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BACKGROUND: Misuse of prescription opioids is a well-established contributor to the US opioid epidemic. The primary objective of this study was to identify which level of care delivery (ie patient, prescriber, or hospital) produced the most unwarranted variation in opioid prescribing after common surgical procedures. STUDY DESIGN: Electronic health record data from a large multihospital healthcare system were used in conjunction with random-effect models to examine variation in opioid prescribing practices after similar inpatient and outpatient surgical procedures between October 2019 and September 2021. Unwarranted variation was conceptualized as variation resulting from prescriber behavior unsupported by evidence. Covariates identified as drivers of warranted variation included characteristics known to influence pain levels or patient safety. All other model variables, including prescriber specialty and patient race, ethnicity, and insurance status were characterized as potential drivers of unwarranted variation. RESULTS: Among 25,188 procedures with an opioid prescription at hospital discharge, 53.5% exceeded guideline recommendations, corresponding to 13,228 patients receiving the equivalent of >140,000 excess 5 mg oxycodone tablets after surgical procedures. Prescribing variation was primarily driven by prescriber-level factors, with approximately half of the total variation in morphine milligram equivalents prescribed observed at the prescriber level and not explained by any measured variables. Unwarranted covariates associated with higher prescribed opioid quantity included non-Hispanic Black race, Medicare insurance, smoking history, later hospital discharge times, and prescription by a surgeon rather than a hospitalist or primary care provider. CONCLUSIONS: Given the large proportion of unexplained variation observed at the provider level, targeting prescribers through education and training may be an effective strategy for reducing postoperative opioid prescribing. [ABSTRACT FROM AUTHOR]

Objective: To understand US hospitals' initial strategic responses to the federal price transparency rule that took effect January 2021. Data Sources and Study Setting: Primary interview data collected from 12 not‐for‐profit hospital organizations in six US metropolitan markets. All but one organization were multihospital systems; the 12 organizations represent a total of 81 hospitals. Study Design: Exploratory, cross‐sectional, qualitative interview study of a convenience sample of hospital organizations across six geographically and compliance diverse markets. Data Collection/Extraction Methods: In‐depth, semi‐structured, qualitative interviews with 16 key informants across sampled organizations between November 2021 and March 2022. Interviews solicited data about internal organizational factors and external market factors affecting strategic responses. Transcribed interviews were de‐identified, coded, and analyzed using the constant comparative method. Principal Findings: Hospitals' strategic responses were influenced internally by the degree of the regulation's alignment with organizational values and goals, and task complexity vis‐a‐vis available resources. We found extensive variation in organizational capabilities to comply, and all but one organization relied on consultants and vendors to some degree. Key external factors driving strategic responses were hospitals' variable perceptions about how available price information would affect their competitive position, bottom line, and reputation. Organizations with more confidence in their interpretation of the environment, including how peers or purchasers would behave, and greater clarity in their own organization's position and goals, had more definitive initial strategic responses. In the first year, organizations' strategic responses skewed toward compliance, especially for the rule's consumer shopping requirements. Conclusions: A deeper understanding of the realities of operationalizing price transparency policy for hospitals is needed to improve its impact. [ABSTRACT FROM AUTHOR]

Objectives: Robust faculty development (FD) is an emerging area of focus within hospital medicine, a relatively new specialty with limited mentorship infrastructure to find and develop a professional niche. There are few descriptions in the literature of establishing and evaluating an FD program with strategies to evaluate success, invite collaboration, and achieve feasible, useful metrics. Methods: We created our University Division of Hospital Medicine's FD Program to help community and academic hospitalist faculty fulfill professional goals in (and beyond) quality improvement, leadership, education, and clinical skills. We describe program development, initial implementation, and early evaluation results. We outline program roles and offerings such as professional development awards, lectures, and mentorship structures. Results: Our program was successfully implemented, measured by engagement and participation via preliminary indicators suggesting programmatic effectiveness: faculty who applied for (and continued participation in) mentorship and faculty development awards and faculty who attended our lecture series. Since program implementation, faculty retention has increased, and percentages of faculty reporting they were likely to remain were stable, even during the coronavirus disease 2019 pandemic. Scholarly production increased and the number of division associate professors/professors grew from 2 in 2015 to 19 in 2024. Conclusions: Our experience can guide institutions seeking to support and encourage faculty professional development. Lessons learned include the importance of needs assessment and leadership commitment to meeting identified needs; how a steering committee can amplify the effectiveness and relevance of FD efforts; and the utility of multiple recognition strategies--quarterly newsletters, monthly clinical recognition, mentions on social media--to support and encourage faculty. [ABSTRACT FROM AUTHOR]

Balancing is an essential challenge in healthcare systems that requires effective strategies. This study aims to address this crucial issue by suggesting a practical approach. We show the potential of balancing a regional healthcare system to improve its utility. We consider a regional healthcare system comprising multiple hospitals with different sizes, capacities, quality of service, and accessibility. We define a utility function for the system based on the sectorization concept, which endeavors to form a balance between hospitals in terms of essential outputs such as waiting times and demands. The dynamic nature of the system means that this balance degrades over time, necessitating periodic sectorization, which is called resectorization. Our methodology stands out for incorporating resectorization as a dynamic strategy, enabling more flexible and responsive adaptations to continuously changing healthcare needs. Unlike previous studies, based on a system-oriented approach, our resectorization scenarios include the periodic closure of some hospitals. This enables us to enhance both the capacity and quality of healthcare facilities. Furthermore, in contrast to other studies, we investigate the states of diminishing demand throughout the resectorization process. To provide empirical insights, we conduct a simulation using data from a real-world case study. Our analysis spans multiple time periods, enabling us to dynamically quantify the utility of the healthcare system. The numerical findings demonstrate that substantial utility improvements are attainable through the defined scenarios. The study suggests a practical solution to the critical challenge of balancing issues in regional healthcare systems. [ABSTRACT FROM AUTHOR]

Background: Predicting the frequency of calls for telestroke and emergency teleneurology consultation is essential to prepare staffing for the immediate management of time-sensitive strokes. In this study, we evaluate Poisson distribution count data using a generalized linear model that predicts the volume of hourly telestroke calls over a 24-h period. Methods: We performed an Institutional Review Board approved retrospective cohort review of patients (January 2019–December 2022) from an institutional telestroke database at a large nonprofit multihospital system in the United States. All patients ≥18 years with a telestroke activation were included. Telestroke calls were quantified in frequency per day and analyzed by multiple time and date intervals. Poisson probability mass function (PMF) and cumulative distribution function (CDF) were used to predict call probabilities. A univariable Poisson regression model was fit to predict call volumes. Results: A total of 8,499 patients at 21 hospitals met inclusion criteria, the mean calls/day were 5.82 ± 2.54, and mean calls/day within each hour increment ranged from a minimum of 0.07 from 5 a.m. to 6 a.m. to a maximum of 0.45 from 7 p.m. to 8 p.m. The Poisson distribution was the most appropriate parametric probability model for these data, confirmed by the fit of the data to the expected distributions corresponding to the calculated means. The predicted probabilities of call frequencies by hour were calculated using the Poisson PMF and CDF; the probability of two or fewer calls/day by hour ranged from 98.9% to 99.9%. Univariable Poisson regression modeled an increase of future calls/day from 6.7 calls/day in July 2023 to 7.6 calls/day in October 2025. Conclusion: Poisson modeling closely fits telestroke call volumes, predicts the future volumes, and can be applied to any health system in which the mean call volume is known, which may inform the number of physicians needed to cover calls in real-time. [ABSTRACT FROM AUTHOR]

