Healthcare Officials Research Articles

A vulnerability assessment for the HCV infections associated with injection drug use

After the 2014–2015 HIV outbreak in Scott County, Indiana, United States Centers for Disease Control and Prevention (CDC) conducted a nationwide analysis to identify vulnerable counties to an outbreak of Hepatitis C Virus (HCV)/Human Immunodeficiency Virus (HIV) and prevent such an outbreak in the future. We developed a jurisdiction-level vulnerability assessment for HCV infections associated with injection drug use (IDU) in Utah.We used three years of data (2015–2017) from 15 data sources to construct a regression model to identify significant indicators of IDU. A ZIP Code, county, or individual-level measure of IDU does not exist, therefore, CDC has suggested using HCV cases as a proxy for IDU. We used the Social Vulnerability Index to highlight vulnerable areas to HCV outbreaks and applied Geographical Information System (GIS) to identify hot spots of HCV infections (i.e. current/ongoing HCV transmissions). Rates of skin infection, buprenorphine prescription, administered naloxone, teen birth, and per capita income were associated with HCV infections.The opioid epidemic is dynamic and over time, it impacts different communities through its sequelae such as HCV outbreaks. We need to conduct this vulnerability assessment frequently, using updated data, to better target our resources. Moreover, we should consider evaluating whether the improvement of HCV screening has an impact on controlling HCV outbreaks. The analysis informs Utah's agencies and healthcare officials to target resources and interventions to prevent IDU-related HCV outbreaks. Our results inform policymakers at the national level on possible indicators of HCV outbreaks as well.

A survey of Psychiatric Disorders and Their Comorbidities in Children and Adolescents.

Background: This community-based study aimed to investigate the psychiatric disorders and their comorbidities according to the kind of psychiatric disorders. Frequency of demographic factors and the prevalence of total psychiatric disorders in term of demographic charactheristics were obtained too. Materials and Methods: The present study focused on 1028 children and adolescent aged 6 to 18 years old across the Razavi Khorasan province by random sampling. The subjects included 496 boys and 532 girls from three age groups (6-9 years, 10-14 years and 15-18 years). Eight clinical psychologists trained to complete the Persian version of K-SADS-PL (Kiddie-SADS present and life time version). This scale measures five diagnostic appendixes of psychiatric disorders. Demographic data of participants were collected too. The data were recorded into the SPSS version 16. The relationship between psychiatric disorders and demographic factors deliberate by descriptive analysis and 95% confidence interval. Results: The total rate of psychiatric disorders among children and adolescent was estimated as 20.5%, elimination disorders with a rate of 12.9% was the most prevalent disorder in the subjects. The lowest prevalence belongs to psychotic disorder and bulimia nervosa (0.1%). Of participants with mood disorders about 71.4% have behavioral disorders too. Anxiety disorders also commonly occurred in person with mood disorders. The comparison of ORs and their 95% confidence interval revealed that there is a significant difference for total psychiatric disorder among boys and girls (OR=0.6 for girls; 95% CI: 0.44-0.82). The rate of total psychiatric disorders in rural and urban areas was 14.9% and 21.1% respectively. Conclusion: With attention to the high prevalence of psychiatric disorders among children and adolescents, it’s necessary that healthcare officials pay more attention to reinforcement of mental health care.

The successful containment of COVID-19 outbreak in Union Territory of Ladakh, India, 2020.

Objectives:A three-member central Rapid Response Team (RRT) was deputed to Union Territory of Ladakh on 26th March 2020, to assess the situation and support the preparedness measures including implementation of cluster containment plan and social distancing measures for coronavirus disease 2019 (COVID-19).Methods:Central RRT addressed the panchayat sarpanch and religious leaders, sensitized doctors and paramedical staff on COVID-19 situation; conducted situational analysis, review of records and logistics, key informant interviews of senior administrative and healthcare officials, focus group discussions with local community people and field visits to various hospitals, isolation centers, quarantine facilities, and containment zones.Results:A total of 14 COVID-19 cases with no deaths were reported and nine patients had recovered till 4 April 2020. The median (range) age of positive cases was found to be 32.5 (6 months–76 years) years and overall attack rate was 1.65 per 1000 population. Ladakh Government declared Chuchot Gongma, Yokma and Sankoo as the containment zones and deputed surveillance teams. A total of 2397 persons were quarantined and 496 samples were tested from Ladakh. COVID-19 sample testing, Srinagar-Leh highway opening and Iran pilgrimage returnees were the major challenges identified.Conclusions:The Ladakh government must continue the robust surveillance system and stringent strategies in key areas for management of COVID-19 namely – aggressive screening and testing, isolation, quarantine, hand hygiene, respiratory etiquettes and social distancing.

