BJGP Open

BackgroundCommunication issues across the primary-secondary care interface are considered one of the most important challenges in improving patient safety in primary care in the UK. Teleconferencing offers a potential means of improving communication during referrals but is largely unevaluated. AimTo explore teleconferencing as an alternative to written Advice and Guidance (A&G) referrals for neurology cases, by assessing its impact on GP-specialist communication and relationships, and exploring implications for patient care. Design and SettingA qualitative case study of a primary care network (PCN) and a secondary care centre in East Anglia. Methods18 clinicians and 10 other stakeholders were interviewed. Observations of teleconferences and a focus group with five PCN staff provided additional data. Data collection and analysis were guided by the Consolidated Framework for Implementation Research and Reflexive Thematic Analysis. ResultsAdvantages of teleconferencing identified by participants included greater clinician satisfaction, mutual educational value, streamlined patient journeys and continuity of care. Teleconferences were also seen to build GP-specialist relationships and reduce unnecessary outpatient referrals. Perceived issues included time constraints, clinical governance and funding sustainability; teleconferences were not seen as appropriate for all referrals. Overall, participants welcomed the teleconference approach but stressed the need to robustly assess its cost-effectiveness and replicability in other settings. ConclusionTeleconferencing is a potentially promising alternative to written A&G referrals and was perceived by participants to help build GP-specialist relationships. However, further studies are needed to assess clinical effectiveness and costs, and to guide future development and implementation. How this fits inO_ST_ABSWhat is known?C_ST_ABSReferral interventions involving direct GP-specialist dialogue can enhance referral quality, reduce outpatient referrals and improve GP-specialist relationships, with some demonstrating improved clinical outcomes. However, they often face sustainability challenges, and their cost-effectiveness and mechanisms of impact require further assessment. What does this study add?This qualitative study identifies key mechanisms through which virtual GP-specialist dialogue may lead to downstream benefits: enabling shared decision-making and delivering consultant-level care closer to home; empowering GPs to manage complex cases; and reducing overall workload across primary and secondary care systems. The programme theory developed can be used to guide future intervention design, implementation and evaluation.

BackgroundDementia affects over 57 million people worldwide. UK and international policy position personalised, conversation-based care planning as central to post-diagnostic support. However, delivery in primary care is inconsistent, and many practitioners lack dementia-specific communication training. Existing evidence focuses on single roles or settings, leaving a gap in understanding how communication operates across the primary care workforce. AimsTo identify what helps and hinders effective communication for integrated dementia care planning and determine the support and training needs of the wider primary care workforce. MethodsO_LISemi-structured interviews - 11 people with dementia, 13 family carers, and 19 primary care practitioners from diverse roles, exploring experiences of care planning conversations C_LIO_LIReflexive thematic analysis C_LI ResultsThree themes were developed, progressing from micro-level communication practices (Theme 1: Beyond the tick-box), through triadic dynamics (Theme 2: Balancing voices in the conversation), to organisational influences (Theme 3: From silos to meaningful shared care planning). Time and Conversation as intervention cut across all themes, shaping trust and disclosure. Participants reported reliance on tick box approaches, inconsistent preparation, and uncertainty about care plan purpose and ownership. Non-clinical roles were commonly viewed as well placed to support meaningful conversations, but were often described as constrained by unclear remit and weak integration. ConclusionsA persistent gap remains between policy ambitions and everyday practice. Time-pressured, checklist-driven encounters and fragmented systems undermine shared decision-making. The expanded primary care workforce offers untapped potential to address these gaps, but this requires clearer roles, formal integration, and targeted investment in communicative skills.

BackgroundHip fracture remains a leading cause of morbidity and mortality among older adults in the United States. The aim of this systematic and meta-analytical review is to synthesize available evidence on predictors of one-year mortality following hip fracture among older adults, guided by a socio-ecological framework. MethodsWe searched PubMed, Embase, Web of Science, CINAHL, and Scopus for U.S.-based studies published between 2010 and 2025 reporting one-year mortality after hip fracture. Studies were included if they evaluated predictors of mortality across pre-injury, perioperative, or post-discharge phases. Data were extracted on study design, population characteristics, mortality outcomes, and risk factors. Predictors examined in [≥]3 studies were pooled using random-effects meta-analysis, and narrative synthesis was conducted for predictors with limited data. Methodological quality was assessed using the Joanna Briggs Institute checklist. ResultsTwenty-eight studies (n = 835,226) met inclusion criteria. Pooled one-year mortality was 21.8%, ranging from 7.1% to 54.4%. Advancing age and male sex were consistent non-modifiable risk factors. Comorbidity burden, including congestive heart failure, chronic kidney disease, myocardial infarction, and dementia, and measures of frailty and functional impairment were among the strongest predictors, often doubling mortality odds. Perioperative factors such as higher injury severity and delayed surgery, and post-discharge factors including hospital readmission, missed follow-up visits, and postoperative complications, were also associated with increased mortality. ConclusionOne-year hip fracture-related mortality remains high and stems from multifactorial causes. A multi-level, systems-oriented approach may be necessary to meaningfully reduce long-term mortality in this growing and vulnerable population.

