Primary Network Research Articles

Developing a digital phenotype to subdivide adult immunosuppressed COVID-19 outcomes within the English Primary Care Sentinel Network.

Adults classified as immunosuppressed have been disproportionately affected by the COVID-19 pandemic. Compared to the immunocompetent, certain patients are at increased risk of suboptimal vaccine response and adverse health outcomes if infected. However, there has been insufficient work to pinpoint where these risks concentrate within the immunosuppressed spectrum; surveillance efforts typically treat the immunosuppressed as a single entity, leading to wide confidence intervals. A clinically meaningful and computerised medical record (CMR) compatible method to subdivide immunosuppressed COVID-19 data is urgently needed. We conducted a rapid scoping review into COVID-19 mortality across UK immunosuppressed categories to assess if differential mortality risk was a viable means of subdivision. We converted the risk hierarchy that surfaced into a pilot digital phenotype-a valueset and series of ontological rules ready to extract immunosuppressed patients from CMR data and stratify outcomes of interest in COVID-19 surveillance dataflows. The rapid scoping review returned COVID-19 mortality data for all immunosuppressed subgroups assessed and revealed significant heterogeneity across the spectrum. There was a clear distinction between heightened COVID-19 mortality in haematological malignancy and transplant patients and mortality that approached the immunocompetent baseline amongst cancer therapy recipients, autoimmune patients, and those with HIV. This process, complemented by expert clinical input, informed the curation of the five-part digital phenotype now ready for testing in real-world data; its ontological rules will enable mutually exclusive, hierarchical extraction with nuanced time and treatment conditions. Unique categorisations have been introduced, including 'Bone Marrow Compromised' and those dedicated to differentiating prescriptions related and unrelated to cancer. Codification was supported by existing reference sets of medical codes; absent or redundant codes had to be resolved manually. Although this work is in its earliest phases, the development process we report has been highly informative. Systematic review, clinical consensus building, and implementation studies will test the validity of our results and address criticisms of the rapid scoping exercise they are predicated on. Comprehensive testing for COVID-19 has differentiated mortality risks across the immunosuppressed spectrum. This risk hierarchy has been codified into a digital phenotype for differentiated COVID-19 surveillance; this marks a step towards the needs-based management of these patients that is urgently required.

A pH-responsive dual-network biopolysaccharide hydrogel with enhanced self-healing and controlled drug release properties.

Traditional hydrogels based on Schiff base reactions frequently encounter issues with rapid drug release when employed as drug delivery systems owing to their susceptibility to hydrolysis under acidic conditions. It is, therefore, necessary to implement improvements to regulate the drug release behavior. In this study, a dual-network and pH-responsive biopolysaccharide hydrogel was developed, which is self-healing, injectable and biocompatible. Most importantly, the hydrogel has excellent tunability for controlled drug release. The hydrogel consisted of a primary network of dibenzaldehyde-functionalized poly(ethylene glycol) (DP) and chitosan (CS) formed through a Schiff base reaction and a secondary network of sodium alginate (SA) and CS formed through electrostatic interactions. It was found that the DP-CS-2%SA hydrogel can prolong the release duration up to four-fold compared to the single-network DP-CS hydrogel at a given release threshold. Significantly, by adjusting the relationship between the two effects through the amount of SA, the release modifiability of drug delivery systems has been greatly enhanced. This study could significantly enhance the tunability of hydrogel drug delivery systems.

Consensus of the Italian Primary Immunodeficiency Network on the use and interpretation of genetic testing for the diagnosis of inborn errors of immunity (IEI)

BackgroundInborn errors of immunity (IEIs) are more than 500 different rare congenital disorders of the immune system characterized by susceptibility to infections and immune dysregulation. The significant overlap of the clinical features among the different forms may lead to diagnostic delay. High throughput sequencing techniques may allow a timely genetic definition. Guidelines for the use and the interpretation of genetic testing produced by the American College of Medical Genetics and Genomics (ACMG) and the European Society of Human Genetics (ESHG) do not cover specificities for the application to IEIs. ObjectiveThe aim of this consensus study is to define the best approach to genetic testing for IEIs. MethodsA panel of experts in the context of the Italian Primary Immunodeficiency Network (IPINet) composed a list of statements that were evaluated using Delphi method. ResultsThe experts recommend that genetic testing for IEIs should be offered to selected patients with warning signs for IEIs and highlight the crucial role of thorough phenotyping and functional tests for the conclusive diagnosis of IEI. Comprehensive educational programs targeted to health care professionals and the public should be developed to increase IEIs awareness and reduce the diagnostic delay. Ethical issues should be pondered over the diagnostic advantages of genetic tests requested for diagnostic purposes. ConclusionAdherence to the guidelines on the use and interpretation of genetic testing for the diagnosis of IEIs should help limiting the inappropriate use of these techniques and reduce the risk of misdiagnosis and apprehension for inconclusive genetic results.

