Layering vaccination with antibiotic therapy results in protection and clearance of Burkholderia pseudomallei in Balb/c mice.

Melioidosis is a disease that is difficult to treat due to the causative organism, Burkholderia pseudomallei being inherently antibiotic resistant and it having the ability to invade, survive, and replicate in an intracellular environment. Combination therapy approaches are routinely being evaluated in animal models with the aim of improving the level of protection and clearance of colonizing bacteria detected. In this study, a subunit vaccine layered with the antibiotic finafloxacin was evaluated in vivo against an inhalational infection with B. pseudomallei in Balb/c mice. Groups of mice vaccinated, infected, and euthanized at antibiotic initiation had a reduced bacterial load compared to those that had not been immunized. In addition, the subunit vaccine provided a synergistic effect when it was delivered with a CpG ODN and finafloxacin was initiated at 48 h post-challenge. Vaccination was also shown to improve the outcome, in a composite measure of survival and clearance. In summary, layering a subunit vaccine with the antibiotic finafloxacin is a promising therapeutic alternative for use in the treatment of B. pseudomallei infections.

A pragmatic, open-label, randomized controlled trial of Plasma-Lyte-148 versus standard intravenous fluids in children receiving kidney transplants (PLUTO).

Acute electrolyte and acid-base imbalance is experienced by many children following kidney transplant. This is partly because doctors give very large volumes of artificial fluids to keep the new kidney working. When severe, fluid imbalance can lead to seizures, cerebral edema and death. In this pragmatic, open-label, randomized controlled trial, we randomly assigned (1:1) pediatric kidney transplant recipients to Plasma-Lyte-148 or standard of care perioperative intravenous fluids (predominantly 0.45% sodium chloride and 0.9% sodium chloride solutions). We then compared clinically significant electrolyte and acid-base abnormalities in the first 72 hours post-transplant. The primary outcome, acute hyponatremia, was experienced by 53% of 68 participants in the Plasma-Lyte-148 group and 58% of 69 participants in the standard fluids group (odds ratio 0·77 (0·34 - 1·75)). Five of 16 secondary outcomes differed with Plasma-Lyte-148: hypernatremia was significantly more frequent (odds ratio 3·5 (1·1 - 10·8)), significantly fewer changes to fluid prescriptions were made (rate ratio 0·52 (0·40-0·67)), and significantly fewer participants experienced hyperchloremia (odds ratio 0·17 (0·07 - 0·40)), acidosis (odds ratio 0·09 (0·04 - 0·22)) and hypomagnesemia (odds ratio 0·21 (0·08 - 0·50)). No other secondary outcomes differed between groups. Serious adverse events were reported in 9% of participants randomized to Plasma-Lyte-148 and 7% of participants randomized to standard fluids. Thus, perioperative Plasma-Lyte-148 did not change the proportion of children who experienced acute hyponatremia compared to standard fluids. However fewer fluid prescription changes were made with Plasma-Lyte-148, while hyperchloremia and acidosis were less common.

Diabetes knowledge, self-efficacy and dietary, psychological and physical health barriers: Comparing young and usual-onset type 2 diabetes.

AIMS: Young-onset (21-39 years old) type 2 diabetes (YOD) is associated with high complication rates and glycaemic levels, and poor self-management plays a significant role. Knowledge, skills and barriers influence self-management behaviours considerably. Therefore, this study assessed diabetes knowledge, self-efficacy and barriers (situational dietary barriers, physical health, mental health and diabetes-related distress) between participants with young and usual-onset (40-59 years old) (UOD) diabetes. METHODOLOGY: A cross-sectional survey was conducted. Differences between YOD and UOD were analysed using bivariate analysis and effect sizes were estimated with Cohen's d. Differences were further adjusted by demographic factors (gender, ethnicity, marital status, educational level, income level) and diabetes duration. RESULTS: A total of 409 (97 YOD, 312 UOD) participants were recruited. Participants with YOD had lower self-efficacy levels (adjusted B = -0.19, CI -0.35 to -0.03) and higher dietary barriers (adjusted B = 3.6, CI 2.1-5.1), lower mental health scores (adjusted B = -3.5, CI -5.7 to -1.4) and higher diabetes-related distress levels (adjusted B = 0.2, CI 0.2-0.4). CONCLUSIONS: Our study found that participants with YOD faced more challenges with adapting to life with diabetes when compared with UOD. More effective self-management programmes are needed to support the multifaceted needs of adults with YOD.

