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Background: Empathy is widely recognized as a multi-dimensional construct, involving emotional and cognitive components. These may cause distinct experiences and behaviors that can be both beneficial and deleterious to individuals' well-being and mental health., Aim: We wished to examine the association between emotional and cognitive empathy of Danish university students as measured by the multidimensional Interpersonal Reactivity Index (IRI) and study major, sex, age, and parental status. Additionally, we aimed to gauge the validity of the Jefferson Scale of Empathy - Student version (JSE-S) as a measure of primarily cognitive empathy in the context of medical majors by comparing JSE-S scores with IRI cognitive scores., Methods: In our national, cross-sectional study, conducted in October 2020, we used survey data from students in their first, third, and final study year. All students from University of Southern Denmark were invited to fill out IRI, and all medical students at Denmark's four medical educations were additionally invited to fill out the JSE-S. Associations were estimated by linear regression models., Results: Of 14,072 invited, 2,595 students completed the questionnaire. Health majors scored statistically significantly higher on cognitive empathy than students from other study majors. The JSE-S correlated significantly with the cognitive empathy subscales of the IRI. Furthermore, the effects found in relation to sex, age-, and parental status were significant., Conclusion: Our study results show that large differences in empathy exist between university students and study majors. Overall, our results highlight (1) the relevance of investigating empathy as a multidimensional versus a global construct in young adult populations (including university students) and (2) the importance of focusing on differences in empathy across different student characteristics.

Two experiments were designed to evaluate later timepoints for fixed-time artificial insemination (FTAI) of beef heifers and cows, with the hypothesis that use of a later timepoint would allow a greater proportion of animals to express estrus prior to FTAI and result in greater conception rates among estrous females inseminated with sex-sorted semen. In Experiment 1, estrus was synchronized for 1640 heifers using the 14 d CIDR-PG protocol: insertion of an intravaginal progesterone-releasing insert (CIDR; 1.38 g progesterone) on Day -33 and removal on Day -19, and administration of prostaglandin F 2α (PG; 500 μg cloprostenol sodium) on Day -3. Heifers were inseminated at one of three FTAI timepoints: 66 h, 70 h, or 74 h after PG administration. In Experiment 2, estrus was synchronized for 414 beef cows using the 7 & 7 Synch protocol: administration of PG coincident with CIDR insertion on Day -17, gonadotropin-releasing hormone (GnRH; 100 μg gonadorelin) on Day -10, and PG coincident with CIDR removal on Day -3. Cows were inseminated at one of two FTAI timepoints: 66 h or 72 h after PG administration. In both experiments, only animals that expressed estrus prior to FTAI were inseminated with sex-sorted semen. In Experiment 1, the proportion of heifers that expressed estrus prior to FTAI (66 h: 62 %; 70 h: 67 %; 74 h: 71 %) was greater when FTAI was performed at 74 h versus 66 h (P = 0.0097); however, conception rate of heifers that expressed estrus and were serviced with sex-sorted semen did not differ among treatments (P = 0.67; 66 h: 56 %; 70 h: 53 %; 74 h: 53 %). In Experiment 2, the proportion of cows expressing estrus prior to FTAI did not differ between treatments (P = 0.30; 66 h: 71 %; 72 h: 76 %). Additionally, conception rate of estrous cows inseminated with sex-sorted semen did not differ between treatments (P = 0.24; 66 h: 45 %; 72 h: 40 %). These results indicate that performing FTAI later following the 14 d CIDR-PG protocol increases the proportion of heifers that express estrus and are serviced with sex-sorted semen but does not improve conception rates. Later timing of FTAI following the 7 & 7 Synch protocol was not observed to increase the proportion of cows expressing estrus prior to FTAI or improve conception rates among estrous cows inseminated with sex-sorted semen. Together, these results provide further insight into optimal timing of FTAI when using sex-sorted semen., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Biocatalytic processes are highly selective and specific. However, their utility is limited by the comparatively narrow scope of enzyme-catalysed transformations. To expand product scope, we are developing biocompatible processes that combine biocatalytic reactions with chemo-catalysis in single-flask processes. Here, we show that a chemocatalysed Pictet-Spengler annulation can be interfaced with biocatalysed alcohol oxidation. This two-step, one-pot cascade reaction converts tyramine and aliphatic alcohols to tetrahydroisoquinoline alkaloids in aqueous buffer at mild pH. Tryptamine derivatives are also efficiently converted to tryptolines. Optimization of stoichiometry, pH, reaction time, and whole-cell catalyst deliver the tetrahydroisouinolines and tryptolines in >90 % and >40 % isolated yield, respectively, with excellent regioselectivity., (© 2023 Wiley-VCH GmbH.)

Introduction: Diabetes distress has been defined as "the negative emotional or affective experience resulting from the challenge of living with the demands of diabetes". Diabetes distress affects 20%-25% of individuals living with diabetes and can have negative effects on both diabetes regulation and quality of life. For people living with diabetes distress, innovative tools/interventions such as online or app-based interventions may potentially alleviate diabetes distress in a cost-effective way. The specific research questions of this scoping review are: (1) what are the effects of online or app-based interventions on diabetes distress for adults with type 1 or type 2 diabetes, and (2) what are the characteristics of these interventions (eg, type of intervention, duration, frequency, mode of delivery, underlying theories and working mechanisms)?, Methods and Analysis: A scoping review will be conducted, using the methodological framework of Arksey and O'Malley along with Levac et al . Eligible studies are: studies of adults ≥18 years old with type 1 or 2 diabetes using an online or app-based intervention and assessing diabetes distress as the primary or secondary outcome. Five databases (Medline, EMBASE, CINAHL, PsycINFO and Scopus) will be searched and is limited to articles written in English, Danish, Norwegian, Swedish or Dutch. Two reviewers will independently screen potentially eligible studies in Covidence, select studies, and together chart data, collate, summarise, and report the results. We will adhere to the Preferred reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews (PRISMA-ScR)., Ethics and Dissemination: The scoping review has been exempt from full ethical review by the Regional Committees on Health Research Ethics for Southern Denmark (case number: S-20232000-88). The results of the review will be published in a peer-reviewed journal and presented at relevant conferences and workshops with relevant stakeholders., 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.)

Objective: Breast cancer is the most common cancer diagnosis among women. The acute crisis and uncertainty that often follow diagnosis put the family at risk of exhaustion and dysfunction. Adolescents have been identified as a particularly vulnerable group of relatives. To investigate how to prevent distress in this group, we systematically reviewed research on adolescents' (11-21 years) needs for information and psycho-social support during their mothers' breast cancer trajectory., Method: Systematic searches were conducted in five bibliometric databases. Peer-reviewed, original research of adolescents aged 11-21 with a mother diagnosed with breast cancer was included. Two researchers conducted screening, quality assessment, and data extraction independently. Thematic synthesis was applied to the included studies., Results: A total of 8066 studies were screened, and five quantitative and six qualitative studies were included. The results indicated that adolescents' information and psycho-social support needs were poorly met. Many were reluctant to share feelings with family and peers and experienced abandonment during the crisis. Adolescents who were not well informed experienced distress. Poor family functioning increased the level of adolescents' distress., Conclusions: Despite limitations regarding heterogeneity among the studies, eligibility criteria, and quality assessment, this review provides clear clinical implications. Encounter groups may support adolescents during their mother's breast cancer trajectory. Furthermore, healthcare professionals could provide more indirect support to adolescents by providing support and clearer guidelines to parents. Finally, adolescents from poor-functioning families need extra attention., (© 2023 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.)

