Search

Histopathology guidelines generally focus on standardised collection of data items to facilitate completeness and reproducibility of histopathology reporting. A data item is categorised as either core (mandatory) or non-core (recommended but not mandatory), irrespective of the clinical scenario. However, a data item that is critical for patient management in one clinical setting may have little clinical significance in another setting. A diagnosis of limited extent Gleason score 3+3=6 prostate cancer is critical in a patient being investigated for raised serum prostate-specific antigen but would be clinically irrelevant in a repeat biopsy from a patient on an active surveillance protocol. We outline an alternative approach that is focused on the clinical utility of the data items and the requirements of personalised medicine. While all core data items are required to be reported, understanding how these parameters are used to guide patient management will enable pathologists to focus time and resources on the critical aspects of an individual case. Detailed immunohistochemical workup and obtaining a second opinion would not be necessary if resolution of the differential diagnosis is of limited clinical significance. We also highlight some challenges encountered when adopting this approach and suggest some solutions that could positively impact histopathology reporting and patient care.

Objectives A key feature of blood-injection-injury (BII) phobia is activation of disgust responses, in addition to fear. Yet, standard treatments have largely neglected addressing disgust responses. The disorder is further complicated by fainting in 75% of sufferers. Moreover, treatments have been traditionally delivered in an individual format, which may not be as efficient as group treatment. The aim of this study was to develop a group-based programme for BII phobia, with components targeting fear, disgust, and fainting, to determine feasibility and effectiveness of such an intervention. Methods Participants took part in an 8-session, group-based Cognitive Behavioural Therapy (CBT) programme for BII phobia (N = 40). The key outcome measure was the Multidimensional Blood/Injury Phobia Inventory, which assesses a range of phobic stimuli and responses (including fear, disgust, and fainting). Results There were significant improvements, with large effect sizes, across symptoms over the course of treatment. Participants with higher disgust sensitivity reported higher pre-treatment symptom severity and greater life interference than those with lower disgust scores. Despite this, neither pre-treatment disgust sensitivity nor fainting history impacted on treatment response. For the first time, however, we showed that greater reductions in disgust to BII stimuli were associated with greater overall symptom reductions, highlighting the importance of disgust in the treatment of this disorder, and potentially others. Conclusion Despite the heterogeneous nature of BII phobia, this group-based, modified CBT intervention was effective in reducing a variety of phobic responses, including fear, disgust, and fainting. Practitioner points Disgust is a key maintaining factor in blood-injection-injury phobia, which clinicians should consider in their assessment and treatment of this disorder. There is little in the existing literature to guide clinicians in this regard. This study examined a novel group treatment for blood-injection-injury phobia which included strategies to target disgust, in addition to traditional CBT strategies to address fear and fainting. The treatment was feasible and acceptable. Symptoms of fear, disgust, and fainting reduced significantly over treatment. Changes in disgust symptoms were associated with overall symptom changes, however a control group is needed to determine the effects of individual treatment components and to make more robust conclusions about the benefits of this enhanced approach.

Background To inform the World Health Organization’s full value of vaccine assessment for group B Streptococcus (GBS) vaccines, a rapid literature appraisal was conducted to inform the operationalization of maternal GBS vaccination. We found limited published information on stakeholder perceptions of the public health importance of GBS disease and vaccination, and we therefore undertook a multicountry survey. Methods An online survey was conducted in late 2019 to collect information on stakeholders’ awareness of GBS disease and the priority accorded to vaccination. The survey was distributed by email to 395 representatives of national pediatric, gynecology, and obstetrics associations, national immunization technical advisory groups (NITAGs), national regulatory agencies, academia, and United Nations organizations. Results Among 101 survey respondents from 66 countries, 36% were pediatricians, 25% obstetricians/gynecologists, 21% immunization specialists, and 18% other public health specialists. More than half (58%) of respondents reported being familiar with GBS disease as a public health problem; familiarity decreased by country income level. Knowledge of GBS disease was greatest in the Americas (68%) and Europe (66%) and lowest in Asia (13%–38%). Perception of GBS disease as a public health problem was highest among pediatricians (71%) and lowest among public health policy makers and NITAG members (30%) across country groupings. Approximately half of respondents (49%) considered the introduction of a GBS vaccine as a priority. Conclusions The information obtained will inform the appropriate packaging and presentation of information to address stakeholder perceptions and promote evidence-based decision making on GBS vaccination.

