The patient education strategy "learning and coping" improves adherence to cardiac rehabilitation in primary healthcare settings: a pragmatic cluster-controlled trial.

BACKGROUND: Adherence and completion of programmes in educational and physical exercise sessions is essential in cardiac rehabilitation (CR) to obtain the known benefits on morbidity, mortality, risk factors, lifestyle, and quality of life. The patient education strategy "Learning and Coping" (LC) has been reported to positively impact adherence and completion in a hospital setting. It is unknown if LC has impact on adherence in primary healthcare settings, and whether LC improves self-management. The aim of this pragmatic primary healthcare-based study was to examine whether patients attending CR based on LC had a better adherence to patient education and physical exercise, higher program completion rate, and better self-management compared to patients attending CR based on a consultation program Empowerment, Motivation and Medical Adherence (EMMA). METHOD: A pragmatic cluster-controlled trial of two types of patient education LC and EMMA including ten primary healthcare settings and 514 patients (LC, n = 266; EMMA, n = 248) diagnosed with ischaemic heart disease discharged from hospital and referred to CR between August 1, 2018 and July 31, 2019. Adherence was defined as participation in ≥ 75% of provided sessions. Completion was defined as patients attended the final interview at the end of the 12-weeks programme. Patient Activation Measure (PAM) was used to obtain information on a person's knowledge, skills and confidence for self-management. PAM questionnaire was completed at baseline and 12-weeks follow-up. Multiple and Linear regression analyses adjusted for potential confounder variables and cluster effect were performed. RESULT: Patients who followed CR based on LC had a higher adherence rate to educational and physical exercise sessions compared to patients who followed CR based on EMMA (p < 0.01). High-level of completion was found at the end of CR with no statistically significant between clusters (78.9% vs. 78.2%, p > 0.05). At 12-weeks, there was no statistical differences in PAM-score between clusters (p > 0.05). CONCLUSION: This study indicates that the LC positively impacts adherence in CR compared to EMMA. We found non-significant difference in completing CR and in patient self-management between the two types of patient education. Future studies are needed to investigate if the higher adherence rate achieved by LC in primary healthcare settings translates into better health outcomes.

Patient perspectives and experiences of the rapid implementation of digital consultations during COVID-19 - a qualitative study among women with gynecological cancer.

PURPOSE: Due to the first COVID-19 outbreak and subsequent restrictions, standard practice for gynecological cancer quickly evolved to include additional digital consultations. Women with gynecological cancer have a high need for information and experience a high symptom burden. We aimed to explore the experiences and perspectives of the rapid implementation of digital consultations during COVID-19. METHODS: We conducted individual telephone interviews with patients with gynecological cancer 1-4 days after a telephone or video consultation during the COVID-19 outbreak in April and May 2020. We applied Braun and Clarke's thematic analysis to analyze the qualitative data. RESULTS: Thirty-two patients with ovarian (50%), cervical (35%), vulvar (12%), and vaginal cancer (3%) participated in the study. The patients experienced that, combined, cancer and COVID-19 restrictions made their situation twice as challenging. In general, the patients valued face-to-face consultations, recommending that they were ideal for the initial appointment to build trust. Overall, there was a willingness to participate in digital consultations because of the restrictions, but the results also showed varying degrees of openness and that individual solutions were favored. CONCLUSION: The findings of this study show that digital consultations were an accepted alternative during COVID-19. Even though this temporary solution was deemed to be beneficial for practical reasons, patients also experienced digital consultations to be impersonal. A key message is that face-to-face encounters create the foundation to establish a trusting relationship from where a valuable dialogue arises. Digital consultations should therefore be implemented with caution since no one-size-fits-all model is recommended. Among patients with gynecological cancer, however, digital technologies represent a promising and flexible method depending on the purpose of consultations, patient preferences, and needs.

Coronary computed tomography angiography - tolerability of ß-blockers and contrast media, and temporal changes in radiation dose.

