Implementation In Daily Practice Research Articles

Statistical versus health care decision Implementation in daily practice the results of the 2 trial TRAAP : A step toward beyond the p value ?✰,✰✰,★

Statistical versus health care decision Implementation in daily practice the results of the 2 trial TRAAP : A step toward beyond the p value ?✰,✰✰,★

Patients\u2019 and professionals\u2019 perspectives on implementation of opportunistic salpingectomy: a mixed-method study

BackgroundTo prevent ovarian cancer, several international societies have issued guidelines which recommend to discuss opportunistic salpingectomy with women undergoing pelvic surgery after completion of childbearing. The opportunistic salpingectomy refers to the additional removal of Fallopian tubes during pelvic surgery for another indication to reduce the risk of developing ovarian cancer. These recommendations emphasize the importance of counselling on benefits and risks of opportunistic salpingectomy but offer no guidance on their implementation in daily practice. The lack of a tailored implementation strategy has resulted in a wide variation in current practice. To reduce this practice variation, we identified influencing factors on implementing opportunistic salpingectomy from patients’ and professionals’ perspectives.MethodsWe conducted a mixed-method study between 2019 and 2020 throughout the Netherlands. In a qualitative phase, we conducted interviews with gynecologic patients (N = 11) and their professionals (N = 20) to explore barriers and facilitators, using an interview guide. In the quantitative phase, we quantified these barriers and facilitators among patients who underwent a hysterectomy or sterilization and were counselled on the opportunistic salpingectomy (N = 77), and members of the Dutch Society of Obstetrics and Gynecology (N = 204), using questionnaires. For both phases, barriers and facilitators were classified into the following domains: innovation, patient, healthcare professional, social setting, organization, and economic and political context.ResultsFor patients, main barriers were lack of knowledge about: the existence of the opportunistic salpingectomy (45%), size of the surgery (44%) and its associated possible disadvantages (37%). In addition, patients attributed their reluctance to concerns about the removal of healthy organs (46%). For professionals, main barriers were: patients’ lack of knowledge of the size of surgery (85%) and its associated possible disadvantages (77%), the gap in evidence on long term risks and benefits (43%), the lack of feasibility in certain patients and during vaginal surgery (66%). Both patients (41%) and professionals (67%) identified the need for counselling material as facilitator.ConclusionTo reduce the variety in care regarding opportunistic salpingectomy, consensus and uniform counselling is needed. Including the opportunistic salpingectomy in gynecological guidelines and a decision aid for counselling could serve as tools to facilitate implementation.

P391 Antibiotics in pediatric Inflammatory Bowel Diseases: a systematic review

Abstract Background Dysbiosis is the central concept in the current thinking regarding IBD pathogenesis. Current available therapies in pediatric Inflammatory Bowel Disease (IBD) focus on targeting the immune system by suppressing the immune response and often fail to sustain long term remission. Antibiotics directly target bacteria but are underrepresented in current (pediatric and adult) IBD treatment guidelines. We aimed to describe available evidence concerning the use of antibiotics in the treatment of pediatric IBD. Methods We systematically assessed efficacy and safety of antibiotics in pediatric IBD. CENTRAL, EMBASE (Ovid) and Medline (Pubmed) were searched for Randomized Controlled Trials (RCTs). Quality assessment of included articles was conducted with the Cochrane risk-of-bias tool. Results Two RCT’s (n=101, 4.4-18 years, 43% male) were included. Both studies had overall low risk of bias. In mild-to-moderate Crohn’s disease, azithromycin+metronidazole (AZ+MET) (n=35) compared to metronidazole (MET) alone (n=38) did not induce a significantly different response (PCDAI drop ≥12.5 points or remission) (p=0.07). For induction of remission (PCDAI≤10), AZ+MET was more effective than MET (p=0.025). In Acute Severe Colitis, the mean 5-day PUCAI was significantly lower in the antibiotic (vancomycin, amoxicillin, metronidazole, doxycycline)+intravenous corticosteroids (IVCS) group (n=16) compared to IVCS (n=12) alone (p=0.037), whereas remission (PUCAI<10) did not differ (p=0.61). No significant drug-related adverse events were reported. Conclusion Our results highlight the lack of evidence in pediatric IBD. More evidence is needed to assess if implementation in daily practice is necessary.

