To examine how health system design and delivery can fail to support the needs of LGBT+ older adults.LGBT+ older adults face barriers in access to care, impacting their ability to receive person‐centred care in old age, which is central to the prevention and management of frailty, disability and disease.Using a conceptual framework of access to care, this commentary illustrates issues LGBT+ older adults may face in accessing health and social care services in Ireland, and provides examples of how access may be improved from the published international literature.Health policies, service design and delivery all impact on the ability of the health system to meet the needs of LGBT+ older adults across all levels and types of care.Heteronormativity and discrimination must be addressed across the whole health system to achieve the health policy goal of supporting all older adults to enjoy health and well‐being.We suggest nursing professionals use a systems perspective to address the multilevel issues relating to care for LGBT+ older adults. Researchers in gerontological nursing should include the experiences and outcomes of service utilization for LGBT+ older adults in their research agenda. For some LGBT+ older adults, prior experiences of discrimination or stigma within health services mean they may not view these services as inclusive spaces where they will be respected, and where their needs will be met  and types of care . We conclude that addressing heteronormativity and discrimination is needed across the whole system of care, to achieve the policy goal of supporting 7Nursing professionals are well placed to address these issues given their scope of practice across the whole system of care, their involvement in policy making and commitment to delivering culturally competent care. We suggest nursing management who are charged with mentoring, training staff and service improvement recognize the importance of taking a systems perspective to improve access and care services for LGBT+ older adults. Researchers in gerontological nursing should add the experiences of service utilization for LGBT+ older adults service users to their research agenda.This commentary is based on existing published literature and did not require ethical approval.


As population aging is accelerating rapidly, there is growing concern on how to best provide patient-centered care for the most vulnerable. Establishing a predictable and affordable cost structure for healthcare services is key to improving quality, accessibility, and affordability. One such effort is the “frailty” adjustment model implemented by the Centers for Medicare & Medicaid Services (CMS) that adjusts payments to a Medicare managed care organization based on functional impairment of its beneficiaries. Earlier studies demonstrated added value of this frailty adjuster for prediction of Medicare expenditures independent of the diagnosis-based risk adjustment. However, we hypothesize that further improvement is possible by implementing more rigorous frailty assessment rather than relying on self-report of ADL difficulties as used for the frailty adjuster. This is supported by the consensus and clinical observations that neither multimorbidity nor disability alone is sufficient for frailty identification. This symposium consists of four talks that leverage data from three CMS-linked cohort studies to investigate the utility of assessment of the frailty phenotype for predicting healthcare utilization and costs. Talk 1 and 2 use data from the NHATS cohort to assess healthcare utilization by frailty status in the general population and the homebound subset. Talk 3 and 4 use data from the MrOS study and the SOF study to investigate the impact of frailty phenotype on healthcare costs. Taken together, their findings highlight the potential of incorporating phenotypic frailty assessment into CMS risk adjustment to improve the planning and management of care for frail older adults.


To learn about the imaging characteristics of pulmonary emboli caused by metallic mercury and be aware that an underlying psychiatric condition might exist when mercury poisoning is not caused by occupational exposure. To learn about the imaging characteristics of pulmonary emboli caused by metallic mercury and be aware that an underlying psychiatric condition might exist when mercury poisoning is not caused by occupational exposure. A 25‐year‐old asymptomatic woman was referred with diffuse, high‐density opacities in a chest radiograph Figure  and dissMunchausen's syndrome is a factitious disorder imposed on the self and usually difficult to identify due to deceptive misrepresentation. Patients intentionally fake or cause symptoms of an illness and/or injury in themselves, even in the absence of obvious external rewards.None declared.WS: wrote the initial draft of the manuscript. YJ: critically appraised and revised the overall content of the manuscript. Both authors: read and approved the final manuscript.Our study has been granted an exemption from the review by the Institutional Review Board of Peking Union Medical College Hospital.Written informed consent was obtained from the patient's brother  for publication of this case report and any accompanying images.


Health literacy assessment tools that are designed and validated specifically for East Asian older adults are limited. This session reviews the existing health literacy assessment tools and discusses possible applications in East Asian older adults. As an alternative to the population-level health literacy assessment, the general literacy measures and assessment approach in the Program for International Assessment of Adult Competencies (PIAAC) data are discussed. As a case demonstration, the PIAAC literacy measures in Japan and Korea are summarized and evaluated for the applicability in aging and health research with East Asian older adults.


Clinics and Practice was launched in 2011 and it has been published over the past nine years by PAGEPress Publications [Clinics and Practice from PAGEPress and wish to ensure the reader that we will continue to serve health professionals and clinicians well. Clinics and Practice complements the MDPI portfolio of medical journals very well [Journal of Clinical Medicine [Medicina [Medical Sciences [We are delighted to take over the publication of ery well ,4, especMedicine , MedicinMedicina , and MedSciences , and strWe will regularly publish four quarterly issues from 2021.Clinics and Practice [We hope that you enjoy publishing your work in Practice !


Lassa fever outbreaks continue to be recurrent after fifty years of its identification. The true burden of the disease in Nigeria is unknown while gaps in knowledge about the infection still persist. Based on the Nigeria national Lassa fever research agenda and the World Health Organisation's roadmap initiative for accelerating research and product development which enables effective and timely emergency response to LF disease epidemics among other infectious diseases; a research pillar was added to the seven existing LF emergency operations centre response pillars in 2019. We describe lessons learnt from the integration of a research pillar into the LF national emergency response.Emerging and re-emerging infectious diseases are becoming more frequent and developing countries are especially at increased risk. A recurring infectious disease outbreak in Nigeria has been that of Lassa fever (LF), a disease that is endemic in Nigeria and other West African countries. Nigeria, between 1 Mastomys natalensis is distributed across this region [Emerging and re-emerging infectious diseases are becoming more frequent and advancing faster than ever before, predominantly in developing countries of Africa, South America and South Asia . Multipls region .st January and 27th October 2019, 743 confirmed cases of LF and 157 deaths in confirmed cases were reported [In West Africa, LF is estimated to affect 100,000-500,000 persons annually; with Nigeria bearing the most burden  recordinThe World Health Organization (WHO) developed a roadmap initiative for accelerating research and product development to enable effective and timely emergency response to LF disease epidemics among other infectious diseases . One of Overview of the national emergency response: a cardinal point in the coordination of any emergency response to a public health event is the activation of an emergency operations or coordinating centre. In 2019, the national EOC for LF in Nigeria was activated on the 22nd of January, following the declaration of the LF outbreak as an emergency by the NCDC due to high case numbers [ numbers . The EOCActivities of the research pillar: the NCDC LF research pillar commenced its activities by identifying and mapping ongoing research by various stakeholders across the country to avoid duplication of efforts. A 3-day capacity building workshop on the development of research proposals was also held for pillar members of the Lassa EOC. The research pillar participated in all meetings of the LF national EOC while also working closely with all the other response pillars to identify gaps from their operations which could be addressed by research. Reviewing daily and weekly reports from these other pillars of the EOC, gaps in knowledge, methods, response activities, assessments and challenges were identified as potential questions that could be addressed by research. Before the outbreak, WHO had supported the NCDC to prioritise its research areas with respect to LF and developed a research agenda. This was also used as a benchmark in the identification of potential research areas. During the outbreak, however, potential operational research that could immediately help to improve response were identified. These potential research areas spanned across case management, infection prevention and control, surveillance, contact tracing, laboratory, risk communication, environmental and vector control activities. The research pillar worked with the other response pillars concerned to develop concept notes around these gaps which would help inform their response subsequently. Those concept notes were prioritized based on the perceived impact on future prevention and response effects and a few of these concept notes were developed into research proposals for implementation by the rapid response teams (RRT) deployed to the field.Lessons learnt: outbreak response activities help to highlight gaps that can be addressed by research which otherwise may be either overlooked or not have been noticed. An example is the actual infection prevention and control practice of healthcare workers during outbreak periods as opposed to during routine care at other seasons. Also having a research pillar helped provide needed guidance on response research activities at national and subnational levels leading to streamlined research activities thereby avoiding duplication of efforts and optimising the available resources. An example was in the utilisation of the same checklist and methodology for household assessment by the RRT across various states and local government areas they were deployed to. Another lesson learnt is the need to have supportive teams with enough research methodology capacity to rapidly develop scientifically sound proposals based on identified gaps during an epidemic response. This was a challenge for the team as there were limited members in the research pillar and the other response pillars were more focused on outbreak response activities rather than on development of proposals. Also studies will need to be conducted in such a way as not to disrupt the much needed response being provided by the RRT and other members of the various response pillars. For implementation, the RRT were saddled with implementation of the operational research in addition to response activities and this led to non-completion of data collection by many due to distraction by response activities. We also learnt that there is need to have pre-dedicated funding such as a certain percentage of outbreak operational funds to support research prior to predictable outbreaks. Some of the studies could not be implemented due to paucity of funds for research during the period and this limitation was also reason for the use of RRT to collect data; obtaining the support of ethics committees for expedited approval is crucial to the implementation of research during outbreaks as it has been noted that epidemics tend to reveal vital knowledge gaps that could neither have been predicted nor prioritized for study before an outbreak occurs [k occurs . Prior tRecommendations: gaps identified during an outbreak should continue to generate research questions for high-priority study as both an integral component of the immediate response and if not possible immediately, could be for longer-term follow-up study. This hopefully would help in both understanding of the disease process and inform best practice for prevention and response activities [tivities ; countrytivities . Howevertivities ; the pertivities ; continuLessons learnt from the incorporation of a research pillar in the 2019 LF disease outbreak response provided an opportunity for both improvement and planning for research. This would inform future approaches to research-related response activities especially for predictable diseases like LF. This will ensure that we learn as much as we can from these significant public health events. The importance of utilizing research during an outbreak to evaluate and or improve our response and institute preventive programmes cannot be over emphasised; and this would go a long way in addressing knowledge gaps to improve prevention and control of outbreaks of infectious diseases such as LF.


