Metagenomic exploration of cold-active enzymes for detergent applications: Characterization of a novel, cold-active and alkali-stable GH8 endoglucanase from ikaite columns in SW Greenland.

Microbial communities from extreme environments are largely understudied, but are essential as producers of metabolites, including enzymes, for industrial processes. As cultivation of most microorganisms remains a challenge, culture-independent approaches for enzyme discovery in the form of metagenomics to analyse the genetic potential of a community are rapidly becoming the way forward. This study focused on analysing a metagenome from the cold and alkaline ikaite columns in Greenland, identifying 282 open reading frames (ORFs) that encoded putative carbohydrate-modifying enzymes with potential applications in, for example detergents and other processes where activity at low temperature and high pH is desired. Seventeen selected ORFs, representing eight enzyme families were synthesized and expressed in two host organisms, Escherichia coli and Aliivibrio wodanis. Aliivibrio wodanis demonstrated expression of a more diverse range of enzyme classes compared to E. coli, emphasizing the importance of alternative expression systems for enzymes from extremophilic microorganisms. To demonstrate the validity of the screening strategy, we chose a recombinantly expressed cellulolytic enzyme from the metagenome for further characterization. The enzyme, Cel240, exhibited close to 40% of its relative activity at low temperatures (4°C) and demonstrated endoglucanase characteristics, with a preference for cellulose substrates. Despite low sequence similarity with known enzymes, computational analysis and structural modelling confirmed its cellulase-family affiliation. Cel240 displayed activity at low temperatures and good stability at 25°C, activity at alkaline pH and increased activity in the presence of CaCl2, making it a promising candidate for detergent and washing industry applications.

Paleoproteomic identification of the species used in fourteenth century gut-skin garments from the archaeological site of Nuulliit, Greenland.

Until recently, the identification of the species of origin for skin and fur materials used in the production of archaeological clothing has been based on the analysis of macro- and microscopic morphological features and on the traditional knowledge of Indigenous groups. This approach, however, is not always applicable due to the deterioration of the archaeological objects. Paleoproteomics was used as an alternative approach to identify the species of origin of fifteen samples of various tissues from approximately 600-year-old garments found in Nuulliit, northern Greenland. Proteomics revealed that a limited group of marine and terrestrial mammals were used for clothing production. The results obtained from the analysis of multiple types of clothing and elements, such as sinew thread and gut skin, suggest that their applications were based on their properties. When conclusive assignment of a sample to a species via proteomics was not possible, the observation by transmitted light microscopy of feather and hair micromorphology, if not affected by diagenesis, was used to improve the identification. The proteomic characterization of animal materials used for clothing production in the Nuulliit archaeological context provides an insight into the practical knowledge and the strategies adopted by the local Indigenous community to exploit natural resources.

The social and organisational factors shaping acceptability of a self-management education and exercise intervention for people with hip or knee osteoarthritis in Greenland.

This study aimed to explore the experiences and perspectives of people with osteoarthritis attending the "Osteoarthritis School" (OA School) in Nuuk, Greenland to generate insights and lessons that can inform the development of self-management education and exercise interventions for people with other lifestyle conditions in a Greenland context. We conducted a qualitative interpretive description (ID) study based on ten semi-structured interviews with people with hip or knee osteoarthritis. Interviews were audio-recorded, transcribed, and coded. Using ID, we identified three themes: 1) perceptions and experiences of how the OA School intervention was organised (time and place); 2) perspectives and experiences of the education and exercise components (social factors, motivation, and education); and 3) significant change stories (physical and mental improvements and increased knowledge of OA). Social and organisational factors, such as working out with peers and the time and place of the intervention, influenced the participants' acceptance of the OA School intervention. Knowledge from this study will help us gain insight into what to address when developing future self-management education and exercise interventions in the Greenlandic healthcare system.

Giant viral signatures on the Greenland ice sheet.

