Daily Practice Research Articles

Patient-initiated follow-up supported by asynchronous telemedicine versus usual care in spondyloarthritis (TeleSpA-study): a randomised controlled trial of clinical and cost-effectiveness.

With rising health-care expenditures and workforce shortages, sustainable alternatives to traditional outpatient follow-up strategies are required to optimise care efficiency. We aimed to investigate the cost-effectiveness and clinical effectiveness of patient-initiated follow-up (PIFU) supported by asynchronous telemedicine for patients with spondyloarthritis compared with usual care in daily practice. TeleSpA was a multicentre, pragmatic, open-label, randomised controlled trial. Patients with spondyloarthritis and stable disease were randomly assigned (1:1) to either the PIFU and asynchronous telemedicine group or usual care group. All patients received a scheduled outpatient visit at baseline and after 1 year. Patients were monitored remotely at 6 months (PIFU and asynchronous telemedicine) or at the discretion of the treating rheumatologist (usual care). The primary outcome was the number of rheumatology visits within a 1-year period. A trial-based 1-year health-economic evaluation from a Dutch health-care perspective (only including health-care costs) and societal perspective (also including travel costs and work productivity losses), per the Dutch guidelines was used to estimate cost-effectiveness. The safety analysis was done in the intention-to-treat population and was based on spontaneous reports of adverse events and serious adverse events or as observed by the research team. The primary analysis was in the intention-to-treat population. Individuals with relevant lived experience were involved in the study design. This trial was registered with the Dutch National Trial Register (NL71041.068.19) and ClinicalTrials.gov (NCT04673825) and is completed. Between Dec 2, 2020, and June 20, 2022, 200 patients were randomly assigned to PIFU and asynchronous telemedicine (n=100) or usual care (n=100). 79 (40%) of 200 participants were women, 121 (60%) were men, and the mean age was 55·0 years (SD 11·9). After 1 year, the mean number of rheumatology visits was 1·9 (SD 1·5) for the PIFU and asynchronous telemedicine group and 2·6 (1·3) in the usual care group (mean difference -0·7 [95% CI -1·0 to -0·3]; 25·4% reduction; p<0·0001). PIFU and asynchronous telemedicine was cost-effective from a health-care perspective, saving health-care costs (-€180 [95% CI -921 to 560]) without a loss in quality-adjusted life-years (0·004 [95 % CI -0·022 to 0·030]). Seven non-trial-related adverse events occurred in the PIFU and asynchronous telemedicine group and eight in usual care group (including one death). PIFU and asynchronous telemedicine resulted in significant and clinically meaningful reductions in rheumatology visits. This was not at the expense of health outcomes and saved health-care costs. Dutch Arthritis Society.

Quality of life improvement after radiotherapy for bone metastases assessed using real-world data: a secondary analysis of a Nationwide Multicenter Cohort Study.

Single-center studies or randomized controlled trials have evaluated the impact of radiotherapy for bone metastases on quality of life (QOL). We investigated the real-world impact of radiotherapy for bone metastases on QOL using nationwide multicenter cohort data. We conducted a prospective observational study at 26 centers in Japan. Of 333 patients who received radiotherapy for bone metastases between December 2020 and March 2021, 232 (70%) were enrolled in the study. Patient-reported QOL was evaluated at enrollment and at two- and six-month follow-up using the European Organization for Research and Treatment of Cancer (EORTC) QOL Questionnaire Core 15-Palliative and the EORTC QOL Questionnaire Bone Metastases module (QLQ-BM22). Possible predictors (patient-, tumor -, and treatment-related factors) of QOL improvement were screened using logistic regression models. QOL scores showed significant improvement at two-month follow-up in seven (global health status/QOL, emotional functioning, pain, insomnia, painful sites, pain characteristics and functional interference) of the 14 scales. Of these seven scales, mean improvement ≥ the minimal clinically important difference (defined by a change of 10 or more on the 0 to 100 scale) was seen in four scales (pain, insomnia, pain characteristics and functional interference). We did not find any predictors of QOL improvement in the functional interference scale of QLQ-BM22. Radiotherapy for bone metastases performed in daily practice is effective in improving some scales of QOL.

