Search

Abstract Background The healthcare sector must navigate the challenge of caring for individuals affected by climate change while being a significant emitter of carbon emissions. This study focuses on direct sources of carbon emissions from hospital surgical care, a major contributor to the sector’s overall carbon footprint. The goal is to identify the main sources of direct carbon emissions in surgical care and to analyze these sources according to the Congruence Model. We employ the Congruence Model for a systemic analysis of emission sources within the organizational context. The change-oriented model examines (in)congruences across the domains of People, Work, Culture, and Structure, aiding in the understanding of organizational change. Methods A qualitative systematic literature review was conducted following PRISMA guidelines, covering three extensive databases: PubMed, Business Source Premier, and EBSCOhost. The review provides a broad perspective on the topic under study. The qualitative analysis is guided by the Congruence Model, which serves as a conceptual lens to analyze and interpret the findings. Results The study offers a comprehensive overview of research focused on emissions related to surgery. Hotspots of carbon emissions in surgical care, such as anesthetic gases, sterilization procedures, and habitual behaviors, are linked with the Work and People elements of the Congruence Model. Additionally, sustainability measures are predominantly associated with the Structural element of the Congruence Model, including policies for recycling and waste segregation. The research reflects on the (in)congruencies between different factors of the Congruence Model and actions related to reducing carbon emissions. Conclusions The Congruence Model provides a useful conceptual lens to categorize the sources of carbon emissions in terms of People, Work, Structure and Culture. In addition, the Congruence Model allows us to explore the (in)congruencies between these functional elements. Ultimately, our research identifies opportunities to improve carbon emissions related to the surgical care process.

Ancillary services e.g., voltage control, congestion management and frequency control, require to be compensated increasingly from the Distributed Energy Resources (DERs). DERs are predominantly wind and photo-voltaic power plants, the major share of which are installed at the distribution grid level. Therefore, the previously passive distribution grids require transformation towards a more active role. Provision of ancillary services from the distribution grid level, requires assessment of active and reactive power flexibility (PQ-flexibility) potentials. Furthermore, increased renewable penetration correlates to increased responsibility of the Distribution System Operators (DSOs) for assessing the flexibility potentials. An aggregation of distribution grid potentials, subject to technical grid constraints and technological power limitations, is termed as Feasible Operating Region (FOR) of the distribution grid. The FOR effectively serves as an interface between the DSOs and the Transmission System Operators (TSO), for flexibility exchanges and planning of ancillary services provision. The determination of the FOR is established in current research, using different algorithms e.g stochastic methods, meta-heuristic programming and mathematical optimization techniques. In this paper, an FOR determination algorithm using successive linear programming (sLP) is proposed and validated against established optimization approaches on a uniform medium voltage (MV) grid model. Comparisons reveal competitiveness with established methods and an added advantage of fast calculation times, suitable for real time assessments. Further enhancement of the FOR is proposed, by integrating discrete transformer tap-changing operational flexibilities using a successive mixed integer linear programming (sMILP). Results demonstrate an increase in the flexibility potential from the distribution grid.

Research in the field of dynamic torque calibration has gained some momentum in the last few years. At PTB, a calibration device for small dynamic torque levels up to about 0.5 N⋅m proved the working principle of dynamic torque calibrations with sinusoidal excitation. In a next step, a new calibration device was developed with the intention of generating higher dynamic torque levels in the range of up to 20 N⋅m. Although this is still less than many industrial applications require, it could pave the way to higher torque levels. The new calibration device features a horizontal arrangement of all components of the drive shaft. The device consists mostly of industrial components that have been modified, rather than custom-made components. After commissioning, optimising the device enabled a frequency range from 10 Hz to up to 400 Hz with dynamic torque amplitudes of up to 20 N⋅m.

Research in the field of dynamic torque calibration has gained some momentum in the last few years. At PTB, a calibration device for small dynamic torque levels up to about 0.5 N m proved the working principle of dynamic torque calibrations with sinusoidal excitation. In a next step, a new calibration device was developed with the intention of generating higher dynamic torque levels in the range of up to 20 N m. Although this is still less than many industrial applications require, it could pave the way to higher torque levels. The new calibration device features a horizontal arrangement of all components of the drive shaft. The device consists mostly of industrial components that have been modified, rather than custom-made components. After commissioning, optimising the device enabled a frequency range from 10 Hz to up to 400 Hz.

Sequential infections of humans by the four different dengue serotypes (DENV-1–4) lead to neutralizing antibodies with group, cross, and type specificity. Virus neutralization of serotypes showed monotypic but mostly multitypic neutralization profiles due to multiple virus exposures. We have studied neutralization to heterologous, reference DENV serotypes using paired sera collected between days 6 and 37 after onset of fever. The DENV-primed neutralization profile of the first serum sample, which was monitored by a foci reduction neutralization test (FRNT), was boosted but the neutralization profile stayed unchanged in the second serum sample. In 45 of 47 paired serum samples, the predominant neutralization was directed against DENV serotypes distinct from the infecting serotype. Homologous neutralization studies using sera and viruses from the same area, 33 secondary sera from DENV-1 infected Cambodian patients and eight virus isolates from Cambodia, showed that the FRNT assay accurately predicted the lack of a predominant antibody response against the infecting DENV-1 serotype in contrast to FRNT results using the WHO set of DENV viruses. This report provides evidence that DENV-primed multitypic neutralizing antibody profiles were mainly boosted and stayed unchanged after secondary infection and that DENV neutralization was predominantly directed to heterologous DENV but not against the infecting homologous serotype.

The aggregation of operational active and reactive power flexibilities as the feasible operation region (FOR) is a main component of a hierarchical multi-voltage-level grid control as well as the cooperation of transmission and distribution system operators at vertical system interconnections. This article presents a new optimization-based aggregation approach, based on a modified particle swarm optimization (PSO) and compares it to non-linear and linear programming. The approach is to combine the advantages of stochastic and optimization-based methods to achieve an appropriate aggregation of flexibilities while obtaining additional meta information during the iterative solution process. The general principles for sampling an FOR are introduced in a survey of aggregation methods from the literature and the adaptation of the classic optimal power flow problem. The investigations are based on simulations of the Cigré medium voltage test system and are divided into three parts. The improvement of the classic PSO algorithm regarding the determination of the FOR are presented. The most suitable of four sampling strategies from the literature is identified and selected for the comparison of the optimization methods. The analysis of the results reveals a better performance of the modified PSO in sampling the FOR compared to the other optimization methods.

There are four distinct antigenic serotypes of dengue viruses (DENV-1-4). Sequential infections with different serotypes lead to cross-reactive but also serotype-specific neutralizing antibody responses. Neutralization assays are considered as gold standard for serotype-specific antibody detection. However, for retrospective seroprevalence studies, access to large serum quantities is limited making neutralization assays well-nigh impossible. Therefore, a serological test, wasting only 10 µL serum, was developed using fusion proteins of maltose binding protein and E protein domain 3 (MBP-ED3) as antigens. Twelve MBP-ED3 antigens for DENV-1-4, three MBP-ED3 antigens for WNV, JEV, and TBEV, and MBP were dotted onto a single nitrocellulose strip. ED3 dot assay results were compared to virus neutralization and ED3 ELISA test results, showing a >90% accordance for DENV-1 and a 100% accordance for DENV-2, making the test specifically useful for DENV-1/-2 serotype-specific antibody detection. Since 2010, DENV-1 has replaced DENV-2 as the dominant serotype in Cambodia. In a retrospective cohort analysis, sera collected during the DENV-1/-2 endemic period showed a shift to DENV-2-specific antibody responses in 2012 paralleled by the decline of DENV-2 infections. Altogether, the ED3 dot assay is a serum-, time- and money-saving diagnostic tool for serotype-specific antibody detection, especially when serum samples are limited.

Slot blot hybridization of membrane-immobilized, single-stranded human DNA with the higher primate-specific alphoid probe D17Z1 is routinely used in forensic science to estimate the amount of DNA in biological samples. Typically, a chemiluminescent signal captured on film records the hybridization, and the quantity of the signal is related to the amount of immobilized DNA. Digital imaging using a cooled CCD camera offers an alternate non-film-based method for image acquisition with comparable sensitivity of detection, a greater dynamic range, enhanced capability of data interpretation, and often faster results than film. In addition, the data support the premise that more accurate and precise human DNA quantification should be obtained by not assuming a linear response of signal to known standards. Instead, quantity should be estimated using a second-order standard curve (R2 = 0.999). Finally, a CCD camera imaging system offers versatility for image capture of different signal sources and analysis of samples on a variety of support media.

