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OBJECTIVE: Map multimorbidity-weighted index (MWI) conditions to International Classification of Diseases, 10th Revision (ICD-10), expand the conditions and codes to develop a new ICD-10-coded MWI (MWI-ICD10) and updated MWI-ICD9, and assess their consistency. DESIGN: Population-based retrospective cohort. SETTING: Large medical centre between 2013 and 2017. PARTICIPANTS: Adults ≥18 years old with encounters in each of 4 years (2013, 2014, 2016, 2017). MAIN OUTCOME MEASURES: MWI conditions mapped to ICD-10 codes, and additional conditions and codes added to produce a new MWI-ICD10 and updated MWI-ICD9. We compared the prevalence of ICD-coded MWI conditions within the ICD-9 era (2013-2014), within the ICD-10 era (2016-2017) and across the ICD-9-ICD-10 transition in 2015 (washout period) among adults present in both sets of comparison years. We computed the prevalence and change in prevalence of conditions when using MWI-ICD10 versus MWI-ICD9. RESULTS: 88 175 adults met inclusion criteria. Participants were 60.8% female, 50.5% white, with mean age 54.7±17.3 years and baseline MWI-ICD9 4.47±6.02 (range 0-64.33). Of 94 conditions, 65 had

BACKGROUND: Simultaneous urine testing for albumin (UAlb) and serum creatinine (SCr), that is, dual testing, is an accepted quality measure in the management of diabetes. As chronic kidney disease (CKD) is defined by both UAlb and SCr testing, this approach could be more widely adopted in kidney care. OBJECTIVE: We assessed time trends and facility-level variation in the performance of outpatient dual testing in the integrated Veterans Health Administration (VHA) system. DESIGN, SUBJECTS AND MAIN MEASURES: This retrospective cohort study included patients with any inpatient or outpatient visit to the VHA system during the period 2009-2018. Dual testing was defined as UAlb and SCr testing in the outpatient setting within a calendar year. We assessed time trends in dual testing by demographics, comorbidities, high-risk (eg, diabetes) specialty care and facilities. A generalised linear mixed-effects model was applied to explore individual and facility-level predictors of receiving dual testing. KEY RESULTS: We analysed data from approximately 6.9 million veterans per year. Dual testing increased, on average, from 17.4% to 21.2%, but varied substantially among VHA centres (0.3%-43.7% in 2018). Dual testing was strongly associated with diabetes (OR 10.4, 95% CI 10.3 to 10.5, p

Objectives: Knowledge about the long-term course and prognosis of persistent somatic symptoms (PSS) is important to improve clinical decision-making and guidance for patients with PSS. Therefore, we aimed to: (1) identify distinct 5-year trajectories of symptom severity, physical and mental functioning in adult patients with PSS and (2) explore patient characteristics associated with these trajectories., Design: We used longitudinal data (seven measurements over a 5-year period) of the PROSPECTS study: a prospective cohort of adult patients with PSS. We applied Latent Class Growth Mixture Modelling to identify distinct trajectories for the three outcomes., Setting and Participants: Patients were recruited in general practices and specialised treatment facilities for PSS throughout the Netherlands. The study population consisted of participants with three or more measurements available (n=297)., Primary Outcome Measures: Symptom severity (Patient Health Questionnaire 15), physical and mental functioning (RAND-36 Physical Component Summary and Mental Component Summary)., Results: For symptom severity, we identified two 'stable' trajectories: 'severe symptoms, stable' (15.8%) and 'moderate symptoms, stable' (84.2%). For physical functioning, we identified three trajectories: 'poor physical functioning, marked improvement' (8.5%); 'poor physical functioning, stable' (34.7%) and 'moderate physical functioning, slight improvement' (56.8%). For mental functioning, we identified three trajectories: 'poor mental functioning, marked improvement' (13.9%); 'moderate mental functioning, deterioration' (12.2%) and 'moderate mental functioning, slight improvement' (73.8%). Patients' characteristics such as personal, social and environmental background, illness stressors, comorbid diseases, cognitive, emotional and behavioural responses varied for the distinct trajectories., Conclusions: We identified distinct 5-year trajectories for the three outcomes. Our findings suggest a high prevalence of persistence of symptoms and limited improvement in physical and mental functioning in the majority of patients with PSS. In a small proportion of patients, we identified trajectories that showed considerable physical or mental improvement or deterioration. Patient characteristics differed for the identified trajectories and may guide early recognition, although predictive studies are warranted., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ.)

Background: Social determinants of health (SDH) impact the health status of individuals around the world. General practitioners (GPs) can take into account the social situation of patients in their care practice. To this end, the College of General Medicine (CGM) issued recommendations in 2022 to propose 100 methods of action., Objective: To assess the acceptability to GPs of the recommendations set out by the CGM to improve the consideration of the social situation of patients in consultations., Design: Quantitative, cross-sectional, descriptive study, using the Delphi method., Setting: The data were collected through the administration of a questionnaire to GPs practising in France., Participants: Participants were recruited by email from the academic network of Sorbonne University. The only criteria for inclusion were to be a GP from Sorbonne University and to complete the full questionnaire. 25 participants were included., Interventions: Proposals were grouped into 24 themes. Participants had to rate the acceptability of these themes by rating their degree of relevance and degree of applicability on a Likert scale., Primary Outcome: The primary outcome was the acceptability by GPs of proposals to take into account the SDH. Acceptability was defined as relevance with a median greater than or equal to 7 and applicability with a median greater than or equal to 7, in the absence of disagreements., Results: After 2 rounds, 12 themes were accepted: 5 addressed interventions at the individual level (eg, 'understanding the context of patients' lives and identifying social difficulties'), 4 addressed interventions at the organisational level (eg, 'communication actions aimed at vulnerable patient populations') and 3 addressed interventions at territorial level (municipality and national). Relevance was very good for all of them, with median responses ranging from 8 to 9 and with no disagreement. Applicability was more mixed, with 12 themes deemed applicable. Justifications were provided through participants' comments. Proposals were made to improve the applicability., Conclusion: This study explored how SDH could be taken into account through the perspective of GPs in the context of the CGM's recommendations. While all proposals were deemed relevant, some were not applicable. The findings emphasise the need for adaptations in the organisation of the practice, of care pathways and more generally, in the organisation of the health system. Those actions require the commitment of professionals and political actors., Competing Interests: Competing interests: GI is an active member of the CGM and was the leader of the working group that drew up the recommendations. The other authors have declared that no competing interests exist., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: On 24 February 2022, the full-scale military invasion of Russia into Ukraine has started, creating one of the largest humanitarian crises in Europe since the World War II. As of 27 July 2022 (by the time when the most of Russian advances have already occurred), more than 900 healthcare facilities in Ukraine were damaged and 127 hospitals were destroyed completely., Methods: Mobile medical units (MMU) were deployed in the frontline-bordering areas. An MMU included a family doctor, a nurse, a social worker and a driver, and aimed to provide medical help in remote areas. 18 260 patients who received medical help in MMUs in Dnipro (Dnipro city) and Zaporizhia (Zaporizhia city and Shyroke village) oblasts from July until October 2022 were included in the study. The patients were subdivided by month of visit, area of residence and area of MMU operation. Patients' sex, age, date of visit and diagnosis were analysed. Comparison between groups was performed using analysis of variance and Pearson's χ 2 tests., Results: Majority of patients were females (57.4%), people aged 60+ years (42.8%) and internally displaced persons (IDPs) (54.8%). The proportion of IDPs increased from 47.4% to 62.8% over the period of study (p<0.01). The most common cause of visit to doctors was cardiovascular diseases (17.9%). The frequency of non-respiratory infections remained stable over the period of study., Conclusions: In the frontline-bordering areas of Ukraine, females, people older than 60 years and IDPs more frequently sought medical help in MMUs. Causes of morbidity in the studied population were similar to the causes of morbidity before the beginning of full-scale military invasion. Maintaining continuous access to healthcare services may be beneficial for the patient outcomes, especially in terms of cardiovascular disease., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objectives: German general practitioners (GPs) either order laboratory tests from external laboratories (initiated laboratory services (ILS)) or perform point-of-care tests (POCTs) within the GP practice. This study investigated the current use and time trends of laboratory testing in German GP practices with a particular focus on POC testing., Design: Retrospective consecutive cross-sectional study by analysis of complete outpatient healthcare claims data (2017-2022)., Setting: Primary care in Thuringia, a federal state in central Germany., Participants: Data from 2061 GPs., Primary and Secondary Outcome Measures: Number of performed laboratory analyses per year, mean number of laboratory analyses per patient and year., Results: In 2022, 1601 GPs performed 16.1 million laboratory analyses, with 14.9 million (92.5%) being ILS and 1.2 million (7.5%) being POCTs conducted within GP practices. The mean number of laboratory tests per patient was 15.5 in 2022. The number of laboratory tests performed per patient decreased by 18.8% from 2017 to 2022. An especially pronounced reduction was observed in the use of POCTs (-36.0%). During the whole study period, the most common initiated laboratory analyses included creatinine, blood cell count, glucose, thyroid-stimulating hormone and HbA1/HbA1c. The most frequently employed POCTs were glucose, urine test strip, prothrombin time/international normalised ratio, HbA1/HbA1c, erythrocyte sedimentation rate and microalbuminuria. POC testing instead of ILS was more likely performed in older patient groups (≥40 years) compared with young adult patients (18-39 years) (adjusted OR (aOR) 40-59 years: 1.19 (95% CI 1.14 to 1.24); aOR 