Employment and deployment of additional roles: What works for whom, how and why?

Background Additional Roles Reimbursement Scheme (ARRS) was introduced in England in 2019 to alleviate workforce pressures in general practice by funding additional staff such as clinical pharmacists, paramedics, first contact physiotherapists and from 2024/25, the scheme will fund recently qualified GPs. However, the employment and deployment models of ARRS staff present ongoing complexities and challenges that require further exploration. Aim This study explores the decision-making processes behind Primary Care Networks (PCNs) and general practice staffing choices, and how these choices influence the operationalisation of ARRS. Design A qualitative case study across four PCNs in England using a realist evaluation framework. Method Data collection took place between September 2022 - November 2023. Semi-structured interviews were conducted with PCN Clinical Directors, GPs, practice managers and ARRS staff (n=42). Transcripts were analysed using a realist evaluation framework to identify the context-mechanism-outcome configuration. Results Direct employment models fostered staff development and retention, contingent upon established trust among practices. Subcontracting was favoured to mitigate employment risks but could lead to unintended consequences like conflicting accountabilities and less integration with existing GP practice staff. The optimal deployment model involved rotations across a limited number of GP practices, ideally two, with one serving as a base, ensuring consistency in training and management. Conclusion This study provides novel insights into the complexities of different employment and deployment models of ARRS staff. These findings will be invaluable for creating a sustainable GP practice workforce and informing future workforce strategies as the scheme expands to include recently qualified GPs.

The Alberta Back Care Pathway: The feasibility of implementing a novel care pathway to improve low back pain management for family physicians in primary care.

Family physicians in Canada's universal healthcare system often manage low back pain patients using interventions not recommended in clinical guidelines, such as pharmaceuticals, imaging and spinal injections, while guideline-based treatments like education and exercise remain unfunded. The Alberta Back Care pathway was developed to address this gap, offering funded, evidence-based care for low back pain patients in 5 streams (acute, sub-acute, chronic, chronic non-responsive and stable radiculopathy). To evaluate the feasibility of implementing the pathway in two urban Primary Care Networks in Alberta, Canada. Each of the 5 pathway streams provided physicians with information scripts, no-cost interventions (pharmaceuticals and otherwise) and interventions to avoid. From April 2021 to November 2023, the RE-AIM framework was used to assess implementation feasibility of the pathway. For the RE-AIM dimension of reach, 25% (n = 41/162) of eligible family physicians in Primary Care Network "A" and 12% (n = 26/221) in Primary Care Network "B" enrolled in the study. Over half of enrolled physicians (n = 21/41 and 21/26) referred at least one patient with most referrals to the GLA:D Back program for chronic low back pain stream (93% in network "A" and 88% in network "B"). Implementation, evaluated as the proportion of referrals by physician compared to their total low back pain caseload, was low (> 0-10% referred) for 52% (n = 11/21) of physicians in network "A", and medium-low (10-25% referred) for 52% (n = 11/21) of physicians in network "B". The number of pathway-appropriate patients in each physician's caseload was unknown. Maintenance at 12 months was 56% (n = 10/18) in network "A" and 39% (n = 7/18) in network "B". The Alberta Back Care pathway was feasible to implement during the pandemic and primarily serving patients with chronic low back pain by providing access to a guideline-based education and exercise group program (GLA:D Back).

