Delay In Administration Research Articles

Antibiotic shortages: An overview by the Alliance for the Prudent Use of Antibiotics (APUA).

Antibiotics have been among the drugs most affected by shortages over the last two decades, with harmful consequences that may persist over years. This position paper was designed by the Alliance for the Prudent Use of Antibiotics (APUA), an international multidisciplinary consortium of experts dedicated to combating antimicrobial resistance. We performed a narrative review to examine the main causes and impacts of antibiotics shortages, and to identify the solutions that may be proposed to prevent and mitigate this public health threat. The main causes of antibiotic shortages are failure to comply with good manufacturing practices, regulatory issues, unavailability of essential components, unanticipated discontinuation of production by a major supplier, unexpected surges in demand, and other logistical challenges. The main consequences include delays in appropriate treatment administration, overuse of broad-spectrum antibiotics with an increased risk of resistance, reduced efficacy, and increased toxicity due to sub-optimal antibiotics use, increased costs, medication errors, and prolonged or repeated hospital stays. Proposed potential solutions for antibiotic shortages include multidisciplinary international initiatives to foster market entry rewards, specific solutions for low-and-middle income countries (LMICs), strengthening supply chains, encouraging local production, implementing market entry incentives and facilitating the registration process for novel antibiotics and vaccines. Antibiotics shortage severely impacts patient care and public health worldwide. The sustainability of both current and future antibiotics depends on the implementation of effective global health strategies and ongoing financial commitment. Immediate and decisive action is necessary to protect global health for future generations.

The Complete Blood Count Sepsis Index Using Monocyte Distribution Width for Early Detection of Sepsis in Patients Without Obvious Signs.

Exploiting the complete blood count (CBC) with differential (CBC-diff) for early sepsis detection has practical value for emergency department (ED) care, especially for those without obvious presentations. The objective of this study was to develop the CBC Sepsis Index (CBC-SI) that incorporates monocyte distribution width (MDW) to enhance rapid sepsis screening. A retrospective observational study. The ED of the University of Kansas Medical Center, United States. All adult patients (age 18 or over) presenting to the ED between August 8, 2020, and April 1, 2022, that received a CBC-diff as part of routine clinical care. MDW, WBC count, and neutrophil-to-lymphocyte ratio were used to develop a CBC-SI (0 low to 5 high risk) for early sepsis detection. The diagnostic performance of CBC-SI was evaluated for patients with and without obvious early signs of sepsis. In a cohort of 51,407 ED visits, 1,683 (3.3%) met sepsis criteria; 1,343 (79.8%) septic patients presented with obvious signs and 340 (20.2%) without. The overall area under the curve of the CBC-SI was 0.83 (95% CI, 0.81-0.85). A CBC-SI of greater than or equal to 1 point exhibited a sensitivity of 83.1% (95% CI, 79.9-86.2%) and specificity of 64.8% (95% CI, 64.0-65.5%). Superior performance was observed in the patient subgroup presenting without obvious signs; greater than or equal to 1 point, 81.1% (95% CI, 73.2-88.9%) sensitivity and 69.1% (95% CI, 68.3-69.9%) specificity. Septic patients without obvious signs exhibited delays in antibiotic administration from arrival (median 4.7 vs. 3.4 hr; p < 0.001) and higher rates of ICU admission (43.8% vs. 27.9%; p < 0.001) and in-hospital mortality (14.7% vs. 9.8%; p = 0.011) compared with the septic subgroup presenting with obvious signs. The CBC-SI demonstrated strong performance for early sepsis detection. Its performance was best for nonobvious presentations, suggesting highest utility in a subgroup that is most susceptible to delayed interventions and poorer outcomes.

Real-World Andexanet Alfa Utilization and the Association Between Delay in Administration Due to Hospital Transfer and All-Cause Inpatient Mortality

Real-World Andexanet Alfa Utilization and the Association Between Delay in Administration Due to Hospital Transfer and All-Cause Inpatient Mortality

2633 Reducing delays in Administration of First Dose Denosumab through introduction of ACP led consent process during inpatient stay

2633 Reducing delays in Administration of First Dose Denosumab through introduction of ACP led consent process during inpatient stay

Determinants of Sexual Dysfunction in Parkinson's Disease Patients: A Secondary Analysis of a Multicenter Cross-Sectional Study.