Case Fatality Rate estimation of COVID-19 for European Countries: Turkey’s Current Scenario Amidst a Global Pandemic; Comparison of Outbreakswith European Countries

Objectives: SARS-CoV-2, which belongs to the Coronaviridae family of RNA viruses, caused an epidemic in China, leading to the pandemic of COVID-19. Various international and national authorities around the world have been attempting to halt the spread of the deadly virus by providing awareness of the disease including daily confirmed cases and deaths related to the pandemic. At this early stage of the outbreak, epidemiological patterns are required for healthcare officials and public, to understand the ongoing situation. The case fatality rate is one of the key parameters for the epidemiology of this type of epidemic. In this study, we aimed to compute the CFR for European countries and Turkey until 31st March 2020. Methods: We used linear regression analysis on the cumulative number of cases and deaths to generate a slope to estimate CFR values of COVID-19 in selected countries. We compared the calculated CFR values of Turkey until 31st March (15 days since first COVID-19 death) with similar first fifteen days’ data since the report of first death from Italy, Spain, the UK, France, Germany, Switzerland, Belgium, Austria, the Netherlands and Portugal. We then calculated CFR values for these countries from their cumulative confirmed cases and cumulative deaths up to March 31st. Results: Based on This data-driven analysis showed that CFR for Turkey was 1.85 (95% CI: 1.513-2.181) with an R2 value of 0.92 which was comparable to fa ifteen day analysis of France as 1.979 (95% CI: 1.798-2.159) and an R2 value of 0.98. However, CFRs for selected countries increased in subsequent analysis when the threshold of fifteen days was released until March 31, 2020. However, the CFR estimates are time-dependent and show a linear trend in the initial stages of the outbreak. Conclusions: Our findings suggest that the CFR of COVID-19 in Turkey at initial stages of the outbreak was similar to France. However, SARS-CoV-2 seemed to have spread quicker in Turkey since the report of first death, as compared to other countries based on the number of confirmed cases. This study was aimed at recording an update on the current epidemiological situation of COVID-19 for Turkey in comparison to European countries during a global pandemic. Keywords: COVID-19, epidemiology, public health, SARS-CoV-2, Turkey, virology

Bayesian Double Feature Allocation for Phenotyping With Electronic Health Records

Electronic health records (EHR) provide opportunities for deeper understanding of human phenotypes—in our case, latent disease—based on statistical modeling. We propose a categorical matrix factorization method to infer latent diseases from EHR data. A latent disease is defined as an unknown biological aberration that causes a set of common symptoms for a group of patients. The proposed approach is based on a novel double feature allocation model which simultaneously allocates features to the rows and the columns of a categorical matrix. Using a Bayesian approach, available prior information on known diseases (e.g., hypertension and diabetes) greatly improves identifiability and interpretability of the latent diseases. We assess the proposed approach by simulation studies including mis-specified models and comparison with sparse latent factor models. In the application to a Chinese EHR dataset, we identify 10 latent diseases, each of which is shared by groups of subjects with specific health traits related to lipid disorder, thrombocytopenia, polycythemia, anemia, bacterial and viral infections, allergy, and malnutrition. The identification of the latent diseases can help healthcare officials better monitor the subjects’ ongoing health conditions and look into potential risk factors and approaches for disease prevention. We cross-check the reported latent diseases with medical literature and find agreement between our discovery and reported findings elsewhere. We provide an R package “dfa” implementing our method and an R shiny web application reporting the findings. Supplementary materials for this article, including a standardized description of the materials available for reproducing the work, are available as an online supplement.