COMPUTERIZATION OF THE SCIENTIFIC FUND: MODERN OBJECTIVE DEVELOPMENT STAGE OF THE SKRYABIN MUSEUM OF HELMINTHOLOGY VNIIP – FSC VIEV

The modern stage of scientific research and public awareness activities of the Skryabin Museum of Helminthology of the VNIIP – FSC VIEV is associated with the creation and implementation in daily practice of a number of the original computer developments related to recording and cataloging biological items, and storage of information materials. The implemented computer projects radically reformed and intensified the Museum’s work, the implementation of which earlier required extensive labor resources, or it was technologically problematic. In 2018–2019, based on implemented computer projects, a methodology was developed for the first time in the practice of the Museum of Helminthology, on the basis of which a complete audit and an up-to-date physical inventory of helminthological specimens was organized and carried out in the Scientific Fund of the Museum Collection of the VNIIP – FSC VIEV. For the first time, a system of digital indexation of the modern structural organization of all specimen depositories of the Scientific Fund of the Museum of Helminthology was developed and implemented. When conducting an audit of the Collection items, a digital index was assigned to each inventory number, which indicates that a specimen and its information parameters is bound to a specific, current location in the Museum's depositories. Information content about the audited items of the Scientific Fund was entered into a draft "2017" of the computer directory for specimens of the Museum of Helminthology of the VNIIP – FSC VIEV. Currently, the Scientific Fund of the Collection includes 6686 inventory numbers of the category "microslide", which include 15878 slides representing total and histological specimens of helminths from various taxonomic groups. 13253 inventory numbers are included in the Collection of "wet specimens" with a mark in the computer database, and placed in the depository. The total number of registered items deposited in the Scientific Funds of the Museum of Helminthology is 29131. Computerization of Scientific Funds of the Museum of Helminthology of the VNIIP – FSC VIEV is objectively necessary modern technology tool set that allows you to comprehensively present and analyze the study items of the important research area of parasitology. The computerization of the Museum has significantly expanded the possibilities for the current methodological development and improvement of museum work, both with collector’s biological items and with accompanying information materials.

Location flexibility in parcel delivery operations: framework and empirical analysis

Abstract In traditional parcel delivery operations, customers determine delivery locations and, hence, the performance of a transporter. We exploit this idea and show that customers can improve the efficiency of a transporter by giving the latter flexibility in choosing the delivery locations. Two possible policies to enable this flexibility are presented and evaluated. The first policy, conceptually similar to roaming vehicle routing, is related to the presence of alternative locations. The second policy is related to the possibility of aggregating/skipping some locations. We show that route optimization behind both policies can be modelled via the well-known generalized travelling salesman problem. Extensive computational experiments with real parcel delivery data are performed to evaluate the potential of the presented policies and to obtain insights for possible implementation in daily practice. The experiments show that under certain conditions, the two proposed policies can lead to 15 to 20% improvement in the route length and in extreme yet realistic cases up to 40 to 50%. Consequently, the concept of flexible delivery locations has potential for practice, especially in densely populated areas.

Psoriatic arthritis screening: A systematic literature review and experts' recommendations.

