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The professional capacity and infrastructure of general practitioners in grass-roots medical and health institutions in China are relatively weak, and the energy of specialists in general hospitals is limited and resources are abundant. Strengthening the cooperation between general practitioners and specialists can effectively improve the quality of community medical care and promote the health of patients. This paper systematically sorts out the typical practices and experiences of the construction of outpatient clinics of integration of general practice and specialty, and takes the source, connotation, construction path and construction path of the concept of full-specialty combination of outpatient clinics development effectiveness, existing problems and strategic recommendations are elaborated. Point out the challenges that may be faced in the construction of outpatient clinics of integration of general practice and specialty management model. In addition, this paper summarizes the possible challenges of the construction of integrated outpatient clinics, and puts forward five suggestions for the different practice methods of integrated outpatient clinics in different regions: improve the rules and regulations for the construction of outpatient clinics of integration of general practice and specialty, coordinate and unify the outpatient path of outpatient clinics of integration of general practice and specialty, pay attention to the protection of outpatient clinics of integration of general practice and specialty teams, clarify the population of outpatient clinics of integration of general practice and specialty services, and improve the health evaluation system for the outcomes of outpatient clinics of integration of general practice and specialty. In order to provide reference for the country to carry out the construction of outpatient clinics of integration of general practice and specialty in depth. Further expanding the community service function and deepening the cooperation with specialist physicians is an important direction for the future exploration of the construction of outpatient clinics of integration of general practice and specialized health care service. The joint participation and promotion of the government, medical institutions and general and specialist physicians can better promote the construction and development of community general and specialized outpatient clinics.

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]

Introduction: Antimicrobial resistance is a major global health threat, driven largely by the misuse and overuse of antibiotics. Point-of-care (POC) tests for inflammatory biomarkers like procalcitonin (PCT) have shown promise in reducing unnecessary antibiotic prescriptions. The hybrid type II ImpPro trial aims to evaluate the implementation and effectiveness of POC-PCT on antibiotic prescriptions by primary care physicians (PCP) in French-speaking Switzerland. Implementation is planned to include a multifaceted strategy delivered mainly, but not exclusively, via PCP quality circles. Currently, little guidance exists on how to best tailor the implementation strategies to a specific context. This study protocol describes the comprehensive approach taken within ImpPro to develop a multifaceted and multilevel strategy for POC-PCT implementation., Methods and Analysis: Our mixed-methods participatory implementation research study consists of four phases: (1) determinant identification; (2) determinant prioritisation; (3) implementation strategy ideation and (4) implementation strategy selection and refinement. All phases of the study will be guided by well-established implementation theories, models and frameworks. For 1, to identify the possible barriers and facilitators for implementation, we will conduct semistructured interviews with stakeholders followed by deductive coding using the updated Consolidated Framework for Implementation Research and inductive thematic analysis. In 2, to identify the key determinants, we will conduct online focus group discussions and vote on the importance and changeability of determinants. In 3, we will conduct interviews and an expert brainstorming session, followed by deductively coding implementation ideas according to the Expert Recommendations for Implementing Change compilation. In 4, we will conduct focus group discussions with experts and stakeholders about the APEASE criteria (ie, affordability, practicability, (cost-)effectiveness, acceptability, side effects and safety and equity) of these strategies, followed by a rapid data analysis approach to select the implementation strategies., Ethics and Dissemination: This study does not fall within the scope of the Human Research Act, and the necessity for a formal evaluation was waived from the Cantonal Ethics Committee (Req-2023-00392). The results of our study will be shared among the Antimicrobial Stewardship in Ambulatory Care Platform network, published in peer-reviewed scientific journals, and will be presented at international and national conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Introduction: While identifying opioid prescriptions in claims data has been instrumental in informing best practises, studies have not evaluated whether certain methods of identifying opioid prescriptions yield better results. We compared three common approaches to identify opioid prescriptions in large, nationally representative databases., Methods: We performed a retrospective cohort study, analyzing MarketScan, Optum, and Medicare claims to compare three methods of opioid classification: claims database-specific classifications, National Drug Codes (NDC) from the Centers for Disease Control and Prevention (CDC), or NDC from Overdose Prevention Engagement Network (OPEN). The primary outcome was discrimination by area under the curve (AUC), with secondary outcomes including the number of opioid prescriptions identified by experts but not identified by each method., Results: All methods had high discrimination (AUC>0.99). For MarketScan (n=70,162,157), prescriptions that were not identified totalled 42,068 (0.06%) for the CDC list, 2,067,613 (2.9%) for database-specific categories, and 0 (0%) for the OPEN list. For Optum (n=61,554,852), opioid prescriptions not identified totalled 9,774 (0.02%) for the CDC list, 83,700 (0.14%) for database-specific categories, and 0 (0%) for the OPEN list. In Medicare claims (n=92,781,299), the number of opioid prescriptions not identified totalled 8,694 (0.01%) for the CDC file and 0 (0%) for the OPEN list., Discussion: This analysis found that identifying opioid prescriptions using methods from CDC and OPEN were similar and superior to prespecified database-specific categories. Overall, this study shows the importance of carefully selecting the approach to identify opioid prescriptions when investigating claims data., Competing Interests: Competing interests: CMB serves as a consultant for Vertex Pharmaceuticals and Merck Pharmaceuticals. In addition, CMB provides expert medicolegal testimony unrelated to this analysis., (© American Society of Regional Anesthesia & Pain Medicine 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Rapid molecular diagnostic tests improve antimicrobial stewardship (AMS) by facilitating earlier refinement of antimicrobial therapy. The INHALE trial tested the application of the BioFire FilmArray Pneumonia Panel (Pneumonia Panel) for antibiotic prescribing for hospital-acquired and ventilator-associated pneumonias (HAP/VAP) in UK intensive care units (ICUs). We report a behavioral study embedded within the INHALE trial examining clinicians' perceptions of using these tests. Semi-structured interviews were conducted with 20 ICU clinicians after using the Pneumonia Panel to manage suspected HAP/VAP. Thematic analysis identified factors reinforcing perceptions of the necessity to modify antibiotic prescribing in accordance with test results and doubts/concerns about doing so. While most acknowledged the importance of AMS, the test's impact on prescribing decisions was limited. Concerns about potential consequences of undertreatment to the patient and prescriber were often more salient than AMS, sometimes leading to "just-in-case" antibiotic prescriptions. Test results indicating a broad-spectrum antibiotic were unnecessary often failed to influence clinicians to avoid an initial prescription or de-escalate antibiotics early as they considered their use to be necessary to protect the patient and themselves, "erring on the side of caution." Some clinicians described cases where antibiotics would be prescribed for a sick patient regardless of test results because, in their opinion, it fits with the clinical picture-"treating the patient, not the result." Our findings illustrate a tension between prescribing guidelines and clinicians' "mindlines," characterized by previous experiences. This highlights the need for a "technology plus" approach, recognizing the challenges clinicians face when applying technological solutions to patient care.IMPORTANCERapid molecular diagnostic tests for pathogens and resistance genes may improve antibiotic-prescribing decisions and stewardship. However, clinicians' desire to protect their patients with antibiotics often overrides more distal concerns about possible resistance selection, limiting the application of these tests in practice. Findings underscore the challenge of changing prescribing decisions based on technical results or guidelines, highlighting factors such as clinicians' previous experience and "knowledge in practice" as more proximal drivers of these decisions. Implementation strategies for technological solutions to antimicrobial resistance must be "behaviorally intelligent," recognizing the challenges facing clinicians when making "life or death" prescribing decisions.CLINICAL TRIALSThis study is registered with ISRCTN as ISRCTN16483855., Competing Interests: The authors declare a conflict of interest (see Acknowledgments).

Backgrounds: Post-dilatation after stenting with a non-compliant (NC) balloon can be used to improve overall percutaneous coronary intervention (PCI) result. Due to lack of evidence on the effect of post-dilatation on adverse clinical endpoints there is no consensus whether post-dilatation should be used routinely. The aim of the current study was to determine the contemporary practice of post-dilatation., Methods: This study included patients from the Netherlands Heart Registration who underwent PCI between the 4th quarter of 2020 and the 3rd quarter of 2021. The primary endpoint was the rate of post-dilatation with a NC balloon. Secondary endpoints included differences in baseline and procedural characteristics of patients that received post-dilatation and patients that did not receive post-dilatation., Results: Out of 12,960 patients from 11 hospitals, 49.9% underwent post-dilatation. There was a variety in post-dilatation between hospitals ranging from 29.3% to 82.7% and among operators ranging from 15.9% to 90.5%. Post-dilatation was used less frequent in patients presenting with ST-elevation myocardial infarction or out of hospital cardiac arrest. Multivessel and left main PCI, long stent length and use of intracoronary imaging and calcium modification were associated with increased use of post-dilatation. When imaging was used, the percentage of post-dilatation was 79.4%., Conclusions: In the Netherlands, stent optimization with post-dilatation using NC balloon is performed in only half of the patients undergoing PCI, with variations in frequency across centres and operators. Post-dilatation is more often used in cases of complex PCI and when intracoronary imaging or calcium modification techniques are used., (© 2025 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Medication exposures and poisonings are a major cause of pediatric morbidity and mortality. Unsafe patient practices are well documented despite the American Academy of Pediatrics recommending that pediatric primary care clinicians discuss medication safety with patients. Current clinician counseling practices for pediatric patients are unknown. Studies of adult patients suggest that physician counseling practices often focus on administration but not storage or disposal. To address this gap, we administered a web-based survey to clinically active pediatric primary care clinicians in two mid-Atlantic health care systems. Survey content focused on characteristics of medication safety counseling practices by age group, including safe medication storage, administration, and disposal. Of 151 clinicians emailed, 40 (26.5%) responded. The majority were physicians (93.5%), female (87.1%), and completed residency/clinical training in pediatrics >15 years ago (58.1%). Most (82.5%) reported having >1 pediatric patient (aged < 19 years) in their practice who experienced an unintentional or intentional medication exposure or poisoning event. Reported practices for medication safety counseling often varied by patient age but safe disposal was rarely addressed for any age group. Respondents generally felt less knowledgeable and less comfortable with providing counseling on safe disposal in comparison to safe storage and safe administration. Nearly all respondents (97%) would like to provide more counseling about medication safety, and the majority (81.3%) wanted additional educational resources. In this survey, we identified several modifiable deficits in pediatric medical counseling practices and a need for additional clinician training and resources, most notably in the content area of safe disposal.

