risk for rebound opioid toxicity and other life-threatening conditions might occur after such episodes. The authors describe the short-term outcome and identify risk factors for death within 48 h after prehospital treatment of opioid overdose in Copenhagen, the capital of Denmark. METHODS: Data on all cases of opioid overdose treated by the medical emergency care unit between 1994 and 2003 were recorded prospectively. Risk factors for death within 48 h after initial medical emergency care unit contact were analysed in a multivariable logistic regression analysis. RESULTS: The authors recorded 4762 episodes of opioid overdose, covering 1967 unique identified patients. A total of 78 patients (8.4%, 95% CI 7.0 to 10.4) died within 48 h in the period 1999-2003, and 85% (66/78) of these had cardiac arrest and died. The authors found age >50 years and overdose during the weekend significantly associated with 48-h mortality. Gender, former episodes of opioid overdose, time of the day, month or year were not significantly associated with increased mortality. CONCLUSIONS: The author found a 48-hours mortality of 8.4%. Advanced age and opioid overdose in the weekends were significant risk factors. Release on scene after treatment was associated with a very small risk.

Social relations and leisure activities as predictors of wellbeing among older adults with multiple sclerosis: A cross-sectional survey study in Denmark.

BACKGROUND: Due to the growing number of people aging with multiple sclerosis (MS), there has been a call for rehabilitation specially targeted older adults with MS in order to support them in better wellbeing, despite physical and cognitive impairment. However, the existing research within the area of rehabilitation has primarily focused on the physical and psychological aspects of aging with MS, omitting the social element. OBJECTIVE: This study aims to examine how social relations and engagement in leisure activities predict wellbeing among older adults with MS living in Denmark. Furthermore, the study aims to identify which sociodemographic and health-related factors are the most important in predicting whether older adults with MS face challenges in participating in leisure activities and experiencing different kinds of social relations. METHOD: A cross-sectional survey was designed to measure social relations, wellbeing, and engagement in leisure activities among older adults with MS. Of the 4,329 people over 65 years diagnosed with MS in Denmark in 2022, 2,574 (59.46%) were invited to participated in the study, and 1,107 (43.03%) ended up answering the survey. Linear and logistic regression analyses and dominance analyses were conducted to examine the associations between wellbeing, leisure activities, social relations, sociodemographic and health-related factors. RESULTS: The results of the study show that perceived emotional social support (mean difference 8.69, 95% CI 5.23; 12.14) and perceived instrumental social support (mean difference 4.15, 95% CI 0.95; 7.35), were associated with better wellbeing among older adults with MS. Perceived strained social relations (mean difference -7.95, 95% CI -10.66; -5.26) were on the contrary associated with lower levels of wellbeing. Strained social relations were the most important predictors of wellbeing accounting for 59% of the predicted variance. Experiencing social emotional support from friends, coworkers, or neighbors (39% of the predicted variance), experiencing instrumental social support from children or children in law (43% of the predicted variance), and experiencing strained social relations with partner (48% of the predicted variance) constituted he most important predictor of wellbeing. Engagement in five out of fourteen leisure activities were associated with better wellbeing among the participants. The leisure activities there was found to be the most important predictor of wellbeing represented both social (37% of the predicted variance), physical (18% of the predicted variance), and creative elements (13% of the predicted variance). Finally, cohabitation was found to be the most important predictor of having perceived emotional social support (59% of the predicted variance), instrumental social support (78.9% of the predicted variance) and strained social relations (18.8% of the predicted variance) and mobility was found to be the most important predictor of challenges in participating in leisure activities (81.8% of the predicted variance). CONCLUSION: The findings of the study highlight that rehabilitation targeting older adults with MS should focus on both physical, psychological, and social elements of peoples' everyday life. Further, the results indicate that future rehabilitation focusing on social elements of aging with MS should take into account health and sociodemographic characteristics such as cohabitation, mobility, age, and sex, as these potentially relate to participation in leisure activities as well as social relations among older adults.

Development of quality indicators for the diagnosis and treatment of urinary tract infections in general practice: a RAND appropriateness method.

OBJECTIVE: To develop a set of quality indicators for the diagnosis and antibiotic treatment of adult patients with suspected urinary tract infections in general practice. DESIGN: A Research and Development/University of California Los Angeles appropriateness method was used. SETTING: Danish general practice. SUBJECTS: A panel of nine experts, mainly general practitioners, was asked to rate the relevance of 27 preliminary quality indicators. The set of indicators was based on the most recent Danish guidelines for the management of patients with suspected urinary tract infection. An online meeting was held to resolve misinterpretations and achieve consensus. MAIN OUTCOME MEASURES: The experts were asked to rate the indicators on a nine-point Likert scale. Consensus of appropriateness was reached if the overall panel median rating was 7-9 with agreement. Agreement was defined as: no more than one expert rated the indicator outside the three-point region (1-3, 4-6 and 7-9) containing the median. RESULTS: A total of 23 of the 27 proposed quality indicators attained consensus. One additional indicator was proposed by the panel of experts, leading to a final set of 24 quality indicators. All indicators focusing on the diagnostic process achieved consensus of appropriateness, while the experts agreed on three quarters of the proposed quality indicators concerning either the treatment decision or the choice of antibiotics. CONCLUSION: This set of quality indicators may be used to strengthen general practice's focus on the management of patients with a possible urinary tract infection and to identify potential quality problems.

Short and long-term psychosocial consequences of participating in a colorectal cancer screening programme: a matched longitudinal study.

