Real-World Use of Oral and Subcutaneous Semaglutide in Routine Clinical Practice in the UK: A Single-Centre, Retrospective Observational Study.

INTRODUCTION: Semaglutide, the only glucagon-like peptide-1 receptor agonist (GLP-1 RA) available in subcutaneous and oral formulation for treatment of type 2 diabetes (T2D), has demonstrated clinically significant improvements in glycaemic control and weight in clinical trials. This study aimed to gain insights into the use of both formulations and evaluate their clinical effectiveness in a secondary care clinic in Wales. METHODS: This was a retrospective observational analysis of adults with T2D initiated on oral or subcutaneous semaglutide. Changes from baseline in glycated haemoglobin (HbA1c), weight and other metabolic parameters were evaluated. RESULTS: At baseline, participants (n = 103) had a mean age of 57.3 years, mean HbA1c of 79.1 mmol/mol (9.38%), mean weight of 111.8 kg and body mass index (BMI) of 39.6 kg/m2 (no statistically significant differences between oral and subcutaneous groups). At 6-month follow-up, statistically significant improvements in HbA1c (- 19.3 mmol/mol [- 1.77%] and - 20.8 mmol/mol [- 1.90%]), body weight (- 9.0 kg and - 7.2 kg), and BMI (- 3.3 kg/m2 and - 2.5 kg/m2) were observed for oral and subcutaneous semaglutide, respectively. No statistically significant differences between the formulations were observed, and safety profiles were comparable. CONCLUSIONS: Both formulations of semaglutide provided clinically and statistically significant reductions in HbA1c and weight in real-world practice. Oral GLP-1 RA may offer a practical and effective option for the management of T2D.

Predictive, preventive and personalised approach as a conceptual and technological innovation in primary and secondary care of inflammatory bowel disease benefiting affected individuals and populations.

Inflammatory bowel disease (IBD) is a global health burden which carries lifelong morbidity affecting all age groups in populations with the disease-specific peak of the age groups ranging between 15 and 35 years, which are of great economic importance for the society. An accelerating incidence of IBD is reported for newly industrialised countries, whereas stabilising incidence but increasing prevalence is typical for countries with a Westernised lifestyle, such as the European area and the USA. Although the aetiology of IBD is largely unknown, the interplay between the genetic, environmental, immunological, and microbial components is decisive for the disease manifestation, course, severity and individual outcomes. Contextually, the creation of an individualised patient profile is crucial for the cost-effective disease management in primary and secondary care of IBD. The proposed pathomechanisms include intestinal pathoflora and dysbiosis, chronic inflammation and mitochondrial impairments, amongst others, which collectively may reveal individual molecular signatures defining IBD subtypes and leading to clinical phenotypes, patient stratification and cost-effective protection against health-to-disease transition and treatments tailored to individualised patient profiles-all the pillars of an advanced 3PM approach. The paradigm change from reactive medical services to predictive diagnostics, cost-effective targeted prevention and treatments tailored to individualised patient profiles in overall IBD management holds a promise to meet patient needs in primary and secondary care, to increase the life-quality of affected individuals and to improve health economy in the area of IBD management. This article analyses current achievements and provides the roadmap for future developments in the area in the context of 3P medicine benefiting society at large.

The paradigm change from reactive medical services to 3PM in ischemic stroke: a holistic approach utilising tear fluid multi-omics, mitochondria as a vital biosensor and AI-based multi-professional data interpretation.

