BMJ Open最新文献

Objectives: To identify early-occurring healthcare and sociodemographic risk factors associated with lower extremity amputation (LEA) by analysing health trajectories up to 10 years before amputation.

Design: A national, observational, registry-based matched case-control study.

Setting: The Danish universal healthcare system, using national health registers.

Participants: We included 2551 individuals who underwent first-time LEA in 2017-2018 and matched each to two control groups: (1) The Community Controls Group representing the average population who were matched on age, sex and municipality (n=12 748) and (2) a Diabetes Mellitus/Peripheral Arterial Disease (DM/PAD) Control Group matched on age, sex and DM or PAD duration (n=12 478) representing a high-risk population.

Primary outcome measures: Presence of healthcare, sociodemographic and medication-related risk factors associated with LEA was evaluated across three time periods leading up to amputation: the Immediate (0-2 years prior), Early (2-5 years prior) and Long-term (5-10 years prior) risk period.

Results: Polypharmacy and antibiotic use-particularly dicloxacillin targeting Staphylococcus aureus-were strongly associated with LEA across all time periods. Dicloxacillin was prescribed on average 7.8 years prior to major amputation, with long-term ORs of 2.99 (95% CI 2.51 to 3.56) and 2.07 (95% CI 1.75 to 2.46) compared with community and DM/PAD controls. Opioid and paracetamol use also showed strong associations. Individuals with LEA were more likely to live alone and have lower educational attainment. Frequent dental visits were inversely associated with risk.

Conclusions: This study identifies characteristics associated with LEA, including long-term exposure to dicloxacillin and opioid analgesics, alongside polypharmacy and socioeconomic disadvantage. These factors were detectable up to 10 years before amputation and may serve as early indicators for risk identification and guide targeted general practitioner interventions.

Objectives: To analyse the trends in the burden of non-alcoholic steatohepatitis (NASH)-related liver cancer associated with high fasting plasma glucose (HFPG) globally and in China from 1990 to 2021, and to project the burden over the next 15 years.

Design: Population-based secondary analysis of data from the Global Burden of Disease (GBD) 2021 study.

Setting: Global and Chinese populations included in the GBD 2021 database.

Participants: Data were derived from individuals aged 20 years and older included in the GBD 2021 study, covering both sexes across all age groups.

Primary and secondary outcome measures: The primary outcomes were mortality and disability-adjusted life years (DALYs) of NASH-related liver cancer associated with HFPG. Secondary outcomes included years lived with disability and years of life lost. Trends were described using the annual percentage change and average annual percentage change. Age-standardised mortality rates and DALY rates were projected to 2036.

Results: In 2021, the burden of NASH-related liver cancer associated with HFPG was higher in men than in women in both the global and Chinese populations and was predominantly concentrated among older age groups. From 1990 to 2021, the burden substantially increased globally and in China, showing a significant upward trend. Projections indicate that the global burden will continue to rise among men but decline among women, whereas both sexes in China are expected to experience a decline in burden over the next 15 years.

Conclusions: From 1990 to 2021, the burden of NASH-related liver cancer associated with HFPG increased substantially in both global and Chinese populations. High-risk groups, including men, older individuals, those with elevated fasting plasma glucose and patients with NASH, should be closely monitored. Targeted screening and preventive strategies for these populations may help manage the disease burden. Future studies are needed to determine whether effective blood glucose control can reduce the risk of NASH-related liver cancer.

Objective: To assess the prevalence and factors associated with depression, anxiety and stress among wives of international migrant workers in Ward 5 of Gauradaha municipality, Jhapa, Nepal.

Design: Community-based cross-sectional study.

Setting: Ward 5 of Gauradaha Municipality, Jhapa, Nepal.

Participants: A total of 179 wives of international migrant workers, aged 20-49 years, whose husbands had been away for at least 6 months.

Outcome measures: Depression, anxiety and stress were assessed using the Depression, Anxiety and Stress Scale (DASS-21). Descriptive statistics, χ²/Fisher's exact test and multivariable logistic regression analyses were performed.

Results: The prevalence of depression, anxiety and stress was 54.7%, 53.1% and 60.9%, respectively. In multivariable analysis, frequency of remittance, debts incurred and daily communication with husbands were significantly associated with depression, anxiety and stress. Additionally, the wives' occupation was significantly associated with anxiety.

Conclusions: More than half of the wives of international migrant workers experience depression, anxiety and stress. Interventions promoting financial security, facilitating regular communication with migrant spouses and providing occupation-related support may improve mental health outcomes in this population. These findings highlight the need for targeted policies and community programmes to support families left behind by international migrant workers in Nepal.

Objectives: This study investigates how lean management (LM) practices align with and contribute to strategic objectives in healthcare using the congruence model as a conceptual framework.

Design: This study employed a qualitative research design, integrating both inductive and deductive approaches. Data were collected from multiple hospital departments using primary and secondary sources. Primary data included semi-structured interviews, guided by a standardised interview protocol. Secondary data consisted of reports on courses of action, annual reports, policy documents and findings from exploratory meetings. The analysis involved iterative cycles of open coding, axial coding and selective coding to systematically identify and refine themes, supporting thematic analysis.