Forensic Mental Health Nurses' Perceptions and Experiences of Trauma-Informed Care in a High-Secure Hospital.

Implementation of trauma-informed care (TIC) into forensic clinical practice may contribute to positive outcomes for both patients and staff. The current study aimed to describe forensic mental health nurses' perceptions and experiences of using TIC within a high-secure forensic hospital. Twenty-seven forensic mental health nurses were interviewed regarding their experiences of using TIC within a high-secure hospital. Participants recognized the importance of understanding the past traumatic experiences of patients in their care but described a number of barriers to the implementation of TIC. A lack of organizational support, the negative impact of patient psychopathology on nurse well-being, and environmental factors were all perceived to negatively impact the successful delivery of TIC. Participants also discussed a widespread lack of knowledge and confidence in the application of TIC but expressed great desire for training to improve service delivery. The application of TIC into daily clinical practice appears to be suboptimal. To support nurse and patient well-being and contribute to a highly skilled trauma-informed workforce, further training in this area is vital. Training in TIC may contribute to enhanced patient outcomes and promote nurse well-being and should be supported organizationally with sufficient resources.

Left Atrial Appendage Closure in Atrial Fibrillation Patients with Cancer

Background: There are limited data about left atrial appendage closure (LAAC) in patients with cancer. We therefore sought to compare the outcome after LAAC in patients with vs. without cancer in a multicentre registry. Methods: In this sub-analysis of the prospective Austrian LAAC Registry, we analysed consecutive patients undergoing LAAC to assess the relationship between baseline characteristics and outcome in patients with vs. without cancer. Inverse probability weighting was performed to adjust for differences in baseline characteristics. Results: A total of 486 consecutive patients from 9 centres with a median age of 75 years (IQR 70–79 years; 35.8% female) were included. Fifty-seven patients (11.7%) had a history of cancer. The median CHA2DS2-VASc and HAS-BLED scores were similar in both groups (median [IQR], 4 [4–6] vs. 5 [3–5], p = 0.415; 4 [3–4] vs. 3 [3–4], p = 0.428 in cancer vs. other patients). Cancer patients were significantly older, and anaemia and gastrointestinal bleeding were significantly more common. Major procedural complications occurred in 5.3% vs. 7.0% (p = 0.276) of patients. The cumulative five-year survival rates were 80.7% and 84.8% in cancer vs. other patients (adjusted hazard ratio for death 1.29 [95% CI 0.67–2.48], p = 0.443). There were also no differences in one-year survival (96.1% vs. 94.0%, p = 0.582) and five-year event-free survival (64.9% vs. 74.4%, p = 0.124). Conclusions: In daily clinical practice, LAAC has already been accepted as a treatment option in patients with cancer. This retrospective analysis shows that short-term and adjusted long-term complications are similar in patients with vs. without cancer undergoing LAAC.

Water Drops

This article examines how individuals of diverse cultural backgrounds in Norway participate in anti-racist activism via social media. It investigates the nature of digital activism compared to traditional paradigms, highlighting the varied forms of engagement enabled by digital technology. Drawing on nine months of ethnographic fieldwork among individuals in the arts and cultural sector, it reveals how seemingly minor actions on social media can spark organized activism, unveiling the political activism inherent in daily life and social media practices. The article argues that individuals not identifying as political activists still contribute to political change through everyday social media activities, suggesting that contemporary activism can exist without activists. Introducing the metaphor of ‘water drops’ the article conceptualizes everyday politics as small contributions that may collectively shape meaningful change. Small acts can be merely drops in a vast ocean without major significance. However, if sustained over time, efforts across disparate online spaces can coalesce to challenge and subvert dominant social narratives regarding difference, racism, discrimination, and exclusion. Thus, contemporary activism can thrive with ordinary people who contribute to collective social transformation through digital and mundane interactions.

