Understanding the causes of missingness in primary care: a realist review.

BACKGROUND: Although missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single 'situational' missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more 'enduring' multiple missed appointments in primary care and the role this has in producing health inequalities. METHODS: We conducted a realist review of the literature on multiple missed appointments to identify the causes of 'missingness.' We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation. RESULTS: Missingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is 'for them'; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place. CONCLUSIONS: Interventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care.

Barriers to help-seeking, accessing and providing mental health support for medical students: a mixed methods study using the candidacy framework.

BACKGROUND: The mental health of medical students is a national and international problem increasing in both demand and acuity. Medical students face barriers to accessing mental health support that is clinically effective, timely and appropriate for their needs. This mixed methods study aimed to explore experiences of these barriers and the challenges to health service delivery aligned to the Candidacy Framework. METHODS: One hundred three medical students studying at The University of Sheffield completed an online survey comprising the CCAPS-34 and follow-up questions about service access and use. Semi-structured interviews with a nested sample of 20 medical students and 10 healthcare professionals explored barriers to service access and provision. A stakeholder panel of medical students and professionals met quarterly to co-produce research materials, interpret research data and identify touchpoints by pinpointing specific areas and moments of interaction between a medical student as a service user and a mental health service. RESULTS: Medical students who experienced barriers to help-seeking and accessing support scored significantly higher for psychological symptoms on the CCAPS-34. Uncertainty and fear of fitness to practice processes were important barriers present across all seven stages of candidacy. The fragmented structure of local services, along with individual factors such as perceived stigma and confidentiality concerns, limited the progression of medical students through the Candidacy Framework (a framework for understanding the different stages of a person's journey to healthcare). CONCLUSION: This study outlines important areas of consideration for mental health service provision and policy development to improve access to and the quality of care for medical students.

Candidacy 2.0 (CC) - an enhanced theory of access to healthcare for chronic conditions: lessons from a critical interpretive synthesis on access to rheumatoid arthritis care.

BACKGROUND: The Dixon-Woods et al. Candidacy Framework, a valuable tool since its 2006 introduction, has been widely utilized to analyze access to various services in diverse contexts, including healthcare. This social constructionist approach examines micro, meso, and macro influences on access, offering concrete explanations for access challenges rooted in socially patterned influences. This study employed the Candidacy Framework to explore the experiences of individuals living with rheumatoid arthritis (RA) and their formal care providers. The investigation extended to assessing supports and innovations in RA diagnosis and management, particularly in primary care. METHODS: This systematic review is a Critical Interpretive Synthesis (CIS) of qualitative and mixed methods literature. The CIS aimed to generate theory from identified constructs across the reviewed literature. The study found alignment between the seven dimensions of the Candidacy Framework and key themes emerging from the data. Notably absent from the framework was an eighth dimension, identified as the "embodied relational self." This dimension, central to the model, prompted the proposal of a revised framework specific to healthcare for chronic conditions. RESULTS: The CIS revealed that the eight dimensions, including the embodied relational self, provided a comprehensive understanding of the experiences and perspectives of individuals with RA and their care providers. The proposed Candidacy 2.0 (Chronic Condition (CC)) model demonstrated how integrating approaches like Intersectionality, concordance, and recursivity enhanced the framework when the embodied self was central. CONCLUSIONS: The study concludes that while the original Candidacy Framework serves as a robust foundation, a revised version, Candidacy 2.0 (CC), is warranted for chronic conditions. The addition of the embodied relational self dimension enriches the model, accommodating the complexities of accessing healthcare for chronic conditions. TRIAL REGISTRATION: This study did not involve a health care intervention on human participants, and as such, trial registration is not applicable. However, our review is registered with the Open Science Framework at https://doi.org/10.17605/OSF.IO/ASX5C .

Adjudications and tinkering with care for socially vulnerable patients with type 2 diabetes in general practice.