Identifying barriers and facilitators to self care in young adults with type 2 diabetes.

AIMS: There is a rising trend of young-onset type 2 diabetes (YOD) occurring before the age of 40 years. Lower adherence to self care behaviours (diet, physical activity and taking medication) contributed to poorer glycaemic control and higher risk of complications. Young adults with YOD face unique challenges, and our study aimed to identify the main barriers and facilitators of self care behaviours in this population. METHODOLOGY: A qualitative study was conducted in the National Healthcare Group Polyclinics, Singapore, using in-depth semi-structured interviews. Maximal variation sampling was employed to include participants with YOD of varied age, ethnicity, educational levels and marital status. Thematic analysis was conducted, and barriers and facilitators were identified and mapped to domains of the theoretical domains framework. RESULTS: Twenty-one participants aged 22-39 years were interviewed. We found patterns of intentions, self care behaviours and mindsets that were associated with different barriers and facilitators. Four patterns were identified and were named according to mindsets: avoidant, indifferent, striving and activated. In addition, experience of stigma and self-blame from having type 2 diabetes in young adulthood was common across all mindsets, contributing to poorer self care behaviours and increased psychological burden. CONCLUSION: Our study identified key barriers and facilitators of diet, physical activity and medication adherence in young adults with type 2 diabetes. Understanding barriers and facilitators, as related to mindsets, intentions and behaviours, will support a more individualised care approach.

Artificial intelligence in clinical decision-making: Rethinking personal moral responsibility.

Artificially intelligent systems (AISs) are being created by software developing companies (SDCs) to influence clinical decision-making. Historically, clinicians have led healthcare decision-making, and the introduction of AISs makes SDCs novel actors in the clinical decision-making space. Although these AISs are intended to influence a clinician's decision-making, SDCs have been clear that clinicians are in fact the final decision-makers in clinical care, and that AISs can only inform their decisions. As such, the default position is that clinicians should hold responsibility for the outcomes of the use of AISs. This is not the case when an AIS has influenced a clinician's judgement and their subsequent decision. In this paper, we argue that this is an imbalanced and unjust position, and that careful thought needs to go into how personal moral responsibility for the use of AISs in clinical decision-making should be attributed. This paper employs and examines the difference between prospective and retrospective responsibility and considers foreseeability as key in determining how personal moral responsibility can be justly attributed. This leads us to the view that moral responsibility for the outcomes of using AISs in healthcare ought to be shared by the clinical users and SDCs.

Exploring the impact of a co-designed shared book reading environment for families in a community hub.

