Consideraciones bioéticas en el manejo de la esclerosis lateral amiotrófica: Una aproximación al quehacer fonoaudiológico

Introducción: La esclerosis lateral amiotrófica (ELA) es la forma más común de enfermedad degenerativa de motoneurona en la edad adulta y es considerada una enfermedad terminal. Por lo mismo, el accionar del fonoaudiólogo debe considerar el respeto a los principios bioéticos básicos para garantizar una asistencia adecuada. Objetivo: Conocer aquellas consideraciones bioéticas relacionadas al manejo y estudio de personas con ELA para luego brindar una aproximación hacia el quehacer fonoaudiológico. Método: Se efectuó una búsqueda bibliográfica en las bases de datos PubMed, Scopus y SciELO. Se filtraron artículos publicados desde 2000 hasta junio de 2023 y fueron seleccionados aquellos que abordaban algún componente bioético en población con ELA. Resultados: Aspectos relacionados al uso del consentimiento informado y a la toma de decisiones compartidas destacaron como elementos esenciales para apoyar la autonomía de las personas. Conclusión: Una correcta comunicación y una toma de decisiones compartida son claves para respetar la autonomía de las personas. A su vez, la estandarización de procedimientos mediante la investigación clínica permitirá aportar al cumplimiento de los principios bioéticos de beneficencia y no maleficencia, indispensables para la práctica profesional.

Introduction: Amyotrophic lateral sclerosis (ALS) is the most common form of degenerative motor neuron disease in adulthood and is considered a terminal disease. For this reason, the actions of the speech therapist must consider respect for basic bioethical principles to guarantee adequate assistance. Objective: To know those bioethical considerations related to the management and study of people with ALS to then provide an approach to speech therapy. Methodology: A bibliographic search was carried out in the PubMed, Scopus, and SciELO databases. Articles published from 2000 to June 2023 were filtered and those that addressed a bioethical component in the population with ALS were selected. Results: Aspects related to the use of informed consent and shared decision-making stood out as essential elements to support people's autonomy. Conclusion: Proper communication and shared decision-making are key to respecting people's autonomy. In turn, the standardization of procedures through clinical research will contribute to compliance with the bioethical principles of beneficence and non-maleficence, essential for professional practice.

Outcomes of a Community of Practice on Quebec Speech Language Pathologists' Voice Assessment Practices and Professional Identity

In a context where different protocols for recommended practices in clinical voice assessment exist, while there are gaps in the literature regarding the evidence base supporting assessment procedures and measures, clinicians from regions where a strong community holding expertise in clinical and scientific voice practices lack can struggle to confidently develop their voice assessment practices. In an effort to improve voice assessment practices and strengthen professional identity among speech-language pathologists in Quebec, Canada, a community of practice (CoP) was established, with the aim of promoting knowledge sharing, implementing change in clinical practice, and improving professional identity. Thirty-nine participants took part in the CoP activities conducted over a four-month period, including virtual meetings and in-person workshops. Participants had a high rate of attendance (> 74% participation rate in virtual meetings), and were highly satisfied with their participation and intended to remain involved after the project's end. Statistically significant changes in voice assessment practices were observed post-CoP, regarding probability of performing assessments (p < .001), and perceived importance of assessment for evaluative purposes (p <.001), as well as improvements in assessment specific confidence, specifically for procedure of auditory-perceptual assessment (p < .001) and purpose of aerodynamic assessment (p = .05). Moreover, there was an increase in professional identity post-CoP (p < .001) and participants felt they made significant learnings. The present study highlighted the need to involve SLPs in future research to identify assessments that are relevant to the specific evaluative objectives of SLPs working with voice, and suggests CoPs are an efficient tool for that purpose.

