Primary care provider-led cancer survivorship care in the first 5 years following initial cancer treatment: a scoping review of the barriers and solutions to implementation

PURPOSE

To synthesize the barriers to primary care provider (PCP)-led cancer survivorship care (≤ 5 years after initial cancer treatment) experienced by healthcare systems around the world, and to explore potential solutions that would succeed within a developed country.

METHODS

A scoping review of peer-reviewed articles and grey literature was conducted. Four electronic databases (Medline, Embase, Web of Science Core Collection, and Google Scholar) were searched for articles prior to April 2021.

RESULTS

Ninety-seven articles published across the globe (USA, Canada, Australia, European Union, and UK) met the review inclusion/exclusion criteria. The four most frequently discussed barriers to PCP-led survivorship care in healthcare systems were as follows: (1) insufficient communication between PCPs and cancer specialists, (2) limited PCP knowledge, (3) time restrictions for PCPs to provide comprehensive survivorship care, and (4) a lack of resources (e.g., survivorship care guidelines). Potential solutions to combat these barriers were as follows: (1) improving interdisciplinary communication, (2) bolstering PCP education, and (3) providing survivorship resources.

CONCLUSIONS

This scoping review identified and summarized key barriers and solutions to the provision of PCP-led cancer survivorship care. Importantly, the findings from this review provide insight and direction to guide optimization of cancer care practice within BC's healthcare system.

IMPLICATIONS FOR CANCER SURVIVORS

Optimizing the PCP-led survivorship care model will be a valuable contribution to the field of cancer survivorship care and will hopefully lead to more widespread use of this model, ultimately lessening the growing demand for cancer-specific care by cancer specialists.

Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system

BACKGROUND

Globally, emergency departments (EDs) are overcrowded and unable to meet an ever-increasing demand for care. The aim of this study is to comprehensively review and synthesise literature on potential solutions and challenges throughout the entire health system, focusing on ED patient flow.

METHODS

An umbrella review was conducted to comprehensively summarise and synthesise the available evidence from multiple research syntheses. A comprehensive search strategy was employed in four databases alongside government or organisational websites in March 2023. Gray literature and reports were also searched. Quality was assessed using the JBI critical appraisal checklist for systematic reviews and research syntheses. We summarised and classified findings using qualitative synthesis, the Population-Capacity-Process (PCP) model, and the input/throughput/output (I/T/O) model of ED patient flow and synthesised intervention outcomes based on the Quadruple Aim framework.

RESULTS

The search strategy yielded 1263 articles, of which 39 were included in the umbrella review. Patient flow interventions were categorised into human factors, management-organisation interventions, and infrastructure and mapped to the relevant component of the patient journey from pre-ED to post-ED interventions. Most interventions had mixed or quadruple nonsignificant outcomes. The majority of interventions for enhancing ED patient flow were primarily related to the 'within-ED' phase of the patient journey. Fewer interventions were identified for the 'post-ED' phase (acute inpatient transfer, subacute inpatient transfer, hospital at home, discharge home, or residential care) and the 'pre-ED' phase. The intervention outcomes were aligned with the aim (QAIM), which aims to improve patient care experience, enhance population health, optimise efficiency, and enhance staff satisfaction.

CONCLUSIONS

This study found that there was a wide range of interventions used to address patient flow, but the effectiveness of these interventions varied, and most interventions were focused on the ED. Interventions for the remainder of the patient journey were largely neglected. The metrics reported were mainly focused on efficiency measures rather than addressing all quadrants of the quadruple aim. Further research is needed to investigate and enhance the effectiveness of interventions outside the ED in improving ED patient flow. It is essential to develop interventions that relate to all three phases of patient flow: pre-ED, within-ED, and post-ED.

Self-driven solutions and resilience adapted by people with drug-resistant tuberculosis and their caregivers in Bengaluru and Hyderabad, India: a qualitative study

Background

One-fifth of people with drug-resistance tuberculosis (DR-TB) who were initiated on newer shorter treatment regimen (with injection) had unfavourable treatment outcomes in India as on 2020. Evidence on self-driven solutions and resilience adapted by people with DR-TB (PwDR-TB) towards their multi-dimensional disease and treatment challenges are scarce globally, which we aimed to understand.

Methods

In this qualitative study using positive deviance framework, we conducted semi-structured in-depth interviews among consenting adult PwDR-TB (7 women, 13 men) who completed shorter treatment regimen (including injections) with maximum treatment adherence. The study was conducted in the southern districts of Bengaluru and Hyderabad, India between June 2020 and December 2022. Caregivers (14 women, 6 men) and health providers (8 men, 2 women) of PwDR-TB were also interviewed. Interviews were conducted in local language (Kannada, Tamil, Telugu, Urdu and Hindi) and inquired about practices, behaviours, experiences, perceptions and attributes which enabled maximum adherence and resilience of PwDR-TB. Interviews were audio recorded, transcribed, and translated to English and coded for thematic analysis using inductive approach.

Findings

Distinctive themes explanatory of the self-driven solutions and resilience exhibited by PwDR-TB and their caregivers were identified: (i) Self-adaptation towards the biological consequences of drugs, by personalised nutritional and adjuvant practices, which helped to improve drug ingestion and therapeutic effects. Also home remedies and self-plans for ameliorating injection pain. (ii) Perceptual adaptation towards drugs aversion and fatigue, by their mind diversion practices, routinisation and normalisation of drug intake process. and constant reinforcement and re-interpretation of bodily signs of disease recovery (iii) Family caregivers intense and participatory care for PwDR-TB, by aiding their essential life activities and ensuring survival, learning and fulfilling special nutritional needs and goal oriented actions to aid drug intake (iv) Health care providers care, marked by swift and timely risk mitigation of side-effects and crisis response (v) Acquired self-efficacy of PwDR-TB, by their decisive family concerns resulting in attitudinal change. Also being sensitised on the detrimental consequences of disease and being motivated through positive examples.

Interpretation

Synthesised findings on self-driven solutions and resilience towards the multi-dimensional DR-TB challenges provides opportunity for developing and testing new interventions for its effectiveness in DR-TB care settings globally. Designing and testing personalised cognitive interventions for PwDR-TB: to inculcate attitudinal change and self-efficacy towards medication, developing cognitive reinforcements to address the perception burden of treatment, skill building and mainstreaming the role of family caregivers as therapeutic partners of PwDR-TB, curating self-adaptive behaviours and practices of PwDR-TB to normalise their drug consumptions experiences could be the way forward in building resilience towards DR-TB.

Funding

United States Agency for International Development (USAID) through Karnataka Health Promotion Trust (KHPT), Bengaluru, India.

Racism as a public health issue in environmental health disparities and environmental justice: working toward solutions

BACKGROUND

Environmental health research in the US has shown that racial and ethnic minorities and members of low-socioeconomic groups, are disproportionately burdened by harmful environmental exposures, in their homes, workplace, and neighborhood environments that impact their overall health and well-being. Systemic racism is a fundamental cause of these disproportionate exposures and associated health effects. To invigorate and inform current efforts on environmental justice and to raise awareness of environmental racism, the National Institute of Environmental Health Sciences (NIEHS) hosted a workshop where community leaders, academic researchers, and NIEHS staff shared perspectives and discussed ways to inform future work to address health disparities.

OBJECTIVES

To share best practices learned and experienced in partnerships between academic researchers and communities that are addressing environmental racism across the US; and to outline critical needs and future actions for NIEHS, other federal agencies, and anyone who is interested in conducting or funding research that addresses environmental racism and advances health equity for all communities.