BACKGROUND: Dark pigmented snow and glacier ice algae on glaciers and ice sheets contribute to accelerating melt. The biological controls on these algae, particularly the role of viruses, remain poorly understood. Giant viruses, classified under the nucleocytoplasmic large DNA viruses (NCLDV) supergroup (phylum Nucleocytoviricota), are diverse and globally distributed. NCLDVs are known to infect eukaryotic cells in marine and freshwater environments, providing a biological control on the algal population in these ecosystems. However, there is very limited information on the diversity and ecosystem function of NCLDVs in terrestrial icy habitats. RESULTS: In this study, we investigate for the first time giant viruses and their host connections on ice and snow habitats, such as cryoconite, dark ice, ice core, red and green snow, and genomic assemblies of five cultivated Chlorophyta snow algae. Giant virus marker genes were present in almost all samples; the highest abundances were recovered from red snow and the snow algae genomic assemblies, followed by green snow and dark ice. The variety of active algae and protists in these GrIS habitats containing NCLDV marker genes suggests that infection can occur on a range of eukaryotic hosts. Metagenomic data from red and green snow contained evidence of giant virus metagenome-assembled genomes from the orders Imitervirales, Asfuvirales, and Algavirales. CONCLUSION: Our study highlights NCLDV family signatures in snow and ice samples from the Greenland ice sheet. Giant virus metagenome-assembled genomes (GVMAGs) were found in red snow samples, and related NCLDV marker genes were identified for the first time in snow algal culture genomic assemblies; implying a relationship between the NCLDVs and snow algae. Metatranscriptomic viral genes also aligned with metagenomic sequences, suggesting that NCLDVs are an active component of the microbial community and are potential "top-down" controls of the eukaryotic algal and protistan members. This study reveals the unprecedented presence of a diverse community of NCLDVs in a variety of glacial habitats dominated by algae.

Analysis of admixed Greenlandic siblings shows that the mean genotypic values for metabolic phenotypes differ between Inuit and Europeans.

BACKGROUND: Disease prevalence and mean phenotype values differ between many populations, including Inuit and Europeans. Whether these differences are partly explained by genetic differences or solely due to differences in environmental exposures is still unknown, because estimates of the genetic contribution to these means, which we will here refer to as mean genotypic values, are easily confounded, and because studies across genetically diverse populations are lacking. METHODS: Leveraging the unique genetic properties of the small, admixed and historically isolated Greenlandic population, we estimated the differences in mean genotypic value between Inuit and European genetic ancestry using an admixed sibling design. Analyses were performed across 26 metabolic phenotypes, in 1474 admixed sibling pairs present in a cohort of 5996 Greenlanders. RESULTS: After FDR correction for multiple testing, we found significantly lower mean genotypic values in Inuit genetic ancestry compared to European genetic ancestry for body weight (effect size per percentage of Inuit genetic ancestry (se), -0.51 (0.16) kg/%), body mass index (-0.20 (0.06) kg/m2/%), fat percentage (-0.38 (0.13) %/%), waist circumference (-0.42 (0.16) cm/%), hip circumference (-0.38 (0.11) cm/%) and fasting serum insulin levels (-1.07 (0.51) pmol/l/%). The direction of the effects was consistent with the observed mean phenotype differences between Inuit and European genetic ancestry. No difference in mean genotypic value was observed for height, markers of glucose homeostasis, or circulating lipid levels. CONCLUSIONS: We show that mean genotypic values for some metabolic phenotypes differ between two human populations using a method not easily confounded by possible differences in environmental exposures. Our study illustrates the importance of performing genetic studies in diverse populations.

Seabirds reveal mercury distribution across the North Atlantic.

