Assessing the performance of health systems is essential to initiate policy processes that further strengthen health systems to improve population health. Starting with WHO's World Health Report of 2000, Health System Performance Assessments (HSPA) gained increasing attention in research and policy. By now, several comparative HSPA initiatives of international organisations  and country specific HSPA  were implemented in Europe. Further countries are currently in the process of developing or piloting an HSPA . The objective of the workshop is to foster and strengthen the interchange of different HSPA initiatives in Europe and beyond. While each health system has its specifics, initiatives likely face similar challenges in the implementation and ongoing development, which holds a lot of potential for learning from each other. The workshop is supposed to be a platform for the exchange of and about HSPA initiatives and related topics by bringing together stakeholders of different countries and professions. Participants are supposed to gain new insights into recent activities in Europe and will be able to discuss challenges and lessons learned. The presentations give insights into recent activities of selected HSPA initiatives in Europe. One presentation originates from the Belgian HSPA which is well established. This presentation will focus on the transversal dimension of equity, on which a separate report was recently published. The second presentation is about the German HSPA which is still in development and currently tested in a pilot study. Both presentations represent HSPA initiatives at different stages, which provides a good basis for the following panel and discussion with all workshop participants. The two presentations of about 20 minutes each will be combined with a panel discussion. Afterwards, there will be room for exchange and discussions between all participants and presenters.• Recent developments of HSPA initiatives in Europe will be presented along two examples from Belgium and Germany and lessons learned and challenges will be discussed.• The workshop provides a platform for the exchange of and about HSPA initiatives and related topics by bringing together stakeholders of different countries and professions.


Over time the prevalence of methamphetamine associated psychosis (MAP) has increased globally including Asia and Europe. Shoptaw et al looked at an RCT and concluded that olanzapine is superior to haloperidol in terms of tolerability and the side effect profile as it causes fewer extrapyramidal symptoms. Another study by Xue et al compared the efficacy of olanzapine and haloperidol and found that they had comparable effects but the onset time in the olanzapine group was significantly earlier than the haloperidol group. Srisurapanont et al analyzed 6 RCTs and concluded that quetiapine and olanzapine are probably superior than aripiprazole and risperidone.The purpose of this review is to find out if olanzapine is better than other antipsychotics in treating methamphetamine-induced psychosis.PubMed, SCOPUS, and Web of Science literature databases were screened and filtered by using specific search terms, inclusion/exclusion criteria. Texts of the selected articles and trials were reviewed and the search terms generated a total of 248 results from the databases. After applying the criteria 200 citations were left and 15 papers were reviewed.The literature review concluded that olanzapine can be used as an effective treatment for methamphetamine-induced psychosis. Olanzapine can help to reduce the psychotic symptoms in MAP with a quicker onset and lesser side effects.Olanzapine can help in the treatment of methamphetamine-associated psychosis and can be considered as the first-line therapy. Research is further needed with a higher pool of candidates in the future to compare the efficacy and tolerability of different typical and atypical antipsychotics.No significant relationships.


Dementia is a progressive, irreversible neurological disorder that causes changes in cognitive function and behaviour. While at least 5% of people who develop dementia every year are under the age of 65, dementia in the workplace is currently not well recognised or supported. The changes associated with dementia present multiple challenges for individuals who wish to continue with their employment. Many lose their positions before receiving a diagnosis, whilst others take sick or disability leave or early retirement. The process of understanding what is happening and coping with this new situation is highly individualistic and involves several transitions. The MCI@work project is an international initiative taking place in Canada, Finland, and Sweden where we examine these transitions through the personal narratives of individuals who have either currently or recently gone through the experience of developing dementia whilst in the workforce. From these data, we have developed a framework for understanding the transitions experienced by people who develop dementia whilst in the workforce. The aim is to assist individuals and their employers to better understand the needs of people living and working dementia as well as engage in appropriate actions that support choices and dignified transitions either within the context of employment or out of the workforce.


This document is written on behalf of the two professional bodies in the United Kingdom that represent genetic counsellors (the Association of Genetic Nurses and Counsellors) and clinical geneticists  and aims to support multidisciplinary working of these professional groups highlighting within a quick-reference format, areas of shared practice and the distinctions between role profiles for a Consultant Clinical Geneticist, Principal/Consultant Genetic Counsellor and the new support role that we have termed ‘Genomic Associate’, see AGNC career structure . This bu In the United Kingdom clinical geneticists are medically qualified Members/Fellows of the Royal College Physicians or equivalent, where Clinical Genetics is an affiliated medical specialty. Genomic or genetic counsellors are allied health professionals with Masters level accreditation from the Genetic Counsellor Registration Board included in the Academy for Healthcare Science register and clinical scientists  accredited by the Health and Care Professions Council.We acknowledge there is currently variability in these roles between NHS trusts and exceptions where the scope of practice for one professional group exceeds what is provided below in Fig. In Fig.


The Sage Resource Project’s goal was to prepare researchers to use the Sage Resources to create Sage Model boards in order to continue to expand and amplify the voice of older adults in aging PCOR/CER research. Training researchers is essential to amplify the voice of older adults in research. This project culminated in the creation of a training manual as well as critical lessons learned for the advancement of engaged research with older adults receiving Long Term Services and Supports (LTSS). After developing a series of webinars for national dissemination, 5 research centers were identified as potential sites for intensive and tailored training on The Sage Model and, ultimately, two research centers completed the training with quite different approaches and results. This session will review the training that was developed as well as the lessons learned from training researchers on creating research advisory boards with older adults.


The COVID-19 pandemic has exposed Public Health system weaknesses due to chronic underinvestment in Public Health. In this context, Essential Public Health Functions (EPHFs) have been revitalized as an integrated, cost effective and sustainable approach to operationalising Public Health. The World Health Organization's recent position paper on building health systems resilience towards universal health coverage and health security recommended investing in EPHFs as a key mean for countries’ health systems recovery and transformation during COVID-19 and beyond. There is a need for conceptual and operational clarity of EPHFs to support countries to build back better, fairer and more resilient health systems.A rapid review of peer-reviewed and grey literature regarding the EPHFs was conducted to identify different actors’ understandings of EPHFs and key lessons of applying the EPHFs at the global, regional and national levels, in order to identify the added value and key enablers to operationalising EPHFs. A crosswalk analysis of different authoritative lists of EPHFs was conducted to develop a common list of EPHFs as a reference for countries in response to Public Health challenges.A consolidated list of 12 EPHFs derived from the crosswalk analysis of different authoritative lists is presented, underpinning the consideration of health systems components and pressing health challenges. Six key enablers are identified from evidence and experience. These enablers are fundamental for countries to build holistic and strong Public Health capacities.The EPHFs provide a clear and integrated framing to operationalise Public Health in countries that can be adapted to country contexts to build resilience. Health authorities and other Public Health stakeholders must seize the opportunity brought by COVID-19 recovery to continue advocating for and strengthening Public Health as a priority in health systems’ reconstruction and reform.