Mapping Rural Mobility in the Global South: Case Studies of Participatory GIS Approach for Assessments of Daily Movement Needs and Practice in Nepal and Kenya

This paper investigates rural mobility in the Global South using a participatory GIS approach to address the lack of mobility data that hampers sustainable planning to support rural development and resilience. Limited rural mobility due to poor infrastructure and financial constraints hinders social and economic activities, impeding development. The study aims to explore the socio-economic impacts of limited mobility, identify software needs for data-scarce environments, and map daily mobility patterns. Fieldwork was conducted in Kenya (2022) and Nepal (2023), collecting geographic data related to mobility. The methodology included community engagement and digital mapping using the QField app for precise data collection. The study highlights the use of participatory GIS to fill data gaps, enabling more accurate mobility assessments. Community engagement revealed gender-specific mobility patterns, with women facing particular challenges in daily activities. The study emphasizes the need for adaptable data models to reflect community-specific mobility needs and the integration of qualitative insights to propose effective and sustainable mobility solutions. This research contributes to understanding rural mobility in the Global South and demonstrates the effectiveness of participatory GIS in overcoming data scarcity and enhancing mobility analysis.

An Analysis on the Reform and Innovation Path of Research-based Teaching of Philosophy Major Courses—Taking Jaeggi's Critical Theory of Life Form as an Example

With the advent of the era of artificial intelligence, the traditional humanities are facing unprecedented challenges and impacts, especially philosophy as a strong foundation, without the characteristics of practical function, facing a particularly severe disciplinary development dilemma. This topic aims at the problems faced by the construction of philosophy professional courses in local colleges and universities, and focuses on the topic of Marxism for graduate professional courses Taking Jaeggi 's critical theory of life form as an example, this paper attempts to explore new teaching methods from daily professional teaching practice, fundamentally changing the traditional single teaching mode of basic philosophy theory courses, overcoming the mechanical rigidity of the binary teaching and research between teachers and students, so as to correct the poor interaction between teachers and students In particular, it has a good effect on stimulating students' initiative and originality of thought, and promotes students to enter the research track as soon as possible. In order to fundamentally form a philosophy academic community with clear boundaries, it provides research exploration experiments in philosophy teaching.

Dystocia in Dairy Cows and Heifers: A Review with a Focus on Future Perspectives

Dairy cow management has evolved tremendously in recent decades, particularly regarding reproductive techniques. The widespread adoption of synchronization protocols, sexed semen, beef semen in dairy cows, reproductive biotechnologies such as in vivo-derived (IVD) or in vitro-produced embryos (IVP), and precision livestock farming is transforming the daily practices of dairy farmers and veterinarians. These implementations are typically adapted in different ways when applied to the breeding of heifers or cows. Considering these developments, dystocia—a significant welfare and productivity concern—may warrant reevaluation. The aforementioned changes are likely to have a substantial impact on its prevalence, severity, and outcome. This review aims to address the main aspects of dystocia in dairy cows and heifers, with a particular focus on the potential impact of recent advances in reproductive and calving management.

Classifying histopathological growth patterns for resected colorectal liver metastasis with a deep learning analysis.