The development of RAPN enabled wider indication of nephron sparing surgery. For the bilateral kidney tumors, RAPN should be considered first to maintain the kidney function and minimum invasiveness. In performing RAPN for the both kidneys suspecting different histology, we must discuss about: What is the suspected histology based on the radiological examination? Is preoperative biopsy necessary? Do we operate sequentially or simultaneously? What is the appropriate interval? Which side should be operated first? Are there any options such as ablation therapy or active surveillance? There may be no concrete answer for these questions, however, we have to present many alternatives to the patients and inform them of the merits and demerits of each strategies. It is very difficult and time consuming effort but absolutely necessary. To treat the renal cell tumors we must have ability to perform many choices of procedures but it is impossible to experience every rare situation like this case. This case report will be very useful in the decision making in the similar circumstances.The author declares no conflict of interest.


Although austerity was particularly strong in the aftermath of the economic crisis of 2008 and its consequences in the euro area, Italian fiscal policies have been characterised by tough consolidation periods ever since the 1990s.


We examined the frequency of participation in cognitive and social type of leisure activities in association with dementia risk over 15 years of follow-up in 12,280 participants aged 50+ from the English Longitudinal Study of Ageing. Cox proportional hazards regression models were used to estimate the hazard of dementia in relation to the cognitive and social type of leisure activities as well as their interactions with sex and marital status. Medium and higher levels of engagement in cognitive leisure activities were associated with a lower risk of dementia. An analysis of the social type of leisure activities showed a similar pattern with protection for higher levels of engagement in a model adjusted for sex and marital status but further explained by wealth. This study shows a reduced risk of dementia for individuals with higher levels of engagement in cognitively stimulating activities, that may preserve cognitive reserve until later in life.


To the Editor,We read with great attention the remarkable research letter by Yang and colleagues studying the utility of optic nerve sheath diameter (ONSD) in predicting sepsis-associated encephalopathy (SAE)  in critically ill patients . HoweverSystemic hypertension itself could be an independent risk factor for increase in ONSD and has been studied in the past . While pWe wish to congratulate the authors for this remarkable work in the critical care setting to risk stratify patients with SAE with the help of ONSD. However, providing further details about the clinical status of the patients in this setting (such as blood pressure readings) and details of past medical background (steroid use and history of endocrinopathies) will provide readers of this journal with much needed clarity and further credibility to this outstanding work.


Communication and interactions are an integral part of care in long-term care settings. Resident variables, such as race and gender, shape communication and interaction between staff and residents. The Quality of Interactions Schedule (QuIS) was developed to measure the quality of verbal and nonverbal interactions among nursing staff and older adults initially for those in acute care and later used as well in a variety of long term care settings. A quantified measurement of the quality of interactions between residents and staff was created to quantify the QuIS. The purpose of this study was to describe the gender and racial differences in scored quality of interactions. Data for the present study was based on baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) implementation study. A total of 535 residents from 55 settings were included in the analyses. An analysis of covariance was conducted to determine a difference in QuIS scores between males and females while controlling for age. The second model tested for differences in QuIS scores between blacks and whites while controlling for age and gender. There was not a statistically significant difference in QuIS scores between male and female residents. There was a significant difference in QuIS scores between those who were black versus white, such that those who were black received more positive interactions from staff than those who were white. Future work should focus on a deeper examination of resident factors and staff factors that may influence these interactions.