BackgroundRecurrent sore throat affects a small minority of adults but can cause substantial morbidity. Evidence to guide tonsillectomy eligibility in adults is limited, and current criteria are extrapolated from paediatric populations. We aimed to describe the epidemiology, management, and prognosis of adult sore throat in UK primary care. MethodsUsing CPRD Aurum (2010-2020 adults with a first coded episode of sore throat or tonsillitis were identified and matched to controls. Episode frequency, antibiotic use, ENT referral, and tonsillectomy were analysed. Predictors of recurrent episodes ([≥]3 in 365 days), referral, and tonsillectomy were assessed using time-to-event, multinomial logistic, and multilevel mixed-effects regression models. FindingsOf 4.45 million adults, 1.70 million (38.3%) had [≥]1 episode; most (61.5%) had only one, but 4.1% experienced [≥]3 within 1 year. Recurrent episodes were more common in younger females and those from more deprived areas. Only 21,869 patients (0.5% of the exposed cohort) underwent tonsillectomy, and just 25.7% of these met Paradise criteria at any time; conversely, only 13.9% of those meeting criteria underwent surgery. Patients who had a tonsillectomy tended to be younger, female, and from less deprived areas. Pre-tonsillectomy episode rates were unexpectedly low, but the data indicated that individuals with high baseline burden continue to experience elevated episode rates over several years. ConclusionsRecurrent sore throat is uncommon, but those affected face substantial disease burden. Current tonsillectomy patterns are poorly aligned with disease burden and show inequities by deprivation. Earlier identification of adults likely to develop recurrent episodes, and more timely surgical intervention, may improve patient outcomes and the cost-effectiveness of tonsillectomy.

BackgroundTotal knee arthroplasty (TKA), partial knee arthroplasty (pKA), and arthroscopic meniscectomy are among the most commonly performed procedures for knee osteoarthritis and degenerative meniscal tears in the United States, yet concerns persist regarding overuse, variable clinical benefit, and high costs. Orthobiologic treatments, including platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), have emerged as less invasive alternatives, but downstream health care resource use (HCRU) and costs associated with these treatments relative to surgery are not well established. MethodsWe conducted a retrospective, observational cohort study using linked commercial insurance claims data and a national orthobiologic treatment registry to compare downstream HCRU and costs following orthobiologic versus surgical treatment of knee conditions. Two comparisons were evaluated separately: (1) PRP versus arthroscopic meniscectomy among patients with degenerative meniscal pathology and minimal osteoarthritis, and (2) BMAC with or without PRP versus TKA or pKA among patients with knee osteoarthritis. Eligible procedures occurred between 2016 and 2023. Propensity score matching was used to balance demographic and clinical confounders. Co-primary outcomes were total health care costs at 12 and 24 months post-procedure, with exploratory analyses at 36 and 48 months. Costs were estimated using multiple approaches, including Medicare-based estimates, commercial payer estimates, and aggregate allowed amounts. HCRU outcomes included outpatient visits, physical therapy, imaging, opioid use, repeat injections, and subsequent surgery. ResultsAfter matching, analyses included 167 PRP-treated patients matched to 1,670 meniscectomy patients and 165 BMAC/PRP-treated patients matched to 1,650 TKA/pKA patients, with good balance across pre-specified confounders. Progression to subsequent surgery after orthobiologic treatment was rare at 12 and 24 months in both cohorts. Compared with TKA/pKA, BMAC/PRP was associated with lower overall health care use for several services, including outpatient visits, physical therapy, knee radiographs, and opioid prescriptions, although magnetic resonance imaging was more frequent following orthobiologic treatment. Total costs at 12 and 24 months were consistently higher for TKA/pKA than for BMAC/PRP across all costing methods. In the PRP versus meniscectomy comparison, differences in health care use were modest, and costs were similar or lower for PRP depending on the costing approach. Exploratory analyses through 48 months showed similar patterns, with persistently low rates of subsequent surgery after orthobiologic treatment and generally higher cumulative costs following surgical intervention. ConclusionsIn this real-world, propensity-matched analysis of commercially insured patients, orthobiologic treatments with PRP or BMAC were associated with similar or lower downstream health care costs compared with commonly performed surgical alternatives for selected patients with degenerative meniscal tears or knee osteoarthritis. Progression to surgery following orthobiologic treatment was uncommon through two years and remained low in longer-term exploratory analyses. These findings support the consideration of orthobiologic therapies as potentially lower-cost alternatives to surgery for appropriately selected patients and may inform shared decision-making and payer policy.

