Ageing populations and health-care staff shortages encourage efforts in primary care to recognise and prevent health deterioration and acute hospitalisation in community-dwelling older adults. The ...PATINA algorithm and decision-support tool alerts home-based-care nurses to older adults at risk of hospitalisation. The study aim was to test whether use of the PATINA tool was associated with changes in health-care use.
An open-label, stepped-wedge, cluster-randomised controlled trial was done in three Danish municipalities, covering 20 area teams providing home-based care to around 7000 recipients. During a period of 12 months, area teams were randomly assigned to an intervention crossover for older adults (aged 65 years or older) who received care at home. The primary outcome was hospitalisation within 30 days of identification by the algorithm as being at risk of hospitalisation. Secondary outcomes were hospital readmission and other hospital contacts, outpatient contacts, contact with primary care physicians (PCPs), temporary care, and death, within 30 days of identification. This study was registered at ClinicalTrials.gov (NTC04398797).
In total, 2464 older adults participated in the study: 1216 (49·4%) in the control phase and 1248 (50·6%) in the intervention phase. In the control phase, 102 individuals were hospitalised within 30 days during 33 943 days of risk (incidence 0·09 per 30 days), compared with 118 individuals within 34 843 days of risk (0·10 per 30 days) during the intervention phase. The intervention was not associated with a reduction in the number of first hospitalisations within 30 days (incidence rate ratio IRR 1·10 90% CI 0·90–1·40; p=0·28). Furthermore it was not associated with reduced rates of other hospital contacts (IRR 1·10 95% CI 0·90–1·40; p=0·28), outpatient contacts (1·10 0·88–1·40; p=0·42), or mortality (0·82 0·58–1·20; p=0·25). The intervention was associated with a 59% reduction in readmissions within 30 days of hospital discharge (IRR 0·41 95% CI 0·24–0·68; p=0·0007), a 140% increase in contacts with PCPs (2·40 1·18–3·20; p<0·0001), and a 150% increase in use of temporary care (2·50 1·40–4·70; p=0·0027).
Despite having no effect on the primary outcome, the PATINA tool showed other benefits for older adults receiving home-based care. Such algorithms have the potential to shift health-care use from secondary to primary care but need to be tested in other home-based care settings. Implementation of algorithms in clinical practice should be informed by analysis of cost-effectiveness and potential harms as well as the benefits.
Innovation Fund Denmark and Region of Southern Denmark.
For the Danish, French and German translations of the abstract see Supplementary Materials section.
Summary
1. Pigment analyses by high performance liquid chromatography (HPLC) are commonly used for determining algal groups in marine and estuarine areas but are underdeveloped in freshwaters. In ...this study, 15 characteristic pelagic algal species (representing five algal groups) of oligo‐ / mesotrophic lakes were cultured and pigment / Chl a ratios determined at three light intensities.
2. With the exception of cyanophytes, light treatment had little effect on pigment / Chl a ratios. This justifies the use of the same pigment / Chl a ratios during seasonal studies where light conditions may change.
3. The determined pigment / Chl a ratios were tested on seasonal samples from five oligo‐ / mesotrophic lakes and three streams using CHEMTAX software. Pigment ratios of both pelagic and benthic algal communities from the lakes and streams were analysed to determine whether the pelagic algae‐based ratios can be used for benthic algal communities.
4. HPLC combined with CHEMTAX was useful for identifying freshwater phytoplankton classes and for quantifying the abundance of phytoplankton groups. However, although correlations were significant for six of seven phytoplankton classes studied, they were weak and varied with season.
5. HPLC was valid for quantifying benthic diatom groups in stream samples, whereas for lakes more benthic algal groups were recorded with HPLC than with microscopy and correlations between the two methods were not significant.
6. The use of both HPLC and microscopy is recommended as a cost‐efficient method for analysing many samples. It is crucial, however, that the CHEMTAX software is calibrated with the correct information, and the user is aware of the limitations.