Histopathological growth patterns are one of the strongest prognostic factors in patients with resected colorectal liver metastases. Development of an efficient, objective and ideally automated histopathological growth pattern scoring method can substantially help the implementation of histopathological growth pattern assessment in daily practice and research. This study aimed to develop and validate a deep-learning algorithm, namely neural image compression, to distinguish desmoplastic from non-desmoplastic histopathological growth patterns of colorectal liver metastases based on digital haematoxylin and eosin-stained slides. The algorithm was developed using digitalized whole-slide images obtained in a single-centre (Erasmus MC Cancer Institute, the Netherlands) cohort of patients who underwent first curative intent resection for colorectal liver metastases between January 2000 and February 2019. External validation was performed on whole-slide images of patients resected between October 2004 and December 2017 in another institution (Radboud University Medical Center, the Netherlands). The outcomes of interest were the automated classification of dichotomous hepatic growth patterns, distinguishing between desmoplastic hepatic growth pattern and non-desmoplatic growth pattern by a deep-learning model; secondary outcome was the correlation of these classifications with overall survival in the histopathology manual-assessed histopathological growth pattern and those assessed using neural image compression. Nine hundred and thirty-two patients, corresponding to 3.641 whole-slide images, were reviewed to develop the algorithm and 870 whole-slide images were used for external validation. Median follow-up for the development and the validation cohorts was 43 and 29 months respectively. The neural image compression approach achieved significant discriminatory power to classify 100% desmoplastic histopathological growth pattern with an area under the curve of 0.93 in the development cohort and 0.95 upon external validation. Both the histopathology manual-scored histopathological growth pattern and neural image compression-classified histopathological growth pattern achieved a similar multivariable hazard ratio for desmoplastic versus non-desmoplastic growth pattern in the development cohort (histopathology manual score: 0.63 versus neural image compression: 0.64) and in the validation cohort (histopathology manual score: 0.40 versus neural image compression: 0.48). The neural image compression approach is suitable for pathology-based classification tasks of colorectal liver metastases.

Analysis of digital capital for social inclusion in educational context

AbstractThis paper focuses on one of the aspects most investigated and monitored in recent years by the Digital Economy and Society Index on the digitisation process in Europe—human capital, with an in‐depth focus on primary school teachers. Human capital is one dimension underlying school digital capital, closely related to integrating digital into daily practices. Starting from this framework, the paper will present the results of a survey on the digital competencies of teachers from five European countries (Italy, Spain, Lithuania, Romania and Poland), carried out in the framework of the European project Erasmus+ CAVE (Communication and Visual Education in homeschooling). This survey is preparatory to a training intervention and didactic experimentation on digital education, foreseen in the project, and used as a theoretical framework of reference for the DigCompEdu survey, promoted by the European Commission. The teachers' profiles, as the output of the research, will be able to give stakeholders a picture of the investment of schools and teachers, in terms of the application of digital competencies on different educational processes: classroom teaching, assessment, professional training, preparation of teaching materials for the lesson and the implementation of competencies, including digital ones, of students.

State Full Practice Authority Regulations and Nurse Practitioner Practice Autonomy: Evidence From the 2018 National Sample Survey of Registered Nurses.

State full practice authority (FPA) laws are designed to permit NPs to practice autonomously from physicians. Little is known regarding how FPA laws affect NPs' practice autonomy in daily practice. This study used nationwide survey data from 20,830 NPs to estimate how NPs' practice autonomy differs between NPs in FPA and non-FPA states. NPs in states with FPA laws were more than twice as likely as NPs in non-FPA states to practice in clinic settings with no onsite physicians and were twice as likely to not have a physician collaborator. Associations between FPA laws and four other indicators of practice autonomy were positive but smaller in magnitude. States with FPA laws more than 10 years experienced larger changes in nurse practitioner (NP) autonomy compared with states with FPA laws in effect less than 10 years. FPA laws may promote the development of autonomous NP practice sites, thereby expanding access in underserved populations.

DEVELOPMENT OF INNOVATIVE MEDICAL DEVICES IN NEONATOLOGY: LITERATURE REVIEW

The aim of this study is to review the development of medical devices in neonatology, exploring technological advances, identifying innovations and challenges, and proposing recommendations for future research. The methodology involved a narrative review of the literature, searching databases such as PubMed, EBSCO, Cochrane, and IEEE Xplore, focusing on studies from the last ten years on medical devices for neonatology. The results highlight that technologies such as artificial intelligence and machine learning have improved the monitoring and prognosis of neonatal conditions, allowing for more precise and personalized interventions. 3D printing emerges as a promising tool for creating personalized medical devices, meeting the specific needs of each patient. Wearable devices for continuous monitoring of vital signs and advanced enteral and parenteral feeding devices have demonstrated a positive impact on neonatal health. Mechanical ventilators with gentler and smarter modes have reduced serious complications, and catheters with antimicrobial coatings have helped to reduce the incidence of neonatal sepsis. The conclusions indicate that technological innovations are fundamental to improving neonatal care. The integration of artificial intelligence, 3D printing and continuous monitoring has the potential to transform neonatology, improving clinical outcomes and the quality of life of newborns. However, challenges such as the variability of neonatal pathologies, cost and accessibility of devices and the need for adequate training of health professionals need to be addressed. Investment in continuous research, clinical validation and interdisciplinary training is recommended to ensure the effective adoption of these innovative technologies in daily clinical practices.

