Incidence and Management of Splanchnic Vein Thrombosis in Pancreatic Diseases.

Splanchnic vein thrombosis (SVT) in pancreatic disease has a 20%-30% incidence rate, leading to increased mortality and complication rates. Therefore, the aim of this review is to summarize recent evidence about the incidence, risk factors, and management of pancreatic cancer, pancreatic cystic neoplasm-, and pancreatitis-related SVT. Doppler ultrasound should be the first imaging choice, followed by contrast-enhanced computed tomography or magnetic resonance imaging. Data regarding SVT treatment in acute pancreatitis and pancreatic cancer are scarce; however, for venous thromboembolism treatment, direct oral anticoagulants and low molecular weight heparin have been effective. Further trials must investigate the length of anticoagulant treatment and the need for interventional radiological procedures.

Prevalence and risk factors for burnout, missed nursing care, and intention-to-leave the job among intensive care unit and general ward nurses: A cross-sectional study across six European countries in the COVID-19 era.

OBJECTIVE: This study aimed to compare the prevalence of burnout, missed nursing care, and intention-to-leave the job among nurses working in general care units and intensive care units (ICUs), and to analyse the risk factors for these outcomes between the two groups. DESIGN: This was a cross-sectional study involving online surveys of nurses at participating hospitals conducted between November 2020 and July 2021 as part of the Magnet4Europe initiative. SETTING AND PARTICIPANTS: A convenience sample was recruited, consisting of 67 acute care hospitals in 6 countries: Belgium, England, Germany, Ireland, Norway, and Sweden. In total, data for 1,150 ICU nurses and 5,145 general ward nurses (1,901 from surgical wards and 3,250 from medical wards) were analysed. RESULTS: The prevalence of burnout was significantly lower among nurses in ICUs (27.1 % vs. 30.3 %), missed care from care was significantly less frequent (65.5 % vs. 75.4 %), while intention-to-leave was similar (28.1 % vs. 29.2 %) compared with nurses in general wards. Nurses working in a better work environment and with lower workloads had statistically significant lower rates of burnout and intention-to-leave their job compared to those working in a poorer work environment and with higher workloads. Country-specific analysis showed a higher burnout rate and the intention-to-leave the job for nurses working in Germany, Ireland, Scandinavia, and the England compared to Belgium. CONCLUSIONS: ICU nurses did not have a higher risk of burnout and had significantly lower risks of missing care and intention-to-leave, compared to nurses in general wards. A better work environment and lower perceived workload were consistently associated with reduced risks for all outcomes studied. IMPLICATIONS FOR CLINICAL PRACTICE: National policies should prioritize creating healthy work environments, reducing workloads, and addressing country-specific challenges to lower burnout rates, minimize missed care, and decrease the intention to leave the job among ICU and general ward nurses.

Practicing health equity in kidney care by establishing improved access to timely disease management and kidney replacement therapy options: from providers to patients.

PURPOSE OF REVIEW: The aim of this article is to review the current understanding of disparities in healthcare experienced by people living with kidney disease and emerging approaches to address root causes. Health equity for any disease state is an aspirational goal commonly sought out by the medical community, but all too often lacking the understanding and support required to improve the outcomes of people with complex conditions such as chronic kidney disease (CKD). RECENT FINDINGS: The main themes of the literature covered in this article include a review of the structural drivers of healthcare outcomes, a description of research in the fields of health literacy and patient activation for patients with CKD, and an analysis of the examples of healthcare disparities in CKD patients that include involuntary discharges from dialysis facilities as well as the toll taken from dialysis populations during natural disasters. The National Forum of the ESRD Networks is a coalition of 18 congressionally mandated ESRD network organizations committed to equitable access to home and in-center dialysis modalities and preemptive kidney transplantation. We conclude with the patient-centered story of a patient living with end-stage kidney disease for over 40 years and how her journey has helped shape her view on what she believes should encompass a 'call to action' to provide more equitable healthcare to people living with kidney disease. SUMMARY: The overarching implications of this article focus on improving the understanding of present-day healthcare inequality within the community of people living with kidney disease and providing a roadmap of resources and ideas that will help achieve more equitable outcomes. The National Forum of the ESRD Networks is committed to the effective implementation of 'Practicing Health Equity in Kidney Care' and improving access to dialysis modalities including home dialysis as well as kidney transplantation including preemptive transplant options.

