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Long wait times for scheduled surgical procedures have long been a concern in Canadian health systems. (1) Access to health services is determined by the demand for services, the supply [...], Background: Little is known about the existing structure and function of referral networks in the prevalent referral system for specialized surgical care in Canada, which is based on direct physician referral to specialists in a largely unmanaged referral marketplace. Our objective was to describe and analyze the referral networks of referring physicians and surgeons for common surgical procedures in Ontario, to better understand potential barriers to single-entry models. Methods: We analyzed referral networks for patients between referring physicians and surgeons for 9 common scheduled surgical procedures from 2016 to 2019 using administrative data sources in Ontario. We described the connectedness of referring physician-surgeon pairs using descriptive measures and graphical social network analysis. Results: The median number of surgeons connected to a referring physician for patients having a particular surgical procedure ranged from 1 (interquartile range [IQR] 1-3) for spine surgery to 3 (IQR 1-4) for knee arthroplasty and 3 (IQR 2-5) for noncancer uterine procedures. Referral network structure varied according to the procedure studied. Spine surgery was highly clustered with a small number of larger groups; gallbladder, inguinal hernia, and noncancer uterine surgery were highly distributed with many small groups within the referral network. Breast cancer surgery occurred in a largely distributed network, but with a skewed distribution reflecting a few small groups with large numbers of patients. Conclusion: Improving surgical wait times by coordinating surgical referrals will require approaches that address the structure of existing referral networks. Most physicians refer their patients to a very small number of surgeons, suggesting that referring physicians largely do not individualize referrals to multiple different surgeons based on specific patient characteristics. Contexte : On en conna t peu sur la structure et le fonctionnement actuels des r seaux d'aiguillage du pr sent syst me de r partition des demandes de consultations en soins chirurgicaux sp cialis s au Canada car ce syst me repose sur les demandes adress es directement aux sp cialistes par les m decins traitants dans un contexte non g r . Notre objectif tait de d crire et d'analyser les r seaux d'aiguillage entre m decins traitants et sp cialistes en chirurgie pour les interventions courantes en Ontario, afin de mieux comprendre les obstacles potentiels aux mod les acc s unique. M thodes : Nous avons analys les r seaux d'aiguillage des patients et patientes entre les m decins traitants et les sp cialistes en chirurgie pour des interventions courantes planifi es de 2016 2019 partir de banques de donn es administratives ontariennes. Nous avons d crit l'appariement m decin traitant-sp cialiste en chirurgie l'aide de mesures descriptives et d'une repr sentation graphique des r seaux d'aiguillage. R sultats : Le nombre m dian de chirurgiennes et chirurgiens appari s un m decin traitant pour un type de chirurgie en particulier allait de 1 ( ventail interquartile [ I] 1-3) pour la chirurgie de la colonne vert brale 3 ( I 1-4) pour l'arthroplastie du genou et 3 ( I 2-5) pour les probl mes ut rins non canc reux. La structure des r seaux d'aiguillage variait selon l'intervention tudi e. La chirurgie de la colonne vert brale pr sentait plus de grappes, comportant un petit nombre de groupes plus denses; les chirurgies de la v sicule biliaire, de la hernie inguinale et des probl mes ut rins non canc reux taient largement distribu es, comportant plusieurs groupes restreints travers tout le r seau d'aiguillage. La chirurgie pour cancer du sein tait largement r partie, mais sa distribution tait asym trique, t moignant d'un nombre restreint de petits groupes plus nombreux de patientes. Conclusion : Pour am liorer les temps d'attente en coordonnant les demandes de consultation en chirurgie, il faudra des approches ax es sur les r seaux d'aiguillage existants. La plupart des m decins traitants orientent leur patient le vers un tr s petit nombre de chirurgiennes et chirurgiens, ce qui laisse entendre que pour une bonne part, ils n'individualisent pas leurs demandes de consultation aupr s de multiples chirurgiennes ou chirurgiens en fonction des caract ristiques sp cifiques des malades.