It is now widely accepted that most microorganisms live within communities and not as single cells. The interaction between species within the community drives the behaviour of the population and its adaptation to various ecosystems and hosts. This relatively recent concept has triggered the emergence of a whole research field in Microbiology aiming at understanding the structure and organisation of bacterial biofilms combined with the detail of microbiome composition and evolution. Researchers also joined forces in what is a multidisciplinary field of investigation calling for knowledge from basic microbiology to surface chemistry and all the way to advanced omics and microscopy methodologies. The National Biofilms Innovation Centre was launched in 2017 to address the impact of biofilms on global challenges from antimicrobial resistance and food safety to water security by bringing together UK research and businesses to drive the translation of biofilm research into innovative solutions. Since its creation, NBIC has built a national partnership with 63 UK research institutions and more than 250 companies and an international partnership with biofilms centres across the world including the Centre for Biofilm Engineering (CBE) in the United States (Montana) and the Singapore Centre for Environmental Life Sciences Engineering (SCELSE).npj Biofilms and Microbiomes has been created to review the impact of biofilm across sectors, illustrate some translational research on biofilm carried out by NBIC partners and highlight key issues on the successful translation of biofilm research. The collection addresses the four interventional pillars of NBIC: prevent, detect, manage and engineer.This special collection in 1, with biofilms being central to some of the most important global challenges. Addressing these challenges through the above interventional pillars opens endless opportunities for growth by harnessing and controlling the biological activities of complex biofilms.Biofilms have an economic impact of 5Tn USD ($) per year across multiple sectors, as detailed in perspective by Camara et al.Prevent theme focuses on the prevention of early stage microbial adhesion and colonisation events at surfaces and interfaces and curtailing the development and maturation of early stage biofilms. The two main approaches used to prevent biofilm formation are through early microbial killing or preventing the establishment of the biofilm in the first place. This collection shows two examples of these approaches. The work from Barbieri et al.2 uses a simple way to functionalise a common silicon-based polymer utilised in biomedical and industrial applications for the slow release of antimicrobials already approved for human use. This modified polymer can drastically reduce the ability of bacteria to colonise these surfaces providing a scalable new alternative for the functionalisation of catheters, dressings and in-dwelling medical devices to existing strategies, such as the in situ generation of silver nanoparticles3. In another study, Pentland et al.4 show that C. albicans uses CO2 found in the host environment to promote its ability to colonise and compete for nutrients. These findings reveal that the design of therapeutic interventions targeting CO2 utilisation could be used as a new approach to prevent C. albicans biofilm formation in high CO2 environments paving the way for new therapeutic approaches against infections caused by this organism.The Detect theme focuses on the requirement for accurate, quantitative biofilm detection and also measurements across multiple scales through innovative sensing, tracking and diagnostic technologies. The detection and quantification of morphological changes in a biofilm is frequently done using confocal microscopy. However, there have been issues with regards to the reproducibility of image analysis across laboratories due to some of them not reporting the full exact imaging methods and parameters used. This is essential when biofilm interventions are compared across laboratories using techniques such as LIVE/DEAD® staining. Mountcastle et al.5 have developed an automated image analysis approach which has shown reproducible and robust results in a range of bacterial species biomass and cell viability measurements. This method is highly accessible to researchers from different disciplines supporting their biofilm translational studies. There is also a need not only to visualise and quantify biofilms but also to develop novel technologies which enable scientists to visualise changes in a biofilm in real time such as viability and metabolic changes. A study by Wang et al.6 shows the use of resonant hyperspectral imaging to monitor in real-time bacterial cell attachment and micro-colony formation. With this technique the authors were able to focus on the underside of the biofilm providing a very clear picture of the early stages of biofilm formation and the fate of biofilms in response to antibiotics treatment. Another study by Hollmann et al.7 show the development of ratiometric fluorescent pH-sensitive nanosensors which enable the visualisation of pH changes in biofilms. Here the authors demonstrated that these nanosensors could be used to detect sugar metabolism in real time. The use of alternative dyes in these nanosensors will generate powerful tools to monitor wider microniche changes within biofilms at high resolution.The Manage theme is to kill, remove or control established biofilms by exploiting the knowledge gained from understanding the mechanisms governing biofilm life cycle dynamics and development, their physicochemical properties, and levels of complexity across a range of environments. Biofilms can adapt quickly to changing environmental conditions and rapidly select for mutants that increase their fitness. This poses a serious issue in the clinic with the adaptation of biofilms to antibiotic use. Some of these biofilms, and the cells sitting within different regions of such an environmentally heterogenous structure, are frequently exposed to sub-inhibitory concentrations of antibiotics yet, there is limited understanding of how they adapt to these levels of antibiotics. Trampari et al.8 show that biofilms from Salmonella Typhimurium exposed to sub-inhibitory concentrations of three antibiotics rapidly evolve resistance to them. This adaptation resulted in a deficit in biofilm formation but strains forming the least biofilms were more virulent in a Galleria mellonella infection model resulting in the lowest survival rates. This is supporting both the concept of lifestyle switch and trade-off when gaining novel function/feature. The resilience of biofilms to the action of antibiotics has also led to a search for novel approaches to eradicate them. One of these approaches is based on the use of phage components such as endolysins. In a study by Arroyo-Moreno et al.9 the authors show that endolysins can disrupt Gardnerella vaginalis both in single species and polymicrobial biofilms with no effect on microorganisms from the commensal vaginal flora nor the emergence of resistance, offering a promising strategy to combat bacterial vaginosis. An alternative approach to identify novel antimicrobials is to search from them in microbiomes as they are a great resource for bioactive molecules which has been very much unexploited. In the study by Mulkern et al.10 the authors used antimicrobial peptides form rumen microbiome that show high effectiveness against Pseudomonas aeruginosa biofilms with low cytotoxicity and hence therapeutic potential. Finally, when designing new antimicrobials, it is important to understand their impact on different components of the biofilm such as the extracellular matrix, especially if the drug interacts with it like polymyxin B. One of the most common ways to visualise changes in this matrix requires the use of dyes which can frequently alter its physicochemical properties preventing an accurate visualisation of the changes. To overcome this limitation, Powel et al.11 have used multiple particle tracking (MPT) to characterise the physical and mechanical properties of antimicrobial resistant (AMR) bacterial biofilms and quantify the effects of antibiotic treatment. Using nanoparticles (NPs) of varying charge and size they were able to quantify the diffusion and mechanical effects of antibiotic therapies within the AMR biofilm matrix as a result of changes in the viscoelasticity of the biofilm. The authors found that this approach offers a valuable tool for the pre-clinical screening of new antibiofilms.The mission of the Engineer theme is the control of biofilms in industrial environments and large-scale infrastructure, and the engineering of bespoke biofilms for targeted applications.The vision of the 12 reveals that microbes in lower abundance could have a key role in anaerobic digestion maintaining the stability and functionality of microbial communities. Therefore, the ecological role of low-abundance taxa should be further investigated in bioreactors with significant environmental impact. Biofilms can also be engineered to reduce the impact of global warming by contributing to the reduction of CO2 levels. A range of approaches, including electrochemical methods, have been developed to reduce CO2 to valuable chemicals. As such, microbial electrosynthesis (MES) offers an alternative for the sustainable conversion of CO2 into valuable organic chemicals at the cathode of bio-electrochemical systems where microorganisms are used as biocatalysts. A major bottleneck with MES lies with the development and scale up of the technology due to the slow development of CO2-reducing biofilms on the cathodes. Izadi et al.13 showed a strategy which can potentially bypass this issue by modifying the potential applied and the inorganic carbon source used as these can enhance the efficiency of the system by affecting the development of the biofilm during MES and its microbial composition. Keeping biofilms under control in drinking water systems is also paramount to maintain water quality standards. Phosphate dosing has been regularly used to prevent plumbosolvency in water supply networks; however, the impact this may have on polymicrobial communities in these networks had not been studied. Del Olmo et al.14 have studied the effect of phosphate on the growth of polymicrobial biofilms from drinking water grown on lead and PVC. They found that changes in phosphate levels can induce changes in the structure of biofilms and affect the level of chlorine in the water. Their studies will help improve the management strategies to control microbial growth in drinking water pipelines helping to increase its quality.Engineering biofilm communities for more effective anaerobic digestion has great potential in organic/wastewater treatment as it offers the opportunity to recover biogas as energy whilst reducing risks to human health and the environment. For the engineering of these systems the core microorganisms have traditionally been considered. However, the study by Guo et al.15 who have created a two-dimensional framework they have termed the Biofilm Research-Industrial Engagement Framework (BRIEF). This framework enables the organisation of current biofilm technologies relevant to biofilms across sectors, based on their accuracy to current science knowledge and industrial application, enabling to predict the chances of evolving through Technology Readiness Levels (TRLs). They also introduce some advisory guidelines to enhance the translational impact of future biofilm research.For all the above findings to be successfully translated from the academic research lab into the industrial environment it is paramount to have a cross-sectorial engagement at the conception of the technology to facilitate its evolution along a Translationally Optimal Path (TOP). This is highlighted by Highmore et al.


Reviews suggest that family interventions including family therapy are effective for a range of disorders in youth. Family sculpting is used in different clinical settings to help young patients, their parents and siblings when words are not enough.Participants will be able to understand the clinical relevance of family sculpting: shifting from discussions about family problems to physical representations of family dynamics and how to apply in their practice.There will be a brief overview of the general principle of family sculpting followed by clinical vignettes of patients combined with videos of the intervention. These examples will guide the discussion on how relevant in our clinical work this therapeutic practice may be. This variation on sculpting incorporates theater warmup exercises and therapists joining the family experience.Family sculpting captures an immediate picture of the family dynamics that is a therapeutic turning point for families and gives voice to the children. The clinical cases and videos will guide clinicians on how to integrate into their own practice.This presentation will make possible integrating family sculpting into your own practice, providing an engaging alternative modality for complex cases.No significant relationships.


The corrected graphical abstract now appears with the article online, and the original and corrected graphical abstract appear here.Cell Press and the authors regret this error.


Informal caregiver support has been defined as different types of interventions. However, it has not been well explained in the social context and not well discussed as an integrative concept for dementia caregivers who are Asian Americans. Therefore, the aim of this study was to conduct a dimensional analysis--a type of evidence synthesis--to explore caregiver support in the context of Asian American dementia caregivers. A synthesis of 40 articles produced four interrelated dimensions of caregiver support: Individual ; Family ; Community ; and Professional healthcare system . The findings provide guidance for future studies on this population in promoting caregiver’s health and developing caregiver interventions.


