Care Perspective Research Articles

Conceptualisations of care: the understanding of ‘care’ across Irish educational legislation, policies, circulars and curriculum

ABSTRACT Set against a context where care for the person, others, and the world in which we live receives increasing attention in the policy and practice nexus, this paper sets out to explore how ‘care’ is understood and reflected in Irish educational legislation, policies, circulars and curricula. The importance of focusing on care has been further accentuated during the COVID-19 pandemic. Each source was searched systematically and following application of inclusion criteria, 616 documents were included in the sample, legislation (n = 39), policies (n = 49), active circulars (n = 179), archived circulars (n = 249) and curriculum specifications (n = 100). Thirteen per cent of the documents included in the review reflected some discussion of care. Thematic analysis of these documents identified that ‘care’ tended to be understood and reflected in five main interrelated ways: (1) care for the individual child and the related duty of care schools/teachers have for children; (2) supporting students to care for themselves and for others; (3) care presented in terms of ‘pastoral care’ or intertwined with ‘well-being’; (4) care presented from the perspective of care for the environment and finally; and (5) care presented from a structural perspective regarding care supports within the school. Some considerations and challenges are presented in terms of supporting schools to navigate these different and at times diverging policy, legislative and curriculum contexts with regards conditions for implementation of care in education.

Cost-Effectiveness of Dapagliflozin vs Empagliflozin for Treating Heart Failure With Reduced Ejection Fraction in the United States

Evidence suggests that adding dapagliflozin to the prior standard of care is cost-effective compared with the standard of care alone. The latest guideline by the American Heart Association/American College of Cardiology/Heart Failure Society of America now recommends the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors for patients with heart failure with reduced ejection fraction (HFrEF). However, the relative cost-effectiveness of different SGLT2 inhibitors, including dapagliflozin and empagliflozin, has not been fully characterized. Therefore, we conducted a cost-effectiveness analysis to compare dapagliflozin and empagliflozin in patients with HFrEF from the US health care perspective. To compare the cost-effectiveness of dapagliflozin and empagliflozin in treating HFrEF, we used a state-transition Markov model. This model was used to estimate the expected lifetime costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) for both medications. The model incorporated patients who were 65 years of age at entry and simulated their health outcomes over a lifetime horizon. The perspective of the analysis was based on the US health care system. To determine the health state transition probabilities, we used a network meta-analysis. All future costs and QALYs were discounted at an annual rate of 3%, and the costs were presented in 2022 US dollars. The base case analysis found that the incremental expected lifetime cost of treating patients with dapagliflozin vs empagliflozin was $37,684, resulting in an ICER of $44,763 per QALY. A price threshold analysis indicated that for empagliflozin to be the most cost-effective SGLT2 inhibitor at a willingness-to-pay threshold of $50,000 per QALY, it may require a 12% discount on its current annual prices. The findings of this study indicate that dapagliflozin may offer greater lifetime economic value when compared with empagliflozin. Given that the current clinical practice guideline does not recommend one SGLT2 inhibitor over the other, it is essential to implement scalable strategies to ensure affordable access to both medications. By doing so, patients and health care practitioners can make informed decisions about their treatment options without being constrained by financial barriers.

EPH32 The Epidemiology of Fragile X Syndrome in the United Kingdom

Fragile X syndrome (FXS) is a genetic condition associated with cognitive and intellectual impairment. In this study we aimed to explore the epidemiology of FXS from the primary care perspective of the United Kingdom.

MSR71 Uniting Health Care Perspectives through Integration of Clinical and Claims Data: An Example of Bariatric Surgery Market

To gain insights into the healthcare utilization, costs, and clinical outcomes of patients undergoing bariatric surgery in the US.

