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Simon Stockmann Poulsen,1 Hanne Irene Jensen,1,2 Karin Due Bruun,3,4 Morten Rune Blichfeldt-Eckhardt,1,3,4 Nina Kvorning1,5 1Department of Anesthesia, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark; 2Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; 3Pain Center of Southern Denmark, Odense University Hospital, Odense, Denmark; 4Department of Clinical Research, University of Southern Denmark, Odense, Denmark; 5Department of Anesthesia and Intensive Care, Hospital of Nykøbing Falster, Nykøbing Falster, DenmarkCorrespondence: Nina Kvorning, Department of Anesthesia and Intensive Care, Slagelse Hospital, Fælledvej 11, Slagelse, DK, 4200, Denmark, Tel +45 51919022, Fax +45 65413028, Email nkv@regionsjaelland.dkPurpose: Increasing recognition of chronic pain diseases, including Fibromyalgia, warrants the need for tools to monitor the impact of the disease as well as the efficacy of interventions. The Revised Fibromyalgia Impact Questionnaire (FIQR) has previously proved to be a valuable tool in both clinical and research settings. The study objective was to translate and validate the FIQR in Danish.Patients and Methods: A forward/backward translation, following the WHO-guidelines, was used to develop the Danish version of FIQR. The Danish translation of FIQR was answered by 101 patients suffering from fibromyalgia. The patients simultaneously answered the Hospital Anxiety and Depression Scale (HADS) and the 36-Item Short-Form Health Survey (SF-36) for validation.Results: The Danish FIQR showed excellent internal consistency, and reliability with Interclass Correlation Coefficients above 0.9. The correlations to HADS and SF-36 ranged from fair to very good. All results were found to have a p-value < 0.05.Conclusion: The present version of the Danish FIQR presents a valid and reliable tool for monitoring the impact of fibromyalgia.Keywords: fibromyalgia, questionnaire, chronic pain, evaluation, validation, translation

Kristina Kock Hansen,1,2 Ole Hilberg,1,2 Hanne Irene Jensen,2,3 Anders Løkke,1,2 Ingeborg Farver-Vestergaard2,4 1Department of Respiratory Diseases, Lillebaelt Hospital, Vejle, University Hospital of Southern Denmark, Denmark; 2Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; 3Department of Anaesthesiology and Intensive Care, Lillebaelt Hospital, Vejle, University Hospital of Southern Denmark, Denmark; 4Department of Medicine, Lillebaelt Hospital, Vejle, University Hospital of Southern Denmark, DenmarkCorrespondence: Kristina Kock Hansen, Department of Respiratory Diseases, Lillebaelt Hospital, Vejle, University Hospital of Southern Denmark, Beriderbakken 4, Vejle, 7100, Denmark, Tel +45 20189828, Email kristina.kock.hansen2@rsyd.dkPurpose: Patients with COPD experience anxiety, depression, and stress more frequently than in the age and gender-matched general population. This cross-sectional study aimed to examine the relationship between cognitive functions and the psychological factors of anxiety, depression and stress among patients with COPD.Patients and Methods: Between January 2021 and January 2023, patients with severe COPD were recruited, along with age-matched controls. Participants completed the Hospital Anxiety and Depression Scale (HADS) and the Perceived Stress Scale (PSS). The Montreal Cognitive Assessment (MoCA), a continuous reaction time test (CRT), and a driving simulator were used to assess cognitive impairment. Hierarchical multiple linear regression analyses were used to explain the variance of the correlations.Results: In total, 80 patients (mean age = 64yrs) and 22 controls (mean age = 61yrs) participated in the study. Patients reported significantly higher levels of psychological symptoms compared to the controls (p ≤ 0.001). We found no differences in anxiety (p = 0.31), depression (p = 0.66) and stress (p = 0.37) between patients with and without cognitive impairment. However, stress showed to be a significant predictor of decreased attention (higher stress score resulted in decreasing CRT-index, indication a reduced stability in reaction time) (p = 0.02). Psychological factors did not explain additional variance in cognitive functions beyond sociodemographic factors such as age and sex.Conclusion: Psychological symptom levels are higher in COPD than controls and perceived stress among patients with COPD appears to be associated with decreased attention. However, psychological factors in general did not appear to contribute to the variance in cognitive functions beyond sociodemographic, physical, and self-perceived symptoms.Keywords: chronic obstructive pulmonary disease, cognitive impairment, Montreal Cognitive Assessment, anxiety, depression, stress

