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BACKGROUND: The authors examined whether use of preventive oral health care services or visits to a dentist or dental clinic for problems during pregnancy is associated with gestational diabetes and hypertensive disorders of pregnancy. METHODS: Data from the 2016-2020 Pregnancy Risk Assessment Monitoring System, comprising 206,080 unweighted responses, were analyzed using descriptive statistics and multivariable logistic regression. The regression estimates were adjusted for sociodemographic and lifestyle characteristics, health history, geography, and survey year. RESULTS: Women who received a diagnosis of gestational diabetes (7.0%) or hypertensive disorders of pregnancy (13.3%) had lower rates of preventive oral health care and visits to a dentist or dental clinic for problems during pregnancy than those who did not have these health outcomes. Women who did not receive preventive oral health care had 1.13-fold greater odds (95% CI, 1.06 to 1.20) of having gestational diabetes and 1.08-fold greater odds (95% CI, 1.03 to 1.13) of having hypertensive disorders of pregnancy than those who did. Lack of needed visits to a dentist or dental clinic during pregnancy was associated with 1.28-fold greater odds (95% CI, 1.13 to 1.44) of having hypertensive disorders of pregnancy than in women without dental problems. CONCLUSIONS: Using oral health care preventive services and visits to a dentist or dental clinic for problems during pregnancy was associated with decreased odds of having gestational diabetes and hypertensive disorders of pregnancy. PRACTICAL IMPLICATIONS: Health care professionals should emphasize the importance of obtaining oral health care services to promote oral and overall health among pregnant women. Dentists need to improve their knowledge and willingness to treat pregnant women, especially those with pregnancy complications.

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Background: Lower urinary tract symptoms particularly affect older men and their quality of life. General practitioners currently have no easily available assessment tools to diagnose lower urinary tract symptom causes. Referrals to urology specialists are increasing. General practitioner access to simple, accurate tests and clinical decision tools could facilitate management of lower urinary tract symptoms in primary care. Objectives: To determine which of several index tests in combination, best predicted three diagnoses (detrusor overactivity, bladder outlet obstruction and/or detrusor underactivity) in men presenting with lower urinary tract symptoms in primary care. To develop and validate three diagnostic prediction models, and a prototype primary care clinical decision support tool. Design: Prospective diagnostic accuracy study. Two participant cohorts, for development and validation, underwent simple index tests and a reference standard (invasive urodynamics). Setting: General practices in England and Wales. Participants: Men (16 years and over) consulting their general practitioner with lower urinary tract symptoms. Sample size: Separate calculations for model development and validation cohorts, from literature estimates of detrusor overactivity, bladder outlet obstruction and detrusor underactivity prevalences of 57%, 31% and 16%, respectively. Predictors and index tests: Twelve potential predictors considered for three diagnostic models. Main outcome measures: The primary outcome was diagnostic model sensitivity and specificity for detecting bladder outlet obstruction, detrusor underactivity and detrusor overactivity, with 75.0% considered minimum clinically useful performance. Statistical analysis: Three separate logistic regression models generated with index test variables to predict the presence of bladder outlet obstruction, detrusor overactivity, detrusor underactivity conditions in men with lower urinary tract symptoms. Results: One model each was developed and validated for bladder outlet obstruction and detrusor underactivity, two for detrusor overactivity (detrusor overactivity main, detrusor overactivity sensitivity analysis 2). Age, voiding symptoms subscore, prostate-specific antigen level, median maximum flow rate, median voided volume were predictors for bladder outlet obstruction. Median maximum flow rate and post-void residual volume were predictors for detrusor underactivity. Age, post-void residual volume and median voided volume were included in detrusor overactivity main model, while age and storage symptoms subscore predicted detrusor overactivity sensitivity analysis 2. For all four models, sensitivity of 75.0% could be achieved with a specificity of 74.2%, 47.3%, 45.6% and 46.2% for bladder outlet obstruction, detrusor underactivity, detrusor overactivity main and detrusor overactivity sensitivity analysis 2 models, respectively. Similarly, a specificity of 75.0% could be achieved with a sensitivity of 71.3%, 39.8%, 33.3% and 62.7% for bladder outlet obstruction, detrusor underactivity, detrusor overactivity main and detrusor overactivity sensitivity analysis 2 models, respectively. The prototype tool (not yet intended for use in practice) is available at Primary care Management of lower Urinary tract Symptoms decision aid for lower urinary tract symptoms (shinyapps.io). General practitioner feedback during tool development and small-scale user-testing in simulated consultation scenarios was favourable. Patients supported such management in primary care. Strengths/limitations: This was a prospective, multicentre study in an appropriate primary care population. Most of the index tests are possible routinely in primary care or at home by patients. The diagnostic models were validated in a separate cohort from the same population. Limitations include that target condition prevalences may differ in other populations. Conclusion: We identified sensitivities and specificities of diagnostic models for detrusor overactivity, bladder outlet obstruction and detrusor underactivity in routine United Kingdom practice and developed a prototype clinical decision support tool. Future work: Economic modelling, a feasibility trial and powered randomised controlled trial are needed to evaluate the Primary care Management of lower Urinary tract Symptoms tool in practice. Study registration: Current Controlled Trials ISRCTN10327305. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/40/05) and is published in full in Health Technology Assessment; Vol. 29, No. 1. See the NIHR Funding and Awards website for further award information.

