Effectiveness of quadrivalent HPV vaccination in reducing vaccine-type and nonvaccine-type high risk HPV infection.

This study aimed to assess human papillomavirus (HPV) vaccine effectiveness (VE) against both vaccine-type and nonvaccine-type high-risk HPV (hrHPV) infection, and duration of protection in United States. The study population was female participants aged 18-35 years with an HPV vaccination history and genital testing for HPV from the National Health and Nutrition Examination Survey, 2007-2016. Participants vaccinated before sexual debut were assessed against 13 nonvaccine-type hrHPV infection including 31/33/35/39/45/51/52/56/58/59/68/73/82. Multivariable logistic regression was used to estimate VE overall, by age at diagnosis, time since vaccination and lifetime sexual partners. A total of 3866 women were included in the analysis, with 23.3% (95% CI 21.3%-25.4%) having been vaccinated (≥1 dose). VE against vaccine-type HPV18/16/11/6 infection was 58% overall, which was mainly driven by those aged 18-22 years (VE = 64%) and 23-27 years (65%). Among participants aged 18-22 years vaccinated before sexual debut, the VE was 47% (23%-64%) against 13 nonvaccine-type hrHPV and 61% (95% CI 36%-77%) against 5 selected nonvaccine-type hrHPV35/39/52/58/59. Both direct effectiveness and cross-protection maintained effective for 5-10 years post vaccination. We also found the prevalence of ever diagnosed cervical cancer among vaccinated was significantly lower (0.46%, 4/874) than that among unvaccinated participants (1.27%, 38/2992). These findings highlight the potential of significant reduction of cervical cancer following the universal HPV vaccination programme.

Impact of a structured older persons health assessment on herpes zoster vaccine uptake in Australian primary care.

Vaccine uptake in adult immunisation programs is often suboptimal. We aimed to assess the impact of the structured older persons health assessment (health assessment) on herpes zoster (zoster) vaccine uptake in Australia. We used national general practice electronic medical records (MedicineInsight) of encounters with patients aged 75-79 years because these patients were age-eligible for both free zoster vaccines and health assessments in the two years following the addition of zoster vaccine to the national immunisation program (Nov 2016-Dec 2018). Due to repeated encounters, we used generalized estimating equations with each patient treated as a clustering variable to analyse the comparison of rates of zoster vaccine administration during encounters where a health assessment was provided versus encounters where the health assessment was not provided. In analyses there were 31,876 patients with a total of 266,204 eligible general practice encounters. Of the 5018 encounters where a health assessment was provided, 592 zoster vaccinations also occurred on the same day (118.0/1000 encounters); for the 261,186 encounters where no health assessment was provided, 9226 zoster vaccinations occurred (35.3/1000 encounters). Zoster vaccine was more likely to be administered during a general practice encounter with a health assessment compared to encounters without one (adjusted odds ratio 2.99; 95% CI: 2.76-3.23). In conclusion, the structured older persons health assessment, which acts as both an incentive and a reminder for healthcare providers to recommend vaccinations in adults improves uptake of zoster vaccine in eligible adults. Such interventions may have a role in improving vaccine uptake among older adults.

Effect of Clinical Inertia on Diabetes Complications among Individuals with Type 2 Diabetes: A Retrospective Cohort Study.

Background and Objectives: Clinical inertia is a key obstacle that leads to suboptimal care in patients with type 2 diabetes mellitus (T2DM). It can occur at any stage of T2DM treatment. However, the effect of clinical inertia on diabetes complications has not been studied sufficiently. This study aimed to evaluate the effect of clinical inertia on the risk of diabetes complications among patients with T2DM. Materials and Methods: A retrospective cohort study was conducted at a tertiary teaching hospital in Thailand between 2011 and 2017. Outpatients with T2DM, aged 40-65 years, presenting an HbA1c greater than 7% were included in this study. Clinical inertia was identified when patients did not get treatment intensification at the index date and a subsequent prescription. The association between clinical inertia and diabetes complications, including a composite of macrovascular complications and a composite of microvascular complications, was determined using a Cox proportional hazard model. Propensity score methods were applied, to control confounding by indication. Results: Of 686 patients with T2DM, 165 (24.0%) experienced clinical inertia. Baseline low-density lipoprotein cholesterol, blood pressure, body mass index, the estimated glomerular filtration rate, and medication between the two groups did not differ significantly. Our study found that clinical inertia was associated with a significantly increased risk of diabetic nephropathy (adjusted HR 1.51, 95% CI 1.01-2.27). The results remained the same as when using propensity score methods. According to the post hoc analysis, lowering the HbA1c levels by 1% results in a significant decrease in the rate of diabetic complications (adjusted HR 0.92, 95% CI 0.86-0.99), the composite of microvascular complications (adjusted HR 0.91, 95% CI 0.84-0.98) and diabetic nephropathy (adjusted HR 0.89, 95% CI 0.80-0.98). Conclusions: Our results demonstrated a significant effect of clinical inertia on diabetic nephropathy. Patients with an HbA1c level over the target range should have their medication intensified to reduce the risk of diabetic nephropathy.

