Frede Olesen

Symptoms and syndromes of bodily distress: An exploratory study of 978 internal medical, neurological, and primary care patients

Objective: Physical complaints not attributable to verifiable, conventionally defined diseases, i.e., medically unexplained or functional somatic symptoms, are prevalent in all medical settings, but their classification is contested as numerous overlapping diagnoses and syndrome labels have been introduced. This study aims to determine whether functional somatic symptoms cluster into distinct syndromes and diagnostic entities. Methods: The 978 consecutively admitted patients from a neurological department (n = 120), a medical department (n = 157), and from primary care (n = 701) were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) diagnostic instrument. Results: Patients complained of a median of five functional somatic symptoms; women of six, men of four (p < .0001). No single symptoms stood out as distinctive for patients with multiple symptoms. Principal component factor analysis identified a cardiopulmonary including autonomic (CP), a musculoskeletal (MS), and a gastrointestinal (GI) symptom group explaining 36.9% of the variance. Latent class analysis showed that the symptom groups are likely to materialize in the same patients, suggesting that they are different manifestations of a common latent phenomenon. Inclusion of a group of five additional general, unspecific symptoms in latent class analysis allowed construction of clinical diagnostic criteria for ‘bodily distress disorder’ dividing patients into three classes: nonbodily distress (n = 589), modest bodily distress (n = 329, prevalence 25.3%, men 20.4%, women 25.6%), and severe bodily distress (n = 60, prevalence 3.3%, men 1.2%, women 4.8%). Conclusion: The study suggests that bodily distress disorder as defined here may unite many of the functional somatic syndromes and some somatoform disorder diagnoses. Bodily distress may be triggered by stress rather than being distinct diseases of noncerebral pathology. SCAN = Schedules for Clinical Assessment in Neuropsychiatry; CP = cardiopulmonary; MS = musculoskeletal; GI = gastrointestinal; CFS = chronic fatigue syndrome; DSM = Diagnostic and Statistical Manual of Mental Disorders; ICD = International Classification of Diseases; SCL = Symptoms Check List; CAGE = cutting down, annoyance by criticism, guilty feeling, and eye-openers; WHO = World Health Organization; STATA = statistical software; IQR = interquartile range; GS = general symptoms; IBS = irritable bowel syndrome.

Mental disorders in primary care: prevalence and co-morbidity among disorders. results from the functional illness in primary care (FIP) study.

BACKGROUND Prevalence and co-occurrence of mental disorders is high among patients consulting their family general practitioner (GP) for a new health problem, but data on diagnostics and socio-demographics are sketchy. METHOD A cross-sectional two-phase epidemiological study. A total of 1785 consecutive patients with new complaints, aged 18-65 years, consulting 28 family practices during March-April 2000 in Aarhus County, Denmark were screened, in the waiting room, for mental and somatic symptoms with SCL-8 and SCL-Somatization questionnaires, for illness worry with Whitely-7 and for alcohol dependency with CAGE. In a stratified random sample of 701 patients, physician interviewers established ICD-10 diagnoses using the SCAN interview. Prevalence was calculated using weighted logistic regression, thus correcting for sample skewness. RESULTS Half of the patients fulfilled criteria for an ICD-10 mental disorders and a third of these for more than one group of disorders. Women had higher prevalence of somatization disorder and overall mental disorders than men. Men had higher prevalence of alcohol abuse and hypochondriasis than women. Psychiatric morbidity tended to increase with age. Prevalence of somatoform disorders was 35.9% (95% CI 30.4-41.9), anxiety disorders 164% (95% CI 12.7-20.9), mood disorders 13.5% (95% CI 11.1-16.3), organic mental disorders 3.1% (95% CI 1.6-5.7) and alcohol abuse 2.2% (95% CI 1.5-3.1). Co-morbidities between these groups were highest for anxiety disorders, where 89% also had another mental diagnosis, and lowest for somatoform disorders with 39%. CONCLUSIONS ICD-10 mental disorders are very prevalent in primary care and there is a high co-occurrence between most disorders. Somatoform disorders, however, more often than not exist without other mental disorders.

Home Sampling versus Conventional Swab Sampling for Screening of Chlamydia trachomatis in Women: A Cluster-Randomized 1-Year Follow-up Study

We compared the efficacy of a screening program for urogenital Chlamydia trachomatis infections based on home sampling with that of a screening program based on conventional swab sampling performed at a physicians office. Female subjects, comprising students at 17 high schools in the county of Aarhus, Denmark, were divided into a study group (tested by home sampling) and a control group (tested in a physicians office). We assessed the number of new infections and the number of subjects who reported being treated for pelvic inflammatory disease (PID) at 1 year of follow-up; 443 (51.1%) of 867 women in the intervention group and 487 (58.5%) of 833 women in the control group were available for follow-up. Thirteen (2.9%) and 32 (6.6%) new infections were identified in the intervention group and the control group, respectively (Wilcoxon exact value, P=.026). Nine (2.1%) women in the intervention group and 20 (4.2%) in the control group reported being treated for PID (P=.045), indicating that a screening strategy involving home sampling is associated with a lower prevalence of C. trachomatis and a lower proportion of reported cases of PID.

