Care Priorities Research Articles

Intraoperative virtual reality for older patients undergoing total knee arthroplasty: study protocol for a randomized clinical trial

BackgroundIn an aging surgical patient population, preventing complications such as oversedation has taken increasing priority in perioperative care. Intraoperative use of virtual reality (VR) may decrease sedative requirements. We hypothesize that the use of immersive VR during total knee arthroplasty (TKA) will lead to decreased propofol requirements, improved patient-reported satisfaction, and reduced postoperative opioid requirements compared to active and usual care controls.MethodsThis is a single-center, randomized clinical trial of older (age > 60) patients undergoing TKA. Participants will be randomized into three groups (2:2:1): VR immersion, music, and sham VR plus usual care. All patients will receive a regional block and spinal anesthesia. Patients in the immersive VR and music groups will use patient-controlled sedation (PCS) with propofol, while those in the sham VR group will act as the standard of care control group and will receive monitored anesthesia care (MAC) with propofol infusion.Statistical analysisAnalyses will be conducted using IBM SPSS Statistics Version 25, considering a two-sided p-value < 0.05 to be statistically significant. The primary outcome is the intraoperative dose of propofol (mg kg−1 min−1). Secondary outcomes include patient satisfaction, post-anesthesia care unit (PACU) length of stay, postoperative pain scores and analgesic requirements, functional outcomes, postoperative delirium, and postoperative neurocognition.DiscussionVR used as a non-pharmacological adjunct to regional and spinal anesthesia during TKA may reduce sedative requirements while maintaining patient satisfaction. If true, this approach to minimizing sedation may impact clinical outcomes including perioperative complications and length of stay for older patients, while maintaining a high degree of patient satisfaction.Trial registrationThis trial was registered on ClinicalTrials.gov on January 29, 2021. The registration number is NCT04748549.

Defining a core set of research and development priorities for virtual care in the post-pandemic environment: a call to action.

To identify research and development priorities for virtual care following the coronavirus disease 2019 pandemic from the perspective of key stakeholders (patients, clinicians, informaticians and academics). Qualitative study using a modified nominal group technique. Online semi-structured interviews and workshops held in November 2022 and February 2023. Health workers involved in delivering virtual care in two metropolitan local health districts and one specialty statewide network, and people who had received care from these sites, were recruited using passive snowball sampling. Research and academic staff from a tertiary institution were also invited to participate. Priorities to support a translational research agenda for virtual care. Twenty-five individuals participated including 18 innovation deliverers, two innovation recipients and five implementation facilitators. Stakeholders identified several key priorities for developing virtual care models and for sustaining and scaling virtual care services. These included demonstrating the economic and societal value of virtual care, developing a common framework to support evaluation and comparison of virtual care services, ensuring virtual care services integrate acute and primary care, and defining which models of care are most appropriate for virtual care delivery. As the health system recalibrates with the return of in-person care, there is a growing need to demonstrate the value of virtual care models to patients, the health system, and society at large. Demonstrating this value while also demonstrating improvements to health outcomes will future-proof virtual care, enabling it to be used to address broader challenges of health care delivery. In addition, sustaining virtual care will depend on robust operational structures and workforce training and education. As services evolve, research and development priorities must be revisited to ensure that translational research aligns with stakeholder interests.

PAPEL DA EQUIPE DE ENFERMAGEM NO ATENDIMENTO DO SETOR DE URGÊNCIA E EMERGÊNCIA INTRA-HOSPITALAR

In-hospital urgent and emergency care is of fundamental importance in meeting the health needs and demands of the population that seeks the sector as the main gateway in search of agility and resolution. Thus, this study sought to understand the importance of assistance from the nursing team in the urgency and emergency sector and its importance. For this, a qualitative bibliographical research was carried out, based on a narrative literature review, using articles published between 2015 and 2024 in the databases of the Scientific Electronic Library Online (SciELO) and Google Scholar portals. It was found that the nursing team plays an extremely important role in the assistance provided in the urgency and emergency sector of hospital institutions, as professionals are responsible for a set of actions that are essential to the capacity to offer care, as in addition to promote reception aimed at expanding access to health services for users seeking emergency care, carry out screening and risk classification processes in favor of establishing care priorities to preserve a greater number of lives and reduce injuries and complications in health. In addition, the team also works directly in the execution of management actions aimed at controlling and managing financial, material and human resources in order to guarantee effectiveness, quality and, above all, the ability to offer humanized and resolute assistance to the public.

