Introduction
The NICE guidelines recommend that patients ≥ 75 years old who have sustained a fragility fracture receive osteoporosis therapy, such as bisphosphonates, alongside appropriate calcium and vitamin D supplementation. Such patients form a major component of orthopaedic inpatients; thus, a QIP was undertaken to review and improve bone protection practice at Buckinghamshire Healthcare NHS Trust.

Methods
From August 2023 to May 2024, a full-loop audit cycle was conducted pre- and post-implementation of a simple checklist, which was incorporated within patient notes to guide ward clinicians safely through osteoporosis treatment. This QIP utilised a cogent PDSA structure and effective stakeholder involvement.

Results
A total of 133 suitable patients were identified in the first cycle, and 83 in the second. When the checklist was utilised, all patients had a senior clinician-led bone protection plan put in place; a significant 37% increase (p=0.00006) compared to pre-implementation. Amongst these, there was a significant 20% increase (p=0.018) in inpatient provision of planned osteoporosis medication, elimination of unsafe prescriptions that did not check adequate renal function or blood calcium levels, and significant improvement in correct vitamin D replacement by 30% (p=0.0004). The checklist did not have a significant effect on the timeliness of bone protection provision, likely due to the wider multifactorial picture of a very busy orthopaedic team caring for unstable, co-morbid patients peri-operatively. However, the communication of correct information on discharge to primary care physicians was significantly ameliorated by 27% (p=0.006), thus hopefully enhancing the continuity of osteoporosis care in the community. Furthermore, feedback surveys from the multidisciplinary team also showed that the checklist intervention was well received, easy-to-use, and educational.

Conclusions
A simple single-page checklist has demonstrably improved the safe provision of bone protection medication for patients with fragility fractures. Hopefully, this will encourage other clinical teams caring for orthogeriatric patients to evaluate their osteoporosis practice and deploy a similar QI strategy.

Survival analysis is crucial for patient management and treatment decisions, particularly for those with advanced lung cancer. Lung cancer remains one of the leading causes of cancer-related mortality globally, with survival rates significantly impacted by factors such as age, gender, performance status, and treatment regimens. This study applies the Weibull survival regression model to examine the survival outcomes of patients with advanced lung cancer. A retrospective dataset from the North Central Cancer Treatment Group (NCCTG) comprising 229 patients with advanced lung cancer was used for analysis. The variables under study included survival times, censoring indicators, and a range of covariates, such as age, gender, ECOG performance score, Karnofsky performance score, calorie intake, and weight loss. The Weibull survival regression model was employed to analyze the impact of these covariates on survival time. Model residuals were studied to assess the fit and appropriateness of the model. The survival regression model revealed a significant difference in survival probability based on key covariates. Factors such as ECOG performance score, Karnofsky performance score, and age were found to significantly influence patients' survival. The model provided a good fit for the data, with the residual analysis indicating no major discrepancies. The survival curve showed the impact of covariates and its consistency in the trend. The findings highlight key prognostic factors that influence patients' survival by providing valuable insight for clinical decision-making and personalized treatment strategies. The Weibull survival regression model offers a robust framework for incorporating multiple covariates and predicting patient survival outcomes more accurately.

Introduction:
The COVID-19 pandemic highlighted the critical need for scalable solutions to manage infectious diseases during health crises. Home isolation and remote monitoring for mild cases became essential to prevent healthcare system collapse. StepCare, a remote monitoring software medical device, facilitates symptom monitoring, prioritization, and early intervention.

Methods:
A single-center, prospective study was conducted at the Osakidetza OSI Bidasoa center to evaluate the reliability, usability, and clinical impact of StepCare during the first wave of the pandemic. Thirty-five symptomatic COVID-19 patients (51% men; 49% women; mean age: 34.5) were monitored for 7.5 days. Clinical safety was evaluated by comparing StepCare's severity categorizations with clinical team assessments across 228 cases. Usability and satisfaction were measured through in-app data and post-study surveys with patients and clinicians.