OBJECTIVE: To analyse the mechanisms at play in the adjudications made by professionals and socially vulnerable patients with type 2 diabetes about their eligibility for care. DESIGN, SETTING AND SUBJECTS: The study included 14 patients and 10 health professionals in seven general practice surgeries in deprived areas in Greater Copenhagen. The study data consist of 17 semi-structured interviews with patients and 22 with health professionals immediately after observation of 23 consultations. Our analytical approach was inspired by Systematic Text Condensation and the concept of 'candidacy' for access to health care. RESULTS: Adjudications of patients not being candidates for services were common, but we also found that both patients and health professionals worked to align the services to the needs of the patients. This could include using services differently than was intended by the providers or by changing routines to make it easier for patients to use the services. We discuss these processes as 'tinkering'. This usually implies that the best individual solution for the patient is aimed for, and in this study, the best solution sometimes meant not focusing on diabetes. CONCLUSION: The study adds to existing knowledge about access to services for socially vulnerable patients by demonstrating that both patients and professionals in general practice engage in tinkering processes to make services work.

Unequal use and benefits of health services play a significant role in relation to social inequality in healthFlexibility in services and alternatives to school-like rehabilitation are needed to reduce inequality in access to health carePatients were sometimes judged as unsuitable for available routine services, but professionals 'tinkered' with services to make them fitAdaptation of services by professionals in general practice implies a longer time frame for obtaining goals.

AI model for predicting adult cochlear implant candidacy using routine behavioral audiometry.

OBJECTIVE: To describe an AI model to facilitate adult cochlear implant candidacy prediction based on basic demographical data and standard behavioral audiometry. METHODS: A machine-learning approach using retrospective demographic and audiometric data to predict candidacy CNC word scores and AzBio sentence in quiet scores was performed at a tertiary academic center. Data for the model were derived from adults completing cochlear implant candidacy testing between January 2011 and March 2023. Comparison of the prediction model to other published prediction tools and benchmarks was performed. RESULTS: The final dataset included 770 adults, encompassing 1045 AzBio entries, and 1373 CNC entries. Isophoneme scores and word recognition scores exhibited strongest importance to both the CNC and AzBio prediction models, followed by standard pure tone average and low-frequency pure tone average. The mean absolute difference between the predicted and actual score was 15 percentage points for AzBio sentences in quiet and 13 percentage points for CNC word scores, approximating anticipated test-retest constraints inherent to the variables incorporated into the model. Our final combined model achieved an accuracy of 87 % (sensitivity: 90 %; precision: 80 %). CONCLUSION: We present an adaptive AI model that predicts adult cochlear implant candidacy based on routine behavioral audiometric and basic demographical data. Implementation efforts include a public-facing online prediction tool and accompanying smartphone program, an embedded notification flag in the electronic medical record to alert providers of potential candidates, and a program to retrospectively engage past patients who may be eligible for cochlear implantation based on audiogram results.

'Everyone needs to know that infant mental health is important' - a commentary/reflection on 'Improving access to mental health interventions for children from birth to five years: a scoping review' (Hickey et al., 2023).

Hickey et al.'s scoping of infant mental health (IMH) services and the challenges faced in ensuring that vulnerable infants can access them highlights important issues and suggests some solutions (Hickey et al., Child and Adolescent Mental Health, 2023). Their synthesis of useful research in the field is limited only by its focus on more affluent English-speaking countries, which is acknowledged. Writing from an Australian perspective, they highlight the need for culturally sensitive service delivery. This commentary draws attention to the concept of candidacy as a helpful way of thinking about patents' journeys into services. It can support a deeper understanding of the barriers to referral for infants most in need. One key issue is the knowledge and understanding of both professionals and the public about the importance of the early years for later well-being. Infants cannot advocate for themselves and depend on those around them to exercise their right to services. Good relationships between professionals and between family members and clinicians are essential for IMH service development and delivery.

Understanding Prognosis: Discrepancy in Prognosis Estimates Between Patients With Cirrhosis and their Hepatologists.