OBJECTIVE: To determine the risk in administering ß-blockers, contrast-induced nephropathy (CIN) and the trend in X-ray use, during coronary computed tomography angiography (CCTA). METHODS: A total of 416 patients were referred for elective CCTA. To achieve a resting heart rate below 60 beats per minute, oral and/or intravenous ß-blockers were administered. Using questionnaires, information on the adverse effects of ß-blockers was collected from the patients. The levels of s-creatinine and estimated GFR (eGFR) were measured before and after contrast enhanced CCTA. Radiation exposure was compared with the exposure 3 years earlier. RESULTS: There was no significant difference in the symptoms (dizziness, lipothymia and palpitations) between patients with and patients without ß-blocker pretreatment. Compared to baseline values, the decrease in s-creatinine was not significant (75.2 vs. 74.6 µmol/L, p = 0.09), while the increase in eGFR was not significant (78 vs. 79 mL/min, p = 0.17). Also, subgroups of patients with hypertension, hypercholesterolemia, diabetes or pre-existing slight impairment in renal function did not develop CIN. The mean radiation exposure decreased from 17.5 to 6.7 mSv, p < 0.0001. CONCLUSIONS: In terms of the side effects of ß-blockers and contrast media, there were no short term complications to CCTA. Furthermore, the radiation dose has been dramatically diminished over the last three years.

Opting out of cardiac rehabilitation in local community healthcare services: Patients' perspectives and reflections.

RATIONALE: Despite cardiac rehabilitation and medical treatment being integrated parts of the pathway of patients with cardiovascular disease, as well as the well-establish positive effect, cardiac rehabilitation remains underutilised. In recent years, cardiac rehabilitation has increasingly been moved from the hospitals to the community healthcare services. This transition may be challenging for patients with cardiovascular disease. AIM: To investigate reflections and perspectives of patients opting out of cardiac rehabilitation in community healthcare services to improve participation and adherence to cardiac rehabilitation in the future. RESULTS: A total of eight patients opting out of cardiac rehabilitation participated in individual interviews. Opting out of cardiac rehabilitation is defined as never enroled or did not complete cardiac rehabilitation. The Interpretive Description methodology was used in the analysis where two themes and six subthemes were identified: (1) 'Structural and organisational factors' with three subthemes; Being a patient in the healthcare system, Enroling into CR when it is meaningful, and Getting back to work is vital, and (2) 'Patients' internal factors' with three subthemes; Feeling a desire to regain control, Seeing yourself as recovered, and Being aware of own needs. The analysis indicates that patients' decision to opt out of CR was multidimensional and based on a combination of factors. CONCLUSION: Ensuring that the healthcare professionals in the community have sufficient information regarding the patient and a clear communication plan between the healthcare professionals and the patient may reduce the transition causing confusion and frustrations for patients. Incorporating a vocational element in CR and ensuring that employers understand the importance of CR may hamper returning to work as a challenge to CR. Ensuring timely CR referral and enrolment and a transition coordinator may reduce the challenge of patients not viewing CR as meaningful. However, further studies are needed to fully understand how CR could become meaningful for patients opting out of CR.

Network of doctors for multimorbidity and diabetes - the NOMAD intervention: protocol for feasibility trial of multidisciplinary team conferences for people with diabetes and multimorbidity.

BACKGROUND: The prevalence of diabetes and coexisting multimorbidity rises worldwide. Treatment of this patient group can be complex. Providing an evidence-based, coherent, and patient-centred treatment of patients with multimorbidity poses a challenge in healthcare systems, which are typically designed to deliver disease-specific care. We propose an intervention comprising multidisciplinary team conferences (MDTs) to address this issue. The MDT consists of medical specialists in five different specialities meeting to discuss multimorbid diabetes patients. This protocol describes a feasibility test of MDTs designed to coordinate care and improve quality of life for people with diabetes and multimorbidity. METHODS: A mixed-methods one-arm feasibility test of the MDT. Feasibility will be assessed through prospectively collected data. We will explore patient perspectives through patient-reported outcomes (PROs) and assess the feasibility of electronic questionnaires. Feasibility outcomes are recruitment, PRO completion, technical difficulties, impact of MDT, and doctor preparation time. During 17 months, up to 112 participants will be recruited. We will report results narratively and by the use of descriptive statistics. The collected data will form the basis for a future large-scale randomised trial. DISCUSSION: A multidisciplinary approach focusing on better management of diabetic patients suffering from multimorbidity may improve functional status, quality of life, and health outcomes. Multimorbidity and diabetes are highly prevalent in our healthcare system, but we lack a solid evidence-based approach to patient-centred care for these patients. This study represents the initial steps towards building such evidence. The concept can be efficiency tested in a randomised setting, if found feasible to intervention providers and receivers. If not, we will have gained experience on how to manage diabetes and multimorbidity as well as organisational aspects, which together may generate hypotheses for research on how to handle multimorbidity in the future. ADMINISTRATIVE INFORMATION: Protocol version: 01 TRIAL REGISTRATION: NCT05913726 - registration date: 21 June 2023.