Urinary symptoms such as a weak flow and frequent urination are common in older men and often bothersome. Men visiting their general practitioner with these symptoms are often referred to a specialist because good diagnostic tools are not available in primary care. Three common causes of symptoms are: bladder obstruction due to non-cancerous growth of the prostate, reduced power of the bladder muscle and bladder overactivity. We aimed to create a tool to help general practitioners manage men with urinary symptoms. This required first to develop mathematical models, which combined results from several simple tests that general practitioners could organise. The web-based tool then constructed would indicate the most likely diagnosis and provide recommendations for treating and managing the condition. The tests included prostate examination, prostate-specific antigen blood test, symptoms questionnaires and home-based urine flow measurements. To develop the mathematical models, 350 men with urinary symptoms underwent the simple tests and a specialist invasive test called urodynamics, which is currently regarded as providing the best diagnosis. A second group of 251 men also had the simple tests and urodynamics. Their results were used to measure the performance of the models. The model to diagnose bladder obstruction performed well (close to the invasive urodynamics 'gold standard' test), and those to diagnose reduced power of the bladder muscle and bladder over-activity performed moderately but less well. A prototype version of the web-based tool was developed. We consulted patients and general practitioners to assess the tool's acceptability. General practitioners confirmed their enthusiasm because they find managing bladder symptoms challenging, and patients said they would prefer to be managed in primary care. We received good feedback about the prototype tool and gained ideas for refining it. Following this project, it would be valuable to estimate the cost, benefits and practicalities of implementing the tool, aided by data from the study, and trial its effectiveness compared with current care.

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BACKGROUND: Polysubstance use is a defining feature of the opioid overdose epidemic in the United States today. Most quantitative studies of polysubstance use rely on 30-day retrospective measures. Understanding how drugs are co-used in shorter (daily and hourly) timeframes enhances our understanding of polysubstance-related overdose risk. METHODS: We used ecological momentary assessment (EMA) to assess polysubstance in community-based sample of people who use drugs in Oakland, CA (N = 117). Participants provided data on substance use three times daily over 28 days, using a smartphone app. We created binary variables of same-day and same-hour polysubstance use and estimated its prevalence with mixed-effects logistic regression models. RESULTS: The response rate to thrice-daily prompts was 64.6 %. The prevalence of same-day polysubstance use on any given day was 0.77 (95 % CI 0.73, 0.82), and the prevalence of same-hour polysubstance use was 0.71 (95 % CI 0.66, 0.76). Defined as the combination of opioids with stimulants, opioids with alcohol, opioids with benzodiazepines, or more than one opioid in the same hour, the probability of risky polysubstance use on a given day was 0.59 (95 % CI 0.52, 0.65). Excluding methadone from a treatment program, the probability of risky polysubstance use on a given day was 0.51 (95 % CI 0.44, 0.58). CONCLUSIONS: Our findings highlight the importance of targeted prevention efforts addressing the diverse substance combinations that increase overdose risk. It is crucial to develop and test substance use treatment and overdose prevention strategies that address the complexities of polysubstance use, in partnership with people who use drugs.

