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Treatment patterns and preferences for patients with Graves’ disease (GD) vary across countries. In this study, we assessed the initial therapies and subsequent treatment modalities employed for GD in real-world clinical practice in Korea. We analyzed 452,001 patients with GD from 2004 to 2020, obtained from the Korean National Health Insurance Service database. Initial treatments included antithyroid drug (ATD) therapy (98% of cases), thyroidectomy (1.3%), and radioactive iodine (RAI) therapy (0.7%). The rates of initial treatment failure were 58.5% for ATDs, 21.3% for RAI, and 2.1% for thyroidectomy. Even among cases of ATD treatment failure or recurrence, the rates of RAI therapy remained low. Regarding initial treatment, the 5-year remission rate was 46.8% among patients administered ATDs versus 91.0% among recipients of RAI therapy; at 10 years, these rates were 59.2% and 94.0%, respectively. Our findings highlight a marked disparity in the use of RAI therapy in Korea compared to Western countries. Further research is required to understand the reasons for these differences in treatment patterns.

Background: This study examined temporal shifts in adjuvant therapy patterns in Japanese patients with resectable gastric cancer (GC) and treatment patterns of first-line and subsequent therapy among those with recurrent disease. Methods: This retrospective analysis of hospital-based administrative claims data (April 1, 2008 to March 31, 2022) included adults (aged ≥ 20 years) with GC who started adjuvant therapy on or after October 1, 2008 (adjuvant cohort) and patients in the adjuvant cohort with disease recurrence (recurrent cohort), further defined by the time to recurrence (≤ 180 or > 180 days after adjuvant therapy). Results: In the adjuvant cohort (n = 17,062), the most common regimen during October 2008–May 2016 was tegafur/gimeracil/oteracil potassium (S-1; 95.7%). As new standard adjuvant regimen options were established, adjuvant S-1 use decreased to 65.0% and fluoropyrimidine plus oxaliplatin or docetaxel plus S-1 use increased to 15.0% and 20.0%, respectively, in September 2019–March 2022. In the recurrent cohort with no history of trastuzumab/trastuzumab deruxtecan treatment (n = 1257), the most common first-line regimens were paclitaxel plus ramucirumab (34.0%), capecitabine plus oxaliplatin (CapeOX; 17.0%), and nab-paclitaxel plus ramucirumab (10.1%) in patients with early recurrence, and S-1 plus oxaliplatin (26.3%), S-1 plus cisplatin (15.3%), CapeOX (14.0%), S-1 (13.2%), and paclitaxel plus ramucirumab (10.8%) in those with late recurrence. Conclusions: This study demonstrated temporal shifts in adjuvant treatment patterns that followed the establishment of novel regimens, and confirmed that post-recurrent treatment patterns were consistent with the Japanese Gastric Cancer Association guideline recommendations. [ABSTRACT FROM AUTHOR]

Background: Treatment decisions about oral anticoagulants (OACs) for atrial fibrillation (AF) are complex in older care home residents. Aim: To explore factors associated with OAC prescription. Design and setting: Retrospective cohort study set in care homes in Wales, UK, listed in the Care Inspectorate Wales Registry 2017/18. Method: Analysis of anonymised individual-level electronic health and administrative data was carried out on people aged ≥65 years entering a care home between 1 January 2003 and 31 December 2018, provisioned from the Secure Anonymised Information Linkage Databank. Results: Between 2003 and 2018, 14 493 people with AF aged ≥65 years became new residents in care homes in Wales and 7057 (48.7%) were prescribed OACs (32.7% in 2003 compared with 72.7% in 2018) within 6 months before care home entry. Increasing age and prescription of antiplatelet therapy were associated with lower odds of OAC prescription (adjusted odds ratio [aOR] 0.96 per 1-year age increase, 95% confidence interval [CI] = 0.95 to 0.96 and aOR 0.91, 95% CI = 0.84 to 0.98, respectively). Conversely, prior venous thromboembolism (aOR 4.06, 95% CI = 3.17 to 5.20), advancing frailty (mild: aOR 4.61, 95% CI = 3.95 to 5.38; moderate: aOR 6.69, 95% CI = 5.74 to 7.80; and severe: aOR 8.42, 95% CI = 7.16 to 9.90), and year of care home entry from 2011 onwards (aOR 1.91, 95% CI = 1.76 to 2.06) were associated with higher odds of an OAC prescription. Conclusion: There has been an increase in OAC prescribing in older people newly admitted to care homes with AF. This study provides an insight into the factors influencing OAC prescribing in this population. [ABSTRACT FROM AUTHOR]

Aim: A recent European Heart Rhythm Association (EHRA) practical guide provides guidance on the use of novel digital devices for heart rhythm analysis using either electrocardiogram (ECG) or photoplethysmography (PPG) technology for the diagnosis of atrial fibrillation (AF). This survey assesses physicians' preferences to use digital devices in patients with possible AF and their impact on clinical decision-making., Methods and Results: Participants of the DAS-CAM III initiated and distributed an online survey assessing physician preferences in using digital devices for the management of AF in different clinical scenarios. A total of 505 physicians (median age: 38 [IQR 33-46] years) from 30 countries completed the survey. A third of respondents were electrophysiologists, the others were cardiologists, cardiology residents, or general practitioners. Electrophysiologists were more likely to have experience with both ECG-based (92% vs. 68%, p < 0.001) and PPG-based (60% vs. 34%, p < 0.001) digital devices. The initial diagnostic approach to each scenario (symptomatic low-risk, symptomatic high-risk, or asymptomatic high-risk patient) was heterogeneous. Electrophysiologists preferred intermittent single-lead ECG monitoring to traditional Holter ECGs to screen for AF. Both electrophysiologists and non-electrophysiologists would rarely use PPG-based devices to diagnose and screen for AF (8.2%-9.8%). Electrophysiologists and non-electrophysiologists use ECG-based technology to confirm PPG-documented tracings suggestive of AF., Conclusion: While PPG-based digital devices are rarely used for diagnosis and screening for AF, intermittent ECG-based digital devices are beginning to be implemented in clinical practice. More education on the potential of novel digital devices is required to achieve diagnostic pathways as suggested by the EHRA practical guide., (© 2024 The Author(s). Clinical Cardiology published by Wiley Periodicals, LLC.)

Objectives: Since the introduction of thrombolytics, stroke teams evolved to improve thrombolytic care delivery. The impact of the advent of endovascular therapy on the composition of acute stroke teams is unknown., Materials and Methods: A two-part pilot-tested survey was deployed to site-Principal Investigators (PIs) of the 27 StrokeNet Regional Coordinating Centers (RCCs) regarding institutional acute stroke teams. Part A inquired about the participation of personnel in each type of stroke response. Part B identified stroke team physicians and the types of responses in which they participate to assess training background of stroke team members., Results: Response rates for Part A and B were 66% and 48%, respectively. In Part A, 67% (12/18) of sites reported trainees always responded to ED stroke activations with significant autonomy. 44% (7/16) and 27% (4/15) of sites reported NP and PA response to ED stroke alerts, respectively, but with limited autonomy. In Part B, 124 physicians involved in ED stroke alerts were identified, the large majority of whom (79%, 95% CI: 71-85) were vascular neurology trained. The 39 (23%) stroke team members involved in endovascular therapy had the following training: 49% (34-64) neurosurgery, 28% (17-44) radiology, 18% (9-33) vascular neurology 5% (1-16) neurology., Conclusions: We identified modest heterogeneity in the composition of acute stroke team members across StrokeNet RCCs. Individuals performing endovascular therapy had a variety of clinical specializations, reflecting the evolving multidisciplinary nature of interventional acute stroke care. At StrokeNet RCCs, teams have significant trainee involvement in both ED and inpatient acute stroke responses., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Lauren E Mamer reports financial support was provided by National Institute of Neurological Disorders and Stroke. Phillip A Scott reports was provided by National Institute of Neurological Disorders and Stroke. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

In Morocco, cervical cancer is a serious public health problem with an estimated number of 2165 new cases and 1199 deaths in 2020. The human papillomavirus (HPV) vaccine has been available in Morocco since 2008. Few data are available on physicians' practices and attitudes toward HPV vaccine. Hence, this study aims to evaluate physicians' awareness and practice towards HPV vaccine and to highlight the main factors affecting physicians' recommendation of this vaccine in Morocco. We have carried out a structured interviewer-administered questionnaire with 500 physicians in different Moroccan regions between March 2019 and March 2020. This study showed an insufficient level of awareness of the two most common types of HPV associated with cervical cancer (36.6%). The rate of HPV vaccine recommendation did not exceed 16.6%. However, more than 63% of participants who were aware of HPV vaccine were willing to recommend it for their future eligible patients. Age (p value < 0.01), sector of activity (p value < 0.01), awareness of the two most common types of HPV associated with genital warts (p value = 0.02), of the vaccine schedules (p value = 0.03), and of the commercial name of this vaccine (p value < 0.01), were significant factors influencing physicians' recommendation of HPV vaccine. Our results showed that, older age (above 51 years old) was associated with negative attitude towards the recommendation of this vaccine (OR: 0.17, 0.06-0.46 CI 95%). Practice in public sector was positively associated with recommendation of HPV vaccine (OR: 7.54, 3.38-16.80 CI 95%). Who were aware of the two most common types of HPV associated with genital warts were more likely to recommend HPV vaccine (OR: 3.36, 1.31-8.65 CI 95%). In the same line, participants, who were also more likely to recommend the vaccine, were those who were aware of HPV vaccine schedules (OR: 6.07, 3.51-10.50 IC 95%); participants who were aware of the commercial name of the HPV vaccine were more likely to recommend the vaccine (OR: 10.04, 5.02-20.09 IC 95%). Indeed, raising physicians' awareness is urgently needed to improve HPV vaccine coverage within Moroccan population., Competing Interests: Declarations Consent for Publication Oral consent was obtained from all the participants for their responses to be published in this study. Competing Interests The authors declare no competing interests., (© 2024. The Author(s) under exclusive licence to American Association for Cancer Education.)

