A quality assurance study of the development of quality of care in outpatient clinics for treatment of addiction in Greenland.

INTRODUCTION: In 2016, a new addiction treatment service, Allorfik, was introduced in Greenland. Allorfik has, throughout the implementation and after, used auditing of patient records with feedback to develop the quality of care in treatment. Audits and feedback are routinely done in each treatment center. This study wishes to investigate the development of the quality of treatment through the case notes from the journal audits. METHODOLOGY: This study is based on case notes audits from 2019, 2020 and 2021. In the audits, the focus has been on the quality of documentation and content for ten specific areas in each patient record. Each area was scored on a Likert scale of 0-4 for both outcomes. Statistical analyses were done using Stata 17, and P-values < 0.05 were considered statistically significant. We present baseline characteristics for patients and illustrate the development of quality for both outcomes as time trends with scatter plots. RESULTS: The analysis was based on data from 454 patients and audits of their case notes. The mean number of weeks in treatment is 12.72, and the mean age for the people in the audited case notes is 39. Time had a positive effect on both outcomes, and so each month, documentation increased by 0.21 points (p-value = <0.001), and content increased by 0.27 points (p-value = <0.001). CONCLUSION: For documentation and content, the quality level has increased significantly with time, and the quality of case notes is at an excellent level at the final audits of all treatment centers.

Screening of coexisting depression or anxiety disorders among Danish patients with alcohol use disorder in outpatient treatment.

BACKGROUND: Depression and anxiety are highly prevalent among patients seeking outpatient treatment for alcohol use disorders (AUD) and if depression and anxiety are addressed the prognosis is improved. Screening instruments for depression and anxiety have been validated in populations suffering from drug use disorders, but not in populations suffering from AUD. The aim of this study was to validate four self-administrated screening instruments (PHQ-9, GAD-7, Kessler-6, and SRQ) and calculate the optimal cut-off value for identifying depression and anxiety. METHODS: The study included 73 patients with self-reported depression or anxiety during AUD treatment. Each patient filled out the above-mentioned instruments and was subsequently interviewed by trained clinicians blinded to the results of the instruments with the Present State Examination to establish a diagnosis of depression or anxiety according to ICD-10. ROC curves were constructed for each instrument and the area under the curve (AUC) was calculated using patients with no depression or anxiety as reference. Youden's index was calculated to assess the optimal cut-off for each instrument. RESULTS: A total of 33 (45.2%) were diagnosed with depression or anxiety. The AUC for PHQ-9, GAD-7, Kessler-6, and SRQ were 0.767, 0.630, 0.793, and 0.698 respectively. Kessler-6, the instruments performing best based on the AUC, identified 27 (82%) of the 33 patients using a cut-off of 10 points. CONCLUSION: Kessler-6 seems to be valid and reliable in identifying patients requiring treatment for depression or anxiety among patients seeking treatment for AUD who are reporting depression or anxiety.

Relapse prevention for alcohol use disorders: combined acamprosate and cue exposure therapy as aftercare.

AIMS: Many patients with alcohol use disorders are challenged by cravings leading to repeated relapses. Both cue exposure therapy (CET) and acamprosate target alcohol cravings and are often combined (CET + acamprosate). The main aim of this study was to investigate whether aftercare treatment consisting of CET combined with acamprosate is equivalent to (A) CET as monotherapy, (B) aftercare as usual (AAU) as monotherapy or (C) AAU combined with acamprosate. METHODS: Patients were randomized to receive either CET with urge-specific coping skills (USCS) as aftercare or AAU. Acamprosate prescription data were extracted from patient case records. Alcohol consumption, cravings, and USCS were assessed at pre-aftercare, post-aftercare, and 6-month follow-up. RESULTS: Overall, patients increased their alcohol consumption during and following aftercare treatment, thereby relapsing despite any treatment. However, CET + acamprosate achieved greater abstinence compared to AAU + acamprosate at follow-up (p=.047). CET + acamprosate also reduced number of drinking days (p=.020) and number of days with excessive drinking (p=.020) at post-aftercare, when compared to AAU monotherapy. CET monotherapy increased sensible drinking at post-aftercare compared to AAU monotherapy (p=.045) and AAU + acamprosate (p=.047). Only CET monotherapy showed improvement in cravings, when compared to AAU at follow-up (mean urge level: p=.032; peak urge level: p=.014). CONCLUSION: The study showed that CET both as monotherapy and combined with acamprosate was superior to AAU monotherapy and AAU + acamprosate in reducing alcohol consumption. Only CET + acamprosate was capable of reducing alcohol consumption in the longer term, indicating that anti-craving medication may not impede CET from exerting an effect on alcohol consumption. Trial registration: ClinicalTrials.gov ID: NCT02298751 (24/11-2014).