The development of a functional vasculature requires the coordinated control of cell fate, lineage differentiation and network growth. Cellular proliferation is spatiotemporally regulated in developing vessels, but how this is orchestrated in different lineages is unknown. Here, using a zebrafish genetic screen for lymphatic-deficient mutants, we uncover a mutant for the RNA helicase Ddx21. Ddx21 cell-autonomously regulates lymphatic vessel development. An established regulator of ribosomal RNA synthesis and ribosome biogenesis, Ddx21 is enriched in sprouting venous endothelial cells in response to Vegfc-Flt4 signalling. Ddx21 function is essential for Vegfc-Flt4-driven endothelial cell proliferation. In the absence of Ddx21, endothelial cells show reduced ribosome biogenesis, p53 and p21 upregulation and cell cycle arrest that blocks lymphangiogenesis. Thus, Ddx21 coordinates the lymphatic endothelial cell response to Vegfc-Flt4 signalling by balancing ribosome biogenesis and p53 function. This mechanism may be targetable in diseases of excessive lymphangiogenesis such as cancer metastasis or lymphatic malformation.

Online cognitive behavioural therapy for insomnia (iCBT-I) provides scalable access to psychological interventions; however, the effectiveness of these courses during COVID-19 has not been examined...

Objective: This paper offers clinical insights and practical guidelines for clinicians about how internet-delivered cognitive behaviour therapy (iCBT) can be safely and effectively integrated into ...

ObjectivesMuscle wasting is a recognised extra-pulmonary complication in chronic obstructive pulmonary disease and has been associated with increased risk of death. Acute respiratory exacerbations are associated with reduction of muscle function, but there is a paucity of data on their long-term effect. This study explores the relationship between acute respiratory exacerbations and long-term muscle loss using serial measurements of CT derived pectoralis muscle area (PMA).Design and settingParticipants were included from two prospective, longitudinal, observational, multicentre cohorts of ever-smokers with at least 10 pack-year history.ParticipantsThe primary analysis included 1332 (of 2501) participants from Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) and 4384 (of 10 198) participants from Genetic Epidemiology of COPD (COPDGene) who had complete data from their baseline and follow-up visits.InterventionsPMA was measured on chest CT scans at two timepoints. Self-reported exacerbation data were collected from participants in both studies through the use of periodic longitudinal surveys.Main outcome measuresAge-related and excess muscle loss over time.ResultsAge, sex, race and body mass index were associated with baseline PMA. Participants experienced age-related decline at the upper end of reported normal ranges. In ECLIPSE, the exacerbation rate over time was associated with an excess muscle area loss of 1.3% (95% CI 0.6 to 1.9, pConclusionsExacerbations are associated with accelerated skeletal muscle loss. Each annual exacerbation was associated with the equivalent of 6 months of age-expected decline in muscle mass. Ameliorating exacerbation-associated muscle loss represents an important therapeutic target.

Background: Group B streptococcus (GBS) colonisation during pregnancy can lead to invasive GBS disease (iGBS) in infants, including meningitis or sepsis, with a high mortality risk. Other outcomes include stillbirths, maternal infections, and prematurity. There are data gaps, notably regarding neurodevelopmental impairment (NDI), especially after iGBS sepsis, which have limited previous global estimates. In this study, we aimed to address this gap using newly available multicountry datasets. Methods: We collated and meta-analysed summary data, primarily identified in a series of systematic reviews published in 2017 but also from recent studies on NDI and stillbirths, using Bayesian hierarchical models, and estimated the burden for 183 countries in 2020 regarding: maternal GBS colonisation, iGBS cases and deaths in infants younger than 3 months, children surviving iGBS affected by NDI, and maternal iGBS cases. We analysed the proportion of stillbirths with GBS and applied this to the UN-estimated stillbirth risk per country. Excess preterm births associated with maternal GBS colonisation were calculated using meta-analysis and national preterm birth rates. Findings: Data from the seven systematic reviews, published in 2017, that informed the previous burden estimation (a total of 515 data points) were combined with new data (17 data points) from large multicountry studies on neurodevelopmental impairment (two studies) and stillbirths (one study). A posterior median of 19·7 million (95% posterior interval 17·9–21·9) pregnant women were estimated to have rectovaginal colonisation with GBS in 2020. 231 800 (114 100–455 000) early-onset and 162 200 (70 200–394 400) late-onset infant iGBS cases were estimated to have occurred. In an analysis assuming a higher case fatality rate in the absence of a skilled birth attendant, 91 900 (44 800–187 800) iGBS infant deaths were estimated; in an analysis without this assumption, 58 300 (26 500–125 800) infant deaths from iGBS were estimated. 37 100 children who recovered from iGBS (14 600–96 200) were predicted to develop moderate or severe NDI. 40 500 (21 500–66 200) maternal iGBS cases and 46 200 (20 300–111 300) GBS stillbirths were predicted in 2020. GBS colonisation was also estimated to be potentially associated with considerable numbers of preterm births. Interpretation: Our analysis provides a comprehensive assessment of the pregnancy-related GBS burden. The Bayesian approach enabled coherent propagation of uncertainty, which is considerable, notably regarding GBS-associated preterm births. Our findings on both the acute and long-term consequences of iGBS have public health implications for understanding the value of investment in maternal GBS immunisation and other preventive strategies. Funding: Bill & Melinda Gates Foundation.

