Health Network Research Articles

Graded Exposure Therapy for Fear Avoidance Behaviour After Concussion (GET FAB): protocol for a multisite Canadian randomised controlled trial

IntroductionPersistent symptoms after mild traumatic brain injury (mTBI) negatively affect daily functioning and quality of life. Fear avoidance behaviour, a coping style in which people avoid or escape from activities...

Mutations and mortality in very young patients with breast cancer.

e13157 Background: Breast cancer diagnoses in young women have increased over the last 10 years. Despite decreasing mortality rates for breast cancer, disparities continue to exist for specific populations including Black women and premenopausal women. Recent studies observe a 41% increased death rate in Black women compared to White women, and a two-fold increased mortality in women younger than 50 years. Many biological and societal factors can affect breast cancer mortality. We sought to evaluate the relationship between germline mutations (GM), breast cancer subtype, and mortality based on race in a unique, young breast cancer patient population. Methods: We assembled a 10-year retrospective chart review (2012 to 2022) of 773 women diagnosed with breast cancer under the age of 40 in a regional health network. Data was collected from electronic medical records. Associations were assessed using the chi-square test using SAS version 9.4. Results: Out of the 773 patient information collected, 60% of patients were White, 36% Black, and 3% Other. A total of 675 patients had genetic results and 124 patients with documented GM. Of patients with GM, 48 were Black and 74 were White. 13 patients with germline mutations had documented deaths. There was no statistical link between germline mutations and mortality. Of the 13 patients, 4 (30%) were Black and 9 (70%) were White. There was no statistical difference amongst area deprivation index (ADI) quintiles for mortality in patients with GM. Of the 675 patients with genetics data, 72 patients without GM died which includes 31 Black patients, 38 White patients, 3 Other. Based on our data, there is a higher prevalence of germline mutations (60%) in White patients over Black patients and a descriptive predominance of mortality despite absence of statistical significance. More patients who resided in areas of higher ADI (2-4) with GM died than in areas of lower ADI. Conclusions: Our data demonstrates a descriptive prevalence in mortality among young White patients compared to young Black patients. Across the USA, the Black population is 13% and in Louisiana, that population is 33%. Given that our cohort population was 36% Black, it is noteworthy that we were unable to demonstrate a statistical mortality predominance among these young patients. [Table: see text]

Impact of semaglutide and tirzepatide administration on weight in women with stage I-III breast cancer.

e24140 Background: Weight gain and obesity are significant problems for women receiving adjuvant therapy for breast cancer and obesity is associated with adverse breast cancer outcomes. In addition, obesity is associated with negative impact on overall physical and mental health. The GLP-1 agonists, semaglutide (S) and tirzepatide (T), are effective in achieving weight loss and have been associated with decreased incidence of diabetes, stroke and overall mortality in the non-diabetic as well as diabetic populations. There are limited data on the efficacy and safety of GLP1 agonists in women with breast cancer. Methods: We performed a retrospective analysis of the association of S and T use with weight loss in patients with stage I-III breast cancer diagnosed and treated at the Yale Cancer Center/Yale New Haven Health Network between 2017 and 2022. After institutional review board approval, a database including 7149 patients including 92,989 office visits was constructed. Maximal weight loss after S/T prescription as well as mean weight loss were calculated. S and T treated patient’s stage distribution and rates of recurrence were compared to untreated patients. For patients without metastatic disease, repeated measures regression analysis was utilized to evaluate changes in weight and BMI. Results: Of the 5430 evaluable patients with non-metastatic disease, 70 (1.3%) were prescribed S or T. Mean age was 58 (41-78). 74% received endocrine therapy. Mean pretreatment weight was 95.8 kg and BMI was 35.9 kg/m2. Mean weight loss for S/T treated patients was 3.03 kg (3.9-2.13, p < .0001) corresponding to reduction in BMI of 1.1 kg/m2 (0.7-1.5 p < .0001). We also calculated maximal weight loss after S/T prescription. Mean maximal weight loss was 8.89 kg (6.71-10.98 P < .0001) corresponding to a mean maximal reduction in BMI of 3.2 kg/m2 (2.3-4.2 P < .0001). Rates of local, locoregional, and distant breast cancer recurrence were 1.5%, 0%, 1.5% in the S/T treated patients and 1.3%, 4.7% and 3.3% in the untreated patients. None of these differences were statistically significant. Conclusions: In this retrospective analysis, GLP-1 agonist are associated with clinically meaningful weight loss in overweight and obese women with early breast cancer. Recurrence risk did not appear to be preliminarily impacted by treatment. Additional research is needed on long term safety as well as weight loss maintenance with these drugs in breast cancer survivors.

