How do parents experience video triage when seeking care for their acute ill children? A qualitative study in a Danish out-of-hours primary care setting.

OBJECTIVE: The objective is to explore parents' experiences with telephone contacts to out-of-hours primary care (OOH-PC) that include use of one-way video (video triage). DESIGN: A qualitative interview study using Braun and Clarke's thematic analysis approach. SETTING: OOH-PC in the Central Denmark Region. PARTICIPANTS: A convenience sampling strategy was used to include parents of young children (aged 1-5 years), who received video triage in OOH-PC: nine women and one man aged 31-42 years. Data were collected from 26 April to 23 May 2023. RESULTS: Three main themes were developed, each containing two subthemes: Theme 1. Video triage accelerates diagnostic clarity and prompt action, enhancing feeling of safety: Parents experienced that video triage provided faster diagnostic clarification than telephone triage. The visual assessment in video triage reduced uncertainties of describing symptoms and increased the parents' feeling of safety. Theme 2. Video triage changed the communicative and relational behaviour: Parents found video triage impersonal as it focused on the physical examination. The conversation before activation of video was found important, as it established a feeling of trust and reassurance. Theme 3. Experiences of presence and involvement in video triage: Parents found their active involvement in video triage challenging, as it required divided attention and shared responsibility. CONCLUSIONS: Our study indicates the importance of paying attention to the changes in communication and consultation processes afforded by the implementation of one-way video triage. One-way video triage is experienced as a valuable tool for examination, yet it is also perceived to impair the building of trust in the patient-physician relationship.

Reasons for encounter in video contacts at a Danish out-of-hours primary care service: a questionnaire study.

OBJECTIVE: To investigate reasons for encounter in telephone triage contacts to an out-of-hours primary care service for which general practitioners (GPs) use video consultations (video contact), overall and stratified for patient age and time of day. DESIGN: A cross-sectional questionnaire study among GPs doing telephone triage in an out-of-hours primary care service. The questionnaire was integrated into the electronic patient registration system, popping up after every third video contact. This setup automatically linked patient register data, including age and sex, with the questionnaire data. SETTING: The study was conducted from 5 September 2022 to 21 December 2022 at the out-of-hours primary care service in the Central Denmark Region. PARTICIPANTS: 649 volunteer GPs who answered 2452 questionnaires. MAIN OUTCOME MEASURES: Reasons for encounter in video contacts registered with codes from International Classification of Primary Care (ICPC) coding system, V.2 (ICPC-2). RESULTS: GPs doing telephone triage in out-of-hours primary care used video contacts for a broad range of ICPC-2 codes within few ICPC-2 chapters. 83% of all reasons for encounter were due to symptoms in chapters S 'Skin' (34.5%), R 'Respiratory' (21.8%), A 'General and unspecified' (14.7%) and L 'Musculoskeletal' (12.0%) in the ICPC-2 classification system. Video contacts concerning skin and musculoskeletal symptoms were more frequent among older children and adults compared with young children. Respiratory symptoms and general and unspecified symptoms dominated by fever were more frequent among video contacts for young children compared with older children and adults. CONCLUSION: Our study suggests a focused use of video contacts in an out-of-hours primary care setting; the majority of registered ICPC-2 codes were within few ICPC-2 chapters.

The impact of the COVID-19 pandemic on antibiotic prescription rates in out-of-hours primary care - a register-based study in Denmark.

BACKGROUND: Antibiotic prescription rates can be affected by pandemic measures such as lockdowns, social distancing, and remote consultations in general practice. Therefore, such emergency states may negatively affect antimicrobial stewardship, specifically in out-of-hours (OOH) primary care. As contact patterns changed in the COVID-19 pandemic, it would be relevant to explore the impact on antimicrobial stewardship. AIM: To study the impact of the pandemic on antibiotic prescription rates in OOH primary care, overall and per age group. METHODS: This cross-sectional register-based study used routine data from OOH primary care in the Central Denmark Region. We included all patient contacts in two equivalent time periods: pre-pandemic and pandemic period. The main outcome measure was defined as the number of antibiotic prescriptions per contact (antibiotic prescription rate). RESULTS: The overall antibiotic prescription rate decreased during the first year of the pandemic compared to the pre-pandemic period (RR = 0.97, 95%CI: 0.96-0.98). Likewise, the rate decreased for clinic consultations (RR = 0.63, 95%CI: 0.62-0.64). However, an increase was seen for telephone consultations (RR = 1.73, 95%CI: 1.70-1.76). The decline in clinic consultations was largest for consultations involving children aged 0-10 years (RR = 0.53, 95%CI: 0.51-0.56). CONCLUSION: Antibiotic prescription rates in Danish OOH primary care decreased during the first year of the COVID-19 pandemic, especially for young children. Prescription rates decreased in clinic consultations, whereas the rates increased in telephone consultations. Further research should explore if antibiotic prescription rates have returned to pre-pandemic levels, and if the introduction of video consultations has affected antibiotic prescription patterns in OOH primary care.

