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Introduction: There are concerns with rising rates of antimicrobial resistance (AMR) across countries with appreciable impact on morbidity, mortality and costs. Amongst low- and middle-income countries, a key driver of AMR is the excessive use of antibiotics in ambulatory care, with a critical area being the appreciable selling of antibiotics without a prescription often driven by patient demand and limited knowledge. There is currently conflicting evidence in South Africa regarding this practice. Consequently, there is a need to explore these critical issues amongst patients, especially in more rural areas of South Africa. A pilot study was undertaken to address this. Methods: A two-step descriptive approach was undertaken. This involved two questionnaires amongst patients exiting chain and independent community pharmacies followed by cognitive interviews. Results: Overall, 21 patients were approached for an interview, including 11 for Part 1 of the questionnaire with 3 declining, and 10 for Part 2, with 2 declining. Subsequently 8 patients completed each part of the questionnaire.. On average, it took 2 min 13 s to complete both parts. 3 of the 5 patients being dispensed an antibiotic were dispensed one without a prescription, with all 3 patients exiting from independent pharmacies. Key reasons for self-purchasing included money and convenience. There was mixed knowledge regarding antibiotics and AMR amongst the 8 patients interviewed with Part 2. Overall, there was a satisfactory understanding of the Part 1 questions, although some modifications were suggested. Some participants had difficulty with fully understanding the questions in Part 2, with a number of suggestions made to improve this for the main study. Conclusion: There were concerns with the extent of purchasing antibiotics without a prescription in this pilot study as well as the knowledge of patients regarding antibiotics and AMR. Both areas need addressing and will be explored further in the main study.

Introduction: There is considerable concern with rising rates of antimicrobial resistance (AMR) with its subsequent impact on morbidity, mortality and costs. In low- and middle-income countries, a key driver of AMR is the appreciable misuse of antibiotics in ambulatory care, which can account for up to 95% of human utilisation. A principal area is the selling of antibiotics without a prescription. There is conflicting evidence in South Africa regarding this practice alongside rising AMR rates. Consequently, there is a need to explore this further, especially in more rural areas of South Africa. A pilot study was undertaken to address this. Materials and Methods: A two-step descriptive approach involving a self-administered questionnaire amongst pharmacists and their assistants followed by cognitive interviews with some of the participants. Results: Twenty-one responses were obtained from nine of the 11 community pharmacies invited to participate. Participating pharmacies were all independently owned. Ten of the 21 participants admitted dispensing antibiotics without a prescription, including both adults and children, representing five of the nine participating pharmacies. A minority dispensed antibiotics before recommending suitable over-the-counter medicines. These high rates were exacerbated by patient pressure. There were issues with the length of the questionnaire and some of the phraseology, which will be addressed in the main study. Conclusion: There were concerns with the extent of purchasing antibiotics without a prescription in this pilot in South Africa study. Key issues will be explored further in the main study.

Abstract Background Robotic-assisted cholecystectomy (RAC) is becoming increasingly common, but the outcomes of emergent/urgent robotic-assisted cholecystectomies compared to emergent laparoscopic (LC) and open cholecystectomies (OC) remain understudied. Methods The PINC AI Healthcare Database was queried to identify adults who underwent emergent or urgent (Em-Ur) cholecystectomy between January 1, 2017, and December 31, 2020. Immediate postoperative and 30-day outcomes were identified including intraoperative complications, transfusion, conversion, postoperative complication, and hospital length of stay. Propensity score matching was done to compare outcomes between Em-Ur robotic-assisted, laparoscopic, and open cholecystectomies Subgroup analyses were performed comparing RAC done with and without fluorescent imaging as well as comparing RAC and LC performed for patients with class 3 obesity (BMI ≥ 40 kg/m2). Results RAC Em-Ur cholecystectomies are being performed with increasing frequency and is the most utilized modality for patients with class 3 obesity. There was no difference in intraoperative complications (0.3%), bile duct injury (0.2%), or postoperative outcomes between RAC and LC. LC had significantly shorter operating room times (96 min (75,128)) compared to RAC (120 min (90,150)). There was a significant lower rate of conversion to open in RAC (1.9%) relative to LC (3.2%) in both the overall population and the class 3 obesity sub-analysis (RAC-2.6% vs. LC-4.4%). There was no difference in outcomes in robotic-assisted cholecystectomies done with and without fluorescent imaging. Conclusions A comparison of propensity score-matched cohorts of emergent/urgent robotic-assisted and laparoscopic cholecystectomy indicates that robotic-assisted cholecystectomy is a safe alternative to laparoscopic cholecystectomy, and that both have superior outcomes to open cholecystectomies.

Abstract The existence of a fine‐grain (FG) sub‐layer between the top large‐grain (LG) layer and the back contact is widely observed in kesterite absorbers prepared with organic solvents. In this paper, the distinguishing features of the lifted‐off carbon‐rich FG layer are investigated through direct analysis with a series of characterization techniques, including X‐ray photoelectron spectroscopy (XPS), attenuated total reflectance, X‐ray diffraction, and scanning electron microscopy. To access the FG layer for direct probing, a scalable and repeatable photonic lift‐off method is developed for carrying out the separation of the kesterite absorber layer from the Mo‐coated glass substrate. A very high light intensity of 4 kW cm−2 for a short interval of 1 ms is optimized by COMSOL simulations, and successful implementation is demonstrated. The XPS analysis has revealed significant carbon content at the exposed FG surface, which explains the hindrance of grain growth due to carbon abundance. The variations in cations and anions concentrations from FG layer leading into LG region are explored through argon ions (Ar+) assisted XPS depth profiling. The observed significant differences between the composition of FG and LG regions are speculated to negatively impact the performance of solar cells.