Development and validation of a rheumatoid arthritis case definition: a machine learning approach using data from primary care electronic medical records

BackgroundRheumatoid Arthritis (RA) is a chronic inflammatory disease that is primarily diagnosed and managed by rheumatologists; however, it is often primary care providers who first encounter RA-related symptoms. This study developed and validated a case definition for RA using national surveillance data in primary care settings.MethodsThis cross-sectional validation study used structured electronic medical record (EMR) data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Based on the reference set generated by EMR reviews by five experts, three machine learning steps: ‘bag-of-words’ approach to feature generation, feature reduction using a feature importance measure coupled with recursive feature elimination and clustering, and classification using tree-based methods (Decision Tree, Random Forest, and Extreme Gradient Boosting). The three tree-based algorithms were compared to identify the procedure that generated the optimal evaluation metrics. Nested cross-validation was used to allow evaluation and comparison and tuning of models simultaneously.ResultsOf 1.3 million patients from seven Canadian provinces, 5,600 people aged 19 + were randomly selected. The optimal algorithm for selecting RA cases was generated by the XGBoost classification method. Based on feature importance scores for features in the XGBoost output, a human-readable case definition was created, where RA cases are identified when there are at least 2 occurrences of text “rheumatoid” in any billing, encounter diagnosis, or health condition table of the patient chart. The final case definition had sensitivity of 81.6% (95% CI, 75.6–86.4), specificity of 98.0% (95% CI, 97.4–98.5), positive predicted value of 76.3% (95% CI, 70.1–81.5), and negative predicted value of 98.6% (95% CI, 98.0-98.6).ConclusionA case definition for RA in using primary care EMR data was developed based off the XGBoost algorithm. With high validity metrics, this case definition is expected to be a reliable tool for future epidemiological research and surveillance investigating the management of RA in CPCSSN dataset.

Performance Study of FSO/THz Dual-Hop System Based on Cognitive Radio and Energy Harvesting System

In order to address the problems of low spectrum efficiency in current communication systems and extend the lifetime of energy-constrained relay devices, this paper proposes a novel dual-hop free-space optical (FSO) system that integrates cognitive radio (CR) and energy harvesting (EH). In this system, the source node communicates with two users at the terminal via FSO and terahertz (THz) hard-switching links, as well as a multi-antenna relay for non-orthogonal multiple access (NOMA). There is another link whose relay acts as both the power beacon (PB) in the EH system and the primary network (PN) in the CR system, achieving the double function of auxiliary transmission. In addition, based on the three possible practical working scenarios of the system, three different transmit powers of the relay are distinguished, thus enabling three different working modes of the system. Closed-form expressions are derived for the interruption outage probability per user for these three operating scenarios, considering the Gamma–Gamma distribution for the FSO link, the α−μ distribution for the THz link, and the Rayleigh fading distribution for the radio frequency (RF) link. Finally, the numerical results show that this novel system can be adapted to various real-world scenarios and possesses unique advantages.

The Philadelphia Beverage Tax and Pediatric Weight Outcomes

Taxation of sweetened beverages is a proposed strategy to reduce excess sugar consumption. The association of such taxes with health outcomes is not well studied. Philadelphia, Pennsylvania, is the largest US city with a beverage tax. To assess whether the 2017 Philadelphia beverage tax was associated with changes in pediatric weight outcomes. This study used difference-in-differences models weighted by inverse probability of treatment weights to adjust for differences between youth in Philadelphia (tax exposed) and in the surrounding counties (control) on age, sex, race, ethnicity, Medicaid insurance status, health care use, and census-tract socioeconomic index. Mixed-effects linear and logistic regression models estimated differences in posttax changes in standardized body mass index (zBMI) and prevalence of obesity (a BMI 95th percentile or higher for age and sex) between Philadelphia and control. Stratified analyses assessed differences by age, sex, race, Medicaid insurance status, and baseline weight. Data came from electronic health records of a primary care network operating in the Philadelphia region. A panel analysis included youth 2 to 18 years old with 1 or more BMI measurement pretax (2014 to 2016) and 1 or more BMI measurement posttax (2018 to 2019). A cross-sectional analysis included youth 2 to 18 years old with 1 or more BMI measurement at any time from 2014 to 2019. These data were analyzed from December 2020 through July 2024. Living in Philadelphia after implementation of the beverage tax. zBMI and obesity prevalence. In panel analysis of 136 078 youth, the tax was associated with a difference in zBMI change of -0.004 (95% CI, -0.009 to 0.001) between Philadelphia and the control and a 1.02 odds ratio (95% CI, 0.97-1.08) of BMIs in the 95th percentile or higher. In cross-sectional analysis of 258 584 youth, the difference in zBMI change was -0.004 (95% CI, -0.009 to 0.001) and the odds ratio of a BMI in the 95th percentile or higher was 1.01 (95% CI, 0.95-1.07). In subgroup analyses, some differences in zBMI change were evident by race, age, Medicaid insurance status, and baseline weight but these differences were small and inconsistent across samples. These results show that 2 years after implementation, the Philadelphia beverage tax was not associated with changes in youth zBMI or obesity prevalence. Though certain subgroups demonstrated small statistically significant changes in zBMI, they are of low clinical significance.

