Search

The complex compositional space of high entropy alloys (HEAs) has shown a great potential to reduce the cost and further increase the catalytic activity for hydrogen evolution reaction (HER) by compositional optimization. Without uncovering the specifics of the HER mechanism on a given HEA surface, it is unfeasible to apply compositional modifications to enhance the performance and save costs. In this work, a combination of density functional theory and Bayesian machine learning is used to demonstrate the unique catalytic mechanism of IrPdPtRhRu HEA catalysts for HER. At high coverage of underpotential-deposited hydrogen, a d-band investigation of the active sites of the HEA surface is conducted to elucidate the superior catalytic performance through electronic interactions between elements. At low coverage, a novel Bayesian learning with oversampling approach is then outlined to optimize the HEA composition for performance improvement and cost reduction. This approach proves more efficacious and efficient and yields higher-quality structures with less training set bias compared with neural-network optimization. The proposed HEA optimization theoretically outperforms benchmark Pt catalysts' overpotential by ≈40% at a 15% reduced synthesis cost comparing to the equiatomic ratio HEA., (© 2024 The Author(s). Small Methods published by Wiley‐VCH GmbH.)

Background: Artificial intelligence (AI) has been increasingly recognized as a potential solution to address mental health service challenges by automating tasks and providing new forms of support., Objective: This study is the first in a series which aims to estimate the current rates of AI technology use as well as perceived benefits, harms, and risks experienced by community members (CMs) and mental health professionals (MHPs)., Methods: This study involved 2 web-based surveys conducted in Australia. The surveys collected data on demographics, technology comfort, attitudes toward AI, specific AI use cases, and experiences of benefits and harms from AI use. Descriptive statistics were calculated, and thematic analysis of open-ended responses were conducted., Results: The final sample consisted of 107 CMs and 86 MHPs. General attitudes toward AI varied, with CMs reporting neutral and MHPs reporting more positive attitudes. Regarding AI usage, 28% (30/108) of CMs used AI, primarily for quick support (18/30, 60%) and as a personal therapist (14/30, 47%). Among MHPs, 43% (37/86) used AI; mostly for research (24/37, 65%) and report writing (20/37, 54%). While the majority found AI to be generally beneficial (23/30, 77% of CMs and 34/37, 92% of MHPs), specific harms and concerns were experienced by 47% (14/30) of CMs and 51% (19/37) of MHPs. There was an equal mix of positive and negative sentiment toward the future of AI in mental health care in open feedback., Conclusions: Commercial AI tools are increasingly being used by CMs and MHPs. Respondents believe AI will offer future advantages for mental health care in terms of accessibility, cost reduction, personalization, and work efficiency. However, they were equally concerned about reducing human connection, ethics, privacy and regulation, medical errors, potential for misuse, and data security. Despite the immense potential, integration into mental health systems must be approached with caution, addressing legal and ethical concerns while developing safeguards to mitigate potential harms. Future surveys are planned to track use and acceptability of AI and associated issues over time., (© Shane Cross, Imogen Bell, Jennifer Nicholas, Lee Valentine, Shaminka Mangelsdorf, Simon Baker, Nick Titov, Mario Alvarez-Jimenez. Originally published in JMIR Mental Health (https://mental.jmir.org).)

Introduction: Development of technical skills is a vital component of surgical residency. The use of animal tissues for operative simulation leads to both the loss of animal life and financial costs for the institution. We hypothesized that maximizing tissue use from investigational large animal models after euthanasia could reduce loss of animal life and institutional costs by replacing commercially purchased tissues., Methods: After animal euthanization, a resident and medical student team harvested porcine tissue commonly used for surgical simulation: abdominal wall, kidney, heart, spleen, and small intestine. Tissues were vacuum-sealed and frozen for future educational use. Outcomes of harvest yield and time and estimated commercial pricing of harvested porcine tissues were analyzed., Results: Three timed procurements were performed with decreasing operative times (36:30, 34:00, and 30:54) and increasing harvest yields (100 cm, 160 cm, and 200 cm small bowel). Procurements were conducted within 15 min of animal euthanization. Harvested tissue was considered to be of similar quality to commercially purchased tissue. Estimated cost of procured tissues from a commercial vendor was $847 compared to $109 for direct procurement from euthanized porcine models., Conclusions: Maximizing tissue use from large animal research models is an innovative approach to adhering to the three Rs of animal research: replace, reduce, and refine. Tissue procurement provides valuable tissues for resident education and simulation, increases surgical trainee operative exposure, and decreases institutional costs., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Outpatient surgery in gynaecology may offer advantages including cost reduction, patient convenience and hospital bed optimisation without compromising patient safety and satisfaction. With the continual rise in health costs since 2000, outpatient surgery could be a line of action to improve financial resource utilisation and a solution for continuing to treat patients during crises such as the coronavirus disease 2019 pandemic., Objective: This systematic review provides an overview of the literature on minimally invasive outpatient hysterectomy for benign indications., Method: A focused systematic review of the medical literature between 2018 and 2022 on outpatient gynaecological surgery for a benign indication was conducted using the PubMed and Google Scholar search engines. We then narrowed our selection to articles that referred to hysterectomy. Successful same-day discharge (SDD) was defined as the patient's return home on the day of the procedure without an overnight stay., Results: Fifteen articles that focused on minimally invasive surgery were included in this review. Most of the studies (n = 11) were conducted in the United States. Outpatient surgery had a mean success rate of 60 % and a mean readmission rate of 3 %. The main reasons for SDD failure were patient choice, failed voiding, the need for pain management, nausea or vomiting, or both and the late timing of surgery. SDD was not associated with more complications and readmissions compared with inpatient care. The three main attribute predictors of SDD were young age, early timing of surgery and short total operative time. Patient satisfaction with SDD was high in absolute terms and relative to satisfaction with hospitalisation., Conclusion: Minimally invasive outpatient hysterectomy for a benign indication is feasible and safe but is associated with a notable risk of failure. To increase the success rate of outpatient management, patients must be well selected and surgery pathways must be planned in advance. The implementation of enhanced recovery protocols may help promote outpatient hysterectomy for a benign indication., Competing Interests: Declaration of competing interest No financial disclosures, (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

We use Benford's law to examine the non-random elements of health care costs. We find that as health care expenditures increase, the conformity to the expected distribution of naturally occurring numbers worsens, indicating a tendency towards inefficient treatment. Government insurers follow Benford's law better than private insurers indicating more efficient treatment. Surprisingly, self-insured patients suffer the most from non-clinical cost factors. We suggest that cost saving efforts to reduce non-clinical expenses should be focused on more severe, costly encounters. Doing so focuses cost reduction efforts on less than 10% of encounters that constitute over 70% of dollars spent on health care treatment.

Background Surgical tray rationalization involves minimizing surgical equipment to reduce operating theater expenses. This study aims to assess whether rationalization of surgical trays is possible in a staged bilateral total hip or total knee replacement by utilizing the first surgical tray as a reference. Methodology A retrospective analysis was conducted of a consecutive cohort of staged bilateral lower limb arthroplasties from August 2009 to February 2020. The staged procedures were performed by the same surgeon using the same technique and the same implant system between the sides. Results A total of 442 out of 511 consecutive staged lower limb arthroplasties were included. For bilateral total knee replacements (BTKRs), 146 joints were operated on in 73 patients. The mean interval between sides was 28 months. Overall, 72/73 (98.6%) patients had both tibial and femoral components that were within one size of the first side operated on. For bilateral total hip replacements (BTHRs), 296 joints were operated on in 148 patients. The time interval between sides was 24 months. Overall, 140/148 (94.6%) patients had an acetabular cup size that was within a one-size difference between the first and second-side surgery. Regarding differences in femoral stem sizes, 130/148 (87.8%) had an implant that was again within a one-size difference between the first and second-side surgery. Our results demonstrated that the rationalization of surgical trays can be adopted for patients who have implants that are within one size of the first side operated on in both BTKRs and BTHRs. This has the potential to reduce costs by £159.81 and £151.26 per case, respectively. Conclusions This cohort study confirms implant sizes used for first-side surgery are a reliable predictor for those used in second-side surgery in staged bilateral lower limb arthroplasty. Used in conjunction with preoperative templating, the surgical team can confidently rationalize surgical trays, thereby improving theater efficiency and decreasing sterilization costs., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Boktor et al.)