En un contexto en el que existen diferentes protocolos para las prácticas recomendadas en la evaluación vocal clínica, y en el que se presentan vacíos en la literatura respecto a la base de evidencia que respalda los procedimientos y medidas de evaluación, los profesionales de regiones donde no hay una comunidad sólida con experiencia en prácticas vocales clínicas y científicas pueden enfrentar dificultades para desarrollar con confianza sus prácticas de evaluación vocal. Con el propósito de mejorar las prácticas de evaluación vocal y fortalecer la identidad profesional entre los logopedas de Quebec, Canadá, se estableció una comunidad de práctica (CdP). Esta tenía como objetivo fomentar el intercambio de conocimientos, implementar cambios en la práctica clínica y mejorar la identidad profesional. Un total de treinta y nueve participantes se involucraron en las actividades de la CdP, llevadas a cabo durante un período de cuatro meses, que incluyeron reuniones virtuales y talleres presenciales. Los participantes tuvieron una alta tasa de asistencia (> 74% de participación en las reuniones virtuales) y expresaron un alto grado de satisfacción con su participación, manifestando su intención de continuar involucrados después de la finalización del proyecto. Se observaron cambios estadísticamente significativos en las prácticas de evaluación vocal posterior a la CdP, en lo que respecta a la probabilidad de llevar a cabo evaluaciones (p < .001) y la percepción de la importancia de la evaluación con fines evaluativos (p < .001), así como mejoras en la confianza específica en la evaluación, particularmente en el procedimiento de evaluación auditivo-perceptual (p < .001) y el propósito de la evaluación aerodinámica (p = .05). Además, se registró un aumento en la identidad profesional posterior a la CdP (p < .001) y los participantes sintieron que obtuvieron aprendizajes significativos. El presente estudio destacó la necesidad de involucrar a los logopedas en investigaciones futuras, para identificar evaluaciones pertinentes a los objetivos evaluativos específicos de los logopedas que trabajan con la voz, y sugiere que las CdP son una herramienta eficiente con ese propósito.

Frailty Syndrome in Rural Communities: A Narrative Review and Interviews With Rural Individuals.

Background With the global increase in aging populations, frailty syndrome, characterized by decreased strength, endurance, and physiological function, has become a critical issue. This study focuses on rural Japanese communities, where the prevalence of frailty syndrome can be notably high due to factors such as multimorbidity, polypharmacy, and a significant population of elderly individuals. This research addresses the gap in understanding frailty's manifestations and impacts in rural settings, considering unique challenges such as social isolation, limited healthcare access, and the broader social determinants of health. Methodology The study employs a narrative review with PubMed and a thematic analysis of semi-structured interviews with 21 elderly community workers in Unnan City. The analysis used the framework of frailty syndrome affected by physiological, social, psychological, and economic factors. The analysis focused on identifying themes related to the social determinants of health affecting frailty and potential solutions. Results The following five themes emerged from the analysis: Aging, Rural Contexts, Isolation, Lack of Knowledge of Frailty Syndrome, and Lack of Help-Seeking Behavior for Frailty Syndrome. Four solution-oriented themes were identified, namely, Public Dialogue and Educational Workshops, Frailty Syndrome Health Meetings, Social Engagement Activities, and Political Advocacy for Accessibility to Community Centers. These findings highlight the critical role of community engagement, education, and infrastructure improvements in addressing frailty syndrome in rural areas. Conclusions This study underscores the complexity of frailty syndrome in rural Japanese communities, emphasizing the need for targeted interventions that address the unique challenges faced by these populations. By fostering public dialogue, improving healthcare access, and enhancing social support, it is possible to mitigate the impacts of frailty syndrome and improve the quality of life for elderly residents in rural settings. This research contributes to a deeper understanding of frailty in aging societies and the importance of considering social determinants of health in developing effective solutions.

The barriers and facilitators to nursing care for patients with permanent colostomy in outpatient centers: A qualitative study.