Gender and Intersecting Barriers and Facilitators to Access the HIV Cascade of Care in Manitoba, Canada, Before and During the COVID-19 Pandemic: A Qualitative Study

Marginalized groups in Manitoba, Canada, especially females and people who inject drugs, are overrepresented in new HIV diagnoses and disproportionately affected by HIV and structural disadvantages. Informed by syndemic theory, our aim was to understand people living with HIV’s (PLHIV) gendered and intersecting barriers and facilitators across the cascade of HIV care before and during the COVID-19 pandemic. This study was co-designed and co-led alongside people with lived experience and a research advisory committee. We employed semi-structured interviews with thirty-two participants and three questionnaires. Interviews were audio-recorded, transcribed, and coded, and descriptive statistics were performed on the first two questionnaires. Qualitative data analysis used thematic analysis and focused on identifying categories (individual, healthcare, and social/structural) related to the barriers and facilitators to HIV care. A total of 32 PLHIV completed this study and over 70% of females and 50% of males reported severe and moderate sexual abuse among other traumatic childhood experiences. Barriers to accessing or continuing in the cascade of HIV care included navigating the initial shock of receiving an HIV diagnosis, mental health challenges and inaccessible supports, substance use, violence (including intimate partner), internalized and enacted compounded stigma related to houselessness and substance use, discrimination by primary care service providers and social networks, lack of preventative and social supports, lack of accessible housing, and programmatic issues. COVID-19 increased mental health problems and disrupted relationships with HIV service providers and peers living with HIV. Facilitators to HIV care included stopping substance use, caring service providers particularly during HIV diagnosis, welcoming healthcare environments, social opportunities and integrated supports, and supportive social networks. Women, men, and non-binary PLHIV experience interconnected factors complicating their experiences with HIV care. Interventions should consider holistic, person-centered, and trauma-informed care options to address the barriers found in this research and appropriately serve PLHIV.

It Takes a Village: How Community-Based Peer Support for Breastfeeding Bolsters Lactation Prevalence Among Black Mississippians on the Gulf Coast.

Breastfeeding rates are considerably lower among African American women and across the U.S. South. Our study introduces the concept of community-based peer support for breastfeeding, as measured through beliefs about women's comfort breastfeeding in various social situations (i.e., in the presence of women and men as well as close friends and strangers). We examine if community-based peer support for breastfeeding is associated with reported lactation prevalence in primary social networks among survey respondents living on the Mississippi Gulf Coast. Special attention is paid to racial differences in the breastfeeding support-prevalence relationship. We use data drawn from a survey that combines a random sample of adults who are representative of the Mississippi Gulf Coast population and a non-random oversample of African Americans in this predominantly rural tri-county area. Analyses of data from wave 1 of the CDC-funded 2019 Mississippi REACH Social Climate Survey reveal low overall levels of African American breastfeeding network prevalence (knowing friends and family who have breastfed). However, community-based peer support for breastfeeding significantly amplifies breastfeeding network prevalence for black Mississippians when compared with their white counterparts. Previous research has indicated that breastfeeding promotional messages have a limited impact on African American breastfeeding propensity along the Mississippi Gulf Coast. However, the current study indicates that enhanced community-based peer support for breastfeeding can be a key facilitator for improved lactation outcomes among African Americans as compared with whites. We establish that breastfeeding is best conceived as both an interpersonal encounter (an activity often conducted in the presence of others) and a collective achievement (a practice influenced by community norms). We discuss study implications and directions for future research.

Implementation and Evaluation of Automated, Online Study Recruitment from Computerised Medical Records in a Primary Care Sentinel Surveillance Network.

Infectious intestinal disease (IID) is a syndrome consisting of diarrhoea and vomiting symptoms linked to a causative pathogen. The Third Study of IID (IID3) will report its incidence in the community within the UK and assess how it has changed since the second IID study (IID2) in 2012. We implemented an automated, online patient recruitment process within a national sentinel surveillance network and compared its performance versus IID2 in terms of: Patient recruitment rates and demographic characteristics of recruited participants. We utilised a text messaging system (TMS) running off a computerised medical record systems (CMR) application programme interface (API). Demographic analysis showed that the majority of those recruited to IID3/IID2 studies were >65 years and female. However, the recruitment of participants of non-white ethnicity was statistically significantly different between IID3/IID2. Further work is required to improve recruitment in the younger patient demographic and in ethnic minority populations.