Introduction: Actinic keratosis (AK) is a precancerous skin lesion that can progress to keratinocyte carcinoma. Objective: The objective of the study was to evaluate the efficacy of a dermocosmetic (DC) formulation containing prebiotic active ingredients (Aqua Posae Filiformis, a complex made of ferments, sugars, plant extracts, panthenol, madecassoside, and zinc) on healing time and local skin reactions (LSR) following cryotherapy of AKs and to compare the application of DC aand boric acid 3% solution soaks (BA) vs. BA alone. Methods: Seventy-five adult patients presenting with a maximum of 5 isolated AKS on the face and/or scalp and who underwent cryotherapy (T0) were enrolled. Post-treatment, patients initiated the application of BA only or BA followed by DC once daily for 30 days (unblinded 1:1 randomization). The evaluation of efficacy in healing time and cosmetic outcomes was assessed 30 days post-treatment (T2); LSR was evaluated 3 days post-treatment (T1). Results: There was a gain of 4.5 days (40%) in healing time in the BA+DC group compared to the BA group, with a median time of 7 days versus 11.5 days (P

Introduction: Actinic keratosis (AK) is a common precancerous skin lesion that arises on chronically UV-exposed skin and can progress to keratinocyte carcinoma. Objective: The aim of this study is to compare efficacy, safety, local skin reaction, time to wound closure, and patient preference of imiquimod (IMQ) 3.75% vs 5-fluorouracil (5-FU) 4% cream treatment for AKs. Methods: Two symmetrical contralateral areas of approximately 25 cm2 harboring a similar (≥5) number of AKs were selected and randomly assigned to IMQ 3.75% or 5- FU 4% cream treatment. The total number of AKs for each patient, was evaluated at baseline (T0) and 90 days after the end of treatments (T1). Local skin reaction (LSR) score was registered the day after the end of both treatments. Complete remission rate of lesions, cosmetic outcome, and patient preference of treatment were assessed after 90 days (T1). Results: The mean variation (ΔT0-T1) of AKs was not significantly different in patients treated with IMQ 3.75% and 5-FU 4% (p=0.35). The mean LSR was not significantly different for patients treated with IMQ 3.75% and 5-FU 4% (p=0.63). No difference in cosmetic outcome was observed in the 2 groups. Patient preference was equally distributed between the treatments. The mean time to wound closure after the end of the treatment was similar after IMQ 3.75% as compared to 5-FU 4% (p=0.83). Conclusions: This study reports a non-superiority of efficacy, tolerability, wound-healing time, and cosmetic outcome of topical IMQ 3.75% treatment compared to topical 5-FU 4% treatment in AK management.

ObjectiveTo characterize the clinical manifestations of yellow fever disease and identify risk factors for mortality.MethodsA retrospective study was conducted in the referral center for infectious diseases (Hospital Eduardo de Menezes-HEM) in Belo Horizonte, Minas Gerais, Brazil. Analysis included data from 283 patients with confirmed YF infection older than 13 years old who presented to HEM between January 2017 and June 2018. In-hospital mortality (hypothesis formulated after data collection), demographic factors and clinical and laboratory assessments were used.ResultsStudy patients were mainly men (87.6%), with a median age of 46.0 (IQR 36.5, 57.0). 131 (46.3%) patients were admitted to the ICU, and 62 (22.0%) used invasive mechanical ventilation for a median of 2 days (IQR 1, 3). The median (IQR) total length of stay (LOS) in the ICU was 6 days (IQR 4, 8). The in-hospital mortality rate was 24.0%. Age was significantly higher in fatal (median 49.5, IQR 41.0, 61.0]) than in non-fatal cases [46 (36, 55)] (p < 0.01). Male sex was associated with an increased risk of death (RR 4.66, 95% CI 1.19, 18.2; p < 0.01). Most common symptoms and signs on admission to HEM were fever (31.9%), myalgia (27.8%), jaundice (24.3%), headache (23.9%), abdominal pain (16.1%), vomiting (12.2%), weakness (10.4%), and arthralgias (10.0%). Initial viral load above the cutoff of 4.45 log10 copies/mL was significantly associated with death prior to discharge (OR 12.2; CI 2.83, 92.3). Five factors were significantly related to increased odds of death prior to discharge: log-transformed AST (OR 3.65; CI 2.02, 7.81; p < 0.001), log-transformed INR (OR 7.40; CI 1.31, 33.0; p = 0.010), log-transformed lactate (OR 4.57; CI 1.48, 17.1; p = 0.013), log-transformed WBC (OR 4.33; CI 1.19, 18.5; p = 0.034), and age (OR 1.06; CI 1.01, 1.12; p = 0.026).Conclusions and relevanceAST, INR, lactate, WBC, and age are statistically associated with death prior to discharge in YF patients. These clinical markers should be applied to improve patient screening and management during future YF epidemics.

