Morten Fenger-Grøn

Freestanding midwifery unit versus obstetric unit: a matched cohort study of outcomes in low-risk women

Objective To compare perinatal and maternal morbidity and birth interventions in low-risk women giving birth in two freestanding midwifery units (FMUs) and two obstetric units (OUs). Design A cohort study with a matched control group. Setting The region of North Jutland, Denmark. Participants 839 low-risk women intending FMU birth and a matched control group of 839 low-risk women intending OU birth were included at the start of care in labour. OU women were individually chosen to match selected obstetric/socio-economic characteristics of FMU women. Analysis was by intention to treat. Main outcome measures Perinatal and maternal morbidity and interventions. Results No significant differences in perinatal morbidity were observed between groups (Apgar scores <7/5, <9/5 or <7/1, admittance to neonatal unit, asphyxia or readmission). Adverse outcomes were rare and occurred in both groups. FMU women were significantly less likely to experience an abnormal fetal heart rate (RR: 0.3, 95% CI 0.2 to 0.5), fetal–pelvic complications (0.2, 0.05 to 0.6), shoulder dystocia (0.3, 0.1 to 0.9), occipital–posterior presentation (0.5, 0.3 to 0.9) and postpartum haemorrhage >500u2005ml (0.4, 0.3 to 0.6) compared with OU women. Significant reductions were found for the FMU groups use of caesarean section (0.6, 0.3 to 0.9), instrumental delivery (0.4, 0.3 to 0.6), and oxytocin augmentation (0.5, 0.3 to 0.6) and epidural analgesia (0.4, 0.3 to 0.6). Transfer during or <2u2005h after birth occurred in 14.8% of all FMU births but more frequently in primiparas than in multiparas (36.7% vs 7.2%). Conclusion Comparing FMU and OU groups, there was no increase in perinatal morbidity, but there were significantly reduced incidences of maternal morbidity, birth interventions including caesarean section, and increased likelihood of spontaneous vaginal birth. FMU care may be considered as an adequate alternative to OU care for low-risk women. Pregnant prospective mothers should be given an informed choice of place of birth, including information on transfer.

The impact of birthplace on women's birth experiences and perceptions of care

Overall birth experience is an important outcome of birth, and studies of psycho-social birth outcomes and womens perspectives on care are increasingly used to evaluate and develop maternity care services. We examined the influence of birthplace on womens birth experiences and perceptions of care in two freestanding midwifery units (FMU) and two obstetric units (OU) in north Denmark, all pursuing an ideal of high-quality, humanistic and patient-centred care. As part of a matched cohort study, a postal questionnaire survey was undertaken. Two hundred and eighteen low-risk women in FMU care, admitted between January-October 2006, and an obstetrically/socio-demographically matched control group of 218 low-risk women admitted to an OU were invited to participate. Three hundred and seventy-five women (86%) responded. Birth experience and satisfaction with care were rated significantly more positively by FMU than by OU women. Significantly better results for FMU care were also found for specific patient-centred care elements (support, participation in decision-making, attentiveness to psychological needs and to wishes for birth, information, and for womens feeling of being listened to). Adjustment for medical birth factors slightly increased the positive effect of FMU care. Subgroup analysis showed that a significant, negative effect of low education and employment level on birth experience was found only for the OU group. Our results provide strong support of FMU care and underline the big challenges in providing individual and supportive care for all women, especially in OUs. Policy-makers and professionals need to consider how the advantages provided by FMU care can support the effort to improve womens birth experience and possibly also the combat of the negative effect of social disadvantage on health.

The epidemiology of microscopic colitis: a 10-year pathology-based nationwide Danish cohort study