BACKGROUND & AIMS: Patients require a clear understanding of their prognosis to make informed decisions about their care. The aim of this study was to compare the perceptions of prognosis and transplant candidacy between patients with cirrhosis and their hepatologists. METHODS: Patients with cirrhosis and their hepatologists were prospectively recruited at an urban liver transplant center. Patients and hepatologists were asked about transplant candidacy and about how many years patients would live with and without a liver transplant. Agreement between patients and hepatologists was assessed with the weighted kappa statistic. Associations between patient/hepatologists' prognostic estimates and those predicted by patients' Model for End-Stage Liver Disease-Sodium (MELD-Na) score were estimated using the Pearson correlation coefficient. RESULTS: Seventy patients and 6 hepatologists were enrolled in the study. Patients were predominantly male (61.4%) and white (68.6%), with a mean MELD-Na score of 19 ± 9. There was no-slight agreement between patients and hepatologists regarding survival without and with a liver transplant (κ = 0.1 and 0.2, respectively), with patients more optimistic than their hepatologists. There was greater agreement between patients and hepatologists about transplant candidacy (κ = 0.6). There was a negligible association between MELD-Na and patient estimates (r = -0.24, P = .05) but a moderate association between MELD-Na and hepatologist estimates (r = -0.51, P < .001), with higher MELD-Na scores associated with lower predicted survival. CONCLUSIONS: Patients with cirrhosis are more optimistic and less accurate in their predictions of survival compared with hepatologists, although they are more realistic about their transplant candidacy. Aligning patient and provider expectations may increase the likelihood that patients receive value-concordant care.

An ethical analysis of obesity as a contraindication of pediatric kidney transplant candidacy.

The inclusion of body mass index (BMI) as a criterion for determining kidney transplant candidacy in children raises clinical and ethical challenges. Childhood obesity is on the rise and common among children with kidney failure. In addition, obesity is reported as an independent risk factor for the development of CKD and kidney failure. Resultantly, more children with obesity are anticipated to need kidney transplants. Most transplant centers around the world use high BMI as a relative or absolute contraindication for kidney transplant. However, use of obesity as a relative or absolute contraindication for pediatric kidney transplant is controversial. Empirical data demonstrating poorer outcomes following kidney transplant in obese pediatric patients are limited. In addition, pediatric obesity is distributed inequitably among groups. Unlike adults, most children lack independent agency to choose their food sources and exercise opportunities; they are dependent on their families for these choices. In this paper, we define childhood obesity and review (1) the association and impact of obesity on kidney disease and kidney transplant, (2) existing adult guidelines and rationale for using high BMI as a criterion for kidney transplant, (3) the prevalence of childhood obesity among children with kidney failure, and (4) the existing literature on obesity and pediatric kidney transplant outcomes. We then discuss ethical considerations related to the use of obesity as a criterion for kidney transplant.

Extending the sociology of candidacy: Bourdieu's relational social class and mid-life women's perceptions of alcohol-related breast cancer risk.

Alcohol is a modifiable breast cancer risk, increasing risk in a dose-dependent manner. Mid-life women (aged 45-64 years) consume alcohol at higher rates than younger women and this, combined with age, make them a high-risk group for breast cancer. This critical public health problem has a seemingly obvious solution (reduce drinking); however, women do not necessarily know alcohol causes breast cancer, and if they do, reducing consumption is not always possible, or desirable. To innovate public health responses, we employ an interpretative sociological framework 'candidacy' to understand women's perspectives on breast cancer risk relative to alcohol consumption and their social class. Drawing on 50 interviews with Australian mid-life women, our findings reveal the socio-structural determinants of 'candidacy', that mean modifying alcohol consumption for breast cancer prevention is impacted by social class. Utilising Bourdieu's relational capitals, our interpretations show how social class shapes women's ascriptions and enactments of breast cancer candidacy. We offer an important theoretical extension to 'candidacy' by demonstrating more or less fluidity in women's assessment of breast cancer risk according to their agency to adopt breast cancer prevention messages. Understanding the social class possibilities and limitations in women's perceptions of breast cancer risk provides a new opportunity to reduce inequities in breast cancer incidence.

Clinical and Psychosocial Factors Considered When Deciding Whether to Offer Deep Brain Stimulation for Childhood Dystonia.