The abstract highlights the global issue of environmental contamination caused by organic compounds and the exploration of various methods for its resolution. One such approach involves the utilization of titanium dioxide (TiO 2 ) as a photocatalyst in conjunction with natural adsorption materials like kaolin. The study employed a modeling-based approach to investigate the sustainable photocatalytic degradation of acidic dyes using a Jordanian nano-kaolin-TiO 2 composite material and solar energy. Mechanistic insights were gained through the identification of the dominant reactive oxygen species (ROS) involved in the degradation process, as well as the synergetic effect between adsorption and photocatalysis. The Jordanian nano-kaolin-TiO 2 composite was synthesized using the sol-gel method and characterized. The nanocomposite photocatalyst exhibited particle sizes ranging from 27 to 41 nm, with the TiO 2 nanoparticles well-dispersed within the kaolin matrix. The efficacy of this nanocomposite in removing Congo-red dye was investigated under various conditions, including pH, initial dye concentration, and photocatalyst amount. The optimal conditions for dye removal were found to be at pH 5, with an initial dye concentration of 20 ppm, and using 0.1 g of photocatalyst, resulting in a 95 % removal efficiency. The mechanistic insights gained from this study indicate that the hydroxyl radicals (•OH) generated during the photocatalytic process play a dominant role in the degradation of the acidic dye. Furthermore, the synergetic effect between the adsorption of the dye molecules onto the photocatalyst surface and the subsequent photocatalytic degradation by the ROS was found to enhance the overall removal efficiency. These findings contribute to the fundamental understanding of the photodegradation mechanisms and guide the development of more efficient photocatalytic systems for the treatment of acidic dye-containing wastewater. The use of solar power during the purification procedure also leads to cost reduction and strengthens sustainability efforts., Competing Interests: The authors declare no conflicts of interest. This research has been funded by Scientific Research Deanship at University of Hail-Saudi Arabia through project number RG-23 199., (© 2024 The Authors.)

Background: Aligned with the Health Sector Transformation Strategy of Saudi Vision 2030, the study analyzed the attitudes and behaviors of cardiologists toward change and identified factors that could either facilitate or hinder the success of leadership interventions. At our cardiac center, the cath lab department is at the forefront of operations, accounting for 80% of the procedures. Our team members may not be fully equipped with the necessary attitudes and behaviors to drive successful improvement projects. Therefore, our top priority is ensuring they remain productive and engaged throughout the process. This is especially crucial because 60% of our budget is allocated to the cath lab department., Objectives: The study aimed to assess the effectiveness of a leadership intervention on cardiologists' performance in terms of safety, speed, and cost. The research analyzed the behavior and attitude of cardiologists towards change and encouraged progress and collaborative learning between doctors, using benchmarking as a tool. Besides, the study sought to determine the contribution of the interventions used to overall efficiency in performing interventions. This case study focuses on four main aspects of the program. First, it aims to explore an innovative approach to improving the PSCCQ cath lab for patients. Second, it assesses the collective effort of all participants involved in the program. Third, it analyzes the program results and compares them with those of international experiences. And finally, it examines the program's potential benefits for our patients., Methods: The study's objectives were evaluated through qualitative analysis of in-depth interviews and quantitative data analysis of three variables in the cath lab: radiation dose, time, and inventory. The reason for using mixed methods was to comprehensively understand the same concept from different angles., Results: According to the study, participants improved the safety and effectiveness of our cath lab by reducing the radiation dose and its cost. The study revealed a 52% decrease in the radiation dose for diagnostic cases and an 11% decrease for interventional cases. Similarly, the cost of the radiation dose decreased by 28% for diagnostic cases and 11% for interventional cases. During the observation, it was noted that the participants were highly engaged and willing to adapt to the situation. Some even viewed it as an opportunity for personal growth and improvement in the cath lab. However, they stressed the significance of awareness as a crucial element in improving their behavior and reinforcing it as the foundation for maintaining progress. Furthermore, the study revealed that collaborative work among the participants could have been more optimal., Conclusion: The study concludes that implementing innovative improvements to the cath lab was a necessary yet complex undertaking. Participants were more inclined to embrace the changes when they were easily understandable and motivating. The study recommends the appointment of a change agent, the establishment of benchmarks, and the creation of a collaborative working environment between leaders and staff. Above all, the leader should support and sponsor the change to facilitate the transition at various levels., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Prince Sultan Cardiac Center Qassim Research Ethics Committee issued approval 19-1509. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, almesned et al.)

Objective: To describe a simple variation of burr hole craniostomy for the management of chronic subdural hematoma (CSDH) that uses a frontal drainage system to facilitate timely decompression in the event of tension pneumocephalus and spares the need for additional surgery., Methods: We conducted a retrospective analysis of 20 patients with CSDH who underwent burr hole craniostomy and 20 patients who underwent the same procedure alongside the placement of a 5 Fr neonatal feeding tube as a backup drainage for the anterior craniostomy. Depending on the situation, the secondary drain stayed for a maximum of 72 hours to be opened and used in emergency settings for drainage, aspiration, or as a 1-way valve with a water seal., Results: The outcomes of 20 patients who underwent this procedure and 20 controls are described. One patient from each group presented tension pneumocephalus. One was promptly resolved by opening the backup drain under a water seal to evacuate pneumocephalus and the other patient had to undergo a reopening of the craniostomy., Conclusions: The described variation of burr hole craniostomy represents a low-cost and easy-to-implement technique that can be used for emergency decompression of tension pneumocephalus. It also has the potential to reduce reoperation rates and CSDH recurrence. Prospective controlled research is needed to validate this approach further., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Respiratory syncytial virus (RSV) poses a significant risk to children under two years old, necessitating rapid and accurate diagnostic methods. This study introduces an innovative approach using peptides and electrochemical potential scanning for RSV detection. By replacing enzymatic catalysis with electrochemical scanning, the method simplifies the process and reduces costs. Unbound peptides undergo potential-induced disulfide bridge opening, while target-bound peptides remain protected. After removing the target protein, copper ions and a reduced short peptide promote disulfide bridge formation, leading to crosslinking and passivation of the electrode surface. The degree of polymerization and passivation correlates with the target protein levels, generating a signal. This novel method offers enhanced sensitivity, specificity, and scalability, potentially revolutionizing RSV diagnostics in children under two years old. By addressing the limitations of traditional assays, it provides a cost-effective, rapid, and efficient approach for early RSV detection and improved clinical outcomes in this vulnerable population., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: To segregate imaging expenditures from claims data by resource utilization bands (RUBs) and underlying conditions to create an "expenditure map" of pediatric imaging costs., Methods: A Claims data for children enrolled in a commercial value-based plan were categorized by RUB 0 non-user, 1 healthy user, 2 low morbidity, 3 moderate morbidity, 4 high morbidity, & 5 very high morbidity. The per member per year (PMPY) expense, total imaging spend, and imaging modality with the highest spend were assessed for each RUB. Diagnosis categories associated with high imaging costs were also evaluated., Results: There were 40,022 pediatric plan members. 14% had imaging-related claims accounting for approximately $2.8 million in expenditures. Member distribution and mean PMPY expenditure RUB was respectively: RUB 0 (3,037, $0), RUB 1 (6,604, $7), RUB 2 - 13,698, $27), RUB 3 - 13,341, $87), RUB 4 (2,810, $268), RUB 5 (532, $841). RUB 3 had the largest total imaging costs at $1,159,523. The imaging modality with the greatest mean PMPY expense varied by RUB with radiography highest in lower RUBs and MRI highest in higher RUBs. The top 3 diagnoses associated with the highest total imaging costs were developmental disorders ($443,980), asthma ($388,797), and congenital heart disease ($294,977) and greatest mean PMPY imaging expenditures malignancy/leukemia ($3,100), transplant ($2,639), and tracheostomy ($1,661)., Discussion: Expense mapping using claims data allows for a better understanding of the distribution of imaging costs across a covered pediatric population. This tool may assist organizations in planning effective cost-reduction initiatives and learning how imaging utilization varies by patient complexity in their system., Competing Interests: Declarations of Competing Interest None., (Copyright © 2024. Published by Elsevier Inc.)