Scientometric and content analysis‐based review of employees in micro‐level corporate social responsibility research

AbstractIn today's fiercely competitive business climate, organisations face challenges that necessitate the implementation of policies to bolster their strategic advantage, regardless of their size or location. One effective strategy employed by present‐day organizations to attain enhanced effectiveness and competitive edge is corporate social responsibility (CSR). This study presents a comprehensive scientometric analysis evaluating current research on micro‐level CSR. This investigation provides valuable insight into current micro‐level CSR research. Utilizing a science mapping method, 4286 Scopus bibliographic records were quantitatively and systematically examined. The findings reveal the most prolific authors, journals, institutions, countries, article citations and co‐occurrence network of keywords via cluster analysis. Additionally, the qualitative analysis uncovered five distinct micro‐level themes concerning CSR, including concepts, drivers, evaluations, reactions, and research design. This study is the first of its kind, and its findings add valuable insights to the existent knowledge. It provides an exhaustive and current literature review of micro‐level CSR. Trends and patterns of the micro‐level CSR field are visualized and comprehended, and the primary research networks, journals, institutions, and countries, along with their interconnections are identified. Furthermore, it introduces a comprehensive framework that classifies the different categories of micro‐level CSR research. Lastly, it highlights the inadequacies in current research and offers insights for future studies. This study will serve as a point of reference for policymakers, practitioners, and research and development agencies.

How did educational institutions respond to students with special needs during COVID-19: considerations for policy?

This bibliometric study analyzes the scientific production on the educational response of institutions to families with children with special educational needs (SEN) during the COVID-19 pandemic. The research identifies emerging trends and distinctive characteristics, providing a foundation for improving strategies in schools. The analysis reveals an increase in publications from 2020 to 2023, peaking at 24 articles in 2022. A total of 246 researchers participated, with Castro-Kemp S and McIntyre LL standing out for their productivity and citations. Institutions such as UCL and the University of Oregon led in publications, while the University of California, Santa Barbara, topped the citations. In terms of scientific production, the United States had the most articles, followed by the United Kingdom and Spain. However, the United Kingdom led in global citations, indicating a high level of interest in the topic. The main journals in this field include Frontiers in Education and Education Science. Twelve collaboration networks among authors were identified, with a primary network of seven closely collaborating researchers. The pandemic exacerbated pre-existing difficulties in the education of children with SEN, increasing stress and emotional burden on parents. The transition to home education and the lack of adapted resources presented significant challenges. However, some strategies, such as dialogic literary gatherings and collaboration between schools and families, proved effective in mitigating negative impacts. The study underscores the need for inclusive public policies that address disparities in educational support and prioritize the psychological well-being of children with SEN. It recommends a proactive and equitable approach in school psychology training and educational practice. In conclusion, this analysis provides a solid foundation for future research and improvements in schools, promoting an inclusive and resilient educational environment.

Management of people after stroke in 383 Victorian general practices, 2014-2018: analysis of linked stroke registry and general practice data.

