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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. 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. 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. 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.

Background A large number of older people depend on others for help with their daily personal care, including oral health care. Nursing home and elder-care staff often face challenges identifying older people, who are exposed to or at an increased risk of oral diseases. Thus, the aim of this study was to identify risk factors that non-dental care staff can use to identify older people at risk of oral diseases and poor oral hygiene. Methods In this cross-sectional study, the oral health and risk factors for poor oral health were determined for 217 care dependent older people living in two nursing homes and a rehabilitation centre or receiving home care in two Danish municipalities. The outcome variables for oral disease i.e. caries, periodontitis, and gingivitis, and oral hygiene, i.e. plaque and calculus, were assessed using standardised oral examinations. Risk factors for oral diseases and poor oral hygiene were assessed based on a questionnaire concerning (1) background information, (2) health status, (3) social support, (4) oral health behaviours, and (5) self-reported oral health. The associations between oral health and risk factors were investigated using logistic regression analyses. Results In general, older people with different living arrangements had quite similarly distributed risk factors. The oral examinations showed that 54.5% had oral diseases, and 14.8% had poor oral hygiene. Not seeing a dentist regularly was significantly associated with having oral diseases (Odds Ratio, 2.87; CI, 1.53–5.39) and poor oral hygiene (OR, 4.50; CI, 1.83–11.05). A significant association was found between the presence of an oral disease and adversely affected quality of life (OR, 2.65; CI, 1.42–4.95), especially due to challenges eating (OR, 3.76; CI, 1.64–8.60) and/or smiling and showing teeth (OR, 3.64; CI, 1.27–10.42). A significant association was also found between poor oral hygiene and taking psychotropic drugs (OR, 2.61; CI, 1.08–6.30). Conclusion Questions regarding the use of the dental care system and oral health problems could be used by nondental care staff in conversations with older people to determine their risk of oral diseases and poor oral hygiene.

Standardized monitoring of BCR::ABL1 mRNA levels is essential for the management of chronic myeloid leukemia (CML) patients. From 2016 to 2021 the European Treatment and Outcome Study for CML (EUTOS) explored the use of secondary, lyophilized cell-based BCR::ABL1 reference panels traceable to the World Health Organization primary reference material to standardize and validate local laboratory tests. Panels were used to assign and validate conversion factors (CFs) to the International Scale and assess the ability of laboratories to assess deep molecular response (DMR). The study also explored aspects of internal quality control. The percentage of EUTOS reference laboratories (n = 50) with CFs validated as optimal or satisfactory increased from 67.5% to 97.6% and 36.4% to 91.7% for ABL1 and GUSB, respectively, during the study period and 98% of laboratories were able to detect MR4.5 in most samples. Laboratories with unvalidated CFs had a higher coefficient of variation for BCR::ABL1IS and some laboratories had a limit of blank greater than zero which could affect the accurate reporting of DMR. Our study indicates that secondary reference panels can be used effectively to obtain and validate CFs in a manner equivalent to sample exchange and can also be used to monitor additional aspects of quality assurance.

The risk of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorders (ASD) may be influenced by environmental factors such as maternal obesity before pregnancy. Previous studies investigating those associations have found divergent results. We aim to investigate in a large birth cohort this association further in children with ADHD, ASD and comorbid ADHD and ASD. Our study population consisted of 81,892 mother–child pairs participating in the Danish National Birth Cohort (DNBC). Information about pre-pregnancy weight and height was collected in week 16 of pregnancy; the analysis was divided into groups based on BMI. Children with a clinical diagnosis of ADHD and/or ASD were identified in the Danish health registries at an average age of 13.3 years. Hazard ratios (HRs) were estimated using time-to-event analysis. Compared to normal weight mothers, the risk of having a child with ADHD was significantly increased if the mother was overweight (HR = 1.28 [95% CI 1.15;1.48]), obese (HR = 1.47 [95% CI 1.26;1.71]) or severely obese (HR = 1.95 [95% CI 1.58;2.40]). The same pattern was seen for the combined ADHD and ASD group. Regarding ASD, an increased risk was observed in underweight (HR = 1.30 [95% CI 1.01;1.69]) and obese (HR = 1.39 [95% CI 1.11;1.75]) mothers. Subgroup analysis revealed that the association in the ADHD group could mostly be attributable to the hyperactive group. Maternal obesity before pregnancy is a risk factor for ADHD in children. Maternal obesity as well as underweight may also be associated with an increased risk for ASD.

