BJGP Open

Objective: To determine outcomes by referral route (any Advice and Guidance [A&G] versus elective referrals only) for patients with inflammatory bowel disease (IBD), Parkinson's disease, and systemic lupus erythematosus (SLE). Design: Population-based retrospective cohort study. Setting: Linked Clinical Practice Research Datalink (CPRD) Aurum primary care records, 2015-2022. Participants: Patients with incident diagnosis of IBD, Parkinson's disease, or SLE. Main Outcome Measures: Time from the earliest recorded A&G or elective referral to diagnosis, first recorded definitive treatment and first attended outpatient appointment. Secondary outcomes included counts of primary care consultations, prescriptions, referrals, and outpatient appointments. Propensity score weighted flexible parametric survival analyses accounted for differences between exposure groups. Results: Among 71,145 eligible patients, A&G was recorded for 1,137 (3.0%) with IBD, 971 (3.4%) with Parkinson's, and 243 (4.9%) patients with SLE. Compared with elective referral only, A&G was associated with slower time to diagnosis for IBD (adjusted median difference 15.9 weeks; hazard ratio 0.58, 95% confidence interval 0.52 to 0.66), Parkinson's disease (11.4 weeks; 0.57, 0.51 to 0.64), and SLE (6.3 weeks; 0.82, 0.73 to 0.91). However, A&G was not associated with a longer time to treatment or first attended outpatient appointment. An increase in primary care consultations following A&G was observed in patients later diagnosed with IBD and SLE. Conclusion: A&G was associated with a longer diagnostic interval than elective referral only. These findings do not establish that A&G caused diagnostic delay. A&G might be used at an earlier stage of more complex diagnostic pathways.

Background: Palliative care is suboptimal in pulmonary fibrosis. Symptom burden is high despite evidence-based interventions, guidelines, and information resources. The application of existing knowledge and methods to optimally manage palliative and end of life care for people with pulmonary fibrosis in the UK has not been realised. Aim: To establish patient views and understanding of how palliative care services and approaches can better meet the needs of people with pulmonary fibrosis. To identify the current barriers and facilitators to receiving palliative care services. Design: Qualitative exploration of patient views via semi-structured interviews and focus groups. Content analysis was conducted. Setting/Participants: The study was conducted from March to August 2024 within an Interstitial Lung Disease Specialist Centre, based in an NHS acute Trust. Results: Two focus groups and four interviews were conducted, involving nine patients. Four overarching themes were identified as to how palliative care can better meet the needs of this group: (1) establishing mechanisms for identifying and addressing palliative care needs; (2) open channels of communication with healthcare professionals; (3) the importance of a palliative care approach within respiratory, community and specialist services; and (4) support for unpaid/family carers. Conclusions: Patients highlighted the importance of person-centred principles and services that adapted to their needs (such as real-time telephone support), rather than services that imposed their own requirements on the patients. Understanding how existing palliative care provision can meet this standard could help improve the palliative and end of life care for people with pulmonary fibrosis.

IntroductionCurrent evidence suggests that patient health passports may improve care for patients with chronic illnesses. This systematic review aimed to evaluate the impact of patient health passports on health outcomes in adults with diabetes. MethodsA systematic review was conducted in February 2025 following PRISMA 2020 guidelines, using Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, Web of Science, and Scopus. The review included studies of adult diabetic patients using paper or digital patient health passport as part of their care in comparison with the standard of care. Data were analysed using meta-analysis and a thematic analysis where appropriate; otherwise, the data are presented narratively. Quality appraisal was undertaken using the Cochrane Collaboration tool for assessing risk of bias and Evidence-based librarianship checklist. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation. ResultsEleven studies (n=14,350) were included. Seven studies were randomised controlled trials, two were retrospective in nature, one was a qualitative and one was a pre-post study. Overall, the studies are limited in design, resulting in high or unclear risk of bias across multiple domains. Results of the meta-analysis of five studies showed a statistically significant mean difference reduction in HbA1c and total cholesterol in favour of the intervention group; however, the certainty of the evidence is low or very low. The narrative analysis of the data revealed little to no improvement in body mass index, blood pressure, blood glucose, and cholesterol levels. Patients opinions and perceptions revealed some benefits in usability, perceived value, and in enhancing collaboration. ConclusionThis review provides evidence suggesting that patient health passports may improve patient care and can inform the design of future high-quality studies. However, the low certainty of the evidence highlights the need for high-quality studies with larger sample sizes. Key PointsO_LIPatient health passports show promise in enhancing diabetes management, however current evidence is limited by high risk of bias; future high-quality studies are required to confirm efficacy. C_LIO_LINurses are pivotal in this process as they play a central role in diabetes education, self-management support and continuity of care. C_LIO_LIPatient health passports could be considered as a structured tool to facilitate ongoing monitoring, reinforce adherence, enhance communication between patient and nurses/multidisciplinary team. C_LI

