Effectiveness of an adaptive, multifaceted intervention to enhance care for patients with complex multimorbidity in general practice: protocol for a pragmatic cluster randomised controlled trial (the MM600 trial).

INTRODUCTION: Patients with complex multimorbidity face a high treatment burden and frequently have low quality of life. General practice is the key organisational setting in terms of offering people with complex multimorbidity integrated, longitudinal, patient-centred care. This protocol describes a pragmatic cluster randomised controlled trial to evaluate the effectiveness of an adaptive, multifaceted intervention in general practice for patients with complex multimorbidity. METHODS AND ANALYSIS: In this study, 250 recruited general practices will be randomly assigned 1:1 to either the intervention or control group. The eligible population are adult patients with two or more chronic conditions, at least one contact with secondary care within the last year, taking at least five repeat prescription drugs, living independently, who experience significant problems with their life and health due to their multimorbidity. During 2023 and 2024, intervention practices are financially incentivised to provide an extended consultation based on a patient-centred framework to eligible patients. Control practices continue care as usual. The primary outcome is need-based quality of life. Outcomes will be evaluated using linear and logistic regression models, with clustering considered. The analysis will be performed as intention to treat. In addition, a process evaluation will be carried out and reported elsewhere. ETHICS AND DISSEMINATION: The trial will be conducted in compliance with the protocol, the Helsinki Declaration in its most recent form and good clinical practice recommendations, as well as the regulation for informed consent. The study was submitted to the Danish Capital Region Ethical Committee (ref: H-22041229). As defined by Section 2 of the Danish Act on Research Ethics in Research Projects, this project does not constitute a health research project but is considered a quality improvement project that does not require formal ethical approval. All results from the study (whether positive, negative or inconclusive) will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05676541.

Hearing Loss, Hearing Aid Use, and Risk of Dementia in Older Adults.

Importance: Hearing loss has been suggested as a risk factor for dementia, but there is still a need for high-quality research to better understand the association between these 2 conditions and the underlying causal mechanisms and treatment benefits using larger cohorts and detailed data. Objective: To investigate the association between hearing loss and incident dementia, as well as how hearing aid use contributes to this association. Design, Setting, and Participants: This population-based cohort study was conducted in Southern Denmark between January 2003 and December 2017 and included all residents 50 years and older. We excluded all persons with dementia before baseline as well as those who did not live in the region 5 years before baseline, with incomplete address history, or who had missing covariate information. Exposures: Individual hearing status based on the Hearing Examinations in Southern Denmark database, which contains data on all pure-tone audiometry examinations performed at public hearing rehabilitation clinics in Southern Denmark. Main Outcomes and Measures: Incident cases of dementia and Alzheimer disease as identified from national registries. Results: The study population comprised 573 088 persons (298 006 women [52%]; mean [SD] age, 60.8 [11.3] years) with 23 023 cases of dementia and mean (SD) follow-up of 8.6 (4.3) years. Having a hearing loss was associated with an increased risk of dementia, with an adjusted hazard ratio (HR) of 1.07 (95% CI, 1.04-1.11) compared with having no hearing loss. Severe hearing loss in the better and worse ear was associated with a higher dementia risk, with an HR of 1.20 (95% CI, 1.09-1.32) and 1.13 (95% CI, 1.06-1.20), respectively, compared with having no hearing loss in the corresponding ear. Compared with people without hearing loss, the risk of dementia was higher among people with hearing loss who were not using hearing aids than those who had hearing loss and were using hearing aids, with HRs of 1.20 (95% CI, 1.13-1.27) and 1.06 (95% CI, 1.01-1.10), respectively. Conclusions and Relevance: The results of this cohort study suggest that hearing loss was associated with increased dementia risk, especially among people not using hearing aids, suggesting that hearing aids might prevent or delay the onset and progression of dementia. The risk estimates were lower than in previous studies, highlighting the need for more high-quality longitudinal studies.

Labour market attachment dynamics in patients with concussion: a Danish nationwide register-based cohort study.