Moving beyond tokenism: Sustaining engagement of persons living with dementia in identifying emergency research priorities.

The Geriatric Emergency Care Applied Research Network 2.0-Advancing Dementia Care (GEAR 2.0-ADC) aims to advance research efforts to improve the emergency care of persons living with dementia (PLWDs). To support this objective, GEAR 2.0-ADC convened a virtual consensus conference to prioritize emergency care research opportunities for PLWDs inclusive of perspectives of PLWDs to ensure identification of research gaps in response to their experiences and priorities. Inclusion of PLWDs as research partners is increasingly recognized as a best practice, however, approaches to facilitating consensus participation are lacking. Best practices for supporting the engagement of PLWDs in a consensus conference, applied across its three phases (pre-conference, during the conference, and post-conference), include: establishing a learning environment focused on research priorities before the event, presenting information in ways that align with participants' learning preferences while accommodating cognitive impairments, and providing multiple opportunities and methods for gathering post-conference feedback from PLWDs. These strategies were identified by PLWDs and care partners (CPs) through semi-structured interviews, who were involved in the convening process, aimed at exploring ways to enhance facilitation techniques for participants. Additionally, these summarized insights aim to encourage the use of community-engaged approaches in discussions and consensus-building around research priorities in emergency care, particularly for PLWDs and their CPs.

Advancing the Quintuple Aim Through Public Health and Health Care Collaboration: Perspectives from Washington State

The Covid-19 pandemic resulted in remarkable collaboration between public health and health care institutions. But without intentional efforts, the end of the U.S. Public Health Emergency could lead to a return to an era when these institutions’ relationships were more limited and their population health improvement efforts less integrated. This is concerning, given that collaboration between public health and health care will be needed to overcome the multiple health crises facing the United States today. The Washington State Department of Health (WA-DOH), the state public health agency, identified health systems and workforce transformation as one of its five strategic priorities. To further define and operationalize its vision for health systems and workforce transformation, WA-DOH conducted an environmental scan that led to the identification of six priorities for public health and health care to align on systems strengthening, as follows: enhancing robust whole-person care; the primary care and rural health safety net; health workforce intelligence and development; population health intelligence; innovation and learning; and health system resilience. WA-DOH is using this six-priority framework to execute its vision for health in Washington, in line with the Quintuple Aim for health care improvement and the fundamental public health goal of ensuring an effective system that enables equitable access to the services and the care people need to be healthy. Public health agencies at the state or local level, looking to partner to improve health care delivery in their jurisdictions, can take advantage of the six-priority framework expounded in this paper.

Exploring the Development of Safety Culture among Physicians with Text Mining of Patient Safety Reports: A Retrospective Study.

Safety culture development is essential for patient safety in healthcare institution. Perceptions of patient safety and cultural changes are shown up in patient safety reports, however, were rarely investigated. The aim of this study was to investigate the perception of physicians and to explore the development of safety culture using quantitative content analysis for patient safety reports. A retrospective analysis of free descriptions of harmful patient safety reports submitted by physicians was performed. Natural language processing and text analysis were conducted using the 'KH Coder'. A co-occurrence analysis was performed in each period to identify and analyze the safety concepts. The study period was grouped into three for comparison. The patient safety reports from physicians were collected between April 2004 and March 2020. Of these, 3351 reports were harmful; 839 reports were included in period 1, 1016 reports in period 2, and 1496 reports in period 3. Natural language processing identified 316 307 words in the free descriptions of 3351 reports. We identified seven concepts from the cluster in co-occurrence analysis as follows: 'explanation of adverse event to patients and families,' 'central venous catheter,' 'intraoperative procedure and injury,' 'minimally invasive surgery,' 'life-threatening events,' 'blood loss,' and 'medical emergency team and critical care.' These seven concepts showed significant differences among the three periods, except for 'blood loss'. The 'explanation of adverse event to patients and families' decreased in proportion from 11.3% to 8.8% (p<0.05). The 'central venous catheter' decreased from 17.3% to 11.3% (p<0.01). Meanwhile, 'minimally invasive surgeries' and 'intraoperative procedures' increased from 3.9% to 12.9% (p<0.01) and from 10.8% to 14.6% (p<0.05), respectively. Focusing on patients' events, 'life-threatening events' decreased from 13.0% to 8.1% (p<0.01); however, 'medical emergency teams and critical care' increased from 3.3% to 10.6% (p<0.01). Free description in patient safety reports is useful for evaluating the safety culture. Co-occurrence analysis revealed multiple concepts of physicians' perceptions. Quantitative content analysis revealed changes in perceptions and attitudes, and a disclosure policy of adverse events and priority of patient care appeared with the development of safety culture.

