Individual Plans Research Articles

Deep learning-based quick MLC sequencing for MRI-guided online adaptive radiotherapy: a feasibility study for pancreatic cancer patients.

One bottleneck of MRI-guided Online Adaptive Radiotherapy (MRoART) is the time-consuming daily online replanning process. The current leaf sequencing method takes up to 10 minutes, with potential dosimetric degradation and small segment openings that increase delivery time. This work aims to replace this process with a fast deep learning-based method to provide deliverable MLC sequences almost instantaneously, potentially accelerating and enhancing online adaption.
Approach: Daily MRIs and plans from 242 daily fractions of 49 abdomen cancer patients on a 1.5T MR-Linac were used. The architecture included: 1) a recurrent conditional Generative Adversarial Network (rcGAN) model to predict segment shapes from a fluence map (FM), recurrently predicting each segment's shape; and 2) a linear matrix equation module to optimize the monitor units (MU) weights of segments. Multiple models with different segment numbers per beam (4-7) were trained. The final MLC sequences with the smallest relative absolute errors were selected. The predicted MLC sequence was imported into treatment planning system for dose calculation and compared with the original plans.
Main results: The gamma passing rate for all fractions was 99.7±0.2% (2%/2mm criteria) and 92.7±1.6% (1%/1mm criteria). The average number of segments per beam in the proposed method was 6.0±0.6 compared to 7.5 ± 0.3 in the original plan. The average total MUs were reduced from 1641 ± 262 to 1569.5 ± 236.7 in the predicted plans. The estimated delivery time was reduced from 9.7 minutes to 8.3 minutes, an average reduction of 14% and up to 25% for individual plans. Execution time for one plan was less than 10 seconds using a GTX1660TIGPU.
Significance: The developed models can quickly and accurately generate an optimized, deliverable leaf sequence from a FM with fewer segments. This can seamlessly integrate into the current online replanning workflow, greatly expediting the daily plan adaptation process.
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Caregivers' Perspectives on Discussions of Medical Treatment Preferences for People Living with Dementia Are Associated with Their Dementia Health Literacy and the Caregiving Relationship.

People living with dementia experience progressive functional decline and increased dependence on caregivers. This study examined the influence of caregivers' dementia health literacy on perceptions of medical care preferences and advanced care planning (ACP) in people living with dementia. This analysis used data from a cross-sectional survey, "Care Planning for Individuals with Dementia", administered nationwide by Alzheimer's Disease Centers. We conducted binary, ordinal, and multinomial logistic regression. On average, surveyed caregivers (n=431) were 78.3 years, had 16 years of education, and were mainly white (88.5%). Most lived with (76.8%) and were the designated healthcare proxy (95.1%), with high dementia knowledge scores (mean=8.4/10). As caregivers' dementia knowledge scores increased, they were 1.27 times more likely (p=0.02) to endorse comfort care. Caregivers with greater knowledge about severe dementia were less likely to need further treatment preference-related discussions (knowing a lot: OR=0.17, p<0.001; knowing some things: OR=0.37, p=0.006). Caregivers live apart from patients were 2.71 times more likely to know about such discussions (p<0.001). Caregivers of people in earlier stages endorsed greater needs for further conversations with clinicians (no impairment & MCI: OR=7.38, p=0.002; mild impairment: OR=5.32, p=0.005) and their care recipients (no impairment & MCI: OR=5.24, p=0.02). These findings highlight the role of dementia-specific education in ACP discussions among people living with dementia, caregivers, and healthcare clinicians. These findings are important since evidence suggests that ACP may promote quality of life, reduce iatrogenic harm, minimize healthcare overutilization, and alleviate care-related burdens.