To evaluate the management in Victorian general practice of people who have been hospitalised with stroke or transient ischaemic attacks (TIA). Retrospective observational study; analysis of linked Australian Stroke Clinical Registry (AuSCR) and general practice data. 383 general practices in the Eastern Melbourne, South Eastern Melbourne, and Gippsland primary health networks (Victoria), 1 January 2014 - 31 December 2018. Adults who had been hospitalised with acute stroke or TIA and had at least two encounters with the same general practice during the observation period (7-18 months after the acute event). Assessment of cardiometabolic risk factors (blood pressure, serum lipids, blood glucose, urinary protein); prescribing of guideline-recommended prevention medications (blood pressure-, lipid-, or glucose-lowering, antithrombotic agents); attainment of guideline targets for cardiometabolic risk factors at final assessment during observation period. During 2014-2018, 3376 eligible AuSCR registrants (1465 women, 43.4%) had at least two encounters with one of the 383 general practices during the observation period; median age at stroke onset was 73.9 (interquartile range, 64.4-81.9) years, 737 events were TIAs (21.8%). Blood pressure was assessed in 2718 patients (80.5%), serum lipids in 1830 (54.2%), blood glucose in 1708 (50.6%). Prevention medications were prescribed for 2949 patients (87.4%), including lipid-lowering (2427, 71.9%) and blood pressure-lowering agents (2363, 70.0%). Blood glucose targets had been achieved by 1346 of 1708 patients assessed for this risk factor (78.8%), blood pressure targets by 1935 of 2717 (71.2%), and serum lipid targets by 765 of 1830 (41.8%). The incidence of having risk factors assessed was lower among patients aged 60 years or younger (incidence rate ratio [IRR], 0.97; 95% confidence interval [CI], 0.92-1.03) and those over 80 years of age (IRR, 0.92; 95% CI 0.88-0.97) than for those aged 61-80 years, and for women (IRR, 0.91; 95% CI, 0.87-0.95) and people with dementia (IRR, 0.89; 95% CI, 0.81-0.98). The likelihood of having classes of prevention medication prescribed was lower for patients aged 60 years or younger (IRR, 0.92; 95% CI, 0.88-0.97) and those over 80 years of age (IRR, 0.96; 95% CI, 0.92-0.997) than for patients aged 61-80 years, and for women (IRR, 0.95; 95% CI, 0.91-0.98) and people with dementia (IRR, 0.88; 95% CI, 0.78-0.98). The general practice management of people who have been hospitalised with stroke or TIA could be improved. Effective monitoring of cardiometabolic risk factors will enable general practitioners to optimise care for people who need careful attention to prevent adverse secondary events.

A processable and recyclable gelatin/carboxymethyl chitosan hydrogel electrolyte for high performance flexible zinc-ion batteries

Hydrogels are currently under extensive research as flexible quasi-solid electrolytes for zinc-ion batteries. However, the non-degradability and non-recyclability of hydrogel electrolytes pose significant issues, leading to resource wastage and plastic pollution. Moreover, the increasing needs of hydrogel electrolyte with various shapes to meet individual requirements of next-generation flexible battery raise significant challenges. In this study, we introduce the Hofmeister effect and multiple non-covalent interactions to fabricate an eco-friendly and recyclable multifunctional hydrogel electrolyte using biomass natural polymers. This is achieved by simply soaking primary hydrogel networks of carboxymethyl chitosan (CMCS) and gelatin in zinc sulfate (ZnSO4) aqueous solutions, abbreviated as GCZ-x. The GCZ-x hydrogels exhibit both stiffness and toughness due to the formation of crystalline domains and ionic crosslinks. The dynamic physical interactions and temperature and pH responsiveness of the GCZ-x hydrogels enable them excellent processability and recyclability. The zinc-ion battery with GCZ-x hydrogel as electrolyte exhibits high specific capacity and superior cyclic performance (2200 h at 0.1 A g−1) without the formation of zinc dendrites. The GCZ-x electrolyte is sustainable with high recycling rate (above 80 %). It is envisaged that the GCZ-x hydrogel electrolyte will initiate new prosperity of green zinc-ion batteries in energy-efficient and environmentally sustainable ways.

Synergies and dis-synergies between universal health coverage and global health security: A case study of Cambodia.

After the coronavirus disease 2019 (COVID-19) pandemic, the global community's increased focus on pandemic preparedness has driven efforts such as the Pandemic Treaty proposed by the World Health Organization (WHO) and the Pandemic Fund managed by the World Bank. While these initiatives will enhance countries' capabilities in pandemic preparedness, synergies could be achieved by exploring the intersections between universal health coverage (UHC) and global health security (GHS). This is particularly relevant for developing countries like Cambodia. As it transitions to higher income status and reduces its reliance on external funding, the synergistic development of UHC and GHS will help Cambodia maximise health investment and align with its population health goals. We aimed to identify synergies and dis-synergies between UHC and GHS and recommend implementations that the government can consider moving forward. We conducted a rapid review of policy documents based on the World Health Organization (WHO) Health System Framework and undertook consultations with key stakeholders in Cambodia. Our findings show the synergies between the two agendas in Cambodia resulted from having a central coordinating authority through the Ministry of Health (MoH), an extensive primary care network, and intersecting human resources that drive both UHC and GHS. We also identified potential dis-synergies such as vertical programmes and funding sources, inadequate regulation and engagement of the private sector, and underutilisation of information and data. Recommendations include cross-consultations between departments within the MoH when developing policies in GHC or UHC, and training programmes to increase awareness of the synergies between UHC and GHS. Our findings reinforce those of previous case studies in Bangladesh, Ethiopia, and Ghana, offering recommendations for building resilient health systems by integrating UHC and GHS.