Population health strategies for health equity in chronic kidney disease management.

PURPOSE OF REVIEW: Chronic kidney disease (CKD) is a widespread health issue, affecting one out of every 10 adults. This prevalence is even higher among vulnerable and underserved populations, including low-income individuals, racial and ethnic minorities, and immigrants. Urban areas such as New York City and Los Angeles County offer municipal safety-net healthcare systems for these groups. RECENT FINDINGS: Safety-net providers are essential to the healthcare landscape for vulnerable populations with chronic diseases including the Los Angeles County Health Services that exemplifies how effective population health strategies can be utilized to manage CKD and at-risk persons. These approaches focus on risk assessment, integrated practices, patient and care-partner education, cost reduction, and strategic partnerships. Kidney care tailored "Expected Practices" ensure that management strategies are equitable and based on clinical evidence. The eConsult system allows CKD patients' primary care providers to efficiently consult nephrologists, facilitating timely specialty care appointments through "Precision Scheduling." Priority goals include slowing CKD progression, equitable access to home dialysis, and preemptive kidney transplantation. As highlighted by Kalantar-Zadeh et al. in 2025 CJASN, advancing equitable kidney care through population health approaches support comprehensive and efficient CKD management, including diabetic kidney disease, in Los Angeles County's safety-net system. SUMMARY: With a large, underserved patient population affected by CKD, urban safety-net healthcare systems like those in Los Angeles County emphasize early detection, multidisciplinary management, shared decision-making, and equitable access to CKD. They prioritize equitable access to home dialysis modality choice and kidney transplantation, aiming to improve outcomes and the quality-of-life for diverse patient groups.

The British NHS at 75: Past, Contemporary, and Future Challenges.

This article assesses how and why the National Health Service (NHS) has remained at the forefront of British politics and society for 75 years amid significant economic pressures, organizational strain, shifting ideological trends, ongoing reforms, and an unprecedented public health emergency. The postwar "years of consensus" evolved into alleged decline and ostensible neglect during the 1980s, while New Labour sought to rejuvenate this core public service after 1997, featuring investment and often controversial reforms that challenged the party's social democratic values. Amid the New Labour era, NHS powers filtered down to devolved administrations, while from 2008 retrenchment and austerity ensued, fueled by global recession. Austerity eventually subsided, yet from early 2020 the NHS swiftly faced the extreme conditions of the globalized Covid-19 pandemic. The service continues to face challenges regarding its longer-term viability, and this article analyzes this scenario, within the context of the NHS's 75-year historical legacy, its contemporary status, comparative international trends, and likely future evolution.

Advancing Equity in Health Care Among Dalits and Tribal People in India: The Progress, Current Realities, and the Way Forward.

The caste system and resulting social exclusion are important social determinants of health inequity in India. This article critically analyzes the influence of the caste system on health inequity in India, starting with a historical perspective and moving to the current status. The article argues that the caste system has deprived Dalits and tribal people in India of achieving health equity. The programs to promote health are often disease-specific and not culturally informed, leading to poor attention at the policy level to the intersecting disadvantages that make Dalits and tribal communities vulnerable, resulting in poor health. The authors suggest strengthening and promoting primary care, improving health access for Dalit and tribal populations, and the need for pivotal changes in the medical education system, shifting the emphasis from specialized care to training family physicians to be oriented toward community health needs, keeping health equity in perspective.

Reducing Wait Times in Child and Adolescent Ambulatory Mental Health: A Lean Six Sigma Process Improvement Study.

Suicide remains a leading cause of death for youth nationally, with access to mental health care continuing to be an emergent care imperative for health care organizations that are struggling to triage and provide critically needed mental health services to the communities they serve. Administrative inefficiencies present a potentially life-threatening delay in access to children seeking mental health care. Health care organizations have successfully used evidence-based process improvement methodologies to improve efficiency and reduce waste, including the Lean Six Sigma methodology. This study highlights the successful use of Lean Six Sigma to create an ambulatory scheduling process that significantly reduced waitlist times and increased timeliness of access to mental health care in a large pediatric hospital.

