Community Healthcare Settings Research Articles

PATH-39. AI-BASED IDENTIFICATION OF GLIOMA IDH MUTATIONAL STATUS FROM H&E-STAINED WHOLE SLIDE IMAGES

Abstract INTRODUCTION Isocitrate-dehydrogenase (IDH) mutational status is diagnostically critical in adult gliomas, with prognostic and therapeutic implications. IDH status cannot be determined by sole histologic assessment and requires molecular testing. We hypothesize that AI-based analysis can accurately predict IDH mutational status in glioma, by retrieving sub-visual cues in H&E-stained digitized tissue sections. MATERIALS AND METHODS A retrospective discovery cohort of 1,534 cases (756/778 IDH-wildtype/IDH-mutant, including all available grades) from the TCGA-LGG/TCGA-GBM collections was used for model development with 10-fold cross-validation (CV). A replication cohort of 114 cases (82/32 IDH-wildtype/IDH-mutant) from the University of Pennsylvania Health System (UPHS) was used for independent hold-out evaluation. Each 20X magnification whole slide image (WSI) underwent comprehensive curation for elimination of artifactual content, followed by partitioning into 256x256 patches, and feature extraction using pre-trained i) ImageNet weights (baseline), and ii) self-supervised vision transformer (ViT). A weakly-supervised attention-based multiple-instance-learning framework distinguished cases as IDH-wildtype or IDH-mutant, while generating visually interpretable attention heatmaps. RESULTS Evaluation on discovery and replication cohorts with the ViT yield accuracy of 90.84% (AUCDiscovery=97.16%) and 93.94% (AUCReplication=97.36%), respectively, with high sensitivity (i.e., high confidence in correctly predicting IDH-wildtype glioma). Comparison of the ViT with the baseline model on the replication cohort indicates the ViT superiority by improvements of 8% and 9.5% in accuracy and AUC, respectively. Histologic assessment of heatmaps indicates IDH-wildtype tumors exhibiting distinct regions of significant pleomorphism and microvascular proliferation, while IDH-mutant tumors exhibit dense nodular cell concentrations, microcystic architecture, and gemistocytic cells. CONCLUSION Our accurate H&E-based computational determination of glioma IDH status, with interpretations aligned with human-identifiable features, can contribute to obviating the need for molecular analyses and enable expedited diagnosis even in community healthcare settings. This study robustly identifies morpho-IDH correlates and could enable expedited patient prognostic stratification.

Understanding How, Why and for Whom Link Work Interventions Promote Access in Community Healthcare Settings in the United Kingdom: A Realist Review.

Inequity in access to healthcare in the United Kingdom can have a profound impact on people's ability to manage their health problems. Link work interventions attempt to overcome the socioeconomic and structural barriers that perpetuate health inequalities. Link workers are typically staff members without professional clinical qualifications who support patients to bridge the gap between services. However, little is currently known about how and why link work interventions might be effective. This realist review attempts to understand the contexts and resultant mechanisms by which link work interventions affect access to community healthcare services. The authors completed a systematic search of empirical literature in Embase, CINAHL, Medline, PsychInfo and SocIndex, as well as grey literature and CLUSTER searches. Context, mechanism and outcome (CMO) configurations were generated iteratively in consultation with an expert panel and grouped into theory areas. Thirty-one eligible manuscripts were identified, resulting in nine CMO configurations within three theory areas. These pertained to adequate time in time-pressured systems; the importance of link workers being embedded across multiple systems; and emotional and practical support for link workers. Although link work interventions are increasingly utilised across community healthcare settings, the contexts in which they operate vary considerably, triggering a range of mechanisms. The findings suggest that careful matching of resources to patient need and complexity is important. It affords link workers the time to develop relationships with patients, embed themselves in local communities and referring teams, and develop knowledge of local challenges. The team included people with lived experience of mental health conditions and a carer who were involved at all stages of the review.

"Pushed to Their Limits": Health Care Provider Perspectives on Barriers and Facilitators to Implementing a Mind-Body and Activity Program for Older Adults With Chronic Pain in a Community Clinic for the Underserved.