Background: International policy is increasingly committed to placing interdisciplinary team-working at the centre of health and social care integration across the lifespan. The National Clinical Programme for Older People in Ireland has a critical role in the design and implementation of the National Older Person’s Service Model, which aims to shift the delivery of care away from acute hospitals towards community-based care. Interdisciplinary Community Specialist Teams for older persons (CST-OPs) play an important role in this service model. To support the development of competencies for interprofessional collaboration and an interdisciplinary team-based approach to care integration, a culture shift will be required within care delivery.Design:This study builds upon a collaborative partnership project which co-designed a framework describing core competencies for interprofessional collaboration in CST-OPs. A realist-informed process evaluation of the framework will be undertaken as the competencies described in the framework are being fostered in newly developed CST-OPs under the national scale-up of the service model. Realist evaluation approaches reveal what worked, why it worked (or did not), for whom and under what circumstances. Three iterative and integrated work packages are proposed which combine multiple methods of data collection, analysis and synthesis. Prospective data collection will be undertaken within four CST-OPs, including qualitative exploration of the care experiences of older people and family carers.Discussion: The realist explanatory theory will provide an understanding of how interprofessional collaboration can be fostered and sustained in various contexts of care integration for older people. It will underpin curriculum development for team-based education and training of health and social care professionals, a key priority area in the national Irish health strategy. It will provide healthcare leaders with knowledge of the resources and supports required to harness the benefits of interprofessional collaboration and to realise the goals of integrated care for older people. International health system policy and operational models have increasingly identified interdisciplinary teamwork as critical for health and social care integration across clinical pathways . InternaInterdisciplinary team working is a core feature of common international models of older people’s health and social care and is considered critical for comprehensive geriatric assessment and care planning . The EurThe ECLECTIC project  sought to address this gap by co-designing a competency framework that provides practical guidance for building competencies for interprofessional collaboration in the context of older people’s integrated care . These CThe ECLECTIC framework was co-designed with healthcare professionals, from across thirteen disciplines involved integrating care for older people in community care settings. Five Public and Patient Representatives (PPRs) also joined the co-design team and were critical in the development and validation of the framework. Furthermore, in-depth qualitative research was undertaken with two interdisciplinary community-based teams integrating care for older people. The qualitative analysis was used to contextualise the core competencies described in the framework  and NCPOP that will enable team members to develop competencies for interprofessional collaboration. These resources will provide specific learning activities and materials aligned to relevant contexts-mechanism-outcome configurations and will be made available to all the CST-OPs supported by NCPOP.4.Contribute to the theoretical understanding of what works (mechanisms) in building proficiency for interprofessional collaboration and under what circumstances (contexts) through the development of a middle-range theory providing a detailed explanation of the dynamic relationship between varying context-mechanism-outcome configurations.Ethical review and approval will be sought from the relevant governance committee once the case-study sites are identified. Furthermore, ethical exemption will be sought from the UCD Life Sciences Ethics Committee.The study adopts a realist evaluation approach which is an interpretive theory-driven approach to evidence synthesis which uses multiple sources of evidence including published peer-reviewed studies, policy documents and grey literature. This evidence is combined with stakeholder theories and explanations of how interventions might work  will be included.3.Public and patient representatives (PPRs) of older people and family carers (our PPI advisory group).i.e., patterns of generative causation). These IPTs will support the evaluation of the implementation of the ECLECTIC framework within CST-OPs operating under the NCPOP (Work Package Two). The realist review will be guided by five steps adapted byThis review will focus on generating initial programme theories (IPTs) for the contexts and the mechanisms that are associated with the outcomes of interventions targeting interprofessional collaboration Finally, four validation workshops will be held with key stakeholders  to review, refine and prioritise the IPTs. This will result in a series of evidence based IPTs which are context specific theories in the form of statements which explain how and why teams build interprofessional collaboration and what the associated outcomes are.versus more established teams). Furthermore, case study site selection will be guided by the IPTs that were prioritised at the end of work package one for testing.The second work package will involve multiple methods to explore, evaluate and test the IPTs . ProspecDue to the given complexity of the system in which the ECLECTIC framework is being implemented, each of the four teams will likely be at different stages in their development proficiency for interprofessional collaboration. This will provide additional nuance and understanding of the role of context in the realist evaluation. Two of the nominated teams will be identified by the research team in collaboration with the project advisors for the collection of extensive process data and a more in-depth realist evaluation. This evaluation will primarily focus on testing and refining the emerging programme theory. The other two teams will provide prospective qualitative data that can be used to contextualise and support the emerging theory.Data Collection: Four case study sitesThe following prospective data will be collected from the four nominated CST-OPs: Structured interviews with team membersQualitative structured interviews will be conducted with members of each of the four nominated CST-OPs (N=24–32) at baseline (T1), six months (T2) and at 12 months (T3). The participants will be purposely selected to ensure representation from each discipline represented on the team as well as a support member such as operational manager (n=6–8 per team). We aim to interview the same team members at each time-point to enable prospective exploration of changes over time. The interviews will be guided by a structured format derived from the IPTs. The participants will review the IPTs and explore each of the configuration elements  from their own experience of interdisciplinary and interprofessional working. The participants will determine whether the interviews will be conducted either face-to-face or remotely using video conferencing technology as per their requirements and preferences.Semi-structured interviews with older people and family carersProspective qualitative interviews will be conducted with older people and/or their nominated family carer who are receiving integrated care from one of the four nominated care teams. Interviews will be conducted in two waves: following initial referral/assessment and following discharge from the CST-OP. We will aim to prospectively interview 16–20 older people and/or family carers across four team sites at each time point (n=4–5 per team). The focus of these interviews will be to explore the participants’ care experiences and needs during their time with the CST-OP and to identify how needs change over time. The IPTs will inform the interview guide and will prompt discussion of the outcomes identified in the configuration statements from the perspective of older people and/or family carers. This discussion may also identify potential causal mechanisms for these outcomes. These interviews will be conducted face-to-face unless otherwise requested by the participant themselves.Quantitative outcome measurementThe quantitative outcomes associated with interdisciplinary collaboration identified from the systematic scoping review in work package one will be measured at three timepoints (baseline (T1), 6 months (T2), 12 months (T3) as above). Each of the CST team members (N=52–55) will complete an online questionnaire measuring outcomes that have been adopted from the mechanisms for evaluating team competency in interprofessional collaboration described in the co-designed ECLECTIC competency framework . Listed Other measures that may emerge from the evidence scoping and realist synthesis include attitude towards interdisciplinary working, knowledge of team roles, knowledge of each competency, trust, conflict, collective leadership/decision-making and sense of work engagement such as feelings of vigour, dedication and absorption. The measurements will be conducted online through individual scaled questionnaires. Previously validated and robust instruments will be used to measure outcomes, where available.Data collection: Two case study sitesIn collaboration with the project advisory committee, two of the nominated CST-OPs will be identified for more extensive data collection and realist evaluation. The following additional sources of data will be collected from these two teams. This will ensure the generation of rich and detailed explanatory programme theory for two case study sites. The data collected from the other sites will be used to support and refine the two case study programme theories.Observations of team meetingsStructured observations of a team meeting will occur at three timepoints (baseline (T1), 6 months (T2), 12 months (T3) as above). The focus of these team observations will be to identify the contextual conditions and related mechanisms which lead to outcomes associated with interprofessional collaboration. A bespoke observation template will be developed to support data collection to promote consistency in data capture across observations. This will be modelled on a tool developed by a member of the research team with colleagues (McAuliffe) for observation and measurement of psychological safety in healthcare teams  as well as standard operating procedures for interdisciplinary team communication and referral processes. The teams will be asked to record adverse events and indicators of care quality including episodes of missed care, duplication of care, declined care . These will be recorded by the team in anonymised format and will be collected for the purposes of tracking frequency of adverse events over the observation time frame (12 months).Data analysisNVIVO Pro 12 Software .Qualtrics XM will be used for the collection of quantitative data and data will be analysed using IBMSPSS Statistics 27. The analysis will be undertaken on an ongoing basis whereby each wave of data collection will iteratively inform the next wave of data collection in each case study site. Data analysis will be guided byQualitative data analysis of the interview transcripts, the documents and the team observational notes will be conducted usingThe focus of data analysis in this second work package will be to observe outcome patterns to inductively identify C-M-O configurations and to deductively test IPTs within each of the two case study sites identified for in-depth realist evaluation. The outcome from this work package will be a refined programme theory for each of the two case study sites nominated for in-depth realist evaluation. The additional case study data from the other two sites will be used to support or refine the theories. At the end of the evaluation period (12 months) data will be reported to each of the case study sites. This will ensure that the knowledge generated from the evaluation can inform the study sites and be used to improve their interprofessional collaboration.The third and final work package will involve the synthesis and sharing of the refined programme theories which emerged from the second work package across case study sites to develop a middle range theory. This is a higher order theory involving a synthesis of more granular programme theories to provide hypotheses about how different types of interventions might work in different types of contexts in realising overall programme outcomes . The metMiddle range theory developmentFindings from each case study will be collated alongside all their support evidence. The first step of analysis will involve combining the programme theories and C-M-O configurations from both cases. Commonalities within the combined PTs and C-M-O configurations will be identified and grouped into a framework. The next step of analysis will be to identify predictable patterns occurring across the data. The additional qualitative data extracted from all four case study sites will be deployed at this stage. Data from all four sites will be reviewed to identify explanatory information to facilitate the synthesis of patterns of causation. This will support and refine the theories that had arisen from each of the two case studies and help manage any discrepancies between the case study findings.In line with realist methodology, the focus of this analysis will be to develop an understanding of the generative causality between different contexts and the mechanisms which are linked to specific outcomes . The resThree final validation workshops will be held with the four key stakeholder groups . The purpose of these workshops will be to refine and validate the theories and to generate discussion on how this theory can support the workforce capacity development with specific reference to teaching and learning approaches.Translation of the middle range theory into operational guidance and curriculum developmentThe realist evaluation proposed for this application will identify guiding principles that can be applied in practice to support effective interprofessional collaboration in the delivery of quality integrated care for older people in the community setting. Through dissemination, it will offer practical guidance and insights for policymakers and health and social care providers as well as organisational leaders, and innovators to support successful implementation programmes across the health systems nationally and internationally.The proposed project will impact the national healthcare workforce planning and development and through the dissemination of outputs will influence international conversations concerning workforce capacity in health and social care. The implementation evaluation of the ECLECTIC framework will directly influence the development of professional standards and guidelines for clinical design to support the implementation of the national older person’s service model. This will inform the recruitment strategy for the programme managers as well as continuing professional development for the integrated care teams established through the programme.We will work with the NCPOP to scale up the findings across the clinical programme for older people as well as translate these findings to other programmes which have been restructured to include a focus on interdisciplinary teams.The next element of work package three will involve the translation of the middle range programme theory into an interdisciplinary curriculum for the education and training of health and social care professionals. This will involve revision of the ECLECTIC framework  to incluA cross-disciplinary and institutional project team will be convened with representation from core health professional programmes  as well as regulatory bodies . The team will be supported by collaborators from the Australian Institute for Health Innovation at Macquarie University who will enable knowledge translation for broader health system impact. The team will also invite public and patient representatives from our PPI advisory group to become members. The aim of this project team is to co-design a curriculum framework which will map the knowledge and skills required for interprofessional collaboration. This framework will enhance interdisciplinary teaching, learning and assessment of interprofessional collaborative practice across health and social care professional curricula. It will be a resource for educators across health professional programmes as well as continuing professional development. It will support incremental learning of the appropriate knowledge and skills as well as provide recommendations for specific learning activities to scaffold competency among students. The middle range theory will be embedded into the framework ensuring that the curriculum is context specific and aligned to the mechanisms associated with measurable outcomes for interprofessional collaborative practice. This framework will be used to foster interdisciplinarity in the health and social care professional curricula and will form the basis for structured elective module development at both undergraduate and taught graduate levels.Members of the research team are academic champions of PPI as part of the UCD PPI Ignite program. The team have long established experience enabling patient, public and practitioner involvement in health system change such as co-designing frailty pathways in acute care settings  Older Persons Office, the HSE and the NCPOP will play a critical role in supporting the translation of the findings across the national integrated care programmes generally. The inclusion of the CST-OP clinical leads is critical for the translation of the findings into clinical design and practice as well as the operational guidelines and procedures within the National Clinical Programme for Older People. Associate Professor Harrison, a collaborator for this project, leads the healthcare engagement and workplace behaviour stream at the Australian Institute of Health Innovation, Macquarie University. The institute is focused on related areas of health services research, health informatics and health systems and safety. Harrison will work with co-applicant Ní Shé who has an honorary appointment at the institute in enabling knowledge translation of the work in Australia.The research team will be in the UCD Centre for Interdisciplinary, Research, Education and Innovation (UCD IRIS) and will harness the knowledge and expertise of the centre in translating study findings into broader health systems research and education. This will ensure that the knowledge generated from this study will have immediate relevance for future workforce capacity development and ongoing professional education. This translation into ongoing professional development will also be facilitated through the creation of learning resources for integrated care teams that will be developed in collaboration with the HSE and NCPOP as a result of this study.The findings from this study will also be disseminated to the international research community through publications in open-access peer-reviewed journals as well as presentations in national and international conferences. UCD Library, as a member of the IReL consortium of Irish academic libraries, has entered into a few Open Access Publishing agreements with key scholarly publishers. The budget request for this study will also provide for publication of two research papers in international open access peer-reviewed journals. Finally, this study protocol and a final study summary will be submitted for publication in HRB Open Research.The results of the realist review will be reported according to the Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) quality and publication standards  revolved around person-centered values but this was not reflected in the figure. Third, when talking about IPC team members, it is relevant to provide a description of the health professionals involved and their roles in the team considering the healthcare landscape in Ireland.Is the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Not applicableReviewer Expertise:Ageing, inteprofessional education and collaborative practice, quantitative research methodsI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. This is an excellently written paper outlining an extensive process to improve care of older people. Starting out by conducting a realist review will situate the subsequent study of 4 cases quite well. I appreciate the conducting of interviews and observations of team meetings initially, in six months and in a year as an important way to see differences in how teams develop and demonstrate competencies. Developing the mid-range theory to support how the competencies are applied to older adult care over different contexts will support the end goal of developing curriculum for interprofessional education. I look forward to further publications as this process unfoldsIs the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?YesReviewer Expertise:Nursing care of older adults, nursing education and interprofession practiceI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This paper describes the methodology for a realist review to evaluate the implementation of the ECLECTIC framework for the development of competencies in interdisciplinary community-based teams for older people. The goals are clearly described with an appropriate methodology clearly described and suitable to answer the research question. There is a structured plan of work packages that is realistic and deliverable. The methodology clearly describes how different sources of information will be identified and used to inform the research.  In particular, the explanation of the chosen methodology and rational for this choice is clearly presented. The plan for ethics review is appropriate. The plan for dissemination of results is also appropriate and hopes to influence policy meaningfully as well as to share learning from the research.Is the study design appropriate for the research question?YesIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Not applicableReviewer Expertise:Geriatric Emergency Medicine, Medical EducationI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