Surge management is important to hospital operations, yet surge literature has mostly focused on the addition of resources (e.g., 25% more beds) during events like pandemics. Such views are limiting, as meeting surge demands requires hospitals to engage in practices tailored to a surge's unique contingencies. We argue that a dynamic view of surge management should include surge management capability, which refers to how resources are deployed to respond to surge contingencies. To understand this capability, we qualitatively studied five hospital systems experiencing multiple surges due to COVID-19 between April 2020 and March 2022. We develop a framework showing that managing surges involves preserving capacity, expanding capacity, smoothing capacity demand, and enabling surge management. We contribute to surge literature by identifying practices hospitals can adopt to address surges and offering a better understanding of surge conditions (e.g., degree of novelty) that make some surge management practices more appropriate than others. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to propose a performance-oriented approach of automatically generative design and optimization of hospital building layouts in consideration of public health emergency, which intended to conduct reasonable layout design of hospital building to meet different performance requirements for both high efficiency during normal periods and low risk in the pandemic. Design/methodology/approach: The research design follows a sequential mixed methodology. First, key points and parameters of hospital building layout design (HBLD) are analyzed. Then, to meet the requirements of high efficiency and low risk, adjacent preference score and infection risk coefficient are constructed as constraints. On this basis, automatic generative design is conducted to generate building layout schemes. Finally, multi-objective deviation analysis is carried out to obtain the optimal scheme of hospital building layouts. Findings: Automatic generative design of building layouts that integrates adjacent preferences and infection risks enables hospitals to achieve rapid transitions between normal (high efficiency) and pandemic (low risk) periods, which can effectively respond to public health emergencies. The proposed approach has been verified in an actual project, which can help systematically explore the solution for better decision-making. Research limitations/implications: The form of building layouts is limited to rectangles, and future work can explore conducting irregular layouts into optimization for the framework of generative design. Originality/value: The contribution of this paper is the developed approach that can quickly and effectively generate more hospital layout alternatives satisfying high operational efficiency and low infection risk by formulating space design rules, which is of great significance in response to public health emergency. [ABSTRACT FROM AUTHOR]

With the global trend towards longer life expectancies, there's an increasing emphasis on not just living longer, but also maintaining health and wellbeing into older age. This study explores the efficacy of Ninjin'yoeito (NYT) in the early stages of frailty, a critical period for preventive interventions. Taking account of the knowledge gap regarding the association between early frailty and NYT, we use data from workplace health checkups to examine the relationship between pre-frailty severity and NYT adaption. The objective of our research is to enhance the comprehension of early treatments using NYT to prevent the progression of frailty. A total of 314 employees of the Kyoto Industrial Health Association who received workplace health checkups between November 2021 and March 2023 and consented to this study were included in the analysis. Information on gender, age, body mass index (BMI), NYT-specific symptoms assessment, the Japanese version of the General Health Questionnaire-12 (GHQ-12), and the Kihon Checklist (KCL) were obtained. The correlation analysis revealed that there was a strong positive correlation between the number of applicable NYT indications and the GHQ-12 score (r = 0.5992, p < 0.0001). Similarly, a moderate positive correlation was observed between the number of applicable NYT indications and the KCL score (r = 0.5030, p < 0.0001). In the multivariate analysis, both GHQ-12 (β = 0.49, SE = 0.06, t = 7.66, 95% CI: 0.36 to 0.62, p = 0.000) and KCL (β = 0.54, SE = 0.12, t = 4.29, 95% CI: 0.29 to 0.79, p = 0.000) showed significant positive associations with the variance in the number of applicable NYT indications, indicating that higher scores on these measures were related to a greater number of indications. NYT has the potential to be utilized not only as a therapeutic intervention for frailty, but also as a preventive measure. [ABSTRACT FROM AUTHOR]

Effective and uninterrupted management of the healthcare supply chain and healthcare system preparedness for natural disasters (e.g., pandemics, earthquakes, forest fires, etc.) is essential to ensure that victims receive critical healthcare services and products with minimal disruption, even in the event of damage to transport and logistics infrastructure as a result of significant disasters. The article examines this issue using the example of Vital Health Systems, a prominent hospital system with multiple facilities across a wide region. The qualitative data for the study was collected through interviews and focus groups with key stakeholders in Vital Health Systems, including supply chain managers, procurement specialists, frontline staff, etc. The quantitative data for the study were based on reports, internal documentation and archival documents, industry reports, market research, government databases. Analysis of the supply chain resilience of Vital Health Systems to natural disasters was carried out using the PESTLE framework, based on which a comprehensive risk reduction strategy was proposed. This strategy, while rooted in theory, is highly practical and feasible, with measures to optimise stocks, creation of alternative transport routes and logistics networks, and use of technological solutions. Organisational and managerial proposals for minimising supply chain disruptions for Vital Health Systems in the event of natural disasters are based on the theory of transformational leadership, Denison's organisational culture, Levitt's diamond model, and McKinsey's theory of strategic horizons. The role of healthcare professionals, supply chain managers, procurement specialists, and researchers in healthcare management and disaster preparedness is crucial in implementing these strategies. [ABSTRACT FROM AUTHOR]

Background: Inpatient falls in hospitals are an acknowledged indicator of quality of care. International comparisons could highlight quality improvement potential and enable cross-national learning. Key to fair cross-national comparison is the availability of a risk adjustment model validated in an international context. This study aimed to 1) ascertain that the variables of the inpatient fall risk adjustment model do not interact with country and thus can be used for risk adjustment, 2) compare the risk of falling in hospitals between Switzerland and Austria after risk adjustment. Methods: The data on inpatient falls from Swiss and Austrian acute care hospitals were collected on a single measurement day in 2017, 2018 and 2019 as part of an international multicentre cross-sectional study. Multilevel logistic regression models were used to screen for interaction effects between the patient-related fall risk factors and the countries. The risks of falling in hospital in Switzerland and in Austria were compared after applying the risk-adjustment model. Results: Data from 176 hospitals and 43,984 patients revealed an inpatient fall rate of 3.4% in Switzerland and 3.9% in Austria. Two of 15 patient-related fall risk variables showed an interaction effect with country: Patients who had fallen in the last 12 months (OR 1.49, 95% CI 1.10–2.01, p = 0.009) or had taken sedatives/psychotropic medication (OR 1.40, 95% CI 1.05–1.87, p = 0.022) had higher odds of falling in Austrian hospitals. Significantly higher odds of falling were observed in Austrian (OR 1.38, 95% CI 1.13–1.68, p = 0.002) compared to Swiss hospitals after applying the risk-adjustment model. Conclusions: Almost all patient-related fall risk factors in the model are suitable for a risk-adjusted cross-country comparison, as they do not interact with the countries. Further model validation with additional countries is warranted, particularly to assess the interaction of risk factors "fall in the last 12 months" and "sedatives/psychotropic medication intake" with country variable. The study underscores the crucial role of an appropriate risk-adjustment model in ensuring fair international comparisons of inpatient falls, as the risk-adjusted, as opposed to the non-risk-adjusted country comparison, indicated significantly higher odds of falling in Austrian compared to Swiss hospitals. [ABSTRACT FROM AUTHOR]

• The MIP bi-objective model can reduce food waste by 19.70 % and cost by 32.66 %. • On average, children waste 35.43 % of their meals, and eat 41.32 g less than adults. • The pediatric ward has the most food waste per meal, leading to a 20 % reduction. • The vegetarian diet exhibits the highest food waste and meal-building cost. • In areas of greatest waste and cost, the models achieved the greatest improvements. Food waste contributes significantly to greenhouse emissions and represents a substantial portion of overall waste within hospital facilities. Furthermore, uneaten food leads to a diminished nutritional intake for patients, that typically are vulnerable and ill. Therefore, this study developed mathematical models for constructing patient meals in a 1000-bed hospital located in Florida. The objective is to minimize food waste and meal-building costs while ensuring that the prepared meals meet the required nutrients and caloric content for patients. To accomplish these objectives, four mixed-integer programming models were employed, incorporating binary and continuous variables. The first model establishes a baseline for how the system currently works. This model generates the meals without minimizing waste or cost. The second model minimizes food waste, reducing waste up to 22.53 % compared to the baseline. The third model focuses on minimizing meal-building costs and achieves a substantial reduction of 37 %. Finally, a multi-objective optimization model was employed to simultaneously reduce both food waste and cost, resulting in reductions of 19.70 % in food waste and 32.66 % in meal-building costs. The results demonstrate the effectiveness of multi-objective optimization in reducing waste and costs within large-scale food service operations. [ABSTRACT FROM AUTHOR]