Implementation of AUDIT in the treatment planning process for alcohol use disorder in Greenland.

INTRODUCTION: The aim was to describe the treatment-seeking population with alcohol use disorder by means of data from the AUDIT questionnaire at referral and to evaluate and discuss if this information can be of use in treatment and service planning. METHODS: Data from 2016 to 2018 were extracted from the National Database on Substance Abuse Treatment. The sample included 1281 individual treatment seekers from all over Greenland. RESULTS: Mean age was 38.2 years (SD 12.1 years). Only 60.1% had a total AUDIT score suggesting dependency, and 15.5% had a harmful use. While most only drank 2-4 times a month, about 95% binge drank. Half reported loss of control at least weekly, and one of three had been unable to do what was expected of them, or needed a drink first thing in the morning weekly or more often. In two-third others had been concerned about the drinking. Users of cannabis had a higher AUDIT score, while gambling was unassociated to alcohol use. Substantial gender and regional differences were seen. DISCUSSION: The AUDIT screening was found useful in individual and national treatment planning. Data suggested that particular focus should be given to women in treatment, and the service offered to the East Greenlandic population.

Sustainable weight loss over three years in children with obesity: a pragmatic family-centered lifestyle intervention.

INTRODUCTION: Childhood obesity has psychological consequences and increases the risk of continuous obesity into adulthood, associated with development of non-communicable disease (e.g. type 2 diabetes). Short-term weight loss intervention studies show good results but long-term studies are limited. METHODS: One hundred ninety-nine obese children (4-18 years of age), with a BMI-SDS (standard deviation score) above + 2 SDS were enrolled into a multifactorial family-centered lifestyle intervention study. The children had yearly visits in the outpatient clinic for anthropometrics, blood samples and DXA-scans, and 6-8 meeting with community health workers between these visits. The children followed the intervention up to 3 years. RESULTS: After a follow-up of 26.7 ± 17.5 months a reduction in BMI-SDS of - 0.25 SDS (p < 0.001) was observed. The 57 children who were adherent to the intervention for ≥ 2 years had significantly reduced BMI-SDS compared to the 142 children with shorter intervention (BMI-SDS: - 0.38 ± 0.67 vs. - 0.20 ± 0.50, p = 0.036). All weight loss was accompanied by decrease in fat mass and increase in muscle mass (p < 0.001). CONCLUSION: The intervention was found to induce long-term reduction in BMI-SDS in obese children, with beneficial change in body composition. Children who followed the intervention the longest had the greatest reduction in BMI-SDS. LEVEL OF EVIDENCE: Level III, longitudinal cohort study.

Does establishing local treatment institutions lead to different populations seeking treatment among Greenlandic Inuit?

Introduction: In 2016, a new addiction treatment service was established in Greenland to tackle the addiction problems with alcohol, cannabis and gambling among the population. The new service has established a treatment center in each of the five municipalities and works in partnership with a central private provider of treatment for those who reside in areas without a local treatment center.Methods: The national addiction database provided us with data from the Alcohol Use Disorder Identification Test, Alcohol Severity Index and questions on cannabis use and gambling behavior received at referral to, and at initiation of treatment. The data were analyzed for differences between the population in local or central treatment using SPSS version 25 (SPSS Inc., Chicago, IL).Results: Significant differences between the individuals in local and central treatment were revealed. Individuals in local treatment are more often women with minor children and a job, and their alcohol use is concentrated on weekends/holidays. Individuals in central treatment are more equal in both genders, few have minor children living at home, heavy drinking is more pronounced, and cannabis is used more frequently as well.Discussion: The findings support our expectations of local treatment being more attractive to individuals with obligations at home. The differences in the populations are worth considering when planning the treatment service, as the needs of the populations might differ. The findings are limited by many missing in the analyses, which we believe is caused by the establishing process of the new service.

Outreach visits improve referral of alcohol dependent patients from psychiatric hospital to continued care. A randomized trial.