Programa Atenas: serviço pioneiro de atenção extra hospitalar ao aborto no primeiro trimestre por telemedicina

ABSTRACT The criminalization of abortion and restricted access to misoprostol in Brazil force women to seek unsafe methods to terminate a pregnancy. Hospital care for miscarriage or abortion is standard. In contrast, telemedicine for the medical management of miscarriage and abortion is the gold standard of care internationally. This article presents the Atenas Program – an unprecedented initiative for first trimester abortion/miscarriage care, aiming at a humanized out-of-hospital service based on telephone monitoring by nurses, allowing women to choose the method of uterine evacuation (expectant, medical or surgical). For this purpose, ethnographic research was carried out in a northeastern public maternity hospital, between 2014 and 2021. In the context of structural and conjunctural difficulties, among the 723 Atenas participants, 73,6% dispensed with hospital admission for miscarriage and abortion resolution: 58,4% occurred spontaneously and 15,2% through hospital misoprostol. No complications were registered. Telephone monitoring by nurses provided the basis for continuity of individualized care for this invisibilized public. Atenas Program, initiative of a SUS institution run without external financial support, represents an advance in humanized care for women with miscarriage and abortion. It should be extended to the entire public health network, to expand access to rounded and humanized care for abortion and miscarriage.

LA FORMACIÓN EN MEDICINA FAMILIAR EN CHILE

The training of Family Medicine specialists in Chile started in academic circles, with a strong focus on primary care shaping its core elements. This includes practical training to address common health issues, a holistic approach considering biological, psychological, and social aspects, and a push for health promotion. Currently, fourteen universities offer residency programs, mostly in Family Medicine, while three universities have differentiated programs targeting specific population groups. In the growth of training programs, key milestones include the 2005 health reform that introduced the Comprehensive Health Care Model (MAIS), the accreditation of training programs, the certification process for medical specialties, and a law enforcing payment for Family Medicine specialists in primary care. Despite reaching around 1,500 professionals, Family Medicine practitioners represent only 4% of specialists in the Chilean health system, mainly working in the public sector and particularly in primary care. The upcoming health system reform suggests Universal Primary Care as a central focus. To achieve this goal, it is crucial to encourage the training of Family Medicine specialists and ensure they stay within the system, recognizing the valuable contributions they make to the overall health network.

EVIDENCE AND LESSONS LEARNED FROM THE EVALUATION OF THE EFFECTIVENESS OF INTERVENTIONS TO IMPROVE THE COORDINATION ANS INTEGRATION OF THE CHILEAN NORTHERN METROPOLITAN SERVICE NETWORK

The purpose of this presentation was to share the experience in Chile of the study “Impact of care integration strategies on the performance of health service network in different health sys­tems in Latin America”(Equity LA II), a participatory action research project carried out from 2013 to 2019 in public care networks in the Metropolitan Region of Chile. The lesson learned in this study showed a conceptual model to understand and analyze the performance of the Integrated Health Services Networks by observing their results in terms of coordination and continuity of care. The design and working methods in Chile evidenced interesting results on the production of knowledge in this area and the possibilities of generating collaborative work processes in the network, with the design and implementation of bottom -up interventions­virtual consultancies and inter-level visits- based on existing resources proved to be effective and sustainable over time. Experiences like this are fundamental in the context of the ongoing process of universalization of primary care, whose challenges requires reflection on ways to effectively integrate primary care into a network that recognizes its role and leadership as axis of the care model.