Background: Chronic obstructive pulmonary disease (COPD) is a progressive condition with high symptom burden. Advanced COPD management should relieve symptoms, optimise daily functioning and reduce carer burden, yet there is limited enactment of policy-advocated person-centred approaches to care and support. The Living with Breathlessness Study sought to establish evidence-based recommendations to inform a new paradigm to improve care and support in advanced COPD. Methods: Comprehensive multiple-perspective longitudinal evidence was collected on care, support, functioning and needs in advanced COPD from a population-based cohort of over 500 patients, their unpaid/family carers and health care professionals through semi-structured interviews and validated outcome measures over an 18-month period. Quantitative data analysed using standard descriptive statistics, numerical and univariate analyses, and qualitative data using a Framework approach. Recommendations were then generated through three linked strategies: (1) an expert multidisciplinary group, (2) a stakeholder workshop and (3) a stakeholder survey. Results: Six inter-related recommendations emerged, linked by the concept of proactive person-centred care, supported by action points to enable delivery. Recommendations in brief: (1) stop focusing on the challenge of prognostication as a barrier to meeting need, (2) change targets to incentivise person-centred care, (3) enable identification of patient support needs, (4) identify and support carers, (5) identify and respond to psychological morbidity, (6) change societal understandings of COPD, breathlessness, palliative care and informal carers. The recommendations garnered significant support from stakeholders, with caution regarding ease of implementation. Conclusions: Enactment of the resulting six evidence-based recommendations, through their action points, could inform a new paradigm to improve care and support in advanced COPD recognising the slow relentless progression of non-malignant disease, and its effect on patients and their carers. They hold potential for other patients and unpaid/family carers who are living in between conventional disease management and end-of-life care, and for those HCPs striving to support them.

Aims: To understand how users believe continuous glucose monitoring (CGM) changes their behaviour, which app features they credit, and whether endorsing more mechanisms of action (MoAs) is linked to reported diet and physical activity change. Methods: We surveyed 112 U.S. adults with type 1 or type 2 diabetes who had used a Dexcom or Abbott Libre CGM within 12 months. Participants rated 26 MoA statements mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model, identified contributing app features, and reported CGM-attributed diet and physical activity change. Logistic regression examined MoA count and COM-B domains as predictors of behaviour change. Results: Participants (mean age 54.5 years; 60.7% female) reported dietary (82.1%) and physical activity (46.4%) change and endorsed a median of 18 MoAs, most often relating to knowledge, skills and behavioural consequences. Real-time glucose and graphs were attributed to many MoAs. Each additional MoA was associated with higher odds of dietary (OR 1.27, 95% CI 1.15-1.44) and physical activity change (OR 1.27, 95% CI 1.16-1.43). Motivation made the strongest distinct contribution among COM-B domains. Conclusions: Users perceive CGM as engaging many behavioural mechanisms; endorsing more was linked to behaviour change. Motivation may be a key target for CGM-based behavioural support.

