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Airway obstruction; Cryobiopsy; Paediatric bronchoscopy Obstrucción de las vías respiratorias; Criobiopsia; Broncoscopia pediátrica Obstrucció de les vies respiratòries; Criobiòpsia; Broncoscòpia pediàtrica Background and objective Cryotherapy in interventional bronchoscopy is a new treatment modality, which has recently been made available for the paediatric airway. Lack of experience and safety concerns have led to hesitant adaptation. The aim of this study was to assess indications, success rates and complications of airway cryotherapy in children. Methods Bronchoscopists from medical centre performing cryotherapy in patients between 0 and 18 years were invited to participate in a prospective study based on an online questionnaire. Patient and participant data were collected between June 2020 and June 2021. Results A total of 69 cryotherapy procedures were performed in 57 patients a for three main indications: Biopsy (30), restoration of airway patency (23) and foreign body aspiration (16). The overall success rate was 93%, the remaining 7% were performed for foreign body removal and required a switch of technique. Restoration of airway patency was successfully applied in various pathologies, including mucus plugs, bronchial casts and post traumatic stenosis. The diagnostic yield of transbronchial biopsies was 96%. No severe complications were encountered; one pneumothorax following a cryobiopsy required a chest drain for 48 h. No child was admitted to intensive care or died from a procedural complication. Conclusion In this largest paediatric case collection to date, cryotherapy was safe and carried a high success rate. Cryobiopsy compares favourably to the widely used forceps biopsy and could replace it in the future. Paediatric bronchoscopists are encouraged to add cryotherapy to their armamentarium of airway interventions. Open Access funding enabled and organized by Projekt DEAL.

Background A high number of children are referred to pediatric departments with a suspected allergic reaction to antibiotics. The prevalence of true allergy is considered to be significantly lower than shown from clinical history and symptoms alone. This study investigated the historical use of direct oral challenges at three specialist pediatric departments in Denmark. Methods In this retrospective medical record review study, 141 children (69 boys and 72 girls) with a clinical history of suspected penicillin class allergy were investigated. A standardized questionnaire for drug allergy was completed in the beginning of the investigation, which also included a skin prick test (SPT), measurement of IgE to different types of penicillin, and a drug challenge (DC). Results Only four (2.8%) of the patients referred for further investigation in our study had a positive DC. We found no correlation between a positive DC, positive SPT or elevated specific IgE. None of the patients with a positive DC reacted with a rash alone prior to investigation. Conclusions Allergy to penicillin in children is rare and probably overestimated. In children reacting to penicillin with a rash alone, our study indicated that the rash was probably not related to allergy and treatment should thus be continued.

Introduction: Multiple breath washout (MBW) is used for early detection of cystic fibrosis (CF) lung disease, with SF6MBW commonly viewed as the reference method. The use of N2MBW in infants and toddlers has been questioned for technical and physiological reasons, but a new correction of the N2signal has minimized the technical part. The present study aimed to assess the remaining differences and the contributing mechanisms for the differences between SF6 and N2MBW,corrected—such as tidal volume reduction during N2 washout with pure O2. Method: This was a longitudinal multicenter cohort study. SF6MBW and N2MBW were performed prospectively at three CF centers in the same visits on 154 test occasions across 62 children with CF (mean age: 22.7 months). Offline analysis using identical algorithms to the commercially available program provided outcomes of N2,original and N2,corrected for comparison with SF6MBW. Results: Mean functional residual capacity, FRCN2,corrected was 14.3% lower than FRCN2, original, and 1.0% different from FRCSF6. Lung clearance index, LCIN2,corrected was 25.2% lower than LCIN2,original, and 7.3% higher than LCISF6. Mean (SD) tidal volume decreased significantly during N2MBWcorrected, compared to SF6MBW (−13.1 ml [−30.7; 4.6], p < 0.0001, equal to −12.0% [−25.7; 1.73]), but this tidal volume reduction did not correlate to the differences between LCIN2,corrected and LCISF6. The absolute differences in LCI increased significantly with higher LCISF6 (0.63/LCISF6) and (0.23/LCISF6), respectively, for N2,original and N2,corrected, but the relative differences were stable across disease severity for N2,corrected, but not for N2,original. Conclusion: Only minor residual differences between FRCN2,corrected and FRCSF6 remained to show that the two methods measure gas volumes very similar in this age range. Small differences in LCI were found. Tidal volume reduction during N2MBW did not affect differences. The corrected N2MBW can now be used with confidence in young children with CF, although not interchangeably with SF6.

Aim: As no data to our knowledge exist, the aim of the study was to describe the national prevalence and characteristics of Danish children and adolescents with severely impaired lung function. Methods: We performed a descriptive, cross-sectional Danish multi-centre study. Children and adolescents between 6 and 18 years old demonstrating severely impaired lung function from 2015 to 2018, defined by forced expiratory volume in 1 second (FEV1) 1 was 46.1% (10.1%) of predicted, and z-score was −4.5 (0.8). The most frequent diagnosis was cystic fibrosis (20.4%), followed by asthma (19.5%) and bronchiolitis obliterans (16.8%), while almost 25% had different elements of airway malformations or non-pulmonary conditions. Two adolescents with cystic fibrosis underwent lung transplantation. Conclusion: The estimated prevalence of severely impaired lung function in Danish children and adolescents was low, and extremely, few children underwent lung transplantation. The most frequent diagnosis was cystic fibrosis, while almost 25% had different elements of airway malformations or non-pulmonary conditions, which may require clinical attention.

Multiple breath washout (MBW) is used for early detection of cystic fibrosis (CF) lung disease, with SFThis was a longitudinal multicenter cohort study. SFMean functional residual capacity, FRCOnly minor residual differences between FRC

Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare immune deficiency with a broad clinical presentation. IPEX syndrome causes dysfunctional regulatory T cells, increasing the risk of autoimmune diseases. In this case report, we describe a 7-year-old boy with lymphocytic interstitial pneumonia and bullous pemphigoid who was recently diagnosed with IPEX syndrome.

