The Impact of Health Equity-Informed Eligibility Criteria to Increase the Delivery of Pharmacist-Delivered Comprehensive Medication Management Services for Patients with High Blood Pressure.

OBJECTIVE: Evaluate a cardiovascular care intervention intended to increase access to comprehensive medication management (CMM) pharmacy care and improve vascular health goals among socially disadvantaged patients. DESIGN: Retrospective electronic health records-based evaluation. SETTING: Thirteen health care clinics serving socially vulnerable neighborhoods within a large health system. PARTICIPANTS: Hypertensive and hyperlipidemic adult patients. INTERVENTION: CMM pharmacists increased recruitment among patients who met clinical criteria in clinics serving more diverse and socially vulnerable communities. CMM pharmacists partnered with patients to work toward meeting health goals through medication management and lifestyle modification. MAIN OUTCOME MEASURES: Changes in the engagement of socially disadvantaged patients between preintervention and intervention time periods; vascular health goals (ie, controlled blood pressure, appropriate statin and aspirin therapies, and tobacco nonuse); and the use of health system resources by CMM care group. RESULTS: The intervention indicated an overall shift in sociodemographics among patients receiving CMM care (fewer non-Hispanic Whites: N = 1988, 55.81% vs N = 2264, 59.97%, P < .001; greater place-based social vulnerability: N = 1354, 38.01% vs N = 1309, 34.68%, P = .03; more patients requiring interpreters: N = 776, 21.79% vs N = 698, 18.49%, P < .001) compared to the preintervention period. Among patients meeting intervention criteria, those who partnered with CMM pharmacists (N = 439) were more likely to connect with system resources (social work: N = 47, 10.71% vs 163, 3.74%, P < .001; medical specialists: N = 249, 56.72% vs N = 1989, 45.66%; P < .001) compared to those without CMM care (N = 4356). Intervention patients who partnered with CMM pharmacists were also more likely to meet blood pressure (N = 357, 81.32% vs N = 3317, 76.15%, P < .001) and statin goals (N = 397, 90.43% vs N = 3509, 80.56%, P < .001) compared to non-CMM patients. CONCLUSIONS: The demographics of patients receiving CMM became more diverse with the intervention, indicating improved access to CMM pharmacists. Cultivating relationships among patients with greater social disadvantage and cardiovascular disease and CMM pharmacists may improve health outcomes and connect patients to essential resources, thus potentially improving long-term cardiovascular outcomes.

Mechanisms of impact of alcohol availability interventions from the perspective of 63 diverse alcohol licensing stakeholders: a qualitative interview study.

Aims: Interventions restricting temporal and spatial availability of alcohol are associated with reduced harm, but the pathways by which specific interventions have impact are poorly understood. We examined mechanisms of impact from the perspective of diverse licensing stakeholders. Methods: Fifty-three in-depth interviews were conducted with licensing stakeholders (from public health teams [PHTs], police, local authority licensing teams and lawyers, and alcohol premises licensing committees) from 20 local government areas. Interviewees were recruited as part of the Exploring the impact of alcohol licensing in England and Scotland (ExILEnS) study. Data were analyzed thematically and preliminary themes/subthemes were discussed during online groups with a different sample of public health and licensing professionals (n = 10). Findings: Most interviewees struggled to articulate how availability interventions might lead to changes in alcohol consumption or harms. Five overarching mechanisms were identified: access, visibility, premises and area-level norms, affordability, and management of the night-time economy, with specific pathways identified for certain subgroups/premises types. The mechanisms by which alcohol availability interventions may impact on alcohol consumption and harms are diverse, but were poorly understood. Conclusions: These findings will inform licensing and availability policy and advocacy, highlighting the need for further scrutiny of the evidence underpinning identified mechanisms, and primary research to address knowledge gaps.

A scoping review of academic and grey literature on migrant health research conducted in Scotland.