The Use of Joyce J. Fitzpatrick's "Life Perspective Rhythm Theory" in a Case with Substance Use Disorder Diagnosed with Craving Severity: Case Report

Objective: In this study, it was aimed to plan the patient care of a male patient with craving severity diagnosed with substance use disorder according to Joyce J. Fitzpatrick's "Life Perspective Rhythm Theory". Theoretical Framework: In this study, nursing care was applied based on the Life Perspectives Rhythm theory. Method: A male patient with severe cravings diagnosed with substance use disorder treated in a psychiatric ward was evaluated according to the rhythmic patterns in Joyce J. Fitzpatrick's "Life Perspective Rhythm Theory". Patient care was planned and implemented based on the five main assumptions of the theory. Results and Discussion: Based on Fitzpatrick's Life Perspective Rhythm Theory, it was determined that the 32-year-old male patient with craving severity who was followed up with a diagnosis of substance use disorder had problems in the process of adaptation to life perspectives in the temporal behavior pattern, increased the number of cigarettes smoked daily in the motor behavior pattern, had impulse uncontrol in the cognitive behavior pattern, and had discourses that his parents mistreated him in the perceptual behavior pattern. According to Fitzpatrick, we determined the priority of care of this case as ineffective coping, decreased self-esteem, denial, risk of violence against self or others, anxiety, ineffectiveness in maintaining health, impaired social interaction and impaired family processes. Research Implications: In this study, the planning, implementation and evaluation stages of the patient care of a male patient with craving severity diagnosed with substance use disorder were carried out according to the Life Perspective Rhythm Theory with the priorities determined by using observation and communication skills. At the end of the process, the patient stated that his level of knowledge increased in order to maintain his physical and mental well-being, and that he knew the symptoms of craving severity and the measures to be taken when these symptoms occur. Since there are very few studies based on the theory developed by Fitzpatrick, it is recommended to study with different patient groups in order to obtain precise results by concretizing the usability of the theory in patterns.

The centrality of nursing in realizing high quality palliative care: Exploring Canada’s framework on palliative care priorities

BackgroundFollowing an earlier mixed-method survey in which we asked stakeholders to report on their perceptions of the progress made in relation to Canada’s Framework on Palliative Care and Action Plan, the purpose of this study was to conduct an in-depth qualitative exploration of the factors influencing that progress, or lack thereof.MethodsThis was a qualitative interview study conducted in Canada. Inclusion criteria included experience with palliative care in Canada in a professional or volunteer capacity. Interviews were conducted by telephone using an interview guide that asked specific questions in relation to the Framework on palliative care priorities (e.g., education, caregiver support, and equitable access). Data was analyzed using qualitative descriptive methods.ResultsThirty-five diverse stakeholders with extensive experience in palliative care were interviewed. In relation to palliative education, participants indicated that although there were excellent palliative care resources available across the country there was further need for embedding palliative care in undergraduate education and for mentored opportunities to engage in care across diverse contexts. The identification, development, and strategic positioning of champions was an important strategy for improving palliative care knowledge and capacity. The development of standard competencies was viewed as an important step forward; although, there was a need to include more members of the care-team and to create pathways for life-long learning. In relation to support for family caregivers, even as participants cited numerous community-based resources offered by not-for-profit organizations, they described significant barriers including a shortage of in-home support, lack of understanding of what caregivers do, and policy-based contractual and privacy issues. In relation to palliative care access, participants described a nurse-centered, consult-based, multi-site and multi-provider model of care that was facilitated by technology. Barriers to this model were systemic healthcare issues of siloed, fragmented, and for-profit care.ConclusionParticipants in this study had clear insights into the factors that would support or impede progress to the development of palliative care in Canada. Some of those factors were achievable within current health and educational systems. Other factors were going to require longer term and more comprehensive solutions.

