Engaging Communities in Emerging Infectious Disease Mitigation to Improve Public Health and Safety.

The COVID-19 pandemic highlighted the need for potent community-based tools to improve preparedness. We developed a community health-safety climate (HSC) measure to assess readiness to adopt health behaviors during a pandemic. We conducted a mixed-methods study incorporating qualitative methods (e.g., focus groups) to generate items for the measure and quantitative data from a February 2021 national survey to test reliability, multilevel construct, and predictive and nomologic validities. The 20-item HSC measure is unidimensional (Cronbach α = 0.87). All communities had strong health-safety climates but with significant differences between communities (F = 10.65; p<0.001), and HSC levels predicted readiness to adopt health-safety behaviors. HSC strength moderated relationships between HSC level and behavioral indicators; higher climate homogeneity demonstrated stronger correlations. The HSC measure can predict community readiness to adopt health-safety behaviors in communities to inform interventions before diseases spread, providing a valuable tool for public health authorities and policymakers during a pandemic.

Real-world outcomes of a dedicated fast-track polymyalgia rheumatica clinic.

OBJECTIVES: To examine the clinical impact of a fast-track PMR clinic to enable early diagnosis and treatment, and to define both patient and disease characteristics in newly diagnosed PMR. METHODS: Primary care physicians were invited to refer patients with new PMR to our fast-track clinic. Referral criteria included new onset shoulder or pelvic girdle pain and/or stiffness with elevated inflammatory markers in patients over 50 years. All patients were seen within 72 h of referral. Patients with a rheumatology diagnosis of PMR had an ultrasound (US) of their temporal and axillary arteries. RESULTS: 172 patients were referred from primary care over 12 months. 39% of patients referred with suspected PMR had an alternative diagnosis for which PMR regimen glucocorticoids was inappropriate. 55% of the non-PMR diagnoses were other inflammatory rheumatological conditions requiring follow-up. Only 20% of patients referred from primary care already on glucocorticoids were commenced on bone protection. PMR patients were co-morbid with a mean of 2.5 other conditions. 75% of PMR patients experienced a glucocorticoid-related adverse event in the first 12 months of treatment. 16% of patients with new PMR had ultrasound features of subclinical giant cell arteritis. CONCLUSION: The commencement of glucocorticoid therapy should be deferred until after specialist evaluation to enable an accurate clinical diagnosis. A delay in treatment can only realistically be avoided if GPs have access to a Fast-track PMR clinic. We believe that rheumatologists should consider establishing fast-track PMR clinics and this study provides a strong case for and a template to support this practice innovation.

Trends in statin use for the primary prevention of atherosclerotic cardiovascular disease among US adults by demographic characteristics, 1999-2020.

PURPOSE: Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of mortality worldwide. Statins, which are effective in preventing ASCVD, are underused, particularly for primary prevention. This study examined trends in statin use for primary ASCVD prevention from 1999 to 2020, focusing on demographic variations. METHODS: Utilizing data from the National Health and Nutrition Examination Survey, the present study includes individuals aged 18 years and older who had a greater than 10% risk of ASCVD over 10 years, and excluded patients with existing ASCVD. Subgroup analyses by demographic categories were performed. We calculated the changes in statin usage and used linear and quadratic tests to assess the linear and nonlinear trends in those changes. RESULTS: A total of 10,037 participants were included. Statin usage increased from 16.16% in 1999 to 36.24% in 2010, and 41.74% in 2020 (quadratic P-value < 0.001). In the 18-44 years age group, statin usage increased from 2.52% in 1999 to 8.14% in 2020 (linear P-value = 0.322), showing no significant linear trend. In the "never-married" group, statin usage increased from 19.16% in 1999 to 30.05% in 2020 (linear P-value = 0.256). CONCLUSION: Statin usage has shown a positive trend among populations requiring primary prevention for ASCVD. Currently, health policies are proving effective. However, the overall statin usage rate remains less than 50%. Additionally, young and never-married individuals should also receive special attention regarding statin usage as primary treatment for ASCVD.

Monitoring sodium content in processed and ultraprocessed foods in Argentina 2022: compliance with National Legislation and Regional Targets.