During the last few decades, the field of rehabilitation has experienced substantial development, growth and acceptance. Rehabilitation addresses the impact of a health condition on a person’s everyday life by optimising their functioning and reducing their experience of disability. Rehabilitation expands the focus of health beyond preventative and curative care to ensure people with a health condition can remain as independent as possible and participate in education, work and meaningful life roles .We also now have a better understanding of the growing global need, demand and recognition of rehabilitation around the world. For example, it has been estimated that 2.41 billion people in the world could benefit from rehabilitation services. This means that at least one in every three persons in the world needs rehabilitation at some point during the course of their disease or injury  seeks to understand and improve how societies organise themselves in achieving collective health goals and how different actors interact in the policy and implementation processes to contribute to policy outcomes   invite researchers in the field of HPSR for rehabilitation to submit their manuscripts to our journals for peer review and possible publication, (2) create a special journal section, series or designation dedicated to HPSR for rehabilitation, (3) appoint editorial board members with expertise in HPSR for rehabilitation and (4) disseminate research articles among funding agencies and policymakers. These actions by our academic journals will help the WRA achieve its goal of strengthening rehabilitation services for all.


It is known that the restrictions and clinical changes experienced during the pandemic period have negative effects on the care and treatment of psychiatric patients. However, insights on how the pandemic environment and the approaches of healthcare professionals serving during the pandemic affect the care and treatment of patients at risk of suicide are insufficient.This ethnographic study aimed to identify the approaches of psychiatric nurses in managing suicide risk during the pandemic period in relation with their work environment.This ethnographic research design used a sample of 13 psychiatric nurses in a psychiatric clinic in Ankara. Data were collected with in-depth interviews, participant observations and observant participations. Data were obtained from a total of 612 hours of observation and 13 planned nurse interviews. Data were analyzed using qualitative thematic analysis.The emergent main theme from data analysis is explained under the title of “The risk of loss of inauthenticity in suicide risk management”. “Risk of loss of inauthenticity” means the fact that the individual suicidal risk factors and differences of the patients cannot be perceived/assessed by the nurses.Supposing all patients having the same suicide risk level by psychiatric nurses caused insensitivity to risky patients in the care process. Nurses’ inadequate approach to patient personality disorder and limited social interactions due to the pandemic atmosphere made it difficult for nurses to have knowledge and understanding of how patients cope with suicidal ideations. These findings show the importance of the use of valid and reliable scales with risk formulations and the significance of triage in crisis periods such as current pandemic. In addition, creating available online consultancy service alternatives may have an important role in the management of suicide risk for patients who are disturbed by long-term hospitalization. Also these findings may contribute to the creation of qualified care and treatment guidelines on suicide risk management for crisis periods.None Declared


Balancing career and family is a hard job for everyone. Academic life with multiple and conflicting demands on our time necessitates prioritizing among responsibilities. This resonates especially for a woman academic who takes care of a baby. The speaker will address specific challenges of mothers who are in both academia and clinical practice, give reflections and elaborate on patterns and ways of dealing with this challenge. The talk is hoped to promote awareness and discussion on addressing the inner and outer sources and planning one’s own way on a career path.None Declared


As one of main aim of broad mental health (MH) reform in Bosnia and Herzegovina (BH), quality of services and continuous improvement are priorities. In last decade network of community services-community mental health centers (CMHC) covered all the parts of the country and is connected with secondary and tertiary medical institutions as well as with broad network of centers for social welfare and growing number of user organizations.As a novel practice that will be involved in standards of quality for all MH services is joint planning of hospital discharge people with mental illnesses, supported by legislative and connected with other positive results of mental health reform in BHReview of implementation of results of MH reform in BH with focus on joint planning hospital discharge.In BH in last decade has been established broad spectrum of services that improved quality of care through multidisciplinary collaboration between sectors. Important role has given to users’ organization. Quality standards are defined trough certification and accreditation. New services were developed or renewed and implemented . Entities’ policies and strategies involved new services and improved MH legislative following the course of more involvement of patients as well as their families, representatives or persons of their trust in decision making and planning of multidisciplinary treatments in the CMHCs. Joint Planning of discharge from the hospital fund as important step in further improvement of quality of care for people with MH disorders, especially for those with severe mental illnesses.Last decade in BH gave important results in the better quality of MH care. Further plans will be focused on implementation of new MH user-oriented services.None Declared


Intraventricular hematoma includes massive clots spreading in all four ventricles and partial clots obstructing cerebrospinal fluid circulation in the foramen of Monro and aqueduct and foramen of Magendie. The authors have described in detail the characteristics of hematocephalus; however, its basic mechanism and clinical management have not been fully discussed, as indicated by the authors. I suppose that many neurosurgeons agree with the authors’ opinion that simple intraventricular drainage is not always successful in the management of hematocephalus associated with massive intraventricular hematoma. Difficulties in management are as follows: the bleeding point is often unknown based on pre-operative imaging; emergent cases cannot allow conventional angiographical examination; even large drainage catheters can sometimes clog with clots of hematoma; intracatheter administration of fibrinolytic agents can cause rebleeding; the selection of neuroendoscopies is not simple; flexible- or rigid-type surgical devices for flexible neuroendoscopy for the removal of hematoma have not been fully developed; and hematocephalus includes variable causes of hemorrhage, which has complex pathological states. Moreover, clinical states often need emergent management, which can be challenging. The paper is of considerable interest to clinicians. The definition of hematocephalus is based on the report by Benes et al (2). The recent categorization of hematocephalus can provide new perspectives on pathological states and therapeutic strategies. The present paper is believed to contribute to the accurate categorization of the knowledge on hydrocephalus caused by intraventricular hematoma and development of new approaches to clinical management.Hematocephalus is a noncommunicating hydrocephalus caused by intraventricular hematoma, as described by Martin et al None