The government of Tanzania has made access to health care a priority. In particular, it has made great efforts to increase the number of facilities available to the rural population. By examining one such rural area, we find that although facilities exist and are staffed with competent clinicians, the quality of care received by patients visiting government facilities is subpar, especially that received by the poor in rural areas compared with urban areas. Importantly, nongovernmental organization (NGO) facilities provide better and more consistent care across the rural-urban divide. Access to high-quality care is inequitable, and this inequality is not inevitable. [ABSTRACT FROM AUTHOR]

Purpose: We investigated sex-related brain metabolic differences in Amyotrophic Lateral Sclerosis (ALS) and healthy controls (HC)., Methods: We collected two equal-sized groups of male (m-ALS) and female ALS (f-ALS) patients (n = 130 each), who underwent 2-[ 18 F]FDG-PET at diagnosis, matched for site of onset, cognitive status and King's stage. We included 168 age-matched healthy controls, half female (f-HC) and half male (m-HC). We compared brain metabolism of males and females separately for ALS and HC, including age as covariate. A differential network analysis was performed to evaluate brain connectivity., Results: M-ALS showed relative hypometabolism of bilateral medial frontal, parietal and occipital cortices, and left temporal cortex, compared to f-ALS. In node-wise comparison, f-ALS showed significantly higher connectivity in right middle cingulate cortex and left superior and medial frontal gyrus. In HC we did not find any sex-related differences., Conclusion: Sex resulted a major determinant of brain metabolism and connectivity in ALS patients., (© 2024 The Author(s). European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Cassava (Manihot esculenta Crantz) holds significant economic importance globally. Evaluating a diverse range of germplasm based on molecular characteristics not only enhances its preservation but also supports its utilization in breeding programs. In this study, we assessed genetic diversity and population structure among 155 cassava genotypes from Uganda using 5247 single nucleotide polymorphism (SNP) markers. Genotyping by sequencing (GBS) was employed for SNP discovery and to evaluate genetic diversity and population structure using the ADMIXTURE software. The cassava accessions comprised two populations: 49 accessions from Ugandan lines and 106 accessions resulting from crosses between South American and Ugandan lines. The average call rate of 96% was utilized to assess marker polymorphism. Polymorphic information content values of the markers ranged from 0.1 to 0.5 with an average of 0.4 which was moderately high. The principal component analysis (PCA) showed that the first two components captured ~ 24.2% of the genetic variation. The average genetic diversity was 0.3. The analysis of molecular variance (AMOVA) indicated that 66.02% and 33.98% of the total genetic variation occurred within accessions and between sub-populations, respectively. Five sub-populations were identified based on ADMIXTURE structure analysis (K = 5). Neighbor-joining tree and hierarchical clustering tree revealed the presence of three different groups which were primarily based on the source of the genotypes. The results suggested that there was considerable genetic variation among the cassava genotypes which is useful in cassava improvement and conservation efforts., Competing Interests: Declarations Conflict of interest The authors declare no competing interests. Disclaimer The funders had no role in the design of the study, data collection, analysis, or interpretation of the results or in the writing of the manuscript., (© 2024. The Author(s), under exclusive licence to Institute of Plant Genetics Polish Academy of Sciences.)

Background: Consumer health libraries connect communities to reliable and accurate health information while Little Free Libraries (LFL) provide communities globally with access to free books with a 'take one leave one' type policy., Objectives: To discuss how medical librarians used already established LFLs as outreach opportunities to provide consumer health books to rural locations in East Tennessee's Appalachia region in the United States., Methods: Researchers reviewed the population's literacy levels, the Index of Medical Underservice scores, and the availability of established LFLs. Twenty-two established LFL locations were selected and one new LFL was built for an eye clinic. Eleven health books were purchased for each established LFL, and 33 books were purchased for the new LFL., Results: Researchers went back to each location 5 months after delivery. 90% of the books were taken from the already established LFLs. Ten books were taken from the new LFL., Discussion: Using already established LFLs is a great opportunity to provide relevant health information to rural communities. The new LFL allowed for a partnership between the library and a rural eye clinic., Conclusion: By distributing health books to already established LFLs, researchers brought relevant health information books to rural and medically underserved communities., (© 2023 Health Libraries Group.)

Importance: Postmastectomy radiation therapy (PMRT) improves local-regional disease control and patient survival. Hypofractionation (HF) regimens have comparable efficacy and complication rates with improved quality of life compared with conventional fractionation (CF) schedules. However, the use of HF after mastectomy in patients undergoing breast reconstruction has not been prospectively examined., Objective: To compare HF and CF PMRT outcomes after implant-based reconstruction., Design, Setting, and Participants: This randomized clinical trial assessed patients 18 years or older undergoing mastectomy and immediate expander or implant reconstruction for breast cancer (Tis, TX, or T1-3) and unilateral PMRT from March 8, 2018, to November 3, 2021 (median [range] follow-up, 40.4 [15.4-63.0] months), at 16 US cancer centers or hospitals. Analyses were conducted between September and December 2023., Interventions: Patients were randomized 1:1 to HF or CF PMRT. Chest wall doses were 4256 cGy for 16 fractions for HF and 5000 cGy for 25 fractions for CF. Chest wall toxic effects were defined as a grade 3 or higher adverse event., Main Outcomes and Measures: The primary outcome was the change in physical well-being (PWB) domain of the Functional Assessment of Cancer Therapy-Breast (FACT-B) quality-of-life assessment tool at 6 months after starting PMRT, controlling for age. Secondary outcomes included toxic effects and cancer recurrence., Results: Of 400 women (201 in the CF arm and 199 in the HF arm; median [range] age, 47 [23-79] years), 330 patients had PWB scores at baseline and at 6 months. There was no difference in the change in PWB between the study arms (estimate, 0.13; 95% CI, -0.86 to 1.11; P = .80), but there was a significant interaction between age group and study arm (P = .03 for interaction). Patients younger than 45 years had higher 6-month absolute PWB scores if treated with HF rather than CF regimens (23.6 [95% CI, 22.7-24.6] vs 22.0 [95% CI, 20.7-23.3]; P = .047) and reported being less bothered by adverse effects (mean [SD], 3.0 [0.9] in the HF arm and 2.6 [1.2] in the CF arm; P = .02) or nausea (mean [SD], 3.8 [0.4] in the HF arm and 3.6 [0.8] in the CF arm; P = .04). In the as-treated cohort, there were 23 distant (11 in the HF arm and 12 in the CF arm) and 2 local-regional (1 in the HF arm and 1 in the CF arm) recurrences. Chest wall toxic effects occurred in 39 patients (20 in the HF arm and 19 in the CF arm) at a median (IQR) of 7.2 (1.8-12.9) months. Fractionation was not associated with chest wall toxic effects on multivariate analysis (HF arm: hazard ratio, 1.02; 95% CI, 0.52-2.00; P = .95). Fewer patients undergoing HF vs CF regimens had a treatment break (5 [2.7%] vs 15 [7.7%]; P = .03) or required unpaid time off from work (17 [8.5%] vs 34 [16.9%]; P = .02)., Conclusions and Relevance: In this randomized clinical trial, the HF regimen did not significantly improve change in PWB compared with the CF regimen. These data add to the increasing experience with HF PMRT in patients with implant-based reconstruction., Trial Registration: ClinicalTrials.gov Identifier: NCT03422003.

Objective: Acute laceration wound (ALW) is one of the most common injuries in Indonesia with potential significant morbidities. In rural areas, povidone-iodine and honey are commonly used as wound dressings. This study aimed to identify the effectiveness of honey compared to paraffin gauze and the commonly used povidone-iodine in improving ALW healing time., Method: This study was a single-blind, pilot randomised controlled trial (RCT) with three intervention groups (honey, povidone-iodine, and paraffin). The outcomes were wound healing time, slow healing, secondary healing, signs of infection, wound dehiscence, oedema, maceration, necrosis, exudate and cost., Results: A total of 35 patients (male to female ratio: 4:1), with a mean age of 22.5 (range: 6-47) years, were included and randomised to treatment groups using predetermined randomisation according to wound location and wound dressing selection: honey group, n=12; povidone-iodine group, n=11; paraffin group, n=12 with one patient lost to follow-up. All groups achieved timely healing, with a mean healing time of 9.45±5.31 days and 11.09±5.14 days for the povidone-iodine and paraffin groups, respectively, and a median healing time of 10 (3-19) days for the honey group (p>0.05). More wounds in the honey group achieved healing in ≤10 days compared with the other groups. Both povidone-iodine and honey groups had fewer adverse events, with the latter having the lowest cost., Conclusion: In this study, honey was clinically effective in accelerating healing time with a lower cost compared to paraffin, and was comparable to povidone-iodine. Future RCTs with a larger sample size should be pursued to determine honey's role in ALW treatment.