Worldwide stroke is the second leading cause of death and the third leading cause of death and disability combined. The estimated global economic burden by stroke is over US$891 billion per year. Within three decades (1990-2019), the incidence increased by 70%, deaths by 43%, prevalence by 102%, and DALYs by 143%. Of over 100 million people affected by stroke, about 76% are ischemic stroke (IS) patients recorded worldwide. Contextually, ischemic stroke moves into particular focus of multi-professional groups including researchers, healthcare industry, economists, and policy-makers. Risk factors of ischemic stroke demonstrate sufficient space for cost-effective prevention interventions in primary (suboptimal health) and secondary (clinically manifested collateral disorders contributing to stroke risks) care. These risks are interrelated. For example, sedentary lifestyle and toxic environment both cause mitochondrial stress, systemic low-grade inflammation and accelerated ageing; inflammageing is a low-grade inflammation associated with accelerated ageing and poor stroke outcomes. Stress overload, decreased mitochondrial bioenergetics and hypomagnesaemia are associated with systemic vasospasm and ischemic lesions in heart and brain of all age groups including teenagers. Imbalanced dietary patterns poor in folate but rich in red and processed meat, refined grains, and sugary beverages are associated with hyperhomocysteinaemia, systemic inflammation, small vessel disease, and increased IS risks. Ongoing 3PM research towards vulnerable groups in the population promoted by the European Association for Predictive, Preventive and Personalised Medicine (EPMA) demonstrates promising results for the holistic patient-friendly non-invasive approach utilising tear fluid-based health risk assessment, mitochondria as a vital biosensor and AI-based multi-professional data interpretation as reported here by the EPMA expert group. Collected data demonstrate that IS-relevant risks and corresponding molecular pathways are interrelated. For examples, there is an evident overlap between molecular patterns involved in IS and diabetic retinopathy as an early indicator of IS risk in diabetic patients. Just to exemplify some of them such as the 5-aminolevulinic acid/pathway, which are also characteristic for an altered mitophagy patterns, insomnia, stress regulation and modulation of microbiota-gut-brain crosstalk. Further, ceramides are considered mediators of oxidative stress and inflammation in cardiometabolic disease, negatively affecting mitochondrial respiratory chain function and fission/fusion activity, altered sleep-wake behaviour, vascular stiffness and remodelling. Xanthine/pathway regulation is involved in mitochondrial homeostasis and stress-driven anxiety-like behaviour as well as molecular mechanisms of arterial stiffness. In order to assess individual health risks, an application of machine learning (AI tool) is essential for an accurate data interpretation performed by the multiparametric analysis. Aspects presented in the paper include the needs of young populations and elderly, personalised risk assessment in primary and secondary care, cost-efficacy, application of innovative technologies and screening programmes, advanced education measures for professionals and general population-all are essential pillars for the paradigm change from reactive medical services to 3PM in the overall IS management promoted by the EPMA.

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis.

Background: Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear. Objective: To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented. Methods: Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains. Results: Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps. Scoping review: 651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations. Effectiveness systematic reviews: studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators. Conclusions: Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children. Study registration: This study is registered as PROSPERO CRD42019159008. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

Between 5% and 30% of children experience constipation at some stage. In one-third of these children, this progresses to chronic functional constipation. Chronic functional constipation affects more children with additional needs. We aimed to find and bring together published information about treatments for chronic functional constipation, to help establish best treatments and treatment combinations. We did not cover assessment or diagnosis of chronic functional constipation. This project was guided by a 'stakeholder group', including parents of children with constipation, people who experienced constipation as children, and healthcare professionals/continence experts. We carried out a 'scoping review' and a series of 'systematic reviews'. Our 'scoping review' provides an overall picture of research about treatments, with 651 studies describing 48 treatments. This helps identify important evidence gaps. 'Systematic reviews' are robust methods of bringing together and interpreting research evidence. Our stakeholder group decided to structure our systematic reviews to reflect who delivered the interventions. We brought together evidence about how well treatments worked when delivered by families/carers (32 studies), the wider children's workforce (e.g. general practitioner, health visitor) (21 studies), continence teams (31 studies) or specialist consultant-led teams (42 studies). We also considered complementary therapies (15 studies) and behavioural strategies (4 studies). Care is affected by what is done and how it is done. We brought together evidence about different models of delivering care (15 studies), barriers and facilitators to implementation of treatments (106 studies) and costs (31 studies). Quality of evidence was mainly low to very low. Despite numerous studies, there was often insufficient information to support generalisable conclusions. Our findings generally agreed with current clinical guidelines. Management of childhood chronic functional constipation should be child-centred, multifaceted and adapted according to the individual child, their needs, the situation in which they live and the health-care setting in which they are looked after. Research is needed to address our identified evidence gaps.

The Effectiveness and Cost-Effectiveness of Community Diagnostic Centres: A Rapid Review.

Objectives: To examine the effectiveness of community diagnostic centres as a potential solution to increasing capacity and reducing pressure on secondary care in the UK. Methods: A comprehensive search for relevant primary studies was conducted in a range of electronic sources in August 2022. Screening and critical appraisal were undertaken by two independent reviewers. There were no geographical restrictions or limits to year of publication. A narrative synthesis approach was used to analyse data and present findings. Results: Twenty primary studies evaluating twelve individual diagnostic centres were included. Most studies were specific to cancer diagnosis and evaluated diagnostic centres located within hospitals. The evidence of effectiveness appeared mixed. There is evidence to suggest diagnostic centres can reduce various waiting times and reduce pressure on secondary care. However, cost-effectiveness may depend on whether the diagnostic centre is running at full capacity. Most included studies used weak methodologies that may be inadequate to infer effectiveness. Conclusion: Further well-designed, quality research is needed to better understand the effectiveness and cost-effectiveness of community diagnostic centres.

A Retrospective Audit of the Triage Process Introduced for Breast Referrals Received During the Covid-19 Pandemic.

