Background: Fatigue, dyspnea, and lack of energy and concentration are commonly interpreted as indicative of symptomatic anemia and may thus play a role in diagnostic and therapeutic decisions. Objective: To investigate the association between symptoms commonly attributed to anemia and the actual presence of anemia. Methods: Data from two independent cohorts of the Study of Health in Pomerania (SHIP) were analyzed. Interview data, laboratory data, and physical examination were individually linked with claims data from the Association of Statutory Health Insurance Physicians. A complete case analysis using logistic regression models was performed to evaluate the association of anemia with symptoms commonly attributed to anemia. The models were adjusted for confounders such as depression, medication, insomnia, and other medical conditions. Results: A total of 5979 participants (53% female, median age 55) were included in the analysis. Of those, 30% reported fatigue, 16% reported lack of energy, 16% reported lack of concentration, and 29% reported dyspnea and/or weakness. Anemia was prevalent in about 6% (379). The symptoms were more prevalent in participants with anemia. However, participants with anemia were older and had a poorer health status. There was no association in multivariate logistic regression models between the symptoms fatigue, lack of concentration, dyspnea, and/or weakness and anemia. Anemia was associated (OR: 1.45; 95% CI: 1.13–1.86) with lack of energy in the multivariate analysis. Other factors such as depression, insomnia, and medication were more strongly associated with the symptoms. Conclusion: The clinical symptoms commonly attributed to anemia are unspecific and highly prevalent both in non-anemic and anemic persons. Even in the presence of anemia, other diagnoses should be considered as causes such as depression, heart failure, asthma, and COPD, which are more closely associated with the symptoms. Further diagnostic research is warranted to explore the association of symptoms in different subgroups and settings in order to help clinical decision making.

Background: Thyroid disorders are common in the adult German population. Little is known about guideline implementation in clinical practice and the prevalence of diagnostic procedures in ambulatory care. The study aims to investigate the use of thyroid hormone measurements, thyroid ultrasound, thyroid scintiscan and associated costs in ambulatory care at population level.Methods: Data were derived from two independent population-based cohorts of the Study of Health In Pomerania (SHIP). Ambulatory billing data from the Association of Statutory Health Insurance Physicians Mecklenburg-Vorpommern were individually linked for the period 2002–2016 with SHIP data. The main outcomes were the frequency of outpatient ultrasound, scintiscan, serum TSH level measurement, free triiodothyronine (fT3) and free thyroxine (fT4) measurement, TSH-receptor-antibodies and microsomal antibodies measurement within 1 year and 3 years prior to the study entrance of the participants. Multinomial logistic regression models were used to assess the association of age, sex, thyroid medication intake and Charlson-Comorbidity-Index with frequency of TSH measurements and ultrasound examinations.Results: A total of 5552 participants (47% male, median age 55) were included in the analysis. 25% (1409/5552) had a diagnosed thyroid disorder or treatment, 40% (2191/5552) had clinical findings based on ultrasound or laboratory testing in SHIP only and 35% (1952/5552) neither a coded thyroid disorder or clinical finding nor thyroid medication. In the total study population 30% (1626/5552) received at least one TSH measurement, 6.8% (378/5552) at least one thyroid ultrasound and 2.6% (146/5552) at least one scintiscan within the past year before the study examination. Tests were performed more frequently in patients with thyroid medication and coded thyroid disorders. Hence, this group caused the highest expenditures.Conclusions: Given the high prevalence of thyroid disorders, diagnostic and monitoring tests should be used rationally with regard to costs. TSH levels should be monitored regularly in patients on thyroid medication. A consensus on monitoring frequency and iteration of monitoring of morphological thyroid disorders with TSH and ultrasound and specific guideline recommendations are needed.Trial registration: Versorgungsforschung Deutschland (VfD_17_003880).