Background: Online communities such as Reddit can provide social support for those recovering from opioid use disorder. However, it is unclear whether and how advice-seekers differ from other users. Our research addresses this gap by identifying key characteristics of r/suboxone users that predict advice-seeking behavior. Objective: The objective of this analysis is to identify and describe advice-seekers on Reddit for buprenorphine-naloxone use using text annotation, social network analysis, and statistical modeling techniques. Methods: We collected 5258 posts and their comments from Reddit between 2014 and 2019. Among 202 posts which met our inclusion criteria, we annotated each post to determine which were advice-seeking (n = 137) or not advice-seeking (n = 65). We also annotated each posting user’s buprenorphine-naloxone use status (current versus formerly taking and, if currently taking, whether inducting or tapering versus other stages) and quantified their connectedness using social network analysis. To analyze the relationship between Reddit users’ advice-seeking and their social connectivity and medication use status, we constructed four models which varied in their inclusion of explanatory variables for social connectedness and buprenorphine use status. Results: The stepwise model containing “total degree” (p = 0.002), “using: inducting/tapering” (p < 0.001), and “using: other” (p = 0.01) outperformed all other models. Reddit users with fewer connections and who are currently using buprenorphine-naloxone are more likely to seek advice than those who are well-connected and no longer using the medication, respectively. Importantly, advice-seeking behavior is most accurately predicted using a combination of network characteristics and medication use status, rather than either factor alone. Conclusions: Our findings provide insights for the clinical care of people recovering from opioid use disorder and the nature of online medical advice-seeking overall. Clinicians should be especially attentive (e.g., through frequent follow-up) to patients who are inducting or tapering buprenorphine-naloxone or signal limited social support.

Supporting prosocial participation and mental health during school lunch has been studied over the past decade, yet surprisingly little in-depth research has addressed how children experience and p...

Background Insomnia is the most prevalent sleep disorder worldwide, and regularly co-occurs with anxiety and depression. Cognitive behavioural therapy is the gold standard treatment for insomnia (CBT-I), however demand for treatment providers drastically exceeds supply. Internet-delivered programs for insomnia (iCBT-I) improve treatment access. However the effects of unguided iCBT-I for individuals with comorbidities within a naturalistic setting remains unexplored. We developed a novel unguided iCBT-I program and evaluated its impact on insomnia, psychological distress, and wellbeing when accessed by the public. Methods 317 participants experiencing insomnia for over 3 months enrolled in the program. The program consisted of 4 lessons delivered online with automated web support. Insomnia symptoms, psychological distress, and general wellbeing were assessed at lesson 1 and 4. Intention-to-treat linear mixed models were used to examine effects on insomnia, distress, and wellbeing. Results Participants experienced large (g = 1.11) and significant reductions in insomnia, moderate (g = 0.55) and significant reductions in distress, and small (g = 0.37) but significant improvements in wellbeing. 65% of participants who reported pre-treatment insomnia severity at clinical levels remitted following treatment. Limitations To examine the program in a naturalistic setting, we did not employ a control group or follow participants beyond the completion of treatment. Conclusions Unguided iCBT-I is effective for individuals in the community who experience insomnia and are likely experiencing comorbid mental health problems. These effects in the absence of guided contact strengthen the utility of unguided iCBT-I as a scalable and cost-effective method of disseminating treatments for this disorder.

This study aimed to compare the aerosol chemistry and in vitro toxicological profiles of two prototype Heated Tobacco Product (p-HTP) variants to the 1R6F Reference Cigarette. In the neutral red uptake screen the p-HTPs were 37-39-fold less potent than 1R6F, in the micronucleus assay, responses to the p-HTPs were 8-22-fold less, and in the Ames test mutagenicity was weak or removed compared to 1R6F. The cardiovascular scratch wound assay revealed 58-fold greater wound healing impairment following exposure to 1R6F smoke extracts than the p-HTPs. Furthermore, in seven cell stress-related high content screening endpoints (cell count, cytochrome c release, mitochondrial membrane potential, GSH depletion, NFkB translocation, phosphorylation of c-jun and phosphorylation of H2AX), at 4 and 24 h, responses were substantially greater to 1R6F smoke extracts at comparable nicotine levels. The reduced in vitro effects of the p-HTPs were attributed to substantial reductions (90-97%) in selected HPHCs measured compared to in 1R6F smoke. The multiple endpoint in vitro assessment approach provides greater mechanistic insight and the first reported toxicological characterisation of these p-HTPs in the literature. Overall, the findings contribute to the growing weight of evidence that HTPs may offer a reduced harm mode of nicotine delivery to adult smokers.