To analyze the performance of psoriatic arthritis (PsA) screening tools, examine their implementation in daily practice, and reach a consensus about the best screening tool for implementation in daily practice in different medical settings. A systematic literature review (SLR), structured telephone interviews to hospitals, and a multidisciplinary nominal group meeting were all conducted. The SLR employed sensitive search strategies using Medline, Embase, and the Cochrane Library up to January 2020. Two reviewers independently selected articles that reported data on PsA screening tools and that included sufficient data to at least calculate the sensitivity and specificity of those tools (e.g., questionnaires, algorithms, specific questions, and biomarkers). The hospital interviews collected data regarding the process of suspected PsA diagnosis and referral to rheumatology, the implementation of PsA screening tools, and barriers and facilitators to implementation of those tools. In the nominal group meeting, a multidisciplinary team of experts discussed all these data and subsequently recommended a screening tool for implementation. The SLR included 41 moderate-quality studies that analyzed 14 PsA screening tools, most of which were questionnaire-based tools. All of these studies reported a moderate-good performance but presented different characteristics regarding the time to completion or the number and type of items or questions. The implementation of screening tools was low (30.5%). The experts ultimately recommended regular use of a PsA screening tool, preferably the PURE-4 questionnaire. The implementation of PsA screening tools like the PURE-4 questionnaire in daily practice likely improves the prognosis of PsA patients.

Abstract P139: Efficacy and Utility of Resident-Run Telestroke Evaluations

Introduction: Exposure to telestroke in neurology residency is sparse despite its implementation in daily practice. Due to COVID-19, we increased our utilization of telestroke. Given this change in workflow, we investigated how residents utilize telestroke for “Code Brain” (CB) acute stroke evaluations and if expanding the use of telestroke in neurology residency programs is justified. Methods: We retrospectively compared the number of CB evaluations, door to needle (DTN) times, door to decision (DTD) times, and NIHSS from March - June 2019 (in-person evaluations) against those in March - June 2020 (telestroke evaluations). We limited our study to resident-involved cases. Nighttime and weekend CBs are run by a neurology resident and are remotely supervised. Daytime CBs can be run by a resident, fellow, or attending. We assumed that nighttime CBs are resident-run and daytime evaluations are the stroke team’s evaluation. Statistical analysis was performed using R. Results: There were a total of 217 CBs in March - June 2019 and 115 in March - June 2020. In 2019, there were 120 daytime and 97 nighttime CBs; in 2020 there were 62 and 53. The mean DTN for the day for 2019 and 2020 was 45.9 ± 23.2 and 48.4 ± 20.2 (P=0.08). The mean DTN during the night for 2019 and 2020 was 67.3 ± 53.7 and 53.8 ± 25.8 (P=0.64). The mean DTD during the day for 2019 and 2020 was 48.1 ± 41.0 and 44.9 ± 37.6 (P=0.25). The mean DTD during the night for 2019 and 2020 was 60.9 ± 51.1 and 65.8 ± 94.6 (P=0.68). Using a generalized linear model approach to correct for shift (day/night), age, NIHSS, we found no significant differences in DTN or DTD before and after implementing resident-run telestroke. Using Cohen’s approach (1988) we estimated a Type 2 error probability at 7%. Discussion: Our findings show that resident-run telestroke CBs are comparable to CBs run by fellows and attendings as DTN and DTD were not significantly different between the CBs run by residents in-person or via telestroke. These metrics are also comparable for CBs in which a fellow or attending are supervising or running the CB. Implementing resident-run telestroke consultation showed no effect on DTN or DTD after accounting for patient age, NIHSS, or the time of day. These data should reassure programs seeking to grant telestroke privileges to trainees.

Barriers and facilitators to the implementation of interventions for medically unexplained symptoms in primary care: A modified Delphi study

ObjectiveMedically Unexplained Symptoms (MUS) are physical symptoms that last for longer than several weeks and for which no (sufficient) somatic explanation can be found. Interventions for treating MUS in primary care are available, but their implementation in daily practice appears difficult. In the current study we aim to explore key barriers and facilitators to the implementation of MUS-interventions in primary care. MethodsA three-round modified Delphi study was performed, using the input of 58 experts that are (in)directly involved in the care for patients with MUS (e.g. general practitioners (GPs), GP mental health workers, policy advisors). In the first online questionnaire, we generated ideas about relevant barriers and facilitators on different implementation levels. These ideas were independently coded by two researchers, and reformulated into unique barriers and facilitators. In round two, participants selected the ten most relevant barriers and facilitators from round one, which were ranked on importance in round three. ResultsWe identified 42 unique barriers and 57 unique facilitators to the implementation of MUS-interventions. The three highest ranked barriers were all related to time, i.e. too little time for treating complex MUS-patients. The most important facilitator was a positive attitude towards MUS-patients. Results varied somewhat per profession. ConclusionKey barriers and facilitators to the implementation of MUS-interventions seem to exist on the level of the patient, intervention, professional, organization, and external context. All of these levels should be taken into account in order to increase implementation success of MUS-interventions in primary care.