Neuropsychological Functioning of Youth Receiving Intensive Interdisciplinary Pain Treatment.

Objective: Chronic pain is associated with school difficulties; however, there is limited published evidence on the cognitive or neuropsychological functioning of youth with chronic pain. Method: When beginning intensive interdisciplinary pain treatment, 94 youth (age = 10-18) with chronic pain completed neuropsychological assessment (e.g., intelligence, academic skills, learning and recall, and attention) and clinical questionnaires (e.g., pain and physical and psychological functioning). We compared neuropsychological scores with test norms and with clinical questionnaires. Results: Youth with chronic pain had higher verbal comprehension and full scale IQ scores than expected, below-average nondominant hand dexterity, and difficulty with visual recall. Self-reported difficulties with executive functioning were associated with small-to-moderate difficulties with objectively measured attention. Performance on neuropsychological measures was generally not associated with pain, impairment, anxiety, or depression, though catastrophizing was negatively correlated with perceptual reasoning. An expected number of these youth had learning disorders (14%); however, more than expected had an autism spectrum disorder (9%) or attention deficit hyperactivity disorder (18%), and nearly a quarter demonstrated characteristics of nonverbal learning disability (22%). Conclusions: Some of these cognitive findings may be a consequence of chronic pain, and others may reflect subtle neurodevelopmental differences that may predate or be comorbid with pain. Regardless of etiology, with more than half the current sample experiencing some type of learning challenge, often undiagnosed, pediatric psychologists evaluating youth with chronic pain may wish to screen for comorbid learning difficulties.

Factors influencing choice of skilled birth attendance at ANC: evidence from the Kenya demographic health survey.

BACKGROUND: In Kenya, skilled attendance at delivery is well below the international target of 90% and the maternal mortality ratio is high at 362 (CI 254-471) per 100,000 live births despite various interventions. The preventative role of skilled attendance at delivery makes it a benchmark indicator for safe motherhood. METHODS: Maternal health data from the Service Provision Assessment Survey, a subset of the 2010 Kenya Demographic Health Survey was analyzed. Logistic regression models were employed using likelihood ratio test to explore association between choice of skilled attendance and predictor variables. RESULTS: Overall, 94.8% of women are likely to seek skilled attendance at delivery. Cost, education level, number of antenatal visits and sex of provider were strongly associated with client's intention to deliver with a skilled birth attendant at delivery. Women who reported having enough money set aside for delivery were 4.34 (p < 0.002, 95% CI: 1.73; 10.87) times more likely to seek skilled attendance. Those with primary education and above were 6.6 times more likely to seek skilled attendance than those with no formal education (p < 0.001, 95% CI: 3.66; 11.95). Women with four or more antenatal visits were 5.95 (p < 0.018, 95% CI: 1.35; 26.18) times more likely to seek skilled attendance. Compared to men, female providers impacted more on the client's plan (OR = 2.02 (p < 0.014, 95% CI: 1.35; 3.53). CONCLUSION: Interventions aimed at improving skilled attendance at delivery should include promotion of formal education of women and financial preparation for delivery. Whenever circumstances permit, women should be allowed to choose gender of preferred professional attendant at delivery.

Evidence-based policy responses to strengthen health, community and legislative systems that care for women in Australia with female genital mutilation / cutting.