Abstract Background Involving patients is a key premise of national and international policies on patient safety, which requires understanding how patients or carers want to be involved and developing resources to support this. This paper examines patients' and carers' views of being involved in patient safety in primary care and their views of potentially using a co‐designed patient safety guide for primary care (PSG‐PC) to foster both involvement and their safety. Methods A qualitative study using semistructured face‐to‐face interviews with 18 patients and/or carers in primary care. Interviews were transcribed and analysis was conducted using an inductive thematic approach. Results Overall participants expressed enthusiasm for the PSG‐PC as a tool to support patients and carers to be involved in patient safety in primary care. However, for some participants being involved in patient safety was seen as taking on the role of General Practitioner and had the potential to add an additional workload for patients. Participants' willingness or ability to be involved in patient safety was influenced by a range of factors including an invisible, often underacknowledged role of everyday safety for patients' interactions with primary care; the levels of involvement that patients wanted in their care and safety and the work of embedding the PSG‐PC for patients into their routine interactions with primary care. Participants identified components of the PSG‐PC that would be useful to them, in particular, if they had a responsibility for caring for a family member if they had more complex care or long‐term conditions. Conclusion Involving patients and carers in patient safety needs a tailored and personalized approach that enables patients and carers to use resources like the PSG‐PC routinely and helps challenge assumptions about their willingness and ability to be involved in patient safety. Doing so would raise awareness of opportunities to be involved in safety in line with personal preference. Patient or Public Contribution Patient and public involvement were central to the research study. This included working in partnership to develop the PSG‐PC with patients and carers and throughout our study including in the design of the study, recruiting participants, interpretation of findings.

Abstract Objective This study aimed to develop interpretive insights concerning Infection Prevention and Control (IPC) in care homes for older people. Design This study had a meta‐ethnography design. Data Sources Six bibliographic databases were searched from inception to May 2020 to identify the relevant literature. Review Methods A meta‐ethnography was performed. Results Searches yielded 652 records; 15 were included. Findings were categorized into groups: The difficulties of enacting IPC measures in the care home environment; workload as an impediment to IPC practice; the tension between IPC and quality of life for care home residents; and problems dealing with medical services located outside the facility including diagnostics, general practice and pharmacy. Infection was revealed as something seen to lie ‘outside’ the control of the care home, whether according to origins or control measures. This could help explain the reported variability in IPC practice. Facilitators to IPC uptake involved repetitive training and professional development, although such opportunities can be constrained by the ways in which services are organized and delivered. Conclusions Significant challenges were revealed in implementing IPC in care homes including staffing skills, education, workloads and work routines. These challenges cannot be properly addressed without resolving the tension between the objectives of maintaining resident quality of life while enacting IPC practice. Repetitive staff training and professional development with parallel organisational improvements have prospects to enhance IPC uptake in residential and nursing homes. Patient or Public Contribution A carer of an older person joined study team meetings and was involved in writing a lay summary of the study findings.

The COVID-19 pandemic and 2021 military coup in Myanmar have greatly exacerbated the existing economic distress of ordinary people across the country. Yet, what has been the impact of the pandemic and the coup on Myanmar migrant workers abroad? To address this question, we investigate the situation of Myanmar migrant domestic workers (MDWs) in Singapore. We find that pandemic-related economic contraction in Myanmar and heightened insecurity following the country's 2021 military coup have increased outmigration and intensified pressures on Myanmar domestic workers in Singapore to increase remittances and set aside aspirations of shortly returning home. These origin-country conditions, mediated through a transnational system of labour brokerage, have increased Myanmar MDWs’ vulnerability to exploitation and abuse relative to MDWs of other nationalities. This article thus contributes to analysis of the transnational constitution of migrant labour regimes.

There are concerns with the current prescribing of antibiotics in both the private and public primary care settings in South Africa. These concerns need to be addressed going forward to reduce rising antimicrobial resistance (AMR) rates in South Africa. Concerns include adherence to current prescribing guidelines. Consequently, there is a need to comprehensively summarise current antibiotic utilization patterns from published studies as well as potential activities to improve prescribing, including indicators and antimicrobial stewardship programs (ASPs). Published studies showed that there was an appreciable prescribing of antibiotics for patients with acute respiratory infections, i.e., 52.9% to 78% or more across the sectors. However, this was not universal, with appreciable adherence to prescribing guidelines in community health centres. Encouragingly, the majority of antibiotics prescribed, albeit often inappropriately, were from the ‘Access’ group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than ‘Watch’ antibiotics to limit AMR. Inappropriate prescribing of antibiotics in primary care is not helped by concerns with current knowledge regarding antibiotics, AMR and ASPs among prescribers and patients in primary care. This needs to be addressed going forward. However, studies have shown it is crucial for prescribers to use a language that patients understand when discussing key aspects to enhance appropriate antibiotic use. Recommended activities for the future include improved education for all groups as well as regularly monitoring prescribing against agreed-upon guidelines and indicators.

Simple compound antimony selenide (Sb2Se3) is a promising emergent light absorber for photovoltaic applications benefiting from its outstanding photoelectric properties. Antimony selenide thin film solar cells however, are limited by low open circuit voltage due to carrier recombination at the metallic back contact interface. In this work, solar cell capacitance simulator (SCAPS) is used to interpret the effect of hole transport layers (HTL), i.e., transition metal oxides NiO and MoOx thin films on Sb2Se3 device characteristics. This reveals the critical role of NiO and MoOx in altering the energy band alignment and increasing device performance by the introduction of a high energy barrier to electrons at the rear absorber/metal interface. Close-space sublimation (CSS) and thermal evaporation (TE) techniques are applied to deposit Sb2Se3 layers in both substrate and superstrate thin film solar cells with NiO and MoOx HTLs incorporated into the device structure. The effect of the HTLs on Sb2Se3 crystallinity and solar cell performance is comprehensively studied. In superstrate device configuration, CSS-based Sb2Se3 solar cells with NiO HTL showed average improvements in open circuit voltage, short circuit current density and power conversion efficiency of 12%, 41%, and 42%, respectively, over the standard devices. Similarly, using a NiO HTL in TE-based Sb2Se3 devices improved open circuit voltage, short circuit current density and power conversion efficiency by 39%, 68%, and 92%, respectively.