Aims: Better prediction of outcome after total hip arthroplasty (THA) is warranted. Systemic inflammation and central neuroinflammation are possibly involved in progression of osteoarthritis and pain. We explored whether inflammatory biomarkers in blood and cerebrospinal fluid (CSF) were associated with clinical outcome, and baseline pain or disability, 12 months after THA., Methods: A total of 50 patients from the Danish Pain Research Biobank (DANPAIN-Biobank) between January and June 2018 were included. Postoperative outcome was assessed as change in Oxford Hip Score (OHS) from baseline to 12 months after THA, pain was assessed on a numerical rating scale, and disability using the Pain Disability Index. Multiple regression models for each clinical outcome were included for biomarkers in blood and CSF, respectively, including age, sex, BMI, and Kellgren-Lawrence score., Results: Change in OHS was associated with blood concentrations of tumour necrosis factor (TNF), interleukin-8 (IL-8), interleukin-6 receptor (IL-6R), glycoprotein 130 (gp130), and IL-1β (R 2 = 0.28, p = 0.006), but not with CSF biomarkers. Baseline pain was associated with blood concentrations of lymphotoxin alpha (LTα), TNFR1, TNFR2, and IL-6R (R 2 = 0.37, p < 0.001) and CSF concentrations of TNFR1, TNFR2, IL-6, IL-6R, and IL-1Ra (R 2 = 0.40, p = 0.001). Baseline disability was associated with blood concentrations of TNF, LTα, IL-8, IL-6, and IL-1α (R 2 = 0.53, p < 0.001) and CSF concentrations of gp130, TNF, and IL-1β (R 2 = 0.26, p = 0.002). Thus, preoperative systemic low-grade inflammation predicted 12-month postoperative outcome after THA, and was associated with preoperative pain and disability., Conclusion: This study highlights the importance of systemic inflammation in osteoarthritis, and presents a possible path for better patient selection for THA in the future. Preoperative central neuroinflammation was associated with preoperative pain and disability, but not change in OHS after THA., Competing Interests: C. Varnum received travel expenses from Stryker and L. E. Rasmussen received travel expenses and fees for participation in advisory board from Stryker, both through a company research grant to their department., (© 2024 Blichfeldt-Eckhardt et al.)

Introduction: Decisions to admit patients to intensive care units are often complex, and assessing patients is essential but difficult. In recent years, the Clinical Frailty Scale has been highlighted as a potential assessment tool for triaging patients for admission to the intensive care unit. This study aimed to investigate the clinical differences and Clinical Frailty Scale scores between patients who are refused and those who are admitted to the intensive care unit., Methods: All patients assessed for intensive care therapy at a Danish hospital from December 2020 to December 2021 were prospectively registered. The patients' descriptive data, Clinical Frailty Scale scores, three-month mortality rates and reasons for refusal were retrospectively extracted from hospital records., Results: During the study period, 571 patients were admitted to the intensive care unit, whereas 106 were refused admission. Patients who were refused had a significantly higher median age, a higher (poorer) Clinical Frailty Scale score and a significantly higher three-month mortality rate than patients who were admitted to the intensive care unit., Conclusions: The results indicate that the Clinical Frailty Scale may be one of several useful tools when assessing patients for intensive care therapy. However, this assessment is a multifactorial task, and further research needs to be conducted to examine the usefulness of this scale., Funding: Lillebaelt Hospital, University Hospital of Southern Denmark and the University of Southern Denmark supported this study., Trial Registration: Not relevant., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Introduction: Podcasts have emerged as a promising tool in patient preparation for hospital visits. However, the nuanced experiences of patients who engage with this medium remain underexplored., Objectives: This study explored patients' experiences of receiving information by way of podcasts prior to their hospital visits., Methods: Semi-structured interviews were conducted with patients with suspected chronic obstructive pulmonary disease (COPD), lung cancer, or sleep apnea. The method of data analysis chosen was thematic analysis., Results: Based on data from 24 interviews, five key themes were identified: technical challenges in utilization of podcasts; individual preferences for information prior to hospital visits; building trust and reducing anxiety through podcasts; the role of podcasts as an accessible and convenient source of information; and enhancement of engagement and empowerment through podcasts. Additionally, the study highlighted the critical importance of tailoring podcasts' content to individual preferences to optimize the delivery of healthcare information., Conclusions: Podcasts can serve as a meaningful supplement to traditional information sources for patients. However, it is important to recognize that not all patients may be able to engage with this medium effectively due to technical challenges or personal preferences.