BACKGROUND: The physical and psychological impact of female genital mutilation / cutting (FGM/C) can be substantial, long term, and irreversible. Parts of the health sector in Australia have developed guidelines in the management of FGM/C, but large gaps exist in community and professional knowledge of the consequences and treatment of FGM/C. The prevalence of FGM/C amongst Australian women is unknown. Our article reviews the literature on research on FGM/C in Australia, which focuses on health system response to women and girls with FGM/C. Recommendations are made for policy reform in health, legislation, and community programs to provide the best healthcare, protect children, and help communities abandon this harmful practice. MAIN BODY: Midwives and doctors in Australia acknowledged a lack of knowledge on FGM/C, clinical guidelines and consequences for maternity care. In a metropolitan Australian hospital with specialised FGM/C care, women with FGM/C had similar obstetric outcomes as women without FGM/C, underlining the importance of holistic FGM/C clinics. Greater focus on integration of refugee and migrant populations into their new cultures may be an important way of facilitating the abandonment of this practice, as is education of communities that practise FGM/C, and experts involved in the care and protection of children. Men could be important advocates for protecting women and girls from violence and FGM/C through a man-to-man strategy with programs focussing on men's health and other personal issues, education, and communication. The Australian Government has identified gender-based violence as an area of priority and has been implementing a National plan to reduce violence against women and their children 2010-2022. A multidisciplinary network of experts on FGM/C could be established within this taskforce to develop well-defined and rapid referral pathways to care for and protect these children, as well as coordinate education and prevention programs to help communities abandon this harmful practice. CONCLUSION: Countries of migration can be part of the solution for abandonment of FGM/C through community interventions and implementation of national and coordinated training in FGM/C of experts involved in the care and protection of children and women. The global focus on collaboration on research, training and prevention programs should be fostered between countries of FGM/C prevalence and migration.

Obstetric outcomes for women with female genital mutilation at an Australian hospital, 2006-2012: a descriptive study.

BACKGROUND: Women, who have been subjected to female genital mutilation (FGM), can suffer serious and irreversible physical, psychological and psychosexual complications. They have more adverse obstetric outcomes as compared to women without FGM. Exploratory studies suggest radical change to abandonment of FGM by communities after migration to countries where FGM is not prevalent. Women who had been subjected to FGM as a child in their countries of origin, require specialised healthcare to reduce complications and further suffering. Our study compared obstetric outcomes in women with FGM to women without FGM who gave birth in a metropolitan Australian hospital with expertise in holistic FGM management. METHODS: The obstetric outcomes of one hundred and ninety-six women with FGM who gave birth between 2006 and 2012 at a metropolitan Australian hospital were analysed. Comparison was made with 8852 women without FGM who gave birth during the same time period. Data were extracted from a database specifically designed for women with FGM and managed by midwives specialised in care of these women, and a routine obstetric database, ObstetriX. The accuracy of data collection on FGM was determined by comparing these two databases. All women with FGM type 3 were deinfibulated antenatally or during labour. The outcome measures were (1) maternal: accuracy and grade of FGM classification, caesarean section, instrumental birth, episiotomy, genital tract trauma, postpartum blood loss of more than 500 ml; and (2) neonatal: low birth weight, admission to a special care nursery, stillbirth. RESULTS: The prevalence of FGM in women who gave birth at the metropolitan hospital was 2 to 3 %. Women with FGM had similar obstetric outcomes to women without FGM, except for statistically significant higher risk of first and second degree perineal tears, and caesarean section. However, none of the caesarean sections were performed for FGM indications. The ObstetriX database was only 35 % accurate in recording the correct FGM type. CONCLUSION: Women with FGM had similar obstetric outcomes to women without FGM in an Australian metropolitan hospital with expertise in FGM management. Specialised FGM services with clinical practice guideline and education of healthcare professionals may increase the detection rate of FGM and improve obstetric management of women with FGM.

Differences in depression between unknown diabetes and known diabetes: results from China health and retirement longitudinal study.