Background: Point-of-care (POC) tests, including C-reactive protein (CRP) tests and rapid antigen detection tests (RADT) for group A streptococci (GAS), are widely used in Swedish primary health care (PHC). This study quantifies their use in pharyngotonsillitis and explore their association with antibiotic prescribing., Material and Methods: Retrospective data from 2012-2016 in Region Kronoberg, Sweden, included all PHC visits with a pharyngotonsillitis diagnosis. Patient characteristics, test usage and antibiotic prescriptions were linked by visit date and personal identification number. Descriptive statistics were used for POC test analysis. Logistic regression assessed the association between CRP levels and antibiotic prescribing., Results: Of 24,237 visits, 68% included RADT and 36% included a CRP test, with 89% of CRP tests performed alongside RADT. CRP testing was more frequent in patients with negative (56%) than positive RADTs (42%) ( p  < .001). Overall, 66% of RADTs were positive. Median CRP levels were 23 mg/l for positive RADT and 31 mg/l for negative RADT ( p  < .001). Antibiotics were prescribed for 95% of positive RADTs and 43% of negative RADTs ( p  < .001). In patients with negative RADTs, CRP testing was associated with higher antibiotic prescribing (57%) compared to no CRP testing (26%) ( p  < .001). Among these patients, CRP levels were associated with prescribing (aOR 1.032; 95% CI 1.029-1.035; p  < .001), with 50% of prescriptions occuring at CRP levels ≤ 20 mg/l., Conclusion: The use of RADTs and the proportion of positive test were higher than expected, indicating inappropriate use and diagnostic bias. CRP testing, contrary to guidelines, was common and associated with increased antibiotic prescribing.

Antibiotics are among the most commonly prescribed medications in neonatal care. Newborns are particularly vulnerable to severe infections and the adverse effects associated with inappropriate antibiotic use. Antibiotic stewardship programs are designed to actively monitor antimicrobial resistance, encourage the judicious use of antibiotics, and collaborate with infection control programs and pharmacy departments to curb the spread of resistant organisms. In this article, the authors will examine studies assessing the impact of excessive antibiotic use and explore the effectiveness of various stewardship strategies aimed at reducing unnecessary antibiotic consumption., Competing Interests: Disclosure None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Design: Cross-sectional study., Objective: To evaluate for areas of consensus and divergence of opinion within the spine community regarding the management of cervical spondylotic conditions and acute traumatic central cord syndrome (ATCCS) and the influence of the patient's age, disease severity, and myelomalacia., Summary of Background Data: There is ongoing disagreement regarding the indications for, and urgency of, operative intervention in patients with mild degenerative myelopathy, moderate to severe radiculopathy, isolated axial symptomatology with evidence of spinal cord compression, and ATCCS without myelomalacia., Methods: A survey request was sent to 330 attendees of the Cervical Spine Research Society (CSRS) 2021 Annual Meeting to assess practice patterns regarding the treatment of cervical stenosis, myelopathy, radiculopathy, and ATCCS in 16 unique clinical vignettes with associated MRIs. Operative versus nonoperative treatment consensus was defined by a management option selected by >80% of survey participants., Results: Overall, 116 meeting attendees completed the survey. Consensus supported nonoperative management for elderly patients with axial neck pain and adults with axial neck pain without myelomalacia. Operative management was indicated for adult patients with mild myelopathy and myelomalacia, adult patients with severe radiculopathy, elderly patients with severe radiculopathy and myelomalacia, and elderly ATCCS patients with pre-existing myelopathic symptoms. Treatment discrepancy in favor of nonoperative management was found for adult patients with isolated axial symptomatology and myelomalacia. Treatment discrepancy favored operative management for elderly patients with mild myelopathy, adult patients with mild myelopathy without myelomalacia, elderly patients with severe radiculopathy without myelomalacia, and elderly ATCCS patients without preceding symptoms., Conclusions: Although there is uncertainty regarding the treatment of mild myelopathy, operative intervention was favored for nonelderly patients with evidence of myelomalacia or radiculopathy and for elderly patients with ATCCS, especially if pre-injury myelopathic symptoms were present., Level of Evidence: Level V., Competing Interests: B.C.: DePuy, A Johnson & Johnson Company: IP royalties, SpinologyTenex: Stock or stock options, Surgalign: paid consultant, Wolters Kluwer Health-Lippincott Williams & Wilkins: publishing royalties, financial or material support, Zimmer: IP royalties. B.A.F.: Ankasa: research support, AO Spine: paid presenter or speaker, Clear Choice Therapeutics: stock or stock options, Kuros: paid consultant, Medtronic: paid consultant; research support, Neuroinnovations: stock or stock options, Synthes: paid consultant, Theradaptive: paid consultant. A.N.N.: American Orthopaedic Association: Board or committee member, AO Spine: research support, Cervical Spine Research Society: Board or committee member, Lumbar Spine Research Society: Board or committee member, Pfizer: research support, Premia Spine: research support, Scoliosis Research Society: Board or committee member, Techniques in Orthopedics: editorial or governing board. B.A.K.: Clinical Spine Surgery: editorial or governing board. A.S.S.: Cerapedics: paid consultant; paid presenter or speaker, CTL Amedica: IP royalties, DePuy, A Johnson & Johnson Company: paid consultant, Jaypee Publishers: IP royalties. J.M.R.: Alphatec Spine: paid consultant; paid presenter or speaker, Biomet: IP royalties, Cervical Spine Research Society: Board or committee member, Medtronic: paid presenter or speaker, Stryker: IP royalties; paid presenter or speaker, Wolters Kluwer Health-Lippincott Williams & Wilkins: publishing royalties, financial or material support, Zimmer: paid presenter or speaker. M.G.F.: Neuraxis: paid consultant. The remaining authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Point-of-care ultrasound (POCUS) has long been a diagnostic tool in family medicine, although most Norwegian general practitioners (GPs) who use POCUS, scans infrequently. The broad scope of family medicine, the relatively low prevalence of illnesses and infrequent use of POCUS imply that GPs may experience diagnostic uncertainty regularly., Aim: To explore how GPs perceived and managed diagnostic uncertainty when using POCUS., Design and Setting: A qualitative focus group study among Norwegian GPs using POCUS., Methods: Four focus group discussions were conducted. Total number of participants were 21. The interview guide was piloted, the focus group discussions were audio-recorded and transcribed, and Systematic Text Condensation, a thematic cross-case analysis, was used to analyse the data., Results: Diagnostic uncertainty using POCUS was considered as aligning to the general clinical uncertainties in family medicine, but there were also POCUS-specific uncertainties in clinical decision-making. We generated six themes: emotional, cognitive, and ethical uncertainty using POCUS, communicating uncertainty to patients, interaction with specialists when using POCUS, and coping strategies of participants. POCUS results were the only results the participants sometimes withheld when communicating with other specialists. POCUS itself stimulated a renewed interest in family medicine. Scanning enough patients was the recommended coping strategy., Conclusion: POCUS-using GPs experienced diagnostic uncertainty when using POCUS that aligned with other diagnostic uncertainties they experienced in everyday practice. However, they did not treat the results like other findings, as the GPs at times withheld their POCUS findings when interacting with secondary care specialists. This requires further investigation.

Objective: To evaluate the impact of a compulsory pop-up form on the ordering pattern of proBNP blood tests by general practitioners in the Capital Region of Denmark., Design: A follow-up study comparing the average number of proBNP tests ordered before and after the implementation of an intervention., Setting and Subjects: From 2016 to 2021, the average number of proBNP tests increased by over 300%. In March 2022, a compulsory pop-up form was introduced in the electronic request system (WebReq), requiring general practitioners to select one of three indications for ordering proBNP, as recommended by the Danish Society of Cardiology. The study included 528 general practitioners in the Capital Region of Denmark, with data available from January 2020 to 2023, encompassing 83,576 proBNP results from 56,645 patients., Main Outcome Measure: The average number of proBNP tests ordered per month and the median level of proBNP before and after the intervention., Results: Following the intervention, the average number of proBNP tests per month decreased by 60% over a 22-month follow-up period. The highest reduction was seen among general practitioners who previously ordered the most tests (≥3 per 1000 biochemical tests). In this group, the median proBNP level increased from 12.1 pmol/L before the intervention to 13.5 pmol/L after the intervention ( p  < 0.0001)., Conclusions: This study demonstrates a significant decrease in the number of proBNP requests from general practitioners in the Capital Region of Denmark after the introduction of a pop-up form in the requisition system containing the current guidelines.