Background: Patients with suspected ischemic stroke and use of Direct Oral Anticoagulants (DOACs) within 48 h are excluded from thrombolysis. We aimed to determine practice patterns across institutions in the NIH StrokeNet, a network of hospitals to conduct NIH-funded stroke clinical trials, in the United States., Methods: A survey was sent electronically to all NIH StrokeNet regional coordinating centers. The survey questions were geared towards understanding practice patterns with intravenous thrombolysis use in patients on DOACs. We reported proportions and percentages answers to the questions. We compared the likelihood of thrombolysis use in patients with recent DOAC ingestion (never vs. all other responses) across characteristics of survey responder using Chi Square., Results: A total of 83 site principal investigators completed the survey; 78.3 % would never give thrombolysis to an otherwise eligible patients within 12-24 h from last DOAC ingestion and 54.2 % would never give thrombolysis to an otherwise eligible patient within 24-48 h from last DOAC ingestion. A higher proportion of vascular neurologists would never give thrombolysis in patients with DOAC ingestion within 12-48 h compared to other subspecialties (60.7 % vs. 36.4 %, p = 0.05). Nearly, 80 % would change their practice if a well-designed prospective study demonstrated that the symptomatic intracranial hemorrhage rate is not >5 %., Conclusions: A well-designed prospective study with a set safety threshold is likely to change practice patterns in giving thrombolysis in patients with recent DOAC ingestion, particularly among vascular neurologists who are more likely to never give thrombolysis in this setting., Competing Interests: Declaration of competing interest The authors have relevant disclosures or conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Despite literature suggesting benefits of a balloon guide catheter (BGC) in stroke thrombectomy, BGCs are not routinely used. This study aimed to get insights in the use of a BGC and the reasons (not) to inflate the balloon., Methods: Data were used of the Maastricht Stroke Quality Registry (MaSQ-Registry), a prospective registry for quality purposes of stroke patients treated between September 2020-February 2023. Additionally, a Dutch nationwide questionnaire was sent among all stroke treating physicians of the Dutch Society of Interventional Radiology (NVIR). Information on the use and reasons for selecting a (non-)BGC and using the BGC was collected., Results: Out of 511 patients registered in the MaSQ-Registry, 458 were included. In 69% (n=317) of the patients a BGC was used; in 68% (n=214) the balloon was not inflated. In 95% of the posterior circulation occlusions a non-BGC was used. In total 47 treating physicians from sixteen stroke centers responded to the questionnaire. 51% (n=24) preferred a non-BGC and 30% (n=14) never used a BGC. 52% and 18% of the BGC-users estimated they inflate the balloon in 80-100% and 0-20% of the times, respectively. The main reasons reported for not inflating the balloon were when the BGC was occlusive (47%) or not placeable (34%) in the carotid artery., Conclusion: This study shows variation in the use of (non-)BGC use with and without inflated balloon among treating physicians in the Netherlands, highlighting current limited consensus regarding the use of (non-)BGCs among stroke treating physicians., Competing Interests: Declaration of competing interest 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., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: A recently published individual participant-level meta-analysis found that EVT alone was not non-inferior to combined intravenous thrombolysis (IVT) and EVT. Our aim was to determine factors that influence physicians' treatment choice of IVT-alone versus EVT-alone versus a combined approach., Methods: We performed an international, structured, invite-only survey among physicians treating patients presenting with AIS. Respondents were asked 16 multiple choice questions. Fourteen questions involved the respondent being provided with a clinical scenario. In each scenario, a patient was presenting with an AIS with LVO, varying a single clinical or imaging feature., Results: A total of 282 stroke physicians (mean age 46 years, 75 % males) participated in the survey. In LVO stroke, eligible for both IVT and EVT, without other qualifiers, 220 (85.9 %) respondents chose to pursue a combined approach. For age over 80 years, 191 (74 %) participants opted for combined approach, which decreased to 121 (48.2 %) with dementia and 148 (57.4 %) if the patient was on dual anti-platelet therapy (DAPT). Of respondents choosing combination therapy in a patient above the age of 80, only 105 (56.8 %) would pursue the same in a patient with dementia. For imaging factors, 177 (72.8 %) opted for a combined approach for intracranial carotid occlusion, which decreased to 160 (65.3 %) in tandem occlusions. Overall, 88 (38 %) respondents agreed to the statement "I am uncomfortable with uncertainty in patient care"., Conclusions: In a typical patient with AIS due to LVO, most respondents still choose a combined revascularization approach but discrepancy in decision-making increases in complex scenarios., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To explore general practitioners' experiences and reflections on how the current Norwegian guideline for screening for gestational diabetes affects their clinical practice., Design: A qualitive study in which data were collected through semi-structured focus group interviews and analyzed thematically., Setting and Subjects: Five focus groups conducted in 2020 among GPs in Norway; three interviews took place face-to-face and two were held digitally. The total number of participants was 31., Results: GPs acknowledged the potential benefits of more extensive screening, but had concerns about the medicalization of pregnancy, stating that some women experienced considerable anxiety. The GPs expressed doubts about the guideline's evidence base but differed in how they interpreted what the guideline was asking them to do. Some offered eligible women the opportunity to be screened, while other set up a screening appointment without consulting the women first. For some, fear of incrimination made them recommend screening without being convinced that it was the right thing for the patient., Conclusions: It is unclear whether the guideline for gestational diabetes requires GPs to recommend screening to pregnant women or if they should provide neutral information about the availability of screening. This ambiguity should be addressed, and the guideline evaluated against the core principles of general practice.

Background: Notable surgeon-to-surgeon variation in rates of uncommon surgery can reflect appropriate concentration of expertise with technically difficult or risky procedures that address problematic impairment due to objective pathophysiology. Examples include vascularized tissue transfer or transplantation to address complex tissue loss and release of bony elbow ankylosis. Perhaps more problematic is notable variation in straightforward, discretionary surgeries intended to alleviate pain, offered in the absence of objectively measurable pathophysiology, and without experimental evidence of benefit over placebo and other nonspecific effects. Evidence of concentration of this type of surgery in the hands of a few surgeons might point to inordinate influence of surgeon opinions on patient behavior. A study of variation in operations for upper extremity peripheral mononeuropathy has the potential to uncover potentially problematic variation. There are billing codes specific to common surgeries that can benefit patients with objectively verifiable neuropathies. And there are billing codes that represent less common nerve decompression surgeries that in many cases are offered in the absence of both objective evidence of pathophysiology as well as experimental evidence that surgery alleviates pain better than simulated surgery., Questions/purposes: We asked the following questions: (1) Among surgeons who billed a mean of at least 10 carpal tunnel releases (CTRs) per year in patients with Medicare insurance in the United States, how many also performed at least one less common peripheral nerve release and cubital tunnel release (CubTR) per year? (2) Among surgeons who billed a mean of at least one less common peripheral nerve release or CubTR on average per year, what is the median and range of the number of less common peripheral nerve releases and CubTRs and the relative proportion of these compared with CTRs per year? (3) Are there any differences in gender, specialty, and number of CTRs and CubTRs between surgeons who performed at least one less common nerve decompression and surgeons who, on average, performed none?, Methods: Using the Medicare Physician & Other Practitioners - by Provider and Service database, we identified surgeons who perform a minimum of 10 CTRs per year. Because this database has all surgeries billed to Medicare performed in any setting by individual surgeons, it is well suited to the study of surgeon-specific operative rates among Medicare patients. Among 7259 clinicians who billed one or more nerve procedure to Medicare between January 2013 and December 2019, we excluded 120 nonsurgical clinicians, 47 podiatrists, and 1561 clinicians who billed procedures as an organization. Among the remaining 5531 surgeons, 5439 performed at least 10 CTRs on average per year, which we considered representative of surgeons who include nerve decompression surgery as a part of their practice. Among these 5439 surgeons, we calculated the mean number of CTRs, CubTRs, and less common peripheral nerve releases (including decompression of a digital nerve, nerve in hand or wrist, ulnar nerve at the wrist, brachial plexus, and unspecified nerve) per year between 2013 and 2019. Decompression of the median nerve at the carpal tunnel, the ulnar nerve at the cubital tunnel, and, much less frequently, the ulnar nerve at the wrist typically addresses measurable neuropathy. The other nerve releases are often performed for illnesses characterized by pain that are defined, in part, by the absence of experimentally verifiable pathophysiology such as radial tunnel and pronator (or lacertus) syndromes. We counted the number of surgeons who billed an average of at least one less common peripheral nerve release and CubTR per year; the median and range of the number of less common nerve releases and CubTRs and their relative proportion among those subsets of surgeons; and differences in the number of surgeons who performed one or none less common surgery by gender, specialty, and volume of CTR/CubTR surgery., Results: Of 5439 surgeons who performed a mean of at least 10 CTRs per year, 2% (93) performed a mean of at least one less common peripheral nerve release per year among patients on Medicare, 14% (775) at least one CubTR, and 1% (47) performed both. Surgeons who performed a mean of at least one less common peripheral nerve release per year performed a median (IQR) of 7 (3 to 17) per year (with a maximum of 153 per year), representing approximately one less common peripheral nerve release for every five CTRs. Sixty-five percent (4076 of 6272) of all less common nerve procedures were performed by the top 20 billing surgeons. Gender was not associated with doing one or more uncommon nerve releases (women 1% [6 of 413], men 2% [87 of 5026]; p = 0.84), but specialty was, with plastic surgeons leading (6% [20 of 340] compared with 1% [73 of 5087] for other types of surgeons; p < 0.001)., Conclusion: The observation that a relatively small number of surgeons perform a large majority of the surgery for nerve syndromes conceptualized as accounting for arm pain suggests that most surgeons are cautious about ascribing pain to conceptual nerve compression syndromes and offering surgery., Clinical Relevance: An approach to surgical care founded on ethical principles regards this type of notable variation as a signal of inordinate influence of surgeon opinion on patient behavior, suggesting that professional conduct may be supported by safeguards such as checklists that help guide patients to choices consistent with their values unclouded by surgeon beliefs, false hope, and common misconceptions., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Objective: Private health insurance is becoming more common in Norway. The aim of this study was to investigate GPs' opinions on private health insurance, and their experiences from consultations where health insurance can affect decisions about referring., Design: A web based cross-sectional survey., Setting: Norwegian general practice., Subjects: All GPs in Norway were in 2019 invited to participate in an online survey., Main Outcome Measures: The GPs' opinions and experiences regarding health insurance were reported as proportions. Multiple logistic regression was used to test associations between how frequently GPs refer patients without further considerations and variables concerning their characteristics, opinions, and experiences., Results: Of 1,309 GPs (response rate 27%), 93% stated that private health insurance raises the risk of overtreatment and 90% considered such insurance to contribute to inequality in health. Frequently being pressured to refer in the absence of a medical indication was reported by 42%. Moreover, 28% often or always chose to refer patients without further consideration, and this was associated with perceptions of pressure with an adjusted odds ratio (AOR) of 3.80, 95% confidence interval (CI) 2.73-5.29, and unpleasant reactions from patients following refusals (AOR 1.63, 95% CI 1.14-2.33)., Conclusion: Although most participating GPs associated private health insurance with overtreatment and inequality in health, more than one in four choose to refer without further consideration. GPs' experience of pressure to refer and negative reactions from patients when they consider referrals not to be medically indicated, raises the risk of medical overuse for patients holding private health insurance.