Developing effective device architectures for energy technologies—such as solar cells, rechargeable batteries or fuel cells—does not only depend on the performance of a single material, but on the performance of multiple materials working together. A key part of this is understanding the behaviour at the interfaces between these materials. In the context of a solar cell, efficient charge transport across the interface is a pre-requisite for devices with high conversion efficiencies. There are several methods that can be used to simulate interfaces, each with an in-built set of approximations, limitations and length-scales. These methods range from those that consider only composition (e.g. data-driven approaches) to continuum device models (e.g. drift-diffusion models using the Poisson equation) and ab-initio atomistic models (developed using e.g. density functional theory). Here we present an introduction to interface models at various levels of theory, highlighting the capabilities and limitations of each. In addition, we discuss several of the various physical and chemical processes at a heterojunction interface, highlighting the complex nature of the problem and the challenges it presents for theory and simulation.

Abstract Background Patients and carers should be actively involved in patient safety and empowered to use person‐centred approaches where they are asked to both identify safety concerns and partner in preventing them. Objectives The aim of this study was to co‐design a patient safety guide for primary care (PSG‐PC) to support patients and carers to address key patient safety questions and identify key points where they can make their care safer. The objectives were to i) identify when and how patients and carers can be involved in primary care patient safety, and ii) identify the relevant information to include in the PSG‐PC. Design An experience‐based co‐design approach. Setting and Participants We conducted three workshops with patients, carers, community pharmacists and general practitioners to develop and refine the PSG‐PC. Results Participants identified both explicit and implicit issues of primary care patient safety especially relating to technical and relational components of involving patients and carers. The importance of communication, understanding roles and responsibilities, and developing partnerships between patients and health‐care providers were considered essential for actively involving patients in patient safety. Co‐developing the PSG‐PC provided insight to improve care to develop the PSG‐PC. Discussion The PSG‐PC is the first guide to be developed for primary care, co‐designed with patients, carers, general practitioners and pharmacists. The PSG‐PC will support patients and carers to partner with health‐care professionals to improve patient safety addressing international and national priorities to continuously improve patient safety.

Abstract Background Despite high level of health care need amongst people experiencing homelessness, poor access is a major concern. This is sometimes due to organisational and bureaucratic barriers, but also because they often feel stigmatised and treated badly when they do seek health care. The COVID-19 pandemic and the required social distancing measures have caused unprecedented disruption and change for the organisation of primary care, particularly for people experiencing homelessness. Against this backdrop there are many questions to address regarding whether the recent changes required to deliver services to people experiencing homelessness in the context of COVID-19 will help to address or compound problems in accessing care and inequalities in health outcomes. Methods An action led and participatory research methodology will be employed to address the study objectives. Interviews with people experiencing homelessness were will be conducted by a researcher with lived experience of homelessness. Researchers with lived experience are able to engage with vulnerable communities in an empathetic, non-judgemental way as their shared experience promotes a sense of trust and integrity, which in turn encourages participation in research and may help people speak more openly about their experience. The experiences of health professionals and stakeholders delivering and facilitating care for people experiencing homelessness during the pandemic will also be explored. Discussion It is important to explore whether recent changes to the delivery of primary care in response to the COVID-19 pandemic compromise the safety of people experiencing homelessness and exacerbate health inequalities. This could have implications for how primary healthcare is delivered to those experiencing homelessness not only for the duration of the pandemic but in the future.

Abstract Background Mitigating or reducing the risk of medication harm is a global policy priority. But evidence reflecting preventable medication harm in medical care and the factors that derive this harm remain unknown. Therefore, we aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings. Methods We performed a systematic review and meta-analysis of observational studies to compare the prevalence of preventable medication harm. Searches were carried out in Medline, Cochrane library, CINAHL, Embase and PsycINFO from 2000 to 27 January 2020. Data extraction and critical appraisal was undertaken by two independent reviewers. Random-effects meta-analysis was employed followed by univariable and multivariable meta-regression. Heterogeneity was quantified using the I 2 statistic, and publication bias was evaluated. PROSPERO: CRD42020164156. Results Of the 7780 articles, 81 studies involving 285,687 patients were included. The pooled prevalence for preventable medication harm was 3% (95% confidence interval (CI) 2 to 4%, I 2 = 99%) and for overall medication harm was 9% (95% CI 7 to 11%, I 2 = 99.5%) of all patient incidence records. The highest rates of preventable medication harm were seen in elderly patient care settings (11%, 95% 7 to 15%, n = 7), intensive care (7%, 4 to 12%, n = 6), highly specialised or surgical care (6%, 3 to 11%, n = 13) and emergency medicine (5%, 2 to 12%, n = 12). The proportion of mild preventable medication harm was 39% (28 to 51%, n = 20, I 2 = 96.4%), moderate preventable harm 40% (31 to 49%, n = 22, I 2 = 93.6%) and clinically severe or life-threatening preventable harm 26% (15 to 37%, n = 28, I 2 = 97%). The source of the highest prevalence rates of preventable harm were at the prescribing (58%, 42 to 73%, n = 9, I 2 = 94%) and monitoring (47%, 21 to 73%, n = 8, I 2 = 99%) stages of medication use. Preventable harm was greatest in medicines affecting the ‘central nervous system’ and ‘cardiovascular system’. Conclusions This is the largest meta-analysis to assess preventable medication harm. We conclude that around one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Our results support the World Health Organisation’s push for the detection and mitigation of medication-related harm as being a top priority, whilst highlighting other key potential targets for remedial intervention that should be a priority focus for future research.

Abstract Background In the course of producing a patient safety toolkit for primary care, we identified the need for a concise safe-systems checklist designed to address areas of patient safety which are under-represented in mandatory requirements and existing tools. This paper describes the development of a prototype checklist designed to be used in busy general practice environments to provide an overview of key patient safety related processes and prompt practice wide-discussion. Methods An extensive narrative review and a survey of world-wide general practice organisations were used to identify existing primary care patient safety issues and tools. A RAND panel of international experts rated the results, summarising the findings for importance and relevance. The checklist was created to include areas that are not part of established patient safety tools or mandatory and legal requirements. Four main themes were identified: information flow, practice safety information, prescribing, and use of IT systems from which a 13 item checklist was trialled in 16 practices resulting in a nine item prototype checklist, which was tested in eight practices. Qualitative data on the utility and usability of the prototype was collected through a series of semi-structured interviews. Results In testing the prototype four of nine items on the checklist were achieved by all eight practices. Three items were achieved by seven of eight practices and two items by six of eight practices. Participants welcomed the brevity and ease of use of the prototype, that it might be used within time scales at their discretion and its ability to engage a range of practice staff in relevant discussions on the safety of existing processes. The items relating to prescribing safety were considered particularly useful. Conclusions As a result of this work the concise patient safety checklist tool, specifically designed for general practice, has now been made available as part of an online Patient Safety Toolkit hosted by the Royal College of General Practitioners. Senior practice staff such as practice managers and GP partners should find it a useful tool to understand the safety of less explored yet important safety processes within the practice.