Epidermolysis bullosa (EB) refers to a group of inherited disorders characterized by skin and mucous membrane fragility. This report presents the case of a 61-year-old Italian male with a localized variant of junctional epidermolysis bullosa (JEB) linked to the R795X mutation in the COL17A1 gene. The patient presented with bullous lesions, erosions, scars, and pigmentary changes on the pretibial areas and dystrophic nails. Genetic analysis confirmed the presence of the COL17A1 variant p.Arg795Ter (R795X) mutation, establishing a rare, localized variant of JEB. This case underscores the criticality of early and accurate diagnosis in the management of rare genetic disorders, as misdiagnosis can lead to ineffective treatments.

Mixed-model assembly systems are widely used to guarantee higher flexibility, variety and throughput. In such assembly systems, fixed worker (FW) and walking worker (WW) workforce strategies are mainly adopted, influencing tactical and operational decisions with different and sometimes contrasting strengths and weaknesses. Thus, several aspects require a joint investigation to evaluate in which context a WW workforce strategy is preferable to the FW one. In this paper, the effect of assembly and station time variability on WW systems performance is investigated and compared to FW systems through a simulative study. Further, the number of workers and workstations and the effect of the travel time are also analysed. Results show that time variability has an impact on the throughput of both systems, in a different way. Starting from the target throughput and the given time variability among tasks, results derived from data elaboration allow us to propose a decision tree and a selection procedure for choosing between FW and WW systems, highlighting their most proper application conditions. According to the results, the time variability among tasks and the ratio between the number of workers and workstations are the two main drivers influencing the choice between WW and FW strategies. [ABSTRACT FROM AUTHOR]

Selecting suppliers strategically is a critical challenge in supply chain design, particularly in a dynamic global marketplace where maintaining competitiveness and sustainability is essential. Supplier location is a key factor that significantly impacts supply chain sustainability. Hence, this study proposes a new Sustainable Joint Economic Lot Size (S-JELS) model that integrates average annual cost and total amount of emissions associated with annual activities related to both buyer and supplier. The developed model accounts for costs and emissions from the buyer’s purchasing, inventory management, and transportation activities, as well as from the supplier’s production, packaging, and delivery processes. Additionally, the model incorporates various transportation modes, including shipping, trucking, and rail, to more accurately assess the environmental impact of different supply chain strategies. The proposed JELS model can support managers performing sustainable purchasing decisions and assess a sustainable supplier selection. The developed model is applied in a leather case study characterized by high resource intensity, significant environmental impacts, and complex global logistics to accomplish supplier selection between one domestic and one international supplier, aiming to determine the most sustainable strategy in terms of cost and emission.