Nervecentre is an application that can be used on mobile devices and desktop computers to record and view physical observations amongst other tools. An audit had been done previously assessing the practice of recording observations using paper documentation. That audit had recommended the use of Nervecentre to improve the recording of observations. This audit was undertaken following the introduction of Nervecentre for documentation of physical observations. The aims were to evaluate if the transition to electronic documentation of NEWS  observations on Nervecentre has improved practice in comparison to paper documentation and to evaluate if our practice could be improved by implementing electronic observations for psychiatric observations in addition.Data were collected over a 10-day period looking at all the documented observations from all inpatients on the MHSOP wards that met the inclusion criteria. Data were collected on the recording of psychiatric observations (recorded on paper charts) and physical observations (recorded on Nervecentre). The data were collated and analysed. The new data were compared to the original data from prior to the introduction of NerveCentre and the findings were presented at a local meeting.This audit has highlighted that the documentation of physical observations on MHSOP wards has greatly improved since Nervecentre was introduced. There was an improvement in recording of physical observations in almost all domains measured. NEWS scores were correctly documented 100% of the time compared to 87% previously. Raised NEWS scores were correctly escalated to a senior and reviewed 80% of the time compared to 0% previously. It has also highlighted that the quality of documentation regarding psychiatric observations could be improved as we are not currently meeting local or national guidance.The most likely cause for the improvement in the recording of the physical observations is the implementation of Nervecentre. Nervecentre prompts users when observations are due, removes the risk of calculation errors and allows for observations to be directly escalated. Implementing Nervecentre for psychiatric observations may similarly improve the quality of these observations therefore improving patient safety.


Older, rural adults have limited access to quality geriatric specialty care for several reasons including relatively few geriatric specialists in rural areas and lack of transportation options or patient ability to travel to more urban centers. GRECC Connect is a promising telehealth-hub and spoke model that provides rural patients access to teams of multidisciplinary geriatric specialists in more urban medical centers primarily by video connection with affiliated community-based outpatient clinics (CBOCs). This model provides a viable option for increasing access to geriatric specialty care for rural patients but is not used to the extent it could be. To date, much of our understanding of this model has come from the experts at the hub medical centers. To learn more about the experience of this model from the field we interviewed CBOC staff and providers as well as Veterans and their caregivers about geriatric specialty telehealth services. In this symposium we will discuss facilitators and barriers to implementing this model from the perspective of the field and then explore more deeply both the context of the CBOC environment and the older patient population served by rural CBOCs to further understand the challenges that are faced in attempting to connect older patients with telehealth services. Finally, we will share the perceived value of the service and alignment with local needs. This deeper understanding of the experience of the ‘spoke’ may help enhance access to much needed geriatric specialty care for rural veterans.


A case report of two patients who underwent auxiliary liver transplantation and two staged hepatectomy was recently published in BMC Surgery. The surgical technique utilised is described as novel but has been published previously also in the setting of chronic liver disease. A new name for this surgical approach therefore seems redundant. The importance of careful hemodynamic monitoring of pressure and flow in the portal vein and artery of the auxiliary graft as well as optimizing venous outflow is paramount to ensure graft regeneration and avoid small for size syndrome. The relevant surgical considerations to ensure optimal safety has also been reported in previous literature. This brief letter to the editor of BMC Surgery gives an overview that put the article content in context with published literature on this transplant surgical technique. We have read the case report from S. Brunner et al. in the recent issue of BMC Surgery  and beliProgress and improvement in clinical medicine is reliant on original and novel scientific contributions as well as stepwise improvements of existing published treatments and concepts. Brunner and co-workers choose to term the described surgical technique as “a new treatment concept for patients with end-stage liver disease» and propose a dedicated acronym for it. We believe this to be incorrect and contributing to confusion in the terminology of the HPB surgical literature .The technique of combining liver resection with auxiliary liver transplantation has been known since 2015 as the RAPID technique  in deceased and living donation respectively , 3. UtilThe original RAPID protocol includes the relevant portal modulation procedures, and successful performance of the RAPID technique in patients with cirrhosis through careful modulation of portal vein perfusion has been published previously . In the Selective attention to the published literature and introduction of established surgical techniques as novel concepts may limit the collective stepwise improvement of surgical techniques. The authors experienced a range of serious complications that certainly are of great concern, and suggest some modifications based on an “optimized technical approach”. The main learning experiences stated in the current paper are already described in other publications such as end to side anastomosis of the graft portal vein to the main portal trunk, the need to resect segments 1–3 as opposed to 2–3, risk of venous outflow obstruction with increasing graft regeneration necessitating endovascular stenting . ModulatNo other report on this technique have found it necessary to delay the biliary reconstruction to a separate day, pack the liver graft, or mandate a second-look procedure, thus making the patients undergo three laparotomies in the course of three weeks. In our experience, this is not justified and increases both the risk and the complexity of the procedure.On this background, we believe that the paper in its current form provides a somewhat skewed presentation of the RAPID technique and therefore think the readers of BMC Surgery should be made aware of this. We cannot see any justification or added value for the proposed acronym “ASPIRE” apart as a designated naming of a prospective trial. There is however no citing of ethical approval or study registration in this paper to suggest that this is the case.


The concern relates to the provenance of this article as brought to our attention by Faisal Alhawaj, who denies authorship of this article and others published in Cureus. These articles were submitted and subsequently published purportedly as an effort coordinated by Imam Abdulrahman Bin Faisal University to ensure all medical interns publish at least one peer-reviewed article in order to qualify for enrollment in a postgraduate residency program as stipulated by The Saudi Commission for Health Specialties (SCFHS).The journal has not been presented with enough evidence to warrant the formal retraction of these articles as both Imam Abdulrahman Bin Faisal University and The Saudi Commission for Health Specialties have failed to respond to numerous communications requesting additional information regarding these allegations. While we acknowledge that the provenance of these articles is very much in question, we cannot act until these claims have been investigated by the appropriate institutions with the results of said investigation communicated to Cureus.The concern and this note will remain appended to the above-mentioned article until Cureus is provided with official confirmation from Imam Abdulrahman Bin Faisal University or The Saudi Commission for Health Specialties.


The approach to providing long-term services and supports (LTSS) has changed dramatically over the last three decades in both the financing and delivery arenas. In the U.S., long-term strategies have varied by state in organizational structure, scope of delivery and administrative practices. In the past two decades an additional change has emerged with over half the states adopting some form of managed LTSS. This shift has deepened the divide in state approaches to LTSS system design and delivery. The shift to managed LTSS has been largely fueled by ideological expectations and concerns about growing Medicaid costs: Empirical research findings have played a minimal role. For example, the large CMS evaluation conducted in this area did not include Medicaid data or encounter data from the managed care plans as part of the study efforts. However, the managed LTSS experiment does create an opportunity to compare costs and outcomes of these different models of financing and delivery. This symposium will present preliminary evaluation findings from two states, Ohio and Pennsylvania, which are generating data to assess both the implementation and outcomes of these alternative LTSS models. To set the context an initial paper will discuss the expansion of managed LTSS programs across the nation and examine how these efforts compare to the development occurring in the European LTSS systems. The third presentation will discuss the results of the Community Catalyst dual eligibles’ managed care demonstration program monitoring project.


The National Institute for Health and Clinical Excellence (NICE) recommend that renal and thyroid function must be checked before lithium is prescribed and for all patients who are prescribed lithium should have their renal and thyroid function checked every six months, and their serum lithium checked every three months. The aim of this audit is to ascertain whether or not routine blood monitoring for bipolar disorder patients, taking lithium is in keeping with the guidelines.Lithium has been a mainstay in the management of bipolar disorder since the 1970's; indeed, lithium carbonate was first used in the early 1880's for the treatment of mania. Despite its usefulness however, the drawback of lithium treatment remains its very narrow therapeutic index, toxic side effects and as such its need for close therapeutic monitoring.A list of patients with a diagnosis of bipolar disorder being treated with lithium was collated from an electronic database of psychiatry patients in Cumbernauld Community and inpatients at Glencairn unit Coathill Hospital and Cleland Hospital. A retrospective analysis using Clinical Portal was conducted looking at blood results; Lithium levels checked 3 times a year and Kidney functions and Thyroid function checked twice a year, over the previous year. Our results were then compared to the NICE Guidelines for lithium monitoring to see if they complied with the expected routine monitoring schedule. We may have missed patients open to Community Psychiatric Nurses (CPN) but not open to Consultant psychiatrists. Other group that might have been missed could be open to General Practitioners but not to secondary care. We attempted to contact them but this was unsuccessful.Total of 690 patients were studied. Of 690 patients 51 patients had the diagnosis of Bipolar Affective Disorder. 49 percent of them were prescribed Lithium. 48percent had their Lithium bloods checked and 60 percent had their Kidney function and thyroid functions checked according to the guidelines. There were no data available for around 7 percent of patients but their Lithium levels were indicated only in Clinical notes.This audit has demonstrated that Lithium monitoring falls short of conforming to accepted standards. Data obtained by this audit have prompted an electronic alert system for patients on Lithium endorsing primary care, mental health and laboratory staff to work together to ensure supporting recommended Lithium monitoring.