BACKGROUND: Concussion may lead to persisting post-concussive symptoms affecting work ability and employment. This study examined the transitions between labour market states an individual can experience after the acute phase of concussion. The aim was to describe the incidence of favourable and adverse transitions between different labour market states (e.g., employment, sick leave) in relation to socioeconomic and health characteristics in individuals with concussion relative to matched controls. METHODS: This Danish nationwide register-based cohort study extracted 18-60-year-old individuals between 2003-2007 with concussion from the Danish National Patient Register (ICD-10 S06.0). Controls were matched on age, sex, and municipality. Patients and controls were followed for 5 years starting three months after injury. Exclusion criteria were neurological injuries and unavailability to the labour market in the inclusion period (2003-2007) and 5-years before injury (1998-2002). Labour market states were defined from transfer income data in the Danish Register for Evaluation of Marginalization. Incidence rates of transitions between these labour market states were analysed in multistate models. Transitions were bundled in favourable and adverse transitions between labour market states and the difference in incidence rates between individuals with concussion relative to matched controls were assessed with hazard ratios from Cox regression models. RESULTS: Persons with concussion (n = 15.580) had a lower incidence of favourable transitions (HR 0.88, CI 0.86-0.90) and a higher incidence of adverse transitions (HR 1.30, CI 1.27-1.35), relative to matched controls (n = 16.377). The effect of concussion differed depending on health and socioeconomic characteristics. Notably, individuals between 30-39 years (HR 0.83, CI 0.79-0.87), individuals with high-income (200.000-300.000 DKK) (HR 0.83, CI 0.80-0.87), and wage earners with management experience (HR 0.60, CI 0.44-0.81) had a markedly lower incidence of favourable transitions compared to controls. Additionally, individuals with high income also had a higher incidence of adverse transitions (HR 1.46, CI 1.34-1.58) compared to controls. CONCLUSIONS: Concussion was associated with enhanced risk of adverse transitions between labour market states and lower occurrence of favourable transitions, indicating work disability, potentially due to persistent post-concussive symptoms. Some age groups, individuals with high income, and employees with management experience may be more affected.

Does children's healthcare seeking change after participation in a musculoskeletal study? A register-based study.

BACKGROUND: Participating in research studies often involves interactions with healthcare professionals, potentially influencing the participant's future help-seeking behaviour. We investigated whether participating in the Childhood Health Activity and Motor Performance School Study - Denmark (CHAMPS) (2008-2014), which involved telephone consultations and clinical assessments by healthcare professionals with participants experiencing musculoskeletal complaints, changed frequency of contacts with primary public healthcare services among participants over the subsequent five-years-period, compared to non-participating children. METHODS: Using Danish health register data from 1998 to 2020, we compared CHAMPS participant's and two control group's contacts with private physiotherapists, chiropractors (outside hospitals), and general practitioners: a random 10% sample of children from Denmark (National Controls), and a secondary local control group (Local Controls) during three periods: Before (1998-31.10.2008), during (01.11.2008-20.06.2014), and after (21.06.2014-31.12.2019) the CHAMPS-study. Separate multivariable Poisson regression models were used to assess the differences between groups for the outcome variables: contacts with physiotherapists, chiropractors, and general practitioners, and overall contacts. RESULTS: Compared to National Controls, the CHAMPS-Group had fewer physiotherapy contacts before the study with an estimated mean of 0.01 vs 0.02 per person-year, and after (0.13 vs 0.18 per person-year), corresponding to a crude incidence rate ratio (IRR) of 0.69 (95% confidence intervals (CI): 0.58-0.83) after the study period. However, they had more chiropractor contacts before (0.05 vs 0.03), and after (0.21 vs 0.09) the study, with a crude IRR of 2.29 (95% CI: 1.93-2.71) after the study period. General practice contacts were equal for the CHAMPS-group compared to national controls (5.84 vs 5.84) before the study but reduced during and after (3.21 vs 3.71), with a crude IRR of 0.86 (95% CI: 0.83-0.90) after the study. Comparable patterns of contacts changes from before to after the study were observed between the CHAMPS-group and the Local Controls except for physiotherapy which was equal between the two groups after the study. CONCLUSION: Our findings suggest that research studies involving systematic engagement with participants experiencing musculoskeletal complaints can influence subsequent healthcare-seeking behaviour. Future research should address the influence of health literacy, health education, and healthcare provider recommendations on healthcare decisions during such research studies.