Introduction The impact of the current economic and environmental climate, both nationally and globally, is further straining the NHS. This has led to scrutiny of high-expenditure areas, including consumables. Clinician's knowledge surrounding health economics is sparse, and we conducted this survey to assess cost-awareness within the Trauma and Orthopaedic (T&O) departmental staff. Methods A questionnaire was digitally distributed to T&O staff in the East Kent Hospitals Trust. This included demographic data and to make estimations of the cost of 10 specialty-specific items. The data were analysed to determine the average, median, and interquartile range (IQR) of the estimated prices and compared to the actual costs. Results Approximately 7.1% of all item estimates were deemed 'correct'. No correlation was seen between years of staff experience and the accuracy of estimates. 'Kenalog 1 mL ampoule' (Kenalog, Bristol-Myers Squibb, NJ) had the highest accuracy of estimation across all responses (13%), whilst both 'kirschner wires' and '3.2 drill bit' had the lowest accuracy (4% each). The median estimated cost was closest to the actual cost for 'cement pack' (median estimate/actual cost = 0.9). The median estimated cost was furthest from the actual cost for 'tourniquet cuffs' (median estimate/actual cost = 0.16). 'Velcro wrist splint' was the item that was the most overestimated (median estimate/actual cost = 1.57), with only two of the 10 items being overestimated ('velcro wrist splint' and 'dynamic hip screw and plate'). The most underestimated item was 'tourniquet cuffs' (median estimate/actual cost = 0.16). Conclusions There is a paucity of knowledge surrounding the cost of specialist T&O consumables. The limitations included the sample size (98 respondents) and geographical area (East Kent Hospitals Trust). This study shows that there is a need for further research into this topic, with long-term outcomes, which may be beneficial both economically and environmentally., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. East Kent Hospitals University NHS Foundation Trust issued approval RN7720007. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Divekar et al.)

This study investigates the potential benefits of integrating coarser particle size distributions (PSDs) of 45-106 µm into laser-based powder bed fusion of metals (PBF-LB/M), aiming to reduce costs while maintaining quality standards. Despite the considerable advantages of PBF-LB/M for producing intricate geometries with high precision, the high cost of metal powders remains a barrier to its widespread adoption. By exploring the use of coarser PSDs, particularly from electron beam-based powder bed fusion of metals (PBF-EB/M), significant cost-saving opportunities are identified. Through a comprehensive powder characterization, process analysis, and mechanical property evaluation, this study demonstrates that PBF-LB/M can effectively utilize coarser powders while achieving comparable mechanical properties as those produced with a 20-53 µm PSD. Adaptations to the process parameters enable the successful processing of coarser powders, maintaining high relative density components with minimal porosity. Additionally, market surveys reveal substantial cost differentials between PBF-LB/M and PBF-EB/M powders, indicating a 40% cost reduction potential for the feedstock material by integrating coarser PSDs into PBF-LB/M. Overall, this study provides valuable insights into the economic and technical feasibility of printing with coarser powders in PBF-LB/M, offering promising avenues for cost reduction without compromising quality, thus enhancing competitiveness and the adoption of the technology in manufacturing applications.

Background: Telemedicine offers a multitude of potential advantages, such as enhanced health care accessibility, cost reduction, and improved patient outcomes. The significance of telemedicine has been underscored by the COVID-19 pandemic, as it plays a crucial role in maintaining uninterrupted care while minimizing the risk of viral exposure. However, the adoption and implementation of telemedicine have been relatively sluggish in certain areas. Assessing the level of interest in telemedicine can provide valuable insights into areas that require enhancement., Objective: The aim of this study is to provide a comprehensive analysis of the level of public and research interest in telemedicine from 2017 to 2022 and also consider any potential impact of the COVID-19 pandemic., Methods: Google Trends data were retrieved using the search topics "telemedicine" or "e-health" to assess public interest, geographic distribution, and trends through a joinpoint regression analysis. Bibliographic data from Scopus were used to chart publications referencing the terms "telemedicine" or "eHealth" (in the title, abstract, and keywords) in terms of scientific production, key countries, and prominent keywords, as well as collaboration and co-occurrence networks., Results: Worldwide, telemedicine generated higher mean public interest (relative search volume=26.3%) compared to eHealth (relative search volume=17.6%). Interest in telemedicine remained stable until January 2020, experienced a sudden surge (monthly percent change=95.7%) peaking in April 2020, followed by a decline (monthly percent change=-22.7%) until August 2020, and then returned to stability. A similar trend was noted in the public interest regarding eHealth. Chile, Australia, Canada, and the United States had the greatest public interest in telemedicine. In these countries, moderate to strong correlations were evident between Google Trends and COVID-19 data (ie, new cases, new deaths, and hospitalized patients). Examining 19,539 original medical articles in the Scopus database unveiled a substantial rise in telemedicine-related publications, showing a total increase of 201.5% from 2017 to 2022 and an average annual growth rate of 24.7%. The most significant surge occurred between 2019 and 2020. Notably, the majority of the publications originated from a single country, with 20.8% involving international coauthorships. As the most productive country, the United States led a cluster that included Canada and Australia as well. European, Asian, and Latin American countries made up the remaining 3 clusters. The co-occurrence network categorized prevalent keywords into 2 clusters, the first cluster primarily focused on applying eHealth, mobile health (mHealth), or digital health to noncommunicable or chronic diseases; the second cluster was centered around the application of telemedicine and telehealth within the context of the COVID-19 pandemic., Conclusions: Our analysis of search and bibliographic data over time and across regions allows us to gauge the interest in this topic, offer evidence regarding potential applications, and pinpoint areas for additional research and awareness-raising initiatives., (©Andrea Maugeri, Martina Barchitta, Guido Basile, Antonella Agodi. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 16.05.2024.)

The jumbo drill is a commonly used driving equipment in tunnel engineering. One of the key decision-making issues for reducing tunnel construction costs is to optimize the main driving parameters to increase the feed speed of the jumbo drill. The optimization of the driving parameters is supposed to meet the requirements of high reliability and efficiency due to the high risk and complex working conditions in tunnel engineering. The flaws of the existing optimization algorithms for driving parameter optimization lie in the low accuracy of the evaluation functions under complex working conditions and the low efficiency of the algorithms. To address the above problems, a driving parameter optimization method based on the XGBoost-DRWIACO framework with high accuracy and efficiency is proposed. A data-driven prediction model for feed speed based on XGBoost is established as the evaluation function, which has high accuracy under complex working conditions and ensures the high reliability of the optimized results. Meanwhile, an improved ant colony algorithm based on dimension reduction while iterating strategy (DRWIACO) is proposed. DRWIACO is supposed to improve efficiency by resolving inefficient iterations of the ant colony algorithm (ACO), which is manifested as falling into local optimum, converging slowly and converging with a slight fluctuation in a certain dimension. Experimental results show that the error by the proposed framework is less than 10%, and the efficiency is increased by over 30% compared with the comparison methods, which meets the requirements of high reliability and efficiency for tunnel construction. More importantly, the construction cost is reduced by 19% compared with the actual feed speed, which improves the economic benefits.

Introduction: Therapeutic plasma exchange (TPE) is used to manage various life-threatening illnesses. It is widely performed by nephrologists, intensivists, pathologists, or experts in transfusion medicine worldwide. However, the costs of TPE sessions are exceedingly high, and they have a huge impact on patients' financial burden. Herein, we investigated the outcomes of the reuse of plasma filters in TPE on several occasions., Methods: This is a retrospective analysis of patients receiving TPE from January 1, 2020, to April 30, 2023, in the Department of Nephrology. A formulation of 4.5% peracetic acid and 24% hydrogen peroxide acid with RO water dilution was used for reprocessing. Clinical outcomes, risks, and cost-benefit were evaluated and compared between the plasma filter reuse group (GP-1) and the no-reuse group (GP-2)., Results: A total of 70 patients were included in this study. 200 and 112 TPE sessions were performed in GP-1 and GP-2, respectively. The most common indication for TPE in both groups was neurological. The clinical efficacy of TPE was similar in both groups. There was no difference in the clotting of the plasma filter, any allergic reaction, infection, or bleeding in the group. However, there was a significant difference in levels of fibrinogen (p=0.03) pre and post-procedure in both groups. The incidence of hypotension was found to be higher in GP-1 (26%) compared to GP-2 (15.6%), p = 0.05. The cost of overall treatment was 38% less in GP-1., Conclusion: The reuse of plasma filters is a safe and effective method for cost minimization in patients requiring TPE. This method can be effectively utilized in resource-poor settings without any increased risk of adverse effects., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Meena et al.)

