Walter Cullen

Patients with infection present to emergency departments (EDs) through multiple referral pathways, including general practitioner (GP) referral and self/ambulance presentation. The impact of referral sources on presentation characteristics, ED processes, and clinical outcomes remains poorly characterised. A retrospective observational study examined ED presentations with infection across eight sampling points in 2025 in an inner-city ED located in an area of severe deprivation. Patients were stratified into general practitioner (GP)/GP out-of-hours (GP-OOH) referrals and other referral pathways. Demographic characteristics, physiological observations, ED process measures, and clinical outcomes were compared using unadjusted analyses, with multivariable median regression used to adjust the principal exploratory ED process outcomes for clinically relevant covariates. Among 277 patients, 55 (19.9%) were referred by GP/GP-OOH and 222 (80.1%) via other routes. GP-referred patients more frequently presented on weekdays and arrived by private transport (both p < 0.001). No statistically detectable differences were observed in most demographic, clinical, and physiological measures, although the study was not designed or powered to establish equivalence. GP-referred patients experienced longer times to triage (p < 0.001) and first physician assessment (p = 0.003). GP-referred patients represented a minority of infection presentations. No statistically significant differences were detected in most clinical outcomes, although admission was less frequent among GP-referred patients (36.4% vs. 51.8%; absolute difference −15.4 percentage points; risk ratio 0.70, 95% CI 0.48–1.02), and clinically important differences cannot be excluded. GP referral was associated with longer waits for early ED assessment, while differences in downstream treatment and clinical outcomes should be interpreted cautiously given the exploratory nature of these comparisons and the small number of GP-referred patients.

BACKGROUND People may have knowledge about well-being, supportive resources, confidence, and opportunities to act, yet still struggle to sustain well-being as circumstances change. Existing constructs address many of these determinants individually, but a capability framework describing their mobilisation and coordination remains insufficiently defined. OBJECTIVE This study proposes Well-being Efficacy (WBE) as such a capability framework, in which WBE itself is conceptualised as an integrative meta-capacity that coordinates these resources into adaptive action for sustaining well-being across changing contexts. METHODS A two-round modified e-Delphi study was conducted with 20 multidisciplinary international experts. Following a prospectively published protocol, experts evaluated the proposed WBE definition and 18 dimensions. Consensus was defined a priori as ≥70% agreement. Qualitative feedback was incorporated between rounds to refine the framework. RESULTS The proposed WBE construct achieved 95% agreement in Round 1 (n=20), and all 18 dimensions reached consensus, with agreement ranging from 70% to 95%. Expert feedback led to refinements in wording and conceptual clarity without substantive alteration of the framework. Following revision, the overall construct and all dimensions achieved full consensus (100% agreement) in Round 2 (n=8). CONCLUSIONS The findings provide international multidisciplinary consensus for an integrative capability framework for WBE, within which WBE itself operates as a meta-capacity concerned with mobilising and coordinating personal and contextual resources to sustain well-being across changing circumstances. The resulting framework distinguishes WBE from established constructs focused primarily on knowledge, beliefs, resources, or opportunities and provides a conceptual basis for subsequent validation and measurement development. CLINICALTRIAL Not applicable. INTERNATIONAL REGISTERED REPORT RR2-https://doi.org/10.1371/journal.pone.0321426

Aim: This study aims to design, implement, and evaluate a virtual exchange programme in global health and primary care, with a focus on building capacity and fostering collaboration between European and Sub-Saharan African institutions. Methods: A mixed-methods approach will be adopted across three phases. First, a scoping review will synthesise evidence on the implementation, outcomes, barriers, and facilitators of virtual exchanges in global health. Second, a virtual exchange curriculum will be co-developed through surveys and focus groups with medical students and educators. Third, the programme will be evaluated using pre- and post-course surveys, and semi-structured interviews to measure changes in knowledge, global health competencies, and intercultural awareness. Quantitative data will be analysed using descriptive and regression analyses, while qualitative data will undergo reflexive thematic analysis. Conclusion: This study will generate evidence on the design and impact of virtual exchanges for global health education, contributing to the development of sustainable and equitable curricula in PHC. By disseminating findings across academic, policy, and professional networks, the VICTORY project seeks to advance global collaboration, support workforce development, and promote health equity.