Background: Incidence of peptic ulcer bleeding can be substantially reduced by prophylactic use of proton pump inhibitors (PPIs) in patients at risk, but use of PPI varies among risk patients, and substantial under-prescribing may exist. The variation in prophylactic prescribing among general practices remains unknown., Methods: A nationwide register-based cross-sectional study analyzing the proportion of patients at risk of ulcer bleeding receiving PPI treatment within Danish general practices. Using logistic regression, we analyze associations between general practice characteristics and prophylactic treatment among patients at risk of ulcer bleeding listed with the general practice., Results: In most general practices, less than 40% of the patients at increased risk of ulcer bleeding were covered by PPI. Geographical variation was present, where practice location outside the capital area was associated with higher odds of PPI coverage among their risk patients. Partnership practices with GPs with a mean age ≥65 years or with only female GPs were associated with higher odds of providing prophylaxis among their risk patients compared to practices with a mean GP age <45 years or with only male GPs. Similar associations were not found for single-handed practices., Conclusions: A significant under-prescribing of ulcer prophylaxis is common across all general practice characteristics, and only few associations with practice characteristics were present. Most efforts to rationalize PPI prescribing have aimed at reducing overprescribing but the findings point to under-prescribing as a problem as well. Development of new methods to assist GPs in identifying individuals at risk of ulcer complications is needed.

Introduction: During recent years, the world-including Scandinavia-has experienced significant challenges with shortages of antibiotics. In Scandinavia, phenoxymethylpenicillin is recommended as first-line antibiotic treatment for most acute respiratory tract infections (ARTIs). However, the Scandinavian countries each constitute rather small markets for phenoxymethylpenicillin. The aim of this discussion paper is to enlighten the differences in Scandinavian ARTI antibiotic treatment recommendations. This information is fundamental for exploring the potential of harmonizing treatment recommendations in Denmark, Norway and Sweden-to help ensure sufficient future supply of phenoxymethylpenicillin., Methods: Information from national ARTI antibiotic treatment recommendations from respectively Denmark, Norway and Sweden has been collated., Results: Several discrepancies exist in recommendations. Adult dosage varies from a minimum of 660 mg x 4 (Denmark) to a maximum of 2000 mg × 3 (Sweden). Within Norway and Sweden, variations in recommended dosage also exist between the different types of ARTIs. A main challenge is that the tablet strengths recommended, and available on the market in the three countries, differs.Also, antibiotic treatment durations vary significantly between countries and infections treated-from five to 10 days of treatment., Conclusion: In the capacity of a well-established network for antibiotic stewardship, we have enlightened the differences in Scandinavian ARTI antibiotic treatment recommendations. This paper is the first step moving forward to scrutinizing the potential for harmonizing recommendations for Denmark, Norway and Sweden-to help ensure continued supply of phenoxymethylpenicillin for use within the Scandinavian countries.

Introduction: Antimicrobial resistance is a global emergency related to overprescribing of antibiotics. Few studies have explored how prescribing behaviours may change as the consequence of changing resistance. Understanding how contextual factors influence antibiotic prescribing will facilitate improved communication strategies to promote appropriate antibiotic prescribing. We aimed to develop and conduct a discrete choice experiment (DCE) to measure how contextual factors influence intended antibiotic prescribing of general practitioner (GP) registrars., Methods: Factors included as attributes in the DCE were level of antibiotic resistance, requirement for an authority to prescribe, existence of a Practice Incentives Program (PIP) for low prescribing and supervisor support for low prescribing. The survey was administered in an online format for GP registrars undergoing training between 2020 and 2021. Regression analysis using a conditional logit model with interaction effects was used on the basis of the assumptions of independence of irrelevant alternatives, independence of error terms and no preference heterogeneity., Results: In total, 617 unique respondents answered at least one choice set question. Respondents showed significant preference for avoiding prescribing antibiotics when antibiotic resistance was 25-35% or 40-60% compared with 5-8%. There was also a significant preference for avoiding prescribing when an authority to prescribe was required, or when there was supervisory support of low antibiotic prescribing. In the main effects analysis, respondents were significantly less likely to choose a prescribing option if there was a PIP; however, when interaction effects were included in the regression analysis there was a significant interaction between PIP and resistance rates, but the preference weights for PIP was no longer significant., Conclusions: Knowledge about community resistance impacts the stated intention of GP registrars to prescribe antibiotics. The use of the DCE may have made it possible to determine factors influencing prescribing that would not be detected using other survey methods. These findings provide guidance for producing, explaining and communicating issues regarding antibiotic prescribing to GP registrars., Competing Interests: Declarations. Funding: Open Access funding enabled and organized by CAUL and its Member Institutions. Funding for this research was through the Centre for Research Excellence in Minimising Antibiotic Resistance in the Community, a National Health and Medical Research Council funded Centre for Research. The authors have no conflicts of interest to declare. Ethics approval: Ethics approval was granted for the DCEs as part of the ReCEnT study (University of Newcastle H-2009-0323). Conflicts of interest: The authors declare no conflicts of interest regarding this manuscript. Consent to participate: All participants provided written consent. Consent for publication: Participants provided written consent for the findings of the study to be published. Data availability: The data that support the findings of this study are available from the corresponding author, G.M., upon reasonable request. Code availability: Not applicable. Author contributions: The authors confirm contribution to the paper as follows: study conception and design: G.M., L.H., P.M., A.T., K.M., A.F., A.D., J.D., and M.v.D.; data collection: P.M., A.T., K.M., and A.F.; analysis and interpretation of results: G.M. and L.H.; and drafting and revising of the manuscript: G.M., L.H., P.M., A.T., K.M., A.F., A.D., J.D., and M.v.D. All authors read and approved the final version. , (© 2025. The Author(s).)

Introduction: The prevalence of sleep disorders and use of sleep medication, particularly melatonin, are rising among adolescents and young adults (13-24 years). In Denmark, melatonin is approved for use in children with autism and ADHD up to 18 years of age, with other prescriptions being off-label in these age groups. The perspectives of medical practitioners on prescribing sleep medications to this age group remain largely unexplored., Aim: This study aims to investigate the considerations of general practitioners (GPs) and child and adolescent psychiatrists (psychiatrists) when prescribing and deprescribing sleep medications for 13-24-year-olds., Methods: We conducted qualitative semi-structured interviews with 10 GPs and six psychiatrists. Data were analyzed using an inductive approach., Results: Psychiatrists typically prescribed melatonin with the expectation that deprescription would occur in general practice. Despite the universal goal of deprescription, it was hindered by various challenges. GPs identified patient motivation and a clear focus on deprescription as facilitative factors and expressed a need for enhanced emphasis on these aspects in general practice., Discussion and Implications: The findings align with existing prescription trends and literature on factors that promote and inhibit deprescription. The study underscores the complexities of deprescribing sleep medications for adolescents and young adults, suggesting the need for expanded guidelines and enhanced continuing education for GPs., Conclusions: The research highlights significant discrepancies among medical practitioners regarding the deprescription process of sleep medications for young individuals, complicated by multiple factors. This underscores the need for better guidelines and further studies.

Background: Some adult transplant surgeons consider transplant to be contraindicated in patients receiving palliative care (PC). Little is known about pediatric transplant surgeons' attitudes toward PC. We sought to ascertain pediatric kidney transplant surgeons' perspectives regarding the routine integration of PC for children with chronic kidney disease., Method: We administered a cross-sectional web-based survey to members of the American Society of Transplant Surgeons listserv in summer 2021. We adapted the survey from the previously validated Provider Survey about Palliative Care for Children with Heart Disease and pretested it with representative kidney transplant surgeons, nephrologists, and PC physicians; queries related to PC included institutional and personal experience, knowledge, and education. Data were summarized descriptively., Results: There were 21 participants. Over half of the respondents were white (57%) males (62%), practicing in urban, academic centers (94%). Although 67% of the participants practiced in an institution with a subspecialty PC team, 24% were unsure if such a team existed in their institution. A minority (19%) perceived PC consultation and kidney transplant to be mutually exclusive. Most surgeons (86%) believed that PC should not be restricted to when a child is dying, and 59% reported that PC consultation should happen at diagnosis for life-threatening conditions. However, surgeons indicated that PC consultation is rarely utilized for pediatric kidney transplant recipients. Transplant surgeons expressed a desire for additional PC-focused training and willingness to engage in additional education., Conclusions: Although a minority of pediatric transplant surgeons perceived PC to be contraindicated for kidney transplant, most indicated openness to PC engagement for their patients., (© 2025 The Author(s). Pediatric Transplantation published by Wiley Periodicals LLC.)

Objective Is the involvement of the regular general practitioner (GP) in the decision to initiate opioid treatment for chronic non-cancer pain (CNCP) associated with two main risk factors for serious adverse events: increased opioid dose and the concomitant use of prescribed benzodiazepines or benzodiazepine-related medications? Design and setting An anonymous web-based survey was conducted in the county of Rogaland, Norway, during the spring of 2021. Subjects GPs who self-reported applying at least once for reimbursement of opioids prescribed to treat CNCP. They were asked to answer the survey based on the last patient for whom they recalled submitting a reimbursement application. Main outcome measures 1) Total opioid dose in daily oral morphine equivalents (OMEQ). 2) Concurrent use of benzodiazepines and/or benzodiazepine-related drugs. Results The daily opioid dose was lower when the surveyed GPs initiated the opioid treatment (36 OMEQ, n  = 25), than when others had initiated the treatment (108 OMEQ, n  = 31, p  = 0.001). For concurrent use of benzodiazepine or benzodiazepine-related drugs, no significant difference was found (33%, n  = 9 with GP involvement vs . 47%, n  = 16, p  = 0.279 with no GP involvement). Conclusions GP involvement in the initiation of opioid medication for CNCP was associated with a lower opioid dose being prescribed. Implications GP involvement in the initiation of opioid prescriptions may facilitate safer prescribing.