P-470. CD4 Testing in HIV Care: Uncovering Patterns of Over-Monitoring

Abstract Background In the realm of HIV care, CD4 monitoring guidelines serve as a cornerstone for managing the health and treatment plans of individuals living with HIV. Various authoritative bodies, including the U.S. Department of Health and Human Services (HHS) offer nuanced guidelines tailored to the latest research and clinical best practices. In our study, we aimed to investigate the frequency of unnecessary CD4 testing and assess healthcare providers' comfort level of less frequent monitoring.Figure 1:Healthcare Provider Comfort Levels with Deferring CD4 Count Testing above 500 Methods We conducted a retrospective cohort study of HIV patients under active care at the Lifespan Immunology Clinic, Miriam Hospital, Providence, Rhode Island, from 2021 to 2023, with undetectable viral loads (&amp;lt; 200 VL) and CD4 counts over 500. Data were extracted from electronic health records, including demographics and clinical measures. Additionally, we conducted qualitative surveys among key healthcare providers to determine adherence to guidelines and to identify any patterns of unnecessary CD4 testing.Figure 2:Awareness of Costs Associated with CD4 Count and HIV Viral Load Testing Among Healthcare Providers Results In our first phase of the study, a cohort of 1,929 active unique patients was monitored for their immunological status in 2021. Among these, 1,226 individuals underwent CD4 testing as the event date, with 825 achieving CD4 counts &amp;gt;500. Further analysis highlighted a subgroup of 712 patients who exhibited undetectable viral loads over a three-year span with CD4 counts &amp;gt;500 in 2021. Additionally, 610 of these patients continued to undergo regular CD4 testing after the event date. This group represents approximately 86% of those who were undetectable from 2021 to 2023. In the second phase of the study, a survey involving 40 healthcare providers at the immunology clinic assessed practices in monitoring with CD4 counts &amp;gt;500. The survey revealed 77% were comfortable not performing further CD4 tests, regardless of the patient's viral load status and 90% preferred not testing patients with undetectable viral loads for 1-2 years. Conclusion Our study observed significant increasing frequency with unnecessary monitoring of CD4 above 500 with undetectable viral loads. This highlights the importance of implementing future guidelines for minimizing CD4 testing in stable patients, aligning clinical practices and improving outcomes. Disclosures All Authors: No reported disclosures

Evaluating the accuracy of impaired skin integrity in critically ill patients: Key characteristics and clinical implications.

To evaluate the accuracy of the defining characteristics of the nursing diagnosis Impaired skin integrity (00046) in patients admitted to intensive care units (ICUs). A cross-sectional diagnostic accuracy study was conducted with 105 adult patients admitted to an ICU. A latent class model with random effects was used to test the sensitivity and specificity of the defining characteristics investigated. The diagnosis Impaired skin integrity (00046) was the dependent variable, whereas sociodemographic and clinical data were the independent variables. Impaired skin integrity was present in 3.75% of the sample. The defining characteristic with the best accuracy for the diagnosis was dry skin, with high sensitivity (0.9994) and specificity (0.9106). Other characteristics stood out in terms of sensitivity measures: altered skin color (0.9994) and foreign matter piercing skin (0.9994). In terms of specificity, the following stood out: desquamation (1.000), localized area hot to touch (0.9901), pruritus (0.9897), bleeding (0.9802), and hematoma (0.9208). The defining characteristics that helped infer the diagnosis Impaired skin integrity (00046) with greater certainty were dry skin, altered skin color, foreign matter piercing skin, desquamation, localized area hot to touch, pruritus, bleeding, and hematoma. Identifying defining characteristics with high diagnostic accuracy for Impaired skin integrity (00046) enables nurses to expand their clinical perspective on this dysfunction, which can affect the skin of critically ill patients, and to develop individualized care plans.