Revolutionizing digital healthcare networks with wearable strain sensors using sustainable fibers

AbstractWearable strain sensors have attracted research interest owing to their potential within digital healthcare, offering smarter tracking, efficient diagnostics, and lower costs. Unlike rigid sensors, fiber‐based ones compete with their flexibility, durability, adaptability to body structures as well as eco‐friendliness to environment. Here, the sustainable fiber‐based wearable strain sensors for digital health are reviewed, and material, fabrication, and practical healthcare aspects are explored. Typical strain sensors predicated on various sensing modalities, be it resistive, capacitive, piezoelectric, or triboelectric, are explained and analyzed according to their strengths and weaknesses toward fabrication and applications. The applications in digital healthcare spanning from body area sensing networks, intelligent health management, and medical rehabilitation to multifunctional healthcare systems are also evaluated. Moreover, to create a more complete digital health network, wired and wireless methods of data collection and examples of machine learning are elaborated in detail. Finally, the prevailing challenges and prospective insights into the advancement of novel fibers, enhancement of sensing precision and wearability, and the establishment of seamlessly integrated systems are critically summarized and offered. This endeavor not only encapsulates the present landscape but also lays the foundation for future breakthroughs in fiber‐based wearable strain sensor technology within the domain of digital health.

Free riding is not the problem: how agency, heterogeneity and authority challenge collective action against antimicrobial resistance in the European Union

ABSTRACT This paper outlines a contextual approach to the governance of collective action in high complexity contexts. Using the major public health threat of antimicrobial resistance (AMR) in Europe as empirical case, we investigate the coordination challenges related to a plurality of agency, heterogeneity of capabilities, preferences and institutions, and various degrees and forms of authority. The analysis draws on original quantitative and qualitative data on senior public servants’ and experts’ preferences for governance arrangements. Allowing for variation in agency, heterogeneity and authority, we identify factors preventing or facilitating transnational governance and explain how and why these factors persist. The pattern of experts’ governance preferences as indicated in surveys and interviews suggests that when collective action fails, it can often be attributed to the heterogeneity among EU member states in terms of their willingness and capacity to address AMR. Also, networks of AMR experts are seen as critical to successful governance, both in the human public health sector where formal authority is limited and in animal health where the EU has extensive formal authority. In human public health, networks are instruments for exchanging ideas, knowledge and learning while in animal health networks support hierarchies and facilitate horizontal coordination.

Authentic nurse leadership: A perspective among nurses in a rural health network.

Authentic nurse leadership: A perspective among nurses in a rural health network.

How can local government be better supported to collaborate for community health and wellbeing?

AbstractCollaboration is a key strategy among local governments as expectations of the sector grow and resources to meet them fall short. Thus, more research is needed to consider how local governments can be supported to collaborate with others, not least for community health and wellbeing outcomes. In an earlier study, we explored inter‐municipal cooperation using social network analysis and local government perspectives on community health and wellbeing in the Australian state of Tasmania. Extending that study in ways reported here, we interviewed elected representatives and council staff to understand how and why Tasmanian local governments might collaborate with others to support community health and wellbeing. Findings show participants want councils to work more collaboratively to effectively deal with common challenges but are impeded by factors such as isolation and resource shortages. Tasmania's local government reform and Healthy Tasmania strategic plan are significant opportunities for collaborative practice to be enhanced among its local governments generally, and specifically in relation to community health and wellbeing. We advocate for a more considered approach to collaboration for community health and wellbeing that could deliver far‐reaching benefits for local governments and their communities.Points for practitioners Collaboration in local government is often described in terms of ‘shared services’ and tends to focus on transactional services that require little tailoring to local communities. Our study found municipal personnel want their councils to work more collaboratively to address common place‐specific issues related to community health and wellbeing, but are influenced by cultures of self‐sufficiency, organisational capacity and support, connections, and legislation and policy processes. Local government collaborative practices could be supported by the development of a place‐based policy framework to guide collaboration across local government service types, establishment of an informal statewide community health and wellbeing network for councils to facilitate peer learning and support, funding guidelines that explicitly support and encourage collaboration, and identifying collaboration as a priority in strategic plans, policies, and frameworks.