Pattern of inappropriate antibiotic use among hospitalized patients in Pakistan: a longitudinal surveillance and implications

BackgroundThe inappropriate use of antibiotics in hospitals increases resistance, morbidity, and mortality. Little is currently known about appropriate antibiotic use among hospitals in Lahore, the capital city of Pakistan.MethodsLongitudinal surveillance was conducted over a period of 2 months among hospitals in Lahore, Pakistan. Antibiotic treatment was considered inappropriate on the basis of a wrong dosage regimen, wrong indication, or both based on the British National Formulary.ResultsA total of 2022 antibiotics were given to 1185 patients. Out of the total prescribed, approximately two-thirds of the study population (70.3%) had at least one inappropriate antimicrobial. Overall, 27.2% of patients had respiratory tract infections, and out of these, 62.8% were considered as having inappropriate therapy. Cephalosporins were extensively prescribed among patients, and in many cases, this was inappropriate (67.2%). Penicillins were given to 283 patients, out of which 201 (71.0%) were prescribed for either the wrong indication or dosage or both. Significant variations were also observed regarding inappropriate prescribing for several antimicrobials including the carbapenems (70.9%), aminoglycosides (35.8%), fluoroquinolones (64.2%), macrolides (74.6%) and other antibacterials (73.1%).ConclusionEducational interventions, institutional guidelines, and antimicrobial stewardship programs need to be developed to enhance future appropriate antimicrobial use in hospitals in Pakistan. Policies by healthcare and Government officials are also needed to minimize inappropriate antibiotic use.

Implementation of exercise therapy in daily clinical practice in psychiatric clinics in Germany

Exercise therapy has proven to be effective in the treatment of multiple mental illnesses. As mental disorders result in tremendous costs for the healthcare system as well as ahuge burden for the affected individuals, improving treatment strategies according to latest scientific evidence should be of highest priority. In 2016 afirst study provided indications that only aminority of patients are treated with exercise therapy during their stay in hospital. Hence, the aim of this study was to assess the actual extent of exercise therapy usage in psychiatric inpatients in Germany, thereby giving ascientific foundation to the call for abetter standard of care. To achieve this, aretrospective analysis was performed on pre-existing data from 2693 patients who were treated in 1 of 4 participating university hospitals. Only 23% of these patients participated in exercise therapy with amean training duration of 36 min per week. Patients with the diagnosis of schizophrenia or patients with multiple comorbidities were even less likely to participate in exercise therapy. With these findings it becomes evident that the healthcare situation concerning exercise therapy is insufficient. Solid evidence for the effectiveness of exercise therapy, the current treatment guidelines as well as the positive side effects, especially when compared to side effects of pharmacotherapy (i.e. weight gain) should motivate healthcare officials to make an effort to improve this situation.

Occupational health and safety-oriented medical waste management: A case study of Istanbul.

The outstanding pace of technological development around the world coupled with increasing population and rapid urbanization have brought along an ever-increasing demand for healthcare services. This trend results in an increasing amount and variety of medical wastes. Accordingly, the issue of effective collection, transportation and disposal of medical wastes, specifically in large cities, has become a critical concern from the viewpoint of urban logistics and holds great importance in terms of safety. This study aims to determine the safety of hospitals in their medical waste management function. The study involves the determination of medical waste management steps, establishment of a hierarchical structure, and weighting of the criteria within the established hierarchical structure by means of the analytic hierarchy process method. Afterwards, the extent to which these criteria are adopted in hospitals was evaluated by the medical waste management officers of those hospitals, and safety scores were obtained for each hospital by associating the results with the weighted values obtained by the analytic hierarchy process method. The model proposed for medical waste management problems encountered by healthcare institutions in Istanbul was implemented for a specific region of Istanbul province, and the obtained results were analyzed. Evaluation of the opinions of the healthcare officials for determination of the medical waste management safety scores showed that the "collection" criterion has significantly higher importance than the "temporary storage" and "transportation" criteria. "The effect on hospital personnel" sub-criterion of the "collection" criterion had the highest score. This revealed the importance of the collection process that takes place between storage and transportation, for evaluating the human waste-based risks.

Social Accountability in Maternal Health Services in the Far-Western Development Region in Nepal: An Exploratory Study.