An Overview and a Reflection of the Process and Product of Ph.D. Programs

This paper aims to analyze the Ph.D. thesis process and outcomes through the perspectives of three key actors— upervisee, supervisor, and academic institution—by drawing upon the personal experiences of the authors. Reflections are based on the authors past experience as supervisees and firsthand involvement in supervision, program management, and committee participation, with the key findings highlighting the intricate dynamics of these roles in shaping Ph.D. education. The aspects discussed in this work are motivation, previous experience, the individual study plan, guidance, and contributions. The motivations for pursuing a Ph.D. were diverse, encompassing personal and professional goals, passion for research, career advancement, and societal contributions. Previous experience from all actors is recognized as a critical factor influencing the success of the Ph.D. journey, where considerations regarding academic background, research interests, and cultural factors may influence the time and the outcome. The individual study plan is recognized by the authors as a vital tool for modeling a Ph.D. student’s research and professional development trajectory. Guidance throughout the Ph.D. process is discussed in terms of frequent and consistent supervision, providing regular support and feedback, which gradually shifts towards fostering research independence. This approach emphasizes the importance of mentorship and effective communication among peers at every stage. Finally, contributions are discussed as a final phase of the Ph.D. journey, where students are expected to demonstrate their expertise and impact through publications, awards, patents, and other forms of recognition. Supervisors and institutions also play a crucial role in supporting and showcasing such contributions. This reflection paper shows the relations between these factors and the collective responsibility shared by the actors in producing a successful Ph.D. thesis and an independent researcher. We argue our reflections are a valuable resource for those involved in Ph.D. programs, offering insights into the various dimensions of the Ph.D. journey and highlighting the importance of collaboration and support among these critical actors.

Longitudinal Reliability of Milestones Learning Trajectories during Anesthesiology Residency.

Longitudinal Milestones data reported to the Accreditation Council for Graduate Medical Education (ACGME) provide a structured framework for assessing the developmental progression of residents in key competencies and subcompetencies. This study aims to investigate the previously underexplored longitudinal reliability of Milestones data, with the goal of identifying patterns in learning trajectories that can inform targeted interventions for residents and programs. We conducted a retrospective cohort study with national anesthesiology Milestones data collected from 2014 to 2020. Mixed-effects growth curve models were fit to model residents' growth trajectories. Longitudinal reliability was assessed using the indices of growth rate reliability (GRR) and growth curve reliability (GCR). We also examined variance components attributable to the factors at both the learner and program levels. Latent class growth analyses (LCGA) were performed to identify latent groups of learners with different learning trajectories. The study included a total of 682,475 ratings for 4976 learners in 140 programs. Growth curve model results indicated that the mean baseline Milestone rating across the 25 subcompetencies was 2.05 (95% CI: 1.96-2.14), with an average increase of 0.49 (95% CI: 0.48-0.51) units per reporting period. The GRR (mean ± SD, 0.58 ± 0.03) suggested a moderate capability of anesthesiology Milestones to detect individual differences in the growth of latent competency. GCR estimates (mean ± SD, 0.76 ± 0.02) suggested acceptable overall reliability of Milestones across all the six assessment points. Significant variability was observed at both the program and learner levels (P < 0.001). LCGA identified 3-4 latent groups of learners with distinct learning trajectories across the 25 subcompetencies. Our study indicated that the anesthesiology Milestones provides moderately reliable information for tracking individual progress over time. The findings underscore the importance of using a multi-faceted approach to assessment and providing individualized learning plans to support resident development.

Psychiatric Home Hospitalization: The Role of Mental Health Nurses—A Scoping Review

The lack of evidence synthesis studies on the role of psychiatric mental health nursing in the context of psychiatric home hospitalization underscores the limited research on nurses providing care in these teams, particularly concerning their experiences and responsibilities and the actual role of nurses in this context. This knowledge has the potential to improve the quality of mental healthcare by guiding nursing practices. Objective: To map the concepts related to the role of mental health nurses in psychiatric home hospitalization. Methods: A scoping review was conducted using the methodology proposed by the JBI, involving five methodological stages. No search limits were applied except for language. Results: The review identified five key dimensions of nursing in psychiatric home hospitalization: satisfaction; care models; the therapeutic relationship; the care environment; the organization of care. These interconnected dimensions influence quality care. Satisfaction among nurses, patients, and families is associated with improved outcomes and reduced stigma. The therapeutic relationship is characterized by a humanistic approach, emphasizing dialogue, empathy, and shared decision making. Additionally, the importance of care organization is highlighted, including individualized care plans, medication management, and intersectoral collaboration. Discussion: The five nursing dimensions align with the Quality Standards of the Portuguese Nursing Council and are consistent with the scientific literature. Conclusions: Although there is a shortage of studies on this topic, this review allows for the synthesis of nursing interventions and reflection on the paradigm shift in care within the scope of psychiatric mental health nursing interventions. Future studies highlighting the value of mental health nursing interventions, with a particular focus on nursing-sensitive indicators and employing quantitative or mixed methods, will be crucial to furthering the analysis conducted thus far.