BACKGROUND: Evidence supports the effectiveness of shared book reading for promoting language and literacy development, but it is known that families experiencing vulnerability may have reduced access to books and are less likely to share books regularly at home. Community hubs often provide support to families experiencing vulnerability and may provide an opportunity to create environments that support families to engage in shared book reading, especially if families are invited into the creation of these environments through co-design. However, there is currently little evidence regarding the impact of co-designing shared book reading environments with families in community settings. AIMS: The current study is part of a broader project which used co-design to develop a shared book reading environment in collaboration with stakeholders in a community hub. This small-scale study aimed to provide a preliminary evaluation of the impact of this co-designed shared book reading environment at the community hub on (1) the frequency of shared book reading at the hub; (2) participants' confidence and enjoyment of reading with children at the hub; and (3) participants' experiences of shared book reading at the hub. METHOD & PROCEDURES: The co-design project was carried out in four phases with families, staff and community partners at the community hub. A convergent mixed-methods approach was used to collect and analyse quantitative and qualitative data in the first and last phase of the project to evaluate project outcomes. Quantitative data (environmental observations of reading at the hub and participant ratings of confidence and enjoyment of reading with children at the hub) were analysed using descriptive statistics and nonparametric statistical tests. Qualitative data (participants' responses regarding their experiences of changes implemented in the community hub) were analysed using inductive content analysis. OUTCOME & RESULTS: An increased frequency of shared book reading was observed within the community hub after changes were implemented, and positive changes in enjoyment of book reading were recorded. Qualitative responses from participants following conclusion of the project were organised into three main categories, which showed that (1) children and families were reading more and enjoying reading activities that were happening; (2) children and families were borrowing more books; and (3) families had changed the way they were reading at home with their children. CONCLUSIONS & IMPLICATIONS: A co-designed shared book reading environment within a community hub had a positive impact on shared book reading experiences for families in areas with high levels of vulnerability. WHAT THIS PAPER ADDS: What is already known on this subject Community hubs provide a unique opportunity to support early language and literacy development in partnership with families in areas of vulnerability; however, there is limited literature investigating the impacts of these supports. A previous study utilised co-design to develop a shared book reading environment with stakeholders at a community hub in an area where a high proportion of children are considered to be 'vulnerable' in terms of language and literacy development. It was found that co-design enabled the development of collaborative changes to support shared book reading that were valued and owned by families, staff and community partners at the community hub. What this study adds The current study focused on evaluating the impact of a co-design project on the frequency of shared book reading at the hub and participants' experiences, confidence and enjoyment of reading with children at the hub. Analysis of pre- and post-data provide preliminary evidence that a co-designed shared book reading environment in a community hub can have a positive impact on increasing families' awareness and engagement with book borrowing, engagement in shared book reading activities in the community and at home, and participants' confidence and enjoyment of reading with children. What are the clinical implications of this work? Speech pathologists have an important role to play in prevention and promotion. This study has shown that collaboration with families experiencing vulnerability can support the implementation of strategies to promote shared reading in a community hub and demonstrate increased quality and frequency of shared book reading. The utilisation of a community hub also highlights the opportunities for the speech pathology profession to deliver community-based promotion and prevention initiatives as a strategy to address equitable language outcomes.

Information-seeking behaviour of primary care clinicians in Singapore at the point-of-care: A qualitative study.

BACKGROUND: Clinicians' information-seeking behaviours impact patient care quality. Earlier studies indicated that barriers to accessing information deter clinicians from seeking answers to clinical questions. OBJECTIVES: To explore primary care clinicians' information-seeking behaviour at point-of-care, focusing on when and how they seek answers to clinical questions. METHODS: Semi-structured interviews were conducted with 45 clinicians after clinical sessions to investigate their information-seeking habits. Follow-up interviews were conducted after a week for those intending to address unanswered queries. RESULTS: Two thirds of clinicians encountered questions during care, with nearly three quarters resolving them during the session. Colleagues, guidelines and online platforms were common information sources, with smartphones being used to access Google, WhatsApp or UpToDate®. Facilitators included reliable sources and the drive to confirm knowledge, while barriers included ineffective search methods and high workload. Despite challenges, most clinicians expressed satisfaction with their information-seeking process. DISCUSSION: The findings underscore the increasing use of smartphones for accessing clinical information among Singaporean primary care clinicians and suggest the need for tailored training programmes and guidelines to optimise information-seeking practices. CONCLUSION: Insights from this study can inform the development of training programmes and guidelines aimed at improving information-seeking practices among primary care clinicians, potentially enhancing patient care quality.

Optimizing the role of 'lead mothers' in seasonal malaria chemoprevention (SMC) campaigns: formative research in Kano State, northern Nigeria.

BACKGROUND: Seasonal malaria chemoprevention (SMC) is a safe and effective intervention for preventing malaria in children under 5 years of age. Lead mothers are community health volunteers that help caregivers comply with monthly administration of anti-malarial drugs during SMC campaigns. The lead mother approach is used in several SMC implementing states across Nigeria, but there is lack of evidence about their roles and how effective they are. This study sought to better understand the current role of lead mothers, identify areas for improvement and ways to optimize the role of lead mothers during SMC campaigns. METHODS: This paper reports the formative phase of a three-phased intervention development study. The formative phase involved semi-structured interviews with stakeholders from national, state, local government and community levels (n = 20). Thematic analysis was used to identify key themes, forming the basis of a subsequent co-design workshop with stakeholders routinely involved in SMC campaigns. RESULTS: The findings of the formative phase converged around four overarching themes: skills and attributes required of lead mothers; factors that affect lead mother's roles; how lead mothers interact with Community Health Influencers Promoters Services (CHIPS) agents and re-imagining the role of lead mothers during SMC campaigns. CONCLUSION: This formative work in Kano state indicates that through their strong connection to communities and unique relationship with caregivers, lead mothers can and do influence caregivers to adopt healthy behaviours during SMC campaigns. However, there is room for improvement in how they are recruited, trained and supervised. There is need to improve lead mothers' knowledge and skills through adequate training and supporting materials, so they can deliver targeted health messages to caregivers. Sustainability of the lead mother approach is at risk if policymakers do not find a way of transitioning their role into the existing community health worker infrastructure, for example by using CHIPs agents, and ensuring less reliance on external donor support.