Background: Social accountability or citizen-led accountability has been promoted in many low- and middle-income countries to improve the quality, access to and use of maternal health services. Experiences with social accountability in maternal health services in Nepal have not yet been documented. This study identifies existing social accountability structures and activities in maternal health services in two districts of Far-Western Nepal and explores their functions, implementation and gaps/challenges. Methods: An exploratory study was conducted that included in-depth interviews with purposively selected policy advisors (8), healthcare officials (11), healthcare providers (12) and non-governmental staff (3); and focus group discussions (FGDs) with 54 women. Data analysis was conducted using thematic content analysis based on George’s information, dialogue and negotiation framework. Results: Social accountability in maternal health existed in terms of structures such as mothers’ groups (MGs), female community health volunteers (FCHVs) and Health Facility Operation and Management Committees (HFOMCs); and activities such as social audits and community health score board (CHSB). MGs and FCHVs were perceived as trusted intermediaries, but their functioning was limited to information. HFOMCs were not fully functional. Social audits and CHSBs were implemented in limited sites and with poor participation by women. Health-sector responses were mainly found at the local level. Factors contributing to these challenges were the absence of a mandate and limited capacity, including resources. Conclusion: Formal structures and activities existed for social accountability in maternal health services in the Far-Western Development Region of Nepal, but there were limitations pertaining to their implementation. The main recommendations are: for clear policy mandates on the social accountability roles of MGs and FCHVs; wider implementation of social audits and CHSBs, with emphasis on the participation of women from disadvantaged groups; improved capacity of HFOMCs; and improved engagement of the health sector at all levels to listen and respond to women’s concerns.

Frequency Distribution of Keratinophilic Dermatophyte Fungi from the Soil of Different Zones in Isfahan Using Morphological and Molecular Methods.

Background:Dermatophytes are one of the most important etiologic agents of cutaneous infections in humans and animals. The present study aimed to study the frequency distribution of keratinophilic dermatophyte fungi using conventional and molecular methods in soil of Isfahan city.Materials and Methods:In this study, 200 soil samples were randomly selected in three northern, southern, and central parts of Isfahan using hair-baiting technique. The fungi were identified by morphology based on macroscopic and microscopic characteristics of fungi. Furthermore, the sequencing of ITS1-5.8S-ITS2 region of the ribosomal DNA of the 60 randomly isolated fungi was investigated.Results:The results of conventional method showed that from a total of 371 fungal colonies, the highest amount of detected colonies was in the central zone (151, 40.26%). Furthermore, in all three areas, the most common detected dermatophyte was Microsporum gypseum (38.3%). The results of the molecular analysis showed that M. gypseum identified by the morphology method was Nannizzia fulva, and also, Chrysosporium sp. with the frequency of 30% in morphology method was the second dominated fungus including Chrysosporium keratinophilum (42.6%) and Chrysosporium shanxiense (21.4%) which confirmed by sequencing method.Conclusion:The results showed that keratinophilic dermatophyte fungi including Nannizzia fulva, Chrysosporium sp., and Trichophyton mentagrophytes are found in the children playgrounds in Isfahan. Therefore, health-care officials should pay more attention to these hygienic issues. C. shanxiense, which is found here for the first time in Iran, has been reported only from China.

About Problems of Palliative Care

The palliative care is determined as "a complex of medical interventions targeted to deliverance from pain and relief of other severe manifestations of disease, for improving quality of life of terminally ill citizens" (Art. 36 of the Federal Law of 21.11.2011 № 323FZ) on the stage of uncontrolled progression of disease. The actual status and accessibility of palliative care was analyzed, including development of this issue in both the Russian Federation and number of foreign countries. According to the WHO, in Russia, 360-460 out of 100,000 population need palliative care. Out of them, 200 individuals with oncologic diseases, 150 individuals with non-malignant diseases and 12 individuals with AIDS/HIV. The health authorities face the task of significant increasing of scope of palliative care to make it more accessible. In recent years, issues of palliative care were intensively considered at the level of patients, of public organizations and legislators, as well as at the level of physicians, the Ministry of Health Care officials and others. Despite the great attention of researchers to issues of palliative care, the majority of physicians confirm its low accessibility to patients, as testify the results of survey of health workers carried out by the Foundation of Independent Monitoring of Medical Services "Zdorovie". The article also considers issues of normative base regulating palliative care provision and application of narcotic analgesics. The analysis of study results permits to conclude that despite considerable attention to palliative care, the issue of its accessibility continoue to be very actual.