Background: Sexual dysfunction (SD) in Parkinson's Disease (PD) patients is a common and distressing concern, although it remains an underdiagnosed and undertreated condition. Indeed, the prevalence of SD in PD ranges from 42.6% to 79% in men and from 36% to 87.5% in women. PD-related SD etiology is multifactorial and includes biological, psychological, and socio-relational factors. In a previous multicenter study on 203 PD patients, we found that there was no gender difference in dysfunction severity, although men were significantly more affected by SD than women. Methods: This paper is a secondary analysis of this previous multicenter study, and aims to investigate the potential risk factors that contribute to SD. The relationship between dysfunction and the experimental factors was assessed using Generalized Linear Mixed-Effects (GLME) model. Results: The final analysis was conducted on a sample of 177 patients (76 women), after excluding individuals with incomplete data, non-compliance with inclusion criteria, or delays in assessment tool administration. The analysis, performed using the GLME model (R2 = 0.68), revealed that gender (p = 0.01), age (p = 0.02), and depression status (HAMD) (p = 0.01) were significant predictors of SD. In contrast, other factors considered in the model, such as diabetes, and autonomic symptoms, did not significantly influence SD. Conclusions: This study demonstrates that age, gender, and depression are important predictors of SD in patients with PD. Although SD is a common NMS in PD patients, it is often neglected in clinical practice and the research on this hot topic is still poor. Then, a multidisciplinary approach, including nursing and coaching, is mandatory in order to improve sexual health in this patient population.

Breaking Coal Lock-In: Unravelling the Policy Hurdles to Decarbonising Indonesia’s Energy Sector

The Indonesian government has ratified the 2015 Paris Agreement, thereby committing itself to a climate commitment to achieve zero carbon emissions by 2060 and to keep the Earth's temperature rise within 1.5 degrees Celsius above the pre-industrial average. This commitment is being implemented in various ways, including the decarbonisation of the electricity sector. This policy was promulgated in Presidential Regulation 112/2022 regarding acceleration of renewable energy development and Ministry of Finance Regulation 103/2023 on the fiscal support of energy transition. In this case, many aspects such as institutionalisation, visibility, intentionality, risk avoidance, and differences of interest appear to lead to procedural policy outcomes which later determine th decarbonisation rate of Coal-Fired Power Plants (CFPP). This article seeks to examine the procedural aspects of the early coal-fired power plant retirement policy innovation, based on Howlett's (2014) theory of climate policy innovation. This research employs qualitative methods, including in-depth interviews with stakeholders and literature studies. This article explains that the policy formulation in Presidential Regulation 112/2022 tends to be procedurally negative and hampers several CFPPs' early retirement processes in West Java and Banten. The weaknesses of this policy are clearly visible in the form of administrative delays and criteria restrictions. The article posits that the existing CFPP early retirement policy exerts varying degrees of influence on Cirebon-1 CFPP, Suralaya CFPP and Pelabuhan Ratu CFPP.

Public Awareness and Perception of the Swasthya Sathi Scheme: Insights from Beneficiaries and Non-Beneficiaries in the Uttar Dinajpur District, West Bengal

The Swasthya Sathi Public Health Program in West Bengal aims to deliver universal medical services to underprivileged groups. This ambitious initiative offers monetary aid and a simple admission to medical care. This analysis explores how computerization optimizes Sathi’s performance and reach. Owing to progress in digitization, the scheme has benefited from streamlined operations, enhanced patient documentation, and better treatment availability. Innovations, such as online registration, digital health cards, and telehealth, have significantly decreased administrative costs and delays, allowing beneficiaries to access care more conveniently. Digitalization has also facilitated real-time data aggregation and tracking, allowing better policy formation and a more efficient allocation of funds. This study examines how digital tools impact various aspects of a scheme’s performance by analyzing case studies and real data from multiple districts in West Bengal. The findings underscore how computerization contributes to the success of the scheme by addressing issues such as fraud prevention, timely reimbursement, and expanded access to healthcare. In the end, this study calls for digital remedies to be fully integrated into Swasthya Sathi's framework to make it stronger and use it as a model for other Indian government-funded health programs.