An evaluation of the impact of the Lambeth PCN pharmacist anticoagulation skills development project

Abstract Background Atrial Fibrillation (AF) is a prevalent heart condition linked to significant morbidity and mortality due to its association with stroke.1 Despite the clear benefits of anticoagulation in reducing stroke risk, its underuse and suboptimal monitoring remain a concern.2 Aim This study aims to evaluate the impact of a pharmacist-led training programme in Lambeth, London, focusing on improving pharmacists' competency and confidence in managing Direct Oral Anticoagulants (DOACs). It assesses if the training met pharmacists' needs, evaluates current monitoring patterns to determine if training was warranted, and identified areas for further training improvement. Methods The study involved 41 GP practices across 9 Primary Care Networks (PCNs) in Lambeth. Practices were eligible based on their involvement in the management of AF patients prescribed DOACs. All pharmacists at these practices who were actively engaged in anticoagulation management and willing to participate in pre- and post-training assessments were invited to take part. Recruitment involved direct communication through practice managers and emails detailing the study’s objectives and benefits. DOAC monitoring data was extracted from patient medication records and subsequently compared to the South East London anticoagulation guidelines3 to establish compliance percentages. A competency assessment was conducted on pharmacists using a pre- and post-training checklist framework devised by the Consultant Anticoagulant Team at Guy’s and St Thomas’ NHS Foundation Trust (GSTT). The Wilcoxon signed-rank test analysed this paired data, with a p < 0.05 set for statistical significance. Additionally, semi-structured interviews were conducted to gather insights on their training experience and perceptions. Transcripts were coded using NVIVO software to identify themes. Ethical approval was obtained from Kingston University London. Results Of the 2,987 AF patients across the 41 GP practices, 87.6% were on DOACs. Prescribing and monitoring trends were consistent across all GPs, with scope to improve compliance across all parameters, such as CHA₂DS₂-VASc score assessment prior to DOAC initiation. The competency assessment, completed by ten pharmacists, showed a significant improvement post-training, with mean scores rising from 3.3 to 4.1 (p< 0.00001). Improvements were seen across all domains, particularly in explaining the rationale for anticoagulation, showing CHA₂DS₂-VASc and HASBLED scores, and discussing modifiable HASBLED factors. Competency in patient communication remained highest, while managing particular cases like reversal procedures and patients with cancer showed lower competency, indicating areas for training improvement. The interviews, conducted with ten pharmacists, revealed three main themes: (1) Confidence and competence in anticoagulant prescribing and optimisation, (2) Evaluation of the training programme's effectiveness, and (3) Professional growth and career development. Pharmacists reported greater confidence in managing DOACs post-training, though challenges remained in patient engagement and collaboration with GPs lacking DOAC knowledge. Discussion / Conclusion The evaluation proved a positive impact on pharmacists' competency and confidence in DOAC management. Suboptimal monitoring practices in Lambeth highlighted the need for this training programme and its crucial role in improving patient outcomes. Limitations include a small interview sample and potential biases in self-reported evaluations. A longitudinal study is recommended to assess long-term impacts. Ongoing training and systematic data collection are essential, and similar training should be extended to other healthcare professionals.

Distinct Neural Mechanisms Underlying Dual-Task Priority During Gait Across Cognitive and Motor Networks.

Background: Prioritization strategy during gait significantly influences gait performance and successful gait relies on interactions between cognitive and motor functions. This study aimed to examine the within- and between-network connectivities of cognitive and motor networks associated with dual-task priority during gait. Methods: Twenty-nine healthy individuals (66.86 ± 8.53 years) underwent the timed-up-and-go (TUG) test alone, TUG with a cognitive task, and the cognitive task alone. The cognitive task involved sequentially subtracting three from a random number between 50 and 100. The resting-state functional magnetic resonance imaging was acquired on the same day. Using independent component analysis, the dorsal attention network (DAN), frontoparietal network (FPN), primary motor network (PM), and lateral motor network were assessed. The participants were divided into cognitive and motor priority groups based on the modified attention allocation index (mAAI). Group comparisons of within- and between-network connectivity were conducted using permutation tests. Additionally, correlation analysis was employed to investigate the association between-network connectivity and task priority. Results: The cognitive priority group showed cognitive dual-task facilitation. In comparison to the motor priority group, they also showed comparable motor dual-task costs and lower combined dual-task costs. They exhibited increased within-network connectivity in the left FPN and enhanced between-network connectivity between the right FPN and both the DAN and PM. These between-network connectivities were negatively correlated with mAAI scores. Conclusion: The results suggest distinct neural mechanisms across cognitive and motor networks based on individuals' dual-task strategies. This may have implications for understanding gait performance in complex contexts.