Plain English summary There is evidence in the literature showing that involving patients and the public in health research can have a positive influence on quality, relevance and impact of research. However, patients and the public are not always involved in all stages of the research. There is often no explanation as to why they were only involved in some stages of the research and not others. Additionally, there is often no description of researchers’ or PPI contributor’s experiences of involvement. This also raises another issue which is a lack of recording of impact such involvement can have on the research process and the people involved in the research. In this paper, we present what PPI in a doctoral research should look like by providing a detailed description of how involvement occurred from pre-funding to dissemination stages of the research process. We provide some practical examples of how this was done and how involving patients made a difference to the research project. Finally, we present reflections from the patient and public contributors and the researcher on involvement in this project along with some recommendations for future doctoral and postdoctoral researchers considering involving public/patient contributors in their research. Abstract Background Patient and Public Involvement (PPI) has received considerable attention in the last two decades and working in partnership and co-design have now become a prerequisite in health services research in the UK. However, there is a lack of evidence and consistency in recording PPI and related activities. Researchers and PPI contributors are encouraged to record and reflect on the impact of PPI on research. There is significant variation in the way PPI contributors are involved, and it is often limited to some stages of the research cycle than others, without any reflections on the decision-making process for such involvement or any transferable learning. This has resulted in failure to provide a narrative of the research journey including researchers’ and PPI contributors’ personal reflections of involvement. Therefore, this paper provides an exemplar of what PPI in a doctoral research context should look like by providing a detailed account of how PPI was embedded in a doctoral research project, the PPI contributors and researcher’s reflections and key recommendations for involving people specifically in doctoral research. Methods A reflective approach was taken using data from PPI contributor and researcher notes, e-mail correspondence, meeting notes. Data is presented narratively to reflect on the experiences of involvement throughout the research cycle. Results Undertaking PPI enhanced the quality and relevance of the doctoral research, contributed to the recruitment of study participants, data analysis and dissemination. Building trust and relationships with PPI contributors was key to continued involvement throughout the life of the project and beyond. There is a need to adopt flexible approaches rather than a one-size-fits-all model when working with PPI contributors. Reflections by PPI contributors and the researcher emphasises that involvement was a rewarding experience. Conclusions This paper contributes to the wider literature by providing an exemplar of how PPI can be embedded in doctoral research and demonstrates the value of PPI to the research process and the individuals involved. We also present recommendations on how PPI can be incorporated by doctoral and postdoctoral researchers when planning PPI in their research project.

Abstract Background Marginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising. Methods Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day. Results The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors. Conclusions This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks. Trial registration Not applicable for a scoping review.

We explored the in-situ doping of cadmium telluride thin films with indium to produce n-type absorbers as an alternative to the near-universal choice of p-type for photovoltaic devices. The films were grown by close space sublimation from melt-synthesised feedstock. Transfer of the indium during film growth was limited to 0.0014%–0.014%—unless reducing conditions were used which yielded 14%–28% efficient transport. While chunks of bulk feedstock were verified as n-type by the hot probe method, carrier type of thin film material was only able to be verified by using hard x-ray photoelectron spectroscopy to determine the Fermi level position within the band gap. The assignment of n-type conductivity was consistent with the rectification behaviour of a p-InP/CdTe:In junction. However, chloride treatment had the effect of compensating n-CdTe:In to near-intrinsic levels. Without chloride, the highest dopant activation was 20% of the chemical concentration of indium, this being for a film having a carrier concentration of n = 2 × 10 ^15 cm ^−3 . However, the activation was often much lower, and compensation due to over-doping with indium and native defects (stoichiometry) are discussed. Results from preliminary bifacial devices comprising Au/P3HT/ZnTe/CdTe:In/CdS/FTO/glass are presented.

Background: Discharge from acute mental health inpatient units is often a vulnerable period for patients. Multiple professionals and agencies are involved and processes and procedures are not standardized, often resulting in communication delays and co-ordination failures. Early and appropriate discharge planning and standardization of procedures could make inpatient care safer.Aim: To inform the development of a multi-component best practice guidance for discharge planning (including the 6 component SAFER patient flow bundle) to support safer patient transition from mental health hospitals to the community.Methods: Using the RAND/UCLA Appropriateness method, a panel of 10 professional stakeholders (psychiatrists, psychiatric nurses, clinical psychologists, pharmacists, academics, and policy makers) rated evidence-based statements. Six hundred and sixty-eight statements corresponding to 10 potential components of discharge planning best practice were rated on a 9-point integer scale for clarity, appropriateness and feasibility (median ≥ 7–9) using an online questionnaire then remote online face-to-face meetings.Results: Five of the six “SAFER” patient flow bundle components were appropriate and feasible for inpatient mental health. One component, “Early Flow,” was rated inappropriate as mental health settings require more flexibility. Overall, 285 statements were rated as appropriate and feasible. Forty-four statements were considered appropriate but not feasible to implement.Discussion: This consensus study has identified components of a best practice guidance/intervention for discharge planning for UK mental health settings. Although some components describe processes that already happen in everyday clinical interactions (i.e., review by a senior clinician), standardizing such processes could have important safety benefits alongside a tailored and timely approach to post-discharge care.

