Cancer Survivors' Receptiveness to Digital Technology-Supported Physical Rehabilitation and the Implications for Design: Qualitative Study.

BACKGROUND: Physical activity is associated with a positive prognosis in cancer survivors and may decrease the risk of adverse effects of treatment. Accordingly, physical activity programs are recommended as a part of cancer rehabilitation services. Digital technology may support cancer survivors in increasing their level of physical activity and increase the reach or efficiency of cancer rehabilitation services, yet it also comes with a range of challenges. OBJECTIVE: The aim of this qualitative study was to explore cancer survivors' receptiveness to using digital technology as a mode of support to increase their physical activity in a municipality-based cancer rehabilitation setting. METHODS: Semistructured interviews were conducted with 11 cancer survivors (3 males, 8 females, age range 32-82 years) who were referred for cancer rehabilitation and had participated in a questionnaire survey using the Readiness and Enablement Index for Health Technology (READHY) questionnaire. Data analysis was based on the content analysis method. RESULTS: Two themes were identified as important for the interviewees' receptiveness to using digital technology services in connection with their physical activity during rehabilitation: their attitude toward physical activity and their attitude toward digital technology-assisted physical activity. Our results indicated that it is important to address the cancer survivors' motivation for using technology for physical activity and their individual preferences in terms of the following: (1) incidental or structured (eg, cardiovascular and strength exercises or disease-specific rehabilitative exercises) physical activity; (2) social or individual context; and (3) instruction (know-how) or information (know-why). CONCLUSIONS: The identified preferences provide new insight that complements the cancer survivors' readiness level and can likely help designers, service providers, and caregivers provide solutions that increase patient receptiveness toward technology-assisted physical activity. Combining digital technology informed by cancer survivors' needs, preferences, and readiness with the capacity building of the workforce can aid in tailoring digital solutions to suit not only individuals who are receptive to using such technologies but also those reluctant to do so.

Early initiated postoperative rehabilitation enhances quality of life in patients with operable lung cancer: Secondary outcomes from a randomized trial.

INTRODUCTION: Patients with lung cancer report a lower degree of Health Related Quality of Life (HRQoL) compared with other cancer patients. HRQoL reflects how patients experience the impact of their disease and its treatment on their quality of daily living. A widely used questionnaire in lung cancer patients is the Functional Assessment of Cancer Therapy - Lung (FACT-L) questionnaire. Here we report the secondary outcomes on FACT-L data from the Postoperative Rehabilitation in Operation for Lung CAncer (PROLUCA) study, which describes the effect of early (14 days) versus late initiated (14 weeks) postoperative rehabilitation. MATERIALS AND METHODS: The PROLUCA study was designed as a two-armed randomized controlled trial with an early rehabilitation group (14 days after surgery (ERG)) or a control arm with a late rehabilitation group (14 weeks after surgery (LRG)). The results for seven domain scores obtained using the FACT-L at the following time-points: baseline, 14 weeks, 26 weeks and 52 weeks after surgery are presented here. RESULTS: 119 patients were randomized to the ERG and 116 to the LRG. In the ERG, HRQoL measured by both FACT-L and FACT-G (general core instrument) showed a continuous improvement up to 26 weeks after which HRQoL decreased after further 26 weeks without structured intervention. In the LRG a non-significant deterioration was detected over the first 14 weeks after surgery. After participation in the 12 weeks rehabilitation program, an increase in HRQoL was seen, without reaching the same level as the early group. CONCLUSION: Analyses of the seven domain scores obtained using FACT-L and FACT-G reflect the importance of starting exercise early after surgery since the ERG avoid a temporary decrease in HRQoL. It is therefore recommended to start up a structured rehabilitation program 14 days after surgery, containing high intensity interval training and strength exercise twice a week for 12 weeks.

Municipality-based pragmatic rehabilitation stratified in accordance with individual needs-results from a longitudinal survey study.