Magnetic resonance imaging and transvaginal ultrasonography for the diagnosis of adenomyosis

OBJECTIVE To compare the diagnostic potential of magnetic resonance imaging (MRI) and transvaginal ultrasonography (TVS) in the diagnosis of adenomyosis. DESIGN Double blind set-up. SETTING University medical school. PATIENT(S) We studied 106 consecutive premenopausal women who underwent hysterectomy for benign reasons. INTERVENTION(S) Transvaginal ultrasonography and MRI were compared with histopathologic examination as the golden standard. MAIN OUTCOME MEASURE(S) Adenomyosis. RESULT(S) Twenty-two (21%) patients had adenomyosis. The sensitivity and specificity were as follows: sensitivity: MRI 0.70 (0.46-0.87) and TVS 0.68 (0.44-0.86) (P=.66); specificity: MRI 0.86 (0.76-0.93) and TVS 0.65 (0.50-0.77) (P=.03). The combination of MRI and TVS was most sensitive (0.89 [0.64-0.98]), but produced the lowest specificity (0.60 [0.44-0.73]). Adenomyosis was not detected by either MRI or TVS at uterine volumes >400 mL. Exclusion of uteri >400 mL from the analysis improved the diagnostic precision of MRI, but not that of TVS. The diagnostic accuracy at MRI was improved by calculating the maximum difference between the thinnest and thickest junctional zone (JZdif) (i.e., > or =5-7 mm). CONCLUSION(S) Magnetic resonance imaging was superior to TVS for the diagnosis of adenomyosis. Magnetic resonance imaging had a higher specificity than TVS, but their sensitivities were in line. The diagnostic accuracy of MRI, as that of TVS, was at an intermediate level, but the diagnostic accuracy of the former improved by exclusion of uteri >400 mL. The combination of MRI and TVS produced the highest level of accuracy for exclusion of adenomyosis, but the low specificity may necessitate further investigation of positive findings. Measurement of the difference in junctional zone thickness may optimize the diagnosis of adenomyosis at MRI.

Delay in diagnosis: the experience in Denmark

Background:Denmark has poorer 5-year survival rates than many other Western European countries, and cancer patients tend to have more advanced stages at diagnosis than those in other Scandinavian countries. Part of this may be due to delay in diagnosis. The aim of this paper is to give an overview of the initiatives currently underway to reduce delays.Methods:Description of Danish actions to reduce delay.Results:Results of surveys of patient-, doctor- and system-related delays are presented and so are the political initiatives to ensure that cancer is seen as an acute disease.Conclusion:In future, fast-track diagnosis and treatment will be provided for suspected cancers and access to general diagnostic investigations will be improved. A large national experiment with cancer seen as an acute disease is currently being implemented, and as yet the results are unknown.

Evaluation of the uterine cavity with magnetic resonance imaging, transvaginal sonography, hysterosonographic examination, and diagnostic hysteroscopy

OBJECTIVE To evaluate and compare the diagnostic accuracy of magnetic resonance imaging (MRI), transvaginal ultrasonography (TVS), hysterosonographic examination (HSE), and hysteroscopy in the evaluation of the uterine cavity. DESIGN Independent double-blind study. SETTING University medical hospital. PATIENT(S) One hundred six consecutive premenopausal women who underwent hysterectomy for benign diseases. INTERVENTION(S) Results of MRI, TVS, HSE, and hysteroscopy were compared with the results of histopathologic examination at hysterectomy (the gold standard). RESULT(S) The overall sensitivity was MRI 0.76, TVS 0.69, HSE 0.83, and hysteroscopy 0.84. The specificity was MRI 0.92, TVS 0.83, HSE 0.90, and hysteroscopy 0.88 (MRI, HSE, hysteroscopy vs. TVS <0.05). Polyps were missed in 9 of 12 cases at MRI, 7 at TVS, 4 at HSE, and 2 at hysteroscopy (MRI vs. hysteroscopy, and TVS vs. hysteroscopy <0.05). The sensitivity for identification of submucous myomas was MRI 1.0, TVS 0.83, HSE 0.90, and hysteroscopy 0.82; the specificity was MRI 0.91, TVS 0.90, HSE 0.89, and hysteroscopy 0.87 (MRI vs. TVS, and MRI vs. hysteroscopy). Magnetic resonance imaging was significantly more precise than TVS, HSE, and hysteroscopy in determining submucous myoma in-growth (2-way ANOVA <0.05). CONCLUSION(S) For exclusion of abnormalities in the uterine cavity, MRI, HSE, and hysteroscopy were equally effective and slightly superior to TVS. Magnetic resonance imaging and TVS missed endometrial abnormalities such as polyps, but MRI and HSE were most accurate for the evaluation of submucous myomas, and MRI was superior in evaluation of exact submucous myoma in-growth.