In South Australia (SA), there were 27 deaths of Aboriginal infants between 2005 and 2014 attributed to SUDI, which often occurs after an infant is placed to sleep (Child Death and Serious Injury Review Committee 2014).The first sentence of the second paragraph is incorrect. It should instead read as follows:The Authors would like to apologise for this mistake.


As much as 40% of dementia cases can be attributed to modifiable risk factors . Much of that risk-reduction can be accomplished by changing behavior in midlife. In light of the emerging evidence that dementia may be preventable, UsAgainstAlzheimer’s convened a workgroup of national experts to develop new recommendations that primary care clinicians and general neurologists can use to initiate primary prevention conversations with their patients about cognitive decline. Few resources address steps that clinicians can take in their routine care to help patients reduce risk. Some relevant resources provide excellent guidance but tend to be more focused on early detection or slowing disease progression rather than primary prevention. The Risk Reduction Workgroup (RRWG) was convened to help address the need for clinicians to know how to discuss cognitive decline with their patients. The workgroup aligned on 11 recommendations for primary care clinicians and general neurologists. In addition the RRWG provide considerations for implementing the recommendations in clinical practice. The recommendations are mindful of social determinants of health, account for cultural differences, and are designed for general accessibility. This effort is part of a broader initiative by UsAgainstAlzheimer’s to address risk-reduction for cognitive decline and early interventions. Under the guidance of a multidisciplinary Provider Leadership Group consisting of representatives from some of the nation's largest health provider serving organizations, three independent workgroups are developing guidance and tools to assist providers in their clinical practice and improve health outcomes for patients at-risk for Alzheimer's and related dementias.


This project was designed to evaluate the use of PRN medication and PRN monitoring charts on an adult learning disability ward. These charts had been designed by the trust to provide us with a way of monitoring the use of psychotropic PRN medication to ensure monitoring of treatment response, physical health and side effects.The data were collected from PRN monitoring charts, electronic case notes and electronic prescribing chart records for all patients on an adult learning disability inpatient unit. The sample consisted of 7 patients who had been prescribed and/or received PRN psychotropic medication over a five week period. Quantitative data were derived by simple calculation for the total amount of PRN medication used and number of PRN monitoring charts completed. Qualitative data were collected of prescription charts and PRN protocols which is supposed to guide treatment.Out of all the incidences where PRN medication was administered, only 64% of monitoring charts were completed. Out of the 7 patients on the ward, 6 had PRN protocol charts and for only 5 patients these were followed.Clinical practice must be improved. The results were presented to ward staff and doctors to discuss the implications for patient care and ways to improve clinical practice by ensuring full monitoring of the use of PRN medication to help reduce the overmedication of people with learning disability by improving the use of the PRN charts. NICE guidelines and The Royal College of Psychiatrists have published guidelines on the prescription of psychotropic drugs for people with learning disabilities. NHS England have also published an article to discourage over-medication of people with learning disabilities. There is a risk that doctors are prescribing medication to treat behaviour that is an expression of distress or a mode of communication rather than a mental disorder. Doctors have a responsibility to ensure they have fully assessed the person's potential to benefit from medication before they prescribe. The audit would serve to provide a baseline for this team prior to any audits in the future.


There is a long-standing literature that has documented the importance of both the immediate and distal context in impacting mental and physical health across the adult lifespan. The goal of this symposium is to bring together a collection of papers that target the extent to which the immediate and distal context as measured through objective and subjective indicators relate to pertinent outcomes of mental and physical health. Staben and colleagues use an intensive longitudinal design in middle-aged adults to show that objective and subjective indicators of the neighborhood are associated with higher levels of and are protective against the impact of monthly adversity on mental health and well-being. Munoz and colleagues evaluate associations between objective and subjective early-life neighborhood contexts and whether they play a role in cognitive function at midlife. They find that poorer age-five self-report conditions were associated with lower working memory. Osuna and colleagues examine how both neighborhood and housing conditions play a role on psychological well-being. They find that housing and neighborhood safety conditions are associated with depressive symptoms over time. Piazza and colleagues examine associations between daily financial thoughts, SES, and indices of emotional and physical health. They find that individuals who reported more daily financial thoughts also reported more negative affect and physical symptoms. The discussion by Crimmins will integrate the four papers by highlighting the importance of how different forms of context can impact development in adulthood and old age, particularly in relation to health and well-being and consider future routes of inquiry.


To improve postgraduate psychiatry education and training in Northern Ireland.Historically within Northern Ireland there has been a postgraduate Member of the Royal College of Psychiatrists (MRCPsych) teaching programme delivered to core trainees in preparation for MRCPsych examinations. There has been no official teaching programme for higher trainees. Northern Ireland Medical and Dental Training Agency (NIMDTA), in collaboration with the Royal College of Psychiatrists in Northern Ireland and all five Trusts developed the novel idea of introducing Postgraduate Education Fellows, to oversee and improve core training, and to develop a bespoke higher training programme.The Postgraduate Education Fellows met to collate information from various sources in relation to issues within the current teaching programme and address these along with the development of new initiatives. The fellows further act as a point of contact for all trainees within their Trust to provide advice and support with education if needed.One higher trainee was appointed to the role of Postgraduate Education Fellow in each Trust within the NIMDTA deanery for a term of 1 year.The starting point was delivering the pre-established teaching timetable and gaining feedback from core trainees to identify areas for improvement. The next phase involved piloting traditional and contemporary methods of feedback. A further development was designing a mock paper A delivered under exam conditions. Two mock Clinical Assessment of Skills and Competencies (CASC) exams were organised under exam conditions, offering other trainees the opportunity to act as simulated patients and examiners.The third aspect of this role involved creating a programme of higher trainee seminars. Baseline data were collated and identified key areas that higher trainees felt they needed further training and guidance in.Using baseline data on the current teaching programme and from higher trainees as well as incorporating quality improvement methodology, we have been making small changes to each aspect of the teaching programme and evaluating the changes made. The feedback from trainees has been positive as evidenced by quantitative and qualitative feedback. 8 candidates sat our first mock CASC with a 100% pass rate in their MRCPsych CASC examination. There has been a positive response to the higher trainee seminar programme.This programme has produced good outcomes to date and sets foundations for the future development of post graduate psychiatry education in Northern Ireland.


The Covid pandemic brought to the forefront the crucial role of social interactions for society at large and in gerontological practice. Social interactions play a paramount role in preserving cognitive reserve in older adults. They rely on neurobehavioral processes that are complex . Pitch mimicry is a well-known and spontaneously arising social phenomenon that requires the integrity of numerous processes of the brain, and we hypothesize that it constitutes a potentially sensitive behavioral marker of neurodegeneration in Alzheimer’s Disease and Related Dementias (ADRD). We developed and validated a series of algorithms to parse verbal exchanges between people and quantify the level of mimicry that each exhibit with their partners. Those algorithms are based on silence thresholding, carefully parametrized CEPSTRAL algorithms for automatic pitch estimation and Synchrosqueezing Transform for validation. We introduce a theoretical model to compare our estimates of pitch mimicry with model’s expectations based on the null hypothesis that its neurobehavioral pathways retain their integrity. Our method will allow researchers to study the evolution of pitch mimicry in aging individuals and its sensitivity to diverse social contexts, including those preserving lasting social engagement. Our method will also allow us to test the hypothesis that Pitch Mimicry is a sensitive behavioral marker of dementia, a condition characterized by a breakdown in social relatedness.


Undergraduate programs  and continuing education programs in gerontology prepare students for entry-level careers in aging and increase competitiveness for graduate work in a variety of fields. Job growth in the field of gerontology is high, especially for positions requiring a bachelor’s degree and less. Gerontology education at this level is essential for meeting the growing demand for workers in social services and health services who understand the opportunities and challenges that come with increased longevity and global aging. This presentation will highlight the new recommendations for competency-based gerontology education for undergraduate and continuing education credentials outlined in the latest edition of AGHE Standards and Guidelines. Whether you are developing a new curriculum or revising an old one, we will offer suggestions for using the AGHE competencies and guidelines to ensure that your program adequately prepares students and offers them a competitive edge in today’s job market.