OBJECTIVE: To assess the current Na levels in a variety of processed food groups and categories available in the Argentinean market to monitor compliance with the National Law and to compare the current Na content levels with the updated Pan American Health Organisation (PAHO) regional targets. DESIGN: Observational cross-sectional study. SETTING AND PARTICIPANTS: Argentina. Data were collected during March 2022 in the city of Buenos Aires in two of the main supermarket chains. We carried out a systematic survey of pre-packaged food products available in the food supply assessing Na content as reported in nutrition information panels. RESULTS: We surveyed 3997 food products, and the Na content of 760 and 2511 of them was compared with the maximum levels according to the Argentinean law and the regional targets, respectively. All food categories presented high variability of Na content. More than 90 % of the products included in the National Sodium Reduction Law were found to be compliant. Food groups with high median Na, such as meat and fish condiments, leavening flour and appetisers are not included in the National Law. In turn, comparisons with PAHO regional targets indicated that more than 50 % of the products were found to exceed the regional targets for Na. CONCLUSIONS: This evidence suggests that it is imperative to update the National Sodium Reduction Law based on regional public health standards, adding new food groups and setting more stringent legal targets.

Prioritization of maternal and newborn health policies and their implementation in the eastern conflict affected areas of the Democratic Republic of Congo: a political economy analysis.

BACKGROUND: Maternal and neonatal mortality remains a major concern in the Democratic Republic of Congo (DRC), and the country's protracted crisis context exacerbates the problem. This political economy analysis examines the maternal and newborn health (MNH) prioritization in the DRC, focussing specifically on the conflict-affected regions of North and South Kivu. The aim is to understand the factors that facilitate or hinder the prioritization of MNH policy development and implementation by the Congolese government and other key actors at national level and in the provinces of North and South Kivu. METHODS: Using a health policy triangle framework, data collection consisted of in-depth interviews with key actors at different levels of the health system, combined with a desk review. Qualitative data were analysed using inductive and then deductive approaches, exploring the content, process, actor dynamics, contextual factors and gender-related factors influencing MNH policy development and implementation. RESULTS: The study highlighted the challenges of prioritizing policies in the face of competing health and security emergencies, limited resources and governance issues. The universal health coverage policy seems to offer hope for improving access to MNH services. Results also revealed the importance of international partnerships and global financial mechanisms in the development of MNH strategies. They reveal huge gender disparities in the MNH sector at all levels, and the need to consider cultural factors that can positively or negatively impact the success of MNH policies in crisis zones. CONCLUSIONS: MNH is a high priority in DRC, yet implementation faces hurdles due to financial constraints, political influences, conflicts and gender disparities. Addressing these challenges requires tailored community-based strategies, political engagement, support for health personnel and empowerment of women in crisis areas for better MNH outcomes.

[Using diagnosis-related groups in Chile: lessons and challengesLições e desafios do uso de grupos de diagnósticos relacionados no Chile]. / Lecciones y desafíos del uso de los grupos relacionados por el diagnóstico en Chile.

Objective: Analyze the implementation of diagnosis-related groups (DRGs) in Chile with a view to optimizing the distribution of public resources. Methods: A chronological narrative analysis of the main milestones was complemented by simulated application of DRGs through emulated competition and cluster analysis for evaluative purposes. Results: In 2001, DRGs were introduced in Chile in an academic context. The National Health Fund (FONASA) began using DRGs in the private sector. A public sector pilot was launched in 2015. After nearly two decades of progress, in 2020 FONASA established the DRG program as a payment mechanism for public hospitals. However, the COVID-19 pandemic slowed its development. In 2022, implementation was resumed. After evaluating the program, it was evident that the hospital clusters that had been predefined for differentiated payment did not successfully differentiate homogeneous groups. In 2023, the program was reformed, financing was increased, a single cluster and base rate were defined, and greater hospital complexity was recognized, compared to previous years. Three hospitals were added to the program, for a total of 68. Conclusions: This experience shows that it is possible to sustain a public health financing policy that achieves greater efficiency and equity in the health system, based on the existence of robust institutions that continuously develop and improve.