Smoking Cessation Efforts for Patients with Asthma and COPD IntroductionSmoking cessation can alter the natural history of both COPD and asthma by reducing the frequency and severity of exacerbations and slowing disease progression. Accordingly, the Global Initiative for Asthma and the Global Initiative for Chronic Obstructive Lung Disease recommend that clinicians address smoking cessation at every visit using counseling and pharmacotherapy. MethodsThe Mount Sinai Health System includes seven hospitals and more than 400 outpatient locations in the New York metropolitan area, all using a unified electronic medical record (Epic). De-identified data from calendar year 2024 were extracted for individuals identified as current smokers via the EMR smoking status tool. Patients with asthma and/or COPD were identified using ICD-10 codes. Tobacco treatment was defined as receipt of counseling or pharmacotherapy, including varenicline, bupropion, or nicotine replacement therapy. ResultsAmong 961,997 patients, 58,566 (6.1%) were identified as current cigarette smokers. Across all health system encounters, 32.6% of smokers with both asthma and COPD were given any treatment, followed by 26.7% of smokers with COPD, 13.0% of smokers with asthma, and 9.9% of cigarette smokers without these conditions. Smokers seen in pulmonary clinics were the most likely to be given treatment (17.4%), followed next by primary care (6.6%).The most commonly used treatment for all cohorts and all treatment settings was nicotine with the exception of the pulmonary clinic where varenicline predominated. DiscussionDespite higher treatment rates among smokers with asthma and COPD, only one-third of those with either condition received cessation treatment over a full year, underscoring the need for sustained system-wide quality improvement efforts.

BackgroundThe United Nations General Assembly High-level Meeting on Antimicrobial Resistance (UNGA HLM-AMR) committed to a target that 70% of global human antibiotic use (ABU) should be from the Access group of the WHO AWaRe system. MethodsWe used 2019 IQVIA MIDAS(R) global ABU Quarterly value sales, volumes (kg/SU) and average ex-manufacturer prices to evaluate price per daily defined dose (DDD) by AWaRe group across countries. IQVIA MIDAS volumes/value data reflect public, private, or mixed sectors. We estimated potential national pharmaceutical expenditure savings if i) the UNGA 70% Access target was met, and ii) national ABU aligned with the WHO Model List of Essential Medicines (EML). We evaluated 7-day treatment prices for common oral and parenteral antibiotics across AWaRe groups. We measured affordability in middle-income countries (MICs) by income group, as the percentage of the population at risk of falling below national poverty lines if paying out-of-pocket, using income distributions and generalised beta distributions of the second kind. Prices were reported in 2019 international dollars (I$). ResultsVolume-weighted ex-manufacturer prices per DDD were lower for Access (I$1{middle dot}2, IQR I$0{middle dot}7) than Watch (I$2{middle dot}6, IQR I$2{middle dot}1) and highest (I$83{middle dot}8, IQR I$80{middle dot}9) for Reserve antibiotics. Lower prices were seen in high-income countries for Access antibiotics. Meeting the 70% Access target could save countries I$0{middle dot}1 million-I$4{middle dot}9 billion annually. Global savings could reach I$10{middle dot}4 billion if only WHO EML-listed antibiotics were used. Seven-day parenteral meropenem could put 7% (IQR 9%) of the population in MICs at risk of impoverishment. ConclusionAntibiotic policies focused on achieving the UNGA-AMR 70% Access target could generate significant potential national and global expenditure savings. FundingThis work was supported by the Wellcome Trust (304681/Z/23/Z) as part of the Antibiotic Data to Inform Local Action (ADILA) project and the Global Antibiotic Policy initiative (GAPi) project (RES 2024-495).