The power of personas: Exploring an innovative model for understanding stakeholder perspectives in an oncology learning health network

AbstractIntroductionLearning health networks (LHNs) improve clinical outcomes by applying core tenets of continuous quality improvements (QI) to reach community‐defined outcomes, data‐sharing, and empowered interdisciplinary teams including patients and caregivers. LHNs provide an ideal environment for the rapid adoption of evidence‐based guidelines and translation of research and best practices at scale. When an LHN is established, it is critical to understand the needs of all stakeholders. To accomplish this, we used ethnographic methods to develop personas of different stakeholders within The Canopy Cancer Collective, the first oncology LHN.MethodsWe partnered with a firm experienced in qualitative research and human‐centered design to conduct interviews with stakeholders of The Canopy Cancer Collective, a newly developed pancreatic cancer LHN. Together with the firm, we developed a personas model approach to represent the wide range of diverse perspectives among the representative stakeholders, which included care team members, patients, and caregivers.ResultsThirty‐one stakeholders from all facets of pancreatic cancer care were interviewed, including 20 care team members, 8 patients, and 3 caregivers. Interview transcripts were analyzed to construct 10 personas felt to represent the broad spectrum of stakeholders within The Cancer Canopy Collective. These personas were used as a foundation for the design and development of The Cancer Canopy Cancer Collective key drivers and aims.ConclusionsAs LHNs continue to facilitate comprehensive approaches to patient‐centered care, interdisciplinary teams who understand each other's needs can improve Network unity and cohesion. We present the first model utilizing personas for LHNs, demonstrating this framework holds significant promise for further study. If validated, such an approach could be used as a dynamic foundation for understanding individual stakeholder needs in similar LHN ecosystems in the future.

Examining tools for assessing the impact of chronic pain on emotional functioning in children and young people with cerebral palsy: stakeholder preference and recommendations for modification

PurposeTo firstly identify tools for assessing the impact of chronic pain on emotional functioning in children and young people with cerebral palsy (CP), and secondly identify suggestions to improve their relevance, comprehensiveness, comprehensibility and feasibility for the CP population. Improving assessment of the impact of pain on emotional functioning can enhance quality of life by improving access to interventions for pain-related physical disability, anxiety and depression.MethodsEthics approval was granted through the Women’s and Children’s Health Network Human Research Ethics Committee (2022/HRE00154). A mixed methods study with people with lived experience and clinicians, and guided by the Consensus-based Standards for Measurement Instruments (COSMIN), was undertaken. An online survey identified the highest rated tools for validation and/or modification for young people with CP and chronic pain. Focus groups and interviews investigated content validity and feasibility of the tools identified as highest rated.ResultsThe Fear of Pain Questionnaire for Children-SF (FOPQ-C-SF) and Modified Brief Pain Inventory (mBPI) were the highest rated for pain coping and multidimensional assessment (respectively) from the online survey (n = 61) of eight tools presented. Focus group and interview data (n = 30), including 58 unique modification suggestions, were coded to six categories: accessibility, comprehensibility, feasibility, relevance, presentation and comprehensiveness.ConclusionPotential modifications have been identified to improve the appropriateness and feasibility of the FOPQ-C-SF and mBPI for children and young people with CP. Future research should implement and test these modifications, prioritising the involvement of people with lived experience to ensure their needs are met alongside clinicians.