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OBJECTIVES: Hemorrhage represents a notable adverse event (AE) associated with the utilization of SSRIs and SNRIs. This study aimed to provide valuable insights for clinical practice by providing a comprehensive understanding of hemorrhage events associated with SSRIs/SNRIs. METHODS: Ten-year data on the main SSRIs/SNRIs were extracted from the FAERS database for the period spanning from 2014 to 2023. Reporting odds ratio (ROR) and proportional reporting ratio (PRR) were employed to quantify the signals. Finally, a comparative analysis was conducted between demographic data, outcomes, and inherent associations among the medications and the signals. RESULTS: Approximately 3.86% of all patients who experienced adverse effects with SSRIs/SNRIs were found to have hemorrhage-related AEs (HrAEs). The majority of these patients were female and aged sixty years or older. The primary outcomes for patients experiencing HrAEs included initial or prolonged hospitalization, mortality, life-threatening conditions, and other complications. After conducting an analysis using ROR and PRR methods, we obtained several positive signals for HrAE (p-HrAEs). Gastrointestinal and nervous system disorders were identified as the predominant p-HrAEs. Sertraline demonstrated the most pronounced signals for gastrointestinal disorders, particularly upper gastrointestinal hemorrhage. Correlations have been observed between the use of citalopram, escitalopram, paroxetine, venlafaxine and cerebral/cerebellar hematoma in terms of nervous system. However, duloxetine did not result in any signals in these two systems. CONCLUSIONS: p-HrAEs associated with SSRIs/SNRIs were identified through real-world pharmacovigilance analysis. It is anticipated that this paper will offer additional information regarding safe and rational medication for patients taking antidepressants.

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An assessment has been carried out to evaluate the annual effective dose to the Irish adult population due to the ingestion of natural radionuclides in food. The assessment is based on the analysis of a range of natural radionuclides (14C, 40K, 210Pb, 210Po, 226Ra, 228Ra, 228Th and 238U) in duplicate diet samples collected from eight volunteers over a one-week period. Measured radionuclide concentrations, together with an average consumption rate obtained directly from the survey (337 ± 40 kg/yr) have been used to calculate the annual ingestion effective dose, which is estimated to be 297 ± 20 µSv/yr. This dose is in good agreement with previous Irish ingestion dose assessments and with estimated worldwide average ingestion dose from natural sources.

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Academic dishonesty is becoming more common among university students in science, technology, engineering, and mathematics (STEM)-based programs. This is concerning because these students hold positions of responsibility in their professional careers. The purpose of this qualitative study was to examine if a student's academic standing and/or first-generation (First-Gen) status would affect their views of academic integrity and dishonesty within their academic coursework. Freshmen completed reflections at the start and end of their first semester of college. Qualitative responses from their reflections were reviewed and organized into common themes. Students were grouped based on university matriculation criteria [high-school grade-point average (GPA), Standards Admissions Test (SAT), and the American College Test (ACT) scores and parental higher education status]. The primary findings of the study demonstrated that the students responded similarly to their views of academic honesty, but some themes were more prevalent across the groups (First-Gen, Honors, and Pre-Math). This study identified several areas to help STEM students in a physiology-based program gain a better understanding of academic integrity and dishonesty.NEW & NOTEWORTHY A qualitative investigation of the views of academic honesty among freshmen in a physiology-based program.

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INTRODUCTION: In the current era of universal antiretroviral treatment (ART), health systems have the dual challenge of a growing number of people living with HIV and on ART who are also receiving chronic, life-long treatment for non-communicable diseases. Current evidence suggests that 6-month multi-month dispensing (6MMD) can maintain at least equivalent clinical outcomes to conventional care and reduce costs, but little is known when integrating 6MMD for multiple conditions. We examined the cost-effectiveness of integrated multi-month drug dispensing for people living with HIV and hypertension. METHODS: Using an age- and sex-specific hybrid decision tree and Markov state-transition model, we constructed a 100,000-person simulated population cohort who may develop HIV and hypertension and initiate treatment at clinics in South Africa over a 10-year time horizon. We assessed the incremental costs and effectiveness of 6MMD versus conventional care from a health system perspective under different conditions of care-seeking, eligibility and uptake of 6MMD for clinically stable patients. Model inputs were sourced from previously published literature. 6MMD was defined as reducing the frequency of clinic visits by increasing the number of medications dispensed to stable patients at each visit from 3 to 6 months. For the integrated 6MMD, we assumed that comorbid patients receive both HIV and hypertension drugs at the same facility on the same day. RESULTS: Our study demonstrates that integrated 6MMD for HIV and hypertension in South Africa can avert between 0.8 and 1 DALYs and increase health systems costs between $24 and $49 per patient per year, compared to the status quo. One-way sensitivity analysis showed that HTN drug cost and prevalence of HIVHTN and HIV were key drivers in the cost per DALYs averted. Overall, integrated 6MMD with a greater proportion of well-controlled patients and lower mortality rates led to greater cost savings or better cost-effectiveness (less than $50 per DALY averted) across a wide range of loss-to-follow-up (LTFU) factor variation. CONCLUSIONS: By better controlling disease among patients already in care, integrated 6MMD can be more beneficial than the status quo treatment by resulting in fewer cases of LTFU and fewer deaths through high-quality care.