Background The COVID-19 pandemic forced the rapid implementation of changes to practice in mental health services, in particular transitions of care. Care transitions pose a particular threat to patient safety. Aims This study aimed to understand the perspectives of different stakeholders about the impact of temporary changes in practice and policy of mental health transitions as a result of coronavirus disease 2019 (COVID-19) on perceived healthcare quality and safety. Method Thirty-four participants were interviewed about quality and safety in mental health transitions during May and June 2020 (the end of the first UK national lockdown). Semi-structured remote interviews were conducted to generate in-depth information pertaining to various stakeholders (patients, carers, healthcare professionals and key informants). Results were analysed thematically. Results The qualitative data highlighted six overarching themes in relation to practice changes: (a) technology-enabled communication; (b) discharge planning and readiness; (c) community support and follow-up; (d) admissions; (e) adapting to new policy and guidelines; (f) health worker safety and well-being. The COVID-19 pandemic exacerbated some quality and safety concerns such as tensions between teams, reduced support in the community and increased threshold for admissions. Also, several improvement interventions previously recommended in the literature, were implemented locally. Discussion The practice of mental health transitions has transformed during the COVID-19 pandemic, affecting quality and safety. National policies concerning mental health transitions should concentrate on converting the mostly local and temporary positive changes into sustainable service quality improvements and applying systematic corrective policies to prevent exacerbations of previous quality and safety concerns.

Physical activity (PA) and Alzheimer's disease are associated. However, how PA influences the cerebral β-amyloid (Aβ) burden remains unclear. The aim of this study was to determine if PA levels and/or functional capacity (FC) are associated with Aβ plaque deposition, and whether these associations differed according to APOE-ε4 genotype. A total of 117 women (69.7 ± 2.6 years; 33.3% APOE-ε4-carriers) from the Women's Healthy Ageing Project cohort (WHAP) were analyzed. PA was measured using the International Physical Activity Questionnaire and, FC was evaluated using the Timed Up and Go test (TUGt). Positron emission tomography with F-18 Florbetaben was carried out to assess cerebral Aβ burden, and quantified using standardized uptake value rations. The sample was split into PA and TUGt tertiles (T1, T2 and T3), and compared according to APOE-ε4 genotype (positive/negative). There were no significant differences in Aβ accumulation according to PA tertiles and APOE-ε4 genotype. Regarding FC, APOE-ε4+ participants in the first TUGt tertile (high performance) obtained significant lower Aβ accumulations compared with the other two tertiles (p < 0.05). Comparing between genotypes, greater Aβ depositions were found between T2 and T3 in APOE-ε4+ compared with those who were APOE-ε4– (p < 0.05). Values of TUGt ≥ 6.5 s (APOE-ε4+) and 8.5 s (APOE-ε4–) were associated with an increased risk of having higher Aβ retention. In conclusion, low performance in TUGt is associated with a negative effect on brain pathology with increasing cerebral Aβ depositions in older women who are APOE-ε4+. In physically active older women (> 600 METs·min/week), higher PA levels are not associated with reduction in Aβ depositions.

Abstract Background Health care-related harm is an internationally recognized threat to public health. The United Kingdom’s national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed. Methods We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of ‘significant harm’. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define “avoidable harm” within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings. Results Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories. Discussion The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety. Conclusion We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients.

BackgroundThe COVID-19 pandemic has already claimed considerable lives. There are major concerns in Africa due to existing high prevalence rates for both infectious and non-infectious diseases and limited resources in terms of personnel, beds and equipment. Alongside this, concerns that lockdown and other measures will have on prevention and management of other infectious diseases and non-communicable diseases (NCDs). NCDs are an increasing issue with rising morbidity and mortality rates. The World Health Organization (WHO) warns that a lack of nets and treatment could result in up to 18 million additional cases of malaria and up to 30,000 additional deaths in sub-Saharan Africa.ObjectiveDocument current prevalence and mortality rates from COVID-19 alongside economic and other measures to reduce its spread and impact across Africa. In addition, suggested ways forward among all key stakeholder groups.Our ApproachContextualise the findings from a wide range of publications including internet-based publications coupled with input from senior-level personnel.Ongoing ActivitiesPrevalence and mortality rates are currently lower in Africa than among several Western countries and the USA. This could be due to a number of factors including early instigation of lockdown and border closures, the younger age of the population, lack of robust reporting systems and as yet unidentified genetic and other factors. Innovation is accelerating to address concerns with available equipment. There are ongoing steps to address the level of misinformation and its consequences including fines. There are also ongoing initiatives across Africa to start addressing the unintended consequences of COVID-19 activities including lockdown measures and their impact on NCDs including the likely rise in mental health disorders, exacerbated by increasing stigma associated with COVID-19. Strategies include extending prescription lengths, telemedicine and encouraging vaccination. However, these need to be accelerated to prevent increased morbidity and mortality.ConclusionThere are multiple activities across Africa to reduce the spread of COVID-19 and address misinformation, which can have catastrophic consequences, assisted by the WHO and others, which appear to be working in a number of countries. Research is ongoing to clarify the unintended consequences given ongoing concerns to guide future activities. Countries are learning from each other.

Background: Acute kidney injury (AKI) is associated with poor health outcomes, including increased mortality and rehospitalisation. National policy and patient safety drivers have targeted AKI as an example to ensure safer transitions of care. Aim: To establish guidance to promote high-quality transitions of care for adults following episodes of illness complicated by AKI. Design & setting: An appropriateness ratings evaluation was undertaken using the RAND/UCLA Appropriateness Method (RAM). The Royal College of General Practitioners (RCGP) AKI working group developed a range of clinical scenarios to help identify the necessary steps to be taken following discharge of a patient from secondary care into primary care in the UK. Method: A 10-person expert panel was convened to rate 819 clinical scenarios, testing the most appropriate time and action following hospital discharge. Specifically, the scenarios focused on determining the appropriateness and urgency for planning: an initial medication review; monitoring of kidney function; and assessment for albuminuria. Results: Taking no action (that is, no medication review; no kidney monitoring; or no albuminuria testing) was rated inappropriate in all cases. In most scenarios, there was consensus that both the initial medication review and kidney function monitoring should take place within 1–2 weeks or 1 month, depending on clinical context. However, patients with heart failure and poor kidney recovery were rated to require expedited review. There was consensus that assessment for albuminuria should take place at 3 months after discharge following AKI. Conclusion: Systems to support tailored and timely post-AKI discharge care are required, especially in high-risk populations, such as people with heart failure.