BACKGROUND: Migration to Scotland has increased since 2002 with an increase in European residents and participation in the Asylum dispersal scheme. Scotland has become more ethnically diverse, and 10% of the current population were born abroad. Migration and ethnicity are determinants of health, and information on the health status of migrants to Scotland and their access to and barriers to care facilitates the planning and delivery of equitable health services. This study aimed to scope existing peer-reviewed research and grey literature to identify gaps in evidence regarding the health of migrants in Scotland. METHODS: A scoping review on the health of migrants in Scotland was carried out for dates January 2002 to March 2023, inclusive of peer-reviewed journals and grey literature. CINAHL/ Web of Science/SocIndex and Medline databases were systematically searched along with government and third-sector websites. The searches identified 2166 journal articles and 170 grey literature documents for screening. Included articles were categorised according to the World Health Organisation's 2016 Strategy and Action Plan for Refugee and Migrant Health in the European region. This approach builds on a previously published literature review on Migrant Health in the Republic of Ireland. RESULTS: Seventy-one peer reviewed journal articles and 29 grey literature documents were included in the review. 66% were carried out from 2013 onwards and the majority focused on asylum seekers or unspecified migrant groups. Most research identified was on the World Health Organisation's strategic areas of right to health of refugees, social determinants of health and public health planning and strengthening health systems. There were fewer studies on the strategic areas of frameworks for collaborative action, preventing communicable disease, preventing non-communicable disease, health screening and assessment and improving health information and communication. CONCLUSION: While research on migrant health in Scotland has increased in recent years significant gaps remain. Future priorities should include studies of undocumented migrants, migrant workers, and additional research is required on the issue of improving health information and communication.

'Give us the real tools to do our jobs': views of UK stakeholders on the role of a public health objective for alcohol licensing.

OBJECTIVES: This study ascertains the views of UK stakeholders on the actual, and possible, impact of a public health licensing objective in their day-to-day work. STUDY DESIGN AND METHODS: Twenty-eight interviews were conducted with members of public health teams who were actively engaged in alcohol licensing in their local area between 2017 and 2019. Six teams were based in Scotland (where there is a public health licensing objective) and 14 in England (where there is no similar objective). RESULTS: Scottish participants reported that while challenges remained in applying the public health licensing objective, progress had been made and the objective was beneficial to their work. Participants in England felt that an objective would increase the legitimacy, value and impact of their contributions. In both Scotland and England, constructive relationships between PHTs, licensing authorities and other key stakeholders were developing suggesting that PHTs could have a sustainable and positive role in licensing. CONCLUSIONS: In many Scottish areas, the alcohol licensing system is evolving to take constructive account of its public health objective. In England, PHTs that have invested resources in engaging in this area have demonstrated an ability to work effectively within licensing systems. Strong support for the adoption of a public health licensing objective among these PHTs adds weights to calls for the UK Government to reconsider its previous decision not to introduce such an objective.

Dental public health in action: The covid-19 restrictions on dentistry in England and their impact on access to dental care for high-risk patient groups in the North-East and North Cumbria.

The Covid-19 pandemic has significantly impacted dental practices with the initial response being a complete suspension of face to face care unless designated as an urgent care centre. Even with subsequent easing of restrictions, a significant change to the delivery of dental care is continuing to restrict patient access. The introduction of new Standard Operating Procedures, with a benchmark fallow time of 15 to 30 minutes after aerosol generating procedures, has also reduced capacity levels within dental practices. Triaging systems have been implemented within practices to ensure those with the highest oral health care needs are prioritised for face to face care. Altered patient attendance, due to the Covid-19 restrictions placed upon dental care, may also be compounded by patients avoiding dental care due to personal perceptions of risks associated with Covid-19 or due to a desire not to overburden health systems. With the additional Covid-19 restrictions in place the access to dental care for vulnerable populations may have been even further impacted, there is therefore a concern that the restrictions may have exacerbated inequalities in oral health for these groups. Public health competencies illustrated: Developing and monitoring the quality of dental services, Dental Public Health Intelligence, and Policy and Strategy Development are illustrated within this project.