One-pot fabrication of sodium deoxycholate based supramolecular self-healing antibacterial double network hydrogels

Double network (DN) hydrogels have emerged as a significant technology for enhancement of mechanical strength of weak supramolecular gels. In the present study, we report the one-pot route for design of a low molecular weight gelator based DN hydrogel wherein sodium deoxycholate (NaDC) forms the primary network entangled with agar matrix. Various compositions of the reported agar-NaDC hydrogels were examined through FTIR, sol-gel transition temperature (Tsg), XRD, circular dichroism (CD), scanning electron microscopy (SEM), hydrophobicity probe studies, Zeta potential studies and rheology measurements. Analysis of all studies together reveal that 1 mg/ml agar-NaDC DN hydrogel is the optimum composition that exhibits dense networking with primarily β-sheet like structure, highest mechanical strength as well as self-healing characteristics with reversed optical activity and highest Tsg. Antibacterial activity studied using inhibition zone method suggests that 1 mg/ml agar-NaDC gel demonstrates significant bactericidal effect unlike the pure gel with an inhibition zone of ∼25 mm against E.coli after 24 h and ∼32 mm after 48 h incubation. The antibacterial activity was unique for this composition of the DN hydrogel which is attributed to its reversal in optical activity exhibiting positive cotton effect resulting in stronger interaction with the bacterial cell wall. Additionally, nearly 2 times reduced water absorption capacity of the 1 mg/ml agar-NaDC DN hydrogel compared to pure NaDC hydrogel ensures the retention of its mechanical strength as well as other properties in high moisture containing environment. Hence, the 1 mg/ml agar-NaDC DN hydrogel holds appreciable potential as a novel strong supramolecular self-healing antibacterial hydrogel with sustained release characteristics primarily important for biomedical applications.

Autonomic and Immune Stress Response Networks in Patients Living With HIV.

Stress response systems are frequently dysregulated in patients with chronic inflammatory disorders. Pre-clinical studies have demonstrated direct influences of the sympathetic and vagal/parasympathetic branches of the autonomic nervous system (ANS) on the immune system. However, these connections have not been examined in humans. We hypothesized that the subtype and severity of autonomic neuropathy (AN) would predict immune phenotypes with distinct clinical and demographic characteristics in people living with HIV. This is a cross-sectional study of 79 adult people with a history of well-controlled HIV on stable combination antiretroviral treatment (CART) recruited from a primary care clinic network within the Mount Sinai Health System in New York City. All participants underwent a standardized battery of autonomic function tests summarized as the Composite Autonomic Severity Score (CASS) and vagal and adrenergic baroreflex sensitivity (BRS-V and BRS-A). Immune profiling included: 1) measurement of interleukin-6 (IL-6) as part of the Olink assay Target 96 Inflammation Panel, 2) non-negative matrix factorization (NMF) clustering analyses on Olink immune biomarkers, and 3) mass cytometry (CyTOF) on a subset of participants with and without autonomic neuropathy (N = 10). Reduced activity of caudal vagal circuitry involved in the cholinergic anti-inflammatory pathway (CAP) predicted higher levels of IL-6 (Spearman's rho = -0.352, p=0.002). The comprehensive assessment of the ANS-immune network showed four immunotypes defined by NMF analyses. A pro-inflammatory immunotype defined by elevations in type 1 cytokines (IL-6, IL-17) and increased numbers of CD8+ T-cells was associated with autonomic neuropathy (AN). This association was driven by deficits in the cardiovascular sympathetic nervous system and remained strongly significant after controlling for the older age and greater burden of co-morbid illness among participants with this immunotype (aOR=4.7, p=0.017). Our results provide novel support for the clinical relevance of the CAP in patients with chronic inflammatory AN. These data also provide insight regarding the role of the sympathetic nervous system and aging in the progression and development of co-morbidities in patients with chronic HIV and support future research aimed at developing therapies focused on modulation of the sympathetic and parasympathetic/vagal nervous system.