Objectives: This study assessed the prevalence of suboptimal prescribing of medicines in First Nations older adults in the Torres Strait. Types of suboptimal prescribing included polypharmacy, over-prescribing, under-prescribing and anticholinergic burden. It also assessed any significant associations between suboptimal prescribing and common age-related problems such as falls, reduced function and cognition., Method: Cross-sectional study (2015-2018) on 18 island and five mainland communities in the Torres Strait and Northern Peninsula Area of Far North Queensland, Australia. Community-dwelling residents aged 45 years and older who identified as Torres Strait Islander and/or Aboriginal with complete medication histories were recruited in this study. Validated prescribing tools were used to identify suboptimal prescribing practises., Results: There were 254 participants with complete medication histories. The mean age was 65.7 (SD ± 10.9, range 45-93), with 65% female. Suboptimal prescribing in this study was 74%. Of these, 49% of participants had polypharmacy, 44% were over-prescribed, and 36% were under-prescribed. Anticholinergic burden was identified in 26% of participants. Polypharmacy was more prevalent in participants who were dependent on instrumental activities of daily living (iADLs)., Conclusions: The results demonstrate the importance of general practitioners, health-care workers or pharmacists, to monitor medication prescribing in this population. Frequent review of medications to reduce suboptimal prescribing practices within these communities may help to reduce adverse outcomes because of prescribing practices., (© 2024 AJA Inc’.)

Objectives: To identify the prevalence of and factors associated with medication use in people living with dementia in the community., Methods: A cross-sectional study using baseline data from a randomised controlled trial known as the Interdisciplinary Home-bAsed Reablement Program (I-HARP) between 2018 and 2021 in Sydney, Australia. Participants included people with mild-moderate dementia and their carers. Medication use was classified according to the Anatomical Therapeutic Chemical codes, while potentially inappropriate medications (PIMs) were defined using 2019 Beer's Criteria and 2024 Australian list. Logistic regression models were used to identify factors associated with use of medication classes., Results: A total of 130 people with dementia and their carers were included. Of the people with dementia, 35% were using antidementia medication, 48% psychotropics, 76% PIMs and 65% polypharmacy (≥5 medications). Polypharmacy was associated with the use of psychotropics (adjusted OR [aOR]: 5.09, 95% confidence interval [CI]: 1.94-13.39) and PIMs (aOR: 17.38, 95% CI: 5.12-59.02). Higher education level was associated with lower odds of psychotropic use (aOR: .33, 95% CI: .15-.76), and age over 80 years was associated with lower odds of antidementia medication use (aOR: .29; 95% CI: .12-.72)., Conclusions: The use of PIMs, psychotropics and polypharmacy were common in this sample of people with dementia living in the community. Associations were seen between participant characteristics and medication use. Future research should focus on reviewing PIMs and polypharmacy in people with dementia living in the community to assess the impact on health outcomes., (© 2024 The Author(s). Australasian Journal on Ageing published by John Wiley & Sons Australia, Ltd on behalf of AJA Inc’.)

Background:  While direct oral anticoagulants (DOACs) may be viewed as simpler to manage then warfarin, they present their own unique management challenges resulting in frequent off-label dosing. It is unknown to what extent off-label dosing occurs when a patient is started on a DOAC versus later in their treatment., Objectives:  We aimed to better characterize when off-label DOAC dosing is occurring and to evaluate the effectiveness of prescribing oversight using a registry-based intervention., Methods:  We evaluated data from the Michigan Anticoagulation Quality Improvement Initiative (MAQI 2 ) registry, a retrospective quality-improvement process using data abstractors, from 2018 to 2022 on the number of "alerts" that are generated in response to dosing deviating from the U.S. Food and Drug Administration instructions for atrial fibrillation (AF) and venous thromboembolism (VTE)., Results:  Among a sample of 789 to 1,022 annual AF patients and 381 to 484 annual VTE patients prescribed a DOAC in the MAQI 2 registry, off-label dosing was relatively common. Over the 5-year period (2018-2022), there were 569 alerts for AF patients and 162 alerts for VTE patients. Alerts occurred more frequently during follow-up than at the time of initial prescribing in AF patients (78.2 vs. 21.8%), but more commonly at initial prescribing in VTE patients (59.9 vs. 40.1%). After initial review by quality-improvement abstractors, 19.3% of AF alerts and 14.8% of VTE alerts resulted in contact to the prescriber. When the prescriber was contacted, it led to an intervention about 75% of the time for both populations. The most common intervention was a change in DOAC dosing., Conclusion:  This study demonstrates the benefit of DOAC prescribing oversight using a registry-based intervention to monitor for off-label dosing for the entirety of the time period a patient is prescribed DOAC, particularly for patients with AF, as off-label prescribing occurs frequently during the follow-up period., Competing Interests: G.D.B received grant funding from Boston Scientific; received consulting fees from Pfizer, Bristol-Myers Squibb, Janssen, Bayer, AstraZeneca, Sanofi, Anthos, Abbott Vascular, Boston Scientific; serve as DSMB—Translational Sciences (Clinical Events Adjudication Committee); is a Board of Directors—Anticoagulation Forum. S.K. received consulting fees from AstraZeneca, Bristol-Myers Squibb, Boston Scientific, Gilead, Inari, Janssen, Pfizer, Phase Bio, and Antos; received grant funding from Osmosis Research, Janssen, Bristol-Myers Squibb, Bayer, and NIH; is a Board of Directors—Anticoagulation Forum, the PERT Consortium; Scientific Advisory Board for the National Blood Clot Alliance. J.B.F received grant funding from Blue Cross Blue Shield of Michigan, Fibromuscular Disease Society of America, and the Pulmonary Embolism Response Team (PERT) Consortium; serves as a committee chair for the American Heart Association. All other authors declare no conflicts of interest., (Thieme. All rights reserved.)

Background: Understanding the dementia disease trajectory and clinical practice patterns in outpatient settings is vital for effective management. Knowledge about the path from initial memory loss complaints to dementia diagnosis remains limited., Objective: This study aims to (1) determine the time intervals between initial memory loss complaints and dementia diagnosis in outpatient care, (2) assess the proportion of patients receiving cognition-enhancing medication prior to dementia diagnosis, and (3) identify patient and provider characteristics that influence the time between memory complaints and diagnosis and the prescription of cognition-enhancing medication., Methods: This retrospective cohort study used a large outpatient electronic health record (EHR) database from the University of Connecticut Health Center, covering 2010-2018, with a cohort of 581 outpatients. We used a customized deep learning-based natural language processing (NLP) pipeline to extract clinical information from EHR data, focusing on cognition-related symptoms, primary caregiver relation, and medication usage. We applied descriptive statistics, linear, and logistic regression for analysis., Results: The NLP pipeline showed precision, recall, and F1-scores of 0.97, 0.93, and 0.95, respectively. The median time from the first memory loss complaint to dementia diagnosis was 342 (IQR 200-675) days. Factors such as the location of initial complaints and diagnosis and primary caregiver relationships significantly affected this interval. Around 25.1% (146/581) of patients were prescribed cognition-enhancing medication before diagnosis, with the number of complaints influencing medication usage., Conclusions: Our NLP-guided analysis provided insights into the clinical pathways from memory complaints to dementia diagnosis and medication practices, which can enhance patient care and decision-making in outpatient settings., (© Hunki Paek, Richard H Fortinsky, Kyeryoung Lee, Liang-Chin Huang, Yazeed S Maghaydah, George A Kuchel, Xiaoyan Wang. Originally published in JMIR Aging (https://aging.jmir.org).)