Social accountability in maternal health services in Baglung district, Nepal: a qualitative study

# Background Despite there being many state and non-governmental organisation (NGO) health programs, Nepal still has a high maternal mortality ratio of 258. Previous research has indicated that social accountability mechanisms can improve maternal health. However, the functioning of these mechanisms has not yet been explored in Nepal. Social accountability mechanisms can be identified and analysed through the information, dialogue & negotiation model. # Objective To identify the role of social accountability mechanisms in maternal health and the challenges regarding these mechanisms in Baglung district, Nepal. # Methods Ten semi-structured interviews were held with healthcare officials, healthcare providers, NGO staff and mothers at the community level, and four focus group discussions were held with pregnant women and recent mothers, healthcare providers and Health Facility Operation and Management Committee (HFOMC) members. Data was coded and analysed with ATLAS.ti using the information, dialogue & negotiation model. # Results Mothers' Groups, Female Community Health Volunteers (FCHVs) and the HFOMC function as a two-step social accountability mechanism. The FCHVs act as a bridge between Mothers' Groups at the community level and the HFOMC. The HFOMC holds dialogues and negotiations with the district and central government. There seem to be two main obstructions in the information flow from the central or district levels to the community. They are located between the central government level and/or district level and the HFOMC, and between the HFOMC and the FCHV and Mothers\' Groups. The information from the community to higher levels seems to have an obstruction in the voicing of service-related needs/complaints in the Mothers' Groups and another obstruction of HFOMCs rarely interacting with health sector actors other than the local health facility. # Conclusions The information, dialogue & negotiation model is a sensitive analytical model to understand the functioning and challenges of social accountability in the maternal health care system of Nepal. The community-based accountability chain of HFOMC, FCHVs and Mothers' Groups presents a structure that facilitates the optimisation of maternal health services. Recommendations are given to improve gaps in this accountability chain.

When Voluntary Donations Meet the State Monopoly: Understanding Blood Shortages in China

AbstractChina's blood-borne HIV catastrophe in the 1990s prompted the government to adopt a blood-collection system that combines voluntary donations with the state's monopoly on blood services. Juxtaposing fieldwork and survey data, this study examines how the intricate interplay between government manoeuvres and citizen reactions has led to blood shortages that are serious yet manageable. This article reveals that even though voluntary blood donations are adversely affected by a public distrust of state-run collection agencies, owing to political concerns healthcare officials shirk from engaging with citizens to overcome the distrust. It also finds that the blood shortages are nevertheless largely manageable because the authorities have the capacity to recruit captive donors through work units, with the caveat that such captive practices are used sparingly. Overall, this study argues that the lack of state–society synergy in voluntary donations, while exacerbated by government involvement, is also partially remedied by the government's mobilization of captive donors.

How (not) to create value based integrated maternity care: Lessons from the Netherlands