DISCUSSION

Through this workshop with community leaders and researchers funded by NIEHS, we learned that partnerships between academics and communities hold great promise for addressing environmental racism; however, there are still profound obstacles. To overcome these barriers, translation of research into plain language and health-protective interventions is needed. Structural changes are also needed in current funding mechanisms and training programs across federal agencies. We also learned the importance of leveraging advances in technology to develop creative solutions that can protect public health.

Challenges and solutions for implementing telemedicine in Iran from health policymakers' perspective

BACKGROUND

Despite significant progress in health technology and growing interest among countries in incorporating telemedicine into healthcare delivery, its usage remains limited in Iran. The aim of this study is to investigate the challenges related to telemedicine in Iran and pinpoint potential solutions from the viewpoint of health policymakers, marking the first such endeavor.

METHODS

This qualitative study was conducted in Iran in 2022. Data were gathered from 19 health policymakers who were selected using purposeful and snowball sampling techniques via in-depth and semi-structured interviews. The research findings were analyzed using the content analysis technique, with coding performed using MAXQDA software. The content analysis approach developed by Erlingsson was utilized to analyze the data.

RESULTS

The study revealed eight main challenges that inhibit the widespread use of telemedicine in Iran. These challenges include policy weaknesses, uncertainty around operating mechanisms, inadequate communication and telecommunication infrastructure, insufficient cultural infrastructure, lack of electronic requirements, redundant bureaucracies, legal gaps, and economic factors. Furthermore, four key solutions to these challenges were identified. These include a national commitment to the development of telemedicine, the establishment of a telemedicine roadmap, the enhancement of e-health requirements and infrastructure, and the preparation of the community to accept telemedicine as a viable option for healthcare delivery.

CONCLUSION

The implementation of telemedicine in Iran faces significant challenges, some of which are related to the national healthcare system, while others stem from various policy-related institutions and organizations. Addressing these challenges will require extensive inter-organizational cooperation and strong leadership at the governance level. However, it should be noted that fully resolving these issues is a time-consuming process.

[Drug shortages : a fatality ?]

In recent years, the number of drug shortages has risen alarmingly both in Belgium and internationally. Between 2010 and 2020, the number of reported shortages is almost 27 times higher, according to the French Agency for the Safety of Medicines and Health Products. A recent survey conducted by the European Association of Hospital Pharmacists showed that 95 % of hospital pharmacists consider drug shortages to be a major problem. The drug classes most affected include anti-infectives, analgesics and anaesthetics. The sudden and unpredictable occurrence of drug shortages has a negative impact on the daily lives of healthcare professionals and patients. Doctors are sometimes forced to prescribe alternative treatments that are considered less effective or even less well tolerated. These alternatives make it more difficult for patients to adhere to their treatment and generate an additional risk of medication errors. There are several possible solutions to minimize these shortages: relocating production sites to Europe, imposing penalties on offending companies, adopting a common European policy for managing shortages of medicines of major therapeutic interest,... As a corollary to these proposals, legal texts have been adopted to regulate and guarantee the supply of medicines in Belgium.

Informing and inspiring worldwide action against marine litter - The impact of the Massive Open Online Course (MOOC) on Marine Litter

Marine litter and plastic pollution are growing environmental problems that require sustainable actions from a wide range of stakeholders. To achieve effective solutions, stakeholders need good knowledge and opportunities for active engagement. To encourage leadership and provide these opportunities, we have developed an action-, and change-oriented Massive Open Online Course (MOOC) on Marine Litter. After five years of running the MOOC, we assessed the impact of the MOOC through an online questionnaire among participants. The results showed significant impact and global reach. Respondents from all over the world reported that they used the information of the MOOC in their careers, volunteer work and personal lives. The results underscore the importance of environmental education to inform and inspire stakeholders. Educational activities should respond to participants' motivations by using activating learning forms and illustrative examples. The MOOC inspired participants to take informed action, engage others, expand their networks, and create real change.

AN X-RAY OF THE NATIONAL MENTAL HEALTH ACT 2021 OF NIGERIA: OPPORTUNITIES, LIMITATIONS AND THE WAY FORWARD

The Nigerian Mental Health Law originated as a Lunacy ordinance in 1916 and matured into Lunacy Act CAP 524 of the law of Nigeria, 1964. This review of the National Mental Health Act (NMHA) 2021 of Nigeria examines the prospects, challenges, and possible ways forward. This act has a schedule, five parts, fifty-eight sections, and many subsections. It was compared with the WHO Checklist while the limitations were examined with a view to recommending solutions and identifying the tasks ahead. The NMHA 2021 provides for enhancing and regulating Mental Health Services through a Mental health Services Department. Also, a Mental Health Assessment committee is set up as a tribunal to protect the rights of persons with intellectual, cognitive and psychosocial disabilities, including the rights to a legal representative, employment, and housing. Persons with mental health conditions are to enjoy standard services and participate in formulating their medical plans devoid of coercion. The Presidential gazetting of the act is a good starting point in a positive direction. It should be adequately implemented with the coordinated efforts of all stakeholders and domesticated by the state governments. Finally, more advocacy by the Association of Psychiatrists in Nigeria and other key players. A key limitation is the access to the health care facility given the rural-urban access challenges and owing to the wide treatment gap and the low Doctor-patient ratio worsened by the brain drain.

Achieving Health Equity in the Care of Patients with Heart Failure

PURPOSE OF REVIEW

To discuss the prevailing racial and ethnic disparities in heart failure (HF) care by identifying barriers to equitable care and proposing solutions for achieving equitable outcomes.

RECENT FINDINGS

Throughout the entire spectrum of HF care, from prevention to implementation of guideline-directed medical therapy and advanced interventions, racial and ethnic disparities exist. Factors such as differential distribution of risk factors, poor access to care, inadequate representation in clinical trials, and discrimination from healthcare clinicians, among others, contribute to these disparities. Recent data suggests that despite improvements, disparities prevail in several aspects of HF care, hindering our progress towards equity in HF care. This review highlights the urgent need to address racial and ethnic disparities in HF care, emphasizing the importance of a multifaceted approach involving policy changes, quality improvement strategies, targeted interventions, and intentional community engagement. Our proposed framework was derived from existing research and emphasizes integrating equity into routine quality improvement efforts, tailoring interventions to specific populations, and advocating for policy transformation. By acknowledging these disparities, implementing evidence-based strategies, and fostering collaborative efforts, the HF community can strive to reduce disparities and achieve equity in HF care.

Staff's insights into fall prevention solutions in long-term care facilities: a cross-sectional study

BACKGROUND

Falls are one of the most common and serious health issues in long-term care facilities (LTCFs), impacting not just residents, but staff and the healthcare system. This study aimed to explore LTCF staff's current practices around falls prevention, and their suggested solutions for better falls prevention.

METHODS

In the southwest of Ireland, a descriptive cross-sectional study was conducted in 13 LTCF sites, across a range of provider types and facility sizes. A survey, measuring staff knowledge, skills and attitudes, was distributed in physical and online formats. Staff suggestions for prioritising fall and fall-related injury prevention activities, and current staff practices regarding fall incidents were also sought. Content analysis was used to analyse responses, mapping categories and subcategories to the refined theoretical domains framework (TDF) and to an existing fall prevention guideline.

RESULTS

There were 155 respondents (15% response rate), from staff of the LTCFs. Environmental reviews and modifications (aligned to the TDF environmental context and resource domain) were the most common suggestions for preventing both falls and fall-related injuries. Other common suggestions for preventing falls were staff education, monitoring of residents, and using alarm/calling systems, while few staff members, across all roles, reported assessing residents, exercises, reviewing medications, and vitamin D supplements. For preventing fall-related injuries, suggestions included protective equipment, hip protectors and alarm/calling systems. Staff used a standardised approach when responding to a fall incident, with intensive and holistic post-fall control measures. HCAs focussed on transferring residents safely, while nurses of all grades focused more on post-fall assessment. Respondents believed that staff education, communication, increasing staffing levels and enhancing specialist care could support their practice.