Improving Collaborative Management of Multiple Mental and Physical Health Conditions: A Qualitative Inquiry into Designing Technology-Enabled Services for Eliciting Patients' Values

People with multiple chronic conditions (MCC) face challenges planning health care collaboratively with primary care clinicians, particularly when their priorities conflict. These challenges intensify with symptoms of anxiety or depression. Elicitation of patients' values is promoted as a means to aligning patient and clinician priorities in primary care, and as a component of psychotherapy for anxiety and depression. But, these approaches remain siloed. We conducted a qualitative interview study to understand patients' preferences for Technology Enabled Services (TESs) to coordinate values elicitation across primary and mental health care settings. Many participants preferred face-to-face elicitation by a mental health clinician; some preferred elicitation via telehealth and some preferred self-directed elicitation. Participants' preferences were influenced by: 1) how they perceived the rationale and benefits of values elicitation; 2) how they perceived the training and credibility of people facilitating elicitation; and 3) how they perceived their own capacity to engage in values elicitation. Participants also shared numerous concerns about values elicitation that warrant critical examination of TESs to support it.

Global Disparities of Cancer and Its Projected Burden in 2050

Cancer prevention and care efforts have been challenged by the COVID-19 pandemic and armed conflicts, resulting in a decline in the global Human Development Index (HDI), particularly in low- and middle-income countries. These challenges and subsequent shifts in health care priorities underscore the need to continuously monitor cancer outcome disparities and statistics globally to ensure delivery of equitable and optimal cancer prevention and care in uncertain times. To measure the global burden of 36 cancers in 2022 by sex, age, and geographic location and to project future trends by 2050. This cross-sectional study used population-based data from 2022 in 185 countries and territories were obtained from the Global Cancer Observatory database. Data extraction and analysis were carried out in April 2024. Counts, rates, prevalence, mortality to incidence ratios (MIRs), and demography-based projections were used to characterize current and future cancer burden. This population-based study included 36 cancer types from 185 countries and territories. By 2050, 35.3 million cancer cases worldwide are expected, a 76.6% increase from the 2022 estimate of 20 million. Similarly, 18.5 million cancer deaths are projected by 2050, an 89.7% increase from the 2022 estimate of 9.7 million. Cancer cases and deaths are projected to nearly triple in low-HDI countries by 2050, compared to a moderate increase in very high-HDI countries (142.1% vs 41.7% for cancer cases and 146.1% vs 56.8% for cancer deaths). Males had a higher incidence and greater number of deaths in 2022 than females, with this disparity projected to widen by up to 16.0% in 2050. In 2022, the MIR for all cancers was 46.6%, with higher MIRs observed for pancreatic cancer (89.4%), among males (51.7%), among those aged 75 years or older (64.3%), in low-HDI countries (69.9%), and in the African region (67.2%). In this cross-sectional study based on data from 2022, cancer disparities were evident across HDI, geographic regions, age, and sex, with further widening projected by 2050. These findings suggest that strengthening access to and quality of health care, including universal health insurance coverage, is key to providing evidence-based cancer prevention, diagnostics, and care.