Abstract Objective. Microscopic colitis (MC) includes two main types: collagenous colitis (CC) and lymphocytic colitis (LC). Previous studies have indicated an increasing incidence, but these have mainly been based on regional databases. We found it important to study the epidemiology based on a comprehensive nationwide cohort. Material and methods. We studied the epidemiological data of MC in Denmark from 2002 to 2011. The cohort consisted of all patients with a recorded diagnosis of either CC or LC in the Danish Pathology Register during the study period. Data on all patients with a registered colon biopsy were also included. Results. A total of 7777 patients, 4749 (61%) with CC and 3028 (39%) with LC, were identified. Over the study period, the annual incidence of diagnosed cases of CC increased from 2.9/105 to 14.9/105 and of LC from 1.7/105 to 9.8/105. In 2011, the incidence of MC was 24.7/105 inhabitants. The age-specific incidence showed that the risk of both CC and LC increased with age. The female/male ratio, distribution of the type of colitis and mean age at diagnosis were relatively stable during the study period. The annual number of registered colon biopsies in the pathology register increased from 21.583 in 2002 to 39.733 in 2011, indicating an increased diagnostic activity. Conclusion. In a nationwide cohort study, the incidence of CC and LC continued to increase from 2002 to 2011. An increased diagnostic activity could in part explain the increase in the number of diagnosed cases.

Reproducibility of depth of extramural tumor spread and distance to circumferential resection margin at rectal MRI: enhancement of clinical guidelines for neoadjuvant therapy.

OBJECTIVEnThe purpose of this study was to evaluate the reproducibility of measurements of minimal distance from an invasive tumor to the anticipated circumferential resection margin in prediction of depth of extramural tumor spread in patients with rectal cancer.nnnMATERIALS AND METHODSnImages from 168 consecutive pelvic MRI examinations of patients with rectal cancer were evaluated by radiologists at five imaging centers, by two expert reviewers, and by a resident. For each tumor, the minimal distance from the tumor to the circumferential resection margin and the maximum extramural tumor spread were evaluated by the observers. Tumors were classified into early (≤ 5 mm invasion) and advanced (> 5 mm invasion), and margin status was evaluated at the 1- and 5-mm levels.nnnRESULTSnThere was good to very good agreement in classifying tumors as early and advanced (κ = 0.65-0.87), moderate to good agreement concerning circumferential resection margin status at the 1-mm level (k = 0.51-0.76), and fair to good agreement concerning circumferential resection margin status at the 5-mm level (k = 0.37-0.70). It was significantly easier to obtain agreement on the division into early and advanced tumors than on margin status at the 5-mm level for both the hospitals (p = 0.043) and the resident (p = 0.024).nnnCONCLUSIONnMeasurements of extramural tumor spread are more reproducible among different observers than are 5-mm distance measurements to the anticipated circumferential resection margin. This factor should be taken into account in the preparation and implementation of guidelines for neoadjuvant therapy for rectal cancer.

Secondary cancers, comorbidities and mortality associated with nitrogen mustard therapy in patients with mycosis fungoides: a 30‐year population‐based cohort study

Topical nitrogen mustard is a widely used therapy in patients with mycosis fungoides (MF). However, it remains controversial whether nitrogen mustard therapy is associated with increased risk of secondary cancers and chronic pulmonary diseases in patients with MF.

Total skin electron beam therapy for cutaneous T-cell lymphoma: a nationwide cohort study from Denmark.

Abstract Background. Total skin electron beam therapy (TSEBT) is an effective palliative treatment for cutaneous T-cell lymphoma (CTCL). In the present study we reviewed the clinical response to TSEBT in Danish patients with CTCL. Material and methods. This retrospective study included 35 patients with CTCL treated with TSEBT in Denmark from 2001 to 2008 and followed for a median time of 7.6 months (range 3 days–3.7 years). Twenty five patients were treated with high-dose (30 Gy) and 10 patients in a protocol with low-dose (4 Gy) TSEBT. Results. Patients treated with low-dose therapy had inadequate response to treatment compared to patients treated with high-dose. Consequently the study with low-dose was discontinued and published. In patients treated with high-dose the overall response rate was 100%. Complete response (CR) rate was 68% and CR occurred after a median time of 2.1 months (range 1.8 months–2.0 years). We found no difference in CR rate in patients with T2 (66.7%) and T3 disease (78.6%) (p = 0.64). Following CR 82.4% relapsed at a median time of four months (range 12 days–11.5 months). Relapse-free-survival was similar in patients with T2 and T3 disease (p = 0.77). Progressive disease (PD) was experienced in 28.0% and the median time to PD was 9.0 months (range 4.6–44.3 months). Overall progression-free survival was 95.3%, 72.1% and 64.1% after 0.5-, 1- and 2-years. Effects of initial therapy on TSEBT treatment response and side effects to TSEBT were also analyzed. Conclusion. In conclusion, the present study confirms that high-dose TSEBT is an effective, but generally not a curative therapy in the management of CTCL. High-dose treatment yielded significantly better results than low-dose treatment with 4 Gy. TSEBT offers significant palliation in most patients when other skin-directed or systemic treatments have failed.