Background Competency-based education has been shown to enhance clinical skills, improve patient care, and reduce number of complications resulting in a better return on investments. Residents constitute an important workforce at many hospitals. Yet, the effect of training on residents’ contribution to production in patient care is scarcely studied. This study evaluated the effects of early competency-based procedural training on residents’ contribution to patient care in central venous catheterization and spinal and epidural anesthesia. Methods The design was a non-randomized cohort study of first-year anesthesiology residents. The intervention group received additional early focused skills training while three control groups received traditional competency-based education. The residents’ contributions to patient care were compared between the intervention group (n = 20), a historical control group (n = 19), and between a contemporary control group (n = 7) and a historical control group (n = 7) from different departments. The residents’ vs specialists’ procedural production share was compared between years within each study group. We calculated specialist time saved compared to the time spent providing additional skills training in the intervention group. Results We found statistically significant increases in residents’ vs specialists’ share of total production after the intervention for epidural anesthesia: 2015: 0.51 (0.23, 0.70) to 2017: 0.94 (0.78, 1.05), p = 0.011 and central venous catheterization: 2015: 0.30 (0.23, 0.36) to 2016: 0.46 (0.35, 0.55), p = .008; and to 2017: 0.64 (0.50, 0.79), p = 0.008. Comparison between residents and specialists on production of the three procedures before and after the intervention showed a surplus of 21 h of freed specialist time per year. Conclusions Early procedural training results in more productive residents and freed specialist time for additional supervision, other clinical tasks or research. This provides empirical support for a positive correlation between early focused training and increased independent production among residents.

Background Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathlessness and wheeze yet is frequently misdiagnosed as asthma. Insight regarding the demographic characteristics, laryngeal abnormalities and impact of EILO is currently limited, with data only available from individual centre reports. The aim of this work was to provide a broader perspective from a collaboration between multiple international expert centres. Methods Five geographically distinct clinical paediatric and adult centres (3 Denmark, 1 UK, 1 USA) with an expertise in assessing unexplained exertional breathlessness completed database entry of key characteristic features for all cases referred with suspected EILO over a 5-year period. All included cases completed clinical asthma workup and continuous laryngoscopy during exercise (CLE) testing for EILO. Results Data were available for 1007 individuals (n=713 female (71%)) with a median (range) age of 24 (8–76) years, and of these 586 (58%) were diagnosed with EILO. In all centres, EILO was frequently misdiagnosed as asthma; on average there was a 2-year delay to diagnosis of EILO, and current asthma medication was discontinued in 20%. Collapse at the supraglottic level was seen in 60%, whereas vocal cord dysfunction (VCD) was only detected/visualised in 18%. Nearly half (45%) of individuals with EILO were active participants in recreational-level sports, suggesting that EILO is not simply confined to competitive/elite athletes. Conclusion Our findings indicate that key clinical characteristics and the impact of EILO/VCD are similar in globally distinct regions, facilitating improved awareness of this condition to enhance recognition and avoid erroneous asthma treatment., Exercise-induced laryngeal obstruction is a prevalent cause of exertional breathlessness and wheeze. In this international multicentre collaboration, 1007 patients waited, on average, 2 years for diagnosis and 20% were mistreated as asthmatic. https://bit.ly/3auXpcp

IntroductionMore than 90% of patients diagnosed with childhood acute lymphoblastic leukaemia (ALL) today will survive. However, half of the survivors are expected to experience therapy-related chronic or late occurring adverse effects, reducing quality of life. Insight into underlying risk trajectories is warranted. The aim of this study is to establish a Nordic, national childhood ALL survivor cohort, to be investigated for the total somatic and psychosocial treatment-related burden as well as associated risk factors, allowing subsequent linkage to nation-wide public health registers.Methods and analysisThis population-based observational cohort study includes clinical follow-up of a retrospective childhood ALL survivor cohort (n=475), treated according to a common Nordic ALL protocol during 2008–2018 in Denmark. The study includes matched controls. Primary endpoints are the cumulative incidence and cumulative burden of 197 health conditions, assessed through self-report and proxy-report questionnaires, medical chart validation, and clinical examinations. Secondary endpoints include organ-specific outcome, including cardiovascular and pulmonary function, physical performance, neuropathy, metabolic disturbances, hepatic and pancreatic function, bone health, oral and dental health, kidney function, puberty and fertility, fatigue, and psychosocial outcome. Therapy exposure, acute toxicities, and host genome variants are explored as risk factors.Ethics and disseminationThe study is approved by the Regional Ethics Committee for the Capital Region in Denmark (H-18035090/H-20006359) and by the Danish Data Protection Agency (VD-2018–519). Results will be published in peer-reviewed journals and are expected to guide interventions that will ameliorate the burden of therapy without compromising the chance of cure.

Background: Exercise-induced laryngeal obstruction (EILO) is an important cause of exertional breathlessness and wheeze. Epidemiological understanding of EILO remains unclear and arises largely from Scandinavian countries. We provide the first international perspective on the demographic characteristics, laryngeal abnormalities and impact of EILO. Methods: Retrospective database review (from 5 expert centres in Denmark, UK, & USA), for patients undergoing clinical asthma and EILO work-up with continuous laryngoscopy during exercise (CLE) testing between 2014–2018. Results: A total of 1,007 individuals completed CLE, of these 586 (58%) demonstrated EILO. Demographic characteristics for cases with EILO were similar across centres; median age of 21 (80% were ≤ 34), a female preponderance (76%) and median 2-year delay to diagnosis; 20% were found to not have asthma despite prescription of inhalers. Half (49%) of subjects were elite athletes. Supraglottic EILO (i.e. collapse of the arytenoid structures) was the predominant form and only 18% had glottic level (i.e. vocal cord dysfunction [VCD]) closure. Conclusion: This international collaboration reveals similarities in the clinical characteristics of EILO highlighting delay to diagnosis, inappropriate asthma treatment and that exercise induced VCD is a misnomer. These findings help to further define this condition and improve clinician’s recognition.

