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The overall objective of the present research is to examine the influence of information technology components on the export-to-GDP ratio, especially focused on the changes caused by the events of the 20th century for Southeast European countries (SEC). The motivation for selecting these countries is to evaluate whether they have achieved a sufficient level to adapt digital developments. To overcome these challenges, the study uses a hybrid technique, employing random-effects (RE) and fixed-effects (FE) regression and Arellano-Bond estimations on panel data gathered from 13 countries from 2006 to 2021. The results confirm that fixed broadband subscriptions (FBS), gross formation capital (GFC) and official exchange rate (ORE), have a strong positive effect on the export-to-GDP ratio. Additionally, fixed telephone subscriptions (FTS), foreign direct investments (FDI) and inflation (INF) have a significant negative impact on the export-to-GDP ratio. The Arellano-Bond technique reveals that FBS, INF and ORE have a positive effect on exports, whereas FTS, GFC and FDI have a negative effect. The novelty of this research is that it uses data comparisons that are not related to a single determinant in the economy but are conditioned to advancement, especially concerning global markets and the exploitation of gaps created by changes in supply chains. Implications for Central European audience: Depending on the research results, it is anticipated that the policy-making structures and other regulatory authorities will create a clear overview of the importance of digitization and its dynamics in the realization of exports and the mitigation of the trade deficit. These discoveries will encourage the highly empowered actors to redesign the policies that will affect the expansion and increase of the quality of the infrastructure of broadband and telephone subscriptions. By expanding and increasing the quality of the economic structure of the respective countries, they will be able to maximize the progress of the export value, which is one of the main goals of almost every country included in the analysis. [ABSTRACT FROM AUTHOR]

Background: Proton pump inhibitors (PPIs) the most frequently prescribed drug class globally, are often overused., Aim: To assess PPI prescribing practice in England., Design & Setting: Electronic medical record (EMR) evaluation from 62 primary care GP practices., Method: Adult patients on continuous PPI treatment (repeat prescription or≥4 acute prescriptions 6 months before data extraction) were included (August 2021-June 2022) to compare PPI prescribing practices vs National Institute for Health and Care Excellence (GORD and dyspepsia management) and Medicines and Healthcare products Regulatory Agency (clopidogrel-PPI interaction) guidelines., Results: We identified 77,356 patients on continuous PPI treatment. The most common (68%) diagnosis recorded in patients' EMRs and indicated for PPI use was gastroprotection, although 62% had no recorded indication. Of these 62% patients, 40% had no medication review in the preceding year. Among those with diagnoses indicated for≤3 months of PPI therapy (34%), 99% received their first PPI prescription≥3 months previously. Of patients with diagnoses indicated for long-term treatment (4%), 41% had no medication review in the preceding year. Furthermore, 18% of patients using omeprazole or esomeprazole were also prescribed clopidogrel, and 19% of those prescribed treatments associated with gastrointestinal risk ( N =14,826) were not prescribed PPIs., Conclusion: This study shows that PPI prescribing in England is not in alignment with existing clinical guidelines and highlights the need for appropriate measures to increase awareness of overuse and support deprescribing where appropriate., (Copyright © 2024, The Authors.)

Background: Recommendations regarding signs and symptoms that should prompt referral of patients with inflammatory bowel disease (IBD) to an IBD specialist for a consultation could serve to improve the quality of care for these patients. Our aim was to develop a consult care pathway consisting of clinical features related to IBD that should prompt appropriate consultation., Methods: A scoping literature review was performed to identify clinical features that should prompt consultation with an IBD specialist. A panel of 11 experts was convened over 4 meetings to develop a consult care pathway using the RAND/UCLA Appropriateness Method. Items identified via scoping review were ranked and were divided into major and minor criteria. Additionally, a literature and panel review was conducted assessing potential barriers and facilitators to implementing the consult care pathway., Results: Of 43 features assessed, 13 were included in the care pathway as major criteria and 15 were included as minor criteria. Experts agreed that stratification into major criteria and minor criteria was appropriate and that 1 major or 2 or more minor criteria should be required to consider consultation. The greatest barrier to implementation was considered to be organizational resource allocation, while endorsements by national gastroenterology and general medicine societies were considered to be the strongest facilitator., Conclusions: This novel referral care pathway identifies key criteria that could be used to triage patients with IBD who would benefit from IBD specialist consultation. Future research will be required to validate these findings and assess the impact of implementing this pathway in routine IBD-related care., (© 2022 Crohn’s & Colitis Foundation. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation.)