Women's preconception health in England: a report card based on cross-sectional analysis of national maternity services data from 2018/2019.

OBJECTIVE: To present the first national-level report card on the state of women's preconception health in England. DESIGN: Cross-sectional population-based study. SETTING: Maternity services, England. POPULATION: All pregnant women in England with a first antenatal (booking) appointment recorded in the national Maternity Services Dataset (MSDS) from April 2018 to March 2019 (n = 652 880). METHODS: We analysed the prevalence of 32 preconception indicator measures in the overall population and across socio-demographic subgroups. Ten of these indicators were prioritised for ongoing surveillance based on modifiability, prevalence, data quality and ranking by multidisciplinary UK experts. RESULTS: The three most prevalent indicators were the proportion of the 22.9% of women who smoked 1 year before pregnancy who did not quit smoking before pregnancy (85.0%), those who had not taken folic acid supplementation before pregnancy (72.7%) and previous pregnancy loss (38.9%). Inequalities were observed by age, ethnicity and area-based deprivation level. The ten indicators prioritised were not taking folic acid supplementation before pregnancy, obesity, complex social factors, living in the most deprived areas, smoking around the time of conception, overweight, pre-existing mental health condition, pre-existing physical health condition, previous pregnancy loss and previous obstetric complication. CONCLUSIONS: Our findings suggest important opportunities to improve the state of preconception health and reduce socio-demographic inequalities for women in England. In addition to MSDS data, other national data sources that record further and possibly better quality indicators could be explored and linked to build a comprehensive surveillance infrastructure.

Cholestatic Pruritus Treatments in Primary Biliary Cholangitis and Primary Sclerosing Cholangitis: A Systematic Literature Review.

BACKGROUND AND AIMS: We conducted a systematic literature review to understand the evidence supporting treatment decisions for cholestatic pruritus associated with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). METHODS: Studies that enrolled ≥ 75% participants with PBC or PSC and reported ≥ 1 endpoint(s) related to efficacy, safety, health-related quality of life (HRQoL) or other patient-reported outcomes were included. Bias was assessed using the Cochrane risk of bias tool for randomised controlled trials (RCTs) and the Quality of Cohort studies tool for non-RCTs. RESULTS: Thirty-nine publications were identified, covering 42 studies and six treatment classes (including investigational and approved products): anion-exchange resins, antibiotics (rifampicin/derivatives), opiates, selective serotonin reuptake inhibitors, fibrates, ileal bile acid transporter inhibitors and other agents not categorised in these six classes. Across studies, median sample size was small (n = 18), 20 studies were over 20 years old, 25 followed patients for ≤ 6 weeks, only 25 were RCTs. Pruritus was assessed using several different tools, with inconsistencies in their application. Cholestyramine, considered first-line therapy for moderate-severe cholestatic pruritus, was assessed in six studies (two RCTs) including 56 patients with PBC and 2 with PSC, with evidence of efficacy demonstrated in only three studies, among which, two RCTs were assessed as having a high risk of bias. Findings were similar for other drug classes. CONCLUSIONS: There is a lack of consistent and reproducible evidence available on efficacy, impact on HRQoL, and safety of cholestatic pruritus treatments, leaving physicians to rely on clinical experience rather than evidence-based medicine for treatment selection.

Impact of Pruritus on Quality of Life and Current Treatment Patterns in Patients with Primary Biliary Cholangitis.