Background Antibiotic pricing is a key determinant of access and stewardship in low- and middle-income countries (LMICs), yet empirical evidence on how prices are formed within pharmaceutical markets remains limited. However, there is little longitudinal evidence on how antibiotic prices behave within national pharmaceutical supply systems. This study evaluated the patterns and determinants of systemic antibiotic pricing in Tanzania using national regulatory import permit data. Methods We conducted a retrospective analysis of antibiotic importation records from the Tanzania Medicines and Medical Devices Authority for 2010-2016. Systemic antibiotics for human use imported via oral or parenteral routes were included. Unit prices (USD per smallest unit of measure) were summarized using the median and interquartile range (IQR). Prices were compared by route of administration, supplier country, and product naming practice (INN-named versus brand-named) using Mann-Whitney U and Kruskal-Wallis tests with false discovery rate adjustment. Results Of the 14,301 records, 10,894 (76.2%) met the inclusion criteria. Oral antibiotics predominated (89.6%). Although the median oral antibiotic prices declined over time, substantial price dispersion persisted across all study years. Parenteral antibiotics were consistently more expensive (USD 0.755-3.370) and more variable than oral antibiotics. Importation was concentrated in a few medicines, with amoxicillin-clavulanate (16.7%) and amoxicillin (11.4%) accounting for over one-quarter of records, and in a few supplier countries, with India representing 44.9% of the records. Significant price differences between INN-named and branded products were observed for amoxicillin (adjusted p<0.001) and ciprofloxacin (adjusted p=0.018), whereas prices differed significantly by supplier country across major medicines (adjusted p<0.05). Across medicines and years, wide within-product price distributions indicate persistent market segmentation rather than price convergence. Conclusions Antibiotic import prices in Tanzania exhibit systematic and reproducible variations associated with formulation type, supplier origin, and product naming practices. The findings indicate that procurement structure and supplier participation strongly influence pricing in the import-dependent pharmaceutical market. Monitoring import-level prices can serve as an upstream indicator of market conditions and support evidence-informed procurement, pricing regulations, and antimicrobial stewardship policies in LMIC settings.

BackgroundArthroscopic rotator cuff repair (RCR) is a common surgical intervention used to address rotator cuff-related pain after other conservative interventions have been exhausted. With a continuing increase in procedures, evidence-based outcomes research is needed to identify key parameters of postoperative rehabilitation planning. ObjectiveWe aim to identify rehabilitation planning factors leading to better outcomes while also providing clinicians with reference data to describe the magnitude of pain and functional improvement following RCR. MethodsFor this observational study of patients undergoing RCR surgery and physical therapy, demographic variables and patient-reported outcome measures (PRO) were collected preoperatively and up to 12 months postoperatively Four multiple linear regression models were created, one for 12-month Visual Analog Scale (VAS) score, the second for VAS improvement, the third for 12-month American Shoulder and Elbow Surgeons (ASES) function score, and the fourth for ASES function improvement. ResultsThe 29 participants had a median age of 62 years, median baseline VAS of 4.9, ASES composite score of 45, and Veterans-Rand 12 Mental Component Score of 53.5. In univariate analysis, one variable was associated with 12-month VAS score and two were associated with 12-month VAS improvement. No associations were found with 12-month ASES function score, and one variable was associated with ASES function improvement. With our sample, multivariable analyses provided no significant association or predictor for VAS or ASES function scores. ConclusionsOur hypothesis was not supported, and we did not find an association between physical therapy wait time prior to evaluation or visit frequency and PRO measures or improvements. We observed that 12-month PRO measures and improvements can be predicted using baseline measures among this population.