What encourages (or discourages) health policymakers to create systems of integrated care? The answer to this important question can be found by looking at Dutch maternity care. Health care officials in several countries are struggling to achieve the “triple aim” in maternity care: to maximize health and satisfaction while minimizing costs. These policymakers often look to the Netherlands, with its well-organized system of referral between primary and specialist care, as a successful model of integrated maternity care that delivers on each of the triple aims. In spite of this favorable attention, Dutch policymakers have been pushing to create “integrale verloskunde zorg” – integrated maternity care – replacing the current system with one that gives obstetricians a more prominent role. This development gives us the opportunity to look more closely at the factors that promote and hinder the creation of integrated care systems. In the case of the Netherlands, the push toward (more) integrated maternity care is the result of an uneasy relationship between midwives and obstetricians, unsound science, critical reports in the media, and the differential political power of the professions. Interprofessional competition: For most of the twentieth century, Dutch midwives and obstetricians had a cooperative relationship, defined and regulated by an “indications list” that determined who was responsible for which types of care. In the 1980s, efforts to revise that list created tension between the two professions, with each group seeking to protect and/or extend their jurisdiction. The shift from collaboration to competition moved the conversation away from what must to done to deliver the most effective maternity care, to efforts to promote the value of the services of one profession over the other. Unsound science: Interprofessional competition has led to the production of unsound science. Rather than collaborative research, where obstetricians and midwives work together to identify the most effective ways to deliver care, there has been a spate of research offering “scientific” evidence for the superiority of each profession’s approach: research done by obstetricians typically shows that the current, integrated system is failing, while research done by midwives shows the success and value of the current system. Media attention: In the contest between midwifery and obstetric science, the media in the Netherlands have sided with the obstetricians. Stories of harm to mothers and babies capture the attention of the public and are more interesting than stories of the success of integrated care. Political power: Midwives have less political power and less access to policymakers in the government and the insurance industry. Their efforts to support and improve the current system have been less persuasive with the Ministry of Health and the Zorginstituut Nederland (ZN – the overseer of the health insurance system) than those of the obstetricians, who are succeeding in increasing their role in maternity care. This analysis of the (dis)integration of Dutch maternity care sheds important light on the factors that move health systems toward, and away from, integrated care. If the value of integrated care is to be realized we must understand these factors.

Assessing the perspectives of users and beneficiaries of a community health worker mHealth tracking system for mothers and children in Rwanda.

IntroductionMobile Health (mHealth) programs have increasingly been used to tackle maternal and child health problems in low and middle income countries. However, few studies have evaluated how these programs have been perceived by intended users and beneficiaries. Therefore, we explored perceptions of healthcare officials and beneficiaries regarding RapidSMS Rwanda, an mHealth system used by Community Health Workers (CHWs) that was scaled up nationwide in 2013.MethodsWe conducted key informant interviews and focus group discussions with key stakeholders, providers, and beneficiaries of maternal and child health services at both the national and community levels. Semi-structured interviews were used to assess perceptions about the impact of and challenges facing the RapidSMS system. Interviews and focus group discussions were recorded (with the exception of one), transcribed verbatim, and analyzed.ResultsWe conducted a total of 28 in-depth interviews and 10 focus group discussions (93 total participants). A majority of respondents believed that RapidSMS contributed to reducing maternal and child mortality rates. RapidSMS was generally accepted by both CHWs and parents. Participants identified insufficient training, a lack of equipment, and low CHW motivation as the main challenges facing RapidSMS.ConclusionOur findings suggest that an mHealth program can be well accepted by both policymakers, health providers, and the community. We also found significant technical challenges that have likely reduced its impact. Addressing these challenges will serve to strengthen future mHealth programs.

Overview of adherence and factors related to medication adherence in hypertensive patients at Puskesmas Tembuku 1 in 2017

Background: Hypertension remains a public health issue in Indonesia as its prevalence increases considerably. Adherence to treatment is an important factor in the long-term health and well-being of hypertensive patients. Basic Health Research (Riskesdas) in 2007 reported that the prevalence of hypertension in the population aged over 18 years in Indonesia is as high as 31.7%, of which only 7.2% known that they had hypertension and only 0.4% took antihypertensive medications. Coverage of hypertension cases at Puskesmas Tembuku I in 2016 increased by 50% from the previous year, from 292 cases to 584 cases.Methods: The research was conducted in the coverage area of Tembuku I Community Health Center, Bangli Regency, in 2017. The descriptive cross-sectional method was used in this research. 81 respondents were chosen as research sample using non-probability consecutive sampling method. Primary data were collected through interviews on the research sample using questionnaire and Morisky Medication Adherence Scale (MMAS-8).Results: Most of the respondents had low medication adherence (96.3%), followed by moderate adherence (3.7%). None of the respondents had high medication adherence. Most of the respondents had low knowledge of hypertension (70.4%) and had sufficient access to healthcare facilities (71.6%). Most of the respondents reported high family support (93.8%), and high support from healthcare officials (71.6%). Most of the respondents (97.5%) reported high motivation.Conclusion: Low medication adherence and low knowledge regarding hypertension were observed, despite sufficient access to healthcare facilities, high family and healthcare officials support, and high motivation in hypertensive patients.