Aim: Abrocitinib is a JAK-1 inhibitor approved for the treatment of moderate-to-severe atopic dermatitis (AD). We conducted a 16-week multicenter retrospective study to assess the short-term effectiveness and safety of abrocitinib in patients with moderate-to-severe AD.Our retrospective study included 85 adult patients from 14 Italian Dermatology Units affected by moderate-to-severe AD treated with abrocitinib 100/200 mg.Methods: Effectiveness of abrocitinib at weeks 4 and 16 was assessed by using the Eczema Area and Severity Index (EASI), the Investigator Global Assessment (IGA), the peak pruritus and sleep- Numerical Rating Scale (PP-NRS and S-NRS, respectively).Results: At week 16, improvement of at least 90% in EASI (EASI90) and IGA 0/1 was observed in 49.4% and 61.2% of patients, respectively. A reduction of at least 4 points in PP-NRS and S-NRS compared with baseline was achieved by 70.6% of patients for both endpoints. No significant safety reports were observed during the study period. Naïve patients had better rates of EASI 90 compared to patients who previously failed dupilumab.Conclusion: Our data confirm the effectiveness of abrocitinib in a real-world setting with better clinical responses at weeks 4 and 16, compared with Phase-III clinical trials. Longer analyses are required to further establish the safety profile of abrocitinib.

O presente artigo tem como objetivo investigar o uso das histórias de ficção, relatadas pelo sujeito em análise, como um recurso em estabelecer uma reorientação fantasmática, durante o processo de adolescer, em busca de certa estabilização subjetiva. Para isso, foi realizado um percurso teórico, ancorado nas pesquisas psicanalíticas, sobre puberdade e adolescência, a fim de compreender os processos e impasses que os sujeitos adolescentes apresentam nesse momento. Articulada a essas investigações, utilizamos as considerações de um caso clínico, procurando demonstrar como o uso das histórias de ficção, relatadas em análise, pode ser um organizador da realidade vivida pelo adolescente, revelando ser um recurso fantasmático importante para o sujeito contornar o insuportável do real que a entrada na puberdade desvela.

This study analyzed data from hospitals located in three regions of Ethiopia: Addis Ababa, Northeastern Ethiopia, and Southern Ethiopia. The research aims to investigate the prevalence and contributing factors associated with skin diseases in these regions. Skin disorders represent a significant health concern in these areas, though their epidemiology differs markedly from that observed in Western countries. We collected data from 6,449 patients, considering factors like education, income, cultural habits, and access to healthcare. Patients in Southern Ethiopia generally had higher Body mass indexes and incomes and were closer to dermatology centers. The findings indicate that infectious diseases and pruritic dermatoses are the most prevalent skin conditions in all regions. The study highlights the significant impact of socio-economic status on skin health, with higher education correlating with a lower incidence of infectious diseases and sebaceous gland disorders. Overcrowding was associated with a higher occurrence of infectious diseases, emphasizing the importance of hygiene and sanitary conditions. Additionally, the distance from a patient’s residence to the hospital influenced the duration of the disease, stressing the need for better accessibility to healthcare services. In conclusion, this research offers important insights into the spectrum of skin diseases in Ethiopia, emphasizing the role of socio-economic factors and the critical need for improved healthcare access and education.

Introduction: Pemphigus, an autoimmune disorder, significantly impacts the quality of life for those affected. Objective: This study examines the sleep quality in patients with pemphigus, a domain for which the existing literature provides limited data without a focused analysis. Methods: A total of 156 individuals, 52 in the case and 104 in the control group, completed several questionnaires (PSQI, GHQ12, and ABQOL). Disease severity was evaluated using the PDAI scale. Results: The case group exhibited significantly higher levels of psychological distress, reflected in GHQ12 scores (p=0.00), and notably poorer sleep quality compared to controls across various parameters (sleep latency [SL], disturbances [SDi], medication [SM], daytime sleep dysfunction [DSD]), and the global PSQI score (GS)] (p=0.00)]. Significant correlations were observed between PDAI scores and sleep duration (SDu) (p=0.01), SM (p=0.03), SL (p=0.03), and GS (p=0.00). An association was found between the equivalent steroid intake and SDu (p=0.00) as well as GS (p=0.02). No statistically significant correlation emerged between disease duration and PSQI scores. Our findings indicated a correlation between poor sleep quality and cutaneous rather than mucosal manifestations (p=0.01). Pemphigus affects sleep quality. Severe disease showed heightened SDi, correlating with higher steroid doses, and in the chronic phase, the impact seems to be more influenced by the pro-inflammatory stage of the disease. Patients with cutaneous pemphigus exhibit reduced sleep quality compared to those with oral pemphigus. Conclusion: Understanding that pemphigus worsens sleep quality can be beneficial for the holistic management of individuals with this condition.