BACKGROUND: There are increasing reports of cardiac and exercise dysfunction in adults with small, unrepaired ventricular septal defects (VSDs). The primary aim of this study was to evaluate pulmonary function in adults with unrepaired VSDs, and secondly to assess the effects of 900 μg salbutamol on lung function and exercise capacity.METHODS: Young adult patients with small, unrepaired VSDs and healthy age- and gender-matched controls were included in a double-blinded, randomised, cross-over study. Participants underwent static and dynamic spirometry, impulse oscillometry, multiple breath washout, diffusion capacity for carbon monoxide, and ergometer bicycle cardiopulmonary exercise test.RESULTS: We included 30 patients with VSD (age 27 ± 6 years) and 30 controls (age 27 ± 6 years). Patients tended to have lower FEV1, 104 ± 11% of predicted, compared with healthy controls, 110 ± 14% (p = 0.069). Furthermore, the patient group had lower peak expiratory flow (PEF), 108 ± 20% predicted, compared with the control group, 118 ± 17% (p = 0.039), and showed tendencies towards lower forced vital capacity and increased airway resistance compared with controls. During exercise, the patients had lower oxygen uptake, 35 ± 8 ml/min/kg (vs 47 ± 7 ml/min/kg, p CONCLUSION: At rest, young adults with unrepaired VSDs are no different in pulmonary function from controls. However, when the cardiorespiratory system is stressed, VSD patients demonstrate significantly impaired minute ventilation and peak oxygen uptake, which may be early signs of parenchymal dysfunction and restrictive airway disease. These abnormalities were unaffected by the inhalation of salbutamol.

Validation of the usage of tracheal aspiration considering children with lung disease This study investigates the usability of nasal tracheal aspiration (NTA) by comparing NTA against bronchoalveolar lavage (BAL) Methods: 173 paired samples of NTA and BAL were performed on 164 paediatric patients. The samples were collected on patients with spontaneous breathing during general anaesthesia. This study retrospectively compares the microbiological cultures obtained by the NTA and BAL Results: Concerning complete bacteria concordance the overall similarity is 49%, sensitivity 35%, specificity 66%, positive predictive value 25% and negative predictive value is 65%. When focusing on +/- growth of pathogen bacteria the similarity is 70%, sensitivity 74%, specificity 66%, positive predictive value 74% and negative predictive value 65%. Patients with cystic fibrosis have statistic significant better parameters than the overall samples regarding similarity 88%, sensitivity 92% and positive predictive value of 92% for +/- growth. If the common throat bacteria H.influenzae and Moraxella are the only difference between NTA and BAL concerning the bacteria concordance the omission of these improves the statistic significant specificity of 91%. Antibiotic treatment at the time of the examinations seems to have a positive tendency towards improved sensitivity, however not statistical significant Conclusion: The study indicates that NTA is clinically useful to evaluate if the lower airways are colonized or not, but generally not concerning which specific bacteria. The clinically usage of NTA remains important as both positive and negative findings are of great value concerning children with chronic lung diseases

BackgroundThere is no long-term evidence on the effectiveness of training for motivational interviewing in diabetes treatment.AimWithin a trial of intensive treatment of people with screen-detected diabetes, which included training in motivational interviewing for GPs, the study examined the effect of the intervention on incident cardiovascular disease (CVD) and all-cause mortality.Design & settingIn the ADDITION-Denmark trial, 181 general practices were cluster randomised in a 2:1:1 ratio to: (i) to screening plus routine care of individuals with screen-detected diabetes (control group); (ii) screening plus training and support in intensive multifactorial treatment of individuals with screen-detected diabetes (intensive treatment group); or (iii) screening plus training and support in intensive multifactorial treatment and motivational interviewing for individuals with screen-detected diabetes (intensive treatment plus motivational interviewing group). The study took place from 2001–2009.MethodAfter around 8 years follow-up, rates of first fatal and non-fatal CVD events and all-cause mortality were compared between screen-detected individuals in the three treatment groups.ResultsCompared with the routine care group, the risk of CVD was similar in the intensive treatment group (hazard ratio [HR] 1.11, 95% confidence interval [CI] = 0.82 to 1.50) and the intensive treatment plus motivational interviewing group (HR 1.26, 95% CI = 0.96 to 1.64). The incidence of death was similar in all three treatment groups.ConclusionTraining of GPs in intensive multifactorial treatment, with or without motivational interviewing, was not associated with a reduction in mortality or CVD among those with screen-detected diabetes.

Background: Pulmonary interstitial glycogenosis (PIG) is a rare interstitial lung disease in children. The clinical hallmark is a rapid onset with respiratory distress and hypoxemia shortly after birth in the absence of an infectious cause or a surfactant dysfunction syndrome. The diagnosis can only be made by lung biopsy. The histopathological pattern defining PIG can exist in diffuse or patchy distribution. Only few cases have been reported. Not much is known on clinical features, outcomes, CT imaging and histopathology. Methods: The clinical course, CT-scans and tissue samples of children diagnosed with PIG were collected and systematically re-analysed by clinicians, radiologists and pathologists all specialized in interstitial lung diseases in children. All data were uploaded into the Kidslungregister for follow up. Results: 11 children diagnosed with PIG were included in this study. All presented with respiratory distress shortly after birth. More than half of the children were diagnosed with additional abnormalities, especially congenital heart defects. The CT-scan of the lungs showed mainly groundglass opacities, consolidations and septal thickening. Of interest each tissue sample had signs of reduced alveolarization. The prognosis was favourable in almost all cases. When systemic glucocorticosteroids were given a fast improvement was noticed. Conclusion: PIG is a interstitial lung disease in infants with mostly favourable outcome. As alveolar growth retardation was present in all subjects this can support a theory of an underlying maturation delay. In all infants with congenital heart defects and unexplained respiratory distress an interstitial lung disease due to PIG should be considered.