Background: Pre-clinical studies have shown that metformin reduces intratumoral hypoxia, improves T-cell function, and increases sensitivity to PD-1 blockade, and metformin exposure has been associated with improved clinical outcomes in various types of cancer. However, the impact of this drug in diabetic melanoma patients has not yet been fully elucidated., Methods: We reviewed 4,790 diabetic patients with stage I-IV cutaneous melanoma treated at the UPMC-Hillman Cancer Center and Memorial Sloan Kettering Cancer Center between 1996-2020. The primary endpoints included recurrence rates, progression free survival (PFS), and overall survival (OS) with and without metformin exposure. Tabulated variables included BRAF mutational status, immunotherapy (IMT) by type, and incidence of brain metastases., Results: The five-year incidence of recurrence in stage I/II patients was significantly reduced with metformin exposure (32.3% vs 47.7%, p=0.012). The five-year recurrence rate for stage III patients was also significantly reduced (58.3% vs 77.3%, p=0.013) in the metformin cohort. OS was numerically increased in nearly all stages exposed to metformin, though this did not reach statistical significance. The incidence of brain metastases was significantly lower in the metformin cohort (8.9% vs 14.6%, p=0.039)., Conclusion: This is the first study to demonstrate significantly improved clinical outcomes in diabetic melanoma patients exposed to metformin. Overall, these results provide further rationale for ongoing clinical trials studying the potential augmentation of checkpoint blockade with metformin in advanced melanoma., Competing Interests: DD: Grant/research support: Bristol Meyers Squibb, Checkmate, Merck, GlaskoSmith Kline, Tesaro, Amgen Honoraria: GlaxoSmith Kline, Tesaro, Instil Bio, Array Biopharma. Advisory board: GlaxoSmith Kline. JK: Grant/research support and/or consultant: BMS, Merck, Novartis, Roche, Genentech, EMD, Serono, Array Biopharma, Prometheus. GD: Grant/research support: Pfizer, Bluebirdbio, TCR2 Therapeutics. Consultant: TTMS, Pieris Pharmaceuticals. AW: Consulting/advisory: Nanobiotix, Iovance, Novartis, Shanghai Jo’Ann Medical Technology, BluePath Solutions, Pfizer, Instil Bio. YGN: Grant/research support: Merck, Bristol Meyers Squibb, Pfizer, Replimune. Consulting/Advisory board: Array Biopharma, InterVenn Bio, Merck, Novartis, Pfizer, BMS and Immunocore. Non-CE Honoraria: Pfizer, Immuncore. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Augustin, Huang, Ding, Zhai, McArdle, Santisi, Davis, Sander, Davar, Kirkwood, Delgoffe, Warner and Najjar.)

Introduction: Despite being a life-preserving medical treatment, the demands of haemodialysis are a significant impost on individuals, posing considerable burdens on their work, vocational activities and involvement with family and community. In our region, patients who have had to relocate considerable distances to a regional city for dialysis, and First Nations people, are less likely to attend all scheduled dialysis sessions. Virtual reality (VR) has been shown to improve engagement with care of people on haemodialysis.This manuscript describes the protocol for a cross-over randomised controlled trial (RCT) that will explore the impact of an immersive VR experience for patients attending a northern Queensland, Australia, haemodialysis service., Methods: The design is a crossover RCT, with 8 clusters according to haemodialysis location and schedule. Clusters (5 participants in each) will be randomized by computer program. Participants in the trial will be patients who undergo haemodialysis three times/week at one of two dialysis units. During the 4-week intervention period (12 haemodialysis sessions), participants will be provided a headset with vision representative of the natural environment, and with audio. The 4-week control period will comprise usual activities, such as watching television, reading and sleeping. Outcomes will be measured by participants': attendance at scheduled dialysis sessions; adherence to lifestyle modifications; wellbeing, anxiety and depression; acceptability and usability of VR; and adverse events such as nausea. The feasibility and acceptability of the intervention from clinicians' perspectives will also be explored., Discussion: If this VR intervention is feasible, then participants may engage more with haemodialysis regimens and self-care in this very clinical environment., Trial Registration: ACTRN12621000732886., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2022 Published by Elsevier Inc.)