Mercury (Hg) is a heterogeneously distributed toxicant affecting wildlife and human health. Yet, the spatial distribution of Hg remains poorly documented, especially in food webs, even though this knowledge is essential to assess large-scale risk of toxicity for the biota and human populations. Here, we used seabirds to assess, at an unprecedented population and geographic magnitude and high resolution, the spatial distribution of Hg in North Atlantic marine food webs. To this end, we combined tracking data of 837 seabirds from seven different species and 27 breeding colonies located across the North Atlantic and Atlantic Arctic together with Hg analyses in feathers representing individual seabird contamination based on their winter distribution. Our results highlight an east-west gradient in Hg concentrations with hot spots around southern Greenland and the east coast of Canada and a cold spot in the Barents and Kara Seas. We hypothesize that those gradients are influenced by eastern (Norwegian Atlantic Current and West Spitsbergen Current) and western (East Greenland Current) oceanic currents and melting of the Greenland Ice Sheet. By tracking spatial Hg contamination in marine ecosystems and through the identification of areas at risk of Hg toxicity, this study provides essential knowledge for international decisions about where the regulation of pollutants should be prioritized.

Subarachnoid haemorrhage and intracranial aneurysms in Greenland in the period 2018-2021: incidence, outcome and familial disposition.

Subarachnoid haemorrhages (SAH) caused by rupture of intracranial aneurysms (IA) are a severe condition. Earlier studies found a higher incidence of SAH in Greenlandic patients compared to Danish patients, with familial aggregation also higher in Greenland. However, updated data is lacking. To investigate the contemporary incidence, outcome, and familial disposition of SAH/IA in Greenlandic patients in 2018-2021. Greenlandic patients diagnosed with ruptured or unruptured IA (UIA) during 2018-2021 were included. Data was obtained from patient files, x-ray department, and discharge registry. Incidence rates were estimated as cases/100,000/year. Direct age-standardised incidence rates were calculated using WHO 2000-2025 as standards. Of 30 SAH patients, 20 (66.7%) were females, 10 (33.3%) males. Of 36 UIA patients, 27 (75.0%) were females, 9 (25.0%) males. For SAH, crude incidence was 13.4/100,000/year, age-standardised incidence was 10.8/100,000/year. Familial history was observed in 30.0% of SAH patients. 5 patients (16.7%) died before treatment, 28-day case-fatality rate (CFR) for all patients was 23.3%. Overall and age-standardised incidence rates were similar to previous studies but higher among females and compared to neighbouring countries. A high occurrence of familial history was reported. SAH remains a serious condition in Greenland, as evidenced by five fatalities before treatment was administered.

Diverse methodological approaches to a Circumpolar multi-site case study which upholds and responds to local and Indigenous community research processes in the Arctic.

This paper outlines the methodological approaches to a multi-site Circumpolar case study exploring the impacts of COVID-19 on Indigenous and remote communities in 7 of 8 Arctic countries. Researchers involved with the project implemented a three-phase multi-site case study to assess the positive and negative societal outcomes associated with the COVID-19 pandemic in Arctic communities from 2020 to 2023. The goal of the multi-site case study was to identify community-driven models and evidence-based promising practices and recommendations that can help inform cohesive and coordinated public health responses and protocols related to future public health emergencies in the Arctic. Research sites included a minimum of 1 one community each from Canada (Nunavut,) United States of America (Alaska), Greenland, Iceland, Norway, Sweden, Finland. The approaches used for our multi-site case study provide a comprehensive, evidence-based account of the complex health challenges facing Arctic communities, offering insights into the effectiveness of interventions, while also privileging Indigenous local knowledge and voices. The mixed method multi-site case study approach enriched the understanding of unique regional health disparities and strengths during the pandemic. These methodological approaches serve as a valuable resource for policymakers, researchers, and healthcare professionals, informing future strategies and interventions.

Arctic puzzle: Pioneering a northern shrimp (Pandalus borealis) habitat model in Disko Bay, West Greenland.