Purpose/objective(s): NIBB has potential advantages over other APBI techniques by delivering highly conformal radiation with minimal collateral dose to the heart and lung compared with external beam techniques, but unlike other brachytherapy techniques NIBB is non-invasive. Previous data has shown encouraging outcomes using a 10-fraction regimen. To improve efficiency, convenience, and cost, reduction in the fraction number is desirable. Final results of a prospective phase II trial are reported., Materials/methods: NIBB APBI was delivered using 28.5Gy in 5 fractions daily over 1 week. Patient eligibility criteria required: invasive carcinoma ≤2.0 cm or DCIS ≤3.0 cm, ER positive (if invasive), lymph node negative, LVI absent, and lumpectomy with margins negative by 2mm. The primary endpoint was grade ≥ 2 subcutaneous fibrosis/induration <30%. Secondary endpoints included any late toxicity, cosmetic outcome, and local control., Results: 40 patients were treated with a median follow-up of 59.7 months. The mean age was 67 years (50-89 years) and tumor size was 1.0cm (0.3-2.0cm). 80% had invasive carcinoma. The mean breast separation with compression was 6.7cm (3.5-8.9cm). The 5-year actuarial local control was 96.6% and overall survival was 96.9%. Grade 2 and 3 late toxicities were 15% and 0%, respectively. The rate of grade 2 subcutaneous fibrosis/induration was 2.5% (+/-2.5%) meeting the study's primary endpoint. The most common late toxicity of any grade was skin telangiectasia; 22.5% grade 1 and 15% grade 2. Only breast separation was associated with telangiectasia risk, p=0.002. Overall cosmetic outcome was excellent, good, and fair/poor in 75%, 25%, and 0%, respectively., Conclusions: NIBB APBI delivered in 5 fractions results in a low rate of late toxicity and a high rate of good/excellent cosmetic outcomes. Telangiectasia risk can be minimized by keeping breast separation ≤7.0cm. The local failure rate was appropriately low. Further investigation of this technique is warranted., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Textilomas are an infrequent but well-known surgical complication. The authors report a series of cases to describe the frequency of abdominal textilomas, the circumstances in which they occur, their clinical and morphological characteristics, and their management, to contextualise these data, which may serve as a basis for preventive measures., Setting and Method: This was a monocentric, retrospective, descriptive study conducted over 10 years at a tertiary hospital. The circumstances of the initial intervention, the diagnosis, and the treatment of textiloma cases treated in the said centre were documented., Results: Twenty-one (21) cases of abdominal textiloma were collected, with an annual frequency of 2.1 cases/year. The cases were predominantly female, with a female-to-male sex ratio of 1.62. The median age of the patients was 37 years. The initial operation was performed in a public facility in 80.95 % of cases. Myomectomy was the main indication (23.81 %). The time for signs to develop before consultation was 16.47 ± 8.82 days. Textiloma extraction was performed in an emergency in 61.90 % of cases. We noted morbidity (38.10 %) and mortality (9.52 %) in our patients., Conclusion: Textilomas are a rare surgical complication, albeit with a high morbidity and mortality rate. Their clinical polymorphism and the difficulties of diagnosis and management mean that prevention is of prime importance., Competing Interests: Declaration of competing interest The authors have no financial, consultative, institutional, or other relationships that might lead to bias or conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction and Importance: Tessier Craniofacial Clefts Numbers 0 and 1 represent unique facial deformities, with Number 0 involving midline structure hypoplasia and Number 1 exhibiting features like a notched soft triangle and affected alar dome. These anomalies can extend near the midline, leading to complications like telecanthus, necessitating innovative surgical strategies for reconstruction., Case Presentation: A five-month-old girl presented with Tessier 0 and 1 clefts and a dorsal nasal lipoma, challenging traditional repair methods due to structural limitations. This case required a comprehensive approach, including aesthetic excision of the lipoma and reconstruction of both the internal and external aspects of the nose., Clinical Discussion: The patient underwent successful nasal reconstruction using a transpositional alar flap with a pedicle from the angular artery and a hinge flap for the inner lining. The procedure involved cranial dissection through the flap incision for lipoma excision. This case highlights the complexity of nasal reconstruction in the presence of facial clefts and demonstrates the effectiveness of the alar transpositional flap as a viable technique for achieving aesthetically pleasing outcomes., Conclusion: The case underscores the necessity for precise surgical planning and execution to address both cosmetic and functional aspects of nasal defects in facial cleft patients., Competing Interests: Conflict of interest statement The authors declare no conflicts of interest related to this study., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The COVID-19 pandemic brought challenges requiring timely health data sharing to inform accurate decision-making at national levels. In Botswana, we adapted and integrated the Research Electronic Data Capture (REDCap) and the District Health Information System version 2 (DHIS2) platforms to support timely collection and reporting of COVID-19 cases. We focused on establishing an effective COVID-19 data flow at the national public health laboratory, being guided by the needs of health care professionals at the National Health Laboratory (NHL). This integration contributed to automated centralized reporting of COVID-19 results at the Ministry of Health (MOH)., Objective: This paper reports the experiences, challenges, and lessons learned while designing, adapting, and implementing the REDCap and DHIS2 platforms to support COVID-19 data management at the NHL in Botswana., Methods: A participatory design approach was adopted to guide the design, customization, and implementation of the REDCap platform in support of COVID-19 data management at the NHL. Study participants included 29 NHL and 4 MOH personnel, and the study was conducted from March 2, 2020, to June 30, 2020. Participants' requirements for an ideal COVID-19 data management system were established. NVivo 11 software supported thematic analysis of the challenges and resolutions identified during this study. These were categorized according to the 4 themes of infrastructure, capacity development, platform constraints, and interoperability., Results: Overall, REDCap supported the majority of perceived technical and nontechnical requirements for an ideal COVID-19 data management system at the NHL. Although some implementation challenges were identified, each had mitigation strategies such as procurement of mobile Internet routers, engagement of senior management to resolve conflicting policies, continuous REDCap training, and the development of a third-party web application to enhance REDCap's capabilities. Lessons learned informed next steps and further refinement of the REDCap platform., Conclusions: Implementation of REDCap at the NHL to streamline COVID-19 data collection and integration with the DHIS2 platform was feasible despite the urgency of implementation during the pandemic. By implementing the REDCap platform at the NHL, we demonstrated the possibility of achieving a centralized reporting system of COVID-19 cases, hence enabling timely and informed decision-making at a national level. Challenges faced presented lessons learned to inform sustainable implementation of digital health innovations in Botswana and similar resource-limited countries., (©Kagiso Ndlovu, Kabelo Leonard Mauco, Onalenna Makhura, Robin Hu, Nkwebi Peace Motlogelwa, Audrey Masizana, Emily Lo, Thongbotho Mphoyakgosi, Sikhulile Moyo. Originally published in JMIR Formative Research (https://formative.jmir.org), 16.04.2024.)

Objective: Penile skin avulsion is a rare complication of circumcision but commonly encountered as the result of traditional practice. We aimed to present the use of honey dressing and the benefit of its wound healing properties for management of such a complex wound., Case: A 24-year-old male patient with penile bleeding presented to the emergency department after undergoing traditional circumcision. Complete degloving of the penis with active bleeding and foul odour, along with heavy contamination of chewed betel leaves and powdered amoxicillin was found. Honey (Madu Nusantara, PT. Madu Nusantara, Indonesia) was used as dressing after copious irrigation using saline and povidone-iodine with bleeding control., Results: Honey dressing was shown to be effective for secondary wound healing of such a complicated and contaminated wound-in this case due to its antimicrobial, anti-inflammatory, immunostimulatory and autolytic debridement properties. A complete re-epithelialisation of the wound was achieved without progression to the hard-to-heal state by day 43. Suboptimal sexual function and aesthetic result due to wound contracture were observed as surgical reconstruction via split-thickness skin graft was refused due to cost., Conclusion: In this case report, honey dressing was shown to be effective for wound healing, even in a penile avulsion with complete skin loss and heavy contamination. In rural settings, where penile avulsion due to traditional circumcision is common, honey should be considered as one of the dressing choices.

Competing Interests: Declaration of Competing Interest None declared.

