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In a very short time, the health commissioner had mobilized an army of volunteers, coordinated the efforts of community organizations, plastered the city with educational literature, isolated the sick, and assuaged the doubts of businesspeople and politicians who feared personal loss from the emergency regulations.1 Milwaukee's actions to quell influenza were similar to or exactly the same as methods tried by other cities.3 Along with liberty bond parades (which in Philadelphia demonstrably spread influenza),4,5 masks carried patriotic value and gave the public a way to exhibit and celebrate their loyalty. Growing in opposition to corrupt and patronage-laden politics, a coalition of ethnic, middle-class, and labor interests joined together under a pragmatic Socialist banner to institute trustworthy, responsive government to address urban problems.8 Comprehensive and efficient health policies to improve public services, such as infant welfare programs and community clinics, drawing on the advice of experts, aimed to build a healthier city. By 1918, when the Socialists retained the mayoralty but no longer controlled the common council, progressive policies and programs that developed private-public cooperation had achieved citywide trust in local government's attempts to ameliorate urban problems.9 Socialist mayor Daniel Hoan and wide-ranging community groups actively supported Ruhland in his work. [...]understanding the responses to the COVID-19 epidemic is incomplete without analysis of medical inequities based on race and class and the prominence of the Black Lives Matter movement.12,13 Unlike during the 1918 epidemic, African American health disparities and deaths are now a prominent and publicized feature.14 Because the health system does not serve all populations equally, many Americans feel they cannot trust medical advice about treatment and vaccinations.

OBJECTIVES Safety-net hospitals disproportionately care for people with substance use disorders (SUDs), yet little is known about trends in hospital admissions related to specific substances. This study uses electronic health record data to describe trends in substance-specific admissions at a Midwest urban safety-net hospital. METHODS We included all admissions from 2008 through 2020 and defined them as non-SUD (N = 154,477) or SUD-related (N = 63,667). We described patient characteristics and trends in substance-specific admissions. We estimated the association of SUD diagnoses with discharge against medical advice and length of stay using logistic regression and generalized linear models. RESULTS Between 2008 and 2020, SUD-related admissions increased from 23.1% to 32.9% of total admissions. Admissions related to SUD had significantly more comorbidities than non-SUD-related admissions (4.7 vs 3.5, P

Background and Aims To investigate the superiority of individualized dietary advice based on dietary assessment for patients with type 2 diabetes. Methods and Results A total of 136 Japanese adults with type 2 diabetes were randomized into either individualized or conventional dietary advice groups after dietary assessment using a self-administered brief-type diet history questionnaire. All participants received three 30-minute face-to-face dietary advice sessions by dietitians at 1, 3, 5 months from study entry. The individualized group received dietary advice based on individual dietary intakes. The conventional group received dietary advice using generalized pamphlets. The primary outcome was the change in HbA1c over 6 months, and secondary outcomes were changes in weight, serum triglyceride, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), and dietary intakes. In total, 126 participants were included in the analysis. After adjustment for age, sex, and baseline measurements, HbA1c significantly decreased larger in the individualized group [−1.1%, 95% CI: −1.3 to −0.8)] than the conventional group [−0.7% (95% CI: −1.0 to −0.4)] (P=0.0495). Weight, serum triglyceride, and LDL-C significantly lowered, and HDL-C significantly increased only in the individualized group, without a significant difference to the conventional group. In dietary changes, the individualized group decreased intakes of energy, confectioneries, meats, oil and fats, and sugar-sweetened beverages. The conventional group decreased alcohol intake, and increased total fat and saturated fatty acid intakes. Conclusions Individualized dietary advice among patients with type 2 diabetes was superior to conventional dietary advice in lowering HbA1c. Trial Registration UMIN000037268 ( https://www.umin.ac.jp/ctr/index.htm ) in July 4, 2019.

Alcohol measurement delivered by health care providers in primary health care settings is an efficacious and cost-effective intervention to reduce alcohol consumption among patients. However, this intervention is not yet routinely implemented in practice. Community support has been recommended as a strategy to stimulate the delivery of alcohol measurement by health care providers, yet evidence on the effectiveness of community support in this regard is scarce. The current study used a pre-post quasi-experimental design in order to investigate the effect of community support in three Latin American municipalities in Colombia, Mexico, and Peru on health care providers’ rates of measuring alcohol consumption in their patients. The analysis is based on the first 5 months of implementation. Moreover, the study explored possible mechanisms underlying the effects of community support, through health care providers’ awareness of support, as well as their attitudes, subjective norms, self-efficacy, and subsequent intention toward delivering the intervention. An ANOVA test indicated that community support had a significant effect on health care providers’ rates of measuring alcohol consumption in their patients (F (1, 259) = 4.56, p = 0.034, ηp2 = 0.018). Moreover, a path analysis showed that community support had a significant indirect positive effect on providers’ self-efficacy to deliver the intervention (b = 0.07, p = 0.008), which was mediated through awareness of support. Specifically, provision of community support resulted in a higher awareness of support among health care providers (b = 0.31, p b = 0.23, p = 0.010). Results indicate that adoption of an alcohol measurement intervention by health care providers may be aided by community support, by directly impacting the rates of alcohol measurement sessions, and by increasing providers’ self-efficacy to deliver this intervention, through increased awareness of support. Trial Registration ID: NCT03524599; Registered 15 May 2018; https://clinicaltrials.gov/ct2/show/NCT03524599

Background For women with gestational diabetes mellitus (GDM) poor dietary choices can have deleterious consequences for both themselves and their baby. Diet is a well-recognised primary strategy for the management of GDM. Women who develop GDM may receive dietary recommendations from a range of sources that may be inconsistent and are often faced with needing to make several dietary adaptations in a short period of time to achieve glycaemic control. The aim of this study was to explore how women diagnosed with GDM perceive dietary recommendations and how this information influences their dietary decisions during pregnancy and beyond. Methods Women diagnosed with GDM before 30 weeks’ gestation were purposively recruited from two GDM clinics in Auckland, New Zealand. Data were generated using semi-structured interviews and thematic analysed to identify themes describing women’s perceptions and experiences of dietary recommendations for the management of GDM. Results Eighteen women from a diverse range of sociodemographic backgrounds participated in the study. Three interconnected themes described women’s perceptions of dietary recommendations and experiences in managing their GDM through diet: managing GDM is a balancing act; using the numbers as evidence, and the GDM timeframe. The primary objective of dietary advice was perceived to be to control blood glucose levels and this was central to each theme. Women faced a number of challenges in adhering to dietary recommendations. Their relationships with healthcare professionals played a significant role in their perception of advice and motivation to adhere to recommendations. Many women perceived the need to follow dietary recommendations to be temporary, with few planning to continue dietary adaptations long-term. Conclusions The value of empathetic, individually tailored advice was highlighted in this study. A greater emphasis on establishing healthy dietary habits not just during pregnancy but for the long-term health of both mother and baby is needed.

OBJECTIVE: The aim of the study was to determine from patient-reported data the relationships between patients' experiences of adverse events (AEs), the disclosure of the events, and patients propensity for complaints or legal action. METHODS: A cross-sectional survey was administered to 20,000 participants randomly chosen from the 45 and Up Study. The surveyed participants were older than 45 years and hospitalized in New South Wales, Australia, between January and June 2014. They were identified using data linkage to capture experiences of AEs. RESULTS: Of the 7661 respondents, 474 participants (7%) reported experiencing an AE. Those who did not receive an apology or expression of regret in the incident disclosure process were significantly more likely to make a complaint (P < 0.05). Those who found out about the event from hospital staff but did not receive a formal open disclosure process were found to be significantly more likely to seek legal advice (P < 0.05). Patients who made a complaint generally perceived that they experienced more problems in their hospital care, with significant differences identified between those who did and did not make a complaint on 13 of the 15-item Picker Patient Experience Questionnaire. CONCLUSIONS: Although incident disclosure was not associated with whether a complaint was made or legal action pursued, significant associations between key aspects of the disclosure process and these outcomes were noted. Significant differences between those who did and did not make a complaint were noted in relation to the timing and apology components of open disclosure. The critical role of overall patient experience in the context of optimal AE management was evident from these data.