Aim: This study aimed to survey general practitioners' (GPs) and radiologists' perspectives on referrals, imaging justification, and unnecessary imaging in Norway., Materials and Methods: The survey covered access to imaging, responsibilities, attitudes toward justification assessment, referral process, and demographics using multiple choice questions, statements to report agreement with using the Likert scale and one open question., Results: Forty radiologists and 58 GPs attending national conferences completed a web-based survey, with a 20/15% response rate, respectively. Both radiologists (97%) and GPs (100%) considered avoiding unnecessary examinations essential to their role in the healthcare service. Still, 91% of GPs admitted that they referred to imaging they thought was not helpful, while about 60% of the radiologists agreed that unnecessary imaging was conducted in their workplace. GPs reported pressure from patients and patients having private insurance as the most common reasons for doing unnecessary examinations. In contrast, radiologists reported a lack of clinical information and the inability to discuss patient cases with the GPs as the most common reasons., Conclusion: This study adds to our understanding of radiologists' and GPs' perspectives on unnecessary imaging and referrals. Better guidelines and, even more importantly, better communication between the referrer and the radiologist are needed. Addressing these issues can reduce unnecessary imaging and improve the quality and safety of care.

Objectives: To describe changes in Swedish primary care physicians' use of, attitudes and intentions toward digital tools in patient care between 2019 and 2022., Design: A survey using a validated questionnaire measuring physician's intentions to use digital tools based on the theory of planned behavior., Setting: Sample of primary health care centers in southern Sweden., Subjects: Primary care physicians., Main Outcome Measures: Self-reported use and intentions to use, digital tools including digital consultations by text or video, chronic disease monitoring and artificial intelligence (AI) and the associations between attitudes, subjective norms, perceived behavioral control and behavioral intentions to use digital tools, in 2019 compared to 2022., Results: In both 2019 ( n  = 198) and 2022 ( n  = 93), physicians reported high intentions to use digital tools. Self-reported use of video was slightly higher in 2022 ( p  = .03). No other changes were seen in the self-reported use or behavioral intentions to use digital tools., Conclusion: The slow adoption of patient-related digital tools in Swedish primary health care does not seem to be explained by a low intention to use them among physicians. Future research on implementation of digital tools should include a focus on contextual factors such as organizational, technical and cultural barriers.

Background: Otomicroscopy and pneumatic methods are superior to otoscopy alone in diagnosing acute otitis media (AOM). There is a lack of knowledge regarding the use of different diagnostic methods for AOM in primary health care in Sweden and Norway., Methods: This cross-sectional study included a questionnaire completed by general practitioners (GPs) and specialist trainees (STs/residents/registrars) working in primary care in Sweden and Norway. Multivariable binary logistic regressions were performed to evaluate the use of diagnostic methods and written advice adjusted for educational level, sex and country., Results: Otoscopy was the most frequently used method. Sweden had greater access to the more accurate diagnostic methods. In Norway, the following methods were used to a lesser extent: pneumatic otoscopy, adjusted OR 0.15 (95% CI 0.10-0.23; p  < .001), otomicroscopy, adjusted OR 0.013 (95% CI 0.070-0.027; p  < .001), pneumatic otomicroscopy, adjusted OR 0.028 (95% CI 0.010-0.078; p  < .001) and tympanometry, adjusted OR 0.31 (95% CI 0.21-0.45; p  < .001). Written advice was used to a greater extent in Norway, adjusted OR 4.5 (95% CI 3.1-6.7; p  < .001). The STs used pneumatic otoscopy and pneumatic otomicroscopy to a lesser extent, adjusted OR 0.65 (95% CI 0.45-0.93; p  = .019) and 0.63 (95% CI 0.43-0.92; p  = .016)., Conclusions: Swedish physicians both used and had greater access to the significantly better diagnostic methods compared with Norwegian physicians while the opposite applied to the use of written information. The GPs used pneumatic otoscopy and pneumatic otomicroscopy to a greater extent than STs. Compared with 2012, the Swedish physicians now more frequently used pneumatic otoscopy.

Objective: A Serous Tubal Intraepithelial Carcinoma (STIC) without concomitant invasive carcinoma is occasionally identified and associated with a high risk of subsequent peritoneal carcinomatosis. Management needs optimisation. This study explores professionals' opinions and clinical practices regarding the diagnosis, counselling, treatment and follow-up of isolated STIC to facilitate clinical decision making and optimise the direction of future research. A secondary aim is to assess international clinical guidelines., Design: Focus group study., Setting: Four online sessions., Population: International panel (n = 12 countries) of gynaecologists, gynaecologic oncologists, pathologists and medical oncologists (n = 49)., Methods: A semi-structured interview guide was used. Two independent researchers analysed transcripts by open and axial coding. Results were organised in domains. Relevant (inter)national guidelines were screened for recommendations regarding isolated STIC., Main Outcome Measures: Professionals' opinions and clinical practices regarding isolated STIC management., Results: Regarding pathology, most professionals identified the SEE-FIM protocol as standard of care for high-risk patients, whereas variation exists in the histopathological examination of fallopian tubes in the general population. Confirmation of STIC diagnosis by a specialised pathologist was recommended. Regarding work-up and follow-up after STIC diagnosis, there was variety and discordance. Data on outcomes is limited. As for treatment, chemotherapy and PARP inhibitors were not recommended by most. Eleven guidelines provided limited recommendations., Conclusions: We identified recommendations and highlighted knowledge gaps in the diagnosis and management of isolated STIC. Moreover, recommendations in clinical guidelines are limited. There is an agreed need for international collaboration for the prospective registration of isolated STIC., (© 2024 The Author(s). BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

This study presents an overview of prescribing patterns and provides insight into the current management practice for the core symptoms and comorbidities of ASD in children. A quantitative retrospective study was conducted at a public hospital in KwaZulu-Natal, South Africa by reviewing patient files of children diagnosed with ASD and meeting the inclusion criteria for the study. A descriptive analysis of data was done to identify treatment trends and patient therapeutic outcomes. A total of 181 children met the inclusion criteria of the study. Risperidone was the most frequently prescribed drug (88%) for the management of comorbidities and/or core symptoms of ASD. Drugs prescribed to manage ASD comorbidities included methylphenidate, melatonin, sodium valproate, risperidone, oxybutynin, carbamazepine, and others. Except for risperidone, there were no additional drugs that targeted the core symptoms of ASD. Non-pharmacological therapies were often used collaboratively with medication to manage ASD symptoms. In 41% of patients, there were improvements in their symptoms., (© 2023. The Author(s).)

Background: Male urinary tract infections (mUTIs) are rare in primary care. The definition of mUTIs varies across countries. The therapeutic management of mUTIs in France is based on a 14-day course of fluoroquinolones despite a high risk of antimicrobial resistance., Objectives: The objective of this qualitative study was to explore general practitioners' (GPs) experiences and behaviours regarding the diagnostic and therapeutic management of mUTIs., Methods: GPs were recruited by convenience sampling in Haute Normandie (France) and interviewed individually with semi-structured guides. GPs' experiences and behaviours were recorded and analysed using an interpretive phenomenological approach., Results: From March 2021 to May 2022, 20 GPs were included in the study. Defining a mUTI was perceived as a diagnostic challenge. A diagnosis based on clinical evidence alone was insufficient and complementary tests were required. For GPs: 'male cystitis does not exist'. A mUTI was considered an unusual disease that could reveal an underlying condition. GPs considered fluoroquinolones to be 'potent' antibiotics and treated all patients with the same 14-day course. GPs implemented improvement strategies for antibiotic stewardship and followed the guidelines using a computerised decision support system., Conclusions: GPs' experiences of mUTIs are limited due to low exposure and variable clinical presentations in primary care, representing a diagnostic and therapeutic challenge. In order to modify GPs' antibiotic prescribing behaviours, a paradigm shift in the guidelines will need to be proposed.KEY MESSAGESDefining a male urinary tract infection represents a diagnostic challenge for GPs.A diagnosis based on clinical evidence alone is insufficient and complementary tests are required.A male urinary tract infection is an unusual disease in primary care and suggests a more serious underlying condition.

Background: Increases in opioid prescriptions have been described; however, recent trends and prescribing patterns of analgesics in Dutch general practice are largely unknown., Objective: To investigate recent changes in the number of analgesic prescriptions, and the indications for prescribing strong opioids. Furthermore, we aim to identify risk factors for chronic opioid use in Dutch general practice., Design and Setting: A retrospective cohort study from 1 July 2013 to 31 June 2022, using a primary care practice based research network., Subjects: Patients with ≥1 prescription for analgesics during the study period were included., Main Outcome Measure: Changes in the number of prescriptions for paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in Dutch general practice during the 9-year study period. Moreover, we analyzed indications for prescribing strong opioids by the general practitioner (GP)., Results: A total of 18,433 analgesic users were identified. Over time, prescriptions for paracetamol, NSAIDs and weak opioids decreased, while the number of strong opioid prescriptions increased. General practitioners prescribed more strong opioids for non-malignant pain, whereas prescriptions for malignant pain remained stable over time. Risk factors for chronic opioid use (≥90 days) included older age, lower educational level, smoking status and having a history of a musculoskeletal or psychological disorder, a malignancy or sexual, physical or psychological abuse., Conclusions: Considering the increase in strong opioid prescriptions for benign conditions, GPs need to be vigilant for patients who are at risk for chronic use. Regular monitoring and awareness for psychosocial factors in treatment of chronic pain may be key in preventing harms associated with persistent opioid use.