Background: Regionalization of surgical care shifts higher acuity patients to larger centers. Hospital-associated infections (HAIs) are important quality measures with financial implications. In our ongoing efforts to eliminate HAIs, we examined the potential role for inter-hospital transfer in our cases of HAI across a multihospital system. Hypothesis: Surgical patients transferred to a regional multihospital system have a higher risk of National Healthcare Safety Network (NHSN)-labeled HAIs. Patients and Methods: The analysis cohort of adult surgical inpatients was filtered from a five-hospital health system administration registry containing encounters from 2014 to 2021. The dataset contained demographics, health characteristics, and acuity variables, along with the NHSN defined HAIs of central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI). Univariable and multivariable statistics were performed. Results: The surgical cohort identified 92,832 patients of whom 3,232 (3.5%) were transfers. The overall HAI rate was 0.6% (528): 86 (0.09%) CLABSI, 133 (0.14%) CAUTI, and 325 (0.35%) CDI. Across the three HAIs, the rate was higher in transfer patients compared with non-transfer patients (CLABSI: n = 18 (1.3%); odds ratio [OR], 4.79; CAUTI: n = 25 (1.8%); OR, 4.20; CDI: n = 37 (1.1%); OR, 3.59); p < 0.001 for all. Multivariable analysis found transfer patients had an increased rate of HAIs (OR, 1.56; p < 0.001). Conclusions: There is an increased risk-adjusted rate of HAIs in transferred surgical patients as reflected in the NHSN metrics. This phenomenon places a burden on regional centers that accept high-risk surgical transfers, in part because of the downstream effects of healthcare reimbursement programs. [ABSTRACT FROM AUTHOR]

OBJECTIVES: In the context of traditional nurse-to-patient ratios, ICU patients are typically paired with one or more copatients, creating interdependencies that may affect clinical outcomes. We aimed to examine the effect of copatient illness severity on ICU mortality. DESIGN: We conducted a retrospective cohort study using electronic health records from a multihospital health system from 2018 to 2020. We identified nurse-to-patient assignments for each 12-hour shift using a validated algorithm. We defined copatient illness severity as whether the index patient's copatient received mechanical ventilation or vasoactive support during the shift. We used proportional hazards regression with time-varying covariates to assess the relationship between copatient illness severity and 28-day ICU mortality. SETTING: Twenty-four ICUs in eight hospitals. PATIENTS: Patients hospitalized in the ICU between January 1, 2018, and August 31, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main analysis included 20,650 patients and 84,544 patient-shifts. Regression analyses showed a patient's risk of death increased when their copatient received both mechanical ventilation and vasoactive support (hazard ratio [HR]: 1.30; 95% CI, 1.05-1.61; p = 0.02) or vasoactive support alone (HR: 1.82; 95% CI, 1.39-2.38; p < 0.001), compared with situations in which the copatient received neither treatment. However, if the copatient was solely on mechanical ventilation, there was no significant increase in the risk of death (HR: 1.03; 95% CI, 0.86-1.23; p = 0.78). Sensitivity analyses conducted on cohorts with varying numbers of copatients consistently showed an increased risk of death when a copatient received vasoactive support. CONCLUSIONS: Our findings suggest that considering copatient illness severity, alongside the existing practice of considering individual patient conditions, during the nurse-to-patient assignment process may be an opportunity to improve ICU outcomes. [ABSTRACT FROM AUTHOR]

Rapid urbanization and population growth have increased the need for optimizing the location of health services in highly urbanized countries like Kingdom of Saudi Arabia (KSA). This study employs a multiple-criteria decision making (MCDM) approach, e.g., fuzzy overlay technique by combining the P-Median location-allocation model, for optimizing health services. First, a geodatabase, containing public hospitals, road networks and population districts, was prepared. Next, we investigated the location and services of five public hospitals in Jeddah city of KSA, by using a MCDM model that included a fuzzy overlay technique with a location-allocation model. The results showed that the allocated five hospitals served 94 out of 110 districts in the study area. Our results suggested additional hospitals must be added to ensure that the entire city is covered with timely hospital services. To improve the existing situation, we prioritized demand locations using the maximize coverage (MC) location problem model. We then used the P-Median function to find the optimal locations of hospitals, and then combined these two methods to create the MC-P-Median optimizer. This optimizer eliminated any unallocated or redundant information. Health planners can use this model to determine the best locations for public hospitals in Jeddah city and similar settings. [ABSTRACT FROM AUTHOR]

In the U.S., multihospital systems (MHSs) charge significantly higher prices for hospital services than stand-alone hospitals. Rivalry restraint theory suggests that MHS with multimarket contact (MMC) can tacitly collude and mutually forebear from price competition to keep their prices above competitive levels. We posit that the success of such MMC-induced rivalry restraints (the truce) is affected by two conflicting roles of IT at the corporate level and market unit levels, respectively. The corporate parent seeks to standardize IT applications enterprise-wide to coordinate market units as a means of jointly implementing the rivalry restraint strategy and keeping prices high enterprise-wide. However, market units, i.e., the member hospitals of MHS clustered in geographic patient markets, face competitive pressures to reduce their service costs. Market units seek to use differentiated IT applications to achieve cost reductions, which then fuel price competition in local markets, jeopardize the sustainability of the truce, and weaken the enterprise-wide price effects of the corporate parent's rivalry restraint strategy. In a longitudinal study of 195 multihospital systems in the U.S. in the 2005-2013 time period, we found support for these ideas. The corporate-wide standardization of the operational IT of MHS complements the rivalry restraint strategy to increase enterprise-wide prices. Market units' use of differentiated analytical IT reduces costs in local markets and weakens the price effects of the rivalry restraint strategy. The study advances IS research and practice by theorizing how the corporate-level and the market unit-level IT of a multi-unit, multimarket (MUMM) organization can have opposing moderating effects on the link between MMC and the average prices charged by the MUMM organization. [ABSTRACT FROM AUTHOR]

The rapid increase of rates of change, disruptive events, risk and uncertainty increasingly threaten the long-term utilisation of hospital buildings. This challenge calls for an evolution in the lifecycle thinking that has always been integral to the hospital building design processes; or an approach that is termed 'future proofing'. Yet the implementation of future proofing as an emerging design requirement is impeded by lack of holistic understanding of the concept, and clarity about its objectives. As such, this research aims to provide a conceptualisation of future proofing via a taxonomic hierarchy. We interviewed sixteen experienced hospital architects from leading consultant firms across Australia to explore their general perceptions, and implementation in practice, of future proofing. The semi-structured interviews were informed by and indeed tested a theoretical model of future proofing previously constructed via literature review and were analysed and validated via thematic analysis and member checking. Our findings align theoretical understanding with hospital architects' practice-based perceptions and experiences of future proofing; elucidating future proofing as a dynamic meta-capability involving a multi-purpose hierarchy. Accordingly, a hierarchical integrated model of future proofing in practice was developed based on three axes (Survive, Evolve and Thrive), respectively defining three sets of spectrums with two extremes ranging from passivity to activity (Resilience-Mitigation, Maintainability-Improvement, and Changeability-Transition). While in previous research future proofing has been oversimplified and perceived largely in terms of adaptability, our findings support a more expansive definition of future proofing that includes various lifecycle design considerations. [ABSTRACT FROM AUTHOR]

Background: Early blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h. Methods: This is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants—after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848). Discussion: The SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting. Trial registration: ISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021. [ABSTRACT FROM AUTHOR]