ObjectiveTo synthesise qualitative literature on (1) the perceptions of patients with cancer of participating in an exercise intervention while undergoing chemotherapy and (2) to inform and guide professionals in oncology and haematology practice.DesignA qualitative meta-synthesis based on Noblit and Hare’s seven-step meta-ethnography.Data sourcesSix electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, PubMed, SCI-Expanded—SSCI and Scopus (final search June 2022) were used to identify qualitative literature containing individual or focus group interviews. The transparency of reporting for each study was assessed using the Consolidated criteria for Reporting Qualitative research checklist.ResultsThe search identified 5002 articles, 107 of which were selected for full-text review. Seventeen articles from five countries with patients undergoing chemotherapy during exercise interventions were included. Eleven articles were included in the meta-synthesis, which comprised 193 patients with various cancer diagnoses, disease stages, sexes and ages. Four main themes were identified: chemotherapy overpowers the body; exercise in battle with side effects; a break from gloomy thoughts; and a question of survivorship.Conclusions and implicationsThe meta-synthesis emphasised that patients with cancer undergoing chemotherapy and simultaneously participating in exercise interventions may experience momentary relief from overwhelming side effects, even though full bodily recovery may be perceived as a distant prospect. The synthesis offers a sparse empirical basis for gaining insight into what patients experience existentially following exercise interventions. It is up to patients to independently apply the transfer value of exercise to their own existential circumstances.

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].

Residential biomass combustion is a significant source of aerosol particles on regional and global scales influencing climate and human health. The main objective of the current study was to investigate the properties of cloud condensation nuclei (CCN) emitted from biomass burning of solid fuels in different cookstoves mostly of relevance to sub-Saharan east Africa. The traditional three-stone fire and a rocket stove were used for combustion of wood logs of Sesbania and Casuarina with birch used as a reference. A natural draft and a forced-draft pellet stove were used for combustion of pelletised Sesbania and pelletised Swedish softwood alone or in mixtures with pelletised coffee husk, rice husk or water hyacinth. The CCN activity and the effective density were measured for particles with mobility diameters of ∽65, ∽100 and ∽200 nm, respectively, and occasionally for 350 nm particles. Particle number size distributions were measured online with a fast particle analyser. The chemical composition of the fuel ash was measured by application of standard protocols. The average particle number size distributions were by number typically dominated by an ultrafine mode, and in most cases a soot mode was centred around a mobility diameter of ∽150 nm. The CCN activities decreased with increasing particle size for all experiments and ranged in terms of the hygroscopicity parameter, κ, from ∽0.1 to ∽0.8 for the ultrafine mode and from ∽0.001 to ∽0.15 for the soot mode. The CCN activity (κ) of the ultrafine mode increased (i) with increasing combustion temperature for a given fuel, and (ii) it typically increased with increasing potassium concentration in the investigated fuels. The primary CCN and the estimated particulate matter (PM) emission factors were typically found to increase significantly with increasing potassium concentration in the fuel for a given stove. In order to link CCN emission factors to PM emission factors, knowledge about stove technology, stove operation and the inorganic fuel ash composition is needed. This complicates the use of ambient PM levels alone for estimation of CCN concentrations in regions dominated by biomass combustion aerosol, with the relation turning even more complex when accounting for atmospheric ageing of the aerosol.

Background There is a lack of knowledge on effective treatment methods for comorbid benzodiazepine dependence in populations undergoing opioid agonist treatment (OAT). Tapering and discontinuation of benzodiazepines has long been considered the standard treatment, even though there is limited evidence for this practice. There is also limited research on benzodiazepine agonist treatment; however, peer and clinical experiences indicate that such approaches may be beneficial for a subgroup of the patients with long-lasting benzodiazepine dependence not responding to other treatment approaches. A randomized controlled trial will be conducted to compare the efficacy and safety of stabilizing agonist treatment using prescribed benzodiazepines with standard treatment in reducing illicit benzodiazepine use. Methods The target sample is 108 participants at outpatient OAT clinics in six Norwegian cities/counties (Bergen/Vestland, Tønsberg/Vestfold, Skien/Telemark, Fredrikstad/Østfold, Tromsø/Troms, and Lillestrøm/Akershus). The main inclusion criteria are benzodiazepine dependence of ≥ 5 years, using ≥ 5 days a week during the last month, and previous attempts at tapering. Participants will be randomly assigned to receive either a 26-week benzodiazepine stabilizing treatment (15–30 mg diazepam or 50–100 mg oxazepam daily), or a 20-week tapering using the same medications and equivalent initial dosages. All participants will be given access to consultations from OAT therapists with psychosocial follow-up in accordance with current clinical practice. The primary outcome is the use of illicit benzodiazepines assessed by observed urinary tests at week 24. Secondary outcomes include mental health symptoms, quality of life, cognitive performance, violence risk, other substance use, treatment retention, and life satisfaction. Additionally, the study will assess treatment-related adverse events as well as the cost-effectiveness of the intervention. Discussion This is the first randomized controlled trial of benzodiazepine agonist treatment for benzodiazepine dependence. The research project will assess efficacy and safety of stabilizing treatment with prescribed benzodiazepines compared to benzodiazepine tapering and discontinuation regarding use of illicit benzodiazepines and accordingly well-being of patients with concurrent benzodiazepine and opioid dependence undergoing OAT. If the intervention is found to be efficacious and safe, it will be considered one of the options to standard treatment for this patient group. Trial registration EU trial number: EudraCT: 2021–004981-37. Registered on December 13, 2021.

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.

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.