Background: Opioid use disorder (OUD) remains a significant public health issue as the number of opioid-related overdose deaths continues to reach new highs each year. Buprenorphine/Naloxone is a medication that has been shown to be highly effective for the treatment of OUD. However, the clinical management of patients on this medication is challenging as many patients discontinue treatment prematurely. We conducted a qualitative study focusing on experienced prescribers of buprenorphine to learn about what they believe are key challenges in prescribing this medication to patients with OUD and related strategies for improving treatment outcomes., Methods: We conducted two rounds of interviews with 12 prescribers who were either trained as a primary care physician, nurse practitioner, or physician assistant. These prescribers were recruited from an academically-based treatment program, a community health center, and a commercial substance use disorder treatment facility. Interview data were coded and analyzed in accordance with a grounded theory approach., Results: Key findings and related recommendations emerged for patient monitoring, integration of behavioral health with prescribing, patient volume requirements, and use of telehealth., Conclusion: The interviews generated a number of recommendations for improving patient outcomes from buprenorphine treatment. Some of these recommendations can be implemented quite readily whereas others entail more substantial resources and time commitments., Competing Interests: Declarations. Ethics approval and consent to participate: Approval was secured from a Northeastern University Institutional Review Board (IRB 19-05-06) and consent was obtained from all study participants. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests., (© 2024. The Author(s).)

Background: Social media has become a vital tool for health care providers to quickly share information. However, its lack of content curation and expertise poses risks of misinformation and premature dissemination of unvalidated data, potentially leading to widespread harmful effects due to the rapid and large-scale spread of incorrect information., Objective: We aim to determine whether social media had an undue association with the prescribing behavior of hydroxychloroquine, using the COVID-19 pandemic as the setting., Methods: In this retrospective study, we gathered the use of hydroxychloroquine in 48 hospitals in the United States between January and December 2020. Social media data from X/Twitter was collected using Brandwatch, a commercial aggregator with access to X/Twitter's data, and focused on mentions of "hydroxychloroquine" and "Plaquenil." Tweets were categorized by sentiment (positive, negative, or neutral) using Brandwatch's sentiment analysis tool, with results classified by date. Hydroxychloroquine prescription data from the National COVID Cohort Collaborative for 2020 was used. Granger causality and linear regression models were used to examine relationships between X/Twitter mentions and prescription trends, using optimum time lags determined via vector auto-regression., Results: A total of 581,748 patients with confirmed COVID-19 were identified. The median daily number of positive COVID-19 cases was 1318.5 (IQR 1005.75-1940.3). Before the first confirmed COVID-19 case, hydroxychloroquine was prescribed at a median rate of 559 (IQR 339.25-728.25) new prescriptions per day. A day-of-the-week effect was noted in both prescriptions and case counts. During the pandemic in 2020, hydroxychloroquine prescriptions increased significantly, with a median of 685.5 (IQR 459.75-897.25) per day, representing a 22.6% rise from baseline. The peak occurred on April 2, 2020, with 3411 prescriptions, a 397.6% increase. Hydroxychloroquine mentions on X/Twitter peaked at 254,770 per day on April 5, 2020, compared to a baseline of 9124 mentions per day before January 21, 2020. During this study's period, 3,823,595 total tweets were recorded, with 10.09% (n=386,115) positive, 37.87% (n=1,448,030) negative, and 52.03% (n=1,989,450) neutral sentiments. A 1-day lag was identified as the optimal time for causal association between tweets and hydroxychloroquine prescriptions. Univariate analysis showed significant associations across all sentiment types, with the largest impact from positive tweets. Multivariate analysis revealed only neutral and negative tweets significantly affected next-day prescription rates., Conclusions: During the first year of the COVID-19 pandemic, there was a significant association between X/Twitter mentions and the number of prescriptions of hydroxychloroquine. This study showed that X/Twitter has an association with the prescribing behavior of hydroxychloroquine. Clinicians need to be vigilant about their potential unconscious exposure to social media as a source of medical knowledge, and health systems and organizations need to be more diligent in identifying expertise, source, and quality of evidence when shared on social media platforms., (©Scott A Helgeson, Rohan M Mudgalkar, Keith A Jacobs, Augustine S Lee, Devang Sanghavi, Pablo Moreno Franco, Ian S Brooks, National COVID Cohort Collaborative (N3C). Originally published in JMIR Infodemiology (https://infodemiology.jmir.org), 18.11.2024.)

Background and Aims: Cardiac Implantable Electronic Device (CIED) infections pose significant mortality and morbidity despite optimal treatment. This survey aimed to understand whether and how the risk of CIED infection is assessed and mitigated in clinical practice in Europe, and to detect gaps with respect to EHRA recommendations., Methods: An Expert Group of 8 European cardiologists with specific expertise across CIED therapy designed and distributed electronically a survey to a number of European Cardiologists., Results: 302 physicians from 18 European countries responded to the survey. 288/302 (95%) physicians agreed that CIED-related infections represent a burden on healthcare resources and are associated with significant morbidity and mortality. 285/302 respondents (94%) primarily assess the risk of CIED infections by only evaluating the patient's clinical profile (137/302, 46%) or with the support of a risk score (148/302, 49%). Intravenous antibiotic prophylaxis is used by 282/302 (93%), followed by the implantation of the lowest number of leads possible (182/302, 60%), and by the use of an antibacterial envelope (173/302, 57%). 230/302 respondents (76%) declared that there is need for clear and concise guidelines and more sensitive risk-scores for CIED infection, to maximize the chances of preventative strategies., Conclusions: This survey demonstrates a high level of awareness about the multifaceted issue of CIED infection, however, it also highlights an incomplete penetration of scoring systems for risk stratification owing to their perceived limitations, and detects a strong commitment to increase the effectiveness of preventative strategies., Competing Interests: Declaration of competing interest Medtronic supported the survey project, however the views and opinions expressed are those of the authors and not Medtronic, therefore no relevant conflicts of interest are reported., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Hypertension is a major risk factor for heart disease, heart failure and stroke. Lifestyle changes are recommended as first-line treatment for management of high blood pressure for young adults, when 10-year atherosclerotic cardiovascular disease risk score is < 10%. If lifestyle changes alone do not control blood pressure, then providers have access to four classes of first-line blood pressure lowering agents to treat hypertension, when other contra-indications are not present., Methods: This is a cross-sectional, retrospective, secondary analysis performed of the MyHEART trial on study participants at enrollment to determine they were prescribed anti-hypertensive medication. Of those prescribed medications, we aimed to determine the frequency first-line medications including thiazide or thiazide-like diuretics, angiotensin converting-enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers were prescribed. This analysis categorized participants into four medication status categories: no antihypertensive medication, prescribed only first-line antihypertensives, prescribed only non-first-line antihypertensives, and prescribed a combination of first-line and non-first-line antihypertensives. Participant clinical and sociodemographic factors by medication use were evaluated. Linear regression models were fit to determine the association between antihypertensive medication and blood pressure., Results: At enrollment, 157/311 (50.5%) participants were not on antihypertensives. Of the 154 on antihypertensives, reported use included monotherapy 97/154 (63.0%), combined therapy 57/154 (37.0%), only first-line antihypertensive 111/154 (72.0%), and only non-first-line antihypertensives 21/154 (13.6%), and combination of first-line and non-first-line antihypertensives 22/154 (14.2%). Antihypertension medication use varied based on age (p < 0.001), sex (p = 0.008), race (p = 0.001), body mass index (BMI) kg/m 2 (p = 0.016), anxiety and/or depression (p = 0.048), diabetes (p = 0.007), and sodium intake (p = 0.042). Participants with only first-line medications had lower in-office systolic (-4.66 mmHg, CI -8.31 to -1.02, p = 0.013) and diastolic (-3.51 mmHg, CI -6.30 to -0.71, p = 0.015), and lower ambulatory diastolic (-2.12 mmHg, CI -4.15 to -0.09, p = 0.041) blood pressure than those without antihypertensives., Conclusions: Among MyHEART study participants, all of which had uncontrolled hypertension, 50.5% were not on an antihypertensive at enrollment. This finding supports the call to improve management of blood pressure earlier in life to potentially contribute to the reduction of long-term cardiovascular disease. Of the participants who were prescribed blood pressure medication, providers prescribed guideline-based antihypertensive therapy the majority of the time, however, this study indicates there may be an opportunity to increase the use of first-line, guideline-based antihypertensives, regardless of age, sex, or type of hypertension to lower long-term cardiovascular risk., Trial Registration: https://www., Clinicaltrials: gov Identifier: NCT03158051, registered 5-15-2017. IRB approval obtained: IRB # 2017 - 0372., Competing Interests: Declarations Ethics approval and consent to participate Participants gave their voluntary, informed consent to participate in the MyHEART Trial. They were reimbursed up to $150 for their participation. This study followed the Declaration of Helsinki principles and Good Clinical Practice Guidelines. This study was approved by the University of Wisconsin Institutional Review Board. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Aims: Women are less likely to receive lipid-lowering therapy (LLT) after acute myocardial infarction (AMI). We analysed whether this under-prescription currently persists and has an impact on long-term outcomes., Methods and Results: The FAST-MI programme consists of nationwide registries including all patients admitted for AMI ≤ 48 h from onset over a 1 month period in 2005, 2010, and 2015, with long-term follow-up. This analysis focused on high-intensity LLT (atorvastatin ≥ 40 mg or equivalent, or any combination of statin and ezetimibe) in women and men. Women accounted for 28% (N = 3547) of the 12 659 patients. At discharge, high-intensity LLT was significantly less prescribed in women [54 vs. 68% in men, P < 0.001, adjusted odds ratio (OR) 0.78(95% confidence interval (CI) 0.71-0.87)], a trend that did not improve over time: 2005, 25 vs. 35% (P = 0.14); 2010, 66 vs. 79% (P < 0.001); 2015, 67 vs. 79.5% (P = 0.001). In contrast, female sex was not associated with a lack of other recommended treatments at discharge: beta-blockers [adjusted OR 0.98(95% CI 0.88-1.10), P = 0.78], or renin-angiotensin blockers [adjusted OR 0.94(95% CI 0.85-1.03), P = 0.18]. High-intensity LLT at discharge was significantly associated with improved 5 year survival and infarct- and stroke-free survival in women [adjusted hazard ratios (HR) 0.74(95% CI 0.64-0.86), P < 0.001 and adjusted HR: 0.81(95% CI: 0.74-0.89); P < 0.001, respectively]. Similar results were found using a propensity score-matched analysis [HR for 5 year survival in women with high-intensity LLT: 0.82(95% CI 0.70-0.98), P = 0.03]., Conclusion: Women suffer from a bias regarding the prescription of high-intensity LLT after AMI, which did not attenuate between 2005 and 2015, with potential consequences on both survival and risk of cardiovascular events., Competing Interests: Conflict of interest: N.D. has received personal fees and non-financial support from Amgen, AstraZeneca, Bayer, BMS, Sanofi, personal fees from Boehringer Ingelheim, Intercept, MSD, Novo Nordisk, Pfizer, Servier, UCB Pharmaceuticals, and Vifor, all outside the submitted work. E.P. reports fees for lectures and/or consulting: Amgen, AstraZeneca, Bayer, Biotronik, BMS, Boehringer Ingelheim, Daiichi Sankyo, Lilly, MSD, The Medicine Company, Sanofi, Saint Jude Medical, Servier, Siemens. J.F. reports speaking fees for Amgen, Sanofi, Servier and MSD. F.S. reports personal fees from Amgen, AstraZeneca, Bayer, BMS, MSD, Pfizer, and Sanofi, outside the submitted work. T.S. reports grants from AstraZeneca, Daiichi Sankyo, Eli-Lilly, GSK, MSD, Novartis, Sanofi, and personal fees for board membership and/or consultancy and/or lectures from AstraZeneca, BMS, Sanofi, and Novartis. J.-L.G. reports personal fees for lectures and/or consulting: Amgen, MSD, Novartis, and Sanofi-Winthrop France., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Aims: To describe weight management and perceptions in China., Materials and Methods: Data were from the Adelphi Real World Obesity Disease Specific Programme™, a cross-sectional survey between April and July 2022 of physicians managing people with obesity or overweight (PwO) and PwO in real-world clinical practice in China. At data collection, eligible PwO were aged ≥18 years, under weight management and/or had a body mass index (BMI) ≥28 kg/m 2 ., Results: In total, 100 physicians and 801 PwO were enrolled. More than two thirds of PwO (70.7%; 531/751) were not diagnosed with obesity until a BMI ≥30 kg/m 2 . Most PwO (78%; 625/801) were on treatment for at least one obesity-related complication (ORC). Physicians commonly initiated weight loss discussions with PwO who already had an ORC (48.0%; 48/100). According to physicians and PwO, the mean target BMI was set at 25.8 kg/m 2 and 24.3 kg/m 2 , and the mean target percentage weight loss was 19.6% and 23.7%, respectively. Over a median 6.4 months of weight management, the mean percentage weight loss was 4.1%. Few PwO achieved the weight loss target set by their physician (9.9%; 69/695) or themselves (2.0%; 14/696). Most physicians and PwO were unsatisfied with the current weight loss (92.3% [739/801] and 82.0% [650/793], respectively)., Conclusions: These findings suggest that earlier intervention may be needed to address obesity as a disease. Most physicians and PwO recognized the importance of normal weight, but few PwO achieved weight loss targets, which may suggest an unmet need for improved weight management., Competing Interests: ZL, SS, HZ, JX, EA and SK are employees of Eli Lilly and Company and EA has minor stock ownership. AL and VH are employees of Adelphi Real World. 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. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Lin, Si, Liu, Zhu, Xu, Artime, Khare, Higgins, Leith and Qu.)