ED Nurse-Led Code Sepsis to Reduce Time to Antibiotics.

Delays in sepsis recognition contribute to delays in antibiotic administration, which lead to increased morbidity and mortality in patients with sepsis. Our objective was to create an Emergency Department (ED) Code Sepsis Nurse-led team to reduce the time to antibiotics and mortality in patients with sepsis. This initiative was implemented at a community hospital in Southern California in response to previous undesirable sepsis outcomes. In fiscal year 2021, the ED Sepsis Nursing Team was launched with the goal of improving sepsis-related outcomes. The following interventions were implemented: First, a group of dedicated Sepsis Nurses with training specific to sepsis recognition was created, and an electronic ED-sepsis screening tool was developed and implemented. Next, the dedicated sepsis nurses designed and educated to a "Code Sepsis" activation process. The code triggered a multidisciplinary response and implementation of standing orders for blood cultures, lactate, complete blood count, complete metabolic panel, and chest x-ray or urinalysis if indicated. Finally, the Sepsis Team Registered Nurse (RN) Captain led house-wide monthly Sepsis Task Force meetings to improve unit-level engagement and to allow the team to have ownership over sharing wins and losses. By Quarter 4 (Q4) of Fiscal Year 2021, door-to-antibiotic time for sepsis patients dropped from 196.7min (Q1) to 144.7 (Q4). Additionally, mortality dropped below the health system average (10.4% vs. 13.5%), and Fiscal Year 2021 surpassed the readmissions benchmark of<1.0 at a rate of 0.5. An RN-led, interprofessional response to accepted sepsis identification criteria enhanced staff and physician engagement and improved sepsis outcomes for patient mortality and hospital reporting outcomes. The process was adopted with very few obstacles that were easily overcome as the understanding of the role and its significance was realized.

Assessment of Human-wildlife Conflict: A Case Study from Kothale Village in the Kalsubai-Harishchandragad Wildlife Sanctuary (KHWS), Maharashtra, India

Human-Wildlife Conflicts (HWCs) refer to the interactions between humans and wild animals that result in negative impacts on both sides. Conflicts between humans and wildlife occur when human intervention encroaches on natural ecosystems and animals' wild behavior. This conflict often arises due to resource competition, crop damage, livestock predation, and human safety concerns. This study investigated the nature, causes, and mitigation strategies of HWCs in the Kothale village of Kalsubai-Harishchandragad Wildlife Sanctuary (KHWS), Maharashtra. The 2011 census recorded 112 households in Kothale village, of which 45% gathered data about HWCs. The investigator identified the causes, consequences, and management approaches of human-wildlife conflict in the study area, as well as the perspectives of the local people, using survey questionnaires, semi-structured interviews, group discussions, and observation. The study discusses the local community's household characteristics, livestock, agricultural activities, crop raiding, local people's perceptions and attitudes towards wildlife, their experiences with wildlife, mitigation and management, etc. The survey revealed that during the five previous seasons, wild animals caused 86.27% crop damage, 62.75% attacked livestock, and 15.69% attacked people. The study found that loss of crops and livestock, as well as decreasing animal resources, were the main causes of conflict, along with habitat degradation and fragmentation brought on by human activity. Many victims do not receive compensation because of a lack of awareness among local residents, administrative delays at the local level, and inadequate documentation. Implementing various programs and recommended action plans can reduce human-wildlife conflict.