Services Addressing Mental Health Needs of Youth in Physical Rehabilitation: Perspectives of Clinicians, Youth and Family Members.

BACKGROUND: Knowledge about services addressing mental health provided in a rehabilitation setting to youth with physical disabilities is limited. This study aimed to better understand the needs, supports, challenges and potential solutions to optimize rehabilitation services for co-occurring physical and mental health needs, from the perspectives of youth, family members and clinicians. METHODS: A qualitative descriptive approach using 22 individual interviews with youth, parents and clinicians from five rehabilitation centres in a large Canadian city was employed. Inductive thematic analysis was conducted. RESULTS: Three themes were identified across the three stakeholder groups: (1) available clinical resources for mental health (access to mental health professionals, impact of organizational structures and mandates and continuity of services during transition to adult care); (2) clinician workforce capacity (mental health knowledge, skills and professional development, and therapeutic rapport between clinician and youth); and (3) links and partnerships with key players (improved pathways to access mental health services across programmes and organizations, and family involvement and advocacy). CONCLUSION: This study provides insights to barriers for mental health care (such as limited mental health knowledge, tools and professional development and access to specialists within the team, restrictive organizational mandates and disruption of services during the transition to adult care), illustrating important aspects to address. Clinicians can be better equipped to address mental health in rehabilitation settings via training opportunities and peer and organizational support in addition to establishing links with external partners. Organizations can also ensure adequate staffing and create pathways within and beyond their institutions to deliver well-coordinated mental health services in a more accessible way.

Prevalence and management of castration-resistant prostate cancer of unknown metastatic status in the real-world setting: The AfroDiTA study.

BACKGROUND: Early identification and management of metastases in prostate cancer (PC) patients is crucial. This study aimed to describe the nonpharmacological management and characteristics of patients with castration-resistant PC with unknown metastatic status (CRPC-MX) and estimate their prevalence in Spain. METHODS: Cross-sectional, multicenter, real-world study including adult (≥18 years) CRPC-MX patients from 46 Urology services. In a first phase, patients on continuous ADT for ≥6 months were screened and classified as hormone-sensitive PC (HSPC), castration-resistant PC (CRPC), and unknown hormonal status, with metastases (M1), without (M0) and unknown metastatic status (MX) using an ad hoc designed algorithm. In Phase 2, 15 months (m) after Phase 1, all patients on ADT were reviewed and reclassified again using the algorithm. RESULTS: Among 6169 eligible PC patients, 294 (4.8%) were classified as CRPC-MX, which decreased to 179 of 4050 (4.4%) 15 m after study initiation. We included 103 CRPC-MX patients with a median age at diagnosis of 75.4 years (IQR: 67.8, 80.4); 26 (25.2%) lacked a histological diagnosis, and only 25 (24.5%) received treatment with curative intent, despite ECOG being ≤1 at inclusion in 83.5%. In the 15 m before inclusion, most CRPC-MX patients had <5 prostate-specific antigen (PSA) determinations (80.6%) and no imaging (63.1%). After CRPC-MX identification (15 m after inclusion), metastatic status was assessed in 55.4%, with an increased number of patients with ≥5 PSA determinations (P = 0.0357), visits per patient (P < 0.0001), patients with some imaging test (P < 0.0001), imaging tests/patient (P < 0.0001), and visits to onco-urology specialized consultation units (52.0% before and 79.2% after). CONCLUSION: A substantial proportion of PC patients on ADT in the real-world setting are not appropriately followed up. Identification of CRPC-MX patients raised awareness among physicians and improved their adherence to guidelines, resulting in improved care for these patients.

Caring for Underserved Populations in Orthopedic Trauma.

Contemporary care of patients with orthopedic trauma is complex from surgical, cultural, administrative, financial, and linguistic perspectives. Surgeons must understand patients' backgrounds and resources to have an idea of the manner in which care can be delivered most effectively. Recognizing patients from traditionally underserved or vulnerable groups will help the surgeon to individualize their approach to the care of each individual patient. Understanding patient funding, or lack thereof, will inform the provider as to the extent of the resources and access available to the patient and assist in planning episodes of care.

Minimizing Donor Site Morbidity and Innovations in Donor Site Management.