Features of adaptation of the bioenergetics system of the organism of young athletes to physical loads

Training of young athletes in modern conditions is characterized by the use of increased volumes and high intensity of training loads. The educational and training process in various sports involves the use of various schemes and approaches to training. The article identifies the physiological mechanisms of reactions of the body of young athletes to the muscular activity of the main energy systems. Such an approach is necessary for the scientific support of planning training programs at different stages of preparation. The study involved young athletes specializing in swimming and water polo. As part of the natural training process, a three-stage comprehensive examination was carried out for each specialization. The aim of the work was to identify individual adaptations of the athlete's body to physical exertion. As a result of the study, it was found that swimmers and water polo players demonstrate certain differences in the ratio of aerobic and anaerobic energy supply during intense muscle work. This is explained by differences in the focus of the training process and the specifics of their motor activity. Analysis of the study results revealed four main options for individual adaptation of the body of young athletes to physical exertion. This approach allowed for adjustments to individual training plans.

P0705 Features of optimal disease control in Crohn’s disease and Ulcerative Colitis: Views on IBD Expectations and Well-being by Patients and Treatment providers

Abstract Background With the expanding array of therapeutic options for Crohn’s disease (CD) and ulcerative colitis (UC), there is an increasing need to examine features of optimal disease control that reflect patient priorities. Views on IBD Expectations and Well-being - Patients and Treatment providers (VIEW-PT): an analysis based on the IBD Disease Specific Programme (DSP)™, aimed to identify features of optimal disease control in CD and UC, with inclusion of patient and healthcare professional (HCP) perspectives. Methods An iterative 3-Stage approach was used to identify features of optimal disease control in CD and UC (Table 1). In Stage 1, features of optimal disease control were identified by gastroenterologist (GI) advisors, a targeted literature search, and exploratory analyses of the Adelphi Real World IBD DSP. In Stage 2, features from Stage 1 were prioritized by patient advisors and additional features recommended for inclusion. In Stage 3, GI and advanced practice provider (APP) advisors provided further input on relevance of the expanded list of features, terminology, and categorisation. Features mentioned unprompted by patient, GI or APP advisors were cross-referenced to earlier stages and included if identified by ≥4 sources (see details in Table 1). GI and APP advisors provided feedback on similarities and differences of features of optimal disease control for CD vs UC. Results In Stage 1, nine features were identified as most relevant in defining optimal disease control in CD and UC: bleeding, bowel movement frequency, bowel urgency, endoscopic healing, fatigue, pain, quality of life, sleep disturbance, and steroid use. Faecal incontinence and mental health were added in Stage 2 following patient input. GI and APP advisors confirmed relevance of the 11 features in Stage 3; extraintestinal manifestations and biomarkers were added based on advisor recommendation and recurrence at earlier stages. Terminology was finalised and features ordered based on advisors’ recommendations, categorised as symptoms, functional outcomes, or markers of inflammation (Figure 1). GI and APP advisors advocated to include the same features for CD and UC, acknowledging expected variation in prioritisation by indication and across individual patients. Conclusion By considering a range of sources and including patient perspectives, optimal disease control in CD and UC was found to be a multi-faceted concept, incorporating symptoms, functional outcomes, and markers of inflammation. Patient advisors highlighted the importance of faecal incontinence and mental health, which may be overlooked in clinical practice. This robust framework of optimal disease control can be adopted to aid with development of individual IBD management plans in clinical practice.

Parental Perceptions of School Experiences for Children With Epilepsy.