IntroductionTraditional bone-setting remains a culturally significant healthcare practice in low- and middle-income countries, particularly in regions like Sudan where modern orthopedic services are often inaccessible or unaffordable .This study examines the role of traditional healing practices in orthopedic care in White Nile State, Sudan, assessing patient perceptions, treatment effectiveness, and sociocultural factors influencing healthcare choices. MethodsA cross-sectional analytical study was conducted among 147 patients, 7 traditional healers, and 4 orthopedic practitioners in urban and rural areas of White Nile State. Data were collected using structured questionnaires and interviews, focusing on treatment preferences, perceived effectiveness, and barriers to integration. Descriptive and inferential statistics were used to analyze quantitative data, while thematic analysis was applied to qualitative responses from healers and practitioners. ResultsFractures (45.6%) and arthritis (23.1%) were the most common orthopedic conditions. 30.6% of patients initially sought traditional treatment, all eventually utilized modern care (medication 71.4%, surgery 42.9%). Traditional healing was perceived as somewhat effective by 40% of users, whereas 59.9% rated modern care as very effective. Key factors influencing treatment choices included cultural beliefs (29.9%), accessibility (18.4%), and cost (16.3%). No significant demographic associations were found with treatment preference or effectiveness (p > 0.05). Traditional healers predominantly treated dislocations (100%) and fractures (71.4%) using manual techniques, with 57.1% referring complex cases to modern practitioners. Barriers to collaboration included lack of communication (85.7% of healers) and differing treatment philosophies (50% of practitioners). ConclusionThis study highlights the persistent dual reliance on traditional and modern orthopedic care in Sudan, with modern treatments perceived as more effective yet traditional methods remaining culturally entrenched especially in rural areas. The path forward requires bridging these systems through mutual respect, shared protocols, and community engagement to ensure safe, equitable, and effective musculoskeletal care for all Sudanese patients.

BackgroundReverse total shoulder arthroplasty (rTSA) is an increasingly common surgical procedure often performed to treat pain related to glenohumeral osteoarthritis or to rotator cuff arthropathy. Although surgical outcomes are generally excellent, recent evidence has found that postoperative pain ([&ge;] 3/10) two years following surgery is reported by an estimated 18% of patients. Recently, the NIH Acute-to-Chronic Pain Signatures program recommended longitudinal studies using select biomarkers to describe and predict individual patient responses to surgery. These data are not yet available for rTSA procedures. MethodsThis was a longitudinal cohort study performed at a single academic medical center. Twenty participants undergoing rTSA surgery were included, recruited from a tertiary hospital system in the southern United States. The first objective of this study was to describe changes in general pain intensity (Numerical Pain Rating Scale), widespread body pain, anxiety (General Anxiety Disorder-7), depression (Patient Health Questionnaire-9), neuropathic pain symptoms (painDETECT), and quantitative sensory testing from baseline to 6 weeks following rTSA. The second objective was to identify the baseline demographic and pain-related factors associated with 6-week postsurgical improvements in pain intensity. ResultsFrom before to after surgery, our cohort demonstrated significant improvement in shoulder pain intensity, widespread body pain, PainDETECT score, and temporal summation magnitude measured at the surgical deltoid. Degree of 6-week pain intensity improvement was associated with baseline pain intensity (F=18.79, p=0.0004) and temporal summation magnitude of the tibialis anterior (F=5.06, p=0.0380). ConclusionsPain intensity, location, nature, and mechanism can serve as biomarkers of the short-term postsurgical changes that can be expected following rTSA. Baseline pain intensity and temporal summation magnitude of the tibialis anterior were associated with the degree of pain improvement, suggesting their use for preoperative risk assessment. Future research should evaluate whether these 6-week biomarker changes are associated with the development of chronic postoperative pain at longer durations after surgery. Level of EvidenceLevel I, Prognostic Study

AimThis research aims to evaluate the effectiveness, cultural appropriateness, and feasibility of the Cook Islands palliative care model te vaerua k[o]p[u] tangata ora within palliative care practice. BackgroundAccess to palliative and end of life care is a recognised human right, yet significant disparities persist for Pacific peoples in Aotearoa, New Zealand. While the understanding of different cultural perspectives has grown, in Aotearoa, there remain gaps in the delivery of culturally appropriate palliative care. MethodologyThis study will use a Cook Islands T[i]vaevae research methodology to guide semi-structured interviews with 25-35 Cook Islands community members and 10 palliative care clinicians. This approach will support a rich, relational, and culturally grounded exploration of how a Cook Islands M[a]ori palliative care model can be integrated into clinical practice. DiscussionRecommendations to improve culturally responsive palliative care will be formulated in collaboration with community members and clinicians. The study will contribute to the limited body of knowledge on Pacific cultural understandings of palliative care and provide practical insights into applying an indigenous Pacific model within the palliative care system.