Donor site morbidity has become a major focus in free tissue transfer as flap success rates have approached 98%. Emphasis is placed on minimizing the morbidity and optimizing cosmetic and functional outcomes at the donor site. This article reviews techniques to mitigate the donor site morbidity of commonly used free flaps in head and neck reconstruction.

Evaluation of Community-Based Mental Health Services in the Framework of SWOT Analysis From the Perspective of Health Providers and Service Recipients: A Case Study.

AIM: This study is a case study that aims to evaluate community-based mental health services from the perspective of health providers and service recipients through SWOT analysis. METHODS: This qualitative case study was conducted through in-depth interviews with five healthcare providers providing services in a community mental health centre and five individuals with severe mental disorders receiving services. The data were analysed by content analysis. FINDINGS: As a result of the content analysis of the data, subthemes were identified under the main themes of strengths, weaknesses, opportunities and threats. For service recipients; under the theme of strengths, the subthemes of multidimensional support systems and treatment adherence, and under the theme of weaknesses, the subthemes of insufficient physical environment and insufficient attention were identified. Under the theme of opportunities, the subthemes of awareness, self-confidence, employment/financial gain, sharing/socialization and problem solving were identified, while under the theme of threats, the subthemes of economic constraints and feeling uncomfortable were revealed. For health providers; under the theme of strengths, the subthemes of holistic approach, early intervention and stigma prevention, under the theme of weaknesses, the subthemes of lack of resources, lack of standards, unqualified team members, inadequate professional/in-service trainings were revealed. Under the theme of opportunities, the subthemes of autonomous working environment, support systems and aids, and training programmes were identified, while under the theme of threats, the subthemes of economic constraints, stigma exposure, political deficiencies, staff reluctance/burnout, negative perceptions about the centre, and getting complacent were identified. CONCLUSION: Community-based mental health services contain strengths, weaknesses, opportunities and threats according to the views of both health providers and service recipients, and the views of the groups overlap with each other within the supply-demand mechanism. It can be said that the effectiveness of community-based mental health services will increase by preventing threats by improving weaknesses and increasing the visibility of opportunities by recognizing strengths.

'It Cuts Both Ways': A Qualitative Analysis of Stakeholders' Views on the Emerging and Potential Unintended Consequences of Telehealth in Rural Australia.

RATIONALE: Telehealth has been consistently viewed as a viable solution for addressing healthcare inaccessibility and mitigating the impact of health workforce shortages in rural areas. However, despite high utilisation in rural areas, little is known about the unintended consequences of telehealth in terms of unexpected benefits and drawbacks. AIMS AND OBJECTIVES: This study aimed to investigate the unintended consequences of telehealth in rural Australia. METHODS: A qualitative exploratory design was employed. Semi-structured interviews were conducted to examine the views of various stakeholders across Australia. Twenty participants were interviewed across Australia, including six telehealth consumers, six providers, six state government representatives and two primary health network representatives. RESULTS: Findings on the unintended consequences of telehealth fell under three overarching themes with both reported unexpected benefits and drawbacks across each theme: (1) person-centred healthcare, (2) safety and quality of healthcare and (3) sustainability of rural healthcare. Under these themes, nine sub-themes were identified. CONCLUSION: This study provides insights into the unintended consequences of telehealth. While telehealth has improved certain aspects of healthcare in rural areas such as the improved support for rural clinicians and the reduced disruption to patients' daily routines, it has also introduced unforeseen challenges such as the transfer of medicolegal burden to local clinicians in rural emergency care facilities to compensate for the absence of physical examinations. These findings feed into decision-making useful for informing and improving telehealth implementation in rural Australia to maximise unexpected benefits, minimise risks, and ensure the long-term viability of telehealth services.

Healthcare delivery in the arctic-telehealth prospects.