Background: Given the centrality of school to the lives of the more than 450 000 US children living with epilepsy, their interface with schools related to medical and educational needs is critical. This qualitative study explores parental experiences with school systems for the care and education of their children with epilepsy. Methods: Two 90-minute focus groups were empaneled with a total of 11 caregivers of children with epilepsy. Facilitators, moderators, and recorders of each group performed semistructured interviews prompting discussion of families' experiences. Conversations were audio recorded, deidentified, transcribed, and coded. Results: Five central themes emerged: Lack of School Resources (46), Lack of School Support (36), Customized Educational Support Plans (32), Academic Impacts (24), and Positive School Support (22). Families demonstrated a lack of awareness of resources available for their children and reported using other families, advocacy groups, health teams, and others to help. Some participants felt burdened as their child's sole advocate through their educational journey, including educating staff on epilepsy care and fighting for individual educational plans or supplemental resources. Families described global adverse effects of their child's epilepsy on family function related to finances/work, relationships, and sibling depression/anxiety, as well as inconsistent staff education to support students with epilepsy and variable staffing. Conclusion: Families of children with epilepsy face barriers that inform potential areas of improvement within schools. Closer interface between the medical community and educational systems may bridge gaps to ease the burden on families of children with epilepsy.

Democratic Theory and Economic Planning

The participatory economics model (ParEcon) of Michael Albert and Robin Hahnel represents an important contribution to the debate about feasible alternatives to capitalism. What distinguishes the model from other proposals, like market socialism or cybersocialism, is the central role given to the participation of citizens in economic planning. Citizens form workers’ and neighbourhood consumers’ councils which develop production and consumption proposals. These councils form federations responsible for the coordination of planning. An Iteration Facilitation Board plays a mere perfunctory role in the facilitation of the planning process. This way, economic planning is done entirely by the citizens themselves rather than planners at a central planning agency. The ParEcon model is thereby supposed to be more democratic than historical central planning.In this paper, I consider whether three possible justifications for democracy can also be used to support this kind of participatory economy. These justifications can be referred to as (1) the protection of citizens’ interests, (2) the revealing of preferences and (3) liberty. In my paper, I show that these three justifications of democracy do not in fact support democratic participation in concrete economic plans in the way envisaged by Albert and Hahnel. Instead of individual plans, citizens should choose general planning procedures. This prevents citizens from being subjected to the arbitrary power of their co-workers or neighbours. Such an algorithmic planning process also prevents central planners from holding arbitrary power since, much like the Iteration Facilitation Board in the ParEcon model, they simply facilitate the prescribed planning process without retaining significant discretion. As I elaborate in the case of consumption planning, citizens can still participate in planning, however they do so through their individual choices rather than a democratic vote. Individual citizens should not require the approval of their neighbours for their personal consumption.

The Meaning of Ageing and the Educational Intervention "Good Life in Old Age": An Ethnographic Study Reflecting the Perspective of Older Adults with Mild Intellectual Disability.

Older adults with intellectual disabilities are not adequately prepared for ageing and show anxiety and uncertainty regarding the future. Therefore, the two-year educational intervention "Good Life in Old Age" was implemented to improve their understanding of ageing and enhance their well-being. This study aimed to explore the meaning of ageing during and after the intervention from the perspective of older adults with mild intellectual disability. The ethnographic design included participant observations, field notes, group interviews, and individual follow-up interviews with 20 adults aged 44-75 (mean 63.2) with intellectual disabilities. The main findings are expressed in four themes; Awareness of ageing with intellectual disabilities, Strengthened as a person through empowering community, Awareness of vulnerability as an older adult, and The educational intervention as a resource to manage vulnerability. The education programme created a social network for healthy ageing with an atmosphere of mutual support fostering greater mental strength and self-confidence. Individual retirement plans should be created to foster socialisation, involving adapted activities and conversations about bereavement and death. There is a need to disseminate and continue developing promising education programmes for older adults with intellectual disabilities to reduce their anxiety about retirement and loneliness and facilitate healthy ageing.

A Narrative Review of the Interplay Between Carbohydrate Intake and Diabetes Medications: Unexplored Connections and Clinical Implications.