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Patient navigation shows promise for improving healthcare access and health information, though its impact on health literacy among underserved populations in developing countries remains underinvestigated. This study evaluated the effectiveness of patient navigation services in improving health literacy in the Philippines. Using a quasi-experimental, one-group pretest-posttest design over 2 months, 105 participants were recruited through random sampling from a tertiary hospital. The intervention provided personalized guidance on healthcare access, health information, appointment scheduling, and referrals. Health literacy was assessed across four dimensions (Access, Understand, Appraise, Apply) using a researcher-developed questionnaire. Participant demographics showed a majority aged 18-30 years (68.6%), female (75.2%), single (63.8%), and college/university educated (53.3%). Nearly half (45.7%) had no income, while 31.4% earned below minimum wage. Participants reported using patient navigation to consult a doctor (75.2%) and were made aware of the available services mostly through other family members (28.6%). Follow-up data revealed significant improvements across all health literacy dimensions (P < .001). In the Access dimension, participants who strongly agreed increased from 18% to 35% in knowing where to find information, and from 16% to 34% in having easy access. The Understand dimension showed gains from 20% to 39% for comprehending provider information, and 21% to 38% for understanding risks and benefits. The Appraise dimension improved from 22% to 36% for evaluating accuracy, and 24% to 39% for asking pertinent questions, while the Apply dimension increased from 25% to 35% for making informed decisions, and 23% to 37% for taking health action. These results suggest that patient navigation services can effectively enhance health literacy among Filipino adults, demonstrating the potential of this patient-centered approach in promoting health equity in similar settings.

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OBJECTIVE: Family history is amongst the most significant risk factors for psychotic and bipolar disorders. Despite being clearly defined, easily and early identifiable, familial high-risk status is minimally accounted for in mainstream prevention paradigms. This study reports on the demographics and clinical characteristics of youth with a first-degree relative affected by psychotic or bipolar disorders within a large academic healthcare system. METHOD: In this quality improvement study, using electronic medical records, the authors examined demographics, psychiatric and medical diagnoses, substance use, service utilisation, and psychotropic medication use in children, adolescents and young adults (age 24 or younger) with and without a family history of psychotic or bipolar disorders within the Mass General Brigham (MGB) healthcare system. RESULTS: Family history-positive (FHP) youth demonstrated markedly higher rates of psychiatric problems (57.8%) compared to family history-negative (FHN) youth (8.5%), including higher rates of psychotic and bipolar disorders, as well as anxiety disorders and depression. FHP youth also had more frequent psychotropic medication use and medical problems. Additionally, FHP youth reported higher cannabis and alcohol use, along with higher rates of suicidal ideation and trauma. Despite this, only 4% of FHP youth visited an MGB psychiatry or psychology department within the six months preceding the analysis. CONCLUSION: FHP youth constitute a distinct and practically identifiable risk cohort within a large academic healthcare system. Increased psychiatric and medical problems coupled with more prevalent risk factors amongst familial high-risk youth highlight the need for tailored clinical programmes to achieve both primary and secondary prevention.