Objective: To assess utilization and perceptions of 2D synthesized mammography (SM) for digital breast tomosynthesis (DBT) among practicing U.S. breast radiologists., Methods: An IRB-exempt 23-question anonymized survey was developed by the Society of Breast Imaging (SBI) Patient Care and Delivery Committee and emailed to practicing U.S. radiologist SBI members on October 9, 2023. Questions assessed respondents' demographics, current mammographic screening protocol, confidence interpreting SM for mammographic findings, and perceived advantages and disadvantages of SM., Results: Response rate was 13.4% (371/2771). Of 371 respondents, 208 were currently screening with DBT/SM (56.1%), 98 with DBT/SM/digital mammography (DM) (26.4%), 61 with DBT/DM (16.4%), and 4 with DM (1.1%). Most respondents felt confident using DBT/SM to evaluate masses (254/319, 79.6%), asymmetries (247/319, 77.4%), and distortions (265/318, 83.3%); however, confidence was mixed for calcifications (agreement 130/320, 40.6%; disagreement 156/320, 48.8%; neutral 34/320, 10.6%). The most frequently cited disadvantage and advantage of SM were reconstruction algorithm false-positive results (199/347, 57.4%) and lower radiation dose (281/346, 81.2%), respectively. Higher confidence and fewer disadvantages were reported by radiologists who had more SM experience, screened with DBT/SM, or exclusively used Hologic vendor (all P <.05)., Conclusion: For most survey respondents (56.1%), SM has replaced DM in DBT screening. Radiologists currently screening with DBT/SM or with more SM experience reported greater confidence in SM with fewer perceived disadvantages., (© Society of Breast Imaging 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Purpose: This study aims to learn about the global adoption of neuromuscular electrical stimulation (NMES) in managing dysphagia, identify the barriers to its adoption, and describe the existing clinical practices., Method: A total of 171 professionals from various international backgrounds initiated a specially developed online survey, and 122 responses were included in the final analysis. The survey consisted of 44 items related to NMES usage, perceived adoption barriers of NMES in dysphagia management, and clinical practices. The data were subjected to descriptive and correlational statistical analysis., Results: NMES is adopted by 50% of the participants' workplaces when considering responses globally and 42.7% in the United States. Most respondents reported both high self-assessed knowledge level and high interest in learning about NMES. Among the 21 posed barriers to NMES adoption, 19 were agreed upon by over 50% of participants, with the most reported being insufficient academic coverage, lack of expert endorsement, and heterogeneity in stimulation parameters. There was considerable diversity in the clinical application of NMES, particularly regarding the duration, frequency, and total number of sessions typically completed when using NMES., Conclusions: NMES is adopted by half of the facilities and utilized by one third of dysphagia practitioners among the international respondents to this survey. The high interest expressed in NMES parallels the increasing volume of related research. Nonetheless, the widespread recognition of barriers and the substantial variability in clinical application underscore the need for international efforts to establish standardized protocols or guidelines, ensuring its effective and consistent use in clinical settings.

Background: A limited transthoracic echocardiogram (TTE) can be an appropriate, lower-cost substitute for a full TTE. We assessed the impact of an electronic health record alternative alert promoting the adoption of limited TTEs on the ordering practices of cardiology clinicians and primary care providers and captured their perspectives on the initiative., Methods: The alert was deployed in a cardiology clinic and 4 primary care clinics at an academic medical center. The alert provided clinical guidance on the appropriate use of limited TTEs when a clinician selected a full TTE order. We used logistic regression to estimate the change in the proportion of limited versus full TTEs ordered between the baseline and intervention periods in clinics with and without the alert. We also conducted interviews with 24 clinicians (5 cardiologists and 19 primary care providers) to identify implementation barriers and facilitators., Results: Cardiology clinicians ordered 10 654 and 3761 TTEs during the baseline and intervention periods, respectively, for 9100 patients. Primary care providers ordered 723 and 617 TTEs during the baseline and intervention periods for 1273 patients. The model estimated that the percentage of limited TTEs ordered increased by 16.1±2.3 percentage points ( P <0.0001) in the cardiology clinic with the alert and by 13.2±1.5 percentage points ( P <0.0001) in the primary care clinics with the alert from baseline to post-intervention. Ordering practices did not change in the cardiology (0.7±0.6 percentage points; P =0.24) or primary care (0.7±1.0 percentage points; P =0.52) clinics without the alert. Clinicians viewed the alert as acceptable. Cardiologists appreciated that the alert was concise, whereas primary care providers wanted more information from the alert., Conclusions: An alternative alert providing clinical guidance on the use of limited TTEs at the point of care increased the selection of this lower-cost test in cardiology and primary care clinics. Perspectives on the alert differed between specialists and nonspecialists, highlighting the importance of tailoring intervention design to clinical expertise., Competing Interests: Dr Levin reports consulting fees from AliveCor. Dr Vilendrer reports a method and apparatus patent for detecting electrocardiographic abnormalities, US10342445B2, granted 07/2019. Dr Winget reports grants from the Robert Wood Johnson Foundation and Stupski Foundation. The other authors report no conflicts.

