Palliative Medicine

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.

IntroductionWith global populations ageing, demand for palliative care is increasing. Population-level assessments of unmet palliative care needs are essential for strategic planning, yet rigorous methods to estimate unmet needs are lacking. This study aimed to develop methods and estimate current and future population-level prevalence of unmet palliative care needs among adults in England and Wales. MethodsSecondary analyses of data from a nationally representative post-bereavement survey in England and Wales in 2022 (n=1,194). Unmet needs in the survey sample were estimated using two methods: (1) reported unresolved symptoms and concerns using Integrated Palliative care Outcome Scale scores, cutoff [≥]34/68; and (2) reported insufficient care provision from general practitioners. These methods were combined to further provide a conservative estimate (1 and 2) and a broad estimate (1 or 2). We examined associations with unmet needs using modified Poisson regression. Age-, gender- and nation-specific sample estimates were applied to mortality data for 2022 and projections from the Office for National Statistics to calculate population-level estimates and prevalence from 2025 to 2050. ResultsIn 2022, 247,993 (46%) adult decedents in England and 17,209 (49%) in Wales had unmet palliative care needs using method 1; 244,612 (46%) and 15,280 (43%), respectively, using method 2. According to conversative and broad estimates, 32% and 61% could have unmet needs in England, and 29% and 62% in Wales. By 2050, prevalence of unmet needs are projected to rise by 21-26% in England and 14-19% in Wales depending on estimate used, with the largest absolute increase among those aged [≥]85 years. ConclusionsUnmet palliative care needs are high in England and Wales and projected to increase by 2050, regardless of method. We contrast methods based on unresolved symptoms and concerns or insufficient care provision, or both, to inform the planning and evaluating of equitable care. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIAlthough understanding population-level unmet palliative care needs is critical for effective service planning, robust and standardised methods to estimate these needs remain limited. C_LI What this study addsO_LIWe use two methods to provide four estimates of population-level prevalence of unmet palliative care needs and discuss their strengths and limitations. C_LIO_LIRegardless of estimate, prevalence of unmet palliative care needs is high, ranging 32-61% in England and in 29-62% in Wales; the number of people with unmet needs is anticipated to increase by 21-26% in England and 14-19% in Wales by 2050. C_LI How this study might affect research, practice or policyO_LIThis advancement in methods to estimate unmet palliative care needs can inform the development and evaluation of population-level strategies to improve end-of-life care. C_LIO_LIOur population-level estimates do not account for multiple long-term conditions which are rising and will likely increase the complexity of needs. C_LIO_LIThere needs to be more investment in primary and community-based services to ensure high-quality symptom management and support for people and their families towards the end of life. C_LI

BackgroundLiving with multiple long-term conditions (MLTC) is becoming increasingly common with far-reaching consequences for individuals and healthcare systems. People with MLTC often face complex care pathways through health systems - especially hospitals, which are largely configured for specialist treatment of single conditions - yet evidence on people with MLTCs lived experience in the hospital setting is limited. This study aimed to understand the hospital care experiences of people living with MLTC who had recently had an inpatient stay. MethodsPeople with MLTC who had experienced an inpatient stay in hospital within the previous six months were recruited via three hospitals in England and via patient networks. Semi-structured one-to-one interviews were conducted with each participant, focussing on their experiences of care from admission to discharge. An inductive thematic analysis was undertaken. ResultsA total of 44 people (mean age 68.4 years, 23 women) who reported living with between 2 and 11 long-term conditions, the majority of whom (96%) reported that their most recent hospital stay was unplanned, participated in the study. Three themes were constructed from the interview data, reflecting perceptions at individual, interpersonal and organisational levels. Participants experiences were shaped by internalised narratives of hospital care, where care was expected to be focussed primarily on single conditions within a resource-constrained environment. Relationally, the degree of alignment between clinician and patient knowledge on conditions was a key contributor to whether hospital care was experienced positively or negatively, and participants perceptions of organisational constraints to holistic care gave insights into their views on system-level barriers shaping the provision of care for MLTC in the hospital setting. ConclusionExperiences of inpatient hospital care for people with MLTC are complex, diverse and shaped by expectations of care in a specialist setting configured to provide care for single conditions. Healthcare professionals should incorporate patients experiential expertise into decision-making processes through consultation with people with lived experience of MLTC. Redesigning hospital services to provide holistic care will require flexibility to respond to the wide spectrum of MLTC experiences.