Background: Accuracy of tumor bed (TB) delineation is essential for targeting boost doses or partial breast irradiation. Multiple studies have shown high interobserver variability with standardly used surgical clip markers (CMs). We hypothesize that a radiopaque filament marker (FM) woven along the TB will improve TB delineation consistency., Methods: An FDA-approved FM was intraoperatively used to outline the TB of patients undergoing lumpectomy. Between January 2020 and January 2022, consecutive patients with FM placed after either (1) lumpectomy or (2) lumpectomy with oncoplastic reconstruction were identified and compared with those with CM. Six "experts" (radiation oncologists specializing in breast cancer) across 2 institutions independently defined all TBs. Three metrics (volume variance, dice coefficient, and center of mass [COM] deviation). Two-tailed paired samples t tests were performed to compare FM and CM cohorts., Results: Twenty-eight total patients were evaluated (14 FM and 14 CM). In aggregate, differences in volume between expert contours were 29.7% (SD ± 58.8%) with FM and 55.4% (SD ± 105.9%) with CM ( P < 0.001). The average dice coefficient in patients with FM was 0.54 (SD ± 0.15), and with CM was 0.44 (SD ± 0.22) ( P < 0.001). The average COM deviation was 0.63 cm (SD ± 0.53 cm) for FM and 1.05 cm (SD ± 0.93 cm) for CM; ( P < 0.001). In the subset of patients who underwent lumpectomy with oncoplastic reconstruction, the difference in average volume was 21.8% (SD ± 20.4%) with FM and 52.2% (SD ± 64.5%) with CM ( P <0.001). The average dice coefficient was 0.53 (SD ± 0.12) for FM versus 0.39 (SD ± 0.24) for CM ( P < 0.001). The average COM difference was 0.53 cm (SD ± 0.29 cm) with FM versus 1.25 cm (SD ± 1.08 cm) with CM ( P < 0.001)., Conclusion: FM consistently outperformed CM in the setting of both standard lumpectomy and complex oncoplastic reconstruction. These data suggest the superiority of FM in TB delineation., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In Indonesia, the prevalence of cleft lip and palate increased from 0.08% to 0.12% between 2013 and 2018. Children with cleft deformities typically undergo staged surgery. However, the coronavirus disease 2019 (COVID-19) pandemic has had negative impacts on the healthcare sector, including the suspension of elective procedures; this has raised concerns about the safety of performing surgery and the functional consequences of delaying treatment, the latter of which is associated with poor prognosis. The purpose of this study was to report the characteristics of clefts treated by the Bandung Cleft Lip and Palate Center team during the pandemic period., Methods: This brief comparative study based on a chart review was conducted at the Bandung Cleft Lip and Palate Center. We statistically evaluated data from all patients treated between September 2018 and August 2021. Frequency analysis was performed to analyze the average number of each procedure by age before and during the COVID-19 pandemic., Results: Data from 18-month periods before (n = 460) and during (n = 423) the pandemic were compared. Cheiloplasty procedures were examined (pre-pandemic, n = 230; pandemic, n = 248); before the pandemic, 86.1% were performed according to the treatment protocol (patient < 1 year old), and this proportion non-significantly dropped to 80.6% during the pandemic (p = 0.904). Palatoplasty procedures were also compared (pre-pandemic, n = 160; pandemic, n = 139); the treatment protocol (patient 0.5-2 years old) was followed for 65.5% of procedures before the pandemic and 75.5% during the pandemic (p = 0.509). Additionally, 70 (mean age, 7.94 years) revision and other procedures were performed before the pandemic and 36 (mean age, 8.52 years) during the pandemic., Conclusion: The cleft procedures performed at the Bandung Cleft Lip and Palate Center did not significantly change during the COVID-19 pandemic.

Background: The use of information and communication technologies for health-eHealth-is described as having potential to improve the quality of health care service delivery. Consequently, there is an increased global trend toward adoption of eHealth interventions by health care systems worldwide. Despite the proliferation of eHealth solutions, many health care institutions especially in transitioning countries are struggling to attain effective data governance approaches. The Ministry of Health in Botswana is an exemplar institution continually seeking better approaches to strengthen health data governance (HDG) approaches following the adoption of eHealth solutions. Recognizing the need for a global HDG framework, the Transform Health coalition conceptualized HDG principles that are structured around 3 interconnected objectives: protecting people, promoting the value of health, and prioritizing equity., Objective: The aim of the study is to solicit and evaluate perceptions and attitudes of health sector workers in Botswana toward the HDG principles by Transform Health and derive any future guidance., Methods: Purposive sampling was used to select participants. A total of 23 participants from various health care organizations in Botswana completed a web-based survey and 10 participated in a follow-up remote round-table discussion. The aim of the round-table discussion was to gain further insight into participants' responses from the web-based survey. Participants were from the following health care cadres: nurses, doctors, information technology professionals, and health informaticians. Both validity and reliability testing were performed for the survey tool before sharing it with study participants. An analysis of participants' close-ended responses from the survey was performed using descriptive statistics. Thematic analysis of open-ended responses from the questionnaire and the round-table discussion was achieved using the Delve software and the widely accepted principles of thematic analysis., Results: Although some participants highlighted having measures in place similar to the HDG principles, there were some who either did not know or disagreed that their organizations already had in place mechanisms similar to the proposed HDG principles. Participants further expressed relevance and importance of the HDG principles in the context of Botswana. However, some modifications to the principles were also suggested., Conclusions: This study highlights the necessity of data governance in health care particularly toward meeting the requirements for Universal Health Coverage. The existence of other health data governance frameworks calls for a critical analysis to assess the most appropriate and applicable framework in the context of Botswana and similar transitioning countries. An organization-centered approach may be most appropriate, as well as strengthening of existing organizations' HDG practices with the Transform Health principles., (©Kagiso Ndlovu, Kabelo Leonard Mauco, Star Chibemba, Steven Wanyee, Tom Oluoch. Originally published in JMIR Formative Research (https://formative.jmir.org), 13.03.2023.)

Purpose: Radiotherapy treatment planning is a complex process with multiple, dependent steps involving an interdisciplinary patient care team. Effective communication and real-time tracking of resources and care path activities are key for clinical efficiency and patient safety., Materials and Methods: We designed and implemented a secure, interactive web-based dashboard for patient care path, clinical workflow, and resource utilization management. The dashboard enables visualization of resource utilization and tracks progress in a patient's care path from the time of acquisition of the planning CT to the time of treatment in real-time. It integrates with the departmental electronic medical records (EMR) system without the creation and maintenance of a separate database or duplication of work by clinical staff. Performance measures of workflow were calculated., Results: The dashboard implements a standardized clinical workflow and dynamically consolidates real-time information queried from multiple tables in the EMR database over the following views: (1) CT Sims summarizes patient appointment information on the CT simulator and patient load; (2) Linac Sims summarizes patient appointment times, setup history, and notes, and patient load; (3) Task Status lists the clinical tasks associated with a treatment plan, their due date, status and ownership, and patient appointment details; (4) Documents provides the status of all documents in the patients' charts; and (5) Diagnoses and Interventions summarizes prescription information, imaging instructions and whether the plan was approved for treatment. Real-time assessment and quantification of progress and delays in a patient's treatment start were achieved., Conclusions: This study indicates it is feasible to develop and implement a dashboard, tailored to the needs of an interdisciplinary team, which derives and integrates information from the EMR database for real-time analysis and display of resource utilization and clinical workflow in radiation oncology. The framework developed facilitates informed, data-driven decisions on clinical workflow management as we seek to optimize clinical efficiency and patient safety., (© 2022 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

We assessed the potential for microbial interactions influencing a well-documented host-pathogen system. Mycoplasma agassizii is the known etiological agent of upper respiratory tract disease in Mojave desert tortoises (Gopherus agassizii), but disease in wild animals is extremely heterogeneous. For example, a much larger proportion of animals harbor M. agassizii than those that develop disease. With the availability of a new quantitative PCR assay for a microbe that had previously been implicated in disease, Pasteurella testudinis, we tested 389 previously collected samples of nasal microbes from tortoise populations across the Mojave desert. We showed that P. testudinis is a common commensal microbe. However, we did find that its presence was associated with higher levels of M. agassizii among the tortoises positive for this pathogen. The best predictor of P. testudinis prevalence in tortoise populations was average size of tortoises, suggesting that older populations have higher levels of P. testudinis. The prevalence of co-infection in populations was associated with the prevalence of URTD, providing additional evidence for an indirect interaction between the two microbes and inflammatory disease. We showed that URTD, like many chronic, polymicrobial diseases involving mucosal surfaces, shows patterns of a polymicrobial etiology., (© 2022. EcoHealth Alliance.)

Objectives: To evaluate response rate, toxicity, and efficacy of the novel combination of nab-paclitaxel, oxaliplatin, 5-fluorouracil, and leucovorin [FOLFOX-A] in patients with advanced pancreatic ductal adenocarcinoma [PDAC]., Methods: BrUOG-292 and BrUOG-318 were two concurrently run, prospective, single-arm phase II studies evaluating FOLFOX-A as first-line therapy in patients with metastatic and locally advanced/borderline resectable PDAC respectively. The FOLFOX-A regimen consisted of 5-fluorouracil, 1200 mg/m 2 /d as a continuous intravenous (IV) infusion over 46 hours, leucovorin 400 mg/m 2 IV, oxaliplatin 85 mg/m 2 IV, and nab-paclitaxel 150 mg/m 2 IV on day 1 every 14 days up to a maximum of 12 cycles. Patients with locally advanced or borderline resectable disease were permitted to stop treatment after 6 cycles and receive radiation therapy and/or surgical exploration if feasible. The primary end point was overall response rate [ORR]. Secondary end points were median progression-free survival [PFS], median overall survival [OS], and safety., Results: Seventy-eight patients with previously untreated PDAC were enrolled between June 2014 and November 2019; 76 patients were evaluable. The median follow-up was 40 months and 32 months, respectively. overall response rate was 34%. Among the patients enrolled on BrUOG-292 [48 patients], the PFS was 5 months and OS was 11 months, respectively. For those enrolled on BrUOG 318 [28 patients], the PFS was 11 months and OS was 22 months. Treatment-related toxicities included grade 3 fatigue [40%], diarrhea [14%], and neuropathy [2%]., Conclusions: The combination of FOLFOX-A has promising activity in PDAC and may represent an alternative to FOLFIRINOX when reduction of gastrointestinal toxicity is required., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Whether sentinel lymph node biopsy (SLNB) should be performed in patients with microinvasive breast cancer (MIBC) has been a matter of debate over the last decade. MIBC has a favorable prognosis and while metastasis to the axilla is rare, it can impact treatment recommendations. In this study we evaluated clinical and histological features in both MIBC and background DCIS including ER, PR, and HER-2, number of foci of MIBC, the extent of the DCIS, nuclear grade, presence of comedo necrosis, as well as surgical procedures, adjuvant treatment and follow up to identify variables which predict disease free survival (DFS), as well as the factors which influence clinical decision making. Our study included 72 MIBC patients with a mean patient follow-up time of 55 months. Three patients with MIBC had recurrence, and two deceased, leaving five patients in total with poor long-term outcomes and a DFS rate of 93.1%. Performing mastectomy, high nuclear grade, and negativity for ER and HER-2 were found to be associated with the use of SLNB, although none of these variables were found to be associated with DFS. One positive lymph node case was discovered following SLNB in our study. This suggests the use of SLNB may provide diagnostic information to some patients, although these are the anomalies. When comparing patients who had undergone SLNB to those which had not there was no difference in DFS. Certainly, the use of SLNB in MIBC is quite the conundrum. It is important to acknowledge that surgical complications have been reported, and traditional metrics used for risk assessment in invasive breast cancer may not hold true in the setting of microinvasion., (© 2022. The Author(s).)