Electronic 1 year follow up after ablation

Abstract Background Several studies have shown that phone calls are an effective but resource intensive Follow-up (FU) method to collect patient reported data (PROM) after discharge from hospital. Regarding patient preference for FU, who has been ablated for atrial fibrillation (AF), most of the AF patients favoured a questionnaire with a stamped return envelope. In 2019 the National registry for ablation and electrophysiology in Norway (AblaNor) was established. All patients who have been in an EP lab receive an electronic FU questionnaire (ePROM) 1 year after the date of ablation. In Norway, it has been developed a technical solution which allows data submitted from the patient to be registered in the Health Network,"ePROM engine". Little is known about the functionality and response rate of electronic solutions. Purpose The aim of our study was to investigate an electronic FU approach in general and in different patient subgroups from AblaNor. Method We used data from the National register of ablation and electrophysiologi in Norway, Ablanor. The data are FU questionnaire who all patients received 1 year after ablation. All questionares are the same, independent diagnosis group. The patients received the FU questionnaires electronically via Helse Norge.no. The data is based on registrations from 2020-21. Results The data shows that amongst the 7169 selected procedures in 2020 and 2021, 5235 completed the ePROM form . There is a difference in response rates for both age and sex alone. Younger women have a higher response rate than men of same age, whereas in older age groups,men have higher response rates than women . Patients who have been ablated for AF have a higher respons rate than other procedures. Patients who have only undergone an electrophysiological examination (EP) have the lowest response rate. Conclusion Mandatory follow-up 1 year after completion of the procedure takes place in electronic form and contains simple registration of PROMS. The response rate among patients is 78% over the two years. This indicates an extremely high level of digital competence and motivation among patients to provide feedback for completed treatment. This shows that there is a discrepancy for FU regarding patient who has been ablated for atrial fibrillation (AF) . Abbreviations RFA: Radiofrequency Ablation; FU: Follow-up; AF: Atrial fibrillation; PROM: Patient reported outcome Measurement

D.6 Neurological care and outcomes of pregnant patients with epilepsy in a Canadian tertiary care center (2014-2020)

Background: Limited data exists on neurological care and outcomes of Canadian pregnant patients with epilepsy (PPWE). This study provides Canadian data to inform practice patterns and observed outcomes for PPWE at a tertiary care center. Methods: PPWE receiving care at the University Health Network (Toronto, Canada) epilepsy clinic from January 1, 2014 to November 20 2020 were retrospectively identified with demographics and neurological data and outcomes collected. Results: A total of 195 cases were identified, with a median maternal age of 32 years (SD 4.58), a median age at first seizure of 17 years (range 1 month – 36 years old), 52% were diagnosed with genetic generalized epilepsy and 50% endorsed 6 months of seizure freedom prior to conception. In pregnancy, 93% took ASM(s) with 77% receiving therapeutic drug monitoring (TDM) and drug dose adjustments reported in 69%. Most cases (73%) maintained a stable seizure frequency. Conclusions: This study provides new Canadian data on PPWE at a tertiary care center. PPWE are overall well controlled, more likely to have young adult onset, genetic generalized epilepsy with nearly all taking ASM(s) during pregnancy. While high rates of TDM and drug dose adjustments were observed, most experienced seizure stability in pregnancy.

E.1 Focal leptomeningeal vascular anomalies on brain MRI: a mimic of leptomeningeal metastatic disease

Background: The diagnosis of leptomeningeal metastatic disease has major prognostic implications. We report 13 patients with a radiologically distinct, focal, enhancing leptomeningeal lesion on brain MRI mimicking leptomeningeal metastatic disease. Methods: These patients were assessed at University Health Network between January 2001 and December 2023. Results: Median age was 68 years and 10 patients were women. All patients had brain MRI including contrast-enhanced T2-weighted FLAIR and T1-weighted spin echo sequences. MRI in all patients showed a focal enhancing lesion along the leptomeningeal surface of the brain. The MRI exams were reported as possible metastatic disease for the majority (9/13) of patients. Each lesion was curvilinear rather than sheet-like, and some consisted of multiple connected/branching curvilinear structures with the appearance of abnormal vessels. Some lesions had visible connection with a nearby cortical vein. The lesions were distinct from normal blood vessels. Follow-up contrast-enhanced brain MRI for 8/13 patients at a median of 3.9 years showed all lesions were unchanged over time. Conclusions: We describe a distinct kind of focal, enhancing leptomeningeal lesion on brain MRI that mimics metastatic disease. These lesions are likely a type of low-flow vascular anomaly. Their curvilinear/branching shape and intense enhancement particularly on T2-weighted FLAIR images distinguishes these lesions from tumor.