Objective: To enable measurement of coping in the general Danish population the aims of this study are to 1) describe the translation and cultural adaption of the Danish Brief Approach/Avoidance Coping Questionnaire (BACQ) and 2) investigate the psychometric properties of the Danish BACQ., Design: The BACQ was translated and adapted into Danish, and the psychometric properties tested in two samples of adult Danish citizens: Sample A  = 167, used for exploratory factor analysis (EFA), and Sample B  = 330 persons, used for confirmatory factor analysis (CFA). Internal consistency was evaluated by Cronbach's Alpha, item-to-rest correlation, and scale-to-scale Pearson correlation., Results: The EFA suggested reasonable fits for both a three-factor and four-factor model, confirmed by the CFA with acceptable goodness-of-fit indices for both models. Using the four-factor-model would require a re-evaluation of the scale. The three-factor model had admissible internal consistency with an overall Cronbach's alpha of 0.66. Individuals with low self-rated health, extreme concern about current health and poor physical fitness, respectively, had lower Approach and higher Diversion and Resignation scores., Conclusion: The psychometric properties showed that the Danish BACQ could be used as a three-factor model. With some limitations, the Danish version had acceptable construct validity, internal consistency, and content validity.

Objectives: Due to increasing pressure on healthcare resources, knowledge of factors that affect healthcare utilization (HCU) is important. However, the evidence of a longitudinal association between loneliness and social isolation respectively, and HCU is limited. The present prospective cohort study investigated the association of loneliness and social isolation with HCU in the general population over time., Method: Data from the 2013 Danish "How are you?" survey (n = 27.501) were combined with individual-level register data with almost complete follow-up over a 6-year follow-up period (2013-2018). Negative binomial regression analyses were performed while adjusting for baseline demographics and preexisting chronic disease., Results: Loneliness measured was significantly associated with more general practice contacts (incident rate ratio [IRR] = 1.03, 95% confidence interval [CI] [1.02, 1.04]), more emergency treatments (IRR = 1.06, [1.03, 1.10]), more emergency admissions (IRR = 1.06, [1.03, 1.10]), and hospital admission days (IRR = 1.05, [1.00, 1.11]) across the 6-year follow-up period. No significant associations were found between social isolation and HCU with one minor exception, in which social isolation was associated with fewer planned outpatient treatments (IRR = 0.97, [0.94, 0.99]). Wald test demonstrated that the association of loneliness with emergency admissions and hospital admissions days was not significantly different from the effects of social isolation on those outcomes., Conclusions: Our findings suggest that loneliness slightly increased the number of general practice contacts and emergency room treatments. Overall, the effects of loneliness and social isolation on HCU were small. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective: The implantable cardioverter defibrillator (ICD) is used to treat malignant ventricular arrhythmias. Since 33% of patients experience ICD-related concerns, we examined sex differences in ICD concerns and correlates of ICD concerns during 24 months of follow-up after implantation of an ICD., Methods: Patients from the DEFIB-WOMEN study (n = 1515; 81.6% male patients) completed questionnaires on ICD concerns, anxiety, depression, and Type D personality at five measure points (baseline, 3-, 6-, 12- and 24-months post-implantation)., Results: Male patients scored on average 7.0 (6.8) points on ICD concerns at the time of implantation and female patients scored on average 10.5 (8.2) points. We found statistically significant sex differences in ICD concerns at all measurement points, with female patients scoring 2.77 points (8.7% of the maximum score of 32) higher than male patients. ICD concerns decreased in both sexes the first 6 months and then levelled out. For both sexes, ICD concerns at baseline were significantly correlated with ICD concerns at 24-months follow-up. Anxiety at baseline was correlated with ICD concerns in female patients, while depression at baseline and at least one experienced shock correlated with ICD concerns in male patients., Conclusion: Female patients reported more ICD concerns at all measurement points compared to male patients, but for both sexes ICD concerns decreased in the first 6 months. ICD shock, anxiety, depression, and ICD concerns at baseline were correlates of ICD concerns at 24-months follow-up., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

The incidence and implications of disparate ovarian and uterine development during the peripubertal period were evaluated in two experiments. In Experiment 1, two consecutive pre-breeding evaluations were performed on 469 heifers. In Experiment 2, data from 22,174 heifers were retrospectively analyzed. For heifers in both experiments, ovarian and uterine maturity were independently assessed via transrectal evaluation, and a two-digit reproductive tract score (RTS: first digit = ovarian; second digit = uterine) was assigned. Measures of the physical maturity of heifers were recorded at the time of pre-breeding evaluation. Heifers were subjected to 14-day progestin-based protocols for synchronization of estrus, and artificial insemination (AI) was performed. Pregnancy diagnosis was performed via transrectal ultrasonography. Incidence of disparate ovarian and uterine score was 33.7 % (158/469) in Experiment 1 % and 16.3 % (3622/22,174) in Experiment 2. Observations of disparate ovarian and uterine maturity were correlated with physical maturity. Heifers with RTS < 3-3 demonstrated poor reproductive performance, as lesser proportions of these animals conceived to the first AI service in Experiment 2 (P < 0.01) or throughout the breeding season in Experiment 1 (P = 0.03). Conception did not differ between heifers assigned congruent or disparate scores of greater than RTS = 3-3. Disparities in ovarian and uterine development are likely observed as the result of rapid, yet asynchronous growth of reproductive tissues during the peripubertal period and are not indicative of inherently reduced potential for fertility. Independent assessment of ovarian and uterine maturity may increase precision in characterizing physiologic maturity of mixed groups of prepubertal, peripubertal, and pubertal heifers., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to explore cardiac nurses' experiences with a comprehensive web-based intervention for patients with an implantable cardioverter defibrillator., Methods: We conducted an explorative qualitative study based on individual semi-structured interviews with 9 cardiac nurses from 5 Danish university hospitals., Results: We found one overall theme: "Between traditional nursing and modern eHealth". This theme was derived from the following six categories: (1) comprehensive content in the intervention, (2) patient-related differences in engagement, (3) following the protocol is a balancing act, (4) online communication challenges patient contact, (5) professional collaboration varies, and (6) an intervention with potential. Cardiac nurses were positive towards the web-based intervention and believe it holds a large potential. However, they felt challenged by not having in-person and face-to-face contact with patients, which they found valuable for assessing patients' wellbeing and psychological distress., Conclusion: Specific training in eHealth communication seems necessary as web-based care entails a shift in the nursing role and requires a different way of communication. Innovation Focusing on the user experience in web-based care from the perspective of cardiac nurses is innovative, and by applying implementation science this leads to new knowledge to consider when developing and implementing web-based care., Competing Interests: Susanne S Pedersen reports financial support was provided by Lundbeck Foundation. Susanne S Pedersen reports financial support was provided by TrygFonden., (© 2022 The Authors.)