Background: A librarian led task force at the University of Tennessee Medical Center sought to evaluate their medical centre's health literacy attributes utilizing a widely used tool. This research ultimately led to the update of the tool., Objectives: To discuss the evaluation of health literacy attributes of health care organizations and detail the process of updating the Health Literacy Environment of Hospitals and Health Centers (HLEHHC) tool., Methods: Subsequent to utilizing the HLEHHC, the task force was invited to assist in updating the tool. A collaborative was formed between the original author and task force. The collaborative performed an extensive literature review focused on emerging health literacy issues, reviewed each section and formulated changes., Results: The collaborative update process yielded an improved instrument for assessing the extent to which a health care organization accommodates low health literacy patients., Discussion: Through editing, creating new questions and rearranging the format, the HLEHHC was improved and updated., Conclusion: The assessment conducted by the health literacy task force is helping shape changes in the organization. Medical librarians acted in leadership roles in the collaborative process of developing the new institutional assessment tool for health literacy (HLE2)., (© 2021 Health Libraries Group.)

Objective: In order to determine the status of scholarly efforts on health literacy by librarians, researchers examined the characteristics of health literacy publications authored by librarians from 2000 to 2020., Methods: Bibliometric analysis was used to assess the indicators of productivity, affiliation, collaboration, and citation metrics of librarians in health literacy-related research. Data were collected using the Scopus database; articles were screened for inclusion before importation into Microsoft Excel for analysis. SPSS software was used to run basic descriptive statistics., Results: Of 797 search results, 460 references met the inclusion criteria of librarian authorship. There was a significant linear trend upward in publications since 2001 with an average increase of 1.52 papers per year. The number of publications per year peaked in 2019 (n=59). Journal of Consumer Health on the Internet was the most prolific journal. The majority of references were authored by at least two authors and by multidisciplinary teams. Nineteen percent (n=107) of the librarian authors were responsible for more than one publication, and 84.1% of publications were cited at least once., Conclusions: In the last two decades, librarian involvement in health literacy publications has exponentially increased, most markedly in the years following 2014. The productivity, multidisciplinary collaboration efforts, and consistent growth in literature indicate that librarians are engaged in health literacy scholarship. Further research is needed to explore the work of librarians whose impacts on health literacy may not be reflected within well-indexed, peer-reviewed publications., (Copyright © 2022 Alexandria Quesenberry Wilson, Courtney Wombles, R. Eric Heidel, Kelsey Leonard Grabeel.)

Background: Similar to many low- and middle-income countries, Botswana has identified eHealth as a means of improving health care service provision and delivery. The National Malaria Programme (NMP) in Botswana has implemented the District Health Information System version 2 (DHIS2) to support timely malaria case reporting across its 27 health districts; however, the implementation of an eHealth system is never without challenges. Barriers to the implementation of eHealth innovations within health care settings may arise at the individual or organizational levels. As such, the evaluation of user perceptions of the technology is an important step that can inform its sustainable implementation. The DHIS2 was implemented without evaluating user perceptions beforehand; therefore, the Botswana Ministry of Health and Wellness was uncertain about the likelihood of acceptance and use of the platform., Objective: We aimed to determine the acceptance of the DHIS2 platform by the NMP in Botswana to gauge whether adoption would be successful., Methods: The study's design was informed by constructs of the technology acceptance model. A survey, with items assessed using a 7-point Likert scale, and focus group discussions were undertaken with DHIS2 core users from 27 health districts and NMP personnel at the Ministry of Health and Wellness. The web-based survey was administered from August 3, 2020 to September 30, 2020., Results: Survey participants were core users (n=27). Focus group participants were NMP personnel (n=5). Overall, participants' survey responses (frequently occurring scores of 7) showed their confidence in the DHIS2 platform for case-based surveillance of malaria; however, participants also noted some organizational issues that could compromise user acceptance of the DHIS2 platform., Conclusions: Participants' responses indicated their acceptance of the DHIS2 platform; however, the consideration of factors related to organizational readiness could further enhance successful acceptance, and consequently, successful adoption of the platform by the malaria program in Botswana., (©Kagiso Ndlovu, Kabelo Leonard Mauco, Mpho Keetile, Khutsafalo Kadimo, Refilwe Yvonne Senyatso, Davies Ntebela, Buthugwashe Valela, Clement Murambi. Originally published in JMIR Formative Research (https://formative.jmir.org), 15.03.2022.)

Background: Trastuzumab is a monoclonal antibody against HER2 (also known as ERBB2). The primary objective of the NRG Oncology/RTOG-1010 trial was to establish whether trastuzumab improves disease-free survival when combined with trimodality treatment (paclitaxel plus carboplatin and radiotherapy, followed by surgery) for patients with untreated HER2-overexpressing oesophageal adenocarcinoma., Methods: NRG Oncology/RTOG-1010 was an open label, randomised, phase 3 trial for which patients were accrued from 111 NRG-affiliated institutions in the USA. Eligible patients were adults (aged ≥18 years) with newly diagnosed pathologically confirmed oesophageal adenocarcinoma, American Joint Committee on Cancer 7th edition T1N1-2 or T2-3N0-2 stage disease, and a Zubrod performance status of 0-2. Patients were stratified by adenopathy (no vs yes [coeliac absent] vs yes [coeliac present ≤2 cm]) and randomly assigned (1:1) to receive weekly intravenous paclitaxel (50 mg/m 2 intravenously over 1 h) and carboplatin (area under the curve 2, intravenously over 30-60 min) for 6 weeks with radiotherapy 50·4 Gy in 28 fractions (chemoradiotherapy) followed by surgery, with or without intravenous trastuzumab (4 mg/kg in week one, 2 mg/kg per week for 5 weeks during chemoradiotherapy, 6 mg/kg once presurgery, and 6 mg/kg every 3 weeks for 13 treatments starting 21-56 days after surgery). The primary endpoint, disease-free survival, was defined as the time from randomisation to death or first of locoregional disease persistence or recurrence, distant metastases, or second primary malignancy. Analyses were done by modified intention to treat. This study is registered with Clinicaltrials.gov, NCT01196390; it is now closed and in follow-up., Findings: 606 patients were entered for HER2 assessment from Dec 30, 2010 to Nov 10, 2015, and 203 eligible patients who were HER2-positive were enrolled and randomly assigned to chemoradiotherapy plus trastuzumab (n=102) or chemoradiotherapy alone (n=101). Median duration of follow-up was 2·8 years (IQR 1·4-5·7). Median disease-free survival was 19·6 months (95% CI 13·5-26·2) with chemoradiotherapy plus trastuzumab compared with 14·2 months (10·5-23·0) for chemoradiotherapy alone (hazard ratio 0·99 [95% CI 0·71-1·39], log-rank p=0·97). Grade 3 treatment-related adverse events occurred in 41 (43%) of 95 patients in the chemoradiotherapy plus trastuzumab group versus 52 (54%) of 96 in the chemoradiotherapy group and grade 4 events occurred in 20 (21%) versus 21 (22%). The most common grade 3 or worse treatment-related adverse events for both groups were haematological (53 [56%] of 95 patients in the chemoradiotherapy plus trastuzumab group vs 55 [57%] of 96 patients in the chemotherapy group) or gastrointestinal disorders (28 [29%] vs 20 [21 %]). 34 (36%) of 95 patients in the chemoradiotherapy plus trastuzumab group and 27 (28%) of 96 patients in the chemoradiotherapy only group had treatment-related serious adverse events. There were eight treatment-related deaths: five (5%) of 95 patients in the chemoradiotherapy plus trastuzumab group (bronchopleural fistula, oesophageal anastomotic leak, lung infection, sudden death, and death not otherwise specified), and three (3%) of 96 in the chemoradiotherapy group (two multiorgan failure and one sepsis)., Interpretation: The addition of trastuzumab to neoadjuvant chemoradiotherapy for HER2-overexpressing oesophageal cancer was not effective. Trastuzumab did not lead to increased toxicities, suggesting that future studies combining it with or using other agents targeting HER2 in oesophageal cancer are warranted., Funding: National Cancer Institute and Genentech., Competing Interests: Declaration of interests LAK reports personal fees from UpToDate and New Beta Innovations, and grants from Varian Medical Systems, outside the submitted work. DHI reports personal fees from Bristol Myers Squibb, Genentech, AstraZeneca, Merck, AMGEN, TAIHO, and Bayer, outside the submitted work. KLL reports personal fees from Elsevier, outside the submitted work. HM reports personal fees from Merck, outside the submitted work, and has received honoraria as chapter co-author for UpToDate (the chapters are all about gastrointestinal malignancies, but not oesophageal cancer). JM and KW report grants from the National Cancer institute (NCI) and other support from Genentech, during the conduct of the study. TD reports a patent for an intraoperative brachytherapy device. AKS, AWK, MGH, HPS, CHC, SS, MR, DADP, TSH, CMA, DW, LPL, XS, JS, and LR declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