Background and Aims: When investigating and treating asthma in children, diagnosing must be precise and valid. There is a need for studies researching asthma in children showing how to use registry-based, epidemiological data. We examined the feasibility and validity of using anti-asthmatic drug prescription data to identify children with asthma and assessed medication patterns in children with and without confirmed asthma.Methods: We used population-based Danish prescription data and hospital discharge registries to identify all children aged 0 to 14 years who had redeemed at least one prescription for an inhaled anti-asthmatic drug. Individual asthma cases were validated by hospital discharge information and by their treating general practitioners according to international asthma guidelines.Results: In total, 2053 children, out of a population of 20181, had redeemed at least one prescription of any inhaled anti-asthmatic drug. The positive predictive value (PPV) of having two different asthma medications prescribed in 1 year was 80.2% for presence of true asthma, with a sensitivity of 59%. Corresponding estimates of PPV/sensitivity of at least one prescription for an inhaled corticosteroid (ICS) were 79% and 58%, respectively, while the true asthma PPV with at least one LABA prescription increased to 97%. Among children with confirmed asthma, one-third had not used Beta2-agonist therapy as part of their treatment. Conversely, among children without confirmed asthma, 40% were prescribed a minimum of two prescriptions for any kind of inhaled anti-asthmatic drug, and 12% and 9% used an ICS or Leukotriene receptor antagonist, respectively.Conclusions: Anti-asthmatic drug prescription data could be used to identify children with true asthma, with reasonable accuracy. The observed pattern of anti-asthmatic medication usage among children with and without confirmed asthma suggests that there is room for therapeutic improvement.

BACKGROUND: Pulmonary interstitial glycogenosis (PIG) is a rare paediatric interstitial lung disease of unknown cause. The diagnosis can only be made by lung biopsy. Less than 100 cases have been reported. Clinical features, treatment and outcomes have rarely been assessed systematically in decent cohorts of patients.METHODS: In this retrospective multicentre study, the clinical presentation, radiologic findings, pattern of lung biopsy, extrapulmonary comorbidities, treatment and outcome of eleven children with PIG were collected systematically.RESULTS: 10/11 children presented with respiratory distress immediatly after birth and 8/11 needed invasive ventilation. In 8/11 children extrapulmonary comorbidities were present, congenital heart defects being the most common. 7/11 children received systemic glucocorticoids and of these four showed a clear favorable response. During a median follow-up of 3.0 years (range 0.42-12.0) one child died, while 10 patients improved. Chest CT-scans showed ground-glass opacities (7/10), consolidations (6/10), linear opacities (5/10) and mosaic attenuation (4/10) without uniform pattern. Besides interstitial thickening related to undifferentiated glycogen positive mesenchymal cells all tissue samples showed growth abnormalities with reduced alveolarization.CONCLUSIONS: PIG is associated with alveolar growth abnormalities and has to be considered in all newborns with unexplained respiratory distress. Apparent treatment benefit of glucocorticosteroids needs to be evaluated systematically.

Background Despite the widespread implementation of competency-based education, evidence of ensuing enhanced patient care and cost-benefit remains scarce. This narrative review uses the Kirkpatrick/Phillips model to investigate the patient-related and organizational effects of graduate competency-based medical education for five basic anesthetic procedures. Methods The MEDLINE, ERIC, CINAHL, and Embase databases were searched for papers reporting results in Kirkpatrick/Phillips levels 3–5 from graduate competency-based education for five basic anesthetic procedures. A gray literature search was conducted by reference search in Google Scholar. Results In all, 38 studies were included, predominantly concerning central venous catheterization. Three studies reported significant cost-effectiveness by reducing infection rates for central venous catheterization. Furthermore, the procedural competency, retention of skills and patient care as evaluated by fewer complications improved in 20 of the reported studies. Conclusion Evidence suggests that competency-based education with procedural central venous catheterization courses have positive effects on patient care and are both cost-effective. However, more rigorously controlled and reproducible studies are needed. Specifically, future studies could focus on organizational effects and the possibility of transferability to other medical specialties and the broader healthcare system.

BackgroundAsthma is a frequent diagnosis in competitive sports, and inhaled β2-agonists are commonly used by athletes. Although inhaled β2-agonists do not seem to improve performance in athletes, it has remained uncertain whether they can increase exercise performance in non-athletes.ObjectiveTo investigate the effect of inhaled β2-agonists on exercise performance in healthy non-athlete individuals.MethodsIn a double-blinded, placebo-controlled, cross-over trial, healthy, non-asthmatic, non-athlete individuals were randomised to inhalation of either 900 µg of salbutamol or placebo. Cardiopulmonary exercise testing, dynamic spirometry and impulse oscillometry were performed. The primary outcome was the effect from salbutamol on peak oxygen uptake, whereas secondary outcomes were breathing reserve and ventilation efficiency, and workload, heart rate, breath rate and minute ventilation at peak exercise under influence of salbutamol.ResultsA total of 36 healthy subjects with a mean age of 26±5 years were included. Salbutamol had no effect on peak oxygen uptake compared with placebo, 46.8±1.3 mL/kg/min versus 46.6±1.2 mL/kg/min, p=0.64. Salbutamol had no effect on workload, p=0.20, heart rate, p=0.23, breath rate, p=0.10, or minute ventilation, p=0.26, at peak exercise compared with placebo. Salbutamol lowered oxygen uptake, p=0.04, and workload, p=0.04, at anaerobic threshold compared with placebo. Forced expiratory volume in 1 s, 116%±13% of predicted, and peak expiratory flow, 122%±16% of predicted, increased after inhalation of salbutamol compared with placebo; 109%±13% and 117%±17%, respectively, pConclusionInhaled salbutamol did not improve peak oxygen uptake in healthy, non-asthmatic, non-athlete individuals compared with placebo.Trial registration numberNCT02914652.