Objetivo: Analisar a implementação de grupos de diagnósticos relacionados (DRG, na sigla em inglês) no Chile, com o objetivo de otimizar a distribuição de recursos públicos. Método: Foi utilizada uma análise narrativa cronológica dos principais marcos, complementada por simulações da implementação de DRG usando concorrência simulada (yardstick competition) e análise de agrupamento para fins de avaliação. Resultados: O modelo de DRG foi introduzido no Chile em 2001, em um contexto acadêmico. Em 2015, o Fundo Nacional de Saúde (FONASA) começou a utilizá-lo no setor privado e, com um projeto-piloto, no setor público. Após quase duas décadas de progresso, em 2020, o programa de DRG foi implementado como mecanismo de pagamento do FONASA para os hospitais públicos. No entanto, a pandemia de COVID-19 interrompeu seu desenvolvimento. Em 2022, a aplicação foi retomada e, após uma avaliação do programa, ficou claro que os grupos hospitalares predefinidos para o pagamento diferenciado por DRG não formavam grupos homogêneos. Em 2023, o programa foi reformulado, com aumento dos recursos financeiros e a definição de um único agrupamento e de uma taxa básica, reconhecendo-se uma maior complexidade hospitalar do que nos anos anteriores. Além disso, três hospitais foram adicionados ao programa, elevando o total para 68. Conclusões: A experiência mostra que é possível dar continuidade a uma política pública de financiamento da saúde para alcançar maior eficiência e equidade no sistema de saúde com base na existência de instituições sólidas que persistam em seu desenvolvimento e contínuo aprimoramento.

Implementation of an Enhanced Recovery After Surgery Protocol for Cranial Vault Remodeling Procedures.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been implemented across surgical disciplines, including cranial vault remodeling for craniosynostosis. The authors aim to describe the implementation of an ERAS protocol for cranial vault remodeling procedures performed for patients with craniosynostosis at a tertiary care hospital. DESCRIPTION: Institutional review board approval was received. All patients undergoing a cranial remodeling procedure for craniosynostosis at the authors' institution over a 10-year period were collected (n = 168). Patient and craniosynostosis demographics were collected as well as operative details. Primary outcome measures were intensive care unit length of stay (ICU LOS) and narcotic usage. Chi squared and independent t-tests were employed to determine significance. A significance value of 0.05 was utilized. RESULTS: During the time examined, there were 168 primary cranial vault remodeling procedures performed at the authors' institution - all of which were included in the analysis. Use of the ERAS protocol was associated with decreased initial 24-hour morphine equivalent usage (p < 0.01) and decreased total morphine equivalent usage (p < 0.01). Patients using the ERAS protocol experienced a shorter ICU LOS (p < 0.01), but the total hospital length of stay was unchanged. CONCLUSION: This study reiterates the benefit of developing and implementing an ERAS protocol for patients undergoing cranial vault remodeling procedures. The protocol resulted in an overall decreased ICU LOS and a decrease in narcotic use. This has implications for ways to maximize hospital reimbursement for these procedures, as well as potentially improve outcomes.

Impact of COVID-19 Pandemic on Cleft Lip/Palate Surgery in Brazil: Assessing the Current Landscape.

OBJECTIVE: This study aims to evaluate the impact of COVID-19 and the current situation for cleft lip/palate treatment surgeries within Brazil's public health system. DESIGN: Our retrospective study analyzed CL/P corrective surgeries in Brazil's health system using DATASUS TabNet data from March 2020 to December 2022, with historical data from January 2016 to February 2020. We employed ARIMA analysis to estimate pandemic-related surgery cancellations. RESULTS: In 2020, 1992 (CI 95%: 989-2995) CL/P surgeries were not conducted due to pandemics, a 44.1% (CI 95%: 28.1-54.2%) decrease compared to expectations for march to December 2020. Between the onset of the pandemic in Brazil and the end of 2022, 10,643 surgeries were performed in the country, representing a 33.8% shortfall compared to the expected number for the period (16,076; 95% CI: 9697-22,456). CONCLUSION: The study highlights COVID-19's impact on CL/P surgeries in Brazil. Post-pandemic, surgeries increased but regional disparities remain, urging collaborative efforts to improve services and support affected patients.

Publication Trends and Surgeon Perceptions: A Comprehensive Analysis of Gender Disparities in Craniofacial Surgery.