The global nursing workforce is aging, yet limited research has explored the lived experiences of never married nurses entering midlife and later adulthood. Existing studies have primarily focused on burnout and retention, with less attention to the social and existential dimensions of aging without a spouse or children. This study aimed to explore the experiences of never married clinical nurses aged 40 years and older, focusing on perceptions of aging, professional identity, social support, and future security. A qualitative descriptive design was employed. Twenty-five never married nurses aged 44-62 years were recruited through purposive sampling from intensive care, emergency, medical, surgical, oncology, outpatient, and community departments across four government hospitals. Semi-structured interviews were conducted and analyzed using reflexive thematic analysis. Trustworthiness was ensured through member checking, peer debriefing, and maintenance of an audit trail. Four themes were identified: Nursing as a Life Anchor, where professional identity provided meaning and structure; Independence Coexisting with Loneliness, reflecting autonomy alongside episodic loneliness; The Invisible but Available Workforce, describing expectations of greater work availability due to single status; and Anticipating an Uncertain Future, capturing concerns about retirement, declining health, and limited advocacy in later life. Never married aging nurses experience a complex balance of professional fulfillment, autonomy, vulnerability, and uncertainty. Healthcare organizations should recognize this subgroup and consider equitable workload policies, tailored retirement planning, and psychosocial support to promote well-being and workforce sustainability.

BackgroundThe dynamic associations of lifestyle factors with fatigue and work ability in colorectal cancer (CRC) from pre-diagnosis, over rehabilitation until convalescence in the first year after rehabilitation are largely unexplored. MethodsN = 682 CRC patients were recruited for the MIRANDA cohort study in 4 German rehabilitation clinics. The five-component Healthy Lifestyle Score (HLS; smoking, alcohol, diet, physical activity, BMI) was assessed pre-diagnosis, during rehabilitation (which was up to 12 months after surgery), and 12 months after rehabilitation. Fatigue and the ability to work were assessed during rehabilitation and in 3-month-intervals thereafter. ResultsThe HLS was rather stable over time, whereas fatigue and ability to work improved in the first 3 months after rehabilitation and remained stable thereafter. Higher HLS points, either assessed prior diagnosis or during rehabilitation, were associated with lower fatigue and better ability to work during in-patient rehabilitation. Compliance with the smoking criterion was the most important factor. Compliance with the physical activity criterion during rehabilitation was also associated with fatigue and ability to work during rehabilitation. In longitudinal analysis adjusted for fatigue and ability to work at rehabilitation, pre-diagnosis adherence to the alcohol consumption criterion was associated with favorable changes of fatigue and ability to work from rehabilitation to 3- and 12-month follow-up. However, the total HLS and other life-style factors were not associated with the outcomes in longitudinal analysis. ConclusionsAddressing lifestyle factors during rehabilitation is an important cornerstone in fatigue management and can improve the ability to work of CRC patients.

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.

BackgroundThe physician assistant (PA) workforce has expanded rapidly in the United States, increasing the importance of effective physician-PA collaboration. Although PAs improve patient outcomes and access to care, the determinants of effective collaboration has not been well studied. North Carolina provides a relevant context due to its growing PA workforce and supervisory regulatory structure, in which physicians retain administrative responsibility for PA supervision across practice settings. This study examines determinants of effective physician-PA collaboration in ambulatory care settings in North Carolina. MethodsFour virtual focus groups were conducted with practicing physicians (n=7) and PAs (n=9) across multiple specialties in NC. Transcripts were analyzed using thematic analysis to identify facilitators and barriers to collaboration. ResultsThematic analysis identified six major themes reflecting relational, organizational, and systemic influences on teamwork. Findings demonstrate collaboration evolves over time through early-career mentorship, continuity of working relationships, and progressive trust development. Differences in professional identity, power dynamics, and misunderstanding of PA scope of practice influenced autonomy and delegation. Systemic factors such as reimbursement structures and organizational supervisory policies hindered efficient teamwork. LimitationsFindings are based on a small, purposive sample within a single state and may not be generalizable to all ambulatory settings or regulatory environments. Perspectives may also reflect self-selection bias among participants with strong views on collaboration. ConclusionsEffective physician-PA collaboration depends on intentional onboarding, role clarity, interprofessional education, and alignment of organizational policies with regulatory standards to support team-based care.