Enhancing palliative care at home: a generalist community nursing case study

Objective: This quality improvement project aimed to explore the experience of home care nurse managers implementing a general palliative approach to care. Implementation comprised several interlinking activities encompassing stakeholder engagement and an education program in the outer eastern region of a home care and nursing organisation in Melbourne, Australia, between September 2019 and December 2020. Background: High quality provision of community based palliative and end-of-life care means people are much more likely to die at home, supported by family, friends and services. To achieve this, care staff must be adequately trained and supported, alongside a collaborative approach with other generalist and specialist providers. Study design and methods: This Case Study reports on the participant perspectives of the stakeholder engagement and education program. Focus groups and an interview were used to elucidate the experience of nursing and allied health professionals providing a general palliative approach in the community. The 2006 National Institute of Clinical Studies framework to identify barriers to best practice healthcare guided the development of focus group questions and the deductive analysis of data. Results: Seven Nursing Care Managers and one Social Worker participated in two online focus groups and one interview. Three overarching themes highlighted the value of tailored education in increasing staff knowledge and confidence, the factors for a successful generalist-specialist partnership, and the unique nature of the home care setting which requires accessible systems and processes. Discussion: This project supports assertions that generalist services can play a valuable role when a palliative approach to care is incorporated. It also underscores the importance of collaborative working partnerships between generalist and specialist services in providing quality community-based palliative care. Future research should examine the needs and perspective of clients, carers and families receiving a general palliative care approach in the community. Implications for research, policy and practice: Investment in developing the capacity and capability of generalist service staff to deliver palliative care is vital, particularly when caring for people in their homes. Although small, this study demonstrates that consideration should be given to embedding staff with specialist palliative care training within generalist organisations to drive and champion evidence-based palliative care provision, training, policies and procedures that meet the unique needs of mobile workforces. Future research should examine the effectiveness of different models and methods for education and generalist-specialist partnerships that meet the needs of mobile home nurses, particularly regarding long-term impact and sustainability. What is already known about the topic? Most Australians prefer to be cared for and die in their own home. Home care nurses are key generalist health professionals who support community-based palliative and end-of-life care, organising and providing care, coordinating the input of other health and social care professionals. Home care nurses face challenges in meeting their clients’ palliative care needs (such as symptom management and communication) and have deficits in their knowledge and confidence of caring for palliative clients. What this paper adds: This case study demonstrated that facilitating ongoing education opportunities that draw on the expertise of local palliative care champions or internal specialists can enhance care provision. Nurse care managers believe the value of generalist services, particularly home care services, in the generalist-specialist palliative care partnership, needs to be understood and respected. Tailored investment in home care to provide a general palliative approach would be beneficial given the unique challenges of this mobile workforce.

Early detection of pancreatic cancer: a primary care perspective

Early detection of pancreatic cancer: a primary care perspective

Reorienting GIScience for a data-intensive society

In this commentary, I explore the potential future for GIScience to broaden its focus from technological advancements to examining the dynamic interactions between geographic information system (GIS) technology, its users, and the places where it is being utilized. Drawing on the postphenomenological perspectives of Don Ihde and his followers, this commentary re-imagines GIScience by emphasizing its ability to shape and be shaped by human experiences and various creative forces across bodies and places. This reorientation decenters GIScience beyond the human body by also encompassing non-human entities such as animals, bots, and algorithms. In the face of a rapidly growing data-intensive society, this commentary underlines the importance of adopting a caring stance when it comes to the use and development of GIS. This perspective of care can enhance our understanding and empathy toward ourselves, the planet, and all other beings. This reorientation of GIScience plays a significant role in shaping future trajectories of GIScience and the discipline of geography, enabling us to effectively tackle the theoretical and practical challenges posed by a rapidly evolving data-intensive society.

Veteran perspectives of epilepsy care: Impact of Veteran satisfaction, knowledge, and proactivity