BackgroundDischarge from acute mental health services has long been associated with mortality, risk, and related adverse outcomes for patients. Many of the interventions that currently aim to reduce adverse outcomes focus on a single group of healthcare professionals within a single healthcare setting. A recent systematic review highlights very few robust interventions that specifically aim to improve communication across services. However the importance of promoting interagency working and improving information flow between services is continually highlighted as a key priority.MethodsUsing a novel codesign and experience based approach we worked with a multistakeholder group to develop possible solutions to reduce the adverse outcomes commonly associated with discharge from acute mental health services. This utilized a modified Nominal Group Technique and creative problem solving method to follow a four-stage process: Problem Identification, Solution Generation, Decision-Making, Prioritization and Implementation. Thirty-two healthcare professionals and an expert by lived experienced engaged with the process that took place over two stakeholder events.ResultsStakeholders at the first event identified and agreed upon 24 potential ideas to improve discharge from acute mental health services. These were refined at the second event to four elements of an interagency intervention: a multiagency ‘Discharge Team’ (with designated discharge coordinator), inclusive technology enabled team meetings, universal documentation and a patient generated discharge plan.ConclusionThis is the first study to codesign an interagency mental health discharge intervention based around a discharge team. We developed a model for working that places a greater focus on a patient generated discharge plan, interagency working, and information flow. A pilot of the proposed intervention is now needed to test the feasibility and effectiveness in reducing adverse outcomes.

BackgroundThere has been an appreciable increase in the number of people in Africa with metabolic syndrome and Type 2 diabetes (T2DM) in recent years as a result of a number of factors. Factors include lifestyle changes, urbanisation, and the growing consumption of processed foods coupled with increasing levels of obesity. Currently there are 19 million adults in Africa with diabetes, mainly T2DM (95%), estimated to grow to 47 million people by 2045 unless controlled. This has a considerable impact on morbidity, mortality and costs in the region. There are a number of issues to address to reduce the impact of T2DM including improving detection rates and current access to services alongside addressing issues of adherence to prescribed medicines. There are also high rates of co-morbidities with infectious diseases such as HIV and tuberculosis in patients in Africa with T2DM that require attention.ObjectiveDocument ongoing activities across Africa to improve the care of patients with T2DM especially around issues of identification, access, and adherence to changing lifestyles and prescribed medicines. In addition, discussing potential ways forward to improve the care of patients with T2DM based on ongoing activities and experiences including addressing key issues associated with co-morbidities with infectious diseases.Our ApproachContextualise the findings from a wide range of publications including internet based publications of national approaches coupled with input from senior level government, academic and other professionals from across Africa to provide future guidance.Ongoing ActivitiesA number of African countries are actively instigating programmes to improve the care of patients with T2DM starting with improved diagnosis. This recognises the growing burden of non-communicable diseases across Africa, which has been neglected in the past. Planned activities include programmes to improve detection rates and address key issues with diet and lifestyle changes, alongside improving monitoring of care and activities to enhance adherence to prescribed medicines. In addition, addressing potential complexities involving diabetes patients with infectious disease co-morbidities. It is too early to fully assess the impact of such activities,ConclusionThere are a number of ongoing activities across Africa to improve the management of patients with diabetes including co-morbidities. However, more needs to be done considering the high and growing burden of T2DM in Africa. Ongoing research will help further benefit resource allocation and subsequent care.

Abstract Background Primary care is changing rapidly to meet the needs of an ageing and chronically ill population. New ways of working are called for yet the introduction of innovative service interventions is complicated by organisational challenges arising from its scale and diversity and the growing complexity of patients and their care. One such intervention is the multi-strand, single platform, Patient Safety Toolkit developed to help practices provide safer care in this dynamic and pressured environment where the likelihood of adverse incidents is increasing. Here we describe the attitudes of staff toward these tools and how their implementation was shaped by a number of contextual factors specific to each practice. Methods The Patient Safety Toolkit comprised six tools; a system of rapid note review, an online staff survey, a patient safety questionnaire, prescribing safety indicators, a medicines reconciliation tool, and a safe systems checklist. We implemented these tools at practices across the Midlands, the North West, and the South Coast of England and conducted semi-structured interviews to determine staff perspectives on their effectiveness and applicability. Results The Toolkit was used in 46 practices and a total of 39 follow-up interviews were conducted. Three key influences emerged on the implementation of the Toolkit these related to their ease of use and the novelty of the information they provide; whether their implementation required additional staff training or practice resource; and finally factors specific to the practice’s local environment such as overlapping initiatives orchestrated by their CCG. Conclusions The concept of a balanced toolkit to address a range of safety issues proved popular. A number of barriers and facilitators emerged in particular those tools that provided relevant information with a minimum impact on practice resource were favoured. Individual practice circumstances also played a role. Practices with IT aware staff were at an advantage and those previously utilising patient safety initiatives were less likely to adopt additional tools with overlapping outputs. By acknowledging these influences we can better interpret reaction to and adoption of individual elements of the toolkit and optimise future implementation.

Background: Multiple measures introduced early to restrict COVID-19 have dramatically impacted the teaching of medical and pharmacy students, exacerbated by the lack of infrastructure and experience with e-learning at the start of the pandemic. In addition, the costs and reliability of the Internet across Africa pose challenges alongside undertaking clinical teaching and practical programmes. Consequently, there is a need to understand the many challenges and how these were addressed, given increasingly complex patients, to provide future direction. Method: An exploratory study was conducted among senior-level medical and pharmacy educators across Africa, addressing four key questions, including the challenges resulting from the pandemic and how these were dealt with. Results: Staff and student members faced multiple challenges initially, including adapting to online learning. In addition, concerns with the lack of equipment (especially among disadvantaged students), the costs of Internet bundles, and how to conduct practicals and clinical teaching. Multiple activities were undertaken to address these challenges. These included training sessions, developing innovative approaches to teaching, and seeking ways to reduce Internet costs. Robust approaches to practicals, clinical teaching, and assessments have been developed. Conclusions: Appreciable difficulties to teaching arising from the pandemic are being addressed across Africa. Research is ongoing to improve education and assessments.