INTRODUCTION: Childhood dystonia is often nonresponsive to medications, and refractory cases are increasingly being treated with deep brain stimulation (DBS). However, many have noted that there is little consensus about when DBS should be offered, and there has been little examination of clinicians' decision-making process when determining whether to offer DBS for childhood dystonia. OBJECTIVES: This study aimed to identify and examine the factors considered by pediatric movement disorder specialists before offering DBS. MATERIALS AND METHODS: Semistructured interviews (N = 29) with pediatric dystonia clinicians were conducted, transcribed, and coded. Using thematic content analysis, nine central themes were identified when clinicians were asked about key factors, clinical factors, and psychosocial factors considered before offering pediatric DBS. RESULTS: Clinicians identified nine main factors. Five of these were classified primarily as clinical factors: early intervention and younger age (raised by 86% of respondents), disease progression and symptom severity (83%), etiology and genetic status (79%), clinicians' perceived risks and benefits of DBS for the patient (79%), and exhaustion of other treatment options (55%). The remaining four were classified primarily as psychosocial factors: social and family support (raised by 97% of respondents), patient and caregiver expectations about outcomes and understanding of DBS treatment (90%), impact of dystonia on quality of life (69%), and financial resources and access to care (31%). CONCLUSIONS: Candidacy determinations, in this context, are complicated by an interrelation of clinical and psychosocial factors that contribute to the decision. There is potential for bias when considering family support and quality of life. Uncertainty of outcomes related to the etiology of dystonia makes candidacy judgments challenging. More systematic examination of the characteristics and criteria used to identify pediatric patients with dystonia who can significantly benefit from DBS is necessary to develop clear guidelines and promote the well-being of these children.

Using the candidacy framework to conceptualize systems and gaps when developing infant mental health (IMH) services: A qualitative study.

The development of infant mental health (IMH) services globally is still in its early stages. This qualitative study aims to understand the challenges of setting up IMH services and explores the views and experiences of 14 multi-disciplinary stakeholders who are part of the IMH implementation group in a large Scottish health board. Six major themes were identified through thematic analysis. This paper examines the most prominent theme "Systems" alongside the theme "Gaps in Current Service". The theoretical framework of "candidacy" is found to be a valuable way to conceptualize the complex systemic layers of micro, meso, and macro factors that contribute to the challenges of setting up services. At the micro level, key themes included the view that services must be accessible, individualized, and involve families. At the meso level, in line with the aims of the service, multiagency integration, aspects of early intervention, and clear operating conditions were all seen as important. Finally, at the macro level, perhaps the biggest challenge perceived by stakeholders is delivering a service that is entirely infant-focused. These findings will help inform policy makers about factors considered by professionals to be vital in the establishment of IMH services in Scotland and across the globe.

El desarrollo de los servicios de salud mental infantil (IMH) globalmente está aún en sus niveles básicos. Este estudio cualitativo se propone comprender los retos de establecer los servicios IMH y explora los puntos de vista y experiencias de 14 personas interesadas de múltiples disciplinas que son parte de un grupo de implementación de IMH dentro de una extensa junta de salud escocesa. A través de análisis temáticos se identificaron seis temas de mayor importancia. Este estudio examina el tema más prominente según la mayor percepción, "Sistemas," junto con el tema "Vacíos en la Actual Prestación de Servicio." Se estima que el marco teorético de trabajo de "candidatura," es una manera valiosa de conceptualizar los complejos niveles sistémicos de micro, medio y macro factores que contribuyen a los retos de establecer los servicios. Al nivel micro, los temas claves incluyen el punto de vista de que los servicios deben ser accesibles, individualizados y deben involucrar a las familias. Al nivel medio, alineados con las metas del servicio, la integración de agencias múltiples, aspectos de temprana intervención y claras condiciones operativas fueron todas estimadas como importantes. Finalmente, al nivel macro, quizás el mayor reto percibido por las personas interesadas es cumplir con el ofrecimiento de un servicio que esté enteramente enfocado en el infante. Estos resultados ayudarán a informar a quienes determinan las políticas a seguir acerca de los factores que los profesionales consideran vitales en el establecimiento de servicios IMH en Escocia y alrededor del globo.