CONCLUSION

Noting the low response rate, the results suggest an awareness gap regarding some evidence-based, resident-focussed falls prevention solutions, such as pro-active fall-risk assessment, exercise, medication review, and Vitamin D supplements. These aspects should be included in future fall prevention education programmes in LTCFs.

CHALLENGES OF RENAL REPLACEMENT THERAPY IN NIGERIA: SOLUTIONS FROM MEDICAL STUDENTS' PERSPECTIVES

Introduction

During our posting at the Renal Unit, Department of Medicine, University College Hospital, Ibadan, we observed numerous difficulties encountered by patients requiring renal replacement therapy and the family members/caregivers of these patients. These are broadly categorized into patents' related challenges, institutional inadequacies, infrastructural challenges, policy, and funding issues.

Perspective

Patients' challenges are poor health-seeking habits culminating in late diagnosis in advanced uremic state and poor economic status resulting in catastrophic out-of-pocket spending. Institutional and infrastructural challenges include epileptic power supply in the dialysis unit, a lack of necessary materials needed for dialysis, among others. Policy issues included the absence of an organ donor system and regulations guiding them. More importantly, there is insufficient support from the government concerning patients with end-stage kidney disease.

Conclusion

Tackling the management of end-stage kidney disease would require paying attention to and addressing these challenges.

Monitor compartments, mitigate sectors: A framework to deconstruct the complexity of plastic pollution

The rapid growth in science, media, policymaking, and corporate action aimed at "solving" plastic pollution has revealed an overwhelming complexity, which can lead to paralysis, inaction, or a reliance on downstream mitigations. Plastic use is diverse - varied polymers, product and packaging design, pathways to the environment, and impacts - therefore there is no silver bullet solution. Policies addressing plastic pollution as a single phenomenon respond to this complexity with greater reliance on downstream mitigations, like recycling and cleanup. Here, we present a framework of dividing plastic use in society into sectors, which can be used to disentangle the complexity of plastic pollution and direct attention to upstream design for the circular economy. Monitoring plastic pollution in environmental compartments will continue to provide feedback on mitigations, but with a sector framework, scientists, industry, and policymakers can begin to shape actions to curb the harmful impacts of plastic pollution at the source.

[Telemedicine and severe asthma in our environment: Views on the experience of professionals and suggestions to make it a reality]

This paper aims to examine the recent experience in telemedicine (TM) management of patients with severe asthma (SA). A committee of health professionals involved in asthma management (pulmonology, allergology, respiratory nursing, and hospital pharmacy) held discussion meetings on the practical experience of TM for the management of SA and the means available complemented with a bibliographic search to know the current status of TM in SA. The main barriers detected for the implementation of TM in SA have been the lack of technological training, the lack of registration of TM in the clinical history, the care overload, or the connectivity problems at the administration level. The practical solutions are provided such as the selection of the patient suitable for TM, the registration of TM in the medical record, its inclusion in the care objectives or the increase of funding for systems. Moreover, the main App and Webapp for use by patients are provided, and the portable equipment for remote functional respiratory tests. In conclusion, it is necessary that the teleconsultation has the same entity as the face-to-face visit with a schedule in the appointment's agenda and a structure of both the medical interview and the tests to be performed in each consultation. Additionally, should be promoted the implementation of a video call system, tools that allow the monitoring of both therapeutic adherence and inhalation technique, as well as the patient's lung function.

Seasonality, mass vaccination and critical policy evaluation on global exit strategy of COVID-19 crisis

There is a strong coordinated effort by vaccination groups all over the world to put an end to the current crisis of COVID-19. Now sufficient data are available to analyse and compare some results to explore the aftereffects of vaccination. Some influence variables on transmissions of the disease were discussed e.g., mass vaccination, lockdown and seasonality. Most studies covered here are up to the beginning of July 2022, while some analyses focused on the earlier period of mass vaccination. Well established, simple statistical techniques to evaluate results were presented those used open data sources of authoritative bodies. Some comparisons between vaccinated vs. unvaccinated were also discussed based on data from UK Government Health Security Agency (UHSA). In terms of mass vaccination, adverse reactions after vaccination received attention, as health and safety issues of the general public are of prime importance. Apart from direct side effects, the secondary effect of mass vaccination needs attention too. After the initiation of the vaccination programme, almost all countries experienced a sudden surge in transmission and most countries had to impose strict lockdown measures. Many countries, with a low prevalence of disease, suddenly showed a steep jump and some countries even followed a synchronized pattern between the rate of transmissions and the variation of vaccine doses. Time series analyses and bar diagram presentations were able to capture those features. In that context, fast mutation of the virus and new variants after mass vaccination and possible mechanisms/consequences were also attended. To understand the effect of seasonality, similarities between COVID-19 and the seasonal Flu are discussed for Europe and US to gain useful insight. Using time series analyses and spatial plots of regional temperature composites we showed, like Flu, seasonality played a dominant role in transmissions of COVID-19 in the Europe. Regulations of vaccine dose and policy implication were explored too. From 22^nd December 2021, global vaccine doses were reduced substantially, which followed a dramatic reduction in cases and thereafter deaths with around one month's lag between each. As strong dependency on seasonality is noticed in certain countries and observing that regulation of vaccine doses has roles in modulating the transmission with certain lags, globally as well as regionally, our results have policy implications for the management of COVID. Debating, questioning and criticism are always the foundation of great science and the major pillars of its progress. Following that objective, it is an effort to explore pragmatically, supported by scientific analyses, areas relating to the effectiveness of the COVID-19 vaccine and the exit strategy via the pathway of vaccination.

Identifying and Reducing Barriers to Breast Imaging

Purpose of Review

The purpose of this review is to discuss disparities in breast health care access and outcomes related to race, gender, cultural diversity, sexual orientation, socioeconomic status, geographic location, and disability. The authors recognize the complexity of eliminating inequalities in health care but are optimistic that all patients will one day have equal access to care through dialogue, acknowledgment, recognition, and action.

Recent Findings

After lung cancer, breast cancer is the second leading cause of death among American women. Mammography as a preventative screening tool has resulted in significant reductions in breast cancer mortality. Despite existing breast cancer recommendations, it has been projected that 43,250 women will die from breast cancer in 2022.

Summary

Disparities in healthcare outcomes exist for many reasons including inequalities based on race, gender, cultural diversity, religion, sexual orientation, and socioeconomic status. Disparities, no matter how large or complex, are not insurmountable.

Combating COVID-19 crisis and exploring heat-based simple solutions

Covid-19 pandemic affected whole of the world taking many lives and impacting the economy and mental health severely. Exit pathways via vaccination though ignited optimism initially but attenuated by the emergence of several new variants which are less sensitive to vaccines. Considering emergency situations, some urgent, simple heat-based solutions for the initial stages of the disease were also proposed at the beginning of pandemic and further elaborated here. Solutions were proposed based on science as follows: exploring results of statistical analyses on the global transmission of COVID-19; observed temperature-dependent behaviours of similar category viruses; temperature-based clinical trial experiments with similar category viruses; successful clinical trial experiments with heat-based intervention for COVID-19 patients; and finally, biological mechanism/response in human bodies to heat-based solution for COVID-19 from medical doctor's perspective. Solutions proposed are practically without side effects, can be even practised in own home and there is no vested interest involved.

Making the current non-surgical treatments for knee osteoarthritis more effective: Solutions from a diverse patient group

OBJECTIVE

To examine patient perceived solutions to barriers to effective non-surgical knee osteoarthritis (OA) treatments in a diverse racial/ethnic group.