Background: Vital signs are objective measurements of the body’s most basic, essential functions, indicating overall health status. However, such assessments are time-consuming and so are not always prioritized. Measuring vital signs before doctor visits may, therefore, be an effective and efficient strategy. Objective: We piloted a preclinic vital signs assessment (PCVSA) procedure within a primary care center to determine its feasibility and acceptability. Methods: A mixed methods cross-sectional design was used for piloting the PCVSA procedure. Study participants included adult patients and practice staff. Patients had vital signs assessed by a primary care assistant before general practitioner (GP) visits. Collected data concerned participants’ study engagement, the timings of PCVSA/GP visits, and surveys/interviews investigating participants’ experiences. Implementation (Results): A total of 16 patients and 4 staff participated. The mean duration for PCVSAs was 2 minutes and 23 seconds (SD 38.8 s), and the mean duration for GP visits was 9 minutes and 21 seconds (SD 252.4 s). Patients said the PCVSA was a “Positive experience” (n=14, 88%), “Helpful” (n=13, 81%), “Valuable” (n=7, 44%), and “Interesting” (n=6, 38%). The GP said the PCVSAs were either “Helpful” (8/15, 53%) or “Extremely Helpful” (7/15, 47%) in each of their consultations and that the PCVSAs improved engagement with patients (12/15, 80%), allowed them to spend more time gaining an understanding of the conditions of patients (14/15, 93%), and enhanced productivity during consultations (11/15, 73%). The GP strongly agreed that collecting PCVSA data before appointments would benefit patients over time. Qualitative interviews with practice staff yielded three themes: (1) improved patient engagement and efficient consultation, (2) time-saving potential, and (3) practicing in general practice and associated challenges. Conclusions: The PCVSA pilot showed good feasibility and acceptability as indicated by high participant engagement, short PCVSA and GP visit times (albeit GP visit times did not measure non–patient-facing clinical activity), and positive feedback from patients and staff. Introducing PCVSAs in health care settings may have potential in terms of improving the standard and efficiency of care.

Background: Long Covid is a multi-factorial condition impacting millions globally. Aims: (1) To describe the demographic and health profiles of adults who have or have had Long Covid, and (2) examine their experiences of Long Covid healthcare, particularly in general practice. A cross-sectional online survey was conducted in the Republic of Ireland in April 2025. Methods: Survey items investigated demographics, medical history, and experiences of Long Covid care. Data was analysed using descriptive statistics and qualitative analysis of open responses. Results: Of 222 (87.05%) eligible respondents, most were 35–64 years (n = 184, 82.14%), female (n = 177, 79.7%), and born in the Republic of Ireland (n = 193, 86.9%). Respondents reported wide-ranging multimorbidity and Long Covid symptoms. Many strongly agreed that their symptoms were severe (n = 196, 88.7%) and detrimental to quality of life (n = 200, 90.1%), physical (n = 202, 91%) and mental (n = 98, 45%) health. Long Covid commonly lasted more than three years (n = 169, 76.1%), indicating substantial long-term impact on daily functioning. Almost all consulted general practitioners for Long Covid care (n = 213, 95.9%). Nearly half (n = 95, 44.6%) were dissatisfied with current GP care, and many felt GPs lacked adequate knowledge of Long Covid (n = 127. 59.6%). Respondents supported proposed GP-based investigative and referral interventions, as well as affirming and advocacy-focused doctor–patient relationships. Conclusions: Continued clinical and research efforts are needed to address future Long Covid care needs. With structured, informed, holistic, and multidisciplinary care, general practice can make a positive contribution to the lives of those affected.

Major AI ethics guidelines and laws, including the EU AI Act, call for effective human oversight, but do not define it as a distinct and developable capacity. This paper introduces human oversight as a well-being capacity, situated within the emerging Well-being Efficacy framework. The concept integrates AI literacy, ethical discernment, and awareness of human needs, acknowledging that some needs may be conflicting or harmful. Because people inevitably project desires, fears, and interests into AI systems, oversight requires the competence to examine and, when necessary, restrain problematic demands. The authors argue that the sustainable and cost-effective development of this capacity depends on its integration into education at every level, from professional training to lifelong learning. The frame of human oversight as a well-being capacity provides a practical path from high-level regulatory goals to the continuous cultivation of human agency and responsibility essential for safe and ethical AI. The paper establishes a theoretical foundation for future research on the pedagogical implementation and empirical validation of well-being effectiveness in multiple contexts.

Background: General practitioners (GPs) in the Republic of Ireland have historically faced limited access to diagnostic imaging. A new national initiative allowing GPs to refer patients to private providers for imaging studies may alter referral patterns and improve patient care. Aims: This exploratory study aimed to evaluate the perceived impact of expanded GP access to diagnostic imaging on referral patterns and patient care quality in Irish primary care. Methods: A cross-sectional analysis was conducted of 620 diagnostic imaging referrals from 45 GP clinics across all Community Health Organization (CHO) regions, spanning June 2021 to August 2022. Data included imaging modalities (X-ray, DEXA, CT, MRI), referral frequencies to emergency departments (EDs), acute medical units (AMUs), outpatient clinics, and GP perceptions of care quality. GPs also provided retrospective assessments of how they would have managed each case prior to the initiative. Results: ED and AMU referrals decreased by 89%, while outpatient clinic referrals declined by 53%. Concurrently, management of cases within GP settings rose substantially. In total, 91% of participating GPs reported improved patient care quality, citing more timely and accessible imaging as a key factor. Conclusion: Despite the study’s exploratory design and reliance on retrospective GP assessments, these findings suggest that broadening GP access to diagnostic imaging may reduce hospital-based referrals and enhance patient care. Ongoing monitoring and further research are recommended to confirm the long-term impacts and sustainability of this initiative.