-A 7-year-old boy with a background of autism presented to the paediatric emergency department with his left arm 'feeling strange' then became difficult to rouse. On examination, he was found to have left arm weakness and a left-sided facial droop without forehead muscle involvement. Three hours later, his symptoms had completely resolved and he was suspected to have had a first seizure. He was admitted for observation and an electroencephalography which showed slower rhythms in the right posterior quadrant, which was reported as within normal appearances for his age. He was discharged home the following day. Three days later he became lethargic and vomited. His parents reported dysphasia with use of single-word phrases only, he also appeared confused. He re-presented to the paediatric emergency department, where he was found to have increased tone in the left arm, ankle clonus and an upgoing plantar reflex on the left hand side., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To explore the perspectives of student midwives, midwifery educationalists and midwifery clinicians from and connected to one University in order to identify strategies to enhance awareness of sexual and gender diversity in a pre- registration midwifery curriculum., Design: A mixed method study including an online survey and a series of focus groups Setting: One University in London Participants: 47 survey respondents and 16 focus group participants Findings: Two Inductive themes were developed from the data analysis: Practising Open Mindedness and Cultivating Openness and four sub themes; Making Assumptions, Developing self- awareness, Challenge and Discomfort and Safe spaces. Participants proposed learning strategies that they thought would facilitate cultivating openness and open mindedness., Competing Interests: Declarations of Competing Interest Two members of the research team had pastoral responsibilities for the student cohort from which participants were drawn. Recruitment occurred as a result of poster advertising and emails, describing the study and sent to all staff and students, via a Faculty administrative hub., (Copyright © 2021. Published by Elsevier Ltd.)

The European Federation of Pharmaceutical Industries and Associations (EFPIA) representing the pharmaceutical industry operating in Europe, introduced three codes of conduct between 2007 and 2013, which had a common goal of self-regulating interactions with healthcare professionals and patient organisations. This former set of rules was appreciated as a first self-regulatory step, although self-regulation itself is still considered by many stakeholders as insufficient to provide thorough transparency. EFPIA agreed to replace the separate codes with a new, consolidated EFPIA Code of Practice. The consolidated Code was broadened to include a new section on medical education that outlines the scope of member companies' engagement in "medical education activities?. This new section is controversial as it explicitly confirms that EFPIA members can be involved in medical education. In our view "independent Medical Education" per se prevents industry from "organising" events, i.e. industry must not influence content, presentation, choice of lecturers or publication of results. What is more, only events respecting this key principle (amongst others) can be recognised for purposes of continuing medical education/continuing professional development (CME/CPD). A substantial portion of the medical education is currently funded by the pharmaceutical and medical device industries. This practice carries a significant risk to public and personal health, especially if it is not adequately safeguarded by a high standard of accreditation. We are most concerned by the fact that EFPIA, representing the pharmaceutical industry, is trying to broaden the approach to medical education, to include activities that are not independently evaluated as free from undue influence and conflicts of interest. We believe that in order to preserve scientific integrity and independence, pharmaceutical companies must not be granted the right to influence the content of medical education., (© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