Family members of persons diagnosed with dementia or a traumatic brain injury (TBI) are often relied upon to provide daily support to their care recipients. However, research on the differing experiences of caregivers based on care recipient diagnosis is limited. The aim of this study was to examine the impact of worry and feelings of vigilance among caregivers of people with cognitive impairment due to either TBI or dementia. This sample included 61 caregivers  of persons with either a TBI (n = 32) or dementia (n = 29). Worry was assessed with the Penn State Worry Questionnaire and Vigilance was assessed with the Caregiver Vigilance Scale. Linear regressions revealed that after controlling for age, care recipient diagnosis moderated the relationship between worry and caregiver vigilance. Specifically, worry was significantly associated with caregiver vigilance in those caring for someone with dementia; however, a similar relationship was not seen in those caring for someone with a TBI. This suggests caregivers of people with TBIs have a different experience of worry and vigilance than caregivers of people with dementia. These findings demonstrate the need for more research on the unique needs of caregivers of people with TBIs. Additionally, this research suggests interventions targeting worry may be particularly effective in supporting caregivers of people with TBIs.


Throughout our lifespan we experience the culture of our families and communities. Our cultural selves guide our understanding of health and illness. However the health care system often ignores our culture in the delivery of care. This can have devastating effects on individuals and particularly the elderly. This presentation reviews a case study of a tribally owned and operated nursing home. The emphasis on maintaining cultural activities, feasting on traditional foods, offering sacred practices led to high satisfaction of the health care experience by residents and staff. Creating this environment was difficult and barriers in culturally responsive care delivery will also be discussed.


The Year 2020 has proved to be a great success for Pakistan Journal of Medical Sciences as we achieved yet another landmark of crossing the Impact Factor of one as per the Journal Citation Report released by Clarivate Analytics for the Year 2020. Our current Impact Factor is 1.088.A critical analysis of the year under review shows that the number of new submissions from Pakistan as well as overseas has also significantly increased. The total submissions in 2020 was 1781. While the number of submission are increasing but our acceptance rate has remained almost static about 20%. The number of manuscripts received from Pakistan during 2020 were 854. Majority of them being from Karachi 261, Lahore 226, Islamabad 101, Peshawar 62 and Rawalpindi 43. The number of submissions and publications from Turkey was increasing during the Years 2013-2018 but decreased in 2019 but has again increased in 2020. However, the number of papers accepted for publication after peer review has not increased much due to strict peer review Researchers are under great pressure to publish their research work as soon as possible to meet deadlines for the completion of their research projects or to defend their PhD thesis but editors of biomedical journals in Pakistan are also faced with a dilemma due to human resource and financial constraints. Publications overseas in Impact Fact journals which the regulatory bodies in Pakistan as well as overseas demand is very expensive which many researchers cannot afford while the number of Impact Factor medical journals published from Pakistan so far remains just three. A few more journals have applied but it may still take some time and the authors who are always impatient will continue to suffer. The situation can be eased if the regulatory bodies in Pakistan like Higher Education Commission can accept Only Online Journals which will reduce the cost of production to a great extent and also enable the editors to accommodate more papers as there will be no page constraints. It will also reduce the publication charges for the authors which is expected to increase further in view of the devaluation of the Pakistani currency. 3However, going for only Online Journals does involve some challenges as well in view of the increasing number of predatory journals. Hence, to check this menace, the authorities can give this permission of Only Online Journals to those publications which have earned Impact Factor, or indexed in Medline, and are covered by important databases like PubMed Central and Scopus. The regulatory bodies should also facilitate the journals to get IF and indexation in international databases. (PAME) on its behalf has taken an initiative in collaboration with University of Health Sciences (UHS) Lahore to start Certificate Course in Medical Editing (CME) to build professional capacity of the editors . This has helped many editors whose journals have now been recognized by the Higher Education Commission as per the latest revised list released last month.5While we would like to thank our valued members of the Editorial Board and Reviewers who have played a vital role in the enhancement of our Impact Factor and improving the quality of manuscripts accepted for publication, we are mindful of our weaknesses as well. We need to increase our presence on Social Media which at present is not satisfactory. Accelerating the peer review system shortening the time from submission to acceptance and publication is also being looked into. We also need understanding by the authors whose papers are not accepted for various reasons and hope situation will improve in the days to come. Repeated lockdowns due to Covid19 Pandemic has also adversely affected our working. However, we were lucky to publish a special issue on Medical Imaging in collaboration with Wuhan Institute of Technology during September 2021 thereby further improving the academic collaboration and cooperation between the healthcare professionals and medical institutions of Peoples Republic of China and Pakistan.Yet another important step that Pakistan Journal of Medical Sciences has taken during the Year 2021 is collaborating with PharmEvo Pharmaceuticals to establish PharmEvo Research Forum with the main objective of promoting research culture and the art of medical writing and scientific publishing.We have also offered Internship facility to one Fellow who is getting training for the last few months. We offer special prize, scholarships in the name of our founder Chief Editor late Dr. Maqbool H. Jafary to junior editors every years and some of the brilliant candidates in the CME Course by UHS are also picked up for this award. At the certificate distribution ceremony of CME Batch-2 held at UHS Lahore on June 23, 2021, four junior editors were presented this prestigious prize/award. This is our humble effort to promote the cause of medical journalism in Pakistan.


Medicaid is the largest payer of long-term services and supports and millions of older Americans rely on the means-tested program for health care coverage. There has been longstanding concern that wealthy older adults are taking advantage of the program by divesting assets in order to qualify for coverage. The existing research on the issue is somewhat dated, does not focus on the question of asset transfer, and often lacks a significant longitudinal view. Thus, questions remain about whether states need to tighten asset eligibility rules to prevent the wealthier older adults from accessing the program. This analysis explores longitudinal data from the Health and Retirement Study (1998 to 2016) to determine the extent to which wealthier Americans age 50 and older engage in asset transfer to access Medicaid. Our findings demonstrate that this may occur among a relatively small proportion of wealthy older adults, and that tightening Medicaid eligibility criteria would likely have a small to modest impact on the financial status of the program.


Most African immigrants report that they had never heard about dementia until their arrival in the United States. Conversations and insights from project advisory board meetings of the African Immigrant Memory Loss and Dementia Education projects (5 conversations and 8 meetings in the Minneapolis area) reveal unique cultural and immigrant characteristics surrounding dementia terminology and awareness. Dementia is often lumped together with mental illness which is associated with stigma. In addition to the fear of bad news and death, mental health issues are often considered a result of witchcraft, spiritual attack or punishment. Additionally, there are no traditional or cultural words for dementia in many African languages and current terms used are related to mental illness and all have negative connotations. There is a need to identify appropriate words for dementia in many tribal and immigrant dialects that can facilitate dementia awareness and education programs in African communities.


These chosen topics covered common significant challenges to patient health in psychiatry. Sessions were delivered to proactively address these important health related issues in a group visit setting.Baseline and post intervention feedback including telephone interviews were conducted to evaluate the effectiveness of the intervention.The qualitative data and the positive feedback obtained from participants indicate the intervention was highly valued and deemed effective in promoting positive health and lifestyle changes. Participants valued the educational and co-production aspects as well as the social and peer support elements of the groups. They appreciated the level of access they had with the clinicians involved, to explore their health and wellbeing in more detail without being limited by the usual 30 minute clinic follow-up sessions.The clinicians involved found the sessions rewarding and more engaging than most of routine 1:1 clinic sessions as they were able to spend quality time exploring important issues and not just educate the patients but also be educated by their questions and feedback about their lived experiences.The project aim was met and we believe this intervention can be successfully incorporated into the identified service provision gap within the CMH T model. There is potential to build on and embed this innovation with roll-out to a wide range of service users in different settings.In line with existing literature from GP settings, the consensus was that the amalgamated group visits/consultations model could be successfully modified to meet the needs of patients in the Mental Health arena who have a range of physical health and lifestyle concerns.We planned to obtain more information about improvement in patient self-management but this was affected by the pandemic. However, we believe it is a cost effective and helpful innovation which warrants further promotion and evaluation.


Even though Germany has a mandatory health and long-term care insurance with no or only very low co-payments, immigrants and the native population differ in their health and social services use. Differences in cultural traits and a lack of knowledge about the institutional setting are frequently mentioned as contributing factors. Relying on the epidemiological approach in the economic literature, this empirical study shows that both cultural traits that prevail in older immigrants’ country of origin and older immigrants’ knowledge about the host country’s institutional setting affect their health and social services use in Germany. We distinguish foreign-born immigrants and their descendants as both groups differ in their connection to the home and the host country. The results will be used to discuss immigrants’ access and potential barriers to the use of health and social services in comparison to the native population.