BACKGROUND AND AIMS: Patients with primary biliary cholangitis (PBC) often suffer with pruritus. We describe the impact of pruritus on quality of life and how it is managed in a real-world cohort. METHODS: TARGET-PBC is a longitudinal observational cohort of patients with PBC across the USA. Data include information from medical records for three years prior to the date of consent up to 5 years of follow-up. Enrolled patients were asked to complete patient-reported outcome surveys: PBC-40, 5-D itch, and the PROMIS fatigue survey. Kruskal-Wallis tests were used to compare differences in symptoms between groups. RESULTS: A total of 211 patients with completed PRO surveys were included in the current study. PRO respondents were compared with non-respondents in the TARGET-PBC population and were broadly similar. Pruritus was reported in 170 patients (81%), with those reporting clinically significant pruritus (30%) scoring worse across each domain of the PBC-40 and 5-D itch, more frequently having cirrhosis, and having significantly greater levels of fatigue. Patients reporting clinically significant pruritus were more likely to receive treatment, but 33% had never received treatment (no itch = 43.9%, mild itch = 38.3%). CONCLUSIONS: The prevalence of pruritus was high in this population, and those reporting clinically significant pruritus had a higher likelihood of having advanced disease and worse quality of life. However, this study found that pruritus in PBC is under-treated. This may be due in part to ineffectiveness of current treatments, poor tolerance, or the lack of FDA-approved medications for pruritus.

Being pregnant and becoming a parent during the COVID-19 pandemic: a longitudinal qualitative study with women in the Born in Bradford COVID-19 research study.

BACKGROUND: Uncertainty around the risk of COVID-19 to pregnant women and their babies prompted precautionary restrictions on their health and care during the pandemic. Maternity services had to adapt to changing Government guidance. Coupled with the imposition of national lockdowns in England and restrictions on daily activities, women's experiences of pregnancy, childbirth and the postpartum period, and their access to services, changed rapidly. This study was designed to understand women's experiences of pregnancy, labour and childbirth and caring for a baby during this time. METHODS: This was an inductive longitudinal qualitative study, using in-depth interviews by telephone with women in Bradford, UK, at three timepoints during their maternity journey (18 women at timepoint one, 13 at timepoint two and 14 at timepoint three). Key topics explored were physical and mental wellbeing, experience of healthcare services, relationships with partners and general impact of the pandemic. Data were analysed using the Framework approach. A longitudinal synthesis identified over-arching themes. RESULTS: Three longitudinal themes captured what was important to women: (1) women feared being alone at critical points in their maternity journey, (2) the pandemic created new norms for maternity services and women's care, and (3) finding ways to navigate the COVID-19 pandemic in pregnancy and with a baby. CONCLUSIONS: Modifications to maternity services impacted significantly on women's experiences. The findings have informed national and local decisions about how best to direct resources to reduce the impact of COVID-19 restrictions and the longer-term psychological impact on women during pregnancy and postnatally.

Clinicians and AI use: where is the professional guidance?

With the introduction of artificial intelligence (AI) to healthcare, there is also a need for professional guidance to support its use. New (2022) reports from National Health Service AI Lab & Health Education England focus on healthcare workers' understanding and confidence in AI clinical decision support systems (AI-CDDSs), and are concerned with developing trust in, and the trustworthiness of these systems. While they offer guidance to aid developers and purchasers of such systems, they offer little specific guidance for the clinical users who will be required to use them in patient care.This paper argues that clinical, professional and reputational safety will be risked if this deficit of professional guidance for clinical users of AI-CDDSs is not redressed. We argue it is not enough to develop training for clinical users without first establishing professional guidance regarding the rights and expectations of clinical users.We conclude with a call to action for clinical regulators: to unite to draft guidance for users of AI-CDDS that helps manage clinical, professional and reputational risks. We further suggest that this exercise offers an opportunity to address fundamental issues in the use of AI-CDDSs; regarding, for example, the fair burden of responsibility for outcomes.

Knowledge and social beliefs of malaria and prevention strategies among itinerant Nomadic Arabs, Fulanis and Dagazada groups in Chad: a mixed method study.

