Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion : a European cross-sectional survey

ALN is supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translation Research Centre, with infrastructure support provided by the NIHR Imperial Biomedical Research Centre (BRC). Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http://dx.doi.org/10.1136/bmjopen-2018-022904).Peer reviewedPublisher PD

Primary care practitioners’ diagnostic action when the patient may have cancer : an exploratory vignette study in 20 European countries

Availability of data To avoid the risk of identification of individual participants, the datasets generated and analysed during the current study are not publicly available. However, they are available (with any possible identifying information redacted) from the corresponding author on reasonable request. Funding This study received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. ALN’s time is supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translation Research Centre, with her infrastructure support provided by the NIHR Imperial Biomedical Research Centre (BRC). Acknowledgements We would like to thank all the PCPs who piloted the questionnaire and those who completed the survey. We would also like to thank the European GP Research Network for its support. We are grateful to Prof. Barbara Silverman and Prof. Lital Keinan for the data on cancer survival rates in Israel, and to Dr Yochai Schonmann for his work on those data. Two of the vignettes were used by kind permission of the ICBP; we also thank Dr Peter Murchie and Dr Rhona Auckland, who generously provided the other two vignettes. Prof. Antonius Schneider kindly organised the Technical University of Munich’s data collection.Peer reviewedPublisher PD

Why do European primary care physicians sometimes not think of, or act on, a possible cancer diagnosis? : A qualitative study

Funding The Swedish application for ethical approval was funded by the Jämtland Cancer and Nursing Foundation. The study had no other external fundingPeer reviewedPostprin

Bone Metabolism Markers and Bone Mineral Density in Patients on Long-Term Acenocoumarol Treatment: A Cross-Sectional Study

The aim of this study was to evaluate levels of osteocalcin (OC), osteoprotegerin (OPG) and total soluble receptor activator of nuclear factor-κB ligand (RANKL), and bone mineral density (BMD) in patients on long-term acenocoumarol (AC) treatment. The cross-sectional study was carried out in 42 patients treated long-term with AC and 28 control subjects. Serum concentrations of OC, OPG, and sRANKL were measured using enzyme linked immunosorbent assay (ELISA) kits, and BMD at the femoral neck and lumbar spine were assessed by dual energy X-ray absorptiometry. A significantly decreased concentration of OC was found in AC users compared to control subjects (4.94 ± 2.22 vs. 10.68 ± 4.5; p < 0.001). Levels of OPG, sRANKL logarithm (log), sRANKL/OPG log ratio, and BMD were comparable between. In female AC users, positive correlations between OC and RANKL log, and between OC and RANKL/OPG log ratio (p = 0.017; p = 0.005, respectively), and a negative correlation between OC and OPG (p = 0.027) were found. Long-term AC anticoagulation significantly decreases OC concentration, but does not affect other bone metabolism markers or BMD. Our results also suggest the possibility that long-term treatment with AC may alleviate bone resorption in postmenopausal women

The Association Between Long-Term Acenocoumarol Treatment and Vitamin D Deficiency

ObjectiveBoth vitamin D and K2 are involved in a number of metabolic processes, including bone metabolism; however, associations between the vitamins are not fully understood. The aim of the study was to evaluate serum concentrations of 25-hydroxyvitamin D [25(OH)D] in adult patients receiving long-term acenocoumarol (AC) treatment.Participants and methodsIn this cross-sectional study, 58 Caucasian patients (31 women, 27 men) with a median age of 65 years receiving long-term AC therapy were evaluated and compared with 35 age- and gender-matched healthy controls. The AC treatment was used due to recurrent venous thromboembolism (34.5%), atrial fibrillation (31%), or mechanical heart valve prostheses (34.5%). Medical records and a questionnaire were used to obtain information about chronic diseases, smoking habits, and the duration of therapy and weekly dose of AC. Anthropometric measurements were performed, and serum concentration of 25(OH)D and total alkaline phosphatase (ALP) activity were measured.ResultsAmong the 58 patients receiving long-term AC treatment, a high proportion (46.6%) demonstrated significant vitamin D deficiency with concentrations of 25(OH)D lower than 20 ng/mL. The median concentration of 25(OH)D in subjects receiving AC was significantly lower compared to the control group [20.4 (17.4; 26.1) vs. 28.2 (24; 32.7); p < 0.001]. No differences were found between women and men receiving AC therapy. In patients receiving AC, a negative correlation was found between the concentration of 25(OH)D and the weekly dose of AC (r = −0.337, p = 0.01). Patients with concentrations of 25(OH)D < 20 ng/mL were found to have a significantly higher median dose of AC, compared to those with concentrations of 25(OH)D ≥ 20 ng/mL [21 (17; 31) vs. 17 (12; 28); p = 0.045].ConclusionIn conclusion, treatment with AC is associated with low 25-hydroxyvitamin D levels, although the path leading to this phenomenon is not entirely clear. Long-term administration of AC in adults may increase the risk of chronic vitamin D deficiency, thus, effective supplementation of vitamin D in these individuals needs careful consideration