Background: The modern medical education is predominantly grounded in the biomedical sciences. In recent years, medical humanities have been included into the medical curricula in many countries around the world one of the objectives being to promote patient-centred, empathic care by future physicians. Studies have been made of the impact of inclusion of medical humanities components within the medical curriculum. Although some results suggest increased empathy, others remain inconclusive. To gain insight into the depth, context, and impact of inclusion of the medical humanities for future physicians, this study aimed to explore Danish medical students' understanding of and reflections on how the medical humanities relate to the medical education, including the clinic., Methods: We conducted a qualitative research study, involving semi-structured interviews with twenty-three Danish medical students across years of curriculum and medical schools. Interviews were recorded, transcribed verbatim and analyzed using Braun and Clarke's thematic analysis., Results: The findings demonstrate the subordinate role of the medical humanities in the medical educational system. Students prioritize biomedical knowledge building in the preclinical curriculum, partly as a reaction to an unbalanced institutional inclusion of the medical humanities. Observing how structural empathy incentives are lacking in the clinical curriculum, the values inherent in the medical humanities are undermined., Conclusion: Danish medical students become part of an educational environment with lacking institutional conditions and structures to promote the strong inclusion of the medical humanities. A focus is therefore needed on the values, norms and structures of the medical educational systems that undermine a strong inclusion of the medical humanities into medical education., (© 2022. The Author(s).)

Background: Clinical empathy has been associated with a range of positive patient- and clinician outcomes. Educating medical students to become empathic physicians has in recent years become a clearly pronounced learning objective in medical education in many countries worldwide. Research knowledge about how medical students experience the learning processes conveyed by empathy-enhancing educational interventions is lacking. Our study aimed to explore Danish medical students' perspectives on which experiences allowed learning processes to take place in relation to empathy and empathic communication with patients., Methods: We conducted a qualitative research study, involving semi-structured interviews with twenty-three Danish medical students across years of curriculum and universities. Braun and Clarke's reflexive thematic analysis (RTA) guided the analytical process, moving on a continuum from inductive to deductive, theoretical approaches. Key concepts in regard to learning processes deriving from Amadeo Giorgi's learning theory were applied to analyse the data., Results: Learning processes in relation to clinical empathy occured: 1. when theoretical knowledge about empathy became embodied and contextualied within a clinical context 2. through interpersonal interactions, e.g., with peers, faculty members and clinicians, that conveyed behavior-mobilizing positive and negative affect and 3. when new learning discoveries in 2. and 3. were appropriated as a personalized and adequate behavior that transcends the situational level., Conclusion: Rather than being an immediate product of knowledge transmission, skill acquisition or training, learning clinical empathy is experienced as a dynamic, temporal process embedded in a daily clinical lifeworld of becoming an increasingly human professional., (© 2022. The Author(s).)

Objective: At a Danish Hospital, we wished to establish a co-designed patient education day about prophylactic interventions for women at high risk of developing breast cancer. However, knowledge is lacking on the women's acceptability and requests for content. The objective of this study is to gain knowledge about the acceptability and requests of the content of a patient education day among women at high risk of breast cancer considering prophylactic mastectomy., Methods: A user panel consisting of patients and health care professionals developed an interview guide for two focus interviews with two groups of women at high risk of breast cancer; one group had received a prophylactic mastectomy and one group considered it. Thematic analysis was used to explore the participants' acceptability and requests for content., Results: Meaningful content was knowledge about prophylactic interventions, how to share knowledge with partners and children, and talking to equals in a safe forum. Not all participants wished to discuss own surgery in a group setting., Conclusion: An education day is an acceptable and supportive format for gaining knowledge about surgery, but since some topics may be vulnerable to discuss in a group setting to some women, we suggest the education day as a valuable supplement to the individual consultations., (© 2022 The Authors. European Journal of Cancer Care published by John Wiley & Sons Ltd.)

Background: Professional empathy has been associated with a range of positive patient- and clinician outcomes and is therefore considered important to develop for future physicians. Measuring changes in empathy scores among medical students by using the Jefferson Scale of Empathy (Student version) (JSE-S) has led to mixed results. So far, no investigation of Danish medical students' empathy development has been conducted. The aim of this study was therefore to examine the associations between empathy scores among Danish medical students and medical school, year of curriculum, age, sex, co-habitation, and parental status, specialty preferences and motivations for choosing medicine as a future profession., Methods: This was a cross-sectional questionnaire study. All medical students from four medical schools in Denmark in their first, third and sixth year (N = 4,178) were invited to participate in the study in October 2020. The associations between JSE-S sum score and the above explanatory factors were analysed by uni- and multivariable linear regression models., Results: The JSE-S was completed by 672 medical students. The overall mean score was 112.7. There were no statistically significant differences in empathy between medical schools, first, third- and sixth- year medical students, age groups or parental status. Female students and students living with a spouse or partner scored higher on JSE-S than male students or students living alone, and the sex difference remained statistically significant in the multivariable regression. In both the univariable and multivariable setting, preference for future medical specialty was statistically significant, with a decrease in scores for students choosing surgery-specialties. Motivational factors were not statistically significantly associated with empathy, although there was a slight upwards trend for one of the motivational categories, named "personal experiences"., Conclusions: Overall, our results showed neither decrease nor increase but instead rather stable empathy scores across years of curriculum of medical students in Denmark, adding to the mixed picture of empathy development among medical students. Our findings are consistent with positive associations found in international studies between empathy scores and higher age, female sex, specialty preferences for psychiatry and general practice and altruistic motivations for choosing to enroll. Although specialty preferences are changing during medical education, they may be used meaningfully as predictors of individual student empathy levels., (© 2022. The Author(s).)

An experiment was conducted to compare the 7 & 7 Synch and 7-day CO-Synch + controlled internal drug release (CIDR®) treatment regimens before fixed-time artificial insemination (FTAI) of beef cows with conventional or sex-sorted semen. Cows (n = 1538) were blocked based on age and days postpartum (DPP) and randomly assigned to treatment regimen and semen type. Cows assigned to the 7-day CO-Synch + CIDR treatment regimen (n = 769) were administered gonadotropin-releasing hormone (GnRH) and an intravaginal progesterone-releasing insert (CIDR) on Day - 10, and administration of prostaglandin F 2α (PG) coincident with CIDR removal on Day - 3. Cows assigned to 7 & 7 Synch (n = 769) were administered PG and a CIDR device on Day - 17, GnRH on Day - 10, and PG coincident with CIDR removal on Day - 3. Cows were administered GnRH coincident with FTAI, which was performed 66 h after CIDR removal with conventional (20 × 10 6 cells) or sex-sorted (4 × 10 6 cells) semen. Expression of estrus was affected by treatment regimen (P = 0.01) and by treatment regimen × DPP (P = 0.0004), as a result of imposing the 7 & 7 Synch regimen; therefore, a greater percentage of cows expressed estrus (82% compared with 64%), particularly among cows with greater DPP. Pregnancy percentages resulting from FTAI were less (P < 0.0001) when using sex-sorted semen but greater among cows treated with 7 & 7 Synch (conventional semen: 72%; sex-sorted semen: 52%) compared with 7-day CO-Synch + CIDR (conventional semen: 61%; sex-sorted semen: 44%)., (Copyright © 2021 Elsevier B.V. All rights reserved.)