Background: Early identification and intervention of Mild Cognitive Impairment (MCI), led by General Physicians (GPs), can delay dementia onset and enhance patient outcomes. GPs recognize MCI risk factors, conduct assessments, and manage associated conditions, playing a crucial role in cognitive pathology intervention, especially in the era of Interprofessional Collaboration (IPC). In India, where cognitive impairment rates are projected to rise sharply, understanding GPs' knowledge, attitudes, and practices (KAP) is vital. This study aimed to investigate the KAP of GPs regarding the diagnosis and treatment of MCI using a customized, predesigned questionnaire., Method: The study employed a cross-sectional design using a convenience sample of 180 invited participants between July and October 2023. A customized questionnaire, based on Lu et al., 2022, evaluated GPs' KAP regarding MCI and IPC in the Indian context towards its assessment and management. The tool including 9 knowledge items, 15 attitude items, and 12 practice items, was made available through Google Forms and disseminated via WhatsApp. Responses were scored to indicate KAP levels, with maximum scores being 50 for knowledge, 75 for attitudes, and 60 for practices., Results: 103 GPs completed the survey, showing varied practice experience. The average knowledge score was 28.1 ± 7.98, indicating uncertainty about MCI-related factors and diagnostic criteria. Attitude scores averaged 53.5 ± 4.73, with most GPs endorsing early detection and non-pharmacological interventions. Practice scores averaged 41.8 ± 8.32, showing mixed adherence to screening and referral practices. Most participants found IPC highly effective for MCI diagnosis and management, with many referring patients to specialists for confirmation, while over half used an IPC approach for both. Education level and previous experience significantly influenced knowledge and practice scores., Conclusion: This study sheds light on the evolving landscape of Indian GPs' KAP related to MCI assessment and management. It identifies areas where understanding could be strengthened and highlight opportunities for growth through education and training. Notably, there is a need for increased involvement in IPC. These findings emphasize the importance of holistic approaches, advocating for enhanced education and the fostering of collaborative relationships across disciplines to tackle the rising prevalence of MCI in India effectively., Competing Interests: Declarations. Ethics approval and consent to participate: The study obtained approval from the Institutional Ethics Committee of Kasturba Medical College Mangalore (IEC KMC MLR 05/2023/229). Informed consent was obtained from all the participants. The manuscript does not contain any identifying information of the participants in the study. All methods were carried out in accordance with relevant guidelines and regulations in the Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Objectives: This study aimed to establish a consensus on key factors that influence medication choices for Parkinson's disease and to identify the behavioural determinants of these factors using behavioural change theory as a theoretical lens., Design: This qualitative study used the nominal group technique to conduct structured online focus group meetings. A facilitator guided participants to (1) individually generate a list of factors that influence their decision to prescribe, (2) collectively share these factors, (3) refine and clarify factors and (4) rank the most important factors. Subsequently, the most important factors identified were mapped to the Theoretical Domains Framework (TDF) and the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify the behavioural determinants that influence medication choice., Participants: Eighteen healthcare professionals, including neurologists, consultants and specialist nurses/practitioners who prescribe medication, were recruited across Europe and participated in one of seven focus groups., Results: There was good consensus among the participants about which factors influence their prescribing decisions. Overall, participants identified 60 unique factors that were broadly categorised into the following themes: medical or symptom concern, patient characteristics, side effects, access to treatment, clinical guidelines, social support and patient preference. Factors discussed and prioritised by the participants aligned with seven of the 14 TDF domains: knowledge; memory, attention and decision processes; beliefs about consequences; goals; social/professional role and identity; environment context and resources; and social influences. Together, these were subsequently mapped onto four of the six subdomains of the COM-B model: psychological capability, reflective motivation, physical opportunity and social opportunity., Conclusions: These findings suggest that prescribing decisions for Parkinson's disease are determined by a complex range of factors linked to the COM-B components capability, motivation and opportunity. These can be further understood by specific behavioural domains, as identified by the TDF, which should be targeted to help optimise subsequent prescribing decisions., Competing Interests: Competing interests: The research is part-funded by Alpharmaxim, where EB has undertaken a placement as Knowledge Transfer Partnership (KTP) Associate and, therefore, has a professional interest. WH is the Founder and CEO of Alpharmaxim and has invested financial interest in the KTP project. JT and CS are academics at Aston University, Birmingham, UK, and have no competing interests to declare., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Delirium is a brain dysfunction characterized by attention and cognitive disturbances in a fluctuating manner. The international guidelines recommend daily screening for delirium. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) are the most commonly used methods for assessing delirium. This study aimed to identify barriers and gaps in knowledge and practice. This was a hospital-based Cross-Sectional study. Stratified random sampling was used in this study. 72 ICU doctors were randomly selected. Statistical analyses were performed using IBM SPSS version 23. Descriptive data were presented, and the chi-squared test was used to determine the associations among variables. Statistical significance was set at p < 0.05. More than 70% of the doctors were ≤ 30 years of age and female. A total of 69.4% of the participants had < 1year of experience. In total, 94.4% of the participants worked in medical ICUs. Less than 20% of the doctors used delirium assessment tools, with a statistically significant difference based on experience ( p =0.012). Delirium was not regularly assessed in 13.9% of the patients. Non-pharmacological management was applied by 76.4% of doctors, and communication with patients was the most frequent (75%). Haloperidol was the most commonly used drug (83.3%). A total of 40.3% of doctors did not stop delirium medication on ICU discharge. A regular delirium assessment was performed. However, the use of validated assessment tools is uncommon. Nonpharmacological management of delirium is important and is mostly performed. Our doctors prescribed antipsychotics for the treatment of both forms of delirium, and almost half of them did not stop the medications on ICU discharge. Medication reconciliation and contact with the next in-charge of the patients are important., Competing Interests: No competing interests were disclosed., (Copyright: © 2025 Seidna Hamid SH et al.)

Background: Level one evidence supports indocyanine green fluorescence angiography (ICGFA) use reducing anastomotic leak rates in colorectal surgery. We surveyed surgeons exploring perceptions and factors affecting its use in daily practice and adoption as routine standard of care., Methods: Validated electronic survey distributed via the Irish Association of Coloproctology, Royal College of Surgeons in Ireland, European Society of Surgical Oncology, European Association for Endoscopic Surgery, Milan Colorectal Congress and social media., Results: 200 colorectal surgeons (143 consultants) responded. 147 (73.5%) surgeons already use ICGFA, with 90 (61.2%) using it routinely and 69 (46.9%) having a concomitant research interest. Strong clinical evidence base (83.5%) and protocol standardisation (78%) were overall rated most important for bowel perfusion technology with a majority of surgeons rating lack of standardisation and inter-user variability as challenges (similar between consultants and non-consultants). Lack of training and staff, reliability concerns and data security were perceived as significant barriers by selective users compared to non-users, and cost and operating time were perceived as significant barriers by selective users compared to routine users. Most surgeons (41.5%) ideated a number needed to treat (NNT) between 20 and 40 acceptable to advocate routine ICGFA use with 28% requiring a NNT < 20. Most surgeons (38.5%) indicate a per case cost savings of €250-500 supports routine use with 17% advocating it > €750., Conclusions: With now a strong evidence base regarding clinical benefit, the survey respondents articulate remaining challenges for ICGFA as standard of care. Levels of expected benefit are largely in keeping with its reported performance., Competing Interests: Declarations. Competing interests: Professor Ronan A Cahill receives speaker fees from Stryker Corp and Ethicon/J&J, consultancy fees from Arthrex, Astellas, Diagnostic Green and Touch Surgery (Medtronic), research funding from Intuitive Corp and Medtronic as well as, recently, from the Irish Government (DTIF) in collaboration with IBM Research in Ireland and from EU Horizon 2020 in collaboration with Palliare and, currently, from Horizon Europe in collaboration with Arctur. Professor Alberto Arezzo receives speaker fees from Karl Storz, Tuttlingen. Professor Luigi Boni receives speaker fees from Ethicon/J&J, Storz and Olympus, consultancy fees from Arthrex, CMR, Storz, Intuitive and Olympus. Mr Ashokkumar Singaravelu, Dr Philip D Mc Entee, Dr Patrick A. Boland, Dr Alice Moynihan, Dr Cathleen McCarrick, Professor Roel Hompes and Professor Alexander L. Vahrmeijer have no conflicts of interest or financial ties to disclose., (© 2025. The Author(s).)