Older adults from underserved backgrounds experience chronic pain at a rate of 60% to 75%. Pharmacological treatments have limited efficacy and involve considerable risks. Mind-body interventions hold promise to improve pain outcomes but are typically not implemented in community clinics in which they are needed most, thus contributing to health disparities in chronic pain treatment. We conducted qualitative focus groups and interviews with 20 providers (eg, primary care doctors, nurses, administrators). We sought their perspectives on barriers and facilitators to implementing an evidence based mind-body activity program for older adults with chronic pain at an underserved community health clinic in Massachusetts. Subthemes were identified within 2 superordinate domains (barriers and facilitators) using a hybrid inductive-deductive thematic analysis approach following the Framework Method. Providers discussed facilitators (partner with clinic staff to facilitate referrals and buy-in, integrate referrals through the electronic medical record, offer groups in different languages, post and tailor advertisements) and barriers (limited staff bandwidth, scheduling challenges, inconsistent patient participation). These results will directly inform tailoring and subsequent effectiveness testing and implementation of the pain management program for older underserved adults with chronic pain in this community health care setting.

How First Nations peoples living in the Torres Strait and Northern Peninsula Area describe and discuss social and emotional well-being.

This study was the first phase of a broader project designed to develop a new tool to screen social and emotional well-being (SEWB). Its objective was to identify words used by First Nations people living in the Torres Strait (Zenadth Kes) and Northern Peninsula Area (NPA) to describe and discuss SEWB. We pay our respects to Elders past and present. We acknowledge the First Nations peoples who took part in this project as holders of their cultural knowledge now and forevermore. This study took place in community and primary health care settings located on islands of the Torres Strait and NPA of Australia. Twelve yarns with 35 community members and health professionals were led by Torres Strait Islander members of the project team between August and December 2022. This study employed a descriptive qualitative design. Yarning, an Australian First Nations relational method, was used to share stories about SEWB. All but one yarn was audio recorded and subsequently professionally transcribed. Inductive thematic analysis was used to analyse the yarns. Worry, sad and stress were the words most often used by participants to describe feelings of low SEWB. Signs of low SEWB included behaviour change, particularly significantly reduced community engagement. Worry is not a word that is used in Australian mainstream tools that screen for psychological distress. Findings of this study indicate that a question that asks about worries should be included when screening for low SEWB in Australian First Nations peoples living in the Torres Strait and NPA.

Epidemiology and population-based incidence of influenza in two communities, Bandung district, West Java, Indonesia, 2008–2011

Influenza surveillance is important for monitoring influenza virus circulation and disease burden to inform influenza prevention and control measures. The aim of this study was to describe the epidemiology and to estimate the incidence of influenza in two communities in West Java, Indonesia, before and after the 2009 H1N1 pandemic. A population-based surveillance study in the community health care setting was conducted to estimate the annual incidence of influenza. A real-time reverse transcription polymerase chain reaction (RT-PCR) assay was used for influenza case ascertainment. A population census was implemented to calculate the population at risk and estimate community health care utilization rate. The mean annual incidence of influenza A and B, adjusted for healthcare utilization, was 1.6 (95%CI: 1.3–2.0) and 0.7 (95%CI: 0.5–1.0) per 1000 persons, respectively, with the most affected group being young and school-age children. The annual cumulative incidence of influenza A for children under five in 2009, 2010, and 2011 was 7.0 (95%CI: 4.4–11.2), 10.6 (95%CI: 7.3–15.4), and 6.3 (95%CI: 3.8–10.2). For influenza B was 4.3 (95%CI: 2.4–7.8), 2.0 (95%CI: 0.8–4.7), and 0.4 (95%CI: 0.1–2.8), respectively. This study highlights that the incidence of influenza among young and school-age children is consistently higher compared to adults and the elderly throughout these periods. These populations are potential targets for influenza vaccination in Indonesia.