BACKGROUND: Both diabetes and depression have become serious public health problems and are major contributors to the global burden of disease. People with diabetes have been shown to have higher risk of depression. The purpose of this study was to observe the differences in depression between older Chinese adults with known or unknown diabetes. METHODS: Data came from the national baseline survey of China Health and Retirement Longitudinal Study (CHARLS). The Center for Epidemiologic Studies Depression Scale was used to assess depression. Participants with a history of diabetes diagnosis were considered to have known diabetes, and those with newly-diagnosed diabetes were considered to have unknown diabetes. Multiple logistic regression analysis was applied to estimate odds ratio (OR) for depression in predictor variables. RESULTS: Overall, 39.1% of the 2,399 participants with diabetes suffered from depression. The prevalence of depression was significantly higher (p < 0.001) in people with known diabetes (43.5%) than those with unknown diabetes (35.1%). The biggest differences between the two groups were found in the middle aged, in women, in the less educated and in married people. In known diabetes, people treated with traditional Chinese medicine (TCM) coupled with oral western medicine (WM) and/or insulin had two-fold odds of depression compared to those without treatment. CONCLUSION: The knowledge of having diabetes, treatments and suffering from other chronic diseases were associated with the higher prevalence of depression in people with known diabetes compared to those with unknown diabetes. Prevention of depression in diabetics should receive more attention in the middle aged, women and the less education.

Evaluation of older Chinese people's macronutrient intake status: results from the China Health and Nutrition Survey.

Little is known about the macronutrient intake status of older Chinese people. The present study evaluated the macronutrient intake status of older Chinese people (aged ≥ 60 years), investigated whether they had intake levels that met the Dietary Reference Intakes (DRI), and explored the associations between macronutrient intakes and age groups, sex, education levels, work status, BMI groups, urbanicity levels and four socio-economic regions of China (Northeast, East Coast, Central and Western). Dietary intake data of 2746 older Chinese with complete dietary intake data in the Longitudinal China Health and Nutrition Survey (2009 wave) carried out across four diverse regions were analysed. Dietary intake data were obtained by interviews using 24 h recalls over three consecutive days. The MUFA:SFA ratios were calculated based on the Chinese Food Composition Table. Less than one-third of the older Chinese people included in the present study had intake levels meeting the adequate intake for carbohydrate-energy and fat-energy; less than one-fifth had intake levels meeting the recommended nutrient intake for protein-energy; and more than half of the older people had fat-energy intakes higher than the DRI. There were strong associations between the proportions of energy from the three macronutrients and education levels, urbanicity levels and the four socio-economic regions of China, with older people living in the East Coast region having different patterns of macronutrient-energy intakes when compared with those living in the other three regions. Macronutrient intakes across different urbanicity levels in the four regions revealed considerable geographical variations in dietary patterns, which will affect the risk factors for non-communicable diseases. Clinical interventions and public health policies should recognise these regional differences in dietary patterns.

Synthesis and biological evaluation of indole-based, anti-cancer agents inspired by the vascular disrupting agent 2-(3'-hydroxy-4'-methoxyphenyl)-3-(3″,4″,5″-trimethoxybenzoyl)-6-methoxyindole (OXi8006).

The discovery of a 2-aryl-3-aroyl indole-based small-molecule inhibitor of tubulin assembly (referred to as OXi8006) inspired the design, synthesis, and biological evaluation of a series of diversely functionalized analogues. In the majority of examples, the pendant 2-aryl ring contained a 3-hydroxy-4-methoxy substitution pattern, and the fused aryl ring featured a 6-methoxy group. Most of the variability was in the 3-aroyl moiety, which was modified to incorporate methoxy (33-36), nitro (25-27), halogen (28-29), trifluoromethyl (30), or trifluoromethoxy (31-32) functionalities. In two analogues (34 and 36), the methoxy substitution pattern in the fused aryl ring varied, while in another derivative (35) the phenolic moiety was translocated from the pendant 2-aryl ring to position-7 of the fused aryl ring. Each of the compounds were evaluated for their cytotoxicity (in vitro) against the SK-OV-3 (ovarian), NCI-H460 (lung), and DU-145 (prostate) human cancer cell lines and for their ability to inhibit tubulin assembly. Four of the compounds (30, 31, 35, 36) proved to be potent inhibitors of tubulin assembly (IC50 <5µM), and three of these compounds (31, 35, 36) were strongly cytotoxic against the three cancer cell lines. The most active compound (36) in this series, which incorporated a methoxy group at position-7, was comparable in terms of inhibition of tubulin assembly and cytotoxicity to the lead compound OXi8006.

Synthesis of a 2-aryl-3-aroyl indole salt (OXi8007) resembling combretastatin A-4 with application as a vascular disrupting agent.