BackgroundCommunity safety is a key determinant of mental well-being, yet racially and ethnically minoritised communities in the UK often face higher exposure to violence alongside barriers to formal protection and support. In these contexts, informal support networks may play a critical role in shaping how safety is experienced and how distress is managed. Although such networks are widely recognised as protective for mental well-being, there is limited qualitative research examining how they operate in relation to community safety in settings shaped by structural inequality. This study explores how informal support networks influence experiences of community safety and mental well-being among racially and ethnically minoritised groups in South East London. MethodsThis qualitative study draws on semi-structured interviews (n = 31) with racially and ethnically minoritised participants aged 16+ living or working in Lambeth and Southwark [South East London]. Using a co-produced qualitative design, community consultations informed the development of interview topics. Interviews explored informal support networks, experiences of community safety and their intersections with mental well-being. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis. ResultsFour themes were identified: (1) experiences of community safety and their mental health impacts; (2) gendered experiences of safety and responsibility; (3) formal support and its barriers; and (4) community and peer-led initiatives as a response to institutional distrust. ConclusionInformal support networks are central to everyday safety and emotional well-being, yet they cannot substitute for adequately resourced, culturally informed public provisions. Strengthening public infrastructure must involve meaningful collaboration with trusted community networks and address the intersectional needs of racially and ethnically minoritised groups.

BackgroundSexual minority (SM) individuals have worse mental health than heterosexual peers. However, there is no total population-based and national-level evidence on differences in risk of self-harm and suicide by sexual orientation. This study provides the first national population-based estimates in England and Wales. MethodsUsing 2021 Census data linked with hospital records and death registrations, we analysed sexual orientation (SO) differences in: (i) at least one hospital inpatient admission/emergency attendance for intentional self-harm, and (ii) death by suicide. We calculated age-standardised rates per 100,000 people by SO between March 2021 and December 2023, and stratified by sociodemographic, geographical, socioeconomic and health-related variables. We calculated rate ratios for lesbian/gay/bisexual/other SO (LGB+) groups compared with heterosexuals to estimate sexual identity disparities. FindingsOur study population included 28.7 million people (mean age 48.1 years, 53.7% female, 84.2% White) aged [≥]16 years who self-reported their SO in Census 2021 and linked to an NHS number. LGB+ individuals had 2.52 (95% CI 2.48-2.56) times higher risk for self-harm and 2.17 (95% CI 1.98-2.37) times higher risk for suicide than heterosexual people. Relative risk of self-harm was highest for LGB+ females, younger adults, and Black individuals. Relative risk of suicide was highest for LGB+ females, older adults, and Black individuals. InterpretationThis study demonstrates stark inequalities in risk of self-harm and suicide by sexual orientation, consistent across multiple sociodemographic factors. These findings are important for informing government prevention programs and further mental health research. FundingThere was no external funding for this study. Research in contextO_ST_ABSEvidence before the studyC_ST_ABSThe substantial evidence on higher risk for self-harm and suicide in sexual minority groups in the UK (and wider Europe) is impacted by regional samples, younger populations, or surveys limited by smaller numbers precluding analyses by key sociodemographic factors (like sex, ethnic group, socioeconomic indicators, faith, housing situations and geographical indicators) or combining all sexual minority groups together. To date, no study has used total population-based data to examine sexual orientation inequalities in self-harm and suicide and in relation to a range of sociodemographic factors. Added value of this studyTo our knowledge, this is the first study in the UK to provide national population-based estimates of intentional self-harm and suicide by sexual orientation, including intersectional analyses across age, sex, ethnic group, and socioeconomic position. This study used a unique linkage between the census, hospital inpatient data, emergency care records and death registrations from across England and Wales, with a study population of 28.7 million people aged [≥]16 years who self-reported their sexual orientation in Census 2021 and linked to a National Health Service (NHS) number. Implications of all the available evidenceThis research provides national population-level evidence of substantial increased risk for self-harm and suicide among sexual minority individuals, compared with heterosexual individuals. This study also identified key groups of individuals at an increased risk of self-harm and suicide. These findings are important for informing government prevention programs and further research supporting the mental health of sexual minority groups.