Background: Clinical decision support (CDS) systems may improve chronic pain management by providing guideline-based recommendations within clinical workflows. However, low clinician use can limit their effectiveness. Understanding the association between CDS use and guideline-recommended care may help distinguish implementation challenges from limitations in CDS functionality. Objective: To estimate the association of OneSheet, a CDS system for chronic pain management, and guideline-recommended care when the system was used during patient encounters. Methods: We conducted a per-protocol secondary data analysis of data from a pragmatic randomized clinical trial conducted from October 2020 to May 2022 across 25 primary care clinics at 2 academic health systems in Indiana and North Carolina. The parent trial enrolled 137 primary care clinicians. This analysis included 145511 eligible chronic pain encounters and 15480 long term opioid therapy (LTOT) encounters that occurred after OneSheet implementation. OneSheet use at a patient encounter was the exposure of interest. Propensity score matching was used to create comparable groups of encounters with and without OneSheet use. Outcomes included documentation of pain-related goals, documentation of pain and function using the Pain, Enjoyment of Life and General Activity (PEG) scale, prescription drug monitoring (PDMP) review, urine drug screening (UDS) orders, and naloxone orders. Results: OneSheet was used in 959 of 145511 chronic pain encounters (0.7%) and 582 of 15480 LTOT encounters (4.0%). In matched analyses, OneSheet use was associated with increased documentation of pain-related goals (relative risk (RR)=11.70 (95% CI 4.25-32.50) and PEG score documentation (RR=9.70 (95% CI 4.14-22.31). Among LTOT encounters, OneSheet use was associated with increased UDS ordering (RR=1.52 (95% CI 1.40-1.65) and PDMP review (RR=1.06 (95% CI 1.03-1.09), but decreased naloxone ordering (RR=0.13 (95% CI, 0.02-0.90). Conclusions: OneSheet use was associated with several guideline-recommended chronic pain management actions, suggesting that they system may support care quality when clinicians use it. However, use was rare, indicating that increasing routine use through better workflow integration may be necessary to achieve population-level improvements in chronic pain care.

Background: Robust evidence linking individual surgeon technical performance to patient outcomes in complex minimally invasive surgery remains scarce. Crowd-sourced video assessment offers a scalable alternative to expert review, but its clinical relevance in complex oncologic procedures such as robot-assisted minimally invasive esophagectomy (RAMIE) is unestablished. Methods: In this exploratory study, video recordings of 60 consecutive RAMIE procedures performed by 7 surgeons (2018-2023) were segmented into five representative surgical steps and rated by 93 blinded crowd-raters per segment using a modified GEARS instrument. Tertiles were used to compare top-performing operations and steps against the remaining two terciles for overall and step-specific performance, and associations with perioperative outcomes were analyzed. Results: Top-tercile overall performance was associated with significantly shorter operative time (abdominal, thoracic, and total) and less intraoperative blood loss (all p<0.05), without differences in postoperative outcomes. In exploratory step-specific analyses, top-tertile performance during infracarinal lymphadenectomy was associated with significantly fewer surgical complications (30.0% vs 60.0%; p=0.028), fewer severe surgical complications (25.0% vs 52.5%; p=0.043), and higher lymph node yield (22.8 vs 18.9; p=0.037), while the purse-string suture step showed the broadest operative-time benefit. These step-specific findings are hypothesis-generating and were not adjusted for multiple testing. Conclusion: Crowd-sourced video assessment enables scalable, step-specific evaluation of surgical performance in RAMIE associated with intraoperative blood loss and operative time. Exploratory analyses suggest that the relationship between technical performance and clinical outcomes might be step-specific, with infracarinal lymphadenectomy emerging as risky step linked to postoperative morbidity. These findings support further investigation of individualized performance assessment for quality improvement and risk stratification.

Background People diagnosed with severe mental illnesses (SMI) including bipolar disorder, schizophrenia and psychosis are disproportionately exposed to adverse social determinants of health, contributing to premature morbidity and mortality. Social prescribing aims to address social risk factors for poor health by linking patients in primary care to community activities. However, whether people with SMI access social prescribing through primary care remains unexplored. Aims To describe prevalence of, and sociodemographic characteristics associated with, social prescribing consultations in patients with SMI in primary care. Methods Using the UK Clinical Practice Research Datalink, we identified patients aged 18+ with a diagnosis of SMI between 2004-2019. We calculated the percentage of patients with SMI who received a social prescribing consultation between 2019-2023 and used logistic regression to examine associations between sociodemographic, health-related factors and social prescribing consultations and refusals. We used fixed effects analysis to determine whether a new diagnosis of SMI made between 2019-2023 was associated with an increased odds of receiving a social prescribing consultation. Results Among 112,334 patients with SMI, 0.8% received a social prescribing consultation in 2019 increasing to 9.5% in 2023. Between 2020-2023, older age (OR=1.18-2.34), being female (OR=1.16-1.31) and living in more deprived areas (OR=1.14-1.49) were associated with higher odds of receiving a social prescribing consultation amongst patients with SMI. Across all years, patients with SMI and depression (OR=1.32-1.92), diabetes (OR=1.19-1.35) or obesity (OR=1.17-1.54) also had increased odds. In 140,514 patients with time-varying SMI status, a new diagnosis of SMI was associated with higher odds of receiving a social prescribing consultation (OR=1.39, 95% CI 1.26-1.53). Conclusion Since 2019, social prescribing consultations among patients with SMI in primary care have increased and are reaching those in areas of higher deprivation and with greater health needs. Strategies to remove barriers to consultations among younger adults and males are still needed