Besides selecting and developing (sub-) targets, evaluating target achievement  is an important aspect of the concept. This article discusses the methodological challenges for impact evaluation in addition to providing approaches to solve these issues.Experiences with the evaluation concept developed by the German forum  The collaboration is based on the principle of consensus. The members jointly develop national health targets, recommend measures to achieve the set goals and present recommendations for the practical implementation of measures. The forum ensures the results are made public and encourages the decentralised implementation of national health targets by stakeholders. The forum regularly evaluates and optimises target achievement rates and processes . GermanyExperiences with the evaluation concept, which was developed and implemented by academic experts, and the results it provides can be of use for prevention reporting. It is built around the following four areas:I. Target selection: Members of the health target forum name relevant fields of interest that are compiled to be assessed on the basis of a scientific catalogue of criteria . Based oII. Workgroups are established to elaborate the targets and sub-targets, guided by the following key points:►Targets are directed at the population and the health and social systems and aim to respect the principles of equal opportunity  ►They are based on the results of the scientific criteria analysis ►Measures recommended to achieve targets should be evidence-based, their implementation feasible and impact measurable►Criteria to quantify targets are also availableIII. Monitoring (sub-) target achievement will be based on the following questions: Has the (sub-) target been achieved? Which measures for target achievement have been implemented and how have they contributed to the achievement of targets? What conclusions do the results allow regarding the need to update targets?The complexity of measures provides methodological challenges at the different intervention levels which differ in extent and form. A broad range of stakeholders  help achieve targets in diverse contexts . Information is often scarce, in particular, concerning the effects of individual measures, the timespan during which such effects are visible and the mechanisms behind such effects, as well as the interplay between different measures in the achievement of targets.Possible steps to limit these methodological challenges include:►Selection of sub-targets and initial measures (priority measures) for evaluation►Focus on the national level (structures and population) or on larger units ►Development of measurable indicators to monitor the implementation and effectiveness of initial measures at different levels►Use of established sources of data►Detection of gaps in the data ►Identification of best practice models and relevant individual measures ►Theoretically grounded assumptions on the mechanisms that lead measures to be effectiveIV. Overall evaluation: a survey of the participating stakeholders was undertaken in 2013 that enquired about their experiences with and expectations of the process we had installed to establish targets. The survey focused on the strategies and model projects that members had developed to initiate and implement the established health targets and on recommendations on how to enhance the additional value provided by the forum. 49 out of the 69 surveyed stakeholders had defined fields of action for their organisation that were related to national health targets. 54 stakeholders could provide at least one example of a measure to implement these health targets [gesundheitsziele.de suggests that the experiences and results of the process to establish targets will be used by prevention reporting and that the evaluation committee and its expert academic members will thereby play an advisory role. Moreover, the results, methods and data that prevention reporting produces should be made available to the health target forum. We believe we should pursue the approach of impact evaluation and promote the methodological discourse on the evaluation of complex interventions as it is currently being discussed in public health research.The forum


In this issue of this journal, van Boxtel and colleagues  reportedLabelling of heart valve substitutes has been confusing since the introduction of the first man-made artificial heart valve, the Starr–Edwards ball valve. That is the reason manufacturers provide them with sizers to measure the annulus where they are to be implanted. This labelling problem is not only with supra-annular bioprosthetic heart valves used for aortic valve replacement but also with mechanical heart valves that are implanted in all positions in the heart as well as with annuloplasty devices used for heart valve repair. This issue is so important that the 3 major European and American cardio-thoracic surgical societies endorsed a document prepared by a panel of experts on heart valve substitute sizing .The ideal prosthetic heart valve substitute should offer minimal impedance to blood flow and this can often be attained by knowing the estimated effective orifice area of each valve type and size and matching to the patient’s body surface area. The initial problem is not the IOD but rather the mislabelling by the various manufacturers and the great variability in sizes for any given size and the effective orifice areas , 4. For The suggestions proposed by van Boxtel and Mariani  should b


After this article was published, similarities were noted between this article  and submIn response to queries about these concerns, the first author provided the underlying data in The authors commented on aspects of how data were collected and analyzed for this study, but overall their responses did not fully resolve the concerns.PLOS ONE Editors issue this Expression of Concern to notify readers of the unresolved concerns discussed above, and to provide the data received from the authors.The S1 File(ZIP)Click here for additional data file.


CPT: Pharmacometrics and Systems Pharmacology showcases recent modeling and simulation examples to develop and assess complex generic drug products, with scientific achievements that are germane to new drug development.Approximately 90% of prescriptions dispensed in the United States are generic drugs.The GDUFA was enacted by Congress in 2012 as a partnership between the generic drug industry and the FDA to bring cost‐saving medicines to patients faster. Under the GDUFA, the FDA assesses generic industry user fees to improve diverse aspects of regulatory review and approval of generic drug applications. Across two re‐authorizations, the GDUFA has enabled expanded research and innovation for complex generic drugs. These products are the generic version of a drug containing complex active ingredients, formulations, routes of delivery, dosage forms, and/or drug‐device combinations and for which early interactions with the FDA may be beneficial to address scientific challenges to avoid delays in approval.Central to the success of the initiative is the burgeoning integration and adoption of model‐integrated evidence (MIE) by generic drug developers and the FDA. MIE integrates evidence from empirical studies with computational models, extending the continuum of knowledge acquired through model‐informed drug development (MIDD) for a new drug application (NDA) with emerging post‐NDA knowledge.The FDA has pioneered advancements in QMM for complex generics to offer developers MIE‐driven frameworks to establish BE. The widening impact of QMM and MIE to demonstrate BE and characterize drug delivery for complex generics is spotlighted extensively in this mini‐themed issue. In 2021, workshops led by the FDA and co‐sponsored by the Center for Research on Complex Generics (CRCG) showcased advanced applications of mechanistic modeling and simulation platforms for determining BE and their utility in addressing complex generic drug development challenges. An overview of the learnings from the locally acting and oral generic drug product workshops are presented by Babiskin et al.Under the GDUFA III (2023 to 2027), utilizing QMM for complex generics to establish BE in place of clinical end point BE studies has the potential to lower development costs and accelerate access to generic drugs. A recent rise in MIE alternative BE approaches in pre‐ANDA and ANDA interactions between the generic drug industry and the FDA is signaling an industry shift from MIE development to implementation; Yoon et al.As MIDD and MBBE become central tenants to innovator and generic product development, there are opportunities to hybridize learnings to advance QMM in both arenas. The MMF may find value across innovator drug development to accelerate new drug approvals as part of the MIE continuum. Curation of standards for data generation, dataset and input parameter assessment, modeling analysis and validation, and reporting to ensure consistency and harmonization across global development and regulatory decision making are pertinent to both new and generic drug development so that QMM approaches are not underutilized. The International Conference on Harmonization (ICH) M15 Concept Paper for new drug approvals provides a foundation to expand these best practices to both innovator and generic products.


The corrected list of affiliations is as shown above.The authors regret that the email address for Muhammad Imran: imraniub86@gmail.com, was incorrectly listed under affiliation The Royal Society of Chemistry apologises for these errors and any consequent inconvenience to authors and readers.


Some evidence converges to consider that suicidal behaviour could be a separate diagnosis and emphasizes the relevance to identify specific biomarkers. Identifying the neural substrates of suicide attempt is key to understanding the etiology of suicide and might be helpful in reducing suicide rates among psychiatric patients by promoting the development of novel therapeutic strategies based on behavioral neuroscience and brain stimulation. Neuroimaging studies have reported structural and functional brain abnormalities located in the prefrontal cortex, insula and striatal regions as well as in the connections between these brain areas. Based on task related and resting state functional MRI studies, we will discuss original data showing the role of the ventral prefrontal cortex in suicide vulnerability.None Declared


Climate change and the need to reduce global carbon emissions drastically in upcoming years pose a challenge to physical activity (PA) promotion. Not only is PA more difficult in heat and people need to adapt, but also many physical activities come with a comparable high carbon footprint. While the field of PA promotion has so far utilized the health-enhancing physical activity (HEPA) concept to define and promote PA, this concept might need to be amended to account for the environmental impacts of PA. The aim of the presentation is to critically analyze the interconnections between PA and planetary health and suggest potential steps towards a concept of sustainable HEPA.


In the published article, there was an error in the Ethics statement. The registries' institutional review boards of Kurashiki Hospital and St. Luke's Hospital were listed, not the institutional review board to which the first author belongs. “The protocols for the studies were approved by the Ethics Committees of Kurashiki Central Hospital  and St. Luke's International Hospital . Written informed consent for participation was not required for these studies in accordance with the institutional requirements.” The correct Ethics statement appears below.“The protocols for the studies were approved by the Ethics Committees of Tokyo Bay Urayasu Ichikawa Medical Center . Written informed consent for participation was not required for these studies in accordance with the institutional requirements.”The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.