Results:

StepCare demonstrated clinical safety and reliability, showing a conservative approach to its severity categorizations in 100% of cases and aligning with the clinical team’s assessments in 90.4% of cases. The patients rated the system as a intuitive, suitable, and safe tool, scoring it 9.12/10 for usability and satisfaction, with an 86% adherence rate and 83% recommending it. From a public health perspective, StepCare significantly improved workflow efficiency by reducing the time required for patient management by 25% and decreasing the associated costs by 84%. The direct cost savings included a 100% reduction in home visits (EUR 144.74) and patient-initiated calls (EUR 17.41) and a 33% reduction in follow-up calls by healthcare staff (EUR 50.79 to EUR33.86), resulting in a total cost drop from EUR 212.94 to EUR 33.86 per patient.

Conclusions:

StepCare highlights telemedicine's role in disaster medicine, supporting remote monitoring of COVID-19 patients, improving clinical decisions, and optimizing the resource allocation while ensuring patient safety. Its high usability and satisfaction among both patients and clinicians make it a scalable solution for health emergencies. This study confirms its reliability, ease of use, and efficiency over standard care.

Introduction

HRT is a core component of treating menopausal symptoms, but it must be prescribed safely. Crucially, patients with a uterus on oestrogenic HRT must also have a concomitant progesterone component to provide protection against endometrial hyperplasia, a major risk factor for endometrial cancer. Therefore, a QIP evaluating HRT prescription and documentation was performed, including steps to try and improve practice.

Methods

At a large Northwest London GP practice, all the registered patients with oestrogen prescribed within the past six months were identified. Their digital records were then checked for the safe co-prescription of progesterone, or a Mirena intrauterine system (IUS) inserted within the past five years, or a preventative factor against endometrial cancer such as previous total hysterectomy. Additionally, clinicians’ notes were assessed for how HRT reviews had been undertaken and documented.

Results

A total of 215 patients received oestrogen, of which 42% had progesterone prescribed and 32% had Mirena IUS safely within its five-year license. However, none of these intrauterine devices had been correctly coded completely to include the expiry date. The remaining 26% did not need simultaneous progesterone as forty-eight patients had a history of total hysterectomy, six were transgender women, one had uterine agenesis, and two were topical vaginal oestrogens. The HRT reviews were not documented in a consistent way, thus highlighting the necessity for a standardised Emis template.

Conclusions

All patients prescribed oestrogen had appropriate endometrial protection at this GP surgery. However, in order to facilitate thorough reviews and efficient prescription of HRT by primary care clinicians in the future, there needs to be consistent documentation. The introduction of the aforementioned template aims to enhance HRT practice in the community healthcare setting, and should be paired with patient education, including awareness regarding IUS lifespan.

Hemochromatosis is an autosomal recessive iron overload disorder characterized by excessive iron accumulation, which can lead to various health complications, including liver fibrosis, cirrhosis, and an increased risk of hepatocellular carcinoma (HCC). Iron overload promotes oxidative stress, DNA damage, and cellular proliferation, all of which are implicated in carcinogenesis. The TFR2 gene variant rs7385804 has been implicated in hemochromatosis; however, its role in the Pakistani population and its potential link to cancer progression remain unexplored. This study aimed to investigate the association between the TFR2 gene variant rs7385804 and hemochromatosis in Pakistani individuals and assess its possible role in cancer-related mechanisms. We employed a case--control study design, recruiting 200 hemochromatosis patients and 200 healthy controls from the Pakistani population. Genomic DNA was extracted from peripheral blood samples using the phenol-chloroform method. Sanger sequencing and Tetra-ARMS PCR were used to detect the TFR2 gene variant rs7385804. Our results demonstrated a significant association between the TFR2 gene variant rs7385804 and hemochromatosis in the Pakistani population (p < 0.001). The frequency of the variant allele was higher in patients (35%) compared to controls (15%). Sanger sequencing confirmed the presence of the variant in 70% of patients, while Tetra-ARMS PCR showed 90% concordance with sequencing results. Iron overload, mediated by TFR2 dysregulation, can lead to oxidative stress and genomic instability, key drivers in the development of hepatocellular carcinoma and other malignancies. This study highlights the utility of Sanger sequencing and Tetra-ARMS PCR in detecting the TFR2 gene variant rs7385804 and provides evidence that this variant may serve as a genetic marker for hemochromatosis and a potential contributor to iron-related carcinogenesis in the Pakistani population. Further studies are required to validate these findings and elucidate the clinical implications of this association in cancer development.