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OBJECTIVE: The present study investigated the associations between symptom-related expectations, self-management experiences and expectation framing on somatic symptom severity in university students in two conditions (positive or standard expectation framing). We hypothesised that symptom-related expectations are significantly associated with concurrent and subsequent levels of somatic symptom depending on expectation framing. DESIGN: A smartphone-based micro-longitudinal ecological momentary assessment study with randomisation to one of two expectation framing groups (positive vs negative) was carried out. Multilevel mixed-effects linear regression analyses were conducted for data analysis. SETTING: Data was collected in real-time from university students via smartphones, with three predetermined assessments per day over seven consecutive days. PARTICIPANTS: A total of 104 students (63.5% male, 0% diverse) who were 18 years or older, possessing sufficient German language skills and had access to an Android-powered smartphone were included. INTERVENTIONS: Participants were randomised to one of two different expectation framing groups, either receiving questionnaires for the expected impairment due to somatic symptoms (negative framing) or for the expected freedom from impairment due to somatic symptoms (positive framing). PRIMARY OUTCOME MEASURES: Somatic symptom severity was assessed using an adapted version of the Patient Health Questionnaire, with 11-point instead of 3-point Likert-scales. Symptom-related expectations were assessed using 11-point Numerical Rating Scales and self-management experiences were assessed using binary variables. RESULTS: Concurrent analysis revealed a significant association between symptom-related expectations and symptom severity (ß=0.934, p<0.001), but no significant associations between self-management experiences and symptom severity. Regarding expectation framing, participants in the negative group reported higher symptom severity levels than those in the positive group (ß=-0.071, p<0.001). Results indicated a stronger association between symptom-related expectations and symptom severity in the negative framing group (ß=-0.088, p<0.001). Time-lagged analysis showed higher levels of symptom-related expectations predicted higher subsequent symptom severity levels (ß=0.502, p<0.001), whereas preceding symptom severity levels or self-management experiences did not predict subsequent symptom severity levels. Negative framing was associated with higher subsequent symptom severity levels (ß=-0.158, p<0.001). The effect of symptom-related expectations on subsequent symptom severity levels was independent of expectation framing. CONCLUSIONS: Our findings highlight the impact of expectations and expectation framing on somatic symptom severity among university students and expand the knowledge needed for the development of expectation management techniques. TRIAL REGISTRATION NUMBER: ISRCTN36251388.

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OBJECTIVE: This study investigates Saudi Arabian physiotherapists' perspectives on direct access to physiotherapy (DAPT) services, focusing on perceived benefits, barriers and implementation in clinical practice. METHODS: A cross-sectional observational study design was used. Data collection occurred between December 2022 and June 2023 via an online structured questionnaire distributed through email and text messages. The DAPT section comprised items on awareness, endorsement, obstacles/barriers to implementation in Saudi Arabia, perceived benefits and expected benefits of various resources to guide evidence-based practice for physiotherapists. This section featured closed-ended questions using a 5-point Likert scale. The study included licensed physiotherapists currently working in Saudi Arabia. RESULTS: The study included 401 participants, with a nearly equal distribution of 203 males (50.6%) and 198 females (49.4%). The most common age group was 25-34 years, comprising 70.6% of the participants. A significant proportion (61.6%) were aware of DAPT, and 88% acknowledged its potential to reduce delays in care. However, 49.9% had not engaged with relevant literature. The primary barriers to DAPT identified were laws and regulations (mean=3.69, SD=1.21), physician support (mean=3.59, SD=0.99), entry-level education (mean=3.45, SD=1.17), patient beliefs (mean=3.38, SD=1.24), self-confidence (mean=3.35, SD=1.15) and professional autonomy (mean=3.34, SD=1.22). CONCLUSION: Physiotherapists in Saudi Arabia demonstrate substantial awareness of direct access. Organisational initiatives and increased awareness are essential to promote direct access. This study highlights that direct patient access to physiotherapists offers significant benefits to patients, healthcare workers and the broader community.