Innovative Model of Creative Tourism as a Factor of Sustainable Development in the Context of Modern Challenges

The aim of this study is to develop an innovative model of creative tourism as a key driver of sustainable development in response to modern challenges. In a world where globalization and technological advancements are reshaping traditional tourism approaches, creative tourism emerges as a novel strategy to attract visitors and foster economic growth. This study employs a data-driven analytical approach (BIG DATA analysis) to examine creative tourism, recognizing the need to manage, systematize, classify, and draw insights from large datasets enabled by digital technologies. Creative tourism systems leverage advanced neural networks with multiple hidden layers to intelligently process and extract maximum value from data, providing essential insights for tourism service consumers. This positions creative tourism as both a critical business asset and a valuable tool for improving the human experience. Research Objectives: 1.To develop a model of creative tourism that supports sustainable development. 2.To examine the daily practices and impact of creative tourism on sustainable development. 3.To identify ways to enhance the effectiveness of creative tourism models and their contribution to sustainable development. The study highlights the essential components of an innovative creative tourism model, integrating local culture, environmental responsibility, digital technologies, and the creation of unique tourism products. Special focus is given to sustainable development principles, which not only protect environmental resources but also promote the social well-being of local communities. The paper also presents successful examples of creative tourism practices, showcasing their potential to open new market opportunities and increase regional competitiveness. The findings underscore that this innovative model of creative tourism holds the potential to revolutionize the tourism industry, advancing economic, social, and environmental progress.

Environmental Education in the Business Context: Practices and Challenges in the Transportation Sector for the Formation of a Socio-Environmental Culture

Objective: The objective of this study is to investigate Environmental Education in the business context, with a focus on the transport sector, in order to reflect on the teaching practices that are developed in all areas, with the aim of presenting environmental practices that can promote the formation of an individual committed to the socio-environmental reality and to life. Theoretical Framework: Environmental Education can be characterized as an educational process based on social values, knowledge, skills, attitudes and competencies aimed at conservation and care for the environment. This definition highlights the need for its operationalization at all levels and sectors of society in a cultural transformation project, which intends the necessary contribution of Formal Education. Based on the proposal, the study supports the need for the rapid implementation of environmental education within urban transport companies, so that in the medium to long term it is possible to observe a strengthened sustainable dynamic in environmental education for this sector. Method: The methodology adopted for this research involves dividing the study into two parts, where the first was based on a systematic review of the scientific literature and the second part, due to the scarcity of significant data on the subject identified in the initial phase, was configured as a professional proposal for implementing environmental education within the urban public transport sector. Results and Discussion: The results obtained revealed important implications for the promotion of sustainability in the transportation sector through Environmental Education by proposing a practical approach that combines educational and operational strategies, highlighting the need for companies to integrate socio-environmental responsibility actions into their daily practices, increasing environmental awareness among employees, but also fostering cultural transformation in organizations, generating a broader impact. In addition, the research can serve as a model for other industrial sectors, offering a replicable framework for implementing sustainability programs in a systematic way and adapted to the needs of each organizational context. By combining a rigorous analysis of the scientific literature with the proposal of a practical product for the implementation of Environmental Education in transportation companies, focusing on the specific needs of the transportation sector, it is possible to bring solutions that are applicable and adaptable to the reality of organizations, which increases its relevance both in the academic field and in the market. The study not only fills gaps identified in the literature, but also contributes with an action model that can be directly implemented, bringing benefits to companies, employees and society in general. Research Implications: The practical and theoretical implications of this research are discussed, providing insights into how the results can be applied or influence practices in the urban transport field. These implications may include the promotion of sustainability in the transport sector through Environmental Education by proposing a practical approach that combines educational and operational strategies, highlighting the need for companies to integrate socio-environmental responsibility actions into their daily practices, increasing environmental awareness among employees, but also fostering cultural transformation in organizations, generating a broader impact. Originality/Value: This study contributes to the literature by also serving as a model for other industrial sectors, offering a replicable framework for implementing sustainability programs in a systematic manner and adapted to the needs of each organizational context. In this context, the work emphasizes the relevance of intersectoral partnerships, which can drive public policies and collaborative actions between the private and public sectors to promote a more sustainable transition.