Young people are increasingly remaining in the parental home for longer - a trend associated with poorer mental health. There is little evidence on this transition for young people with disability. We used three waves of the Australian Census Longitudinal Dataset, a 5% sample of linked Census records. Two analyses compared transitions between 2011-2016 and 2016-2021 among people 15-34y living with parents at baseline with complete data on disability and housing. The proportion of people no longer living with parents at follow-up was calculated, comparing people with and without disability, along with absolute and relative inequalities. Young people with disability were half as likely to leave the parental home as their peers without disability. Inequalities were greatest for people 25-29y (relative difference 0.41 (95%CI 0.36-0.45), living outside major cities (0.48, 0.44-0.52), or with higher income (0.53 (0.47-0.59). Patterns were consistent over time. Targeted supports are needed to enable independent living. Points of interestO_LIWe found that less people with disability leave the parental home than people without disability C_LIO_LIWe also found the gap between people with and without disability was biggest outside major cities. C_LIO_LIThis may mean people with disability in rural, regional and remote areas find it more difficult to move out of home C_LIO_LIBetter housing and income supports are needed to help young people with disability live in the way they choose C_LI

ObjectivesPeople impacted by the criminal-legal system face significant challenges to securing and sustaining permanent housing. This study was designed to assess housing outcomes of an integrated intervention that offered housing, medical, and behavioral health services to individuals with criminal-legal system involvement. MethodsAfter a baseline needs assessment, participants were linked to services and completed quarterly study visits for up to 12 months. We used descriptive statistics to assess frequency and multivariate logistic regression to assess correlates of being housed at last follow-up. ResultsBetween June 2019 and November 2023, 187 participants were enrolled in Project CHANGE from an area with high incarceration and overdose rates. At baseline, 43% of participants were unstably housed, 37% were homeless, and the remaining resided in a shelter or institution. At the time of last follow-up, 49 participants (26.2%) reported improved housing outcomes, and an additional 121 participants (64.7%) housing situation did not worsen. In multivariate models, individuals who were older (AOR 1.1; 95% CI 1.0-1.1), unstably housed at baseline (AOR 7.2; 95% CI 3.3-16.0), and enrolled in the study for longer (AOR 1.1; 95% CI 1.1-1.3) had higher odds of being housed at last follow-up, whereas those with high severity substance use had lower odds of being housed (AOR 0.3; 95% CI 0.1-0.6.) ConclusionsIn this comprehensive program, integrated housing/health services were time- and cost-intensive to deliver but led to positive housing outcomes. People involved in the criminal-legal system face unique barriers to housing, particularly when compounded by substance use.

Abstract/SummaryFinancial exploitation of older adults is an increasingly prevalent public health concern, yet few have characterized fraud prevalence longitudinally or evaluated whether financial exploitation vulnerability measures prospectively predict fraud outcomes. Using data from the Health and Retirement Study, we examined fraud prevalence across a 14-year period and tested whether the Perceived Financial Vulnerability Scale (PFVS) predicts subsequent fraud victimization among older adults. Fraud prevalence increased steadily over time, rising from 5.0% in 2008 (347 of N=6,920) to a peak of 10.2% in 2022 (448 of N=4,380). Higher PFVS scores measured in 2018 were associated with greater odds of fraud victimization reported in 2022 (OR=1.62, 95% CI [1.25-2.15], p<.001). Most individuals who later reported fraud fell within the highest group of PFVS scores up to five years earlier. Together, these findings highlight financial exploitation as an emerging aging-related vulnerability and support the PFVS as a brief indicator of future fraud risk.

