DCIS knowledge of women choosing between active surveillance and surgery for low-risk DCIS.

BACKGROUND: Ductal carcinoma in situ (DCIS) can progress to invasive breast cancer (IBC), but often never will. As we cannot predict accurately which DCIS-lesions will or will not progress to IBC, almost all women with DCIS undergo breast-conserving surgery supplemented with radiotherapy, or even mastectomy. In some countries, endocrine treatment is prescribed as well. This implies many women with non-progressive DCIS undergo overtreatment. To reduce this, the LORD patient preference trial (LORD-PPT) tests whether mammographic active surveillance (AS) is safe by giving women with low-risk DCIS a choice between treatment and AS. For this, sufficient knowledge about DCIS is crucial. Therefore, we assessed women's DCIS knowledge in association with socio-demographic and clinical characteristics. METHODS: LORD-PPT participants (N = 376) completed a questionnaire assessing socio-demographic and clinical characteristics, risk perception, treatment choice and DCIS knowledge after being informed about their diagnosis and treatment options. RESULTS: 66 % of participants had poor knowledge (i.e., answered ≤3 out of 7 knowledge items correctly). Most incorrect answers involved overestimating the safety of AS and misunderstanding of DCIS prognostic risks. Overall, women with higher DCIS knowledge score perceived their risk of developing IBC as being somewhat higher than women with poorer knowledge (p = 0.049). Women with better DCIS knowledge more often chose surgery whilst most women with poorer knowledge chose active surveillance (p = 0.049). DISCUSSION: Our findings show that there is room for improvement of information provision to patients. Decision support tools for patients and clinicians could help to stimulate effective shared decision-making about DCIS management.

[The readiness of Kazakhstan to implementation of medicinal insurance: the sociological substantiation and education activities of public organizations].

Until recently, in Kazakhstan, both health care services and medication support of population were financed from National budget and compulsory social health insurance foundation. But actual system meet needs of Kazakhstanis in medications not in full measure. The purpose of the study is to identify readiness of citizens to implementation of new medicinal insurance program with state co-financing. The study was carried out in 2022 in 17 regions of Kazakhstan. The readiness of Kazakhstanis to participate in medicinal insurance program with state co-financing was studied through sociological survey of 5 819 Kazakhstanis. The sociological survey revealed that respondents express average degree of readiness to implementation of new medicinal insurance program with state co-financing and to purchasing of insurance policy. The correlation between social demographic characteristics (objective indicators) and readiness indicator (subjective indicator) was revealed. The younger males with higher education, residing in urban areas, with average and high income and officially married are more inclined to purchase insurance policy. At that, according to results of sociological survey, one third of respondents have no relevant information about health insurance in general and medicinal insurance in particular. They found it difficult to express their personal position about this issues. It is supposed that Kazakhstanis in the result of educational measures will take part in medicinal insurance program with state co-financing. The education projects can be implemented through public organizations operating locally and communicating with population at the micro level. It is determined that it is especially important to apply educational measures to rural residents, middle-aged and elderly people, females and persons with low average income per family member.

[Medical and legal aspects of the responsibility of medical workers in cases of improper provision of medical care].

The article considers the concept of medical incidents of «improper provision of medical care¼, implying the action or inaction of a medical worker who violates the procedure for providing medical care established by regulatory legal acts and standards. The relevance of the study of issues related to the medical and legal norms of holding medical workers accountable when medical care is of inadequate quality is due to the importance of understanding offenses in the medical field and assessing the responsibility of medical workers, who act as criteria for the presence of problems in the medical field and the impetus for reforming the health system.

[Inadequate first medical aid on board a sea vessel as a risk factor for crew members' health].

Currently, one of the most important health and social problems in the world is the constant increase in injuries and deaths at work. Statistics show that timely provision of first aid to victims has a positive effect on further medical support and a reduction in the number of deaths. First aid for crew members of sea vessels is a set of simple medical actions performed by seafarers directly on board the ship, as soon as possible after an injury or illness. As a rule, it is associated with emergency resuscitation of the victim. The lack of necessary skills and training among current ship crew members to carry out first aid operations shows an objective need to develop recommendatory measures to revise the current training system.

