Fiscal Implications of an Aging Population

<sec><title>Background</title><p>Lung cancer is a deadly disease. An early diagnosis can significantly improve the patient survival and quality of life. One potential solution is using deep learning (DL) algorithms to automate the diagnosis using patient computed tomography (CT) scans. However, the limited availability of training data and the computational complexity of existing algorithms, as well as their reliance on high-performance systems, limit the potential of DL algorithms. To improve early lung cancer diagnoses, this study proposes a low-cost convolutional neural network (CNN) that uses a Mavage pooling technique to diagnose lung cancers.</p></sec><sec><title>Methods</title><p>The DL-based model uses five convolution layers with two residual connections and Mavage pooling layers. We trained the CNN using two publicly available datasets comprised of the IQ_OTH/NCCD dataset and the chest CT scan dataset. Additionally, we integrated the Mavage pooling in the AlexNet, ResNet-50, and GoogLeNet architectures to analyze the datasets. We evaluated the performance of the models based on accuracy and the area under the receiver operating characteristic curve (AUROC).</p></sec><sec><title>Results</title><p>The CNN model achieved a 99.70% accuracy and a 99.66% AUROC when the scans were classified as either cancerous or non-cancerous. It achieved a 90.24% accuracy and a 94.63% AUROC when the scans were classified as containing either normal, benign, or malignant nodules. It achieved a 95.56% accuracy and a 99.37% AUROC when lung cancers were classified. Additionally, the results indicated that the diagnostic abilities of AlexNet, ResNet-50, and GoogLeNet were improved with the introduction of the Mavage pooling technique.</p></sec><sec><title>Conclusions</title><p>This study shows that a low-cost CNN can effectively diagnose lung cancers from patient CT scans. Utilizing Mavage pooling technique significantly improves the CNN diagnostic capabilities.</p></sec>

<p>COVID-19 vaccines reduce infection, disease severity, and death by SARS-CoV-2 by reducing viral load. This study aimed to evaluate the change of cycle threshold (Ct) value in COVID-19 patients and investigate factors related to the Ct value change on the 3rd (D3), 7th (D7), 10th (D10), and 14th (D14) day after hospital admission in Dak Lak in 2021. Nasopharyngeal swabs and serum samples were obtained from 251 COVID-19 patients. Samples were collected on D3, D7, D10, and D14 after hospital admission and tested for SARS-CoV-2 by real-time RT-PCR tests. Ct values were categorized as <italic>high viral load</italic>, <italic>moderate viral</italic>, and <italic>low viral load</italic>. Electrochemiluminescence immunoassay was used to estimate the anti-SARS-CoV-2 antibodies. The results demonstrated that vaccinated individuals against COVID-19 have a faster rate of hospital discharge than the unvaccinated group, most clearly on D10. The Ct change on D10 of vaccinated individuals was statistically significantly higher (1.35 times) than of unvaccinated individuals (<italic>P</italic> < 0.01). The mean Ct values of unvaccinated individuals on D3, D7, D10, and D14 were lower than that of vaccinated individuals. However, there was a statistically significant increase in Ct of vaccinated individuals compared to unvaccinated individuals only on D10 and D14 (<italic>P</italic> < 0.03). The percentage of Ct value ≥ 30 and negative of vaccinated persons on D7 (60.9%) was similar to that of unvaccinated persons on D10 (59.4%) (<italic>P</italic> > 0.05). Vaccinated individuals at hospital admission with Ct ≤ 20 on D1 had a statistically significant decline in viral load on D10 and D14, 1.55 and 1.30 times higher compared to unvaccinated individuals (<italic>P</italic> < 0.05). The percentage of Ct ≥ 30 was significantly higher in males than females, especially on D7 and D14 with PR = 1.26 and 1.11 (<italic>P</italic> < 0.05). In conclusion, individuals vaccinated against COVID-19 had reduced transmission by a significant decline in viral load and recovered faster than unvaccinated individuals.</p>