Real world delays in antivenom administration: patient, snake or hospital factors (ASP-33)

Objective Early antivenom administration is essential for effective treatment. We investigated the delays in antivenom administration. Methods We reviewed snakebites from the Australian Snakebite Project (2006–2021) given antivenom, presenting to hospital within 12 h. We extracted demographics, snake type, time of bite, hospital arrival, blood collection, antivenom treatment and hospital transfer. Results There were 2,169 patients recruited to Australian Snakebite Project 1,132 patients received antivenom within 12 h of the bite, and 1,019 of these were envenomated: median age 41 years (IQR: 24–57 years); 738 (72%) males. A pressure bandage was applied in 950 (93%), a median of 15 min (IQR: 5–30 min) post-bite. Specific snakes were identified by venom assays in 855 patients (80%), including 328 brown snakes (32%), 173 tiger snakes (17%), 74 rough-scaled snakes (7%), 85 red-bellied black snakes (8%), 49 taipans (5%) and 26 death adders (3%). Seventy-seven patients (7%) received antivenom without envenomation. The median length of hospital stay was 41 h (IQR: 24–67 h). The median time to hospital was 60 min (IQR: 30–105 min), to first blood tests was 90 min (IQR: 59–154 min) and to antivenom was 235 min (IQR: 155–345 min). There was a median delay in blood tests of 20 min (IQR: 10–37 min) and a median delay to antivenom of 147 min (IQR: 84–249 min). Non-specific systemic symptoms occurred in 641 (63%) patients, which occurred a median of 24 min (IQR: 10–60 min) post-bite, which was at a median of 180 min (IQR: 106 to 275 min) prior to antivenom administration. Time to antivenom in the 314 transferred patients was similar to those not transferred. Time to antivenom was significantly shorter for 189 patients given antivenom prior to transfer, median 183 min (IQR: 110–270 min), compared to 130 patients given antivenom after transfer, median 363 min (IQR: 289–513 min; P <0.001). Discussion Antivenom administration was delayed on average by 2.5 h after hospital presentation, despite three-quarters arriving in hospital within 3 h, the optimal time for antivenom administration. Patients requiring transfer received antivenom in a similar time, but earlier if administered prior to transfer, highlighting the possible benefits of pragmatic clinical decision-making prior to blood tests. Conclusion We found the leading cause of delays to antivenom administration after patients arrive in hospital was waiting for blood results. Systemic symptoms occurred early in most cases and could be given greater weight in decisions about early antivenom.

Preferences for speed of access versus certainty of the survival benefit of new cancer drugs: a discrete choice experiment.

The extent to which patients with cancer are willing to accept uncertainty about the clinical benefit of new cancer drugs in exchange for faster access is not known. This study aims to examine preferences for access versus certainty, and to understand factors that influence these preferences. A US nationally representative sample of older adults were recruited via Cint, an online platform for survey research, to take part in an online discrete choice experiment. To be eligible, respondents had to self-report some experience with cancer-ie, they themselves, a close friend or a family member, previously or currently diagnosed with cancer. In the experiment, respondents chose between two cancer drugs, considering five attributes: functional status, life expectancy, certainty of the survival benefit of a new drug, effect of the drug on a surrogate endpoint, and delay in US Food and Drug Administration (FDA) approval time. The first primary outcome was the relative importance of certainty of survival benefit and wait time to respondents. The second primary outcome was willingness to wait for greater certainty of survival benefit, including subgroup analysis by cancer experience, age, education status, race or ethnicity and income. Secondary outcomes were changes in sensitivity to certainty and wait time, depending on the drug's effect on a surrogate endpoint, respondents' functional status, and life expectancy. The study plan was registered with ClinicalTrials.gov, NCT05936632. Between July 7 and July 20, 2023, 998 eligible respondents completed the survey. 870 respondents (461 [53%] male, 406 [47%] female, and three [<1%] other) were included in the final analysis. Respondents showed strong preferences for high certainty of survival benefit (coefficient 2·61, 95% CI 2·23 to 2·99), and strong preferences against a 1-year delay in FDA approval time (coefficient -1·04, 95% CI -1·31 to -0·77). Given very low certainty a drug would provide survival benefit (no evidence linking a surrogate endpoint to overall survival), respondents were willing to wait up to 21·68 months (95% CI 17·61 to 25·74) for high certainty (strong evidence) of survival benefit. A drug's effect on a surrogate endpoint had no significant impact on drug choices (coefficient 0·02, 95% CI -0·21 to 0·25). Older respondents (aged ≥55 years), non-White, lower-income (<$40 000 per year) individuals, and those with the lowest life expectancy, were most sensitive to wait time. Many cancer drugs approved through the FDA's accelerated approval pathway do not offer any survival benefit to patients. In this study, individuals expressed strong preferences for certainty that a cancer drug would offer survival benefit. Some individuals also expressed a higher willingness to wait for greater certainty than would be necessary to assess the survival benefit (over progression-free survival benefit) of most cancer drugs used in the metastatic setting. The London School of Economics and Political Science Phelan United States Centre.