To investigate vaccine hesitancy leading to underimmunization and a measles outbreak in Rwanda and to develop a conceptual, community-level model of behavioural factors.Local immunization systems in two Rwandan communities (one recently experienced a measles outbreak) were explored using systems thinking, human-centred design and behavioural frameworks. Data were collected between 2018 and 2020 from: discussions with 11 vaccination service providers (i.e. hospital and health centre staff); interviews with 161 children's caregivers at health centres; and nine validation interviews with health centre staff. Factors influencing vaccine hesitancy were categorized using the 3Cs framework: confidence, complacency and convenience. A conceptual model of vaccine hesitancy mechanisms with feedback loops was developed.A comparison of service providers' and caregivers' perspectives in both rural and peri-urban settings showed that similar factors strengthened vaccine uptake: (i) high trust in vaccines and service providers based on personal relationships with health centre staff; (ii) the connecting role of community health workers; and (iii) a strong sense of community. Factors identified as increasing vaccine hesitancy (e.g. service accessibility and inadequate follow-up) differed between service providers and caregivers and between settings. The conceptual model could be used to explain drivers of the recent measles outbreak and to guide interventions designed to increase vaccine uptake.The application of behavioural frameworks and systems thinking revealed vaccine hesitancy mechanisms in Rwandan communities that demonstrate the interrelationship between immunization services and caregivers' vaccination behaviour. Confidence-building social structures and context-dependent challenges that affect vaccine uptake were also identified.Analyser l'hésitation vaccinale menant à une immunisation insuffisante et à une épidémie de rougeole au Rwanda, mais aussi développer un modèle conceptuel de facteurs comportementaux à l'échelle communautaire.Nous avons examiné les systèmes d'immunisation locaux dans deux communautés rwandaises (l'une ayant récemment subi une épidémie de rougeole) en utilisant la pensée systémique, une approche centrée sur l'humain et des cadres comportementaux. Les données ont été récoltées entre 2018 et 2020 auprès de plusieurs sources: les discussions avec 11 prestataires de services liés à la vaccination (hôpitaux et centres médicaux); des entretiens avec 161 aides-soignants du département pédiatrique dans divers centres médicaux; et enfin, neuf entretiens de validation avec le personnel des centres médicaux. Nous avons classé les facteurs conditionnant l'hésitation vaccinale conformément à la règle des 3 C: confiance (D'après une comparaison entre les perspectives des prestataires de services et aides-soignants, tant en milieu rural que périurbain, des facteurs similaires renforcent la prise vaccinale: (i) un degré de confiance élevé envers les vaccins et les prestataires de services, fondé sur les relations entretenues avec le personnel des centres médicaux; (ii) le rôle d'intermédiaire joué par les agents de santé communautaires; et enfin, (iii) un fort sentiment d'appartenance à la collectivité. Les facteurs qui ont tendance à accroître l'hésitation vaccinale (parmi lesquels figurent l'accessibilité aux services et l'absence de suivi adéquat) varient entre prestataires de services et aides-soignants, ainsi que selon les milieux. Le modèle conceptuel pourrait servir à identifier les moteurs de la récente épidémie de rougeole, et orienter les actions destinées à améliorer la prise vaccinale.L'application des cadres comportementaux et de la pensée systémique ont révélé les mécanismes qui sous-tendent l'hésitation vaccinale au sein des communautés rwandaises, et qui prouvent la corrélation entre les services d'immunisation et le comportement des aides-soignants en la matière. Nous avons également découvert des structures sociales de restauration de la confiance ainsi que des défis qui, en fonction du contexte, ont un impact sur la prise vaccinale.Estudiar la reticencia a las vacunas que ha causado la falta de vacunación y la aparición de un brote de sarampión en Ruanda, y desarrollar un modelo conceptual a nivel comunitario de los factores de comportamiento.Se analizaron los programas locales de vacunación en dos comunidades de Ruanda (una de las que experimentó un brote de sarampión hace poco) mediante el uso de marcos de pensamiento sistémico, de diseño centrado en el ser humano y de comportamiento. Los datos se recopilaron entre 2018 y 2020 a partir de conversaciones con 11 proveedores de servicios de vacunación (es decir, personal de hospitales y de centros sanitarios); entrevistas con 161 cuidadores de niños en centros sanitarios; y 9 entrevistas de validación con personal de centros sanitarios. Los factores que influyen en la reticencia a la vacunación se clasificaron mediante el modelo de las 3 C: confianza, complacencia y conveniencia. Asimismo, se elaboró un modelo conceptual de los mecanismos de reticencia a la vacunación que incluye ciclos de retroalimentación.Una comparación entre las perspectivas de los proveedores de servicios y de los cuidadores, tanto en entornos rurales como periurbanos, indicó que factores similares reforzaban la adopción de las vacunas: i) la gran confianza en las vacunas y en los proveedores de servicios gracias a las relaciones