BACKGROUND: Allergy immunotherapy targets the immunological cause of allergic rhinoconjunctivitis and allergic asthma and has the potential to alter the natural course of allergic disease.OBJECTIVE: The primary objective was to investigate the effect of the SQ grass sublingual immunotherapy tablet compared with placebo on the risk of developing asthma.METHODS: A total of 812 children (5-12 years), with a clinically relevant history of grass pollen allergic rhinoconjunctivitis and no medical history or signs of asthma, were included in the randomized, double-blind, placebo-controlled trial, comprising 3 years of treatment and 2 years of follow-up.RESULTS: There was no difference in time to onset of asthma, defined by prespecified asthma criteria relying on documented reversible impairment of lung function (primary endpoint). Treatment with the SQ grass sublingual immunotherapy tablet significantly reduced the risk of experiencing asthma symptoms or using asthma medication at the end of trial (odds ratio = 0.66, P < .036), during the 2-year posttreatment follow-up, and during the entire 5-year trial period. Also, grass allergic rhinoconjunctivitis symptoms were 22% to 30% reduced (P < .005 for all 5 years). At the end of the trial, the use of allergic rhinoconjunctivitis pharmacotherapy was significantly less (27% relative difference to placebo, P < .001). Total IgE, grass pollen-specific IgE, and skin prick test reactivity to grass pollen were all reduced compared to placebo.CONCLUSIONS: Treatment with the SQ grass sublingual immunotherapy tablet reduced the risk of experiencing asthma symptoms and using asthma medication, and had a positive, long-term clinical effect on rhinoconjunctivitis symptoms and medication use but did not show an effect on the time to onset of asthma.

Karen Schreiber,1 Matthias Kant,2 Claudia Pfleger,3 Henrik Boye Jensen,4 Ole Oesterberg,5 Anne Rieper Hald,5 Frederik K Nielsen,5 Sune Rubak6 1Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; 2Department of Neurology, Hospital of Southern Jutland, Soenderborg, Denmark; 3Department of Neurology, Aalborg University Hospital, Denmark; 4Department of Neurology, Kolding Hospital, Kolding, Denmark; 5Novartis Pharmaceutical, Copenhagen, Denmark; 6Department of Child and Adolescent Health, Aarhus University Hospital Skejby, Aarhus Denmark Purpose: Treatment adherence is a prerequisite for treatment success and therefore an important consideration to assure that therapeutic goals are achieved both from a patient point of view and for optimal health care resource utilization. Published data on treatment adherence with fingolimod (Gilenya®) are limited. Therefore, this study investigated treatment adherence in patients with relapsing-remitting multiple sclerosis (RRMS) treated with fingolimod in Denmark. Patients and methods: This was a 24-month, multicenter, open-label study, investigating treatment adherence, satisfaction, motivation, and health-related quality of life (QoL) in RRMS patients treated with fingolimod. In addition, the effect of a motivational interview support program on these measures was evaluated. Treatment adherence was assessed by pill count. Treatment satisfaction, motivation, and QoL were assessed by patient-reported outcomes (PROs). Results: A total of 195 patients were enrolled in the study. A very high treatment adherence was observed during the entire study with no statistically significant difference between study visits before (99%) and after (97%) the motivational interview. In accordance, a high level of treatment satisfaction was found in the Treatment Satisfaction Questionnaire for Medication 9, which was scored high throughout the study with the highest scores seen for the convenience domain (ranging from 94.51 to 95.78). Furthermore, additional PROs demonstrated a high health-related QoL, a self-determined form of motivation for taking medication, and a patient perception of an autonomy supportive approach provided by the health care provider, at all study visits. Conclusion: High levels of treatment adherence, satisfaction, motivation, and QoL were observed in Danish RRMS patients treated with fingolimod. As these positive measures were observed at all study visits and throughout the study, no effect of the motivational interview support program was found. Keywords: Gilenya®, multiple sclerosis, treatment adherence, motivational interview, quality of life, Treatment Satisfaction Questionnaire for Medication

Objective To examine the experience of women with a pre-pregnant BMI >30 kg/m2, in their encounters with healthcare professionals during pregnancy. Design Qualitative study using a phenomenological methodology approach. Setting Face-to-face interviews with pregnant women in their own home who were referred from their general practitioner to specialist antenatal follow-up at their local hospital. Sample Sixteen women with pre-pregnant BMI >30 kg/m2. Methods Qualitative in-depth interviews. Participant's experiences of their encounters with health care professionals were recorded verbatim, transcribed and analysed using a phenomenological approach. Results Two main themes were identified, an accusatorial response from healthcare professionals and a lack of advice and helpful information on how being obese and pregnant might affect the women's health and that of their child. Conclusions Pregnant women with obesity may experience prejudice from healthcare professionals. These women felt they were treated with a lack of respect, an accusatorial response, and the feeling that information which could have been helpful was not forthcoming. Communication between obese pregnant woman and healthcare professionals appears to be lacking. Improved training in communication skills, less judgemental behaviour and better dissemination of information from healthcare professionals working with pregnant women with obesity are needed.