Objectives: The presence of nodal metastases in patients with papillary thyroid carcinoma (PTC) has both staging and treatment implications. However, lymph nodes are often not removed during thyroidectomy. Prior work has demonstrated the capability of artificial intelligence (AI) to predict the presence of nodal metastases in PTC based on the primary tumor histopathology alone. This study aimed to replicate these results with multi-institutional data. Methods: Cases of conventional PTC were identified from the records of 2 large academic institutions. Only patients with complete pathology data, including at least 3 sampled lymph nodes, were included in the study. Tumors were designated "positive" if they had at least 5 positive lymph node metastases. First, algorithms were trained separately on each institution's data and tested independently on the other institution's data. Then, the data sets were combined and new algorithms were developed and tested. The primary tumors were randomized into 2 groups, one to train the algorithm and another to test it. A low level of supervision was used to train the algorithm. Board-certified pathologists annotated the slides. HALO-AI convolutional neural network and image software was used to perform training and testing. Receiver operator characteristic curves and the Youden J statistic were used for primary analysis. Results: There were 420 cases used in analyses, 45% of which were negative. The best performing single institution algorithm had an area under the curve (AUC) of 0.64 with a sensitivity and specificity of 65% and 61% respectively, when tested on the other institution's data. The best performing combined institution algorithm had an AUC of 0.84 with a sensitivity and specificity of 68% and 91% respectively. Conclusion: A convolutional neural network can produce an accurate and robust algorithm that is capable of predicting nodal metastases from primary PTC histopathology alone even in the setting of multi-institutional data. [ABSTRACT FROM AUTHOR]

Introduction Polypharmacy can lead to drug–drug interactions (DDIs), especially with ART. The burden of co-medications, including over-the-counter (OTC) drugs and self-medications, could be underestimated. We aimed to investigate the proportion of people living with HIV (PLHIV) with declared and undeclared co-medications, as well as their potential burden. Methods We conducted a national, multicentre, 1 week cross-sectional study between 10 December and 16 December 2019 in 23 French hospitals amongst consecutive adult PLHIV presenting for a routine outpatient visit. A standardized questionnaire filled in by the physicians assessed all medications and other active chemical substances taken by the PLHIV. Results Overall we enrolled 496 participants from 23 centres. Median age was 50.6 years; ART regimens included an integrase inhibitor in 61% (n  = 302), an NNRTI in 34% (n  = 169) and a PI in 14% (n  = 70) of the cases. Co-medications involved 392 (79%) PLHIV, among which 85 (17%) received polypharmacy (≥5 medications). Previously unknown co-medications or other active substances were found for 32% (n  = 159) of the participants. Corticosteroids (9%, n  = 46) and proton pump inhibitors (10%, n  = 50) were frequently administered. These co-medications did not differ according to age range. Illegal drug use was declared by 11% (n  = 54) and OTC drugs by 23% (n  = 113) of PLHIV. Potential DDIs were discovered for 11% (n  = 53), leading to treatment modifications in 47% (25/53) of cases. Conclusions Potential DDIs that lead to therapeutic modifications remain significant whatever the age of PLHIV. More devoted time to identify co-medications and OTC treatment is needed in all PLHIV. [ABSTRACT FROM AUTHOR]

Introduction: Ethylene glycol (EG) is a frequently considered toxicant in poisoned patients. Definitive diagnosis relies on gas chromatography (GC), but this is unavailable at most hospitals. A glycerol dehydrogenase (GDH)-based assay rapidly detects EG. A rapid turnaround time and wide availability of necessary instrumentation suggest this method could facilitate the rapid detection of EG. Methods: This is a prospective, observational analysis of banked, remnant serum samples submitted to the laboratory of a large, multi-hospital healthcare system. Samples were submitted over a 12-month period for the explicit purpose of testing for suspected EG ingestion. All samples underwent GC and the GDH-based assay. Results: Of the 118 analyzed samples, 88 had no EG detected by GC, and 30 were "positive." At the manufacturer's threshold of 6 mg/dL EG, there was 100% (95%CI; 88.7–100) positive percent agreement (PPA) and 98% (92.1-99.6) negative percent agreement (NPA). Adjusted to a threshold of 9 mg/dL, both the PPA and NPA were 100%. Deming regression of the observed concentrations revealed a slope of 1.16 (1.01 to 1.32) and intercept of −5.3 (−8.9 to −1.7). Conclusions: The GDH assay provides a sensitive and specific method for the detection and quantification of EG that is comparable to a GC-based method. More widespread use of this rapid, inexpensive assay could improve the care of patients with suspected toxic alcohol exposure. Further study is needed to evaluate the test performance in real-time patient treatment decisions. [ABSTRACT FROM AUTHOR]

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Real-world data sources can facilitate essential understanding of the epidemiological features of anaphylaxis. However, the accuracy of case-identifying definitions based on diagnosis codes for anaphylaxis in healthcare databases remains understudied. We conducted a cross-sectional study analyzing claims data from the largest multi-institutional healthcare system in Taiwan during 2017–2021. We included patients with incident anaphylaxis identified by either ICD-10-CM codes for anaphylaxis (Group 1) or ICD-10-CM codes for severe allergic or drug adverse events and additional modifier codes for acute allergy events (Group 2). We randomly selected 20% of the cases to determine the positive predictive value (PPV) of anaphylaxis case-identifying definitions in Groups 1 and 2 after review of electronic medical records by two physicians. From the original cohort (n = 2,176), we randomly selected 433 patients with either a diagnosis of anaphylaxis (Group 1), or a diagnosis of severe allergic and drug adverse events with additional modifier codes for acute allergy events (Group 2). In Group 1, we judged 135 / 170 patients as true anaphylaxis cases, giving a PPV of 79.4% (95% CI: 73.3–85.5). In Group 2, we judged 47 / 263 patients as true anaphylaxis cases, giving a PPV of 17.9% (95% CI: 13.3–22.5). In conclusion, acceptable PPVs were observed when anaphylaxis cases were identified by ICD-10-CM codes for anaphylaxis, but not by ICD-10-CM codes for severe allergic or drug adverse event with additional modifier codes for acute allergy events. Our multi-institutional findings could serve as a fundamental reference for further studies of anaphylaxis based on real-world healthcare databases. [ABSTRACT FROM AUTHOR]

Home health care (HHC) services provide the elderly, disabled, and those with chronic diseases health services in their homes. The demand for HHC services has increased due to the growth of the elderly population, the increase in hospital occupancy rates during the pandemic, and developments in medical device technologies. In this study, team formation is taken into consideration in a multi-period and multi-objective HHC assignment, scheduling and routing problem. The team and the assigned patients to this team must be compatible with skill levels and operational requirements. The objective functions are minimization of total completion time and maximum working time overall caregivers. To evaluate our approach, an HHC service unit in a state hospital is adopted as the operational scenario, and we propose a multi-objective mathematical model to solve the problem. In this model, HHC teams are formed, the patients are assigned to the teams, and the route of each team is determined in an integrated manner. The variable neighborhood search algorithm is modified to solve the multi-objective optimization model and is improved with a local search algorithm. The proposed algorithm has been compared with the state-of-the-art multi-objective algorithms in the literature over test problems. Current results show that the model to be an effective means of estimating and predicting system behavior in this complex environment. [ABSTRACT FROM AUTHOR]