Au niveau global, le développement de service de santé mentale du nourrisson et de la petite enfance en est encore à ses débuts. Cette étude qualitative s'est donnée pour but de comprendre les défis que pose l'installation de services IMH. Elle explore les vues et les perspectives de 14 parties prenantes de diverses disciplines qui font partie d'un groupe de mise en place IMH dans un grand conseil de santé en Ecosse. Six thèmes principaux ont été identifiés au travers une analyse thématique. Cet article examine le thème ayant été perçu comme le plus grand et proéminent, Systèmes, ainsi que le thème « Brèches dans les services actuels ¼. La structure théorique de la 'candidature' a été utilisée pour trouver une manière utile de conceptualiser les couches systémiques complexes de facteurs micro, méso, et macro qui contribuent aux défis qu'il y a dans l'installation de services. Au niveau micro, les thèmes clés ont inclus l'idée que les services doivent être accessibles, individualisés et engager les familles. Au niveau méso, s'alignant avec les buts du service, l'intégration de plusieurs agences, les aspects d'une intervention précoce et des conditions d'opération claires ont tous été estimé être importants. Enfin, au niveau macro, le défi étant peut-être le plus grand selon les parties prenantes est d'offrir un service qui est entièrement focalisé sur le nourrisson. Ces résultats aideront les décideurs pour ce qui s'agit des facteurs considérés comme étant vitaux par les professionnels pour ce qui concerne l'établissement de services IMH en Ecosse et au travers du globe.

Dialysis Nonadherence and Kidney Transplant Outcomes: A Retrospective Cohort Study.

RATIONALE & OBJECTIVE: Concerns about nonadherent behaviors often prevent dialysis patients from entering waitlists for transplant even though there is an inconsistent association of these behaviors with posttransplant outcomes. We examined the association between plausible metrics of nonadherence related to dialysis treatment and posttransplant outcomes. STUDY DESIGN: Retrospective cohort. We linked national dialysis treatment data with transplant registry data. SETTING AND PARTICIPANTS: Adult patients receiving maintenance hemodialysis from January 1, 2004, through December 31, 2014, who received a kidney transplant at a US center. EXPOSURES: We examined 5 nonadherence metrics: serum potassium level (≥5.2 mEq/L), serum phosphorus level (>5.5 mg/dL), interdialytic weight gain (IDWG; ≥5 L), shortened treatments (≥30 min), and missed treatments (≥1); missed treatment data were available only for 2004-2009. These metrics were characterized per proportion of time under observation. Dialysis observation time was divided into 3-month intervals (quarters), and the number of nonadherent measurements in each domain was calculated for each quarter. OUTCOMES: Allograft loss, mortality, and acute rejection in the first posttransplant year. ANALYTICAL APPROACH: Using Cox proportional hazards and logistic regression, we estimated the hazard ratios for graft loss and mortality and odds ratios for rejection. RESULTS: 9,543 patients met inclusion criteria. In our primary model, hyperphosphatemia (adjusted hazard ratio [aHR], 1.27 [95% CI, 1.08-1.49]), large IDWG (aHR, 1.39 [95% CI, 1.23-1.59]), and shortened treatments (aHR, 1.54 [95% CI, 1.12-2.13]) were associated with greater rates of allograft loss, but hyperkalemia was not. Large IDWG (aHR, 1.49 [95% CI, 1.29-1.73]) and shortened treatments (aHR, 1.34 [95% CI, 1.13-1.58]) were associated with mortality, whereas hyperkalemia and hyperphosphatemia were not. Only shortened treatments were associated with an increased risk of acute rejection (adjusted odds ratio, 3.88 [95% CI, 1.98-7.58]). In models limited to the years 2004-2009 that included missed treatments, missed treatments were associated only with mortality. LIMITATIONS: Unmeasured confounding (eg, dietary data); adherence metrics used may have multiple, complex causes. CONCLUSIONS: Plausible measures of dialysis nonadherence have long-term associations with allograft and patient survival. Behavioral metrics were more closely associated with outcomes than laboratory markers were. The implications of nonadherent behaviors for dialysis patients must be carefully considered before patients are excluded from transplantation.

Using Clinical Audiologic Measures to Determine Cochlear Implant Candidacy.