Understanding Facilitators and Challenges to Care Transition in Cardiac Rehabilitation: Perspectives and Assumptions of Healthcare Professionals.

Cardiac rehabilitation is an essential part of treatment for patients with cardiovascular disease. Cardiac rehabilitation is increasingly organized outside hospital in community healthcare services. However, this transition may be challenging. The aim of this study was to examine assumptions and perspectives among healthcare professionals on how facilitators and challenges influence the transition from hospital to community healthcare services for patients in cardiac rehabilitation. The study followed the Interpretive Description methodology and data consisted of participant observations and focus group interviews. The analysis showed that despite structured guidelines aimed to support the collaboration, improvements could be made. Facilitators and challenges could occur in the collaboration between the healthcare professionals, in the collaboration with the patient, or because of the new reality for patients when diagnosed with cardiovascular disease.

Understanding healthcare providers' experiences with video recording of patient consultations.

AIM: To understand healthcare providers' experiences with video recording of patient consultations. BACKGROUND: Video recordings have been recognised to be an effective method to evaluate in situ interactions in clinical practice. The video recordings are often conducted by researchers, but active involvement of healthcare providers into the process of recording is evolving. Still, little is known of how video recordings by healthcare providers may influence daily clinical practice and potentials for direct use to guide practice development. METHODS: A qualitative design was used, conducting two focus group interviews including 12 healthcare providers representing eight different healthcare services who provide municipal cardiac rehabilitation. Interpretive description was used as the methodological framework, and symbolic interactionism served as the theoretical lens. FINDINGS: Three themes were identified reflecting healthcare providers' experiences with video recording of patient consultations: 'Concerns of compromising primary work tasks', 'Exposing professional and personal skills' and 'A new learning dimension'. Overall, the three themes represent the process of video recording own practices attached to patient consultations and the personal investment attached to the video data. Also, how the recordings may provide new insights for practice development in terms of individual and team-based performance in patient consultations. CONCLUSION: Video recordings by healthcaref providers may be a useful source to provide information and learning about patient consultation practice to use in research and supervision, keeping in mind their challenges of implementation into daily clinical practice.

Monocytes mediate shaving of B-cell-bound anti-CD20 antibodies.

Anti-CD20 monoclonal antibodies are promising for the treatment of B-cell malignancies such as chronic lymphocytic leukaemia and autoimmune diseases where auto-antibodies play an important role. Anti-CD20 such as rituximab (RTX) mediates B-cell depletion through mechanisms such as complement-mediated cytotoxicity and antibody-dependent cellular cytotoxicity. However, in haematological malignancies, such effector mechanisms can be saturated and result in release of malignant B cells with reduced levels of CD20. It has been hypothesized that this is the result of monocyte-mediated shaving of the CD20/RTX complex from the B-cell surface. Here, we confirm, that in vitro co-culture of human monocytes and RTX-labelled syngeneic B cells results in reduced expression of CD20/RTX complex on the B cell surface. This shaving mechanism was the result of active protease activity because EDTA and PMSF were able to mediate partial inhibition. Also, a series of alternative anti-CD20 antibodies representing both type I and type II antibodies were tested for their ability to induce the shaving reaction. These results demonstrate that a monocyte-mediated shaving reaction can lead to complete loss of most anti-CD20 antibodies from the surface of B cells even from healthy donors and this is an important obstacle for antibody-mediated immune therapy. The findings demonstrate the necessity of developing novel antibodies that maintain high effector functions without enabling activation of the shaving reaction.

Implementation of patient involvement methods in the clinical setting: A qualitative study exploring the health professional perspective.