Legal obstacles jeopardise research in personalised medicine - experiences from a Nordic collaboration within rheumatology.

Personalised medicine in chronic complex diseases such as rheumatoid arthritis (RA) is within reach but requires international multi-stakeholder collaboration. We exemplify how national implementations of the General Data Protection Regulation (GDPR) have introduced administrative delays and created disincentives for data sharing and collaborative research. Our Danish/Swedish/Norwegian research collaboration (the 3-year NordForsk-funded "NORA" project) aims to develop a personalised medicine approach for the management of RA, built on the exploitation of unique existing data sources: longitudinal data from clinical rheumatology registries, research cohorts, nationwide health care registries, and biobank material from >20 sample collections. Data and results are shared and accessed remotely by collaborators at secure servers. New biomarker assays and patient-centric implementations of the results are to be explored, validated, and disseminated to patients and health care via the development of digital tools. Following the advice of legal experts at the involved academic or public institutions and private companies, GDPR compliance resulted in >20 legal documents to govern the collaboration (consortium-, joint controller-, research collaboration-, data sharing-, and a series of unique two-way data processing-, and material transfer agreements). Lack of agreed-upon templates, policies, procedures, and a shortage of legal resources have caused considerable delays. Thus, our research consortium has spent more time ensuring GDPR compliance than on actual research activities. The current interpretation and implementation of the legal premises (rather than the GDPR per se) for research collaborations caused unnecessary barriers and delays. Our experiences call for Nordic trust-based code-of-conduct-like framework agreements, and for harmonisation of procedures and templates, lest the Nordic advantage in research be lost.

Multidisciplinary standardized protocol decreases time to antibiotic administration for open fractures.

Wound complications after open fracture are common, including superficial and deep infections. Many factors may contribute to outcomes after open fracture, including comorbidities, injury location and characteristics, timing and quality of surgical debridement, and soft tissue coverage. Early prophylactic antibiotic administration is one of the few modifiable factors demonstrated to reduce infection rates. Retrospective comparative study at a single Level 1 Trauma Center evaluated patients age > 18 who presented directly to and were admitted with open long-bone fracture. Primary outcome measure was time from arrival to antibiotic administration pre- and post-implementation of a standardized open fracture protocol. Secondary analysis evaluated percentage of patients receiving antibiotics within one hour for open long-bone fracture, injury characteristics and patient demographics influence on time to antibiotics. Median time to antibiotic administration improved post-protocol (69min vs. 39min, p < 0.001). Patients receiving antibiotics within one hour improved after protocol implementation (42.9% vs. 79.0%, p < 0.001). Antibiotic administration was more often delayed for patients with penetrating injuries compared to blunt injuries (80min vs. 54min, p = 0.003). Patients with penetrating injuries were less likely to receive antibiotics within one hour (46% vs 56%, p < 0.001). The implementation of a standardized protocol reduced the time to antibiotic administration and increased the percentage of patients with open fractures receiving antibiotics within one hour. Penetrating injuries were often not appreciated as open fractures during the initial evaluation, which led to a delay in antibiotic administration. Level III, Therapeutic/Care Management.

Immunosuppressive therapies in scorpion envenomation: new perspectives for treatment.