Implementation of colonoscopy quality monitoring in a Belgian university hospital with integrated computer-based extraction of adenoma detection rate.

Background and study aims Quality in colonoscopy has been promoted in last decade with definition of different quality indicators (QI) as benchmarks. Currently, automatized monitoring systems are lacking, especially for merging pathologic and endoscopic data, which limits quality monitoring implementation in daily practice. We describe an adapted endoscopy reporting system that allows continuous QI recording, with automatic pathological data inclusion. Material and methods We locally adapted a reporting system for colonoscopy by adding and structuring in a dedicated tab selected key QI. Endoscopic data from a reporting system and pathological results were extracted and merged in a separate database. During the initial period of use, performing physicians were encouraged to complete the dedicated tab on a voluntary basis. In a second stage, completing of the tab was made mandatory. The completeness of QI recording was evaluated across both periods. Performance measures for all endoscopists were compared to global results for the department and published targets. Results During the second semester of 2017, a total of 1827 colonoscopies were performed with a QI tab completed in 100 % of cases. Among key QI, the cecal intubation rate was 93.8 %, the rate of colonoscopies with adequate preparation was 90.7 %, and the adenoma detection rate was 29.8 % considering all colonoscopies, irrespective of indication; 28.8 % considering screening procedures; and 36.6 % in colonoscopies performed in people older than age 50 years. Conclusion This study shows that quality monitoring for colonoscopy can be easily implemented with limited human resources by adapting a reporting system and linking it to a pathology database.

Expectations and Perceptions of Dutch Pharmacy Staff Regarding a New Framework for Continence Care: A Focus Group Study.

Based on complaints that patients with urinary incontinence were not receiving the correct medical aids, the Dutch Ministry of Health, Wellbeing, and Sports requested further exploration. This resulted in a new framework based on considering individual activities of daily living when providing continence products. We aimed to explore the expectations of pharmacy staff regarding this new framework for continence care in the Netherlands and to establish the facilitators and barriers associated with that care. In total, 15 participants from 7 different pharmacies participated in 2 focus groups. Data analysis was by thematic content analysis. Pharmacy employees were positive about the idea of considering individual daily activities when providing continence products in the new framework, but they did have some reservations about the feasibility of implementation in daily practice. Barriers to optimal continence care included low reimbursement for patients with incontinence, especially with non-standard needs, and poor communication between the various stakeholders in continence care. Efforts must be extended to review the current reimbursement system and to change the policies and information provided by stakeholders in continence care, before the new framework will make a real impact in clinical practice.

Internet-based psychotherapeutic interventions

Over the past few years, research and application of internet-based psychotherapeutic interventions has grown rapidly. This kind of new therapeutic format offers a variety of chances for treating patients with psychotherapeutic disorders, but also arouses skepticism and concerns. This overview focuses on different forms of internet-based psychotherapeutic interventions, reflects the current state of research, and points out new areas of development as well as its implementation in daily practice.

The response of the mental health network of the Salamanca area to the COVID-19 pandemic: The role of the telemedicine.