GOAL: As strategies emerge to off-load hospital systems and prevent readmissions amid the COVID-19 pandemic, pragmatic assessments of readmission risk become increasingly important. The simplified HOSPITAL score is an extensively validated tool that predicts 30-day potentially avoidable readmission (PAR). Scores of 0 to 4 predict a 30-day PAR risk of 6.4%, while scores ≥ 5 predict a 30-day PAR risk of 17.3%. Its role in patients with COVID-19 is unknown. Our goal was to assess the simplified HOSPITAL score's accuracy in patients with COVID-19 and explore outcomes related to a hospital-at-home program. METHODS: Patients discharged following an admission for clinically symptomatic COVID-19 from two hospitals belonging to the same healthcare system in the Midwest were included. Those who died, discharged to hospice or an acute care hospital, whose length of stay was < 1 day, or who discharged against medical advice were excluded. The simplified HOSPITAL score was tabulated for included patients to predict their 30-day PAR risk. The Brier score was calculated to compare the observed rates of 30-day readmission with rates predicted by the simplified HOSPITAL score. Prediction models with a Brier score

Sexting has become a new form of intimate interaction in line with contemporary communication methods. This phenomenon often leads to positive outcomes, but it can also have negative repercussions depending on the situation, such as the context of the relationship, and whether it is consensual or coercive. Despite this, the main types of sexting behaviors (sending, receiving, and third-party forwarding) must be addressed in order to promote safe and healthy practices. However, the approach to tackling this phenomenon remains unclear. This systematic review sought to summarize the lines of action proposed or conducted in the scientific literature to address sexting, to help researchers and educators create and evaluate effective programs. A systematic search of 21 databases was conducted; only articles relating to sexting education, prevention, and intervention among child and adolescent populations were considered. In total, 456 articles were identified, 91 of which were included for the purposes of this research. The results highlighted a need to respond to the aforementioned sexting behaviors and to tackle the resulting conflict situations. Although interventions across different areas are recommended (e.g., health, family, policies, legal advice, law enforcement, technology experts, and even society as a whole), most studies agree that school is the most practical setting for intervention. Thus, the 15 lines of action identified in this systematic review must all be considered to effectively address sexting in childhood and adolescence.

Background Urinary incontinence (UI) in women is a common problem worldwide. It has a major impact on the physical and social activities and interpersonal relationships. The societies in the Gulf countries are conservative and favours large families, high parity and short inter-pregnancy intervals. Moreover, there is a high prevalence of gestational diabetes with many macrosomic babies. This study aimed to review the published literature on UI among women in this region. Methods All published literature which investigated the prevalence, social impact and help-seeking behavior in women with UI in the Gulf countries was reviewed. Results Nine studies met the criteria and were very heterogeneous. None of them was a true population-based study and all except one, investigated subjects from healthcare facilities. The prevalence of UI ranged from 20.3% to 54.5%. Stress UI was the main type reported. The main predisposing factors were chronic respiratory diseases and constipation. There was a large impact on the quality of life with major interference with prayers (34-90%) and sexual relationships (18-57%). The main reasons for not seeking medical advice were embarrassment to see doctors especially male doctors and the belief that UI is common, normal or incurable disease. Conclusions There is a need for true whole population-based studies of UI in this region with the use of validated international questionnaires. UI was shown to have a major impact on the act of prayers and sexual relationships. A large proportion of women are still embarrassed to discuss the issue with doctors especially male doctors.

Objective To investigate how doctors deliver lifestyle advice to patients in ordinary general practice consultations. Method A secondary analysis of audio/video recorded primary care consultations between doctors and patients. Instances of lifestyle related talk were identified and analysed according to the methods of Conversation Analysis. Results The most frequently used format for delivering advice was found to be if-conditional forms. Conditional forms work to convey how advice is relevant to the individual’s health circumstances 1) topicalising the problematic risk to the patient, 2) informing and warning the patient of reoccurring or future health risks, and 3) offering changes in lifestyle in addition to or as a replacement for medication. Conclusion The results show that doctors use if-conditional constructions to navigate anticipated or actual difficulties evidenced through misalignment in delivering lifestyle advice, by conveying the importance of the advice to the individual patient. Practice Implications Using if-conditional constructions when talking with patients regarding their problematic risk factors provides a technique enabling doctors to navigate the sensitivities associated with giving advice, whilst delivering personalised and preventative medicine.

Background/objective Neural tube defects (NTDs) affect approximately 300,000 pregnancies worldwide each year. Many of these pregnancies are lost to miscarriage or termination of pregnancy. Here, we have analysed the trends of termination of pregnancy for NTDs from the national data for England and Wales. Methods Data for all terminations for residents in England and Wales for the period of 2007-2017 were obtained through Health and Social Act 4 (HSA4) submitted to the Department of Health. Using the ICD-10 codes, terminations for NTDs were selected for analysis. The statistical test Chi-squared was performed using SPSS-v25, where appropriate. Results In the 11-year period, there were 28,866 terminations under Ground E; of which 4425 (15.33%) had a diagnosis of NTD. The number of NTD cases increased over the time period from 308 in 2007 to 517 in 2017 (67.9%). Significant results were also seen when analysing the relationship between ethnicity, gestation and terminations where an NTD was diagnosed. Conclusion With the availability of routine prenatal ultrasound, the termination for NTDs is on the rise in England and Wales, in spite of the health advice of periconceptional folic acid. This study demonstrates the need for implementation of further programmes to increase public health awareness of folic supplementation and government initiation of fortification to reduce NTDs.

BACKGROUND: Focusing on employees with psychological strain, this research draws on Fredrickson’s ‘undoing hypothesis’ to examine praise and recognition from one’s supervisor as an organizational resource. OBJECTIVE: A model is tested in which psychological strain is a mediator in the positive relationship between role demands and employees’ intentions to take sick leave and seek medical advice, and positions supervisor praise and recognition as a buffer of psychological strain on such intentions. METHODS: The model was tested using two Australian samples in the tourism sector, consisting of motel workers (n = 104) and museum workers (n = 168). RESULTS: For museum workers, but not motel workers, there was a positive indirect effect of each role demand on sick leave intentions through psychological strain that weakened as a function of supervisor praise and recognition. The proposed moderated mediated model was supported for both samples in regards to intentions to seek medical advice. CONCLUSIONS: This research contributes new evidence regarding the antecedents of employees’ intentions to take sick leave and seek medical advice for work stress-related problems. It also contributes to the limited evidence regarding supervisor praise and recognition as a protective factor for employees exhibiting the symptoms of psychological strain.

Objective To assess primiparous and multiparous women, and singleton and multiple pregnancies in a recently published randomized trial. Study design Secondary analysis of a randomized clinical trial was performed. In total, 500 women with sacroiliac dysfunction diagnosed in pregnancy were randomized into a study group (who received expert advice about therapeutic exercise) and a control group (who continued with their normal lifestyle habits). The outcome measures assessed were: pain intensity [visual analogue scale (VAS)] and degree of functional disability (Quebec scale) at enrolment and after 3 and 6 weeks. Primiparous and multiparous women, and singleton and multiple pregnancies in the study and control groups were analysed separately. Results Sacroiliac dysfunction was more common in primiparous women compared with multiparous women (84.70% vs 77.16%), and in multiple pregnancies compared with singleton pregnancies (86.53% vs 80.07%). For all four subgroups analysed in this secondary analysis, the reduction in pain intensity (p = 0.001) and the degree of functional disability (p = 0.001) were better in the study group compared with the control group. Better results for the two outcome measures were found when comparing primiparous and multiparous women in the study group at follow-up, but the difference in functional disability disappeared 6 weeks after enrolment (p = 0.383). There was no difference in the two outcome measures between singleton and multiple pregnancies 3 and 6 weeks after enrolment (p = 0.061, p = 0.489 and p = 0.741, p = 0.353, respectively). Conclusion Expert advice about therapeutic exercise is effective for the reduction of symptoms of sacroiliac dysfunction in all four subgroups (primiparous and multiparous women, singleton and multiple pregnancies). Earlier reduction of pain intensity and degree of functional disability were obtained in primiparous women compared with multiparous women in the study group.