Bridging gaps at key intersections: Strategies to improve early intervention and treatment access for eating disorders

ABSTRACTMental health is at the forefront of discussions in healthcare, education, and social settings, yet eating disorders remain poorly understood and inadequately treated. This paper presents evidence on risk factors for insufficient recognition and intervention for eating disorders across clinical and community healthcare settings and proposes actionable strategies to improve awareness and early intervention for eating disorders. Specifically, gaps in eating disorder awareness and treatment access are exacerbated at two key intersections within health and social systems. First, eating disorders manifest themselves at the intersection of mental and physical categories of health, which places them at risk of being misunderstood, poorly diagnosed, and insufficiently intervened upon. Second, the peak onset of eating disorders falls at the intersection of adolescence and young adulthood, which is a period of rapid developmental, social change, and transitions in care. This analysis highlights how systemic issues within existing social and health systems underlie these intersections and contribute to the continued stigmatization and inadequate treatment access for eating disorders. Given their increased incidence and severity, there is an urgent need to address both the individual and societal burden of these disorders. Healthcare systems must prioritize coordination between physical and mental health practices and improve transitions in care from pediatric and adult healthcare services. Identifying gaps at intersections provides the opportunity to make concrete progress toward improving awareness and treatment.

Debate: Bridging the gap - role of nonspecialists in child and adolescent mental health care.

The first point of contact for patients and families seeking professional help for health problems is often in nonspecialist community healthcare settings that vary widely across the countries in funding sources, resources and support from specialist services. They typically involve general practitioners, family physicians, general and community paediatricians, and nonphysician health workers such as nurses, social workers and public health professionals. This article discusses the role of nonspecialists in addressing the challenges of limited resources in Child and Adolescent Mental Health (CAMH) care services as healthcare systems struggle to meet the high demand. Stakeholders and decision-makers need to reconsider traditional healthcare models and service delivery. Integrating nonspecialist community care can be a potential solution but is beset with ethical, geopolitical, practical and economic challenges. The urgency and complexity of the issue are highlighted, emphasising the need for global discussion around CAMH care.

8288 Navigating Diagnostic Challenges of Amiodarone Induced Thyrotoxicosis in a Psychiatrically Complex Patient within a Community Hospital Setting

Abstract Disclosure: M.S. Shah: None. K.P. Sanu: None. S. Humayon: None. R. Chawla: None. N.K. Bains: None. This case delves into the intricate diagnostic and therapeutic journey of a 64-year-old male who presented to a community hospital with psychosis. Medical history was pertinent for ventricular arrhythmias treated with amiodarone 400 mg once daily, bipolar disorder with medication non-compliance and heart failure with reduced ejection fraction status post automatic implantable cardioverter-defibrillator placement. Collaboration with the patient's family revealed a history of repeated hospitalizations for similar presentations as well as recent weight loss. The challenge lay in distinguishing between manic episodes and other potential underlying medical causes. The patient's recent weight loss and amiodarone use prompted a thyroid panel, revealing a TSH of 0.01 mlU/L (n = 0.27 to 4.20 mIU/L), free T4 of >7.77ng/dL (n = 0.93 to 1.70 ng/dL), and free T3 of >7.51ng/dL (n = 2.00 to 4.40 pg/mL). Inadequate facilities for a radioactive iodine uptake (RAIU) scan and thyroid doppler ultrasound heightened the diagnostic challenge, making the history and physical exam pivotal in steering the course of this patient's care. The Burch-Wartofsky score was found to be elevated at 30 due to delirium and abdominal pain reported in the emergency department. Amiodarone use for over two years with no prior history of thyroid dysfunction, along with the absence of a goiter or thyroid antibodies suggestive of Graves disease heightened the suspicion for amiodarone-induced thyrotoxicosis type 2 (AIT type 2). Due to the lack of RAIU scan and thyroid ultrasound to better differentiate between AIT type 1 and type 2, the patient was treated with methimazole and prednisone along with an antipsychotic medication regimen. The discontinuation of antipsychotic medications became necessary due to QTc prolongation and subsequent defibrillator discharge. The patient's further improvement without psychiatric medications highlighted the success of the tailored treatment strategy, emphasizing the importance of accurate diagnosis in patients with psychiatric comorbidities. The patient’s relatively rapid clinical response also aids in differentiating AIT type 1 from type 2. This case brings awareness to the importance of a comprehensive history and physical exam, particularly in the setting of a community hospital with limited diagnostic resources. Despite the inability to obtain history directly from the patient and having diagnostic constraints, the judicious use of available resources and clinical acumen led to the diagnosis of Amiodarone-induced thyrotoxicosis type 2. Clinicians should keep a broad differential to avoid confirmation bias in treating psychiatric patients with a complex medical history. This case serves as a testament to the importance of a holistic approach to patient care and the need for ongoing advancements in diagnostic capabilities within community healthcare settings. Presentation: 6/2/2024