METHODS

Nominal groups were conducted with consecutive patients with knee OA at a medical center clinic, oversampling for African Americans with knee OA. Participants discussed potential solutions and rank-ordered their concerns.

RESULTS

Thirteen nominal groups with 46 knee OA patients were conducted with mean age, 60.8 years (standard deviation [sd], 10.0) and knee OA duration, 8.1 years (sd, 5.4); 22% were men, and 56% were African American. The following solutions were in the top three ranked solutions in 13 NGTs: (A) more research, effective and/or safer new medications/treatments, and joint cartilage restoration (8 groups; 15% votes [43/276]); (B) early diagnosis (2 groups; 7% votes [20/276]); (C) better and more effective communication (5 groups; 10% votes [29/276]); (D) public and patient education (4 groups; 8% votes [22/276]); (E) motivation and behavioral modification (4 groups; 9% votes [26/276]); (F) team approach (1 group; 1% votes [2/276]); (G) personalized medicine (6 groups; 8% votes [24/276]); (H) cheaper and more affordable medications and treatments (3 groups; 5% votes [15/276]).

CONCLUSIONS

A diverse group of participants with knee OA identified several solutions to barriers to the effectiveness of current knee OA treatments. This new knowledge can inform the development and implementation of future interventions to improve the outcomes of people with knee OA.

Exploring challenges and mitigation strategies towards practicing Teledentistry

BACKGROUND

Since the beginning of the COVID-19 pandemic, many dentists have opted for Teledentistry as a mechanism for patient consultation, oral lesion evaluation, diagnosis, and monitoring. The current study explores the challenges faced and potential solutions proposed by dentists practicing Teledentistry in a developing country like Pakistan.

METHODS

A qualitative case study was carried out from January to December 2021. A purposive maximum variation sample of 10 dentists was interviewed in two focus groups. The interview guide was developed using the technology-organization-environment framework. The data was transcribed verbatim using otter.ai. The analysis involved immersion in the data and open coding. The conceptually related codes were synthesized into themes and subthemes.

FINDINGS

The study found various Personnel, Technological and Organizational challenges, and potential solutions from those practicing Teledentistry. The challenges included operational cost, minimal financial returns, lack of awareness, hardware and software support, and other challenges related to the availability of specialization, accessibility, and institutional encouragement. They suggested Institutional Based Practice, staff training, hiring, development of government regulations, and supporting infrastructures such as designated space, central registry, internet, and using/building software to provide 3D images as solutions.

CONCLUSION

Teledentists face Personnel, Technological and Organizational challenges and related potential solutions from those practicing Teledentistry in Pakistan. Government should encourage Teledentistry to reduce long-term costs, encourage preventive services and enable rural access to dental care. They should also involve all stakeholders to develop regulations for practicing Teledentistry in Pakistan.

The plastic pandemic: COVID-19 has accelerated plastic pollution, but there is a cure

Plastic pollution is now present in all areas of our planet, including its last wilderness, Antarctica, and the plastic crisis has further escalated because of COVID-19. The pandemic has caused a significant increase in the global consumption of single-use protective items such as masks and gloves. These and other plastic items add to the suite of plastic pollution issues, from entanglement of wildlife to microplastic bioaccumulation. Given plastics are a major threat facing humans and wildlife, swift action to reduce plastic pollution is urgently needed. Solutions to plastic pollution are within reach. With collective, impactful action we will ensure a better future for our planet and ourselves. Here, we propose several measures for decision-makers to implement to achieve a solution and tackle plastic pollution as a united, global community.

Systematic reviews of convalescent plasma in COVID-19 continue to be poorly conducted and reported: a systematic review

OBJECTIVES

To suggest possible approaches to combatting the impact of the COVID-19 infodemic to prevent research waste in future health emergencies and in everyday research and practice.

STUDY DESIGN AND SETTING

Systematic review. The Epistemonikos database was searched in June 2021 for systematic reviews on the effectiveness of convalescent plasma for COVID-19. Two reviewers independently screened the retrieved references with disagreements resolved by discussion. Data extraction was completed by one reviewer with a proportion checked by a second. We used the Assessment of Multiple Systematic Reviews to assess the quality of conduct and reporting of included reviews.

RESULTS

Fifty one systematic reviews are included with 193 individual studies included within the systematic reviews. There was considerable duplication of effort; multiple reviews were conducted at the same time with inconsistencies in the evidence included. The reviews were of low methodological quality, poorly reported, and did not adhere to preferred reporting items for systematic reviews and meta-analysis guidance.

CONCLUSION

Researchers need to conduct, appraise, interpret, and disseminate systematic reviews better. All in the research community (researchers, peer-reviewers, journal editors, funders, decision makers, clinicians, journalists, and the public) need to work together to facilitate the conduct of robust systematic reviews that are published and communicated in a timely manner, reducing research duplication and waste, increasing transparency and accessibility of all systematic reviews.

Enhancing consumption responsibility to address global plastic pollution

Plastic pollution is a global crisis, especially in the marine environment. Excessive consumption and unsound disposal are responsible for the constant accumulation of plastic waste, resulting in plastic litter and microplastic contamination on a global scale. Establishing a new global framework is regarded as a promising tool to address plastic pollution, including marine plastic litter. However, there is a need to raise awareness of the role of consumers at individual and national levels in reducing the use of unnecessary plastics and increasing the recycling of plastic waste. The global framework should incorporate aspects of the importance of consumption responsibility in solutions addressing the issue of plastic pollution.

Antibiotics and antibiotic-resistant bacteria in greywater: Challenges of the current treatment situation and predictions of future scenario

The current work reviews the quantitative microbiological risk assessment of antibiotic-resistant bacteria (ARB) in greywater and discusses the international strategies currently used for reducing antimicrobial resistance. The work highlights the countries that have a plan for the treatment and reuse of greywater and the current guidelines used in these countries. The paper also investigates the role of greywater in the distribution of antimicrobial resistance because of antibiotics and ARB. A bibliometric analysis was conducted for the studies on greywater, pathogenic bacteria, and antibiotics. The studies obtained from Scopus database were screened and compared to obtain the data for global antimicrobial resistance in 2000 and 2021. The strategies used by developed countries that led to the reduction in the recorded antimicrobial resistance are also listed. The challenges and limitations associated with the current plans adopted by several countries to minimise the spreading of the antimicrobial resistance are highlighted, while proposed solutions are provided. Two main issues associated with the distribution of antimicrobial resistance are (1) the absence of a plan in developing counties and presence of antimicrobial agents and ARB in the environment and (2) the difficulties in the current treatment technologies used for the removal of these antimicrobial agents from the water and wastewater. Based on the review and discussion, it was concluded that more advanced technologies are required to ensure total elimination of the antimicrobial agents and ARB from the environment. In addition, a new international standard should be drafted for the ARB in the environment, as they differ from the one currently used for medical applications.

Practicalities, challenges and solutions to delivering a national organisational survey of cancer service and processes: Lessons from the National Prostate Cancer Audit

Organisational surveys are a critical process to assess the configuration and availability of services within health care systems. Cancer service organizational surveys enable understanding of variation in structure, processes and outcomes of cancer care according to the availability of facilities and their geographical organisation. This is critical for evaluating the delivery of cancer care services across a specified region. Furthermore, the organisational survey provides essential information about patient support services which can be used to inform patients where particular allied health services are available. The National Prostate Cancer Audit (NPCA) is an audit of all prostate cancer services in England and Wales. The NPCA encompasses all prostate cancer diagnostics, treatments (including surgery, radiotherapy and systemic therapy) and allied services. The NPCA conducted an organisational survey in 2021 via an online questionnaire sent to the prostate cancer clinical leads within each of the 138 NHS providers and we had a response rate of 93 %. There are many challenges to conducting an organisational survey and gaining a high completion rate is still difficult. The challenges that the NPCA faced included accuracy, completion, duplicates and discrepancies in responses. From this experience, we have developed some suggestions for the practical delivery and development of future organisational surveys. It was thanks to the use of many of these strategies, and the engagement of clinicians with the NPCA, that we were able to achieve such a high response rate. Despite these challenges, the importance of organisational surveys of cancer services is demonstrated by the better understanding of structure, processes and outcomes of cancer care according to the accessibility of facilities and their geographical organisation. This is essential for evaluating and improving the delivery of cancer care services across a region.