PURPOSE: Many patients with alcohol use disorder (AUD) fail to initiate outpatient treatment after being discharged from inpatient detoxification. The aim of the present study was to investigate the effect of outreach visits (OV) on subsequent attendance in outpatient AUD treatment. METHODS: Patients admitted to a detoxification unit at a mental health hospital were randomized to either referral as usual (TAU) or OV. OV involved a nurse from the outpatient clinic meeting the patients at the hospital and advising them about outpatient treatment, presenting an 'attendance contract' and offering a first appointment. RESULTS: One hundred consecutive patients were randomized while hospitalized, 55 received TAU and 45 OV. About 84.4% OV patients presented for treatment at the outpatient clinic compared to 58.2% TAU-patients (p = .004). About 46.7% OV patients received continuing care for at least 3 months compared to 23.6% TAU-patients (p = .016). CONCLUSION: OV are an effective strategy for ensuring continued treatment.

Elderly alcoholics compared to middle-aged alcoholics in outpatient treatment - 6-month follow-up.

PURPOSE: This study examined 6-month drinking outcomes of elderly patients compared with middle-aged patients in a clinical sample after initiation of outpatient treatment for alcoholism. MATERIALS AND METHODS: In a clinical prospective cohort study, 1398 consecutive patients from a municipality outpatient alcohol clinic were included. A total of 208 elderly patients aged from 60 to 82 years and 1190 middle-aged patients from 40 to 59 years participated in the study. The following psychosocial treatment interventions were offered: cognitive behavioral therapy, family therapy and supportive consultations. Using an 'intention-to-treat' method, primary outcomes included drinking outcomes (self-reported abstinence rates, drinking 3 drinks or less per day, and change in Addiction Severity Index [ASI] composite scores) during the 30 days prior to 6-month follow-up; secondary outcome was compliance to the recommended treatment. RESULTS: Compared to middle-aged, among elderly patients a higher proportion were females (33.5% vs. 42.8%) and had a lower family/social ASI-composite score (0.17 vs. 0.12) at baseline. Higher alcohol and family/social ASI-composite scores were inversely correlated with abstinence. Elderly patients had a higher chance for abstinence compared to middle-aged patients (Odds ratio 95% [confidence interval]) 1.40 (1.03-1.92). The proportion of elderly patients that drank 3 or less drinks per day was 17.8%, compared to 10.8% among middle-aged (p < .01). Finally, elderly patients obtained a higher compliance, which was similarly associated with abstinence (OR =2.46 (1.95-3.11)). DISCUSSION AND CONCLUSIONS: Elderly patients, who receive psychosocial outpatient treatment for alcoholism, have better 6-month outcomes within a range of drinking outcome measures compared to middle-aged patients.

Simple benchmark for mesothelioma projection for Great Britain.

BACKGROUND: It is of considerable interest to forecast the future burden of mesothelioma mortality. Data on deaths are available, whereas no measure of asbestos exposure is available. METHODS: We compare two Poisson models: a response-only model with an age-cohort specification and a multinomial model with epidemiologically motivated frequencies. RESULTS: The response-only model has 5% higher peak mortality than the dose-response model. The former performs slightly better in out-of-sample comparison. CONCLUSIONS: Mortality is predicted to peak at about 2100 deaths around 2017 among males in cohorts until 1966 and below 90 years of age. The response-only model is a simple benchmark that forecasts just as well as more complicated models.

A randomized controlled study of exposure therapy as aftercare for alcohol use disorder: study protocol.

BACKGROUND: It is well documented that individuals with Alcohol Use Disorder (AUD) respond well during evidence-based psychological treatment, but also that a large proportion relapses when discharged from treatment and confronted with alcohol in real life. Cue Exposure Treatment (CET) focuses on exposing individuals to alcohol cues in order to reduce cravings as well as the likelihood of relapse. The aims of the study are: 1) to investigate whether CET aftercare delivered via a smartphone or in group sessions increases the effect of Cognitive Behavioural Treatment in groups of alcohol dependent individuals; 2) to investigate whether CET as a smartphone application is as or more effective than CET group therapy, and 3) to investigate whether CET as a smartphone application is more cost-effective than CET group aftercare and Aftercare as Usual. DESIGN AND METHODS: The study will be implemented as an investigator-blinded randomized controlled trial. A total of 300 consecutively enrolled alcohol use disorder individuals recruited from an alcohol outpatient clinic will be randomized into one of the three following aftercare groups after concluding primary treatment: (1) CET as a smartphone application; (2) CET as group therapy, and (3) Aftercare as Usual. It is hypothesized that the two experimental groups will achieve better treatment outcomes compared to the control group (3). DISCUSSION: Individuals in the CET groups are given the opportunity to practise coping strategies during exposure to alcohol stimuli before being unavoidably confronted with alcohol and associated stimuli in real life. Thus, CET may help prevent patients from relapsing after concluding treatment, and in the long term. Moreover, the CET application has the potential to improve AUD treatment and continuing care by offering psychological treatment whenever and wherever the patient finds it convenient. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02298751 Registration date: 6 November 2014.