Zusammenfassung Hintergrund In der SARS-CoV-2-Pandemie muss die Politik weitreichende Entscheidungen treffen, die von wissenschaftlichen Erkenntnissen gestutzt sein sollten. Angesichts der zumeist limitierten Evidenz in Krisensituationen stellt dies eine grose Herausforderung dar, insbesondere in fruhen Phasen der Pandemie. Entscheidungstrager*innen haben daher wissenschaftliche Expert*innen einbezogen, welche die Evidenzlage vermitteln und kontextualisieren sollten. Die Formen dieser Konsultationen variierten stark. Zum Teil wurden sogenannte Expert*innenrate mit Vertreter*innen verschiedenster Disziplinen einberufen. Die Zusammensetzung dieser Expert*innenrate hat jedoch Fragen der Reprasentation und Transparenz aufgeworfen. Unser Forschungsvorhaben untersucht, ob und wie Expert*innenrate in Deutschland auf Bundes- und Landesebene einberufen wurden, um die Regierungen und Ministerien in der SARS-CoV-2-Pandemie zu beraten. Es wurden die disziplinare Zusammensetzung, die Geschlechterverteilung und die Transparenz der Arbeitsablaufe analysiert. Methoden Wir fuhrten eine mehrstufige Dokumentenanalyse durch. Zwischen Mai und Juli 2020 wurden Anfragen an die Regierungseinrichtungen der Lander und die Bundesministerien nach dem Informationsfreiheitsgesetz gestellt. Erganzend zur Analyse der Antwortschreiben wurde eine Sichtung und Analyse der i) Pandemieplane, ii) der offiziellen Pressemitteilungen und iii) der kleinen Anfragen auf Bundes- und auf Landesebene zu Expert*innenraten im SARS-CoV-2-Kontext fur den Zeitraum von Januar bis Anfang Dezember 2020 durchgefuhrt. Die Auswertung erfolgte mittels qualitativer Inhaltsanalyse. Ergebnisse Zehn Bundeslander und vier Bundesministerien etablierten insgesamt 21 Expert*innenrate. Fur elf Gremien waren Namen und disziplinarer Hintergrund der Mitglieder bekannt. In diesen Gremien betrug der Frauenanteil 26%. Am haufigsten waren biomedizinische Fachbereiche wie Virologie, Krankenhaushygiene, Medizin, und Biologie vertreten. Weitere Disziplinen (Wirtschafts-, Rechts- und Sozialwissenschaften) und nichtwissenschaftliche Expert*innen waren in sieben Bundeslandern vertreten. Die zehn Rate ohne namentliche Nennung der Mitglieder waren verschiedenen Themenbereichen (Schule und Kita, Burgerbeteiligung, Medizin und Pflege, Wirtschaft) zuzuordnen, ihre Mitglieder waren haufig Akteur*innen aus der Praxis und Betroffene. Diskussion Die SARS-CoV-2-Pandemie hat zu einer verstarkten Konsultation von Expert*innen durch die Politik gefuhrt. Die entsprechenden Gremien in Deutschland sind jedoch nicht ausreichend reprasentativ, trans- und interdisziplinar zusammengesetzt, um die Politik in komplexen Pandemielagen zu beraten und unterschiedliche Perspektiven zu berucksichtigen. Die Arbeitsweise der Gremien ist unter anderem durch einen erschwerten Zugang zu Informationen nicht ausreichend transparent. Schlussfolgerung Aufgrund fehlender Transparenz ist unklar, ob und wie die identifizierten Expert*innenrate Einfluss auf die Politik genommen haben. Transparenz politischer Entscheidungsprozesse und die Berucksichtigung pluralistischer Perspektiven gelten jedoch als wesentlich fur die Legitimation und Gute politischer Entscheidungen in einer Pandemie und sollten in Deutschland im Pandemiemanagement gestarkt werden.

Objective To characterize the general health status of infertile men in the United States using a nationally representative sample of men. Methods Using the National Survey for Family Growth from 2011 to 2017, infertile subgroups were created using a range of inclusion criteria. Univariate and multivariate analyses were conducted comparing these men to fertile men. Results Using population estimates, 6.5 million men with reduced fertility potential were compared to 26 million fertile men. After controlling for demographic and healthcare utilization factors, these groups did not have significantly different rates of key medical co-morbidities, including cancer, obesity, and overall disability. Looking at the subset of men who had received a specific infertility diagnosis, estimated as a population of nearly 600,000 men, this pattern held, in that there were no significant differences in the rates of medical co-morbidities. Notably, the rate of male infertility evaluation among potentially infertile men was only 50%. These findings also persisted after a propensity-matched analysis. Conclusion In this cohort, there was no significant relationship between infertility and specific medical co-morbidities. We must consider the influence of sample selection as we continue to investigate the relationship between medical co-morbidities and reduced fertility potential. Given the persistent low rates of infertility evaluation, even among men who seek medical advice to conceive, we must continue to search for ways to characterize the infertile male population while simultaneously working to improve access.

Adaptation and validation of the BTI-St© to assess the level of competence in brief tobacco intervention in general practitioners and nurses in Primary Health Care. Cross-sectional study of adaptation and psychometric validation of a criterion-referenced test. Primary Health Care. One hundred fifty-five general practitioners and nurses working at Primary Health Care. Three clinical scenarios were designed. Using an online platform, participants first viewed each scenario in which brief tobacco intervention was given. Health professional had to assess whether or not the scenarios were carried out in accordance with the 5A+5R model. Competence in brief tobacco intervention measured by the BTI-Prof©. Results related to reliability were obtained through Kuder-Richardson coefficient, being for scenario 1, 0.880, for scenario 2, 0.829, and for scenario 3, 0.826. The test-retest shows adequate temporal stability: intraclass correlation coefficient for scenario 1 0.857 (95% CI 0.734-0.923), p The BTI-Prof© is a robust tool with adequate psychometric properties to assess competence in brief tobacco intervention in Primary Health Care general practitioners and nurses.

This article analyzes lay people’s use of nutritionistic discourse in written correspondence with the Swedish Food Agency, an authority responsible for dietary advice. Examining 60 food related written digital messages, we apply a critical discourse analysis to parse the lexical items and grammar people use when constructing “food” in scientific terms. The findings show how message writers place nutrients at the discursive center. Message writers’ grammatical constructions instrumentalize food and eating. This is reinforced by the message writers’ frequent use of terms that indicate preciseness, such as numbers and amounts. Messages therefore emphasize the what, but not the how, of eating, implying a focus on food as subject to regulation and control. As such, eating is discursively reduced to an act of ingesting nutrients that can be decontextualized and managed in isolation—as entities to increase or avoid separately. These discursive features preclude the conceptualization of food choice and eating as subjective experiences of feelings, taste, and tradition.