The natural products colchicine and combretastatin A-4 are potent inhibitors of tubulin assembly, and they have inspired the design and synthesis of a large number of small-molecule, potential anticancer agents. The indole-based molecular scaffold is prominent among these SAR modifications, leading to a rapidly increasing number of agents. The water-soluble phosphate prodrug 33 (OXi8007) of 2-aryl-3-aroylindole-based phenol 8 (OXi8006) was prepared by chemical synthesis and found to be strongly cytotoxic against selected human cancer cell lines (GI50 = 36 nM against DU-145 cells, for example). The free phenol, 8 (OXi8006), was a strong inhibitor (IC50 = 1.1 µM) of tubulin assembly. The corresponding phosphate prodrug 33 (OXi8007) also demonstrated pronounced interference with tumor vasculature in a preliminary in vivo study utilizing a SCID mouse model bearing an orthotopic PC-3 (prostate) tumor as imaged by color Doppler ultrasound. The combination of these results provides evidence that the indole-based phosphate prodrug 33 (OXi8007) functions as a vascular disrupting agent that may prove useful for the treatment of cancer.

Are informal healthcare providers knowledgeable in tuberculosis care? A cross-sectional survey using vignettes in West Bengal, India.

BACKGROUND: India accounts for one-quarter of the world's TB cases. Despite efforts to engage the private sector in India's National TB Elimination Program, informal healthcare providers (IPs), who serve as the first contact for a significant TB patients, remain grossly underutilised. However, considering the substantial evidence establishing IPs' role in patients' care pathway, it is essential to expand the evidence base regarding their knowledge in TB care. METHODS: We conducted a cross-sectional study in the Birbhum district of West Bengal, India. The data were collected using the TB vignette among 331 IPs (165 trained and 166 untrained). The correct case management was defined following India's Technical and Operational Guidelines for TB Control. RESULTS: Overall, IPs demonstrated a suboptimal level of knowledge in TB care. IPs exhibited the lowest knowledge in asking essential history questions (all four: 5.4% and at least two: 21.7%) compared with ordering sputum test (76.1%), making a correct diagnosis (83.3%) and appropriate referrals (100%). Nonetheless, a statistically significant difference in knowledge (in most domains of TB care) was observed between trained and untrained IPs. CONCLUSIONS: This study identifies gaps in IPs' knowledge in TB care. However, the observed significant difference between the trained and untrained groups indicates a positive impact of training in improving IPs' knowledge in TB care.

Barriers and facilitators to informal healthcare provider engagement in the national tuberculosis elimination program of India: An exploratory study from West Bengal.

India has a high burden of Tuberculosis (TB), accounting for a significant portion of global cases. While efforts are being made to engage the formal private sector in the National TB Elimination Program (NTEP) of India, there remains a significant gap in addressing the engagement of Informal Healthcare Providers (IPs), who serve as the first point of contact for healthcare in many communities. Recognizing the increasing evidence of IPs' importance in TB care, it is crucial to enhance their engagement in the NTEP. Therefore, this study explored various factors influencing the engagement of IPs in the program. A qualitative study was conducted in West Bengal, India, involving 23 IPs and 11 Formal Providers (FPs) from different levels of the formal health system. Thematic analysis of the data was conducted following a six-step approach outlined by Braun and Clarke. Three overarching themes were identified in the analysis, encompassing barriers and facilitators to IPs' engagement in the NTEP. The first theme focused on IPs' position and capacity as care providers, highlighting their role as primary care providers and the trust and acceptance extended by the community. The second theme explored policy and system-level drivers and prohibitors, revealing barriers such as role ambiguity, competing tasks, and quality of care issues. Facilitators such as growing recognition of IPs' importance in the health system, an inclusive incentive system, and willingness to collaborate were also identified. The third theme focused on the relationship between the formal and informal systems, highlighting a need to strengthen the relationship between the two. This study sheds light on factors influencing the engagement of IPs in the NTEP of India. It emphasizes the need for role clarity, knowledge enhancement, and improved relationships between formal and informal systems. By addressing these factors, policymakers and stakeholders can strengthen the engagement of IPs in the NTEP.

Electronic Cigarette Use and Other Factors Associated with Cigarette Smoking among Thai Undergraduate Students.