PURPOSE: Due to restrictions on breast clinic appointments during the Covid-19 pandemic, a triage process was introduced for new patient referrals. The robustness of this process was examined by analysing the incidence of cancer diagnosis and wait times to treatment. METHODS: Patients were triaged by secondary care consultant surgeons to an urgent appointment if they had high-risk symptoms based on prespecified guidelines eg, a lump or previous cancer. Those with non-urgent symptoms were seen on a deferred basis. A retrospective audit of patients referred between March 23 and July 20, 2020 was performed, to investigate incidence of cancer, concordance of primary and secondary care diagnosis, and the wait times to first appointment. RESULTS: Most patients with breast-related symptoms received a face-to-face appointment (69%) with a Primary Care Physician (PCP) or Nurse Practitioner (NP), with 544 (31%) having a telephone PCP/NP appointment. Of 2023 patients, 1461 were triaged by the receiving breast unit to an urgent appointment, 461 to a deferred appointment and 101 to a breast pain telephone clinic. A diagnosis of breast cancer was made in 111/1461 (7.6%), 5/461 (1.1%) and 0% in these triaged groups respectively, and the median wait time to first appointment was 14 days (range 1-94), 32 days (range 6-114) and 21 days (range 10-52, P < .001). CONCLUSION: The one-stop triage process was safe, with statistically fewer cancer diagnoses in patients allocated a deferred appointment, at a rate similar to that seen in a screening population.

Systematic review and meta-analysis of the accuracy of McIsaac and Centor score in patients presenting to secondary care with pharyngitis.

BACKGROUND: Centor and McIsaac scores are clinical prediction rules for diagnosing group A streptococcus (GAS) infection in patients with pharyngitis. Their recommended thresholds vary between guidelines. OBJECTIVES: To estimate the sensitivity and specificity of the McIsaac and Centor scores to diagnose GAS pharyngitis and evaluate their impact on antibiotic prescribing at each threshold in patients presenting to secondary care. DATA SOURCES: MEDLINE, Embase, and Web of Science were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA: Studies of patients presenting with acute pharyngitis to emergency or outpatient clinics that estimated the accuracy of McIsaac or Centor scores against throat cultures and/or rapid antigen detection tests (RADT) as reference standards. TESTS: Centor or McIsaac score. REFERENCE STANDARD: Throat cultures and/or RADT. ASSESSMENT OF RISK OF BIAS: Quality Assessment of Diagnostic Accuracy Studies. METHODS OF DATA SYNTHESIS: The sensitivities and specificities of the McIsaac and Centor scores were pooled at each threshold using bivariate random effects meta-analysis. RESULTS: Fourteen studies were included (eight McIsaac and six Centor scores). Eight studies had unclear and six had a high risk of bias. The McIsaac score had higher estimated sensitivity and lower specificity relative to Centor scores at equivalent thresholds but with wide and overlapping confidence regions. Using either score as a triage to RADT to decide antibiotic treatment would reduce antibiotic prescription to patients with non-GAS pharyngitis relative to RADT test for everyone, but also reduce antibiotic prescription to patients with GAS. DISCUSSION: Centor and McIsaac scores are equally ineffective at triaging patients who need antibiotics presenting with pharyngitis at hospitals. At high thresholds, too many true positive cases are missed, whereas at low thresholds, too many false positives are treated, leading to the over prescription of antibiotics. The former may be compensated by adequate safety netting by clinicians, ensuring that patients can seek help if symptoms worsen.

Performance evaluation of the LumiraDx quantitative microfluidic point-of-care CRP test.

C-reactive protein (CRP) is an established acute-phase marker for infection, inflammation and tissue injury, used to guide clinical decision-making in primary and secondary care. This study compared the analytical performance of the quantitative microfluidic point-of-care LumiraDx CRP Test to a laboratory-based reference method (Siemens RCRP Flex assay on the Dimension® Xpand®) and evaluated equivalence of sample matrices (blood versus plasma) in point-of-care settings using samples from patients presenting with symptoms of infection or inflammation. The LumiraDx CRP Test demonstrated close agreement with the lab reference test (range, 5.1 to 245.2 mg/L, r = 0.992, slope = 0.998, intercept = -0.476; n = 205) and notable agreement between fingerstick and venous blood and plasma (r = 0.974-0.983; n = 44). Paired replicate precision had mean coefficients of variation of 6.4 % (plasma), 6.6 % (capillary direct) and 8.1 % (venous blood); overall error rates were 2.9 %. The quantitative LumiraDx CRP Test showed robust analytical performance across sample matrices and close agreement compared to the laboratory reference method when used at the point of care.

Health-care resource use among patients who use illicit opioids in England, 2010-20: A descriptive matched cohort study.