Addressing health disparities in food allergy: A Position Statement of the AAAAI Prior Authorization Task Force

Self-reported food allergies (FAs) affect approximately 8% of the US pediatric and approximately 10% of the adult population, which reflects potentially disproportionate increases among ethnically and racially minoritized groups. Multiple gaps and unmet needs exist regarding FA disparities. There is reported evidence of disparities in FA outcomes, and the FA burden may also be disproportionate in low-income families. Low family income has been associated with higher emergency care spending and insecure access to allergen-free food. Pharmacoinequity arises in part as a result of structural racism still experienced by historically marginalized populations today. Historically redlined communities continue to experience greater rates of neighborhood-level air pollution and indoor allergen exposure, lack of transportation to medical appointments, poverty, and lower prescription rates of necessary medications. Clinical research needs racially and ethnically diverse participation to ensure generalizability of research findings and equitable access to medical advances, but race reporting in clinical trials has been historically poor. Addressing health disparities in FA is a priority of clinical care, with professional organizations such as the American Academy of Allergy, Asthma & Immunology having a prominent role to play in mitigating the challenges faced by these individuals. In this position statement we recommend some key steps to address this important issue.

6.G. Scientific session: The importance of using country-specific severity distributions in burden of disease indicators

Abstract One of the most commonly used health gap summary measures in the field of public health is the Disability-adjusted life year (DALY). It has become the key metric for quantifying the burden of disease (BoD) and is used as an information source for setting priorities for health care and health service planning. The DALY metric quantifies gaps between a theoretical population in perfect health and the current health status related to both morbidity and mortality. It is the sum of the number of healthy life years lost due to disability (YLD) and death (YLL). The YLD summarises the loss of healthy life time using the frequency of diseases differentiated by severities or related health states (including sequelae). Depending on each health state, it converts the time spent with diseases into YLD by weighting each year with health limitation with so-called disability weights. This allows the two indicators YLL and YLD to be added to the DALY. Consequently, severity distributions are a means of describing the range of health loss along specific health states, which enables an accurate mapping with disability weights. For most of the diseases, these distributions are usually categorised as mild, moderate, severe, or no health loss (asymptomatic). Conditions with higher severity levels contribute more to the YLD and thus, to the overall disease specific BoD. The severity distributions are highly dependent on utilization at the individual level, but also on available health care services at the society level, which indicates that differences by settings are to be expected. Changes over time in the share of severe cases, for instance, may reflect the effectiveness of health interventions and policies. This underlines the importance of severity distributions, as they also reflect information about the quality of healthcare for those affected. The Global Burden of Disease (GBD) study applies for a significant proportion of their considered diseases uniform severity distributions across countries and broader regions. They acknowledge concerns over applying estimates of severity distributions based on limited data, noting that it is the only available information that they were able to use. As the YLD estimates are often utilized to develop and prioritize health policy interventions, there is a necessity for country-specific estimates that are evidence based and less susceptible to model assumptions. In most cases, the estimation of severity distributions involves complex methodology as data for such assessments are very limited or hardly reliable. In the following workshop, general concepts and country cases from Germany, Scotland, and Belgium will be presented covering a variety of diseases. The examples underline the importance of estimating national and even regional severity distributions when identifying the importance of diseases or comparing the health conditions of populations across time. Key messages • As the Burden of disease indicators are predominantly used to prioritize health interventions and allocate resources, it is crucial to use accurate information in the severity levels of disease. • Severity distributions reflect the health care services and vary across different settings. Utilising country-specific severity distributions when estimating Burden of Disease indicators is essential.

An ACNAP survey assessing the cardiology multidisciplinary learning needs to support lipid management