In 2013 the Berlin Health Conference  implemented intervention reporting for the first time within a kindergarten setting. Results from the survey of LGK Berlin members on current measures in kindergartens in Berlin that are related to the child health targets enabled us to map socio-spatial interventions and subsequently identify needs. This article highlights the potential and limits of intervention reporting as an element in the wider field of health and prevention reporting. The LGK Berlin is a network of institutions and associations that actively partake in health policy at the federal state level in Berlin and/or hold health policy responsibility. In 2012 the LGK decided to begin internal intervention reporting. Intervention reporting aims to create an instrument to optimise the management of activities and will be based on the self-commitment of LGK members to transparency in the implementation of measures in the context of Berlin's health target process [Intervention reporting was implemented for the first time in 2013 referring to measures in a kindergarten setting. LGK members were asked which measures they were implementing in kindergartens that relate to the fields of activity for Berlin's child health targets. To judge whether offers meet the (estimated) needs, the locations of the kindergartens in which LGK stakeholders were implementing measures were projected onto a map providing information on Berlin's social structure [Most LGK stakeholders view intervention reporting as a useful tool to identify social spaces with a heightened need for measures and those where needs are already being satisfied. Reporting can help account for socially compensatory aspects in the planning of measures. One risk is the potential to misinterpret results: a high number of offers in a particular area does not automatically mean that health is being effectively promoted here and vice versa, particularly because whilst intervention reporting does provide information on the kind and number of measures, it cannot say anything about how effective these measures were. Because intervention reporting only collects information on activities by the members of the LGK, it also does not provide a full picture of the activities in a social space that are directed at promoting health.Generally speaking, intervention reporting is a potential element of prevention reporting. Meaningful prevention reporting should cover all phases of the Public Health Action Cycle  , 4. Heal


Editorial on the Research TopicImpact of COVID-19 on cancer care and rehabilitationThe pandemic of COVID-19 had a significant impact on healthcare worldwide, affecting the care of many high risk patients including those with cancer . ReferraFor example, short-course radiotherapy was used to delay the need for surgery in locally advanced rectal cancer and reduced attendance requirement in the hospital setting . This haA number of healthcare settings utilised technology in their outpatient clinics switching to virtual consultations thus further reducing hospital attendance whilst still providing a high quality level of care . StudiesThe British Oncology Pharmacy Association collated changes in oncology pharmacy services during the pandemic and provided a guide for its members on reviewing and evaluating these changes for consideration for future services in the endemic phase . An examThe purpose of this collection of papers is to showcase and share learning from those who have had experience of these changes including implementing the use of IT solutions and/or IT science to assist and improve clinical outcomes for patients.There are four articles in this research topic each providing insight into the affects COVID-19 has had on cancer care around the world and the initiatives that have been implemented. Each study had a unique angle to investigate with some focusing on the impact of mental wellbeing on treatment delays while others examining predictive models measuring the impact of the pandemic on hospital admissions.Cigarini et al. described the impact that the pandemic had on cancer care pathways in northern Italy and proposes a tool for providing high levels of quality care even in the most critical health situations.He et al. described factors influencing delayed treatment in people living with breast cancer. This study took place in Chengdu, China and described a cross sectional investigation of close to 400 patients living with breast cancer.Liu et al. report on an interrupted time series analysis investigating the impact of the pandemic on monthly hospital admissions for cancer patients in Henan, China. They also review the delays to diagnosis and recognise that telemedicine is not only a helpful IT solution for those that cannot visit a hospital but it can also be used to support reduction of the backlog caused by the pandemic.Jani et al. reviews the risk factors associated with worse outcomes from COVID-19 in cancer patients and understanding a suitable method to mitigate the risks of COVID-19 for this patient cohort.The final article submitted by The COVID-19 pandemic was disruptive to most health care services and healthcare professionals displayed resilience and agility in adapting the care they provided to their patients. The impact and resulting learnings were valuable and will help better prepare for any future similar disruptions.Both editors of this research topic wish to thank all submitting authors for their work. As the editorial team, we hope that this research continues to prove a useful resource to provide care to cancer patients during unprecedented times.


To review the current state of diabetes treatment from a clinical and management perspective and explore the role that new biologic pharmaceuticals may offer patients who fail to meet or maintain glycemic goals with existing treatment options.Key clinical areas involve the role that insulin resistance and beta-cell dysfunction/failure play in the progression of type 2 diabetes as well as current treatment modalities and how they address those core defects. Management issues include a discussion of the economics of the disease and the implications of theUnited Kingdom Prospective Diabetes Study (UKPDS)—that good glucose control reduces the occurrence of microvascular complications and improves quality of life for diabetic patients. While an intensive approach may be costly in the short term,statistics on the rising pandemic of the disease argue compellingly for early and aggressive treatment to delay fatal complications and improve the quality of life for persons suffering from type 2 diabetes. Current pharmaceutical regimens are not successfully enabling patients with type 2 diabetes to reach glycemic goals. The ramifications of this failure have profound repercussions in the managed care organization environment. Fortunately,new treatment modalities are in various stages of development. These will be reviewed with a more in-depth exploration of the potential of incretin mimetics, a new biologic, injectable class of drugs for the treatment of type 2 diabetes. Emphasis will be given to exenatide, an incretin mimetic that demonstrates particular efficacy for patients not achieving glycemic goal with oral medications and are insulin naive. Biologics are administered by injection or infusion and are generally costly. Apart from their cost, however, what is even more critical to managed care executives and decision makers is that these medications indicate a trend in pharmacotherapy,a groundswell of new medications. In addition, few practitioners and even fewer health care executives understand molecular medicine. The key message is that making formulary decisions about these pharmaceuticals will become more pressing every year.Managed care executives will be faced with the significant challenge of investing their limited resources in the most clinically and fiscally responsible manner within a milieu of ever increasing pharmacologic options that could significant lystrain budgets and result in less than optimal patient outcomes.


ACS Sensors entitled “Sensing Technologies for Extravasation Detection:A Review”1 and we appreciate theinterest it has generated in the scientific community.We recently received and checkedyour Comment about our latest Review in perse.2The authorsof the Letter pointed out remarkable observations aboutthe procedure of peripheral intravenous cannulation (PIVC) and citedinnovative and recent technologies that practitioners and cliniciansare learning to use. Since the main goal of our review is to providethe reader with an overview of the systems and strategies developedover the years to monitor the inserted catheter and possibly detectIntravenous Extravasation (IE) events, we did not go into the detailsof technologies realized for the placement of the device. Indeed,we believe that these technologies refer to a different topic (improvingthe placement and insertions of catheters in veins and arteries) anddo not really fall within the scope of our paper but could be treatedas a separate work, probably worthy of a review paper 6 The cited works are mainly related to the possibility of buildinga panel of guidelines and best practices for nurses and professionalsfor the prevention and management of IE events. This aspect is ofcourse extremely important in clinical practice and we thank the authorsof the letter for highlighting it, since these tools could be exploitedsynergistically with the technological devices we presented in ourreview and could support the human component.Some works reportedby the Comment’s authors clearly demonstratethe growing interest and awareness of the need to continuously researchmethods for detection and treatment of extravasation.help themwith this. Indeed—as the authors of the Comment also mentioned—weshould be able to offer to the patient the best method of early detectionand identification of peripheral intravenous extravasation.This aspect isalso linked to the last comment raised by the Comment’sauthors: we are aware that these technologies are not yet ready forclinical use, which is why in the last section Concluding Remarks,Challenges, and Perspectives we provided some considerations on whatwe believe are important features that an IE prevention device shouldhave. The ultimate goal was not to compare a practitioner’sexperience with a technological device in detecting extravasationbut to find the best way technology can


Evidence suggests that green space use for physical activity significantly benefits to maintenance and improvement of public health. Settlements need to provide adequate access to public green spaces which enable and encourage physical activity. Provision of publicly accessible green spaces is therefore often included in different sectoral strategies and policies. However, to really meet goals and objectives, declared in these documents, appropriate and efficient actions need to be taken in spatial development practice on a local level.We present the approach, developed within the first year of the national research project PREZENCA, which aims at developing indicators for the assessment of the provision of settlements with green spaces for outdoor physical activity in Slovenian municipalities. The approach may be of interest to countries which have adequately developed strategic spatial planning of urban green spaces but lack useful tools to assess the current state and to monitor changes in the provision of quality green and other outdoor spaces to encourage physical activity.The approach is based on a comprehensive analysis of examples and possibilities for measuring presence and quantity of green spaces, defining green space types, and measuring citizens’ accessibility and use of green spaces for physical activity. Content analysis of existing planning documents on a local level was carried out to elaborate: (1) whether the provision of green spaces in settlements in Slovenia is defined and how (2) which population groups are addressed and (3) where such content should be put into policy documents to support implementation in practice. Based on the results, the suggestions on relevant factors and indicators of green space provision and quality for physical activity were prepared to be further developed for evaluation and monitoring on the local level and included into spatial planning practice and policies.Furthermore, we discuss the importance of establishing local standards and possibilities to include them into planning documents to form the basis for long-term monitoring of the condition of publicly accessible green spaces for recreational use by residents.