OBJECTIVE: Evidence on municipality-based cancer rehabilitation is sparse. This longitudinal study explores the following: (1) Rehabilitation needs, (2) effectiveness of municipality-based rehabilitation, and (3) whether rehabilitative services are stratified according to individual needs in breast cancer patients. METHODS: We collected data from a longitudinal survey among 82 breast cancer patients referred to municipality-based rehabilitation at the Copenhagen Centre for Cancer and Health. Rehabilitation needs, health-related quality of life (HRQoL), and functional status were collected using patient-reported outcomes (PROs) including distress thermometer, problem list, Functional Assessment of Cancer Therapy-Breast questionnaire (FACT-B), and upper body function with the abbreviated disability of the arm, shoulder, and hand (Quick-DASH) questionnaire. Data collection time points are as follows: entry, follow-up, and end of intervention. RESULTS: At referral, scores were (mean (range)) distress 4.0 (0-10), problems 9.5 (0-24), and FACT-B 103.0 (49.8-135.5). HRQoL increased during rehabilitation (FACT-B ∆ mean 8.1 points (> MID, p < 0.0001)); 56% had a positive change, 34% no difference, and 11% a decline. Those with the lowest FACT-B entry score had significantly longer duration of rehabilitation (10.9 vs 8.7 months, p < 0.001), higher number of services (7.0 vs 5.3, p < 0.003), and participated more in group-based exercise (+3 sessions: 57% vs 8%, p < 0.001). CONCLUSION: This is the first study to report on pragmatic municipality-based cancer rehabilitation. The results suggest that services are aimed at patients with rehabilitation needs, improve HRQoL, and are properly stratified to those who need it the most. We suggest future monitoring of municipality-based rehabilitation services to ensure quality of care.

Socioeconomic position, referral and attendance to rehabilitation after a cancer diagnosis: A population-based study in Copenhagen, Denmark 2010-2015.

Background: Implementation of new cancer services may lead to socioeconomic differences in uptake and despite reports of more unmet needs among patients with low socioeconomic position studies have found that these patients receive less rehabilitation. We aimed to investigate associations between indicators for socioeconomic position and referral as well as attendance to rehabilitation for cancer. Methods: Through the Danish Cancer Registry, we identified all persons diagnosed with cancer in Copenhagen municipality 2010-2015 and obtained information on referral to and visits at the municipal rehabilitation center from municipal records. We linked the population with information on socioeconomic information and vital status through national registries. Associations were analyzed using multivariate Cox regression models. Results: Among 13,059 persons diagnosed with cancer a total of 2523 were referred for rehabilitation within 2.5 years from diagnosis. Compared to persons with short education, men and women with long education and men with medium education had higher adjusted hazard ratios (HR) for being referred to rehabilitation (Long: HR-men, 1.30 (95% CI: 1.06-1.59) and HR-women, 1.33 (95% CI: 1.15-1.53; Medium: HR-men, 1.23 (95% CI: 1.02-1.49)). Both men and women with children living at home had higher HR of referral (HR-men, 1.23 (95% CI: 1.00-1.52) and HR-women, 1.28 (95% CI: 1.11-1.48)). Among patients referred to rehabilitation, 81% attended a visitation consultation. Long education was associated with attendance in both genders while in men, medium education and in women high income, respectively was associated with attendance. Conclusion: Clear socioeconomic differences in referral and attendance to rehabilitation services indicate that socioeconomic inequality exists in patients' transition from cancer treatment into post-treatment care. Systematic needs assessment and clarification of wish for rehabilitation should be a requisite for all cancer patients independent of their socioeconomic position.

Development of the Multidimensional Readiness and Enablement Index for Health Technology (READHY) Tool to Measure Individuals' Health Technology Readiness: Initial Testing in a Cancer Rehabilitation Setting.