Medical abortion in Ghana: a non-randomized, non-inferiority study of access through pharmacies compared with clinics.

OBJECTIVES: To compare self-reported clinical outcomes following medical abortion with mifepristone and misoprostol sourced from either a pharmacy or health clinic. STUDY DESIGN: We conducted a prospective, non-randomized, non-inferiority cohort study across four regions in Ghana, from high-volume pharmacies and health clinics. Participants seeking medical abortion (less than nine weeks' gestation) who met usual medical abortion eligibility criteria were recruited. Data collection included baseline surveys, follow-up phone interviews, and self-reported assessments of medical abortion outcomes. The study aimed to enroll 2,000 medical abortion users (1,000 from each source). RESULTS: Complete outcome data was available and analyzed from 1,958 participants (of 2208 enrolled), with the adjusted risk difference of need for additional treatment to complete the abortion indicating non-inferiority of the pharmacy group compared to the clinic group [-2.3% (95% CI -5.3% to 0.7%)]. Both groups reported low rates of additional treatment (4.9%) and adhered similarly to the abortion regimen. Secondary outcomes showed no significant differences, with moderate acceptability in both groups (65.4% pharmacy, 52.3% facility). Adverse outcomes were rare: one ectopic pregnancy, one blood transfusion and no deaths or other major complications were reported. CONCLUSIONS: Accessing medical abortion pills directly from pharmacies without prior consultation from a provider demonstrated non-inferior self-reported clinical outcomes compared to seeking care from health clinics. The findings align with the growing global evidence supporting the safety and effectiveness of medical abortion self-care. IMPLICATIONS: This study contributes data which support future registration of over-the-counter use of medical abortion drugs up to nine weeks' gestation. Such measures could expand options for safe abortion care, especially in regions where unsafe abortion poses a substantial maternal health risk. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03727308).

Managing ecosystem services in oleaginous forests for bioenergy provision and climate change mitigation.

Oleaginous forests provide diverse ecosystem services, including timber, seed yield (a vital feedstock for biodiesel production), and substantial carbon savings. These carbon savings encompass carbon sequestration related to timber growth and carbon savings resulting from substituting fossil fuel with biodiesel. However, oleaginous forests are vulnerable to seed wasp attacks (disservice), which significantly threaten both seed yield and carbon savings. Using an integrated ecological-economic model that includes Faustmann's Land Expectation Value model and a pest damage control model, we aim to understand the intricate relationship among multiple ecosystem services and disservices of oleaginous forests. The results reveal four distinct phases contingent on varying pesticide application rates: the pesticide under-use phase, substitution phase, complementary phase, and over-use phase. Notably, a potential avenue to minimize pest damage is identified during the complementary phase by reducing the optimal rotation age at the expense of decreased carbon sequestration and bioenergy provision, posing a challenge to climate change mitigation. These findings have implications for formulating policies to manage conflicting ecosystem services of energy forests, offering valuable insights into the intersection of sustainable forest management and climate policy.

The relationship between community food environment around schools and student meal participation: the role of school CEP participation status.