Background: Type 2 Diabetes Mellitus (T2DM) stands as a significant global health challenge for individuals and societies. In the context of Palestine, T2DM affects about 9.2% of the Palestinian population and contributes to a relatively high complication rate. Effectivemanagement strategies including glucose self- monitoring need to be optimized to improve patient outcomes and alleviate the strain on the healthcare system. One of the physicians' roles in T2DM management is explaining and guiding patients towards the integration of glucose self-monitoring into their personal diabetes management routine. This study investigates the knowledge, attitudes, and practices of primary health care physicians who care for (T2DM) patients in the West Bank regarding glucose self-monitoring., Methods: A cross-sectional study was conducted among physicians working in PHC centers. The study period was from January to March 2024. Data was collected through a self-administered questionnaire., Results: Five hundred ten medical doctors were surveyed and 300 of them replied, giving a response rate of 58.8%. The median age of the respondents was 35.0 [30.0, 41.0] years. Of the respondents, 180 (60.0%) were males. The median duration of practice as a doctor was 9.0 [5.0, 15.0] years. Most, 252 (84.0%), were general practitioners, 38 (12.7%) family medicine specialists, and 10 (3.3%) other specialties. Female respondents and those who saw more patients reported better knowledge (p < 0.05). The majority believed that glucose self-monitoring can improve patient outcomes, knew values of glucose self-monitoring that corresponded to HbA1c control and the microvascular complications of diabetes, and realized the importance of glucose self-monitoring for patients. However, 40% of them are not confident or somewhat confident about interpreting data and adjusting treatment plans. Regarding the respondent's practices, 39.3% of the doctors stated that they would recommend glucose- self monitoring to newly diagnosed type 2 diabetes patients more than one time a day., Conclusion: There was a positive attitude toward glucose self-monitoring among the respondents in the primary healthcare clinics. Conversely, the clinicians' glucose self-monitoring practices were suboptimal. Future research should examine the knowledge, attitudes, and practices of physicians who provide patient care in the private sector., Competing Interests: Declarations. Ethics approval and consent to participate: An-Najah National University institutional review board approved the study with ref. number: Med. Oct.2023/82. All subjects involved in the study were invited to participate on a voluntary basis after the study purpose, risk, and advantage of participation were clarified. Informed consent was obtained from all participants. Interviews were carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Routine seeking of imaging for patients with low back pain is not concordant with the evidence-based recommendation that imaging is rarely of diagnostic value. Inappropriate imaging is a waste of resources and can lead to undesirable downstream effects for individuals and health systems. To develop effective strategies to reduce unwarranted referrals for imaging in primary care, we must understand the drivers for, and barriers to, guideline-adherent practice. We explored clinicians' views to identify the dominant influences on clinicians as they choose to pursue, or avoid, imaging for their patients with low back pain., Methods: We interviewed a purposeful sample of 47 primary care clinicians (14 physiotherapists, 18 chiropractors, 15 physicians) throughout Ontario, Canada, with a guide based on the Theoretical Domains Framework (TDF). We investigated clinicians' views about their use of imaging in the management of low back pain. Interviews were recorded and transcribed verbatim. We analysed transcripts, then identified themes within TDF domains., Results: Most clinicians reported that, for most clinical encounters, they adhered to guideline recommendations about imaging. Many clinicians across disciplines expressed the following themes: (1) imaging may result in an incidental finding or otherwise cause harm to patients, and drive up health system costs (TDF domain Beliefs about consequences); (2) clinicians were confident in their abilities to diagnose, to explain to patients the rationale for not recommending imaging, and to respond to their needs (domains Beliefs about capabilities; Skills). Many clinicians identified that patients occasionally want the validation that imaging provides (domain Social influences). Some clinicians described the value of imaging to corroborate a diagnosis (domain Beliefs about consequences)., Conclusions: This study is the first to examine influences on imaging behaviours of a large interprofessional sample of primary care clinicians in Canada. Even among knowledgeable, skilled, confident clinicians who reported mostly adhering to guideline recommendations, there are potential influences on deviating from guideline-adherent care., Competing Interests: Declarations. Ethics approval and consent to participate: This research was approved by the Health Sciences and Affiliated Teaching Hospitals Research Ethics Board at Queen's University (REH-736–18) was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Introduction: Sri Lanka has no formal care pathway to assess for developmental dysplasia of the hip (DDH), which may lead to later diagnosis, more invasive treatments, and long-term adverse health outcomes. With the goal of developing a care pathway for DDH in Sri Lanka, we first surveyed relevant medical specialties regarding their experience with DDH screening, diagnosis, and treatment to understand current screening and diagnosis practices., Methodology: A panel composed of four members affiliated with three Sri Lankan organizations collaborated with our team of researchers to inform the development of three specialty specific surveys. We distributed the surveys electronically to radiologists, pediatricians, neonatologists, and orthopedic surgeons., Results: From the surveys, we gained an understanding of the present screening procedures. We identified potential areas to improve screening and diagnosis, including investigating the reliability of ultrasound (US) imaging reports and providing guidance on conducting appropriate referrals., Discussion: These results will help inform the development of a DDH care pathway specific to the local context and needs in Sri Lanka., Conclusion: Care pathway development must be mindful of resource availability and strive to increase awareness of best care practices among healthcare practitioners., (Copyright © 2025 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Purpose: This study aimed to evaluate the current clinical practice patterns regarding the utilization of "Urolithiasis Guidelines" in Turkey and to identify critical factors influencing their application by urologists., Methods: The study targeted practicing urologists in Turkey, primarily those involved in the management of urolithiasis, to assess their perspectives and experiences regarding the clinical application of established guidelines. A total of 415 urology specialists were invited to participate in a survey-based study conducted via Google Forms. Participation was voluntary, and 65.08% of the invited urologists completed the survey., Results: Among the respondents, 84.7% reported utilizing the available guidelines in their routine clinical practice, with varying frequencies of reference. The primary motivations for guideline use were the prevention of potential complications and the avoidance of legal risks, as indicated by 90.5% of respondents. While 56.9% of participants adhered to the guidelines as a clinically standardized practice, 41.6% reported applying the recommendations on a case-by-case basis. Notably, 41.0% of respondents emphasized the need for locally adapted versions of guideline texts. Additionally, nearly half of the participants reported receiving no formal education or training on the significance, content, and practical application of these guidelines. Furthermore, 12.7% expressed skepticism about the evidence-based foundation of the guidelines, questioning whether the recommendations were derived from rigorously conducted studies., Conclusion: The available urolithiasis guidelines are recognized as valuable resources offering key recommendations for the effective and safe management of urolithiasis. However, findings from this survey highlight significant variability in clinical practice patterns due to local conditions and the individual experience and attitudes of practicing urologists. The application of guideline recommendations is further influenced by perceptions regarding their development, content, and practicality. Insights gathered from this study may contribute to improving the preparation, dissemination, and implementation of urolithiasis guidelines, particularly in adapting them to local clinical settings., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Introduction: Healthcare institutions have sought to standardize opioid prescribing after elective total joint arthroplasty. The purpose of this study was (1) to compare opioid prescriptions at discharge with perceived opioid prescribing patterns and (2) to determine the relationship between preoperative adjunctive treatments and opioids prescribed at discharge., Methods: All surgeons who performed total joint arthroplasty of the shoulder, hip, or knee from January 1, 2021, to October 4, 2023, at a single academic institution were included. Surgeons completed a survey assessing perceived opioid prescriptions at discharge and perioperative pain protocols. Actual prescriptions were captured using our institutional opioid database. All opioid prescriptions were converted to morphine milligram equivalents (MMEs)., Results: Orthopaedic surgeons prescribed on average 594.2 MMEs more than they perceived as their postoperative protocol. They prescribed an additional 60.9 MMEs for every 10 MMEs that they perceived they were prescribing. Patients receiving liposomal bupivacaine were prescribed on average 597 fewer MMEs and had fewer opioid prescriptions (P < 0.001). Genicular nerve blocks and cryoneurolysis were associated with fewer prescribed MMEs (P < 0.001)., Conclusion: Orthopaedic surgeons prescribe substantially more opioids than intended. This study underscores the need for standardized opioid prescribing practices and the potential of adjunctive treatments in reducing opioid prescribing., (Copyright © 2025 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: On the one hand, climate change affects health and healthcare systems worldwide. On the other hand, the healthcare system contributes to environmental pollution. These environmental issues concern rhythmology, particularly because of the use of complex, often plastic, single-use devices., Aims: To assess current practices, as well as the training received by rhythmologists and their willingness to implement the necessary changes., Methods: A four-part questionnaire with 15 questions was designed, and was distributed online to rhythmologists, via the French Society of Cardiology., Results: Eighty-seven responses were received from 42 French departments. Most rhythmologists (98.9%) had never attended courses on climate change and its impact on human health during their medical studies; they thought it would be relevant to offer courses on these issues as part of initial medical training (59.5% of answers), continuing medical education (62.3% of answers) and training in interventional rhythmology (55.9% of answers). The participants had already been able to implement actions in their healthcare establishments, in the following categories: transport; food; waste management; scientific studies; and political work. One hundred percent of rhythmologists were willing to change some of their interventional practices if the changes did not alter the risk for the patient or diminish the clinical benefit. However, there were numerous obstacles to overcome: "I don't know where to start"; "I'm not helped by my healthcare institution"; "regulatory constraints are too important"; "I don't have the time" and "I don't know what's relevant"., Conclusions: These responses reinforce the importance of supporting these doctors so that their interventional practices can evolve. This evolution in interventional practices, based on scientific studies, and within a legislative and regulatory framework adapted to environmental issues, will enable the development of a more sustainable rhythmology practice., Competing Interests: Disclosure of interest The authors declare that they have no competing interest., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Objective: To investigate (1) the current level of awareness and knowledge on Auditory Processing Disorder (APD) among Audiologists and other hearing healthcare professionals; (2) current practices in screening, diagnosis, and management of APD in children and adults across the UK; (3) professional's acceptance of APD assessment and diagnosis., Design: An online survey was disseminated through the British Academy of Audiology and ENT UK., Study Sample: A total of 191 hearing healthcare professionals responded to the survey., Results: Overall, while 63% of the respondents considered themselves to be adequately informed about APD, only 4% viewed themselves as very informed on the topic. Fewer than half of the respondents report screening (31%), diagnosing (14%), or managing (36%) cases of APD. For screening APD, professionals most commonly use auditory processing tests in adults and take case histories in children, whereas routine audiological procedures are the primary method for diagnosing APD in both adults and children. Although modifying the listening environment is a widely recommended management strategy for APD, half of the respondents indicated that a diagnosis of APD has no implications for patient management., Conclusions: There is a critical need to promote APD-related training to ensure they can provide appropriate referrals and management.

Falls in older adults and those with neurodegenerative disease (ND) are a current public health hazard and the primary cause of sustaining a mild traumatic brain injury (mTBI)/concussion. Little is known regarding how post-concussion symptoms present in older adults and patients with ND, even though they are the demographic at highest risk. A combination of under-reporting of falls and a lack of awareness regarding potential consequences of falls, results in the underdiagnosis of post-fall issues and concussions in this population. Our aim was to conduct a quality assessment survey to assess physician practice regarding falls and their general knowledge of concussion symptoms. We sent surveys through email to 1400 North American physicians, mostly those working at university affiliated hospitals, who specialized in seeing older adults and patients with ND. One hundred forty-one physicians completed the survey. 71.4% of all responding physicians either never inquired or inquired in less than 5% of their patients with ND or older adult patients, about history of falls. Over half of the physicians (51.8%) either never ask or do not consider it necessary to ask about concussion symptoms post-fall. The majority of physicians (92%) recognized that concussions can have lasting effects on patients, particularly on mood and demonstrated good knowledge of post-concussion symptoms by correctly identifying them. Additionally, more than 70% of responding physicians believed that patients with ND or older adults can fully recover from a concussion with the same probability as any other age group if treated. Only 50% of physicians felt confident in managing post-concussion symptoms themselves, 53.9% of physicians did not know of, or did not have nearby concussion clinics to refer patients to. The gaps in practice are clearly reflective of the gaps in the literature regarding falls and concussions in older adults and ND patients. There is a very low rate of physician inquiry about history of falls and concussion symptoms in older patients and those with NDs. Failure to recognize a concussion, can lead to missed opportunities for targeted interventions to address reversible symptoms. Additionally, the misattribution of post-concussion symptoms to disease progression in older patients or those with NDs may delay and hinder appropriate management., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to American Aging Association.)