Recent advancements in spatial modelling leverage remote sensing data and statistical species-environment relationships to forecast the distribution of a specific species. Our study focuses on Disko Bay in West Greenland, recognized as a significant marine biodiversity hotspot in the region. We conducted comprehensive analyses using multiple datasets spanning from 2010 to 2019, incorporating shrimp and fish surveys, commercial shrimp fishery catches, high-resolution (25 × 25 m) multibeam bathymetry and backscatter data along with a medium-resolution (200 × 200 m) bathymetric model, measured and modelled oceanographic data, and satellite chlorophyll data. Through multivariate regression analysis, we tested the significance of various physical factors (seafloor depth, sediment class, bottom water temperature, bottom water salinity, bottom current velocity, space, and time), biological factors (chlorophyll a, Greenland halibut (Reinhardtius hippoglossoides)), and anthropogenic impact (shrimp fishery; standardized catch per unit effort) on the density of northern shrimp in the area. Our results indicate a significant association between northern shrimp density, seafloor depth, and sediment class, explaining 36 % of the variation in shrimp density. Subsequently, we developed a high-resolution (optimized) spatial linear mixed-effect model to map the distribution of northern shrimp across Disko Bay, representing the first model of its kind developed for an Arctic area. The optimal habitat for northern shrimp is characterized by medium-deep waters (approximately 150-350 m), turbulent conditions, and mixed sediments, predominantly located in the northern and southern regions of Disko Bay. Notably, the northern region hosts a relatively diverse benthic community, with northern shrimp and sponges as the primary contributors of epibenthic biomass. This novel high-resolution model significantly enhances our understanding of the physical drivers and detailed spatial patterns influencing the distribution of northern shrimp in the Arctic.

Acoustic monitoring reveals a diel rhythm of an arctic seabird colony (little auk, Alle alle).

The child-like question of why birds sing in the morning is difficult to answer, especially in polar regions. There, in summer animals live without the time constraints of daylight, and little is known about the rhythmicity of their routines. Moreover, in situ monitoring of animal behavior in remote areas is challenging and rare. Here, we use audio data from Greenland to show that a colony of a key Arctic-breeding seabird, the little auk (Alle alle), erupts with acoustic excitement at night in August, under the midnight sun. We demonstrate that the acoustic activity cycle is consistent with previous direct observations of the feeding and attendance patterns of the little auk. We interpret this pattern as reflecting their foraging activities, but further investigation on fledging and predators is needed. The study demonstrates that acoustic monitoring is a promising alternative to otherwise demanding manual observations of bird colonies in remote Arctic areas.

The prevalence and disease course of autoimmune liver diseases in Greenland.

Autoimmune liver diseases are rare serious diseases causing chronic inflammation and fibrosis in the liver parenchyma and bile ducts. Yet, the prevalence and burden of autoimmune liver diseases are largely unexplored in Arctic native populations. We investigated the prevalence and management of autoimmune liver diseases in Greenland using nationwide cross-sectional register data and subsequent medical chart reviews validating diagnoses and extracting liver histology examinations and medical treatments. The overall prevalence of autoimmune liver diseases in Greenland was 24.6 per 100,000 (95% CI: 14.7-41.3). This was based on 7 patients with autoimmune hepatitis (AIH) (12.3 per 100,000), 3 patients with primary biliary cholangitis (PBC) (5.3 per 100,000), 4 patients with AIH/PBC overlap disease (7.0 per 100,000), and no patients with primary sclerosing cholangitis. All diagnoses were confirmed by liver histology examinations. Medical treatments adhered to internal recommendations and induced complete remission in most patients with AIH, and complete or partial remission in 1 patient with PBC and 3 patients with AIH/PBC overlap disease. One patient had established cirrhosis at the time of diagnosis, while 2 patients progressed to cirrhosis. In conclusion, the prevalence of autoimmune liver diseases was lower in Greenland than in Scandinavia and among Alaska Inuit.

Reproducibility and validity of a 45 item food-frequency questionnaire for inuit in Greenland.