To design and evaluate a mental health treatment program and internet-based delivery platform for patients with ischemic heart disease (IHD) attending cardiac rehabilitation with the aim of reducing the risks associated with anxiety and/or depression. Patients diagnosed with IHD and comorbid anxiety and/or depression. Participatory design of treatment program and internet platform through staged inclusion of participants in two groups. Group 1 was enrolled as co-researchers with prolonged engagement in the project. Group 2 participated only in the pilot evaluation workshop. Three patients were included in Group 1, two patients in Group 2. Inclusion of patients proved challenging, but the extended collaboration with co-researchers yielded valuable circumstantial insight and resulted in the design of a novel nine-module treatment program. Additionally, the inclusion of two participant groups helped shape the development of an internet platform based on an open-source content management system. Our grouped participation method contributes with several recommendations and reflections of advantages of this approach. Collaboration with co-researchers helped us gain a deeper understanding of the impact of language on self-perception and potential stigma. Prolonged participation led to a higher level of trust and familiarity, which enabled uncovering of issues otherwise hidden.

Aims: Anxiety and depression are prevalent in 20% of patients with ischaemic heart disease (IHD); however, treatment of psychological conditions is not commonly integrated in cardiac rehabilitation (CR). Internet-based psychological treatment holds the potential to bridge this gap. To examine the feasibility of an eHealth intervention targeting anxiety and depression in patients with IHD attending CR., Methods and Results: We used a mixed-methods design, including quantitative methods to examine drop-out and change in anxiety and depression scores, and qualitative methods (thematic analysis) to evaluate patients' and nurses' experiences with the intervention. The therapist-guided intervention consisted of 12 modules provided via a web-based platform. The primary outcome was drop-out, with a drop-out rate <25% considered acceptable. Patients were considered as non-drop-out if they completed ≥5 modules. Out of 60 patients screened positive for anxiety and/or depression, 29 patients were included. The drop-out rate was 24% (7/29). Patients had a mean improvement in anxiety and depression scores of 5.5 and 4.6, respectively. On average, patients had 8.0 phone calls with their therapist and 19.7 written messages. The qualitative analysis of patients' experiences identified four themes: treatment platform, intervention, communication with therapist, and personal experience. Patients were positive towards the intervention, although some found the assignments burdensome. From the nurses, we identified three themes: intervention, inclusion procedure, and collaboration with study team. The nurses were positive, however, due to limited time some struggled with the inclusion procedure., Conclusion: Integrating an eHealth intervention in CR is feasible and the drop-out rate acceptable., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Research suggests that loneliness and social isolation (SI) are serious public health concerns. However, our knowledge of the associations of loneliness and SI with specific chronic diseases is limited., Purpose: The present prospective cohort study investigated (a) the longitudinal associations of loneliness and SI with four chronic diseases (cardiovascular disease [CVD], chronic obstructive pulmonary disease [COPD], diabetes mellitus Type 2 [T2D], and cancer), (b) the synergistic association of loneliness and SI with chronic disease, and (c) baseline psychological and behavioral explanatory factors., Methods: Self-reported data from the 2013 Danish "How are you?" survey (N = 24,687) were combined with individual-level data from the National Danish Patient Registry on diagnoses in a 5 year follow-up period (2013-2018)., Results: Cox proportional hazard regression analyses showed that loneliness and SI were independently associated with CVD (loneliness: adjusted hazard ratio (AHR) = 1.20, 95% confidence interval [CI; 1.03, 1.40]; SI: AHR = 1.23, 95% CI [1.04, 146]) and T2D (loneliness: AHR =1.90, 95% CI [1.42, 2.55]; SI: AHR = 1.59, 95% CI [1.15, 2.21]). No significant associations were found between loneliness or SI and COPD and cancer, respectively. Likewise, loneliness and SI did not demonstrate a synergistic effect on chronic disease. Multiple mediation analysis indicated that loneliness and SI had an indirect effect on CVD and T2D through both baseline psychological and behavioral factors., Conclusion: Loneliness and SI were independently associated with a diagnosis of CVD and T2D within a 5 year follow-up period. The associations of loneliness and SI with CVD and T2D were fully explained by baseline psychological and behavioral factors., (© Society of Behavioral Medicine 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: One in five patients with ischaemic heart disease (IHD) develop comorbid depression or anxiety. Depression is associated with risk of non-adherence to cardiac rehabilitation (CR) and dropout, inadequate risk factor management, poor quality of life (QoL), increased healthcare costs and premature death. In 2020, IHD and depression are expected to be among the top contributors to the disease-burden worldwide. Hence, it is paramount to treat both the underlying somatic disease as well as depression and anxiety. eMindYourHeart will evaluate the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention targeting depression and anxiety in patients with IHD, which may help fill this gap in clinical care., Methods: eMindYourHeart is a multi-center, two-armed, unblinded randomised controlled trial that will compare a therapist-assisted eHealth intervention to treatment as usual in 188 CR patients with IHD and comorbid depression or anxiety. The primary outcome of the trial is symptoms of depression, measured with the Hospital Anxiety and Depression Scale (HADS) at 3 months. Secondary outcomes evaluated at 3, 6, and 12 months include symptoms of depression and anxiety (HADS), perceived stress, health complaints, QoL (HeartQoL), trial dropout (number of patients dropped out in either arm at 3 months) and cost-effectiveness., Discussion: To our knowledge, this is the first trial to evaluate both the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention in patients with IHD and comorbid psychological distress as part of CR. Integrating screening for and treatment of depression and anxiety into standard CR may decrease dropout and facilitate better risk factor management, as it is presented as "one package" to patients, and they can access the eMindYourHeart program in their own time and at their own convenience. The trial holds a strong potential for improving the quality of care for an increasing population of patients with IHD and comorbid depression, anxiety or both, with likely benefits to patients, families, and society at large due to potential reductions in direct and indirect costs, if proven successful. Trial registration The trial was prospectively registered on https://clinicaltrials.gov/ct2/show/NCT04172974 on November 21, 2019 with registration number [NCT04172974].