Evidence for time-reversal symmetry-breaking kagome superconductivity.

Superconductivity and magnetism are often antagonistic in quantum matter, although their intertwining has long been considered in frustrated-lattice systems. Here we utilize scanning tunnelling microscopy and muon spin resonance to demonstrate time-reversal symmetry-breaking superconductivity in kagome metal Cs(V, Ta)3Sb5, where the Cooper pairing exhibits magnetism and is modulated by it. In the magnetic channel, we observe spontaneous internal magnetism in a fully gapped superconducting state. Under the perturbation of inverse magnetic fields, we detect a time-reversal asymmetrical interference of Bogoliubov quasi-particles at a circular vector. At this vector, the pairing gap spontaneously modulates, which is distinct from pair density waves occurring at a point vector and consistent with the theoretical proposal of an unusual interference effect under time-reversal symmetry breaking. The correlation between internal magnetism, Bogoliubov quasi-particles and pairing modulation provides a chain of experimental indications for time-reversal symmetry-breaking kagome superconductivity.

Task shifting from general practitioners to other health professionals in out-of-hours primary care - a systematic literature review on content and quality of task shifting.

BACKGROUND: Task shifting from general practitioners (GPs) to other health professionals could solve the increased workload, but an overview of the evidence is lacking for out-of-hours primary care (OOH-PC). OBJECTIVES: To evaluate the content and quality of task shifting from GPs to other health professionals in clinic consultations and home visits in OOH-PC. METHODS: Four database literature searches were performed on 13 December 2021, and updated in August 2023. We included articles that studied content (patient characteristics, reason for encounter) and/or quality (patient satisfaction, safety, efficiency) of task shifting in face-to-face contacts at OOH-PC. Two authors independently screened articles for inclusion and assessed the methodological quality of included articles using the JBI critical appraisal checklist. Data was extracted and results were synthesised in a narrative summary. RESULTS: The search identified 1,829 articles, resulting in the final inclusion of seven articles conducted in the UK or the Netherlands. Studies compared GPs with other health professionals (mainly nurses). These other health professionals saw patients with less urgent health problems, younger patients, and patients with less complex health problems than GPs. Most studies concluded that other health professionals provided safe and vastly efficient care corresponding to the level of GPs but findings about productivity were inconclusive. CONCLUSION: The level of safety and efficiency of care provided by other health professionals in OOH-PC seems like that of GPs, although they mainly see patients presenting with less urgent and less complex health problems.

Task shifting from general practitioners to other health professionals could increase treatment capacity in out-of-hours primary care.Task shifting occurs for care to patients with less urgent and less complex health issues.The long-term implications of task shifting in out-of-hours primary care should be investigated.

Use of Video in Telephone Triage in Out-of-Hours Primary Care: Register-Based Study.

Background: Out-of-hours primary care (OOH-PC) is challenging due to high workloads, workforce shortages, and long waiting and transportation times for patients. Use of video enables triage professionals to visually assess patients, potentially ending more contacts in a telephone triage contact instead of referring patients to more resource-demanding clinic consultations or home visits. Thus, video use may help reduce use of health care resources in OOH-PC. Objective: This study aimed to investigate video use in telephone triage contacts to OOH-PC in Denmark by studying rate of use and potential associations between video use and patient- and contact-related characteristics and between video use and triage outcomes and follow-up contacts. We hypothesized that video use could serve to reduce use of health care resources in OOH-PC. Methods: This register-based study included all telephone triage contacts to OOH-PC in 4 of the 5 Danish regions from March 15, 2020, to December 1, 2021. We linked data from the OOH-PC electronic registration systems to national registers and identified telephone triage contacts with video use (video contact) and without video use (telephone contact). Calculating crude incidence rate ratios and adjusted incidence rate ratios (aIRRs), we investigated the association between patient- and contact-related characteristics and video contacts and measured the frequency of different triage outcomes and follow-up contacts after video contact compared to telephone contact. Results: Of 2,900,566 identified telephone triage contacts to OOH-PC, 9.5% (n=275,203) were conducted as video contacts. The frequency of video contact was unevenly distributed across patient- and contact-related characteristics; it was used more often for employed young patients without comorbidities who contacted OOH-PC more than 4 hours before the opening hours of daytime general practice. Compared to telephone contacts, notably more video contacts ended with advice and self-care (aIRR 1.21, 95% CI 1.21-1.21) and no follow-up contact (aIRR 1.08, 95% CI 1.08-1.09). Conclusions: This study supports our hypothesis that video contacts could reduce use of health care resources in OOH-PC. Video use lowered the frequency of referrals to a clinic consultation or a home visit and also lowered the frequency of follow-up contacts. However, the results could be biased due to confounding by indication, reflecting that triage GPs use video for a specific set of reasons for encounters.

Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark.

BACKGROUND: Point-of-care testing may reduce diagnostic uncertainty in case of suspicion of bacterial infection, thereby contributing to prudent antibiotic prescribing. We aimed to study variations in the use of point-of-care tests (C-reactive protein test, rapid streptococcal antigen detection test, and urine dipstick) among general practitioners (GPs) and the potential association between point-of-care testing and antibiotic prescribing in out-of-hours general practice. METHODS: We conducted a population-based observational register-based study, based on patient contacts with out-of-hours general practice in the Central Denmark Region in 2014-2017. The tendency of GPs to use point-of-care testing was calculated, and the association between the use of point-of-care testing and antibiotic prescribing was evaluated with the use of binomial regression. RESULTS: Out-of-hours general practice conducted 794,220 clinic consultations from 2014 to 2017, of which 16.1% resulted in an antibiotic prescription. The GP variation in the use of point-of-care testing was largest for C-reactive protein tests, with an observed variation (p90/p10 ratio) of 3.0; this means that the GPs in the 90th percentile used C-reactive protein tests three times as often as the GPs in the 10th percentile. The observed variation was 2.1 for rapid streptococcal antigen detection tests and 1.9 for urine dipsticks. The GPs who tended to use more point-of-care tests prescribed significantly more antibiotics than the GPs who tended to use fewer point-of-care tests. The GPs in the upper quintile of the tendency to use C-reactive protein test prescribed 22% more antibiotics than the GPs in the lowest quintile (21% for rapid streptococcal antigen detection tests and 8% for urine dipsticks). Up through the quintiles, this effect exhibited a positive linear dose-response correlation. CONCLUSION: The GPs varied in use of point-of-care testing. The GPs who tended to perform more point-of-care testing prescribed more antibiotics compared with the GPs who tended to perform fewer of these tests.

Video consultation in general practice during COVID-19: a register-based study in Denmark.

BACKGROUND: During the COVID-19 pandemic, general practices in Denmark rapidly introduced video consultations (VCs) to prevent viral transmission. AIM: To study the use of VCs in daytime general practice by describing the rate of VCs, and the patient characteristics associated with having VCs. DESIGN & SETTING: Register-based study of consultations in daytime general practice in Denmark. METHOD: We included all consultations in daytime general practice from 1 January 2019-30 November 2021. We calculated the rate of video use and categorised the general practices into no, low, and high use. Logistic regression was used to calculate adjusted odds ratios (aOR) for having a VC for different patient characteristics when contacting a video-using practice, stratified for low- and high-using practices. RESULTS: A total of 30 148 478 eligible consultations were conducted during the pandemic period. VCs were used mostly during the early stage pandemic period, declining to about 2% of all clinic consultations in the late-stage period. Patients having more VCs were young, had a long education, were employed, and lived in big cities. In low-using practices, native Danes and 'western' immigrants had higher odds of receiving a VC than 'non-western' immigrants, and patients with ≥2 comorbidities had lower odds than those without comorbidities. CONCLUSION: Patients of a younger age, with long education, or employment had higher odds of receiving a VC, while patients of an older age and patients who had retired had lower odds. This difference in the access to VCs warrants further attention.

Flocculating and dewatering of lake sediment: An in-situ pilot study comparing synthetic polymers and biopolymers for restoring lake water quality and reusing phosphorus.