This narrative review examines the dynamic interplay between carbohydrate intake and diabetes medications, highlighting their combined molecular and clinical effects on glycemic control. Carbohydrates, a primary energy source, significantly influence postprandial glucose regulation and necessitate careful coordination with pharmacological therapies, including insulin, metformin, glucagon-like peptide (GLP-1) receptor agonists, and sodium-glucose cotransporter-2 (SGLT2) inhibitors. Low-glycemic-index (GI) foods enhance insulin sensitivity, stabilize glycemic variability, and optimize medication efficacy, while high-GI foods exacerbate glycemic excursions and insulin resistance. Continuous glucose monitoring (CGM) offers real-time insights to tailor dietary and pharmacological interventions, improving glycemic outcomes and reducing complications. Despite advancements, gaps persist in understanding nutrient-drug interactions, particularly with emerging antidiabetic agents. This review underscores the need for integrating carbohydrate-focused dietary strategies with pharmacotherapy to enhance diabetes management. Future research should prioritize clinical trials leveraging CGM technology to explore how glycemic index, glycemic load, and carbohydrate quality interact with newer diabetes medications. Such studies can refine evidence-based recommendations, support individualized care plans, and improve long-term outcomes. Addressing systemic barriers, such as limited access to dietitians and CGM technology in underserved regions, is critical for equitable care. Expanding the roles of community health workers and training healthcare providers in basic nutrition counseling can bridge gaps, promoting sustainable and inclusive diabetes management strategies. These efforts are essential for advancing personalized, effective, and equitable care for individuals with diabetes.

RELATIONSHIP BETWEEN ACCOMMODATING LEARNING STYLE AND ACADEMIC ACHIEVEMENT OF SECONDARY SCHOOL STUDENTS IN KAMWENGE DISTRICT, UGANDA. A CROSS-SECTIONAL STUDY

Background Academic achievement was seen as a symbol of social status and provided avenues for further education. The aim of the study is to assess the relationship between accommodating learning style and academic achievement of secondary school students in Kamwenge District, Uganda. Methodology This study employed a descriptive, correlational and crosses- sectional survey design. The quantitative technique provided detailed numerical analysis of the research problem and investigated the relationship between the research variables. Respondents comprised of 265 students (s4), 58 teachers, 04 head teachers and 05 Education administrators within Kamwenge District. Results 55.3% of the respondents were male while 44.7% were female. The correlation between accommodating learning styles and academic achievements among secondary students in Kamwenge District was 0.634 indicating a moderately strong positive correlation between accommodating learning styles and academic achievements among secondary students in Kamwenge District. The p-value (Significance) being less than 0.05 indicates that this correlation is statistically significant, suggesting that it is unlikely to have occurred by chance. The coefficient for accommodating learning style (B1) is 2.329, indicating that for each unit increase in accommodating learning style, there is an associated increase of 2.329 units in academic achievements. The R Square value of 0.34 suggests that approximately 34% of the variance in academic achievements can be explained by accommodating learning style in this model. Conclusions Accommodating and kinesthetic learning styles demonstrate stronger positive correlations with academic achievements compared to audio learning style. Recommendations Secondary schools and Ministry of Education should develop individualized learning plans for students based on their identified learning styles.

Fall Risk Assessment in Acute Rehabilitation: Comparison of Two Assessment Tools.

Many fall risk assessment tools exist. However, few of these fall risk assessment tools have been tested in the acute rehabilitation setting. The purpose of our study was to compare the accuracy of the Hendrich II Fall Risk Model (HIIFRM) and Sunnyview Test Scale in predicting falls. We also identified factors associated with falls in the rehabilitation patient. In this retrospective cohort study, we extracted electronic health record data from two acute inpatient rehabilitation units and compared the predictive validity of the HIIFRM and the Sunnyview Test Scale. Our sample included 134 fallers and 1,667 nonfallers. The HIIFRM and the Sunnyview Test Scale had similar predictive performance with area under the receiver operating characteristic curve (AUC) of .62 and .60, respectively. The HIIFRM and the Sunnyview Test Scale had poor performance (AUC < .70) predicting falls in this acute rehabilitation setting. Using a fall risk assessment tool alone does not consider unique risk factors and makes implementation of individualized prevention interventions challenging. Nurses need a framework to use individualized factors to determine high fall risk. Further research is needed to clarify variables specific to the inpatient rehabilitation population. Current fall risk assessment tools are inadequate in the inpatient rehabilitation setting; an individualized fall prevention plan is recommended to ensure patient safety.