An experiment was designed to evaluate later timepoints for Split-Time AI (STAI), with the hypothesis that delaying AI may improve estrous response and pregnancy per AI when using sex-sorted semen. Timing of estrus was synchronized among 794 heifers using the 14-d CIDR®-PG protocol (1.38 g progesterone intravaginal insert from Day 0-14, followed by 25 mg dinoprost tromethamine on Day 30) with STAI performed based on estrous status. Heifers were blocked based on breed, source, sire, reproductive tract score (RTS), and BW and assigned within block to one of two approaches. In Approach 66, heifers that were estrual by 66 h after PG administration were inseminated at 66 h, and remaining heifers were inseminated 24 h later (90 h). In Approach 72, heifers that were estrual by 72 h were inseminated at 72 h, and remaining heifers were inseminated 24 h later (96 h). With both approaches, heifers that were non-estrual by the final timepoint were administered 100 μg gonadorelin acetate (GnRH). Within approach, heifers were pre-assigned to receive SexedULTRA 4M™ sex-sorted or conventional semen. The proportion of heifers estrual by the first timepoint was greater (P < 0.0001) with Approach 72 (76 %; 302/395) compared to Approach 66 (61 %; 242/399). The proportion of heifers pregnant as a result of AI differed (P = 0.0005) by semen type (59 % [240/404] for conventional compared with 48 % [187/390] for sex-sorted) but was not affected by approach or approach × semen type. In summary, pregnancy per AI of heifers receiving sex-sorted or conventional semen following the 14-d CIDR®-PG protocol did not differ when STAI was delayed 6 h. The proportion of estrual heifers prior to the first timepoint, however, was greater with later STAI., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To examine whether anxiety and depression at time of implantation of an implantable cardioverter defibrillator (ICD) is associated with ventricular arrhythmias (VAs) and mortality 7 years later., Methods: A cohort of 399 patients (80% men; mean (SD) age = 58.3 (12.2)) implanted with an ICD completed the Hospital Anxiety and Depression Scale (HADS) and the State-Trait Anxiety Inventory at time of implantation. Patients were followed up for VAs and mortality at 7 years., Results: At 7-years follow-up, 34% of the patients had died and 38% had experienced VAs. Baseline depression (score ≥ 8) (HR:2.10; 95% CI:1.44-3.05, p < 0.001) was associated with 7-year mortality in adjusted analyses while state anxiety (score ≥ 40) (HR:1.45; 95% CI:1.02-2.06, p = 0.039) and trait anxiety (score ≥ 40) (HR:1.51; 95% CI:1.06-2.16, p = 0.022) showed a trend towards an association with mortality. No association was found between VAs and anxiety and depression. There was a dose-response relationship with higher burden of anxiety (HR:2.13; 95% CI:1.31-3.46, p = 0.002) and depression (HR:2.13; 95% CI:1.33-3.42, p = 0.002) measured with the HADS (scores < 8, 8-10 and > 10) being associated with an increased risk of mortality., Conclusion: Patients with depression had greater risk of mortality, whereas anxiety only showed a trend. Neither anxiety nor depression was associated with VAs during follow-up., Competing Interests: Declaration of competing interest CMA, DAMJT, SSP: no conflict of interest to declare. JBJ: Speaker bureau: Medtronic and Merit Medical; Advisory board: Biotronic and Medtronic., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aims: Psychosocial factors increase risk for incident heart disease and poor prognosis. In patients with an implantable cardioverter-defibrillator (ICD), negative emotions have been associated with increased mortality risk, although the association with ventricular arrhythmias (VAs) is less consistent. Anger has been linked to incident ICD shocks, but no prospective study has examined the association of anger (state and trait) with mortality or VAs in the ICD population. In a consecutively recruited cohort of first-time ICD patients, we examined the association of state and trait anger with 7-year mortality risk and time to first VA., Methods and Results: A consecutive cohort of patients implanted with a first-time ICD (n = 388; 80% men) between 2003 and 2010 completed the State-Trait Anger Scale and were followed for 7 years. Outcomes were mortality and time to first appropriate ICD therapy. State anger at the time of implant was associated with increased mortality risk in adjusted analyses, with a 1-point increase in score on the state anger measures associated with a 5% [hazard ratio 1.05; 95% confidence interval 1.01-1.09; P = 0.015] increased 7-year mortality risk. We found no statistically significant differences in mortality risk for trait anger, nor an effect for state or trait anger on time to first treated VA (all ps > 0.05)., Conclusion: This is the first study to examine the association of state and trait anger with long-term clinical outcomes in ICD patients. Evaluating anger reduction strategies in newly implanted ICD patients, such as self-regulation or mindfulness techniques, may be warranted for reducing mortality risk., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Background: Clinical empathy has been associated with positive outcomes for both physicians and patients such as: more accurate diagnosis and treatment, increased patient satisfaction and compliance, and lower levels of burnout and stress among physicians. International studies show mixed results regarding the development of empathy among future physicians associating medical education with decline, stability or increase in empathy levels. These mixed results are due to several study limitations. In Denmark, no investigation of Danish medical students' empathy trajectory has yet been conducted wherefore such a study is needed that optimizes the study design of earlier studies., Methods: The aim of the study is to examine and analyze empathy levels and empathy changes among Danish medical students from the four medical faculties in Denmark, employing a cross-sectional and longitudinal mixed-methods design including a control group of non-medical students. By supplementing cross-sectional and longitudinal questionnaire studies with a focus group interview study it is the aim to identify and analyze factors (including educational) that are perceived by medical students to influence the development of empathy and its expression in clinical care., Discussion: The results of the study will provide insight into the trajectory of medical students' empathy and in undergraduate and graduate students' experiences with and perceptions of empathy development. In addition, the study will provide evidence to support further research on how targeted educational programmes can best be designed to educate empathic and patient-centered physicians.

Background: Empathy allows a physician to understand the patient's situation and feelings and respond appropriately. Consequently, empathy gives rise to better diagnostics and clinical outcomes. This systematic review investigates the level of empathy among medical students across the number of educational years and how this level relates to gender, specialty preferences, and nationality., Method: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors conducted a systematic search of studies published between February 2010 and March 2019 investigating the level of empathy among medical students. The databases PubMed, EMBASE, and PsycINFO were searched. Studies employing quantitative methodologies and published in English or Scandinavian language and examining medical students exclusively were included., Results: Thirty studies were included of which 24 had a cross-sectional and 6 a longitudinal study design. In 14 studies, significantly lower levels of empathy were reported by increase in the number of educational years. The remaining 16 studies identified both higher, mixed and unchanged levels. In 18 out of 27 studies it was reported that females had higher empathy scores than males. Only three out of nine studies found an association between empathy scores and specialty preferences. Nine out of 30 studies reported a propensity towards lower mean empathy scores in non-Western compared to Western countries., Conclusion: The results revealed equivocal findings concerning how the empathy level among medical students develops among medical students across numbers of educational years and how empathy levels are associated with gender, specialty preferences, and nationality. Future research might benefit from focusing on how students' empathy is displayed in clinical settings, e.g. in clinical encounters with patients, peers and other health professionals.