Aims: To analyze glycemic and bodyweight control in people with type 2 diabetes mellitus (T2DM), and prescribing patterns in primary care., Methods: We reviewed the electronic medical records of 5009 randomly selected T2DM patients, from 70 health centers in Spain. We analyzed results by age group and presence/absence of obesity. All data were collected in 2022., Results: Regarding treatment, 13.2 % of the sample were on lifestyle therapy only, 76.5 % received metformin, 37.6 % SGLT2 inhibitors, 32.2 % DPP-4 inhibitors, 12.2 % GLP-1 agonists, 18.9 % insulin, 6.5 % sulfonylureas, and 1.3 % glitazones. Glycated Hemoglobin (HbA1c) was below 7 % in 57.7 % of patients, and 62.3 % met their individualized HbA1c targets. Overall, 42 % of the population was obese (45.6 % of women vs 39.1 % of men; p = 0.001). Obesity rates decreased with age in both sexes. We found no association between obesity and poor glycemic control (HbA1c<7 %) (43,5 % vs 41,4 %; p = 0,17)., Conclusions: In 2022, over 60 % of people with T2DM treated by family doctors in Spain met their individualized glycemic control targets, but only one in three had good glycemic control without obesity. The use of drugs with cardiorenal benefits (particularly SGLT2 inhibitors) is higher than previous published data in our setting., 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. The author is an Associate Editor for [Primary Care Diabetes Journal] and was not involved in the editorial review or the decision to publish this article., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Dietary supplements (DSs) are commonly used supplements among children to support disease treatment, however, overuse and inappropriate prescription of outpatient DS can negatively affect health and treatment costs. This study aimed to evaluate DS use in outpatient treatment in children., Methods: The present study used a cross-sectional descriptive retrospective method based on data from 188,579 outpatient prescriptions of children for 1 year., Results: DSs were commonly prescribed in pediatric patients ≤5 years old (63.48 %) with diagnosing respiratory, infectious, and gastrointestinal diseases (>50 %). DS costs account for a high proportion (24.86 %) of total outpatient prescription costs. In addition, pediatric prescriptions containing one DS product (88.16 %) showed a higher rate than prescriptions containing two DS products (11.84 %) with the main ingredients being vitamin D 3 (80.55 %), vitamin B 6 (63.01 %), vitamin B 1 (60.22 %), and vitamin B 2 (59.04 %), and calcium (51.0 %). The majority of DS products contained multivitamins (69.52 %) with DS containing ≥5 vitamins of 59.04 % and DS containing 2-4 vitamins of 10.48 %. Besides, non-compliance with DS prescribing guidelines for age (21.38 %), dose (14.13 %), and both age and dose (5.54 %) was found primarily in highly prescribed DSs (vitamin-amino acid-mineral ingredients), pediatric patients <2 years old, prescriptions containing one DS product or multivitamins, and respiratory disease group (J and R04-09 ICD). The univariate and multivariate regression analyses showed that vitamin-mineral products and groups <2 years old were significantly associated with guideline-adherent DS prescribing for age and/or dose. Meanwhile, foreign DSs and vitamin-mineral ingredients of prescription showed significant associations with guideline-adherent DS prescribing for age or dose., Conclusion: Instructions for DS use regarding recommended age and maximum dosage may not be carefully considered by doctors due to belonging to an over-the-counter medicine group. Therefore, there is a strong need for a national public policy to prevent and control overprescribing and inappropriate prescribing of DS., Competing Interests: Declaration of competing interest The authors stated that there was no conflict of interest associated with the publication and no financial support, which could have influenced the outcome., (Copyright © 2024 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

ACCORDING TO THIS STUDY., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Policymakers aiming to increase access to health care while simultaneously keeping costs low and quality high are considering expanding the practice authority and prescriptive authority of nurse practitioners in order to address primary care shortages. While we know this increases access, some researchers argue that the expansion of job autonomy of nurse practitioners can compromise the quality and safety of rendered medical services. This paper investigates quality and safety outcomes in prescribing behaviors of nurse practitioners who have prescribed opioids for Medicare Part D beneficiaries using a unique source of policy variation, nurse practitioners with the ability to prescribe medication who move to either states with or without physician supervision. We find that scope of practice expansions do not compromise quality and safety in terms of potential abuse or misuse of prescriptive authority., (© 2024 John Wiley & Sons Ltd.)

Purpose: In cochlear implantation (CI) surgery, there are a wide variety of intraoperative tests available. However, no clear guide exists on which tests must be performed as the minimum intraoperative testing battery. Toward this end, we studied the usage patterns, recommendations, and attitudes of practitioners toward intraoperative testing., Methods: This study is a multicentric international survey of tertiary referral CI centers. A survey was developed and administered to a group of CI practitioners (n = 34) including otologists, audiologists and biomedical engineers. Thirty six participants were invited to participate in this study based on a their scientific outputs to the literature on the intraoperative testing in CI field and based on their high load of CI surgeries. Thirty four, from 15 countries have accepted the invitation to participate. The participants were asked to indicate the usage trends, perceived value, influence on decision making and duration of each intraoperative test. They were also asked to indicate which tests they believe should be included in a minimum test battery for routine cases., Results: Thirty-two (94%) experts provided responses. The most frequently recommended tests for a minimum battery were facial nerve monitoring, electrode impedance measurements, and measurements of electrically evoked compound action potentials (ECAPs). The perceived value and influence on surgical decision-making also varied, with high-resolution CT being rated the highest on both measures., Conclusion: Facial nerve monitoring, electrode impedance measurements, and ECAP measurements are currently the core tests of the intraoperative test battery for CI surgery., Competing Interests: Declarations. Conflict of interest: The authors have no competing interest to declare. The authors have no relevant financial or non-financial interests to disclose., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: To describe the clinical characteristics, comorbidity, and medical treatment in a primary care population with chronic kidney disease (CKD). Additionally, to investigate how primary care physicians (PCPs) diagnose, manage and treat impaired kidney function, including uptake of cardio-renoprotective renin-angiotensin-aldosterone system inhibitors (RAASis) and sodium glucose co-transporter 2 inhibitors (SGLT2is)., Design: An observational study of CKD prevalence, treatment patterns and comorbidities in primary care based on patient record data combined with a questionnaire on diagnosis, management and treatment of impaired kidney function in a real-world, primary care setting., Setting: In all 128 primary care clinics in Denmark of 211 randomly invited and a quetionnaire completed by 125/128 participating PCPs., Methods: A computerized selection identified 12 random individuals with CKD per clinic with ≥ 2 measurements of eGFR < 60 mL/min/1.73 m 2 or UACR > 30 mg/g within two years (N = 1 497). Pre-specified data collected from individual electronic health records included demographics, clinical variables, comorbidities, and relevant prescribed medications., Results: Of the CKD study population (N = 1 497), 80% had hypertension, 32% diabetes (DM), 13% heart failure (HF), 59% no DM/HF. ACEis/ARBs were prescribed to 65%, statins to 56%, SGTL2is to 14%, and MRAs to 8% of all individuals. Treatment patterns differed between individuals with varying comorbidities, e.g., ACEis/ARBs usage was higher in DM (76%) or HF (74%) vs. no DM/HF (58%), as was statin usage (76% in DM vs. 45% in no DM/HF). SGTL2i usage in no DM/HF was low. Most PCPs identified CKD using eGFR < 60 mL/min/1.73 m 2 (62%) or UACR > 30 mg/g (58%) and 62% reported initiating treatment to retard kidney function decline., Conclusions: Despite good PCP awareness and wish to use relevant guidelines, a gap exists in implementation of cardio-renoprotective treatment, especially in individuals without DM/HF. This offers an opportunity for clear recommendations to PCPs to optimize early cardio-renal protection in individuals with CKD., Competing Interests: Declarations. Ethics approval and consent to participate: The study (including patient data collection) and the questionnaire represented observational, non-interventional, quality-improvement research with significant societal impact using anonymized data and no patient involvement. Thus, no specific legal approval or informed patient consent in accordance with Danish legislation was required. Consent for publication: Not required, and not done, in accordance to national regulations. Competing interests: The authors did not receive payment related to the development of the manuscript. All authors received an honorarium from Boehringer Ingelheim with respect to this study for their role as Steering Committee members. ML: has received speaker and consultancy fees from AstraZeneca, Bayer, Boeringer Ingelheim, Novo Nordisk, GlaxoSmithKline, and is an investigator in clinical studies sponsored by Amgen, Bayer, Boehringer Ingelheim, Janssen, MSD and Novo Nordisk. STK: has received research grants from and lecture fees from Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, MSD, Novo Nordisk, and Sanofi and has served as a consultant for Bayer, Boehringer Ingelheim, MSD, Mundipharma, Novo Nordisk, and Sanofi. TS: none; MC: has received speaker/expert testimony honoraria from Novo Nordisk Denmark, Boehringer Ingelheim Denmark, and Abbott Rapid Diagnostics. RB: has received speaker honoraria or consultancy fees from AstraZeneca, Bayer, and Boehringer Ingelheim, is an investigator in clinical studies sponsored by Boehringer Ingelheim, AstraZeneca, Bayer, and has received unrestricted research grants from Boehringer Ingelheim., (© 2025. The Author(s).)