BACKGROUND: The increasing digitization of health care services with enhanced access to fast internet connections, along with wide use of smartphones, offers the opportunity to get health advice or treatment remotely. For service providers, it is important to consider how consumers can take full advantage of available services and how this can create an enabling environment. However, it is important to consider the digital context and the attributes of current and future users, such as their readiness (ie, knowledge, skills, and attitudes, including trust and motivation). OBJECTIVE: The objective of this study was to evaluate how the eHealth Literacy Questionnaire (eHLQ) combined with selected dimensions from the Health Education Impact Questionnaire (heiQ) and the Health Literacy Questionnaire (HLQ) can be used together as an instrument to characterize an individual's level of health technology readiness and explore how the generated data can be used to create health technology readiness profiles of potential users of health technologies and digital health services. METHODS: We administered the instrument and sociodemographic questions to a population of 305 patients with a recent cancer diagnosis referred to rehabilitation in a setting that plans to introduce various technologies to assist the individuals. We evaluated properties of the Readiness and Enablement Index for Health Technology (READHY) instrument using confirmatory factor analysis, convergent and discriminant validity analysis, and exploratory factor analysis. To identify different health technology readiness profiles in the population, we further analyzed the data using hierarchical and k-means cluster analysis. RESULTS: The confirmatory factor analysis found a suitable fit for the 13 factors with only 1 cross-loading of 1 item between 2 dimensions. The convergent and discriminant validity analysis revealed many factor correlations, suggesting that, in this population, a more parsimonious model might be achieved. Exploratory factor analysis pointed to 5 to 6 constructs based on aggregates of the existing dimensions. The results were not satisfactory, so we performed an 8-factor confirmatory factor analysis, resulting in a good fit with only 1 item cross-loading between 2 dimensions. Cluster analysis showed that data from the READHY instrument can be clustered to create meaningful health technology readiness profiles of users. CONCLUSIONS: The 13 dimensions from heiQ, HLQ, and eHLQ can be used in combination to describe a user's health technology readiness level and degree of enablement. Further studies in other populations are needed to understand whether the associations between dimensions are consistent and the number of dimensions can be reduced.

Technology in exercise-based cancer rehabilitation: a cross-sectional study of receptiveness and readiness for e-Health utilization in Danish cancer rehabilitation.

Background: During recent years, there has been an increased focus on technology within cancer survivorship and physical activity rehabilitation. Failure to acknowledge the individuals wishes and/or limitations in the use of technology introduces risk of neglecting or excluding low-resource individuals, thus adding to an already existing inequity within cancer management. It is important to identify vulnerable sub-populations with particular needs when introducing health technology to offer appropriate rehabilitation and support individuals in taking advantage of technology in their physical activity rehabilitation. We report how a population of cancer survivors referred to municipality-based rehabilitation can be segmented, according to their receptiveness and readiness for health technology utilization, to understand their potential barriers towards using technology. Methods: We used a cross-sectional design with convenience sampling among Danish cancer survivors (n = 305) referred to rehabilitation. Participants completed a questionnaire survey covering background information and a new tool to assess self-reported health technology readiness. Demographic, disease and behavioral factors were described in relation to the participants' receptiveness to use technology in physical activity rehabilitation. Participants were stratified according to their health technology readiness and the resulting groups described with regards to the above-mentioned factors. Results: Almost 30% of the participants were un-receptive to use technology in relation to physical activity rehabilitation and were characterized by being more vulnerable with regards to sociodemographic characteristics and scoring lower on dimensions related to eHealth literacy. Stratification of the participants according to their health technology readiness profile revealed four distinct profiles that were significantly different in sociodemographic, disease and behavioral factors. Conclusion: To reduce the risk of alienating low-resource individuals when introducing health technology, evaluation of the individuals' receptiveness to use technology in a rehabilitation context and their readiness for health technology may help tailor the extent to which technology should be offered to assist the cancer survivors.

Early initiated postoperative rehabilitation reduces fatigue in patients with operable lung cancer: A randomized trial.