Topical nitrogen mustard therapy in patients with mycosis fungoides or parapsoriasis

Backgroundu2002 Topical nitrogen mustard is a chemotherapeutic agent used in treatment of mycosis fungoides (MF).

Topical nitrogen mustard therapy in patients with Langerhans cell histiocytosis.

Backgroundu2002 Langerhans cell histiocytosis (LCH) is characterized by abnormal proliferation and infiltration of Langerhans cells in different organs. The skin is frequently involved either as unisystem or multisystem disease.

Subsequent cancers, mortality, and causes of death in patients with mycosis fungoides and parapsoriasis: A Danish nationwide, population-based cohort study

BACKGROUNDnData on subsequent cancers, prognostic factors for mortality, and causes of death are limited in mycosis fungoides (MF) and parapsoriasis.nnnOBJECTIVESnTo assess subsequent cancers, mortality, and causes of death in MF and parapsoriasis.nnnMETHODSnUsing the Danish nationwide population-based registries, we identified 368 MF patients and 582 parapsoriasis patients and compared them with the general Danish population for subsequent cancers, mortality, and causes of death.nnnRESULTSnSubsequent cancers were significantly increased in parapsoriasis patients (standardized incidence ratio [SIR], 2.0 [95% confidence interval {CI}, 1.6-2.5]), and a trend was observed in MF (SIR, 1.2 [95% CI, 0.9-1.5]). Mortality was significantly increased in MF (SIR, 2.0 [95% CI, 1.8-2.3]) and parapsoriasis (SIR, 1.3 [95% CI, 1.1-1.5]). Excess mortality from MF was highest during the first 5 years of follow-up, and causes of increased death included both malignant and nonmalignant diseases.nnnLIMITATIONSnWe have no information regarding clinical stage, treatments, and patient lifestyles.nnnCONCLUSIONnPatients with parapsoriasis had a significantly increased risk of subsequent cancers and increased mortality. In addition, the highest excess mortality in the MF group was observed during the first 5 years of follow-up, which suggests that MF exists in both an aggressive and a more indolent form.

Postgraduate Multidisciplinary Development Program: Impact on the Interpretation of Pelvic MRI in Patients With Rectal Cancer: A Clinical Audit in West Denmark

BACKGROUND: Pelvic MRI in patients with rectal cancer is an accepted tool for the identification of patients with poor prognostic tumors who may benefit from neoadjuvant therapy. In Denmark, this examination has been mandatory in the workup on rectal cancer since 2002. OBJECTIVE: This study aimed to assess the impact of a multidisciplinary team course for doctors in West Denmark on the technical quality, reporting, and interpretation of pelvic MRI in rectal cancer. DESIGN: This study is interventional and observational. Two expert reviewers served as reference standard in the evaluation of consecutively performed pelvic MRI scans against which the evaluations from the participating centers were compared. SETTINGS: Five imaging centers in West Denmark performed pelvic MRI in rectal cancer from March 1 to December 31, 2007. PATIENTS: One hundred and eighty patients with newly diagnosed rectal cancer were enrolled. INTERVENTIONS: This study involved a multidisciplinary team course including on-site visits. MAIN OUTCOME MEASURES: The MR scans were evaluated concerning technical performance, reporting, interpretation, and the ability to correctly allocate patients to chemoirradiation based on imaging findings pre- and postcourse. RESULTS: Eighteen percent of the scans were of satisfying technical quality for staging rectal cancer before the course compared with 74% after (P < .001). After the course, the T-stage subclassification, the depth of extramural spread, the N stage, and the presence of extramural vascular invasion was reported significantly more frequently. Based on imaging findings, we observed no significant effect on the ability to perform correct treatment stratification according to Danish guidelines. LIMITATIONS: The evaluation process itself may have improved the performance of the participating centers. CONCLUSIONS: Performance and reporting of pelvic MRI in patients with rectal cancer can be improved significantly through multidisciplinary development courses and on-site visits, whereas improvements in image interpretation with regard to treatment stratification may demand more intensive efforts.