BACKGROUND: Nomadic populations in Chad are at increased risk of contracting malaria because of their lifestyle. Being highly mobile they are often excluded from disease control programmes, and access to preventive measures and treatment is more difficult. Effective malaria control interventions take account of local modes of transmission, patterns of care-seeking behaviour and community perceptions of cause and prevention practices. There is currently little information about malaria knowledge and perceptions among nomadic groups in Chad, or their awareness of malaria control interventions and this study sought to address this knowledge gap. METHODS: A mixed methods study, including a cross-sectional survey with men and women (n = 78) to determine the level of knowledge and use of malaria prevention strategies among Arabs, Peuls and Dagazada nomadic groups. Three focus group discussions were conducted with women to explore their representation of malaria and knowledge of preventive methods. Key informant interviews were held with leaders of nomadic groups (n = 6) to understand perception of malaria risk among itinerant communities. RESULTS: Nomads are aware of the risk of malaria, recognize the symptoms and have local explanations for the disease. Reported use of preventive interventions such as Seasonal Malaria Chemoprevention (SMC) for children and Intermittent Preventive Treatment (IPT) of malaria in pregnancy was very low. However, 42.3% of respondents reported owning at least one LLIN and 60% said they slept under an LLIN the night before the survey. In case of a malaria episode, nomads seek clinicians, informal drug sellers in the street or market for self-medication, or traditional medicine depending on their financial means. Interviews with nomad leaders and discussions with women provide key themes on: (i) social representation of malaria risk and (ii) social representation of malaria and (iii) perspectives on malaria prevention and (iv) malaria treatment practices. CONCLUSION: The nomadic groups included in this study are aware of risk of malaria and their level of exposure. Local interpretations of the cause of malaria could be addressed through tailored and appropriate health education. Except for LLINs, malaria prevention interventions are not well known or used. Financial barriers lowered access to both mosquito nets and malaria treatment. Reducing the barriers highlighted in this study will improve access to the healthcare system for nomadic groups, and increase the opportunity to create awareness of and improve uptake of SMC and IPT among women and children.

Delivery of seasonal malaria chemoprevention with enhanced infection prevention and control measures during the COVID-19 pandemic in Nigeria, Burkina Faso and Chad: a cross-sectional study.

BACKGROUND: Seasonal malaria chemoprevention (SMC) is a WHO-recommended intervention for children aged 3-59 months living in areas of high malaria transmission to provide protection against malaria during the rainy season. Operational guidelines were developed, based on WHO guidance, to support countries to mitigate the risk of coronavirus disease 2019 (COVID-19) transmission within communities and among community distributors when delivering SMC. METHODS: A cross-sectional study to determine adherence to infection prevention and control (IPC) measures during two distribution cycles of SMC in Nigeria, Chad and Burkina Faso. Community distributors were observed receiving equipment and delivering SMC. Adherence across six domains was calculated as the proportion of indications in which the community distributor performed the correct action. Focus group discussions were conducted with community distributors to understand their perceptions of the IPC measures and barriers and facilitators to adherence. RESULTS: Data collectors observed community distributors in Nigeria (n = 259), Burkina Faso (n = 252) and Chad (n = 266) receiving IPC equipment and delivering SMC. Adherence to IPC indications varied. In all three countries, adherence to mask use was the highest (ranging from 73.3% in Nigeria to 86.9% in Burkina Faso). Adherence to hand hygiene for at least 30 s was low (ranging from 3.6% in Nigeria to 10.3% in Burkina Faso) but increased substantially when excluding the length of time spent hand washing (ranging from 36.7% in Nigeria to 61.4% in Burkina Faso). Adherence to safe distancing in the compound ranged from 5.4% in Chad to 16.4% in Nigeria. In Burkina Faso and Chad, where disinfection wipes widely available compliance with disinfection of blister packs for SMC was low (17.4% in Burkina Faso and 16.9% in Chad). Community distributors generally found the IPC measures acceptable, however there were barriers to optimal hand hygiene practices, cultural norms made social distancing difficult to adhere to and caregivers needed assistance to administer the first dose of SMC. CONCLUSION: Adherence to IPC measures for SMC delivery during the COVID-19 pandemic varied across domains of IPC, but was largely insufficient, particularly for hand hygiene and safe distancing. Improvements in provision of protective equipment, early community engagement and adaptations to make IPC measures more feasible to implement could increase adherence.

Assessing the mechanisms contributing to self-care behaviours in young and usual-onset diabetes.