The Arctic region, characterised by its remote and geographically challenging environment, is home to predominantly Indigenous populations who experience significant healthcare disparities compared to urban counterparts. This paper synthesises evidence on the persistent challenges in delivering healthcare in the Arctic, including geographical remoteness, healthcare personnel shortages, and cultural and language barriers. Telehealth emerges as a crucial solution, offering a nuanced approach to overcoming physical and systemic barriers. We review current implementations of telehealth in the Arctic, highlighting successful adaptations to local cultural contexts and technological limitations. By integrating a patient-centred approach, infrastructure readiness, and relevant telehealth services, a holistic healthcare delivery model tailored for the Arctic environment is proposed. New type of technologies is also proposed to enhance remote care possibilities. This paper underscores the need for collaborative efforts in research, policy making, and healthcare provision to ensure the sustainability and effectiveness of health services in the Arctic, aiming to close the gap in health equity. Key references from seminal works and recent studies provide a foundation for the discussions and recommendations presented.

A Health Systems Strengthening Approach to Address the High Burden of Hepatitis C in Pakistan.

Hepatitis C virus infection is a serious liver disease that can progress to cirrhosis and, in chronic cases, lead to liver cancer or liver failure. Pakistan has the second highest burden of HCV in the world, a rising number of liver cancer cases and a unique pattern of healthcare-associated HCV transmission. Unfortunately, the country is not on track to meet the WHO's target of complete elimination of HCV by 2030. The current reliance on vertical programmes for hepatitis elimination may seem effective in the short term, but is often unsustainable, ineffective and contributes to the fragmentation of the health system. This review proposes a health system strengthening approach to HCV detection and prevention in the country. It critically evaluates the country's health system and the existing evidence on HCV prevention and treatment, proposing evidence-based strategies for decentralising HCV services and integrating them into the primary healthcare infrastructure. It examines the effectiveness of methods such as task shifting and targeted interventions while suggesting changes to healthcare practices to reduce healthcare-associated transmission of HCV and other blood-borne pathogens.

The State of Medical Care for Adults With Intellectual and/or Developmental Disabilities.

For more than 2 decades, medical care for adults with intellectual and/or developmental disabilities (IDDs) has been difficult to access and has not substantially changed the persistently poor health status that is common in this population cohort. While there has been some progress in the development of models of care that are designed with and for adults with IDD, it has been slow and sporadic, with little data or analyses of efficacy or effectiveness. Very few medical schools and other health science professional education in the United States include curricular content on adults with IDD, resulting in health care practitioners being under or altogether unprepared to provide care to them. Public and private health care policy and financing are not responsive to the medical care needs and experiences of adults with IDD. More recently, the impact of the COVID-19 pandemic on adults with IDD was disproportionally more severe, with significantly higher rates of morbidity and mortality than on adults without IDD, having nothing to do with the presence of an IDD itself. This commentary reviews persistent barriers to accessible, responsive medical care for adults with IDD and reviews a number of health care models that have been developed since the turn of the 21st century. It also offers a brief review of Medicaid Managed Care as a potential policy and financing solution to long-standing financing and related obstacles to optimal medical care.

'Whatever the GP says, is what I'll do'-A qualitative study of patient perspectives in accessing primary eye care for type 2 diabetes.

INTRODUCTION: To investigate the perspectives of people accessing a general medical practitioner (GP)-optometry model of collaborative care that was established to increase access to diabetes eye care. METHODS: Qualitative study of patient barriers and facilitators to accessing primary diabetes eye care located in a metropolitan area in Australia. One-on-one interviews were recorded, transcribed and thematically analysed using a determinant framework on patient-centred access to health care. RESULTS: Twenty-four people with type 2 diabetes, including 15 males and 9 females, who accessed the service between September 2021 and June 2022 agreed to participate. Mean (SD) age of the participants was 52 (12) years and 50% had been diagnosed with diabetes for <2 years. Facilitators to accessing diabetes eye care included a referral from a GP or GP nurse, fee-free consultations, availability of after-hours appointments and short waiting times. Barriers to access included perceived out-of-pocket costs, competing responsibilities and lack of awareness of diabetic retinopathy screening recommendations. CONCLUSION: Considering diabetic retinopathy may present asymptomatically, primary health practitioners (optometrists and GPs) are well positioned to raise patient awareness of the importance of routine eye examinations. In Australia, access to routine screening could be facilitated by fee-free eye checks and personalised text message reminders implemented at a health system level.

Deprivation and NHS General Ophthalmic Service sight testing activity in England in 2022-2023.