The concern relates to the provenance of this article as brought to our attention by Faisal Alhawaj, who denies authorship of this article and others published in Cureus. These articles were submitted and subsequently published purportedly as an effort coordinated by Imam Abdulrahman Bin Faisal University to ensure all medical interns publish at least one peer-reviewed article in order to qualify for enrollment in a postgraduate residency program as stipulated by The Saudi Commission for Health Specialties (SCFHS).The journal has not been presented with enough evidence to warrant the formal retraction of these articles as both Imam Abdulrahman Bin Faisal University and The Saudi Commission for Health Specialties have failed to respond to numerous communications requesting additional information regarding these allegations. While we acknowledge that the provenance of these articles is very much in question, we cannot act until these claims have been investigated by the appropriate institutions with the results of said investigation communicated to Cureus.The concern and this note will remain appended to the above-mentioned article until Cureus is provided with official confirmation from Imam Abdulrahman Bin Faisal University or The Saudi Commission for Health Specialties.


Practical Uses of Bioelectric Stimulation. Here you will find six examples of the use of imposed or modified electric fields to greatly influence tissue functions. This is only a very small sampling of the thousands of practical uses of bioelectricity today, and many more examples of this subtopic will appear regularly in this journal.It has been a great honor to be a guest editor for this special issue on the + on the immune system. In contrast, this issue of Bioelectricity focuses on the use of imposed electric fields to modify cell and organism functions.The discipline of bioelectricity encompasses both endogenous ionic currents and electric fields used by living organisms in their daily functions as well as the use of imposed electric fields to influence or modify these functions. The endogenous ion channels and currents associated with cancer cells was highlighted in the September issue that contained eight articles focused on the bioelectricity of cancer and covered many characteristics of cancer cells that are intimately associated with bioelectricity, including the control of metastasis, the localization of specific ion channels, and the influence of extracellular KThe common theme of four of these bioelectricity applications is the use of pulsed electric fields to influence cell permeability. The first article is a broad review of the past 5 years of electrochemotherapy, the use of microsecond-domain electric fields that trigger transient or reversible permeabilization to locally enhance the uptake of drugs that kill dividing cancer cells. This approach has been used extensively in Europe but is not yet approved for use in the United States. In human oncology electrochemotherapy is fully recognized as a local therapy for cutaneous tumors and metastases and its effectiveness is also being explored in combination with immunomodulatory drugs.The second article reviews irreversible electroporation (IRE), the use of larger pulsed electric fields in the microsecond domain that generates permanent pores in the plasma membrane resulting in the loss of homeostatic equilibrium leading to necrosis within minutes to hours. This technique has been approved for human use in both the United States and Europe for soft tissue ablation. It has established a clinical niche as an alternative to thermal ablation for the eradication of unresectable tumors, particularly those near critical vascular structures. IRE clinical data have shown promise in treating tumors in the prostate, pancreas, and liver.The third article describes the use of much shorter electrical pulses to treat skin lesions called Nano-Pulse Stimulation. This is a nonthermal technology that has been used to eliminate several types of skin lesions in clinical trials approved as nonsignificant risk trials supervised by IRBs and has not yet been approved for human use. These pulses generate reversible nanopores in all membranes exposed to them that are much smaller than the pores generated by the longer microsecond pulses. In addition, they have been shown to penetrate into cells and permeabilize the organelles as well as the plasma membrane resulting in the initiation of regulated cell death when a sufficient number of pulses are applied.The fourth article describes a very new application of Nano-Pulse Stimulation, cardiac defibrillation. The standard method for defibrillation uses much longer millisecond pulses that often cause long-term damage to the heart. Nano-Pulse Stimulation requires only about 12% as much energy to defibrillate so will probably result in less tissue damage.The fifth article is an exception to the increased permeability theme and instead provides a review of tissue inflammation and regeneration responses to imposed sinusoidal magnetic fields. In addition, some new data are presented showing that 5 and 15 Hz sinusoidal magnetic fields can induce very weak electric fields that can modulate inflammation and tissue regeneration. The mechanisms by which such low sinusoidal fields affect inflammation are likely to be very different from those used by much higher amplitude pulsed fields. We have much to learn about the targets of and mechanisms used by these weak oscillating electromagnetic fields.The final article in this special issue utilizes a light-activated ion channel to modify the membrane potential of brain tissue and reverse the abnormal brain and eye morphologies created by ethanol exposure. This is a striking demonstration of the critical role of membrane potential in the development of the brain that was not possible before optogenetics came on the scene. It is an amazing example of the signaling power of bioelectricity brought to light through the use of technological advances.


This paper reviews 63 policy documents in four Canadian jurisdictions that guide long term residential care staff on how to enhance 11 resident quality of life in Canada. We found guidance in each jurisdiction that provide clear language to support staff discretion and flexibility to navigate regulatory tensions and enhance resident quality of life. Newer policies tend to reflect more interpretive approaches to staff flexibility and broader quality of life concepts. We argue that if interpreted through a resident quality of life lens and with the right structural supports, these promising texts offer important counters to the rigidity of long term residential care policy landscape and can be leveraged to effectively broaden and enhance quality of life for residents in long term residential care.


This research tested whether performing an action themselves leads young and older adults to have difficulty remembering which of a number of other people had performed that same action. It also tested whether observing another person perform an action leads to false memory for self-performance of that action. Young adults and healthy older adults 62 to 88 years of age viewed videos of actors performing actions. After viewing some of the actions, participants were instructed to perform those same actions themselves. Participants were tested one week later on their memory for their own actions and for the actions of the actors in the videos. Older adults were more strongly influenced by self-performance than were young adults when asked whether the actor in a test item had performed the same action previously. Young adults performed better than older adults at discriminating the correct and incorrect actors in the videos, although both groups showed reduced discrimination for actions that they had also performed themselves. The two groups were equally likely to falsely remember having performed an action that had only appeared in the videos, but young adults were better able than older adults to correctly identify the actions that they had in fact performed. Older adults thus have greater difficulty than young adults at distinguishing self-performed actions from actions performed by other people. This suggests the existence of common representations for the actions of oneself and others that must be bound to identity information to specify the correct source of the actions.


The aim of this audit was to look into patients on high dose antipsychotics who had developed complications of constipation in the PICU setting .Antipsychotics are usually used in the treatment of Schizophrenia and other psychotic illnesses. Drug such as Clozapine mainly has a higher risk profile due to gastrointestinal hypo motility. It could present as constipation, fecal impaction or a bowel obstruction and could even lead to death.During ward rounds enquired on bowel habits and diet.Physical examination of patients complaining of abdominal pain.Screened notes in past to see how many patients complained of constipation and interventions suggested and used.I65.3 of the 10 patients on PICU were on high dose antipsychotics and 2 of them had reported constipation. Of which one required daily review and vigorous treatment with laxatives and dietary changes.RecommendationBristol stool chart introduced as part of care plan for all patients.Teaching presentation of constipation and its treatment management was given to the PICU team.Involving medical team early on for assessment and prophylactic laxatives prescription.Liaison with the pantry team to include more options of fruits and vegetables into daily meal plan for patients.Data and material handed over to next trainee to Re-audit and complete audit cycle.Appropriate prevention and early management of side effects can enhance the benefits of antipsychotics. Bowel function monitoring and the use of prophylactic laxatives for patient on high dose antipsychotics such as clozapine is advisable to prevent complications related to it.