BACKGROUND AND AIMS: People who use illicit opioids have higher mortality and morbidity than the general population. Limited quantitative research has investigated how this population engages with health-care, particularly regarding planned and primary care. We aimed to measure health-care use among patients with a history of illicit opioid use in England across five settings: general practice (GP), hospital outpatient care, emergency departments, emergency hospital admissions and elective hospital admissions. DESIGN: This was a matched cohort study using Clinical Practice Research Datalink and Hospital Episode Statistics. SETTING: Primary and secondary care practices in England took part in the study. PARTICIPANTS: A total of 57 421 patients with a history of illicit opioid use were identified by GPs between 2010 and 2020, and 172 263 patients with no recorded history of illicit opioid use matched by age, sex and practice. MEASUREMENTS: We estimated the rate (events per unit of time) of attendance and used quasi-Poisson regression (unadjusted and adjusted) to estimate rate ratios between groups. We also compared rates of planned and unplanned hospital admissions for diagnoses and calculated excess admissions and rate ratios between groups. FINDINGS: A history of using illicit opioids was associated with higher rates of health-care use in all settings. Rate ratios for those with a history of using illicit opioids relative to those without were 2.38 [95% confidence interval (CI) = 2.36-2.41] for GP; 1.99 (95% CI = 1.94-2.03) for hospital outpatient visits; 2.80 (95% CI = 2.73-2.87) for emergency department visits; 4.98 (95% CI = 4.82-5.14) for emergency hospital admissions; and 1.76 (95% CI = 1.60-1.94) for elective hospital admissions. For emergency hospital admissions, diagnoses with the most excess admissions were drug-related and respiratory conditions, and those with the highest rate ratios were personality and behaviour (25.5, 95% CI = 23.5-27.6), drug-related (21.2, 95% CI = 20.1-21.6) and chronic obstructive pulmonary disease (19.4, 95% CI = 18.7-20.2). CONCLUSIONS: Patients who use illicit opioids in England appear to access health services more often than people of the same age and sex who do not use illicit opioids among a wide range of health-care settings. The difference is especially large for emergency care, which probably reflects both episodic illness and decompensation of long-term conditions.

The Brazilian Cardioprotective Nutritional (BALANCE) Program improves diet quality in patients with established cardiovascular disease: Results from a multicenter randomized controlled trial.

Dietary modifications are essential strategies for cardiovascular disease prevention. However, studies are needed to investigate the diet quality of individuals undergoing secondary prevention in cardiology and who received dietary intervention based on cardiovascular disease management. We prospectively evaluated the diet quality in the Brazilian Cardioprotective Nutritional Program Trial (BALANCE Program Trial). We hypothesized that the BALANCE Program could improve patients' dietary pattern according to different indices of diet quality such as the Dietary Inflammatory Index (DII); the dietary total antioxidant capacity; overall, healthful, and unhealthful Plant-Based Diet Index (PDI, hPDI, and uPDI, respectively); and modified Alternative Healthy Eating Index (mAHEI). This multicenter randomized, controlled trial included patients aged ≥45 years randomly assigned to either the experimental or control group. Data from 2185 participants at baseline and after 12, 24, 36, and 48 months showed that the intervention group (n = 1077) had lower mean values of DII and higher dietary total antioxidant capacity, PDI, hPDI, and mAHEI than the control group. The results also showed differences between the follow-up times for DII, hPDI, and uPDI (48 months vs baseline) and for PDI and mAHEI (24 months vs baseline), regardless of group. The interaction analysis demonstrated that the intervention group showed better results than the control group at 12, 24, 36, and 48 months for the DII and at months 12, 36, and 48 for the mAHEI. Our results provide prospective evidence that the BALANCE Program improved the diet quality in those in secondary cardiovascular prevention according to different indices, with the intervention group showing better results than the control group.

'A lot of people think it's just a Mickey Mouse role': Role ambiguity among dementia support workers within secondary care and community hospital settings.

Purpose: Dementia support workers (DSWs) are employed to improve the hospital care for patients living with dementia. An evaluation sought to understand the perspectives and experiences of DSWs and related healthcare practitioners within one health board, to identify any role ambiguity and inform future role development.Design/methodology/approach: Framework analysis was used to synthesise data from semi-structured interviews and focus groups with dementia support workers, and a wider group of related healthcare practitioners.Findings: Thirteen semi-structured interviews were conducted with DSWs. Two focus groups were held with DSWs (n = 2 and 4) and two with associated healthcare practitioners (n = 3 and 5). Participants described inconsistencies in the understanding and delivery of the DSW role. Role ambiguity was identified as a key theme.Originality/value: This paper offers insight into challenges experienced by DSWs and addresses factors that could help improve and support the DSW role, and potentially the experience of other staff, and patients/people living with dementia. Overall, this evaluation highlights both the value of the DSW role in supporting the needs of patients/people living with dementia and the potential for person-centred activities to be used as therapeutic interventions.