personales con el personal del centro sanitario; ii) el rol de conexión de los profesionales sanitarios de la comunidad; y iii) el gran sentido de pertenencia a la comunidad. Los factores identificados que aumentan la reticencia a las vacunas (por ejemplo, la accesibilidad a los servicios y el seguimiento insuficiente) difieren entre los proveedores de servicios y los cuidadores y entre los distintos entornos. El modelo conceptual se podría utilizar para explicar los factores que influyeron en el reciente brote de sarampión y para orientar las intervenciones diseñadas con el objetivo de aumentar la adopción de vacunas.La aplicación de marcos de comportamiento y del pensamiento sistémico reveló mecanismos de reticencia a las vacunas en las comunidades de Ruanda que evidencian la interrelación entre los servicios de vacunación y el comportamiento de vacunación de los cuidadores. También se identificaron las estructuras sociales de fomento de la confianza y los desafíos específicos del contexto que afectan a la adopción de las vacunas.الاستقصاء عن التردد في تعاطي اللقاح وهو ما يؤدي إلى نقص المناعة وتفشي مرض الحصبة في رواندا، وتطوير نموذج مفاهيمي على مستوى المجتمع للعوامل السلوكية.تم استكشاف أنظمة التحصين المحلية في مجتمعين روانديين (تعرض أحدهما مؤخرًا لتفشي مرض الحصبة)، باستخدام التفكير النظامي، والتصميم المرتكز على الإنسان، وأطر العمل السلوكية. تم تجميع البيانات بين عامي 2018 و2020 من: مناقشات مع 11 من مقدمي خدمة التطعيم (أي فريق العمل بالمستشفى والمركز الصحي)؛ ومقابلات شخصية مع 161 من مقدمي الرعاية للأطفال في المراكز الصحية؛ وتسع مقابلات شخصية للتحقق مع فريق عمل المركز الصحي. تم تصنيف العوامل التي تؤثر على التردد في تعاطي اللقاح باستخدام إطار عمل 3Cs: الثقة (Confidence)، والرضا (Complacency)، والراحة (Convenience). تم تطوير نموذج مفاهيمي لآليات التردد في تعاطي اللقاح مع حلقات طرح التعليقات.إن المقارنة بين وجهات نظر مقدمي الخدمات، ووجهات نظر مقدمي الرعاية، في كل من المناطق الريفية وشبه الحضرية، أظهرت أن هناك عوامل مماثلة قد زادت من نسبة تعاطي اللقاح: (1) ثقة عالية في اللقاحات ومقدمي الخدمة على أساس العلاقات الشخصية مع فريق عمل المركز الصحي؛ و(2) الدور المتصل للعاملين الصحيين بالمجتمع؛ و (3) شعور قوي بالانتماء للمجتمع. إن العوامل التي تم التوصل إلى أنها تزيد من التردد في تعاطي اللقاح (مثل إمكانية الحصول على الخدمة، والمتابعة غير الكافية)، اختلفت بين مقدمي الخدمة ومقدمي الرعاية، وفيما بين المواقع. يمكن استخدام النموذج المفاهيمي لشرح دوافع تفشي مرض الحصبة مؤخرًا، ولتوجيه التدخلات المقررة لزيادة نسبة تعاطي اللقاح.إن كل من تطبيق أطر العمل السلوكية والتفكير النظامي كشفا عن آليات التردد في تعاطي اللقاح في المجتمعات الرواندية، والتي توضح العلاقة المتبادلة بين خدمات التحصين وسلوك التطعيم لدى مقدمي الرعاية. كما تم التوصل إلى الهياكل الاجتماعية لبناء الثقة، والتحديات التي تعتمد على السياق، والتي تؤثر على نسبة تعاطي اللقاح.调查导致卢旺达免疫不足和麻疹爆发的“疫苗犹豫”，并开发一个社区层面的概念性行为因素模型。.采用系统思维、以人为本的设计理念和行为框架，探索了卢旺达两个社区（其中一个地区最近经历了麻疹爆发）的当地免疫系统。收集的 2018 年至 2020 年数据来自：与 11 位疫苗接种服务提供者（即医院和卫生中心工作人员）的讨论；采访了卫生中心的 161 名儿童看护人员；以及与卫生中心工作人员进行的九次验证访谈。使用 3C 框架对影响“疫苗犹豫”的因素进行分类：信心感、满足度和便利性。开发了具有反馈回路的“疫苗犹豫”机制的概念模型。.对农村和城郊环境中服务提供者和看护人员的观点进行比较，结果表明以下类似因素加强了疫苗接种：(I) 基于与卫生中心工作人员的个人关系对疫苗和服务提供者的高度信任；(ii) 社区卫生工作者所起到的纽带作用；(iii) 强烈的社区意识。被确定为增加“疫苗犹豫”的因素（例如服务的可及性和后续随访不足）在不同的环境中以及在不同的服务提供者和看护人员之间有所差异。该概念模型可用于解释近期麻疹爆发的驱动因素，并指导提高疫苗接种率的干预措施。.行为框架和系统思维的应用揭示了卢旺达社区的“疫苗犹豫”机制，证明了免疫服务与护理人员的疫苗接种行为之间的相互关系。还确定了营造信心的社会结构和不同环境下影响疫苗接种的挑战。.Изучить недоверие к вакцинации, ведущее к недостаточной иммунизации и вспышке кори в Руанде, а также разработать концептуальную модель поведенческих факторов на общинном уровне.Были изучены местные системы по иммунизации в двух руандийских общинах (одна из которых недавно пережила вспышку кори) с использованием системного мышления, дизайна, ориентированного на потребности человека, и поведенческих структур. Были собраны данные в период с 2018 по 2020 год в результате обсуждений с 11 поставщиками услуг в области вакцинации (то есть персоналом больниц и центров здравоохранения), интервью с 161 лицом, осуществляющим уход за детьми в центрах здравоохранения, и девяти оценочных интервью с персоналом центра здравоохранения. Факторы, влияющие на недоверие к вакцинации, были классифицированы с использованием «системы 3 факторов»: доверие, удовлетворенность жизненной ситуацией и удобство. Была разработана концептуальная модель механизмов недоверия к вакцинации с обратной связью.Сравнение мнений поставщиков услуг и лиц, осуществляющих уход, в сельских и пригородных районах показало, что увеличению охвата вакцинацией способствовали аналогичные факторы: (i) высокое доверие к вакцинам и поставщикам услуг, основанное на личных отношениях с персоналом центра здравоохранения; (ii) связующая роль местных медицинских работников; (iii) сильное чувство общности. Факторы, идентифицированные как растущее недоверие к вакцинации (например, доступность обслуживания и недостаточное последующее наблюдение), различались между поставщиками услуг и лицами, осуществляющими уход, а также между районами. Концептуальную модель можно использовать для объяснения причин недавней вспышки кори и для разработки мероприятий, направленных на увеличение охвата вакцинацией.Применение поведенческих структур и системного мышления выявило в руандийских общинах механизмы недоверия к вакцинации, которые демонстрируют взаимосвязь между иммунизационным обслуживанием и поведением лиц, осуществляющих уход, в отношении вакцинации. Были также определены социальные структуры, способствующие укреплению доверия, и контекстно зависимые проблемы, влияющие на охват вакцинацией.