This study investigated the purification of bromelain obtained from pineapple fruit using a new adsorbent for immobilized metal ion affinity chromatography (IMAC), with chlorophyll obtained from plant leaves as a chelating agent. The purification of bromelain was evaluated in batches from the crude extract of pineapple pulp (EXT), and the extract precipitated with 50 % ammonium sulfate (EXT.PR), the imidazole buffer (200 mM, pH 7.2) being analyzed and sodium acetate buffer, pH 5.0 + 1.0 NaCl as elution solutions. All methods tested could separate forms of bromelain with molecular weights between ±21 to 25 kDa. Although the technique using EXT.PR stood out in terms of purity, presenting a purification factor of around 3.09 ± 0.31 for elution with imidazole and 4.23 ± 0.12 for acetate buffer solution. In contrast, the EXT methods obtained values between 2.44 ± 0.23 and 3.21 ± 0.74 for elution with imidazole and acetate buffer, respectively, for purification from EXT.PR has lower yield values (around 5 %) than EXT (around 15 %). The number of steps tends to reduce yield and increase process costs, so the purification process in a monolithic bed coupled to the chromatographic system using the crude extract was evaluated. The final product obtained had a purification factor of 6, with a specific enzymatic activity of 59.61 ± 0.00 U·mg -1 and a yield of around 39 %, with only one band observed in the SDS-PAGE electrophoresis analysis, indicating that the matrix produced can separate specific proteins from the total fraction in the raw material. The IMAC matrix immobilized with chlorophyll proved promising and viable for application in protease purification processes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

In critically ill patients with acute respiratory failure, thoracic images are essential for evaluating the nature, extent and progression of the disease, and for clinical management decisions. For this purpose, computed tomography (CT) is the gold standard. However, transporting patients to the radiology suite and exposure to ionized radiation limit its use. Furthermore, a CT scan is a static diagnostic exam for the thorax, not allowing, for example, appreciation of "lung sliding". Its use is also unsuitable when it is necessary to adapt or decide to modify mechanical ventilation parameters at the bedside in real-time. Therefore, chest X-ray and lung ultrasound are today's contenders for shared second place on the podium to acquire a thoracic image, with their specific strengths and limitations. Finally, electrical impedance tomography (EIT) could soon have a role, however, its assessment is outside the scope of this review. Thus, we aim to carry out the following points: (1) analyze the advancement in knowledge of lung ultrasound use and the related main protocols adopted in intensive care units (ICUs) over the latest 30 years, reporting the principal publications along the way, (2) discuss how and when lung ultrasound should be used in a modern ICU and (3) illustrate the possible future development of LUS., (© 2024. The Author(s).)

To evaluate the usefulness of robot-assisted total laparoscopic hysterectomy with four equally-spaced ports (RA-TLH/4e) without an assistant port. In RA-TLH/4e, four da Vinci ports were placed horizontally at a height of 4 cm above the umbilicus with 8 cm equal spacing. Poor development of the surgical field or difficult forceps manipulations were handled with the endoscope and forceps movement (port-hopping). Patient background, surgical outcomes, complications, port-hopping frequency were compared in three groups: RA-TLH/4e, RA-TLH with four unequally-spaced ports (RA-TLH/4u), and conventional RA-TLH with five ports (RA-TLH/5). There were no significant differences in patient background or surgical outcomes among the three groups except for age, preparation time, and hospital stay, and no cases of laparotomy conversion or serious complications. RA-TLH/4e had fewer port-hoppings than RA-TLH/4u. The minimum abdominal width showed a weak negative correlation with port-hopping frequency in RA-TLH/4u, but not in RA-TLH/4e. RA-TLH/4e allowed for a reduction in personnel and costs compared to RA-TLH/5. The equal placement of four ports allowed sufficient port spacing even for patients with narrow abdominal widths. In addition, the port-hopping technique was able to fully compensate for the lack of an assistant port. RA-TLH/4e is a highly useful technique that not only excels in safety but also reduces costs., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Companies dedicated to the large-scale propagation of plant species are known as biofactories or agricultural biotechnology companies. Globally, there are a large number of biofactories (large-scale production) or plant tissue culture laboratories (small-scale production) in charge of supplying commercial propagules of plants of economic interest. Each biofactory implements technological developments such as temporary immersion (TIS) systems that allow them to reduce costs. This chapter analyzes some of the biofactories established globally, the main plant species propagated, and whether or not they implement the use of TIS., (© 2024. The Author(s), under exclusive license to Springer Science+Business Media, LLC, part of Springer Nature.)

Aim: Each year, approximately 25,000 patients present to NHS hospitals in the UK with epistaxis. This study aims to investigate the financial implications of epistaxis, focusing on cases managed conservatively. Specifically, the research explores the average cost of hospital bed stays, the length of hospitalization, and the impact of blood thinners on healthcare expenses.  Methods: A retrospective study spanning June 2022 to June 2023 collected data from electronic health records at our local district general hospital. Patients meeting inclusion criteria were analyzed for demographic information, duration of hospital stay, use of blood thinners, and outcomes. Statistical software (SAS and Excel) was used for data analysis., Results: Out of 126 patients, conservatively managed epistaxis cases (n = 119) had an average age of 73.9 years, with 53.6% males. The mortality rate was 4.5%. The average hospital stay was 2.92 days. Approximately 57% of patients were taking blood thinners. The average cost of a hospital bed stay for epistaxis patients was £1,712.84, with a £259.69 difference between those on blood thinners and those not., Conclusion: Epistaxis imposes a significant financial burden on hospitals, with conservatively managed cases incurring substantial costs. Recognizing and addressing the financial implications of epistaxis is essential for healthcare providers and policymakers. Investment in preventative medicine and patient education can potentially reduce the incidence of epistaxis and alleviate the financial burden on healthcare systems., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Elamin et al.)

Introduction: Virtual fracture clinics (VFC) involve a consultant-led multidisciplinary team meeting where cases are reviewed before a telephone consultation with the patient. VFCs have the advantages of reducing waiting times, outpatient appointments and time off school compared to face-to-face (F2F) fracture clinics. There has been a surge in VFC use since the COVID-19 pandemic but there are still concerns over safety in the paediatric population. Fractures make up a large burden of paediatric injuries, therefore research is required on the safety and efficacy of paediatric VFCs. This systematic review will look at the safety and effectiveness of paediatric VFCs, as well as determine the cost-effectiveness and parent preferences., Methods: As per the PRISMA guidelines two independent reviewers searched the following databases: Medline, Embase and Web of Science. Studies were included if children under 18 years old presented to A&E with a suspected or confirmed simple un-displaced fracture and were referred to a VFC. The primary outcomes assessed were effectiveness and safety, with the secondary outcomes of cost-effectiveness and parent satisfaction., Results: Six studies met the inclusion criteria for this systematic review. There was a high rate of direct discharge from the VFC leading to reduced outpatient appointments. All patients were seen within 72 h of presentation. There were limited incidences of missed fractures and the rates of re-presentation were similar to that of F2F orthopaedic clinics. There were significant cost savings for the hospitals and high parent satisfaction., Discussion: VFCs have shown to be safe and effective at managing most stable, low operative risk paediatric fractures. Safety must be ensured with a telephone helpline and an open return to fracture clinic policy. More research is needed into specific paediatric fracture types to be managed in the VFC., Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#searchadvanced, identifier: CRD42023423795., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (© 2023 Waite and Ahmed.)