AimTo outline the opportunities and barriers when using hairdressing salons as a novel site for enhancing cardiovascular risk factor assessment and management in women. MethodsA process evaluation nested within a cluster-randomised trial, Hairdressers for Health. The trial evaluated a nudge intervention advising women [&ge;]45years attending hairdressing salons to undertake a Heart Health Check with their General Practitioner. The UK Medical Research Council process evaluation framework was used to guide the design, data collection and analysis. Nineteen interviews were conducted with nine hairdressers, nine study participants and a project officer. Thematic analysis assessed recruitment, reach, acceptability, and adoption. Characteristics of the salons and participants were analysed using descriptive statistics. ResultsRecruitment of the planned 88 metropolitan and 28 regional salons for the trial was challenging, requiring resource-intensive face-to-face visits. The nudge intervention was well accepted by participants, and salons were perceived to be an appropriate setting to effectively reach women. Adoption of the study by salons was limited with only 54 of the 116 salons recruiting participants (total recruited 239, range 1-22 participants per salon). Barriers to participant recruitment included technological constraints while using a decentralised online recruitment and data collection platform, client preferences and privacy concerns. Established hairdresser-client relationships in smaller salons facilitated greater client participation and was perceived as a good mechanism for health promotion. ConclusionsCardiovascular health prevention messaging for women in salons was acceptable to hairdressers and clients. Designing the study to make better use of hairdresser-client personal relationships may have improved project implementation. Trial RegistrationACTRN12621001740886

IntroductionChronic pain in fibromyalgia may be driven by abnormal ongoing activity in a subclass of C-fibre nociceptors known as Type1B or CMi nociceptors. As is common in C-nociceptor microneurography studies, the modest patient numbers in these prior studies generate large confidence intervals around the point estimate of the prevalence of this abnormal activity. This complicates the interpretation of the relative importance of this ongoing nociceptor activity as a pain generating mechanism in fibromyalgia. The study aims to improve precision via an adaptive Bayesian protocol that maximises the yield and quality of data collection whilst minimising patient burden. MethodsThe study employs an optimised microneurography protocol with an adaptive study design. The microneurography protocol incorporates early identification of CMi nociceptors via an abbreviated activity dependent slowing protocol to increase yields enabling efficient collection of the primary outcome data. The adaptive study design will use Bayesian principles to iteratively assess the predictive probability of futility, and terminate early if there is high confidence that the hypothesis is false. Furthermore, the study will employ questionnaires to explore links with pain in the area under study to the electrophysiology data. Finally, quantitative sensory testing will be used to investigate whether the irritable nociceptor phenotype is associated with abnormalities in CMi nociceptor physiology. Ethics & DisseminationThis study has received HRA REC approval in the UK. Participants will provide written informed consent, and may withdraw at any time without consequence. At the end of the study, the results will be disseminated through peer-reviewed publication, and the data made available via a data repository. Strengths & limitations of this studyBayesian predictive probability of futility to minimise patient burden in microneurography Microneurography for objective interrogation of the peripheral nervous system Optimised microneurography protocol to efficiently answer primary hypotheses Subjective elements of early termination criteria of the study assessed and co-developed with Patient and Public Inclusion and Engagement Group

BackgroundHypertension guidelines recommend the use of automated BP devices over manual devices to reduce observer bias, such as terminal digit preference. We aimed to evaluate systematic differences in BP readings and the association with incident stroke according to type of measurement. MethodsUsing de-identified electronic health record data from Optum Labs Data Warehouse from primary care visits in 2024, we classified providers BP measurement method using proportion of odd terminal digit preference as a proxy for manual devices (defined as <0.5% odd digits) and automated devices (defined as 45-55% odd digits). Patients from the manual and automated groups were matched on demographic and clinical covariates. We evaluated cross-sectional BP distributions by measurement modality, and compared mean BP and proportions meeting clinical thresholds using t-tests, and chi squared tests, respectively. In a separate 2019 cohort created using the same methods, we evaluated whether longitudinal associations between systolic BP and incident stroke differ by measurement method. ResultsAmong 336,634 matched patients, mean SBP in the automated group was 131.7 (19.3) mmHg and 125.9 (14.8) mmHg in the manual group. The absolute percentage of patients meeting BP clinical thresholds differed substantially (<130/80: automated 33.2% vs. manual 38.8%; <140/90: automated 61.2% vs. manual 70.9%). Among 686,482 matched patients in the 2019 cohort, the manual group had a 1.16-fold (1.10-1.22) higher risk of stroke at any given BP compared to the automated group. ConclusionManual BP measurement was associated with lower mean BP, BP control, and potential underestimation of stroke risk.