The COVID-19 pandemic reached world-wide causing a great impact on healthcare services. The aim of this work is to describe the response of the Mental Health Network of the Salamanca´ Area (Spain) to this crisis and the reorganization of its resources within the first 8 weeks after the state of alarm was declared. The Psychiatry Service applied a contingency plan which included the reorganization of the human resources, the closure of some of the units and the implementation of telemedicine programs along with two specific programs, namely a mental health assistance program in the context of the infection by coronavirus, and another program for homeless people. 9.038 phone interviews were carried out in the outpatients and community mental health programs. The activity in subacute and acute wards, as well as that of the day hospital programs was decreased to 50%.Based on that this real-world response provided we concluded that the usage of telemedicine is promising in patients with any kind of disorder. Its implementation in daily practice will be considered in the future. Research must continue on COVID-19′s impact on patients with mental disorders and Psychiatry's necessary adaptations and new approaches to them.

Post-Caesarean section niche-related impaired fertility: hypothetical mechanisms.

Caesarean section can result in an indentation of the myometrium at the site of the Caesarean scar, called a niche. Niches can cause symptoms of abnormal uterine blood loss, dysmenorrhoea, chronic pelvic pain and dyspareunia and are possibly related to subfertility. Various other explanations for the cause of subfertility after Caesarean section have been proposed in the literature, such as uterine pathology, intra-abdominal adhesions and women’s reproductive choices. Not all niches cause symptoms and the relation with subfertility and a niche in the uterine scar still needs further study since direct evidence is lacking so far. Based on the limited available evidence, and in combination with observations made during sonographic hysteroscopic evaluations and laparoscopic niche repair, we propose and discuss three hypothetical mechanisms: (i) the environment for sperm penetration and implantation may be detrimental; (ii) there could be a physical barrier to embryo transfer and implantation; and (iii) psychogenic factors may reduce the likelihood of pregnancy. Several innovative surgical treatments have been developed and are being implemented for niche-related problems. Promising results are reported, but more evidence is needed before further implementation in daily practice. The additional value of niche resections should be compared to expectant management or fertility therapies, such as ART, in randomized controlled trials. Therefore, our suggested hypotheses should, for the time being, not be used for justification of any specific procedures outside clinical trials.

Comparative results of the implementation in daily practice of an evaluation checklist for patients with axial spondyloarthritis and psoriatic arthritis

ObjectiveTo analyse and compare changes in the collection of clinical variables after the implementation in daily practice of an evaluation checklist for patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA). MethodsAn observational study was performed based on medical records review. The number and type of variables of the evaluation checklist in the medical records were collected. The first review was made before the implementation of the checklist, and the second one 6 months after the implementation (in different patients). A descriptive and bivariate analysis was carried out. ResultsSix hospitals and 11 rheumatologists participated. A total of 83 and 68 medical records were reviewed before and after the implementation of the checklist. After the implementation, in the axSpA patients, a significant increase was recorded in alcohol consumption, diarrhoea or IBD and urethritis, diabetes mellitus, hyperlipidaemia, depression, obesity or gout/hyperuricaemia, weight, height, blood pressure, patient and physician global assessments of disease activity, BASDAI and DAS28. And, in the PsA patients, alcohol consumption, hypertension, diabetes mellitus, hyperlipidaemia, disease, gout/hyperuricaemia, thoracic expansion, cervical rotation, weight, height, blood pressure, patient and physician global assessments of disease, ASDAS, BASDAI, and BASFI were recorded. In general, there was a trend towards greater recording in axSpA compared with PsA. ConclusionsThe implementation of a specific checklist in daily practice improves the evaluation of patients with axSpA and PsA. More efforts are necessary to continue improving the evaluation of patients with axSpA, but especially of those with PsA.

Using Artificial Intelligence Resources in Dialysis and Kidney Transplant Patients: A Literature Review.