Effective Recruitment and Employee Development Tools in the Context of Labor Shortages in the Service Sector

The labor shortage in the food service, retail, and hospitality industries is becoming an increasingly pressing issue, complicating business growth. High employee turnover significantly raises costs associated with recruitment, training, and adaptation, which is particularly challenging for small and medium–sized enterprises. This article examines the causes of the labor shortage, including demographic decline, seasonality, competition for talent, and evolving employee expectations.Special attention is given to effective methods of recruitment and employee retention. The study explores non–material motivation tools, such as individual development plans, career planning, and workBlife balance support. Streamlining the hiring process through automation, HR branding, and the cultivation of corporate culture are highlighted as key strategies for reducing turnover.Furthermore, the importance of a systematic approach to employee training and development is emphasized, contributing to increased engagement and service quality. The article concludes that a comprehensive approach to personnel management is essential for enhancing companies’ competitiveness in the context of labor shortages.

Use of patient-centred outcome measures alongside the personal wheelchair budget process in NHS England: A mixed methods approach to exploring the staff and service user experience of using the WATCh and WATCh-Ad.

Personal wheelchair budgets (PWBs) are offered to everyone in England eligible for a wheelchair provided through the National Health Service (NHS) to support their choice of equipment. The WATCh (Wheelchair outcomes Assessment Tool for Children) and related WATCh-Ad for adults are patient-centred outcome measures (PCOMs) developed to help individual users express their main outcome needs when obtaining a wheelchair and rate their satisfaction with subsequent outcomes after receiving their equipment. Use was explored in a real-world setting, aiming to produce guidance for use alongside the PWB process. Three wheelchair service provider organisations across four sites participated. Staff and users completed surveys about their experience of assessments using the WATCh and/or WATCh-Ad. Selected patients were interviewed after receipt of their equipment, and staff were interviewed after experiencing a number of assessments. Thematic analysis was undertaken using the tool, survey and interview data. Results of pre- and post-equipment provision were presented graphically. Information on 75 assessments by 15 staff was obtained. Three-quarters of users or their carers rated the use of the tools in the assessment process as 'helpful' or 'very helpful'. Staff reported that the WATCh or WATCh-Ad had been considered 'useful' in developing individual care plans in around 1 in 3 cases and affected the prescription in 1 in 4 cases. Concerns were expressed about the length of time taken to administer the tools in clinic. However, some staff noted this reduced with more hands-on experience and by providing the tools to users in advance of the appointment. The WATCh and WATCh-Ad PCOMs are suitable for routine use by wheelchair service providers to assist the assessment process. It is recommended that tool materials are provided in advance to users/carers and that staff are allowed time to develop their ways of working with them.

Toothbrushes made and adapted for patients with special needs

Introduction: People with special needs often have a high number of caries and periodontal diseases, related to difficulties in ensuring oral health care, access to dental treatment, and sometimes to the socioeconomic context. Objective: to argue the importance of making adapted toothbrushes for patients with special needs. Methods: a narrative bibliographic review was carried out through Google Scholar, of scientific articles published in the last ten years, in different digital databases such as: SciELO, Medline, Pubmed, digital libraries, in English and Spanish, using the following descriptors: "disability", "special needs", "oral hygiene", "mechanical and electric toothbrush", "bamboo toothbrush" "partial and/or total assistance". Development: the effectiveness of tooth brushing depends on the type of toothbrush, its use, the method and time of brushing, the use of mouthwash and/or dental floss. Although there are different methods for preventing plaque formation, the use of toothbrushes has proven to be the most effective way. This group includes patients with moderate or severe physical or mental disabilities and with significant motor limitations in the upper limbs. Many of them remain in wheelchairs or are bedridden for a large part of the time, need help to carry out any oral hygiene procedure and in this sense, with rare exceptions, cannot assume any type of responsibility in the process. Conclusions: the dentist must perceive the problem of the particular individual and formulate an individual plan, as well as inform the parents and the patient how to carry out such a program. Most patients with disabilities will require the supervision of parents or substitutes to carry it out

Maternal and perinatal outcomes after implementation of a more active management in late- and postterm pregnancies in Sweden: A population-based cohort study.