Definition and delimitation of multimorbidity.

Multimorbidity is often defined as two or more long-term conditions, the definition may, however, vary. This review summarises various definitions of multimorbidity. The prevalence of multimorbidity in Denmark is between 7% and 29% depending on data sources and definition and is increasing with age; nonetheless most patients with multimorbidity are of working age. Several multimorbidity indices have been developed for research purposes, but with no clinical consensus. The concept of complex multimorbidity adds psychosocial context and health-care patterns to better describe the group of patients with multimorbidity having the highest needs.

Older adults' perceptions of navigating eye healthcare in Denmark. A qualitative study.

BACKGROUND: Vision impairment can have an impact on cognition, health and social function. Vision loss may be avoided if detected early and treated promptly. Eye health is a minor topic in general practice, but the ongoing relationship between doctor and patient has the potential to assist the patient in navigating the healthcare system and guaranteeing timely healthcare service delivery. AIM: To explore the attitudes of older members of the public (MOP) of navigating primary sector eye healthcare in Denmark, with a focus on optometrists, practising ophthalmologists (PO), and general practitioners (GP). DESIGN & SETTING: Qualitative study design set in the capital area of Denmark METHOD: Focus-group interviews performed in the spring of 2022 with 21 MOP. RESULTS: Older MOPs perceived optometrists and POs to be the most relevant health professionals to consult about eye health. MOPs identified several opportunities for enhancing the function of general practice that are currently unexplored. CONCLUSION: Older MOPs seek help from health professionals who are directly qualified to treat the symptoms of ageing that they are experiencing or expect to face in the near future. However, included MOPs identify relevant potentials for GPs' to address vision impairment. This includes a focus on the patient's general health and function, as well as potential comorbidities influencing treatment trajectories. The current denigration of general practice risks missing out on the potential benefits of robust engagement from general practice in eye health.

Opioid dispensing in relation to arthroscopic knee surgery in Denmark from 2006 to 2018.

INTRODUCTION: In the US, opioids are commonly prescribed after arthroscopic knee surgery. We aimed to investigate opioid dispensing in relation to arthroscopic knee surgeries from 2006 to 2018 in Denmark. METHODS: In Danish registries, we identified patients (≥ 15 years old) having arthroscopic knee surgery (anterior cruciate ligament (ACL) reconstruction; meniscal surgery; cartilage resection; synovectomy and diagnostic arthroscopy) between 1 January 2006 and 31 December 2018 and opioid dispensing (oral morphine equivalents (OMEQ)) within seven days after discharge from surgery. RESULTS: Among 218,940 patients, 15,263 (7%) had an opioid dispensed within seven days after being discharged following surgery. The opioid dispensing incidence (per 1,000 persons/year) increased during the study period for all procedures. This trend was more pronounced for ACL reconstruction, which recorded an increase from 86 (95% confidence interval (CI): 75-99) in 2006 to 278 (95% CI: 255-301) in 2018, corresponding to 9% and 28% of ACL patients, respectively. In the same period, the average amount of opioids dispensed within the first seven days after discharge decreased (change: 70.0 OMEQ (95% CI: 12.4-127.5)). Tramadol and oxycodone were the most commonly dispensed opioids. CONCLUSION: About 7% of patients had an opioid dispensed within the first seven days after discharge following arthroscopic knee surgery. The incidence of opioids dispensed increased for all investigated procedures from 2006 to 2018. In the same period, the average amount of opioids dispensed within the first seven days after discharge decreased. FUNDING: None. TRIAL REGISTRATION: Not relevant.