INTRODUCTION: Little is known about the optimal amount and timing of exercise strain in concern of the operation wound and with regard improvement of physical function and quality of life (QOL) after surgery for lung cancer. On this background, we decided to investigate the effect of early vs. late initiated postoperative rehabilitation in patients with operable lung cancer on exercise capacity, functional capacity, muscle strength, and QOL. METHODS: The study was designed as a two-armed randomized controlled trial with randomization to either early initiated postoperative rehabilitation (14 days after surgery (ERG)) or a control arm with late initiated postoperative rehabilitation (14 weeks after surgery (LRG)). The primary endpoint was a change in maximum oxygen consumption (VO2peak) from baseline to post intervention 26 weeks following lung resection. Fatigue was measured with EORTC QLQ C30 LC13. RESULTS: From April 2013 to June 2016, 582 patients with operable NSCLC were screened for eligibility. With 119 patients randomized in the early rehabilitation group (ERG) and 116 randomized to late rehabilitation group (LRG). There was no significant difference from baseline to 26 weeks between ERG and LRG (p = 0.926). There was a significant difference from baseline to 14 weeks between groups (p = 0.0018). There was a significant difference from 14 weeks to 26 weeks between the two groups (p < 0.001). We found no significant differences in QOL but we found a significant difference between ERG and LRG from baseline to 14 weeks in fatigue level in favour of ERG. CONCLUSION: This is the first randomized controlled trial to investigate the effects of early vs. late initiated postoperative rehabilitation in patients with lung cancer. There is no difference in the commencement (early vs. late) of a postoperative exercise program for patients with lung cancer on exercise capacity. But to reduce fatigue patients should be recommended to initiate early exercise programs.

Effect of postsurgical rehabilitation programmes in patients operated for lung cancer: A systematic review and meta-analysis.

OBJECTIVE: To review the evidence concerning the effects of postoperative exercise interventions on exercise capacity and health-related quality of life following resection for non-small cell lung cancer, and to review whether different initiation times of exercise produce different effects on exercise capacity. DATA SOURCES: Comprehensive literature search of MEDLINE, Embase, CENTRAL, CINAHL and PEDro. STUDY SELECTION: Randomized controlled trials examining the effects of exercise interventions were eligible for inclusion. DATA EXTRACTION: Postoperative outcome measurements were extracted and the quality of evidence was graded using Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. DATA SYNTHESIS: Four randomized controlled trials were identified involving 262 participants. Short-term follow-up (12-20 weeks) showed significantly higher exercise capacity and physical component of health-related quality of life in the intervention group (standardized mean difference (SMD) 0.48; 95% confidence interval (CI) 0.04-0.93) compared with the control group (SMD 0.50; 95% CI 0.19-0.82). There was no difference between the effect of late- and early-initiated exercise intervention. CONCLUSION: Exercise has a small-to-moderate effect at short-term follow-up on exercise capacity and the physical component of health-related quality of life in patients operated for lung cancer. The long-term effects of exercise capacity are unknown. Early-initiated exercise programmes (2 weeks post-operation) did not show an effect on exercise capacity. These findings should be interpreted with caution.

[Coordinating rehabilitation and palliative care].

There is an increased focus on coordinating rehabilitation and palliative care (CRPC). A systematic Danish literature review on CRPC highlights the following: the main arguments and recommendations for such a coordination, that CRPC might be meaningful for patients throughout the disease trajectory and until the very end of it, that there is a lack of evidence-based research in this area, and that there is a lot of structural, organizational and professional challenges in securing CRPC.

Changes in Health-Related Quality of Life During Rehabilitation in Patients With Operable Lung Cancer: A Feasibility Study (PROLUCA).

INTRODUCTION: Surgical resection in patients with non-small cell lung cancer (NSCLC) may be associated with significant morbidity, functional limitations, and decreased quality of life. OBJECTIVES: The objective is to present health-related quality of life (HRQoL) changes over time before and 1 year after surgery in patients with NSCLC participating in a rehabilitation program. METHODS: Forty patients with NSCLC in disease stage I to IIIa, referred for surgical resection at the Department of Cardiothoracic Surgery RT, Rigshospitalet, were included in the study. The rehabilitation program comprised supervised group exercise program, 2 hours weekly for 12 weeks, combined with individual counseling. The study endpoints were self-reported HRQoL (Functional Assessment of Cancer Therapy-Lung, European Organization for Research and Treatment in Cancer-Quality of Life Questionnaire-QLQ-C30, Short-Form-36) and self-reported distress, anxiety, depression, and social support (National Comprehensive Cancer Network Distress Thermometer, Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support), measured presurgery, postintervention, 6 months, and 1 year after surgery. RESULTS: Forty patients were included, 73% of whom completed rehabilitation. Results on emotional well-being ( P < .0001), global quality of life ( P = .0032), and mental health component score ( P = .0004) showed an overall statistically significant improvement during the study. CONCLUSION: This feasibility study demonstrated that global quality of life, mental health, and emotional well-being improved significantly during the study, from time of diagnosis until 1 year after resection, in patients with NSCLC participating in rehabilitation.