Cross-sectional data has shown that compassion for self and from others may be a protective factor for greater psychosocial wellbeing in the COVID-19 pandemic whilst fears of compassion act as a risk factor for experiencing mental health difficulties.The current study sought out to explore the natural fluctuation of compassion  and of fears of compassion  across time during the COVID-19 pandemic in a multinational community sample.Data from 4057 participants from 21 countries was collected at 3 time points during the pandemic . Other than demographic variables, participants completed the Compassionate Engagement and Action Scales and the Fears of Compassion Scales. Multilevel latent growth modelling was used to investigate the main aims.There was a significant increase in compassion for self and from others, whilst compassion for others remained unchanged throughout the 3 time points . Fears of self-compassion and compassion for others significantly reduced throughout the pandemic whilst fears of compassion from others remained stable .The findings from this study seem to suggest that in a period of shared suffering people from multiple countries and nationalities tend to become more compassionate and less afraid of and resistant to compassion for and from others.None Declared


In 2020 – 2021 the Robert B. Greenblatt, M.D. Library at Augusta University implemented two projects leveraging virtual reality (VR) technology to provide immersive experiential learning opportunities for health sciences students. The projects shared some commonalities in spite of having differing objectives and desired outcomes. These common facets led to the success of both projects and will be helpful for other institutions considering implementing VR projects. This project is described in detail in a previously published article  and was The second project utilized virtual reality technology to create a VR escape room to introduce concepts of data literacy and research data management in a more engaging way. The primary objective of this project was to instruct graduate students in the health sciences disciplines how to ethically manage data. The scholarship and data librarian was inspired to find a way to gamify the information and decided to develop the virtual reality escape room. She and the allied health sciences librarian collaborated with the Department of Physical Therapy (PT) to launch a pilot project to develop the data literacy modules for the PT graduate students. The escape room game is an innovative component to engage students in a non-traditional way beyond the classroom setting. Students work their way through the escape room by finding clues, answering questions and following instructions related to data management principles. Research shows that game-based learning can increase student learning by incorporating elements of game mechanics with established learning theories .Both projects involved partnering with Augusta University's School of Computer and Cyber Sciences, in particular a faculty member who is an expert in virtual and augmented reality. His students chose to build out the VR experiences for the library's projects as capstone projects for their degree programs. This expertise proved invaluable as the library's faculty and staff did not have the skills to build the experiences themselves. The other common elements for both of these projects are that they both involved partnership and collaboration with other academic units on campus . They also both utilized the same equipment, allowing for interoperability see . Lastly,Both of the projects have been well-received. The virtual reality space in the Greenblatt Library is being utilized by at least three groups per week. The Physical Therapy students provided positive feedback about the virtual reality escape room as a method to learn data management principles.


These results are noteworthy as they were obtained in patients with high degree of cartilage degeneration (Kellgren&Lawrence grades III and IV) although commonly HTO surgery is applied for patients with early and moderate OA with lower degree of cartilage degradation [I read with great interest an article by Dong et al. . The autradation . It is aradation –5 and deradation , we reporadation , 8 whereAnother concern about the article by Dong et al.  and otheIn conclusion, comprehensive studies of various orthobiologics associated with osteotomies including evaluation of functional outcomes at the molecular level such as analysis of proinflammatory environment and regenerative machineries should be encouraged in search for further improvement of treatment options for patients with OA.