'They only smoke in the house when I'm not in': understanding the limited effectiveness of a smoke-free homes intervention.

BACKGROUND: Children's second-hand smoke (SHS) exposure in the home is highest in socio-economically disadvantaged areas. Personalized household air-quality measurements can promote changes in smoking that reduce SHS exposure. The 'First Steps 2 Smoke-free' (FS2SF) intervention is the first to trial this approach delivered as part of health professionals' routine work. This paper reports the findings of qualitative interviews with participants that explored their experiences of the intervention and why outcomes varied. METHODS: 120 women were recruited from the NHS First Steps Programme, which supports disadvantaged mothers. They received either personalized feedback on their home air quality and advice on reducing SHS or standard SHS advice. Qualitative interviews with 15 mothers were analyzed thematically using the Capability, Opportunity, Motivation, Behaviour (COM-B) model. RESULTS: The intervention increased women's capability to change home-smoking behaviour, through increasing awareness and salience of SHS risks to their children, and motivation to act. However, taking effective action was constrained by their limited social and environmental opportunities, including others' smoking in the home. CONCLUSIONS: The FS2SF intervention was ineffective as it was unable to fully address the precarious, complex life circumstances that make creating a smoke-free home particularly difficult for women experiencing intersecting dimensions of disadvantage.

Patient safety ward round checklist via an electronic app: implications for harm prevention.

INTRODUCTION: Patient safety is a value at the core of modern healthcare. Though awareness in the medical community is growing, implementing systematic approaches similar to those used in other high reliability industries is proving difficult. The aim of this research was twofold, to establish a baseline for patient safety practices on routine ward rounds and to test the feasibility of implementing an electronic patient safety checklist application. METHODS: Two research teams were formed; one auditing a medical team to establish a procedural baseline of "usual care" practice and an intervention team concurrently was enforcing the implementation of the checklist. The checklist was comprised of eight standard clinical practice items. The program was conducted over a 2-week period and 1 month later, a retrospective analysis of patient charts was conducted using a global trigger tool to determine variance between the experimental groups. Finally, feedback from the physician participants was considered. RESULTS: The results demonstrated a statistically significant difference on five variables of a total of 16. The auditing team observed low adherence to patient identification (0.0%), hand decontamination (5.5%), and presence of nurse on ward rounds (6.8%). Physician feedback was generally positive. CONCLUSIONS: The baseline audit demonstrated significant practice bias on daily ward rounds which tended to omit several key-proven patient safety practices such as prompting hand decontamination and obtaining up to date reports from nursing staff. Results of the intervention arm demonstrate the feasibility of using the Checklist App on daily ward rounds.

Measuring the Effect of Carers on Patients' Risk of Adverse Healthcare Outcomes Using the Caregiver Network Score.

BACKGROUND: Although caregivers are important in the management of frail, community-dwelling older adults, the influence of different caregiver network types on the risk of adverse healthcare outcomes is unknown. OBJECTIVE: To examine the association between caregiver type and the caregiver network subtest of The Risk Instrument for Screening in the Community (RISC), a five point Likert scale scored from one ("can manage") to five ("absent/liability"). To measure the association between caregiver network scores and the one-year incidence of institutionalisation, hospitalisation and death. DESIGN: Observational cohort study. SETTING AND PARTICIPANTS: Community-dwelling adults, aged >65, attending health centres in Ireland, (n=779). PROCEDURE AND MEASUREMENTS: The caregiver network subtest of the RISC was scored by public health nurses. Caregivers were grouped dichotomously into low-risk (score of one) or high-risk (scores two-five). RESULTS: The majority of patients had a primary caregiver (582/779; 75%), most often their child (200/582; 34%). Caregiver network scores were highest, indicating greatest risk, when patients had no recognised primary caregiver and lowest when only a spouse or child was available. Despite this, patients with a caregiver were significantly more likely to be institutionalised than those where none was required or identified (11.5% versus 6.5%, p=0.047). The highest one-year incidence of adverse outcomes occurred when state provided care was the sole support; the lowest when private care was the sole support. Significantly more patients whose caregiver networks were scored high-risk required institutionalisation than low-risk networks; this association was strongest for perceived difficulty managing medical domain issues, odds ratio (OR) 3.87:(2.22-6.76). Only perceived difficulty managing ADL was significantly associated with death, OR 1.72:(1.06-2.79). There was no association between caregiver network scores and risk of hospitalisation. CONCLUSION: This study operationalizes a simple method to evaluate caregiver networks. Networks consisting of close family (spouse/children) and those reflecting greater socioeconomic privilege (private supports) were associated with lower incidence of adverse outcomes. Caregiver network scores better predicted institutionalisation than hospitalisation or death.