Objective: Despite marked improvements in the accessibility of childhood vaccines, knowledge gaps remain about the vaccination of children in special risk groups (SRG). This study aimed to analyze the clinical data of children vaccinated in SRG in a single-center unit to contribute to the clinical evidence for the specific planning of immunization of children in SRG. The secondary aim is to present institutional consensus on the vaccination of children in SRG. Materials and Methods: This retrospective study was conducted at a single-center pediatric vaccination clinic. Patient charts between 2018 and 2021 were retrospectively reviewed, and clinical and laboratory data were extracted. Serial joint meetings with multiple healthcare professionals were performed to develop an institutional protocol for vaccination. Results: There were 479 children vaccinated between 2018 and 2021 for reasons such as postchemotherapy, after hematopoietic stem cell transplantation, before/after solid organ transplantation, allergies, and chronic diseases. Of these, 298 (62.2%) children vaccinated in the unit due to a history of food or vaccine allergies were excluded. One hundred eighty-one children were vaccinated at a median age of 11 [7-15] years. Most children were vaccinated after treatment for malignancies. Solid tumors were the most frequent malignancy (67%), followed by acute lymphoblastic leukemia (29.0%) and acute myeloid leukemia (4.0%). Institutional vaccination protocols for cancer survivors, hematopoietic stem cells, and solid organ recipient children were developed and presented. Conclusion: There is a need to prepare national guidelines for vaccinating children with altered immunocompetence. Sharing vaccination practices by multidisciplinary vaccination units might increase and provide knowledge to develop national policies. [ABSTRACT FROM AUTHOR]

Background: Multidrug-resistant (MDR) and rifampicin-resistant (RR) tuberculosis (TB) is related to high healthcare costs. However, studies on direct healthcare expenditure in different settings remain inconclusive. Hence, we aimed to examine the direct medical expenses (DME) of patients with MDR/RR-TB and assessed which patient characteristics were associated with higher costs.Methods: DME was evaluated using records from the hospital information system in three cities with different economic levels in Zhejiang Province, Eastern China, matching with data (including socio-demographics, disease treatment status, etc.) collected in the Tuberculosis Management Information System. A logistic regression model was used to identify variables associated with higher costs.Results: Of 193 patients with MDR/RR-TB, the average DME was $10,491 (interquartile range (IQR) $4679– 16,710), consisting of $2696 (IQR $1019– 5100) out-of-pocket costs, medical reimbursement, and subsidies, accounting for 32%, 50.3% and 14%, respectively. A total of 74.2% and 56% of DME were for drugs and anti-TB drugs, respectively. Only 16.9% of the patients were treated with an all-oral regimen. Higher DME was significantly associated with local residents 7.29 (95% confidence interval (CI) [2.62– 20.3]), hospitalization experience 7.63 (95% (CI) [2.54– 22.95]), longer duration of treatment 6.63 (95% CI [2.27– 19.35]), and lower health insurance reimbursement 5.65 (95% CI [1.90– 16.79]).Conclusion: DME of patients with MDR/RR-TB was still significant, and domestic migrants, hospitalization, long treatment duration, and high health insurance rates increased the financial burden on MDR/RR-TB patients. Reasonable intervention programs should be developed to reduce the medical burden of patients with MDR/RR-TB, according to the DME and its component of MDR-TB patients, besides the economic status of their regions. [ABSTRACT FROM AUTHOR]

Purpose Challenges with monitoring and detecting drug diversion in healthcare facilities continue to be a trending topic amid the opioid epidemic. This article aims to provide insight into the expansion of an academic medical center's drug diversion and controlled substances compliance program. The justification and structure of a multihospital, centralized program are discussed. Summary Establishing dedicated controlled substances compliance and drug diversion resources has become increasingly common as awareness of the widespread healthcare impact has grown. One academic medical center recognized the value in expanding from 2 dedicated full-time equivalents (FTEs) with a scope of one facility to multiple FTEs with a scope of 5 facilities. The expansion included considering current practices at each facility, establishing the centralized team's scope, gaining organizational support, recruiting a diverse team, and forming an effective committee structure. Conclusion There are multiple organizational benefits from establishing a centralized controlled substances compliance and drug diversion program, including standardization of processes, associated efficiencies, and effective risk mitigation by identifying inconsistent practices across the multifacility organization. [ABSTRACT FROM AUTHOR]

This study investigates whether inequalities in the utilization of resection and/or ablation for synchronous colorectal liver metastases (SCLM) between patients diagnosed in expert and non-expert hospitals changed since a multi-hospital network started. Patients diagnosed with SCLM between 2009 and 2020 were included. The likelihood of receiving ablation and/or resection was analyzed in the prenetwork (2009–2012), startup (2013–2016), and matured-network (2017–2020) periods. Nationwide, 13.981patients were diagnosed between 2009 and 2020, of whom 1.624 were diagnosed in the network. Of patients diagnosed in the network's expert hospitals, 36.7% received ablation and/or resection versus 28.3% in nonexpert hospitals (p < 0.01). The odds ratio (OR) of receiving ablation and/or resection for patients diagnosed in expert versus nonexpert hospitals increased from 1.38 (p = 0.581, pre-network), to 1.66 (p = 0.108, startup), to 2.48 (p = 0.090, matured-network). Nationwide, the same trend occurred (respectively OR 1.41, p = 0.011; OR 2.23, p < 0.001; OR 3.20, p < 0.001). Patients diagnosed in expert hospitals were more likely to receive ablation and/or resection for SCLM than patients diagnosed in non-expert hospitals. This difference increased over time despite the startup of a multi-hospital network. Establishing a multi-hospital network did not have an effect on reducing the existing unequal odds of receiving specialized treatment. Specialized oncology treatments are increasingly provided through multi-hospital networks. However, scant empirical evidence on the effectiveness of these networks exists. This study analyzes whether a regional multi-hospital network was able to improve equal access to specialized oncology treatments. [ABSTRACT FROM AUTHOR]

Background: Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA. Methods: We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis. Results: All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values. Conclusion: This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making. [ABSTRACT FROM AUTHOR]

Background: Patients hospitalized with cirrhosis, ascites, and elevated INR often experience delays in timely diagnostic paracentesis. Aims: Identify whether delays in diagnostic paracentesis were associated with adverse outcomes in a hospital system serving a large disadvantaged population. Methods: Retrospective cohort analysis of patients admitted from January 2017 to October 2019 with cirrhosis, ascites, and INR ≥ 1.5 across a multi-hospital health system in central Texas. We examined demographic and clinical characteristics of patients with diagnostic paracentesis (1) ≤ 24 h; (2) > 24 h; (3) therapeutic only or no paracentesis. We used logistic regression to examine differences in clinical outcomes controlling for confounders. Results: 479 patients met inclusion criteria. 30.0% (N = 143) were Latino, 6.7% (N = 32) African American, and 67.8% (N = 325) under or uninsured. 54.1% of patients received a diagnostic paracentesis ≤ 24 h of admission and 21.1% did not receive a diagnostic paracentesis during the hospitalization. Undergoing diagnostic paracentesis > 24 h of admission was associated with a 2.3 day increase in length of stay (95% CI 0.8–3.8), and OR 1.7 for an Emergency Room visit within 30 days of discharge (95% CI 1.1–2.7) compared to receiving a diagnostic paracentesis ≤ 24 h. Patients receiving diagnostic paracentesis in radiology were more likely to have a delay in procedure OR 5.8 (95% CI 2.8–8.6). Conclusion: Delayed diagnostic paracentesis is associated with increased preventable healthcare utilization compared with timely diagnostic paracentesis. Health systems should support efforts to ensure timely diagnostic paracentesis for patients with advanced liver disease, including performance at the bedside. [ABSTRACT FROM AUTHOR]