Ever since the establishment of Indus Hospital Health Network (IHHN) by Dr. Abdul Bari and his colleagues, they have made a commendable progress and practically demonstrated that provision of free tertiary care is possible with the help of philanthropists and donors. It only becomes possible once an institution has earned credibility and the donors are confident that their contributions are being used judiciously for the purpose they are made.Starting with a major hospital at Karachi, IHHN has now expanded its network in the country and this institution has emerged as an important non-governmental player in health sector. It offers treatment facilities in almost every discipline of medicine with a multidisciplinary team approach with exceptional results. Apart from providing healthcare, it also realized the importance of documentation and publication for which they established a Research Department. Hospitals in Pakistan are considered as goldmine of data offering innumerable opportunities for research but most of them lack proper record keeping hence the data needed for research publications is not easy to find. However, IHHN knowing its importance managed to install the Health Information Management System which makes their researcher’s job easy. Since the researchers are also lucky to get help, guidance and assistance from the Research Department, IHHN faculty members and postgraduate trainees have managed to complete numerous research project thus showcasing their research work at international conferences which IHHN holds regularly and much of this research work is also published.We in Pakistan Journal of Medical Sciences published a special issue at the time of their last conference ICON 2021. This year too, we were approached and after initial discussions on working modalities, the project was started in March 2021.As agreed IHHN provided us manuscript after peer review by two reviewers which were then finally reviewed and edited by our editorial team before they were accepted for publication in this “Only Online Edition”. The workshop that we organized at Indus Hospital on Medical Writing and Peer Review during 2020 was very helpful and the experience which the IHHN Research Department gained while working with us last year proved very helpful with the result that this time it was mostly a smooth sailing.This special issue covers some very important subjects. Faiza Ahmed and colleagues in their write up has highlighted the knowledge and perceptions of sepsis among doctors. Sepsis, they have concluded remains a challenge to treat, it is often misdiagnosed. Early diagnosis and prompt management is the key to improving the outcome. 1Asthma severity and hospital admissions measured by PRAM score have been discussed by Kazi et al. Their conclusions are that this score is the best predictor for the need for hospitalization for these patients suffering from asthma. They have suggested that this should be put to use in clinical practice in paediatric emergency departments. They suggest better facilitation of intensive therapy of patients at triage which will decrease the need for hospitalization.2Obstructive lung disease is an important NCD. According to Saima Saeed and colleagues the OLD programme at IHHN uses capacity building, gold standard diagnostic and management strategies in primary care. This enables early diagnosis of suspected patients which improves the morbidity and mortality. 3Drug resistant tuberculosis remains yet another important problem in Paksitan. Nazia Khursheed and colleagues have identified in their study a number of such cases. They have advocated development of new strategies to reduce the spread of this disease.4Safety and efficacy of Remdesivir on mortality and length of stay in hospitalized Covid19 patients has been studied by Quratulain Shaikh et al., in this prospective cohort study which enrolled two hundred sixty eight patients. The findings of this study showed that there was no difference in in-hospital mortality while length of stay was longer in these patents. In addition more patients had severe ARDS in the RDV group. 5Ensuring privacy and confidentiality while examining a patient is extremely important but unfortunately practically it is not possible in overcrowded Out Patients Departments of public hospitals. Syed Ghuzzanfar Saleem et al studied the patient’s perceptions on this issue who visited the emergency department of Indus Hospital Adult Emergency Department. They found out that despite overcrowded and busy environment patients generally felt that privacy and confidentiality were maintained which must be very satisfying for the hospital administration.6There are numerous other studies covered in this special issue which shed light on many important subjects which the researchers have discussed which make an important reading. We are delighted to be a part of this project and by offering highly concessional publication charges despite the massive devaluation of the currency, we have contributed our share to promote and project the image of this remarkable institution of which the country should be proud of. In future too, we will be delighted to help, assist and cooperate with IHHN to showcase its research work thereby making significant contribution to the world medical literature from Pakistan.We are extremely grateful to the management of IHHN for providing us this opportunity and the two Guest Editors Dr. Farhana Amanullah and Dr. Naila Baig Ansari for their hard work in compiling, this special supplement.


Ambulatory assessment methods offer new possibilities to study cognitive, emotional, and social processes in the setting in which they naturally occur, namely in the daily life of individuals and couples. This allows to zoom into processes with great relevance for healthy aging and well-being over the lifespan. Research on daily psychological processes opens the door for investigating the interplay with contextual  and stable factors  that are known to shape these dynamic processes. This symposium will present and discuss innovative contributions investigating daily emotional and cognitive functioning and their interplay with social and individual characteristics over the adult lifespan. The first study by Haas and colleagues will present experience sampling data on daily prospective memory performance in couples. Haas et al. will offer a dyadic perspective on cognitive functioning by examining how prospective memory performance is co-regulated in the daily lives of younger and older couples. Meier et al. will present another study from the same couples project; here the focus is on age differences in couples’ “we-ness” and its relationship with daily positive emotional experiences and how they are shared with the partner. The series of talks will be completed by Zavala et al. who examined associations between stress and emotional health in daily life and its interplay with prior discrimination experiences of an age-diverse sample of BIPOC adults. After these individual contributions, Christina Roecke will discuss the presented studies and provide her reflections on the results and their implications.


This poster reflects how the experience of staying with people of diverse nations and cultural background helped the stranded IMGs cope with this agony in a foreign land during an unprecedented tumultuous situation. The aim is to show that despite diversity among people, the hard times made them unite and overcome countless difficulties.The COVID 19 pandemic has been a period of global health crisis and has exponentially affected mental health issues in the world population. In these difficult times, several International Medical Graduates (IMGs), who had come to the UK to attend their PLAB exams, were left stranded as the exams were postponed, flights cancelled and borders sealed. Faced with huge uncertainty their mental health was of great concern.At this time the British Association of Physicians of Indian Origin (BAPIO) came forward to help this cohort of stranded doctors in terms of accommodation, finances, mental health support, preparation for exams to the extent of liaising with General Medical Council (GMC) and Home Office. The virtual support group provided a platform for IMGs from different nations and cultures to get in touch with each other helping overcome mental burden and stress.The stories presented in the poster show how unity in diversity helped these young doctors deal with mental trauma amidst the Pandemic.276 doctors from 27 countries were looked after by BAPIO. From those excerpts taken from 26 IMGs, personal narratives was used as a method for qualitative assessment.The percentage of IMGs clearing their exams and getting jobs in the NHS has been used for quantitative assessment.Qualitative: The personal narratives of the IMGs show how they were positively impacted by staying together albeit different nationalities and cultural background.Quantitative: A total of 21 IMGs out of the 26 cleared their PLAB 2 exams and got registration under General Medical Council giving a percentage of 81.7%. 20 IMGs have successfully joined the NHS in various posts giving a job success rate of 95.2%.The experience of living and sharing housings with people from different nationalities, has increased appreciation and also prepared them to work in the NHS which has a diverse work force. This learning experience has been integral for all of us in shaping our life in the UK making everyone more compassionate.


Up to 35% of Dutch elderly patients still receive an ostomy after colorectal cancer (CRC) surgery.We performed a nationwide comprehensive analysis on the postoperative results and survival after CRC surgery in elderly Dutch patients (≥ 75 years), comparing the outcomes of patients with primary anastomosis (PA) with those with end ostomy (EO).The pace of population aging is much faster than in the past; elderly and frail patients are rapidly becoming the new challenges in the future of colorectal surgery. In contrary to popular belief, those elderly patients might not necessarily benefit from a stoma. More information is needed regarding how frailty combined with a stoma impacts postoperative outcomes and survival. Our hopes for the future are vested in the development of a surgical prediction model for colorectal surgery for elderly patients, focusing on which patients would benefit from conservative therapy and which patients would benefit from an ostomy. This is important for our clinical practice; it will change our surgical decision making and hopefully reduce the number of unnecessary elderly ostomy patients.


Racial and socioeconomic disparities are prevalent in long-term services and supports (LTSS). There is a need for innovative research with practical application informing aging and disability policies to reduce health care disparities for older adults and people with disabilities using LTSS. This presentation will provide an overview of the career trajectory of Dr. Chanee Fabius, whose research agenda is informed by applied care management experience, where she helped older adults remain at home and delay the need for nursing home care. She will also present findings from work that (1) examines networks of care used by older adults  and how they vary by race and socioeconomic status and (2) describes the effect of LTSS utilization on quality of life and health service utilization across diverse groups of older adults.


Introduction. This paper examines regulations which govern procedures for reporting incidents other than accidents or serious incidents related to unmanned aircraft system (UAS) operations. The regulations are discussed in the context of available data and the paper included an analysis of them from both a European and national perspective. The goal of the paper is to provide a series of recommendations with regard to the procedures for reporting and analyzing UAS incidents in order to improve the safe integration of unmanned and manned aviation. This article also explores the legal consequences that arise from the midair collision between a UAS and a manned aircraft. Material and methods: The method of study comprises a content analysis of existing legislations. The current doctrine was confronted with existing regulations, documents and materials. Results: The results of the study show that there is a practical problem of objectively identifying operators of a UAS as well as in defining what exactly constitutes an “incident”. It can be reasonably concluded that reporting and analyzing UAS-related incidents allows for the assessment and development of strategies for integrating manned and unmanned aviation. It is worth mentioning that drones and UAS technology requires refinement, especially in technological terms. It is reasonable to take action aimed at raising awareness amongst UAS users of the need to report incidents, as well as engaging UAS users in the investigative process which follows such occurrences.


Behavioral and psychological symptoms of dementia are increasingly being reconceptualized as expressions of distress and unmet needs. Measures that evaluate context are needed to increase our understanding of factors that influence these expressions. This review evaluated measures for two common behavioral states that are experienced as challenging for caregivers: apathy and resistance to care. A systematic literature search identified measures of apathy or resistance to care for people living with dementia. Eight measures of apathy and three measures of resistance to care were identified. Reliability and validity of these measures were evaluated using the COSMIN framework, as well as reported contextual factors within which the behavior occurs. The identified measures had fair to good reliability and validity in people living with dementia. However, available measures need to move beyond symptomatic constructs for this complex paradigm, and toward the varied interpersonal and contextual factors associated with behavioral expression.