60-79 years: 1.48 (95% CI 1.40 to 1.57); aOR >79 years: 1.43 (95% CI 1.34 to 1.54))., Conclusions: German GPs regularly employ laboratory testing, primarily utilising external laboratory service, while POC testing plays a relatively minor role. The notable decline in the use of POCT testing may be attributed to several factors, including regulations from healthcare authorities, reimbursement guidelines and increasing test costs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives: The aim of the present study was to assess the effect of sociodemographic factors on knowledge, attitudes, motivation and potential barriers of university students towards blood donation in the order to more effective donation promotion., Design: The cross-sectional study was conducted on 1000 participants (500 non-blood donors-NBD, 276 first time blood donors-FTBD and 224 regular blood donors-RBD) from the 14 faculties of the University of Novi Sad, Serbia. The measurement tool used was a pretested survey questionnaire that included 22 questions focused on the factors influencing blood donation., Results: Males accounted for 61.5% of participants. Average age of participants was 23.19 years, and over 80% were pursuing basic academic studies. University students: (1) correctly answered 65% of the questions about blood donation (NBD 59.2%, FTBD 59.7%, RBD 84.3%); (2) expressed 70.5% positive attitude towards donating blood (NBD 58.6%, FTBD 76.9%, RBD 89.1%), in both cases statistically significantly higher in RBD. Helping others who need blood (47.5%) was the main reason for donating blood and fear of needles (41.4%) was the most common potential barrier, with a significant statistical difference among the other factors., Conclusions: The study demonstrates that university students show good knowledge and philanthropic attitude towards blood donation. Donation promotion should be focused on addressing potential barriers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The available literature reviews of shift work among care workers are almost exclusively focused on 8-hour shifts and 12-hour shifts or 24-hour on-call shifts for physicians. We do not yet know the scope of evidence regarding extended-duration work shifts (defined as on-duty shifts of 16 or more hours per shift) in diverse healthcare settings, such as the impact on care workers and recipients of care. In this proposed scoping review, we aim to provide an overview of the current research regarding extended-duration work shifts among care workers in various healthcare settings., Methods and Analysis: We will conduct this scoping review in accordance with the Joanna Briggs Institute scoping review methodology. Comprehensive searches will be conducted in PubMed, Embase, MEDLINE, Web of Science and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases and grey literature sources. We will include empirical studies that focus on extended-duration work shifts among care workers working in different healthcare settings, including home care, community, acute care settings, long-term care homes and assisted living facilities. We will not apply language restrictions. We will conduct searches in August 2024, followed by screening of records. We will exclude research on on-call work shifts and investigations that solely focus on interns. The included literature will be screened independently by pairs of reviewers at the title and abstract review phase, followed by a full-text review for relevant literature. Any disagreement will be resolved by consensus or discussion with a third reviewer. The results will be extracted and summarised in the final report in tabular form, when possible, along with narrative synthesis., Ethics and Dissemination: All data for this study will come from published literature, so an ethics review is not necessary. The findings will be disseminated through conference presentations and publication in peer-reviewed journals, with the expectation that they will guide future research and inform future management of work shifts in care workers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Providing clinical performance feedback to physicians is an established method to improve care, but the impact on physician well-being is unclear. This evaluation aimed to better understand physician perspectives on clinical feedback and its potential impact on well-being., Design: A qualitative design using semi-structured interviews was undertaken. Data were analysed via consensus coding using an inductive-deductive approach informed by Clinical Performance Feedback Intervention Theory. Findings were used to develop a novel framework describing the relationship between feedback and well-being., Setting: Interviews were conducted in a large academic medical centre from June-September 2021., Participants: We conducted 25 semi-structured interviews with general outpatient and inpatient paediatricians and internists., Results: Physicians felt that feedback supported well-being based on its perceived purpose (intended to promote professional growth vs serving an alternative purpose), which they discerned based on feedback content (aligned with physician priorities vs not aligned), validity (accurate vs inaccurate), actionability (specific vs not, within a physician's sphere of control vs not) and delivery (supportive vs punitive). The Clinical Performance Feedback Well-Being Model is presented to understand how feedback and recipient variables impact well-being., Conclusions: Attention to the process and content of physician clinical performance feedback may advance both the quality of care and physician well-being., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate associations between the availability and timing of digitally available advance care planning (ACP) documents and hospital use and costs during the last 6 months of life., Design: Retrospective population-based cohort study using data linkage., Setting: 11 public hospitals in Queensland, Australia., Participants: 5586 decedents with ACP documents were directly matched 1:2 to 11 172 control decedents based on age category, sex, location, year of death and principal diagnosis code for the last-known hospital admission., Exposure: ACP discussions with documents uploaded to a widely accessible statewide digital platform. Directly matched subgroup analyses investigated differences between decedents with ACP documents available at three different times prior to death: ≥6 months, between 1 and 6 months, and <1 month., Main Outcomes and Measures: Emergency department (ED) presentations, hospital and intensive care unit (ICU) admissions, and in-hospital deaths, expressed as adjusted OR (aOR). Secondary outcomes were hospital bed-days and costs., Results: ACP decedents with documents uploaded ≥6 months prior to death, compared with controls, had fewer ED presentations (aOR 0.90, 95% CI 0.81 to 1.00), hospitalisations (aOR 0.83, 95% CI 0.74 to 0.92), ICU admissions (aOR 0.23, 95% CI 0.10 to 0.48), and in-hospital deaths (aOR 0.56, 95% CI 0.51 to 0.63), and lower adjusted mean hospital costs per person over the last 6 months of life ($A2290 less (95% CI -$4116 to -$463)). Conversely, decedents with ACP documents uploaded less than 6 months prior to death showed higher rates of ED presentations and hospital admissions and greater hospital costs relative to controls., Conclusion: The association between digitally available ACP documents and health service use and cost differed based on the timing of ACP upload, with documents available ≥6 months prior to death being associated with less hospital use and costs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Point-of-care ultrasound (POCUS) is ultrasound brought to the patient's bedside and performed in 'real time' by the healthcare provider. The utility of POCUS to facilitate management of the acutely ill patient has been demonstrated for multiple pathologies. However, the integration of ultrasonography and echocardiography training into residency curriculum varies across the acute care specialties.Study Design: After an institutional review board approval, anaesthesiology, emergency medicine, family medicine, internal medicine, paediatrics and general surgery programme directors (PDs) were surveyed. The survey consisted of 11 questions evaluating the primary bedside assessment tool for common acute care situations, POCUS topics that the PDs were comfortable practising and topics that the PDs felt were useful for their specialty. Barriers to POCUS use, certification and documentation were also surveyed.Results: Overall, 270 PD surveys were completed. The preferred primary assessment tool for common acute care situations varied with specialty; emergency medicine PDs consistently responded that POCUS was the diagnostic modality of choice (p<0.0001). The majority of the PDs reported lack of educational opportunities as the primary barrier to learning POCUS (64%). Most PDs indicated that POCUS examinations should be documented (95.7%), and 39% reported that departmental certification would be sufficient.Conclusions: This study is the first to evaluate differences in the preferred initial bedside assessment tool between the acute care specialties. Although POCUS is a superior tool for evaluating acute pathologies, disconnect between education and utilisation remains. This study highlights the need to incorporate POCUS into the acute care specialty curriculum. [ABSTRACT FROM AUTHOR]

Cardiovascular disease (CVD) is one of the leading causes of death across the world. CVD can lead to angina, heart attacks, heart failure, strokes, and eventually, death; among many other serious conditions. The early intervention with those at a higher risk of developing CVD, typically with statin treatment, leads to better health outcomes. For this reason, clinical prediction models (CPMs) have been developed to identify those at a high risk of developing CVD so that treatment can begin at an earlier stage. Currently, CPMs are built around statistical analysis of factors linked to developing CVD, such as body mass index and family history. The emerging field of machine learning (ML) in healthcare, using computer algorithms that learn from a dataset without explicit programming, has the potential to outperform the CPMs available today. ML has already shown exciting progress in the detection of skin malignancies, bone fractures and many other medical conditions. In this review, we will analyse and explain the CPMs currently in use with comparisons to their developing ML counterparts. We have found that although the newest non-ML CPMs are effective, ML-based approaches consistently outperform them. However, improvements to the literature need to be made before ML should be implemented over current CPMs. [ABSTRACT FROM AUTHOR]