Atendimento odontológico de pacientes com necessidades especiais na atenção secundária em um estado do nordeste do Brasil / Dental care of special needs patients in secondary care in a northeastern state of Brazil / Atención odontológica a pacientes con necesidades especiales en la atención secundaria en un estado del nordeste de Brasil

O objetivo desse estudo foi descrever a produção dos atendimentos oferecidos aos pacientes com necessidades especiais nos Centros de Especialidades Odontológicas (CEO) da Paraíba (Brasil) e sua relação com o cumprimento das metas de produtividade, entre o período de 2019 e 2022. Trata-se de um estudo descritivo e ecológico em que foram coletados dados secundários do Sistema de Informações Ambulatoriais do SUS (SIA/SUS), através da captação da produção ambulatorial individualizada (BPA-I), por meio da ferramenta TabWin, dos 98 CEO operantes na Paraíba. Realizou-se análise descritiva e analítica, por meio dos testes Qui-Quadrado de Pearson e Exato de Fisher entre a variável dependente "alcance da meta" e a variável independente "adesão à Rede de Cuidados à Pessoa com Deficiência (RCPD)". Em todos os anos, a porcentagem de CEO cumpridores da meta (15,3% em 2019; 1% em 2020; 12,2% em 2021; e 11,2% em 2022) foi substancialmente menor que os números expressados por aqueles que não alcançaram a produção mínima. Os resultados também apontaram maior realização de procedimentos restauradores (29,6% em 2019; 28,6% em 2020; 32,7% em 2021; e 37,8% em 2022) em detrimento aos periodontais, cirúrgicos e preventivos. No que concerne a estar aderido à RCPD, no ano de 2022, 90,9% dos CEO que alcançaram a meta estavam aderidos à Rede (p<0,05). Concluiu-se que uma baixa frequência de CEO alcançou o cumprimento da meta de produtividade da especialidade de Odontologia para Pacientes com Necessidades Especiais nos CEO. No entanto, a adesão à RCPD manifestou-se como elemento influenciador para aqueles que cumpriram suas metas mensais e anuais.

The objective of this study was to describe the production of care provided to special needs patients in the Dental Specialties Centers (CEO) of Paraíba (Brazil) and its relationship with the achievement of productivity goals, between the period 2019 and 2022. This is a descriptive and ecological study in which secondary data were collected from the SUS Outpatient Information System (SIA/SUS), by capturing the individualized outpatient production (BPA-I), through the TabWin tool, of the 98 operating CEOs in Paraíba. We carried out descriptive and analytical analysis, using Pearson's Chi-square and Fisher's Exact tests between the dependent variable "goal attainment" and the independent variable "adherence to the Care Network for People with Disabilities (RCPD)". In all years, the percentage of CEOs meeting the goal (15.3% in 2019; 1% in 2020; 12.2% in 2021; and 11.2% in 2022) was substantially lower than the numbers expressed by those who did not meet the minimum output. The results also indicated greater performance of restorative procedures (29.6% in 2019; 28.6% in 2020; 32.7% in 2021; and 37.8% in 2022) to the detriment of periodontal, surgical, and preventive procedures. Regarding being adhered to the RCPD, in the year 2022, 90.9% of the CEOs who reached the goal were adhered to the Network (p<0.05). It was concluded that a low frequency of CEOs achieved compliance with the productivity target of the specialty of Dentistry for Special Needs Patients in CEOs. However, adherence to the RCPD manifested itself as an influential element for those who met their monthly and annual goals.

El objetivo de este estudio fue describir la producción de la atención prestada a pacientes con necesidades especiales en los Centros de Especialidades Odontológicas (CEO) de Paraíba (Brasil) y su relación con el alcance de las metas de productividad, entre el período de 2019 y 2022. Se trata de un estudio descriptivo y ecológico en el que se recogieron datos secundarios del Sistema de Información Ambulatoria del SUS (SIA/SUS), mediante la captura de la producción ambulatoria individualizada (BPA-I), a través de la herramienta TabWin, de los 98 CEOs en funcionamiento en Paraíba. Se realizaron análisis descriptivos y analíticos, utilizando las pruebas Chi-cuadrado de Pearson y Exacta de Fisher entre la variable dependiente "cumplimiento de metas" y la variable independiente "adhesión a la Red de Atención a Personas con Discapacidad (RCPD)". En todos los años, el porcentaje de directores generales que cumplieron el objetivo (15,3% en 2019; 1% en 2020; 12,2% en 2021; y 11,2% en 2022) fue sustancialmente inferior a las cifras expresadas por los que no alcanzaron el rendimiento mínimo. Los resultados también indicaron una mayor realización de procedimientos restauradores (29,6% en 2019; 28,6% en 2020; 32,7% en 2021; y 37,8% en 2022) en detrimento de los procedimientos periodontales, quirúrgicos y preventivos. Respecto a estar adherido a la RCPD, en el año 2022, el 90,9% de los CEOs que alcanzaron el objetivo estaban adheridos a la Red (p<0,05). Se concluyó que una baja frecuencia de CEOs alcanzó el cumplimiento de la meta de productividad de la especialidad de Odontología para Pacientes con Necesidades Especiales en CEOs. Sin embargo, la adhesión al RCPD se manifestó como un elemento influyente para aquellos que cumplieron sus objetivos mensuales y anuales.