This study aimed to evaluate the influence of formulation and procedure parameters in obtaining thick and continuous chitosan/PVA/glycerol nanofibres to be applied in skin care. For that, the polymers were characterized by nuclear magnetic resonance, Fourier-transform infrared spectroscopy, and size-exclusion chromatography. After this, 96 chitosan/PVA/glycerol nanofibre scaffolds were prepared by electrospinning method, using factorial designs. The independent variables were crude and pure chitosan, 2 brands of PVA, 2 needle gauges, high and low polymer concentration, high and low glycerol concentration, and final solution with and without ultrafiltration. Morphological analysis was performed by scanning electron microscopy, atomic force microscopy, and confocal microscopy. The best sample (NF67) presented an average thickness of 268.3 nm, uniform distribution, and high yield. It was obtained at a 1:3.5 (crude chitosan: PVA with lower molecular weight, but more hydrolysed) ratio and lower glycerol concentration, suggesting that the degree of hydrolysis of the PVA is more important than its molecular weight for obtaining better quality nanofibres and that the glycerol also makes the electrospinning process difficult. Thus, it was possible to choose parameters that provide scaffolds that could be applied as a matrix extracellular-like material in wound healing., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purpose: Renovation of the brachytherapy program at a leading cancer center utilized methods of the AAPM TG-100 report to objectively evaluate current clinical brachytherapy workflows and develop techniques for minimizing the risk of failures, increasing efficiency, and consequently providing opportunities for improved treatment quality. The TG-100 report guides evaluation of clinical workflows with recommendations for identifying potential failure modes (FM) and scoring them from the perspective of their occurrence frequency O, failure severity S, and inability to detect them D. The current study assessed the impact of differing methods to determine the risk priority number (RPN) beyond simple multiplication., Methods and Materials: The clinical workflow for a complex brachytherapy procedure was evaluated by a team of 15 staff members, who identified discrete FM using alternate scoring scales than those presented in the TG-100 report. These scales were expanded over all clinically relevant possibilities with care to emphasize mitigation of natural bias for scoring near the median range as well as to enhance the overall scoring-system sensitivity. Based on staff member perceptions, a more realistic measure of risk was determined using weighted functions of their scores., Results: This new method expanded the range of RPN possibilities by a factor of 86, improving evaluation and recognition of safe and efficient clinical workflows. Mean RPN values for each FM decreased by 44% when changing from the old to the new clinical workflow, as evaluated using the TG-100 method. This decreased by 66% when evaluated with the new method. As a measure of the total risk associated with an entire clinical workflow, the integral of RPN values increased by 15% and decreased by 31% with the TG-100 and new methods, respectively., Conclusions: This appears to be the first application of an alternate approach to the TG-100 method for evaluating the risk of clinical workflows. It exemplifies the risk analysis techniques necessary to rapidly evaluate simple clinical workflows appropriately., (Copyright © 2021 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Although rare, electrical injury in pediatrics is potentially life threatening and has significant and long-term impact in life. It is challenging to manage such cases in rural areas., Presentation of Case: A fully conscious 13-year-old boy was admitted to the emergency room after being electrocuted by high-voltage power cable, with superficial partial thickness burn over right arm, trunk, and left leg (26 % of total body surface area). Tachycardia and non-specific ST depression was found on ECG examination and was diagnosed with high-voltage electrical injury. Treatments were based on ANZBA algorithm with several modifications, i.e., administering lower concentration of oxygen with nasal cannula instead of non-rebreathing mask as well as Ketorolac and Antrain® for analgesic instead of morphine., Discussion: Different choices of treatments were given due to limited resources. Despite possible cardiac and renal complication, further tests could not be done. Fortunately, after strict monitoring, no signs of abnormality were found. We used silver sulfadiazine, Sofratulle® and dry sterile gauze as a dressing of choice following immediate surgical debridement. The patient was observed daily through 7 days of hospitalization and followed-up for 1 year, achieving normal physiologic function of the affected area but unsatisfactory esthetic result., Conclusion: Lack of infrastructure, drugs, and trained personnel are some of the challenges that still exist in most rural areas. Thus, implementation of available standardized guidelines such as ANZBA, and giving similar training to personnel as well as providing feasible equipment followed by strict monitoring for the patient are needed to achieve maximum results., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: The noninvasive image-guided breast brachytherapy (NIBB) technique is a novel noninvasive yet targeted method for accelerated partial breast irradiation. We established a multi-institutional registry to evaluate the toxicity and efficacy of this technique across various practice settings., Methods and Materials: Institutions using the NIBB technique were invited to participate. Data for acute/late toxicity, cosmetic outcome, and tumor recurrence were collected. Toxicity and cosmetic outcome were graded based on the Common Terminology Criteria for Adverse Events version 3.0 and NRG/Radiation Therapy Oncology Group scale, respectively. Treatment variables were analyzed for association with outcomes., Results: A total of 252 patients from eight institutions were analyzed. The median age was 69 years. The mean tumor size was 1.1 cm (0.1-4.0 cm). Treatment was delivered 10 fractions (34-36 Gy) in 75% and five fractions (28.5 Gy) in 22%. B.i.d. fractionation was used in 9%. Acute radiation dermatitis was Grade 0-1, 2, and 3 in 77%, 19%, and 4%, respectively. One hundred ninety-one patients with a median followup of 18 months (4-72 months) were evaluable for late outcomes. Late toxicity Grades 2 and 3 were observed in 8.8% and 1%, respectively. Cosmetic outcome was excellent, good, and fair/poor in 62%, 36%, and 2%, respectively. B.i.d. fractionation was associated with higher acute and late toxicity. Second-generation applicators were associated with lower late toxicity and better cosmetic outcome. Actuarial freedom from ipsilateral breast tumor recurrence and true recurrence were 98.3% and 98.3% at 2 years and 90.9% and 95.4% at 5 years, respectively., Conclusions: Accelerated partial breast irradiation using NIBB was well tolerated with a low rate of acute and late toxicity across various practice settings. Ipsilateral breast tumor recurrence and cosmetic outcomes were favorable. b.i.d. fractionation was associated with higher toxicity. Longer followup is needed to confirm late endpoints., (Copyright © 2021 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Purpose: Mammographically based noninvasive image-guided breast brachytherapy (NIBB) partial breast irradiation (PBI) is ideally suited for preoperative treatment. We hypothesize that delivering NIBB PBI to the preoperative tumor volume compared with the postoperative lumpectomy bed would simplify target identification and allow for a reduction in irradiated volume along each orthogonal axis., Methods and Materials: Patients with invasive breast cancer treated with NIBB PBI at our institution were identified. Preoperative NIBB treatments were modeled along orthogonal craniocaudal and mediolateral axes with an applicator encompassing the gross lesion plus a 1 cm clinical target volume margin. Preoperative treatment volumes were calculated along each axis using the selected applicator surface area multiplied by the preoperative mammogram separation. The actual applicator size and breast separation from the first fraction of postoperative treatment was used to calculate the postoperative treatment volume. Paired -test was used to compare the preoperative and postoperative treatment separation, area, and volume for each patient., Results: Forty-eight patients with Stage I-II breast cancer had imaging and treatment data available for review. Along the axis, the mean preoperative treatment volume was significantly less than the mean postoperative treatment volume (116 cm 3 vs. 204 cm 3 , respectively; p < 0.0001). Similarly, along the mediolateral axis, the mean preoperative treatment volume was significantly less than the mean postoperative treatment volume (125 cm 3 vs. 216 cm 3 , respectively; p < 0001)., Conclusions: Based on our retrospective comparison, PBI delivered using NIBB to the preoperative tumor may reduce the volume of healthy breast tissue receiving radiation as compared with NIBB to the postoperative tumor bed., (Copyright © 2020 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Background: Starting in the 1990s, health care providers began prescribing opioids to patients as pain relievers, believing they were safe. However, many patients became addicted to these pills. In 2017, the US Department of Health and Human Services declared a public health emergency to fight the opioid epidemic. This crisis was prevalent in East Tennessee, where many residents were prescribed opioids., Case Presentation: Librarians at an academic medical center library in East Tennessee analyzed the health information requests related to pain, mental health, and addiction over the last fifteen years. We reviewed the pattern of requests related to these topics, the counties requesting this information, and the impact that these hospital policies had on these requests., Conclusions: From 2005 to 2014, there were few requests about mental health, pain, and substance abuse. However, once the library moved into the hospital and there was an increase in awareness of opioid addiction, requests on those topics increased. Most of the requests were about pain, with the height occurring in 2017, during which year the public health emergency to fight the epidemic was declared. Additionally, 2017 was the year the hospital implemented visitor limitations for patients with infections associated with intravenous drug use, which might explain the drastic drop in substance abuse information requests in 2018. Future outreach will target counties that have a high opioid prescription rate., (Copyright © 2021 Kelsey Leonard Grabeel, Jenny C. Moore.)