Abstract Background/ Introduction: Reducing LDL cholesterol is a high priority in cardiovascular care but requires knowledge and skills to deliver effectively. Nurses and allied professionals (NAPs) can play a major role in supporting lipid optimisation. Most NAPs will work together with patients prescribed lipid lowering therapies, and some may be more closely involved in initiation and monitoring. The Association of Cardiovascular Nursing and Allied Professionals (ACNAP) wanted to gauge the level of understanding, confidence and learning needs of cardiology professionals to better implement European Society of Cardiology (ESC) lipid lowering guidelines. Purpose The aim of the project was to highlight gaps in knowledge to better inform needs for training and educational programmes developed by ACNAP. Methods A 29 question electronic survey was developed by expert consensus, exploring previous experience, clinical knowledge, and perceptions of learning needs. It was launched at the EuroHeartCare conference in June 2023, on social media, and members of the ESC were emailed inviting participation. Results 123 people responded. 29.5% of the respondents were physicians and 70.5% NAPs. Most respondents were involved in lipid optimisation of some description with only 7.0% of respondents having no direct involvement in their patient cohort. A higher percentage of respondents responded "totally agree" when asked it they knew what cholesterol targets to aim for in secondary prevention, compared to primary prevention (61% v 41.5%). 94% of respondents felt comfortable when to initiate statins and and 82% ezetimibe. This reduced to 45% for inclisiran and 40% for bempedoic acid. Similarly, the majority felt comfortable counselling a patient newly initiated on statins or ezetimibe, but significantly fewer the newer lipid lowering therapies. Experience and understanding of familial hypercholesterolaemia (FH) was also explored. Only half the respondents would be comfortable in identifying and diagnosing FH and a further 25% unsure. A large percentage (37%) were unaware of the Simon Broome criteria or the Dutch Lipid Criteria Network (49%). When considering learning needs, 71% of NAP respondents needed extra support to help make lipid lowering decisions. This rises to 84% and 74% when looking at nurses and pharmacists separately, respectively. Nearly 76% would prefer any learning to be delivered online, with interactive online training packages being the most popular method. Conclusions The three main gaps identified by NAPs were: management in primary prevention (initiation and targets), the newer innovative medicines (bempedoic acid, inclisiran and PCSK9 monoclonal antibodies) and FH. Interestingly, these are the same gaps highlighted by physician responders. These findings can help guide ACNAP and ESC in the development of educational programmes with the aim to improve better lipid management overall.

Wasting coexisting with underweight and stunting among children aged 6‒59 months hospitalised in Garissa County Referral Hospital, Kenya.

Management of undernourished children depends only on wasting yet it can coexist with underweight and/or stunting. Among children admitted to hospital with acute illness, we determined the proportion with wasting coexisting with underweight and/or stunting and their risk factors. A retrospective review of hospital records of children 6‒59 months old admitted at Garissa County referral hospital, Kenya, from January 2017 to December 2019 was conducted. Using World Health Organization 2006 growth standards, undernutrition were defined: wasting as Weight-for-height Z-score < -2, stunting Height-for-age Z-score < -2 and underweight Weight-for-age Z-score < -2. We studied wasting coexisting with underweight and/or stunting. Among 624 children recruited, 347 (56%) were males and 511 (82%) <24 months old. Diarrhoea 210 (34%) and pallor/anaemia 310 (50%) were the most frequent admission diagnosis. HIV infection was present among 8 (1.3%) children. Wasting, underweight and stunting were present among 595 (95%), 518 (83%) and 176 (28%) children respectively. 161 (26%), 506 (81%) and 161 (26%) children had wasting coexisting with stunting, underweight and both stunting and underweight respectively. In the multivariable regression, diarrhoea was positively associated with wasting coexisting with stunting (adjusted risk ratio [aRR = 2.96] [95% CI = 2.06‒4.23]) and anaemia with wasting coexisting with underweight (aRR = 1.23) (95% CI = 1.03‒1.47). Overall, 343 (55%) children were discharged alive, 67 (11%) absconded from the wards, 164 (26%) were transferred to another hospital and 50 (8.0%) died before discharge. The risk of inpatient death was 10.3%, 7.9%, 8.4% and 6.8% among children not wasted, wasted only, wasted & underweight, and wasted and underweight and stunted respectively (Chi-square p = 0.60). The study reports an unacceptably high levels of undernourishment, including coexisting forms of undernutrition among hospitalised children. This highlights a public health priority for current nutrition therapeutic care and need of continuity of care among those children discharged alive in the community-based management of acute malnutrition programmes.