ObjectiveVeterans are at elevated risk of epilepsy due to higher rates of traumatic brain injury (TBI). However, little work has examined the extent to which quality of care is associated with key outcomes for Veterans with epilepsy (VWE). This study aimed to examine the impact of quality of care on three outcomes: patients’ knowledge of epilepsy self-care, proactive epilepsy self-management, and satisfaction with care. MethodWe conducted a cross-sectional study of Post-9/11 Veterans with validated active epilepsy who received VA care (n = 441). Veterans were surveyed on care processes using American Academy of Neurology epilepsy quality measures, and a patient-generated measure related to the use of emergency care. Outcome measures included epilepsy self-care knowledge, proactive epilepsy self-management, and satisfaction with epilepsy care. Covariates included sociodemographic and health status variables and a measure of patient-provider communication. An ordinary least-squares (OLS) regression model was used to determine if the quality of care was associated with the outcomes adjusting for multiple comparisons. ResultsSelf-reported measures of quality of care were broadly associated with satisfaction with care and epilepsy knowledge. OLS modeling indicated that healthcare provider guidance on when to seek emergency care was significantly associated with higher Veteran satisfaction with care (p < 0.01). Veterans who were asked about seizure frequency at every visit by their provider also reported higher satisfaction with care (p < 0.01) and increased epilepsy knowledge (p < 0.01). Veteran-provider communication was positively associated with epilepsy knowledge and proactive epilepsy self-management. Veterans with epilepsy with drug resistance epilepsy were significantly less satisfied with their care and reported lower proactivity compared to epilepsy controlled with medications. Further analysis indicated Black VWEs reported lower scores on epilepsy self-care knowledge compared to Whites (p < 0.001). ConclusionsThis study found that quality measures were associated with satisfaction and epilepsy knowledge but not associated with proactive self-management in multivariable models. The finding that better communication between providers and Veterans suggests that in addition to technical quality, interpersonal quality is important for patient outcomes. The secondary analysis identified racial disparities in epilepsy knowledge. This work offers opportunities to improve the quality of epilepsy care through the practice of patient-centered care models that reflect Veteran priorities and perceptions.

Evaluating a multimodal, clinical and work-directed intervention (RTW-PIA) to support sustainable return to work among employees with mental disorders: study protocol of a multicentre, randomised controlled trial

BackgroundMental disorders (MDs) are one of the leading causes for workforce sickness absence and disability worldwide. The burden, costs and challenges are enormous for the individuals concerned, employers and society at large. Although most MDs are characterised by a high risk of relapse after treatment or by chronic courses, interventions that link medical-psychotherapeutic approaches with work-directed components to facilitate a sustainable return to work (RTW) are rare. This protocol describes the design of a study to evaluate the (cost-)effectiveness and implementation process of a multimodal, clinical and work-directed intervention, called RTW-PIA, aimed at employees with MDs to achieve sustainable RTW in Germany.MethodsThe study consists of an effectiveness, a health-economic and a process evaluation, designed as a two-armed, multicentre, randomised controlled trial, conducted in German psychiatric outpatient clinics. Sick-listed employees with MDs will receive either the 18-month RTW-PIA treatment in conjunction with care as usual, or care as usual only. RTW-PIA consists of a face-to-face individual RTW support, RTW aftercare group meetings, and web-based aftercare. Assessments will be conducted at baseline and 6, 12, 18 and 24 months after completion of baseline survey. The primary outcome is the employees´ achievement of sustainable RTW, defined as reporting less than six weeks of working days missed out due to sickness absence within 12 months after first RTW. Secondary outcomes include health-related quality of life, mental functioning, RTW self-efficacy, overall job satisfaction, severity of mental illness and work ability. The health-economic evaluation will be conducted from a societal and public health care perspective, as well as from the employer’s perspective in a cost–benefit analysis. The design will be supplemented by a qualitative effect evaluation using pre- and post-interviews, and a multimethod process evaluation examining various predefined key process indicators from different stakeholder perspectives.DiscussionBy applying a comprehensive, multimethodological evaluation design, this study captures various facets of RTW-PIA. In case of promising results for sustainable RTW, RTW-PIA may be integrated into standard care within German psychiatric outpatient clinics.Trial registrationThe study was prospectively registered with the German Clinical Trials Register (DRKS00026232, 1 September 2021).

Cost-Effectiveness Analysis of MammaPrint® to Guide the Use of Endocrine Therapy in Patients with Early-Stage Breast Cancer.