Preliminary Effect of Challenge-Based Learning on Fostering Nursing Students’ Multidisciplinary Collaboration in Community Health Care Settings

BackgroundCompetence in multidisciplinary collaboration is an essential attribute of nurses working in community health settings. Nursing students should be equipped with this attribute during undergraduate training. AimTo examine the effect of Challenge-Based Learning (CBL) on multidisciplinary collaboration among nursing students. MethodsA one-group pretest-posttest study. Nursing students worked in multidisciplinary groups to conduct community projects framed with CBL. The students designed, planned, and implemented health promotion activities for the selected health topics over a 14-week semester. Multidisciplinary collaboration was measured by Collaboration Scale at baseline and after the projects were completed. Wilcoxon signed-rank test was used to compare the total and subdomain collaboration scores within-group. p-value <0.05 was statistical significance. ResultsThe total and subdomain collaboration scores were significantly greater than those of the pretest ones (p<0.001), with the effect sizes (r) ranging from 0.48 to 0.71. ConclusionsThe present findings shed light on the potential positive effect of CBL on strengthening nursing students’ competence in multidisciplinary collaboration. Future studies with a more rigorous approach are needed to verify the findings.

Clinical utility of upfront liquid biopsy in non-small cell lung cancer in the community setting.

316 Background: Molecular diagnosis of advanced non-small cell lung cancer (NSCLC) is critical to guide therapeutic decisions. Blood next generation sequencing (NGS) allows for non-invasive screening for targetable genetic abnormalities. Many studies have validated using the liquid biopsies to screen for resistant mutations at the emergence of treatment failure. However, the clinical utility of liquid biopsy for newly diagnosed NSCLC, as part of a comprehensive molecular profiling, is an area of active research. Methods: Retrospective analysis of the molecular landscape and clinical outcomes in NSCLC patients who had liquid biopsy done between December of 2017 to February of 2022. Patients had EGFR, ALK, ROS-1, and BRAF tested in the tissue, and underwent liquid biopsy for broad molecular profiling. The plasma genotyping was conducted using a 73-gene panel by Guardant 360 test. Actionable mutations were stratified accordingly to the OncoKB database based on the level of preclinical and clinical evidence of drug targetability. Survival analysis was conducted by August of 2023. Results: We enrolled 122 NSCLC patients who 84% were treatment-naïve and 78% had the liquid biopsy performed at the initial diagnosis. We found that 86 patients had oncogenic mutations and 43 (35%) had actionable mutations, with 37 (29%) falling under level 1 of evidence mutations. EGFR and KRAS G12C mutations were the two most common level 1 genetic abnormalities (23% and 11% of all actionable mutations, respectively). We identified two germline BRCA carriers who were referred for genetic counselling. 25 patients (20%) received treatment based on the liquid biopsy results, with 15 (12%) achieving partial response. Six patients had liquid biopsy done at progression of EGFR or MET therapies, which identified a resistance mechanism in three of them. Conclusions: Upfront liquid biopsy identified a significant proportion of patients with targetable mutations. Here, we reported actionable mutations in 35% of our patients who 84% had no prior systemic treatment. Our results complement prior literature and shows that blood next generation sequencing can be a useful tool to guide upfront therapeutical options at the community healthcare setting.