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This study aims to analyze changes in the disease burden of cystic echinococcosis in China from 1990 to 2019 and to predict trends from 2020 to 2044. Using the Global Burden of Disease 2019 (GBD 2019) database, we analyzed the trends in annual percentage change (APC) and average annual percentage change (AAPC) for incidence, prevalence, death, and disability-adjusted life years (DALY) rates of cystic echinococcosis in China via the Joinpoint Regression Program 4.8.0.1 software. Additionally, we applied Nordpred modeling to predict future trends in disease burden over the next 25 years. From 1990 to 2019, the incidence and prevalence of cystic echinococcosis in the Chinese population showed an overall increasing trend, whereas the death and DALY rates exhibited an overall decreasing trend. The disease burden of cystic echinococcosis was greater in males than in females, with significant differences across age groups. The highest incidence and prevalence rates were observed in the 10-24 years age group, whereas the lowest occurred in the 0-9 years age group. Fatalities and DALY rates increased with age, particularly in the 70 and older age groups. According to the Nordpred modeling results, the incidence, prevalence, and DALY rates of cystic echinococcosis in China are expected to rise slightly over the next 25 years. The overall disease burden of cystic echinococcosis is projected to increase gradually between 2020 and 2044, with men exhibiting higher incidence, prevalence, and DALY rates than women.

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OBJECTIVE: The Montreal Cognitive Assessment (MoCA) is a brief screening instrument for detecting mild cognitive dysfunction, a precursor to many cognitive disorders, such as dementia, which have increased in prevalence globally. Qatar, a small high-income country, has the largest projected increase in dementia of any country in the Middle East. Yet no population-based norms for cognitive function are available to date. METHODS: As part of the first national cross-sectional study of mental health, a total of 395 Qatari and non-Qatari Arabs, 18-74 years of age, were evaluated face-to-face using the Arabic version of the original MoCA (version 7.1). We computed raw and demographically (gender, age in years, and four education categories) adjusted scores for the overall MoCA test and six domains (visuospatial, executive function, attention, language, delayed memory, and orientation). The percentile ranking of raw and adjusted normative (z) scores was computed. The 5th percentile ranking was used to derive potential cut-offs for the overall test and the six related domains. RESULTS: Female gender, older age, and lower levels of education were associated with poorer overall test scores. The following MoCA overall test and domains cut-off scores (rounded to the nearest integer) were identified: MoCA (22), visuospatial (2), executive (2.5), attention (4), language (4), and delayed memory (3). CONCLUSIONS: On the basis of our population-based data, scores below these 5th percentile cut-offs may warrant further testing and clinical follow-up for mild cognitive impairment (MCI) in otherwise healthy Arab adults.

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Mating and labor markets are fundamental drivers of societal dynamics. Yet, equity of access to these domains differs between the sexes due to numerous biological, economic, psychological, and socio-cultural factors. These inequalities and their impacts can accentuate perceptions, preferences, and behaviors of males and females in different ways. Utilizing a large cross-sectional sample of those currently engaged in the Australian mating market (n = 1072 online daters), we explored the impact of sex and individual differences on the perceptions of men's ease of access to a decent job in the labor market (opportunity), women's economic dependence on men (economic inequality), and relative reproductive opportunity (dating access) for both sexes. Our study identifies both sex differences and symmetries in socio-economic factors (such as education level and having offspring) correlating with the perceptions of both economic and dating market access for Australian online daters. Additionally, key resource endowment indicators (income and unemployment) also reflect differences in both sexes' perceptions of both access and gender equity. That said, our study finds that perceptions of access to both (economic and mating) markets shows far greater variation based on biological age (especially for women) than any other factor.

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OBJECTIVES: To assess real-world survival and healthcare resource utilization (HCRU) in US patients with non-cystic fibrosis bronchiectasis (NCFBE). METHODS: This retrospective analysis, using data from the STATinMED RWD Insights database from Jan 2015-Oct 2022, included adults with NCFBE (from Jan 2015-Oct 2021) and non-NCFBE comparators (from Jan 2015-Aug 2020); baseline characteristics were balanced by inverse probability treatment weighting. Outcomes included survival through end of study. HCRU was assessed over 12 months. RESULTS: 117,718 patients with NCFBE and 306,678 comparators were included. Patients with NCFBE had a 77% higher risk of death than comparators (hazard ratio [HR] 1.77 [95% CI 1.74-1.80]). Risk of death was higher among patients aged ≥65 years (vs 18-34 years; HR 11.03 [95% CI 10.36-11.74]), among Black patients (vs White; HR 1.53 [95% CI 1.50-1.55]), and among patients with comorbid COPD (HR 1.42 [95% CI 1.40-1.44]). Patients with NCFBE incurred higher all-cause and respiratory-related HCRU than comparators for outpatient office, outpatient hospital, emergency department (ED), inpatient and respiratory-related pulmonologist visits (all p < .0001); HCRU increased with exacerbations. CONCLUSIONS: Patients with NCFBE have high mortality burden and incur high HCRU, both of which are further increased with exacerbations. Prevention and delay of exacerbations are key areas for improvement of disease management.