Dredging of lake sediment is a method to remove accumulated phosphorus and nitrogen in lakes and thereby reducing the risk of eutrophication. After dredging, the sediment is dewatered to reduce the volume. It is important to get a high dry matter content and ensure that the filtrate does not contain harmful compounds so it can be returned to the lake. A pilot-scale belt filter and flexible intermediate bulk containers (FIBC) were used for dewatering lake sediment with the sediment treated with a synthetic polymer or three different biopolymers. The goal of the study was to retain the phosphorus in the filter cake while returning the filtrate to the lake with a minimal phosphorus content. Results showed dry matter content of up to 16 % in the dewatered sediment and the sediment retained 96-99 % of the phosphorus. Furthermore, nitrogen was reduced by 27-71 % in the filtrate water. Toxicity tests found low ecotoxicity for most biopolymer filtrates, whereas synthetic polymer showed the highest potential ecotoxicity. Consequently, biopolymers provided satisfactory results, proving more environmentally friendly despite requiring longer filtration time.

Urticaria.

Urticaria is a frequent skin condition presenting with wheals, angioedema or both due to the activation of mast cells. Acute urticaria (less-than 6 weeks duration) is associated with infections and allergies, whereas chronic urticaria (≥ 6 weeks) is either spontaneous (chronic spontaneous urticaria (CSU)), inducible or both. Quality of life (QoL) is frequently impaired. The pathogenesis of CSU is often of an autoimmune nature. As argued in this review, the treatment aims to restore QoL with a stepwise approach, most often using second-generation H1-antihistamines, omalizumab and cyclosporine.

Membrane fouling monitoring by 3ω sensing.

Membrane fouling significantly reduces membrane permeability, leading to higher operational expenses. In situ monitoring of membrane fouling can potentially be used to reduce operation cost by optimizing operational parameters and cleaning conditions. In this study, a platinum wire with a diameter of 20 µm was attached to the surface of a ceramic ultrafiltration membrane, and by measuring the voltage across the wire while applying an AC current, the amplitude of the third harmonic wave, the so-called 3ω signal, was obtained. Results showed increasing 3ω signals during formation of fouling layers, which correlates directly to the hydraulic resistance of the formed fouling layer in semi-dead end filtration of polymeric core shell particles and crossflow filtration of diluted milk. This is explained by the insulating effect of the fouling layers which reduces heat convection by crossflow and the different thermal conductivity in the fouling layer compared with the feed. After membrane cleaning, the permeability and the magnitude of the 3ω signal were partly restored, showing that the 3ω method can be used to monitor the effect of cleaning. The frequency of the AC current was varied so it was possible to measure the heat conductivity in the fouling layer (high frequency) and heat convection due to cross-flow (low frequency). This may potentially be used to get information of the type of fouling (heat conductivity) and thickness of the fouling layer (AC frequency where heat conductivity becomes dominating).

Factors associated with undertriage and overtriage in telephone triage in Danish out-of-hours primary care: a natural quasi-experimental cross-sectional study of randomly selected and high-risk calls.

OBJECTIVES: We aim to explore undertriage and overtriage in a high-risk patient population and explore patient characteristics and call characteristics associated with undertriage and overtriage in both randomly selected and in high-risk telephone calls to out-of-hours primary care (OOH-PC). DESIGN: Natural quasi-experimental cross-sectional study. SETTING: Two Danish OOH-PC services using different telephone triage models: a general practitioner cooperative with GP-led triage and the medical helpline 1813 with computerised decision support system-guided nurse-led triage. PARTICIPANTS: We included audio-recorded telephone triage calls from 2016: 806 random calls and 405 high-risk calls (defined as patients ≥30 years calling with abdominal pain). MAIN OUTCOME MEASURES: Twenty-four experienced physicians used a validated assessment tool to assess the accuracy of triage. We calculated the relative risk (RR) for clinically relevant undertriage and overtriage for a range of patient characteristics and call characteristics. RESULTS: We included 806 randomly selected calls (44 clinically relevant undertriaged and 54 clinically relevant overtriaged) and 405 high-risk calls (32 undertriaged and 24 overtriaged). In high-risk calls, nurse-led triage was associated with significantly less undertriage (RR: 0.47, 95% CI 0.23 to 0.97) and more overtriage (RR: 3.93, 95% CI 1.50 to 10.33) compared with GP-led triage. In high-risk calls, the risk of undertriage was significantly higher for calls during nighttime (RR: 2.1, 95% CI 1.05 to 4.07). Undertriage tended to be more likely for calls concerning patients ≥60 years compared with 30-59 years (11.3% vs 6.3%) in high-risk calls. However, this result was not significant. CONCLUSION: Nurse-led triage was associated with less undertriage and more overtriage compared with GP-led triage in high-risk calls. This study may suggest that to minimise undertriage, the triage professionals should pay extra attention when a call occurs during nighttime or concerns elderly. However, this needs confirmation in future studies.