Operating room (OR) turnover time (TOT) is the time it takes to prepare an OR for the next surgery after the previous one has been completed. Reducing OR TOT can improve the efficiency of the OR, reduce costs, and improve surgeons' and patients' satisfaction. The objective of this study is to evaluate the effectiveness of an operating room (OR) turnover time (TOT) reduction initiative using the Lean Six Sigma methodology (DMAIC) in the bariatric and thoracic service lines. Performance improvement strategies consist of simplifying steps (surgical tray optimization) and concurrent steps (parallel task execution). We compared 2-month pre-implementation vs. post-implementation. A paired t-test was used to assess whether the difference in the measurements was statistically significant. The study found that TOT was reduced by 15.6% from an average of 35.6 ± 8.1 to minutes 30.09 ± 9.7 min (p < 0.05). Specifically, in the bariatric service line, TOT was reduced by 17.15% and in the thoracic service line, TOT was reduced by 9.6%. No adverse events related to the initiative were reported. The results of this study indicate that the TOT reduction initiative was effective in reducing TOT. The efficient use of operating rooms is crucial in hospital management, as it not only impacts finances but also affects the satisfaction of surgical teams and patients. This study shows the effectiveness of Lean Six Sigma methodology in reducing TOT and improving the efficiency in the OR., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: The Friedewald formula (FF) was originally designed 50 years ago and has been in use to this day despite better methods for estimating LDL cholesterol (LDL-C). Its success was mainly due to its simplicity. Nowadays most laboratories determine or can determine LDL-C by the direct method. The SCORE2 tables, recommended by the European Society of Cardiology, are based on non-HDL cholesterol (non-HDL-C). To calculate its value, one needs to know the values of total cholesterol (TC) and HDL-C. The presented idea is to use the FF to calculate non-HDL-C based on the values of LDL-C and TG instead of TC and HDL-C., Methods and Findings: Based on database of 26,914 laboratory results, covering the complete lipid panel, the error regarding non-HDL-C values calculated in both ways (recommended and proposed) was determined. The average error in the LDL-C value calculated with the FF compared to the LDL-C value measured in the laboratory is 9.77%, while for non-HDL-C the error between the calculated and laboratory-determined value amounts to 8.88%. The proposed transformation of the FF also yields a much lower percentage of error calculations. Both LDL-C and non-HDL-C (calculated) in our material are strongly correlated with LDL-C and non-HDL-C (measured) values of r  = 0.965 ( p  < 0.000) and r  = 0.962 ( p  < 0.000), respectively., Conclusion: Non-HDL-C may be calculated based on the values of LDL-C and TG (without the need to determine the levels of TC and HDL-C). The proposed calculation may greatly reduce the cost of testing, given the price of a complete lipid profile., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Romaszko, Gromadziński and Buciński.)

Background: There are nonestablished protocols in use for first-line allergy screening based on IgE testing. These protocols attempt to address an unmet need for sustainability of clinical laboratories, at a time when demand is increasing., Objective: To present a novel protocol for first-line allergy screening and to evaluate the implementation benefits for patients, the health care system, and payers., Methods: We carried out an observational retrospective study analyzing 4359 interventions on primary care testing requests. Interventions included overriding redundant serum IgE (sIgE) testing for allergen mixes, extracts included in mixes, low-prevalence extracts, and milk and egg molecular components without previous positive results when exposed to extracts. We also added prevalent allergen testing., Results: The strategy saved 683 tests from being performed unnecessarily. Test volume decline was primarily driven by the cancelation of 2186 egg and milk components tests; 561 tests were added for mixes, together with 942 allergen extracts tests., Discussion: The results of this study show how the allergy laboratory plays a key role in actively managing demand for sIgE testing, leading to optimized diagnosis., (© The Author(s) 2023. Published by Oxford University Press on behalf of American Society for Clinical Pathology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Appendiceal stump leak rate after laparoscopic appendectomy is extremely low. Various methods are used to close the appendiceal stump. This study aimed to compare the outcome of three appendiceal stump closure methods., Methods: A retrospective study comparing stump closure methods and postoperative outcomes was conducted from January 2018 to June 2020. Patient data included demographics, pre-operative data, surgical technique, findings, and postoperative complications., Results: Out of 1021 appendectomy patients, 733 underwent laparoscopic appendectomy for acute appendicitis utilizing one of the three compared appendiceal stump closure methods. Consequently, 360 appendixes were ligated with one endoloop (1EL group), 300 appendixes had two endoloops (2EL group), and 73 appendixes were ligated with two endoclips (2EC group). All groups used a LigaSure for resection. The rate of postoperative intra-abdominal abscess was 1% (4 patients) in 1EL group vs. 1% (3 patients) in 2EL group vs. none in 2EC group (p = 0.43). There were no reported appendiceal stump leaks. Overall complication rates were 4% (14 patients), 3% (9 patients), and 0 (p = 0.15), and the mean operative length was 43 ± 21, 54 ± 22, and 43 ± 20 mins for the 1EL, 2EL, and 2EC, respectively (p < 0.01). Average cost of one endoloop is 110$, and one endoclip cartridge is 180$., Conclusions: None of the methods were found clinically superior over the others. Considering the low and mild complication rate, it appears reasonable to prefer one method simply by cost. The use of a single endoloop may result in substantial cost reduction. Medical centers may advise surgeons to use a single-endoloop technique., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Harnessing the immune system to combat disease has revolutionized medical treatment. Monoclonal antibodies (mAbs), in particular, have emerged as important immunotherapeutic agents with clinical relevance in treating a wide range of diseases, including allergies, autoimmune diseases, neurodegenerative disorders, cancer, and infectious diseases. These mAbs are developed from naturally occurring antibodies and target specific epitopes of single molecules, minimizing off-target effects. Antibodies can also be designed to target particular pathogens or modulate immune function by activating or suppressing certain pathways. Despite their benefit for patients, the production and administration of monoclonal antibody therapeutics are laborious, costly, and time-consuming. Administration often requires inpatient stays and repeated dosing to maintain therapeutic levels, limiting their use in underserved populations and developing countries. Researchers are developing alternate methods to deliver monoclonal antibodies, including synthetic nucleic acid-based delivery, to overcome these limitations. These methods allow for in vivo production of monoclonal antibodies, which would significantly reduce costs and simplify administration logistics. This review explores new methods for monoclonal antibody delivery, including synthetic nucleic acids, and their potential to increase the accessibility and utility of life-saving treatments for several diseases.

Background: Inappropriate testing remains a high healthcare cost driver. Tumour marker tests are more expensive than routine chemistry testing. Implementing test demand management systems like electronic gatekeeping (EGK) has reportedly decreased test requests., Objective: This study aimed to describe the appropriateness of tumour marker tests, carcinoembryonic antigen, alpha foetal protein, prostate-specific antigen, carbohydrate antigen 19-9, cancer antigen 15-3, cancer antigen 125, and human chorionic gonadotropin, and determine the effectiveness of the EGK used in the public health sector in KwaZulu-Natal, South Africa., Methods: Tumour marker test data for the KwaZulu-Natal province were extracted from the National Health Laboratory Service Central Data Warehouse for 01 January 2017 - 30 June 2017 (pre-EGK) and 01 January 2018 - 30 June 2018 (post-EGK implementation). Questionnaires were sent to the clinicians in the regional hospitals ordering the most tumour marker tests to assess ordering practices. In addition, we assessed monthly rejection reports to determine the effect of the EGK., Results: The EGK minimally reduced tumour marker requests or associated costs (1.4% average EGK rejection rate). An overall 18% increase in the tumour marker tests occurred in 2018. The data suggest inappropriate tumour marker test utilisation, particularly for screening., Conclusion: The introduction of EGK as a test demand management had little impact on tumour marker test requests and costs. Continuous education and reiteration of indications for tumour marker test use are required., What This Study Adds: This study demonstrates the ineffectiveness of EGK in tumour marker orders, and provides some insight as to why these markers are being ordered, which is important in trying to decrease inappropriate ordering of these tests., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article, except where otherwise indicated., (© 2023. The Authors.)

Background: Implementation of an anesthesiology-led cardiac implantable electronic device (CIED) service can be viewed to have economic and efficiency challenges. This study evaluates the cost savings of an anesthesiology-led CIED service., Methods: A total of 830 patients presented in the pre-implementation period from 1 March 2016 to 31 December 2017, and 1981 patients presented in the post-implementation period from 1 January 2018 to 31 October 2021. Interrupted time-series analysis for single-group comparisons was used to evaluate the cost savings resulting from reduction in operating room (OR) start delays for patients with CIEDs., Results: OR start-time delay was reduced by 10.6 min (95%CI: -20.5 to -0.83), comparing pre- to post-implementation. For an OR cost of USD 45/min, we estimated the direct cost to the department to be USD 1.68/min. The intervention translated into a total cost reduction during the intervention period of USD 250,000 (USD 18,000 to USD 470,000) per year for the institution and USD 9800 (USD 730 to USD 17,000) per year for the department. The yearly cost of employing a full-time team of CIED specialists would have been USD 135,456. The service triggered electrophysiology consultation on 13 device malfunctions., Conclusions: An anesthesiology-led CIED service resulted in substantial cost savings, increased OR efficiency and patient safety.

While radiographs and magnetic resonance imaging (MRI) have long been used in the assessment of osteoarthritis (OA), ultrasound imaging has been rapidly accepted by musculoskeletal providers in both the assessment and treatment of OA. A limiting factor in the use of ultrasound is the proper training required by the user for results to be reliable and reproducible. A standardized ultrasound protocol can potentially address this limiting factor. The critical information to consider in a standardized protocol include proper patient positioning, probe alignment, probe orientation, and identification of the appropriate anatomic landmarks. The outlined protocol considers these factors with the purpose of providing a step-by-step method to assess and monitor knee OA., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Vomer et al.)