We examine how and when executive style affects strategy implementation in Danish Small and Medium Size Enterprises SMEs. We propose a framework that allows a simple diagnosis of executive style and ...strategy implementation, and we then measure and assess the performance consequences of (mis)alignment between the two. Executive style determines how executives deal with information, i.e., how they delegate, make decisions, and respond to uncertainty. Strategy implementation is the realization of strategy and what the firm does. Analyzing data from 407 small- and medium-sized (SME) Danish manufacturing firms, we show that a failure to align SME executive style and strategy leads to a significant performance loss. Moreover, our findings demonstrate that the alignment of executive style and strategy is especially crucial for SMEs pursuing change and innovation. We conclude with managerial and theoretical implications.
The administration of lycopene to female rats at doses ranging from 0.001 to 0.1 g/kg b.w. per day for 2 weeks was found to alter the drug-metabolizing capacity and antioxidant status of the exposed ...animals. An investigation of four cytochrome P450-dependent enzymes revealed that benzyloxyresorufin O-dealkylase activity in the liver was significantly induced in a dose-dependent fashion at all lycopene doses investigated. Likewise, ethoxyresorufin O-dealkylase activity was induced, although only at the two highest lycopene concentrations tested. An investigation of selected phase 2 detoxification enzymes provided evidence that lycopene was capable of inducing hepatic quinone reductase, approximately two-fold, at doses between 0.001 and 0.05 g/kg b.w. per day, whereas no effect was observed at the remaining doses tested. Glutathione transferase, using the two substrates, 2,4-dichloronitrobenzene and 1-chloro-2,4-dinitrobenzene, was significantly induced at the 0.1 g/kg b.w. per day dose, whereas no effect was observed at the remaining lycopene doses. Analysis of the antioxidant status of the blood compartment revealed that three out of four antioxidant enzymes were affected by lycopene treatment. The activity of superoxide dismutase was thus significantly induced at lycopene doses of 0.005 and 0.05 g/kg b.w, whereas glutathione reductase and glutathione peroxidase was only induced at the 0.005 g/kg b.w. per day dose. For all antioxidant enzymes investigated, the activities seemed to return to the control level after exerting peak induction at doses between 0.005 and 0.05 g/kg b.w. per day. The explanation for this remains unknown. The plasma concentration of lycopene at dietary levels of 0.001, 0.005, 0.05 and 0.1 g/kg b.w. per day was estimated to be 16, 32, 71 and 67 nM, which is barely within the lower range of the mean human plasma concentration of lycopene, which ranges from 70–1790 nM. Oxidative stress induced by the heterocyclic amine, 2-amino-1-methyl-6-phenylimidazo 4,5–
bpyridine (PhIP), and investigated by analyzing for malondialdehyde in plasma, was not found to be affected by prior lycopene exposure. The level of PhIP–DNA adducts in the liver or colon was likewise not affected by lycopene at any dose. Overall, the present study provides evidence that lycopene administered in the diet of young female rats exerts minor modifying effects toward antioxidant and drug-metabolizing enzymes involved in the protection against oxidative stress and cancer. The fact that these enzymatic activities are induced at all of these very low plasma levels, could be taken to suggest that modulation of antioxidant and drug-metabolizing enzymes may indeed be relevant to humans, which in general exhibit a plasma lycopene level several fold above the effective levels observed in this study.
This study aimed at unraveling the structure underlying the taxon-richness matrix of shallow lakes. We assessed taxon richness of a large variety of food-web components at different trophic levels ...(bacteria, ciliates, phytoplankton, Zooplankton, fish, macro-invertebrates, and water plants) in 98 shallow lakes from three European geographic regions: Denmark (DK), Belgium/The Netherlands (BNL), and southern Spain (SP). Lakes were selected along four mutually independent gradients of total phosphorus (TP), vegetation cover (SUBMCOV), lake area (AREA), and connectedness (CONN). Principal-components analysis (PCA) indicated that taxon diversity at the ecosystem level is a multidimensional phenomenon. Different PCA axes showed associations with richness in different subsets of organism groups, and differences between eigenvalues were low. Redundancy analysis showed a unique significant contribution to total richness variation of SUBMCOV in all three regions, of TP in DK and SP, and of AREA in DK and BNL. In DK, several organism groups tended to show curvilinear responses to TP, but only one was significantly hump shaped. We postulate that the unimodal richness responses to TP that are frequently reported in the literature for many organism groups may be partly mediated by the unimodal response of macrophyte vegetation to lake productivity.