The RESCueH Programme: Testing New Non-Pharmacologic Interventions for Alcohol Use Disorders: Rationale and Methods.

Excessive alcohol consumption is one of the most important lifestyle factors affecting the disease burden in the Western world. The results of treatment in daily practice are modest at best. The aim of the RESCueH programme is to develop and evaluate methods, which are as practice-near as possible, and therefore can be implemented quickly and easily in everyday clinical practice. It is the first clinical alcohol programme to be transatlantic in scope, with implementation in treatment centers located in Denmark, Germany and the US. The RESCueH programme comprises 5 randomized controlled trials, and the studies can be expected to result in (1) more patients starting treatment in specialized outpatient clinics, (2) a greater number of elderly patients being treated, (3) increased patient motivation for treatment and thus improved adherence, (4) more patients with stable positive outcomes after treatment and (5) fewer patients relapsing into harmful drinking. The aim of this paper is to discuss the rationale for the RESCueH programme, to present the studies and expected results.

Relay model for recruiting alcohol dependent patients in general hospitals--a single-blind pragmatic randomized trial.

BACKGROUND: A large proportion of the Danish population consumes more than the officially recommended weekly amount of alcohol. Untreated alcohol use disorders lead to frequent contacts with the health care system and can be associated with considerable human and societal costs. However, only a small share of those with alcohol use disorders receives treatment. A referral model to ensure treatment for alcohol dependent patients after discharge is needed. This study evaluates the i) cost-effectiveness ii) efficacy and iii) overall impact on societal costs of the proposed referral model - The Relay Model. METHOD/DESIGN: The study is a single-blind pragmatic randomized controlled trial including patients admitted to the hospital. The study group (n = 500) will receive an intervention, and the control group (n = 500) will be referred to treatment by usual procedures. All patients complete a lifestyle questionnaire with the Alcohol Use Disorders Identification Test embedded as a case identification strategy. The primary outcome of the study will be health care expenditures 12 months after discharge. The secondary outcome will be the percentage of the target group, who 30 days after discharge, reports at the alcohol treatment clinics. In order to analyse both outcomes, difference-in-difference models will be used. DISCUSSION: We expect to establish evidence as to whether The Relay Model is either cost-neutral or cost-effective, compared to referral by usual procedures. TRIAL REGISTRATION: https://register.clinicaltrials.gov/by identifier: RESCueH_Relay NCT02188043 Project Relay Model for Recruiting Alcohol Dependent Patients in General Hospitals (TRN Registration: 07/09/2014).

Coercion in psychiatry: the importance of extramural factors.

BACKGROUND: Mechanical restraints and forced procedures in psychiatric wards are of major concern in Denmark and there is a desire to reduce these procedures to a minimum. So far, focus has primarily been on identifying and changing internal (intramural) factors when seeking to reduce coercion. AIM: To identify possible external (extramural) factors that may increase the risk of coercion during admission to a closed psychiatric ward. METHOD: Using a retrospective case-controlled design, 235 patients admitted to a closed ward during 2011-2013 were randomly selected. Coercion comprised belt restraint, physical restraint, and forced medication. The data source was the electronic patient records, which include statutory information on all forced measures. Multiple logistic regression analyses were applied to calculate the risk (odds ratio, OR (95% confidence interval)) of forced measures being used. RESULTS: Out of the 235 patients, 66 (28%) were subject to coercion. The time of forced procedures was predominately during the first hours after admission. The risk of forced measures being applied was significantly higher if patients were involuntarily admitted (OR = 6.4 (3.4-11.9)), or were acutely intoxicated by substances at the time of admission (OR = 3.7 (1.7-8.2)). CONCLUSION: Extramural factors should be included when mental health authorities plan efforts to reduce coercion during admission to psychiatric wards. A reduced threshold for admission and improved integrated effort between mental health services and treatment for substance abuse could improve the course of disease for this group of patients and reduce the need for involuntary admissions and subsequently coercion.

Extrinsic and intrinsic charge trapping at the graphene/ferroelectric interface.