Study Purpose: Malignant central airway obstruction (CAO) in non-small cell lung cancer (NSCLC) is associated with high morbidity and requires endobronchial palliative treatment to re-establish a free air passage. We investigate intratumoral therapy combining anti-angiogenic and cytotoxic as a feasible therapeutic modality to treat malignant CAO.Study Design: Ten NSCLC subjects with symptomatic malignant CAO underwent endobronchial intratumoral cisplatin and Endostar co-injection after tumour debulking next to systemic cisplatin-based chemotherapy. Injection was performed immediately after debulking surgery and was then carried out on day 2, day 6 and day 10 past systemic chemotherapy. Nine subjects of control group constantly received traditional cisplatin-based chemotherapy. Bronchoscopy, CT scanning, histology, FEV1/FVC ratio, Karnofsky performance (KPS) and shortness of breath scores were analysed to assess therapeutic efficacy.Results: All 10 subjects benefited from the intratumoral cisplatin and endostar co-injection and systemic chemotherapy combination therapy. Bronchoscopy and CT scanning analyses showed a massive airway widening after treatment. Increased KPS and reduced shortness of breath score were also observed. A substantial improvement of lung function was further confirmed by increased FEV1/FVC ratio. For subjects of control group, the improvement was moderate and obviously not as optimal as the 10 subjects with intratumoral injection.Conclusions: We have shown that the intratumoral injection of cytotoxic cisplatin plus anti-angiogenic Endostar is an effective and safe adjuvant therapeutic option to treat malignant CAO in clinical practice. This time-staggered local and systemic treatment combination improves quality of life and clinical parameters, thus may provide a feasible therapeutic option for symptomatic CAO. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of coadministering statins with direct oral anticoagulants (DOACs) on the risk of major bleeding events in patients with venous thromboembolism (VTE)., Design: Observational cohort analysis based on a multicentre international registry., Setting: Data were extracted from the Registro Informatizado de Enfermedad TromboEmbolica Registry, which involves 205 centres across 27 countries., Participants: A total of 73 659 patients diagnosed with VTE were classified based on their anticoagulant therapy (DOACs) versus low-molecular-weight heparin (LMWH) or vitamin K antagonists (VKAs) and concurrent use of statins., Methods: Multivariable Cox proportional hazards models adjusted for confounding variables to assess the risk of major bleeding events stratified by the type of anticoagulant use and statin use., Results: From October 2013 to February 2023, 73 659 patients were recruited: 2573 were statin users on DOACs, 14 090 were statin users on LMWH or VKA therapy, 10 088 were non-statin users on DOACs and 46 908 were non-statin users on LMWH or VKA therapy. Statin users were 10 years older and more likely to have hypertension, diabetes, renal failure or prior artery disease. During anticoagulation (median, 187 days), 1917 patients (2.6%) suffered major bleeding. Rates of major bleeding per 100 patient-years were 2.33 (95% CI 1.72 to 3.09), 3.75 (95% CI 3.43 to 4.10), 1.39 (95% CI 1.13 to 1.69) and 3.10 (95% CI 2.93 to 3.27), respectively. On multivariable analysis, patients treated with DOACs had a significantly lower risk of major bleeding compared with those on LMWH or VKA therapy (adjusted HR 0.59; 95% CI 0.48 to 0.74). The adjusted HR in statin users versus non-users was 1.03 (95% CI 0.92 to 1.14), while in statin users on DOACs versus the rest of patients, it was 1.18 (95% CI 0.79 to 1.76)., Conclusions: In patients with VTE receiving statins, long-term anticoagulation with DOACs was associated with a reduced risk of major bleeding, regardless of the statin use. These findings support the safety profile of DOACs over VKAs or LMWH in the management of VTE in patients requiring statins., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Diabetes is closely associated with risk of stroke and its adverse sequelae. Approximately 20%-33% of patients with stroke have diabetes. In China, however, it is unclear how stroke affects healthcare utilisation, medications and complications among people with diabetes. This study aimed to analyse the clinical characteristics, treatment options, medical expenses and complications of hospital outpatient healthcare associated with stroke in patients with diabetes in China., Design: A retrospective, multicentre, observational study., Setting: Beijing Municipal Medical Insurance Database, with data from 2016 to 2018., Participants: The study included patients with diabetes whose data included 2016-2018 outpatient medication records and who had Beijing medical insurance. Patients who did not have continuous prescription records for more than 2 months were excluded from the analysis. In total, 2 853 036 people with diabetes were included, and patients who had and did not have a stroke were compared., Results: In our study, 19.75%-22.30% of patients with diabetes suffered from stroke between 2016 and 2018. The average annual medical cost for a patient diagnosed with diabetes is ¥9606.65, and the cost increases to ¥13 428.39 when diabetes was combined with stroke; thus, stroke increases the medical cost for patients with diabetes by 39.78% (p<0.0001). Among patients with diabetes who had a stroke, 4.76 medications were used (1.8 hypoglycaemic drugs and 2.97 non-hypoglycaemic drugs); these numbers were significantly greater than for patients with diabetes who did not have a stroke receiving both hypoglycaemic drugs and non-hypoglycaemic drugs (p<0.0001). Among patients with diabetes who did not have a stroke, 3.58 medications were used (1.66 hypoglycaemic drugs and 1.92 non-hypoglycaemic drugs). Patients with diabetes who had a stroke also had significantly greater incidences of diabetic peripheral neuropathy, diabetic kidney disease, diabetic retinopathy and diabetic angiopathy than those who did not have a stroke (p<0.0001). These drugs and costs increased with the number of complications (p<0.0001). The increased medical costs for each specific complication are also listed. We also analysed the medical costs and medication regimens stratified by sex, age group and complications., Conclusions: Stroke is associated with a significant increase in complications and medications for patients with diabetes and greatly adds to the economic burden of these patients. Early identification of stroke risk factors in patients with diabetes, as well as targeted poststroke diabetes management, is crucial from a socioeconomic perspective for a comprehensive management and treatment of stroke in patients with diabetes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: With physician maldistribution recognised as a global issue, Japan implemented the physician uneven distribution (PUD) index as a strategic measure. Currently, there is a lack of objective assessment of core clinical competencies in regions influenced by varying levels of physician distribution. In this study, we objectively assess the core clinical competencies in regions affected by physician maldistribution and explore the relationship between the PUD index and the clinical competencies of resident physicians., Design, Setting and Participants: In this cross-sectional study, we gathered data from the January 2023 General Medicine In-Training Examination (GM-ITE) survey. Participants included postgraduate year 1 and 2 resident physicians in Japanese hospitals mandating the GM-ITE or those who voluntarily took it. The GM-ITE scores of the resident physicians were assessed. The PUD index, a Japanese policy indicator, reflects regional physician disparities. A low PUD index signals a medical supply shortage compared with local demand. The trial registration number is 23-7., Results: The high and low PUD index groups included 2143 and 1580 participants, respectively. After adjusting for relevant confounders, multivariate linear regression analyses revealed that the low PUD index group had significantly higher GM-ITE scores than the high PUD index group (adjusted coefficient: 1.14; 95% CI 0.62 to 1.65; p<0.001)., Conclusions: The study revealed no clinically differences in GM-ITE scores between residents in regions with disparate physician distributions, suggesting that factors beyond PUD may influence clinical competency. This finding prompts a re-evaluation of whether current assessment methodologies or educational frameworks fully support learning across varied community settings., Competing Interests: Competing interests: JAMEP was involved in collecting and managing data as the GM‐ITE administrative organisation. It did not participate in designing and conducting the study, data analysis and interpretation, preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication. KS received an honorarium from the JAMEP as a speaker on the JAMEP lecture and exam preparer for the GM-ITE. YN received an honorarium from the JAMEP as a GM-ITE project manager. YT is the JAMEP director and received an honorarium from the JAMEP as a speaker on the JAMEP lecture. HK received an honorarium from the JAMEP as a speaker on the JAMEP lecture. TS and YY received an honorarium from the JAMEP as exam preparers for the GM-ITE., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Germany and the European Union have experienced successive waves of refugees since 2014, resulting in over 1.6 million arrivals, including families with young children. These vulnerable populations often face xenophobia, discrimination, substandard living conditions and limited healthcare access, contributing to a high prevalence of mental health problems (MHP). Our primary goal is to proactively address MHP in refugee parents and prevent its potential impact on their children through effective early interventions. Using a low-threshold, primary care-based approach, we aim to enhance parenting skills and address parental psychopathology, creating a supportive environment for parents and children., Methods and Analysis: In this randomised controlled trial, 188 refugee parents of 6-year-old children or younger who meet the clinical cut-off on the MHP scale will participate. They are randomly assigned to either the experimental psychotherapeutic intervention, delivered by general practitioners (10-week Improve intervention), or treatment as usual, in a ratio of 1:1. The randomisation will be masked only for outcome assessors. Improve includes face-to-face sessions with general practitioners, an interactive online parenting programme (Triple P Online) and regular protocol-based telephone calls by psychologists. Primary outcomes will assess the intervention's effects on parental and child MHP and parenting skills, with secondary outcomes including psychosocial and physical health indicators. Outcomes will be assessed at pre, post and at 3-month and 6-month follow-ups. The study is scheduled to run from February 2019 to July 2025., Ethics and Dissemination: The project Improve-MH (application number 602) was approved by the local ethics committee of Ruhr-University of Bochum and is being conducted in accordance with the Declaration of Helsinki. The study is also conducted in full accordance with the German Data Protection Act, and the Good Clinical Practice guideline (GCP) and is sensitive to specific ethical considerations. Results will be disseminated at scientific conferences, published in peer-reviewed journals and provided to consumers of healthcare., Trial Registration Number: The trial was prospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS-ID: DRKS00019072) on 16 March 2020., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Case