Ocena jakości doustnej antykoagulacji podczas leczenia antagonistami witaminy K u pacjentów w poradniach lekarzy rodzinnych w Polsce: badanie wieloośrodkowe

Background: Vitamin K antagonists (VKAs) remain the mainstay of anticoagulation therapy, which requires monitoring of international normalised ratio (INR). Quality of oral anticoagulation, clinical benefits, and the risk related to VKA use are determined by the time in therapeutic range (TTR). Aim: The aim of this study was to assess the therapeutic quality of oral anticoagulation and to determine the factors that affect the incidence of INR outside the recommended range in primary care patients undergoing long-term VKA therapy in Poland. Methods: A multi-centre cross-sectional analysis was carried out in 15 general practices from three voivodeships of Poland. At the planned time, INRs measured closest to the designated date in all patients were assessed in terms of being within the therapeutic range. TTR was determined as the percentage of visits with INR in therapeutic range on a given date. Results: Overall, 430 patients aged 70.3 ± 12.7 years (222 men aged 72 ± 12.8 years and 208 women aged 68.5 ± 12.4 years) were included in the study. In the groups with INR below, within, and above therapeutic range, the patients’ age was 67.3 ± 13.4, 72 ± 12, and 70.5 ± 13 years (p = 0.001), respectively. TTR for all the participants was 55%. Statistically significant factors associated with INRs outside the therapeutic range were: age below 60 years (compared to older persons; p = 0.003), more or less frequent INR control compared to the recommended intervals of four to eight weeks (p &lt; 0.001), and the type of the VKA used, i.e. acenocoumarol compared to warfarin (p &lt; 0.001). Logarithmic regression analysis showed that the use of acenocoumarol compared to warfarin, increased the chances of INRs below therapeutic range (odds ratio [OR] 3.19; 95% confidence interval [Cl] 1.65–6.16), while male sex increased the probability of INR being above this range (OR 2.01; 95% Cl 1.12– 3.59). Conclusions: The TTR in primary care patients on VKA therapy was 55%. Better quality of oral anticoagulation with VKA could be achieved by using warfarin instead of acenocoumarol, proper INR monitoring in the recommended interval of four to eight weeks, and tighter INR control in younger and male patients.Wstęp: Antagoniści witaminy K (VKA) są podstawą terapii przeciwkrzepliwej wymagającą kontroli międzynarodowego współczynnika znormalizowanego (INR). Jakość doustnej antykoagulacji, kliniczne korzyści i ryzyko związane ze stosowaniem VKA są określane przez czas utrzymywania się INR w zakresie terapeutycznym (TTR). Cel: Celem pracy była ocena jakości doustnej antykoagulacji i czynników wpływających na występowanie INR poza zalecanym zakresem terapeutycznym u pacjentów leczonych długoterminowo VKA w gabinetach lekarzy rodzinnych w Polsce. Metody: Przeprowadzono wieloośrodkową przekrojową analizę wszystkich pacjentów leczonych długoterminowo za pomocą VKA w 15 poradniach lekarzy rodzinnych z trzech województw Polski. W zaplanowanym czasie u wszystkich pacjentów oceniano INR, wykonany najbliżej wyznaczonej daty, analizując, czy był w zakresie terapeutycznym. TTR obliczono jako procent wizyt z INR w zakresie terapeutycznym w określonej dacie. Wyniki: Ostatecznie, 430 pacjentów w wieku średnio 70,3 ± 12,7 roku (222 mężczyzn w wieku 72 ± 12,8 oraz 208 kobiet w wieku 68,5 ± 12,4) włączono do badania i zmierzono INR. Średni wiek pacjentów w grupie z INR poniżej, w zakresie i powyżej wyniósł odpowiednio 67,3 ± 13,4, 72 ± 12, 70,5 ± 13 (p = 0,001). TTR dla wszystkich uczestników badania wyniósł 55%. Na występowanie INR poza zakresem terapeutycznym istotny statystycznie wpływ miały takie czynniki, jak: wiek poniżej 60 lat w stosunku do osób starszych (p = 0,003), rzadsza lub częstsza kontrola INR, w stosunku do zalecanej w przedziale od 4 do 8 tygodni (p < 0.001) oraz rodzaj stosowanego VKA, acenocumarol w stosunku do warfaryny (p < 0,001). Metodą regresji logarytmicznej wykazano, że stosowanie acenokumarolu zamiast warfaryny zwiększało prawdopodobieństwo występowania INR poniżej zakresu terapeutycznego (OR 3,19; 95% Cl 1,65–6,16), a płeć męska zwiększała prawdopodobieństwo występowania INR powyżej zakresu terapeutycznego (OR 201; 95% Cl 1,12–3,59). Wnioski: TTR wśród pacjentów leczonych VKA, będących pod opieką lekarzy rodzinnych, wyniósł 55%. Poprawę jakości leczenia przeciwkrzepliwego u osób stosujących VKA w poradniach lekarzy rodzinnych można uzyskać poprzez stosowanie warfaryny zamiast acenokumarolu, zalecanie badania INR w rekomendowanym przedziale od 4 do 8 tygodni, a także objęcie większą kontrolą INR u pacjentów młodszych i płci męskiej