BACKGROUND: Despite the many benefits of school meals, not all students participate. One reason students may not participate in school meals is because they instead purchase breakfast or lunch from food outlets located around schools that mostly carry unhealthy items. This study examined whether school participation in the Community Eligibility Provision (CEP), which allows qualifying schools to serve free meals to all students, moderated the association between the community food environment around schools and student meal participation. METHODS: This study employed a longitudinal repeated-measures design using school-level data collected between 2014 and 2020 within four low-income school districts (n = 126 schools) in the US. We obtained meal participation data from state records and created a measure characterizing the community food environment within 0.25 miles of schools (characterized as low-density of unhealthy food outlets vs. high-density of unhealthy food outlets) through a latent class analysis. Regression analysis estimated associations between community food environments, CEP participation, and participation rates in school breakfast and school lunch, assessed in separate models. RESULTS: While no moderating effect of school CEP status was observed for breakfast or lunch participation, school breakfast participation was predicted to be 4% lower in high-density food environments than in low-density environments (P-value = .049) among non-CEP schools, and there was no difference in participation by the community food environment among CEP-participating schools. Differences in breakfast participation by the community food environment among non-CEP schools were mostly attributable to middle/high schools, with participation predicted to be 10% lower in high-density environments than in low-density environments among non-CEP middle/high schools (P-value < .001), whereas such a difference in participation was not observed among non-CEP elementary schools. CONCLUSIONS: Negative associations between food environment around schools and school breakfast participation were observed only among middle and high schools not participating in CEP, suggesting that policy actions to increase access to free school meals may benefit students, particularly older children and adolescents.

How effective are digital/e-health interventions for supporting prisoners with mental ill-health? An integrative review.

PURPOSE: There has been a move towards the implementation of digital/e-health interventions for some time. Digital/e-health interventions have demonstrable efficacy in increasing individual empowerment, providing timely access to psychological interventions for those experiencing mental ill-health and improving outcomes for those using them. This study aims to determine the efficacy of digital/e-health interventions for individuals detained in prison who experience mental ill-health. DESIGN/METHODOLOGY/APPROACH: A systematic search of five academic databases - CINAHL, ASSIA, PsycINFO, Embase and Medline - was completed in December 2020 and updated in February 2022. The review was guided by the Whittemore and Knafl (2005) framework for integrative reviews. A total of 6,255 studies were returned and screened by title and abstract. A full-text screening of nine (n = 9) studies was conducted. FINDINGS: No study met the inclusion criteria for the clinical efficacy of digital/e-health interventions in a prison setting. Subsequently, a review of the literature that made it to the full-text review stage was conducted, and gaps in the literature were identified to inform policy, practice and future research. ORIGINALITY/VALUE: To the best of the authors' knowledge, this is the first integrative review conducted on the efficacy of digital/e-health interventions for mental ill-health in prison settings.

Mind the gap: Comparing parents' information needs about impending preterm birth to current clinical practices using a mixed methods approach.

Objective: To identify parents' information needs about impending very preterm birth and compare these needs to current information practices in the Netherlands. Methods: Step 1: We surveyed N = 203 parents of preterm infants to assess their information needs. Data were analyzed using inductive thematic analysis. Step 2a: We collected information resources from hospitals (N = 9 NICUs) and via an online search. These materials were analyzed using deductive thematic analysis. Step 2b: We compared findings from Steps 1-2a. Results: We identified four themes pertaining to parents' information needs: (1) participation in care, (2) emotional wellbeing, (3) experience/success stories, and (4) practical information about prematurity. Clinicians' communicative skills and time were considered prerequisites for optimal information-provision. Notably, hospital resources provided mainly medical information about prematurity with some emphasis on participation in care, while parent associations mainly focused on emotional wellbeing and experience/success stories. Conclusion: While parents demonstrate clear information needs about impending very preterm birth, current information resources satisfy these partially. Innovation: Our multidisciplinary research team included both scholars and veteran NICU parents. As such, we identified parents' information needs bottom-up. These parent-driven insights will be used to design an innovative, tailored information platform for parents about impending very preterm birth.

The maintenance and interface of two wheelchairs used by children with cerebral palsy in Kenya: a cross-sectional study.