Introduction: Rises in average life expectancy, increased comorbidities and frailty among older patients lead to higher admission rates to intensive care units (ICU). During an ICU stay, loss of physical and cognitive functions may occur, causing prolonged rehabilitation. Some functions may be lost permanently, affecting quality of life (QoL). There is a lack of understanding regarding how many variables are relevant to health-related outcomes and which outcomes are significant for the QoL of frail, elderly patients following discharge from the ICU. Therefore, this scoping review aims to identify reported variables for health-related outcomes and explore perspectives regarding QoL for this patient group., Methods and Analysis: The Joanna Briggs Institute guidelines for scoping reviews will be employed and original, peer-reviewed studies in English and Scandinavian languages published from 2013 to 2023 will be included. The search will be conducted from July 2023 to December 2023, according to the inclusion criteria in Embase, MEDLINE, PsycINFO and CINAHL. References to identified studies will be hand-searched, along with backward and forward citation searching for systematic reviews. A librarian will support and qualify the search strategy. Two reviewers will independently screen eligible studies and perform data extraction according to predefined headings. In the event of disagreements, a third reviewer will adjudicate until consensus is achieved. Results will be presented narratively and in table form and discussed in relation to relevant literature., Ethics and Dissemination: Ethical approval is unnecessary, as the review synthesises existing research. The results will be disseminated through a peer-reviewed publication in a scientific journal., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Burnout and mental illness are frequent among healthcare professionals, leading to increased sick leave. Simulation-based team training has been shown to improve job satisfaction and mental health among healthcare professionals. This study seeks to investigate the relationship between simulation-based team training and sick leave., Design: Cohort study., Setting and Intervention: Five Danish hospitals., Participants: A total of 15 751 individuals were screened for eligibility. To meet the eligibility criteria, individuals had to be employed in the same group (intervention or control) for the whole study period. A total of 14 872 individuals were eligible for analysis in the study., Intervention: From 2017 to 2019, a simulation-based team training intervention was implemented at two hospital sites. Three hospital sites served as the control group., Outcome Measures: Data on sick leave from 2015 to 2020 covered five hospital sites. Using a difference-in-difference analysis, the rate of sick leave was compared across hospital sites (intervention vs control) and time periods (before vs after intervention)., Results: Significant alterations in sick leave were evident when comparing the intervention and control groups. When comparing groups over time, the increase in sick leave was -0.3% (95% CI -0.6% to -0.0%) lower in the intervention group than in the control group. The difference-in-difference for the complete case analysis showed that this trend remained consistent, with analysis indicating a comparable lower increase in sick leave by -0.7% (95% CI -1.3% to -0.1%) in the intervention group., Conclusion: The increase in sick leave rate was statistically significantly lower in the intervention group, implying that simulation-based team training could serve as a protective factor against sick leave. However, when investigating this simulation intervention over 5 years, other potential factors may have influenced sick leave, so caution is required when interpreting the results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Chronic pain is a major health problem worldwide but the limited knowledge of its underlying pathophysiology impairs the opportunities for diagnostics and treatment. Biomarkers of chronic pain are greatly needed to understand the disease and develop new targets for interventions and drug treatments, and potentially introduce more precise diagnostic procedures. Much evidence points to a neuroimmune pathology for many chronic pain conditions and that important neuroimmune biomarkers exist in the cerebrospinal fluid (CSF) of patients with chronic pain. Systematic collection of CSF in large cohorts of chronic pain patients and healthy volunteers has proven difficult, however. We established the Danish Pain Research Biobank (DANPAIN-Biobank) with the aim of studying potential neuroimmune and glia-related biomarkers of chronic pain. In this paper, we describe the methods and the study population of the DANPAIN-Biobank., Methods: In this cross-sectional study, we included (I) participants with high-impact (HI) chronic pain from a tertiary, interdisciplinary pain center; (II) participants with osteoarthritic pain scheduled for arthroplasty surgery of the hip or knee at a regional hospital; and (III) pain-free volunteers. All participants completed a questionnaire assessing pain, functional impairment, anxiety, depression, and insomnia before samples of blood and CSF were extracted. Quantitative sensory tests were performed on participants with HI chronic pain and pain-free volunteers, and postoperative outcome scores were available on participants with osteoarthritic pain., Results: Of the 352 participants included, 201 had HI chronic pain (of which 71% had chronic widespread pain), 81 had chronic osteoarthritic pain, and 70 were pain-free volunteers. Samples were handled uniformly, and CSF samples were frozen within 30 minutes., Conclusions: We describe the content of the DANPAIN-Biobank, which is unique in terms of the number of participants (including pain-free volunteers), extensive clinical data, and uniformity in sample handling. We believe it presents a promising new platform for the study of neuroimmune and glia-related biomarkers of chronic pain., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-22-5319/coif). CV received travel expenses from Stryker. The other authors have no conflicts of interest to declare., (2023 Annals of Translational Medicine. All rights reserved.)

Background: One way in which patients can participate in care is by taking part in medical documentation. Producing documentation together with patients has been found to decrease the amount of incorrect information, help patients to be involved, and promote shared decision-making. The aims of this study were to develop and implement a practice of producing documentation together with patients and to examine staff and patient experiences of this practice., Methods: A quality improvement study was conducted from 2019 to 2021 at a Day Surgery Unit in a Danish University Hospital. Before implementing a practice of documenting together with patients, nurses' perceptions of doing documentation together with patients were examined via a questionnaire survey. After an implementation period, a similar follow-up survey with staff was conducted, together with structured patient phone interviews., Results: A total of 24 nursing staff out of 28 (86%) filled in the questionnaire at baseline and 22 out of 26 (85%) at follow-up. A total of 61 out of 74 invited patients (82%) were interviewed. At baseline, the majority (71-96%) of participants agreed that documentation done together with the patient would contribute to increased patient safety, fewer errors, real-time documentation, patient involvement, visible patient perspective, correction of errors, more accessible information and less duplication of work. At follow-up, significant decreases in the staffs' positive perceptions of the benefits of documenting together with patients were found for all areas except for "real-time documentation" and "less duplication of work". Almost all patients found it okay that the nurses wrote up medical documentation during the interview, and more than 90% of patients found the staff responsive or very responsive and present during the reception interview., Conclusion: Before implementation of a practice of documenting together with patients, the majority of staff assessed such documentation as being beneficial, but a significant decrease in positive assessment was found at follow-up, with challenges such as feeling less connected with the patient and practical, IT-related issues being described. The patients found the staff to be present and responsive and felt that it was important to know what was being written in their medical record., (© 2023. The Author(s).)

Background: Conducting a conversation about wishes for treatment at end of life (EOL) has been shown to improve EOL care for patients and relatives. Still, only a minority of physicians conduct the conversation, which might lead to unwanted interventions and treatments., Objectives: The purpose of this survey was to examine which factors facilitate and hinder physicians across a wide range of health care facilities to initiate the conversation about wishes for treatment at EOL., Design: A questionnaire survey based on a Delphi-developed questionnaire., Setting/subjects: The questionnaire was sent to both hospital physicians and general practitioners (GPs) in a Danish region., Results: More than 3000 physicians were invited to participate in the survey. Of these, 782 responded, 622 working at a hospital department, and 160 from general practice clinics. Results showed that senior physicians, GPs, and physicians working in a medical department feel best equipped to conduct the conversation. Moreover, senior physicians pointed to their experience as physicians as being of great importance for conducting the conversation, whereas junior physicians found training in conducting the conversation as an important factor., Conclusion: Our study indicates that different factors depending on the health care setting and the seniority of the physician facilitate or hinder physicians from conducting the conversation about wishes for treatment at EOL. Being aware of these differences and making a concerted effort depending on setting and seniority might help implement and conduct the conversation., Competing Interests: No competing financial interests exist., (© Mette Aaby Smith et al., 2022; Published by Mary Ann Liebert, Inc.)