Scorpion envenoming is a relevant and neglected public health problem in some countries. The use of antivenom is widespread in many regions, targeting specific species of scorpions. However, the uncontrolled proliferation and adaptation of these animals to urban environments, combined with limited access to treatments in remote areas and delays in antivenom administration contribute to a significant number of fatalities from scorpion-related incidents. In recent decades, new research has revealed that the immune system plays an important role in triggering immunopathological reactions during scorpion envenoming, which places it as a therapeutic target; however, few clinical studies have been conducted. This work provides a review of the main immunopathological aspects of scorpion envenoming, as well as the clinical trials conducted to date on the use of corticosteroids for the treatment of scorpionism. We highlight emerging treatment perspectives as well as the need for further clinical trials. The use of corticosteroids in scorpionism, when appropriate, could significantly enhance access to treatment and help reduce fatalities associated with scorpion stings.

EHospitals and Parkinson’s disease care: audit insights from an EPIC-integrated Hospital

Abstract Introduction Parkinson’s disease (PD) is a neurodegenerative condition that affects approximately 145,000 individuals in the UK. PD symptoms are managed primarily through medications such as levodopa and dopamine agonists. Delays or omissions in administering these medications is the primary reason for increased length of stay in up to 73% of emergency admissions.1 This audit investigated the management of PD medications at Cambridge University Hospitals to identify areas for improvement in clinical practice. Aim This audit aimed to evaluate the pharmacological management of PD patients admitted to Cambridge University Hospitals NHS Trust. Specifically, it sought to assess the accuracy of drug histories, the quality of medication administration, and adherence to standards set by Parkinson’s UK ‘Get it on Time’ campaign and NICE.2,3 Methods A cross-sectional audit was conducted, reviewing the records of PD patients admitted over a three-month period. The sample included patients with a confirmed diagnosis of idiopathic PD who were prescribed at least one PD medication. Data were collected retrospectively from the electronic patient records, focusing on ten performance standards. Ethical approval was not required as the study involved a retrospective review of existing clinical records. Results The audit included 63 admissions, predominantly male (65%) with a mean age of 78.5 years. A significant portion of patients (81%) had their drug histories completed by a doctor after clerking, and 90% had orders for their regular treatment generated immediately post-clerking. Pharmacy staff completed drug histories within 24 hours for 81% of patients, though discrepancies between medical and pharmacy histories were noted in 70% of cases. Medication reconciliation within 24 hours was achieved for 83% of patients, yet only 29% received their PD medications on time for every dose. Additionally, 76% did not miss a dose or had a valid reason recorded for missed doses. 83% had PD listed in their electronic problem list after clerking. Alarmingly, just 5% were assessed for Self-Administration of Medicines (SAM), and 76% were assessed by a PD specialist during their stay. Discussion and conclusion The audit revealed substantial gaps in PD medication management, particularly regarding discrepancies between medical and pharmacy drug histories and delays in medication administration. The low rate of SAM assessments and inconsistent PD specialist consultations were also significant concerns. These findings highlight the need for improved documentation practices, such as standardized templates within the EPIC system, and increased pharmacy involvement during early stages of admission. Appropriate staffing levels and better interdisciplinary coordination are essential. The audit identified critical areas for improvement, emphasizing the need for better documentation, timely administration, and enhanced interdisciplinary coordination. Future audits should aim to randomize patient selection over a longer period to minimize bias and provide a more comprehensive assessment of medication management practices. The audit was limited by its retrospective design and the specific three-month timeframe, which may not fully represent broader trends. The exclusion of admissions shorter than 24 hours and the focus on a single hospital trust also limit the generalizability of the findings. Future studies should consider a larger, more randomized sample to validate and expand upon these results.

Experiences of the emergency department environment: a qualitative study with caregivers of people with dementia.