RATIONALE, AIMS AND OBJECTIVES: Patient involvement is increasingly recognized as a key component on the international health care agenda. This attention has brought a need for developing generic and standardized open-source methods, tools, and guidelines on how to systematically implement patient involvement initiatives in the clinical setting. The large-scale project the User-involving Hospital was initiated to implement two systematic methods for patient involvement at a Danish university hospital, but the required methods can only be implemented if embraced by the health professionals. This evaluation study aimed to explore the health professional perspective on the development and implementation of shared decision making (SDM) and user-led health care. Specifically, the objectives were to identify the most crucial preconditions for success and to translate the findings into practice recommendations. METHOD: The study was based on a simple questionnaire survey and a qualitative descriptive analysis of semistructured focus group interviews with representatives of 21 multidisciplinary clinical teams (nine interviews) and 18 health professional department managers (six interviews). RESULTS: Two years after the initiation of the User-involving Hospital, 13 out of 21 developed patient involvement initiatives were fully incorporated into clinical practice. Five domains were found significant for successful development and implementation of the patient involvement methods: the patients' perspectives, composition of multidisciplinary teams, bottom-up and skill building, support from management, and information sharing with colleagues. CONCLUSIONS: The findings draw attention to several significant factors for successful implementation of large-scale patient involvement initiatives in hospitals, including the importance of having both a top-down and bottom-up approach and of active listening to the patients' perspectives. On the basis of these findings, the study outlines four recommendations incorporating the five identified key domains, which may inspire future projects on systematic development and implementation of patient-involvement initiatives based on either shared decision making or user-led health care in the clinical setting.

[Melatonin for children with insomnia].

Treatment for insomnia with melatonin (MT) in children and adolescents aged 0-17 years has doubled since 2011. The efficacy and safety profile for MT in children has not been determined. Recent clinical trials indicate, that MT only has a clinical effect on sleep latency, not on total sleep time. Furthermore, it has emerged, that proper sleep hygiene can cure the sleep problem in 50% of the children. Typically, the safety evaluation only entails an unclassified report of adverse events. Two long-term studies investigate and dispel the potential influence of MT on puberty.

Detection of Paroxysms in Long-Term, Single-Channel EEG-Monitoring of Patients with Typical Absence Seizures.

Absence seizures are associated with generalized 2.5-5 Hz spike-wave discharges in the electroencephalogram (EEG). Rarely are patients, parents, or physicians aware of the duration or incidence of seizures. Six patients were monitored with a portable EEG-device over four times 24 h to evaluate how easily outpatients are monitored and how well an automatic seizure detection algorithm can identify the absences. Based on patient-specific modeling, we achieved a sensitivity of 98.4% with only 0.23 false detections per hour. This yields a clinically satisfying performance with a positive predictive value of 87.1%. Portable EEG-recorders identifying paroxystic events in epilepsy outpatients are a promising tool for patients and physicians dealing with absence epilepsy. Albeit the small size of the EEG-device, some children still complained about the obtrusive nature of the device. We aim at developing less obtrusive though still very efficient devices, e.g., hidden in the ear canal or below the skin.

[Liquorice consumption may induce torsades de pointes ventricular tachycardia].

This case report describes an often forgotten cause of hypokalaemia resulting in electrocardiograpic changes in a 75-year-old man known with hypertension, atrial fibrillation and ischaemic heart disease. A detailed anamnesis, a prompt replacement of potassium and cessation of liquorice consumption resulted in a favourable outcome.

The Danish Cerebral Palsy Follow-up Program.