The age for starting cervical cancer screening for women who were fully vaccinated against human papilloma virus (HPV) in adolescence could be increased from 25 to 30 years. In Italy, some regional governments have revised their screening programs accordingly, though others haven't. Local data on the effectiveness of the HPV vaccine may be helpful in encouraging updates in the screening protocols. We conducted a case-control study based on routine-collected anonymized administrative health data to evaluate the outcomes of first round cervical screening in women living in the Udine area of Italy, according to their vaccinal status. In the study, we included women born between 1993 and 1997, those that were living in the Udine area from 2008 to 2022, and those that participated in the regional cervical cancer screening program for at least one round from 2018 to 2022 (n = 2191). Of these women, 850 had been fully vaccinated before 15 years of age, 887 were vaccinated at age 15 or later, 39 were incompletely vaccinated, and 415 had never been vaccinated. 2140 women had a negative pap-test result and 51 had some type of non-normal result. The odds ratio for having a non-negative result was 0.23 for vaccinated vs non-vaccinated women (95% confidence interval 0.13–0.40). Only 0.2% of vaccinated women had CIN2+ lesions compared to 1.0% of CIN2 and 2.6% of CIN3 of non-vaccinated women (odds ratio of CIN2+ was 0.10, 95% confidence interval 0.04–0.26). The first invitation to the regional cervical cancer screening could be delayed in women who were vaccinated against HPV.

This paper explored significant advancements in integrative child psychotherapy in the UK, aiming to establish a common core and unified theory. Informed by infant-parent observations, attachment theory, neuroscience, and socio-cognitive developmental psychology research, the findings integrated clinical approaches from a developmental and family systems perspective. The objective was to provide a framework based on common factors and a unified psychogenesis theory, emphasising a therapeutic action model and understanding child development. The escalating prevalence and severity of mental health issues among children and young people (CYP) are highlighted, with factors like the COVID-19 pandemic, educational disruptions, increased digital reliance, and the current cost of living crisis contributing to the surge. The impact of these changes necessitates a holistic approach to mental health care, specifically by specialists in integrative child psychotherapy. Current data underestimates CYP mental health needs due to the absence of a national approach to data collection and analysis. Moreover, there is a lack of consensus on the assessment and case formulation in CYP mental health treatment. The diversity in practitioners' approaches, training, and understanding of child development, evidence-based practices, and CYP mental health support is noted. Critiquing the limitations of evidence-based practices, the paper argues for a systematic assessment and case formulation framework. It advocates for an evidence base that acknowledges the individuality of CYP, emphasising psychotherapy's dynamic, relational foundation. The proposed framework seeks to inform training and practice requirements, challenging the conventional mechanistic understanding of mental health treatment and promoting a more integrative and client-centred approach.

This paper concerns the aptitudes of medical staff to explore new therapies and training exercises for image-assisted robotic diligent interventions. This exploration can be carried out using physical, digital, or both copies of patients. Such physical and digital phantoms should approximate real living tissues through realistic biological properties. Such a realistic assessment could be achieved through strategies to reduce physical and numerical uncertainties. The concept of physical-virtual matched pairs is used in image-assisted robotic interventions to enable such reduction. The present commentary aimed to analyze and illustrate possibilities for increasing the capabilities of medical personnel to explore new therapies and training exercises for image-assisted robotic diligent interventions. In this context, the manuscript focused on the use of the physical-virtual digital twin (DT) concept to monitor image-assisted robotic interventions, thereby reducing the complexity and uncertainties involved in such a procedure. Extensions involve robotic operations assisted by human-in-the-loop DT, artificial intelligence (AI), and augmented reality (AR). The various topics covered in this commentary are supported by a review of the literature.

<sec><b>Objective</b>This paper sought to evaluate the impact of a year-long Health Equity Curriculum (HEC) on the knowledge of health disparities, cross-cultural humility, and empathy among physicians, trainees, and research staff.</sec><sec><b>Background</b>There has been an increase in the inclusion of equity, cultural humility, and the social determinants of health into medical education at various levels. However, the frequency of this education is low and not well quantified or defined. The authors report the results of an education program, namely the HEC, on the knowledge of health disparities, cross-cultural humility, and empathy.</sec><sec><b>Materials and methods</b>The HEC was delivered between March 2020 and May 2021. It included the following four modules: the social determinants of health, cultural humility, health literacy, and unconscious bias. The participants attended lectures and reviewed articles/videos using online modules and reflection assignments. The Jefferson Scale of Empathy (JSE) and the Cross-Cultural Competence Instrument for Health Care Professionals (CCCHP) were administered pre- and post-HEC. The results were statistically analyzed.</sec><sec><b>Results</b>Of the 102 enrolled participants, 46 completed the entire course. The JSE showed a statistically significant improvement in the empathy scores from pre-HEC to post-HEC (p < 0.01). The CCCHP showed a significant improvement from pre-HEC to post-HEC total scores and in subcomponent scores of Motivation/Curiosity, Attitude, and Knowledge (p < 0.05). There were no significant differences in scores for the Skills and Emotions/Empathy subcomponents.</sec><sec><b>Conclusions</b>Enrollment and completion in the HEC were associated with statistically significant improvements in the validated measures of cultural competence and empathy. Scaling this type of content and curriculum can educate professionals on equity and serving diverse communities. A further study is warranted.</sec>