Low-cost and convenient screening of disease using analysis of physical measurements and recordings

In recent years, there has been substantial work in low-cost medical diagnostics based on the physical manifestations of disease. This is due to advancements in data analysis techniques and classification algorithms and the increased availability of computing power through smart devices. Smartphones and their ability to interface with simple sensors such as inertial measurement units (IMUs), microphones, piezoelectric sensors, etc., or with convenient attachments such as lenses have revolutionized the ability collect medically relevant data easily. Even if the data has relatively low resolution or signal to noise ratio, newer algorithms have made it possible to identify disease with this data. Many low-cost diagnostic tools have been created in medical fields spanning from neurology to dermatology to obstetrics. These tools are particularly useful in low-resource areas where access to expensive diagnostic equipment may not be possible. The ultimate goal would be the creation of a “diagnostic toolkit” consisting of a smartphone and a set of sensors and attachments that can be used to screen for a wide set of diseases in a community healthcare setting. However, there are a few concerns that still need to be overcome in low-cost diagnostics: lack of incentives to bring these devices to market, algorithmic bias, “black box” nature of the algorithms, and data storage/transfer concerns.

Development and psychometric evaluation of the catheter assessment, management and performance (CAMP) scale for nurses

AimTo develop and test the psychometric properties of a self-administered scale to assess the knowledge, skills, attitudes and behaviour of nurses to support the self-management of patients living with indwelling urinary catheters. BackgroundNurses are pivotal in supporting patients with urinary catheter self-management to prevent potentially avoidable hospital presentations. However, no validated scale is available to assess nurses’ attitudes and readiness for this task. DesignA quasi-experimental design was used to collect survey data both at baseline and after the completion of the intervention. A total of 128 participants were recruited from the Western Sydney region (New South Wales, Australia), who were working in community healthcare settings. Research Electronic Data Capture (REDCap™) database was used to manage the survey data collected for data analysis purposes. This study has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN126210 0 0683831) MethodsUsing a three-stage process of concept identification, item construction and pilot testing to develop the Catheter Assessment, Management and Performance (CAMP) scale, followed by factorial and discriminant validity and reliability testing. This 23-item CAMP scale is theoretically informed by the COM-B (Capability, Opportunity, Motivation-Behaviour) model, recognised for its effectiveness in understanding and influencing behaviour change. The scale was distributed to nurses working in three community health care settings to assess their knowledge, attitude and behaviour regarding catheter management and performance. ResultsFour factors were identified using scree plot, accounting for 63.36 % of total explained variance, which reflected the four dimensions of the COM-B model. Cronbach's alpha of the overall CAMP scale (0.93) and subscales (0.92, 0.87, 0.85 and 0.86) indicate good internal consistencies. The CAMP scale was able to detect changes in nurses’ self-reported behaviour change following educational intervention (85.53 versus 95.98, p < 0.001). ConclusionThe CAMP scale is valid and reliable scale, capable of assessing nurses’ capability, opportunity and motivation to support patients, through delivery of catheter self-management education that can potentially prevent catheter-related complications and avoid hospital presentations. Future research could explore using CAMP scale among non-specialist nurses and in various clinical settings to enhance its effectiveness and generalisability.

Substance Use Disorder as a Risk Factor for Postpartum Depression: A Retrospective Chart Review in a Community Hospital.

This retrospective study examines the relationship between postpartum depression (PPD) and substance use disorder (SUD) in a community hospital setting. This retrospective chart review explored the association between SUD and PPD in a community hospital. Data from January 2016 to December 2018 were extracted from electronic medical records (EPIC EMR (Epic Systems Corporation, Verona, WI)), identifying mothers with PPD (n = 99) using billing code F53.0. Substance use disorder was assessed using diagnostic codes F10-F19. Odds ratios (OR), relative risk (RR), and chi-square tests were calculated to quantify and assess the significance of the association between SUD and PPD. Ethical approval was obtained from the Institutional Review Board (IRB). Among 2,517 deliveries during the study period, 51 cases of PPD co-occurred with SUD. Mothers with SUD had a 4.3 times higher risk of PPD compared to those without SUD (OR = 4.8), highlighting a significant association. These findings emphasize the importance of screening for PPD and SUD in pregnant and postpartum women, especially in community healthcare settings where routine screening may be limited. Targeted interventions can mitigate adverse effects on maternal and infant well-being.