1. We studied the effects of increased water temperatures (0-4.5 °C) and nutrient enrichment on the stoichiometric composition of different primary producers (macrophytes, epiphytes, seston and ...sediment biofilm) and invertebrate consumers in 24 mesocosm ecosystems created to mimic shallow pond environments. The nutrient ratios of primary producers were used as indicative of relative nitrogen (N) or phosphorus (P) limitation. We further used carbon stable isotopic composition (δ¹³C) of the different primary producers to elucidate differences in the degree of CO₂ limitation. 2. Epiphytes were the only primary producer with significantly higher δ¹³C in the enriched mesocosms. No temperature effects were observed in δ¹³C composition of any primary producer. Independently of the treatment effects, the four primary producers had different δ¹³C signatures indicative of differences in CO₂ limitation. Seston had signatures indicating negligible or low CO₂ limitation, followed by epiphytes and sediment biofilm, with moderate CO₂ limitation, while macrophytes showed the strongest CO₂ limitation. CO₂ together with biomass of epiphytes were the key variables explaining between 50 and 70% of the variability in δ¹³C of the different primary producers, suggesting that epiphytes play an important role in carbon flow of temperate shallow lakes. 3. The ratio of carbon to chlorophyll a decreased with increasing temperature and enrichment in both epiphytes and seston. The effects of temperature were mainly attributed to changes in algal Chl a content, while the decrease with enrichment was probably a result of a higher proportion of algae in the seston and epiphytes. 4. Macrophytes, epiphytes and seston decreased their C : N with enrichment, probably as an adaptation to the different N availability levels. The C : N of epiphytes and Elodea canadensis decreased with increasing temperature in the control mesocosms. Sediment biofilm was the only primary producer with lower C : P and N : P with enrichment, probably as a result of higher P accumulation in the sediment. 5. Independently of nutrient level and increased temperature effects the four primary producers had significantly different stoichiometric compositions. Macrophytes had higher C : N and C : P and, together with epiphytes, also the highest N : P. Seston had no N or P limitation, while macrophytes and epiphytes may have been P limited in a few mesocosms. Sediment biofilm indicated strong N deficiency. 6. Consumers had strongly homeostatic stoichiometric compositions in comparison to primary producers, with weak or no significant treatment effects in any of the groups (insects, leeches, molluscs and crustaceans). Among consumers, predators had significantly higher N content and lower C : N than grazers.
It is important to monitor equity of access to health services in all countries. We assessed the levels of out‐of‐pocket (OOP) health spending in three European countries: Denmark, Germany and ...Poland. Using data from national databases (i.e., Statistics Denmark, German Socio‐Economic Panel, and National Statistical Office of Poland) for the period 2000–2010, we applied common methods to assess the rate of households with ‘catastrophic’ OOP health spending and the concentration of health spending in income‐ordered groups of citizens. 20.3 per cent of Polish households experienced ‘catastrophic’ expenditure defined by OOP health spending/income ratio >10 per cent, compared to 1.0 per cent of households in Germany and 3.2 per cent of households in Denmark. 8.8 per cent of Polish households experienced ‘catastrophic’ expenditure defined by OOP health spending/capacity to pay ratio >40 per cent, compared to 0.4 per cent of households in Germany and 0.8 per cent of households in Denmark. Concentration indexes for OOP on drugs in 2010 were 0.01978 and –0.114 for Denmark and Poland, respectively. The rate of households with ‘catastrophic’ OOP expenditure in Poland is much higher than in both Denmark and Germany; health spending in Poland is concentrated among the worst‐off groups of citizens while in Denmark and Germany they are distributed more equitably.
Equity and fairness should be carefully considered as health policy strategic objectives in the process of decision making regarding financing new health care technologies from public funds.