The interface between graphene and the ferroelectric superlattice PbTiO3/SrTiO3 (PTO/STO) is studied. Tuning the transition temperature through the PTO/STO volume fraction minimizes the adorbates at the graphene/ferroelectric interface, allowing robust ferroelectric hysteresis to be demonstrated. "Intrinsic" charge traps from the ferroelectric surface defects can adversely affect the graphene channel hysteresis and can be controlled by careful sample processing, enabling systematic study of the charge trapping mechanism.

The effect of co-morbid depression and anxiety on the course and outcome of alcohol outpatient treatment: A naturalistic prospective cohort study.

BACKGROUND: Studies examining the effect of alcohol treatment among patients with alcohol use disorders (AUD) and co-morbid depression and/or anxiety are few and show inconsistent, but mainly negative drinking outcomes. AIMS: To describe the prevalence of anxiety and depression among Danish patients seeking treatment for an AUD, and to investigate the influence of psychiatric co-morbidity on the course and effect of treatment. METHOD: A consecutive sample of 363 outpatients with an AUD diagnosis according to the ICD-10 Diagnostic Criteria for Research was assessed by the means of the Addiction Severity Index at treatment start and 276 (76%) followed up after 1 year. RESULTS: 15.7% of the patients suffered from depression and 12.7% from anxiety at baseline. Both patients with or without co-morbidity had improved on drinking outcome measures at follow-up with medium to large effect sizes. No difference was found between patients with and without co-morbidity. CONCLUSION: In contrast to the majority of prior studies, this study provides evidence that depression and anxiety do not have an effect on alcohol treatment. However, because of the naturalistic setting, a number of limitations should be taken into consideration interpreting the results.

Identification and forecasting in mortality models.

Mortality models often have inbuilt identification issues challenging the statistician. The statistician can choose to work with well-defined freely varying parameters, derived as maximal invariants in this paper, or with ad hoc identified parameters which at first glance seem more intuitive, but which can introduce a number of unnecessary challenges. In this paper we describe the methodological advantages from using the maximal invariant parameterisation and we go through the extra methodological challenges a statistician has to deal with when insisting on working with ad hoc identifications. These challenges are broadly similar in frequentist and in Bayesian setups. We also go through a number of examples from the literature where ad hoc identifications have been preferred in the statistical analyses.

Guiding early revascularization using [15O]H2O positron emission tomography myocardial perfusion imaging: impact of atrial fibrillation.

AIMS: Myocardial perfusion imaging (MPI) using [15O]H2O positron emission tomography (PET) is used to guide the selection of patients with angina for invasive angiography and possible revascularization. Our study evaluated (i) whether atrial fibrillation (AF) reduces global hyperaemic myocardial blood flow (MBF) and (ii) whether [15O]H2O PET MPI effectively guides revascularization procedures for patients with ongoing AF. METHODS AND RESULTS: We prospectively recruited 346 patients with angina and persistent or paroxysmal AF referred for baseline/hyperaemic [15O]H2O PET MPI. The primary outcome was revascularization within 3 months of MPI. In the analyses, patients were divided into four groups based on whether they had ongoing AF or sinus rhythm (SR) and whether they had previously documented coronary artery disease (CAD) or not. Thus, four groups were compared: SR-noCAD, AF-noCAD, SR-CAD, and AF-CAD. Hyperaemic MBF was affected by both ongoing AF and prior CAD [MBF (mL/min/g): 2.82 (SR-noCAD) vs. 2.12 (AF-noCAD) vs. 2.22 (SR-CAD) vs. 1.80 (AF-CAD), two-way analysis of variance P < 0.0001]. In multiple linear regression, ongoing AF was independently associated with reduced hyperaemic MBF. Every 0.1 mL/min/g decrease in hyperaemic MBF was associated with a 23% increase in odds of early revascularization. Receiver operating characteristic (ROC) analysis of vessel-specific hyperaemic MBF to predict early revascularization yielded the following areas under the ROC curve: SR-noCAD: 0.95 (P < 0.0001); AF-noCAD: 0.79 (P < 0.0001); SR-CAD: 0.78 (P < 0.0001); and AF-CAD: 0.88 (P < 0.0001). CONCLUSION: Ongoing AF is associated with 19-25% reduced global hyperaemic MBF as measured by [15O]H2O MPI PET. Regardless, vessel-specific hyperaemic MBF still predicts early revascularization in patients with AF.

Exercise Hemodynamics and Mitochondrial Oxidative Capacity in Disease Stages of Wild-Type Transthyretin Amyloid Cardiomyopathy.