Background: Although point-of-care testing is the standard method for inpatient glucose monitoring; it is associated with patient discomfort and late detection of dysglycaemic events. Continuous glucose monitoring (CGM) may improve glycaemic management; however, limited staff education and experience among may hinder its implementation. Aim: To investigate experience, perceptions and training needs on CGM use among inpatient nursing staff across diverse hospital wards. Methods: This is a single-centre, 38-item online survey recruited inpatient nurses in a hospital in the UK. Participants were invited via the e-newsletter and posters; the survey remained open for five months. Results: Nineteen nurses reported positive perceptions of inpatient CGM. Most considered CGM reliable (77.8%) and preferred CGM combined with POCT (66.7%). Views on its impact on workload and patient-room entries were mixed (30% agreed, 30% disagreed). Training needs included sensor placement (92.9%) and alarm management (78.6%). Conclusion: Nurses viewed CGM favourably but highlighted important training needs for inpatient use.

Introduction: Primary care electronic health records (EHRs) are an important resource for health research, but death recording in primary care EHRs may be incomplete or differ from Office for National Statistics (ONS) death registrations. We used OpenSAFELY-TPP to assess the completeness and concordance of death recording and provide recommendations for using date-of-death information. Methods: Using linked primary care EHRs and ONS death registrations, we assessed whether ONS-registered deaths from 2020-2025 had a primary care date of death and, where present, calculated the difference between dates. Where a primary care date was absent, we assessed death-related SNOMED CT codes. Analyses were conducted overall and by year, population subgroup, and general practice. We also examined GP registration end dates and primary-care-recorded deaths without a corresponding ONS record, including monthly patterns near the data extraction date. Results: Among 1,409,275 ONS-registered deaths, 88% had the same date recorded in primary care and 8% had no corresponding primary care date. Among 1,324,995 deaths recorded in primary care, <2% had no corresponding ONS record. Deaths recorded in only one source were more frequent among people aged <45 years and those from Mixed, Asian or Asian British, Black or Black British, and Chinese or Other ethnic groups. ONS-only dates were also more frequent in London and the West Midlands. Primary-care-only deaths increased close to date of data extraction, reaching 7% in February 2026. Same-day GP deregistration increased from 9% in 2020 to 85% in 2025. Conclusions: Death recording in primary care EHRs showed high completeness and concordance with ONS registrations, but discrepancies remained for recent deaths and some population groups. Data recency and population-specific completeness should therefore be considered when using linked mortality data for research.

Background: Multiple performance measures are used to assess the management of common cardiovascular conditions, such as coronary artery disease (CAD), heart failure with reduced ejection fraction (HFrEF), and atrial fibrillation (AF). These measures are sometimes used to assess individual clinicians, despite lack of evidence of reliability and accuracy. We used national Veteran Affairs (VA) data to test medication-based performance measures for assessment of clinician performance in outpatient cardiology care. Methods: This retrospective study examined VA cardiology clinician/Veteran dyads from 2017-2023 to evaluate 10 medication-based performance measures for CAD, HFrEF, or AF with elevated stroke risk. Achievement of each performance measure was defined as an active prescription of an indicated medication for each eligible patient encounter, summarized at the clinician level. Reliability was calculated using the beta-binomial method. A Bayesian causal model was used to assess the impact of case complexity on performance measure achievement. Finally, we performed peer review of a subset of cases (n=952) to assess the accuracy of three representative performance measures. Results: Of 456,071 unique cardiology encounters, 312,331 included CAD, 224,599 included HFrEF, and 178,678 included AF. These patients were treated by 1,043 cardiology clinicians. Median performance measure achievement ranged from 0.23 (SGLT2i for HFrEF) to 0.99 (beta blocker for HFrEF). Measure reliability varied from 0.63 to 0.90. Case complexity did not significantly affect performance measure achievement. Using peer review as the gold standard, accuracy was poor to moderate (balanced accuracy 0.51-0.73), and measures underestimated performance relative to peer review. Conclusions: Ten medication-based performance measures for CAD, HFrEF, and AF can be efficiently measured using electronic health record data, and most have sufficient reliability to support clinician benchmarking and the identification of potential care gaps. However, suboptimal accuracy compared with a peer review indicates that these measures may be insufficient as a standalone assessment of clinician quality.