Development over time in point-of-care test use in Danish daytime and out-of-hours general practice: a register-based study.

OBJECTIVE: To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT). DESIGN AND SETTINGS: A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018. SUBJECTS: All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period. MAIN OUTCOME MEASURES: We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use. RESULTS: Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40-59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0-19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing. CONCLUSION: The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal.Key pointsCRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting.There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018.CRP POCTs were associated with age of 40-59 years and co-morbidity, while the use of RADT was mostly associated with younger age.

Interprofessional team-based collaboration between designated GPs and care home staff: a qualitative study in an urban Danish setting.

BACKGROUND: Being a general practitioner for residents in many care homes may challenge communication with residents, relatives, and care home staff, and potentially lead to lower quality of care. Several countries have therefore introduced different solutions to reduce the number of general practitioners at each care home. In 2017, the designated general practitioner model was introduced at many Danish care homes. This study aimed to evaluate experiences from the interprofessional team-based collaboration between designated general practitioners and care home staff with regular contact with the designated general practitioners in an urban Danish setting. METHODS: A qualitative design was applied using semi-structured interviews. Eight interviews (three group interviews and five individual interviews) were conducted with four designated general practitioners and seven care home staff members at four care homes in an urban setting of Central Denmark Region, Denmark. The interviews were transcribed verbatim, and data were analysed using content analysis with inspiration from the theory of relational coordination. The study followed the guidelines addressed in the COREQ (Consolidated Criteria for Reporting Qualitative Research) framework. RESULTS: The initiation of the designated general practitioner model was experienced to contribute to more clear, precise, and timely communication between care homes and the general practitioner. An improved mutual acknowledgement of roles and competencies was experienced between designated general practitioners, care home nurses, and sometimes also social and health care assistants. The more frequent visits by the general practitioners at the care homes, as a result of the designated general practitioner model, resulted in more face-to-face communication between care home staff and designated general practitioners. Professional differences in the interpretation of the patient's needs were still present, which at times caused a frustrating compromise of own professional competencies. An important reason for the overall perception of improved collaboration was attributed to the more frequent dialogue in which the care homes staff and the designated general practitioners exchanged knowledge that could be applied in future patient encounters. CONCLUSION: The designated general practitioner model implied an improved collaboration between general practitioners and care homes staff. Clear, precise, and timely communication between care homes and the general practitioners, as well as mutual trust and acknowledgement was experienced to be essential for the collaboration. An important reason for the overall perception of an improved collaboration was attributed to the more frequent dialogue (more frequent general practitioner visits at the care homes) in which the care homes staff and the designated general practitioners exchange knowledge which again could be applied in future patient encounters.

Synthetic and biopolymers for lake restoration - An evaluation of flocculation mechanism and dewatering performance.

In the frame of the global phosphorus (P) crisis and ongoing eutrophication issues in the environmental sector, lake sediment can be considered as an alternative P source after its removal from eutrophic lakes. However, high water contents make sediment dewatering a crucial step towards the efficient reusability of remaining solids. The application of polymeric substances facilitates solid-liquid separation by flocculation of suspended particles. To lower the environmental risk of contamination with toxic, non-biodegradable monomeric residues during and after the application of synthetic polyacrylamide(PAM)-based polymers, switching to natural polymeric substances (biopolymers), e.g., starch- or chitosan-based, is increasingly emphasized. The dewatering performance of four conventional PAM-based polymers was compared to two starch- and one chitosan-based biopolymer. Laboratory experiments were conducted to determine the dewatering rate, floc size and strength, and reject water quality. Biopolymers generally caused the formation of smaller but less shear-sensitive flocs, and lower P levels in the reject water compared to synthetic polymers. Dewatering performance was correlated to the most important functioning influencing polymer-specific properties intrinsic viscosity (polymer extension) and surface charge density (CD). Due to the high CD and low intrinsic viscosity of the biopolymers, electrostatic patch flocculation seems to be the favored flocculation mechanism, while for synthetic polymers bridging seems to be dominating. Solid-liquid separation technologies should be adjusted to the resulting floc size and structure, while surface CD and intrinsic viscosity are important properties for the choice of biopolymer. Overall, biopolymers can function as a more environmentally friendly alternative to synthetic products for lake sediment dewatering accompanied by the potential for P recovery.

Tracking structural solvent reorganization and recombination dynamics following e- photoabstraction from aqueous I- with femtosecond x-ray spectroscopy and scattering.