Background The purpose of this review is to depict current research and impact of artificial intelligence/machine learning (AI/ML) algorithms on dialysis and kidney transplantation. Published studies were presented from two points of view: What medical aspects were covered? What AI/ML algorithms have been used? Methods We searched four electronic databases or studies that used AI/ML in hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KT). Sixty-nine studies were split into three categories: AI/ML and HD, PD, and KT, respectively. We identified 43 trials in the first group, 8 in the second, and 18 in the third. Then, studies were classified according to the type of algorithm. Results AI and HD trials covered: (a) dialysis service management, (b) dialysis procedure, (c) anemia management, (d) hormonal/dietary issues, and (e) arteriovenous fistula assessment. PD studies were divided into (a) peritoneal technique issues, (b) infections, and (c) cardiovascular event prediction. AI in transplantation studies were allocated into (a) management systems (ML used as pretransplant organ-matching tools), (b) predicting graft rejection, (c) tacrolimus therapy modulation, and (d) dietary issues. Conclusions Although guidelines are reluctant to recommend AI implementation in daily practice, there is plenty of evidence that AI/ML algorithms can predict better than nephrologists: volumes, Kt/V, and hypotension or cardiovascular events during dialysis. Altogether, these trials report a robust impact of AI/ML on quality of life and survival in G5D/T patients. In the coming years, one would probably witness the emergence of AI/ML devices that facilitate the management of dialysis patients, thus increasing the quality of life and survival.

Filling the gap between microscopic and automated analysis of the tumor-stroma ratio

Determining the tumor-stroma ratio (TSR) using a conventional microscope is an easy to apply and highly reproducible method. Due to digitalization in the pathology workflow, the demand for automated analysis of the TSR method is rising. However, the process of automation is rather time consuming and needs validation before implementation in daily practice. In addition, international studies ask for exchange of digital images instead of the actual slides. This calls for an alternative digital scoring method. This brief report describes the pitfalls of analyzing the TSR using digital images and proposes essential adaptations to create a standardized and reproducible scoring protocol. By using a circular annotation to mimic the microscopic method, these pitfalls can be avoided. Scoring the TSR digitally using a circular annotation does not take much additional effort compared to the microscopic method. When a fixed size of the annotation is saved, new cases can be scored in less than two minutes. With this brief report we propose an adjusted method for scoring the TSR on digital images to fill the gap between microscopically and automated scoring of the TSR. In addition, it opens the opportunity for application in daily diagnostics.

Effectiveness of the multi-component dynamic work intervention to reduce sitting time in office workers – Results from a pragmatic cluster randomised controlled trial

ObjectiveProlonged sitting, which is highly prevalent in office workers, has been associated with several health risks. The aim of this study was to evaluate the Dynamic Work intervention by determining its effect on total sitting time at the 8-month follow-up in comparison to the control. MethodsThis two-arm pragmatic cluster randomised controlled trial included 244 office workers from 14 different departments of a large, Dutch insurance company. The Dynamic Work intervention was a real-life, worksite intervention that included environmental components (i.e. sit-stand workstations), organisational components (i.e. group sessions), and individual components (e.g. activity/sitting trackers). Outcomes were assessed at baseline, 4-month follow-up, and 8-month follow-up. The primary outcome was total sitting time per day, objectively assessed using the activPAL activity monitor at 8-month follow-up. Secondary outcomes included other total and occupational movement behaviour outcomes, health-related outcomes, and work-related outcomes. Data analyses were performed using linear and logistic mixed models. ResultsTotal sitting time did not differ between the intervention and control group at the 8-month follow-up. Secondary outcomes also showed no difference between the intervention and control group at either the 4-month or at 8-month follow-up, with the exception of number of occupational steps, which showed a statistically significant effect at 4-month follow-up (but not at 8-month follow-up) of 913 (95% CI = 381–1445) steps/8-h working day. ConclusionsThis study evaluated the effectiveness of a real-life worksite intervention to reduce sitting time and showed little to no effect. This may be due to the relatively low intensity of the intervention, i.e. that it only involved the replacement of 25% of sitting workstations with sit-stand workstations. Future research should focus on the evaluation of more intensive real-life worksite interventions that are still feasible for implementation in daily practice. Clinicaltrials.gov, registration numberNCT03115645.