Seit Mai 2020 können Hersteller einen Antrag zur Aufnahme einer digitalen Gesundheitsanwendung (DiGA) in das Verzeichnis nach § 139e Fünftes Buch Sozialgesetzbuch (SGB V) beim für das Bewertungsverfahren zuständigen Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM) stellen. Diesem neuen Antragsverfahren liegen spezifische Anforderungen und Bewertungsparameter zugrunde, zu denen sich herstellerseitig eine Vielzahl an Verfahrens- und wissenschaftlichen Fragestellungen an das BfArM ergibt. Um diesem Bedarf Rechnung zu tragen, hat das BfArM seine etablierten Informations- und Beratungsangebote gezielt für diese neuen Fragestellungen erweitert. Welche dies bezogen auf DiGA im Einzelnen sind, wo entsprechende Informationen und Unterlagen zu finden sind und was diese jeweils auszeichnet, wird in diesem Beitrag dargelegt. Des Weiteren wird mit Blick auf die zwischen Mai 2020 und April 2021 durchgeführten Beratungsgespräche analysiert, welchen Einfluss diese auf das Ergebnis im jeweiligen Antragsverfahren zur Aufnahme in das DiGA-Verzeichnis haben. Dabei bestätigt sich, dass die frühzeitige Erörterung bewertungsrelevanter Parameter und die Berücksichtigung der Beratungsempfehlungen mit einem positiven Bewertungsergebnis korrelieren: Zu den im Verzeichnis gelisteten DiGA hatten 80 % der Hersteller zuvor eine Beratung durch das BfArM in Anspruch genommen. Die Quote zurückgezogener bzw. abgelehnter Anträge war dagegen deutlich höher, wenn Hersteller zuvor keine Beratung in Anspruch genommen hatten, gegenüber Herstellern, die im Vorfeld zentrale Aspekte mit dem BfArM diskutiert hatten (63 % vs. 35 %). Insgesamt profitieren alle Seiten von dem frühzeitigen, intensiven Austausch – letztendlich insbesondere die Patientinnen und Patienten durch einen unverzögerten Einzug von DiGA in die Regelversorgung aufgrund höherer Antragsqualität. Since May 2020, manufacturers have been able to submit an application to the Federal Institute for Drugs and Medical Devices (BfArM) for the inclusion of a digital health application (DiGA) in the directory pursuant to section 139e of the German Social Code Book V. This new application procedure is based on specific requirements and assessment parameters for which a large number of procedural and scientific questions arise on the side of the manufacturers. In order to meet this need, the BfArM has specifically expanded its established information and advisory services for these new questions. This article describes in detail what these are in relation to DiGA, where the corresponding information and documents can be found and what distinguishes them in each case. Furthermore, with a view to the counselling interviews conducted between May 2020 and April 2021, their influence on the outcome of the respective application procedure for inclusion in the DiGA directory is analysed. This confirms that the early discussion of parameters relevant to the evaluation and the consideration of the advisory recommendations correlate with a positive evaluation result. For the DiGA listed in the directory, 80% of the manufacturers had previously received advice from the BfArM. The rate of withdrawn or rejected applications, on the other hand, was significantly higher if manufacturers had not previously sought advice from the BfArM in advance compared to manufacturers who discussed key aspects (63% vs. 35%). Overall, all sides benefit from the early, intensive exchange – in the end especially the patients through introduction of DiGA into standard healthcare due to higher application quality without delay.

Background With increasing psychiatric hospitalizations among adolescents and constrained hospital resources, there are times when youth are hospitalized in adult inpatient psychiatry units. Evidence on the prevalence of this practice and associated impacts is lacking. Aims We sought to explore the prevalence, determinants, and outcomes related to the hospitalization of adolescents aged 12-17 years on adult inpatient psychiatry units in Ontario. Methods Using health administrative data, we constructed a cohort of adolescents with an inpatient psychiatric admission in Ontario (2007-2011). We classified adolescents as having an admission to an adult psychiatry unit or to other inpatient units. Multivariable regression models were used to estimate prevalence ratios (PR) for factors associated with adult admission, as well as risk ratios (RR) for the impact of adult admission on length of stay, discharge against medical advice, and 30-day readmission. Results Over the study period, 22.6% of adolescents with a psychiatric hospitalization (n = 16 998) had an admission to an adult psychiatry unit. Older age (16 vs. 15 years: PR = 2.27, 95% CI = 2.07-2.48; 17 vs. 15 years: PR = 2.91, 95% CI = 2.66-3.18), rural residence (PR = 1.46, 95% CI = 1.38-1.55), psychotic (PR = 1.25, 95% CI = 1.15-1.36) or personality disorder (PR = 1.59, 95% CI = 1.41-1.80) diagnoses, and involuntary status (PR = 2.18, 95% CI = 2.05-2.31) were independently associated with adult admission. Adolescents admitted to adult units were more likely to be discharged against medical advice (RR = 1.77, 95% CI = 1.45-2.17). Conclusions Nearly one in four adolescent psychiatric admissions occurs on an adult psychiatric unit. These findings help to fill gaps in the prior literature, and highlight the need for further research to inform policy decisions and resource allocation for adolescent inpatient psychiatric care.

Purpose We aimed to test the effects of providing municipal support and training to primary health care providers compared to both training alone and to care as usual on the proportion of adult patients having their alcohol consumption measured. Methods We undertook a quasi-experimental study reporting on a 5-month implementation period in 58 primary health care centres from municipal areas within Bogotá (Colombia), Mexico City (Mexico), and Lima (Peru). Within the municipal areas, units were randomized to four arms: (1) care as usual (control); (2) training alone; (3) training and municipal support, designed specifically for the study, using a less intensive clinical and training package; and (4) training and municipal support, designed specifically for the study, using a more intense clinical and training package. The primary outcome was the cumulative proportion of consulting adult patients out of the population registered within the centre whose alcohol consumption was measured (coverage). Results The combination of municipal support and training did not result in higher coverage than training alone (incidence rate ratio (IRR) = 1.0, 95% CI = 0.6 to 0.8). Training alone resulted in higher coverage than no training (IRR = 9.8, 95% CI = 4.1 to 24.7). Coverage did not differ by intensity of the clinical and training package (coefficient = 0.8, 95% CI 0.4 to 1.5). Conclusions Training of providers is key to increasing coverage of alcohol measurement amongst primary health care patients. Although municipal support provided no added value, it is too early to conclude this finding, since full implementation was shortened due to COVID-19 restrictions. Trial Registration Clinical Trials.gov ID: NCT03524599; Registered 15 May 2018; https://clinicaltrials.gov/ct2/show/NCT03524599

A variety of eating patterns are recommended by international guidelines to help people with type 2 diabetes mellitus (T2DM) achieve general health and glycemia goals. Apart from eating patterns, there is evidence that other approaches related to the everyday application of dietary advice, such as meal frequency, breakfast consumption, daily carbohydrate distribution, and order of food consumption during meals, have significant effects on glycemia management. The aims of this review were to examine published diabetes nutrition guidelines concerning specific recommendations with regard to the above approaches, as well as to review evidence from studies that have investigated their effect on glycemia in T2DM. The data suggest that eating breakfast regularly, consuming most carbohydrates at lunch, avoiding large dinners late at night, and applying the carbohydrate-last meal pattern are effective practices towards better nutritional management of T2DM.

BACKGROUND AND PURPOSE A large proportion of headache sufferers do not routinely seek medical care. App-based technologies permit the collection of real-world data over time and between countries that can help assess true burden of headache. This study used a mobile phone application to collect information on the real-world burden of self-diagnosed headache and to describe its impact on daily life in headache sufferers who do not routinely seek medical advice. METHODS This retrospective, non-interventional, cross-sectional study analysed self-reported data from users of the 'Migraine Buddy' app. The main objective was to describe self-reported characteristics of headache and migraine (triggers, duration, frequency), treatment patterns and impact on daily activity in headache sufferers from Australia, Brazil, France, Germany and Japan. Data including demographics, self-diagnosed episode type (headache/migraine), duration, potential triggers and impact on daily activity are reported. All analyses were exploratory and performed per country. RESULTS Self-reported data were collected from 60,474 users between August 2016 and August 2018. Approximately 90% of users were females; >60% were aged 24-45 years. Over one-third of users reported having two to five episodes of headache or migraine per month; impact included impaired concentration, being slower and missing work or social activities. Variations across countries were observed; within countries, episode characteristics were very similar for self-diagnosed headache versus migraine. CONCLUSIONS Headache tracking was used to describe the experience, impact and self-management approaches of migraine and headache sufferers in a real-world setting. Headache disorders present a range of important issues for patients that deserve more study and reinforce the need for better approaches to management.