The hippocampus plays an important role in stress regulation and has been the focus of research regarding the effects of early life stress on brain development. Much of this research has focused on severe forms of early adversity, particularly maltreatment. However, a handful of studies are now examining the effects of more subtle variations in quality of early caregiving on hippocampal development. In addition, both early caregiving and hippocampal volumes have been linked to psychopathology, particularly borderline personality disorder (BPD) and its associated features, such as suicidality. In the context of a 30-year longitudinal study, we assessed associations between maternal withdrawal in infancy, hippocampal volume, and BPD features in adulthood. Hippocampal volume was assessed among 18 adults (29.33 ± 0.49 years) assessed for caregiving quality at 18 months (M =18.55 months, SD = 1.21 months) and followed longitudinally to age 29. Left hippocampal volume in adulthood was associated with maternal withdrawal in infancy, but not by other components of disrupted parenting. Other risk factors, including maternal psychosocial risk and severity of maltreatment in childhood, were not significantly related to left hippocampal volume. Left hippocampal volume was further associated with increased BPD features and suicidality/self-injury. In addition, left hippocampal volume partially mediated the association between early maternal withdrawal and later suicidality/self-injury. Results point to the importance of quality of early care for hippocampal development and suggest that the first two years of life may be an early sensitive period during which intervention could have important consequences for long-term psychological functioning into adulthood., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To examine whether the quality of the patient-physician relationship, assessed by the general practitioner (GP) and the patient, associates with GPs' use of gut feeling (GF) in cancer diagnosis., Design: Cross-sectional questionnaire survey of cancer patients and their GPs., Setting: Danish primary care., Participants: Newly diagnosed cancer patients and their GPs. Patients completed a questionnaire and provided the name of the GP to whom they have presented their symptoms. The named GP subsequently received a questionnaire., Primary and Secondary Outcome Measures: GPs' use of GF in the diagnostic process for the particular patient. GPs who answered that they used their GF 'to a high degree' or 'to a very high degree' were categorised as 'used their GF to a great extent'. GPs who answered that they used their GF 'to some degree', 'to a limited degree' or 'not at all' were categorised as 'limited or no use of GF'., Results: GPs were less likely to use GF when they assessed relational aspects of the patient encounter as difficult compared with less difficult (OR=0.67; 95% CI 0.46 to 0.97). The physician-reported level of empathy was positively associated with use of GF (OR=2.60; 95% CI 1.60 to 4.22). The lower use of GF in difficult encounters was not modified by level of empathy., Conclusions: Experiencing relational aspects of patient encounter as difficult acted as a barrier for the use of GF in cancer diagnosis. Although physician-rated empathy increased use of GF, high empathy did not dissolve the low use of GF in difficult encounters. As diagnosis of cancer is a key challenge in primary care, it is important that GPs are aware that the sensitivity of cancer-related GF is compromised by a difficult patient-physician relationship., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Preliminary evidence suggests that poor patient-reported quality of life (QoL) predicts mortality on the short term in patients with an implantable cardioverter defibrillator (ICD). It is unclear if this association persists on the long term. We evaluated whether patient-reported QoL at the time of implantation predicts mortality and ventricular tachyarrhythmias (VTa's) during 7 years' follow-up in patients with an ICD. A consecutive cohort of patients (80% men; mean [SD] age = 58 [12]) implanted with an ICD completed the Short Form Health Survey (SF-36). The 8 SF-36 subscales and the 2 component summary scores were used as predictors of VTa's and mortality at 7 years' follow-up. At 7 years' follow-up, 34% (132/392) of patients had died. Baseline physical functioning (hazard ratio [HR]: 1.59; 95% confidence interval [CI]: 1.11 to 2.29), role physical functioning (HR: 1.59; 95% CI: 1.09 to 2.31), vitality (HR: 1.53; 95% CI: 1.05 to 2.22), and general health (HR: 1.57; 95% CI: 1.09 to 2.27) were associated with 7-year mortality in adjusted analyses. There was a trend for low mental health being associated with an increased risk of mortality (HR: 1.38; 95% CI: 0.98 to 1.96). The other SF-36 dimensions were not significantly associated with mortality. Only baseline social functioning was associated with risk of VTa's during follow-up. In conclusion, patients with lower levels of physical functioning, role physical functioning, vitality, or general health had a greater risk of mortality, whereas only poor social functioning was associated with VTa's during 7 years' follow-up. Patient-reported QoL at the time of implant could be used to identify patients at risk for long-term mortality., (Copyright © 2018. Published by Elsevier Inc.)

Social and temporal comparisons may help the individual anchor his or her self-image in a social and temporal context. In the Life-Span Theory of Control, comparisons are included in the repertoire of secondary control strategies individuals may apply when primary control strategies are obstructed, for example, by age-related losses or physical decline. The aim of this study was to explore differences in prevalence and effects of social and temporal comparisons in younger and older adults and healthy and diseased individuals ( n = 34). Semistructured interviews were conducted and analyzed using a mixed-methods approach combining qualitative and quantitative data analysis. The results revealed that older adults engaged in more comparisons than younger adults and that the outcomes of comparisons were more positive for older adults, particularly older cancer patients. The results indicate that comparisons may be applied more often by older and diseased individuals in the service of maintaining well-being.

Objectives: Adjustment to life with an implantable cardioverter defibrillator (ICD) may be challenging for some patients and their partners, with disease and individual characteristics likely influencing the process. We examined whether perceived social support and clinical patient characteristics are associated with change in couples' symptoms of anxiety and depression in the first year after ICD implantation, and explored whether the associations differ between patients and partners., Method: A cohort of consecutively implanted patients (n = 286; 21% women) and their partners completed questionnaires on social support and symptoms of anxiety and depression prior to ICD implantation and 12 months later. Information on demographic and clinical characteristics were captured from patients' medical records or purpose-designed questions. Data were analyzed using multilevel models accounting for the interdependency of scores within couples with adjustment for possible confounders., Results: Higher ratings of perceived social support prior to ICD implantation were associated with greater reductions in couples' symptoms of anxiety and depression, whereas having received an ICD shock was associated with less improvement. Secondary prevention indication for ICD implantation and symptomatic heart failure were associated with less improvement in anxiety symptoms. These associations applied to both patients' and partners' levels of distress., Conclusion: The patient's heart disease affects both patients' and partners' psychological adjustment in the first year after ICD implantation. Interventions are warranted that address this issue not only in patients but also in partners. Targeting social support as a resource for both could be one avenue to pursue., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Patients with an implantable cardioverter defibrillator (ICD) and co-morbid depression are at greater risk of poor quality of life and premature death. We examined if treatment expectations predict depressive symptoms 12months post implant., Methods: First-time implant patients from the WEBCARE study (n=177; 83.1% men) completed the EXPECTations towards ICD therapy questionnaire and the Type D Scale at baseline, and the Patient Health Questionnaire at baseline and 12months., Results: Using hierarchical linear regression with 3 models, we identified the following independent predictors of 12-months depressive symptoms: Model 1: Negative treatment expectations (β=0.202; p=0.020) and baseline depression (β=0.376; p<0.0001). Model 2: Baseline depression (β=0.350; p<0.0001) and Type D personality (β=0.162; p=0.042); negative treatment expectations was borderline significant (β=0.169; p=0.051). Model 3: Baseline depression (β=0.353; p<0.0001) and negative treatment expectations (β=0.180; p=0.043); Type D personality was not significant (β=0.150; p=0.067), adjusting for positive treatment expectations, heart failure, sex, and shocks during follow-up. The models accounted for 22.2%, 24.1%, and 23.3% of the variance in 12-months depressive symptoms, respectively., Conclusion: Further research is warranted to explore the role of treatment expectations at the time of implant and its overlap with personality as a determinant of depression in patients with an ICD., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The Relationship Scale Questionnaire (RSQ) is a widely-used measure of adult attachment, but whether the results obtained by the RSQ fit the attachment construct has only been examined to a limited extent., Objective: The objectives of this study were to investigate the psychometric properties of the Danish translation of the RSQ and to test whether the results are consistent with the hypothesized model of attachment., Methods: The study included two samples: 602 general practitioners and 611 cancer patients. The two samples were analyzed separately. Data quality was assessed by mean, median and missing values for each item, floor and ceiling effects, average inter-item correlations and Cronbach's α for each subscale. Test-retest was assessed by intra-class correlations among 76 general practitioners. A confirmatory factor analysis was conducted to establish evidence of the four proposed subscales. Due to an inadequate fit of the model, data was randomly split into two equally sized subsamples and an exploratory factor analysis was conducted for all 30 items in the first subsample comprised of 286 cancer patients and 285 general practitioners. The EFA yielded a three-factor structure which was validated through a confirmatory factor analyses in a second subsample comprised of 278 cancer patients and 289 general practitioners., Results: The data quality of the RSQ was generally good, except low internal consistency and low to moderate test-retest reliability. The four subscales of the RSQ were not confirmed by the confirmatory factor analysis. An exploratory factor analysis suggested a three-factor solution for both general practitioners and patients, which accounted for 61.1% of the variance among general practitioners and 62.5% among patients. The new three-factor solution was verified in a confirmatory factor analyses., Conclusion: The proposed four-factor model of the RSQ could not be confirmed in this study. Similar challenges have been found by other studies validating the RSQ. An alternative three-factor structure was found for the RSQ.