BACKGROUND: Ostomy care nurses are responsible for the management of patients with colostomy from the time of diagnosis. Currently, most ostomy care services are provided in outpatient ostomy care centers in order to reduce patients' hospital stay and reduce hospitalization-related costs. Many different factors can affect colostomy nursing care provision in these centers. Identification of these factors can facilitate quality care provision. MATERIALS AND METHODS: This descriptive qualitative study was conducted in 2020-2021 to explore the barriers and facilitators to nursing care for patients with permanent colostomy in Tehran and Qom ostomy centers. Participants were twelve nurses with ostomy care licenses, two adult patients with permanent colostomy for at least two years, and one family caregiver of a patient with permanent colostomy purposefully selected from outpatient ostomy care centers in Iran. RESULT: Data were collected via fifteen in-depth semi-structured interviews and were analyzed using Graneheim and Lundman's conventional content analysis. The barriers and facilitators to nursing care for patients with permanent colostomy in outpatient centers came into three main categories, namely specialized capabilities of colostomy care, care continuity, and caring status in the family. CONCLUSION: These findings imply that not only nurses, but also patients, family caregivers, and referral systems can influence nursing care provision to permanent colostomy. Effective management of these factors can improve the quality of ostomy nursing care.

Pre-service nurses' experiences of simulated health education classes: A phenomenological study.

With the growing demand for health education, enhancing nurses' ability to deliver such education is vital. This phenomenological qualitative study, employing convenience sampling, investigates pre-service nurses' experiences in simulated health education classes. The study included 32 fourth-year pre-service nurses from the Department of Nursing at a South Korean university. Between April 20 and June 30, 2022, these participants documented their perceptions of the simulated classes in self-reflection journals. The researcher utilized the phenomenological research method as proposed by Colaizzi (1978) to analyze the data. The findings suggest that simulated health education classes offer an opportunity to bolster pre-service nurses' practical knowledge, fostering their growth as nursing educators. The pre-service nurses reported gaining confidence in their roles as educators and enhancing their professionalism through these simulated classes. Therefore, as public health promotion becomes increasingly crucial and the demand for health education rises, simulated health education classes serve as a valuable adjunct to teaching methods in health education.

Pediatric End-of-Life Simulation Workshop to Clinical Care: Lasting Implications on Clinical Practice.

Background: Simulations are an important modality for practicing high-acuity, low-frequency events. We implemented a deliberate practice simulation-based workshop to improve pediatric end-of-life care skills (PECS) competence. Purpose: To understand pediatric subspecialty fellows' perceptions about influences of a simulation-based workshop on PECS provided at the bedside several months following participation. Methods: Pediatric subspecialty fellows were recruited to voluntary focus groups during regular educational sessions six months following PECS workshop participation with aims to identify perceptions about their workshop participation and any implication on their clinical practice. Inductive qualitative content analysis of focus group interview data was performed adhering to the Standards for Reporting Qualitative Research. Results: Ten fellows participated in one of three focus groups. Researchers identified three major themes of fellow experience: burden, safe practice space, and self-efficacy. Fellows described practice implications from workshop participation, including incorporation of specific practices, improved anticipatory guidance, and increased team leader confidence. Conclusions: Targeted, deliberate simulation-based practice of PECS can help close the gap from learning to practice, contributing to provider self-efficacy and potentially improving clinical care for pediatric patients and families at end of life.

Involving community pharmacists in interprofessional collaboration in primary care: a systematic review.

BACKGROUND: The World Health Organization supports interprofessional collaboration in primary care. On over the past 20 years, community pharmacists had been taking a growing number of new responsibilities and they are recognized as a core member of collaborative care teams as patient-centered care providers. This systematic review aimed to describe interprofessional collaboration in primary care involving a pharmacist, and its effect on patient related outcomes. METHODS: A systematic review of randomized controlled trials cited in the MEDLINE, EMBASE, PsycInfo and CINAHL in English and French was conducted from inception to November 2022. Studies were included if they described an intervention piloted by a primary care provider and included a pharmacist and if they evaluated the effects of intervention on a disease or on patient related outcomes. The search generated 3494 articles. After duplicates were removed and titles and abstracts screened for inclusion, 344 articles remained. RESULTS: Overall, 19 studies were included in the review and assessed for quality. We found 14 studies describing an exclusive collaboration between physician and pharmacist with for all studies a three-step model of pharmacist intervention: a medication review, an interview with the patient, and recommendations made to physician. Major topics in the articles eligible for inclusion included cardiovascular diseases with blood pressure, diabetes, dyslipidemia, and risk of cardiovascular diseases. Positive effects concerned principally blood pressure. CONCLUSIONS: Collaboration involving pharmacists is mainly described in relation to cardiovascular diseases, for which patient-centered indicators are most often positive. It underscores the need for further controlled studies on pharmacist-involved interprofessional collaboration across various medical conditions to improve consensus on core outcomes measures.