Variation in daytime general practice services and association with out-of-hours use for older patients: protocol for a Danish cohort study.

INTRODUCTION: Out-of-hours primary care services cannot provide the same continuity and coordination of care as general practice. Thus, patients with high risk of complex care trajectories should, when possible, be treated by the general practitioner during daytime opening hours. This study aims to analyse the variation among general practices in the frequencies of daytime services for persons aged ≥75 years and how it relates to the patients' use of out-of-hours services. METHODS AND ANALYSIS: Register-based cohort study of all Danish citizens aged ≥75 years, of whom >98% are listed with a general practice. Using Poisson regression, we will estimate each practice's excess variation in delivered daytime services compared with the expected based on the characteristics of its listed patients. Delivered daytime services will be analysed overall and separately for face-to-face, phone, email, home visit and preventive services. The association with the use of out-of-hours services will be analysed by Poisson regression. ETHICS AND DISSEMINATION: Complying with European data protection rules, the legal services at University of Southern Denmark (Research & Innovation Organisation) approved the data processing activities regarding this project (journal number 11.593). According to section 14.2 of the Act on Research Ethics Review of Health Research Projects, because the study is based solely on register data, approval from the ethics committee and informed consent are not required. Results from the study will be disseminated as publications in peer-reviewed scientific journals and at international conferences.

DETECT: DEveloping and testing a model to identify preventive vision loss among older paTients in gEneral praCTice - protocol for a complex intervention in Denmark.

INTRODUCTION: The number of people living with visual impairment is increasing. Visual impairment causes loss in quality of life and reduce self-care abilities. The burden of disease is heavy for people experiencing visual impairment and their relatives. The severity and progression of age-related eye diseases are dependent on the time of detection and treatment options, making timely access to healthcare critical in reducing visual impairment. General practice plays a key role in public health by managing preventive healthcare, diagnostics and treatment of chronic conditions. General practitioners (GPs) coordinate services from other healthcare professionals. More involvement of the primary sector could potentially be valuable in detecting visual impairment. METHODS: We apply the Medical Research Council framework for complex interventions to develop a primary care intervention with the GP as a key actor, aimed at identifying and coordinating care for patients with low vision. The development process will engage patients, relatives and relevant health professional stakeholders. We will pilot test the feasibility of the intervention in a real-world general practice setting. The intervention model will be developed through a participatory approach using qualitative and creative methods such as graphical facilitation. We aim to explore the potentials and limitations of general practice in relation to detection of preventable vision loss. ETHICS AND DISSEMINATION: Ethics approval is obtained from local authority and the study meets the requirements from the Declaration of Helsinki. Dissemination is undertaken through research papers and to the broader public through podcasts and patient organisations.

Effectiveness of dementia education for professional care staff and factors influencing staff-related outcomes: An overview of systematic reviews.

BACKGROUND: Care staff often lack knowledge, confidence, skills, and competency to provide optimal care for people with dementia. Dementia education can increase staff competency and wellbeing along with the actual care of people with dementia. Several factors can affect the effectiveness of dementia education; however, it is not yet established which factors are most important. OBJECTIVE: The aim of the overview of systematic reviews is to investigate the effectiveness of dementia education for care staff on staff-related outcomes and influencing factors, identify needs for future research, and provide practical recommendations for effective dementia education. METHODS: Systematic searches were conducted in PubMed, Cinahl, and PsycInfo accompanied by manual citation and reference searches. For inclusion, reviews must report on either effectiveness of one staff-related outcome or on factors influencing the effectiveness of dementia education for care staff. Quality assessments were conducted using AMSTAR2. After data extraction, results on effectiveness were structured according to satisfaction, learning, behavior, and results. Results on contributing factors to effectiveness were categorized into program, personal and organizational factors. All results were qualitatively summarized and reported according to the PRISMA statement. RESULTS: Seventeen systematic reviews of low to medium quality were included. Dementia education positively affects knowledge, self-efficacy, and attitudes towards dementia and people with dementia. Care staff experienced improvements in communication and behavior management and reduction in behavioral symptoms of dementia of people with dementia was seen as well. Most reviews found no changes within restraints, medication, staff well-being and job satisfaction. Factors contributing to effectiveness are relevant and directly applicable content, active learning methods, classroom teaching combined with practical experience, theory-driven approaches and feedback sessions. Finally, the instructor needs to be experienced within dementia and sensitive to the needs of participants. CONCLUSION: There is no one-size-fits-all in dementia education: however, perceived relevance and applicability are key elements for effective dementia education. Due to low quality of primary studies, further research of high methodological quality is needed on effectiveness of dementia education on staff behavior, wellbeing, and job satisfaction as well as on influencing factors and their impact on mechanisms of change.