In academic craniofacial surgery, gender disparities exist across various metrics including faculty positions, leadership roles, and conference representation. This study benchmarks the academic productivity of craniofacial surgeons in 2022 and surveys their perspectives regarding diversity, equity, and inclusion (DEI).Total, first author, and senior author PubMed publications in 2022 were recorded for 193 craniofacial attendings and fellows. Craniofacial surgeons were also surveyed regarding academic experience, leadership roles, and DEI perceptions.Electronic.26 craniofacial attendings.Total, first author, and senior author publication counts in 2022.Women comprised 27% (n = 53) of the craniofacial surgeon cohort. Men led total publications (81% vs 19%, p < 0.001), senior-author publications (84% vs 16%, p < 0.001), average total publications (6.6 vs 4.0, p = 0.043), and average senior-author publications (3.1 vs 1.5, p = 0.02). Sub-analysis of craniofacial fellows showed a higher proportion of women (65%) with no statistical difference in total or average publication counts. Survey responses (n = 26) included a perceived lack of female representation in academic and leadership roles. Barriers included inadequate support from current leadership, systemic issues, and biases. Recommendations for improvement included mentorship programs, targeted recruitment, and equitable conference speaker selection.Ongoing gender disparities are evident in craniofacial surgery, particularly in academic metrics. However, trends in younger cohorts exhibit more balanced gender representation, publication records, and leadership positions, indicating potential improvements. Further studies are needed to examine these cohorts more comprehensively and longitudinally. Sustained commitment, including mentorship programs and enhanced DEI efforts, is needed to continue this progress.

"A National Review of Crowdfunding for Plagiocephaly Helmets".

OBJECTIVE: Custom prescription helmets for plagiocephaly may be a significant financial burden for families, especially when not covered by insurance. This study aims to identify factors that influence the success of crowdsourcing campaigns for this therapy. DESIGN: GoFundMe campaigns were collected by searching terms such as "plagiocephaly" and "baby helmet." Two reviewers analyzed each campaign for variables, including demographic data, story elements, and photo characteristics. Univariate logistic regression was used to determine each variable's impact on success, defined as attaining ≥75% of a campaign goal and significance of p ≤ 0.05. RESULTS: Campaign data from 2011 to 2022 were analyzed. Initial search yielded 1464 campaigns; among these 413 met final inclusion criteria. On average, campaigns raised $2005 (range: $0-$7799) and requested $3151 (range: $160-$30,000). In total, 228 (54%) achieved success, 167 (40%) met their goal, and 35 (8%) raised no funds. A total of $828,256 was raised from the requested $1,301,317. The average reported age was six months (range: 2-17 m). Significant factors associated with success were military affiliation, providing multiple images, including a quoted cost, providing campaign updates, indicating a sense of urgency, diagnosis of torticollis, and mentioning possible complications without treatment. Raising additional funds for therapy, multiple helmets, and unrelated medical costs negatively impacted success. Racial disparities were observed between campaigns. Additionally, regional differences were noted between campaigns. CONCLUSIONS: Crowdsourcing can be a successful endeavor for some families experiencing financial hardships from helmet therapy. This study highlights current gaps within healthcare coverage for helmet treatment and identifies various factors influencing crowdfunding campaigns.

"It's On Your Shoulders Now" Transitioning from Child-to-Adult UK Cleft Lip/Palate Services: An Exploration of Young Adults' Narratives.

OBJECTIVES: Treatment for cleft lip and/or palate (CL/P) in the United Kingdom is administered on a standardised pathway from diagnosis to early adulthood, with options to be re-referred in later life. At age 16, patients become responsible for their treatment decisions. Evidence from the wider health literature indicates this transition can be challenging and that this population may require additional support. The present study explored young people's experiences of transition to adult care in the context of CL/P services, with the aim of identifying support needs and informing future service delivery. DESIGN: Individual semi-structured interviews were conducted with 15 individuals with CL/P (aged 17-25 years) to explore transition experiences. Interviews lasted an average of 69 min and data were analysed using reflexive thematic analysis. RESULTS: Four themes, with subthemes, were identified: 1) Readiness for Transition covered feelings of preparedness and how health professionals approached transition; 2) Making Decisions as an Adult described concerns and considerations when making treatment decisions; 3) Finding and Using Support, reflected the roles of caregivers and peers in developing self-advocacy; and 4) Reflections on Transition Care offered insight into how care could be improved. CONCLUSION: Individuals born with CL/P may experience challenges in becoming responsible for their own care and treatment decisions. The findings of this study indicate that a dedicated transition protocol may be beneficial, such that adolescents are prepared to confidently access and manage their care into adulthood. Opportunities for improvements in transition planning and provision are discussed.