Objectives To examine the prevalence of interruptions during UK secondary care outpatient consultations, their association with clinician mental workload, and the strategies clinicians use to manage them. Design Nationwide cross-sectional online survey. Setting Secondary care outpatient clinics, United Kingdom. Participants A sample of 465 UK secondary care doctors across a range of grades and specialties, recruited through a medical defence organisation's network. Primary and secondary outcome measures Mental workload (NASA Task Load Index, Raw-TLX); interruption frequency; perceived cognitive impact of interruptions; task resumption difficulty; perceived social effects on colleague interactions and team cohesion; and interruption-management strategy use. Results 61.1% of clinicians reported being interrupted often or very often, and mean overall workload was high (Raw-TLX 66.2, SD 11.5). Interruption frequency, patient complexity and perceived cognitive impact were each associated with higher workload across multiple NASA-TLX subscales. In fully adjusted models, interruption frequency retained independent associations with overall workload (beta = 1.79, p = 0.004) and temporal demand (beta = 0.94, p < 0.001). Task resumption difficulty was associated with worse perceived performance (beta = -0.59, p = 0.014), while perceiving interruptions as socially positive was associated with better performance (beta = 0.75, p = 0.003) and lower frustration (beta = -1.16, p < 0.001). Years of experience showed only small effects, and self-reported strategy use (38.7%) was not consistently associated with lower workload. Exploratory natural language processing of open-text descriptions identified three strategy clusters; cognitive offloading, anticipating and preparing, and blunt responses, with distinct emotional profiles. Conclusions Interruptions were commonly reported during UK secondary care outpatient consultations and were associated with measurable cognitive and temporal burden. The perceived social framing of interruptions was independently associated with frustration and self-rated performance. Binary strategy use showed no consistent workload association, indicating a need for system-level approaches addressing interruption frequency, task resumption support and the social context of interruptions rather than reliance on individual coping.

Abstract Background: Heart failure (HF) is a major public health challenge in ageing populations and a leading cause of unplanned hospital readmissions. Biological, social, and economic factors contribute to recurrent hospitalisation, but gaps remain in understanding how these factors interact and patterns of healthcare use following hospitalisation. Methods: We conducted an explanatory sequential mixed-methods study of patients aged ?60 years with an HF hospital admission between 2016 and 2020 who completed the Sax Institute?s 45 and Up Study baseline questionnaire. Data were linked to Admitted Patient Data Collection, Medicare Benefits Schedule, and Pharmaceutical Benefits Scheme data. HF readmission within 30 days of the index admission was the outcome. Cox proportional hazards models estimated crude and adjusted hazard ratios (HRs and adjHRs) with 95% confidence intervals (CIs). Kaplan-Meier curves and log-rank tests compared survival between groups. Time-series plots mapped healthcare interactions over 1 year following the index admission. Results: Among 4,252 patients with HF, 409 were readmitted within 30 days. Significant predictors included age ?80 years (adjHR, 1.30; 95%CI, 1.01?1.67), 1 chronic condition (adjHR, 2.49; 95%CI, 1.41?4.40), ?2 chronic conditions (adjHR, 1.75; 95%CI, 1.04?2.95), and alcohol consumption above national guidelines (adjHR, 1.45; 95%CI, 1.06?1.98). Time-series analysis indicated that participants with readmission had more frequent out-of-hospital health service contact following their initial HF admission than those without readmission. Conclusions: Older age, chronic conditions, and high alcohol intake increased 30-day HF readmission risk. Differences in healthcare use after admission highlight opportunities for targeted and coordinated post-discharge care.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have rapidly expanded from primarily glucose-lowering agents for type 2 diabetes (T2D) to therapies used across diabetes, obesity, and cardiometabolic disease. Prescribing has risen sharply since 2018, especially with the broader uptake of semaglutide-based products. Still, real-world initiation patterns remain incompletely characterized in older adults with varying levels of cognitive vulnerability and frailty. Methods: We analyzed treatment patterns of GLP-1RA use in a retrospective cohort of adults aged >=65 years with T2D in a regional healthcare system from 2018 to 2026. We describe the demographic and clinical characteristics of new initiators of GLP-1RAs compared with initiators of alternative therapies, including sodium-glucose cotransporter-2 inhibitors (SGLT2i) and dipeptidyl peptidase-4 inhibitors (DPP-4i). We analyzed a sub-cohort of patients to identify the prevalence of baseline cognitive concerns using a large language model (LLM). We used a LASSO logistic regression to identify important predictors of GLP-1RA initiation compared to other therapies. Results: Of 58,754 adults aged 65 years or older with T2D, 5,095 initiated GLP-1RA, 5,483 initiated a SGLT2 inhibitor, and 1,516 initiated a DPP-4 inhibitor. GLP-1RA initiators were younger (mean 75.2 [SD 4.9] vs 77.7 [6.0] and 79.5 [7.1] years) and less often aged 80 years or older (17.7% vs 35.0% and 47.6%). The largest difference across groups was adiposity: mean BMI was 33.8 (6.2) vs 29.7 (5.7) and 28.6 (5.6) kg/m2 (SMD 0.592), with a BMI of 30 kg/m2 or higher in 72.1% vs 41.9% and 34.0%. Glycemic control was similar (mean HbA1c 7.46% vs 7.38% and 7.70%; SMD 0.165). GLP-1RA initiators were younger; more likely to be overweight; had lower average comorbidity index; and less dementia, heart failure, and renal disease than those initiating alternative therapies. GLP-1RA initiators had fewer hospitalizations 1-year prior to drug initiation. In a LASSO model, BMI greater than 27 kg/m2 was the strongest predictor of GLP-1RA initiation (positive), followed by baseline congestive heart failure (negative) and baseline hospitalization (negative). Conclusion: In this cohort of older adults, those with T2D who initiated GLP-1RAs were younger and had less comorbidities at baseline compared to initiators of other T2D therapies. Overweight BMI was the strongest predictor of GLP-1RAs initiation, whereas baseline HbA1c was similar across groups, suggesting that the decision to start GLP1-RA is more influenced by adiposity than glycemic control. Our analysis of real-world prescribing patterns appear to be in alignment with guidelines for Type II diabetes treatment1, which recommend GLP-1RA treatment for glucose lowering and weight management and SGLT2 treatment in those with risk of cardiovascular disease or heart failure.