A review of the cost and effectiveness of solutions to address plastic pollution

Plastic usage increases year by year, and the growing trend is projected to continue. However as of 2017, only 9% of the 9 billion tons of plastic ever produced had been recycled leaving large amounts of plastics to contaminate the environment, resulting in important negative health and economic impacts. Curbing this trend is a major challenge that requires urgent and multifaceted action. Based on scientific and gray literature mainly published during the last 10 years, this review summarizes key solutions currently in use globally that have the potential to address at scale the plastic and microplastic contaminations from source to sea. They include technologies to control plastics in solid wastes (i.e. mechanical and chemical plastic recycling or incineration), in-stream (i.e. booms and clean-up boats, trash racks, and sea bins), and microplastics (i.e. stormwater, municipal wastewater and drinking water treatment), as well as general policy measures (i.e. measures to support the informal sector, bans, enforcement of levies, voluntary measures, extended producer responsibility, measures to enhance recycling and guidelines, standards and protocols to guide activities and interventions) to reduce use, reuse, and recycle plastics and microplastics in support of the technological options. The review discusses the effectiveness, capital expenditure, and operation and maintenance costs of the different technologies, the cost of implementation of policy measures, and the suitability of each solution under various conditions. This guidance is expected to help policymakers and practitioners address, in a sustainable and cost-efficient way, the plastic and microplastic management problem using technologies and policy instruments suitable in their local context.

Pervasive structural racism in environmental epidemiology

BACKGROUND

Epistemological biases in environmental epidemiology prevent the full understanding of how racism's societal impacts directly influence health outcomes. With the ability to focus on "place" and the totality of environmental exposures, environmental epidemiologists have an important opportunity to advance the field by proactively investigating the structural racist forces that drive disparities in health.

OBJECTIVE

This commentary illustrates how environmental epidemiology has ignored racism for too long. Some examples from environmental health and male infertility are used to illustrate how failing to address racism neglects the health of entire populations.

DISCUSSION

While research on environmental justice has attended to the structural sources of environmental racism, this work has not been fully integrated into the mainstream of environmental epidemiology. Epidemiology's dominant paradigm that reduces race to a mere data point avoids the social dimensions of health and thus fails to improve population health for all. Failing to include populations who are Black, Indigenous, and people of color (BIPOC) in health research means researchers actually know very little about the effect of environmental contaminants on a range of population health outcomes. This commentary offers different practical solutions, such as naming racism in research, including BIPOC in leadership positions, mandating requirements for discussing "race", conducting far more holistic analyses, increasing community participation in research, and improving racism training, to address the myriad of ways in which structural racism permeates environmental epidemiology questions, methods, results and impacts.

Trends, causes and solutions of maternal mortality in Jinan, China: the epidemiology of the MMR in 1991-2020

BACKGROUND

China was one of the few countries to achieve the Millennium Development Goals 5. China had taken many effective measures to reduce maternal mortality ratio (MMR) and has achieved encouraging progress. These measures were worth sharing for other countries to reduce the MMR, but the introduction of these measures from the national perspective was too grand, and the measures implemented in a city and the results achieved were more valuable. However, there were few studies on the prevalence and trends of prolonged maternal mortality in a city. In this study, we mainly introduced the prevalence of the MMR in Jinan,China from 1991 to 2020, analyzed the causes of trends and put forward some solutions to the difficulty existing in the process of reducing the MMR,hoping to serve as a model for some developing cities to reduce MMR.

METHODS

We collected maternal mortality data from paper records, electronic files and network platforms. The time trend of MMR was tested by Cochran-Armitage Test (CAT). We divided the study period into three stages with 10 years as a stage and the Chi-square test or Fisher's exact test was used to test the difference in MMR of different periods.

RESULTS

From 1991 to 2020, We counted 1,804,162 live births and 323 maternal deaths, and the MMR was 17.93 per 100,000 live births. The MMR declined from 44.06 per 100,000 live births in 1991 to 5.94 per 100,000 live births in 2020, with a total decline of 86.52% and an annual decline of 2.89%. The MMR declined by 88.54% in rural areas, with an average annual decline 2.95%, faster than that in urban areas (82.06, 2.73%). From 1991 to 2020, the top five causes of maternal deaths were obstetric haemorrhage (4.55 per 100,000 live births), amniotic fluid embolism (3.27 per 100,000 live births), pregnancy-induced hypertension (2.61 per 100,000 live births), heart disease (2.33 per 100,000 live births) and other medical complications (2.05 per 100,000 live births). Postpartum hemorrhage, amniotic fluid embolism, pregnancy-induced hypertension showed a downward trend (P < 0.05) and other medical complications showed an upward trend (P < 0.05).

CONCLUSIONS

Subsidy for hospitalized delivery of rural women, free prenatal check-ups for pregnant women and rapid referral system between hospitals have contributed to reducing MMR in Jinan. However, it was still necessary to strengthen the treatment of obstetric hemorrhage by ensuring blood supply, reduce the MMR due to medical complications by improving the skills of obstetricians to deal with medical diseases, and reduce the MMR by strengthening the allocation of emergency equipment in county hospitals and the skills training of doctors.

The voice of Mexican small-scale fishers in times of COVID-19: Impacts, responses, and digital divide

The COVID-19 pandemic has dramatically, quickly, and extensively affected fisheries, the effects of which have yet to be quantified globally, although some efforts have already been made locally and regionally. This study provides insights regarding the impacts of the pandemic in Mexican small-scale fisheries, explores community responses and digital divide. A total of 1493 interviews were conducted, and a social media analysis that reviewed 9079 posts from April to December 2020 was performed. The results show large socio-economic and environmental impacts (e.g. 89% of the markets closed in April, and 72% of respondents perceived an increase in the amount of solid waste). Women have faced increased inequalities when accessing fishing resources or healthcare. Responses have been varied and include closing communities, and fishing organizations distributing emergency funds. Fishers relate feeling very or moderately comfortable with technology and have spent more time using digital platforms during the pandemic than before. While the effects are still unfolding, there is an urgent need to breach the digital divide to guarantee equal opportunities for all. Efforts are needed to ensure that the most vulnerable groups (e.g. women, indigenous people, and elderly individuals) are not excluded from opportunities to access, use or manage resources, including technology. This global crisis may also bring opportunities for adaptation and the implementation of local solutions (e.g. reducing the fishing effort for high-value products), to prepare for future shocks. The findings in this study serve to promote development strategies that build resilience in fishing communities for healthier oceans.