The prevalence of smoking among young adults in Thailand has gradually increased. Therefore, this study aimed to identify factors associated with cigarette smoking among undergraduate students. This cross-sectional study used a self-administered, anonymous online questionnaire to gather data from undergraduate students across four universities in Chiang Mai Province, Thailand. All 1126 participants were an average age of 21.30 years old (SD 1.48). The findings revealed seven factors significantly associated with cigarette smoking (p < 0.05), including male sex, having no medical conditions, consuming alcohol daily and consuming alcohol in the past, having brothers or sisters who smoked cigarettes, having a father or mother who smoked cigarettes, having parents who considered smoking acceptable and having parents who had uncertain concerns about smoking, and had or have used electronic cigarettes (e-cigarettes). These associated factors could be useful in implementing appropriate tobacco-control programs to prevent cigarette smoking among undergraduate students. Relevant organizations, universities and healthcare professionals should communicate correct and appropriate information about the illness and diseases caused by using tobacco products to strengthen the correct perceptions of the harms of cigarette smoking and e-cigarette use among undergraduate students. Furthermore, smoke-free policies should be monitored and strictly enforced, particularly in university areas.

Universal Health Coverage and the Pacific Islands: An Overview of Senior Leaders' Discussions, Challenges, Priorities and Solutions, 2015-2020.

In 1995, Pacific Health Ministers articulated their vision of a healthy Pacific as 'a place where children are nurtured in body and mind; environments invite learning and leisure; people work and age with dignity; where ecological balance is a source of pride; and where the ocean is protected.' Central to this vision is the achievement of universal health coverage (UHC). To provide an indication of the UHC-related priorities of Pacific health authorities and promote alignment of domestic and international investments in health sector development, we thematically analyzed the discussion, resolutions, and recommendations from 5 years (2015-2020) of senior-level Pacific health meetings. Five main themes emerged: (i) the Healthy Islands vision has (and continues to have) a unifying influence on action for UHC; (ii) adoption of appropriate service delivery models that support integrated primary health care at the community level are needed; (iii) human resources for health are critical if efforts to achieve UHC are to be successful; (iv) access to reliable health information is core to health sector improvement; and (v) while not a panacea for all challenges, digital health offers many opportunities. Small and isolated populations, chronic workforce limitations, weak governance arrangements, ageing and inadequate health facilities, and supply chain and logistics difficulties (among other issues) interact to challenge primary health care delivery across the Pacific Islands. We found evidence that the Healthy Islands vision is a tool that garners support for UHC; however, to realize the vision, a realistic understanding of needed political, human resource, and economic investments is required. The significant disruptive effect of COVID-19 and the uncertainty it brings for implementation of the medium- to long-term health development agenda raises concern that progress may stagnate or retreat.

Smartphone Application for Smoking Cessation (Quit with US): A Randomized Controlled Trial among Young Adult Light Smokers in Thailand.

This study aimed to determine the efficacy of a smartphone application named Quit with US among young adult smokers. An open-label, parallel, 2-group, randomized controlled trial with a 12-week follow-up was conducted between March and November 2020 among undergraduate students (18 to 24 years) in Chiang Mai Province, Thailand. A total of 273 participants were assigned by simple randomization procedure to the Quit with US intervention group (n = 137) or the control group (n = 136). All participants received pharmacists' smoking cessation counseling at baseline and follow-ups. In addition, the intervention group's participants were advised to use Quit with US. The baseline and 12-week follow-up assessments were conducted at a study unit, whereas other follow-ups were completed over the telephone. The primary abstinence outcome was the exhaled CO concentration level (≤6 ppm) verified 7-day point prevalence abstinence. At baseline, the participants' mean (standard deviation) age was 21.06 (1.62) years. Most identified as daily smokers (57.9%, n = 158), consumed ≤10 cigarettes daily (89.4%, n = 244), and expressed low level of nicotine dependence as measured by Heaviness of Smoking Index score (86.1%, n = 235). Regarding intention-to-treat analyses, participants in the Quit with US intervention group achieved significantly greater smoking abstinence rate than those in the control group (58.4% (80/137) vs. 30.9% (42/136), risk ratio = 1.89, 95% confidence intervals = 1.42 to 2.52, p < 0.001). In conclusion, Quit with US integrated with pharmacists' smoking cessation counseling significantly enhanced smoking abstinence rates among young adult light smokers consuming ≤ 10 cigarettes daily.