Current wheelchairs used in low-resource settings lack the adjustability required for children with cerebral palsy and are not well-suited for rough terrain environments. This study aimed to examine the durability and functional interface of two wheelchairs specifically designed for use in low-resource settings. This descriptive study assessed 14 wheelchairs used by children with cerebral palsy living in Kenya, Africa (Momentum Wheels for Humanity's Liberty II wheelchair n = 6, Beeline's Honey Bee wheelchair n = 8). Four physical and occupational therapists evaluated durability using the Wheelchair Components Questionnaire (WCQ) and functionality using the Wheelchair Interface Questionnaire (WIQ). Medians were used to compare differences in the chair types using the Wilcoxon-Mann-Whitney test in Statistical Analysis Software (SAS) 9.4 with an alpha = 0.05. Median scores on the WCQ were 8.3/10 for the Liberty II and 7.8/10 for Beeline's Honey Bee wheelchair; however, the durability of the wheel locks was lower in the Beeline wheelchair (5.1/10 compared to the Liberty II 8.1/10 (p = 0.002). Median scores on the WIQ were lower and significantly different in the area of preventing distal lower extremity pain (Liberty II =3.7/10 and Beeline = 7.6/10, p = 0.045). Low scores occurred in both chairs in the areas of transfers and transporting the chairs in the community. The Beeline wheelchairs demonstrated higher average ratings for all areas of the WIQ, indicating the wheelchairs fit the children better and were more functional for use in the home and community environment.

Beeline Honey Bee and Clasp Liberty II wheelchairs demonstrate strengths supporting children in their communities, although no single type of wheelchair is perfect for children with cerebral palsy in low to middle-income countries with rough terrain.Rehabilitation professionals can use their physiological expertise to provide feedback on durability and functionality of wheelchairs in collaboration with wheelchair manufacturers to provide the most durable, cost-effective assistive technologies that support the user's physiological needs.The appropriate provision of wheelchairs can increase the quality of life for the child and their families, enabling them to participate in their local communities more fully.

Exploring the care coordination experiences of professionals and caregivers of youth with acquired brain injuries in rural areas.

PURPOSE: Acquired brain injuries (ABIs) can have devastating effects on children and their families. Families living in rural communities experience unique barriers to receiving and coordinating care for complex medical needs, but little research has examined those barriers for rural youth with ABIs. MATERIALS AND METHODS: This qualitative study explored the experiences of rural adults caring for children with ABIs through interviews with six caregivers, three school staff members, and three medical professionals who had treated at least one child with an ABI. RESULTS: Themes in their accounts include difficulty navigating complex situations, support from small communities, isolation and loneliness, the need for more professional education about ABI, and feelings of hope. Barriers to quality care coordination include navigating complex situations, access to transportation, and a lack of communication and education from healthcare agencies. Facilitators of rural care coordination include support from small communities and interagency communication. CONCLUSIONS: The results support the need for more comprehensive coordination among rural agencies involved in ABI care. Suggestions for care improvement include providing flexibility due to transportation barriers, capitalizing on the benefits of a small and caring community, and providing healthcare and education professionals with more education about ABI interventions.

Practitioners should implement tailored support systems that include initiatives to facilitate direct communication between rural medical agencies and schools.Expanding the role of care coordinators to bridge gaps across healthcare, education, and community services could enhance care coordination for children with acquired brain injuries in rural areas.Schools in rural areas should develop formal reintegration programs tailored to the needs of children with mild acquired brain injuries, leveraging existing sports protocols for non-sports-related injuries.Collaborative efforts between schools, medical teams, and community agencies can provide comprehensive education programs tailored to the rural context.The development of online options for follow-up appointments would be particularly beneficial in rural areas, where transportation barriers are more pronounced.

Experiences and challenges of acute coronary syndrome patients in care provision: a qualitative systematic review.