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BACKGROUND: Public involvement in reporting adverse drug reactions (ADRs) generates a broader database on drug safety. Underreporting remains a hindrance to implementing an effective pharmacovigilance system that ultimately affects public health. Hence, it is critical to appraise the public's awareness of ADR reporting and pharmacovigilance to address the gaps for the enhancement of ADR reporting rate. OBJECTIVES: The current study explored public knowledge and attitudes toward ADR reporting in Karachi, Pakistan. METHODS: A quantitative cross-sectional study was conducted from 3rd Jan 2022 to 30th Nov 2022 using a forty-item questionnaire to evaluate public insights regarding the ADR and its reporting. Descriptive analysis was executed to determine frequencies and percentages for the respondents' baseline characteristics and the responses toward ADR reporting. The chi-square test (χ2) was applied to determine the association between the dependent and independent variables considering a p-value < 0.05 as statistically significant. RESULTS: The response rate of the present study was 78.3%. More than 80% of the respondents deemed that ADR occurs only with high doses of medicines and over-the-counter medications do not cause any ADR. More than 75% of the respondents did not know that the ADR reporting form is available on the Drug Regulatory Authority of Pakistan (DRAP) website; the response varied significantly with the education (p = 0.002) and social status (p = 0.0001) of the respondents. More than 50% of the participants refused to ever report an ADR to health professionals. Physicians (n = 364; 47.7%) and pharmacists (n = 253; 33.1%) were the respondents' professed most reliable sources to whom ADR can be reported; responses varied significantly with their education (p = 0.003) and age (p = 0.001). CONCLUSIONS: The study has provided insight into the challenges and gaps needed to improve ADR reporting in Pakistan. The outcomes revealed that the public is aware of the benefits of reporting ADRs; however, they do not realize their role and the potentially significant impact on the healthcare system by contributing to ADR reporting. Therefore, it is a need of time to educate the public on the value of reporting ADRs and implement user-friendly and accessible ADR reporting systems in patient care areas to facilitate easier reporting.

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Background The Behavioural Assessment Screening Tool (BAST), which measures self-reported neurobehavioural symptoms experienced by adults with traumatic brain injury (TBI), was specifically developed as a self-reported measure for remote symptom reporting. Our aim was to assess the convergent, discriminant, and known-groups validity of the BAST among community-dwelling adults with TBI. Methods We assessed correlations and group differences with previously validated measures in two existing datasets (n =111, n =134). Other measures were the Patient Health Questionnaire-9 (depression), Generalized Anxiety Disorder-7 (anxiety), Positive and Negative Affect Schedule, Frontal Systems Behavior Scale (Executive Dysfunction, Apathy, Disinhibition), Modified Fatigue Impact Scale, Patient-Reported Outcomes Measurement Information System (Fatigue), Aggression Questionnaire (anger, hostility, physical and verbal aggression), and Alcohol Use Disorders Identification Test (alcohol misuse). Results BAST subscales had stronger correlations with measures of similar (|r |=0.602-0.828, P r |=0.364-0.589, P r |d =1.2-1.9) for known groups with moderate-severe depression, moderate-severe anxiety, fatigue, problematic disinhibited and frontal executive behaviours, and alcohol misuse. Results support the construct validity of the BAST subscales. Conclusion(s) The BAST demonstrated good convergent, discriminant, and known-groups validity, supporting its use for remote self-reported symptom reporting to improve chronic symptom monitoring in community-dwelling adults with TBI.