The effects of individually tailored nurse navigation for patients with newly diagnosed breast cancer: a randomized pilot study.

AIM: Our aim was to determine the feasibility and effectiveness of an individual, nurse-navigator intervention for relieving distress, anxiety, depression and health-related quality of life in women who have been treated for breast cancer (BC) and are experiencing moderate-to-severe psychological and physical symptoms. METHODS: Fifty women with newly diagnosed BC who reported distress (score ≥7 on distress thermometer) before surgery were included consecutively in a pilot study and randomized 1:1 to the intervention or the control group. The intervention comprised repeated screening with patient reported outcome measures and nurse navigation. A total of 66 women who were not distressed (score <7) were followed longitudinally as an observational group. Participants filled in four questionnaires, at baseline, after 6 months and 12 months. The primary outcome was psychological distress and the secondary outcomes were anxiety, depression, health-related quality of life and feasibility of the intervention. RESULTS: Women in the intervention group reported significantly greater satisfaction with treatment and rehabilitation and lower levels of distress (mean 2.7 vs. 5.1, p<.01), anxiety (mean 5.1 vs. 7.8, p = .02) and depression (mean 2.2 vs. 4.4, p = .04) after 12 months compared to the control group. No significant effects were seen on health-related quality of life. CONCLUSIONS: The study shows promising feasibility of the individually tailored nurse-navigation intervention and while no significant effects were observed after 6 months, we did find statistically significant effects on distress, anxiety and depression 12 months after diagnosis. Our results will assist in developing rehabilitation to the most vulnerable patients.

Perioperative Rehabilitation in Operable Lung Cancer Patients (PROLUCA): A Feasibility Study.

Introduction Surgical resection in patients with non-small cell lung cancer (NSCLC) may be associated with significant morbidity, functional limitations, and decreased quality of life. Objectives The safety and feasibility of a preoperative and early postoperative rehabilitation program in patients operated for NSCLC was determined in a nonhospital setting, with focus on high-intensity interval exercise. Methods Forty patients with biopsy-proven NSCLC stages I to IIIa referred for surgical resection at the Department of Cardiothoracic Surgery RT, Rigshospitalet, University of Copenhagen, were randomly assigned to 1 of 4 groups (3 intervention groups and 1 control group). The preoperative intervention consisted of a home-based exercise program, while the postoperative exercise program comprised a supervised group exercise program involving resistance and high-intensity interval cardiorespiratory exercise 2 hours weekly for 12 weeks combined with individual counseling. The study endpoints were inclusion rate, adherence, and number of adverse events. Results Forty patients (of 124 screened; 32%) were included and randomized into the 4 groups. The postoperative exercise was completed by 73% of the patients randomized to this intervention. No adverse events were observed, indicating that the early postoperative exercise program is safe. The preoperative home-based exercise program was not feasible due to interfering diagnostic procedures and fast-track surgery that left only 1 to 2 weeks between diagnosis and surgery. Conclusion The early postoperative exercise program for patients with NSCLC was safe and feasible, but in a fast-track set up, a preoperative home-based exercise program was not feasible for this population.

Social position and referral to rehabilitation among cancer patients.

OBJECTIVES: In Denmark, most healthcare services, including cancer treatment and rehabilitation, are offered free of charge by referral from a treating physician; thus, social equality should be expected. In a population-based cohort study of registry-based data, we examined the association between socioeconomic position, measured as educational level, and referral to rehabilitation services among cancer patients. MATERIAL AND METHODS: Through the Danish Cancer Registry, we identified all people resident in the Municipality of Copenhagen with cancer diagnosed in 2007-2012. Information on all rehabilitation referrals was retrieved from the Municipal Centre for Cancer Rehabilitation for 2009-2012. Information on demographic and socioeconomic characteristics was obtained from national Danish registers. The Cox proportional hazards model was used to investigate associations between educational level and referral to rehabilitation with adjustment for sex, age, diagnosis, disposable income, cohabitation status and number of children living at home at the time of diagnosis. RESULTS: A primary cancer was diagnosed in 13 840 people, of whom 2148 (16%) were referred to rehabilitation services during follow-up. In the fully adjusted model, we found education to be a predictor of referral, with a hazard ratio of 1.33 (95% CI 1.19-1.49) for patients with long education and a hazard ratio of 1.15 (95% CI 1.03-1.29) for patients with medium education as compared with patients with short education. CONCLUSIONS: Our findings suggest that, even after differences in demographics and cancer characteristics are accounted for, referral to rehabilitation services is not equally distributed by social group. Higher educational level is associated with a higher probability of referral to rehabilitation services.