Beyond the Hospital Walls: The Role of the Ethicist in Community Healthcare Settings.

AbstractCommunity-based "free" clinics can be a key site of primary and preventive care, especially for underserved members of the community. Ethical issues arise in community clinics. Despite this-and the fact that ethics consultation is a well-established practice within hospitals-ethics support is rarely integrated within community clinics, and the clinical ethicist's role in community care settings remains unexplored. In this article I explore what community-engaged practice might look like for the clinical ethicist. I share my experience of being invited into a local community clinic where a team of volunteers, in partnership with a local church, provide care to persons experiencing housing and food security in our county. First, I outline some of the key ethical issues we encounter in our clinic, including how to promote the agency of community members, develop shared standards for clinic volunteers, and balance different values and priorities within the partnership. Second, I explore how the ethicist's knowledge and skills translate into this setting. I argue that, given the range of ethical issues that arise in community clinics and the need for ongoing dialogue, education, and critical reflection within such partnerships, there is a role for the clinical ethicist in this space. I discuss how clinical ethicists might begin to develop community-based partnerships and practices.

Mobile-linked point-of-care diagnostics in community-based healthcare: a scoping review of user experiences

BackgroundWhile mobile-linked point-of-care diagnostics may circumvent geographical and temporal barriers to efficient communication, the use of such technology in community settings will depend on user experience. We conducted a scoping review to systematically map evidence on user experiences of mobile-linked point-of-care diagnostics in community healthcare settings published from the year 2016 up to the year 2022.MethodologyWe conducted a comprehensive search of the following electronic databases: Scopus, Web of Science, and EBSCOhost (Medline, CINAHL, Africa-wide, Academic Search Complete). The inter-reviewer agreement was determined using Cohen’s kappa statistic. Data quality was appraised using the mixed method appraisal tool version 2018, and the results were reported according to the preferred reporting items for systematic reviews and meta-analyses for scoping reviews (PRISMA-ScR).ResultsFollowing the abstract and full article screening, nine articles were found eligible for inclusion in data extraction. Following the quality appraisal, one study scored 72.5%, one study scored 95%, and the remaining seven studies scored 100%. Inter-rater agreement was 83.54% (Kappa statistic = 0.51, p < 0.05). Three themes emerged from the articles: approaches to implementing mobile-linked point-of-care diagnostics, user engagement in community-based healthcare settings, and limited user experiences in mobile-linked point-of-care diagnostics. User experiences are key to the sustainable implementation of mobile-linked point-of-care diagnostics. User experiences have been evaluated in small community healthcare settings. There is limited evidence of research aimed at evaluating the usability of mobile-linked diagnostics at the community level.ConclusionMore studies are needed to assess the user experience of mobile-linked diagnostics in larger communities. This scoping review revealed gaps that need to be addressed to improve user experiences of mobile-linked diagnostics, including language barriers, privacy issues, and clear instructions.

The landscape of use of NCCN-guideline chemotherapy regimens in stage I-IIIA breast cancer in an integrated healthcare delivery system.