Bone Metabolism Markers and Bone Mineral Density in Patients on Long-Term Acenocoumarol Treatment: A Cross-Sectional Study

The aim of this study was to evaluate levels of osteocalcin (OC), osteoprotegerin (OPG) and total soluble receptor activator of nuclear factor-&kappa;B ligand (RANKL), and bone mineral density (BMD) in patients on long-term acenocoumarol (AC) treatment. The cross-sectional study was carried out in 42 patients treated long-term with AC and 28 control subjects. Serum concentrations of OC, OPG, and sRANKL were measured using enzyme linked immunosorbent assay (ELISA) kits, and BMD at the femoral neck and lumbar spine were assessed by dual energy X-ray absorptiometry. A significantly decreased concentration of OC was found in AC users compared to control subjects (4.94 &plusmn; 2.22 vs. 10.68 &plusmn; 4.5; p &lt; 0.001). Levels of OPG, sRANKL logarithm (log), sRANKL/OPG log ratio, and BMD were comparable between. In female AC users, positive correlations between OC and RANKL log, and between OC and RANKL/OPG log ratio (p = 0.017; p = 0.005, respectively), and a negative correlation between OC and OPG (p = 0.027) were found. Long-term AC anticoagulation significantly decreases OC concentration, but does not affect other bone metabolism markers or BMD. Our results also suggest the possibility that long-term treatment with AC may alleviate bone resorption in postmenopausal women

Comparison of Selected Parameters of Redox Homeostasis in Patients with Ataxia-Telangiectasia and Nijmegen Breakage Syndrome

This study compared the antioxidant status and major lipophilic antioxidants in patients with ataxia-telangiectasia (AT) and Nijmegen breakage syndrome (NBS). Total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), and concentrations of coenzyme Q10 (CoQ10) and vitamins A and E were estimated in the plasma of 22 patients with AT, 12 children with NBS, and the healthy controls. In AT patients, TAS (median 261.7 μmol/L) was statistically lower but TOS (496.8 μmol/L) was significantly elevated in comparison with the healthy group (312.7 μmol/L and 311.2 μmol/L, resp.). Tocopherol (0.8 μg/mL) and CoQ10 (0.1 μg/mL) were reduced in AT patients versus control (1.4 μg/mL and 0.3 μg/mL, resp.). NBS patients also displayed statistically lower TAS levels (290.3 μmol/L), while TOS (404.8 μmol/L) was comparable to the controls. We found that in NBS patients retinol concentration (0.1 μg/mL) was highly elevated and CoQ10 (0.1 μg/mL) was significantly lower in comparison with those in the healthy group. Our study confirms disturbances in redox homeostasis in AT and NBS patients and indicates a need for diagnosing oxidative stress in those cases as a potential disease biomarker. Decreased CoQ10 concentration found in NBS and AT indicates a need for possible supplementation