Introduction: Levels of sepsis-associated aromatic microbial metabolites (AMMs) of tyrosine and phenylalanine in the blood serum were demonstrated to correlate with severity of critical condition, particularly with SOFA score, and levels of some mitochondrial metabolites, reflecting the impact on mitochondrial dysfunction [DOI:10.3390/metabo9100196].

Objectives: To assess the extracorporeal detoxification effect on the AMM (including phenyllactic, 4-hydroxyphenylacetic, and 4-hydroxyphenyllactic acids) and mitochondrial metabolite (fumaric, succinic, and itaconic acids) dynamics, and their relationship with the severity assessment of intensive care patients.

Methods: Two critically ill patients (A and B) after severe injury, and patient C after complex cardiac surgery, underwent several sessions of hemodiafiltration and hemoperfusion due to development of multiple organ failure and sepsis. Metabolite concentrations in the serum samples (n=27) were detected using gas chromatography–mass spectrometry.

Results: In patients A and B with septic complications on the 1^st day, SOFA scores were 12 and 10 points, and AMM was 5 and 9 µM, respectively. Extracorporeal therapy was carried out over the next few days. On the 4^th and 6^th day for patients A and B, respectively, their condition was improved, and by the 13^th and 7^th day, SOFA scores and AMM reached their minimum values (3 µM for AMM), respectively [DOI:10.1134/S106193482470117X]. Patient C developed multiple organ dysfunction and demonstrated animprovement from 8 to 2 SOFA scores and from 38 to 5 µM after using extracorporeal therapy over 13 days. All three patients survived. The general direction of the dynamics of the SOFA scores and the AMM and mitochondrial metabolites coincided, at the same time, and the AMM positive dynamics was about one day ahead of the SOFA score for patients A and B.

Conclusion: Monitoring AMM levels may be useful for evaluating the effects of extracorporeal therapy in critically ill patients.

Background: This study investigates the survival outcomes of HIV-infected individuals receiving different treatment regimens compared to a control group. Utilizing a cohort dataset with demographic and clinical information, this research aims to assess the impact of various factors, including age, education, and travel time, on survival while controlling for confounding effects using propensity score adjustment.

Methods: A total of 380 HIV-infected patients were included in the study, categorized into an intervention group receiving a specific treatment regimen and a control group. The primary outcome measured was the time to death or censoring. Survival analysis was performed using the Cox proportional hazards model, adjusted for potential confounders, including treatment (intervention and control), age, education, travel time, and gestational age at enrollment. Propensity scores were also incorporated to adjust for treatment selection bias.

Results: The Cox model revealed a significant protective effect of the intervention on survival (hazard ratio (HR) = 0.583, p = 0.045), indicating that the treatment improved survival outcomes compared to the control group. After adjusting for propensity scores, the relationship between the intervention and survival remained significant (HR = 0.631, p = 0.106), suggesting the robustness of the treatment’s effect even after accounting for confounding variables. Other covariates, such as age, education, and travel time, did not show significant independent effects on survival, likely due to their correlation with the treatment variable.

Conclusion: This study highlights the crucial role of the intervention in enhancing survival among HIV-infected individuals. The use of propensity score adjustment improves the validity of these findings by mitigating confounding bias in observational data. These results highlight the importance of ART (antiretroviral therapy) in HIV management and demonstrate the utility of statistical methods like propensity scores in clinical research.

Keywords: HIV; survival analysis; intervention; control group; treatment effect; propensity score; Cox proportional hazards model; clinical trial.

Objective: The aim of this study was to analyze the temporal evolution in the intervals between consultation, diagnosis, and treatment of leukemias and lymphomas in children and adolescents in São Paulo State, Brazil, from 2000 to 2023, identifying patterns of periodicity, temporal trends, and possible seasonality. Methods: An ecological time series study was conducted using data from 77 institutions registered with the Oncocenter Foundation of the State of São Paulo, grouped according to the International Classification of Childhood Cancer. Monthly median times between consultation, diagnosis, and treatment were calculated. Kwiatkowski–Phillips–Schmidt–Shin tests were applied to assess trends and stationarity; Seasonal Effects and Autocorrelation Structure was applied for the assessment of seasonality; and the Ljung–Box test was employed for autocorrelation, supporting the application of Autoregressive Integrated Moving Average models. Results: The time series analysis showed significant trends in the median times between consultation and diagnosis and between diagnosis and treatment for both groups of neoplasms analyzed (p < 0.01). Significant autocorrelation was observed for leukemia and myeloproliferative diseases, as well as lymphomas and reticuloendothelial neoplasms, with no indication of seasonality. Autoregressive models indicated robust temporal patterns necessary to predict the series' behavior over the study period (2000–2023). Conclusion: This study identified significant trends in the times between consultation, diagnosis, and treatment for childhood leukemia and lymphomas, with no evidence of seasonality. These findings highlight the need for faster interventions in pediatric oncology care and reinforce the importance of robust databases to guide public policies aimed at early detection and appropriate treatment.