Bjerregaard L., Rubak S., Host A. & Wagner L. (2011) Alcohol consumption patterns among parents of hospitalized children: findings from a brief intervention study. International Nursing Review59, 132–138 Aims: This study aimed to explore parents' perception and experience of a brief intervention (BI), focusing on their alcohol consumption habits to assess the impact on parents of staff members using motivational interviewing (MI) and to gain knowledge of how to reinforce initiatives regarding behavioural changes of lifestyle problems in a clinical setting. Background: Substantial parental alcohol consumption influences children's development negatively. Nursing staff lacks knowledge and training in communicating with parents about alcohol issues. Little is known about parents' attitudes towards, and perception of, nursing staff addressing issues concerning their use of alcohol. Methods: A qualitative approach by use of phenomenological and hermeneutic methods was applied. Through interviews with 15 parents, their opinions and perceptions of a brief alcohol intervention were explored. Results: Three themes emerged from the phenomenological reduction: (1) experiencing respect and genuine interest from the nursing staff, (2) BI causing reflections on own use of alcohol, and (3) reflections continuing and developing over time. Conclusion and practice implications: The parents did not mind having their lifestyle habits discussed in connection with having their child admitted to hospital. The method MI proved effective in getting the parents to talk about and reflect on alcohol consumption habits. The effects of the intervention seemed to last beyond the first months after the intervention took place.

OBJECTIVE: This article systematically reviews empirical studies that have evaluated different aspects of motivational interviewing (MI) training for general health care professionals. METHODS: Studies were obtained from several databases. To be included, the MI training had to be provided specifically for general health care practitioners for use in their regular face-to-face counselling. The training outcomes had to be linked to the MI training. RESULTS: Ten studies were found. The median length of the training was 9h. The most commonly addressed training elements were basic MI skills, the MI spirit, recognizing and reinforcing change talk, and rolling with resistance. Most studies involved follow-up training sessions. The study quality varied considerably. Five studies assessed training outcomes at a single point in time, which yields low internal validity. Four studies used random assignment of practitioners to the MI training and comparison conditions. The training generated positive outcomes overall and had a significant effect on many aspects of the participants' daily practice, but the results must be interpreted with caution due to the inconsistent study quality. CONCLUSIONS: The generally favourable training outcomes suggest that MI can be used to improve client communication and counselling concerning lifestyle-related issues in general health care. However, the results must be interpreted with caution due to inconsistent methodological quality of the studies. PRACTICE IMPLICATIONS: This review suggests that MI training outcomes are generally favourable, but more high-quality research is needed to help identify the best practices for training in MI.

Background: There is no systematic identification of parents with excessive alcohol use who have a child admitted to hospital. Children in families with excessive alcohol issues form a high risk group as substantial alcohol consumption has a damaging influence on a child emotionally, cognitively, socially and physically. Alcohol consumption is a sensitive issue, and health staff needs knowledge, qualifications and adequate training in communicating with parents about this taboo. Aim: To identify specific patterns in subgroups of parents by comparing results from screening and demographic variables • To identify systematic patterns in staff members by demographic variables to decide whether these factors influence the screening results. Methods: During 1 year, screening and brief intervention (SBI) was accomplished, including health staff conducting dialogues with parents of a hospitalized child using motivational interviewing (MI) and screening for risky alcohol behaviour by Cut down, Annoyance from others, feel Guilty, Early-morning Craving (CAGE)-C. Data were analysed by descriptive statistics, and relationships were tested with a statistical significance level of 0.05, using SPSS (version 16.0). Results: Motivational dialogues with 779 parents were conducted by 43 staff members, and 11% of the parents were screened positive for risky alcohol behaviour. Drinking alcohol 4 days a week or more and drinking alcohol outside mealtimes were main risk factors. Parents' gender was the strongest predictor of screening positive and OR was 6.8 for men (CI 4.03-11.74) compared to women, p Language: en

To examine the experience of women with a pre-pregnant BMI30 kg/m², in their encounters with healthcare professionals during pregnancy.Qualitative study using a phenomenological methodology approach.Face-to-face interviews with pregnant women in their own home who were referred from their general practitioner to specialist antenatal follow-up at their local hospital.Sixteen women with pre-pregnant BMI30 kg/m².Qualitative in-depth interviews. Participant's experiences of their encounters with health care professionals were recorded verbatim, transcribed and analysed using a phenomenological approach.Two main themes were identified, an accusatorial response from healthcare professionals and a lack of advice and helpful information on how being obese and pregnant might affect the women's health and that of their child.Pregnant women with obesity may experience prejudice from healthcare professionals. These women felt they were treated with a lack of respect, an accusatorial response, and the feeling that information which could have been helpful was not forthcoming. Communication between obese pregnant woman and healthcare professionals appears to be lacking. Improved training in communication skills, less judgemental behaviour and better dissemination of information from healthcare professionals working with pregnant women with obesity are needed.

Duodenal injury following a blunt abdominal trauma is a rare condition. It poses a diagnostic challenge since symptoms are often subtle in the beginning and the trauma may initially remain undisclosed. We present a case of a 16 month-old girl, who was admitted to hospital due to critical illness after a tumble the day before. An explorative laparotomy revealed a perforation of the duodenum. This case demonstrates the importance of thoroughly evaluating anamnesis information and emphasises the need of considering a variety of potential diagnoses when assessing the critically ill child.