Since 1993, dietary assessment has been carried out in Greenland as part of recurrent population health surveys. In preparation for the next survey in 2024, 91 participants from the survey in 2018 were selected for a validation study of the Food Frequency Questionnaire (FFQ). The 91 participants were reinterviewed 38-50 months after the first FFQ and invited to complete a food diary. As part of the 2018 survey, blood was analysed for mercury. The food diary was completed by 65 participants. The agreement between the two FFQ interviews was very good for macronutrients and fatty acids (p > 0.20), whereas the calculated intake of mercury was 22% higher in the second FFQ (p = 0.04) due to a higher intake of whale meat and muktuk (whale skin). The agreement between the second FFQ and the food diary was good for local food, imported meat and cakes/sweets/snacks but fruit and vegetables, dairy products, beverages and added sugar were significantly underreported in the food diary. Food items not included in the FFQ were identified from the food diaries. The correlation between the intake of marine mammals and blood mercury was moderate (Spearman's rho = 0.41-0.50; p < 0.0001). The results will inspire future dietary studies in the circumpolar North.

The 1919-21 influenza pandemic in Greenland.

In Alaska, the 1918-20 influenza pandemic was devastating, with mortality rates up to 90% of the population, while in other arctic regions in northern Sweden and Norway mortality was considerably lower. We investigated the timing and age-patterns in excess mortality in Greenland during the period 1918-21 and compare these to other epidemics and the 1889-92 pandemic. We accessed the Greenlandic National Archives and transcribed all deaths from 1880 to 1921 by age, geography, and cause of death. We estimated monthly excess mortality and studied the spatial-temporal patterns of the pandemics and compared them to other mortality crises in the 40-year period. The 1918-21 influenza pandemic arrived in Greenland in the summer of 1919, one year delayed due to ship traffic interruptions during the winter months. We found that 5.2% of the Greenland population died of the pandemic with substantial variability between counties (range, 0.1% to 11%). We did not see the typical pandemic age-pattern of high young-adult mortality, possibly due to high baseline mortality in this age-group or remoteness. However, despite substantial mortality, the mortality impact was not standing out relative to other mortality crises, or of similar devastation reported in Alaskan populations.

Children with otitis media in Greenland - A qualitative study of parental experiences.

INTRODUCTION: The Greenlandic population has one of the world's highest prevalence of otitis media (OM). Approximately 9-14% of all children suffer from OM during childhood. Due to the climate, lack of infrastructure, and minimal access to specialist services, the Greenlandic healthcare system operates under significant challenges. To support treatment implementation, we explored parental experiences of having a child with recurrent acute otitis media (rAOM) and chronic suppurative otitis media in Greenland (CSOM). METHODS: We applied a qualitative methodology with semi-structured interviews, to investigate parents' individual experiences. We included parents from six selected towns and settlements in Greenland, who were primary caregivers to minimum one child who had suffered from rAOM or CSOM. The interviews followed a semi-structured interview guide. RESULTS: Eight interviews were conducted with ten parents (nine mothers, one father) to 13 children (nine girls, four boys) aged two to 20 years (median age five years). We carried out a hermeneutic-phenomenological, Ricoeur-inspired text analysis of data. The first episode of OM was associated with uncertainty about the condition, including pain relief and treatment. However, recurrence led to symptom recognition and a changed disease perception among the parents: from being a simple case of childhood OM to a recognition of a chronic condition that might lead to delayed linguistic development and hearing impairment. CONCLUSION: Under difficult healthcare situations, parents represented a unique resource in care and treatment implementation. Parents often feel alone with the responsibility of care and had concerns for their child's hearing and language development, and they wished for their experiences and observations to be actively included in consultations.

Evaluation of the efficacy of a light ration adapted to cold weather during a 20-day expedition in Greenland.