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BACKGROUND: Despite several service delivery models that aim to improve uptake and persistence of pre-exposure prophylaxis (PrEP) in sub-Saharan Africa, the full costs of daily oral PrEP provision in routine care settings remain largely unknown. We aimed to evaluate outcomes and costs of daily oral PrEP delivery among key and priority populations at in-facility and community outreach programmes in South Africa. METHODS: This retrospective cohort study was done at seven urban sites across South Africa with in-facility or community outreach PrEP service delivery models. We did top-down and bottom-up microcosting, from the provider perspective, of routine oral PrEP provision in programmes focusing on men who have sex with men (MSM), female sex workers, and adolescent girls and young women (aged 15-24 years) who initiated oral PrEP between March 12, 2018, and Aug 13, 2019. The primary outcome was PrEP in-hand at 6 months, defined as having sufficient PrEP drug dispensed at the last visit to have the drug available 6 months after PrEP initiation. A subset of enrolled participants with sufficient potential follow-up were included in a 12-month outcome analysis. We report the cost per client initiated on PrEP in 2021 US dollars. FINDINGS: We enrolled 1281 people aged at least 15 years who initiated oral PrEP in either in-facility or community outreach programmes between March 12, 2018, and Aug 13, 2019. The proportion of participants with PrEP in-hand at 6 months varied from 41·8% (95% CI 31·9-52·2; 41 of 98 participants) at one MSM-focused clinic to 0% (0-6·7; 0 of 53 participants) in an MSM-focused outreach programme. Among 633 clients receiving oral PrEP with the potential for 12 months follow-up, 86 (13·6%) had PrEP in-hand at 12 months. The mean average 6-month costs per client initiating oral PrEP ranged from US$29 (95% CI 26-31) to $590 (488-692), with higher costs generally observed for in-facility programmes ($152, 140-164) than for outreach programmes ($84, 79-88). The mean average monthly cost per client with PrEP in-hand at 6 months ranged from $18 (15-21) to $160 (126-194). INTERPRETATION: Costs and outcomes of daily oral PrEP provision across several populations and service delivery models in real-world settings show substantial variability. Policy makers should consider this variability when planning further scale-up of oral PrEP programmes in South Africa and the sub-Saharan Africa region to maximise opportunities to improve efficiency based on local context. FUNDING: The US President's Emergency Plan for AIDS Relief, the US Agency for International Development, and the National Institutes of Health.

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Urinary tract infections (UTIs) are prevalent; however, comprehensive and current epidemiological data remain scarce. This study examined the global, national, and regional burden of UTIs by sex, age, and socio-demographic index (SDI) from 1990 to 2021. The 2021 Global Burden of Disease study included age-standardised incidence rate (ASIR), age-standardised prevalence rate (ASPR), age-standardised death rate (ASDR), and age-standardised disability-adjusted life years rate (ASDAR). The estimated annual percentage change was used to depict temporal trends, whereas Pearson correlation analysis explore its correlation with the human development index (HDI), the SDI, and age-standardised rates (ASRs). An autoregressive integrated moving average model forecasted the UTI burden trends. From 1990 to 2021, the number of UTI cases increased by 66.45%, reaching 4.49 billion cases, with an ASIR of 5,531.88 per 100,000 population. The greatest incidence of UTIs was seen in women and older adult men. Tropical Latin America and low-middle SDI regions exhibited the highest ASIR, ASPR, ASDR, and ASDAR, while East Asia showed the lowest. ASDR and ASDAR decreased with higher SDI levels. ASR and HDI were weakly positively correlated with ASDR and ASDAR. ASIR, ASPR, and ASDAR are projected to increase until 2050. The global burden of UTIs is rising and is influenced by geographical location, age, sex, and economic development, crucial for guiding medical practices and forming relevant policies.

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Loss and absence of melanocytes due to a number of factors is responsible for vitiligo; known to be the commonest disorder of pigmentation. The aim of the study was to assess clinically and dermoscopically the efficacy of topical trichloroacetic acid 70% versus methoxsalen 0.2% paint in stable acral vitiligo. The patients were randomly divided into 2 groups. Group a (n = 35) received topical 0.2% methoxsalen every other day for 4 months duration with dermoscopic follow up while group b (n = 35) received received topical TCA 70% application at the clinic every two weeks for 4 months with dermoscopic follow up. The majority of subjects in both groups experienced either no or mild improvement. In TCA group, mean improvement was 4.0 ± 11.6% with range of 0-60% while in the methoxsalen group, mean improvement was 0.57 ± 3.3% with range of 0-20% (p = 0.051). The majority of patients reported poor satisfaction. Both modalities did not demonstrate a significant clinical nor dermoscopic response. TCA 70% had a lower effective rate than other studies probably due to resistance of acral vitiliginous lesions to treatment in comparison to other sites of the body. Further larger multi centre studies with different concentration and combination modalities are required to detect promising treatments for vitligo.