BackgroundA Hospital Medicine Advanced Practice Provider (HMAPP)-led care model developed in response to the high acuity and increased patient volumes associated with the Covid-19 pandemic. Although anecdotally perceived as a successful model, questions remained if there was adequate pre-planning and formal implementation strategy for stakeholder buy-in. ObjectiveTo elicit HM physicians and APPs perceptions of the HMAPP-led care model implementation and consider necessary steps for optimal future APP care model development and operation. Design, Setting and ParticipantsThis qualitative study used 10 (5 physicians and 5 APPs involved in the care model pre- and post-implementation) individual semi-structured, virtual interviews based on the Consolidated Framework for Implementation Research (CFIR). Deductive and inductive rapid analysis was utilized to analyze the data. ResultsTwo themes emerged as strengths: 1) Experienced APPs delivered the care model, 2) Acceptance of the care model evolved over time. Four themes suggested opportunities for future development: 1) Guidelines should expand from patient distribution to include minimal collaboration and escalation expectations, 2) Culture change was a barrier to model implementation and acceptance, 3) Intentional collaboration between APPs and Physicians is necessary, 4) Investment in standardized onboarding enhances buy-in of the care model. ConclusionThe impact of an APP care model can be elevated if implemented with key principles and strategies. This is critical in an evolving health care landscape where all providers need to collaborate and practice with their full expertise to maximize safe, efficient and quality patient care.

IntroductionSequence-based typing (SBT) has been the standard molecular typing method for understanding Legionella pneumophila genetic relationships. However, genome-scale typing approaches, namely core-genome (cg) or whole-genome (wg) multilocus sequence typing (MLST), provide higher discriminatory power. To advance these capabilities, the Legionella International Typing (LIT) workgroup was established to develop, evaluate, and disseminate a novel cgMLST schema with enhanced wgMLST resolution for L. pneumophila investigations. MethodsWe created and populated the LIT cg/wgMLST schema with chewBBACA software using more than 9000 genome assemblies representative of the species diversity. We applied a multi-step refinement workflow, considering loci prevalence, diversity and presence/absence profile across the species tree, to select the final cg/wgMLST loci, and compared the performance of the LIT cgMLST schema with the previously used 1521-loci schema and assessed its congruence with SBT. ResultsThe LIT schema includes 2009 loci present in 98% of the dataset, forming the static cgMLST schema for routine genomic surveillance, plus 2698 accessory loci for an in-depth wgMLST analysis of clusters of interest. The LIT cgMLST schema maintains moderate agreement with SBT and presents high clustering congruence with the 1521-loci schema, while providing increased resolution. Analysis of epidemiologically related isolates using the LIT cgMLST schema for initial cluster delineation, followed by cluster-specific dynamic wgMLST analysis extending the cgMLST with accessory loci shared among isolates within each cluster, demonstrated increased confidence for outbreak investigation and source identification. ConclusionsThe LIT schema is expected to contribute to harmonizing genomic surveillance of Legionnaires disease at both local and global levels. The schema and associated resources for local implementation are available on Zenodo (https://doi.org/10.5281/zenodo.17871973).

ObjectivesThe therapeutic efficacy of rituximab has reduced the discriminatory power of the International Prognostic Index (IPI) in diffuse large B-cell lymphoma (DLBCL), particularly within intermediate-risk categories. To address this "risk dilution," we aimed to develop and internally validate the AB-IPI (Albumin-BCL2 Refined Prognostic Index) using a hypothesis-driven approach that integrates tumor burden, host fitness, and tumor biology. MethodsThis multi-center retrospective study analyzed 289 patients with de novo DLBCL treated uniformly with R-CHOP immunochemotherapy. We combined the standard IPI with serum albumin < 3.6 g/dL (representing host fitness/rituximab pharmacokinetics) and BCL2 protein expression > 50% (representing tumor biology). The model was validated internally using bootstrapping with 1,000 resamples in accordance with TRIPOD Type 1b guidelines. This study adhered to the TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) statement for model development and internal validation (Type 1b). ResultsDuring the observation period, 115 death events were recorded. Multivariate Cox regression identified albumin < 3.6 g/dL (Hazard Ratio 2.62), IPI score > 2 (HR 2.13), and BCL2 > 50% (HR 1.72) as independent prognostic factors. The model maintained a robust Events Per Variable (EPV) ratio of 38.3. The AB-IPI stratified patients into four distinct risk groups with 5-year overall survival rates of 88.0% (Low), 76.1% (Intermediate-1), 45.0% (Intermediate-2), and 29.0% (High). The calibration plot demonstrated excellent agreement between predicted and observed probabilities, with a calibration slope of 0.98, indicating minimal optimism and robust risk estimation. Decision Curve Analysis (DCA) demonstrated that the AB-IPI provided a superior Net Benefit across a wide range of clinically relevant threshold probabilities. ConclusionsThe AB-IPI demonstrates superior clinical utility and calibration compared to the standard IPI. By identifying patients with compounded biological risks who are unlikely to be cured by R-CHOP alone, this score offers a practical framework for optimizing therapeutic strategies, such as the allocation of polatuzumab vedotin.