<abstract> <p>The detrimental effects of high amounts of sedentary time on various health outcomes have been well documented. Particularly among youth, there are many sedentary pursuits that compete with active leisure time choices, which contribute to a high prevalence of insufficiently active children and adolescents. Therefore, the present study examined the time spent in various sedentary behaviors and the association with body weight in Austrian adolescents. Sedentary time was assessed with the “Heidelberg Questionnaire to Record the Sitting Behavior of Children and Adolescents” for 1225 (49.8% male) middle- and high-school students between 11 and 17 years of age. Their body weights and heights were measured with participants wearing gym clothes. The weight categories were established based on body mass index (BMI) percentiles using the German reference system. The average daily sedentary time across the entire sample was 12.0 ± 1.6 h, and 45% of the sedentary behaviors during the entire week were attributed to schoolwork. Normal weight participants reported a lower amount of sitting time compared to their overweight and obese peers, where they spent more time with physical activity and sleeping. Specifically, a higher body weight was associated with more time spent with recreational sedentary behaviors, while differences across the weight categories were limited for work-related sitting. Given the detrimental health effects of high amounts of sedentary behaviors, additional efforts are needed to promote physical activity in adolescents, particularly for those with an excess body weight. As almost half of the sedentary behaviors were attributed to work, schools could be a particularly viable setting for interventions that target an active lifestyle.</p> </abstract>

<abstract><sec> <title>Background</title> <p>Multiple sclerosis (MS), is a debilitating neurological disease that currently has various treatments, like disease-modifying therapies, monoclonal antibodies, corticosteroids, and hormonal derivatives. Melatonin has several actions, like regulating circadian rhythms, which are usually used for insomnia. This scoping review aimed to explore the efficacy of melatonin, both as a standalone treatment and in conjunction with other drugs, in the management of MS in animal models.</p> </sec><sec> <title>Methods</title> <p>We searched PubMed, Web of Science, EMBASE, and Google Scholar using (“melatonin” OR “melatonin receptor”) AND (“multiple sclerosis”) AND (“animal”). Animal studies that evaluated the effects of melatonin on the development, progression, and outcomes of MS were included. Human studies and other types of studies like case reports were excluded. We used narrative synthesis for reporting the results.</p> </sec><sec> <title>Results</title> <p>Overall, 21 studies were included, conducted on mice (n = 15) and rats (n = 6). Mostly, studies reported that melatonin led to normal circadian rhythms in animals. Melatonin in doses of both 50 and 100 mg/kg were useful in nociception latency. Melatonin in combination with other drugs like H-89, diisopropylamine dichloroacetate, gibberellins, and IFN-1β improved outcomes, while there was not improved cognition in combination with mesenchymal stem cells. In some tests, male subjects showed significantly better responses. There were controversial results regarding the effects of melatonin on cytokines, but overall, it led to a reduction in proinflammatory cytokines.</p> </sec><sec> <title>Conclusions</title> <p>Melatonin overall demonstrated favorable outcomes regarding oxidative stress, anti-inflammation, and cytokine levels across various doses. It is recommended conducting systematic reviews and meta-analyses with a larger number of primary studies to provide more comprehensive insights.</p> </sec></abstract>

<abstract><sec> <title>Objectives</title> <p>Telehealth services became commonplace during the COVID-19 pandemic and were widely reported to improve access to medical care in a variety of settings. The primary aim of this study was to assess patient- and provider-reported satisfaction with telehealth services within a multidisciplinary outpatient program for children with feeding disorders.</p> </sec><sec> <title>Methods</title> <p>Caregivers and healthcare providers who participated in telehealth multidisciplinary visits within an outpatient pediatric feeding disorders clinic between April and June 2020 completed an online survey that assessed their visit satisfaction. The visit completion rates of in-person 2019 and virtual 2020 visits were compared.</p> </sec><sec> <title>Results</title> <p>Thirty-six caregivers of children between 1-month and 8-years-old completed the survey. Caregivers indicated their overall satisfaction with telehealth services, finding it more convenient than seeing specialists in person. Caregivers demonstrated interest in continuing telehealth visits. Providers indicated being satisfied with the telehealth visits, with many noting that they were as effective as in-person visits. There was an increase in the number of in-person visits between 2019 compared to virtual visits in 2020, though there were no differences for the visit completion rates.</p> </sec><sec> <title>Conclusions</title> <p>Both caregivers and providers were satisfied with the telehealth services and highlighted various benefits in response to open-ended questions. However, there were concerns with the lack of available anthropometric data and measurements. Although there were no differences in the no-show rates following the implementation of telehealth, there was a significant increase in the total number of completed visits. Telehealth visits are a crucial resource for caregivers and providers in multidisciplinary pediatric feeding clinics, yet enhancing anthropometric measurements is necessary to provide quality care.</p> </sec></abstract>