INTRODUCTION: Only a small percentage (6-10%) of patients who are candidates receive cochlear implants (CIs). One potential reason contributing to low usage rates may be confusion regarding which patients to refer for CI evaluation. The extent to which information provided by standard clinical audiologic assessments is sufficient for selecting appropriate CI evaluation referrals is uncertain. The objective of this study is to evaluate the capacity of standard clinical audiologic measures to differentiate CI candidates from noncandidates. METHOD: The study design is a retrospective review of a prospectively maintained CI database from a university-based tertiary medical center of 518 patients undergoing CI evaluations from 2012 to 2020. Each ear of each patient was treated as an independent value. Receiver operating characteristic (ROCs) curves were constructed using aided AzBio sentence recognition scores in quiet and aided AzBio +10 dB signal-to-noise ratio scores <60% as binary classifiers for CI candidacy. For each ROC, we examined the capacity of multiple pure-tone thresholds, pure-tone average (PTA), and CNC word recognition scores (WRSs) measured under earphones to determine CI candidacy. Area under the curve ROC (AUC-ROC) values were calculated to demonstrate the capacity of each model to differentiate CI candidates from noncandidates. RESULTS: Variables with the greatest capacity to accurately differentiate CI candidates from noncandidates using aided AzBio in quiet scores were earphone CNC WRS, earphone pure-tone threshold at 1,000 Hz, and earphone PTA (AUC-ROC values = 0.86-0.88). Using aided AzBio +10 scores as the measure for candidacy, only CNC word recognition had a fair capacity to identify candidates (AUC-ROC value = 0.73). Based on the ROCs, a 1,000 Hz pure-tone threshold >50 dB HL, PTA >57 dB HL, and a monosyllabic WRS <60% can each serve as individual indicators for referral for CI evaluations. CONCLUSION: The current study provides initial indicators for referral and a first step at developing evidence-based criteria for CI evaluation referral using standard audiologic assessments.

UK healthcare services for people with fibromyalgia: results from two web-based national surveys (the PACFiND study).

BACKGROUND: The UK's "Getting It Right First Time" programme recommends that management of people with fibromyalgia should centre on primary care. However, it remains unclear as to how best to organise health systems to deliver services to optimise patient outcomes. AIM: To profile UK healthcare services for people with fibromyalgia: provision of National Health Services (NHS) and use of non-NHS services by people with fibromyalgia. METHODS: Two online open surveys (A and B) incorporating questions about diagnosis, treatment and management of fibromyalgia and gaps in healthcare services were conducted between 11th September 2019 and 3rd February 2020. These were targeted to NHS healthcare professionals consulting with people with fibromyalgia (Survey A) and people ≥16 years diagnosed with fibromyalgia using non-NHS services to manage their condition (Survey B). Descriptive statistics were used to report quantitative data. Thematic analysis was undertaken for qualitative data. RESULTS: Survey A received 1701 responses from NHS healthcare professionals across the UK. Survey B received 549 responses from people with fibromyalgia. The results show that NHS services for people with fibromyalgia are highly disparate, with few professionals reporting care pathways in their localities. Diagnosing fibromyalgia is variable among NHS healthcare professionals and education and pharmacotherapy are mainstays of NHS treatment and management. The greatest perceived unmet need in healthcare for people with fibromyalgia is a lack of available services. From the pooled qualitative data, three themes were developed: 'a troublesome label', 'a heavy burden' and 'a low priority'. Through the concept of candidacy, these themes provide insight into limited access to healthcare for people with fibromyalgia in the UK. CONCLUSION: This study highlights problems across the NHS in service provision and access for people with fibromyalgia, including several issues less commonly discussed; potential bias towards people with self-diagnosed fibromyalgia, challenges facing general practitioners seeking involvement of secondary care services for people with fibromyalgia, and a lack of mental health and multidisciplinary holistic services to support those affected. The need for new models of primary and community care that offer timely diagnosis, interventions to support self-management with access to specialist services if needed, is paramount.

In an era of bilateral funding and changing criteria, when is unilateral cochlear implantation a better option?

BACKGROUND: Funding for paediatric bilateral cochlear implantation became available in Ireland in 2014. Prior to this, children eligible for cochlear implantation received a unilateral implant. OBJECTIVE: To examine the cohort of children who received a unilateral cochlear implant in the 4 year period following bilateral cochlear implantation funding becoming available. METHODS: A clinical audit of all children implanted for the first time between July 2014 and July 2018. The unilaterally implanted children (n = 105) were divided into 3 groups according to whether they met the audiometric thresholds for implantation in neither ear (Group 1), one ear (Group 2) or both ears (Group 3). One year post operative functional outcomes were examined for all 3 groups. RESULTS: All 3 groups showed significant improvements in functional outcomes at 1 year post op. To date, 20% of the unilaterally implanted children have proceeded to get a sequential CI, often where there was no change in audiological status. CONCLUSIONS: The number of children in Groups 1 and 2 highlighted how our decision making around cochlear implantation has changed in recent years. Unilateral cochlear implantation in certain circumstances is good practice, independent of the audiological profile when an experienced multi-disciplinary team (MDT) is involved in the decision making process. Decision making using a holistic model approach is key, including involving the parent/carer and, where appropriate, the child/teenager themselves. A staged bilateral cochlear implant is also a good option, where careful monitoring and support for the first implant has resulted in positive outcomes.