Purpose Therapeutic success of surgical interventions is significantly affected by patients’ adherence. Patient autonomy can lead to unreasonable behavior. We analyzed the consequences and predisposing factors of patient self-discharge in a plastic and hand surgery cohort. Study design and setting Data was collected retrospectively in a case–control study with n = 73 patients who had self-discharged in a 10-year time period and n = 130 controls (discharge by the surgeon). Data was collected through the hospital information systems and a particular questionnaire. Statistical analyses were performed via chi-squared test and logistic regression analyses. Results Patients who self-discharged against medical advice had a significantly higher complication rate (p = 0.045) and a higher number of revision operations (p p p = 0.002; OR 5.387 (1.734–16.732)) or had to take care of their children at home (p = 0.006; OR 1.481 (1.280–1.741)). There was a significantly lower pain score (NAS) on time of self-discharge (p = 0.002) as well as 24 h after self-discharge (p Conclusion Self-discharge was associated with predisposing factors and poorer outcomes. Patient autonomy can lead to health-compromising behavior and patients should be counseled accordingly.

An Editor-in-Chief leads the editorial team and supervises the daily tasks required to prepare articles for publication while managing the overall content and style of the journal. To become Editor-in-Chief, one must have dedicated work ethic, close attention to detail, passion for the editorial process, and a keen ability to work with and give feedback to section editors and authors. For this article, we interviewed Dr. Steven L. Lewis, Dr. Joseph E. Safdieh, and Dr. S. Andrew Josephson about their collective experience of becoming Editors-in-Chief of Continuum, Neurology Today, and JAMA Neurology, respectively. We have compiled tips for aspiring medical writers and editors, based on their expert advice, to guide trainees in this potential career path.

Background Healthy lifestyle and rehabilitation may mitigate late effects after cancer treatment, but knowledge about lifestyle and rehabilitation information needs among long-term young adult cancer survivors (YACSs) (≥ 5 years from diagnosis) is limited. The present study aimed to examine such information needs among long-term YACSs, and identify characteristics of those with needs. Material and methods The Cancer Registry of Norway identified long-term YACSs diagnosed with breast cancer, colorectal cancer, non-Hodgkin lymphoma, leukemia, or malignant melanoma at the age of 19–39 years, between 1985 and 2009. Survivors were mailed a questionnaire, in which respondents reported their information needs on physical activity, diet, and rehabilitation services 5–30 years post-diagnosis. Descriptive statistics and logistic regression analyses were used to examine the prevalence of information needs and associated factors. Results Of 1488 respondents (a response rate of 42%), 947 were included. Median age at diagnosis was 35 years (range 19–39) and median observation time since diagnosis was 14 years (range 5–30). In total, 41% reported information needs for information about physical activity, 45% about diet, and 47% about rehabilitation services. Information needs were associated with higher treatment intensity, increasing number of late effects, and an unhealthy lifestyle. Conclusion A large proportion of long-term YACSs report information needs regarding lifestyle and/or rehabilitation more than a decade beyond treatment. Assessments of such information needs should become a part of long-term care of these cancer survivors.

A key component of effective diabetes care is understanding patients’ perceptions about diabetes management. Patients’ attitudes and intentions towards taking medical advice may predict the outcomes for effective diabetes care. This study aims to measure participants’ attitudes, beliefs and intentions towards following medical advice to manage their diabetes using the Theory of Planned Behaviour (TPB). The domains of the TPB are correlated with clinical measures of diabetes to determine if these attitudes and intentions are predictive of better diabetes control. A pilot study was conducted. A 34-item survey was designed using the Theory of Planned Behaviour (TPB) framework and administered via mail by four general practice clinics. Included participants (N = 104; response rate 29.5%) had a diagnosis of type 2 diabetes and were taking medication for glycaemic control. Scores for each domain of the TPB survey were correlated with participants’ clinical indicators for diabetes: HbA1c, blood pressure, lipid profile, cholesterol, and kidney health (eGFR and albumin: creatinine ratio) and BMI. Participants surveyed generally reported positive attitudes and intention to follow medical advice. Medical advice was perceived to be beneficial and useful by the majority. However, in general, there was no correlation between positive intentions and improved clinical indicators of disease. Clinical indicators did not improve with duration of illness. The burden of illness is likely a mitigating factor for positive intention as participants perceive medical advice as difficult and inconvenient to follow. Patients’ individual capacity to implement medical advice should be addressed in shared-decision making models to potentially improve patient outcomes towards therapeutic targets.

Background There is much evidence to implement physical activity interventions for medical reasons in healthcare settings. However, the prescription of physical activity as a treatment, referring to as ‘Exercise is Medicine’ (E = M) is currently mostly absent in routine hospital care in The Netherlands. To support E = M prescription by clinicians in hospitals, this study aimed: (1) to develop an E = M-tool for physical activity advice and referrals to facilitate the E = M prescription in hospital settings; and (2) to provide an E = M decision guide on key decisions for implementation to prepare for E = M prescription in hospital care. Methods A mixed method design was used employing a questionnaire and face-to-face interviews with clinicians, lifestyle coaches and hospital managers, a patient panel and stakeholders to assess the needs regarding an E = M-tool and key decisions for implementation of E = M. Based on the needs assessment, a digital E = M-tool was developed. The key decisions informed the development of an E = M decision guide. Results An online supportive tool for E = M was developed for two academic hospitals. Based on the needs assessment, linked to the different patients’ electronic medical records and tailored to the two local settings (University Medical Center Groningen, Amsterdam University Medical Centers). The E = M-tool existed of a tool algorithm, including patient characteristics assessed with a digital questionnaire (age, gender, PA, BMI, medical diagnosis, motivation to change physical activity and preference to discuss physical activity with their doctor) set against norm values. The digital E = M-tool provided an individual E = M-prescription for patients and referral options to local PA interventions in- and outside the hospital. An E = M decision guide was developed to support the implementation of E = M prescription in hospital care. Conclusions This study provided insight into E = M-tool development and the E = M decision-making to support E = M prescription and facilitate tailoring towards local E = M treatment options, using strong stakeholder participation. Outcomes may serve as an example for other decision support guides and interventions aimed at E = M implementation.

There is currently no treatment for early/intermediate Age-related Macular Degeneration (AMD) but Eye Care Professionals (ECPs) are recommended to advise patients about modifiable lifestyle factors, including dietary changes, that can slow disease progression. The aim of this review was to understand advice currently given to patients with AMD by ECPs and to evaluate evidence regarding patient compliance. A systematic review was conducted of literature published in electronic databases: CINAHL, MEDLINE, PsycINFO, PyscARTICLES, EMBASE, AMED. Methods followed PRISMA guidelines (PROSPERO registration number: CRD42020223724). Twenty-four reports were eligible for inclusion, 12 focused on ECP experience, 7 on patient experience, and 6 on impact of advice (one paper reported on the ECP and patient experience). Studies reported that a substantial proportion of patients did not recall receiving lifestyle modification advice from their ECP (57.95%, range 2–95% across patient based studies). Practitioners were most likely to provide advice about nutritional supplements (80%, range 67–93% across ECP studies), and least likely about smoking (44%, range 28–71% across ECP studies), however supplements advised did not always comply with evidence-based guidelines. The main reason for patients not following lifestyle advice was lack of provision by the ECP (54.5%, range 21–94% across studies on the impact of advice). The review highlighted a need for more studies to understand patient preferences for receiving advice and research on ECP perceived barriers to advice provision. S.D. is funded by The Macular Society

There has been a renewed interest in the role of dietary therapies to manage irritable bowel syndrome (IBS), with diet high on the agenda for patients. Currently, interest has focussed on the use of traditional dietary advice (TDA), a gluten-free diet (GFD) and the low FODMAP diet (LFD). A consensus meeting was held to assess the role of these dietary therapies in IBS, in Sheffield, United Kingdom.Evidence for TDA is from case control studies and clinical experience. Randomised controlled trials (RCT) have demonstrated the benefit of soluble fibre in IBS. No studies have assessed TDA in comparison to a habitual or sham diet. There have been a number of RCTs demonstrating the efficacy of a GFD at short-term follow-up, with a lack of long-term outcomes. Whilst gluten may lead to symptom generation in IBS, other components of wheat may also play an important role, with recent interest in the role of fructans, wheat germ agglutinins, as well as alpha amylase trypsin inhibitors. There is good evidence for the use of a LFD at short-term follow-up, with emerging evidence demonstrating its efficacy at long-term follow-up. There is overlap between the LFD and GFD with IBS patients self-initiating gluten or wheat reduction as part of their LFD. Currently, there is a lack of evidence to suggest superiority of one diet over another, although TDA is more acceptable to patients.In view of this evidence, our consensus group recommends that dietary therapies for IBS should be offered by dietitians who first assess dietary triggers and then tailor the intervention according to patient choice. Given the lack of dietetic services, novel approaches such as employing group clinics and online webinars may maximise capacity and accessibility for patients. Further research is also required to assess the comparative efficacy of dietary therapies to other management strategies available to manage IBS.