Understanding and Practices of Oral Hygiene in the Intensive Care Units: Perspectives of Medical Staff at Two University Hospital Centers.

Objective: This study assesses the knowledge, practices, and attitudes of medical staff in intensive care units (ICUs) regarding oral hygiene care for critically ill, bedridden patients. Material and methods: A cross-sectional study included 65 employees from the Intensive Care Units of the Sestre Milosrdnice Clinical Hospital Centre (CHC SM) and the Clinic for Anesthesiology and Intensive Care at the University Clinical Hospital Centre Zagreb (CHC ZG). A self-administered questionnaire was used to assess knowledge, methods, frequency, and attitudes towards oral care for mechanically ventilated patients. The data were examined through descriptive statistical methods, presented in terms of proportions (percentages). For the purpose of comparing the feedback across the two hospital centers and different educational backgrounds, the Chi-square and Fisher's exact tests were employed. Results: Results of a survey of 65 participants (18 from CHC SM and 47 from CHC ZG) revealed a notable disparity in oral hygiene knowledge, with graduate nurses displaying the highest proportion of adequate knowledge (100%) and regular nurses showing the least (30.3%) (p<.001). Although the execution of oral care practices did not vary significantly among the groups, graduate nurses performed oral care more frequently (80% vs. baccalaureate technicians 33.33% and nurses 57.6%, three or more times a day) and demonstrated better proficiency in both mechanical (p=.005) and chemical (p<.001) biofilm management compared to their counterparts. No significant difference was observed in the delivery of oral care to orotracheally intubated patients across different educational levels (p=.127). However, a marked difference was noted in the perception of being adequately trained for such care, with nurses feeling less prepared (12.1%, p<.001). Despite these variances, all respondents recognized the importance of oral hygiene, thus showing a strong dedication to oral health care. Conclusions: This study highlights variability in ICU oral hygiene practices and points to the importance of standardized care protocols and improved training for healthcare staff.

Prospective Evaluation of Dental Practitioners' Knowledge, Attitude, and Practice Toward Adult Dental Pain Management: A Cross-Sectional Multicenter Study.

Background Dental pain among adults is a prevalent concern impacting oral health and quality of life. Dental pain management presents a significant challenge for dental practitioners in effectively alleviating patient discomfort. Among the medications available, non-steroidal anti-inflammatory drugs (NSAIDs) are considered the most effective analgesics in dental care. While numerous studies have been conducted to assess the role of antibiotics in dental practice, there is a scarcity of studies specifically examining the prescription patterns of analgesics. The primary aim of this study was to evaluate the knowledge, attitudes, and practices of dental practitioners (DPs) in India concerning the management of adult dental pain. Method This survey utilized a computer-aided questionnaire-based approach. A total of 110 dentists, including 16 from metropolitan areas and 84 from non-metropolitan cities practicing at dental healthcare setups, clinics, and hospitals, were interviewed as part of the survey. The participants comprised dental professionals specializing in prosthodontics, endodontics, orthodontics, periodontics, oral surgery, pedodontics, and oral medicine. The study was conducted between September 2022 and January 2023. Results The primary reason patients seek dental consultation, as reported by 95% of dentists, is tooth cavities, followed by tooth sensitivity, post-root canal treatment, and pulpitis. All surveyed dentists prescribed NSAIDs to their patients for managing dental pain. Local anesthesia (LA) was the second choice for 75% of dentists, prescribed to 23% of their patients. The primary use of NSAIDs was for patients experiencing severe pain and to manage post-procedure pain. Eighty percent of DPs recognized ketorolac as a fast-acting molecule, providing immediate relief within 10-15 minutes. Overall, analysis indicated that 98% of DPs are satisfied and 67% are extremely satisfied with ketorolac among monotherapies for dental pain management due to its quick onset of action, fast pain relief, and usefulness in post-surgical pain management. Conclusion NSAIDs like ketorolac, diclofenac, and aceclofenac were the preferred prescriptions for overall dental pain management. Dental practitioners associated ketorolac with fast pain relief, quick onset of action, and effectiveness in post-surgical pain management, emphasizing its lasting effects. The insights from the study contribute to enhancing dental pain management strategies.