ED crowding and boarding adversely impact older patients' care and outcomes. Little is known about how ED crowding impacts persons living with dementia, a vulnerable population. This study sought to explore ED experiences of caregivers of people with dementia during a period of ED crowding and boarding. We performed semi-structured interviews with caregivers of people with dementia with an ED visit during a period of ED crowding and boarding at two public hospitals experiencing a threefold increasein boardingfrom pre-pandemic levels. Participants were recruited via chart review. We coded data using an inductive approach. Three themes emerged from 29 caregiver interviews: (1) difficulty obtaining assistance, (2) patient harms, and (3) concerns about triage and rooming processes. First, caregivers described having to be proactive to obtain symptom control and assistance with mobility. Second, caregivers observed harms of noise and stimulation provoking agitation and delays in administration of routine medications. Third, caregivers felt it was inappropriate for people with dementia to receive care in waiting room chairs or to receive prolonged hallway care. Caregivers advocated for preferential considerations for rooming and rapid assessment to avoid agitation, facilitatd access to ED staff, and promote patient comfort. Caregivers of people with dementia associated ED environments with difficulty obtaining assistance, patient harms, and triage concerns. Strategies to mitigate the negative impacts of ED crowding on people with dementia should focus on environmental modifications, uptriage of people with dementia, supporting activities of daily living and mobility, andinnovation around patient disposition.

The Black Box of Single-Family Zoning Reform

America faces a staggering housing affordability crisis. The consequences of the crisis include reduced economic productivity, suppressed labor mobility, greater social inequity, and increased homelessness. A scholarly consensus blames excessive land-use regulation for these problems and advocates now call for deregulation. Several jurisdictions have recently elected to allow middle housing—small, multi-family developments—in areas previously zoned for single-family detached housing. The results of these reforms, however, have been disappointing. This Article examines why they have fallen short and how to do better. This Article identifies an analytical disconnect between the deregulatory consensus and actual single-family zoning reforms adopted to date. Given this disconnect and the limited success of single-family zoning reforms thus far, it is unclear why such reforms continue to be adopted. Moreover, these reforms cannot achieve their promised ends. Interviews of middle housing builders in reform jurisdictions reveal legal and structural barriers that prevent market participants from responding to the housing crisis with scale and urgency. This Article proposes several regulatory alternatives that offer a greater probability of success in achieving the consensus’s goals: (1) modestly expanding multi-family zones to allow redevelopment and densification of underutilized non-residential properties; (2) providing affordable-housing density bonuses; (3) streamlining land-use procedures and eliminating administrative delay to reduce uncertainty in permitting processes; and (4) reevaluating financing mechanisms for new housing development. Taken together, these policies are necessary complements to single-family zoning reforms for addressing undersupply of market- and below-market-rate housing.

Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration in Out-of-Hospital Cardiac Arrest ― Composite Time-Dependent Effects of Prehospital Interventions on 30-Day Favorable Neurological Outcomes and Social Implications From a Prospective Nationwide Population-Based Cohort Study ―

Our study investigated the prognostic impacts of the interval between collapse and the initiation of cardiopulmonary resuscitation (CPR), and subsequent intervals to defibrillation or epinephrine administration, on 30-day favorable neurological outcomes following out-of-hospital cardiac arrest (OHCA). This nationwide population-based cohort study used the All Japan Utstein Registry, encompassing OHCA patients in Japan between January 2006 and December 2021. The primary outcome was 30-day favorable neurological outcomes, defined as Cerebral Performance Category 1 or 2. Three-dimensional plots and multivariable logistic regression models were used to assess the time-dependent prognostic impacts of prehospital CPR interventions. In all, 184,731 OHCA patients (86,246 with shockable rhythm and 98,485 with non-shockable rhythm) were included in the study. Three-dimensional plots revealed that the interval between collapse and initiation of CPR, and subsequent intervals to defibrillation or epinephrine, were independently associated with 30-day favorable neurological outcomes in the groups with shockable and non-shockable rhythms, respectively (P<0.05 for all). Among patients with witnessed OHCA, there was a dose-response relationship between delays in the collapse-CPR initiation interval, and subsequent intervals to defibrillation or epinephrine administration, and 30-day favorable neurological outcomes. Our findings provide valuable insights into OHCA management.

Development and Validation of a Machine Learning Model for Early Detection of Untreated Infection.