<abstract> <p>Piriformis syndrome is characterised as being one of the possible causes of sciatic pain, as well as being a syndrome that tends to become chronic. Because of this, different types of treatments for both this syndrome and the associated pain it causes have been investigated over the years. Nowadays, the evidence increasingly favors treating chronic pain with a multimodal physiotherapy treatment based on a biobehavioral approach. This case report describes the physiotherapy intervention performed on a 44-year-old woman with chronic pain related to piriformis syndrome. The multimodal intervention lasted for 9 weeks with a total of 12 sessions and included manual therapy, therapeutic exercise, neural mobilization, and pain neuroscience education. Initially, the pain characteristics alongside somatosensory, motor-functional, and psychosocial factors were assessed. Due to the Covid-19 pandemic, only the pain characteristics and psychosocial factors could be reassessed post intervention. Improvements in both pain characteristics and psychosocial factors were achieved, resulting in a better general condition of the patient. This case report suggests that a multimodal physiotherapy intervention adapted to telerehabilitation was an effective option to improve the pain symptoms and psychosocial factors in the reported patient during the Covid-19 pandemic. Therefore, this may be a treatment option in patients with chronic pain that are in a situation where face-to-face physiotherapy is not feasible.</p> </abstract>

<abstract><sec> <title>Introduction</title> <p>Cervical cancer (CC) poses a substantial burden in low-and middle-income countries (LMICs), where challenges in implementing effective screening programs and achieving high participation rates persist.</p> </sec><sec> <title>Aims</title> <p>This study sought to compare different strategies for recruiting women for CC screening in Albania, Montenegro, and Morocco, and compared usual care (ongoing invitation method) with an alternative approach (intervention strategy).</p> </sec><sec> <title>Methods</title> <p>Within each country, the following comparisons were made: face-to-face (FF) invitations versus phone calls (PCs) in Albania, PCs versus letter invitations in Montenegro, and FF invitations to women attending healthcare centers versus a combined approach termed “Invitation made in Morocco” (utilizing PC and FF for hard-to-reach women) in Morocco. Questionnaires that assessed facilitators and barriers to participation were administered to women who either attended or refused screening.</p> </sec><sec> <title>Results</title> <p>In Albania, significant differences in the examination coverage were observed between the invitation methods (PC: 46.1% vs. FF: 87.1%, p < 0.01) and between the rural and urban settings (rural: 89.1% vs. urban: 76.3%, p < 0.01). In Montenegro, the coverage varied based on the recruitment method (PC: 17.7% vs. letter invitation: 7.6%; p < 0.01), the setting (urban: 28.3% vs. rural: 13.2%; p < 0.01), and age (<34 years: 10.9% vs. 34+: 9.6%, p < 0.01). In Morocco, no significant differences were observed. Common screening facilitators included awareness of CC prevention and understanding the benefits of early diagnosis, while key barriers included a limited perception of personal CC risk and the fear of testing positive.</p> </sec><sec> <title>Discussion</title> <p>FF appeared to be effective in promoting participation, but its broader implementation raised sustainability concerns. PC invitations proved feasible, albeit necessitating updates to population registries. Restricting FF contacts for hard-to-reach communities may enhance the affordability and equity.</p> </sec></abstract>