To disinfect or not to disinfect that is the question - Procedure when drawing blood for alcohol measurements in Denmark.

Swabbing with ethanol to disinfect the skin before venipuncture does not bias measurements of blood ethanol, as previously suspected. International evidence-based theory may not always be successfully integrated into local practices, where old customs may remain. So how are the local protocols for swabbing in practice - if they even do swab? Not disinfecting may risk patient safety. We aim to put a focus on the venipuncture disinfection procedure in practice when measuring blood alcohol for clinical matters and if their procedure refers to a guideline. Specialized biomedical laboratory scientists (BLS) are typically responsible for the phlebotomy procedure in Denmark, thus questionnaires were sent to the relevant BLS in 2020 to map disinfection procedures in all Danish hospitals and affiliated blood draw clinics (n = 58). The response rate was 93% (54/58). We observed an inter-laboratory dissimilarity in swabbing procedures, when measuring blood alcohol: A quarter did not use any disinfectant (26%), while the remaining disinfected with ethanol 55%, isopropanol 13%, and 6% with ethanol/chlorhexidine. Of the five Danish regions, three had a regional guideline (3/5), otherwise the swabbing protocol was locally based. There was a regional difference in disinfecting or not (Chi2 p < 0,0001). Danish protocols do not always parallel international literature and international guidelines. Not applying disinfectant may jeopardize patient safety. Laboratories are encouraged to work with evidence-based practice or follow newest standardized international guidelines.

Experiences of clinicians and managers in the implementation of a family focused model in child and adult psychiatry.

Introduction: This paper describes the process of implementing a family focused model, The Family Model, in child and adolescent and adult mental health services in Sweden. Additionally, it describes a service development project carried out in both services within a defined geographical area of Region Stockholm. The Family Model is a communication tool designed to assist clinicians in both services to have family focused conversations with their patients and relatives. Internationally, the needs of individuals experiencing mental health challenges (parents, children and young people) and their close relatives are now well recognized, but barriers to family focused practice nevertheless persist. The aim of this study was to better understand clinicians` experiences in implementing The Family Model in both services. Methods: Three preplanned focus group interviews were carried out with 14 clinicians and managers across both services and the data were analyzed in accordance with methods of Naturalistic inquiry. Result: Findings suggest that The Family Model has utility in both services. The Naturalistic inquiry analyses revealed three main themes: individual, relational and organizational aspects with a total of 10 sub-themes of how the models influence the participants. Furthermore, analyses on a meta understanding level explored that participants underwent a developmental journey in learning about and using The Family Model in practice which was expressed through three themes: "Useful for burdened families", "Influencing prevention", and "To integrate this would be fantastic". Conclusions: The Family Model, when adapted for the Swedish context, is a useful tool for assisting experienced clinicians to engage in family focused practice in both child and adolescent and adult mental health services. The Family Model highlights different aspects in everyday clinical services that were of special interest for clinicians, families, and the system. Future research could explore families' perspectives of the utility of the model.

Kidney trajectory charts improve GP management of patients with reduced kidney function: a randomised controlled vignette study.