Introduction: Critical illness and admission to an intensive care unit (ICU) can affect patients for months or years following discharge as many suffer from cognitive impairment. Long-term cognitive impairment affects patients' quality of life and ability to adapt to everyday life. Exploring their experiences on how and which cognitive impairments are affecting their everyday lives facilitates planning of relevant research on interventions that may serve to alleviate the burden of post-ICU cognitive impairment. The objective of this scoping review is to map the existing research on patients' experiences of cognitive impairment following critical illness., Methods and Analysis: The methodology will follow the Joanna Briggs Institute guidelines for scoping reviews. The databases MEDLINE, CINAHL, PsycINFO and Embase will be searched to identify studies appropriate for inclusion. Any peer-reviewed original studies meeting the inclusion criteria and include statements from adult patients about how they experience cognitive impairment following critical illness and ICU admission will be considered. Studies published in English and Scandinavian languages will be included, with no further geographical or cultural limitations. The included studies will be screened by two independent researchers using a standardised data extraction tool and the Mixed Methods Appraisal Tool will be used for critical appraisal. The results will be presented in a tabular form, and data will be supported by narrative descriptions or a narrative summary., Ethics and Dissemination: Since the scoping review methodology aims at synthetising existing research on patients' experiences of cognitive impairment following critical illness, the scoping review does not require ethical approval. The results will be disseminated though a peer-reviewed publication in a scientific journal., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Iatrogenic opioid use by patients with chronic malignant pain remains an important focus point. The positive effects of opioids seem to decline over time, whereas tapering will have positive effects in many patients. The purpose of the project was to optimise the process for patients with a wish or a need to taper opioids., Methods: Patients were referred to a multidisciplinary pain treatment centre with the aim of tapering their opioid use. The use of opioids before and after the intervention at the pain treatment centre was registered. Questionnaires about quality of life, sleep quality and level of depression were completed before and after the study, participants were allowed to add comments to the questionnaires and interviews were conducted., Results: A total of 22 patients participated. They had complex pain issues and had received opioids for a median period of nine years. The participants achieved a significant reduction of opioids (median 23 mg). Four patients completely stopped using opioids in the project period, four did not benefit from the project and two achieved reductions to the lowest dose possible allowing them to maintain an acceptable level of function. The remaining patients had a tapering plan to be continued in cooperation with their general practitioner. Most patients experienced the process as very satisfactory or satisfactory but achieved no measurable improvements in quality of life, sleep quality or level of depression., Conclusion: Even though the tapering of opioids had appeared difficult beforehand, a significant reduction in opioid consumption was achieved., Funding: The project was funded by the Danish Health Authority., Trial Registration: not relevant., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Objective: To explore patients' and physicians' perspectives on a decision-making conversation for life-sustaining treatment, based on the Danish model of the American Physician Orders for Life Sustaining Treatment (POLST) form., Design: Semi-structured interviews following a conversation about preferences for life-sustaining treatment., Setting: Danish hospitals, nursing homes, and general practitioners' clinics., Subjects: Patients and physicians., Main Outcome Measures: Qualitative analyses of interview data., Findings: After participating in a conversation about life-sustaining treatment using the Danish POLST form, a total of six patients and five physicians representing different settings and age groups participated in an interview about their experience of the process. Within the main research questions, six subthemes were identified: Timing, relatives are key persons, clarifying treatment preferences, documentation across settings, strengthening patient autonomy, and structure influences conversations. Most patients and physicians found having a conversation about levels of life-sustaining treatment valuable but also complicated due to the different levels of knowledge and attending to individual patient needs and medical necessities. Relatives were considered as key persons to ensure the understanding of the treatment trajectory and the ability to advocate for the patient in case of a medical crisis. The majority of participants found that the conversation strengthened patient autonomy., Conclusion: Patients and physicians found having a conversation about levels of life-sustaining treatment valuable, especially for strengthening patient autonomy. Relatives were considered key persons. The timing of the conversation and securing sufficient knowledge for shared decision-making were the main perceived challenges.KEY POINTSConversations about preferences for life-sustaining treatment are important, but not performed systematically.When planning a conversation about preferences for life-sustaining treatment, the timing of the conversation and the inclusion of relatives are key elements.Decision-making conversations can help patients feel in charge and less alone, and make it easier for health professionals to provide goal-concordant care.Using a model like the Danish POLST form may help to initiate, conduct and structure conversations about preferences for life-sustaining treatment.

