The coronavirus disease 2019 (COVID-19) pandemic has brought drastic changes globally in the past three years, one of which is an increase in the use of digital media or electronic devices. Previous studies have shown that long screen time may stimulate the neurobiological system, resulting in various behavioural and emotional problems; however, there is insufficient population-based evidence. This study aimed to investigate the influence of screen time on behavioural and emotional problems in Indonesian adolescents at three time points: the pre-, peak, and post-peak periods of COVID-19. Data were collected using an online community mental health survey. This survey incorporated the Youth Screen Time Survey to gauge screen time and the adolescent version of the Strengths and Difficulties Questionnaire to assess emotional, conduct, and prosocial behaviour problems. The participants were adolescents in secondary and senior high schools, with 337, 423, and 1,096 participants from the pre-, peak-, and post-pandemic periods, respectively, included in the analysis. Daily average screen time was compared, followed by the calculation of odds ratios for screen time and mental health problems during the different periods. The results demonstrated significant differences in adolescents’ total daily average screen time between the different pandemic periods. Decreased screen time was associated with reduced emotional, conduct, and prosocial behaviour problems, especially during the peak period. Thus, psychoeducation on screen time in adolescents should be considered as a point of interest for mental well-being interventions.

Objective This study aimed to explore the prognostic impact of cognitive impairment on the long-term risk of major adverse cardiovascular events (MACEs) in older patients with non-ST-elevation acute coronary syndrome (NSTEACS) undergoing invasive treatment. Methods Patients aged ≥75 years with NSTEACS undergoing an invasive strategy were included in the multicentre prospective study (NCT01933581). Montreal Cognitive Assessment was used to evaluate cognitive status at baseline (scores ≥26 classified as normal, <26 as cognitive impairment). Long-term follow-up data were obtained from electronic patient care records. The primary endpoint was MACE as a composite of all-cause deaths, reinfarction, stroke/transient ischaemic attack, urgent revascularisation and significant bleeding. Results 239 patients with baseline cognitive assessment completed long-term follow-up. Median age was 80.9 years (IQR 78.2–83.9 years) and 62.3% were male. On 5-year follow-up, there was no significant difference in the occurrence of MACE between the cognitively impaired group and the normal cognition group (p=0.155). Cognition status was not associated with MACE (HR 1.37 (95% CI 0.96 to 1.95); p=0.082). However, there was significantly more deaths (p=0.005) in those with cognitive impairment. Kaplan-Meier survival analysis (log-rank p=0.003) and Cox regression analysis (aHR 1.85 (95% CI 1.11 to 3.08); p=0.018) revealed increased risk of all-cause mortality, even after adjusting for frailty and GRACE (Global Registry of Acute Coronary Events) score. Conclusion Cognitive impairment in older patients with NSTEACS undergoing an invasive strategy was associated with long-term all-cause mortality. Routine cognitive screening may aid risk stratification and further studies are needed to identify how this should influence management strategies and individual decision-making in this patient group. Trial registration number NCT01933581.

Objective This study describes the differences in treatment and clinical outcomes in patients aged ≥75 years compared with those aged ≤74 years presenting with acute coronary syndrome (ACS) and undergoing invasive management. Methods A large-scale cohort study of patients with ST-elevation/non-ST-elevation myocardial infarction (MI)/unstable angina underwent coronary angiography (January 2015–December 2019). Patients were classified as older (≥75 years) and younger (≤74 years). Regression analysis was used to yield adjusted risks of mortality for older versus younger patients (adjusted for history of heart failure, hypercholesterolaemia, peripheral vascular disease, chronic obstructive pulmonary disease, ischaemic heart disease, presence of ST-elevation MI on presenting ECG, female sex and cardiogenic shock at presentation). Results In total, 11 763 patients were diagnosed with ACS, of which 39% were aged ≥75 years. Percutaneous coronary intervention was performed in fewer older patients than younger patients (81.2% vs 86.2%, p<0.001). At discharge, older patients were prescribed less secondary-prevention medications than younger patients. Median follow-up was 4.57 years. Older patients had a greater risk of in-hospital mortality than younger patients (adjusted OR (aOR) 2.12, 95% CI 1.62 to 2.78, p<0.001). Older patients diagnosed with ST-elevation MI had greater adjusted odds of dying in-hospital (aOR 2.47, 95% CI 1.79 to 3.41, p<0.001). Older age was not an independent prognostic factor of mortality at 1 year (adjusted HR (aHR) 0.95, 95% CI 0.82 to 1.09, p=0.460) and at longer term (aHR 0.98, 95% CI 0.87 to 1.10, p=0.684). Conclusions Older patients are discharged with less secondary prevention. Patients aged ≥75 years are more likely to die in-hospital than younger patients.