Gene expression profiling tests can predict the risk of disease recurrence and select patients who are expected to benefit from therapy, while allowing other patients to forgo therapy. For breast cancers, these tests were initially designed to tailor chemotherapy decisions, but recent evidence suggests that they may also guide the use of endocrine therapy. This study evaluated the cost effectiveness of a prognostic test, MammaPrint®, to guide the use of adjuvant endocrine therapy in patients eligible according to Dutch treatment guidelines. We constructed a Markov decision model to calculate the lifetime costs (in 2020 Euros) and effects (survival and quality-adjusted life-years) of MammaPrint® testing versus usual care (endocrine therapy for all patients) in a simulated cohort of patients. The population of interest includes patients for whom MammaPrint® testing is currently not indicated, but for whom it may be possible to safely omit endocrine therapy. We applied both a health care perspective and a societal perspective and discounted costs (4%) and effects (1.5%). Model inputs were obtained from published research (including randomized controlled trials), nationwide cancer registry data, cohort data and publicly available data sources. Scenario and sensitivity analyses were conducted to explore the impact of uncertainty around input parameters. Additionally, threshold analyses were performed to identify under which circumstances MammaPrint® testing would be cost effective. Adjuvant endocrine therapy guided by MammaPrint® resulted in fewer side effects, more (quality-adjusted) life-years (0.10 and 0.07 incremental QALYS and LYs, respectively) and higher costs (€18,323 incremental costs) compared with the usual care strategy in which all patients receive endocrine therapy. While costs for hospital visits, medication costs and productivity costs were somewhat higher in the usual care strategy, these did not outweigh costs of testing in the MammaPrint® strategy. The incremental cost-effectiveness ratio was €185,644 per QALY gained from a healthcare perspective and €180,617 from a societal perspective. Sensitivity and scenario analyses showed that the conclusions remained the same under changed input parameters and assumptions. Our results show that MammaPrint® can become a cost-effective strategy when either the price of the test is reduced (>50%), or the proportion of patients for which treatment is altered (i.e. those with ultra-low risk) increases to >26%. Standard MammaPrint® testing to guide the use of endocrine therapy in our simulated patient population appears not to be a cost-effective strategy compared with usual care. The cost effectiveness of the test can be improved by reducing the price or preselecting a population more likely to benefit from the test.

Non-restrictive open vial policy combined with the home visit vaccinations for improving BCG coverage in a high-incidence outreach region: A model-based cost-effectiveness analysis for Indonesia

Bacillus Calmette-Guérin (BCG) vaccination is recommended at birth or in the first week of life to achieve the most beneficial effects in protecting against the most severe type of tuberculosis (TB) disease in children. However, delayed vaccination is commonly reported, especially in outreach or rural areas. We assessed the cost-effectiveness of combining non-restrictive open vial and home visit vaccination strategies in order to increase timely BCG vaccination in a high-incidence outreach setting. We applied a simplified Markov model for the Papua setting, which resembled a high-incidence outreach setting in Indonesia, to assess the cost-effectiveness of these strategies from a health care and a societal perspective. A moderate increase (75% wastage rate and 25% home vaccination) and a large increase (95% wastage rate and 75% home vaccination) scenario were assessed in the analysis. We calculated incremental cost-effectiveness ratios (ICER) based on the incremental costs and quality-adjusted life years (QALYs) gained by comparing the two strategies to the base case scenario (35% wastage rate and no home vaccination). The costs per vaccinated child were US$10.25 in the base case scenario, increasing slightly in the moderate (US$10.54) and large increase scenarios (US$12.38). The moderate increase scenario was predicted to prevent 5783 TB-related deaths and 790 TB cases while the large increase scenario predicted the prevention of 9865 TB-related deaths and 1348 TB cases for the entire lifespan of our cohort. From a health care perspective, the ICERs were predicted to be US$288/QALY and US$487/QALY, respectively, for the moderate and large increase scenarios. Using Indonesia's gross domestic product (GDP) per person as a threshold, both strategies were considered to be cost-effective. We found that the allocation of resources for timely BCG vaccination based on combining home vaccination and a less restrictive open vial strategy could substantially reduce childhood TB cases and TB-related mortality. Although outreach activities are more expensive than vaccination at a health care facility only, these activities proved to be cost-effective. These strategies might also be beneficial in other high-incidence outreach settings.