Virtual Reality Programs Applications in Healthcare

Current Virtual Reality (VR) applications in healthcare demonstrate potential abilities to address cognitive, psychological, motor, functional impairments and opportunities for training and education of clinical practitioners. Bearing in mind the overall wellness of their communities, healthcare officials had supported the idea of incorporating modern technology by increasing the budget shares and arranging for an access to advanced equipment and professional expertise. Clinicians are becoming more interested in applying VR simulation into their research and clinical trials because of the encouraging feedback published in the medical literature across a wide range of clinical health conditions. Numerous published articles propose novel concepts on applications VR technologies and their potential on disease prevention and management. Finally, the ability of sharing data collected by VR simulation systems through communication networks and electronic health records make it more attractive for the reason that it plays a role in decision making for specific case studies and distance learning.

The threat of urban yellow fever in tropical America.

Abstract Yellow fever (YF) is an infectious disease caused by the YF virus (YFV) that, in its most severe form, is characterized by jaundice, fever, liver and renal failure, and neurologic and haemorrhagic manifestations. In the Americas, the virus has two well-established cycles of transmission: the wild (sylvatic) and the urban cycle. Urban YF will occur when the transmission cycle in a specific area is maintained only between humans and Aedes aegypti mosquitoes. Factors that increase the risk of urban YF are the increased number of sylvatic cases, YF-infected individuals making the transition from wooded areas to the urban environment, the high density of Ae. aegypti population in urban areas and the low vaccination coverage. Although possible, the risk to the development of urban YF may be reduced to a minimum, if all the approaches to control this disease are applied in the context of a sylvatic YF outbreak. Here, using the current Brazilian sylvatic YF outbreak as an example, we discuss the tools health-care officials have to use in order to avoid the development of an urban outbreak of YF.

Machine learning in medicine

Machine learning (ML) is a powerful and flexible tool that can be used to analyze and predict outcomes from biological and clinical data. ML models have the potential to improve healthcare efficiency in a number of ways. Algorithms that predict prognosis empower healthcare officials to allocate resources optimally and physicians to select better treatment options for patients. Diagnostic models can be used in screening, in risk stratification, and to recommend appropriate testing and treatment. This would decrease the burden on physicians, increase and expedite patient access to care, save resources, and reduce costs. However, despite the research advances of ML in medicine, its role in the clinic is currently limited. Model building and validation may require large amounts of high-quality data that can be difficult and expensive to obtain, and diagnostic models must be individually built for each disease, a lengthy process. The psychological aspect of trusting black box algorithms may also be challenging to accept. Continued ML research, however, may enable the use of smaller datasets and the development of more transparent models. Careful trials in the clinic will need to be conducted before the more impactful uses of ML, such as diagnosis, can be implemented.

Wait Times for Melanoma Surgery: Is There an Association with Overall Survival?

Wait times for access to care have been of increasing interest to public health care officials, health care providers, and the public. There is a paucity of data determining whether extended wait times for melanoma surgery influence patient outcomes. This study measured the association of wait times to surgical treatment with overall survival in patients with melanoma. Population-based health administrative databases were used to identify all Ontario adults diagnosed with melanoma between 2004 and 2011, time to various treatment modalities, and death dates. Proportional hazards modeling using time-dependent covariates was used to determine the adjusted association of time from melanoma diagnosis to various post-diagnostic surgical interventions with overall survival. A total of 2573 patients were included. The 5-year overall survival was 81.1% [95% confidence interval (CI) 79.1-83.0]. Of all patients, 82.9% underwent a wide local excision (WLE) with a median wait time of 43days [interquartile range (IQR) 24-64], 29.1% underwent a sentinel lymph node biopsy (SNB) with a median wait time of 59days (IQR 41-81), and 35.0% underwent a lymph node dissection (LND) with a median wait time of 63days (IQR 43-91). After adjusting for age, sex, rural residence, and risk of mortality from comorbidities, wait times to WLE [hazard ratio (HR) 0.97; 95% CI 0.87-1.08; p=0.62], SNB [HR 1.04; 95% CI 0.68-1.59; p=0.86], and LND [HR 0.99; 95% CI 0.89-1.11; p=0.92] were not associated with overall survival. Overall survival for patients with melanoma was not influenced by wait times to WLE, SNB, and LND.