Update on HPV-associated head and neck cancer-highlights from the 2019 ASCO Annual Meeting

At this year's Annual Meeting of the American Society for Clinical Oncology (ASCO), the keyword search "HPV-associated head and neck cancer" resulted in 920 hits-74% of the hits on human papillomavirus (HPV). This underlines the relevance of the topic. The spectrum ranged from validation and separation of the prognostic groups of patients with HPV-associated oropharyngeal carcinoma (OPSCC) according to TNM8, to the characterization of new tumor markers and tumor mutational burden for possible de-escalation strategies to avoid toxicity of standard multimodal treatments. It has been shown that the separation of p16-positive OPSCC into Union for International Cancer Control (UICC) stagesI andII with the current TNM8 classification without further markers is not sufficiently successful to justify de-escalation strategies. Following publication of the results of the De-ESCALaTE- and RTOG-1016 trials in 2018, which confirm the current standard of care for p16-positive OPSCC, no further phaseIII studies on de-escalation were presented. In apresented prospective phaseII study (NCT02281955), the radiotherapy dose was reduced to cumulative 60 Gy, whereby the simultaneous chemotherapy regimen with cisplatin 30 mg/m2 weekly is not standard of care and could be administered as an alternative to cisplatin cetuximab. Some work dealt with the oral and intestinal microbiota as prognostic markers or their treatment-related changes, particularly under immunotherapy. Modification seems to have apositive impact on the success of therapy. However, robust data are still lacking for the various modified treatments for HPV-associated OPSCC, which are needed before their implementation in daily practice.

Implementing a multidisciplinary psychotropic medication review among nursing home residents with dementia: a process evaluation

Before drawing conclusions on the contribution of an effective intervention to daily practice and initiating dissemination, its quality and implementation in daily practice should be optimal. The aim of this process evaluation was to study these aspects alongside a randomized controlled trial investigating the effects of a multidisciplinary biannual medication review in long-term care organizations (NTR3569). Process evaluation with multiple measurements. Thirteen units for people with dementia in six long-term care organizations in the Netherlands. Physicians, pharmacists, and nursing staff of participating units. The PROPER intervention is a structured and biannually repeated multidisciplinary medication review supported by organizational preparation and education, evaluation, and guidance. Web-based questionnaires, interviews, attendance lists of education sessions, medication reviews and evaluation meetings, minutes, evaluation, and registration forms. Participation rates in education sessions (95%), medication reviews (95%), and evaluation meetings (82%) were high. The intervention's relevance and feasibility and applied implementation strategies were highly rated. However, the education sessions and conversations during medication reviews were too pharmacologically oriented for several nursing staff members. Identified barriers to implementation were required time, investment, planning issues, and high staff turnover; facilitators were the positive attitude of professionals toward the intervention, the support of higher management, and the appointment of a local implementation coordinator. Implementation was successful. The commitment of both higher management and professionals was an important factor. This may partly have been due to the subject being topical; Dutch long-term-care organizations are pressed to lower inappropriate psychotropic drug use.

Point-of-care ultrasound: Is it time to include it in the paediatric specialist training programme?

Point-of-care ultrasound (POCUS) has become an essential tool for clinical practice in recent years. It should be considered as an extension of the standard physical examination, which complements and enriches it without substituting it. POCUS enables the physician to answer specific clinical questions about the diagnosis, to understand better the pathophysiological context, to orientate the treatment, and to perform invasive procedures more safely. Despite its current use in many centres, and in most paediatric sub-specialties, there are currently no specific recommendations addressing educational aims in the different training areas, as well as methodology practice and the certification process in paediatrics. These ingredients are essential for POCUS implementation in daily practice, with a quality guarantee in terms of efficiency and safety.Several POCUS experts in different paediatric medicine environments performed a non-systematic review addressing the main paediatric POCUS applications in paediatrics. The lack of educational programmes in POCUS in Spain is also discussed, and the experience in the United States of America in this topic is provided.Considering the current situation of POCUS in paediatrics, we strongly believe that it is urgent to establish evidence-based recommendations for POCUS training that should be the base to develop educational programmes and to include POCUS in the paediatric residency training.