Barriers in Accessing Orthodontic Care for Patients with Orofacial Clefts: Insights from a Florida-Based Survey and National Database Analysis.

OBJECTIVE: To assess the barriers to obtaining care for patients with orofacial clefts through a survey of Florida-based orthodontists and families and an analysis of the Pediatric Health Information System (PHIS) database. DESIGN: A cross-sectional study utilizing multiple-choice questionnaires completed by Florida orthodontists and caregivers of patients who attended a Florida-based cleft and craniofacial clinic. Additionally, data from the PHIS database were analyzed to investigate national factors affecting the age of alveolar bone grafting (ABG). SETTING: Craniofacial team in Florida. PATIENTS/PARTICIPANTS: The survey included 39 orthodontists (7.1% response rate) and 48 caregivers (41% response rate) The PHIS study included 1182 patients. MAIN OUTCOME MEASURES: Barrier to orthodontic care and age of ABG. RESULTS: Orthodontic Survey: Among the surveyed orthodontists, 71% treated cleft/craniofacial patients, 37% accepted Medicaid, and 55% provided pro-bono care. Poor reimbursement was identified as the most common barrier (58%). Caregiver Survey: Most patients were insured by Medicaid (67%), with 55% incurring out-of-pocket expenses. PHIS Database: The average age of ABG was 10.3 years (SD = 3.2). Government funding was associated with a 6.0-month delay in ABG (p = 0.047) and residing in non-Medicaid expanded states was linked to a 6.0-month delay (p = 0.023). Post-Medicaid expansion status was also associated with a delay (p = 0.004). CONCLUSIONS: Access to oral care is difficult for patients with OFC. Despite both federal and state mandates, many financial and non-financial barriers still exist in accessing orthodontic care and a majority of patients experience significant out-of-pocket expenses despite statutorily mandated insurance coverage.

Worldwide Control and Management of Chagas Disease in a New Era of Globalization: a Close Look at Congenital Trypanosoma cruzi Infection.

Population movements have turned Chagas disease (CD) into a global public health problem. Despite the successful implementation of subregional initiatives to control vectorial and transfusional Trypanosoma cruzi transmission in Latin American settings where the disease is endemic, congenital CD (cCD) remains a significant challenge. In countries where the disease is not endemic, vertical transmission plays a key role in CD expansion and is the main focus of its control. Although several health organizations provide general protocols for cCD control, its management in each geopolitical region depends on local authorities, which has resulted in a multitude of approaches. The aims of this review are to (i) describe the current global situation in CD management, with emphasis on congenital infection, and (ii) summarize the spectrum of available strategies, both official and unofficial, for cCD prevention and control in countries of endemicity and nonendemicity. From an economic point of view, the early detection and treatment of cCD are cost-effective. However, in countries where the disease is not endemic, national health policies for cCD control are nonexistent, and official regional protocols are scarce and restricted to Europe. Countries of endemicity have more protocols in place, but the implementation of diagnostic methods is hampered by economic constraints. Moreover, most protocols in both countries where the disease is endemic and those where it is not endemic have yet to incorporate recently developed technologies. The wide methodological diversity in cCD diagnostic algorithms reflects the lack of a consensus. This review may represent a first step toward the development of a common strategy, which will require the collaboration of health organizations, governments, and experts in the field.

Evidence-informed guidelines in oral health: insights from a systematic survey.