BACKGROUND: Coronary artery disease including acute coronary syndrome (ACS) constitutes the most common cause of death in people with cardiovascular disease. Prompt diagnosis and early initiation of treatment significantly impact on patient outcomes. Positive patient experience with their initial care is linked to positive clinical outcomes. OBJECTIVE: This qualitative review aimed to investigate patients' experience of care provision and the challenges faced by them during their different stages of care following an ACS. METHODS: Searches of four databases - MEDLINE, Embase, CINAHL and PsychINFO - were conducted from inception until July 13, 2022, and were limited to English-language publications. Assessment of methodological quality of studies was performed using the Jonna Briggs Institute (JBI) qualitative assessment and review instrument. Data were extracted using the standardised data extraction tool from JBI. Data synthesis following the JBI approach of meta-aggregation was performed. The level of confidence for each synthesised finding was established based on ConQual. RESULTS: Overall, from 578 records, 10 studies were included with 39 findings extracted from the included studies. The main synthesised findings were the need to provide tailored information and appropriate management at different stages of care, and that timely management and trust in health care workers are associated with greater patient satisfaction and more positive experiences. CONCLUSION: Patients with an ACS experience many challenges during different stages of their care. Clinicians should be aware of the challenges they face and provide tailored information to patients that is appropriate for their different stages of management in order to best optimise patient experience and improve patient outcomes.

Elucidating managerial, staff and client perspectives on the Speech and Language Therapy service in Malta.

BACKGROUND: Speech and language therapy (SLT) services are fundamental for communication, academic and social development. Evidence shows that demand for services is increasing, and this can adversely affect the quality of care. There are limited published studies in relation to the demand and quality of speech and language services in Malta. AIMS: To elucidate the perspectives of speech-language pathologists (SLPs), service managers and parents of clients about the impact of factors pertaining to human resource development (HRD), human resource management (HRM) and the environment on the quality of the children's SLT service in western Malta. Also, to outline the beneficial strategies or recommendations to improve the quality of the service provided. METHODS & PROCEDURES: A mixed-method study was used. Quantitative data provided by the Speech and Language Center (SLC) were analysed to determine demand over time using descriptive statistics. Qualitative data from one-to-one interviews using a bespoke questionnaire with managers, SLPs and parents were transcribed and analysed. Common and distinct themes in relation to the quality of services were then formulated and evaluated. OUTCOME & RESULTS: Quantitative results highlighted that clients were not receiving the required number of the therapeutic sessions. In total, nine themes in relation to the quality of the SLT service were identified by parents, SLPs and managers. The factors affecting the service quality were outlined and subdivided under three branches: HRD, HRM and the environment. All factors within these subgroups are expected to enhance the quality of the service provided if they are enhanced and improved upon. Additionally, the results showed that a discrepancy between the perceived and offered SLT services was felt from the managers' and SLPs' perspectives; however, this was not felt by parents. For parents, the main concern was the availability and frequency of the therapeutic sessions provided. CONCLUSION & IMPLICATIONS: Insights from SLPs, managers and parents of clients highlighted the barriers and enablers of quality of service in SLT services for children. These findings can be used to improve services in Malta and other countries with similar contexts, mainly by altering time management, reducing demands and improving availability. WHAT THIS PAPER ADDS: What is already known on the subject SLT is proven to enhance a child's communication skills. Increasing demands for therapy can affect the quality of the service provided, ultimately affecting the child's progress. There is a gap in the evidence base regarding the quality of speech and language services for children in Malta and the factors which affect the quality of the service. What this study adds to the existing knowledge This is the first study of its kind in Malta. It seeks to identify the quality of SLT services for children from three different perspectives: service managers, SLPs and parents. In addition, this study investigated what affects the quality of SLT services positively or negatively. Through this study, the impeding factors were divided into three domains; HRD factors, HRM factors and environmental factors. These domains were mentioned by all three groups of participants because they affected the service negatively or positively. The main negative aspects included bad time management, high demands, and reduced availabilities and accessibilities, whilst positive aspects included improved support, relationships and the environment. What are the practical and clinical implications of this work? This study suggests reducing the managerial and administrational demands on SLPs and improving session frequency would enhance the quality of service. In relation to the three domains, the HRD factors that would enhance the quality of service are: SLPs' and parental competencies, enhancing SLPs' positive characteristics, positive attitudes and cooperation from all personas; for HRM resources the factors important for quality are strategic and risk management, workforce and recruitment; and for the environmental factors the physical environment and resources are important as they affect the service depending on their condition, that is, improved resources result in improved service. Such alterations would reduce the SLPs' demotivation and burnout due to reduced responsibilities, whilst improving accessibility and availability, ultimately enhancing the quality of the service provided.