ObjectivesVisit-to-visit blood pressure variability (VVV BPV) is an underutilised risk factor for cardiovascular disease (CVD). This study aims to determine the minimum number of BP measurements needed and to identify cut-off values for the standard deviation (SD), coefficient of variation (CV), and average real variability (ARV) of systolic and diastolic VVV BPV to predict CVD risk in primary care. MethodsWe analysed data from the electronic practice-based research network (ePBRN) in Southwestern Sydney, including patients aged 18-55 with at least eight BP readings. Patients with incomplete data or no follow-up beyond age 55 were excluded. The agreement between SD calculated from 3-5 measurements and 8 measurements (reference) was evaluated using Pearsons correlation coefficient and the intraclass correlation coefficient. Then, after identifying that a minimum of five BP measurements is needed, another cohort with at least five BP measurements was developed. Percentile-based cut-offs (10th - 90 th, 5-percentile increments) were derived for systolic and diastolic BPV (SD, CV, ARV). Predictive accuracy was assessed using the C-statistic. The outcome was the first CVD occurrence. ResultsA total of 1,549 patients were included in the first study. Five BP measurements showed good agreement with eight measurements (ICC: 0.79; correlation: 0.80). A total of 3,022 patients were included (55.2% women). Higher VVV BPV (SD, CV. ARV) was associated with increased CVD risk. Optimal cut-off values for systolic BP were 19 mmHg (SD), 14% (CV), and 15 mmHg (ARV), and for diastolic BP were 11 mmHg (SD), 12% (CV), and 11 mmHg (ARV). Predictive performance was consistent across time frames. ConclusionsThese BPV cut-offs provide clinically relevant thresholds for CVD risk prediction. At least five BP measurements are sufficient to estimate BPV for this purpose.

IntroductionPatients undergoing anterior cruciate ligament (ACL) reconstruction experience substantial postoperative pain, which delays recovery and leads to both immediate and long-term opioid use. In other knee procedures, infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) has demonstrated analgesic and opioid reducing effects. However, the effect in patients undergoing ACL reconstruction has not been investigated. We aimed to investigate the real-world effect of IPACK in patients undergoing ACL reconstruction on immediate postoperative opioid consumption. ParticipantsIn this single-centre difference-in-differences cohort study, all patients who underwent ACL reconstruction surgery at Bispebjerg Hospital, Denmark, from 1 February 2024 to 30 June 2025 are included. The study further includes a similar reference cohort, comprising all patients who underwent trochleaplasty, Elmslie-Trillat, or medial patellofemoral ligament reconstruction during the same period, and at the same hospital. InterventionThe primary exposure is the implementation of IPACK as part of perioperative management for ACL reconstruction on 1 January 2025. The IPACK was performed under ultrasound guidance, immediately before surgery, administering 20 mL of ropivacaine 0.5% between the popliteal artery and the posterior knee capsule. OutcomesThe primary outcome is the cumulative opioid consumption from surgical incision to 2 hours postoperatively. Secondary outcomes include the cumulative opioid consumption from incision to 24 hours postoperatively, the worst reported pain score at 0-24h postoperatively, occurrence of postoperative nausea or vomiting (PONV) 0-24h postoperatively, length of PACU stay, length of hospital stay, and nerve injuries. As an exploratory outcome, carbon dioxide emissions will be investigated. Statistical analysisThe main analysis will be a standard two-way fixed effects DiD regression assessing the changes occurring at the time of implementation of IPACK in the ACL cohort, with adjustment for the underlying time trend. Continuous outcomes are reported as mean difference (95% confidence interval [CI]), and binary outcomes as absolute and relative risks (95% CI).