BACKGROUND: Oral diseases are a major global public health problem, impacting the quality of life of those affected. While consensus exists on the importance of high-quality, evidence-informed guidelines to inform practice and public health decisions in medicine, appropriate methodologies and standards are not commonly adhered to among producers of oral health guidelines. This study aimed to systematically identify organizations that develop evidence-informed guidelines in oral health globally and survey the methodological process followed to formulate recommendations. METHODS: We searched numerous electronic databases, guideline repositories, and websites of guideline developers, scientific societies, and international organizations (January 2012-October 2023) to identify organizations that develop guidelines addressing any oral health topic and that explicitly declare the inclusion of research evidence in their development. Pairs of reviewers independently evaluated potentially eligible organizations according to predefined selection criteria and extracted data about the organization's characteristics, key features of their guidelines, and the process followed when formulating formal recommendations. Descriptive statistics were used to analyze and summarize data. RESULTS: We included 46 organizations that developed evidence-informed guidelines in oral health. The organizations were mainly professional associations and scientific societies (67%), followed by governmental organizations (28%). In total, organizations produced 55 different guideline document types, most of them containing recommendations for clinical practice (77%). Panels were primarily composed of healthcare professionals (87%), followed by research methodologists (40%), policymakers (24%), and patient partners (18%). Most (60%) of the guidelines reported their funding source, but only one out of three (33%) included a conflict of interest (COI) policy management. The methodology used in the 55 guideline document types varied across the organizations, but only 19 (35%) contained formal recommendations. Half (51%) of the guideline documents referred to a methodology handbook, 46% suggested a structured approach or system for rating the certainty of the evidence and the strength of recommendations, and 37% mentioned using a framework to move from evidence to decisions, with the GRADE-EtD being the most widely used (27%). CONCLUSION: Our findings underscore the need for alignment and standardization of both terminology and methodologies used in oral health guidelines with current international standards to formulate trustworthy recommendations.

Chronic Disease, Functional Limitations, and Workforce Participation Among Medicaid Enrollees Over 50: The Potential Impact of Medicaid Work Requirements Post-COVID-19.

From 2018-2020, 19 states enacted Medicaid work requirements as a strategy for reducing program enrollment and overall cost. While these requirements were later rescinded, strategies to reduce Medicaid costs are likely to reemerge as states attempt to recover economically from the COVID-19 pandemic. Here, we evaluated the impact of Medicaid work requirements on adults aged > 50, a group that likely faces significant age-related chronic disease burden. Using 2016 Health and Retirement Study data, we evaluated the chronic disease burden of adult Medicaid beneficiaries aged 51-64 years (n = 1460) who would be at risk of losing their Medicaid coverage due to work requirements. We compared Medicaid beneficiaries working <20 hours per week (i.e. those at risk of coverage loss) to those working at least 20 hours per week on eight chronic health conditions, adjusting for demographic characteristics. Among those with chronic health conditions, we also evaluated differences in disease severity based on hours worked per week. Among those working fewer than 20 hours per week, odds of disease were greater for seven of eight chronic conditions, including history of stroke (OR: 5.66; 95% CI: 2.22-14.43) and lung disease (OR: 3.79; 95% CI: 2.10-6.85). Further, those with greater disease severity were likely to work fewer hours. Thus, the introduction of Medicaid work requirements would likely result in coverage loss and lower access to care among older Medicaid beneficiaries with multiple chronic health conditions.

Fluoride and caries prevention: a scoping review of public health policies.

Background: Dental caries is the most common infectious disease, affecting approximately 60 to 90% of the world population, especially young children, and disadvantaged communities. Due to the extremely high prevalence and the significant negative impact on general health, well-being, and quality of life it is considered a global public health problem. Despite the improvement of policies to promote oral health care in the past decades, dental caries is still a healthcare challenge, characterized by increasing disparities among different social groups between and within countries. Fluoride-based prevention of dental caries is a cost-effective approach, that has been implemented since 1940's. It includes systemic and topical administrations, through community-based or individual programs. Preventive interventions should be tailored to individual and community caries risk assessment and estimate of cumulative fluoride intake, in order to maximize the preventive effect and avoid the risk of potential adverse effects associated with excessive fluoride exposure. Regulation of public health policies plays a major role in this context. Study design: Scoping review. Methods: The aim of this scoping review was to report an overview of current guidelines regarding fluoride-based preventive strategies for dental caries and relevant policies on the matter, as well as to address current issues related to public health aspects of dental caries prevention. We searched for the relevant literature on the matter, focusing on policy documents, such as recommendations, position papers and guidelines, issued from the major scientific and regulatory institutions involved in oral health promotion and on publications concerning relevant aspects of public health law. Results: Prevention of dental caries through fluoride can rely on topical fluorides for home-use (toothpastes and mouthrinses), professionally applied topical fluorides (gels, varnishes, silver diamine fluoride, fluoride-releasing restorative materials and sealants), fluoride supplements (tablets and drops), and community-based strategies (community water fluoridation, fluoridated salt and milk). Current relevant guidelines for all these preventive aids are outlined in the paper. A significantly greater preventive effect of topical fluorides has been widely established in the recent past, as compared to systemic effects. Furthermore, increasing concerns have emerged on potential adverse effects on general health associated with early and excessive systemic exposure to fluoride, especially for children, supported by recent meta-analyses. Also, community water fluoridation has raised significant aspects of relevance for health law and policies. In a public health perspective, healthcare policymakers should tackle social iniquities by promoting information and oral health literacy, through community and school-based programs, ensuring access to early dental visits and basic dental care and improving availability and affordability of fluoride topical products. Conclusions. Fluoride-based prevention can provide a simple and cost-effective approach to reduce the incidence of dental caries and the associated social burden. Among fluoride-based preventive strategies, systemic community-based administration of fluoride should be considered with great caution, due to the unfavorable risk-benefit ratio currently established. Topical fluoridated pro-ducts are generally preferred, given the optimal risk-benefit ratio. Further efforts must be made to identify and tackle the barriers to dental caries prevention and related social iniquities from a public health perspective. Policies and laws on oral health should promote access to caries prevention with targeted comprehensive strategies.