Background Anxiety, depression and menstrual problems are conditions that significantly impact an individual's health and wellbeing yet, barriers to healthcare can prevent access to appropriate medical care. Trust in doctors is a notable factor as previous studies have shown that it affects engagement with healthcare services and has declined in recent years. Methods Using the Avon Longitudinal Study of Parents and Children, we investigated associations between trust in doctors and healthcare access at two timepoints, for anxiety, depression (mothers and partners) and menstrual problems (mothers only). Results Mothers reporting greater trust in doctors were more likely to access care for anxiety (n=1849, adjusted odds ratio (AOR) 1.11, 95% confidence interval (95% CI) 1.08-1.14), depression (n=2411, AOR 1.10, 95% CI 1.07-1.12), and menstrual problems (n=1723, AOR 1.04 95% CI 1.01-1.06). If mothers and partners endorsed 'the doctor is always helpful', they were more likely to access care for depression (mothers: n=2005, AOR 1.30, 95% CI 1.16-1.46; partners: n=580, AOR 1.46, 95% CI 1.05-2.03) and for anxiety (mothers: n=1892, AOR 1.35, 95% CI 1.19 to 1.54; partners: n=734, AOR 1.40, 95% CI 1.02-1.91). Implications This study supports association between trust in doctors and healthcare access for anxiety, depression and menstrual problems, particularly amongst mothers. This contributes to previous literature that suggests that trust remains an important factor in understanding treatment gaps, and that researchers and clinicians must work to improve public trust in healthcare systems.