Early diagnostic uncertainty for infection causes delays in antibiotic administration in infected patients and unnecessary antibiotic administration in noninfected patients. To develop a machine learning model for the early detection of untreated infection (eDENTIFI), with the presence of infection determined by clinician chart review. Three thousand three hundred fifty-seven adult patients hospitalized between 2006 and 2018 at two health systems in Illinois, United States. We validated in 1632 patients in a third Illinois health system using area under the receiver operating characteristic curve (AUC). Using a longitudinal discrete-time format, we trained a gradient boosted machine model to predict untreated infection in the next 6 hours using routinely available patient demographics, vital signs, and laboratory results. eDENTIFI had an AUC of 0.80 (95% CI, 0.79-0.81) in the validation cohort and outperformed the systemic inflammatory response syndrome criteria with an AUC of 0.64 (95% CI, 0.64-0.65; p < 0.001). The most important features were body mass index, age, temperature, and heart rate. Using a threshold with a 47.6% sensitivity, eDENTIFI detected infection a median 2.0 hours (interquartile range, 0.9-5.2 hr) before antimicrobial administration, with a negative predictive value of 93.6%. Antibiotic administration guided by eDENTIFI could have decreased unnecessary IV antibiotic administration in noninfected patients by 10.8% absolute or 46.4% relative percentage points compared with clinicians. eDENTIFI could both decrease the time to antimicrobial administration in infected patients and unnecessary antibiotic administration in noninfected patients. Further prospective validation is needed.

UTILITY OF CONTRAST-ENHANCED T2-FLAIR FOR IMAGING OF BRAIN METASTASESUSING A HALF-DOSE HIGH-RELAXIVITY CONTRAST AGENT IN COMPARISON WITH ROUTINE DOSE CONTRAST-ENHANCED BRAIN IMAGING

Aim &amp; Objectives: This study aims to assess the efficacy of delayed contrast-enhanced T2 fluid-attenuated inversion recovery (CE-T2 FLAIR) by using half dose high relaxivity contrast agent to assess the degree of enhancement among the lesions and to detect additional metastatic brain lesions usually smaller lesions(&lt;5mm), which are significantly missed on routine-dose CE-T1 weighted imaging (CE-T1WI). Material &amp; Methods:The main source of data for this study was radiologically diagnosed lung cancer patients who were clinically suspected to have brain metastasis referred from various departments of Silchar Medical College and Hospital. The studywas carried out for a period of 1 year from March 1, 2023, to February 29, 2024, A total of 40 patients with brain metastases were scanned using a SIEMENS TIM AVANTO 1.5T scanner, routine MR pulse sequences pre- and post-contrast administration were acquired. Results: Out of 40 patients, males were more affected (57.5 %) than females (42.5 %). The highest number of cases were found between the 61-70 years age group with the lung (31 cases) being the most common primary malignancy causing brain metastases. A total of 90 lesions were detected among 40 patients which were grouped into A (25 lesions), B (36 lesions), and C (29 lesions) groups. A total of 6 lesions were missed on Routine dose contrast-enhanced brain imaging of which 2 lesions belong to group B (Rim enhancing lesions &gt;5mm) and 4 lesions belong to group C (Lesions &lt;5mm), however, these lesions were picked up on delayed half dose contrast-enhanced FLAIR images. The contrast ratio (CR) on 3 consecutive half dose CE-T2 FLAIR ranged between 59.09%-76.80%, suggesting that delay in imaging post-contrast administration resulted in a significant increase in the contrast ratio (CR) among metastatic lesions. Conclusions: CE-T1-weighted sequences and CE-T2 FLAIR sequences complement each other effectively in evaluating brain metastases. Bigger and homogenously enhancing lesions are best seen on CE-T1-weighted sequences. Smaller lesions and lesions showing rim enhancement are best visualized on delayed (5 min) CE-T2 fluid-attenuated inversion recovery (FLAIR) sequences with half the dose ofcontrast agent (gadobenatedimeglumine) compared to routine dose CE-T1-weighted sequences. This approach serves as a cost-saving measure for both patients and the healthcare system.