Perioperative rehabilitation in operation for lung cancer (PROLUCA) - rationale and design.

BACKGROUND: The purpose of the PROLUCA study is to investigate the efficacy of preoperative and early postoperative rehabilitation in a non-hospital setting in patients with operable lung cancer with special focus on exercise. METHODS: Using a 2 x 2 factorial design with continuous effect endpoint (Maximal Oxygen Uptake (VO2peak)), 380 patients with non-small cell lung cancer (NSCLC) stage I-IIIa referred for surgical resection will be randomly assigned to one of four groups: (1) preoperative and early postoperative rehabilitation (starting two weeks after surgery); (2) preoperative and late postoperative rehabilitation (starting six weeks after surgery); (3) early postoperative rehabilitation alone; (4) today's standard care which is postoperative rehabilitation initiated six weeks after surgery. The preoperative rehabilitation program consists of an individually designed, 30-minute home-based exercise program performed daily. The postoperative rehabilitation program consists of a supervised group exercise program comprising cardiovascular and resistance training two-hour weekly for 12 weeks combined with individual counseling. The primary study endpoint is VO2peak and secondary endpoints include: Six-minute walk distance (6MWD), one-repetition-maximum (1RM), pulmonary function, patient-reported outcomes (PROs) on health-related quality of life (HRQoL), symptoms and side effects of the cancer disease and the treatment of the disease, anxiety, depression, wellbeing, lifestyle, hospitalization time, sick leave, work status, postoperative complications (up to 30 days after surgery) and survival. Endpoints will be assessed at baseline, the day before surgery, pre-intervention, post-intervention, six months after surgery and one year after surgery. DISCUSSION: The results of the PROLUCA study may potentially contribute to the identification of the optimal perioperative rehabilitation for operable lung cancer patients focusing on exercise initiated immediately after diagnosis and rehabilitation shortly after surgery. TRIAL REGISTRATION: NCT01893580.

Psychological consequences of lymphoedema associated with breast cancer: a prospective cohort study.

BACKGROUND: The aim of this prospective cohort study of women attending a rehabilitation course at the Dallund Rehabilitation Centre was to explore the emotional and psychological aspects of living with lymphoedema, expressed as psychological distress, poorer quality of life and poorer self-reported health. METHODS: Between November 2002 and January 2007 within the FOCARE study, self-completed questionnaires were collected 3 weeks before and 6 and 12 months after the rehabilitation course to elicit sociodemographic, physical and lifestyle information and responses to three psychometric tests. The population consisted of 633 women, 125 with and 508 without verified lymphoedema (time since surgery, 1 month-5 years). The population was reduced to 553 women at the first follow-up and 494 at the second. RESULTS: Multivariate analysis showed that, in comparison with women without lymphoedema, those with lymphoedema had a 14% higher risk for scoring one level higher on the POMS-SF test, a 9% higher probability of scoring one point lower on the quality of life scale and a 29% higher likelihood of reporting poorer or bad health than women without lymphoedema. These findings were seen at all three measurement times. CONCLUSIONS: In this cohort of women with breast cancer, women with lymphoedema after surgery for breast cancer had significantly worse overall emotional well-being and adjustment to life compared to women without lymphoedema.

[Diabetes passport--understanding and use among different ethnic groups of diabetes patients. Interviews with Turkish, Pakistani and Danish patients]. / Diabetespatienters forståelse for og vurdering af egen vandrejournal. Interview med tyrkiske, pakistanske og danske patienter.