ObjectiveTo quantify trends in annual mean healthcare costs per person living with HIV from 2003 to 2018 from a publicly funded healthcare system perspective. DesignWe conducted a retrospective population-based study using administrative health data in Ontario, Canada, including 25,842 people living with HIV diagnosed and entering care between 1992 and 2018. A nested cohort from the Ontario HIV Treatment Network Cohort Study (n=3,516) provided additional HIV-related characteristics. MethodsAnnual mean healthcare costs per person were estimated using a validated costing algorithm and inflated to 2025 Canadian dollars. Trends were examined overall and stratified by sociodemographic factors (age, sex, rurality, neighbourhood income, immigration status) and year of entry into HIV care. Within the nested cohort, trends were stratified by nadir CD4 count and any antiretroviral therapy use since diagnosis. ResultsAnnual mean cost per person increased from $11,963 in 2003 to $16,721 in 2018. Medication costs remained the largest cost component throughout (47.4-61.7%) and closely mirrored overall trends. Higher annual mean costs were consistently observed among individuals diagnosed at older ages, lower-income neighbourhood residents, long-term Ontario residents (Canadian-born or immigrated before 1985), and individuals with nadir CD4<200cells/{micro}L. ConclusionMedication expenditures continue to drive healthcare costs for people living with HIV. Cost containing strategies, including expanded generic substitution and strengthened price negotiation, may reduce costs without compromising outcomes. Persistent cost disparities highlight the need to address delayed treatment initiation and broader social determinants shaping HIV treatment access and sustained engagement in care.

BackgroundTuberculosis (TB) incidence peaks in women during their reproductive years and is a leading cause of maternal mortality. Pregnant women with TB have a high risk of failure to initiate TB treatment and poor TB treatment and pregnancy outcomes. We determined the time to treatment initiation in pregnant women diagnosed with TB in a routine programmatic setting. MethodsUsing routine linked electronic data, we identified women 15-45 years of age with laboratory-confirmed and/or clinically diagnosed TB, October 2018-December 2020, in two high-burden sub-districts in Cape Town, South Africa. We compared demographic and clinical characteristics in women with TB by pregnancy status, used time-to-event analysis to determine the time from TB diagnosis to initiation of antituberculosis treatment and Cox regression to assess determinants of treatment initiation. ResultsOf 5,459 women diagnosed with TB, 292 (5.3%) were pregnant. The median age for pregnant women was 28.6 years (interquartile range [IQR]: 23.7-33.7) and non-pregnant women 31 years (IQR:25.2-36.5). HIV prevalence was similar in pregnant (177/292; 60.6%) vs non-pregnant (3200/5167; 61.9%) women. Median time to treatment initiation was two days for pregnant and non-pregnant women. Most women initiated treatment within the first month after their TB diagnosis, after which the rate plateaued in both groups. Time to treatment initiation over 6 months was statistically different (Kaplan Meier Log-rank test, p = 0.0064) with pregnant women lagging behind non-pregnant women. ConclusionsMore than 5% of women diagnosed with TB were pregnant at the time of TB diagnosis. While pregnant women with TB were appropriately initiated on treatment, almost 15% were never started on treatment and there were delays in treatment initiation. While strategic interventions to prioritise early treatment initiation are needed, there should be a specific focus on pregnant women who have not initiated treatment within one month after TB diagnosis.