Aim: This study explores how healthcare professionals included in the COVID-19 contingency plan experienced organizational changes, and explores factors associated with the experiences. Additionally, the study aimed to identify learning points for future similar scenarios., Design: A cross-sectional study., Methods: A questionnaire survey of healthcare professionals at three Danish hospitals, June 2020., Results: A total of 1,448 healthcare professionals completed the questionnaire. Hereof, 813 (57%) were relocated to new settings/new jobs. The majority experienced that their relocation was totally (49%) or partially (31%) imposed, and 51% reported that the overall experience of the new job function was satisfactory. Type of profession and whether relocation to the new job function was imposed were the main variables associated with the overall experience of being part of the contingency plan. Suggestions for future scenarios included training adjusted to individual competencies, more targeted information, voluntariness with consideration of individual needs and clarification of expectations., (© 2021 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Background: A growing body of evidence supports the existence of an association between patient safety culture (PSC) and patient outcomes. PSC refers to shared perceptions and attitudes towards norms, policies and procedures related to patient safety. Existing literature shows that PSC varies among health professionals depending on their specific profession and specialty. However, these studies did not investigate whether PSC can be improved. This study investigates whether length of education is associated with improvements in PCS following a simulation intervention., Methods: From April 2017 to November 2018, a cross-sectional intervention study was conducted at two regional hospitals in Denmark. Two groups with altogether 1230 health professionals were invited to participate. One group included nurses, midwives and radiographers; the other group included doctors. A train-the-trainer intervention approach was applied consisting of a 4-day simulation instructor course that emphasised team training, communication and leadership. Fifty-three healthcare professionals were trained as instructors. After the course, instructors performed in situ simulation in their own hospital environment., Outcomes: The Safety Attitude Questionnaire (SAQ), which has 6 dimensions and 32 items, was used to collect main outcome variables. All employees from both groups were surveyed before the intervention and again four and nine months after the intervention., Results: Mean baseline scores were higher among doctors than among nurses, midwives and radiographers for all SAQ dimensions. At the second follow-up, four of six dimensions improved significantly (p ≤ 0.05) among nurses, midwives and radiographers, whereas no dimensions improved significantly among doctors., Conclusion: Over time, nurses, midwives and radiographers improved more in PSC attitudes than doctors did., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Medically frail and/or chronically ill patients are often admitted to Danish hospitals without documentation of patient preferences. This may lead to inappropriate care. Modelled on the American Physician Orders for Life-Sustaining Treatment (POLST) form, the purpose of the study was to develop and pilot test a Danish POLST form to ensure that patients' preferences for levels of life-sustaining treatment are known and documented., Methods: The study was a mixed methods study. In the initial phase, a Danish POLST form was developed on the basis of literature and recommendations from the National POLST organisation in the US. A pilot test of the Danish POLST form was conducted in hospital wards, general practitioners' clinics, and nursing homes. Patients were eligible for inclusion if death was assessed as likely within 12 months. The patient and his/her physician engaged in a conversation where patient values, beliefs, goals for care, diagnosis, prognosis, and treatment alternatives were discussed. The POLST form was completed based on the patient's values and preferences. Family members and/or nursing staff could participate. Participants' assessments of the POLST form were evaluated using questionnaires, and in-depth interviews were conducted to explore experiences with the POLST form and the conversation., Results: In total, 25 patients participated, 45 questionnaires were completed and 14 interviews were conducted. Most participants found the POLST form readable and understandable, and 93% found the POLST form usable to a high or very high degree for discussing preferences regarding life-sustaining treatment. Three themes emerged from the interviews: (a) an understandable document is essential for the conversation, (b) handling and discussing wishes, and (c) significance for the future., Conclusion: The Danish version of the POLST form is assessed by patients, families, physicians, and nurses as a useful model for obtaining and documenting Danish patients' preferences for life-sustaining treatment. However, this needs to be confirmed in a larger-scale study., (© 2022. The Author(s).)

Purpose: The COVID-19 pandemic has influenced hospital work and healthcare workers all over the world. We explored how Danish nurses coped with the fast, comprehensive organisational changes in their workplace and identified barriers to and facilitators for organisations ensuring the best possible conditions for nurses to meet these challenges. The study focuses on the organisational setting and how it did or did not support the nurses in their work., Methods: A qualitative explorative design was used in interviewing 23 nurses who had worked at a COVID-19 ward in one of three hospitals. Data were collected in the summer of 2020, and the analysis was inspired by Paul Ricoeur's theory of narratives and interpretation., Results: The presence of managers in the wards helped the nurses in the form of psychological and practical support. Working within an organisation that provides a safe environment was essential for nurses. The experience of a safe environment allowed nurses to ask questions, which supported them in finding solutions to specific tasks in the new and critical working environment. Barriers to handling the new situation were an absence of managers and a lack of a sense of belongingness and trust., Conclusion: This study highlights the need for management to be present in the ward and for organisational support to be available to nurses so they can provide optimal treatment and care when working in new and unknown conditions during a pandemic. Practical assistance from managers to ease the job is beneficial. Furthermore, the presence of management is essential to provide psychological support and create a safe environment because this allows nurses to ask questions about how to better manage new and critical tasks., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The coronavirus (COVID-19) pandemic and the risk of an extensive overload of the healthcare systems have elucidated the need to make decisions on the level of life-sustaining treatment for patients requiring hospitalisation. The purpose of the study was to investigate the proportion and characteristics of COVID-19 patients with limitation of life-sustaining treatment decisions and the degree of patient involvement in the decisions., Methods: A retrospective observational descriptive study was conducted in three Danish regional hospitals, looking at all patients ≥ 18 years of age admitted in 2020 with COVID-19 as the primary diagnosis. Lists of hospitalised patients admitted due to COVID-19 were extracted. The data registration included age, gender, comorbidities, including mental state, body mass index, frailty, recent hospital admissions, COVID-19 life-sustaining treatment, ICU admission, decisions on limitations of life-sustaining treatment before and during current hospitalisation, hospital length of stay, and hospital mortality., Results: A total of 476 patients were included. For 7% (33/476), a decision about limitation of life-sustaining treatment had been made prior to hospital admission. At the time of admission, one or more limitations of life-sustaining treatment were registered for 16% (75/476) of patients. During the admission, limitation decisions were made for an additional 11 patients, totaling 18% (86/476). For 40% (34/86), the decisions were either made by or discussed with the patient. The decisions not made by patients were made by physicians. For 36% (31/86), no information was disclosed about patient involvement., Conclusions: Life-sustaining treatment limitation decisions were made for 18% of a COVID-19 patient cohort. Hereof, more than a third of the decisions had been made before hospital admission. Many records lacked information on patient involvement in the decisions., (© 2021. The Author(s).)