Nicotine is an Immunosuppressant: Implications for Women's Health and Disease

A plethora of evidence supports that nicotine, the primary alkaloid in tobacco products that is generally accepted for maintaining use, is immunoregulatory and may function as an immunosuppressant. Women have unique experiences with use of nicotine-containing products and also undergo significant reproductive transitions throughout their lifespan which may be impacted by nicotine use. Within the extant literature, there is conflicting evidence that nicotine may confer beneficial health effects in specific disease states (e.g., in ulcerative colitis). Use prevalence of nicotine-containing products is exceptionally high in individuals presenting with some comorbid disease states that impact immune system health and can be a risk factor for the development of diseases which disproportionately impact women; however, the mechanisms underlying these relationships are largely unclear. Further, little is known regarding the impacts of nicotine's immunosuppressive effects on women's health during the menopausal transition, which is arguably an inflammatory event characterized by a pro-inflammatory peri-menopause period. Given that post-menopausal women are at a higher risk than men for the development of neurodegenerative diseases such as Alzheimer's disease and are also more vulnerable to negative health effects associated with diseases such as HIV-1 infection, it is important to understand how use of nicotine-containing products may impact the immune milieu in women. In this review, we define instances in which nicotine use confers immunosuppressive, anti-inflammatory, or pro-inflammatory effects in the context of comorbid disease states, and focus on how nicotine impacts neuroimmune signaling to maintain use. We posit that regardless of potential health benefits, nicotine use cessation should be a priority in the clinical care of women. The synthesis of this review demonstrates the importance of systematically defining the relationships between volitional nicotine use, immune system function, and comorbid disease states in women to better understand how nicotine impacts women's health and disease.

Highlights From the 2023 Revision of Pediatric Tactical Emergency Casualty Care Guidelines.

In 2023 the Committee for Tactical Emergency Casualty Care (C-TECC) issued updated Pediatric Tactical Emergency Casualty Care (TECC) Guidelines (Guidelines) that focus on the delivery of stabilizing care of children who are the victims of high-threat incidents such as an active shooter event. The Guidelines provide evidence-based and best practice recommendations to those individuals and departments that specifically provide operational medical support to law enforcement agencies caring for children in this uniquely dangerous environment where traditional resources may not be available. This article highlights key takeaway points from the Guidelines, including several updates since the first version was released in 2013.The evidence base for the care of children in this environment is lacking, and medical care delivered in the high-threat environment is inconsistent and often not optimized for the care of infants and children. The Guidelines are supported from the existing literature base where possible, and where it is not, by consensus as to the current best practices as determined by iterative deliberations among the diverse and experienced group of stakeholders who are members of C-TECC. The Guidelines provide patient assessment and management information specific to the care of children in the following 3 dynamic phases of the high-threat environment: Direct Threat, Indirect Threat, and Evacuation. The phases represent a continuum of risk to the patient and the responder ranging from extreme (such as ongoing gunfire) to minimal (during movement toward definitive medical care).The high-threat environment is dynamic and there is competing safety, tactical/operational, and patient care priorities for responders when infants and children are injured. The Guidelines provide recommendations on the type of medical and psychological care that should be considered under each phase of threat and establishes the context for how and why to deliver (or potentially defer) certain interventions under some circumstances in order the maximize the opportunity for a good outcome for an injured pediatric patient. The Guidelines also emphasize the importance of synergizing hospital-based pediatric trauma care with those law enforcement and fire/emergency medical services that may provide field care to children under high-threat circumstances.

Dental outpatient departments and patient safety: Priority for a safe care

Patient safety is an essential aspect of healthcare, including dentistry. Dental Outpatient Departments (OPDs) pose unique challenges, where the risk of infections, procedural errors, and patient discomfort can compromise safety. This review examines patient safety issues in dental OPDs, focusing on common hazards, preventive measures, and evolving strategies to ensure safer care. Infection control, medical emergencies, equipment sterilization, and patient data protection are key concerns. The complex interplay of patient management, dental procedures, and clinician awareness requires robust protocols to mitigate risks. Dental professionals must be vigilant in managing cross-contamination risks, such as through the use of personal protective equipment (PPE) and strict hand hygiene practices. Moreover, regular staff training in handling medical emergencies, such as allergic reactions or fainting, is crucial for effective management.This article also explores the role of technological advancements in enhancing patient safety, such as digital record-keeping, which minimizes documentation errors, and advanced diagnostic tools that reduce invasive procedures. Additionally, patient-centered approaches, including improved communication and informed consent practices, foster trust and reduce misunderstandings. The implementation of evidence-based guidelines and adherence to professional standards further contribute to a culture of safety. By synthesizing current research, this review aims to highlight best practices for improving patient safety in dental OPDs and underscores the importance of continuous monitoring and improvement in these settings. Addressing these safety concerns is critical not only to improve patient outcomes but also to ensure that dental OPDs remain a safe and trusted environment for all.