PURPOSE: Socioeconomic deprivation is associated with an increased incidence of sight-loss. To inform potential developments in eyecare, General Ophthalmic Service (GOS) sight-testing activity was explored in relation to deprivation for GOS contractors submitting National Health Service (NHS) claims in England. METHODS: Data on NHS sight-test claims for the financial year 2022-2023 were sought from NHS England (NHSE), including number of sight-tests by GOS contractors, their unique Organisation Data Service codes and postcodes and age-bands of patients accessing sight-testing. Deprivation scores were assigned to contractor practices using the Index of Multiple Deprivation (IMD) and the average number of sight-tests for all contractors within each IMD decile calculated, allowing rate of sight-testing per 1000 population per decile of deprivation to be estimated using Office of National Statistics (ONS) Lower Layer Super Output Area mid-year population estimates. Inequality was examined using the Odds Ratio (OR) and slope and relative index of inequality measures (SSI and RII). RESULTS: Overall, 12.94 million NHS sight-tests were provided by 5622 GOS contractors in England in 2022-2023. Most affluent decile GOS contractors undertook an average ~2200 NHS sight-tests, while in the most deprived decile, average NHS sight-tests per contractor was ~1100. Rate of sight-testing per 1000 population in the most deprived decile was one quarter of that in the most affluent, with an OR of 5.29 (95% CI 5.27-5.30), indicating those in the most affluent areas were ~five times more likely to access NHS sight-tests. Overall, SII and RII were 333.5 (95% CI 333.52-333.53) and 6.4 (95% CI 6.39-6.40), respectively, findings reflective of substantial inequality in uptake. CONCLUSION: There remains substantial unwarranted variation in uptake of NHS sight-testing, with those in more affluent areas accessing sight-testing substantially more than those in more deprived areas. Strategies are required to facilitate primary care optometry to provide more equitable access to eyecare.

Toward Equity in Global Access to SoHO-based Therapies: Recommendations for Action.

Therapies derived from substances of human origin (SoHOs) such as organs, cells, and tissues provide life-saving or life-changing treatment for millions of people worldwide each year. However, many people lack timely access to SoHO-based therapies because of insufficient supplies of these exceptional health resources and/or broader barriers in access to healthcare. Despite well-established governmental commitments to promote health equity in general and equity of access to SoHOs in particular, information about inequities in access to most SoHO-based therapies is scarce. Furthermore, the issue of equitable allocation of SoHO-based therapies has received little attention from policymakers and ethicists, except in the context of organ allocation for transplantation. Consequently, the extent and nature of potential inequities within and between countries are largely unknown, and few sources of guidance are available to support progress toward equity in global access to SoHO-based therapies. We present here the findings of an international ethics working group convened in preparation for the 2023 Global Summit on Convergence in Transplantation, organized in Santander, Spain. The group sought to assess potential gaps in knowledge about inequities involving SoHO-based therapies, to elucidate systemic factors that may influence access to these therapies, and to consider how policies and frameworks governing access to and allocation of SoHO-based therapies may promote equity when it is necessary to define boundaries in access because of insufficiency of supply. In discussing these challenges, we also outline several recommendations for action by governments and health authorities.

Transplantation: A Priority in the Healthcare Agenda.

BACKGROUND: In November 2023, in the context of the Spanish Presidency of the Council of the European Union, the Organization National de Transplante organized a global summit discussing global action in transplantation for the next decade. This article reports the recommendations supporting the need to prioritize transplantation in healthcare systems. METHODS: The working group investigated how transplantation addresses noncommunicable disease mortality, particularly related to kidney and liver disease. They also investigated how transplantation can contribute to the achievement of several of the United Nations Sustainable Development Goals, especially Goal 3 (good health and well-being), Goal 8 (sustained, inclusive, and sustainable economic growth and employment for all), and Goal 13 (combat climate change and its impact). RESULTS: By prioritizing transplantation, the increased availability and accessibility of life-saving organs and tissues to the public will not only lead to saving more lives and improving health outcomes for individual patients but also contribute to the development of a resilient health system in general in that country as a consequence of developing the infrastructure required for transplantation. CONCLUSIONS: The ethical principles associated with transplantation promote the principles of solidarity in society by fostering the donation process and equity in access to therapy. This article aims to advocate for the widespread availability of solid organ, tissue, and cell transplantation for all patients.