In the 2019 Guidelines for the Management of Hypertension by the Japanese Society for Hypertension, lifestyle modification is recommended for all individuals except those with normal blood pressure. However, no detailed methods have been established to achieve the target blood pressure and resolve clinical inertia. CureApp HT, a digital therapeutic for hypertension that contributes to blood pressure reduction through lifestyle modification, was approved as software as a medical device for reimbursement by Japanese national health insurance in September 2022. This study aimed to survey physicians who implemented CureApp HT to assess how it changes physician-patient communication and contributes to clinical inertia resolution. A questionnaire survey was conducted at three time points: before the first prescription (first survey), 3 months (second survey), and 6 months (third survey) after the first prescription for physicians who had implemented CureApp HT. The primary outcome was the total score of five items on a Likert scale related to physician-patient communication, and it was analyzed based on the 47 physicians who responded to all three questionnaires. The total score of physician-patient communication significantly improved after 6 months of the introduction of CureApp HT, reflecting that physicians observed positive changes in patients' knowledge and attitudes regarding hypertension treatment. Furthermore, the number of physicians who set a target home blood pressure of 125/75 mmHg for their patients significantly increased. CureApp HT allows physicians to recognize changes in patients' disease knowledge and treatment attitudes, enabling them to set more stringent blood pressure targets and addressing clinical inertia. Physicians who implemented CureApp HT recognized changes in the patients' stages of behavioral change through improvements in patients' knowledge of the disease and their attitudes towards treatment, and by experiencing more effective communication, they set stricter blood pressure targets., Competing Interests: Compliance with ethical standards. Conflict of interest: Author TK received honoraria from CureApp, Inc. FH, MA, YH, YT, YI, and TT are employees of CureApp, Inc., (© 2024. The Author(s).)

Background: Thyroid hormone is one of the most commonly prescribed medications in the United States. Misuse of and overtreatment with thyroid hormone is common in older adults and can lead to cardiovascular and skeletal adverse events. Even though deprescribing can reduce inappropriate care, no studies have yet explored specific barriers and facilitators to guide thyroid hormone deprescribing in older adults (defined as discontinuation of thyroid hormone when initiated without an appropriate indication or dose reduction in those overtreated)., Methods: We conducted semi-structured interviews with 19 endocrinologists, geriatricians, and primary care physicians who prescribe thyroid hormone. Interviews were completed between July 2020 and December 2021 via two-way video conferencing. We used both an inductive and deductive content analysis guided by the Theoretical Domains Framework to evaluate transcribed and coded participant responses. Thematic analysis characterized themes related to barriers and facilitators to thyroid hormone deprescribing practices in older adults., Results: The most commonly reported barriers to thyroid hormone deprescribing were related to patient-level factors, followed by physician- and system-level factors. Patient factors included patients' perceived need for thyroid hormone use and patient anxiety/concerns about potential side effects related to thyroid hormone dose reduction, patient lack of knowledge, and misinformation regarding deprescribing. Physician- and system-level barriers included clinic visit time constraints, physician inertia, physician lack of knowledge about deprescribing, perceived lack of sufficient patient follow-up, and electronic health record limitations. The most prominent physician-reported facilitators to thyroid hormone deprescribing were effective physician-to-patient communication, and positive physician-patient relationship, including patients' trust in their treating physician., Conclusion: Barriers and facilitators to thyroid hormone deprescribing in older adults were reported at multiple levels including patient-, physician-, and system-level factors. Interventions to improve thyroid hormone deprescribing in older adults should aim to improve patient education and expectations, increase multidisciplinary physician awareness, and overcome physician inertia., (© 2024 The American Geriatrics Society.)

Background: Secondary hyperparathyroidism (SHPT) is common in patients with chronic kidney disease (CKD). Many recommendations in the Kidney Disease Improving Global Outcomes (KDIGO) CKD-mineral and bone disorder guidelines are supported by modest evidence and predate the approval of newer agents. Therefore, an expert panel defined consensus SHPT practice patterns in the United States with real-world context from the nephrology community., Methods: Ten US healthcare providers and one patient participated in a modified Delphi method comprising three phases. Consensus was determined via iterative responses to a questionnaire based on the 2009 and 2017 KDIGO guidelines and published literature on the identification, evaluation, monitoring, and interventional strategies for patients with SHPT. The threshold for consensus was 66% agreement., Results: Panelists generally agreed with KDIGO recommendations, with some differences. Consensus was reached on 42/105 (40%), 95/105 (90.5%), and 105/105 (100%) questions after phases 1, 2, and 3, respectively. Panelists unanimously agreed that SHPT treatment is often started late. There was a preference for serum phosphate level <4.6 mg/dL, and consensus to maintain serum calcium levels <9.5 mg/dL. There was unanimous agreement for vitamin D analogues as first-line options in patients not on dialysis with severe, progressive SHPT and unanimous preference for intravenous calcimimetic, etelcalcetide, in appropriate in-center dialysis patients. Factors such as formularies, dialysis center protocols, and insurance were recognized to influence therapeutic strategies., Conclusions: Expert consensus was reached on SHPT management, further defining therapeutic strategies and medication use and emphasizing need for treatment early. Despite evidence-based treatment preferences supported by clinical experience, factors other than scientific evidence influence decision making, particularly with medications., Competing Interests: The competing interest statement does not alter the adherence to PLOS ONE policies on sharing data and materials. In the interest of scientific sharing, the panelist and patient questionnaires have been provided in the supplemental materials, (Copyright: © 2025 Henner et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Diagnostic testing is prevalent among children with persistent non-specific symptoms (PNS), and both undertesting and overtesting have negative consequences for child and society. Research in adults with PNS has shown that GPs use diagnostic testing for reasons other than diagnosis, but comparable research has not, to the best of our knowledge, been conducted in children. Understanding GPs' perspectives of testing decisions in children could provide insights into mechanisms of undertesting and overtesting., Aim: To investigate GPs' perspectives of conducting or refraining from diagnostic testing in children with PNS and the differences compared with their motives when treating adults., Design and Setting: Qualitative study using semi-structured interviews with Dutch GPs., Method: We purposively sampled GPs until data saturation. Reasons for conducting or refraining from diagnostic tests were explored using two real-life cases from daily practice. Online video interviews were transcribed verbatim. Data were collected and analysed concurrently by thematic content analysis., Results: Twelve GPs participated. Their decision making involved a complex trade-off among four themes: medical considerations (for example, alarm symptoms), psychosocial factors (for example, doctor-patient relationship), consultation management (for example, 'quick fix'), and efficient resource utilisation (for example, sustainability). Compared with when treating adults, GPs were more hesitant to conduct diagnostic testing in children because of their higher vulnerability to fearing invasive procedures, lower probability of organic disease, and reduced autonomy., Conclusion: As in adults, GPs' decisions to conduct diagnostic tests in children were motivated by reasons beyond diagnostic uncertainty. Educational programmes, interventions, and guidelines that aim to change the testing behaviours of GPs in children with PNS should target these reasons., (© The Authors.)

Introduction: The global prevalence of antimicrobial resistance transcends geographical and economic boundaries, affecting populations worldwide. Excessive and incorrect use of antibiotics encourages antimicrobial resistance which leads to complex treatment strategies for infectious diseases and possible failure of treatment. The incorrect and unnecessary prescribing of antibiotics places a burden on healthcare costs and thus, antimicrobial resistance is evident globally as a major public health concern. The impact is particularly pronounced in low to middle-income countries, where limited access to healthcare exacerbates the crisis. This scoping review aims to comprehensively map the evidence of antimicrobial resistance in healthcare settings, encompassing the exploration of antibiotic prescribing practices and the implementation of antimicrobial stewardship initiatives in South Africa., Methodology: This protocol has been registered in the Open Science Framework (https://doi.org/10.17605/OSF.IO/PWMFB). This review will consider all types of study designs, conducted within South Africa. Studies that are published in English for the period 2019-2024, and that explore antimicrobial resistance (AMR) evidence in healthcare in South Africa, including antibiotic prescribing trends and antimicrobial stewardship and surveillance initiatives will be included. Non-English publications, studies outside of South Africa, animal and environmental studies will be excluded. The criteria for the scoping review will be set by two reviewers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) tool will be used. Studies will be identified through an extensive search of peer-reviewed and grey literature databases. The results of the review will be tabulated and include a narrative synthesis of the findings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Ahmed et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Offering medication for opioid use disorder (MOUD) in primary care can increase access to effective opioid use disorder treatment and help address the US opioid crisis. We describe a primary care office-based opioid treatment program and addiction consultation service model designed to support small, rural clinics to increase their capacity for MOUD., Methods: This is an evaluation of an intervention to increase clinic capacity to offer MOUD. The intervention consists of a standardized curriculum, addiction medicine consultants, practice facilitation, and financial incentives. Fifteen Colorado primary care practices participated from January 2022 through January 2023. Primary outcomes included overall change in the number of active buprenorphine prescriptions and implementation of MOUD milestones before and after the intervention., Results: The mean number of active buprenorphine prescriptions in the 3 months preceding the intervention (baseline) increased from 2.1 (SD = 7.7) to 11.3 (SD = 11.2) at 13 months. Adjusted means from the Poisson model demonstrated significant improvement over time ( P <.001). Mean implementation of MOUD milestones ranged from 23% to 40% at baseline and grew to 84% to 93% by the end of the program ( P <.001)., Conclusions: This model supported primary care practices that were initially doing little to no MOUD prescribing, to prescribe at significantly higher levels by the end of the program. This scalable model for addiction consultation in primary care settings illustrates how education and support to clinical teams can help practices makes changes, especially those with limited MOUD experience., (© 2025 Annals of Family Medicine, Inc.)

New U.S. guidelines support shared decision-making regarding breastfeeding for mothers living with HIV and their neonates. We surveyed Pediatric Infectious Diseases Society members about the implementation of these guidelines. We found heterogeneity in uptake, variability in clinical practice, and concerns about implementation. Future research should address these policy-practice gaps., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. 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.)