Background: The adoption and accessibility of laparoscopy have been serious issues in countries with limited resources, and for varied reasons. This study assessed resource capacity and barriers to the effective practice of laparoscopic surgery in training hospitals affiliated with the College of Surgeons of East, Central and Southern Africa (COSECSA). Methods: A multi-country survey was conducted from January 2021 to October 2021 using a questionnaire distributed to surgeons in COSECSA hospitals located in 16 different countries. Available resources and surgical volume were assessed, and the barriers to routinely performing laparoscopy were determined. Results: Ninety-four surgeons working in 44 different hospitals from 16 countries participated in the survey. The majority of respondents were general surgeons (n = 75, 79.7%). Other specialties included urology (n = 12, 12.8%) and pediatric surgery (n = 7, 7.4%). Senior surgeons accounted for 60.6% of participants, more than 40% had a managerial position and approximately 20% were surgical trainees. Most respondents practiced in public hospitals (n = 66, 70.2%). A median of three surgeons per hospital performed laparoscopic surgery with, on average, two laparoscopic towers and two sets of laparoscopic instruments available. A median of 10 procedures was carried out per month. The cost of laparoscopic procedures and laparoscopic consumables were reported as being covered by some health insurance payments in 76.9% and 48.4% of cases, respectively. Cholecystectomy was the most commonly reported laparoscopic procedure performed. The five top barriers to performing laparoscopic surgery were: a lack of consumables, a limited quantity of equipment, a lack of skilled surgeons, the high cost of laparoscopic procedures and complicated cases. In addition, having access to skilled anesthesiologists and anesthesia equipment, carbon dioxide, a consistent electric power supply and equipment maintenance were cited as significant challenges. Conclusion: The practice of laparoscopy is currently limited in COSECSA countries due to a scarcity of skilled staff and the lack of a funding plan to make laparoscopic services accessible. Therefore, policymakers and stakeholders should take strategic measures to respond to this need. [ABSTRACT FROM AUTHOR]

To estimate the prevalence of, and identify risk factors associated with, endometrial hyperplasia and/or cancer (EH/EC) in patients ≤45 years old undergoing endometrial sampling for abnormal uterine bleeding (AUB). We performed a retrospective cohort study of patients 18–45 years old with AUB who underwent endometrial sampling between 2016 and 2019 within a US-based multi-hospital system using billing code queries. We used multivariable Poisson regression to identify factors associated with EH/EC and calculated prevalence stratified by these factors. We estimated predicted probabilities within combinations of characteristics in order to examine the range of risk in this population. Among 3175 patients, median age was 39 years (interquartile range [IQR]:35–43) and BMI was 29.7 kg/m2 (IQR: 24.2–36.9). Thirty-nine percent were non-Hispanic White, 41% non-Hispanic Black, 9% Hispanic, and 11% Asian/Other/Unknown. BMI and polycystic ovarian syndrome (PCOS) were associated with higher EH/EC risk; non-Hispanic Black race was associated with lower risk. EH/EC prevalence ranged from 2% in BMI <25 to 16% in BMI ≥50 kg/m2 (p-trend <0.001). These prevalence estimates differed by race/ethnicity with the lowest estimates in non-Hispanic Black patients (0.5% BMI <25 vs. 9% BMI ≥50) and highest in Hispanic patients (1.5% BMI <25 vs. 33% BMI ≥50). Accounting for combinations of risk factors, predicted probabilities were highest – 34–36% – among patients with PCOS, diabetes, BMI ≥50, and Hispanic or Asian/Other/Unknown race/ethnicity. When accounting for combinations of key risk factors, risk of EH/EC in patients ≤45 years old with AUB ranges widely; the more nuanced estimates of risk presented here could help inform clinical decision-making about endometrial sampling in this population. • Recommendations for biopsy in patients ≤45 years old with abnormal uterine bleeding (AUB) are guided by very little data. • In patients ≤45 years old with AUB undergoing biopsy, risk of endometrial hyperplasia/cancer (EH/EC) ranged from <1% to 36%. • Polycystic ovarian syndrome, magnitude of obesity, and race/ethnicity were independent risk factors for EH/EC. • Combinations of risk factors provided more nuanced estimates of estimated risk of endometrial hyperplasia/cancer. • Practical figures demonstrate the range of risk and could be used in shared decision-making regarding endometrial sampling. [ABSTRACT FROM AUTHOR]

To assess the value of screening for Clostridioides difficile colonization (CDC) at hospital admission in an endemic setting. A multi-centre study was conducted at four hospitals located across the Netherlands. Newly admitted patients were screened for CDC. The risk of development of Clostridioides difficile infection (CDI) during admission and 1-year follow-up was assessed in patients with and without colonization. C. difficile isolates from patients with colonization were compared with isolates from incident CDI cases using core genome multi-locus sequence typing to determine whether onwards transmission had occurred. CDC was present in 108 of 2211 admissions (4.9%), whereas colonization with a toxigenic strain (toxigenic Clostridoides difficile colonization [tCDC]) was present in 68 of 2211 admissions (3.1%). Among these 108 patients with colonization, diverse PCR ribotypes were found and no 'hypervirulent' PCR ribotype 027 (RT027) was detected (95% CI, 0–0.028). None of the patients with colonization developed CDI during admission (0/49; 95% CI, 0–0.073) or 1-year follow-up (0/38; 95% CI, 0–0.93). Core genome multi-locus sequence typing identified six clusters with genetically related isolates from patients with tCDC and CDI; however, in these clusters, only one possible transmission event from a patient with tCDC to a patient with CDI was identified based on epidemiological data. In this endemic setting with a low prevalence of 'hypervirulent' strains, screening for CDC at admission did not detect any patients with CDC who progressed to symptomatic CDI and detected only one possible transmission event from a patient with colonization to a patient with CDI. Thus, screening for CDC at admission is not useful in this setting. [ABSTRACT FROM AUTHOR]

Carbapenemase resistance in Enterobacterales is a global public health problem and rapid and effective methods for detecting these resistance mechanisms are needed urgently. Our aim was to evaluate the performance of a MALDI-TOF MS-based "Klebsiella pneumoniae carbapenemase" (KPC) detection protocol from patients' positive blood cultures, short-term cultures, and colonies in healthcare settings. Bacterial identification and KPC detection were achieved after protein extraction with organic solvents and target spot loading with suitable organic matrices. The confirmation of KPC production was performed using susceptibility tests and blaKPC amplification using PCR and sequencing. The KPC direct detection (KPC peak at approximately 28.681 Da) from patients' positive blood cultures, short-term cultures, and colonies, once bacterial identification was achieved, showed an overall sensibility and specificity of 100% (CI95: [95%, 100%] and CI95: [99%, 100%], respectively). The concordance between hospital routine bacterial identification protocol and identification using this new methodology from the same extract used for KPC detection was ≥92%. This study represents the pioneering effort to directly detect KPC using MALDI-TOF MS technology, conducted on patient-derived samples obtained from hospitals for validation purposes, in a multi-resistance global context that requires concrete actions to preserve the available therapeutic options and reduce the spread of antibiotic resistance markers. [ABSTRACT FROM AUTHOR]

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Digital cognitive aids have the potential to serve as clinical decision support platforms, triggering alerts about process delays and recommending interventions. In this mixed-methods study, we examined how a digital checklist for pediatric trauma resuscitation could trigger decision support alerts and recommendations. We identified two criteria that cognitive aids must satisfy to support these alerts: (1) context information must be entered in a timely, accurate, and standardized manner, and (2) task status must be accurately documented. Using co-design sessions and near-live simulations, we created two checklist features to satisfy these criteria: a form for entering the pre-hospital information and a progress slider for documenting the progression of a multi-step task. We evaluated these two features in the wild, contributing guidelines for designing these features on cognitive aids to support alerts and recommendations in time- and safety-critical scenarios. [ABSTRACT FROM AUTHOR]

Objective: Little is known about the efficacy of using artificial intelligence (AI) to identify laryngeal carcinoma from images of vocal lesions taken in different hospitals with multiple laryngoscope systems. This multicentre study aimed to establish an AI system and provide a reliable auxiliary tool to screen for laryngeal carcinoma. Study design: Multicentre case–control study. Setting: Six tertiary care centres. Participants: Laryngoscopy images were collected from 2179 patients with vocal fold lesions. Outcome measures: An automatic detection system of laryngeal carcinoma was established and used to distinguish malignant and benign vocal lesions in 2179 laryngoscopy images acquired from 6 hospitals with 5 types of laryngoscopy systems. Pathological examination was the gold standard for identifying malignant and benign vocal lesions. Results: Out of 89 cases in the malignant group, the classifier was able to correctly identify laryngeal carcinoma in 66 patients (74.16%, sensitivity). Out of 640 cases in the benign group, the classifier was able to accurately assess the laryngeal lesion in 503 cases (78.59%, specificity). Furthermore, the region‐based convolutional neural network (R‐CNN) classifier achieved an overall accuracy of 78.05%, with a 95.63% negative predictive value and a 32.51% positive predictive value for the testing data set. Conclusion: This automatic diagnostic system has the potential to assist clinical laryngeal carcinoma diagnosis which may improve and standardise the diagnostic capacity of laryngologists using different laryngoscopes. [ABSTRACT FROM AUTHOR]