Non-alcoholic fatty liver disease in patients with atrial fibrillation: a report from a global federated health network

Abstract Background Few data are available on the clinical course of patients with Atrial Fibrillation (AF) and Nonalcoholic Fatty Liver Disease (NAFLD). Purpose To evaluate the 1-year risk of all-cause death, thromboembolic events, and bleeding in AF patients with NAFLD. Methods Retrospective cohort study within the global TriNetX platform. Patients with AF were categorized into two groups: i) AF with NAFLD and ii) AF without liver diseases. The primary outcomes were the 1-year risks of a composite outcome of i) all-cause death and thrombotic events (all-cause death, acute myocardial infarction, ischemic stroke, systemic arterial thromboembolism, deep vein thrombosis, and pulmonary embolism), and hemorrhagic outcome (intracranial hemorrhage and gastrointestinal bleeding). Secondary outcomes were each component of the composite primary outcomes. Cox regression analysis before and after propensity-score-matching (PSM) was used to estimate HR and 95% confidence interval (95%CI). Sensitivity analyses were done to investigate the risk associated with cirrhosis and type of oral anticoagulant. Results We identified 22,636 AF patients with NAFLD (69±12 years, 46.7% females) and 391,014 AF patients without NAFLD (72±12 years, 42.7% females). Before PSM, AF patients with NAFLD were younger, and with a higher prevalence of cardiovascular risk factors than those without liver disease. After PSM, no difference was found between the two groups, but NAFLD patients showed a higher 1-year risk of thrombotic (HR 1.54, 95%CI 1.47-1.61) and hemorrhagic (HR 1.56, 95%CI 1.42-1.72) composite outcomes (Figure 1). The higher risk in NAFLD was consistent also for all the secondary outcomes (Figure 1). On the sensitivity analyses (Figure 2), a progressively increased risk of thrombotic and hemorrhagic events was found in non-cirrhotic and cirrhotic patients compared to patients without liver diseases, whereas non-vitamin-k antagonist (NOAC) seems to be safer and more effective than warfarin. Conclusion In AF patients, NAFLD is associated with a higher 1-year risk of all-cause death, thrombotic and hemorrhagic events. Further studies are needed to establish the best clinical approach to manage NAFLD in AF patients.Figure 1Figure 2

Children and adolescents in a neglectful environment Early detection as the first response to their needs

Neglect of children and adolescents is the most common form of abuse and occurs when their basic needs are not met. The negative impact on physical and mental health can be significant. Early detection by primary care physicians and support for parents and the community, in collaboration with the social and health network, are essential to ensure that minors have an environment conducive to their healthy development. Recognizing the needs of children and teenagers is an important issue in social and preventive medicine, as is defending their interests and rights.

Apical Suspension Repair for Vaginal Vault Prolapse

The optimal surgical repair of vaginal vault prolapse after hysterectomy remains undetermined. To compare the efficacy and safety of 3 surgical approaches for vaginal vault prolapse after hysterectomy. This was a multisite, 3-arm, superiority and noninferiority randomized clinical trial. Outcomes were assessed biannually up to 60 months, until the last participant reached 36 months of follow-up. Settings included 9 clinical sites in the US National Institute of Child Health and Human Development (NICHD) Pelvic Floor Disorders Network. Between February 2016 and April 2019, women with symptomatic vaginal vault prolapse after hysterectomy who desired surgical correction were randomized. Data were analyzed from November 2022 to January 2023. Mesh-augmented (either abdominally [sacrocolpopexy] or through a vaginal incision [transvaginal mesh]) vs transvaginal native tissue repair. The primary outcome was time until composite treatment failure (including retreatment for prolapse, prolapse beyond the hymen, or prolapse symptoms) evaluated with survival models. Secondary outcomes included patient-reported symptom-specific results, objective measures, and adverse events. Of 376 randomized participants (mean [SD] age, 66.1 [8.7] years), 360 (96%) had surgery, and 296 (82%) completed follow-up. Adjusted 36-month failure incidence was 28% (95% CI, 20%-37%) for sacrocolpopexy, 29% (95% CI, 21%-38%) for transvaginal mesh, and 43% (95% CI, 35%-53%) for native tissue repair. Sacrocolpopexy was found to be superior to native tissue repair (adjusted hazard ratio [aHR], 0.57; 99% CI, 0.33-0.98; P = .01). Transvaginal mesh was not statistically superior to native tissue after adjustment for multiple comparisons (aHR, 0.60; 99% CI, 0.34-1.03; P = .02) but was noninferior to sacrocolpopexy (aHR, 1.05; 97% CI, 0-1.65; P = .01). All 3 surgeries resulted in sustained benefits in subjective outcomes. Mesh exposure rates were low (4 of 120 [3%] for sacrocolpopexy and 6 of 115 [5%] for transvaginal mesh) as were the rates of dyspareunia. Among participants undergoing apical repair for vaginal vault prolapse, sacrocolpopexy and transvaginal mesh resulted in similar composite failure rates at study completion; both had lower failure rates than native tissue repair, although only sacrocolpopexy met a statistically significant difference. Low rates of mesh complications and adverse events corroborated the overall safety of each approach. ClinicalTrials.gov Identifier: NCT02676973.