Context: Young-onset diabetes (YOD) (age of onset 21-39 years) is associated with a poorer metabolic profile and a higher risk of complications, and poor self-care behaviours play a significant role. However, few studies have comprehensively examined the mechanisms (self-efficacy, dietary barriers, illness perceptions, knowledge, diabetes-related distress) that may contribute to poor self-care behaviours in YOD. Objectives: Our study aims to compare these mechanisms and self-care behaviours between participants with YOD and usualonset diabetes (age of onset 40-59 years). Study design: A cross-sectional survey was conducted in primary care clinics in participants with YOD or UOD, and type 2 diabetes for 10 years or less. Survey tools included the Diabetes Empowerment Scale short-form (DES-SF), dietary barriers of the Personal Diabetes Questionnaire (PDQ-DB), Brief Illness Perceptions Questionnaire (BIPQ), revised Michigan Diabetes Knowledge Test (DKT), diabetes distress scale (DDS), Summary of Diabetes Self-care Activities (SDSCA), International Physical Activity Questionnaire (IPAQ-SF) and medication adherence report scale (MARS-5), and means of both groups were compared using independent T-tests and effect sizes were analysed (Cohen's d). Results: 97 participants with YOD and 312 with UOD completed the survey. Compared with UOD, participants with YOD reported a lower adherence to a specific diet (d=0.45), with no significant differences in levels of physical activity or medication adherence. Participants with YOD experienced greater diabetes-related distress (d=0.35), especially with emotional (d=0.37), regimen-related (d=0.43) and interpersonal (d=0.39) distress. At the same time, perception of self-efficacy was significantly lower (d=0.27) and more dietary barriers were perceived (d=0.76). Participants with YOD also perceived that diabetes affected their lives more severely (consequence) (d=0.26), had a larger effect on their emotions (emotional representation) (d=0.28), will last longer (timeline) (d=0.37), and perceived that treatment was less likely help their diabetes (treatment control) (d=0.26). Conclusions: Participants with YOD experienced greater diabetes-related distress, lower self-efficacy and reported lower dietary adherence with more dietary barriers than those with UOD. Patients with YOD have distinctly different issues from UOD, and in providing care for YOD, clinicians should actively seek to identify and address these issues.

Discharge preparation and readiness after birth: a scoping review of global policies, guidelines and literature.

BACKGROUND: Despite the existence of global recommendations, postnatal care provided following childbirth is variable and often fails to address a woman's concerns about herself and the parents' concerns about their baby. Discharge from a facility after birth is a key moment to ensure the woman, parents and newborn receive support for the transition to care in the home. We mapped the current policies, guidance and literature on discharge preparation and readiness to identify key concepts and evidence and inform recommendations to be considered in a World Health Organization (WHO) guidance on postnatal care. METHODS: We were guided by the Johanna Briggs Institute approach, and developed inclusion criteria based on existing defintions of discharge preparation and readiness, and criteria for discharge readiness compiled by international professional organisaitons. To identify guidelines and policies we searched websites and archives of guideline organisations, and contacted individuals and professional societies working on postnatal care. We searched 14 electronic databases to locate published research and other literature on discharge preparation and readiness. For documents that met the inclusion criteria we extracted key characteristics, summarised discharge readiness criteria and components and discharge preparation steps, and characterised interventions to improve discharge preparation. RESULTS: The review provides a systematic map of criteria for discharge that are in use and the common steps healthcare providers take in preparing women and newborns for the transition home. The mapping also identified interventions used to strengthen discharge preparation, theories and models that conceptualise discharge preparation, scales for measuring discharge readiness and qualitative studies on the perspectives of women, men and healthcare providers on postnatal discharge. CONCLUSIONS: The findings highlight contrasts between the research literature and policy documents. They indicate potential gaps in current discharge policies, and point to the need for more comprehensive discharge assessment and education to better identify and meet the needs of women, parents/caregivers and families prior to discharge and identify those who may require additional support. PROTOCOL REGISTRATION DETAILS: The protocol for the review was registered with protocols.io on 23 November 2020: https://doi.org/10.17504/protocols.io.bpzymp7w.

Improving prescribing: a feasibility study of pharmacogenetic testing with clinical decision support in primary healthcare in Singapore.