BACKGROUND: The stages of chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) reference ranges are currently determined without considering age. AIM: To determine whether a chart that graphs age with eGFR helps GPs make better decisions about managing patients with declining eGFR. DESIGN & SETTING: A randomised controlled vignette study among Australian GPs using a percentile chart plotting the trajectory of eGFR by age. METHOD: Three hundred and seventy-three GPs received two case studies of patients with declining renal function. They were randomised to receive the cases with the chart or without the chart, and asked a series of questions about how they would manage the cases. RESULTS: In an older female patient with stable but reduced kidney function, use of the chart was associated with GPs in the study recommending a longer follow-up period, and longer time until repeat pathology testing. In a younger male First Nations patient with normal but decreasing kidney function, use of the chart was associated with GPs in the study recommending a shorter follow-up period, shorter time to repeat pathology testing, increased management of blood pressure and lifestyle, and avoidance of nephrotoxic medications. This represents more appropriate care in both cases. CONCLUSION: Having access to a chart of percentile eGFR by age was associated with more appropriate management review periods of patients with reduced kidney function, either by greater compliance with current guidelines or greater awareness of a clinically relevant kidney problem.

Drivers of citations in social pharmacy and practice research articles.

BACKGROUND: Research in Social and Administrative Pharmacy has been expanding in the last decade. The recently published Granada Statements offer key recommendations to improve the quality of research in this field. OBJECTIVES: To identify the factors associated with the citations of articles in the field of social, administrative, clinical pharmacy and practice research. METHODS: This study was a retrospective, observational analysis of articles published in three leading journals. Per article Google Scholar citations was the dependent variable. Predictor variables were extracted from all articles published from 2013 to 2015. The dependent variable was dichotomized using sample's median Google Scholar citations. Logistic regression analysis was performed to identify independent predictors of citations ≥ median. RESULTS: The median number of citations per article was 17 (range 0-341), with a mean of 24.2 (SD 27.6). The number of references included in the articles (OR 1.03, CI 1.02-1.04), the year of publication (OR 0.31 CI 0.21-0.46 for articles published 2015), article social media mentions (OR = 1.01, CI 1.01-1.03 and OR 1.10 CI 1.04-1.18 for Facebook and X, respectively), the topic area of research namely pharmacy services (OR 1.65, CI 1.06-2.57) and medication adherence (OR 2.22 CI 1.13-4.33) were independently associated with article having citations ≥ median. CONCLUSIONS: The number of references, the year of publication, social media mentions and the topic area of research, namely pharmacy services and medication adherence, were associated with citations above median in the leading journals of social and administrative pharmacy research. Authors may consider providing a thorough literature review in their articles, while researchers, editors, and publishers are advised to use social media to promote newly published work. This article complements the Granada Statements and may contribute to fostering wider dissemination of the discipline's outputs.

A focused update to the 2019 NLA scientific statement on use of lipoprotein(a) in clinical practice.

Since the 2019 National Lipid Association (NLA) Scientific Statement on Use of Lipoprotein(a) in Clinical Practice was issued, accumulating epidemiological data have clarified the relationship between lipoprotein(a) [Lp(a)] level and cardiovascular disease risk and risk reduction. Therefore, the NLA developed this focused update to guide clinicians in applying this emerging evidence in clinical practice. We now have sufficient evidence to support the recommendation to measure Lp(a) levels at least once in every adult for risk stratification. Individuals with Lp(a) levels <75 nmol/L (30 mg/dL) are considered low risk, individuals with Lp(a) levels ≥125 nmol/L (50 mg/dL) are considered high risk, and individuals with Lp(a) levels between 75 and 125 nmol/L (30-50 mg/dL) are at intermediate risk. Cascade screening of first-degree relatives of patients with elevated Lp(a) can identify additional individuals at risk who require intervention. Patients with elevated Lp(a) should receive early, more-intensive risk factor management, including lifestyle modification and lipid-lowering drug therapy in high-risk individuals, primarily to reduce low-density lipoprotein cholesterol (LDL-C) levels. The U.S. Food and Drug Administration approved an indication for lipoprotein apheresis (which reduces both Lp(a) and LDL-C) in high-risk patients with familial hypercholesterolemia and documented coronary or peripheral artery disease whose Lp(a) level remains ≥60 mg/dL [∼150 nmol/L)] and LDL-C ≥ 100 mg/dL on maximally tolerated lipid-lowering therapy. Although Lp(a) is an established independent causal risk factor for cardiovascular disease, and despite the high prevalence of Lp(a) elevation (∼1 of 5 individuals), measurement rates are low, warranting improved screening strategies for cardiovascular disease prevention.