Broadening placement opportunities for nursing students through an indirect supervision model.

BACKGROUND: Higher Education Institutions struggle to fill national deficits in student placement capacity, especially in social care and the voluntary sector. The Indirect Placement Supervision and Assessment Model and its holistic focus helps redress this deficit. METHODS: A Microsoft Forms survey was distributed to a self-selecting sample of 50 students, placement providers, and university staff, all of whom had been involved in indirect supervision as either an assessor, student, or supervisor. RESULTS: Three key themes emerged from the data collected; responses suggested that the model generated greater placement variety, increased placement capacity, and brought about reciprocal gains in the learner-supervisor matrix. CONCLUSION: The study's key implication for healthcare institutions pertains to a strong evidence base that the indirect supervision model provides an efficient means of broadening nursing placement variety and capacity alike.

Prosocial behaviors in rodents.

Prosocial behaviors (i.e., actions that benefit others) are central for social interactions in humans and other animals, by fostering social bonding and cohesion. To study prosociality in rodents, scientists have developed behavioral paradigms where animals can display actions that benefit conspecifics in distress or need. These paradigms have provided insights into the role of social interactions and transfer of emotional states in the expression of prosociality, and increased knowledge of its neural bases. However, prosociality levels are variable: not all tested animals are prosocial. Such variation has been linked to differences in animals' ability to process another's state as well as to contextual factors. Moreover, evidence suggests that prosocial behaviors involve the orchestrated activity of multiple brain regions and neuromodulators. This review aims to synthesize findings across paradigms both at the level of behavior and neural mechanisms. Growing evidence confirms that these processes can be studied in rodents, and intense research in the past years is rapidly advancing our knowledge. We discuss a strong bias in the field towards the study of these processes in negative valence contexts (e.g., pain, fear, stress), which should be taken as an opportunity to open new venues for future research.

A oferta do café de rua nas capitais São Paulo e Vitória / The offer of coffee on the streets of the state capitals São Paulo and Vitória / La oferta de café en las calles de las capitales estatales São Paulo y Vitória

A pandemia gerou impactos sociais e econômicos, como o trabalho informal dos que se ocupam do serviço de café de rua, ampliado na retomada pós-isolamento. O artigo analisa as significações construídas pelas instalações do serviço nas ruas de São Paulo (SP) e Vitória (ES), enquanto manifestações do empreendedo-rismo por necessidade. O corpus foi coletado em dias úteis, no início das manhãs, em diversos pontos das capitais. A semiótica discursiva sustentou a análise, e o seu método permitiu traçar isotopias conectoras de figuras e temas. Os resultados apontam para comunicação dos sentidos da informalidade, casualidade e familiaridade, marcados pela presença feminina, pela autonomia imposta aos sujeitos produtor/vendedor e consumidor e pela conexão entre a energia proporcionada pela bebida e o trabalho. Esses significadosvêm embebidos no risco vivido por esses sujeitos, aconchegados entre si e alijados da proteção de políticas públicas de trabalho, condições sanitárias, serviços de transporte e saúde.

The pandemic has generated social and economic impacts, such as the informal work of those who sell coffee on the streets, expanded in the post-isolation resumption. The article analyzes the meanings constructed by the service facilities in São Paulo (SP) and Vitória (ES), as demonstrations of the entrepreneurship by necessity. The corpus was collected on weekdays, in places of the state capitals. Discursive semiotics underpins the analysis, suggesting connective isotopies of figures and themes. The results point to the communication of the senses of informality, casualness and familiarity, marked by the female presence, by the autonomy imposed on the subjects producer/seller and consumer and by the connection between the energy given by the drink and the work. These meanings are embedded in the risk experienced by these subjects, snuggled among themselves and excluded from the protection of public policies of work, sanitary conditions, transportation and health services.