Health Promotion and the case of social prescription of laughter

Abstract Introduction The use of laughter to change lifestyle and promote active and successful ageing is an area of interest within the scope of health promotion. The positive effects of laughter practices occur throughout the life cycle. That is why “laughing” has been identified and indicated as a human activity of social prescription promoting healthy lifestyles. This communication aims to (1) identify the benefits for health, health promotion, well-being, and healthy lifestyle of using laughter activities and practices, (2) identify “laughing” as a social prescription activity that promotes a healthy lifestyle. Methods This work is structured in a narrative review of the literature and the authors’ lived experience as professionals in the well-being area. Results Studies show that laughing and using laughter-inducing approaches have immediate effects on the person who experiences them (e.g. increased general well-being, reduced cortisol levels) with benefits for the immune system and cardiovascular health. Daily practices that are structured and systematic interventions that induce laughter were revealed to have lasting and durable effects. Studies also highlighted the effectiveness of laughter and its important role in improving communication in healthcare professional-patient encounters. Discussion Several behaviors are associated with well-being, happiness and positive affect, but the one that is accessible to all people and with the most immediate effects is laughter. Daily practices, structured and systematic interventions that induce laughter are part of non-pharmacological approaches that promote health and well-being. The principles underlying laughter practices are aligned with the Sustainable Development Goals, namely goal 3 (Health), goal 4 (Education) and goal 16 (Peace).

Home-based nursing care for clients carrying multidrug-resistant organisms: a focus group study

Abstract Background The growing population of vulnerable clients receiving home-based nursing care, combined with the worldwide increase in the prevalence of multidrug-resistant organisms (MDROs), poses a new burden on nursing staff. This study aimed to gain insight into the experiences, attitudes, perceptions, dilemmas in daily practice and needs of nursing staff providing home-based nursing care for clients carrying MDROs. Methods Seven focus group discussions with home-based nursing staff (N = 34) were performed in the Netherlands between April and July 2022, using a semi-structured, open-ended topic list based on the I-change model and seven domains synthesized by Flottorp et al. Data were analysed using thematic analysis. Results Home-based nursing staff often considered infection prevention and control recommendations inconsistent, unclear or inapplicable in daily practice. Although participants acknowledged the importance of these precaution measures, their proportionality was sometimes questioned. Participants indicated to be influenced by perceptions, knowledge and behaviour of their colleagues and clients. In addition, they frequently experienced untimely, incomplete or inconspicuous information transfers about clients carrying MDROs. Concerns were expressed that clients were often insufficiently informed, debating the roles and responsibilities of involved healthcare professionals in providing and exchanging information. Finally, participants elaborated on the effect of the covid-19 pandemic and expressed the need for organisational support in providing education and sufficient resources regarding MDROs. Conclusions Insights of this study have aided in aligning upcoming MDRO guidelines for home-based nursing care in the Netherlands. Organisational support in expanding knowledge and providing sufficient resources is essential and clarity about roles and responsibilities of involved healthcare professionals regarding information transfer and informing patients is needed. Key messages • Expanding knowledge, sufficient resources and adequate information transfer about MDRO carriage are essential to ultimately prevent transmission and spread of MDROs. • The specific context of home-based nursing care for clients carrying MDROs should be acknowledged in MDRO guidelines.