Background:Long-term weight loss in people living with obesity can reduce the risk and progression of noncommunicable diseases. Observational studies suggest that digital coaching can lead to long-term weight loss.Objective:We investigated whether an eHealth lifestyle coaching program for people living with obesity with or without type 2 diabetes led to significant, long-term (12-month) weight loss compared to usual care.Methods:In a randomized controlled trial that took place in 50 municipalities in Denmark, 340 people living with obesity with or without type 2 diabetes were enrolled from April 16, 2018, to April 1, 2019, and randomized via an automated computer algorithm to an intervention (n=200) or a control (n=140) group. Patients were recruited via their general practitioners, the Danish diabetes organization, and social media. The digital coaching intervention consisted of an initial 1-hour face-to-face motivational interview followed by digital coaching using behavioral change techniques enabled by individual live monitoring. The primary outcome was change in body weight from baseline to 12 months.Results:Data were assessed for 200 participants, including 127 from the intervention group and 73 from the control group, who completed 12 months of follow-up. After 12 months, mean body weight and BMI were significantly reduced in both groups but significantly more so in the intervention group than the control group (–4.5 kg, 95% CI –5.6 to –3.4 vs –1.5 kg, 95% CI –2.7 to –0.2, respectively; P.46).Conclusions:Compared to usual care, digital lifestyle coaching can induce significant weight loss for people living with obesity, both with and without type 2 diabetes, after 12 months. Background: Long-term weight loss in people living with obesity can reduce the risk and progression of noncommunicable diseases. Observational studies suggest that digital coaching can lead to long-term weight loss. Objective: We investigated whether an eHealth lifestyle coaching program for people living with obesity with or without type 2 diabetes led to significant, long-term (12-month) weight loss compared to usual care. Methods: In a randomized controlled trial that took place in 50 municipalities in Denmark, 340 people living with obesity with or without type 2 diabetes were enrolled from April 16, 2018, to April 1, 2019, and randomized via an automated computer algorithm to an intervention (n=200) or a control (n=140) group. Patients were recruited via their general practitioners, the Danish diabetes organization, and social media. The digital coaching intervention consisted of an initial 1-hour face-to-face motivational interview followed by digital coaching using behavioral change techniques enabled by individual live monitoring. The primary outcome was change in body weight from baseline to 12 months. Results: Data were assessed for 200 participants, including 127 from the intervention group and 73 from the control group, who completed 12 months of follow-up. After 12 months, mean body weight and BMI were significantly reduced in both groups but significantly more so in the intervention group than the control group (-4.5 kg, 95% CI -5.6 to -3.4 vs -1.5 kg, 95% CI -2.7 to -0.2, respectively; P.46). Conclusions: Compared to usual care, digital lifestyle coaching can induce significant weight loss for people living with obesity, both with and without type 2 diabetes, after 12 months.

Background: It seems that nonspecific low back pain (NSLBP) cannot be successfully treated with a single intervention of any kind. However, a positive effect of an active lifestyle including physical activities in NSLBP is reported on pain and disability. Advising regular physical activity is one of the mainstays in physical therapy treatment, appealing to patients' adherence. Many patients with low back pain do not seem to adhere to their physiotherapist's advice. In this study, the influence of social support on adherence to an activity advice will be investigated.Objective: Objective of the study is to investigate if patients with low back pain randomised to receive social support adhere better to an activity advice than patients randomised to the control group.Methods: In a randomized controlled clinical trial, in private physiotherapy practices in the Netherlands, patients >= 18 years presenting with at least a second episode of nonspecific low back pain will be randomized over two groups: activity advice and social support as an add-on to usual care versus usual care alone. The primary outcome measure is adherence to an activity advice measured by an activity monitor at 1, 6 and 12 weeks. All other objectives will be measured by questionnaires.Discussion: This project is the first comprehensive research project to assess whether social support influences adherence to an activity advice outside the clinical setting without supervision of a healthcare provider. Where evidence of influence on social support is lacking, findings may have implications for the management of patients with low back pain. In addition, findings may enable physiotherapists to predict in which patients with low back pain an activity advice with social support makes sense.

Counseling by health professionals has promising results in behavior change and is recommended as part of integrated community interventions. However, the knowledge about sedentary behavior (SB) counseling is incipient. The study aimed to identify the prevalence and explore the associated factors with SB counseling received from healthcare professionals by adults in primary health care (PHC) in Brazil. A cross-sectional study was conducted in 2019 that included a representative sample of 779 users in all 15 basic health units (BHU) in São José dos Pinhais, Paraná. We identified those who reported having received SB counseling during a consultation. The association between the sociodemographic factors, chronic diseases, access to health services, physical activity, SB, and counseling were analyzed using Poisson regression in a hierarchical model. The prevalence of counseling was 12.2% (95% CI: 10.1–14.7%); it was higher in women (PR: 1.77; 95% CI: 1.10–2.83), those aged ≥60 yrs (PR: 1.84; 95% CI: 1.14–2.98), BMI ≥ 30 kg/m2 (PR: 2.60; 95% CI: 1.31–5.17), who consume ≥3 medications (PR: 2.21; 95% CI: 1.06–4.59), and those who spend a prolonged period of the day engaged in SB (4th quartile PR: 3.44; 95% CI: 1.88–6.31). The results highlight that SB counseling is underutilized and incipient in PHC. Understanding these results can help managers and healthcare professionals in BHU teams to implement and direct specific actions to reduce SB in adults through counseling.

BACKGROUND AND AIMS: Screening for celiac disease (CD) is recommended in children with affected first-degree relatives (FDR). However, the frequency of screening and at what age remain unknown. The aims of this study were to detect variables influencing the risk of CD development and develop and validate clinical prediction models to provide individualized screening advice. METHODS: We analyzed prospective data from the 10 years of follow-up of the PreventCD-birth cohort involving 944 genetically predisposed children with CD-FDR. Variables significantly influencing the CD risk were combined to determine a risk score. Landmark analyses were performed at different ages. Prediction models were created using multivariable Cox proportional hazards regression analyses, backward elimination, and Harrell's c-index for discrimination. Validation was done using data from the independent NeoCel cohort. RESULTS: In March 2019, the median follow-up was 8.3 years (22 days-12.0 years); 135/944 children developed CD (mean age, 4.3 years [range, 1.1-11.4]). CD developed significantly more often in girls (P = .005) and in Human Leukocyte Antigen (HLA)-DQ2 homozygous individuals (8-year cumulative incidence rate of 35.4% vs maximum of the other HLA-risk groups 18.2% [P < .001]). The effect of homozygosity DR3-DQ2/DR7-DQ2 on CD development was only present in girls (interaction P = .04). The prediction models showed good fit in the validation cohort (Cox regression 0.81 [0.54]). To calculate a personalized risk of CD development and provide screening advice, we designed the Prediction application https://hputter.shinyapps.io/preventcd/. CONCLUSION: Children with CD-FDR develop CD early in life, and their risk depends on gender, age and HLA-DQ, which are all factors that are important for sound screening advice. These children should be screened early in life, including HLA-DQ2/8-typing, and if genetically predisposed to CD, they should get further personalized screening advice using our Prediction application. TRIAL REGISTRATION NUMBER: ISRCTN74582487.