Purpose: Noninvasive image guided breast brachytherapy (NIBB) is a novel approach to delivery of accelerated partial breast irradiation (APBI) that may hold advantages over established techniques. NIBB is not invasive but maintains a high level of precision by using breast immobilization via breast compression and image guidance; it therefore does not require large planning tumor volume margins. We present the primary outcomes of this prospective phase 2 study (BrUOG Br-251)., Methods and Materials: Eligible patients with early-stage breast cancer underwent NIBB APBI using a dose 34 Gy in 10 fractions delivered daily or twice a day. Treatment was delivered using an Ir-192 high-dose-rate source via specialized applicators. Two orthogonal treatment axes were used for each fraction. The primary endpoints were late toxicity and cosmesis assessed at 2 and 5 years. Toxicity was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events v3.0. Cosmesis was assessed using the NRG/Radiation Therapy Oncology Group scale. Ipsilateral breast tumor recurrence was defined as any recurrence or new primary in the treated breast., Results: Forty patients underwent protocol treatment. Median patient age was 68 years (50-92 years). Mean tumor size was 1.1 cm (0.3-3.0 cm). Among the cohort, 62.5% had invasive carcinoma and 37.5% had ductal carcinoma in situ. Thirty-nine percent elected to receive hormone therapy. No grade ≥3 late toxicities were observed at any time point. Grade 2 toxicity was 5% and 10% at 2 and 5 years, respectively. Telangiectasia grade 1 and 2 occurred in 27.5% and 5%, respectively. Breast separation of >7 cm was associated with telangiectasia (P < .01). The rate of good to excellent cosmetic outcome was 95% at 2 years and 100% at 5 years. With a median follow-up of 68 months, the actuarial 5-year freedom from ipsilateral breast tumor recurrence was 93.3% (±4.8%), and overall survival was 93.7% (±4.4%)., Conclusions: NIBB to deliver APBI is well tolerated with a low incidence of significant late toxicity and has favorable cosmetic outcomes. Continued evaluation of the NIBB APBI technique in a larger cohort is warranted., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Studies document e-health as having potential to improve quality of healthcare services, resulting in both developed and developing countries demonstrating continued interest in e-health uptake and use. e-Health implementations are not always successful as high failure rates have been reported in both developed and developing countries. These failures are often a result of lack of e-health readiness. e-Health readiness has been defined as the preparedness of healthcare institutions or communities for the anticipated change brought by programs related to information and communication technologies. As such it is critical to conduct an e-health readiness assessment prior to implementation of e-health innovations so as to reduce chances of project failure. Noting the absence of an adequate e-health readiness assessment framework (eHRAF) suitable for use in developing countries, the authors conceptualised, designed, and created a developing country specific eHRAF to aid in e-health policy planning. The aim of this study was to validate the developed eHRAF and to determine if it required further refinement before empirical testing., Methods: Published options for a framework validation process were adopted, and fifteen globally located e-health experts engaged. Botswana experts were engaged using saturation sampling, while international experts were purposively selected. Responses were collated in an Excel spreadsheet, and NVivo 11 software used to aid thematic analysis of the open ended questions., Results: Analysis of responses showed overall support for the content and format of the proposed eHRAF. Equivocal responses to some open ended questions were recorded, most of which suggested modifications to terms within the framework. One expert from the developed world had alternate views., Conclusions: The proposed eHRAF provides guidance for e-health policy development and planning by identifying, in an evidence based manner, the major areas to be considered when preparing for an e-health readiness assessment in the context of developing countries.

Purpose: To evaluate cardiac imaging abnormalities after modern radiotherapy and trastuzumab in breast cancer patients., Patients and Methods: All patients treated with trastuzumab and radiotherapy for breast cancer between 2006 and 2014 with available cardiac imaging (echocardiogram or multigated acquisition scan) were retrospectively analyzed. Cardiac abnormalities included myocardial abnormalities (atrial or ventricular dilation, hypertrophy, hypokinesis, and impaired relaxation), decreased ejection fraction > 10%, and valvular abnormalities (thickening or stenosis of the valve leaflets). Breast laterality (left vs. right) and heart radiation dose volume parameters were analyzed for association with cardiac imaging abnormalities., Results: A total of 110 patients with 57 left- and 53 right-sided breast cancers were evaluated. Overall, 37 patients (33.6%) developed a new cardiac abnormality. Left-sided radiotherapy was associated with an increase in new cardiac abnormalities (relative risk [RR] = 2.51; 95% confidence interval [CI], 1.34-4.67; P = .002). Both myocardial and valvular abnormalities were associated with left-sided radiotherapy (myocardial: RR = 2.21; 95% CI, 1.06-4.60; P = .029; valvular: RR = 3.30; 95% CI, 0.98-10.9; P = .044). There was no significant difference in decreased ejection fraction between left- and right-sided radiotherapy (9.6% vs. 2.1%; P = .207). A mean heart dose > 2 Gy as well as volume of the heart receiving 20 Gy (V20), V30, and V40 correlated with cardiac abnormalities (mean heart dose > 2 Gy: RR = 2.00; P = .040)., Conclusion: New cardiac abnormalities, including myocardial and valvular dysfunction, are common after trastuzumab and radiotherapy. The incidence of new abnormalities correlates with tumor laterality and cardiac radiation dose exposure. Long-term follow-up is needed to understand the clinical significance of these early imaging abnormalities., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: While the noninvasive breast brachytherapy (NIBB) treatment procedure, known as AccuBoost, for breast cancer patients is well established, the treatment quality can be improved by the efficiency of the workflow delivery. A formalized approach evaluated the current workflow through failure modes and effects analysis and generated insight for developing new procedural workflow techniques to improve the clinical treatment process., Methods and Materials: AccuBoost treatments were observed for several months while gathering details on the multidisciplinary workflow. A list of possible failure modes for each procedure step was generated and organized by timing within the treatment process. A team of medical professionals highlighted procedural steps that unnecessarily increased treatment time, as well as introduced quality deficiencies involving applicator setup, treatment planning, and quality control checks preceding brachytherapy delivery. Procedural improvements and their impact on the clinical workflow are discussed., Results: The revised clinical workflow included the following key procedural enhancements. Prepatient arrival: Improvement of prearrival preparation requires advance completion of dose calculation documentation with patient-specific setup data. Patient arrival pretreatment: Physicists carry out dwell time calculations and check the plan, while the therapist concurrently performs several checks of the ensuing hardware configuration., Treatment: An electronic method to export the associated HDR brachytherapy paperwork to the electronic medical record system with electronic signatures and captured approvals was generated. Posttreatment: The therapist confirms the applicators were appropriately positioned, and treatment was delivered as expected., Conclusions: The procedural improvements reduced the overall treatment time, improved consistency across users, and eased performance of this special procedure for all participants., (Copyright © 2020 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Recent studies reveal public-sector healthcare providers in low- and middle-income countries (LMICs) are frequently absent from work, solicit informal payments for service delivery, and engage in disrespectful or abusive treatment of patients. While extrinsic factors may foster and facilitate these negative practices, it is not often feasible to alter the external environment in low-resource settings. In contrast, healthcare professionals with strong intrinsic motivation and a desire to serve the needs of their community are less likely to engage in these negative behaviors and may draw upon internal incentives to deliver a high quality of care. Reforming medical education admission and training practices in LMICs is one promising strategy for increasing the prevalence of medical professionals with strong intrinsic motivation.