INTRODUCTION: Diabetes passports for patients have been used for years in hospitals in our region. Since 2004 data have been printed from the electronic database DiabetesRASK and a new edition of the passport is given to patients at each visit. One of the objectives of the passport is to serve as a pedagogic tool. However, patients' understanding and use of the passport has never been studied. MATERIALS AND METHODS: Inclusion criteria for patients: type 2 diabetes, born in Turkey (T) or Pakistan (P), regular attendees at the outpatient clinics at Hvidovre Hospital or Amager Hospital and their personal diabetes data in the database DiabetesRASK. A comparable group of Danish diabetes patients was selected. All were invited to participate in a semi-structured interview. RESULTS: 14 T, 11 P and 10 D patients participated in the study. 53% T and 73% P had the ability to read in their own language while 15% T and 55% P were able to read in Danish. In the groups fewer than 25% had ever shown their passport to the GP. Between 0% and 36% of any of the given questions were understood or identified correctly by T patients. Similar figures for the P and D patients were 0-55% and 30-100%. CONCLUSION: It is demonstrated that the diabetes passport is not widely used by patients. Furthermore, we found poor understanding of information on the passport in general but with great individual variability. The poorest understanding was found among immigrants, which might be the result of language problems. However, Danish patients also had insufficient understanding of the information. We recommend that the diabetes passport be rewritten so that it is more easily understood by patients and that outpatient clinics also allocate more resources to the guidance of patients concerning the passport.

[Immigrants and type 2 diabetes. Occurrence, treatment and prevention seen in a gender perspective]. / Indvandrere og type 2-diabetes. Forekomst, behandling og forebyggelse set i et kønsperspektiv.

Danish studies present a prevalence of DM2 that is 5-7 times higher among immigrants than non-immigrants and a relatively high rate of contacts to hospitals for that reason, especially for women. Studies so far present a relatively scarce knowledge about the disease and prevention-related issues in Denmark. The National Board of Health has developed an organizational programme to treat patients with chronic diseases in the Danish health system, where some of the services are transferred from the secondary to the primary sector. It is discussed whether the planned structural changes are sufficient to serve the immigrant group.

Decrease of collagen deposition in wound repair in type 1 diabetes independent of glycemic control.

HYPOTHESIS: Type 1 and type 2 diabetes mellitus and glycemic control influence wound healing in humans. DESIGN: Experimental study using a human wound-healing model. SETTING: Collaboration among a multidisciplinary wound-healing department, department of medicine, and research laboratories. PATIENTS, CONTROL SUBJECTS, AND METHODS: In 34 patients with type 1 (insulin-dependent) and 25 with type 2 (non-insulin-dependent) diabetes and 5 nondiabetic control subjects matched with the type 2 diabetic patients, wound-healing capacity was determined as subcutaneous accumulation of collagen measured as hydroxyproline. Two expanded polytetrafluoroethylene tubes were implanted and removed 10 days later. The hydroxyproline level was determined by means of high-performance liquid chromatography; the collagenase activity, by using a radiolabeled collagen substrate. Proliferation of fibroblasts cultured from the wounds was studied in patient groups. RESULTS: The deposition of hydroxyproline decreased by 40% (P =.03) in type 1 compared with type 2 diabetes (median, 0.70 vs 1.16 nmol/mg; interquartile range, 0.48-1.04 vs 0.56-1.63 nmol/mg), which in turn did not differ significantly from that of controls (median, 1.35 nmol/mg; interquartile range, 0.72-1.88 nmol/mg). The decreased collagen deposition in type 1 diabetes was not caused by increased collagenase activity. The deposition of hydroxyproline did not correlate significantly (r(s) = 0.07; P =.63) with glycosylated hemoglobin levels in either diabetic group. Fibroblast growth was also decreased in type 1 compared with type 2 diabetic patients and controls. CONCLUSIONS: Collagen deposition in acute wounds is impaired in type 1 diabetes, possibly due to a decreased fibroblast proliferation. In type 2 diabetes, collagen deposition is normal. Glycemic control does not influence collagen deposition in acute wound repair in type 1 or in type 2 diabetes mellitus.