The association between childhood motor performance and developmental trajectories of sport participation over 5 years in Danish students aged 6-16-year-old.

Sports participation has potential to promote physical activity in youth. Unfortunately, sports participation and physical activity may decline from childhood to adolescence and into adulthood. Globally, only 20% of 13-15-year-olds meet the World Health Organisation recommendations for physical activity. This study aimed to investigate the 5-year trajectories of sports participation and their association with baseline motor performance in Danish school children as part of the Childhood Health Activity and Motor Performance School Study-Denmark (CHAMPS-DK), a school-based physical activity intervention study which investigated the health benefits of increased physical education lessons. Five distinct trajectories were identified, with group 1 maintained a stable trajectory of little to no sports participation, and group 2 showing a low decreasing trend. Group 3-5, the most sports active, demonstrated increasing sport participation at different rates. Baseline motor performance score was associated with the two most active sports participation groups. Students who were more physically active during school hours participated less in organised leisure time sports. This suggest focusing on improving motor performance in youth may support future sports participation and thus health-related physical activity. But also, that it might be necessary to engage and maintain children and adolescents in leisure time sports while implementing physical activity promotion interventions.

Increasing the chance of dying at home: roles, tasks and approaches of general practitioners enabling palliative care: a systematic review of qualitative literature.

BACKGROUND: Many elderly people wish to die at home but end up dying at the hospital. If the patient wishes to die at home, palliative care provided by General Practitioners (GPs) may increase the chance of dying at home, however, there is a lack of knowledge on how GPs should provide palliative care. We aimed to identify roles, tasks and approaches of GPs enabling palliative care, by exploring the experiences of GPs, other healthcare professionals, patients, and relatives through a systematic review of the qualitative literature. METHODS: We searched PubMed, EMBASE, PsycINFO, Web of Science, and CINAHL in March 2022. Thematic analysis was used for synthesizing the results. RESULTS: Four thousand five hundred sixty three unique records were retrieved, and 12 studies were included for review. Of these, ten were interview or focus group studies and two were survey studies with additional open-ended questions. Only qualitative findings from the studies were used in synthesizing the results. Thematic analysis produced four main themes describing the roles, tasks and approaches of GPs enabling palliative care to increase the chance for patients to die at home. GPs can support patients in the final phases of life by applying a holistic, patient-centred, and proactive approach to palliative care and by having sufficient education and training. Furthermore, the palliative care consultation should include symptom management, handling psychosocial and spiritual needs, maintaining a fragile balance, and proper communication with the patient. Lastly, GPs must address several palliative care elements surrounding the consultation including initiating the palliative care, being available, being the team coordinator/collaborator, providing continuous care and having sufficient knowledge about the patient. CONCLUSIONS: The roles, tasks and approaches of the GPs enabling palliative care include being aware of elements in the palliative care consultation and elements surrounding the consultation and by having sufficient education and training and a broad, proactive, and patient-centred approach.

Validity of the Brief Assessment of Impaired Cognition case-finding instrument for identification of dementia subgroups and staging of dementia.