The National Comprehensive Cancer Network (NCCN) guidelines recommend a variety of drug combinations with specific administration schedulesfor the treatment ofearly-stagebreast cancer, allowing physicians to deliver treatments recognizing individual patient complexities, including comorbidities, and patient-physician preference. While use of guideline regimens has shifted over time, there is little data to describe changes in how treatment for early-stage breast cancer has evolved over time. In a cohort of 34,109 women treated for stage I-IIIA breast cancer between 2006-2019 at Kaiser Permanente Northern California and Kaiser Permanente Washington, we present the changes in chemotherapy regimens over time, and explore use of NCCN-guideline regimens (GR), guideline regimens used when said regimens were not included in guidelines, referred to as time-discordant regimens (TDR), and non-guideline regimens (NGR). Results are presented by drug combination and over time. Among 12,506 women receiving chemotherapy, 77.4% (n = 9681) received GRs, 9.1% (n = 1140) received TDRs, and 13.5% (n = 1685) received NGRs. In 2006, AC-T (cyclophosphamide-doxorubicin, paclitaxel) was the most common regimen, with TC (cyclophosphamide-docetaxel) becoming the most prevalent by 2019. NGRs were more common in cyclophosphamide-methotrexate-5-fluorouracil (CMF); cyclophosphamide-doxorubicin-paclitaxel-trastuzumab (ACTH); and paclitaxel-trastuzumab (TH). The use of GR has increased over time (p-trend < 0.001), while use of NGR(both in terms of administration schedule and drug combination)and TDRhave decreased, although patterns vary by drug combination. Chemotherapy delivery has changed markedly over time, with a move toward more use of GR. These data are important for understanding the landscape of chemotherapy delivery in community healthcare settings.

Exploring the Therapeutic Potential of High Dose Co-amoxiclav (1 gm) in Different Clinical Conditions: A Review.

Amoxicillin/clavulanate (co-amoxiclav) is a widely used antibiotic in community healthcare settings, combining amoxicillin and clavulanate potassium to combat β-lactamase-producing bacteria. Despite its extensive use, limited pharmacokinetic/pharmacodynamic data support current dosing guidelines. This review explores the significance of high-dose co-amoxiclav (875 mg/125 mg) in treating various infections amidst rising antibiotic resistance. A comprehensive narrative literature review was conducted using MEDLINE, PubMed, and Google Scholar, focusing on co-amoxiclav 875 mg/125 mg from 1992 to 2024. Keywords included "Co-amoxiclav 875mg/125mg," "amoxicillin 875mg," "Co-amoxiclav dosing," "pharmacology," "PK," and "safety." Studies on non-safety aspects, those on cost-effectiveness, non-English articles, and those without full-text access were excluded. Clinical efficacy studies demonstrate the effectiveness of co-amoxiclav (875 mg/125 mg) in treating conditions such as cutaneous actinomycosis, actinomycetoma, lower respiratory tract infections, acute bacterial maxillary sinusitis, and community-acquired pneumonia. Comparative studies reveal similar or superior efficacy of co-amoxiclav (875 mg/125 mg) compared to other dosing regimens and antibiotics such as clindamycin, cefaclor, cefuroxime, and ciprofloxacin. Safety and tolerability assessments indicate that co-amoxiclav is generally well-tolerated, with common mild-to-moderate gastrointestinal side effects. In summary, co-amoxiclav 1 gm remains a crucial antibiotic with optimized dosing regimens enhancing clinical outcomes while addressing resistance challenges.

Compliance and satisfaction with BRCA surveillance in specialized clinics versus community follow-up.

To assess adherence to medical follow-up protocols among BRCA1/2 carriers and compare outcomes between dedicated carrier clinics and community healthcare settings. This cross-sectional study was conducted by distributing an anonymous questionnaire within the 'Good BRCA Genes - Support and Information Group for BRCA Carriers' association. The questionnaire assessed adherence to recommended surveillance and satisfaction with various aspects of the follow-up. Of the 682 BRCA carriers surveyed, 68.5% reported fully adhering to recommended medical follow-up. Those not fully adhering cited bureaucracy challenges, scheduling difficulties, timing uncertainties, and difficulty remembering examination dates. Less than 50% were satisfied with appointment availability, scheduling, contact persons, and general practitioners' knowledge of BRCA carrier risks and follow-up. The 417 women monitored in dedicated breast clinics reported notably higher optimal adherence to recommended surveillance (78.3 vs. 53.6%, P < 0.0001). In addition, they noted greater satisfaction with appointment availability (63.7 vs. 25.0%, P < 0.0001), appointment scheduling process (58.1 vs. 24.7%, P < 0.0001), availability of breast surgeons/gynecology specialists (67.4 vs. 50.8%, P < 0.0001), and availability of a contact person for consultations between appointments (53.5 vs. 20.8%, P < 0.0001). Our findings highlight the advantages of surveillance in dedicated BRCA1/2 clinics, including closer monitoring and increased satisfaction. Given the limited availability of such clinics and the growing number of BRCA1/2 carriers, the opening of additional dedicated clinics and the consideration of alternative surveillance-enhancing solutions, such as training healthcare professionals, using digital tools, and employing artificial intelligence, are essential.