Background: The aim of this paper is to assess cognitive parameters in coronary artery bypass grafting (CABG) patients using cognitive training with double tasks.
Methods. This prospective randomized study included 62 patients aged 64 [60; 72] years old. One group received cognitive training (n=29), and group went without training (n=33), and they were comparable in terms of clinical characteristics. The median score according to the MoCA was 24 [22.0; 27.0], which indicates the presence of mild cognitive impairment. An assessment of psychomotor and executive functioning, attention, and short-term memory was carried out 2-3 days before the operation and 11-12 days after CABG. The threshold for deterioration in test scores was 20%. The mean duration of cardiopulmonary bypass was 77.0 [60.0; 94.0] min, and the surgery duration was 180.0 [160.0; 210.0] min.
The patients were given a daily course (5-7 days) of computer cognitive exercises featuring tasks on visual motor reaction and simultaneous execution of one of the other tasks (naming items with a certain letter, verbal counter counting, and naming objects that begin with a certain letter).
Results: The results of the cognitive tests before surgery showed no intergroup differences. In total, a 20% reduction was found in the post-operative tests: evaluations of psychomotor and executive functions revealed an increase in missed signals in 21% of patients who underwent training and in 30% who did not undergo training (p=0.05); we also observed increased errors in 6.9% of patients who underwent training and 15.2% who did not(p=0.02). In the Burdon test, the performance index deteriorated in 14% of patients in the training group and in 24% who did not undergo training (p=0.04). Short-term memory was worse in 14% of patients who underwent the cognitive learning tasks and 27% who did not (p=0.03).
Conclusion: The results of cognitive training demonstrated a reduction in the severity of cognitive disorders after coronary bypass.

Introduction: This study aimed to explore the relationship between thyroid hormone sensitivity indices and 1-year all-cause mortality as well as readmission in hospitalized heart failure patients.

Methods: A total of 402 patients admitted to the Department of Cardiology at Heze Hospital, affiliated to Shandong First Medical University, between 2022 and 2023 were included. The composite primary endpoint was defined as all-cause mortality and heart failure readmission within one year after discharge. Four thyroid hormone sensitivity indices were calculated: the free triiodothyronine (FT3)/free thyroxine (FT4) ratio, the thyroid stimulating hormone index (TSHI), the thyroid feedback quantile-based index (TFQI), and the thyrotroph thyroxine resistance index (TT4RI). Participants were grouped based on the quartiles of these indices. The Cox model assessed the effect of thyroid sensitivity on outcomes, with Kaplan–Meier survival analysis and Restricted Cubic Spline (RCS) analysis for non-linear relationships.

Results: In the multivariable Cox proportional hazards model, the hazard ratio (HR) for the composite endpoint in the highest FT3/FT4 ratio group was 0.59 (95% CI: 0.36–0.96, P for trend = 0.047). Kaplan–Meier survival analysis indicated that a lower FT3/FT4 ratio was associated with a worse prognosis (Log-rank P = 0.048). RCS demonstrated a linear relationship between the FT3/FT4 ratio and poor outcomes. In contrast, TT4RI in quartile 2 was associated with the lowest risk, while no significant associations were observed for TSHI or TFQI.

Conclusions: The FT3/FT4 ratio is inversely associated with 1-year all-cause mortality and readmission risk in heart failure patients. TT4RI in quartile 2 was linked to the lowest risk, while TSHI and TFQI showed no significant association with outcomes. These findings suggest that thyroid hormone sensitivity indices, especially the FT3/FT4 ratio, may have prognostic value in heart failure patients.