Nitroproteomics is instrumental for stratification and targeted treatments of astrocytoma patients: expert recommendations for advanced 3PM approach with improved individual outcomes.

Protein tyrosine nitration is a selectively and reversible important post-translational modification, which is closely related to oxidative stress. Astrocytoma is the most common neuroepithelial tumor with heterogeneity and complexity. In the past, the diagnosis of astrocytoma was based on the histological and clinical features, and the treatment methods were nothing more than surgery-assisted radiotherapy and chemotherapy. Obviously, traditional methods short falls an effective treatment for astrocytoma. In late 2021, the World Health Organization (WHO) adopted molecular biomarkers in the comprehensive diagnosis of astrocytoma, such as IDH-mutant and DNA methylation, which enabled the risk stratification, classification, and clinical prognosis prediction of astrocytoma to be more correct. Protein tyrosine nitration is closely related to the pathogenesis of astrocytoma. We hypothesize that nitroproteome is significantly different in astrocytoma relative to controls, which leads to establishment of nitroprotein biomarkers for patient stratification, diagnostics, and prediction of disease stages and severity grade, targeted prevention in secondary care, treatment algorithms tailored to individualized patient profile in the framework of predictive, preventive, and personalized medicine (PPPM; 3P medicine). Nitroproteomics based on gel electrophoresis and tandem mass spectrometry is an effective tool to identify the nitroproteins and effective biomarkers in human astrocytomas, clarifying the biological roles of oxidative/nitrative stress in the pathophysiology of astrocytomas, functional characteristics of nitroproteins in astrocytomas, nitration-mediated signal pathway network, and early diagnosis and treatment of astrocytomas. The results finds that these nitroproteins are enriched in mitotic cell components, which are related to transcription regulation, signal transduction, controlling subcellular organelle events, cell perception, maintaining cell homeostasis, and immune activity. Eleven statistically significant signal pathways are identified in astrocytoma, including remodeling of epithelial adherens junctions, germ cell-sertoli cell junction signaling, 14-3-3-mediated signaling, phagosome maturation, gap junction signaling, axonal guidance signaling, assembly of RNA polymerase III complex, and TREM1 signaling. Furthermore, protein tyrosine nitration is closely associated with the therapeutic effects of protein drugs, and molecular mechanism and drug targets of cancer. It provides valuable data for studying the protein nitration biomarkers, molecular mechanisms, and therapeutic targets of astrocytoma towards PPPM (3P medicine) practice. Supplementary Information: The online version contains supplementary material available at 10.1007/s13167-023-00348-y.

Perceptions of primary and secondary care clinicians treating diabetic foot: A pan India study and quantitative analysis.

AIM: The study quantifies clinicians' perceptions and challenges during different stages of diabetic foot treatment. Diabetic neuropathy (DN), which is a major consequence of diabetes, significantly increases the risk of lower limb amputation. This can be prevented to a large extent by foot care, early detection, and lesion treatment. METHODS: Ninety-two Indian clinicians of various demographics, medical specializations, and experiences were interviewed. Diabetic foot treatment by primary and secondary care clinicians was assessed. This study evaluates aspects related to patient awareness, compliance, and shortcomings of current diagnostic techniques. RESULTS: A two-sample Mann-Whitney statistical method was used to infer the perceptions of clinicians on hypothesis questions. Primary and secondary care clinicians' perceptions differed for the hypotheses related to objective assessment (p-value = 0.001), operator variability (p-value = 0.03), and patient compliance (p-value = 0.047). Conversely, both groups held comparative perspectives for the awareness (p-value = 0.369) and examination time (p-value = 0.276) hypotheses. CONCLUSIONS: All clinicians strongly supported the need for an objective assessment to reduce the misdiagnosis of DN. Further, DNis often underdiagnosed due to a lack of awareness and knowledgeamong people with diabetes. Secondary care clinicians acknowledged a need for trained operators to reduce reliability errors. These insights provide directions for future research in this field.

The impact of travel time to cancer treatment centre on post-diagnosis care and mortality among cancer patients in Scotland.