The risk of perinatal death and severe neonatal morbidity increases gradually after 41 weeks of pregnancy. We evaluated maternal and perinatal outcomes after a national shift from expectancy and induction at 42+0 weeks to a more active management of late-term pregnancies in Sweden offering induction from 41+0 weeks or an individual plan aiming at birth or active labour no later than 42+0 weeks. Women with a singleton pregnancy lasting 41+0 weeks or more with a fetus in cephalic presentation (N = 150,370) were included in a nationwide, register-based cohort study. Elective cesarean sections were excluded. Outcomes during period 1, January 2017 to December 2019 (before the shift) versus outcomes during period 2, January 2020 to October 1, 2023 (after the shift) were analysed. For comparison, outcomes of pregnancies lasting 39+0 to 40+6 weeks (N = 358,548) were also studied. Primary outcomes were: First, peri/neonatal death (stillbirth or neonatal death before 28 days); second, composite adverse peri/neonatal outcome (peri/neonatal death, Apgar score <4 at 5 min, hypoxic ischemic encephalopathy grades 1-3, meconium aspiration syndrome, birth trauma, or admission to a neonatal intensive care unit (NICU) ≥4 days); third, composite adverse peri/neonatal outcome excluding admission to NICU; and fourth, emergency cesarean section. Secondary outcomes included the components of the primary composite outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) for binary outcomes period 2 versus period 1 were computed using modified Poisson regression analyses with adjustments for maternal age, parity, body mass index (BMI), smoking, and educational level. Induction rates among pregnancies lasting 41+0 weeks or more increased from 33.7% in period 1 to 52.4% in period 2. Mean (standard deviation) gestational age at birth decreased from 290.7 (2.9) days to 289.6 (2.3) days. Infants born during period 2 were at lower risk of peri/neonatal death compared to infants born during period 1; 0.9/1,000 versus 1.7/1,000 born infants (adjusted RR 0.52; 95% CI [0.38, 0.69]; p < 0.001), and they had a lower risk of having the composite adverse neonatal outcome, both including (50.5/1,000 versus 53.9/1,000, adjusted RR 0.92; 95% CI [0.88, 0.96]; p < 0.001) or excluding NICU admission (18.5/1,000 versus 22.5/1,000, adjusted RR 0.79; 95% CI [0.74, 0.85]; p < 0.001). The cesarean section rate increased from 10.5% in period 1 to 11.9% in period 2 (adjusted RR 1.07; 95% CI [1.04, 1.10]; p < 0.001). For births at 39 to 40 weeks the adjusted RR for peri/neonatal death was 0.86 (95% CI [0.72, 1.02]). One limitation of the study is that we had no data on to what extent monitoring of fetal health was performed. A more active management of pregnancies lasting 41+0 weeks or more was associated with a decrease in peri/neonatal deaths, and a decrease in composite adverse peri/neonatal outcomes. Increased rate of emergency cesarean sections was observed. Women with pregnancies advancing towards 41 gestational weeks should be given balanced information on the benefits and risks of induction of labour at 41 weeks compared to expectant management until 42 weeks and be offered induction of labour at 41 weeks or active surveillance of pregnancies from 41 weeks in order to decrease peri/neonatal mortality.

Vision of Nikolograd. The endgame

On June 17, 2024, a defense of a group of students from the Department of Architecture of Residential Buildings, the workshop of Professor M. A. Belov and Associate Professor P. K. Zavadovsky, who took part in a unique experiment, was successfully held at the Moscow Architectural Institute. It took three years to develop a general project for the city of Nikolograd – Klausburg, in which the authors could realize both general and individual plans. The images of Nikolograd architecture have deep historical roots. An attempt was made in student projects to develop the neoclassical and symbolic direction in architecture.