Setting: Six departments: Kidney and vascular surgery, Care core movement, Clinical department, Systemic diseases, Oncology, Care core Hepato-Pancreato-Biliary disease (HPB), which were part of one business unit within a tertiary care institution, a University Medical Centre in the Netherlands.

Participants: 22 respondents aged 18 years or older were purposefully selected based on their organisational roles and LM experience. Respondents had to be involved in LM practices, which meant they had to understand LM and have passed at least one LM training programme, or they should be enrolled in a training course during the research.

Results: Interviewees identified several barriers to LM implementation, including insufficient management support for a culture of continuous improvement, limited time for LM projects, inadequate recognition from management and poor communication of strategic objectives. Despite positive individual experiences with LM projects, their contribution to strategic objectives was deemed limited due to these barriers. Specific challenges included an experienced lack of leadership commitment, inadequate follow-up on projects, insufficient resource allocation, limited access to training and leaders failing to acknowledge employee value. Facilitators of success were fostering a culture of continuous improvement, committed managers and providing training.

Conclusions: LM practices have the potential to contribute to strategic objectives in healthcare organisations by reducing waste, improving patient care quality and optimising processes. However, their impact is constrained by organisational barriers and misalignments. Challenges such as insufficient resources, poor project follow-up, lack of management support and the absence of a continuous improvement culture minimise LM's effectiveness.

Background: The Veterans Health Administration (VA) integrated mental and physical health services to better detect and treat depression. Primary care nurses conduct screening annually. Clinicians, including Primary Care Mental Health Integration (PCMHI) specialists, follow-up as needed for treatment. Depression detection and management processes are complex, involve multilevel stakeholders, and are subject to significant disruption from COVID-19 and from the resulting expansion of telehealth, aiming to preserve care access. This study aimed to examine whether the COVID-19 pandemic worsened depression-related care quality and/or patient outcomes (eg, suicide).

Methods: Given hypothesised care disruption (lowered care quality) during COVID-19, we will first assess the VA population's trajectory from a new positive depression (and suicide risk) screen to appropriate treatment (ie, medication, therapy) in the Fiscal Year 2019-2323. We will also examine the changing mix of virtual and in-person depression care delivered. Second, we will use interrupted time series analyses to explore the extent to which psychiatric emergency visits and hospitalisations may be mitigated by clinician detection of depression. As well as compare mental health-related mortality rates between patients detected and not detected to have depression. Subanalyses will reveal where (eg, clinics with low PCMHI access) and for whom (eg, minorities) detection does not systematically occur, and downstream negative sequelae, to guide future intervention. Finally, we will interview 40 veterans, half of whom were detected and half not detected to have depression and 40 VA primary care and PCMHI providers about changes brought on by the pandemic and the expansion of virtual care across three VA facilities. In addition to contextualising disrupted care findings, qualitative data will help identify best practices on patient-to-provider and provider-to-provider interactions in hybrid in-person/telehealth depression care models.

Ethics and dissemination: Ethics approval was granted by the VA Greater Los Angeles Healthcare System Institutional Review Board. Alongside journal publications, dissemination activities include briefings to our policy and operational partners, and presentations to clinical, research and policy-oriented audiences.

Background: Artificial intelligence (AI) in healthcare often requires large, confidential clinical datasets. However, a recent UK government survey revealed that 20-40% of the public remain sceptical of its use in health research due to concerns about data security, patient-practitioner communication and commercialisation of data. A greater understanding of public attitudes is therefore needed, particularly in the context of stroke research.In this article, we describe the patient and public involvement work undertaken for the AI-Based-Stroke-Risk-fActor-Classification-and-Treatment (ABSTRACT) project, which aims to train AI models to predict future stroke risk from the electronic health records of 1 18 736 patients.

Aims: We aimed to evaluate the opinions of stroke/transient ischaemic attack (TIA) patients, caregivers and members of the public on the following themes: (1) the acceptability of using AI to predict stroke from electronic health records, (2) obtaining these data using an opt-out model of consent and (3) allowing access to this dataset from members both within and outside of the routine clinical care team.

Methods: A total of 83 participants were recruited via the National Health Service social media and by approaching hospital inpatients. Participants were first provided with background information on stroke, AI in medical research and ABSTRACT's proposed data handling protocol. A mixed methods approach was then used to explore each of the above themes using online survey, semistructured focus groups and one-to-one interviews.

Results: Nearly all participants felt that it was appropriate to use patient data to train AI models to predict stroke risk and that it was acceptable to obtain these data via an opt-out model of consent. Almost all participants also agreed that data could be shared within and outside of the routine clinical care team, provided it was General Data Protection Regulation compliant and used for medical research only.

Conclusion: The public and those with lived stroke/TIA experience appeared to support using deidentified medical datasets for AI-driven stroke risk prediction under an opt-out consent model. However, this is provided that the research conducted is transparent, for a clear medical purpose and adheres to strict data security measures.