The implementation of a texturing pattern on the surface of a solar cell is well known for reducing reflection, thus increasing the absorption of sunlight by the solar cell. Nanowires (NWs) that are large in their height have been widely used for this purpose. Through rigorous numerical simulations, this work explores the benefits of short but index-matched NWs and how these designs are also affected by surface recombination. Additionally, this work further optimized power conversion efficiency (PCE) by placing two or three NWs of different heights and diameters on top of each other to mimic the performance of two-NW and three-NW ARC designs with PCEs of 16.8% and 17.55%, respectively, when a radial pn junction is considered. These are the highest reported so far for such a thin silicon solar cell. Furthermore, we also show how these designs were impacted by surface recombination velocity and compare these findings to simple NWs of different heights and diameters.

Sensory attributes are essential factors in determining the quality of wines. However, it can be challenging for consumers, even experts, to differentiate and quantify wines' sensory attributes for quality control. Soft sensors based on rapid chemical analysis offer a potential solution to overcome this challenge. However, the current limitation in developing soft sensors for wines is the need for a significant number of input parameters, at least 12, necessitating costly and time-consuming analyses. While such a comprehensive approach provides high accuracy in sensory quality mapping, the expensive and time-consuming studies required do not lend themselves to the industry's routine quality control activities. In this work, Box plots, Tucker-1 plots, and Principal Component Analysis (PCA) score plots were used to deal with output data (sensory attributes) to improve the model quality. More importantly, this work has identified that the number of analyses required to fully quantify by regression models and qualify by classification models can be significantly reduced. Based on regression models, only four key chemical parameters (total flavanols, total tannins, A 520nm HCl , and pH) were required to accurately predict 35 sensory attributes of a wine with R 2 values above 0.6 simultaneously. In addition, for classification models to accurately predict 35 sensory attributes of a wine at once with prediction accuracy above 70%, only four key chemical parameters (A 280nm HCl , A 520nm HCl , chemical age and pH) were required. These models with reduced chemical parameters complement each other in sensory quality mapping and provide acceptable accuracy. The application of the soft sensor based on these reduced sets of key chemical parameters translated to a potential reduction in analytical cost and labour cost of 56% for the regression model and 83% for the classification model, respectively, making these models suitable for routine quality control use., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors. Published by Elsevier B.V.)

Background: Evinacumab is a first-in-class inhibitor of angiopoietin-like protein 3 (ANGPTL3) for treatment of the rare disease homozygous familial hypercholesterolemia (HoFH). With projected drug costs of $450,000 per person per year, the question rises if cost-efficacy of evinacumab can be further improved., Objectives: To develop an individualized dosing regimen te reduce drug expenses., Methods: Using the clinical and pharmacological data as provided by the license holder, we developed an alternative dosing regimen in silico based on the principles of reduction of wastage by dosing based on weight bands rather than a linear milligram per kilogram body weight (mg/kg) dosing regimen, as well as dose individualization guided by low density lipoprotein cholesterol (LDL-C) response., Results: We found that the average quantity of drug used for a dose could be reduced by 34% without predicted loss in efficacy (LDL-C reduction 24 weeks after treatment initiation)., Conclusion: Dose reductions without compromising efficacy seem feasible. We call for implementation and prospective evaluation of this strategy to reduce treatment costs of HoFH., Competing Interests: Declarations of Competing Interest None., (Copyright © 2023. Published by Elsevier Inc.)

Background: To assess urinary symptoms and urine cytology as screening tools for cystoscopic detection of local recurrence after bladder-preserving trimodality treatment (TMT)., Methods: Patients with muscle-invasive bladder cancer receiving definitive TMT follow-up three monthly for 2 years, six monthly for the next 3 years and then yearly, with a clinical review, urine cytology and cystoscopy at each visit (triple assessment, TA). Grade 2+ cystitis/haematuria absent/present was scored 0/1, and urine cytology reported negative/suspicious or positive was scored 0/1, respectively. The performance of these two parameters for predicting local recurrence in cystoscopic biopsy was tested. Other hypothetical surveillance schedules included cystoscopy on alternate visits (COAV), or suspected recurrence (COSR), six-monthly COSR and six-monthly TA., Results: A total of 630 follow-up visits in 112 patients with 19 recurrences (7 muscle invasive, 12 non-muscle invasive) at a median follow-up of 19 months were analysed. The sensitivity and specificity of clinical symptoms were 47.4% and 92%, and for urine cytology 58% and 85%, respectively. The combination of clinical symptoms and cytology (COSR) was 95% sensitive and 78% specific for local recurrence but 100% sensitive for muscle-invasive recurrence. Both COAV and COSV schedules showed a high area under the curve (AUC) for detecting local recurrence (COAV = 0.84, COSR = 0.83), muscle-invasive recurrence (AUC = 0.848 each) and non-muscle-invasive recurrence (COAV = 0.82, COSR = 0.81); reducing the need for TAs by 64% and 67% respectively, and overall cost by 18% and 33%, respectively., Conclusion: Cystoscopy at suspected recurrence during follow-up is safe and the most cost-effective for detecting muscle-invasive local recurrences, while cystoscopy at alternate visits may be more optimal for detecting any local recurrence., (© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

This research proposes an internal organizational framework that explains why firms implement corporate social responsibility (CSR). Based on the perspective of managers in the mining sector of the Democratic Republic of Congo (DRC), wellbeing of employees and cost reduction were identified as internal driving factors of CSR. This study was carried out on a sample of 103 mining, using a structural equation through LISREL. The findings of the study reveal; first, that firms' pursuit of cost reduction positively influences the implementation of CSR; second, firms are driven by CSR in order to ensure the wellbeing of their employees, fostered by compliance with labor standards in the mining sector. Therefore, CSR compliance was included as a mediating variable. Lastly, the lack of resources remains a barrier to CSR implementation. This research adds to the growing body of literature on CSR antecedents by demonstrating that in the Congolese mining sector, CSR implementation is linked to the wellbeing of employees as well as compliance to labor standards and regulations, cost reduction, and financial resources as well as human resources. This research responds to deficiency in novelty and lack of academic studies on drivers of CSR in the mining sector in Sub-Saharan regions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Sun and Bahizire.)

Background: In recent years, the world's health system faces with increasing trend of costs. In this regard, Hospital is one of the environments that consumes a large share of the total expenditure of the health system. Medications are one of the most expensive components in hospitals, which require appropriate measurements to control and reduce costs. The present systematic review was conducted to identify strategies and actions for cost containment in hospital., Method: Using the PRISMA protocol, a systematic review of the texts was performed to identify strategies and actions for reducing drug cost. In this systematic review, the selected keywords were searched in the following databases: web of sciences, Scopus, PubMed, Google Scholar, and Embase. The inclusion criteria included English-language articles, hospital-level studies, and those studies performed on reducing and controlling hospital costs. The exclusion criteria also included the followings: primary health care studies, non-English language studies, health system studies, and studies solely focussed on the cost-effectiveness of a particular drug. The quality of these articles was investigated using the checklist adapted and modified in the present study., Results: A total of 4696 articles were identified from the reviewed databases and 26 articles were identified from some other sources. After removing duplicate studies and reviewing the title, summary, and full text of articles using reference check and supplemental search, 21 articles were finally included. A number of strategies or managerial actions were extracted from the final articles. According to the qualitative results, qualitative meta-synthesis was used and after eliminating duplicate solutions, the data were classified into five groups: procurement, storage, distribution, prescription, and use., Conclusion: According to the increasing cost of medicines, some hospital managers now attempt to reduce hospital costs using drug chain management. Drug cost reduction strategies can be applied for any component of drug chain management such as procurement, storage, distribution, prescription, and use. Also, proper implementation of these strategies and rationalisation of drug use will result in more efficiency of the hospital., (© 2022 John Wiley & Sons Ltd.)