Current demographic and auditory profiles of adult cochlear implant candidates and factors affecting uptake.

OBJECTIVES: Despite growth of CI and widening of implantation criteria, penetration rates remain low and the clinical profile of adult CI candidates has not substantially changed. This study evaluated the demographic and auditory profiles of current adult CI candidates and identified factors affecting CI uptake. DESIGN: Preoperative data from patients who underwent CI candidacy evaluation between 2016-2018 were retrospectively reviewed. Data included demographics, medical reports, audiological results, and reasons for not pursuing implantation. Comparisons between candidates who pursued implantation and those who did not were performed. STUDY SAMPLE: Ninety-five candidates (54 females), average age 52 years. RESULTS: Most candidates exhibited post-lingual bilateral hearing loss with mean unaided PTA4 of 105dBHL and monosyllabic word score of 26%. Forty-nine candidates were implanted, and the main reason for not pursuing CI was candidates' reluctance. Candidates that pursued CI were mostly younger females with poorer unaided PTA4. Age was the only significant predictor of CI uptake. CONCLUSIONS: While current candidates demonstrated greater demographic diversity and better speech perception compared to previous findings, unaided thresholds are still within the profound range. Our findings indicate that eligible candidates face barriers to the utilisation of CI, some of which are modifiable by means of updated candidacy protocols.

Investigations on Anticancer Potentials by DNA Binding and Cytotoxicity Studies for Newly Synthesized and Characterized Imidazolidine and Thiazolidine-Based Isatin Derivatives.

Imidazolidine and thiazolidine-based isatin derivatives (IST-01-04) were synthesized, characterized, and tested for their interactions with ds-DNA. Theoretical and experimental findings showed good compatibility and indicated compound-DNA binding by mixed mode of interactions. The evaluated binding parameters, i.e., binding constant (Kb), free energy change (ΔG), and binding site sizes (n), inferred comparatively greater and more spontaneous binding interactions of IST-02 and then IST-04 with the DNA, among all compounds tested under physiological pH and temperature (7.4, 37 °C). The cytotoxic activity of all compounds was assessed against HeLa (cervical carcinoma), MCF-7 (breast carcinoma), and HuH-7 (liver carcinoma), as well as normal HEK-293 (human embryonic kidney) cell lines. Among all compounds, IST-02 and 04 were found to be cytotoxic against HuH-7 cell lines with percentage cell toxicity of 75% and 66%, respectively, at 500 ng/µL dosage. Moreover, HEK-293 cells exhibit tolerance to the increasing drug concentration, suggesting these two compounds are less cytotoxic against normal cell lines compared to cancer cell lines. Hence, both DNA binding and cytotoxicity studies proved imidazolidine (IST-02) and thiazolidine (IST-04)-based isatin derivatives as potent anticancer drug candidates among which imidazolidine (IST-02) is comparatively the more promising.

KDOQI US Commentary on the 2020 KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation.

Evaluation of patients for kidney transplant candidacy is a comprehensive process that involves a detailed assessment of medical and surgical issues, psychosocial factors, and patients' physical and cognitive abilities with an aim of balancing the benefits of transplantation and potential risks of surgery and long-term immunosuppression. There is considerable variability among transplant centers in their approach to evaluation and decision-making regarding transplant candidacy. The 2020 KDIGO (Kidney Disease: Improving Guidelines Outcome) clinical practice guideline on the evaluation and management of candidates for kidney transplantation provides practice recommendations that can serve as a useful reference guide to transplant professionals. The guideline, covering a broad range of topics, was developed by an international group of experts from transplant and nephrology through a review of literature published until May 2019. A work group of US transplant nephrologists convened by NKF-KDOQI (National Kidney Foundation-Kidney Disease Quality Initiative) chose key topics for this commentary with a goal of presenting a broad discussion to the US transplant community. Each section of this article has a summary of the key KDIGO guideline recommendations, followed by a brief commentary on the recommendations, their clinical utility, and potential implementation challenges. The KDOQI work group agrees broadly with the KDIGO recommendations but also recognizes and highlights the decision-making challenges that arise from lack of high-quality evidence and the need to balance equity with utility of organ transplantation.