AIM OF DATABASE: The Danish Cerebral Palsy Follow-up Program is a combined follow-up program and national clinical quality database that aims to monitor and improve the quality of health care for children with cerebral palsy (CP). STUDY POPULATION: The database includes children with CP aged 0-15 years and children with symptoms of CP aged 0-5 years. MAIN VARIABLES: In the follow-up program, the children are offered examinations throughout their childhood by orthopedic surgeons, physiotherapists, occupational therapists, and pediatricians. Examinations of gross and fine motor function, manual ability, muscle tone, passive range of motion, use of orthotics, and assistive devices are performed once a year; radiographic examination of the hips is planned based on the child's age and gross motor function; and the diagnosis is performed once before the age of 5 years. Six indicators were developed based on scientific literature and consensus in the steering committee, and their calculation is based on the following four main variables: radiographic examination of the hip, gross motor function, manual ability, and diagnosis. DESCRIPTIVE DATA: The 2014 annual report includes results of the quality indicators in three of five regions in Denmark comprising 432 children with CP, corresponding to a coverage of 82% of the expected population. CONCLUSION: The Danish Cerebral Palsy Follow-up Program is currently under development as a national clinical quality database in Denmark. The database holds potential for research in prevalence, clinical characteristics of the population, and the effects of prevention and treatment.

Does financial strain explain the association between children's morbidity and parental non-employment?

OBJECTIVES: To investigate whether family financial resources explain the association between parental labour market participation and children's health in families in Denmark and Sweden. DESIGN: Parent reported questionnaire data from the survey of health and welfare among children and adolescents in the Nordic countries, 1996. PARTICIPANTS: 4299 children aged 2-17 years. MEASURES: Three indicators measured children's health: recurrent psychosomatic symptoms, chronic illness, and prescribed medicine. Four variables and a composite index were used to measure family financial resources. The variable on family labour market participation consisted of five groups according to family type and parents' labour market participation. RESULTS: Children in families with one or both parents without paid work had an increased prevalence of recurrent psychosomatic symptoms (odds ratio from 1.52 to 3.20) and chronic illnesses (odds ratio from 1.43 to 2.25), whereas the use of prescribed medicine did not differ (odds ratio from 0.67 to 1.15). The five indicators on family financial resources only slightly reduced the odds ratios for recurrent psychosomatic symptoms (odds ratio from 1.12 to 2.75) and chronic illnesses (odds ratio from 1.34 to 2.22), and the odds ratios for children's use of prescribed medicine remained unchanged and non-significant (odds ratio from 0.62 to 1.18). CONCLUSIONS: Financial strain associated with non-employment does not explain the increased prevalence of health problems among children in families affected by non-employment in Denmark and Sweden. However, the associations between family labour market participation and children's health differ according to family financial status.

[Pain among children with cerebral palsy]. / Smerter hos børn og unge med cerebral parese.

Although children diagnosed with cerebral palsy have a number of pain triggers (directly from the cerebral palsy, from sequelae and iatrogenic), pain is underdiagnosed. The gap between research and clinical practice is well-known as this group of patients demand special knowledge regarding monitoring of pain. This article presents various pain-monitoring methods. Combining different methods may improve pain assessment and thereby improve quality of life for children with cerebral palsy.

Systematic suicide risk assessment for patients with schizophrenia: a national population-based study.

OBJECTIVES: Systematic suicide risk assessment is recommended for patients with schizophrenia; however, little is known about the implementation of suicide risk assessment in routine clinical practice. The study aimed to determine the use of systematic suicide risk assessment at discharge and predictors of suicide attempt among hospitalized patients with schizophrenia in Denmark. METHODS: A one-year follow-up study was conducted of 9,745 patients with schizophrenia who were discharged from psychiatric wards and registered in a national population-based schizophrenia registry between 2005 and 2009. RESULTS: The proportion of patients receiving suicide risk assessment at discharge from a psychiatric ward increased from 72% (95% confidence interval [CI]=71%-74%) in 2005, when the national monitoring began, to 89% (CI=89%-90%) in 2009. Within one year after discharge, 1% of all registered patients had died by suicide and 8% had attempted suicide. One out of three patients who died by suicide had no documented suicide risk assessment before discharge. CONCLUSIONS: The use of systematic suicide risk assessment at discharge among patients with schizophrenia increased in Denmark between 2005 and 2009, in accordance with recommendations in national clinical guidelines and monitoring in a national clinical registry. Additional efforts are warranted to ensure a lower risk of suicidal behavior after hospital discharge.

Processes of in-hospital psychiatric care and subsequent criminal behaviour among patients with schizophrenia: a national population-based, follow-up study.