Missed care or missed opportunities in general practice nursing

BackgroundResearch into missed care has been conducted in various acute and some community healthcare settings; however, the experiences of general practice nurses (GPNs) are poorly represented in the literature. AimTo explore the role of the GPN and whether care activities are missed. MethodsA qualitative descriptive design was used, employing semistructured interviews with 10 participants. The participants were GPNs working in a metropolitan or regional general practice in Australia, with a minimum of three years of experience in the role. A six-step process for thematic analysis was utilised for the extraction and presentation of findings. FindingsGPNs rarely miss care; it is either delayed or rescheduled. Findings illustrate missed opportunities to provide care and enhance the role of the GPN. Factors contributing to missed opportunity are as follows: (i) difficulties navigating the GPN–general practitioner (GP) relationship, (ii) GPNs lack ongoing education commensurate with their scope of practice, (iii) Medicare policy fails to fund the GPN role, (iv) a rise in the number of salaried GPs leads to time pressures that limit the GPN role, (v) scope of practice constrained by time deficits, and (vi) communication problems within a siloed healthcare system limit GPN scope of practice. DiscussionThe initial aim was to identify missed care; however, findings suggest that GPNs rarely miss care, but they do miss opportunities to provide care and practice to their full scope. ConclusionInternal and external factors specific to the general practice context can contribute to missed opportunities for the work of the GPN.

Pediatric Maxillofacial Infections During COVID-19: What Have We Learned?

BackgroundThe COVID-19 pandemic significantly affected healthcare systems worldwide, and the field of dentistry is no exception. Odontogenic infections in pediatric patients pose unique challenges to treatment and diagnosis. PurposeThe purpose of this study was to evaluate the incidence, characteristics, and treatment of pediatric maxillofacial odontogenic infections during COVID-19 compared to pre-COVID-19. Study design, setting, and sampleThis retrospective cohort study included all pediatric patients (0-18 years) who visited the emergency department (ED) at Tzafon Medical Center, Israel, between March 2020 and February 2021 (COVID-19), or between March 2018 and February 2020 (Pre-COVID-19), and were diagnosed with maxillofacial odontogenic infections. Patients with missing demographic data and patients who did not complete the medical examination were excluded. Predictor/exposure/independent variableThe exposure variable was the date of presentation, categorized as COVID-19 or pre-COVID-19. Main outcome variable(s)The main outcome variables were the proportion of patients diagnosed with odontogenic infections, hospitalization rate, treatment methods, and length of hospital stay (LOS). CovariatesCovariates included patient demographics, involved dentition and associated spaces, and the administration of antibiotics before ED arrival. AnalysesFisher exact test and Pearson's chi-squared test were applied to assess differences in categorical variables. Wilcoxon rank-sum test was used for independent variables. A logistic regression model was used to predict outcome variables. P-values were two-tailed and statistical significance was defined as p<0.05. ResultsThe study sample comprised 471 patients: 357 (76%) in the pre-COVID-19 period and 114 (24%) during COVID-19. The relative-risk of visits to the ED out of total oral and maxillofacial ED visits was lower during COVID-19 (RR=0.65, p=0.0001). The hospitalization rate increased from 72% (257 patients) pre-COVID-19 to 86.8% (99 patients) during the COVID-19 period (p=0.001). LOS during Covid-19 was significantly shorter than pre-COVID-19 (p<0.001). ConclusionsThe findings of this study reveal a significant reduction in odontogenic infection incidents referred to the ED during the pandemic. This implies that many of these incidents can be successfully treated in community healthcare settings, without referral to the ED.