management (CM) is among the most studied effective models of integrated care for people with complex needs. The goal of this study is to scale up and assess CM in primary healthcare for people with complex needs., Methods and Analysis: The research questions are: (1) which mechanisms contribute to the successful scale-up of CM for people with complex needs in primary healthcare?; (2) how do contextual factors within primary healthcare organisations contribute to these mechanisms? and (3) what are the relationships between the actors, contextual factors, mechanisms and outcomes when scaling-up CM for people with complex needs in primary healthcare? We will conduct a mixed methods Canadian interprovincial project in Quebec, New-Brunswick and Nova Scotia. It will include a scale-up phase and an evaluation phase. At inception, a scale-up committee will be formed in each province to oversee the scale-up phase. We will assess scale-up using a realist evaluation guided by the RAMESES checklist to develop an initial programme theory on CM scale-up. Then we will test and refine the programme theory using a mixed-methods multiple case study with 10 cases, each case being the scalable unit of the intervention in a region. Each primary care clinic within the case will recruit 30 adult patients with complex needs who frequently use healthcare services. Qualitative data will be used to identify contexts, mechanisms and certain outcomes for developing context-mechanism-outcome configurations. Quantitative data will be used to describe patient characteristics and measure scale-up outcomes., Ethics and Dissemination: Ethics approval was obtained. Engaging researchers, decision-makers, clinicians and patient partners on the study Steering Committee will foster knowledge mobilisation and impact. The dissemination plan will be developed with the Steering Committee with messages and dissemination methods targeted for each audience., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Older adults are more likely to be vitamin D deficient. The aim of the study was to determine whether these patients have worse outcomes with COVID-19.Methods: We conducted a prospective cohort study between 1 March and 30 April 2020 to assess the importance of vitamin D deficiency in older patients with COVID-19. The cohort consisted of patients aged ≥65 years presenting with symptoms consistent with COVID-19 (n=105). All patients were tested for serum 25-hydroxyvitamin D (25(OH)D) levels during acute illness. Diagnosis of COVID-19 was confirmed via viral reverse transcriptase PCR swab or supporting radiological evidence. COVID-19-positive arm (n=70) was sub-divided into vitamin D-deficient (≤30 nmol/L) (n=39) and -replete groups (n=35). Subgroups were assessed for disease severity using biochemical, radiological and clinical markers. Primary outcome was in-hospital mortality. Secondary outcomes were laboratory features of cytokine storm, thoracic imaging changes and requirement of non-invasive ventilation (NIV).Results: COVID-19-positive arm demonstrated lower median serum 25(OH)D level of 27 nmol/L (IQR=20-47 nmol/L) compared with COVID-19-negative arm, with median level of 52 nmol/L (IQR=31.5-71.5 nmol/L) (p value=0.0008). Among patients with vitamin D deficiency, there was higher peak D-dimer level (1914.00 μgFEU/L vs 1268.00 μgFEU/L) (p=0.034) and higher incidence of NIV support and high dependency unit admission (30.77% vs 9.68%) (p=0.042). No increased mortality was observed between groups.Conclusion: Older adults with vitamin D deficiency and COVID-19 may demonstrate worse morbidity outcomes. Vitamin D status may be a useful prognosticator. [ABSTRACT FROM AUTHOR]

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been caused the greatest pandemic of our century. Many of the deaths related to it are due to a systemic inflammatory response, which has been called 'cytokine storm'.Objectives: We developed a comprehensive review of the pathophysiology mechanisms of COVID-19 and of the rationale for drugs and therapeutics that have been tested in clinical trials.Methods: A narrative review of the literature was conducted using PubMed, SciELO, Bireme, Google Scholar and ClinicalTrials.Results: SARS-CoV-2 has evolutive mechanisms that made it spread all around the globe, as a higher latency period and a lesser lethality than other coronaviruses. SARS-CoV-2 causes a delay in the innate immune response and it disarranges the immune system leading to an overwhelming inflammatory reaction (the 'cytokine storm'). In this scenario, high levels of interleukins (IL), notably IL-6 and IL-1, create a positive feedback of chemokines and immune responses, and powers pulmonary and systemic tissue damage, leading to capillary leakage and SARS, the main cause of death in patients with COVID-19. On 17 July 2020, there were 1450 entries on ClinicalTrials.gov of ongoing studies on COVID-19. The mechanisms of the main therapeutic approaches were comprehensively reviewed throughout the text. Therapies focus on blocking viral entry (remdesivir, umifenovir, among others) and blocking of immune system for cytokine storm control (IL-1 and IL-6 inhibitors, glucocorticoids, convalescent plasma, among others).Conclusions: Understanding of action mechanisms of SARS-CoV-2 enables us to direct efforts on effective therapeutic targets. This comprehensive review helps to interpret the clinical results of the several trials ongoing. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Improved drug labelling for chronic pill-form medications has been shown to promote patient comprehension, adherence and safety. We extended health literacy principles and included patients perspectives to improve instructions for: (1) non-pill form, (2) short term, (3) as needed, (4) tapered and (5) escalating dose medications. SETTING: Participants were recruited via convenience sampling from primary care clinics in Chicago, Illinois and San Francisco, California, USA. PARTICIPANTS: 40 adult, English-speaking participants who reported taking at least one prescription drug in the past 12 months were enrolled in the study. PRIMARY AND SECONDARY OUTCOMES: Participant opinions, preferences and comprehension of standard and improved medication instructions were assessed during four iterative waves of discussion groups. Brief interviews preceding the discussion groups measured individuals literacy skills, sociodemographic and health characteristics. RESULTS: On average, participants were 46 years old, took four medications and reported two chronic health conditions. Patients varied sociodemographically; 40% were men and 33% had limited literacy skills. Patients agreed on the need for simpler terminology and specificity in instructions. Discussions addressed optimal ways of presenting numeric information, indication and duration of use information to promote comprehension and safe medication use. Consensus was reached on how to improve most of the instructions. CONCLUSIONS: Through this patient-centred approach, we developed a set of health literacy-informed instructions for more challenging medications. Findings can inform current drug labelling initiatives and promote safe and appropriate medication use.

Background: As a key enzyme of natriuretic peptides system playing an integral role in energy homeostasis, furin may be a potential contributor to obesity. However, the association between furin and obesity has been scarcely studied. This study aims to examine the prospective association between serum furin and abdominal obesity.Methods: Waist circumference (WC) was measured twice 4 years apart for a total of 892 Chinese adults free of abdominal obesity at baseline. Abdominal obesity was defined as WC over 85 cm for men and as WC over 80 cm for women. A Cox proportional hazard model was constructed to examine the association of baseline serum furin with incident abdominal obesity.Results: After an average 4 years of follow-up, 184 participants developed new abdominal obesity. Baseline serum furin was significantly associated with dynamic body weight during follow-up (β=-0.593, p=0.003). Participants with a higher level of serum furin at baseline were less likely to develop new abdominal obesity compared with those with a lower level of serum furin (HR=0.81, 95% CI 0.67 to 0.97).Conclusions: A lower level of serum furin predicts a higher risk of developing future abdominal obesity in Chinese adults. Furin deficiency may be a contributor to abdominal obesity but still needs further investigations. [ABSTRACT FROM AUTHOR]

Purpose Of the Study: Hypophosphataemia and hyperphosphataemia are frequently encountered in hospitalised patients and are associated with significant clinical consequences. However, the prognostic value of normal-range phosphorus levels on all-cause mortality and hospitalisations is not well established. Therefore, we examined the association between normal-range phosphorus levels, all-cause mortality and hospitalisations in patients presenting to the emergency department of a tertiary medical centre in Israel.Study Design: A retrospective analysis of patients presenting to the Chaim Sheba Medical Center emergency department between 2012 and 2018. The cohort was divided into quartiles based on emergency department phosphorus levels: 'very-low-normal' (p ≥ 2 mg/dL and p ≤ 2.49 mg/dL), 'low-normal' (p ≥ 2.5 mg/dL and p ≤ 2.99 mg/dL), 'high-normal' (p≥  3 mg/dL and p≤3.49 mg/dL) and 'very-high-normal' (p ≥  3.5 mg/dL and p ≤ 4 mg/dL). We analysed the association between emergency department phosphorus levels, hospitalisation rate and 30-day and 90-day all-cause mortality.Results: Our final analysis included 223 854 patients with normal-range phosphorus levels. Patients with 'very-low-normal' phosphorus levels had the highest mortality rate. Compared with patients with 'high-normal' phosphorus levels, patients with 'very-low-normal' levels had increased 30-day all-cause mortality (OR 1.3, 95% CI 1.1 to 1.4, p<0.001), and increased 90-day all-cause mortality (OR 1.2, 95% CI 1.1 to 1.3, p<0.001). Lower serum phosphorus levels were also associated with a higher hospitalisation rate, both for the internal medicine and general surgery wards (p<0.001).Conclusions: Lower phosphorus levels, within the normal range, are associated with higher 30-day and 90-day all-cause mortality and hospitalisation rate. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between schizophrenia, antipsychotic medication adherence and driver responsibility for motor vehicle crash., Design: Retrospective observational cohort study using 20 years of population-based administrative health and driving data., Setting: British Columbia, Canada., Participants: Licensed drivers who were involved in a police-attended motor vehicle crash in British Columbia over a 17-year study interval (2000-16)., Exposures: Incident schizophrenia was identified using hospitalisation and physician services data. Antipsychotic adherence was estimated using prescription fill data to calculate the 'medication possession ratio' (MPR) in the 30 days prior to crash., Primary Outcome Measures: We deemed drivers 'responsible' or 'non-responsible' for their crash by applying a validated scoring tool to police-reported crash data. We used logistic regression to evaluate the association between crash responsibility and exposures of interest., Results: Our cohort included 808 432 drivers involved in a police-attended crash and for whom crash responsibility could be established. In total, 1689 of the 2551 drivers with schizophrenia and 432 430 of the 805 881 drivers without schizophrenia were deemed responsible for their crash, corresponding to a significant association between schizophrenia and crash responsibility (66.2% vs 53.7%; adjusted OR (aOR), 1.67; 95% CI, 1.53 to 1.82; p<0.001). The magnitude of this association was modest relative to established crash risk factors (eg, learner license, age ≥65 years, impairment at time of crash). Among the 1833 drivers with schizophrenia, near-optimal antipsychotic adherence (MPR ≥0.8) in the 30 days prior to crash was not associated with lower crash responsibility (aOR, 1.04; 95% CI, 0.83 to 1.30; p=0.55)., Conclusions: Crash-involved drivers with schizophrenia are more likely to be responsible for their crash, but the magnitude of risk is similar to socially acceptable risk factors such as older age or possession of a learner license. Contemporary driving restrictions for individuals with schizophrenia appear to adequately mitigate road risks, suggesting more stringent driving restrictions are not warranted., Competing Interests: Competing interests: WH is a consultant to Translational Life Sciences, AbbVie, Newron, and Otsuka., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Chronic non-malignant diseases (CNMDs) are under-represented in specialist palliative home care (SPHC). The timely integration of SPHC for patients suffering from these diseases can reduce hospitalisation and alleviate symptom burdens. An intervention of an SPHC nurse-patient consultation followed by an interprofessional telephone case conference with the general practitioner (GP) was tested in the KOPAL trial ('Concept for strengthening interprofessional collaboration for patients with palliative care needs'). As part of the trial, the aim of this study was to gain in-depth insights into SPHC physicians' perspective on care with and without the KOPAL intervention for patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia (D)., Design: Qualitative evaluation of the KOPAL intervention from the perspective of SPHC physicians as part of the KOPAL trial. Thematic-focused narrative interviews analysed with grounded theory., Setting: We conducted the KOPAL study and its qualitative evaluation in Lower Saxony and the greater Hamburg area, Germany., Participants: 11 physicians from 14 SPHC teams who participated in the trial were interviewed., Results: A grounded theory of the necessity of collaboration between GPs and SPHC teams for patients with CHF, COPD and dementia was developed. From the perspective of SPHC physicians, patients with CNMD are generally difficult to manage in GP care. The timing of SPHC initiation is patient-specific, underscoring the need for collaboration between SPHC physicians and GPs. However, the primary mandate for healthcare should remain with GPs. SPHC physicians actively seek collaboration with GPs (eg, through the KOPAL intervention), viewing themselves as advisors for GPs and aspiring to collaborate as equal partners., Conclusion: Effective communication and the negotiation of future interprofessional collaboration are essential for SPHC teams., Trial Registration Number: DRKS00017795., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are common in multimorbid patients. This study aims to describe PIMs and PPOs in an open-access outpatient setting and to investigate any association between continuity of care (CoC) and PIMs and PPOs in multimorbid older patients., Design: Cross-sectional study using patient-confirmed outpatient medication plans to describe PIMs and PPOs using the 'Screening Tool of Older Person's Prescription/Screening Tool to Alert to Right Treatment' version 2. Four Poisson regressions modelled the number of PIMs and PPOs using context-adapted versions of the Usual Provider of Care (UPC) and the Modified Modified Continuity Index (MMCI) as measures for CoC., Setting: Southern Germany, outpatient setting., Participants: 321 participants of the LoChro-trial at 12-month follow-up (both arms). The LoChro-trial compared healthcare involving an additional care manager with usual care. Inclusion criteria were age over 64, local residence and scoring over one in the Identification of Older patients at Risk Screening Tool., Primary Outcomes: Numbers of PIMs and PPOs., Results: The mean number of PIMs was 1.5 (SD 1.5), lower than the average number of PPOs at 2.9 (SD 1.7). CoC showed similar results for both indices with a mean of 0.548 (SD 0.279) for MMCI and 0.514 (SD 0.262) for UPC. Both models predicting PPOs indicated more PPOs with higher CoC; statistical significance was only demonstrated for MMCI (MMCI~PPO: Exp(B)=1.42, 95% CI (1.11; 1.81), p=0.004; UPC~PPO: Exp(B)=1.29, 95% CI (0.99; 1.67), p=0.056). No significant association between PIMs and CoC was found (MMCI~PIM: Exp(B)=0.72, 95% CI (0.50; 1.03), p=0.072; UPC~PIM: Exp(B)=0.83, 95% CI (0.57; 1.21), p=0.337)., Conclusion: The results did not show a significant association between higher CoC and lesser PIMs. Remarkably, an association between increased CoC, represented through MMCI, and more PPOs was found. Consultation of different care providers in open-access healthcare systems could possibly ameliorate under-prescribing in multimorbid older patients., Trial Registration: German Clinical Trials Register (DRKS): DRKS00013904., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We aimed to assess the associations between sleep duration and Visceral Adiposity Index (VAI)., Design: Cross-sectional study., Setting: The National Health and Nutrition Examination Survey (2007-2018)., Participants: A total 11 252 eligible participants who have complete information for sleep duration and VAI., Outcome Measure: The VAI index, which is sex-specific and takes into consideration factors such as waist circumference, body mass index, high-density lipoprotein cholesterol and triglycerides, was calculated in accordance with prior research. Multiple linear regressions and subgroup analyses were employed to evaluate the connection between the duration of sleep and the VAI., Results: The mean sleep duration and VAI of included participants were 7.05 hours/day and 2.03, respectively. After adjusting for the sociodemographic, lifestyle and other covariates, short sleep was significantly linked to increased VAI (β=0.15, 95% CI 0.01 to 0.28) in relation to middle sleep duration, whereas no significant association was found between long sleep duration and VAI. An L-shaped relationship was observed between sleep duration and VAI. When sleep duration was less than 7.5 hours/day, a negative association between sleep duration and VAI was obvious. However, when sleep duration was >7.5 hours/day, VAI was increased with a longer sleep duration, although it was not significant., Conclusions: An L-shaped relationship was observed between sleep duration and VAI, with insufficient sleep, being independently linked to a higher VAI. This implies that sleep deprivation might be associated with visceral adipose distribution and disfunction., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The utilisation of pH level measurements from gastric contents may indicate the preferred tip position of a nasogastric tube or monitor the efficacy of stress ulcer prophylaxis in critically ill patients. We aimed to determine the accuracy of pH strip (pHS) tests and pH liquid (pHL) tests compared with the standard pH meter (pHM)., Design: Diagnostic accuracy study., Setting: Gastric contents from medically critically ill patients., Participants: In total, 113 gastric samples were collected from 27 critically ill patients., Outcome Measure: The level of pH measured by pHM, pHS and pHL., Results: The pH values measured by pHM, pHS and pHL were 5.83 (IQR 5.12-6.61), 5.50 (IQR 5.00-6.00) and 5.75 (IQR 5.25-6.25), respectively. The pHS test showed greater accuracy, exhibiting a more positive correlation with the standard pHM measurement than the pHL test, with Y=0.95*X+0.56; rho=0.91, p<0.001, and Y=1.09*X - 0.72; rho=0.75, p<0.001, respectively. However, the pHS test demonstrated less agreement with the pHM than the pHL test, with biases of -0.27 versus 0.18, respectively. Noticeably, a slight variation in pHL from the standard pH values was found when we measured gastric contents with a pH lower than 5., Conclusion: Both the pHS and pHL methods were good options for measuring gastric pH in critically ill patients. However, it was advisable to find alternative approaches to the pHL testing method when anticipated gastric acidity levels fall below 5., Trial Registration Number: TCTR20220530004., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In our study, we aimed to characterise adult childhood cancer survivors (ACCS), assess their health issues, gauge health-related quality of life (HRQOL) and evaluate visit satisfaction., Design: Prospective cohort study using data from clinical visits and questionnaires., Setting: Interdisciplinary follow-up programme for ACCS based on the long-term follow-up (LTFU) guidelines of the Children's Oncology Group and overseen by internists in two Swiss hospitals., Participants: ACCS attending our LTFU clinics between April 2017 and January 2022 were eligible., Interventions: We documented medical history, current health status and assessed HRQOL using Short Form-36 V.2, comparing it with Swiss general population (SGP) norms (T mean=50, SD=10; age stratified). 3 months post visit, a feedback questionnaire was distributed., Main Results: Among 102 ACCS (mean age: 32 years (range: 18-62 years), 68% women), 43 had no prior follow-up (36 ACCS>28 years, 7 ACCS≤28 years). A notable 94% had health issues, affecting an average of 6.1 (SD=3.3) organ systems. HRQOL was lower in ACCS>28 years than the SGP>28 years (physical: 44.8 (SD=11.65) vs 49.3 (SD=10.29), p=0.016; mental: 44.4 (SD=13.78) vs 50.53 (SD=9.92), p=0.004). Older ACCS (>28 years) reported inferior physical (44.8 vs 50.1 (SD=9.30), p=0.017) and mental HRQOL (44.4 vs 50.3 (SD=7.20), p=0.009) than younger ACCS. The majority of respondents reported high levels of satisfaction with the consultation, exceeding 90%., Conclusion: ACCS attending LTFU clinics face diverse health issues impacting multiple organ systems and exhibit lower HRQOL compared with the SGP. Thus, internist-led LTFU clinics are crucial for optimising follow-up care., Competing Interests: Competing interests: A-EM is a specialist for porphyria and received financial support via an unrestricted research grant from Clinuvel Pharmaceuticals and for a porphyria nurse from Alnylam Pharmaceuticals. Both are paid into the ‘Stiftung für wissenschaftliche Forschung, Stadtspital Triemli’ and are not related to this scientific work. JDL is supported by grants from the Swiss National Science Foundation (SNF 160072 and 185592) as well as by the Swiss Personalised Health Network (SPHN 2018DR108). JDL has also received unrestricted grants from AstraZeneca AG Switzerland, Boehringer Ingelheim GmbH Switzerland, GSK AG Switzerland, Novartis AG Switzerland and Sanofi AG Switzerland. None of them are related to this scientific work. No other conflicting interests were declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the association between type 1 diabetes (T1D)/type 2 diabetes (T2D) and periodontitis and assess the influence of periodontitis on diabetes-related complications., Design: Observational study; longitudinal analysis of register data., Setting: Swedish primary care centres, hospitals and dental clinics reporting to nationwide healthcare registers (2010-2020)., Participants: 28 801 individuals with T1D (13 022 women; mean age 42 years) and 57 839 individuals without diabetes (non-T1D; 26 271 women; mean age 43 years). 