Background and aims\udSmoking is extremely common among adults experiencing homelessness, but there is lack of evidence for treatment efficacy. E-cigarettes are an effective quitting aid, but they have not been widely tested in smokers with complex health and social needs. Here we build upon our cluster feasibility trial and evaluate the offer of an e-cigarette or usual care to smokers accessing a homeless centre.\ud\udDesign, Setting and Participants\udMulti-centre two-arm cluster-randomized controlled trial with mixed-method embedded process and economic evaluation in homeless centres in England, Scotland and Wales. Adult smokers (18+ years; n = 480) accessing homeless centres and who are known to centre staff and willing to consent.\ud\udIntervention and Comparator\udClusters (n = 32) will be randomized to either an e-cigarette starter pack with weekly allocations of nicotine containing e-liquid for 4 weeks [choice of flavours (menthol, fruit and tobacco) and strengths 12 mg/ml and 18 mg/ml] or the usual care intervention, which comprises very brief advice and a leaflet signposting to the local stop smoking service.\ud\udMeasurements\udThe primary outcome is 24-week sustained carbon monoxide-validated smoking cessation (Russell Standard defined, intention-to-treat analysis). Secondary outcomes: (i) 50% smoking reduction (cigarettes per day) from baseline to 24 weeks; (ii) 7-day point prevalence quit rates at 4-, 12- and 24-week follow-up; (iii) changes in risky smoking practices (e.g. sharing cigarettes, smoking discarded cigarettes) from baseline to 4, 12 and 24 weeks; (iv) cost-effectiveness of the intervention; and (v) fidelity of intervention implementation; mechanisms of change; contextual influences and sustainability.\ud\udConclusions\udThis is the first study, to our knowledge, to randomly assign smokers experiencing homelessness to an e-cigarette and usual care intervention to measure smoking abstinence with embedded process and economic evaluations. If effective, its results will be used to inform the larger-scale implementation of offering e-cigarettes throughout homeless centres to aid smoking cessation.

Persistent pulmonary hypertension of the neonate (PPHN) refractory to inhaled nitric oxide still represents a frequent clinical challenge with negative outcomes in neonatal critical care. Several pulmonary vasodilators have become available thanks to improved understanding of pulmonary hypertension pathobiology. These drugs are commonly used in adults and there are numerous case series and small studies describing their potential usefulness in neonates, as well. New vasodilators act on different pathways, some of them can have additive effects and all have different pharmacology features. This information has never been summarized so far and no comprehensive pathobiology-driven algorithm is available to guide the treatment of refractory PPHN.Conclusion: We offer a rational clinical algorithm to guide the treatment of refractory PPHN based on expert advice and the more recent pathobiology and pharmacology knowledge. What is Known: • Refractory PPHN occurs in 30-40% of iNO-treated neonates and represents a significant clinical problem. Several pulmonary vasodilators have become available thanks to a better understanding of pulmonary hypertension pathobiology. What is New: • Available vasodilators have different pharmacology, mechanisms of action and may provide additive effect. We provide a rational clinical algorithm to guide the treatment of refractory PPHN based on expert advice and the more recent pathobiology and pharmacology knowledge.

This article examines the current BHIVA/BASHH guidelines on the disclosure of HIV+ status in the context of sexual activity. It assesses whether the guidance provided on how to avoid criminal prosecution accurately reflects the prevailing position in law. Given that aspects of the guidance related to non-disclosure of HIV infection in the context of low or negligible risk are as yet untested in UK law, it is argued that there is some uncertainty as to whether the professional body guidelines and the law can be reconciled with each other. The article also considers whether the BHIVA/BASHH guidelines stray beyond the boundaries of medical advice as normally understood (focused on the protection of health and the prevention of onward transmission), by posing both as legal advice on how to avoid prosecution and offering what could be viewed as a moral judgement as to when disclosure is required. While a bio-medical assessment of risk naturally shapes clinical guidelines and may also inform views as to appropriate sexual behaviour and risk-taking, it is unclear whether scientific assessment of risk should be the sole guide when it comes to determining the nature of any disclosure obligation or the medical advice to be given on this matter.

Background Home care clients are typically older and have some degree of medical, physical, cognitive or social conditions that require formal or informal support to promote healthy aging in the community. Home care clients contribute a significant proportion of health service use, including emergency department visits. The DIVERT-CARE trial introduced a cardio-respiratory management model to improve client motivation, symptoms and rates of unwarranted health service use. Our objective was to explore the perceptions and experiences of individuals who participated in the DIVERT-CARE self-management support and education intervention. Methods A qualitative study was nested within a pragmatic randomized control trial and conducted following a 15-week multi-component cardio-respiratory intervention. A phenomenological descriptive design was employed using thematic analysis. Post-intervention, clients and their caregivers were invited to participate in a semi-structured telephone interview. Interview questions were designed to elicit the experience with the intervention components. Results A total of 29 interviews were completed from June 2018 to March 2020 from participants in Ontario, Newfoundland, and British Columbia. Three themes were identified; self-care trajectory and burden of responsibility, learning and behaviour change, and feeling connected pre-emptively to care providers, the information and medical advice, and connection through the therapeutic relationship. Conclusions Home care clients experience unique challenges in managing cardio-respiratory related chronic disease. Home-based interventions fostered a therapeutic relationship of connectedness while equipping clients with necessary knowledge and skills. These results inform recommendations for community nursing, and home-based self-management supports for older community-residing individuals.

Physicians expressing opinions on medical matters that run contrary to the consensus of experts pose a challenge to licensing bodies and regulatory authorities. While the right to express contrarian views feeds a robust marketplace of ideas that is essential for scientific progress, physicians advocating ineffective or dangerous cures, or actively opposing public health measures, pose a grave threat to societal welfare. Increasingly, a distinction has been made between professional speech that occurs during the physician-patient encounter and public speech that transpires beyond the clinical setting, with physicians being afforded wide latitude to voice empirically false claims outside the context of patient care. This paper argues that such a bifurcated model does not sufficiently address the challenges of an age when mass communications and social media allow dissenting physicians to offer misleading medical advice to the general public on a mass scale. Instead, a three-tiered model that distinguishes between citizen speech, physician speech and clinical speech would best serve authorities when regulating physician expression.

Purpose This study explored cancer survivors’ views and experiences of receiving physical activity advice post-diagnosis. We also determined the influence of sociodemographic characteristics on the recall of physical activity advice and whether receiving advice was associated with meeting physical activity guidelines. Methods An anonymised, mixed-methods, 27-item survey was distributed to cancer survivors via online cancer communities in the UK. Results Of the 242 respondents, 52% recalled receiving physical activity advice. Of those who recalled receiving advice, only 30% received guidance on type of physical activity and 14% were referred to another source of information or exercise specialist. Advice was most often given after treatment cessation, with only 19% of respondents receiving advice during active treatment. Most respondents (56%) expressed a need for further information. There was no evidence of associations between sociodemographic characteristics and recall of physical activity advice. However, cancer survivors who perceived the physical activity advice they received as being appropriate (odds ratio [OR] 3.8, 95% confidence interval [95% CI]: 1.4–10.7) and those with a higher level of education (OR 3.2, 95% CI: 1.8–5.8) were more likely to meet aerobic exercise guidelines. Females were less likely to meet resistance exercise guidelines than males (OR 0.44, 95% CI: 0.21–0.90). Conclusion There is scope to improve the provision of physical activity advice in cancer care by providing advice in a timely manner after diagnosis, referring patients to a suitable exercise or rehabilitation specialist when indicated, and using a tailored approach to ensure the advice is appropriate for specific sociodemographic groups.