A whole-slide foundation model for digital pathology from real-world data

Digital pathology poses unique computational challenges, as a standard gigapixel slide may comprise tens of thousands of image tiles1–3. Prior models have often resorted to subsampling a small portion of tiles for each slide, thus missing the important slide-level context4. Here we present Prov-GigaPath, a whole-slide pathology foundation model pretrained on 1.3 billion 256 × 256 pathology image tiles in 171,189 whole slides from Providence, a large US health network comprising 28 cancer centres. The slides originated from more than 30,000 patients covering 31 major tissue types. To pretrain Prov-GigaPath, we propose GigaPath, a novel vision transformer architecture for pretraining gigapixel pathology slides. To scale GigaPath for slide-level learning with tens of thousands of image tiles, GigaPath adapts the newly developed LongNet5 method to digital pathology. To evaluate Prov-GigaPath, we construct a digital pathology benchmark comprising 9 cancer subtyping tasks and 17 pathomics tasks, using both Providence and TCGA data6. With large-scale pretraining and ultra-large-context modelling, Prov-GigaPath attains state-of-the-art performance on 25 out of 26 tasks, with significant improvement over the second-best method on 18 tasks. We further demonstrate the potential of Prov-GigaPath on vision–language pretraining for pathology7,8 by incorporating the pathology reports. In sum, Prov-GigaPath is an open-weight foundation model that achieves state-of-the-art performance on various digital pathology tasks, demonstrating the importance of real-world data and whole-slide modelling.

Analysing the performance of a health innovation ecosystem in the COVID-19 crisis: complexity and chaos theory perspective

BackgroundThis research delves into the complexity management of collaborative networks and interorganizational systems in the health innovation ecosystem on the basis of a best practice in the coronavirus disease 2019 (COVID-19) crisis. The objective is to offer specific solutions and guidelines to stakeholders in the health innovation ecosystem to control the chaos resulting from unexpected events along the ecosystem development and evolution path.MethodsFor this purpose, the performance of the Health Innovation Ecosystem in Iran (the Every Home is a Health Base plan) has been examined through a detailed and in-depth analysis of events and actions taken using documents, reports and interviews with experts. The practical application of chaos and complex adaptive system features (adaptation, time horizons, edge of chaos, sensitivity to initial conditions, state space and strange attractors) is introduced to identify and manage the transition from a state where the health innovation ecosystem is on the edge of chaos and prone to failure. Data were collected through studying documents, reports and interviews with experts, and then analysed using qualitative content analysis techniques, open and axial coding and metaphors derived from complexity and chaos theories.ResultsThe findings indicate that to understand and embrace the complexity of the health innovation ecosystem throughout its development and evolution and manage and lead it through the edge of chaos towards successful interorganizational systems performance, it is necessary to use gap analysis to achieve consensus, establish a highly interactive governance structure with key stakeholders of the ecosystem, maintain flexibility to control bifurcations (butterfly effect), prevent transforming emergency solutions into standard routines and ensure the sustainability of the ecosystem against future threats by long-term financial security.ConclusionsThis research provides insights into the dynamics of complex health systems and offers strategies for promoting successful innovation through collaborative networks and interorganizational systems in the development and evolution of the health innovation ecosystem. By embracing complexity and chaos, healthcare professionals, policy-makers and researchers can collaboratively address complex challenges and improve outcomes in health network activities. The conclusion section provides guidelines for successfully managing the complexity of the ecosystem and offers suggestions for further research.