Burnout is characterized by emotional exhaustion, depersonalization and reduced personal accomplishment. In agreement with international studies, Danish figures have revealed an increase in prevalence of severe burnout from 2.8% in 2004 to 5.3% in 2012. There is only little research on the consequences for the burned-out general practitioner (GP) and his patients as well as on appropriate intervention strategies. Even though burnout appears to be caused by a combination of personality factors and environmental conditions, the literature has one-sidedly focused on the resilience of the individual GP.

Information therapy is the prescription of information intended to help patients understand their health and their health care issues. Information therapy is not a new concept, but the increasing emphasis on patient-centric care, the use of electronic information technologies, and the interest of consumers in health information make the use of information therapy appear more feasible than in the past. This article reviews the background of information therapy, shows the link between information therapy and patient-centric care, and suggests steps for developing an information therapy program within a health care organization.

Background. We assessed risk of burnout in GPs during a 7-year followup and examined whether (1) thoughts about changing medical specialty increased the risk of burnout and (2) burned out GPs had higher job turnover rates than burnout-free GPs. Methods. In 2004 and 2012, all GPs in the county of Aarhus, Denmark, were invited to participate in a survey. Retirement status of physicians who participated in 2004 was obtained through the Registry of Health Providers in 2012. Results. 216 GPs completed both surveys. The risk of developing burnout during the 7-year followup was 13.2% (8.2-19.6%). GPs who in 2004 were burnout-free and reported that they would not select general practice as medical specialty again had a statistically significant increased risk of burnout in 2012 (OR = 4.5; 95% CI = 1.2-16.5; P = 0.023). Among GPs with burnout in 2004, 25.0% had withdrawn from general practice during followup compared to 28.8% of burnout-free GPs in 2004 (adj. OR = 0.99; 95% CI = 0.48-2.02; P = 0.975). Conclusion. The 7-year incidence of burnout was 13%. Thoughts about changing medical specialty were an important predictor of burnout. Burned out GPs had not higher job turnover rates than burnout-free GPs.

In this article, security regulations under the Health Insurance Portability and Accountability Act concerning data sanitization and the disposal of media containing stored electronic protected health information are discussed, and methods for effective sanitization and media disposal are presented. When disposing of electronic media, electronic waste-or e-waste-is produced. Electronic waste can harm human health and the environment. Responsible equipment disposal methods can minimize the impact of e-waste. Examples of how health care organizations can meet the Health Insurance Portability and Accountability Act regulations while also behaving responsibly toward the environment are provided. Examples include the environmental stewardship activities of reduce, reuse, reeducate, recover, and recycle.

Maintenance of indeterminacy is fundamental to the generation of plant architecture and a central component of the plant life strategy. Indeterminacy in plants is a characteristic of shoot and root meristems, which must balance maintenance of indeterminacy with organogenesis. The Petunia hybrida HAIRY MERISTEM (HAM) gene, a member of the GRAS family of transcriptional regulators, promotes shoot indeterminacy by an undefined non-cell-autonomous signaling mechanism(s). Here, we report that Arabidopsis (Arabidopsis thaliana) mutants triply homozygous for knockout alleles in three Arabidopsis HAM orthologs (Atham1,2,3 mutants) exhibit loss of indeterminacy in both the shoot and root. In the shoot, the degree of penetrance of the loss-of-indeterminacy phenotype of Atham1,2,3 mutants varies among shoot systems, with arrest of the primary vegetative shoot meristem occurring rarely or never, secondary shoot meristems typically arresting prior to initiating organogenesis, and inflorescence and flower meristems exhibiting a phenotypic range extending from wild type (flowers) to meristem arrest preempting organogenesis (flowers and inflorescence). Atham1,2,3 mutants also exhibit aberrant shoot phyllotaxis, lateral organ abnormalities, and altered meristem morphology in functioning meristems of both rosette and inflorescence. Root meristems of Atham1,2,3 mutants are significantly smaller than in the wild type in both longitudinal and radial axes, a consequence of reduced rates of meristem cell division that culminate in root meristem arrest. Atham1,2,3 phenotypes are unlikely to reflect complete loss of HAM function, as a fourth, more distantly related Arabidopsis HAM homolog, AtHAM4, exhibits overlapping function with AtHAM1 and AtHAM2 in promoting shoot indeterminacy.

ABSTRACT While use of electronic medical records is not uniform across all settings, there is an increase in electronic system and software use in healthcare. This use of electronic methods to record initial and discharge evaluations and intervention for the patient is under current consideration in outpatient rehabilitation settings. Health information management professionals can offer therapists guidance on selection and use of new software. The purpose of this article is to offer suggestions on the software purchase team, exploration of vendor and software options, review of selection criteria, and software selection strategies. The article includes criteria checklists, a discussion of purchase issues, and suggests resources to assist purchase team members and therapists who contribute opinions to software selection and use.