La pandemia generó impactos sociales y económicos, como el trabajo informal de quienes se ocupan del servicio de café en las calles, ampliado en la reanudación post-aislamiento. El artículo analiza los signifi-cados construidos por las instalaciones de servicios en las calles de São Paulo (SP) y Vitória (ES), como manifestaciones de emprendimiento por necesidad. El corpus fue recolectado entresemana, en puntos de las capitales. La semiótica discursiva sustenta el análisis y permitió trazar isotopías conectoras de figuras y temas. Los resultados apuntan para la comunicación de los significados de informalidad, marcados por la presencia femenina, por la autonomía impuesta a los sujetos productor/vendedor y consumidor, y por la conexión entre la energía dada por la bebida y el trabajo. Estos significados están incrustados en el riesgo vivido por estos sujetos, y excluidos de la protección de las políticas públicas laborales, las condiciones sanitarias, los servicios de transporte y salud.

Defying the odds: Facilitating integration of abortion care into clinical practice in the United States.

OBJECTIVES: We sought to describe the experiences of physicians who successfully incorporated abortion care into their practices in the United States. We explored facilitators of and barriers to abortion provision. STUDY DESIGN: In this qualitative study, we conducted semistructured interviews with a national sample of obstetrician-gynecologists and family medicine physicians providing abortion care. Interviews addressed facilitators of and barriers to abortion provision, lessons learned and recommendations for future providers. We analyzed data using a content analysis approach. RESULTS: We interviewed 14 obstetrician-gynecologists and 11 family medicine physicians providing abortion care as part of their practices. We identified four categories of facilitators and barriers: personal, community, training, and workplace factors. Major facilitators included supportive leadership and professional mentorship. Major barriers included antagonistic colleagues and leadership. Lessons learned included proactively assessing leadership support, identifying institutional allies, actively minimizing workplace conflict and being perceived as a team player. Recommended resources to increase abortion provision included clinical support, mentorship, funding, negotiation coaching, and access to clinical policies. CONCLUSIONS: Institutional leadership support emerged as a critical facilitator for initiating and continuing to offer abortion care. Efforts to expand abortion access should include investments in supportive leadership, both in academic and community practices. IMPLICATIONS: Maximizing abortion access is essential to counteract the legislative and political restrictions imposed on abortion care. Institutional support is a critical facilitator of abortion provision, and efforts to expand abortion access should include investments in supportive leadership and health care administration.

A multi-method exploration of a cardiac rehabilitation service delivered by registered Clinical Exercise Physiologists in the UK: key learnings for current and new services.

BACKGROUND: Cardiac rehabilitation has been identified as having the most homogenous clinical exercise service structure in the United Kingdom (UK), but inconsistencies are evident in staff roles and qualifications within and across services. The recognition of Clinical Exercise Physiologists (CEPs) as a registered health professional in 2021 in the UK, provides a potential solution to standardise the cardiac rehabilitation workforce. This case study examined, in a purposefully selected cardiac exercise service that employed registered CEPs, (i) how staff knowledge, skills and competencies contribute to the provision of the service, (ii) how these components assist in creating effective service teams, and (iii) the existing challenges from staff and patient perspectives. METHODS: A multi-method qualitative approach (inc., semi-structured interviews, observations, field notes and researcher reflections) was employed with the researcher immersed for 12-weeks within the service. The Consolidated Framework for Implementation Research was used as an overarching guide for data collection. Data derived from registered CEPs (n = 5), clinical nurse specialists (n = 2), dietitians (n = 1), service managers/leads (n = 2) and patients (n = 7) were thematically analysed. RESULTS: Registered CEPs delivered innovative exercise prescription based on their training, continued professional development (CPD), academic qualifications and involvement in research studies as part of the service. Exposure to a wide multidisciplinary team (MDT) allowed skill and competency transfer in areas such as clinical assessments. Developing an effective behaviour change strategy was challenging with delivery of lifestyle information more effective during less formal conversations compared to timetabled education sessions. CONCLUSIONS: Registered CEPs have the specialist knowledge and skills to undertake and implement the latest evidence-based exercise prescription in a cardiac rehabilitation setting. An MDT service structure enables a more effective team upskilling through shared peer experiences, observations and collaborative working between healthcare professionals.