We read with interest the review by Dastoorpoor and colleagues , highligWe would like to highlight the importance of contrasting work related to the prevalence of sexual dysfunction in MS against broader community samples when considering this research, given that sexual dysfunction in men is prevalent and increases with age and common ageing-related comorbidities (e.g. diabetes and cardiovascular disease) . For exaWhile a systematic review and meta-analysis are limited to available data from the original studies, we believe there is a need to consider sexual dysfunction across the spectrum of severity from mild through severe. The current review aptly pointed out the differences in measurement tools used across studies, but some discussion about the measurement of severity and its impact on prevalence estimates is warranted. A Danish community study found that 11% of male respondents reported sexual dysfunction (frequent and perceived as a problem), while 68% of males reported less severe sexual difficulties . Many ofWe again wish to thank the authors for bringing this research together and summarising information about the prevalence of sexual dysfunction for men with MS to date. We hope to have encouraged a follow-up article detailing some of the above aspects and that future reviews on this topic will be considered from the perspective of sexual dysfunction in men more broadly, across the severity of dysfunction and potential causal aspects to contextualise knowledge in this area. A more detailed understanding of this important clinical issue would assist with appropriate clinical attention and management, as well as referral for support to maximise the quality of life for men with MS who experience sexual dysfunction.


Following the publication of the original article  the authDNA2 gene [18].""Another special IBDD patient, with a severe lack of speech development and lack of social interactions, was reported to be associated with autism that was genetically confirmed in the The correct sentence should read:"Another special IBDD patient, with a severe lack of speech development and lack of social interactions, was reported to be associated with autism [18]."The original article has already been corrected as above.


The Coronavirus disease 2019 (COVID-19) pandemic has introduced numerous challenges to the global scientific community and has been particularly disruptive to the conduct of ongoing clinical trials. Gerontological studies that focus on older adults with cognitive impairments have endured additional challenges ranging from increased vulnerability of this group to COVID-19, thereby prohibiting study participation, to difficulties in participant engagement as a product of a worsening Digital Divide. The purpose of this talk is to describe the pandemic-related factors that have influenced recruitment and enrollment of older adults with mild cognitive impairment and mild dementia in an ongoing feasibility study of a physical activity smartphone app. We discuss the changes we made to recruitment procedures and the impact those changes have had on the success of enrolling individuals in the study. We conclude with a discussion of feasible strategies and procedural alterations moving forward that may facilitate achievement of enrollment goals.


Following publication of the article , it cameThe figure has been updated in the published article and the correct values may be found in this correction article.The authors thank you for reading and apologize for any inconvenience caused.


Family members of persons diagnosed with dementia or a traumatic brain injury (TBI) are often relied upon to provide daily support to their care recipients. However, research on the differing experiences of caregivers based on care recipient diagnosis is limited. The aim of this study was to examine the impact of worry and feelings of vigilance among caregivers of people with cognitive impairment due to either TBI or dementia. This sample included 61 caregivers  of persons with either a TBI (n = 32) or dementia (n = 29). Worry was assessed with the Penn State Worry Questionnaire and Vigilance was assessed with the Caregiver Vigilance Scale. Linear regressions revealed that after controlling for age, care recipient diagnosis moderated the relationship between worry and caregiver vigilance. Specifically, worry was significantly associated with caregiver vigilance in those caring for someone with dementia; however, a similar relationship was not seen in those caring for someone with a TBI. This suggests caregivers of people with TBIs have a different experience of worry and vigilance than caregivers of people with dementia. These findings demonstrate the need for more research on the unique needs of caregivers of people with TBIs. Additionally, this research suggests interventions targeting worry may be particularly effective in supporting caregivers of people with TBIs.


The concern relates to the provenance of this article as brought to our attention by Faisal Alhawaj, who denies authorship of this article and others published in Cureus. These articles were submitted and subsequently published purportedly as an effort coordinated by Imam Abdulrahman Bin Faisal University to ensure all medical interns publish at least one peer-reviewed article in order to qualify for enrollment in a postgraduate residency program as stipulated by The Saudi Commission for Health Specialties (SCFHS).The journal has not been presented with enough evidence to warrant the formal retraction of these articles as both Imam Abdulrahman Bin Faisal University and The Saudi Commission for Health Specialties have failed to respond to numerous communications requesting additional information regarding these allegations. While we acknowledge that the provenance of these articles is very much in question, we cannot act until these claims have been investigated by the appropriate institutions with the results of said investigation communicated to Cureus.The concern and this note will remain appended to the above-mentioned article until Cureus is provided with official confirmation from Imam Abdulrahman Bin Faisal University or The Saudi Commission for Health Specialties.


The is session will demonstrate how to use the Canvas learning management system (LMS) to organize and facilitate interprofessional education experiences (IPE) amongst students and faculty. Emphasis will be placed on the use modules as a way to organize content and facilitate requirements associated with IPE. In addition, the session will include demonstration on how to assign disciplines to sections to aide in faculty abilities to review of student submissions.


The study highlighted that the integration of new FPs into the healthcare team requires active management, including the need for role clarification and supporting role maturation over time.Interviews with district managers to understand the impact of family physicians (FPs) on the South African health system confirmed several benefits, including their ability to increase access to a more comprehensive and coordinated health service, to improve clinical care, to capacitate the healthcare team and facilitate clinical governance activities.3 A survey was held amongst South African Academy of Family Physicians (SAAFPs) members to explore the needs and suggestions for activities for this special interest group, which is named Next5 (see At the April 2021 meeting of the South African Academy of Family Physicians education and training committee (ETC), it was agreed to set up a working group to look at an initiative on how the academy can assist newly qualified FPs within their first 5 years of qualifying, similar to the First five concept of the Royal College of General Practitioners and the Young Doctors Movements of WONCA (World Organization of Family Doctors).1 By encouraging existing FPs to support new FPs in their transition from registrar to expert generalist trained to work in both public and private healthcare sectors, we trust that this new Academy initiative will assist with creating an ongoing ‘sense of belonging’ in the SAAFP community and tangible membership benefits for all newly qualified FPs. We encourage all registrars to continue their full membership of the SAAFP after graduation and become involved with the Next5 activities. If you are keen to learn more about this initiative and wish to become involved, please email to admin@saafp.org.As part of the August 2021 ETC presentation, we reviewed the number of registrars who became SAAFP members after graduation . Reassur


Unpaid work carried out inside the home has increased in the pandemic, and evidence points to women’s share in care responsibilities and domestic tasks remaining higher than those of men in the pandemic, continuing the gender divides of past decades.


The main aim of this audit was to determine the prevalence of HDAP in Havering Community Recovery Team (CRT). The secondary aim was to determine how well HDAP has been monitored and documented - specifically, whether discussions around the reasons for continuing and the risks and benefits have been discussed.There is a focus to reduce high dose antipsychotic prescribing (HDAP) due to the lack of evidence that it is efficacious and that smaller doses have an equivalent effect and are better tolerated. Similarly, the consensus by the Royal College of Psychiatrists is that any prescribing of high dose antipsychotics should be an 'explicit, time-limited individual trial’ with a distinct treatment target. There should be a clear plan for regular clinical review including safety monitoring. The high-dose regimen should only be continued if the trial shows evidence of benefit that is not outweighed by tolerability or safety problems.' Following a CQC inspection in 2014 of NELFT which found that the trust was failing to comply with the relevant requirements of the Health and Social Care Act 2008 with regards to safe use of medicines, yearly audits of inpatient HDAP have been undertaken. Although improvements have been made in the inpatient setting, no such audits have been performed in the community setting and consequently there is no data in NELFT regarding community services compliance with the above regulations.All 349 patients in Havering CRT clinical records were screen by either using RIO or GP letters from recent CPA reviews. A data collection and analysis tool was created using Microsoft Excel. Data collection and analysis was carried out by the project lead and checked by a fellow project member.16 (4.58%) of patients were prescribed a high-dose antipsychoticOf the 16 prescribed high dose antipsychotics:0 out of 16 had the high dose antipsychotic monitoring form available12 (75%) had well documented evidence of review of HDAP.4 (25%) had no documented evidence of review of HDAP.Of the 349 patients included for analysis:There is a small group of patients receiving high dose antipsychotic therapy for which better monitoring is needed. This should include education of staff regarding HDAP, better documentation in their care plans and working with pharmacy to make HDAP monitoring forms available widely in the community.


Concerns about loneliness and social isolation for older adults were already evident but have been exacerbated during the pandemic. Home and Community Based Organizations (HCBOs) provide support for their older clients in the community and need to support their staff, who may be working remotely. We are exploring the potential of video chat technology to connect older adults with their friends, families, and other support. We review the technologies available to older adults in the community and staff working with older adults to promote social engagement. We are collaborating with OneClick.chat to identify the needs of the HCBOs through a literature review and qualitative interviews of staff members from different senior living environments. Their challenges and successes of engaging older adults through video chat technologies will provide guidance for design of an HCBO dashboard for OneClick.chat that will support diverse needs.