Background: A diagnosis of breast cancer (BC) can result in multifactorial stress. If not addressed, distress can have a negative impact on outcomes. The experience of patients with newly diagnosed BC has not been sufficiently investigated. This study characterizes distress among new patients in a multidisciplinary care (MDC) clinic. The study aimed to determine the degree of distress at presentation, to characterize the sources, and to evaluate the impact of an MDC visit., Methods: A retrospective review was performed from January 2015 to November 2017. Charts were accessed for demographics, tumor characteristics, and treatment data. Distress scores (DS) and problems as captured using the National Comprehensive Cancer Network (NCCN) Distress Thermometer were completed before evaluation and in a subgroup after an MDC visit. Predictors of severe distress (DS ≥4) were investigated using multivariable logistic regression. The paired t test was used to determine the impact of an MDC visit., Results: The mean initial DS (n = 474) was 4.98. The top four sources of distress were worry, anxiety, fears, and sadness. Age younger than 65 years was significantly associated with a higher DS at presentation (p < 0.003). Among the patients queried before and after MDC (n = 137), a significant reduction in distress was identified (5.58-2.94; p < 0.0005)., Conclusions: Severe distress was found in 66 % of the patients with a recent diagnosis of BC, with younger age related to higher distress scores at presentation. Emotional stressors were the predominant factors accounting for distress. A same-day MDC visit was associated with a significant reduction in DS. These data indicate the importance and feasibility of proactively screening patients. Our research lends support to the value of multidisciplinary evaluation in this setting.

Background: Electronic health (eHealth) readiness has been defined as the preparedness of health care institutions or communities for the anticipated change brought about by programs related to information and communication technology use. To ascertain the degree of such preparedness, an eHealth readiness assessment (eHRA) is needed. Literature on the existing eHRA frameworks and tools shows high inconsistency in content, definitions, and recommendations, and none have been found to be entirely suitable for assessing eHealth readiness in the context of developing countries. To develop an informed eHRA framework and tools with applicability to Botswana and similar developing countries, insight was sought from a broad spectrum of eHealth key informants in Botswana to identify and inform relevant issues, including those not specifically addressed in available eHRA tools., Objective: The aim of this study was to evaluate key informant (local expert) opinions on aspects that need to be considered when developing an eHRA framework suitable for use in developing countries., Methods: Interviews with 18 purposively selected key informants were recorded and transcribed. Thematic analysis of transcripts involved the use of an iterative approach and NVivo 11 software. The major themes, as well as subthemes, emerging from the thematic analysis were then discussed and agreed upon by the authors through consensus., Results: Analysis of interviews identified four eHealth readiness themes (governance, stakeholder issues, resources, and access), with 33 subthemes and 9 sub-subthemes. A major finding was that these results did not directly correspond in content or order to those previously identified in the literature. The results highlighted the need to perform exploratory research before developing an eHRA to ensure that those topics of relevance and importance to the local setting are first identified and then explored in any subsequent eHRA using a locally relevant framework and stakeholder-specific tools. In addition, seven sectors in Botswana were found to play a role in ensuring successful implementation of eHealth projects and might be targets for assessment., Conclusions: Insight obtained from this study will be used to inform the development of an evidence-based eHealth readiness assessment framework suitable for use in developing countries such as Botswana., (©Kabelo Leonard Mauco, Richard Ernest Scott, Maurice Mars. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 22.08.2019.)

When Preston Medical Library moved inside the Medical Center in September 2014, the new patient library, called the Health Information Center (HIC), was added. This addition is a patient focused, consumer health library that, among other things, offers health information and books. After the initial marketing plan was implemented, a task force was created to focus specifically on marketing the consumer health library and its resources. This article discusses how the task force revamped the marketing strategy to include outreach into the medical center's waiting rooms and other opportunities for collaboration.

Background: Brain metastases (BM) occur in ∼5% of breast cancer patients. BRCA1-associated cancers are often basal-like and basal-like cancers are known to have a predilection for central nervous system metastases. We performed a matched-pair analysis of breast cancer patients with and without BRCA mutations and compared the frequency of BM in both groups., Materials and Methods: From a database of 1935 patients treated for localized breast cancer at our institution from 2009 to 2014 we identified 20 patients with BRCA1 or BRCA2 mutations and manually matched 40 patients without BRCA mutations accounting for age, stage, estrogen receptor expression, and human epidermal growth factor receptor 2 (HER2) expression. Comparisons of freedom from brain metastasis, brain metastasis-free survival, and overall survival were made using the log rank test. Testing for a basal-type phenotype using the immunohistochemistry definition (ER/PR/HER2 and either CK 5/6 or EGFR) was performed for BRCA patients who developed BM and their matched controls., Results: We analyzed 60 patients: 20 BRCA and 40 were matched controls. Median follow-up was 37 and 49 months, respectively. Three years freedom from brain metastasis was 84% for BRCA patients and 97% for BRCA controls (P=0.049). Three years brain metastasis-free survival was 84% and 97% for the BRCA+ and controls, respectively (P=0.176). Mean time to brain failure was 11 months from diagnosis for the BRCA patients. All 3 BRCA1 patients who developed BM were of a basal-type triple negative phenotype., Conclusions: Breast cancer patients with germline BRCA1 mutations appear to have a shorter interval to brain progression while accounting for confounding factors.

Purpose: To improve efficiency, convenience, and cost, a prospective phase II trial was initiated to evaluate accelerated partial breast irradiation delivered with noninvasive image-guided breast brachytherapy (NIBB) via five once-daily fractions., Methods and Materials: Women ≥50 years old with early-stage breast cancer undergoing breast conserving surgery were enrolled. Eligibility criteria included invasive carcinoma ≤2.0 cm or ductal carcinoma in situ ≤3.0 cm, ER positive (if invasive), lymph node negative, LVI absent, and margins negative by 2 mm. Patients received a total dose of 28.5 Gy in five daily fractions. NIBB was delivered using two orthogonal axes for each fraction. Applicators were selected to encompass the lumpectomy cavity with a 1.0 cm clinical target volume margin and 0 to 0.5 cm planning target volume margin. Acute and late toxicity was assessed based on CTCAE v3.0., Results: Forty patients with a mean age of 67 years underwent protocol treatment. Mean tumor size was 1.0 cm (0.3-2.0 cm). Eighty percent had invasive carcinoma and the remainder had ductal carcinoma in situ. Mean tumor bed volume was 21 cc (5-79 cc) and mean breast volume was 1319 cc (499-3044 cc). Mean breast separation with compression was 6.7 cm (3.5-8.9 cm). All patients tolerated well. Median discomfort with compression was 1 (range: 0-7) on a 10-point pain scale. Acute skin reaction was Grade 0-1 in 70%, Grade 2 in 28%, and Grade 3 in 3%. Acute skin toxicity was not associated with breast size but was associated with larger breast separation with compression (p < 0.01) and larger applicator size (p < 0.01). No Grade 3+ late toxicity or local recurrences have been observed at a median followup of 14 months., Conclusions: Accelerated partial breast irradiation delivered using NIBB over five daily fractions is a convenient treatment option that is feasible and well tolerated., (Copyright © 2018 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Background: The Food Insecurity Experience Scale (FIES) is a UN FAO-Voices of the Hungry project (FAO-VoH) metric of food insecurity (FI). The FAO-VoH tested the psychometric properties of FIES with the use of global 2014 Gallup World Poll (GWP) data. However, similarities in its psychometric structure in sub-Saharan Africa (SSA) to allow aggregation of SSA results were untested., Objectives: We aimed to 1) assess the validity of FIES for use in SSA, 2) determine the prevalence of FI by country, age group, and gender, and 3) examine the sociodemographic and economic characteristics of individuals with FI., Methods: The Rasch modeling procedure was applied to data collected by GWP in 2014 and 2015 on 57,792 respondents aged ≥19 y in SSA., Results: FIES largely met the Rasch model assumptions of equal discrimination and conditional independence. However, 34.3% of countries had high outfits (≥2.0) for the item "went without eating for a whole day." Four countries had significant correlations for the items "were hungry but did not eat" and "ran out of food." The overall prevalence of severe FI (SFI) was 36.4%, ranging from 6.0% in Mauritius to 87.3% in South Sudan. Older adults were at significantly higher risk of SFI than younger adults (38.6% and 35.8%, respectively, P  < 0.0001), and women more than men (37.3% and 35.4%, respectively, P  < 0.0001). Higher proportions of individuals with SFI were rural residents, less educated, lower income, unemployed, and lived in households with many children under the age of 15 y., Conclusions: FIES has acceptable levels of internal validity for use in SSA. However, the item "went without eating for a whole day" may need cognitive testing in a few SSA countries. For countries with correlated items, 1 of the items may be excluded.

Patient engagement in health care decisions largely depends on a patient's health literacy and the health literacy attributes of the health care organization. Librarians have an established role in connecting patients with health information in the context of their care. However, librarians can play a larger role in helping to make changes in their organization's health literacy attributes. This article discusses one medical library's process of leading systematic assessment of their organization's health literacy attributes. Included in this discussion is the institutional support, timeline, assessment tool, the results for five areas of health literacy, marketing and the event-planning process to disseminate results. The systematic assessment process described employs the Health Literacy Environment of Hospitals and Health Centers document, which provides assessment tools for Print Communication, Oral Communication, Navigation, Technology, and Policies and Protocols.