BackgroundOnline communities can provide social support for those recovering from opioid use disorder. However, advice-seekers on these platforms risk exposure to uncurated medical advice, potentially harming their health or recovery efforts. The objective of this analysis is to combine text annotation, social network analysis, and statistical modeling to identify advice-seekers on online social media for buprenorphine-naloxone use and study their characteristics.MethodsWe collected 5,258 posts and their comments from Reddit between 2014 and 2019. Among 202 posts which met our inclusion criteria, we annotated each post to determine which were advice-seeking (n=137) and not advice-seeking (n=65). We also annotated each posting user’s medication use stage and quantified their connectedness using social network analysis. In order to analyze the relationship between advice-seeking with a user’s social connectivity and medication use stage, we constructed four models which varied in explanatory variables.ResultsThe stepwise model (containing “total degree” (P=0.002), “using: inducting/tapering” (PConclusionsOur findings provide insights for the clinical care of people recovering from opioid use disorder and the nature of online medical advice-seeking overall. Clinicians should be especially attentive (e.g., through frequent follow-up) to patients who are inducting or tapering buprenorphine-naloxone or signal limited social support.

Little is known about the prevalence and impact on treatment of comorbid personality disorders for adults undertaking online cognitive behaviour therapy (internet-delivered or internet-based cognitive behaviour therapy (iCBT)) for anxiety and depressive disorders. This study explored how common comorbid personality difficulties were in a large sample of consecutive patients (N = 1 132) seeking iCBT for their symptoms of anxiety and depression in routine care settings. Patients completed the Standardized Assessment of Personality-abbreviated Scale Self-Report prior to commencing an iCBT programme, as well as completing assessments of anxiety and depression symptom severity and psychological distress pre-iCBT and post-iCBT. Consistent with previous studies, a high proportion of the sample (62.6%) reported experiencing comorbid personality difficulties. However, comorbid personality difficulties were not significantly associated with poorer treatment adherence or higher post-treatment symptom severity or psychological distress (controlling for baseline symptom severity, demographic characteristics and treatment variables). Current findings support an inclusive approach to iCBT provision where comorbid personality difficulties do not appear to be a contraindication for treatment. © 2021 John Wiley & Sons, Ltd.

Acknowledgements This paper results from a cooperation between the authors in a project coordinated by Training and Research Support Centre in association with University of Aberdeen on Building policy support for Family and Child Health and Well-being (https://www.shapinghealth.org/case-studies-fchw). We acknowledge the Robert Wood Johnson Foundation and the Charities Aid Foundation of America for support of the project. Funding We acknowledge a prior Robert Wood Johnson Foundation and the Charities Aid Foundation of America (RWJF/CAFA) grant for background work on building policy support for family and child health and wellbeing.