Delaying Cochlear Implantation Impacts Postoperative Speech Perception of Nontraditional Pediatric Candidates.

INTRODUCTION: As pediatric cochlear implant (CI) candidacy expands, children with greater degrees of residual hearing are receiving CIs. These nontraditional candidates have audiometric thresholds that meet adult manufacturer labeling but are better than current pediatric guidelines allow. The purpose of this study was to determine the impact of delayed cochlear implantation on speech perception in nontraditional pediatric CI recipients. METHODS: Pediatric CI recipients with a history of progressive hearing loss and a preoperative 4-frequency pure-tone average of ≤75 dB HL at the time of implantation were considered for this retrospective study. Preoperative serial audiograms and word recognition scores were reviewed, and a method was created to establish a date when each individual ear 1st met nontraditional candidacy. The length of time between the date of candidacy and implantation was calculated and defined as the "delay time." A multiple linear regression investigated delay time, age at surgery, surgery type (1st vs. 2nd side), and array type as predictive factors of maximum postoperative Consonant-Nucleus-Consonant (CNC) word scores. A one-way ANCOVA was performed comparing the postoperative CNC scores between subjects grouped by delay time. RESULTS: A significant regression was found (F(4, 38) = 5.167, p = 0.002, R2 = 0.353). Both age at implantation (p = 0.023) and delay time (p = 0.002) predicted CNC word scores. Longer delay time was associated with poorer word recognition scores, while older age at implantation correlated with higher CNC word scores in this progressive hearing loss group. A significant difference was noted between subjects implanted with <1 year of delay and those with 3 or more years of delay (p = 0.003). All ears implanted within a year of candidacy achieved word recognition abilities that are generally accepted as above average (M = 84.91). CONCLUSION: CI candidacy for adults has evolved to allow for greater degrees of residual hearing, while audiometric guidelines for children have not changed since 2000. Our findings suggest that delay of cochlear implantation, even for children with significant levels of residual hearing, leads to poorer outcomes. Modified candidacy guidelines for children should be established to expedite referral to multidisciplinary CI teams and minimize delays in this population.

Management of Sonographically Suspicious Thyroid Nodules 1 cm or Smaller and Candidacy for Active Surveillance: Experience of a Tertiary Center in China.

OBJECTIVE: Our objective was to investigate the management of patients with asymptomatic suspicious thyroid nodules ≤1 cm. METHODS: We retrospectively reviewed medical records of patients with sonographically suspicious thyroid nodules ≤1 cm and without distant metastases, suspicious lymph node metastasis (LNM), or extrathyroidal extension (ETE). RESULTS: Of the 386 enrolled patients, 174 (45.1%) had immediate surgery (IS), while 212 (54.9%) underwent active surveillance (AS). In the IS group, 166 (95.4%) patients were confirmed as having papillary thyroid microcarcinoma. LNM and ETE were observed in 24.7% and 2.4% cases, respectively. In the AS group, nodule size increased by ≥3 mm in 11 (5.2%) patients and 39 (18.4%) had a >50% increase in nodule volume after a median follow-up of 12 months. Nodules with smaller volume at diagnosis were more likely to increase in volume later. Newly suspicious LNM was detected in 23 (10.8%) patients. Delayed surgery (DS) was performed in 101 patients, with 27 showing disease progression. ETE and LNM were detected in 3% and 36%, respectively, of patients with papillary thyroid microcarcinoma. Compared with IS, tumors in the DS group more frequently showed lateral LNM and capsular invasion (P < .05). No patient had recurrence or died of thyroid cancer during postoperative follow-up (median 26 [4-60] months). CONCLUSIONS: IS or DS of patients with asymptomatic suspicious thyroid nodules ≤1 cm was relatively high in China. The inertia of low-risk nodules and the effectiveness of DS for those that progressed make AS a feasible strategy.