Objective. ?Motivational interviewing? (MI) has shown to be broadly applicable in the management of behavioural problems and diseases. Only a few studies have evaluated the effect of MI on type 2 diabetes treatment and none has explored the effect of MI on target-driven intensive treatment. Methods. Patients were cluster-randomized by GPs, who were randomized to training in MI or not. Both groups received training in target-driven intensive treatment of type 2 diabetes. The intervention consisted of a 1?-day residential course in MI with half-day follow-up twice during the first year. Blood samples, case record forms, national registry files, and validated questionnaires from patients were obtained. Results. After one year significantly improved metabolic status measured by HbA1c (p

Renal involvement in Henoch-Schönlein purpura (HSP) constitutes a risk of end-stage renal disease (ESRD), especially in patients presenting with nephrotic syndrome.The clinical courses of six patients (mean age 13.2 years; four boys and two girls) admitted from 2000 to 2007 with HSP and nephrotic syndrome were reviewed. Average follow-up was 44 months (28-59). Treatment protocols included oral prednisolone and in non-responders cyclosporin A, cyclophosphamide, mycophenolate mofetil or tacrolimus. Five patients were treated immediately after presentation of nephrotic syndrome/nephrotic range proteinuria (median 277 mg/m(2)/h). The last patient was treated locally with low-dose prednisolone (0.2-0.9 mg/kg/day) and 3 months of low-dose cyclophosphamide (1 mg/kg/day).All five patients treated promptly with high-dose immunosuppressant had normal estimated glomerular filtration rate (eGFR) (median 159 ml/min/1.73 m(2)) at follow-up. One obtained complete remission, two had positive dipstick proteinuria and two needed angiotensin-converting enzyme inhibitors to stay normotensive. The patient receiving low-dose immunosuppression at onset progressed to ESRD 44 months later. At initial presentation eGFR, blood pressure, renal biopsy grading, proteinuric range and plasma albumin were similar in all patients.Follow-up data from the patients suggest that an early aggressive immunosuppressive approach improves long-term renal outcome in HSP patients with nephrotic syndrome.

Udgivelsesdato: 2009-null OBJECTIVE: To examine whether training GPs in motivational interviewing (MI) can improve type 2 diabetic patients' (1) understanding of diabetes, (2) beliefs regarding prevention and treatment, and (3) motivation for behaviour change. METHODS: A randomized controlled trial including 65 GPs and 265 type 2 diabetic patients. The GPs were randomized in two groups, one with and one without MI training. Both groups received training in target-driven intensive treatment of type 2 diabetic patients. The intervention was a 1(1/2)-day residential course in MI with (1/2)-day follow-up twice during the first year. The patient data stemmed from previously validated questionnaires. MAIN OUTCOME MEASURES: The Health Care Climates Questionnaire assesses the patient-doctor relationship and type of counselling. The Treatment Self-Regulation Questionnaire assesses the degree to which behaviour tends to be self-determined. The Diabetes Illness Representation Questionnaire assesses beliefs and understanding of type 2 diabetes. The Summary of Diabetes Self Care Activities assesses the extent of various self-care activities related to type 2 diabetes. RESULTS: The response rate to our questionnaires was 87%. Patients in the intervention group were significantly more autonomous and motivated in their inclination to change behaviour after one year compared with the patients from the control group. Patients in the intervention group were also significantly more conscious of the importance of controlling their diabetes, and had a significantly better understanding of the possibility of preventing complications. CONCLUSION: MI improved type 2 patients' understanding of diabetes, their beliefs regarding treatment aspects, their contemplation on and motivation for behaviour change. Whether our results can be sustained long term and are clinically relevant in terms of changes in risk profile advocates further research.

This is an intervention-study discussing the long-term effects of a 3-day "Train the trainers course" (TTC). In the intervention (I) group 98.4% of doctors participated in a TTC, both specialists and trainees. Knowledge about teaching skills increased in the I group by 25% after the TTC; a result which was sustained at six months. Teaching behaviour was significantly changed as the use of feedback and supervision had increased from a score of 4 to 6 (max. score = 9).A 3-day residential TTC has a significant impact on knowledge gain concerning teaching skills, teaching behaviour and clinical learning culture after six months.

Feedback may be described as a process comprising communication of information and reactions to such communication. It has been defined as specific information about the difference between a trainee's observed performance and a given standard with the intent of achieving performance improvement. Feedback is essential in medical education and has great implications for the educational climate. It has been shown that a common language regarding the principles of feedback has a sustained effect on quality and frequency of feedback. Further research is needed on feedback and educational climate, and on how to motivate trainees to improve future learning through feedback.

Udgivelsesdato: 2008-Jul Objectives This study aimed to establish the longterm effects of a 3-day 'Training for Trainers' course (TTC) on doctors' knowledge, teaching behaviour and clinical learning climate. Methods The study was designed as an intervention study with pre-, post- and long-term measurements. The intervention group (I-group) included 118 doctors from the departments of internal medicine and orthopaedic surgery at one university hospital. The control group (C-group) consisted of 125 doctors from the corresponding departments at another university hospital. Gains in knowledge about teaching skills were assessed by a written test. Teaching behaviour and learning climate were evaluated by questionnaires. Results In the I-group, 98.4% of doctors, both specialists and trainees, participated in a TTC. Response rates on the written test varied from 90% at baseline to 70% at 6 months after the intervention. Knowledge about teaching skills increased in the I-group by 25% after the TTC and was sustained at 6 months. Questionnaire response rates varied from 98.4% at baseline to 84.8% at 6 months. Post-course, the teaching behaviour of the I-group significantly changed and its learning climate improved compared with the C-group. Scores for use of feedback and supervision in the I-group increased from 4-5 to 6-7 (maximum score = 9). This was significantly higher than in the C-group. Conclusions A 3-day residential TTC has a significant impact in terms of gains of knowledge concerning teaching skills, teaching behaviour and learning climate after 6 months. The positive effects demonstrated in this study were rooted in both the specialists and trainees who attended the course.