Comparing the Effect of Early Versus Delayed Metformin Treatment on Glycaemic Parameters Among Australian Adults With Incident Diabetes: Evidence Using a National General Practice Database.

PURPOSE: To compare the effect of early vs delayed metformin treatment for glycaemic management among patients with incident diabetes. METHODS: Cohort study using electronic health records of regular patients (1+ visits per year in 3 consecutive years) aged 40+ years with 'incident' diabetes attending Australian general practices (MedicineInsight, 2011-2018). Patients with incident diabetes were defined as those who had a) 12+ months of medical data before the first recording of a diabetes diagnosis AND b) a diagnosis of 'diabetes' recorded at least twice in their electronic medical records or a diagnosis of 'diabetes' recorded only once combined with at least 1 abnormal glycaemic result (i.e., HbA1c ≥6.5%, fasting blood glucose [FBG] ≥7.0 mmol/L, or oral glucose tolerance test ≥11.1mmol/L) in the preceding 3 months. The effect of early (<3 months), timely (3-6 months), or delayed (6-12 months) initiation of metformin treatment vs no metformin treatment within 12 months of diagnosis on HbA1c and FBG levels 3 to 24 months after diagnosis was compared using linear regression and augmented inverse probability weighted models. Patients initially managed with other antidiabetic medications (alone or combined with metformin) were excluded. FINDINGS: Of 18,856 patients with incident diabetes, 38.8% were prescribed metformin within 3 months, 3.9% between 3 and 6 months, and 6.2% between 6 and 12 months after diagnosis. The untreated group had the lowest baseline parameters (mean HbA1c 6.4%; FBG 6.9mmol/L) and maintained steady levels throughout follow-up. Baseline glycaemic parameters for those on early treatment with metformin (<3 months since diagnosis) were the highest among all groups (mean HbA1c 7.6%; FBG 8.8mmol/L), reaching controlled levels at 3 to 6 months (mean HbA1c 6.5%; FBG 6.9mmol/L) with sustained improvement until the end of follow-up (mean HbA1c 6.4%; FBG 6.9mmol/L at 18-24 months). Patients with timely and delayed treatment also improved their glycaemic parameters after initiating treatment (timely treatment: mean HbA1c 7.3% and FBG 8.3mmol/L at 3-6 months; 6.6% and 6.9mmol/L at 6-12 months; delayed treatment: mean HbA1c 7.2% and FBG 8.4mmol/L at 6-12 months; 6.7% and 7.1mmol/L at 12-18 months). Compared to those not managed with metformin, the corresponding average treatment effect for HbA1c at 18-24 months was +0.04% (95%CI -0.05;0.10) for early, +0.24% (95%CI 0.11;0.37) for timely, and +0.29% (95%CI 0.20;0.39) for delayed treatment. IMPLICATIONS: Early metformin therapy (<3 months) for patients recently diagnosed with diabetes consistently improved HbA1c and FBG levels in the first 24 months of diagnosis.

Asymptomatic intraspinal epidermoid cyst in a 7-year-old male with juvenile idiopathic arthritis identified by an advanced physiotherapist practitioner: a case report.