OBJECTIVES: To investigate the psychosocial consequences of receiving a false-positive (no abnormalities) result or being diagnosed with polyps compared with receiving a negative result in a colorectal cancer (CRC) screening programme. DESIGN AND SETTING: This was a longitudinal study nested in the roll-out of the Danish CRC screening programme that targets all individuals aged 50-74 years. PARTICIPANTS: In the inclusion period (April-September 2017), all positive screenees (n=1854) were consecutively enrolled and matched 2:1:1 on sex, age (±2 years), municipality and screening date with negative screenees (n=933) and individuals not yet invited to screening (n=933).Questionnaires were sent by mail to all eligible participants in Region Zealand, Denmark, after the screening result, 2 months and 12 months after the final result.Positive screenees who did not receive the follow-up procedure were excluded. MAIN OUTCOME MEASURES: The primary outcomes were psychosocial consequences. Outcomes were measured with the CRC screening-specific questionnaire Consequences of screening in CRC with 11 outcomes after the screening result and with 21 outcomes at the two later assessments. RESULTS: After receiving the screening result, individuals with no abnormalities, low-risk and medium-risk and high-risk polyps scored significantly worse on 8 of 11 outcomes compared with the negative screenee group. At the 12-month follow-up, the differences were still significant in 8 of 21 outcomes (no abnormalities), 4 of 21 outcomes (low-risk polyps) and 10 of 21 outcomes (medium-risk and high-risk polyps). The negative screenee group and the group not yet invited to screening differed psychosocially on 5 of 11 outcomes after the screening result, but on none of the 21 outcomes at the 2 months and 12 months follow-up. CONCLUSIONS: The study showed that there are both short-term and long-term psychosocial consequences associated with receiving a no abnormalities result or being diagnosed with polyps. The consequences were worst for individuals diagnosed with medium-risk and high-risk polyps.

Effects of Heavy Slow Resistance Training Combined With Corticosteroid Injections or Tendon Needling in Patients With Lateral Elbow Tendinopathy: A 3-Arm Randomized Double-Blinded Placebo-Controlled Study.

BACKGROUND: Lateral elbow tendinopathy is a disabling tendon overuse injury. It remains unknown if a corticosteroid injection (CSI) or tendon needling (TN) combined with heavy slow resistance (HSR) training is superior to HSR alone in treating lateral elbow tendinopathy. PURPOSE/HYPOTHESIS: The purpose was to investigate the effects of HSR combined with either (1) a CSI, (2) TN, or (3) placebo needling (PN) as treatment for lateral elbow tendinopathy. We hypothesized that 12 weeks of HSR in combination with a CSI or TN would have superior effects compared with PN at 12, 26, and 52 (primary endpoint) weeks' follow-up on primary (Disabilities of the Arm, Shoulder and Hand [DASH] score) and secondary outcomes in patients with chronic unilateral lateral elbow tendinopathy. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 60 patients with chronic unilateral lateral elbow tendinopathy were randomized to perform 12 weeks of home-based HSR with elastic band exercises combined with either (1) a CSI, (2) TN, or (3) PN, and at 12, 26, and 52 weeks, we assessed the primary outcome, the DASH score, and secondary outcomes: shortened version of the DASH (QuickDASH) score, pain (numerical rating scale [NRS] score), pain-free grip strength, and hypervascularization (power Doppler area). RESULTS: A CSI, TN, and PN improved patient outcomes equally based on the DASH (Δ20 points), QuickDASH (Δ21 points), and NRS (Δ2.5 points) scores after 12 weeks. Further, after 12 weeks, a CSI also resulted in decreased hypervascularization (power Doppler area) compared with PN (Δ-2251 pixels, P = .0418). Except for the QuickDASH score (CSI increased score by Δ15 points compared with PN; P = .0427), there were no differences between the groups after 52 weeks. CONCLUSION: These results suggest that 12 weeks of HSR improved symptoms in both the short and the long term and that a CSI or TN did not amplify this effect. In addition, a CSI seemed to impair patient-reported outcomes compared with HSR alone at long-term follow-up. REGISTRATION: NCT02521298 (ClinicalTrials.gov identifier).

Conjunctival intraepithelial neoplasia and carcinoma: distinct clinical and histological features in relation to human papilloma virus status.

AIMS: Human papillomavirus (HPV) is considered a causative agent for the development of a broad range of human carcinomas. The role of HPV in the development of conjunctival intraepithelial neoplasia (CIN) and carcinoma (cSCC) remains unclear. The purpose of the present study was to investigate the HPV prevalence in a nationwide cohort and to describe clinical and histopathological features in relation to HPV status. METHODS: All cases of CIN and cSCC in Denmark from 1980 to 2016 were included. We combined p16 immunohistochemistry (IHC), RNA in situ hybridisation (RNA ISH) and HPV DNA PCR to detect HPV. The results were correlated to clinical and histopathological parameters. RESULTS: One hundred twelve primary tumours and 33 recurrent tumours were included for HPV analysis. Twenty-four (21%) of the primary tumours were HPV positive by PCR. Eighteen of out 19 HPV-positive tumours were positive by RNA ISH. HPV16 was the most prevalent genotype (n=18, 75%). The patients with HPV-positive tumours were significantly younger (mean difference 11.5 years, 95% CI 5.2 to 17.9, p=0.0005) and had a higher recurrence compared with patients with HPV-negative tumours (HR 2.30, 95% CI 1.02 to 5.21, p=0.046). The HPV-positive tumours were associated with a positive p16 IHC and a non-keratinising morphology. CONCLUSION: We describe distinct clinical and histopathological features associated with HPV status in cSCC. The finding of transcriptionally active HPV in this material lends support to a causal role of HPV in a subset of cSCC.