Background As an innovative approach to providing web-based health care services from physical hospitals to patients at a distance, e-hospitals (ie, extended care hospitals through the internet) have been extensively developed in China. This closed health care delivery chain was developed by combining e-hospitals with physical hospitals; treatment begins with web-based consultation and registration, and then, patients are diagnosed and treated in a physical hospital. This approach is promising in its ability to improve accessibility, efficiency, and quality of health care. However, there is limited research on end users’ acceptance of e-hospitals and the effectiveness of strategies aimed to prompt the adoption of e-hospitals in China. Objective This study aimed to provide insights regarding the adoption of e-hospitals by investigating patients’ willingness to use e-hospitals and analyzing the barriers and facilitators to the adoption of this technology. Methods We used a pretested self-administered questionnaire and performed a cross-sectional analysis in 1032 patients across three hierarchical hospitals in West China from June to August 2019. Patients’ sociodemographic characteristics, medical history, current disease status, proficiency with electronic devices, previous experience with web-based health services, willingness to use e-hospitals, and perceived facilitators and barriers were surveyed. Multiple significance tests were employed to examine disparities across four age groups, as well as those between patients who were willing to use e-hospitals and those who were not. Multivariate logistic regression was also performed to identify the potential predictors of willingness to use e-hospitals. Results Overall, it was found that 65.6% (677/1032) of participants were willing to use e-hospitals. The significant predictors of willingness to use e-hospitals were employment status (P=.02), living with children (P Conclusions We identified the variables, facilitators, and barriers that play essential roles in the adoption of e-hospitals. Based on our findings, we suggest that efforts to increase the adoption of e-hospitals should focus on making target populations accustomed to web-based health care services while maximizing ease of use and providing assistance for technological inquiries.

The growth and development of smartphone and e-health technologies has enabled the employment of extended care hospitals such as e-hospitals in China in order to facilitate the success of a primary healthcare center (PHC) based integrated delivery model. Although the adoption of this innovation in healthcare delivery is essential, few studies have directed their research towards understanding the perspectives of healthcare providers. This study aims to identify the current readiness of healthcare providers to adopt e-hospital technologies, determine factors influencing their adoption, and describe perceived facilitators and barriers in regards to e-hospital use. A cross-sectional study was conducted from July to September of 2019 in Western China. This study included a self-administered questionnaire that was used to assess participants socio-demographic characteristics, online medical practice, willingness to use e-hospitals, and perceived facilitators/barriers to using e-hospitals. Multivariate regression analysis was performed in order to evaluate independent factors associated with e-hospital use. The survey population consisted of 2,298 medical professionals from a tertiary hospital, secondary hospital, PHC, and private hospital. Overall, 86.3% had a positive response toward the usage of e-hospitals. Age (P

IntroductionWe present the integration of telemedicine into the healthcare system of West China Hospital of Sichuan University (WCH), one of the largest hospitals in the world with 4300 inpatient beds, as a means for maximising the efficiency of healthcare delivery during the COVID-19 pandemic.MethodsImplemented on 22 January 2020, the telemedicine technology allowed WCH providers to conduct teleconsultations, telerounds, teleradiology and tele-intensive care unit, which in culmination provided screening, triage and treatment for COVID-19 and other illnesses. To encourage its adoption, the government and the hospital publicised the platform on social media and waived fees.DiscussionFrom 1 February to 1 April 2020, 10557 online COVID-19 consultations were conducted for 6662 individuals; meanwhile, 32676 patients without COVID completed virtual follow-ups. We discuss that high-quality, secure, affordable and user-friendly telemedical platforms should be integrated into global healthcare systems to help decrease the transmission of the virus and protect healthcare providers from infection.

Objectives To map the integration of existing maternal tetanus immunization programmes within antenatal care (ANC) services for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with high performance maternal vaccine service delivery. Design A mixed methods, cross sectional study with four data collection phases including a desk review, online survey, telephone and face-to-face interviews and in country visits was undertaken between 2016 and 2018. Associations of different service delivery process components with protection at birth (PAB) and with country groups were established. PAB was defined as the proportion of neonates protected at birth against neonatal tetanus. Regression analysis and structural equation modelling was used to assess associations of different variables with maternal tetanus immunization coverage. Latent class analysis (LCA), was used to group country performance for maternal immunization, and to address the problem of multicollinearity. Setting LMICs. Results The majority of LMICs had a policy on recommended number of ANC visits, however most were yet to implement the WHO guidelines recommending eight ANC contacts. Countries that recommended > 4 ANC contacts were more likely to have high PAB > 90%. Passive disease surveillance was the most common form of disease surveillance performed but the maternal and neonatal morbidity and mortality indicators recorded differed between countries. The presence of user fees for antenatal care and maternal immunization was significantly associated with lower PAB ( Conclusions Recommendations include implementing the current WHO ANC guideline to facilitate increased opportunities for vaccination during each pregnancy. Improved utilisation of ANC services by increasing the demand side by increasing the quality of services, reducing any associated costs and supporting user fee exemptions, or the supply side can also enhance utilisation of ANC services which are positioned as an ideal platform for delivery of maternal vaccines.