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

Abstract Background Diagnostic uncertainty is one of the largest contributory factors to the occurrence of diagnostic errors across most specialties in medicine and arguably uncertainty is greatest in primary care due to the undifferentiated symptoms primary care physicians are often presented with. Physicians can respond to diagnostic uncertainty in various ways through the interplay of a series of cognitive, emotional and ethical reactions. The consequences of such uncertainty however can impact negatively upon the primary care practitioner, their patients and the wider healthcare system. Understanding the nature of the existing empirical literature in relation to managing diagnostic uncertainty in primary medical care is a logical and necessary first step in order to understand what solutions are already available and/or to aid the development of any training or feedback aimed at better managing this uncertainty. This review is the first to characterize the existing empirical literature on managing diagnostic uncertainty in primary care. Methods Sixteen databases were systematically searched from inception to present with no restrictions. Hand searches of relevant websites and reference lists of included studies were also conducted. Two authors conducted abstract/article screening and data extraction. PRISMA guidelines were adhered to. Results Ten studies met the inclusion criteria. A narrative and conceptual synthesis was undertaken under the premises of critical reviews. Results suggest that studies have focused on internal factors (traits, skills and strategies) associated with managing diagnostic uncertainty with only one external intervention identified. Cognitive factors ranged from the influences of epistemological viewpoints to practical approaches such as greater knowledge of the patient, utilizing resources to hand and using appropriate safety netting techniques. Emotional aspects of uncertainty management included clinicians embracing uncertainty and working with provisional diagnoses. Ethical aspects of uncertainty management centered on communicating diagnostic uncertainties with patients. Personality traits and characteristics influenced each of the three domains. Conclusions There is little empirical evidence on how uncertainty is managed in general practice. However we highlight how the extant literature can be conceptualised into cognitive, emotional and ethical aspects of uncertainty which may help clinicians be more aware of their own biases as well as provide a platform for future research. Trial registration PROSPERO registration: CRD42015027555

Introduction: There is continued unmet medical need for new medicines across countries especially for cancer, immunological diseases, and orphan diseases. However, there are growing challenges with funding new medicines at ever increasing prices along with funding increased medicine volumes with the growth in both infectious diseases and non-communicable diseases across countries. This has resulted in the development of new models to better manage the entry of new medicines, new financial models being postulated to finance new medicines as well as strategies to improve prescribing efficiency. However, more needs to be done. Consequently, the primary aim of this paper is to consider potential ways to optimize the use of new medicines balancing rising costs with increasing budgetary pressures to stimulate debate especially from a payer perspective.Methods: A narrative review of pharmaceutical policies and implications, as well as possible developments, based on key publications and initiatives known to the co-authors principally from a health authority perspective.Results: A number of initiatives and approaches have been identified including new models to better manage the entry of new medicines based on three pillars (pre-, peri-, and post-launch activities). Within this, we see the growing role of horizon scanning activities starting up to 36 months before launch, managed entry agreements and post launch follow-up. It is also likely there will be greater scrutiny over the effectiveness and value of new cancer medicines given ever increasing prices. This could include establishing minimum effectiveness targets for premium pricing along with re-evaluating prices as more medicines for cancer lose their patent. There will also be a greater involvement of patients especially with orphan diseases. New initiatives could include a greater role of multicriteria decision analysis, as well as looking at the potential for de-linking research and development from commercial activities to enhance affordability.Conclusion: There are a number of ongoing activities across countries to try and fund new valued medicines whilst attaining or maintaining universal healthcare. Such activities will grow with increasing resource pressures and continued unmet need.

Polycrystalline carbonate minerals (including calcite, Mg-calcite, and aragonite) can show distinctive variations in their far-infrared (FIR) spectra. We describe how to identify mixed-phase samples by correlating FIR spectral changes with mid-infrared spectra, X-ray diffraction data, and simple peak overlap simulations. Furthermore, we show how to distinguish portlandite-containing (Ca(OH) 2 ) mixtures that are common in heated calcium carbonate samples. Ultimately, these results could be used for tracking how minerals are formed and how they change during environmental exposure or processing after extraction.

Background: The Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness. Objectives: To explore the process of implementation of the SICP and the impact on patient outcomes and costs. Design: Qualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies. Setting: Salford in the north-west of England. Participants: Older people aged ≥ 65 years, carers, and health and social care professionals. Interventions: A large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’). Main outcome measures: Patient self-management, care experience and quality of life, and health-care utilisation and costs. Data sources: Professional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation. Results: The SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776). Limitations: The Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were

OBJECTIVES:Vascular disease remains a leading cause of death. There are several vascular risk factors identified that can mitigate development of disease in ageing. We examine reported rates of modifiable risk factors in women responding to an online health questionnaire advertised by popular media. METHODS:A sample of 26 620 women aged over 18 was examined in 2015 with a cross-sectional health questionnaire. The questionnaire included self-reported health, mood, lifestyle and vascular risk factors. RESULTS:There remains high rates of modifiable risk factors present in women. The vast majority of women (80%) reported not eating enough fruit and vegetables. Compared to the guidelines for health, the majority did not perform enough weekly physical activity (70%) and more than half the participants were overweight (54%). Sufficient fruit, vegetables, fish, legumes and physical activity were reported in less than 30% of women! CONCLUSIONS:Women continue to report low rates of physical activity, fruit and vegetable intake and higher BMI than recommended for good health, despite worldwide health promotion activities aimed at changing these lifestyle factors. Programs to support healthy living need to be reviewed and revised to reduce the burden of vascular disease and dementia in women. Previous guidelines are not having the important impact they should, particularly in women.