Healthcare professionals' perceptions on providing support to informal carers within stroke care.

The sudden nature of stroke onset does not provide carers with sufficient time to prepare for the demands associated with caring. Healthcare professionals can have a vital role in providing carers with support and training, which may reduce carer stress and strain, and allow for better health and rehabilitation outcomes for the stroke survivor. The experiences of healthcare professionals on supporting carers in stroke care, however, remain unclear. To understand the experiences and perceptions of healthcare professionals working in stroke care on implementing resources and support to informal stroke carers. Semi-structured interviews were conducted with 11 healthcare professionals (5 occupational therapists, 5 physiotherapists, 1 psychologist) with at least 12 months' experience in working with stroke survivors. Interviews ranged from 25-70 minutes in duration, and were recorded, transcribed, and analysed using thematic analysis. Three overarching categories that were explored were: (1) Experiences of working in stroke care and supporting carers; (2) Recommendations for a program designed for carers; and (3) Future priorities in stroke care. Participants discussed a variety of strategies they utilised to support carers including collaborating with other healthcare professionals and utilising skills and experience. Healthcare professionals highlighted the need for additional resources that are designed specifically for carers and explored key topics including carer stress and fatigue, support services, stroke education, and how to look after oneself. Participants identified priorities for stroke care including additional professional training and resource availability. This study provided a unique insight from the perspectives of healthcare professionals on supporting carers. Participants identified the need for additional training and resources to equip healthcare professionals to better support carers. Future programs designed for carers should be informed by the needs and experiences of both informal carers and healthcare professionals.

Priorities for multimorbidity management and research in cancer: a Delphi study of Australian cancer survivors, clinicians, and researchers.

Multimorbidity is common in people with cancer and associated with increased complexity of care, symptoms, mortality, and costs. This study aimed to identify priorities for care and research for cancer survivors with multimorbidity. A Delphi consensus process was conducted. Elements of care and research were based on Australia's National Strategic Framework for Chronic Conditions, a literature review, and expert input. In Round 1, health professionals, cancer survivors, and researchers rated the importance of 18 principles, 9 enablers, and 4 objectives. In Round 2, new elements were rated and all elements were ranked. In Round 1, all elements reached consensus for care delivery; three principles and one enabler did not reach consensus for research and were eliminated. One principle and two enablers were added, reaching consensus. In the final list, 19 principles, 10 enablers, and 4 objectives were included under care delivery; 14 principles, 9 enablers, and 4 objectives were included under research. For care delivery, principles of 'survivorship' and 'self-management' were ranked highest, and 'peer support' and 'technology' were the most important enablers. For research, 'survivorship' and 'coordinated care' were the highest-ranked principles, with 'peer support' and 'education' the most important enablers. Most elements apply to the general population and cancer survivors; however, additional elements relevant to survivorship need consideration when managing multimorbidity in cancer survivors. Chronic disease frameworks should be more inclusive of issues prioritised by people with, managing, or researching cancer through interdisciplinary approaches including acute and primary care.

Orofacial Pain.

This article explores the multiple etiologies, diagnosis, and management of orofacial pain. Published in 2019, the International Classification of Orofacial Pain has become the internationally accepted classification system for primary and secondary facial pain. New discoveries in temporomandibular disorders have demonstrated that they are far more complex than the traditional dental mechanistic point of view. A 2020 consensus report released by the National Academies of Sciences, Engineering, and Medicine entitled "Temporomandibular Disorders: Priorities for Research and Care" highlighted this paradigm shift and its importance for patient care, education, and research. Orofacial pain comprises many disorders with different etiologies and pathophysiologies. The subjectivity of the pain experience and the interrelated anatomy and physiology of the craniofacial area add to the complexity of diagnosis when the source and etiology of pain are not clear. As orofacial pain straddles the expertise of multiple disciplines, a multidisciplinary approach combining medication, physical therapy, and procedural and psychological strategies is essential in treating patients with orofacial pain.