Exercise is overwhelmingly beneficial for physical and mental health, but for some people exercise addiction (EA) can develop and negatively impact an individual. This study sought to (a) compare the latent structure of two instruments assessing EA and (b) examine differences in attitudes toward stopping exercise, if required to on medical grounds, among exercise-addicted and non-addicted athletes. In a cross-sectional study, 1,011 athletes competing at different levels completed an anonymous on-line survey. The survey contained Exercise Dependence Scale-Revised (EDS-R), Exercise Addiction Inventory (EAI), and questions on adherence to medical prescriptions to stop exercise. We tested the latent structure of EDS-R and EAI with multigroup confirmatory factor analyses (CFA), across gender and competition level. Finally, we measured the difference of athletes' attitudes toward stopping exercise, if prescribed by a physician. Both instruments showed good fit indexes, even across gender. CFAs on EAI scores showed some violations of measurement invariance across competition level (ΔCFI = .03; ΔRMSEA = .02). On the contrary, CFAs on EDS-R scores did not show invariance violations across competition level (ΔCFI =

Study Objective To explore key aspects of menstrual health literacy and menstrual management in young women at school or in tertiary education. Design Cross-sectional online survey. Setting Australia-wide. Participants A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781). Interventions Online survey hosted by Qualtrics between November 2017 and January 2018. Data were collected on contraceptive use, management strategies, sources of information, and knowledge of menstruation. Main Outcome Measures Information on prevalence and effectiveness of different management strategies, health-seeking behavior, knowledge about menstruation, and common menstrual disorders such as endometriosis. Results The majority of young women did not seek medical advice for their menstrual symptoms, but used information from the Internet (50%) and engaged in self-management, most commonly with over-the-counter medications such as paracetamol (51%) or ibuprofen (52%). Oral contraceptive use was relatively common (35%), and mostly for reduction of menstrual pain (58%). Despite having significant dysmenorrhea, approximately one-half of the participants (51%) thought that their period was normal. Women with higher pain scores were more likely to rate their period as “abnormal” (P Conclusion Self-management of menstrual symptoms is common, but a significant minority of women are underdosing or choosing ineffective methods. Most women do not seek medical advice even when symptoms are severe, and cannot identify symptoms suggestive of secondary dysmenorrhea. Improved education on menstruation is vital.

In the past five years, nursing practice has changed drastically in Poland. Nurses have received many new competencies in response to the need to provide services to patients. The purpose of the study was to analyze nurses’ opinions on the new rights to provide nursing advice and to identify factors that influence their opinions in this regard. A descriptive cross-sectional study was conducted among 798 nurses who work in various medical facilities. The influence of selected variables on nurses’ opinions on the provision of nursing advice to patients was evaluated using logistic regression. The nurses surveyed had a positive attitude towards new competencies and believed that they were able to independently provide the patient with advice within the scope provided by Polish legislation. Logistic regression showed that the factors that statistically significantly influenced nurses’ opinions on particular types of nursing advice were age (p = 0.038), education (p = 0.000), and the place of work of the respondents; that is, hospital (p = 0.016). More research is needed to demonstrate the effectiveness and quality of the implemented nursing advice and its impact on the functioning of the health system.

Background To help resolve high suicide rates in Bristol, North Somerset and South Gloucestershire, the charity Second Step was commissioned to roll-out the Hope service offering a psychosocial intervention for men, supporting them through acute distress and addressing financial difficulties. This study evaluated the impact of the Hope service on men at risk of suicide experiencing financial and other difficulties. Methods Mixed methods study using: (i) a prospective cohort study design to compare depression, suicidal ideation and financial self-efficacy scores of men aged 30–64, referred to the service between October 2018 and July 2020, at baseline and 6 months follow-up and between low and moderate to high-intensity service users; and (ii) a qualitative interview study to evaluate the acceptability and impact of the Hope service to Hope service users. Results There was a 49% reduction in depression score (mean reduction − 10.0, 95% CI − 11.7 to − 8.3) and in the proportion of service users with suicidal ideation (percent reduction − 52.5, 95% CI − 64.1% to − 40.9%) at 6 months follow-up compared to baseline. Financial self-efficacy scores increased by 26% (mean increase 2.9, 95% CI 1.8 to 3.9). Qualitative accounts illustrated how ‘Hope saved my life’ for several men interviewed; most respondents described being able to move forward and tackle challenges with more confidence following the Hope intervention. Professional advice to tackle financial and other difficulties such as housing helped to relieve anxiety and stress and enable practical issues to be resolved. Conclusions The Hope service offered practical and emotional support to men who have experienced suicidal feelings, redundancy, homelessness and poverty and occupies an important space between mental health and social care provision. Hope demonstrates the value of an intervention which cuts across traditional boundaries between psychiatric care and social advice agencies to provide, what is, in effect, an integrated care service.

Introduction: The APOE ϵ4 allele predisposes to high cholesterol and increases the risk for lifestyle-related diseases such as Alzheimer's disease and cardiovascular diseases (CVDs). The aim of this study was to analyse interrelationships of APOE genotypes with lipid metabolism and lifestyle factors in middle-aged Finns among whom the CVD risk factors are common. Methods: Participants (n = 211) were analysed for APOE ϵ genotypes, physiological parameters, and health- and diet-related plasma markers. Lifestyle choices were determined by a questionnaire. Results: APOE genotypes ϵ3/ϵ4 and ϵ4/ϵ4 (ϵ4 group) represented 34.1% of the participants. Genotype ϵ3/ϵ3 (ϵ3 group) frequency was 54.5%. Carriers of ϵ2 (ϵ2 group; ϵ2/ϵ2, ϵ2/ϵ3 and ϵ2/ϵ4) represented 11.4%; 1.9% were of the genotype ϵ2/ϵ4. LDL and total cholesterol levels were lower (p < 0.05) in the ϵ2 carriers than in the ϵ3 or ϵ4 groups, while the ϵ3 and ϵ4 groups did not differ. Proportions of plasma saturated fatty acids (SFAs) were higher (p < 0.01), and omega-6 fatty acids lower (p = 0.01) in the ϵ2 carriers compared with the ϵ4 group. The ϵ2 carriers had a higher (p < 0.05) percentage of 22:4n-6 and 22:5n-6 and a lower (p < 0.05) percentage of 24:5n-3 and 24:6n-3 than individuals without the ϵ2 allele. Conclusions: The plasma fatty-acid profiles in the ϵ2 group were characterized by higher SFA and lower omega-6 fatty-acid proportions. Their lower cholesterol values indicated a lower risk for CVD compared with the ϵ4 group. A novel finding was that the ϵ2 carriers had different proportions of 22:4n-6, 22:5n-6, 24:5n-3, and 24:6n-3 than individuals without the ϵ2 allele. The significance of the differences in fatty-acid composition remains to be studied. publishedVersion

School attendance is crucial for the development of a child. Sickness absence is the most common type of absenteeism and can be a red flag for underlying problems. To address sickness absence, the intervention Medical Advice for Sick-reported Students for Primary School (MASS-PS) was recently developed. It targets children at risk and is a school-based child and youth health care intervention. The present study is a process evaluation of the intervention. MASS-PS was implemented and evaluated in 29 schools in the West-Brabant region of the Netherlands, during three school years (2017–2020). Attendance coordinators (ACs) from the different schools were interviewed in six focus group interviews as well as in over 200 individual conversations, of which logbooks were kept. Content analysis was used based on a framework of implementation elements. During the first year of the study, the uptake was low. Changes were made by the project group to improve the uptake. The ACs generally considered the MASS-PS as compatible and relevant, but suggested improvements by adding a medical consultation function with a child and youth healthcare physician and increasing the threshold for selecting children at risk. They saw several personal benefits, although time was necessary to learn to use the intervention. An organisational barrier was the lack of teaching staff. A strength in the organisational structure was the appointment of ACs. A major event in the sociological structure was the COVID-19 pandemic. ACs felt that the intervention helped them keep track of sickness absence during the pandemic. The Medical Advice for Sick-reported Students for Primary School intervention was implemented successfully, and the process evaluation gave insight into possible improvements.