251 645 individuals with T2D (110 627 women; mean age 61 years) and 539 805 individuals without diabetes (non-T2D; 235 533 women; mean age 60 years). Diabetes and non-diabetes groups were matched for age, gender and county of residence., Main Outcome Measures: Prevalent periodontitis, diabetes-related complications (retinopathy, albuminuria, stroke and ischaemic heart disease) and mortality., Results: Periodontitis was more common among T2D (22%) than non-T2D (17%). Differences were larger in younger age groups (adjusted RR at age 30-39 years 1.92; 95% CI 1.81 to 2.03) and exacerbated by poor glycaemic control. Periodontitis prevalence was 13% in T1D and 11% in non-T1D; only the subgroup with poor glycaemic control was at higher risk for periodontitis. Periodontitis was associated with a higher incidence of retinopathy (T1D: HR 1.08, 95% CI 1.02 to 1.14; T2D: HR 1.08, 95% CI 1.06 to 1.10) and albuminuria (T1D: HR 1.14, 95% CI 1.06 to 1.23; T2D: HR 1.09, 95% CI 1.07 to 1.11). Periodontitis was not associated with a higher risk for stroke, cardiovascular disease or higher mortality in T1D/T2D., Conclusions: The association between T2D and periodontitis was strong and exacerbated by poor glycaemic control. For T1D, the association to periodontitis was limited to subgroups with poor glycaemic control. Periodontitis contributed to an increased risk for retinopathy and albuminuria in T1D and T2D., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare: ATE, CT, TB and JD had financial support from the Eklund Foundation (grant 2018-132) and TUA Research Funding (grants TUAGBG-919531 & TUAGBG-979382) for the submitted work; CT serves as a consultant for PreBiomics S.r.I (outside the present work); TB serves as an advisor for the Swedish Quality Registry for Caries and Periodontal Diseases (SKaPa); KEO serves as the director of the Swedish National Diabetes Register (NDR) and has received fees for lecturing and/or honoraria for consulting from Sanofi, Novo Nordisk, Eli Lilly and Abbot Diabetes Care (all outside the present work); no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Non-small cell lung cancer (NSCLC) has a poor prognosis. Transvascular intervention is an important approach for treating NSCLC. Drug-eluting bead bronchial artery chemoembolisation (DEB-BACE) is a technique of using DEBs loaded with chemotherapeutic drugs for BACE. This study aims to conduct a meta-analysis to comprehensively assess the effectiveness and safety of DEB-BACE in treating NSCLC and investigate a novel therapeutic strategy for NSCLC., Methods and Analysis: Wanfang, China National Knowledge Infrastructure, Medline (via PubMed), Cochrane Library, Scopus and Embase databases will be searched in November 2024. A meta-analysis will be conducted to assess the effectiveness and safety of DEB-BACE in the treatment of NSCLC. The following keywords will be applied: "Carcinoma, Non-Small-Cell Lung", "Non-Small Cell Lung Cancer", "Drug-Eluting Bead Bronchial Arterial Chemoembolization" and "drug-eluting beads". Reports in Chinese or English comparing the efficacy of DEB-BACE with other NSCLC treatment options will be included. Case reports, single-arm studies, conference papers, abstracts without full text and reports published in languages other than English and Chinese will not be considered. The Cochrane Handbook for Systematic Reviews of Interventions will be used to independently assess the risk of bias for each included study. In case of significant heterogeneity between studies, possible sources of heterogeneity will be explored through subgroup and sensitivity analysis. For the statistical analysis of the data, RevMan V.5.3 will be used., Ethics and Dissemination: This meta-analysis will seek publication in a peer-reviewed journal on completion. Ethical approval is not required for this study as it is a database-based study., Prospero Registration Number: CRD42023411392., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aim of this study was to investigate the prevalence of indigenous herbal medicine use and its associated factors among pregnant women attending antenatal care (ANC) at public health facilities in Dire Dawa, Ethiopia., Design: A facility-based cross-sectional study design., Setting: The study was conducted in seven public health facilities (one referral hospital, three urban and three rural health centres) in Dire Dawa, Ethiopia, from October to November 2022., Participants: 628 pregnant women of any gestational age who had been on ANC follow-up at selected public health facilities were included., Main Outcome Measures: Prevalence of indigenous herbal medicine (users vs non-users) and associated factors., Results: The study revealed that 47.8% (95% CI 43.8% to 51.6%) of pregnant women used herbal medicines. Lack of formal education (adjusted OR, AOR 5.47, 95% CI 2.40 to 12.46), primary level (AOR 4.74, 95% CI 2.15 to 10.44), housewives (AOR 4.15, 95% CI 1.83 to 9.37), number of ANC visits (AOR 2.58, 95% CI 1.27 to 5.25), insufficient knowledge (AOR 4.58, 95% CI 3.02 to 6.77) and favourable perception (AOR 2.54, 95% CI 1.71 to 3.77) were factors significantly associated with herbal medicine use. The most commonly used herbs were garden cress ( Lepidium sativum ) (32%), bitter leaf ( Vernonia amygdalina ) (25.2%), moringa ( Moringa oleifera ) (24. 5 %). Common indications were related to gastrointestinal problems, blood pressure and sugar., Conclusion: The prevalence of herbal medicine use is high (one in two pregnant women) and significantly associated with education level, occupation, ANC visits, knowledge and perceptions. The study's findings are helpful in advancing comprehension of herbal medicines using status, types and enforcing factors. It is essential that health facilities provide herbal counselling during ANC visits, and health regulatory bodies ought to raise awareness and implement interventions to lower the risks from over-the-counter herbal medicine use by pregnant women., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Empowering people living with multimorbidity (multiple chronic conditions) to gain greater confidence in managing their health can enhance their quality of life. Education focused on self-management is a key tool for fostering patient empowerment and is mostly provided on an individual basis. Virtual communities of practice (VCoP) present a unique opportunity for online education in chronic condition self-management within a social context. This research aims to evaluate the effectiveness/cost-effectiveness of individualised, online self-management education compared with VCoP among middle-aged individuals living with multiple chronic conditions., Methods and Analysis: People aged 30-60, living with ≥2 chronic conditions and receiving care in primary care (PC) centres and outpatient hospital-based clinics in Madrid and Canary Islands will enrol in an 18-month parallel-design, blinded (intervention assessment and data analysts), pragmatic (adhering to the intention-to-treat principle), individually randomised trial. The trial will compare two 12-month web-based educational offers of identical content; one delivered individually (control) and the other with online social interaction (VCoP, intervention). Using repeated measures mixed linear models, with the patient as random effect and allocation groups and time per group as fixed effects, we will estimate between-arm differences in the change in Patient Activation Measure from baseline to 12 months (primary endpoint), including measurements at 6-month and 18-month follow-up. Other outcomes will include measures of depression and anxiety, treatment burden, quality of life. In addition to a process evaluation of the VCoP, we will conduct an economic evaluation estimating the relative cost-effectiveness of the VCoP from the perspectives of both the National Health System and the Community., Ethics and Dissemination: The trial was approved by Clinical Research Ethics Committees of Gregorio Marañón University Hospital in Madrid/Nuestra Señora Candelaria University Hospital in Santa Cruz de Tenerife. The results will be disseminated through workshops, policy briefs, peer-reviewed publications and local/international conferences., Trial Registration Number: NCT06046326., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Inappropriate antibiotic prescribing is a major cause of antimicrobial resistance (AMR). The aim of this study was to explore paediatric general practitioners' (GP Peds) antibiotic prescription practice in suspected respiratory tract infections (RTIs), using the capability-opportunity-motivation-behaviour framework., Design: The design is a qualitative study based on individual, semistructured telephone or virtual interviews., Setting: Paediatric general practice in Hungary. We applied stratified maximum variation sampling to cover the categories of age, sex and geographical location of participants., Participants: We interviewed 22 GP Peds. Nine were male and 13 were female: 2 of them were less than 40 years old, 14 were between 40 and 60 years, and 6 were above 60 years. 10 worked in low-antibiotic prescription areas, 5 in areas with medium levels of antibiotic prescription, 3 in high-antibiotic prescription areas, and 4 in and around the capital city., Results: Study participants had varying antibiotic prescription preferences. Personal experience and physical examination play a central role in GP Peds' diagnostic and treatment practice. Participants emphasised the need to treat children in their entirety, taking their personal medical record, social background and sometimes parents' preferences into account, besides the acute clinical manifestation of RTI. Most respondents were confident they apply the most effective therapy even if, in some cases, this meant prescribing medicines with a higher chance of contributing to the development of AMR. Some participants felt antibiotic prescription frequency has decreased in recent years., Conclusions: Our findings suggest that a more prudent attitude toward antibiotic prescribing may have become more common but also highlight relevant gaps in both physicians' and public knowledge of antibiotics and AMR. To reinforce awareness and close remaining gaps, Hungary should adopt its national AMR National Action Plan and further increase its efforts towards active professional communication and feedback for primary care physicians., Competing Interests: Competing interests: The National Center for Public Health and Pharmacy received funding and language editing support from the WHO Regional Office for Europe, for conducting this piece of research and preparing this manuscript., (© World Health Organization 2024. Licensee BMJ.)