Type 2 diabetes is impacting millions of people globally; however, many future cases can be prevented through lifestyle changes and interventions. Primary care is an important setting for diabetes prevention, for at-risk populations, because it is a patient's primary point of contact with the health care system and professionals can provide lifestyle counselling and support, as well as monitoring health outcomes. These are all essential elements for diabetes prevention for at-risk adults.To understand the factors related to the delivery and uptake of type 2 diabetes prevention interventions within primary care in higher income countries.For this narrative systematic review, we combined qualitative and quantitative studies of diabetes prevention within a primary care setting for patients at-risk of developing the condition. We used an iterative approach for evidence collection, which included using several databases (MEDLINE, Embase, Pysch info, BNI, SSCI, CINAHL, ASSIA), where we combined diabetes terms with primary care terms. Narrative and thematic synthesis were utilised to identify the prominent themes emerging from the data.A database of 6646 records was screened by the research team, and 18 papers were included. Three major themes were identified in this review. The first theme of context and setting of diabetes progression includes the risk and progression of diabetes, primary care as a setting, and where the responsibility for change is thought to lie. This review also found mixed views on the value of preventative services within primary care. The second theme focused on the various patient factors associated with diabetes prevention such as a patient's motivation to modify their current lifestyle, perceptions and knowledge (or lack thereof) of the impacts of diabetes, lack of follow-up in healthcare settings, and trust in healthcare professionals. The third theme was centred on professional factors impacting on diabetes prevention which included workload, time constraints, resources, self-efficacy and knowledge as well as professionals' perception of patient motivations towards change.This review explored the factors influencing diabetes prevention in primary care, and identified the context of prevention, as well as patient and professional factors related to preventative services being offered in primary care. This systematic review complements previous reviews of real-world settings by exploring the significant factors in prevention, and the findings are relevant to academics, policymakers, patients and practitioners interested in understanding the factors associated with the delivery and uptake of diabetes prevention interventions.

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BACKGROUND:Diagnostic errors are costly and they can contribute to adverse patient outcomes, including avoidable deaths. Differential diagnosis (DDX) generators are electronic tools that may facilitate the diagnostic process. METHODS AND FINDINGS:We conducted a systematic review and meta-analysis to investigate the efficacy and utility of DDX generators. We undertook a comprehensive search of the literature including 16 databases from inception to May 2015 and specialist patient safety databases. We also searched the reference lists of included studies. Article screening, selection and data extraction were independently conducted by 2 reviewers. 36 articles met the eligibility criteria and the pooled accurate diagnosis retrieval rate of DDX tools was high with high heterogeneity (pooled rate = 0.70, 95% CI = 0.63 to 0.77; I2 = 97%, p

Recent scholarship on precarious labour has called attention to global transformations in employment regimes, which have given management greater freedom in setting the terms of work. Such ‘flexibility’ in employment is associated with a decrease in work, wage and livelihood security; more temporary, rather than open-ended, job contracts; a roll-back of employment benefits; heavy restrictions on workers’ collective organisation; and a greater reliance on migrant labour. To date, scholars have mostly emphasised the negative impact this transformation has had on workers’ solidarity. However, as this article highlights, flexibilisation can also function as an enabler of solidarity. Presenting an ethnographic case study of a workplace struggle at an export processing zone in northwest Thailand, it is argued that where flexible labour regimes incite shared grievances among workers and occlude the representative role of trade unions officials, they have facilitated self-organised struggles among workers based on a clear sense of common cause.

Aim: National validation of quality indicators for cardiovascular prevention in primary care in Slovenia and comparison with a set of internationally validated indicators. Methods: A list of indicators derived from guidelines, recommendations and good clinical practice was developed internationally within a wider Epa-cardio study. In each participating country a panel of national experts were recruited to assess the indicators using a Delphi Technique methodology in two rounds for clarity, validity and feasibility. In Slovenia, 14 national experts, all general practitioners with special interest in cardiovascular diseases, were recruited. Results: Most of validated indicators belonged to the health-care management of people with established cardiovascular disease. Fewer numbers of indicators were validated for primary prevention, mostly on life style recording and advice. Only very few indicators on outcome measures (level of risk factors) were validated. No indicators of patients’ involvement or new risk factors, such as socioeconomic circumstances, got consensus. Conclusion: Slovenia validated more indicators than the international study, especially indicators of primary prevention. The experts did not achieve consensus on indicators of patients’ perspective, despite the paradigm of family medicine that the patient is in the centre of care. Validated indicators can now be tested for systematic quality assessment of cardiovascular prevention in the country.

BACKGROUND: The management of patients with heart failure (HF) needs to account for changeable and complex individual clinical characteristics. The use of renin angiotensin system inhibitors (RAAS-I) to target doses is recommended by guidelines. But physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence. METHODS: To examine the coherence of primary care (PC) physicians' knowledge and self-perceived competencies regarding RAAS-I with their respective prescribing behavior being related to patient-associated barriers. Cross-sectional follow-up study after a randomized medical educational intervention trial with a seven month observation period. PC physicians (n = 37) and patients with systolic HF (n = 168) from practices in Baden-Wuerttemberg. Measurements were knowledge (blueprint-based multiple choice test), self-perceived competencies (questionnaire on global confidence in the therapy and on frequency of use of RAAS-I), and patient variables (age, gender, NYHA functional status, blood pressure, potassium level, renal function). Prescribing was collected from the trials' documentation. The target variable consisted of ≥50% of recommended RAAS-I dosage being investigated by two-level logistic regression models. RESULTS: Patients (69% male, mean age 68.8 years) showed symptomatic and objectified left ventricular (NYHA II vs. III/IV: 51% vs. 49% and mean LVEF 33.3%) and renal (GFR

This article examines a South Korean cultural chronotope from the perspective of Korea’s world-renowned digital gaming culture, including its professional electronic sports (e- sports) scene and the experiences of amateur gamers in online gaming cafés (PC bang). My analysis centers on two of Korean digital gaming culture’s recognizable social types and the spatiotemporal qualities of their play: professional gamers and the quickness em- bodied in their e-sports performances; and a specific kind of amateur PC bang gamer who is more socially isolated and whose engagement with games is slow and repetitive. I argue that through their performances in digital games’ virtual and actual-world participation frameworks, gamers orient to these social types in ways that differentially construe their relationships to semiotic depictions of places, times, and personhoods. Thinking through these orientations and their spatial, temporal, and social qualities is critical to under- standing chronotopic representations of contemporary Korea.