AbstractsO_ST_ABSBackgroundC_ST_ABSAccurate dengue forecasting is vital for public health preparedness. Despite a surge in forecasting approaches, a quantitative ranking of the relative performance and practical utility of dengue forecasting is lacking. MethodsA systematic review and Network Meta-Analysis (NMA) of studies comparing dengue forecasting methods (2014-2024) was conducted. Models were categorised into five groups: Time Series, Deep Learning (DL), Machine Learning (excluding DL), Hybrid, and Ensembles. NMA was applied to the logarithm of the most common forecast error metric to rank relative performance--an "Implementability Score" quantified analyst and data requirements, and computational costs. Results59 studies were included. NMA of Root Mean Squared Error identified k-Nearest Neighbour (k-NN) models as achieving the highest predictive accuracy, followed closely by Vector Autoregression, Kalman Filtering, Generalised Linear Model and Autoregressive Neural Network (ARNN). While DL models showed high potential, they scored lowest in implementability due to poor interpretability and high data requirements. Most studies utilised meteorological covariates, with significant gaps in the use of socio-economic and entomological predictors. ConclusionsAlthough there was some trade-off between accuracy and implementability, traditional statistical models were often comparable in accuracy to machine learning approaches, with advantages in interpretability and data needs. Under-explored areas for future research include the use of ensemble models and the use of socio-economic and entomological data. RegistrationPROSPERO CRD420251016662. Author SummaryDengue is a critical global health threat affecting the worlds population. While many forecasting models exist to help officials prepare for outbreaks, there has been no standardised way to compare their performance. This leaves health experts in resource-limited areas uncertain about which tools are truly reliable or easy to use under their specific local conditions. We conducted a network meta-analysis of studies comparing dengue forecasting methods accuracy, grouping them into five categories: Machine Learning, Deep Learning, Time Series, Ensemble, and Hybrid. Beyond ranking their accuracy, we developed an "Implementability Score" to evaluate the practical feasibility of each model, accounting for technical complexity, data requirements, and software accessibility. Our analysis identified the top-performing models. Notably, traditional statistical models often performed as well as complex Deep Learning algorithms. While advanced models show potential, they are often difficult to implement or explain to decision-makers. There is no "one-size-fits-all" solution; the best model depends on capacity and data in each setting. This study provides a roadmap for public health officials to select tools that are both accurate and feasible.

Advances in our understanding of the biology of skeletal muscle ageing are being made at pace, with great potential for these findings to inform the identification of novel treatments for sarcopenia. However, translation of findings from animal models to humans has been hampered by limitations of existing human muscle biopsy studies. Devised to directly address this challenge, the Muscle Ageing and Sarcopenia Study (MASS) Lifecourse is a unique resource for the study of human muscle ageing across adulthood. This deep-phenotyped observational study of 260 community-dwelling men and women aged 18 to 85 years living in North East England includes muscle biopsy samples and detailed characterisation of physical function, health status and sociodemographic and behavioural risk factors. Underpinned by broad interdisciplinary research and clinical expertise this study is catalysing cutting-edge translational research on human muscle ageing across the adult life course.

BackgroundIn pharmacoepidemiological studies, days of treatment (DoT) duration associated with individual electronic drug utilization records (DUR) are usually missing. Researcher-defined duration (RDD) calculation approaches, as opposed to data-driven approaches, can be used to estimate DoT based on the specific choices and assumptions made by investigators. These are usually underreported or even undocumented. We aimed to develop a framework for the standardization of terminology, formulas, implementation, and reporting of possible RDD approaches. MethodsA systematic classification of RDD calculation approaches was developed via expert consensus. Universal concepts used to operationalise RDDs were identified and described using standard terminologies. An open-source R function, CreateDoT, was created to implement the formulas universal concepts as input parameter. A step-by-step workflow was developed to facilitate implementation and reporting. ResultsRDD approaches were classified in two main classes: I) daily dose (DD)-based calculation approaches (n=3 formulas), and II) fixed-duration approaches (n=2). Seven universal concepts were identified to describe the five corresponding generalized formulas for DoT calculation. Input parameters of the CreateDoT function can be retrieved from source data through its mapping to universal concepts, or inputted by the investigator based on the chosen calculation approach. The input file structure itself represents a standard reporting template for documenting investigators assumptions and methodological choices adopted for DoT calculation. ConclusionsThe CreateDoT framework can facilitate the documentation and reporting of RDD approaches for DoT calculation, increasing transparency and reproducibility of pharmacoepidemiological studies regardless of the data model used, and facilitates sensitivity analyses to evaluate the impact of alternative assumptions in DoT calculation.