Practice guidelines consistently encourage short-term use of benzodiazepines for the management of common medical conditions. However, these medications are often prescribed long-term for unclear or variable indications. These prescribing patterns may be attributed to perceived low risk and low rate of benzodiazepine use disorders (0.2% of US adults). Compared with other addictive substances, benzodiazepines may have less overall risk and fewer adverse outcomes. Benzodiazepines have limited accessibility compared with alcohol and tobacco. When used alone, benzodiazepines have less risk of lethal overdose than when they are coprescribed with opioids. Although benzodiazepine use for pain management is declining, this use often co-occurs with opioid analgesics, which is associated with greater risk of adverse events. Physician prescribing patterns have a tremendous impact on benzodiazepine use disorder and misuse. Primary care physicians play a vital role in preventing these conditions and in the management of benzodiazepine withdrawal. Effective management of benzodiazepine use disorder and misuse relies on targeted screening and intervention. Concomitant conditions associated with benzodiazepine misuse (eg, chronic pain, anxiety, insomnia) should be adequately addressed in treatment planning. Due to questionable effectiveness of alternative medications in managing benzodiazepine withdrawal, intervention should entail a gradual dose reduction that is facilitated by patient-centered tapering schedules., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Background: A polypill containing all 4 classes of guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF) has been proposed to change the heart failure treatment paradigm. The acceptability, appropriateness, and feasibility of a HFrEF polypill-based strategy are unknown. The purpose of this study was to elicit patients' and providers' priorities in the design of HFrEF polypills., Methods: From April 2023 to December 2023, we conducted a convergent parallel mixed-methods study at Washington University in St. Louis, the University of California, San Francisco, and the American College of Cardiology. We administered physician surveys containing adapted implementation outcome measures to elicit physicians' perspectives on the acceptability, feasibility, and appropriateness of a HFrEF polypill (Likert scale ranging from 1 [low] to 5 [high]). We used a purposive sampling frame to select patients and physicians for in-depth interviews. Using semi-structured interview guides, we elicited participants' perspectives on current HFrEF care, HFrEF polypill design, and supportive strategies. The Consolidated Framework for Implementation Research v2.0 guided thematic analysis., Results: Of the 214 survey respondents across the United States, physicians agreed that HFrEF polypills are highly acceptable (mean [SD], 4.2 [0.7]), highly appropriate (4.1 [0.8]), and highly feasible (4.1 [0.7]). Key themes from 9 patient and 22 provider interviews included the following: (1) current determinants of HFrEF care, including medication adherence, variations in clinical practice, and health care access, (2) provider-level differences in preferred HFrEF polypill design, (3) cost and equity considerations in the implementation of HFrEF polypills, and (4) research priorities for evaluating polypill effectiveness and implementation., Conclusions: A HFrEF polypill-based strategy was viewed as highly acceptable, appropriate, and feasible by patients and physicians. Participants described key priorities in HFrEF polypill design, titratability, and potential impacts on health equity that will directly inform future randomized controlled trials., Competing Interests: Dr Huffman has received travel support from the World Heart Federation. Dr Huffman has an appointment at The George Institute for Global Health, which holds a patent and license, has received investment funding with the intent to commercialize fixed-dose combination therapy through its social enterprise business, George Medicines. Drs Huffman and Agarwal plan to submit patents for heart failure with reduced ejection fraction polypills. Dr DeJong’s spouse is employed by and holds stock in iRhythm Technologies. The other authors report no conflicts.

Functional neurological disorder (FND) is common among children and adolescents, results in significant impairments in quality of life, and places a substantial burden on healthcare systems. Despite this, there is minimal literature to guide prescribing for this population. The purpose of this article is to provide common sense prescribing recommendations for providers who treat pediatric FND. A narrative review was conducted by searching PubMed using keywords related to FND and pharmacology. The narrative synthesis was guided by the objective of providing evidence for generally accepted practices and highlighting contributions and gaps in the literature. There is a dearth of evidence, and unique challenges exist in prescribing for pediatric patients with FND. Efforts should be made to limit prescribing and to discontinue, or de-prescribe, medications that may contribute to polypharmacy or overmedicalization of functional symptoms. Pediatric patients with FND require a thoughtful, multidisciplinary approach.

Background: Acute chest syndrome (ACS) is the leading cause of mortality, accounting for 25% of all deaths among individuals with sickle cell disease (SCD). There is a lack of evidence-based laboratory and clinical risk stratification guidelines for the diagnosis and management of ACS., Study Design and Methods: To better understand physician practices for the management of ACS in the United States, we created an ACS Working Group including hematology and transfusion medicine physicians from four different SCD treatment centers in the United States. The working group created a physician survey that included physician demographics and ACS diagnostic criteria that they had to rate. The survey also included three case scenarios to assess physician attitudes about the management of ACS. Management options included supportive and preventive strategies in addition to transfusion therapy options., Results: Out of 455 physicians who received the survey, 195 responded (response rate = 43%). The respondents were primarily hematology/oncology physicians. The responses showed wide variability among physicians in how diagnostic criteria for ACS are used and how physicians risk-stratify ACS patients in their practice. The responses also reflected variability in the use of transfusions for ACS., Discussion: Based on our results, we conclude that ACS is diagnosed and managed inconsistently among expert physicians, especially in their transfusion practices due to a lack of consensus on risk stratification criteria. Our data suggest an urgent need for well-designed prospective studies to provide evidence-based guidelines and minimize management variability among physicians who care for individuals with SCD and ACS., (© 2024 The Author(s). Transfusion published by Wiley Periodicals LLC on behalf of AABB.)

Objective: This study aims to assess current diagnostic and management for systemic Juvenile Idiopathic Arthritis (sJIA) among physicians, evaluate the challenges encountered in diagnosis and treatment, and identify the educational needs and professional development engagements of physicians managing sJIA., Methods: A nationwide survey was conducted from November 2023 to March 2024 across tertiary and secondary pediatric and general hospitals in China. The survey targeted physicians with at least three years of specialty experience, resulting in 310 valid responses from 25 provinces, autonomous regions, and municipalities. The survey collected data on diagnostic practices, treatment approaches, and professional development related to sJIA. Data collection was facilitated through WeChat, and statistical analysis was performed using descriptive statistics. Ethical approval was obtained from the Ethics Committee of Beijing Children's Hospital, with informed consent provided electronically by participants., Results: The survey indicated that all physicians encountered suspected or confirmed cases of sJIA, highlighting its prevalence and the diagnostic challenges associated. Regarding diagnostic standards, 53.9% of physicians used the "Consensus on the Diagnosis and Treatment of sJIA and Macrophage Activation Syndrome," 18.1% followed the International League of Associations for Rheumatology (ILAR) standards, and 24.8% adhered to the Pediatric Rheumatology International Trials Organization (PRINTO) standards. In treatment strategies, glucocorticoids and IL-6 receptor monoclonal antibodies were extensively used, with the latter receiving "excellent" and "satisfactory" ratings of 46.5% and 36.1%, respectively, demonstrating high efficacy and acceptance. Main challenges included high treatment costs, complexity of diagnosis, patient compliance issues, and potential long-term side effects of biologics. Additionally, 126 doctors (40.7%) actively participated in more than three academic conferences or systematic learning courses related to sJIA, indicating a strong demand for ongoing education, particularly in new treatment developments and diagnostic skills., Conclusion: The findings emphasize the necessity for standardized diagnosis and customized treatment plans tailored to patient-specific conditions in managing sJIA. Key Points • The survey highlights the prevalence and clinical challenges of sJIA among physicians, emphasizing the importance of vigilant diagnosis, multi-system involvement, and differential diagnosis to improve treatment outcomes and patient quality of life., (© 2024. The Author(s).)

Introduction: Supraventricular tachycardia (SVT) is a common pediatric arrhythmia. Beta blockers (BBs) and calcium channel blockers (CCBs) are used for treatment despite little data examining their use. We describe the prescriptive tendencies, efficacy, and tolerability of BBs and CCBs used in the treatment of pediatric SVT., Methods and Results: This is a multicenter retrospective cohort study from three academic children's hospitals. Individuals aged 1-21 years at time of SVT diagnosis initiated on a BB or a CCB between 01/01/2010 and 12/31/2020 were included. Exclusion criteria were pre-excitation, ectopic atrial tachycardia, and hemodynamically significant heart disease. Demographic, comorbidity, symptomatology, and medication data were collected. Treatment success was defined using a composite data abstraction tool. Of 164 patients, 151 received a BB and 13 received a CCB. The success rate on the initial dosage was 46% for both BB and CCB; the success rate following dosage adjustments was also comparable for BBs (98/151, 65%) and CCBs (9/13, 69%). While 27 (18%) BB patients experienced intolerable side effects, no CCB patient did., Conclusion: Treatment with a BB or CCB was successful in half of patients. BBs were prescribed more frequently than CCBs but were associated with more side effects., (© 2024 Wiley Periodicals LLC.)

Introduction: A nationwide pay-for-performance (P4P) scheme was introduced in the Netherlands between 2018 and 2023 to incentivize appropriate prescribing in general practice. Appropriate prescribing was operationalised as adherence to prescription formularies and measured based on electronic health records (EHR) data. We evaluated this P4P scheme from a learning health systems perspective., Methods: We conducted semi-structured interviews with 15 participants representing stakeholders of the scheme: general practitioners (GPs), health insurers, pharmacists, EHR suppliers and formulary committees. We used a thematic approach for data analysis., Results: Using EHR data showed several benefits, but lack of uniformity of EHR systems hindered consistent measurements. Specific indicators were favoured over general indicators as they allow GPs to have more control over their performance. Most participants emphasized the need for GPs to jointly reflect on their performance. Communication to GPs appeared to be challenging. Partly because of these challenges, impact of the scheme on prescribing behaviour was perceived as limited. However, several unexpected positive effects of the scheme were mentioned, such as better EHR recording habits., Conclusions: This study identified benefits and challenges useful for future P4P schemes in promoting appropriate care with EHR data. Enhancing uniformity in EHR systems is crucial for more consistent quality measurements. Future P4P schemes should focus on high-quality feedback, peer-to-peer learning and establish a single point of communication for healthcare providers., Competing Interests: Declaration of competing interest None of the authors had a conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

Introduction: The use of expensive oral targeted agents for advanced prostate cancer can be influenced by those who stand to gain from their use. The 340B drug pricing program allows eligible hospitals to purchase medications at steep discounts, generating millions of dollars in savings. The extent to which hospitals engage in higher-risk prescribing due to program incentives is unclear., Methods: Medicare claims were used to perform a retrospective study of men with advanced prostate cancer. The primary outcome was targeted therapy use in men with high noncancer mortality risk. Secondary outcomes included androgen biosynthesis inhibitor use in men with cardiovascular history, androgen receptor inhibitor use in men with neurocognitive history, and therapy within 14 days of death. Proportional hazards models were used to assess time-to-event outcomes, while logistic regression was used for binary outcomes., Results: In men with high noncancer mortality risk, targeted therapy use did not differ at 340B participating compared to nonparticipating hospitals (hazard ratio [HR] 1.1, 95% CI 0.67-1.5). There was no difference in androgen biosynthesis inhibitor use in men with a prior cardiac event (HR 0.96, 95% CI 0.70-1.3) or androgen receptor inhibitor use in men with a prior neurocognitive event (HR 1.5, 95% CI 0.65-3.4) in those treated at 340B participating compared to nonparticipating hospitals. Therapy use in the last 14 days of life did not vary by 340B participation (odds ratio 1.3, 95% CI 0.86-1.9)., Conclusions: In men with advanced prostate cancer, high-risk prescribing and futility measures did not vary by participation in the 340B drug pricing program.