Indicators of Quality in Health Care

Systems of Quality Assurance are necessary, partly to advance service and professional development, and partly to provide accountability. Such systems require criteria and standards on the basis of...

Classification of somatization and functional somatic symptoms in primary care

Objective: A substantial proportion of patients found in primary care complain of physical symptoms not attributable to any known conventionally defined disorder, that is, medically unexplained or functional somatic symptoms. The objective of this paper is to outline the problems with the current classification and propose a classification more suitable for primary health care. Method: We refer to and discuss relevant literature including papers on our own research on the topic in the light of our experiences from major projects on somatizing patients in primary health care. Results: Functional somatic symptoms may impose severe suffering on the patient and are costly for society because of high health-care utilization, lost working years and social expenses. At present, studies on functional somatic symptoms and disorders and their treatment are hampered by lack of a valid and reliable diagnostic classification. The diagnostic categories of somatoform disorders are overlapping. Thus, the present situation is that patients with identical symptoms and clinical pictures may receive different diagnostic labels depending on the focus of interests of the assessing physician. A particular problem in primary care is that the somatoform diagnostic categories only include persistent cases and do not offer the opportunity for classification of the patients with short-symptom duration found in this setting. We present a framework for a new descriptive classification of functional somatic symptoms and unfounded illness worrying, and outline a new classification that covers the whole spectrum of severity seen in clinical practice. Conclusion: A precondition for an appropriate management of patients with functional somatic symptoms is a valid taxonomy common for all medical specialties facilitating cooperative care. Classification systems as outlined in this paper may be a candidate for such a system, but it should be subject to further evaluation in research.

Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients

BackgroundDelay in diagnosis of cancer may worsen prognosis. The aim of this study is to explore patient-, general practitioner (GP)- and system-related delay in the interval from first cancer symptom to diagnosis and treatment, and to analyse the extent to which delays differ by cancer type.MethodsPopulation-based cohort study conducted in 2004-05 in the County of Aarhus, Denmark (640,000 inhabitants). Data were collected from administrative registries and questionnaires completed by GPs on 2,212 cancer patients newly diagnosed during a 1-year period. Median delay (in days) with interquartile interval (IQI) was the main outcome measure.ResultsMedian total delay was 98 days (IQI 57-168). Most of the total delay stemmed from patient (median 21 days (7-56)) and system delay (median 55 days (32-93)). Median GP delay was 0 (0-2) days. Total delay was shortest among patients with ovarian (median 60 days (45-112)) and breast cancer (median 65 days (39-106)) and longest among patients with prostate (median 130 days (89-254)) and bladder cancer (median 134 days (93-181)).ConclusionSystem delay accounted for a substantial part of the total delay experienced by cancer patients. This points to a need for shortening clinical pathways if possible. A long patient delay calls for research into patient awareness of cancer. For all delay components, special focus should be given to the 4th quartile of patients with the longest time intervals and we need research into the quality of the diagnostic work-up process. We found large variations in delay for different types of cancer. Improvements should therefore target both the population at large and the specific needs associated with individual cancer types and their symptoms.

Population-Based Strategies for Outreach Screening of Urogenital Chlamydia trachomatis Infections: A Randomized, Controlled Trial

The effect of 2 population-based outreach screening strategies that used in-home sampling was compared with usual care practices for Chlamydia trachomatis infection. All 30,439 persons 21-23 years old in Aarhus County, Denmark, were divided randomly into 3 groups: group 1 (n=4500) had a home sampling kit mailed directly to their centrally registered home address; group 2 (n=4500) had a reply card mailed to their home address with which a home sampling kit could be ordered; and group 3 (n=21,439) had access to usual care. For women in groups 1 and 2, the relative risks of being tested were 4.1 (95% confidence interval [CI], 3.8-4.4) and 3.5 (95% CI, 3.2-3.9), respectively, compared with usual care. The corresponding figures for men were 19.1 (95% CI, 16.0-22.8) and 11.8 (95% CI, 9.8-14.2), respectively. Both screening strategies were highly effective, but men benefited the most from having the home sampling kit provided directly.