(045) Standard of Care and Patient Perspectives Regarding Early Genital Surgery for Infants with Congenital Adrenal Hyperplasia

Abstract Introduction Opposition to normalizing genital surgeries for children with disorders of sex development (DSD) continues to grow. However, some have argued that congenital adrenal hyperplasia (CAH) should not be lumped in with other DSD conditions and therefore normalizing surgery for CAH infants with XX chromosomes and ambiguous genitalia is justifiable. Furthermore, patient and caregiver perspectives/satisfaction regarding early genital surgery varies greatly. The heterogeneity of views regarding early genital surgery in CAH infants may make navigating the treatment of CAH patients difficult and unique from the treatment of other DSD. Objective This project seeks to summarize the viewpoints regarding CAH and early genital surgery available in the biomedical literature. Methods We conducted a systematic literature review using the database Ovid MEDLINE using the terms “congenital adrenal hyperplasia,” “urogenital surgical procedures,” “sex reassignment surgery,” “genitalia surgery,” and “reconstructive surgical procedures.” We limited the search to English articles published from 2000 to October 2022. We limited the age range to children from birth to 23 months. We included articles with results that offered recommendations regarding decision making in early genital surgery, patient/parent perspectives or satisfaction regarding early surgery, and clinicians’ perspectives. We excluded articles that discussed the science of disease or surgical techniques and outcomes but did not address the complex perspectives regarding CAH surgery. Results Of the 118 articles initially retrieved, we included 53 articles. A variety of views were expressed regarding early genital surgery. Of the three articles that explicitly evaluated patient perspectives using a survey, most people with CAH seemed to approve of early genital surgery. In contrast, narrative pieces have highlighted the psychological trauma of receiving early genital surgery without their consent. Interestingly, many of the excluded articles discussed surgical techniques and their aesthetic outcomes for people with CAH, but failed to investigate the psychological impact that surgeries might have on the patient. Seven articles specifically evaluated the perspectives of the parent/caregiver in the decision making or possible regret process. One article addressed the effects of early surgery on fertility. Finally, genital surgeries and expectations also drastically vary from country to country. In more conservative countries such as Egypt, Sudan, and Nigeria, normalizing surgery is acceptable as a way to clearly define the child’s sex. In more progressive countries, such as Germany and Malta, these surgeries are not accepted or expected. Conclusions The biomedical literature is unclear about the global standard of care regarding CAH early genital surgery. Although there is a plethora of research regarding surgical technique, aesthetic outcomes, and even parental and caregiver decision making, there is less research regarding the long-term psychological impact of these surgeries. More research needs to amplify the voices of patients with CAH to inform the evolution of the standard of care. Disclosure No

Facilitators and Barriers to Speech Intervention of Patients with Orofacial Cleft in the Philippines: A Qualitative Study.

Most individuals with orofacial cleft require various healthcare services, including speech therapy. However, Filipino patients constantly face challenges in availing these services due to limitations in the healthcare system of the Philippines. This study aimed to explore the perceptions of patients with orofacial cleft on the factors that may serve as facilitators and barriers to speech intervention. A descriptive phenomenological approach to qualitative research was used to obtain an in-depth understanding of the perceptions of these patients. Semistructured interviews were conducted through online video conferences or mobile phone calls. Twenty-one participants were interviewed, most of who were mothers (90%) of children with orofacial cleft. Ten themes were derived from the transcripts. Five were categorized as facilitators, while the rest were considered as barriers. Generally, the respondents showed positive attitudes toward orofacial cleft, were aware of the communication and swallowing issues of the patients, and actively sought services to address these issues. Most barriers to speech intervention resulted from limited access to quality healthcare services and information. These findings highlight the importance of considering patient perspectives in clinical care. Maximizing facilitators and addressing barriers may improve access to universal healthcare among Filipinos with orofacial cleft.

Toward certifiable optimal motion planning for medical steerable needles

Medical steerable needles can follow 3D curvilinear trajectories to avoid anatomical obstacles and reach clinically significant targets inside the human body. Automating steerable needle procedures can enable physicians and patients to harness the full potential of steerable needles by maximally leveraging their steerability to safely and accurately reach targets for medical procedures such as biopsies. For the automation of medical procedures to be clinically accepted, it is critical from a patient care, safety, and regulatory perspective to certify the correctness and effectiveness of the planning algorithms involved in procedure automation. In this paper, we take an important step toward creating a certifiable optimal planner for steerable needles. We present an efficient, resolution-complete motion planner for steerable needles based on a novel adaptation of multi-resolution planning. This is the first motion planner for steerable needles that guarantees to compute in finite time an obstacle-avoiding plan (or notify the user that no such plan exists), under clinically appropriate assumptions. Based on this planner, we then develop the first resolution-optimal motion planner for steerable needles that further provides theoretical guarantees on the quality of the computed motion plan, that is, global optimality, in finite time. Compared to state-of-the-art steerable needle motion planners, we demonstrate with clinically realistic simulations that our planners not only provide theoretical guarantees but also have higher success rates, have lower computation times, and result in higher quality plans.