Milwaukee has become home to one of the largest US populations of Rohingya refugees, who face barriers to health care, including poor service integration impeded by the absence of a formal written language. Clinicians also face barriers to delivering adequate, culturally attuned health services, so suboptimal outcomes are common. This article describes a community-based intervention using an interprofessional, multi-organizational, and ethnographically focused approach to address Rohingya refugee health needs that incorporates Rohingya participants’ making educational videos in their native language. Mutually beneficial outcomes are outlined for Rohingya, students, and clinicians. [ABSTRACT FROM AUTHOR]

Purpose: In addition to opioid abuse and dependency, opioid use can lead to opioid related adverse drug events (ORADEs). ORADEs are associated with increased length of stay, cost of care, 30-day readmission rate, and inpatient mortality. The addition of scheduled non-opioid analgesic medications has shown to be effective in reducing opioid utilization in post-surgical and trauma populations, but evidence in entire hospital patient populations is limited. The objective of this study was to determine the effects of a multimodal analgesia order set on opioid utilization and adverse drug events in adult hospitalized patients. Methods: This retrospective pre/post implementation analysis was conducted at 3 community hospitals and a level II trauma center between January 2016 and December 2019. Patients included were 18 years of age or older, admitted for greater than 24 hours, and had at least one opioid ordered during hospital admission. The primary outcome of this analysis was the average oral morphine milligram equivalents (MME) used on days 1 through 5 of hospitalization. Secondary outcomes included the percentage of hospitalized patients with an opioid ordered for analgesia who received a scheduled non-opioid analgesic medication, the average number of ORADEs recorded in nursing assessments on hospitalization days 1 through 5, length of stay, and mortality. Multimodal analgesic medications included acetaminophen, gabapentinoids, non-steroidal anti-inflammatory drugs, muscle relaxants, and transdermal lidocaine. Results: The pre- and post-groups included 86 535 patients and 85 194 patients, respectively. The average oral MMEs used on days 1 through 5 were lower in the post-group (P <.0001). Utilization of multimodal analgesia as measured by the percentage of patients with 1 or more scheduled multimodal analgesia agent ordered increased from 33% to 49% at the end of the analysis. Conclusion: Utilization of a multimodal analgesia order set was associated with a decrease in opioid use and an increase in multimodal analgesia use in an entire hospital adult population. [ABSTRACT FROM AUTHOR]

There is growing interest in developing causal inference methods for multi‐valued treatments with a focus on pairwise average treatment effects. Here we focus on a clinically important, yet less‐studied estimand: causal drug‐drug interactions (DDIs), which quantifies the degree to which the causal effect of drug A is altered by the presence versus the absence of drug B. Confounding adjustment when studying the effects of DDIs can be accomplished via inverse probability of treatment weighting (IPTW), a standard approach originally developed for binary treatments and later generalized to multi‐valued treatments. However, this approach generally results in biased results when the propensity score model is misspecified. Motivated by the need for more robust techniques, we propose two empirical likelihood‐based weighting approaches that allow for specifying a set of propensity score models, with the second method balancing user‐specified covariates directly, by incorporating additional, nonparametric constraints. The resulting estimators from both methods are consistent when the postulated set of propensity score models contains a correct one; this property has been termed multiple robustness. In this paper, we derive two multiply‐robust estimators of the causal DDI, and develop inference procedures. We then evaluate their finite sample performance through simulation. The results demonstrate that the proposed estimators outperform the standard IPTW method in terms of both robustness and efficiency. Finally, we apply the proposed methods to evaluate the impact of renin‐angiotensin system inhibitors (RAS‐I) on the comparative nephrotoxicity of nonsteroidal anti‐inflammatory drugs (NSAID) and opioids, using data derived from electronic medical records from a large multi‐hospital health system. [ABSTRACT FROM AUTHOR]

This research proposes a novel mobile health-based hospital selection framework for remote patients with multi-chronic diseases based on wearable body medical sensors that use the Internet of Things. The proposed framework uses two powerful multi-criteria decision-making (MCDM) methods, namely fuzzy-weighted zero-inconsistency and fuzzy decision by opinion score method for criteria weighting and hospital ranking. The development of both methods is based on a Q-rung orthopair fuzzy environment to address the uncertainty issues associated with the case study in this research. The other MCDM issues of multiple criteria, various levels of significance and data variation are also addressed. The proposed framework comprises two main phases, namely identification and development. The first phase discusses the telemedicine architecture selected, patient dataset used and decision matrix integrated. The development phase discusses criteria weighting by q-ROFWZIC and hospital ranking by q-ROFDOSM and their sub-associated processes. Weighting results by q-ROFWZIC indicate that the time of arrival criterion is the most significant across all experimental scenarios with (0.1837, 0.183, 0.230, 0.276, 0.335) for (q = 1, 3, 5, 7, 10), respectively. Ranking results indicate that Hospital (H-4) is the best-ranked hospital in all experimental scenarios. Both methods were evaluated based on systematic ranking and sensitivity analysis, thereby confirming the validity of the proposed framework. [ABSTRACT FROM AUTHOR]

Broad availability and cost-effectiveness of 99Mo/99mTc generators worldwide support the use, and thus the development, of novel 99mTc-labelled radiopharmaceuticals. In recent years, preclinical and clinical developments for neuroendocrine neoplasms patient management focused on somatostatin receptor subtype 2 (SST2) antagonists, mainly due to their superiority in SST2-tumour targeting and improved diagnostic sensitivity over agonists. The goal of this work was to provide a reliable method for facile preparation of a 99mTc-labelled SST2 antagonist, [99mTc]Tc-TECANT-1, in a hospital radiopharmacy setting, suitable for a multi-centre clinical trial. To ensure successful and reproducible on-site preparation of the radiopharmaceutical for human use shortly before administration, a freeze-dried three-vial kit was developed. The final composition of the kit was established based on the radiolabelling results obtained during the optimisation process, in which variables such as precursor content, pH and buffer, as well as kit formulations, were tested. Finally, the prepared GMP-grade batches met all predefined specification parameters together with long-term kit stability and stability of the product [99mTc]Tc-TECANT-1. Furthermore, the selected precursor content complies with micro-dosing, based on an extended single-dose toxicity study, where histopathology NOEL was established at 0.5 mg/kg BW, being more than 1000 times higher than the planned human dose of 20 µg. In conclusion, [99mTc]Tc-TECANT-1 is suitable to be advanced into a first-in-human clinical trial. [ABSTRACT FROM AUTHOR]

Purpose Over the past decade there has been increased attention on the need for highly skilled and trained pharmacy technicians; however, few best practices to assist health-system pharmacies in meeting technician workforce challenges have been identified. These challenges have been further revealed since 2019 through rising inflation, increased cost of living, and competing opportunities for skilled technical workers. This article describes an 18-hospital academic health system's experience implementing an innovative pharmacy technician career structure focused on increasing pharmacy technician engagement as well as improving recruitment and retention. Methods Prior to creating a new career structure, the department of pharmacy had one development track for pharmacy technicians, which included only 2 nonsupervisory job titles. Due to recruitment, retention, and employee engagement challenges, the department of pharmacy, in collaboration with the human resources department, developed a new pharmacy technician structure that included 3 pharmacy technician tracks and 4 nonsupervisory levels. Outcomes collected to determine the success of the program included pharmacy technician engagement survey scores, annual voluntary turnover rate, rolling 12-month voluntary turnover rate, monthly vacancy rate, and average years of service at termination. The monthly discharge prescription capture rate was also measured to support efforts to keep the cost of the new structure budget neutral. Conclusion The change in career structure assisted in the improvement of each outcome identified. The close collaboration of the departments of pharmacy and human resources can lead to positive solutions of national problems and have a sustained impact on department operations. [ABSTRACT FROM AUTHOR]