Motivational interviewing has been shown to be broadly usable in a scientific setting in the management of behavioural problems and diseases. However, data concerning implementation and aspects regarding the use of motivational interviewing in general practice is missing.To evaluate GPs' conception of motivational interviewing in terms of methods, adherence to and aspects of its use in general practice after a course.In a randomised controlled trial concerning intensive treatment of newly diagnosed patients with type 2 diabetes detected by screening, the GPs were randomised to a course in motivational interviewing or not. The study also included a third group of GPs outside the randomised controlled trial, who had 2 years previously received a similar course in motivational interviewing.General practice in Denmark.The intervention consisted of a 1.5-day residential course in motivational interviewing with 0.5-day follow-ups, twice during the first year. Questionnaire data from GPs were obtained.We obtained a 100% response-rate from the GPs in all three groups. The GPs trained in motivational interviewing adhered statistically significantly more to the methods than did the control group. More than 95% of the GPs receiving the course stated that they had used the specific methods in general practice.A course in motivational interviewing seems to influence GPs professional behaviour. Based on self-reported questionnaires, this study shows that the GPs after a course in motivational interviewing seemed to change their professional behaviour in daily practice using motivational interviewing compared with the control group. GPs evaluated motivational interviewing to be more effective than 'traditional advice giving'. Furthermore, GPs stated that the method was not more time consuming than 'traditional advice giving'.

Motivational Interviewing is a well-known, scientifically tested method of counselling clients developed by Miller and Rollnick and viewed as a useful intervention strategy in the treatment of lifestyle problems and disease.To evaluate the effectiveness of motivational interviewing in different areas of disease and to identify factors shaping outcomes.A systematic review and meta-analysis of randomised controlled trials using motivational interviewing as the intervention.After selection criteria a systematic literature search in 16 databases produced 72 randomised controlled trials the first of which was published in 1991. A quality assessment was made with a validated scale. A meta-analysis was performed as a generic inverse variance meta-analysis.Meta-analysis showed a significant effect (95% confidence interval) for motivational interviewing for combined effect estimates for body mass index, total blood cholesterol, systolic blood pressure, blood alcohol concentration and standard ethanol content, while combined effect estimates for cigarettes per day and for HbA(1c) were not significant. Motivational interviewing had a significant and clinically relevant effect in approximately three out of four studies, with an equal effect on physiological (72%) and psychological (75%) diseases. Psychologists and physicians obtained an effect in approximately 80% of the studies, while other healthcare providers obtained an effect in 46% of the studies. When using motivational interviewing in brief encounters of 15 minutes, 64% of the studies showed an effect. More than one encounter with the patient ensures the effectiveness of motivational interviewing.Motivational interviewing in a scientific setting outperforms traditional advice giving in the treatment of a broad range of behavioural problems and diseases. Large-scale studies are now needed to prove that motivational interviewing can be implemented into daily clinical work in primary and secondary health care.

Aim/Objectives: Evaluation of how the substitution system has been implemented, how it was assessed by the general practitioners (GPs), pharmacists (PHs) and patients, and clarification of benefits and problems related to the system.Methods: The study was based on specific question-naires to GPs, PHs and patients. The questionnaires were based on qualitative interviews with all three groups and afterwards validated and pilot tested.Results: 80% of 300 GPs, 72% of PHs and 82% of 105 patients responded. The study showed that 84% of the patients were satisfied with the system. Of the patients, 83% had tried a substituted drug previously. Of these, 4% had experienced various side effects, and 7% had experienced a weaker effect from the substi tuted drug. One case of adverse medical treatment as a consequence of substitution was reported. The study showed that 61% of GPs were dissatisfied with the system and assessed that it should be abolished.Conclusions: The GPs' reasons for suggesting that the system be abolished were that the system was incomprehensible, badly introduced and created an extra workload. Half of the PHs were dissatisfied with the system, primarily due to the excessive workload imposed. In spite of this, about half of the PHs wanted the system to be continued, because the overall intention was good, in terms of getting the prescribed drug as cheaply as possible for the patient. Nearly all statements from the patients showed that overall the patients thought the benefits greater than the disadvantages in the system. All GPs and nearly all PHs were of the opinion that analogue substitution (substitution between drugs with the same effect obtained by different means) was medically unjustifiable, did not have potentially desirable effects, and should therefore not be introduced. How do general practitioners, pharmacists and patients evaluate the substitution system for prescription in Denmark?. Available from: http://www.researchgate.net/publication/243131968_How_do_general_practitioners_pharmacists_and_patients_evaluate_the_substitution_system_for_prescription_in_Denmark [accessed Oct 2, 2015].

Background Many countries have recently reformed their postgraduate medical education (PGME). New pedagogic initiatives and blueprints have been introduced to improve quality and effectiveness of the education. Yet it is unknown whether these changes improved the daily clinical training. The purpose was to examine the impact of a national PGME reform on the daily clinical training practice. Methods The Danish reform included change of content and format of specialist education in line with outcome-based education using the CanMEDS framework. We performed a questionnaire survey among all hospital doctors in the North Denmark Region. The questionnaire included items on educational appraisal meetings, individual learning plans, incorporating training issues into work routines, supervision and feedback, and interpersonal acquaintance. Data were collected before start and 31/2 years later. Mean score values were compared, and response variables were analysed by multiple regression to explore the relation between the ratings and seniority, type of hospital, type of specialty, and effect of attendance to courses in learning and teaching among respondents. Results Response rates were 2105/2817 (75%) and 1888/3284 (58%), respectively. We found limited impact on clinical training practice and learning environment. Variances in ratings were hardly affected by type of hospital, whereas belonging to the laboratory specialities compared to other specialties was related to higher ratings concerning all aspects. Conclusions The impact on daily clinical training practice of a national PGME reform was limited after 31/2 years. Future initiatives must focus on changing the pedagogical competences of the doctors participating in daily clinical training and on implementation strategies for changing educational culture.