Assessing the function of homologous recombination DNA repair in malignant pleural effusion (MPE) samples.

BACKGROUND: Patients with malignant pleural effusions (MPEs) generally have advanced disease with poor survival and few therapeutic options. Cells within MPEs may be used to stratify patients for targeted therapy. Targeted therapy with poly(ADP ribose) polymerase inhibitors (PARPi) depends on identifying homologous recombination DNA repair (HRR)-defective cancer cells. We aimed to determine the feasibility of assaying HRR status in MPE cells. METHODS: A total of 15 MPE samples were collected from consenting patients with non-small-cell lung cancer (NSCLC), mesothelioma and ovarian and breast cancer. Primary cultures were confirmed as epithelial by pancytokeratin, and HRR status was determined by the detection of γH2AX and RAD51 foci following a 24-h exposure to rucaparib, by immunofluorescence microscopy. Massively parallel next-generation sequencing of DNA repair genes was performed on cultured MPE cells. RESULTS: From 15 MPE samples, 13 cultures were successfully established, with HRR function successfully determined in 12 cultures. Four samples - three NSCLC and one mesothelioma - were HRR defective and eight samples - one NSCLC, one mesothelioma, one sarcomatoid, one breast and four ovarian cancers - were HRR functional. No mutations in DNA repair genes were associated with HRR status, but there was probable loss of heterozygosity of FANCG, RPA1 and PARP1. CONCLUSIONS: HRR function can be successfully detected in MPE cells demonstrating the potential to stratify patients for targeted therapy with PARPi.

Gastric-type adenocarcinoma of the cervix in a patient with Lynch syndrome: A case report.

•Lynch syndrome (LS) is an uncommon, genetic disorder which predisposes affected individuals to colorectal, endometrial and ovarian malignancies.•We report a case of cervical gastric-type adenocarcinoma in a patient with LS.•Immunohistochemistry for mismatch repair proteins is a useful screening tool in tumours suspected to be associated with LS.

Physiological sex steroid replacement in premature ovarian failure: randomized crossover trial of effect on uterine volume, endometrial thickness and blood flow, compared with a standard regimen.