Background: Hospital strategies aimed at increasing quality of care and simultaneously reducing costs show potential to improve healthcare, but knowledge on real-world effectiveness is limited. In 2014, two Dutch hospitals introduced such quality-driven strategies. Our aim was to evaluate contexts, mechanisms, and outcomes of both strategies using multiple perspectives., Methods: We conducted a mixed methods evaluation. Four streams of data were collected and analysed: (1) semi-structured interviewing of 62 stakeholders, such as medical doctors, nurses, managers, general practitioners (GPs), and consultants; (2) financial statements of both organisations and other hospitals in the Netherlands (counterfactual); (3) national database of quality indicators, and patient-reported experiences; and (4) existing material on strategy development and effects., Results: Both strategies resulted in a relative decrease in volume of care within the hospital, while quality of care has not been affected negatively. One hospital failed to cut operating costs sufficiently, resulting in declining profit margins. We identified six main mechanisms that impacted these outcomes: (1) Quality-improvement projects spur change and commitment; (2) increased coordination between hospital and primary care leads to substitution of care; (3) insufficient use of data and support hinder quality improvement; (4) scaling down hospital facilities is required to convert volume reductions to cost savings; (5) shared savings through global budgets lead to shared efforts between payer and hospital; and (6) financial security for physicians facilitates shift towards quality-driven care., Conclusion: This integrated analysis of mixed data sources demonstrated that the institution-wide nature of the strategies has induced a shift from a focus on production towards quality of care. Longer-term (financial) sustainability of hospital strategies aimed at decelerating production growth requires significant efforts in reducing fixed costs. This strategy poses financial risks for the hospital if operating costs are insufficiently reduced or if payer alignment is compromised., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: A lack of knowledge exists on real world hospital strategies that seek to improve quality, while reducing or containing costs. The aim of this study is to identify hospitals that have implemented such strategies and determine factors influencing the implementation., Methods: We searched PubMed, EMBASE, Web of Science, Cochrane Library and EconLit for case studies on hospital-wide strategies aiming to increase quality and reduce costs. Additionally, grey literature databases, Google and selected websites were searched. We used inductive coding to identify factors relating to implementation of the strategies., Results: The literature search identified 4198 papers, of which our included 17 papers describe 19 case studies from five countries, mostly from the United States. To accomplish their goals, hospitals use different management strategies, such as continuous quality improvement (CQI), clinical pathways, Lean, Six Sigma and value-based healthcare (VBHC). Reported effects on both quality and costs are predominantly positive. Factors identified to be relevant for implementation were categorized in eleven themes: (1) strategy, (2) leadership, (3) engagement, (4) reorganization, (5) finances, (6) data and information technology (IT), (7) projects, (8) support, (9) skill development, (10) culture, and (11) communication. Recurring barriers for implementation are a lack of physician engagement, insufficient financial support, and poor data collection., Conclusion: Hospital strategies that explicitly aim to provide high quality care at low costs may be a promising option to bend the cost curve while improving quality. We found a limited amount of studies, and varying contexts across case studies. This underlines the importance of integrated evaluation research. When implementing a quality enhancing, cost reducing strategy, we recommend considering eleven conditions for successful implementation that we were able to derive from the literature., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Introduction British Orthopaedic Association Standards for Trauma (BOAST) guidelines state that a radiograph of the wrist at the time of removal of immobilisation is not required in conservatively managed distal radius fracture (DRF) patients unless there is clinical cause for concern. The aim of this pilot audit was to investigate local compliance with these guidelines. Materials and methods The first cycle of a retrospective audit was performed on conservatively managed DRF patients presenting between August and October 2021. An intervention was introduced in the form of education to highlight current guidelines. A second cycle was then performed prospectively on patients presenting between February and April 2022. Data was analysed to assess whether radiographs were taken at the time of cast removal, if the indication for the radiograph was documented and whether it affected the management plan. Results In the first cycle, 20 of 46 patients (43.5%) had repeat radiographs at the time of cast removal compared to 12 of 41 patients (29.3%) in the second cycle (p=0.170). None of the first-cycle patients had any documentation on the indication for radiograph at the time of cast removal and none of the radiographs altered the management plan. In the second cycle documentation on the indication for the radiograph was present for seven of the 12 radiographs and two altered the management plan. Conclusion Through education on adherence to national guidelines, the number of radiographs in patients with conservatively managed DRFs was reduced., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Kazzam et al.)

Background With the ever-increasing complexity of today's healthcare environment, it is evident that there is a higher demand to deliver high-quality, accessible, efficient, and affordable healthcare. At the same time, these changes are accompanied by decreasing rates of reimbursement. This can be attributed to the shift from fee-for-service to value-based payment methods in the industry. The reception of such changes in the appropriate manner is crucial to improvement and the much-demanded reform in our healthcare system. To adapt to this changing landscape, hospitals and healthcare systems must incorporate proper measures to identify extraneous spending, control costs, and streamline patient care. Our goal in this study was to use the time-driven, activity-based costing (TDABC) model to quantify the costs at every step as an inpatient goes through the care process in an interventional radiology department. Methodology After identification and mapping of all the steps involved from interventional radiology (IR) consult placement to patient transport to the postoperative recovery area, time data were collected for each step of the process. One of the steps was then selected for intervention. Our focus was on the time interval between one patient leaving after a completed procedure and the next scheduled patient entering the IR suite (heretofore referred to as idle time). To decrease the idle room time between patients, the interventional radiologists, IR administrations, nurse manager, transportation manager, and charge nurse first met as a group to set a realistic initial goal. Pre-intervention data were collected. Results After the collection of pre-intervention data, the average idle time of the IR suite was found to be 40 minutes. After a multidisciplinary discussion, our goal was to reduce this time to 25 minutes. Post-intervention data found the average time decreased to 24 minutes. Calculation of average costs per unit time for staff, IR room, and equipment yielded an approximate cost of $57 per minute of time in the IR suite. Conclusions Considering the near 40% decrease in suite idle time as well as the cost per minute of material, equipment, and staff (at ~80% capacity), this study proves that the TDABC system is a viable method of targeting bottlenecks in operations and streamlining patient care by reducing costs while optimizing the process patients go through during care continuum., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Ghasemi Rad et al.)

Background: Rising health care costs, coupled with an emphasis on cost containment, continue to gain importance. Surgeon cost scorecards developed to track case-based expenditures can help surgeons compare themselves with their peers and identify areas of potential quality improvement. Purpose: We sought to investigate what effect surgeon scorecards had on operating room (OR) costs in orthopedic surgery. Methods: Our hospital distributed OR cost scorecards to 4 adult reconstruction fellowship-trained orthopedic surgeons beginning in 2012. The average direct per-case supply cost of procedures was calculated quarterly and collected over a 5-year period, and each surgeon's data were compared with that of their peers. All 4 surgeons were made aware of the costs of other surgeons at the 2-year mark. The initial 2 years of data was compared with that of the final 2 years. Results: The average direct per-case supply cost ranged from $4955 to $5271 for total knee arthroplasty (TKA) and $5469 to $5898 for total hip arthroplasty (THA) during the initial 2-year period. After implementing disclosures, the costs for TKA and THA, respectively, ranged from $4266 to $4515 (14% annual cost savings) and from $5073 to $5727 (5% annual cost savings); 3 of the 4 surgeons said that cost transparency altered their practice. Conclusion: Our comparison suggests that orthopedic surgeons' participation in a program of operative cost disclosure may be useful to them; we found a possible association with reduced per-case costs for TKA and THA at our institution over a 5-year period. More rigorous study that incorporates the effects of the scorecards on patient outcomes is warranted., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Fabio R. Orozco, MD, reports a relationship with Stryker. Zachary D. Post, MD, reports relationships with Ortho Development and DePuy Synthes. Alvin C. Ong, MD, reports relationships with Stryker, Smith & Nephew, and Journal of Arthroplasty. The other authors declare no potential conflicts of interest., (© The Author(s) 2021.)

Purpose: Anastomotic leakage (AL) and surgical site infection (SSI) account for most postoperative complications in colorectal surgery. The aim of this retrospective trial was to investigate whether perioperative selective decontamination of the digestive tract (SDD) reduces these complications and to provide a cost-effectiveness model for elective colorectal surgery., Methods: All patients operated between November 2016 and March 2020 were included in our analysis. Patients in the primary cohort (PC) received SDD and those in the historical control cohort (CC) did not receive SDD. In the case of rectal/sigmoid resection, SDD was also applied via a transanally placed Foley catheter (TAFC) for 48 h postoperatively. A propensity score-matched analysis was performed to identify risk factors for AL and SSI. Costs were calculated based on German diagnosis-related group (DRG) fees per case., Results: A total of 308 patients (154 per cohort) with a median age of 62.6 years (IQR 52.5-70.8) were analyzed. AL was observed in ten patients (6.5%) in the PC and 23 patients (14.9%) in the CC (OR 0.380, 95% CI 0.174-0.833; P = 0.016). SSI occurred in 14 patients (9.1%) in the PC and 30 patients in the CC (19.5%), representing a significant reduction in our SSI rate (P = 0.009). The cost-effectiveness analysis showed that SDD is highly effective in saving costs with a number needed to treat of 12 for AL and 10 for SSI., Conclusion: SDD significantly reduces the incidence of AL and SSI and saves costs for the general healthcare system., (© 2022. The Author(s).)