Introduction: Antimicrobial resistance (AMR) is a major public health threat. Improving antimicrobial use is the main strategy against AMR, but it is challenging to implement especially in low-resource settings. Thus, this review aims to explore the efficacy of telehealth-based antimicrobial stewardship programs (ASP), which is more accessible. Methods: Registered to PROSPERO and following PRISMA guidelines, literature search was performed in databases including PubMed, Scopus, Cochrane, Science Direct, EBSCOhost, EMBASE, and Google Scholar, searching for studies implementing telehealth ASP. Critical appraisal of studies was performed using Newcastle-Ottawa Scale for Cohort Studies (NOS), Cochrane Risk-of-Bias tool (RoB) 2.0, and Risk Of Bias In Non-randomised Studies-of Interventions (ROBINS-I). We utilized inverse variance, random effects model to obtain the pooled odds ratio (OR) and mean difference (MD) estimates, as well as sensitivity and subgroup analysis. Results and Discussion: The search yielded 14 studies. Telehealth-based ASP was associated with better adherence to guidelines (pooled OR: 2.78 [95%CI:1.29–5.99], p = 0.009; I2 = 93%), within which streamlining yielded better odds (pooled OR: 30.54 [95%CI:10.42–89.52], p < 0.001) more than the compliance with policy subgroup (pooled OR: 1.60 [95%CI:1.02–2.51], p = 0.04). The odds of antimicrobial prescription rate reduced significantly (pooled OR: 0.60 [95%CI:0.42–0.85], p = 0.005; I2 = 94%), especially for the lower respiratory infection subgroup (pooled OR: 0.37 [95%CI:0.28–0.49], p < 0.001). Days of therapy decreased (pooled MD: -47.12 [95%CI: −85.78– −8.46], p = 0.02; I2 = 100%), with the greatest effect in acute care settings (pooled MD: -97.73 [95%CI:−147.48–47.97], p = 0.0001). Mortality did not change significantly (pooled OR: 1.20 [95%CI:0.69–2.10], p = 0.52; I2 = 63%). Conclusion: Telehealth-based ASP was proven beneficial to increase adherence to guideline and reduce prescription rates, without significantly affecting patient clinical outcome. After further studies, we recommend more widespread use of telemedicine to combat AMR.

Background: Affected by various hurdles during COVID-19, preclinical medical students are at an elevated risk for mental health disturbances. However, the effects of modern mental health problems on preclinical medical students have not been adequately researched. Thus, this study was aimed to identify the proportions and implications of current mental health problems for depression, sleep quality and screen time among Indonesian medical preclinical students during the COVID-19 pandemic.Methods: This cross-sectional study was conducted using crowdsourcing between October 2020 and June 2021. During the study period, 1,335 subjects were recruited, and 1,023 datasets were identified as valid. General Health Questionnaire-12 (GHQ-12) was used to measure current mental health disturbances (categorized as without current mental health disturbances, psychological distress, social dysfunction, or both). The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression, the Pittsburgh Sleep Quality Index (PSQI) was employed to assess sleep quality, and a questionnaire devised for this study was used to assess screen time length per day. Multivariate data analysis was conducted using SPSS version 24 for Mac.Results: According to the findings, 49.1% of the 1,023 participants had current mental health disturbances: 12.8% had psychological distress, 15.9% had social dysfunction, and the rest (20.4%) had both psychological distress and social dysfunction. The statistical analysis provided strong evidence of a difference (p< 0.001) between the medians of depression and sleep quality with at least one pair of current mental health disturbance groups, but the difference for screen time was not significant (p= 0.151). Dunn’s post-hoc analysis showed that groups without current mental health problems had significantly lower mean ranks of depression and sleep quality compared to groups that had current mental health problems (p< 0.001).Conclusion: Current mental health disturbances during the COVID-19 pandemic were significantly associated with preclinical medical students’ depression and sleep quality in preclinical medical students. Thus, mental health programs for this specific population should be tailored to integrate mindfulness therapy, support groups, stress management, and skills training to promote mental wellbeing.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer‐related mortality worldwide. Malnutrition is highly prevalent among people living with HCC and has a substantial impact on morbidity and mortality. Nutrition influences the development of HCC and is also a consequence of chronic liver disease and liver cancer. Routine screening and nutritional assessment using validated tools, along with evaluation of muscle mass and functional status, are essential in the optimal care of patients with HCC. Nutritional interventions may change throughout the disease trajectory depending on the stage of HCC, the severity of liver cirrhosis, and the overall treatment options and intent. Evidence supports the use of oral nutritional supplements, branched‐chain amino acids, exercise interventions, and the preferential use of enteral over parenteral nutrition. Optimizing nutrition is integral to HCC management across all disease stages and is best accomplished with a multidisciplinary team to individualize the nutritional care across the disease continuum. In this review, we summarize current evidence on the impact and role of nutritional therapy in HCC and provide actionable recommendations for clinical practice. We highlight the current challenges and provide future directions for future HCC nutritional care pathways.