Setting targets for antibiotic use in general practice in Europe: a scoping review

Abstract Background National Action Plans (NAPs) aim to address antimicrobial resistance (AMR) understanding and awareness but struggle to translate targets into clinically relevant guidance for general practice. This scoping review aims to identify and map antibiotic use targets in European general practice and explore if and how these targets are linked to NAPs. Methods A systematic search strategy was carried out in MEDLINE (OVID), EMBASE and SCOPUS, with additional manual searches. Two research questions were addressed: ‘What are existing targets for antibiotic use in general practice in the 31 European countries?’ and ‘How are these targets linked to the NAPs on AMR?’. The results are presented narratively. Results 77 reports were included, of which 33 focused on national targets and general practice or linking national targets to local areas. Reports describe local strategies or initiatives to achieve targets, such as feedback to prescribers, systems with benchmarks (at local, regional, and national levels) and financial incentives. However, these reports provide aggregated targets for general practice, such as a percentage reduction of antibiotics prescribed. These targets are set in general, for a specific type of antibiotic, for an amount per number of patients, in defined daily doses (DDD) or in items. None of the reports translate national targets into clinically relevant or practical targets for general practitioners (GPs). Conclusions Most European countries have a NAP with national targets. The type of targets and their implementation at the national and local level vary between countries. Translating national targets into daily clinical practice is challenging and often lacks the involvement and input of prescribers (GPs). Key messages • Translating targets into daily clinical practice is challenging and often lacks the involvement and input of prescribers (GPs). • Local strategies, feedback to prescribers, benchmark systems (local, regional, national), and financial incentives drive successful target achievement.

Discussing health behavior change during pregnancy: co-creation of a training and conversation tool

Abstract Background Health risk behaviors during pregnancy are major risk factors for adverse health outcomes for mother and child, and they are more prevalent among vulnerable pregnant women. However, interventions often do not sufficiently meet the needs of disadvantaged groups. Changing behavior is more likely when people feel autonomous and when a behavior aligns with our identity (how we see ourselves). Despite the clear importance of identity in health behavior change, very few identity- based interventions exist for pregnant women, let alone for vulnerable pregnant women. Through co-creation, this study aims to develop an identity- and autonomy- based training program and conversation tool tailored to the needs and preferences of healthcare professionals and vulnerable pregnant women. Methods Four co-creation sessions were conducted with five professionals from medical and social domains, and five (expectant) parents in vulnerable situations. The Participatory Learning and Action research methodology was applied to ensure an equal and democratic process in designing the training and conversation tool. Results The training for professionals will focus on enhancing knowledge about the importance of identity and autonomy in behavior change, and on improving their self-efficacy through practicing the conversation tool. Example of the conversation tool, which can be integrated into daily practice, is a comic strip illustrating the conflict of being a smoker and a mother. Conclusions During intervention development, it is important to consider the needs and preferences of end-users, particularly for whom few appropriate interventions exist. Involving end-users yields valuable insights for feasible (e.g. one-consultation time frame) and accessible (e.g. easy-to-understand language) interventions. This study aligns with public health efforts toward early intervention and health promotion among vulnerable groups. Key messages • During intervention development, it is important to consider the needs and preferences of end-users. • This study aligns with public health efforts toward early intervention and health promotion among vulnerable groups.