A stable, synchronized colony of whitefly ( Bemisia tabaci MEAM1 Gennadius) was established in a single ~30 cu.ft. reach-in incubator and supported on cabbage host plants which were grown in a 2 × 2' mesh cage without the need for a greenhouse or dedicated growth rooms. The colony maintenance, including cage cleaning and rotation of plants, was reduced to less than 10 h per week and executed by minimally experienced researchers. In our hands, this method was approximately 10-fold less expensive in personnel and materials than current typical implementations. A predator-prey model of whitefly colony maintenance that included whitefly proliferation and host plant health was developed to better understand and avoid colony collapse. This quantitative model can be applied to inform decisions such as inoculum planning and is a mathematical framework to assess insect control strategies. Extensive measurements of colony input and output (such as image analysis of leaf area and whitefly population size) were performed to define basic 'feedback control' parameters to gain reproducibility of this inherently unstable scaled-down whitefly colony. Quantitative transfer of ~100 whiteflies repeatedly produced more than 5000 adult whiteflies over a 6-week, two-generation period. Larger scale experimentation could be easily accommodated by transferring adult whiteflies from the maintenance colony with a low flow vacuum capture device. This approach to colony maintenance would be useful to programs that lack extensive plant growth room or greenhouse access and require a "clean" implementation that will not contaminate an axenic tissue culture laboratory., Competing Interests: The authors have no conflicts of interest., (© 2022 The Authors. Journal of Applied Entomology published by Wiley‐VCH GmbH.)

Deployment of molecular testing for SARS-CoV-2 in resource-limited settings is challenging. Scale-up of molecular had to be conducted with a laboratory system strengthening approach that emphasize laboratory integration. National reference laboratories play a central role. In Malawi the molecular testing was underpinned by existing pathogen control programs for human immunodeficiency virus and tuberculosis that use Abbott and GeneXpert machines and reagents. Despite this, the impact on these programs was well managed. Antigen testing increased access to testing. Pooled testing and direct-to-polymerase chain reaction methods have the potential to save costs and further increase access to molecular tests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Pharmacists' compliance with a medication partial fill policy at a Veterans Affairs healthcare system has been underwhelming. Academic detailing, an educational outreach approach conducted by trained health care professionals to improve patient care, is an attractive method for improving pharmacists' compliance with the policy., Objective: To evaluate the impact of academic detailing on pharmacists' compliance with the partial fill policy., Methods: A pre-post analysis was performed to evaluate the impact of academic detailing outreach visits on pharmacists' compliance with the partial fill policy. Data collection included all partial fill medication orders verified during the study duration. Student's t-test was used to analyze the change in the day supply of partial fills following the academic detailing intervention. Total partial fill drug expense during the pre- and post-intervention phases was calculated as drug cost plus material cost for each partial fill., Results: A total of 36 (97.3%) pharmacists received an academic detailing outreach visit. Total percentage of partial fills limited to a 7-day supply was significantly increased following academic detailing outreach visits (49.2% pre-intervention vs. 84.2% post-intervention, p-value <0.001). Total partial fill drug expense decreased from $12,144.42 to $9,713.50. Percentage of partial fills limited to a 7-day supply remained significant during the 6-month follow-up period (p-value = 0.03)., Conclusions: Academic detailing is an effective method for improving pharmacists' compliance with an outpatient pharmacy partial fill policy and decreasing total partial fill drug expense for the pharmacy department.

Objectives: Reducing healthcare costs is a constant endeavor of all healthcare organizations, governments, policy makers, and individuals. A comparative study of available healthcare policies from the patient's perspective is not available. Furthermore, an analysis of how the various components of these policies affect the healthcare cost of a patient is required., Methods: Data were collected from 150 hospitalized patients in India regarding their views on 7 healthcare cost categories covering 22 cost components. These are statistically analyzed under 4 commonly used health insurance policies (2 government insurance schemes: ex-servicemen contributory health scheme and employee state insurance; private insurance schemes; and self-financing-ie, no insurance) to assess which healthcare cost component is more important under which policy option., Results: Under 7 healthcare cost categories, 22 cost components were studied, and out of these 22, 16 were found statistically significant. Results revealed that the treatment of all 16 significant cost components under the 4 health insurance policy options was statistically different., Conclusions: Patients covered under government sector health insurance policies were found to be less concerned about healthcare costs, whereas those covered under private health insurance policies were found to be more cost-conscious. Access to healthcare or transportation costs to the healthcare facility is a key concern area for self-financed patients., (Copyright © 2021 ISPOR--The professional society for health economics and outcomes research. Published by Elsevier Inc. All rights reserved.)

Government incentive policies play an important role in the promotion of distributed photovoltaic power. However, which policy is more effective for the diffusion of distributed photovoltaic power? This is a question that needs to be answered. Based on this, we combined the two-factor learning curve and system dynamics model to study the dynamic diffusion process of China's distributed photovoltaic power (DSP). The results show that (1) the coefficients of learning by doing and learning by researching for DSP are 0.0435 and 0.2971 respectively. This indicates that technological innovation caused by R&D expenditures in the DSP is the driving force for cost reduction. (2) Both demand-pull and technology-push policies contribute to the diffusion of DSP; (3) the effect of FIT policy on the diffusion of distributed photovoltaic technology is more significant than that of R&D policy; and the reduction of production cost of photovoltaic power industry by R&D policy is more significant than FIT policy., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Albumin is an expensive non-blood plasma substitutes with limited availability that has been reported to be inappropriately used in healthcare settings. Hence, interventions are recommended to control its misuse. Objective: To evaluate the impact of clinical pharmacist implemented dispensing protocol on optimization of albumin use in an intensive care unit (ICU). Design: A retrospective prospective 3-phase interventional study was conducted in an ICU in a tertiary Egyptian hospital over a period of 2 years. Methods: The study included three phases; a preparation phase where a local albumin dispensing protocol and a restriction dispensing form were prepared by clinical pharmacists and was approved by the local Drugs and Therapeutics Committee, a retrospective pre-implementation phase in which the medical records of all ICU patients receiving albumin were evaluated for appropriateness of albumin use according to the developed protocol, and a prospective implementation phase where the dispensing protocol and restriction dispensing form were applied. The pattern of albumin consumption and cost were recorded and compared between the retrospective and prospective phases. Results: In the retrospective phase, 190 ICU patients received albumin of whom 83.6% was considered inappropriate indications for albumin compared to only 44 patients in the prospective phase of whom 16% was considered inappropriate ( p -value <0.001). Clinical pharmacists' interventions significantly decreased the inappropriate albumin consumption from 4.7 vials/patient in the retrospective phase to 2.7 vials/patient in the prospective phase ( p -value <0.001) with a total cost savings of 313,900 Egyptian Pounds (19,930 US Dollars). Conclusion: The current study showed that clinical pharmacists' interventions led to a significant control on albumin use and consequently reduced the cost associated with its consumption., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ibrahim, Shawki, Solayman and Sabri.)

For proton exchange membrane water electrolysis (PEMWE) to become competitive, the cost of stack components, such as bipolar plates (BPP), needs to be reduced. This can be achieved by using coated low-cost materials, such as copper as alternative to titanium. Herein we report on highly corrosion-resistant copper BPP coated with niobium. All investigated samples showed excellent corrosion resistance properties, with corrosion currents lower than 0.1 µA cm -2 in a simulated PEM electrolyzer environment at two different pH values. The physico-chemical properties of the Nb coatings are thoroughly characterized by scanning electron microscopy (SEM), electrochemical impedance spectroscopy (EIS), X-ray photoelectron spectroscopy (XPS), and atomic force microscopy (AFM). A 30 µm thick Nb coating fully protects the Cu against corrosion due to the formation of a passive oxide layer on its surface, predominantly composed of Nb 2 O 5 . The thickness of the passive oxide layer determined by both EIS and XPS is in the range of 10 nm. The results reported here demonstrate the effectiveness of Nb for protecting Cu against corrosion, opening the possibility to use it for the manufacturing of BPP for PEMWE. The latter was confirmed by its successful implementation in a single cell PEMWE based on hydraulic compression technology.