Introduction: In the dynamic landscape of metastatic NSCLC (mNSCLC) management, marked by several frontline options and the integration of next generation sequencing (NGS) for informed decision-making, barriers persist despite advancements. This includes challenges in clinical trial recruitment. To gain global insights into clinicians' practices, we conducted a survey on their testing and management approaches for patients with mNSCLC., Methods: The survey, conducted from July 12 to August 20, 2023, utilized multiple-choice questions and qualitative research questions, employing the Likert Scale for comprehensive insights., Results: A total of 127 individuals responded, with 72% affiliated with academic health systems, and 55% practicing in the USA. Regarding testing practices, 93% consistently ordered NGS for non-squamous histology, while 54% did so for squamous cell histology. Concurrent tissue and liquid biopsies were routinely ordered by 28%, while 39% reported ordering both testing platforms concurrently for select cases only. Respondents cited logistical barriers, such as insufficient tissue and lack of infrastructure, as the most common hindrance to molecular testing (76%), followed by reimbursement challenges (56%) and concerns about delayed turnaround time (50%). While most respondents were confident in interpreting NGS results, 22% lacked confidence. Concerning treatment decisions, 72% preferred awaiting molecular testing results before initiating systemic therapy. Less than 50% routinely referred patients for clinical trials in the frontline setting for mNSCLC. For patients with disease expressing high PD-L1 levels, most oncologists preferred pembrolizumab monotherapy. For disease with low PD-L1 expression, a platinum doublet chemotherapy regimen combined with pembrolizumab was favored. In disease cases with negative PD-L1 expression, a platinum doublet chemotherapy regimen with pembrolizumab was preferred. Key factors influencing oncologists' preferred immune checkpoint inhibitor (ICI) included experience with one ICI over another, preferred status per national guidelines, availability of trial data with a significant follow-up period, and consideration of drug cost., Conclusion: Although this study demonstrates an improved awareness and adoption of ordering NGS for the management of mNSCLC, it underscores the persistence of various barriers that must be addressed to improve upon the quality of care for patients diagnosed with mNSCLC., Competing Interests: Disclosure AS: None. HJW: Howard Jack West reports a relationship with Summit Therapeutics plc that includes: employment. Howard Jack West reports a relationship with AbbVie Inc that includes: consulting or advisory. Howard Jack West reports a relationship with Amgen Inc that includes: consulting or advisory. Howard Jack West reports a relationship with Genetech Biotech Co Ltd that includes: consulting or advisory. Howard Jack West reports a relationship with Gilead Sciences Inc that includes: consulting or advisory. Howard Jack West reports a relationship with Merck & Co Inc that includes: consulting or advisory. Howard Jack West reports a relationship with Mirati Therapeutics Inc that includes: consulting or advisory. Howard Jack West reports a relationship with Regeneron Pharmaceuticals Inc that includes: consulting or advisory. Howard Jack West reports a relationship with AstraZeneca Pharmaceuticals LP that includes: speaking and lecture fees. Howard Jack West reports a relationship with Merck & Co Inc that includes: speaking and lecture fees. EKS: Eric K. Singhi reports a relationship with AstraZeneca Pharmaceuticals LP that includes: consulting or advisory. Eric K. Singhi reports a relationship with Novocure that includes: consulting or advisory. Eric K. Singhi reports a relationship with Amgen Inc that includes: consulting or advisory. Eric K. Singhi reports a relationship with Janssen Pharmaceuticals Inc that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Botulinum toxin application into the abdominal wall prior to major hernia repair can reduce the complexity of surgery and has been increasingly used in recent years, even if it is an off-label use., Objective: To what extent is botulinum toxin used in hernia surgery in German-speaking countries and what is the current evidence in the literature?, Material and Methods: In a voluntary online survey of German Society for General and Visceral Surgery (DGAV)-certified competence centers and reference centers for hernia surgery, aspects of botulinum toxin application were surveyed and the results analyzed., Results: A total of 57 centers took part in the survey, of which 27 (47%) use botulinum toxin. The main reasons for not using it were lack of experience and reimbursement. Of the centers 85% have treated less than 50 patients with botulinum toxin. The main indications were midline hernias (M2-4 according to the EHS classification) with a hernia gap > 10 cm (W3 according to EHS classification) and loss of domain situations. The application was predominantly ultrasound-guided by designated hernia surgeons with 100-200 Allergan or 500 Speywood units 4-6 weeks preoperatively and without complications related to the botulinum toxin application., Conclusion: Botulinum toxin injections in hernia surgery appear to be safe and effective. Ultrasound-guided preoperative bilateral administration is supported by the available data. Specific course and information formats should be offered by the hernia surgery institutions., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: To explore return-to-work (RTW) policies and practices for total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients in three European countries., Materials and Methods: An exploratory study in Denmark, Germany, and the Netherlands consisting of three aspects: (1) description of the healthcare and social security systems; (2) identification of national RTW guidelines; (3) a survey to gain insight into RTW practices and perceptions of orthopaedic surgeons, including barriers, facilitators, and needs., Results: Healthcare and social security systems differed (e.g. fast-track vs longer postoperative stay; coverage of rehabilitation costs). National guidelines were available in Germany (THA, TKA) and the Netherlands (TKA), containing limited RTW information. The survey was completed by 168 orthopaedic surgeons (Denmark n  = 51; Germany n  = 39; the Netherlands n  = 78). Overall, orthopaedic surgeons reported being in need of more knowledge and better collaboration with other healthcare practitioners., Conclusion: We found considerable variation in healthcare and social security systems. When available, national guidelines contained limited information. In all three countries surgeons need more knowledge and better collaboration with other healthcare practitioners. We advise that RTW multidisciplinary recommendations post THA/TKA be established by the national associations of the healthcare practitioners involved.

Key Points: Data on current practice patterns for the management of chronic rhinosinusitis with nasal polyps, including which medications are deemed by otolaryngologists to better manage patient symptoms, are limited. This study demonstrated that contemporary practice patterns are largely consistent with published clinical consensus statements. Off-label nasal steroid irrigations and dupilumab are the most commonly used topical and systemic therapies for chronic rhinosinusitis with nasal polyps, respectively., (© 2024 ARS‐AAOA, LLC.)

Background: In order to identify opportunities to streamline hepatopancreaticobiliary (HPB) multidisciplinary teams (MDT) for cancer care, it is important to first document variability in MDT team practices worldwide. We aimed to develop a comprehensive checklist of parameters to evaluate existing practices and guide the development of MDTs for new cancer services., Methods: Participants were recruited via the International Hepato-Pancreato-Biliary Association (IHPBA) and European-African HPB Association (E-AHPBA) and emailed an anonymised online survey. The survey comprised 29 questions, including a combination of closed-ended and open-ended questions. Responses were analysed using descriptive statistics and inductive content analysis., Results: Analysing 72 responses from 31 countries, we found substantial variations in HPB MDT practices across regions. Notable variability was found in core team composition, chairing practices, caseload planning, information practices and MDT audit practices. Issues impacting efficiency were common to many MDTs., Discussion: MDT care is understood and applied differently across the world. There is a lack of standardisation of practice, and an apparent need for better case preparation, effective specialist contribution, improved audit frequency and metrics to improve performance. It may be valuable to consider human factors while designing MDTs to support team decision processes, minimise errors, and enhance efficiency., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council's complex interventions framework., Methods: A phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout., Results: From numerous modifiable prescribing behaviours identified, active 'antibiotic time-out' was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers' capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit., Conclusion: This novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit's feasibility and effectiveness.