COVID-19 pandemic and healthcare solid waste management strategy - A mini-review

Healthcare waste comprises the waste generated by healthcare facilities, medical laboratories and biomedical research facilities. Improper treatment of this waste poses serious risks of disease transmission to waste pickers, waste workers, health workers, patients, and the community in general through exposure to infectious agents. Poor management of the waste emits harmful and deleterious contaminants into society. However, contamination of highly contagious agents such as the COVID-19 virus has created enormous instability in healthcare waste handling and subsequent recycling because of the volume of the waste generated and its contagious nature. Several countries have adopted safety measures to combat this contamination and manage healthcare waste; however, these measures are insufficient and vary depending on the context of the country. In addition, the WHO has set out guidelines for management of healthcare waste. These guidelines are helping to manage the highly contagious healthcare waste resulting from the current pandemic. Proper healthcare waste management may add value by reducing the spread of the COVID-19 virus and increasing the recyclability of materials instead of sending them to landfill. Disinfecting and sorting out healthcare waste facilitates sustainable management and allows their utilization for valuable purposes. This review discusses the different healthcare solid waste management strategies practiced in different countries, the challenges faced during this management, and the possible solutions for overcoming these challenges. It also provides useful insights into healthcare solid waste management scenarios during the COVID-19 pandemic and a possible way forward.

COVID-19 pandemic and healthcare solid waste management strategy - A mini-review

Healthcare waste comprises the waste generated by healthcare facilities, medical laboratories and biomedical research facilities. Improper treatment of this waste poses serious risks of disease transmission to waste pickers, waste workers, health workers, patients, and the community in general through exposure to infectious agents. Poor management of the waste emits harmful and deleterious contaminants into society. However, contamination of highly contagious agents such as the COVID-19 virus has created enormous instability in healthcare waste handling and subsequent recycling because of the volume of the waste generated and its contagious nature. Several countries have adopted safety measures to combat this contamination and manage healthcare waste; however, these measures are insufficient and vary depending on the context of the country. In addition, the WHO has set out guidelines for management of healthcare waste. These guidelines are helping to manage the highly contagious healthcare waste resulting from the current pandemic. Proper healthcare waste management may add value by reducing the spread of the COVID-19 virus and increasing the recyclability of materials instead of sending them to landfill. Disinfecting and sorting out healthcare waste facilitates sustainable management and allows their utilization for valuable purposes. This review discusses the different healthcare solid waste management strategies practiced in different countries, the challenges faced during this management, and the possible solutions for overcoming these challenges. It also provides useful insights into healthcare solid waste management scenarios during the COVID-19 pandemic and a possible way forward.

Restricted Eating in Preschoolers with Autism: Mother Stressors and Solutions

Feeding interventions for children with Autism Spectrum Disorder (ASD) focus solely on the child, not the family milieu. This qualitative study aimed to understand mothers' perspectives on managing restricted eating among preschoolers with ASD. Focus groups were conducted with eleven mothers of preschoolers with ASD. Audio recordings were transcribed, and data analyzed for themes. Mothers experienced stressors balancing priorities of adequate nutrition with family mealtime demands and found solutions in support from other mothers, strategies from a wide array of sources, and resorting to trial and error to improve eating. Healthcare practitioners should explore and consider family stressors, competing demands, and coping skills when recommending mealtime interventions for optimal child and family well-being.

The Failed Deltoid Ligament in the Valgus Misaligned Ankle-How to Treat?

This article deals with the treatment of a chronically failed deltoid ligament complex in the valgus misaligned ankle. This is a challenging task in every orthopedic foot and ankle surgery. Before embarking on any surgery that relates to the deltoid ligament complex, it is mandatory to analyze any underlying cause that could promote the impairment. Once this is done, it might be of value in considering anatomic reconstructions. The article provides an anatomic reconstruction technique, which should help address the problem.

Challenges of lung transplantation in India

Lung transplantation (LTx) is the definitive treatment for select progressive end-stage lung disease patients despite being on optimum medical therapy. Asian countries like China, Japan and India have started LTx programmes despite various odds and challenges. Some of these challenges seem to be unique to developing countries. We have elaborated the challenges of LTx in India and their proposed solutions and shared our experience in setting up a successful LTx programme.

Shear-induced transitions in colloidal and polymeric liquids

This review reflects different aspects of wide current studies of the phenomena related to the shear-induced structure transformation in various complex liquids. Experimental data, being the basis of this discussion, were obtained for polymeric liquids (melts, blends, solutions) and different dispersions (colloidal solutions, suspensions, emulsions). The general initial input of shearing is the creation of inhomogeneities which can continue to remain as separate domains, become the nuclei of new phases, or become diffuse, leading to phase separation. The following effects are discussed: diffusion-induced phase separation, phase transitions occurring mainly due to the deformation-driven orientation of polymer chains and worm-like micelles that results in the formation of a liquid-crystal state, as well as self-assembly effects. It can be stressed that the appearance of regular structures takes place in systems that can coexist in different concentrations or phase states at the same stress or shear rate. This is linked with the existence of two-value points on flow curves (part of a flow curve with negative slope) or transient regimes of deformation that lead to instability of the flow. The described experimental facts are briefly discussed on the basis of the application of different constitutive molecular or phenomenological rheological models.

Increasing the fine particle fraction of pressurised metered dose inhaler solutions with novel actuator shapes

In this paper we demonstrate that the use of multiple orifices can improve the fine particle fraction (FPF) of pressurised metered-dose inhaler solution formulations by up to 75% when compared to a single orifice with an equivalent cross sectional area (p<0.05). While prior work has relied on metal actuator components, improvements in micro injection moulding and micro drilling now make it possible to mass produce novel orifice shapes to achieve similar FPF gains in plastic parts, with orifice diameters less than 0.2 mm. The ability to create internal features inside the actuator is also demonstrated. We show through in vitro high speed imaging that twin orifice sprays merge quickly and act as a single, modified plume. We also show for the first time that FPF and fine particle dose (FPD) are strongly correlated with the distance at which the plume velocity decays to half its initial value (R²=0.997 and 0.95 respectively). When plume velocity & FPF are increased, mouthpiece deposition decreases. This suggests that while smaller orifices produce more fine particles, higher sustained plume velocities also entrain more of the fine particles produced at the periphery of the spray due to increased shear. The effect occurs within the mouthpiece and is thus unlikely to alter the flow field in the upper airway.

Dataset on the Hanoian suburbanites' perception and mitigation strategies towards air pollution

Although air pollution has become a significant global environmental problem posing many negative impacts on human health and society, there has been a little known about how people think and respond to it, especially in developing and emerging countries. This article presents a dataset on how the suburbanites perceived and reacted with air pollution in Vietnam, an emerging country in Southeast Asia. A stratified random sampling technique and a face-to-face interview method were employed to survey 302 inhabitants living within Hanoi suburban, during November and December 2019. The constructed data contains three groups of information: (1) perspectives on air quality, causes, and impacts of polluted air, (2) respondent's preventative measures to air pollution, and suggested solutions to improve air quality, and (3) demographic information of interviewees. The dataset could be useful for many scholars who want to conduct a further in-depth study and or environmentalists, policymakers who want to keep society informed about the air pollution-related progression, which could help design a desirable policy for mitigating and or controlling air pollution in Vietnam and beyond.

The efficiency of devices intended to reduce microfibre release during clothes washing

The washing of synthetic clothes is considered to be a substantial source of microplastic to the environment. Therefore, various devices have been designed to capture microfibres released from clothing during the washing cycle. In this study, we compared 6 different devices which varied from prototypes to commercially available products. These were designed to either be placed inside the drum during the washing cycle or fitted externally to filter the effluent wastewater discharge. The aim of this study was to examine the efficacy of these devices at mitigating microfibre release from clothing during washing or at capturing any microfibres released in the wastewater. When compared to the amount of microfibres entering the wastewater without any device (control), the XFiltra filter was the most successful device. This device captured microfibres reducing their release to wastewater by around 78%. The Guppyfriend bag was the second most successful device, reducing microfibre release to wastewater by around 54%; it appeared to mainly work by reducing microfibre shedding from the clothing during the washing cycle. Despite some potentially promising results it is important to recognise that fibres are also released when garments are worn in everyday use. Researchers and industry need to continue to collaborate to better understand the best intervention points to reduce microfibre shedding, by considering both product design and fibre capture.