Aim: To explore how nurses experienced working in a newly organized COVID-19 ward with high-risk patients during a new and unknown pandemic., Design: A qualitative explorative study using a phenomenological-hermeneutic approach., Methods: Semi-structured individual telephone interviews were conducted in June-July 2020 with 23 nurses working in COVID-19 wards from three regional hospitals in Denmark. The nurses had been transferred from other departments at their hospital to the newly organized COVID-19 wards. Data analysis was influenced by Paul Ricoeur's theory of narrative and interpretation, including three analytical levels: naïve reading, structural analysis and critical interpretation and discussion., Results: During the structural analysis four themes were generated: (a) Challenging and uncertain situation, but also a positive experience (b) Professional and personal development (c) Lack of nurses' rights during a pandemic (d) Reward in itself or a desire for financial reward., (© 2021 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Objectives: This study aimed to investigate staff's perceptions of patient safety culture (PSC) in two Danish hospitals before and after an in situ simulation intervention., Design: A repeated cross-sectional intervention study., Setting: Two Danish hospitals. Hospital 1 performs emergency functions, whereas hospital 2 performs elective functions., Participants: A total of 967 healthcare professionals were invited to participate in this study. 516 were employed in hospital 1 and 451 in hospital 2. Of these, 39 were trained as simulation instructors., Intervention: A 4-day simulation instructor course was applied. Emphasis was put on team training, communication and leadership. After the course, instructors performed simulation in the hospital environment. No systematic simulation was performed prior to the intervention., Main Outcome Measures: The Safety Attitude Questionnaire investigating PSC was applied prior to the intervention and again 4 and 8 weeks after intervention. The proportion of participants with a positive attitude and mean scale scores were measured as main outcomes., Results: The response rate varied from 63.6% to 72.0% across surveys and hospitals. Baseline scores were generally lower for hospital 1. The proportion of staff with positive attitudes in hospital 1 improved by ≥5% in five of six safety culture dimensions, whereas only two dimensions improved by ≥5% in hospital 2. The mean scale scores improved significantly in five of six safety culture dimensions in hospital 1, while only one dimension improved significantly in hospital 2., Conclusions: Safety attitude outcomes indicate an improvement in PSC from before to after the in situ simulation intervention period. However, it is possible that an effect is more profound in an acute care hospital versus an elective setting., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Targeting the B-cell receptor (BCR) pathway with inhibitors of Bruton tyrosine kinase (BTK) and PI3Kδ is highly effective for the treatment of chronic lymphocytic leukemia (CLL). However, deep remissions are uncommon, and drug resistance with single-agent therapy can occur. In vitro studies support the effectiveness of combing PI3Kδ and BTK inhibitors. Experimental Design: As CLL proliferation and survival depends on the microenvironment, we used murine models to assess the efficacy of the BTK inhibitor acalabrutinib combined with the PI3Kδ inhibitor ACP-319 in vivo We compared single-agent with combination therapy in TCL1-192 cell-injected mice, a model of aggressive CLL. Results: We found significantly larger reductions in tumor burden in the peripheral blood and spleen of combination-treated mice. Although single-agent therapy improved survival compared with control mice by a few days, combination therapy extended survival by over 2 weeks compared with either single agent. The combination reduced tumor proliferation, NF-κB signaling, and expression of BCL-xL and MCL-1 more potently than single-agent therapy. Conclusions: The combination of acalabrutinib and ACP-319 was superior to single-agent treatment in a murine CLL model, warranting further investigation of this combination in clinical studies. Clin Cancer Res; 23(19); 5814-23. ©2017 AACR ., (©2017 American Association for Cancer Research.)

Background: Families' perspectives are of great importance in evaluating quality of care in the intensive care unit (ICU). This Danish-Dutch study tested a European adaptation of the "Family Satisfaction in the ICU" (euroFS-ICU). The aim of the study was to examine assessments of satisfaction with care in a large cohort of Danish and Dutch family members and to examine the measurement characteristics of the euroFS-ICU., Methods: Data were from 11 Danish and 10 Dutch ICUs and included family members of patients admitted to the ICU for 48 hours or more. Surveys were mailed 3 weeks after patient discharge from the ICU. Selected patient characteristics were retrieved from hospital records., Results: A total of 1077 family members of 920 ICU patients participated. The response rate among family members who were approached was 72%. "Excellent" or "Very good" ratings on all items ranged from 58% to 96%. Items with the highest ratings were concern toward patients, ICU atmosphere, opportunities to be present at the bedside, and ease of getting information. Items with room for improvement were management of patient agitation, emotional support of the family, consistency of information, and inclusion in and support during decision-making processes. Exploratory factor analysis suggested four underlying factors, but confirmatory factor analysis failed to yield a multi-factor model with between-country measurement invariance. A hypothesis that this failure was due to misspecification of causal indicators as reflective indicators was supported by analysis of a factor representing satisfaction with communication, measured with a combination of causal and reflective indicators., Conclusions: Most family members were moderately or very satisfied with patient care, family care, information and decision-making, but areas with room for improvement were also identified. Psychometric assessments suggest that composite scores constructed from these items as representations of either overall satisfaction or satisfaction with specific sub-domains do not meet rigorous measurement standards. The euroFS-ICU and other similar instruments may benefit from adding reflective indicators.