BACKGROUND AND PURPOSE: The aims of this study were to examine the psychometric properties of the Brief Assessment of Impaired Cognition (BASIC) case-finding instrument in clinical settings focusing on (i) test-retest reliability, (ii) the discriminative validity of BASIC and its components for identification of Alzheimer disease (AD) dementia and non-AD dementia, and (iii) the association of expert clinical rating of cognitive status with BASIC performance. METHODS: The test-retest reliability analysis was based on a sample of general practice patients (n = 59) retested with a mean interval of 19 days. Discriminative validity analyses and analysis of the association of cognitive status with BASIC performance were based on data from the primary validation study of BASIC in memory clinics. RESULTS: The test-retest reliability of BASIC was high (r = 0.861). No significant difference in discriminative validity was found for identification of AD dementia (sensitivity = 0.99, specificity = 0.98) and non-AD dementia (sensitivity = 0.90, specificity = 0.98). All components of BASIC contributed to the high discriminative validity of both AD and non-AD dementia. BASIC performance was significantly correlated with expert clinical rating of the cognitive status of patients. A crude staging model for cognitive status using BASIC score intervals had superior classification accuracy (70%) compared to a Mini-Mental State Examination (MMSE) score range-based model (58% accuracy). CONCLUSIONS: BASIC is a reliable and valid case-finding instrument for AD dementia and non-AD dementia in clinical settings. BASIC performance is significantly associated with the degree of cognitive impairment, and BASIC seems to be superior to MMSE for staging of impairment.

Trends in prevalence and incidence of registered dementia and trends in multimorbidity among patients with dementia in general practice in Flanders, Belgium, 2000-2021: a registry-based, retrospective, longitudinal cohort study.

OBJECTIVES: With the ageing of our population, it seems plausible that the prevalence of both dementia and multimorbidity will increase in the following decades. The aim of this study is to examine the trends in prevalence and incidence of registered dementia and trends in multimorbidity in patients with dementia in general practice in Flanders. DESIGN: Retrospective, longitudinal cohort study. SETTING: Primary care practices across Flanders, Belgium. PARTICIPANTS: Patients included in the Intego database. METHODS: Data were collected from the Intego database, a Belgian general practice registration network, from 1 January 2000 to 31 December 2021. Joinpoint regression, the Cochran-Armitage test and Jonckheere-Terpstra test were used for the trend analysis. RESULTS: Data from 149 492 unique patients aged 65 years and older were available. From 2000 to 2021, 3835 incident cases of dementia were found. The age-adjusted prevalence of registered dementia significantly increased during this study period, from 1.19% to 2.43% (average annual percentage change (AAPC) 3.3; 95% CI 2.7 to 4.0). Incidence increased from 3.68 to 5.86 per 1000 patient years overall (AAPC 1.8, 95% CI -2.0 to 5.7), but declined in recent years (annual percentage change -8.1, 95% CI -14.8 to -0.8). Almost three-quarters of the patients with dementia (74.8%) suffered from multimorbidity (three or more comorbidities) and this increased significantly during the study period (p=0.0031). By 2021, 86.7% and 74.8% of the patients with dementia suffered from two or more or three or more chronic conditions, respectively. Hypertension (47.9%), osteoarthritis (29.7%) and lipid metabolism disorders (25.7%) were the most prevalent conditions. CONCLUSIONS: The prevalence of registered dementia doubled over a 22-year time period, mirroring the increasing health burden by this disease globally. Furthermore, three-quarters of the patients with dementia suffered from multimorbidity, underlining the urgent need to implement comorbidity management and patient-centred care in dementia.

Home-based training technology for persons with dementia: a qualitative study of barriers and facilitators for mobility-based training at home.