Decoding healthcare strategies: providing comprehensive care for type II diabetes in Ecuador

Abstract Background Diabetes is a major global health challenge, impacting millions and disproportionately affecting low- and middle-income countries (LMICs), where approximately three-quarters of affected individuals reside. Despite abundant guidance on diabetes management, most evidence is derived from high-resource settings, potentially impeding effective application in low-resource settings. This study explored issues related to the application of the current clinical practice guidelines (CPG) for diabetes management in Ecuador, from the perspective of local health professionals. Methods We developed 5 focus groups in Quito, the capital of Ecuador, in a low-income district. The groups included doctors, nurses, and health promoters; they discussed four sections of the CPG concerning their daily practice. Qualitative results are contrasted with quantitative research based on patient records. Results The Ecuadorian health system considers patients with diabetes a priority group, yet a patient may wait up to 4 months to receive their first appointments and once they receive their diagnosis several criteria set out in the CPG are not followed due to lack of time and resources, particularly the delivery of multidisciplinary attention. Access to specialized consultations, such as an ophthalmological assessment is severely restricted, and it can take up to a year to get an appointment. Clinicians expressed difficulties in adapting the nonpharmacological recommendations to different socioeconomic backgrounds, while at times, prescription choices are determined by medicine stock regardless of the patient’s actual needs. Conclusions Healthcare professionals have developed a series of ad-hoc strategies to ensure healthcare for their patients, pointing out the difficulties of applying CPG within a health system that lacks basic resources. Healthcare is intertwined with social inequalities among the Ecuadorian population that have worsened since the covid19 pandemic. Key messages • We identified significant challenges in applying the CPG in low resource settings. Clinicians adapt by introducing novel ways to overcome limitations at times to the detriment of the patient’s health. • CPGs need to be tailored to the context considering socioeconomic realities of the population and limited resources in the health setting.

Prognostic value of C-reactive protein / albumin ratio for amputation and/or mortality after lower extremity revascularization in haemodialysis patients with peripheral artery disease

Abstract Background Hypoalbuminemia, a manifestation of protein-energy wasting (PEW) or malnutrition, which is commonly observed in patients with chronic kidney disease, is associated with increasing cardiovascular risk. Recently, C-reactive protein (CRP) / albumin ratio has been developed as a newly surrogate marker of the PEW because the PEW seems to result not only from an inadequate diet but also rather be induced by chronic inflammatory status. The aim of this study was to clarify whether pre-procedural CRP/albumin ratio levels could predict amputation and/or mortality after lower extremity revascularization for peripheral artery disease (PAD) in patients on haemodialysis (HD). Methods A total of consecutive 1,850 HD patients successfully undergoing lower extremity revascularization (494 bypass surgery and 1,356 endovascular therapy) were enrolled in this study. Patients were divided into tertiles according to pre-procedural CRP/albumin ratio levels; low (&amp;lt;0.6, n=619), middle (0.6-3.7, n=609) and high tertile (&amp;gt;3.7, n=622). They were followed up for up to 8-year. The primary endpoint was defined as amputation and/or mortality. Results During follow-up period (median of 53 months), 162 major amputation (8.8%) was performed and 508 patients (27.5%) died. Cumulative incidence rates of amputation and/or mortality at 8-year were 47.4%, 56.2% and 70.0% in low, middle and high tertile of CRP/albumin ratio, respectively (p&amp;lt;0.0001). After adjustment for male, age, traditional risk factors, body mass index, history of coronary artery disease or stroke, procedure (bypass vs. endovascular therapy), infrapopliteal disease and ulcer/gangrene, the CRP/albumin ratio was identified as an independent predictor for amputation and/or mortality [adjusted hazard ratio (aHR) 1.39, 95% confidence interval (CI) 1.12-1.72, p=0.0028 for middle vs. low tertile, and aHR 2.53, 95% CI 2.07-3.09, p&amp;lt;0.0001 for high vs. low tertile, respectively]. Similar results were also observed even for major amputation and mortality, respectively (aHR 2.73, 95% CI 1.77-4.31 for amputation and aHR 2.32, 95% CI 1.82-2.97 for mortality with p&amp;lt;0.0001 for high vs. low tertile in both, respectively, Figure). Conclusion Pre-procedural CRP/albumin ratio could predict both of amputation and mortality after lower extremity revascularization, and could stratify the risk in HD patients with PAD. Measurement of CRP/albumin ratio in such high-risk population may be useful because this newly surrogate marker of the PEW is simple and can be easily obtained in daily practice.