OBJECTIVES: It is unknown whether evidence-based, in-hospital processes of care may influence the risk of criminal behaviour among patients with schizophrenia. Our study aimed to examine the association between guideline recommended in-hospital psychiatric care and criminal behaviour among patients with schizophrenia. METHODS: Danish patients with schizophrenia (18 years or older) discharged from a psychiatric ward between January 2004 and March 2009 were identified using a national population-based schizophrenia registry (n = 10 757). Data for in-hospital care and patient characteristics were linked with data on criminal charges obtained from the Danish Crime Registry until November 2010. RESULTS: Twenty per cent (n = 2175) of patients were charged with a crime during follow-up (median = 428 days). Violent crimes accounted for 59% (n = 1282) of the criminal offences. The lowest risk of crime was found among patients receiving the most processes of in-hospital care (top quartile of received recommended care, compared with bottom quartiles, adjusted hazard ratio = 0.86, 95% CI 0.75 to 0.99). The individual processes of care associated with the lowest risk of criminal behaviour were antipsychotic treatment and staff contact with relatives. CONCLUSIONS: High-quality, in-hospital psychiatric care was associated with a lower risk of criminal behaviour after discharge among patients with schizophrenia.

Objectifs : On ne sait pas si les processus de soins à l'hôpital bas sur des données probantes peuvent influencer le risque de comportement criminel chez des patients souffrant de schizophrénie. Notre étude visait à examiner l'association entre soins psychiatriques à l'hôpital recommandés par des lignes directrices et le comportement criminel chez des patients souffrant de schizophrénie. Méthodes : Des patients danois souffrant de schizophrénie (de 18 ans et plus) et ayant reçu leur congé d'une unité psychiatrique entre janvier 2004 et mars 2009 ont été identifiés à l'aide du registre national de la schizophrénie dans la population (n = 10 757). Les données des soins à l'hôpital et des caractéristiques des patients ont été couplées avec les données sur les accusations criminelles obtenues du registre danois de la criminalité jusqu'en novembre 2010. Résultats : Vingt pour cent (n = 2175) des patients ont été accusés d'un crime durant le suivi (moyenne = 428 jours). Les crimes violents représentaient 59 % (n = 1282) des infractions criminelles. Le risque de comportement criminel le plus faible a été constaté chez les patients recevant le plus de processus de soins à l'hôpital (quartile supérieur des soins recommandés reçus, comparé aux quartiles inférieurs, rapport de risques corrigé = 0.86, IC à 95 % 0,75 à 0,99). Les processus de soins individuels associés au risque le plus faible de comportement criminel étaient le traitement par antipsychotiques et les contacts du personnel avec les membres de la famille. Conclusions : Les soins psychiatriques de grande qualité, à l'hôpital, étaient associés à un risque plus faible de comportement criminel après le congé chez des patients souffrant de schizophrénie.

Challenges in validating quality of care data in a schizophrenia registry: experience from the Danish National Indicator Project.

BACKGROUND: Improvement of quality of care for psychiatric patients is a key objective of health care systems worldwide. Consequently, there is an increasing interest in documenting quality of care; however, little is known about the validity of the available data on psychiatric care. OBJECTIVE: To assess the validity of process of care data recorded in the Danish National Indicator Project (DNIP), a national population-based registry containing quality of care data of patients diagnosed with schizophrenia in Denmark. METHODS: A random sample of 1% of patients with schizophrenia registered in the DNIP between 2004 and 2009 (111 inpatient and 85 outpatient) was identified for validation. Medical records for these patients, which were used as the gold standard, were retrieved and reviewed for information on the processes of care received. Agreement between the data in the DNIP and the medical records were assessed by computing sensitivity, specificity, and positive and negative predictive values. RESULTS: The agreement between the recorded processes of care in the DNIP and in the medical records varied substantially across the individual process of care variables. However, a collection of the processes of care demonstrated a high agreement (80% or more) between data in the DNIP and the medical records, according to all examined aspects of data validity (sensitivity, specificity, and positive and negative predictive values). The medical records contained varying levels of missing information regarding the processes of care, from 1% for antipsychotic medication prescription to 54% for psychoeducation. CONCLUSION: Current documentation practices in Danish psychiatric hospitals appear to be inconsistent and may preclude the use of psychiatric medical records as the gold standard when validating registry data.