Management of children and adolescents having type 1 diabetes during COVID-19 pandemic in India: challenges and solutions

Purpose

Type 1 diabetes (T1D) requires a holistic approach and continuous care. The current COVID-19 pandemic has made the health care professionals realise its challenges even more ardently than in the normal times. In a country like India with its huge population burden and a significant number of people having T1D, the risk of COVID-19 in people having T1DM is considerably high.

Methods

In this article, we are sharing our practical experiences of problems faced by children and adolescents having T1DM during the past 2 months of lockdown.

Results

We have classified the challenges into 3 broad categories based on diabetes self-management, healthcare system and psychosocial aspects. We have tried to provide precise, comprehensive and region specific solutions to these challenges. Solutions briefly include maintaining the supply chain of essentials like insulin, syringes and glucose meter strips to psychological support, financial aid and support for hospitalization in case of COVID-19 itself or diabetes complications including diabetic ketoacidosis.

Conclusions

Children and adolescents having T1DM require special care and attention during this period of COVID-19 pandemic because of various challenges as discussed. Our proposed solutions may help them overcome these problems and help them in better diabetes management during such emergency situations.

Understanding loneliness in the twenty-first century: an update on correlates, risk factors, and potential solutions

PURPOSE

Loneliness is increasingly recognised as the next critical public health issue. A plausible reason for this concern may be related to emerging societal trends affecting the way we relate, communicate, and function in our social environment. In 2006, a prominent review of the clinical significance of loneliness was published. However, there has not been a comprehensive update on known and emerging risk factors and correlates of loneliness since then. Furthermore, there is no conceptual model that has been developed to better account for the complexity of loneliness and to inform the development of evidence-based solutions as we challenge the issues of the twenty-first century.

METHODS

We reviewed the current literature to identify either known or emerging risk factors and correlates of loneliness since 2006. This includes new or known evidence on: (1) demography; (2) health, including physical health; mental health; cognitive health; brain, biology, and genetics; and (3) socio-environmental factors including digital communication and the workplace.

RESULTS

We synthesized the literature according to a new proposed conceptual model of loneliness which showed the interplay between known and emerging correlates and risk factors from demography, health, to socio-environmental factors. In the conceptual model of loneliness, we illustrated how solutions can be delivered and tailored to an individual based on their life circumstances and preferences.

CONCLUSION

We concluded by making specific recommendations in advancing our scientific understanding of loneliness. Our knowledge can only be deepened if we increase scientific rigour via accounting for confounding variables and using longitudinal, multi-disciplinary, and multiple methodologies in research. We also call for the rigorous evaluation of programs targeting loneliness.

Addressing challenges for clinical research responses to emerging epidemics and pandemics: a scoping review

BACKGROUND

Major infectious disease outbreaks are a constant threat to human health. Clinical research responses to outbreaks generate evidence to improve outcomes and outbreak control. Experiences from previous epidemics have identified multiple challenges to undertaking timely clinical research responses. This scoping review is a systematic appraisal of political, economic, administrative, regulatory, logistical, ethical and social (PEARLES) challenges to clinical research responses to emergency epidemics and solutions identified to address these.

METHODS

A scoping review. We searched six databases (MEDLINE, Embase, Global Health, PsycINFO, Scopus and Epistemonikos) for articles published from 2008 to July 2018. We included publications reporting PEARLES challenges to clinical research responses to emerging epidemics and pandemics and solutions identified to address these. Two reviewers screened articles for inclusion, extracted and analysed the data.

RESULTS

Of 2678 articles screened, 76 were included. Most presented data relating to the 2014-2016 Ebola virus outbreak or the H1N1 outbreak in 2009. The articles related to clinical research responses in Africa (n = 37), Europe (n = 8), North America (n = 5), Latin America and the Caribbean (n = 3) and Asia (n = 1) and/or globally (n = 22). A wide range of solutions to PEARLES challenges was presented, including a need to strengthen global collaborations and coordination at all levels and develop pre-approved protocols and equitable frameworks, protocols and standards for emergencies. Clinical trial networks and expedited funding and approvals were some solutions implemented. National ownership and community engagement from the outset were a key enabler for delivery. Despite the wide range of recommended solutions, none had been formally evaluated.

CONCLUSIONS

To strengthen global preparedness and response to the COVID-19 pandemic and future epidemics, identified solutions for rapid clinical research deployment, delivery, and dissemination must be implemented. Improvements are urgently needed to strengthen collaborations, funding mechanisms, global and national research capacity and capability, targeting regions vulnerable to epidemics and pandemics. Solutions need to be flexible to allow timely adaptations to context, and research led by governments of affected regions. Research communities globally need to evaluate their activities and incorporate lessons learnt to refine and rehearse collaborative outbreak response plans in between epidemics.

Microplastics in the freshwater and terrestrial environments: Prevalence, fates, impacts and sustainable solutions

The ubiquitous occurrences of microplastics in the environment have raised much concern and resulted in voluminous studies related to microplastics. Studies on microplastics pollution of the marine environment have received significantly higher attention compared to those of the freshwater and terrestrial environments. With the impetus to better understand microplastics in the freshwater and terrestrial environments, this review elucidates the findings of >100 articles related to the prevalence, fates and impacts of microplastics therein and the sustainable solutions, mostly in the past 10 years. This review shows the interconnection between terrestrial and freshwater microplastics with wastewater and sewage treatment plants as the most significant contributors of environmental microplastics via sludge and effluent discharges. Microplastics in both ecosystems comprise the primary and secondary forms with the latter resulted from weathering of the former. Besides retaining in soil and infiltrating with rainwater underground, terrestrial microplastics also enter the freshwater environment. The environmental microplastics interact with the biotic and abiotic components resulting in entrainment, settlement, biofouling, degradation, fragmentation and entry into the food chain, with subsequent transfer across the food chain. The abundance of environmental microplastics is attributed to population density and urbanization though tidal cycle, storms, floods and human activities can affect their distribution. The leaching of additives from microplastics poses major health concern and sustainable solutions target at reduction of plastics use and disposal, substitution with bioplastics and wastewater treatment innovations. Further studies on classification, detection, characterization and toxicity of microplastics are necessary to permit more effective formulation of solutions.

Investigation of the microplastics profile in sludge from China's largest Water reclamation plant using a feasible isolation device

Sewage sludge, which is widely applied to land as a fertilizer, is a key source of microplastics in the environment. We sought to develop a feasible device for isolation of microplastic from sewage sludge for further understanding their fates in the environment. In the present study, an effective isolation device, consisting of a fritted glass funnel and a glass filtration apparatus, was constructed to extract microplastics from sludge with nearly 100% recovery efficiency. Then, a high abundance of microplastics was detected in sludge sampled from China's largest sewage treatment plant. Among the 25 types of microplastic polymers confirmed by Fourier transform infrared spectroscopy, poly(11-bromoundecyl acrylate) (PBA) and poly(11-bromoundecyl methacrylate) (PBMA) accounted for 23.63% of total microplastics detected. Rayon, polyethylene (PE), polyethylene terephthalate (PET), polypropylene (PP), and copolymers, such as PP/PE and poly(styrene:acrylonitrile:butadiene) (ABS), were also detected. The shapes of these microplastics consisted of pellets, fragments, films, and microfibers. Characterization of the isolated microplastics revealed that domestic applications and vehicle products were the major sources of microplastic in sewage treatment sludge. Some priority recommendations were issued based on these results. In conclusion, the present study demonstrate that the device is effective for the isolation of microplastics from sludge.