An evaluation of outpatient service provision in the National Health Service in Great Britain: A freedom of information request.

RATIONALE: The National Health Service (NHS) Long Term Plan was published in January 2019. One of its objectives was restructuring outpatient services, as part of an Outpatient Transformation initiative. Monitoring of trusts' adherence to the objectives of the Long Term Plan is therefore required to benchmark progress against national objectives. AIMS AND OBJECTIVES: We aimed to explore whether outpatient transformation initiatives and phlebotomy services that are managed by outpatients are appropriately staffed and to evaluate trusts' adherence to the objectives outlined in the Long Term Plan. METHOD: A freedom of information (FOI) request was sent in January 2023 to 153 trusts across Great Britain (time span: 1 January 2022-31 December 2022). Parameters requested included number of outpatients seen/discharged, phlebotomy episodes, number of sites/wards covered by phlebotomy, target/actual did not attend (DNA) rates, time since inception of the outpatient transformation project (OTP), advice and refer (A&R) and patient-initiated follow-up (PIFU), phlebotomy and outpatient managerial establishment and use of electronic notes and patient portals. RESULTS: A total of 117 trusts (76.5%) provided responses to the FOI request. The mean number of new outpatients seen face-to-face was 185,810. Of 73 trusts reporting both actual and target DNA rates, 62 (84.9%) did not meet their DNA targets. The actual DNA rate was significantly greater than the target DNA rate across trusts (p < 0.001, mean: 8.8% vs. 6.5%, respectively). A total of 58 different electronic systems and 29 patient portals were utilised across trusts. Thirty-six trusts (30.3%) did not have an outpatient transformation project manager and 16 trusts (13.7%) did not initiate an OTP. With phlebotomy provision, the mean number of outpatient phlebotomy episodes was lower than inpatient episodes (83,383 vs. 91,020, respectively). CONCLUSION: There are deficiencies in current outpatient establishments that may hinder the achievement of objectives set in the NHS Long Term Plan. Changes at all levels of healthcare are required, with increased reliance on technologies and investment in support for transformation management.

Boosting Electrochemical Nitrate Reduction at Low Concentrations Through Simultaneous Electronic States Regulation and Proton Provision.

Electrochemically converting nitrate (NO3 -) into ammonia (NH3) has emerged as an alternative strategy for NH3 production and effluent treatment. Nevertheless, the electroreduction of dilute NO3 - is still challenging due to the competitive adsorption between various aqueous species and NO3 -, and unfavorable water dissociation providing *H. Herein, a new tandem strategy is proposed to boost the electrochemical nitrate reduction reaction (NO3RR) performance of Cu nanoparticles supported on single Fe atoms dispersed N-doped carbon (Cu@Fe1-NC) at dilute NO3 - concentrations (≤100 ppm NO3 --N). The optimized Cu@Fe1-NC presents a FENH3 of 97.7% at -0.4 V versus RHE, and a significant NH3 yield of 1953.9 mmol h-1 gCu -1 at 100 ppm NO3 --N, a record-high activity for dilute NO3RR. The metal/carbon heterojunctions in Cu@Fe1-NC enable a spontaneous electron transfer from Cu to carbon substrate, resulting in electron-deficient Cu. As a result, the electron-deficient Cu facilitates the adsorption of NO3 - compared with the pristine Cu. The adjacent atomic Fe sites efficiently promote water dissociation, providing abundant *H for the hydrogenation of *NOx e at Cu sites. The synergistic effects between Cu and single Fe atom sites simultaneously decrease the energy barrier for NO3 - adsorption and hydrogenation, thereby enhancing the overall activity of NO3 - reduction.