Objectives: Japanese medical academia continues to depend on quantitative indicators, contrary to the general trend in research evaluation. To understand this situation better and facilitate discussion, this study aimed to examine how Japanese medical researchers perceive quantitative indicators and qualitative factors of research evaluation and their differences by the researchers' characteristics., Design: We employed a web-based cross-sectional survey and distributed the self-administered questionnaire to academic society members via the Japanese Association of Medical Sciences., Participants: We received 3139 valid responses representing Japanese medical researchers in any medical research field (basic, clinical and social medicine)., Outcomes: The subjective importance of quantitative indicators and qualitative factors in evaluating researchers (eg, the journal impact factor (IF) or the originality of the research topic) was assessed on a four-point scale, with 1 indicating 'especially important' and 4 indicating 'not important'. The attitude towards various opinions in quantitative and qualitative research evaluation (eg, the possibility of research misconduct or susceptibility to unconscious bias) was also evaluated on a four-point scale, ranging from 1, 'strongly agree', to 4, 'completely disagree'., Results: Notably, 67.4% of the medical researchers, particularly men, younger and basic medicine researchers, responded that the journal IF was important in researcher evaluation. Most researchers (88.8%) agreed that some important studies do not get properly evaluated in research evaluation using quantitative indicators. The respondents perceived quantitative indicators as possibly leading to misconduct, especially in basic medicine (strongly agree-basic, 22.7%; clinical, 11.7%; and social, 16.1%). According to the research fields, researchers consider different qualitative factors, such as the originality of the research topic (especially important-basic, 46.2%; social, 39.1%; and clinical, 32.0%) and the contribution to solving clinical and social problems (especially important-basic, 30.4%; clinical, 41.0%; and social, 52.0%), as important. Older researchers tended to believe that qualitative research evaluation was unaffected by unconscious bias., Conclusion: Despite recommendations from the Declaration on Research Assessment and the Leiden Manifesto to de-emphasise quantitative indicators, this study found that Japanese medical researchers have actually tended to prioritise the journal IF and other quantitative indicators based on English-language publications in their research evaluation. Therefore, constantly reviewing the research evaluation methods while respecting the viewpoints of researchers from different research fields, generations and genders is crucial., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The objective of this study was to investigate associations between knowledge of health issues and healthcare satisfaction and propensity to complain including the association between knowledge and greater patient involvement., Design: The present study is a secondary analysis of a larger cross-sectional case vignette survey., Setting: Survey conducted in adult Danish men., Participants: Participants included 6755 men aged 45-70 years., Interventions: Participants responded to a survey with scenarios illustrating prostate-specific antigen (PSA) testing and different information provision., Primary and Secondary Outcome Measures: Using Likert scales (scored 1-5), participants rated their satisfaction with the care described and their inclination to complain and responded to a short quiz (scored 0-3) assessing their knowledge about the PSA test., Results: Satisfaction with healthcare increased with better quiz performance (Likert difference 0.13 (95% CI .07 to 0.20), p <0.001, totally correct vs totally incorrect responders) and correspondingly, the desire to complain significantly decreased (Likert difference -0.34 (95% CI 0.40 to -0.27), p <0.001). Respondents with higher education performed better (mean quiz score difference 0.59 (95% CI 0.50 to 0.67), p <0.001, most educated vs least educated). Responders who received information about the PSA test generally performed better (quiz score difference 0.41 (95% CI 0.35 to 0.47), p<0.001, neutral vs no information). Overestimation of PSA merits was more common than underestimation (7.9% vs 3.8%)., Conclusions: Mens' knowledge of the benefits of screening varies with education, predicts satisfaction with care and the desire to complain, and may be improved through greater involvement in decision-making., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: General practitioners (GPs) are mostly the first point of contact for patients with health problems in Germany. There is only a limited epidemiological overview data that describe the GP consultation hours based on other than billing data. Therefore, the aim of Saxon Epidemiological Study in General Practice-6 (SESAM-6) is to examine the frequency of reasons for encounter, prevalence of long-term diagnosed diseases and diagnostic and therapeutic decisions in general practice. This knowledge is fundamental to identify the healthcare needs and to develop strategies to improve the GP care. The results of the study will be incorporated into the undergraduate, postgraduate and continuing medical education for GP., Methods and Analysis: This cross-sectional study SESAM-6 is conducted in general practices in the state of Saxony, Germany. The study design is based on previous SESAM studies. Participating physicians are assigned to 1 week per quarter (over a survey period of 12 months) in which every fifth doctor-patient contact is recorded for one-half of the day (morning or afternoon). To facilitate valid statements, a minimum of 50 GP is required to document a total of at least 2500 doctor-patient contacts. Univariable, multivariable and subgroup analyses as well as comparisons to the previous SESAM data sets will be conducted., Ethics and Dissemination: The study was approved by the Ethics Committee of the Technical University of Dresden in March 2023 (SR-EK-7502023). Participation in the study is voluntary and will not be remunerated. The study results will be published in peer-reviewed scientific journals, preferably with open access. They will also be disseminated at scientific and public symposia, congresses and conferences. A final report will be published to summarise the central results and provided to all study participants and the public., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In the summer of 2019, the Center for Disease Control and Prevention (CDC) declared an emergency of electronic cigarettes and/or vaping (vaping)-associated lung injury (EVALI) in the USA. The outbreak abated by January 2020, which the CDC attributed to heightened public awareness, 'user actions to reduce risk' and potentially the removal of vitamin E acetate (VEA) from vaping products (VEA is an oily chemical cutting agent, strongly associated with the disease). Even though the EVALI outbreak appears to be over, numerous epidemiological and medical questions are left still open. First, why were there practically no cases outside the USA, which represents nearly a quarter of the global vaping market? Comparative studies to map the differences in device/fluids/user habits between countries might be needed urgently. Second, what is the pathomechanism that sickens vapers irrespective of VEA exposure? VEA was only confirmed in about half of the cases and the presumed toxicity is yet to be determined. Aetiology/epidemiology focused research is needed to investigate/interpret the broader context to explain the outbreak. Third, could any socioeconomic/environmental factors have influenced the course of the outbreak? Finally, what should we expect in the years to come? Was EVALI a serious but reversible emergency medicine condition or is vaping as detrimental to long-term health as smoking? Besides the complex legislative, regulatory, ethical aspects of EVALI, biomedical research is also difficult: in-vitro experiments have limited inferential value to real real-life vaping due to its complexity; user habits are self-reported and under-researched; there is an active black market pouring unknown quality counterfeit products and, in the USA, federal restrictions limit cannabis research. Vaping is a toxicological, multidimensional conundrum; therefore, stringent quality control, transparent legal/ethical boundaries, meticulous international research and user education are paramount to prevent potential future outbreaks and determine the parameters safe vaping (if these exist). [ABSTRACT FROM AUTHOR]

Objectives: An increasing percentage of the US population is obese. Cardiometabolic risk in the population increases with body mass index (BMI), but whether this correlation changes over time is unknown. We analysed the National Health and Nutrition Examination Survey (NHANES) database from 1999 to 2016 to determine if the prevalence of cardiometabolic disease and cardiovascular events within each BMI category is changing over time as the BMI of the population is increasing.Study Design: For each of the nine survey cycles covering this period, we divided the population by BMI category (normal, overweight, class 1 obesity, class ≥2 obesity) and subsequently by the presence of cardiovascular events or cardiometabolic disease. NHANES participants are a group of 5000 individuals/cycle selected to be representative of the US population. We used the weighted data sets to perform trend analyses for each risk/BMI group adjusted for relevant confounders.Results: The distribution of the highest risk category (cardiovascular event) has not changed over time within any BMI category. The distribution of the lowest risk category (cardiometabolically healthy) increased significantly over time in all BMI categories. This was noted in the 18- to 45-year subgroup but not in the group aged >45 years.Conclusions: The increase in the prevalence of overweight and obese individuals might be associated with a 'healthy obesity' phenotype in those <45 years; however, individuals >45 years showed a proportional increase in associated cardiometabolic risk. [ABSTRACT FROM AUTHOR]