Background: The effects of non-sedation on cognitive function in critically ill patients on mechanical ventilation are not yet certain. This trial is a substudy of the NONSEDA trial where critically ill patients are randomized to non-sedation or to sedation with a daily wake-up attempt during mechanical ventilation in the intensive care unit (ICU). The aim of this substudy is to assess the effects of non-sedation versus sedation with a daily wake-up attempt on long-term cognitive function., Methods: This is an investigator-initiated, randomized, clinical, parallel-group, superiority trial, including 200 patients. Inclusion criteria will be adult patients who are intubated and on mechanical ventilation with an expected duration of more than 24 hours. Exclusion criteria will be patients who are comatose at admission and patients with conditions requiring therapeutic coma (i.e., severe head trauma, status epilepticus, patients treated with therapeutic hypothermia and patients with severe hypoxia). The experimental intervention will be non-sedation supplemented with pain management during mechanical ventilation. The control intervention will be sedation with a daily wake-up attempt. The primary outcome will be cognitive function 3 months after discharge from intensive care. The secondary outcomes will be the results of seven specific cognitive tests, performed 3 months after discharge from intensive care, and the association between hypoactive and agitated delirium during ICU admission and long-term cognitive function., Discussion: If non-sedation can improve long-term cognitive function, it could be an approach worth considering for a larger group of critically ill patients., Trial Registration: The study has been approved by the relevant scientific ethics committee and is registered at ClinicalTrials.gov (ID: NCT02035436 , registered on 10 January 2014).

Objective: To describe the associations between demographics and health-related quality of life for chronic non-malignant pain patients., Design: A cohort study., Setting: A multidisciplinary Danish pain centre., Study Participants: All patients treated at the centre between 2007 and 2013., Main Outcome Measures: Levels of pain, anxiety and depression, and physical and mental status. The Hospital Anxiety and Depression Scale and the Medical Outcomes Study Short-Form Health Survey (SF-36) were used., Results: A total of 1176 patients were included. The majority were women (64%), the mean age was 46.7 ± 14.4 (range 18-89), and 21% were able to work full or part time. On a Numeric Rating Scale from 0 to 10, median pain-intensity was 8 (interquartile range 7-8) and pain-discomfort 8 (interquartile range 7-9) at time of referral. More than half of the patients had symptoms of anxiety and depression. Most of the individual SF-36 domains had median scores between 0 and 40 (Scale from 0 to 100). Patients younger than 50 years of age as well as patients on sick leave/disability pension had significantly lower SF-36 scores. Level of pain, anxiety and depression decreased and SF-36-scores increased significantly after a course of treatment which in most cases consisted of both medical, physiotherapeutic and psychological treatment as well as health-oriented education. The chi-square test, Mann-Whitney U-test, the Kruskal-Wallis and Wilcoxon Signed-rank test were used for analyses., Conclusions: In order to improve treatment at a multidisciplinary pain centre, it may be of value to target treatments to different patient subgroups based on, amongst other things, age and employment status., (© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

Background: Critically ill patients rapidly loose much of their muscle mass and strength. This can be attributed to prolonged admission, prolonged mechanical ventilation and increased mortality, and it can have a negative impact on the degree of independence and quality of life. In the NONSEDA trial we randomize critically ill patients to non-sedation or sedation with a daily wake-up trial during mechanical ventilation in the intensive care unit. It has never been assessed whether non-sedation affects physical function. The aim of this study is to assess the effects of non-sedation versus sedation with a daily wake-up trial on physical function after discharge from intensive care unit., Methods/design: Investigator-initiated, randomized, clinical, parallel-group, superiority trial, including 700 patients in total, with a substudy concerning 200 of these patients. Inclusion criteria will be intubated, mechanically ventilated patients with expected duration of mechanical ventilation >24 h. Exclusion criteria will be patients with severe head trauma, coma at admission or status epilepticus, patients treated with therapeutic hypothermia, patients with PaO2/FiO2<9 where sedation might be necessary to ensure sufficient oxygenation or placing the patient in a prone position. The experimental intervention will be non-sedation supplemented with pain management during mechanical ventilation. The control intervention will be sedation with a daily wake-up trial. The co-primary outcome will be quality of life regarding physical function (SF-36, physical component) and degree of independence in activities of daily living (Barthel Index), and this will be assessed for all 700 patients participating in the NONSEDA trial. The secondary outcomes, which will be assessed for the subpopulation of 200 NONSEDA patients in the trial site, Kolding, will be 6-min walking distance, handgrip strength, muscle size (ultrasonographic measurement of the rectus femoris muscle cross-sectional area) and biomechanical data on lower extremity function (maximal voluntary contraction, rate of force development and endurance)., Discussion: This study is the first to investigate the effect of no sedation during critical illness on physical function. If an effect is found, it will add important information on how to prevent muscle weakness following critical illness., Trial Registration: The study has been approved by the relevant scientific ethics committee and is registered at ClinicalTrials.gov (ID: NCT02034942, 9 January 2014).