BACKGROUND: The study of genetic variation as a factor influencing drug safety, efficacy, and effectiveness has brought about significant breakthroughs in understanding the clinical application of gene-drug interactions to better manage drug therapy. OBJECTIVE: This study was designed to assess the feasibility of collecting buccal samples by general practitioners (GPs) at private practices in Singapore within a usual consultation, incorporating use of a pharmacogenetics-based medical decision support system to guide subsequent drug dosing. METHODS: We used a prospective cohort study design, with GPs recruiting 189 patients between October 2020 and March 2021. The genotypes of 51 biallelic SNPs were determined using Illumina Infinium Global Screening Array. RESULTS: Seven GPs from 6 private practices recruited and obtained buccal samples from a total of 189 patients. All patients had at least one actionable variant. The prevalence of patients having 2, 3, or 4 variants was 37.0%, 32.8%, and 12.7%, respectively. Potential alterations to medications were identified using the Clinical Decision Support System. Patients were accepting and the GPs were enthusiastic about the potential of pharmacogenetics to personalize medicine for their patients. CONCLUSION: This is the first study in Singapore to demonstrate the feasibility of pharmacogenetic testing in primary care. The high prevalence of genetic variants underscores the potential use of pharmacogenetics in this setting.

Reducing delayed transfer of care in older people: A qualitative study of barriers and facilitators to shorter hospital stays.

INTRODUCTION: Growing numbers of older patients occupy hospital beds despite being 'medically fit' for discharge. These Delayed Transfers of Care amplify inefficiencies in care and can cause harm. Delayed transfer because of family or patient choice is common; yet, research on patient and family perspectives is scarce. To identify barriers to, and facilitators of, shorter hospital stays, we sought to understand older people's and caregivers' thoughts and feelings about the benefits and harms of being in hospital and the decisions made at discharge. METHODS: A multimethod qualitative study was carried out. Content analysis was carried out of older people's experiences of health or care services submitted to the Care Opinion online website, followed by telephone and video interviews with older people and family members of older people experiencing a hospital stay in the previous 12 months. RESULTS: Online accounts provide insight into how care was organized for older people in the hospital, including deficiencies in care organization, the discharge process and communication, as well as how care was experienced by older people and family members. Interview-generated themes included shared meanings of hospitalization and discharge experiences and the context of discharge decisions including failure in communication systems, unwarranted variation and lack of confidence in care and lack of preparation for ongoing care. CONCLUSION: Poor quality and availability of information, and poor communication, inhibit effective transfer of care. Communication is fundamental to patient-centred care and even more important in discharge models characterized by limited assessments and quicker discharge. Interventions at the service level and targeted patient information about what to expect in discharge assessments and after discharge could help to address poor communication and support for improving discharge of older people from hospital. PATIENT OR PUBLIC CONTRIBUTION: The Frailty Oversight Group, a small group of older people providing oversight of the Community Aging Research 75+ study, provided feedback on the research topic and level of interest, the draft data collection tools and the feasibility of collecting data with older people during the COVID-19 pandemic. The group also reviewed preliminary findings and provided feedback on our interpretation.

Understanding the journeys of patients with an asthma exacerbation requiring urgent therapy at a primary care clinic.

BACKGROUND: Asthma is a significant health issue in primary care. We examined the journeys of patients with asthma exacerbations requiring urgent therapy at a primary care clinic in Singapore. METHODS: Face-to-face semi-structured interviews were conducted with patients who received urgent therapy for asthma exacerbation at a primary care clinic. Data collected was used to construct themes. RESULTS: Fifteen multi-ethnic adult patients were recruited. Participants cited treatment cost, underuse of preventer medication, difficulties attending routine asthma care due to work, and stigma as barriers to asthma control. Reasons for delay in seeking urgent care for asthma were: inability to access medical care out of hours, competing priorities, perception that an exacerbation was 'not serious enough', difficulty recognizing symptoms of asthma exacerbation, and being tired or despondent. Participants were triggered to seek care due to failure of reliever inhalers, duration of symptoms, sleep disturbance, inability to work, or advice from others. During an exacerbation, participants often initiated other self-management measures besides using reliever medication. This included over-the-counter medications and non-pharmacological interventions (e.g. drinking water). Of the 15 patients interviewed, only one stepped up preventer inhaler adequately, according to their Asthma Action Plan (AAP). CONCLUSIONS: In caring for patients with asthma, primary care providers should address patients' asthma self-management skills, such as recognizing symptoms of asthma exacerbations and regular preventer use, and provide clear instructions on how to respond to asthma symptoms (AAP). Minimizing direct (medication and consultation fees) and indirect costs (loss of earnings and adverse impact on employment prospects) are also important considerations.