Abstract Continuous glucose monitoring (CGM) is recommended for type 1 diabetes, but the supporting evidence derives almost entirely from high-income settings, and the technology is not routinely available in Kenya's public sector. This prospective study assessed the feasibility and sustainability of CGM implementation and changes in glycemic control after three months of use in a public-sector pediatric diabetes clinic in Nairobi. Forty patients aged 4 to 25 years, recruited by proportional quota sampling across age bands at Kenyatta National Hospital, used an intermittently scanned sensor system across five visits combining sensor data review, standardized diabetes education and insulin titration. Glycated hemoglobin (HbA1c) was measured at baseline and three months, alongside sensor-derived glucose metrics, wear time and diabetes-related admissions. Thirty-eight patients (95%) completed the study; median sensor wear time was 89.0%. Adjusted mean HbA1c fell from 10.82% to 9.42%, a difference of minus 1.40 percentage points (95% confidence interval minus 2.07 to minus 0.68). Time in target range (3.9 to 10.0 mmol/L) rose from 32.4% to 38.0%, and time above 10.0 mmol/L fell from 63.1% to 56.9%. Time below 3.9 mmol/L rose minimally, from 3.7% to 4.2%, while time below 3.0 mmol/L did not increase significantly, by 0.2%. Diabetes-related admissions fell from 7 of 40 in the three months before the study to 1 of 38 by its end. The uncontrolled design and small sample preclude an unbiased effect estimate. Since CGM efficacy is established internationally, these data add local evidence of transferability, which national guidelines and benefit-package decisions require.

Introduction Low back pain (LBP) is a common leading cause of functional disability in adults worldwide, presenting with Modic changes that are visible within the endplates of the vertebral body under magnetic resonance imaging (MRI). Modic changes (MC) are not just a coincidental imaging finding; they reflect underlying pathology that needs treatment focus. This study aimed to ascertain the prevalence and patterns of Modic changes in the lumbar spine among adult patients with a history of low back pain attending the Kilimanjaro Christian Medical Centre (KCMC) Orthopedic clinic. Methods A descriptive cross-sectional study was conducted at the KCMC orthopedic clinic from 2nd October 2024 to 30th May 2025. Data from adult patients with a history of low back pain who had undergone lumbar spine MRI were collected, cleaned, and analyzed in SPSS (version 25). Categorical variables were summarized by frequency and proportion, while continuous variables were summarized using the mean and standard deviation. Frequency tables, histograms, and pie charts were used for results presentation. Results Of the 283 patients enrolled in the study, the mean age was (57.2 {+/-}15.7) years, with the majority (145; 51.2%) being aged > 59 years. Most patients, 203 (71.7%), were females, while 176 (62.2%) were married, and 142 (50.2%) were overweight. The prevalence of MC on the lumbar spine among patients with a history of low back pain was 66.4% (n=188). Among patients with lumbar spine MC, the majority, 112 (59.6%), were aged over 59 years, and 125 (66.5%) had lumbar spine MC type II, which was the most predominant compared to other types of MC. Conclusion Modic changes on the lumbar spine are prevalent in adult patients with low back pain, particularly those over 59 years, with type II being the most common. Healthcare professionals and policymakers should recognize Modic changes as clinically relevant findings that require consideration in the management of patients with a history of low back pain rather than dismissing them as mere incidental or coincidental observations.

Introduction Maintaining long-term positive airway pressure (CPAP) adherence is a major challenge when treating obstructive sleep apnea (OSA). We evaluated factors associated with one-year CPAP adherence and developed models predicting Month-12 adherence and CPAP-use trajectories. Methods CPAP-naive adults with OSA (apnea-hypopnea index[&ge;]5) at Kaiser Permanente Southern California with 364-day observation period were analyzed (development/internal-validation cohort, n=14,906; temporal holdout, n=1,676). Logistic regression evaluated baseline associations with Month-12 adherence (mean[&ge;]4 hours/night during days 331-360). XGBoost models utilized baseline features (clinical, sleep-study, questionnaire data), early CPAP data (days 1-7), or combined to predict long-term CPAP use. A latent-class model identified trajectories over days 8-364. Predictive models were evaluated in both random and temporal holdouts. Results About one-third (34.6%) of the primary cohort (49.7{+/-}13.8 years, 63.2% male) were adherent during Month-12. Higher AHI and longer self-reported sleep duration favored adherence while greater comorbidity burden, depression, and substance-use disorder were associated with lower adherence. In held-out testing, adherence prediction using baseline features yielded an AUROC of 0.678. Using CPAP-only data, AUROCs were higher from 0.787 with seven days of usage data to 0.816 and 0.854 with 14 and 30 days. Models combining CPAP and baseline features increased Day-7 AUROC to 0.810. We identified four one-year trajectories: Early-Decliners (42.9%), Gradual-Decliners (17.4%), Stable-Moderate (19.0%), Stable-High (20.7%). Models predicting patient trajectory revealed macro-average AUROCs of 0.619, 0.756, and 0.770 for baseline, CPAP-only, and combined models. Conclusion Baseline predictors may identify strategies for adherence support, while early CPAP data substantially improved predictive performance. These models may guide personalized follow-up but should not restrict CPAP access. External and implementation validation are needed.