Introduction: Research suggests that cancer patients' age may affect the quality of their treatment. Yet, there is little knowledge of how and why age affects treatment quality. This study explores staff attitudes and perceptions of age-related differences in treatment and care at a Danish oncology department., Material and Methods: Qualitative analyses of nine semi-structured interviews with strategically selected staff members were conducted using a grounded theory-inspired approach. The interviews were independently coded by four raters through a process of meaning condensation and meaning was structured into core-categories., Results: Although eight of nine participants denied that age was a reason for differential treatment, all nine participants gave examples of age-related differences in treatment. Younger patients were generally offered: 1) more intensive treatment, 2) more consultation time with physicians, 3) allocation to physicians with higher seniority, and 4) increased continuity in the staff assigned to them. The differences were explained as due to: a) differences in patients' physical health and b) sympathy for younger patients' life situation and needs., Discussion: Two co-dominant values were identified: 1) "equality in treatment and care" and 2) "normative life course expectations" of serious disease belonging to old age and thus being more tragic for young individuals (life script model). Values of equality are explicit and govern formal health care system guidelines, while values related to the staff's life course expectations are more implicit and may account for some age-related differences in treatment quality.

Objective: To evaluate the reliability and validity of the PedsQL 3.0 Neuromuscular Module (NMM) in assessing health-related quality of life in the Duchenne muscular dystrophy (DMD) population for use as a secondary outcome measure in phase III clinical trials., Background: DMD is the most common genetic form of muscular dystrophy in childhood. Clinical trials are underway to evaluate modalities of treatment. The NMM was developed based on interviews of patients with DMD and spinal muscular atrophy. To determine the PedsQL reliability and validity, we administered the NMM to patients with DMD and their caregivers., Design/methods: Boys 8 to 18 years old with DMD were recruited from a neuromuscular disease clinic. At baseline, the child and caregiver completed the NMM and the PedsQL 4.0 Generic Core Scales (GC). The NMM was repeated 2 to 6 weeks later. Reliability was assessed using Cronbach's coefficient alpha (internal consistency) and intraclass correlation (ICC) (test-retest consistency). Construct validity was assessed by comparing baseline child and caregiver NMM total scores with the GC Total Score, forced vital capacity, cardiac ejection fraction, and ambulatory status., Results: Forty-four children and their caregivers completed the study. Internal consistency reliability of the total scale score of the NMM was demonstrated (Child alpha = 0.85; Caregiver alpha = 0.87). Test-retest reliability of the NMM was also demonstrated (Child ICC = 0.75, P = 0.001; Caregiver ICC = 0.85, P < 0.001). Validity of the total scale score of the NMM when compared with the GC Total Scale Score was supported (Child r (41) = 0.63, P < 0.001; Caregiver r (42) = 0.64, P < 0.001). Validity of the NMM compared with forced vital capacity was also supported (Child r (38) = 0.35, P = 0.032; Caregiver r (39) = 0.41, P = 0.01). The NMM parent-proxy-report and child self-report "About My Child's Neuromuscular Disease" scale was significantly related to wheelchair use (P < 0.008 and 0.016, respectively); the GC "Child Self-Report "Physical Health" scale was also significantly related to wheelchair use (P < 0.001). We were unable to conduct any analysis with ejection fraction because of the small number of children across all categories., Conclusions: The PedsQL NMM is a reliable measure of disease-specific health-related quality of life in the DMD population and may be used as an outcome measure in clinical trials.

Ligand binding alters the conformational structure and physico-chemical characteristics of bovine folate binding protein (FBP). For the purpose of achieving further information we analyzed ligand (folate and methotrexate)-induced changes in the fluorescence landscape of FBP. Fluorescence excitation and emission two-dimensional (2D) spectra were recorded over a wide range of wavelengths on a Perkin-Elmer LS 55 spectrofluorometer at varying pH in different buffers, and the resulting three-dimensional data were subjected to a chemometric analysis, parallel factor analysis (PARAFAC). The most important finding was the occurrence of two maximum intensity emission wavelengths of tryptophan, 350 nm (component one) and 330 nm (component two). In contrast to the first component, the score of the short wavelength component increased with increasing ligation of FBP. Since the emission wavelengths of indole groups in tryptophan shorten with increasing distance from the solvent surface of proteins, an increasing number of the 11 tryptophan residues seem to reorientate from the solvent surface to the interior of FBP with increasing ligation. The sharp decrease in hydrophobicity at pI=7-8 following binding of folate accords fairly well with the disappearance of strongly hydrophobic tryptophan residues from the solvent-exposed surface of FBP. The PARAFAC has thus proven useful to establish a hitherto unexplained link between parallel changes in conformational structure and physico-chemical characteristics of FBP induced by folate binding. Parameters for ligand binding derived from PARAFAC analysis of the fluorescence data were qualitatively and quantitatively similar to those obtained from binding of radiofolate to FBP. Herein, methotrexate exhibited a higher affinity for FBP than in competition with radiofolate. This could suggest a rapid and firm complexation of folate to FBP, blocking access of competing ligands.

Degradation of the potential photosensitizers, riboflavin, chlorophyll, and porphyrin, in Danbo cheese by monochromatic light of wavelength 366, 436, or 546 nm was studied. Three cheeses were investigated, two conventional (16% fat and 25% fat) and one "organic" (25% fat). The effect of illumination was measured by fluorescence spectroscopy and analyzed using multiway and multivariate data analysis. Riboflavin was found to degrade only by 436 nm light, whereas chlorophylls and porphyrins also were influenced by 436 and 546 nm light. The organic cheese had the largest chlorophyll content both before and after similar light exposure, and no change in chlorophyll of this cheese was observed for any of the illumination wavelengths. Upon light exposure of the cheeses, volatile compounds were formed, as analyzed by gas chromatography-mass spectrometry (GC-MS). The relative concentrations of methyl butanoate, 1-pentanol, benzaldehyde, 2-butanone, 2-heptanone, and butyl acetate were found to weakly correlate with the surface fluorescence intensity. 1-Pentanol and the ketones are secondary lipid oxidation products, consistent with a chemical coupling between photosensitizer degradation and formation of volatile lipid oxidation products.

This paper gives a critical evaluation of the use of fluorescence spectroscopy for measuring chemical and physical changes in dairy products caused by processing and storage. Fluorescence spectroscopy is able to determine various properties of foods without use of chemicals and time-consuming sample preparation. This is shown by examples where the measurement of a given chemical parameter has been appropriately described and validated, as well as situations showing potential applications, but where further research and validation is required. The interpretation of fluorescence spectroscopic data is complex due to absorbance by other molecular groups, changes caused by variation in the sample matrix, etc. It is illustrated how advanced data analytical techniques are required to obtain optimal interpretation of the data. Even though the review focuses on examples from the dairy industry, the principles are broader and can be applied to other fields of food and agricultural research.

Developing research proposals that protect human participants and understanding the institutional review board (IRB) approval process require high-level application of many skills. The purpose of this article is to describe how faculty can use formative evaluation techniques and checklists to guide students to build skills in writing research proposals for studies that involve human participants or their data. Formative evaluation, the process of critically reviewing work to improve it, is emphasized, and checklists that summarize IRB criteria and standards and present the critical content of research proposals for studies involving human participants are provided. Teaching principles that can guide faculty in using the checklists to give feedback and help students develop high-quality research proposals are discussed.