BACKGROUND: Physical training is increasingly used in rehabilitation for older people with dementia and several studies have documented positive results. Currently, welfare nations promote motion-based technology (MBT) at home to replace group training in various rehabilitation interventions. Research on the use of MBT by people with dementia is sparse. Therefore, this study explores how people with mild dementia and their relatives experience home-based MBT training in an intervention facilitated by a Danish municipality. METHODS: The study is part of a feasibility study and builds on participant observation and interviews with people with dementia (n = 4), their relatives (n = 4), and health care workers (n = 3) engaged in the project. RESULTS: Participants compared MBT training to group training and found that MBT was not a satisfactory replacement for group training. Some participants used and enjoyed MBT daily while others were challenged by the technology, the placement of the device, or motivation to independently complete the training program. CONCLUSION: MBT is possibly best considered as a supplement to group training, suitable for individuals able to use it in daily life.

Adaptation of a Danish online version of the Oxford Physical Activity Questionnaire (OPAQ) for secondary school students-a pilot study.

OBJECTIVE: To adapt and partly validate a Danish online version of the patient-reported outcome measure (PROM) Oxford Physical Activity Questionnaire ("OPAQ") and evaluate mobile phones and tablets as data capturing tool to identify potential problems and deficiencies in the PROM prior to implementation in the full study. METHODS: The OPAQ was translated into Danish by a formalised forward-backward translation procedure. Face validity was examined by interviewing 12 school students aged 10-15, recruited from two Danish public schools. After modifications, the online version of the Danish OPAQ was pilot tested in a convenience sample of seven school students for 1 week. Simultaneous objective accelerometer data were captured during the registration period. RESULTS: No major challenges were identified when translating OPAQ. Based on the interviews, the Danish version of OPAQ was perceived to be easy to understand in general, and the questions were relevant for tracking activities during the week. Five of the 12 participants had difficulties with understanding the introductory question: "what is your cultural background" in the original OPAQ. The interviews revealed that the participants recalling 7 days forgot to record some of the physical activity they had done during the week, indicating issues with the weekly recall method. After transforming to the online version, this was reported to be easy and quick to fill in (taking 1-3 min per day), and participants reported the daily design was helpful to remember activities. There was good correspondence between the online version and objective actigraphs with a tendency to underreport. Six participants reported 10-60 min less moderate to vigorous physical activity compared to the actigraphs, while one participant reported 3 min more. CONCLUSION: Participants found the online OPAQ quick and easy to complete during a 1-week period. Completing daily rather than weekly may help limit issues with recall. Overall, there was good agreement between the objective actigraphs and the OPAQ, though the OPAQ tended to slightly underreport moderate to vigorous physical activity. The Danish online version of OPAQ may be useful for capturing school students' physical activity when objective measures are not feasible.

Physicians' experiences, attitudes, and beliefs towards medical cannabis: a systematic literature review.

BACKGROUND: An increasing number of countries legalise the use of medical cannabis or allow it for a narrow range of medical conditions. Physicians, and often the patients' general practitioner, play a major role in implementing this policy. Many of them, however, perceive a lack of evidence-based knowledge and are not confident with providing patients with medical cannabis. The objectives of this review are to synthesise findings about hospital physicians' and GPs' experiences, attitudes, and beliefs towards the use of medical cannabis with the purpose of identifying barriers and facilitators towards providing it to their patients. METHODS: Peer-reviewed articles addressing hospital physicians' and GPs' experiences, attitudes, and beliefs towards the use of medical cannabis were searched systematically in PubMed, Scopus, EMBASE, and the Cochrane Library. RESULTS: Twenty-one articles were included from five different countries in which the medical cannabis laws varied. The studied physicians experienced frequent inquiries about medical cannabis from their patients (49-95%), and between 10 and 95% of the physicians were willing to prescribe and/or provide it to the patients, depending on setting, specialty and experience among the physicians. This review found that physicians experienced in prescribing medical cannabis were more convinced of its benefits and less worried about adverse effects than non-experienced physicians. However, physicians specialized in addiction treatment and certain relevant indication areas seemed more sceptical compared to physicians in general. Nevertheless, physicians generally experienced a lack of knowledge of clinical effects including both beneficial and adverse effects. CONCLUSION: This review indicates that GPs and hospital physicians from various specialties frequently experience patient demands for medical cannabis and to some degree show openness to using it, although there was a wide gap between studies in terms of willingness to provide. Hospital physicians and GPs' experienced in prescribing are more convinced of effects and less worried of adverse effects. However, most physicians experience a lack of knowledge of beneficial effects, adverse effects and of how to advise patients, which may comprise barriers towards prescribing. More research, including larger studies with cohort designs and qualitative studies, is needed to further examine facilitators and barriers to physicians' prescribing practices.