BACKGROUND: Premature ovarian failure (POF) is currently managed by non-physiological sex steroid regimens which are inadequate at optimizing uterine characteristics. Previous short-term studies have demonstrated some benefits of a sex steroid replacement (SSR) regimen devised to replicate the physiological cycle. This study aimed to directly compare the effects of longer-term administration of physiological SSR (pSSR) and standard SSR (sSSR) regimens on the uterine volume, blood flow and endometrial thickness (ET) in women with POF. METHODS: In a controlled crossover trial, 34 women with POF were randomized to receive 12 months of 4-week cycles of transdermal estradiol and vaginal progesterone (pSSR) followed by 12 months of 4-week cycles of oral ethinylestradiol and norethisterone (sSSR), or vice versa. Each treatment period was preceded by a 2-month washout period. At 0, 3, 6 and 12 months of each treatment period, transvaginal ultrasound examined the uterine volume and ET, as primary end-points, and uterine artery resistance (UARI) and pulsatility indices (UAPI), as secondary end-points. Serum estradiol, progesterone and gonadotrophins were also measured. RESULTS: Of the 29 women eligible for the uterine analysis, 17 completed the entire study protocol, but 25 women contributed data to statistical analysis of treatment effect. There was a greater estimated mean ET with the use of pSSR (4.8 mm) compared to that with standard therapy (3.0 mm), with an estimated difference of 1.8 mm [95% confidence interval (CI), 0.7 to 2.8, P=0.002]. The estimated mean uterine volume was also greater during physiological treatment (24.8 cm(3)) than during standard treatment (20.6 cm(3)), but the estimated difference of 4.2 cm(3) (95% CI -0.4 to 8.7) was not statitsically significant, P=0.070. The small differences between the two treatments in the mean UARI and mean UAPI were not statistically significant. The estimated treatment differences were fairly constant across the treatment periods, suggesting that prolonged treatment does not increase response. CONCLUSIONS: pSSR has a greater beneficial effect upon ET in women with POF in comparison with standard therapy. A similar trend was seen for uterine volume. Further studies are required to optimize treatment and to assess pregnancy rate and outcome. Trial Registration www.ClinicalTrials.gov, NCR00732693.

A panel of antibodies for identifying squamous metaplasia in endobronchial biopsies from smokers.

Toxic injury can induce squamous metaplasia of respiratory epithelium, which normally is pseudostratified. Terminally differentiated squamous epithelial cells have a flattened, elongated appearance. During differentiation, they have an intermediate phenotype that is difficult to identify and distinguish from tangentially cut columnar cells in tissue sections from endobronchial biopsies, whose small size makes orientation difficult. The aim of our study was to develop a panel of antibodies that could be employed to distinguish normal epithelium from metaplastic epithelium and would be suitable for use on endobronchial biopsies. Nasal polyp tissue and tonsil tissue, which have pseudostratified and squamous epithelia, respectively, were collected from surgical cases and embedded in glycol methacrylate resin. Cut sections were stained immunohistochemically with a panel of antibodies to cytokeratins (CK), whose expression varies with epithelial type and stage of differentiation, and involucrin, a marker of terminal squamous differentiation. Squamous epithelium stained positively for CK5/6, CK13 and involucrin. In the pseudostratified epithelium, basal cells exhibited weak staining for CK13 and strong staining for CK5/6, and columnar cells exhibited strong immunoreactivity for CK7, CK8 and CK18. Application of this panel to endobronchial biopsies from smokers enabled areas of squamous metaplasia to be distinguished from tangentially sectioned epithelium.

Compressive osseointegration promotes viable bone at the endoprosthetic interface: retrieval study of Compress implants.

The Compress implant (Biomet, Warsaw, IN) is an innovative device developed to enable massive endoprosthetic fixation through the application of compressive forces at the bone-implant interface. This design provides immediate, stable anchorage and helps to avoid the long-term complication of aseptic loosening secondary to stress shielding and particle-induced osteolysis seen in conventional, stemmed megaprostheses. The purpose of our study was to evaluate the in vivo biological effects of the high compressive forces attained. Twelve consecutive Compress patients undergoing revision surgery for infection, periprosthetic fracture, or local tumour recurrence were reviewed in order to exclude the possibility of osteonecrosis at the prosthetic interface. Compressive forces ranged from 400-800 lb. Duration of implantation averaged 3.3 years (range 0.4-12.2 years). Two patients with infection demonstrated loosening at the bone-prosthetic interface; otherwise, there was no radiographic evidence of prosthetic failure in any of the patients. No patient demonstrated histological evidence of osteonecrosis. In fact, new woven bone and other findings consistent with viable bone were noted in all of the retrieved specimens.

An international parentage and identification panel for the domestic cat (Felis catus).