Background: Clinical practice guidelines have the potential to improve healthcare quality and safety in those with cardiovascular disease. However, guideline adherence is a challenge worldwide. Aims: We aim to determine the types and effects of interventions that target healthcare professionals to improve adherence to cardiovascular disease treatment guidelines—specifically for atrial fibrillation, ischaemic heart disease, heart failure, dyslipidaemia, and/or hypertension in ambulatory care. Methods: The following databases were searched from January 2012 to September 2023: MEDLINE, CINAHL, EMBASE,Cochrane, PsycINFO, ERIC International, Applied Social Sciences Index and Abstracts, clinicatrial.gov, and EUtrials. The search was supplemented by reviewing the reference lists of included studies, cited articles, and systematic reviews published in the field. Randomised trials, including cluster randomised trials and cross-over designs, were included. Two investigators independently extracted data and assessed study quality. Results: Forty-six studies examining the impact of healthcare-targeted interventions on improving guideline adherence were identified. Various approaches were employed, with educational interventions being the most frequently used. Given the heterogeneity in types of intervention and outcomes reported in the included trials, a narrative synthesis of the data was difficult, and meta-analysis was not planned. Conclusions: This review demonstrates that a diverse range of interventions aimed at healthcare professionals have the potential to improve adherence to CVD guidelines, but their overall effectiveness remains mixed. To narrow the gap between best practice and real-world guideline application, effective implementation strategies must become as important as guideline development itself.

Rationale: After completing treatment for cancer, survivors may experience late cardiotoxic effects: consequences of treatment that persist or arise after a latent period. Primary care providers are well situated to manage these effects. Risk prediction models may assist with this. Purpose: To identify and describe all models that predict the risk of late effects and could be used in an ambulatory care setting. Data sources: Searches will be conducted across MEDLINE and EMBASE supplemented by manual reference list reviews and targeted grey literature searches using Google. Study Selection: Studies to be included are those describing models that 1) predicted the absolute risk of a late cardiotoxic effect present at least one year post-treatment, across all cancer treatment modalities, and 2) could be used in an ambulatory care clinical setting, Data Extraction & Synthesis: Data will be extracted as per the CHARMS checklist, an assessment of bias will be conducted as per the McGinn Checklist. Discussion: This scoping review will comprehensively map existing tools for risk prediction of the late cardiotoxic effects of cancer therapy in cancer survivors, applicable to an ambulatory care setting. Registration: This protocol was registered on 21.6.25 to Zenodo : 10.5281/zenodo.15708760 Key Messages: Cancer survivors face a significant long-term risk of late-onset cardiotoxicity, often undetected until advanced stages. This review will identify and map validated multivariable risk prediction models that could support the early identification of cardiotoxicity in ambulatory and primary care settings. Integrating prediction tools into primary care may help address growing oncology workforce gaps while enabling timely, risk-adapted cardiovascular follow-up.

BACKGROUND Vital signs assessment can be crucial. However, such assessments are time-consuming and so are not always prioritised. Measuring vital signs before doctor visits may therefore be an effective and efficient strategy. OBJECTIVE We piloted a pre-clinic vital signs assessment (PCVSA) within a primary care centre to determine its feasibility and acceptability. METHODS A mixed methods cross-sectional design was piloted. Study participants included adult patients and practice staff. Patients had vital signs assessed by a Primary Care Assistant before GP visits. Data collected concerned participants’ study engagement, the timings of PCVSA / GP visits, and surveys / interviews investigating participants’ experiences. RESULTS Sixteen patients and four staff participated. The mean PCVSA was 2mins23secs (SD = 38.8) and the mean GP visit was 9mins 21secs (SD = 252.4). Patients said the PCVSA was a ‘Positive experience’ (87%), ‘Helpful’ (81%), ‘Valuable’ (44%), and ‘Interesting’ (38%). The GP said the PCVSA was either ‘Helpful’ (n=8, 54%) or ‘Extremely Helpful’ (n=7, 47%) in each of their consultations, and that it improved engagement with 80% of patients, allowed them to spend more time gaining understanding of the conditions of 93% of patients, and enhanced productivity in 73% of consultations. The GP strongly agreed that collecting PCVSA data before appointments would benefit patients over time. Qualitative interviews with practice staff yielded three themes: (1) Improved patient engagement and efficient consultation, (2) Time-saving potential, and (3) Practicing in general practice and associated challenges. CONCLUSIONS The PCVSA pilot showed good feasibility and acceptability as indicated by high participant engagement, short PCVSA and GP visit times (albeit GP visit times did not measure non-patient facing clinical activity), and positive feedback from patients and staff. Introducing PCVSA in healthcare settings may have potential in terms of improving the standard and efficiency of care. CLINICALTRIAL N/A