We present a sub-picosecond resolved investigation of the structural solvent reorganization and geminate recombination dynamics following 400 nm two-photon excitation and photodetachment of a valence p electron from the aqueous atomic solute, I-(aq). The measurements utilized time-resolved X-ray Absorption Near Edge Structure (TR-XANES) spectroscopy and X-ray Solution Scattering (TR-XSS) at the Linac Coherent Light Source x-ray free electron laser in a laser pump/x-ray probe experiment. The XANES measurements around the L1-edge of the generated nascent iodine atoms (I0) yield an average electron ejection distance from the iodine parent of 7.4 ± 1.5 Å with an excitation yield of about 1/3 of the 0.1M NaI aqueous solution. The kinetic traces of the XANES measurement are in agreement with a purely diffusion-driven geminate iodine-electron recombination model without the need for a long-lived (I0:e-) contact pair. Nonequilibrium classical molecular dynamics simulations indicate a delayed response of the caging H2O solvent shell and this is supported by the structural analysis of the XSS data: We identify a two-step process exhibiting a 0.1 ps delayed solvent shell reorganization time within the tight H-bond network and a 0.3 ps time constant for the mean iodine-oxygen distance changes. The results indicate that most of the reorganization can be explained classically by a transition from a hydrophilic cavity with a well-ordered first solvation shell (hydrogens pointing toward I-) to an expanded cavity around I0 with a more random orientation of the H2O molecules in a broadened first solvation shell.

Contacts in general practice during the COVID-19 pandemic: a register-based study.

BACKGROUND: The COVID-19 pandemic has altered the provision of health care and expanded telehealth consultations. AIM: To study the effect of the COVID-19 pandemic on contact patterns in general practice, and to identify patient groups at risk of losing care. DESIGN AND SETTING: Register-based study of Danish general practice, including daytime and out-of-hours (OOH) services. METHOD: All individuals residing in Denmark from 1 January 2017 to 31 October 2020 were included. The incidence rate for six contact types in general practice and adjusted incidence rate ratio were calculated by comparing the incidence rate in the pandemic period with the adjusted expected incidence rate based on the incidence rate in the pre-pandemic period. RESULTS: The number of face-to-face in-clinic consultations declined during the lockdown in March 2020. A subsequent increase in the number of clinic consultations was observed, rising to a level above that of the pre-pandemic period; this increase resulted mainly from the introduction of telehealth consultations (that is, video and extended telephone). The number of daytime email consultations increased, whereas the number of daytime home visits decreased. Likewise, the number of OOH telephone consultations increased, whereas the number of OOH home visits and clinic consultations decreased. Consultation rates of patients who are vulnerable, that is, those with low education, old age, and comorbidity, were most adversely affected by the pandemic. The most adverse impact in OOH clinic consultations was seen for children aged 0-9 years. CONCLUSION: New methods are called for to ensure access to general practice for patients who are vulnerable during a pandemic. The potential of telehealth consultations should be further investigated.

Distance decay 2.0 - A global synthesis of taxonomic and functional turnover in ecological communities.

Aim: Understanding the variation in community composition and species abundances (i.e., ß-diversity) is at the heart of community ecology. A common approach to examine ß-diversity is to evaluate directional variation in community composition by measuring the decay in the similarity among pairs of communities along spatial or environmental distance. We provide the first global synthesis of taxonomic and functional distance decay along spatial and environmental distance by analysing 148 datasets comprising different types of organisms and environments. Location: Global. Time period: 1990 to present. Major taxa studied: From diatoms to mammals. Method: We measured the strength of the decay using ranked Mantel tests (Mantel r) and the rate of distance decay as the slope of an exponential fit using generalized linear models. We used null models to test whether functional similarity decays faster or slower than expected given the taxonomic decay along the spatial and environmental distance. We also unveiled the factors driving the rate of decay across the datasets, including latitude, spatial extent, realm and organismal features. Results: Taxonomic distance decay was stronger than functional distance decay along both spatial and environmental distance. Functional distance decay was random given the taxonomic distance decay. The rate of taxonomic and functional spatial distance decay was fastest in the datasets from mid-latitudes. Overall, datasets covering larger spatial extents showed a lower rate of decay along spatial distance but a higher rate of decay along environmental distance. Marine ecosystems had the slowest rate of decay along environmental distances. Main conclusions: In general, taxonomic distance decay is a useful tool for biogeographical research because it reflects dispersal-related factors in addition to species responses to climatic and environmental variables. Moreover, functional distance decay might be a cost-effective option for investigating community changes in heterogeneous environments.