INTRODUCTION: Limiting body mass loss during military expeditions/training in the cold by providing rations containing easy-to-use, highly palatable, and familiar foods is feasible, but the bulk/weight is too high to be realistically used in a military context. We carried out an analysis of lighter rations adapted to cold weather (1,011 g, 15.7 MJ/3750 kcal) during a 20-day expedition in Greenland. METHODS: Ten French soldiers daily reported all foods and beverages consumed, the reasons they did not consume certain foods, the palatability of each consumed food, the timing of intake, and the sensation of hunger using a diary. RESULTS: Although energy intake increased in the 3rd week (vs 1st week; p = 0.015), it was insufficient to prevent the loss of body mass (-4.2 ± 1.9 kg, p = 0.002). More extensive analyses showed that 1) energy intake increased only during dinner (p = 0.024) and that hunger levels continued to increase before dinner (p = 0.029), 2) palatability increased during the 3rd week (vs 1st week) especially for savory day foods (p< 0.001), and 3) lack of hunger and lack of appeal (33 % each) were the main reasons for not consuming certain items. CONCLUSION: Soldiers placed in total autonomy during a 20-day expedition in the cold and provided rations that were slightly undersized but adapted for cold conditions, surprisingly, remained picky, leading to large losses of body mass. Our results suggest a margin for improvement to stimulate spontaneous food intake. For example, more energy-dense and savory foods during the day and the replacement of certain disliked items.

The use of artificial intelligence to assess diabetic eye disease among the Greenlandic population.

Background: Retina fundus images conducted in Greenland are telemedically assessed for diabetic retinopathy by ophthalmological nurses in Denmark. Applying an AI grading solution, in a Greenlandic setting, could potentially improve the efficiency and cost-effectiveness of DR screening.Method: We developed an AI model using retina fundus photos, performed on persons registered with diabetes in Greenland and Denmark, using Optos® ultra wide-field scanning laser ophthalmoscope, graded according to ICDR.Using the ResNet50 network we compared the model's ability to distinguish between different images of ICDR severity levels in a confusion matrix.Results: Comparing images with ICDR level 0 to images of ICDR level 4 resulted in an accuracy of 0.9655, AUC of 0.9905, sensitivity and specificity of 96.6%.Comparing ICDR levels 0,1,2 with ICDR levels 3,4, we achieved a performance with an accuracy of 0.8077, an AUC of 0.8728, a sensitivity of 84.6% and a specificity of 78.8%. For the other comparisons, we achieved a modest performance.Conclusion: We developed an AI model using Greenlandic data, to automatically detect DR on Optos retina fundus images. The sensitivity and specificity were too low for our model to be applied directly in a clinical setting, thus optimising the model should be prioritised.

Quality of care among patients diagnosed with atrial fibrillation in Greenland.

This cross-sectional study sought to assess the prevalence of atrial fibrillation (AF) diagnosis in Greenland among various age groups and examine the corresponding quality of care. We collected data from Greenland's electronic medical records and evaluated the quality of care using six internationally recommended indicators, which are: percentage of AF patients with an assessment of smoking status within the previous year, an assessment of body mass index within the previous year, assessment of blood pressure within the previous year, measurement of thyroid stimulating hormone (TSH), treatment with an anticoagulant and percentage of patients with a measurement of serum-creatinine. We found the prevalence of AF among patients aged 20 years or older in Greenland to be 1.75% (95% CI 1.62-1.88). We found an increasing prevalence of AF with age and a greater proportion of men than women until the age of 74 years. Our study suggests that the associated quality of care could be higher as the requirement of only one of the six quality indicators was met. A lack of registration may partly explain this, and initiatives to improve the quality of care are recommended.

A Field Study of Carbon Monoxide Levels in Snow Caves During Short-Term Stove Use.