BACKGROUND Older adults who are discharged following emergency department evaluation are at increased risk for functional decline and health care utilization, and are likely to benefit from close follow-up and additional care services. Understanding factors associated with a return emergency department visit within 30 days among older fee-for-service Medicare beneficiaries discharged to the community may assist in identifying patients at greatest need for interventions. METHOD Predictors from Medicare data and public sources were evaluated in a retrospective data analysis of North and South Carolina residents (2011-2012) aged ≥ 65 years using Cox regression proportion hazards ratios (HR) and 95% confidence intervals (CI) for time-to-30-day return events. RESULTS 30-day return rates varied markedly among the 167 emergency department facilities studied (18%-39%). Predictors of 30-day return included: age (85+ versus 65-74; HR, 1.24; 95% CI, 1.22-1.27); male sex (HR, 1.11; 95% CI, 1.14-1.10); non-white race (HR, 1.07; 95% CI, 1.05-1.09); Medicaid eligibility (HR, 1.20; 95% CI, 1.18-1.22); Charlson Score (3+ vs. 0; HR, 1.33; 95% CI, 1.30-1.36); and prior emergency department encounter (3+ vs. 0; HR, 2.35; 95% CI 2.30-2.41). LIMITATIONS This study was limited to Medicare beneficiaries in North Carolina and South Carolina, 2011-2012. Administrative claims data are limited to information required for financial reimbursement. Because we limited our study to older fee-for-service patients, our findings may not be generalizable to managed care patients and other age groups. Patients transferred to another emergency department or facility were not included in the analysis. CONCLUSION Factors predicting 30-day return to the emergency department or hospitalization suggest the potential for care transition improvement efforts to better meet patient needs, thereby potentially improving post-emergency department outcomes., (©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Objective: To assess implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units., Design: Mixed-methods implementation evaluation., Setting/local Problem: Labor and delivery units (N = 18) in 10 states participating in the Safety Program for Perinatal Care (SPPC). Shoulder dystocia is unpredictable, requiring rapid and coordinated action., Participants: Key informants were labor and delivery unit staff who implemented SPPC safety strategies., Intervention/measurements: The SPPC was implemented by using the TeamSTEPPS teamwork and communication framework and tools, applying safety science principles (standardization, independent checks, and learn from defects) to shoulder dystocia management, and establishing an in situ simulation program focused on shoulder dystocia to practice teamwork and communication skills. Unit staff received training, a toolkit, technical assistance, and unit-specific feedback reports. Quantitative data on unit-reported process improvement measures and qualitative data from staff interviews were used to understand changes in use of safety principles, teamwork/communication, and in situ simulation., Results: Use of shoulder dystocia safety strategies improved on the units. Differences between baseline and follow-up (10 months) were as follows: in situ simulation (50% vs. 89%), teamwork and communication (67% vs. 94%), standardization (67% to 94%), learning from defects (67% vs. 89%), and independent checks (56% vs. 78%). Interview data showed reasons to address management of shoulder dystocia, various approaches to implement safety practices, and facilitators and barriers to implementation., Conclusion: Successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The SPPC strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances., (Copyright © 2018 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Motor, sensory, and autonomic abnormalities are reported for toll-like receptor 9 (TLR9) knock-out (KO) mice. However, a physiological role of TLR9 in the nervous system is largely unknown. Since altered synaptic transmission can contribute to sensory and motor abnormalities, we evaluated neuromuscular junction (NMJ) function and morphology of TLR9 KO mice. Triangularis sterni nerve-muscle preparations were dissected from TLR9 KO and age-matched control mice. Two-electrode voltage clamp of the motor endplate revealed that the amplitude and frequency of miniature end plate currents (mEPCs) for TLR9 KO NMJs were significantly greater than control. In contrast, mean endplate current (EPC, 1Hz) amplitude was equivalent to control. The ratio of mean EPC to mean mEPC amplitude indicated a decline of quantal content (m) for TLR9 KO NMJs. Furthermore, m declined more rapidly than control in response to 50-Hz stimulus trains. A rightward shift of the mEPC amplitude distribution suggested formation of vesicles containing larger amounts of acetylcholine (ACh). Staining with rhodamine α-bungarotoxin revealed a significant decline of endplate size in TLR9 KO mice. This alteration may result from ACh-induced decline of acetylcholine receptor (AChR) expression resulting from increased frequency and amplitude of mEPCs. At the same time, excessive spontaneous vesicular ACh release may initiate retrograde suppression of excitation-secretion coupling. These data suggest a novel role of TLR9 in the development of the NMJ., (Copyright © 2016 IBRO. Published by Elsevier Ltd. All rights reserved.)

The quality, skills and attitudes of staff working in the healthcare system are central to multidisciplinary learning and working, and to the delivery of the quality of care patients expect. Patients want to know that the staff supporting them have the right knowledge and attitudes to work in partnership, particularly for conditions such as diabetes where 95% of all care is delivered by the person with diabetes themselves. With the current changes in the NHS structures in England, and the potential for greater variation in the types of 'qualified provider', along with the recent scandal at Mid-Staffordshire Hospital, staff need to be shown to be competent and named/accredited or recognized as such. This will help to restore faith in an increasingly devolved delivery structure. The education and validation of competency needs to be consistently delivered and assured to ensure standards are maintained for different roles and disciplines across each UK nation. Diabetes UK recommends that all NHS organizations prioritize healthcare professional education, training and competency through the implementation of a National Diabetes Competency Framework and the phased approach to delivery to address this need., (© 2015 The Authors. Diabetic Medicine © 2015 Diabetes UK.)