Purpose: To determine whether a cobalt-chrome genetic reactivity (CoGR) score - originally developed to identify patients at greater risk of developing adverse reaction to metal-on-metal hips - is associated with poorer patient-reported outcomes after knee arthroplasty (KA). Methods: In a prospective multicentre study, patients at a minimum two years post all cobalt-chrome KA were invited to research clinics. Participants provided samples for blood metal ion measurements and DNA sequencing and completed Forgotten Joint Scores (FJS). Component alignment was assessed on AP and lateral plain radiographs. The association between CoGR and FJS was assessed using regression adjusted for time since surgery, age, gender, BMI and tested for modification by blood cobalt. In a case-control analysis, CoGR scores of revised patients with histologically confirmed adverse reactions to metal debris (and specifically aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL)) were compared with controls (revised patients with no signs of ARMD and unrevised patients with FJS of 75 or more) using Firth logistic regression. Results: 376 patients were included: 312 unrevised patients and 64 patients who underwent revision. Each one-unit increase in CoGR score was associated with a 9.8 point lower FJS (95% confidence interval (CI) 4.2 to 15.4 points; p < 0.001). This increased to a 17.5 (9.4 to 25.5) point reduction per CoGR score unit in patients with blood cobalt above the median level. Comparing 28 ARMD cases (12 with ALVAL) with 177 controls, each one-unit CoGR increase was associated with odds ratios of 1.90 (CI 1.34 to 2.75) for ARMD and 3.05 (CI 1.89 to 5.34) for ALVAL. Conclusions: A higher CoGR score was associated with worse patient-reported outcome and higher odds of histologically confirmed adverse reaction to metal debris at revision. Adverse immune responses may be a more significant factor in unexplained pain after KA than is generally recognised.

Abstract Background: Respiratory failure (RF) and atrial fibrillation/flutter (AF/AFL) often occur together in older adults, but long-term national mortality trends for the two conditions combined have not been described. We examined trends and disparities in deaths with co-listed RF and AF/AFL among U.S. adults aged 65 years and older from 1999 to 2024, and projected rates through 2035. Methodology: We used the CDC WONDER Multiple Cause of Death database to identify deaths with ICD 10 codes J96 (RF) and I48 (AF/AFL) listed together. Age-adjusted mortality rates (AAMRs) per 100,000 were standardized to the 2000 U.S. population and stratified by sex, race/ethnicity, census region, urbanization, state, and place of death. Joinpoint regression was used to estimate annual percent changes (APCs) and average annual percent changes (AAPCs). Forecasts for 2025 to 2035 were generated with an exponential smoothing (ETS) model. Results: A total of 433,598 deaths were recorded. The overall AAMR rose from 12.8 in 1999 to 66.7 in 2024 (AAPC 8.11%; 95% CI, 7.35 to 8.87; P < 0.0001). Three segments were identified: an increase from 1999 to 2018 (APC 7.73%), a sharp rise from 2018 to 2021 (APC 18.10%), and a decline from 2021 to 2024 (APC -5.25%). Males had a higher AAMR and a steeper increase than females (AAPC 8.44% vs 7.81%). Non-Hispanic White adults had the highest mean AAMR, Hispanic adults had the largest relative increase (AAPC 8.72%), and Non-Hispanic Asian/Pacific Islander adults had the smallest (AAPC 6.23%). The Midwest had the fastest regional growth (AAPC 9.35%). From 1999 to 2020, non-metropolitan areas increased faster than metropolitan areas (AAPC 10.09% vs 8.21%). State AAMRs ranged from 24.7 in Ohio to 85.1 in Louisiana. Most deaths occurred in hospital inpatient settings (64.1%), followed by nursing homes (14.1%) and the home (11.9%). The model projects an AAMR of 122.96 per 100,000 by 2035 (95% prediction interval, 85.42 to 160.50). Conclusions: Mortality involving RF with AF/AFL among older U.S. adults increased more than fivefold over 25 years, with a marked surge during the COVID 19 period and only a partial decline afterward. Differences by sex, race/ethnicity, region, and urbanization point to groups that may benefit from earlier detection and coordinated cardiopulmonary care.