Background: Low back pain is a common reason for patients to seek medical care. Physician non-adherence to clinical guidelines has been observed. We investigated the extent to which patient expectations correspond to recommendations of the German national guideline for management of low back pain (G-LBP) and whether patient characteristics, history of LBP and previous treatment experience are associated with expectations.Methods: A cross-sectional study including patients from 13 general practices was conducted. Data were collected using a questionnaire. Inverse probability weights were used to address non-response bias. Descriptive analysis and multivariate logistic regression models were performed.Results: A total of 977 patients were included in analyses (median age 57 years, 39% male). 75% of patients reported experiencing LBP currently or within the last year. More than 65% indicated they would agree to forgo further examinations if their LBP was judged by their physician to be of no serious concern. This was associated with the highest level of education and no prior imaging, and negatively associated with good-to-poor health status and moderate-to-severe pain intensity. 40% of participants expected imaging. The highest educational level, female gender and no prior imaging were associated with a decreased expectation of imaging. 70% expected prescriptions for massages. Females, participants with good-to-poor health status, current LBP or LBP in the last 12 months had an increased expectation for massages. Expectations for injection therapy (45%) were mainly associated with previous injections. Expectations for physiotherapy (64%) were associated with female gender, lower educational level, good-to-poor health status, current LBP or in the last 12 months. The perspective that daily activities should be continued (66%) was associated with female gender and higher educational level. Participants who agreed to the statement ‘There is no effective treatment for LBP’ (11%) had a poor health status, current LBP and a severe pain intensity.Conclusion: Patient views regarding LBP management are partially concordant with guideline recommendations and are strongly influenced by previous treatment experiences and education level. Exploration of patient expectations and experiences in LBP treatment may help minimize dissatisfaction of patients expecting treatments not endorsed by guidelines and simultaneously increase physician guideline adherence.

Background: Ear irrigation is a commonly used method for removing earwax in general practice. There is no firm evidence if no pre-treatment is as good as pre-treatment with various standard preparations. Aim: To assess the effectiveness of no pre-treatment compared to pre-treatment with commercially available cerumenolytics and to assess which preparation is best suited for pre-treatment. Methods: This is a pragmatic observational study of patients with cerumen treated from a single GP with 3 different preparations or no preparation prior to standardized ear irrigation. Generalized linear mixed models with logit link function were performed to assess the effectiveness of pre-treatment with different preparations and no pre-treatment. The models were adjusted for age group (<70, ≥70) and sex. Results: A total of 168 patients (298 ears, 58 % female, median age 65 years) consulted for obstructive cerumen, some of them several times. The cerumen was successfully removed in 70% (208/298). Comparing any preparation to no preparation (aggregated comparison), the odds ratio for complete clearance was 1.35 (95%confidence interval: 0.69-2.65). Comparing the preparations individually, the odds ratio of the docusate-sodium-based preparation was 1.87 (95% CI: 0.79-4.42) indicating a higher effectiveness. Although, not statistically significant. Ear irrigation was less successful for patients aged ≥ 70 years (OR = 0.48, 95% CI: 0.23-0.98). Conclusions: The aggregated comparison indicates a slight trend toward a higher effectiveness of any pre-treatment compared to no pre-treatment. The effect-size of docusate-sodium-based pre-treatment indicates a higher effectiveness of cerumen impaction removal. Nevertheless, superiority could not be shown conclusively according to the statistical significance given the restricted sample size.

Objective: Thyroid disorders are common. Information on the long-term progression of morphologic disorders is scarce. The aim of this study was to describe the course of thyroid nodules and volume over a period of up to 10 years. Design and Methods: Data from the population-based Study of Health in Pomerania were used for longitudinal analysis of 10 years, on average. Billing data from the Association of Statutory Health Insurance Physicians were matched to the data to exclude participants with thyroid surgery, radioiodine therapy and thyroid carcinoma. Changes in the number and size of thyroid nodules and thyroid volume were observed using ultrasound. Results: A total of 1270 participants were included (53% female, median age at baseline 51 years). The proportion of subjects with at least one thyroid nodule increased from 34.9 to 47.5% after 10 years. The majority of participants had an unchanged or reduced number of nodules. About one-quarter had at least one nodule of size ≥ 1 cm. The proportion of participants with goitre increased from 35 to 37% after 10 years. Nevertheless, individual thyroid volume increased by < 1 mL (95% CI: 0.38–3.66) after adjusting for age and BMI irrespective of thyroid medication. Conclusion: Thyroid nodules and goitre are common. After 10 years, the number of nodules did not increase in about 70% of people. This proportion did not differ substantially when excluding people with thyroid medication. Thyroid volume increased slightly over the follow-up period. These changes do not seem clinically relevant. Our results support a more restrictive approach regarding follow-up diagnostics in asymptomatic patients with thyroid nodules or minimally enlarged thyroid.