BACKGROUND As an innovative approach to providing web-based health care services from physical hospitals to patients at a distance, e-hospitals (ie, extended care hospitals through the internet) have been extensively developed in China. This closed health care delivery chain was developed by combining e-hospitals with physical hospitals; treatment begins with web-based consultation and registration, and then, patients are diagnosed and treated in a physical hospital. This approach is promising in its ability to improve accessibility, efficiency, and quality of health care. However, there is limited research on end users’ acceptance of e-hospitals and the effectiveness of strategies aimed to prompt the adoption of e-hospitals in China. OBJECTIVE This study aimed to provide insights regarding the adoption of e-hospitals by investigating patients’ willingness to use e-hospitals and analyzing the barriers and facilitators to the adoption of this technology. METHODS We used a pretested self-administered questionnaire and performed a cross-sectional analysis in 1032 patients across three hierarchical hospitals in West China from June to August 2019. Patients’ sociodemographic characteristics, medical history, current disease status, proficiency with electronic devices, previous experience with web-based health services, willingness to use e-hospitals, and perceived facilitators and barriers were surveyed. Multiple significance tests were employed to examine disparities across four age groups, as well as those between patients who were willing to use e-hospitals and those who were not. Multivariate logistic regression was also performed to identify the potential predictors of willingness to use e-hospitals. RESULTS Overall, it was found that 65.6% (677/1032) of participants were willing to use e-hospitals. The significant predictors of willingness to use e-hospitals were employment status (P=.02), living with children (PP=.046), information technology skills (PP CONCLUSIONS We identified the variables, facilitators, and barriers that play essential roles in the adoption of e-hospitals. Based on our findings, we suggest that efforts to increase the adoption of e-hospitals should focus on making target populations accustomed to web-based health care services while maximizing ease of use and providing assistance for technological inquiries.

Introduction Randomised controlled trials have shown that internet-delivered cognitive behavioural treatment (iCBT) is an effective treatment for health anxiety, but the effectiveness of these programs in routine care has not been investigated. This study examined the effectiveness of iCBT for health anxiety symptoms in routine care settings in the community. Methods Using an open-trial design, we investigated adherence to, and effectiveness of a 6-lesson iCBT program for health anxiety symptoms amongst individuals (n = 391, mean age 41 years, 64% female) who enrolled in the program either self-guided (n = 312) or under the supervision of community clinicians (general practitioners, psychologists and other allied health professionals) (n = 79). Primary outcome was health anxiety severity on the Short Health Anxiety Inventory (SHAI), and secondary outcomes were depression severity on the Patient Health Questionnaire 9-item (PHQ-9) (depression) and distress (Kessler-10: K-10). Results Adherence to the iCBT program was modest (45.6% in the clinician-supervised group, 33.0% in the unguided group), but within-subjects effect sizes were large (SHAI: g = 1.66, 95%CI: 1.45–1.88; PHQ-9: g = 1.12, 95%CI: 0.92–1.32; K-10: g = 1.35, 95%CI: 1.15–1.56). Limitations No control group, lack of follow-up data. Conclusions iCBT is an effective treatment for health anxiety symptoms in routine care, but methods to increase adherence are needed to optimise benefits to participants. Randomised controlled effectiveness trials with long-term follow-up are needed.

Background There has been a worldwide rise in planned caesarean sections over recent decades, with significant variations in practice between hospitals and countries. Guidelines are known to influence clinical decision-making and, potentially, unwarranted clinical variation. The aim of this study was to review guidelines for recommendations in relation to the timing and indications for planned caesarean section as well as recommendations around the process of decision-making. Method A systematic search of national and international English-language guidelines published between 2008 and 2018 was undertaken. Guidelines were reviewed, assessed in terms of quality and extracted independently by two reviewers. Findings In total, 49 guidelines of varying quality were included. There was consistency between the guidelines in potential indications for caesarean section, although guidelines vary in terms of the level of detail. There was substantial variation in timing of birth, for example recommended timing of caesarean section for women with uncomplicated placenta praevia is between 36 and 39 weeks depending on the guideline. Only 11 guidelines provided detailed guidance on shared decision-making. In general, national-level guidelines from Australia, and overseas, received higher quality ratings than regional guidelines. Conclusion The majority of guidelines, regardless of their quality, provide very limited information to guide shared decision-making or the timing of planned caesarean section, two of the most vital aspects of guidance. National guidelines were generally of better quality than regional ones, suggesting these should be used as a template where possible and emphasis placed on improving national guidelines and minimising intra-country, regional, variability of guidelines.