INTRODUCTION: While the use of camping stoves in poorly ventilated areas is discouraged, the need to address dehydration challenges in harsh arctic conditions has led to their unconventional use inside snow caves for snow melting, subjecting occupants to unknown carbon monoxide (CO) levels. This study, located at sea level in northeastern Greenland, aimed to assess CO levels and dynamics during short cooking sessions in newly constructed emergency snow caves. METHODS: In 5 snow caves, constructed according to the same design principles by 4 different individuals, a single MSR Whisperlite multifuel burner, primed with ethanol and burning white gas, was used to melt snow. CO concentrations were monitored every minute until all the snow in a 5-L pot was converted to water and CO levels returned to below 10 ppm. RESULTS: A total of 16 experiments conducted showed that the priming phase generated the highest CO peaks, with a maximum of 120 ppm. Time-weighted averages ranged from 14 ppm to 67 ppm, with trial durations of 15 to 21 min. A single trial with a dirty burner resulted in up to a 10-fold increase in CO levels. CONCLUSIONS: While single, short cooking sessions of less than 10 min burn time in newly constructed snow caves may be tolerated under specific conditions, the study highlighted substantial variation between caves and the importance of using clean burners, emphasizing the need for further research to gain a comprehensive understanding of CO exposure dynamics in snow caves.

Variation in Muskox (Ovibos moschatus) Guard Hair Growth Rates: Implications for Measuring Chronological Biomarkers.

Segmental analyses of hair may be useful for measuring biomarkers over several seasons to years from a single sample. To attribute hair segments to specific time periods, a known chronological marker, or a hair growth rate, is needed. We examined guard hair growth rates of captive muskoxen (Ovibos moschatus) in Fairbanks, Alaska, USA. We sought to determine if a general growth rate could be applied across muskox populations, thus facilitating the use of segmental analyses for various biomarkers. We used archived samples from 16 muskoxen that had guard hairs sampled at six, 14, and 30 wk after shaving. We measured the lengths of 10 guard hairs per sample, calculated weekly and annual growth rates, and then fitted linear mixed-effects models to assess the effect of different covariates on hair growth rate. The period in which hair had been grown had a significant effect (P<0.05) on growth rate. Extrapolated annual hair growth rates were 277±40 mm/yr (weeks 0-6), 248±47 mm/yr (weeks 7-14), and 165±36 mm/yr (weeks 15-30), with an overall average rate of 210±14 mm/yr. These rates were significantly faster than those of free-ranging Greenland muskoxen-78 mm/yr as measured by stable isotope analyses-and varied intra-annually. This suggests that a universal growth rate cannot be generalized across muskox populations and time.

Hospital-based antimicrobial stewardship in Denmark, Greenland and the Faroe Islands - current landscape and barriers.

OBJECTIVES: To describe the current organization and implementation of formalized, multi-disciplinary hospital-based antimicrobial stewardship (AMS) structures in Denmark, the Faroe Islands and Greenland. METHODS: A structured electronic questionnaire was sent to all trainees and specialists in clinical microbiology (N=207) and infectious diseases (N=260), as well as clinical pharmacists (N=20) and paediatricians (N=10) with expertise in infectious diseases. The survey had 30 multiple-choice, rating-scale, and open-ended questions based on an international consensus checklist for hospital AMS, adapted to a Danish context. RESULTS: Overall, 145 individual responses representing 20 hospitals were received. Nine hospitals (45%) reported a formal AMS strategy, eight (40%) a formal organizational multi-disciplinary structure and a multi-disciplinary AMS team, and six (30%) a designated professional as a leader of the AMS team. A majority of hospitals reported access to updated guidelines (80%) and regularly monitored and reported the quantity of antibiotics prescribed (70% and 65%, respectively). Only one hospital (5%) reported a dedicated, sustainable and sufficient AMS budget, three hospitals (15%) audited courses of therapy for specific agents/clinical conditions and four hospitals (20%) had a document clearly defining roles, procedures of collaboration and responsibilities for AMS. A total of 42% of all individual respondents had received formal AMS training. Main barriers were a lack of financial resources (52%), a lack of mandate from the hospital management (30%) and AMS not being a priority (18%). CONCLUSIONS: Core elements important for multi-disciplinary hospital-based AMS can be strengthened in Danish hospitals. Funding, clear mandates, prioritization from the hospital management and the implementation of multi-disciplinary AMS structures may help close the identified gaps.