Background: Canine distemper is a worldwide spread disease that has been described in 12 families of mammals, especially in the Carnivora order, being better studied in domestic canines where vaccination represents the best means of control. Canine distemper is controlled by vaccination, but many cases of the disease still occur in vaccinated animals. Aim: The aim of this work was to study antigen specific epitopes that can subsidize the development of a new vaccine approach. Methods: Mapping of T cell reactive epitopes for Canine Distemper Virus (CDV) was carried out through ELISPOT assays using 119 overlapped synthetic peptides from the viral hemagglutinin protein, grouped in 22 pools forming a matrix to test the immune response of 32 animals. Results: Evaluations using the criteria established to identify reactive pools, demonstrated that 26 animals presented at least one reactive pool, that one pool was not reactive to any animal, and six pools were the most frequent among the reactive peptides. The crisscrossing of the most reactive pools in the matrix revealed nine peptides considered potential candidate epitopes for T cell stimulation against the Canine Distemper Virus and those were used to design an in-silico protein, containing also predicted epitopes for B cell stimulation, and further analyzed using immune epitope databases to ensure protein quality and stability. Conclusion: The final in silico optimized protein presents characteristics that qualifies it to be used to develop new prototype epitope based anti-CDV vaccine. [Open Vet J 2024; 14(4.000): 1019-1028]

Keratinocyte-derived skin cancers comprise basal cell carcinoma, squamous cell carcinoma, its precursor actinic keratosis, and Bowen’s disease. Historically, this group of neoplasms has been subsumed under the term non-melanoma skin cancer. However, the term non-melanoma skin cancer can be misleading and lacks precision. Therefore, more precise and reasonable terminology, valuing the relevance of keratinocyte-derived cancer, appears pertinent to meet its clinical and scientific significance. A group of experienced dermato-oncologists initiated a consensus approach to promote the use of the term “keratinocyte cancer” instead of “non-melanoma skin cancer” when referring to carcinomas and their precursors that are derived from keratinocytes. The vote among members of the consensus group indicated unanimous agreement on the consistent use of the term “keratinocyte cancer” instead of “non-melanoma skin cancer”. International delegates also voted in favour of the revised terminology. The more precise and, by means of etiopathogenesis, correct term “keratinocyte cancer” should be consistently used for malignancies originated from keratinocytes. This is expected to have a positive impact on patient–physician communication and gives better justice to this important group of keratinocyte-derived cancers.

Giant cell tumors (GCT) are usually benign, typically found in the epiphyseal area of long bones, affect individuals in the third decade, and have a slight female predilection. GCT represent about 4% to 9.5% of all bone tumors and 20% of all benign ones. Approximately 2% of all GCT occur in the head and neck region. However, primary laryngeal GCT is an infrequent entity, with 43 cases reported to date. Therefore, the present study aimed to report an issue of laryngeal GCT in a young male patient. Given the uncertainty of clinical and radiological distinction between the wide variety of differential diagnoses, histopathological examination is indispensable for a definitive diagnosis and therapeutic management. The treatment of GCT is controversial. However, currently, the literature supports surgical management. The incidence of GCT is not a common situation in medical practice, and the diversity of differential diagnoses is quite broad, which may lead the physician to suspect other diseases that affect the larynx. GCT is rarely considered among the diagnostic hypotheses, its incidence is sporadic, and management data must be studied.