Evaluating person-centered care in residential care facilities from the perspective of caregivers in South Korea: a survey

BackgroundAs many older people spend their time in residential care facilities, the demand for person-centered care (PCC), which affects their quality of life, is increasing. Many residential care facility residents have cognitive problems, such as dementia and strokes. Providing quality care upholds their rights as human beings. Currently, the PCC tools used in South Korea are only translations of foreign tools into Korean, so it is necessary to develop tools for older adult care facilities that reflect the reality of Korean care facilities for older adults. This study aims to develop a tool for measuring PCC in residential care facilities for older people from the perspectives of care givers.MethodsThe draft of 34 questions was developed through literature reviews, interviews with LTC practitioners and researchers. This developed questionnaire was then administered to 402 direct caregivers working in the residential care facilities because many of the residents had cognitive problems. By measuring the interrater reliability, the items with high levels of agreement were selected and the validity of the construct was checked through factor analysis. To determine whether the domains adequately measured each concept, we calculated correlation coefficients and Cronbach’s α.ResultsFour domains and 32 items concerning service conditions, resident’s right to self-determination, a comfortable living environment for all residents, and resident and staff satisfaction are derived, thus explaining 24.7%, 23.6%, 14.6%, and 8.00% of the total variance, respectively. Cronbach’s alphas for each domain are 0.965, 0.948, 0.652, and 0.525, respectively, thus demonstrating internal consistency. The inter-rater agreement is high (66.7%~100.0%). The correlation between service conditions and resident’s right to self-determination (r = 0.643, p < 0.001), a comfortable living environment for all residents, resident and staff satisfaction (r = 0.674, p < 0.001), and resident’s right to self-determination and comfortable living environment (r = 0.695, p < 0.001) is strong.ConclusionsIt is important that caregivers recognize PCC and provide services. When evaluating the residential care services, measuring the degree of PCC should be made compulsory. If the facility becomes more person-centered, it will be possible to promote quality of life for older people.Trial registrationNot applicable.

Identification of behavioural changes in reporting adverse events early during COVID-19: An ambulatory care perspective in Israel.

This study examined adverse event reporting centred on three significant dates in the months before the pandemic arrived in Israel. On these dates, broad media coverage exposed citizens and health care providers with indications about the forthcoming pandemic. The current study tracked whether parameters related to reporting adverse medical events provided early indications that a large crisis was unfolding. The method for analysing the data was based on a statistical test called Regression Discontinuity Design, which helped identify parameters related to medical reporting patterns which significantly changed. The examination indicated nurses' reports were unique in relation to others and indicated three phases: (1) upon declaration of the upcoming pandemic, there was a rise in reporting; (2) when the disease was named, there was moderation and maintenance in a steady quantity of reports, and finally, (3) when the first case arrived in Israel, a slight decrease in reporting began. Nurses' behaviours manifested as changes in reporting patterns. In this process of increase, moderation and decrease, it can be concluded that these are three stages that may characterise the beginning of a large event. The research method presented reinforces the need for forming tools by which significant events such as the COVID-19 pandemic can be identified quickly, and aid in proper planning of resources, optimise staffing and maximise utilization of the health systems.