Determinants, consequences and potential solutions to poor adherence to anti-osteoporosis treatment: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Osteoporosis Foundation (IOF)

Many patients at increased risk of fractures do not take their medication appropriately, resulting in a substantial decrease in the benefits of drug therapy. Improving medication adherence is urgently needed but remains laborious, given the numerous and multidimensional reasons for non-adherence, suggesting the need for measurement-guided, multifactorial and individualized solutions.

INTRODUCTION

Poor adherence to medications is a major challenge in the treatment of osteoporosis. This paper aimed to provide an overview of the consequences, determinants and potential solutions to poor adherence and persistence to osteoporosis medication.

METHODS

A working group was organized by the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) to review consequences, determinants and potential solutions to adherence and to make recommendations for practice and further research. A systematic literature review and a face-to-face experts meeting were undertaken.

RESULTS

Medication non-adherence is associated with increased risk of fractures, leading to a substantial decrease in the clinical and economic benefits of drug therapy. Reasons for non-adherence are numerous and multidimensional for each patient, depending on the interplay of multiple factors, suggesting the need for multifactorial and individualized solutions. Few interventions have been shown to improve adherence or persistence to osteoporosis treatment. Promising actions include patient education with counselling, adherence monitoring with feedback and dose simplification including flexible dosing regimen. Recommendations for practice and further research were also provided. To adequately manage adherence, it is important to (1) understand the problem (initiation, implementation and/or persistence), (2) to measure adherence and (3) to identify the reason of non-adherence and fix it.

CONCLUSION

These recommendations are intended for clinicians to manage adherence of their patients and to researchers and policy makers to design, facilitate and appropriately use adherence interventions.

Quality of TB care among people living with HIV: Gaps and solutions

Tuberculosis (TB) is the leading infectious cause of death among people living with HIV, causing one third of AIDS-related deaths globally. The concerning number of missing TB cases, ongoing high TB mortality, slow reduction in TB incidence, and limited uptake of TB preventive treatment among people living with HIV, all indicate the urgent need to improve quality of TB services within HIV programs. In this mini-review we discuss major gaps in quality of TB care that impede achieving prevention and treatment targets within the TB-HIV care cascades, show approaches of assessing gaps in TB service provision, and describe outcomes from innovative quality improvement projects among HIV and TB programs. We also offer recommendations for measuring quality of TB care.

The devastating Venezuelan crisis

The Venezuelan crisis is filling the headlines and truly deserves the world's attention. It is a wake-up call to all as it holds relevant lessons for both developing and developed countries. The country suffers a severe humanitarian crisis. Its economy has declined at a faster pace than any other peacetime economy worldwide. Hardship and repression have led millions to flee the country creating a refugee crisis in Colombia and other neighboring countries, and millions more are expected to flee unless conditions improve. It raises serious security concerns in the whole Western Hemisphere. The country of Venezuela sits on and owns the largest oil reserves in the world. Oil helps explain the "rent-seeking" behavior that is at the root of this crisis. ("Rent-seeking" is simply getting money from the government for the oil it sells and giving little or nothing back to the government in return. -EEd) However, oil cannot be blamed for this crisis - it helped Venezuela get out of the poverty trap and become a modern democratic society in the 20^th century. This crisis comes from the perverse combination of bad politics, bad policy, and corruption that besieged the country over the last 20 years. Since he was elected in 1998, Hugo Chávez paved the way to authoritarianism while making the economy more vulnerable to the ups and downs of oil prices. Chávez died in early 2013. When Nicolás Maduro, his anointed heir, was elected to succeed him, the economy was in bad shape and institutions were already weak, but problems had been papered over thanks to high oil prices and the money the government made from its sale. When oil prices were high worldwide, Venezuelan governments did not save money for possible future economic losses. When oil prices began falling in 2014 and threatened the money from "rent-seeking" by many Venezuelans, Maduro chose the road to overt authoritarianism instead of seeking to restore the basics of an open society and a prosperous economy: the rule of law, property rights, transparency, prudent fiscal and monetary policy, and essential public goods such as education, health, housing, transportation, and infrastructure. This paper is a brief history of how the present Crisis in Venezuela developed and how it can be reasonably resolved. The Venezuelan people are suffering. There are lessons here for everyone in the world (A Venezuelan and James Ausman).

Gelation of cellulose-NaOH solutions in the presence of cellulose fibers

It is well known that when cellulose is dissolved in aqueous NaOH-based solvent, solutions are gelling with increasing time and temperature. The goal of this work was to understand if the presence of non-dissolved cellulose fibers influences gelation behavior of the whole system. One of the motivations is to control gelation when making all-cellulose composites with short fibers dispersed in cellulose-NaOH-water solutions. Gelation kinetics of cellulose(dissolving pulp)-NaOH-water solutions with added softwood kraft fibers were investigated using dynamic rheology. Fiber concentration, dissolving pulp degree of polymerization and solution temperature were varied. In all cases the addition of kraft fibers accelerates gelation and increases modulus at gel point while the presence of "inert" carbon fibers does not influence solution gelation kinetics. It was suggested that acceleration of gelation and reinforcement of cellulose gels is due to the interactions between dissolved and non-dissolved cellulose.

Oral Food Challenge Implementation: The First Mixed-Methods Study Exploring Barriers and Solutions

BACKGROUND

Because of inaccuracies in commonly used tests for food allergy, oral food challenges (OFCs) are considered the criterion standard, but OFC implementation is suboptimal.

OBJECTIVE

To use a mixed-methods approach to describe OFC barriers at multiple levels and investigate solutions.

METHODS

Surveys of Canadian allergists, pediatricians, and parents investigated barriers to offering or participating in OFCs, and possible solutions. Parent focus groups were held to understand these barriers and solutions. Allergist offices in British Columbia were contacted via telephone to confirm their OFC practices.

RESULTS

Of 62 responding allergists, 80.6% reported performing OFCs, 72.6% reported lack of resources as an influential barrier, and 72.6% reported that creation of standard guidelines for hospital versus community OFCs would influence them to perform more OFCs. Of 101 responding pediatricians, 51.5% reported having moderate-to-extensive OFC knowledge; these pediatricians were more likely to refer to allergists who performed them (odds ratio, 2.37; 95% CI, 1.06-5.30). Of 27 pediatricians who stated they refer more to allergists who do not perform OFCs, 40.7% reported long wait times as a deterrent. The most common parent barriers from surveys (N = 110) and focus groups (N = 27) were fear and anxiety about the procedure and about experiencing reactions during OFCs, suggesting the need for better information and psychosocial resources.

CONCLUSIONS

Multiple barriers prevent widespread use of OFCs. Efforts targeting OFC training for allergists, education for pediatricians, and standardized guidelines created with clinician and parent input (including consistent OFC information for families and guidance on which OFCs should be performed in-hospital versus the community) are likely to increase OFC acceptance.

Addressing medication errors in an adult oncology department in Saudi Arabia: A qualitative study

OBJECTIVE

There is a wide range of strategies that could help in minimizing medication errors during healthcare delivery. We undertook a qualitative study to identify recommended solutions to minimize medication errors in an adult oncology department in Saudi Arabia from the perspectives of healthcare professionals.

METHODS

This was a qualitative study conducted in an adult oncology department in Saudi Arabia. After obtaining the required ethical approvals and written consents from the participants, seven focus group discussions were carried out for data collection. A stratified purposive sampling strategy was used to recruit medical doctors, pharmacists, and nurses. NVivo Pro version 11 was used for data analyses. Inductive content analysis was adopted in the coding of collected data.

RESULT

Our study showed that improving organizational support, staff education, and communication could help in minimizing medication errors in the adult oncology department.

CONCLUSION

The adoption of multiple strategies is required to improve the safety of the medication process in the adult oncology department. We argue that the availability of supportive leadership should be prioritized as it plays a crucial role in determining the effectiveness and efficiency of both staff education and communication.