<abstract><sec> <title>Introduction</title> <p>Our aim was to compare the prealbumin/fibrinogen ratio (PFR) of diabetic patient populations with or without diabetic nephropathy.</p> </sec><sec> <title>Materials and methods</title> <p>People with type 2 diabetes who attended the internal medicine outpatient clinic were enrolled in the study. Two groups were formed according to the proteinuria of the patients: Diabetic nephropathy and non-nephropathy group. Diabetic nephropathy was calculated using the mathematical formula of spot urine albumin/spot urine creatinine x100. Patients with proteinuria above 200 mg/g were considered to have nephropathy. PFR was simply calculated by dividing prealbumin by fibrinogen.</p> </sec><sec> <title>Results</title> <p>A total of 152 patients who attended our outpatient clinic were enrolled in the study. There were 68 patients in the diabetic nephropathy group and 84 in the non-nephropathy group. The prealbumin/fibrinogen ratios (PFR) were significantly lower in the nephropathic group [0.061 (0.02–0.16)] than the non-nephropathic group [0.0779 (0.01–0.75)] (p = 0.002).</p> </sec><sec> <title>Conclusions</title> <p>We suggest that decreased levels of PFR can indicate diabetic nephropathy in subjects with type 2 diabetes mellitus.</p> </sec></abstract>

<abstract> <p>Low back pain and its chronification are among the most common causes of disabilities worldwide. This is why multiple interventions and treatment approaches have been investigated around this pathology in recent years. Currently, the evidence is increasingly leaning towards treating chronic low back pain with a treatment based on the patient's centered biopsychosocial model. This case report presents the evaluation and treatment of a 43-year-old woman with chronic low back pain using a multimodal physiotherapy based on a biobehavioral approach. In the physiotherapy intervention, the patient's pain characteristics and somatosensory, motor-functional, and affective-cognitive states were first evaluated. Subsequently, a multimodal treatment including therapeutic exercise, pain neuroscience education, and orthopedic manual and physical therapies was applied for a total of 14 sessions over a period of 9 weeks. Finally, a post-intervention evaluation and at the one-month follow-up were carried out, in which it was observed that the treatment had significantly improved the patient's symptomatology and their general state. This case suggests that a multimodal physiotherapy treatment based on a biobehavioral approach is an effective option to improve pain symptoms and somatosensory, motor-functional, and affective-cognitive aspects in the reported patient; therefore, a treatment of these characteristics may be an option for patients with chronic low back pain.</p> </abstract>

Leukemoid reaction is defined as leukocytosis of more than 50 × 10<sup>3</sup> cells/µL of blood, which is a physiological response to stress or infections, as opposed to a primary blood malignancy (leukemia). It is seen in various conditions including sepsis, burns, and inflammatory states associated with systemic inflammatory response syndrome (SIRS). Here, we report a 40-year-old cachexic and paraplegic male who presented with a leukemoid reaction and pressure injuries at the gluteal region with a total leukocyte count (TLC) of 103 × 10<sup>3</sup> cells/µL of blood and reactive thrombocytosis. A bone marrow (BM) examination revealed no malignancy. With the administration of broad-spectrum antibiotics, the TLC after two weeks at the time of discharge was reduced to 18.83 × 10<sup>3</sup> cells/µL of blood and the patient was referred to surgical unit for further management of pressure injuries. BM examination is mandatory in patients with suspected malignancies; however, for bed-bound patients with longer durations, pressure injuries should be inspected and treated with broad spectrum antibiotics before performing invasive procedures such as a BM examination.

<abstract> <p>This study presents a novel approach to enhance cardiovascular disease prediction using a hybrid machine learning (ML) model. Leveraging on Synthetic Minority oversampling techniques (SMOTE) and adaptive boosting (AdaBoost), we integrate these methods with prominent classifiers, including Random Forest (RF), Extreme Gradient Boosting (XGBoost), and Extra Tree (ET). Focused on heart rate data as stress level indicators, our objective is to jointly predict cardiovascular disease, thereby addressing the global health challenge of early detection and accurate risk assessments. In response to class imbalance issues in cardiology databases, our hybrid model, which combines SMOTE and AdaBoost, demonstrates promising results. The inclusion of diverse classifiers, such as RF, XGBoost, and ET, enables the model to capture both linear and nonlinear relationships within the heart rate data, significantly enhancing the prediction accuracy. This powerful predictive tool empowers healthcare providers to identify individuals at a high risk for heart disease, thus facilitating timely interventions. This article underscores the pivotal role of ML and hybrid methodologies in advancing health research, particularly in cardiovascular disease prediction. By addressing the class imbalance and incorporating robust algorithms, our research contributes to the ongoing efforts to improve predictive modeling in healthcare. The findings presented here hold significance for medical practitioners and researchers striving for the early detection and prevention of cardiovascular diseases.</p> </abstract>