Criteria-based dispatch of emergency medical services in non-traumatic subarachnoid haemorrhage.

INTRODUCTION: Timely admission to a facility capable of providing highly specialised treatment is key in patients with spontaneous subarachnoid haemorrhage. We aimed to determine the time elapsed from the initial emergency telephone call to arrival at a neurosurgical department. Also, we aimed to determine the ambulance dispatch criteria used and the activated prehospital responses. METHODS: This was a retrospective study. Patients admitted in the Capital Region of Denmark within a 3.5-year period were identified in the Danish National Patient Register. Data were extracted from medical records and from automated telephone logs at the Emergency Medical Dispatch Centre. RESULTS: Time intervals were available in 124 out of 262 patients and ambulance dispatch criteria in 98 patients. The median time from call to neurosurgical admission was 207.5 minutes. The dispatch criterion sudden severe headache had a sensitivity of 17.4%. An ambulance with lights and sirens was dispatched to 77% of patients and 28% were brought directly to a hospital with neurosurgical facilities. CONCLUSIONS: The median time from emergency call to neurosurgical admission was 3.5 hours. No single dispatch criterion detected the condition with an acceptable sensitivity. A high proportion of patients received an ambulance with lights and sirens, but more than two out of three were not initially brought to a hospital with neurosurgical facilities. FUNDING: the non-profit organisation Trygfonden Trial registration: NCT03786068 - www.clinicaltrials.gov.

Residential exposure to transportation noise in Denmark and incidence of dementia: national cohort study.

OBJECTIVE: To investigate the association between long term residential exposure to road traffic and railway noise and risk of incident dementia. DESIGN: Nationwide prospective register based cohort study. SETTING: Denmark. PARTICIPANTS: 1 938 994 adults aged ≥60 years living in Denmark between 1 January 2004 and 31 December 2017. MAIN OUTCOME MEASURES: Incident cases of all cause dementia and dementia subtypes (Alzheimer's disease, vascular dementia, and Parkinson's disease related dementia), identified from national hospital and prescription registries. RESULTS: The study population included 103 500 participants with incident dementia, and of those, 31 219 received a diagnosis of Alzheimer's disease, 8664 of vascular dementia, and 2192 of Parkinson's disease related dementia. Using Cox regression models, 10 year mean exposure to road traffic and railway noise at the most (Ldenmax) and least (Ldenmin) exposed façades of buildings were associated with a higher risk of all cause dementia. These associations showed a general pattern of higher hazard ratios with higher noise exposure, but with a levelling off or even small declines in risk at higher noise levels. In subtype analyses, both road traffic noise and railway noise were associated with a higher risk of Alzheimer's disease, with hazard ratios of 1.16 (95% confidence interval 1.11 to 1.22) for road Ldenmax ≥65 dB compared with <45 dB, 1.27 (1.22 to 1.34) for road Ldenmin ≥55 dB compared with <40 dB, 1.16 (1.10 to 1.23) for railway Ldenmax ≥60 dB compared with <40 dB, and 1.24 (1.17 to 1.30) for railway Ldenmin ≥50 dB compared with <40 dB. Road traffic, but not railway, noise was associated with an increased risk of vascular dementia. Results indicated associations between road traffic Ldenmin and Parkinson's disease related dementia. CONCLUSIONS: This nationwide cohort study found transportation noise to be associated with a higher risk of all cause dementia and dementia subtypes, especially Alzheimer's disease.