Association between Combined Metals and PFAS Exposure with Dietary Patterns: A Preliminary Study.

Background: The global burden of chronic diseases has been increasing, with evidence suggesting that diet and exposure to environmental pollutants, such as per- and polyfluoroalkyl substances (PFAS) and heavy metals, may contribute to their development. The Dietary Inflammatory Index (DII) assesses the inflammatory potential of an individual's diet. However, the complex interplay between PFAS, heavy metals, and DII remains largely unexplored. Objective: The goal of this cross-sectional study was to investigate the associations between diet operationalized as the DII with individual and combined lead, cadmium, mercury, perfluorooctanoic acid (PFOA), and perfluorooctanesulfonic acid (PFOS) exposures using data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018. Methods: Descriptive statistics, a correlational analysis, and linear regression were initially used to assess the relationship between the variables of interest. We subsequently employed Bayesian kernel Machine regression (BKMR) to analyze the data to assess the non-linear, non-additive, exposure-response relationships and interactions between PFAS and metals with the DII. Results: The multi-variable linear regression revealed significant associations between the DII and cadmium and mercury. Our BKMR analysis revealed a complex relationship between PFAS, metal exposures, and the DII. In our univariate exposure-response function plot, cadmium and mercury exhibited a positive and negative linear relationship, respectively, which indicated a positive and negative relationship across the spectrum of exposures with the DII. In addition, the bivariate exposure-response function between two exposures in a mixture revealed that cadmium had a robust positive relationship with the DII for different quantiles of lead, mercury, PFOA, and PFOS, indicating that increasing levels of cadmium are associated with the DII. Mercury's bivariate plot demonstrated a negative relationship across all quantiles for all pollutants. Furthermore, the posterior inclusion probability (PIP) results highlighted the consistent importance of cadmium and mercury with the inflammatory potential of an individual's diet, operationalized as the DII in our study, with both showing a PIP of 1.000. This was followed by PFOS with a PIP of 0.8524, PFOA at 0.5924, and lead, which had the lowest impact among the five environmental pollutants, with a PIP of 0.5596. Conclusion: Our study suggests that exposures to environmental metals and PFAS, particularly mercury and cadmium, are associated with DII. These findings also provide evidence of the intricate relationships between PFAS, heavy metals, and the DII. The findings underscore the importance of considering the cumulative effects of multi-pollutant exposures. Future research should focus on elucidating the mechanistic pathways and dose-response relationships underlying these associations in a study that examines causality, which will enable a deeper understanding of the dietary risks associated with environmental pollutants.

Controversies in rheumatology: telemedicine-friend or foe?