The distribution of these silver nanostars on the surface allowed excellent reproducibility of the detection with a low relative standard derivation (RSD) of SERS intensity of 8%. This work potentially builds a platform for an ultrasensitive detector where samples can be probed with little to no pre-processing and a range of pollutants can be detected at very low levels.Strategies for synthetic control of anisotropic metal nanostructures have grown in recent years in part due to their great potential for application as surface-enhanced Raman scattering (SERS) sensing substrates. It has been shown that SERS using silver substrates is a powerful tool for identification and qualification of trace chemical analysis on the basis of their unique molecular vibrations. In this work, we synthesized star-shaped silver nanostructures and fabricated SERS substrates to use the SERS enhancement of the Raman signal to detect neonicotinoid pesticides. These silver nanostar substrates were prepared by assembling the nanostar particles on a glass substrate surface using a self-assembly technique with various layers of silver nanostars film. The silver nanostar distribution on the solid substrate surface was found to have good reproducibility, reusability and were a stable SERS substrate giving SERS enhancements for pesticide detection at concentrations as low as 10 Technically, SERS occurs when conduction electrons of metal nanoparticles on the surface interact with electromagnetic radiation such as light waves, which can lead to an amplification of natural electronic oscillation. This phenomenon enhances the optical near fields to allow single molecule detection. Thus, the SERS technique is commonly used in chemistry and biology analysis because of the high sensitivity and the fact that the spectra of molecular vibrations provide a fingerprint to identify molecules .Joseph George Shapter was supported by Data will be made available on request.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Oestrogen plays a vital role in maintaining a normal vulvovaginal epithelium, vaginal lubrication, as well as a healthy microbiome to ensure an acidic pH. The decrease in oestrogen levels in women going through menopause results in both physiological and physical changes of the genitourinary system, and more specifically the vulva. We conducted a literature review on the effects of low oestrogen levels on the physiology and function of the vulva and the vulvovaginal epithelium. ‘Genitourinary syndrome of menopause’ (GSM) is the term used to describe the signs and symptoms of a low oestrogen state. The symptoms and signs of GSM can overlap or coexist with other vulval dermatoses. Expert opinion is needed to diagnose and manage vulval dermatoses in menopause. This article will discuss the signs and symptoms of GSM, as well as the different management options available. Other vulval dermatoses that can be affected by hypo‐oestrogenism are also reviewed. The low oestrogen levels during menopause lead to physical and physiological changes to the female genitourinary tract. This can lead to the characteristic changes known as genitourinary syndrome of menopause (GSM). The symptoms and signs of GSM can overlap or coexist with other vulval dermatoses. Expert opinion is needed to diagnose and manage vulval dermatoses in menopause.here for the corresponding questions to this CME article.Click  This article reviews the effects of menopause on genital skin, by discussing the features and management of genitourinary syndrome of menopause (GSM), as well as other vulval dermatoses.The Cochrane Library, National Institute for Health and Care Excellence (NICE) Evidence database and the Turning Research into Practice database were searched from 2001 to 2021. In total, 116 original research articles were found on menopause in dermatology, 42 of which related to vulval conditions. Individual searches were performed for specific queries related to our paper.The embryological origin of the vulva is the primitive urogenital sinus, which is rich in oestrogen receptors, whereas the epithelium of the labia majora is derived from the ectoderm, which has more androgen receptors.Oestrogen is vital in maintaining a normal vulvovaginal epithelium, lubrication and microbiota.GSM is a constellation of symptoms and signs caused by low levels of oestrogen.A holistic and individualized approach is required to manage GSM. The aim of treatment is to relieve the symptoms and improve QoL. It is important to exclude other causes of vulvovaginal symptoms. Treatment can be classified into hormonal or nonhormonal. Nonhormonal topical therapy options are summarized in Table Vaginal and vulval lubricants and moisturizers are important first‐line management options to relieve the symptoms of GSM. They help to reduce the friction and discomfort caused by the dryness and atrophy of the genital tissues. A water‐based lubricant is generally preferred with minimal excipients to reduce vulval irritation.Hyaluronic acid (HA) is an important component of the extracellular matrix, and plays a role in the repair of the epidermis and dermis. Menopause causes a reduction of collagen and water retention of the vaginal epithelium. HA is available in various formulations, including gel, vaginal tablets, pessaries and oral tablets.The mainstay of treatment of GSM is topical oestrogen preparation. This has consistently been shown to be the most effective treatment for the symptoms of GSM, especially vulvovaginal atrophy.Topical testosterone (dehydroepiandrosterone) is also used to help with dyspareunia and urinary symptoms of GSM.Systemic HRT is an effective treatment for the symptoms associated with menopause including those of GSM.Selective oestrogen receptor modulators are a synthetic nonsteroidal class of drugs, which act on the oestrogen receptor.Lasers and radiofrequency devices have been used to treat the symptoms of GSM.Pelvic floor exercises for women who have pelvic floor dysfunction have shown to be effective as measured by improvement in QoL and GSM assessment scores.Vulval dermatoses that can present in any age group but can potentially be exacerbated by menopause include lichen sclerosus (LS), lichen planus (LP), irritant dermatitis, and vulvodynia and vulvovaginal candidiasis. Vulval malignancy is also more common with age, and therefore more common in post‐menopausal women.Vulval LS is an inflammatory scarring dermatosis that predominantly affects postmenopausal women. The true aetiology is unknown but an autoimmune cause and a genetic predisposition are implicated.LP is a mucocutaneous autoimmune condition. It can cause irreversible architectural change and significant morbidity.The different types of dermatitis that can affect the vulva are atopic dermatitis, irritant contact and allergic contact dermatitis. Urinary incontinence in postmenopausal women can make them susceptible to irritant dermatitis.Vulvodynia is a chronic pain syndrome in the absence of an identifiable cause.The low oestrogen state in menopause means that candidal infections are less likely, and studies have found that vulvovaginal candidiasis is more common in women taking HRT.Premalignant and malignant conditions that can affect the vulva are listed in Table Oestrogen is vital in maintaining a healthy female genitourinary system, and the low levels of oestrogen in menopause results in characteristic changes.Decreasing levels of oestrogen in menopause lead to physical and physiological changes in the vulva, which can present as vulvovaginal atrophy.GSM is the specific diagnosis given to the effects of the low oestrogen state of menopause on the genitourinary system.This review summarizes the effects of menopause on the vulva, including the specific changes associated with GSM, and giving an overview of the management of GMS, along with a discussion of other dermatoses affecting the vulva.The mainstay of treatment of GSM is topical oestrogen therapy, which is best used in conjunction with water-based lubricants and moisturizers; systemic HRT is not routinely indicated for the symptoms of GSM alone.Dermatoses affecting the vulva include LS, LP and irritant dermatitis; the symptoms of these can overlap with GSM.A holistic and multidisciplinary team approach is needed to improve QoL for postmenopausal women.Menopause and low oestrogen states lead to physical and physiological changes in the genital skin, leading to significant morbidity. It is important to recognize the changes associated with menopause in order to offer appropriate treatment and improve QoL for affected women. More research is needed on the role of hypo‐oestrogenism on vulval conditions and the potential role of HRT.The authors declare that they have no conflict of interest.None.Ethics approval and informed consent not applicable.To gain up‐to‐date knowledge on the female genitourinary system and disorders that can be associated with menopause.(a) The labia minora is derived from the ectoderm.(b) The ectoderm has more androgen receptors.(c) The labia majora originates from the primitive urogenital sinus.(d) The epithelium of the labia minora is lacking in oestrogen receptors.(e) An alkaline pH is ideal for the maintenance of a healthy vulvovaginal epithelium and microbiota.Which of the following is correct regarding the embryological origins of the female urogenital tract and the healthy vulvovaginal epithelium?(a) Atrophy of the vulval tissues is the only physical sign of GSM.(b) GSM affects a small minority of menopausal women.(c) Symptom severity usually correlates with physical findings.(d) The symptoms and signs of GSM can have a significant impact on patient quality of life (QoL).(e) The symptoms of GSM tend to get better with time.Which of the following statements about genitourinary syndrome of menopause (GSM) is correct?(a) Systemic hormone replacement therapy (HRT) is indicated for the management of the vulval symptoms of menopause alone in the absence of other symptoms of menopause such as vasomotor symptoms.(b) Topical lubricants and moisturizers are not routinely recommended for the relief of symptoms of GSM.(c) There is no evidence that hyaluronic acid (HA) preparations are useful in the management of the vulval symptoms of GSM.(d) Ospemifene acts on the progesterone receptors.(e) There is not enough evidence for laser‐based treatment to routinely recommend their use for the management of GSM.Which of the following statements about the management of genitourinary syndrome of menopause (GSM) is correct?(a) Topical oestrogen therapy should be continued as long as it is needed.(b) Regular monitoring of endometrial thickness is advised for women on long‐term topical oestrogen therapy.(c) Topical oestrogen therapy has rapid onset for the relief of the symptoms of GSM.(d) Topical oestrogen therapy is safe in women taking aromatase inhibitors for the treatment of breast cancer.(e) Gel‐based preparations are superior.Topical oestrogen therapy is first‐line management of the genitourinary syndrome of menopause (GSM); which of the following statements is correct?(a) It is easy to differentiate between the clinical findings of vulval lichen sclerosus (LS) and late genitourinary syndrome of menopause (GSM).(b) Genital candidiasis is more common in menopause.(c) Low oestrogen levels lead to impaired water retention in the epidermis and impaired skin barrier function.(d) Vulvodynia usually has a clear cause.(e) Menopausal women have the same risk as premenopausal women of developing a vulval malignancy.Which of the following statements about vulval dermatoses and menopause is correct?http://www.wileyhealthlearning.com/cedThis learning activity is freely available online at Read the article in print or online, paying particular attention to the learning points and any author conflict of interest disclosures.Reflect on the article.http://www.wileyhealthlearning.com/ced and answer the CPD questions.Register or login online at Complete the required evaluation component of the activity.Users are encouraged toOnce the test is passed, you will receive a certificate and the learning activity can be added to your RCP CPD diary as a self‐certified entry.This activity will be available for CPD credit for 2 years following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional period.


The treatment of psychological trauma is an integral part of the health care provided to military patients in Tunisia. For patients with PTSD several therapeutic options are proposed to patients as EMDR but there are various barriers to the use of EMDR . It seems that being patients consider the therapy which necessitate recognition and expression of emotional distress as a weakness. Added to that patients may be judged negatively by others and experiencing social rejection and isolation which limited the use of EMDR in a military setting.The aim of this study is to study the contribution of the EMDR associated to pharmacological treatment in PTSD among military patients comparing to patients who received only medication .The study was conducted since 2021 during ten months at the military hospital concerned two groups of patients with PTSD the first one composed of four military patients with PTSD who received 11 sessions of EMDR associated to medication and the second one four patients exposed to the same trauma under medication only. The evolution oftroubles were assessed using PCL-5 scale and medication compliance was assessed by psychometric scale MARS .Other data was gathered from medical files .The first group of four military patients who were followed for PTSD since a year under pharmacological treatment presented sleep disorders with flaschbaks and nightmares , . The patients consulted for a depressive disorder and asocial isolation with feelings of insecurity about others. Psychiatrists proposed to associate 11 sessions of EMDR . At the end of sessions the evolution was interesting with regression of symptoms and remission comparing to the second group who presented relapses ten months later.To improve symptoms of PTSD The use of EMDR is not systematic in a culture where emotional expression is restrictive in an environment that favors the intellect over the emotions. However EMDR can help the military patients with PTSD to link cognition to the emotions. PsychiatristS should propose this therapy as well as possible to patient with severe trauma to avoid relapse .None Declared


In the published article, there was an error. A correction has been made to the Conclusion section.The Conclusion previously stated:“Building resilience into a reformed health system will be key in ensuring Ireland's ability to respond to future threats such as pandemics. Operationalization of the EPHFs can help ensure the health system is prepared to meet the next challenge affordably and sustainably. The findings of the review have been utilized to support high level advocacy for the shift toward public health required to build and ensure health system resilience against future threats. Work is currently underway to utilize the EPHFs to define the operational scope of public health in Ireland and to identify the scope and functions of a new national public health institute and will help inform ongoing implementation of public health reform. Given the current focus on strengthening public health capacities globally, the findings in Ireland have applicability and relevance to policy audiences and key decision makers within Ireland as well as more broadly to other WHO regions and member states for health systems recovery and building back better, fairer and more resilient health systems.”The corrected section appears below:“Building resilience into a reformed health system will be key in ensuring Ireland's ability to respond to future threats such as pandemics. Operationalization of the EPHFs can help ensure the health system is prepared to meet the next challenge affordably and sustainably. The findings of the review have been utilized to support high level advocacy for the shift toward public health required to build and ensure health system resilience against future threats. Given the current focus on strengthening public health capacities globally, the findings in Ireland have applicability and relevance to policy audiences and key decision makers within Ireland as well as more broadly to other WHO regions and member states for health systems recovery and building back better, fairer and more resilient health systems.”The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.