Introduction: Thiamine is the only therapy for prevention and treatment of Wernicke Encephalopathy among patients with Alcohol Use Disorder (AUD). Despite this fact, up to 75 % of inpatients with AUD are not prescribed thiamine during hospitalization. Even fewer patients are prescribed high-dose thiamine which many experts recommend should be standard of care. Previous attempts to improve thiamine prescribing for inpatients have had limited success., Methods: We conducted an evaluation of thiamine prescribing in the year before and year after an intervention to increase high-dose thiamine prescribing. Pre-post study analysis occurred on two distinct study cohorts: those with alcohol-related diagnoses and those with elevated alcohol levels. The intervention was new electronic health record-based decision support which encouraged high-dose thiamine when any thiamine order was sought. No educational support was provided. The primary outcome was prescription of high-dose thiamine before versus after intervention. Of those with alcohol-related diagnoses, the monthly percentage of thiamine treatment courses including high-dose thiamine were graphed on a control chart., Results: We examined 5307 admissions with alcohol-related diagnoses (2285 pre- and 3022 post-intervention) and 698 admissions with elevated alcohol levels (319 pre- and 379 post-intervention). Among admissions with alcohol-related diagnoses, the intervention was associated with a higher proportion of admissions receiving high-dose thiamine prescriptions in the first 24 h (4.7 % vs. 1.1 %, adjusted odds ratio 4.50, CI 2.93 to 6.89, p < 0.001). A similar difference in high-dose thiamine was seen post-intervention among admissions with elevated alcohol levels (14.3 % vs. 2.5 %, adjusted odds ratio 6.43, CI 3.05 to 13.53, p < 0.001). The control chart among those with an alcohol-related diagnosis demonstrated special cause variation: the median percentage of thiamine treatment courses including high-dose thiamine improved from 8.2 % to 13.0 %., Conclusions: Electronic decision support without educational interventions increased the use of high-dose thiamine among patients with alcohol-related diagnoses and with elevated alcohol levels during hospitalization. This increase occurred immediately in the month after the intervention and was sustained in the year-long study period after., Competing Interests: Declaration of competing interest The authors of the present manuscript have no conflicts of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: People with HIV (PWH) in suppressive antiretroviral treatment suffer from chronic inflammation-related comorbidities, mainly cardiovascular diseases. However, given the lack of specific evidence about inflammation in PWH, clinical guidelines do not provide recommendations for the management of this issue. To date, physician awareness of inflammation in PWH remains unclear. We analyzed the knowledge, attitudes, and practices (KAP) related to inflammation, particularly in the clinical management of PWH, of infectious disease specialists (IDS)/internists compared to other specialists treating inflammation directly (rheumatologists) or its cardiovascular consequences (cardiologists)., Methods: A committee of IDS/internists treating PWH, cardiologists, and rheumatologists designed the KAP questionnaire. The survey was completed by 405 participants (135 physicians per specialty) stratified by Spanish geography, hospital size, and number of PWH under care (IDS/internists only)., Results: IDS/internists treating PWH scored higher than cardiologists and rheumatologists on knowledge of inflammation (5.5±1.4 out of 8 points vs. 5.2±1.3 and 4.6±1.4 points, respectively; p<0.05). Nevertheless, rheumatologists showed the most proactive attitude toward inflammation (i.e., biomarkers monitoring, anti-inflammatory drug prescription and cardiologist referral), followed by cardiologists and IDS/internists (13±3 of a total of 16 points vs. 11±3 and 10±3.3 points, respectively; p<0.05), irrespective of hospital size and years of experience. Most IDS/internists (59%) include inflammation in their therapeutic recommendations. However, in IDS/internists treating PWH, we observed a negative correlation between years of experience and concern about the clinical consequences of inflammation., Conclusion: Our findings show that, compared to other specialists, infectious disease specialists/internists have high knowledge about inflammation in HIV infection, but, in the absence of scientific evidence to base their decisions on inflammatory markers, the therapeutic implications are scarce. The results support the need for more evidence on the monitoring and treatment of inflammation in PWH., (Copyright © 2023 Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: The aim of this study was to assess the utilization of surgical interventions in patients diagnosed with superficial vein thrombosis (SVT) and its potential association with the occurrence of venous thromboembolism (VTE) and bleeding events., Methods: INSIGHTS-SVT, a prospective, non-interventional, multicenter study in Germany, investigated the management and outcomes of patients with acute SVT who received conservative and/or invasive treatments at the discretion of the treating physician., Results: Among the 872 patients with 12-month data, 657 had medical therapy only, and 215 patients underwent vascular surgery (70 within 3 months of SVT diagnosis, 136 between months 4 and 12, and nine had an intervention in both periods). The most commonly performed procedures included endovenous thermal ablation, ligation of the saphenofemoral or saphenopopliteal junction, and vein stripping. The primary outcome of symptomatic VTE was observed in 5.8% of conservatively treated patients and 6.3% of those who underwent surgical intervention. Additionally, the secondary outcome of recurrent or extended SVT was documented in 4.7% of conservatively treated patients and 5.3% of invasively treated patients. Bleeding events occurred in 1.4% of conservatively treated patients and 2.1% of surgically treated patients. These differences were statistically not significant. Furthermore, our analysis indicated a potential protective effect associated with surgical treatments, such as ligation of the saphenofemoral or saphenopopliteal junction, stripping and endovenous thermal ablation, concerning the endpoint of VTE for patients when applied after 3 months from the index SVT event., Conclusions: In line with previous research, our study suggests that surgical interventions are not frequently employed in the management of SVT, although they may be warranted in select cases. Nevertheless, additional research is essential to gain a deeper understanding of the indications, criteria, and benefit of surgical interventions in the treatment of SVT., Competing Interests: Disclosures E.R. has received honoraria for lectures and advisory boards from Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Leo Pharma, and Pfizer. R.B. has received research support from AFNET, CPC, and FADOI; and honoraria from Bayer, BMS, Leo, Pfizer, and Viatris. H.G. has received honoraria for lectures and advisory boards from Aspen, Mylan, Bayer, and Boehringer-Ingelheim. D.P. has received honoraria for consultancy, advisory boards, or lectures by Actelion, Bayer, Biogen, Aspen, Amgen, MSD, Boehringer Ingelheim, Novartis, Daiichi Sankyo, Genzyme, and Zambon. F.L. has received honoraria for lectures or consultancy from Aspen, Bayer, Bristol-Myers Squibb, Daiichi Sankyo, LEO Pharma, Pfizer, Sanofi, and Viatris. U.H. has received research support and honoraria for lectures and advisory boards from Bayer HealthCare Pharmaceuticals, Bristol-Myers-Squibb, Pfizer, Boehringer Ingelheim, Daiichi Sankyo, Leo Pharma, and Aspen. T.N. has received honoraria for consultancy from Medi Bayreuth; and honoraria for presentations from Aspen, Bayer, Bristol-Myers Squibb, and Mylan. A.H. was, at the time of the study, a full-time employee of Aspen Pharma GmbH, Munich, and is now an employee of Amgen GmbH, Germany. A.S. is a full-time employee of Mylan Germany GmbH, Germany., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Between 2003 and 2018, incident prescriptions of beta-blockers for anxiety increased substantially, particularly for young adults. National Institute for Health and Care Excellence guidance for anxiety does not recommend beta-blockers, probably due to a lack of evidence to support such use. Recent reports have highlighted the potential risks of beta-blockers., Aim: To understand when and why GPs prescribe beta-blockers for people with anxiety., Design and Setting: In-depth interviews with 17 GPs in Bristol and the surrounding areas., Method: Interviews were held by telephone or video call. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and analysed thematically., Results: Many GPs viewed beta-blockers as 'low risk', particularly for young adults. Some GPs viewed beta-blockers as an alternative to benzodiazepines, acting quickly and not leading to dependence. GPs reflected that some patients appeared to want an 'immediate fix' to their symptoms, which GPs thought beta-blockers could potentially offer. This is salient in light of substantial waiting lists for talking therapies and delays in antidepressants taking effect. GPs described how some patients seemed more willing to try beta-blockers than antidepressants, as patients did not perceive them as 'mental health drugs' and therefore viewed them as potentially more acceptable and less stigmatising. Further, GPs viewed beta-blockers as 'patient-led', with patients managing their own dose and frequency, without GP input., Conclusion: Many GPs believe that beta-blockers have a role to play in the management of anxiety. Given recent increases in the prescribing of these drugs in primary care, there is a need to assess their safety and effectiveness as a treatment for people with anxiety disorders., (© The Authors.)

Background: Incident benzodiazepine prescriptions in primary care for anxiety decreased between 2003 and 2018. However, from 2008, incident prescribing of benzodiazepines for anxiety increased among those aged 18-34 years. There are increasing concerns around prescribing of benzodiazepines. Further, although guidelines state benzodiazepines should only be prescribed short term, in 2017, 44% of incident prescriptions were prescribed for longer than the recommended duration of 2-4 weeks., Aim: To understand when and why GPs prescribe benzodiazepines for anxiety in young adults., Design and Setting: A qualitative study was undertaken using in-depth interviews with 17 GPs from 10 general practices in South West England., Method: Interviews were conducted by telephone or videocall. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and data analysed using reflexive thematic analysis., Results: GPs described caution in prescribing benzodiazepines for anxiety in young adults, but thought they had an important role in acute situations. GPs described caution in prescribing duration, but some thought longer-term prescriptions could be appropriate. In light of these views, some GPs questioned whether primary care needs to revisit how clinicians are using benzodiazepines. GPs perceived that some young adults requested benzodiazepines and suggested this might be because they wanted quick symptom relief. GPs noted that refusing to prescribe felt uncomfortable and that the number of young adults presenting to general practice, already dependent on benzodiazepines, had increased., Conclusion: Patient-driven factors for prescribing benzodiazepines suggest there are current unmet treatment needs among young adults with anxiety. Given increases in prescribing in this age group, it may be timely to revisit the role of benzodiazepines in the management of people with anxiety in primary care., (© The Authors.)

Background: At least 10% of Covid-19 recovered individuals experience persistent symptoms (Long Covid). Primary healthcare and general practitioners (GPs) are at the forefront in their care. In this study, GPs' knowledge, perceptions and experiences with Long Covid, and the definition used in two countries, are investigated to provide insight into GPs' care for Long Covid patients at a cross-country level., Methods: A cross-sectional study targeted towards GPs was conducted in Belgium and Malta during spring and early summer 2022. An online survey consisting of 15 questions on Long Covid was disseminated. Additionally, country-specific practice and demographic characteristics were collected. Descriptive and logistic regression analyses were performed., Results: A total of 150 GPs (Belgium = 105; Malta = 45) responded. Female GPs represented 58.0%, median age was 49 years (IQR: 37-61). Concerning GPs' knowledge and perception on Long Covid, in both countries, most GPs reported insufficient scientific knowledge and information on Long Covid diagnosis and treatment. Access to educational material was limited and an awareness-rising campaign on Long Covid was deemed necessary. Moreover, two out of three GPs stated that Long Covid patients were not well followed up by primary healthcare in mid-2022. For diagnosing Long Covid, 54.7% required a positive Covid-19 test, more often among Belgian GPs than Maltese (64.3% vs. 45.2%, p = 0.036). To assess Long Covid, GPs mainly applied diagnostic criteria by themselves (47.3%) in combination with persistent symptoms (4 weeks to 5 months). Most GPs had experience with Long Covid patients in their practice, regardless of practice type and GPs' country, sex or age (p = 0.353; p = 0.241; p = 0.194; p = 0.058). Although most GPs (94.7%) stated that Long Covid patients should follow multidisciplinary approach, 48.3% reported providing care for these patients themselves or with GP colleagues and only 29.8% by multidisciplinary cooperation., Conclusions: GPs frequently provide (multidisciplinary) care to Long Covid patients and GPs' care showed similarities at cross-country level. Although GPs perceive lack of scientific knowledge and educational material on Long Covid, similar diagnostic criteria among GPs were noted. Uniform evidence-based guidelines, scientific support and training for GP across Europe must be a priority to enhance their treatment approach to Long Covid., (© 2024. The Author(s).)