748 Accidental Thermal Injury From Ignition of Home Oxygen: Is Burn Center Admission Advantageous?

Abstract Introduction Home oxygen therapy is available for the supportive treatment of patients with chronic lung disease. Nevertheless, complications associated with home oxygen use have been well described. The typical injury pattern associated with the accidental ignition of home oxygen does not mandate emergent intubation. However, due to the thermal component of the injury, patients are initially directed towards admission to burn units. The recent stress applied to the healthcare system by COVID-19 has highlighted the potential benefit of flexibility in the disposition of injured patients. In particular, we wanted to determine if there is a demonstrable benefit from admission to an American Burn Association (ABA) verified burn center for patients presenting with home oxygen ignition injuries. Methods After obtaining approval from our local Institutional Review Board, we conducted a retrospective review of our institution's ABA-verified burn center database from January 2016 through May 2022. Individual charts were inspected for discrete data points related to the general descriptor of the patient's injuries, comorbidities, and hospital course. Using independent samples t-tests, we compared patients admitted to the burn service with those primarily cared for by non-burn service teams. Results We identified 49 adult patients admitted with burn injuries associated with home oxygen use during the study period. These patients were divided into those intubated at or near the time of admission and those managed without intubation. Of the 29 patients intubated on admission, the burn service managed 19 of these patients, and non-burn services managed 10. There were no identified differences in the outcomes of ventilator days, days in the ICU, total length of stay, or mortality between the two groups. Similarly, we examined the 20 patients admitted without intubation. The burn service managed 7 of these patients, and non-burn services managed 13. Again, the two groups had no identified differences in the outcomes of days in the ICU, total length of stay, or mortality. Conclusions This single-center review revealed no difference in outcomes between patients cared for in an ABA-verified burn center versus non-burn services for home oxygen ignition injury. From a care perspective and resource utilization, the outcomes appear similar. Further, we note that patients required only brief periods of mechanical ventilation – supportive of the opportunity to avoid intubation in these patients. Prevention efforts, like those in the burn center, need to continue, and further studies must be done to confirm these preliminary findings. Applicability of Research to Practice These findings are supportive of potential opportunities to wisely use Burn Center capacity.

Smart Elderly Care: An Intelligent e-Procurement System for Elderly Supplier Selecting

(1) Objective: to accelerate the digitalization of the elderly care service industry and the construction of the smart elderly care industry, this paper designs an intelligent e-procurement system for elderly suppliers selecting from the perspective of smart elderly care, which can enhance the efficiency of elderly care supply chains and assist manufacturers of elderly products in choosing a reliable, high-quality supplier during trades. (2) Methods: the e-procurement system, including six modules, is built with an improved dynamic Markov Decision Process selection model combined with an Analytic Network Process, bringing dynamic evolution of both inventory cost and purchasing cost into long-term reward calculation, and taking into account 15 common indexes and 7 specific indexes when evaluating suppliers’ competitiveness. (3) Results: a real sample shows that when facing 50 suppliers with 50 different quotations, the e-procurement system selects a stable and reliable supplier that brings the best long-term profits for demand enterprises in ten purchase periods, and it makes the selecting process more efficient and more prompt. (4) Conclusions: the model can be used in the circumstance where an elderly product producer is forced to decide on a long-term strategy or reselect a new stable supplier since it is focused on choosing long-term and high-quality suppliers over numerous periods.

Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different contextof care.

To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.

An Abdominoplasty Modification for Postpregnancy Abdomen with Rectus Diastasis and Midline Hernia: The Technique and Results.

After pregnancy, some women experience severe rectus diastasis (RD), with body control dysfunction, midline hernia, or other quality-of-life impairment. The purpose of this study was to describe the authors' experience using hydrodissection and epidural anesthesia for lateral plication modification of abdominoplasty to restore abdominal wall firmness. A total of 46 consecutive patients with RD after pregnancy were enrolled. The mean intraoperative inter-rectus distance was 4.6 cm. RD is not always the only structure that has been elongated. Firmness of the abdominal wall also depends on lateral fascia structures. This study reports the total plicated distance addressing the lateral laxity in the abdominal wall. In this series, total plication was 7.8 cm, and 16 patients had a midline hernia. No hernia recurrences occurred, and the rectus bellies were less than 5 mm apart from each other in all participants, verified with ultrasound after 2 years of follow-up. Patient perspective of care and surgical outcome were recorded. Health-related quality-of-life domains were significantly improved postoperatively. Lumbar back pain visual analogue scale score was 4.5 ± 2.3 preoperatively and 0.5 ± 0.9 postoperatively. The ability to perform sit-ups increased from zero to 11, suggesting better motor control. The total complication rate was 10.9%. Hydrodissection and epidural anesthesia for lateral plication modification offers a reliable and effective treatment method for RD repair with and without a small midline hernia with a low complication rate. Therapeutic, IV.