Background: Cancer treatment-induced bone loss (CTIBL) is the most common adverse event experienced by patients affected by breast cancer (BC) patients, without bone metastases. Bone modifying agents (BMAs) therapy is prescribed for the prevention of CTIBL, but it exposes patients to the risk of MRONJ. Methods: This multicentre hospital-based retrospective study included consecutive non-metastatic BC patients affected by MRONJ related to exposure to low-dose BMAs for CTIBL prevention. Patients' data were retrospectively collected from the clinical charts of seven recruiting Italian centres. Results: MRONJ lesions were found in fifteen females (mean age 67.5 years), mainly in the mandible (73.3%). The mean duration of BMAs therapy at MRONJ presentation was 34.9 months. The more frequent BMAs was denosumab (53.3%). Ten patients (66.7%) showed the following local risk factors associated to MRONJ development: periodontal disease (PD) in three cases (20%) and the remaining six (40%) have undergone PD-related tooth extractions. One patient presented an implant presence-triggered MRONJ (6.7%). In five patients (33.3%) no local risk factors were observed. Conclusions: This is the first case series that investigated BC patients under BMAs for CTIBL prevention suffering from MRONJ. These patients seem to have similar probabilities of developing MRONJ as osteo-metabolic ones. Breast cancer patients under BMAs for CTIBL prevention need a regular prevention program for MRONJ, since they may develop bone metastases and be treated with higher doses of BMAs, potentially leading to a high-risk of MRONJ. [ABSTRACT FROM AUTHOR]

Early in the pandemic, New York City's public hospital system partnered with multiple philanthropic foundations to offer an unconditional cash transfer program for low-income New Yorkers affected by COVID-19. The $1000 cash transfers were designed to help people meet their most immediate health and social needs and were incorporated into healthcare delivery and contact tracing workflows as a response to the public health emergency. To better understand program recipients' experiences, researchers conducted 150 telephone surveys with randomly sampled cash transfer recipients and 20 in-depth qualitative interviews with purposefully sampled survey participants. Survey participants were predominantly Latinx (87%) and women (65%). The most common reported uses of the $1000 were food and rent. Most participants (79%) reported that without the $1000 cash transfer they would have had difficulty paying for basic expenses or making ends meet, with specific positive effects reported related to food, housing, and ability to work. The majority of survey participants reported that receiving the cash assistance somewhat or greatly improved their physical health (83%) and mental health (89%). Qualitative interview results generally supported the survey findings. [ABSTRACT FROM AUTHOR]

Background: Medication errors are common and can compromise patient safety. Commonly seen at discharge, they can be identified and resolved even during admission. Medication reconciliation is recommended to prevent errors arising from medication discrepancies. Aim: To conduct medication reconciliation in two multispeciality hospitals and classify the identified medication discrepancies according to their potential to cause harm. Materials and Methods: This prospective interventional study was carried out in medicine and surgery departments of two urban hospitals over a period of six months. Patients who satisfied the criteria were enrolled and medication reconciliation was performed. Interventions were provided whenever necessary. The identified discrepancies were then given to an expert panel for classifying them based on their potential to cause harm. Results: 580 medication discrepancies were identified from a total 372 patients, drug interaction (n=345, 61.6%) was the most commonly observed discrepancy, followed by omission error (n=127, 12.9%). The medication discrepancies observed from both the hospitals were found to be statistically not significant (p=0.246). From a total of 580 discrepancies, 454 (78.27%) discrepancies were Significant, 80 (13.79%) Serious and 46 (7.93%) Not Significant. Conclusion: The results of our study show that there are discrepancies in medication use when the patient transitions in a hospital. It is recommended that medication reconciliation practices be performed by clinical pharmacist during the hospital stay to ensure continuity of healthcare and for patient safety. An electronic medical record capable of capturing and continuously updating medication information may be a long-term solution. To achieve this, professional development of clinical pharmacists is of paramount importance. [ABSTRACT FROM AUTHOR]

Healthcare generates large amounts of waste, harming both environmental and human health. Waste audits are the standard method for measuring and characterizing waste. This is a systematic review of healthcare waste audits, describing their methods and informing more standardized auditing and reporting. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE, Embase, Inspec, Scopus and Web of Science Core Collection databases for published studies involving direct measurement of waste in medical facilities. We screened 2398 studies, identifying 156 studies for inclusion from 37 countries. Most were conducted to improve local waste sorting policies or practices, with fewer to inform policy development, increase waste diversion or reduce costs. Measurement was quantified mostly by weighing waste, with many also counting items or using interviews or surveys to compile data. Studies spanned single procedures, departments and hospitals, and multiple hospitals or health systems. Waste categories varied, with most including municipal solid waste or biohazardous waste, and others including sharps, recycling and other wastes. There were significant differences in methods and results between high- and low-income countries. The number of healthcare waste audits published has been increasing, with variable quality and general methodologic inconsistency. A greater emphasis on consistent performance and reporting standards would improve the quality, comparability and usefulness of healthcare waste audits. [ABSTRACT FROM AUTHOR]

Introduction: The literature on studies reporting trifecta or pentafecta outcomes following robot-assisted partial nephrectomy (RAPN) in Indian patients is limited. The primary aim of this study was to report and evaluate the factors predicting trifecta and pentafecta outcomes following RAPN in Indian patients using the multicentric Vattikuti collective quality initiative (VCQI) database. Methods: From the VCQI database for patients who underwent RAPN, data for Indian patients were extracted and analyzed for factors predicting the achievement of trifecta and pentafecta following RAPN. Trifecta was defined as the absence of complications, negative surgical margins, and warm ischemia period shorter than 25 min or zero ischemia. Pentafecta covers all the trifecta criteria as well as >90% preservation of estimated glomerular filtration rate (eGFR) and no stage upgrade of chronic kidney disease at 12 months. Results: In this study, among 614 patients, the trifecta was achieved in 374 patients (60.9%) and pentafecta was achieved in 24.2% of the patients. Patients who achieved trifecta had significantly higher mean age (54.1 vs. 51.0 years, P = 0.005), body mass index (BMI) (26.7 vs. 26.03 kg/m2, P = 0.022), and smaller tumor size (38.6 vs. 41.4 mm, P = 0.028). The preoperative eGFR (84.2 vs. 91.9 ml/min, P = 0.012) and renal nephrometry score (RNS) (6.96 vs. 7.87, P ≤ 0.0001) were significantly lower in the trifecta group. Comparing patients who achieved pentafecta to those who did not, we noted a statistically significant difference between the two groups for tumor size (36.1 vs. 41.5 mm, P = 0.017) and RNS (6.6 vs. 7.7, P = 0.0001). On multivariate analysis, BMI and RNS were associated with trifecta outcomes. Similarly, only RNS was identified as an independent predictor of pentafecta. Conclusions: RNS and BMI were independent predictors of the trifecta. At the same time, RNS was identified as an independent predictor of pentafecta following RAPN. [ABSTRACT FROM AUTHOR]

This article presents the findings of a study on the amount of waste generated during gastrointestinal endoscopic examinations in German hospitals and offices. The study aimed to calculate the recycling potential of this waste. Over a four-week period, waste was collected and categorized into residual waste, accessories, personal protective equipment, plastics, and paper. The study found that an average of 1.15 kg of waste was generated per examination, with 69.9% being residual waste. Although the recycling potential for plastic and paper was low, it could still contribute to reducing the amount of residual waste. [Extracted from the article]