Seventeen commercial and research laboratories participated in two comparison tests under the auspices of the International Society for Animal Genetics to develop an internationally tested, microsatellite-based parentage and identification panel for the domestic cat (Felis catus). Genetic marker selection was based on the polymorphism information content and allele ranges from seven random-bred populations (n = 261) from the USA, Europe and Brazil and eight breeds (n = 200) from the USA. Nineteen microsatellite markers were included in the comparison test and genotyped across the samples. Based on robustness and efficiency, nine autosomal microsatellite markers were ultimately selected as a single multiplex 'core' panel for cat identification and parentage testing. Most markers contained dinucleotide repeats. In addition to the autosomal markers, the panel included two gender-specific markers, amelogenin and zinc-finger XY, which produced genotypes for both the X and Y chromosomes. This international cat parentage and identification panel has a power of exclusion comparable to panels used in other species, ranging from 90.08% to 99.79% across breeds and 99.47% to 99.87% in random-bred cat populations.

Effect of chemotherapy on initial compressive osseointegration of tumor endoprostheses.

Chemotherapy has long been suspected of having an adverse effect on bone healing. Massive tumor endoprostheses which achieve osseointegration via compressive force provide a unique model to study the effects of chemotherapy on bone healing. We compared distal femoral bone hypertrophy in patients who received chemotherapy with those who did not. Fifty four patients underwent distal femoral reconstruction with a compression implant. Thirty patients received chemotherapy (Group 1), and 24 did not (Group 2). The group of patients receiving chemotherapy was younger, had lower body mass indices, and had different diagnoses compared to the group of patients not receiving chemotherapy. We used a standardized technique to measure bone growth at the bone-prosthetic interface. The rate of cortical width increase at the bone-prosthetic junction was faster in Group 2 compared to Group 1. Similarly, the increase in cortical width from immediate postop to 3 months and 6 months postop was greater in Group 2 when compared to Group 1. The data suggest chemotherapy administration for musculoskeletal malignancy has a substantial initial adverse effect on bone hypertrophy and a trend towards reduced prosthetic survival. These findings have important implications for the patients with musculoskeletal tumors.

Early distal femoral endoprosthetic survival: cemented stems versus the Compress implant.

Aseptic loosening is well known following endoprosthetic replacement (EPR) using cemented intramedullary stems (CISs). The Compress (CPS) implant uses a novel spring system, achieving immediate, high compression fixation that induces bone hypertrophy and avoids stress shielding. We compared 26 oncologic distal femoral CPS patients treated at the University of California, San Francisco (UCSF, USA) with 26 matched CIS patients from the Royal Orthopaedic Hospital, Birmingham (ROH, UK). The predominant diagnosis was osteosarcoma. Each centre had only one device-related prosthetic failure. In the short term these results show CPS to be safe and effective. We await longer follow-up to assess the ongoing potential for prosthetic failure.

Epidemiology, prescribing patterns and resource use associated with overactive bladder in UK primary care.

This study aimed to estimate the incidence and prevalence of overactive bladder (OAB) symptoms in the UK and analyse the use of anticholinergic/antispasmodic medications and other healthcare resources within UK general practice. Patients with a record of urinary frequency, urgency, nocturia, urge incontinence or irritable/unstable bladder between 1987 and 2004 were identified from the General Practice Research Database. Demographic characteristics, referrals, consultations, investigations and prescriptions for medications licensed for use in OAB were identified. Regression analyses were used to identify the factors determining switches between medications, referrals and use of healthcare resources. The overall prevalence of OAB-related symptoms was 3.87 per 1000 persons, with an incidence of 2.79 per 1000 person-years. Among 68,910 patients with OAB symptoms, 19,444 (28.2%) received anticholinergic medication, of whom 14,454 (74.3%) received one drug and 4055 (20.9%) received two medications sequentially. Overall, 59.1% of patients were referred to relevant secondary care specialities, 2.8% underwent urinary tests/investigations in primary care and 0.2% were seen by a continence nurse. Resource use was higher among patients who tried several different medications. In conclusion, this study suggests that OAB may be under-diagnosed in the UK and that current guidelines recommending use of anticholinergic medication, continence nurse consultations and urinary tests/investigations are inadequately followed.