BACKGROUND: Wild-type transthyretin amyloid (ATTRwt) cardiomyopathy is increasingly recognized in the development of heart failure. The link between cardiac performance, hemodynamics, and mitochondrial function in disease stages of ATTRwt has not previously been studied but may provide new insights into the pathophysiology and clinical performance of the patients. METHODS AND RESULTS: The study investigated 47 patients diagnosed with ATTRwt at Aarhus University Hospital, Denmark. Patients were stratified according to the disease stages of the National Amyloidosis Centre (NAC) as NAC I with low levels of NT-proBNP (N-terminal pro-B-type natriuretic peptide) (NAC I-L, n=14), NAC I with high levels NT-proBNP (NAC I-H, n=20), and NAC II-III (n=13). Exercise testing with simultaneous right heart catheterization was performed in all patients. Endomyocardial biopsies were collected from the patients and the mitochondrial oxidative phosphorylation capacity was assessed. All NAC disease groups, even in the NAC I-L group, a significant abnormal increase in biventricular filling pressures were noted during exercise while the filling pressures was normal or near normal at rest. The inotropic response to exercise was reduced with diminished increase in cardiac output which was significantly more pronounced in the NAC I-H (Diff. -2.4, 95% CI (-4.2: -0.7), P=0.00) and the NAC II-III group (Diff: -3.1 L/min, 95% CI (-5.2: -1.1), P=0.00) compared with the NAC I-L group. The pulmonary artery wedge pressure to cardiac output ratio at peak exercise was significantly different between NAC I-L and NAC II-III (Diff: 1.6 mm Hg*min/L, 95% CI (0.01:3.3, P=0.04)). Patients with ATTRwt had a reduced oxidative phosphorylation capacity which correlated to left ventricular mass but not to cardiac output capacity. CONCLUSIONS: An abnormal restrictive left ventricle and right ventricle response to exercise was demonstrated, even present in patients with early-stage ATTRwt. In more advanced disease stages a progressive impairment of the pressure-flow relationship was noted. The myocyte energetics is deranged but not associated to the contractile reserve or restrictive filling characteristics in ATTRwt.

Outreach visits by clinical pharmacists improve screening for the metabolic syndrome among mentally ill patients.

BACKGROUND: Patients suffering from schizophrenia and affective disorder have an increased risk of the metabolic syndrome (MeS); hence identification of patients developing MeS may help preventing morbidity and mortality. AIMS: The aim of the study was to evaluate the effect of outreach visit by clinical pharmacists to support the implementation of screening of MeS at a psychiatric ward. METHODS: The study was conducted at the psychiatric ward, Odense University Hospital. In 2008, clinical guidelines for systematic screening and prevention of metabolic risk were developed and implemented by passive dissemination (PD) followed by a period of active implementation (AI). AI contained outreach visits by clinical pharmacists on a weekly basis. Patients with affective disorder or schizophrenia were included. The study was designed as a before-and-after study, and electronic patient charts were used for assessment of adherence to the clinical guidelines. RESULTS: In total, 205 patients were included in the study (93 patients in the PD group, 112 patients in the AI group). A significant improvement of the use of the screening sheet from 36% in the PD group to 81% in the AI group was found (p < 0.001). Consequently, the quality of the screening increased significantly resulting in 45% in the AI group being identified with MeS compared with 10% in the PD group (p < 0.001). CONCLUSION: The outreach visits by clinical pharmacists significantly improved the use of the screening sheet and resulted in a significant increase in the proportion of patients identified with MeS (p < 0.001). CLINICAL IMPLICATIONS: The increase in the use of a screening sheet for MeS among patients admitted to a psychiatric ward as a result of outreach visits by clinical pharmacist improve assessment for MeS. This may lead to better identification of patients suffering from MeS and hence increase the possibility of treating MeS and preventing morbidity and mortaligy.

PrehospitaL Ultrasound in Undifferentiated DyspnEa (PreLUDE): a prospective, clinical, observational study.

BACKGROUND: Diagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy. METHODS: Prospective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea. RESULTS: In total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%-69%) before POCUS compared to 65% (95% CI 53%-75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66-0.78) before POCUS compared to 0.79 (0.73-0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82-0.91) before POCUS and 0.93 (0.88-0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%-94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%-100%). CONCLUSION: Supplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure. TRIAL REGISTRATION: Registered in Clinical Trials, 05.04.2019 (identifier: NCT03905460) https://clinicaltrials.gov/ct2/show/study/NCT03905460?term=NCT03905460&cond=Dyspnea&cntry=DK&draw=2&rank=1 .