The increasing number of resistant bacterial strains in infective endocarditis (IE) emphasizes the need for a constant development of antimicrobials. Linezolid is an oxazolidinone with an effect on ...Gram-positive cocci. Only a few casuistic reports describe its utilization in the treatment of IE. The objective of this study is to report our experience with linezolid from a large consecutive cohort of IE patients. In a retrospective cohort study, data on 550 consecutive IE patients were collected at two tertiary University Hospitals in Copenhagen, Denmark. The main endpoints were differences in the in-hospital and 12 months post-discharge mortality between IE patients receiving linezolid for a part of the treatment and IE patients receiving conventional treatment. Of the 550 patients enrolled in the study, 38 patients received linezolid treatment and 512 received conventional treatment. Reasons for adding linezolid were antibiotic intolerance (
n
= 13), nephrotoxicity (
n
= 5), pharmaceutical interactions (
n
= 1), inadequate clinical response (
n
= 14), or inadequate microbial response (
n
= 5). No significant differences in the cure rate (74 % vs. 71 %,
p
> 0.05), in-hospital mortality (13 % vs. 14 %,
p
> 0.05), or post-discharge mortality at 12 months follow-up (26 % vs. 26 %,
p
> 0.05) were observed. In the current study, we found that linezolid, in general, was well tolerated and associated with the same outcome as in patients with Gram-positive IE treated with other antibiotics.
Abstract
Objective
This study explores dose–response relationships when treating fibromyalgia with low-dose naltrexone.
Design
A single-blinded clinical trial was carried out using the “up-and-down” ...method.
Subjects
Subjects included women with a diagnosis of fibromyalgia aged 18–60 years who had been referred to treatment at a public pain clinic at a Danish university hospital.
Methods
The test doses were in the range 0.75–6 mg, and the dosing interval was 0.75 mg. The method was sequential and allowed predicting the dose effective in 50% (ED50) and 95% (ED95) of the subjects when the dose had shifted direction 10 times, and six pairs of “up-and-down” data were available.
Results
A total of 27 subjects were included in the study; two subjects were withdrawn. After inclusion of 25 evaluable subjects, the dose estimates were calculated as 3.88 mg for ED50 and 5.40 mg for ED95. As a secondary outcome, the effects on 10 common fibromyalgia symptoms were evaluated. A high interindividual variation was observed both in the symptom presentation at baseline and in which symptoms were reduced by low-dose naltrexone.
Conclusions
This study is the first to explore dose–response relationships in the treatment of fibromyalgia with low-dose naltrexone. Future placebo-controlled randomized clinical trials are needed, and according to our findings, 4.5 mg, which has previously been used, seems to be a relevant test dose. We recommend that future studies include additional nonpain fibromyalgia symptoms as outcome measures.
Change in the abundance of benthic macroinvertebrates and the stable isotope composition (C, N) of benthic invertebrates and zooplankton in Lake Vaeng, Denmark, was investigated over an 18-year ...period following biomanipulation (removal of cyprinids). During the first nine years after biomanipulation, the lake was clear and submerged macrophytes were abundant; after this period, a shift occurred to low plant abundance and high turbidity. Two years after the biomanipulation, total density of benthic macroinvertebrates reached a maximum of 17042 (±2335 SE) individuals m
−2
and the density was overall higher when the lake was in a clear state. Redundancy analysis (RDA) suggested macrophyte abundance and total nitrogen (TN) concentration were the dominant structuring forces on the benthic macroinvertebrate assemblage. Stable isotope analysis revealed that δ
13
C of macroinvertebrates and zooplankton was markedly higher in years with high submerged macrophyte abundance than in years without macrophytes, most likely reflecting elevated δ
13
C of phytoplankton and periphyton mediated by a macrophyte-induced lowering of lake water CO
2
concentrations. We conclude that the strong relationship between macrophyte coverage and δ
13
C of macroinvertebrates and cladocerans may be useful in paleoecological studies of past changes in the dynamics of shallow lakes, as change in macrophyte abundance may be tracked by the δ
13
C of invertebrate remains in the sediment.
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