Limited data exist on the effect of travelling time on post-diagnosis cancer care and mortality. We analysed the impact of travel time to cancer treatment centre on secondary care contact time and one-year mortality using a data-linkage study in Scotland with 17369 patients. Patients with longer travelling time and island-dwellers had increased incidence rate of secondary care cancer contact time. For outpatient oncology appointments, the incidence rate was decreased for island-dwellers. Longer travelling time was not associated with increased secondary care contact time for emergency cancer admissions or time to first emergency cancer admission. Living on an island increased mortality at one-year. Adjusting for cancer-specific secondary care contact time increased the hazard of death, and adjusting for oncology outpatient time decreased the hazard of death for island-dwellers. Those with longer travelling times experience the cancer treatment pathway differently with poorer outcomes. Cancer services may need to be better configured to suit differing needs of dispersed populations.

A retrospective analysis of infantile haemangioma referrals: a comparison with the IH European Task Force 'Infantile Haemangioma Referral Score'.

BACKGROUND: Infantile haemangiomas (IH) are common vascular tumours of infancy that can have significant complications. The IH European Task Force developed the IH Referral Score (IHReS) to help non-specialists quickly identify IH that need to be referred to optimise outcomes in high-risk lesions. AIMS: The aim of this study was to assess the quality of IH referrals to a national care centre and compare the IH referred to the IHReS tool. METHODS: This was a retrospective cross-sectional study that collected data from a random sample of 56 IH patients over a 13-month period. RESULTS: Less than 10% included a photograph (8.93%) and a minority of referrals included if there were complications including ulceration (1.79%) or function threatening (8.93%). Three-quarters of patients satisfied the IHReS criteria. CONCLUSION: The IHReS screening tool is a convenient and efficient resource for non-experts to identify children who require referral to a specialist centre.

Postnatal Kangaroo mother care practice at home and comparison of improvement in vital parameters in low-birth-weight babies in-home setup and non-teaching hospital setup in rural coal mines area Jharkhand, India: A community-based observational study.

Introduction: Low birth weight (LBW) newborns especially those <2000 g are more prone to hypothermia due to which other physiological parameters gets deteriorated in the 1st week of life. The objective of this observational study was to continue Kangaroo mother care practice at home and to ascertain whether KMC was effective in improving the vital parameters of LBW babies when it is given at home in a rural coal mines area, in Jharkhand, India. Materials and Methods: This study was a community-based prospective observational study, done over three years from November 2019 to November 2022. In this study, we included 156 pairs of both mothers and LBW babies (weight 1500 g to <2000 g). After discharge from the hospital on day 3, KMC was continued at home on day 4, day 5, and day 6. Data of four physiological parameters, namely, temperature, oxygen saturation, respiratory rate, and heart rate were collected before and after KMC and analyzed. Results: Among 400 newborns, 156 LBW babies (39.0%) who were given KMC at home showed similar but statistically significant improvement of vital parameters, especially in temperature and oxygen saturation (P < 0.0001) compared to the same babies 156 (39.0%) given KMC in the hospital (P < 0.001). Conclusion: Kangaroo mother care, which was continued at home, has a significant role in the Improvement of vital parameters, especially concerning temperature and oxygen saturation. If the babies in the weight range of 1500 g to <2000 g are healthy, well-breast-fed, and have no other risk factors, they can be discharged early and managed at home by delivering supportive care and nursing care along with Kangaroo mother care with continuous follow-up.

Identifying benefits and concerns with using digital health services during COVID-19: Evidence from a hospital-based patient survey.

Despite large-scale adoption during COVID-19, patient perceptions on the benefits and potential risks with receiving care through digital technologies have remained largely unexplored. A quantitative content analysis of responses to a questionnaire (N = 6766) conducted at a multi-site acute trust in London (UK), was adopted to identify commonly reported benefits and concerns. Patients reported a range of promising benefits beyond immediate usage during COVID-19, including ease of access; support for disease and care management; improved timeliness of access and treatment; and better prioritisation of healthcare resources. However, in addition to known risks such as data security and inequity in access, our findings also illuminate some less studied concerns, including perceptions of compromised safety; negative impacts on patient-clinician relationships; and difficulties in interpreting health information provided through electronic health records and mHealth apps. Implications for future research and practice are discussed.

The treatable traits approach to adults with obstructive airways disease in primary and secondary care.

The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.

Antidepressants in pregnancy: applying causal epidemiological methods to understand service-use outcomes in women and long-term neurodevelopmental outcomes in exposed children.