What do general practitioners want from specialist alcohol and other drug services? A qualitative study of New South Wales metropolitan general practitioners.

INTRODUCTION: Alcohol and other drug (AOD) use is common in Australia with significant health and community impacts. General practitioners (GP) often see people with AOD use; however, there is little research to understand how specialist AOD services could assist GPs in the management of patients with AOD issues. METHODS: Thirty-five GPs working in general practice in a metropolitan area in Sydney in New South Wales, Australia, participated in one of three focus groups. The groups were recorded, transcribed and thematically analysed. RESULTS: The five themes raised by participants were: GP personal agency and interest in AOD issues; GP education and training gaps; improving pathways between GP and specialist AOD services; easier access to AOD specialist advice; and improving access to collaborative care for patients with complex AOD presentations. Participants requested education on screening, assessing, managing AOD issues, focused on alcohol, stimulants and high-risk prescription medicines. They suggested better referral processes, discharge summaries and care planning for complex presentations. Participants wanted easy access to specialist advice and suggested collaborative care assisted by experienced AOD liaison nurses. DISCUSSION AND CONCLUSIONS: Australia has several existing programs; online referral pathways and specialist phone advice, that address some of the issues raised. Unfortunately, many participants were not aware of these. GP education must be supported by multiple processes, including durable referral pathways, ready access to local specialist advice, clear communication (including patient attendance and a treatment plan), care planning and written summaries.

Time to Treatment Intensification to Reduce Diabetes-Related Complications: A Post Hoc Study.

Patients with type 2 diabetes mellitus (T2DM) can be affected by clinical inertia, leading to abysmal results. Studies on a suitable timeframe for treatment intensification remain scarce-especially outside of developed countries. This study aimed to explore the association between time to treatment intensification and diabetes-related complications. A database from a tertiary care hospital in Thailand was retrieved in order to conduct a retrospective cohort study for the years 2011-2017. This study comprised outpatients with T2DM presenting an HbA1c of ≥7.0%. Eligible patients were divided into three groups based on the time of treatment intensification: no delayed treatment intensification, treatment intensification within 6 months, and treatment intensification after 6 months. A Cox proportional hazards model was used to investigate the association between time to treatment intensification and diabetes-related complications. A total of 686 patients were included in the final analysis. During 6.5 years of median follow-up, the group with treatment intensification within 6 months was more strongly associated with diabetic nephropathy compared to the group with no delayed treatment intensification (adjusted HR 2.35; 95%CI 1.35-4.09). Our findings reveal that delaying treatment intensification by even 6 months can increase the likelihood of diabetic nephropathy compared to no delayed treatment intensification. We suggest that patients with T2DM whose blood glucose levels are outside the target range promptly receive treatment intensification.

What are the tuberculosis care practices of informal healthcare providers? A cross-sectional study from Eastern India.

India is the highest TB burden country, accounting for an estimated 26% of the global TB cases. Systematic engagement of the private sector is a cornerstone of India's National Strategic Plan for TB Elimination (2017-25). However, informal healthcare providers (IPs), who are the first point of contact for a large number of TB patients, remain significantly underutilized in the National TB Elimination Program of India. Non-prioritization of IPs has also resulted in a limited understanding of their TB care practices in the community. We, therefore, undertook a descriptive study to document IPs' TB care practices, primarily focusing on their approach to screening, diagnosis, treatment and referral. This cross-sectional study was carried out from February to March 2020 in the Birbhum District of West Bengal, India. Interviews were conducted utilizing the retrospective case study method. A total of 203 IPs participated who reported seeing at least one confirmed TB patient in 6 months prior to the study. In that duration, IPs reported interacting with an average of five suspected TB cases, two of which were later confirmed as having TB. Antibiotic use was found to be common among IPs (highest 69% during the first visit); however, they were prescribed before the patient was suspected or confirmed as having TB. We noted the practice of prolonged treatment among IPs as patients were prescribed medicines until the second follow-up visit. Referral was the preferred TB case management approach among IPs, but delayed referral was observed, with only one-third (34%) of patients being referred to higher health facilities during their first visit. This study presents important findings on IPs' TB care practices, which have consequences for achieving India's national goal of TB elimination.