Introduction: Interdisciplinary collaboration in end-of-life decision-making is challenging. Guidelines developed within the interdisciplinary team may help to clarify, describe, and obtain consensus on standards for end-of-life decision-making and care. The aim of the study was to develop, implement, and evaluate guidelines for withholding and withdrawing therapy in the intensive care unit., Methods: An intervention study in two Danish intensive care units, evaluated in a pre-post design by a retrospective hospital record review and a questionnaire survey. The hospital record review included 1,665 patients at baseline (12-month review) and 897 patients after the intervention (6-month review). The questionnaire survey included 273 nurses, intensivists, and primary physicians at baseline and 229 post-intervention., Results: For patients with therapy withdrawn, the median time from admission to first consideration on level of therapy decreased from 1.1 to 0.4 days (p=0.03), and the median time from admission to a withdrawal decision decreased from 3.1 to 1.1 days (p=0.02). Sixty-five percent of the participants who used the guidelines concerning end-of-life decision-making considered them helpful to high or very high extent. No significant changes were found in satisfaction with interdisciplinary collaboration or in withholding or withdrawing decisions being changed or unnecessarily postponed. The healthcare professionals' perception of the care following withdrawal of therapy increased significantly after implementation of the guidelines., Conclusions: The study indicates that working with guidelines for withholding and withdrawing therapy in the intensive care unit may facilitate improvements in end-of-life decision-making and patient care, but further studies are needed to provide robust evidence.

Background: Practices for withholding or withdrawing therapy vary according to professional, cultural and religious differences. No Danish-validated questionnaire examining withholding and withdrawing practices exists, thus the aim of this study was to develop and validate a questionnaire for surveying the views of intensive care nurses, intensivists, and primary physicians regarding collaboration and other aspects of withholding and withdrawing therapy in the ICU., Methods: A questionnaire was developed on the basis of literature, focus group interviews with intensive care nurses and intensivists, and individual interviews with primary physicians. The questionnaire was validated in the following 3 phases: a qualitative test with 17 participants; a quantitative pilot test with 60 participants; and a survey with 776 participants. The validation process included tests for face and content validity (by interviewing participants in the qualitative part of the pilot study), reliability (by assessing the distribution of responses within the individual response categories), agreement (by conducting a test-retest, evaluated by paired analyses), known groups' validity (as a surrogate test for responsiveness, by comparing two ICUs with a known difference in end-of-life practices), floor and ceiling effect, and missing data., Results: Face and content validity were assessed as good by the participants in the qualitative pilot test; all considered the questions relevant and none of the participants found areas lacking. Almost all response categories were used by the participants, thus demonstrating the questionnaires ability to distinguish between different respondents, agreement was fair (the average test-retest agreement for the Likert scale responses was 0.54 (weighted kappa; range, 0.25-0.73), and known groups' validity was proved by finding significant differences in level of satisfaction with interdisciplinary collaboration and in experiences of withdrawal decisions being unnecessarily postponed. Floor and ceiling effect was in accordance with other questionnaires, and missing data was limited to a range of 0-7% for all questions., Conclusions: The validation showed good and fair areas of validity of the questionnaire. The questionnaire is considered a useful tool to assess the perceptions of collaboration and other aspects of withholding and withdrawing therapy practices in Danish ICUs amongst nurses, intensivists, and primary physicians.

Objective: The aim of this study was to examine the assessments and priorities by children and adolescents of health care in a paediatric outpatient clinic, to examine the influence of the time factor on the assessments and priorities by children and adolescents of health care, and to determine their preferred method of evaluation., Design: A quasi-randomized follow-up study in which children and adolescents either completed a questionnaire at an outpatient clinic and again 3-6 weeks after the visit, or only 3-6 weeks after the visit., Setting: A Danish paediatric outpatient clinic., Participants: Children and adolescents from the outpatient clinic., Main Outcome Measures: Comparison between assessments given at the clinic and assessments given 3-6 weeks after the visit., Results: Three hundred forty-six children and adolescents completed at least one questionnaire. Children and adolescents were generally satisfied with the consultation at the paediatric outpatient clinic, but the visit was assessed less positive 3-6 weeks post-visit compared with assessments given immediately after the visit. Assessments and priorities of more general matters were not influenced by the time factor. Electronic surveys via touch screen computers were preferred to paper questionnaires by children and adolescents., Conclusions: When comparing user satisfaction from different studies and when planning a survey of user satisfaction, the interval between the rendering of the health-care service and the assessment should be taken into consideration.

We have isolated a stable, transplantable, and small glucagonoma (MSL-G-AN) associated with abrupt onset of severe anorexia occurring 2-3 wk after subcutaneous transplantation. Before onset of anorexia, food consumption is comparable to untreated controls. Anorexia is followed by adipsia and weight loss, and progresses rapidly in severity, eventually resulting in reduction of food and water intake of 100 and 80%, respectively. During the anorectic phase, the rats eventually become hypoglycemic and hypothermic. The tumor-associated anorexia shows no sex difference, and is not affected by bilateral abdominal vagotomy, indicating a direct central effect. The adipose satiety factor leptin, known to suppress food intake by reducing hypothalamic neuropeptide Y (NPY) levels, was not found to be expressed by the tumor, and circulating leptin levels were reduced twofold in the anorectic phase. A highly significant increase in hypothalamic (arcuate nucleus) NPY mRNA levels was found in anorectic rats compared with control animals. Since elevated hypothalamic NPY is among the most potent stimulators of feeding and a characteristic of most animal models of hyperphagia, we conclude that the MSL-G-AN glucagonoma releases circulating factor(s) that overrides the hypothalamic NPY-ergic system, thereby eliminating the orexigenic effect of NPY. We hypothesize a possible central role of proglucagon-derived peptides in the observed anorexia.