Background: Antidepressants are commonly prescribed during pregnancy, despite a lack of evidence from randomised trials on the benefits or risks. Some studies have reported associations of antidepressants during pregnancy with adverse offspring neurodevelopment, but whether or not such associations are causal is unclear. Objectives: To study the associations of antidepressants for depression in pregnancy with outcomes using multiple methods to strengthen causal inference. Design: This was an observational cohort design using multiple methods to strengthen causal inference, including multivariable regression, propensity score matching, instrumental variable analysis, negative control exposures, comparison across indications and exposure discordant pregnancies analysis. Setting: This took place in UK general practice. Participants: Participants were pregnant women with depression. Interventions: The interventions were initiation of antidepressants in pregnancy compared with no initiation, and continuation of antidepressants in pregnancy compared with discontinuation. Main outcome measures: The maternal outcome measures were the use of primary care and secondary mental health services during pregnancy, and during four 6-month follow-up periods up to 24 months after pregnancy, and antidepressant prescription status 24 months following pregnancy. The child outcome measures were diagnosis of autism, diagnosis of attention deficit hyperactivity disorder and intellectual disability. Data sources: UK Clinical Practice Research Datalink. Results: Data on 80,103 pregnancies were used to study maternal primary care outcomes and were linked to 34,274 children with at least 4-year follow-up for neurodevelopmental outcomes. Women who initiated or continued antidepressants during pregnancy were more likely to have contact with primary and secondary health-care services during and after pregnancy and more likely to be prescribed an antidepressant 2 years following the end of pregnancy than women who did not initiate or continue antidepressants during pregnancy (odds ratioinitiation 2.16, 95% confidence interval 1.95 to 2.39; odds ratiocontinuation 2.40, 95% confidence interval 2.27 to 2.53). There was little evidence for any substantial association with autism (odds ratiomultivariableregression 1.10, 95% confidence interval 0.90 to 1.35; odds ratiopropensityscore 1.06, 95% confidence interval 0.84 to 1.32), attention deficit hyperactivity disorder (odds ratiomultivariableregression 1.02, 95% confidence interval 0.80 to 1.29; odds ratiopropensityscore 0.97, 95% confidence interval 0.75 to 1.25) or intellectual disability (odds ratiomultivariableregression 0.81, 95% confidence interval 0.55 to 1.19; odds ratiopropensityscore 0.89, 95% confidence interval 0.61 to 1.31) in children of women who continued antidepressants compared with those who discontinued antidepressants. There was inconsistent evidence of an association between initiation of antidepressants in pregnancy and diagnosis of autism in offspring (odds ratiomultivariableregression 1.23, 95% confidence interval 0.85 to 1.78; odds ratiopropensityscore 1.64, 95% confidence interval 1.01 to 2.66) but not attention deficit hyperactivity disorder or intellectual disability; however, but results were imprecise owing to smaller numbers. Limitations: Several causal-inference analyses lacked precision owing to limited numbers. In addition, adherence to the prescribed treatment was not measured. Conclusions: Women prescribed antidepressants during pregnancy had greater service use during and after pregnancy than those not prescribed antidepressants. The evidence against any substantial association with autism, attention deficit hyperactivity disorder or intellectual disability in the children of women who continued compared with those who discontinued antidepressants in pregnancy is reassuring. Potential association of initiation of antidepressants during pregnancy with offspring autism needs further investigation. Future work: Further research on larger samples could increase the robustness and precision of these findings. These methods applied could be a template for future pharmaco-epidemiological investigation of other pregnancy-related prescribing safety concerns. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (15/80/19) and will be published in full in Health Technology Assessment; Vol. 27, No. 15. See the NIHR Journals Library website for further project information.

About one in seven women experience depression during pregnancy. Left untreated, this may harm them and their unborn babies. However, the decision to take antidepressants during pregnancy is difficult because women often worry about the risks to their unborn baby. Research findings have been inconsistent, so women often do not have clear information to enable them to make informed decisions. We studied women's and children's outcomes after starting (compared with not starting) or continuing (compared with stopping) antidepressants in pregnancy. We used a large UK primary care database and several novel methods of analysis. We tracked 80,103 pregnancies of women with depression for up to 2 years after pregnancy. We also tracked 34,274 children from these pregnancies for at least 4 years to check for developmental outcomes. Women prescribed antidepressants were more likely than women not prescribed antidepressants to use general practice and mental health services during and after pregnancy, and to be prescribed antidepressants 2 years after pregnancy. This suggests that antidepressants were being prescribed to women with greater clinical need. Women who continued antidepressants in pregnancy had no higher likelihood than those who discontinued antidepressants of autism, attention deficit hyperactivity disorder or intellectual disability in their children. This should reassure women making the decision to continue taking their medications in pregnancy. Women who started antidepressants in pregnancy may possibly have had a slightly higher likelihood of autism in their children than those who did not start them. These findings were not seen in all analyses and were based on smaller numbers; therefore, they should be viewed with caution. Importantly, over 98 in every 100 children of women who initiated or continued antidepressants in pregnancy did not receive an autism diagnosis. The findings may help women and clinicians make informed decisions on treatment with antidepressants in pregnancy.