All animal life on earth is thought to have a common origin and have common genetic mechanisms. Evolution has enabled differentiation of species. Pathogens likewise have evolved within various species and mostly come to a settled dynamic equilibrium such that co-existence results (pathogens ideally should not kill their hosts). Problems arise when pathogens jump species because the new host had not developed any resistance. These infections from related species are known as zoonoses. COVID-19 is the latest example of a virus entering another species but HIV (and various strains of influenza) were previous examples. HIV entered the human population from monkeys in Africa. These two papers outline the underlying principle of HIV and the differing epidemiologies in Africa, the USA and in Edinburgh. The underlying immunosuppression of HIV in Africa was initially hidden behind common infections and HIV first came to world awareness in focal areas of the USA as a disease seemingly limited to gay males. The epidemic of intravenous drug abuse in Edinburgh was associated with overlapping epidemics of bloodborne viruses like hepatitis B, hepatitis C and HIV. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of syncope or collapse in pulmonary embolism (PE).Methods: A retrospective cohort study was conducted. We examined the frequency with which syncope or collapse (presyncope) occurred alone or with other symptoms and signs in an unselected series of 224 patients presenting to a district general hospital with PE between September 2012 and March 2016. Confirmation of PE was by CT pulmonary angiogram in each case.Results: Our cohort of 224 patients comprised 97 men and 127 women, average age 66 years with age range of 21-94 years. Syncope or collapse was one of several symptoms and signs that led to a diagnosis of PE in 22 patients (9.8%) but was never the sole presenting feature. In descending order, these other clinical features were hypoxaemia (17 patients), dyspnoea (12), chest pain (9), tachycardia (7) and tachypnoea (7). ECG abnormalities reported to occur more commonly in PE were found in 13/17 patients for whom ECGs were available. Patients with PE presenting with syncope or collapse were judged to have a large clot load in 15/22 (68%) cases.Conclusion: Syncope was a frequent presenting symptom in our study of 224 consecutive patients with PE but was never the sole clinical feature. It would be difficult to justify routine testing for PE in patients presenting only with syncope or collapse. [ABSTRACT FROM AUTHOR]

Objectives: To estimate all-cause mortality in ventilator-associated pneumonia (VAP) and determine whether antibiotic duration beyond 8 days is associated with reduction in all-cause mortality in patients admitted with VAP in the intensive care unit., Design: A prospective cohort study of patients diagnosed with VAP based on the National Healthcare Safety Network definition and clinical criteria., Setting: Single tertiary care hospital in Southern India., Participants: 100 consecutive adult patients diagnosed with VAP were followed up for 28 days postdiagnosis or until discharge., Outcome Measures: The incidence of mortality at 28 days postdiagnosis was measured. Tests for association and predictors of mortality were determined using χ 2 test and multivariate Cox regression analysis. Secondary outcomes included baseline clinical parameters such as age, underlying comorbidities as well as measuring total length of stay, number of ventilator-free days and antibiotic-free days., Results: The overall case fatality rate due to VAP was 46%. There was no statistically significant difference in mortality rates between those receiving shorter antibiotic duration (5-8 days) and those on longer therapy. Among those who survived until day 9, the observed risk difference was 15.1% between both groups, with an HR of 1.057 (95% CI 0.26 to 4.28). In 70.4% of isolates, non-fermenting Gram-negative bacilli were identified, of which the most common pathogen isolated was Acinetobacter baumannii (62%)., Conclusion: In this hospital-based cohort study, there is insufficient evidence to suggest that prolonging antibiotic duration beyond 8 days in patients with VAP improves survival., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Uncomplicated urinary tract infections (uUTIs) in women are common infections encountered in primary care. Evidence suggests that rapid point-of-care tests (POCTs) to detect bacteria and erythrocytes in urine at presentation may help primary care clinicians to identify women with uUTIs in whom antibiotics can be withheld without influencing clinical outcomes. This pilot study aims to provide preliminary evidence on whether a POCT informed management of uUTI in women can safely reduce antibiotic use., Methods and Analysis: This is an open-label two-arm parallel cluster-randomised controlled pilot trial. 20 general practices affiliated with the Bavarian Practice-Based Research Network (BayFoNet) in Germany were randomly assigned to deliver patient management based on POCTs or to provide usual care. POCTs consist of phase-contrast microscopy to detect bacteria and urinary dipsticks to detect erythrocytes in urine samples. In both arms, urine samples will be obtained at presentation for POCTs (intervention arm only) and microbiological analysis. Women will be followed-up for 28 days from enrolment using self-reported symptom diaries, telephone follow-up and a review of the electronic medical record. Primary outcomes are feasibility of patient enrolment and retention rates per site, which will be summarised by means and SDs, with corresponding confidence and prediction intervals. Secondary outcomes include antibiotic use for UTI at day 28, time to symptom resolution, symptom burden, number of recurrent and upper UTIs and re-consultations and diagnostic accuracy of POCTs versus urine culture as the reference standard. These outcomes will be explored at cluster-levels and individual-levels using descriptive statistics, two-sample hypothesis tests and mixed effects models or generalised estimation equations., Ethics and Dissemination: The University of Würzburg institutional review board approved MicUTI on 16 December 2022 (protocol n. 109/22-sc). Study findings will be disseminated through peer-reviewed publications, conferences, reports addressed to clinicians and the local citizen's forums., Trial Registration Number: ClinicalTrials.gov NCT05667207., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To determine the prevalence and incidence of polypharmacy/hyperpolypharmacy and which medications are most prescribed to patients with varying burden of polypharmacy., Design: Retrospective, population-based cohort study., Setting: Iceland., Participants: Including patients (≥18 years) admitted to internal medicine services at Landspitali - The National University Hospital of Iceland, between 1 January 2010 with a follow-up of clinical outcomes through 17 March 2022., Main Outcomes Measures: Participants were categorised into medication use categories of non-polypharmacy (<5), polypharmacy (5-10) and hyperpolypharmacy (>10) based on the number of medications filled in the year predischarge and postdischarge. The primary outcome was prevalence and incidence of new polypharmacy. Secondary outcomes were mortality, length of hospital stay and re-admission., Results: Among 85 942 admissions (51% male), the median (IQR) age was 73 (60-83) years. The prevalence of preadmission non-polypharmacy was 15.1% (95% CI 14.9 to 15.3), polypharmacy was 22.9% (95% CI 22.6 to 23.2) and hyperpolypharmacy was 62.5% (95% CI 62.2 to 62.9). The incidence of new postdischarge polypharmacy was 33.4% (95% CI 32.9 to 33.9), and for hyperpolypharmacy was 28.9% (95% CI 28.3 to 29.5) for patients with preadmission polypharmacy. Patients with a higher level of medication use were more likely to use multidose drug dispensing and have a diagnosis of adverse drug reaction. Other comorbidities, including responsible subspeciality and estimates of comorbidity and frailty burden, were identical between groups of varying polypharmacy. There was no difference in length of stay, re-admission rate and mortality., Conclusions: Preadmission polypharmacy/hyperpolypharmacy and postdischarge new polypharmacy/hyperpolypharmacy is common amongst patients admitted to internal medicine. A higher level of medication use category was not found to be associated with demographic, comorbidity and clinical outcomes. Medications that are frequently inappropriately prescribed were among the most prescribed medications in the group. An increased focus on optimising medication usage is needed after hospital admission., Trial Registration Number: NCT05756400., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Task-shifting from primary care physicians (PCPs) to nurses is one option to better and more efficiently meet the needs of the population in primary care and to overcome PCP shortages. This protocol outlines an overview of systematic reviews to assess the effects of delegation or substitution by nurses of PCPs' activities regarding clinical, patient-relevant, professional and health services-related outcomes., Methods and Analysis: We will conduct a systematic literature search for secondary literature in PubMed/MEDLINE, EMBASE, CINAHL and Cochrane databases. Systematic reviews, meta-analyses and Health Technology Assessments in German and English comprising randomised controlled trials and prospective controlled trials will be considered for inclusion. Search terms will include Medical Subject Headings combined with free text words. At least one-third of abstracts and full-text articles are reviewed by two independent reviewers. Methodological quality will be assessed using the Overview Quality Assessment Questionnaire. We will only consider reviews if they include controlled trials, if the profession that substituted or delegated tasks was a nurse, if the profession of the control was a PCP, if the assessed intervention was the same in the intervention and control group and if the Overview Quality Assessment Questionnaire score is ≥5. The corrected covered area will be calculated to describe the degree of overlap of studies in the reviews included in the study. We will report the overview according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses., Ethics and Dissemination: The overview of secondary literature does not require the approval of an Ethics Committee and will be published in a peer-reviewed journal., Prospero Registration Number: CRD42020183327., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The widespread use of electronic health records (EHRs) has led to a growing number of large routine primary care data collection projects globally, making these records a valuable resource for health services and epidemiological and clinical research. This scoping review aims to comprehensively assess and compare strengths and limitations of all German primary care data collection projects and relevant research publications that extract data directly from practice management systems (PMS)., Methods: A literature search was conducted in the electronic databases in May 2021 and in June 2022. The search string included terms related to general practice, routine data, and Germany. The retrieved studies were classified as applied studies and methodological studies, and categorised by type of research, subject area, sample of publications, disease category, or main medication analysed., Results: A total of 962 references were identified, with 241 studies included from six German projects in which databases are populated by EHRs from PMS. The projects exhibited significant heterogeneity in terms of size, data collection methods, and variables collected. The majority of the applied studies (n = 205, 85%) originated from one database with a primary focus on pharmacoepidemiological topics (n = 127, 52%) including prescription patterns (n = 68, 28%) and studies about treatment outcomes, compliance, and treatment effectiveness (n = 34, 14%). Epidemiological studies (n = 77, 32%) mainly focused on incidence and prevalence studies (n = 41, 17%) and risk and comorbidity analysis studies (n = 31, 12%). Only 10% (n = 23) of studies were in the field of health services research, such as hospitalisation., Conclusion: The development and durability of primary care data collection projects in Germany is hindered by insufficient public funding, technical issues of data extraction, and strict data protection regulations. There is a need for further research and collaboration to improve the usability of EHRs for health services and research., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)