BackgroundArthroscopic release for elbow stiffness is considered a minimally invasive and effective treatment. However, the extent to which each intraoperative step contributes to improvement in range of motion (ROM) has not been well investigated. PurposeTo sequentially evaluate the relationship between intraoperative surgical steps and changes in elbow ROM during arthroscopic release for severe elbow stiffness, and to identify the key procedural stage contributing most significantly to ROM improvement. MethodsFive elbows in five patients with severe elbow stiffness following fracture or dislocation were retrospectively reviewed. Arthroscopic release was performed using a stepwise posterior-based approach, starting from the posterior soft-spot portal, followed by exposure of the olecranon fossa and progression into the posteromedial compartment. Changes in elbow ROM were assessed at each intraoperative step, and ROM at final follow-up was also evaluated. ResultsAll patients demonstrated improvement in elbow ROM at final follow-up. Intraoperative ROM improvement did not occur in a continuous manner but rather in a stepwise fashion. Gradual improvement was observed with establishment of the posterior and posteromedial working spaces, followed by the most substantial increase in ROM immediately after release of the soft tissue attached to the posterior aspect of the humeral medial epicondyle. Although the maximum ROM achieved intraoperatively was not fully maintained at final follow-up, no patient experienced deterioration to preoperative ROM levels. ConclusionsIn arthroscopic release for severe elbow stiffness, improvement in elbow ROM occurs in a stepwise rather than continuous pattern. Release of the posteromedial structures attached to the posterior aspect of the humeral medial epicondyle may represent a critical turning point contributing significantly to ROM improvement.

Artificial intelligence (AI), particularly large language models (LLMs), is increasingly explored in healthcare, yet its real-world usability and safety in high-risk clinical pharmacy tasks remain uncertain. Vancomycin therapeutic drug monitoring (TDM), which requires precise pharmacokinetic calculations and context-sensitive interpretation within a narrow therapeutic window, provides a stringent test case for AI-assisted decision support. This proof-of-concept study developed and evaluated a hybrid clinical decision support system (TDM-AID) integrating a validated deterministic pharmacokinetic calculation engine, GPT-4o-based structured clinical interpretation, and retrieval-augmented guideline support. Thirty retrospective adult vancomycin TDM cases were assessed using a weighted six-domain rubric covering pharmacokinetic accuracy, AUC estimation, prospective prediction, timing recommendations, clinical judgment, and documentation quality. Two independent expert pharmacists evaluated system outputs against benchmark consultations. The overall median performance was 78% (IQR 12%), classified as Acceptable, and 73% (IQR 14%) when deterministic calculations were excluded. Foundational pharmacokinetic calculations achieved 100% accuracy. Clinical judgment demonstrated Good performance (83%), whereas prospective prediction was limited (58%), and timing recommendations were absent in all cases. Safety violations occurred in 17% of cases, including dose recommendations exceeding 4 g/day. Inter-rater reliability was good (ICC 0.87). These findings suggest that hybrid AI-driven decision support is technically feasible and usable as a pharmacist-augmenting draft generator; however, limitations in predictive reasoning, timing logistics, and safety enforcement necessitate deterministic safeguards and mandatory expert oversight before clinical implementation.

BackgroundHypertension is a major modifiable risk factor for cardiovascular disease, yet blood pressure (BP) control remain suboptimal, particularly in socially disadvantaged communities. Guidelines recommend initiating single-pill combination (SPC) therapy to improve adherence and BP control, but uptake in primary care is limited. ObjectivesTo evaluate the SOLO care improvement project, promoting SPC initiation among general practitioners (GPs) in Amsterdam Zuidoost, a disadvantaged, multi-ethnic community in The Netherlands with a high hypertension burden. MethodsIn a cluster quasi-randomized cluster design, adult hypertensive patients from nine general practices within one health facility were allocated to intervention (IC; n=5) or usual care (UC; n=4). Intervention practices received case-specific guidance on SPC therapy. Outcomes were SPC uptake, changes in systolic and diastolic BP (SBP and DBP), target BP achievement and cardiovascular events. Analyses used intention-to-treat adjusted regression and Cox models, with additional as-treated analysis among SPC users. ResultsAmong 438 patients (mean age 64.5{+/-}12.2 years; median follow-up of 367 days [213-467]), SPC initiation was higher in the IC than US (25.1% vs. 9.6%, p<0.001). SBP/DBP decreased by -15.7/-6.9 mmHg in the IC and -10.4/-4.6 mmHg in the UC. Target BP was more often achieved in the IC (57.3% vs. 48.1%; OR: 1.4, 95%CI:1.0-2.1). Among SPC users, SBP/DBP decreased by -22.4/-10.5 mmHg. ConclusionPromoting SPC therapy improved blood pressure control, supporting local, targeted implementation as a pragmatic strategy to enhance hypertension management. Summary box, bullet points- In the SOLO care improvement project, SPC initiation was increased and improved blood pressure control in routine primary care. - The real-world implementation and cluster-based comparison enhanced practical relevance and reduced contamination between practices. - Although conducted in a large community health center, generalizability cannot be assumed; the non-blinded, non-randomized design allows residual confounding.