Telemedicine is increasingly used in rheumatology. While telemedicine guaranteed care of patients during the COVID-19 pandemic, it is now increasingly used to facilitate triage of patients, monitoring of disease activity, and patients' education. In addition, tele-visits as well as remote physio- and psychotherapy are replacing traditional face-to-face contacts between patients and their healthcare provider. While this may save resources in a world in which the gap between the demand and the provision of healthcare increases, there is also a danger of losing essential information, for example by non-verbal communication, that can only be retrieved during face-to-face contact in the office. In addition, it may be challenging to build a trusting relationship between patients and healthcare professionals by virtual means only. Globally acting companies that see market opportunities already amply offer 'simple' technical solutions for telemedicine. While such solutions may seem (economically) interesting at first glance, there is a risk of monopolization, leaving the most valuable parts of healthcare to a small number of profit-seeking companies. In this article, the opportunities and threats of telemedicine in rheumatology are debated. A possible way forward is to complement traditional face-to-face visits with information gained by telemedicine, in order to render these consultations more efficient rather than replacing personal contact by technology.

Recommendations for ethnic equity in health: A Delphi study from Denmark.

AIMS: A key issue in public health is how to approach ethnic inequities. Despite an increased focus on the health of people from ethnic minorities in the last 15 years, significant ethnic health inequities still exist in Denmark. These arise during pregnancy and are exacerbated by higher rates of exposure to health risks during the life course. This study aimed to formulate recommendations on both structural and organisational levels to reduce ethnic health inequities. METHODS: Nine decision-makers - representing municipalities, regions, the private sector and voluntary organisations in Denmark - participated in the formulation of recommendations inspired by the Delphi method. The consensus process was conducted in three rounds during spring 2020, resulting in eight overall recommendations, including suggestions for action. RESULTS: The recommendations address both structural and organisational levels. They aim to strengthen: 1) health policies and strategies related to the needs of people from ethnic minorities, including health literacy, linguistic, cultural and social differences; 2) health-promoting local initiatives developed in co-creation with people from ethnic minorities; 3) health promotion and prevention from a life course perspective with a focus on early intervention; 4) cross-sectoral and interdisciplinary collaborations that facilitate transitions and coordination; 5) competencies of professionals in terms of cultural knowledge, awareness, reflexivity and skills; 6) access to healthcare services by increasing information and resources; 7) interpreting assistance for, and linguistic accessibility to, healthcare services; 8) documentation and intervention research. CONCLUSIONS: To reduce ethnic health inequities, it is crucial that Danish welfare institutions, including their strategies, approaches and skills of employees, are adapted to serve an increasingly heterogeneous population.

Deaths during the first year of the COVID-19 pandemic: insights from regional patterns in Germany and Poland.

BACKGROUND: Given the nature of the spread of SARS-CoV-2, strong regional patterns in the fatal consequences of the COVID-19 pandemic related to local characteristics such as population and health care infrastructures were to be expected. In this paper we conduct a detailed examination of the spatial correlation of deaths in the first year of the pandemic in two neighbouring countries - Germany and Poland, which, among high income countries, seem particularly different in terms of the death toll associated with the COVID-19 pandemic. The analysis aims to yield evidence that spatial patterns of mortality can provide important clues as to the reasons behind significant differences in the consequences of the COVID-19 pandemic in these two countries. METHODS: Based on official health and population statistics on the level of counties, we explore the spatial nature of mortality in 2020 in the two countries - which, as we show, reflects important contextual differences. We investigate three different measures of deaths: the officially recorded COVID-19 deaths, the total values of excessive deaths and the difference between the two. We link them to important pre-pandemic regional characteristics such as population, health care and economic conditions in multivariate spatial autoregressive models. From the point of view of pandemic related fatalities we stress the distinction between direct and indirect consequences of COVID-19, separating the latter further into two types, the spatial nature of which is likely to differ. RESULTS: The COVID-19 pandemic led to much more excess deaths in Poland than in Germany. Detailed spatial analysis of deaths at the regional level shows a consistent pattern of deaths officially registered as related to COVID-19. For excess deaths, however, we find strong spatial correlation in Germany but little such evidence in Poland. CONCLUSIONS: In contrast to Germany, for Poland we do not observe the expected spatial pattern of total excess deaths and the excess deaths over and above the official COVID-19 deaths. This difference cannot be explained by pre-pandemic regional factors such as economic and population structures or by healthcare infrastructure. The findings point to the need for alternative explanations related to the Polish policy reaction to the pandemic and failures in the areas of healthcare and public health, which resulted in a massive loss of life.