BACKGROUND: Pediatric intraspinal epidermoid cysts are rare with potential to cause life-altering outcomes if not addressed. Reports to date describe symptomatic presentations including loss of bladder or bowel function and motor and sensory losses. This case report identifies the diagnostic challenge of an asymptomatic intraspinal epidermoid cyst in the cauda equina region presenting in a 7-year-old male with juvenile idiopathic arthritis (JIA). DIAGNOSIS: An advanced physiotherapist practitioner assessed and diagnosed a previously healthy 7-year-old-male of South Asian descent with JIA based on persistent knee joint effusions. Complicating factors delayed the investigation of abnormal functional movement patterns, spinal and hip rigidity and severe restriction of straight leg raise, all atypical for JIA. Further delaying the diagnosis was the lack of subjective complaints including no pain, no reported functional deficits, and no neurologic symptoms. A spinal MRI investigation 10-months from initial appointment identified intraspinal epidermoid cysts occupying the cauda equina region requiring urgent referral to neurosurgery. DISCUSSION: Clinical characteristics and pattern recognition are essential for diagnosing spinal conditions in pediatric populations. Diagnostic challenges present in this case included co-morbidity (JIA), a severe adverse reaction to treatment, a lack of subjective complaints and a very low prevalence of intraspinal epidermoid cysts. IMPACT STATEMENTS: Early signs of pediatric asymptomatic intraspinal epidermoid cysts included abnormal functional movement patterns, rigidity of spine, severely limited straight leg raise and hip flexion without pain. Advanced physiotherapist practitioners can be integral to pediatric rheumatology teams considering their basic knowledge in musculoskeletal examination and functional mobility assessment when identifying rare spinal conditions that present within the complex context of rheumatic diseases.

Comparing GPs according to their model of practice: are multiprofessional group practices associated with more favourable working conditions?

In the generalized context of general practitioner shortages and transitions towards team-based primary care, we investigated how the different practising models relate to general practitioners' labour supply. More precisely, we analysed the association between practice models-solo, groups of general practitioners, and multiprofessional groups-and their reported labour supply and level of satisfaction with work-life balance. We used a French cross-sectional survey from 2018 that surveyed a representative national sample of 3,032 self-employed general practitioners about their working conditions. We found that the model of practice was significantly associated with differences in physician labour supply at the intensive margin and that group practice appeared to be positively associated with general practitioners' reported satisfaction with work-life balance. In terms of weekly working time, only practice in groups of general practitioners was associated with a significantly lower labour supply. However, general practitioners in groups-whether groups of general practitioners or multiprofessional groups-reported more annual leave and seemed more willing to diversify their activity by devoting more time to secondary activities, including salaried activities. Consistently, general practitioners working in groups were also more likely than solo practitioners to report being satisfied with their work-life balance. Although group practice, whether multiprofessionnal or not, seems to be well suited to meeting the new aspirations of general practitioners, those working in multiprofessional groups are associated with a higher level of weekly work supply, which might justify special attention from the public authorities.

Practice-Oriented Research: An Introduction to New Developments and Future Directions.

Aimed at understanding and improving psychological therapies as they are conducted in clinical routine, practice-oriented research (POR) is now a well-established approach to the scientific foundations of mental health care services. Resting on the accumulation of a wide range of practice-based evidence related to treatment outcome and process, as well as factors associated with the participants of psychotherapy and its context, POR is ripe for new developments - regarding what to investigate and how to investigate it. This paper is the introduction of a series devoted to recent advances and future directions of POR as their pertained to routine outcome monitoring, technologies and artificial intelligence, the integration of constructs and methods from program evaluation and implementation science, and the investigation of populations with limited financial resources across various regions of the world. The series also includes commentaries from two leaders of POR.

Influencing Factors on Death Acceptance Among Thai Older Persons.

OBJECTIVES: This study aimed to investigate both the direct and indirect effects of various factors on the acceptance of death. METHODS: This cross-sectional study included 800 older Buddhist persons in Thailand, who were recruited through a multistage sampling method. Data were collected using six questionnaires and analyzed through path analysis using the MPlus program. RESULTS: Death anxiety was the main factor influencing death acceptance, with death anxiety exerting a negative direct effect on death acceptance. Buddhist beliefs about death demonstrated both a positive direct effect on death acceptance and a positive indirect effect on death acceptance through Buddhist practices. Furthermore, Buddhist practices exhibited a positive direct effect on death acceptance, while social support also showed a positive direct effect on death acceptance. CONCLUSIONS: This study highlights the significant direct and indirect effects on death acceptance among older Thai Buddhists. CLINICAL IMPLICATIONS: Buddhist-aligned interventions may be more effective and readily embraced by Thai older persons. For those who are receptive, nurses can foster death acceptance by developing interventions that reduce death anxiety and promote Buddhist beliefs about death, Buddhist practices, and social support.