Introduction: Cardiovascular disease (CVD) risk remains high but unevenly distributed in patients with type 2 diabetes mellitus (T2DM). Current risk stratification strategies are far from optimal, leading to both undertreatment and overtreatment of patients. The STENO INTEN-CT trial aims to evaluate a strategy of improved CVD risk management by using cardiac CT (coronary artery calcification (CAC)) for stratification and tailoring of multifactorial cardiovascular treatment based on CAC score. We hypothesise that (1) intensified medical treatment will lower CVD event rates in high-risk patients (CAC≥100), and (2) less intensive multifactorial treatment is safe in very low-risk patients (CAC=0).

Methods and analysis: The Steno INTEN-CT trial is an investigator-initiated, pragmatic, open-label, event-driven randomised controlled trial including patients with T2DM without known CVD. All participants (expected n=7300) will be invited for a non-contrast coronary CT scan. After the scan, participants will be randomised to either standard treatment (blinded for CAC results) or CAC-based treatment. Participants in CAC-based treatment and their general practitioner (GP) will receive information on CAC and a recommendation of multifactorial treatment. High-risk participants in the interventional arm will be invited for one or more initial study visits to intensify treatment with a combination of sodium glucose co-transporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, high-dose lipid-lowering, antihypertensive and antithrombotic treatment. Very low-risk patients in the interventional arm will be recommended less intensive treatment targets. After initial study-related activities, all participants will continue to be taken care of by their GP guided by specific treatment recommendations. The primary outcome in the primary hierarchical analysis (the rate of the combined CVD endpoint of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke and hospitalisation for heart failure) will be monitored through national health registries. The trial is event-driven, but a median follow-up of 5 years is expected. Key secondary outcomes include patient-reported outcomes, quality-adjusted life years and healthcare costs.

Ethics and dissemination: The protocol V.1.9 is approved by the Research Ethics Committee and the Danish Medicines Agency and the Danish Data Protection Agency. The results of the study-positive, negative or neutral-will be published in peer-reviewed journals and through www.

Clinicaltrials: org.

Trial registration number: NCT05700877.

Objectives: To explore the experiences of clinicians providing pastoral and mental health services to racially and ethnically minoritised students (REMS) at UK universities, aiming to understand the challenges REMS face in accessing support and to identify ways to improve service inclusivity.

Design: Qualitative study using semi-structured interviews.

Setting: Student health and well-being services at five universities in the North East of England, a region with comparatively low racial diversity.

Participants: Ten clinicians (nine female, one male; nine White British, one other ethnic background; mean age 42.8 years) working in therapeutic roles with experience supporting REMS. Participants were recruited via opportunity sampling.

Methods: Semi-structured interviews, averaging 44 min, were video-recorded, transcribed verbatim and analysed using thematic analysis to identify key themes.

Results: Six overarching themes were identified: (1) the chokehold of layered systemic challenges, (2) dynamics of power, (3) lack of safety for REMS, (4) "Am I really getting it?", (5) psychological therapies for white people by white people and (6) the thirst for expertise. Clinicians were enthusiastic about providing culturally responsive care but reported limited access to reflective spaces and training. Contextual factors-including racism, Brexit and the marketisation of higher education-were perceived to affect service delivery and REMS' engagement with mental health support. Business-model approaches to service provision were sources of frustration.

Conclusions: Clinicians face structural and systemic challenges in providing culturally sensitive mental health support to REMS. Enhancing staff training, reflective practice and service adaptation may improve access and efficacy. Findings offer practical insights for universities aiming to strengthen equity in student mental health services, and future work could evaluate interventions to increase clinician preparedness and REMS engagement.

Objectives: To evaluate the impact of various antihypertensive drugs on secondary stroke prevention in a real-life setting.

Design: Nationwide historic cohort study.

Setting: French healthcare system data (SNDS).

Participants: Adults hospitalised for ischaemic stroke between 2014 and 2015 were followed up until December 2021 and stratified based on the presence of atrial fibrillation (AF).

Outcome measures: Risk of stroke recurrence was assessed using a time-dependent Cox cause-specific model accounting for changes in drug exposure. We also investigated the risk of major adverse cardiovascular events (MACE) or all-cause death. Models were adjusted on stroke characteristics, coprescriptions and co-morbidities, at inclusion and across follow-up.

Results: Among 54 764 patients without AF (median age 71; 46% women) and 17 960 with AF (median age 79; 51% women), stroke recurrence occurred in 11% and 13%, respectively. In non-AF patients, reduced recurrence risk was associated only with use of calcium channel blockers (adjusted HR (aHR) 0.91, 95% CI 0.86 to 0.97), thiazide diuretics (aHR 0.90, 95% CI 0. 83 to 0.97), loop diuretics (aHR 0.86, 95% CI 0.77 to 0.95) and potassium-sparing agents (aHR 0.83, 95% CI 0.70 to 0.98). In AF patients, only potassium-sparing agents (aHR 0.82, 95% CI 0.69 to 0.99) were associated with reduced recurrence risk. All antihypertensive drugs, apart from loop diuretics, were associated with a reduced risk of MACE or all-cause death.

Conclusions: In this large cohort, only diuretics and calcium channel blockers were associated with a reduced risk of recurrent stroke. Most antihypertensive drugs, however, may be more effective in overall cardiovascular prevention.